2 Sample Questions to Help You Ace the Family Medicine ITE

A few weeks ago, TrueLearn announced major updates to our Family Medicine SmartBanks, and your response was heard loud and clear – more sample questions!

With the Family Medicine ITE right around the corner, we couldn’t be happier to oblige to this request. So without further adieu, here’s another pair of family medicine practice questions to help you in your ITE prep.

FAMILY MEDICINE ITE SAMPLE QUESTION #1:

A 65 year old male with a past medical history of gout and a recent chemotherapy regimen presents with right flank pain. He tells you the pain was rapid in onset, and radiates to his groin. Physical exam shows an agitated male who can’t seem to find a position of ease. Lab analysis shows microscopic hematuria. A KUB is negative but a noncontrast CT scan is diagnostic. Which of the following should be used to prevent this condition from occurring again?

A) Citrate

B) Sodium Restriction

C) Penicillamine

D) Thiazide Diuretics

E) Surgery

EXPLANATION & ANALYSIS

Correct Answer: A

Nephrolithiasis, or renal calculi are usually composed of calcium oxalate but may also be composed of calcium phosphate, struvite, uric acid or cysteine. Risk factors include a positive family history, low fluid intake, gout, medications such as allopurinol, chemotherapy and loop diuretics, enzyme deficiencies, type I TRA and hyperparathyroidism.  Hydration and analgesia are the initial treatments in all patients with nephrolithiasis. Sodium bicarbonate or citrate can be used to prevent the formation of uric acid stones as they alkalinize the urine. Citrate is converted to bicarbonate in the liver.

Answer B: Sodium restriction is a mainstay in the treatment of nephrolithiasis in patients with calcium oxalate, calcium phosphate stones or cystine stones.

Answer C: Penicillamine is used to treat cystine stones in addition to hydration and dietary sodium restriction.

Answer D: Thiazide diuretics help the kidney retain calcium and are a mainstay in the treatment of nephrolithiasis in patients with calcium oxalate or calcium phosphate stones.

Answer E: Surgery is reserved for the removal of large staghorn calculi and stones that are too large to be treated with extracorporeal shock wave lithotripsy.

Bottom Line: Uric acid stone formation can be prevented by alkalinizing the urine with citrate.

For more information, see: Kidney Stones. AAFP

FAMILY MEDICINE ITE SAMPLE QUESTION #2:

Regarding the use of loop diuretics in the treatment of congestive heart failure, which of the following answer choices is correct?

A) A common side effect of their use is hypercalcemia

B) Loop diuretics decrease mortality

C) They are more effective than thiazide diuretics in treating of hypertension

D) They have a short half life and rapid onset of action

E) Loop diuretics are contraindicated in patients with renal insufficiency

EXPLANATION & ANALYSIS

The Correct Answer: D

Loop diuretics are effective in treating patients with heart failure due to their short half life and rapid onset of action.

Loop diuretics act on the Na+-K+-2Cl− symporter (cotransporter) in the thick ascending limb of the loop of Henle. They work to inhibit sodium and chloride resorption by competing for the Cl− binding site. Because magnesium and calcium resorption also occur in the same part of the nephron, loop diuretics also inhibit their resorption. This decreased resorption of osmotically active ions, results in increased urine production. A secondary effect of loop diuretics is to increase the production of prostaglandins, which results in afferent arteriolar vasodilation and an increase in renal blood flow. Not surprisingly, then, NSAIDs can reduce the efficacy of loop diuretics.

Most patients with cardiomyopathy retain fluid. Diuretics are the most effective pharmacologic means to provide symptomatic relief, but their effect on survival is unknown. Diuretics also provide rapid symptomatic relief of pulmonary and peripheral edema, due to their rapid onset of action. Loop diuretics are more effective for the treatment of symptomaitc fluid retention in cardiomyopathy than thiazide-type diuretics.

Loop diuretics should be used, instead of thiazide diuretics, to treat hypertension in patients with moderate to severe renal impairment. In patients with normal renal function, loop diuretics are less effective than thiazide diuretics for the treatment of hypertension. Ethacrynic acid can be used for patients allergic to sulfonamides (thiazide and loop diuretics, other than ethacrynic acid, contain sulfonamide moieties).

Diuretics should be initiated at a low dose, which can be titrated until urine output increases and weight decreases. Patients with renal dysfunction or prior refractoriness to loop diuretics can be treated with higher doses of diuretics. Intravenous administration, concurrent use of 2 different diuretics, or the addition of an aldosterone antagonist can sometimes overcome diuretic resistance.

The most common adverse effect of diuretic therapy is hypokalemia. Diuretics must therefore be used with caution, especially if a patient is taking digoxin. Diuretics can also cause worsening of renal function. The specific choice of a loop diuretic is less important than knowing the indications and contraindications of diuretic use. Torsemide is better absorbed than furosemide and has a longer duration of action, but there is no clinical evidence that torsemide or bumetanide is more effective than furosemide at improving symptoms.

Answer A: Hypercalcemia is a known side effect of thiazide diuretics. Loop diuretics inhibit the reabsorption of magnesium and calcium.

Answer B: Loop diuretics are the most effective pharmacologic means of providing symptomatic relief to patients with cardiomyopathy, but their effect on survival is unknown.

Answer C: Loop diuretics are used instead of thiazide diuretics to treat hypertension in patients with moderate to severe renal impairment. In patients with normal renal function, loop diuretics are less effective than thiazide diuretics for the treatment of hypertension. Ethacrynic acid can be used for patients allergic to sulfonamides (thiazide and loop diuretics, other than ethacrynic acid, contain sulfonamide moieties).

Answer E: Loop diuretics are used instead of thiazide diuretics to treat hypertension in patients with moderate to severe renal impairment. However, in severe renal disease, larger doses of diuretics are usually required.

Bottom Line: Understand the role loop diuretics play in the treatment of cardiomyopathy and hypertension.

For more information, see: McPhee, Stephen J., Papadakis, Maxine A., and Rabow, Micheal W., 2012 Current Medical Diagnosis and Treatment; Fifty-First Edition. McGraw-Hill Medical; 2012. Treatment Guidelines from The Medical Letter., Drugs for Hypertension., Vol. 12;141., May 2014.