NBME Family Medicine Form 1 - Answers & Explanations

Updated: Jul 28

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)

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 60-99%

25) Indomethacin

• NSAIDs are the preferred treatment for acute gouty arthritis

• Colchicine or glucocorticoids are recommended in patients with cirrhosis or CHF (NSAIDs are contraindicated)

• Urate-lowering drugs (eg, allopurinol) are indicated for patients with recurrent attacks or complicated disease (eg. Uric acid kidney stones)

26) Smoking cessation • There are multiple modifications that would benefit this patient, however, smoking cessation is the most beneficial

27) Exposure to human papillomavirus

• Most common cause of SCC in the perineal region is HPV infection

28) Recommend participation in a smoking cessation program

• COPD patients that smoke see a decrease in lung function at twice the rate compared to non-smoking COPD patients

• The only therapies proven to prolong survival in COPD patients are smoking cessation, supplemental O2, and lung reduction surgery

29) Enuresis alarm • This patient is a ‘deep sleeper’, therefore a bedwetting alarm would be best

30) Upper endoscopy • This older patient with a 20 year history of GERD and new alarm symptoms (eg, dysphagia/odynophagia) raises concern for esophageal adenocarcinoma

• Dx: Endoscopy with biopsy, CT scan for staging

31) Treatment of latent tuberculosis now

• ⊕PPD with a ⊖CXR = latent TB • Latent TB tx: Isoniazid + Pyridoxine

32) Reassurance • This patient shows signs of normal aging and does not require further evaluation

• Unaffected daily and executive functioning with a mini-mental exam score >26

33) Oral valacyclovir • CN V1 branch involvement with varicella zoster virus = herpes zoster opthalmicus

• Antiviral medication (eg, valacyclovir) → ↓ duration of symptoms & ↓ risk of postherpetic neuralgia

34) Varicocele • Scrotal mass (‘bag of worms’) • ↑ with standing or valsalva; ↓ in supine position

35) Warm saline gargle • Viral pharyngitis → supportive treatment

36) Cast immobilization • Non-displaced scaphoid fractures should be managed with wrist immobilization

• Monitor with serial x-ray to rule out osteonecrosis of the proximal segment and non-union of the fracture

37) Lisinopril • 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)

38) Compression fracture

• Presents with back pain, ↓ spinal mobility, tenderness at affected level, and a normal neurological exam

• Risk factors include: Older age, Prolonged corticosteroid use (prednisone for chronic asthma), No hormone replacement after menopause (estrogen inhibits osteoclasts; menopause → ↓ estrogen)

39) Measurement of serum cholesterol • This patient should have her cholesterol concentration re-checked to see if her low-fat diet has been effective

Screening protocol: Pap smear q3 years, Colonoscopy q3-5 years beginning at age 40 or 10 years before onset of CRC in relative, Mammography q2 years in women age 50-75 years

40) Renal artery stenosis • Renovascular disease (eg, renal artery stenosis due to atherosclerosis) is the most likely underlying cause of resistant hypertension in a male patient with diffuse atherosclerosis

41) Measurement of postvoid residual volume

• BPH → prostatic urethra compression → incomplete bladder emptying (eg, overflow incontinence) → ↑ risk of hydronephrosis (→ rising creatinine)

• Normal postvoid residual volume in men = <50 mL

42) Aspiration of the knee joint • Progressive pain, swelling, erythema and no history of trauma → arthrocentesis indicated to rule out septic arthritis

43) Subacute thyroiditis

• Weight loss, tachycardia, tender thyroid, ↑ T4, low radioactive iodine uptake

• Typically follows an URI • Tx: symptomatic (eg, NSAIDs, β-blockers)

44) Oral ibuprofen therapy

• This patient likely has a lumbosacral strain (back pain with paravertebral tenderness) after lifting furniture

• Tx: maintain moderate activity, NSAIDs

45) Serum ferritin concentration • Suspected iron deficient anemia → iron studies (serum iron, ferritin, TIBC)

46) Colonoscopy • Iron deficiency anemia in elderly is assumed to be from GI blood loss until proven otherwise • Lack of response to iron supplementation indicates ongoing blood loss

47) “Sometimes when people are as upset as you are, they think about suicide. Have you thought about ending your life?”

• Patients that appear to be clinically depressed should be screened for suicide risk

48) Cluster headache • Male with excruciating periorbital pain that arises during sleep

• May present with Horner syndrome

49) Hyperthyroidism

• ↑ T3, ↑ T4, ↓ TSH, ↑ uptake on RAIU scan

50) Oral amitriptyline therapy • Initial treatment for painful diabetic neuropathy include TCAs (eg, amitriptyline), SNRIs (eg, duloxetine), or anticonvulsants (eg, gabapentin)

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