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«IN-TRAINING EXAMINATION TIME–4 HOURS Publication or reproduction in whole or in part is strictly prohibited. Copyright © 2015 The American Board ...»

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American Board of Family Medicine

IN-TRAINING EXAMINATION

TIME–4 HOURS

Publication or reproduction in whole or in part is strictly prohibited.

Copyright © 2015 The American Board of Family Medicine. All rights reserved.

1. A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea,

cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note

conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia.

What is the most likely etiologic agent?

A) Staphylococcus species

B) Chlamydia trachomatis

C) Respiratory syncytial virus

D) Parainfluenza virus

2. A 36-year-old obese female presents to your office with a chief complaint of amenorrhea. On examination you note hirsutism and body acne. She is on no medications and a pregnancy test is negative. Serum testosterone is at the upper limits of normal and TSH is within normal limits.

In addition to weight loss and exercise, which one of the following would be the most appropriate initial management?

A) High-dose combined oral contraceptives

B) Progestin-only contraceptives

C) Metformin (Glucophage)

D) Levothyroxine (Synthroid)

3. A factory worker sustains a forced flexion injury of the distal interphalangeal (DIP) joint, resulting in a small bone fragment at the dorsal surface of the proximal distal phalanx (mallet fracture). Which one of the following is the most appropriate management strategy?

A) Buddy taping and early range of motion

B) Splinting the DIP joint in extension

C) Splinting the DIP joint in flexion

D) Referral for surgical repair

4. Which one of the following drugs is NOT effective for maintenance therapy in bipolar disorders?

A) Haloperidol

B) Lamotrigine (Lamictal)

C) Lithium

D) Quetiapine (Seroquel)

E) Valproate sodium (Depacon) 1

5. A 30-year-old ill-appearing male presents with right hand and arm pain and a rapidly expanding area of redness. On examination he has a temperature of 38.9°C (102.0°F), a pulse rate of 120 beats/min, and a blood pressure of 116/74 mm Hg. He also has erythema from the dorsal hand to the elbow, violaceous bullae on the dorsal hand and wrist, and severe pain with dorsiflexion of the wrist or fingers.

Which one of the following is the most appropriate initial step in the management of this patient?

A) Oral dicloxacillin and outpatient follow-up within the next 24 hours

B) Intravenous metronidazole

C) Consultation with an infectious disease specialist for antibiotic management

D) Immediate surgical consultation for operative debridement

E) Incision and drainage with wound cultures in the emergency department

6. Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum levels of

–  –  –

7. A mother brings her 2-year-old daughter to your office because the child is not using her left arm. Earlier in the day the mother left the toddler under the supervision of her 12-year-old sister while she went to the store. When she returned the toddler was playing with toys using only her right arm, and was holding the left arm slightly pronated, flexed, and close to her body. The older daughter was unaware of any injury to the girl’s arm, and the child does not seem distressed or traumatized.

Physical examination of the child’s clavicle, shoulder, wrist, and hand do not elicit any signs of pain or change in function. She does seem to have some tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow.

Which one of the following would be most appropriate at this point?

A) Plain radiographs of the affected elbow

B) Ultrasonography of the affected elbow

C) Evaluation by an orthopedic surgeon within 24 hours

D) Attempted reduction of the subluxed radial head

E) Placement in a splint and follow-up in the office if there is no improvement in the next 1–2 weeks

–  –  –

Which one of the following medications would be most appropriate?

A) Inhaled medium-dose corticosteroids

B) A scheduled short-acting bronchodilator

C) A scheduled long-acting bronchodilator

D) A leukotriene inhibitor

9. Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?

A) Combined monophasic oral contraceptives

B) Combined multiphasic oral contraceptives

C) Subdermal etonogestrel (Nexplanon)

D) Intramuscular medroxyprogesterone (Depo-Provera)

E) NSAIDs

10. While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ultrasonography. The most appropriate next step in the evaluation of this finding is a

–  –  –

11. Which one of the following medications should be started at a low dosage and titrated slowly to minimize the risk of Stevens-Johnson syndrome?





–  –  –

Which one of the following is recommended by the Centers for Disease Control and Prevention (CDC) for this situation?

A) Chemoprophylaxis with appropriate medications for all residents

B) Treatment initiated on an individual basis once testing confirms that a resident has influenza

C) Prophylaxis only for staff who have had direct patient contact with a resident with laboratory-confirmed infection

D) No chemoprophylaxis for staff or residents who have been appropriately vaccinated

13. Information derived from which one of the following provides the best evidence when selecting a specific treatment plan for a patient?

–  –  –

14. Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time?

–  –  –

15. American Urological Association guidelines define asymptomatic microscopic hematuria as which one of the following in the absence of an obvious benign cause?

–  –  –

4

16. A 70-year-old male with widespread metastatic prostate cancer is being cared for through a local hospice. Surgery, radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. Over the past few days he has been experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min.

Which one of the following would be best at this point?

–  –  –

17. A 30-year-old female with a history of prolonged QT syndrome presents with severe acute bacterial sinusitis. Which one of the following antibiotics should be avoided?

–  –  –

19. A 56-year-old male complains of daily early awakening and low energy for the past 3 weeks.

Six weeks ago he had a myocardial infarction treated with a coronary artery stent. During that hospitalization his CBC, fasting glucose level, and thyroid function were normal. A recent phone note from the cardiac rehabilitation nurse indicates that he became apathetic and stopped attending his rehabilitation sessions. He admits to a feeling of hopelessness. He denies chest pain, dyspnea, orthopnea, and palpitations. His vital signs and physical examination are remarkable for a healing radial artery catheterization wound.

In addition to resumption of cardiac rehabilitation, which one of the following would be most appropriate at this point?

–  –  –

5

20. A 5-year-old white male is brought to your office with a chief complaint of chronic nocturnal limb pain. His mother states that his pain is often severe enough that it awakens him at night and she often gives him ibuprofen to help alleviate his calf pain, but she has never seen him limp or heard him complain of pain during the day. She also has not noticed any grossly swollen joints, fever, rash, or weight change. She is concerned because of a family history of juvenile rheumatoid arthritis in a distant cousin. The physical examination is within normal limits, as are a CBC and an erythrocyte sedimentation rate.

Which one of the following would be most appropriate at this point?

–  –  –

21. According to the guidelines developed by the JNC 8 panel, which one of the following should NOT be used as a first-line treatment for hypertension?

–  –  –

22. A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness accompanied by upper arm tenderness. On examination there is soreness about both shoulders and the patient has great difficulty raising his arms above his shoulders. There is no visual disturbance, and no tenderness over the temporal arteries. C-reactive protein is elevated and the erythrocyte sedimentation rate is 65 mm/hr (N 0–17).

Which one of the following would help to confirm the most likely diagnosis?

–  –  –

6

23. A 70-year-old male with hypertension, benign prostatic hyperplasia, depression, and well-controlled diabetes mellitus sees you because of increasing fatigue. His medical history also includes stent placement for coronary artery disease. A physical examination is unremarkable except for decreased peripheral pulses. A CBC, basic metabolic profile, hemoglobin A1c level, free T4 level, and TSH level are all normal, except for a serum sodium level of 125 mEq/L (N 135–145). His serum osmolality is 268 mOsm/kg (N 275–290). His urine sodium level is 50 mEq/L (N 20) and his urine osmolality is 300 mOsm/kg.

Which one of the patient’s medications is most likely to cause this problem?

–  –  –

24. A 21-year old female comes to her family physician’s office with an unintended pregnancy and states that she wishes to have a medical abortion. Elective abortion is against the physician’s personally held moral principles.

According to the American Academy of Family Physicians, which one of the following would be the most appropriate course of action for the physician in this situation?

A) Explaining the rationale for morally opposing medical abortions

B) Providing no further assistance at this visit

C) Offering to match the patient with prospective adoptive parents

D) Advising the patient that it would be safer for her to continue the pregnancy

E) Providing resources that explain how to access a safe and legal medical abortion

25. A 65-year-old male presents to an urgent care center with a foot ulcer. His past medical history is significant for hypertension, COPD, and diabetes mellitus. He has been hospitalized several times in the past year for COPD exacerbations and a hip fracture. He does not have any other current problems.

On examination he has a temperature of 37.3°C (99.1°F), a pulse rate of 105 beats/min, a respiratory rate of 16/min, and a blood pressure of 142/83 mm Hg. His examination is unremarkable except for a 2-cm ulcer on the ball of his left foot that has 3 cm of surrounding erythema and some purulent drainage. His CBC is normal except for a WBC count of 14,300/mm3 (N 4300–10,800).

Which one of the following would be the most appropriate choice for initial treatment?

A) Amoxicillin/clavulanate (Augmentin)

B) Linezolid (Zyvox)

C) Ciprofloxacin (Cipro)

D) Ceftriaxone (Rocephin) and levofloxacin (Levaquin)

E) Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)

–  –  –

27. A 45-year-old male presents with shortness of breath and a cough. On pulmonary function testing his FVC is 80% of predicted, his FEV1/FVC is 90% of predicted, and there is no improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide (DLCO) is also low.

Based on these results, which one of the following is most likely to be the cause of this patient’s problem?

–  –  –

28. A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion.

Which one of the following is the most appropriate initial treatment?

–  –  –

29. A 4-year-old male has a BMI of 17.5 kg/m2, which places him between the 90th and 95th percentiles for BMI. According to the CDC, he should be classified as being

–  –  –

31. A 71-year-old female comes in for follow-up of hypertension. She is worried about her heart and says that some of her friends have had stress tests and she would like to get one as well just to be on the safe side. She has no chest pain, shortness of breath, or exercise intolerance, and a complete review of systems is negative.

The patient’s current medications include lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 25 mg daily; and omeprazole (Prilosec), 20 mg daily. Her past medical history includes hypertension, obesity, and gastroesophageal reflux disease. A physical examination reveals a blood pressure of 130/70 mm Hg, a heart rate of 90/min, and a BMI of

31.2 kg/m2. An EKG 2 years ago was normal.

Which one of the following should be ordered to assess this patient’s cardiovascular risk?

–  –  –

32. Which one of the following is true regarding respiratory syncytial virus (RSV) infection?

A) Most infections in the United States occur between August and December

B) Corticosteroids should be a routine part of treatment



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