DFT-EMREE-FAMILY MEDICINE AND PRIMARY CARE-10/10/2025

A 45 Y/O F with a known Hx of DM, HTN, & bilateral knee OA is seen in the primary care clinic. She was recently started on paracetamol for her knee pain, which has improved her mobility. She was advised to walk 30 mins daily. At her follow-up, she confirms she has been walking every day for the past 3 weeks but states, "Doctor, I am doing what you said, but I'm not sure if this walking is actually helping my health." According to the Transtheoretical Model of Change, which stage does this patient's behavior best represent?

• Precontemplation

• Contemplation

• Preparation

• Action

• Maintenance

Answer explanation

The patient is in the Action stage because she has actively started the new behavior (walking daily) within the last 6 months. Her expressed doubts are characteristic of this stage, where individuals work to overcome challenges and prevent relapse.

A 62 Y/O M with a Hx of CAD and a recent NSTEMI 3 months ago presents for follow-up. He has smoked 1.5 packs/day x40 yrs. O/E: BP 145/90 mmHg, HR 88 bpm. When you broach the topic of smoking cessation, he becomes defensive, stating, "Doctor, with all due respect, my father smoked his whole life and lived to be 90. These cigarettes are the only thing that helps me with my stress. I have no intention of quitting." Which of the following stages of the Transtheoretical Model of Change does this patient currently represent?

• Contemplation

• Preparation

• Action

• Precontemplation

• Relapse

Answer explanation

The patient is in the Precontemplation stage. He is not currently considering change and is unaware of or under-appreciates the problem, as evidenced by his statement "I have no intention of quitting" and his justification using his father's history. Individuals in this stage are often characterized as resistant or unmotivated.

A 40 Y/O F with a known Hx of IBS and tension headaches c/o recurrent episodes of palpitations, chest tightness, and SOB over the past month. Each episode is abrupt in onset, lasts approximately 15 minutes, and is associated with intense fear of dying. O/E during a symptom-free period in the clinic reveals normal vital signs. Cardiac, respiratory, and neurological exams are unremarkable. Initial Ix, including a 12-lead ECG, CBC, and TSH, are all within normal limits. What is the most likely diagnosis?

• Paroxysmal supraventricular tachycardia (PSVT)

• Generalized anxiety disorder (GAD)

• Panic disorder

• Somatic symptom disorder

• Stable angina

Answer explanation

The diagnosis is Panic Disorder. This is strongly suggested by the constellation of recurrent, discrete episodes of intense fear accompanied by classic somatic symptoms (palpitations, SOB, chest tightness) in the setting of a normal physical exam and negative initial organic workup. The patient's history of other functional disorders (IBS, tension headaches) further increases the likelihood of a primary anxiety disorder.

An 82 Y/O F with a Hx of osteoporosis and dementia is brought to the ED by her caregiver due to confusion, constipation, and generalized weakness x1W. O/E: The patient is lethargic and dehydrated. BP 150/95, HR 105, RR 16. Ix labs reveal: Serum Ca²⁺ 13.8 mg/dL (high), PO₄³⁻ 5.1 mg/dL (high), Creatinine 1.9 mg/dL (high). Further tests show a markedly ↑ 25-hydroxyvitamin D [25(OH)D] level at 180 ng/mL and a suppressed PTH level. Which of the following is the most likely underlying cause of this patient's presentation?

• Primary hyperparathyroidism

• Sarcoidosis

• Excessive intake of cholecalciferol supplements

• Milk-alkali syndrome

• Malignancy-associated hypercalcemia

Answer explanation

The combination of severe hypercalcemia, hyperphosphatemia, suppressed Parathyroid Hormone (PTH), and a markedly elevated 25-hydroxyvitamin D level is pathognomonic for Vitamin D toxicity, most commonly from iatrogenic overdose of over-the-counter cholecalciferol (Vitamin D3) supplements, especially in an elderly patient with cognitive impairment.

A 62 Y/O postmenopausal F presents to the clinic c/o bilateral knee pain for the past year, worse with activity & relieved by rest. She is concerned about "weak bones" due to her Hx of smoking (20 pack-years) & intermittent inhaled corticosteroid use for asthma. O/E, there is crepitus on passive flexion of both knees. A recent DEXA scan was ordered, revealing a T-score of +2.0. What is the most likely diagnosis explaining her primary complaint?

• Osteoporosis

• Osteoarthritis

• Rheumatoid arthritis

• Glucocorticoid-induced osteonecrosis

• Paget's disease of bone

Answer explanation

The patient's age, presentation of bilateral knee pain that is worse with activity and improves with rest ("mechanical pain"), and the physical finding of crepitus are classic for osteoarthritis. The DEXA T-score of +2.0 definitively rules out osteoporosis, making osteoarthritis the most fitting diagnosis for her symptomatic joint pain.

A 58 Y/O M presents with a clean, minor laceration on his index finger from a kitchen knife. His immunization status is unknown, but he is certain he has not received any vaccines in at least 15 years. The wound is cleaned and sutured in the clinic. Which of the following is the most appropriate immunoprophylaxis to administer to this patient?

• Tetanus and diphtheria (Td) toxoids

• Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine

• Tetanus immune globulin (TIG) only

• Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine

• Tdap vaccine and Tetanus immune globulin (TIG)

Answer explanation

For adults with an unknown or incomplete tetanus vaccination history, guidelines recommend a one-time dose of Tdap to provide protection against pertussis (whooping cough), in addition to tetanus and diphtheria. Since his last vaccine was >10 years ago, a tetanus booster is indicated for this clean, minor wound.

A 49 Y/O African M, a known hypertensive on Rx, requests routine HIV testing during a clinic visit. Fx Hx is positive for stroke & HTN. O/E: BP 155/95 mmHg, HR 82/min, BMI 31 kg/m ². Abdominal exam is limited 2° to obesity. Which set of initial Ix is most appropriate for this patient's comprehensive health screening?

• 4th generation HIV Ag/Ab assay, lipid profile, HbA1c

• HIV ELISA only

• Fasting blood glucose, urinalysis, ECG

• Lipid profile and abdominal aortic ultrasound

• HIV Western blot, TSH, serum creatinine

Answer explanation

This option provides the most comprehensive and appropriate screening. It addresses the patient's primary request with the standard 4th generation HIV assay. Critically, it also includes a lipid profile and HbA1c, which are essential for assessing cardiovascular and metabolic risk in a patient with obesity, hypertension, and a strong family history of stroke.

An 18 Y/O university student c/o severe sore throat, fever (38.9°C), and profound malaise x4D, forcing him to miss classes. O/E: Marked tonsillar exudate and palatal petechiae are visible. There is tender posterior and anterior cervical lymphadenopathy. Abdominal exam reveals mild splenomegaly. A rapid strep test performed in the clinic is negative. What is the most likely Dx?

• Streptococcal pharyngitis

• Acute HIV infection

• Cytomegalovirus (CMV) infection

• Diphtheria

• Infectious mononucleosis

Answer explanation

The clinical triad of fever, pharyngitis, and lymphadenopathy in an adolescent is highly suggestive of infectious mononucleosis (IM). The presence of profound fatigue, posterior cervical lymphadenopathy, palatal petechiae, and splenomegaly makes IM the classic and most probable diagnosis, especially after a negative rapid strep test.

A 68 Y/O F with a Hx of a large anterior MI one year ago presents to the clinic c/o gradually worsening dyspnea on exertion and bilateral ankle swelling over the past 3 months. O/E: JVP is elevated to 5 cm, bibasilar crackles are heard on lung auscultation, and 2+ pitting edema is present up to the mid-shins. An echocardiogram is performed. The echocardiogram shows a left ventricular ejection fraction (LVEF) of 30% with akinesis of the anterior wall. Which of the following is the most accurate diagnosis?

• Heart failure with preserved ejection fraction (HFpEF)

• Diastolic heart failure

• Cor pulmonale

• Heart failure with reduced ejection fraction (HFrEF)

• Constrictive pericarditis

Answer explanation

This patient's symptoms (dyspnea, edema, elevated JVP, crackles) are classic for congestive heart failure. The key diagnostic information is the echocardiogram result. An LVEF of 30% is severely reduced (normal is >50-55%). Heart failure is classified based on ejection fraction; an LVEF <40% defines heart failure with reduced ejection fraction (HFrEF), also known as systolic heart failure. The history of a prior anterior MI explains the etiology—ischemic cardiomyopathy leading to impaired myocardial contractility.

An 82 Y/O M is brought to the clinic by his family due to recent falls and memory decline. His wife notes he has also developed urinary incontinence over the past few months. O/E, the patient walks with slow, wide-based, "magnetic" steps. When asked to turn, he takes multiple small steps, turning his whole body as a single unit. There is no resting tremor. What is the most likely diagnosis?

• Parkinson's disease

• Normal Pressure Hydrocephalus

• Alzheimer's disease

• Cervical spondylotic myelopathy

• Vitamin B12 deficiency

Answer explanation

The clinical triad of gait disturbance (wide-based, magnetic), dementia (memory decline), and urinary incontinence is classic for Normal Pressure Hydrocephalus (NPH). The "en bloc" turning is also highly characteristic.