Family Medicine
Certification Exam Review

Educational Objective:

Treat pneumonia due to Streptococcus pneumoniae in the intensive care unit.

Key Point:

In bacteremic or critically ill patients who have pneumonia due to due to Streptococcus pneumoniae, there is a survival advantage with combination therapy (beta lactam plus either azithromycin or a fluoroquinolone).

Explanation:

The patient has pneumococcal pneumonia.In bacteremic or critically ill patients who have pneumonia due to due to Streptococcus pneumoniae, there is a survival advantage with combination therapy (beta lactam with either azithromycin or a fluoroquinolone). Ceftriaxone plus azithromycin is the only combination therapy among the answer choices.

References:

Baddour LM, Yu VL, Klugman KP, et al. Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia. Am J Respir Crit Care Med. 2004;170:440.

Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014;371:1619.

Septiums E. Bacterial pneumonia. In: Kellermen RD, Bope ET. Conn’s Current Therapy. 2018:794-797.

Globus sensation is a feeling of a lump or ball in the throat that is usually present independent of swallowing. Globus is generally not painful, and it can usually be distinguished from symptoms of dysphagia. For a patient with significant risk factors for head and neck malignancy, including smoking and changes in voice, the work-up should begin with an ear, nose, and throat evaluation and nasopharyngoscopy and laryngoscopy. If symptoms of dysphagia are also present, then upper endoscopy or barium esophagram could also be considered. There is no role for a leukotriene inhibitor in this setting.

Reference:

Kahrilas PJ, Smout AJ. Esophageal disorders. Am J Gastroenterol. 2010;105(4):747-756.

Educational Objective:  

Discuss the level of investigation for coronary artery disease according to perceived risk.

Key Point:

Stress testing to detect ischemic heart disease is not indicated in asymptomatic patients with no family history of heart disease.

Explanation:

A stress test is not indicated in this low-risk patient who does not have any symptoms suggestive of CAD nor any family history of ischemic heart disease.

Exercise stress testing is used to detect inducible cardiac ischemia in symptomatic patients who can exercise and who have interpretable electrocardiography results, It is also helpful for risk stratification in patients undergoing vascular surgery and in patients with cardiac symptoms before undergoing nonemergent noncardiac surgery. 

It would not be appropriate to perform an invasive diagnostic procedure such as a heart catheterization in this low-risk asymptomatic patient. Folic acid has not been shown to have a clinically significant protective effect for primary or secondary coronary artery disease prevention.

References: 

Garner KK, Pomeroy W, Arnold JJ, Exercise Stress Testing: Indications and Common Questions, Am Fam Physician, 2017; 96: 293-299A

Wolk MJ, Bailey SR, Dohety JU, et al.;American College of Cardiology Foundation Appropriate Use Criteria Task Force, ACCF/AHA/AS/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol, 2014; 63: 380-406

Li Y, Huang T, et al. Folic acid supplementation and the risk of cardiovascular diseases: A metanalysis of randomized controlled trials, J. Am Heart Assoc., 2016; 5: e003768

Educational Objective:

Diagnose multiple myeloma.

Key Point:

The initial work-up of a patient with suspected multiple myeloma is an SPEP along with immunofixation, and a serum free light chain assay.

Explanation:

This patient has a clinical presentation consistent with possible multiple myeloma (MM). His age, lower back pain, and laboratory results are all consistent with this diagnosis. The first studies that should be done in the evaluation of a patient with suspected MM are an SPEP plus immunofixation.

Skeletal surveys are not part of the initial MM diagnosis, and they are reserved for patients who are cannot tolerate the preferred imaging with whole-body computed tomography, magnetic resonance imaging, or positron emission tomography. Although 24-hour urinalysis (for urine electrophoresis and immunofixation) is appropriate, it should only be performed after the initial studies already mentioned suggest MM. If those study findings are not abnormal, then a clonal plasma cell disorder is unlikely. In addition, 24-hour urinalysis would not necessitate admission to the hospital.

References:

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 2.2019. Accessed February 25, 2019.

Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol. 2014;15:e538.

Swerdlow SH, et al, eds. World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed., 2017.

Educational Objective:

Recognize the importance of sleep hygiene in patients with insomnia.

Key Point:

Treatment of insomnia includes developing good sleep hygiene habits, a hypnotic medication, and undergoing cognitive behavior therapy.

Explanation:

The information needed for a patient with insomnia includes a 24-hour schedule and sleep-partner observations regarding limb movements or apneic events. Other recommendations include a journal of all activities, including her tobacco use, caffeine intake, sleep routine, and medicine intake for 3 weeks. Furthermore, assessment of the patient’s sleep hygiene is useful in determining habits that may be contributing to insomnia. Treatment includes cognitive behavior therapy and a hypnotic medication.

Polysomnography would be appropriate if the patient reported symptoms of sleep apnea or if her condition failed to respond to multiple medications. Pramipexole is a treatment used for restless leg syndrome, which is not consistent with the patient’s history. Obstructive sleep apnea and obesity hypoventilation syndrome are treated with continuous positive airway pressure, neither of which would be diagnosed in this patient. Increasing her dose of melatonin may provide some therapeutic relief for this patient’s insomnia; however, it would not be effective if her sleep hygiene issues were not identified.

Reference:

Vaughn B. Disorders of sleep. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016:2415-2424.