FP-I

1. A pregnant patient is found to have an elevated serum alpha-fetoprotein level on routine screening.
It is confirmed on repeat testing. Which one of the following should be done next?
1.
2.
3.
4.

A lecithin/sphingomyelin ratio
Ultrasonography
Nonstress testing
Amniocentesis

2. Which one of the following nonsteroidal anti-inflammatory agents is contraindicated in patients

allergic to sulfonamides?
1.
2.
3.
4.
5.

Celecoxib (Celebrex)
Rofecoxib (Vioxx)
Diclofenac (Voltaren)
Ketoprofen (Orudis)
Ibuprofen

3. Which one of the following statements is true regarding retrobulbar neuritis?

1.
2.
3.
4.

Less than 10% of patients will have full visual recovery

It is unusual for only one eye to be involved
This symptom is strongly associated with multiple sclerosis
Pallor of the optic disk is usually present at the onset

4. A 42-year-old African-American male with a duodenal ulcer is diagnosed with Helicobacter pylori
infection. Which one of the following treatment regimens do you recommend?
1.
2.
3.
4.
5.

Ranitidine (Zantac)
Clarithromycin (Biaxin) and omeprazole (Prilosec)
Penicillin, along with sucralfate (Carafate)
Mylanta, double-strength
Misoprostol (Cytotec)

5. Which one of the following statements regarding home visits by physicians is most accurate?
1. End-of-life decisions are more comfortably discussed with the patient in a controlled
environment within a health care facility, rather than at home during a physician visit
2. Important issues for physicians to assess during home visits include patient mobility, nutrition,
safety, and medication compliance
3. Home visits by physicians should be made independently of home health nursing personnel in
order to obtain nonbiased patient care data
4. A defibrillator, bag-valve mask, and tackle box containing ACLS medications are considered
essential equipment for physicians making home visits

6. Which one of the following is most appropriate for family members of patients with autosomal
dominant polycystic kidney disease?
1.
2.
3.
4.
5.

Monitoring with yearly renal function tests

Screening using renal ultrasonography
Screening for intracranial aneurysms
Reassurance that the absence of cysts by age 18 indicates that they will be unaffected
Reassurance that the likelihood of their having the disease is minimal

7. A 72-year-old white male in otherwise good health complains of generalized pruritus that worsens in
the winter. The itch is most intense after he bathes. Recently, he noticed a rash on his abdomen and
legs as well. On examination, you note poorly defined red, scaly plaques with fine fissures on the
abdomen. No eruption is present at other pruritic sites.
Which one of the following is the most likely cause of this problem?
1.
2.
3.
4.
5.

Candidiasis
Rosacea
Xerosis
Lichen simplex chronicus
Stasis dermatitis

8. Patients with neurogenic claudication (lumbar spinal stenosis) complain of

severe back pain of rapid onset, associated with tenderness to palpation
leg and back pain that awakens the patient from sleep, relieved by ambulation
bilateral leg pain after walking for some distance, relieved by standing in place
bilateral leg pain with the onset of ambulation, relieved by lying down
9. Which one of the following most increases insulin sensitivity in an overweight diabetic?
1.
2.
3.
4.

NPH insulin
Glyburide (DiaBeta, Micronase)
Acarbose (Precose)
Metformin (Glucophage)

10. Which one of the following is true regarding commercial air travel?
1. Pregnant women should not travel by air near term, to prevent fetal compromise due to oxygen
desaturation
2. Patients who have an uncomplicated myocardial infarction should wait 3-6 months before
traveling by air
3. Patients on chronic O2 therapy need to make arrangements to carry their own O2 on board
when traveling by air
4. At cruising altitude, the normal person has a PaO2 of 60-70 mm Hg
ANSWERS:
1. Right answer: Ultrasonography
When interpreted in relation to maternal age, maternal serum alpha-fetoprotein, maternal serum
estriols, and hCG can be used in combination to identify approximately 65% of pregnancies with

trisomy 21 (Down syndrome). The lecithin/sphingomyelin ratio is an indicator of lung maturity.

Nonstress testing is used to assess fetal well being. The next step should be to use ultrasonography to
evaluate for twins, incorrect dates, fetal death, or structural abnormalities of the fetus. If the results are
negative, amniocentesis should be considered.
2. Right answer: Celecoxib (Celebrax)
Celecoxib has a reactive sulphur molecule and can cause allergic reactions in patients allergic to
sulfonamide antibiotics.
3. Right answer: This symptom is strongly associated with multiple sclerosis
Forty percent of multiple sclerosis patients will have an episode of optic neuritis during their lives;
nearly half of first attacks of multiple sclerosis present as a single symptom. Less than half of optic
neuritis patients will have detectable optic nerve head inflammation (papillitis) at the onset, but will
later develop optic atrophy. Usually, only one eye is involved. Vision returns completely in one-third
of patients, partially returns in one-third, and does not return at all in one-third. Visual loss may be
mild, moderate, or total, or color perception may be diminished as the first symptom.
4. Right answer: Clarithromycin (Biaxin) and omeprazole (Prilosec)
Most duodenal ulcers not associated with use of NSAIDs are caused by H. pylori infection.
Treatment regimens have included an antibiotic with an H2-blocker or a protease pump inhibitor. Of
the options listed, only clarithromycin/omeprazole reflects this regimen.
5. Right answer: Important issues for physicians to assess during home visits include patient mobility,
nutrition, safety, and medication compliance
Although an increasing proportion of medical care is being provided in the home setting, the
frequency of home visits by physicians remains low. Older generalists, providers with long-established
relationships with patients, and providers in rural areas are more likely to make home visits. Key
issues to be assessed during a home visit include patient mobility, nutrition, the home environment, the
social support system, medications, a symptom-directed physical examination, safety, spiritual health,
and the status of home health services. Essential equipment includes an otoscope/ophthalmoscope,
stethoscope, blood pressure cuff, thermometer, stool guaiac cards, lubricant, tongue depressors, urine
dipsticks, and specimen cups. End-of-life decisions and discussions regarding spirituality may be more
comfortably discussed during home visits than during visits to a health care facility. Having home
health personnel present during physician home visits can enhance communication and cooperation
among the physician, the home health agency, and the patient.
6. Right answer: Screening using renal ultrasonography
Ultrasonography is the preferred technique for screening asymptomatic family members of patients
with polycystic kidney disease. It is likely to be familial, as 90% of cases are inherited as an autosomal
dominant trait. Ultrasonography is used for diagnosis of asymptomatic patients, not renal function
tests. Although intracranial aneurysms are present in 5%-10% of asymptomatic patients with
polycystic kidney disease, screening is not recommended unless there is a positive family history of
intracranial aneurysm. The disease most frequently becomes symptomatic in the third and fourth
decade, and almost 100% of patients will have detectable cysts after age 30.
7. Right answer: Xerosis
The term xerosis describes the dry quality of the skin that is especially prominent in the elderly. The
exact etiology of this condition remains unknown, but the decrease in water content and sebum
production of aging skin seems to be a factor, as well as age-related abnormalities in the keratinocyte
maturation process. Xerosis often intensifies in winter, with the seasons lower humidity and cold

temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown

discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or
rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and
thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption,
which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection
favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds,
inframammary folds, axillae, interdigital areas, and corners of the mouth.
8. Right answer: bilateral leg pain with the onset of ambulation, relieved by lying down
Neurogenic claudication is secondary to compression of the lumbar canal, most often by acquired
degenerative or arthritic changes of the discs, ligaments, and facet joints, and causes pain with the
onset of ambulation which is relieved by lying down, and sometimes by sitting. Vascular claudication
produces symptoms that begin after ambulation for a certain distance. Night pain relieved by
ambulation is a sign of spinal neoplasm. A rapid onset of severe pain with local tenderness suggests
infection.
9. Right answer: Metformin (Glucophage)
Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower
insulin levels achieve the same level of glycemic control, and may be one reason that weight changes
are less likely to be seen in diabetic patients on metformin. Acarbose is an alpha-glucosidase inhibitor
which delays glucose absorption.
10. Right answer: At cruising altitude, the normal person has a PaO2 of 60-70 mm Hg
Family physicians are frequently asked questions about commercial air travel. Commercial jet
aircraft maintain a relative cabin altitude between 5000 and 8000 feet. At the 8000-foot environment,
the barometric pressure decreases from a normal sea level 760 mm Hg to around 560 mm Hg, causing
the normal baseline arterial partial pressure of oxygen (PaO2) of 98 mm Hg at sea level to decrease to
60-70 mm Hg in normal individuals.
Passengers with stable medical conditions requiring low-flow oxygen cannot bring their own oxygen
on board according to Federal Air Regulations concerning hazardous cargo. Most air carriers will
provide O2 for a fee. A recent study of patients who traveled aboard commercial jet aircraft following
myocardial infarction suggests that most complications occurred within the first 2 weeks. Most experts
agree that patients should not fly within 3 weeks after a myocardial infarction. The reason women
should not travel near term is to avoid a delivery during the flight. The fetal circulation and fetal
hemoglobin protect the fetus against desaturation during routine air flight.
__________________________________________________________________________________
FP-II
1. Your 38-year-old recently divorced partner confides in you that he is becoming attracted to a single
woman your group is treating for ulcerative colitis. He enjoys seeing her for periodic follow-ups of her
medication, and at a visit that morning she asked him to accompany her on a church picnic the next
week. He is concerned about the ethical implications of accepting a date with this patient.
Drawing on your detailed knowledge of the principles of medical ethics, you are able to advise him
that
1. he can see the patient both professionally and socially for a few months, since his professional
judgment is unlikely to be affected during the initial stages of a romantic relationship
2. he should inform her that he can no longer see her as a patient if they begin a dating
relationship

3. if her colitis was in prolonged remission and required only medication monitoring, this would
be acceptable behavior
4. "once a patient, always a patient," and any romantic encounters would constitute unethical
conduct
2. Treating preterm labor with beta-adrenergic agonists has been shown to decrease the rate of which
one of the following?
1. Delivery within 48 hours of treatment
2. Low birth weight infants
3. Preterm delivery
4. Perinatal deaths
3. A high-school wrestler who is a type 1 (insulin-dependent) diabetic comes to see you before a match
because his glucose level is high. You confirm that it is 275 mg/dL. You should
1. check his urine for ketones and, if positive, do not let him participate
2. advise him that type 1 diabetes is a contraindication to wrestling
3. encourage him to take concentrated glucose, as his glucose level should be 300 mg/dL or more
before a strenuous match
4. tell him to go ahead and participate, as the exercise will lower his glucose level to a normal
range
4. An 18-year-old white male comes to your office complaining of rectal pain and drainage.
Examination reveals that the drainage is not from the rectum at all, but from the area above the gluteal
cleft in the lower back. Erythema, induration, and purulent drainage are noted. The diagnosis of a
pilonidal abscess is made. The patients past history is otherwise unremarkable, as is the remainder of
his examination. Which one of the following is the best treatment?
1. Incision and drainage with packing
2. Parenteral antibiotics
3. Oral antibiotics
4. Watchful waiting, as this condition often heals spontaneously
5. A 25-year-old male visits your office concerned about a painless ulcer on the glans of his penis.
After appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 million
units of benzathine penicillin intramuscularly in a single dose. Eight hours later, while you are
working the evening clinic, he returns because he has a fever of 100.6 F and a bad headache, which
he rarely gets. He says he "aches all over." Which one of the following is the most appropriate action
at this time?
1. Reassure and prescribe antipyretics
2. Add doxycycline (Vibramycin), 100 mg orally twice a day for 14 days
3. Perform a spinal tap
4. Order a CT scan of his head
5. Obtain three blood cultures from different sites at 30-minute intervals
6. An 81-year-old white female comes to your office complaining of being depressed. She also
complains of recurrent muscle cramping and tingling of her fingers. During your evaluation, you
discover that her serum calcium level is 6.8 mg/dL (N 8.5-10.8) and her serum phosphorous level is
5.6 mg/dL (N 2.5-4.5). Which one of the following additional findings would most suggest the
diagnosis of primary hypoparathyroidism?
1. Normal renal function
2. Intracranial calcifications

3. Papilledema
4. Prolongation of the QT interval on EKG
7. Which one of the following preventive measures is recommended for nearly all international
travelers to developing countries?
1.
2.
3.
4.
5.

Yellow fever vaccination

Typhoid vaccination
Hepatitis B vaccination
Hepatitis A vaccination
Gamma globulin administration

8. A high-school football player is brought to you the day after a game in which he suffered a sudden
valgus impact to his knee. He reported feeling a "pop" with the injury, was unable to continue activity
immediately after the injury, and has the feeling that the knee "gives way" or is unstable. He also
reports that the knee began swelling almost immediately.
When you examine his knee you find it tensely swollen. Aspiration of the joint returns a bloody
effusion. Based on this information, the most likely diagnosis is which one of the following?
1. Posterior cruciate ligament tear
2. Anterior cruciate ligament tear
3. Lateral collateral ligament tear
4. Patellar subluxation
9. Which one of the following statements concerning treatment of acute myocardial infarction is
correct?
1. Beta blockers reduce infarct size and chest pain when given for acute myocardial infarction
2. Calcium channel blockers reduce mortality from acute myocardial infarction
3. Angiotensin converting enzyme (ACE) inhibitors cause congestive heart failure if given during
an acute myocardial infarction
4. Lidocaine must be given routinely for myocardial infarction
5. Magnesium reduces the risk of sudden death from myocardial infarction
10. Which one of the following conditions is associated with high serum cholesterol?
1. Diabetes insipidus
2. Amyloidosis
3. Multiple sclerosis
4. Nephrotic syndrome
5. Hyperthyroidism
ANSWERS:
1. Right answer: he should inform her that he can no longer see her as a patient if they begin a dating
relationship
Contrary to a frequently held belief, it is not always unethical for a physician to enter into a dating,
romantic, or sexual relationship with a patient. The current principles of medical ethics clearly state
that "sexual contact that occurs concurrent with the physician-patient relationship constitutes sexual
misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of
the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the
physicians objective judgment concerning the patients health care, and ultimately may be detrimental
to the patients well-being.

"If a physician has reason to believe that nonsexual contact with a patient may be perceived as or may
lead to sexual contact, then he or she should avoid the nonsexual contact. At a minimum, a physicians
ethical duties include terminating the physician-patient relationship before initiating a dating,
romantic, or sexual relationship with a patient.
"Sexual or romantic relationships between a physician and a former patient may be unduly influenced
by the previous physician-patient relationship. Sexual or romantic relationships with former patients
are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from
the previous professional relationship." If the physician is not using his position to exploit trust,
knowledge or influence derived from the previous professional relationship he may enter a dating or
more intimate relationship with the patient provided the physician-patient relationship is terminated
before the relationship begins. This should be a formal termination detailing why the physician will
not be able to provide further care for the patient. If further doctor-patient contact can be limited to
emergency situations, it would not be necessary for the patient to change medical groups, but rather to
select another physician who can provide continuing care.
2. Right answer: Delivery within 48 hours of treatment
In women with premature labor, beta-adrenergic agonists have been clearly shown to reduce the
incidence of delivery within 24 and 48 hours of administration. These tocolytic agents have not been
shown to consistently reduce the rates of preterm delivery, low birth weight, severe respiratory
distress, or perinatal death. A statistically non-significant trend toward reduced perinatal mortality has
been suggested in women given beta-adrenergic agonists earlier in pregnancy, for preterm labor before
28 weeks gestation. It appears that more effective use of the 24-48 hours gained by tocolysis with betaadrenergic agonists holds promise for reducing perinatal morbidity and mortality, perhaps through
more liberal use of predelivery glucocorticoid therapy.
3. Right answer: check his urine for ketones and, if positive, do not let him participate
Athletes with glucose levels greater than 300 mg/dL should postpone exercise even if no ketones are
in the urine. Athletes with glucose levels of 250-300 mg/dL should check their urine for ketones.
Exercise can raise, rather than lower, glucose levels when there is an increase in glucagon,
epinephrine, growth hormone, and cortisol in an already hypoinsulinemic patient. Urinary ketones may
indicate that severe hypoinsulinemia has caused release of fatty acids from adipose tissues and
subsequent conversion to ketones in the liver.
4. Right answer: Incision and drainage with packing
Pilonidal abscesses occur in young people, primarily men, and often have hair within the abscess
(as the pilo word root implies). These are best treated with incision and drainage, as antibiotics alone
are not sufficient. A simple stab incision will not suffice, as they will often close prematurely.
Therefore, an ellipse of tissue should be removed, allowing for adequate drainage and proper healing.
5. Right answer: Reassure and prescribe antipyretics
This man is experiencing the Jarisch-Herxheimer reaction-an acute, transient febrile reaction that
occurs within the first few hours after treatment for syphilis. The illness peaks at 6-8 hours, and
disappears within 12-24 hours after therapy. Temperature elevation is usually low grade, and there is
often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be
treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to
liberation of antigens from the spirochetes.
6. Right answer: Normal renal function

Hypocalcemia is an abnormal reduction in the serum ionized calcium concentration. Reduction of

total serum calcium may be seen in patients with hypoalbuminemia, but it does not necessarily reflect
a reduction in ionized calcium. It is the ionized calcium which affects neuromuscular function.
Hypocalcemic disorders can be divided according to pathogenesis into two broad categories: primary
hypoparathyroidism and target-organ malfunction. In hypoparathyroidism, mobilization of calcium
from bone, renal reabsorption of calcium, phosphaturia, and 1,25(OH)2D formation are all reduced,
which results in a decrease in intestinal calcium absorption. The end results are hypocalcemia and
hyperphosphatemia. Renal failure and acute phosphate loads are other causes of hypocalcemia with
hyperphosphatemia. With vitamin D deficiency or malabsorption, hypocalcemia occurs with normal
and low serum phosphorous levels. Hypocalcemia with low or normal serum phosphate levels is also
seen in acute pancreatitis and in some patients with osteoblastic tumor metastasis. However,
hypocalcemia and hyperphosphatemia with normal renal function are pathognomonic of
hypoparathyroidism.
7. Right answer: Hepatitis A vaccination
More than a dozen vaccines are available for diseases with a high prevalence in developing
countries. The primary care physician should make sure that international travelers are up to date in
their routine immunizations, given that vaccine-based immunity to tetanus, diphtheria, polio, and
measles wanes over time, and these diseases are highly prevalent abroad. While location-specific
situations may require specific immunizations such as typhoid, yellow fever, and hepatitis B
vaccinations, and/or administration of gamma globulin, hepatitis A vaccine is recommended for nearly
all international travelers.
8. Right answer: Anterior cruciate ligament tear
Eighty-five percent of patients who have an anterior cruciate ligament tear are immediately
disabled and cannot continue their activity. Patients often describe a feeling of "giving way" and report
hearing or feeling a "pop" at the time of injury. If the knee swells within the first 24 hours, the swelling
is most likely due to hemarthrosis rather than inflammation. Seventy percent of episodes of acute knee
hemarthrosis are the result of anterior cruciate ligament tears.
9. Right answer: Beta blockers reduce infarct size and chest pain when given for acute myocardial
infarction
Beta blockers should be given to all patients with acute myocardial infarctions to reduce pain and
infarct extension. Neither calcium channel blockers nor magnesium have been proven to reduce
mortality, and lidocaine is not recommended for routine prophylaxis in acute myocardial infarction.
ACE inhibitors prevent congestive heart failure when given during myocardial infarction.
10. Right answer: Nephrotic syndrome
Elevated total serum cholesterol is associated with diabetes mellitus, hypothyroidism, and
nephrotic syndrome. In hypothyroidism in particular, treatment of the underlying condition will lower
serum cholesterol.
__________________________________________________________________________________