AAFPExplanations

Home Family Med Your library Create Free trial Study sets, textbooks, ...
Study

AAFP Family Med

Terms in this set (85)

A 56-year-old female has been on combined continuous hormone therapy Hormone replacement therapy that includes estrogen has been shown to decrease osteoporosis and bone fracture
for 6 years. This is associated with a reduced risk for which one of the risk. The risk for colorectal cancer also is reduced after 5 years of estrogen use. The risk for myocardial infarction, stroke,
following? (check one)
breast cancer, and venous thromboembolism increases with long-term use.
A. Bone fracture

B. Myocardial infarction

C. Stroke

D. Breast cancer

E. Venous thromboembolism

A 62-year-old white male complains of fatigue and proximal extremity Polymyalgia rheumatica is a disease of the middle-aged and elderly. Discomfort is common in the neck, shoulders, and
discomfort without any localized joint pain. Which one of the following hip girdle areas. There is an absence of objective joint swelling, and findings tend to be symmetric. Elevation of muscle
conditions is associated with a consistently normal creatine kinase enzyme enzymes strongly suggests another diagnosis.
level at all phases of disease? (check one)

A. Polymyalgia rheumatica

B. Polymyositis

C. Dermatomyositis

D. Drug-induced myopathy

E. Hypothyroid endocrinopathy
 AAFP18-year-old
An anxious and agitated Familywhite
Med male presents to your office with Study an acute dystonic
The acute treatment of choice is diphenhydramine or benztropine. While rarely life threatening,
a 2-hour history of severe muscle spasms in the neck and back. He was seen reaction can be frightening and painful to the patient and confusing to the treating physician who may be unaware of
2 days ago in a local emergency department with symptoms of AGE, treated what medications the patient is taking. Dystonia can be caused by any agent that blocks dopamine, including
with IV fluids, and sent home with a Rx for prochlorperazine (Compazine). prochlorperazine, metoclopramide, and typical neuroleptic agents such as haloperidol.
The best therapy for this problem is IV administration of:

A. Atropine

B. Diphenhydramine (Benadryl)

C. Haloperidol (Haldol)

D. Succinylcholine (Anectine)

E. Carbamazepine (Tegretol)

A 3-year-old white female is brought to your office because she is Subluxation of the radial head (nursemaid's elbow) is a common childhood orthopedic problem. There is conflicting
complaining of pain in her right arm. Her mother tells you the pain began information in various textbooks on the proper technique to reduce the subluxed radial head.
after she pulled her daughter by the arm while the girl was fighting with her
brother. You examine the child and diagnose "nursemaid's elbow." You
recommend which one of the following? (check one)

A. Manipulation of the forearm to reduce radial head subluxation

B. Long arm cast immobilization

C. Use of a sling for arm rest

D. A cock-up wrist splint

Which one of the following is consistent with spinal stenosis but not Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be
herniated vertebral disk? (check one)
present in both. Pain in spinal stenosis is relieved by sitting and aggravated by standing. PAIN FROM A HERNIATED
A. Numbness
DISC IS AGGRAVATED BY SITTING and relieved by standing.
B. Muscle weakness

C. Pain relieved by sitting

D. Pain relieved by standing

 AAFP
A 75 y.o. F presents Family
with a 1-month Med
history of pain in her hips and shoulders Study
It is generally not considered necessary to refer patients with classic polymyalgia rheumatica for a temporal artery
bilaterally, accompanied by marked stiffness in the mornings. In addition, biopsy in the absence of symptoms or signs of giant cell arteritis (e.g., headache, visual complaints, jaw claudication,
she reports a 4-lb weight loss and fatigue. She specifically denies any visual fever, scalp tenderness, abnormal funduscopic exam). Corticosteroids should be started at relatively low doses (10-20
symptoms or headache. Her physical examination is unremarkable. Labs Hb mg daily) and the patient followed for what should be a rapid clinical response.
11.8 g/dL, a HCT of 36%, and an ESR rate of 84 mm/hr (N <20). What is the
most appropriate management at this point?

A. Begin prednisone, 60 mg daily, and refer for a temporal artery biopsy as

soon as possible

B. Begin prednisone, 60 mg daily, and plan to refer for a temporal artery

biopsy if her symptoms do not respond

C. Begin prednisone, 15 mg daily, with no plans for a biopsy

D. Begin a COX-2 inhibitor such as rofecoxib (Vioxx), with no plans for a

biopsy

A 3-week-old male is brought to your office because of a sudden onset of Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a
bilious vomiting of several hours duration. He is irritable and refuses to history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to
breastfeed, but stools have been normal. He was delivered at term after a thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which
normal pregnancy, and has had no health problems to date. A physical shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However,
examination shows a fussy child with a distended abdomen. Radiography of the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for
the abdomen shows a double bubble sign. Which one of the following is the diagnosing volvulus.
most likely diagnosis? (check one)

A. Infantile colic

B. Necrotizing enterocolitis

C. Hypertrophic pyloric stenosis

D. Intussusception

E. Midgut volvulus

What condition is typically seen in the distressed neonate in the NICU, but Necrotizing enterocolitis
can occasionally be seen in the healthy neonate within the first 2 weeks of
life? The child will appear ill, with symptoms including irritability, poor
feeding, a distended abdomen, and bloody stools. Abdominal plain films
will show pneumatosis intestinalis, caused by gas in the intestinal wall, which
is diagnostic of the condition.
 AAFP
Hypertrophic pyloric Family
stenosis Medof the pyloric canal caused by
is a narrowing Pyloric stenosis. Often seen in first born males. Study

hypertrophy of the musculature. It usually presents during the third to fifth

weeks of life. Projectile vomiting after feeding, weight loss, and dehydration
are common. The vomitus is always nonbilious, because the obstruction is
proximal to the duodenum. If a small olive-size mass cannot be felt in the
right upper or middle quadrant, what can confirm the dx?

What condition is seen most frequently between the ages of 3 months and 5 Intussusception. An air enema using fluoroscopic guidance is useful for dx and tx.
years, predominates in males, and has classic triad of intermittent colicky
abdominal pain, vomiting, and bloody, mucous stools? Know that at least
two of these findings will be present in approximately 60% of patients. The
abdomen may be distended and tender, and there may be an elongated
mass in the right upper or lower quadrants. Rectal examination may reveal
either occult blood or frankly bloody, foul-smelling stool, classically
described as currant jelly. What's used for both diagnosis and treatment?

A previously healthy 3-year-old male is brought to your office with a 4-hour Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because
history of abdominal pain followed by vomiting. Just after arriving at your it may contain heterotopic gastric mucosa.
office he passes bloody stool. A physical examination reveals normal vital
signs, and guarding and tenderness in the right lower quadrant. A rectal
examination shows blood on the examining finger. Which one of the
following is the most likely diagnosis? (check one)

A. Appendicitis

B. Viral gastroenteritis

C. Midgut volvulus

D. Meckels diverticulum

E. Necrotizing enterocolitis

Which one of the following is a risk factor for acute pancreatitis? (check one)
Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive alcohol use.
A. Gastroesophageal reflux disease

B. Intravenous drug abuse

C. Angiotensin receptor blocker use

D. Pyelonephritis

E. Gallstones
 AAFP Family Med Study
Which one of the following is associated with ulcerative colitis rather than Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and
Crohn's disease? (check one)
anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years
A. The absence of rectal involvement
duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if
B. Transmural involvement of the colon
the disease is in remission. All of the other options listed are features typically associated with Crohn's disease. Virtually
C. Segmental noncontinuous distribution of inflammation
all patients with UC have rectal involvement, even if that is the only area affected. In Crohn's disease, rectal involvement
D. Fistula formation
is variable. Noncontinuous and transmural inflammation are also more common with Crohn's disease. Transmural
E. An increased risk of carcinoma of the colon inflammation can lead to eventual fistula formation, which is not seen in UC.

First line treatment for AOM and acute bacterial sinusitis? Alternatives?
Amoxicillin is first line. Augmentin (= amoxicillin + clavulanate), cephalosporins, or macrolides.

First line for strep pharyngitis (i.e. group A strep throat)?

Penicillin is first line for strep throat, and alternatives include amoxicillin, cephalosporins, clindamycin, and macrolides.

First line for acute bronchitis in healthy adults? First line in COPD with an Acute bronchitis in otherwise healthy adults should NOT be treated with antibiotics! In patients with COPD and an acute
acute exacerbation? exacerbation, treat with antibiotics (amoxil or bactrim), albuterol, and steroids.

A 54-year-old white female has been taking amoxicillin for 1 week for Oral flagyl is first line since Clostridium is an anaerobe (can also use PO Vanc). The two main culprits of
sinusitis. She has developed diarrhea and has had 6-8 stools per day for the pseudomembranous colitis are ampicillin and clindamycin.

past 2 days. Examination shows the patient to be well hydrated with normal

vital signs and a normal physical examination. The stool is positive for occult The colonic mucosa is studded with raised yellowish plaques). What you are most looking for is someone who is
blood, and a stool C.diff assay is positive. The most appropriate treatment at hospitalized and started on antibiotics, and acquires diarrhea within 3 days ‡ probably is C diff.

this time would be:

MOA: spores produce Toxin A (enterotoxin) or Toxin B (cytotoxin).
A. vancomycin (Vancocin) intravenously

B. metronidazole (Flagyl) orally

C. trimethoprim/sulfamethoxazole (Bactrim, Septra) orally

D. ciprofloxacin (Cipro) orally

Traveler's diarrhea can be effectively treated in the great majority of cases Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler's
by a 3-day course of: (check one)
diarrhea when given for 1-3 days. Loperamide (Imodium) can be used with antibiotics for most adults with traveler's
A. Erythromycin
diarrhea.
B. Penicillin V

C. Sulfacetamide (Sultrin)

D. Ciprofloxacin (Cipro)
Which one of the AAFP
following Family
is the best Med
SCREENING test for hereditary Study 1 in 200-300
Hereditary hemochromatosis is the most common genetic disorder in the United States, affecting
hemochromatosis?
Americans (mostly males aged 30-50 with northern European descent). It's autosomal recessive. SERUM TRANSFERRIN
A. Hemoglobin
is the best screening test.

B. Serum ferritin
Hemochromatosis is a disease with excess iron deposition in organs due to increased iron absorption from the GI tract.
C. Serum transferrin saturation
It is assoc with HLA-A3, and the treatment is repeated phlebotomy + deferoxamine. ("Hemochromatosis Can Cause
D. Serum iron
Bronze Diabetes")
E. Liver biopsy

For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic
ascites has had diffuse abdominal discomfort, fever, and night sweats. His ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic
current meds are furosemide and spironolactone. On exam, his temperature for peritonitis and a protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis. Once peritonitis
is 38.0° C (100.4° F), BP 100/60, HR 92. The presence of ascites is easily is diagnosed, antibiotic therapy should be started immediately without waiting for culture results.
verified. You perform diagnostic paracentesis and send a sample of fluid for
analysis. Which one of the following findings would best establish the
suspected diagnosis of spontaneous bacterial peritonitis?

A. pH <7.2

B. Bloody appearance

C. Neutrophil count >300/mL

D. Positive cytology

E. Total protein >1 g/dL

A 60-year-old male indicates that he occasionally brings up what appears to The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker's diverticulum. Patients
be undigested food long after his meal. He also admits that he sometimes may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.
chokes on food, and that his wife says he has bad breath. The most likely
diagnosis is:
 AAFP
A 38-year-old male who is aFamily Med
new patient reports mild intermittent jaundice Study
Gilbert's syndrome is the most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and
without other associated symptoms for the past several years. His liver liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely
function tests are normal except for a total bilirubin of 1.3 mg/dL (N 0.3-1.0) diagnosis is Gilbert's syndrome. Fasting, heavy physical exertion, sickle cell anemia, and drug toxicity can also cause
and an indirect or unconjugated bilirubin of 1.0 mg/dL (N 0.2-0.8). His CBC is hyperbilirubinemia.
normal. His past medical and surgical history is unremarkable. Findings are
similar on repeat laboratory testing. The most likely cause of these findings
is: (check one)

A. Hepatitis C

B. Wilson's disease

C. Sickle cell anemia

D. Gilbert's syndrome

E. Drug toxicity

A positive spot urine test for homovanillic acid (HMA) and vanillylmandelic Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and
acid (VMA) is a marker for which one of the following? (check one)
vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be
A. Hepatoblastoma
collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated
B. Wilms' tumor
in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and
C. Lymphoma
germ cell tumors.
D. Malignant teratoma

E. Neuroblastoma

A 6-month-old Hispanic female has had itching and irritability for 4-5 weeks. This child has atopic dermatitis (eczema). It is manifested by a pruritic rash on the face and/or extensor surfaces of the
There is a family history of atopy and asthma. Physical examination reveals arms and/or legs, especially in children. There often is a family history of atopy or allergies. In addition to the regular use
an excoriated dry rash bilaterally over the antecubital and popliteal fossae, of EMOLLIENTS, the mainstay of maintenance therapy, TOPICAL STEROIDS have been shown to be the best first-line
as well as some involvement of the face. In addition to maintenance therapy treatment for flare-ups of atopic dermatitis.
with an emollient, which one of the following topical medications would be
appropriate first-line treatment for flare-ups in this patient?

A. A calcineurin inhibitor such as pimecrolimus (Elidel)

B. An anesthetic

C. An antihistamine

D. An antibiotic

E. A corticosteroid
 AAFP
Intravenous magnesium Family
is used Med
to correct which one of the following Study
A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of torsades de
arrhythmias? (check one)
pointes. Results of a meta-analysis suggest that 1.2-10.0 g of intravenous magnesium sulfate also is a safe and effective
A. Wenckebach second-degree heart block
strategy for the acute management of rapid atrial fibrillation.
B. Complete heart block

C. Idioventricular rhythm

D. Reentrant supraventricular tachycardia

E. Ventricular tachycardia of torsades de pointes

A 7-year-old male with moderately severe atopic dermatitis has been Tacrolimus is an immunomodulator indicated for the treatment of atopic dermatitis when corticosteroids and other
treated with a variety of moisturizers and topical corticosteroid preparations conventional remedies are inadvisable, ineffective, or not tolerated. It is approved for use in patients over 2 years of
over the past year. The results have been less than satisfactory. Which one of age.
the following topical medications is appropriate at this time? (check one)

A. Mupirocin (Bactroban)

B. Terbinafine (Lamisil)

C. Penciclovir (Denavir)

D. Hydroquinone (Eldopaque, Eldoquin)

E. Tacrolimus (Protopic)

Which one of the following would be considered first-line therapy for mild The majority of psoriasis patients can be managed with TOPICAL STEROIDS. Systemic treatment is reserved for patients
to moderately severe psoriasis confined to the elbows and knees? (check with disabling psoriasis that does not respond to topical treatment. This would include phototherapy, methotrexate, and
one)
etretinate.
A. Phototherapy using ultraviolet B light

B. Methotrexate

C. Etretinate (Tegison)

D. Betamethasone dipropionate (Diprolene)

Which one of the following is the most effective initial treatment of head lice Malathion is currently the most effective treatment for head lice and is less toxic than lindane.

in an 8-year-old child? (check one)

A. Lindane (Kwell)
MALATHION = HEAD LICE

B. Wet combing every 4 days, to continue for 2 weeks after any louse is PERMETHRIN = SCABIES
found

C. Head shaving

D. Nightly application of petrolatum to the scalp, covered by a shower cap

E. Malathion (Ovide)
A 75-year-old WFAAFP
presents Family Med
with back pain of several months' duration, which Study
Obtain a bone marrow examination--The dx is confirmed by a bone marrow examination showing >10% plasma cells in
is worsened by movement, and has noticed constipation the last few the marrow. The serum level of M-protein is typically >3 g/dL..

months. Her examination is unremarkable except for mild pallor. She takes

furosemide (Lasix) for hypertension. Labs: Hg 10, Cr 2, Calcium elevated, and Know your ABCDE's in MM. Multiple myeloma commonly has Anemia, Back pain, hyperCalcemia/Constipation, renal
Serum IgG elevated. The Urine was positive for Bence-Jones proteins. Which Dysfunction and Elevated ESR. (Know that hypercalcemia can cause constipation.) Realize metastatic bone cancers can
one of the following would be most appropriate at this point?
cause the same symptoms, but with multiple myeloma patient's will have "lytic bone lesions."
A. Take the patient off the diuretic and repeat the laboratory evaluation in 1
month

B. Obtain a bone scan

C. Obtain a bone marrow examination

A newborn term male infant at 2 hours of age is noted by the nurse to be In physiologic jaundice (icterus neonatorum), the level of indirect-reacting bilirubin in umbilical cord serum is 1-3 mg/dL
mildly jaundiced. Which one of the following causes of jaundice can be and rises at a rate of less than 5 mg/dL/24 hours. As a result, physiologic jaundice first becomes apparent on the
ruled out because of the infant's age? (check one)
second or third day of life. Jaundice appearing on the first day of life may be due to erythroblastosis fetalis, sepsis,
A. Sepsis
concealed hemorrhage, cytomegalic inclusion disease, rubella, or congenital toxoplasmosis.
B. Erythroblastosis fetalis

C. Congenital toxoplasmosis

D. Concealed hemorrhage

E. Physiologic jaundice (icterus neonatorum)

A 43-year-old African-American male is hospitalized for treatment of a deep Heparin-induced thrombocytopenia (HIT) results from the formation of heparin-dependent IgG antibody.
venous thrombosis of the right leg extending to the mid-thigh. His baseline Characteristically developing 5-10 days after the initiation of heparin by any route, it is manifested by a fall in the platelet
platelet count on admission is 250,000/mm3 (N 150,000-450,000). On the count to less than 50% of the baseline or to an absolute level of <50,000/mm3, mandating discontinuation of heparin.
day of admission he is started on heparin and warfarin (Coumadin). He The primary treatment of HIT is to STOP HEPARIN AND WARFARIN and substitute a non-heparin anticoagulant. A
shows steady clinical improvement, and discharge is planned for the fifth hypercoagulable state exists for several days after heparin is stopped, mandating continuation of monitoring and
hospital day. On the morning he is to be discharged, laboratory results show further antithrombotic measures. LMW heparins are also contraindicated b/c HIT-IgG crossreacts with all low-
therapeutic values for both prothrombin time and partial thromboplastin molecular-weight heparins.
time, but his platelet count is 45,000/mm3. Which one of the following
would be most appropriate at this time? (check one)

A. Stop the heparin but continue the warfarin

B. Stop the warfarin but continue the heparin

C. Stop the heparin and warfarin and substitute a low-molecular-weight

heparin

D. Stop the heparin and warfarin and start a non-heparin anticoagulant

E. Discharge the patient, as clinical improvement has occurred

 AAFP
You make a diagnosis Familyin Med
of depression a 26-year-old female. Her BMI is 32 Study loss. All of the other
Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight
kg/m² and she has been trying to lose weight. Which one of the following choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the most weight gain and
antidepressants would be LEAST likely to cause her to gain weight? (check fluoxetine with the least. Mirtazapine has been associated with more weight gain than the SSRIs.
one)

A. Mirtazapine (Remeron)

B. Amitriptyline

C. Bupropion (Wellbutrin)

D. Paroxetine (Paxil)

E. Citalopram (Celexa)

A 5-year-old female is seen for a kindergarten physical and is noted to be This patient has delayed bone age coupled with a reduced growth velocity, which suggests an underlying systemic
below the 3rd percentile for height. A review of her chart shows that her cause. Growth hormone deficiency is one possible cause for this. Although bone age can be delayed with constitutional
height curve has progressively fallen further below the 3rd percentile over growth delay, after 24 months of age growth curves are parallel to the 3rd percentile. Bone age would be normal with
the past year. She was previously at the 50th percentile for height. The genetic short stature. Patients with Turner syndrome or skeletal dysplasia have dysmorphic features, and bone age
physical examination is otherwise normal, but your workup shows that her would be normal.
bone age is delayed. Dx?

A. Constitutional growth delay

B. Growth hormone deficiency

C. Genetic short stature

D. Turner syndrome

E. Skeletal dysplasia

A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. These conditions
8.6-10.2) on routine laboratory screening. To confirm the hypercalcemia you must be differentiated early to provide the patient with optimal treatment and an accurate prognosis. Humoral
order an ionized calcium level, which is 1.49 mmol/L (N 1.14-1.32). Additional hypercalcemia of malignancy implies a very limited life expectancy—often only a matter of weeks. On the other hand,
testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15-75) primary hyperparathyroidism has a relatively benign course. Intact parathyroid hormone (PTH) will be suppressed in
and a urine calcium excretion of 386 mg/24 hr (N 100-300).
cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma.

Which one of the following is the most likely cause of the patient's
hypercalcemia? (check one)

A. Primary hyperparathyroidism

B. Malignancy

C. Familial hypocalciuric hypercalcemia

D. Hypoparathyroidism

E. Hyperthyroidism
 AAFP Family Med Study

A 25-year-old female has been trying to conceive for over 1 year without This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism,
success. Her menstrual periods occur approximately six times per year. infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis.

Laboratory evaluation of her hormone status has been negative, and her

husband has a normal semen analysis. Her only other medical problem is Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to
hirsutism, which has not responded to topical treatment. Pelvic decrease hirsutism and improve insulin resistance and menstrual irregularities. Metformin and clomiphene alone or in
ultrasonography of her uterus and ovaries is unremarkable.
combination are first-line agents for ovulation induction.

Of the following, which one would be the most appropriate treatment for
her infertility? (check one)

A. Metformin (Glucophage)

B. Danazol

C. Medroxyprogesterone (Provera)

D. Spironolactone (Aldactone)

The CHADS2 score is a validated clinical prediction rule for determining the risk of stroke and who should be
Which one of the following would be most appropriate for stroke
anticoagulated. Points are assigned based on the patient's comorbidities. One point is given for each of the following:
prevention in a patient with hypertension, diabetes mellitus, and atrial
history of congestive heart failure (C), hypertension (H), age ³75 (A), and diabetes mellitus (D). Two points are assigned
fibrillation? (check one)

for a previous stroke or TIA (S2 ).

A. Clopidogrel (Plavix)

B. Aspirin

For patients with a score of 0 or 1, the risk of stroke is low and warfarin would not be recommended. WARFARIN is the
C. Dipyridamole (Persantine)

agent of choice for the prevention of stroke in patients with atrial fibrillation and a score ³2. In these patients, the risk of
D. Warfarin (Coumadin)

stroke is higher than the risks associated with taking warfarin. Enoxaparin is an expensive injectable anticoagulant and is
E. Enoxaparin (Lovenox)
not indicated for the long-term prevention of stroke.

An elevation of serum methylmalonic acid is both sensitive and specific for a An elevation in serum methylmalonic acid is both sensitive and specific for cellular vitamin B 12 deficiency.
cellular deficiency of which vitamin? (check one)

A. Vitamin A

B. Vitamin B 6

C. Vitamin B 12

D. Vitamin D

E. Folate
According to the AAFP
guidelinesFamily
of the JointMed
National Committee on Prevention, Study
130/80 mm Hg. JNC 7, an evidence-based consensus report, recommends that patients with diabetes and hypertension
Detection, Evaluation, and Treatment of High Blood Pressure, for be treated to reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg for other adults.
hypertensive patients who also have diabetes mellitus, the blood pressure
goal is below a threshold of:

A patient who takes fluoxetine (Prozac), 40 mg twice daily, develops Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin syndrome. SSRIs
shivering, tremors, and diarrhea after taking an over-the-counter cough and such as fluoxetine are also associated with serotonin syndrome, and there are many other medications that increase the
cold medication. On examination he has dilated pupils and a heart rate of risk for serotonin syndrome when combined with SSRIs. The other medications listed here are not associated with
110 beats/min. His temperature is normal.
serotonin syndrome, however.
Which one of the following medications in combination with fluoxetine
could contribute to this patient's symptoms? (check one)

A. Dextromethorphan

B. Pseudoephedrine

C. Phenylephrine

D. Guaifenesin

E. Diphenhydramine (Benadryl)

The best available evidence supports which one of the following statements Metformin is the only hypoglycemic agent shown to reduce mortality rates in patients with type 2 diabetes mellitus. A
regarding the cardiovascular effects of hypoglycemic agents? (check one)
recent systematic review concluded that cardiovascular events are neither increased nor decreased with the use of
A. Sulfonylureas increase cardiovascular events
sulfonylureas.
B. Metformin (Glucophage) reduces cardiovascular mortality rates

C. Incretin mimetics reduce the risk of cardiovascular events

D. α-Glucosidase inhibitors have no effect on cardiovascular events

A 46-year-old female presents to your office for follow-up of elevated Primary hyperaldosteronism is relatively common in patients with stage 2 hypertension (160/100 mm Hg or higher) or
blood pressure on a pre-employment examination. She is asymptomatic, treatment-resistant hypertension. It has been estimated that 20% of patients referred to a hypertension specialist suffer
and her physical examination is normal with the exception of a blood from this condition. Experts recommend screening for this condition using a ratio of morning plasma aldosterone to
pressure of 160/100 mm Hg. Screening blood work reveals a potassium level plasma renin. A ratio >20:1 with an aldosterone level >15 ng/dL suggests the diagnosis.
of 3.1 mEq/L (N 3.7-5.2). You consider screening for primary
hyperaldosteronism. (check one)

A. 24-hour urine aldosterone levels

B. An ACTH infusion test

C. Adrenal venous sampling

D. CT of the abdomen

E. A serum aldosterone-to-renin ratio

Which one of the AAFP
following Family Med
is diagnostic for type 2 diabetes mellitus? (check Study plasma glucose level
Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A 1c >=6.5%, a fasting
one)
>=126 mg/dL, or a 2-hour plasma glucose level >=200 mg/dL. These results require confirmation by repeat testing.

A. A fasting plasma glucose level ≥126 mg/dL on two separate occasions

You can also make the diagnosis if the patient is symptomatic with a random blood glucose level ³200 mg/dL (doesn't
B. An oral glucose tolerance test (75-g load) with a 2-hour glucose level require 2 separate readings).
≥160 mg/dL

C. A random blood glucose level ≥200 mg/dL on two occasions in an

asymptomatic person

D. A hemoglobin A 1c ≥6.0% on two separate occasions

Which one of the following is the most common cause of recurrent and Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates
persistent acute otitis media in children? (check one)
from the middle ear fluid of children with acute otitis media. Penicillin-resistant S. pneumoniae is the most common
A. Haemophilus influenzae
cause of recurrent and persistent acute otitis media.
B. Moraxella catarrhalis

C. Penicillin-resistant Streptococcus pneumoniae

D. Pseudomonas aeruginosa

E. Staphylococcus aureus

For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should be given a
Which one of the following should be used first for ventricular fibrillation vasopressor, which can be either epinephrine or vasopressin. Vasopressin may be substituted for the first or second
when an initial defibrillation attempt fails? (check one)
dose of epinephrine.

A. Amiodarone (Cordarone)

B. Lidocaine (Xylocaine)
Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor.
C. Adenosine (Adenocard)
Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available. Magnesium
D. Vasopressin (Pitressin)
may terminate or prevent torsades de pointes in patients who have a prolonged QT interval during normal sinus rhythm.
E. Magnesium Adenosine is used for the treatment of narrow complex, regular tachycardias and is not used in the treatment of
ventricular fibrillation.
Which one of the AAFP
following Family
is the best Med
radiographic test for confirming the Study to those of
CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior
diagnosis of renal colic? (check one)
ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized
A. A KUB radiograph
by CT.
B. Ultrasonography

C. CT

D. Intravenous pyelography

E. MRI

A 50-year-old male has a pre-employment chest radiograph showing a Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation.
pulmonary nodule. There are no previous studies available.
Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric
calcification, and a doubling time of less than 1 month or more than 1 year.

Which one of the following would raise the most suspicion that this is a

malignant lesion if found on the radiograph? . (check one)

Features of malignant nodules include a size >10 mm, an irregular border, a "ground glass" appearance, either no
A. The absence of calcification
calcification or an eccentric calcification, and a doubling time of 1 month to 1 year (SOR B).
B. Location above the midline of the lung

C. A diameter of 4 mm

D. A solid appearance

A 29-year-old gravida 2 para 1 presents for pregnancy confirmation. Her last Maternal hypothyroidism can have serious effects on the fetus, so thyroid dysfunction should be treated during
menstrual period began 6 weeks ago. Her medical history is significant for pregnancy. Because of hormonal and metabolic changes in early pregnancy, the levothyroxine dosage often needs to
hypothyroidism, which has been well-controlled on levothyroxine be increased at 4-6 weeks gestation, and the patient eventually may require a 30%-50% increase in dosage in order to
(Synthroid), 150 μg daily, for the past 2 years.
maintain her euthyroid status.

Which one of the following would be the most appropriate next step in the
treatment of this patient's hypothyroidism during her pregnancy? (check
one)

A. Add liothyronine (Cytomel) to her current regimen

B. Decrease the levothyroxine dosage

C. Increase the levothyroxine dosage

D. Continue her current regimen

 AAFP
A 72-year-old male Family
with a history Med and a previous myocardial
of hypertension Study
ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of
infarction is diagnosed with heart failure. Echocardiography reveals systolic severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both asymptomatic and
dysfunction, and recent laboratory tests indicated normal renal function. He symptomatic patients, in randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used
is currently asymptomatic. Which one of the following medications would be in all heart failure patients.

the best choice for initial management in this patient?

Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been
A. Furosemide (Lasix)
shown to be superior. β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A),
B. Isosorbide dinitrate (Isordil)
except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to
C. Spironolactone (Aldactone)
reduce mortality from heart failure.

D. Digoxin
A diuretic (furosemide) and Aldosterone antagonists (spironolactone) are indicated in patients with symptomatic heart
E. Lisinopri failure.

A 55-year-old female with diabetes mellitus, hypertension, and Metformin is contraindicated in patients with chronic kidney disease. It should be stopped in females with

hyperlipidemia presents to your office for routine follow-up. Her serum a creatinine level ≥1.4 mg/dL and in males with a creatinine level ≥1.5 mg/dL. Insulin glargine can be used in patients with
creatinine level is 1.5 mg/dL (estimated creatinine clearance 50 mL/min).
renal disease at any stage, but the dosage may need to be decreased.

Which one of the following diabetes medications would be contraindicated

in this patient?
Extra: Metformin should be withheld 48 hours before and after radiographic procedures with contrast, due to its
A. Metformin (Glucophage)
interaction with iodinated contrast materials.
B. Exenatide (Byetta)

C. Acarbose (Precose)

D. Insulin glargine (Lantus)

A 35-year-old male with a previous history of kidney stones presents with A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a
symptoms consistent with a recurrence of this problem. The initial workup parathyroid hormone (PTH) level would be appropriate. Elevated PTH is caused by a single parathyroid adenoma in
reveals elevated serum calcium. Which one of the following tests would be approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having
most appropriate at this point? (check one)
laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis.
A. Serum calcitonin

B. 24-hour urine for calcium and phosphate

C. Serum phosphate and magnesium

D. Serum parathyroid hormone

E. Spot urine for microalbumin

 AAFP
A 68-year-old white femaleFamily Med
is hospitalized for pneumonia. She appears The likelihood that this patient has significant thyroid disease is very low given the minimal Study
elevation of TSH, normal
acutely ill and slightly lethargic. Her examination is consistent with right clinical examination, and concomitant pneumonia. The elevated TSH level is likely due to her illness rather than to any
lower lobe pneumonia but is otherwise normal. Her pulse rate is 90 underlying thyroid condition.
beats/min and regular. Her weight is normal for height. Her TSH level is 9.0
_U/mL (N 1.0-5.0). The most appropriate initial step for managing her thyroid
abnormality is: (check one)

A. Follow-up testing after discharge

B. Free T4 and rT3 levels now

C. Thyroid antimicrosomal antibody levels now

D. Levothyroxine (Synthroid), 0.025 mg every day

E. Levothyroxine, 0.1 mg every day

In evaluating an adult with anemia, which one of the following findings most A low serum ferritin is diagnostic for iron deficiency even in its early stages. The total iron-binding capacity (TIBC) is
reliably indicates a diagnosis of iron deficiency anemia? (check one)
elevated in iron deficiency anemia, while serum iron is decreased just like ferritin.
A. Low total iron-binding capacity

B. Low serum iron

C. Low serum ferritin

D. Microcytosis

E. Hypochromia

Which one of the following is more likely to occur with glipizide (Glucotrol) Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is
than with metformin (Glucophage)? (check one)
that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment.

A. Lactic acidosis
Gli-ides are sulfonylureas and are notorious for causing hypoglycemia. The only things that cause hypoglycemia more
B. Hypoglycemia
are short acting insulins and possibly NPH (intermediate acting insulin).
C. Weight loss

D. Gastrointestinal distress
 AAFP
A 73-year-old white femaleFamily
presents toMed
the office with her daughter. She Study is unable to keep the
Stress incontinence is common in older women. It occurs when the bladder's internal sphincter
complains of a several-year history of intermittent involuntary loss of urine bladder neck closed against the rise in intravesicular pressure resulting from normal activities. While only small amounts
which is gradually worsening. She frequently loses small amounts of urine of urine may be lost with each episode, the cumulative effect can severely impair a patient's quality of life.
when she rises from a low chair, and greater amounts if she coughs, sneezes, Nonpharmacologic therapy is important in the treatment of stress incontinence. Adjusted voiding intervals and pelvic
or laughs. If nonpharmacologic interventions are not completely successful floor (Kegel) exercises can be helpful, for example. The tone of the internal sphincter of the bladder is modulated
in the management of this patient's problem, which one of the following through alpha-adrenergic receptors. Stimulation of these receptors with agents such as pseudoephedrine or
medications is most likely to help?
imipramine can increase internal sphincter tone and alleviate symptoms. Tolterodine, flavoxate, and hyoscyamine
A. Bethanechol (Urecholine)
reduce bladder contractions and are potentially helpful to patients with urge incontinence from detrusor overactivity.
B. Flavoxate (Urispas)

C. Hyoscyamine (Anaspaz NuLev)

D. Pseudoephedrine

E. Tolterodine (Detrol, Detrol LA)

Which one of the following is the most appropriate screening test for When screening a child for reflux, the initial test should be voiding cystourethrography (VCUG). Although renal
vesicoureteral reflux in the initial evaluation of a child with a urinary tract ultrasonography is less invasive, findings are normal in 50%-75% of patients with reflux. Regardless, perform an
infection? (check one)
ultrasound after the child has its first febrile UTI.
A. Renal ultrasonography

B. Intravenous pyelography (IVP)

C. Voiding cystourethrography (VCUG)

D. A technetium-99m dimercaptosuccinic acid (DMSA) renal flow scan

E. Nuclear cystography

Which one of the following fluoroquinolones should NOT be used in the When first line therapy trimethoprim/sulfamethoxazole (Bactrim) is contraindicated, a 3-day course of Cipro (or
treatment of urinary tract infections? (check one)
levofloxacin, norfloxacin, lomefloxacin, or gatifloxacin) is a reasonable alternative. Moxifloxacin is the only
A. Ciprofloxacin (Cipro)
fluorquinolone that won't work because it doesn't attain adequate urinary concentrations and should not be used in the
B. Gatifloxacin (Tequin)
management of UTIs.
C. Levofloxacin (Levaquin)

D. Moxifloxacin (Avelox)

E. Norfloxacin (Noroxin)
 AAFP
A 75-year-old male Family
presents Med history of back pain in the
with a several-hour Study
Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are
interscapular region. His history includes a previous MI several years ago, a managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal
history of cigarette smoking until the time of the MI, and HTN that is well space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level
controlled with HCTZ and lisinopril. The patient appears anxious, but all tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be
pulses are intact. BP 170/110 mm Hg and HR 110 beats/min. An EKG shows first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added.

evidence of an old inferior wall MI but no acute changes. A chest A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement.
radiograph shows a widened mediastinum and a normal aortic arch, and CT Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is
of the chest shows a dissecting aneurysm of the descending aorta that is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology.
distal to the proximal abdominal aorta but does not involve the renal
arteries. Which one of the following would be the most appropriate next
step in the management of this patient?

A. Immediate surgical intervention

B. Arteriography of the aorta

C. Intravenous nitroprusside (Nipride)

D. A nitroglycerin drip

E. Intravenous labetalol (Normodyne, Trandate)

A 36-year-old white female presents to the emergency department with If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by
palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular the administration of IV verapamil or a β-blocker.
tachycardia with a narrow complex QRS and no apparent P waves. The
patient fails to respond to carotid massage or to two doses of intravenous
adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step
would be to administer intravenous (check one)

A. amiodarone (Cordarone)

B. digoxin (Lanoxin)

C. flecainide (Tambocor)

D. propafenone (Rhythmol)

E. verapamil (Calan)
 AAFP Family
A 60-year-old African-American Med
female has a history of hypertension that Study or calcium channel
Monotherapy for hypertension in African-American patients is more likely to consist of diuretics
has been well controlled with hydrochlorothiazide. However, she has blockers; these are preferred over β-blockers or ACE inhibitors.
developed an allergy to the medication. Successful monotherapy for her
hypertension would be most likely with which one of the following?

A. Lisinopril (Prinivil, Zestril)

B. Hydralazine (Apresoline)

C. Clonidine (Catapres)

D. Atenolol (Tenormin)

E. Diltiazem (Cardizem)

A 55-year-old male who has a long history of marginally-controlled The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with
hypertension presents with gradually increasing shortness of breath and Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness,
reduced exercise tolerance. His physical examination is normal except for a and valve function. The test should be performed during the initial evaluation. CXR and 12-lead EKG should be
blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting performed in all patients presenting with heart failure, but should not be used as the primary basis for determining
edema. Which one of the following ancillary studies would be the preferred which abnormalities are responsible for the heart failure.
diagnostic tool for evaluating this patient?

A. 12-lead electrocardiography

B. Posteroanterior and lateral chest radiographs

C. 2-dimensional echocardiography with Doppler

D. Radionuclide ventriculography

E. Cardiac MRI

A 68-year-old female has an average blood pressure of 150/70 mm Hg Randomized, placebo-controlled trials have shown that isolated systolic hypertension in the elderly responds best to
despite appropriate lifestyle modification efforts. Her only other medical diuretics and to a lesser extent, β-blockers. Diuretics are preferred, although long-acting dihydropyridine calcium
problems are osteoporosis and mild depression. The most appropriate channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. Thiazide
treatment at this time would be (check one)
diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance.
A. lisinopril (Prinivil, Zestril)
B. clonidine (Catapres)

C. propranolol (Inderal)

D. amlodipine (Norvasc)

E. hydrochlorothiazide
 AAFP
A 56-year-old white Family
male presents withMed
a 2-week history of intermittent pain Study
The ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for
in his left leg. The pain usually occurs while he is walking and is primarily in peripheral vascular occlusive disease (PVOD) in this patient. The ABI is the ratio of systolic blood pressure measured in
the calf muscle or Achilles region. Sometimes he will awaken at night with the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9-1.2 is considered normal. Severe
cramps in the affected leg. He has no known risk factors for atherosclerosis. disease is defined as a ratio <0.50.
Which one of the following would be the best initial test for peripheral
vascular occlusive disease? (check one)

A. Ankle-brachial index

B. Arterial Doppler ultrasonography

C. Arteriography

D. Magnetic resonance angiography (MRA)

E. Venous ultrasonography

A 69-year-old male has a 4-day history of swelling in his left leg. He has no LMW heparin and Coumadin. Know Low-molecular-weight heparin (LMWH) is more effective than unfractionated
history of trauma, recent surgery, prolonged immobilization, weight loss, or heparin, and may be as effective as oral anticoagulants, although all are associated with some adverse effects.
malaise. His examination is unremarkable except for a diffusely swollen left
leg. A CBC, chemistry profile, prostate-specific antigen level, chest
radiograph, and EKG are all normal; however, compression ultrasonography
of the extremity reveals a clot in the proximal femoral vein. He has no past
history of venous thromboembolic disease. Treat the patient's DVT with what
two drugs?
 AAFP
You see a 23-year-old Family
gravida 1 para 0Med
for her prenatal checkup at 38 weeks She has HTN and proteinuria, thus she is pre-eclamptic. his patient manifests a rapid onsetStudy
of preeclampsia at term. The
gestation. She complains of severe headaches and epigastric pain. She has symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the
had an uneventful pregnancy to date and had a normal prenatal process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and
examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis delivery of the infant.
shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting
edema of her legs. The most appropriate management at this point would
be: (check one)

A. Strict bed rest at home and reexamination within 48 hours

B. Admitting the patient to the hospital for bed rest and frequent monitoring
of blood pressure, weight, and proteinuria

C. Admitting the patient to the hospital for bed rest and monitoring, and
beginning hydralazine (Apresoline) to maintain blood pressure below
140/90 mm Hg

D. Admitting the patient to the hospital, treating with parenteral magnesium

sulfate, and planning prompt delivery either vaginally or by cesarean section

You perform a health maintenance examination on a 2-year-old white male. Children who have a murmur that is diastolic or is greater than 2/6 should be referred for cardiovascular evaluation,
He is asymptomatic and is meeting all developmental milestones. The only perhaps after an echocardiogram is obtained.
significant finding is a grade 3/6 diastolic murmur heard at the right upper
sternal border. Which one of the following would be most appropriate at
this time? (check one)

A. No further evaluation

B. Referral to a pediatric cardiologist

C. Reevaluation in 6 months

D. Maintenance doses of digoxin

For long-term therapy, the most effective control of heart rate in atrial For long-term therapy, beta-blockers drugs provide the most effective control of heart rate in atrial fibrillation, both at
fibrillation, both at rest and with exercise, occurs with which one of the rest and during exercise. And warfarin is the best anti-coagulant to use (superior to lmwh and aspirin).
following? Plus, what should you also treat these patients with to prevent
strokes?
 AAFP Family
A 60-year-old African-American male Med
was recently diagnosed with an Study
Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100
abdominal aortic aneurysm. A lipid profile performed a few months ago mg/dL. Many may not realize that this goal extends to people with CAD-equivalent diseases, including peripheral artery
revealed an LDL level of 125 mg/dL. You would now advise him that his goal disease, symptomatic carotid artery disease, and abdominal aortic aneurysm.
LDL level is: (check one)

A. <100 mg/dL

B. <130 mg/dL

C. <150 mg/dL

D. <160 mg/dL

A 70-year-old white male has a slowly enlarging, asymptomatic abdominal Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches
aortic aneurysm. You should usually recommend surgical intervention when 5.5 cm in diameter.
the diameter of the aneurysm approaches:

A. 3.5 cm

B. 4.5 cm

C. 5.5 cm

D. 6.5 cm

E. 7.5 cm

A male infant weighing 3000 g (6 lb 10 oz) is born at 36 weeks' gestation, Cyanotic congenital heart disease can appear at the time of ductus closure. A heart murmur is not usually audible, and
with normal Apgar scores and an unremarkable initial examination. At 48 murmurs heard this early are usually not due to heart disease. The failure to correct hypoxemia with 100% oxygen is
hours of age he is noted to have dusky episodes while feeding, and does diagnostic for abnormal mixing of blood from the right and left circulations. Transient tachypnea presents earlier, and
not feed well. On repeat examination the child is tachypneic, with subcostal the hypoxia corrects with supplemental oxygen. Hyaline membrane disease can occur at 36 weeks, but would cause
retractions. Lung sounds are clear and there is no heart murmur. Pulse problems in the first hours of life.
oximetry on room air is 82%. Chest radiograph - increased vascular
markings; large thymus Blood culture results are pending. Which one of the
following is the most likely diagnosis?

A. Transient tachypnea of the newborn

B. Congenital heart disease

C. Hyaline membrane disease

D. Neonatal sepsis
Which one of the AAFP
following Family Med
is the medical treatment of choice for acute Studyphysiologic side effects.
Intravenous haloperidol has been found to be more effective than lorazepam and has minimal
delirium in the intensive care unit? (check one)
Chlorpromazine can worsen confusion and lower blood pressure. Droperidol can cause akathisia. Diphenhydramine
A. Intravenous haloperidol (Haldol) in increasing doses every 30 minutes as can increase confusion due to its anticholinergic effects.
needed

B. Intravenous droperidol (Inapsine) every 6-8 hours

C. Intravenous lorazepam (Ativan)

D. Intramuscular chlorpromazine (Thorazine)

E. Intramuscular diphenhydramine (Benadryl)

A 55-year-old white male sees you for a routine annual visit. His fasting Metformin is widely accepted as the first-line drug for type 2 diabetes mellitus. It is relatively effective, safe, and
blood glucose level is 187 mg/dL. Repeat testing 1 week later reveals a inexpensive, and has been used widely for many years. Unlike other oral hypoglycemics and insulin, it does not cause
fasting glucose level of 155 mg/dL and an HbA1c of 9.4%. His BMI is 30 weight gain. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and
kg/m2. He does not seem to have any symptoms of diabetes mellitus. In exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione, or insulin can be
addition to lifestyle changes, which one of the following would you added, with the choice based on the severity of the hyperglycemia. Also know that Metformin increases insulin
prescribe initially? (check one)
sensitivity much more than sulfonylureas or insulin.
A. Metformin (Glucophage)

B. Glyburide (DiaBeta, Micronase)

C. Poiglitazone (Actos)

D. Bedtime long-acting insulin (Lantus, Levamir)

E. Bedtime long-acting insulin and rapid-acting insulin (NovoLog, Humalog)

with each meal

A healthy 72-year-old female comes to your office for a follow-up visit. She In primary hyperparathyroidism, hypercalcemia is the result of excessive PTH secretion by one or more abnormal,
has hypertension which is well controlled with an ACE inhibitor. Routine enlarged parathyroid glands. Laboratory findings in most patients with primary hyperparathyroidism reflect the mild
laboratory tests are normal except for a serum calcium level of 10.8 mg/dL clinical presentation of the disorder. The serum calcium level is often 1 mg/dL or more above the upper limits of normal.
(N 8.5-10.5). A repeat calcium level is 11.1 mg/dL. Which one of the following
would be most appropriate at this point?

A. Radiographs of the hands

B. An osteocalcin level

C. An intact parathyroid hormone (PTH) level

D. Bone densitometry
 AAFP
A 75-year-old white Family
male with Med type 2 diabetes mellitus is
well-controlled Study
Metformin should be withheld before and after radiographic procedures with contrast, due to its interaction with
scheduled for an abdominal CT scan with oral and intravenous iodinated iodinated contrast materials. This interaction may cause impaired renal function or lactic acidosis. The other drugs listed
contrast. Which one of the following medications should be withheld 48 do not carry this risk.
hours before and after the procedure? (check one)

A. Glyburide (Micronase, DiaBeta)

B. Glipizide (Glucotrol)

C. Acarbose (Precose)

D. Metformin (Glucophage)

E. Rosiglitazone (Avandia)

A 70-year-old male sees you because of slowly increasing problems with This patient is suffering from severe COPD (stage III) and has a history of frequent exacerbations -- know that since his
COPD. He has had frequent exacerbations requiring emergency department FEV1 is less than 50%, you should add a steroid inhaler! The addition of a corticosteroid inhaler for patients with severe
visits. He currently uses a tiotropium (Spiriva) inhaler once a day, as well as disease has been found to significantly decrease the number of exacerbations, but has no effect on overall mortality.
an albuterol (Proventil) inhaler, 2 puffs 4 times a day as needed. An Side effects of oral candidiasis and easy bruising of the skin are increased. Continuous oxygen has been shown to
examination shows decreased breath sounds throughout, and an oxygen improve overall mortality and endurance in patients with an oxygen saturation of 88% or less.
saturation of 92%. Spirometry shows he has severe COPD (stage III); his
FEV1/FVC ratio is 65% of predicted and his FEV1 is 45% of predicted. The
most reasonable change in treatment would be to add:

A. oxygen, 2 L/min while sleeping

B. inhaled fluticasone (Flovent), 2 puffs BID

C. oral low-dose prednisone daily

D. oral theophylline BID

 AAFP
A 42-year-old female Family
presents Medhistory of chest pain. She
with a 2-day Studydisorders, and
This patient has pleurisy. Patients presenting with pleuritic chest pain may have life-threatening
describes the pain as sharp, located in the right upper chest, and worsened pulmonary embolism, acute myocardial infarction, and pneumothorax should be excluded. An EKG and chest
by deep breathing or coughing. She also complains of shortness of breath. radiograph are recommended in the evaluation of acute/subacute pleuritic chest pain.
She was previously healthy and has no recent history of travel. Her vital
signs are normal. A pleural friction rub is noted on auscultation of the lungs.
The remainder of the examination is normal. An EKG, cardiac enzymes,
oxygen saturation, and a D-dimer level are all normal. Which one of the
following would be most appropriate at this point? (check one)

A. No further testing

B. A chest radiograph

C. An antinuclear antibody test

D. Echocardiography

E. Pulmonary angiography

A 32-year-old African-American female presents with a 3-day history of For previously healthy patients with community-acquired pneumonia and no risk factors for drug resistance, a macrolide
fever, cough, and shortness of breath. She has been healthy otherwise, such as azithromycin is the preferred treatment (SOR A). Doxycycline is also acceptable (SOR C). Patients who have
except for a sinus infection 2 months ago treated with amoxicillin. She does been treated with antibiotics within the previous 3 months should be treated with a respiratory fluoroquinolone
not appear toxic. A chest radiograph reveals an infiltrate in the right lower (moxifloxacin, gemifloxacin, or levofloxacin) (SOR A).
lobe, consistent with pneumonia. Which one of the following would be the
best choice for antibiotic treatment? (check one)

A. High-dose amoxicillin

B. Azithromycin (Zithromax)
C. Doxycycline

D. Levofloxacin (Levaquin)

E. Cefuroxime axetil (Ceftin)

 AAFP
A healthy 24-year-old maleFamily Med
presents with a sore throat of 2 days' duration. Study
In clinical screening, the most reliable predictors of streptococcal pharyngitis are the Centor criteria. These include
He reports mild congestion and a dry cough. On examination, his tonsillar EXUDATE, tender anterior cervical LYMPHADENOPATHY, absence of cough, and history of FEVER. The
temperature is 37.2 degrees C (99.0 degrees F). His pharynx is red without presence of three or four of these criteria has a positive predictive value of 40%-60%, and the absence of three or four
exudates, and there are no anterior cervical nodes. His tympanic of these criteria has a negative predictive value of 80%. Patients with four positive criteria should be treated with
membranes are normal, and his chest is clear. You would do which one of antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0-1 positive criteria
the following? (check one)
should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and
A. Treat with analgesics and supportive care
according to the panel should not be tested or treated with antibiotics.
B. Treat with azithromycin (Zithromax)

C. Perform a throat culture and begin treatment with penicillin

D. Perform a rapid strep test

A 12-year-old white male asthmatic has an acute episode of wheezing. You The treatment of choice for occasional acute symptoms of asthma is an inhaled beta2-adrenergic agonist such as
diagnose an acute asthma attack and prescribe an inhaled beta2-adrenergic albuterol, terbutaline, or pirbuterol. However, acute symptoms that do not respond to beta-agonists should be treated
agonist, but despite 1-2 hours of treatment he continues to experience with a short course of systemic corticosteroids.
wheezing and shortness of breath. Which one of the following is the most
appropriate addition to acute outpatient management?

A. Oral theophylline

B. Oral corticosteroids

C. An oral beta2-adrenergic agonist

D. Inhaled cromolyn
E. Inhaled corticosteroids

A 7-year-old male presents with a 3-day history of sore throat, hoarseness, Pharyngitis is a common complaint, and usually has a viral cause. The key factors in diagnosing streptococcal
fever to 100 degrees (38 degrees C), and cough. Examination reveals pharyngitis are a fever over 100.4 degrees F, tonsillar exudates, anterior cervical lymphadenopathy, and absence of
injection of his tonsils, no exudates, and no abnormal breath sounds. Which cough. Age plays a role also, with those <15 years of age more likely to have streptococcal infection, and those 10-25
one of the following would be most appropriate? (check one)
years of age more likely to have mononucleosis.
A. Recommend symptomatic treatment

B. Perform a rapid antigen test for streptococcal pharyngitis

C. Treat empirically for streptococcal pharyngitis

D. Perform a throat culture for streptococcal pharyngitis

E. Perform an office test for mononucleosis

Which one of the AAFP
following Family Med control of mild persistent
is true concerning Studyfor symptom relief
Increasing the use of short-acting beta-2-agonists or using them more than two days per week
asthma?
generally indicates inadequate control of asthma and the need to initiate or intensify anti-inflammatory therapy.
A. Cromolyn sodium should not be used for chronic control of asthma in INHALED STEROIDS are the most potent and consistently effective long-term control medication for asthma.

children under 5 years of age

B. Inhaled anticholinergic agents, such as ipratropium bromide (Atrovent), Oral systemic corticosteroids are recommended for moderate to severe asthma exacerbations.

should be added if inhaled beta-adrenergic agents do not maintain chronic

control of asthma
Ipratropium bromide is useful in the treatment of COPD but has very limited use for asthma.
C. A long-acting beta-agonist should be added if a short-acting beta-
agonist is ineffective

D. Inhaled beta-adrenergic agents may be used every 2 hours to maintain

chronic control of asthma

E. Inhaled glucocorticoids should be used initially to maintain chronic

control of asthma

The treatment of choice for a 4-month-old infant with suspected pertussis is: E. Erythromycin (macrolide)
(check one)

A. Supportive care (respiratory, fluids) only

B. Ceftriaxone (Rocephin)

C. Ampicillin

D. Gentamicin (Garamycin)

E. Erythromycin

Which one of the following drugs would be the most appropriate empiric E. Levofloxacin: In the absence of collectible or diagnostic sputum Gram's stains or cultures, empiric therapy must cover
therapy for nursing home-acquired pneumonia in a patient with no other Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and gram-negative bacteria. Levofloxacin
underlying disease?
is the best single agent for providing against this spectrum of organisms.
A. Cefazolin (Ancef, Kefzol)

B. Erythromycin

C. Ampicillin

D. Tobramycin (Nebcin)

E. Levofloxacin (Levaquin)
 AAFP
A 4-year-old Hispanic Family
female has beenMed
discovered to have a congenital Cytomegalovirus (CMV) is the most common congenital infection and occurs in up to 2.2%Study
of newborns. It is the
hearing loss. Her mother is an 18-year-old migrant farm worker who is leading cause of congenital hearing loss. Risk factors for CMV include low socioeconomic status, birth outside North
currently at 8 weeks' gestation with her second pregnancy. The mother has America, first pregnancy prior to age 15, a history of cervical dysplasia, and a history of sexually transmitted diseases.
been found to have cervical dysplasia on her current Papanicolaou (Pap) Infection can be primary or a reactivation of a previous infection.
smear and has also tested positive for Chlamydia. The most likely cause of
this child's hearing loss is: (check one)

A. Human parvovirus B19

B. Varicella zoster virus

C. Herpes simplex virus

D. Toxoplasmosis

E. Cytomegalovirus

Which one of the following is the most common cause of visual loss in Evaluation of visual symptoms in children can be challenging, but is important for identifying correctable conditions.
children? (check one)
Amblyopia, or "lazy eye," is the most common cause of visual loss, with a prevalence of 2% in childhood. It is often
A. Iritis
related to strabismus, in which the image from one eye is suppressed in order to eliminate diplopia.
B. Glaucoma

C. Amblyopia

D. Eye trauma

E. Conjunctivitis

A 62-year-old male with a previous history of hypertension, smoking, and Carotid stenosis is an important cause of transient ischemic attacks and stroke. For patients with symptomatic carotid
hypercholesterolemia comes to your office after being seen in the stenosis of more than 70%, the value of carotid endarterectomy has been firmly established on the basis of three major
emergency department with an episode of dysarthria and weakness on the randomized trials.
left side of his body. Physical examination reveals a right carotid bruit.
Carotid ultrasonography shows 70%-80% stenosis of the right carotid artery,
which is confirmed by magnetic resonance angiography. In addition to
management of risk factors, which one of the following is appropriate?
(check one)

A. Long-term aspirin therapy

B. Aspirin plus clopidogrel (Plavix)

C. Warfarin (Coumadin)

D. Carotid endarterectomy