ABFM Practice Questions (2026) — Free Sample Questions with Answers

Answer: D

Naproxen 500 mg twice daily: NSAIDs can cause acute kidney injury and should be avoided at an eGFR below 30.

Low-dose colchicine: Contraindicated here: clarithromycin, a strong CYP3A4 and P-glycoprotein inhibitor, with kidney impairment can cause fatal colchicine toxicity.

Allopurinol 100 mg daily alone: Urate-lowering therapy does not treat a flare, and starting it without anti-inflammatory cover can worsen symptoms.

Oral prednisone 30–40 mg daily for 5 days: Correct. This is a typical gout flare. The ACR 2020 guideline lists colchicine, NSAIDs and glucocorticoids as first-line options, and here comorbidity decides. Stage 4 CKD rules out NSAIDs, and clarithromycin with reduced kidney function makes colchicine dangerous. A short course of oral glucocorticoids is effective and safe for him, since he has no diabetes.

Probenecid 250 mg twice daily: A uricosuric that does not treat flares and is ineffective at low eGFR.

Choose gout flare therapy by comorbidity: avoid NSAIDs in advanced CKD and avoid colchicine with strong CYP3A4/P-gp inhibitors; a short glucocorticoid course is the safe option.

Answer: E

Wait until the COWS score is above 24 before buprenorphine: Unnecessary delay and suffering; mild-to-moderate withdrawal (COWS about 8–12 or higher) is enough to start safely.

Oral naltrexone 50 mg today: Naltrexone requires 7–10 days without opioids; giving it now would cause severe precipitated withdrawal.

Clonidine taper without opioid agonist therapy: Withdrawal management alone has high relapse and overdose rates; it does not treat opioid use disorder.

Prescribe methadone tablets from the office: Methadone for opioid use disorder can be dispensed only through a certified opioid treatment program, not by office prescription.

Buprenorphine-naloxone 4 mg now, reassessing in 1–2 hours: Correct. He is in objective moderate withdrawal (COWS 14) from a short-acting opioid, with no fentanyl or methadone exposure, so buprenorphine can be started with little risk of precipitated withdrawal. Give 2–4 mg, repeat as needed toward 8–16 mg on day 1, and co-prescribe naloxone. Since 2023 any clinician with a standard DEA registration that includes Schedule III can prescribe buprenorphine for opioid use disorder; no X-waiver is needed.

Start buprenorphine once objective withdrawal is present (COWS about 8–12 or more); no X-waiver is needed, and naloxone should be co-prescribed.

Answer: B

Major depressive disorder: A history of a distinct hypomanic episode excludes unipolar depression; screening for past mania or hypomania is essential before starting an antidepressant.

Bipolar II disorder: Correct. Under DSM-5-TR, a current major depressive episode plus at least one past hypomanic episode (4 or more days of raised energy and activity, noticed by others, with no marked impairment, psychosis or hospitalization) is bipolar II disorder. It matters now because antidepressant monotherapy can trigger mood switching. Her past episode was not severe enough for mania, which rules out bipolar I.

Bipolar I disorder: The runner-up: bipolar I requires a manic episode (7 days, or any length if hospitalized, with marked impairment or psychosis); she kept working without impairment.

Cyclothymic disorder: Requires 2 years of subthreshold mood symptoms without ever meeting full criteria for a major depressive episode; she meets them now.

Borderline personality disorder: Features hours-long mood shifts tied to interpersonal stress, not discrete multi-day episodes of decreased need for sleep.

Before treating depression, ask about past hypomania; a major depressive episode plus hypomania for 4 or more days without marked impairment is bipolar II.

Answer: B

Hypothyroidism: Endocrine causes slow length growth first, with weight relatively kept; his length is normal, and the newborn screen was normal.

Inadequate caloric intake: Correct. His weight has fallen across major percentile lines, from about the 75th to below the 5th, while length and head circumference are preserved. That weight-first pattern points to too few calories. The history fits: a feeding change at 6 months, juice filling him up and little solid food. AAP guidance calls for a detailed feeding history and calorie assessment before extensive lab testing.

Familial short stature: Affects length, which tracks along a low but steady percentile with weight in proportion; his length is normal.

Growth hormone deficiency: Causes slowing of length growth with weight relatively kept, the opposite of his pattern.

Cystic fibrosis: Usually causes poor growth from early infancy with abnormal stools, and newborn screening includes CF.

When weight falls first while length and head circumference are preserved, look for inadequate caloric intake; slowing of length growth first suggests an endocrine cause.

Answer: B

Ceftriaxone 500 mg IM once plus doxycycline for 7 days: This is the cervicitis regimen; PID needs 14 days of doxycycline plus anaerobic coverage with metronidazole.

Ceftriaxone 500 mg IM plus 14 days of doxycycline and metronidazole: Correct. Lower abdominal pain with cervical motion and adnexal tenderness in a sexually active young woman meets the clinical criteria for PID. CDC STI Treatment Guidelines 2021 recommend outpatient ceftriaxone 500 mg IM once plus doxycycline 100 mg twice daily and metronidazole 500 mg twice daily for 14 days; this beats the 7-day cervicitis regimen, which omits anaerobic coverage and is too short.

Hospital admission for intravenous cefoxitin and oral doxycycline: Admission is for pregnancy, tubo-ovarian abscess, severe illness, inability to take oral medication or failed outpatient therapy; she has none of these.

Azithromycin 1 g orally once weekly for 2 weeks: Azithromycin regimens are alternatives only for severe cephalosporin allergy, and this one lacks reliable gonococcal coverage.

Oral levofloxacin plus metronidazole for 14 days: A fluoroquinolone regimen is only an alternative when a cephalosporin cannot be used and gonorrhea risk is low with a negative test; she can receive ceftriaxone.

Outpatient PID: ceftriaxone 500 mg IM once plus doxycycline 100 mg twice daily and metronidazole 500 mg twice daily for 14 days.

Answer: C

Oral iron with a repeat CBC in 3 months: Iron should be replaced, but treating without finding the source can miss a gastrointestinal cancer.

Hemoglobin electrophoresis: Electrophoresis evaluates thalassemia trait, in which ferritin is normal or high; his ferritin of 8 confirms iron deficiency.

Upper endoscopy and colonoscopy: Correct. Microcytic anemia with a ferritin of 8 ng/mL confirms iron deficiency. In a man or postmenopausal woman without an obvious source, the AGA guideline recommends bidirectional endoscopy to look for a gastrointestinal lesion, especially colorectal or gastric cancer; this beats a fecal immunochemical test, which is a screening tool and cannot exclude a bleeding lesion.

Fecal immunochemical test: FIT is designed for average-risk screening; a negative result does not exclude a source of iron deficiency.

Bone marrow aspiration and biopsy: Marrow examination is unnecessary when serum ferritin already establishes iron deficiency.

Iron deficiency anemia in men and postmenopausal women warrants bidirectional endoscopy; do not substitute fecal testing.

Answer: C

Hydrochlorothiazide: Thiazides reduce renal lithium clearance and can raise lithium levels by 25–40%, risking toxicity.

Lisinopril: ACE inhibitors lower lithium excretion and can cause toxicity; they need close monitoring and are not the best first choice here.

Amlodipine: Correct. She has stage 1 hypertension (130–139/80–89 mm Hg) with diabetes, so the 2025 AHA/ACC guideline recommends starting a first-line drug, with a goal below 130/80 mm Hg. First-line classes are thiazide-type diuretics, ACE inhibitors or ARBs, and dihydropyridine calcium channel blockers. Thiazides and ACE inhibitors or ARBs reduce lithium clearance and can cause toxicity. She has no albuminuria or other compelling reason for RAS blockade, so amlodipine controls her pressure without disturbing a stable lithium level.

Losartan: ARBs, like ACE inhibitors, can raise lithium levels; with no albuminuria there is no compelling indication to accept that risk.

Metoprolol succinate: Beta-blockers are not first-line for hypertension without a compelling indication such as coronary disease or HFrEF.

In a patient on lithium, prefer a dihydropyridine calcium channel blocker for hypertension; thiazides, ACE inhibitors, ARBs and NSAIDs raise lithium levels.

Answer: D

1. CHA2DS2-VASc: CHF 1, Hypertension 1, Age ≥75 2, Diabetes 1, Stroke/TIA 2, Vascular disease 1, Age 65–74 1, Sex category (female) 1.
2. Her points: hypertension 1 + age 65–74 1 + female sex 1 = 3.
3. The 2023 ACC/AHA/ACCP/HRS guideline recommends oral anticoagulation at a score ≥2 in men or ≥3 in women (annual stroke risk ≥2%), whether AF is paroxysmal or persistent.
4. No mechanical valve or moderate–severe mitral stenosis, so a DOAC is preferred; she meets no apixaban dose-reduction criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL).

Aspirin 81 mg daily: Aspirin is not recommended for stroke prevention in AF; it is less effective than anticoagulation with similar bleeding risk.

Aspirin plus clopidogrel daily: Dual antiplatelet therapy is inferior to anticoagulation for AF and carries comparable bleeding risk.

Warfarin with a target INR of 2.0–3.0: Warfarin is effective but second choice; DOACs are preferred unless she has a mechanical valve or moderate–severe mitral stenosis.

Apixaban 5 mg twice daily: Correct. Her CHA2DS2-VASc score is 3 (hypertension, age 65–74, female sex), which meets the 2023 ACC/AHA/ACCP/HRS threshold of ≥3 for women regardless of AF pattern. A DOAC is preferred over warfarin without valve disease, and she meets no dose-reduction criteria; this beats warfarin, which has more intracranial bleeding.

No antithrombotic therapy while in sinus rhythm: Paroxysmal AF carries stroke risk similar to persistent AF; being in sinus rhythm today does not remove the indication.

Anticoagulate AF at CHA2DS2-VASc ≥2 (men) or ≥3 (women), regardless of paroxysmal pattern; prefer a DOAC over warfarin when there is no mechanical valve or moderate–severe mitral stenosis.

Answer: C

IV thrombolysis now, without first treating blood pressure: Starting thrombolysis at a pressure above 185/110 raises the risk of symptomatic intracranial hemorrhage.

Aspirin 325 mg now: Aspirin does not replace thrombolysis, and it is withheld for 24 hours after a thrombolytic.

IV labetalol to below 185/110 mm Hg, then thrombolysis: Correct. He has a disabling ischemic stroke within 4.5 hours, with no hemorrhage, so he qualifies for IV thrombolysis. Blood pressure must first be lowered to below 185/110 mm Hg, for example with IV labetalol or nicardipine, then kept below 180/105 for 24 hours afterward. The 2026 AHA/ASA acute ischemic stroke guideline keeps this long-standing threshold. Thrombectomy evaluation goes on in parallel.

Permissive hypertension unless above 220/120 mm Hg: This threshold applies to patients who will not receive thrombolysis; he is eligible.

MRI of the brain before deciding on treatment: Noncontrast CT is enough to decide on thrombolysis; MRI delays treatment, and every minute counts.

Before IV thrombolysis, lower blood pressure to below 185/110 mm Hg and keep it below 180/105 for 24 hours afterward.

Answer: D

Urine culture, then an office recheck in 24 hours: Under-treatment: outpatient observation is an option only for some well-appearing infants 29–60 days old with normal testing.

Inflammatory markers, with lumbar puncture only if abnormal: This is the AAP pathway for infants 22–28 days old; for 8–21 days, a lumbar puncture is done regardless of inflammatory markers.

Blood and urine cultures and admission without antibiotics: Omits CSF testing and empiric parenteral antimicrobials, both of which the AAP recommends for every febrile infant 8–21 days old.

Blood, urine and CSF cultures, IV antibiotics, admission: Correct. A well-appearing febrile infant 8–21 days old has the highest risk of invasive bacterial infection, and inflammatory markers do not reliably exclude it at this age. The AAP 2021 guideline recommends a urinalysis, blood culture and lumbar puncture, then parenteral antimicrobials and admission, whatever the urinalysis shows. The 22–28-day pathway that lets normal markers guide the lumbar puncture does not apply to him.

Blood culture and inflammatory markers, then home if normal: Applies the 29–60-day approach to a 15-day-old infant, who needs CSF testing, antibiotics and admission.

Well-appearing febrile infants 8–21 days old get a urinalysis, blood culture and lumbar puncture, then parenteral antimicrobials and hospital admission (AAP 2021).

Answer: B

Oral methyldopa 250 mg: Methyldopa is used for chronic hypertension in pregnancy; it acts too slowly for severe-range pressures.

Intravenous labetalol 20 mg: Correct. Proteinuria with blood pressures ≥160/110 mm Hg confirmed 15 minutes apart and a persistent headache define preeclampsia with severe features. ACOG recommends treating severe-range BP within 30–60 minutes with IV labetalol, IV hydralazine or oral immediate-release nifedipine to prevent stroke; magnesium prevents seizures but does not lower BP, so labetalol beats awaiting the magnesium effect.

Intravenous furosemide 40 mg: Diuretics reduce the already contracted plasma volume in preeclampsia and are not used for acute BP control.

Oral lisinopril 10 mg: ACE inhibitors are contraindicated in pregnancy because of fetal renal toxicity.

Intravenous nitroprusside infusion: Nitroprusside is a last-resort agent in pregnancy because of fetal cyanide toxicity.

Severe-range BP in pregnancy (≥160 systolic or ≥110 diastolic, persisting 15 minutes) is treated within 30–60 minutes with IV labetalol, IV hydralazine or oral immediate-release nifedipine.

Answer: A

Isotonic fluids and IV potassium, insulin delayed: Correct. She has DKA (glucose 486, pH 7.10, bicarbonate 8, anion gap 27, ketonemia) with total-body potassium depletion already showing as a serum potassium of 3.1 mEq/L. The ADA hyperglycemic crises consensus calls for fluid resuscitation and potassium replacement first, holding insulin until potassium is safely replenished, because insulin drives potassium into cells and can trigger arrhythmia; this beats starting the insulin infusion now.

Intravenous regular insulin bolus, then infusion: Insulin before potassium repletion will lower potassium further and risk fatal arrhythmia.

Intravenous sodium bicarbonate infusion: Bicarbonate is not indicated unless pH is below about 7.0, and it worsens hypokalemia.

Subcutaneous insulin glargine 20 units: Basal subcutaneous insulin is started during the transition off the infusion, not as initial DKA therapy.

Isotonic fluids with an insulin infusion started now: Fluids are right, but starting insulin with a potassium of 3.1 mEq/L risks life-threatening hypokalemia.

In DKA, check potassium before insulin: if it is low, replace potassium with fluids first and delay the insulin infusion until potassium is repleted.

Answer: E

Discharge with a 14-day ambulatory ECG monitor: Outpatient monitoring is for unexplained syncope without a diagnosis; this strip already shows the cause, and she is at risk of asystole.

Discharge with an echocardiogram and cardiology visit next week: Delaying care after syncope from complete heart block risks sudden death.

Observation unit with tilt-table testing tomorrow: Tilt testing evaluates reflex syncope; her syncope without prodrome and the strip point to an arrhythmic cause.

General medical ward admission without telemetry: Admission is right but an unmonitored bed is not: a wide escape rhythm after syncope can fail into asystole without warning, so she needs continuous monitoring and pacing pads.

Telemetry admission with pacing pads and pacemaker evaluation: Correct. Regular P waves (about 86/min) march through a slow, regular wide-complex escape rhythm (about 38/min) with no fixed PR relationship: third-degree AV block. Syncope plus a wide escape rhythm means a high risk of asystole, so the 2018 ACC/AHA/HRS bradycardia guideline supports monitored admission, transcutaneous pacing on standby and permanent pacemaker placement; this beats discharge with monitoring, which ignores a diagnosis already made.

P waves and QRS complexes that march independently mean complete heart block; symptomatic patients need monitored admission, pacing backup and a permanent pacemaker.

Answer: A

Intravenous diltiazem: Correct. The strip shows an irregularly irregular narrow-complex tachycardia with no discernible P waves, atrial fibrillation with rapid ventricular rate. She is hemodynamically stable with preserved ejection fraction, so the 2023 ACC/AHA/ACCP/HRS AF guideline supports rate control with an IV nondihydropyridine calcium channel blocker or beta-blocker; this beats amiodarone, which is a rhythm-control or second-line rate agent.

Synchronized electrical cardioversion: Emergency cardioversion is for hemodynamic instability (hypotension, ischemia, pulmonary edema); she is stable.

Intravenous adenosine: Adenosine terminates AV-nodal reentrant tachycardia; this rhythm is irregular and will not convert with adenosine.

Intravenous amiodarone: Amiodarone is reserved for rate control when first-line agents fail or are contraindicated (for example, decompensated HFrEF).

Intravenous digoxin: Digoxin has a slow onset and is weaker than a calcium channel blocker or beta-blocker for acute rate control.

Stable AF with RVR and preserved EF: rate control first with an IV beta-blocker or nondihydropyridine CCB; cardiovert only if unstable.

Answer: A

Withhold clearance and obtain echocardiography: Correct. Exertional symptoms, a family history of sudden death before age 50 and a murmur that grows louder when preload falls (standing, Valsalva) suggest hypertrophic cardiomyopathy. The preparticipation evaluation calls for withholding clearance until cardiac evaluation is done, starting with echocardiography and ECG, usually with cardiology input. A normal ECG alone cannot exclude the disease.

Clear for full participation with yearly follow-up: Ignores three red flags: exertional symptoms, early sudden death in a relative and a dynamic murmur.

Clear for participation if a resting ECG is normal: An ECG is often abnormal in hypertrophic cardiomyopathy but is not sensitive enough to clear him without imaging.

Exercise stress testing before clearance: The wrong first test: imaging is needed to define structure, and exercise testing in suspected obstruction is a specialist decision.

Clear for noncontact sports only: Restricting by contact level does not address the risk of sudden death with exertion; he needs evaluation first.

A systolic murmur that gets louder with Valsalva or standing, plus exertional symptoms or a family history of sudden death, means no clearance until echocardiography is done.

Answer: C

Norovirus: Norovirus incubation is 12–48 hours, and person-to-person spread produces later waves; every case here began within 8 hours.

Clostridium perfringens: Incubation is usually 8–16 hours, with watery diarrhea and cramps rather than prominent vomiting.

Staphylococcus aureus enterotoxin: Correct. The single sharp peak, with all cases within about 1–8 hours of one meal, is a point-source common-vehicle outbreak. The very short incubation means a preformed toxin. Sudden vomiting without fever that resolves within a day, linked to ham and custard pastries left unrefrigerated, is typical of staphylococcal enterotoxin food poisoning. Infectious agents that must multiply in the gut need longer.

Nontyphoidal Salmonella: Usually 6–72 hours, with fever and diarrhea lasting several days.

Shiga toxin–producing Escherichia coli: Incubation is about 3–4 days, often with bloody diarrhea.

An epidemic curve with one sharp peak points to a point source; incubation and symptoms then narrow the agent. Vomiting within 1–8 hours suggests a preformed toxin (S. aureus or Bacillus cereus).