FAMILY MEDICINE BOARD EXAMS SET
FEATURING SOLVED QUESTIONS AND
ACCURACY CHECKED ANSWERS
●● What is the most common cause of hypertension in children under 6
years of age?
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?
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?
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?
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?
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
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
FEATURING SOLVED QUESTIONS AND
ACCURACY CHECKED ANSWERS
●● What is the most common cause of hypertension in children under 6
years of age?
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?
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?
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?
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?
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
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
