Family Medicine COMAT Command Center Family Medicine Shelf Exam Command Center

Screening guidelines are meticulously codified by the United States Preventive Services Task Force (USPSTF). Candidates must memorize exact ages, intervals, and discontinuation criteria:

• Colorectal Cancer (CRC): Recommended for all average-risk adults aged 45 to 75 years (Grade A/B). Options include colonoscopy every 10 years, annual high-sensitivity fecal immunochemical test (FIT) or guaiac-based fecal occult blood test (gFOBT), or stool DNA-FIT (Cologuard) every 3 years. Screening between 76-85 years is individualized based on prior screening and life expectancy (>10 years); routinely discontinue at age 85. High-risk caveat: Patients with a first-degree relative diagnosed with CRC before age 60 must begin colonoscopy at age 40 or 10 years younger than the youngest affected relative, repeated every 5 years.
• Breast Cancer: Biennial screening mammography is recommended for women aged 40 to 74 years (updated USPSTF Grade B). Clinical breast exams and self-exams are not recommended as standalone screening. For patients with known BRCA mutations or high lifetime risk (>20%), annual breast MRI screening begins at age 25-30 alongside annual mammography.
• Cervical Cancer: Screen women aged 21 to 65 years. For women aged 21–29: cervical cytology (Pap smear) alone every 3 years. For women aged 30–65: cytology alone every 3 years, high-risk HPV (hrHPV) co-testing every 5 years, or hrHPV alone every 5 years. Discontinuation: At age 65 if adequate prior screening (3 consecutive negative Pap tests or 2 negative HPV tests in prior 10 years, with most recent within 5 years) and no history of CIN2+. Discontinue immediately post-hysterectomy with cervix removal for benign disease.

Cardiovascular and smoking-related screenings test strict patient cohort inclusion criteria:

• Lung Cancer Screening: Annual low-dose CT (LDCT) scan for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Discontinue once the individual has not smoked for 15 consecutive years or develops a health problem that substantially limits life expectancy or ability to undergo curative surgery.
• Abdominal Aortic Aneurysm (AAA): One-time screening with abdominal duplex ultrasound in men aged 65 to 75 years who have ever smoked (at least 100 lifetime cigarettes; Grade B). Repair criteria: aneurysm diameter ≥ 5.5 cm, rapid expansion (>0.5 cm in 6 months or >1 cm in 1 year), or symptomatic.
• Prostate Cancer: PSA screening is a Grade C recommendation (shared decision-making) for men aged 55 to 69 years. Do not screen men ≥ 70 years. Digital rectal exam (DRE) is not recommended by USPSTF as an independent screening tool.
• Osteoporosis: Routine screening with dual-energy X-ray absorptiometry (DEXA) in women aged ≥ 65 years, or younger postmenopausal women whose 10-year fracture risk (FRAX score) equals or exceeds that of a 65-year-old white woman (≥ 9.3%). T-score ≤ -2.5 defines osteoporosis; T-score between -1.0 and -2.5 defines osteopenia.

Preventive pharmacotherapy recommendations have shifted significantly in recent updates:

• Aspirin for Primary CVD Prevention: USPSTF recommends against initiating low-dose aspirin in adults aged ≥ 60 years for primary prevention due to bleeding risk exceeding net cardiovascular benefit. In adults aged 40–59 with ≥ 10% 10-year CVD risk, decision is individualized.
• Statin Therapy for Primary Prevention: Prescribe low-to-moderate intensity statins for adults aged 40–75 with no prior CVD, ≥ 1 CVD risk factor (dyslipidemia, diabetes, HTN, smoking), and a calculated 10-year ASCVD risk ≥ 10% (Grade B).
• Adult Vaccinations: Shingrix (recombinant zoster vaccine) 2-dose series for all immunocompetent adults aged ≥ 50 years regardless of previous shingles or Zostavax history. Pneumococcal conjugate (PCV20 alone or PCV15 followed by PPSV23 1 year later) for all adults aged ≥ 65 years or adults 19-64 with high-risk conditions (diabetes, chronic lung/heart/liver disease, smoking). RSV vaccine (single dose) for adults ≥ 60 years using shared decision making or all adults ≥ 75. Tdap booster every 10 years (or during every pregnancy at 27-36 weeks).

Hypertension is diagnosed based on an average of ≥ 2 properly measured blood pressure readings on ≥ 2 separate occasions:

• Normal: SBP < 120 mmHg AND DBP < 80 mmHg.
• Elevated BP: SBP 120–129 mmHg AND DBP < 80 mmHg. Treatment: Lifestyle modification (DASH diet, sodium reduction < 1500-2300 mg/day, 150 min aerobic exercise/week, weight loss).
• Stage 1 Hypertension: SBP 130–139 mmHg OR DBP 80–89 mmHg. If 10-year ASCVD risk < 10%, lifestyle trial for 3–6 months. If ASCVD risk ≥ 10% or diabetes/CKD present, initiate monotherapy alongside lifestyle changes.
• Stage 2 Hypertension: SBP ≥ 140 mmHg OR DBP ≥ 90 mmHg. Initiate two first-line agents of different classes simultaneously if BP is >20/10 mmHg above goal.
• First-Line Antihypertensive Classes: Thiazide diuretics (chlorthalidone, hydrochlorothiazide), Dihydropyridine Calcium Channel Blockers (amlodipine, nifedipine), and ACE inhibitors / Angiotensin Receptor Blockers (lisinopril, losartan).

Antihypertensive selection must align with comorbid systemic disease:

• Chronic Kidney Disease with Proteinuria: ACEi or ARB is mandatory (reduces intraglomerular hyperfiltration and retards renal progression). Discontinue if serum creatinine rises >30% or refractory hyperkalemia occurs.
• Heart Failure with Reduced Ejection Fraction (HFrEF): Quadruple guideline-directed medical therapy (GDMT): ARNI/ACEi + Beta-blocker (carvedilol, metoprolol succinate, bisoprolol) + MRA (spironolactone) + SGLT2 inhibitor (dapagliflozin/empagliflozin).
• Post-Myocardial Infarction / Stable Ischemic Heart Disease: Beta-blocker (cardioselective) and ACEi/ARB.
• Black / African American Population without CKD: Initial therapy should include a Thiazide diuretic or DHP-CCB (amlodipine) due to lower plasma renin activity. ACE inhibitors have lower efficacy and higher risk of angioedema.
• Secondary Hypertension Workup: Suspect when onset < 30 or > 55 years, resistant HTN (uncontrolled on 3 drugs including a diuretic), or sudden loss of control. Primary hyperaldosteronism (plasma aldosterone/renin ratio > 20:1 with aldosterone > 15 ng/dL), Renal Artery Stenosis (atherosclerotic in older men, fibromuscular dysplasia in young women with abdominal bruit), Cushing syndrome, Pheochromocytoma, and Obstructive Sleep Apnea.

Diagnostic criteria require two abnormal test results from either the same sample or two separate test samples:

• Fasting Plasma Glucose (FPG): ≥ 126 mg/dL (fasting for ≥ 8 hours).
• 2-Hour 75-g Oral Glucose Tolerance Test (OGTT): ≥ 200 mg/dL.
• Hemoglobin A1c: ≥ 6.5% (NGSP certified).
• Random Plasma Glucose: ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, unexplained weight loss) — diagnostic immediately without repeat testing.
• Prediabetes Cutoffs: FPG 100–125 mg/dL; 2-hr OGTT 140–199 mg/dL; HbA1c 5.7%–6.4%.
• Glycemic Goals: HbA1c < 7.0% for most non-pregnant adults. Less stringent goals (< 8.0%) are appropriate for patients with limited life expectancy, extensive vascular complications, severe hypoglycemia unawareness, or advanced dementia.

Pharmacologic management is no longer purely glucocentric; contemporary ADA guidelines emphasize organ-protective therapy independent of baseline A1c:

• Metformin (Biguanide): First-line agent unless contraindicated. Decreases hepatic gluconeogenesis and increases peripheral insulin sensitivity. Weight neutral/mild loss, zero hypoglycemia risk. Contraindicated if eGFR < 30 mL/min/1.73m² due to lactic acidosis risk. Monitor for Vitamin B12 deficiency.
• SGLT2 Inhibitors (Empagliflozin, Dapagliflozin): Blocks proximal tubular glucose and sodium reabsorption. Mandatory indications: HFrEF, CKD with albuminuria (>30 mg/g), and established ASCVD. Benefits: reduces heart failure hospitalizations, slows CKD progression, promotes weight loss and mild BP reduction. Adverse effects: mycotic genital infections, euglycemic DKA, volume depletion.
• GLP-1 Receptor Agonists (Semaglutide, Liraglutide): Incretin mimetic: stimulates glucose-dependent insulin secretion, inhibits glucagon, delays gastric emptying. Mandatory indications: Established ASCVD or high ASCVD risk, obesity. High potency A1c reduction and profound weight loss. Contraindications: history of medullary thyroid carcinoma or MEN 2; caution in pancreatitis.
• Sulfonylureas (Glipizide, Glimepiride): Close K+ channels on beta-cells causing insulin release. High hypoglycemia risk, weight gain. Avoid glyburide in elderly/renal impairment due to active metabolite accumulation.
• DPP-4 Inhibitors (Sitagliptin): Weight neutral, well-tolerated oral incretin enhancer. Avoid combining with GLP-1 RA. Avoid saxagliptin in heart failure.

Accurate clinical diagnosis requires specific orthopedic provocative maneuvers:

• Rotator Cuff Pathology: Supraspinatus is the most commonly torn muscle (tested via Empty Can / Jobe test and Drop Arm test). Infraspinatus/Teres Minor tested via resisted external rotation. Subscapularis tested via Lift-off test or Bear Hug test. Subacromial Impingement is evaluated via Neer test (forced forward flexion with forearm pronated) and Hawkins-Kennedy test (internal rotation of shoulder at 90° flexion).
• Anterior Cruciate Ligament (ACL): Lachman test is the most sensitive physical exam maneuver (anterior tibial translation at 20-30° knee flexion). Anterior drawer test is less sensitive due to hamstring spasm. Sudden 'pop' with rapid hemarthrosis after non-contact deceleration or pivoting.
• Meniscal Tears: Joint line tenderness (most sensitive sign) and McMurray test (audible/palpable click or pain with knee extension during tibial axial loading and rotation: internal rotation tests lateral meniscus; external rotation tests medial meniscus).
• Patellofemoral Pain Syndrome: Chronic anterior peripatellar aching in young females, worse with prolonged sitting ('theater sign') or descending stairs. Positive patellar compression/grind (Clarke test). First-line treatment: VMO (vastus medialis oblique) strengthening.

Low back pain is the most frequent outpatient MSK presentation. Most cases represent acute mechanical/musculoskeletal strain resolving within 4–6 weeks without imaging:

• Red Flags Warranting Immediate MRI: Cauda Equina Syndrome (saddle anesthesia, bowel/bladder incontinence, progressive lower extremity weakness; emergent neurosurgical decompression), Spinal Epidural Abscess / Infection (fever, IV drug use, ESR/CRP elevation), Malignancy (history of cancer, unexplained weight loss, night pain unrelieved by rest, age > 50).
• Lumbosacral Radiculopathy (Sciatica): Positive Straight Leg Raise (Lasegue test) (pain radiating below knee at 30–70° elevation) and Crossed Straight Leg Raise (highly specific: elevating unaffected leg reproduces contralateral sciatica, indicating herniated disc). Conservative therapy (NSAIDs + physical therapy) for first 6 weeks unless motor deficits progress.
• Ottawa Ankle Rules: Ankle X-rays indicated only if pain in malleolar zone AND: bone tenderness at posterior edge or tip of lateral malleolus (distal 6 cm), OR posterior edge/tip of medial malleolus (distal 6 cm), OR inability to bear weight both immediately and in the clinic (4 steps).
• Ottawa Knee Rules: Knee X-rays required only if acute knee injury plus any of: age ≥ 55, isolated tenderness of patella, tenderness at head of fibula, inability to flex knee to 90°, or inability to bear weight immediately and in clinic.

Differentiating cutaneous malignancies requires recognizing pathognomonic physical features and dermatopathology:

• Basal Cell Carcinoma (BCC): Most common skin cancer worldwide. Classically appears as a pearly, translucent papule or nodule with rolled borders, central ulceration, and overlying branching telangiectasias on sun-exposed head/neck. Histopathology demonstrates peripheral palisading of basaloid cells with clefting artifact. Rarely metastasizes. Excision with negative margins or Mohs micrographic surgery (for high-risk facial lesions) is curative.
• Squamous Cell Carcinoma (SCC): Second most common skin cancer; arises from keratinocytes. Presents as a firm, hyperkeratotic, scaly plaque or ulcerated indurated nodule on sun-exposed skin. Precursor lesion is actinic keratosis (erythematous rough sandpaper-like macules treated with cryotherapy or topical 5-FU). Histopathology shows atypical keratinocytes with keratin pearls. Potential for metastasis, especially on the lip and ear.
• Malignant Melanoma: ABCDE criteria: Asymmetry, Border irregularity, Color variation, Diameter > 6 mm, Evolving. Most important prognostic factor for non-metastatic melanoma is Breslow thickness (depth of invasion from granular layer of epidermis to base of tumor). Initial biopsy must be an excisional biopsy with 1-3 mm margins; never perform partial shave biopsy of suspected melanoma.

High-yield ambulatory eruptions tested on COMLEX:

• Erythema Migrans (Lyme Disease): Expanding erythematous annular patch with central clearing ('bullseye') appearing 7–14 days following an Ixodes scapularis tick bite in endemic regions (Northeast/Midwest). Clinical diagnosis; do not order serology in early localized disease (antibodies are negative). Treatment: Doxycycline (100 mg BID for 10-14 days); amoxicillin or cefuroxime in pregnant women.
• Psoriasis: Well-demarcated salmon-pink plaques with silvery micaceous scale on extensor surfaces (knees, elbows, scalp). Auspitz sign (pinpoint bleeding when scale is scraped); Koebner phenomenon (lesions induced by local trauma). Treatment: Topical corticosteroids and Vitamin D analogues (calcipotriene); biologic agents (anti-TNF, IL-17/23 inhibitors) for moderate-to-severe disease or psoriatic arthritis.
• Atopic Dermatitis (Eczema): Pruritic, erythematous excoriations and lichenification on flexural surfaces (antecubital and popliteal fossae). Associated with asthma and allergic rhinitis (atopic triad). First-line: emollients and topical corticosteroids or topical calcineurin inhibitors (tacrolimus).
• Pityriasis Rosea: Solitary oval herald patch on the trunk followed days later by a diffuse secondary eruption of salmon-colored oval macules oriented along Langer cleavage lines in a 'Christmas tree' pattern. Self-limited (resolves in 6-8 weeks); symptomatic management with antihistamines.

Antibiotic stewardship requires strict application of clinical diagnostic criteria:

• Pharyngitis (Centor / McIsaac Criteria): Criteria: (1) Fever (>38°C / 100.4°F), (2) Tender anterior cervical lymphadenopathy, (3) Tonsillar exudates, (4) Absence of cough. Age modifier: +1 if 3-14 years; 0 if 15-44; -1 if ≥ 45. Score 0–1: No testing or antibiotics (viral). Score 2–3: Rapid Antigen Detection Test (RADT); treat with oral Penicillin V or Amoxicillin if positive. In children with negative RADT, follow-up throat culture is mandatory to prevent acute rheumatic fever.
• Acute Rhinosinusitis: Majority is viral (rhinovirus, influenza). Prescribe antibiotics only if bacterial sinusitis criteria are met: (1) Persistent symptoms ≥ 10 days without clinical improvement, (2) Severe onset (high fever ≥ 39°C and purulent nasal discharge) for ≥ 3 consecutive days, or (3) 'Double sickening' (worsening after initial recovery). First-line antibiotic: Amoxicillin-clavulanate (Augmentin); doxycycline in penicillin-allergic patients.
• Acute Otitis Media (AOM): Bulging, erythematous tympanic membrane with impaired mobility. Pathogens: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis. First-line: High-dose Amoxicillin (80-90 mg/kg/day); augmentin if treatment failure or concurrent purulent conjunctivitis.

Genitourinary tract infections are categorized based on anatomical location and host complications:

• Uncomplicated Cystitis: Dysuria, frequency, urgency in healthy, non-pregnant premenopausal female. No pelvic exam or urine culture required. First-line options: Nitrofurantoin (100 mg BID for 5 days; avoid if eGFR < 30), TMP-SMX (1 DS tab BID for 3 days; avoid if local resistance >20%), or Fosfomycin (3 g single oral sachet). Reserve fluoroquinolones.
• Acute Pyelonephritis: Fever, chills, flank pain, and costovertebral angle (CVA) tenderness. Outpatient therapy for mild/stable cases: oral Ciprofloxacin (500 mg BID for 7 days) or Levofloxacin, preceded by a single IV dose of Ceftriaxone. Urine culture is mandatory.
• Acute Bacterial Prostatitis: Fevers, chills, dysuria, pelvic/perineal pain, and exquisitely tender, boggy prostate on gentle DRE. Caution: Vigorous prostatic massage is strictly contraindicated (risk of bacteremia). In men < 35 years: N. gonorrhoeae and C. trachomatis (treat with Ceftriaxone IM + Doxycycline). In men > 35 years: E. coli and coliforms (treat with Ciprofloxacin or TMP-SMX for 4–6 weeks to ensure tissue penetration).

Contraception must be tailored to patient comorbidities, efficacy desires, and contraindications:

• Long-Acting Reversible Contraceptives (LARCs): Most effective methods (>99% efficacy). Copper IUD (ParaGard): hormone-free, lasts 10 years, can cause increased menorrhagia/dysmenorrhea, excellent emergency contraceptive (up to 5 days). Levonorgestrel IUD (Mirena/Kyleena): lasts 5-8 years, induces amenorrhea, first-line for abnormal uterine bleeding. Subdermal Etonogestrel implant (Nexplanon): lasts 3-5 years, irregular spotting is most common side effect.
• Combined Hormonal Contraceptives (CHCs - Estrogen + Progestin): Oral pills, transdermal patch, vaginal ring. Absolute Contraindications: Age ≥ 35 years who smoke ≥ 15 cigarettes/day; history of DVT/PE or inherited thrombophilia; history of ischemic heart disease or stroke; migraine with aura (increased stroke risk); active breast or estrogen-dependent cancer; severe cirrhosis or liver adenoma; uncontrolled hypertension (BP ≥ 160/100).
• Progestin-Only Options: Depo-medroxyprogesterone acetate (DMPA) injection every 12 weeks (adverse effect: bone mineral density loss with use > 2 years; weight gain). Progestin-only pills (mini-pill): safe in postpartum breastfeeding women, smokers > 35, and those with contraindications to estrogen.

Common male ambulatory presentations require systematic medical escalation:

• Benign Prostatic Hyperplasia (BPH): Hyperplasia of the transitional zone of the prostate causing lower urinary tract symptoms (LUTS: hesitancy, weak stream, nocturia, post-void dribbling). DRE reveals a smoothly enlarged, nontender prostate without nodules.
• BPH Pharmacotherapy: Alpha-1 adrenergic antagonists (Tamsulosin, Alfuzosin, Terazosin) are first-line for rapid symptom relief (relax smooth muscle in bladder neck and prostate; side effect: orthostatic hypotension, floppy iris syndrome during cataract surgery). 5-alpha reductase inhibitors (Finasteride, Dutasteride) block conversion of testosterone to DHT, reducing actual prostate volume over 6–12 months; useful for enlarged prostates > 30-40 g (reduces serum PSA by 50%). Combination therapy is superior for severe progression risk.
• Erectile Dysfunction (ED): Most common etiology is vascular disease (endothelial dysfunction). First-line: PDE-5 inhibitors (Sildenafil, Tadalafil). Strict Contraindication: Concurrent use with nitrates (nitroglycerin, isosorbide mononitrate) due to synergistic cGMP elevation causing life-threatening refractory hypotension. Hold sildenafil for ≥ 24 hours (tadalafil ≥ 48 hours) before administering nitrates.

The American Geriatrics Society (AGS) Beers Criteria guide avoidance of medications with unfavorable benefit-to-risk profiles in adults aged ≥ 65 years:

• Anticholinergics (Diphenhydramine, Hydroxyzine, Oxybutynin): High risk of acute confusion, hallucinations, dry mouth, severe constipation, urinary retention, and increased falls. Avoid for insomnia or allergic rhinitis.
• Sedative-Hypnotics & Benzodiazepines (Zolpidem, Lorazepam, Diazepam): Significant risk of motor vehicle collisions, falls, hip fractures, and cognitive decline. First-line therapy for insomnia in elderly: Cognitive Behavioral Therapy for Insomnia (CBT-I).
• Tricyclic Antidepressants (Amitriptyline, Imipramine): Highly anticholinergic, causes sedation, orthostatic hypotension, and cardiac conduction slowing. Avoid for depression or neuropathic pain.
• Antipsychotics (Haloperidol, Quetiapine, Olanzapine): Increased mortality from cardiovascular events and infection when used for behavioral disturbances in dementia. Reserve strictly for patients who are a danger to themselves or others and non-pharmacologic interventions have failed.
• NSAIDs (Ibuprofen, Naproxen, Ketorolac): Chronic use increases risk of peptic ulcer disease, GI hemorrhage, acute renal failure, and heart failure exacerbations.
• Sulfonylureas (Glyburide): Long-acting secretagogue with high risk of severe prolonged hypoglycemia. Use glipizide if a sulfonylurea is unavoidable.

Differentiating urinary incontinence mechanisms dictates distinct non-pharmacologic and pharmacologic interventions:

• Stress Incontinence: Leakage with coughing, sneezing, laughing, or lifting. Etiology: urethral hypermobility or intrinsic sphincter deficiency (often post-multiparity or pelvic surgery). First-line: Pelvic floor muscle exercises (Kegel exercises) and pessaries; midurethral sling surgery if refractory.
• Urgency Incontinence: Sudden overwhelming urge to void followed by involuntary leakage. Etiology: detrusor muscle overactivity. First-line: Bladder training, scheduled voiding, and fluid modification. Pharmacotherapy: Mirabegron (beta-3 adrenergic agonist; preferred over anticholinergics in elderly to avoid cognitive side effects) or antimuscarinics (oxybutynin, tolterodine).
• Overflow Incontinence: Continuous dribbling, incomplete emptying, elevated post-void residual (> 200-300 mL). Etiology: detrusor underactivity (neurogenic bladder in diabetes) or outlet obstruction (severe BPH). Relieve obstruction; cholinergic agonist (bethanechol) or intermittent catheterization.
• Cognitive Impairment Workup: Differentiate Normal Aging, Mild Cognitive Impairment (MCI: objective deficit on MoCA/MMSE but preserved functional independence in IADLs), and Dementia (cognitive deficit impairs independence in IADLs/ADLs). Required reversible cause workup: TSH, Vitamin B12, and non-contrast head CT/MRI; add RPR/syphilis and HIV if clinically indicated.