ABFM ITE EXAM WITH QUESTIONS AND
CORRECT ANSWERS UPDATED
Question 1
An ill-appearing 50-year-old male presents with malaise, nausea, anorexia, and
lethargy. He has a recent diagnosis of a high-grade lymphoma and is undergoing
aggressive chemotherapy. His last chemotherapy session was 2 days ago. An
examination is nonspecific. Initial laboratory studies reveal a creatinine level of 2.1
mg/dL (N 0.6-1.2). His baseline creatinine level is 1.0 mg/dL.
Which one of the following laboratory findings would be expected in this patient?
A) Hypercalcemia
B) Hyperuricemia
C) Hypokalemia
D) Hypophosphatemia
E) Low LDH
Correct Answer
ANSWER: B
Tumor lysis syndrome is considered the most common oncologic emergency. It is
caused by the rapid release of intracellular material from lysis of the malignant cells.
The breakdown of nucleic acids releases large amounts of uric acid and leads to
acute kidney failure, which limits clearance of potassium, phosphorus, and uric acid.
This leads to hyperuricemia, secondary hypocalcemia, hyperkalemia, and
hyperphosphatemia. It can result in acute renal failure, arrhythmia, seizure, and
sudden death. While tumor lysis syndrome has been reported with many cancer
types, it is more common with acute leukemia and high-grade lymphomas. Patients
with this condition generally present within 7 days of cancer treatment, including
chemotherapy, radiation, or biologic therapies. It can also occur spontaneously. An
LDH elevation related to a high cell turnover rate prior to cancer treatment may
indicate an increased risk of tumor lysis syndrome. Hypercalcemia, hypokalemia,
hypophosphatemia, and low LDH would not be expected laboratory findings in
patients with tumor lysis syndrome.
Page 1 of 702
,Question 2
A 90-year-old male with metastatic prostate cancer and osteoarthritis of the knees is
brought to the hospital with acute kidney injury due to dehydration, along with
generalized weakness and ambulatory dysfunction. Prior to his hospitalization he lived
independently with part-time caregiver assistance. Over the next 2 days his renal
function improves, although physical and occupational therapy evaluations reveal
significant deficits in his activities of daily living. The decision is made to transfer him
to a skilled nursing facility. In planning for his discharge, you discuss completion of a
Physician Orders for Life-Sustaining Treatment (POLST) form with the patient and his
daughter, who says that her father already has an advance directive. She asks you
what distinguishes a POLST form from other advanced care planning documents. You
explain to her that, as opposed to an advance directive, a POLST form
A) does not
Correct Answer
ANSWER: C
An organization that is now known as National POLST began as an advisory panel
and task force to improve consistency in honoring the wishes of patients with
serious illness or frailty regarding end-of-life care. POLST, originally an acronym for
Physician Orders for Life-Sustaining Treatment, varies in name at the state level,
although at the national level POLST is defined as a portable medical order. POLST
forms differ from other legal advanced care planning documents such as advance
directives and living wills, although the processes can work together. The primary
purpose of a POLST form is to provide specific medical orders in the event that a
patient is unable to communicate. Legal advanced care planning documents, in
contrast, express general treatment wishes and identify a health care proxy for
surrogate decision-making but do not provide specific orders for care. POLST forms
are completed by a treating physician and signed by the patient or surrogate and
the physician, unlike advance directive documents, which are completed by the
individual and are often notarized.
POLST forms are intended only for patients with serious illness and frailty, not for
healthy persons, whereas advance directives can be completed by any competent
adult. POLST completion is voluntary and is neither a requirement for entering
hospice nor a routine part of the Medicare annual wellness visit. Neither document
type is intended to supersede the expressed wishes of a patient who can
communicate.
Page 2 of 702
,Question 3
According to the Ottawa knee rule, which one of the following factors may warrant
radiography in a patient with an acute knee injury?
A) Age <30
B) Injury from a fall or blunt trauma
C) A twisting mechanism of injury
D) Inability to flex the knee to 90°
E) The presence of a joint effusion within 24 hours of the injury
Correct Answer
ANSWER: D
Knee injuries are an extremely common cause for primary care visits and knowing
which injuries require radiography can ensure high-value care. The Ottawa knee rule
has been repeatedly validated with a sensitivity of 98.5%-100% and can decrease
unnecessary imaging. The major criteria of the Ottawa knee rule are age >55, the
inability to bear weight for four steps both immediately after the injury and at the
time of the examination, the inability to flex the knee to 90°, tenderness over the
head of the fibula, and isolated tenderness to the patella without other bony
tenderness. If a patient meets any of these criteria, radiography of the knee may be
indicated.
Page 3 of 702
, Question 4
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
Correct 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
variceal hemorrhage is based on the risk of bleeding. Findings associated with a
high risk of bleeding include small varices in patients with decompensated cirrhosis,
small varices with red wale signs (thinning of the variceal wall), and medium to large
varices. Patients with small varices not meeting these criteria have a low risk of
hemorrhage and do not require prophylaxis. They should be rescreened with EGD
every 1-2 years.
For patients requiring treatment due to high-risk features, options for primary
prophylaxis of hemorrhage include nonselective -blockers such as propranolol or
endoscopic variceal ligation. Treatment decisions are based on patient preference,
other potential contraindications, and local resources. The need for repeat
endoscopy in these cases will depend on the clinical circumstances. If nonselective -
blockers are used, they should be continued indefinitely. Octreotide is only given
intravenously for acute hemorrhage. There is no evidence that omeprazole slows
the progression of esophageal varices.
Page 4 of 702
CORRECT ANSWERS UPDATED
Question 1
An ill-appearing 50-year-old male presents with malaise, nausea, anorexia, and
lethargy. He has a recent diagnosis of a high-grade lymphoma and is undergoing
aggressive chemotherapy. His last chemotherapy session was 2 days ago. An
examination is nonspecific. Initial laboratory studies reveal a creatinine level of 2.1
mg/dL (N 0.6-1.2). His baseline creatinine level is 1.0 mg/dL.
Which one of the following laboratory findings would be expected in this patient?
A) Hypercalcemia
B) Hyperuricemia
C) Hypokalemia
D) Hypophosphatemia
E) Low LDH
Correct Answer
ANSWER: B
Tumor lysis syndrome is considered the most common oncologic emergency. It is
caused by the rapid release of intracellular material from lysis of the malignant cells.
The breakdown of nucleic acids releases large amounts of uric acid and leads to
acute kidney failure, which limits clearance of potassium, phosphorus, and uric acid.
This leads to hyperuricemia, secondary hypocalcemia, hyperkalemia, and
hyperphosphatemia. It can result in acute renal failure, arrhythmia, seizure, and
sudden death. While tumor lysis syndrome has been reported with many cancer
types, it is more common with acute leukemia and high-grade lymphomas. Patients
with this condition generally present within 7 days of cancer treatment, including
chemotherapy, radiation, or biologic therapies. It can also occur spontaneously. An
LDH elevation related to a high cell turnover rate prior to cancer treatment may
indicate an increased risk of tumor lysis syndrome. Hypercalcemia, hypokalemia,
hypophosphatemia, and low LDH would not be expected laboratory findings in
patients with tumor lysis syndrome.
Page 1 of 702
,Question 2
A 90-year-old male with metastatic prostate cancer and osteoarthritis of the knees is
brought to the hospital with acute kidney injury due to dehydration, along with
generalized weakness and ambulatory dysfunction. Prior to his hospitalization he lived
independently with part-time caregiver assistance. Over the next 2 days his renal
function improves, although physical and occupational therapy evaluations reveal
significant deficits in his activities of daily living. The decision is made to transfer him
to a skilled nursing facility. In planning for his discharge, you discuss completion of a
Physician Orders for Life-Sustaining Treatment (POLST) form with the patient and his
daughter, who says that her father already has an advance directive. She asks you
what distinguishes a POLST form from other advanced care planning documents. You
explain to her that, as opposed to an advance directive, a POLST form
A) does not
Correct Answer
ANSWER: C
An organization that is now known as National POLST began as an advisory panel
and task force to improve consistency in honoring the wishes of patients with
serious illness or frailty regarding end-of-life care. POLST, originally an acronym for
Physician Orders for Life-Sustaining Treatment, varies in name at the state level,
although at the national level POLST is defined as a portable medical order. POLST
forms differ from other legal advanced care planning documents such as advance
directives and living wills, although the processes can work together. The primary
purpose of a POLST form is to provide specific medical orders in the event that a
patient is unable to communicate. Legal advanced care planning documents, in
contrast, express general treatment wishes and identify a health care proxy for
surrogate decision-making but do not provide specific orders for care. POLST forms
are completed by a treating physician and signed by the patient or surrogate and
the physician, unlike advance directive documents, which are completed by the
individual and are often notarized.
POLST forms are intended only for patients with serious illness and frailty, not for
healthy persons, whereas advance directives can be completed by any competent
adult. POLST completion is voluntary and is neither a requirement for entering
hospice nor a routine part of the Medicare annual wellness visit. Neither document
type is intended to supersede the expressed wishes of a patient who can
communicate.
Page 2 of 702
,Question 3
According to the Ottawa knee rule, which one of the following factors may warrant
radiography in a patient with an acute knee injury?
A) Age <30
B) Injury from a fall or blunt trauma
C) A twisting mechanism of injury
D) Inability to flex the knee to 90°
E) The presence of a joint effusion within 24 hours of the injury
Correct Answer
ANSWER: D
Knee injuries are an extremely common cause for primary care visits and knowing
which injuries require radiography can ensure high-value care. The Ottawa knee rule
has been repeatedly validated with a sensitivity of 98.5%-100% and can decrease
unnecessary imaging. The major criteria of the Ottawa knee rule are age >55, the
inability to bear weight for four steps both immediately after the injury and at the
time of the examination, the inability to flex the knee to 90°, tenderness over the
head of the fibula, and isolated tenderness to the patella without other bony
tenderness. If a patient meets any of these criteria, radiography of the knee may be
indicated.
Page 3 of 702
, Question 4
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
Correct 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
variceal hemorrhage is based on the risk of bleeding. Findings associated with a
high risk of bleeding include small varices in patients with decompensated cirrhosis,
small varices with red wale signs (thinning of the variceal wall), and medium to large
varices. Patients with small varices not meeting these criteria have a low risk of
hemorrhage and do not require prophylaxis. They should be rescreened with EGD
every 1-2 years.
For patients requiring treatment due to high-risk features, options for primary
prophylaxis of hemorrhage include nonselective -blockers such as propranolol or
endoscopic variceal ligation. Treatment decisions are based on patient preference,
other potential contraindications, and local resources. The need for repeat
endoscopy in these cases will depend on the clinical circumstances. If nonselective -
blockers are used, they should be continued indefinitely. Octreotide is only given
intravenously for acute hemorrhage. There is no evidence that omeprazole slows
the progression of esophageal varices.
Page 4 of 702
