Board Certified in Family Medicine Practice Test

ABFM test Format | Course Contents | Course Outline | test Syllabus | test Objectives

Number of questions: 200 questions Percent
01. Basic science aspects of vascular neurology 4-6%
02. Risk factors and epidemiology 8-12%
03. Clinical features of cerebrovascular diseases 8-12%
04. Evaluation of the patient with cerebrovascular disease 13-17%
05. Causes of stroke 18-22%
06. Complications of stroke 4-6%
07. Treatment of patients with stroke 28-32%
08. Recovery, regenerative approaches, and rehabilitation 4-6%
TOTAL 100%

Content Areas
01. Basic science aspects of vascular neurology
A. Vascular neuroanatomy
1. Extracranial arterial anatomy
2. Intracranial arterial anatomy
3. Collaterals
4. Alterations of vascular anatomy
5. Venous anatomy
6. Spinal cord vascular anatomy
7. Specific vascular-brain anatomic correlations
8. End vessel syndromes
B. Stroke pathophysiology
1. Cerebral blood flow
a. Vascular smooth muscle control
b. Vasodilation and vasoconstriction
c. Autoregulation
d. Vasospasm
e. Rheology
f. Blood flow in stroke
2. Blood-brain barrier in stroke
3. Coagulation cascade
a. Clotting factors
b. Platelet function
c. Endothelium function
d. Biochemical factors
4. Metabolic and cellular consequences of ischemia
a. Ischemic cascade
b. Reperfusion changes
c. Electrophysiology
d. Gene regulation
5. Inflammation and stroke
6. Brain edema and increased ICP
a. Secondary effects
7. Restoration and recovery following stroke
8. Secondary consequences from intracranial bleeding
C. Neuropathology of stroke
1. Vascular neuropathology
2. Atherosclerosis and atherosclerotic plaque
3. Brain and meningeal biopsy
a. Indications
4. Pathological/imaging/clinical correlations
02. Prevention, risk factors, and epidemiology
A. Populations at risk for stroke
1. Non-modifiable risk factors
2. Age, gender, ethnicity, geography, family history
B. Modifiable risk factors for stroke
1. Hypertension
2. Diabetes mellitus
3. Cholesterol
4. Homocysteine
5. Obesity
6. Alcohol abuse
7. Tobacco use
8. Drug abuse
9. Exercise and other lifestyle factors
C. Infections predisposing to stroke
D. Genetic factors predicting stroke
E. Stroke as a complication of other medical illness
F. Special populations at risk for stroke
1. Children and adolescents
2. Young adults
3. Pregnancy
G. Stroke education programs and regional health services
1. Screening
2. Medical economics
3. Primary versus high risk prevention
4. National stroke programs
H. Concepts of clinical research
1. Use and interpretation of statistics
2. Clinical trial design and methodology
3. Understanding the medical literature
4. Rules of evidence and guidelines
5. Rating instruments and stroke scales
I. Outcomes
1. Prognosis
2. Mortality and morbidity of stroke subtypes
03. Clinical features of cerebrovascular diseases
A. Neuro-otology
1. Head and neck pathology
2. Vertigo and hearing loss in stroke
B. Neuro-ophthalmology
1. Retinal changes of vascular disease, including arterial hypertension
and retinal embolism
2. Other ocular manifestations of vascular disease
a. Ischemic oculopathy
b. Horner syndrome
c. Cavernous sinus syndrome
3. Disorders of ocular motility
4. Visual field defects
C. Transient ischemic attack (TIA)
1. General features of TIA
2. Carotid circulation TIA including amaurosis fugax
3. Vertebrobasilar circulation TIA
4. Asymptomatic carotid bruit or stenosis
5. Differential diagnosis of TIA
D. Ischemic stroke syndromes—cerebral hemispheres
1. Cortical stroke syndromes
a. Branch cortical artery syndromes
b. Watershed syndromes
2. Subcortical stroke syndromes
a. Lacunar strokes
b. Striatocapsular infarctions
c. Multiple lacunar infarcts
3. Major hemispheric syndromes
a. Internal carotid artery occlusion
b. Middle cerebral, anterior cerebral, or posterior cerebral artery
4. Behavioral and cognitive impairments following stroke
5. Bi-hemispheric stroke, including hypotensive events
6. Multifocal or diffuse disease
E. Ischemic stroke syndromes—brainstem and cerebellum
1. Basilar artery occlusion
a. Locked-in syndrome
b. Major brainstem strokes
2. Vertebral artery occlusion
3. Branch brainstem stroke syndromes
4. Syndromes from cerebellar arteries (brainstem/cerebellum)
5. Top-of-the-basilar syndromes
6. Thalamic syndromes
F. Ischemic stroke syndromes of the spinal cord
G. Vascular dementia (vascular cognitive impairment) and vascular cognitive
syndromes
1. Multi-infarction (multiple subcortical infarctions)
2. White matter disease (leukoaraiosis, Binswanger subcortical
leukoencephalopathy)
H. Features differentiating hemorrhagic or ischemic stroke
I. Intracerebral hemorrhage
1. Hypertension
2. Cerebral amyloid angiopathy
3. Coagulopathy/bleeding diatheses
4. Locations
a. Putamen
b. Thalamus
c. Lobar and white matter
d. Brainstem
e. Cerebellum
J. Subarachnoid hemorrhage
1. Saccular aneurysms
2. Other aneurysms
3. Unruptured aneurysm
4. Trauma
K. Vascular malformations
1. Hemorrhage
2. Other presentations
L. Primary intraventricular hemorrhage
M. Subdural or epidural hematoma
N. Venous thrombosis
1. Cavernous sinus
2. Superior sagittal sinus
3. Other sinus
4. Cortical thrombophlebitis
5. Deep cerebral veins
O. Carotid cavernous or dural fistulas
P. Pituitary apoplexy
Q. Hypertensive encephalopathy and eclampsia
R. Clinical presentations of primary and multisystem vasculitides
S. Hypoxia-ischemia
1. Cardiac arrest
2. Carbon monoxide poisoning
3. Cortical laminar necrosis
4. Other
T. Brain death
U. MELAS and metabolic disorders causing neurologic symptoms
V. Nonstroke presentations of vascular disease
W. Cardiovascular diseases
1. Heart disease, including coronary artery disease
2. Cardiac complications of stroke
3. Peripheral arterial disease
4. Aortic disease
5. Venous disease
X. Vascular presentations of other diseases of the central nervous system
Y. Infectious diseases and stroke
Z. Migraine
04. Evaluation of the patient with cerebrovascular disease
A. Evaluation of the brain and spinal cord
1. Computed tomography of brain
a. Acute changes of ischemic stroke
b. Acute changes of hemorrhagic stroke
c. Chronic changes of stroke
d. Complications of stroke
e. Vascular imaging by CT
f. Differential diagnosis by CT
g. CT perfusion
h. MR perfusion
2. Computed tomography of spine and spinal cord
3. Magnetic resonance imaging of brain
a. MRI sequences—T1, T2, FLAIR, DWI, PWI, gradient echo
b. MR spectroscopy
c. Acute changes of ischemic stroke
d. Acute changes of hemorrhagic stroke
i. Changes affected by time
e. Functional MRI
f. Vascular imaging by CT
g. Vascular imaging by MRI
4. PET and SPECT
5. EEG and evoked potentials—stroke
a. Changes in stroke
b. Complications of stroke
c. Monitoring
6. Examination of the CSF
7. ICP monitoring
B. Evaluation of the vasculature—occlusive or non-occlusive
1. Arteriography and venography
a. Cerebral
b. Spinal cord
2. Extracranial ultrasonography
a. Duplex and other imaging
b. Collateral flow challenges
c. Monitoring
3. Intracranial ultrasonography
a. Collateral flow changes
b. Contrast enhancement
c. Monitoring
4. CT angiography and CT venography
5. MR angiography and MR venography
C. Evaluation of the heart and great vessels
1. Electrocardiography
a. Monitoring
b. Holter and event monitors
2. TTE and TEE
a. Contrast-enhanced studies
3. Other chest imaging studies
a. Chest x-ray
b. Chest CT
c. Chest MRI
4. Other studies
a. Blood pressure monitoring
b. Blood cultures
c. Testing for ischemic heart disease
d. Peripheral artery disease
D. Other diagnostic studies
1. Hematologic studies
a. Blood count
b. Platelet count
c. Special coagulation studies
d. Antiplatelet (aspirin, clopidogrel) resistance studies
2. Immunological studies
a. Inflammatory markers
b. Other autoimmune studies (multisystem)
c. Serologic studies
3. Biochemical studies
a. Glucose
b. Cholesterol
c. Blood gases
d. Hepatic and renal tests
4. Urine tests
5. Biopsies
6. Evaluation for the complications of stroke
7. Evaluation for the consequences of stroke
a. Swallowing
b. Orthopedic
c. Other
8. Genetic testing
05. Causes of stroke
A. Atherosclerosis—ischemic stroke
1. Evaluation of patients prior to non-cerebrovascular operations
2. Asymptomatic bruit or stenosis
3. Aortic atherosclerosis
B. Non-atherosclerotic vasculopathies—ischemic stroke
1. Non-inflammatory
a. Dissection
b. Moyamoya disease
c. Fibromuscular dysplasia
d. Trauma
e. Radiation-induced vasculopathy
f. Saccular aneurysm
g. Other
2. Infectious
a. Syphilis
b. Herpes zoster
c. AIDS
d. Cysticercosis
e. Bacterial meningitis
f. Aspergillosis
g. Mucormycosis
h. Cat-scratch disease
i. Behçet syndrome
j. Other
3. Inflammatory, non-infectious (angiitis)
a. Isolated CNS vasculitis
b. Multisystem vasculitis
c. Cogan syndrome
d. Eales disease
e. Polyarteritis nodosa
f. Wegener granulomatosis with polyangiitis
g. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss
syndrome)
h. Takayasu disease
i. Systemic lupus erythematosus
j. Scleroderma
k. Rheumatoid arthritis
l. Mixed connective tissue disease
m. Ulcerative colitis and regional enteritis
n. Sarcoidosis
o. Other
C. Migraine
D. Other causes of ischemic stroke
1. Kawasaki disease
2. Lyme disease
3. Susac syndrome
E. Genetic and metabolic causes of stroke
1. CADASIL
2. MELAS
3. Fabry-Anderson disease
4. Homocystinuria
5. Kearns-Sayre syndrome
6. Myoclonus epilepsy with ragged red fibers
7. Ehlers-Danlos syndrome, type IV
8. Marfan syndrome
9. CARASIL
10. Other monogenetic small vessel brain diseases
11. Other
F. Drugs that cause stroke, including drugs of abuse
G. Cerebral amyloid angiopathy—infarction or hemorrhage
H. Cardioembolic causes of stroke
1. Atrial fibrillation
2. Cardiovascular procedures and operations
3. Acute myocardial infarction
4. Dilated cardiomyopathy
5. Rheumatic mitral or aortic stenosis
6. Infective endocarditis
7. Libman-Sacks endocarditis
8. Non-bacterial thrombotic endocarditis
9. Mechanical or bioprosthetic valves
10. Atrial myxoma
11. Sick sinus syndrome
12. Mitral valve prolapse
13. Patent foramen ovale, including atrial septal aneurysm
14. Congenital heart diseases, including cyanotic heart disease
15. Other
I. Prothrombotic causes of stroke
1. Inherited
a. Sickle cell disease
b. Factor V Leiden—activated protein C resistance
c. Prothrombin gene mutation
d. Protein S, C, antithrombin
e. Thalassemia
f. Iron deficiency anemia
g. Others
2. Acquired
a. Pregnancy
b. Cancer
c. Dehydration
d. Thrombocytosis
e. Thrombotic thrombocytopenic purpura
f. Heparin-induced thrombocytopenia and thrombosis (HITT)
g. Leukemia
h. Disseminated intravascular coagulation
i. Nephrotic syndrome
j. Hemolytic uremic syndrome
k. Sepsis and inflammation
l. Other
3. Autoimmune causes of thrombosis
a. Lupus and lupus anticoagulant, Sneddon syndrome and
antiphospholipid antibodies
b. Others
4. Iatrogenic/drugs/toxins
a. Antineoplastic
b. Prothrombotic agents
c. Others
J. Bleeding diatheses
1. Inherited
a. Hemophilia
b. Sickle cell disease
c. Thalassemia
d. von Willebrands disease
e. Others
2. Acquired
a. Leukemia
b. Thrombocytopenia
c. Disseminated intravascular coagulation
d. Others
3. Systemic diseases
4. Iatrogenic/drugs/toxins
a. Anticoagulants
b. Antiplatelet aggregating agents
c. Thrombolytic agents
d. Drugs of abuse
e. Others
K. Aneurysms
1. Saccular
2. Infected
3. Traumatic
4. Neoplastic
5. Dolichoectatic
6. Dissecting
L. Vascular malformations
1. Arteriovenous
2. Developmental venous anomaly
3. Cavernous
4. Telangiectasia
5. Dural arteriovenous fistula
M. Trauma and intracranial bleeding
N. Moyamoya disease and syndrome
O. Hypertensive hemorrhage
P. Other causes of hemorrhage
1. Vasculitis
2. Tumors
a. Primary
b. Metastatic
3. Iatrogenic
Q. Genetic diseases causing hemorrhagic stroke
06. Complications of stroke
A. Early neurologic complications
1. Brain edema, increased ICP, and herniation
2. Hydrocephalus
3. Seizures
4. Hemorrhagic transformation
5. Recurrent infarction
6. Recurrent hemorrhage
7. Other
B. Early medical complications
1. Cardiac
2. Gastrointestinal
3. Pulmonary
4. Electrolyte
5. Other
C. Chronic neurologic sequelae
D. Chronic medical sequelae
07. Treatment of patients with stroke
A. Outpatient management
1. Patient educational materials
B. Medical therapies to prevent stroke
1. Antiplatelet agents
a. Aspirin
b. Clopidogrel
c. Ticlodipine
d. Dipyridamole
e. Cilostazol
f. Prasugrel
g. Ticagrelor
h. Others
2. Anticoagulant agents
a. Warfarin
b. Heparin
c. LMW heparins
d. Direct thrombin inhibitors
e. Factor X inhibitors
3. Thrombolytic agents
4. Neuroprotective agents and other acute treatments
5. Cardioactive agents
6. Medications to prevent stroke by treating risk factors
a. Hyperlipidemia
b. Diabetes mellitus
c. Hypertension
d. Smoking
e. Hyperhomocysteinemia
f. Antiinflammatory
g. Alcohol dependence and detoxification
7. Medications to treat autoimmune diseases and vasculitis
8. Medications to treat complications of stroke
a. Anticonvulsants
b. Antidepressants
c. Brain edema and increased ICP
i. Hypertonic saline
ii. Mannitol
9. Medications to Improve or restore neurologic function or to
augment rehabilitation
10. Medications to prevent rebleeding or vasospasm following a
hemorrhage
a. Aminocaproic acid
b. Tranexamic acid
c. Nimodipine
11. Antimigraine medications
12. Vitamins
13. Interactions between medications
C. Hyperacute treatment of ischemic stroke
1. Emergency department
a. Intravenous thrombolytics
b. Intra-arterial thrombolytics
c. Mechanical thrombectomy
d. Anticoagulants and antiplatelet agents
e. Antihypertensives
f. Anticonvulsants
g. Other
2. Hospitalization – general management
a. Prevention of recurrent stroke
b. Prevention of deep vein thrombosis and pulmonary
embolism
c. Blood pressure management
d. Treatment of complications
e. Treatment of comorbid diseases
f. Treatment of risk factors for stroke
g. Other
3. Intensive care unit
a. Osmotic agents
b. Steroids
c. Sedation
d. Blood products
e. Anti-vasospasm therapy
f. Management of ventriculostomy
g. Temperature control
h. Antiarrhythmics
i. Ventilator management
j. Pressors
k. Antibiotics
l. Other
4. Neurosurgical management
a. Hemorrhage
i. Evacuation
ii. Ventriculostomy
b. Ruptured aneurysms
i. Management of vasospasm
c. Vascular malformations
d. Surgical treatment of brain edema – decompressive
craniectomy
e. Other
D. Chronic care
1. Antidepressants
2. Sedatives
3. Stimulants
E. Treatment of venous thrombosis
F. Treatment of spinal cord vascular disease
G. Treatment of pituitary apoplexy
H. Professionalism, ethics, systems-based practice
1. Palliative care
2. End-of-life decisions
3. Advanced directives, informed consent, regulations
4. Other
08. Recovery, regenerative approaches, and rehabilitation
A. Functional assessment
B. Regeneration and plasticity
C. Predicting outcomes
D. Pharmacologic effects on recovery
E. Rehabilitation principles
F. Emerging approaches

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Question: 1189
Which of the following is not a covered service under theMedicare hospice benefit?
1. Home health aide services
2. Homemaker services
3. Physical therapy
4. Laboratory testing
5. Transportation for physician office visits
Answer: E Explanation:
The hospice benefit covers all testing, treatment, medications, and home-based support services necessary for palliative care of the terminal illness. Transportation costs are not covered.
Question: 1190
history of cigarette smoking who presents to your officefor a routine physical examination. Ordering a chest x-ray towhich of the following?
1. Primary prevention; supported by U.S. Preventive Services
2. Primary prevention; not supported by USPSTF guidelines
3. Secondary prevention; supported by USPSTF guidelines
4. Secondary prevention; not supported by USPSTF guidelines
F. screen for lung cancer for Mr. would be best described as
Answer: D Explanation:
Numerous studies have shown routine chest x-rays to not be beneficial in screening for lung cancer. Screening for asymptomatic disease is considered secondary prevention.
Question: 1191
The ability of a test to detect disease when the disease istruly present is a description of which of the following?
1. Sensitivity
2. Specificity
3. Positive predictive value
4. Negative predictive value
5. Selection bias
Answer: A
Explanation:
The sensitivity of a test reflects its ability to detect disease when the disease is present. For example, if a �rapid strep test� is positive in 80 out of 100 patients with culture-proven streptococcal pharyngitis, the sensitivity of the rapid test is 80/100 or 80%.
Question: 1192
In a study to determine the accuracy of fecal occult bloodtesting (FOBT) to detect polyps in the colon, 1,100 adults olderthan age 65 completed a six-card FOBT screening, followed by afull colonoscopy 1 week later to detect polyps. From the resultslisted in Table 8.1, which of the following is true?
1. Sensitivity of FOBT equals 60/60 (50%).
2. Specificity of FOBT equals 40/60 (67%).
3. Positive predictive value of FOBT equals 60/940 (6%).
4. Negative predictive value of FOBT equals 940/980 (96%).
5. The prevalence of polyps cannot be determined.
Answer: D Explanation:
Colonoscopy is considered a �gold standard� test for colonic polyps and determines the prevalence of polyps in the study group (100/1,100). Sensitivity, the ability of FOBT to detect polyps when they are present, is 60/100 or 60%. Specificity, the ability of FOBT to indicate nondisease when no polyps are present, is 940/1,000 or 94%. Positive predictive value indicates what proportion of patients with positive FOBT actually have polyps, 60/120 or 50%. The only correct answer is for negative predictive value, the proportion of patients with a negative FOBT who do not have polyps, 940/980 or 96%.
Question: 1193
Which of the following procedures is an indication forsubacute bacterial endocarditis prophylaxis in a susceptiblepatient?
1. Routine dental filling
2. Circumcision
3. Cardiac catheterization
4. Root canal
5. Tympanostomy tube insertion
Answer: D Explanation:
Subacute bacterial endocarditis (SBE) prophylaxis is recommended in patients at increased risk for bacterial endocarditis undergoing many common procedures. Patients at highest risk include those with complex cardiac abnormalities (e.g., tetralogy of Fallot), prosthetic valves, and surgically constructed shunts. Patients with problems such as hypertrophic cardiomyopathy, mitral valve regurgitation, and rheumatic heart disease are at moderate risk. Procedures likely to cause bacteremia include dental procedures (including routine cleaning and root canal) and surgery of the respiratory, gastrointestinal, and genitourinary tracts. SBE prophylaxis is not required for routine dental filling, x-rays, or fluoride treatments; cardiac catheterization; circumcision; intubation; flexible
bronchoscopy; or pressure equalization tube insertion.
Question: 1194
The Goldman scale helps determine the cardiac risk ofnoncardiac procedures. All of the following are risk factorsexcept:
1. Age older than 70 years
2. Signs of congestive heart failure
3. Aortic operation
4. Premature atrial contractions
5. accurate myocardial infarction (less than 6 months ago)
Answer: D Explanation:
The Goldman scale is a multifactorial index of cardiac risk in noncardiac surgical procedures. Risk is increased most with accurate myocardial infarction, signs of congestive heart failure, more than five premature ventricular contractions per minute, and rhythm other than sinus or premature atrial contractions. Risk is increased somewhat less dramatically with age older than 70 years, significant aortic stenosis, general debilitation, major surgery, or an emergency operation.
Question: 1195
Appropriate perioperative medication management includeswhich of the following?
1. For patients with well-controlled diabetes, administer the full
2. Never augment the dose of a corticosteroid in a patient on
3. Continue beta-blockers the morning of surgery with a sip of
4. Unless a patient quits smoking for 1 year, there is no
5. Discontinue aspirin use the day before surgery to diminish the
Answer: C Explanation:
Patients with well-controlled diabetes should typically hold shortacting insulin and take one-half to two-thirds of their intermediate or long-acting insulin on the morning of surgery. Corticosteroids should be increased to reflect the stress of surgery, both perioperatively and postoperatively. Cardiac and antihypertensive medications can be given with a sip of water on the morning of surgery. Smoking cessation is valuable, even if it is only 6 weeks prior to surgery (and although less well proven, many authorities would recommend cessation if only for shorter periods). Aspirin and nonsteroidal antiinflammatory drugs ideally should be stopped 1 week prior to surgery.
Question: 1196
The Public Health Service recommends five steps tois not one of the recommended steps?
1. Asking a patient about tobacco use at every visit
2. Advising all tobacco users to quit
3. Assessing readiness to quit
4. Administering the Fagerstrom nicotine dependence assessment
5. Arranging follow-up
G. effective smoking cessation counselinWhich of the following
Answer: D Explanation:
Although assessing nicotine dependence may play a role in smoking cessation, it is not part of the routine steps suggested by the Public Health Service. The other step is assisting the patient in quitting.
Question: 1197
Which of the following is true regarding transmission oftuberculosis?
1. D. patient is only considered infectious if three consecutive
2. More than 1,000 bacilli are required to initiate a primary
3. Infection is not possible without coming into direct contact
4. E. PPwill turn positive within 48 hours of initial exposure.
5. PPD will turn positive within 48 hours of initial exposure.
Answer: A Explanation:
Transmission of tuberculosis occurs primarily through inhalation of aerosolized bacilli. These bacilli can exist in droplet nuclei that can remain suspended in a room even if the patient is no longer present. As few as 1 to 10 bacilli entering an alveolus can cause infection. A single sputum demo containing acid-fast bacilli is diagnostic of active or recurrent tuberculosis.
Question: 1198
A 29-year-old construction worker seeks a disability opinionfrom you regarding low back pain from a accurate accident. Yourexamination is normal and you believe the patient isthe following?
1. D. referral to a pain clinic
2. Refusal to complete the disability form
3. Discussion with the patient and family to explore job
4. A referral to a pain clinic
5. Prescription of an SSRI
G. malingerinAn appropriate response might include which of
Answer: C
Explanation:
Developing rapport with a patient seeking disability or workers� compensation can be challenging. However, overzealous referral, inappropriate medicalization through overuse of tests and medications, and inadequate attention to job satisfaction and psychosocial issues can jeopardize longer term functional outcomes. Job satisfaction is highly associated with return to work and functional outcomes. Exploration of the psychosocial aspects of the patient's life, including family relationships, substance use, and psychiatric symptoms, is important. The physician should emphasize functional outcomes and address underlying problems.
Question: 1199
When considering a living will or a durable power ofattorney for health care, which of the following is true?
1. D. living will takes precedence over the durable power of
2. A living will allows the patient to choose a health care proxy
3. Either one can be easily revoked by the patient, either orally
4. A living will takes precedence over the durable power of
5. Both a living will and a durable power of attorney must be
Answer: C Explanation:
The content of advance directives documents is regulated by state laws. The durable power of attorney for health care allows patients to choose someone they trust to make health care decisions for them if they are unable to do so. A patient can easily and immediately revoke either document with a simple oral statement. The two documents serve different purposes in health care decisions, and one does not take precedence over the other.

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