ABFM CKSA 24-25 Exam Study Guide 150 Questions with Correct Answers 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?
- Lactulose
- No additional treatment
- Methotrexate
- Neomycin
E. Prednisone - Correct Answer 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?
- Thyroid hormone resistance
- Graves disease
- A toxic nodular goiter
- Excess thyroid hormone intake
E. A thyrotropin-secreting pituitary tumor - Correct Answer 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. 1 / 4
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?
- Empagliflozin
- Exenatide
- Insulin glargine
- Pioglitazone
E. Sitagliptin - Correct Answer 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 Answer A.Ascaris lumbricoides (roundworm)
- Enterobius vermicularis (pinworm)
- Giardia lamblia
- Necator americanus (hookworm)
- Taenia solium (tapeworm)
.
. 2 / 4
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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. 3 / 4
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 Answer A. Reassurance that the skin lesions are benign
- A skin biopsy
- Referral to a dermatologist
- CT of the abdomen and pelvis
- Upper and lower endoscopy
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