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Rosh Review family med Exam Actual Questions & Answers with complete solutions 100- Correct
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Rosh Review family med Exam Actual Questions and Answerswith complete solutions 100% Correct.
A businessman, who frequently travels in airplanes, complains of painful ear popping every time he flies. He has
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tried yawning, swallowing, chewing gum and pinching his nose, but nothing seems to relieve the pain. He has even
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tried using ibuprofen two hours prior to flight.
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Which of the following would you recommend?
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A.Myringotomy
B.Nifedipine
C.Oxymetazoline o
D.Ranitidine - Correct Answer - Correct Answer ( C )
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Explanation:
Barotitis media, barotrauma, or ear popping, are all names for eustachian tube dysfunction, a condition that occurs
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when the tube does not open properly during swallowing or yawning. This tube, connecting the middle ear to the
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pharynx, equalizes pressure inside the ear to the atmospheric pressure. Blockage of the tube can arise from
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congenital stenosis, abnormal peristaltic function, abnormal ciliary function, adenoid hypertrophy, nasal congestion
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and tumors. Risk factors include ear or sinus infections, allergies and rapid altitude changes. Symptoms include ear
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fullness, otalgia, tinnitus, hearing impairment and vertigo. Diagnosis is mainly clinical, but further evaluation may
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involve an audiogram, tympanogam or otolaryngologist referral. Treatment includes chewing gum, multiple swallows
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and exhalation through closed nostrils. If refractory, medications may be necessary, and include analgesics, oral
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antihistamines and nasal decongestants or steroids. Oxymetazoline is an over-the-counter nasal spray
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decongestant.
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A 26-year-old woman presents for her annual exam and is inquiring about birth control. She is current on her
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immunizations and her last pap smear was 2 years ago. She is in a monogamous relationship with her boyfriend
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and does not have any immediate plans for pregnancy. She has a history of migraines with aura but does not
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require any prescription medication.
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Which of the following birth control methods is the best option for her?
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A. Behavioral methods such as the withdrawal method and periodic abstinence
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B. Etonogestrel/ethinyl estradiol vaginal
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,C. Medroxyprogesterone acetate
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D. Norelgestromin/ethinyl estradiol transdermal - Correct Answer - Correct Answer ( C )
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Explanation:
Contraception counseling should be routinely performed in all women of child-bearing age at every annual visit.
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There are many options such as behavioral, barrier and pharmacological methods. However, pharmacological
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therapy has the highest rate of pregnancy prevention and should be recommended in all women, unless there are
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contraindications. This patient has a history of migraines with aura which is considered a contraindication to
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estrogen use. Other contraindications to estrogen are history of deep vein thrombosis, breast cancer within the past
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5 years, cigarette smoking in women more than 35 years of age who smoke more than 15 cigarettes per day,
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ischemic heart disease, stroke, active liver disease, major surgery with prolonged immobilization and poorly
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controlled hypertension. In these cases, progesterone only therapy (medroxyprogesterone) should be used in the
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form of the intrauterine device, the injection or the subcutaneous implantation in the arm.
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A 24-year-old woman with no past medical history presents with left wrist pain after a fall. The left extremity is
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grossly deformed and the patient complains of severe pain. The patient has a blood pressure of 183/100 mm Hg.
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While awaiting X-rays, what management is indicated for the patients elevated blood pressure?
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A. Arrange admission for blood pressure control
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B. Start an oral beta-blocker and monitor for response
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C. Start intravenous beta-blocker and admit to the intensive care unit
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D. Treat the patient's pain and reassess the blood pressure - Correct Answer - Correct Answer ( D )
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Explanation:
The patient presents with a markedly elevated blood pressure in the setting of pain from a trauma and should have
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pain control initiated and her blood pressure rechecked. Hypertension is defined as a persistent SBP >140 mm Hg
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or DBP >90 mm Hg. Pain and anxiety are common causes of elevated blood pressure and heart rate in the
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outpatient setting. Historically, patients with elevated blood pressure and nonspecific symptoms were referred to as
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hypertensive urgency but this term has fallen out of use. In a patient presenting with elevated blood pressure who
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does not have signs or symptoms of end-organ damage, the clinician's focus should be on identifying external
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reasons for the elevated pressure and treating or addressing these. In this case, the reduction or relief of pain will
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likely lead to decreased blood pressure.
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(A) Patients with elevated blood pressure and an absence of end-organ damage (e.g. acute coronary syndrome,
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oaortic dissection, encephalopathy, change in renal function) do not require admission for management. A primary
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ocare physician in the outpatient setting best manages these patients.
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,(B) Starting a beta-blocker will not be beneficial in a patient with acute pain as the cause of elevated blood pressure.
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(C) Similarly, administration of an intravenous beta-blocker and admission to the intensive care unit is not indicated
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oas the patient exhibits no end-organ damage.
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Which of the following disorders causes a normal anion gap metabolic acidosis?
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A. Cyanide exposure
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B. Diabetic ketoacidosis
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C. Diarrhea
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D. Salicylate ingestion - Correct Answer - Correct Answer ( C )
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Diarrhea is a common cause of normal anion gap metabolic acidosis. Metabolic acidosis is defined as a reduced
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serum bicarbonate concentration. Normal anion gap metabolic acidosis is thought to be less immediately dangerous
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than anion gap metabolic acidosis. Normal anion gap metabolic acidosis can be caused by a variety of conditions
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including rapid infusion of 0.9% saline, renal tubular acidosis, ingestion of acetazolamide and calcium chloride and
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hypoaldosteronism.
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Cyanide (A), diabetic ketoacidosis (B) and salicylate ingestion (D) are all causes of increased anion gap metabolic
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acidosis.
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A 58-year-old man presents with 3 months of headache and diplopia. He also reports that chewing tough foods has
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been progressively painful. Laboratory testing reveals a normocytic anemia and ESR of 88 mm/hour. A brain CT is
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normal. Which of the following is the most appropriate initial intervention?
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A. Intravenous methylprednisolone
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B. Oral methotrexate
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C. Temporal artery biopsy
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D. Ultrasonography - Correct Answer - Correct Answer ( A )
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Giant cell arteritis (GCA), as known as temporal arteritis, is the most common primary vasculitis of the elderly, and
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predominately affects those aged over 50 years. It is a syndrome of systemic inflammation which mainly affects the
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branches of the internal and external carotid arteries, but it can affect any vessel in the body. The most common
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symptoms are a temporal or occipital headache, jaw claudication (mandibular, tooth and tongue pain with chewing
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tough foods), visual changes (partial or complete blindness, diplopia, visual field cuts or amaourosis fugax) and
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arthralgias. It is associated with constitutional symptoms, anemia, an enlarged tender nodular erythematous
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, o temporal artery, ESR > 50 mm/hour and polymyalgia rheumatica. Temporal artery biopsy confirms the diagnosis.
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o Since unilateral partial or complete blindness occurs in up to 20% of patients with GCA, immediate treatment is
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o necessary when this condition is suspected. High-dose corticosteroids are the standard treatment, and typical
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o options include 40-60 mg per day of oral prednisone, or intravenous methylprednisolone. High-dose therapy is
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o usually continued for 2-4 weeks, and titrated against visual and headache improvement, not serial ESR monitoring.
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o After symptoms lessen, steroids are slowly tapered over 6 months, with complete tapering off in 2 to 3 years. As
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o such, the clinician must monitor for complications of long-term corticosteroid therapy. These include hypertension,
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o diabetes, osteoporosis, steroid myopathy (proximal weakness), fluid retention, bruising, insomnia, restlessness,
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o hypomania and hypercholesterolemia. o o
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Adjuvant methotrexate (B) is not routinely recommended for treating GCA as studies of its efficacy are inconclusive.
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If GCA is suspected, intravenous methylprednisolone should be started even before a temporal bio
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A 33-year-old woman with no medical problems presents with chest pain and shortness of breath. The symptoms
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worsened over the previous two days and increase with exertion. The patient denies cough, but last week reports
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fevers, chills, coughing and myalgias. Her ECG demonstrates sinus tachycardia without ST segment changes. Vital
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signs are T 100.7°F, HR 120, BP 108/60, RR 16, 100% saturation on room air. Which of the following is the most
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likely diagnosis?
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AAcute coronary syndrome
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BMediastinitis
CMyocarditis
DPulmonary embolism - Correct Answer - Correct Answer ( C )
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Explanation:
Myocarditis is typically caused by a viral infection, most commonly coxsackie B virus, adenovirus, parvovirus B19
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and Echovirus. Trypanasoma cruzi (Chagas disease) is the most common etiology worldwide. Myocardial necrosis
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occurs likely as a result of direct invasion of the offending organism as well cytotoxic effects of the host's immune
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system. Individuals develop flulike symptoms and in adults chest pain and shortness of breath. One of the hallmark
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signs of myocarditis is tachycardia out of proportion to fever. Depending on the time of presentation, patients may
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have symptoms of heart failure as the left ventricular ejection fraction is impaired as a result of the myocarditis.
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Troponin is often elevated as the disease progresses. The gold standard for diagnosis is endocardial biopsy.
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Management is supportive. ACE inhibitors help reduce myocardial inflammation.
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Acute coronary syndrome (A) is a possibility in this patient but is less likely given her age and absence of medical
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history. It is also atypical for a person with acute coronary syndrome to have a fever and viral symptoms.
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Mediastinitis (B) may present with fever, chest pain and shortness of breath. However, there is often a history of
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either severe retching or a procedure that caused esophageal perforation. Patients with air in the mediastinum from
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a perforation may have Hamman's sign, a crunching sound on auscultation. Pulmonary embolism (D) does cause
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