Family Practice Written Board Exam Sample Questions
Book 1 - 2004
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QUESTION

10. A 55-year-old white woman presents to your office with left knee pain. Upon further questioning, she states that the discomfort first started as fullness behind her left knee. Over time, the area has gotten swollen and become painful.

On examining her left knee, you note a fluid filled cystic structure lateral to the medial hamstring tendons. It is mildly tender to palpation. She has full range of motion, full stability, and no effusion of the left knee. No abnormality is found in the right knee. You make your diagnosis.

Which ONE of the following diseases is associated with a worse prognosis of this condition?

A) Discoid lupus
B) Rheumatoid arthritis
C) Sarcoidosis
D) Muscular dystrophy
E) Scleroderma

ANSWER

10.     B     Rheumatoid arthritis

The condition being described is that of a Baker’s cyst. A Baker’s cyst is a fluid filled sac, which may be connected to the knee cavity and associated with degeneration of the posterior horn of the medical meniscus. It often originates from the medial hamstring tendons. Patients often present with tenderness and swelling behind the knee and will complain of fullness and aching. Symptoms get worse as the cyst expands, and lessen once the cyst reaches a stable size. In patients with rheumatoid arthritis, these cysts may become extremely large and extend down to the ankle. Aspiration can be attempted to relieve pain and swelling, but this is usually a temporary measure as the cyst usually reoccurs. Surgical removal is recommended if the symptoms are intolerable or there is neurovascular compromise.

1. Snider, Robert K., MD, ed. Essentials of Musculoskeletal Care. 1st edition. American Academy of Orthopaedic Surgeons. Rosemont, Illinois. 1997:327-28.

11. A 45-year-old white man with a history of non-alcoholic cirrhosis presents to your office because a hepatic mass was found on ultrasound. You think it may be hepatocellular carcinoma, and order further diagnostic testing.

Which ONE of the following tumor markers is elevated in 80% of hepatocellular carcinomas?

A) Cancer Antigen 27.29 (CA 27.29)
B) Cancer Antigen 19-9 (CA 19-9)
C) Carcinoembryonic Antigen (CEA)
D) Alpha-Fetoprotein (AFP)
E) Cancer Antigen 125 (CA 125)

ANSWER

11.     D     Alpha-Fetoprotein

There are several tumor markers that are currently used in medicine to either follow response to therapy or detect relapse. None are used for screening because of their generally poor sensitivity and specificity. Alpha-Fetoprotein (AFP) is a major protein found in fetal serum but declines to an undetectable level after birth. Patients with viral hepatitis or cirrhosis can have increased AFP levels, but usually below 500ng per mL. AFP is associated with two malignancies: hepatocellular carcinoma and nonseminomatous germ cell tumors. 80% of hepatocellular carcinomas are associated with an elevated Alpha-Fetoprotein (AFP), with 40% of them having a level higher than 1000ng per mL. The use of AFP in hepatocellular carcinoma screening in high-risk patients is controversial, as there is not sufficient evidence that it makes a difference in outcome.

The major tumor markers can be associated with a variety of malignancies and conditions, but specific markers have a higher incidence with certain malignancies. Cancer antigen 27.29 is associated with breast cancer, whereas cancer antigen 19-9 is often seen with pancreatic or biliary tract cancers. An elevated cancer antigen 125 makes one suspicious for ovarian cancer. Colorectal adenocarcinoma often expresses carcinoembryonic antigen (CEA), and is used to follow therapy and watch for relapse.

1. Perkins, Greg L., M.D., et.al. “Serum Tumor Markers” American Family Physician 2003:68(6):1075-82.

150. A 38-year-old woman has a seizure in your office lobby. You arrive after the seizure has stopped and find the patient to be breathing with a normal pulse. She is non-verbal however and fails to follow commands. Her pupils are round and equally reactive and there is no nystagmus. Shortly after you call 911 she exhibits abrupt loss of consciousness with bilateral tonic extension of the trunk and limbs. This is followed by bilaterally synchronous muscle jerking and urinary incontinence.

What is the BEST diagnosis?

A) Generalized tonic-clonic seizure
B) Status Epilepticus
C) Simple partial seizure
D) Complex partial seizure
E) Epilepsia partialis continua

ANSWER

150.     B     Status Epilepticus

Status epilepticus is defined as two or more sequential seizures without full recovery of consciousness between seizures or more than 30 minutes of continuous seizure activity. This patient demonstrated the former. Epilepsia partialis continua refers to continuous focal seizures of one side of the body only. The patient’s isolated seizures do appear to be generalized tonic-clonic but by having then sequentially she has achieved status epilepticus. Simple partial seizures do not have impairment of consciousness. Complex partial seizures can be of temporal lobe or frontal lobe origin and are associated with automatisms and bizarre motor manifestations respectfully. Again, the sequential nature of this patient’s seizures makes status epilepticus the best diagnosis of those offered.

1. Sirvin JI, Waterhouse E. Management of Status Epilepticus. American Family Physician. 2003;68:469.

2. Goldman L, Bennett JC, (eds.). Cecil Textbook of Medicine. 21st edition. W.B. Saunders. Philadelphia PA. 2000:2153-2155.

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