Family Medicine Written Board Exam Sample Questions
Book 1- 2005
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QUESTION

69. A 76-year-old African-American male is seen in the hospital for a hip fracture after a mild fall. You are consulted by the orthopedic surgeon to evaluate him for a possible malignancy after radiographs reveal multiple lytic bone lesions in his spine and pelvis.

All of the following primary malignancies are likely to produce lytic bone metastases EXCEPT:

A) Breast
B) Lung
C) Thyroid
D) Kidney
E) Prostate

ANSWER

69.     E     Prostate

Many common malignancies metastasize to bone. The lesions they produce, whether they are osteoblastic or osteoclastic, result in a disruption of the cortical bone and a weakened bony architecture at higher risk of fracture. The mnemonic, Bacon Lettuce and Tomato (BLT) with Kosher Pickles, can aid in remembering the primary malignancies that metastasize to the bone:

B reast
L ung
T hyroid
K idney
P rostate

All of these malignancies can produce lytic lesions. Prostate cancer, however, is more likely to induce accelerated and poorly constructed overgrowth of bone then it is to cause demineralization and bony lysis.

1. Rosenthal, DI. Bone Tumors. Cecil Textbook of Medicine 22nd Ed. Goldman, Ausiello, 2004:1446-1448.

2. Ferri, FF. Ferri’s Clinical Advisor. Mosby, 2004:701-702.

142. You are seeing a 4-month-old child for a health maintenance visit. The parents are so far happy with the child’s development but state that when they enter his room or speak from across the room he does not turn to their voice.

On examination you find a healthy appearing infant with normal vocalizations of cooing and crying. A social smile is present and he is able to track with his eyes a red pompom across the midline but does not turn his head to the sound of the bell.

Which of the following statements is MOST accurate regarding his hearing at this time?

A) He is developmentally normal for his age
B) Infants who are deaf exhibit normal vocalizations
C) A normal auditory brainstem evoked response at birth indicates normal hearing now
D) The threshold for hearing impairment on audiology evaluation is 25 dB for infants
E) Assessment of his ability to hear should be deferred until he completes one week of empiric steroid treatment for otitis media with effusion

ANSWER

142.     B     Infants who are deaf exhibit normal vocalizations

Infants who are without any hearing continue to make normal vocalizations. It is not until a documented delay in the ability to form words that hearing deficits can be diagnosed by speech and vocalization alone. Because of the need for proper hearing to develop language, intellectual and social skills it is important that hearing deficits are detected much sooner. Risk factors associated with hearing deficits include:

• A family history of loss of hearing at < 5-years
• Prematurity, low birth weight, or NICU stay
• APGAR < 3 at 5 minutes
• Use of ototoxic agents including antibiotics in the neonatal period
• Prenatal infections
• Craniofacial anomalies

All high risk newborns receive hearing screening prior to hospital discharge and many states require it of all infants before leaving the nursery regardless of risk. These screenings are preformed with either an auditory brainstem evoked response or a transient evoked otoacoustic emissions test. The failure rate for these tests can be as high as 20% and ongoing screening must occur at every well-child check. Being able to track a visually stimulating object across the midline and not being able to elicit the same response with an auditory stimulus in a 4-month-old child is an indication of an abnormality. For any child in whom a concern exists, screening tests should be repeated. The threshold for hearing impairment in infants and young children is 15 dB unlike the 25 dB threshold for adults. A history of chronic or recurrent otitis media in an older child with clinical evidence of middle ear effusion with a documented speech delay warrants evaluation for myringotomy tube placement. Watchful waiting is time wasting when language and intellectual development are at risk.

1. Taylor, R (ed). Family Medicine Principles and Practice, 6th Ed., Springer-New York, 2003:613-614.

170. A 14-year-old female with a history of Down’s syndrome, hypothyroidism, obesity and obstructive sleep apnea syndrome (OSA) is brought to you for evaluation of persistent snoring and daytime fatigue. She was first diagnosed with OSA one year prior by a sleep study which revealed an apnea/hypopnea score of 18.2 events per hour (normal is less than 5), 19.3 arousals per hour (normal is less than 15), and oxygen desaturations to 80%. Her ECG and her echocardiogram were normal. She subsequently underwent an adenotonsillectomy. A follow-up sleep study preformed 6-months after her surgery revealed an apnea/hypopnea score of 4.2 events per hour with 16.3 arousals and oxygen desaturation to 88%.

Her physical exam reveals her to be 50% for height and 90% for weight. She is pleasant and well-appearing with an otherwise normal examination except for a mildly enlarged tongue. Her only medication is Synthroid and her last TSH was therapeutic 2-weeks prior to today’s visit.

Which of the following is the MOST likely cause of her persistent daytime fatigue?

A) Residual obstructive sleep apnea syndrome
B) Hypoventilation due to generalized hypotonia
C) Upper airway resistance syndrome
D) Hypothyroidism
E) Deconditioning

ANSWER

170.      A      Residual obstructive sleep apnea syndrome

Obstructive sleep apnea occurs in 30 to 60% of all patients with Down’s syndrome and is a consequence of the midfacial and mandibular hypoplasia, macroglossia, adenotonsillar hyperplasia, laryngotracheal anomalies, and obesity. Most patients with Down’s syndrome associated OSA are treated by a single surgical approach to correct only one of the constellations of anatomical factors that predisposes these patients to OSA. Persistent snoring with daytime fatigue as well as residual nocturnal oxygen desaturation and a borderline apnea/hypopnea score make residual OSA very likely in this population. Confirmation and evaluation for intervention includes assessing the anatomy further with a lateral neck xray, fluoroscopy, and an upper airway MRI. Many of these patients fail surgical interventions and require nightly Continuous Positive Airway Pressure (CPAP).

Hypoventilation during sleep is common in patients with hypotonia and results in a sleep-disordered, breathing-related hypoxemia but is not associated with obstructive events. Upper airway resistance syndrome is the triad of snoring, arousals, and fatigue without obstruction or oxygen desaturation. Fragmentation of sleep results in neurocognitive deficits and daytime fatigue. Untreated or suboptimal treated hypothyroidism may lead to central apnea but a therapeutic TSH makes this an unlikely cause. Both obesity and deconditioning may exacerbate daytime fatigue but it is necessary to first exclude more pathologic diagnoses before attributing the symptoms to these conditions alone.

1. Clinical practice guideline: diagnosis and management pf childhood obstructive sleep apnea. Pediatrics. Vol. 109, No. 4; 2002:704-712.

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