FAMILY MEDICINE COMAT QUESTIONS
WITH ACCURATE ANSWERS.
B (although treatment with methimazole, proylthiouracil, radioactive iodine, and surgical removal of the
thyroid gland are plausible treatments for Grave's disease, methimazole is recommnded as a first line
agent over propylthiouracil due to potential hepatotoxicity) ANS - A 56-year-old female complains of
palpitations and an unintentional 20 lb weight loss in the past six months. History reveals that her
menstrual periods stopped approximately 7 years ago. Vital signs include a blood pressure of 135/85
and a heart rate of 110. Physical examination reveals a non-tender enlarged thyroid gland without
nodules. Structural examination reveals tissue texture changes at T2 associated with an upper thoracic
flexion hump. Laboratory studies reveal the following
TSH: 0.05
free T3: 380
free T4: 22
A thyroid stimulating immunoglobulin test is positive. The most appropriate initial management is
A. levothyroxine
B. methimazole
C. proylthiouracil
D. radioactive iodine ablation
E. thyroidectomy
D (the most likely diagnosis is onychomycosis - microscopic evaluation is the best first step to make the
diagnosis) (A; bacterial infection is less likely than fungal) (B; Sabouraud's agar is used to grow fungal
specimens - culture results usually return after weeks, a microscopic evaluation would be faster -
culturing would be indicated if the initial KOH prep shows absent fungi) (C; this procedure stains fungal
cell walls and helps in visualization - however, while this test is more sensitive, it is more expensive) (E;
empiric treatment is not recommended due to side effects - additionally, treatment usually lasts 3
months, not 1, due to the slow growing nature of toenails) ANS - A 66-year old female complains that
the nail of her right great toe is discolored and brittle. She states that she first noticed it 4 months ago
during a pedicure. Physical examination reveals the right great toenail to be yellowed, thickened, and
has white subungual debris. The most appropriate modality to confirm the most likely diagnosis is
,A. bacterial culture of nail clippings
B. culture of toenail scrapings on Sabouraud's medium
C. histopathologic examination of nail clippings under periodic acid-Schiff stain
D. microscopic evaluation of toenail scrapings using KOH prep
E. one month terbinafine to confirm resolution
D (indwelling catheter can cause a UTI with Pseudomonas aeruginosa - the indicated treatment is with a
fluoroquinolone like ciprofloxacin or levofloxacin) (none of the other answer choices have action against
Pseudomonas) ANS - A 70-year-old female who is 3 days status-post urologic surgery develops a fever
overnight in the hospital. She has an indwelling Foley catheter with good urine output. Her past medical
history includes hypertension and urinary incontinence. She has no significant family history. Vitals
reveal her temperature to be 102.2F, pulse 82, respirations 15, and blood pressure 134/85. Physical
examination is remarkable for mild suprapubic tenderness. You note a tender nodule on the lateral
border of the umbilicus. Urinalysis reveals 60 WBC/hpf, trace protein, positive leukocyte esterase,
positive nitrites, and no casts. A reflex culture grows motile, gram-negative rods with a dark green
appearance and fruity odor. The most appropriate pharmacologic therapy includes
A. amoxicillin
B. cefotaxime
C. ceftriaxone
D. ciprofloxacin
E. trimethoprim-sulfamethoxazole
E (threatened abortion is used to describe any vaginal bleeding that occurs within the first 20 weeks of
pregnancy) (A; a complete abortion is when the products of conception have completely evacuated the
uterus and the cervical os is closed) (B; an incomplete abortion is when the products of conception can
be seen or palpated in the cervical canal, and the cervical os is open) (C; an inevitable abortion is when
the products of conception can be seen or palpated within the uterus through the dilated cervical os) (D;
partial abortion is not an appropriate or defined medical term) ANS - A 32-year-old G1P0 female at 16
weeks' gestation presents with vaginal bleeding. History reveals she had pelvic inflammatory disease of
unknown etiology prior to conception. Pelvic examination reveals the cervical os to be closed. The most
likely diagnosis is
A. complete abortion
,B. incomplete abortion
C. inevitable abortion
D. partial abortion
E. threatened abortion
D (the most documented causes of miscarriages are maternal age, history of previous miscarriage, and
maternal smoking) (A; risk of miscarriage according to maternal age is 20% for 35 years, 40% for 40
years, and 80% for 45 years) (B; miscarriages can be related to increased gravidity but not nulliparity) (C;
PID increases a patient's risk for infertility, but not miscarriage unless there is an active infection) (E;
there are no studies to indicate that this is a significant contributor) ANS - A 32-year-old G1P0 female at
16 weeks' gestation presents with vaginal bleeding. History reveals she had pelvic inflammatory disease
of unknown etiology prior to conception. Pelvic examination reveals the cervical os to be closed. The
patient ultimately has a miscarriage and undergoes a successful dilation and curettage. You explain that
she is likely to experience another miscarriage because she has a history of
A. advanced maternal age
B. nulliparity
C. pelvic inflammatory disease
D. spontaneous abortion
E. uterine instrumentation
A (contamination of the specimen must be ruled out in a patient with asymptomatic bacteriuria) (B, C, E;
these diagnoses would likely have symptoms, including dysuria, fever, suprapubic or costovertebral
tenderness, as well as positive findings on dipstick such as leukocyte esterase or nitrites ) (D; pyuria is
defined as 6-10 WBC/hpf) ANS - A 30-year-old female presents to the office for a health maintenance
examination. She states she feels healthy and wants a routine check as she is planning to become
pregnant in the near future. Physical exam is normal and osteopathic structural exam reveals only mild
anterior innominate rotation on the left without significant TART changes throughout the spine. A
urinalysis is obtained and dipstick reveals the following
Color: yellow
Specific gravity: 1.012
pH: 5.5
Blood: none
, Protein: none
Glucose: none
Leukocyte esterase: none
Nitrite: none
Bacteria: occult
RBC: 2/hpf
WBC: 5/hpf
A follow-up urine culture is obtained revealing two different types of bacteria with 10^3 CFU/mL. The
most likely diagnosis is
A. contaminated specimen
B. cystitis
C. pyelonephritis
D. pyuria
E. urinary tract infection
A (the diagnosis is mastitis - the treatment for mastitis is to continue breastfeeding, or to pump milk if
the baby is no longer breastfeeding, to encourage emptying, as well as taking an appropriate antibiotic)
ANS - A new mother presents with fever, chills and unilateral right breast pain. She has been
breastfeeding without complications since delivery two weeks ago. Physical examination reveals right
breast tenderness, erythema, swelling, and purulent nipple discharge. The most appropriate
recommendation and treatment is to
A. continue breast feeding and take dicloxacillin
B. continue breast feeding and take fluconazole
C. discontinue breast feeding and take cephalexin
D. pump milk and discard while taking amoxicillin/clavulanate
E. pump milk and discard while taking clindamycin
WITH ACCURATE ANSWERS.
B (although treatment with methimazole, proylthiouracil, radioactive iodine, and surgical removal of the
thyroid gland are plausible treatments for Grave's disease, methimazole is recommnded as a first line
agent over propylthiouracil due to potential hepatotoxicity) ANS - A 56-year-old female complains of
palpitations and an unintentional 20 lb weight loss in the past six months. History reveals that her
menstrual periods stopped approximately 7 years ago. Vital signs include a blood pressure of 135/85
and a heart rate of 110. Physical examination reveals a non-tender enlarged thyroid gland without
nodules. Structural examination reveals tissue texture changes at T2 associated with an upper thoracic
flexion hump. Laboratory studies reveal the following
TSH: 0.05
free T3: 380
free T4: 22
A thyroid stimulating immunoglobulin test is positive. The most appropriate initial management is
A. levothyroxine
B. methimazole
C. proylthiouracil
D. radioactive iodine ablation
E. thyroidectomy
D (the most likely diagnosis is onychomycosis - microscopic evaluation is the best first step to make the
diagnosis) (A; bacterial infection is less likely than fungal) (B; Sabouraud's agar is used to grow fungal
specimens - culture results usually return after weeks, a microscopic evaluation would be faster -
culturing would be indicated if the initial KOH prep shows absent fungi) (C; this procedure stains fungal
cell walls and helps in visualization - however, while this test is more sensitive, it is more expensive) (E;
empiric treatment is not recommended due to side effects - additionally, treatment usually lasts 3
months, not 1, due to the slow growing nature of toenails) ANS - A 66-year old female complains that
the nail of her right great toe is discolored and brittle. She states that she first noticed it 4 months ago
during a pedicure. Physical examination reveals the right great toenail to be yellowed, thickened, and
has white subungual debris. The most appropriate modality to confirm the most likely diagnosis is
,A. bacterial culture of nail clippings
B. culture of toenail scrapings on Sabouraud's medium
C. histopathologic examination of nail clippings under periodic acid-Schiff stain
D. microscopic evaluation of toenail scrapings using KOH prep
E. one month terbinafine to confirm resolution
D (indwelling catheter can cause a UTI with Pseudomonas aeruginosa - the indicated treatment is with a
fluoroquinolone like ciprofloxacin or levofloxacin) (none of the other answer choices have action against
Pseudomonas) ANS - A 70-year-old female who is 3 days status-post urologic surgery develops a fever
overnight in the hospital. She has an indwelling Foley catheter with good urine output. Her past medical
history includes hypertension and urinary incontinence. She has no significant family history. Vitals
reveal her temperature to be 102.2F, pulse 82, respirations 15, and blood pressure 134/85. Physical
examination is remarkable for mild suprapubic tenderness. You note a tender nodule on the lateral
border of the umbilicus. Urinalysis reveals 60 WBC/hpf, trace protein, positive leukocyte esterase,
positive nitrites, and no casts. A reflex culture grows motile, gram-negative rods with a dark green
appearance and fruity odor. The most appropriate pharmacologic therapy includes
A. amoxicillin
B. cefotaxime
C. ceftriaxone
D. ciprofloxacin
E. trimethoprim-sulfamethoxazole
E (threatened abortion is used to describe any vaginal bleeding that occurs within the first 20 weeks of
pregnancy) (A; a complete abortion is when the products of conception have completely evacuated the
uterus and the cervical os is closed) (B; an incomplete abortion is when the products of conception can
be seen or palpated in the cervical canal, and the cervical os is open) (C; an inevitable abortion is when
the products of conception can be seen or palpated within the uterus through the dilated cervical os) (D;
partial abortion is not an appropriate or defined medical term) ANS - A 32-year-old G1P0 female at 16
weeks' gestation presents with vaginal bleeding. History reveals she had pelvic inflammatory disease of
unknown etiology prior to conception. Pelvic examination reveals the cervical os to be closed. The most
likely diagnosis is
A. complete abortion
,B. incomplete abortion
C. inevitable abortion
D. partial abortion
E. threatened abortion
D (the most documented causes of miscarriages are maternal age, history of previous miscarriage, and
maternal smoking) (A; risk of miscarriage according to maternal age is 20% for 35 years, 40% for 40
years, and 80% for 45 years) (B; miscarriages can be related to increased gravidity but not nulliparity) (C;
PID increases a patient's risk for infertility, but not miscarriage unless there is an active infection) (E;
there are no studies to indicate that this is a significant contributor) ANS - A 32-year-old G1P0 female at
16 weeks' gestation presents with vaginal bleeding. History reveals she had pelvic inflammatory disease
of unknown etiology prior to conception. Pelvic examination reveals the cervical os to be closed. The
patient ultimately has a miscarriage and undergoes a successful dilation and curettage. You explain that
she is likely to experience another miscarriage because she has a history of
A. advanced maternal age
B. nulliparity
C. pelvic inflammatory disease
D. spontaneous abortion
E. uterine instrumentation
A (contamination of the specimen must be ruled out in a patient with asymptomatic bacteriuria) (B, C, E;
these diagnoses would likely have symptoms, including dysuria, fever, suprapubic or costovertebral
tenderness, as well as positive findings on dipstick such as leukocyte esterase or nitrites ) (D; pyuria is
defined as 6-10 WBC/hpf) ANS - A 30-year-old female presents to the office for a health maintenance
examination. She states she feels healthy and wants a routine check as she is planning to become
pregnant in the near future. Physical exam is normal and osteopathic structural exam reveals only mild
anterior innominate rotation on the left without significant TART changes throughout the spine. A
urinalysis is obtained and dipstick reveals the following
Color: yellow
Specific gravity: 1.012
pH: 5.5
Blood: none
, Protein: none
Glucose: none
Leukocyte esterase: none
Nitrite: none
Bacteria: occult
RBC: 2/hpf
WBC: 5/hpf
A follow-up urine culture is obtained revealing two different types of bacteria with 10^3 CFU/mL. The
most likely diagnosis is
A. contaminated specimen
B. cystitis
C. pyelonephritis
D. pyuria
E. urinary tract infection
A (the diagnosis is mastitis - the treatment for mastitis is to continue breastfeeding, or to pump milk if
the baby is no longer breastfeeding, to encourage emptying, as well as taking an appropriate antibiotic)
ANS - A new mother presents with fever, chills and unilateral right breast pain. She has been
breastfeeding without complications since delivery two weeks ago. Physical examination reveals right
breast tenderness, erythema, swelling, and purulent nipple discharge. The most appropriate
recommendation and treatment is to
A. continue breast feeding and take dicloxacillin
B. continue breast feeding and take fluconazole
C. discontinue breast feeding and take cephalexin
D. pump milk and discard while taking amoxicillin/clavulanate
E. pump milk and discard while taking clindamycin
