Family Medicine Certification Longitudinal Assessment (FMCLA) — Questions and Answers

Question 1: Which medication is used to treat postpartum hemorrhage due to uterine atony as first-line?

Tranexamic acid
Carboprost
Oxytocin (Correct answer)
Misoprostol

Correct answer: Oxytocin

IV oxytocin is the first-line uterotonic agent for postpartum hemorrhage due to uterine atony.

Question 2: What is the first-line pharmacological treatment for managing hypertension in adults according to current guidelines?

Calcium channel blockers
Beta-blockers
Thiazide diuretics (Correct answer)
ACE inhibitors

Correct answer: Thiazide diuretics

According to current guidelines, including those from the American College of Cardiology/American Heart Association (ACC/AHA) and the Eighth Joint National Committee (JNC 8), thiazide diuretics are recommended as first-line pharmacological treatment for managing hypertension in most adults. They are effective, well-tolerated, and have been shown to reduce cardiovascular morbidity and mortality. Other classes like ACE inhibitors, ARBs, and calcium channel blockers are also considered first-line options, but thiazide diuretics are often preferred initially.

Question 3: What is the CHA2DS2-VASc score used to determine in patients with atrial fibrillation?

Appropriate antiarrhythmic drug selection
Risk of stroke and need for anticoagulation (Correct answer)
Need for cardioversion
Rate vs. rhythm control strategy

Correct answer: Risk of stroke and need for anticoagulation

The CHA2DS2-VASc score estimates thromboembolic stroke risk in AF patients and guides the decision to initiate anticoagulation.

Question 4: In a patient with stable ischemic heart disease, which medication has demonstrated mortality benefit beyond symptom control?

Calcium channel blockers
Long-acting nitrates
Aspirin and statin therapy (Correct answer)
Short-acting nitrates

Correct answer: Aspirin and statin therapy

Antiplatelet therapy (aspirin) and high-intensity statin therapy are proven to reduce mortality and cardiovascular events in stable ischemic heart disease.

Question 5: A 22-year-old sexually active woman presents with mucopurulent cervical discharge, cervical motion tenderness, and uterine tenderness. The most likely diagnosis is:

Vulvovaginal candidiasis
Pelvic inflammatory disease (Correct answer)
Bacterial vaginosis
Cervical cancer

Correct answer: Pelvic inflammatory disease

The combination of cervical motion tenderness, uterine tenderness, and mucopurulent discharge meets criteria for pelvic inflammatory disease.

Question 6: Which HPV types are responsible for the majority of cervical cancer cases?

HPV 31 and 33
HPV 45 and 52
HPV 16 and 18 (Correct answer)
HPV 6 and 11

Correct answer: HPV 16 and 18

HPV types 16 and 18 account for approximately 70% of all cervical cancers worldwide.

Question 7: A 55-year-old diabetic presents with warmth, erythema, swelling, and tenderness of the lower leg without crepitus or purulent drainage. The most appropriate antibiotic for non-purulent cellulitis is:

Doxycycline 100 mg BID
Vancomycin IV
Cephalexin 500 mg QID or dicloxacillin (Correct answer)
Trimethoprim-sulfamethoxazole

Correct answer: Cephalexin 500 mg QID or dicloxacillin

Non-purulent cellulitis is caused predominantly by beta-hemolytic streptococci; cephalexin or dicloxacillin provides appropriate gram-positive streptococcal coverage.

Question 8: A 30-year-old presents with well-defined depigmented macules on the hands and periorbital region. Wood's lamp examination reveals chalk-white fluorescence. The diagnosis is:

Pityriasis alba
Tinea versicolor
Vitiligo (Correct answer)
Post-inflammatory hypopigmentation

Correct answer: Vitiligo

Vitiligo presents with well-demarcated depigmented (not hypopigmented) macules that fluoresce chalk-white under Wood's lamp due to complete absence of melanocytes.

Question 9: A 50-year-old non-smoker develops spontaneous pneumothorax. Which underlying condition is most commonly associated?

Asthma
Marfan syndrome or tall thin body habitus with subpleural blebs (Correct answer)
Sarcoidosis
Pulmonary fibrosis

Correct answer: Marfan syndrome or tall thin body habitus with subpleural blebs

Primary spontaneous pneumothorax most commonly occurs in tall, thin young men with subpleural apical blebs, and is associated with connective tissue disorders like Marfan syndrome.

Question 10: A 28-year-old presents with a 3-day history of sore throat, fever, and tonsillar exudate. Rapid strep test is positive. Which antibiotic is first-line?

Azithromycin
Amoxicillin (Correct answer)
Doxycycline
Ciprofloxacin

Correct answer: Amoxicillin

Amoxicillin (or penicillin V) remains the first-line antibiotic for Group A streptococcal pharyngitis due to its efficacy and narrow spectrum.

Question 11: Which intervention is most effective in preventing pressure ulcers in bedridden elderly patients?

Daily vitamin C supplementation
Prophylactic antibiotics
Regular repositioning every 2 hours (Correct answer)
Moisture barrier creams alone

Correct answer: Regular repositioning every 2 hours

Repositioning every 2 hours relieves sustained pressure and is the most evidence-based intervention for pressure ulcer prevention.

Question 12: Which medication is recommended for prophylaxis against altitude sickness when ascending rapidly above 8,000 feet?

Furosemide
Ibuprofen
Dexamethasone
Acetazolamide (Correct answer)

Correct answer: Acetazolamide

Acetazolamide (Diamox) accelerates acclimatization and is the first-line prophylactic agent for acute mountain sickness.

Question 13: Which developmental milestone is expected at 9 months of age?

Saying "mama" and "dada" specifically
Using a pincer grasp
Waving bye-bye (Correct answer)
Walking independently

Correct answer: Waving bye-bye

Waving bye-bye is a common social-emotional developmental milestone expected around 9 months of age. This gesture demonstrates the infant's ability to imitate and engage in reciprocal communication. While other milestones like specific word usage or walking occur later, waving bye-bye indicates emerging social understanding and interaction skills.

Question 14: Which joint is most commonly affected in rheumatoid arthritis that is rarely involved in osteoarthritis?

First CMC joint
DIP joints
MCP joints (Correct answer)
Knee joint

Correct answer: MCP joints

Rheumatoid arthritis classically involves the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, sparing the DIP joints.

Question 15: What defines severe preeclampsia apart from hypertension?

Edema of the ankles
Mild proteinuria only
Weight gain of 2 lb/week
Severe-range BP (≥160/110) plus end-organ damage (Correct answer)

Correct answer: Severe-range BP (≥160/110) plus end-organ damage

Severe preeclampsia is defined by BP ≥160/110 mmHg or evidence of end-organ damage (renal, hepatic, neurologic, hematologic).

Question 16: What is the first-line pharmacologic treatment for moderate-to-severe menopausal vasomotor symptoms in a woman without contraindications?

Hormone therapy (estrogen ± progesterone) (Correct answer)
Clonidine
SSRIs
Gabapentin

Correct answer: Hormone therapy (estrogen ± progesterone)

Hormone therapy remains the most effective treatment for menopausal vasomotor symptoms in appropriate candidates.

Question 17: A 75-year-old patient is found to have an ABI (ankle-brachial index) of 0.65. What does this indicate?

Venous insufficiency
Mild peripheral arterial disease
Normal peripheral circulation
Moderate-to-severe peripheral arterial disease (Correct answer)

Correct answer: Moderate-to-severe peripheral arterial disease

An ABI of 0.4–0.69 indicates moderate-to-severe peripheral arterial disease with significant arterial occlusion.

Question 18: What is the pathophysiology underlying hypoxemia in pulmonary embolism?

Decreased respiratory drive
Ventilation-perfusion (V/Q) mismatch (Correct answer)
Airway obstruction
Alveolar flooding

Correct answer: Ventilation-perfusion (V/Q) mismatch

PE causes dead space ventilation (ventilated but unperfused alveoli), resulting in V/Q mismatch and subsequent hypoxemia.

Question 19: At what age is it recommended to start routine screening for autism spectrum disorder (ASD) in children?

24 months
36 months
12 months
18 months (Correct answer)

Correct answer: 18 months

The American Academy of Pediatrics (AAP) recommends routine screening for autism spectrum disorder (ASD) in children at 18 months and 24 months of age. This universal screening is crucial for early detection, even in the absence of specific concerns. Early identification allows for prompt intervention, which has been shown to significantly improve developmental outcomes for children with ASD.

Question 20: Which imaging modality is first-line for evaluating suspected rotator cuff tear?

MRI (Correct answer)
CT scan
Bone scan
Plain X-ray

Correct answer: MRI

MRI is the gold standard for evaluating soft tissue structures including the rotator cuff, providing excellent detail of tear size and location.

Question 21: Which of the following is a contraindication to corticosteroid joint injection?

Bursitis
Tendinopathy
Overlying skin infection (Correct answer)
Osteoarthritis

Correct answer: Overlying skin infection

Overlying skin infection is a contraindication to joint injection due to the risk of introducing bacteria into the joint space.

Question 22: Which of the following is the most appropriate initial management for a simple febrile seizure in a 2-year-old?

Immediate CT head
Supportive care and fever management (Correct answer)
Initiate anticonvulsant therapy
Lumbar puncture

Correct answer: Supportive care and fever management

Simple febrile seizures are self-limiting and benign; supportive care and antipyretics are appropriate without neuroimaging or anticonvulsants.

Question 23: A patient with COPD has an FEV1 of 45% predicted. According to GOLD staging, this falls into which category?

GOLD 3 (Severe) (Correct answer)
GOLD 1 (Mild)
GOLD 2 (Moderate)
GOLD 4 (Very Severe)

Correct answer: GOLD 3 (Severe)

GOLD Grade 3 (Severe) is defined as FEV1 between 30% and 49% predicted, indicating significant airflow limitation.

Question 24: A 60-year-old male smoker presents with progressive dyspnea and chronic cough. Spirometry shows FEV1/FVC of 0.58. What is the diagnosis?

Congestive heart failure
Asthma
COPD (Correct answer)
Pulmonary fibrosis

Correct answer: COPD

COPD is confirmed by post-bronchodilator FEV1/FVC <0.70 in a patient with relevant exposure history and symptoms.

Question 25: What is the most common site of ectopic pregnancy implantation?

Fallopian tube ampulla (Correct answer)
Cervix
Abdominal cavity
Ovary

Correct answer: Fallopian tube ampulla

Approximately 70% of ectopic pregnancies implant in the ampullary portion of the fallopian tube.

Question 26: A patient on ACE inhibitor therapy develops a dry, persistent cough. What is the most appropriate management?

Continue therapy and reassure
Switch to an ARB (Correct answer)
Add an antihistamine
Add a short-acting bronchodilator

Correct answer: Switch to an ARB

ACE inhibitor-induced cough is a class effect due to bradykinin accumulation; switching to an ARB eliminates the cough while maintaining cardiovascular benefit.

Question 27: A patient presents with suspected deep vein thrombosis. Which scoring system should be applied before ordering imaging?

Wells criteria (Correct answer)
CHADS2 score
Ottawa rules
CURB-65 score

Correct answer: Wells criteria

The Wells criteria stratify pretest probability for DVT and guide the decision to perform D-dimer testing or duplex ultrasound.

Question 28: Which functional assessment tool evaluates basic activities of daily living (ADLs) in older adults?

Tinetti Scale
Katz Index (Correct answer)
MMSE
Geriatric Depression Scale

Correct answer: Katz Index

The Katz Index of Independence in Activities of Daily Living assesses bathing, dressing, toileting, transferring, continence, and feeding.

Question 29: A patient presents with exertional dyspnea, orthopnea, and bilateral leg edema. BNP is 850 pg/mL. The most likely diagnosis is:

Pulmonary embolism
Decompensated heart failure (Correct answer)
Pneumonia
COPD exacerbation

Correct answer: Decompensated heart failure

Elevated BNP with dyspnea, orthopnea, and edema strongly indicates decompensated heart failure with volume overload.

Question 30: Which of the following vaccines is recommended annually for all adults?

Tdap (Tetanus, Diphtheria, Pertussis)
Varicella
Influenza (Correct answer)
MMR (Measles, Mumps, Rubella)

Correct answer: Influenza

The influenza (flu) vaccine is recommended annually for all adults, especially those at higher risk for complications. This recommendation is due to the flu virus constantly evolving, requiring a new vaccine formulation each year to target the most prevalent strains. Annual vaccination helps protect individuals and communities from seasonal flu outbreaks and reduces the severity of illness.

Question 31: Which of the following screening tools is commonly used to assess for anxiety disorders in primary care settings?

GAD-7 (Correct answer)
PHQ-9
CAGE questionnaire
Beck Depression Inventory

Correct answer: GAD-7

The GAD-7 (Generalized Anxiety Disorder 7-item scale) is a widely used and validated screening tool specifically designed to assess for anxiety disorders in primary care settings. It helps clinicians quickly identify and gauge the severity of generalized anxiety symptoms. While other tools like PHQ-9 screen for depression, GAD-7 focuses on anxiety.

Question 32: What is the recommended interval for Pap smear screening in a 30-year-old woman with no prior abnormalities using co-testing?

Every year
Every 10 years
Every 5 years (Correct answer)
Every 3 years

Correct answer: Every 5 years

Women aged 30–65 who undergo co-testing (Pap + HPV) should be screened every 5 years if both tests are negative.

Question 33: Which behavioral intervention has the strongest evidence for effectiveness in treating insomnia?

Hypnosis
Sleep hygiene education
Relaxation techniques
Cognitive-behavioral therapy for insomnia (CBT-I) (Correct answer)

Correct answer: Cognitive-behavioral therapy for insomnia (CBT-I)

Cognitive-behavioral therapy for insomnia (CBT-I) has the strongest evidence for effectiveness in treating chronic insomnia and is considered the gold standard non-pharmacological treatment. CBT-I addresses the underlying thoughts and behaviors that contribute to insomnia, including sleep restriction, stimulus control, and cognitive restructuring. It provides more durable improvements in sleep than medication alone.

Question 34: Which finding on spirometry is most consistent with obstructive lung disease?

Increased TLC with elevated DLCO
Reduced FVC with normal FEV1/FVC ratio
FEV1/FVC ratio less than 0.70 (Correct answer)
Reduced TLC with normal FEV1/FVC ratio

Correct answer: FEV1/FVC ratio less than 0.70

An FEV1/FVC ratio below 0.70 post-bronchodilator is the diagnostic criterion for obstructive lung disease per GOLD guidelines.

Question 35: Which screening test is recommended at 24–28 weeks gestation to detect gestational diabetes?

Urinalysis for glucose
Hemoglobin A1c
1-hour 50g glucose challenge test (Correct answer)
Fasting blood glucose alone

Correct answer: 1-hour 50g glucose challenge test

The 1-hour 50g glucose challenge test (GCT) is the standard screening tool for gestational diabetes between 24–28 weeks.

Question 36: Which type of depression screening tool is validated specifically for use in elderly patients?

PHQ-9
Edinburgh Postnatal Depression Scale
MADRS
Geriatric Depression Scale (GDS) (Correct answer)

Correct answer: Geriatric Depression Scale (GDS)

The Geriatric Depression Scale was developed and validated specifically for older adults and avoids somatic items that confound depression assessment in the elderly.

Question 37: Which lifestyle modification has the most significant impact on reducing blood pressure in patients with hypertension?

Smoking cessation (Correct answer)
Increasing physical activity
Adopting the DASH diet
Reducing alcohol intake

Correct answer: Smoking cessation

Smoking cessation has the most significant impact on reducing blood pressure in patients with hypertension, often leading to substantial and rapid improvements. Smoking directly damages blood vessels and increases arterial stiffness, contributing to higher blood pressure. Quitting smoking not only lowers blood pressure but also dramatically reduces overall cardiovascular risk, making it a critical lifestyle modification.

Question 38: A 60-year-old male presents with sudden painless vision loss in one eye. Which diagnosis must be ruled out immediately?

Central retinal artery occlusion (Correct answer)
Open-angle glaucoma
Diabetic macular edema
Refractive error

Correct answer: Central retinal artery occlusion

Central retinal artery occlusion is an ophthalmic emergency requiring immediate treatment within hours to restore vision.

Question 39: A 35-year-old female presents with right lower quadrant pain, nausea, and fever. The Alvarado score is 8. What is the next step?

Repeat exam in 4 hours
Urgent surgical consultation (Correct answer)
Abdominal X-ray
Discharge with oral antibiotics

Correct answer: Urgent surgical consultation

An Alvarado score of 7–10 indicates high likelihood of appendicitis and warrants urgent surgical consultation.

Question 40: A 55-year-old woman presents with pain and stiffness of the shoulder girdle and hip girdle, ESR 80 mm/hr, and CRP elevated. The most likely diagnosis is:

Systemic lupus erythematosus
Polymyalgia rheumatica (Correct answer)
Fibromyalgia
Rheumatoid arthritis

Correct answer: Polymyalgia rheumatica

Polymyalgia rheumatica presents with bilateral shoulder and hip girdle pain, morning stiffness, and markedly elevated inflammatory markers in patients over 50.

Question 41: A 5-year-old presents with honey-crusted lesions clustered around the mouth and nose. The most appropriate treatment for localized, non-bullous impetigo is:

Topical mupirocin 2% ointment (Correct answer)
Topical hydrocortisone cream
Oral amoxicillin
Oral clindamycin

Correct answer: Topical mupirocin 2% ointment

Topical mupirocin is first-line for localized non-bullous impetigo because it effectively eradicates Staphylococcus aureus and Group A Streptococcus with minimal systemic side effects.

Question 42: Which auscultatory finding is most characteristic of aortic stenosis?

Diastolic murmur at the left sternal border
Fixed split S2
Crescendo-decrescendo systolic murmur at the right upper sternal border (Correct answer)
Holosystolic murmur at the apex

Correct answer: Crescendo-decrescendo systolic murmur at the right upper sternal border

Aortic stenosis produces a harsh crescendo-decrescendo systolic ejection murmur best heard at the right upper sternal border with radiation to the carotids.

Question 43: What is the first-line pharmacologic treatment for major depressive disorder in adults?

Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
Selective serotonin reuptake inhibitors (SSRIs) (Correct answer)
Benzodiazepines

Correct answer: Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacologic treatment for major depressive disorder in adults. They are generally well-tolerated, effective, and have a relatively safer side effect profile compared to older antidepressants like TCAs and MAOIs. SSRIs work by increasing serotonin levels in the brain, which helps regulate mood.

Question 44: A 2-year-old presents with pruritic, erythematous, weeping patches on the cheeks and extensor surfaces. Family history is positive for asthma and hay fever. The most likely diagnosis is:

Seborrheic dermatitis
Atopic dermatitis (Correct answer)
Contact dermatitis
Psoriasis

Correct answer: Atopic dermatitis

Atopic dermatitis presents in infants on the cheeks and extensor surfaces with a personal or family history of atopy (asthma, allergic rhinitis, eczema) — the atopic triad.

Question 45: Which of the following is the most appropriate first-line treatment for fibromyalgia?

Corticosteroid injections
NSAIDs alone
Aerobic exercise and cognitive behavioral therapy (Correct answer)
Opioid analgesics

Correct answer: Aerobic exercise and cognitive behavioral therapy

Multimodal management including aerobic exercise and cognitive behavioral therapy is the most effective first-line treatment for fibromyalgia.

Question 46: Which antihypertensive is preferred for treating hypertension during pregnancy?

Labetalol (Correct answer)
Lisinopril
Amlodipine
Hydrochlorothiazide

Correct answer: Labetalol

Labetalol is a preferred antihypertensive in pregnancy; ACE inhibitors like lisinopril are teratogenic and contraindicated.

Question 47: A 60-year-old fair-skinned patient presents with multiple rough, erythematous, scaly patches on sun-damaged skin of the face and forearms. This condition is considered premalignant and may progress to squamous cell carcinoma. The most likely diagnosis is:

Seborrheic keratosis
Bowen's disease
Actinic keratosis (Correct answer)
Squamous cell carcinoma in situ

Correct answer: Actinic keratosis

Actinic keratosis is a premalignant epidermal lesion caused by chronic UV exposure that carries a risk of progression to invasive squamous cell carcinoma if untreated.

Question 48: Which test is most sensitive for detecting acute pulmonary embolism?

D-dimer
V/Q scan
Chest X-ray
CT pulmonary angiography (CTPA) (Correct answer)

Correct answer: CT pulmonary angiography (CTPA)

CT pulmonary angiography is the gold-standard imaging modality for diagnosing PE with high sensitivity and specificity.

Question 49: A woman at 32 weeks gestation presents with sudden painless vaginal bleeding. Which diagnosis is most likely?

Placenta previa (Correct answer)
Vasa previa
Bloody show
Placental abruption

Correct answer: Placenta previa

Placenta previa classically presents with painless bright red vaginal bleeding in the third trimester due to the low-lying placenta.

Question 50: Which of the following best characterizes a CURB-65 score of 3 in a patient with community-acquired pneumonia?

ICU admission required
Consider hospitalization (Correct answer)
Outpatient treatment appropriate
No further workup needed

Correct answer: Consider hospitalization

A CURB-65 score of 3 indicates severe pneumonia and warrants hospitalization and consideration of ICU-level care.

Question 51: Which feature of a pigmented skin lesion is MOST concerning for malignant melanoma?

Irregular border with multiple colors (tan, brown, black) (Correct answer)
Symmetric shape with uniform tan color
Diameter less than 3 mm
A smooth, raised papule with well-defined margins

Correct answer: Irregular border with multiple colors (tan, brown, black)

Irregular borders and multiple colors are hallmark ABCDE criteria for melanoma, reflecting uncontrolled, asymmetric tumor cell proliferation.

Question 52: A woman presents with a 3-cm simple ovarian cyst found incidentally on pelvic ultrasound. She is premenopausal. What is the recommended management?

Repeat ultrasound in 6–12 weeks (Correct answer)
CA-125 measurement
No follow-up needed
Immediate surgical removal

Correct answer: Repeat ultrasound in 6–12 weeks

Simple ovarian cysts under 5 cm in premenopausal women are typically benign and warrant follow-up ultrasound to confirm resolution.

Question 53: What is the most appropriate pain management strategy for a cognitively impaired elderly patient who cannot self-report pain?

Rely on caregiver report alone
Avoid opioids entirely
Use behavioral observation scales like PAINAD (Correct answer)
Assume no pain if no complaints

Correct answer: Use behavioral observation scales like PAINAD

Validated behavioral pain scales like PAINAD assess facial expressions, vocalizations, and body language to detect pain in non-verbal patients.

Question 54: Which vitamin deficiency is extremely common in homebound elderly patients and contributes to falls and fractures?

Vitamin A
Vitamin E
Vitamin B12
Vitamin D (Correct answer)

Correct answer: Vitamin D

Vitamin D deficiency is prevalent in homebound elderly due to lack of sun exposure and impairs calcium absorption, increasing fall and fracture risk.

Question 55: What is the Ottawa Knee Rule used for?

Determining the need for knee X-ray after injury (Correct answer)
Grading ligamentous laxity
Screening for osteoarthritis
Diagnosing meniscal tears

Correct answer: Determining the need for knee X-ray after injury

The Ottawa Knee Rules identify clinical criteria that predict which patients with acute knee injury require radiographic evaluation to rule out fracture.

Question 56: A patient with known COPD presents in acute exacerbation with SpO2 of 84%. What oxygen delivery target is appropriate?

SpO2 > 95%
SpO2 88–92% (Correct answer)
SpO2 > 98%
No supplemental oxygen needed

Correct answer: SpO2 88–92%

COPD patients should be targeted to SpO2 88–92% to avoid hypercapnia worsening due to blunted hypoxic drive.

Question 57: At what gestational age is a fetus considered viable by US obstetric standards?

28 weeks
18 weeks
22–24 weeks (Correct answer)
32 weeks

Correct answer: 22–24 weeks

Fetal viability is generally accepted at 22–24 weeks gestation, though survival rates significantly improve with advancing gestational age.

Question 58: A 30-year-old develops widespread urticaria, throat tightness, and hypotension minutes after taking ibuprofen. The immediate first-line treatment is:

IV methylprednisolone 125 mg
Epinephrine 0.3 mg IM in the anterolateral thigh (Correct answer)
Oral cetirizine 10 mg
Diphenhydramine 50 mg IV

Correct answer: Epinephrine 0.3 mg IM in the anterolateral thigh

Epinephrine IM is the first-line treatment for anaphylaxis because it rapidly reverses bronchoconstriction, vasoconstriction, and urticaria through alpha and beta-adrenergic effects.

Question 59: According to the Beers Criteria, which analgesic should be avoided in elderly patients due to risk of GI bleeding and renal impairment?

Codeine
Tramadol
Acetaminophen
NSAIDs (Correct answer)

Correct answer: NSAIDs

NSAIDs are explicitly listed in the Beers Criteria as high-risk medications in older adults due to GI, renal, and cardiovascular adverse effects.

Question 60: A pregnant woman at 36 weeks is found to have GBS colonization on vaginal-rectal culture. What is the appropriate management?

No treatment required
Cesarean delivery
IV penicillin G during labor (Correct answer)
Oral amoxicillin started immediately

Correct answer: IV penicillin G during labor

Intrapartum IV penicillin G is given to GBS-positive mothers during labor to prevent neonatal early-onset GBS disease.

Question 61: What is the first-line treatment for urge urinary incontinence in older adults that avoids anticholinergic side effects?

Bladder training and pelvic floor exercises (Correct answer)
Tolterodine
Alpha-blockers
Oxybutynin

Correct answer: Bladder training and pelvic floor exercises

Behavioral therapies including bladder training and pelvic floor muscle exercises are first-line and preferred in older adults to avoid anticholinergic burden.

Question 62: Which clinical feature best differentiates bacterial sinusitis from viral upper respiratory infection?

Low-grade fever
Nasal congestion lasting 3 days
Symptoms worsening after initial improvement (double sickening) (Correct answer)
Clear nasal discharge

Correct answer: Symptoms worsening after initial improvement (double sickening)

Double sickening — initial improvement followed by worsening — is a hallmark feature suggesting bacterial superinfection in sinusitis.

Question 63: Which finding on urinalysis is most consistent with a diagnosis of nephrolithiasis in a patient with acute flank pain?

Hematuria (Correct answer)
Glucosuria
Proteinuria
Pyuria

Correct answer: Hematuria

Hematuria is present in approximately 85% of nephrolithiasis cases and is the hallmark urinalysis finding.

Question 64: A 16-year-old male basketball player presents with anterior knee pain below the patella that worsens with activity. The most likely diagnosis is:

Patellar fracture
Patellofemoral syndrome
Osgood-Schlatter disease (Correct answer)
Meniscus tear

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease causes tibial tubercle apophysitis due to repetitive quadriceps traction in adolescent athletes.

Question 65: Which medication is first-line for rate control in a patient with atrial fibrillation with rapid ventricular response?

Digoxin
Flecainide
Metoprolol (Correct answer)
Amiodarone

Correct answer: Metoprolol

Beta-blockers such as metoprolol or calcium channel blockers (diltiazem) are first-line for ventricular rate control in atrial fibrillation.

Question 66: The ABCDE criteria for melanoma screening include all of the following EXCEPT:

Border irregularity
Asymmetry
Elevation (Correct answer)
Color variation

Correct answer: Elevation

The ABCDE criteria are Asymmetry, Border, Color, Diameter (>6 mm), and Evolution; 'Elevation' is not one of the five criteria.

Question 67: For patients with type 2 diabetes, what is the target HbA1c level recommended by most guidelines?

<7.5%
<7.0% (Correct answer)
<6.0%
<6.5%

Correct answer: <7.0%

For most non-pregnant adults with type 2 diabetes, the target HbA1c level recommended by major guidelines, such as those from the American Diabetes Association (ADA), is <7.0%. This target aims to reduce the risk of microvascular complications like retinopathy and nephropathy. Individualized targets may vary based on factors like age, comorbidities, and risk of hypoglycemia, but <7.0% serves as a general goal for many patients.

Question 68: Which vaccine is recommended at birth for all newborns?

Hepatitis B (Correct answer)
DTaP
MMR
Rotavirus

Correct answer: Hepatitis B

The Hepatitis B vaccine is recommended at birth for all newborns, ideally within 24 hours of delivery. This early vaccination is crucial for preventing perinatal transmission of the virus from an infected mother to her baby. It is part of a series that provides long-term protection against Hepatitis B infection, which can lead to serious liver disease.

Question 69: A 65-year-old presents with a firm, indurated nodule with overlying crust on the lower lip and palpable cervical lymphadenopathy. The most likely diagnosis is:

Sebaceous cyst
Basal cell carcinoma
Keratoacanthoma
Squamous cell carcinoma (Correct answer)

Correct answer: Squamous cell carcinoma

Squamous cell carcinoma on the lip (a high-risk sun-exposed site) can metastasize to regional lymph nodes, unlike basal cell carcinoma which rarely metastasizes.

Question 70: A patient presents with rough, hyperkeratotic papules on the dorsal hands. Close inspection reveals small black dots within the lesion surface. The diagnosis is:

Verruca vulgaris (common warts) (Correct answer)
Seborrheic keratosis
Molluscum contagiosum
Actinic keratosis

Correct answer: Verruca vulgaris (common warts)

Verruca vulgaris (common warts) caused by HPV presents with rough, hyperkeratotic papules containing thrombosed capillaries that appear as black dots on the surface.

Question 71: A 45-year-old woman presents with persistent facial erythema, flushing, and papulopustules on the cheeks and nose. She reports triggers including alcohol and spicy foods. The most likely diagnosis is:

Acne vulgaris
Rosacea (Correct answer)
Seborrheic dermatitis
Systemic lupus erythematosus

Correct answer: Rosacea

Rosacea presents with centrofacial erythema, flushing, and papulopustules without comedones, commonly triggered by alcohol, spicy foods, heat, and sun exposure.

Question 72: A patient with acute gout flare is unable to tolerate NSAIDs due to peptic ulcer disease. What is the most appropriate alternative?

Allopurinol
Colchicine (Correct answer)
Probenecid
Febuxostat

Correct answer: Colchicine

Colchicine is an effective alternative anti-inflammatory for acute gout flares in patients who cannot tolerate NSAIDs.

Question 73: What is the recommended approach for managing mild to moderate postpartum depression?

Immediate pharmacotherapy
Electroconvulsive therapy (ECT)
Hospitalization
Cognitive-behavioral therapy (CBT) and supportive counseling (Correct answer)

Correct answer: Cognitive-behavioral therapy (CBT) and supportive counseling

For managing mild to moderate postpartum depression, cognitive-behavioral therapy (CBT) and supportive counseling are recommended as the first-line approach. These non-pharmacological interventions help mothers develop coping strategies, challenge negative thought patterns, and improve their emotional well-being. Pharmacotherapy may be considered if symptoms are severe or do not respond to initial therapy, often in conjunction with counseling.

Question 74: Which fracture pattern is most commonly seen in osteoporotic vertebral compression fractures?

Chance fracture
Burst fracture with retropulsion
Hangman's fracture
Wedge compression fracture (Correct answer)

Correct answer: Wedge compression fracture

Osteoporotic vertebral compression fractures typically present as anterior wedge deformities due to preferential failure of the anterior vertebral body.

Question 75: A patient presents with anaphylaxis after a bee sting. What is the first-line treatment?

Diphenhydramine IV
Epinephrine 0.3 mg IM (Correct answer)
Methylprednisolone IV
Albuterol inhaler

Correct answer: Epinephrine 0.3 mg IM

Intramuscular epinephrine in the anterolateral thigh is the first-line and life-saving treatment for anaphylaxis.

Question 76: Which maneuver is used to test for anterior cruciate ligament (ACL) integrity?

Lachman test (Correct answer)
McMurray test
Patellar grind test
Valgus stress test

Correct answer: Lachman test

The Lachman test is the most sensitive clinical test for ACL rupture, assessing anterior tibial translation at 20–30° knee flexion.

Question 77: Which organism is most commonly responsible for bacterial vaginosis?

Candida albicans
Chlamydia trachomatis
Trichomonas vaginalis
Gardnerella vaginalis (Correct answer)

Correct answer: Gardnerella vaginalis

Gardnerella vaginalis drives the disruption of normal vaginal flora that characterizes bacterial vaginosis.

Question 78: An 80-year-old patient has a blood pressure of 152/84 mmHg. According to current US guidelines for elderly patients, what is the recommended BP target?

<120/80 mmHg
<140/90 mmHg
<130/80 mmHg (Correct answer)
<160/90 mmHg

Correct answer: <130/80 mmHg

ACC/AHA 2017 guidelines recommend a BP target of <130/80 mmHg for most elderly patients when treatment is indicated.

Question 79: A 35-year-old presents with well-demarcated, erythematous plaques with silvery scales on the elbows and knees. The most likely diagnosis is:

Lichen planus
Pityriasis rosea
Nummular eczema
Psoriasis vulgaris (Correct answer)

Correct answer: Psoriasis vulgaris

Psoriasis vulgaris classically presents with well-demarcated erythematous plaques covered with silvery-white scales on extensor surfaces such as elbows and knees.

Question 80: A 70-year-old farmer presents with a pearly, translucent nodule with rolled borders and central ulceration on the nose. The most likely diagnosis is:

Basal cell carcinoma (Correct answer)
Merkel cell carcinoma
Squamous cell carcinoma
Actinic keratosis

Correct answer: Basal cell carcinoma

Basal cell carcinoma classically presents as a pearly, translucent papule with rolled telangiectatic borders and central ulceration, most commonly on sun-exposed areas of the face.

Question 81: A 72-year-old woman with osteoporosis sustains a hip fracture from a minor fall. Which bisphosphonate is commonly used for fracture prevention in this setting?

Calcitonin
Alendronate (Correct answer)
Raloxifene
Denosumab

Correct answer: Alendronate

Alendronate (a bisphosphonate) reduces fracture risk and is first-line pharmacotherapy for osteoporosis in postmenopausal women.

Question 82: A 17-year-old male presents with mild acne vulgaris consisting primarily of comedones with few papules. Which topical agent is considered first-line monotherapy?

Topical dapsone
Topical tretinoin (retinoid) (Correct answer)
Topical clindamycin
Topical benzoyl peroxide

Correct answer: Topical tretinoin (retinoid)

Topical retinoids are first-line for comedonal acne because they normalize follicular keratinization and prevent microcomedo formation.

Question 83: A patient develops a pruritic, erythematous vesicular rash on the wrists after wearing a new metal watch. The most likely diagnosis is:

Nummular eczema
Allergic contact dermatitis (Correct answer)
Atopic dermatitis
Irritant contact dermatitis

Correct answer: Allergic contact dermatitis

Allergic contact dermatitis from nickel (common in metal watches) is a Type IV hypersensitivity reaction presenting with pruritic vesicular rash confined to the contact area.

Question 84: What is the most appropriate screening test for cervical cancer in women aged 21 to 29 years?

HPV test every 5 years
Pap smear every 3 years (Correct answer)
Pap smear and HPV test co-testing every year
No screening needed

Correct answer: Pap smear every 3 years

For women aged 21 to 29 years, the most appropriate screening test for cervical cancer is a Pap smear every 3 years. HPV co-testing is not recommended in this age group unless the Pap smear results are abnormal. This frequency balances the need for early detection with avoiding over-screening, which can lead to unnecessary procedures and anxiety given the high rate of transient HPV infections in younger women.

Question 85: A patient presents with intense nocturnal pruritus and linear burrows between the fingers and wrist folds. The most appropriate first-line treatment is:

Topical hydrocortisone 1%
Topical diphenhydramine cream
Oral ivermectin alone as single-agent therapy
Permethrin 5% cream applied to the entire body from neck down (Correct answer)

Correct answer: Permethrin 5% cream applied to the entire body from neck down

Permethrin 5% cream applied from the neck down and left on for 8–14 hours is first-line treatment for scabies because it is scabicidal against Sarcoptes scabiei mites and eggs.

Question 86: What is the recommended frequency for monitoring lipid levels in patients with hyperlipidemia who are on statin therapy?

Every 3 months
Every 6 months
Annually (Correct answer)
Every 2 years

Correct answer: Annually

For patients with hyperlipidemia who are on statin therapy, it is generally recommended to monitor lipid levels annually. This frequency allows healthcare providers to assess treatment adherence, evaluate the effectiveness of the statin, and identify any potential side effects. While initial monitoring might be more frequent to ensure the target LDL-C is reached, annual checks are sufficient for maintenance once stable.

Question 87: Which vaccine is routinely recommended in the third trimester of every pregnancy?

Varicella
Tdap (Correct answer)
MMR
HPV

Correct answer: Tdap

Tdap is recommended at 27–36 weeks gestation each pregnancy to provide passive immunity to the newborn against pertussis.

Question 88: A 4-year-old presents with multiple, umbilicated, flesh-colored pearly papules on the trunk. The most likely diagnosis is:

Chickenpox (varicella)
Verruca vulgaris (common warts)
Milia
Molluscum contagiosum (Correct answer)

Correct answer: Molluscum contagiosum

Molluscum contagiosum caused by a poxvirus presents with umbilicated, dome-shaped, pearly papules in children and is spread by skin-to-skin contact.

Question 89: What is the primary purpose of using the CAGE questionnaire in clinical practice?

To measure cognitive function
To screen for depression
To assess for alcohol use disorder (Correct answer)
To evaluate anxiety levels

Correct answer: To assess for alcohol use disorder

The CAGE questionnaire is a widely used screening tool specifically designed to assess for alcohol use disorder in clinical practice. The acronym CAGE stands for Cut down, Annoyed, Guilty, and Eye-opener, referring to questions about a person's drinking habits. A positive response to two or more questions suggests a potential alcohol problem requiring further evaluation.

Question 90: A patient presents with acute monoarthritis of the first MTP joint with overlying erythema and severe pain. Synovial fluid shows negatively birefringent crystals. The diagnosis is:

Rheumatoid arthritis
Gout (Correct answer)
Pseudogout
Septic arthritis

Correct answer: Gout

Gout is caused by monosodium urate crystals, which appear needle-shaped and negatively birefringent under polarized light microscopy.

Question 91: Which medication class is most associated with fall risk in elderly patients?

Metformin
Benzodiazepines (Correct answer)
Statins
ACE inhibitors

Correct answer: Benzodiazepines

Benzodiazepines cause sedation, impaired balance, and psychomotor slowing, making them a major fall risk in older adults.

Question 92: A patient with an ejection fraction of 35% and NYHA Class II symptoms is started on an ARNI. Which medication is this?

Sacubitril/valsartan (Correct answer)
Lisinopril
Losartan
Spironolactone

Correct answer: Sacubitril/valsartan

Sacubitril/valsartan (Entresto) is an ARNI (angiotensin receptor-neprilysin inhibitor) shown to reduce cardiovascular death in HFrEF compared to enalapril.

Question 93: Which drug class is considered first-line for reducing cardiovascular mortality in patients with reduced ejection fraction heart failure?

Nitrates
Calcium channel blockers
Loop diuretics
Beta-blockers (Correct answer)

Correct answer: Beta-blockers

Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) have demonstrated robust mortality reduction in HFrEF in multiple large trials.

Question 94: What is the primary purpose of preventive care in family medicine?

To provide emergency care
To prevent diseases before they occur (Correct answer)
To treat chronic diseases
To conduct surgical procedures

Correct answer: To prevent diseases before they occur

The primary purpose of preventive care in family medicine is to proactively maintain health and prevent diseases from developing or worsening. This involves strategies like vaccinations, screenings, and lifestyle counseling. By identifying risk factors and intervening early, preventive care aims to reduce the incidence and impact of illness, ultimately improving long-term health outcomes for patients.

Question 95: A 45-year-old male presents with sudden onset crushing chest pain radiating to the left arm. Which initial diagnostic test is most critical?

Chest X-ray
Troponin level
12-lead ECG (Correct answer)
Echocardiogram

Correct answer: 12-lead ECG

A 12-lead ECG is the first-line diagnostic tool for suspected acute MI and should be obtained within 10 minutes of presentation.

Question 96: A woman presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. The most likely diagnosis is:

Ovarian torsion
Pelvic inflammatory disease
Endometriosis (Correct answer)
Uterine fibroids

Correct answer: Endometriosis

The triad of dysmenorrhea, dyspareunia, and cyclic pelvic pain is classic for endometriosis, a common gynecologic condition.

Question 97: Which finding on physical exam is a 'red flag' in a patient presenting with low back pain?

Pain worse with prolonged sitting
Pain radiating to the posterior thigh
Lumbar paraspinal muscle tenderness
Bilateral lower extremity weakness and saddle anesthesia (Correct answer)

Correct answer: Bilateral lower extremity weakness and saddle anesthesia

Bilateral weakness, saddle anesthesia, and bowel/bladder dysfunction suggest cauda equina syndrome, a surgical emergency.

Question 98: Which antiarrhythmic drug is the most commonly used for long-term maintenance of sinus rhythm in atrial fibrillation?

Amiodarone (Correct answer)
Lidocaine
Digoxin
Adenosine

Correct answer: Amiodarone

Amiodarone is the most effective antiarrhythmic for maintaining sinus rhythm in AF and is widely used despite its side effect profile.

Question 99: Which antibiotic class is contraindicated in a patient with a known sulfa allergy who requires treatment for a UTI?

Nitrofurantoin
Fosfomycin
Fluoroquinolones
Trimethoprim-sulfamethoxazole (Correct answer)

Correct answer: Trimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole contains a sulfonamide component and is contraindicated in patients with sulfa allergy.

Question 100: Which of the following is a risk factor for iron deficiency anemia in infants?

Introduction of solid foods before 4 months
Low birth weight
Exclusive breastfeeding beyond 6 months without iron supplementation
Both A and C (Correct answer)

Correct answer: Both A and C

Both exclusive breastfeeding beyond 6 months without iron supplementation and low birth weight are significant risk factors for iron deficiency anemia in infants. Breast milk alone may not provide sufficient iron after 6 months, and low birth weight infants have smaller iron stores at birth. Therefore, ensuring adequate iron intake through fortified foods or supplements is crucial for preventing anemia in these vulnerable populations.

Family Medicine Certification Longitudinal Assessment (FMCLA)

The FMCLA is a continuous board recertification assessment administered by the ABFM, delivering 25 open-book clinical questions per quarter that span acute care, chronic disease management, emergent care, and preventive medicine domains.

100

Questions

120 min

Time Limit

70%

To Pass

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