Name

American Board of Family Practice

IN-TRAINING EXAMINATION
BOOK II: CLINICAL SET PROBLEMS
TIME–1 HOUR

Read the instructions on the back first.

Do not break the seal until you are told to do so.

*** SAMPLE ***

1 Write your name in the blank at the top of the

page.

2. Record your Program Number, Resident Number,

and Residency Year on the answer sheet, as shown
in the sample on the right. Be sure to fill in both
the boxes and the circles.

Publication or reproduction in whole or in part is strictly

prohibited.
Copyright © 2004 The American Board of Family Practice. All rights reserved.
 PATIENT A

Options 1–10

A 16-year-old white female comes to the emergency department with the chief complaint of profuse vaginal
bleeding for the past 10 days. She denies being sexually active. Menarche was at 13 years of age, and her
periods are generally irregular with intervals of 14–31 days. She describes the flow as “heavy with clots.”
She complains of no abdominal pain or urinary difficulties.

On examination she is pale and her temperature is 37.2° C (99.0° F), pulse 124 beats/min, respirations
normal, and blood pressure 85/50 mm Hg supine. A pelvic examination reveals a vagina full of clots and
a normal uterus with a closed cervical os. There is no adnexal mass or tenderness; the ovaries are not
palpable.

Which of the following should you order at this time?

1. A pelvic CT scan
2. A CBC
3. A $-hCG level
4. An endometrial biopsy
5. Coagulation studies
6. Blood typing and screening

Your workup points to a diagnosis of dysfunctional uterine bleeding. Initial management options include

7. a combination oral contraceptive pill

8. uteri ne curett age
9. high-dose intravenous estrogen
10. intramuscular medroxyprogesterone acetate (Depo-Provera)

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 PATIENT B

Options 11–18

A 45-year-old white male presents with a 2-month history of sleep disturbance (early morning awakening),
loss of appetite with a 5-lb weight loss, difficulty concentrating, sadness, and feeling “worthless.” He is
recently divorced and living alone. He has a history of two previous episodes of major depression requiring
treatment with antidepressants; with both episodes, he stopped taking his medications after approximately
6 months. He is a nonsmoker and says that his alcohol consumption is limited to one glass of wine per night.
His only current medications are hydrochlorothiazide for hypertension and simvastatin (Zocor) for
hypercholesterolemia. The review of systems is otherwise negative.

On physical examination, you note a flat affect, good hygiene, normal vital signs, and normal findings on
cardiovascular, pulmonary, abdominal, rectal, and neurologic examinations. A CBC, a chemistry profile,
and thyroid tests are unremarkable.

In addition to beginning an antidepressant, which of the following would be approp ri ate at this time?

11. Asking about suicidal ideation and pl ans

12. Discontinuing his other current medications
13. Cautioning him that alcohol may disrupt his sleep cycle
14. A CT sc an of the abdomen
15. An MRI sc an of the brain

Four weeks later he reports feeling much improved, with minimal side effects from his medication. At this
time, your plans should include

16. reducing his antidepressant medication to a low maintenance dose

17. consideri ng lifelong antidepressant therapy
18. referral to a psychiat ri st for long-term psycho analytic treatment

PATIENT C

Options 19–27

At a 6-week postpartum visit, a 24-year-old white female reports weight loss below pre-pregnancy levels.
She also reports excessive sweating, weakness, and heat intolerance. She is successfully breastfeeding.

A physical examination reveals a pulse rate of 124 beats/min, moist skin, mild thyromegaly, and an upper
eyelid 1 mm above the upper corneal limbus.

When conside ring possible diagnoses in this case, which of the following would be true?

19. Subacute thyroiditis may present with painless thyrotoxicosis

20. Multinodular goiters are the most common cause of hyperthyroidism
21. Graves’ disease is more likely to occur in elderly males

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Which of the following tests would now be indicated?

22. A TSH level

23. A free thyroxine (T 4 ) level
24. An antinuclear antibody level

If hyperthyroidism is confirmed, which of the following treatments would be approp ri ate?

25. Propranolol (Inderal)

26. Subtotal thyroidectomy
27. Radioactive iodine

PATIENT D

Options 28–39

A 22-year-old African-American primigravida is now at 42 weeks gestation by menstrual dates. She is

becoming increasingly anxious and frustrated because her due date has passed.

Which of the following would help determine the accuracy of the estimated gestational age?

28. Findings on first-trimester ultrasonography

29. Findings on second-trimester ultrasonography
30. Ultrasonography obtained now
31. Consistency of uterine size with dates in the first trimester
32. Documentation of a positive pregnancy test at the first visit

Risks to the fetus from a post-term pregnancy include which of the following?

33. Placental insufficiency

34. Meconium aspiration
35. Macrosomia
36. Polyhydramnios

On vaginal examination the cervix is soft, 50% effaced, and 2 cm dilated. The infant is in cephalic
presentation. The fundal height is 41 cm, and has increased steadily each week. The patient’s blood pressure
is 100/65 mm Hg, and her urine is clear and free of glucose or protein.

After discussion with the patient regarding ri sks and options, appropriate m an agement might include which
of the following at this time?

37. Routine follow-up in 1 week

38. Admission for induction of labor
39. Admission for elective cesarean section

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 PATIENT E

Options 40–52

A 45-year-old Hispanic female presents to the emergency department with severe abdominal pain of 8 hours’
duration. The pain is sharp, constant, and maximal in the upper abdomen, and radiates toward the back. She
vomited once 6 hours ago, but did not notice any blood in the emesis. She has no past history of chronic
medical illness, and does not take any prescription medications. She smokes one pack of cigarettes daily and
denies alcohol or illicit drug use.

Physical Findings

Blood pressure 110/70 mm Hg

Pulse 110 beats/min
Respirations 16/min
Temperature 37.2° C (99.0° F)
Skin normal turgor
Eyes conjunctiva red, sclera not icteric
Pharynx normal
Lungs clear to auscultation and percussion
Heart tachycardia, regular rhythm, no murmurs
Abdomen decreased bowel sounds, very tender to
palpation of epigastrium, no rebound; liver
and spleen normal size
Rectal guaiac-negative stool
Neurologic normal

After completing your examination, you obtain the following laboratory data:

Laboratory Findings
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WBCs 13,000/mm (N 4000–10,000)
Segs 80%
B an ds 5%
Lymphocytes 15%
Hemoglobin 14 g/dL (N 12–16)
Hematocrit 44% (N 37–48)
3
Platelet count 300,000/mm (N 130,000–400,000)
Sodium 144 mEq/L (N 136–145)
Potassium 3.7 mEq/L (N 3.5–5.0)
Chloride 108 mEq/L (N 98–106)
CO 2 22 mEq/L (N 21–30)
BUN 35 mg/dL (N 10–20)
Creatinine 1.4 mg/dL (N 0.6–1.5)
AST (SGOT) 22 U/L (N 0–35)
Amylase 600 U/L (N 60–180)
Lipase 450 U/L (N 0–160)
Urinalysis specific gravity 1.020, 1–2 WBC/hpf, 1–2
RBC/hpf

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Diagnostic studies generally indicated to determine the etiology of this patient’s illness include

40. a serum triglyceride level

41. right upper quadrant abdominal ultrasonography
42. an acetaminophen level
43. a Helicobacter pylori antibody titer

Which of the following additional studies would be useful in helping to predict the degree of morbidity and
mortality associated with this condition?

44. A serum glucose level

45. A serum calcium level
46. An LDH level
47. A pO2
48. An abdominal CT scan

You decide to admit the patient to the hospital for continuing care. Appropriate initial therapeutic
interventions would include which of the following?

49. A low-fat, low-sodium diet

50. Ranitidine (Zantac), 50 mg intravenously every 8 hours
51. Morphine sulfate intravenously, as needed for pain
52. Intravenous normal saline at 150–200 cc/hr

PATIENT F

Options 53–60

An unusual number of lead poisoning cases have been found in young children in your community recently.
The health department has asked you to designate approp ri ate populations to be screened.

You would advise screening

53. residents of housing constructed p ri or to 1950

54. all farm workers
55. playmates of children with lead poisoning
56. children who eat more than two servings of tuna or swordfish per week

You are also asked to recommend secondary preventive measures. Approp ri ate actions in areas where high
levels of lead are found might include

57. residential paint hazard remediation

58. high-efficiency particulate air vacuuming
59. soil abatement
60. abrasive blasting of lead-contaminated walls in older buildings

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 PATIENT G

Options 61–72

A 41-year-old female accountant comes to your office concerned about information she has seen on the
Internet recommending universal hepatitis C testing. She complains of fatigue and has been told by another
doctor that she has chronic fatigue syndrome. A review of systems is otherwise negative.

You counsel her that patients at high risk for hepatitis C include

61. injection drug users who share needles

62. sexual partners of persons who have hepatitis C
63. recipients of blood transfusions p ri or to 1992
64. recipients of long-term hemodialysis
65. household contacts of persons with hepatitis C

After assessing her level of risk, you order a serum anti-HCV antibody which is positive, and subsequent
laboratory studies show an abnormally elevated ALT (SGPT) and an HCV RNA level of 1 million
copies/mL.

Appropriate management at this time would include

66. a serum ceruloplasmin level

67. hepatitis B serologic studies
68. hepatitis C genotype analysis
69. referral to a specialist for further evaluation
70. a CT scan of the abdomen

The patient is subsequently diagnosed with hepatitis C, and e-mails your office with further concerns. In
response to her questions, which of the following would be accurate?

71. The current risk of contracting chronic hepatitis C from a blood transfusion is estimated at 1.0%
per unit tran sfused
72. Consumption of more than one alcoholic beverage per day is associated with a higher ri sk of
progressing to liver failure

PATIENT H

Options 73–80

At a routine office visit, a 55-year-old female tells you about a long history of an intermittent “crawling”
sensation in her legs at night, which has become more frequent in the past year. She says that the sensation
is difficult to describe, but when pressed says it feels like “worms crawling under my skin.” After taking
additional history, you suspect the diagnosis of restless legs syndrome (RLS).

6
Which of the following would be consistent with this syndrome?

73. Stereotyped, repetitive flexion of the limbs

74. A compelling urge to move the limbs, usually associated with paresthesias/dysesthesias
75. Symptoms that are worse at rest, or present only at rest
76. Involvement of only one leg at a time during most episodes, but not necessa ri ly the same leg each
time
77. A normal neurologic examination

On the basis of your history and physical examination, you determine that the patient fulfills the diagnostic
c riteria for RLS. Laboratory tests helpful in identifying secondary causes include

78. a fasting serum glucose level

79. a serum creatinine level
80. sleep studies (polysomnography)

PATIENT I

Options 81–90

A 22-year-old male presents with a painless mass on the right side of his neck. He reports that it has been
enlarging for several months. On examination the mass feels rubbery and discrete, and a few shot-sized
mobile lymph nodes are palpated on the left side of the neck. No other lymph nodes are palpated and the
liver and spleen are not enlarged. The patient is afebrile, with normal vital signs. He is otherwise healthy
and on no medications.

His initial evaluation should include

81. a postero anteri or chest film

82. a liver biopsy
83. exploratory laparotomy
84. lymphangiography
85. a bone marrow biopsy

Microscopic evaluation of a biopsy sample from the ri ght neck mass reveals Reed-Ste rnberg cells with a
lymphocyte predominance in the lymph node. Additionally, the patient begins to complain of pain in his
thoracic spine, and an area of tende rn ess is discovered from about T8 to T10.

Appropriate staging procedures at this time would include

86. a thoracic CT scan

87. an abdominal/pelvic CT scan
88. a brain CT scan
89. staging laparotomy
90. a lumbar puncture

7
 PATIENT J

Options 91–105

A 69-year-old white male undergoes aortofemoral bypass grafting and awakens from an esthesia with some
clinical manifestations of a stroke. You are called to the recovery room to help with evaluation and
management.

The patient’s previous medical history includes lumbar disk surgery under general anesthesia about 15 years
ago an d an uncomplicated myocardial infarction (MI) 12 years ago. He has had no subsequent an gina
pectoris. An EKG performed about 6 months ago showed only residual changes fr om the MI. The patient
stopped smoking after his MI and dri nks a glass or two of wine most evenings with dinner. His current
medications are enteric-coated aspi rin, 81 mg daily; atorvastatin (Lipitor), 40 mg daily; a multivitamin
capsule daily; and sildenafil (Viagra), 50 mg.

Likely intraoperative causes of stroke in this patient include which of the following?

91. Paroxysmal atrial premature beats

92. Hypotension
93. Fat embolism
94. Bleeding diathesis
95. Septic embolism

When you reach the recovery room, the patient is awake and responding to external stimuli. Your
examination shows findings suggestive of an acute, dense cortical stroke that you suspect is confined to the
left middle cerebral artery distribution. The patient is right-handed.

Likely neurologic findings on examination include

96. hemiparesis of the contralateral side

97. hemiplegia of the ipsilateral side
98. impaired speech
99. paralysis of the eye with ptosis an d miosis (Horner’s syndrome) on the contralateral side
100. bilateral blindness

Which of the following would be appropriate in the evaluation of this patient?

101. A prothrombin time

102. An MRI scan
103. A lumbar puncture
104. An EKG
105. An EEG

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 PATIENT K

Options 106–117

A 25-year-old male is working on an antique car when the radiator cap blows off, scalding his face, chest,
and arms. Within 30 minutes he arrives at the emergency department where you are on call. He is in severe
pain. His pulse rate is 120 beats/min and his respiratory rate is 30/min, but other vital signs are normal.
Examination of his skin reveals large areas that are dry and red, and that blanch on mild pressure. These
areas are painful an d cover much of his face, chest, and anterior arms, but not his hands. In addition, there
are areas on the chest and arms that are red, moist, weeping, and covered with blisters. These areas also
blanch with pressure and are very painful to contact with air. You estimate that these blistered areas cover
approximately 8% of the patient’s total body surface area.

At this time, which of the following would be included in your diagnosis?

106. Superficial burn (first degree)

107. Superficial partial-thickness burn (superficial second degree)
108. Full-thickness burn (third degree)
109. Pulmonary edema

The patient’s pulse and respirations normalize within a short time. At this point, appropriate initial treatment
would include

110. hyperbaric oxygen therapy

111. cooling the burned areas with normal saline dressings
112. cleansing wounds with povidone-iodine solution (Betadine)
113. application of silver sulfadiazine cream (Silvadene) to chest and arm burns
114. application of a sterile dressing to significant burns

Which of the following would be appropriate advice to the patient?

115. He must be admi tted to the hospital for observation and treatment
116. There is no danger of hypertrophic scar ri ng
117. There is a strong possibility that skin grafts will be necessary

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 PATIENT L

Options 118–124

A 14-month-old white male has a 1-week history of recurrent high fever up to 103.0° F. Symptoms have
included conjunctivitis; dry, red, fissured lips; red palms; and mild edema of the hands and feet. Before this
episode, the child was last seen for his 12-month visit, and his immunizations were updated at that time.
Physical examination reveals nonexudative conjunctivitis, an injected pharynx, cervical adenopathy, and a
maculopapular rash. The remainder of the examination is unremarkable.
3
A CBC is normal except for a platelet count of 1,200,000/mm (N 130,000–400,000). Serum electrolyte
levels and liver function tests are within normal limits. Additional laboratory findings include the following:

Erythrocyte sedimentation rate . . . 88 mm/hr (N 0–20)

ASO titer ............................................ negative
Chest film ........................................... no infiltrates or adenopathy
Blood culture (×3) .............................. negative at 48 hours
Throat culture ..................................... no growth of $-hemolytic streptococci

Since the child has not improved with symptomatic care, you decide to admit him for further evaluation and
treatment. Appropriate management at this point would include

118. the addition of an aminoglycoside such as gentamicin (Garamycin) to the regimen

119. surgical consultation for biopsy of a cervical lymph node
120. an echocardiogram
121. aspirin, 80–100 mg/kg/day
122. intravenous (-globulin infusion

The patient becomes afeb ri le after 24 hours. Approp ri ate follow-up would include

123. administration of all vaccines at the usual time

124. se ri al cardiovascular examinations after discharge

PATIENT M

Options 125–132

Your local county health department surveillance data indicates that the rates of sexually transmi tted diseases
(STDs) among adolescents in your community are much higher than the state’s average. As a
community-o ri ented family physici an you are asked to chair a task force to help the community address this
problem. One of your first tasks is to identify the population of adolescents who are at highest ri sk for STDs.

10
According to the latest evidence, which of the following factors should be included in your ri sk assessment?

125. A history of multiple sexual partners

126. A history of inconsistent condom use
127. The frequency of alcohol use
128. The frequency of marijuana use
129. The ages of sexual partners

As you consider a program for addressing the STD problem, in addition to identifying the target population
you must also decide which STDs to target and which method of screening is best.

True statements regarding infectious agents in adolescents aged 15–19 include which of the following?

130. Trichomonal infection is the most prevalent reportable STD

131. The highest rates of Neisseria gonorrhoeae infection occur in sexually experienced males
132. The highest rates of Chlamydia trachomatis infection occur in sexually experienced females

PATIENT N

Options 133–144

A 60-year-old female presents to the emergency department with new-onset chest pain of 3 hours’ duration.
Which of the following, if present in her history, would increase her baseline probability of having coronary
artery disease?

133. Diabetes mellitus

134. Current cigare tte smoking
135. The death of her mother fr om a myocardial infarction (MI) at age 63
136. An HDL cholesterol level of 70 mg/dL
137. A history of hypertension treated with medication, with a current blood pressure of 120/80 mm
Hg

The patient’s EKG indicates an acute anterior MI, but her CK-MB and troponin levels are normal. Which
of the following would now be appropriate?

138. Oral aspirin

139. Sublingual nitroglyce ri n
140. Intravenous morphine sulfate
141. Intravenous heparin
142. Assessment for immediate reperfusion
143. Admission to the intermediate-care unit
144. Oxygen, 2 L by nasal cannula

11
 PATIENT O

Options 145–154

A 51-year-old nulliparous married female presents with 4 weeks of irregular vaginal bleeding amounting to
light spotting every 2–3 days. She is sexually active but uses no birth control because of her history of
infertility. She says she has been overweight most of her adult life an d has been told she is “borderline”
diabetic. Menarche was at age 11. Her periods have always been infr equent, occurring every 60–90 days
and lasting 7–10 days. She is now experiencing hot flashes.

The physical examination is unremarkable except for a BMI of 29 and the presence of coarse hair under her
chin and around her areola.

Which of the following would be appropriate at this time?

145. A CBC
146. A pregnancy test
147. A serum TSH level
148. A serum aldosterone level
149. 24-hr urine for vanillylmandelic acid

As part of the workup you perform an endomet ri al biopsy. The results are reported as adenomatous
hyperplasia without atypia. Other significant laboratory findings include a fasting serum glucose level of
154 mg/dL (N 70–110) and a hemoglobin A 1c level of 7.8%.

Appropriate INITIAL management at this point would include

150. dilatation an d curettage

151. conjugated estrogens (Premarin), 0.625 mg/day
152. medroxyprogesterone (Provera), 10 mg/day for 10–14 days monthly for 3 months
153. metformin (Glucophage), 500 mg/day
154. spironolactone (Aldactone), 25 mg/day

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 PATIENT P

Options 155–160

A 28-year-old white female delivers a 1985-g (4 lb 6 oz) girl spontaneously at 35 weeks gestation. The
pregnancy was complicated by third-trimester bleeding secondary to placenta previa. At the time of delivery,
the mother’s hematocrit is 31%.

The infant has no major problems during her hospital stay and is discharged 6 days after delivery. At the
time of discharge the infant weighs 1840 g (4 lb 1 oz) and has a hematocrit of 40%. The mother has elected
to bottle feed the infant.

Which of the following would increase the probability of the infant developing iron deficiency?

155. The infant’s hematocrit

156. The mother’s hematocrit
157. Premature delivery

At her 1-year
3 checkup, the infant’s hematocrit is 30% (N 33–42), with a mean corpuscular volume (MCV)
of 64 :m (N >70). The diagnosis of iron deficiency anemia can be confirmed by which of the following?

158. Elevated serum ferritin

159. Elevated transferrin saturation
160. A rise in the hemoglobin concentration following a therapeutic trial of ferrous sulfate

END OF BOOK

Please check the top of your answer sheet to insure that your
Program Number, Resident Number, and Residency Year are filled in correctly.

13
 GENERAL INSTRUCTIONS

This book is designed to assess certain aspects of clinical problem solving.

Each problem in this section of the examination consists of a clinical framework in which information is
given about a patient. You will be asked to make choices regarding diagnosis and management. You will
be directed in your decision making by questions or incomplete statements, which will be followed by a
group of options, each of which is either true or false. You should presume that all the options listed are
available in the se tting of the case. You should also be aware that in some groups of options the choices
could be either all true or all false.

Use the answer sheet enclosed in this test book. Every option must be marked either “T” for True or “F” for
False on the answer sheet. An option that is not marked either “T” or “F” will be counted as incorrect. There
is no penalty for guessing; however, any option that is marked both “T” and “F” will be counted as wrong.

The answer sheet you will be using is designed to accommodate 160 options, which is the exact number of
options in this test book.

SAMPLE PROBLEM

Patient A

A 45-year-old business executive has blood pressure measurements in the r an ge of 135/95 mm Hg on three
successive visits to your office. The patient is approximately 20 lb overweight; otherwise, the physical
examination is unremarkable. The family history is negative.

Minimum baseline laboratory tests which should be obtained p ri or to starting therapy include

1. serum potassium
2. serum cortisol
3. fasting and 2-hour postprandial blood glucose
4. urinalysis
5. 24-hour urine for metanephrine
6. rapid sequence intravenous pyelography

Reasonable management for this patient includes which of the following?

7. A weight-reducing diet
8. Restricting daily protein intake to 40 g
9. Advising the patient to avoid caffeine
10. Advising the patient to avoid alcohol

Options 1, 4, and 7 are true for the sample problem above, so the circle containing the “T” has been filled
in for the corresponding numbers. Options 2, 3, 5, 6, 8, 9, an d 10 are false, so the circle containing the “F”
has been filled in for these numbers.