br10022025

​Board review 10/2/25

By Frank Moskos

Multiple Choice

A 32-year-old male has presented to your office 4 times over the past several months because of

periods of intractable nausea and vomiting lasting 1–2 days, with up to 14 episodes each day. He has

also experienced moderate abdominal pain, flushing, sweating, and dry mouth during these episodes.

On 2 occasions he has required brief admission to the hospital for fluid resuscitation. Promethazine,

ondansetron, and metoclopramide (Reglan) have been ineffective in treating his symptoms, but hot

showers provide him relief. His medical history is significant for allergic rhinitis and obesity. His

social history includes episodes of binge drinking approximately twice monthly and daily marijuana

use since age 21. He has no history of intravenous drug use or tobacco abuse.

Physical findings are significant for a weight loss of 4.5 kg (10 lb) over the past 3 months and

moderate tenderness to epigastric palpation. During acute episodes, laboratory evaluations have

revealed only mild elevations in BUN and creatinine levels and hematocrit. Abdominal

ultrasonography and CT scans have been normal.

Which one of the following is the most likely diagnosis?

• A) Abdominal migraines

• B) Cannabinoid hyperemesis syndrome

• C) Carcinoid syndrome

• D) Pancreatitis

• E) Peptic ulcer disease

ANSWER: B

Cannabinoid hyperemesis syndrome (CHS) has become more common with increased

legalization and acceptance of cannabis use. While it can be used as an antiemetic,

cannabis can also promote vomiting in susceptible individuals who have a significant

history of cannabinoid use. Long duration, higher frequency of use, and higher amounts

of cannabis use are all risk factors for CHS. Symptomatic relief with hot showers or

baths is not found in abdominal migraines, carcinoid syndrome, or peptic ulcer disease.

Pancreatitis would cause elevations in lipase levels and some findings on imaging would

be expected. Nausea from the other causes is generally relieved with traditional

antiemetics. Carcinoid syndrome also causes episodic symptoms such as facial flushing,

diarrhea, hypotension, and tachycardia, but not nausea or vomiting.

Multiple Choice

Which one of the following conditions is most associated with an increased risk for venous

thromboembolism?

• A) Active cancer

• B) COPD

• C) Poorly controlled type 2 diabetes

• D) Severe intermittent asthma

• E) Stage 3 chronic kidney disease

ANSWER: A

Patients with venous thromboembolism (VTE) should receive anticoagulant therapy for at least 3 months to reduce the risk for further embolization. In patients with persistent provoking factors such as active cancer or antiphospholipid syndrome, or who have had previous episodes of unprovoked VTE, the long-term risk for recurrence is high and indefinite anticoagulation therapy is recommended. The risk for VTE is much higher with active cancer compared to COPD, poorly controlled type 2 diabetes, severe intermittent asthma, and stage 3 chronic kidney disease.

A) active cancer: up to 9-fold higher than in the general population. Certain cancers (pancreatic, brain, lung, stomach, ovarian) and metastatic disease confer even higher risk. Chemotherapy, targeted therapies, and hospitalization further increase VTE risk. 

B) chronic obstructive pulmonary disease (COPD): COPD is a moderate independent risk factor for VTE, with an odds ratio between 2 and 9 compared to individuals without COPD. The absolute risk is higher during acute exacerbations and hospitalization, and pulmonary embolism may be underdiagnosed in this population. The risk of VTE in stable COPD is increased, but is highest during periods of acute illness.[4-6]

C) poorly controlled type 2 diabetes: ~1.4-fold increased risk of VTE compared to non-diabetic controls. Poor glycemic control (HbA1c >7%) may further increase risk, particularly in women

D) severe intermittent asthma: Severe asthma, especially with chronic corticosteroid use, is associated with a 3- to 4-fold increased risk of pulmonary embolism, but not deep vein thrombosis.The prothrombotic state correlates with asthma severity and systemic inflammation. Mild asthma does not confer a significant increase in VTE risk.[9-10]

E) stage 3 chronic kidney disease (CKD): Stage 3 CKD (eGFR 30–59 mL/min/1.73 m²) confers a 1.7- to 2-fold increased risk of incident VTE

In summary, all listed conditions increase VTE risk, with active cancer and severe asthma (with corticosteroid use) conferring the highest relative risks, followed by stage 3 CKD, COPD, and poorly controlled type 2 diabetes.

Multiple Choice

A 59-year-old female asks when she should consider screening for osteoporosis. Her last menstrual

period was at age 53.

According to the U.S. Preventive Services Task Force, which one of the following risk factors, if

present, should lead to a calculation of osteoporosis risk with a screening tool and consideration of

screening for osteoporosis now?

• A) Low caffeine consumption

• B) High alcohol consumption

• C) Body weight >100 kg (220 lb)

• D) A maternal aunt with a history of hip fracture

• E) Nonsmoking status

ANSWER: B

In postmenopausal women younger than age 65, the U.S. Preventive Services Task

Force recommendations for osteoporosis screening include assessing for osteoporosis

risk factors (parental history of hip fracture, smoking, high alcohol consumption, or low

body weight) and use of a clinical risk assessment tool if 1 or more risk factors are

present.

Multiple Choice

A 62-year-old female sees you for evaluation of pain and stiffness in her neck. For several years she

has attributed these symptoms to the aging process, but she has recently developed a loss of dexterity

in her hands that makes typing and knitting difficult. She does not have any loss of sensation or

weakness in her extremities but has noticed some difficulties with balance in recent weeks. The pain

does not radiate, and she does not have any history of recent trauma. She feels well otherwise and has

not had any fevers, chills, bowel incontinence, or bladder incontinence.

On examination you note mild tenderness of the spinous processes and paraspinous muscles of the

cervical spine without focal tenderness. Her range of motion at the neck is limited due to pain. There

are brisk reflexes in the bilateral upper and lower extremities and a positive Hoffman sign bilaterally

with 4 beats of clonus on the right and 5 on the left. Her strength and sensation to light touch are

intact in the bilateral upper extremities.

Which one of the following cervical spine conditions is the most likely diagnosis?

• A) Facet joint arthropathy

• B) Myelopathy

• C) Radiculopathy

• D) Vertebral compression fracture

• E) Vertebral osteomyelitis

ANSWER: B

The patient history and physical examination findings are most consistent with

degenerative cervical myelopathy, a condition in which spinal cord dysfunction develops

due to compression in the neck. Spinal cord compression can be due to disk herniation,

ligament hypertrophy, or osteophyte formation, sometimes collectively called

spondylosis. Symptoms can initially be nonspecific and subtle, and they can overlap

with less serious conditions. Loss of hand dexterity, ataxia, and urinary urgency can be

signs of spinal cord compression and warrant a comprehensive neurologic examination.

The development of upper motor neuron signs including hyperreflexia, a positive

Hoffmann sign (digital reflex of the fingers), and clonus are key findings that warrant

urgent evaluation with MRI.

Facet joint arthropathy causes more focal pain and is not associated with neurologic

symptoms. Cervical radiculopathy involves compression of the nerve root rather than

the spinal cord. Symptoms include shooting pain with sensory changes and weakness in

a dermatomal distribution. A vertebral compression fracture leads to focal pain in the

neck at the site of the fracture without neurologic symptoms. Osteomyelitis also causes

more focal pain in the setting of systemic symptoms such as malaise and fever.

Multiple Choice

A 30-year-old female presents to your office to discuss fertility and her irregular menses. The patient

and her husband have been trying to conceive for the past 3 years but have been unsuccessful due to

her irregular menstrual periods. Physical examination findings are significant for hirsutism and acne

with hyperpigmentation on the posterior aspect of the neck and in the axillae. Her BMI is 35 kg/m2

Laboratory studies from 1 month ago show a hemoglobin A1c of 5.0%.

Which one of the following medications would be the most appropriate treatment of this patient’s

infertility?

• A) A GLP-1 receptor agonist

• B) Letrozole (Femara)

• C) Metformin

• D) Spironolactone (Aldactone)

ANSWER: B

This patient likely has polycystic ovary syndrome (PCOS) based on the clinical history

and physical examination findings. Letrozole is an aromatase inhibitor that decreases

the amount of estrogen produced by the body and is considered the first-line treatment

for inducing ovulation in women with PCOS.GLP-1 receptor agonists reduce the degree of metabolic syndrome in patients with PCOS and are not indicated for ovulation induction.

Metformin is inferior to letrozole for ovulation induction in patients with PCOS. Furthermore, this patient's hemoglobin A1c indicates that she does not have prediabetes or diabetes mellitus. Spironolactone is an

antiandrogen and is used to treat many PCOS symptoms, such as hirsutism, but does not induce ovulation.

The exact rate of ovulation induction with letrozole in patients with polycystic ovary syndrome (PCOS) is approximately 61–75% per cycle, whereas with metformin alone, the ovulation rate is approximately 30–50% per cycle.

•*Letrozole is associated with a low incidence of adverse effects, most commonly mild fatigue and dizziness. Serious adverse events, including ovarian hyperstimulation syndrome (OHSS), multiple pregnancy, and congenital anomalies, are rare and occur at rates similar to or lower than other ovulation induction agents. There is no evidence of increased teratogenicity or fetal abnormality rates with letrozole compared to clomiphene citrate or natural conception**.[1-3] The American Society for Reproductive Medicine and the Endocrine Society recommend letrozole as first-line therapy for ovulation induction in PCOS, citing its favorable safety profile.[1-2]

•*Metformin is most commonly associated with gastrointestinal side effects, including nausea, vomiting, diarrhea, and abdominal discomfort, which occur in up to 20–40% of patients. These side effects are usually mild but can lead to discontinuation in some cases. Metformin does not increase the risk of OHSS, multiple pregnancy, or congenital anomalies, and is considered safe in pregnancy. However, metformin is less effective than letrozole for ovulation induction and is not recommended as first-line therapy for this indication**.[1-2][4-6] The American Society for Reproductive Medicine guideline specifically advises counseling women about the potential for mild gastrointestinal side effects with metformin.

Multiple Choice

Which one of the following is present in polycythemia vera?

• A) An α-1 antitrypsin deficiency

• B) An elevated α-fetoprotein level

• C) An elevated erythropoietin level

• D) Antimitochondrial antibodies

• E) A Janus kinase 2 mutation

ANSWER: E

The World Health Organization’s major diagnostic criteria for polycythemia vera include

an elevated hemoglobin or hematocrit level, abnormal bone marrow biopsy results, and

the presence of the Janus kinase 2 (JAK2) genetic mutation, found in 98% of cases.

The only minor criterion is a subnormal erythropoietin level, which helps distinguish

polycythemia vera from common causes of secondary erythrocytosis such as smoking,

sleep apnea, and testosterone use.

Multiple Choice

A 72-year-old male presents to your office 3 months after hospitalization for an ischemic stroke. He

has a history of diabetes mellitus that is well controlled on basal insulin. He has impaired mobility

and balance, as well as left upper and lower extremity spasticity. He has fallen twice in the last week.

His blood pressure is well controlled and recent laboratory studies are notable for an LDL-cholesterol

level of 64 mg/dL and a hemoglobin A1c of 6.9%. There is no evidence of cognitive impairment. His

Patient Health Questionnaire–9 (PHQ-9) score is 3.

Which one of the following would be the most appropriate next step in optimizing his post-stroke

care?

• A) Repeating neuroimaging

• B) Increasing the basal insulin dosage

• C) Initiating lorazepam (Ativan), 1–2 mg at bedtime

• D) Initiating sertraline (Zoloft), 50 mg daily

• E) Referral to a physical therapist

ANSWER: E

This patient has common post-stroke complications and will benefit from physical

therapy to address his mobility and spasticity, and to prevent falls. Repeat

neuroimaging would only be indicated with a change in neurologic examination,

including new focal neurologic deficits. His diabetes mellitus is adequately controlled

and further increasing his insulin puts him at increased risk of hypoglycemia. Lorazepam

is not first-line therapy for spasticity and is also associated with increased fall risk.

Depression is common post stroke, but this patient is not reporting symptoms of low

mood and has a normal Patient Health Questionnaire–9 score.

Multiple Choice

You see a 50-year-old female for a health maintenance examination. She is the primary caregiver for

her father who has dementia, and she has heard that Alzheimer disease is genetic and asks if there is

anything she can do to reduce her risk. She is in perimenopause and experiences severe hot flashes.

She recently started a kickboxing class and drinks 1–2 beers per week. On examination her vital signs

include a blood pressure of 138/80 mm Hg, a pulse rate of 63 beats/min, and a BMI of 30 kg/m2.

Which one of the following should you recommend to decrease this patient’s risk for dementia?

• A) A memory training app on her smartphone

• B) Abstaining from alcohol

• C) Testing for biomarkers associated with Alzheimer disease

• D) A target systolic blood pressure ≤130 mm Hg

• E) Hormone therapy with estrogen and progesterone

ANSWER: D

Maintaining a systolic blood pressure ≤130 mm Hg in midlife has been shown to reduce

the risk for developing dementia. While reading, playing music, and speaking a foreign

language have demonstrated benefits in maintaining cognition, there is no good-quality

evidence to show that computer-based memory training games prevent cognitive

decline. Extremes of alcohol use (both long-term abstinence and abuse) are associated

with an increased risk for dementia. Most people who are positive for biomarkers

associated with Alzheimer disease will not go on to develop the disease. Additionally,

there is no evidence that presymptomatic identification of Alzheimer disease is

beneficial. Hormone therapy with estrogen and progesterone is an effective treatment

for vasomotor symptoms of menopause but is associated with an increased risk for

dementia when administered in women ≥65 years of age. For women in their 40s and

50s, hormone therapy with estrogen only has demonstrated a significant decrease in

dementia, while estrogen plus progesterone therapy has demonstrated a nonsignificant

decrease.

B) abstaining from alcohol: Abstaining from alcohol in midlife is associated with a higher risk of developing dementia compared to light-moderate alcohol consumption. Large prospective cohort studies and meta-analyses show that midlife abstainers have a 33–47% increased risk of dementia (hazard ratio range 1.33–1.47) compared to those consuming 1–14 units/week.

D) maintaining a target systolic blood pressure of ≤130 mm Hg: Maintaining a target systolic blood pressure of ≤130 mm Hg is associated with a 12–19% reduction in risk of developing dementia. The American College of Cardiology and American Heart Association recommend intensive blood pressure control as a reasonable strategy for dementia prevention, based on large randomized trials and meta-analyses.[7-9] The SPRINT MIND trial found a 19% reduction in combined mild cognitive impairment and dementia incidence with a target SBP <120 mm Hg versus <140 mm Hg.
Intensive SBP lowering resulted in a statistically significant reduction in the composite outcome of mild cognitive impairment (MCI) or probable dementia (hazard ratio [HR] 0.89, 95% CI 0.79–0.99), but the reduction in probable dementia alone did not reach statistical significance (HR 0.86, 95% CI 0.72–1.02).[1][3-4] The absolute risk reduction for the composite outcome over 5 years was approximately 1.1%.[5]

The number needed to treat (NNT) to prevent one case of MCI or probable dementia with intensive SBP control over 5 years is approximately 91.[5] For probable dementia alone, the NNT is higher and the effect did not reach statistical significance.

E) hormone therapy with estrogen and progesterone: Hormone therapy with estrogen and progesterone (combined therapy) is associated with a small increase in risk of developing Alzheimer disease and dementia (odds ratio 1.13, 95% CI 1.05–1.21). Estrogen-only therapy initiated within 5 years of menopause and continued for 3–5 years may reduce AD risk (relative risk 0.56–0.70), but combined therapy or progesterone-only regimens increase risk.[10-11] The effect is formulation- and timing-dependent.

Multiple Choice

Which one of the following attention-deficit/hyperactivity disorder (ADHD) medications is

considered safest to take while breastfeeding?

• A) Amphetamine (Evekeo)

• B) Atomoxetine (Strattera)

• C) Clonidine

• D) Guanfacine

• E) Methylphenidate (Ritalin)

ANSWER: E

Racemic methylphenidate has been studied in breastfeeding mothers and drug levels in

breast milk were found to be about 0.2% of the adult dose. Drug levels were

undetectable in breastfed infants and the infants had no long-term growth or

developmental issues. Methylphenidate can reduce serum prolactin levels, but this has

not been shown to have any clinical impact on milk supply. Less is known about

amphetamine in breastfeeding, but milk and infant serum levels are significantly higher

than with methylphenidate. Atomoxetine and guanfacine have no reliable data in

breastfeeding and should be avoided until more is known. Clonidine has been shown to

be present in significant amounts in breast milk and serum from breastfed infants (up

to 50% of the maternal serum levels). While no adverse effects have been shown, this

high level of medication in the infant raises concerns, and experts recommend avoiding

clonidine while breastfeeding.

Multiple Choice

A 20-year-old female is brought to the emergency department after experiencing blunt abdominal

trauma during a motor vehicle accident. A focused assessment with sonography for trauma (FAST)

examination is performed at the bedside and there are no signs of internal bleeding.

Based on these results, which one of the following should be the next step in evaluation?

• A) No further imaging to evaluate for internal bleeding

• B) Additional imaging only if the patient develops signs of hemodynamic compromise

• C) Additional imaging to confirm the absence of bleeding

• D) Diagnostic peritoneal lavage

ANSWER: C

The focused assessment with sonography for trauma (FAST) evaluates the pericardium

and 3 potential spaces within the peritoneal cavity for hemoperitoneum and

hemopericardium. This bedside examination can be completed in less than 5 minutes,

so it is ideal for emergency department settings. FAST has replaced diagnostic

peritoneal lavage as a bedside evaluation for bleeding. A Cochrane review found that

FAST has a 96% specificity but only a 74% sensitivity for detecting internal bleeding.

The sensitivity in children was found to be even lower at 62%. Therefore, while a

positive result will almost always be reliable and should prompt immediate bleeding

control measures, a negative result carries the risk of being a false negative and must

be confirmed by additional imaging such as CT.