ABFM CKSA 22-23 || with Faultless Solutions.
A 56-year-old male with a history of hepatitis C cirrhosis is admitted to the hospital with GI
bleeding. The patient has been stable, taking only furosemide and spironolactone. Upper GI
endoscopy confirms variceal bleeding and the gastroenterologist performs appropriate variceal
banding. A nurse calls you because laboratory studies ordered in the emergency department
reveal a serum ammonia level of 120 µg/dL (N 39-90). The patient has no signs of confusion,
insomnia, or decreased mental alertness. A physical examination reveals mild ascites but no
other abnormalities. Which one of the following would be most appropriate for addressing the
elevated ammonia level?
A. Lactulose
B. No additional treatment
C. Methotrexate
D. Neomycin
E. Prednisone correct answers ANSWER: B
Elevated ammonia levels may occur in multiple clinical scenarios (i.e. portosystemic shunting,
UTI from urease-producing organisms, GI bleeding, shock, renal disease, parenteral nutrition,
salicylate intoxication, alcohol use). In patients with chronic liver disease, hepatic
encephalopathy is diagnosed based on the overall clinical presentation and not by an ammonia
level. It is important to remember that a normal ammonia level neither excludes nor confirms the
diagnosis of hepatic encephalopathy. This patient had an elevated serum ammonia level that was
found incidentally during his hospital admission for gastrointestinal bleeding. Because there is
no clinically significant encephalopathy, treatment based on ammonia levels is not indicated.
Lactulose, methotrexate, neomycin, or prednisone would not be appropriate.
A 33-year-old female presents with palpitations and excessive sweating. A physical examination
is normal. Laboratory findings include a TSH (thyrotropin) level of 0.02 µU/mL (N 0.40-4.00)
and a free T4 level of 3.9 ng/dL (N 0.7-1.9). Radionuclide scanning reveals no uptake. Which
one of the following would explain these findings?
A. Thyroid hormone resistance
B. Graves disease
C. A toxic nodular goiter
D. Excess thyroid hormone intake
E. A thyrotropin-secreting pituitary tumor correct answers ANSWER: D
Excess thyroid hormone intake would cause a low TSH (thyrotropin) level with a high free T4
level and no uptake on radionuclide scan. Other possibilities include an hCG-secreting tumor and
the thyrotoxic phase of subacute thyroiditis.
An elevated TSH (thyrotropin) level would be seen with thyroid-hormone resistance or a
thyrotropin-secreting pituitary tumor. Graves disease causes a homogeneous increased thyroid
uptake on radionuclide scanning, whereas a hot nodule would be expected with a toxic nodular
goiter.
,A 60-year-old male with type 2 diabetes comes to your office with an acute onset of fever, chills,
and malaise. He says that he is feeling progressively worse. His temperature is 40.0°C (104.0°F).
An examination reveals redness, tenderness, and swelling of the penis, scrotum, and perineal
area. Which one of the following medications is most likely to predispose this patient to this
condition?
A. Empagliflozin
B. Exenatide
C. Insulin glargine
D. Pioglitazone
E. Sitagliptin correct answers ANSWER: A
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) are associated
with a higher rate of genitourinary infections. Most often these are fungal in etiology, however
there are associations with more serious infections including necrotizing fasciitis of the perineum
(Fournier's gangrene). While rare, this is a life-threatening infection associated with this class of
medication that is being used more frequently to treat diabetes mellitus and other cardiac
conditions. Because of this risk, the FDA issued a Drug Safety Warning in 2018.
The drug classes that include exenatide, insulin glargine, pioglitazone, and sitagliptin are not
associated with genitourinary infections.
A 5-year-old male is brought to your office after passing an intestinal worm. He lives on a farm
with cattle, pigs, and dogs. He has never traveled very far from home. He does not have any
respiratory symptoms or diarrhea, but has experienced some abdominal bloating. His parents
bring a picture of the worm (shown below). Which one of the following is the infecting
organism? correct answers A. Ascaris lumbricoides (roundworm)
B. Enterobius vermicularis (pinworm)
C. Giardia lamblia
D. Necator americanus (hookworm)
E. Taenia solium (tapeworm)
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ANSWER: A
This case and image are consistent with Ascaris lumbricoides infestation. A. lumbricoides is a
large roundworm that typically infects the ileum. Symptoms are variable but large infections can
lead to intestinal obstruction.
Pinworms (Enterobius vermicularis) are much smaller and typically present with anal pruritus.
Giardia lamblia is a microscopic protozoan parasite that is not visible on gross examination.
Hookworms (Necator americanus) are also round, but are typically 6-12 mm in length. They are
a significant cause of anemia in children globally. Tapeworms can be large, but are flat and
segmental in appearance, and are typically found in the stool as segments called proglottids.
A 58-year-old male with a history of tobacco use disorder and alcohol use disorder presents with
the sudden onset of many well circumscribed brown, oval, rough papules with a "stuck-on"
appearance on his trunk and proximal extremities (see image). On examination you also note an
unintentional 6-kg (13-lb) weight loss over the last 3 months and conjunctival pallor. A review of
systems is positive for abdominal pain, decreased appetite, and mild fatigue. You order a
laboratory workup. Which one of the following would be most appropriate at this point? correct
answers A. Reassurance that the skin lesions are benign
B. A skin biopsy
C. Referral to a dermatologist
D. CT of the abdomen and pelvis
E. Upper and lower endoscopy
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ANSWER: E
The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic keratoses, which
is an unusual finding that often indicates an underlying malignancy, most commonly an
adenocarcinoma of the stomach. This patient's age, risk factors, red-flag symptoms, and other
clinical findings indicate the need for endoscopy.
Further skin evaluation and lifestyle changes, which are indicated, will not address the need for
evaluation of weight loss and other abnormal symptoms and findings. CT is not an initial
approach for diagnosing a suspected malignancy of the stomach or colon.
A 46-year-old female with a past medical history of polycystic ovary syndrome and migraine
headaches presents with bilateral, hyperpigmented patches along her mandible. The patches are
asymptomatic but bother her cosmetically and seem to be darkening. Which one of her
medications would be most likely to contribute to her melasma?
A. B-complex vitamins
B. Metformin
C. Oral contraceptives
D. Spironolactone (Aldactone)
E. Sumatriptan (Imitrex) correct answers ANSWER: C
Melasma is a progressive, macular, nonscaling hypermelanosis of skin exposed to the sun,
typically involving the face and more rarely the dorsal forearms. It is often associated with
pregnancy and the use of oral contraceptives or anticonvulsants. Although thought previously to
involve only activation of melanocytes, it is now seen as a complex syndrome involving an
interplay of keratinocytes, dermal mast cells, gene regulation, and vascular changes. Women are
more likely to be affected than men, and darker-skinned individuals with Fitzpatrick skin types
III-IV are more commonly affected. There are three common patterns of melasma that are
A 56-year-old male with a history of hepatitis C cirrhosis is admitted to the hospital with GI
bleeding. The patient has been stable, taking only furosemide and spironolactone. Upper GI
endoscopy confirms variceal bleeding and the gastroenterologist performs appropriate variceal
banding. A nurse calls you because laboratory studies ordered in the emergency department
reveal a serum ammonia level of 120 µg/dL (N 39-90). The patient has no signs of confusion,
insomnia, or decreased mental alertness. A physical examination reveals mild ascites but no
other abnormalities. Which one of the following would be most appropriate for addressing the
elevated ammonia level?
A. Lactulose
B. No additional treatment
C. Methotrexate
D. Neomycin
E. Prednisone correct answers ANSWER: B
Elevated ammonia levels may occur in multiple clinical scenarios (i.e. portosystemic shunting,
UTI from urease-producing organisms, GI bleeding, shock, renal disease, parenteral nutrition,
salicylate intoxication, alcohol use). In patients with chronic liver disease, hepatic
encephalopathy is diagnosed based on the overall clinical presentation and not by an ammonia
level. It is important to remember that a normal ammonia level neither excludes nor confirms the
diagnosis of hepatic encephalopathy. This patient had an elevated serum ammonia level that was
found incidentally during his hospital admission for gastrointestinal bleeding. Because there is
no clinically significant encephalopathy, treatment based on ammonia levels is not indicated.
Lactulose, methotrexate, neomycin, or prednisone would not be appropriate.
A 33-year-old female presents with palpitations and excessive sweating. A physical examination
is normal. Laboratory findings include a TSH (thyrotropin) level of 0.02 µU/mL (N 0.40-4.00)
and a free T4 level of 3.9 ng/dL (N 0.7-1.9). Radionuclide scanning reveals no uptake. Which
one of the following would explain these findings?
A. Thyroid hormone resistance
B. Graves disease
C. A toxic nodular goiter
D. Excess thyroid hormone intake
E. A thyrotropin-secreting pituitary tumor correct answers ANSWER: D
Excess thyroid hormone intake would cause a low TSH (thyrotropin) level with a high free T4
level and no uptake on radionuclide scan. Other possibilities include an hCG-secreting tumor and
the thyrotoxic phase of subacute thyroiditis.
An elevated TSH (thyrotropin) level would be seen with thyroid-hormone resistance or a
thyrotropin-secreting pituitary tumor. Graves disease causes a homogeneous increased thyroid
uptake on radionuclide scanning, whereas a hot nodule would be expected with a toxic nodular
goiter.
,A 60-year-old male with type 2 diabetes comes to your office with an acute onset of fever, chills,
and malaise. He says that he is feeling progressively worse. His temperature is 40.0°C (104.0°F).
An examination reveals redness, tenderness, and swelling of the penis, scrotum, and perineal
area. Which one of the following medications is most likely to predispose this patient to this
condition?
A. Empagliflozin
B. Exenatide
C. Insulin glargine
D. Pioglitazone
E. Sitagliptin correct answers ANSWER: A
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) are associated
with a higher rate of genitourinary infections. Most often these are fungal in etiology, however
there are associations with more serious infections including necrotizing fasciitis of the perineum
(Fournier's gangrene). While rare, this is a life-threatening infection associated with this class of
medication that is being used more frequently to treat diabetes mellitus and other cardiac
conditions. Because of this risk, the FDA issued a Drug Safety Warning in 2018.
The drug classes that include exenatide, insulin glargine, pioglitazone, and sitagliptin are not
associated with genitourinary infections.
A 5-year-old male is brought to your office after passing an intestinal worm. He lives on a farm
with cattle, pigs, and dogs. He has never traveled very far from home. He does not have any
respiratory symptoms or diarrhea, but has experienced some abdominal bloating. His parents
bring a picture of the worm (shown below). Which one of the following is the infecting
organism? correct answers A. Ascaris lumbricoides (roundworm)
B. Enterobius vermicularis (pinworm)
C. Giardia lamblia
D. Necator americanus (hookworm)
E. Taenia solium (tapeworm)
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.
.
.
.
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.
.
.
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.
.
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,.
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ANSWER: A
This case and image are consistent with Ascaris lumbricoides infestation. A. lumbricoides is a
large roundworm that typically infects the ileum. Symptoms are variable but large infections can
lead to intestinal obstruction.
Pinworms (Enterobius vermicularis) are much smaller and typically present with anal pruritus.
Giardia lamblia is a microscopic protozoan parasite that is not visible on gross examination.
Hookworms (Necator americanus) are also round, but are typically 6-12 mm in length. They are
a significant cause of anemia in children globally. Tapeworms can be large, but are flat and
segmental in appearance, and are typically found in the stool as segments called proglottids.
A 58-year-old male with a history of tobacco use disorder and alcohol use disorder presents with
the sudden onset of many well circumscribed brown, oval, rough papules with a "stuck-on"
appearance on his trunk and proximal extremities (see image). On examination you also note an
unintentional 6-kg (13-lb) weight loss over the last 3 months and conjunctival pallor. A review of
systems is positive for abdominal pain, decreased appetite, and mild fatigue. You order a
laboratory workup. Which one of the following would be most appropriate at this point? correct
answers A. Reassurance that the skin lesions are benign
B. A skin biopsy
C. Referral to a dermatologist
D. CT of the abdomen and pelvis
E. Upper and lower endoscopy
.
.
.
.
.
.
.
.
.
.
.
, .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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.
.
ANSWER: E
The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic keratoses, which
is an unusual finding that often indicates an underlying malignancy, most commonly an
adenocarcinoma of the stomach. This patient's age, risk factors, red-flag symptoms, and other
clinical findings indicate the need for endoscopy.
Further skin evaluation and lifestyle changes, which are indicated, will not address the need for
evaluation of weight loss and other abnormal symptoms and findings. CT is not an initial
approach for diagnosing a suspected malignancy of the stomach or colon.
A 46-year-old female with a past medical history of polycystic ovary syndrome and migraine
headaches presents with bilateral, hyperpigmented patches along her mandible. The patches are
asymptomatic but bother her cosmetically and seem to be darkening. Which one of her
medications would be most likely to contribute to her melasma?
A. B-complex vitamins
B. Metformin
C. Oral contraceptives
D. Spironolactone (Aldactone)
E. Sumatriptan (Imitrex) correct answers ANSWER: C
Melasma is a progressive, macular, nonscaling hypermelanosis of skin exposed to the sun,
typically involving the face and more rarely the dorsal forearms. It is often associated with
pregnancy and the use of oral contraceptives or anticonvulsants. Although thought previously to
involve only activation of melanocytes, it is now seen as a complex syndrome involving an
interplay of keratinocytes, dermal mast cells, gene regulation, and vascular changes. Women are
more likely to be affected than men, and darker-skinned individuals with Fitzpatrick skin types
III-IV are more commonly affected. There are three common patterns of melasma that are
