Family Medicine Clerkship Exam

The computer-based exam consists of two parts.

Part I is a closed-book knowledge-based assessment consisting of multiple choice, true/false, matching, fill-in, and short answer questions. There are 56 questions in this section, and you will have 1 hour to complete it.
How to study: Complete required readings (reading the corresponding materials in advance of each didactic day), actively participate in didactic days, and read about the patients you see at your site.
How to take the exam: All the questions appear in one long scrollable page on the computer. You may skip around and answer the questions in any order you wish. At the end, when done, submit your answers. After you have submitted, all of the CORRECT answers will appear in one page. The purpose is to give you closure and have you leave the clerkship knowing the correct information rather than wondering what the right answers were. If seeing the correct answers immediately is too stressful for you, feel free to skip this page.

Part II is open-internet (online resources are allowed; your phone, written materials, email, messaging/social media sites, and contacting others are not allowed). This section contains 7 short answer questions and you will have 1 hour to complete it. Part II tests medical knowledge along with information mastery. To that end, your goal is to efficiently locate answers to questions using appropriate sources. Answers will earn full or partial credit based on the content of the answer, citation of the source, and a notation of the strength of the evidence. You do not need to further analyze the strength of the evidence if you provide a standard rating (e.g., Level A, Level 2). As long as the above are addressed, answers should be brief.
How to study: Practice using common online resources discussed during your information mastery workshop. Familiarity with these websites in looking up foreground questions will help you be more efficient when you are under time pressure, both on the exam and in real life.
How to take the exam: Pace yourself. There are 7 questions so you’ll need to move efficiently. Some questions take longer than others. You may copy and paste from a website to generate an answer if you wish. Most students do finish, but students typically report time feels tight.

***REMINDER: per the TUSM Honor Code, Discussion of the contents of the Family Medicine Clerkship Exam (both parts) with students who have not yet taken it is strictly forbidden.***

FM Clerkship Exam, Part II
Sample Questions

QUESTION:

Mr. Art DeZees is your 55 year old Caucasian patient. He has hypertension (140/80 today), BPH and arthritis and takes Lisinopril-HCTZ, Flomax and Extra Strength Tylenol. His wife sent him to ask if he should be taking a statin drug. Of note, he does not have diabetes and his most recent cholesterol was 244 with an HDL 35.

Do you prescribe him a statin? Show the evidence behind your answer, cite your source, and rate its Strength of Recommendation.

Outstanding Answer:
1)From Mobile Medicard: adults > 21 with risk > 7.5% should get a statin (SoR A)

2)From Dynamed:

• for patients without known cardiovascular disease (primary prevention)
• statins reduce cardiovascular disease events and stroke (level 1 [likely reliable] evidence) and may reduce all-cause mortality (level 2 [mid-level] evidence)
• absolute benefit from statins for primary prevention of heart disease depends more on overall risk than cholesterol levels

Abbreviations: CVD, cardiovascular disease.

* No apparent mortality reduction in lowest-risk patients (BMJ 2013 Oct 22;347:f6123).

NNT for Statins for 5 Years:

• guidelines vary regarding threshold for using statins for primary prevention
  • American College of Cardiology/American Heart Association (ACC/AHA) recommends statin therapy if 10-year risk of cardiovascular disease ≥ 7.5% (ACC/AHA
    Class I, Level A) with consideration at risk 5% to < 7.5% (ACC/AHA Class IIa, Level B)
  • National Institute for Health and Care Excellence (NICE) recommends statin therapy if 10- year risk of cardiovascular disease ≥ 10%

His 10 year risk is 12.9% so I would recommend statin (level 1 or 2 evidence)

Both sources (background from Medicard and foreground from Dynamed) agree so I would prescribe a statin.

Poor Answer:

As of 2010, a number of statins are on the market: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altocor), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor).[6] Several combination preparations of a statin and another agent, such as ezetimibe/simvastatin, are also available. In 2005 sales were estimated at $18.7 billion in the United States.[7] The best-selling statin is atorvastatin, which in 2003 became the best-selling pharmaceutical in history.[8] The manufacturer Pfizer reported sales of US$12.4 billion in 2008.[9] Due to patent expirations, several statins are now available as less expensive generics.[10][11]

QUESTION:

Ms. Vama Ting is a 29 year old G1 who is 10 weeks pregnant. She has had moderate to severe nausea and vomiting and wants some recommendations. She would prefer not to take any prescription medications.

What do you advise? Cite your source and rate its Strength of Recommendation.

Outstanding Answer:

1)From AAFP 2014

Vitamin B6 should be prescribed as first-line treatment for nausea and vomiting of pregnancy.
A  32, 33

Physicians should consider prescribing doxylamine (Unisom SleepTabs) in addition to vitamin B6 for treatment of nausea and vomiting of pregnancy because the combination reduces symptoms by 70%.
C  34

2)Dynamed

• non-pharmacologic therapies
  • dietary modification is commonly recommended to help alleviate nausea and vomiting in pregnancy
    • common suggestions include
      • eating frequent, small meals
      • avoiding greasy, spicy, or fatty foods
      • eating bland, low-fiber, or dry foods and high-protein snacks and meals
      • eating crackers upon awakening, before getting out of bed
      • avoiding foods with strong smell and liquid content
      • ginger may not reduce nausea symptoms in women with pregnancy-associated nausea and vomiting but evidence is limited (level 2 [mid-level] evidence)
      • acupressure or electrical acustimulation (but not acupuncture) may reduce nausea and vomiting in pregnancy (level 2 [mid-level] evidence)
• consider pharmacologic therapy after other causes of nausea and vomiting have been ruled out
  • first-line pharmacological treatments include monotherapy or combination therapy with (ACOG Level A)
    • pyridoxine (vitamin B6) 10-25 mg every 8 hours (first-line treatment)
    • doxylamine (Unisom sleeping tablets) 12.5-25 mg every 8 hours
  • if symptoms do not resolve, consider 1 or both of (ACOG Level B)
    • adding promethazine 12.5-25 mg intramuscularly, orally, or rectally every 4-6 hours
    • substituting dimenhydrinate 50-100 mg orally or rectally every 4-6 hours for doxylamine
  • if symptoms do not resolve, consider (1 at a time, may be substituted in stepwise manner) (ACOG Level B)
    • metoclopramide (Reglan) 10 mg intramuscularly or orally every 6 hours
    • ondansetron (Zofran) 4-8 mg orally disintegrating tablet every 6 hours
    • trimethobenzamide (Tigan) 300 mg intramuscularly or orally every 6-8 hours
    • methylprednisolone 16 mg orally or IV every 8 hours (or 48 mg/day) for 3 days
      • reserve as a last resort in women with nausea and vomiting refractory to other treatments and who require enteral or parenteral nutrition due to weight loss (ACOG Level B)
      • taper over 2 weeks in patients who respond to treatment
      • treatment should be stopped if no response within 3 days
  • if available, alternative antiemetics and antihistamines/anticholinergics may be considered in women refractory to other medications (ACOG Level B)

There is reliability between AAFP and Dynamed. Suggest acupressure (SOR B) and vitamin B6 (SOR A) first.

Poor Answer:

From babycenter.com

Which medications can I take for morning sickness during pregnancy?

The BabyCenter Editorial Team

It’s always worth trying nondrug remedies first, because it’s best not to expose your developing baby to any drugs if you can help it. But if these approaches don’t bring relief, ask your practitioner which nausea medications might be effective for you. A variety of drugs – in both pill and suppository form – are considered safe to take for nausea and vomiting during pregnancy, although not all of them will work for everyone.

Let’s start with what’s available over the counter:

Although not officially approved for morning sickness, Emetrol is a nonprescription nausea medication that’s considered safe during pregnancy. Reflux medications such as Zantac or Pepcid sometimes work for expectant moms whose nausea and vomiting is triggered by gastrointestinal distress.

Vitamin B6 is often helpful for moms-to-be with mild to moderate nausea.

Antihistamines have also been used to treat nausea and vomiting in pregnancy. Your practitioner may recommend doxylamine, an antihistamine that’s available as a sleeping pill under the brand name Unisom Nighttime Sleep-Aid. (Don’t confuse Unisom Nighttime Sleep-Aid with Maximum Strength Unisom SleepGels
– they’re two different things.) One caution: Doxylamine can make you sleepy, so don’t drive when taking it.

QUESTION:

Britt L. Bones is a 72-year-old female with osteoporosis. She has been taking alendronate 70 mg weekly since age 65. She has not had any fractures or side effects from the medication. She asks you if you recommend that she take this medication forever. What do you tell her?

Outstanding Answer:

(1) AAFP 2006: “The optimal length of oral bisphosphonate therapy is unknown. A recent study found that women who take alendronate for five years followed by five years of placebo have no increase in the incidence of nonvertebral or hip fractures compared with women who take alendronate for 10 years. There is, however, an increase in vertebral fractures.⁴⁰ This suggests that relatively low-risk women (i.e., no personal history of vertebral fractures and only modestly reduced T-score) may consider an interruption in bisphosphonate treatment.”
Based on FLEX trial in JAMA 2006.

(2)Dynamed, based on same trial: “continuation of alendronate for 5 years might decrease risk for clinical vertebral fracture (level 2 [mid-level] evidence); continuation of alendronate for 10 years might decrease risk for nonvertebral fracture compared with stopping alendronate after 5 years (level 2 [mid-level] evidence)” (Actually should be vertebral fracture.)

(3)JAMA 2006, FLEX trial: “Conclusions: Women who discontinued alendronate after 5 years showed a moderate decline in BMD and a gradual rise in biochemical markers but no higher fracture risk other than for clinical vertebral fractures compared with those who continued alendronate. These results suggest that for many women, discontinuation of alendronate for up to 5 years does not appear to significantly increase fracture risk. However, women at very high risk of clinical vertebral fractures may benefit by continuing beyond 5 years.”

My conclusion: She should continue for 10 years if she has no symptoms and if high vertebral fracture risk. Otherwise, OK to stop since it’s been > 5 years. Also, keep checking the literature for updates because all of this is based on only one RCT that may have had Big Pharma influence. (SORT B)

Poor Answer:

From Wikipedia, the free encyclopedia

Osteoporosis (“porous bones”, from Greek: οστούν/ostoun meaning “bone” and πόρος/poros meaning “pore”) is a progressive bone disease that’s characterised by a decrease in bone mass and density and that leads to an increased risk of fracture.[1][2] In osteoporosis, the bone mineral density (BMD) is reduced, bone microarchitecture deteriorates, and the amount and variety of proteins in bone are altered. Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy X-ray absorptiometry; the term “established osteoporosis” includes the presence of a fragility fracture.[3] The disease may be classified as primary type 1, primary type 2, or secondary.[1]