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Family Medicine Board Certification Exam

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Question: 1189

Which of the following is not a covered service under theMedicare hospice benefit?

1. Home health aide services

2. Homemaker services

3. Physical therapy

4. Laboratory testing

5. Transportation for physician office visits

Answer: E
Explanation:

The hospice benefit covers all testing, treatment, medications, and home-based support services necessary for palliative care of the terminal illness. Transportation costs are not covered.

Question: 1190

history of cigarette smoking who presents to your officefor a routine physical examination. Ordering a chest x-ray towhich of the following?

1. Primary prevention; supported by U.S. Preventive Services

2. Primary prevention; not supported by USPSTF guidelines

3. Secondary prevention; supported by USPSTF guidelines

4. Secondary prevention; not supported by USPSTF guidelines

F. screen for lung cancer for Mr. would be best described as

Answer: D
Explanation:

Numerous studies have shown routine chest x-rays to not be beneficial in screening for lung cancer. Screening for asymptomatic disease is considered secondary prevention.

Question: 1191

The ability of a test to detect disease when the disease istruly present is a description of which of the following?

1. Sensitivity

2. Specificity

3. Positive predictive value

4. Negative predictive value

5. Selection bias

Answer: A

Explanation:

The sensitivity of a test reflects its ability to detect disease when the disease is present. For example, if a ôrapid strep testö is positive in 80 out of 100 patients with culture-proven streptococcal pharyngitis, the sensitivity of the rapid test is 80/100 or 80%.

Question: 1192

In a study to determine the accuracy of fecal occult bloodtesting (FOBT) to detect polyps in the colon, 1,100 adults olderthan age 65 completed a six-card FOBT screening, followed by afull colonoscopy 1 week later to detect polyps. From the resultslisted in Table 8.1, which of the following is true?

1. Sensitivity of FOBT equals 60/60 (50%).

2. Specificity of FOBT equals 40/60 (67%).

3. Positive predictive value of FOBT equals 60/940 (6%).

4. Negative predictive value of FOBT equals 940/980 (96%).

5. The prevalence of polyps cannot be determined.

Answer: D
Explanation:

Colonoscopy is considered a ôgold standardö test for colonic polyps and determines the prevalence of polyps in the study group (100/1,100). Sensitivity, the ability of FOBT to detect polyps when they are present, is 60/100 or 60%. Specificity, the ability of FOBT to indicate nondisease when no polyps are present, is 940/1,000 or 94%. Positive predictive value indicates what proportion of patients with positive FOBT actually have polyps, 60/120 or 50%. The only correct answer is for negative predictive value, the proportion of patients with a negative FOBT who do not have polyps, 940/980 or 96%.

Question: 1193

Which of the following procedures is an indication forsubacute bacterial endocarditis prophylaxis in a susceptiblepatient?

1. Routine dental filling

2. Circumcision

3. Cardiac catheterization

4. Root canal

5. Tympanostomy tube insertion

Answer: D
Explanation:

Subacute bacterial endocarditis (SBE) prophylaxis is recommended in patients at increased risk for bacterial endocarditis undergoing many common procedures. Patients at highest risk include those with complex cardiac abnormalities (e.g., tetralogy of Fallot), prosthetic valves, and surgically constructed shunts. Patients with problems such as hypertrophic cardiomyopathy, mitral valve regurgitation, and rheumatic heart disease are at moderate risk. Procedures likely to cause bacteremia include dental procedures (including routine cleaning and root canal) and surgery of the respiratory, gastrointestinal, and genitourinary tracts. SBE prophylaxis is not required for routine dental filling, x-rays, or fluoride treatments; cardiac catheterization; circumcision; intubation; flexible

bronchoscopy; or pressure equalization tube insertion.

Question: 1194

The Goldman scale helps determine the cardiac risk ofnoncardiac procedures. All of the following are risk factorsexcept:

1. Age older than 70 years

2. Signs of congestive heart failure

3. Aortic operation

4. Premature atrial contractions

5. Recent myocardial infarction (less than 6 months ago)

Answer: D
Explanation:

The Goldman scale is a multifactorial index of cardiac risk in noncardiac surgical procedures. Risk is increased most with recent myocardial infarction, signs of congestive heart failure, more than five premature ventricular contractions per minute, and rhythm other than sinus or premature atrial contractions. Risk is increased somewhat less dramatically with age older than 70 years, significant aortic stenosis, general debilitation, major surgery, or an emergency operation.

Question: 1195

Appropriate perioperative medication management includeswhich of the following?

1. For patients with well-controlled diabetes, administer the full

2. Never augment the dose of a corticosteroid in a patient on

3. Continue beta-blockers the morning of surgery with a sip of

4. Unless a patient quits smoking for 1 year, there is no

5. Discontinue aspirin use the day before surgery to diminish the

Answer: C
Explanation:

Patients with well-controlled diabetes should typically hold shortacting insulin and take one-half to two-thirds of their intermediate or long-acting insulin on the morning of surgery. Corticosteroids should be increased to reflect the stress of surgery, both perioperatively and postoperatively. Cardiac and antihypertensive medications can be given with a sip of water on the morning of surgery. Smoking cessation is valuable, even if it is only 6 weeks prior to surgery (and although less well proven, many authorities would recommend cessation if only for shorter periods). Aspirin and nonsteroidal antiinflammatory drugs ideally should be stopped 1 week prior to surgery.

Question: 1196

The Public Health Service recommends five steps tois not one of the recommended steps?

1. Asking a patient about tobacco use at every visit

2. Advising all tobacco users to quit

3. Assessing readiness to quit

4. Administering the Fagerstrom nicotine dependence assessment

5. Arranging follow-up

G. effective smoking cessation counselinWhich of the following

Answer: D
Explanation:

Although assessing nicotine dependence may play a role in smoking cessation, it is not part of the routine steps suggested by the Public Health Service. The other step is assisting the patient in quitting.

Question: 1197

Which of the following is true regarding transmission oftuberculosis?

1. D. patient is only considered infectious if three consecutive

2. More than 1,000 bacilli are required to initiate a primary

3. Infection is not possible without coming into direct contact

4. E. PPwill turn positive within 48 hours of initial exposure.

5. PPD will turn positive within 48 hours of initial exposure.

Answer: A
Explanation:

Transmission of tuberculosis occurs primarily through inhalation of aerosolized bacilli. These bacilli can exist in droplet nuclei that can remain suspended in a room even if the patient is no longer present. As few as 1 to 10 bacilli entering an alveolus can cause infection. A single sputum sample containing acid-fast bacilli is diagnostic of active or recurrent tuberculosis.

Question: 1198

A 29-year-old construction worker seeks a disability opinionfrom you regarding low back pain from a recent accident. Yourexamination is normal and you believe the patient isthe following?

1. D. referral to a pain clinic

2. Refusal to complete the disability form

3. Discussion with the patient and family to explore job

4. A referral to a pain clinic

5. Prescription of an SSRI

G. malingerinAn appropriate response might include which of

Answer: C

Explanation:

Developing rapport with a patient seeking disability or workersÆ compensation can be challenging. However, overzealous referral, inappropriate medicalization through overuse of tests and medications, and inadequate attention to job satisfaction and psychosocial issues can jeopardize longer term functional outcomes. Job satisfaction is highly associated with return to work and functional outcomes. Exploration of the psychosocial aspects of the patient's life, including family relationships, substance use, and psychiatric symptoms, is important. The physician should emphasize functional outcomes and address underlying problems.

Question: 1199

When considering a living will or a durable power ofattorney for health care, which of the following is true?

1. D. living will takes precedence over the durable power of

2. A living will allows the patient to choose a health care proxy

3. Either one can be easily revoked by the patient, either orally

4. A living will takes precedence over the durable power of

5. Both a living will and a durable power of attorney must be

Answer: C
Explanation:

The content of advance directives documents is regulated by state laws. The durable power of attorney for health care allows patients to choose someone they trust to make health care decisions for them if they are unable to do so. A patient can easily and immediately revoke either document with a simple oral statement. The two documents serve different purposes in health care decisions, and one does not take precedence over the other.