Name

American Board of Family Practice

IN-TRAINING EXAMINATION
BOOK II: CLINICAL SET PROBLEMS
TIME1 HOUR
Read the instructions on the back first.
Do not break the seal until you are told to do so.

ttt SAMPLE ttt

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 2002 The American Board of Family Practice. All rights reserved.

PATIENT A
Options 111
A 65-year-old retired male university professor who is in vigorous health comes to you for a periodic health
examination. While palpating the abdomen you note a pulsatile mass left of the midline, between the xiphoid
and the umbilicus. You estimate that the mass measures about 34 cm, and suspect an abdominal aortic
aneurysm. When you discuss these findings with the professor, he asks how common this problem is.
Which of the following would be an accurate response to his question?
1.
2.
3.

It is more common in smokers

It is more prevalent in men
It is more common in people who have a first degree relative with an abdominal aortic aneurysm

Based on the estimated size of the mass, you determine that an imaging examination is required. Appropriate
choices include
4.
5.
6.
7.

plain abdominal radiography

$-mode ultrasonography
a CT scan
arteriography

The results of the imaging procedure indicate that the aneurysm measures 5.2 cm in diameter. You discuss
management options with your patient.
True statements about the natural history of the problem and surgical options include which of the following?
8.
9.
10.
11.

The annual risk of rupture for an aneurysm of this size is around 20%
Current guidelines from the Society for Vascular Surgery and the International Society for
Cardiovascular Surgery recommend following asymptomatic aneurysms between 5.0 and 7.0 cm
with an imaging examination every 6 months
In this patient, surgery should be delayed until the aneurysm reaches 7.0 cm
Once the aneurysm is repaired, the patient can expect a 5-year survival rate better than that of his
age-matched peers

PATIENT B
Options 1222
A 32-year-old white male visits your office complaining of pain of 12 hours duration in the
metatarsophalangeal joint of his left large toe. He says the joint is exquisitely tender to touch, and denies
any history of trauma. He takes no medications and was last seen by you 15 months ago for an unrelated
problem. Physical examination is within normal limits except for a large area of erythema extending over
his left large toe and up onto the dorsum of his foot. No lymphangitis is noted.
Tests which would help establish a definitive diagnosis include which of the following?
12.
13.
14.
15.
16.

A Grams stain of fluid aspirated from the joint

24-hour urine collection for protein
A radiograph of the foot and ankle
Microscopic examination for crystals in synovial fluid aspirate
Intravenous pyelography

Appropriate drug choices for initial management of this acute problem include which of the following?
17.
18.
19.
20.
21.
22.

Colchicine
Probenecid (Benemid)
Nafcillin (Unipen)
Prednisone
Indomethacin (Indocin)
Allopurinol (Zyloprim)
PATIENT C

Options 2335
A 33-year-old white male presents to your office with colicky flank pain radiating into a testicle. His
symptoms are similar to those he had when he passed kidney stones on two occasions in the past 3 years.
He was treated in emergency departments both times and never came in for follow-up evaluations. His
history and physical findings are otherwise unremarkable.
A KUB done on the same day demonstrates a 3-mm radiopaque calculus in the distal third of the right ureter.
Further management at this time should include
23.
24.

a renal MRI
urology referral for stone extraction

Analysis of the stone shows it to be calcium oxalate. Appropriate studies to obtain at this point include
25.
26.
27.
28.

serum calcium
24-hr urine for citrate, calcium, and oxalate
24-hr urine cystine
parathyroid hormone

You order a 24-hr urine for uric acid which is elevated. All other metabolic studies are normal.
Appropriate management would include
29.
30.
31.
32.
33.
34.
35.

encouraging large intakes of fluid on a regular basis

a low-sodium diet
a thiazide diuretic
potassium citrate
allopurinol (Zyloprim)
probenecid (Benemid)
a diet rich in nuts and leafy green vegetables
PATIENT D

Options 3645
You are called to the hospital to examine a male infant born 12 hours earlier. The mother had noticed that
the baby was not moving one of his arms, and asked that you be called immediately. The mother had a
difficult vaginal delivery after a labor of 18 hours. This is her first child. Apgar scores were 7 and 9. The
infant weighs 4800 g (10 lb 9 oz). When you examine the baby, you elicit a Moro response and note the
infants left arm stays motionless by his side, remarkably different from the normal movement of the right
arm. The remainder of the examination is within normal limits. Your tentative diagnosis is Erb-Duchenne
palsy.
Other possible diagnoses include
36.
37.
38.
39.

fracture of the left clavicle

intracranial hemorrhage
hypoglycemia
pyridoxine deficiency

Findings in this infant which are associated with an increased risk for Erb-Duchenne palsy include
40.
41.
42.
43.

birth weight
length of labor
mothers parity
Apgar scores

Appropriate advice to the parents would include which of the following?

44.
45.

Physical therapy with passive range of motion of the shoulder is indicated

The majority of infants with this condition have permanent residual arm weakness

PATIENT E
Options 4654
A 45-year-old white female presents with a 6-month history of abnormal uterine bleeding. It began with
intermenstrual spotting and has now progressed to moderate painless flow for 2 weeks of each month on an
irregular basis. She had a tubal ligation 10 years ago, and is otherwise healthy. Physical examination is
unremarkable except for moderate obesity and a slightly enlarged uterus.
Appropriate initial methods of obtaining endometrial tissue in this situation include
46.
47.
48.

a Papanicolaou test
outpatient endometrial biopsy
fractional dilatation and curettage under anesthesia

Histologic evaluation of tissue obtained from the patient reveals simple adenomatous endometrial
hyperplasia. Which of the following may be associated with this finding?
49.
50.
51.
52.
53.
54.

Polycystic ovarian disease

Obesity
Estrogen-producing tumors
Premature ovarian failure
Cyclic estrogen and progestin replacement therapy
Anovulatory perimenopausal ovaries
PATIENT F

Options 5568
As the physician in charge of the employee health clinic at a community hospital, you evaluate all potentially
positive reactions to the annual tuberculin skin testing. Everyone tested this year was asymptomatic, and the
test was administered 4872 hours before you saw them.
Which of the following reactions should be considered positive?
55.
56.
57.
58.

15 mm erythema without induration in a 27-year-old radiology technician

10 mm erythema and 10 mm induration in a 42-year-old emergency department nurse
10 mm erythema and 5 mm induration in a 32-year-old billing clerk who is HIV-positive
20 mm erythema and 20 mm induration in a 52-year-old maintenance worker who was previously
vaccinated with BCG

Which of the following should be included in the evaluation of those with positive reactions who previously
had negative skin reactions or are uncertain about previous skin reactions?
59.
60.
61.
62.
63.

A PA/lateral chest film

A lordotic chest film
Baseline (pretreatment) lipid levels if there is a history of hyperlipidemia
Baseline (pretreatment) liver function tests if there is a history of a liver disorder
Aerosolized saline-induced sputum for acid-fast bacilli smear, culture, and sensitivity testing

You decide to institute prophylactic treatment with isoniazid (INH) in a staff member who had a positive
reaction to the tuberculin skin test. Side effects of this drug regimen include
64.
65.
66.
67.
68.

peripheral neuropathy
drug-induced hepatitis
drug-induced hyperlipidemia
nausea, vomiting, and abdominal pain
acute urinary retention
PATIENT G

Options 6976
A 75-year-old Asian female comes to your office complaining of mid-back pain. She states that it began
while she was weeding her garden. She feels better when she is lying down but worse when she tries to
change position in bed. She denies any neurologic symptoms. On physical examination, palpation of the
back shows tenderness over the lower thoracic vertebrae. Pain is elicited on extension of the back. Findings
are normal on a straight leg raising test; strength and sensation are intact, and pulses are normal.
Radiographs show an anterior wedge deformity of T11.
Common sequelae of this injury include which of the following?
69.
70.
71.
72.

Spinal cord injury

Nerve root compression
Long-term severe pain
Loss of height

Appropriate therapy for this injury includes

73.
74.
75.
76.

2 weeks of strict bed rest

an exercise program once her pain is relieved
immobilization in a body spica cast for 2 weeks
spinal fusion

PATIENT H
Options 7787
A 66-year-old African-American male presents with a 2-day history of the abrupt onset of dizziness. As you
take additional history, which of the following facts should you keep in mind?
77.
78.
79.
80.

Loss of consciousness during a dizzy spell is not consistent with a purely vestibular dysfunction
Vertigo indicates dysfunction of the vestibular system, either peripherally or centrally
Serious central vestibular causes are present in less than 10% of cases
Hypoglycemia is a common cause of dizziness

The patient reveals that the dizzy spells last only a few seconds, and occur a few seconds after he rolls over
in bed or turns his head to the left. He experiences a severe swirling sensation and nausea which lasts for
about a minute and is relieved by lying very still. He has no tinnitus or headache, and there is no history of
trauma. He feels well otherwise, and has noted no other symptoms.
When placed in the Dix-Hallpike, head-hanging-left position, the patient is symptomatic and is noted to have
horizontal nystagmus with a slight rotary component. With repetitive head turning, the symptoms and the
nystagmus abate. There are no other significant findings on examination.
Tests indicated at this time include which of the following?
81.
82.
83.
84.
85.
86.
87.

An MRI scan of the brain

Holter monitoring
An automated chemistry panel
A CBC
Urinalysis
Tomography of the labyrinth system
Carotid duplex scanning
PATIENT I

Options 8897
A 25-year-old white male comes to the office with his wife because he has been feeling fatigued over the last
3 months. He says that he is always tired but does not sleep well. He usually falls asleep about 11 p.m.
but wakes up at 3 a.m. and is unable to get back to sleep. He cannot concentrate at work and has no energy
to complete tasks at home. He has stopped bowling with his league on Tuesday nights since he is not
interested in leaving the house. He is easily irritated and has been yelling in anger at his wife and toddler
at home, which is very uncharacteristic of his usual personality. He has a poor appetite and states that he eats
only because he knows he must. He denies fevers, chills, night sweats, trouble breathing, cough, or other
associated symptoms. He has no significant medical history. He takes no prescription medications, but has
been taking a mega-vitamin which he thought might help his fatigue. Physical examination is normal.

You decide to take some additional history. Pertinent areas to explore include
88.
89.
90.
91.

excessive use of alcohol

thoughts of suicide
urinary incontinence
use of over-the-counter medications

The history reveals no additional significant findings. You order laboratory tests which are all normal,
including a CBC, serum electrolytes, BUN, creatinine, serum glucose, liver enzymes, erythrocyte
sedimentation rate, and TSH.
Which of the following have been proven to help with this patients condition?
92.
93.
94.
95.
96.
97.

Cognitive psychotherapy
Citalopram (Celexa)
Diazepam (Valium)
Prednisone
Risperidone (Risperdal)
Ceftriaxone (Rocephin)
PATIENT J

Options 98104
A 50-year-old white male is brought to the emergency department via ambulance complaining of severe
substernal chest pain associated with nausea and diaphoresis. His blood pressure during transport is 90 mm
Hg systolic with a pulse of 120 beats/min. Upon arrival his pulse disappears and the monitor shows
ventricular tachycardia. Venous access has been established and he is receiving oxygen via mask.
At this time appropriate management options include
98.
99.
100.
101.

lidocaine (Xylocaine), 1 mg/kg intravenous push

procainamide (Procan), 20 mg/min intravenous infusion
cardioversion
a transvenous pacemaker

His rhythm stabilizes and you note evidence of an acute myocardial infarction on his EKG. Which of the
following should be taken into account when considering thrombolytic therapy?
102.
103.
104.

The degree of coronary artery obstruction

Whether the patient has a history of stroke
The time interval from the onset of symptoms

PATIENT K
Options 105114
During office hours you see a 5-year-old white male with right hip pain and a limp. His mother tells you that
he has had a cold for about 10 days and that it seemed to be clearing 4 days ago when his hip pain began.
Your history discloses no other systemic or joint symptoms, and there has been no trauma to the hip.
Physical Findings
Weight . . . . . . . . . . . . . . . . . . . . .
Height . . . . . . . . . . . . . . . . . . . . . .
Temperature . . . . . . . . . . . . . . . . .
Pulse . . . . . . . . . . . . . . . . . . . . . . .
Blood pressure . . . . . . . . . . . . . . .

18 kg (40 lb)
107 cm (42 in)
38.0 C (100.4 F)
92 beats/min
88/64 mm Hg

Physical examination reveals no abnormal findings except for slight flexion, abduction, and external rotation
when the patient walks; his right hip motion shows limited passive internal rotation and abduction. There
are no other joint findings.
Based on these findings, which of the following diagnoses should be considered?
105.
106.
107.
108.

Septic arthritis
Transient monoarticular synovitis
Osteomyelitis
Slipped capital femoral epiphysis
Laboratory Findings
Hemoglobin . . . . . . . . . . . . . . . . .
Hematocrit . . . . . . . . . . . . . . . . . .
WBCs . . . . . . . . . . . . . . . . . . . . . .
Erythrocyte sedimentation
rate . . . . . . . . . . . . . . . . . . . . . .

12.0 g/dL (N 11.513.5)

40% (N 3440)
10,200/mm3 (N 550015,000)
30 mm/hr (N 010)

A rapid direct antigen test is negative for $-hemolytic streptococci. Radiographs of the right hip show
normal anteroposterior and frog lateral views.
You order additional diagnostic studies and receive the following results:
Technetium bone scan . . . . . . . . .
Synovial fluid analysis . . . . . . . . .
Blood glucose . . . . . . . . . . . . . . . .
Blood cultures . . . . . . . . . . . . . . . .

no areas of abnormal uptake

clear; 60 WBCs/mm 3 ; glucose 98 mg/dL;
Grams stainno organisms
100 mg/dL
pending

Based on this information, treatment options include which of the following?

109.
110.
111.
112.
113.
114.

Systemic corticosteroids
Intravenous antibiotics
Surgical drainage
Casting or bracing with the femur abducted
Acetaminophen
Surgical stabilization
PATIENT L

Options 115123
A 27-year-old female presents with a 4-month history of amenorrhea. She denies any change in weight; she
performs aerobic exercise three times a week for 30 minutes at a time. Her periods previously occurred
regularly every 2830 days, and lasted 4 days. She denies any galactorrhea or changes in body hair. She is
160 cm (63 in) tall and weighs 54 kg (119 lb). A physical examination is unrevealing. Her past medical
history is significant for two miscarriages and subsequent dilatation and curettage with both.
Her initial evaluation should include
115.
116.
117.

a CBC
a fasting blood glucose level
a pregnancy test

Initial studies are negative. Which of the following should be ordered now?
118.
119.
120.

A TSH level
A prolactin level
A coned-down view of the sella turcica

Medroxyprogesterone acetate (Provera), 10 mg for 5 days, does not produce withdrawal bleeding, but a cycle
of combined estrogen-progesterone does.
Which of the following would be acceptable to order next?
121.
122.
123.

An FSH level
An endometrial biopsy
Karyotyping

PATIENT M
Options 124136
A 70-year-old white female who has been living at home is admitted to the hospital with a 5-day history of
persistent cough, fever and chills, and shortness of breath. She has had no previous illnesses which she
considers pertinent. She has had no operations. She does not drink alcohol, and stopped smoking 3 years
ago after a 60 pack/year history.
Physical Findings
Height . . . . . . . . . . . . . . . . . . . . . .
Weight . . . . . . . . . . . . . . . . . . . . .
Blood pressure . . . . . . . . . . . . . . .
Pulse . . . . . . . . . . . . . . . . . . . . . . .
Respirations . . . . . . . . . . . . . . . . .
Temperature . . . . . . . . . . . . . . . . .

160 cm (63 in)

54 kg (119 lb)
130/86 mm Hg
120 beats/min
24/min
38.9 C (102.0 F)

Examination reveals an ill-appearing, tachypneic woman. Positive findings are limited to the chest; there
are generalized rhonchi with bronchial breath sounds, rales, and dullness to percussion over the right base.
Laboratory Findings
Hemoglobin . . . . . . . . . . . . . . . . .
WBCs . . . . . . . . . . . . . . . . . . . . . .
PaO2 . . . . . . . . . . . . . . . . . . . . . . .
PaCO2 . . . . . . . . . . . . . . . . . . . . . .
Chest film . . . . . . . . . . . . . . . . . . .
Sputum Grams stain . . . . . . . . . .

15.4 g/dL (N 1216)

18,200/mm3 (N 430010,800), 90% segs, 3%
bands
49 mm Hg (N 75100)
34 mm Hg (N 3545)
right lower lobe consolidation, no effusion
polymorphonuclear leukocytes with grampositive intracellular diplococci; a few
squamous cells are present

Initial management of this patient should include which of the following?

124.
125.
126.
127.

Pulmonary function testing

Bronchoscopy
Endotracheal intubation
Blood cultures

Reasonable choices for single antibiotic therapy in this patient include

128.
129.
130.
131.

doxycycline (Vibramycin)
levofloxacin (Levaquin)
gentamicin (Garamycin)
cefixime (Suprax)

10

After 5 days of appropriate treatment, the patient is afebrile; arterial blood gases show a PaO2 of 64 mm Hg
with a PaCO2 of 42 mm Hg; a urinalysis is normal. The patient is comfortable, and she is discharged from
the hospital. She continues to do well at home. At a follow-up visit after 3 weeks, chest radiographs reveal
clearing of the infiltrate. Pulmonary function testing reveals moderately increased total lung capacity,
decreased vital capacity, and decreased forced expiratory volume in 1 second (FEV1 ) which is unaffected
by bronchodilators.
Management at this time should include
132.
133.
134.
135.
136.

administration of home oxygen

continuous antibiotic therapy
an expectorant
a $-agonist by intermittent positive pressure breathing (IPPB)
corticosteroids every other day
PATIENT N

Options 137147
A 31-year-old African-American female at 41.5 weeks gestation is in labor. The nurse calls to tell you that
the patient is dilated to 5 cm and just had a spontaneous rupture of membranes, and that the fluid contains
thick meconium. The fetal heart rate pattern is reassuring and the patient has had a good labor pattern with
good progress so far.
Appropriate actions at this time include which of the following?
137.
138.
139.

Notify surgery to prepare for an urgent cesarean section

Start oxytocin (Pitocin) to augment labor
Instruct the nurse to have a DeLee suction available at delivery

True statements regarding the passage of meconium include which of the following?
140.
141.
142.

Thick meconium is less toxic to pulmonary tissue than thin meconium

This infant is very unlikely to develop meconium aspiration syndrome
Intervention at delivery can reduce this infants risk of meconium aspiration syndrome

As you are preparing to leave your office, the nurse pages you again to tell you the baby is crowning and
delivery is imminent. You rush to the delivery room in time to attend the delivery.
You manage the infant with which of the following?
143.
144.
145.
146.
147.

Suction of the pharynx before delivery of the shoulders

Tracheal suctioning dependent on the vigor of the infant
Saline lavage of the airway
Immediate intubation and positive pressure mechanical ventilation
Instillation of surfactant into the airway

11

PATIENT O
Options 148160
A 75-year-old white male who has been vigorous and healthy comes to your office for his annual influenza
immunization and routine evaluation. He describes some vague symptoms of fatigue and weakness, but
attributes them to his advancing age. He reports no specific symptoms on a thorough review of systems, and
his physical examination is unremarkable aside from conjunctival pallor. A hemoglobin measurement in
your office is 10.0 g/dL.
The initial evaluation of this patients anemia should include
148.
149.
150.
151.
152.

a CBC
a serum vitamin B12 level
a serum iron level
a serum folate level
a reticulocyte count

The results of this evaluation lead you to suspect that your patient suffers either from anemia of chronic
disease or from iron deficiency anemia. Laboratory tests that will help differentiate these disorders include
which of the following?
153.
154.
155.
156.

Serum methylmalonic acid

Serum homocysteine
Serum iron and total iron-binding capacity
Serum ferritin

You diagnose iron deficiency anemia and begin replacement with oral elemental iron. Appropriate additional
evaluation would include
157.
158.
159.
160.

upper gastrointestinal endoscopy

colonoscopy
a reticulocyte count in 1 week
stool for occult blood

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.

12

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 setting 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 is found to be mildly hypertensive, with blood pressure measurements in
the range of 145/100 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 prior to starting therapy include
1.
2.
3.
4.
5.
6.

serum potassium
serum cortisol
fasting and 2-hour postprandial blood glucose
urinalysis
24-hour urine for metanephrine
rapid sequence intravenous pyelography

Reasonable management for this patient includes which of the following?

7.
8.
9.
10.

Weight reduction diet

Restricting daily protein intake to 40 g
Advising the patient to avoid caffeine
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, and 10 are false, so the circle containing the F
has been filled in for these numbers.