AAFP Family Medicine Board Exam
UPDATED QUESTIONS AND CORRECT
ANSWERS
A 70yo M with h/o HTN and DM presents with a 2-mo h/o increasing paroxysmal nocturnal
dyspnea and SOB with minimal exertion. An echocardiogram shows an ejection fraction of
25%. Which one of the patients current medications should be discontinued?
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL) - CORRECT ANSWER Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can be
complicated by the development of heart failure. Caution is necessary when prescribing
TZDs in patients with known heart failure or other heart diseases, those with preexisting
edema, and those on concurrent insulin therapy
What is the most common cause of hypertension in children under 6 years of age? -
CORRECT ANSWER Renal Parenchymal Disease
The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine
culture, and renal ultrasonography should be ordered for all children presenting with
hypertension.
A 72-year-old African-American male with New York Heart Association Class III heart
failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient
is adherent to his medication regimen. His current medications include lisinopril (Prinivil,
Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80
mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular.
Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on
examination of the heart, and no edema on examination of the legs. An EKG reveals a left
bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other
abnormalities. What's the appropriate next step? - CORRECT ANSWER Refer for
cardiac resynchronization therapy (CRT)
,Note: he's already on maximum doses of ACEI, loop diuretic, beta-blocker
Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously,
overcoming the delayed contraction of the left ventricle caused by the left bundle-branch
block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated
that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or
nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are
NYHA functional class III or IV despite maximal medical therapy for heart failure.
What dietary change recommended for the prevention and treatment of cardiovascular
disease has been shown to decrease the rate of sudden death? - CORRECT
ANSWER increase intake of omega 3 fatty acids
Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet
aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American
Heart Association guidelines state that omega-3 supplements may be recommended to
patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as
to patients who do not like or are allergic to fish. The Italian GISSI study found that the use
of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal
myocardial infarction, and stroke, with particular decreases in the rate of sudden death.
A 75-year-old male presents to the emergency department with a several-hour history of back
pain in the interscapular region. His medical history includes a previous myocardial
infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and
hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril).
The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg
and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no
acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch,
and CT of the chest shows a dissecting aneurysm of the descending aorta that is 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? - CORRECT
ANSWER Dx: aortic dissection
next step: Intravenous labetalol (Normodyne, Trandate)
,Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the
lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart
rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains
over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade,
vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous
system, causing increased ventricular contraction and increased shear stress on the aorta.
According to the U.S. Preventive Services Task Force, what are the screening
recommendations for an abdominal aortic aneurysm? - CORRECT ANSWER The
guideline recommends one-time screening with ultrasonography for AAA in men 65-75 years
of age who have ever smoked. No recommendation was made for or against screening
women. Men with a strong family history of AAA should be counseled about the risks and
benefits of screening as they approach 65 years of age.
A 36-year-old white female presents to the emergency department with palpitations. Her
pulse rate is 180 beats/min. An EKG reveals a regular 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 - CORRECT ANSWER verapamil (Calan)
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia
can usually be terminated by the administration of intravenous verapamil or a β-blocker. If
that fails, intravenous propafenone or flecainide may be necessary. It is also important to look
for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte
disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the
tachyarrhythmia.
The blood pressure goal for a patient who has uncomplicated diabetes mellitus is -
CORRECT ANSWER BP goal: 130/80mmHg
Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients and to
<130/80 mm Hg in diabetic patients is recommended. Lowering blood pressure may reduce
stroke rates by 40%-52% and cardiovascular morbidity by 18%-20%
A 60-year-old African-American female has a history of hypertension that has been well
controlled with hydrochlorothiazide. However, she has 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) - CORRECT ANSWER Diltiazem (Cardizem)
Monotherapy for hypertension in African-American patients is more likely to consist of
diuretics or calcium channel blockers than β-blockers or ACE inhibitors. It has been
suggested that hypertension in African-Americans is not as angiotensin II-dependent as it
appears to be in Caucasians.
An asymptomatic 3-year-old male presents for a routine check-up. On examination you
notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short
tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and
seems to decrease with inspiration. The remainder of the examination is normal. What is the
most likely diagnosis? - CORRECT ANSWER Still's murmur
There are several benign murmurs of childhood that have no association with physiologic or
anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of
Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar
valves, or ventricular wall.
A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which
one of the following would most likely require a significant dosage adjustment from the
standard protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA) - CORRECT ANSWER Enoxaparin
UPDATED QUESTIONS AND CORRECT
ANSWERS
A 70yo M with h/o HTN and DM presents with a 2-mo h/o increasing paroxysmal nocturnal
dyspnea and SOB with minimal exertion. An echocardiogram shows an ejection fraction of
25%. Which one of the patients current medications should be discontinued?
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL) - CORRECT ANSWER Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can be
complicated by the development of heart failure. Caution is necessary when prescribing
TZDs in patients with known heart failure or other heart diseases, those with preexisting
edema, and those on concurrent insulin therapy
What is the most common cause of hypertension in children under 6 years of age? -
CORRECT ANSWER Renal Parenchymal Disease
The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine
culture, and renal ultrasonography should be ordered for all children presenting with
hypertension.
A 72-year-old African-American male with New York Heart Association Class III heart
failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient
is adherent to his medication regimen. His current medications include lisinopril (Prinivil,
Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80
mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular.
Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on
examination of the heart, and no edema on examination of the legs. An EKG reveals a left
bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other
abnormalities. What's the appropriate next step? - CORRECT ANSWER Refer for
cardiac resynchronization therapy (CRT)
,Note: he's already on maximum doses of ACEI, loop diuretic, beta-blocker
Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously,
overcoming the delayed contraction of the left ventricle caused by the left bundle-branch
block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated
that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or
nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are
NYHA functional class III or IV despite maximal medical therapy for heart failure.
What dietary change recommended for the prevention and treatment of cardiovascular
disease has been shown to decrease the rate of sudden death? - CORRECT
ANSWER increase intake of omega 3 fatty acids
Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet
aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American
Heart Association guidelines state that omega-3 supplements may be recommended to
patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as
to patients who do not like or are allergic to fish. The Italian GISSI study found that the use
of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal
myocardial infarction, and stroke, with particular decreases in the rate of sudden death.
A 75-year-old male presents to the emergency department with a several-hour history of back
pain in the interscapular region. His medical history includes a previous myocardial
infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and
hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril).
The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg
and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no
acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch,
and CT of the chest shows a dissecting aneurysm of the descending aorta that is 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? - CORRECT
ANSWER Dx: aortic dissection
next step: Intravenous labetalol (Normodyne, Trandate)
,Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the
lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart
rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains
over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade,
vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous
system, causing increased ventricular contraction and increased shear stress on the aorta.
According to the U.S. Preventive Services Task Force, what are the screening
recommendations for an abdominal aortic aneurysm? - CORRECT ANSWER The
guideline recommends one-time screening with ultrasonography for AAA in men 65-75 years
of age who have ever smoked. No recommendation was made for or against screening
women. Men with a strong family history of AAA should be counseled about the risks and
benefits of screening as they approach 65 years of age.
A 36-year-old white female presents to the emergency department with palpitations. Her
pulse rate is 180 beats/min. An EKG reveals a regular 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 - CORRECT ANSWER verapamil (Calan)
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia
can usually be terminated by the administration of intravenous verapamil or a β-blocker. If
that fails, intravenous propafenone or flecainide may be necessary. It is also important to look
for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte
disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the
tachyarrhythmia.
The blood pressure goal for a patient who has uncomplicated diabetes mellitus is -
CORRECT ANSWER BP goal: 130/80mmHg
Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients and to
<130/80 mm Hg in diabetic patients is recommended. Lowering blood pressure may reduce
stroke rates by 40%-52% and cardiovascular morbidity by 18%-20%
A 60-year-old African-American female has a history of hypertension that has been well
controlled with hydrochlorothiazide. However, she has 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) - CORRECT ANSWER Diltiazem (Cardizem)
Monotherapy for hypertension in African-American patients is more likely to consist of
diuretics or calcium channel blockers than β-blockers or ACE inhibitors. It has been
suggested that hypertension in African-Americans is not as angiotensin II-dependent as it
appears to be in Caucasians.
An asymptomatic 3-year-old male presents for a routine check-up. On examination you
notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short
tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and
seems to decrease with inspiration. The remainder of the examination is normal. What is the
most likely diagnosis? - CORRECT ANSWER Still's murmur
There are several benign murmurs of childhood that have no association with physiologic or
anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of
Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar
valves, or ventricular wall.
A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which
one of the following would most likely require a significant dosage adjustment from the
standard protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA) - CORRECT ANSWER Enoxaparin
