Family Medicine EOR Exam: Personal
Review (Rosh) well answered
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? -
correct answer ✔✔ 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.
Though all infants are recommended to receive pertussis vaccination with a DTaP, what form of
vaccination is recommended for adults? - correct answer ✔✔ The CDC recommend that all
adults, including those over 64 years of age, receive a booster with a Tdap once during their
lifetime.
,An 81-year-old man presents to the emergency department in respiratory distress. He is sitting
upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of
190/110 mm Hg, heart rate of 130 bpm, respiratory rate of 35/min, and oxygen saturation of
85% on room air.
Which of the following physical examination findings most strongly suggests heart failure as the
cause of his respiratory distress? - correct answer ✔✔ Third heart sound
Explanation:
Respiratory distress can result from numerous pathologic states, including obstructive airway
disease (e.g., asthma and chronic obstructive pulmonary disease), decompensated heart failure,
myocardial infarction, pneumonia, upper airway obstruction, tension pneumothorax, pulmonary
embolism, fat embolism, and neuromuscular disease. Emergency clinicians must quickly
determine the cause of respiratory distress in order to initiate appropriate treatment.
Heart failure is a common cause of respiratory distress. A weakened or diseased left ventricle or
one facing high systemic pressures cannot adequately pump blood and, as a result, blood pools
in the lungs, leading to pulmonary edema and clinical symptoms of congestive heart failure.
Symptoms include dyspnea on exertion, dyspnea at rest, orthopnea, paroxysmal nocturnal
dyspnea, and peripheral edema. However, these symptoms are seen in many conditions and
cannot be used to distinguish congestive heart failure from other causes of dyspnea. Physical
exam findings that suggest congestive heart failure include the presence of a third heart sound
or S3 gallop (likelihood ratio [LR] 11.0), hepatojugular reflux (LR 6.4), and jugular venous
distention (LR 5.1). The combination of an S3 gallop and a chest radiograph showing pulmonary
venous congestion or interstitial edema is highly suggestive of congestive heart failure.
Which class of medications should be given initially for acute pulmonary edema? - correct
answer ✔✔ Nitrates
An otherwise healthy 27-year-old man presents with several days of fever, drenching sweats,
and shaking chills one week after returning from India.
,Which of the following is most likely to reveal the diagnosis? - correct answer ✔✔ Thick and
thin peripheral smear
Explanation:
Malaria must be considered in any patient with a history of fever and travel to an endemic
region. Four species cause disease in humans: Plasmodium falciparum, Plasmodium ovale,
Plasmodium vivax, and Plasmodium malariae. P. falciparum is the most virulent form of the
disease able to cause severe organ dysfunction and death. The lifecycle of the organism causes
irregular or cyclic fevers in patients that is associated with RBC lysis. Other symptoms include
headache, nausea, abdominal pain, and upper respiratory complaints. The gold standard
includes thick and thin smears of the blood viewed under light microscopy to identify the
parasite.
What test may be falsely positive in malaria patients? - correct answer ✔✔ VDRL (Venereal
Disease Research Laboratory test)
A 62-year-old man with a history of hypertension on amlodipine and type 2 diabetes mellitus on
metformin presents to the emergency department with dull chest pain that started 8 hours ago.
The patient appears mildly diaphoretic. Vital signs include a heart rate of 104 bpm, blood
pressure of 135/92 mm Hg, and respiratory rate of 22 breaths per minute. He has a regular rate
and rhythm, and his lungs are clear to auscultation bilaterally. An ECG was performed and is
shown above. The initial cardiac troponin I is 9.8 ng/mL. You discuss with the cardiologist on call
who plans to perform cardiac catheterization with coronary angiography in 24 hours.
Which of the following is an appropriate treatment to administer now? - correct answer ✔✔
Unfractionated heparin
Explanation:
The patient in the vignette meets the diagnostic criteria for a non-ST elevation myocardial
infarction (NSTEMI). Non-ST elevation myocardial infarction is marked by an elevated troponin
due to myocardial ischemia in the absence of new ST elevation or pathologic Q waves in
contiguous leads on an electrocardiogram. Patients often present with chest pain or other
, anginal equivalents, such as dyspnea with exertion. The chest pain often radiates to one or both
extremities, and patients frequently experience diaphoresis and nausea and vomiting with the
chest pain. Anginal chest pain is classically worse with exertion and improved with rest.
According to the Fourth Universal Definition of myocardial infarction, the typical ECG findings
for non-ST elevation myocardial infarction are new horizontal or downsloping ST depression of
at least 0.5 mm in two contiguous leads, T wave inversion > 1 mm in two contiguous leads with
prominent R wave or R/S ratio, or both. Troponin is the cardiac biomarker that is most sensitive
and specific for myocardial injury. The clinical setting must be considered to determine if
myocardial infarction is the cause of the troponin elevation since there are several other causes
of troponin elevation. In patients who present with suspected acute coronary syndrome, the
initial troponin may be negative. In these cases, a troponin measurement should be repeated 2-
6 hours later. The treatment of non-ST elevation myocardial infarction consists of dual
antiplatelet therapy, anticoagulation, and, in most patients, early coronary angiography with
revascularization. The recommended dual antiplatelet regimen is aspirin and a P2Y12 receptor
antagonist, such as ticagrelor or prasugrel. Unfractionated heparin is the preferred
anticoagulant in patients with non-ST elevation myocar
What are some possible explanations for a patient experiencing a non-ST elevation myocardial
infarction and subsequently having a normal coronary angiography? - correct answer ✔✔ Rapid
clot lysis, vasospasm, or coronary microvascular disease.
A 7-day-old infant presents for eye discharge. He was born at home with the aid of a midwife.
On exam, the infant has copious mucopurulent discharge from both eyes, swollen eyelids, and
chemosis.
Which of the following is the most appropriate treatment? - correct answer ✔✔ Oral
erythromycin
Explanation:
Oral erythromycin is the treatment of choice for neonatal chlamydial conjunctivitis. Chlamydia
trachomatis is the most common bacterial sexually transmitted infection in the United States.
Conjunctivitis and pneumonia are the most frequent clinical manifestations of neonatal C.
trachomatis infections. C. trachomatis is the most common cause of conjunctivitis in the
newborn. Vaginal delivery has the highest risk transmission to the newborn. The incubation
Review (Rosh) well answered
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? -
correct answer ✔✔ 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.
Though all infants are recommended to receive pertussis vaccination with a DTaP, what form of
vaccination is recommended for adults? - correct answer ✔✔ The CDC recommend that all
adults, including those over 64 years of age, receive a booster with a Tdap once during their
lifetime.
,An 81-year-old man presents to the emergency department in respiratory distress. He is sitting
upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of
190/110 mm Hg, heart rate of 130 bpm, respiratory rate of 35/min, and oxygen saturation of
85% on room air.
Which of the following physical examination findings most strongly suggests heart failure as the
cause of his respiratory distress? - correct answer ✔✔ Third heart sound
Explanation:
Respiratory distress can result from numerous pathologic states, including obstructive airway
disease (e.g., asthma and chronic obstructive pulmonary disease), decompensated heart failure,
myocardial infarction, pneumonia, upper airway obstruction, tension pneumothorax, pulmonary
embolism, fat embolism, and neuromuscular disease. Emergency clinicians must quickly
determine the cause of respiratory distress in order to initiate appropriate treatment.
Heart failure is a common cause of respiratory distress. A weakened or diseased left ventricle or
one facing high systemic pressures cannot adequately pump blood and, as a result, blood pools
in the lungs, leading to pulmonary edema and clinical symptoms of congestive heart failure.
Symptoms include dyspnea on exertion, dyspnea at rest, orthopnea, paroxysmal nocturnal
dyspnea, and peripheral edema. However, these symptoms are seen in many conditions and
cannot be used to distinguish congestive heart failure from other causes of dyspnea. Physical
exam findings that suggest congestive heart failure include the presence of a third heart sound
or S3 gallop (likelihood ratio [LR] 11.0), hepatojugular reflux (LR 6.4), and jugular venous
distention (LR 5.1). The combination of an S3 gallop and a chest radiograph showing pulmonary
venous congestion or interstitial edema is highly suggestive of congestive heart failure.
Which class of medications should be given initially for acute pulmonary edema? - correct
answer ✔✔ Nitrates
An otherwise healthy 27-year-old man presents with several days of fever, drenching sweats,
and shaking chills one week after returning from India.
,Which of the following is most likely to reveal the diagnosis? - correct answer ✔✔ Thick and
thin peripheral smear
Explanation:
Malaria must be considered in any patient with a history of fever and travel to an endemic
region. Four species cause disease in humans: Plasmodium falciparum, Plasmodium ovale,
Plasmodium vivax, and Plasmodium malariae. P. falciparum is the most virulent form of the
disease able to cause severe organ dysfunction and death. The lifecycle of the organism causes
irregular or cyclic fevers in patients that is associated with RBC lysis. Other symptoms include
headache, nausea, abdominal pain, and upper respiratory complaints. The gold standard
includes thick and thin smears of the blood viewed under light microscopy to identify the
parasite.
What test may be falsely positive in malaria patients? - correct answer ✔✔ VDRL (Venereal
Disease Research Laboratory test)
A 62-year-old man with a history of hypertension on amlodipine and type 2 diabetes mellitus on
metformin presents to the emergency department with dull chest pain that started 8 hours ago.
The patient appears mildly diaphoretic. Vital signs include a heart rate of 104 bpm, blood
pressure of 135/92 mm Hg, and respiratory rate of 22 breaths per minute. He has a regular rate
and rhythm, and his lungs are clear to auscultation bilaterally. An ECG was performed and is
shown above. The initial cardiac troponin I is 9.8 ng/mL. You discuss with the cardiologist on call
who plans to perform cardiac catheterization with coronary angiography in 24 hours.
Which of the following is an appropriate treatment to administer now? - correct answer ✔✔
Unfractionated heparin
Explanation:
The patient in the vignette meets the diagnostic criteria for a non-ST elevation myocardial
infarction (NSTEMI). Non-ST elevation myocardial infarction is marked by an elevated troponin
due to myocardial ischemia in the absence of new ST elevation or pathologic Q waves in
contiguous leads on an electrocardiogram. Patients often present with chest pain or other
, anginal equivalents, such as dyspnea with exertion. The chest pain often radiates to one or both
extremities, and patients frequently experience diaphoresis and nausea and vomiting with the
chest pain. Anginal chest pain is classically worse with exertion and improved with rest.
According to the Fourth Universal Definition of myocardial infarction, the typical ECG findings
for non-ST elevation myocardial infarction are new horizontal or downsloping ST depression of
at least 0.5 mm in two contiguous leads, T wave inversion > 1 mm in two contiguous leads with
prominent R wave or R/S ratio, or both. Troponin is the cardiac biomarker that is most sensitive
and specific for myocardial injury. The clinical setting must be considered to determine if
myocardial infarction is the cause of the troponin elevation since there are several other causes
of troponin elevation. In patients who present with suspected acute coronary syndrome, the
initial troponin may be negative. In these cases, a troponin measurement should be repeated 2-
6 hours later. The treatment of non-ST elevation myocardial infarction consists of dual
antiplatelet therapy, anticoagulation, and, in most patients, early coronary angiography with
revascularization. The recommended dual antiplatelet regimen is aspirin and a P2Y12 receptor
antagonist, such as ticagrelor or prasugrel. Unfractionated heparin is the preferred
anticoagulant in patients with non-ST elevation myocar
What are some possible explanations for a patient experiencing a non-ST elevation myocardial
infarction and subsequently having a normal coronary angiography? - correct answer ✔✔ Rapid
clot lysis, vasospasm, or coronary microvascular disease.
A 7-day-old infant presents for eye discharge. He was born at home with the aid of a midwife.
On exam, the infant has copious mucopurulent discharge from both eyes, swollen eyelids, and
chemosis.
Which of the following is the most appropriate treatment? - correct answer ✔✔ Oral
erythromycin
Explanation:
Oral erythromycin is the treatment of choice for neonatal chlamydial conjunctivitis. Chlamydia
trachomatis is the most common bacterial sexually transmitted infection in the United States.
Conjunctivitis and pneumonia are the most frequent clinical manifestations of neonatal C.
trachomatis infections. C. trachomatis is the most common cause of conjunctivitis in the
newborn. Vaginal delivery has the highest risk transmission to the newborn. The incubation
