ABFM STUDY TEST GUIDE : Questions
AND ANSWERS
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? - ANS 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 inducing antibiotic resistance and causing central nervous system side effects, QTc
prolongation, medication interactions, and tendon injuries. Probiotics have insufficient evidence
of benefit for preventing traveler's diarrhea
facial swelling + dyspnea in a patient with non Hodgkin lymphoma, with Chest Xray notable for
large hilar mass; In addition to hospitalization what would be the most appropriate urgent next
step? - ANS Radiation; This is an oncologic emergency with the patient presenting symptoms
of superior vena cava syndrome
After ensuring that the patient is hospitalized and stable, the initial treatment options include
intravenous corticosteroids, chemotherapy, radiation, and occasionally intravascular stenting.
What is hyperviscocity syndrome? - ANS Hyperviscosity syndrome is an oncologic emergency
associated with leukemia, multiple myeloma, and Waldenström macroglobulinemia. It is treated
with chemotherapy and plasmapheresis
What medications are involved in SMART therapy for asthma? - ANS single maintenance and
reliever therapy (SMART) approach for asthma control, combination therapy with an inhaled
corticosteroid and a long-acting bronchodilator is used as both controller and rescue medication
,Formoterol is the only medication available in the United States recommended for use in
SMART therapy due to its rapid onset of action (Budesonide/Formoterol, Symbicort)
What is an indication for long term rather than short term proton pump inhibitor therapy? - ANS
Gastroprotection in users of high dose NSAIDs at high risk for GI bleeding
In 2022 the American Gastroenterological Association published 10 best practice statements to
assist clinicians in addressing this issue. Key recommendations include regular review and
documentation of the indication for any ongoing PPI use, and to consider discontinuing PPIs for
any patient without a clear indication.
Strategies for PPI discontinuation include tapering or abrupt discontinuation. Rebound acid
hypersecretion can lead to a temporary increase in symptoms in either approach. If
deprescribing is attempted but not tolerated, patients may reasonably be continued on the
lowest effective dose
in, in some situations the benefits of PPIs do clearly outweigh the risks. Such indications include
Barrett esophagus, severe erosive esophagitis, eosinophilic esophagitis, and high risk for upper
gastrointestinal (GI) bleeding.
Risk factors for GI bleeding include prior ulcer, age >65, high-dose NSAID therapy, or
concurrent use of aspirin, corticosteroids, or anticoagulants. Such patients should be advised to
use PPIs indefinitely.
Greatest risk factor for alzheimers? - ANS age
Most appropriate initial pharmacotherapy for a temoporomandibular disorder in an otherwise
healthy 54 yo male? - ANS The initial first-line pharmacologic therapy for temporomandibular
disorders is naproxen. Cyclobenzaprine may also be added if there is evidence of muscle
spasm (A recommendation). If this is unsuccessful, other options include a trial of amitriptyline
or gabapentin. Opioid therapy is not appropriate first-line treatment for temporomandibular
disorders. Corticosteroid injections should be avoided due to potential cartilage damage (B
recommendation).
Most common causes of thyroiditis? - ANS Thyroiditis, a general term for inflammation of the
thyroid gland, is associated with thyroid gland dysfunction. It is classified based on clinical
symptoms: painless or painful, acute or subacute, and underlying etiology (medication-induced,
infection, radiation-induced, or autoimmune). The most common forms of thyroiditis include
Hashimoto, subacute, and postpartum. Thyroiditis often results in a triphasic disease pattern of
thyroid dysfunction: hyperthyroidism due to the release of preformed thyroid hormone from
damaged thyroid cells followed by hypothyroidism when the thyroid stores are depleted.
Eventually normal thyroid function is restored, or the patient develops permanent
hypothyroidism. This patient presents with symptoms commonly seen in thyroid disease. Further
, testing reveals elevated TSH and thyroid peroxidase (TPO) levels. Elevated TPO levels are
found in 95% of patients with Hashimoto thyroiditis. In addition, this patient's family history
includes rheumatoid arthritis, another autoimmune disease, making Hashimoto thyroiditis the
most likely diagnosis. Treatment is lifelong thyroid hormone therapy
Elevated TPO levels are found in 95% of patients with what type of thyroiditis? - ANS
Hashimotos
What kinds of medications are linked to thyroiditis? - ANS Several medications are linked to
thyroiditis, including lithium, amiodarone, interferon-alfa, interleukin-2, immune checkpoint
inhibitors, and tyrosine kinase inhibitors
When would post partum thyroiditis occur? - ANS s. Postpartum thyroiditis occurs within 1 year
of delivery, miscarriage, or medical abortion, not 2-3 years
How do you treat subacute thyroiditis? - ANS Subacute thyroiditis is self-limited and often
occurs after upper respiratory infections, causing thyroid pain and dysphagia due to
inflammatory destruction of thyroid follicles.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Sometimes corticosteroids, a beta-blocker, or both
Mild discomfort (eg, sore throat, mild neck tenderness, muscle aches, low-grade fever) is
treated with high doses of aspirin or NSAIDs. In moderately or severely symptomatic cases (eg,
high fever, tachycardia, shortness of breath), corticosteroids (eg, prednisone 15 to 30 mg orally
once a day, gradually decreasing the dose over 3 to 4 weeks) eradicate all symptoms within 48
hours.
Bothersome symptoms of hyperthyroidism may be treated with a short course of a beta-blocker.
If hypothyroidism is pronounced or persists, thyroid hormone replacement therapy may be
required, rarely permanently.
testicular cancer screening? - ANS Although testicular cancer is the most common solid cancer
in men ages 15-34, with effective treatment and an overall survival rate of 97%, the U.S.
Preventive Services Task Force recommends against screening for testicular cancer in
asymptomatic adolescent or adult males (D recommendation). A detailed history and physical
examination should be obtained in symptomatic patients, followed by scrotal ultrasonography if
there are positive findings on history and physical examination. Tumor markers and CT of the
abdomen and pelvis are required for staging, treatment recommendations, and surveillance, but
not for screening purposes.
82-year-old female in your palliative care service who has stage 4 breast cancer is experiencing
frequent episodes of delirium. Her pain is well controlled on long-acting oral opioid therapy.
Additionally, no other reversible causes of delirium are noted. Her delirium is not responding to
conservative measures, and her family asks if there are any medications that can effectively
manage her symptoms? - ANS The first step in managing delirium in end-of-life care is to
AND ANSWERS
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? - ANS 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 inducing antibiotic resistance and causing central nervous system side effects, QTc
prolongation, medication interactions, and tendon injuries. Probiotics have insufficient evidence
of benefit for preventing traveler's diarrhea
facial swelling + dyspnea in a patient with non Hodgkin lymphoma, with Chest Xray notable for
large hilar mass; In addition to hospitalization what would be the most appropriate urgent next
step? - ANS Radiation; This is an oncologic emergency with the patient presenting symptoms
of superior vena cava syndrome
After ensuring that the patient is hospitalized and stable, the initial treatment options include
intravenous corticosteroids, chemotherapy, radiation, and occasionally intravascular stenting.
What is hyperviscocity syndrome? - ANS Hyperviscosity syndrome is an oncologic emergency
associated with leukemia, multiple myeloma, and Waldenström macroglobulinemia. It is treated
with chemotherapy and plasmapheresis
What medications are involved in SMART therapy for asthma? - ANS single maintenance and
reliever therapy (SMART) approach for asthma control, combination therapy with an inhaled
corticosteroid and a long-acting bronchodilator is used as both controller and rescue medication
,Formoterol is the only medication available in the United States recommended for use in
SMART therapy due to its rapid onset of action (Budesonide/Formoterol, Symbicort)
What is an indication for long term rather than short term proton pump inhibitor therapy? - ANS
Gastroprotection in users of high dose NSAIDs at high risk for GI bleeding
In 2022 the American Gastroenterological Association published 10 best practice statements to
assist clinicians in addressing this issue. Key recommendations include regular review and
documentation of the indication for any ongoing PPI use, and to consider discontinuing PPIs for
any patient without a clear indication.
Strategies for PPI discontinuation include tapering or abrupt discontinuation. Rebound acid
hypersecretion can lead to a temporary increase in symptoms in either approach. If
deprescribing is attempted but not tolerated, patients may reasonably be continued on the
lowest effective dose
in, in some situations the benefits of PPIs do clearly outweigh the risks. Such indications include
Barrett esophagus, severe erosive esophagitis, eosinophilic esophagitis, and high risk for upper
gastrointestinal (GI) bleeding.
Risk factors for GI bleeding include prior ulcer, age >65, high-dose NSAID therapy, or
concurrent use of aspirin, corticosteroids, or anticoagulants. Such patients should be advised to
use PPIs indefinitely.
Greatest risk factor for alzheimers? - ANS age
Most appropriate initial pharmacotherapy for a temoporomandibular disorder in an otherwise
healthy 54 yo male? - ANS The initial first-line pharmacologic therapy for temporomandibular
disorders is naproxen. Cyclobenzaprine may also be added if there is evidence of muscle
spasm (A recommendation). If this is unsuccessful, other options include a trial of amitriptyline
or gabapentin. Opioid therapy is not appropriate first-line treatment for temporomandibular
disorders. Corticosteroid injections should be avoided due to potential cartilage damage (B
recommendation).
Most common causes of thyroiditis? - ANS Thyroiditis, a general term for inflammation of the
thyroid gland, is associated with thyroid gland dysfunction. It is classified based on clinical
symptoms: painless or painful, acute or subacute, and underlying etiology (medication-induced,
infection, radiation-induced, or autoimmune). The most common forms of thyroiditis include
Hashimoto, subacute, and postpartum. Thyroiditis often results in a triphasic disease pattern of
thyroid dysfunction: hyperthyroidism due to the release of preformed thyroid hormone from
damaged thyroid cells followed by hypothyroidism when the thyroid stores are depleted.
Eventually normal thyroid function is restored, or the patient develops permanent
hypothyroidism. This patient presents with symptoms commonly seen in thyroid disease. Further
, testing reveals elevated TSH and thyroid peroxidase (TPO) levels. Elevated TPO levels are
found in 95% of patients with Hashimoto thyroiditis. In addition, this patient's family history
includes rheumatoid arthritis, another autoimmune disease, making Hashimoto thyroiditis the
most likely diagnosis. Treatment is lifelong thyroid hormone therapy
Elevated TPO levels are found in 95% of patients with what type of thyroiditis? - ANS
Hashimotos
What kinds of medications are linked to thyroiditis? - ANS Several medications are linked to
thyroiditis, including lithium, amiodarone, interferon-alfa, interleukin-2, immune checkpoint
inhibitors, and tyrosine kinase inhibitors
When would post partum thyroiditis occur? - ANS s. Postpartum thyroiditis occurs within 1 year
of delivery, miscarriage, or medical abortion, not 2-3 years
How do you treat subacute thyroiditis? - ANS Subacute thyroiditis is self-limited and often
occurs after upper respiratory infections, causing thyroid pain and dysphagia due to
inflammatory destruction of thyroid follicles.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Sometimes corticosteroids, a beta-blocker, or both
Mild discomfort (eg, sore throat, mild neck tenderness, muscle aches, low-grade fever) is
treated with high doses of aspirin or NSAIDs. In moderately or severely symptomatic cases (eg,
high fever, tachycardia, shortness of breath), corticosteroids (eg, prednisone 15 to 30 mg orally
once a day, gradually decreasing the dose over 3 to 4 weeks) eradicate all symptoms within 48
hours.
Bothersome symptoms of hyperthyroidism may be treated with a short course of a beta-blocker.
If hypothyroidism is pronounced or persists, thyroid hormone replacement therapy may be
required, rarely permanently.
testicular cancer screening? - ANS Although testicular cancer is the most common solid cancer
in men ages 15-34, with effective treatment and an overall survival rate of 97%, the U.S.
Preventive Services Task Force recommends against screening for testicular cancer in
asymptomatic adolescent or adult males (D recommendation). A detailed history and physical
examination should be obtained in symptomatic patients, followed by scrotal ultrasonography if
there are positive findings on history and physical examination. Tumor markers and CT of the
abdomen and pelvis are required for staging, treatment recommendations, and surveillance, but
not for screening purposes.
82-year-old female in your palliative care service who has stage 4 breast cancer is experiencing
frequent episodes of delirium. Her pain is well controlled on long-acting oral opioid therapy.
Additionally, no other reversible causes of delirium are noted. Her delirium is not responding to
conservative measures, and her family asks if there are any medications that can effectively
manage her symptoms? - ANS The first step in managing delirium in end-of-life care is to
