NBME Family Medicine Form 1 -

Answers & Explanations

Updated: Oct 3
1) Median nerve entrapment • Paresthesia and pain in the first 31⁄2 digits =
Carpal tunnel syndrome • Common during the third-trimester of pregnancy due
to accumulation of fluid in the carpal tunnel; usually resolves following delivery
2) Mitral valve stenosis • Acute rheumatic fever → mitral regurgitation (early)
and mitral stenosis (later)
• Diastolic murmur is consistent with mitral stenosis
3) Ask the wife to accompany her husband to his appointment and express
her concerns in her husband’s presence
• The physician should speak with the couple in person so that the wife can
express her concerns and so the husband can share his perspective
4) Calcium • Vegan diets lack calcium
5) Weight loss of 9 kg (20 lb) • Weight loss is the most effective non-
pharmacologic measure to decrease blood pressure in patients with a BMI <25 •
Systolic pressure decreased 5-20 mm Hg for every 10kg lost
6) Oral griseofulvin for the patient only • Tinea capitis (most common in
African American children) presents scaly erythematous patch with hair loss on
scalp
• Tx: Oral griseofulvin or terbinafine
7) No, no, no • PPSV23 is given alone to adults <65 with other chronic medical
conditions (eg, heart/lung/liver disease, diabetes) • Influenza vaccination should
be given annually in the fall (not the spring)
8) Baroreceptor-mediated ADH (vasopressin) secretion • Exertional
dyspnea, bilateral basilar crackles, S3 = CHF • CHF → ↓ ejection fraction → ↓
stimulation of baroreceptors → ADH secretion → fluid retention & hyponatremia
9) Keeping a log of ordered tests that require follow-up by the office
• Creates a system that will reduce the chances of delay in follow-up and care
• The patient should return for a follow-up visit. However, it is not the patients
responsibility to identify the systemic communication error between the doctors
office and the radiology facility.
10) Daily use of alcohol-acetic acid ear drops
• Acetic acid, when used after exposure to moisture, is an excellent prophylactic
for otitis externa
11) Inhaled corticosteroid therapy • This patients asthma is not well
controlled on an albuterol inhaler alone (step 1
therapy) → Low-dose inhaled corticosteroid should be added (step 2 therapy)

Asthma severity & step therapy

12) Fecal impaction

• Fecal impaction is common in older patients • Obstruction of fecal flow →
backup of stool • Passage of liquid stool around impaction → loose
stool/incontinence
13) Metformin • Elevated creatinine indicates diminished renal function •
Metformin is nephrotoxic and should not be given to patients with renal failure
as it increases risk of lactic acidosis
14) Provide symptomatic care only
• This patient likely has a viral URI
• Acute bacterial rhino sinusitis can be distinguishes from a viral URI by the
presence of severe (eg, fever > 102 with purulent nasal discharge), persistent
(>10 days with no improvement) or worsening symptoms (after initial
improvement)
15) Abstinence from alcohol • Mildly elevated liver enzymes • Patients hasn’t
traveled in a year - no carrier state with hepatitis A
16) Prescribe transdermal nicotine and recommend a behavior
modification program
• Nicotine patches are not contraindicated in patients with angina pectoris
17) Topical selenium sulfide • Tinea versicolor (pityriasis versicolor) • Tx:
topical ketoconazole, terbinafine, or selenium sulfide
18) Angiotensin-converting enzyme (ACE) inhibitor
• Drugs that improve long-term survival in patients with LV systolic dysfunction
usually have some effect on the renin-angiotensin-aldosterone system (eg, β-
blockers, ACEi)
• Diuretics will likely provide symptomatic relief, but will not improve chances of
survival
19) Scheduling a follow-up examination with the patient
• Foster physician-patient relationship
20) Folic acid • Macrocytic anemia and ⊖ neurological exam
21) Change in knowledge and dietary habits of each participant • This study
aimed to teach something (health benefits). Therefore the effectiveness of the
program can be measure by a change in knowledge of the participants
22) The patient should not have access to car keys until her driving skills
are formally assessed
• The family should ensure that the patient does not have access to care keys
until a formal evaluation of her driving can be completed
• A physician can’t revoke a persons driver license (only the DMV can)
23) Serum Helicobacter pylori antibody assay • To narrow down the
differential diagnosis in this patient (GERD vs peptic ulcer disease), H pylori
infection should be ruled out
24) Continue his current regimen • Carotid endarterectomy should be
considered for asymptomatic patients with carotid stenosis between 60-99%
25) Indomethacin
• NSAIDs are the preferred treatment for acute gouty arthritis
• Colchicine or glucocorticoids are recommended in patients with cirrhosis or
CHF (NSAIDs are contraindicated)
• Urate-lowering drugs (eg, allopurinol) are indicated for patients with recurrent
attacks or complicated disease (eg. Uric acid kidney stones)
26) Smoking cessation • There are multiple modifications that would benefit
this patient, however, smoking cessation is the most beneficial
27) Exposure to human papillomavirus
• Most common cause of SCC in the perineal region is HPV infection
28) Recommend participation in a smoking cessation program
• COPD patients that smoke see a decrease in lung function at twice the rate
compared to non-smoking COPD patients
• The only therapies proven to prolong survival in COPD patients are smoking
cessation, supplemental O2, and lung reduction surgery

GOLD stage & treatment in COPD

29) Enuresis alarm • This patient is a ‘deep sleeper’, therefore a bedwetting

alarm would be best
30) Upper endoscopy • This older patient with a 20 year history of GERD and
new alarm symptoms (eg, dysphagia/odynophagia) raises concern for
esophageal adenocarcinoma
• Dx: Endoscopy with biopsy, CT scan for staging

31) Treatment of latent tuberculosis now

• ⊕PPD with a ⊖CXR = latent TB • Latent TB tx: Isoniazid + Pyridoxine
32) Reassurance • This patient shows signs of normal aging and does not
require further evaluation
• Unaffected daily and executive functioning with a mini-mental exam score >26
33) Oral valacyclovir • CN V1 branch involvement with varicella zoster virus =
herpes zoster opthalmicus
• Antiviral medication (eg, valacyclovir) → ↓ duration of symptoms & ↓ risk of
postherpetic neuralgia
34) Varicocele • Scrotal mass (‘bag of worms’) • ↑ with standing or valsalva; ↓ in
supine position
35) Warm saline gargle • Viral pharyngitis → supportive treatment
36) Cast immobilization • Non-displaced scaphoid fractures should be managed
with wrist immobilization
• Monitor with serial x-ray to rule out osteonecrosis of the proximal segment and
non-union of the fracture
37) Lisinopril • Drugs that improve long-term survival in patients with LV
systolic dysfunction usually have some effect on the renin-angiotensin-
aldosterone system (eg, β- blockers, ACEi)
38) Compression fracture
• Presents with back pain, ↓ spinal mobility, tenderness at affected level, and a
normal neurological exam
• Risk factors include: Older age, Prolonged corticosteroid use (prednisone for
chronic asthma), No hormone replacement after menopause (estrogen inhibits
osteoclasts; menopause → ↓ estrogen)
39) Measurement of serum cholesterol • This patient should have her
cholesterol concentration re-checked to see if her low-fat diet has been effective
• Screening protocol: Pap smear q3 years, Colonoscopy q3-5 years beginning at
age 40 or 10 years before onset of CRC in relative, Mammography q2 years in
women age 50-75 years
40) Renal artery stenosis • Renovascular disease (eg, renal artery stenosis due
to atherosclerosis) is the most likely underlying cause of resistant hypertension
in a male patient with diffuse atherosclerosis
41) Measurement of postvoid residual volume
• BPH → prostatic urethra compression → incomplete bladder emptying (eg,
overflow incontinence) → ↑ risk of hydronephrosis (→ rising creatinine)
• Normal postvoid residual volume in men = <50 mL
 Types of urinary incontinence

42) Aspiration of the knee joint • Progressive pain, swelling, erythema and no
history of trauma → arthrocentesis indicated to rule out septic arthritis
43) Subacute thyroiditis
• Weight loss, tachycardia, tender thyroid, ↑ T4, low radioactive iodine uptake
• Typically follows an URI • Tx: symptomatic (eg, NSAIDs, β-blockers)

Hyperthyroidism workup

44) Oral ibuprofen therapy

• This patient likely has a lumbosacral strain (back pain with paravertebral
tenderness) after lifting furniture
• Tx: maintain moderate activity, NSAIDs
45) Serum ferritin concentration • Suspected iron deficient anemia → iron
studies (serum iron, ferritin, TIBC)
46) Colonoscopy • Iron deficiency anemia in elderly is assumed to be from GI
blood loss until proven otherwise • Lack of response to iron supplementation
indicates ongoing blood loss
47) “Sometimes when people are as upset as you are, they think about
suicide. Have you thought about ending your life?”
• Patients that appear to be clinically depressed should be screened for suicide
risk
48) Cluster headache • Male with excruciating periorbital pain that arises
during sleep
• May present with Horner syndrome
49) Hyperthyroidism
• ↑ T3, ↑ T4, ↓ TSH, ↑ uptake on RAIU scan
50) Oral amitriptyline therapy • Initial treatment for painful diabetic
neuropathy include TCAs (eg, amitriptyline), SNRIs (eg, duloxetine), or
anticonvulsants (eg, gabapentin)