Family Medicine Flashcards

A 58-year-old man with type 2 diabetes and stage 3b CKD (eGFR 38 mL/min/1.73m²) presents with HbA1c of 8.9%. He is currently on metformin 1000 mg BID and glipizide 10 mg BID. Which modification to his diabetes regimen is most appropriate?

Answer: Discontinue metformin and initiate a GLP-1 receptor agonist such as semaglutide

Metformin is contraindicated when eGFR falls below 30 and requires dose reduction/caution at eGFR <45. SGLT-2 inhibitors like empagliflozin lose glycemic efficacy at eGFR <45 (though empagliflozin retains cardiorenal benefit at lower eGFRs, it's not the primary fix here). GLP-1 agonists like semaglutide are safe in CKD stage 3b and provide cardiovascular protection plus improved glycemic control — making them the most appropriate addition/switch. Glyburide is the worst sulfonylurea choice in CKD due to accumulation of active metabolites causing prolonged hypoglycemia.

A 44-year-old woman presents with 6 months of fatigue, cold intolerance, and a TSH of 6.8 mIU/L with a free T4 of 0.9 ng/dL (low-normal). Anti-TPO antibodies are strongly positive. She is 10 weeks pregnant. What is the most appropriate next step?

Answer: Initiate levothyroxine immediately with a TSH target of 0.5–2.5 mIU/L

In pregnancy, subclinical hypothyroidism with TSH >2.5 mIU/L in the first trimester (especially with positive anti-TPO antibodies) warrants immediate levothyroxine therapy to prevent adverse fetal neurodevelopmental outcomes. The target TSH in the first trimester is 0.5–2.5 mIU/L per ATA guidelines. Waiting to recheck would delay treatment during a critical developmental window. Liothyronine is not recommended in pregnancy because it does not cross the placenta as effectively. Immediate initiation by the family physician is appropriate; referral should not delay treatment.

A 67-year-old man with COPD (FEV1 42% predicted, GOLD Stage 3) is on tiotropium and salmeterol/fluticasone. He has had 2 exacerbations requiring oral steroids in the past year but no hospitalizations. His blood eosinophil count is 380 cells/µL. Which add-on therapy has the strongest evidence for reducing his future exacerbation risk?

Answer: Add azithromycin 250 mg daily given his exacerbation frequency

Azithromycin 250 mg daily has robust evidence (MACRO trial) for reducing COPD exacerbations in patients with frequent exacerbations not adequately controlled on inhaled therapy. Roflumilast is indicated primarily when chronic bronchitis with productive cough is present (which is not specified here) and has more GI side effects. Dupilumab is approved for severe eosinophilic asthma, not COPD (at the time of standard SPEX content). Elevated eosinophils do predict inhaled corticosteroid responsiveness, but the patient is already on ICS. Theophylline has a narrow therapeutic window and limited evidence as add-on in this context.

A 52-year-old woman presents with a new-onset seizure. MRI shows a ring-enhancing lesion in the right temporal lobe with surrounding edema. She is HIV-positive with a CD4 count of 48 cells/µL and is not on antiretroviral therapy. Serum Toxoplasma IgG is positive. CSF analysis shows elevated protein, normal glucose, and 12 lymphocytes. Which is the most appropriate initial management?

Answer: Initiate empiric pyrimethamine + sulfadiazine + leucovorin and reassess by day 14

In an HIV-positive patient with CD4 <100, positive Toxoplasma IgG, and a ring-enhancing brain lesion, empiric treatment for cerebral toxoplasmosis with pyrimethamine + sulfadiazine + leucovorin is the standard of care. Clinical and radiographic response at 2 weeks confirms the diagnosis and avoids the risk of stereotactic biopsy. Biopsy is reserved for patients who fail empiric therapy or have atypical features suggesting primary CNS lymphoma. Initiating ART immediately (immune reconstitution inflammatory syndrome risk) and steroids alone are not appropriate first steps. Leucovorin must accompany pyrimethamine to prevent myelosuppression.

A 38-year-old man presents requesting benzodiazepines for anxiety. He reports daily alcohol use of 6–8 drinks and takes no other medications. On exam, he is mildly tremulous with a heart rate of 104 bpm. He states his last drink was 18 hours ago. CIWA-Ar score is 14. What is the most appropriate management?

Answer: Administer IV thiamine, then dextrose, and initiate symptom-triggered diazepam in a monitored inpatient setting

A CIWA-Ar score of 14 indicates moderate-to-severe alcohol withdrawal risk, warranting inpatient management. Thiamine MUST be given before any glucose-containing fluids to prevent precipitating Wernicke encephalopathy in alcohol-dependent patients. Symptom-triggered benzodiazepine protocols (diazepam preferred for long half-life) in a monitored setting reduce total drug exposure and risk of seizures/delirium tremens. Outpatient benzodiazepine prescribing in a patient with CIWA ≥10 and active tremulousness is dangerous. Naltrexone addresses relapse prevention, not acute withdrawal. Phenobarbital outpatient is not standard first-line for this severity.

A 71-year-old woman with osteoporosis (T-score −2.9 at lumbar spine) has been on oral alendronate for 7 years. She reports new right thigh pain for 3 weeks with no trauma. X-ray of the femur shows focal cortical thickening of the lateral cortex at the subtrochanteric region. What is the most appropriate next step?

Answer: Obtain an MRI of the femur and discontinue bisphosphonate therapy pending results

This presentation is classic for an atypical femoral fracture (AFF) — a well-recognized but rare complication of long-term bisphosphonate therapy. The lateral cortical thickening ('beaking') at the subtrochanteric region on X-ray is the prodromal 'dreaded black line.' Bisphosphonates must be discontinued immediately when AFF is suspected, and MRI is the most sensitive imaging to characterize the incomplete fracture and guide orthopedic intervention. Continuing bisphosphonates or switching to denosumab (which has a similar mechanism of osteoclast suppression) is inappropriate. Teriparatide is sometimes used adjunctively after AFF diagnosis but is not the immediate next step before confirming the diagnosis.