Family Medicine Board Exam
e - ulnar nerve
Initial general neurovascular assessment of an upper extremity injury includes evaluating for
radial pulse
and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism
is indicative
of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential
brachial plexus
injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index
finger,
and long finger. Weakness of supination of the forearm would indicate a potential
musculocutaneous nerve
✅✅
injury. Weakness of active wrist extension would indicate a potential radial nerve injury. -
-A 30-year-old male comes to your office for evaluation of hand weakness. On
examination you
detect weakness when he tries to bring his thumb and index finger together. For confirmation
you ask him to try to hold on to a piece of paper between his thumb and index finger while you
try to pull it away. He is unable to resist when you pull on the paper.
The most likely explanation for these findings is an injury to the
✅✅
Weakness of the thumb and index finger pincer mechanism is indicative
of an *ulnar* nerve injury. - -Weakness of the thumb and index finger pincer mechanism is
indicative
of an _________ nerve injury.
Symptoms related to the *median* nerve generally include paresthesia of the thumb, index
✅✅
finger,
and long finger. - -Symptoms related to the __________ nerve generally include
paresthesia of the thumb, index finger, and long finger.
✅✅
Weakness of supination of the forearm would indicate a potential * musculocutaneous* nerve
injury. - -Weakness of supination of the forearm would indicate a potential ________ nerve
injury.
✅✅
Weakness of active wrist extension would indicate a potential *radial* nerve injury. -
-Weakness of active wrist extension would indicate a potential ________ nerve injury.
A) chronic liver disease
Hereditary hemochromatosis is a common inherited disorder of iron metabolism. Iron deposits in
the liver
,may lead to chronic liver disease and hepatocellular cancer. Screening for hereditary
hemochromatosis
includes serum ferritin levels, a family history, and genetic testing. Chronic renal disease,
encephalopathy,
✅✅
myelofibrosis, and Wilson disease (disorder of copper transport) do not result from iron
overload. - -A 30-year-old male is diagnosed with hereditary hemochromatosis. Periodic
therapeutic phlebotomy may be appropriate to prevent
A) chronic liver disease B) chronic renal disease C) encephalopathy D) myelofibrosis E) Wilson
disease
ANSWER: C
This patient has severe aortic stenosis that is asymptomatic. Watchful waiting is recommended
for most
asymptomatic patients. In asymptomatic patients with severe aortic stenosis, monitoring with
serial
echocardiography is recommended every 6-12 months. Antibiotic prophylaxis is not indicated
unless the
patient has undergone aortic valve replacement or has a history of endocarditis.
Transesophageal
echocardiography is not indicated in this situation. Aortic valve replacement is indicated to
✅✅
decrease
mortality in patients with symptomatic aortic stenosis. - -A 70-year-old female sees you for
a Medicare annual wellness visit. Her past medical history includes hypertension treated with
enalapril (Vasotec). She states that she "couldn't be better" and says that she has no new
symptoms or health concerns. She has a blood pressure of 159/90 mm Hg, a temperature of
36.7°C (98.1°F), a heart rate of 76 beats/min, a respiratory rate of 17/min, and an oxygen
saturation of 98% on room air. On examination you note a new harsh systolic murmur that is
heard best at the second right intercostal space and can also be heard over the right carotid
artery. A transthoracic echocardiogram reveals severe aortic stenosis. Which one of the
following should you recommend for this patient? A) Antibiotic prophylaxis for dental procedures
B) Transesophageal echocardiography C) Repeat echocardiography in 6 months D) Referral for
aortic valve replacement
ANSWER: D - ipratropium (Atrovent)
Upper respiratory tract infections are the most common acute illness in the United States.
Symptoms are
self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise,
and a
low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis,
antitussives and
expectorants are no more effective than placebo for cough.
Intranasal ipratropium is the only medication
,that improves persistent cough related to upper respiratory infection in adults.
✅✅
Intranasal antibiotics,
antihistamines, corticosteroids, and saline would not improve this patient's cough. - -After
a thorough history and examination you determine that a 30-year-old male has an upper
respiratory infection with a persistent cough. He is afebrile and is otherwise healthy. The best
treatment for symptomatic relief of his persistent cough would be intranasal A) antibiotics B)
antihistamines C) corticosteroids D) ipratropium (Atrovent) E) saline
ANSWER: D - IgA deficiency
Celiac disease is a chronic malabsorptive disorder with an estimated worldwide prevalence of
1.4%. The
preferred initial diagnostic test includes a serum IgA transglutaminase-2 (TG2) antibody level,
which has
a 98% sensitivity and 98% specificity for the diagnosis of celiac disease. False-negative
serologic results
may occur in patients with an IgA deficiency, which includes up to 3% of patients with celiac
disease.
Therefore, when a diagnosis of celiac disease is strongly suspected despite a negative IgA TG2
antibody
test, a total IgA level should be obtained. Diagnostic confirmation for patients with positive
serologic
testing is accomplished with endoscopic mucosal biopsy.
Dietary elimination of gluten, not an increase in gluten intake, prior to serologic testing may lead
to
false-negative results. Recent use of medications, including loperamide, would not be expected
✅✅
to interfere
with t - -A 30-year-old female presents for evaluation of chronic abdominal bloating,
cramping, diarrhea, and recent weight loss. An abdominal examination is unremarkable, and
stool guaiac testing is negative. She requests testing for celiac disease. Which one of the
following would be most likely to cause a false-negative result on serologic testing for celiac
disease? A) A recent increase in dietary wheat consumption B) Recent use of loperamide
(Imodium A-D) C) A skin rash consistent with dermatitis herpetiformis D) IgA deficiency E) Iron
deficiency anemia
Tuft fractures are the most common type of distal phalanx fracture. They rarely require
orthopedic referral
but often result in up to 6 months of hyperesthesia, pain, and numbness. Treatment involves
splinting the
affected digit for 2-4 weeks, followed by range of motion and strengthening exercises.
Symptomatic
treatment may also be involved, but splinting is needed. Taping digits would likely not provide
enough
, stability for the second digit distal phalanx, which extends beyond the first digit. Patients with
distal finger
injuries need careful physical examination to evaluate for a nail bed injury, but in this case there
✅✅
is no
evidence of nail bed damage or laceration. - -A 20-year-old male presents with a painful
second finger after his right hand was stepped on 3 days ago while he was playing basketball.
He has marked pain as well as numbness of the distal finger. There are no open wounds and
the skin color and nail appear normal other than moderate edema of the fingertip. A radiograph
reveals a distal phalanx fracture. Which one of the following would be the most appropriate next
step?
A) Treat symptomatically with ice and an anti-inflammatory medication B) Tape the first and
second digits together until symptoms resolve C) Splint the affected digit for 2-4 weeks D)
Remove the nail to evaluate for a nail bed injury E) Refer to a hand surgeon
ANSWER: A: * L thyroxine has no proven benefit*
Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4
level. It
is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST
(Thyroid
Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of
randomized,
controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle
strength,
fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A),
and up to
60% of cases resolve within 5 years without intervention in older adults.
Appropriate management of an elevated TSH level includes repeat testing in 1-3 months along
with a free
T4
✅✅
level. If SCH is diagnosed, levels should be monitored yearly. Only 2%-4% of patients with SCH
develop overt hypothyroidism. - -A 72-year-old female with a history of type 2 diabetes and
hypertension presents to your clinic because of fatigue and depression for the last 5-6 months.
She has gained about 7 kg (15 lb) and now has a BMI of 32 kg/m2 . A physical examination is
otherwise unremarkable. Laboratory studies reveal a TSH level of 8.2 U/mL (N 0.4-4.0). A
repeat test 1 month later shows a TSH level of 7.4 U/mL and a free T4 level of 1.6 ng/dL (N
0.8-2.8). Treatment of this patient with L-thyroxine
A) has no proven benefit B) can increase grip strength C) can increase her energy level D) can
help improve depression symptoms E) can reduce her BMI
Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4
level.
e - ulnar nerve
Initial general neurovascular assessment of an upper extremity injury includes evaluating for
radial pulse
and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism
is indicative
of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential
brachial plexus
injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index
finger,
and long finger. Weakness of supination of the forearm would indicate a potential
musculocutaneous nerve
✅✅
injury. Weakness of active wrist extension would indicate a potential radial nerve injury. -
-A 30-year-old male comes to your office for evaluation of hand weakness. On
examination you
detect weakness when he tries to bring his thumb and index finger together. For confirmation
you ask him to try to hold on to a piece of paper between his thumb and index finger while you
try to pull it away. He is unable to resist when you pull on the paper.
The most likely explanation for these findings is an injury to the
✅✅
Weakness of the thumb and index finger pincer mechanism is indicative
of an *ulnar* nerve injury. - -Weakness of the thumb and index finger pincer mechanism is
indicative
of an _________ nerve injury.
Symptoms related to the *median* nerve generally include paresthesia of the thumb, index
✅✅
finger,
and long finger. - -Symptoms related to the __________ nerve generally include
paresthesia of the thumb, index finger, and long finger.
✅✅
Weakness of supination of the forearm would indicate a potential * musculocutaneous* nerve
injury. - -Weakness of supination of the forearm would indicate a potential ________ nerve
injury.
✅✅
Weakness of active wrist extension would indicate a potential *radial* nerve injury. -
-Weakness of active wrist extension would indicate a potential ________ nerve injury.
A) chronic liver disease
Hereditary hemochromatosis is a common inherited disorder of iron metabolism. Iron deposits in
the liver
,may lead to chronic liver disease and hepatocellular cancer. Screening for hereditary
hemochromatosis
includes serum ferritin levels, a family history, and genetic testing. Chronic renal disease,
encephalopathy,
✅✅
myelofibrosis, and Wilson disease (disorder of copper transport) do not result from iron
overload. - -A 30-year-old male is diagnosed with hereditary hemochromatosis. Periodic
therapeutic phlebotomy may be appropriate to prevent
A) chronic liver disease B) chronic renal disease C) encephalopathy D) myelofibrosis E) Wilson
disease
ANSWER: C
This patient has severe aortic stenosis that is asymptomatic. Watchful waiting is recommended
for most
asymptomatic patients. In asymptomatic patients with severe aortic stenosis, monitoring with
serial
echocardiography is recommended every 6-12 months. Antibiotic prophylaxis is not indicated
unless the
patient has undergone aortic valve replacement or has a history of endocarditis.
Transesophageal
echocardiography is not indicated in this situation. Aortic valve replacement is indicated to
✅✅
decrease
mortality in patients with symptomatic aortic stenosis. - -A 70-year-old female sees you for
a Medicare annual wellness visit. Her past medical history includes hypertension treated with
enalapril (Vasotec). She states that she "couldn't be better" and says that she has no new
symptoms or health concerns. She has a blood pressure of 159/90 mm Hg, a temperature of
36.7°C (98.1°F), a heart rate of 76 beats/min, a respiratory rate of 17/min, and an oxygen
saturation of 98% on room air. On examination you note a new harsh systolic murmur that is
heard best at the second right intercostal space and can also be heard over the right carotid
artery. A transthoracic echocardiogram reveals severe aortic stenosis. Which one of the
following should you recommend for this patient? A) Antibiotic prophylaxis for dental procedures
B) Transesophageal echocardiography C) Repeat echocardiography in 6 months D) Referral for
aortic valve replacement
ANSWER: D - ipratropium (Atrovent)
Upper respiratory tract infections are the most common acute illness in the United States.
Symptoms are
self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise,
and a
low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis,
antitussives and
expectorants are no more effective than placebo for cough.
Intranasal ipratropium is the only medication
,that improves persistent cough related to upper respiratory infection in adults.
✅✅
Intranasal antibiotics,
antihistamines, corticosteroids, and saline would not improve this patient's cough. - -After
a thorough history and examination you determine that a 30-year-old male has an upper
respiratory infection with a persistent cough. He is afebrile and is otherwise healthy. The best
treatment for symptomatic relief of his persistent cough would be intranasal A) antibiotics B)
antihistamines C) corticosteroids D) ipratropium (Atrovent) E) saline
ANSWER: D - IgA deficiency
Celiac disease is a chronic malabsorptive disorder with an estimated worldwide prevalence of
1.4%. The
preferred initial diagnostic test includes a serum IgA transglutaminase-2 (TG2) antibody level,
which has
a 98% sensitivity and 98% specificity for the diagnosis of celiac disease. False-negative
serologic results
may occur in patients with an IgA deficiency, which includes up to 3% of patients with celiac
disease.
Therefore, when a diagnosis of celiac disease is strongly suspected despite a negative IgA TG2
antibody
test, a total IgA level should be obtained. Diagnostic confirmation for patients with positive
serologic
testing is accomplished with endoscopic mucosal biopsy.
Dietary elimination of gluten, not an increase in gluten intake, prior to serologic testing may lead
to
false-negative results. Recent use of medications, including loperamide, would not be expected
✅✅
to interfere
with t - -A 30-year-old female presents for evaluation of chronic abdominal bloating,
cramping, diarrhea, and recent weight loss. An abdominal examination is unremarkable, and
stool guaiac testing is negative. She requests testing for celiac disease. Which one of the
following would be most likely to cause a false-negative result on serologic testing for celiac
disease? A) A recent increase in dietary wheat consumption B) Recent use of loperamide
(Imodium A-D) C) A skin rash consistent with dermatitis herpetiformis D) IgA deficiency E) Iron
deficiency anemia
Tuft fractures are the most common type of distal phalanx fracture. They rarely require
orthopedic referral
but often result in up to 6 months of hyperesthesia, pain, and numbness. Treatment involves
splinting the
affected digit for 2-4 weeks, followed by range of motion and strengthening exercises.
Symptomatic
treatment may also be involved, but splinting is needed. Taping digits would likely not provide
enough
, stability for the second digit distal phalanx, which extends beyond the first digit. Patients with
distal finger
injuries need careful physical examination to evaluate for a nail bed injury, but in this case there
✅✅
is no
evidence of nail bed damage or laceration. - -A 20-year-old male presents with a painful
second finger after his right hand was stepped on 3 days ago while he was playing basketball.
He has marked pain as well as numbness of the distal finger. There are no open wounds and
the skin color and nail appear normal other than moderate edema of the fingertip. A radiograph
reveals a distal phalanx fracture. Which one of the following would be the most appropriate next
step?
A) Treat symptomatically with ice and an anti-inflammatory medication B) Tape the first and
second digits together until symptoms resolve C) Splint the affected digit for 2-4 weeks D)
Remove the nail to evaluate for a nail bed injury E) Refer to a hand surgeon
ANSWER: A: * L thyroxine has no proven benefit*
Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4
level. It
is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST
(Thyroid
Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of
randomized,
controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle
strength,
fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A),
and up to
60% of cases resolve within 5 years without intervention in older adults.
Appropriate management of an elevated TSH level includes repeat testing in 1-3 months along
with a free
T4
✅✅
level. If SCH is diagnosed, levels should be monitored yearly. Only 2%-4% of patients with SCH
develop overt hypothyroidism. - -A 72-year-old female with a history of type 2 diabetes and
hypertension presents to your clinic because of fatigue and depression for the last 5-6 months.
She has gained about 7 kg (15 lb) and now has a BMI of 32 kg/m2 . A physical examination is
otherwise unremarkable. Laboratory studies reveal a TSH level of 8.2 U/mL (N 0.4-4.0). A
repeat test 1 month later shows a TSH level of 7.4 U/mL and a free T4 level of 1.6 ng/dL (N
0.8-2.8). Treatment of this patient with L-thyroxine
A) has no proven benefit B) can increase grip strength C) can increase her energy level D) can
help improve depression symptoms E) can reduce her BMI
Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4
level.
