Family Medicine Shelf Practice Questions: Core Vignettes & Board Strategy

In patients with COPD who have frequent exacerbations (≥ 2 moderate exacerbations or ≥ 1 hospitalization per year) despite maintenance dual bronchodilator therapy (LAMA + LABA) and a peripheral blood eosinophil count ≥ 300 cells/µL, escalating to triple therapy by adding an inhaled corticosteroid (such as fluticasone) is recommended. Blood eosinophils serve as a predictive biomarker for corticosteroid responsiveness. Phosphodiesterase-4 inhibitors, prophylactic macrolides, and oxygen therapy are reserved for more advanced or refractory clinical criteria.

For adults aged 40–75 with diabetes mellitus, moderate-intensity statin therapy (such as atorvastatin 10–20 mg or rosuvastatin 5–10 mg daily) is recommended for primary prevention of atherosclerotic cardiovascular disease, regardless of baseline LDL cholesterol level. Lifestyle interventions remain essential but are insufficient alone for patients with diabetes. Non-statin agents like niacin, fibrates, or ezetimibe monotherapy lack proven cardiovascular outcome benefits as primary initial therapy in this setting.

Resistant hypertension is defined as blood pressure that remains above goal despite concurrent adherence to optimal doses of three antihypertensive agents from different classes, including a diuretic. In this clinical scenario, adding spironolactone (a mineralocorticoid receptor antagonist) is the most effective fourth-line intervention, and screening for secondary causes—predominantly primary aldosteronism with a morning plasma aldosterone-to-renin ratio—is indicated. Low serum potassium is not required to suspect primary aldosteronism; up to half of patients remain normokalemic.

In patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease (such as a prior myocardial infarction), adding an SGLT2 inhibitor (such as empagliflozin) or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended to reduce major adverse cardiovascular events and cardiovascular mortality, independent of baseline HbA1c. Sulfonylureas, DPP-4 inhibitors, and insulin promote glycemic control but do not confer cardiovascular mortality protection, and thiazolidinediones are contraindicated due to heart failure risk.