br01222026

​Board review 1/22/26

By Frank Moskos

Why did we miss this? some common disconnects. 

Test taking style themes Content based themes

1. second guessed myself 1. local vs national standard

2. misread question 2. regency bias

3. missed key word or setting 3. emergent vs continuity setting 

4. answered too quickly 4. weaker in some subject areas

5. misunderstood testing point 5. information out of date. 

6. other 6. other.

Recency bias is a cognitive bias that favors recent events over historic ones.

Multiple Choice

35. A 40-year-old male presents to the office with a 2-day history of right eye pain associated with redness and swelling. He does not wear contact lenses. Pertinent findings on a physical examination include a temperature of 37.3 °C (99.1 °F), visual acuity of 20/70 in the right eye and 20/20 in the left eye, erythema and edema of the right eyelid, and pain with extraocular movements.

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

• 1. A)  Frequent warm, moist compresses, and follow-up tomorrow

• 1. B)  Empiric treatment with an oral antibiotic

• 1. C)  A same-day evaluation with an ophthalmologist

• 1. D)  Noncontrast CT of the orbits and sinuses

• 1. E)  Transfer to the emergency department

ANSWER: E

This patient's unilateral orbital swelling, erythema, pain with extraocular movements, and decreased visual acuity are concerning for orbital cellulitis. Prompt recognition and early treatment are vital to avoid worsening outcomes associated with this ocular emergency. A patient who presents in the outpatient setting with clinical findings that are suspicious for orbital cellulitis should be promptly directed to the emergency department (ED) for expedited evaluation and anticipated hospitalization for urgent ophthalmology consultation and broad-spectrum intravenous antibiotics, if the diagnosis is confirmed. CT with intravenous contrast is the imaging modality of choice, although MRI is an alternative. Ordering noncontrast CT would potentially yield a less accurate diagnosis and could delay definitive treatment. Same-day outpatient evaluation by an ophthalmologist would cause a diagnostic delay, compared to transfer to the ED. Symptomatic treatment with warm compresses and close outpatient follow-up would cause a treatment delay with a risk of further clinical deterioration. Empiric treatment with an oral antibiotic would not provide adequate initial treatment of the infection compared to hospitalization for intravenous antibiotic treatment and closer clinical monitoring.
question stats: 

our % right: 44

national % right: 60

pgy1: 3

pgy2: 5

pgy3: 4

so, why did i miss this?
we dont' do alot of eye stuff.

Multiple Choice

35. A 63-year-old male presents with a 2-day history of right lower extremity edema and pain. He has a past medical history of hypertension, stage 4 chronic kidney disease, and type 2 diabetes, for which he takes insulin. His last glomerular filtration rate was 22 mL/min/1.73 m2. He does not report any trauma, chest pain, or shortness of breath.

    On examination he has a weight of 70 kg (154 lb) and the remainder of his vital signs are within normal limits. Examination of his right lower extremity reveals erythema, tenderness, and 2+ edema at the back of the knee. A Doppler venous duplex ultrasound of the right thigh shows a noncompressible right femoral vein.

    Which one of the following would be the most appropriate initial treatment for this patient’s condition?

• 1. A)  Oral dabigatran (Pradaxa), 75 mg twice daily

• 1. B)  Oral rivaroxaban (Xarelto), 15 mg twice daily for 14 days, then 20 mg daily

• 1. C)  Oral warfarin, 5 mg daily

• 1. D)  Subcutaneous enoxaparin (Lovenox), 70 mg daily

• 1. E)  Admission for intravenous heparin

ANSWER: D

This patient has an acute deep vein thrombosis (DVT) with no evidence of pulmonary embolism. Outpatient treatment would be appropriate and a low-molecular-weight heparin such as enoxaparin is a reasonable option in this patient. Renal dosing is the reason for daily, rather than twice-daily, dosing for enoxaparin. Dabigatran is not preferred due to a higher risk for bleeding. Direct oral anticoagulants such as rivaroxaban are not appropriate in this patient due to his glomerular filtration rate <30 mL/min/1.73 m2. Furthermore, the initial dose of rivaroxaban, 15 mg twice daily, should be 21 days, not 14 days. Warfarin is not recommended for the acute phase treatment of DVT in this patient. Admission for intravenous heparin is generally not indicated for uncomplicated DVT.
question stats: 

our % right: 30

national % right: 10

pgy1: 2

pgy2: 3

pgy3: 3

so, why did i miss this?
nitpicky question that leaves out half the treatment.
we would just use Eliquis anyways.....
normal kidney function 10mg bid x7d, then 5mg bid thereafter...
adjust dose for Scr > 1.5, age >80, wt <60kg (2 of 3 of these)

Multiple Choice

37. A 65-year-old male presents to your office with a 4-month history of ill-defined lower pelvic pain. He is afebrile. An abdominal examination is unremarkable. A digital rectal examination yields a boggy prostate with moderate tenderness. Urinalysis is positive for leukocyte esterase and 10–20 WBCs/hpf, and testing for common sexually transmitted infections is negative.

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

• 1. A)  Amoxicillin

• 1. B)  Ceftriaxone

• 1. C)  Ciprofloxacin

• 1. D)  CT of the abdomen and pelvis

• 1. E)  Referral to a urologist

ANSWER: C

This patient has chronic bacterial prostatitis (CBP) and should be treated with a fluoroquinolone. Fluoroquinolones are the first-line treatment for CBP because they favorably cover the common uropathogens that cause CBP, penetrate prostatic tissue well, and have high oral bioavailability. Amoxicillin and ceftriaxone are not preferred for the treatment of prostatitis. CT is not necessary to make the diagnosis. Referral to a urologist is unnecessary in this clinical scenario because the diagnosis and management of CBP is within the scope of family medicine.
question stats: 

our % right: 85

national % right: 65

pgy1: 7

pgy2: 9

pgy3: 7

so, why did i miss this?
didn't listen to dr. howell.

Multiple Choice

37. A 25-year-old male presents to the emergency department with a sudden onset of right-sided chest pain that started about 2 hours ago while he was resting and playing video games. He reports feeling slightly short of breath. He has no history of lung disease, and he smokes 1 pack of cigarettes per day. On examination he has a blood pressure of 120/80 mm Hg, a heart rate of 115 beats/min, a respiratory rate of 20/min, and an oxygen saturation of 90% on room air. A chest x-ray reveals a pneumothorax involving <10% of the lung space.

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

• 1. A)  Reassurance and discharge home with return precautions for worsening symptoms

• 1. B)  Initiation of oxygen via nasal cannula, and a repeat chest x-ray in 6 hours

• 1. C)  CT of the chest to verify x-ray findings

• 1. D)  Emergent needle decompression at the right second intercostal space in the anterior midclavicular line

• 1. E)  Placement of a chest tube at the right fourth or fifth intercostal space in the midaxillary to anterior axillary line

ANSWER: B

For patients who are stable with a small (<15% of the hemithoracic cavity) primary pneumothorax, conservative management with initiation of oxygen via nasal cannula and observation for at least 6 hours is recommended, followed by a repeat chest x-ray to assess for stability in size of the pneumothorax. If stable at 6 hours, patients can return home with a repeat follow-up in 24 hours. CT imaging can aid in diagnosis if the initial chest x-ray is nondiagnostic or equivocal; however, it is not needed to confirm definitive findings of pneumothorax on chest x-ray. Patients who are clinically unstable with a large pneumothorax or severe symptoms should receive emergent needle decompression, followed by an ipsilateral tube thoracostomy.
question stats: 

our % right: 67

national % right: 55

pgy1: 7

pgy2: 6

pgy3: 5

so, why did i miss this?
we dont' really deal with pneumothorax's very much and when we do they get a chest tube....

Multiple Choice

39. A 17-year-old female with well-controlled diabetes mellitus is brought to your office by her mother for a sports preparticipation physical evaluation prior to playing soccer. She has intermittent knee pain when running but no other symptoms.

    Which one of the following, if present in this patient, would be a CONTRAINDICATION to playing soccer?

• 1. A)  A BMI >30 kg/m2

• 1. B)  An enlarged spleen

• 1. C)  Insulin-dependent diabetes

• 1. D)  Mitral valve prolapse

• 1. E)  Tibial tubercle apophysitis

ANSWER: B

A sports preparticipation evaluation is important for assessing health risks and ensuring an athlete is not unnecessarily restricted from play. An athlete with an acutely enlarged spleen or liver faces an increased risk of organ rupture during contact sports. This patient should be evaluated for a cause of the organomegaly, if present, prior to participation.

Obesity in an athlete increases the risk for heat-related illness, but it is not an indication to restrict play. Exercise is beneficial for adolescents with diabetes mellitus and may require modification of insulin and eating regimens. Asymptomatic mild mitral valve prolapse is not a reason to deny participation. Tibial tubercle apophysitis is not a contraindication to play, and most experts encourage activity and conservative management.
question stats: 

our % right: 67

national % right: 87

pgy1: 6

pgy2: 6

pgy3: 6

so, why did i miss this?
forgot that soccer is a contact sport and that an enlarged spleen can get ruptured.

Multiple Choice

39. An otherwise healthy 26-year-old female presents to your clinic with a history of 3 episodes of vertigo occurring over the last week. Each episode lasts for several hours. During the episodes, she notes fullness in the right ear with tinnitus and hearing loss. She has not noticed anything specific that triggers the episodes, and reports consuming 1 glass of wine per night. She does not report headache, visual changes, fever, or upper respiratory symptoms. She is currently asymptomatic and a physical examination is unremarkable.

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

• 1. A)  Recommending a reduction in alcohol intake

• 1. B)  Performing the Epley maneuver

• 1. C)  Ordering audiometry

• 1. D)  Initiating oral hydrochlorothiazide, 25 mg daily

• 1. E)  Initiating oral prednisone, 20 mg daily for 5 days

ANSWER: C

Meniere disease is characterized by spontaneous recurring episodes of vertigo with associated unilateral hearing loss, tinnitus, and nystagmus. Even though there are no specific diagnostic tests, audiometry should be performed in patients suspected of having this condition. Sensorineural hearing loss may or may not be present on audiometric evaluation.

Acute attacks should be treated with medication such as promethazine, diazepam, or prochlorperazine to suppress vestibular function. Lifestyle interventions, including salt restriction and reduction in alcohol and caffeine intake, have traditionally been recommended. However, there is no sufficient evidence to support these recommendations. The Epley maneuver is a repositioning treatment used for benign paroxysmal positional vertigo and not Meniere disease. There is no good-quality evidence that diuretics, antivirals, or corticosteroids treat or prevent Meniere disease.
question stats: 

our % right: 11

national % right:18

pgy1: 1

pgy2: 0

pgy3: 2

so, why did i miss this?
we don't deal with meneire's much

Multiple Choice

39. A new lipid-lowering drug is being evaluated for its cardioprotective effects. The event rate for acute myocardial infarction is 0.085 in the low-intensity treatment group and 0.045 in the high-intensity treatment group, yielding an absolute risk reduction (ARR) of 0.04.

    Which one of the following is the number needed to treat (NNT)?

• 39. A) <1

• 39. B) 25

• 39. C) 40

• 39. D) 50

ANSWER: B

The number needed to treat (NNT) is the number of patients who need to receive a particular treatment in order for 1 patient to benefit. The NNT is the inverse of the absolute risk reduction (ARR), the amount by which a particular treatment reduces the risk of a negative outcome. The ARR must be calculated first in order to determine the NNT.

To calculate the ARR, the experimental event rate (EER) is subtracted from the control event rate (CER). In this example, the low-intensity treatment group had a risk of acute myocardial infarction (bad outcome) of 0.085 (CER) whereas the high-intensity treatment group had a risk of 0.045 (EER). This would make the equation: 0.085 – 0.045 = an ARR of 0.04. The NNT is then calculated by dividing 1 by the ARR: 1 / 0.04 = 25. This means that 25 patients would need to receive the high-intensity treatment to prevent 1 additional myocardial infarction.
question stats: 

our % right: 74

national % right: 72
pgy1: 6

pgy2: 7

pgy3: 7

so, why did i miss this?
didn't pay attention in EBM....

Multiple Choice

42. A 75-year-old female presents to your office with a 3-month history of episodes of lightheadedness on standing. Orthostatic blood pressure testing in your office reveals an initial blood pressure of 134/76 mm Hg that drops to 104/46 mm Hg on standing. A laboratory evaluation is unremarkable and review of her medications does not show an obvious cause for her symptoms. Echocardiography and tilt table testing are unremarkable. You diagnose orthostatic hypotension.

    Monotherapy with which one of the following would be indicated for the management of this patient's neurogenic orthostatic hypotension?

• 1. A)  Atomoxetine (Strattera)

• 1. B)  Fludrocortisone

• 1. C)  Methylphenidate (Ritalin)

• 1. D)  Midodrine

• 1. E)  Sodium bicarbonate

ANSWER: D

Midodrine has been found to be the safest and best-tolerated medication for the management of neurogenic orthostatic hypotension (SOR B). Atomoxetine is an adjunctive treatment for neurogenic orthostatic hypotension that is generally successful when added to medication such as midodrine, but it is not effective as monotherapy. Although fludrocortisone is sometimes used off-label for this indication, it should be used with caution because of the risk of left ventricular hypertrophy, renal failure, and hypokalemia. Methylphenidate has not been shown to have a role in the successful treatment of neurogenic orthostatic hypotension. Treatment with sodium tablets is usually inadequate, does not correct the neurogenic issue, and substantially increases the risk of hypernatremia and resultant renal injury.
question stats: 

our % right: 63

national % right: 77
pgy1: 5

pgy2: 7

pgy3: 5

so, why did i miss this?
didn't know how to treat OS...
focused too much on flourinef....

Multiple Choice

42. A 22-year-old female with a past medical history of type 1 diabetes presents to the emergency department with multiple bouts of vomiting. She says that she is not consistently adherent to her insulin regimen. She has a plasma glucose level of 350 mg/dL, elevated ketones, and high anion gap metabolic acidosis. Treatment for diabetic ketoacidosis is initiated with intravenous fluids and insulin therapy.

    Glucose should be added to this patient’s saline infusion when her plasma glucose levels reach which one of the following ranges?

• 1. A)  <150 mg/dL

• 1. B)  150–200 mg/dL

• 1. C)  201–250 mg/dL

• 1. D)  251–300 mg/dL

• 1. E)  301–350 mg/dL

ANSWER: C

The mainstay of treatment for diabetic ketoacidosis is intravenous fluid replacement and insulin therapy along with careful monitoring and frequent reassessment. Once plasma glucose levels reach 201–250 mg/dL, glucose should be added to the saline infusion to maintain plasma glucose levels in the 150–200 mg/dL range. Because acidosis and ketosis resolve more slowly than hyperglycemia, glucose needs to be added while insulin and saline therapy are continued.
question stats: 

our % right: 22

national % right: 31
pgy1: 4

pgy2: 1

pgy3: 1

so, why did i miss this?
didn't remember the dka protocol....

Multiple Choice

44. A 32-year-old female with a recent diagnosis of posttraumatic stress disorder presents to your clinic with difficulty sleeping. She recently left an abusive relationship and has been attending trauma-focused psychotherapy. She has found the psychotherapy helpful, but she continues to experience midsleep awakening due to hyperarousal and nightmares.

    Which one of the following would be the most appropriate treatment?

• 1. A)  Amitriptyline

• 1. B)  Mirtazapine (Remeron)

• 1. C)  Prazosin

• 1. D)  Risperidone (Risperdal)

• 1. E)  Temazepam (Restoril)

ANSWER: C

Prazosin is an α2-agonist that decreases sympathetic nervous tone during sleep and has been found to be helpful for midsleep awakening due to hyperarousal and nightmares in patients with posttraumatic stress disorder. Amitriptyline, mirtazapine, and risperidone have significant side-effect profiles and would not be appropriate initial treatments for this patient's sleep symptoms. Temazepam is a benzodiazepine and should be avoided if possible due to its potential for misuse and chronic long-term effects.
question stats: 

our % right: 81

national % right: 89
pgy1: 6

pgy2: 7

pgy3: 9

so, why did i miss this?
we really did not. we know how to deal with this.