ABFM ITE MID & FINAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES

ABFM ITE MID & FINAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
A 42-year-old Asian male presents for follow-up of elevated blood pressure. He
has no additional chronic medical problems and is otherwise asymptomatic. An
examination is significant for a blood pressure of 162/95 mm Hg but is otherwise
unremarkable.
Laboratory work shows that his BMP is within normal limits.
According to the American College of Cardiology/American Heart Association
2017 guidelines, which one of the following would be the most appropriate
medication to initiate at this time?
A) Clonidine (Catapres), 0.1 mg twice daily
B) Hydralazine, 25 mg three times daily
C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily
D) Metoprolol tartrate (Lopressor), 25 mg twice daily
E) Triamterene (Dyrenium), 50 mg daily
ANSWER: C
This patient has hypertension and according to both JNC 8 and American College of
Cardiology/American Heart Association 2017 guidelines, antihypertensive treatment
should be initiated. For the general non-African-American population, monotherapy with
an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a
thiazide diuretic would be appropriate for initial management. It is also appropriate to
initiate combination antihypertensive therapy as an initial management strategy,
although patients should not take an ACE inhibitor and an angiotensin receptor blocker
simultaneously. Studies have shown that blood pressure control is achieved faster with
the initiation of combination therapy compared to monotherapy, without an increase in
morbidity. Lisinopril/hydrochlorothiazide would be an appropriate choice in this patient.
Alpha blockers, vasodilators, beta-blockers, and potassium-sparing diuretics are not
recommended as initial choices for the treatment of hypertension.
A 36-year-old female presents for evaluation of elevated blood pressure. She is
asymptomatic and does not take any medications. On examination her blood
pressure is 160/96 mm Hg and her BMI is 26 kg/m2. Fasting laboratory studies
include the following:
Sodium 142.
Potassium 3.0.
Creatinine 0.76.
Glucose 97.
Which one of the following additional laboratory evaluations should be performed
to assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level
ANSWER: B
Primary hyperaldosteronism should be suspected as a cause for hypertension if a
patient has a spontaneously low potassium level or persistent hypertension despite the
use of three or more antihypertensive medications, including a diuretic. This can be
evaluated by checking a serum renin activity level and a serum aldosterone
concentration and determining the aldosterone/renin ratio. Primary hyperaldosteronism
typically presents with a very low serum renin activity level and an elevated serum
aldosterone concentration.
A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA) would be used to
evaluate for a neuroendocrine tumor, which can present as chronic flushing and
diarrhea. Cortisol levels can be checked if Cushing syndrome is suspected.
Hypertension can be present in Cushing syndrome, but it is typically associated with
other signs such as obesity and an elevated blood glucose level due to insulin
resistance. Cystatin C is a marker of renal function and measurement would not be
indicated given this patient's normal creatinine level.
A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a
rash on the extensor surfaces of his lower legs consisting of painful,
subcutaneous, nonulcerated, erythematous nodules. This rash is consistent with
which one of the following?
A) Erythema ab igne
B) Erythema infectiosum
C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum
ANSWER: E
Erythema nodosum, a panniculitis that typically affects the subcutaneous fat on the
anterior surface of the lower legs, is associated with coccidioidomycosis (valley fever)
and can suggest the diagnosis. It is a manifestation of the patient's immune response
and often indicates a good prognosis. In addition to coccidioidomycosis, it can also be
associated with streptococcal infections as well as tuberculosis.
Erythema ab igne is a cutaneous rash caused by prolonged heat exposure (such as a
heating pad) presenting as an otherwise asymptomatic, red, reticulated pattern on the
skin. Erythema infectiosum is associated with parvovirus B19 infection and is usually
seen in young children. It manifests as an erythematous rash of the face (slapped cheek
appearance), arms, and legs. Erythema migrans is an expanding, erythematous,
annular rash with or without central clearing and is often associated with tick exposure
(Lyme disease). Erythema multiforme consists of raised, annular, target-like lesions with
central erythema and is usually associated with herpes simplex virus type 1.

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