AAFP questions

Question 1

When is allergy testing helpful?

Answer 1

Allergy testing can be helpful in patients with persistent
sinus infections, allergic rhinitis, and poorly controlled asthma. Allergy testing for insect stings is indicated
only following systemic/anaphylactic or large local reactions, not with limited localized reactions.

Question 2

recommended first-line agent to prevent steroid-induced osteoporosis?

Answer 2

Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term
glucocorticoid therapy, defined as >2.5 mg of prednisone for a duration of 3 months or longer.

Oral bisphosphonates are recommended as first-line agents for preventing glucocorticoid-induced
osteoporotic fractures, although intravenous bisphosphonates can be used if patients are unable to use the
oral forms. Supplementation of calcium (800–1000 mg) and vitamin D (400–800 IU) is also recommended.

Question 3

snuffbox tenderness after fall with outstreched hand? what is the diagnosis and management?

Answer 3

The finding of anatomic snuffbox tenderness is highly sensitive but not specific for a scaphoid fracture.
Initial radiographs often do not demonstrate a fracture. When there is a high clinical suspicion for a
scaphoid fracture but radiographs are negative, it is reasonable to immobilize in a thumb spica splint and
reevaluate in 2 weeks.

Question 4

treatment for vasomotor symptoms in menopause

Answer 4

Combination estrogen
and progesterone therapy is highly effective for vasomotor symptoms and provides protection against
uterine neoplasia. Although micronized progesterone decreases vasomotor symptoms there are no
long-term studies to assess the safety of progestin-only treatment for menopausal symptoms.

Question 5

tx for provoked PE/DVT

Answer 5

Current guidelines recommend treatment for at least 3 months. In patients who have
a reversible provoking factor such as surgery, anticoagulation beyond 3 months is not recommended.

Question 6

focal hyperhidrosis (too much sweating) in the armpits - what is the tx?

Answer 6

The recommended first-line treatment for primary focal hyperhidrosis is topical 20% aluminum chloride.
It should be applied to affected areas nightly for 6–8 hours and works by obstructing the eccrine sweat
glands and destroying secretory cells. Iontophoresis and botulinum toxin are alternative first- or second-line
therapies for palmar and plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or
face.

Question 7

how does TSH change in pregnancy?

Answer 7

The TSH reference range is lower during pregnancy because of the cross-reactivity of the -subunit of
hCG. Levels of hCG peak during weeks 7–13 of pregnancy, and hCG has mild TSH-like activity, leading
to slightly high free T4 levels in early pregnancy. This leads to a feedback decrease in TSH.

Question 8

older man with normocytic anemia with renal insufficiency - what can’t miss diagnosis / lab should you be thinking about?

Answer 8

spep/upep

MM

Question 9

what med to help pass stone 5-10mm in diameter

Answer 9

Tamsulosin promotes passage of ureter stones that are 5–10 mm in diameter.

Question 10

what is a good sleep med after melatoniin?

Answer 10

lunesta Eszopiclone

Question 11

treatments for PCOS in pt who does not want to get pregnant?

Answer 11

In a patient who is not interested in near-term fertility and whose goal is
to control menstrual irregularities, a levonorgestrel IUD is most likely to reduce the frequency, duration,
and volume of bleeding. Metformin is used to treat insulin resistance, dietary modifications are used to
treat obesity, spironolactone can be used to treat hirsutism or acne, and clomiphene is used to induce
ovulation and fertility.

Question 12

what kind of surveillance do sarcoidosis pts need on yearly level?

Answer 12

Because inflammation of the eye can result in
permanent impairment and is often asymptomatic, patients require yearly eye examinations as well as
additional monitoring with disease flares.

Question 13

safe alternative to combined hormonal product for vasomotor symptoms of menopause?

Answer 13

Black cohosh is
considered a safe alternative for treating menopausal vasomotor symptoms, but not for treating sexual
arousal dysfunction in women who are premenopausal.

Question 14

medial joint knee pain

Answer 14

This patient has medial knee pain related to repetitive use, most likely caused by pes anserine bursitis.
Iliotibial band syndrome is often related to overuse but causes pain in the lateral knee. The fibular head
is also lateral to the knee joint.

Question 15

when is radiographic imaging of ankle useful?

Answer 15

A radiograph of the ankle is recommended if there is pain in the malleolar zone along with the inability to bear weight for at least four steps immediately after the injury and in the physician’s office or emergency department (ED), or tenderness at the tip of the posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain in the midfoot zone along with the inability to bear weight for four steps immediately after the injury and in the physician’s office or ED, or tenderness at the base of the fifth metatarsal or over the navicular bone.

Question 16

which joints does OA spare in the hand?

Answer 16

MCP

Osteoarthritis does not typically cause the soft-tissue swelling seen in the photograph of this patient’s hands. It usually affects the distal and proximal interphalangeal joints while sparing the MCP joints, and it results in osteophytes and joint space narrowing that can be seen on radiographs.

Question 17

how is microscopic colitis diagnosed?

Answer 17

Microscopic colitis (MC) is characterized by secretory diarrhea usually seen in older patients, although all ages can be affected. Chronic or frequent use of proton pump inhibitors, NSAIDs, or SSRIs has been associated with MC, however a causal relationship has not been identified. Current smoking also increases the risk of MC. Females have a higher prevalence of this condition.

Biopsies from the right and left sides of the colon are required for analysis as endoscopic appearance may be normal.

Question 18

what tx has benefit in mild croup?

Answer 18

Randomized studies have shown that even with mild croup (an occasional barking cough with no stridor at rest), oral corticosteroids provide some benefit.

Question 19

what is a treatment for cluster headache, esp in women with unilateral symptoms and more during the day?

Answer 19

cluster headaches, including chronic paroxysmal hemicrania, which resembles cluster headache but has some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.

Question 20

Tx for diarrhea predominant IBS?

Answer 20

SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS

Question 21

Bupropion .. used to treat GAD or not?

Answer 21

No. Bupropion is approved for the treatment of depression but is not used to treat GAD.

Question 22

Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal spirometry indicates…..

Answer 22

process like chronic pulmonary emboli,…a disease process that disrupts gas transfer in the lungs without causing lung restriction or airflow obstruction.

Question 23

Patients with anaphylactic reaction are at risk of what kind of reaction?

Answer 23

biphasic - go to ED even after epi pen!

Question 24

when in course of sinusitis should you expect bacterial vs viral?

Answer 24

In the first 3 to 4 days of illness, viral rhinosinusitis cannot be distinguished from early acute bacterial rhinosinusitis. If the patient seems to be improving and then symptoms start to worsen on days 5–10 of the illness (double sickening), acute bacterial rhinosinusitis should be suspected. The color of the nasal discharge should not be used as the sole indication for antibiotic therapy. One study showed that unilateral predominance with purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis. After 10 days of upper respiratory symptoms, the probability of acute bacterial rhinosinusitis is 60%.

Question 25

Gastroesophageal reflux accounts for a significant number of cases of what kind of conditions in children?

Answer 25

failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia.

Question 26

Abx for ACS in sickle cell pts?

Answer 26

azithro and ctx due to atypicals!

Studies have shown that atypical pathogens predominate in ACS and it is therefore important to treat all patients with ACS with antibiotics that cover Mycoplasma and Chlamydophila . Viral infections are also common, especially in children with ACS. Other possible pathogens include Staphylococcusaureus , Streptococcus pneumoniae , and Haemophilus influenzae . Therefore, the use of a third-generation cephalosporin along with azithromycin is the recommended antibiotic coverage.

Question 27

vitamin D deficiency - what do you test?

Answer 27

The recommended test for this condition is a 25-hydroxyvitamin D level. A 1,25-dihydroxyvitamin D level is recommended to monitor, not diagnose, certain conditions. Parathyroid hormone, calcium, and alkaline phosphatase levels are poor indicators of vitamin D status.

Question 28

What is the best BP med to prevent HF?

Answer 28

In the largest head-to-head comparison of first-step drug therapy for hypertension, the thiazide-type diuretic chlorthalidone was superior to the calcium channel blocker amlodipine and the ACE inhibitor lisinopril in preventing heart failure.

Question 29

When should thiazide diuretics be avoided?

Answer 29

Pts with gout (can increase risk), and also CKD stage >4 (ineffective)

Question 30

What is the HPV dosing schedule? What is the difference before 15 yo and after?

Answer 30

The recommended HPV vaccine series includes two or three doses depending on the age of initiation. Two doses of HPV vaccine are recommended for children and adolescents who start the series before 15 years of age. The second dose should be administered 6–12 months after the initial dose. If the patient is 15 years or older at vaccine initiation, then a three-dose series would be indicated at 0, 1–2, and 6 months. In this case, neither child has received HPV vaccine previously, so the 11-year-old needs a two-dose HPV vaccine series and the 17-year-old needs three doses. Although the optimal timing for HPV vaccination is before the initiation of sexual activity, it can still provide protection if administered after a patient has become sexually active.

Question 31

Between NSAIds and acetaminophen, what should you use in cirrhotic patients?

Answer 31

NSAIDs such as ibuprofen should be avoided in patients with cirrhosis due to the risk of renal insufficiency (SOR B). While toxic to the liver at high doses, acetaminophen can be safely used for analgesia in cirrhotic patients, though many hepatologists recommend limiting dosing to 2 g daily (SOR C).

Question 32

What kind of hallucinatinos with PD? visual only or auditory only?

Answer 32

Visual hallucinations are associated with Parkinson’s disease, and are seen with Parkinson’s dementia, which is a type of Lewy body dementia. The combination of auditory and visual hallucinations is associated with schizophrenia.

Question 33

What should scaphoid fractured be treated if displaced? Not displaced?

Answer 33

To improve healing and decrease the risk of nonunion and avascular necrosis, displaced fractures should be treated with surgical fixation. Nondisplaced fractures of the distal third of the scaphoid may be treated with a short arm thumb spica cast for 4–6 weeks. Middle and proximal fractures should be treated with a long arm thumb spica cast for 6 weeks, followed by a short arm thumb spica cast.

Question 34

What form of contraception can be placed/used at any point in mensutral cycle and not need back up?

Answer 34

A copper-containing IUD may be placed at any time during the menstrual cycle and does not require the use of backup contraception. I

Question 35

what conditions affect levothyroxine absorption?

Answer 35

Absorption of levothyroxine is impaired by several gastrointestinal conditions, including atrophic gastritis, chronic proton pump inhibitor use, and Helicobacter pylori infection. Treatment of H. pylori infection reverses this effect, and following eradication of the infection a reduction of the levothyroxine dosage by 30% or more will often be required.

Question 36

when should you start latent TB tx in pregnant women?

Answer 36

positive PPD in the last 2 years, treatment with isoniazid (INH), 300 mg daily, is recommended starting after the first trimester. Treatment should last 6–9 months. Pregnant women are at an increased risk for peripheral neuropathy when treated with INH. Vitamin B6 supplementation decreases the risk of developing peripheral neuropathy with the use of INH.

Question 37

What is cubital tunnel syndrome? what testing can you do?

Answer 37

Your doctor may perform the Tinel’s Test by tapping lightly along the inside of the elbow, directly over the ulnar nerve. If the ulnar nerve is irritated, it will send a tingling sensation into the pinky and ring fingers (Tinel’s sign). This may occur when the nerve is in normal condition.

This patient has signs and symptoms of cubital tunnel syndrome, which is the second most common peripheral neuropathy. Symptoms develop because of ulnar nerve compression in the upper extremity, leading to sensory paresthesias in the ulnar digits and intrinsic muscular weakness. Vague motor problems, including poor coordination of the fingers and hand clumsiness, are frequent complaints. Provocative testing includes demonstration of Tinel’s sign over the cubital tunnel, and the elbow flexion test with paresthesias elicited over the ulnar nerve.

Question 38

tx of clavicular fx that is minimally displaced and in the mid clavicle?

Answer 38

Eighty percent of these fractures occur in the midclavicle. Unless significantly displaced, these fractures do not require referral. They can be treated with just a sling for 2–6 weeks. A sling is more comfortable and less irritating than a figure-of-eight bandage. Passive range of motion of the shoulder is indicated as soon as the pain allows. Physical therapy may be started at 4 weeks after the injury.

Question 39

DVT tx in cancer patient?

Answer 39

In a patient with cancer, deep vein thrombosis of the leg or a pulmonary embolus is considered to be cancer-associated thrombosis. Low molecular weight heparin (LMWH), such as enoxaparin, should be chosen over the other anticoagulant options listed.

Question 40

oppositional defiant disorder - what are the four symptom categories

Answer 40

oppositional defiant disorder (ODD). To meet the DSM-5 criteria for ODD, the child must demonstrate at least four symptoms from any of the following categories: angry/irritable mood (often loses temper, is often touchy or easily annoyed, is often angry and resentful), argumentative/defiant behavior (often argues with authority figures or with adults, often actively defies or refuses to comply with requests from authority figures, often deliberately annoys others, often blames others for his/her mistakes or misbehavior), and vindictiveness (has been spiteful or vindictive at least twice within the past 6 months). These behaviors must be directed toward at least one person other than a sibling.

Question 41

CAP in kids? what are main organisms and s/s?

Answer 41

Community-acquired pneumonia in children is treated based on age. The most likely etiologic agents in a school-age child are Mycoplasma pneumoniae , Chlamydia pneumoniae , and Streptococcus pneumoniae . Group A Streptococcus and Haemophilus influenzae are less common causes. Staphylococcus aureus that is methicillin-resistant has become increasingly common. The preferred treatment for community-acquired pneumonia is a macrolide antibiotic such as azithromycin.
In children ages 5–16, Mycoplasma pneumonia tends to have a gradual onset of symptoms and seldom causes respiratory distress. Signs and symptoms may vary. The patient may develop a rash, musculoskeletal symptoms, or gastrointestinal symptoms. Radiographs may reveal bronchopneumonia, nodular infiltrates, hilar adenopathy, pleural effusions, or plate-like atelectasis. Ear pain may be due to bullous myringitis, although this may be viral as well. Laboratory findings may not be helpful, as the WBC count may be normal or slightly elevated.

Question 42

When is a likelihood ratio more useful than NNT

Answer 42

assessing diagnostic testing (likelihood) vs treatment (NNT)

Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. Clinically useful statistics for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratio.

The likelihood ratio indicates how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.

The number needed to treat is useful for evaluating data regarding treatments, not diagnosis.

Question 43

GLP-1 agonists are contraindicated in which patients?

Answer 43

patients with medullary thyroid cancer or multiple endocrine neoplasm syndrome, or with a family history of these conditions.

Question 44

when should Fe supplementation begin in infants who are born before 37 weeks?

Answer 44

According to the guidelines of the American Academy of Pediatrics, elemental iron supplementation (2 mg/kg per day) should begin at 1 month of age for exclusively breastfed infants born before 37 weeks gestation and should continue until 12 months of age, unless the infant had multiple blood transfusions.

Question 45

mgmt of infantinle hemangioma

Answer 45

Infantile hemangiomas usually appear by 4 weeks of age and stop growing by 5 months of age. As many as 70% leave residual skin changes, including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring. Systemic corticosteroids were the mainstay of treatment for hemangiomas during infancy until 2008, when the FDA approved oral propranolol for this indication. Intralesional corticosteroids can be effective for small, bulky, well localized lesions in infants. Laser therapy can also be used to treat early lesions or residual telangiectasia. Once involution is complete, however, as is the case with this child, elective surgical excision is the treatment of choice, producing better outcomes.

Question 46

drug indicated for shock due to sepsis

Answer 46

levophed - norepi

Question 47

when can LARCs be placed?

Answer 47

Long-acting reversible contraception (LARC) includes the copper IUD, levonorgestrel IUDs, and subdermal implants. LARCs can be placed at any point in the patient’s menstrual cycle (SOR A). There should be evidence that the patient is not pregnant prior to placement.

Question 48

tx for olecranon bursitis?

Answer 48

The initial management for this condition includes conservative measures such as padding,
elevation, icing, and analgesics (SOR B). If significant pain is associated with the swelling, or a decrease
in range of motion is present due to severe swelling, aspiration should be offered. This is not indicated in
this particular case and should be avoided to reduce the risk of septic bursitis.

Question 49

what is post exposure prophylaxis for meningoccocal disease?

Answer 49

Close contacts include those exposed in households, dormitories, or day care centers, and those who have direct contact with oral secretions. There are several options for prophylaxis, including ciprofloxacin, 500 mg orally one time; azithromycin, 500 mg orally one time; ceftriaxone, 250 mg intramuscularly one time; or rifampin, 600 mg orally twice daily for 2 days. Treatment should begin as soon as possible after exposure but no later than 14 days.

Question 50

What is a skin finding/sign that you get with dermatomyosiitis?

Answer 50

This disease is distinguished from autoimmune myopathies and polymyositis by distinct dermatologic findings, including Gottron’s sign (nonpalpable macules over the extensor surface of joints). Patients may also have dilated nail-fold capillaries and ragged, thickened cuticles.