Board Review Questions in Family Medicine

Edward T. Bope, MD, ABFM, Program Director; Curtis Gingrich, MD, ABFM, Associate Program Director; Ann M. Aring, MD, ABFM, Assistant Program Director; Darrin L. Bright, MD, ABFM Faculty; Miriam Chan, PharmD, Director, Pharmacy Education; Christine D. Huda

1. Mrs Jones is an 81-year-old woman with chronic hypertension that you have controlled very well. Today she presents with a left ischemic cerebrovascular accident. She was found at home still dressed from the day before. Which of the following answers regarding orders you would write are true and which are false?

A. Administer recombinant tissue plasminogen activator (TPA)

C. Carotid imaging

E. Fasting lipid profile

2. Mr Smith is a 55-year-old man who has had no medical care since childhood. He presents with no symptoms but asks about tests for colon cancer. He has no family history for any cancer. What test(s) would you advise?

A. A series of 3 fecal occult blood tests (FOBT)B. Flexible sigmoidoscopy

D. Digital rectal examination (DRE) and FOBT

3. Which of the following medications is the most appropriate treatment for patients with gestational diabetes?

A. Pioglitazone HCl (Actos)

C. Metformin HCl (Glucophage)

E. Rosiglitazone maleate/metformin HCl (Avandamet)

4. Which of the following test result abnormalities is most likely to be seen in a patient with bulimia?

A. Metabolic acidosis

C. Elevated thyroid-stimulating hormone (TSH) levels

E. Elevated liver enzymes

5. Of the following conditions, which one is NOT an indication for hospitalization of children with viral croup?

A. Depressed sensorium

C. Hoarseness

E. Progressive stridor

6. All the following statements regarding the diagnosis of pelvic inflammatory disease (PID) are true, except:

A. Isolation of a sexually transmitted infectious agent from the cervix is neededB. Minimum criteria for the empiric treatment of PID include uterine, adnexal, or cervical motion tenderness, with no other cause for the symptoms identified

D. No single symptom, physical examination finding, imaging study, or laboratory test is sensitive and specific for diagnosis

7. Which of these conditions is/are risk factors for PID?

A. Multiple sexual partners

C. Nonuse of barrier contraceptives

E. All the above

8. An 18-month-old boy who attends day care presents with runny nose, fever (38?C), and restless sleep. Examination reveals the child has a yellowish-orange, bulging tympanic membrane with almost no movement on pneumatic otoscopy. He has no known allergy and weighs 30 lb. Which of the following treatments would be appropriate?

A. Amoxicillin/potassium clavulanate (Augmentin), 45 mg/kg daily, given in 2 divided doses every 12 hours for 10 days

C. Azithromycin (Zithromax), 10 mg/kg daily for 3 days

E. No antibiotic treatment; reassure the parents

9. A 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and congestive heart failure presents to the emergency department with signs and symptoms of pneumonia. He was treated with levofloxacin (Levaquin) 2 months ago for an acute exacerbation of chronic bronchitis. His vital signs are: respiratory rate, 33 breaths/min; BP, 90/60 mm Hg; pulse, 120 beats/min; temperature, 39?C. What would be appropriate empiric antibiotic therapy?

A. Doxycycline (eg, Adoxa, Doryx, Vibra-Tabs), 100 mg po bid

C. Ceftriaxone sodium (Rocephin), 1 g/day intravenously (IV), plus azithromycin (Zithromax), 500 mg/day IV

E. Ampicillin, 1 g IV, every 6 hours, plus gentamicin (Garamycin), 3 mg/kg daily IV

10. A 24-year-old man presents to your office with gonococcal infection of the urethra. He says that he has just returned from California, and he had a male sexual partner. What would be the recommended treatment?

A. Levofloxacin (Levaquin), 250 mg po, single dose, plus azithromycin (Zithromax), 1 g po, single dose

C. Ciprofloxacin (Cipro), 500 mg po, single dose

E. Ciprofloxacin, 500 mg po, single dose, plus azithromycin, 1 g po, single dose

11. You have just received a Papanicolaou (Pap) smear report on a healthy 25-year-old woman that reads ?epithelial cell abnormality - low-grade squamous intraepithelial lesion.? What is the next appropriate step in management?

A. Human papilloma virus (HPV) DNA testing to determine if high-risk HPV types are present

C. Repeat Pap smear at 6 and 12 months

E. Perform colposcopy and endometrial biopsy

12. When explaining to a patient the role of HPV in causing an abnormal Pap smear, all the following statements are correct, except:

A. Use of a condom will prevent transmission to a partner

C. Most HPV infections are transient and will resolve spontaneously

E. Patients can be infected with more than 1 subtype of the virus in their lifetimes

13. Current trends show a decrease in the use of which of the following drugs?

A. MarijuanaB. LSD (lysergic acid diethylamide)

D. Inhalants

14. Which population group in the United States has the highest rate of suicide?

A. Alcoholic menB. Black women

D. Puerto Rican men

15. Which of the following statements about the prevention of perinatal group B streptococcal (GBS) disease is NOT true?

A. All pregnant women should be screened for vaginal and rectal GBS colonization at 35 to 37 weeks' gestation

C. Women found to have GBS bacteriuria during pregnancy should be treated with antibiotics at the time of detection and receive intrapartum antibiotics without retesting for GBS at 35 to 37 weeks' gestation

E. The recommended antibiotic regimen for intrapartum prophylaxis is penicillin G, 5 million units IV, every 4 hours until delivery, assuming the patient does not have penicillin allergy

16. You are the team physician covering a local high school football game. During the first quarter of the game, the running back sustains a blow to his helmet from an opposing player's knee while being tackled. He had no loss of consciousness after the injury and was able to walk off the field on his own. While you are evaluating him on the sidelines, he is complaining of a headache, and he seems a little confused. He has never sustained a concussion before. Appropriate sideline neuropsychologic testing demonstrates he is having problems with concentration and short-term memory. You decide to remove him from the game. A repeat evaluation 5 minutes later demonstrates that his confusion is gone, and the neuropsychologic deficits have resolved. However, his headache persists. According to the Summary and Agreement Statement of the First International Conference on Concussion in Sport, what would be the appropriate next step?

A. Continue to withhold him from competition since he suffered a grade 2 concussionB. Continue to withhold him from competition since he has persisting symptoms

D. Transport him to an emergency department for a computed tomography scan of the head to rule out subdural hematoma

17. You are a family physician examining a patient with the chief complaint of knee pain. While you are taking a more detailed history, you discover he is an avid runner, averaging 30 to 40 miles per week. What is the most common cause of knee pain in a runner?

A. Patellofemoral syndromeB. Iliotibial band syndrome

D. Arthritis

18. What causes a mallet finger?

A. Extensor tendon ruptureB. Bony avulsion of the distal phalanx at the insertion of the extensor tendon

D. All the above

19. All the following modalities are effective treatments for Achilles tendinosis, except:

A. IceB. Stretching and strengthening exercises

D. Iontophoresis

20. A 56-year-old white woman presents to your office with several complaints of a few weeks' duration. She notes morning blurred vision that resolves in several hours. She denies headache, chest pain, dizziness, or changes in her diet. She has been trying to lose some weight and has been pleasantly surprised to see that, according to your office scale, she has lost 10 lb in the past 4 weeks. She is a well-nourished, slightly obese woman holding a bottle of water. Her BP is 118/74 mm Hg. The remainder of the physical examination is unremarkable. You suspect she may be diabetic, which you confirm with a random measurement of blood glucose level at 212 mg/dL and a fasting blood glucose level of 139 mg/dL. In addition to a consultation with a dietitian, which of the following medications would be the most appropriate?

A. Rosiglitazone maleate (Avandia)

C. Lente insulin

E. Acarbose (Precose)

21. While you work on bringing the 56-year-old woman's blood glucose level down, you wonder about the indications for starting renal protective therapy. Which of the following is an indication for starting an angiotensin-converting enzyme (ACE) inhibitor in a patient with type 2 diabetes?

A. Hypoglycemic episodes

C. Diabetes that is suddenly more difficult to control

E. The patient read an article on WebMD and thinks she should be taking one

ANSWERS

1 - A. false, B. true, C. true, D. false, E. true. Ischemic/embolic stroke is a very common condition seen by primary care physicians. Since this patient's stroke occurred more than 3 hours before presentation, she is not a candidate for recombinant TPA. Her BP should not be tightly controlled to allow for perfusion. In fact, you should consider withholding hypertensive medicines while monitoring her BP. Cardiac monitoring is required to check for dysrhythmia. The carotid arteries should be imaged to look for critical stenosis or ulcer. Modifying risk factors is important to reduce risk of stroke, so measuring lipids is a good idea.

Reference

Conn's Current Therapy

2005

Clark WM. Ischemic cerebrovascular disease. In: Rakel R, Bope E, eds. , . Philadelphia, Pa: Elsevier/Saunders; 2005:900-905.

2 - C. The US Preventive Services Task Force recommends colonoscopy beginning at age 50 years for men and women. Three consecutive FOBT specimens is a proven screening method but it suffers from diet interference, causing false-positive results. Flexible sigmoidoscopy, DRE, and a single FOBT are not adequate screening strategies.

Reference

Guide to Clinical Preventive Services

2005

US Preventive Services Task Force. Screening for colorectal cancer. In: , . Available at www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed March 30, 2005.

3 - D. Using insulin therapy in patients with gestational diabetes reduces the incidence of fetal macrosomia. Oral hypoglycemic medications are not recommended because of potential teratogenicity. Many studies have shown that glyburide does not cross the placenta. However, the American College of Obstetricians and Gynecologists and the American Diabetes Association agree that glyburide should not be used to treat gestational diabetes until additional randomized, controlled trials validate its safety and efficacy. Reference Turok DK, Ratcliffe SD, Baxley EG. Management of gestational diabetes mellitus. Am Fam Physician. 2003;68:1767-1772.

4 - B. Patients with bulimia exhibit hypochloremia and hypokalemia as well as metabolic alkalosis from laxative or diuretic use and vomiting. Patients with anorexia nervosa demonstrate hypoglycemia, elevated liver enzymes, and low TSH levels. In addition, the electrocardiographic findings associated with either bulimia or anorexia are low voltage, prolonged QT intervals, and bradycardia.

Reference

Am Fam Physician

Pritts S, Susman J. Diagnosis of eating disorders in primary care. . 2003;67:297-304.

5 - C. Depressed sensorium, hypoxemia, progressive stridor, and restlessness are all indications for hospitalization of children with viral croup. Stridor at rest, pallor, respiratory distress, and suspected epiglottitis are additional indications. Hoarseness is a common symptom in viral croup that does not require hospitalization. Reference Knutson D, Aring A. Viral croup. Am Fam Physician. 2004;69:535-540, 541-542.

6 - A. Failure to isolate a sexually transmitted infectious agent from the cervix does not rule out PID. According to the 2002 Centers for Disease Control and Prevention (CDC) guidelines, minimum criteria for the empiric treatment of PID includes uterine, adnexal, or cervical motion tenderness when no other cause for the symptoms can be identified. Women younger than 25 years comprise 75% of PID cases. No single symptom, physical examination finding imaging study, or laboratory test is sensitive and specific for diagnosis.

Reference

Morb Mortal Recomm Rep.

Centers for Disease Control and Prevention. Sexually transmitted disease guidelines - 2002. 2002;51(RR-6):1-80.

7 - E. Multiple sexual partners, a history of sexually transmitted infection and PID, nonuse of barrier contraceptives, and age younger than 25 years are all considered risk factors for PID. Additional risk factors include young age at first intercourse, multiple sexual partners, and increased frequency of sexual intercourse. Reference Beigi RH, Wiesenfeld HC. Pelvic inflammatory disease: new diagnostic criteria and treatment. Obstet Gynecol Clin North Am. 2003; 30:777-793.

Streptococcus pneumoniae, Haemophilus influenzae

Moraxella catarrhalis

S pneumoniae

S pneumoniae

8 - D. The acute onset of signs and symptoms and the clinical findings on otoscopic examination confirm the diagnosis of acute otitis media (OM). Since this child is younger than 2 years, treatment with antibiotics is appropriate. At present, amoxicillin remains the antibiotic of first choice for uncomplicated OM. It is effective against the majority of strains of the 3 most common bacteria responsible for acute OM (, and ), has few side effects, and is low-cost and palatable. In patients at higher risk for drug-resistant - for example, those younger than 2 years, those in daycare, or those who have recently used antibiotics (ie, within the past 30 days) - high doses of amoxicillin (80-90 mg/kg daily, in 2 divided doses) are recommended, which produce sufficient middle-ear fluid concentrations in children with acute OM to eradicate drug-resistant .

9 - C. Current guidelines for the management of community-acquired pneumonia advocate the use of the Pneumonia Severity Index as an objective measure of risk stratification to help determine the initial site of treatment. Based on age, comorbidities, and clinical findings, this patient is assigned to class IV (moderate risk). He should be hospitalized (not in the intensive care unit) and treated with IV therapy until clinically improved. Since he was given a course of antibiotics within the past 3 months, he is at risk for drug-resistant S pneumoniae. In this case, a beta-lactam (ie, cefuroxime [Ceftin], cefotaxime sodium [Claforan], ceftriaxone sodium, ampicillin sodium/sulbactam sodium [Unasyn]) and an advanced macrolide (ie, azithromycin, clarithromycin) or respiratory fluoroquinolone (ie, moxifloxacin HCl [Avelox], gatifloxacin [Tequin], levofloxacin, gemifloxacin mesylate [Factive]) would be appropriate. Depending on the class of antibiotics recently given, one or another of the suggested options may be selected. Recent use of a fluoroquinolone should dictate selection of a nonfluoroquinolone regimen.

Neisseria gonorrhoeae

N gonorrhoeae

Chlamydia trachomatis

C trachomatis

10 - B. Recommended antibiotics for gonococcal infections are a single dose of cefixime (Suprax), 400 mg; ceftriaxone sodium, 125 mg; ciprofloxacin, 500 mg; ofloxacin (Floxin), 400 mg; or levofloxacin, 250 mg. Recent data from the CDC-sponsored sentinel surveillance system indicate an increase in the prevalence of quinolone-resistant among men who have sex with men (MSM). In the absence of antimicrobial susceptibility testing, fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in MSM in the United States. Patients infected with are often coinfected with . Hence, patients treated for gonococcal infection should also be treated with an agent effective against uncomplicated genital infection, unless chlamydial infection is ruled out. Recommended antibiotic regimens for chlamydial infection are azithromycin, 1 g, in a single dose, or doxycycline (eg, Adoxa, Doryx, Vibra-Tabs), 100 mg bid, for 7 days. Oral azithromycin, 2 g, in a single dose is not recommended for the treatment of gonorrhea because of a high rate of gastrointestinal (GI) side effects and high cost.

Reference

Centers for Disease Control and Prevention. Gonococcal Isolate Surveillance Project. Available at www.cdc.gov/std/gisp/Default.htm. Accessed April 7, 2005.

11 - B. According to the management guidelines of the American Society of Colposcopy and Cervical Pathology, low-grade squamous intraepithelial lesion Pap smear results should be evaluated by colposcopy. Repeat cervical cytology has a low sensitivity and should not be used as a diagnostic test. HPV DNA typing will not be helpful, because approximately 80% of women with low-grade squamous intraepithelial lesions will test positive for high-risk HPV types. Endometrial biopsy is not necessary, since no abnormal endometrial cells were reported. Reference Wright TC Jr, Cox JT, Massad LS, et al. 2001 Consensus guidelines for the management of women with cervical intraepithelial neoplasia. Am J Obstet Gynecol. 2003;189:295-304.

12 - A. Though condom use should always be recommended since it can decrease the spread of many sexually transmitted infections, it does not protect against the transmission of HPV. Some studies estimate the prevalence of HPV infection to be 60% or more in college-aged women. Most HPV infections last less than 24 months. Persistent infection is necessary for the development of cervical cancer. More than 30 types of HPV are known that can cause cervical dysplasia.

Reference

N Engl J Med

Ho GYF, Bierman R, Beardsley NP, et al. Natural history of cervicovaginal papilloma virus infection in young women. . 1998;338:423-428.

13 - C. The use of crack/cocaine appears to be decreasing, especially in the northeast United States. Most areas have seen an increase in marijuana use, mainly attributed to renewed popularity among adolescents. The use of other substances, including inhalants and LSD, is also on the rise among adolescents and even preadolescents. Reference Parson EB. Substance abuse. In: Sahler OJ, Carr J, eds. The Behavioral Sciences and Health Care. Cambridge, Mass: Hogrefe & Huber; 2003:161-166.

14 - C. Elderly men have the highest rates of suicide. Some data suggest that persons who have their first episode of major depression diagnosed after age 65 years are at a very high risk of suicide. The lowest rates are in black women, regardless of age. Compared with their peers still living in Puerto Rico, suicide rates in Puerto Ricans living in the United States are increased by 3-fold.

Reference

The Behavioral Sciences and Health Care.

Llorente MD. Suicide. In: Sahler OJ, Carr J, eds. Cambridge, Mass: Hogrefe & Huber; 2003:175-180.

15 - D. The prevention of neonatal GBS disease is a serious issue facing physicians who care for pregnant women and newborns. Studies have shown that 10% to 30% of all pregnant women are colonized with GBS. The 2002 CDC guidelines recommend universal screening for GBS at 35 to 37 weeks' gestation. Screening should include vaginal and rectal specimen collections, because the GI tract is the likely source for vaginal colonization, and swabbing the rectum has been shown to substantially increase the yield. Women who have GBS bacteriuria during pregnancy should be treated at the time of a positive urine culture if the count is greater than 100,000 colony-forming units or if they have symptoms of urinary tract infection. Such women should also be treated intrapartum, because GBS bacteriuria represents a marker for heavy genital tract colonization. Penicillin G, 5 million units IV, every 4 hours until delivery, is the antibiotic regimen of choice for chemoprophylaxis. Penicillin-allergic patients should receive IV clindamycin (Cleocin) or erythromycin (Erythrocin Lactobionate). It is recommended that women in labor with an unknown GBS status should receive intrapartum antibiotics if they have 1 or more of the following risk factors: gestation less than 37 weeks, duration of membrane rupture at 18 hours or more, or temperature of 100.4?F or higher. Women with none of these risk factors should be followed conservatively and not be treated with antibiotics. Reference Schrag S, Gorwitz R, Fultz-Butts K, et al. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep. 2002;51(RR-11):1-22.

16 - B. In 2001, the Concussion in Sport Group (CISG) formulated recommendations for the safety and health of athletes who suffer concussions. The return-to-play protocol established by the CISG states that return to play after a concussion should follow a stepwise process:

1. No activity, complete rest. Once asymptomatic, proceed to 22. Light aerobic exercise (eg, walking, stationary cycling)

4. Noncontact training drills

6. Game play

Since this young man is still suffering from a headache, he should not be allowed to return to play. Once his headache resolves, he can complete the appropriate return-to-play protocol.

Reference

Br J Sports Med

Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. . 2002;36:6-10.

17 - A. The most common cause of knee pain in a runner is patellofemoral syndrome, which accounts for approximately 50% of all knee pain in runners. The syndrome is caused by an imbalance in the quadriceps muscle group. The patella is a sesamoid bone that is contained in the distal quadriceps tendon. The quadriceps muscle group controls the movement of the patella within the trochlear groove. Running is a vastus lateralis-dominant sport that can result in an imbalance between the vastus lateralis and vastus medialis muscles. As the muscular imbalance progresses, the patella tracks abnormally within the trochlear groove, with resulting inflammation. The second most common cause of knee pain in a runner is iliotibial band syndrome, accounting for approximately 25% of all knee pain.

Reference

Textbook of Running Medicine

O'Connor FG, Wilder RP, Nirschl R, eds. . New York, NY: McGraw-Hill; 2001.

18 - D. A mallet finger can result from any of these conditions. The term implies an injury to the extensor tendon that results in a flexion deformity of the distal interphalangeal joint. Reference Green DP, Butler TE Jr. Fractures and dislocations of the hand. In: Rockwood CA, Green DP, Bucholz RW, et al, eds. Rockwood and Green's Fractures in Adults. 4th ed. Vol 1. Philadelphia, Pa: Lippincott-Raven; 1996:616-617.

19 - C. A corticosteroid injection in the Achilles tendon is contraindicated because of the increased risk of tendon rupture after the injection.

20 - B. Patients recently diagnosed with type 2 diabetes or impaired glucose tolerance should be given clear goals for diet and exercise. This type of diabetes involves beta-cell fatigue and an insulin decrease, along with peripheral receptor insensitivity. In patients who are not obese, sulfonylureas are an excellent first choice, since they address both pathways. In obese patients, metformin HCl has recently gained favor because of its ability to reduce triglycerides, increase peripheral adipocyte sensitization, and decrease hepatic glucose production. There is also evidence that metformin may lessen the incidence of cardiovascular events in persons with diabetes. Reference American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28(suppl 1):S4-S36.

21 - D. There is mounting evidence for the use of ACE inhibitors or angiotensin receptor blockers (ARBs) in patients with diabetes. Type 2 diabetes is unique in that the benefits of ACE inhibitors and ARBs outweigh the risks in 2 patient populations: those with hypertension and those with microalbuminuria. So whereas all type 1 diabetics should receive ACE inhibitor or ARB therapy, this is not true for all patients with type 2 diabetes. The interesting pathophysiology stems from hyperglycemia leading to increased glomerular filtration rate (GFR) and ultimately podocyte (and glomerular basement membrane) destruction. This initially leads to microalbuminuria that progresses to proteinuria. Left untreated, the glomerulus will be destroyed. ACE inhibitors and ARBs are thought to reduce the GFR at the efferent arteriole.

Reference

Diabetes Care

American Diabetes Association. Standards of medical care in diabetes. . 2005;28(suppl 1):S4-S36.