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​Board Review 12/10/25

By Frank Moskos

Multiple Choice

1. Your practice management team has reviewed the clinic-wide cancer screening rates and found that the frequency of cervical cancer screening appears to have fallen behind other cancer screenings. You are asked to lead a quality improvement project to increase rates of cervical cancer screening for appropriate patients.

   Which one of the following would be the most appropriate first step?

• 1. Your practice management team has reviewed the clinic-wide cancer screening rates and found that the frequency of cervical cancer screening appears to have fallen behind other cancer screenings. You are asked to lead a quality improvement project to increase rates of cervical cancer screening for appropriate patients.

     Which one of the following would be the most appropriate first step?

• 1. Evaluating barriers to cervical cancer screening and reporting

• 1. Placing posters with information about cervical cancer screening inside the clinic

• 1. Sending generalized reminders to patients who may qualify for cervical cancer screening

• 1. Sending generalized reminders to all clinicians regarding cervical cancer screening guidelines

ANSWER: B

Quality improvement is a key area for clinical practice, but initiating these projects can be challenging. Many different methodologies have been used, including the Plan-Do-Study- Act cycle or Plan-Do-Check-Act cycle, but clear identification of the current issues is critical in any framework. In order to plan appropriate interventions, it must first be determined what barriers are responsible for hindering performance in a certain area.

If evaluation shows that there is a systemic issue in capturing data, rather than a clinician issue, no other interventions will be beneficial. When used as part of an organizational plan for staffing and clinical procedures, patient-specific reminders and use of the entire health care team are more likely to improve screening uptake than other methods, but the initial step should be delineating any current issues prior to implementing a change. Educating patients about preventive health care and screenings is essential and should be part of routine care. However, general materials such as clinic posters are less likely to increase screening rates than direct physician recommendations or conversations. Sending generalized reminders for preventive care may miss the patients in most critical need of services. General reminders that rely on clinician evaluation of every individual visit may be less effective than patient-specific reminders that can be addressed at the point of care.

Multiple Choice

1. You are seeing a 32-year-old male in the office. His most recent hemoglobin A1c was 6.1%, indicating prediabetes.

   Which one of the following is most likely to prevent the development of diabetes?

• 1. A)  Intensive lifestyle and behavior change program

• 1. B)  Low-carbohydrate diet

• 1. C)  Reduction in daily caloric intake by 250 kcal per day

• 1. D)  Strength training for 90 minutes per week

​ANSWER: A

Given the growing prevalence of diabetes mellitus, clinicians should be familiar with effective prevention strategies. Intensive lifestyle and behavior modification programs, such as the National Diabetes Prevention Program, are low-cost and can reduce the development of diabetes, with one U.S. study demonstrating a 27% reduction over 15 years. These programs help patients set weight loss goals ≥7% of their baseline, which is thought to be a key component of diabetes prevention. This is typically achieved through a caloric reduction of 500–1000 kcal per day, with activity goals ≥150 minutes per week, including up to 75 minutes per week of strength training. While a variety of dietary patterns are thought to be effective for diabetes prevention, including low intake of carbohydrates, the evidence for changes in dietary patterns is not as strong as that of intensive lifestyle programs.

Multiple Choice

An otherwise healthy 47-year-old male presents to the urgent care clinic with pain and swelling of his right foot after sustaining an injury during a game of ultimate frisbee. He jumped to catch the frisbee and landed on uneven ground. He is unsure of how he landed, but thinks he may have twisted his right foot, causing him to trip and fall. He has significant pain and swelling of his right foot but is weight-bearing. He rates the pain as 10 on a scale of 10.

On examination, his vital signs are unremarkable. His right lateral foot shows significant bruising and swelling. The skin is intact. Range of movement is impaired due to the swelling and discomfort, and sensation and circulation are intact. An x-ray of the right foot is shown below.

Which one of the following is the most appropriate next step in management?

• 1. A)  Weight-bearing with a walking boot for 3–6 weeks

• 1. B)  Non–weight-bearing with a walking boot for 3–6 weeks

• 1. C)  Non–weight-bearing with a short leg cast for 6 weeks

• 1. D)  Referral to a physical therapist

• 1. E)  Referral to an orthopedic surgeon

ANSWER: A

This patient's imaging reveals a fifth metatarsal shaft fracture, which should be managed with a boot or hard-soled shoe for 3–6 weeks with weight-bearing. Foot fractures are typically caused by an axial or twisting force on the foot or a crush injury and account for about one-third of lower extremity fractures in adults. Patients present with swelling and bony point tenderness of the affected area, as seen in this patient. The ability to bear weight varies based on the patient's pain tolerance and the extent of the fracture. Complications of foot fractures include infection, arthritis, nonunion, malunion, and compartment syndrome. A short leg cast is not appropriate because it is used to treat proximal fifth metatarsal and tarsal bone fractures. Physical therapy is not first-line management for this patient's injury. If reduction is needed or if nonunion is present after 6 months, then referral to an orthopedic surgeon would be indicated.

Immediate surgical referral is required for all open fractures and for all fractures with associated vascular compromise or nerve injury. Early referral is also recommended for fractures with significant skin damage. Other indications for referral include the following

●Fractures of multiple metatarsals

●Displaced fractures near the metatarsal head

●Intra-articular fractures

●Displaced fractures of the first metatarsal, even if displacement is minimal, because anatomic position is necessary for optimal weight-bearing function

●Unstable fractures of the first metatarsal, judged by clinical findings or stress radiographs

●Concurrent injuries of other structures, including injury of the tarso-metatarsal (ie, Lisfranc) ligament complex and fractures of other foot or ankle bones

A post-operative (post-op) shoe is advised if the patient does not have suitable shoes or the foot is too swollen to fit in supportive shoes.

A well-molded, short-leg walking cast may be necessary if the patient has significant pain while bearing minimal weight. Generally, a cast is placed several days after the injury when swelling is reduced. Radiographs should be repeated one week after the injury (or during the initial follow-up visit, if this takes place five days or longer after the injury) to ensure the fracture remains nondisplaced. After two to three weeks, the cast may be replaced with a firm shoe or post-op shoe for two to three additional weeks.

Most fractures are considered "healed" when callus is visible on radiographs and point tenderness has resolved, which usually occurs by six weeks in adults. Complete healing requires many months. Radiographs should be repeated four to six weeks after the injury to document healing . If callus is seen and the fracture has minimal to no tenderness, protection can be discontinued and regular activities gradually resumed. At this point, the patient will need ankle range of motion and calf strengthening/stretching exercises to speed full recovery of function.

Multiple Choice

4. A 78-year-old female presents to the emergency department with a 2-day history of cough and fever and a 2-hour history of confusion. Her vital signs include a weight of 67 kg (148 lb), a temperature of 38.8 °C (101.8 °F), a pulse rate of 122 beats/min, and a blood pressure of 72/44 mm Hg with a mean arterial pressure (MAP) of 53 mm Hg. A chest x-ray shows left lower lobe pneumonia. She is given 2 L of lactated Ringer solution and started on broad- spectrum antibiotics for sepsis secondary to pneumonia. Her blood pressure 3 hours later is 82/46 mm Hg with a MAP of 58 mm Hg.

   Which one of the following is the most appropriate immediate next step in management?

• 1. A)  A 1-L bolus of normal saline

• 1. B)  A dopamine infusion

• 1. C)  A norepinephrine infusion

• 1. D)  A vasopressin infusion

• 1. E)  Placement of a central line

ANSWER: C

This patient is in septic shock secondary to pneumonia. Surviving Sepsis Campaign guidelines recommend early goal-directed therapy (EGDT) consisting of initial fluid resuscitation with 30 mL/kg of crystalloid solution within the first 3 hours and appropriate antibiotics within 1 hour of evaluation, which have already been done for this patient. The guidelines also recommend initiating vasopressor therapy with norepinephrine as the first- line agent if the mean arterial pressure remains <65 mm Hg after fluid resuscitation. Norepinephrine is a more potent vasoconstrictor than dopamine. Additional fluid therapy is controversial and patient-specific, with some experts recommending discrete 500-mL boluses with hemodynamic monitoring of response, and others recommending balanced crystalloids such as lactate Ringer solution over normal saline. Vasopressin should be added for adults with septic shock who are receiving norepinephrine but continue to have inadequate mean arterial pressure. Vasopressor therapy should not be delayed for placement of a central line.
Also:
1. assess if MRSA or pseudomonas coverage are needed.
2. test for legionella.
3. sputum culture
4. consider steroids in refractory septic shock or ARDS (avoid in influenza, tuberculosis, and fungal pathogens,
5. treat with antiviral if flu is diagnosed.
Interesting aside:
1. the 30mL/kg bolus came from goal directed sepsis trial and has not been replicated and may cause harm in some patients (think severe chf or pulmonary hypertension).

Multiple Choice

4. You are called to the emergency department (ED) to admit a 48-year-old female with a past medical history of hyperthyroidism who presented with agitation, palpitations, and diarrhea. The ED team diagnosed thyroid storm secondary to the abrupt discontinuation of the patient's methimazole 2 weeks ago due to a lapse in insurance.

   On examination, she is tachycardic and hypertensive but can sustain a conversation without dyspnea. Laboratory studies are significant for elevated free T3 and T4 levels and an undetectable TSH level. A urine pregnancy test is negative.

   Which one of the following would be the most appropriate initial step in management?

• 1. A)  Inorganic iodine

• 1. B)  Prednisone

• 1. C)  Propylthiouracil

• 1. D)  Plasmapheresis

ANSWER: C

Thyroid storm is a medical emergency that must be treated promptly. The initial treatment for thyroid storm is propylthiouracil (PTU). While PTU has been shown to decrease circulating T3 hormone levels more quickly than methimazole, they have both been shown to be equally effective clinically. Glucocorticoids can also be used to block the conversion of T4 to T3. Hydrocortisone and dexamethasone, not prednisone, are the preferred glucocorticoids if used in addition to PTU. While iodine is used to block the synthesis of new thyroid hormone, it should be started at least 1 hour after the initiation of PTU. Plasmapheresis is reserved for patients who do not respond to pharmacologic treatment.

For most patients with clinical features of thyroid storm or with impending storm (ie, severe thyrotoxicosis that does not fully meet the criteria for thyroid storm), we begin immediate treatment with:

●Beta blocker – Propranolol preferred.

also esmolol drip

●Thionamide – Propylthiouracil (PTU) preferred.

PTU – The dose of PTU is 200 to 250 mg every four hours. We do not typically administer a loading dose of PTU since the initial dose is generally adequate to block thyroid hormone synthesis. The American Thyroid Association (ATA) guidelines suggest a loading dose of 500 to 1000 mg

●Methimazole – The dose of methimazole is 20 mg orally every four to six hours.

●Iodine – Potassium iodide solution (SSKI) or potassium iodide-iodine solution

●SSKI – 5 drops (50 mg iodide/drop [0.05 mL]) orally every six hours

●Lugol's solution – 10 drops (6.25 mg iodide/iodine per drop [0.05 mL]) orally three times daily

For patients with clinical features of thyroid storm, we also administer:

●Hydrocortisone – 300 mg loading dose, then hydrocortisone, 100 mg intravenously every eight hour

Multiple Choice

6. According to guidelines from the American Gastroenterological Association, which one of the following is recommended as the best pharmacologic treatment of typical symptoms in diarrhea-predominant irritable bowel syndrome?

• 1. A)  Amitriptyline

• 1. B)  Dicyclomine

• 1. C)  Linaclotide (Linzess)

• 1. D)  Lubiprostone (Amitiza)

• 1. E)  Rifaximin (Xifaxan)

ANSWER: E

According to the 2022 American Gastroenterological Association guidelines for diarrhea- predominant irritable bowel syndrome (IBS-D), the nonabsorbable antibiotic rifaximin has the best evidence for controlling diarrhea, discomfort, bloating, and abdominal pain. It has a broad spectrum with activity against gram-positive, gram-negative (including Clostridioides difficile), and anaerobic bacteria. It is thought to work by reducing bacterial byproducts and altering the gut flora. It is prescribed as a 14-day course for acute and recurrent symptoms. Rifaximin does not have any significant adverse effects, but it is a high-cost medication.

Low-dose amitriptyline and dicyclomine are often effective in reducing symptoms, but the evidence is not as strong as that of rifaximin. Linaclotide is used for constipation- predominant IBS (IBS-C), but its chief side effect of diarrhea results in many patients discontinuing the medication. Lubiprostone is another medication used for IBS-C and for opioid-induced constipation, not IBS-D
Therapies:
1. physical activity
2. sleep hygiene
3. brain-gut behavioral therapy.
4. tca/antispasmotics
5. Low FODMAP diet

• Fermentable: Fermented in the gut, producing gas.

• Oligosaccharides: Wheat, rye, onions, garlic, legumes.

• Disaccharides: Lactose (milk, yogurt, soft cheese).

• Monosaccharides: Fructose (honey, apples, pears).

• Polyols: Sugar alcohols (sorbitol, mannitol) and fruits with pits/seeds (avocado, cherries, peaches). 

Multiple Choice

6. A 56-year-old female with moderately controlled type 2 diabetes presents with painful diabetic neuropathy in her feet. You address her diabetic control and other risk factors, but she says the pain continues and is affecting her life adversely.

   Which one of the following is considered a first-line treatment for pain relief in this condition?

• 1. A)  Topical capsaicin

• 1. B)  Topical lidocaine

• 1. C)  Oral gabapentin

• 1. D)  Oral hydrocodone

• 1. E)  Peripheral transcutaneous electrical nerve stimulation

ANSWER: C

First-line treatments for the relief of painful diabetic neuropathy include amitriptyline, duloxetine, gabapentin, and pregabalin.

Second-line treatments include topical lidocaine and capsaicin, with less evidence of benefit.

Opioids such as hydrocodone should be avoided in the treatment of neuropathic pain.

Studies of peripheral transcutaneous electrical nerve stimulation have shown modest benefit; however, it is not a first-line treatment.

Multiple Choice

8. A generally healthy 60-year-old female presents to your office because she is concerned about urinary leakage. Her symptoms started a couple of years ago and have worsened. The leakage occurs when she coughs or laughs, but can also happen if she waits too long to urinate. She hydrates throughout the day. She does not take any medications and does not smoke. She has a remote surgical history of a hysterectomy after delivering her third child. She does not have any fever or abdominal pain and has not been exposed to any sexually transmitted infections. Recent laboratory studies, including a CBC, comprehensive metabolic panel, TSH level, and hemoglobin A1c, were unremarkable. Today she has a blood pressure of 120/70 mm Hg and a BMI of 32 kg/m2.

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

• 1. A)  No testing

• 1. B)  Urinalysis

• 1. C)  Renal and bladder ultrasonography

• 1. D)  Urodynamic testing

• 1. E)  Cystoscopy

ANSWER: B

Urinary incontinence is common among women and can substantially diminish quality of life while contributing to increased financial strain. Risk factors include obesity, parity, increasing age, and a history of hysterectomy. The initial evaluation includes a thorough history and should establish whether the incontinence is transient or chronic. It should also identify the incontinence subtype as well as any red flags that would warrant subspecialist referral, such as pelvic organ prolapse or fistula. Urinalysis should be ordered for all patients with urinary incontinence. An incontinence screening questionnaire, cough stress test (SOR C), postvoid residual measurement, and a 3-day voiding diary are helpful tools. Renal and bladder ultrasonography, urodynamic testing, and cystoscopy are not recommended for the initial evaluation of uncomplicated urinary incontinence.
Treatments include weight loss, pelvic floor training, lifestyle modifications including appropriate fluid intake, smoking cessation, and pharmacologic therapy. Patients with refractory urinary incontinence can be referred for more invasive treatments, such as mechanical devices, intravesical onabotulinumtoxinA injection, and surgical procedures.

Multiple Choice

8. A 68-year-old female with previously diagnosed immune thrombocytopenia presents to your office to establish care. She has no current bleeding. A CBC is normal except for a platelet count of 47,000/mm3 (N 130,000–400,000). You refer her to a hematologist for long-term management.

   Which one of the following is the most appropriate treatment for this patient's current thrombocytopenia?

• 1. A)  No treatment

• 1. B)  Oral hydroxychloroquine sulfate (Plaquenil)

• 1. C)  Oral prednisone

• 1. D)  Intravenous methylprednisolone sodium succinate (Solu-Medrol)

• 1. E)  Intravenous rituximab (Rituxan)

ANSWER: A

Immune thrombocytopenia (ITP) is caused by autoimmune destruction of platelets in the spleen and causes chronic thrombocytopenia of varying severity. Although hematologists typically oversee care for patients with ITP, family physicians may need to make acute treatment decisions in collaboration with these patients. The American Society of Hematology recommends not to treat ITP unless there is active bleeding or very low platelet counts, defined as <30,000/mm3. This patient does not require treatment at this time because she does not have any current bleeding and her platelet count is above the threshold for treatment. Corticosteroids and rituximab are both used to treat ITP, along with intravenous immunoglobulin. Hydroxychloroquine sulfate is not typically recommended in the treatment of ITP.

Multiple Choice

10. A 45-year-old male who is living with HIV and has been on highly active antiretroviral therapy (HAART) for the past 10 years presents for routine follow-up. Which one of the following would be part of an appropriate screening strategy for long-term complications associated with HAART?

• 1. A)  Calculation of the Framingham Risk Score now, and a fasting lipid profile annually

• 1. B)  Neurocognitive screening annually

• 1. C)  Transient elastography annually

• 1. D)  A DXA scan annually

• 1. E)  Urinalysis annually, and a glomerular filtration rate twice yearly

ANSWER: E

The Infectious Diseases Society of America recommends performing urinalysis at least once yearly and obtaining a glomerular filtration rate at least twice yearly in stable patients on highly active antiretroviral therapy (HAART) to detect kidney function abnormalities and drug nephrotoxicity. While cardiovascular risk assessment is important in persons living with HIV, the Framingham Risk Score is not well validated in this population. The American College of Cardiology/American Heart Association recommend using traditional risk factors and clinical judgment for cardiovascular risk assessment in this population.

Neurocognitive screening is typically performed based on clinical indications rather than as an annual routine screening for all patients on HAART. Liver fibrosis screening is appropriate in patients with coinfection with hepatitis B or C, but it is not a routine annual screening. Although bone mineral density screening is important in persons living with HIV, especially those at risk for osteoporosis, it is not recommended annually for all patients on HAART.