Family Practice Written Board Exam Sample Questions
Book 3 - 2004
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QUESTION

2. A 46-year-old Caucasian woman presents to the emergency room because of abdominal pain. She states that over the past several months she has had crampy abdominal pain intermittently, usually after eating a meal. This time the pain has persisted and she feels weak. Vital signs show a temperature of 103º F, respiratory rate of 16, heart rate of 110, and blood pressure of 82/40.

Examination shows an overweight female with jaundiced skin and right upper quadrant abdominal pain with a positive Murphy’s sign. You order an emergent surgical consult.

Based on history and examination, which ONE of the following diagnoses most COMPLETELY describes this patient’s condition?

A) Acute pancreatitis
B) Acute cholecystitis
C) Cholelithiasis
D) Acute ascending cholangitis
E) Choledocholithiasis

ANSWER

2.     D     Acute ascending cholangitis

Disorders of the biliary tree are common in general surgery and it is important for the family physician to determine the urgency of the situation when a patient presents with a surgical condition of the biliary system. There are many Americans who have asymptomatic gallstones, or cholelithiasis, and live with them for decades with no problems. About 20% of patients with asymptomatic gallstones will eventually develop symptoms. Acute cholecystitis is diagnosed when a gallstone blocks the opening of the gallbladder (usually in Hartmann’s pouch) or the cystic duct causing congestion and colicky right upper quadrant abdominal pain. Choledocholithiasis is when there is presence of a gallstone in the common bile duct, which can then cause back up of bile and systemic jaundice.

The most worrisome complication of obstructive biliary disease is that of acute ascending cholangitis. This occurs when a gallstone blocks the common bile duct and an infection takes place. The classic triad of acute ascending cholangitis, termed Charcot’s triad, consists of jaundice, right upper quadrant pain, and high fever. When the patient also has mental confusion and hypotension (Reynolds pentad), the patient almost certainly has acute suppurative cholangitis. This is a surgical emergency and intervention is needed immediately.

1. Lawrence, Peter F., M.D. ed. Essentials of General Surgery 2nd edition. Williams & Wilkins, Baltimore. 1992:244-54.

92. Pharmacologic therapy used in the management of lipid abnormalities includes:

A) Folic Acid and HMG CoA reductase inhibitors (statins)
B) HMG CoA reductase inhibitors (statins) and Fibric Acid derivatives
C) Bile acid Sequestrants and niacin
D) A & B
E) B & C

ANSWER

92.     A     Folic Acid and HMG CoA reductase inhibitors (statins)

Pharmacologic management of lipid abnormalities includes the use of:

HMG-Co A reductase inhibitors (Statins). Statins lower LDL-C levels by interfering with cholesterol synthesis within the liver. Side effects include increased liver enzymes, myopathy, rhabdomyolysis and acute renal failure. Liver enzymes should be monitored periodically. If they become elevated to three times the upper limit of normal on two separate occasions, the statin therapy should be discontinued.
Fibric acid derivatives may be used in patients with elevated triglycerides. They act by blocking VLDL synthesis and increasing VLDL clearance in the liver. Fibric acids should be taken 30 minutes before the morning and evening meals as food may interfere with their action. Fibric Acids may increase the overall level of warfarin. The most common side effect is the development of gallstones and dyspepsia.

Bile acid sequestrants used in the treatment of LDL-C are associated with GI side effects such as bloating, constipation and heartburn. They are used in patients who have abnormal liver function tests. They are contraindicated in patients with elevated triglycerides, as they are known to increase triglyceride levels. Patients should be instructed to eat fruits, vegetables and high fiber foods to avoid constipation.

Nicotinic Acid is an inexpensive and effective means for lowering triglycerides and total cholesterol levels. It raises the HDL-C levels while lowering the LDL-C levels. Adverse reactions include: gastritis, flushing of skin and GI upset and gout exacerbation. Taking Nicotinic acid with a hot beverage and Aspirin 30 minutes before Nicotinic acid may limit the flushing. One should advise patients to avoid taking Nicotinic acid with meals and alcohol. Nicotinic Acid is also contraindicated in patients with diabetes; it can increase insulin resistance.

Folic acid is used to control Homocysteine levels. Homocysteine is an amino acid found in the blood stream. Elevated levels may increase a person’s risk for CAD. Homocysteine may also damage the inner layer of the artery, initiating cellular events that may cause atherosclerosis.

1. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285(19): 2486-2497.

2. Johnson D et al. Complementary approaches to combating atherosclerosis. JAAP 1998; 11:53-56, 63-64

3. Stemestrand IF et al. “Early Statin Treatment Following Acute Myocardial Infarction. And 1 year survival: JAMA 2001; 285: 430-436.

109. The Centers for disease Control and Prevention (CDC) recommends that primary care physicians evaluate the vaccination status for all patients over 50 years of age.

Which of the following are the three vaccine-preventable diseases?

A) Pneumococcal, influenza, Lyme vaccine
B) Influenza, Hepatitis B and Tetanus/diphtheria Toxoids
C) Hepatitis B, Pneumococcal and Influenza
D) Tetanus/Diphtheria, Measles, mumps and rubella (MMR) and Hepatitis A
E) Influenza, MMR and Tetanus

ANSWER

109.     C     Hepatitis B, Pneumococcal and Influenza

Influenza, pneumococcal and hepatitis B virus is responsible for the deaths of 50,000-70,000 American adults each year. Hepatitis B virus is the most transmissible of all the blood-borne viruses and at present is the only blood-borne virus in which transmission is preventable by vaccination. Hepatitis B is transmitted by blood and serum-derived fluids. The vaccine is given I.M. in three separate doses and repeated one to six months later. Medical, behavioral and occupational indications for the vaccine include those that are on hemodialysis and receiving clotting factor concentrations, health care workers and public safety workers who have exposure to blood in the work place or in schools training for medical and allied health professions, IV drug users, partners having multiple sex partners (hetero and homosexuals), and staff for those taking care of institutionalized patients or inmates. Two other vaccine preventable diseases; influenza and pneumococcal disease, contribute to the mortality of older patients in the United States. Influenza caused an average of 20,000 deaths per year during the influenza epidemic from 1969-1996; persons aged greater 65 accounted for approximately 90% of these deaths. Pneumococcal disease caused approximately 3,400 deaths among persons in the same age range in 1998. Continued efforts are needed to increase the proportion of older adults who receive influenza and pneumococcal vaccines. Health care providers should offer pneumococcal vaccine all year and should continue to offer influenza vaccine during December and throughout the influenza season.

1. Lewis C. “Standards of adult immunization and strategies for improving coverage”. Family Practice Recertification. December 2001; 23:19-29.

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