TRUELEARN SAMPLE QUESTIONS

Family Medicine
MC-FP IN-TRAINING EXAM

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QUESTION 1

Exam: MC-FP | Peer Score: 56.6%

Regarding dietary recommendations in the treatment of hypertension, which of the following answer
choices is correct?

a. The costs associated with dietary treatment of hypertension are modest and affordable
b. Effects of dietary modifications are equivalent in normotensive or hypertensive patients
c. There is no specific diet that has proven effective in the treatment of hypertension
d. While the need for regular guidance and follow up seems obvious there is no evidence
recommending dietary changes is of any objective clinical benefit
e. None of the above

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EXPLANATION:
CORRECT ANSWER: [a. ] The costs of treating dietary hypertension are modest and affordable

Hypertension is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm
Hg or higher in adults younger than 60 years of age. High blood pressure is associated with an increased risk of stroke,
myocardial infarction, heart failure, renal failure, and cognitive impairment. Systolic blood pressure above 120 mm Hg
is the most important determinant of the risk of death worldwide. In cultures where persons adhere to diets including
strict vegetarian, low sodium intake and high potassium have virtually no increase in hypertension with age.

Two effective interventions for lowering blood pressure in patients with hypertension are reducing sodium intake and
reducing weight. Reductions in dietary salt lessen the amount of sodium the kidney has to excrete to restore normal
blood volume. Compliance in the aorta and carotid artery in older patients with hypertension is improved and so is
arterial vasodilatation. Weight loss moderates activation of the renin-angiotensin-aldosterone axis and the sympathetic
nervous system and diminishes sodium retention. Decreases in abdominal visceral fat also improve the functioning of
both conduit and resistance vessels.

The kinds of dietary patterns that have lowered blood pressure emphasize fruits, vegetables, and low-fat dairy
products. This includes whole grains, poultry, fish, and nuts. In addition, use unsaturated vegetable oils and contain
smaller amounts of red meat, sweets, and sugar-containing beverages. The most carefully studied and established
healthful dietary patterns are the Dietary Approaches to Stop Hypertension (DASH) diet, variants of that diet, and
variations of the Mediterranean diet. In the original DASH, trial adults whose systolic blood pressure was less than
160 mm Hg and whose diastolic blood pressure was 80 to 95 mm Hg, 133 of whom had hypertension, were randomly
assigned to a control diet typical of the average U.S. diet. The diet was rich in fruits and vegetables, or a combination
diet rich in fruits, vegetables, and low-fat dairy products and relatively low in saturated and total fat. Sodium intake and
body weight were maintained at constant levels.

After 8 weeks, among the participants with hypertension, the diet rich in fruits and vegetables significantly reduced
systolic and diastolic blood pressure by 7.2 and 2.8 mm Hg more, respectively, than the control diet. The effects were
less pronounced among participants who did not have hypertension at baseline. A further study found reducing sodium
intake resulted in a significant incremental reduction in both systolic and diastolic blood pressure.

Dietary management is appropriate for all patients with prehypertension and hypertension. Patients should not skip
meals, should consume at least one-third of their daily food intake at breakfast, and should limit eating in restaurants
to no more than once weekly. Compliance with dietary therapy is better and success rates in achieving blood pressure
control are higher, when accompanied by active guidance or counseling of the patient by clinicians or ancillary medical
personnel. Patients record their dietary intake for 1 or 2 weeks and discuss their record. This is especially important
when weight loss is needed. The costs associated with dietary treatment of hypertension are surprisingly relatively
modest. In one study, the cost of the DASH meal plan was $31 per week in areas with low socioeconomic status and
$40 per week in areas with high socioeconomic status.

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ANSWER B ::
The effects were less pronounced among participants who did not have hypertension at baseline.

ANSWER C ::
The kinds of dietary patterns that have lowered blood pressure emphasize fruits, vegetables, and low-fat dairy
products. This includes whole grains, poultry, fish, and nuts. In addition, use unsaturated vegetable oils and contain
smaller amounts of red meat, sweets, and sugar-containing beverages.

ANSWER D ::
Compliance with dietary therapy is better and success rates in achieving blood pressure control are higher, when
accompanied by active guidance or counseling of the patient by clinicians or ancillary medical personnel.

ANSWER E ::
See correct answer choice.

THE BOTTOM LINE ::

A healthy diet, or lack thereof, is necessary and can result in powerful positive, or negative, health
effects.

For more information: Campos, H., and Sacks, F.M., Dietary Therapy in Hypertension., N Engl J Med 2010:362:2102-12.

QUESTION 2

Exam: MC-FP | Peer Score: 53.9%

A neonate presents with jaundice, hypotonia, and a protruding tongue. What is the most likely diagnosis?

a. Physiologic jaundice
b. Biliary atresia
c. Kernicterus
d. ABO incompatibility
e. Hypothyroidism

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EXPLANATION:
CORRECT ANSWER: [e. ] Hypothyroidism

Hypothyroidism can also present with jaundice. Other findings include hypotonia, protruding tongue, and delayed
closure of the fontanelles.

ANSWER A ::
Physiologic jaundice starts on the second to third day after birth and usually self-resolves by the end of the week
(it may last up to two weeks in pre-mature infants). It is caused by immaturity of the conjugating enzymes. If the
bilirubin rises above 15mg/dL (depending on risk factors and time since birth), phototherapy may be indicated to
prevent kernicterus.

ANSWER B ::
Biliary atresia typically is not evident in the neonatal period. Extrahepatic bile ducts are typically present at birth, but
are destroyed by idiopathic inflammatory processes. After an initial period of asymptomatic jaundice, liver damage
rapidly progresses to symptomatic cirrhosis and portal hypertension.

ANSWER C ::
Kernicterus is an irreversible, potentially fatal complication of elevated indirect (unconjugated) bilirubin. The
unconjugated fraction passes the blood-brain barrier and deposits in the basal ganglia. Symptoms include hypertonia,
seizures, poor feeding and high-pitched cry.

ANSWER D ::
ABO incompatibility causes hemolysis which leads to elevated indirect bilirubin and jaundice. Jaundice usually appears
early and is confirmed by a positive Coombs test.

THE BOTTOM LINE ::

Hypothyroidism can also present with jaundice. Other findings include hypotonia, protruding tongue, and
delayed closure of the fontanelles.

TRUELEARN INSIGHT // There are numerous causes of jaundice in the newborn. You should be
able to differentiate one from another based on what day the jaundice occurs.

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QUESTION 3

Exam: MC-FP | Peer Score: 50%

A 34-year-old woman presents to your urgent care clinic with acute complaints of dizziness. The patient
notes she has also been experiencing mild, intermittent palpitations associated with her dizziness.
The symptoms have been present since starting metoprolol, which another provider gave to her for
hypertension. Her vital signs indicate a heart rate of 55 beats per minute and a blood pressure of 120/73
mmHg. Physical examination reveals a healthy appearing woman with mild bradycardia on cardiac
auscultation, and a normal examination otherwise. To further assess the patient you decide to order an
electrocardiogram (ECG) in the office.

Based on the attached ECG findings below, what is this patients most likely diagnosis?

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 a. First degree AV block
b. Mobitz I (Wenckebach) heart block
c. Mobitz II heart block
d. Normal sinus rhythm
e. Third degree AV block

EXPLANATION:
CORRECT ANSWER: [b. ] Mobitz I (Wenckebach) heart block

A Mobitz I (Wenckebach) heart block is defined as a narrow QRS complex which is associated with a progressive
increase in PR interval until there is a loss of a ventricular beat. The sequence is subsequently repeated along the
course of ECG monitoring and is usually seen in a typical pattern of two to more than eight cycles. This particular heart
block is usually located in the AV node. This is commonly associated with digitalis or beta blocker toxicity, increased
vagal tone (e.g., parasympathetic excess), or inferior MI. This heart block is usually transient.

ANSWER A ::
A first degree AV block is described as a fixed prolongation of the PR interval more than 0.20 seconds in duration.
Also, there is absence of AV conduction failure. Potential causes include the following: normal variant, increased
vagal tone, medications such as beta-blockers, calcium channel blockers, or digoxin.

ANSWER C ::
A Mobitz II heart block is described as a fixed PR interval with a widened QRS complex. Occasionally, a loss of
beats in a pattern of 2:1, 3:1, or 4:1 is seen. Potential causes include myocardial infarction or an abnormal conduction
system.

ANSWER E ::
A third degree AV block is defined as a complete failure of conduction between the atria and ventricles of the heart.
Potential causes include myocardial infarction, digitalis toxicity, or an abnormal conduction system.

THE BOTTOM LINE ::

A Mobitz I (Wenckebach) heart block is described as a progressively increasing PR interval and eventual
loss of QRS complex on ECG monitoring.

FOR MORE INFORMATION: Dubin, Dale. Chapter 6: Rhythm, Part II. Rapid Interpretation of EKGs. 6th
ed. Fort Myers: COVER, 2000. 178-179. Print.

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TRUELEARN INSIGHT // Sometimes a short series of Wenckebach sequences can produce small
groups which may be confused for couplets of premature beats. Close examination of the ECG
patterns is necessary to avoid this incorrect assumption.

QUESTION 4

Exam: In-Training Exam | Peer Score: 52.2%

An 80-year-old female presents to the office for a routine 3-month follow up visit. She has a past medical
history of type 2 diabetes and mild osteoarthritis. Her cognition and functional status are excellent, and
she continues to live independently in the community.

Which of the following are appropriate Hemoglobin A1C and fasting glucose goals for this patient?

a. Hemoglobin A1C of 5.5 % and fasting glucose range of 70-100 mg/dL

b. Hemoglobin A1C of 6.0 % and fasting glucose range of 70-130 mg/dL
c. Hemoglobin A1C of 7.5 % and fasting glucose range of 90-130 mg/dL
d. Hemoglobin A1C of 8.0 % and fasting glucose range of 90-150 mg/dL
e. Hemoglobin A1C of 8.5 % and fasting glucose range of 100-180 mg/dL

EXPLANATION:
CORRECT ANSWER: [c. ] Hemoglobin A1C of 7.5 % and fasting glucose range of 90-130 mg/dL

The goals for diabetes management of adults over the age of 65 are different from those for younger patients. Few
studies have shown a benefit of intensive glycemic control in older adults, and the risks of hypoglycemia outweigh the
benefits of microvascular complications in frail individuals with limited life expectancy. A consensus framework has
been agreed upon by the American Diabetes Association, which takes into account the patients overall health and
functional status. Older adults are divided into 3 categories Healthy if they have few co-existing chronic conditions
and good cognition and function; Intermediate health/complex if multiple chronic illnesses and moderately impaired
function and cognition; Poor health/very complex if end-stage chronic illnesses and moderate to severely impaired
function and cognition. The goals for hemoglobin A1C and fasting glucose for each group are shown below. The patient
described in this question would be considered Healthy, with few medical conditions and excellent function and
cognition. Her goals are an A1C of less than 7.5% and a fasting glucose range of 90-130.

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ANSWER A ::
An A1C of < 5.5 and fasting glucose of 70-100 are goals for a young, healthy patient.

ANSWER B ::
An A1C of < 6.0 and fasting glucose of 70-130 are too intensive for an adult over 65.

ANSWER D ::
An A1C of < 8.0 and fasting glucose of 90-150 are appropriate for an older adult with several chronic medical
conditions and/or moderate cognitive and functional impairment.

ANSWER E ::
An A1C of < 8.5 and fasting glucose of 100-180 are appropriate for an older adult with end stage medical conditions
and/or severely declined function and cognition.

THE BOTTOM LINE ::

Less intensive glycemic control and avoidance of hypoglycemia is appropriate in adults over the age
of 65. As health status, function, and cognition decline, treatment goals for A1C and fasting glucose
are relaxed.

FOR MORE INFORMATION: Standards of Medical Care in Diabetes 2014. American Diabetes Association.
Diabetes Care 2014; 37(suppl 1).

QUESTION 5

Exam: In-Training Exam | Peer Score: 52.2%

A middle-aged female with a past medical history of basal cell carcinoma, presents with a non-healing
ulcer on her left leg. She states it started as a rough spot that she was able to scratch off on multiple
occasions. On exam, you notice she is very tan and she admits she frequents tanning salons often. You
note a small red ulcer on her left lower extremity. A biopsy is taken and the patient was educated on the
negative effects of tanning salons. What is the most likely diagnosis?

a. Squamous Cell Carcinoma

b. Basal Cell Carcinoma
c. Malignant Melanoma
d. Kaposis Sarcoma
e. Actinic Keratosis

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EXPLANATION:
CORRECT ANSWER: [a. ] Squamous Cell Carcinoma

The patient in the above scenario has squamous cell carcinoma, which is a common non-melanoma skin cancer
common in fair-skinned individuals who have had long-term sun exposure. They are more common in patients who
frequent tanning salons as well as organ transplant patients. There are approximately 700,000 cases of squamous
cell carcinoma diagnosed annually in the United States. This is a highly curable skin cancer with early diagnosis and
treatment. It presents as a non-healing ulcer or waxy, warty nodule on sun-exposed skin. It can occur on the lips,
mouth, and genitals as well.

ANSWER A ::
Basal cell carcinoma is the most common cancer, despite it being the lease serious of all the skin cancers. They occur in
sun-exposed areas in fair-skinned individuals and present as scabs or nodules with a central erosion and telangiectasias.

ANSWER B ::
Malignant Melanoma is the most serious type of skin cancer. It may spread rapidly to the lymph nodes, blood, or
internal organs and may be fatal.

ANSWER C ::
Kaposis Sarcoma is a type of skin cancer that occurs in immunocompromised patients, including patients with HIV/
AIDS and cancer.

ANSWER D ::
Actinic Keratosis are small macules or papules that are flesh-colored, pink or hyperpigmented and feel like sandpaper.
These are considered pre-malignant or pre-cancerous but approximately 1 in every 1,000 lesions may become
squamous cell carcinomas.

THE BOTTOM LINE ::

Squamous cell carcinoma is a common non-melanoma skin cancer that occurs in fair-skinned individuals
who have had long-term sun exposure. They are highly curable with early diagnosis and treatment.

For more information: Medical Diagnosis & Treatment, 2011. Pages 146-48.

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ABFM In-Training Exam

SMARTBANK CATEGORIES
Cardiovascular Population-based care
Endocrine Psychogenic
Gastrointestinal Reproductive - female
Hematologic/ immune Reproductive - male
Integumentary Respiratory
Musculoskeletal Special sensory
Nephrologic
Neurologic
Nonspecific
Patient-based systems

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SIMULATED
EXAM INTERFACE

WHAT PHYSICIANS ARE SAYING

ABOUT TRUELEARN
Mark U. D.O. Ryan T.
FAMILY PRACTICE ATTENDING EMERGENCY MEDICINE
NORTON MEDICAL CENTER ATTENDING
ARIA MEDICINE / EMERGENCY
MEDICINE

I used TrueLearn as my main resource in preparation
for the Osteopathic Family Medicine Board Exam and I
know that it was because of this preparation that I was
able to easily pass the exam.
Preparing for any board exam is difficult. Studying for
two at the same time makes the situation even more
daunting. I used TrueLearns emergency medicine and
family medicine board review content and passed both
exams with scores well above the mean. Their statistical
progress analysis on how you are progressing with
studying for your family medicine boards keeps you on
track and allows you to focus on weak subjects. My entire
residency class used TrueLearn for both exams and we
all passed. I recommend as the first online board review
material bought.

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