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NBME Family Med Form 1

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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
Common Questions About Streptococcal Pharyngitis - American Family Physician
https://www.aafp.org/afp/2016/0701/p24.html

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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