Family Practice Written Board Exam Sample Questions
Book 2 - 2004
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QUESTION

7. A 3-year-old Hispanic male toddler arrives at your office with his mother. She is concerned because the child has had vomiting and diarrhea for the past 36 hours. His illness began with vomiting and then about 24 hours later he began having profuse watery diarrhea and a low-grade fever. It has been difficult to get him to drink liquids or eat anything. He is in daycare where several other children have had diarrhea. The diarrhea is described as greenish in color and there has been no blood or mucus.

Examination reveals a tired appearing child with a low-grade fever, no tenting of the skin, mucus membranes are moist, and there is lymphadenopathy of the cervical and inguinal areas. The rest of the exam including the abdomen is benign. You make your diagnosis.

Which ONE of the following infectious agents is the most likely cause of this child’s illness?

A) Parvovirus
B) Salmonella enteritidis
C) Giardia lamblia
D) Campylobacter jejuni
E) Rotavirus

ANSWER

7.      E      Rotavirus

The most common cause of acute gastroenteritis in both developing and developed countries is viruses, of which rotavirus is the most prevalent. In America, rotavirus mostly affects children aged 3 to 15 months, usually in the winter months. The virus is transmitted via the fecal-oral route and is quite hardy, lasting for days on environmental fomites. Rotavirus infection begins with vomiting and then follows with voluminous watery diarrhea and low-grade fevers. Treatment of this infection is supportive, with emphasis on hydration status. Some children have severe cases and need to be hospitalized for intravenous fluids. Prevention is good hygiene with frequent handwashing. A rotavirus oral vaccine was developed in the late 1990’s but it was associated with intussusception and is therefore not recommended.

Parvovirus does not cause gastroenteritis. Giardia lamblia can cause profuse watery diarrhea, but it is not the most common cause and it does not usually cause vomiting. Salmonella and Campylobacter cause diarrhea that is often bloody in nature and occur after food poisoning. These bacterial infections are more rare than viral infections.

1. Hay, William W., Jr., M.D. et. al. (eds.) Current Pediatric Diagnosis & Treatment Mc-Graw Hill, New York, 2001:553-54.

19. A 34-year-old Caucasian man is brought in by ambulance after a motor vehicle accident. The man was trapped inside his car when it broke out in flames.

Examination of the patient reveals stable vital signs and a normal mental status. His airway is patent. There are extensive second and third degree burns on approximately 54% of his body.

The MOST important treatment for this patient in the first 24 hours is:

A) Topical wound care
B) Intravenous antibiotics
C) Intravenous crystalloid
D) Pain control
E) Intravenous dopamine

ANSWER

19.     C     Intravenous crystalloid

Extensive burns should be approached as a severe trauma and be treated accordingly. It is important to assess the airway, breathing, and circulation of a burned patient first and then address the injuries. When examining the patient, it is important to make sure that the burning process is not still occurring, because of affected clothing or chemicals on the body. Pharyngeal examination is important to make sure there is no edema that could compromise the airway. Approximation of surface area involved can be assessed using a burn chart. Patients with more than 20% of surface area burned should be evaluated for transfer to a burn center.

The most important treatment for burn victims in the first 24 hours is intravenous crystalloid. Due to the trauma to the skin, there can be a massive amount of fluid loss. The Parkland formula is used to determine the amount of fluid needed. During the initial 24 hours, the burn patient requires approximately 400mL of crystalloid solution per kilogram of total body weight multiplied by the percent of body surface area burned. Half of this requirement should be given in the first 8 hours followed by the other half in the next 16 hours. This formula is only an estimate and the patient’s urinary output should be followed to evaluate proper hydration. Pain control and proper wound care are necessary as well, but not as important as initial fluid resuscitation for survival.

1. Lawrence, Peter F., M.D. ed. Essentials of General Surgery 2nd edition. Williams & Wilkins, Baltimore. 1992:161-64.

102. Clinically you suspect a primary tuberculosis infection. You order a chest x-ray.

Which one of the following results will you MOST likely find?

A) Parenchymal lung calcifications
B) Hilar lymph nodes
C) Solitary nodule at the base of the lungs
D) Diffuse infiltrates
E) Fibronodular upper lobe infiltrate

ANSWER

102.     E     Fibronodular upper lobe infiltrate

Tuberculosis (TB) is caused by a small bacterium with thick lipid walls, which make it very resistant to destruction by macrophages or drugs. It multiples slowly and can be dormant for many years. The infection is spread by droplet nuclei from infected people. Once inhaled it causes a local inflammatory reaction in the periphery of the lung. Clinical disease rarely occurs at this stage. The asymptomatic infection leaves most people with a positive skin test and possibly a parenchymal lung calcification (Ghon lesion). The chest radiograph in patients with active TB most frequently shows a fibronodular upper lobe infiltrate. Cavities may form, along with hilar adenopathy, pleural effusion, or upper lobe volume loss may be present. After this initial infection parenchymal lung calcifications (Ghon lesions) can be associated with calcified hilar lymph nodes. Of those who have converted skin test (newly infected), 3-5% will develop active TB within the first year of exposure. Of all those with positive skin tests, no risk factors, normal chest x-ray, not recent converters, approximately one in 2000 will develop active TB each year.

1. Pulmonary Infections. In: Taylor RB editors. Family Medicine Principles and Practices. 5th ed. New York. Springe, 1998:740-743.

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