ABFM ITE COMPLETE EXAM TEST WITH 100
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES
1. An 85-year-old female with a previous history of diabetes mellitus, hypertension,
dementia, and peptic ulcer disease has been in a skilled nursing facility for 4 weeks for
rehabilitation after a hip fracture repair secondary to a fall during an ischemic stroke. She is
transported to the emergency department today when she develops confusion, shortness of
breath, and diaphoresis. Her blood pressure is 172/98 mm Hg, her heart rate is 122 beats/min
with an irregular rhythm, and her respiratory rate is 22/min. An EKG demonstrates atrial
fibrillation and 0.2 mV ST-segment elevation compared to previous EKGs. Her first troponin
level is elevated.
Which one of the following conditions in this patient is considered an ABSOLUTE
contraindication to fibrinolytic therapy?
A) Poorly controlled hypertension
B) Peptic ulcer disease
C) Alzheimer's dementia
D) Hip fracture repair
E) Ischemic stroke --CORRECT ANSWER--ANSWER: E
A history of an ischemic stroke within the past 3 months is an absolute contraindication to
fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI), unless
the stroke is diagnosed within 41⁄2 hours. Poorly controlled hypertension, dementia, peptic
ulcer disease, and major surgery less than 3 weeks before the STEMI are relative
contraindications that should be considered on an individual basis.
Page | 1
,2. An otherwise healthy 57-year-old female presents with a sudden onset of hearing loss. She
awoke this morning unable to hear out of her left ear. There was no preceding illness and she
currently feels well otherwise. She does not have ear pain, headache, runny nose, congestion,
or fever, and she does not take any daily medications.
On examination you note normal vital signs and find a normal ear, with no obstructing
cerumen and with normal tympanic membrane motion on pneumatic otoscopy. You perform
a Weber test by placing a tuning fork over her central forehead. She finds that the sound
lateralizes to her right ear. The Rinne test shows sounds are heard better with bone
conduction on the left and with air conduction on the right.
You refer her to an otolaryngologist for further evaluation including audiometry. You should
also consider initiating which one of the following medications at this visit in order to optim -
-CORRECT ANSWER--ANSWER: E
This patient has sudden sensorineural hearing loss (SSNHL) of the left ear without any
accompanying features to suggest a clear underlying cause. An appropriate evaluation will
fail to identify a cause in 85%-90% of cases. Idiopathic SSNHL can be diagnosed if a patient
is found to have a 30-dB hearing loss at three consecutive frequencies and an underlying
condition is not identified by the history and physical examination.
The most recent guideline from the American Academy of Otolaryngology-Head and Neck
Surgery recommends that oral corticosteroids be considered as first-line therapy for patients
who do not have a contraindication. While there is equivocal evidence of benefit, for most
patients the risk of a short-term course of corticosteroids is thought to be outweighed by the
potential benefit, especially when considering the serious consequences of long-term
profound hearing loss. Because the greatest improvement in hearing tends to occur in the first
2 weeks, corticosteroid treatment should be started immediately. The recommended dosage is
1 mg/kg/day with a maximum dosage of 60 mg daily for 10-14 days.
Antiviral medications, antiplatelet agents, and vasodilators such as nifedipine have no
evidence of benefit. Antibiotics also have no evidence of benefit in the absence of signs of
infection.
Page | 2
,3. You are the team physician for the local high school track team. During a meet one of the
athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She
is able to bear weight but with significant pain. She reports pain across her right midfoot. An
examination reveals edema over the lateral malleolus and diffuse tenderness, but she does not
have any pain with palpation of the navicular, the base of the fifth metatarsal, or the posterior
distal lateral and medial malleoli.
Which one of the following would be most appropriate at this time?
A) Radiographs of the right ankle only
B) Radiographs of the right foot only
C) Radiographs of the right foot and ankle
D) Lace-up ankle support, ice, compression, and clinical follow-up
E) Crutches and no weight bearing for 2 weeks, followed by a slow return to weight
bearing --CORRECT ANSWER--ANSWER: D
The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot
and ankle injuries. A radiograph of the ankle is recommended if there is pain in the malleolar
zone along with the inability to bear weight for at least four steps immediately after the injury
and in the physician's office or emergency department (ED), or tenderness at the tip of the
posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain
in the midfoot zone along with the inability to bear weight for four steps immediately after
the injury and in the physician's office or ED, or tenderness at the base of the fifth metatarsal
or over the navicular bone. The Ottawa foot and ankle rules are up to 99% sensitive for
detecting fractures, although they are not highly specific. In this case there are no findings
that would require radiographs, so treatment for the ankle sprain would be recommended.
Compression combined with lace-up ankle support or an air cast, along with cryotherapy, is
recommended and can increase mobility. Early mobilization, including weight bearing as
tolerated for daily activities, is associated with better long-term outcomes than prolonged rest.
Page | 3
, 5. Which one of the following factors related to pregnancy and delivery increases the risk of
developmental dysplasia of the hip in infants?
A) A large-for-gestational age infant
B) Twin birth
C) Breech presentation
D) Cesarean delivery
E) Premature birth --CORRECT ANSWER--ANSWER: C
Risk factors for developmental dysplasia of the hip in infants include a breech presentation in
the third trimester, regardless of whether the delivery was cesarean or vaginal. Other
indications to evaluate an infant for this condition include a positive family history, a history
of previous clinical instability, parental concern, a history of improper swaddling, and a
suspicious or inconclusive physical examination. Twin birth, a large-for-gestational age
infant, and prematurity are not considered risk factors.
6. A healthy 2-month-old female is brought to your office for a routine well baby
examination by both of her parents, who have no concerns. The parents refuse routine
recommended vaccines for their daughter because of their personal beliefs.
You want to incorporate patient-centeredness and are also concerned about improving the
health of the population. You decide to follow the CDC recommendations by
A) accepting their decision without further action
B) not offering vaccines at future visits to preserve a positive doctor-patient relationship
C) having the parents sign a refusal to vaccinate form
D) dismissing the family from the practice
E) pursuing a court order for vaccine administration since the child has no medical
Page | 4
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES
1. An 85-year-old female with a previous history of diabetes mellitus, hypertension,
dementia, and peptic ulcer disease has been in a skilled nursing facility for 4 weeks for
rehabilitation after a hip fracture repair secondary to a fall during an ischemic stroke. She is
transported to the emergency department today when she develops confusion, shortness of
breath, and diaphoresis. Her blood pressure is 172/98 mm Hg, her heart rate is 122 beats/min
with an irregular rhythm, and her respiratory rate is 22/min. An EKG demonstrates atrial
fibrillation and 0.2 mV ST-segment elevation compared to previous EKGs. Her first troponin
level is elevated.
Which one of the following conditions in this patient is considered an ABSOLUTE
contraindication to fibrinolytic therapy?
A) Poorly controlled hypertension
B) Peptic ulcer disease
C) Alzheimer's dementia
D) Hip fracture repair
E) Ischemic stroke --CORRECT ANSWER--ANSWER: E
A history of an ischemic stroke within the past 3 months is an absolute contraindication to
fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI), unless
the stroke is diagnosed within 41⁄2 hours. Poorly controlled hypertension, dementia, peptic
ulcer disease, and major surgery less than 3 weeks before the STEMI are relative
contraindications that should be considered on an individual basis.
Page | 1
,2. An otherwise healthy 57-year-old female presents with a sudden onset of hearing loss. She
awoke this morning unable to hear out of her left ear. There was no preceding illness and she
currently feels well otherwise. She does not have ear pain, headache, runny nose, congestion,
or fever, and she does not take any daily medications.
On examination you note normal vital signs and find a normal ear, with no obstructing
cerumen and with normal tympanic membrane motion on pneumatic otoscopy. You perform
a Weber test by placing a tuning fork over her central forehead. She finds that the sound
lateralizes to her right ear. The Rinne test shows sounds are heard better with bone
conduction on the left and with air conduction on the right.
You refer her to an otolaryngologist for further evaluation including audiometry. You should
also consider initiating which one of the following medications at this visit in order to optim -
-CORRECT ANSWER--ANSWER: E
This patient has sudden sensorineural hearing loss (SSNHL) of the left ear without any
accompanying features to suggest a clear underlying cause. An appropriate evaluation will
fail to identify a cause in 85%-90% of cases. Idiopathic SSNHL can be diagnosed if a patient
is found to have a 30-dB hearing loss at three consecutive frequencies and an underlying
condition is not identified by the history and physical examination.
The most recent guideline from the American Academy of Otolaryngology-Head and Neck
Surgery recommends that oral corticosteroids be considered as first-line therapy for patients
who do not have a contraindication. While there is equivocal evidence of benefit, for most
patients the risk of a short-term course of corticosteroids is thought to be outweighed by the
potential benefit, especially when considering the serious consequences of long-term
profound hearing loss. Because the greatest improvement in hearing tends to occur in the first
2 weeks, corticosteroid treatment should be started immediately. The recommended dosage is
1 mg/kg/day with a maximum dosage of 60 mg daily for 10-14 days.
Antiviral medications, antiplatelet agents, and vasodilators such as nifedipine have no
evidence of benefit. Antibiotics also have no evidence of benefit in the absence of signs of
infection.
Page | 2
,3. You are the team physician for the local high school track team. During a meet one of the
athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She
is able to bear weight but with significant pain. She reports pain across her right midfoot. An
examination reveals edema over the lateral malleolus and diffuse tenderness, but she does not
have any pain with palpation of the navicular, the base of the fifth metatarsal, or the posterior
distal lateral and medial malleoli.
Which one of the following would be most appropriate at this time?
A) Radiographs of the right ankle only
B) Radiographs of the right foot only
C) Radiographs of the right foot and ankle
D) Lace-up ankle support, ice, compression, and clinical follow-up
E) Crutches and no weight bearing for 2 weeks, followed by a slow return to weight
bearing --CORRECT ANSWER--ANSWER: D
The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot
and ankle injuries. A radiograph of the ankle is recommended if there is pain in the malleolar
zone along with the inability to bear weight for at least four steps immediately after the injury
and in the physician's office or emergency department (ED), or tenderness at the tip of the
posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain
in the midfoot zone along with the inability to bear weight for four steps immediately after
the injury and in the physician's office or ED, or tenderness at the base of the fifth metatarsal
or over the navicular bone. The Ottawa foot and ankle rules are up to 99% sensitive for
detecting fractures, although they are not highly specific. In this case there are no findings
that would require radiographs, so treatment for the ankle sprain would be recommended.
Compression combined with lace-up ankle support or an air cast, along with cryotherapy, is
recommended and can increase mobility. Early mobilization, including weight bearing as
tolerated for daily activities, is associated with better long-term outcomes than prolonged rest.
Page | 3
, 5. Which one of the following factors related to pregnancy and delivery increases the risk of
developmental dysplasia of the hip in infants?
A) A large-for-gestational age infant
B) Twin birth
C) Breech presentation
D) Cesarean delivery
E) Premature birth --CORRECT ANSWER--ANSWER: C
Risk factors for developmental dysplasia of the hip in infants include a breech presentation in
the third trimester, regardless of whether the delivery was cesarean or vaginal. Other
indications to evaluate an infant for this condition include a positive family history, a history
of previous clinical instability, parental concern, a history of improper swaddling, and a
suspicious or inconclusive physical examination. Twin birth, a large-for-gestational age
infant, and prematurity are not considered risk factors.
6. A healthy 2-month-old female is brought to your office for a routine well baby
examination by both of her parents, who have no concerns. The parents refuse routine
recommended vaccines for their daughter because of their personal beliefs.
You want to incorporate patient-centeredness and are also concerned about improving the
health of the population. You decide to follow the CDC recommendations by
A) accepting their decision without further action
B) not offering vaccines at future visits to preserve a positive doctor-patient relationship
C) having the parents sign a refusal to vaccinate form
D) dismissing the family from the practice
E) pursuing a court order for vaccine administration since the child has no medical
Page | 4
