ABFM ITE FINAL EXAM Questions with 100% correct Answers Latest Updates 2024 Grade A+ with, Exams of Community Corrections

Download ABFM ITE FINAL EXAM Questions with 100% correct Answers Latest Updates 2024 Grade A+ with and more Exams Community Corrections in PDF only on Docsity!

ABFM ITE FINAL EXAM Questions with 100%

correct Answers Latest Updates 2024 Grade A+

with Explanation

• A 42-year-old Asian male presents for follow-up of elevated blood pressure. He has no additional chronic medical problems and is otherwise asymptomatic. An examination is significant for a blood pressure of 162/95 mm Hg but is otherwise unremarkable. Laboratory Findings Sodium 138 mEq/L (N 135 - 145) Potassium 3.9 mEq/L (N 3.5-5.5) Fastingglucose 86mg/dLBUN 14 mg/dL (N 10-20) Creatinine 0.6mg/dL(N0.6-1.3) Urinemicroalbumin negative According to the American College of Cardiology/American Heart Association 2017 guidelines, which one of the following would be the most appropriate medication to initiate at this time? A) Clonidine (Catapres), 0.1 mg twice daily B) Hydralazine, 25 mg three times daily C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily D) Metoprolol tartrate (Lopressor), 25 mg twice daily E) Triamterene (Dyrenium), 50 mg daily {{Correct Ans- ANSWER: C Explanation This patient has hypertension and according to both JNC 8 and American College of Cardiology/American Heart Association 2017 guidelines, antihypertensive treatment should be initiated. For the general non-African-American population, monotherapy with an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a thiazide diuretic would be appropriate for initial management. It is also appropriate to initiate combination antihypertensive therapy as an initial management strategy, although patients should not take an ACE inhibitor and an angiotensin receptor blocker simultaneously. Studies have shown that blood pressure control is achieved faster with the initiation of combination therapy compared to monotherapy, without an increase in morbidity. Lisinopril/hydrochlorothiazide would be an appropriate choice in this patient. - Blockers, vasodilators, - blockers, and potassium-sparing diuretics are not recommended as initial choices for the treatment of hypertension.
• During rounds at the nursing home, you are informed that there are two residents on the unit with laboratory-confirmed influenza. According to CDC guidelines, who should receive chemoprophylaxis for influenza? A) Only symptomatic residents on the same unit

B) Only symptomatic residents in the entire facility C) All asymptomatic residents on the same unit D) All residents of the facility regardless of symptoms E) All staff regardless of symptoms {{Correct Ans- ANSWER: C Explanation In long-term care facilities, an influenza outbreak is defined as two laboratory-confirmed cases of influenza within 72 hours in patients on the same unit. The CDC recommends chemoprophylaxis for all asymptomatic residents of the affected unit. Any resident exhibiting symptoms of influenza should be treated for influenza and not given chemoprophylaxis dosing. Chemoprophylaxis is not recommended for residents of other units unless there are two laboratory-confirmed cases in those units. Facility staff of the affected unit can be considered for chemoprophylaxis if they have not been vaccinated or if they had a recent vaccination, but chemoprophylaxis is not recommended for all staff in the entire facility.

• A 24-year-old female presents with a 2 - day history of mild to moderate pelvic pain. She has had two male sex partners in the last 6 months and uses oral contraceptives and sometimes condoms. A physical examination reveals a temperature of 36.4°C (97.5°F) and moderate cervical motion and uterine tenderness. Urine hCG and a urinalysis are negative. Vaginal microscopy shows only WBCs. The initiation of antibiotics for treatment of pelvic inflammatory disease in this patient A) is appropriate at this time B) requires an elevated temperature, WBC count, or C-reactive protein level C) should be based on the results of gonorrhea and Chlamydia testing D) should be based on the results of pelvic ultrasonography {{Correct Ans- ANSWER: A Explanation Pelvic inflammatory disease (PID) is a clinical diagnosis, and treatment should be administered at the time of diagnosis and not delayed until the results of the nucleic acid amplification testing (NAAT) for gonorrhea and Chlamydia are returned. The clinical diagnosis is based on an at-risk woman presenting with lower abdominal or pelvic pain, accompanied by cervical motion, uterine, or adnexal tenderness that can range from mild to severe. There is often a mucopurulent discharge or WBCs on saline microscopy. Acute phase indicators such as fever, leukocytosis, or an elevated C-reactive protein level may be helpful but are neither sensitive nor specific. A positive NAAT is not required for diagnosis and treatment because an upper tract infection may be present, or the causative agent may not be gonorrhea or Chlamydia. PID should be considered a polymicrobial infection. Pelvic ultrasonography may be used if there is a concern about other pathology such as a tubo-ovarian abscess.

• A 24-year-old patient wants to start the process of transitioning from female to male. He has been working with a psychiatrist who has confirmed the diagnosis of gender dysphoria. Which one of the following would be the best initial treatment for this patient? A) Clomiphene B) Letrozole (Femara) C) Leuprolide (Eligard) D) Spironolactone (Aldactone) E) Testosterone {{Correct Ans- ANSWER: E Explanation For patients with gender dysphoria or gender incongruence who desire hormone treatment, the treatment goal is to suppress endogenous sex hormone production and maintain sex hormone levels in the normal range for their affirmed gender. For a female - to-male transgender patient this is most easily accomplished with testosterone. When testosterone levels are maintained in the normal genetic male range, gonadotropins and ovarian hormone production is suppressed, which accomplishes both goals for hormonal treatment without the need for additional gonadotropin suppression from medications such as leuprolide. Clomiphene can increase serum testosterone levels, but only in the presence of a functioning testicle. Letrozole is an estrogen receptor antagonist, but it would not increase serum testosterone levels. Spironolactone has androgen receptor blocking effects and would not accomplish either of the hormone treatment goals.
• Based on American Cancer Society guidelines for cervical cancer screening, when should HPV DNA co- testing first be performed along with Papanicolaou testing? A) At the onset of sexual activity B) At age 21 C) At age 25 D) At age 30 E) At age 35 {{Correct Ans- ANSWER: D

Explanation According to American Cancer Society guidelines for cervical cancer screening, Papanicolaou (Pap) testing should begin at age 21 irrespective of sexual activity and should be continued every 3 years until age 29. The preferred screening strategy beginning at age 30 is Pap testing with HPV co-testing, which should be continued every 5 years until age 65. Cervical screening may be discontinued at that time if the patient's last two tests have been negative and the patient was tested within the previous 5 years.

• Long-term proton pump inhibitor use is associated with an increased risk for A) Barrett's esophagus B) gout C) hypertension D) pneumonia E) type 2 diabetes {{Correct Ans- ANSWER: D Explanation Acid suppression therapy is associated with an increased risk of community-acquired and health care- associated pneumonia, which is related to gastric overgrowth by gram-negative bacteria. Long-term treatment of Barrett's esophagus is an indication for chronic proton pump inhibitor (PPI) use. PPI therapy does not increase the risk of gout, hypertension, or type 2 diabetes.
• An 87-year-old female comes to your office for an annual health maintenance visit. She appears cachectic and tells you that for the past 6 months she has had a decreased appetite and generalized muscle weakness. The patient is alert and oriented to person and place. She has a 10% weight loss, dry mucous membranes, and tenting of the skin on the extensor surface of her hands. While inflating the blood pressure cuff on her right arm you observe carpopedal spasms. Which one of the following is the most likely electrolyte disturbance? A) Hypercalcemia B) Hypocalcemia C) Hypokalemia D) Hypernatremia E) Hyponatremia {{Correct Ans- ANSWER: B

Explanation A Trousseau sign, defined as spasmodic contraction of muscles caused by pressure on the nerves that control them, is present in up to 94% of patients with hypocalcemia. Hypercalcemia is more likely to present with hyperreflexia. Patients with hypokalemia, hypernatremia, or hyponatremia may present with weakness and confusion, but tetany is not a common sign of either sodium or potassium imbalance.

• A 24-year old female presents to your office with a 3 - month history of difficulty sleeping. She says that she struggles to fall asleep and wakes up multiple times at night at least three times a week. She tries to go to bed at 10:00 p.m. and wakes up at 6:30 a.m. to start her day. She lies awake for an hour in bed before falling asleep and spends up to 2 hours awake in the middle of the night trying to fall back asleep. Lately she has been feeling fatigued and having difficulty concentrating at work. You conduct a full history and physical examination and tell her to return in 2 weeks with a sleep diary. At this follow-up visit you see from her diary that she is sleeping an average of 51⁄2 hours per night. Which one of the following would be the most appropriate recommendation? A) Set her alarm for 5:30 a.m. B) Add a mid-afternoon nap C) Move her bedtime to 9:00 p.m. D) Move her bedtime to 12:30 a.m. E) Stay up for an hour if she wakes up at 3:00 a.m. {{Correct Ans- ANSWER: D Explanation This patient presents with symptoms of chronic insomnia. Cognitive - behavioral therapy for insomnia (CBT-I) and brief behavioral therapy for insomnia (BBT-I) are effective nonpharmacologic treatments for chronic insomnia. Modified CBT-I and BBT-I can be administered by a primary care physician. The basic principles include stimulus control (sleep hygiene) and sleep restriction. Reducing time in bed increases sleep efficiency. In this case, 6 hours of time in bed would improve the patient's sleep efficiency and a bedtime of 12:30 a.m. would accomplish this goal. Generally, reduced time in bed is accomplished by postponing bedtime rather than getting up earlier. Naps generally do not improve sleep efficiency. While getting out of bed is recommended after being in bed for 30 minutes without falling asleep, or being awake for 30 minutes after being asleep, staying up for a prescribed period of time is not recommended.

• A 45-year-old female presents to the emergency department with a 1 - week history of facial swelling and progressive dyspnea with exertion. She was diagnosed 1 week ago with non-Hodgkin's lymphoma but her medical history is otherwise unremarkable. A chest radiograph is shown below. After hospital admission, which one of the following would be the most appropriate next step in the management of this condition? A) Intravenous antibiotics B) Urgent chemotherapy and radiation C) Urgent chemotherapy and plasmapheresis D) Urgent echocardiography E) Urgent bronchoscopy {{Correct Ans- ANSWER: B Explanation Because of the prevalence of cancer in the United States, it is important for family physicians to recognize oncologic emergencies. This patient presents with signs and symptoms related to superior vena cava syndrome, which is caused by compression of the superior vena cava. This is most often caused by lung cancer or lymphoma, but it can also be related to indwelling catheters, lymph nodes, or metastatic tumors. After ensuring that the patient is hospitalized and stable, the initial treatment options include intravenous corticosteroids, chemotherapy, radiation, and occasionally intravascular stenting. Antibiotics are not warranted because this condition is not the result of an infection. Hyperviscosity syndrome is another oncologic emergency associated with leukemia, multiple myeloma, and Waldenström's macroglobulinemia. It is treated with chemotherapy and plasmapheresis. Echocardiography and bronchoscopy are not indicated in the initial management of superior vena cava syndrome.
• A nonverbal 22-year-old male with intellectual disability is brought to your office by the staff of the group home where he lives. They report that the patient has been functioning at his baseline until this morning when he was found to have loud breathing. No other history is available at the time of this visit. On examination he has a temperature of 37.3°C (99.1°F), a blood pressure of 124/82 mm Hg, a pulse rate of 100 beats/min, and a respiratory rate of 16/min. The patient appears to be in mild distress and a high-pitched whistling, crowing sound on inspiration is heard as you walk in the room. Which one of the following would be the most appropriate next step for this patient? A) Oral antibiotics

B) Oral corticosteroids C) Nebulized albuterol D) Nebulized epinephrine E) Urgent evaluation in the emergency department {{Correct Ans- ANSWER: E Explanation Stridor is a high-pitched whistling, crowing sound on inspiration. It can be caused by obstruction of the larynx or trachea by a foreign body, vocal cord edema, a neoplasm, or a pharyngeal abscess. Acute stridor requires urgent evaluation for obstruction. This patient may have a foreign body or other obstruction in his airway and requires urgent assessment. Oral antibiotics, oral corticosteroids, nebulized albuterol, or nebulized epinephrine would not be appropriate at this time.

• A 16-year-old female presents with chronic acne on her nose, forehead, and chin consisting of a few comedones and a few mildly inflamed papules and pustules. She says it is minimally improved after 12 weeks of daily adapalene 0.1% gel. There are no scars or cysts. The patient would like to try to achieve better control. Which one of the following would you recommend at this time? A) Continue adapalene 0.1% gel for 12 more weeks B) Add clindamycin (Cleocin T) 1% gel for up to 12 weeks C) Add clindamycin 1% gel for maintenance D) Stop adapalene 0.1% gel and start clindamycin 1% gel for maintenance E) Stop adapalene 0.1% gel and start erythromycin 2% gel for maintenance {{Correct Ans- ANSWER: B Family physicians are often asked to manage mild to moderate acne vulgaris. Topical retinoids such as adapalene and benzoyl peroxide are first-line therapy and a trial of therapy is typically 8-12 weeks. Topical antibiotics may be added to topical retinoids or benzoyl peroxide to achieve better symptom control. To decrease emerging antibiotic resistance, studies support limiting antibiotic use to 12 weeks except in severe cases, not using antibiotics as monotherapy, and using clindamycin rather than erythromycin. Adding clindamycin gel rather than erythromycin gel for up to 12 weeks is recommended for this patient at this time.
• A 32-year-old female who is one of your longtime patients calls you because of a 24 - hour history of painful urination with urinary frequency and urgency. She is otherwise healthy and does not have any

fever, chills, back pain, or vaginal discharge. She uses an oral contraceptive pill and states that her last menstrual period was normal and occurred last week. Which one of the following would be most appropriate at this time? A) Empiric antibiotic treatment B) A urinalysis C) A urine culture D) Plain abdominal radiographs E) Pelvic ultrasonography {{Correct Ans- ANSWER: A This patient has symptoms of acute simple cystitis and does not have any symptoms that would suggest a complicated urinary tract infection or vaginal infection. In these cases treatment with oral antibiotic therapy may be prescribed without further evaluation (SOR B). Simple cystitis is a clinical diagnosis and a urinalysis and urine culture are not necessary. The patient does not have any symptoms that warrant evaluation with abdominal radiographs or pelvic ultrasonography.

• A 70-year-old female develops thrombocytopenia during a prolonged hospitalization for endocarditis. Her current medications include scheduled unfractionated heparin injections for venous thromboembolism prophylaxis. You suspect heparin-induced thrombocytopenia (HIT). Assuming that her thrombocytopenia is caused by HIT, which one of the following is the most likely complication? A) Anaphylaxis B) Disseminated intravascular coagulation C) Hemorrhage D) Sepsis E) Thrombosis {{Correct Ans- ANSWER: E Heparin-induced thrombocytopenia (HIT) is an immune-mediated process that occurs in approximately 1 in 5000 hospitalized patients. Patients are at highest risk 7-10 days after exposure to unfractionated heparin, and the risk is particularly high after cardiac surgery, which is associated with an estimated rate of 1%-3%. In contrast to other causes of thrombocytopenia, HIT places patients at a paradoxical ly increased risk of thrombotic complications, with clotting events occurring in roughly 50% of confirmed cases of HIT. Lower-extremity deep vein thrombosis and pulmonary embolism are the most common thrombotic complications, followed by arterial thrombose s, stroke, and myocardial infarction, in

descending order of frequency. Thromboses often occur concurrently with the development of thrombocytopenia or shortly thereafter. The risk of HIT can be determined with the 4T scoring system, which evaluates the acuity of thrombocytopenia, timing of onset, presence of thrombosis, and alternative causes of thrombocytopenia. Patients with an intermediate or high pretest probability should be managed with prompt discontinuation of heparin and initiation of full-dose anticoagulation with a non-heparin anticoagulant, such as argatroban, danaparoid, fondaparinux, or bivalirudin, pending results of further HIT diagnostic evaluation. Anaphylaxis, disseminated intravascular coagulation, hemorrhage, and sepsis are all less common complications of HIT compared to thrombotic events.

• You are asked for your advice as part of a committee formed by your local health system to focus on fall prevention. Based on U.S. Preventive Services Task Force recommendations, which one of the following interventions has the strongest evidence for preventing falls in community-dwelling older adults at increased risk for falls? A) Calcium supplementation B) Vitamin D supplementation C) Supportive footwear D) Exercise classes E) Cognitive-behavioral therapy {{Correct Ans- ANSWER: D In the United States falls are the leading cause of injury-related morbidity and mortality among older adults. The U.S. Preventive Services Task Force (USPSTF) concluded with moderate certainty that exercise interventions provide a moderate net benefit in fall prevention in community-dwelling adults 65 years of age or older who are at increased risk for falls (B recommendation). The USPSTF also concluded with moderate certainty that supplementation with calcium and vitamin D has no clear benefit in preventing falls in older adults. Environmental modifications and psychological interventions lack sufficient evidence for fall prevention.
• A 42-year-old male presents with a 10 - day history of hoarseness. He also has a 2-month history of reflux symptoms and has been taking antacids as needed. He does not take any other medications. There is no history of fever, weight loss, night sweats, or appetite changes. You note that the patient is hoarse, and a physical examination is normal, including HEENT, cardiovascular, and pulmonary examinations. He is a member of a community choir that rehearses twice a week. In addition to voice rest, which one of the following would be most appropriate at this time?

A) Supportive care only B) Azithromycin (Zithromax) C) Omeprazole (Prilosec) D) A course of prednisone {{Correct Ans- ANSWER: C This patient has hoarseness that has been present for less than 2 weeks. In addition to voice rest, treatment in patients with a history of GERD should include a 3- to 4-month trial of a high-dose proton pump inhibitor (SOR C). In patients with hoarseness lasting longer than 2 weeks without an apparent benign etiology, the larynx should be examined by direct or indirect laryngoscopy (SOR C). Antibiotics and oral corticosteroids should not be used for the empiric treatment of hoarseness in the absence of signs and symptoms that suggest an underlying cause.

• A 57 - year-old male with a history of heart failure sees you for follow-up. He describes symptoms of mild dyspnea on exertion with ordinary activities such as shopping or yard work. An echocardiogram shows an ejection fraction of 37%. According to the New York Heart Association criteria, this patient's heart failure would be classified as which one of the following? A) Class I B) Class II C) Class III D) Class IV {{Correct Ans- ANSWER: B The appropriate classification of heart failure is important for monitoring the disease. The most common currently used system is the New York Heart Association (NYHA) functional classification. In this system, class I is defined as heart disease in a patient with no symptoms and no limitations of physical activity. Patients with class II heart failure have mild symptoms with normal physical activity. Class III heart failure refers to significant limitations of activity, including symptoms with less than normal activities. Patients with class IV heart failure have symptoms at rest and are unable to carry on activity without discomfort.
• A 40-year-old runner presents with pain in the left leg. He is training for a marathon and has been increasing his running distance in recent weeks. He reports localized pain and swelling at the midpoint of the shin over the past 4 weeks that begins after a run and lasts for a few days, but now the swelling and tenderness have lasted for several days and there is severe pain when he tries to run. You suspect a tibial stress fracture.

Which one of the following imaging modalities would be indicated initially? A) A plain film B) Ultrasonography C) CT D) MRI E) Bone scintigraphy {{Correct Ans- ANSWER: A For a suspected tibial stress fracture, plain radiography is indicated as the initial imaging modality due to its availabilityand low cost. Its sensitivity is highest when symptoms have been present for at least 3 weeks, as in this case. Ultrasonography and CT are not indicated for this patient. If plain radiography is normal and further imaging is warranted, MRI or bone scintigraphy should be considered. Both modalities have a similar sensitivity, but MRI is preferred due to the greater specificity and ability to inform alternate diagnoses.

• A 24-year-old female presents with progressively worsening vulvar pain for 3 days. On examination a 3×3-cm tender, fluctuant mass is noted on the right labia minora. She had a similar episode of this problem last year. Which one of the following would be the most appropriate management? A) Expectant management B) Fine-needle aspiration C) Incision and drainage D) Marsupialization E) Excision under general anesthesia {{Correct Ans- ANSWER: D The most appropriate management of a recurrent Barthol in gland abscess would be marsupialization, which has a 0% recurrence rate at 6 months. Local anesthesia can be used in the office to effectively treat Bartholin gland abscesses and sedation is not required (SOR A). If the Bartholin gland abscess is > cm, referral to a gynecologist is recommended. Expectant management, fine-needle aspiration, or incision and drainage would likely lead to recurrence.
• Which one of the following should NOT be consumed during pregnancy due to a potentially high mercury content?

A) Catfish B) Crawfish, shrimp, and lobster C) Flounder and haddock D) Salmon and trout E) Shark and swordfish {{Correct Ans- ANSWER: E Larger ocean fish that consume other fish may accumulate mercury levels that can cause neurologic problems when consumed, so these fish should be avoided by children and pregnant or nursing women. Shark and swordfish are among the fish with the highest mercury content. Catfish, crawfish, shrimp, lobster, flounder, haddock, salmon, and trout have the least amount of mercury.

• An 18 - month-old female is brought to your office by her mother for evaluation of a cough. The patient has had low-grade fevers and a runny nose for 2 days. She now has a cough that is worse at night. On examination she has a temperature of 37.5°C (99.5°F), a pulse rate of 120 beats/min, a respiratory rate of 30/min, and an oxygen saturation of 92% on room air. She is noted to have hoarseness, mild inspiratory stridor, and a barking cough. She does not have drooling or a muffled voice. Which one of the following should be ordered to confirm the diagnosis? A) No further testing B) ACBC C) A viral culture D) Rapid antigen testing E) A radiograph of the neck {{Correct Ans- ANSWER: A This patient has croup, which is diagnosed clinicallyand no further testing is usually indicated. A CBC is nonspecific and is usually only indicated if a bacterial cause of stridor is suspected, such as bacterial tracheitis, epiglottitis, retropharyngeal abscess, or peritonsillar abscess. Viral cultures and rapid antigen testing should be reserved for instances in which the patient fails to respond as expected to initial treatment. A neck radiograph is not indicated in the absence of findings that suggest possible epiglottitis, such as drooling or a muffled voice.
• A 25-year-old male presents with a 4 - month history of crampy abdominal pain, diarrhea, and fatigue. His symptoms began gradually but have become more severe and he is now experiencing rectal bleeding. He says that his abdominal pain seems to temporarily improve after eating. He has smoked

five cigarettes per day for the past 8 years. He is surprised to learn that he has lost 7 kg (15 lb) when he is weighed today. His vital signs include a blood pressure of 116/70 mm Hg, a heart rate of 76 beats/min, a respiratory rate of 12/min, and a temperature of 37.7°C (99.9°F). A physical examination reveals abdominal tenderness and mild distention. An anorectal examination is significant for a perianal fistula. A laboratory evaluation is notable for mild anemia. His kidney and liver function are normal. Which one of the following is the most likely diagnosis? A) Celiac disease B) Chronic pancreatitis C) Crohn's disease D) Irritable bowel syndrome E) Ulcerative colitis {{Correct Ans- ANSWER: C Crohn's disease may present insidiouslywith diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and fatigue. Red-flag symptoms include perianal lesions, a first degree relative with inflammatory bowel disease, weight loss of 5% of the patient's usual weight, abdominal pain for more than 3 months, nocturnal diarrhea, fever, the absence of abdominal pain for 30 - 45 minutes after eating, and the absence of rectal urgency. This patient exhibits symptoms consistent with Crohn's disease. While anemia is also common in celiac disease, rectal bleeding is not. Chronic pancreatitis does not generally present with improved pain after eating. Irritable bowel syndrome is not associated with fever, rectal bleeding, anemia, or perianal fistulas. Ulcerative colitis is not associated with perianal lesions.

• A 34-year-old female at 32 weeks gestation presents with a right-sided, pounding headache that began 8 hours ago and is similar to headaches she has had in the past. She is sensitive to light and sound, and has vomited several times since the onset of pain. She has taken acetaminophen without relief. She takes prenatal vitamins but no other routine medications. On examination her blood pressure is normal. Which one of the following would be the most appropriate treatment for this patient? A) Dihydroergotamine B) Metoclopramide (Reglan) C) Naproxen D) Oxycodone (OxyContin) E) Sumatriptan (Imitrex) {{Correct Ans- ANSWER: B

Metoclopramide and acetaminophen are the only two medications considered safe for abortive migraine treatment during pregnancy (SOR B). The dopamine antagonist antiemetics are considered second-line abortive treatments in the general population. Dihydroergotamine should not be used during pregnancy due to its oxytocic properties and the potential risk of intrauterine growth restriction with its use. NSAIDs are not considered safe during pregnancy, particularly in the first and third trimesters. Opioids are only moderately useful for migraine treatment and should be avoided during pregnancy due to their abuse potential. Triptans are generally considered safe during the first trimester but not in the second and third trimesters. Their use has been associated with uterine atony, increased risk of bleeding during delivery, and increased risk of preterm birth.

• Which one of the following U-100 insulin products has the longest duration of action? A) Degludec (Tresiba) B) Glargine (Lantus) C) Isophane NPH (Humulin N) D) Lispro (Humalog) E) Regular (Humulin R) {{Correct Ans- ANSWER: A Among the available U-100 insulin products, the one with the longest duration of action is ultralong- acting degludec, which lasts 42 hours. The duration of action of rapid-acting lispro is 3 - 6.5 hours, short- acting regular is 5-8 hours, intermediate-acting isophane is 12-16 hours, and long-acting glargine is 11- 24 hours.
• When performing a geriatric assessment, which one of the following is an instrumental activity of daily living? A) Bathing B) Dressing C) Transferring between the bed and a chair D) Using the telephone E) Using the toilet {{Correct Ans- ANSWER: D The foundation of geriatric assessment is assessing the individual's ability to perform tasks required for living. Activities of daily living are self-care activities that are performed daily, such as eating, bathing, dressing, transferring between the bed and a chair, and toileting, including bladder and bowel function.

Instrumental activities of daily living include activities necessary to live independently, such as using a telephone, doing housework, preparing meals, taking medications properly, and managing finances.

• A 21-year-old female sees you for a medical evaluation prior to admission to a treatment program for anorexia nervosa. The effects of anorexia on the hypothalamic-pituitary axis can cause which one of the following? A) Bone loss B) Elevated testosterone C) Hyperglycemia D) Hypothyroidism E) Menorrhagia {{Correct Ans- ANSWER: A Anorexia has multiple effects on the hypothalamic-pituitary axis. Bone loss can be significant. In a study of 130 women, bone mineral density was reduced by at least 1.0 standard deviation at one or more skeletal sites in 92% of patients. Testosterone levels are often low, contributing to bone loss. Hypoglycemia, not hyperglycemia, can occur but this is not common. Anorexia often results in amenorrhea and infertility, and TSH and T4 levels may be normal or low.
• A 9-year-old male with a history of moderate persistent asthma is brought to the emergency department with an acute exacerbation. His symptoms began with a runny nose and nasal congestion 2 days ago. His parents state that he has not had any fevers or chills and he was eating and drinking well until a few hours ago when his breathing started to appear more labored. After multiple treatments with inhaled albuterol (Proventil, Ventolin) and oral prednisolone he remains tachypneic and wheezy. Which one of the following intravenous medications should be added to the patient's current treatment to reduce the likelihood of hospital admission? A) Ketorolac B) Magnesium sulfate C) Methylprednisolone D) Omalizumab (Xolair) E) Theophylline {{Correct Ans- ANSWER: B Children who present to the emergency department with an asthma exacerbation and fail to improve adequately with inhaled short-acting bronchodilators and corticosteroids may benefit from treatment

with intravenous (IV) magnesium sulfate. A 2016 Cochrane review of three randomized, controlled trials found that this reduced hospital admissions by 68%. Ketorolac is not known to have any benefit in the treatment of asthma. Oral administration of corticosteroids is as effective as IV administration, so there is no reason to give IV methylprednisolone. Omalizumab may be used to prevent exacerbations in patients with severe asthma who do not achieve adequate control with high-dose inhaled corticosteroids, but it has no role in the management of acute exacerbations. IV theophylline is not recommended for asthma exacerbations given its safety profile and poor efficacy compared to short- acting bronchodilators.

• A 10-year-old female is brought to your office for a sports preparticipation examination. You note thoracic rib asymmetry during the Adams forward bend test. Radiographs confirm rightward thoracolumbar scoliosis with a Cobb angle of 32°. Which one of the following would be most appropriate at this time? A) Genetic testing (ScoliScore) B) MRI of the thoracic and lumbar spine without contrast C) Scoliosis radiography in 1 year D) Referral to physical therapy E) Referral to a pediatric orthopedist {{Correct Ans- ANSWER: E This patient is a skeletally immature female with a Cobb angle that puts her at increased risk for progression (>29°). Referral to a spine specialist for consideration of bracing and appropriate follow - up is recommended. Genetic testing is available to help determine the risk of progression, but it is not a widely validated tool at this time. MRI does not provide any additional information to help with decision-making. Because of the patient's increased risk of progression, simple follow-up in 1 year is not recommended. Physical therapy is not indicated for the primary treatment of scoliosis.
• An 85-year-old nursing home patient with dementia who has bilateral hearing aids has been slightly more confused over the past 2 weeks according to the staff. He is also speaking at a louder volume than normal. He does not have any pain, but an examination shows impacted cerumen in both ears. Which one of the following would be most appropriate in the management of this patient? A) No therapy B) Irrigation of the ears with cold water C) Use of olive oil drops

D) Removal of the cerumen using peroxide E) Restraining the patient and attempting manual removal of the cerumen {{Correct Ans- ANSWER: D Removal of cerumen should be attempted when the patient has symptoms such as pain, tinnitus, hearing loss, or itching. Removal of the impaction is also indicated in patients who are not able to communicate about their symptoms, such as patients with developmental delay or dementia, a nonverbal patient who has had recent behavioral changes, or children with fever or speech delay. Cerumen impaction resulting in hearing loss can cause reversible cognitive impairment in older persons with dementia. Treatment options include irrigation with warm water, cerumenolytic agents such as carbamide peroxide otic, or manual removal if the patient is cooperative and if the procedure can be completed without the use of restraints. The use of cold water, olive oil drops, ear candling, or cotton - tipped swabs should be avoided.

• A previously healthy 18 - year-old female presents with finger pain. About 5 days ago she started to have mild burning of her left distal index finger. Two days later she developed worsening pain and redness of her fingertip. She does not remember injuring her finger or having a similar problem previously. On examination you note erythema of the medial palmar tip of her affected finger, with several vesicles that have opaque fluid in them. The distal digital pulp is soft but tender. Which one of the following is the most appropriate treatment for this condition? A) Warm water soaks B) Pain control and dressings C) Antibiotics D) Antifungals E) Incision and drainage {{Correct Ans- ANSWER: B This patient has herpetic whitlow, which is a viral infection of the distal finger caused by herpes simplex. Primary herpetic whitlow is generally a self-limited infection. The recommended treatment is pain management and keeping it covered with a dressing to prevent transmission. Warm water soaks are useful to manage superficial hand infections but are not indicated to treat herpetic whitlow. Herpetic whitlow is a viral infection, so antibiotics and antifungals would not be beneficial, although antibiotics would be appropriate if a secondary bacterial infection is suspected or if an abscess is confirmed by ultrasonography. Off-label use of antiviral medications should be considered only for patients with recurrent lesions, those with symptoms for less than 48 hours, and those who are immunocompromised. Incision and drainage should not be performed because it increases the risk of bacterial superinfection.

• A 52 - year-old gravida 4 para 4 presents with bothersome incontinence, predominantly with coughing and straining. In addition to a physical examination, urinalysis, and measurement of postvoid residual volume, which one of the following tests is recommended as part of the initial evaluation? A) Cough stress testing B) Urodynamic testing C) Pelvic ultrasonography with a vaginal probe D) Cystoscopy {{Correct Ans- ANSWER: A Cough stress testing helps detect urine leakage with coughing in patients with at least 200 - 300 cc of urine in the bladder or with the sensation of a full bladder. This test is recommended as part of the initial evaluation of women with symptoms of stress urinary incontinence. It has excellent sensitivity when compared to urodynamic testing. The initial evaluation could also include the cotton swab test (insertion of a lubricated swab into the urethra and evaluating angle change with the Valsalva maneuver). Urodynamic testing, pelvic ultrasonography, and cystoscopy are not recommended.
• The mother of a 1 - year-old child wants to know how useful influenza vaccine is for preventing influenza in young children. The influenza season is typically significant in your area and the child attends day care. You answer her question by explaining how many children need to be vaccinated in order to prevent one case of influenza. This statistic is referred to as the A) absolute risk reduction B) relative risk reduction C) number needed to treat D) number needed to harm E) prevalence {{Correct Ans- ANSWER: C The number needed to treat (NNT) is the number of patients that must be treated with a particular therapy to prevent one bad outcome. It is calculated as 1/absolute risk reduction (ARR) where the ARR is written as a decimal (if the ARR is 5%, the NNT = 1/0.05 = 20). ARR is the arithmetic difference in risk or outcome rates between the treatment group and the control group. The relative risk reduction indicates how much the risk or outcome was reduced in the treatment group compared to the control group. The number needed to harm is the number of patients necessary to receive an intervention instead of the alternative in order for one additional patient to experience an adverse event. Prevalence is the

proportion of a particular population found to be affected by a medical condition (SOR A). According to a recent Cochrane review, five children would need to receive influenza vaccination to prevent one case of influenza, and 12 children would need to be vaccinated to prevent influenza-like illness.

• A 45-year-old male comes to your office for a routine health maintenance examination. His medical history is significant for sarcoidosis, which was diagnosed 5 years ago during a workup for hilar adenopathy seen on a routine chest radiograph. He has been entirely asymptomatic for the past 2 years and has never required any treatment. Which one of the following annual screenings would be most appropriate? A) Bone density screening B) Echocardiography C) High-resolution CT of the chest D) An ophthalmologic examination E) A urinalysis {{Correct Ans- ANSWER: D There are numerous extrapulmonary manifestations of sarcoidosis that require periodic monitoring, even in asymptomatic patients. Because ocular involvement occurs in 20%-50% of patients and asymptomatic inflammation of the eye caused by sarcoidosis can cause permanent damage, an annual eye examination is very important. Anterior uveitis and keratoconjunctivitis are the most common symptomatic presentations of eye disease. Bone density screening is indicated for monitoring bone health during corticosteroid treatment. Cardiopulmonary manifestations of sarcoidosis are we ll known, but general testing, such as echocardiography or high-resolution CT of the chest, is reserved for the evaluation of symptoms, or possibly as a response to ongoing therapy. The genitourinary tract is generally not impacted by sarcoidosis and routine urine studies are not required.
• A 34-year-old female has a "bump" on her middle finger (shown below). She thinks it has been there approximately a month but says that it only recently began to bother her. She has not tried to treat it. This lesion is most likely a A) basal cell carcinoma B) dermatofibroma C) keratoacanthoma D) mucous cyst

E) wart {{Correct Ans- ANSWER: D This patient's lesion is a digital mucous cyst, also known as a cutaneous myxoid cyst. Mucous cysts most commonly occur on the dorsal surface of the distal phalanx. Toe lesions are less common. The etiology is controversial. Treatment options include intralesional corticosteroid injections, repeated puncture and drainage, or surgical excision (SOR A). The other options listed are unlikely to be found on the finger with the exception of a wart, which would have a verrucous texture and appearance. While basal cell carcinomas and dermatofibromas are also smooth and nodular, neither are common on the fingers. Keratoacanthomas are smooth, dome-shaped, red papules that often expand rapidly over a few weeks' time on sun-damaged skin and may have a central keratin plug. They are more common in older patients.

• A 73-year-old female sees you for the first time for a health maintenance visit. Her medical history includes hyperlipidemia, GERD, insomnia, and osteoarthritis, but she is otherwise healthy. Her estimated 10 - year risk of atherosclerotic cardiovascular disease is 14%. She lives independently. She has a past history of alcohol abuse but has not used alcohol in 20 years, and is a lifetime nonsmoker. Her current medication regimen includes aspirin, 81 mg once daily; melatonin, 3 mg at bedtime; acetaminophen, 500 mg three times daily; atorvastatin (Lipitor), 20 mg once daily; and famotidine (Pepcid), 20 mg once daily. Today her blood pressure is 130/70 mm Hg, pulse rate 72 beats/min, and oxygen saturation 95% on room air. Which one of the following changes to her current medication regimen would improve the likelihood of benefit and reduce the likelihood of harm? A) Stopping aspirin B) Stopping melatonin C) Stopping acetaminophen and starting diclofenac, 50 mg twice daily D) Stopping atorvastatin and starting rosuvastatin (Crestor), 40 mg at bedtime E) Stopping famotidine and starting omeprazole (Prilosec), 20 mg once daily {{Correct Ans- ANSWER: A This patient is generally healthy and highly functional at baseline. She has multiple medical problems but they are unlikely to significantly reduce her longevity. She has no known history of cardiovascular or cerebrovascular disease, so aspirin was being used for primary prevention. The U.S. Preventive Services Task Force (USPSTF) has stated that there is insufficient evidence to recommend for or against the use of aspirin for primary prevention of cardiovascular disease in adults over the age of 70. Since the USPSTF guidelines were published, evidence from two large randomized, controlled trials provided strong

support for the discontinuation of aspirin for most older adults without prior cardiovascular disease, with an indication that it increases the risk of all-cause mortality. In this patient at low to moderate risk who is already taking a statin, the risk of continuing aspirin exceeds the potential benefit. There is no indication for changing this patient from a moderate - intensity to a high-intensitystatin. For uncomplicated gastric reflux in older adults, H2-blockers are preferred over proton pump inhibitors, which are associated with an increased risk of infections and fractures. This patient has no concerns about osteoarthritis, and although she has a remote history of alcohol abuse, her dosing of daily acetaminophen is well below the threshold of concern for liver injury. Switching to an NSAID such as diclofenac would place her at risk for short-term and long-term renal complications. Melatonin is not known to have long-term adverse effects in older adults.

• A 14 - year-old female is brought to your office as a new patient for a routine well child examination. She has had very little medical care since the pre-kindergarten evaluation. She feels well and does not take any medications. Her past medical, surgical, family, and social histories are unremarkable. A review of systems is notable for no history of menstruation. An examination is notable for a height at the first percentile and a lack of any breast development. Laboratory studies reveal an elevated FSH level. Which one of the following would be the most appropriate next step? A) Follow-up every 3 - 6 months for assessment of pubertal development B) A corticotropin stimulation test C) Karyotyping D) Radiography of the hand for bone age E) MRI of the brain and pituitary {{Correct Ans- ANSWER: C Family physicians are often asked to evaluate delays in puberty. Underlying etiologies should be excluded in females >13 years of age who lack any breast development, which may signify delayed puberty. A past medical history and a physical examination, as well as a gonadotropin measurement, should be performed. The incidence of Turner syndrome (TS) is 1/3000 births. Females with TS lack normal X chromosome gene expression and typically have delayed puberty; amenorrhea; elevated FSH, reflecting hypogonadism; and short stature. Delayed diagnosis of TS is common, and short stature and delayed puberty are sometimes the only symptoms. This patient has unexplained short stature, delayed puberty, and an elevated FSH level, so karyotyping to rule out TS is the next step in evaluation. Ongoing surveillance after 13 years is not indicated and may delay therapy. A corticotropin stimulation test would usually be used to rule out Cushing syndrome in a setting of precocious puberty and would not be used in this situation. Radiography of the hand for bone age may support a finding of delayed growth (and thus support treatment with growth hormone for a TS patient), but would not provide

valuable diagnostic information in this scenario. An elevated FSH level is consistent with a functioning hypothalamus and pituitary and does not support obtaining MRI of the brain.

• A 42-year-old male sees you for follow-up after his third episode of pneumonia. He has no other significant medical history. He has never smoked, drinks alcohol occasionally, and has no other drug use or known exposures. A physical examination is normal. Pulmonary function tests demonstrate an FEV1 of 72% of predicted and an FEV1/FVC ratio of 0.68, which does not normalize with bronchodila tor administration. A chest radiograph shows hyperinflation but no other significant findings. Laboratory Findings Platelets 102,000/mm3 (N150,000-450,000) Creatinine 0.7mg/dL(N0.6-1.2) AST 56U/L(N8-48) ALT 43U/L(N7-55) Albumin 3.3g/dL(N3.5-5.0)Which one of the following conditions best explains this patient's abnormal findings? A) 1 - Antitrypsin deficiency B) Cystic fibrosis C) Goodpasture syndrome D) Hereditary hemochromatosis E) Sarcoidosis {{Correct Ans- ANSWER: A This patient is in his forties without clear risk factors and has both an irreversible obstructive pulmonary defect consistent with COPD (FEV1 <80% of predicted and an FEV1/FVC ratio <0.70) and liver abnormalities associated with advanced fibrosis. These combined findings are the hallmark of 1- antitrypsin deficiency. This patient has a high likelihood of advanced liver fibrosis based on the low albumin level and noninvasive scoring using the fibrosis- 4 (FIB-4) index (age × AST/(platelets [in mm3] × ALT1⁄2 = 3.52 for this patient). Further evaluation with transient elastography should be performed to confirm cirrhosis. Cystic fibrosis is less likely to cause a typical obstructive picture on pulmonary function tests (PFTs) and does not typically cause liver fibrosis. Goodpasture syndrome is a vasculitis that classically involves the lungs and the kidneys and is more likely to cause a restrictive pattern on PFTs. Hereditary hemochromatosis can cause early liver disease, including cirrhosis, but is not a significant cause of respiratory disease. Sarcoidosis may involve both the lung and the liver, and can cause obstructive or restrictive patterns on PFTs. However, this patient's radiograph did not show the characteristic hilar adenopathy and granulomatous disease of sarcoidosis.

• Which one of the following is most likely to cause a false-positive urine drug screen for amphetamines? A) Amlodipine (Norvasc) B) Bupropion (Wellbutrin) C) Levofloxacin (Levaquin) D) Pantoprazole (Protonix) E) Sertraline (Zoloft) {{Correct Ans- ANSWER: B False-positive results on drug testing can occur from cross-reactivity of commonly used medications with the assay. Multiple commonly used medications are known to cause a false - positive result for amphetamines, including bupropion, labetalol, ranitidine, and trazodone. Amlodipine is not implicated in abnormal drug screen results. Levofloxacin can cause a false-positive result for opioids. Proton pump inhibitors such as pantoprazole are known to cause a false-positive result for cannabinoids. Sertraline can cause a false-positive result for benzodiazepines.
• The U.S. Preventive Services Task Force recommends screening for depression for A) all adults B) all women but not men C) only adults with a family history of depression D) only adults with a known personal history of depression E) only adults with a history of disability, medical illness, complicated grief, chronic sleep disturbance, and/or loneliness {{Correct Ans- ANSWER: A Currently the U.S. Preventive Services Task Force recommends that all adults should be screened for depression, as it is one of the leading causes of disability in persons older than 15 years of age (B recommendation). The optimal interval is yet to be defined. Depression is more common in women, but screening is recommended for all adults. While a family history of depression, a personal history of depression, disability, medical illness, grief, sleep disturbance, and loneliness are all risk factors for depression, these factors do not need to be present to screen.
• A 62-year-old female sees you for a routine health maintenance examination. She has a history of breast cancer diagnosed 6 years ago that was treated with lumpectomy, radiation, and endocrine therapy. She is feeling well today and has no symptoms of concern. There is no family history of breast, ovarian, colon, or prostate cancers.

In addition to mammography, which one of the following annual tests would improve this patient's chance of survival? A) No tests B) CT of the chest C) MRI of the breast D) Breast ultrasonography E) A bone scan {{Correct Ans- ANSWER: A Breast cancer, the most common noncutaneous malignancy among women, has a 5 - year survival rate of almost 90%, so medical care of such patients is increasingly common. To help provide guidance to primary care physicians, the American Cancer Society and the American Society of Clinical Oncology published their joint Breast Cancer Survivorship Care Guideline in 2016. This guideline includes a recommendation for annual mammography for women with prior treatment for breast cancer to screen for local recurrence or a new primary breast cancer. MRI is not recommended in the absence of specific high-risk criteria such as a BRCA mutation. Similarly, other imaging modalities such as ultrasonography are not recommended in the absence of symptoms. Imaging is not indicated to screen for metastatic disease. Though breast cancer most commonly metastasizes to the lung, bone, and liver, there is no evidence that screening CT or a bone scan provides mortality or quality-of-life benefits.

• A 62-year-old male with hypertension presents to your office with substernal chest pain radiating into his left arm for the past 20 minutes. He also has diaphoresis and nausea. He has a blood pressure of 156/96 mm Hg, a pulse rate of 84 beats/min, and an oxygen saturation of 93% on room air. An EKG shows ST-segment elevations in leads V1 and V2. Your medical assistant calls 911 for immediate transport to the local hospital's emergency department. While awaiting the ambulance's arrival you give the patient low-dose aspirin and sublingual nitroglycerin. Which one of the following would be most appropriate regarding oxygen therapy at this time? A) No oxygen therapy B) Oxygen via nasal cannula at 2 L/min C) Oxygen via nasal cannula at 6 L/min D) 100% oxygen with a regular mask E) 100% oxygen with a nonrebreathing mask {{Correct Ans- ANSWER: A While oxygen supplementation is routinely initiated for patients who are suspected of having acute coronary syndrome, evidence does not support a benefit from this unless the patient is hypoxic. Oxygen

supplementation is recommended if the patient has an oxygen saturation <90%, if the patient is at risk for hypoxemia, or if the patient is in respiratory distress.

• You see an 89-year-old female with advanced dementia who has stopped eating. The patient's daughter asks you about the role of tube feeding in this situation. You discuss the risks and benefits. In patients with advanced dementia who have a feeding tube placed, there is evidence of increased A) nutritional status B) healing of pressure ulcers C) quality of life D) survival E) emergency department visits {{Correct Ans- ANSWER: E Eating problems in patients with advanced dementia are common and include oral dysphagia, pharyngeal dysphagia including aspiration, the inability to feed oneself, and refusal to eat. Patients with these symptoms should be examined for reversible causes such as dental problems. In the absence of a reversible cause, conservative measures such as altering food texture or offering small portions and high-calorie supplements may promote weight gain, although none of these interventions improve function or survival. Tube feeding patients who have advanced dementia has not been compared to hand feeding in randomized, controlled trials. Observational studies have shown no difference in survival, quality of life, nutritional status, functional status, the prevention of aspiration, or the prevention and healing of pressure ulcers between the two groups. Risks associated with feeding tubes include the risks associated with placement of the tube, including the chemical and physical restraint of patients who attempt to remove the tube. Once the tube is in place, tube blockages and dislodgments are common reasons for transfer to an emergency department (ED) for care, and in one study accounted for 47% of all ED visits by nursing home residents with advanced dementia.
• A 55-year-old male with a BMI of 32 kg/m2 presents to your office to discuss weight management. He has moderately well controlled type 2 diabetes and hypertension. He prefers not to modify his diet and would like to know if he can expect significant weight loss from exercising. He plans to walk briskly for 45 minutes daily. Which one of the following would be the best advice for this patient? A) Moderate exercise alone is ineffective for weight loss