NBME Shelf Exam Review* Family Medicine Modular Exam Content Musculoskeletal System and Connective Tissue: 15-20% Overall:

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1 NBME Shelf Exam Review* *Thanks t the University f Cincinnati Department f Family and Cmmunity Medicine, FM Clerkship and Flrida Atlantic University Cllege f Medicine Family Medicine Clerkship fr this cntent Family Medicine Mdular Exam Questins: 110 Cre Cntent: 90 questins (n anything related t Family Medicine) Chrnic Care: 10 questins (management f patients with chrnic medical cnditins) Musculskeletal: 10 questins Time: 2 hurs 45 minutes Cntent Age breakdwn Childhd: 5-15% Adlescence: 5-10% Adulthd: 65-75% Geriatric: 10-15% Organ Systems Immunlgic: 1-5% Bld and Bld frming Organs: 1-5% Mental Disrders: 5-10% Nervus System and Special Senses: 5-10% Cardivascular: 10-15% Respiratry System: 10-15% Nutritin and Digestive disrders: 10-15% Gyneclgic Disrders: 5-10% Renal, Urinary, and Male Reprductive System: 5-10% Pregnancy, Childbirth and the Puerperium: 1-5% Skin and Subcutaneus Tissue: 1-5% Musculskeletal System and Cnnective Tissue: 15-20% Endcrine and Metablic Disrders: 5-10% Physician Task Health Maintenance: 15-20% Understanding Mechanism f Disease: 5-10% Establishing a Diagnsis: 30-35% Applying Principles f Management: 25-30% Overall: Mstly utpatient based The test stresses management A few zebras but nt wrth studying fr these (yu either will knw it r yu wn t and just mve n) Study yur bread and butter family medicine tpics (MSK, HTN, DM, high chl, asthma, COPD, depressin, anxiety, cmmn utpatient infectins, back pain, health maintenance, etc) Only a few OB questins and usually nt t difficult. A cmmunity family dc that is nt delivering babies shuld be able t answer them. Mst students d nt have truble with time, but if yu are a cnsistent slw test taker, watch yur time carefully. It is nt a bad idea t take sme shrt timed practice tests.

2 Studying: I highly recmmend a cmbinatin f readings and questins Readings: Step-Up t Family Medicine: Outline frmat, easy t get thrugh in 4 weeks, written by the UC DFCM specifically t d well n the FM Clerkship and shelf exam. Review articles n AAFP.rg Case Files fr FM: gd if yu are a cased based learner and can get thrugh in a 6-week clerkship Blueprints FM: I d nt recmmend - nt detailed enugh fr the shelf exam Essentials f FM: Very gd bk, but very lng, maybe difficult t get thrugh in 6 weeks. Questins: AAFP bard review questins Becme a student member fr free and yu will have free access t these questins. Past students have fund these very helpful. It takes a few days t activate yur accunt, s sign up early in the rtatin. Well ver 1000 questins. On average the questin stems may be a little shrter than the nes n the shelf. Pretest FM If yu like Pretest fr ther clerkships yu will prbably like it fr this clerkship as well. It des cst mney. HTN: Diagnsis: BP 140/90 n 2 ccasins (nt the same day) fllwing an initial screening. Initial wrk up t include: CMP, CBC, TSH, U/A, ECG Treatment Gal: (JNC8) <60 y: <140/90 60 y: <150/90 DM r chrnic kidney disease at any age: <140/90 Lifestyle Mdificatin Nn-black: ACE-I, ARB, CCB, thiazide diuretic Black: CCB, thiazide diuretic Chrnic kidney disease: ACE-I, ARB Test Pearls: If still nt at gal with initial therapy: ptimize 1 st med r add 2 nd med frm the abve list. If still nt cntrlled with 2 nd med ptimize the 2 meds r add a 3 rd med (ne f these shuld be a thiazide diuretic) The test really likes secndary causes f hypertensin s knw them and hw t recgnize/diagnse them bstructive sleep apnea, renvascular disease, hyperaldsternism, chrnic kidney disease, thyrid/parathyrid disease, phechrmcytma, Cushing s, drugs OSA mst cmmn Think hyperald if lw ptassium r if ptassium drps a lt n initiatin f a thiazide diuretic If ptimized dses f three meds including a thiazide diuretic are nt cntrlling the BP, lk fr secndary causes. When starting lisinpril (ACE-I), expect a small bump in the creatinine level. Up t 30% is cnsidered nrmal and the med shuld be cntinued.

3 The test favrs ACE-I s knw their mechanism, side effects, etc. Chse these fr patients with DM and HTN, r DM and micralbuminuria DM II Diagnsis: HbA1c 6.5 Fasting glucse 126 n 2 ccasins Randm glucse 200 with symptms (plydipsia, plyphagia, plyuria, weight lss) 2 hur ral glucse tlerance test 200 (this is rarely dne) Gals: HbA1c: < 7 (< 9 fr geriatric patients) BP: <140/90 LDL: <100 N tbacc use Lw dse aspirin use unless cntraindicated Ft exam yearly Eye exam yearly Urine micralbumin yearly The 1 st 5 are called the D-5. Used by many rganizatins t measure quality. FYI: D5 actually uses HbA1c <8. Lifestyle mdificatin 1 st line med: metfrmin (d nt use if Cr 1.5 in r 1.4 in ) 2 nd line med: many chices including lng acting insulin Asthma Diagnsis: Requires spirmetry: bstructive cmpnent (FEV1/FVC rati <0.7) and reversible with shrt acting beta agnist (SABA) f 12% and an increase in FEV1 by 200mL. Peak flw nt reliable fr diagnsis but excellent fr mnitring symptms Acute exacerbatin: SABA, ral sterids, +/- xygen Chrnic care: Try t identify and avid triggers Establish an asthma actin plan including peak flw measurements at baseline and when having symptms. Escalate therapy ( Step-up therapy ) is needing t use SABA 2 r mre times a week r if having night time symptms 1 r mre time a week. SABA fr acute symptms r prir t exercise if has exercise induced symptms 1 st line daily med: lw dse inhaled sterids If nt cntrlled, increase dse f inhaled sterid. If still nt cntrlled, can add Mntelukast r LABA t the inhaled sterid If still nt cntrlled, can add thephylline D nt use LABA withut an inhaled sterid in asthma as it increases mrtality

4 COPD Diagnsis: Requires spirmetry: bstructive cmpnent, a pst-brnchdilatr FEV1/FVC rati < 0.7 (nt reversible) Almst always seen in smkers (beware f calling a smker asthmatic as treatment differs) Acute exacerbatin: SABA, ral sterids, +/- antibitic (usually a macrlide), +/- xygen Chrnic Care Stp smking Avid ccupatinal expsures and air pllutin Regular physical activity Meds: SABA fr acute symptms 1 st line daily med: antichlinergics: ipratrpium and titrpium (titrpium has better evidence and is dsed nce a day) 2 nd line meds: LABA (can be used as mntherapy in COPD) Inhaled sterids/laba cmbinatin (inhaled sterids d nt have as gd evidence as in asthma and increase risk f DM) Thephylline Pulmnary rehab can help with symptms Smking cessatin at any stage and xygen in end stage are the nly therapies that decrease mrtality rate. Depressin and anxiety Cunseling and SSRI s are first line treatment D nt use the SSRI Paxil (parxetine) as it has a very shrt half life with n active metablite - withdrawal symptms are cmmn even with missing just ne dse Benzs are never the right answer unless asked which med t wean ff r if yu are treating alchl withdrawal. Wellbutrin (buprpin) has less sexual side effects. Back Pain Mst ften muscular Knw the red flags f back pain: h/ cancer, weight lss, immunsuppressed, IV drug use, fever, significant trauma, bladder r bwel changes/incntinence, urinary retentin, saddle anesthesia, lss f anal sphincter tne, majr mtr weakness, persistent neurlgic findings, vertebral tenderness, age (ld and yung) Meds: NSAID (A recmmendatin), muscle relaxants (B recmmendatin) Opiids are never the right answer n this test Other MSK Study this a lt Knw the Ottawa ankle rules Knw hw t diagnse and treat cmmn prblems Knee: ACL, MCL, LCL, meniscal tear Shulder: biceps tendnitis, rtatr cuff prblems, labral tear Elbw: lateral epicndylitis Wrist: carpal tunnel syndrme, DeQuervain s, scaphid fracture

5 Gut Ostearthritis Plantar fasciitis Infectins Knw antibitics fr cmmn utpatient infectins UTI, cellulitis, cmmunity acquired pneumnia, titis media and externa, strep pharyngitis, sinusitis URIs and brnchitis are caused by viruses and shuld nt be given antibitics - treat symptmatically Allergies Nasal sterids are the mst effective meds in seasnal allergies. Avid antihistamines in elderly patients as antichlinergic effects can affect cgnitin. Health Maintenance The test stresses USPSTF recmmendatins, s knw thse. Yu dn t need t memrize the CDC child and adult immunizatin tables, but knw apprximately when shts are indicated. They are unlikely t ask abut make-up schedules. Knw which are live and their cntraindicatins. Anemia Knw the different causes and hw t determine (i.e. what is micrcytic, macrcytic, etc)