br10162025

​board review 10/16/25

By Frank Moskos

Multiple Choice

A 65-year-old male sees you for follow-up after he was hospitalized for pneumonia a few months

ago. He has smoked 1 pack of cigarettes per day for 40 years. Pulmonary function testing today

shows an FEV1 of 60% of predicted and an FEV1/FVC ratio of 0.65. Physical examination findings

include a BMI of 24 kg/m2 and scattered rhonchi in the chest.

Which one of the following inhalers is the recommended initial treatment to decrease this patient’s

number of exacerbations?

• A) Budesonide/formoterol (Symbicort)

• B) Fluticasone propionate

• C) Ipratropium bromide/albuterol (Combivent Respimat)

• D) Salmeterol (Serevent Diskus)

• E) Tiotropium (Spiriva)

ANSWER: E

According to the GOLD Spirometry Classification, an FEV1/FVC ratio <0.70 and an FEV1

≥50% and <80% of predicted is stage 2 COPD. Initial inhaler pharmacotherapy can be

guided by the GOLD ABCD assessment that integrates symptoms and exacerbations.

Moderate exacerbations require either an oral antibiotic, an oral corticosteroid, or both,

while a severe exacerbation results in an emergency department visit or hospitalization.

Patients with 2 or more moderate exacerbations or 1 or more hospitalizations, such as

this patient, should be prescribed a long-acting muscarinic antagonist (LAMA) as first-

line therapy. Monotherapy with this group of medications reduces symptoms, decreases

exacerbations, and decreases hospitalizations.

Inhaled corticosteroids (ICS) such as fluticasone propionate are not recommended as

monotherapy for COPD, particularly for those who have had pneumonia. Using a long-

acting β-agonist (LABA) with an ICS is less effective at reducing exacerbations and

increases the risk for pneumonia. Monotherapy with a LABA such as salmeterol reduces

exacerbations requiring hospitalization, but symptoms are better controlled when a

LABA is used in combination with a LAMA. Short-acting β-adrenergic agonists and short-

acting musc

Multiple Choice

You are the attending physician at a nursing home and the charge nurse notifies you that 3

symptomatic patients in 1 unit have tested positive for influenza A. The facility is implementing

enhanced contact and droplet precautions.

To prevent additional cases, you should recommend chemoprophylaxis with oseltamivir (Tamiflu)

for

• A) no residents or staff

• B) only residents of the affected unit who have not received influenza vaccine

• C) only residents of the affected unit

• D) only residents of the facility who have not received influenza vaccine

• E) all residents of the facility

ANSWER: C

In its 2018 clinical practice guideline, the Infectious Diseases Society of America

summarized its recommendations on the diagnosis and management of seasonal

influenza, including institutional outbreak management. These recommendations

include active surveillance for additional cases any time a resident of a long-term care

facility is diagnosed with laboratory-confirmed influenza. Influenza can spread rapidly in

the long-term care setting and outbreak control measures should be implemented

immediately. The risk for severe disease and complications from influenza are high in

frail older adults, and those with cognitive impairment may be less able to describe their

symptoms, making case-finding more difficult. When a resident develops any

respiratory symptoms during an influenza outbreak, empiric antiviral treatment should

be initiated as soon as possible without waiting for diagnostic testing results. Residents

who have been exposed to those with influenza should receive chemoprophylaxis as

soon as possible, regardless of their vaccination status. It is not necessary to initiate

chemoprophylaxis for residents who are located on remote units.

Multiple Choice

A 65-year-old female with no chronic medical problems presents for an annual Medicare wellness visit.

You initiate a discussion regarding cervical cancer screening.

According to current clinical guidelines, which one of the following would be an indication for

additional cervical cancer screening in this patient?

• A) A family history of cervical cancer in a first-degree relative

• B) Loop excision of a high-grade precancerous lesion 15 years ago, with consecutive normal results

  since then

• C) Three consecutive normal cytology results within the past 10 years, most recently 3 years ago

• D) Two consecutive normal cytology results with negative high-risk HPV co-testing within the past

  10 years, most recently 4 years ago

• E) Unprotected intercourse with a new sex partner

ANSWER: B

The U.S. Preventive Services Task Force (USPSTF) recommends against cervical cancer

screening for women >65 years of age with normal Papanicolaou (Pap) smears, who

have had adequate prior screening, and who otherwise are not at increased risk for

cervical cancer (D recommendation). The most recent definition of “adequate prior

screening” given by the American Cancer Society (ACS) is 3 consecutive negative

cytology results, 2 consecutive negative co-testing results, or 2 consecutive negative

high-risk HPV tests in the 10 years prior to discontinuation of screening, with the most

recent test having occurred within the relevant recommended testing interval. The

recommended interval is every 3 years for cytology, and 5 years for both high-risk HPV

and co-testing.

Importantly, USPSTF guidelines do not apply to individuals who are at increased risk for

cervical cancer, including women with a history of high-grade precancerous cervical

lesions or cervical cancer. The ACS and the American Society of Colposcopy and

Cervical Pathology (ASCCP) guidelines recommend continuation of cervical cancer

screening for women with a history of a high-grade precancerous lesion (defined as

cervical intraepithelial neoplasia [CIN] grade 2 or higher) for a minimum of 25 years

beyond the treatment of the lesion, even if this extends beyond 65 years of age. Thus,

if this patient had a history of treatment for a high-grade lesion 15 years ago, this

would warrant continued screening for an additional 10 years.

The presence of a new sex partner should not impact the decision to discontinue

screening for women who otherwise are eligible for cessation of screening. In fact, ACS

recommendations apply to all asymptomatic people with a cervix, without regard to

their sexual history. In contrast to several other common cancer types, cervical cancer

risk is not associated with a familial/genetic inheritance pattern; therefore, a family

history of cervical cancer, even in a first-degree relative, should not impact a cervical

cancer screening decision.

Multiple Choice

A 67-year-old male presents for an annual health maintenance visit. His medical conditions include

hypertension, dyslipidemia, severe aortic stenosis, and osteoarthritis. He is under the care of a

cardiologist and is scheduled for an annual echocardiogram next week. He reports that he generally

feels well but “can’t keep up with the grandkids” anymore. He has not had any lightheadedness, chest

pain, shortness of breath, or lower extremity edema.

Which one of the following findings would support surgical treatment for aortic stenosis at this time?

• A) An elevated 10-year atherosclerotic cardiovascular disease risk

• B) A left ventricular ejection fraction of 40%–45%

• C) A need for an elective total knee replacement

• D) A normal exercise stress test result

ANSWER: B

Aortic stenosis (AS) occurs primarily in older adults and is a result of narrowing of the

aortic valve area due to damage from the aging process that involves lipid

accumulation, calcification, and inflammation. While survival rates in patients with

asymptomatic AS match those without AS, survival rates drop dramatically once

symptoms develop. Because there is no effective medical management for preventing

the progression of AS, recognizing indications for aortic valve replacement (AVR) results

in improved survival and symptoms. Any symptomatic patient with severe AS

(maximum transaortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mm Hg)

should undergo AVR. It is difficult to determine whether this patient is truly

symptomatic from AS, but a left ventricular ejection fraction <50% would support a

need for AVR in this patient. An abnormal exercise stress test, rather than a normal

test, would also indicate a need for AVR. Finally, a need for other cardiac surgery, such

as coronary artery bypass grafting, would also prompt AVR. An elevated atherosclerotic

cardiovascular disease risk should prompt consideration of statin and aspirin prophylaxis

but does not play a role in deciding when to perform AVR. A need for a noncardiac,

elective surgical intervention would not lead to a recommendation for AVR due to the

high-risk nature of AVR.

Multiple Choice

A 44-year-old male presents for evaluation of left shoulder pain and stiffness that has developed

gradually over the past few months after a fall while skiing. He describes a dull, deep, poorly

localized ache. On examination he has impaired active and passive range of motion in all planes.

Radiography of the shoulder is unremarkable.

Which one of the following is most likely to lead to symptom resolution?

• A) Wearing a sling on the left arm for 4–6 weeks

• B) Extracorporeal shock wave therapy

• C) Biceps tendon sheath injection and physical therapy

• D) Glenohumeral corticosteroid injection and physical therapy

• E) Surgical repair

ANSWER: D

This patient presents with adhesive capsulitis, manifested as the typical cardinal

symptoms of pain, stiffness, and dysfunction of the affected shoulder. A combination of

glenohumeral or subacromial corticosteroid injection and physical therapy is most likely

to produce early and sustained improvement in symptoms and joint functioning.

Prolonged use of a sling would worsen the condition. Referral for surgery may be

indicated after a 3-month trial of conservative treatment fails. While extracorporeal

shock wave therapy has shown benefit for frozen shoulder, its current role is as an

adjunct to other primary therapies.

Multiple Choice

A 6-year-old male is brought to your office by his parents for follow-up after being seen in the

emergency department (ED) for an unprovoked, nonfebrile seizure. He does not have any prior

seizure history and his past medical history is unremarkable. An EEG in the ED was normal. The

parents are concerned about his risk for recurrent seizure and ask about treatment with anti-epileptic

drug (AED) therapy.

Which one of the following should you recommend?

• A) Starting AED monotherapy only if he has a second seizure

• B) Starting AED monotherapy now

• C) Starting combination AED therapy only if he has a second seizure

• D) Starting combination AED therapy now

ANSWER: A

In the absence of risk factors such as abnormal EEG results, the presence of a

predisposition to seizures, or an etiology such as severe head trauma or cerebral palsy,

anti-epileptic drug (AED) therapy is not indicated after a first unprovoked childhood

seizure. There is no significant difference in 1- to 2-year seizure remission rates

between starting AED therapy after the first or second seizure, and there are significant

risks associated with AED treatment. AED monotherapy should be attempted before

starting AED combination therapy.

Multiple Choice

A 48-year-old female presents to your office because of an erythematous rash on her left posterior

calf and right posterior thigh (shown below). Five days ago she was stung by wasps in those

locations. The stings were initially associated with intense pain and small areas of erythema that have

since expanded to approximately 10-cm erythematous patches surrounding the original sting sites.

On examination there are erythematous patches on her left posterior calf and right posterior thigh

with warmth, induration, and tenderness to palpation. She does not have any fevers or chills. The

examination findings are otherwise within normal limits.

Which one of the following would be the most appropriate treatment at this time?

• A) Topical neomycin/polymyxin B/pramoxine (Neosporin)

• B) Oral cephalexin

• C) Oral diphenhydramine

• D) Oral prednisone

• E) Oral sulfamethoxazole/trimethoprim (Bactrim)

ANSWER: D

This patient is experiencing a large local reaction to an insect sting, occurring between

a few days to 1 week after the initial sting. This occurs in about 19% of reactions and

carries a 5%–10% risk for a systemic reaction in subsequent exposures. The treatment

is prednisone, 40–60 mg daily for 3–5 days. This is not an infection but rather a

reaction to the Hymenoptera sting, so oral or topical antibiotics are not indicated.

Antihistamines such as diphenhydramine are useful for pruritus but are not a treatment

for the reaction.

Multiple Choice

A 39-year-old female presents with a sudden onset of palpitations. Her vital signs include a blood

pressure of 114/68 mm Hg and a pulse rate of 166 beats/min. She is cooperative and alert. An EKG

shows regular narrow complex tachycardia with normal intervals. She has tried vagal maneuvers with

no improvement.

Which one of the following would be the most appropriate treatment at this time?

• A) Adenosine

• B) Atropine

• C) Diltiazem (Cardizem)

• D) Metoprolol

• E) Synchronized cardioversion

ANSWER: A

If vagal maneuvers are not effective in the management of stable supraventricular

tachycardia (SVT), the most appropriate next step is treatment with intravenous

adenosine at an initial dose of 6 mg. Atropine is a treatment option for bradycardia,

particularly in the setting of heart block. Diltiazem or metoprolol may be used acutely in

atrial fibrillation or in the prevention of SVT. Synchronized cardioversion is indicated in

patients with SVT who become hypotensive or unresponsive.

Multiple Choice

A 29-year-old female presents with low back pain that began after giving birth 3 months ago. She

reports pain on her right side when climbing and descending stairs and when lying on her right side.

On examination she has mild lumbar paraspinal muscle tightness on the left and moderate tenderness

inferomedial to the posterior superior iliac spine on the right. Muscle strength testing and lower

extremity reflexes are normal.

Which one of the following conditions is the most likely cause of this patient’s pain?

• A) Lumbar strain

• B) Piriformis syndrome

• C) Pudendal nerve entrapment

• D) Sacroiliac joint dysfunction

• E) Spondyloarthropathy

ANSWER: D

Sacroiliac joint dysfunction is commonly seen in primary care and is an important

consideration in the evaluation of low back pain. It often occurs during pregnancy and

post partum. Other inciting incidents include a motor vehicle accident or a mechanical

fall onto the buttocks. It can be associated with ankylosing spondylitis and other

spondyloarthropathies; however, the etiology in this case is more likely to be childbirth.

Symptoms often include pain at the sacroiliac joint that worsens with climbing stairs,

lying on the affected side, prolonged standing and sitting, and weight-bearing on the

leg of the affected side. Examination findings include tenderness that is inferomedial to

the posterior superior iliac spine. A number of provocation tests for sacroiliac joint

dysfunction can help to confirm the diagnosis. NSAIDs, physical therapy, and joint

manipulation are first-line treatments. Pelvic belts, corticosteroid injections, and

sacroiliac joint fusion are used for refractory cases.

Lumbar strain is in the differential diagnosis, but sacroiliac joint dysfunction is more

likely given this patient’s history and the duration and location of tenderness. Piriformis

syndrome is usually unilateral and causes sciatic-like symptoms. Pudendal nerve

entrapment would cause perineal pain or labial numbness. Spondyloarthropathies are

associated with sacroiliac joint inflammation but are not as likely in this postpartum

patient.

Multiple Choice

Most elder abuse is perpetrated by

• A) family members

• B) friends

• C) nurses

• D) paid caregivers

• E) physicians

ANSWER: A

Most elder abuse occurs in the home and is perpetrated by family members (90% of all

cases). A small proportion of older adults live in nursing homes, with only 4% of abuse

perpetrated by paid caregivers.

Risk factors for elder abuse include shared living arrangements, increased age,

decreased physical health, cognitive impairment, disruptive behaviors, alcohol misuse,

and social isolation. Caregiver characteristics associated with abuse include mental

illness, substance abuse, and dependence on the victim (often financially).

There are validated screening instruments available, notably the Elder Abuse Suspicion

Index, but the U.S. Preventive Services Task Force has found insufficient evidence for

screening older adults for abuse and neglect when there are no recognized signs and

symptoms of abuse. Identification of elder abuse is a professional responsibility of

family physicians. However, physicians report a very small number of elder abuse cases

(1.4%). Family members, social service workers, friends, and law enforcement most

commonly report abuse. Most states mandate reporting of elder abuse but there is a

dearth of training for physicians in recognizing elder abuse. Signs are often subtle and

physical findings are not always evident.