Eran Section tern 10t% National Board of#Medical Examiners fee ferniing

Fatty Medicine sett Assessment 1met4min 54 ec

1. A16-year-old boy is brought to the office because of a 1-month history of intermittent sharp pain of the ring and small fingers of his night hand. He does not recall any trauma to the hand and has not had
fever, weakness, chills, or rash. He has no history of serious illness and takes no medications. He is right-hand dominant. He plays varsity basketball and pitches for the varsity baseball team. He has a
hands
appear
part-time after-school job bagging groceries at a local store. His mother has moderately severe rheumatoid arthritis. The patient's vital signs are within normal limits. Both wrists and normal.
s pain?
Muscle strength is 5/5 in the upper extremities. Range of motion of the shoulders, elbows, wrists, and finger joints is full bilaterally Which of the following is the most likely cause of this patient

0 A) Occupational tasks
OB) Osteoarthritis
OC) Sports activities
OD) Synovial crystal deposition
OE) The cause is idiopathic

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nm Section Item 2of50 National Board of AMeical Examiners Tee Remaining
e Famity Medicine Self Assessment 1mr10min 48 sec

2. Si hours after a 10-year-0ld boy undergoes operative repair of a humerus fracture, his parents notice that he is unresponsive and barely breathing and notify the nursing staff. The patient has no history
of serious illness. His only medication is intravenous morphine. On evaluation, he is unconscious. His temperature is 37C (98.6F), pulse is 120/min, respirations are 10/min, and blood pressure is
90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. The pupils are 2 mm. The remainder of the examination shows no abnormalities. Intravenous naloxone is administered,and
the patient regains consciousness. His respirations now are 18/min. It is most appropriate for the hospital to investigate this incident as which of the following?

@ A)4ct of negligence
OB) improper hand-off
OC) Perioperative risk
OD) Quality indicator
OE) Sentinel event

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Exam Section Item J 0t National Board of Medical Examiners fee Remaining
\ex Family Medicine Self Assessment 1hr10min39 sec

3. An82-year-old man comes to the physician because of an 8-month history of progressive urinary frequency and decreased urinary stream. He underwent transurethral resection of the prostate 11 years
ago because of benign hyperplasia. He takes no medications. Examination shows a moderately enlarged prostate. His serum creatinine concentration has increased from 1.3 mg/dl 10 months ago to
2.4 mg/dl today. Which of the following is the most appropriate initial step in management?

A) Measurement of postvoid residual volume

OB) Urine cytology
OC) intravenous pyelography
OD) Retrograde urethrography
OE)CT scan of the abdomen

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Exam Section Item 4 0t5 National Board of Medical Earners Tee Remaining
e Famity Medicine Sett Assessment the7min 19 sec

4. An 80-year-old woman comes to the office for a routine examination. She has osteoarthritis, hypertension, and peptic ulcer disease. Her medications are acetaminophen, lisinopril, and omeprazole. She
says she has joint pain and stiffness, which limit her mobility and make it difficult for her to open her medication bottles, shop for groceries, cook, and clean. She lives alone. Vital signs are within normal
limits. Examination shows bony enlargement of the shoulders, joints of the hands, and knees. There is crepitus. Range of motion is limited by joint tenderness. Which of the following is the most
appropriate next step in management? L
A) Addition of a nonsteroidal anti-inflammatory drug to the medication regimen
OB) intra-articular administration of a corticosteroid
QC) Multidisciplinary geriatrics assessment
OD) Orthopaedic consultation
OE)Placement in a nursing care facility

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Exam Section Item 50t National Board of Medical Examiners Tee Remaining
e Family Medicine Self Assessment th6min37 sec

5. A32-year-old man comes to the physician because of a 6-week history f mild headaches and fatigue. He has no history of serious illness and takes no medications. He does not smoke cigarettes. He
drinks two to three beers nightly. Four months ago, he began a highly stressful new job, in which he has a verbally abusive boss. He says he has financial concerns and is worried about job security. He
used to exercise three times weekly but stopped exercising 3 months ago because he is too busy.' He lives alone and is not in a romantic relationship. He appears tired and withdrawn and responds to
of
questions with short phrases. Physical examination shows no abnormalities. Which the followingis the most likely diagnosis?

O A) Alcohol use disorder

B) Antisocial personality disorder
OC) Generalized anxiety disorder
OD) Major depressive disorder
OE)Post-traumatic stress disorder

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Exam Section Item6 0t50 National Board of Medical Examiners Time Remaining
Family Medicine Self Assessment 1hr2min 9sec

6. A55-year-old woman comes to the office as a new patient because she was dissatisfied with her last physician. Four months ago, she had the onset of moderate chest pain. Cardiac stress scintigraphy
showed a smal area of reversible ischemia. The patient was diagnosed with stable angina; after beginning metoprolol therapy, her chest pain decreased from twice to once weekly. She has no other
history of serious ilness and takes no other medications. Her temperature is 36.9'C (98.4'F), pulse is 62/min, respirations are 16/min, and blood pressure is 11570 mm Hg. Examination shows no
abnormalities. Her previous physician recommended that she undergo cardiac catheterization, but she declined after researching the procedure on the Internet. She says she has read that medication
alone is an acceptable alternative to cardiac catheterization and that she is unwilling to accept the risks associated with the procedure. She agrees to add atorvastatin to her medication regimen. Which of
the following is the most appropriate next step in management?

A) Attempting to persuade the patient to undergo catheterization

OB) Relerral to a cardiologist
0 C) Repeat cardiac stress scintigraphy
OD) Stress echocardiography
0 E) No further management is indicated at this time

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Exam Section item 7 of$ National Board of Medical E miners fee Remaining
e Fumity Medicine Self Assessment the0min20 sec

7. A19.year-old woman comes to the office because of a 1-month history of frequent nausea and feeling hot when others do not. During the past year, she has had a 4.5-kg (10-4b) weight gain despite no
change in appetite; her weight is unchanged since her last visit 1 month ago. Menarche was at the age of 13 years. Since then, menses have occurred at irregular 28- to 42-day intervals with varying
amount of flow. Her last menstrual period was 3 weeks ago and was much lighter than she expected. She is sexually active with one male partner; they use condoms inconsistently. She is
168 cm (5 f 6 in) tall and weighs 77 kg (170 1lb) BMI is 27 kg/m?. Vital signs are within normal limits. Examination shows no abnormalities. Which of the following is most likely to confirm the diagnosis?

A) Determination of serum estrogen. progesterone ratio

B)Measurement of serum free thyroxine concentration
OC)Measurement of serum prolactin concentration
(D)Measurement of serum thyroid-stimulating hormone concentration
E)Measurement of urine 3-hCG concentration

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Exam Section Item 8 of 5 National Board of Medical Examiners
Family Medicine Sett Assessment
fee Remaining
58min 44 sec

8. A45-year-old man, who was diagnosed with type 2 diabetes melitusEicT E7 fo the[ofice for a routine follow-up visit. His diabetes mellitus has been fairly well controled with mettormin. At his
last visit 3 months ago, his hemoglobin A,, was 7.8%, and his metformin was increased from 850 mg twice daily to 1000 mg twice daily. He also takes glipizide and atorvastatin. Laboratory studies,
including a complete metabolic panel, serum lipid studies, and screening of the urine for microalbumin done during the previous visit 3 months ago, were all within the reference ranges. In addition to
measuring this patient's hemoglobin A, which of the following is the most appropriate next step in evaluation at today's visit?

O A) Examination of the patient's feet

OB) Fasting serum glucose concentration
C)Liver function tests
OD) Serum lipid studies
OE) Urine microalbumin concentration

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Exam Section Item 9 of50 National Board of Medical Examiners
family Medicine Self Assessment
nee Remaining
56min24 sec

9. A15-month-old girl is brought to the physician by her mother because of a 5-day history of fever, difficulty sleeping, decreased appetite, and fussiness. She has no history of serious illness or known
allergies. She receives no medications. She appears mildly ill but is interactive. She is at the 75th percentile for length and 50th percentile for weight. Her temperature is 38.3'C (101'F). Examination
shows purulent nasal drainage. The left tympanic membrane is edematous and erythematous. The right tympanic membrane and oropharynx are normal. Which of the following is the most appropriate
pharmacotherapy?

O A) Amoxicilin
OB) A2thromycin
OC) Cefuroxime
OD) Cidamycin
OE) Tetracycline

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Em Section Item 10 0f50 National Board of Medical E miners Time Remaining

a family Medicine Self Assessment 55min 32 sec

10. A 13-year-old boy is brought to the office by his mother for a well-child examination. He has no history of serious illness and takes no medications. Growth and development have been normal. His
medical records indicate that vaccinations were up-to-date through age 9 years; he has not received any vaccinations since that time. Vital signs are within normal limits and physical examination shows
no abnormalities. Administration of which of the following vaccines is most appropriate at this time?

O A) Hepatitis B
OB) inactivated poliovirus
C) Measles-umps-rubella
OD) Meningococcal
OE) Pneumococcal
0 F) Varicella

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Exam Section item 11 of 5 National Board of Medical Examiners fee Remaining

la famity Medicine Self Assessment 54min9 sec

11. A42-year-old man comes to the physician for a routine life insurance examination. He feels well. He has smoked one pack of cigarettes daily for 25 years and drinks two to four alcoholic beverages daily.
His work as a journalist sometimes takes him to developing countries, but he has not traveled abroad during the past year. He has not had any immunizations during adulthood except for tetanus toxoid
12 years ago. He has never had a blood transfusion. Examination shows no abnormalities. Laboratory studies show:
Hemoglobin 16.2g/L
Serum
Albumin 3.8g/d
Total bilirubin 1.1 mg/l
Alkaline phosphatase 95 UI\.
AST 68UI\.
ALT 44UI\.
Ferritin 50 nglml

Which of the following is most likely to have prevented these laboratory abnormalities?

(A) Abstinence from alcohol

OB) Administration of diphtheria-tetanus toroid
OC)Administration of hepatitis A vaccine
OD)Low-protein, branched-chain amino acid-enriched diet
E) Smoking cessation
OF) Weekly phlebotomy

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Eram Section Item 120f50 National Board of Medical Examiners Time Remaining
a Family Medicine Self Assessment 52min8 sec

12. An asymptomatic 27-year-old woman comes for a routine health maintenance examination. She works as a lawyer. Her temperature is 37.2'C (98.9'F), pulse is 96/min, respirations are 16/min, and
blood pressure is 144/82 mm Hg. Serum studies show a thyroxine (T,) concentration of 14 pg/dL, a triodothyronine (T) concentration of 250 ng/dl. and a thyroid-stimulating hormone concentration of
0.1U/ml. A radioactive thyroid scan shows increased uptake and a diffusely enlarged gland. Which of the following is the most likely cause of this patient's findings?

A) Acute suppurative thyroiditis

B) Chronic lymphocytic thyroiditis (Hashimoto disease) D
O C) Drug-induced hypothyroidism
OD) Euthyroid sick syndrome
OE) Exogenous administration of thyroid hormone
F) Hyperthyroidism
G) Multiple endocrine neoplasia syndrome
OH) Subacute thyroiditis
O1) Thyroid cancer

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Exam Section Item 1 0f 5 National Board of Medical Examiners'me Remaining
e Family Medicine Self Assessment $0min 36 sec

13. A45-year-old man with type 2 diabetes mellitus and hypertension comes to the physician as
a new patient. He has no other history of serious illness. He takes metformin and hydrochlorothiazide. He has
smoked one pack of cigarettes daily for 20 years. His blood pressure is 142/82 mm Hg. The remainder of the examination shows no abnormalities. Laboratory studies from 1 month ago show.
Hemoglobin A,, 7.8%
Serum
Na 142 mEq/L
K" 4.3mEqL
cl 109 mEq/L
Urea nitrogen 14 mg/dl
Glucose 135 mg/dl
Creatinine 0.7mg/dl
Cholesterol, total 214 mg/dl
HDL-cholesterol 50 mg/dL
LDL-cholesterol 120 mg/dl
Triglycerides 142 mg/dt

Which of the following modifications would be most beneficial to this patient?

O A) Smoking cessation
OB)Adding lisinopril therapy to the medication regimen
OC)Adding pravastatin therapy to the medication regimen
OD) increasing the dosage of hydrochlorothiazide
OE) Increasing the dosage of metformin

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Exam Section Item 14 0t50 National Board of Medical Examiners Time Remaining
a Family Medicine Self Assessment 49 min9 sec

14. A72year-old woman comes to the clinic becaus 're pain and progressively decreasing mobility of her left shoulder. She has congestive heart failure, coronary
artery disease, kidney disease, and type 2 diabetes mellitus. Her medications are metoprolol, enalapnl, and glipiide. Vital signs are within normal limits. Range of motion of the left shoulder is
decreased and causes crepitus. Examination shows no other abnormalities. X-ray of the left shoulder is shown. Which of the following is the most appropriate next stepin management?

O4) Celecoxb therapy

QB) Glucosamine supplementation
O C) Ibuprofen therapy
OD) Physical therapy
GE) Recommendation for an anti-inflammatory diet

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Exam Section ltem 15 0f5 National Board of AMeical Examiners nee Remaining
la family Medicine Self Assessment 46 min27 sec

15. A17-year-old boy comes to the physician because of a 3-day history of increasingly severe pain of his Light testicle. He also has had sweating, chills, and burning pain with urination during this time. He
has no history of serious illness and takes no medications. His temperature is 38.5C (101.3'F); other vital signs are within normal limits. Examination shows edema and tenderness to palpation behind
step in management?
the night testicle. Which of the following is the most appropriate next

O A) Antibiotic therapy
OB) Scrotal elevation and warm baths
OC) Ultrasonography of the scrotum
OD) Referral to a urologist
OE)Bed rest and reassurance

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Exam Section Item 16 0t50 National Board of Medical Examiners Time Remaining
e Family Medicine set Assessment 45 min23 sec

16. Arandomized, double-bind trial is performed to assess the efficacy of a new drug for the treatment of streptococcal pharyngitis. A total of 590 women between the ages of 20 and 34 years, who have
culture-confirmed streptococcal pharyngitis, are enrolled; 295 women receive treatment with penicillin V potassium, and 295 receive treatment with the new drug. Results show bacteria eradication of
94.2% in the group treated with penicillin V potassium compared with 99.4% in the group treated with the new drug (P=0.04). Which of the following is the most accurate conclusion based on these
findings? b
QA) The new drug should be the gold standard for treatment of streptococcal pharyngitis
OB) The results are not statistically significant
OC) The study does not have a control group
OD) The study has good internal validity
OE) The study uses a case-control study design

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Exam Section ltem 17 050 National Board of Medical Eaminers
Family Medicine Self Assessment
Time Remaining
42min 9 sec

17. A64-year-old woman comes to the office because of a 1-year history ot She reports that the lesion does not itch, bleed, or drain. She has not attempted any
treatments or remedies, and she does not wear any clothing or other items that rub the affected area. Vital signs are within normal limits. Examination of the left lower extremity discloses the findings
shown in the photograph. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

A) Atypical melanoma
OB) Basal cell carcinoma
C)Malignant melanoma
OD) Psoriasis

18. A4-month-old breast-fed male infant is brought to the clinic by his parents for a well-child examination. His birth weight was 3500 g (7 lb 11 oz) and his current weight is 7000 g (15lb 7 oz). The
parents ask if their child's weight gain is appropriate. Ihe patient's growth and development are as shown in the growth chart. Vital signs are within normal limits and physical examination shows no
abnormalities. Which of the following is the most appropriate statement to the parents about this patient's weight at this time?

A) He should be switched from breast-feeding to bottle-feeding

B) He should be taken to a nutritionist for further evaluation
C) His thyroid-stimulating hormone concentration should be checked
( D) His weight gain is appropriate
0 E) His weight gain is loo rapid for his age

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19. A56-year-0ld postmenopausal woman with type 2 diabetes mellitus and hypertension comes to the clinic for a routine follow-up examination. Her parents immigrated from Libya. She says she has been
feeling more tired than usual for the past 2 months; she has been sleeping well but becomes fatigued as the day progresses. She otherwise has no symptoms. Vital signs are within normal limits.
Physical examination shows no abnormalilies. Laboratory studies show:
Hemoglobin 10.5 g/dl
Hematocrit 33%
Mean corpuscular volume 75 gm?
Red cell distribution width 17% (N=11.5-14.5)
Serum
Ferritin 45 ng/mu
Thyroid-stimulating hormone 2.7 Uimu

Which of the following is the most likely cause of this patient's current condition?

(A) Anemia of chronic disease

OB) Colon cancer
OC) Folic acid deficiency
0 D) Iron deficiency anemia
OE) Thalassemia minor

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am Section Item 20 0f50 National Board of Medical Examiners' Time Remaining
Famity Medicine Sef Assessment 37min 6 sec

20. A50-year-old woman comes to the physician because of a -day history of swelling, redness, and aching pain from her night foo to just above her knee. There is no history of trauma. She has a 10-year
history of hypertension and a -year history of type 2 diabetes mellitus. Her medications are metformin and hydrochlorothiazide. She works as a bus driver. Her temperature is 37.3'C (99.2'F), pulse is
88/min, respirations are 12/min, and blood pressure is 14892 mm Hg. Examination shows an edematous, erythematous, tender night leg. The remainder of the examination shows no abnormalities.
is the most appropriate nert step in diagnosis?
Which of the following

O A) Complete blood count

B)Measurement of serum hemoglobin A,,
OC) Duplex ultrasonography of the rightlowerexllemity
OD) Spial CT scan of the chest

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Exam Section Item 21 of50 National Board of Medical Examiners'
Family Medicine Set Assessment
fime Remaining
36min51 sec

21. A25-year-old woman who is a schoolteacher has a positive PPD skin test at a routine examination. She was exposed to a person with active tuberculosis when she was a child; however, all previous
PPD skin tests since that time have been negative. Her last PPD skin test was 5 years ago. A x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in
management?
0 A) Repeat PPD skin test in 10 weeks
0 B) Repeat PPD skin test in 1 year
C) Second strength PPD skin test (250 tuberculin units) now
0 DJ Treatment of latent tuberculosis now
OE) Treatment of active tuberculosis now
F) No testing or therapy indicated

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Em Section Item 22of 50 National Board of Medical Examiners' le Remaining

a Family Medicine Self Assessment 34min5 sec

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months ago, she decided to eliminate wheat products from her diet, which has improved her symptoms. She has no history of serious illness and takes no medications. She appears mildly anxious. She
is 168 cm (5 ft 6 in) tall and weighs 52 kg (115 lb). BM is 19 kg/im3. Her pulse is 90/min, respirations are 16/min, and blood pressure is 102/58 mm Hg. Examination shows no other abnormalities. Which
of the folowing is the most likely cause of this patient's
symptoms?

A) increased serum triodothyronine (T) concentration

8) Laxative abuse
QC) Transmural intestinal inflammation
( D) Ulceration of colonic mucosa
OE) Vilous atrophy

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Exam Section Item 230f 50 National Board of Medical Examiners' Time Remaining
i Famity Medicine Self Assessment 34min1sec

23. An 81-year-old woman who recently emigrated from Ethiopia comes to the office because of a 1-year history of knee pain. The patient does not speak English and is accompanied by her son; a medical
interpreter is used. Two weeks ago, she was evaluated by another provider in the practice. Results of laboratory screening studies ordered at that time were positive for syphilis, tuberculosis, and
hepatitis C. CT scan of the liver obtained 1 week ago was suspicious for late-stage hepatocellular carcinoma. A biopsy is scheduled for next week. The patient's son asks to speak with the physician
one He ss hate teas net oa e peter aboa. he moss cneer denoss tr aural reasons Miah cf me to[IL'IEE7E77JI7EIII:at
A) Ask the patient how much she desires to know about her medical condition
B) Cancel the biopsy appointment
QC) Do not discuss the results with the patient or her son to respect their cultural practices
D) Honor the stated cultural wishes of the son and speak to him instead of the patient
E) Treat the patient's latent syphilis

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Em Section Item 24 of50 National Board of Medical Examiners Tee Remaining
a Famity Medicine Self Assessment 32min21 sec

24. An asymptomatic 37-year-old man with alcohol use disorder comes for an initial examination. He drinks approximately 12 cans of beer daily. Examination shows palmar erythema and multiple spider
angiomata over the upper back and chest. The spleen is palpated 3 cm below the left costal margin. Abdominal examination shows shifting dullness. Despite the physician's strong recommendation for
the patient to stop drinking alcohol, he says he has no intention of abstaining. Which of the following is the most appropriate immunization for this patient?

O A) Acellular pertussis
OB) Haemophilus ifluenzae
n type b, conjugated
OC) Live Salmonella typhi
OD) Meningococcal
0 E) 23-Valent pneumococcal

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Em Section Item 25.26 0 50 National Board of Medical Eminers me Remaining

e Fumity Medicine sett Assessment 31min 37 sec

]The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item. you will not be able to add or change an answer.
A 66-year-old woman comes to the office for a routine health maintenance examination. Her last menstrual period was 10 years ago. She has no history of serious illness and takes no medications. Five years
ago. a routine Pap smear showed no abnormalities and human papilomavirus testing was negative. A mammogram obtained 1 year ago showed no abnormalities. A colonoscop»owoe "@a"s showed no
anomalies. she does net sole coaretes she has been in a monooamous re aionshi fir me past 40 years. Meal sons awe wti omal ago
ZEE'EEC!EI7EEZ7JEZ3E777
25. Item 1 of 2
Which of the following screening tests is most appropriate at this time?

O A) DEXA scan
0 B) Measurement of serum CA-125 concentration
0 C) Pap smear
OD) Test of the stool for occult blood
E) Ultrasonography of the abdominal aorta

Proceed to Net Item

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Em Section Item 25-26 0f 50

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National Board of Medical Examiners'

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Time Remaining
u Family Medicine Sett Assessment 30min 28 sec

The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item you will not be able to add or change an answer.

A66-year-old woman comes to the office for a routine health maintenance examination. Her last menstrual period was 10 years ago. She has no history of serious illness and takes no medications. Five
no
years ago, a routine Pap smear showed no abnormalities and human papilomavirus testing was negative. A mammogram obtained 1 year ago showed abnormalities. A colon0scopy done 8 years ago
showed no abnormalities. She does not smoke cigarettes. She has been in a monogamous relationship for the past 40 years. Vital signs are within normal limits
and physical examination shows no
abnormalities.

25. Item 1 of2

Which of the following screening tests is most appropriate at this time?

A) DEXA scan
B) Measurement of serum CA-125 concentration
CJ Pap smear
D) Test of the stool for occult blood
E) Ultrasonography of the abdominal aorta

26. Item 2 of 2
The patient returns to the office 2 weeks later to discuss the results of her screening tests. She has started calcium and vitamin D supplementation. Results of the DEA scan show a lumbar spine T-
score of -2.8. Serum lipid studies show a total cholesterol concentration of 230 mg/dL and HDL-cholesterol concentration of 60 mg/dL.. Her estimated 10-year arteriosclerotic cardiovascular disease risk
is 5.7%. Which of the following is the most appropriate next step in treatment?
2
0 A) Alendronate therapy
0 B) Atorvastatin therapy
OC) Calcitonin therapy
OD) Omega-3 fish oil supplementation
OE) Raloxfene therapy
F) No further treatment is indicated at this time

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Exam Section Item 27 0t 50 National Board of Medical Examiners Time Remaining
a Family Medicine Sett Assessment 28min31sec

27. A62-year-old man comes to the physician because of a 2-month history of shortness of breath with exertion. He also has had paroxysmal nocturnal dyspnea and orthopnea. He has type 2 diabetes
mellitus and coronary artery disease; he had a myocardial infarction 3 years ago. Current medications include simvastatin and aspirin. His pulse is 100/min, respirations are 12/min, and blood pressure is
100/60 mm Hg. Crackles are heard on auscultaton. Ihere isa>,Bay of the chest shows cardiomegaly. cephalization of blood flow, and Kerley B lines. Which of the following is the most
swat maracanenr o »EE'EIEEIEEEI,
A) 4ngiotensin-converting enzyme (ACE) inhibitor
8) Calcium-channel blocking agent
0 C) Digitalis
0 D) Diuretic
OE) Ntrates

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£Hamn Section ltem 28 0f 50 National Board of Medical Examiners
Family Medicine Set Assessment
me Remaining
27min2l sec

28. A65-year-old man comes to the office because of a 5-year history of slowly worsening constipation. During this time, his stools have been hard and have decreased in frequency. He reports often having
to strain and a sensation of incomplete evacuation following bowel movements. This is the first time he has sought treatment. Colonoscopy 5 years ago showed no abnormalities. He has a history of
hypertension for which he takes hydrochlorothiazide. Vital signs are within normal limits. Physical examination discloses a palpable colon with hard stool over the left of the abdomen; the remainder of
the
physical examination shows no other abnormalities. Results of laboratory studies are within the reference ranges. In addition to increasing fluid intake,which of the following is the most appropriate
initial pharmmacotherapy?
OA)Lactulose
8)Linaclotide
O C) Lubiprostone
OD) Magnesium citrate
OE) Psylium

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Eran Section Item 29 0f50 National Board of Medical Examiners Tee Remaining
a Fity Medicine sett Assessment 26min 25 sec

29. A65-year-old man comes to the physician to request prostate cancer screening. He has not had urinary symptoms. He has no history of serious illness and takes no medications. His father had prostate
cancer at the age of 85 years. Examination of the patient shows no abnormalities. Which of the folowing is tbe most appropriate next step regarding prostate cancer screening for this patient?

A) Digital rectal examination and measurement of serum prostate-specific antigen (PSA) concentration
8) Digital rectal examination only
OC) Discussing the risks and benefits of prostate cancer screening options and allowing the patient to decide
(D) Measurement of serum PSA concentration only
OE)Prostate cancer screening is not indicated for this patient

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Exam Section Item 300t50 National Board of edical Examiners' lime Remaining
Family Medicine Self Assessment 24 min 18 sec

30. A55-year-old man comes to the office for a routine examination. Eighteen months ago, he had progressive difficulty reading and seeing small things.' His symptoms initially improved with the use of
weak reading glasses: he then required stronger reading glasses. He reports no other current problems with his vision and is otherwise asymptomatic. He has hypertension treated with
hydrochlorothiazide. Vital signs are within normal limits. Visual acuity is 20/30 in the left eye and 20/20 in the right eye. No other abnormalities are noted. Which of the following is the most appropriate
next step in management?

A) Glaucoma screening
OB)Measurement of fasting serum glucose concentration
O C) Referral to an ophthalmologist
OD) Ultrasonography of the carotid arteries
OE)No further management is indicated

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Limn Section ltem 31 t5 National Board of Medical Examiners nee Remaining
Family Medicine Self Assessment 22min43sc

31. A72-year-old man has had increasing shortness of breath for 6 months. He has lost 1.4 kg (3 lb) in the last 3 months, but his appetite has not decreased. He has had a nonproductive cough for more
than 40 years. He has smoked two packs of cigarettes daily for 50 years and worked from age 30 to 40 years in a factory making automobile brake linings. He is afebrile and not cyanotic. There is
dullness to percussion; on auscultation, diminished breath sounds and egophony over the night lower chest are noted. X-rays of the chest show a night pleural effusion and a mass contiguous with the
pleura in the night lateral chest Tere are infuse irregular ear opacities that are most ense in the lower long tels Whi&ELIZ77·T I:EZ'EE7:
O A) 4thracosis
0 B ) Asbestosis
OC) Berylliosis
0 D) Byssinosis
OE) Silicosis

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Exam Section Item 320f 5 National Board of edical Eaminers fime Remaining
a Family Medicine Sett Assessment 2min57 sec

32. A52year-old Egyptian woman comes to the office with her adult daughter because of a 5-day history of headaches. The patient is visiting her daughter in the United States for 3 months and does not
speak much English. The daughter offers to translate for her mother and reports that the patient has a history of hypertension. She says that the patient's medications are amlodipine, lisinopril, and
hydrochlorothiazide, and further explains that the patient ran out of her medications 2 weeks ago. Blood pressure is 175/105 mm Hg; remaining vital signs are within normal limits. Physical examination
shows no abnormalities. Which of the following is the most appropriate next step in management? l
6A) Arange for telephone interpreter services
GB)Ask the daughter to step out of the room so the patient can be tuly examined
0 C) Obtain an ECG
0 D) Refill the patient's prescriptions and schedule a follow-up appointment in 2 days
OE) Send the patient to the emergency department for further evaluation

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Exam Section Item 330f50 National Board of Medical Examiners' Time Remaining
i Famity Medicine Sef Assessment 18 min 26 sec

33. A35-year-0ld man comes to the office because of a 3-month history of fatigue, increased sleepiness, and feeling that he cannot enjoy his usual activities. During this time, he also has had decreased
appetite, resulting in a 4.5-kg (10-lb) weight loss. He has no history of serious ilness and takes no prescribed medications. Three weeks ago, he was fired from his job because of decreased productivity.
He describes his marriage as 'good' but says there have been recent marital strains because of financial concerns. Which of the following is the most appropriate additional history to obtain from this
paten b
4A) Frequency of the couple's sexual activity during the past month
B) The patient's alcohol consumption
C) Whether the patient has a financial advisor
( D) Whether the patient has sought other means of employment
E) Whether the patient takes over-the-counter medications

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Em Section Item 34 of 50 National Board of Medical E miners nee Remaining
Family Medicine Self Assessment 17min21sec

34. A48-year-old woman with mitral valve prolapse and mild mitral regurgitation comes to the physician for a follow-up examination. At her last visit 12 weeks ago, her pulse was 76/min, and blood pressure
was 138/82 mm Hg. She says she feels well. Eight months ago, she began a low-sodium diet and exercise program to decrease her blood pressure. She takes no medications. She is allergic to
penicillin. Her pulse is 72/min, and blood pressure is 124/76 mm Hg. On cardiac examination, a gradeprw&fJ� muf1]1ur is heard best at the apex. The remainder of the examination shows no
abnormalities. In 1 week, she will undergo a dental leaning. Which of the following is the most appro; [ [;hylaxis for this patient?

O A) Amoxicillin
0 B) Celazolin
0 C) Clarithromycin
OD) Cindaryoin
OE)No prophylaxis is required

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Exam Section Item 35 0t 50 National Board of Medical Examiners7me Remaining
e Family Medicine Self Assessment 16min3 sec

35. A24-year-old woman, gravida 1, para 1, comes to the office because of a 1-day history of moderate night lower abdominal pain and vaginal bleeding. One year ago, her uncomplicated pregnancy ended
in a spontaneous vaginal delivery of a healthy newborn at term. Her last menstrual period was 7 weeks ago; previously, menses occurred at regular 28-day intervals. Five years ago, she had pelvic
inflammatory disease, which resolved with cefoxitin and dorycycine therapy. She has smoked one pack of cigarettes daily for 7 years; 4 days ago, she began varenicine therapy. She takes no other
medications. Prior to her pregnancy, she used a copper IUD; she currently uses no contraception. She is 163 cm (5 f 4 in) tall and weighs 66 kg (145 lb); BMl is 25 kg/m}. Her temperature is
372€(99.0'F), pulse is 88/min, respirations are 16/min, and blood pressure is 11476 mm Hg. Abdominal examination shows moderate tenderness to palpation of the night lower quadrant; there are no
palpable masses. Pelvic examination shows a dosed cervical os; there is no blood or discharge. There is mild cervical motion tenderness. No adnexal masses are palpated. A urine pregnancy lest is
positive. Which oft the following is the most appropriate next
step in diagnosis?
O A) Culdocentesis
0 B) Lapar0sopy
QC) Measurement of serum 3-hCG concentration
OD) Testing for Chlamydi atrachomati and
s Neisseria gonorhoeae
OE) Transvaginal ultrasonography

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Exam Section Item 0t 50 National Board of Medical Examiners Time Remaining

Fumity Medicine set Assessment 15min 14 sec

36. A36-year-old man is brought to the office by his running partner after he completed a 26.2-mile marathon. Shortly after the race, the patient reported nausea, moderate headache, and dizziness. He also
had difficulty maintaining his balance and was oriented to person but not place or time. His running partner reports that the patient drank a lot of fluids' during the race because the ambient temperature
during the race was 94.Q'F, The patient has no history of serious illness and takes no medications. He appears pale and is diaphoretic. He is oriented to day and time but not to place. His temperature is
37.0'C (98.6') pulse is 90mi. respirations re 16/mi. and blood pressure is 144/84 mm Hg Examination shows o other abnormaites. we.ELIE717Z7I:77Z hey to be
noted in this patient?

OA) Hyperkalemia
OB) Hyperatremia
O C) Hypoglycemia
D) Hypokalemia
OE)Hyponatremia

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 Eam Section item 37 0f50 National Board of Medical Examiners Tee Remaining
Family Medicine Self Assessment 12min 51 sec

37. A46-year-old man with thrombocytopenia comes to the office for a preoperative evaluation prior to the extraction of four wisdom teeth. The patient says he feels well. He takes no medications. Vital signs
are within normal limits and physical examination shows no abnormalities. A complete blood count discloses a platelet count of 110,000/mm. Which of the following is the most appropriate
recommendation for this patient?

O A) Begin desmopressin therapy

OB) Cancel the dental extraction
0 C) Proceed with dental extraclion
(D) Reschedule another appointment to establish platelet count prior to the dental extraction
OE) Transfuse platelets prior to dental extraction

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Exam Section Item 38 0t5 National Board of Medical Examiners Time Remaining
Famity Medicine Self Assessment 10min 54 sec
i

38. A26-year-old woman comes to the office because of a 12-hour history of moderate chest pain and cough productive of blood-tinged sputum. She has no other history of serious illness. Her only
medication is an oral contraceptive. She took a 10-hour airplane flight 2 days ago. She appears to be in mid respiratory distress. Her temperature is 37.3'C (99.1'F), pulse is 110/min and regular
respirations are 18/min, and blood pressure is 132/94 mm Hg. There is no cyanosis. Cardiopulmonary examination shows no abnormalities. There is erythema and edema of the right calf. Which of the
following is the most appropriate next step in diagnosis?

OA) CT angiography of the chest

B) Determination of mixed venous oxygen saturation
0 C) Serum p-dimer assay
OD) Venography of the right lower extremity
OE) Venous duplex ultrasonography of the night lower extremity

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Em Section Item 39 0f 50 National Board of Medical Examiners Tee Remaining
family Medicine Self Assessment 9min48 sec

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39. A15year-old boy is brought to the physician by his mother for examination prior to participation in school sports. He has history of serious illness and takes no medications. There is a strong family
history of obesity, and his mother struggles to keep her weight in the normal range. His father, maternal aunt, and maternal grandmother have type 2 diabetes mellitus. The patient says he eats healthy
food, but on questioning, he reports that yesterday he ate 12 oz of frosted cereal with whole milk for breakfast; a hot dog, potato chips, cookie, fruit cocktail, and soda for lunch; a candy bar for an after-
school snack; and a large fast-food cheeseburger, extra large French fries, and a chocolate milkshake for dinner. He watches television and plays video games when he is not in school. He is popular
and socially active, but he does not have a girlfriend. He is obese but otherwise appears healthy. He is 160 cm (5 f 3 in) tall and weighs 90 kg (198 lb); BMl is 35 kg/m. His temperature is
37.1C (98.8'F), pulse is 87/min, respirations are 22/min, and blood pressure is 12890 mm Hg. Examination shows moderate acne over the face. Genital pubic hair development are sexual maturity
and
rating stage 4. His hemoglobin A,, is 6.3%, and his fingerstick blood glucose concentration is 128 mg/dL. Which of the following is the most appropriate next step in management?

QA) Counseling the patient on the importance of aerobic exercise

OB) Recommending an intensive weight-lifting regimen
O C) ACE inhibitor therapy
D) Combination insulin therapy
0 E) Hypoglycemic agent therapy

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Exam Section Item 40 0f 50 National Board of Medical Examiners time Remaining

i family Medicine Sett Assessment 8min 1sec

40. A72-year-old woman is brought to the physician by her son because of a 5-day history of mild left arm pain. She reports that she must have bumped the wall' when she was getting off the toilet. She
has mild dementia, Alzheimer type, and rate-controlled atrial fibrillation. Her only medication is warfarin. She lives with her son. Her two other children live in the same city as the patient and visit her
regularly. The patient's pulse is 84/min and irregularly irregular. Physical examination shows several ecchymoses over the upper extremities and older, healing ecchymoses over the forearms. On mental
status examination, she has a slightly depressed mood and normal affect. She recalls 0 of 3 items after 5 minutes and is oriented to self and place only. X-rays of the upper extremities show no
abnormalities. On further questioning, the patient's son says he does not know how she got the bruises. Without her son present, the patient is asked if anyone has hurt her ; she appears uncomfortable
and says she is clumsy. Which of the following is the most appropriate next step in management?

O A) Call the patient's other children to inquire about the injuries

B) Call the police and have them come to the office immediately
OC) Contact senior protective services t
GD) Document the physical findings in the patient's medical record and ask the patient again about the injuries at her next routine examination
OE) Order a complete skeletal series

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Exam Section Item 41 of50 National Board of Medical Examiners Time Remaining
Fmity Medicine Self Assessment 7min 17 sec

41. A5year-old boy is brought to the office by his mother for a well-child examination. The patient's mother reports that he has been more fidgety lately and has not been able to focuson his school work for
more than a few minutes at a time. He also does not multitask well. The patient is otherwise healthy, sleeps well, and has a happy demeanor. He has no history of serious ilness and receives no
medications. Vaccinations are up-to-date. Vital signs are within normal limits, and physical examination discloses no abnormalities.Which of the following is the most
appropriatenext stepin
management?

QA)Ask parents and teachers to complete validated behavioral rating scales

B) initiate methyiphenidate therapy
0 C) Obtain genetic testing
(D) Recommend decreasing dietary sugar intake
OE) Reassure the patient's mother this is normal behavior at this age

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Exam Section Item 42 0t50 National Board of Medical Examiners' Time Remaining
Fumity Medicine Self Assessment 6min 4 sec

42. Over the past 4 days, an &-year-old gird has had joint pain, first in he right knee and then in her left ankle. She had a severe sore throat 2 weeks ago after a camping trip in Georgia. Her temperature is
38.9'C(102'F), pulse is 128/min, and blood pressure is 10870 mm Hg. The right knee and left ankle are red, swollen, and exquisitely tender. The lungs are clear to auscultation. A grade 3/6, hol0systolic
apical murmur is heard. Which of the following is
the most likely diagnosis?
4) 4cute rheumatic fever
0 B) Juvenile idiopathic arthritis
OC) Lme disease
D) Rocky Mountain spotted fever
OE) Serum sickness

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 -
Em Section Item 43 0f 50 National Board of Medical Examiners Tee Remaining
ace Famity Medicine Self Assessment 5min 50 sec

43. A22-year-old man comes to the physician because of a 3-month history of thick, flaky fingernails. During this time, he also has had dry, scaly, red patches of skin on his forearms and chest. He has no
history of serious iliness and takes no medications. During the past 2 years, he has worked as a restaurant dishwasher. A photograph of the left hand and right forearm is shown; similar findings are
seen over the left forearm and trunk. Which of the following is the mostlikely diagnosis?

O A) Atopic dermatitis
OB) Hydradenitis suppurativa
QC) Nummular eczema
@ D) Psoriasis
OE) Tinea corporis

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Exam Section Item 44 of50 National Board of Medical Examiners Time Remaining
a Family Medicine Self Assessment 5min38 sec

44. An 11-year-old boy is brought to the physician because of a 2-day history of nasal congestion and mild sore throat; he has coughing and sneezing productive of green mucus. He has not had fever or ear
pain. He has had no sick contacts. His temperature is 37C (98.6'F), and pulse is 84/min and regular. Examination shows clear and mobile tympanic membranes. The tonsils are mildly enlarged and
erythematous; there is no exudate. There is postnasal drainage in the posterior pharynx and copious yellow-green nasal drainage. The lungs are clear to auscultation. Heart sounds are normal. Which of
he tioig is me most aororite re[EDIE'IL3Lt?
2
A) Provide symptomatic care only
B) Recommend sinus lavage in the clinic
0 CJ Culture of the nasal discharge
D) X-ray of the sinuses
OE) Antiviral therapy
OF) Broad-spectrum antibiotic therapy

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Exam Section Item 44 of50 National Board of Medical Examiners Time Remaining
la Family Medicine Self Assessment 4min6 sec

44. An 11-year-old boy is brought to the physician because of a 2-day history of nasal congestion and mild sore throat; he has coughing and sneezingproductive of green mucus. He has not had fever or ear
pain. He has had no sick contacts. His temperature is 37C (98.6'F), and pulse is 84/min and regular. Examination shows clear and mobile tympanic membranes. The tonsils are mildly enlarged and
of
erythematous; there is no exudate. There is postnasal drainage in the posterior pharynx and copious yellow-green nasal drainage. The lungs are clear to auscultation. Heart sounds are normal. Which
the following is the most appropriate next step in management?

@ A) Provide symptomatic care only

OB) Recommend sinus lavage in the clinic
0 C) Culture of the nasal discharge
OD) X-ray of the sinuses
OE) Antiviral therapy
OF) Broad-spectrum antibiotic therapy

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Em Section Item 45 0t50 National Board of Medical Eaminers' Time Remaining
a Family Medicine Sett Assessment 4min0sec

45. AT7.year-old man with coronary artery disease comes to the physician for a follow-up examination. He underwent coronary artery bypass grafting 4 years ago. He has a 3-year history of intermittent
claudication. His blood pressure measurements from his last eight visits show.
Number of Blood Pressure
Months Ago (mm Hg)
24 130/80
2 130/60
15 14070
12 130/80
8 160/90
6 170/96
4 180/110
2 180/100

Current medications include aspirin and atorvastatin. His temperature is 36.5'C (977'F), pulse is 80/min, and blood pressure is 180/110 mm Hg. Heart sounds are normal. Dorsalis pedis and posterior
tibial pulses are not palpable bilaterally. Serum studies show
K' 3.1m£qt
HCO, 28,mEot
Urea nitrogen 20 mg/l
Glucose 911 mgldl
Creatinine 1.1mg/t

Which of the following is the most likely cause of thispatient's increased blood pressure?

0 A) Dissecting abdominal aortic aneurysm

OB) Essential hypertension
0 C) Renal artery stenosis
D) Renal failure
E) White-coat hypertension

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Exam Section Item 46 0f50
----- National Board of Medical Examiners Time Remaining
Famity Medicine Self Assessment 2min 54 sec

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46. A76.-year-old man comes to the physician because of a 5-year history of progressive redness and scaling over bald areas of his scalp. He has hypertension, hypercholesterolemia, and psoriasis over
his arms. His medications are lisinopri, hydrochlorothiazide, lovastatin, lobetasol, and aspirin. He is a retired high school sports coach. Vital signs are within normal limits. A photograph of the scalp is
shown. There are large areas of scaly, dry rash over the upper extremities. Which of the following is the most likely diagnosis of this
patient's scalp findings?
�
A) Actinic keratosis
OB) Basal cell carcinoma
0 C) Melanoma
0 OJ Psoriasis
E) Seborrheic dermatitis

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Exam Section Item 47 0t50 National Board of Medical Eaminers Time Remaining
a Family Medicine Set Assessment min4 sec

47. A56-year-old man comes to the office because of a 1-month history of a nonhealing lesion on his tongue. He says he thinks the lesion may have appeared when he bit his tongue while sleeping. He has
a 2year history of type 2 diabetes mellitus well controlled with metformin and diet. He works as an electrician at a shipyard. He has smoked one pack of cigarettes daily for 17 years. le drinks three
12-oz beers weekly. Vital signs are within normal limits. There is a 2-cm, ulcerated lesion over the left aspect of the tongue. The remainder of the examination, including that of the head and neck, shows
his
no abnormalities. Which of the following is most likely to have pre "Ee patient's lesion?
O A) Alcohol abstinence
OB) Human papilomavirus vaccination
O C) Smoking cessation
0 D} Use of a mask at work
OE) Use of a mouth guard at night

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Exam Section Item 48 0of 50 National Board of Medical Examiners Time Remaining
a Funity Medicine sett Assessment 2min 16 sec

48. A37-year-old woman comes to the physician because of a 3-month history of frequent headaches. She has no history of serious illness and takes no medications. Her last health maintenance
examination 3 years ago showed no abnormalities. There is no family history of serious illness. She is 165 cm (5 ft 5 in) tall and weighs 66 kg (145 lb); BMl is 24 kg/m?. Her temperature is
37.1C (98.8'F), pulse is 88/min, respirations are 16/min, and blood pressure is 190/120 mm Hg. The remainder of the examination shows no abnormalities except for an epigastric bruit. Arteriography
shows fibromuscular hyperplasia of the left renal artery. The underlying mechanism of this patient's condition was most likely initiated by the release of which of the following substances?

0 A) Aldosterone
8) Angiotensin I
O C) Angiotensin II
0 D) Angiotensin Ill
OE) Renn

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Exam Section Item 49 0f50 National Board of Medical E miners' lee Remaining
a family Medicine Self Assessment 1min32sec

49. A47-year-old woman comes to the physician because il' outstretched arm while playing tennis. She has had limited use of her hand and wrist
since the injury occurred. She is otherwise healthy. There is tenderness to palpation over the radial and dorsal aspect of the right anatomic snuffbox. Muscle strength of the right fingers is 5/5, and
sensation throughout the hand is intact. Plain x-rays of the hand and wrist show mild degenerative changes at the first carpometacarpal joint. Which of the following is the most appropriate next step in
management?

A) Reassurance that the pain should subside within 1 week

0 B) Athrography
OC) Cast immobilization
O D) Arthroscopy
OE) Surgical exploration and repair

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Exam Section ltem 50 0t50 National Board of Medical Examiners'
famity Medicine Set Assessment
Time Remaining
32sec

50. A9-year-old boy is brought to the physician by his mother because of a 1-month history of intermittent wheezing and mild shortness of breath. The mother reports that his symptoms occur once or twice
weekly, occasionally before exercise, and never at night. When his symptoms occur, he must sit and rest. He has no history of serious illness or known allergies. He receives no medications. His older
brother and younger sister have asthma. His parents do not smoke cigarettes. The patient's temperature is 37C (98.6'F), pulse is 92/min, respirations are 16/min, and blood pressure is 90/50 mm Hg.
Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows enlarged, pale nasal turbinates: mildly enlarged tonsils; and shotty cervical lymphadenopathy. Cardiopulmonary
examination shows no abnormalities. Spirometry shows a peak expiratory flow rate of 200 Limin (88%0f predicted) In addition to short-acting p +adrenergic agonist therapy which of the following is the
most
appropriate pharmacotherapy?

0 A) leukotriene therapy
8)Low-dose corticosteroid and long-acting f ,-adrenergic agonist therapy
0 C) low-dose corticosteroid therapy
0 D) Medium-dose corticosteroid therapy
OE)No additional pharmacotherapy is indicated

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