Family Medicine Board Review(Questions from the ABFM ITE exams) 2024/2025

A 42-year-old Asian male presents for follow-up of elevated blood pressure. He has no additional chronic medical problems and is otherwise asymptomatic. An examination is significant for a blood pressure of 162/95 mm Hg but is otherwise unremarkable. Laboratory Findings unremarkable Urine microalbumin negative According to the American College of Cardiology/American Heart Association 2017 guidelines, which one of the following would be the most appropriate medication to initiate at this time? A) Clonidine (Catapres), 0.1 mg twice daily B) Hydralazine, 25 mg three times daily C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily D) Metoprolol tartrate (Lopressor), 25 mg twice daily E) Triamterene (Dyrenium), 50 mg daily ANSWER: C This patient has hypertension and according to both JNC 8 and American College of Cardiology/American Heart Association 2017 guidelines, antihypertensive treatment should be initiated. For the general non-African-American population, monotherapy with an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a thiazide diuretic would be appropriate for initial management. It is also appropriate to initiate combination antihypertensive therapy as an initial management strategy, although patients should not take an ACE inhibitor and an angiotensin receptor blocker simultaneously. Studies have shown that blood pressure control is achieved faster with the initiation of combination therapy compared to monotherapy, without an increase in morbidity. Lisinopril/hydrochlorothiazide would be an appropriate choice in this patient. -Blockers, vasodilators, -blockers, and potassium-sparing diuretics are not recommended as initial choices for the treatment of hypertension. During rounds at the nursing home, you are informed that there are two residents on the unit with laboratory-confirmed influenza. According to CDC guidelines, who should receive chemoprophylaxis for influenza? A) Only symptomatic residents on the same unit B) Only symptomatic residents in the entire facility C) All asymptomatic residents on the same unit D) All residents of the facility regardless of symptoms E) All staff regardless of symptoms ANSWER: C In long-term care facilities, an influenza outbreak is defined as two laboratory-confirmed cases of influenza within 72 hours in patients on the same unit. The CDC recommends chemoprophylaxis for all asymptomatic residents of the affected unit. Any resident exhibiting symptoms of influenza should be treated for influenza and not given chemoprophylaxis dosing. Chemoprophylaxis is not recommended for residents of other units unless there are two laboratory-confirmed cases in those units. Facility staff of the affected unit can be considered for chemoprophylaxis if they have not been vaccinated or if they had a recent vaccination, but chemoprophylaxis is not recommended for all staff in the entire facility. 00:45 01:07 A 24-year-old female presents with a 2-day history of mild to moderate pelvic pain. She has had two male sex partners in the last 6 months and uses oral contraceptives and sometimes condoms. A physical examination reveals a temperature of 36.4°C (97.5°F) and moderate cervical motion and uterine tenderness. Urine hCG and a urinalysis are negative. Vaginal microscopy shows only WBCs. The initiation of antibiotics for treatment of pelvic inflammatory disease in this patient A) is appropriate at this time B) requires an elevated temperature, WBC count, or C-reactive protein level C) should be based on the results of gonorrhea and Chlamydia testing D) should be based on the results of pelvic ultrasonography ANSWER: A Pelvic inflammatory disease (PID) is a clinical diagnosis, and treatment should be administered at the time of diagnosis and not delayed until the results of the nucleic acid amplification testing (NAAT) for gonorrhea and Chlamydia are returned. The clinical diagnosis is based on an at-risk woman presenting with lower abdominal or pelvic pain, accompanied by cervical motion, uterine, or adnexal tenderness that can range from mild to severe. There is often a mucopurulent discharge or WBCs on saline microscopy. Acute phase indicators such as fever, leukocytosis, or an elevated C-reactive protein level may be helpful but are neither sensitive nor specific. A positive NAAT is not required for diagnosis and treatment because an upper tract infection may be present, or the causative agent may not be gonorrhea or Chlamydia. PID should be considered a polymicrobial infection. Pelvic ultrasonography may be used if there is a concern about other pathology such as a tubo-ovarian abscess. A 24-year-old patient wants to start the process of transitioning from female to male. He has been working with a psychiatrist who has confirmed the diagnosis of gender dysphoria. Which one of the following would be the best initial treatment for this patient? A) Clomiphene B) Letrozole (Femara) C) Leuprolide (Eligard) D) Spironolactone (Aldactone) E) Testosterone ANSWER: E For patients with gender dysphoria or gender incongruence who desire hormone treatment, the treatment goal is to suppress endogenous sex hormone production and maintain sex hormone levels in the normal range for their affirmed gender. For a female-to-male transgender patient this is most easily accomplished with testosterone. When testosterone levels are maintained in the normal genetic male range, gonadotropins and ovarian hormone production is suppressed, which accomplishes both goals for hormonal treatment without the need for additional gonadotropin suppression from medications such as leuprolide. Clomiphene can increase serum testosterone levels, but only in the presence of a functioning testicle. Letrozole is an estrogen receptor antagonist, but it would not increase serum testosterone levels. Spironolactone has androgen receptor blocking effects and would not accomplish either of the hormone treatment goals. Based on American Cancer Society guidelines for cervical cancer screening, when should HPV DNA co-testing first be performed along with Papanicolaou testing? A) At the onset of sexual activity B) At age 21 C) At age 25 D) At age 30 E) At age 35 ANSWER: D According to American Cancer Society guidelines for cervical cancer screening, Papanicolaou (Pap) testing should begin at age 21 irrespective of sexual activity and should be continued every 3 years until age 29. The preferred screening strategy beginning at age 30 is Pap testing with HPV co-testing, which should be continued every 5 years until age 65. Cervical screening may be discontinued at that time if the patient's last two tests have been negative and the patient was tested within the previous 5 years. Long-term proton pump inhibitor use is associated with an increased risk for A) Barrett's esophagus B) gout C) hypertension D) pneumonia E) type 2 diabetes ANSWER: D Acid suppression therapy is associated with an increased risk of community-acquired and health care-associated pneumonia, which is related to gastric overgrowth by gram-negative bacteria. Long-term treatment of Barrett's esophagus is an indication for chronic proton pump inhibitor (PPI) use. PPI therapy does not increase the risk of gout, hypertension, or type 2 diabetes. An 87-year-old female comes to your office for an annual health maintenance visit. She appears cachectic and tells you that for the past 6 months she has had a decreased appetite and generalized muscle weakness. The patient is alert and oriented to person and place. She has a 10% weight loss, dry mucous membranes, and tenting of the skin on the extensor surface of her hands. While inflating the blood pressure cuff on her right arm you observe carpopedal spasms. Which one of the following is the most likely electrolyte disturbance? A) Hypercalcemia B) Hypocalcemia C) Hypokalemia D) Hypernatremia E) Hyponatremia ANSWER: B A Trousseau sign, defined as spasmodic contraction of muscles caused by pressure on the nerves that control them, is present in up to 94% of patients with hypocalcemia. Hypercalcemia is more likely to present with hyperreflexia. Patients with hypokalemia, hypernatremia, or hyponatremia may present with weakness and confusion, but tetany is not a common sign of either sodium or potassium imbalance. 24-year old female presents to your office with a 3-month history of difficulty sleeping. She says that she struggles to fall asleep and wakes up multiple times at night at least three times a week. She tries to go to bed at 10:00 p.m. and wakes up at 6:30 a.m. to start her day. She lies awake for an hour in bed before falling asleep and spends up to 2 hours awake in the middle of the night trying to fall back asleep. Lately she has been feeling fatigued and having difficulty concentrating at work. You conduct a full history and physical examination and tell her to return in 2 weeks with a sleep diary. At this follow-up visit you see from her diary that she is sleeping an average of 5½ hours per night. Which one of the following would be the most appropriate recommendation? A) Set her alarm for 5:30 a.m. B) Add a mid-afternoon nap C) Move her bedtime to 9:00 p.m. D) Move her bedtime to 12:30 a.m. E) Stay up for an hour if she wakes up at 3:00 a.m. ANSWER: D This patient presents with symptoms of chronic insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) and brief behavioral therapy for insomnia (BBT-I) are effective nonpharmacologic treatments for chronic insomnia. Modified CBT-I and BBT-I can be administered by a primary care physician. The basic principles include stimulus control (sleep hygiene) and sleep restriction. Reducing time in bed increases sleep efficiency. In this case, 6 hours of time in bed would improve the patient's sleep efficiency and a bedtime of 12:30 a.m. would accomplish this goal. Generally, reduced time in bed is accomplished by postponing bedtime rather than getting up earlier. Naps generally do not improve sleep efficiency. While getting out of bed is recommended after being in bed for 30 minutes without falling asleep, or being awake for 30 minutes after being asleep, staying up for a prescribed period of time is not recommended. A 45-year-old female presents to the emergency department with a 1-week history of facial swelling and progressive dyspnea with exertion. She was diagnosed 1 week ago with non-Hodgkin's lymphoma but her medical history is otherwise unremarkable. After hospital admission, which one of the following would be the most appropriate next step in the management of this condition? A) Intravenous antibiotics B) Urgent chemotherapy and radiation C) Urgent chemotherapy and plasmapheresis D) Urgent echocardiography E) Urgent bronchoscopy ANSWER: B Because of the prevalence of cancer in the United States, it is important for family physicians to recognize oncologic emergencies. This patient presents with signs and symptoms related to superior vena cava syndrome, which is caused by compression of the superior vena cava. This is most often caused by lung cancer or lymphoma, but it can also be related to indwelling catheters, lymph nodes, or metastatic tumors. After ensuring that the patient is hospitalized and stable, the initial treatment options include intravenous corticosteroids, chemotherapy, radiation, and occasionally intravascular stenting. Antibiotics are not warranted because this condition is not the result of an infection. Hyperviscosity syndrome is another oncologic emergency associated with leukemia, multiple myeloma, and Waldenström's macroglobulinemia. It is treated with chemotherapy and plasmapheresis. Echocardiography and bronchoscopy are not indicated in the initial management of superior vena cava syndrome. A nonverbal 22-year-old male with intellectual disability is brought to your office by the staff of the group home where he lives. They report that the patient has been functioning at his baseline until this morning when he was found to have loud breathing. No other history is available at the time of this visit. On examination he has a temperature of 37.3°C (99.1°F), a blood pressure of 124/82 mm Hg, a pulse rate of 100 beats/min, and a respiratory rate of 16/min. The patient appears to be in mild distress and a high-pitched whistling, crowing sound on inspiration is heard as you walk in the room. Which one of the following would be the most appropriate next step for this patient? A) Oral antibiotics B) Oral corticosteroids C) Nebulized albuterol D) Nebulized epinephrine E) Urgent evaluation in the emergency department ANSWER: E Stridor is a high-pitched whistling, crowing sound on inspiration. It can be caused by obstruction of the larynx or trachea by a foreign body, vocal cord edema, a neoplasm, or a pharyngeal abscess. Acute stridor requires urgent evaluation for obstruction. This patient may have a foreign body or other obstruction in his airway and requires urgent assessment. Oral antibiotics, oral corticosteroids, nebulized albuterol, or nebulized epinephrine would not be appropriate at this time. A 16-year-old female presents with chronic acne on her nose, forehead, and chin consisting of a few comedones and a few mildly inflamed papules and pustules. She says it is minimally improved after 12 weeks of daily adapalene 0.1% gel. There are no scars or cysts. The patient would like to try to achieve better control. Which one of the following would you recommend at this time? A) Continue adapalene 0.1% gel for 12 more weeks B) Add clindamycin (Cleocin T) 1% gel for up to 12 weeks C) Add clindamycin 1% gel for maintenance D) Stop adapalene 0.1% gel and start clindamycin 1% gel for maintenance E) Stop adapalene 0.1% gel and start erythromycin 2% gel for maintenance ANSWER: B Family physicians are often asked to manage mild to moderate acne vulgaris. Topical retinoids such as adapalene and benzoyl peroxide are first-line therapy and a trial of therapy is typically 8-12 weeks. Topical antibiotics may be added to topical retinoids or benzoyl peroxide to achieve better symptom control. To decrease emerging antibiotic resistance, studies support limiting antibiotic use to 12 weeks except in severe cases, not using antibiotics as monotherapy, and using clindamycin rather than erythromycin. Adding clindamycin gel rather than erythromycin gel for up to 12 weeks is recommended for this patient at this time. A 32-year-old female who is one of your longtime patients calls you because of a 24-hour history of painful urination with urinary frequency and urgency. She is otherwise healthy and does not have any fever, chills, back pain, or vaginal discharge. She uses an oral contraceptive pill and states that her last menstrual period was normal and occurred last week. Which one of the following would be most appropriate at this time? A) Empiric antibiotic treatment B) A urinalysis C) A urine culture D) Plain abdominal radiographs E) Pelvic ultrasonography ANSWER: A This patient has symptoms of acute simple cystitis and does not have any symptoms that would suggest a complicated urinary tract infection or vaginal infection. In these cases treatment with oral antibiotic therapy may be prescribed without further evaluation (SOR B). Simple cystitis is a clinical diagnosis and a urinalysis and urine culture are not necessary. The patient does not have any symptoms that warrant evaluation with abdominal radiographs or pelvic ultrasonography.