Category: Family Medicine Forms

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1. An asymptomatic 42-year-old man with a 1-month history of essential hypertension comes for a follow-up…

Weight loss of 9 kg (20 lb)

• Key idea: Best interventions for reducing blood pressure in order from greatest effect to smallest effect: Weight loss (to BMI < 25) > DASH diet > Increased exercise > Reduced alcohol intake
• Reducing coffee and tobacco use should also reduce blood pressure, but weight loss is #1 strategy for anyone with BMI > 25

2. A 67-year-old woman comes to the physician because of constant, severe, nonradiating low back…

Compression fracture

• Post-menopausal older woman with chronic steroid use who presents with non-traumatic back pain found to have normal vitals with point tenderness over lumbar spine most concerning for compression fracture
• Key idea: Back pain with point tenderness has a limited differential: 1. Fracture (older woman, history of chronic steroid use, etc.); 2. Malignancy (prostate, breast, lung, multiple myeloma, etc.); 3. Osteomyelitis/Epidural abscess (fever, IVDU, etc.)
• Ankylosing spondylitis –> Young patient with back pain worse in the morning that improves with use and imaging showing involvement of sacroiliac joints
• Spondylolisthesis –> Adolescent with back pain that worsens with spinal extension

3. A 62-year-old woman comes to the physician because she is concerned about her risk for type 2…

Metformin

• Middle-aged woman with increased BMI and strong family history of T2DM found to have laboratory evidence of diabetes (HgbA1c > 6.5%) with signs of renal disease who therefore would NOT be a candidate for Metformin
• Key idea: Metformin is cleared by the kidneys and therefore patients with acute or chronic reduction in GFR (i.e. creatinine clearance) could have build-up of metformin that could lead to feared side effect of lactic acidosis (reason metformin often held among patients admitted to hospital)
• Key idea: Metformin contraindicated among men with creatinine > 1.5 and women with creatinine > 1.4

4. A 57-year-old man comes to the physician because of a 6-month history of cough productive of gray to light yellow…

Recommend participation in a smoking cessation program

• Middle-aged man with >50 pack-year smoking history who presents with chronic productive cough and is found to have erythrocytosis, expanded lung volumes and right-axis deviation most concerning for chronic obstructive pulmonary disease
• Key idea: Although patient already has signs of complications related to tobacco use, stopping tobacco will reduce the progression of smoking-related complications and be more beneficial than any form of symptomatic therapy
• Key idea: Chronic productive cough should make you think of chronic bronchitis (form of COPD) vs bronchiectasis (chronic infections, cystic fibrosis, etc.)
• COPD –> Hypoxemia –> Decreased O2 sensed by kidneys –> Increased EPO production –> Erythrocytosis
• COPD –> Low oxygen tension throughout many lung fields –> Diffuse vasoconstriction in pulmonary vasculature (to try to shunt blood to better oxygenated areas of lung, unique aspect of pulmonary vasculature) –> Increased resistance faced by right ventricle (i.e. pulmonary hypertension) –> RV hypertrophy –> Right-axis deviation

5. The wife of a 72-year-old patient calls the physician because she is concerned that it is no longer…

Ask the wife to accompany her husband to his appointment and express her concerns in her husband’s presence

• Key idea: Better to not be the middle-man of conversations between two parties and difficult to make recommendations without first seeing/evaluating the patient
• Key idea: Physicians CANNOT revoke a patient’s driver’s license (only can be done by DMV), but can recommend a patient not be allowed to drive (seizures, dementia, etc.)

6. A 52-year-old man comes for a follow-up examination 2 weeks after sustaining an inferior wall...

Lisinopril

• Medications shown to have mortality benefit in patients with HF or following an acute MI:
  • 1. Statins
  • 2. Aspirin
  • 3. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
  • 4. RAAS blockers (ACE inhibitor, ARB)

7. A 16-year-old girl comes to the physician for a routine health maintenance examination. She says she…

Calcium

• Strict vegans should definitely receive supplementation for Vitamin B12 since it is almost exclusively found in animal products and may also benefit from supplementation for Calcium (although many vegetables are good sources of calcium)

8. A 56-year-old woman comes to the physician because of a 3-day history of an itchy, burning rash…

Oral valacyclovir

• Middle-aged immunocompetent woman who developed an itchy, burning vesicular rash in the left V1 distribution most concerning for herpes zoster (i.e. shingles)
• Key idea: Simple herpes zoster infections in immunocompetent individuals can often be treated with a 7-day course of oral valacyclovir
• Patients with herpes zoster who are immunocompromised or have signs of complications (herpes zoster ophthalmicus, meningitis/encephalitis, disseminated zoster, etc.) are often treated with IV acyclovir and then transitioned to PO valacyclovir

9. A 47-year-old woman come to the physician because of a 1-week history of progressive pain and swelling…

Aspiration of the knee joint

• Middle-aged woman with morbid obesity and diabetes (relatively immunocompromised) who presents with progressive unilateral knee pain and difficulty bearing weight found to have near-fever, arthritis and severe pain with both passive and active range of motion concerning for possible septic arthritis
• Key idea: Patients with suspected septic arthritis (which is clinical diagnosis and often has normal imaging) require urgent joint drainage for diagnostic and therapeutic purposes
• Risk factors for septic arthritis: Abnormal joint (OA, RA, etc.), elderly, diabetes, IVDU, alcoholism, intra-articular glucocorticoid injections
• Key idea: Septic arthritis most commonly caused by Staph aureus and therefore empiric treatment is often vancomycin, but if patient not responding to vancomycin may consider switch to ceftriaxone for better gram negative coverage
• Key idea: Patient with septic arthritis will have joint fluid with WBC >50,000 with neutrophilic predominance, with only other causes of arthritis with similarly elevated WBCs being inflammatory arthritis (gout, CPPD, etc.)

10. A 15-year-old girl is brought to the physician because of left ear pain for 2 days. She competes in long-distance…

Daily use of alcohol-acetic acid ear drops

• Adolescent with significant exposure to water/swimming who presents with unilateral ear pain with erythema and discharge of outer ear canal and pain with manipulation of pinna, most consistent with otitis externa
• Key idea: Otitis externa often treated with antibiotic drops (often fluoroquinolone)
• Key idea: Risk of otitis externa can be reduced through use of earplugs, with some authors also recommending acidifying drops (acetic acid) with an astringent (alcohol): https://www.aafp.org/afp/2001/0301/p927.html

11. A 77-year-old woman comes to the physician because of a 1-week history of decreased appetite, nausea…

Fecal impaction

• Elderly woman on anticholinergic medication (oxybutynin) without a bowel movement for past 5 days presents for 1-week of decreased appetite, nausea and occasional vomiting is found to have normal abdominal exam with firm stool in rectal vault most consistent with fecal impaction
• Key idea: Loose stool 5 days prior may represent encopresis, which is where watery stool collects behind area of impaction and eventually squeezes past area of solid stool impaction
• Key idea: Given history of hysterectomy, would be important to also consider small bowel obstruction 2/2 adhesions, but in that case would expect hyperactive bowel sounds and greater component of colicky abdominal pain without stool in rectal vault
• Key idea: Anticholinergic medications are relatively contraindicated in the elderly because it can lead to urinary retention, fecal retention, confusion, decreased sweating (“warm, dry skin”), etc.

12. A previously healthy 14-year-old boy is brought to the physician because of a 1-week history of a rash over…

Topical selenium sulfide

• Adolescent with asymptomatic hypopigmented rash composed of macules coalescing into patches on the neck, back and chest most consistent with tinea versicolor
• Key idea: Tinea versicolor is NOT a true tinea infection and is best treated with selenium sulfide or ketoconazole-containing shampoo
• Key idea: Important to contrast with vitiligo, which would lead to fully depigmented (white) lesions with predilection for acral areas and the face

13. A 14-year-old boy with reactive airway disease is brought to the physician because of repeated episodes of…

Inhaled corticosteroid therapy

• Adolescent boy with history of reactive airway disease currently using albuterol treatments with poorly controlled disease (repeated hospitalizations, missed school, reduced FEV1) who could benefit from step-up in therapy to inhaled corticosteroid for better baseline control
• Key idea: Step-up therapy in asthma often precedes from short-acting beta agonist (albuterol) –> low dose inhaled corticosteroid (budesonide) –> high dose inhaled corticosteroid +/- long-acting beta agonist (salmeterol) –> Biologics (omalizumab) or systemic steroids
• Key idea: Ways to track control of asthma include nighttime awakenings, frequency of short-acting beta-agonist use, and major events (hospitalizations, ED visits, etc.)
• https://www.ncbi.nlm.nih.gov/books/NBK7222/figure/A2212/

14. A 45-year-old man with gout has the sudden onset of extreme pain, swelling, and exquisite…

Indomethacin

• Middle-aged man with known history of gout presents with sudden onset arthritis of right knee concerning for acute gout flare, which is best treated with NSAIDs (indomethacin, naproxen, etc.)
• Key idea: Chronic gout medications that control levels of uric acid (allopurinol, probenecid, febuxostat, etc.) should NOT be used in setting of acute gout flare because it can lead to fluctuations in uric acid levels that can precipitate/worsen gout flare

15. An 82-year-old woman with dementia, Alzheimer type, is brought to the physician by her daughter for recommendations…

The patient should not have access to car keys until her driving skills are formally assessed

• Key idea: Physicians themselves are NOT allowed to revoke a patient’s driver license, with that power/responsibility falling under control of DMV; in this case, given that patient has Alzheimer’s and has not driven in years, would be best for her to be reassessed or re-evaluated before determining her capacity to drive
• Key idea: Diagnosis of Alzheimer’s or any other form of dementia does NOT necessarily mean patient should not be allowed to drive (although does imply that patient should be evaluated carefully for driving capacity)

16. A 62-year-old man returns to the physician because of a 4-month history of progressive difficulty swallowing…

Keeping a log of ordered tests that require follow-up by the office

• Middle-aged man with dysphagia to solids progressing to liquids who was found to have evidence of esophageal carcinoma on barium swallow 2 months ago but never received results, likely due to inefficiency or error of medical office
• Key idea: Some tests are more urgent than others, and it is a best practice to keep a log of test results that require closer follow-up

17. A 37-year-old man comes to the physician because of a 6-week history of epigastric pain…

Serum Helicobacter pylori antibody assay

• Young man with subacute postprandial epigastric pain relieved by antacids without evidence of significant GI blood loss most consistent with peptic ulcer disease
• Key idea: The two most common causes of peptic ulcer disease are H pylori infection and NSAIDs, and in this case given no history of NSAID use, concern for H pylori infection would be high
• Key idea: Duodenal ulcers improve after eating (because of release of bicarbonate into duodenum to neutralize stomach acid) whereas gastric ulcers worsen after eating (because of release of stomach acid)
• Key idea: If patient had signs of a perforation secondary to peptic ulcer disease (severe persistent pain, rebound/guarding, sepsis, etc.), then next best step would be abdominal imaging to look for peritoneal free air

18. A 72-year-old man comes to the physician as a new patient. He recently moved to the area. He feels well…

Continue his current regimen

• Asymptomatic elderly man with ASCVD risk factors currently on statin, aspirin and ACE inhibitor found to have 30% stenosis of right carotid and 10% stenosis of left carotid who should continue to be managed with intensive medical management
• Key idea: All patients with carotid atherosclerosis should be on statin, aspirin (as long as no bleeding risk factors) and blood pressure control medications
• Indications for carotid endarterectomy:
  • [ABSOLUTE indication] –> Symptomatic (TIA/stroke in compatible distribution) with at least moderate [>50%] stenosis without relative contraindications (persistent disabling neurologic symptoms, life expectancy < 5 years, etc.)
  • [RELATIVE indication] –> Asymptomatic with high-grade stenosis (>80%)

19. A previously healthy 47-year-old woman comes to the physician because of a 1-week history of low…

Oral ibuprofen therapy

• Middle-aged woman with unilateral back pain radiating down leg after lifting heavy objects without systemic symptoms found to have normal neurologic exam with paraspinal tenderness most consistent with lumbosacral muscle strain
• Key idea: Most common cause of back pain is muscle strain, which should be managed with ~6 week trial of NSAIDs and continued activity (don’t advice bed rest!)
• Indications for x-ray with low back pain: Compression fracture, ankylosing spondylitis, suspected malignancy
• Indications for MRI with low back pain: Osteomyelitis/epidural abscess, neurologic symptoms

20. One hundred patients participate in a health education program designed to teach health benefits of…

Change in knowledge and dietary habits of each participant

• Key idea: Select an outcome measure that is focused on the primary objective of the intervention and does not have a lag time of many years (mortality, morbidity, etc.)

21. An 11-year-old boy is brought to the physician because of a 2-day history of nasal congestion and mild sore throat…

Provide symptomatic care only

• Young child with 2 days of runny nose, cough and sore throat without fever or oropharyngeal exudates, most consistent with a viral URI (i.e. cold) that should be managed symptomatically
• Key idea: Antibiotics would be indicated for strep throat, which would NOT show viral symptoms (cough, rhinorrhea) and would often lead to more predominant tonsillar/oropharyngeal erythema and exudates
• Key idea: Antiviral therapy sometimes used in setting of suspected influenzae infection during first 48 hours or in individuals with high risk of complications (elderly, immunocompromised, etc.), but would expect more systemic symptoms (muscle aches, +/- fevers, etc.)

22. A 62-year-old woman comes to the physician because of a 6-month history of shortness of breath…

Baroreceptor-mediated ADH (vasopressin) secretion

• Middle-aged woman without close medical follow-up who presents with signs of heart failure (dyspnea, bilateral lung crackles, S3, laterally displaced PMI, lower extremity edema) also found to have hyponatremia to 132 likely due to overactive RAAS
• Poorly compensated heart failure –> Decreased effective circulating volume –> Decreased blood pressure sensed by kidneys –> Increased renin secretion –> Increased production of Angiotensin 2 –> Increased aldosterone (eunatremia, hypokalemia and metabolic alkalosis) and increased ADH (hyponatremia due to free water reabsorption)
• Key idea: Hyperaldosteronism classically leads to hypokalemia and metabolic alkalosis due to ENaC mediated Na+ reabsorption in exchange for K+ and H+ secretion but doe not lead to Na+ changes due to aldosterone escape method (aldosterone vs BNP/ANP)

23. A 25-year-old woman comes to the physician because of a 2-week history of neck pain, palpitations…

Subacute thyroiditis

• Young woman presents with signs of hyperthyroidism (palpitations, sweating, weight loss, tachycardia) found to have tender thyroid gland with decreased uptake on thyroid scan most consistent with subacute granulomatous (de Quervain’s) thyroiditis
• Key idea: Subacute granulomatous (de Quervain’s) thyroiditis, which makes you feel in pain (Quervain’s = pain)
• Key idea: Hyperthyroidism with decreased thyroid uptake consistent with thyroiditis (release of preformed thyroid hormone but decreased current production) or exogenous thyroid hormone usage (thyroid gland not producing hormone)
• Graves disease –> Diffuse uptake into thyroid gland with more eye-related thyroid symptoms
• Toxic multinodular goiter –> Multiple foci of increased thyroid uptake with decreased uptake elsewhere
• Exogenous thyroid ingestion –> Decreased thyroid uptake with atrophic/small thyroid gland

24. A 6-year-old boy is brought to the physician because of a 2-week history of scaling of his scalp…

Oral griseofulvin for the patient only

• Dark-skinned child presents with subacute, annular scaly plaque on his scalp most concerning for tinea capitis
• Key idea: Most dermatophyte infections can be treated with topical treatments, with the two infections being tinea capitis and onychomycosis which require oral antifungals (terbinafine, griseofulvin)
• Key idea: Risk factor for tinea infections include shared spaces/mats (wrestlers, college, gymnasts) and family pets

25. An 82-year-old woman comes to the physician because her memory is “not as good as it used to be.” She…

Reassurance

• Elderly woman with mild impairments in memory who has intact ADLs/iADLs and MMSE of 29/30 with normal laboratory work-up for reversible cause of dementia most consistent with normal aging
• Normal aging: Decrease in short-term memory but normal ADLs/iADLs
• Mild cognitive impairment: Decline in at least 1 cognitive domain with intact ADLs/iADLs with compensation
• Major cognitive impairment (dementia): Significant decline in cognitive functioning with marked functional decline in ADLs/iADLs
• Reversible causes of dementia: Hyper/Hypothyroidism, B12 deficiency, depression, medication side effect (anticholinergics, etc.)

26. A 55-year-old woman comes to the office because of a 3-month history of fatigue. She typically walks to work…

Serum ferritin concentration

• Middle-aged woman using daily NSAID who presents with subacute/chronic fatigue found to have anemia with borderline decreased MCV and normal ESR most concerning for iron deficiency anemia
• Key idea: One potential cause of iron deficiency anemia in this patient would be peptic ulcer disease in setting of chronic NSAID use, but OLDER MEN AND POST-MENOPAUSAL WOMAN WITH IRON DEFICIENCY ANEMIA HAVE COLON CANCER UNTIL PROVEN OTHERWISE!!!
• Key idea: Most common causes of microcytic anemia include:
  • Iron deficiency anemia: Menstruation, GI blood loss, celiac disease, etc.
    • Low iron, Low ferritin, Increased TIBC
  • Anemia of chronic disease: Patient with chronic inflammatory condition (RA, psoriasis, etc.)
    • Low iron, High ferritin, Low TIBC
  • Sideroblastic anemia: Most common lead poisoning –> abdominal pain and neurologic symptoms in patients with exposure (old homes, mechanic, battery factory, etc.)
• Key idea: Iron deficiency anemia is most common cause of fatigue and shortness of breath among young woman due to blood loss from menstruation

27. The patient’s serum ferritin concentration is 5 ng/mL. She is advised to discontinue naproxen therapy and begin…

Colonoscopy

• Key idea: Iron deficiency anemia (especially refractory to standard therapies) in older men and post-menopausal women is due to colon cancer until proven otherwise, and therefore requires a colonoscopy

28. A 45-year-old man with type 2 diabetes mellitus and hypertension and comes to the physician as a new patient…

Smoking cessation

• Middle-aged man with well-controlled T2DM (HgbA1c < 8%), moderately controlled blood pressure (BP 142/82) and 20 pack-year smoking history with labs notable for normal renal function, sufficient HDL levels and normal LDL levels who would most benefit from smoking cessation
• Note: All patients with hypertension and T2DM should be on an ACE inhibitor or ARB for renal protective effects, but in this case smoking cessation would be even more beneficial

29. A 67-year-old man comes to the physician requesting a prescription for nicotine patches. He has smoked…

Prescribe transdermal nicotine and recommend a behavior modification program

• Key idea: Although past case reports have recounted cases of patients who developed acute MI shortly after starting nicotine replacement therapy, no causal relationship has been demonstrated and the benefits in long-term cardiac risk from stopping smoking far outweigh any potential/theoretical cardiac harm from the nicotine patch, and angina is NOT a contraindication to nicotine patch

31. A previously healthy 47-year-old man comes to the physician because of a 2-month history of severe headaches…

Cluster headache

• Middle-aged man with recurrent nighttime headaches with severe retroorbital pain associated with periorbital symptoms (ptosis, miosis) most consistent with cluster headaches
• Key idea: Can also see rhinorrhea, lacrimation, sweating and flushing associated with cluster headaches, which classically occur recurrently at night and can wake someone from their sleep
• Idiopathic intracranial hypertension –> Heavy young woman with headache and nausea in the morning found to have papilledema
• Migraine without aura –> Pulsatile, unilateral headache associated with photophobia and nausea
• Trigeminal neuralgia –> Shooting, “lightning-like” pain of the lateral face

32. A 62-year-old man comes to the physician because of a 2-month history of shortness of breath with…

Angiotensin-converting enzyme (ACE) inhibitor

• Middle-aged man with ASCVD risk factors and history of MI who presents with chronic dyspnea found to have signs of heart failure (bilateral lung crackles, S3, cardiomegaly, Kerley B lines)
• Key idea: Medications with mortality benefit in setting of CHF include:
  • Beta blockers: Carvedilol, metoprolol succinate, bisoprolol
  • ACE inhibitor or ARB
  • Spironolactone
• Key idea: Diuretics and digoxin can improve quality of life among patients with CHF, but have not been shown to have mortality benefit

33. A 12-year-old boy is brought to the physician for evaluation of bed wetting; he was toilet trained for daytime…

Enuresis alarm

• Key idea: First step in setting of enuresis is lifestyle changes (decreasing fluid intake before bed, void before bedtime, etc.) –> Enuresis alarm –> Medical management (desmopressin)
• Key idea: In this patient who is a “deep sleeper”, they may particularly benefit from an enuresis alarm
• Deprivation of water starting at 5 pm may be a bit extreme!
• Key idea: Enuresis in a child who was previously toilet trained can be potentially concerning for obstructive sleep apnea

34. A 42-year-old woman with type 2 diabetes mellitus comes to the physician because of a lesion on her…

Exposure to human papillomavirus

• Key idea: HPV is the #1 risk factor for squamous cell carcinoma of the cervix, vagina, vulva, penis and anus

35. A 77-year-old man with coronary artery disease comes to the physician for a follow-up…

Renal artery stenosis

• Elderly man with known CAD and PAD who has had increase in BP to 180/100 over 2 year period found to have hypokalemia and metabolic alkalosis most concerning for renal artery stenosis
• Renal artery stenosis –> Kidneys sense reduced effective circulating volume –> Increased RAAS activation –> Resistant/severe hypertension due to increased aldosterone and ADH levels
• Key idea: Aldosterone acts upon ENaC channels, which reabsorb Na+ in exchange for K+ or H+ to maintain electrical neutrality, thereby leading to loss of K+ and H+ –> Hypokalemia and metabolic alkalosis
• Key idea: Severe/resistant hypertension coupled with hypokalemia and metabolic alkalosis consistent with increased mineralocorticoid activity, which could either be:
  • Renal artery stenosis: Elderly patient with ASCVD risk factors or young woman with possible fibromuscular dysplasia (neurologic symptoms, abdominal bruit, abnormal renal arteriography)
  • Conn syndrome (primary hyperaldosteronism): Pure hypertension with hypokalemia and metabolic alkalosis
  • Cushing syndrome: Increased weight, moon facies, striae, insulin resistance, etc.
    • Key idea: When cortisol gets exceedingly elevated (as with Cushing syndrome), it can start to bind to aldosterone/mineralocorticoid receptors and lead to same electrolyte derangements as hyperaldosteronism

36. A 16-year-old boy comes for an examination prior to participation in school sports. A painless mass…

Varicocele

• Key idea: Varicocele is classically described as a “bag of worms” and is more likely to occur on the left side due to increased venous pressure due to left spermatic vein draining into left renal vein (rather than directly into IVC)
• Key idea: Varicocele is a common cause of male infertility with increased pooling of blood –> increased temperature –> impaired sperm maturation but intact androgen production

37. A 22-year-old primigravid woman at 34 weeks’ gestation comes to the physician because of a 1-week history of burning…

Median nerve entrapment

• Young woman in her 3rd trimester of pregnancy presenting with sensory abnormalities in a median nerve distribution of the right hand most concerning for carpal tunnel syndrome
• Risk factors for carpal tunnel syndrome (often associated with soft tissue enlargement):
  • Hypothyroidism
  • Diabetes
  • Pregnancy (due to increased edema)
  • Rheumatoid arthritis
  • Acromegaly
  • End-stage renal disease (due to amyloid deposition)
  • Idiopathic (+/- overuse)
• Cervical radiculopathy –> LMN signs in upper extremities with UMN signs of lower extremities
• Meralgia paresthetica –> Obese patient with tight clothing with numbness of anterolateral thigh
• Radial nerve palsy –> Wrist drop

38. A 42-year-old man comes to the physician for a routine life insurance examination. He feels well…

Abstinence from alcohol

• Young man with 25 pack-year smoking history and excessive alcohol use with labs notable for elevated AST > ALT and mild hyperbilirubinemia, consistent with alcoholic liver disease
• Key idea: Classically alcoholic liver disease leads to AST > ALT, but will not always have 2:1 ratio on NBME exams
• Key idea: Men of his age demographic should drink <14 alcoholic beverages per week and <4 alcoholic beverages per day
• Hemochromatosis (which can be treated through phlebotomy) would lead to elevated hemoglobin with an extremely elevated ferritin
• Hepatitis A infection only leads to acute infection (no chronic form) and often leads to clinical symptoms (nausea, vomiting, fever) with AST/ALT > 1000

39. A 47-year-old woman comes to the physician for a routine health maintenance examination. She has 11-year-old twin…

“Sometimes when people are as upset as you are, they think about suicide. Have you thought about ending your life?”

• Middle-aged mother meeting criteria for major depressive disorder who should be screened for suicidal thoughts/ideation
• Key idea: Greatest immediate risk of depression is suicide, so EVERY PATIENT WITH DEPRESSION NEEDS TO BE SCREENED FOR SUICIDAL THOUGHTS/IDEATION!
• MDD diagnostic criteria (at least 2 weeks with at least 5/9):
  • Sleep disturbances
  • Interest decreased
  • Guilty feelings
  • Energy decreased
  • Cognitive problems
  • Appetite changes
  • Psychomotor slowing
  • Suicidal thoughts/ideation
  • Poor mood or anhedonia

40. A 47-year-old woman comes to the physician because of right wrist pain that began 2 days ago when she fell on her…

Cast immobilization

• Middle-aged woman presenting 2 days after fall on outstretched hand (FOOSH) injury with tenderness to palpation of anatomic snuffbox who should have cast immobilization for possible scaphoid fracture despite reassuring imaging
• Key idea: Tenderness over the anatomic snuffbox very suspicious for a scaphoid fracture, with imaging often being normal early after injury especially if the fracture is non-displaced
• Key idea: In setting of suspected scaphoid fracture (i.e. tenderness over anatomic snuffbox), next best step is MRI imaging or casting/immobilizing wrist for 7-10 days and then repeating x-rays

41. A previously healthy 82-year-old woman comes to the physician because of generalized weakness and…

Folic acid

• Elderly woman with 6 month history of “tea and toast” diet who presents with 1 month of weakness and tongue pain found to have normal neurologic exam and macrocytic anemia with generally depressed cell lines (platelets, WBCs) most consistent with folic acid deficiency
• Ways to differentiate between folic acid and B12 deficiency (which both lead to megaloblastic/macrocytic anemia):
  • Clinically: B12 deficiency will also lead to neurologic symptoms compatible with subacute combined degeneration (weakness/tingling of lower extremities, impaired proprioception, etc.)
  • Labs: Both B12 and folate deficiency lead to increased homocysteine levels, but B12 deficiency also leads to increased methylmalonic acid levels
• Key idea: Both vitamin B12 deficiency and folic acid deficiency can be associated with glossitis; neurologic signs/symptoms more accurate way to differentiate between diagnoses
• Thiamine deficiency –> Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia); Korsakoff syndrome (confabulation, confusion); Beriberi (nerve damage +/- edema)

42. A healthy 37-year-old woman comes for a routine physical examination. She has a history of rheumatic fever…

Mitral valve stenosis

• Young woman with history of rheumatic fever found to have diastolic murmur at apex with an S4, most consistent with mitral valve stenosis
• Honestly, an S4 is most often associated with significant LV hypertrophy so it is unclear why mitral valve stenosis would lead to LV hypertrophy; answer to this question primarily dependent upon finding of diastolic murmur at apex
• Left-sided systolic murmurs:
  • Aortic stenosis (Ejection murmur, R 2nd intercostal space, worsens with increased preload)
  • HOCM (Ejection murmur, upper sternal border, improves with increased preload)
  • Mitral regurgitation (Holosystolic murmur, apex)
  • Mitral valve prolapse (mid-systolic click and then murmur of MR)
• Left-sided diastolic murmurs
  • Aortic regurgitation (Decrescendo murmur, R 2nd intercostal space, widened pulse pressure)
  • Mitral stenosis (low-pitched decrescendo-crescendo murmur, apex)
• Key idea: Mitral valve stenosis is almost always caused by rheumatic fever, especially among young individuals

43. A 37-year-old woman, gravida 3, para 3, comes to the physician for a routine health maintenance examination…

Measurement of serum cholesterol concentration

• Young woman with known history of hypercholesterolemia who has been trialing lifestyle interventions for 1 year and should have cholesterol levels re-checked to determine whether medication management is needed/indicated
• Mammography starts sometime between 40-50 years of age in patients without significant history of breast cancer or known genetic mutations
• Colonoscopy starts at 45 years old (recently changed from 50 yo) for most patients, but patients with a first-degree relative with colon cancer before age 60 should have colonoscopy at age 40 or 10 years before diagnosis in relative, whichever comes earlier
• Pap smear done in women 25-65 every 3 years or every 5 years with HPV co-testing (recently changed from starting at 21 yo)
• Diabetes screened for with HgbA1c, with glucose tolerance test only used during pregnancy

44. A 25-year-old woman who is a schoolteacher has a positive PPD skin test at a routine examination. She was exposed…

Treatment of latent tuberculosis now

• Young woman with known exposure to patient with active tuberculosis who has a positive PPD without systemic symptoms or x-ray findings, most consistent with latent tuberculosis which should be treated
• Key idea: Patients with latent tuberculosis are virtually always treated in order to prevent them from developing active tuberculosis down the line

45. A 57-year-old man come to the physician because of a 3-month history of intermittent chest pain with eating…

Upper endoscopy

• Middle-aged man with 20-year history of GERD and obesity presents with chronic, progressive post-prandial chest pain associated with dysphagia to solids but not liquids who should receive an upper endoscopy to rule-out a mass/cancer
• Key idea: Dysphagia to both solids and liquids more concerning for motility problem (e.g., achalasia), whereas progressive dysphagia from solids –> solids and liquids more concerning for obstruction (e.g., cancer, stenosis)
• 2 major types of esophageal cancer are:
  • Squamous cell carcinoma: Most important risk factors are smoking and alcohol use, which show a synergistic effect with one another
  • Adenocarcinoma: Often seen in setting of prolonged GERD, Barrett’s esophagus is precursor lesion, obesity also a risk factor
• Patients with GERD who should have upper endoscopy:
  • Men > 50 yo with >5 years of symptoms
  • Men > 50 yo with cancer risk factors (alcohol use, smoker, etc.)
  • Alarm symptoms (melena, hematemesis, weight loss, anemia, dysphagia/odynophagia)

46. During a routine health maintenance examination, a 15-year-old girl says that she has used marijuana with friends on four…

Scheduling a follow-up examination with the patient

• Young girl who is healthy other than several occasions of marijuana use, which should be kept confidential and not shared with parents at the patient’s request
• Key idea: Minors are generally not considered to have capacity to make medical decisions are require parental consent, but there are exceptions that can be remembered with mnemonic “sex, drugs and rock n’ roll”:
  • Sex: Contraception, treatment of STDs, treatment of pregnancy, confidentiality regarding sexual practices (Note: Abortion treatment often not protected)
  • Drugs: Substance abuse treatment, confidentiality surrounding alcohol or drug-related activities
  • Rock n’ roll: Emergency situations in which minors need to be treated before parents can be contacted
• No evidence of substance abuse (impaired functioning, withdrawal, increased cravings, etc.)
• Pap smears do not begin until 21-25 years old, and HPV testing does not begin until 30 years of age because many young adults will have HPV infections that are not clinically relevant because they will be cleared (we only care about chronic HPV infections –> cancer)

47. An 82-year-old man comes to the physician because of an 8-month history of progressive urinary frequency and decreased…

Measurement of postvoid residual volume

• Elderly man with chronic history of BPH symptoms (urinary frequency, decreased urinary stream) with an associated increase in her serum creatinine concentration over that time concerning for BPH complicated by post-renal AKI, which could be evaluated either by measurement of PVR or renal ultrasound (looking for hydronephrosis)
• Key idea: Although patient had a TURP procedure 11 years ago, he would be expected to have continued prostatic hyperplasia since then and could very well develop recurrence of BPH and measurement of PVR with ultrasound is a simple, non-invasive test
• Retrograde urethrography –> Suspected urethral injury (pelvic fracture or straddle injury + blood at urethral meatus and other urinary symptoms)
• Urine cytology –> Bladder cancer (male smoker with hematuria or other urinary symptoms)

48. A 47-year-old man comes to the physician because of a 2-day history of progressive sore throat and a 1-day history of a…

Warm saline gargle

• Middle-aged man with acute cough and pharyngitis without systemic symptoms or pharyngeal exudates, most consistent with a viral URI (cold) that can be managed conservatively
• Key idea: Risk of strep throat in setting of pharyngitis (particularly in adults) can be quantified by using Centor criteria (see diagram below), with this patient having a Centor score of 0 and thereby not being a good candidate for strep testing or empiric strep treatment
• Monospot test –> Adolescent with exudative pharyngitis + lymphadenopathy +/- hepatosplenomegaly

49. A 42-year-old man comes to the physician because of a 2-month history of severe leg pain, especially at night. He has poorly…

Oral amitriptyline therapy

• Young man with poorly controlled T1DM showing signs of end-organ complications (nephropathy and neuropathy) who complains of severe neuropathic pain at night and may benefit from a neuropathic pain medication:
  • TCAs (amitriptyline)
  • SNRIs (duloxetine)
  • Gabapentin
• Key idea: Neuropathic pain is often not responsive to conventional pain medications (NSAIDs, tylenol) and opiates should often be avoided except in setting of severe pain

50. An asymptomatic 27-year-old woman comes for a routine health maintenance examination. She works as a lawyer…

Hyperthyroidism

• Young woman presents with lab abnormalities consistent with hyperthyroidism (increased T3/T4, decreased TSH) found to have diffusely increased uptake on thyroid scan, most consistent with Graves disease
• Thyroid scan findings in hyperthyroidism:
  • Graves disease –> Diffusely enlarged gland (overall gland is being hyperstimulated by TSH-stimulating antibodies)
  • Toxic goiter (single or multinodular) –> One or multiple foci of increased uptake with decreased uptake in remainder of thyroid
  • Thyroiditis –> Decreased uptake (patient transiently hyperthyroid due to release of preformed thyroid hormone, but thyroid actually producing less thyroid hormone due to inflammation)
  • Exogenous thyroid intake –> Exogenous thyroid hormone leads to decreased TSH, which leads to decreased stimulation of thyroid gland and decreased thyroid hormone production by thyroid gland itself
• MEN syndrome associated with medullary thyroid cancer
• Subacute thyroiditis = De Quervain’s thyroiditis –> Painful thyroid gland

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1. A previously healthy 27-year-old woman, gravida 2, para 1, at 26 weeks’ gestation comes to the physician for a routine prenatal…

Domestic abuse

• Key idea: Bruises “in various stages of healing” tells you that bruising has occurred chronically, with distribution on forearms particularly concerning for domestic abuse (“defensive wounds”)
• Key idea: Pregnant woman, unfortunately, are at high risk for domestic abuse
• Pre-eclampsia –> 3rd trimester pregnancy with HTN, proteinuria, edema
• HELLP –> Pre-eclampsia with Hemolysis (anemia), Elevated Liver enzymes and Low Platelets
• ITP –> Most common cause of isolated thrombocytopenia
• von Willebrand disease –> Often presents with signs of platelet dysfunction (nose bleeds, heavy periods, petechiae/purpura) along with normal platelet count, normal PT, normal/increased aPTT (because vWF carries factor 8)

2. A 19-year-old college student comes to the physician because of a 3-month history of cough that occurs only in midafternoon…

Asthma

• Young man with cough at night associated with cold weather with normal work-up, most concerning for cough variant asthma
• Common triggers of asthma: Cold weather, exercise, allergens
• Common causes of chronic cough:
  • Asthma
  • GERD
  • Post-nasal drip
  • COPD
  • ACE inhibitor side effect
• Sarcoidosis –> Bilateral hilar adenopathy, hypercalcemia
• GPA –> Upper respiratory tract (ear infections, nasal symptoms) + Lower respiratory tract (cough, hemoptysis) + Renal (glomerulonephritis)
• Cocaine use –> Nose bleeds, destructive nasal lesions, hypertension, blown pupils, agitated/aggressive behavior

3. A previously healthy 37-year-old woman who works as a prison guard comes to the physician because of a 2-month history of low-grade fever…

Tuberculosis

• Young woman exposed to prisons who presents with subacute fever, fatigue and hemoptysis found to have a right upper lung infiltrate most concerning for tuberculosis
• Key idea: Subacute/chronic presentation with fever, malaise, weight loss, and/or night sweats should always make you think of malignancy vs indolent infection (mycobacterial, fungal) –> In this case malignancy is less likely given the patient’s age (too young) and the tempo of disease (lung CA would be more chronic)
• High-risk settings for Tb transmission:
  • Immigrant
  • Homeless shelters
  • Prisons
  • Congregate living facilities
• Tuberculosis almost always involves the upper lobe of the lung because it is a very aerophilic organism and the upper lobe has a higher V/Q ratio
• Environmental irritants –> Hypersensitivity pneumonitis –> Recurrent episodes of pneumonia-like illnesses following exposure with eventual development of interstitial lung disease

4. An 82-year-old man comes to the physician for a follow-up examination. He has a 2-year history of a painful tingling sensation…

Nortriptyline

• Elderly man with chronic history of T2DM who presents with painful lower extremity tingling refractory to gabapentin and carbamazepine –> next best options for neuropathic pain would be TCA (-triptyline) or SNRI (duloxetine)
• Phenelzine –> MAO inhibitor –> Watch out for tyramine-induced hypertensive episode (associated with wine/cheese consumption) and serotonin syndrome (Agitation, increased Activity and Autonomic symptoms)

5. An otherwise healthy 9-year-old girl is brought to the physician by her mother because she noticed a lump in her daughter’s left…

Follow-up examination in 6 months

• Healthy 9-year old girl who is Tanner stage 2 brought to doctor because of unilateral, 2 x 2.5cm, slightly tender mass beneath left areola most consistent with normal development of a breast bud that can be managed with close follow-up
• Key idea: Breast development may proceed asymmetrically and is completely normal
• Key idea: First step in new breast mass in woman over 35 is mammography, whereas in women under 35 best imaging modality would be ultrasound given increased breast density
• Key idea: Typical development of puberty in girls is breast development –> growth spurt –> menarche

6. A previously healthy 30-year-old woman comes to the physician because of fever, nonproductive cough, and left-sided chest pain…

Mycoplasma pneumoniae

• Young woman presents with 5 days of fever, cough and chest pain with mild diffuse crackles most consistent with atypical pneumonia (“walking pneumonia”), which is most often caused by Mycoplasma pneumoniae in young adults
• Key idea: Best treatment would be macrolide (azithromycin)
• Key idea: While Strep pneumo most common cause of bacterial, lobar pneumonia, young people more common to have atypical pneumonia due to Mycoplasma (which is confirmed by diffuse crackles rather than auscultatory findings localized to one lobe)
• Borrelia burgdorferi –> Lyme disease –> Bullseye rash, non-specific symptoms (fatigue, fever), Bell’s palsy, arthritis, neurologic symptoms
• Coxsackievirus –> Pleurisy, myocarditis
• Influenza virus –> Non-specific symptoms (fever, fatigue) + muscle fatigue

7. A healthy 14-year-old girl is brought for a routine health maintenance examination. On questioning, she says that she has…

Inquire about her attitudes toward smoking and health

• Key idea: For communication questions, best answer is often some form of non-judgmental, open-ended response, which will help physician determine next best step in management

8. The mother of a 16-year-old boy telephones the physician to request drug screening during his annual examination…

Do not agree to testing unless her son agrees to the drug testing

• Key idea: Minors often cannot provide consent or have confidentiality regarding their medical care, with the key exceptions being remembered by the mnemonic “sex, drugs and rock n’ roll”:
  • Sex: STD testing, pregnancy care, contraception, privacy regarding sexual practices
  • Drugs: Privacy regarding drug use, substance use programs
  • Rock n’ roll: Emergency situations where parents cannot be contacted quickly enough

9. A 32-year-old man comes to the physician because of painful blisters on his penis for 2 days. During the past 2 years…

Acyclovir

• Young man with unsafe sexual practices presenting with intermittent episodes of painful genital ulcers found to have vesicular penile lesions with bilateral inguinal lymphadenopathy, most concerning for HSV infection that is best treated with acyclovir
• Painful genital ulcers:
  • HSV –> Vesicles on erythematous base that can progress to become shallow ulcers, can be recurrent, mild lymphadenopathy
  • Chancroid (H. ducreyi infection) –> Large deep ulcers with severe lymphadenopathy that may be suppurative
• Painless genital ulcers:
  • Syphilis –> Single ulcer (chancre) with well-defined borders and firm base –> Treatment with penicillin
  • Condyloma acuminata –> Verrucous (wart-like), skin-colored papules
  • Lymphogranuloma venereum –> Shallow ulcers with predominant painful lymphadenopathy (buboes) –> Treated with ceftriaxone (form of Chlamydia)

10. A 37-year-old woman comes to the physician because of a 3-month history of generalized fatigue. She has noticed a decreased…

Assay for anti-transglutaminase antibodies

• Young woman with chronic history of GI symptoms (bloating, diarrhea) after carb-rich meals along with microcytic anemia most c/f celiac disease c/b iron deficiency anemia
• Key idea: Celiac disease commonly leads to iron deficiency anemia because it leads to inflammation of the duodenum, which is the primary site of iron absorption (Iron Fist Bro –> Iron (duodenum), Folate (jejunum), B12 (ileum)
• Schilling test –> Useful for suspected pernicious anemia (B12 deficiency [Megaloblastic anemia] with chronic atrophic gastritis)
• Chronic pancreatitis can also lead to intermittent diarrhea and particularly post-prandial pain, but is not associated with iron deficiency anemia

11. A 77-year-old woman who is a resident of a skilled nursing care facility is brought to the physician because of a 1-week history…

Drug-induced esophagitis

• Common causes of drug-induced esophagitis:
  • Tetracyclines
  • NSAIDs
  • Bisphosphonates (alendronate)
  • Potassium chloride
  • Iron
• Infectious causes of esophagitis in immunosuppressed
  • CMV –> Deep linear ulcers
  • HSV –> Vesicles and round shallow ulcers
  • Candida –> White plaques +/- oral thrush

12. A 32-year-old woman is brought to the emergency department by her husband because of the onset of shortness of breath…

Panic disorder

• Panic disorder = At least one untriggered panic attack + at least 1 month of worry and/or avoidance behavior related to fear of having another attack
• Panic attack symptoms:
  • Palpitations, pallor, perspiration
  • Abdominal pain
  • Nausea
  • Intense fear of dying or losing control, LIghtheadedness
  • Coughing, choking, chest pain
• Key idea: In a young patient without significant cardiac risk factors who presents with severe chest pain and feelings that they are going to die, panic attack should be high on differential
• Key idea: Panic attacks are not specific to panic disorder, and can also be triggered in setting of phobias, anxiety disorders, etc.
• Generalized anxiety disorder –> Symptoms have to be present for at least 6 months
• Hyperthyroidism –> Weight loss, hair/nail changes, brisk reflexes, etc.

13. A 47-year-old woman comes to the physician because of a 6-month history of mild hand pain that occurs primarily over the palmar…

Use of wrist splints

• Middle-aged woman with history of T2DM who presents with chronic history of pain, numbness and tingling in a median nerve distribution that is worsened by prolonged typing and awakens her from sleep found to have positive Tinel sign, most consistent with carpal tunnel syndrome
• Key idea: Carpal tunnel syndrome can often be managed with behavioral modification and splinting, which prevents the wrists from being in a flexed position overnight –> Next step would be steroid injection followed by definitive treatment with surgical release of the carpal tunnel
• Median nerve sensory distribution: Thumb, finger 2, finger 3, half of finger 4
• Risk factors for carpal tunnel syndrome:
  • Obesity
  • Pregnancy
  • Type 2 diabetes
  • Hypothyroidism
  • Acromegaly
  • End-stage renal disease
  • Rheumatoid arthritis
  • +/- Repetitive activities

14. A 77-year-old man comes to the physician because of a 4-week history of moderately severe aching and morning…

Prednisone therapy

• Elderly man presenting with subacute aching/stiffness of shoulders and hips without muscle weakness found to have an elevated ESR most concerning for polymyalgia rheumatica –> Best treated with corticosteroids
• Key idea: Polymyalgia rheumatica is associated with giant cell (temporal) arteritis, which can lead to blindness –> Remember that patients with suspected giant cell arteritis should IMMEDIATELY be started on steroids, even before temporal artery biopsy is performed
• Amitriptyline –> Neuropathic pain (diabetes)
• Allopurinol –> CHRONIC gout (don’t start during acute flare)
• Colchicine –> Acute gout flare (unilateral arthritis)

15. A 9-month-old girl is brought to the physician for a well-child examination. Two weeks ago, she had viral gastroenteritis…

Lactose intolerance

• Key idea: Viral gastroenteritis can lead to inflammation/damage of the brush border, which can lead to an acquired, transient lactose intolerance
• Important to differentiate from cow milk allergy, which often presents with bloody stools without other systemic or GI symptoms
• Celiac disease –> Steatorrhea after consuming gluten-based foods (cereal, pasta, etc.)
• Patients GI symptoms of vomiting and diarrhea have largely resolved, so bacterial enteritis or persistent viral gastroenteritis don’t fit

16. A previously healthy 22-year-old woman comes to the physician because of a 3-day history of malodorous vaginal discharge…

Metronidazole therapy

• Young woman presents with 3 days of malodorous vaginal discharge found to have gray vaginal discharge without vaginal/cervical inflammation with clue cells on gram stain most consistent with bacterial vaginosis (Gardnerella infection), which is best treated with metronidazole (clindamycin second-line)
• Vaginal discharge differential:
  • Bacterial vaginosis
    • Gray, fishy smelling discharge
    • Absent cervical/vaginal erythema
    • Wet mount demonstrates clue cells (vaginal epithelial cells studded with bacteria)
    • pH > 4.5
    • Tx: Metronidazole or clindamycin
  • Candidal vaginosis
    • White, cottage-cheese like discharge
    • Cervical/vaginal erythema present
    • Wet mount demonstrates hyphae
    • pH < 4.5
    • Tx: Fluconazole
  • Trichomonal vaginosis
    • Green-yellow discharge
    • Cervical/vaginal erythema present
    • Wet mount demonstrates motile trichomonads
    • pH > 4.5
    • Tx: Metronidazole
• Key idea: Most common cause of malodorous vaginal discharge in a child is actually foreign body (i.e. toilet paper)

17. A 16-year-old girl comes to the physician because of a 2-day history of urinary frequency and urgency and pain with…

Postcoital single-dose nitrofurantoin therapy

• Adolescent girl who is sexually active who presents with 3rd UTI in past 2 months, who may benefit from prophylactic antibiotics (daily TMP-SMX or post-coital nitrofurantoin)
• Postcoital urination is often suggested to reduce risk of subsequent UTI
• Depot medroxyprogesterone shot would not put patient at increased risk for UTI and therefore does not need to be stopped; if anything a diaphragm would probably increase risk of UTI (foreign body)

18. An asymptomatic 42-year-old man with polycystic kidney disease comes for a routine follow-up examination. He has hypertension…

Lisinopril therapy

• Young man with polycystic kidney disease on HCTZ who continues to be hypertensive found to have proteinuria, who could benefit from additional antihypertensive treatment with a RAAS inhibitor (ACE inhibitor, ARB)

19. A 27-year-old man comes to the physician because of a 1-week history of yellow eyes and dark urine. He has a history…

Hepatitis C infection

• Young man with history of IVDU and positive HBsAb (consistent with vaccination or prior infection) who presents with acute scleral icterus and jaundice with dark urine and hepatomegaly most consistent with hepatitis C infection
• Key idea: IVDU puts patients at increased risk for both hepatitis B and hepatitis C infection, but in this patient we know he does not have current hepatitis B infection because he has a negative hepatitis B surface antigen
• Key idea: Hepatitis A infection only comes in acute form and cannot be reactivated or chronic; acute hepatitis A infection often presents with nausea/vomiting/diarrhea after shellfish consumption
• Key idea: Hepatitis D infection (delta virus) can ONLY be seen in setting of active hepatitis B and leads to a superinfection of hepatitis B infection

20. A 52-year-old woman comes to the physician because of a 14-month history of generalized muscle pain and difficulty sleeping…

Antidepressant therapy

• Middle-aged woman with >6 month history of anxiety symptoms (difficulty sleeping, fatigue) also found to have muscle point tenderness most consistent with fibromyalgia, which often is associated with anxiety disorders
• Key idea: Fibromyalgia can often be managed with exercise program and mindfulness training, but can sometimes benefit from specific antidepressant medications (TCAs, SSRIs, duloxetine)
• Glucocorticoid therapy would be appropriate for polymyalgia rheumatica, which would occur in elderly patients and predominantly lead to proximal joint stiffness (rather than point tenderness) with signs of systemic inflammation

21. A 42-year-old woman comes to the physician because of recent high blood pressure readings. During the past month…

Beta-Adrenergic blocking agent

• Young woman with poorly controlled hypertension and migraines who could best be managed for both conditions with beta blockers
• Indications to use beta blockers to treat HTN:
  • Heart failure
  • Post-MI
  • Hyperthyroidism
  • Migraines
  • Atrial fibrillation
• Indications for prophylactic/preventive migraine medications:
  • Frequent (>4/month) or long-lasting (>12 hours) migraines
  • Disabling symptoms (missing work/school)
  • Unable to take or no relief from abortive medications
• Prophylactic migraine medications:
  • Beta blockers
  • Topiramate
  • Valproic acid
  • TCAs

22. A 42-year-old man comes to the physician for a routine follow-up examination. He feels well. He has a 2-year history of mild hypertension…

Hypertension

• Key idea: Single most important risk factor for stroke is HTN (strong expulsion of blood from aorta –> Sheer stress of carotids –> Atherosclerosis), whereas most important risk factor for other forms of ASCVD (heart attack, PAD) is often smoking > diabetes

23. A 47-year-old woman comes to the physician to discuss weight loss. She has a 5-year history of hypertension and was recently…

Gastric bypass

• Middle-aged woman with BMI of 38 complicated by HTN and T2DM who has struggled with traditional weight loss methods and would likely benefit from a gastric bypass operation with continued lifestyle interventions
• Indications for gastric bypass:
  • BMI > 40
  • BMI >35 and one of the following complications:
    • Diabetes mellitus
    • Obesity hypoventilation syndrome
    • Obesity-related cardiomyopathy
    • Severe sleep apnea
    • Osteoarthritis interfering with daily activity

24. A previously healthy 2-year-old boy is brought to the physician by his mother because of hoarse cough and difficulty breathing…

Laryngotracheobronchitis (croup)

• Previously healthy 2 year old with up-to-date immunizations presents with one day of hoarse cough and difficulty breathing found to have mild fever, hypoxia and inspiratory stridor most consistent with croup infection
• Key idea: Croup classically affects patients 6 months – 3 years of age and leads to inspiratory stridor + seal-like barking cough
• Key idea: Patients with croup without stridor at rest can often be managed with humidified air +/- corticosteroids, whereas patients with stridor at rest often receive corticosteroids and nebulized epinephrine
• Key idea: If patient presenting with croup becomes increasingly more ill-appearing (high fever, biphasic stridor, increased respiratory distress), important to consider whether patient has progressed to have bacterial trachieitis
• Bronchiolitis –> Infants (often <1 year of age) presenting with wheezing and coughing, often without fever

25. Over the past 4 months, a 66-year-old woman has had progressive shortness of breath on exertion. For 2 weeks…

Measurement of left ventricular ejection fraction

• Elderly woman with history of untreated hypertension who presents with progressive shortness of breath, PND, orthopnea found to have borderline JVD, bilateral inspiratory crackles, laterally displaced point of maximal impulse and S3 most consistent with congestive heart failure, which could be confirmed with echocardiography and measurement of LVEF
• Serial measurement of serum cardiac enzymes –> Suspected myocardial infarction (chest pain radiating to left arm, diaphoresis, etc.)
• Stress test and coronary artery angiography –> May be useful to determine etiology of HF (ischemic vs non-ischemic), but more invasive than echocardiography and cannot diagnose HF

26. A healthy 52-year-old woman comes to the physician because she is concerned about her risk for developing thyroid cancer…

Palpation of the thyroid gland

• Key idea: There is no validated screening test for thyroid cancer, so routine follow-up with history and physical directed at evaluating the thyroid gland are your best bet!
• Key idea: In setting of thyroid nodule, ultrasound > CT

27. A 67-year-old woman comes to the physician because of a 1-month history of diffuse abdominal cramps and worsening constipation…

Trial of fiber supplementation

• Elderly woman with psychiatric comorbidities and history of fluctuations between constipation and 2 bowel movements per day who presents with 1 month of abdominal pain and constipation with reassuring exam and work-up most consistent with irritable bowel syndrome –> Conservative management with mindfulness training and increased fiber consumption/supplementation
• Features more consistent with IBS rather than IBD:
  • Fluctuations between diarrhea and constipation
  • Lack of inflammatory signs (fever, weight loss, bloody stools)
  • Abdominal pain/symptoms relieved by defecation

28. An asymptomatic 67-year-old woman comes to the physician for a follow-up visit. She has a 10-year history…

Adverse effect of medication

• Key idea: Very common side effect associated with calcium channel blockers is lower extremity edema
• Key idea: Often lower extremity edema is associated with disease affecting the heart, liver or kidney, but this patient has no signs/symptoms or lab findings compatible with these diseases and is taking a common culprit medication

29. A 56-year-old woman comes to the physician for a routine examination in October. She has type 2 diabetes…

“Patients who are incubating the influenza virus when they receive the vaccine mistakingly attribute their symptoms to the vaccine. You should get the vaccine.”

• Basically this answer is all that is left after eliminating the other answer choices, which either are overly paternalistic, rely upon guilt-tripping patient or insult their intelligence

30. A 62-year-old woman comes to the physician because of a 9-month history of pain and swelling of her finger joints…

Acetaminophen

• Middle-aged woman with chronic history of painful, swollen PIP and DIP joints that worsens with activity most consistent with osteoarthritis which can be managed with acetaminophen or NSAIDs
• Key idea: Arthritis/arthropathy with involvement of DIP joints almost always due to osteoarthritis or psoriatic arthritis on the NBME
• Key idea: Joint pain that worsens with activity most consistent with osteoarthritis, whereas joint pain that improves with activity most consistent with inflammatory arthritis (RA, seronegative spondyloarthritis, etc.)

31. A 57-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious illness…

Exercise program

• Middle-aged woman with no history of serious illness found to have dyslipidemia (low HDL and high LDL), with first step in management being lifestyle changes; in her case, exercise program > weight loss because she is already of normal weight (BMI < 25)
• Indications for statin therapy:
  • History of ASCVD (MI, stroke, etc.)
  • LDL > 190
  • Diabetic aged 40-75
  • 10-year pooled ASCVD risk > 7.5%
• Key idea: In order to be diagnosed with hypertension, need readings >140/90 at >2 office visits; first step in treatment of newly diagnosed hypertension would be lifestyle changes (weight loss, DASH diet, etc.)

32. A 27-year-old man comes to the physician because of sadness, loss of appetite, and difficulty falling asleep since he and his wife…

Cognitive behavioral therapy

• Young man with recent life stressor who presents with >2 weeks of sad mood, appetite changes, sleep changes, low energy, and decreased interest in activities, most consistent with major depressive disorder which can be treated with cognitive behavioral therapy +/- antidepressants
• Test-taking strategy: Cognitive behavioral therapy is often the answer on NBME questions when asked to select the type of therapeutic technique

33. A 37-year-old man comes to the physician because of intermittent chest pain over the past 2 days. Four days ago, he…

Pleurodynia

• Young man with recent viral URI with intermittent stabbing chest pain with elevated creatine kinase but normal ECG and troponin most consistent with pleurodynia 2/2 coxsackievirus infection (“devil’s grip”)
• Key idea: In a young patient with chest pain, pre-test probability of MI is often low and you should prioritize other diagnoses such as costochondritis, panic attack, pericarditis, pleuritis and pulmonary embolism
• Empyema –> Bacterial pneumonia (fever + cough) with significant illness or non-resolving symptoms
• SLE –> Pericarditis and pleuritis
• PE –> Sudden onset pleuritic chest pain in patient with risk factor (long plane flight, OCPs, etc.)
• Pericarditis –> Pleuritic, positional chest pain +/- fever –> Treat with NSAIDs (in most cases)

34. An 82-year-old woman comes to the physician because of a 6-month history of frequent falls. Prior to each fall, she…

Physical therapy

• Elderly woman with history of recurrent falls without loss of consciousness or orthostasis who has lower extremity weakness and is likely having mechanical falls that could be managed with physical therapy to strengthen muscles
• Key idea: Fall without loss of consciousness decreases probability of cardiac or orthostatic cause
• 24-Hr ECG monitoring and duplex ultrasound of carotids would be appropriate work-up in a patient with a TIA or stroke to search for etiologies
• Meclizine is an antihistamine which could be useful for vertigo but should generally be AVOIDED in elderly patients given risk for significant anticholinergic side effects (confusion, urinary retention, etc.)

35. An 18-year-old woman comes to the physician because of a pruritic facial rash for 2 days. The rash began around the lips and then spread…

Atopic dermatitis with eczema herpeticum

• Young woman with personal/family history of atopy with chronic eczematous rash involving the bilateral antecubital fossa, neck and cheeks who presents due to an acute vesicular facial rash of the lips and cheeks concerning for herpes superinfection of underlying atopic dermatitis
• Key idea: Atopic dermatitis leads to disruption of the skin barrier and puts patients at very high risk for bacterial (Strep, Staph) or viral (HSV) skin infections, which should always be suspected in setting of worsening/flaring disease
• Key idea: Classic distribution of atopic dermatitis among adolescents is in flexural areas (antecubital fossa, popliteal fossa) but patients can also have disease affecting the facial area
• Chronic contact dermatitis with superinfection –> Would expect well-defined plaques and the distribution would need to be at sites of contactants
• Dermatitis herpetiformis –> Affects extensor surfaces and buttocks
• Erythema multiforme with bullous formation –> Classically leads to target lesions, with common triggers being HSV infection and Mycoplasma infections
• Psoriasis –> Classically affects extensor surfaces, sacral area, intergluteal crease, scalp, nails

36. An 82-year-old woman comes to the physician because of difficulty sleeping at night for 6 months. She says she watches television…

Begin sertraline therapy

• Elderly woman with multiple life stressors in past few years who reports a 6 month history of sleep changes, decreased energy, appetite changes, and cognitive impairment most consistent with major depressive disorder –> Treat with CBT +/- SSRIs
• Key idea: Complex grief reaction would include longing for the deceased, etc.
• Key idea: MDD requires symptoms for >2 weeks and requires at least 5 of the following 9 symptoms:
  • Sleep changes
  • Interest decreased
  • Guilty feelings
  • Energy changes
  • Cognitive problems
  • Appetite changes
  • Psychomotor slowing
  • Suicidal ideation/thoughts
  • Depressed mood or anhedonia
• Reversible causes of dementia (i.e. “pseudodementia”)
  • Depression
  • Hypothyroidism
  • B12 deficiency
  • Normal pressure hydrocephalus

37. A 42-year-old woman comes to the physician because of a 1-day history of severe pain, swelling, and warmth in her left knee…

Arthrocentesis

• Young woman presents with acute arthritis of left knee with limited range of motion, with next best step being arthrocentesis for diagnostic purposes given concern for possible septic arthritis (although she lacks fever)
• Key idea: Most likely has calcium pyrophosphate deposition disease, which can often occur following surgery or a period of intense exertion (i.e. kickboxing class)
• Key idea: Acute asymmetric inflammatory arthritis should make you consider:
  • Septic arthritis (fever, history of joint disease, IVDU, young sexually active individual, etc.) –> WBCs > 100,000 with neutrophilic predominance
  • Gout –> WBCs ~50,000 with negatively birefringent needle-shaped crystals
  • Calcium pyrophosphate disease –> WBCs ~50,000 with weakly positively birefringent rhomboid-shaped crystals

38. An 11-year-old boy is brought to the camp infirmary by his cabinmates 1 hour after collapsing. The boys had been playing…

Cerebral hypoperfusion

• Patient likely had syncopal episode (i.e. period of cerebral hypoperfusion) because he performed multiple maneuvers that each are associated with cerebral hypoperfusion:
  • Standing rapidly –> Drop in venous return due to gravity –> Decreased preload –> Decreased CO –> Decrease in cerebral blood flow
  • Breathing deeply and rapidly –> Respiratory alkalosis –> Decreased PaCO2 –> Decrease in cerebral blood flow
  • Breathing against closed mouth –> Valsalva –> Acute drop in preload –> Decreased CO –> Decrease in cerebral blood flow
• German medical students who used this exact method in study to show that twitching movements after loss of consciousness is not specific for seizure and can also be seen with syncope: https://www.youtube.com/watch?v=SOsNeUg1iGA

39. A 23-year-old woman comes to the physician because of moderate pain and swelling of her right ankle after twisting it yesterday…

Use of a soft protective brace and early range of motion exercises

• Young woman who twisted her ankle and presents with pain/ecchymosis of lateral malleolus who can bear weight and lacks tenderness at posterior margin of lateral malleolus most consistent with ankle sprain –> Does not meet Ottawa rules and therefore does not require imaging to rule out possible fracture; manage conservatively with bracing and early mobilization
• Ottawa ankle rule: X-ray of ankle required if pain at the malleolar zone AND:
  • Tender at posterior margin of medial malleolus
  • Tender at posterior margin of lateral malleolus
  • Unable to bear weight for 2 steps on each foot

40. A 62-year-old man comes to the physician for a routine follow-up examination. He has type 2 diabetes mellitus and peripheral vascular disease…

Lipid lowering therapy to decrease LDL-cholesterol concentration to less than 100 mg/dL

• Middle-aged patient with history of T2DM and PAD who has an elevated LDL on 2 repeat measurements and would likely benefit from cholesterol lowering medication (i.e. statin) with a goal LDL < 100 given his burden of comorbidities

41. A previously healthy 4-year-old girl is brought to the physician because of a sore throat and temperatures to 38.8…

Low sensitivity

• Young girl presents with exudative pharyngitis and fever found to have negative rapid strep antigen test but positive strep throat cultures, likely because of low sensitivity of rapid antigen test
• High false negative rate –> Low sensitivity –> Bad screening test (miss a lot of patients with disease)
• High false positive rate –> Low specificity –> Bad confirmatory test (overdiagnose a lot of patients without disease)
• Key idea: Sensitivity and specificity are characteristics inherent to the test, whereas PPV and NPV are also influenced by prevalence of disease (i.e. pre-test probability)

42. A 42-year-old woman comes to the physician for a follow-up examination. She has had persistent right heel pain…

Impaired renal excretion of sodium

• Young woman with well-controlled T1DM and HTN who has been taking naproxen for 3 weeks for right heel pain and now presents with 4 days of lower extremity edema to the mid-calf, likely in the setting of NSAID-induced AKI
• Key idea: NSAIDs –> Decreased prostaglandins –> Decreased vasodilation of afferent arteriole –> Decreased GFR (i.e. AKI)
• Key idea: Edema often due to dysfunction of the heart, kidneys or liver
• Key idea: A common class of medications known to cause edema is calcium channel blockers
• Key idea: ACE inhibitors and ARBs can also lead to an acute drop in GFR because they decrease levels of angiotensin 2, thereby leading to vasodilation of the efferent arteriole and decreased glomerular filtration pressure

43. A 32-year-old woman is referred to the physician because of anemia noted on routine testing prior to blood donation…

Measurement of serum iron and ferritin concentrations

• Young woman with regular menstrual periods found to have microcytic anemia with blood smear showing hypochromasia (enlarged area of central pallor) which is consistent with iron deficiency anemia and should be worked up with iron panel
• Key idea: Microcytic anemia due to problem with production of hemoglobin, either due to decreased iron availability (IDA, ACD), impaired globin protein (thalassemia) or impaired heme production (sideroblastic anemia)
• Causes of microcytic anemia and iron panel results:
  • IDA
    • Causes: Blood loss (obvious, overt), celiac disease
    • Iron studies: Low iron, Low ferritin, High TIBC, Low % sat
    • Increased red cell distribution width (RDW) because some cells get enough iron whereas others get very little, leading to wide distribution of RBC sizes
  • Anemia of chronic disease
    • Causes: Chronic infection, autoimmune disease or malignancy
    • Iron studies: Low/Normal iron, High ferritin, Low TIBC, Normal/High % sat
  • Thalassemia
    • Causes: Genetic (Alpha: Asian and African American, Beta: Mediterranean)
    • Iron studies: Normal/High iron, Normal/High ferritin, Low/Normal TIBC
    • Normal/Narrow RDW because all of the cells have dysfunctional globin and will be uniform in size
    • Dx test: Hemoglobin electrophoresis (beta), genetic testing (alpha)
  • Sideroblastic anemia
    • Causes: Lead poisoning, alcohol, genetic, etc.
    • Iron studies: Same as thalassemia
    • Lead to basophilic stippling on smear and ringed sideroblasts on bone marrow biopsy
• Key idea: In a young woman with anemia, pre-test probability highest for iron deficiency anemia 2/2 blood loss from menstruation –> Also most common cause of shortness of breathe in young women
• Folic acid deficiency –> Megaloblastic anemia (MCV > 100 with hypersegmented neutrophils)

44. A previously healthy 32-year-old man comes to the physician because of a 4-month history of constant pain on the outside…

Use of a forearm strap

• Young man with recent increase in lifting/exercise who presents with refractory lateral elbow pain found to have tenderness over lateral elbow with worsened pain with wrist extension most consistent with lateral epicondylitis (“tennis elbow”) –> Conservative management with assistive devices and activity modifications
• B6 deficiency often seen secondary to isoniazid use in a patient with tuberculosis and leads to neuropathy
• Oral steroid therapy would be appropriate for rheumatologic joint disease (other than psoriatic arthritis), but in that case would expect symmetric symptoms affecting multiple joints in a female>male patient

45. An 82-year-old man is brought to the physician by his daughter because of a 6-month history of memory problems and strange behavior…

Add donepezil to the current regimen

• Elderly man with chronic progressive cognitive issues that are impairing daily functioning with an MMSE < 25, concerning for dementia that can be managed (minimally) with acetylcholinesterase inhibitors such as donepezil or rivastigmine
• Key idea: Other option would be the NMDA antagonist memantine
• Diltiazem can lead to hypotension or lower extremity edema
• Simvastatin can (rarely) lead to myopathy or liver damage
• Clopidogrel would be useful if patient had evidence of TIA or stroke (neurologic findings, asymmetric exam findings, etc.)
• Selegiline is a Parkinson’s treatment, would expect patient to have TRAPS symptoms: Tremor (resting), Rigidity, Akinesia, Postural instability, Shuffling gait
• Depression could lead to pseudodementia and would be treated with SSRIs such as sertraline, but patient does not meet SIGECAPS criteria

46. A previously healthy 6-year-old boy comes to the physician because of a 1-week history of an itchy, nonpainful…

Clotrimazole

• Young boy with 1-week history of pruritic erythematous, scaly plaque with raised borders and central clearing most consistent with tinea corporis which can be treated with a topical antifungal
• Key idea: Oral antifungal needed for treatment of tinea capitis and onychomycosis
• Clindamycin –> Infection (cellulitis, folliculitis, impetigo)
• Hydrocortisone would be useful in many conditions, particularly atopic dermatitis in children which leads to poorly demarcated eczematous plaques predominantly of the antecubital fossa, popliteal fossa, and face
• Permethrin –> Scabies –> Significant nighttime pruritis with burrows of the finger webspaces, wrist, umbilicus, waist and genitals
• Selenium sulfide –> Seborrheic dermatitis –> Greasy, scaling plaques of the scalp and T-zone of the face

47. A 16-year-old boy is brought to the physician because of a 1-year history of severe acne that has not responded…

Avoidance of sun exposure

• Key idea: Many acne treatments can lead to increased photosensitivity, including topical retinoids and oral antibiotics such as doxycycline (as were prescribed in this patient)
• Key idea: Some evidence to suggest that decreased dairy and sugar consumption may help acne in some patients, but evidence is not strong
• Key idea: Alcohol is excessively drying and would likely lead to worsening of acne
• Typical progression of acne therapy with worsening severity (note that treatments are often combined): Benzoyl peroxide or salicylic acid –> Topical retinoid –> topical antibiotic –> systemic antibiotic –> systemic retinoid (isotretinoin)

48. A 55-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He has no history of serious…

Serum lipid studies

• Middle-aged man with >50 pack-year smoking history and excessive alcohol consumption who also consumes high-fat diet with increased BMI who should receive serum lipid screening
• USPSTF strongly recommends screening men > 35yo for lipid disorders, which would be particularly important in this patient given his family history and personal history of smoking and obesity
• Stress test is not often used as a screening test but rather in a patient with suspected coronary artery disease
• HgbA1c or fasting glucose levels >>> 5-hour glucose tolerance test for screening for diabetes
• Ultrasound screening for AAA: Men 65-75 years of age with any smoking history

49. Results of serum lipid studies are within the reference ranges. During a follow-up examination 2 weeks later, the patient’s…

Smoking

• Key idea: Smoking is the strongest modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which is the #1 cause of mortality in the US

50. A 16-year-old girl is brought to the physician by her parents because she has become increasingly withdrawn…

Assessment for suicide risk

• Adolescent girl with 5 months of increased social withdrawal, decreased interest in activities, somatic symptoms, sleep changes, appetite changes, decreased energy, and sad mood most consistent with major depressive disorder –> ALL PATIENTS WITH DEPRESSION SHOULD BE SCREENED FOR SUICIDAL IDEATION/PLAN
• EBV –> Mononucleosis –> Lymphadenopathy, exudative pharyngitis, leukopenia, fatigue

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