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AAFP Family Medicine Board (180) Questions and Answers
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AAFP Family Medicine Board Questions and Answers
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AAFP Family Medicine Board Questionsand Answers
A 1-year-old infant is brought to your office for a well child visit. A screening CBC
reveals her hemoglobin to be 10.5 g/dL (N 11.0-14.0) with a mean corpuscular volume
of 69 µm3 (N 70-84). What is the most likely cause of her anemia? - ANSWER-Iron
deficiency
This child has evidence of a mild microcytic anemia, which is most commonly caused by
iron deficiency related to reduced dietary intake. Less common causes are thalassemia
and lead poisoning. Hemolysis usually causes a normocytic anemia with an elevated
reticulocyte count. Chronic liver disease and hypothyroidism result in macrocytic
anemias.
A 10-week-old term male infant is brought to your office with a 2-day history of difficulty
breathing. He has been healthy since birth, with the exception of a 3-day episode of
wheezing and rhinorrhea 3 weeks ago. Your initial examination shows an alert infant
with increased work of breathing, rhinorrhea, and wheezing. His oxygen saturation is
93% and his temperature is 38.4°C (101.1°F).
What's the appropriate next step? - ANSWER-A trial of nebulized albuterol (AccuNeb)
The American Academy of Pediatrics guideline on the diagnosis and management of
bronchiolitis recommends against the use of laboratory or radiographic studies to make
the diagnosis, although additional testing may be appropriate if there is no
improvement. Bronchiolitis can be caused by a number of different viruses, alone or in
combination, and the knowledge gained from virologic testing rarely influences
management decisions or outcomes for the vast majority of children.
While the guideline does not support routine use of bronchodilators in the management
of bronchiolitis, it does allow for a trial of bronchodilators as an option in selected cases,
and continuation of the treatment if the patient shows objective improvement in
respiratory status. Bronchodilators have not been shown to affect the course of
bronchiolitis with respect to outcomes.
The guideline places considerable emphasis on hygienic practices, including the use of
alcohol-based hand sanitizers before and after contact with the patient or inanimate
objects in the immediate vicinity. Education of the family about hygienic practices is
recommended as well. Returning the child to day care the next day is potentially
harmful.
A 10-year-old male is brought to your office after sustaining a fall on an outstretched
hand. Radiographs show a nondisplaced fracture of the middle third of the clavicle.
Appropriate management would include: - ANSWER-A figure-of-8 splint or sling support
,In treating the midshaft clavicular fracture, the goal is reduction of motion at the fracture
site. This rarely requires operative intervention and can be managed by the family
physician without orthopedic referral. The fracture site is best stabilized by restricting
shoulder motion to less than 45 degree abduction. Either an arm sling or a figure-of-8
clavicular splint holding the shoulder back at the "position of attention" may be used.
The figure-of-8 splint offers the advantage of leaving the elbow and hand free for
activity. Ice and analgesics are used as needed during the acute stage of injury. Early
use of heat may increase the inflammatory response. The patient may use the arm as
pain permits, but should not abduct the arm more than 45 degrees for several weeks.
The risk of adhesive capsulitis is negligible in children. Repeat radiographs at each
follow-up office visit are not necessary, but a final radiograph should be ordered when
clinical union has occurred to assess callus formation.
A 10-year-old white male is brought to your office with a chief complaint of "head
congestion" associated with moderate malaise and a low-grade fever for 7 days. He has
had a thick, discolored nasal discharge for the last 2 days. What's the appropriate next
step? - ANSWER-No antibiotics should be used at this time
Clinical diagnosis of bacterial sinusitis requires the following: prolonged nonspecific
upper respiratory signs and symptoms (i.e., rhinosinusitis and cough without
improvement for >10-14 days), or more severe upper respiratory tract signs and
symptoms (i.e., fever of 39 degrees C or higher, facial swelling, and facial pain). This
individual does not meet these criteria, so antibiotics should not be used at this time.
Although some believe that mucopurulent rhinitis (thick, opaque, or discolored nasal
discharge) indicates the presence of bacterial sinusitis, this sign should be recognized
as part of the natural course of a nonspecific, uncomplicated viral upper respiratory
infection (URI). Sinus radiographs can demonstrate thickened mucosa, infundibular
occlusion, and occasional air-fluid levels in uncomplicated viral URI.
A 12-year-old female has a cough and slight shortness of breath on a daily basis. She is
awakened by the cough at least 3 nights per week. What would be the most appropriate
treatment for this patient? - ANSWER-Inhaled corticosteroids daily
This patient has moderate persistent asthma. The preferred and most effective
treatment is daily inhaled corticosteroids. A leukotriene inhibitor would be less effective.
Oral prednisone daily is not recommended because of the risk of inducing adrenal
insufficiency. Short- and long-acting β-agonists are not recommended as daily therapy
because either can cause tachyphylaxis. They are considered rescue medications
rather than preventive treatments.@@//d3cgb598vs7bfg.cloudfront.net/images/upload-
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A 12-year-old female is brought to your office with an 8-day history of sore throat and
fever, along with migratory aching joint pain. She is otherwise healthy and has no
history of travel, tick exposure, or prior systemic illness. A physical examination is
notable for exudative pharyngitis; a blanching, sharply demarcated macular rash over
,her trunk; and a III/VI systolic ejection murmur. Joint and neurologic examinations are
normal. A rapid strep test is positive and her C-reactive protein level is elevated.
Of the following, the most likely diagnosis is: - ANSWER-acute rheumatic fever
Acute rheumatic fever is very common in developing nations. It was previously rare in
the U.S., but had a resurgence in the mid-1980s. It is most common in children ages 5-
15 years. The diagnosis is based on the Jones criteria. Two major criteria, or one major
criterion and two minor criteria, plus evidence of a preceding streptococcal infection,
indicate a high probability of the disease.
Major criteria include carditis, migratory polyarthritis, erythema marginatum, chorea, and
subcutaneous nodules. Minor criteria include fever, arthralgia, an elevated erythrocyte
sedimentation rate or C-reactive protein (CRP) level, and a prolonged pulse rate interval
on EKG. The differential diagnosis is extensive and there is no single laboratory test to
confirm the diagnosis. This patient meets one major criterion (erythema marginatum
rash) and three minor criteria (fever, elevated CRP levels, and arthralgia).
Echocardiography should be performed if the patient has cardiac symptoms or an
abnormal cardiac examination, to rule out rheumatic carditis.
A 12-year-old male middle-school wrestler comes to your office complaining of a
recurrent painful rash on his arm. There appear to be several dry vesicles. Most likely
diagnosis? -
ANSWER-//d3cgb598vs7bfg.cloudfront.net/images/upload-flashcards/front/
2/9/58292319_m.jpg@@Herpes gladiatorum
The most common infection transmitted person-to-person in wrestlers is herpes
gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes
keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm,
which is manifested by round to oval raised areas with central clearing.
A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose
an acute asthma attack and prescribe an inhaled beta2-adrenergic agonist, but despite
1-2 hours of treatment he continues to experience wheezing and shortness of breath.
Which one of the following is the most appropriate addition to acute outpatient
management? - ANSWER-Oral corticosteroids
The treatment of choice for occasional acute symptoms of asthma is an inhaled beta2-
adrenergic agonist such as albuterol, terbutaline, or pirbuterol. However, acute
symptoms that do not respond to beta-agonists should be treated with a short course of
systemic corticosteroids. Theophylline has limited usefulness for treatment of acute
symptoms in patients with intermittent asthma; it is a less potent bronchodilator than
subcutaneous or inhaled adrenergic drugs, and therapeutic serum concentrations can
cause transient adverse effects such as nausea and central nervous system stimulation
in patients who have not been taking the drug continuously. Cromolyn can decrease
airway hyperreactivity, but has no bronchodilating activity and is useful only for
prophylaxis. Inhaled corticosteroids should be used for suppressing the symptoms of
, chronic persistent asthma. Oral beta2-selective agonists are less effective and have a
slower onset of action than the same drugs given by
inhalation.@@//d3cgb598vs7bfg.cloudfront.net/images/upload-flashcards/back/
6/9/58396658_m.jpg
A 13-year-old male is found to have hypertrophic cardiomyopathy. His father also had
hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis.
The boy's mother asks you for advice regarding his condition. What advice should you
give her? - ANSWER-His siblings should undergo echocardiography
Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of
affected individuals should be screened. The hypertrophy usually stays the same or
worsens with age. This patient should not participate in strenuous sports, even those
considered noncontact. Beta-blockers have not been shown to alter the progress of the
disease. The mortality rate is believed to be about 1%, with some series estimating 5%.
Thus, in most cases lifespan is normal.
A 14-year-old female is brought to your office by her mother because of a 3-month
history of irritability, hypersomnia, decline in school performance, and lack of interest in
her previous extracurricular activities. The mother is also your patient, and you know
that she has a history of depression and has recently separated from her husband. After
an appropriate workup, you diagnose depression in the daughter.
For initial therapy you recommend: - ANSWER-cognitive-behavioral therapy
This patient has multiple risk factors for depression: the hormonal changes of puberty, a
family history of depression, and psychosocial stressors. Cognitive-behavioral therapy is
effective in treating mild to moderate depression in children and adolescents (SOR A).
SSRIs are an adjunctive treatment reserved for treatment of severe depression, and
have limited evidence for effectiveness in children and adolescents.
Amitriptyline should not be used because of its limited effectiveness and adverse effects
(SOR A). Methylphenidate is used for treating attention deficit disorder, not depression.
Divalproex sodium is used to treat bipolar disorder.
A 14-year-old female with a history of asthma is having daytime symptoms about once a
week and symptoms that awaken her at night about once a month. Her asthma does
not interfere with normal activity, and her FEV1 is >80% of predicted.
What is the most appropriate treatment plan for this patient? - ANSWER-A short-acting
inhaled β-agonist as needed
Based on this patient's reported frequency of asthma symptoms, she should be
classified as having intermittent asthma. The preferred first step in managing
intermittent asthma is an inhaled short-acting β-agonist as needed. Daily medication is
reserved for patients with persistent asthma (symptoms >2 days per week for mild, daily
for moderate, and throughout the day for severe) and is initiated in a stepwise
approach, starting with a daily low-dose inhaled corticosteroid or leukotriene receptor
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