Family Medicine COMAT
Case 1
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
CORRECT ANSWER: B (although treatment with methimazole, proylthiouracil,
radioactive iodine, and surgical removal of the thyroid gland are plausible treatments for
Grave's disease, methimazole is recommended as a first-line agent over propylthiouracil
due to potential hepatotoxicity).
,Case 2
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
CORRECT ANSWER: D (the most likely diagnosis is onychomycosis - microscopic
evaluation is the best first step to make the diagnosis).
Case 3
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. 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
CORRECT ANSWER: D (indwelling catheter can cause a UTI with Pseudomonas
aeruginosa - the indicated treatment is with a fluoroquinolone like ciprofloxacin or
levofloxacin).
Case 4
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
CORRECT ANSWER: E (threatened abortion is used to describe any vaginal bleeding
that occurs within the first 20 weeks of pregnancy).
Case 5
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
CORRECT ANSWER: D (the most documented causes of miscarriages are maternal age,
history of previous miscarriage, and maternal smoking).
Case 6
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
Case 1
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
CORRECT ANSWER: B (although treatment with methimazole, proylthiouracil,
radioactive iodine, and surgical removal of the thyroid gland are plausible treatments for
Grave's disease, methimazole is recommended as a first-line agent over propylthiouracil
due to potential hepatotoxicity).
,Case 2
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
CORRECT ANSWER: D (the most likely diagnosis is onychomycosis - microscopic
evaluation is the best first step to make the diagnosis).
Case 3
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. 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
CORRECT ANSWER: D (indwelling catheter can cause a UTI with Pseudomonas
aeruginosa - the indicated treatment is with a fluoroquinolone like ciprofloxacin or
levofloxacin).
Case 4
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
CORRECT ANSWER: E (threatened abortion is used to describe any vaginal bleeding
that occurs within the first 20 weeks of pregnancy).
Case 5
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
CORRECT ANSWER: D (the most documented causes of miscarriages are maternal age,
history of previous miscarriage, and maternal smoking).
Case 6
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
