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ABFM CKSA 22-23 QUESTIONS AND ANSWERS
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ABFM CKSA 22-23 QUESTIONS AND ANSWERS
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ABFM CKSA 22-23 QUESTIONS
AND ANSWERS
A 56-year-old male with a history of hepatitis C cirrhosis is admitted to the hospital with
GI bleeding. The patient has been stable, taking only furosemide and spironolactone.
Upper GI endoscopy confirms variceal bleeding and the gastroenterologist performs
appropriate variceal banding. A nurse calls you because laboratory studies ordered in
the emergency department reveal a serum ammonia level of 120 µg/dL (N 39-90). The
patient has no signs of confusion, insomnia, or decreased mental alertness. A physical
examination reveals mild ascites but no other abnormalities. Which one of the following
would be most appropriate for addressing the elevated ammonia level?
A. Lactulose
B. No additional treatment
C. Methotrexate
D. Neomycin
E. Prednisone - Answers-ANSWER: B
Elevated ammonia levels may occur in multiple clinical scenarios (i.e. portosystemic
shunting, UTI from urease-producing organisms, GI bleeding, shock, renal disease,
parenteral nutrition, salicylate intoxication, alcohol use). In patients with chronic liver
disease, hepatic encephalopathy is diagnosed based on the overall clinical presentation
and not by an ammonia level. It is important to remember that a normal ammonia level
neither excludes nor confirms the diagnosis of hepatic encephalopathy. This patient had
an elevated serum ammonia level that was found incidentally during his hospital
admission for gastrointestinal bleeding. Because there is no clinically significant
encephalopathy, treatment based on ammonia levels is not indicated. Lactulose,
methotrexate, neomycin, or prednisone would not be appropriate.
A 5-year-old male is brought to your office after passing an intestinal worm. He lives on
a farm with cattle, pigs, and dogs. He has never traveled very far from home. He does
not have any respiratory symptoms or diarrhea, but has experienced some abdominal
,bloating. His parents bring a picture of the worm (shown below). Which one of the
following is the infecting organism? - Answers-A. Ascaris lumbricoides (roundworm)
B. Enterobius vermicularis (pinworm)
C. Giardia lamblia
D. Necator americanus (hookworm)
E. Taenia solium (tapeworm)
.
ANSWER: A
This case and image are consistent with Ascaris lumbricoides infestation. A.
lumbricoides is a large roundworm that typically infects the ileum. Symptoms are
variable but large infections can lead to intestinal obstruction.
Pinworms (Enterobius vermicularis) are much smaller and typically present with anal
pruritus. Giardia lamblia is a microscopic protozoan parasite that is not visible on gross
examination. Hookworms (Necator americanus) are also round, but are typically 6-12
mm in length. They are a significant cause of anemia in children globally. Tapeworms
can be large, but are flat and segmental in appearance, and are typically found in the
stool as segments called proglottids.
A 58-year-old male with a history of tobacco use disorder and alcohol use disorder
presents with the sudden onset of many well circumscribed brown, oval, rough papules
with a "stuck-on" appearance on his trunk and proximal extremities (see image). On
examination you also note an unintentional 6-kg (13-lb) weight loss over the last 3
months and conjunctival pallor. A review of systems is positive for abdominal pain,
decreased appetite, and mild fatigue. You order a laboratory workup. Which one of the
following would be most appropriate at this point? - Answers-A. Reassurance that the
skin lesions are benign
B. A skin biopsy
C. Referral to a dermatologist
D. CT of the abdomen and pelvis
E. Upper and lower endoscopy
.
.
.ANSWER: E
The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic
keratoses, which is an unusual finding that often indicates an underlying malignancy,
most commonly an adenocarcinoma of the stomach. This patient's age, risk factors, red-
flag symptoms, and other clinical findings indicate the need for endoscopy.
Further skin evaluation and lifestyle changes, which are indicated, will not address the
need for evaluation of weight loss and other abnormal symptoms and findings. CT is not
an initial approach for diagnosing a suspected malignancy of the stomach or colon.
A 46-year-old female with a past medical history of polycystic ovary syndrome and
migraine headaches presents with bilateral, hyperpigmented patches along her
,mandible. The patches are asymptomatic but bother her cosmetically and seem to be
darkening. Which one of her medications would be most likely to contribute to her
melasma?
A. B-complex vitamins
B. Metformin
C. Oral contraceptives
D. Spironolactone (Aldactone)
E. Sumatriptan (Imitrex) - Answers-ANSWER: C
Melasma is a progressive, macular, nonscaling hypermelanosis of skin exposed to the
sun, typically involving the face and more rarely the dorsal forearms. It is often
associated with pregnancy and the use of oral contraceptives or anticonvulsants.
Although thought previously to involve only activation of melanocytes, it is now seen as
a complex syndrome involving an interplay of keratinocytes, dermal mast cells, gene
regulation, and vascular changes. Women are more likely to be affected than men, and
darker-skinned individuals with Fitzpatrick skin types III-IV are more commonly affected.
There are three common patterns of melasma that are described: centrofacial, malar,
and mandibular, although most clinical cases are not clearly one type only.
Initial treatment of melasma may include sun protection and discontinuation of any
provoking medications. Traditionally, melasma has been treated with topical agents
such as hydroquinone, tretinoin, and corticosteroids, or combinations of these agents.
Tranexamic acid has gained popularity as a systemic therapy for melasma and is
available in oral, topical, and injectable forms.
A 33-year-old female presents with palpitations and excessive sweating. A physical
examination is normal. Laboratory findings include a TSH (thyrotropin) level of 0.02
µU/mL (N 0.40-4.00) and a free T4 level of 3.9 ng/dL (N 0.7-1.9). Radionuclide scanning
reveals no uptake. Which one of the following would explain these findings?
A. Thyroid hormone resistance
B. Graves disease
C. A toxic nodular goiter
D. Excess thyroid hormone intake
E. A thyrotropin-secreting pituitary tumor - Answers-ANSWER: D
Excess thyroid hormone intake would cause a low TSH (thyrotropin) level with a high
free T4 level and no uptake on radionuclide scan. Other possibilities include an hCG-
secreting tumor and the thyrotoxic phase of subacute thyroiditis.
An elevated TSH (thyrotropin) level would be seen with thyroid-hormone resistance or a
thyrotropin-secreting pituitary tumor. Graves disease causes a homogeneous increased
thyroid uptake on radionuclide scanning, whereas a hot nodule would be expected with
a toxic nodular goiter.
, A 60-year-old male with type 2 diabetes comes to your office with an acute onset of
fever, chills, and malaise. He says that he is feeling progressively worse. His
temperature is 40.0°C (104.0°F). An examination reveals redness, tenderness, and
swelling of the penis, scrotum, and perineal area. Which one of the following
medications is most likely to predispose this patient to this condition?
A. Empagliflozin
B. Exenatide
C. Insulin glargine
D. Pioglitazone
E. Sitagliptin - Answers-ANSWER: A
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) are
associated with a higher rate of genitourinary infections. Most often these are fungal in
etiology, however there are associations with more serious infections including
necrotizing fasciitis of the perineum (Fournier's gangrene). While rare, this is a life-
threatening infection associated with this class of medication that is being used more
frequently to treat diabetes mellitus and other cardiac conditions. Because of this risk,
the FDA issued a Drug Safety Warning in 2018.
The drug classes that include exenatide, insulin glargine, pioglitazone, and sitagliptin
are not associated with genitourinary infections.
A 55-year-old female presents to your office because she has intermittent locking of her
right ring (fourth) finger when it is flexed. It is painful and she often has to use her other
hand to extend the finger. Her job involves repetitive movement of her hands and she
requests a treatment option that will involve as little missed time from work as possible.
Which one of the following would be the most cost-effective option? - Answers-A. A
course of oral NSAIDs
B. A corticosteroid injection
C. Splinting of the distal interphalangeal joint
D. Physical therapy
E. Surgical correction
.
NSWER: B
Trigger finger is a common reason for referral to a hand surgeon. Risk factors for this
condition include trauma, overuse, diabetes mellitus, and carpal tunnel syndrome. It is
much more common in women than in men and the average age of onset is 58. Trigger
finger develops when there is scarring and inflammation of the A1 pulley, the first of a
five-pulley system in the hand. Stenosis of the A1 canal or nodules on the tendon can
produce locking, cracking, and pain when the digit is flexed.
The most cost-effective treatment strategy is the use of corticosteroid injections. The
success rate is 57% after the initial injection and 86% following the second injection
within a 6-month time frame. NSAID injections with diclofenac or ketorolac are also an
option and have similar outcomes to corticosteroid injections. When the problem is mild,
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