br10232025

​board review 10/23/25

By Frank Moskos

Multiple Choice

A 52-year-old male presents to the emergency department with a sudden onset of what he describes

as the worst headache of his life. You are concerned about the possibility of an intracranial

hemorrhage.

After performing an examination to rule out neurologic deficits, which one of the following would be

the most appropriate next step in evaluation?

• A) CT of the head without contrast

• B) CT of the head with contrast

• C) MRI of the head with and without contrast

• D) A lumbar puncture

ANSWER: A

A patient describing a headache as the worst headache of their life can be a red-flag

symptom of an intracranial hemorrhage, and CT of the head without contrast is the

recommended next step in evaluation. Contrast should not be used because it can

obscure the signs of bleeding. If a subarachnoid hemorrhage is suspected, CT of the

head should be completed before performing a lumbar puncture to ensure there is no

evidence of intracranial hemorrhage or midline shift.

Multiple Choice

A 45-year-old male with a history of hypertension and poorly controlled anxiety and depression

presents to your office to establish care. He requests refills of his current medications, which include

the following:

Alprazolam (Xanax), 0.5 mg nightly

Buspirone, 10 mg 3 times daily

Gabapentin (Neurontin), 600 mg 3 times daily

Lorazepam (Ativan), 1 mg twice daily

Losartan (Cozaar), 50 mg daily

Sertraline (Zoloft), 200 mg daily

You tell the patient that you will provide refills for buspirone, gabapentin, losartan, and sertraline

without dosage adjustments; however, he will need to taper and ultimately discontinue the alprazolam

and lorazepam. You both agree hospitalization is not necessary. After discussion, the patient agrees

with your approach.

In addition to cognitive behavioral therapy, which one of the following strategies would be most

appropriate for this patient?

• A) Discontinuing both benzodiazepines and initiating buprenorphine maintenance therapy

• B) Discontinuing both benzodiazepines and initiating flumazenil maintenance therapy

• C) Discontinuing lorazepam now and gradually decreasing alprazolam over 6 months

• D) Tapering the alprazolam and lorazepam dosages simultaneously over 6 months

• E) Switching both alprazolam and lorazepam to diazepam (Valium), and then decreasing the

  diazepam dosage over 6 months

ANSWER: E

Benzodiazepine prescriptions and overdoses have increased over the last 15 years and

long-term benzodiazepine use is rarely recommended. Current recommendations

include the following: substitution of multiple benzodiazepines for a single longer-acting

benzodiazepine such as diazepam, tapering of medication over weeks to months, and

use of cognitive behavioral therapy. Buprenorphine is indicated for patients with opioid

use disorder and can be helpful for patients who are taking both opioids and

benzodiazepines. Flumazenil is an intravenous injection that is used for benzodiazepine

overdoses and reversing benzodiazepine sedation. It is not used in maintenance

therapy for benzodiazepine cessation.

Multiple Choice

A 15-year-old female is brought to your office in May with a 3-week history of nasal congestion,

sneezing, and itchy eyes. She reports that these episodes occur every spring and last about 6 weeks.

She has been taking oral cetirizine (Zyrtec) with no improvement. You initiate an intranasal

corticosteroid.

The patient returns for follow-up 4 weeks later and says that she has seen some improvement but is

dissatisfied with her progress. The patient and her parent ask about further steps in diagnosis.

Which one of the following would be the most appropriate next step in diagnosis?

• A) A CBC

• B) Skin allergen testing

• C) Serum allergy testing

• D) Chest radiography

• E) Sinus CT

ANSWER: B

This patient most likely has seasonal allergic rhinitis that has not responded to empiric

treatment. The most appropriate next step in diagnosis is skin allergen testing. Serum

allergy testing is more expensive and less specific than skin allergen testing. It also

does not provide the immediate results of skin allergen testing.

A CBC will likely show eosinophilia, given the patient’s likely diagnosis of allergic rhinitis.

However, this is a nonspecific finding. This patient likely does not have a true

respiratory illness such as pneumonia, so a chest x-ray would not be appropriate. Sinus

CT likely will not lead to actionable management. It is also expensive and carries the

risk for radiation exposure, which needs to be weighed carefully in a pediatric patient.

Multiple Choice

Which one of the following conditions is most likely to impair swallowing of both solids and liquids?

• A) Achalasia

• B) Eosinophilic esophagitis

• C) Esophageal cancer

• D) Esophageal stricture

• E) Schatzki ring

ANSWER: A

Achalasia is a smooth muscle motility disorder that impairs swallowing of both solids and liquids. In contrast, anatomic causes of dysphagia that impede the lumen of the esophagus through mass effect or inflammation, such as eosinophilic esophagitis, esophageal cancer, esophageal stricture, and Schatzki rings, typically impair swallowing of solids but not liquids.

Multiple Choice

A 55-year-old male with a medical history of GERD and osteoarthritis presents to the emergency

department 2 hours after a sudden onset of intense epigastric pain. He takes naproxen almost daily for

joint pain.

On examination the patient is noticeably pale. His vital signs include a blood pressure of 90/60 mm

Hg and a pulse rate of 125 beats/min. He is exquisitely tender to palpation in his abdomen,

particularly at the epigastrium. There is no fluid wave or hepatomegaly. You do not note any obvious

stigmata of chronic liver disease.

Which one of the following tests should be performed to assist in the diagnosis?

• A) Aortic ultrasonography

• B) Abdominal radiography

• C) Abdominal and pelvic CT

• D) Abdominal paracentesis

• E) Exploratory laparotomy

ANSWER: C

This patient most likely has a perforated peptic ulcer and the recommended test is CT of the abdomen and pelvis. Aortic ultrasonography is not productive in this case, as the patient’s symptoms are unlikely to be caused by an abdominal aortic aneurysm.

Abdominal radiography lacks the definition to visualize a perforated peptic ulcer. This patient's abdomen is not distended, and it is unlikely that abdominal paracentesis will yield the diagnosis or be therapeutic. Exploratory laparotomy is excessive and premature, as CT is diagnostic and less invasive.

Multiple Choice

A 55-year-old male presents for evaluation of recent-onset tinnitus that has adversely affected his

sleep and concentration. A physical examination including otoscopy is unremarkable.

Which one of the following additional findings, if present, would be an indication for head imaging?

• A) Associated development of major depressive disorder

• B) Bilateral hearing loss on audiometry

• C) Lack of improvement with a trial of a tricyclic antidepressant

• D) A pulsatile quality of the tinnitus

• E) Symptom duration >6 months

ANSWER: D

Tinnitus is a common problem that is experienced by up to 25% of adults, although

<10% of affected individuals report bothersome symptoms that impair sleep, focus,

emotions, or general quality of life. Audiometry should be performed for patients with

severe or persistent symptoms, as hearing loss is a common comorbid finding.

Evaluation for potential structural causes with MRI or CT of the temporal bone is

indicated for any of the following: a pulsatile quality of the tinnitus, unilateral tinnitus,

asymmetric hearing loss, or focal neurologic findings. Of the options given in this clinical

scenario, only pulsatile tinnitus would provide an indication for head imaging.

While patients with tinnitus may be more susceptible to mood disturbances due to the

adverse impact on quality of life and functioning that their symptoms may cause, an

associated onset of major depression would not provide a reason to order diagnostic

head imaging. Bilateral hearing loss on audiometry is often noted in the setting of

tinnitus and does not suggest the presence of a structural lesion. No medication

strategies have proven effective to treat tinnitus; thus, prescribing a tricyclic

antidepressant would not be expected to provide benefit. Symptoms often persist for

months to years; the duration of symptoms alone does not provide a reason to order

head imaging.

Multiple Choice

1. A 46-year-old female presents to your office with a 2-week history of pain in her left shoulder. She does not recall any injury, and the pain is present when she is resting and at night. Her only chronic medical problem is type 2 diabetes mellitus.

   On examination, she has limited movement of the shoulder and almost complete loss of external rotation. Radiographs of the shoulder are normal, as is her erythrocyte sedimentation rate.

   Which one of the following is the most likely diagnosis?

• 1. A)  Frozen shoulder

• 1. B)  Torn rotator cuff

• 1. C)  Impingement syndrome

• 1. D)  Chronic posterior shoulder dislocation

• 1. E)  Osteoarthritis

ANSWER: A

Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and 60. Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory tests and plain films are normal; the diagnosis is clinical (SOR C).

Frozen shoulder is differentiated from chronic posterior shoulder dislocation and osteoarthritis on the basis of radiologic findings. Both shoulder dislocation and osteoarthritis have characteristic plain film findings. A patient with a rotator cuff tear will have normal passive range of motion. Impingement syndrome does not affect passive range of motion, but there will be pain with elevation of the shoulder.

Multiple Choice

Intravenous magnesium is used to correct which one of the following arrhythmias?

• 1. A)  Wenckebach second-degree heart block

• 1. B)  Complete heart block

• 1. C)  Idioventricular rhythm

• 1. D)  Reentrant supraventricular tachycardia

• 1. E)  Ventricular tachycardia of torsades de pointes

ANSWER: E

A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes.






2010 stuff:
Results of a meta-analysis suggest that 1.2–10.0 g of intravenous magnesium sulfate also is a safe and effective strategy for the acute management of rapid atrial fibrillation.

Multiple Choice

Which one of the following is a physiologic difference between males and females that can affect the pharmacokinetics of medications with a narrow therapeutic index?

• 1. A)  A consistently higher glomerular filtration rate in women

• 1. B)  The typically higher BMI in women

• 1. C)  Smaller fat stores in women

• 1. D)  Greater gastric acid secretion in women

• 1. E)  Slower gastrointestinal transit times in women

ANSWER: E

There are key physiologic differences between women and men that can have important implications for drug activity. Gastrointestinal transit times are slower in women than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.

Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole. Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions. Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action. Women also have lower glomerular filtration rates than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.

Multiple Choice

A 52-year-old female with a 60-pack-year history of cigarette smoking and known COPD presents with a 1-week history of increasing purulent sputum production and shortness of breath on exertion. Which one of the following is true regarding the management of this problem?

• 1. A)  Antibiotics should be prescribed

• 1. B)  Intravenous corticosteroids are superior to oral corticosteroids

• 1. C)  Inhaled corticosteroids should be started or the dosage increased

• 1. D)  Levalbuterol (Xopenex) is superior to albuterol

• 1. E)  Acetylcysteine should be given if the patient is hospitalized

ANSWER: A

Antibiotic use in moderately or severely ill patients with a COPD exacerbation reduces the risk of treatment failure or death, and may also help patients with mild exacerbations. Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures. Studies have not shown a difference between oral and intravenous corticosteroids. Inhaled corticosteroids are not helpful in the management of an acute exacerbation. Levalbuterol and albuterol have similar benefits and adverse effects. Acetylcysteine, a mucolytic agent, has not been shown to be helpful for routine treatment of COPD exacerbations.

Multiple Choice

During rounds, you notice a new rash on a full-term 2-day-old white female. It consists of 1-mm pustules surrounded by a flat area of erythema, and is located on the face, trunk, and upper arms. An examination is otherwise normal, and she does not appear ill.

Which one of the following is the most likely diagnosis?

• 1. A)  Erythema toxicum neonatorum

• 1. B)  Transient neonatal pustular melanosis

• 1. C)  Acne neonatorum

• 1. D)  Systemic herpes simplex

• 1. E)  Staphylococcus aureus sepsis