NBME Family Medicine Form 1 - Answers & Explanations

1) Median nerve entrapment • Paresthesia and pain in the first 31⁄2 digits = Carpal tunnel syndrome • Common during the third-trimester of pregnancy due to accumulation of fluid in the carpal tunnel; usually resolves following delivery

2) Mitral valve stenosis • Acute rheumatic fever → mitral regurgitation (early) and mitral stenosis (later)

• Diastolic murmur is consistent with mitral stenosis

3) Ask the wife to accompany her husband to his appointment and express her concerns in her husband’s presence

• The physician should speak with the couple in person so that the wife can express her concerns and so the husband can share his perspective

4) Calcium • Vegan diets lack calcium

5) Weight loss of 9 kg (20 lb) • Weight loss is the most effective non-pharmacologic measure to decrease blood pressure in patients with a BMI > 25 • Systolic pressure decreased 5-20 mm Hg for every 10kg lost

6) Oral griseofulvin for the patient only • Tinea capitis (most common in African American children) presents scaly erythematous patch with hair loss on scalp

• Tx: Oral griseofulvin or terbinafine

7) No, no, no • PPSV23 is given alone to adults <65 with other chronic medical conditions (eg, heart/lung/liver disease, diabetes) • Influenza vaccination should be given annually in the fall (not the spring)

8) Baroreceptor-mediated ADH (vasopressin) secretion • Exertional dyspnea, bilateral basilar crackles, S3 = CHF • CHF → ↓ ejection fraction → ↓ stimulation of baroreceptors → ADH secretion → fluid retention & hyponatremia

9) Keeping a log of ordered tests that require follow-up by the office

• Creates a system that will reduce the chances of delay in follow-up and care

• The patient should return for a follow-up visit. However, it is not the patients responsibility to identify the systemic communication error between the doctors office and the radiology facility.

10) Daily use of alcohol-acetic acid ear drops

• Acetic acid, when used after exposure to moisture, is an excellent prophylactic for otitis externa

11) Inhaled corticosteroid therapy • This patients asthma is not well controlled on an albuterol inhaler alone (step 1

therapy) → Low-dose inhaled corticosteroid should be added (step 2 therapy)

Asthma severity & step therapy

12) Fecal impaction

• Fecal impaction is common in older patients • Obstruction of fecal flow → backup of stool • Passage of liquid stool around impaction → loose stool/incontinence

13) Metformin • Elevated creatinine indicates diminished renal function • Metformin is nephrotoxic and should not be given to patients with renal failure as it increases risk of lactic acidosis

14) Provide symptomatic care only

• This patient likely has a viral URI

• Acute bacterial rhino sinusitis can be distinguishes from a viral URI by the presence of severe (eg, fever > 102 with purulent nasal discharge), persistent (>10 days with no improvement) or worsening symptoms (after initial improvement)

15) Abstinence from alcohol • Mildly elevated liver enzymes • Patients hasn’t traveled in a year - no carrier state with hepatitis A

16) Prescribe transdermal nicotine and recommend a behavior modification program

• Nicotine patches are not contraindicated in patients with angina pectoris

17) Topical selenium sulfide • Tinea versicolor (pityriasis versicolor) • Tx: topical ketoconazole, terbinafine, or selenium sulfide

18) Angiotensin-converting enzyme (ACE) inhibitor

• Drugs that improve long-term survival in patients with LV systolic dysfunction usually have some effect on the renin-angiotensin-aldosterone system (eg, β- blockers, ACEi)

• Diuretics will likely provide symptomatic relief, but will not improve chances of survival

19) Scheduling a follow-up examination with the patient

• Foster physician-patient relationship

20) Folic acid • Macrocytic anemia and ⊖ neurological exam

21) Change in knowledge and dietary habits of each participant • This study aimed to teach something (health benefits). Therefore the effectiveness of the program can be measure by a change in knowledge of the participants

22) The patient should not have access to car keys until her driving skills are formally assessed

• The family should ensure that the patient does not have access to care keys until a formal evaluation of her driving can be completed

• A physician can’t revoke a persons driver license (only the DMV can)

23) Serum Helicobacter pylori antibody assay • To narrow down the differential diagnosis in this patient (GERD vs peptic ulcer disease), H pylori infection should be ruled out

24) Continue his current regimen • Carotid endarterectomy should be considered for asymptomatic patients with carotid stenosis between 6