Rosh Review Family Med Exam
A businessman, who frequently travels in airplanes, complains of painful ear popping every time he flies.
He has tried yawning, swallowing, chewing gum and pinching his nose, but nothing seems to relieve the
pain. He has even tried using ibuprofen two hours prior to flight.
Which of the following would you recommend?
A.Myringotomy
B.Nifedipine
C.Oxymetazoline
D.Ranitidine VERIFIED ANSWER ( C )
Explanation:
Barotitis media, barotrauma, or ear popping, are all names for eustachian tube dysfunction, a condition
that occurs when the tube does not open properly during swallowing or yawning. This tube, connecting
the middle ear to the pharynx, equalizes pressure inside the ear to the atmospheric pressure. Blockage
of the tube can arise from congenital stenosis, abnormal peristaltic function, abnormal ciliary function,
adenoid hypertrophy, nasal congestion and tumors. Risk factors include ear or sinus infections, allergies
and rapid altitude changes. Symptoms include ear fullness, otalgia, tinnitus, hearing impairment and
vertigo. Diagnosis is mainly clinical, but further evaluation may involve an audiogram, tympanogam or
otolaryngologist referral. Treatment includes chewing gum, multiple swallows and exhalation through
closed nostrils. If refractory, medications may be necessary, and include analgesics, oral antihistamines
and nasal decongestants or steroids. Oxymetazoline is an over-the-counter nasal spray decongestant.
A 26-year-old woman presents for her annual exam and is inquiring about birth control. She is current
on her immunizations and her last pap smear was 2 years ago. She is in a monogamous relationship with
her boyfriend and does not have any immediate plVERIFIED ANSWER for pregnancy. She has a history of
migraines with aura but does not require any prescription medication.
Which of the following birth control methods is the best option for her?
A. Behavioral methods such as the withdrawal method and periodic abstinence
,B. Etonogestrel/ethinyl estradiol vaginal
C. Medroxyprogesterone acetate
D. Norelgestromin/ethinyl estradiol trVERIFIED ANSWERdermal VERIFIED ANSWER ( C )
Explanation:
Contraception counseling should be routinely performed in all women of child-bearing age at every
annual visit. There are many options such as behavioral, barrier and pharmacological methods.
However, pharmacological therapy has the highest rate of pregnancy prevention and should be
recommended in all women, unless there are contraindications. This patient has a history of migraines
with aura which is considered a contraindication to estrogen use. Other contraindications to estrogen
are history of deep vein thrombosis, breast cancer within the past 5 years, cigarette smoking in women
more than 35 years of age who smoke more than 15 cigarettes per day, ischemic heart disease, stroke,
active liver disease, major surgery with prolonged immobilization and poorly controlled hypertension. In
these cases, progesterone only therapy (medroxyprogesterone) should be used in the form of the
intrauterine device, the injection or the subcutaneous implantation in the arm.
A 24-year-old woman with no past medical history presents with left wrist pain after a fall. The left
extremity is grossly deformed and the patient complains of severe pain. The patient has a blood
pressure of 183/100 mm Hg.
While awaiting X-rays, what management is indicated for the patients elevated blood pressure?
A. Arrange admission for blood pressure control
B. Start an oral beta-blocker and monitor for response
C. Start intravenous beta-blocker and admit to the intensive care unit
D. Treat the patient's pain and reassess the blood pressure VERIFIED ANSWER ( D )
Explanation:
The patient presents with a markedly elevated blood pressure in the setting of pain from a trauma and
should have pain control initiated and her blood pressure rechecked. Hypertension is defined as a
persistent SBP >140 mm Hg or DBP >90 mm Hg. Pain and anxiety are common causes of elevated blood
pressure and heart rate in the outpatient setting. Historically, patients with elevated blood pressure and
,nonspecific symptoms were referred to as hypertensive urgency but this term has fallen out of use. In a
patient presenting with elevated blood pressure who does not have signs or symptoms of end-organ
damage, the clinician's focus should be on identifying external reasons for the elevated pressure and
treating or addressing these. In this case, the reduction or relief of pain will likely lead to decreased
blood pressure.
(A) Patients with elevated blood pressure and an absence of end-organ damage (e.g. acute coronary
syndrome, aortic dissection, encephalopathy, change in renal function) do not require admission for
management. A primary care physician in the outpatient setting best manages these patients.
(B) Starting a beta-blocker will not be beneficial in a patient with acute pain as the cause of elevated
blood pressure.
(C) Similarly, administration of an intravenous beta-blocker and admission to the intensive care unit is
not indicated as the patient exhibits no end-organ damage.
Which of the following disorders causes a normal anion gap metabolic acidosis?
A. Cyanide exposure
B. Diabetic ketoacidosis
C. Diarrhea
D. Salicylate ingestion VERIFIED ANSWER ( C )
Diarrhea is a common cause of normal anion gap metabolic acidosis. Metabolic acidosis is defined as a
reduced serum bicarbonate concentration. Normal anion gap metabolic acidosis is thought to be less
immediately dangerous than anion gap metabolic acidosis. Normal anion gap metabolic acidosis can be
caused by a variety of conditions including rapid infusion of 0.9% saline, renal tubular acidosis, ingestion
of acetazolamide and calcium chloride and hypoaldosteronism.
Cyanide (A), diabetic ketoacidosis (B) and salicylate ingestion (D) are all causes of increased anion gap
metabolic acidosis.
, A 58-year-old man presents with 3 months of headache and diplopia. He also reports that chewing
tough foods has been progressively painful. Laboratory testing reveals a normocytic anemia and ESR of
88 mm/hour. A brain CT is normal. Which of the following is the most appropriate initial intervention?
A. Intravenous methylprednisolone
B. Oral methotrexate
C. Temporal artery biopsy
D. Ultrasonography VERIFIED ANSWER ( A )
Giant cell arteritis (GCA), as known as temporal arteritis, is the most common primary vasculitis of the
elderly, and predominately affects those aged over 50 years. It is a syndrome of systemic inflammation
which mainly affects the branches of the internal and external carotid arteries, but it can affect any
vessel in the body. The most common symptoms are a temporal or occipital headache, jaw claudication
(mandibular, tooth and tongue pain with chewing tough foods), visual changes (partial or complete
blindness, diplopia, visual field cuts or amaourosis fugax) and arthralgias. It is associated with
constitutional symptoms, anemia, an enlarged tender nodular erythematous temporal artery, ESR > 50
mm/hour and polymyalgia rheumatica. Temporal artery biopsy confirms the diagnosis. Since unilateral
partial or complete blindness occurs in up to 20% of patients with GCA, immediate treatment is
necessary when this condition is suspected. High-dose corticosteroids are the standard treatment, and
typical options include 40-60 mg per day of oral prednisone, or intravenous methylprednisolone. High-
dose therapy is usually continued for 2-4 weeks, and titrated against visual and headache improvement,
not serial ESR monitoring. After symptoms lessen, steroids are slowly tapered over 6 months, with
complete tapering off in 2 to 3 years. As such, the clinician must monitor for complications of long-term
corticosteroid therapy. These include hypertension, diabetes, osteoporosis, steroid myopathy (proximal
weakness), fluid retention, bruising, insomnia, restlessness, hypomania and hypercholesterolemia.
Adjuvant methotrexate (B) is not routinely recommended for treating GCA as studies of its efficacy are
inconclusive. If GCA is suspected, intravenous methylprednisolone should be started even before a
temporal bio
A 33-year-old woman with no medical problems presents with chest pain and shortness of breath. The
symptoms worsened over the previous two days and increase with exertion. The patient denies cough,
but last week reports fevers, chills, coughing and myalgias. Her ECG demonstrates sinus tachycardia