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High Yield Test Questions Donald J. Sefcik, DO, MS, MBA, FACOFP
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High Yield
Test Questions
Donald Sefcik, DO, MBA, FACOFP
Introductory Comments
• Test-Wise Test-Preparers focus their
studying on topics most likely to appear
on the examination.
• These High Yield Questions can be
divided into two basic groups:
High Frequency (prevalent)
High Acuity (significant morbidity & mortality)
Blueprint – High Yield Topics?
Exam Content %
Addiction Medicine 3
Adolescent Medicine 4 Orthopedics
Behavioral Sciences 12
General Medicine 48
Geriatrics 5 Orthopedics
Surgery 13 Orthopedics
Obstetrics / Gynecology 4
Pediatrics 4 Orthopedics
Sports Medicine 3 Orthopedics
Women’s Issues 4
http://www.aobfp.org/cert-req/cert-app.html
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Selected Topics – High Yield • Ophthalmology
– Unilateral Red Eye & Unilateral Visual Loss
• Acute Glaucoma, Iritis & Vascular Occlusions
• Cardiac Topics
– Myocardial Infarction - ACLS Protocols
– Arrhythmias - Atrial Fibrillation
– Murmurs - Endocarditis
• Miscellaneous
– Headaches – Subarachnoid Hemorrhage
– Orthopedics – Infections & Pediatric-specific conditions
Most common ocular presentation in
ambulatory primary care
• Inflammation or Infection of anterior segment
• Suggestive of Emergent / Urgent condition
• Pain
• Alteration in Vision
• Photophobia
• Proptosis
Red Eyes
Acute Glaucoma
• Photophobia
• Periorbital Pain
• Decreased VA (visual acuity)
• Haloes around lights
• Mid-Dilated, Fixed pupil
• Elevated IOP (intraocular pressure)
• Hazy Cornea
• PPT event – Dark Environment
Unilateral Red Eye
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Iritis
• Acute eye pain; Photophobia
• Slight decreased VA (visual acuity)
• Constricted (miotic) pupil
• Ciliary / Limbic flush• Circumcorneal (corneal-scleral) Injection
• Pain with light reflex – direct and consensual
• Thorough Exam • R/O Keratitis / corneal erosion or ulceration
Unilateral Red Eye
Unilateral Red Eye
Conjunctivitis Iritis Glaucoma
Visual Changes N/A Slight Significant
Photophobia N/A Moderate Severe
Injection Diffuse
(+ lid)
Circumcorneal
(limbic)
Diffuse
Pupil Normal Miotic Mydriatic
Unilateral Visual Loss
• Central Retinal Artery Occlusion
• Cherry red spot (fovea)
• Embolism (origin: carotids / cardiac)
• Central Retinal Vein Occlusion
• Blood-streaked retina & tortuous veins
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Unilateral Visual Loss
• Temporal Arteritis – temporal headache; jaw claudication
– Women > 50yo
– polymyalgia rheumatica
• Tender; occasionally pulseless temporal artery
– afferent pupillary defect
• Elevated ESR (usually > 50)
• Consult + Systemic Steroids
– prevent blindness
Myocardial Infarctions
ACLS Protocols
Emergency Cardiovascular Care (ECC)
Cardiopulmonary Resuscitation (CPR)
• Recognition
• Early Management (BLS plus)
• Airway / Breathing / Circulation
• Pharmacology
• Cardioversion/ Defibrillation
Electrocardiogram
Basic Interpretation
Waves
• Atrial (p-waves)
• Ventricular (R-waves)
• Prominent in LVH (aVL > 11 mm)
Intervals
• PR = shortened in WPW & LGL (no delta wave)
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Arrhythmias
Basic Interpretation
Regular
• Sinus Bradycardia & Tachycardia
• Ventricular Tachycardia
Irregular
• Underlying plus PACs and/or PVCs
• (some) AV Blocks
• Atrial Fibrillation
Arrhythmias
Atrial Fibrillation
10% of individuals > 80yo
• Paroxysmal episodes common prior to becoming
established
• History of reduced cardiac output (symptoms)
• Goals (if can’t be cardioverted)
• Rate control (Ventricular) of 50–100 (80–100)
• Reduce risk embolization (~ 4.5% per year)
Valvular Heart Disease
Initial Sign = Commonly a Murmur
• Significance?
• Timing = Diastolic; Holosystolic
• Associated Symptoms and/or Signs
• Intervention?
• Timing?
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Murmurs
Left-sided (outflow obstruction)
Aortic Stenosis
• Left Ventricular Enlargement (Hypertrophy)
• S4 gallop
• Symptoms
• Angina
• Syncope
• Dyspnea on Exertion
Murmurs
Left-sided (volume overload)
Aortic Regurgitation
• Left Ventricular Enlargement (Dilation)
• S3 gallop
• Signs
• Widened Pulse Pressure
Murmurs
Left-sided
Mitral Stenosis
• Diastolic Rumble
• Opening Snap
• Atrial Fibrillation
• Symptoms
• Dyspnea on Exertion; Orthopnea
• Hemoptysis
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Murmurs
Left-sided
Mitral Stenosis
• Holosystolic Murmur
• Apex toward Axilla
• Atrial Fibrillation
Murmurs
Endocarditis
New or Changing Murmur and Fever • Evidence of systemic emboli
• Vegetation on echocardiogram
• Positive Blood Cultures (95%)
• Etiology
• IV Drug Use = Staphylococcus aureus (> 60%)
• Tricuspid Valve
• Prosthetic Valves
• < 2 months = Staphylococcus
• > 2 months = Streptococcus
• Prophylaxis
Headaches
Hemorrhages
Subarachnoid
• Saccular Aneurysms
• 50% = History of Sentinel Bleed
• First or Worst Episode of Cephalgia
• Stiff Neck
• Altered Level of Consciousness
• Syncopal Episode
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Orthopedics
Infections
Septic Joints
• Gonococcal
• Common in previously healthy individual
• Prodrome migratory polyathralgias (1-4 days)
• Tenosynovitis (60% of presentations)
• Monoarthritis (40% of presentations)
• Usually the knee
• Symptoms of urethritis frequently absent
• R/O Endocarditis
Orthopedics
Infections
Septic Joints
• Non-Gonococcal
• Damaged Joints (RA) or Bacteremia (IVDU)
• Large Joint Effusions
• Monoarthritis
• Usually the knee
• Sternoclavicular or SI joints (IVDU)
Orthopedics
Pediatric-specific
Nursemaid’s Elbow
Radial Head Subluxation
• Age < 5-years old
• History of axial traction to distal forearm-hand
• Presentation = Pronated forearm
• Reduction = Supinate Forearm / Flex Elbow
• NOTE: Fat Pads on X-ray (Fracture; Effusion)
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Orthopedics
Pediatric-specific
Slipped Femoral Capital Epiphysis
• Age 9 – 16 years old
• Classically males with high BMI
• History of insidious limp (+ hip and/or knee pain)
• X-Ray: “Ice Cream falling off of the Cone”
• Untreated: Osteoarthritis; Avascular Necrosis
Summary Comments
• Test-Wise Test-Preparers focus their
studying on topics most likely to appear
on the examination.
• These High Yield Questions can be
divided into two basic groups:
High Frequency (prevalent)
High Acuity (significant morbidity & mortality)
Miscellaneous
• Don’t forget
• Barrett’s Esophagus
• Colonic Malignancies
• Apple core lesions (descending)
• Occult anemia (ascending)
• Pre & Post-Operative Issues
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References
1. Current Medical Diagnosis and Treatment (53rd ed)
Papadakis MA, McPhee SJ, Rabow MW
McGraw-Hill. 2013 ISBN: 0071806334
2. Emergency Medicine: A Comprehensive Study Guide (7th ed)
Tintinalli JE, Kelen GB, Stapczynski JS
McGraw-Hill. 2010 ISBN: 0071484809