ABFM ITE: IN-TRAINING EXAMINATION ACTUAL QUESTIONS WITH
CORRECT ANSWERS AND EXPLANATIONS
Question 1: Which of the following is the most appropriate initial management for a 45-year-old
asymptomatic patient with a newly discovered 1.2-cm adrenal incidentaloma that has benign features
on computed tomography (homogeneous, low attenuation <10 Hounsfield units)?
A. Laparoscopic adrenalectomy
B. 24-hour urine metanephrines and cortisol evaluation
C. Repeat abdominal CT scan in 3 to 6 months
D. Immediate fine-needle aspiration biopsy
CORRECT ANSWER: B. 24-hour urine metanephrines and cortisol evaluation
Rationale: According to the American Association of Clinical Endocrinologists and the Endocrine Society
guidelines, all newly discovered adrenal incidentalomas require initial biochemical evaluation to rule out
hormone hypersecretion, specifically pheochromocytoma (via plasma-free metanephrines or 24-hour
urine fractionated metanephrines) and Cushing syndrome (via an overnight 1-mg dexamethasone
suppression test or 24-hour urine free cortisol). Subclinical primary aldosteronism should also be
assessed in hypertensive patients. Imaging features that are benign (low attenuation, <4 cm) do not
require immediate surgical resection or repeat imaging for stability unless hormonal hypersecretion is
found or malignancy is suspected.
Question 2: A 68-year-old man with a history of hypertension and type 2 diabetes mellitus presents for
a routine health maintenance evaluation. His blood pressure is 138/84 mm Hg, and his estimated
glomerular filtration rate is 52 mL/min/1.73 $m^2$. He has a urine albumin-to-creatinine ratio of 220
mg/g. Which of the following medications is most beneficial to reduce the progression of his chronic
kidney disease?
A. Amlodipine
B. Chlorthalidone
C. Lisinopril
D. Metoprolol succinate
CORRECT ANSWER: C. Lisinopril
Rationale: Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, or angiotensin II receptor
blockers (ARBs) are first-line therapy for patients with chronic kidney disease and persistent albuminuria
(urine albumin-to-creatinine ratio $\ge$ 30 mg/g), particularly in the presence of diabetes mellitus or
,hypertension. They reduce intraglomerular pressure by efferent arteriolar vasodilation, thereby slowing
the progression of diabetic nephropathy and reducing proteinuria. Other antihypertensive agents like
amlodipine or chlorthalidone can be added for blood pressure control but do not provide the same
targeted nephroprotective reduction in intraglomerular pressure.
Question 3: A 32-year-old pregnant woman at 28 weeks gestation presents with severe pruritus,
particularly on her palms and soles, which is worse at night and not associated with a primary skin
rash. Laboratory evaluation reveals an elevated total serum bile acid concentration of 35 micromol/L
and mildly elevated serum transaminases. Which of the following is the most appropriate definitive
management for this patient?
A. Observation and daily emollient application
B. Initiation of ursodeoxycholic acid and delivery planning at 36 to 38 weeks gestation
C. Immediate induction of labor regardless of gestational age
D. Administration of high-dose systemic corticosteroids
CORRECT ANSWER: B. Initiation of ursodeoxycholic acid and delivery planning at 36 to 38 weeks
gestation
Rationale: This patient has intrahepatic cholestasis of pregnancy, characterized by pruritus of the palms
and soles with elevated serum bile acids. First-line medical therapy is ursodeoxycholic acid, which
relieves pruritus and improves biochemical markers. Because intrahepatic cholestasis of pregnancy
carries an increased risk of sudden intrauterine fetal demise, routine delivery is recommended between
36 and 38 weeks gestation, depending on bile acid levels and fetal well-being, rather than waiting for
spontaneous term labor or performing immediate delivery at 28 weeks.
Question 4: A 55-year-old man comes to the office for evaluation of a chronic, nonproductive cough
and progressive shortness of breath over the past year. He has a 40-pack-year smoking history.
Physical examination reveals fine dry crackles at both lung bases and digital clubbing. High-resolution
computed tomography of the chest demonstrates peripheral reticular opacities, honeycombing, and
traction bronchiectasis predominantly in the lower lobes. Which of the following is the most likely
diagnosis?
A. Chronic obstructive pulmonary disease
B. Idiopathic pulmonary fibrosis
C. Sarcoidosis
D. Hypersensitivity pneumonitis
CORRECT ANSWER: B. Idiopathic pulmonary fibrosis
,Rationale: Idiopathic pulmonary fibrosis is a specific form of chronic, progressive fibrosing interstitial
pneumonia of unknown cause, occurring primarily in older adults. Typical clinical features include a dry
cough, progressive dyspnea, bibasilar dry crackles (Velcro crackles), and digital clubbing. High-resolution
computed tomography is the diagnostic modality of choice and typically demonstrates a usual interstitial
pneumonia pattern characterized by subpleural, basal-predominant reticular abnormalities,
honeycombing, and traction bronchiectasis.
Question 5: A 24-year-old college student presents with a 3-day history of sore throat, low-grade fever,
fatigue, and tender posterior cervical lymphadenopathy. Physical examination also reveals mild
pharyngeal erythema and moderate tonsillar enlargement with a thin white exudate. A rapid
streptococcal antigen test is negative. Which of the following diagnostic tests is most appropriate to
confirm the most likely diagnosis?
A. Throat culture for group A beta-hemolytic Streptococcus
B. Heterophile antibody test (Monospot)
C. Serum antistreptolysin O titer
D. Epstein-Barr virus early antigen immunoglobulin G antibody
CORRECT ANSWER: B. Heterophile antibody test (Monospot)
Rationale: The clinical presentation of severe fatigue, pharyngitis, posterior cervical lymphadenopathy,
and tonsillar exudate in a young adult is characteristic of infectious mononucleosis caused by the
Epstein-Barr virus. The heterophile antibody test (Monospot) is the most widely used and practical initial
diagnostic test due to its high specificity during acute infection, though sensitivity can be lower in the
first week of illness. Group A streptococcal pharyngitis is ruled out by the negative rapid antigen test, and
streptococcal cultures are not indicated for suspected viral syndromes unless coinfection is strongly
suspected.
Question 6: A 60-year-old postmenopausal woman undergoes routine dual-energy X-ray
absorptiometry. The resulting T-score is -2.8 at the femoral neck and -2.6 at the lumbar spine. She has
no history of fragility fractures and takes no medications. Laboratory workup, including serum calcium,
vitamin D, and a complete blood count, is normal. Which of the following is the most appropriate
initial pharmacological treatment?
A. Teriparatide
B. Alendronate
C. Denosumab
D. Calcitonin nasal spray
CORRECT ANSWER: B. Alendronate
, Rationale: A T-score of -2.5 or lower at the femoral neck, total hip, or lumbar spine establishes the
diagnosis of osteoporosis. First-line pharmacological therapy for postmenopausal women with
uncomplicated osteoporosis is an oral bisphosphonate, such as alendronate or risedronate, which has
been shown to significantly reduce the risk of vertebral and nonvertebral fractures. Teriparatide is
typically reserved for severe osteoporosis (e.g., T-score $\le$ -3.0 or presence of prior fragility fractures)
or patients who fail or cannot tolerate bisphosphonates.
Question 7: A 72-year-old man is brought to the emergency department by his family because of acute
confusion, fluctuating levels of consciousness, and visual hallucinations that began two days ago. He
has a history of mild cognitive impairment and Parkinson disease. On examination, he is disoriented to
time and place, and exhibits resting tremor, mild rigidity, and generalized bradykinesia. Which of the
following is the most likely underlying diagnosis?
A. Alzheimer disease dementia
B. Dementia with Lewy bodies
C. Delirium secondary to a urinary tract infection
D. Creutzfeldt-Jakob disease
CORRECT ANSWER: B. Dementia with Lewy bodies
Rationale: Dementia with Lewy bodies is characterized by fluctuating cognition, recurrent visual
hallucinations, and spontaneous parkinsonism (bradykinesia, resting tremor, rigidity) that typically
manifests concurrently with or before the onset of cognitive decline. While intercurrent medical illnesses
can precipitate delirium in patients with underlying neurodegenerative disorders, the constellation of
core features points specifically toward dementia with Lewy bodies. Patients with this condition are also
exquisitely sensitive to neuroleptic medications, which can cause severe extrapyramidal side effects.
Question 8: A 19-year-old male college athlete comes to the clinic for a routine pre-participation sports
physical examination. He reports no chest pain, shortness of breath, syncope, or palpitations. His
father died suddenly at the age of 42 while running. Physical examination reveals a grade 2/6
midsystolic murmur heard best at the lower left sternal border, which increases in intensity when the
patient performs the Valsalva maneuver. Which of the following is the most likely diagnosis?
A. Bicuspid aortic valve
B. Hypertrophic cardiomyopathy
C. Mitral valve prolapse
D. Coarctation of the aorta
CORRECT ANSWER: B. Hypertrophic cardiomyopathy
CORRECT ANSWERS AND EXPLANATIONS
Question 1: Which of the following is the most appropriate initial management for a 45-year-old
asymptomatic patient with a newly discovered 1.2-cm adrenal incidentaloma that has benign features
on computed tomography (homogeneous, low attenuation <10 Hounsfield units)?
A. Laparoscopic adrenalectomy
B. 24-hour urine metanephrines and cortisol evaluation
C. Repeat abdominal CT scan in 3 to 6 months
D. Immediate fine-needle aspiration biopsy
CORRECT ANSWER: B. 24-hour urine metanephrines and cortisol evaluation
Rationale: According to the American Association of Clinical Endocrinologists and the Endocrine Society
guidelines, all newly discovered adrenal incidentalomas require initial biochemical evaluation to rule out
hormone hypersecretion, specifically pheochromocytoma (via plasma-free metanephrines or 24-hour
urine fractionated metanephrines) and Cushing syndrome (via an overnight 1-mg dexamethasone
suppression test or 24-hour urine free cortisol). Subclinical primary aldosteronism should also be
assessed in hypertensive patients. Imaging features that are benign (low attenuation, <4 cm) do not
require immediate surgical resection or repeat imaging for stability unless hormonal hypersecretion is
found or malignancy is suspected.
Question 2: A 68-year-old man with a history of hypertension and type 2 diabetes mellitus presents for
a routine health maintenance evaluation. His blood pressure is 138/84 mm Hg, and his estimated
glomerular filtration rate is 52 mL/min/1.73 $m^2$. He has a urine albumin-to-creatinine ratio of 220
mg/g. Which of the following medications is most beneficial to reduce the progression of his chronic
kidney disease?
A. Amlodipine
B. Chlorthalidone
C. Lisinopril
D. Metoprolol succinate
CORRECT ANSWER: C. Lisinopril
Rationale: Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, or angiotensin II receptor
blockers (ARBs) are first-line therapy for patients with chronic kidney disease and persistent albuminuria
(urine albumin-to-creatinine ratio $\ge$ 30 mg/g), particularly in the presence of diabetes mellitus or
,hypertension. They reduce intraglomerular pressure by efferent arteriolar vasodilation, thereby slowing
the progression of diabetic nephropathy and reducing proteinuria. Other antihypertensive agents like
amlodipine or chlorthalidone can be added for blood pressure control but do not provide the same
targeted nephroprotective reduction in intraglomerular pressure.
Question 3: A 32-year-old pregnant woman at 28 weeks gestation presents with severe pruritus,
particularly on her palms and soles, which is worse at night and not associated with a primary skin
rash. Laboratory evaluation reveals an elevated total serum bile acid concentration of 35 micromol/L
and mildly elevated serum transaminases. Which of the following is the most appropriate definitive
management for this patient?
A. Observation and daily emollient application
B. Initiation of ursodeoxycholic acid and delivery planning at 36 to 38 weeks gestation
C. Immediate induction of labor regardless of gestational age
D. Administration of high-dose systemic corticosteroids
CORRECT ANSWER: B. Initiation of ursodeoxycholic acid and delivery planning at 36 to 38 weeks
gestation
Rationale: This patient has intrahepatic cholestasis of pregnancy, characterized by pruritus of the palms
and soles with elevated serum bile acids. First-line medical therapy is ursodeoxycholic acid, which
relieves pruritus and improves biochemical markers. Because intrahepatic cholestasis of pregnancy
carries an increased risk of sudden intrauterine fetal demise, routine delivery is recommended between
36 and 38 weeks gestation, depending on bile acid levels and fetal well-being, rather than waiting for
spontaneous term labor or performing immediate delivery at 28 weeks.
Question 4: A 55-year-old man comes to the office for evaluation of a chronic, nonproductive cough
and progressive shortness of breath over the past year. He has a 40-pack-year smoking history.
Physical examination reveals fine dry crackles at both lung bases and digital clubbing. High-resolution
computed tomography of the chest demonstrates peripheral reticular opacities, honeycombing, and
traction bronchiectasis predominantly in the lower lobes. Which of the following is the most likely
diagnosis?
A. Chronic obstructive pulmonary disease
B. Idiopathic pulmonary fibrosis
C. Sarcoidosis
D. Hypersensitivity pneumonitis
CORRECT ANSWER: B. Idiopathic pulmonary fibrosis
,Rationale: Idiopathic pulmonary fibrosis is a specific form of chronic, progressive fibrosing interstitial
pneumonia of unknown cause, occurring primarily in older adults. Typical clinical features include a dry
cough, progressive dyspnea, bibasilar dry crackles (Velcro crackles), and digital clubbing. High-resolution
computed tomography is the diagnostic modality of choice and typically demonstrates a usual interstitial
pneumonia pattern characterized by subpleural, basal-predominant reticular abnormalities,
honeycombing, and traction bronchiectasis.
Question 5: A 24-year-old college student presents with a 3-day history of sore throat, low-grade fever,
fatigue, and tender posterior cervical lymphadenopathy. Physical examination also reveals mild
pharyngeal erythema and moderate tonsillar enlargement with a thin white exudate. A rapid
streptococcal antigen test is negative. Which of the following diagnostic tests is most appropriate to
confirm the most likely diagnosis?
A. Throat culture for group A beta-hemolytic Streptococcus
B. Heterophile antibody test (Monospot)
C. Serum antistreptolysin O titer
D. Epstein-Barr virus early antigen immunoglobulin G antibody
CORRECT ANSWER: B. Heterophile antibody test (Monospot)
Rationale: The clinical presentation of severe fatigue, pharyngitis, posterior cervical lymphadenopathy,
and tonsillar exudate in a young adult is characteristic of infectious mononucleosis caused by the
Epstein-Barr virus. The heterophile antibody test (Monospot) is the most widely used and practical initial
diagnostic test due to its high specificity during acute infection, though sensitivity can be lower in the
first week of illness. Group A streptococcal pharyngitis is ruled out by the negative rapid antigen test, and
streptococcal cultures are not indicated for suspected viral syndromes unless coinfection is strongly
suspected.
Question 6: A 60-year-old postmenopausal woman undergoes routine dual-energy X-ray
absorptiometry. The resulting T-score is -2.8 at the femoral neck and -2.6 at the lumbar spine. She has
no history of fragility fractures and takes no medications. Laboratory workup, including serum calcium,
vitamin D, and a complete blood count, is normal. Which of the following is the most appropriate
initial pharmacological treatment?
A. Teriparatide
B. Alendronate
C. Denosumab
D. Calcitonin nasal spray
CORRECT ANSWER: B. Alendronate
, Rationale: A T-score of -2.5 or lower at the femoral neck, total hip, or lumbar spine establishes the
diagnosis of osteoporosis. First-line pharmacological therapy for postmenopausal women with
uncomplicated osteoporosis is an oral bisphosphonate, such as alendronate or risedronate, which has
been shown to significantly reduce the risk of vertebral and nonvertebral fractures. Teriparatide is
typically reserved for severe osteoporosis (e.g., T-score $\le$ -3.0 or presence of prior fragility fractures)
or patients who fail or cannot tolerate bisphosphonates.
Question 7: A 72-year-old man is brought to the emergency department by his family because of acute
confusion, fluctuating levels of consciousness, and visual hallucinations that began two days ago. He
has a history of mild cognitive impairment and Parkinson disease. On examination, he is disoriented to
time and place, and exhibits resting tremor, mild rigidity, and generalized bradykinesia. Which of the
following is the most likely underlying diagnosis?
A. Alzheimer disease dementia
B. Dementia with Lewy bodies
C. Delirium secondary to a urinary tract infection
D. Creutzfeldt-Jakob disease
CORRECT ANSWER: B. Dementia with Lewy bodies
Rationale: Dementia with Lewy bodies is characterized by fluctuating cognition, recurrent visual
hallucinations, and spontaneous parkinsonism (bradykinesia, resting tremor, rigidity) that typically
manifests concurrently with or before the onset of cognitive decline. While intercurrent medical illnesses
can precipitate delirium in patients with underlying neurodegenerative disorders, the constellation of
core features points specifically toward dementia with Lewy bodies. Patients with this condition are also
exquisitely sensitive to neuroleptic medications, which can cause severe extrapyramidal side effects.
Question 8: A 19-year-old male college athlete comes to the clinic for a routine pre-participation sports
physical examination. He reports no chest pain, shortness of breath, syncope, or palpitations. His
father died suddenly at the age of 42 while running. Physical examination reveals a grade 2/6
midsystolic murmur heard best at the lower left sternal border, which increases in intensity when the
patient performs the Valsalva maneuver. Which of the following is the most likely diagnosis?
A. Bicuspid aortic valve
B. Hypertrophic cardiomyopathy
C. Mitral valve prolapse
D. Coarctation of the aorta
CORRECT ANSWER: B. Hypertrophic cardiomyopathy
