ABFM ITE EXAM NEWEST 2026 ACTUAL EXAM TEST
BANK| AMERICAN BOARD OF FAMILY MEDICINE IN
TRAINING FINAL EXAM REVIEW WITH 200 REAL EXAM
QESTIONS AND CORRECT DETAILED ANSWERS — 200
Questions
Section 1: Care of Adults and Older Adults (Questions 1-20)
1 A 74-year-old patient with a history of hypertension, type 2 diabetes, and osteoarthritis presents for a routine
visit. Current medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, and ibuprofen 600 mg
three times daily as needed for joint pain. Blood pressure is 148/92 mm Hg, heart rate 78 bpm, and creatinine
1.4 mg/dL (baseline 1.0). Which of the following is the most appropriate next step in managing this patient's
hypertension?
A) Add hydrochlorothiazide 12.5 mg daily
B) Increase lisinopril to 40 mg daily
C) Discontinue ibuprofen and reassess blood pressure in 2-4 weeks
D) Add amlodipine 5 mg daily
Answer: C
Rationale: NSAIDs can cause sodium and water retention, increase blood pressure, and impair renal function,
especially in patients on ACE inhibitors. Discontinuing ibuprofen may improve BP control and renal function
without additional antihypertensive therapy. Hydrochlorothiazide or amlodipine could be added if BP remains
elevated after NSAID cessation, but lisinopril should not be increased further given rising creatinine.
2 Which of the following medication adjustments is recommended for an 80-year-old patient with atrial
fibrillation and a CHA2DS2-VASc score of 4 who develops acute kidney injury (creatinine clearance 25
mL/min) while on apixaban?
A) Switch to warfarin with a target INR of 2-3
B) Reduce apixaban dose to 2.5 mg twice daily
C) Continue apixaban 5 mg twice daily with close monitoring
D) Discontinue anticoagulation and consider left atrial appendage closure
Answer: B
Rationale: In patients with creatinine clearance 15-29 mL/min, the apixaban dose should be reduced to 2.5 mg twice
daily if they meet two of three criteria: age "e80 years, weight "d60 kg, or serum creatinine "e1.5 mg/dL. This patient
meets at least age and renal impairment, so dose reduction is indicated. Warfarin may be used but requires frequent
monitoring; however, apixaban is preferred in this setting. Continuing full dose increases bleeding risk.
3 A 68-year-old patient with a 30-pack-year smoking history and mild COPD (post-bronchodilator FEV1/FVC
<0.7, FEV1 65% predicted) reports increasing dyspnea on exertion and occasional wheezing. Current
medications include albuterol as needed. Which of the following is the most appropriate initial step in
management?
A) Start tiotropium daily
B) Start fluticasone-salmeterol twice daily
C) Refer for pulmonary rehabilitation
D) Prescribe a course of oral prednisone
,Answer: A
Rationale: According to GOLD guidelines, for patients with group B COPD (FEV1 <80% predicted, low
exacerbation risk), a long-acting bronchodilator (LAMA or LABA) is recommended as initial therapy. Tiotropium
(LAMA) is a first-line option. Combination ICS/LABA is reserved for patients with high exacerbation risk or
eosinophilia. Pulmonary rehabilitation is adjunctive, and oral steroids are for acute exacerbations.
4 An 82-year-old patient with moderate Alzheimer's disease (MMSE 16) is on donepezil 10 mg daily. The
patient's caregiver reports increased agitation and delusions over the past week. Vital signs are normal, and there
are no signs of infection. Which of the following is the most appropriate next step?
A) Add risperidone 0.5 mg twice daily
B) Increase donepezil to 23 mg daily
C) Discontinue donepezil and start memantine
D) Add sertraline 50 mg daily
Answer: A
Rationale: For severe agitation and psychosis in Alzheimer's disease, atypical antipsychotics like risperidone are
indicated after non-pharmacologic measures fail, with careful monitoring for side effects. The donepezil dose is
already at the maximum for moderate disease (10 mg; 23 mg is for severe). Memantine can be added but does not
acutely treat agitation. Sertraline may help depression but not psychosis.
5 A 76-year-old patient with osteoporosis (T-score -3.2) and a history of a hip fracture 2 years ago is currently on
alendronate 70 mg weekly for 5 years. Recent DXA shows T-score -2.8 at the hip. Which of the following is the
most appropriate management?
A) Continue alendronate for another 5 years
B) Switch to denosumab 60 mg subcutaneously every 6 months
C) Take a 2-year drug holiday and reassess
D) Add teriparatide daily for 2 years
Answer: C
Rationale: After 5 years of bisphosphonate therapy, a drug holiday of 2-3 years is recommended for patients at
moderate risk (T-score > -2.5 without fracture). This patient has T-score -2.8, which is above -3.0, and no recent
fracture, so a holiday is appropriate. Continuing beyond 5 years increases risk of atypical femur fractures.
Denosumab or teriparatide are reserved for those with T-score "d -3.0 or multiple fractures.
6 A 70-year-old patient with type 2 diabetes (HbA1c 8.2%) on metformin 2000 mg daily and glipizide 10 mg
twice daily presents with a fasting glucose of 280 mg/dL and no ketones. The patient has stage 3b CKD (eGFR
35 mL/min/1.73 m²) and a history of heart failure with preserved ejection fraction. Which of the following is
the most appropriate next step in therapy?
A) Start insulin glargine 10 units daily
B) Add empagliflozin 10 mg daily
C) Add sitagliptin 100 mg daily
D) Increase glipizide to 20 mg twice daily
Answer: A
Rationale: Given the patient's poor glycemic control on dual oral therapy, insulin is indicated. Empagliflozin is
relatively contraindicated with eGFR <45 mL/min and may not be effective. Sitagliptin requires dose adjustment
(50 mg daily for eGFR 30-44) but is less potent. Increasing glipizide beyond maximum dose (20 mg/day) is not
recommended and may cause hypoglycemia. Insulin glargine is safe and effective.
,7 An 85-year-old patient with advanced dementia (FAST stage 7c) is admitted with aspiration pneumonia. The
patient is unable to swallow and has a poor appetite. The family requests aggressive treatment including
antibiotics and tube feeding. Which of the following is the most appropriate approach?
A) Initiate parenteral antibiotics and place a nasogastric tube for feeding
B) Provide antibiotics via IV but recommend against tube feeding due to lack of benefit
C) Withhold all life-sustaining treatments and focus on comfort care
D) Consult ethics committee to resolve the conflict
Answer: B
Rationale: In advanced dementia, tube feeding does not improve survival, quality of life, or prevent aspiration; it
may increase discomfort. Antibiotics are reasonable for pneumonia but goals of care should be discussed. Comfort
care is appropriate if the patient's wishes are known, but the family's request for treatment should be honored to
some extent. An ethics consult may be needed if conflict persists, but the best initial step is to explain evidence and
recommend against tube feeding.
8 A 72-year-old patient with a history of hypertension and osteoarthritis is started on amlodipine 5 mg daily. Two
weeks later, the patient reports new-onset bilateral lower extremity edema. Blood pressure is 130/80 mm Hg.
Which of the following is the most appropriate next step?
A) Add hydrochlorothiazide 12.5 mg daily
B) Switch to lisinopril 10 mg daily
C) Reduce amlodipine to 2.5 mg daily
D) Discontinue amlodipine and start metoprolol 25 mg daily
Answer: B
Rationale: Amlodipine causes peripheral edema due to precapillary vasodilation. Switching to an ACE inhibitor
(lisinopril) is effective and may also treat hypertension. Adding a diuretic may reduce edema but does not address
the cause and can cause electrolyte disturbances. Reducing the dose may help but often leads to inadequate BP
control. Metoprolol is not first-line for isolated hypertension in older adults without compelling indications.
9 A 78-year-old patient with a history of gout and stage 3a CKD (eGFR 50 mL/min) presents with an acute gout
flare in the first metatarsophalangeal joint. Current medications include allopurinol 300 mg daily and losartan
50 mg daily. Which of the following is the most appropriate treatment for the acute flare?
A) Indomethacin 50 mg three times daily for 5 days
B) Colchicine 1.2 mg followed by 0.6 mg one hour later
C) Prednisone 40 mg daily for 5 days
D) Intra-articular methylprednisolone acetate 40 mg
Answer: C
Rationale: In patients with CKD, NSAIDs are contraindicated due to risk of further renal impairment. Colchicine
requires dose adjustment for eGFR <50 (maximum 0.6 mg/day) and the loading dose may be toxic. Systemic
corticosteroids (prednisone) are safe and effective for acute gout in renal impairment. Intra-articular steroids are an
option for monoarticular flare but require joint injection expertise and may not be preferred for a first MTP joint.
10 A 75-year-old patient with a history of hypertension, hyperlipidemia, and benign prostatic hyperplasia is found
to have a PSA of 6.5 ng/mL (previous 4.2 one year ago). Digital rectal exam reveals a firm, asymmetric
prostate without nodules. Which of the following is the most appropriate next step?
A) Repeat PSA in 6 months
B) Start finasteride and reassess PSA in 3 months
C) Order multiparametric MRI of the prostate
D) Refer for transrectal ultrasound-guided biopsy
, Answer: C
Rationale: Given the rapid rise in PSA (velocity >0.75 ng/mL/year) and abnormal DRE, further evaluation is
warranted. Multiparametric MRI is recommended before biopsy to identify suspicious lesions and reduce
unnecessary biopsies. Finasteride would lower PSA but delay diagnosis. Repeat PSA in 6 months is not appropriate
with these findings. Biopsy is indicated if MRI shows suspicious areas, but MRI first is the current standard.
11 A 72-year-old patient with a history of hypertension and type 2 diabetes presents with a blood pressure of
148/92 mm Hg on two separate visits. Current medications include lisinopril 10 mg daily, metformin 1000 mg
twice daily, and atorvastatin 20 mg daily. Estimated glomerular filtration rate (eGFR) is 55 mL/min/1.73 m²,
and urine albumin-to-creatinine ratio (UACR) is 45 mg/g. According to the 2017 ACC/AHA hypertension
guideline, what is the most appropriate next step in managing this patient's blood pressure?
A) Continue current therapy and recheck blood pressure in 6 months
B) Increase lisinopril to 20 mg daily and add a thiazide diuretic
C) Add a calcium channel blocker and refer to nephrology
D) Increase lisinopril to 40 mg daily and add spironolactone
Answer: B
Rationale: The patient's blood pressure is above the goal of <130/80 mm Hg for adults with diabetes and CKD
(stage 3a, eGFR 45-59). The UACR is moderately increased (30-300 mg/g), indicating albuminuria. The 2017
ACC/AHA guideline recommends intensifying therapy with two first-line agents (ACEi/ARB and thiazide diuretic)
when BP is >20/10 mm Hg above goal. Increasing lisinopril to 20 mg and adding a thiazide diuretic is appropriate.
Spironolactone is not first-line, and calcium channel blockers are less preferred in albuminuric CKD.
12 A 68-year-old patient with a history of coronary artery disease and heart failure with reduced ejection fraction
(HFrEF, LVEF 35%) is on guideline-directed medical therapy including metoprolol succinate 50 mg daily,
lisinopril 10 mg daily, and furosemide 40 mg daily. The patient reports persistent dyspnea on exertion and
fatigue. Vital signs: BP 110/70 mm Hg, HR 65 bpm, oxygen saturation 97% on room air. Serum creatinine 1.1
mg/dL, potassium 4.2 mEq/L. Which medication adjustment is most likely to improve outcomes?
A) Increase metoprolol succinate to 100 mg daily
B) Add sacubitril/valsartan 24/26 mg twice daily
C) Add spironolactone 12.5 mg daily
D) Increase lisinopril to 20 mg daily
Answer: B
Rationale: In patients with HFrEF who remain symptomatic despite ACEi/ARB, beta-blocker, and diuretic, the
PARADIGM-HF trial demonstrated that switching from ACEi to sacubitril/valsartan reduces cardiovascular death
and heart failure hospitalizations. The patient is on low-dose ACEi and beta-blocker; further up-titration is
reasonable, but the addition of sacubitril/valsartan is a proven next step. Spironolactone is indicated for NYHA
class II-IV with LVEF "d35%, but it is typically added after optimization of ACEi and beta-blocker. The patient's
BP and potassium are acceptable for initiation.
13 A 75-year-old patient with a history of osteoarthritis and hypertension presents with an acute onset of severe,
colicky right flank pain radiating to the groin, associated with nausea and vomiting. Urinalysis shows
hematuria (3+ RBCs) and no signs of infection. Noncontrast CT reveals a 6 mm calculus in the proximal right
ureter with mild hydronephrosis. The patient's serum creatinine is 1.0 mg/dL. Which of the following is the
most appropriate initial management?
A) Immediate ureteroscopic lithotripsy
B) Extracorporeal shock wave lithotripsy (ESWL)
C) Medical expulsive therapy with tamsulosin and hydration
D) Percutaneous nephrostomy tube placement
BANK| AMERICAN BOARD OF FAMILY MEDICINE IN
TRAINING FINAL EXAM REVIEW WITH 200 REAL EXAM
QESTIONS AND CORRECT DETAILED ANSWERS — 200
Questions
Section 1: Care of Adults and Older Adults (Questions 1-20)
1 A 74-year-old patient with a history of hypertension, type 2 diabetes, and osteoarthritis presents for a routine
visit. Current medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, and ibuprofen 600 mg
three times daily as needed for joint pain. Blood pressure is 148/92 mm Hg, heart rate 78 bpm, and creatinine
1.4 mg/dL (baseline 1.0). Which of the following is the most appropriate next step in managing this patient's
hypertension?
A) Add hydrochlorothiazide 12.5 mg daily
B) Increase lisinopril to 40 mg daily
C) Discontinue ibuprofen and reassess blood pressure in 2-4 weeks
D) Add amlodipine 5 mg daily
Answer: C
Rationale: NSAIDs can cause sodium and water retention, increase blood pressure, and impair renal function,
especially in patients on ACE inhibitors. Discontinuing ibuprofen may improve BP control and renal function
without additional antihypertensive therapy. Hydrochlorothiazide or amlodipine could be added if BP remains
elevated after NSAID cessation, but lisinopril should not be increased further given rising creatinine.
2 Which of the following medication adjustments is recommended for an 80-year-old patient with atrial
fibrillation and a CHA2DS2-VASc score of 4 who develops acute kidney injury (creatinine clearance 25
mL/min) while on apixaban?
A) Switch to warfarin with a target INR of 2-3
B) Reduce apixaban dose to 2.5 mg twice daily
C) Continue apixaban 5 mg twice daily with close monitoring
D) Discontinue anticoagulation and consider left atrial appendage closure
Answer: B
Rationale: In patients with creatinine clearance 15-29 mL/min, the apixaban dose should be reduced to 2.5 mg twice
daily if they meet two of three criteria: age "e80 years, weight "d60 kg, or serum creatinine "e1.5 mg/dL. This patient
meets at least age and renal impairment, so dose reduction is indicated. Warfarin may be used but requires frequent
monitoring; however, apixaban is preferred in this setting. Continuing full dose increases bleeding risk.
3 A 68-year-old patient with a 30-pack-year smoking history and mild COPD (post-bronchodilator FEV1/FVC
<0.7, FEV1 65% predicted) reports increasing dyspnea on exertion and occasional wheezing. Current
medications include albuterol as needed. Which of the following is the most appropriate initial step in
management?
A) Start tiotropium daily
B) Start fluticasone-salmeterol twice daily
C) Refer for pulmonary rehabilitation
D) Prescribe a course of oral prednisone
,Answer: A
Rationale: According to GOLD guidelines, for patients with group B COPD (FEV1 <80% predicted, low
exacerbation risk), a long-acting bronchodilator (LAMA or LABA) is recommended as initial therapy. Tiotropium
(LAMA) is a first-line option. Combination ICS/LABA is reserved for patients with high exacerbation risk or
eosinophilia. Pulmonary rehabilitation is adjunctive, and oral steroids are for acute exacerbations.
4 An 82-year-old patient with moderate Alzheimer's disease (MMSE 16) is on donepezil 10 mg daily. The
patient's caregiver reports increased agitation and delusions over the past week. Vital signs are normal, and there
are no signs of infection. Which of the following is the most appropriate next step?
A) Add risperidone 0.5 mg twice daily
B) Increase donepezil to 23 mg daily
C) Discontinue donepezil and start memantine
D) Add sertraline 50 mg daily
Answer: A
Rationale: For severe agitation and psychosis in Alzheimer's disease, atypical antipsychotics like risperidone are
indicated after non-pharmacologic measures fail, with careful monitoring for side effects. The donepezil dose is
already at the maximum for moderate disease (10 mg; 23 mg is for severe). Memantine can be added but does not
acutely treat agitation. Sertraline may help depression but not psychosis.
5 A 76-year-old patient with osteoporosis (T-score -3.2) and a history of a hip fracture 2 years ago is currently on
alendronate 70 mg weekly for 5 years. Recent DXA shows T-score -2.8 at the hip. Which of the following is the
most appropriate management?
A) Continue alendronate for another 5 years
B) Switch to denosumab 60 mg subcutaneously every 6 months
C) Take a 2-year drug holiday and reassess
D) Add teriparatide daily for 2 years
Answer: C
Rationale: After 5 years of bisphosphonate therapy, a drug holiday of 2-3 years is recommended for patients at
moderate risk (T-score > -2.5 without fracture). This patient has T-score -2.8, which is above -3.0, and no recent
fracture, so a holiday is appropriate. Continuing beyond 5 years increases risk of atypical femur fractures.
Denosumab or teriparatide are reserved for those with T-score "d -3.0 or multiple fractures.
6 A 70-year-old patient with type 2 diabetes (HbA1c 8.2%) on metformin 2000 mg daily and glipizide 10 mg
twice daily presents with a fasting glucose of 280 mg/dL and no ketones. The patient has stage 3b CKD (eGFR
35 mL/min/1.73 m²) and a history of heart failure with preserved ejection fraction. Which of the following is
the most appropriate next step in therapy?
A) Start insulin glargine 10 units daily
B) Add empagliflozin 10 mg daily
C) Add sitagliptin 100 mg daily
D) Increase glipizide to 20 mg twice daily
Answer: A
Rationale: Given the patient's poor glycemic control on dual oral therapy, insulin is indicated. Empagliflozin is
relatively contraindicated with eGFR <45 mL/min and may not be effective. Sitagliptin requires dose adjustment
(50 mg daily for eGFR 30-44) but is less potent. Increasing glipizide beyond maximum dose (20 mg/day) is not
recommended and may cause hypoglycemia. Insulin glargine is safe and effective.
,7 An 85-year-old patient with advanced dementia (FAST stage 7c) is admitted with aspiration pneumonia. The
patient is unable to swallow and has a poor appetite. The family requests aggressive treatment including
antibiotics and tube feeding. Which of the following is the most appropriate approach?
A) Initiate parenteral antibiotics and place a nasogastric tube for feeding
B) Provide antibiotics via IV but recommend against tube feeding due to lack of benefit
C) Withhold all life-sustaining treatments and focus on comfort care
D) Consult ethics committee to resolve the conflict
Answer: B
Rationale: In advanced dementia, tube feeding does not improve survival, quality of life, or prevent aspiration; it
may increase discomfort. Antibiotics are reasonable for pneumonia but goals of care should be discussed. Comfort
care is appropriate if the patient's wishes are known, but the family's request for treatment should be honored to
some extent. An ethics consult may be needed if conflict persists, but the best initial step is to explain evidence and
recommend against tube feeding.
8 A 72-year-old patient with a history of hypertension and osteoarthritis is started on amlodipine 5 mg daily. Two
weeks later, the patient reports new-onset bilateral lower extremity edema. Blood pressure is 130/80 mm Hg.
Which of the following is the most appropriate next step?
A) Add hydrochlorothiazide 12.5 mg daily
B) Switch to lisinopril 10 mg daily
C) Reduce amlodipine to 2.5 mg daily
D) Discontinue amlodipine and start metoprolol 25 mg daily
Answer: B
Rationale: Amlodipine causes peripheral edema due to precapillary vasodilation. Switching to an ACE inhibitor
(lisinopril) is effective and may also treat hypertension. Adding a diuretic may reduce edema but does not address
the cause and can cause electrolyte disturbances. Reducing the dose may help but often leads to inadequate BP
control. Metoprolol is not first-line for isolated hypertension in older adults without compelling indications.
9 A 78-year-old patient with a history of gout and stage 3a CKD (eGFR 50 mL/min) presents with an acute gout
flare in the first metatarsophalangeal joint. Current medications include allopurinol 300 mg daily and losartan
50 mg daily. Which of the following is the most appropriate treatment for the acute flare?
A) Indomethacin 50 mg three times daily for 5 days
B) Colchicine 1.2 mg followed by 0.6 mg one hour later
C) Prednisone 40 mg daily for 5 days
D) Intra-articular methylprednisolone acetate 40 mg
Answer: C
Rationale: In patients with CKD, NSAIDs are contraindicated due to risk of further renal impairment. Colchicine
requires dose adjustment for eGFR <50 (maximum 0.6 mg/day) and the loading dose may be toxic. Systemic
corticosteroids (prednisone) are safe and effective for acute gout in renal impairment. Intra-articular steroids are an
option for monoarticular flare but require joint injection expertise and may not be preferred for a first MTP joint.
10 A 75-year-old patient with a history of hypertension, hyperlipidemia, and benign prostatic hyperplasia is found
to have a PSA of 6.5 ng/mL (previous 4.2 one year ago). Digital rectal exam reveals a firm, asymmetric
prostate without nodules. Which of the following is the most appropriate next step?
A) Repeat PSA in 6 months
B) Start finasteride and reassess PSA in 3 months
C) Order multiparametric MRI of the prostate
D) Refer for transrectal ultrasound-guided biopsy
, Answer: C
Rationale: Given the rapid rise in PSA (velocity >0.75 ng/mL/year) and abnormal DRE, further evaluation is
warranted. Multiparametric MRI is recommended before biopsy to identify suspicious lesions and reduce
unnecessary biopsies. Finasteride would lower PSA but delay diagnosis. Repeat PSA in 6 months is not appropriate
with these findings. Biopsy is indicated if MRI shows suspicious areas, but MRI first is the current standard.
11 A 72-year-old patient with a history of hypertension and type 2 diabetes presents with a blood pressure of
148/92 mm Hg on two separate visits. Current medications include lisinopril 10 mg daily, metformin 1000 mg
twice daily, and atorvastatin 20 mg daily. Estimated glomerular filtration rate (eGFR) is 55 mL/min/1.73 m²,
and urine albumin-to-creatinine ratio (UACR) is 45 mg/g. According to the 2017 ACC/AHA hypertension
guideline, what is the most appropriate next step in managing this patient's blood pressure?
A) Continue current therapy and recheck blood pressure in 6 months
B) Increase lisinopril to 20 mg daily and add a thiazide diuretic
C) Add a calcium channel blocker and refer to nephrology
D) Increase lisinopril to 40 mg daily and add spironolactone
Answer: B
Rationale: The patient's blood pressure is above the goal of <130/80 mm Hg for adults with diabetes and CKD
(stage 3a, eGFR 45-59). The UACR is moderately increased (30-300 mg/g), indicating albuminuria. The 2017
ACC/AHA guideline recommends intensifying therapy with two first-line agents (ACEi/ARB and thiazide diuretic)
when BP is >20/10 mm Hg above goal. Increasing lisinopril to 20 mg and adding a thiazide diuretic is appropriate.
Spironolactone is not first-line, and calcium channel blockers are less preferred in albuminuric CKD.
12 A 68-year-old patient with a history of coronary artery disease and heart failure with reduced ejection fraction
(HFrEF, LVEF 35%) is on guideline-directed medical therapy including metoprolol succinate 50 mg daily,
lisinopril 10 mg daily, and furosemide 40 mg daily. The patient reports persistent dyspnea on exertion and
fatigue. Vital signs: BP 110/70 mm Hg, HR 65 bpm, oxygen saturation 97% on room air. Serum creatinine 1.1
mg/dL, potassium 4.2 mEq/L. Which medication adjustment is most likely to improve outcomes?
A) Increase metoprolol succinate to 100 mg daily
B) Add sacubitril/valsartan 24/26 mg twice daily
C) Add spironolactone 12.5 mg daily
D) Increase lisinopril to 20 mg daily
Answer: B
Rationale: In patients with HFrEF who remain symptomatic despite ACEi/ARB, beta-blocker, and diuretic, the
PARADIGM-HF trial demonstrated that switching from ACEi to sacubitril/valsartan reduces cardiovascular death
and heart failure hospitalizations. The patient is on low-dose ACEi and beta-blocker; further up-titration is
reasonable, but the addition of sacubitril/valsartan is a proven next step. Spironolactone is indicated for NYHA
class II-IV with LVEF "d35%, but it is typically added after optimization of ACEi and beta-blocker. The patient's
BP and potassium are acceptable for initiation.
13 A 75-year-old patient with a history of osteoarthritis and hypertension presents with an acute onset of severe,
colicky right flank pain radiating to the groin, associated with nausea and vomiting. Urinalysis shows
hematuria (3+ RBCs) and no signs of infection. Noncontrast CT reveals a 6 mm calculus in the proximal right
ureter with mild hydronephrosis. The patient's serum creatinine is 1.0 mg/dL. Which of the following is the
most appropriate initial management?
A) Immediate ureteroscopic lithotripsy
B) Extracorporeal shock wave lithotripsy (ESWL)
C) Medical expulsive therapy with tamsulosin and hydration
D) Percutaneous nephrostomy tube placement
