Family Medicine EOR Exam: Personal Review
(Rosh)
26-year old man who is sexually active presents with a 3-day history of unilateral, painful
testicular swelling. He reports subjective fevers and dysuria but denies nausea and vomiting.
Urinalysis shows leukocyte esterase with greater than 10 white blood cells.
What is the next step in management for this patient? - ANS-Doxycycline and ceftriaxone
therapy
Explanation:
Epididymitis is the most common cause of scrotal pain in adults and is characterized by acute
unilateral pain and swelling. The pain usually begins at the epididymis and can spread to the
entire testicle (epididymo-orchitis). Other symptoms include fever, erythema of the scrotal skin,
and dysuria. It is associated with a C-reactive protein level greater than 24 mg per L and
increased blood flow on ultrasonography. Chlamydia trachomatis and Neisseria gonorrhoeae
are the most common organisms responsible for bacterial epididymitis in males younger than 35
years. Guidelines recommend ceftriaxone (500 mg IM x 1) and doxycycline (100 mg PO BID x
10-14 days) for treatment of suspected epididymitis in males younger than 35 years.
34-year-old woman presents to the emergency department five days after total thyroidectomy
with tingling in her hands. On physical examination, she has twitching at the corner of her mouth
upon tapping the side of her face.
Which of the following laboratory abnormalities is most likely? - ANS-Hypocalcemia
Explanation:
This patient is exhibiting signs and symptoms of hypocalcemia, most commonly caused by
hypoparathyroidism. Signs and symptoms are exclusively related to hypocalcemia, and include
reduced myocardial contractility, perioral and distal extremity paresthesias, and tetany. There
are two hallmark physical exam findings with significant hypocalcemia: Chvostek sign and
Trousseau sign. Chvostek sign consists of facial twitching caused by tapping the facial nerve
anterior to the ear. Trousseau sign consists of carpal spasm when a blood pressure cuff is
inflated on the upper arm above the systolic pressure for greater than three minutes. Partial or
total thyroidectomy is the most common etiology of hypoparathyroidism as the parathyroid is
located immediately behind and is often partially or totally attached to the thyroid gland. Other
causes of hypoparathyroidism include a congenital deficiency or infiltrate of the parathyroid
glands from metastatic carcinoma, hemochromatosis, or Wilson disease. Diagnosis of
hypocalcemia is often made on physical exam; however, laboratory testing should be obtained
including both a total and ionized calcium level, serum 25-(OH) and 1,25-(OH) vitamin D, and
parathyroid hormone levels. An ECG should also be performed to evaluate for prolongation of
,the QT interval. Management includes calcium and vitamin D supplementation. In severe,
symptomatic hypocalcemia, calcium gluconate or calcium chloride should be administered
intravenously, depending on the severity of symptoms. Calcium chloride has three times more
calcium per equal volume, but has the risk of tissue ischemia and necrosis if infused
peripherally. Thus, calcium gluconate is preferred.
A 12-year-old boy presents with his parent with concerns about daily underwear soiling with
loose stools as well as small, hard stools about once a week. The patient has a history of autism
spectrum disorder, chronic constipation, and eating difficulties. He is able to take food and liquid
by mouth but is supplemented through a gastrostomy tube to support his nutrition. His vital
signs include a heart rate of 80 bpm, blood pressure of 112/77 mm Hg, respirations of
17/minute, and oxygen saturation of 99% on room air. On exam, the patient is able to respond
to questions and follow commands. Abdominal exam reveals a gastrostomy tube in place that is
clean, dry, and intact, and his abdomen is nondistended and soft. The patient does not show
signs of pain on abdominal palpation. Rectal exam shows good sphincter tone, with hard stool
palpable in the rectum and a small external hemorrhoid. An X-ray obtained today is shown a -
ANS-Overflow of loose stool
Explanation:
Fecal incontinence is the process of involuntarily passing stool in the underwear in children 4
years and older without underlying neuromuscular anorectal dysfunction. It can be classified as
retentive or nonretentive. Retentive, also known as functional fecal incontinence or encopresis,
is the most common, occurring in about 80% of children with fecal incontinence. It is associated
with functional constipation. Risk factors and contributing factors for developing functional
constipation or fecal incontinence include dietary changes, starting school, and toilet training
issues. The condition is often seen in patients with attention-deficit/hyperactivity disorder, autism
spectrum disorder, and anxiety or depression. The patient presents with parents reporting
repeated underwear soiling. The parent may state the patient has diarrhea, and the patient may
act as if there is no problem due to embarrassment. Obtaining a thorough stooling history is
essential to ascertain what is normal for the patient, the events around potty training, how long
symptoms have been present, and any indications for an organic cause. A rectal exam is
important to determine if hard stool is present as chronic fecal soiling is due to an overflow of
loose stool, which makes its way around impacted stool in the rectum. Thus, the incontinence is
involuntary, and therapy should focus on addressing the long-standing constipation. This
includes initial disimpaction followed by dietary changes, stool softeners, laxatives, and bulkers.
In addition, a stooling regimen is essential, which includes regular times for sitting on the toilet,
assuring easy access to the toilet, and rewards for bowel movements. In nonretentive fecal
incontinence, there is no known cause, but it may be more situational. There is no underlying
A 13-month-old girl presents with her mother who says that her daughter has been sick for 10
days. The girl had an initial period of head-cold symptoms and is now coughing constantly. She
is a well-nourished infant who demonstrates a rapid, consecutive cough with a high-pitched
inspiratory whoop. Records show that the family declined vaccinations.
,Which of the following interventions is most indicated in managing this patients illness? -
ANS-Oral clarithromycin
Explanation:
Oral macrolide antibiotics, using either erythromycin, azithromycin, or clarithromycin, are the
first-line treatment for the respiratory infection pertussis. Pertussis is an acute respiratory illness
that primarily causes illness in children under 2 years of age. Though immunization exists
against the causative pathogen, Bordetella pertussis, neither immunization nor history of
infection ensures lasting immunity, and adults often serve as infectious reservoirs for the
disease. Pertussis generally begins with a one to two-week period of malaise, sneezing, and
anorexia. It is followed by a persistent cough, with the classic, high-pitched inspiratory whoop.
Posttussive emesis also suggests pertussis. Non-specific laboratory findings can include a white
blood cell count of 15,000-20,000 with up to 80% lymphocytes. However, pertussis is definitively
diagnosed by isolating the organism from a nasopharyngeal culture. A 4-7 day course of
treatment with a macrolide antibiotic should be used to reduce coughing severity (if given early
enough) and shorten the duration of carriage. Close contacts should receive the same treatment
as prophylaxis against illness.
A 15-year-old girl presents with generalized abdominopelvic pain that occurs every month after
her regular, nonpainful menses. The pain, which is associated with headaches, bloating, and
depressed mood, begins 18 days after the last day of menstruation. She also reports cyclic
ankle swelling but does not report a history of increased salt intake.
Which of the following is the most likely diagnosis? - ANS-Premenstrual disorder
Explanation:
This patient displays some of the common symptoms of premenstrual syndrome (PMS), a
poorly understood condition of physical, mood, and behavioral changes that occur during the
second half of the typical 28-day menstrual cycle. On average, menstrual flow lasts 4-5 days,
beginning on day 1 of the menstrual cycle (the beginning of the follicular phase), and ending on
day 4 or 5. Around day 14, ovulation occurs, and the second half of the cycle, the luteal phase,
begins. If the oocyte is not fertilized, the luteal phase, on average, ends around day 28.
Subsequently, a new cycle commences with the onset of another menses. The symptoms of
premenstrual syndrome occur in this second half period (days 14-28), most commonly occurring
on day 23-27, which is typically 18-19 days after the last day of the preceding menstruation.
A 16-year-old boy is taken to his doctor for snoring. His mother reports that his snoring keeps
others in the house awake and that sometimes his breathing pauses during sleep with gasping
or choking. His teachers report that he falls asleep frequently at school. On exam, he has a
body mass index of 31 kg/m² and has enlarged tonsils. His symptoms are concerning for
obstructive sleep apnea so the pediatrician refers him for an overnight polysomnography.
Which of the following can be a longterm complication of obstructive sleep apnea? -
ANS-Pulmonary hypertension
, Explanation:
Children with obstructive sleep apnea (OSA) often are obese, have enlarged tonsils or have
significant allergies. OSA can lead to abnormal growth and development, bedwetting, behavioral
and learning problems, daytime sleepiness, and hyperactivity. Long-standing repetitive oxygen
desaturations and hypercapnia episodes during sleep can lead to vascular remodeling and
pulmonary hypertension which can lead to cor pulmonale (right ventricular hypertrophy).
Treatment may include weight loss, managing allergic rhinitis, and removal of the adenoids and
tonsils. Nonsurgical approaches to treatment include weight loss, CPAP, and bite guards that
bring the lower jaw forward. Surgical treatments include uvulopalatopharyngoplasty, jaw surgery,
or removal of the tonsils and adenoids.
A 17-year-old boy presents to his pediatrician complaining of persistent drainage from his ear.
He has a history of chronic ear infections and, one month prior, was started on amoxicillin
secondary to symptoms of hearing loss and drainage along with physical exam findings of an
inflamed, bulging tympanic membrane. When his symptoms failed to resolve, his medication
was changed to amoxicillin-clavulanate; however, the patient is still experiencing symptoms.
Given his history and the persistence of symptoms despite antibiotic therapy, what diagnosis
should be considered? - ANS-Cholesteatoma
Explanation:
The development of an acquired cholesteatoma should be considered in a patient with a history
of frequent ear infections and persistent ear drainage despite appropriate antibiotic therapy. A
cholesteatoma is a cystic structure typically located within the middle ear or mastoid process. It
is the result of keratinizing squamous epithelial cells and may cause symptoms of otorrhea,
hearing loss, and dizziness. It also has the potential to continue to grow and invade surrounding
structures. A cholesteatoma may be congenital or acquired. Acquired cholesteatomas are most
common among those who have chronic otitis media; however, it is also seen in those with
tympanic perforation or unintentional surgical placement of skin into the middle ear.
A 17-year-old girl is seen in clinic due to vaginal discharge. She complains of yellow-green
discharge and pruritus around her vaginal area. She is sexually active since last year and has
had three partners. She denies taking any medication and uses condoms occasionally. Her last
menstrual period was last week. On physical exam, you note frothy discharge with vaginal
erythema and cervical hemorrhages.
Which of the following is the next best step? - ANS-Obtain a wet mount
Explanation:
The patient has signs and symptoms of acute cervicitis with findings most likely due to
trichomoniasis. It presents with malodorous vaginal discharge, vulvovaginal irritation, dysuria,
and dyspareunia. Physical exam may reveal a frothy discharge with vaginal erythema, and
cervical hemorrhages (strawberry cervix) with the latter being a classic finding. The discharge
(Rosh)
26-year old man who is sexually active presents with a 3-day history of unilateral, painful
testicular swelling. He reports subjective fevers and dysuria but denies nausea and vomiting.
Urinalysis shows leukocyte esterase with greater than 10 white blood cells.
What is the next step in management for this patient? - ANS-Doxycycline and ceftriaxone
therapy
Explanation:
Epididymitis is the most common cause of scrotal pain in adults and is characterized by acute
unilateral pain and swelling. The pain usually begins at the epididymis and can spread to the
entire testicle (epididymo-orchitis). Other symptoms include fever, erythema of the scrotal skin,
and dysuria. It is associated with a C-reactive protein level greater than 24 mg per L and
increased blood flow on ultrasonography. Chlamydia trachomatis and Neisseria gonorrhoeae
are the most common organisms responsible for bacterial epididymitis in males younger than 35
years. Guidelines recommend ceftriaxone (500 mg IM x 1) and doxycycline (100 mg PO BID x
10-14 days) for treatment of suspected epididymitis in males younger than 35 years.
34-year-old woman presents to the emergency department five days after total thyroidectomy
with tingling in her hands. On physical examination, she has twitching at the corner of her mouth
upon tapping the side of her face.
Which of the following laboratory abnormalities is most likely? - ANS-Hypocalcemia
Explanation:
This patient is exhibiting signs and symptoms of hypocalcemia, most commonly caused by
hypoparathyroidism. Signs and symptoms are exclusively related to hypocalcemia, and include
reduced myocardial contractility, perioral and distal extremity paresthesias, and tetany. There
are two hallmark physical exam findings with significant hypocalcemia: Chvostek sign and
Trousseau sign. Chvostek sign consists of facial twitching caused by tapping the facial nerve
anterior to the ear. Trousseau sign consists of carpal spasm when a blood pressure cuff is
inflated on the upper arm above the systolic pressure for greater than three minutes. Partial or
total thyroidectomy is the most common etiology of hypoparathyroidism as the parathyroid is
located immediately behind and is often partially or totally attached to the thyroid gland. Other
causes of hypoparathyroidism include a congenital deficiency or infiltrate of the parathyroid
glands from metastatic carcinoma, hemochromatosis, or Wilson disease. Diagnosis of
hypocalcemia is often made on physical exam; however, laboratory testing should be obtained
including both a total and ionized calcium level, serum 25-(OH) and 1,25-(OH) vitamin D, and
parathyroid hormone levels. An ECG should also be performed to evaluate for prolongation of
,the QT interval. Management includes calcium and vitamin D supplementation. In severe,
symptomatic hypocalcemia, calcium gluconate or calcium chloride should be administered
intravenously, depending on the severity of symptoms. Calcium chloride has three times more
calcium per equal volume, but has the risk of tissue ischemia and necrosis if infused
peripherally. Thus, calcium gluconate is preferred.
A 12-year-old boy presents with his parent with concerns about daily underwear soiling with
loose stools as well as small, hard stools about once a week. The patient has a history of autism
spectrum disorder, chronic constipation, and eating difficulties. He is able to take food and liquid
by mouth but is supplemented through a gastrostomy tube to support his nutrition. His vital
signs include a heart rate of 80 bpm, blood pressure of 112/77 mm Hg, respirations of
17/minute, and oxygen saturation of 99% on room air. On exam, the patient is able to respond
to questions and follow commands. Abdominal exam reveals a gastrostomy tube in place that is
clean, dry, and intact, and his abdomen is nondistended and soft. The patient does not show
signs of pain on abdominal palpation. Rectal exam shows good sphincter tone, with hard stool
palpable in the rectum and a small external hemorrhoid. An X-ray obtained today is shown a -
ANS-Overflow of loose stool
Explanation:
Fecal incontinence is the process of involuntarily passing stool in the underwear in children 4
years and older without underlying neuromuscular anorectal dysfunction. It can be classified as
retentive or nonretentive. Retentive, also known as functional fecal incontinence or encopresis,
is the most common, occurring in about 80% of children with fecal incontinence. It is associated
with functional constipation. Risk factors and contributing factors for developing functional
constipation or fecal incontinence include dietary changes, starting school, and toilet training
issues. The condition is often seen in patients with attention-deficit/hyperactivity disorder, autism
spectrum disorder, and anxiety or depression. The patient presents with parents reporting
repeated underwear soiling. The parent may state the patient has diarrhea, and the patient may
act as if there is no problem due to embarrassment. Obtaining a thorough stooling history is
essential to ascertain what is normal for the patient, the events around potty training, how long
symptoms have been present, and any indications for an organic cause. A rectal exam is
important to determine if hard stool is present as chronic fecal soiling is due to an overflow of
loose stool, which makes its way around impacted stool in the rectum. Thus, the incontinence is
involuntary, and therapy should focus on addressing the long-standing constipation. This
includes initial disimpaction followed by dietary changes, stool softeners, laxatives, and bulkers.
In addition, a stooling regimen is essential, which includes regular times for sitting on the toilet,
assuring easy access to the toilet, and rewards for bowel movements. In nonretentive fecal
incontinence, there is no known cause, but it may be more situational. There is no underlying
A 13-month-old girl presents with her mother who says that her daughter has been sick for 10
days. The girl had an initial period of head-cold symptoms and is now coughing constantly. She
is a well-nourished infant who demonstrates a rapid, consecutive cough with a high-pitched
inspiratory whoop. Records show that the family declined vaccinations.
,Which of the following interventions is most indicated in managing this patients illness? -
ANS-Oral clarithromycin
Explanation:
Oral macrolide antibiotics, using either erythromycin, azithromycin, or clarithromycin, are the
first-line treatment for the respiratory infection pertussis. Pertussis is an acute respiratory illness
that primarily causes illness in children under 2 years of age. Though immunization exists
against the causative pathogen, Bordetella pertussis, neither immunization nor history of
infection ensures lasting immunity, and adults often serve as infectious reservoirs for the
disease. Pertussis generally begins with a one to two-week period of malaise, sneezing, and
anorexia. It is followed by a persistent cough, with the classic, high-pitched inspiratory whoop.
Posttussive emesis also suggests pertussis. Non-specific laboratory findings can include a white
blood cell count of 15,000-20,000 with up to 80% lymphocytes. However, pertussis is definitively
diagnosed by isolating the organism from a nasopharyngeal culture. A 4-7 day course of
treatment with a macrolide antibiotic should be used to reduce coughing severity (if given early
enough) and shorten the duration of carriage. Close contacts should receive the same treatment
as prophylaxis against illness.
A 15-year-old girl presents with generalized abdominopelvic pain that occurs every month after
her regular, nonpainful menses. The pain, which is associated with headaches, bloating, and
depressed mood, begins 18 days after the last day of menstruation. She also reports cyclic
ankle swelling but does not report a history of increased salt intake.
Which of the following is the most likely diagnosis? - ANS-Premenstrual disorder
Explanation:
This patient displays some of the common symptoms of premenstrual syndrome (PMS), a
poorly understood condition of physical, mood, and behavioral changes that occur during the
second half of the typical 28-day menstrual cycle. On average, menstrual flow lasts 4-5 days,
beginning on day 1 of the menstrual cycle (the beginning of the follicular phase), and ending on
day 4 or 5. Around day 14, ovulation occurs, and the second half of the cycle, the luteal phase,
begins. If the oocyte is not fertilized, the luteal phase, on average, ends around day 28.
Subsequently, a new cycle commences with the onset of another menses. The symptoms of
premenstrual syndrome occur in this second half period (days 14-28), most commonly occurring
on day 23-27, which is typically 18-19 days after the last day of the preceding menstruation.
A 16-year-old boy is taken to his doctor for snoring. His mother reports that his snoring keeps
others in the house awake and that sometimes his breathing pauses during sleep with gasping
or choking. His teachers report that he falls asleep frequently at school. On exam, he has a
body mass index of 31 kg/m² and has enlarged tonsils. His symptoms are concerning for
obstructive sleep apnea so the pediatrician refers him for an overnight polysomnography.
Which of the following can be a longterm complication of obstructive sleep apnea? -
ANS-Pulmonary hypertension
, Explanation:
Children with obstructive sleep apnea (OSA) often are obese, have enlarged tonsils or have
significant allergies. OSA can lead to abnormal growth and development, bedwetting, behavioral
and learning problems, daytime sleepiness, and hyperactivity. Long-standing repetitive oxygen
desaturations and hypercapnia episodes during sleep can lead to vascular remodeling and
pulmonary hypertension which can lead to cor pulmonale (right ventricular hypertrophy).
Treatment may include weight loss, managing allergic rhinitis, and removal of the adenoids and
tonsils. Nonsurgical approaches to treatment include weight loss, CPAP, and bite guards that
bring the lower jaw forward. Surgical treatments include uvulopalatopharyngoplasty, jaw surgery,
or removal of the tonsils and adenoids.
A 17-year-old boy presents to his pediatrician complaining of persistent drainage from his ear.
He has a history of chronic ear infections and, one month prior, was started on amoxicillin
secondary to symptoms of hearing loss and drainage along with physical exam findings of an
inflamed, bulging tympanic membrane. When his symptoms failed to resolve, his medication
was changed to amoxicillin-clavulanate; however, the patient is still experiencing symptoms.
Given his history and the persistence of symptoms despite antibiotic therapy, what diagnosis
should be considered? - ANS-Cholesteatoma
Explanation:
The development of an acquired cholesteatoma should be considered in a patient with a history
of frequent ear infections and persistent ear drainage despite appropriate antibiotic therapy. A
cholesteatoma is a cystic structure typically located within the middle ear or mastoid process. It
is the result of keratinizing squamous epithelial cells and may cause symptoms of otorrhea,
hearing loss, and dizziness. It also has the potential to continue to grow and invade surrounding
structures. A cholesteatoma may be congenital or acquired. Acquired cholesteatomas are most
common among those who have chronic otitis media; however, it is also seen in those with
tympanic perforation or unintentional surgical placement of skin into the middle ear.
A 17-year-old girl is seen in clinic due to vaginal discharge. She complains of yellow-green
discharge and pruritus around her vaginal area. She is sexually active since last year and has
had three partners. She denies taking any medication and uses condoms occasionally. Her last
menstrual period was last week. On physical exam, you note frothy discharge with vaginal
erythema and cervical hemorrhages.
Which of the following is the next best step? - ANS-Obtain a wet mount
Explanation:
The patient has signs and symptoms of acute cervicitis with findings most likely due to
trichomoniasis. It presents with malodorous vaginal discharge, vulvovaginal irritation, dysuria,
and dyspareunia. Physical exam may reveal a frothy discharge with vaginal erythema, and
cervical hemorrhages (strawberry cervix) with the latter being a classic finding. The discharge
