ABFM ACTUAL EXAM PAPER 2026
COMPLETE QUESTIONS AND SOLUTIONS
CERTIFICATION READY
◉ A 48-year-old male with a history of type 2 diabetes, obesity, and
tobacco use disorder presents to your office for evaluation of a 4-day
history of fever, malaise, and a productive cough. He smokes a half-
pack of cigarettes per day but does not use recreational drugs or
drink alcohol in excess. He has no known medication allergies. Aside
from a temperature of 38.2°C (100.8°F) and a BMI of 32 kg/m2 , his
vital signs, including oxygen saturation, are normal. On physical
examination he appears mildly ill although well hydrated and is
breathing comfortably. Lung auscultation reveals focal right-sided
crackles and decreased breath sounds. Which one of the following
oral treatment options would be best in this situation?
Answer: This patient presents with symptoms and examination
findings that are consistent with community-acquired pneumonia
(CAP) with significant medical comorbidity, and he is stable for
outpatient treatment. Medical comorbidities in this context include
chronic heart, lung, liver, or kidney disease; diabetes mellitus;
alcohol use disorder; cancer; or asplenia. One option for treatment
in this situation is monotherapy with a respiratory fluoroquinolone,
such as levofloxacin or moxifloxacin. Other options for outpatient
treatment of CAP in adults with comorbidities include either the -
lactam amoxicillin/clavulanate or a cephalosporin (specifically
cefpodoxime, a third-generation cephalosporin, or cefuroxime, a
,second-generation cephalosporin), in combination with either
doxycycline or a macrolide (SOR A). Of the available choices, only
amoxicillin/clavulanate plus azithromycin would provide the
appropriate spectrum of antimicrobial coverage. Amoxicillin or
doxycycline monotherapy would be appropriate outpatient CAP
treatment for an adult without a significant medical comorbidity.
Another option in such a case is a macrolide such as azithromycin if
the local pneumococcal resistance rate to macrolides is known to be
less than 25% (SOR B). Oral cefuroxime would be appropriate in
combination with either doxycycline or azithromycin in this
scenario, but it would not provide broad enough coverage as
monotherapy. Sulfamethoxazole/trimethoprim has encountered
increasing pneumococcal resistance over the past several decades
and therefore does not factor into current management for CAP,
either alone or in combination with cephalexin, a first-generation
cephalosporin that provides coverage against skin flora but not
against typical CAP pathogens
◉ healthy 78-year-old female with no history of osteoporosis has a
family history of hip fracture. Bone density screening reveals a
lumbar T-score of -2.0 and a right hip T-score of -1.5. Her FRAX score
is calculated at a 20% risk of major osteoporotic fracture and an
11% risk of hip fracture. She is concerned about the possibility of
breaking her hip. Which one of the following interventions would be
most appropriate?
Answer: National Osteoporosis Foundation supports treatment of
postmenopausal women with low bone mass and a 10-year risk
>20% for any major fracture or 3% for hip fracture. First-line
,treatment options include bisphosphonates (alendronate,
ibandronate, risedronate, and zoledronic acid), teriparatide, and
denosumab. These medications are considered first line due to their
proven efficacy in reducing both hip and vertebral fractures.
Hormonal treatment such as raloxifene and hormone replacement
therapy is not recommended as first-line treatment due to
associated risk and side effects as well as lack of evidence
supporting efficacy in preventing hip fractures. Women with a 10-
year fracture risk <20% but who have osteopenia and/or risk factors
for bone loss can be monitored with periodic bone density scans,
though the optimal intervals for repeat evaluation have not been
definitively established.
◉ Which one of the following tests has the highest negative
predictive value to rule out celiac disease?
Answer: The likelihood that a person who has a negative test result
indeed does not have the disease, condition, biomarker, or mutation
(change) in the gene being tested. The negative predictive value is a
way of measuring how accurate a specific test is. Also called NPV
Celiac disease occurs almost exclusively in people with HLA-DQ2 or
HLA-DQ8 genotypes. Though not routinely performed, a negative
result has more than a 99% negative predictive value for the disease.
A positive IgA tissue transglutaminase (tTG) antibody test is helpful
in making a diagnosis if symptoms are present and has 95%
sensitivity and specificity for active disease, but a negative IgA tTG
test does not rule out future risk. A negative antigliadin antibody test
, has lower sensitivity and specificity than IgA tTG, and is used to
diagnose the disease in the presence of symptoms rather than to
rule out future risk.
Negative C-reactive protein and fecal calprotectin levels make active
inflammatory bowel disease less likely.
◉ 42-year-old male with a history of chronic low back pain managed
with extended-release morphine sulfate (MS Contin) comes to your
office to discuss fatigue. Among other causes, you consider the
impact that long-term opioid therapy may have on the endocrine
system. Which one of the following endocrine conditions is most
commonly associated with long-term opioid therapy?
Answer: Hypogonadism; . A 2020 systematic review and meta-
analysis that included 52 studies on the endocrine effects of opioids
found hypogonadism in 69% of male patients. Lower androgen
levels were also found in women, while estradiol was not affected.
Menstrual cycle disorders were noted in 87% of premenopausal
women taking opioids chronically. Seven of the included studies
assessed prolactin levels, which were elevated in 40% of
participants. Adrenal insufficiency was noted in 24% of patients.
Parathyroid disorders were not included in this manuscript and
have not been reported to have an association with opioid use. Two
included studies showed lower free T4 levels in those taking opioids,
with an estimated incidence of 34%.
COMPLETE QUESTIONS AND SOLUTIONS
CERTIFICATION READY
◉ A 48-year-old male with a history of type 2 diabetes, obesity, and
tobacco use disorder presents to your office for evaluation of a 4-day
history of fever, malaise, and a productive cough. He smokes a half-
pack of cigarettes per day but does not use recreational drugs or
drink alcohol in excess. He has no known medication allergies. Aside
from a temperature of 38.2°C (100.8°F) and a BMI of 32 kg/m2 , his
vital signs, including oxygen saturation, are normal. On physical
examination he appears mildly ill although well hydrated and is
breathing comfortably. Lung auscultation reveals focal right-sided
crackles and decreased breath sounds. Which one of the following
oral treatment options would be best in this situation?
Answer: This patient presents with symptoms and examination
findings that are consistent with community-acquired pneumonia
(CAP) with significant medical comorbidity, and he is stable for
outpatient treatment. Medical comorbidities in this context include
chronic heart, lung, liver, or kidney disease; diabetes mellitus;
alcohol use disorder; cancer; or asplenia. One option for treatment
in this situation is monotherapy with a respiratory fluoroquinolone,
such as levofloxacin or moxifloxacin. Other options for outpatient
treatment of CAP in adults with comorbidities include either the -
lactam amoxicillin/clavulanate or a cephalosporin (specifically
cefpodoxime, a third-generation cephalosporin, or cefuroxime, a
,second-generation cephalosporin), in combination with either
doxycycline or a macrolide (SOR A). Of the available choices, only
amoxicillin/clavulanate plus azithromycin would provide the
appropriate spectrum of antimicrobial coverage. Amoxicillin or
doxycycline monotherapy would be appropriate outpatient CAP
treatment for an adult without a significant medical comorbidity.
Another option in such a case is a macrolide such as azithromycin if
the local pneumococcal resistance rate to macrolides is known to be
less than 25% (SOR B). Oral cefuroxime would be appropriate in
combination with either doxycycline or azithromycin in this
scenario, but it would not provide broad enough coverage as
monotherapy. Sulfamethoxazole/trimethoprim has encountered
increasing pneumococcal resistance over the past several decades
and therefore does not factor into current management for CAP,
either alone or in combination with cephalexin, a first-generation
cephalosporin that provides coverage against skin flora but not
against typical CAP pathogens
◉ healthy 78-year-old female with no history of osteoporosis has a
family history of hip fracture. Bone density screening reveals a
lumbar T-score of -2.0 and a right hip T-score of -1.5. Her FRAX score
is calculated at a 20% risk of major osteoporotic fracture and an
11% risk of hip fracture. She is concerned about the possibility of
breaking her hip. Which one of the following interventions would be
most appropriate?
Answer: National Osteoporosis Foundation supports treatment of
postmenopausal women with low bone mass and a 10-year risk
>20% for any major fracture or 3% for hip fracture. First-line
,treatment options include bisphosphonates (alendronate,
ibandronate, risedronate, and zoledronic acid), teriparatide, and
denosumab. These medications are considered first line due to their
proven efficacy in reducing both hip and vertebral fractures.
Hormonal treatment such as raloxifene and hormone replacement
therapy is not recommended as first-line treatment due to
associated risk and side effects as well as lack of evidence
supporting efficacy in preventing hip fractures. Women with a 10-
year fracture risk <20% but who have osteopenia and/or risk factors
for bone loss can be monitored with periodic bone density scans,
though the optimal intervals for repeat evaluation have not been
definitively established.
◉ Which one of the following tests has the highest negative
predictive value to rule out celiac disease?
Answer: The likelihood that a person who has a negative test result
indeed does not have the disease, condition, biomarker, or mutation
(change) in the gene being tested. The negative predictive value is a
way of measuring how accurate a specific test is. Also called NPV
Celiac disease occurs almost exclusively in people with HLA-DQ2 or
HLA-DQ8 genotypes. Though not routinely performed, a negative
result has more than a 99% negative predictive value for the disease.
A positive IgA tissue transglutaminase (tTG) antibody test is helpful
in making a diagnosis if symptoms are present and has 95%
sensitivity and specificity for active disease, but a negative IgA tTG
test does not rule out future risk. A negative antigliadin antibody test
, has lower sensitivity and specificity than IgA tTG, and is used to
diagnose the disease in the presence of symptoms rather than to
rule out future risk.
Negative C-reactive protein and fecal calprotectin levels make active
inflammatory bowel disease less likely.
◉ 42-year-old male with a history of chronic low back pain managed
with extended-release morphine sulfate (MS Contin) comes to your
office to discuss fatigue. Among other causes, you consider the
impact that long-term opioid therapy may have on the endocrine
system. Which one of the following endocrine conditions is most
commonly associated with long-term opioid therapy?
Answer: Hypogonadism; . A 2020 systematic review and meta-
analysis that included 52 studies on the endocrine effects of opioids
found hypogonadism in 69% of male patients. Lower androgen
levels were also found in women, while estradiol was not affected.
Menstrual cycle disorders were noted in 87% of premenopausal
women taking opioids chronically. Seven of the included studies
assessed prolactin levels, which were elevated in 40% of
participants. Adrenal insufficiency was noted in 24% of patients.
Parathyroid disorders were not included in this manuscript and
have not been reported to have an association with opioid use. Two
included studies showed lower free T4 levels in those taking opioids,
with an estimated incidence of 34%.
