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