NBME Family Medicine Form 2 - Answers & Explanations

Updated: Nov 16, 2019

1) Add donepezil to current regimen • Acetylcholinesterase inhibitors (eg, donepezil, rivastigmine) may provide moderate symptom relief and temporarily improve functioning of Alzheimer’s dementia; however, long-term disease course remains unaltered

2) Avoidance of sun exposure • Doxycycline and Retinoids can both cause photosensitivity - patient should be counseled about these new medications side effects

3) “Patients who are incubating the influenza virus when they receive the vaccine mistakenly attribute their symptoms to the vaccine. You should get the vaccine.”

• Should rationally explain the reason to the patient without being condescending or guilt tripping them

4) Pleurodynia • Sudden occurrence of lancinating chest pain • Caused by viruses, most commonly Coxsackie B • Intercostal muscles necrose → ↑ creatine kinase

5) Panic disorder • Recurrent and unexpected panic attacks with at least one month of preoccupation with the attack

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

7) Do not agree to testing unless her son agrees to the drug testing

• Would violate physician-patient relationship

8) Trial of fiber supplementation • This patient has chronic, worsening constipation with a failed trial of laxatives - she should be offered another treatment option (eg, fiber)

9) Hypertension

• HTN is the greatest risk factor for both ischemic and hemorrhagic stroke (4x risk of CVA compared to normotensive individuals)

• The elevated pressure shearing on the intracerebral vasculature accelerates atherosclerosis

10) Gastric bypass • Indicated in patients with a BMI >40 that have attempted lifestyle modifications

• Indicated in patient with a BMI >35 that have attempted lifestyle modifications and have comorbid conditions (eg, HTN, T2DM)

11) Impaired renal excretion of sodium • NSAID (→ afferent arteriole constriction) + ACEi (→ efferent arteriole dilation) → ↓ GFR

12) Follow-up examination in 6 months • Unilateral thelarche with firm tissue under the areolar complex heralds onset of puberty (commonly mistaken as a mass)

13) Laryngotracheobronchitis (croup) • Inspiratory stridor, barking cough, hoarseness • Children age 6 months to 3 years • Up to date on vaccinations and no drooling or dysphagia help rule out epiglottis

• Bronchiolitis would present with wheezing/crackles rather than stridor

14) Use of wrist splints

• Wrist splinting is the best next step in management for a patient with suspected carpal tunnel syndrome

• Glucocorticoids or decompression surgery may be considered in patients with refractory symptoms

15) Atopic dermatitis with eczema herpeticum • Eczema herpticum = superimposed HSV-1 infection in the distribution of eczema

• Atopic patient with chronic rash in flexural areas = eczema

16) Low sensitivity • Rapid Streptococcal antigen test (RSAT) doesn’t rule out the disease (aka it has a high specificity)

17) Lactose intolerance • Transient lactose intolerance following viral gastroenteritis; the virus is gone but the epithelial cells are still regenerating (insufficient lactase in the brush border)

18) Clotrimazole • Tinea corporis (ringworm) • Tx: topical antifungals (eg, clotrimazole, terbinafine)

19) Lipid lowering therapy to decrease LDL cholesterol concentration to less than 100 mg/dL

• Statin therapy should be initiated in patients with diabetes (and other cardiovascular risk factors) with a target LDL cholesterol of <100 mg/dl

20) Use of a forearm strap • Lateral epicondylitis (tennis elbow)

• Pain with resisted wrist extension or supination

• Pain with passive wrist flexion

• Tx: inelastic counterforce brace

21) Measurement of serum iron and ferritin concentrations • Iron studies should be performed in patients with microcytic anemia suspicious for iron deficiency • No indication for parenteral (non oral administration) treatment

22) Acetaminophen • If nonpharmacological treatment (eg, exercise, weight loss) fail to improve pain of osteoarthritis, NSAIDs or Acetaminophen should be given • If that fails, topical NSAIDs or intra-articular glucocorticoids can be given

23) Exercise program

• This patient has metabolic syndrome; diagnosed when ≥ of the 5 following criteria are met:

• Abdominal obesity (waist circumference > 40 inches in males, > 35 inches in females)

• Fasting glucose (> 100-110 mg/dL)

• Blood pressure (> 130/80 mmHg)

• Triglycerides (> 150 mg/dL)

• HDL cholesterol (< 40 mg/dL in men, < 50 mg/dL in women)

• This patient, with a healthy BMI, should start an exercise program; exercise → ↑ HDL

24) Inquire about her attitudes toward smoking and health • Motivational interviewing: Open questions, affirmations, reflections, summaries

25) Asthma • Coughing episodes with triggers such as cold weather is classic for undiagnosed asthma