Family Medicine Flashcards

A 52-year-old woman with type 2 diabetes, CKD stage 3b (eGFR 38), and heart failure with reduced ejection fraction (HFrEF, EF 35%) presents for medication review. Which antidiabetic agent provides both cardiovascular mortality benefit and renal protection most appropriate for her combined conditions?

Answer: Empagliflozin

Empagliflozin (an SGLT2 inhibitor) is the most appropriate choice because it has demonstrated cardiovascular mortality reduction in HFrEF patients (EMPEROR-Reduced trial) AND slows CKD progression (EMPA-KIDNEY trial). It is approved down to eGFR ≥20 for heart failure benefit. Sitagliptin is heart-failure neutral but has no renal protection signal. Pioglitazone causes fluid retention and is contraindicated in HFrEF. Liraglutide (GLP-1 RA) reduces MACE in atherosclerotic CVD but has not shown benefit—and may worsen outcomes—in HFrEF, and its renal benefit is secondary to the SGLT2 inhibitors in this scenario.

A 68-year-old man on warfarin for atrial fibrillation (INR target 2.0–3.0) starts clarithromycin for community-acquired pneumonia. His INR is checked 5 days later and is 4.9 with no bleeding. What is the most appropriate next step?

Answer: Hold warfarin 1–2 doses, recheck INR in 1–2 days, resume at a lower dose

With a supratherapeutic INR of 4.9 and no active bleeding, the guideline-recommended approach (CHEST guidelines) is to hold 1–2 warfarin doses and recheck INR in 1–2 days, then resume at a reduced dose. IV vitamin K 10 mg is reserved for serious/life-threatening bleeding or INR >10. Switching to a DOAC is a separate clinical decision not warranted urgently here. Continuing unchanged risks bleeding as clarithromycin inhibits CYP3A4 and P-glycoprotein, amplifying warfarin's effect.

A 34-year-old woman presents with episodic hypertension, palpitations, diaphoresis, and headaches. Plasma free metanephrines are elevated at 3× the upper limit of normal. She is scheduled for adrenalectomy in 4 weeks. Which preoperative medication regimen is most critical to initiate first?

Answer: Alpha-adrenergic blockade (phenoxybenzamine), then add beta-blockade after adequate alpha blockade is achieved

For pheochromocytoma, alpha-blockade MUST precede beta-blockade. Initiating a beta-blocker first (or simultaneously) can cause unopposed alpha-adrenergic stimulation, triggering a hypertensive crisis because catecholamine-mediated vasodilation via beta-2 receptors is blocked while alpha-1-mediated vasoconstriction remains uninhibited. Phenoxybenzamine (non-selective, irreversible alpha-blocker) is standard for 7–14 days before surgery; only then is a beta-blocker added for reflex tachycardia. Calcium channel blockers are an acceptable alternative or adjunct but not first-line monotherapy when metanephrines are markedly elevated.

A 71-year-old man with COPD GOLD Group E (multiple exacerbations, CAT score 24) remains symptomatic on dual bronchodilator therapy (LABA + LAMA). Spirometry shows FEV1 42% predicted. Blood eosinophil count is 380 cells/μL. What is the most evidence-supported next step?

Answer: Escalate to triple therapy by adding an inhaled corticosteroid (ICS)

Per GOLD 2024 guidelines, patients in Group E with blood eosinophils ≥300 cells/μL have a strong predictor of ICS response, and escalation to triple therapy (ICS + LABA + LAMA) is the recommended step after dual bronchodilator failure — supported by the IMPACT and ETHOS trials showing exacerbation reduction and mortality benefit. Roflumilast is an option for chronic bronchitis phenotype with frequent exacerbations but is not first-line before triple therapy in this eosinophilic profile. Long-term oral corticosteroids are not recommended in COPD due to systemic side effects. Removing the LAMA (switching to ICS+LABA alone) is a downgrade, not an escalation.

A 28-year-old woman at 10 weeks gestation is found to have a TSH of 6.8 mIU/L with a free T4 of 0.7 ng/dL (low). She has no history of thyroid disease and is asymptomatic. Anti-TPO antibodies are positive. What is the most appropriate management?

Answer: Start levothyroxine therapy targeting TSH < 2.5 mIU/L

Overt hypothyroidism in pregnancy (elevated TSH with low free T4) requires immediate levothyroxine treatment regardless of symptoms. Current ATA guidelines recommend a TSH target of 10 is inappropriate in pregnancy as untreated hypothyroidism increases risks of miscarriage, preterm birth, and impaired fetal neurodevelopment. Methimazole is for hyperthyroidism. Termination is not indicated.

A 45-year-old man presents with a 3-month history of progressive proximal muscle weakness, difficulty rising from a chair, and a heliotrope rash with Gottron's papules. CK is 4,200 U/L. ANA is positive; anti-Jo-1 antibody is detected. Which associated condition must be actively screened for at diagnosis?

Answer: Interstitial lung disease

Anti-Jo-1 antibody positivity defines the antisynthetase syndrome, a subset of inflammatory myopathy characterized by myositis, mechanic's hands, Raynaud's phenomenon, arthritis, and — most importantly — interstitial lung disease (ILD). ILD occurs in up to 70% of anti-Jo-1 positive patients and is a major cause of morbidity and mortality. High-resolution CT of the chest and pulmonary function tests are mandatory at diagnosis. While dermatomyositis overall carries elevated malignancy risk (especially ovarian, lung, colorectal cancers), anti-synthetase syndrome has lower malignancy association compared to MDA5 or TIF1-γ antibodies. Renal cell carcinoma is not specifically linked. Primary biliary cholangitis is associated with Sjögren's and systemic sclerosis, not antisynthetase syndrome.