Family Medicine Board Review

Family Medicine Board Review

Trust Your Gut Feeling!

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Test Taking Sterategies

Trust Your Gut Feeling!

The best strategy for any test success is to know the content tested. Medical knowledge is only 50% of the job. You also need to to learn each test's style. In-Training Exam, Board Certification exam and USMLE are all checking your knowledge of medicine but each has its unique character. Another important factor is the time management. Time puts a lot of stress on the test takers and affect their performance significantly.

Let's begin with this fact that you will face lots of questions that you don't know the answer. That's the time that "Art of test taking" comes to rescue.

1. Read the last line of the Question

Most the USMLE questions are long. Recently FM Board Exam questions and recently FM In-Training Exam questions are becoming longer and more complicated. The favorite technique to deal with thses long questions are to read the very last line of the questions first. The question usually has lots of unnecessary and time wasting info. A typical question would explain a detailed symptoms and exam and lab findings. But opposite to what you expect, it wouldn't ask about the diagnosis, it will even tell you the diagnosis and then asks about the vignette about that disease. So first read the last phrase. then covering the answers read the main body of the question. It helps you to read directed towards the point that is being asked.

2. Thinking phase

Before looking at the answers, try to see if you know the answer. Now it is time to check the answers. If you see the answer, good for you! But if not, don't worry you are not out of options yet. These exams have been around for many years and lots of studies conducted by officials to see what are the common mistake choices for each question. Don't be surprised if those are being used to distract you too!

3. Trust your gut feeling!

Unfortunatley, most of the questions can get very tricky and you are not sure about the answer. Now is time to use another strategy which is to narrow down to two possible correct answers. That would increase you probability of choosing the correct one if you are not sure. So don't rush and chose a random answer. If you want to guess, narrow it down first. It is extremely important to trust your gut feeling and when you made choice, stick to it. Most of those choices are coming from your unconscoious knowledge of medicine which here we refer to as "Gut feeling".

My personal suggestion is to finish each question first time you read them. Usually it is hard to mark them and review them later. Make a choice. At this time there is no penalty with wrong answers. No answe and wrong answer are the same.

It is important to try to learn this approach to the test by practicing it on the prep exams. Don't try to change your style on the main test!

Random tips:

1- An average 4 months is required for preparation for USMLE and FM Board exams. You might need less with In-training exam.

2- Enough rest is the key to score better

3- You may also find exercise and/or other relaxation techniues like meditation or Yoga useful.

4- Don't be surprised and disappointed if you did poorly on the first block. Soemtimes that's atrick they play.

(Last edited on 1/09/2010)

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Family Medicine In-Training Exam (FM-ITE)

FM-ITE is first introduced in 1979 by American Board of Family Medicine to evaluate family medicine residents during their training. It has evolved significantly since then. It is definitely a moving target and quality of the questions and also format of the exam are constantly review by board and changes are made accordingly. The major emphasize of the questions are major journals of medicine like AFP (American Family Physician) and New England Journal and USPSTF (U.S. Preventive Services Task Force). Here we are going to offer a free review of the common topics asked in FM-ITE. It will be in the format of pearls.

Hypertension (Last Edit 1/24/10)

African American patients: Better response to monotherapy with Ca channel blockers or Thiazides compare to ACE inhibitors or Beta blockers.
Increasing the dose of Thiazides only increases the side effects like hypokalemia, hyperuricemia and glucose intolerance.
While on thizides, low salt diet reduces the risk of hypokalemia
Monitoring for hypokalemia is warranted with thiazide diuretics. Highest risk is in the first two weeks of therapy.
Goal of treatment is <140/90 with no risk factor and <130/80 with DM, proteinuric CKD and known CAD.
Monotherapy is mostly failing if baseline blood pressure is >160/100, so initial combination therapy is recommended.
If monotherapy with thiazides is chosen, it's best to use Chlothslidone secondary to its long acting effects compare to HCTZ. It has more risk of hypokalemia, glucose intolerance and new onset DM compare to HCTZ.
Best response to ACEInh or ARBs and Beta Blockers: younger patients.
Best response to thiazides or Ca channel blockers: elderly and African Americans since they have lower plasma renin activity.
Beta Blockers improve survivial in systolic heart failure or prior MI.
First line therapy in heart failure or asymptomatic LV dysfunction, ST elevation MIs, Non ST elevation Anterior MI with diabetes or systolic dysfunction, or proteinuric CKD: ACE inhibitors. (Same effects with ARBs)
Only two occasions that ARBs are superior to ACE inhibitors: Cough from the medication, or severe hypertension with LVH on ECG.
The preferred thiazide is Chlorthalidone (HCTZ is shorter acting and less potent).
COPD patients are good candidates for Ca channel blockers.
Systolic blood pressure in patients over age of 50 is more important CVD rsik factor than diastolic.
Think of Pheochromocytoma: HTN + Headache + Palpitation
Think of Coarctation of Aorta: HTN + absent femoral pulses
Think of Hyperparathyroidism: HTN + Hypercalcemia
Think of Aldosteronism: HTN + Hypokalemia
Among lifestyle changes weight reduction has the strongest effect in lowering the blood pressure followed by DASH diet and then sodium intake reduction and exercise.
Beta blockers shouldn't be the first line therapy for HTN if not post-MI or with stable heart Failure especially after age of 60.
Of all classes of anti-hypertensive drugs, beta-blockers are associated with higher risk of stroke and all cardiovascualr events.
Beta blockers except Carvedilol and Nebivolol are increasing the risk of new onset diabetes and impaired glucose tolerance.
Beta blockers reduce angiotensin II formation, so they make ACE inhibitors less effective if used in combination.
Classification and management of blood pressure for adults

DM2 (Last Edit 1/24/10)

American Diabetic Association (ADA) 's targer hemoglobin A1c : <7%.
DM2 pathophysiology: Decreased incretin function and insulin sensitivity and beta cell function.
Treatment steps: First lifestyle changes, then oral medications and at last, addition of insulin.
Oral agents can't stop the decline in beta cell function.
One of the side effects of insulin therapy is weight gain.
Incretins (GLP-1 and GIP) are released in the intestine after food intake, but in DM2 there is adecrease in secretion of GLP-1 and insulinotropic effects of GIP.
Main problem with GLP-1 receptor agonists like Exenatide and Liraglutide is Nausea especially in first two weeks of therapy.

Hip Fracture (Last Edit 1/25/10)

If patient is medically stable: surgery is indicated as soon as possible. Delay beyond 48 hours will increase mortality rate. Perioperatibe beta blockers lower the mortality and morbidity.
Evidence suggests there is no benefit to do DVT prophylaxis immidiately after Hip Fracture prior to surgery.
There is benefit for DVT prophylaxis after surgery. Aspirin is not enough and Coumadin or Arixtra or Heparin are recommended.
Most common contraindication for DVT prophylaxis is active bleeding at the surgery site. So if there is a concern, hold anticoagulation for 12-24 hours and use TEDs/SCDs.
Duration of anticoagulation therapy is 4-5 weeks postoperatively, especially with Hx of DVT, lack of activity and obesity and older age and presecence of cancer.
Postoperatively, if Hgb was less than 8 g/dl, tansfusion is recommended before discharge.
A perioperative prophylactic antibiotic is recommended, also urinary catheters should be discontinued within 24 hours post-op period.

Newborn Skin lesions (Last Edit 1/29/10)

Cutis Marmorata: Benign reticulated mottling of trunk and extremities. Symmetric. Resolves when skin is warmed. No treatment needed.
Harlequin color change: Red discoloration of the side baby lies on. Resolves with muscle activity or crying. Affects up to 10% of full-term babies. Caused by hypothalamic center.
Erythema Toxicum Neonatorum: Most common pustular lesion in neonates. Most common in full term infant heavier than 2500 g. Appears on day 2-3 of life. "Flea-Bitten" appearance. Lesions are on face, trunk and extremities. No palms or sole involvement. Diagnosis is made clinically unless the baby is sick. Cytologic exam: Eosinophilia. Lesions fade in 5-7 days. No treatment is needed.
Sick infants with vesicular or pustular rash: Test for Candida, Syphilis, Strep or CMV, HSV or VZV.
Transient Neonatal Pustular Melanosis: More common in black newborns. All areas of the body may be affected. Hallmark: pigmented macules in cesiculopustular lesions.