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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

26) Measurement of left ventricular ejection fraction

• When diagnosing heart failure (HF), ejection fraction can help differentiate between systolic failure (reduced ejection fraction, HFrEF) and diastolic failure (preserved ejection fraction, HFpEF)

• Normal EF = 55-70% • HFpEF (diastolic dysfunction): left ventricle EF ≥ 50%

• HFrEF (systolic dysfunction): left ventricle EF ≤ 40%

27) Antidepressant therapy

• Initial management for fibromyalgia includes exercise program, patient education, and good sleep hygiene

• For patients that fail initial measures, SNRIs (eg, duloxetine, milnacipran) or TCAs (eg, amitriptyline) can be given

28) Assay for anti-transglutaminase antibodies • Celiac disease → ↓ mucosal absorption in distal duodenum (which is where iron is absorbed) → iron deficient anemia

29) Nortiptyline • TCAs can be used to treat peripheral neuropathy • 2° TCAs (eg, nortriptyline) have fewer anticholinergic and sedating side effects compared to 3° TCAs (eg, amitriptyline) and are therefor preferred in the elderly

30) Arthrocentesis

• This patient has acute joint pain with erythema, swelling, and effusion

• Septic arthritis must be ruled out out (patient can become septic and lose joint function if not treated)

• Arthrocentesis is both diagnostic and therapeutic

31) Postcoital single-dose nitrofurantoin therapy • Women with >3 recurrent UTIs in a year that are associated with sexual intercourse should be offered postcoital prophylaxis (single dose of antibiotic)

32) Serum lipid studies

• Lipid screening should begin at age 35 (men) or age 45 (women) in 5 year intervals; the USPSTF recommends screening in men aged 20-35 for lipid disorders if they are at increased risk of coronary heart disease

• Universal lipid screening is recommended for children ages 9-11 (prior to puberty) and again between ages 17-21 (after puberty)

• USPSTF recommends one-time screening for AAA with U/S in men ages 65-75 with a smoking history

33) Smoking • When it comes to mortality, smoking is usually the winner

34) Hepatitis C infection • ⊖ Hep B surface antigen, ⊕ Hep B surface antibody = immunity

• Can’t be infected with Hep D (Δ virus) if not infected with Hep B

• ⊕ Hep A antibody = immunity (no carrier or chronic state)

35) Use of a soft protective brace and early range of motion exercises • Using the Ottawa Anke rules, an ankle X-ray is only requires if there is pain in the

malleolar zone, plus one of the following: • Tenderness at the posterior lateral malleolus • Tenderness at the posterior medial malleolus • Inability to bear weight (both immediately and in the ED)

36) β-Adrenergic blocking agent

• Sumatriptans abort migraine • Beta-blockers and TCAs are prophylactic

37) Cerebral hypoperfusion • Hyperventilation → ↓ CO2 → cerebral vasoconstriction → ↓ blood supply to brain

• Valsalva → ↓ preload → ↓ cardiac output → ↓ blood supply to brain • ↓ blood supply to brain → loss of consciousness

38) Palpation of the thyroid gland • No screening for thyroid disease - can proceed with further testing and imaging if

something abnormal presents itself in the history or physical exam

39) Acyclovir

• Genital herpes (HSV-2) → cluster of painful vesicles

• Associated with high risk of recurrence

40) Adverse effect of medication

• Dihydropyridine Ca2+-channel blockers (eg, amlodipine) cause peripheral edema as a side effect (due to preferential dilation of precapillary vessels [arteriolar dilation] which increases capillary hydrostatic pressure)

• ACE inhibitors can reduce the Ca2+ channel blocker-induced peripheral edema via post-capillary venodilation

41) Prednisone therapy

• Polymyalgia rheumatica - pain and stiffness in the shoulders and pelvic girdle (↑ ESR, normal CK)

• Tx: glucocorticoids

42) Begin sertraline therapy • This patient has MDD → prescribe an SSRI (eg, sertraline)

• Difficulty sleeping

• Fatigue

• Weight loss

• Psychomotor retardation

• ↓ concentration (took her 5 minutes to draw clock face, and she had to be reminded)

43) Cognitive behavioral therapy • CBT + SSRI = first-line treatment for MDD

44) Physical therapy • The USPSTF recommends exercise or physical therapy to prevent falls in community-dwelling adults >65 years old who are at increased risk for falls

45) Mycoplasma pneumoniae • Fever, nonproductive cough, crackles = atypical (walking [or hiking...]) pneumonia

46) Lisinopril therapy • Polycystic kidneys tend to produce excess renin leading to HTN

• ACEi preferred medication for HTN associated with ADPKD

47) Metronidazole therapy • Clue cells (epithelial cells coated with bacteria) = bacterial vaginosis (Gardnerella vaginalis) • Tx: Metronidazole or Clindamycin

48) Tuberculosis • Works in a prison (levels of TB in prisons are up to 100x higher than that of the civilian population) with low grade fever, fatigue, hemoptysis

• Reactivation of TB preferentially infects the lung apices

49) Domestic abuse • Ecchymoses healing at different stages • USPSTF recommends clinicians screen for intimate partner violence in women of reproductive age and provide or refer women to support services

50) Drug-induced esophagitis • Bisphosphonates and Potassium chloride are both associated with pill-esophagitis

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