What screening test has most potential for overdx? - PSA- Overdiagnosis is the diagnosis of a disease that will not produce symptoms during a patient's lifetime. It tends to occur with cancers that have very slow rates of growth. Prostate cancer is most often a slow-growing cancer and is often pres...
AAFP Board Exam Review 2022 COMPLETE SOLUTION
325 Questions with 100% Correct Answers
What screening test has most potential for overdx? Correct Answer: PSA- Overdiagnosis is the
diagnosis of a disease that will not produce symptoms during a
patient's lifetime. It tends to occur with cancers that have very slow rates of growth.
Prostate cancer is most often a slow-growing cancer and is often present without
symptoms in older men. The introduction of prostate-specific antigen (PSA) screening was
accompanied by a marked rise in the rate of diagnosis of prostate cancer while mortality
decreased much less significantly, and this decrease was probably largely attributable to
improved treatment.
What is the treatment for mallet fracture? Correct Answer: The recommended treatment for a
mallet fracture is splinting the distal interphalangeal (DIP) joint in
extension (SOR B). The usual duration of splinting is 8 weeks. It is important that extension be
maintained
throughout the duration of treatment because flexion can affect healing and prolong the time
needed for
treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or
orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes
similar
to those of surgical treatment and therefore is generally preferred.
If subluxed radial head is suspected in a child, is imaging needed? Correct Answer: As long as
there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt
reduction of the radial head before moving on to imaging studies. With the child's elbow in 90°
of flexion, the hand is fully supinated by the examiner and the elbow is then brought into full
flexion. Usually the child will begin to use the affected arm again within a couple of minutes. If
ecchymosis, significant swelling, or pain away from the joint is present, or if symptoms do not
improve after attempts at reduction, then a plain radiograph is recommended.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a day for the
last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual period was 3 months
ago. Other than the fact that she appears to be slightly underweight, her examination is normal.
To fit the criteria for the female athlete triad, she must have which one of the following? Correct
Answer: The initial definition of the female athlete triad was amenorrhea, osteoporosis, and
disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing
that the triad components occur on a continuum rather than as individual pathologic conditions.
The definitions have therefore expanded. Disordered eating is no longer defined as the formal
diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus
exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions
and substantial energy expenditures disrupt pituitary and ovarian function.
Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress
fracture resulting from minimal trauma should have a bone density test. Low bone mineral
,density for age is the term used to describe at-risk female athletes with a Z-score of -1 to -2.
Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-
score <-2.
what is the work up for secondary amenorrhea? Correct Answer: This patient suffers from
secondary amenorrhea (defined as the cessation of regular menses for 3 months or irregular
menses for 6 months). The most common causes of secondary amenorrhea are polycystic ovary
syndrome, primary ovarian failure, hypothalamic amenorrhea, and hyperprolactinemia. With a
normal physical examination, negative pregnancy test, and no history of chronic disease, a
hormonal
workup is indicated, including TSH, LH, and FSH levels (SOR C).
A hormonal challenge with medroxyprogesterone to provoke withdrawal bleeding is used to
assess
functional anatomy and estrogen levels (SOR C). However, it has poor specificity and sensitivity
for
ovarian function and a poor correlation with estrogen levels.
Pelvic ultrasonography is indicated in the workup of primary amenorrhea to confirm the
presence of a uterus and detect structural abnormalities of the reproductive organs. Likewise,
karyotyping can be used for patients with primary amenorrhea, as conditions such as Turner's
syndrome and androgen insensitivity syndrome are due to chromosomal abnormalities.
A CBC and metabolic panel would not be initial considerations in the workup of amenorrhea
unless the patient has a known chronic disease which may affect the results.
What's the first line treatment for primary dysmenorrhea? Correct Answer: The first-line
treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be started
at the onset of menses and continued for the first 1-2 days of the menstrual cycle.
Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of
high-quality randomized, controlled trials demonstrating pain improvement (SOR B). They may
be a good choice if the patient also desires contraception. Although combined oral contraceptives
and intramuscular and subcutaneous progestin-only contraceptives are effective treatments for
dysmenorrhea caused by endometriosis, they are NOT first-line therapy for primary
dysmenorrhea.
A 24-year-old female presents with pelvic pain. She says that the pain is present on most days,
but is worse during her menses. Ibuprofen has helped in the past but is no longer effective. Her
menses are normal and she has only one sexual partner. A physical examination is normal.
Which one of the following should be the next step in the workup of this patient? Correct
Answer: The initial evaluation for chronic pelvic pain should include a urinalysis and culture,
cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG
level, and pelvic ultrasonography. CT and MRI are not part of the recommended initial
diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic
,ultrasonography. Referral for diagnostic laparoscopy is appropriate if the initial workup does not
reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would
be indicated if the history or examination suggests a gastrointestinal source for the pain after the
initial evaluation.
what can induce ovulation in PCOS? Correct Answer: This patient fits the criteria for polycystic
ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms
also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis.
Metformin has the most evidence supporting its use in this situation, and is the only treatment
listed that is likely to decrease hirsutism and improve insulin resistance and menstrual
irregularities. Metformin and clomiphene alone or in combination are first-line agents for
ovulation induction. Clomiphene does not improve hirsutism, however. Progesterone is not
indicated for any of this patient's problems. Spironolactone will improve hirsutism and menstrual
irregularities, but is not indicated for ovulation induction.
What is the first step for evaluating a thyroid nodule? Correct Answer: Thyroid nodules >1 cm
that are discovered incidentally on examination or imaging studies merit further evaluation.
Nodules <1 cm should also be fully evaluated when found in patients with a family history of
thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node
enlargement.
Reasonable first steps include measurement of TSH or ultrasound examination. The American
Thyroid Association's guidelines recommend that TSH be the initial evaluation (SOR A) and that
this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic
ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular
goiter, or a nodule found
incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or
calcitonin levels is not currently recommended.
CDC guidelines for a flu outbreak? Correct Answer: The occurrence of two or more laboratory-
confirmed cases of influenza A is considered an outbreak in a long-term care facility. The CDC
has specific recommendations for managing an outbreak, which include *chemoprophylaxis with
an appropriate medication for all residents who are asymptomatic and treatment for all residents
who are symptomatic*, regardless of laboratory confirmation of infection or vaccination
status.
All staff should be considered for chemoprophylaxis regardless of whether they have had direct
patient contact with an infected resident or have received the vaccine. Requesting restriction of
visitation is recommended; however, it cannot be strictly enforced due to residents' rights.
number needed to treat
A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If
the usual incidence of this complication were 1% per year, how many patients with this disease
would have to be treated with this medication for 1 year to prevent one occurrence of this
, complication? Correct Answer: Considering relative risk reduction without also considering the
absolute rate can distort the importance of a therapy. A useful way to assess the importance of a
therapy is to determine the number needed to treat to benefit one patient. To calculate this
number, the percentage of absolute risk reduction of a particular therapy is divided into 100. In
the case in question, the absolute risk reduction is 0.5% (0.5×.01). Thus, the number-needed-to-
treat for the example cited is 200 (100/0.5).
Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base
located on the face and trunk, containing eosinophils. Which one of the following would be most
appropriate at this time? Correct Answer: This infant has findings consistent with erythema
toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No testing
is usually necessary because of the distinct appearance of the lesions. The cause is unknown.
American Urological Association guidelines define asymptomatic microscopic hematuria as
which one of the following in the absence of an obvious benign cause? Correct Answer: The
American Urological Association guidelines define asymptomatic microscopic hematuria
(AMH) as ≥3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious
benign cause (SOR C).
A positive dipstick does not define AMH, and evaluation should be based solely on findings
from microscopic examination of urinary sediment and not on a dipstick reading. A positive
dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH.
How to manage respiratory distress in the terminally ill patient at 94% O2? Correct Answer:
Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of
hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment
and other measures may be appropriate in specific circumstances. For example, inhaled
bronchodilators or glucocorticoids may be
helpful in patients with COPD, and diuresis may be helpful in patients with heart failure. The
evidence for oxygen in patients with hypoxemia is not clear, but
there is no benefit from oxygen for nonhypoxemic patients
According to the guidelines developed by the JNC 8 panel, which one of the following should
NOT be used as a first-line treatment for hypertension? Correct Answer: ACE inhibitors,
angiotensin receptor blockers (ARBs), calcium channel blockers, and
thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high
blood
pressure in the nonblack population, including patients with diabetes mellitus.
B-Blockers were not recommended for the initial treatment of hypertension because one study
found there was a higher rate of the primary composite outcome of cardiovascular death,
myocardial infarction, or stroke with use of these drugs compared to the use of an ARB.
A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness
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