AAFP Missed Questions – Comprehensive Family Medicine Board
Review with Correct Answers and Explanations
Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)?
(check one)
A. Age >80 years
B. A cardiac pacemaker
C. An implantable cardioverter-defibrillator
D. Pregnancy
E. There are no absolute contraindications to ECT - correct answer There are no absolute
contraindications to electroconvulsive therapy (ECT), but factors that have been associated with
reduced efficacy include a prolonged episode, lack of response to medication, and coexisting
psychiatric diagnoses such as a personality disorder. Persons who may be at increased risk for
complications include those with unstable cardiac disease such as ischemia or arrhythmias,
cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial
pressure. ECT can be used safely in elderly patients and in persons with cardiac pacemakers or
implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with
proper precautions and in consultation with an obstetrician.
A 15-month-old male is brought to your office 3 hours after the onset of an increased
respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His
immunizations are up to date and he attends day care regularly. His temperature is 38.2°C
(100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min.
The child is sitting quietly on his mother's lap. His oxygen saturation is 94% on room air. On
examination you note inspiratory crackles in the left lower lung field. The child appears to be
well hydrated and the remainder of the examination, including an HEENT examination, is
normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted.
Which one of the following would be most appropriate in the management of this patient?
(check one)
A. Laboratory evaluation
B. Inpatient monitoring, with no antibiotics at this time
C. Hospitalization and intravenous ceftriaxone (Rocephin - correct answer The diagnosis of
community-acquired pneumonia is mostly based on the history and physical examination.
,Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory
finding in the history or physical examination. Children under 2 years of age who are in day care
are at higher risk for developing community-acquired pneumonia. Laboratory tests are rarely
helpful in differentiating viral versus bacterial etiologies and should not be routinely performed.
Outpatient antibiotics are appropriate if the child does not have a toxic appearance,
hypoxemia, signs of respiratory distress, or dehydration. Streptococcus pneumoniae is one of
the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice.
A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture.
Although he can walk without pain, he cannot run without pain.
The most appropriate treatment at this point includes which one of the following? (check one)
A. A short leg walking cast
B. A non-weight-bearing short leg cast
C. A non-weight-bearing long leg cast
D. An air stirrup leg brace (Aircast)
E. Low-intensity ultrasonic pulse therapy - correct answer Midshaft posteromedial tibial stress
fractures are common and are considered low risk. Management consists of relative rest from
running and avoiding other activities that cause pain. Once usual daily activities are pain free,
low-impact exercise can be initiated and followed by a gradual return to previous levels of
running. A pneumatic stirrup leg brace has been found to be helpful during treatment (SOR C).
Non-weight bearing is not necessary, as this patient can walk without pain. Casting is not
recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has
not been shown to be beneficial in stress fractures.
A 59-year-old male reports decreases in sexual desire and spontaneous erections, as well as
reduced beard growth. The most appropriate test to screen for late-onset male hypogonadism
is: - correct answer A serum total testosterone level is recommended as the initial screening
test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is
recommended only if the total testosterone level is borderline and abnormalities in sex
hormone-binding globulin are suspected. Follow-up LH and FSH levels help to distinguish
primary from secondary hypogonadism.
A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine
(Synthroid), 125 μg/day. Her TSH level is 0.2μU/mL (N 0.5-5.0). She has no symptoms of either
hypothyroidism or hyperthyroidism.
,Which one of the following would be most appropriate at this point? (check one)
A. Continuing levothyroxine at the same dosage
B. Increasing the levothyroxine dosage
C. Decreasing the levothyroxine dosage
D. Discontinuing levothyroxine
E. Ordering a free T 4 - correct answer Because of the precise relationship between circulating
thyroid hormone and pituitary TSH secretion, measurement of serum TSH is essential in the
management of patients receiving levothyroxine therapy. Immunoassays can reliably
distinguish between normal and suppressed concentrations of TSH. In a patient receiving
levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage
should be reduced slightly and the TSH level repeated in 2-3 months' time. There is no need to
discontinue therapy in this situation, and repeating the TSH level in 2 weeks would not be
helpful. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for
detecting mild states of excess thyroid hormone.
You see a 22-year-old female who sustained a right knee injury in a recent college soccer
game.She is a defender and executed a sudden cutting maneuver. With her right foot planted
and her ankle locked, she attempted to shift the position of her body to stop an oncoming ball
and felt her knee pop. She has had a moderate amount of pain and swelling, which began
within 2 hours of the injury, but she is most concerned about the loss of knee hyperextension.
Which one of the following tests is most likely to be abnormal in this patient? (check one)
A. Anterior drawer
B. Lachman
C. McMurray
D. Pivot shift - correct answer Anterior cruciate ligament (ACL) tears occur more commonly in
women than in men. The intensity of play is also a factor, with a much greater risk of ACL
injuries occurring during games than during practices. The most accurate maneuver for
detecting an ACL tear is the Lachman test (sensitivity 60%-100%, mean 84%), followed by the
anterior drawer test (sensitivity 9%-93%, mean 62%) and the pivot shift test (sensitivity 27%-
95%, mean 62%) (SOR C). McMurray's test is used to detect meniscal tears.
When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis
can be decreased by: (check one)
A. using a valved holding chamber
, B. limiting use of the inhaled corticosteroid to once daily
C. adding nasal fluticasone propionate (Flonase)
D. adding montelukast (Singulair)
E. adding salmeterol (Serevent) - correct answer Pharyngeal and laryngeal side effects of
inhaled corticosteroids include sore throat, coughing on inhalation of the medication, a weak or
hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the
medication and using a valved holding chamber when it is delivered with a metered-dose
inhaler can minimize the risk of oral candidiasis.
A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She
works as a high-school teacher. The most appropriate management at this time would be:
(check one)
A. voice therapy
B. azithromycin (Zithromax)
C. a trial of inhaled corticosteroids
D. a trial of a proton pump inhibitor
E. laryngoscopy - correct answer Hoarseness most commonly affects teachers and older adults.
The cause is usually benign, but extended symptoms or certain risk factors should prompt
evaluation; specifically, laryngoscopy is recommended when hoarseness does not resolve
within 3 months or when a serious underlying cause is suspected (SOR C). The American
Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that antireflux
medications should not be prescribed for patients with hoarseness without reflux symptoms
(SOR C). Antibiotics should not be used, as the condition is usually caused by acute laryngitis or
an upper respiratory infection, and these are most likely to be viral. Inhaled corticosteroids are
a common cause of hoarseness. Voice therapy should be reserved for patients who have
undergone laryngoscopy first (SOR A).
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She
complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to
date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm
Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema
of her legs. The most appropriate management at this point would be: (check one)
A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
Review with Correct Answers and Explanations
Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)?
(check one)
A. Age >80 years
B. A cardiac pacemaker
C. An implantable cardioverter-defibrillator
D. Pregnancy
E. There are no absolute contraindications to ECT - correct answer There are no absolute
contraindications to electroconvulsive therapy (ECT), but factors that have been associated with
reduced efficacy include a prolonged episode, lack of response to medication, and coexisting
psychiatric diagnoses such as a personality disorder. Persons who may be at increased risk for
complications include those with unstable cardiac disease such as ischemia or arrhythmias,
cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial
pressure. ECT can be used safely in elderly patients and in persons with cardiac pacemakers or
implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with
proper precautions and in consultation with an obstetrician.
A 15-month-old male is brought to your office 3 hours after the onset of an increased
respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His
immunizations are up to date and he attends day care regularly. His temperature is 38.2°C
(100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min.
The child is sitting quietly on his mother's lap. His oxygen saturation is 94% on room air. On
examination you note inspiratory crackles in the left lower lung field. The child appears to be
well hydrated and the remainder of the examination, including an HEENT examination, is
normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted.
Which one of the following would be most appropriate in the management of this patient?
(check one)
A. Laboratory evaluation
B. Inpatient monitoring, with no antibiotics at this time
C. Hospitalization and intravenous ceftriaxone (Rocephin - correct answer The diagnosis of
community-acquired pneumonia is mostly based on the history and physical examination.
,Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory
finding in the history or physical examination. Children under 2 years of age who are in day care
are at higher risk for developing community-acquired pneumonia. Laboratory tests are rarely
helpful in differentiating viral versus bacterial etiologies and should not be routinely performed.
Outpatient antibiotics are appropriate if the child does not have a toxic appearance,
hypoxemia, signs of respiratory distress, or dehydration. Streptococcus pneumoniae is one of
the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice.
A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture.
Although he can walk without pain, he cannot run without pain.
The most appropriate treatment at this point includes which one of the following? (check one)
A. A short leg walking cast
B. A non-weight-bearing short leg cast
C. A non-weight-bearing long leg cast
D. An air stirrup leg brace (Aircast)
E. Low-intensity ultrasonic pulse therapy - correct answer Midshaft posteromedial tibial stress
fractures are common and are considered low risk. Management consists of relative rest from
running and avoiding other activities that cause pain. Once usual daily activities are pain free,
low-impact exercise can be initiated and followed by a gradual return to previous levels of
running. A pneumatic stirrup leg brace has been found to be helpful during treatment (SOR C).
Non-weight bearing is not necessary, as this patient can walk without pain. Casting is not
recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has
not been shown to be beneficial in stress fractures.
A 59-year-old male reports decreases in sexual desire and spontaneous erections, as well as
reduced beard growth. The most appropriate test to screen for late-onset male hypogonadism
is: - correct answer A serum total testosterone level is recommended as the initial screening
test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is
recommended only if the total testosterone level is borderline and abnormalities in sex
hormone-binding globulin are suspected. Follow-up LH and FSH levels help to distinguish
primary from secondary hypogonadism.
A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine
(Synthroid), 125 μg/day. Her TSH level is 0.2μU/mL (N 0.5-5.0). She has no symptoms of either
hypothyroidism or hyperthyroidism.
,Which one of the following would be most appropriate at this point? (check one)
A. Continuing levothyroxine at the same dosage
B. Increasing the levothyroxine dosage
C. Decreasing the levothyroxine dosage
D. Discontinuing levothyroxine
E. Ordering a free T 4 - correct answer Because of the precise relationship between circulating
thyroid hormone and pituitary TSH secretion, measurement of serum TSH is essential in the
management of patients receiving levothyroxine therapy. Immunoassays can reliably
distinguish between normal and suppressed concentrations of TSH. In a patient receiving
levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage
should be reduced slightly and the TSH level repeated in 2-3 months' time. There is no need to
discontinue therapy in this situation, and repeating the TSH level in 2 weeks would not be
helpful. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for
detecting mild states of excess thyroid hormone.
You see a 22-year-old female who sustained a right knee injury in a recent college soccer
game.She is a defender and executed a sudden cutting maneuver. With her right foot planted
and her ankle locked, she attempted to shift the position of her body to stop an oncoming ball
and felt her knee pop. She has had a moderate amount of pain and swelling, which began
within 2 hours of the injury, but she is most concerned about the loss of knee hyperextension.
Which one of the following tests is most likely to be abnormal in this patient? (check one)
A. Anterior drawer
B. Lachman
C. McMurray
D. Pivot shift - correct answer Anterior cruciate ligament (ACL) tears occur more commonly in
women than in men. The intensity of play is also a factor, with a much greater risk of ACL
injuries occurring during games than during practices. The most accurate maneuver for
detecting an ACL tear is the Lachman test (sensitivity 60%-100%, mean 84%), followed by the
anterior drawer test (sensitivity 9%-93%, mean 62%) and the pivot shift test (sensitivity 27%-
95%, mean 62%) (SOR C). McMurray's test is used to detect meniscal tears.
When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis
can be decreased by: (check one)
A. using a valved holding chamber
, B. limiting use of the inhaled corticosteroid to once daily
C. adding nasal fluticasone propionate (Flonase)
D. adding montelukast (Singulair)
E. adding salmeterol (Serevent) - correct answer Pharyngeal and laryngeal side effects of
inhaled corticosteroids include sore throat, coughing on inhalation of the medication, a weak or
hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the
medication and using a valved holding chamber when it is delivered with a metered-dose
inhaler can minimize the risk of oral candidiasis.
A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She
works as a high-school teacher. The most appropriate management at this time would be:
(check one)
A. voice therapy
B. azithromycin (Zithromax)
C. a trial of inhaled corticosteroids
D. a trial of a proton pump inhibitor
E. laryngoscopy - correct answer Hoarseness most commonly affects teachers and older adults.
The cause is usually benign, but extended symptoms or certain risk factors should prompt
evaluation; specifically, laryngoscopy is recommended when hoarseness does not resolve
within 3 months or when a serious underlying cause is suspected (SOR C). The American
Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that antireflux
medications should not be prescribed for patients with hoarseness without reflux symptoms
(SOR C). Antibiotics should not be used, as the condition is usually caused by acute laryngitis or
an upper respiratory infection, and these are most likely to be viral. Inhaled corticosteroids are
a common cause of hoarseness. Voice therapy should be reserved for patients who have
undergone laryngoscopy first (SOR A).
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She
complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to
date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm
Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema
of her legs. The most appropriate management at this point would be: (check one)
A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
