Family Medicine EOR Exam: Personal
Review (Rosh)
A 13-month-old girl presents with her mother who says that her daughter has been sick
for 10 days. The girl had an initial period of head-cold symptoms and is now coughing
constantly. She is a well-nourished infant who demonstrates a rapid, consecutive cough
with a high-pitched inspiratory whoop. Records show that the family declined
vaccinations.
Which of the following interventions is most indicated in managing this patients illness? -
ANS-Oral clarithromycin
Explanation:
Oral macrolide antibiotics, using either erythromycin, azithromycin, or clarithromycin,
are the first-line treatment for the respiratory infection pertussis. Pertussis is an acute
respiratory illness that primarily causes illness in children under 2 years of age. Though
immunization exists against the causative pathogen, Bordetella pertussis, neither
immunization nor history of infection ensures lasting immunity, and adults often serve as
infectious reservoirs for the disease. Pertussis generally begins with a one to two-week
period of malaise, sneezing, and anorexia. It is followed by a persistent cough, with the
classic, high-pitched inspiratory whoop. Posttussive emesis also suggests pertussis.
Non-specific laboratory findings can include a white blood cell count of 15,000-20,000
with up to 80% lymphocytes. However, pertussis is definitively diagnosed by isolating
the organism from a nasopharyngeal culture. A 4-7 day course of treatment with a
macrolide antibiotic should be used to reduce coughing severity (if given early enough)
and shorten the duration of carriage. Close contacts should receive the same treatment
as prophylaxis against illness.
Though all infants are recommended to receive pertussis vaccination with a DTaP, what
form of vaccination is recommended for adults? - ANS-The CDC recommend that all
adults, including those over 64 years of age, receive a booster with a Tdap once during
their lifetime.
An 81-year-old man presents to the emergency department in respiratory distress. He is
sitting upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood
pressure of 190/110 mm Hg, heart rate of 130 bpm, respiratory rate of 35/min, and
oxygen saturation of 85% on room air.
,Which of the following physical examination findings most strongly suggests heart
failure as the cause of his respiratory distress? - ANS-Third heart sound
Explanation:
Respiratory distress can result from numerous pathologic states, including obstructive
airway disease (e.g., asthma and chronic obstructive pulmonary disease),
decompensated heart failure, myocardial infarction, pneumonia, upper airway
obstruction, tension pneumothorax, pulmonary embolism, fat embolism, and
neuromuscular disease. Emergency clinicians must quickly determine the cause of
respiratory distress in order to initiate appropriate treatment.
Heart failure is a common cause of respiratory distress. A weakened or diseased left
ventricle or one facing high systemic pressures cannot adequately pump blood and, as
a result, blood pools in the lungs, leading to pulmonary edema and clinical symptoms of
congestive heart failure. Symptoms include dyspnea on exertion, dyspnea at rest,
orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. However, these
symptoms are seen in many conditions and cannot be used to distinguish congestive
heart failure from other causes of dyspnea. Physical exam findings that suggest
congestive heart failure include the presence of a third heart sound or S3 gallop
(likelihood ratio [LR] 11.0), hepatojugular reflux (LR 6.4), and jugular venous distention
(LR 5.1). The combination of an S3 gallop and a chest radiograph showing pulmonary
venous congestion or interstitial edema is highly suggestive of congestive heart failure.
Which class of medications should be given initially for acute pulmonary edema? -
ANS-Nitrates
An otherwise healthy 27-year-old man presents with several days of fever, drenching
sweats, and shaking chills one week after returning from India.
Which of the following is most likely to reveal the diagnosis? - ANS-Thick and thin
peripheral smear
Explanation:
Malaria must be considered in any patient with a history of fever and travel to an
endemic region. Four species cause disease in humans: Plasmodium falciparum,
Plasmodium ovale, Plasmodium vivax, and Plasmodium malariae. P. falciparum is the
most virulent form of the disease able to cause severe organ dysfunction and death.
The lifecycle of the organism causes irregular or cyclic fevers in patients that is
associated with RBC lysis. Other symptoms include headache, nausea, abdominal pain,
,and upper respiratory complaints. The gold standard includes thick and thin smears of
the blood viewed under light microscopy to identify the parasite.
What test may be falsely positive in malaria patients? - ANS-VDRL (Venereal Disease
Research Laboratory test)
A 62-year-old man with a history of hypertension on amlodipine and type 2 diabetes
mellitus on metformin presents to the emergency department with dull chest pain that
started 8 hours ago. The patient appears mildly diaphoretic. Vital signs include a heart
rate of 104 bpm, blood pressure of 135/92 mm Hg, and respiratory rate of 22 breaths
per minute. He has a regular rate and rhythm, and his lungs are clear to auscultation
bilaterally. An ECG was performed and is shown above. The initial cardiac troponin I is
9.8 ng/mL. You discuss with the cardiologist on call who plans to perform cardiac
catheterization with coronary angiography in 24 hours.
Which of the following is an appropriate treatment to administer now? -
ANS-Unfractionated heparin
Explanation:
The patient in the vignette meets the diagnostic criteria for a non-ST elevation
myocardial infarction (NSTEMI). Non-ST elevation myocardial infarction is marked by an
elevated troponin due to myocardial ischemia in the absence of new ST elevation or
pathologic Q waves in contiguous leads on an electrocardiogram. Patients often present
with chest pain or other anginal equivalents, such as dyspnea with exertion. The chest
pain often radiates to one or both extremities, and patients frequently experience
diaphoresis and nausea and vomiting with the chest pain. Anginal chest pain is
classically worse with exertion and improved with rest. According to the Fourth
Universal Definition of myocardial infarction, the typical ECG findings for non-ST
elevation myocardial infarction are new horizontal or downsloping ST depression of at
least 0.5 mm in two contiguous leads, T wave inversion > 1 mm in two contiguous leads
with prominent R wave or R/S ratio, or both. Troponin is the cardiac biomarker that is
most sensitive and specific for myocardial injury. The clinical setting must be considered
to determine if myocardial infarction is the cause of the troponin elevation since there
are several other causes of troponin elevation. In patients who present with suspected
acute coronary syndrome, the initial troponin may be negative. In these cases, a
troponin measurement should be repeated 2-6 hours later. The treatment of non-ST
elevation myocardial infarction consists of dual antiplatelet therapy, anticoagulation,
and, in most patients, early coronary angiography with revascularization. The
recommended dual antiplatelet regimen is aspirin and a P2Y12 receptor antagonist,
, such as ticagrelor or prasugrel. Unfractionated heparin is the preferred anticoagulant in
patients with non-ST elevation myocar
What are some possible explanations for a patient experiencing a non-ST elevation
myocardial infarction and subsequently having a normal coronary angiography? -
ANS-Rapid clot lysis, vasospasm, or coronary microvascular disease.
A 7-day-old infant presents for eye discharge. He was born at home with the aid of a
midwife. On exam, the infant has copious mucopurulent discharge from both eyes,
swollen eyelids, and chemosis.
Which of the following is the most appropriate treatment? - ANS-Oral erythromycin
Explanation:
Oral erythromycin is the treatment of choice for neonatal chlamydial conjunctivitis.
Chlamydia trachomatis is the most common bacterial sexually transmitted infection in
the United States. Conjunctivitis and pneumonia are the most frequent clinical
manifestations of neonatal C. trachomatis infections. C. trachomatis is the most
common cause of conjunctivitis in the newborn. Vaginal delivery has the highest risk
transmission to the newborn. The incubation period for neonatal chlamydial
conjunctivitis is 5-14 days after delivery. Neonates with chlamydial conjunctivitis typically
present with mucopurulent ocular discharge, eyelid swelling, and erythematous
conjunctiva. Culture is the gold standard for diagnosing chlamydial conjunctivitis. The
American Academy of Pediatrics and the Centers for Disease Control both recommend
oral erythromycin as the first-line treatment for chlamydial conjunctivitis. Oral
azithromycin is an alternative to oral erythromycin. The infant's mother and sexual
partners should also be screened and treated for chlamydia. The best method for
preventing chlamydial conjunctivitis is screening and treating the mother. Topical
prophylactic antibiotics are ineffective at preventing chlamydial conjunctivitis.
In infants, erythromycin use is a risk factor for development of what gastrointestinal
condition? - ANS-Infantile hypertrophic pyloric stenosis
A 3-year-old previously healthy, fully immunized boy presents after a seizure that
occurred two hours prior to arrival. He has never had a seizure before. Today, he
experienced a 35 second generalized tonic-clonic seizure. He had a postictal period of
20 minutes and is now at his neurologic baseline. Emergency Medical Services were
called and he had a blood glucose level of 84 mg/dL on scene. He has had a cough and
runny nose for the past day. Shortly before the seizure, he developed a fever to 39.3°C.
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