Family Medicine Board Review
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 ho - ANS-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.
43-year-old male presents to the emergency department with the acute onset of sharp, stabbing
chest pain when inhaling and exhaling. The pain worsens with coughing and deep breathing. He
has no significant previous medical history but recently returned from a work trip to Japan and
has noted right leg swelling for the past week. He has no other symptoms. He is a smoker and
has a family history of coronary artery disease in his paternal grandfather. On examination he
appears uncomfortable, and his lungs are clear. A cardiac examination is notable for
tachycardia. He has a blood pressure of 110/70 mm Hg, a heart rate of 112 beats/min, a
respiratory rate of 18/min, a temperature of 37.7°C (99.9°F), and an oxygen saturation of 89%
on room air. Which one of the following test results is most likely to confirm the diagnosis?
A) Elevated troponin levels
B) Acid-fast bacilli on a Gram stain
C) A filling defect on CT angiogra - ANS-ANSWER: C
,The differential diagnosis of pleuritic chest pain includes several serious causes that should be
considered in the evaluation of a patient with this type of pain. Pulmonary embolism is the most
common cause of pleuritic chest pain. This patient presents with the acute onset of pleuritic
chest pain associated with travel, a swollen leg, and smoking, which are common risk factors for
pulmonary embolism. A filling defect on CT angiography can confirm this diagnosis. Elevated
troponin levels would confirm a diagnosis of acute myocardial infarction, which would be more
likely if the patient were older, experienced pain with exertion, and had other red-flag symptoms
such as diaphoresis, nausea and vomiting, or radiating pain. Acid-fast bacilli on a Gram stain
would confirm a diagnosis of tuberculosis (TB), which is associated with travel to or exposure to
contacts from high-risk areas. TB would also present with other red-flag symptoms such as
hemoptysis, fever, night sweats, and weight loss. A chest radiograph showing air in the pleural
space would confirm a diagnosis of pneumothorax, which is usually present with decreased
breath sounds on physical examination. An EKG with diffuse ST-segment elevation would
confirm a diagnosis of pericarditis, which is usually associated with a recent or current viral
infection or prior history of pericarditis.
A 10-year-old female is brought to your office for a sports preparticipation examination. You note
thoracic rib asymmetry during the Adams forward bend test. Radiographs confirm rightward
thoracolumbar scoliosis with a Cobb angle of 32°. Which one of the following would be most
appropriate at this time?
A) Genetic testing (ScoliScore)
B) MRI of the thoracic and lumbar spine without contrast
C) Scoliosis radiography in 1 year
D) Referral to physical therapy
E) Referral to a pediatric orthopedist - ANS-ANSWER: E
This patient is a skeletally immature female with a Cobb angle that puts her at increased risk for
progression (>29°). Referral to a spine specialist for consideration of bracing and appropriate
follow-up is recommended. Genetic testing is available to help determine the risk of progression,
but it is not a widely validated tool at this time. MRI does not provide any additional information
to help with decision-making. Because of the patient's increased risk of progression, simple
follow-up in 1 year is not recommended. Physical therapy is not indicated for the primary
treatment of scoliosis.
A 12-year-old female is brought to your office because of a lesion on her left lateral upper eyelid.
The lesion started 3 days ago as a small, red "pimple," and since then it has increased in size
and is tender. She does not have any fever, tearing, or conjunctival irritation. No treatment has
been attempted. Which one of the following would be the most appropriate initial management?
A) Warm, damp compresses for 10 minutes four times daily
B) Topical erythromycin ophthalmic ointment (Ilotycin)
C) Topical hydrocortisone 0.5%
D) Systemic antibiotics with coverage for staphylococci
E) Incisional drainage using a sterile 18- or 20-gauge needle - ANS-ANSWER: A
This patient presents with an external hordeolum or stye. Warm, damp compresses for 10
minutes four times a day would be the best initial management. Topical erythromycin ointment
,and topical hydrocortisone cream are not indicated for treatment of a stye. Although
staphylococci are commonly involved in this process, antibiotics are not recommended unless
there is evidence of adjoining cellulitis. Warm compresses allow for spontaneous drainage and
resolution. Anti-inflammatory medications are not recommended for hordeolum externum
management, however they could become necessary if it becomes a chalazion. If the
hordeolum has not resolved in about 1 week, incision may be necessary.
A 12-year-old male is brought to your office by his guardian. In the last 12 months he was
suspended from school multiple times for bullying and fighting. He kicks the family dog and goes
out at night without permission. He ran away from home 2 weeks ago and he lies constantly. He
skips school and does not care about his grades. Attention-deficit/hyperactivity disorder was
previously ruled out. Two days ago he was grounded and retaliated by destroying his guardian's
computer. During the office visit he says school is "boring and stupid." Which one of the
following would be the most appropriate next step in managing this patient?
A) Carbamazepine (Tegretol)
B) Haloperidol
C) Lithium
D) Quetiapine (Seroquel)
E) Referral for psychosocial intervention - ANS-ANSWER: E
This patient meets the criteria for conduct disorder, which is a psychiatric syndrome occurring in
childhood and adolescence. Aggression toward people or animals, deceitfulness, theft,
destruction of property, and serious violations of rules are characteristic symptoms. Risk factors
include poverty in childhood, male sex, exposure to sexual or physical abuse, and domestic
violence. The DSM-5 specifies that at least 3 of 15 criteria should have been present in the past
12 months for a formal diagnosis. The treatment is multifaceted. Psychosocial interventions are
recommended as the first-line treatment (C evidence rating). The FDA has not approved
medications for the treatment of conduct disorder unless they are indicated for concurrent
attention-deficit/hyperactivity disorder (ADHD). The FDA recommends considering risperidone
as a short-term treatment for explosive anger or severe aggression after comorbid ADHD is
treated. Carbamazepine, haloperidol, lithium, and quetiapine would not be appropriate
treatments for this patient's conduct disorder.
A 13-year-old female is brought to your office by her adoptive mother. They do not know the
patient's biological family history. They are concerned because, unlike all of her friends, she has
not yet started to menstruate. Breast development began 2 years ago. On examination her
breasts show a secondary mound from the areola and nipple above the contour of her breast.
She has dark, coarse hair covering the mons pubis consistent with a stage 4 sexual maturity
rating. If her sexual development continues to be normal, at what age should you recommend
evaluation for primary amenorrhea?
A) 13
B) 14
C) 15
D) 16
E) 17 - ANS-ANSWER: C
, Delayed puberty in girls is defined as the absence of breast development by age 13. Typically,
menarche starts 2.5 years after the onset of breast development, with an average age of 12.5
years (normal range 9-15 years). In girls with otherwise normal sexual development, the
absence of menarche by 15 years of age should prompt an evaluation for primary amenorrhea.
A 14-year-old female is brought to your office as a new patient for a routine well child
examination. She has had very little medical care since the pre-kindergarten evaluation. She
feels well and does not take any medications. Her past medical, surgical, family, and social
histories are unremarkable. A review of systems is notable for no history of menstruation. An
examination is notable for a height at the first percentile and a lack of any breast development.
Laboratory studies reveal an elevated FSH level. Which one of the following would be the most
appropriate next step?
A) Follow-up every 3-6 months for assessment of pubertal development
B) A corticotropin stimulation test
C) Karyotyping
D) Radiography of the hand for bone age
E) MRI of the brain and pituitary - ANS-ANSWER: C
Family physicians are often asked to evaluate delays in puberty. Underlying etiologies should be
excluded in females >13 years of age who lack any breast development, which may signify
delayed puberty. A past medical history and a physical examination, as well as a gonadotropin
measurement, should be performed.
The incidence of Turner syndrome (TS) is 1/3000 births. Females with TS lack normal X
chromosome gene expression and typically have delayed puberty; amenorrhea; elevated FSH,
reflecting hypogonadism; and short stature. Delayed diagnosis of TS is common, and short
stature and delayed puberty are sometimes the only symptoms. This patient has unexplained
short stature, delayed puberty, and an elevated FSH level, so karyotyping to rule out TS is the
next step in evaluation. Ongoing surveillance after 13 years is not indicated and may delay
therapy. A corticotropin stimulation test would usually be used to rule out Cushing syndrome in a
setting of precocious puberty and would not be used in this situation. Radiography of the hand
for bone age may support a finding of delayed growth (and thus support treatment with growth
hormone for a TS patient), but would not provide valuable diagnostic information in this
scenario. An elevated FSH level is consistent with a functioning hypothalamus and pituitary and
does not support obtaining MRI of the brain.
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 - ANS-ANSWER: B
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 ho - ANS-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.
43-year-old male presents to the emergency department with the acute onset of sharp, stabbing
chest pain when inhaling and exhaling. The pain worsens with coughing and deep breathing. He
has no significant previous medical history but recently returned from a work trip to Japan and
has noted right leg swelling for the past week. He has no other symptoms. He is a smoker and
has a family history of coronary artery disease in his paternal grandfather. On examination he
appears uncomfortable, and his lungs are clear. A cardiac examination is notable for
tachycardia. He has a blood pressure of 110/70 mm Hg, a heart rate of 112 beats/min, a
respiratory rate of 18/min, a temperature of 37.7°C (99.9°F), and an oxygen saturation of 89%
on room air. Which one of the following test results is most likely to confirm the diagnosis?
A) Elevated troponin levels
B) Acid-fast bacilli on a Gram stain
C) A filling defect on CT angiogra - ANS-ANSWER: C
,The differential diagnosis of pleuritic chest pain includes several serious causes that should be
considered in the evaluation of a patient with this type of pain. Pulmonary embolism is the most
common cause of pleuritic chest pain. This patient presents with the acute onset of pleuritic
chest pain associated with travel, a swollen leg, and smoking, which are common risk factors for
pulmonary embolism. A filling defect on CT angiography can confirm this diagnosis. Elevated
troponin levels would confirm a diagnosis of acute myocardial infarction, which would be more
likely if the patient were older, experienced pain with exertion, and had other red-flag symptoms
such as diaphoresis, nausea and vomiting, or radiating pain. Acid-fast bacilli on a Gram stain
would confirm a diagnosis of tuberculosis (TB), which is associated with travel to or exposure to
contacts from high-risk areas. TB would also present with other red-flag symptoms such as
hemoptysis, fever, night sweats, and weight loss. A chest radiograph showing air in the pleural
space would confirm a diagnosis of pneumothorax, which is usually present with decreased
breath sounds on physical examination. An EKG with diffuse ST-segment elevation would
confirm a diagnosis of pericarditis, which is usually associated with a recent or current viral
infection or prior history of pericarditis.
A 10-year-old female is brought to your office for a sports preparticipation examination. You note
thoracic rib asymmetry during the Adams forward bend test. Radiographs confirm rightward
thoracolumbar scoliosis with a Cobb angle of 32°. Which one of the following would be most
appropriate at this time?
A) Genetic testing (ScoliScore)
B) MRI of the thoracic and lumbar spine without contrast
C) Scoliosis radiography in 1 year
D) Referral to physical therapy
E) Referral to a pediatric orthopedist - ANS-ANSWER: E
This patient is a skeletally immature female with a Cobb angle that puts her at increased risk for
progression (>29°). Referral to a spine specialist for consideration of bracing and appropriate
follow-up is recommended. Genetic testing is available to help determine the risk of progression,
but it is not a widely validated tool at this time. MRI does not provide any additional information
to help with decision-making. Because of the patient's increased risk of progression, simple
follow-up in 1 year is not recommended. Physical therapy is not indicated for the primary
treatment of scoliosis.
A 12-year-old female is brought to your office because of a lesion on her left lateral upper eyelid.
The lesion started 3 days ago as a small, red "pimple," and since then it has increased in size
and is tender. She does not have any fever, tearing, or conjunctival irritation. No treatment has
been attempted. Which one of the following would be the most appropriate initial management?
A) Warm, damp compresses for 10 minutes four times daily
B) Topical erythromycin ophthalmic ointment (Ilotycin)
C) Topical hydrocortisone 0.5%
D) Systemic antibiotics with coverage for staphylococci
E) Incisional drainage using a sterile 18- or 20-gauge needle - ANS-ANSWER: A
This patient presents with an external hordeolum or stye. Warm, damp compresses for 10
minutes four times a day would be the best initial management. Topical erythromycin ointment
,and topical hydrocortisone cream are not indicated for treatment of a stye. Although
staphylococci are commonly involved in this process, antibiotics are not recommended unless
there is evidence of adjoining cellulitis. Warm compresses allow for spontaneous drainage and
resolution. Anti-inflammatory medications are not recommended for hordeolum externum
management, however they could become necessary if it becomes a chalazion. If the
hordeolum has not resolved in about 1 week, incision may be necessary.
A 12-year-old male is brought to your office by his guardian. In the last 12 months he was
suspended from school multiple times for bullying and fighting. He kicks the family dog and goes
out at night without permission. He ran away from home 2 weeks ago and he lies constantly. He
skips school and does not care about his grades. Attention-deficit/hyperactivity disorder was
previously ruled out. Two days ago he was grounded and retaliated by destroying his guardian's
computer. During the office visit he says school is "boring and stupid." Which one of the
following would be the most appropriate next step in managing this patient?
A) Carbamazepine (Tegretol)
B) Haloperidol
C) Lithium
D) Quetiapine (Seroquel)
E) Referral for psychosocial intervention - ANS-ANSWER: E
This patient meets the criteria for conduct disorder, which is a psychiatric syndrome occurring in
childhood and adolescence. Aggression toward people or animals, deceitfulness, theft,
destruction of property, and serious violations of rules are characteristic symptoms. Risk factors
include poverty in childhood, male sex, exposure to sexual or physical abuse, and domestic
violence. The DSM-5 specifies that at least 3 of 15 criteria should have been present in the past
12 months for a formal diagnosis. The treatment is multifaceted. Psychosocial interventions are
recommended as the first-line treatment (C evidence rating). The FDA has not approved
medications for the treatment of conduct disorder unless they are indicated for concurrent
attention-deficit/hyperactivity disorder (ADHD). The FDA recommends considering risperidone
as a short-term treatment for explosive anger or severe aggression after comorbid ADHD is
treated. Carbamazepine, haloperidol, lithium, and quetiapine would not be appropriate
treatments for this patient's conduct disorder.
A 13-year-old female is brought to your office by her adoptive mother. They do not know the
patient's biological family history. They are concerned because, unlike all of her friends, she has
not yet started to menstruate. Breast development began 2 years ago. On examination her
breasts show a secondary mound from the areola and nipple above the contour of her breast.
She has dark, coarse hair covering the mons pubis consistent with a stage 4 sexual maturity
rating. If her sexual development continues to be normal, at what age should you recommend
evaluation for primary amenorrhea?
A) 13
B) 14
C) 15
D) 16
E) 17 - ANS-ANSWER: C
, Delayed puberty in girls is defined as the absence of breast development by age 13. Typically,
menarche starts 2.5 years after the onset of breast development, with an average age of 12.5
years (normal range 9-15 years). In girls with otherwise normal sexual development, the
absence of menarche by 15 years of age should prompt an evaluation for primary amenorrhea.
A 14-year-old female is brought to your office as a new patient for a routine well child
examination. She has had very little medical care since the pre-kindergarten evaluation. She
feels well and does not take any medications. Her past medical, surgical, family, and social
histories are unremarkable. A review of systems is notable for no history of menstruation. An
examination is notable for a height at the first percentile and a lack of any breast development.
Laboratory studies reveal an elevated FSH level. Which one of the following would be the most
appropriate next step?
A) Follow-up every 3-6 months for assessment of pubertal development
B) A corticotropin stimulation test
C) Karyotyping
D) Radiography of the hand for bone age
E) MRI of the brain and pituitary - ANS-ANSWER: C
Family physicians are often asked to evaluate delays in puberty. Underlying etiologies should be
excluded in females >13 years of age who lack any breast development, which may signify
delayed puberty. A past medical history and a physical examination, as well as a gonadotropin
measurement, should be performed.
The incidence of Turner syndrome (TS) is 1/3000 births. Females with TS lack normal X
chromosome gene expression and typically have delayed puberty; amenorrhea; elevated FSH,
reflecting hypogonadism; and short stature. Delayed diagnosis of TS is common, and short
stature and delayed puberty are sometimes the only symptoms. This patient has unexplained
short stature, delayed puberty, and an elevated FSH level, so karyotyping to rule out TS is the
next step in evaluation. Ongoing surveillance after 13 years is not indicated and may delay
therapy. A corticotropin stimulation test would usually be used to rule out Cushing syndrome in a
setting of precocious puberty and would not be used in this situation. Radiography of the hand
for bone age may support a finding of delayed growth (and thus support treatment with growth
hormone for a TS patient), but would not provide valuable diagnostic information in this
scenario. An elevated FSH level is consistent with a functioning hypothalamus and pituitary and
does not support obtaining MRI of the brain.
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 - ANS-ANSWER: B
