Family Medicine Board Review Questions

Based on the American Board of Family Medicine format.


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Sample Stem:

A 17-year-old girl presents with a "bad cough" that has lasted for 2-3 weeks. How much should the presence or absence of any of the 3 classic pertussis symptoms—paroxysmal cough, post-tussive whoop, and post-tussive emesis—strengthen or weaken a clinical concern for pertussis?


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Answer Options:

 "Paroxysmal cough" is commonly reported both by patients who do and do not have pertussis; its presence does not significantly increase the likelihood of pertussis.
 The absence of an inspiratory whoop is more powerful in ruling out pertussis than the absence of a paroxysmal cough.
 The presence of all 3 classic pertussis symptoms simultaneously doubles the likelihood of a pertussis diagnosis.
 The absence of all 3 classic pertussis symptoms is highly predictive of the absence of pertussis.


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Correct Answer:

"Paroxysmal cough" is commonly reported both by patients who do and do not have pertussis; its presence does not significantly increase the likelihood of pertussis.

Educational Objective:

Discuss factors that should increase a concern for pertussis in an adolescent with a persistent cough.

Key Point:

Studies show that the symptom of "paroxysmal cough" is commonly reported by both patients who do and do not have pertussis. Therefore, the presence of just a "paroxysmal cough" by itself is a fairly insensitive indicator for pertussis (likelihood ratio [LR] is close to 1).


The presence/absence of most classic pertussis symptoms only modestly increases/decreases the probability of pertussis (with the presence of paroxysmal cough by itself being nearly meaningless either for or against a pertussis diagnosis); clinicians need to consider the clinical context when deciding about the need to test and/or treat for pertussis.

More specifically:

In a teenager with cough, the presence of a "paroxysmal cough" by itself is not a sensitive indicator for pertussis. The presence of either of the other 2 pertussis symptoms in isolation – "post-tussive emesis" or "whoop"-- each modestly raises the likelihood that the patient has pertussis (LR of 1.8 and 1.9, respectively).

The absence of any of the 3 classic pertussis symptoms modestly decreases a patient's likelihood of having pertussis, with the absence of paroxysmal cough (LR = 0.52) being the most predictive of the absence of pertussis, followed by post-tussive emesis (LR = 0.58), and finally (weakest association) inspiratory whoop (LR = 0.78).

Unfortunately, no study to date has investigated the predictive power of multiple pertussis symptoms being simultaneously present or absent.


Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis? JAMA. 2010;304(8):890-896.

Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2018;67(2):1–44.

Pertussis (Whooping Cough). Centers for Disease Control and Prevention.  7 Aug. 2017, Accessed 26 Feb 2019.

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Reproductive – Female3%
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Reproductive – Male1%


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