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American Board of Family Medicine American Board of Family Medicine IN-TRAINING EXAMINATION TIME–4 HOURS Publication or reproduction in whole or in part is strictly prohibited. Copyright © 2013 The American Board of Family Medicine. All rights reserved. 1. A 52-year-old female with a history of hypertension and hypercholesterolemia presents with mild edema, weakness, and body aches. Her only medications are atorvastatin (Lipitor) and chlorthalidone. Her previously normal serum creatinine level is now 2.6 mg/dL (N 0.64–1.27). Her BUN level is 32 mg/dL (N 6–20) and her serum is clear without pigmentation. The urine dipstick is positive for blood, but a microscopic examination is negative for WBCs, RBCs, and casts. The most likely diagnosis is A) allergic interstitial nephritis B) glomerulonephritis C) hemolysis D) pyelonephritis E) rhabdomyolysis 2. A 36-year-old male with a history of ankylosing spondylitis and atrial fibrillation presents with a 3-week history of cough with hemoptysis, anorexia, night sweats, and an 11-lb weight loss. On examination he has rales in the right upper lobe, but there is no lymphadenopathy or hepatosplenomegaly. A chest radiograph shows a cavitary lesion in the right lung apex, with mediastinal hilar lymphadenopathy. His chronic disease symptoms have been well controlled with a combination of meloxicam (Mobic), adalimumab (Humira), esomeprazole (Nexium), ondansetron (Zofran), docusate sodium (Colace), and amiodarone (Cordarone). Which one of the patient’s medications is most likely contributing to his current problem? A) Adalimumab B) Amiodarone C) Esomeprazole D) Meloxicam E) Ondansetron 3. You have just finished giving a prescription with instructions to a 28-year-old male from El Salvador who speaks limited English. You gave the instructions with the aid of an interpreter, but are concerned that the patient might not fully understand them. Which one of the following is the best course of action? A) Refer the patient to a website about his condition B) Repeat the instructions slowly to the interpreter and ask him or her to speak clearly to the patient C) Contact a family member who speaks English and ask him or her to repeat the instructions to the patient D) Ask the patient to repeat the instructions to you in his own words 1 4. Which one of the following accurately describes the classic rash of erythema migrans? A) Scattered individual purple macules on the ankles and wrists B) An annular rash with a bright red outer border and partial central clearing C) A dry, scaling, dark red rash in the groin, with an active border and central clearing D) A diffuse eruption with clear vesicles surrounded by reddish macules E) A migratory pruritic, erythematous, papular eruption 5. A patient with chronic atrial fibrillation treated with dabigatran (Pradaxa) sees you for follow-up. She says she can no longer afford the dabigatran and would like to switch to warfarin (Coumadin). She has normal renal function. Which one of the following would be the most appropriate approach? A) Start warfarin and stop dabigatran when her INR is 2.0–3.0 B) Start warfarin now and stop dabigatran in 3 days C) Stop dabigatran, start warfarin, and start low molecular weight heparin and enoxaparin (Lovenox) every 12 hr until her INR is 2.0–3.0 D) Stop dabigatran for 24 hr and then start warfarin E) Hospitalize the patient, stop dabigatran, start warfarin, and treat with heparin until her INR is 2.0–3.0 6. A 27-year-old male requests your advice regarding colon cancer screening. His brother died of colon cancer, which was diagnosed at the age of 40. You suggest that he begin colonoscopy screening A) now B) at age 30 C) at age 40 D) at age 45 E) at age 50 7. Which one of the following is the major mechanism of action of metformin (Glucophage)? A) Stimulation of pancreatic insulin release B) Inhibition of glucose production by the liver C) Inhibition of carbohydrate absorption in the small intestine D) Improved insulin sensitivity of skeletal muscle 8. Which one of the following medications is most appropriate for treating moderate to severe shortness of breath in a hospice patient with lung cancer? A) Dexamethasone B) Haloperidol C) Scopolamine D) Morphine 2 9. A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic range. She has no symptoms of hypothyroidism. Which one of the following is the patient most likely to require if she becomes pregnant? A) A decreased dosage of levothyroxine B) An increased dosage of levothyroxine C) The addition of liothyronine (Cytomel) D) Substitution of desiccated thyroid hormone preparation (Armour Thyroid) for the levothyroxine 10. Which one of the following is considered to be the highest strength of recommendation by the Strength of Recommendation Taxonomy (SORT) used by family medicine journals? A) Expert opinion B) A consensus guideline C) A retrospective cohort study D) Multiple good quality randomized, controlled trials 11. Which one of the following tumors is most likely to cause hormonally induced hypercalcemia? A) Squamous cell carcinoma of the lung B) Pheochromocytoma C) Medullary thyroid cancer D) Prostatic carcinoma 12. A 32-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. On the ship they both ate the “usual foods” in addition to oysters. Findings on examination are negative, and a stool specimen is negative for white blood cells. Which one of the following is the most likely cause of his illness? A) Escherichia coli B) Rotavirus C) Norovirus D) Hepatitis A E) Giardia 3 13. A 47-year-old postmenopausal female falls while carrying groceries into her house and sustains a right distal radial fracture. A chemistry panel reveals a calcium level of 11.2 mg/dL (N 8.6–10.6) and further evaluation leads to a diagnosis of primary hyperparathyroidism. Which one of the following is the best course of treatment for this patient? A) Estrogen replacement therapy B) Long-term bisphosphonate therapy C) Daily furosemide treatment with increased oral fluids D) Elimination of calcium and vitamin D from the diet E) Referral to a surgeon for consideration of parathyroidectomy 14. Activated protein C resistance (factor V Leiden) is most commonly found in patients with A) hemolytic anemia B) carcinoma of the lung C) familial hypercholesterolemia D) venous thrombotic disease E) cystic fibrosis 15. Which one of the following is most consistent with a diagnosis of asthma? A) Reduced FEV1 and a decreased FEV1/FVC ratio B) Reduced FEV1 and a normal FEV1/FVC ratio C) Reduced FEV1 and an increased FEV1/FVC ratio D) Reduced FVC and a normal FEV1/FVC ratio E) Reduced FVC and an increased FEV1/FVC ratio 16. A 43-year-old female presents to your office 2 days after discovering a rash on her back, shown below. Which one of the following treatments will decrease her chances of developing long-term sequelae? A) Amitriptyline B) Gabapentin (Neurontin) C) Oral corticosteroids D) Topical corticosteroids E) Oral acyclovir (Zovirax) 4 17. You receive a telephone call from the mother of a 5-year-old female. The child has had diarrhea and a decreased appetite for the past 2 days. She is still playing some. The mother reports no vomiting, but says her daughter has complained of a dry mouth and does not have tears when she cries. You suspect that the child may be mildly dehydrated. Which one of the following would you advise? A) Increased water intake B) Clear liquids with sodium, such as chicken broth C) An over-the-counter oral rehydration solution D) Intravenous fluids in the emergency department E) Loperamide (Imodium) 18. A 42-year-old male with a history of chronic hepatitis C develops left leg cellulitis and is treated with cephalexin (Keflex). He returns to your office 5 days later for follow-up, and the cellulitis is responding favorably to treatment. However, the patient has a generalized maculopapular rash and a low-grade fever, which he says began 3 days ago. He also complains of arthralgias. You admit him to the hospital for further evaluation. His serum creatinine level is 3.2 mg/dL (N 0.6–1.5), which is elevated from his baseline level of 0.8 mg/dL. A urinalysis is normal, except for the presence of occasional eosinophils. The remainder of his evaluation, including liver enzyme levels and renal ultrasonography, is normal. Which one of the following is the most appropriate next step in the management of this patient? A) A postvoid residual urine volume B) A hepatitis C viral load and genotype C) Discontinuing cephalexin D) Antibiotics to cover methicillin-resistant Staphylococcus aureus (MRSA) E) Aggressive fluid resuscitation with normal saline 19. Which one of the following medications is most likely to cause hypokalemia? A) Albuterol (Proventil, Ventolin) B) Doxazosin (Cardura) C) Erythromycin D) Felodipine (Plendil) E) Lisinopril (Prinivil, Zestril) 5 20. An abandoned infant is brought to the hospital for evaluation. Based on the presence of a dried umbilical cord remnant and her overall appearance, you believe her to be no more than 5 days of age. A thorough examination is normal except for a finding of bilateral conjunctival erythema and exudate. A Gram stain of the exudate is remarkable for numerous WBCs, very few of which are noted to contain gram-negative diplococci. Which one of the following treatment options is most appropriate? A) Application of moist, warm saline eye compresses B) Irrigation of both eyes with povidone-iodine (Betadine) C) One-time application of ophthalmic erythromycin ointment into both eyes D) Instillation of silver nitrate solution into both eyes E) Intramuscular injection of ceftriaxone (Rocephin) 21.
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