AAFP Board Exam Review
What screening test has most potential for overdx? - Answers -PSA- Overdiagnosis is
the diagnosis of a disease that will not produce symptoms during a
patient's lifetime. It tends to occur with cancers that have very slow rates of growth.
Prostate cancer is most often a slow-growing cancer and is often present without
symptoms in older men. The introduction of prostate-specific antigen (PSA) screening
was
accompanied by a marked rise in the rate of diagnosis of prostate cancer while mortality
decreased much less significantly, and this decrease was probably largely attributable
to
improved treatment.
What is the treatment for mallet fracture? - Answers -The recommended treatment for a
mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension (SOR B). The usual duration of splinting is 8 weeks. It is important that
extension be maintained
throughout the duration of treatment because flexion can affect healing and prolong the
time needed for
treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a
hand or orthopedic surgeon can be considered. However, conservative therapy appears
to have outcomes similar
to those of surgical treatment and therefore is generally preferred.
If subluxed radial head is suspected in a child, is imaging needed? - Answers -As long
as there are no outward signs of fracture or abuse it is considered safe and appropriate
to attempt reduction of the radial head before moving on to imaging studies. With the
child's elbow in 90° of flexion, the hand is fully supinated by the examiner and the elbow
is then brought into full flexion. Usually the child will begin to use the affected arm again
within a couple of minutes. If ecchymosis, significant swelling, or pain away from the
joint is present, or if symptoms do not improve after attempts at reduction, then a plain
radiograph is recommended.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a
day for the last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual
period was 3 months ago. Other than the fact that she appears to be slightly
underweight, her examination is normal.
To fit the criteria for the female athlete triad, she must have which one of the following?
- Answers -The initial definition of the female athlete triad was amenorrhea,
osteoporosis, and disordered eating. The American College of Sports Medicine modified
this in 2007, emphasizing that the triad components occur on a continuum rather than
as individual pathologic conditions. The definitions have therefore expanded.
Disordered eating is no longer defined as the formal diagnosis of an eating disorder.
Energy availability,defined as dietary energy intake minus exercise energy
,expenditures, is now considered a risk factor for the triad, as dietary restrictions and
substantial energy expenditures disrupt pituitary and ovarian function.
Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a
stress fracture resulting from minimal trauma should have a bone density test. Low
bone mineral density for age is the term used to describe at-risk female athletes with a
Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for
experiencing a fracture, along with a Z-score <-2.
what is the work up for secondary amenorrhea? - Answers -This patient suffers from
secondary amenorrhea (defined as the cessation of regular menses for 3 months or
irregular menses for 6 months). The most common causes of secondary amenorrhea
are polycystic ovary syndrome, primary ovarian failure, hypothalamic amenorrhea, and
hyperprolactinemia. With a normal physical examination, negative pregnancy test, and
no history of chronic disease, a hormonal
workup is indicated, including TSH, LH, and FSH levels (SOR C).
A hormonal challenge with medroxyprogesterone to provoke withdrawal bleeding is
used to assess
functional anatomy and estrogen levels (SOR C). However, it has poor specificity and
sensitivity for
ovarian function and a poor correlation with estrogen levels.
Pelvic ultrasonography is indicated in the workup of primary amenorrhea to confirm the
presence of a uterus and detect structural abnormalities of the reproductive organs.
Likewise, karyotyping can be used for patients with primary amenorrhea, as conditions
such as Turner's syndrome and androgen insensitivity syndrome are due to
chromosomal abnormalities.
A CBC and metabolic panel would not be initial considerations in the workup of
amenorrhea unless the patient has a known chronic disease which may affect the
results.
What's the first line treatment for primary dysmenorrhea? - Answers -The first-line
treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be
started
at the onset of menses and continued for the first 1-2 days of the menstrual cycle.
Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a
lack of high-quality randomized, controlled trials demonstrating pain improvement (SOR
B). They may be a good choice if the patient also desires contraception. Although
combined oral contraceptives and intramuscular and subcutaneous progestin-only
contraceptives are effective treatments for dysmenorrhea caused by endometriosis,
they are NOT first-line therapy for primary dysmenorrhea.
,A 24-year-old female presents with pelvic pain. She says that the pain is present on
most days, but is worse during her menses. Ibuprofen has helped in the past but is no
longer effective. Her menses are normal and she has only one sexual partner. A
physical examination is normal.
Which one of the following should be the next step in the workup of this patient? -
Answers -The initial evaluation for chronic pelvic pain should include a urinalysis and
culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte
sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part
of the recommended initial diagnostic workup, but may be helpful in further assessing
any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy
is appropriate if the initial workup does not reveal a source of the pain, or if
endometriosis or adhesions are suspected. Colonoscopy would be indicated if the
history or examination suggests a gastrointestinal source for the pain after the initial
evaluation.
what can induce ovulation in PCOS? - Answers -This patient fits the criteria for
polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism,
infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is
not required for the diagnosis.
Metformin has the most evidence supporting its use in this situation, and is the only
treatment listed that is likely to decrease hirsutism and improve insulin resistance and
menstrual irregularities. Metformin and clomiphene alone or in combination are first-line
agents for ovulation induction. Clomiphene does not improve hirsutism, however.
Progesterone is not indicated for any of this patient's problems. Spironolactone will
improve hirsutism and menstrual irregularities, but is not indicated for ovulation
induction.
What is the first step for evaluating a thyroid nodule? - Answers -Thyroid nodules >1 cm
that are discovered incidentally on examination or imaging studies merit further
evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a
family history of thyroid cancer, a personal history of head and neck irradiation, or a
finding of cervical node enlargement.
Reasonable first steps include measurement of TSH or ultrasound examination. The
American
Thyroid Association's guidelines recommend that TSH be the initial evaluation (SOR A)
and that this be followed by a radionuclide thyroid scan if results are abnormal.
Diagnostic ultrasonography is recommended for all patients with a suspected thyroid
nodule, a nodular goiter, or a nodule found
incidentally on another imaging study (SOR A). Routine measurement of serum
thyroglobulin or calcitonin levels is not currently recommended.
CDC guidelines for a flu outbreak? - Answers -The occurrence of two or more
laboratory-confirmed cases of influenza A is considered an outbreak in a long-term care
, facility. The CDC has specific recommendations for managing an outbreak, which
include *chemoprophylaxis with an appropriate medication for all residents who are
asymptomatic and treatment for all residents who are symptomatic*, regardless of
laboratory confirmation of infection or vaccination
status.
All staff should be considered for chemoprophylaxis regardless of whether they have
had direct patient contact with an infected resident or have received the vaccine.
Requesting restriction of visitation is recommended; however, it cannot be strictly
enforced due to residents' rights.
number needed to treat
A new drug treatment is shown to reduce the incidence of a complication of a disease
by 50%. If the usual incidence of this complication were 1% per year, how many
patients with this disease would have to be treated with this medication for 1 year to
prevent one occurrence of this complication? - Answers -Considering relative risk
reduction without also considering the absolute rate can distort the importance of a
therapy. A useful way to assess the importance of a therapy is to determine the number
needed to treat to benefit one patient. To calculate this number, the percentage of
absolute risk reduction of a particular therapy is divided into 100. In the case in
question, the absolute risk reduction is 0.5% (0.5×.01). Thus, the number-needed-to-
treat for the example cited is 200 (100/0.5).
Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous
base
located on the face and trunk, containing eosinophils. Which one of the following would
be most
appropriate at this time? - Answers -This infant has findings consistent with erythema
toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No
testing is usually necessary because of the distinct appearance of the lesions. The
cause is unknown.
American Urological Association guidelines define asymptomatic microscopic hematuria
as
which one of the following in the absence of an obvious benign cause? - Answers -The
American Urological Association guidelines define asymptomatic microscopic hematuria
(AMH) as ≥3 RBCs/hpf on a properly collected urine specimen in the absence of an
obvious benign cause (SOR C).
A positive dipstick does not define AMH, and evaluation should be based solely on
findings from microscopic examination of urinary sediment and not on a dipstick
reading. A positive dipstick reading merits microscopic examination to confirm or refute
the diagnosis of AMH.
What screening test has most potential for overdx? - Answers -PSA- Overdiagnosis is
the diagnosis of a disease that will not produce symptoms during a
patient's lifetime. It tends to occur with cancers that have very slow rates of growth.
Prostate cancer is most often a slow-growing cancer and is often present without
symptoms in older men. The introduction of prostate-specific antigen (PSA) screening
was
accompanied by a marked rise in the rate of diagnosis of prostate cancer while mortality
decreased much less significantly, and this decrease was probably largely attributable
to
improved treatment.
What is the treatment for mallet fracture? - Answers -The recommended treatment for a
mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension (SOR B). The usual duration of splinting is 8 weeks. It is important that
extension be maintained
throughout the duration of treatment because flexion can affect healing and prolong the
time needed for
treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a
hand or orthopedic surgeon can be considered. However, conservative therapy appears
to have outcomes similar
to those of surgical treatment and therefore is generally preferred.
If subluxed radial head is suspected in a child, is imaging needed? - Answers -As long
as there are no outward signs of fracture or abuse it is considered safe and appropriate
to attempt reduction of the radial head before moving on to imaging studies. With the
child's elbow in 90° of flexion, the hand is fully supinated by the examiner and the elbow
is then brought into full flexion. Usually the child will begin to use the affected arm again
within a couple of minutes. If ecchymosis, significant swelling, or pain away from the
joint is present, or if symptoms do not improve after attempts at reduction, then a plain
radiograph is recommended.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a
day for the last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual
period was 3 months ago. Other than the fact that she appears to be slightly
underweight, her examination is normal.
To fit the criteria for the female athlete triad, she must have which one of the following?
- Answers -The initial definition of the female athlete triad was amenorrhea,
osteoporosis, and disordered eating. The American College of Sports Medicine modified
this in 2007, emphasizing that the triad components occur on a continuum rather than
as individual pathologic conditions. The definitions have therefore expanded.
Disordered eating is no longer defined as the formal diagnosis of an eating disorder.
Energy availability,defined as dietary energy intake minus exercise energy
,expenditures, is now considered a risk factor for the triad, as dietary restrictions and
substantial energy expenditures disrupt pituitary and ovarian function.
Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a
stress fracture resulting from minimal trauma should have a bone density test. Low
bone mineral density for age is the term used to describe at-risk female athletes with a
Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for
experiencing a fracture, along with a Z-score <-2.
what is the work up for secondary amenorrhea? - Answers -This patient suffers from
secondary amenorrhea (defined as the cessation of regular menses for 3 months or
irregular menses for 6 months). The most common causes of secondary amenorrhea
are polycystic ovary syndrome, primary ovarian failure, hypothalamic amenorrhea, and
hyperprolactinemia. With a normal physical examination, negative pregnancy test, and
no history of chronic disease, a hormonal
workup is indicated, including TSH, LH, and FSH levels (SOR C).
A hormonal challenge with medroxyprogesterone to provoke withdrawal bleeding is
used to assess
functional anatomy and estrogen levels (SOR C). However, it has poor specificity and
sensitivity for
ovarian function and a poor correlation with estrogen levels.
Pelvic ultrasonography is indicated in the workup of primary amenorrhea to confirm the
presence of a uterus and detect structural abnormalities of the reproductive organs.
Likewise, karyotyping can be used for patients with primary amenorrhea, as conditions
such as Turner's syndrome and androgen insensitivity syndrome are due to
chromosomal abnormalities.
A CBC and metabolic panel would not be initial considerations in the workup of
amenorrhea unless the patient has a known chronic disease which may affect the
results.
What's the first line treatment for primary dysmenorrhea? - Answers -The first-line
treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be
started
at the onset of menses and continued for the first 1-2 days of the menstrual cycle.
Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a
lack of high-quality randomized, controlled trials demonstrating pain improvement (SOR
B). They may be a good choice if the patient also desires contraception. Although
combined oral contraceptives and intramuscular and subcutaneous progestin-only
contraceptives are effective treatments for dysmenorrhea caused by endometriosis,
they are NOT first-line therapy for primary dysmenorrhea.
,A 24-year-old female presents with pelvic pain. She says that the pain is present on
most days, but is worse during her menses. Ibuprofen has helped in the past but is no
longer effective. Her menses are normal and she has only one sexual partner. A
physical examination is normal.
Which one of the following should be the next step in the workup of this patient? -
Answers -The initial evaluation for chronic pelvic pain should include a urinalysis and
culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte
sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part
of the recommended initial diagnostic workup, but may be helpful in further assessing
any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy
is appropriate if the initial workup does not reveal a source of the pain, or if
endometriosis or adhesions are suspected. Colonoscopy would be indicated if the
history or examination suggests a gastrointestinal source for the pain after the initial
evaluation.
what can induce ovulation in PCOS? - Answers -This patient fits the criteria for
polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism,
infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is
not required for the diagnosis.
Metformin has the most evidence supporting its use in this situation, and is the only
treatment listed that is likely to decrease hirsutism and improve insulin resistance and
menstrual irregularities. Metformin and clomiphene alone or in combination are first-line
agents for ovulation induction. Clomiphene does not improve hirsutism, however.
Progesterone is not indicated for any of this patient's problems. Spironolactone will
improve hirsutism and menstrual irregularities, but is not indicated for ovulation
induction.
What is the first step for evaluating a thyroid nodule? - Answers -Thyroid nodules >1 cm
that are discovered incidentally on examination or imaging studies merit further
evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a
family history of thyroid cancer, a personal history of head and neck irradiation, or a
finding of cervical node enlargement.
Reasonable first steps include measurement of TSH or ultrasound examination. The
American
Thyroid Association's guidelines recommend that TSH be the initial evaluation (SOR A)
and that this be followed by a radionuclide thyroid scan if results are abnormal.
Diagnostic ultrasonography is recommended for all patients with a suspected thyroid
nodule, a nodular goiter, or a nodule found
incidentally on another imaging study (SOR A). Routine measurement of serum
thyroglobulin or calcitonin levels is not currently recommended.
CDC guidelines for a flu outbreak? - Answers -The occurrence of two or more
laboratory-confirmed cases of influenza A is considered an outbreak in a long-term care
, facility. The CDC has specific recommendations for managing an outbreak, which
include *chemoprophylaxis with an appropriate medication for all residents who are
asymptomatic and treatment for all residents who are symptomatic*, regardless of
laboratory confirmation of infection or vaccination
status.
All staff should be considered for chemoprophylaxis regardless of whether they have
had direct patient contact with an infected resident or have received the vaccine.
Requesting restriction of visitation is recommended; however, it cannot be strictly
enforced due to residents' rights.
number needed to treat
A new drug treatment is shown to reduce the incidence of a complication of a disease
by 50%. If the usual incidence of this complication were 1% per year, how many
patients with this disease would have to be treated with this medication for 1 year to
prevent one occurrence of this complication? - Answers -Considering relative risk
reduction without also considering the absolute rate can distort the importance of a
therapy. A useful way to assess the importance of a therapy is to determine the number
needed to treat to benefit one patient. To calculate this number, the percentage of
absolute risk reduction of a particular therapy is divided into 100. In the case in
question, the absolute risk reduction is 0.5% (0.5×.01). Thus, the number-needed-to-
treat for the example cited is 200 (100/0.5).
Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous
base
located on the face and trunk, containing eosinophils. Which one of the following would
be most
appropriate at this time? - Answers -This infant has findings consistent with erythema
toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No
testing is usually necessary because of the distinct appearance of the lesions. The
cause is unknown.
American Urological Association guidelines define asymptomatic microscopic hematuria
as
which one of the following in the absence of an obvious benign cause? - Answers -The
American Urological Association guidelines define asymptomatic microscopic hematuria
(AMH) as ≥3 RBCs/hpf on a properly collected urine specimen in the absence of an
obvious benign cause (SOR C).
A positive dipstick does not define AMH, and evaluation should be based solely on
findings from microscopic examination of urinary sediment and not on a dipstick
reading. A positive dipstick reading merits microscopic examination to confirm or refute
the diagnosis of AMH.
