AAFP Missed Questions Exam With Complete
Solutions
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 - 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 - 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 - 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: - 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 - 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 - 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) - 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 - 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
Solutions
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 - 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 - 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 - 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: - 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 - 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 - 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) - 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 - 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
