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Trắc nghiệm ABFM 2022
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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 work shows that his BMP is within normal limits.
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
ANSWER: C
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.
Alpha blockers, vasodilators, beta-blockers, and potassium-sparing diuretics are not
recommended as initial choices for the treatment of hypertension.
A 36-year-old female presents for evaluation of elevated blood pressure. She is
asymptomatic and does not take any medications. On examination her blood pressure
is 160/96 mm Hg and her BMI is 26 kg/m2. Fasting laboratory studies include the
following:
Sodium 142.
Potassium 3.0.
Creatinine 0.76.
Glucose 97.
Which one of the following additional laboratory evaluations should be performed to
assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level
ANSWER: B
Primary hyperaldosteronism should be suspected as a cause for hypertension if a
patient has a spontaneously low potassium level or persistent hypertension despite the
use of three or more antihypertensive medications, including a diuretic. This can be
evaluated by checking a serum renin activity level and a serum aldosterone
concentration and determining the aldosterone/renin ratio. Primary hyperaldosteronism
typically presents with a very low serum renin activity level and an elevated serum
aldosterone concentration.
A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA) would be used to
evaluate for a neuroendocrine tumor, which can present as chronic flushing and
diarrhea. Cortisol levels can be checked if Cushing syndrome is suspected.
Hypertension can be present in Cushing syndrome, but it is typically associated with
other signs such as obesity and an elevated blood glucose level due to insulin
resistance. Cystatin C is a marker of renal function and measurement would not be
indicated given this patient's normal creatinine level.
A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a rash on
the extensor surfaces of his lower legs consisting of painful, subcutaneous,
nonulcerated, erythematous nodules. This rash is consistent with which one of the
following?
A) Erythema ab igne
B) Erythema infectiosum
C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum
ANSWER: E
Erythema nodosum, a panniculitis that typically affects the subcutaneous fat on the
anterior surface of the lower legs, is associated with coccidioidomycosis (valley fever)
and can suggest the diagnosis. It is a manifestation of the patient's immune response
and often indicates a good prognosis. In addition to coccidioidomycosis, it can also be
associated with streptococcal infections as well as tuberculosis.
Erythema ab igne is a cutaneous rash caused by prolonged heat exposure (such as a
heating pad) presenting as an otherwise asymptomatic, red, reticulated pattern on the
skin. Erythema infectiosum is associated with parvovirus B19 infection and is usually
seen in young children. It manifests as an erythematous rash of the face (slapped cheek
appearance), arms, and legs. Erythema migrans is an expanding, erythematous,
annular rash with or without central clearing and is often associated with tick exposure
(Lyme disease). Erythema multiforme consists of raised, annular, target-like lesions with
central erythema and is usually associated with herpes simplex virus type 1.
A 50-year-old male presents with chronic abdominal pain. A workup leads you to
suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small
duodenal ulcer. The endoscopist also notes some small esophageal varices without red
wale signs.
Further evaluation confirms that the patient has compensated cirrhosis in the setting of
alcohol use disorder. He readily accepts this diagnosis and enters an Alcoholics
Anonymous program. His ulcer symptoms resolve with antibiotic therapy for
Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would
like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his esophageal varices would be:
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1-2 years
ANSWER: E
Primary prevention of variceal hemorrhage is an important consideration in the
management of patients with cirrhosis. Although this patient's varices were diagnosed
incidentally, patients with cirrhosis and clinically significant portal hypertension should
be screened for varices every 2-3 years with esophagogastroduodenoscopy (EGD).
EGD can be deferred in patients with platelet counts <150,000/mm3 and transient
elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the
criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of
bleeding. Findings associated with a high risk of bleeding include small varices in
patients with decompensated cirrhosis, small varices with red wale signs (thinning of the
variceal wall), and medium to large varices. Patients with small varices not meeting
these criteria have a low risk of hemorrhage and do not require prophylaxis. They
should be rescreened with EGD every 1-2 years.
For patients requiring treatment due to high-risk features, options for primary
prophylaxis of hemorrhage include nonselective -blockers such as propranolol or
endoscopic variceal ligation. Treatment decisions are based on patient preference,
other potential contraindications, and local resources. The need for repeat endoscopy in
these cases will depend on the clinical circumstances. If nonselective -blockers are
used, they should be continued indefinitely. Octreotide is only given intravenously for
acute hemorrhage. There is no evidence that omeprazole slows the progression of
esophageal varices.
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 work shows that his BMP is within normal limits.
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
ANSWER: C
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.
Alpha blockers, vasodilators, beta-blockers, and potassium-sparing diuretics are not
recommended as initial choices for the treatment of hypertension.
A 36-year-old female presents for evaluation of elevated blood pressure. She is
asymptomatic and does not take any medications. On examination her blood pressure
is 160/96 mm Hg and her BMI is 26 kg/m2. Fasting laboratory studies include the
following:
Sodium 142.
Potassium 3.0.
Creatinine 0.76.
Glucose 97.
Which one of the following additional laboratory evaluations should be performed to
assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level
ANSWER: B
Primary hyperaldosteronism should be suspected as a cause for hypertension if a
patient has a spontaneously low potassium level or persistent hypertension despite the
use of three or more antihypertensive medications, including a diuretic. This can be
evaluated by checking a serum renin activity level and a serum aldosterone
concentration and determining the aldosterone/renin ratio. Primary hyperaldosteronism
typically presents with a very low serum renin activity level and an elevated serum
aldosterone concentration.
A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA) would be used to
evaluate for a neuroendocrine tumor, which can present as chronic flushing and
diarrhea. Cortisol levels can be checked if Cushing syndrome is suspected.
Hypertension can be present in Cushing syndrome, but it is typically associated with
other signs such as obesity and an elevated blood glucose level due to insulin
resistance. Cystatin C is a marker of renal function and measurement would not be
indicated given this patient's normal creatinine level.
A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a rash on
the extensor surfaces of his lower legs consisting of painful, subcutaneous,
nonulcerated, erythematous nodules. This rash is consistent with which one of the
following?
A) Erythema ab igne
B) Erythema infectiosum
C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum
ANSWER: E
Erythema nodosum, a panniculitis that typically affects the subcutaneous fat on the
anterior surface of the lower legs, is associated with coccidioidomycosis (valley fever)
and can suggest the diagnosis. It is a manifestation of the patient's immune response
and often indicates a good prognosis. In addition to coccidioidomycosis, it can also be
associated with streptococcal infections as well as tuberculosis.
Erythema ab igne is a cutaneous rash caused by prolonged heat exposure (such as a
heating pad) presenting as an otherwise asymptomatic, red, reticulated pattern on the
skin. Erythema infectiosum is associated with parvovirus B19 infection and is usually
seen in young children. It manifests as an erythematous rash of the face (slapped cheek
appearance), arms, and legs. Erythema migrans is an expanding, erythematous,
annular rash with or without central clearing and is often associated with tick exposure
(Lyme disease). Erythema multiforme consists of raised, annular, target-like lesions with
central erythema and is usually associated with herpes simplex virus type 1.
A 50-year-old male presents with chronic abdominal pain. A workup leads you to
suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small
duodenal ulcer. The endoscopist also notes some small esophageal varices without red
wale signs.
Further evaluation confirms that the patient has compensated cirrhosis in the setting of
alcohol use disorder. He readily accepts this diagnosis and enters an Alcoholics
Anonymous program. His ulcer symptoms resolve with antibiotic therapy for
Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would
like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his esophageal varices would be:
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1-2 years
ANSWER: E
Primary prevention of variceal hemorrhage is an important consideration in the
management of patients with cirrhosis. Although this patient's varices were diagnosed
incidentally, patients with cirrhosis and clinically significant portal hypertension should
be screened for varices every 2-3 years with esophagogastroduodenoscopy (EGD).
EGD can be deferred in patients with platelet counts <150,000/mm3 and transient
elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the
criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of
bleeding. Findings associated with a high risk of bleeding include small varices in
patients with decompensated cirrhosis, small varices with red wale signs (thinning of the
variceal wall), and medium to large varices. Patients with small varices not meeting
these criteria have a low risk of hemorrhage and do not require prophylaxis. They
should be rescreened with EGD every 1-2 years.
For patients requiring treatment due to high-risk features, options for primary
prophylaxis of hemorrhage include nonselective -blockers such as propranolol or
endoscopic variceal ligation. Treatment decisions are based on patient preference,
other potential contraindications, and local resources. The need for repeat endoscopy in
these cases will depend on the clinical circumstances. If nonselective -blockers are
used, they should be continued indefinitely. Octreotide is only given intravenously for
acute hemorrhage. There is no evidence that omeprazole slows the progression of
esophageal varices.
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