Final
Similar to the case questions at the end; some questions about facts
Questions are pretty long; 100 questions in 3 hours
Thursday before end of rotation; may have to go to clinic next morning depending on site
1.
2.
3.
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PHQ-2 has sensitivity of 96% and specificity of 70%; what does this mean
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It is a good ​screening tool ​for depression —> negative rules you out
● I think it is that 30% of depressed patients will answer the questions
negatively
● PHQ2 questions: over the past 2 weeks have you 1) had little interest or
pleasure in doing things 2) been feeling down, depressed or hopeless?
● If PHQ2 is positive then perform PHQ9
Question about the target heart range: know equation
Target heart range= (220-age) * 0.7-0.8
Question about routine vaccines for a 9-month-old who is up to date
Inactivated influenza
3rd dose of IPV if didn’t receive at 6 mos
3rd dose Hep B if didn’t receive at 6 mos
4.
Question about woman on ACE inhibitor, aspirin, Ca channel blocker, beta
blocker, and statin who wants to get rid of one, which one is safest to eliminate?
● Aspirin?​ It’s just cardioprotective whereas the other meds have a real purpose
5.
Question about how to increase HDL
● Estrogen
● Mediterranean diet
● Diet & exercise
● Fibrates
6.
Questions about diagnosis of knee pain and shoulder pain; gives range of motion
measurements
Knee Exam
● Lachman’s test: ACL stability
● Drawer sign: ACL (anterior) or PCL (posterior) integrity
● Valgus stress: MCL
● Varus stress: LCL
● McMurray: lateral meniscus (internal tibial rotation), medial meniscus (external
tibial rotation)
Shoulder Exam ROM
● Cervical spine ROM: evaluate for cervical pathology
● Active ROM shoulder: allows patient to show you what they can do without pain
on their own
● Passive ROM shoulder: you are moving their arm for them and they tell you when
they have pain
● Joint issue —> loss of active & passive ROM
● Muscle issue —> loss of active ROM
Shoulder Exam Strength
● Empty Can or Jobes Test —> Strength of muscles surrounding shoulder
● Isolate each rotator cuff muscle —> resist internal (subscapularis) and external
(infraspinatous/teres minor) rotation
● Push against wall —> winged scapula
Shoulder Maneuvers
● Impingement test —> Neer, Hawkins Kennedy
● Stability testing
● Apprehension test
● Relocation test
● Speed’s test
● Yergason’s test
● Clunk test
● O Brien Test
● SLAP test
7.
Preventative medicine type questions; person of certain age and past medical
procedures; sometimes seemed like there were 2 possible right answers
Screenings
● Colorectal Cancer: 50 - 75 yo
● Elevated BP: 18yo +
● Depression: 18 yo +
● Mammography: 50-74 yo, can do before 50 if high risk
● AAA: men 65-75 yo w/ hx of smoking
● Lipid panel: women 45 yo + w/ increased risk CAD
● T2DM: 40-70 yo who are overweight or obese
● Cervical cancer: 21-65 yo
● Lung Cancer: 55-80 yo w/ 30 pack yr smoking hx or have quit within 15 yrs
Vaccines
● Tdap: 11-_ yo should get the shot, booster every 10yrs
● Pneumococcal 23: once prior to 65 yo, once again at 65 yo
● Influenza: annually everyone
● Zoster: 60yo +, Shingrix one dose
CHD Prevention
● Daily Aspirin (low dose): prevents CVD & Colorectal cancer, 50-59 yo with 10%+
ASCVD risk and life expectancy of at least 10 yrs , 60-60 yo with 10%+ ASCVD
risk
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8.
Know reasons why a person needs an x ray for ankle injury
● Ottawa Ankle rules are how you determine to do Xray or not
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9.
Know the 4 Ps related to helping distinguish chest pain
a.
Pleuritic, pulsating, positional, reproduced by palpation​-> lower likelihood
that the pain is due to ACS.​ also stabbing quality
10.​ ​Question about person with new onset dizziness, what type of imaging to do
a.
MRI
11.​ ​Question about interpretation of Dix-Hallpike maneuver – for vertigo dx
● Dix Hallpike: turn head 45 degrees then lean them back so head is extended
over table, otolith that was dislodged should re-enter semicircular canal causing
reproduction of the vertigo sx & nystagmus (positive test)
● Rx: meclizine, Epley Maneuver
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12.​ ​Questions about components of SPIKES; Guy has one procedure and wants to know
all information. During imaging, they find a renal tumor. Suspecting cancer, doc tells him
everything that will happen step by step—go see other doc, tx for kidney thing, other tx
for first problem, come back and see me, etc. Then at the end, only asks patient if that
sounds good.
a.
I think it was the emotional component
13.​ ​Criteria for when to do strep rapid test
● Centor criteria: tonsillar exudate, tender anterior cervical
lymphadenopathy, fever, and absence of cough. Each presents gets a 1; >3
is increased likelihood that they have strep throat.
14.​ ​Question about woman with black “mole” for 7 years, no itching, regular borders;
what is the most concerning characteristic?
● ABCDE’s: asymmetry, border irregularity, color non-uniform, diameter >6mm,
evolution, enlargement, or elevation over time. Enlargement is the most specific
metric for metastatic melanoma, while diameter is the most sensitive.
● Depth of invasion is the most important risk factor for melanoma
● Nevi larger than 6 mm in diameter are more likely to be malignant than smaller
nevi
15.​ ​Procedure to remove 1 cm skin lesion
a.
Biopsy, not Mohs because it is too small: Pts w/ nonmelanomatous skin
cancer > 2 cm, lesions w/ indistinct margins, recurrent lesions, and those close to
important structures [eyes, nose, mouth ] should be considered for referral for
complete excision via Mohs micrographic surgery w/ possible plastic repair
● Surgical Excision is used for well defined <2cm lesions
● An Excisional Biopsy can be done as diagnostic and therapeutic
technique
16.​ ​Young guy who is ginger and pale skin; gets sunburnt a lot, has lots of freckles; what
to do for him? Dad had melanoma on his arm
a.
Educate: SPF 15 + , wide brim hat, shade as much as possible, tightly
woven clothes, reapply sunscreen every 2-3hrs and after swimming
17.​ ​Question about childhood milestones; standing on one foot 8-10 seconds, writes
name, knows 4 colors, draws person with 6 parts lots of stuff, but asks minimum age that
child can do all the things listed.
a.
Answer choices were like ​4​, 5, 6, 7, or 8, so not easy to distinguish
18.​ ​Question about teen girl whose LMP was 3 weeks ago but was light; urine
pregnancy test was negative last week; what test to do?
a.
Quantitative​ serum test v. qualitative v. urine
19.​ ​Asthma tx, already has albuterol
a.
Low Dose Inhaled Corticosteroid
20.​ ​Asthma symptoms severity
a.
Moderate persistent, mild persistent, etc.
21.​ T
​ x for baby with colic
a.
No rx proven to work , continue breastfeeding
22.​ ​11 year old male with pain that comes rapidly and wakes him up in the night; testicle
is tender to palpation, no problems urinating
a.
Testicular torsion, emergency
23.​ ​EKG reading
a.
I thought it was irregular sinus rhythm… was definitely irregular, but
thought there was some T wave elevation
24.​ ​Person with vision problems, high TSH and high T4
a.
Pituitary tumor
25.​ ​Question about RUQ pain; pt had constipation right before; palpation caused pain in
the region​: positive Murphy sign [palpating liver while patient inhales; cessation of
breathing is a + sign] is indicative of gall bladder pathology [cholecystitis]
a.
I think it was constipation
26.​ ​Kid that only drinks like 6-8 glasses of 2% milk a day; doesn’t like fruits and veggies;
what might be a problem to address?
a.
Either the answer was ​anemia​ or it was nutritional assessment
● Drinking more than 24oz cow milk per day can lead to iron deficiency
anemia
● Anemia screening done at 1 yo, Preschool entry, Kindergarten entry
27.​ ​One question about diabetic woman with pretty good A1C, but now foot tenderness;
what should be next step
● Serum B12 ​—> can be low in patients on Metformin
● Foot exam to ensure no ulcer, Monofilament test
● Labs for Diabetic: HbA1c, finger stick glucose (if complaining of hyper or
hypoglycemia sx), serum Cr, GFR, urine album:Cr, serum B12, lipid panel
28.​ ​Question about man who hurt his back while lifting; has decreased foot sensation,
decreased Achilles reflex, ​& problems walking on toes (plantar flexion).
● S1​ nerve root irritation
● Most common causes of back pain: 1) lumbar strain, 2) degenerative
joint disease, 3) herniated disc
29.​ ​Question about what is suggestive of a disc herniation
● worse when sitting or bending
● better with​ ​standing & lying supine
● pain that shoots down the leg
● Paresthesias
● Muscle weakness (foot drop)
● Increased pain with coughing or sneezing
● Crossed leg raise test: raise asymptomatic leg, test is positive if pain
increased in contralateral leg
30.​ ​Tx for a woman with sx like rheumatoid arthritis
● Colchicine or ​Ibuprofen 800​?
● RA Rx: Exercise/PT, NSAIDs, low dose Corticosteroids, DMARDs
(Methotrexate, Leflunomide, Hydroxychloroquine, Sulfasalazine)
31.​ ​Question about woman with gallbladder attack, received fluids and pain meds and
observed; now not in pain; what is best next step?
a.
Expectant management or surgery or ursodiol
● Biliary colic —> expectant management
● Ursodiol is for dissolving gallstones and preventing future gallstones
● Cholecystectomy for cholecystitis
32.​ ​Question about the differences in women who use family med or OB for pregnancy
care
a.
I think it was either “only trained OB should do a c-section” or “women
who see OB instead of family end up having more c-sections”
33.​ ​Importance of EMR
a.
Maybe something about easily being able to transfer information to other
providers
34.​ ​What is the reason for having a doula for a single pregnant person
a.
I think it was ​patient safety
​i.
Other options were like ask for appropriate amount
of pain meds
35.​ ​Kid with sx like strep or pertussis; what imaging would provide enough info for
diagnosis
a.
X-ray : thumbprint sign? ​Epiglottitis
36.​ ​Different types of headaches
● Tension
● Migraine
● Cluster
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Medication overuse (analgesics)
Meningitis
Intracranial hemorrhage
Brain tumor
Traumatic brain injury
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37.​ ​Tx for lady with occipital headache; ibuprofen provides some relief; what tx?
a.
I think increase ibuprofen dose
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Migraine: triptans, ergots, excedrin (acetaminophen/asa/caffeine),
bubalbital, opioids
● Tension: ibuprofen, acetamenophen
● Cluster: ?
38.​ ​Questions about chest pain (seemed to be indicating anxiety)
39.​ ​Question about man with delirium, asks what is the cause
a.
Post residual volume was 400ml —> urinary obstruction
40.​ ​Question about man with dementia who is having delirium, no changes in urination,
took Benadryl for allergy stuff, what is cause
a.
Diphenhydramine effect (​remember Beer’s criteria)
41.​ ​Question about man who has been showing depressive sx after wife died. Has
lasted 1.5 years; what tx?
a.
SSRI
42.​ ​Person with depression who doesn’t want medication
a.
CBT
43.​ ​Question about sx of baby who is small for gestational age
a.
Hypoglycemia
● Risks for SGA newborns: 1) Hypoglycemia —> poor feeding &
listlessness, 2) Hypothermia —> poor feeding & listlessness, 3)
Polycythemia —> ruddy skin & respiratory distress
44.​ ​APGAR score for emergency birth
a.
I think it was 3; Pulse was good, was breathing, everything else was bad
● Appearance, Pulse, Grimace, Activity, Respirations
● Score < 7 at 5 min —> continued resuscitation w/ re-assessment every 5
min up to 20 min
45.​
46.​
47.​
48.​
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​NO BIRTH DATE CALCULATIONS
​NO DOMESTIC ABUSE STUFF
​NO ELDER ABUSE
​NO QUESTIONS ABOUT FETAL HEART RATE
49.​ ​Question about 50+ woman whose grandmother was diagnosed with breast cancer
recently, drinks 2 glasses of wine daily, some other stuff; what is most concerning about
her risk for breast cancer?
a.
Alcohol use-> important modifiable risk
50.​ ​Question about man with swelling in one leg from inguinal ligament down; very active
a.
I think it was venous insufficiency​-> most likely DVT
51.​ ​Question about the first thing to do for DVT
a.
Doppler ultrasound of leg
st​
52.​ ​PHQ-2: 1​ question: almost daily; 2​nd​ question more than half the days; what is the
next step?
a.
Do a​ PHQ-9
Ottawa Knee rules: x-ray series is only required for knee injury pts w/ any of these findings:
1.​ ​Age 55 or older
2.​ ​Isolated tenderness of the patella [no bone tenderness of the knee other than the patella]
3.​ ​Tenderness at head of fibula
4.​ ​Inability to flex to 90 degrees
5.​ ​Inability to bear wt both immediately and in the ED [4 steps; unable to transfer wt twice
onto each lower limb regardless of limping]