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J Each of the numbered items is followed by lettered answers. Select the ONE lettered answer that is BEST in each case. ® _ al i= (+5) £ wn Item 1 (C) Empagliflozin w wo A 62-year-old man is evaluated in a follow-up appoint- (D) Metformin wn 72) ment for a 10-year history of low back and knee pain. ou = He reports trouble falling asleep at night and describes a Item 4 significant changes in his functional activity and social ie)

i= (+5) £ wn Item 1 (C) Empagliflozin w wo A 62-year-old man is evaluated in a follow-up appoint- (D) Metformin wn 72) ment for a 10-year history of low back and knee pain. ou = He reports trouble falling asleep at night and describes a Item 4 significant changes in his functional activity and social ie) interactions. He feels that his pain will never improve. A 58-year-old man is evaluated for a 6-month history of Current medications are acetaminophen and ibuprofen. persistent low back pain. The patient is a postal employee On physical examination, vital signs are normal. who first developed pain after lifting a heavy mailbag onto Range of motion is limited by pain at the lumbar spine and a truck. The pain is localized to the lumbar back, is bilat- knees bilaterally. eral, and does not radiate. An MRI obtained 3 months ago demonstrated minor disk herniations that did not corre-

interactions. He feels that his pain will never improve. A 58-year-old man is evaluated for a 6-month history of Current medications are acetaminophen and ibuprofen. persistent low back pain. The patient is a postal employee On physical examination, vital signs are normal. who first developed pain after lifting a heavy mailbag onto Range of motion is limited by pain at the lumbar spine and a truck. The pain is localized to the lumbar back, is bilat- knees bilaterally. eral, and does not radiate. An MRI obtained 3 months ago demonstrated minor disk herniations that did not corre- Which of the following is the most appropriate next step in spond to his area of pain. He has no other symptoms, and management? medical history is otherwise unremarkable. He continues to work. His only medication is naproxen for pain control. (A) Diazepam at bedtime On physical examination, vital signs are normal. BMI (B) Oral tramadol is 25. There is pain to palpation over the lumbar paraspinal (C) Screen for depression muscles. Range of motion with back flexion and extension is limited. Results of the straight leg raise test are negative (D) Spinal manipulation bilaterally. Lower extremity muscle strength and reflexes are normal.

(C) Screen for depression muscles. Range of motion with back flexion and extension is limited. Results of the straight leg raise test are negative (D) Spinal manipulation bilaterally. Lower extremity muscle strength and reflexes are normal. Item 2 Which of the following is the most appropriate treatment? A 44-year-old woman is evaluated during routine follow- up of type 2 diabetes mellitus. She also has hypertension. (A) Amitriptyline Current medications are metformin, canagliflozin, lisino- (B) Exercise therapy pril, and hydrochlorothiazide. (C) Gabapentin On physical examination, vital signs are normal. BMIis 26. Triglyceride level is 165 mg/dL (1.86 mmol/L). (D) Oxycodone Her 10-year risk for atherosclerotic cardiovascular (E) Surgical intervention disease is 3.8%. Using shared decision making, the patient opts to follow the recommendation of the American Heart Association/American College of Cardiology for cholesterol Item 5 management. A 59-year-old woman is evaluated for long-standing chronic pain due to rheumatoid arthritis associated with Which of the following is the most appropriate treatment? reduced overall functional status. She is in regular follow- up with a rheumatologist and a pain medicine specialist. (A) High-intensity rosuvastatin She recently started immediate-release oxycodone at a (B) Icosapent ethyl daily dose equal to 22.5 morphine milligram equivalents. (C) Moderate-intensity rosuvastatin Her Opioid Risk Tool score was 2, indicating low risk for

Item 2 Which of the following is the most appropriate treatment? A 44-year-old woman is evaluated during routine follow- up of type 2 diabetes mellitus. She also has hypertension. (A) Amitriptyline Current medications are metformin, canagliflozin, lisino- (B) Exercise therapy pril, and hydrochlorothiazide. (C) Gabapentin On physical examination, vital signs are normal. BMIis 26. Triglyceride level is 165 mg/dL (1.86 mmol/L). (D) Oxycodone Her 10-year risk for atherosclerotic cardiovascular (E) Surgical intervention disease is 3.8%. Using shared decision making, the patient opts to follow the recommendation of the American Heart Association/American College of Cardiology for cholesterol Item 5 management. A 59-year-old woman is evaluated for long-standing chronic pain due to rheumatoid arthritis associated with Which of the following is the most appropriate treatment? reduced overall functional status. She is in regular follow- up with a rheumatologist and a pain medicine specialist. (A) High-intensity rosuvastatin She recently started immediate-release oxycodone at a (B) Icosapent ethyl daily dose equal to 22.5 morphine milligram equivalents. (C) Moderate-intensity rosuvastatin Her Opioid Risk Tool score was 2, indicating low risk for (D) Omega-3 fatty acid supplements future opioid abuse. In addition to oxycodone, she takes meloxicam, etanercept, topical diclofenac, duloxetine, prednisone, and acetaminophen. Item 3 On physical examination, vital signs are normal.

(D) Omega-3 fatty acid supplements future opioid abuse. In addition to oxycodone, she takes meloxicam, etanercept, topical diclofenac, duloxetine, prednisone, and acetaminophen. Item 3 On physical examination, vital signs are normal. A 54-year-old man is evaluated for a 3-week history of Active synovitis and typical rheumatoid arthritis deformi- ties are seen in the hands, wrists, elbows, and feet. worsening bilateral lower extremity edema. He has no A urine drug screen before opioid initiation 2 months other symptoms. One month ago, he was diagnosed with ago was negative. hypertension. Other medical problems include dyslipid- emia and type 2 diabetes mellitus. Current medications are The patient requests a refill of her oxycodone prescrip- tion today. metformin, empagliflozin, atorvastatin, and amlodipine. On physical examination, vital signs are normal. BMI is 28. Bilateral lower extremity edema with pitting to the Which of the following is the most appropriate risk mid-tibia is present. Jugular venous pressure and heart mitigation step before refilling this patient’s opioid sounds are normal. prescription? Urinalysis results are normal. (A) Change oxycodone to an extended-release, once-daily formulation Which of the following is the most likely cause of the edema? (B) Order a urine drug screen (A) Amlodipine (C) Prescribe a naloxone rescue kit (B) Atorvastatin (D) Review the state prescription monitoring database 111

Salfifasessment Text rn & ah Item 6 Item 9 b wn A retrospective case-control study at a single rheuma- A 39-year-old man is evaluated for depression. Four wn oO tology center analyzed a new treatment for catastrophic months ago, he was diagnosed with grade III anaplastic wn wn antiphospholipid syndrome. The study included 50 women astrocytoma, which was treated with subtotal resection, 3 who received the new treatment and were matched against radiation, and adjuvant temozolomide. The average life @o = oP 50 women who received usual care. The patients receiving expectancy for patients with this tumor is 1.5 to 3 years. He = the new treatment were twice as likely to survive (OR, 0.51; describes depressed mood, anhedonia, difficulty with sleep oO wn rr 95% CI, 0.42-0.67). The statistical analysis controlled for initiation, fatigue, and difficultly with concentration that insurance status and age group. have persisted for the past month and significantly affected his quality of his life. He also reports feeling as ifhe is a bur- Which of the following is the most important threat to the den to his family, along with pervasive worry and anxiety. validity of this study’s conclusions? His medications are temozolomide and levetiracetam.

Salfifasessment Text rn & ah Item 6 Item 9 b wn A retrospective case-control study at a single rheuma- A 39-year-old man is evaluated for depression. Four wn oO tology center analyzed a new treatment for catastrophic months ago, he was diagnosed with grade III anaplastic wn wn antiphospholipid syndrome. The study included 50 women astrocytoma, which was treated with subtotal resection, 3 who received the new treatment and were matched against radiation, and adjuvant temozolomide. The average life @o = oP 50 women who received usual care. The patients receiving expectancy for patients with this tumor is 1.5 to 3 years. He = the new treatment were twice as likely to survive (OR, 0.51; describes depressed mood, anhedonia, difficulty with sleep oO wn rr 95% CI, 0.42-0.67). The statistical analysis controlled for initiation, fatigue, and difficultly with concentration that insurance status and age group. have persisted for the past month and significantly affected his quality of his life. He also reports feeling as ifhe is a bur- Which of the following is the most important threat to the den to his family, along with pervasive worry and anxiety. validity of this study’s conclusions? His medications are temozolomide and levetiracetam. (A) Confounding bias Which of the following is the most appropriate treatment? (B) Lack of statistical power (A) Lorazepam (C) Patients lost to follow-up (B) Methylphenidate (D) Rarity of catastrophic antiphospholipid syndrome (C) Olanzapine (D) Sertraline Item 7 A 74-year-old man is evaluated for right posterior hip pain that has worsened over the past 6 months. He points to the Item 10 middle of his right buttock to indicate the location of the A 36-year-old woman is evaluated for a 10-year history pain. The pain worsens with prolonged standing or walk- of fluctuating, migratory burning pain and paresthe- ing long distances. He has no pain at rest or at night, and sia involving multiple parts of her body. Her symptoms the pain does not radiate. He is otherwise well and takes are stable but disruptive. She has previously undergone acetaminophen for pain. extensive evaluation, with normal results. She has tried On physical examination, vital signs are normal. BMI nortriptyline, gabapentin, pregabalin, and topical lido- is 28. The patient has no pain with passive or active hip caine without benefit. Medical history is significant for movement. The FADIR (Flexion, ADduction, and Internal migraine, temporomandibular joint dysfunction, and Rotation) test is painless, with normal range of motion. The irritable bowel syndrome. Results of recent screening for FABER (Flexion, ABduction, and External Rotation) test depression and generalized anxiety disorder were neg- reproduces the posterior hip pain. ative. Current medications are duloxetine, propranolol, and sumatriptan. Which of the following is the most likely diagnosis? Vital signs and findings on general and neurologic examinations are normal. (A) Acetabular labrum tear Review of the electronic health record documents (B) Greater trochanteric pain syndrome normal complete blood count, electrolytes, liver enzymes, (C) Osteoarthritis of the hip vitamin B,, thyroid-stimulating hormone, fasting glucose, (D) Sacroiliac joint dysfunction and serum protein electrophoresis. Results of electromyography and skin biopsy for small nerve fiber neuropathy are normal. Item 8 A 79-year-old man is evaluated for dyspnea that has been Which of the following is the most appropriate worsening insidiously over the past year. He has an 8-year management? history of severe COPD, with no exacerbations in the past (A) Cognitive behavioral therapy year. He reports occasional cough with scant white sputum (B) MRI of the spine production. Medications are inhaled aclidinium, inhaled formoterol, and inhaled fluticasone propionate. He dis- (C) Oxycodone plays good inhaler technique. (D) Urine and plasma porphyrin measurement On physical examination, vital signs are normal, and oxygen saturation is 94% breathing ambient air at rest and with ambulation. Breath sounds are diminished bilaterally; Item 11 other findings are normal. A 67-year-old man is evaluated at hospital discharge after a myocardial infarction. He is an active smoker with a Which of the following is the most appropriate treatment? 35-pack-year smoking history. He has never tried to quit smoking but is willing to try now. Medications are metop- (A) Azithromycin rolol, lisinopril, rosuvastatin, and aspirin. (B) Continuous oxygen therapy The patient is willing to participate in a smoking (C) Nebulized saline cessation clinic or use a telephone quit line support and (D) Pulmonary rehabilitation counseling service.

(A) Confounding bias Which of the following is the most appropriate treatment? (B) Lack of statistical power (A) Lorazepam (C) Patients lost to follow-up (B) Methylphenidate (D) Rarity of catastrophic antiphospholipid syndrome (C) Olanzapine (D) Sertraline Item 7 A 74-year-old man is evaluated for right posterior hip pain that has worsened over the past 6 months. He points to the Item 10 middle of his right buttock to indicate the location of the A 36-year-old woman is evaluated for a 10-year history pain. The pain worsens with prolonged standing or walk- of fluctuating, migratory burning pain and paresthe- ing long distances. He has no pain at rest or at night, and sia involving multiple parts of her body. Her symptoms the pain does not radiate. He is otherwise well and takes are stable but disruptive. She has previously undergone acetaminophen for pain. extensive evaluation, with normal results. She has tried On physical examination, vital signs are normal. BMI nortriptyline, gabapentin, pregabalin, and topical lido- is 28. The patient has no pain with passive or active hip caine without benefit. Medical history is significant for movement. The FADIR (Flexion, ADduction, and Internal migraine, temporomandibular joint dysfunction, and Rotation) test is painless, with normal range of motion. The irritable bowel syndrome. Results of recent screening for FABER (Flexion, ABduction, and External Rotation) test depression and generalized anxiety disorder were neg- reproduces the posterior hip pain. ative. Current medications are duloxetine, propranolol, and sumatriptan. Which of the following is the most likely diagnosis? Vital signs and findings on general and neurologic examinations are normal. (A) Acetabular labrum tear Review of the electronic health record documents (B) Greater trochanteric pain syndrome normal complete blood count, electrolytes, liver enzymes, (C) Osteoarthritis of the hip vitamin B,, thyroid-stimulating hormone, fasting glucose, (D) Sacroiliac joint dysfunction and serum protein electrophoresis. Results of electromyography and skin biopsy for small nerve fiber neuropathy are normal. Item 8 A 79-year-old man is evaluated for dyspnea that has been Which of the following is the most appropriate worsening insidiously over the past year. He has an 8-year management? history of severe COPD, with no exacerbations in the past (A) Cognitive behavioral therapy year. He reports occasional cough with scant white sputum (B) MRI of the spine production. Medications are inhaled aclidinium, inhaled formoterol, and inhaled fluticasone propionate. He dis- (C) Oxycodone plays good inhaler technique. (D) Urine and plasma porphyrin measurement On physical examination, vital signs are normal, and oxygen saturation is 94% breathing ambient air at rest and with ambulation. Breath sounds are diminished bilaterally; Item 11 other findings are normal. A 67-year-old man is evaluated at hospital discharge after a myocardial infarction. He is an active smoker with a Which of the following is the most appropriate treatment? 35-pack-year smoking history. He has never tried to quit smoking but is willing to try now. Medications are metop- (A) Azithromycin rolol, lisinopril, rosuvastatin, and aspirin. (B) Continuous oxygen therapy The patient is willing to participate in a smoking (C) Nebulized saline cessation clinic or use a telephone quit line support and (D) Pulmonary rehabilitation counseling service. 112

Self-Assassnvant Text abet Which of the following is the most appropriate additional ECG reveals left ventricular hypertrophy. o fom treatment? et = o Which of the following is the most appropriate management? (A) Bupropion = wn (B) Nicotine patch (A) Ambulatory ECG monitoring wn Y rn (C) Nortriptyline (B) Inpatient cardiac monitoring nr (D) Varenicline (C) Tilt-table testing = = (D) Reassurance and discharge home oa nr

(D) Varenicline (C) Tilt-table testing = = (D) Reassurance and discharge home oa nr ltem 12 An 87-year-old woman is evaluated for a 1-year history of Item 15 bothersome insomnia. She reports taking up to 2 hours to A 79-year-old man is evaluated for an 8-month history of fall asleep. She also feels that her sleep is less refreshing. She forgetfulness, memory loss, and confusion. He is a retired wakes up early in the morning without setting an alarm and banker. He is widowed, lives alone, and independently sometimes takes 20-minute naps during the day. She has no managed his own affairs until recently. His daughter now other sleep-related symptoms, no current mood concerns, helps with paying bills and shopping. and no history of depression. She is otherwise healthy. On physical examination, vital signs are normal. BMI is 25 and unchanged from his last visit. Screening physical Which of the following is the most appropriate treatment? examination, including neurologic examination, is nor- (A) Cognitive behavioral therapy for insomnia mal. Screen for depression is negative.

ltem 12 An 87-year-old woman is evaluated for a 1-year history of Item 15 bothersome insomnia. She reports taking up to 2 hours to A 79-year-old man is evaluated for an 8-month history of fall asleep. She also feels that her sleep is less refreshing. She forgetfulness, memory loss, and confusion. He is a retired wakes up early in the morning without setting an alarm and banker. He is widowed, lives alone, and independently sometimes takes 20-minute naps during the day. She has no managed his own affairs until recently. His daughter now other sleep-related symptoms, no current mood concerns, helps with paying bills and shopping. and no history of depression. She is otherwise healthy. On physical examination, vital signs are normal. BMI is 25 and unchanged from his last visit. Screening physical Which of the following is the most appropriate treatment? examination, including neurologic examination, is nor- (A) Cognitive behavioral therapy for insomnia mal. Screen for depression is negative. (B) Diphenhydramine Which of the following is the most appropriate test to (C) Gabapentin perform next? (D) Melatonin (E) Pramipexole (A) Apolipoprotein-E (ApoE-e4) allele testing (B) CT of the head without contrast (C) Fluorodeoxyglucose PET ltem 13 (D) Mini-Cog testing A 59-year-old man undergoes follow-up evaluation for persistent major depressive disorder of several years’ dura- tion. He is currently being treated with venlafaxine; he Item 16 previously took fluoxetine titrated to the maximum dosage A 70-year-old woman is evaluated for pain in the left before it was tapered off owing to lack of response and intolerable sexual side effects. He also takes aripiprazole great toe that has been present for 5 years and has steadily

(B) Diphenhydramine Which of the following is the most appropriate test to (C) Gabapentin perform next? (D) Melatonin (E) Pramipexole (A) Apolipoprotein-E (ApoE-e4) allele testing (B) CT of the head without contrast (C) Fluorodeoxyglucose PET ltem 13 (D) Mini-Cog testing A 59-year-old man undergoes follow-up evaluation for persistent major depressive disorder of several years’ dura- tion. He is currently being treated with venlafaxine; he Item 16 previously took fluoxetine titrated to the maximum dosage A 70-year-old woman is evaluated for pain in the left before it was tapered off owing to lack of response and intolerable sexual side effects. He also takes aripiprazole great toe that has been present for 5 years and has steadily and receives psychotherapy. He reports no improvement worsened. The pain is exacerbated by standing for long periods and wearing shoes with higher heels. At times the in his symptoms, which do not include mania or hypo- mania. He has not had suicidal ideation. He has no other toe becomes inflamed, and throbbing pain may persist throughout the day and night. Oral and topical NSAIDs do medical conditions and takes no other medications. On physical examination, vital signs are normal. He not help. She is otherwise well and takes no medications. appears tired, with a sad, blunted affect. Score on the Findings on physical examination are shown. No pal- PHQ-9 is 17, unchanged from his previous score. pable masses or interdigital clicks are observed when the foot is compressed.

appears tired, with a sad, blunted affect. Score on the Findings on physical examination are shown. No pal- PHQ-9 is 17, unchanged from his previous score. pable masses or interdigital clicks are observed when the foot is compressed. Which of the following is the most appropriate treatment? (A) Add intranasal esketamine (B) Add lithium (C) Discontinue aripiprazole and initiate risperidone (D) Discontinue venlafaxine and initiate sertraline Item 14 A 62-year-old man is evaluated in the emergency depart- ment for syncope while playing basketball 1 hour earlier. The syncopal event lasted approximately 30 seconds as reported by his grandson. He had no symptoms before the event, and he experienced only fatigue afterward. Medical history is significant for hyperlipidemia. His only medica- tion is moderate-intensity rosuvastatin. On physical examination, blood pressure is 101/62 mm Hg, and pulse rate is 58/min. A late-peaking, grade 4/6 systolic murmur is best heard at the right upper sternal border, with radiation to the carotid arteries. 113

Self-Assessment Test rn © On physical examination, vital signs are normal. ah Which of the following is the most likely diagnosis? b= There is swelling of the entire wrist. Pain is elicited with wn wn (A) Avascular necrosis of the metatarsal head palpation of the anatomic snuffbox. The remainder of the Oo 72) (B) Bunion examination is unremarkable. wn =] (C) Morton neuroma Radiographs of the hand and wrist are negative for oO fracture. s (D) Stress fracture - = oO n Which of the following is the most appropriate next step in vr Item 17 management?

=] (C) Morton neuroma Radiographs of the hand and wrist are negative for oO fracture. s (D) Stress fracture - = oO n Which of the following is the most appropriate next step in vr Item 17 management? A 79-year-old man is evaluated in the emergency depart- Bone scintigraphy of the right wrist ment for a 30-hour history of dizziness. He describes a con- oS BE MRI of the right wrist stant “room spinning” sensation that is worse with position eS Repeat radiography in 2 weeks changes and when he tries to ambulate. Symptoms are asso ciated with nausea, and he has vomited twice. He reports no wh@ —_—~_ Splinting alone change in hearing, tinnitus, or recent viral symptoms. The eh & Reassurance and acetaminophen patient has a history of hypertension and hyperlipidemia. Medications are amlodipine, enalapril, and atorvastatin. On physical examination, blood pressure is 156/92 mm Item 20 Hg, and pulse rate is 84/min; other vital signs are normal. A published systematic review and meta-analysis assessed. The patient is ataxic. HINTS (Head Impulse, Nystagmus, the effect of a new biologic agent for treatment of metastatic and Test of Skew) examination is positive only for the pres- appendiceal adenocarcinoma. Six randomized controlled ence of vertical skew. trials met the inclusion criteria for the systematic review. The largest of these demonstrated a statistically signifi- Which of the following is the most appropriate next step in cant benefit associated with the new biologic agent. Three management? smaller trials showed a trend toward benefit that was not (A) Audiometry significant, and two trials showed a nonsignificant trend (B) Canalith repositioning maneuver toward no benefit. In the trials that showed no benefit, the disease was considerably more advanced and patients had (C) Meclizine poorer performance status. Studies demonstrating trend (D) MRI of the brain toward benefit varied regarding inclusion of patients previ- (E) Vestibular and balance rehabilitation therapy ously treated with other agents. The meta-analysis showed a beneficial treatment effect (P= 0.048).

A 79-year-old man is evaluated in the emergency depart- Bone scintigraphy of the right wrist ment for a 30-hour history of dizziness. He describes a con- oS BE MRI of the right wrist stant “room spinning” sensation that is worse with position eS Repeat radiography in 2 weeks changes and when he tries to ambulate. Symptoms are asso ciated with nausea, and he has vomited twice. He reports no wh@ —_—~_ Splinting alone change in hearing, tinnitus, or recent viral symptoms. The eh & Reassurance and acetaminophen patient has a history of hypertension and hyperlipidemia. Medications are amlodipine, enalapril, and atorvastatin. On physical examination, blood pressure is 156/92 mm Item 20 Hg, and pulse rate is 84/min; other vital signs are normal. A published systematic review and meta-analysis assessed. The patient is ataxic. HINTS (Head Impulse, Nystagmus, the effect of a new biologic agent for treatment of metastatic and Test of Skew) examination is positive only for the pres- appendiceal adenocarcinoma. Six randomized controlled ence of vertical skew. trials met the inclusion criteria for the systematic review. The largest of these demonstrated a statistically signifi- Which of the following is the most appropriate next step in cant benefit associated with the new biologic agent. Three management? smaller trials showed a trend toward benefit that was not (A) Audiometry significant, and two trials showed a nonsignificant trend (B) Canalith repositioning maneuver toward no benefit. In the trials that showed no benefit, the disease was considerably more advanced and patients had (C) Meclizine poorer performance status. Studies demonstrating trend (D) MRI of the brain toward benefit varied regarding inclusion of patients previ- (E) Vestibular and balance rehabilitation therapy ously treated with other agents. The meta-analysis showed a beneficial treatment effect (P= 0.048). Item 18 Which of the following is the most important limitation to A 49-year-old man is evaluated for increasing abdominal this meta-analysis? pain in the right upper quadrant and epigastrium. He was (A) Confounding diagnosed 6 weeks ago with metastatic cholangiocarci- noma. He rates his pain intensity as 7 out of 10 and reports (B) Heterogeneity

Item 18 Which of the following is the most important limitation to A 49-year-old man is evaluated for increasing abdominal this meta-analysis? pain in the right upper quadrant and epigastrium. He was (A) Confounding diagnosed 6 weeks ago with metastatic cholangiocarci- noma. He rates his pain intensity as 7 out of 10 and reports (B) Heterogeneity that it is now interfering with sleep. After his diagnosis, (C) Lack of power he was started on immediate-release morphine sulfate (D) Random error and noted an initial reduction in his pain. Over the past 2 weeks, he reports taking an average of five to six doses per day, waking up from sleep with pain, and noticing sig- Item 21 nificant escalation of his pain 3 hours after a dose. He also A 68-year-old man is evaluated in the emergency depart- takes polyethylene glycol. ment for worsening of chronic right hip pain and difficulty walking over the past 3 days. The pain is most intense in the Which of the following is the most appropriate adjustment posterior hip and buttocks and is nonradiating. It worsens to this patient’s pain treatment? with rising from a chair, ambulation, and prolonged stand- (A) Add duloxetine ing; it improves with lying down. On physical examination, vital signs are normal. (B) Add tramadol BMI is 30. Antalgic gait, pain in the buttocks with FADIR (C) Change morphine sulfate to oxycodone (Flexion, ADduction, and Internal Rotation) testing of the (D) Start sustained-release morphine sulfate right hip, and reduced active flexion are observed. No pain is elicited with palpation of the lumbar spine or over the sacroiliac joints. The remainder of the physical examina- Item 19 tion is normal. A 27-year-old man is evaluated for acute-onset pain on the radial aspect of the right wrist accompanied by stiff- Which of the following is the most likely diagnosis? ness and swelling. The patient fell onto outstretched hands while skiing yesterday. He reports no numbness or tingling (A) Acetabular labrum injury in the hand or fingers. He takes no medications. (B) Hip osteoarthritis

that it is now interfering with sleep. After his diagnosis, (C) Lack of power he was started on immediate-release morphine sulfate (D) Random error and noted an initial reduction in his pain. Over the past 2 weeks, he reports taking an average of five to six doses per day, waking up from sleep with pain, and noticing sig- Item 21 nificant escalation of his pain 3 hours after a dose. He also A 68-year-old man is evaluated in the emergency depart- takes polyethylene glycol. ment for worsening of chronic right hip pain and difficulty walking over the past 3 days. The pain is most intense in the Which of the following is the most appropriate adjustment posterior hip and buttocks and is nonradiating. It worsens to this patient’s pain treatment? with rising from a chair, ambulation, and prolonged stand- (A) Add duloxetine ing; it improves with lying down. On physical examination, vital signs are normal. (B) Add tramadol BMI is 30. Antalgic gait, pain in the buttocks with FADIR (C) Change morphine sulfate to oxycodone (Flexion, ADduction, and Internal Rotation) testing of the (D) Start sustained-release morphine sulfate right hip, and reduced active flexion are observed. No pain is elicited with palpation of the lumbar spine or over the sacroiliac joints. The remainder of the physical examina- Item 19 tion is normal. A 27-year-old man is evaluated for acute-onset pain on the radial aspect of the right wrist accompanied by stiff- Which of the following is the most likely diagnosis? ness and swelling. The patient fell onto outstretched hands while skiing yesterday. He reports no numbness or tingling (A) Acetabular labrum injury in the hand or fingers. He takes no medications. (B) Hip osteoarthritis 114

Sel seseoeene Test stant (C) Lumbar radiculopathy Which of the following is the most appropriate additional ct — eee (D) Sacroiliac joint dysfunction treatment? a w (A) Colchicine = wn B) Ezetimibe wn Item 22 is) v2) C) High-intensity rosuvastatin 2) A 58-year-old woman is evaluated in the emergency =f department within 1 hour of syncope that occurred while D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) =

(A) Colchicine = wn B) Ezetimibe wn Item 22 is) v2) C) High-intensity rosuvastatin 2) A 58-year-old woman is evaluated in the emergency =f department within 1 hour of syncope that occurred while D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) = she was waiting in the grocery checkout line. She experi- inhibitor a rn enced a sensation of warmth and lightheadedness before the event. She did not have chest pain, shortness of breath, or palpitations. She reports no trauma. She recovered Item 25 quickly and recalls the episode. Medical history is signifi- A 28-year-old woman is evaluated during a follow-up visit. cant for hypertension, hyperlipidemia, and type 2 diabetes Six weeks ago, she was diagnosed with her first episode of mellitus. Current medications are lisinopril, hydrochloro- major depressive disorder. Her score on the PHQ-9 was thiazide, rosuvastatin, and metformin. 14. Low-dose fluoxetine was initiated. At a follow-up visit On physical examination, cardiovascular auscultation 2 weeks later, she was tolerating the medication with no and neurologic examination are normal. significant side effects, and her PHQ-9 score was 10; flu- An ECG is normal. oxetine dosage was increased. Two weeks after the dosage increase, her PHQ-9 score was 7. The dosage of fluoxetine Which of the following is the most appropriate diagnostic was again increased, and today her PHQ-9 score is 4. She test to perform next? has no other medical or psychiatric problems and takes no (A) Cardiac enzyme testing other medications.

she was waiting in the grocery checkout line. She experi- inhibitor a rn enced a sensation of warmth and lightheadedness before the event. She did not have chest pain, shortness of breath, or palpitations. She reports no trauma. She recovered Item 25 quickly and recalls the episode. Medical history is signifi- A 28-year-old woman is evaluated during a follow-up visit. cant for hypertension, hyperlipidemia, and type 2 diabetes Six weeks ago, she was diagnosed with her first episode of mellitus. Current medications are lisinopril, hydrochloro- major depressive disorder. Her score on the PHQ-9 was thiazide, rosuvastatin, and metformin. 14. Low-dose fluoxetine was initiated. At a follow-up visit On physical examination, cardiovascular auscultation 2 weeks later, she was tolerating the medication with no and neurologic examination are normal. significant side effects, and her PHQ-9 score was 10; flu- An ECG is normal. oxetine dosage was increased. Two weeks after the dosage increase, her PHQ-9 score was 7. The dosage of fluoxetine Which of the following is the most appropriate diagnostic was again increased, and today her PHQ-9 score is 4. She test to perform next? has no other medical or psychiatric problems and takes no (A) Cardiac enzyme testing other medications. (B) CT of the head (C) Orthostatic blood pressure measurement Which of the following is the most appropriate management? (D) Transthoracic echocardiography (A) Add cognitive behavioral therapy (B) Continue fluoxetine at half the current dosage for Item 23 6 months A 56-year-old man is evaluated during a routine follow-up (C) Continue fluoxetine at the current dosage for appointment. He has schizophrenia treated with olanza- 6 months pine. Currently, the patient experiences no hallucinations (D) Stop fluoxetine or delusions. He is otherwise healthy. Previous ECGs have been normal. On physical examination, vital signs are normal. BMI is 27. The examination shows flat affect. Speech is normal, Item 26 and thoughts appear organized. A 20-year-old woman is evaluated at a follow-up A fasting blood glucose measurement is pending. appointment for a 6-month history of disordered eat- ing. She describes an intermittent uncontrollable urge Which of the following should also be monitored in this to eat large amounts of food. When this occurs, she rap- patient? idly consumes substantially more food than most people

(B) CT of the head (C) Orthostatic blood pressure measurement Which of the following is the most appropriate management? (D) Transthoracic echocardiography (A) Add cognitive behavioral therapy (B) Continue fluoxetine at half the current dosage for Item 23 6 months A 56-year-old man is evaluated during a routine follow-up (C) Continue fluoxetine at the current dosage for appointment. He has schizophrenia treated with olanza- 6 months pine. Currently, the patient experiences no hallucinations (D) Stop fluoxetine or delusions. He is otherwise healthy. Previous ECGs have been normal. On physical examination, vital signs are normal. BMI is 27. The examination shows flat affect. Speech is normal, Item 26 and thoughts appear organized. A 20-year-old woman is evaluated at a follow-up A fasting blood glucose measurement is pending. appointment for a 6-month history of disordered eat- ing. She describes an intermittent uncontrollable urge Which of the following should also be monitored in this to eat large amounts of food. When this occurs, she rap- patient? idly consumes substantially more food than most people e would consume and eats until she is uncomfortably full, Complete blood count sometimes when she does not feel hungry. She reports Lipid levels feeling embarrassed and remorseful about these epi- Liver chemistries sodes. She does not vomit or self-induce vomiting. She Prolactin level has been treated with cognitive behavioral therapy and SEas QT interval citalopram, which has reduced the frequency of binge eating, but the symptoms persist. She is concerned about her weight gain. She is otherwise healthy and takes no Item 24 additional medications. On physical examination, BMI is 29. Vital signs and A 64-year-old man is seen as a new patient. He is asymp- other findings are normal. tomatic. He has not received medical care since a myocar- dial infarction 7 months ago. He does not exercise and quit smoking 5 years ago. Which of the following is the most appropriate next step in On physical examination, blood pressure is 138/82 mm treatment? Hg. BMI is 28. Other physical examination findings are (A) Admission to an inpatient facility specializing in eating normal. disorders Hospital records are requested. Counseling on life- style modification is provided. Laboratory tests are sched- (B) Fluoxetine uled. Metoprolol and aspirin are initiated, and a follow-up (C) Lisdexamfetamine appointment is scheduled. (D) Monitored dietary intake

e would consume and eats until she is uncomfortably full, Complete blood count sometimes when she does not feel hungry. She reports Lipid levels feeling embarrassed and remorseful about these epi- Liver chemistries sodes. She does not vomit or self-induce vomiting. She Prolactin level has been treated with cognitive behavioral therapy and SEas QT interval citalopram, which has reduced the frequency of binge eating, but the symptoms persist. She is concerned about her weight gain. She is otherwise healthy and takes no Item 24 additional medications. On physical examination, BMI is 29. Vital signs and A 64-year-old man is seen as a new patient. He is asymp- other findings are normal. tomatic. He has not received medical care since a myocar- dial infarction 7 months ago. He does not exercise and quit smoking 5 years ago. Which of the following is the most appropriate next step in On physical examination, blood pressure is 138/82 mm treatment? Hg. BMI is 28. Other physical examination findings are (A) Admission to an inpatient facility specializing in eating normal. disorders Hospital records are requested. Counseling on life- style modification is provided. Laboratory tests are sched- (B) Fluoxetine uled. Metoprolol and aspirin are initiated, and a follow-up (C) Lisdexamfetamine appointment is scheduled. (D) Monitored dietary intake 115

Self-Assessment Test 172) 2. =i Item 27 Which of the following is the most appropriate management > of this patient? 7) wn A 78-year-old woman is evaluated for a nonhealing Oo wn venous ulcer on the medial aspect of the right ankle that (A) Continue care in the hospital until she is able to 72) has been present, unchanging, for 6 months. She reports ambulate safely 3 no fever. She has no other medical problems and takes no oO (B) Discharge home with home physical and occupational = medications. Cal therapy On physical examination, vital signs are normal. BMI o (C) Discharge to a skilled nursing facility 2) - is 28. A shallow, exudative, nonpainful ulcer is located above the right medial malleolus. There is no surrounding (D) Discharge to an acute rehabilitation hospital erythema. Hyperpigmentation, varicosities, and edema are seen in both lower extremities. Item 30 Ankle-brachial index measurement on the right is 0.9. A 62-year-old woman is evaluated for slowly progressive Wound care is initiated. swelling of the right posterior elbow of 3 days’ duration. She works as a gardener. The patient has no chronic medi- Which of the following is the most appropriate additional cal conditions. She takes no medications. treatment? On physical examination, vital signs are normal. The (A) Cephalexin posterior aspect of the right elbow is swollen and slightly tender to palpation. No warmth, drainage, or other skin (B) Compression therapy changes are noted. Range of motion of the right elbow is (C) Honey normal. There are no other joint abnormalities. (D) Topical hydrogen peroxide (E) Topical povidone-iodine Which of the following is the most appropriate management?

172) 2. =i Item 27 Which of the following is the most appropriate management > of this patient? 7) wn A 78-year-old woman is evaluated for a nonhealing Oo wn venous ulcer on the medial aspect of the right ankle that (A) Continue care in the hospital until she is able to 72) has been present, unchanging, for 6 months. She reports ambulate safely 3 no fever. She has no other medical problems and takes no oO (B) Discharge home with home physical and occupational = medications. Cal therapy On physical examination, vital signs are normal. BMI o (C) Discharge to a skilled nursing facility 2) - is 28. A shallow, exudative, nonpainful ulcer is located above the right medial malleolus. There is no surrounding (D) Discharge to an acute rehabilitation hospital erythema. Hyperpigmentation, varicosities, and edema are seen in both lower extremities. Item 30 Ankle-brachial index measurement on the right is 0.9. A 62-year-old woman is evaluated for slowly progressive Wound care is initiated. swelling of the right posterior elbow of 3 days’ duration. She works as a gardener. The patient has no chronic medi- Which of the following is the most appropriate additional cal conditions. She takes no medications. treatment? On physical examination, vital signs are normal. The (A) Cephalexin posterior aspect of the right elbow is swollen and slightly tender to palpation. No warmth, drainage, or other skin (B) Compression therapy changes are noted. Range of motion of the right elbow is (C) Honey normal. There are no other joint abnormalities. (D) Topical hydrogen peroxide (E) Topical povidone-iodine Which of the following is the most appropriate management? (A) Bursa aspiration ltem 28 (B) Glucocorticoid injection A 50-year-old man is evaluated for lateral right knee pain (C) Joint aspiration that worsens after long runs. (D) Rest, ice, and protection On physical examination, pain occurs with palpation (E) Surgical drainage over the lateral femoral condyle and lower thigh. There is no pain with palpation over the patella or pain with squat- ting. The patient’s pain is reproduced with flexion and Item 31 extension of the patient’s right knee with the examiner’s A 31-year-old man is evaluated for persistent difficulties thumb over the lateral femoral condyle. at work related to intermittent flashbacks of a near-death experience during a tour of duty in Iraq years ago. These Which of the following is the most likely diagnosis? flashbacks occur without warning during the day and at night, with associated palpitations, diaphoresis, and severe (A) Iliotibial band syndrome anxiety. The unpredictable nature of the flashbacks has (B) Lateral meniscal injury caused generalized anxiety throughout the day, difficulty (C) Patellofemoral pain syndrome with sleep initiation, and a desire to avoid being at work (D) Popliteal tendinopathy because he is afraid of his response to having a flashback in public. He does not drink alcohol. The patient is referred for cognitive behavioral therapy. Item 29 A 74-year-old woman is evaluated before hospital dis- Which of the following is the most appropriate additional charge. She was hospitalized 3 days ago for surgical treatment? repair of a left hip fracture after a fall. She has been (A) Lorazepam evaluated by physical and occupational therapists and (B) Medical cannabis is thought to be unsafe for discharge home, where she lives alone, because of her inability to safely stand with a (C) Prazosin walker and ambulate in the hospital room. Her tolerance (D) Sertraline for physical therapy is estimated to be less than 3 hours per day. Medical history is significant for hypertension and prior stroke with residual right-sided weakness. She Item 32 required a cane to ambulate before the fall. Medications A 68-year-old woman is evaluated for involuntary urine are aspirin, amlodipine, atorvastatin, and acetamino- loss that occurs with coughing, sneezing, and laughing and phen as needed for pain. occasionally with physical exertion. She has no dysuria, On physical examination, blood pressure is 130/80 mm urinary frequency, hematuria, or nocturia but does report Hg and pulse rate is 78/min. Physical examination confirms vaginal dryness and dyspareunia. She performs pelvic floor the findings of the physical and occupational therapists muscle training exercises four times daily. and reveals frailty and right-sided arm and leg weakness. On physical examination, vital signs are normal. BMI There is a healing surgical incision on the left hip. is 22. Pelvic examination reveals vaginal atrophy. Mild

(A) Bursa aspiration ltem 28 (B) Glucocorticoid injection A 50-year-old man is evaluated for lateral right knee pain (C) Joint aspiration that worsens after long runs. (D) Rest, ice, and protection On physical examination, pain occurs with palpation (E) Surgical drainage over the lateral femoral condyle and lower thigh. There is no pain with palpation over the patella or pain with squat- ting. The patient’s pain is reproduced with flexion and Item 31 extension of the patient’s right knee with the examiner’s A 31-year-old man is evaluated for persistent difficulties thumb over the lateral femoral condyle. at work related to intermittent flashbacks of a near-death experience during a tour of duty in Iraq years ago. These Which of the following is the most likely diagnosis? flashbacks occur without warning during the day and at night, with associated palpitations, diaphoresis, and severe (A) Iliotibial band syndrome anxiety. The unpredictable nature of the flashbacks has (B) Lateral meniscal injury caused generalized anxiety throughout the day, difficulty (C) Patellofemoral pain syndrome with sleep initiation, and a desire to avoid being at work (D) Popliteal tendinopathy because he is afraid of his response to having a flashback in public. He does not drink alcohol. The patient is referred for cognitive behavioral therapy. Item 29 A 74-year-old woman is evaluated before hospital dis- Which of the following is the most appropriate additional charge. She was hospitalized 3 days ago for surgical treatment? repair of a left hip fracture after a fall. She has been (A) Lorazepam evaluated by physical and occupational therapists and (B) Medical cannabis is thought to be unsafe for discharge home, where she lives alone, because of her inability to safely stand with a (C) Prazosin walker and ambulate in the hospital room. Her tolerance (D) Sertraline for physical therapy is estimated to be less than 3 hours per day. Medical history is significant for hypertension and prior stroke with residual right-sided weakness. She Item 32 required a cane to ambulate before the fall. Medications A 68-year-old woman is evaluated for involuntary urine are aspirin, amlodipine, atorvastatin, and acetamino- loss that occurs with coughing, sneezing, and laughing and phen as needed for pain. occasionally with physical exertion. She has no dysuria, On physical examination, blood pressure is 130/80 mm urinary frequency, hematuria, or nocturia but does report Hg and pulse rate is 78/min. Physical examination confirms vaginal dryness and dyspareunia. She performs pelvic floor the findings of the physical and occupational therapists muscle training exercises four times daily. and reveals frailty and right-sided arm and leg weakness. On physical examination, vital signs are normal. BMI There is a healing surgical incision on the left hip. is 22. Pelvic examination reveals vaginal atrophy. Mild 116

: Self-Assessment Test as 4 to 5 days before the onset of menses and include feeling o leakage of urine occurs during the pelvic examination with — emt bearing down. tense, unusually anxious, and unhappy. She also experi- = C<F) ences increased irritability, angry outbursts, breast pain and = Which of the following is the most appropriate management? bloating, and insomnia. She describes her mood in between wn wn menses as “generally good.” Medical history is significant ao (A) Oral estradiol for migraine with aura, for which she takes sumatriptan as wn wn =< (B) Oxybutynin needed. An intrauterine device was placed 3 years ago. = (C) Timed voiding On physical examination, vital signs and other exam- wy wa ination findings are normal. (D) Topical vaginal estrogen therapy

4 to 5 days before the onset of menses and include feeling o leakage of urine occurs during the pelvic examination with — emt bearing down. tense, unusually anxious, and unhappy. She also experi- = C<F) ences increased irritability, angry outbursts, breast pain and = Which of the following is the most appropriate management? bloating, and insomnia. She describes her mood in between wn wn menses as “generally good.” Medical history is significant ao (A) Oral estradiol for migraine with aura, for which she takes sumatriptan as wn wn =< (B) Oxybutynin needed. An intrauterine device was placed 3 years ago. = (C) Timed voiding On physical examination, vital signs and other exam- wy wa ination findings are normal. (D) Topical vaginal estrogen therapy Which of the following is the most appropriate Item 33 treatment?

4 to 5 days before the onset of menses and include feeling o leakage of urine occurs during the pelvic examination with — emt bearing down. tense, unusually anxious, and unhappy. She also experi- = C<F) ences increased irritability, angry outbursts, breast pain and = Which of the following is the most appropriate management? bloating, and insomnia. She describes her mood in between wn wn menses as “generally good.” Medical history is significant ao (A) Oral estradiol for migraine with aura, for which she takes sumatriptan as wn wn =< (B) Oxybutynin needed. An intrauterine device was placed 3 years ago. = (C) Timed voiding On physical examination, vital signs and other exam- wy wa ination findings are normal. (D) Topical vaginal estrogen therapy Which of the following is the most appropriate Item 33 treatment? A 54-year-old woman is evaluated in the emergency (A) Cognitive behavioral therapy department for coffee-ground emesis. Medical history is (B) Perimenstrual lorazepam significant for schizoaffective disorder. She lives in a group (C) Replace the intrauterine device with an oral combina- home and is accompanied to the hospital by her group tion estrogen-progesterone contraceptive home manager. She identifies as an active Jehovah’s Wit- ness. Medications are risperidone and escitalopram. (D) Sertraline On physical examination, blood pressure is 90/60 mm Hg and pulse rate is 110/min. The remainder of the physical examination is unremarkable. Item 36 Laboratory studies reveal a hemoglobin level of 6.0 g/dL A study evaluated the test characteristics of a new rapid (60 g/L). diagnostic test for influenza. Polymerase chain reaction- Transfusion is planned; however, the patient refuses, based testing of nasal secretions was used as the gold stan- stating that the procedure is against her religious beliefs as dard for diagnosis. The study was performed during the a Jehovah's Witness, and expresses a desire to return home. summer, when influenza rates are at their nadir. The sensitivity and specificity of the rapid diagnostic Which of the following is the most appropriate test are 70.6% and 92.8%, respectively. The positive and neg- management? ative predictive values are 90.7% and 75.9%, respectively.

A 54-year-old woman is evaluated in the emergency (A) Cognitive behavioral therapy department for coffee-ground emesis. Medical history is (B) Perimenstrual lorazepam significant for schizoaffective disorder. She lives in a group (C) Replace the intrauterine device with an oral combina- home and is accompanied to the hospital by her group tion estrogen-progesterone contraceptive home manager. She identifies as an active Jehovah’s Wit- ness. Medications are risperidone and escitalopram. (D) Sertraline On physical examination, blood pressure is 90/60 mm Hg and pulse rate is 110/min. The remainder of the physical examination is unremarkable. Item 36 Laboratory studies reveal a hemoglobin level of 6.0 g/dL A study evaluated the test characteristics of a new rapid (60 g/L). diagnostic test for influenza. Polymerase chain reaction- Transfusion is planned; however, the patient refuses, based testing of nasal secretions was used as the gold stan- stating that the procedure is against her religious beliefs as dard for diagnosis. The study was performed during the a Jehovah's Witness, and expresses a desire to return home. summer, when influenza rates are at their nadir. The sensitivity and specificity of the rapid diagnostic Which of the following is the most appropriate test are 70.6% and 92.8%, respectively. The positive and neg- management? ative predictive values are 90.7% and 75.9%, respectively. (A) > Ask the home manager for permission to transfuse Which of the following reflects how the new test will (B) Assess the patient’s decision-making capacity perform at the peak of influenza season? (C) Discharge the patient (A) Negative predictive value will increase ) Transfuse (B) Positive predictive value will increase BS ) Urgently petition the court for an evaluation of com- petence (C)_ Sensitivity will increase (D) Specificity will increase

(A) > Ask the home manager for permission to transfuse Which of the following reflects how the new test will (B) Assess the patient’s decision-making capacity perform at the peak of influenza season? (C) Discharge the patient (A) Negative predictive value will increase ) Transfuse (B) Positive predictive value will increase BS ) Urgently petition the court for an evaluation of com- petence (C)_ Sensitivity will increase (D) Specificity will increase Item 34 A 68-year-old man is evaluated for an episode of syn- ltem 37 cope and repeated episodes of near-fainting when standing A 53-year-old woman is evaluated for refractory chronic and working on his tractor. Current medical problems are cough. She has had a bothersome dry cough for longer than hypertension and dyslipidemia. Medications are chlor- 1 year. She has undergone empiric trials of glucocorticoid thalidone, lisinopril, and atorvastatin. nasal sprays, decongestants, cough suppressants, predni- On physical examination, vital signs are normal. sone, and omeprazole, alone and in combination, with no Supine blood pressure is 124/78 mm Hg, and pulse rate is improvement in symptoms. Results of allergy skin test- 76/min. After the patient stands for 3 minutes, standing ing, rhinoscopy, CT of the sinuses and chest, spirometry, blood pressure is 88/68 mm Hg, and pulse rate is 94/min. ambulatory pH monitoring, and sputum testing have been The remainder of the examination is normal. normal. She currently takes no medications. On physical examination, vital signs and other find- Which of the following is the most appropriate management? ings are unremarkable. The patient is referred for a multimodal speech pathol- (A) Adjust dosage of antihypertensive medications ogy intervention. (B) Midodrine administration (C) Thigh-high compression garments Which of the following is the most appropriate additional (D) Tilt-table testing treatment?

Item 34 A 68-year-old man is evaluated for an episode of syn- ltem 37 cope and repeated episodes of near-fainting when standing A 53-year-old woman is evaluated for refractory chronic and working on his tractor. Current medical problems are cough. She has had a bothersome dry cough for longer than hypertension and dyslipidemia. Medications are chlor- 1 year. She has undergone empiric trials of glucocorticoid thalidone, lisinopril, and atorvastatin. nasal sprays, decongestants, cough suppressants, predni- On physical examination, vital signs are normal. sone, and omeprazole, alone and in combination, with no Supine blood pressure is 124/78 mm Hg, and pulse rate is improvement in symptoms. Results of allergy skin test- 76/min. After the patient stands for 3 minutes, standing ing, rhinoscopy, CT of the sinuses and chest, spirometry, blood pressure is 88/68 mm Hg, and pulse rate is 94/min. ambulatory pH monitoring, and sputum testing have been The remainder of the examination is normal. normal. She currently takes no medications. On physical examination, vital signs and other find- Which of the following is the most appropriate management? ings are unremarkable. The patient is referred for a multimodal speech pathol- (A) Adjust dosage of antihypertensive medications ogy intervention. (B) Midodrine administration (C) Thigh-high compression garments Which of the following is the most appropriate additional (D) Tilt-table testing treatment? (A) Budesonide Item 35 (B) Esomeprazole A 29-year-old woman is evaluated for mood swings that (C) Gabapentin occur with every menstrual cycle. Symptoms typically begin (D) Morphine 117

alr es easie tit task 72) o = Item 38 (C) Prompted voiding > 2) A 67-year old woman is evaluated after admission to the (D) Tamsulosin n @ hospital for severely painful and progressive ulcerations on wn nn her abdomen and lower extremities due to calciphy lavxis. =} She rates the pain as an 8 ona lO point scale. Her medical @ Item 41 s history includes type 2 diabetes mellitus, end stage kidney ca A 72-year-old woman is evaluated for oral pain. Five years — disease managed with hemodialysis, and hypertension. @o ago, she underwent treatment for squamous cell carcinoma wn os Medications are sevelamer, sodium bicarbonate, amlodi in the oral cavity; she now shows no evidence of cancer. Her pine, labetalol, and basal and prandial insulin. treatment course was complicated by radiation-induced On physical examination, the patient appears to be in osteonecrosis of the jaw. Medical history also includes acute pain. Vital signs are normal. Multiple areas of viola hypertension and anxiety. Medications are amlodipine, ceous erythema, three with raised black eschars, are seen chlorthalidone, immediate-release morphine (20 mg daily), on the abdomen and thighs. bupropion, and lorazepam.

alr es easie tit task 72) o = Item 38 (C) Prompted voiding > 2) A 67-year old woman is evaluated after admission to the (D) Tamsulosin n @ hospital for severely painful and progressive ulcerations on wn nn her abdomen and lower extremities due to calciphy lavxis. =} She rates the pain as an 8 ona lO point scale. Her medical @ Item 41 s history includes type 2 diabetes mellitus, end stage kidney ca A 72-year-old woman is evaluated for oral pain. Five years — disease managed with hemodialysis, and hypertension. @o ago, she underwent treatment for squamous cell carcinoma wn os Medications are sevelamer, sodium bicarbonate, amlodi in the oral cavity; she now shows no evidence of cancer. Her pine, labetalol, and basal and prandial insulin. treatment course was complicated by radiation-induced On physical examination, the patient appears to be in osteonecrosis of the jaw. Medical history also includes acute pain. Vital signs are normal. Multiple areas of viola hypertension and anxiety. Medications are amlodipine, ceous erythema, three with raised black eschars, are seen chlorthalidone, immediate-release morphine (20 mg daily), on the abdomen and thighs. bupropion, and lorazepam. Which of the following is the most appropriate pain Which of the following poses the greatest risk for overdose treatment? and death in this patient? (A) Intravenous hydromorphone (A) Amlodipine coadministration (B) Intravenous morphine (B) Bupropion coadministration (C) Oral oxycodone (C) Lorazepam coadministration (D) Oral tramadol (D) Morphine total dose (EF) Transdermal fentany! patch (E) Short-acting morphine formulation

Which of the following is the most appropriate pain Which of the following poses the greatest risk for overdose treatment? and death in this patient? (A) Intravenous hydromorphone (A) Amlodipine coadministration (B) Intravenous morphine (B) Bupropion coadministration (C) Oral oxycodone (C) Lorazepam coadministration (D) Oral tramadol (D) Morphine total dose (EF) Transdermal fentany! patch (E) Short-acting morphine formulation Item 39 A 57-year-old man is evaluated for a 2-month history of Item 42 neck pain and stiffness accompanied by unsteadiness on A 45-year-old woman is evaluated for pain and swelling of his feet, especially while climbing up or down stairs. He is the left lower leg of 3 days’ duration. She just returned from otherwise healthy and takes no medications. a trip to western Canada, where she hiked extensively in On physical examination, vital signs are normal. the Canadian Rocky Mountains. She has had no recent sur- Muscle strength is 4/5 for both hip flexors and arm flex- geries or immobilization, has no other medical problems, ors. Hyperreflexia and clonus are present in the lower and takes no medication. extremities, as are bilateral upgoing extensor reflexes On physical examination, vital signs are normal. in the toes. Diminished reflexes are present in the upper Swelling of the left lower extremity is present. The extremities. Forward flexion of the neck produces electric skin is slightly erythematous up to the knee but is not shock-like pain that radiates from the neck to the arms. warm or painful to the touch. The right leg calf is 4 cm larger than the left, measured 10 cm below the tibial Which of the following is the most likely diagnosis? tuberosity. (A) Cervical myelopathy (B) Cervical radiculopathy Which of the following is the most appropriate management? = C) Cervical sprain

Item 39 A 57-year-old man is evaluated for a 2-month history of Item 42 neck pain and stiffness accompanied by unsteadiness on A 45-year-old woman is evaluated for pain and swelling of his feet, especially while climbing up or down stairs. He is the left lower leg of 3 days’ duration. She just returned from otherwise healthy and takes no medications. a trip to western Canada, where she hiked extensively in On physical examination, vital signs are normal. the Canadian Rocky Mountains. She has had no recent sur- Muscle strength is 4/5 for both hip flexors and arm flex- geries or immobilization, has no other medical problems, ors. Hyperreflexia and clonus are present in the lower and takes no medication. extremities, as are bilateral upgoing extensor reflexes On physical examination, vital signs are normal. in the toes. Diminished reflexes are present in the upper Swelling of the left lower extremity is present. The extremities. Forward flexion of the neck produces electric skin is slightly erythematous up to the knee but is not shock-like pain that radiates from the neck to the arms. warm or painful to the touch. The right leg calf is 4 cm larger than the left, measured 10 cm below the tibial Which of the following is the most likely diagnosis? tuberosity. (A) Cervical myelopathy (B) Cervical radiculopathy Which of the following is the most appropriate management? = C) Cervical sprain ( Myofascial pain (A) Cephalexin (E ~~ Whiplash injury (B) Compression therapy (C) Deep venous thrombosis testing (D) Rest, ice, crutches, and elevation Item 40 An 88-year-old man is evaluated for incontinence. When he needs to urinate, he is very slow getting to the bath- room. He has dementia, and he uses a walker for ambula- Item 43 tion. He lives with his daughter. He takes no medications. An 82-year-old woman is evaluated after a motor vehicle On physical examination, he is stooped and appears collision. She has had three minor motor vehicle col- frail. He cannot stand from sitting without use of the arm- lisions in the past 2 years. Her family has noticed mild rests. The prostate is mildly enlarged. memory lapses in the past 6 months. Her only medical Urinalysis results are normal. problem is depression, which is treated effectively with sertraline. Which of the following is the most appropriate On physical examination, vital signs are normal. Oph- management? thalmic examination reveals bilateral minimal opacity of the lenses consistent with early cataracts. Visual acuity (A) Finasteride is 20/40 bilaterally. The Mini-Cog test shows inability to (B) Oxybutynin recall three words.

( Myofascial pain (A) Cephalexin (E ~~ Whiplash injury (B) Compression therapy (C) Deep venous thrombosis testing (D) Rest, ice, crutches, and elevation Item 40 An 88-year-old man is evaluated for incontinence. When he needs to urinate, he is very slow getting to the bath- room. He has dementia, and he uses a walker for ambula- Item 43 tion. He lives with his daughter. He takes no medications. An 82-year-old woman is evaluated after a motor vehicle On physical examination, he is stooped and appears collision. She has had three minor motor vehicle col- frail. He cannot stand from sitting without use of the arm- lisions in the past 2 years. Her family has noticed mild rests. The prostate is mildly enlarged. memory lapses in the past 6 months. Her only medical Urinalysis results are normal. problem is depression, which is treated effectively with sertraline. Which of the following is the most appropriate On physical examination, vital signs are normal. Oph- management? thalmic examination reveals bilateral minimal opacity of the lenses consistent with early cataracts. Visual acuity (A) Finasteride is 20/40 bilaterally. The Mini-Cog test shows inability to (B) Oxybutynin recall three words. 118

sultBaamesmeant That beh Which of the following is the most appropriate The patient’s 10-year risk for atherosclerotic cardio- o - oa management? vascular disease is 15.7%. <= ae (A) Discontinue sertraline £ In addition to therapeutic lifestyle changes, which of the wn 72) (B) Recommend she retire from driving following is the most appropriate treatment? wa wv (C) Refer for cataract removal 72}

(A) Discontinue sertraline £ In addition to therapeutic lifestyle changes, which of the wn 72) (B) Recommend she retire from driving following is the most appropriate treatment? wa wv (C) Refer for cataract removal 72} (D) Restrict driving to within a 5-mile radius of home (A) Ezetimibe = — (B) Gemfibrozil F) 2) (C) High-intensity atorvastatin Item 44 (D) Moderate-intensity atorvastatin \ 56-vear old woman is evaluated in the hospital for man agement of alcohol withdrawal. Her last drink was 8 hours Item 47 ago. One year ago. she was hospitalized for more than 2 weeks A 47-year-old man is evaluated for low back pain. The with delirium tremens. She has no other medical conditions pain began 5 days ago while he was playing basketball. It or evidence of liver disease. She takes no medications. is localized to the lumbar back and does not radiate. The On physical examination, temperature is 37.1 “¢ patient is unable to sit or stand for long periods, but the pain (99.1°F), blood pressure is 163.93 mm Hg. and pulse rate is improves when lying down. Bladder and bowel habits have 127 min. The patient is intermittently tangential and con not changed. His only medication is ibuprofen for pain. frontational, but mentation is otherwise intact. On physical examination, the patient appears uncom- fortable. Pain is induced with palpation of the lumbar paraspi- Which of the following is the most appropriate treatment? nal muscles and by flexion and extension of the lower back,

(D) Restrict driving to within a 5-mile radius of home (A) Ezetimibe = — (B) Gemfibrozil F) 2) (C) High-intensity atorvastatin Item 44 (D) Moderate-intensity atorvastatin \ 56-vear old woman is evaluated in the hospital for man agement of alcohol withdrawal. Her last drink was 8 hours Item 47 ago. One year ago. she was hospitalized for more than 2 weeks A 47-year-old man is evaluated for low back pain. The with delirium tremens. She has no other medical conditions pain began 5 days ago while he was playing basketball. It or evidence of liver disease. She takes no medications. is localized to the lumbar back and does not radiate. The On physical examination, temperature is 37.1 “¢ patient is unable to sit or stand for long periods, but the pain (99.1°F), blood pressure is 163.93 mm Hg. and pulse rate is improves when lying down. Bladder and bowel habits have 127 min. The patient is intermittently tangential and con not changed. His only medication is ibuprofen for pain. frontational, but mentation is otherwise intact. On physical examination, the patient appears uncom- fortable. Pain is induced with palpation of the lumbar paraspi- Which of the following is the most appropriate treatment? nal muscles and by flexion and extension of the lower back, (A) Scheduled lorazepam and lumbar movement is limited by pain. Reflexes are normal, and no weakness or sensory deficits are noted. Ipsilateral and (B) Scheduled plus symptom triggered oxazepam contralateral straight leg raise test results are negative. (C) Symptom. triggered chlordiazepoxide

(A) Scheduled lorazepam and lumbar movement is limited by pain. Reflexes are normal, and no weakness or sensory deficits are noted. Ipsilateral and (B) Scheduled plus symptom triggered oxazepam contralateral straight leg raise test results are negative. (C) Symptom. triggered chlordiazepoxide (D) Symptom triggered haloperidol Which of the following is the most appropriate next step in management? (A) Bed rest Item 45 (B) MRI of the lumbar spine A 72-year-old man is evaluated in the emergency depart- ment for a 24-hour history of worsening shortness of (C) Nonpharmacologic treatments breath. He has COPD. His only medication is an albuterol- (D) Oxycodone ipratropium inhaler. Vital signs are normal. At the beginning of the exam- Item 48 ination, the patient insists that he be cared for only by White clinicians. \ 28 year old woman is evaluated in the emergency depart ment for an episode of syncope. Before the syncopal event, she

(A) Bed rest Item 45 (B) MRI of the lumbar spine A 72-year-old man is evaluated in the emergency depart- ment for a 24-hour history of worsening shortness of (C) Nonpharmacologic treatments breath. He has COPD. His only medication is an albuterol- (D) Oxycodone ipratropium inhaler. Vital signs are normal. At the beginning of the exam- Item 48 ination, the patient insists that he be cared for only by White clinicians. \ 28 year old woman is evaluated in the emergency depart ment for an episode of syncope. Before the syncopal event, she Which of the following is the most appropriate next step in was standing motionless in a warm environment for several management? minutes, and then she felt warm, dizzy, and nauseated. She lost consciousness for less than 30 seconds. She experienced (A) Assume the patient lacks decision-making capacity no trauma during the event and had no confusion afterward. (B) Explore the reasons for the request She has previously experienced presyncope at work while (C) Inform the patient that his wishes are racist standing for long periods of time but had never lost conscious ness. She has no medical problems and takes no medications. (D) Inform the patient that his wishes will be accommodated On physical examination. vital signs and the remain der of the examination are normal. An ECG is normal. Item 46 A 58-year-old man is evaluated during a routine visit. Which of the following is the most appropriate treatment? He has psoriatic arthritis and hypertension. His father had a myocardial infarction at age 53 years. His current (A) Avoidance of triggers

Which of the following is the most appropriate next step in was standing motionless in a warm environment for several management? minutes, and then she felt warm, dizzy, and nauseated. She lost consciousness for less than 30 seconds. She experienced (A) Assume the patient lacks decision-making capacity no trauma during the event and had no confusion afterward. (B) Explore the reasons for the request She has previously experienced presyncope at work while (C) Inform the patient that his wishes are racist standing for long periods of time but had never lost conscious ness. She has no medical problems and takes no medications. (D) Inform the patient that his wishes will be accommodated On physical examination. vital signs and the remain der of the examination are normal. An ECG is normal. Item 46 A 58-year-old man is evaluated during a routine visit. Which of the following is the most appropriate treatment? He has psoriatic arthritis and hypertension. His father had a myocardial infarction at age 53 years. His current (A) Avoidance of triggers medications are methotrexate, allopurinol, lisinopril, and (B) Fludrocortisone amlodipine. The patient is White. (C) Midodrine On physical examination, blood pressure is 140/82 mm (1) Propranolol Hg, and pulse rate is 70/min. BMI is 28. Other physical examination findings are normal.

medications are methotrexate, allopurinol, lisinopril, and (B) Fludrocortisone amlodipine. The patient is White. (C) Midodrine On physical examination, blood pressure is 140/82 mm (1) Propranolol Hg, and pulse rate is 70/min. BMI is 28. Other physical examination findings are normal. Laboratory studies: Item 49 LDL cholesterol 160 mg/dL (4.14 mmol/L) \76 year old woman is evaluated in the emergency depart HDL cholesterol 40 mg/dL (1.04 mmol/L) ment for presumed community acquired pneumonia. She Total cholesterol 270 mg/dL (6.99 mmol/L) lives with her daughter and cares for her grandchildren Triglycerides 350 mg/dL (3.95 mmol/L) when they return from school. 119

Self-Assessment Test 7.) © = On physical examination, temperature is 38.1 °C (C) Piperacillin-tazobactam > (100.5 °F), blood pressure is normal, pulse rate is 110/min. wn (D) Pressure offloading m4) CONT. and respiration rate is 20/min. Oxygen saturation is 86% © (E) Switch to gauze dressings W mM) with the patient breathing ambient air and increases to =} 91% on 3 L/min of oxygen by nasal cannula. Crackles are @ —] auscultated at the right lung base. Item 52 --r Chest radiograph demonstrates a right lower lobe oO nH infiltrate. A study compares a new treatment for symptom reduction vr in fibromyalgia versus treatment with pregabalin over a She is offered admission for treatment, which she 1-year period. The target symptom reduction on a standard accepts. She is deemed to have decision-making capacity. symptom inventory was reached in 30% of patients in the A nurse reports hearing the patient’s daughter tell her new treatment group and 25% of patients in the pregaba- mother, “If you cannot take care of my kids, I am going lin group. However, 15% of patients in the new treatment to put you in a nursing home.” After this exchange, the group had to discontinue the treatment because of adverse patient insists that she must leave the hospital. She will not effects; treatment was discontinued for this reason in 5% of explain the reason for the change in her decision. patients in the pregabalin group.

7.) © = On physical examination, temperature is 38.1 °C (C) Piperacillin-tazobactam > (100.5 °F), blood pressure is normal, pulse rate is 110/min. wn (D) Pressure offloading m4) CONT. and respiration rate is 20/min. Oxygen saturation is 86% © (E) Switch to gauze dressings W mM) with the patient breathing ambient air and increases to =} 91% on 3 L/min of oxygen by nasal cannula. Crackles are @ —] auscultated at the right lung base. Item 52 --r Chest radiograph demonstrates a right lower lobe oO nH infiltrate. A study compares a new treatment for symptom reduction vr in fibromyalgia versus treatment with pregabalin over a She is offered admission for treatment, which she 1-year period. The target symptom reduction on a standard accepts. She is deemed to have decision-making capacity. symptom inventory was reached in 30% of patients in the A nurse reports hearing the patient’s daughter tell her new treatment group and 25% of patients in the pregaba- mother, “If you cannot take care of my kids, I am going lin group. However, 15% of patients in the new treatment to put you in a nursing home.” After this exchange, the group had to discontinue the treatment because of adverse patient insists that she must leave the hospital. She will not effects; treatment was discontinued for this reason in 5% of explain the reason for the change in her decision. patients in the pregabalin group. Which of the following is the most appropriate next step in management? Which of the following is the number needed to treat for one patient to benefit from the new medication for (A) Consult with the hospital ethics committee fibromyalgia? (B) Discharge the patient home with oral antibiotics (A) 10 (C) Hospitalize the patient (B) 20 (D) Obtain psychiatric assessment of capacity (C) 30 (D) 40 Item 50 A 37-year-old woman is evaluated for left knee pain. She is training for a marathon. The pain is worse toward the Item 53 end of a run and also occurs when she goes down stairs. A 27-year-old man is evaluated during a follow-up visit. Ibuprofen has not provided any benefit. He recently visited the emergency department for a burn On physical examination, crepitus is noted on range sustained while setting off fireworks at a party while of motion testing of the left knee. Pain is reproduced with intoxicated. He has a history of depression but never fol- squatting and with palpation of and pressure on the patella. lowed up for treatment. Since that time, he reports that The remainder of the knee examination is normal. his mood has improved remarkably, and he is able to stay up “all night ifI need to” to catch up on work. He has elab- Which of the following is the most appropriate treatment? orate plans for starting his own cybersecurity business,

Which of the following is the most appropriate next step in management? Which of the following is the number needed to treat for one patient to benefit from the new medication for (A) Consult with the hospital ethics committee fibromyalgia? (B) Discharge the patient home with oral antibiotics (A) 10 (C) Hospitalize the patient (B) 20 (D) Obtain psychiatric assessment of capacity (C) 30 (D) 40 Item 50 A 37-year-old woman is evaluated for left knee pain. She is training for a marathon. The pain is worse toward the Item 53 end of a run and also occurs when she goes down stairs. A 27-year-old man is evaluated during a follow-up visit. Ibuprofen has not provided any benefit. He recently visited the emergency department for a burn On physical examination, crepitus is noted on range sustained while setting off fireworks at a party while of motion testing of the left knee. Pain is reproduced with intoxicated. He has a history of depression but never fol- squatting and with palpation of and pressure on the patella. lowed up for treatment. Since that time, he reports that The remainder of the knee examination is normal. his mood has improved remarkably, and he is able to stay up “all night ifI need to” to catch up on work. He has elab- Which of the following is the most appropriate treatment? orate plans for starting his own cybersecurity business, (A) Arthroscopic surgery running for city council, and working on an invention to prevent power grid failures. Medical history is otherwise (B) Glucocorticoid injection unremarkable. (C) Knee brace On physical examination, vital signs and other exam- (D) Physical therapy ination findings are normal. He has an elevated mood, is very talkative, and laughs somewhat inappropriately at the circumstances that led to the accident. He has a diffi- Item 51 cult time focusing on questions and is easily distracted by An 86-year-old woman is evaluated in the hospital after events in the corridor. admission from her nursing home for a gluteal pressure injury. She has advanced Alzheimer dementia and is bed- Which of the following is the most likely diagnosis? bound and noncommunicative. Nutritional status is judged to be adequate and has been maintained by assistance with (A) Attention-deficit/hyperactivity disorder feeding. The nursing home treated the pressure injury with (B) Bipolar 1 disorder hydrocolloid dressings. (C) Personality disorder On physical examination, vital signs are normal. BMI is (D) Schizophrenia 23. The patient is resting on an air-fluidized mattress. Skin examination shows a 5-cm = 6-cm area of full-thickness tis sue loss with visible subcutaneous fat over the right gluteus; Item 54 no tendon, muscle, or bone is visibly exposed. There is no ery thema or fluctuance in the surrounding tissue and no puru- A 68-year-old woman is evaluated in the hospital for agi-

(A) Arthroscopic surgery running for city council, and working on an invention to prevent power grid failures. Medical history is otherwise (B) Glucocorticoid injection unremarkable. (C) Knee brace On physical examination, vital signs and other exam- (D) Physical therapy ination findings are normal. He has an elevated mood, is very talkative, and laughs somewhat inappropriately at the circumstances that led to the accident. He has a diffi- Item 51 cult time focusing on questions and is easily distracted by An 86-year-old woman is evaluated in the hospital after events in the corridor. admission from her nursing home for a gluteal pressure injury. She has advanced Alzheimer dementia and is bed- Which of the following is the most likely diagnosis? bound and noncommunicative. Nutritional status is judged to be adequate and has been maintained by assistance with (A) Attention-deficit/hyperactivity disorder feeding. The nursing home treated the pressure injury with (B) Bipolar 1 disorder hydrocolloid dressings. (C) Personality disorder On physical examination, vital signs are normal. BMI is (D) Schizophrenia 23. The patient is resting on an air-fluidized mattress. Skin examination shows a 5-cm = 6-cm area of full-thickness tis sue loss with visible subcutaneous fat over the right gluteus; Item 54 no tendon, muscle, or bone is visibly exposed. There is no ery thema or fluctuance in the surrounding tissue and no puru- A 68-year-old woman is evaluated in the hospital for agi- lent drainage. The remainder of the examination is normal. tated delirium. She has metastatic non-small cell lung cancer. She was admitted to the hospital 5 days ago with Which of the following is the most appropriate treatment? acute hypoxic respiratory failure, and she opted for a comfort-directed care strategy. She is currently receiving (A) Ascorbic acid supplementation oxygen through nasal cannula and parenteral opioids for (B) Hyperbaric oxygen dyspnea and bone pain. She became agitated 2 days ago,

lent drainage. The remainder of the examination is normal. tated delirium. She has metastatic non-small cell lung cancer. She was admitted to the hospital 5 days ago with Which of the following is the most appropriate treatment? acute hypoxic respiratory failure, and she opted for a comfort-directed care strategy. She is currently receiving (A) Ascorbic acid supplementation oxygen through nasal cannula and parenteral opioids for (B) Hyperbaric oxygen dyspnea and bone pain. She became agitated 2 days ago, 120

Self-Assessment Test eet and after a thorough search excluded reversible causes, Which of the following is the most appropriate management? CH — cod she was treated with intravenous haloperidol. Response to = (A) Bupropion QD haloperidol was initially positive but is now waning. Her only other medication is morphine. (B) Cognitive behavioral therapy & wn wn On physical examination, pulse rate is 121/min, respi- (C) Paroxetine a wn ration rate is 26/min, and oxygen saturation is 93% breath- ( D) Reassurance wn

and after a thorough search excluded reversible causes, Which of the following is the most appropriate management? CH — cod she was treated with intravenous haloperidol. Response to = (A) Bupropion QD haloperidol was initially positive but is now waning. Her only other medication is morphine. (B) Cognitive behavioral therapy & wn wn On physical examination, pulse rate is 121/min, respi- (C) Paroxetine a wn ration rate is 26/min, and oxygen saturation is 93% breath- ( D) Reassurance wn ing 3 L/min oxygen by nasal cannula. The patient is not = = oriented or responding appropriately to questions. She is Qo rn agitated and is attempting to climb out of bed. C) Item 57 A 32-year-old man is evaluated in the emergency department Which of the following is the most appropriate next step in for low back pain of several weeks’ duration. The pain is in the management? lumbar area and does not radiate. He has no other symptoms.

ing 3 L/min oxygen by nasal cannula. The patient is not = = oriented or responding appropriately to questions. She is Qo rn agitated and is attempting to climb out of bed. C) Item 57 A 32-year-old man is evaluated in the emergency department Which of the following is the most appropriate next step in for low back pain of several weeks’ duration. The pain is in the management? lumbar area and does not radiate. He has no other symptoms. (A) Add parenteral lorazepam Medical history is significant for injection drug use. On physical examination, temperature is 37.4 °C (B) Change haloperidol to olanzapine (99.4 °F); other vital signs are normal. Pain is present (C) Stop haloperidol with gentle palpation of L3 and L4. The pain worsens with (D) Stop morphine hyperextension or flexion of the spine. Marks from injec- tion drug use are seen on the forearms. The remainder of the examination is normal. Item 55 Interferon-y release assay, HIV test results, and blood A 43-year-old man is evaluated for cough. His symptoms and urine cultures are pending. started 12 days ago with headache, runny nose, cough, subjective fever, and fatigue. The headache, runny nose, Which of the following is the most appropriate next step in and fever have improved, but the cough has persisted. management? He reports no shortness of breath. Medical history is (A) CT of the lumbar spine significant for major depressive disorder treated with fluoxetine. (B) Empirical antibiotic therapy

(A) Add parenteral lorazepam Medical history is significant for injection drug use. On physical examination, temperature is 37.4 °C (B) Change haloperidol to olanzapine (99.4 °F); other vital signs are normal. Pain is present (C) Stop haloperidol with gentle palpation of L3 and L4. The pain worsens with (D) Stop morphine hyperextension or flexion of the spine. Marks from injec- tion drug use are seen on the forearms. The remainder of the examination is normal. Item 55 Interferon-y release assay, HIV test results, and blood A 43-year-old man is evaluated for cough. His symptoms and urine cultures are pending. started 12 days ago with headache, runny nose, cough, subjective fever, and fatigue. The headache, runny nose, Which of the following is the most appropriate next step in and fever have improved, but the cough has persisted. management? He reports no shortness of breath. Medical history is (A) CT of the lumbar spine significant for major depressive disorder treated with fluoxetine. (B) Empirical antibiotic therapy On physical examination, temperature is 37.4 °C (C) MRI of the lumbar spine (99.4 °F), blood pressure is 128/89 mm Hg, and respiration (D) Radiography of the lumbar spine rate is 16/min. The oropharynx is clear and without exu- dates. Lungs are clear bilaterally. Testing for SARS-CoV-2 is negative. Item 58 A 72-year-old man is evaluated during an annual physical Which of the following is the most appropriate next step in examination. The patient is a widower and has one daugh- management? ter, from whom he is estranged. He has not completed an advance directive. His father died of complications of (A) Albuterol inhaler stroke after a prolonged hospital stay. (B) Azithromycin The patient mentions that he does not want to die like (C) Chest radiography his father did, “hooked up to machines.” He is worried that (D) Dextromethorphan he will receive aggressive care at the end of life, which he

On physical examination, temperature is 37.4 °C (C) MRI of the lumbar spine (99.4 °F), blood pressure is 128/89 mm Hg, and respiration (D) Radiography of the lumbar spine rate is 16/min. The oropharynx is clear and without exu- dates. Lungs are clear bilaterally. Testing for SARS-CoV-2 is negative. Item 58 A 72-year-old man is evaluated during an annual physical Which of the following is the most appropriate next step in examination. The patient is a widower and has one daugh- management? ter, from whom he is estranged. He has not completed an advance directive. His father died of complications of (A) Albuterol inhaler stroke after a prolonged hospital stay. (B) Azithromycin The patient mentions that he does not want to die like (C) Chest radiography his father did, “hooked up to machines.” He is worried that (D) Dextromethorphan he will receive aggressive care at the end of life, which he (E) Education and reassurance does not want. The physician engages the patient in a discussion of health care preferences and goals for future care.

On physical examination, temperature is 37.4 °C (C) MRI of the lumbar spine (99.4 °F), blood pressure is 128/89 mm Hg, and respiration (D) Radiography of the lumbar spine rate is 16/min. The oropharynx is clear and without exu- dates. Lungs are clear bilaterally. Testing for SARS-CoV-2 is negative. Item 58 A 72-year-old man is evaluated during an annual physical Which of the following is the most appropriate next step in examination. The patient is a widower and has one daugh- management? ter, from whom he is estranged. He has not completed an advance directive. His father died of complications of (A) Albuterol inhaler stroke after a prolonged hospital stay. (B) Azithromycin The patient mentions that he does not want to die like (C) Chest radiography his father did, “hooked up to machines.” He is worried that (D) Dextromethorphan he will receive aggressive care at the end of life, which he (E) Education and reassurance does not want. The physician engages the patient in a discussion of health care preferences and goals for future care. Item 56 Which of the following best describes this interaction A 38-year-old woman is evaluated for a 3-month his- between the patient and his physician? tory of depressed mood. She meets the diagnostic criteria for major depression. She reports no suicidal ideation or (A) Advance care planning episodes of mania or hypomania. Her most troublesome (B) Creation of a living will symptoms at this time are difficulty concentrating at work (C) Execution of an advance directive and low self-esteem. She is in a new relationship, and there is the possibility of becoming sexually active at some (D) Identification of a health care proxy point in the future. She has a copper intrauterine device for contraception. She has obesity and prediabetes and has experienced some success with weight reduction, but since Item 59 the onset of depression, she has struggled with overeating. A 29-year-old man is evaluated for fatigue and difficulty Medical history is also significant for hyperlipidemia and concentrating. He finds himself worrying frequently juvenile myoclonic epilepsy. Medications are atorvastatin and reports that he loses energy easily during the week, and levetiracetam. worries about being evaluated negatively at work, and The patient would like to avoid an additional medica- sometimes snaps at his coworkers when he is particularly tion, if possible, but wishes to be provided with effective tense. These symptoms have been present most days of treatment. the week for the past year. Family and personal medical

Item 56 Which of the following best describes this interaction A 38-year-old woman is evaluated for a 3-month his- between the patient and his physician? tory of depressed mood. She meets the diagnostic criteria for major depression. She reports no suicidal ideation or (A) Advance care planning episodes of mania or hypomania. Her most troublesome (B) Creation of a living will symptoms at this time are difficulty concentrating at work (C) Execution of an advance directive and low self-esteem. She is in a new relationship, and there is the possibility of becoming sexually active at some (D) Identification of a health care proxy point in the future. She has a copper intrauterine device for contraception. She has obesity and prediabetes and has experienced some success with weight reduction, but since Item 59 the onset of depression, she has struggled with overeating. A 29-year-old man is evaluated for fatigue and difficulty Medical history is also significant for hyperlipidemia and concentrating. He finds himself worrying frequently juvenile myoclonic epilepsy. Medications are atorvastatin and reports that he loses energy easily during the week, and levetiracetam. worries about being evaluated negatively at work, and The patient would like to avoid an additional medica- sometimes snaps at his coworkers when he is particularly tion, if possible, but wishes to be provided with effective tense. These symptoms have been present most days of treatment. the week for the past year. Family and personal medical 121

Self-Assessment Test wn e a history is otherwise noncontributory, and he takes no in 3 months ago. There are several adult family members in > medications. wv the home. The patient is able to ambulate short distances in w oO On physical examination, vital signs and other find- the home with a walker. She does not toilet independently wn n ings are normal. and requires assistance with feeding, bathing, and dress- 3 Results of laboratory studies show normal thyroid ing. Current medical problems include type 2 diabetes @ ij function. A urine drug screen is negative. mellitus, hypertension, and osteoarthritis. Medications are - metformin, losartan, atorvastatin, and acetaminophen. > Which of the following is the most likely diagnosis? wn On physical examination, vital signs are normal. BMI is ~~ 22. The patient is disheveled. She speaks very little and only (A) Attention-deficit/hyperactivity disorder to answer yes-or-no questions. Dry mucous membranes (B) Generalized anxiety disorder are noted. The perineum is soiled with caked feces and (C) Panic attacks urine, and skin in the area is erythematous. An early stage 2 (D) Social anxiety disorder sacral decubitus ulcer is noted. There is bruising on the right upper arm. The remainder of the examination is normal.

wn e a history is otherwise noncontributory, and he takes no in 3 months ago. There are several adult family members in > medications. wv the home. The patient is able to ambulate short distances in w oO On physical examination, vital signs and other find- the home with a walker. She does not toilet independently wn n ings are normal. and requires assistance with feeding, bathing, and dress- 3 Results of laboratory studies show normal thyroid ing. Current medical problems include type 2 diabetes @ ij function. A urine drug screen is negative. mellitus, hypertension, and osteoarthritis. Medications are - metformin, losartan, atorvastatin, and acetaminophen. > Which of the following is the most likely diagnosis? wn On physical examination, vital signs are normal. BMI is ~~ 22. The patient is disheveled. She speaks very little and only (A) Attention-deficit/hyperactivity disorder to answer yes-or-no questions. Dry mucous membranes (B) Generalized anxiety disorder are noted. The perineum is soiled with caked feces and (C) Panic attacks urine, and skin in the area is erythematous. An early stage 2 (D) Social anxiety disorder sacral decubitus ulcer is noted. There is bruising on the right upper arm. The remainder of the examination is normal. Item 60 Which of the following is the most appropriate management? A 42-year-old man is seen for a routine evaluation. Medical (A) Adult Protective Services referral history is unremarkable. He takes no medications. (B) Enteral nutritional supplementation On physical examination, vital signs are normal. BMI is 35. The remainder of the physical examination is normal. (C) Hwalek-Sengstock Elder Abuse Screening Test Laboratory studies reveal an LDL cholesterol level of (D) Hydrocolloid wound dressing 128 mg/dL (3.32 mmol/L) and triglyceride level of 348 mg/dL (3.93 mmol/L). Item 63 His 10-year risk for atherosclerotic cardiovascular dis- ease based on the Pooled Cohort Equations is 2.4%. A 28-year-old man is evaluated in follow-up after a visit for multiple fluctuating somatic symptoms, including Which of the following is the most appropriate management? paresthesia, nausea, sensitivity to light and sound, dizzi- ness, muscle spasms, and fatigue. An extensive evaluation, (A) Initiate fibrate therapy including subspecialty consultation, laboratory testing, (B) Initiate statin therapy imaging, and diagnostic procedures, showed no clear diag- (C) Recommend lifestyle interventions nosis. He is frustrated at the lack of diagnosis and is con- cerned that “something is being missed.” (D) Recommend omega-3 fatty acid supplements On physical examination, vital signs and other find- ings are normal.

Item 60 Which of the following is the most appropriate management? A 42-year-old man is seen for a routine evaluation. Medical (A) Adult Protective Services referral history is unremarkable. He takes no medications. (B) Enteral nutritional supplementation On physical examination, vital signs are normal. BMI is 35. The remainder of the physical examination is normal. (C) Hwalek-Sengstock Elder Abuse Screening Test Laboratory studies reveal an LDL cholesterol level of (D) Hydrocolloid wound dressing 128 mg/dL (3.32 mmol/L) and triglyceride level of 348 mg/dL (3.93 mmol/L). Item 63 His 10-year risk for atherosclerotic cardiovascular dis- ease based on the Pooled Cohort Equations is 2.4%. A 28-year-old man is evaluated in follow-up after a visit for multiple fluctuating somatic symptoms, including Which of the following is the most appropriate management? paresthesia, nausea, sensitivity to light and sound, dizzi- ness, muscle spasms, and fatigue. An extensive evaluation, (A) Initiate fibrate therapy including subspecialty consultation, laboratory testing, (B) Initiate statin therapy imaging, and diagnostic procedures, showed no clear diag- (C) Recommend lifestyle interventions nosis. He is frustrated at the lack of diagnosis and is con- cerned that “something is being missed.” (D) Recommend omega-3 fatty acid supplements On physical examination, vital signs and other find- ings are normal. Item 61 Which of the following is the most appropriate A 47 year old man is evaluated in the hospital after treat management? ment for acute alcoholic pancreatitis. During the hosp ization, he is diagnosed with moderately severe alcohol! usc (A) Acknowledge the patient’s feelings disorder. Medical history includes hypertension (B) Assess for malingering been prescribed antihypertensives in the past b (C) Confirm that a cure is possible with medication adherence; he recognizes this as a poten tial problem. Medical history is otherwise unremarkable. (D) Recommend visits only if new symptoms occur

Item 61 Which of the following is the most appropriate A 47 year old man is evaluated in the hospital after treat management? ment for acute alcoholic pancreatitis. During the hosp ization, he is diagnosed with moderately severe alcohol! usc (A) Acknowledge the patient’s feelings disorder. Medical history includes hypertension (B) Assess for malingering been prescribed antihypertensives in the past b (C) Confirm that a cure is possible with medication adherence; he recognizes this as a poten tial problem. Medical history is otherwise unremarkable. (D) Recommend visits only if new symptoms occur and screens for depression, other mood disorders. and additional substance use disorders are negative. He take: Item 64 no medications at the present time. He agrees toattend a 12 step facilitation prog hospital discharge. but he is concerned that it will not he! sufficiently. Which of the following is the most appropriate additional treatment? (A) Bupropion (B) Injectable naltrexone (C) Lorazepam (D) Oral naltrexone Which of the following is the most appropriate medication nianagement to reduce this patient's risk for falls? Item 62 A 79-year-old woman is evaluated for weight loss. She is Startoxvbuty nit brought to the office by her niece, with whom she moved start Vitamin p> 122

Self-Assessment Test hres! (C) Stop diphenhydramine Which of the following is the most appropriate treatment? ® a a (J) Stop metopr (=| CONT. (A) Diphenhydramine cr.) (B) Doxepin = wn wn Item 65 (C) Trazodone c.f) wn A 28-year-old woman is evaluated for a 2-month history (D) No pharmacologic treatment wr zx of left-sided neck and shoulder pain and paresthesia in her = @ left arm from her fingers to her shoulder. Her symptoms Item 68 rn

A 28-year-old woman is evaluated for a 2-month history (D) No pharmacologic treatment wr zx of left-sided neck and shoulder pain and paresthesia in her = @ left arm from her fingers to her shoulder. Her symptoms Item 68 rn worsen with overhead arm activity. She takes no medi- A 74-year-old man undergoes follow-up evaluation 4 weeks cations. after an urgent care visit for benign paroxysmal positional On physical examination, she has full range of motion vertigo. He is concerned about an upcoming trip and the pos- in her left neck, shoulder, elbow, and wrist. Muscle bulk, sibility of falling. He has had no recent falls but did have a near tone, and strength in the upper extremities are normal fall. Medical history is significant for atrial fibrillation. Cur- bilaterally. Neurologic examination reveals normal reflexes rent medications are metoprolol, apixaban, and meclizine. and sensation in the upper extremities bilaterally. Upper On physical examination, blood pressure and pulse extremity pulses are full and equal. There is no cyanosis, rate are normal and without orthostatic changes. Cardiac swelling, or edema. examination reveals an irregular rhythm. Screening neu- rologic examination is normal. Which of the following is the most likely diagnosis? The Timed Up and Go Test result is prolonged (16 seconds). (A) Arterial thoracic outlet syndrome The patient undergoes canalith repositioning with the (B) Cervical radiculopathy Epley maneuver.

worsen with overhead arm activity. She takes no medi- A 74-year-old man undergoes follow-up evaluation 4 weeks cations. after an urgent care visit for benign paroxysmal positional On physical examination, she has full range of motion vertigo. He is concerned about an upcoming trip and the pos- in her left neck, shoulder, elbow, and wrist. Muscle bulk, sibility of falling. He has had no recent falls but did have a near tone, and strength in the upper extremities are normal fall. Medical history is significant for atrial fibrillation. Cur- bilaterally. Neurologic examination reveals normal reflexes rent medications are metoprolol, apixaban, and meclizine. and sensation in the upper extremities bilaterally. Upper On physical examination, blood pressure and pulse extremity pulses are full and equal. There is no cyanosis, rate are normal and without orthostatic changes. Cardiac swelling, or edema. examination reveals an irregular rhythm. Screening neu- rologic examination is normal. Which of the following is the most likely diagnosis? The Timed Up and Go Test result is prolonged (16 seconds). (A) Arterial thoracic outlet syndrome The patient undergoes canalith repositioning with the (B) Cervical radiculopathy Epley maneuver. (C) Neurogenic thoracic outlet syndrome Which of the following is the most appropriate additional (D) Venous thoracic outlet syndrome management to reduce this patient’s risk for falls?

(C) Neurogenic thoracic outlet syndrome Which of the following is the most appropriate additional (D) Venous thoracic outlet syndrome management to reduce this patient’s risk for falls? (A) Discontinue meclizine Item 66 (B) Discontinue metoprolol An 80-year-old man is brought to the emergency depart- (C) Prescribe a four-prong cane ment with fever, confusion, and productive cough. He (D) Prescribe vitamin D has COPD. A chest radiograph shows left lower lobe consolidation. The emergency department has been simultaneously involved in caring for several patients Item 69 critically injured in a motor vehicle accident. The emer- A 76-year-old man is evaluated for a several-year history of gency department team provides nebulizer treatment and bilateral lower extremity edema and hyperpigmentation. intravenous glucocorticoids to the patient. Admission He has also noticed that his legs are tired by the end of the to the hospital for COPD exacerbation is recommended. day and feel heavy. He has hypertension and obesity. His The hospitalist team is notified of the admission but is only medication is lisinopril. interrupted by the activation of a rapid response team for On physical examination, vital signs are normal. BMI another patient. The inpatient nurse team is not notified is 30. Skin findings are shown. of this patient admission. Several hours later, the patient is found in his hospital room unresponsive with agonal breathing and hypotension. Which of the following is the fundamental basis for this diagnostic error? (A) Hypothetico-deductive reasoning (B) Incorrect estimation of pretest probability (C) Poor time management (D) Systems factors

(A) Discontinue meclizine Item 66 (B) Discontinue metoprolol An 80-year-old man is brought to the emergency depart- (C) Prescribe a four-prong cane ment with fever, confusion, and productive cough. He (D) Prescribe vitamin D has COPD. A chest radiograph shows left lower lobe consolidation. The emergency department has been simultaneously involved in caring for several patients Item 69 critically injured in a motor vehicle accident. The emer- A 76-year-old man is evaluated for a several-year history of gency department team provides nebulizer treatment and bilateral lower extremity edema and hyperpigmentation. intravenous glucocorticoids to the patient. Admission He has also noticed that his legs are tired by the end of the to the hospital for COPD exacerbation is recommended. day and feel heavy. He has hypertension and obesity. His The hospitalist team is notified of the admission but is only medication is lisinopril. interrupted by the activation of a rapid response team for On physical examination, vital signs are normal. BMI another patient. The inpatient nurse team is not notified is 30. Skin findings are shown. of this patient admission. Several hours later, the patient is found in his hospital room unresponsive with agonal breathing and hypotension. Which of the following is the fundamental basis for this diagnostic error? (A) Hypothetico-deductive reasoning (B) Incorrect estimation of pretest probability (C) Poor time management (D) Systems factors Item 67 A 58-year-old woman is evaluated for follow-up of chronic insomnia. She has participated in cognitive behavioral therapy for insomnia; however, she continues to have difficulties maintaining sleep. After a discussion of risks and benefits and shared decision making, the patient has opted for a limited course of pharmacologic therapy for her insomnia. She has no other medical problems and takes no medications. 123

Self-Assessment Test wn = area Which of the following is the most appropriate His calculated 10-year risk for atherosclerotic cardio- > management? vascular disease (ASCVD) is 4.3%. 7.) wn @o m2 (A) Cefadroxil 7) Which of the following is the most appropriate treatment? 3 (B) Compression duplex ultrasonography @o (C) Compression stockings (A) Initiate fenofibrate = - (D) Furosemide (B) Initiate moderate-intensity statin therapy 7 wv (C) Recommend decreased alcohol intake or (D) Recommend intensive diet and exercise regimen Item 70 A 35-year-old woman is evaluated in the emergency department for a second episode of syncope that occurred Item 73 while standing. She had a prodrome of diaphoresis and A 29-year-old woman requests advice after receipt of a nausea with both episodes. After the episodes, she felt tired direct-to-consumer genetic test result that included BRCA but not confused. gene analysis. She has no breast symptoms and has not On physical examination, vital signs and the remain- undergone any previous breast cancer screening. Her der of the examination are normal. mother was diagnosed with breast cancer at age 48 years An ECG is normal. and ovarian cancer at age 60 years; she died at age 62 years. The patient’s sister was recently diagnosed with breast Which of the following is the most appropriate cancer at age 41 years and is still living. The genetic test management? report is negative for BRCA1 and BRCA2 variants. Family members have not undergone genetic testing. (A) Cardiac monitoring On physical examination, vital signs, breast examina- (B) CT of the head tion, and other findings are normal. (C) Discharge home (D) Echocardiography Which of the following is the most appropriate management?

wn = area Which of the following is the most appropriate His calculated 10-year risk for atherosclerotic cardio- > management? vascular disease (ASCVD) is 4.3%. 7.) wn @o m2 (A) Cefadroxil 7) Which of the following is the most appropriate treatment? 3 (B) Compression duplex ultrasonography @o (C) Compression stockings (A) Initiate fenofibrate = - (D) Furosemide (B) Initiate moderate-intensity statin therapy 7 wv (C) Recommend decreased alcohol intake or (D) Recommend intensive diet and exercise regimen Item 70 A 35-year-old woman is evaluated in the emergency department for a second episode of syncope that occurred Item 73 while standing. She had a prodrome of diaphoresis and A 29-year-old woman requests advice after receipt of a nausea with both episodes. After the episodes, she felt tired direct-to-consumer genetic test result that included BRCA but not confused. gene analysis. She has no breast symptoms and has not On physical examination, vital signs and the remain- undergone any previous breast cancer screening. Her der of the examination are normal. mother was diagnosed with breast cancer at age 48 years An ECG is normal. and ovarian cancer at age 60 years; she died at age 62 years. The patient’s sister was recently diagnosed with breast Which of the following is the most appropriate cancer at age 41 years and is still living. The genetic test management? report is negative for BRCA1 and BRCA2 variants. Family members have not undergone genetic testing. (A) Cardiac monitoring On physical examination, vital signs, breast examina- (B) CT of the head tion, and other findings are normal. (C) Discharge home (D) Echocardiography Which of the following is the most appropriate management? (A) Clinical BRCA genetic test Item 71 (B) Genetic counseling A 34-year-old woman is evaluated for a 3-month history (C) MRI of the breast of dry cough. She does not use tobacco. A chest radiograph (D) Reassurance and no further testing obtained 1 month ago was normal. The patient has a history of seasonal rhinitis. Since the onset of the cough, she has used fluticasone nasal spray daily without improvement. Item 74 She has no other symptoms. Vital signs and physical examination are normal. A 33-year-old woman is evaluated in the emergency depart ment after a friend found her unresponsive and called

(A) Clinical BRCA genetic test Item 71 (B) Genetic counseling A 34-year-old woman is evaluated for a 3-month history (C) MRI of the breast of dry cough. She does not use tobacco. A chest radiograph (D) Reassurance and no further testing obtained 1 month ago was normal. The patient has a history of seasonal rhinitis. Since the onset of the cough, she has used fluticasone nasal spray daily without improvement. Item 74 She has no other symptoms. Vital signs and physical examination are normal. A 33-year-old woman is evaluated in the emergency depart ment after a friend found her unresponsive and called Which of the following is the most appropriate next step in emergency medical services. She is now alert and reports

(A) Clinical BRCA genetic test Item 71 (B) Genetic counseling A 34-year-old woman is evaluated for a 3-month history (C) MRI of the breast of dry cough. She does not use tobacco. A chest radiograph (D) Reassurance and no further testing obtained 1 month ago was normal. The patient has a history of seasonal rhinitis. Since the onset of the cough, she has used fluticasone nasal spray daily without improvement. Item 74 She has no other symptoms. Vital signs and physical examination are normal. A 33-year-old woman is evaluated in the emergency depart ment after a friend found her unresponsive and called Which of the following is the most appropriate next step in emergency medical services. She is now alert and reports management? that she had used heroin hours earlier, as well as oxycodone and clonazepam just before this episode. She was treated (A) Ambulatory pH monitoring in another local emergency department 2 months ago for a (B) Chest CT similar accidental polysubstance overdose. (C) Omeprazole (D) Spirometry Which of the following is the most appropriate measure for preventing another overdose in this patient? (E) Sputum eosinophil evaluation (A) Intranasal naloxone (B) Oral clonidine Item 72 (C) Naltrexone A 45-year-old man is evaluated during a routine examina- (D) Transdermal buprenorphine tion. He does not exercise. He has never smoked and drinks one to two beers, 4 nights per week. There is no family his- tory of premature atherosclerotic cardiovascular disease. Item 75 The patient is Black. A 60-year-old man is evaluated for a 3-week history of On physical examination, blood pressure is 124/78 mm dry cough. The cough occurs intermittently during the day Hg. BMI is 28, and waist circumference is 106 cm (42 in). and seems to be more prominent in the evening. He has no Laboratory studies: other symptoms. Medical history is otherwise significant Fasting blood glucose 106 mg/dL (5.9 mmol/L) for hypertension, for which he takes chlorthalidone and LDL cholesterol 148 mg/dL (3.83 mmol/L) lisinopril. HDL cholesterol 38 mg/dL (0.98 mmol/L) On physical examination, vital signs and other find- Triglycerides 160 mg/dL (1.81 mmol/L) ings are unremarkable.

management? that she had used heroin hours earlier, as well as oxycodone and clonazepam just before this episode. She was treated (A) Ambulatory pH monitoring in another local emergency department 2 months ago for a (B) Chest CT similar accidental polysubstance overdose. (C) Omeprazole (D) Spirometry Which of the following is the most appropriate measure for preventing another overdose in this patient? (E) Sputum eosinophil evaluation (A) Intranasal naloxone (B) Oral clonidine Item 72 (C) Naltrexone A 45-year-old man is evaluated during a routine examina- (D) Transdermal buprenorphine tion. He does not exercise. He has never smoked and drinks one to two beers, 4 nights per week. There is no family his- tory of premature atherosclerotic cardiovascular disease. Item 75 The patient is Black. A 60-year-old man is evaluated for a 3-week history of On physical examination, blood pressure is 124/78 mm dry cough. The cough occurs intermittently during the day Hg. BMI is 28, and waist circumference is 106 cm (42 in). and seems to be more prominent in the evening. He has no Laboratory studies: other symptoms. Medical history is otherwise significant Fasting blood glucose 106 mg/dL (5.9 mmol/L) for hypertension, for which he takes chlorthalidone and LDL cholesterol 148 mg/dL (3.83 mmol/L) lisinopril. HDL cholesterol 38 mg/dL (0.98 mmol/L) On physical examination, vital signs and other find- Triglycerides 160 mg/dL (1.81 mmol/L) ings are unremarkable. 124

Self-Assessment Test oe? d Which of the following is the most appropriate next step in with her first child. The pregnancy is uncomplicated. Her — het management? only medication is a prenatal vitamin. = CH) On physical examination, she walks with a limp (A) Azithromycin = favoring the left leg. Hip range of motion is normal. There w wn (B) Chest radiography is no pain with hip flexion, abduction, or external rotation. a wn (C) Guaifenesin There is left-sided hip and leg pain with straight leg raise of wn both the left and right legs. There is no pain with flexion or =< (D) Spirometry = extension of the lumbar spine. ® (E) Stop lisinopril and begin amlodipine 72)

both the left and right legs. There is no pain with flexion or =< (D) Spirometry = extension of the lumbar spine. ® (E) Stop lisinopril and begin amlodipine 72) Which of the following is the most likely diagnosis? Item 76 (A co Osteoarthritis of the hip A 70-year-old man is evaluated for a 1-year history of (B Se Radiculopathy of the sciatic nerve fatigue and sleeping difficulties that he finds distressing. (C Ta Round ligament pain He reports going to bed at 10 pm and watching television (D Sacroiliitis for 20 minutes before attempting sleep. However, it takes a

Which of the following is the most likely diagnosis? Item 76 (A co Osteoarthritis of the hip A 70-year-old man is evaluated for a 1-year history of (B Se Radiculopathy of the sciatic nerve fatigue and sleeping difficulties that he finds distressing. (C Ta Round ligament pain He reports going to bed at 10 pm and watching television (D Sacroiliitis for 20 minutes before attempting sleep. However, it takes a up to 2 hours to fall asleep. He wakes once a night to uri- nate and takes about an hour to fall back asleep. He takes a 2-hour nap every afternoon. Item 79 Vital signs and physical examination are normal. A 45-year-old man is evaluated for generalized dull, throb- The patient has no access to cognitive behavioral ther- bing pain in the left shoulder. He also reports an intermit- apy in his community. tent catching sensation with movement and a feeling of shoulder joint instability. There is no history of trauma. He Which of the following is the most appropriate treatment? is an avid weightlifter. On physical examination, there is no pain with pal- (A) Avoid daytime naps pation of the left shoulder; palpation of the biceps ten- (B) Avoid watching television in bed don elicits crepitus but no pain. Passive range of motion (C) Brief behavioral therapy for insomnia is within normal limits, and active range of motion is (D) Melatonin limited by pain. Pronation of the forearm and abduction and external rotation of the left arm reproduce pain. (E) Sleep restriction therapy Clicking in the glenohumeral joint is noted with passive rotation of the arm in an abducted position. Tests for Item 77 rotator cuff injury are negative. Strength is 5/5 through- out the left arm. A 62-year-old woman is evaluated for a change in her abdominal and pelvic pain symptoms. The patient has been Which of the following is the most likely diagnosis? followed for 3 years for medically unexplained symptoms. Her typical symptoms have included chronic pelvic pain (A) Acromioclavicular joint degeneration of unknown cause and migrating upper abdominal pain. (B) Adhesive capsulitis An extensive evaluation, including endoscopy, advanced (C) Biceps tendinopathy imaging, and laboratory evaluation, has been negative. Her symptoms have been stable for the past 2 years until (D) Labral tear recently. Her new abdominal symptom is central boring pain that has been present for 6 weeks and is associated with anorexia, diarrhea, and a 2-kg (4.4-Ib) weight loss. Item 80 She is currently taking no medications. An 81-year-old woman is evaluated for dyspnea that On physical examination, vital signs are normal. The has slowly worsened over the past 3 months. She has mid-abdomen is tender to deep palpation. a history of severe COPD and has been on continuous oxygen therapy for 6 years. She has a minimal cough Which of the following is the most appropriate initial productive of scant sputum. Two weeks ago, she fin- management? ished pulmonary rehabilitation, which provided some improvement in symptoms. Her medications are inhaled ( A) CT of the abdomen and pelvis vilanterol trifenatate, umeclidinium bromide, and flu- ( B) Depression screening ticasone furoate. (C) ) Exploration of psychosocial stressors On physical examination, vital signs are normal. (D) Nortriptyline Breath sounds are diminished bilaterally.

up to 2 hours to fall asleep. He wakes once a night to uri- nate and takes about an hour to fall back asleep. He takes a 2-hour nap every afternoon. Item 79 Vital signs and physical examination are normal. A 45-year-old man is evaluated for generalized dull, throb- The patient has no access to cognitive behavioral ther- bing pain in the left shoulder. He also reports an intermit- apy in his community. tent catching sensation with movement and a feeling of shoulder joint instability. There is no history of trauma. He Which of the following is the most appropriate treatment? is an avid weightlifter. On physical examination, there is no pain with pal- (A) Avoid daytime naps pation of the left shoulder; palpation of the biceps ten- (B) Avoid watching television in bed don elicits crepitus but no pain. Passive range of motion (C) Brief behavioral therapy for insomnia is within normal limits, and active range of motion is (D) Melatonin limited by pain. Pronation of the forearm and abduction and external rotation of the left arm reproduce pain. (E) Sleep restriction therapy Clicking in the glenohumeral joint is noted with passive rotation of the arm in an abducted position. Tests for Item 77 rotator cuff injury are negative. Strength is 5/5 through- out the left arm. A 62-year-old woman is evaluated for a change in her abdominal and pelvic pain symptoms. The patient has been Which of the following is the most likely diagnosis? followed for 3 years for medically unexplained symptoms. Her typical symptoms have included chronic pelvic pain (A) Acromioclavicular joint degeneration of unknown cause and migrating upper abdominal pain. (B) Adhesive capsulitis An extensive evaluation, including endoscopy, advanced (C) Biceps tendinopathy imaging, and laboratory evaluation, has been negative. Her symptoms have been stable for the past 2 years until (D) Labral tear recently. Her new abdominal symptom is central boring pain that has been present for 6 weeks and is associated with anorexia, diarrhea, and a 2-kg (4.4-Ib) weight loss. Item 80 She is currently taking no medications. An 81-year-old woman is evaluated for dyspnea that On physical examination, vital signs are normal. The has slowly worsened over the past 3 months. She has mid-abdomen is tender to deep palpation. a history of severe COPD and has been on continuous oxygen therapy for 6 years. She has a minimal cough Which of the following is the most appropriate initial productive of scant sputum. Two weeks ago, she fin- management? ished pulmonary rehabilitation, which provided some improvement in symptoms. Her medications are inhaled ( A) CT of the abdomen and pelvis vilanterol trifenatate, umeclidinium bromide, and flu- ( B) Depression screening ticasone furoate. (C) ) Exploration of psychosocial stressors On physical examination, vital signs are normal. (D) Nortriptyline Breath sounds are diminished bilaterally. Which of the following is the most appropriate treatment? Item 78 (A) Chest physiotherapy A 29-year-old woman is evaluated for a 2-week history of (B) Handheld fan left-sided back pain. The pain begins in the lumbar spine and radiates through the left buttock and hip into the thigh. (C) Levofloxacin The pain is sharp and shooting. She is 19 weeks pregnant (D) Pulmonary rehabilitation

Which of the following is the most appropriate treatment? Item 78 (A) Chest physiotherapy A 29-year-old woman is evaluated for a 2-week history of (B) Handheld fan left-sided back pain. The pain begins in the lumbar spine and radiates through the left buttock and hip into the thigh. (C) Levofloxacin The pain is sharp and shooting. She is 19 weeks pregnant (D) Pulmonary rehabilitation 125

Self-Assessment Test wn © as Item 81 Which of the following is the most appropriate diagnostic b test to perform next? wn A 58-year-old woman is evaluated for a 1-week history m1) ry wn of urinary incontinence and increased urinary frequency. (A) Comprehensive neuropsychological evaluation She reports having a sudden urge to urinate and needing to z 7) rush to the bathroom. There is often leakage of urine before (B) Depression assessment (C) MRI of the brain = - she reaches the toilet. She has had no dysuria, nocturia, or hematuria. She has been postmenopausal for 4 years and (D) Vitamin B,, measurement o wo - had three vaginal deliveries between 24 and 30 years of age. On physical examination, vital signs are normal. Item 84 Pelvic examination is normal. A 57-year-old woman is evaluated for worsening right Which of the following is the most appropriate shoulder pain of several months’ duration, which she management? describes as a dull ache deep within the shoulder. She has had difficulty with fastening her bra behind her back and (A) Bladder training with timed voiding with performing overhead activities. (B) Pelvic floor muscle training On physical examination, there is no pain with pal- (C) Topical vaginal estrogen pation of the right shoulder. During full passive abduction of the right arm, pain occurs at 90 degrees. She is able to (D) Urinalysis lower her arm smoothly from a fully abducted position. Resisted abduction strength and forward flexion strength are 4/5; strength is otherwise 5/5 in the right arm. The Item 82 remainder of the shoulder examination is normal. A 37-year-old woman is evaluated for a 4-day history of acute-onset, right-sided neck pain with radiation to the Which of the following is the most appropriate next step in right arm. The pain worsens when she turns her head to management? the right and with right lateral flexion, and it improves when she lies down. She also notes a sporadic tingling (A) Glucocorticoid injection sensation on the lateral aspect of the right hand. She has (B) MRI of the right shoulder not had any other symptoms. She reports recreational use (C) Physical therapy of oral opioids. (D) Sling immobilization On physical examination, active and passive range of motion of the neck are severely limited by pain. Right upper extremity muscle strength and reflexes are normal. Item 85 There is no cervical spine tenderness. Pain is reproduced by A 40-year-old woman is evaluated for constant worry about applying downward pressure to the patient’s head while work and family, feeling on edge, irritability, difficulty con- it is bent to the right and extended (Spurling test). Pain is centrating at work, and insomnia. These symptoms have relieved by lifting her right arm above her head. developed over the past 7 months and have resulted in family discord and absenteeism from work. The patient has Which of the following is the most appropriate a history of alcohol use disorder that has been in remission management? for 18 months. She is otherwise well, and her only medica-

wn © as Item 81 Which of the following is the most appropriate diagnostic b test to perform next? wn A 58-year-old woman is evaluated for a 1-week history m1) ry wn of urinary incontinence and increased urinary frequency. (A) Comprehensive neuropsychological evaluation She reports having a sudden urge to urinate and needing to z 7) rush to the bathroom. There is often leakage of urine before (B) Depression assessment (C) MRI of the brain = - she reaches the toilet. She has had no dysuria, nocturia, or hematuria. She has been postmenopausal for 4 years and (D) Vitamin B,, measurement o wo - had three vaginal deliveries between 24 and 30 years of age. On physical examination, vital signs are normal. Item 84 Pelvic examination is normal. A 57-year-old woman is evaluated for worsening right Which of the following is the most appropriate shoulder pain of several months’ duration, which she management? describes as a dull ache deep within the shoulder. She has had difficulty with fastening her bra behind her back and (A) Bladder training with timed voiding with performing overhead activities. (B) Pelvic floor muscle training On physical examination, there is no pain with pal- (C) Topical vaginal estrogen pation of the right shoulder. During full passive abduction of the right arm, pain occurs at 90 degrees. She is able to (D) Urinalysis lower her arm smoothly from a fully abducted position. Resisted abduction strength and forward flexion strength are 4/5; strength is otherwise 5/5 in the right arm. The Item 82 remainder of the shoulder examination is normal. A 37-year-old woman is evaluated for a 4-day history of acute-onset, right-sided neck pain with radiation to the Which of the following is the most appropriate next step in right arm. The pain worsens when she turns her head to management? the right and with right lateral flexion, and it improves when she lies down. She also notes a sporadic tingling (A) Glucocorticoid injection sensation on the lateral aspect of the right hand. She has (B) MRI of the right shoulder not had any other symptoms. She reports recreational use (C) Physical therapy of oral opioids. (D) Sling immobilization On physical examination, active and passive range of motion of the neck are severely limited by pain. Right upper extremity muscle strength and reflexes are normal. Item 85 There is no cervical spine tenderness. Pain is reproduced by A 40-year-old woman is evaluated for constant worry about applying downward pressure to the patient’s head while work and family, feeling on edge, irritability, difficulty con- it is bent to the right and extended (Spurling test). Pain is centrating at work, and insomnia. These symptoms have relieved by lifting her right arm above her head. developed over the past 7 months and have resulted in family discord and absenteeism from work. The patient has Which of the following is the most appropriate a history of alcohol use disorder that has been in remission management? for 18 months. She is otherwise well, and her only medica- A) Cervical collar tion is an oral contraceptive. On physical examination, vital signs are normal. Score MRI of the cervical spine on the Generalized Anxiety Disorder-7 instrument is 16. Neck exercises Thyroid-stimulating hormone level is 2 wU/mL D) Oxycodone (2 mU/L). E) Radiography of the cervical spine The patient is offered cognitive behavioral therapy but prefers a trial of medication.

A) Cervical collar tion is an oral contraceptive. On physical examination, vital signs are normal. Score MRI of the cervical spine on the Generalized Anxiety Disorder-7 instrument is 16. Neck exercises Thyroid-stimulating hormone level is 2 wU/mL D) Oxycodone (2 mU/L). E) Radiography of the cervical spine The patient is offered cognitive behavioral therapy but prefers a trial of medication. Item 83 Which of the following is the most appropriate management? An 84-year-old woman is brought to the office by her son for evaluation of dementia. He reports that since the (A) Alprazolam patient’s husband died 8 months ago, she has neglected ( B) Amitriptyline her personal hygiene, naps during the day, has difficulty sleeping at night, and has lost interest in going out. She ( C) Paroxetine takes no medications. ( D) Repeat the Generalized Anxiety Disorder-7 assessment On physical examination, vital signs are normal. BMI in1 month 1 year ago was 26; today, BMI is 24. She appears sad and has a blunted affect. Neurologic examination is without focal motor deficits. On the Mini-Cog assessment of cognitive Item 86 function, the patient cannot recall two of three words and A 58-year-old man is evaluated at a follow-up appoint- did not attempt to draw a clock face due to fatigue. ment. He is feeling well and has no symptoms. Medical 126

Self-Assessment Test Cal history is significant for hypertension and type 2 diabetes Which of the following is the most appropriate ct = thet mellitus. He exercises by walking 4 miles daily. He has management? = a never smoked and drinks one or two glasses of wine per day. Current medications are lisinopril, metformin, cana- (A) Frailty assessment = w gliflozin, and aspirin. He is also receiving maximum-dose (B) Knee strengthening exercises 1%) a wn therapy with atorvastatin and ezetimibe. His baseline LDL (C) Timed Up and Go Test 72)

gliflozin, and aspirin. He is also receiving maximum-dose (B) Knee strengthening exercises 1%) a wn therapy with atorvastatin and ezetimibe. His baseline LDL (C) Timed Up and Go Test 72) cholesterol level before starting atorvastatin and ezetimibe (D) Total knee replacement =< — was 220 mg/dL (5.70 mmol/L). a ” On physical examination, blood pressure is 124/73 mm Hg. BMI is 28. Item 89 Laboratory studies: A 34-year-old woman is evaluated for concerns about Hemoglobin A,, 6.9% long-term stressors. She reports ongoing court battles with HDL cholesterol 35 mg/dL (0.91 mmol/L) her former spouse over child custody. She also describes LDL cholesterol 140 mg/dL (3.63 mmol/L) frustration about her current living situation stemming Total cholesterol 190 mg/dL (4.92 mmol/L) from arguments with her roommate about rent payments. Triglycerides 100 mg/dL (1.13 mmol/L) She was previously treated by a psychiatrist for major depression but terminated the relationship because she Which of the following is the most appropriate additional and the psychiatrist “did not see eye to eye” about treat- treatment? ment options; she becomes angry when discussing this (A) > Fenofibrate situation. She takes no medications.

cholesterol level before starting atorvastatin and ezetimibe (D) Total knee replacement =< — was 220 mg/dL (5.70 mmol/L). a ” On physical examination, blood pressure is 124/73 mm Hg. BMI is 28. Item 89 Laboratory studies: A 34-year-old woman is evaluated for concerns about Hemoglobin A,, 6.9% long-term stressors. She reports ongoing court battles with HDL cholesterol 35 mg/dL (0.91 mmol/L) her former spouse over child custody. She also describes LDL cholesterol 140 mg/dL (3.63 mmol/L) frustration about her current living situation stemming Total cholesterol 190 mg/dL (4.92 mmol/L) from arguments with her roommate about rent payments. Triglycerides 100 mg/dL (1.13 mmol/L) She was previously treated by a psychiatrist for major depression but terminated the relationship because she Which of the following is the most appropriate additional and the psychiatrist “did not see eye to eye” about treat- treatment? ment options; she becomes angry when discussing this (A) > Fenofibrate situation. She takes no medications. (B) Icosapent ethyl Which of the following is the most likely diagnosis? (C) Niacin @)

cholesterol level before starting atorvastatin and ezetimibe (D) Total knee replacement =< — was 220 mg/dL (5.70 mmol/L). a ” On physical examination, blood pressure is 124/73 mm Hg. BMI is 28. Item 89 Laboratory studies: A 34-year-old woman is evaluated for concerns about Hemoglobin A,, 6.9% long-term stressors. She reports ongoing court battles with HDL cholesterol 35 mg/dL (0.91 mmol/L) her former spouse over child custody. She also describes LDL cholesterol 140 mg/dL (3.63 mmol/L) frustration about her current living situation stemming Total cholesterol 190 mg/dL (4.92 mmol/L) from arguments with her roommate about rent payments. Triglycerides 100 mg/dL (1.13 mmol/L) She was previously treated by a psychiatrist for major depression but terminated the relationship because she Which of the following is the most appropriate additional and the psychiatrist “did not see eye to eye” about treat- treatment? ment options; she becomes angry when discussing this (A) > Fenofibrate situation. She takes no medications. (B) Icosapent ethyl Which of the following is the most likely diagnosis? (C) Niacin @) ( =) Proprotein convertase subtilisin/kexin type 9 (PCSK9) (A) Bipolar disorder inhibitor (B) Generalized anxiety disorder (C) Personality disorder (D) Schizophrenia Item 87 A 58-year-old woman is evaluated in follow-up after her third hospitalization for severe dyspnea in the past Item 90 6 months. She has pulmonary arterial hypertension and A 63-year-old man is evaluated in the emergency department stage G4 chronic kidney disease. During the visit, she for confusion after being found by his wife. He recently visited describes a progressive decline in her functional status. Her an urgent care center for symptoms of an upper respiratory resuscitation status is listed as “full code” in her discharge tract infection and was prescribed codeine-guaifenesin. His summary, but she has noted in previous meetings that she wife reports that he took the medicine as directed. does not want to be a “vegetable” if she has an incurable On physical examination, respiration rate is 10/min. disease. Medications are bumetanide, aspirin, apixaban, All other vital signs are normal. The patient is somnolent. and treprostinil. She is on supplemental oxygen at home. Miotic pupils and shallow inspirations are noted. Treatment with naloxone rapidly improves mental Which of the following is the most appropriate next step in status and respiration. eliciting this patient’s goals of care?

( =) Proprotein convertase subtilisin/kexin type 9 (PCSK9) (A) Bipolar disorder inhibitor (B) Generalized anxiety disorder (C) Personality disorder (D) Schizophrenia Item 87 A 58-year-old woman is evaluated in follow-up after her third hospitalization for severe dyspnea in the past Item 90 6 months. She has pulmonary arterial hypertension and A 63-year-old man is evaluated in the emergency department stage G4 chronic kidney disease. During the visit, she for confusion after being found by his wife. He recently visited describes a progressive decline in her functional status. Her an urgent care center for symptoms of an upper respiratory resuscitation status is listed as “full code” in her discharge tract infection and was prescribed codeine-guaifenesin. His summary, but she has noted in previous meetings that she wife reports that he took the medicine as directed. does not want to be a “vegetable” if she has an incurable On physical examination, respiration rate is 10/min. disease. Medications are bumetanide, aspirin, apixaban, All other vital signs are normal. The patient is somnolent. and treprostinil. She is on supplemental oxygen at home. Miotic pupils and shallow inspirations are noted. Treatment with naloxone rapidly improves mental Which of the following is the most appropriate next step in status and respiration. eliciting this patient’s goals of care? (A) Document patient preferences Which of the following is the most likely cause of this patient’s adverse drug reaction? (B) Explain that her prognosis is limited (C) Explore what she knows about her illness (A) Polymorphism of a cytochrome P450 gene (D) Readdress the patient’s resuscitation preferences (B) Polymorphism of thiopurine methyltransferase gene (C) Presence of HLA-B*57:01 allele (D) Presence of HLA-B*58:01 allele Item 88 An 85-year-old man is evaluated during a routine wellness visit. He reports that he generally has less stamina, his Item 91 activity level is decreasing, and he is considerably slower A 38-year-old woman is evaluated after a recent diagnosis performing his usual activities of daily living. He has also of systemic exertion intolerance disease. She fulfilled the noticed increasing right knee pain that is limiting his diagnostic criteria of fatigue of at least 6 months’ duration mobility. His only medications are acetaminophen and with substantial reduction in pre-illness activities, postex- topical diclofenac for his knee pain. ertional malaise, unrefreshing sleep, and cognitive impair- On physical examination, vital signs are normal. BMI ment. She reports no pain, depressed mood, anhedonia, is 22 and similar to the value obtained 6 months ago. Bony snoring, or daytime hypersomnolence. Medical history hypertrophy, crepitus, and decreased range of motion of is significant for migraine and irritable bowel syndrome the right knee are noted. Cardiac and pulmonary examina- with predominant diarrhea. Medications are sumatriptan, tions are unremarkable. topiramate, loperamide, and nortriptyline.

(A) Document patient preferences Which of the following is the most likely cause of this patient’s adverse drug reaction? (B) Explain that her prognosis is limited (C) Explore what she knows about her illness (A) Polymorphism of a cytochrome P450 gene (D) Readdress the patient’s resuscitation preferences (B) Polymorphism of thiopurine methyltransferase gene (C) Presence of HLA-B*57:01 allele (D) Presence of HLA-B*58:01 allele Item 88 An 85-year-old man is evaluated during a routine wellness visit. He reports that he generally has less stamina, his Item 91 activity level is decreasing, and he is considerably slower A 38-year-old woman is evaluated after a recent diagnosis performing his usual activities of daily living. He has also of systemic exertion intolerance disease. She fulfilled the noticed increasing right knee pain that is limiting his diagnostic criteria of fatigue of at least 6 months’ duration mobility. His only medications are acetaminophen and with substantial reduction in pre-illness activities, postex- topical diclofenac for his knee pain. ertional malaise, unrefreshing sleep, and cognitive impair- On physical examination, vital signs are normal. BMI ment. She reports no pain, depressed mood, anhedonia, is 22 and similar to the value obtained 6 months ago. Bony snoring, or daytime hypersomnolence. Medical history hypertrophy, crepitus, and decreased range of motion of is significant for migraine and irritable bowel syndrome the right knee are noted. Cardiac and pulmonary examina- with predominant diarrhea. Medications are sumatriptan, tions are unremarkable. topiramate, loperamide, and nortriptyline. 127

Self-Assessment Test wn @ oh Which of the following is the most appropriate management? His 10-year risk for atherosclerotic cardiovascular dis- > ease is 8.0%. wn my) A) Graded exercise program oO Ww B) Modafinil Which of the following is the most appropriate test to 3 @o ) Pregabalin perform before starting statin therapy? = D) Sertraline - (A) Aminotransferase measurement o w (B) Creatine kinase measurement - Item 92 (C) Fasting blood glucose measurement

wn @ oh Which of the following is the most appropriate management? His 10-year risk for atherosclerotic cardiovascular dis- > ease is 8.0%. wn my) A) Graded exercise program oO Ww B) Modafinil Which of the following is the most appropriate test to 3 @o ) Pregabalin perform before starting statin therapy? = D) Sertraline - (A) Aminotransferase measurement o w (B) Creatine kinase measurement - Item 92 (C) Fasting blood glucose measurement A 64-year-old man is evaluated in the emergency depart- (D) Treadmill stress testing ment for low back pain and difficulty climbing stairs that has worsened over the past several days. The pain radiates into his legs bilaterally. He has not urinated in the past Item 95 24 hours. He has a history of prostate cancer treated with A 40-year-old man is evaluated for episodic dizziness. external beam radiation therapy. Three years ago, he developed left ear sensorineural hear- On physical examination, vital signs are normal. Ankle ing loss confirmed by audiometry, with associated tinni- reflexes and patellar reflexes are decreased bilaterally. Dor tus. For the past 6 months, he has had episodes of “room siflexion and plantar flexion weakness are present bilater- spinning” that last from 30 minutes to several hours; epi- ally, as is mild but detectable weakness of the major muscle sodes are associated with nausea and sometimes vomiting. groups of the legs and thighs. There is no spinal tenderness. He experiences disequilibrium intermittently. MRI of the brain performed 6 months ago was normal. The patient is Which of the following is the most likely diagnosis? otherwise healthy and takes no medications. On physical examination, vital signs are normal. The (A) Cauda equina syndrome Dix-Hallpike maneuver on the left side causes dizziness (B) Piriformis syndrome without vertigo or nystagmus. (C) Radiation-induced pelvic insufficiency fracture (D) Vertebral compression fracture Which of the following is the most likely diagnosis?

A 64-year-old man is evaluated in the emergency depart- (D) Treadmill stress testing ment for low back pain and difficulty climbing stairs that has worsened over the past several days. The pain radiates into his legs bilaterally. He has not urinated in the past Item 95 24 hours. He has a history of prostate cancer treated with A 40-year-old man is evaluated for episodic dizziness. external beam radiation therapy. Three years ago, he developed left ear sensorineural hear- On physical examination, vital signs are normal. Ankle ing loss confirmed by audiometry, with associated tinni- reflexes and patellar reflexes are decreased bilaterally. Dor tus. For the past 6 months, he has had episodes of “room siflexion and plantar flexion weakness are present bilater- spinning” that last from 30 minutes to several hours; epi- ally, as is mild but detectable weakness of the major muscle sodes are associated with nausea and sometimes vomiting. groups of the legs and thighs. There is no spinal tenderness. He experiences disequilibrium intermittently. MRI of the brain performed 6 months ago was normal. The patient is Which of the following is the most likely diagnosis? otherwise healthy and takes no medications. On physical examination, vital signs are normal. The (A) Cauda equina syndrome Dix-Hallpike maneuver on the left side causes dizziness (B) Piriformis syndrome without vertigo or nystagmus. (C) Radiation-induced pelvic insufficiency fracture (D) Vertebral compression fracture Which of the following is the most likely diagnosis? (A) Benign paroxysmal positional vertigo

A 64-year-old man is evaluated in the emergency depart- (D) Treadmill stress testing ment for low back pain and difficulty climbing stairs that has worsened over the past several days. The pain radiates into his legs bilaterally. He has not urinated in the past Item 95 24 hours. He has a history of prostate cancer treated with A 40-year-old man is evaluated for episodic dizziness. external beam radiation therapy. Three years ago, he developed left ear sensorineural hear- On physical examination, vital signs are normal. Ankle ing loss confirmed by audiometry, with associated tinni- reflexes and patellar reflexes are decreased bilaterally. Dor tus. For the past 6 months, he has had episodes of “room siflexion and plantar flexion weakness are present bilater- spinning” that last from 30 minutes to several hours; epi- ally, as is mild but detectable weakness of the major muscle sodes are associated with nausea and sometimes vomiting. groups of the legs and thighs. There is no spinal tenderness. He experiences disequilibrium intermittently. MRI of the brain performed 6 months ago was normal. The patient is Which of the following is the most likely diagnosis? otherwise healthy and takes no medications. On physical examination, vital signs are normal. The (A) Cauda equina syndrome Dix-Hallpike maneuver on the left side causes dizziness (B) Piriformis syndrome without vertigo or nystagmus. (C) Radiation-induced pelvic insufficiency fracture (D) Vertebral compression fracture Which of the following is the most likely diagnosis? (A) Benign paroxysmal positional vertigo Item 93 (B) Labyrinthitis (C) Meniere disease A 53-year-old woman is evaluated during a follow-up appointment for a multiyear history of chronic back pain (D) Vertebrobasilar stroke in the setting of osteoporotic compression fractures. In (E) Vestibular migraine addition to nonpharmacologic treatment, including exer- cise, she has previously undergone vertebroplasty, facet joint injections, medial branch blocks with radiofrequency Item 96 ablation, and transforaminal epidural glucocorticoid injec- A 40-year-old man undergoes cardiac risk evaluation. He is tions. Her pain is not well controlled with gabapentin, asymptomatic but leads a sedentary lifestyle. topical lidocaine patches, and an oral NSAID, resulting in On physical examination. vital signs are normal. BMI interference with work and leisure activities. Other med- is 27. The remainder of the examination is normal. ications include zoledronic acid, vitamin D, and calcium. Laboratory studies: There are no changes noted on her physical examina- Total cholesterol 180 mg/dL (4.66 mmol/L) tion from previous visits. LDL cholesterol 100 mg/dL (2.59 mmol/L) Opioid therapy is being considered. HDL cholesterol 40 mg/dL (1.03 mmol/L) Fasting plasma glucose 98 mg/dL (5.43 mmol/L) Which of the following is the most appropriate next step in management? Calculated risk for atherosclerotic cardiovascular dis- ease using the Pooled Cohort Equations is 1.4%. (A) Calcitonin (B) Opioid risk assessment Which of the following is the most appropriate management? (C) Thoracic and lumbar radiography (A) Intensive diet and exercise counseling (D) Urine drug screening (B) Low-dose aspirin (C) Moderate-intensity statin therapy Item 94 (D) Treadmill stress exercise testing A 54-year-old man is evaluated before starting statin therapy for dyslipidemia. He also has hypertension. He reports no exertional chest pain or dyspnea. Therapeutic lifestyle changes Item 97 have been implemented. His only medication is losartan. A 72-year-old woman is evaluated for an intense urge to On physical examination, vital signs and other find- empty her bladder and inability to get to the bathroom fast ings are normal. BMI is 24. enough. She rushes to the bathroom six to eight times per

Item 93 (B) Labyrinthitis (C) Meniere disease A 53-year-old woman is evaluated during a follow-up appointment for a multiyear history of chronic back pain (D) Vertebrobasilar stroke in the setting of osteoporotic compression fractures. In (E) Vestibular migraine addition to nonpharmacologic treatment, including exer- cise, she has previously undergone vertebroplasty, facet joint injections, medial branch blocks with radiofrequency Item 96 ablation, and transforaminal epidural glucocorticoid injec- A 40-year-old man undergoes cardiac risk evaluation. He is tions. Her pain is not well controlled with gabapentin, asymptomatic but leads a sedentary lifestyle. topical lidocaine patches, and an oral NSAID, resulting in On physical examination. vital signs are normal. BMI interference with work and leisure activities. Other med- is 27. The remainder of the examination is normal. ications include zoledronic acid, vitamin D, and calcium. Laboratory studies: There are no changes noted on her physical examina- Total cholesterol 180 mg/dL (4.66 mmol/L) tion from previous visits. LDL cholesterol 100 mg/dL (2.59 mmol/L) Opioid therapy is being considered. HDL cholesterol 40 mg/dL (1.03 mmol/L) Fasting plasma glucose 98 mg/dL (5.43 mmol/L) Which of the following is the most appropriate next step in management? Calculated risk for atherosclerotic cardiovascular dis- ease using the Pooled Cohort Equations is 1.4%. (A) Calcitonin (B) Opioid risk assessment Which of the following is the most appropriate management? (C) Thoracic and lumbar radiography (A) Intensive diet and exercise counseling (D) Urine drug screening (B) Low-dose aspirin (C) Moderate-intensity statin therapy Item 94 (D) Treadmill stress exercise testing A 54-year-old man is evaluated before starting statin therapy for dyslipidemia. He also has hypertension. He reports no exertional chest pain or dyspnea. Therapeutic lifestyle changes Item 97 have been implemented. His only medication is losartan. A 72-year-old woman is evaluated for an intense urge to On physical examination, vital signs and other find- empty her bladder and inability to get to the bathroom fast ings are normal. BMI is 24. enough. She rushes to the bathroom six to eight times per 128

Self-Assessment Test — od day and wakes several times in the night to urinate. She Item 100 — ood has no hematuria or dysuria. She has no other medical A 50-year-old man is evaluated for worsening depres- = a problems and takes no medications. sive symptoms. He has major depressive disorder, £ On physical examination, vital signs are normal. BMI which was previously well controlled with fluoxetine, n wn is 25. Pelvic examination is normal except for mild anterior 20 mg daily. oY wn w wall prolapse. On physical examination, vital signs are normal. The = Findings on urinalysis are unremarkable. patient appears anxious and tired. He becomes tearful =) wo when discussing his current situation. “2) Which of the following is the most appropriate management? Repeat score on PHQ-9 is 15; his previous score was 8.

is 25. Pelvic examination is normal except for mild anterior 20 mg daily. oY wn w wall prolapse. On physical examination, vital signs are normal. The = Findings on urinalysis are unremarkable. patient appears anxious and tired. He becomes tearful =) wo when discussing his current situation. “2) Which of the following is the most appropriate management? Repeat score on PHQ-9 is 15; his previous score was 8. (A) Bladder training with timed voiding Which of the following is the most important next step in (B) Mirabegron management? (C) Oxybutynin (A) Add olanzapine (D) Pelvic floor muscle training (B) Administer the Mood Disorder Questionnaire (C) Increase fluoxetine Item 98 (D) Inquire about suicidal ideation A 45-year-old man is evaluated after admission to the hos- pital for pneumonia. He has a history of T4 paraplegia from a motor vehicle accident 20 years ago. He performs inter- Item 101 mittent bladder catheterization for urinary retention. He A 53-year-old woman is evaluated during a follow-up has no other medical conditions and takes no medications. appointment. She has a 6-year history of relapsing-remitting On physical examination, temperature is 37.3 °C multiple sclerosis, which is complicated by chronic pain (99.2 °F), blood pressure is 108/70 mm Hg, pulse rate is from spasticity of the large muscle groups in the lower 99/min, and respiration rate is 20/min. Oxygen saturation extremities and diffuse burning pain in the upper and is 92% on 2 L of oxygen by nasal cannula. BMI is 33. The lower extremities with associated sensory derangements. patient is supine in a hospital bed. He has crackles and Her pain syndrome has led to significant functional debility reduced breath sounds in the right lower lobe. The skin and has been minimally responsive to oral opioid, antiepi- over the back, buttocks, and lower extremities shows no leptic, and gabapentinoid therapies. Current medications evidence of pressure injury. He is asensate below T4. are meloxicam, baclofen, and duloxetine. On physical examination, vital signs are normal. There Which of the following is the most appropriate measure to is significant tenderness in the quadriceps bilaterally. prevent pressure injury in this patient? Numbness and loss of temperature distinction are noted in the right arm and hand as well as in the left foot. (A) Alternating air mattress (B) Hourly repositioning Which of the following is most appropriate to manage this (C) Local skin care with emollients patient’s chronic pain? (D) Nutritional supplementation (A) Hydrocodone/acetaminophen (E) Static mattress overlay (B) Medical cannabis

(A) Bladder training with timed voiding Which of the following is the most important next step in (B) Mirabegron management? (C) Oxybutynin (A) Add olanzapine (D) Pelvic floor muscle training (B) Administer the Mood Disorder Questionnaire (C) Increase fluoxetine Item 98 (D) Inquire about suicidal ideation A 45-year-old man is evaluated after admission to the hos- pital for pneumonia. He has a history of T4 paraplegia from a motor vehicle accident 20 years ago. He performs inter- Item 101 mittent bladder catheterization for urinary retention. He A 53-year-old woman is evaluated during a follow-up has no other medical conditions and takes no medications. appointment. She has a 6-year history of relapsing-remitting On physical examination, temperature is 37.3 °C multiple sclerosis, which is complicated by chronic pain (99.2 °F), blood pressure is 108/70 mm Hg, pulse rate is from spasticity of the large muscle groups in the lower 99/min, and respiration rate is 20/min. Oxygen saturation extremities and diffuse burning pain in the upper and is 92% on 2 L of oxygen by nasal cannula. BMI is 33. The lower extremities with associated sensory derangements. patient is supine in a hospital bed. He has crackles and Her pain syndrome has led to significant functional debility reduced breath sounds in the right lower lobe. The skin and has been minimally responsive to oral opioid, antiepi- over the back, buttocks, and lower extremities shows no leptic, and gabapentinoid therapies. Current medications evidence of pressure injury. He is asensate below T4. are meloxicam, baclofen, and duloxetine. On physical examination, vital signs are normal. There Which of the following is the most appropriate measure to is significant tenderness in the quadriceps bilaterally. prevent pressure injury in this patient? Numbness and loss of temperature distinction are noted in the right arm and hand as well as in the left foot. (A) Alternating air mattress (B) Hourly repositioning Which of the following is most appropriate to manage this (C) Local skin care with emollients patient’s chronic pain? (D) Nutritional supplementation (A) Hydrocodone/acetaminophen (E) Static mattress overlay (B) Medical cannabis (C) Topical capsaicin Item 99 (D) Transdermal buprenorphine A 57-year-old woman is evaluated for low back pain of 2 weeks’ duration. The pain is localized to the lumbar area. Item 102 Her bowel and bladder habits are unchanged. She is otherwise healthy, and her only medication is naproxen for back pain. A 67-year-old woman is evaluated for left knee pain of On physical examination, she appears generally uncom- insidious onset over the past 1 to 2 years. She remains fortable. There is pain bilaterally on palpation of the paraspi- active and exercises daily by walking, swimming, or bik- nal muscles of the lumbar spine. Pain is worsened with flexion ing. Her left knee swells after long walks and hikes. She or extension of the lumbar spine. Lower extremity strength also describes popping of her left knee. and reflexes are normal. There are no sensory deficits. Results of the Thessaly test and McMurray test in the Nonpharmacologic treatment options are discussed left knee suggest a meniscal tear. Lower extremity strength with the patient. is normal.

(C) Topical capsaicin Item 99 (D) Transdermal buprenorphine A 57-year-old woman is evaluated for low back pain of 2 weeks’ duration. The pain is localized to the lumbar area. Item 102 Her bowel and bladder habits are unchanged. She is otherwise healthy, and her only medication is naproxen for back pain. A 67-year-old woman is evaluated for left knee pain of On physical examination, she appears generally uncom- insidious onset over the past 1 to 2 years. She remains fortable. There is pain bilaterally on palpation of the paraspi- active and exercises daily by walking, swimming, or bik- nal muscles of the lumbar spine. Pain is worsened with flexion ing. Her left knee swells after long walks and hikes. She or extension of the lumbar spine. Lower extremity strength also describes popping of her left knee. and reflexes are normal. There are no sensory deficits. Results of the Thessaly test and McMurray test in the Nonpharmacologic treatment options are discussed left knee suggest a meniscal tear. Lower extremity strength with the patient. is normal. Which of the following is the most appropriate additional Which of the following is the most appropriate management? management? (A) Acetaminophen (A) Arthroscopic meniscal repair (B) Lorazepam (B) Immobilization of left knee (C) Patient education (C) MRI of the left knee (D) Systemic glucocorticoids (D) Physical therapy 129

Self-Assessment Test | 172) @o on Item 103 Which of the following is the most appropriate next step in pb) management? wn A 46-year-old woman is evaluated for an 8-month history wn @o of chest pain. She describes constant pain in the chest that A) Canalith repositioning maneuver wn intermittently worsens both at rest and with exertion. She z @o misses work once or twice per month because of the pain. B) Meclizine ) MRI of the brain —] — Results of previous evaluations, including cardiac enzyme = levels, ECG, chest radiography, echocardiography, exercise D) Prednisone @ “A stress testing, and CT of the chest, have been normal. She E) Vestibular and balance rehabilitation therapy -

Self-Assessment Test | 172) @o on Item 103 Which of the following is the most appropriate next step in pb) management? wn A 46-year-old woman is evaluated for an 8-month history wn @o of chest pain. She describes constant pain in the chest that A) Canalith repositioning maneuver wn intermittently worsens both at rest and with exertion. She z @o misses work once or twice per month because of the pain. B) Meclizine ) MRI of the brain —] — Results of previous evaluations, including cardiac enzyme = levels, ECG, chest radiography, echocardiography, exercise D) Prednisone @ “A stress testing, and CT of the chest, have been normal. She E) Vestibular and balance rehabilitation therapy - is worried and frustrated that a diagnosis has not been established, and she spends several hours daily searching for answers on the internet. She has no other medical Item 106 problems. She currently takes acetaminophen, but it does A 50-year-old man is evaluated for three episodes of hema- not relieve the pain. tochezia in the past 2 months. His last colonoscopy was On physical examination, vital signs and other find- 5 years ago, and the results were normal. His family his- ings are normal. Screens for depression and generalized tory includes colon cancer in his father, diagnosed at age anxiety disorder are negative. 55 years. The patient prefers to pursue a stool-based colon cancer screening strategy. Which of the following is the most likely diagnosis? A stool-based test that is 95% accurate in diagnosing colon cancer in average-risk individuals is available. The (A) Conversion disorder accuracy and effectiveness of this test were established in a ( B) oS Factitious disorder randomized controlled trial. ( C) Illness anxiety disorder (D) = Malingering Which of the following best explains why the evidence (E) Somatic symptom disorder does not support performing this stool-based test in this patient?

is worried and frustrated that a diagnosis has not been established, and she spends several hours daily searching for answers on the internet. She has no other medical Item 106 problems. She currently takes acetaminophen, but it does A 50-year-old man is evaluated for three episodes of hema- not relieve the pain. tochezia in the past 2 months. His last colonoscopy was On physical examination, vital signs and other find- 5 years ago, and the results were normal. His family his- ings are normal. Screens for depression and generalized tory includes colon cancer in his father, diagnosed at age anxiety disorder are negative. 55 years. The patient prefers to pursue a stool-based colon cancer screening strategy. Which of the following is the most likely diagnosis? A stool-based test that is 95% accurate in diagnosing colon cancer in average-risk individuals is available. The (A) Conversion disorder accuracy and effectiveness of this test were established in a ( B) oS Factitious disorder randomized controlled trial. ( C) Illness anxiety disorder (D) = Malingering Which of the following best explains why the evidence (E) Somatic symptom disorder does not support performing this stool-based test in this patient? (A) Impracticable number needed to screen Item 104 (B) Lack of external validity A 36-year-old woman is evaluated for left heel pain of (C) Low level of evidence 6 weeks’ duration. She is training for a half-marathon. The pain worsens with activity and improves after rest. (D) Presence of lead-time bias She reports no morning stiffness, trauma, swelling, or paresthesia. Percussion of the left heel, squeezing of the calcaneal Item 107 tuberosity, and hopping on the foot elicit pain. No ecchy- A 54-year-old woman is evaluated for an 18-month history mosis or edema is present; pulses, sensation, and strength of insidiously progressive dyspnea. She is typically seden- are normal. tary, but when she walks three blocks to the post office, she Radiograph of the left foot demonstrates a fracture has unaccountable fatigue and shortness of breath. Resting line in the calcaneus. alleviates the symptoms in a few minutes. She has no cardiac or pulmonary symptoms; has never smoked cigarettes; and Which of the following is the most appropriate works as an accountant, mainly from home. She has no other management? symptoms or medical problems and takes no medications. On physical examination, vital signs are normal. (A) Casting Oxygen saturation breathing ambient air is 97%. BMI is 31. (B) Electrical stimulation Cardiac and pulmonary examinations are normal. There (C) MRI of the foot is no edema.

(A) Impracticable number needed to screen Item 104 (B) Lack of external validity A 36-year-old woman is evaluated for left heel pain of (C) Low level of evidence 6 weeks’ duration. She is training for a half-marathon. The pain worsens with activity and improves after rest. (D) Presence of lead-time bias She reports no morning stiffness, trauma, swelling, or paresthesia. Percussion of the left heel, squeezing of the calcaneal Item 107 tuberosity, and hopping on the foot elicit pain. No ecchy- A 54-year-old woman is evaluated for an 18-month history mosis or edema is present; pulses, sensation, and strength of insidiously progressive dyspnea. She is typically seden- are normal. tary, but when she walks three blocks to the post office, she Radiograph of the left foot demonstrates a fracture has unaccountable fatigue and shortness of breath. Resting line in the calcaneus. alleviates the symptoms in a few minutes. She has no cardiac or pulmonary symptoms; has never smoked cigarettes; and Which of the following is the most appropriate works as an accountant, mainly from home. She has no other management? symptoms or medical problems and takes no medications. On physical examination, vital signs are normal. (A) Casting Oxygen saturation breathing ambient air is 97%. BMI is 31. (B) Electrical stimulation Cardiac and pulmonary examinations are normal. There (C) MRI of the foot is no edema. (D) Walking boot Chest radiograph, ECG, spirometry, and echocardio- gram are normal.

(A) Impracticable number needed to screen Item 104 (B) Lack of external validity A 36-year-old woman is evaluated for left heel pain of (C) Low level of evidence 6 weeks’ duration. She is training for a half-marathon. The pain worsens with activity and improves after rest. (D) Presence of lead-time bias She reports no morning stiffness, trauma, swelling, or paresthesia. Percussion of the left heel, squeezing of the calcaneal Item 107 tuberosity, and hopping on the foot elicit pain. No ecchy- A 54-year-old woman is evaluated for an 18-month history mosis or edema is present; pulses, sensation, and strength of insidiously progressive dyspnea. She is typically seden- are normal. tary, but when she walks three blocks to the post office, she Radiograph of the left foot demonstrates a fracture has unaccountable fatigue and shortness of breath. Resting line in the calcaneus. alleviates the symptoms in a few minutes. She has no cardiac or pulmonary symptoms; has never smoked cigarettes; and Which of the following is the most appropriate works as an accountant, mainly from home. She has no other management? symptoms or medical problems and takes no medications. On physical examination, vital signs are normal. (A) Casting Oxygen saturation breathing ambient air is 97%. BMI is 31. (B) Electrical stimulation Cardiac and pulmonary examinations are normal. There (C) MRI of the foot is no edema. (D) Walking boot Chest radiograph, ECG, spirometry, and echocardio- gram are normal. Item 105 Which of the following diagnostic tests should be A 39-year-old woman is evaluated for dizziness. For the performed next?

(D) Walking boot Chest radiograph, ECG, spirometry, and echocardio- gram are normal. Item 105 Which of the following diagnostic tests should be A 39-year-old woman is evaluated for dizziness. For the performed next? past week, upon awakening, she has experienced a spin- (A) Cardiopulmonary exercise testing ning sensation for 20 to 60 seconds with associated nau- (B) D-dimer measurement sea. She has had intermittent lightheadedness at various times during the day since symptom onset. She reports no (C) 6-Minute walk test hearing loss or tinnitus. She recovered from a viral upper (D) Ventilation/perfusion lung scan respiratory tract illness 3 weeks ago. The patient is other- wise healthy and takes no medications. On physical examination, vital signs are normal. The Item 108 Dix-Hallpike maneuver on the right side shows delayed A 53-year-old woman is evaluated for chronic pain. She unidirectional nystagmus associated with vertigo and nau- describes an 18-month history of aching pressure in her sea. The remainder of the examination is normal. back, neck, and chest that has affected her quality of life. 130

Self-Assessment Test _ An appropriate evaluation has failed to identify the source CH — of the patient’s symptoms; the patient understands that tet Ee additional testing is unlikely to be helpful. Acetaminophen, ow duloxetine, and NSAIDs have been minimally effective. She = w was recently diagnosed with major depressive disorder. nn aw ~” Her only medications are ibuprofen and fluoxetine. 7) On physical examination, vital signs are normal. There = is minimal tenderness to palpation in the paraspinal mus- = Q cles of the lumbar and thoracic spine, posterior neck, and ” anterior chest wall. The remainder of the physical exam- ination is unremarkable. Which of the following is the most appropriate management? (A) Lorazepam (B) Multimodal pain management program (D) Topical triamcinolone (C) Oxycodone (E) Reassurance (D) Pregabalin

anterior chest wall. The remainder of the physical exam- ination is unremarkable. Which of the following is the most appropriate management? (A) Lorazepam (B) Multimodal pain management program (D) Topical triamcinolone (C) Oxycodone (E) Reassurance (D) Pregabalin Item 111 Item 109 A 55-year-old woman is evaluated for left lateral hip pain A 32-year-old woman is evaluated during a new patient that has progressed over the past 6 weeks. She describes visit. Her family history is notable for myocardial infarc- an aching pain that radiates to the knee and is worse at tion in her father at age 52 years and brother at age night when lying on the affected side. She reports no other 40 years. Her only medication is an oral contraceptive. symptoms. On physical examination, blood pressure is 115/65 mm On physical examination, there is tenderness to palpa- Hg. BMI is 26. Other physical examination findings are tion over the left lateral hip. The FABER (Flexion, ABduction, normal. and External Rotation) test elicits lateral hip pain. Sensation

Item 111 Item 109 A 55-year-old woman is evaluated for left lateral hip pain A 32-year-old woman is evaluated during a new patient that has progressed over the past 6 weeks. She describes visit. Her family history is notable for myocardial infarc- an aching pain that radiates to the knee and is worse at tion in her father at age 52 years and brother at age night when lying on the affected side. She reports no other 40 years. Her only medication is an oral contraceptive. symptoms. On physical examination, blood pressure is 115/65 mm On physical examination, there is tenderness to palpa- Hg. BMI is 26. Other physical examination findings are tion over the left lateral hip. The FABER (Flexion, ABduction, normal. and External Rotation) test elicits lateral hip pain. Sensation Laboratory studies: to light touch and pinprick over the thigh are normal. LDL cholesterol 205 mg/dL (5.31 mmol/L) HDL cholesterol 45 mg/dL (1.17 mmol/L) Which of the following is the most likely diagnosis? Triglycerides 160 mg/dL (1.81 mmol/L) (A) Femoroacetabular impingement syndrome Thyroid-stimulating hormone 2.0 tU/mL (2.0 mU/L) (B) Greater trochanteric pain syndrome In addition to therapeutic lifestyle changes, which of the (C) Hip osteoarthritis following is the most appropriate treatment? (D) Meralgia paresthetica (A) High-intensity statin therapy (B) High-intensity statin therapy and ezetimibe Item 112 (C) High-intensity statin therapy and icosapent ethyl \n 83 vear old man is evaluated for opioid related con (D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) suipation. He was prescribed opioids for back pain in the inhibitor setting of multilevel osteoporotic vertebral compression fractures. Medications are calcium. vitamin D. zoledronic acid, polyethylene glycol, and oxycodone. Item 110 On physical examination, vital signs are normal. Nor An 81-year-old woman is evaluated for bruising. For the mal bowel sounds are present. The abdomen is distended past few years, she has noticed dark red patches appearing nd tender to very deep palpation in the lower quadrants, intermittently on the forearms without trauma or other with no rebound and no guarding. triggers. They are not painful and resolve without treat- ment. History includes hypertension, for which she takes Which of the following is the most appropriate hydrochlorothiazide. treatment? On physical examination, vital signs, including blood pressure, are normal. Skin is dry, and skin findings on the (\)) Docusate sodium

Laboratory studies: to light touch and pinprick over the thigh are normal. LDL cholesterol 205 mg/dL (5.31 mmol/L) HDL cholesterol 45 mg/dL (1.17 mmol/L) Which of the following is the most likely diagnosis? Triglycerides 160 mg/dL (1.81 mmol/L) (A) Femoroacetabular impingement syndrome Thyroid-stimulating hormone 2.0 tU/mL (2.0 mU/L) (B) Greater trochanteric pain syndrome In addition to therapeutic lifestyle changes, which of the (C) Hip osteoarthritis following is the most appropriate treatment? (D) Meralgia paresthetica (A) High-intensity statin therapy (B) High-intensity statin therapy and ezetimibe Item 112 (C) High-intensity statin therapy and icosapent ethyl \n 83 vear old man is evaluated for opioid related con (D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) suipation. He was prescribed opioids for back pain in the inhibitor setting of multilevel osteoporotic vertebral compression fractures. Medications are calcium. vitamin D. zoledronic acid, polyethylene glycol, and oxycodone. Item 110 On physical examination, vital signs are normal. Nor An 81-year-old woman is evaluated for bruising. For the mal bowel sounds are present. The abdomen is distended past few years, she has noticed dark red patches appearing nd tender to very deep palpation in the lower quadrants, intermittently on the forearms without trauma or other with no rebound and no guarding. triggers. They are not painful and resolve without treat- ment. History includes hypertension, for which she takes Which of the following is the most appropriate hydrochlorothiazide. treatment? On physical examination, vital signs, including blood pressure, are normal. Skin is dry, and skin findings on the (\)) Docusate sodium forearm are shown (top of next column). (Bb) Senna

Laboratory studies: to light touch and pinprick over the thigh are normal. LDL cholesterol 205 mg/dL (5.31 mmol/L) HDL cholesterol 45 mg/dL (1.17 mmol/L) Which of the following is the most likely diagnosis? Triglycerides 160 mg/dL (1.81 mmol/L) (A) Femoroacetabular impingement syndrome Thyroid-stimulating hormone 2.0 tU/mL (2.0 mU/L) (B) Greater trochanteric pain syndrome In addition to therapeutic lifestyle changes, which of the (C) Hip osteoarthritis following is the most appropriate treatment? (D) Meralgia paresthetica (A) High-intensity statin therapy (B) High-intensity statin therapy and ezetimibe Item 112 (C) High-intensity statin therapy and icosapent ethyl \n 83 vear old man is evaluated for opioid related con (D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) suipation. He was prescribed opioids for back pain in the inhibitor setting of multilevel osteoporotic vertebral compression fractures. Medications are calcium. vitamin D. zoledronic acid, polyethylene glycol, and oxycodone. Item 110 On physical examination, vital signs are normal. Nor An 81-year-old woman is evaluated for bruising. For the mal bowel sounds are present. The abdomen is distended past few years, she has noticed dark red patches appearing nd tender to very deep palpation in the lower quadrants, intermittently on the forearms without trauma or other with no rebound and no guarding. triggers. They are not painful and resolve without treat- ment. History includes hypertension, for which she takes Which of the following is the most appropriate hydrochlorothiazide. treatment? On physical examination, vital signs, including blood pressure, are normal. Skin is dry, and skin findings on the (\)) Docusate sodium forearm are shown (top of next column). (Bb) Senna (C) Sodium phosphate enema

Laboratory studies: to light touch and pinprick over the thigh are normal. LDL cholesterol 205 mg/dL (5.31 mmol/L) HDL cholesterol 45 mg/dL (1.17 mmol/L) Which of the following is the most likely diagnosis? Triglycerides 160 mg/dL (1.81 mmol/L) (A) Femoroacetabular impingement syndrome Thyroid-stimulating hormone 2.0 tU/mL (2.0 mU/L) (B) Greater trochanteric pain syndrome In addition to therapeutic lifestyle changes, which of the (C) Hip osteoarthritis following is the most appropriate treatment? (D) Meralgia paresthetica (A) High-intensity statin therapy (B) High-intensity statin therapy and ezetimibe Item 112 (C) High-intensity statin therapy and icosapent ethyl \n 83 vear old man is evaluated for opioid related con (D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) suipation. He was prescribed opioids for back pain in the inhibitor setting of multilevel osteoporotic vertebral compression fractures. Medications are calcium. vitamin D. zoledronic acid, polyethylene glycol, and oxycodone. Item 110 On physical examination, vital signs are normal. Nor An 81-year-old woman is evaluated for bruising. For the mal bowel sounds are present. The abdomen is distended past few years, she has noticed dark red patches appearing nd tender to very deep palpation in the lower quadrants, intermittently on the forearms without trauma or other with no rebound and no guarding. triggers. They are not painful and resolve without treat- ment. History includes hypertension, for which she takes Which of the following is the most appropriate hydrochlorothiazide. treatment? On physical examination, vital signs, including blood pressure, are normal. Skin is dry, and skin findings on the (\)) Docusate sodium forearm are shown (top of next column). (Bb) Senna (C) Sodium phosphate enema Which of the following is the most appropriate next step in () Subcutaneous methy naltrexone management?

Laboratory studies: to light touch and pinprick over the thigh are normal. LDL cholesterol 205 mg/dL (5.31 mmol/L) HDL cholesterol 45 mg/dL (1.17 mmol/L) Which of the following is the most likely diagnosis? Triglycerides 160 mg/dL (1.81 mmol/L) (A) Femoroacetabular impingement syndrome Thyroid-stimulating hormone 2.0 tU/mL (2.0 mU/L) (B) Greater trochanteric pain syndrome In addition to therapeutic lifestyle changes, which of the (C) Hip osteoarthritis following is the most appropriate treatment? (D) Meralgia paresthetica (A) High-intensity statin therapy (B) High-intensity statin therapy and ezetimibe Item 112 (C) High-intensity statin therapy and icosapent ethyl \n 83 vear old man is evaluated for opioid related con (D) Proprotein convertase subtilisin/kexin type 9 (PCSK9) suipation. He was prescribed opioids for back pain in the inhibitor setting of multilevel osteoporotic vertebral compression fractures. Medications are calcium. vitamin D. zoledronic acid, polyethylene glycol, and oxycodone. Item 110 On physical examination, vital signs are normal. Nor An 81-year-old woman is evaluated for bruising. For the mal bowel sounds are present. The abdomen is distended past few years, she has noticed dark red patches appearing nd tender to very deep palpation in the lower quadrants, intermittently on the forearms without trauma or other with no rebound and no guarding. triggers. They are not painful and resolve without treat- ment. History includes hypertension, for which she takes Which of the following is the most appropriate hydrochlorothiazide. treatment? On physical examination, vital signs, including blood pressure, are normal. Skin is dry, and skin findings on the (\)) Docusate sodium forearm are shown (top of next column). (Bb) Senna (C) Sodium phosphate enema Which of the following is the most appropriate next step in () Subcutaneous methy naltrexone management? (A) Complete blood count Item 113 (B) Discontinue hydrochlorothiazide A 54-year-old man is evaluated after his second episode (C) Skin biopsy of synovial fluid-confirmed gout in the past year.

Which of the following is the most appropriate next step in () Subcutaneous methy naltrexone management? (A) Complete blood count Item 113 (B) Discontinue hydrochlorothiazide A 54-year-old man is evaluated after his second episode (C) Skin biopsy of synovial fluid-confirmed gout in the past year. 131

Self-Assessment Test 7.) 2. = Urate-lowering therapy is being considered. He takes no the past few hours, with associated nausea and vomiting. > other medications. He is of Korean descent. wa She reports feeling unsteady when walking. She recovered wn © Serum urate level is 8.4 mg/dL (0.5 mmol/L), and from a viral upper respiratory tract infection 1 week ago 172) wn creatinine level is 0.9 mg/dL (79.6 umol/L). and has had reduced hearing in the right ear since then. = She has no tinnitus. She is otherwise healthy and takes no 7) 5 Which of the following is most appropriate initial medications. - management? On physical examination, vital signs are normal. The ry wn Dix-Hallpike maneuver shows unidirectional nystagmus on ton ol (A) Allopurinol plus colchicine the right side. Head impulse testing shows catch-up saccades. Allopurinol plus prednisone The remainder of the neurologic examination is normal. HLA-B*58:01 genotyping D) Thiopurine methyltransferase enzyme activity mea- Which of the following is the most likely diagnosis? surement (A) Benign paroxysmal positional vertigo (B) Labyrinthitis ltem 114 (C) Meniere disease A 47-year-old woman is evaluated in the emergency (D) Ramsay Hunt syndrome department for constant vertigo that has worsened over (E) Vertebrobasilar ischemia 132

Answers and Critiques Bibliography Wittens C, Davies AH, Beekgaard N, et al. Editor’s choice - management of chronic venous disease: clinical practice guidelines of the European e Tliotibial band syndrome is an overuse injury in runners Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49: that can be localized over the lateral femoral condyle. 678-737. [PMID: 25920631] doi:10.1016/j.ejvs.2015.02.007

Bibliography Wittens C, Davies AH, Beekgaard N, et al. Editor’s choice - management of chronic venous disease: clinical practice guidelines of the European e Tliotibial band syndrome is an overuse injury in runners Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49: that can be localized over the lateral femoral condyle. 678-737. [PMID: 25920631] doi:10.1016/j.ejvs.2015.02.007 Bibliography Flato R, Passanante GJ, Skalski MR, et al. The iliotibial tract: imaging, anat- Item 28 Answer: A omy, injuries, and other pathology. Skeletal Radiol. 2017;46:605-22. [PMID: 28238018] doi:10.1007/s00256-017-2604-y Educational Objective: Diagnose iliotibial band syndrome. Item 29 Answer: C The most likely diagnosis is iliotibial band syndrome (ITBS) (Option A). Classically a disorder of runners, ITBS is an Educational Objective: Select an appropriate level of overuse injury that can be localized over the lateral femoral care for posthospital rehabilitation. wn a condyle. Pain is reported in the lateral knee and/or the distal = Subacute rehabilitation in a skilled nursing facility (Option lateral thigh. ITBS also can occur in competitive cyclists who = C) is most appropriate for this frail older woman who no aia pedal against resistance. The Noble test consists of repeated 1S longer requires acute inpatient hospital care. In this setting, flexion and extension of the supine patient’s knee with the Ss she can gradually improve her functional status over a period & thumb over the lateral femoral condyle. If this test repro- co of up to 100 days, such that she can be discharged to inde wn duces the pain, the result is considered diagnostic. Imaging ee pendent living. Her current functional status, coupled with ao is not necessary to diagnose ITBS. Initial treatment of ITBS > a medical history of preexisting functional impairment due nn involves abstaining from inciting activities and use of ice, < to stroke, suggests that she requires a rehabilitation environ followed by a gradual return to activity, stretching, strength- <= ment that allows for a slow recovery pace. ening, and local massage. Continued care in the inpatient setting (Option A), Lateral meniscal injury (Option B) is usually post- where rehabilitation resources are limited, is not a reason traumatic rather than insidious in onset. Pain is in the able or cost. effective strategy for this patient. whose medical lateral joint line. Meniscal injury can be differentiated condition no longer substantiates a need for acute inpatient from ITBS by a positive result on the McMurray or Thes- treatment. saly test and a negative Noble test result. The McMurray For this patient to be discharged home with outpatient test is performed with the patient supine. The examiner or home physical and occupational therapy (Option B), she fully flexes the knee and rotates the tibia externally. The would need to be able to function unsupervised or have knee is then extended with the hand over the medial continuous assistance to compensate for any functional defi joint line. The maneuver is then repeated with the tibia ciencies. This patient lives alone and has demonstrated that internally rotated and the hand over the lateral joint line. she is in need of supervision when working with therapists Snapping detected over the joint line with extension of in the inpatient setting. the knee is a positive result for meniscal injury. The Thes- Discharge to an acute rehabilitation hospital (Option saly test for meniscal tear is performed by holding the D) would require that the patient be able to participate in patient’s outstretched hands while the patient stands on 3 hours of therapy on 5 days per week. A clinical estimation the uninjured leg with the knee flexed to 5 degrees; the of her tolerance for therapy is less than 3 hours daily. other knee is flexed with the foot off the floor. The patient rotates the body internally and externally on the knee three times. The test is repeated with the knee flexed e In patients requiring posthospitalization care to improve to 20 degrees. This process is repeated with the injured functional status who cannot tolerate 3 hours of physical knee. Medial or lateral joint line pain is a positive result or occupational therapy on 5 days per week, subacute for meniscal tear. rehabilitation is an appropriate option. Patellofemoral pain syndrome (Option C) is also com- mon in runners, primarily women. Although it causes knee Bibliography pain, patellofemoral pain syndrome tends to be associated Boland L, Légaré F, Perez MM, et al. Impact of home care versus alternative with generalized pain or pain located anteriorly. Crepitus locations of care on elder health outcomes: an overview of systematic with movement can be present on physical examination. reviews. BMC Geriatr. 2017;17:20. [PMID: 28088166] doi:10.1186/s12877- 016-0395-y Almost universally, squatting elicits knee pain. Given this patient’s physical examination findings, patellofemoral pain syndrome is unlikely. Item 30 Answer: D Popliteal tendinopathy (Option D) causes knee pain Educational Objective: Treat noninfectious olecranon associated with running. The pain is mostly posterolateral bursitis. and is worse with downhill running. Popliteal tendinopathy can be distinguished from ITBS on the basis of anatomic The most appropriate management is rest, ice, and protection location and history. (elbow pads) (Option D). This patient has olecranon bursitis,

Bibliography Flato R, Passanante GJ, Skalski MR, et al. The iliotibial tract: imaging, anat- Item 28 Answer: A omy, injuries, and other pathology. Skeletal Radiol. 2017;46:605-22. [PMID: 28238018] doi:10.1007/s00256-017-2604-y Educational Objective: Diagnose iliotibial band syndrome. Item 29 Answer: C The most likely diagnosis is iliotibial band syndrome (ITBS) (Option A). Classically a disorder of runners, ITBS is an Educational Objective: Select an appropriate level of overuse injury that can be localized over the lateral femoral care for posthospital rehabilitation. wn a condyle. Pain is reported in the lateral knee and/or the distal = Subacute rehabilitation in a skilled nursing facility (Option lateral thigh. ITBS also can occur in competitive cyclists who = C) is most appropriate for this frail older woman who no aia pedal against resistance. The Noble test consists of repeated 1S longer requires acute inpatient hospital care. In this setting, flexion and extension of the supine patient’s knee with the Ss she can gradually improve her functional status over a period & thumb over the lateral femoral condyle. If this test repro- co of up to 100 days, such that she can be discharged to inde wn duces the pain, the result is considered diagnostic. Imaging ee pendent living. Her current functional status, coupled with ao is not necessary to diagnose ITBS. Initial treatment of ITBS > a medical history of preexisting functional impairment due nn involves abstaining from inciting activities and use of ice, < to stroke, suggests that she requires a rehabilitation environ followed by a gradual return to activity, stretching, strength- <= ment that allows for a slow recovery pace. ening, and local massage. Continued care in the inpatient setting (Option A), Lateral meniscal injury (Option B) is usually post- where rehabilitation resources are limited, is not a reason traumatic rather than insidious in onset. Pain is in the able or cost. effective strategy for this patient. whose medical lateral joint line. Meniscal injury can be differentiated condition no longer substantiates a need for acute inpatient from ITBS by a positive result on the McMurray or Thes- treatment. saly test and a negative Noble test result. The McMurray For this patient to be discharged home with outpatient test is performed with the patient supine. The examiner or home physical and occupational therapy (Option B), she fully flexes the knee and rotates the tibia externally. The would need to be able to function unsupervised or have knee is then extended with the hand over the medial continuous assistance to compensate for any functional defi joint line. The maneuver is then repeated with the tibia ciencies. This patient lives alone and has demonstrated that internally rotated and the hand over the lateral joint line. she is in need of supervision when working with therapists Snapping detected over the joint line with extension of in the inpatient setting. the knee is a positive result for meniscal injury. The Thes- Discharge to an acute rehabilitation hospital (Option saly test for meniscal tear is performed by holding the D) would require that the patient be able to participate in patient’s outstretched hands while the patient stands on 3 hours of therapy on 5 days per week. A clinical estimation the uninjured leg with the knee flexed to 5 degrees; the of her tolerance for therapy is less than 3 hours daily. other knee is flexed with the foot off the floor. The patient rotates the body internally and externally on the knee three times. The test is repeated with the knee flexed e In patients requiring posthospitalization care to improve to 20 degrees. This process is repeated with the injured functional status who cannot tolerate 3 hours of physical knee. Medial or lateral joint line pain is a positive result or occupational therapy on 5 days per week, subacute for meniscal tear. rehabilitation is an appropriate option. Patellofemoral pain syndrome (Option C) is also com- mon in runners, primarily women. Although it causes knee Bibliography pain, patellofemoral pain syndrome tends to be associated Boland L, Légaré F, Perez MM, et al. Impact of home care versus alternative with generalized pain or pain located anteriorly. Crepitus locations of care on elder health outcomes: an overview of systematic with movement can be present on physical examination. reviews. BMC Geriatr. 2017;17:20. [PMID: 28088166] doi:10.1186/s12877- 016-0395-y Almost universally, squatting elicits knee pain. Given this patient’s physical examination findings, patellofemoral pain syndrome is unlikely. Item 30 Answer: D Popliteal tendinopathy (Option D) causes knee pain Educational Objective: Treat noninfectious olecranon associated with running. The pain is mostly posterolateral bursitis. and is worse with downhill running. Popliteal tendinopathy can be distinguished from ITBS on the basis of anatomic The most appropriate management is rest, ice, and protection location and history. (elbow pads) (Option D). This patient has olecranon bursitis, 147

Answers and Critiques manifesting as an accumulation of fluid in the olecranon Item 31 Answer: D bursa. Common causes include trauma, intensive physical Educational Objective: Treat posttraumatic stress labor, infection (septic bursitis), crystal deposition (uric disorder with a selective serotonin reuptake inhibitor. acid, calcium phosphate), and inflammation from rheu- matologic disorders. In this patient without symptoms of Sertraline (Option D) is the most appropriate drug treat- infection (no erythema, warmth, or significant pain) or ment for this patient with posttraumatic stress disorder rheumatologic disease, bursitis was probably induced by (PTSD). PTSD is a disorder triggered by the experience of a repetitive stress due to gardening. Supportive care with traumatic event. The experience can be personal, through joint rest, ice, elbow protection, and as-needed NSAID a loved one, or by repeated exposure to details or footage therapy provides the best clinical outcome for aseptic, of such an event. Patients have intrusive memories of the mechanical olecranon bursitis. event, such as nightmares and flashbacks, and avoid situa- In some patients with evidence of olecranon bur- tions that remind them of the event. PTSD also causes func-

therapy provides the best clinical outcome for aseptic, of such an event. Patients have intrusive memories of the mechanical olecranon bursitis. event, such as nightmares and flashbacks, and avoid situa- In some patients with evidence of olecranon bur- tions that remind them of the event. PTSD also causes func- = sitis, needle aspiration of the bursa (Option A) for fluid tional impairment, hypervigilance, irritability, and sleep = wn Gram stain, examination for crystals, and culture is indi- disturbance. Cognitive behavioral therapy is the corner- = cated if the bursitis is associated with pain, erythema, and stone of therapy for patients with PTSD; it helps decrease @ = wn warmth. Infected superficial bursae, such as the olecranon PTSD-associated symptom burden and increase adaptive rs) and prepatellar, can lead to sepsis if not recognized and coping strategies. However, more than three quarters of = fee treated with needle drainage and antibiotics. In these patients with PTSD are also treated with pharmacologic a = cases, contiguous skin infection is commonly present. therapies to relieve PTSD-related symptoms. Both ser- = This patient has no evidence of concomitant skin infection traline and paroxetine are FDA approved for PTSD, and 2 <= or local signs of inflammation, and bursa aspiration is not venlafaxine is commonly used as well. In this patient with oO wn indicated. significant generalized anxiety on most days, sertraline is Glucocorticoid injection (Option B) should be avoided an appropriate drug treatment. in patients with aseptic olecranon bursitis. In a systematic Lorazepam (Option A) can be helpful in the short-term review, patients with aseptic bursitis treated with glucocor- treatment of panic attacks, but it should not be used for ticoid injection had increased complications, including skin long-term management. In addition, for patients in the early atrophy, without improved outcomes. phases of PTSD, lorazepam can cause a paradoxical effect Joint aspiration (Option C) with Gram stain, micros- of increasing PTSD symptoms. Benzodiazepines, such as copy for crystals, and culture should be performed when lorazepam, also have significant potential for adverse effects, joint infection is suspected. Involvement of the joint is sug- given the high rates of concomitant substance use and sui- gested by pain with elbow extension. In patients with fluid cidality in PTSD. within the elbow joint, full extension decreases the volume Medical cannabis (Option B) is increasingly recognized of the joint capsule, thus distending the inflamed joint cap- as a potential option for the treatment of PTSD and its asso- sule and causing pain. This patient was able to extend the ciated symptom burden, and many statewide medical can- elbow joint without pain, ruling out joint infection and the nabis statutes list PTSD as a qualifying criterion for medical need for joint aspiration. cannabis use. However, there is significant heterogeneity

= sitis, needle aspiration of the bursa (Option A) for fluid tional impairment, hypervigilance, irritability, and sleep = wn Gram stain, examination for crystals, and culture is indi- disturbance. Cognitive behavioral therapy is the corner- = cated if the bursitis is associated with pain, erythema, and stone of therapy for patients with PTSD; it helps decrease @ = wn warmth. Infected superficial bursae, such as the olecranon PTSD-associated symptom burden and increase adaptive rs) and prepatellar, can lead to sepsis if not recognized and coping strategies. However, more than three quarters of = fee treated with needle drainage and antibiotics. In these patients with PTSD are also treated with pharmacologic a = cases, contiguous skin infection is commonly present. therapies to relieve PTSD-related symptoms. Both ser- = This patient has no evidence of concomitant skin infection traline and paroxetine are FDA approved for PTSD, and 2 <= or local signs of inflammation, and bursa aspiration is not venlafaxine is commonly used as well. In this patient with oO wn indicated. significant generalized anxiety on most days, sertraline is Glucocorticoid injection (Option B) should be avoided an appropriate drug treatment. in patients with aseptic olecranon bursitis. In a systematic Lorazepam (Option A) can be helpful in the short-term review, patients with aseptic bursitis treated with glucocor- treatment of panic attacks, but it should not be used for ticoid injection had increased complications, including skin long-term management. In addition, for patients in the early atrophy, without improved outcomes. phases of PTSD, lorazepam can cause a paradoxical effect Joint aspiration (Option C) with Gram stain, micros- of increasing PTSD symptoms. Benzodiazepines, such as copy for crystals, and culture should be performed when lorazepam, also have significant potential for adverse effects, joint infection is suspected. Involvement of the joint is sug- given the high rates of concomitant substance use and sui- gested by pain with elbow extension. In patients with fluid cidality in PTSD. within the elbow joint, full extension decreases the volume Medical cannabis (Option B) is increasingly recognized of the joint capsule, thus distending the inflamed joint cap- as a potential option for the treatment of PTSD and its asso- sule and causing pain. This patient was able to extend the ciated symptom burden, and many statewide medical can- elbow joint without pain, ruling out joint infection and the nabis statutes list PTSD as a qualifying criterion for medical need for joint aspiration. cannabis use. However, there is significant heterogeneity Nonsurgical management of olecranon bursitis is sig- in the data evaluating cannabis as a therapeutic agent. In nificantly more effective than surgical management (Option addition, variations in the types of products available from E), leading to higher rates of clinical resolution. In addition, state to state and even within each state make it difficult to

Nonsurgical management of olecranon bursitis is sig- in the data evaluating cannabis as a therapeutic agent. In nificantly more effective than surgical management (Option addition, variations in the types of products available from E), leading to higher rates of clinical resolution. In addition, state to state and even within each state make it difficult to surgical incision and drainage is associated with higher rates recommend medical cannabis as an initial therapeutic agent of complications, persistent drainage, and bursal infections. at this time. Surgery may be necessary for infectious or refractory bursi- Prazosin (Option C) is an o,-blocker that has been used tis. In some cases of chronic olecranon bursitis, arthroscopic to treat PTSD-related symptoms, but it has failed to show bursectomy is required. benefit in larger controlled trials, making sertraline a better choice. e In patients with local swelling of the elbow joint, the ability to extend the elbow without pain excludes joint ¢ Cognitive behavioral therapy is the cornerstone of infection and is compatible with olecranon bursitis. therapy for patients with posttraumatic stress disorder. ¢ Supportive care with joint rest, ice, elbow protection, and as-needed NSAID therapy provides the best clinical ¢ Sertraline, paroxetine, and venlafaxine, in conjunction outcome for aseptic, mechanical olecranon bursitis. with cognitive behavioral therapy, may help relieve posttraumatic stress disorder symptoms.

infection and is compatible with olecranon bursitis. therapy for patients with posttraumatic stress disorder. ¢ Supportive care with joint rest, ice, elbow protection, and as-needed NSAID therapy provides the best clinical ¢ Sertraline, paroxetine, and venlafaxine, in conjunction outcome for aseptic, mechanical olecranon bursitis. with cognitive behavioral therapy, may help relieve posttraumatic stress disorder symptoms. Bibliography Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Bibliography Arch Orthop Trauma Surg. 2014;134:1517-36. [PMID: 25234151] doi:10.1007/ Shalev A, Liberzon I, Marmar C. Post-traumatic stress disorder. N Engl J s00402-014-2088-3 Med. 2017;376:2459-69. [PMID: 28636846] doi:10.1056/NEJMra1612499 148

Answers and Critiques Item 32 Answer: D Bibliography Vaughan CP, Markland AD. Urinary incontinence in women. Ann Intern Educational Objective: Treat stress incontinence with Med. 2020;172:ITC17-32. [PMID: 32016335] doi:10.7326/AITC202002040 topical estrogen therapy.

Item 32 Answer: D Bibliography Vaughan CP, Markland AD. Urinary incontinence in women. Ann Intern Educational Objective: Treat stress incontinence with Med. 2020;172:ITC17-32. [PMID: 32016335] doi:10.7326/AITC202002040 topical estrogen therapy. The most appropriate management is topical vaginal estro- gen therapy (Option D). Urinary incontinence after activities Item 33 Answer: B that increase intra-abdominal pressure, such as sneezing, Educational Objective: Evaluate decision-making laughing, physical exertion, or bearing down, is consistent capacity. with stress incontinence, which primarily affects multipa- The most appropriate next step in management is to assess rous, postmenopausal women. This patient has attempted the patient’s capacity to refuse blood products (Option first-line therapy for stress incontinence with pelvic floor B). Patients are presumed to be legally competent to make muscle training, without success. Vaginal estrogen formu- medical decisions for themselves unless determined to lations may increase continence compared with placebo wn be incompetent by the court. However, in routine clinical ® and should be attempted as second-line therapy for post- care, physicians must frequently determine a patient’s — menopausal women with stress incontinence. Evidence 7 decision-making capacity, including the patient’s ability = from clinical trials is generally of low quality, and statistical TS to understand relevant information; consider treatment YY heterogeneity limits confidence in conclusions. However, options; appreciate the potential medical consequences a] because this patient is experiencing genitourinary symp- = of their decision; and communicate a choice, preferably a & toms of menopause (vaginal dryness and dyspareunia), a wr choice that is stable over time. Unlike competence, which = trial of topical vaginal estrogen is appropriate and reason- a is a global determination, decision-making capacity needs = able. Weight loss in women with overweight or obesity also wn to be evaluated for each decision to be made. In this < improves urinary control in multiple types of incontinence. instance, the patient’s capacity to refuse blood products = An 8% decrease in BMI has been shown to reduce incon- needs to be evaluated before any transfusion. Her men- tinence by 50%. This patient, with a BMI of 22, would be tal health disorder does not automatically invalidate her unlikely to benefit from weight loss. capacity, and her refusal of blood products, if consistent Oral estradiol (Option A), transdermal estrogen, or with previously expressed religious beliefs, makes her estrogen implants should not be used to manage stress decision more valid. incontinence and may make it worse. Because of the risks Asking the group home manager for permission to associated with systemic hormone replacement therapy perform transfusion (Option A) assumes that the patient (breast cancer, coronary events, stroke, venous thromboem- lacks capacity to consent to or refuse blood product trans- bolism), its use should be reserved for vasomotor symptoms fusion, which may not be the case. An evaluation of deci- of menopause (hot flashes) at the lowest effective dosage for sion-making capacity must be performed first. the shortest time required. Discharging the patient (Option C) without appro- Oxybutynin (Option B) is a treatment for urge inconti- priately treating her disease (for example, with endoscopy nence when bladder training is only partially successful or and intravenous isotonic volume expansion) would violate has failed. It is not recommended for the treatment of stress the fiduciary physician-patient relationship. Patients with incontinence. decision-making capacity may refuse certain aspects of care Timed voiding (Option C) or bladder training comprises while participating in others. scheduled voiding attempts at intervals shorter than the Performing transfusion (Option D) against the patient’s usual time between incontinence episodes, regardless of the will is unethical. Should she lack capacity, a surrogate would urge to void, with a gradual increase in the time between be sought to make decisions for the patient in all but emer- voids. If an episode of urgency occurs before the designated gency situations. voiding time, patients are encouraged to use pelvic floor Petitioning the court for an evaluation of competence muscle contraction until the urge passes and then proceed (Option E) would be a lengthy process and would not be with voiding directly afterward. Timed voiding is a behav- appropriate in an urgent situation such as this one. In addi- ioral technique used for patients with urge incontinence tion, this patient may be able to make medical decisions for (urine leakage preceded by a sudden urge to void) and would herself. not be helpful in this patient with stress incontinence.

The most appropriate management is topical vaginal estro- gen therapy (Option D). Urinary incontinence after activities Item 33 Answer: B that increase intra-abdominal pressure, such as sneezing, Educational Objective: Evaluate decision-making laughing, physical exertion, or bearing down, is consistent capacity. with stress incontinence, which primarily affects multipa- The most appropriate next step in management is to assess rous, postmenopausal women. This patient has attempted the patient’s capacity to refuse blood products (Option first-line therapy for stress incontinence with pelvic floor B). Patients are presumed to be legally competent to make muscle training, without success. Vaginal estrogen formu- medical decisions for themselves unless determined to lations may increase continence compared with placebo wn be incompetent by the court. However, in routine clinical ® and should be attempted as second-line therapy for post- care, physicians must frequently determine a patient’s — menopausal women with stress incontinence. Evidence 7 decision-making capacity, including the patient’s ability = from clinical trials is generally of low quality, and statistical TS to understand relevant information; consider treatment YY heterogeneity limits confidence in conclusions. However, options; appreciate the potential medical consequences a] because this patient is experiencing genitourinary symp- = of their decision; and communicate a choice, preferably a & toms of menopause (vaginal dryness and dyspareunia), a wr choice that is stable over time. Unlike competence, which = trial of topical vaginal estrogen is appropriate and reason- a is a global determination, decision-making capacity needs = able. Weight loss in women with overweight or obesity also wn to be evaluated for each decision to be made. In this < improves urinary control in multiple types of incontinence. instance, the patient’s capacity to refuse blood products = An 8% decrease in BMI has been shown to reduce incon- needs to be evaluated before any transfusion. Her men- tinence by 50%. This patient, with a BMI of 22, would be tal health disorder does not automatically invalidate her unlikely to benefit from weight loss. capacity, and her refusal of blood products, if consistent Oral estradiol (Option A), transdermal estrogen, or with previously expressed religious beliefs, makes her estrogen implants should not be used to manage stress decision more valid. incontinence and may make it worse. Because of the risks Asking the group home manager for permission to associated with systemic hormone replacement therapy perform transfusion (Option A) assumes that the patient (breast cancer, coronary events, stroke, venous thromboem- lacks capacity to consent to or refuse blood product trans- bolism), its use should be reserved for vasomotor symptoms fusion, which may not be the case. An evaluation of deci- of menopause (hot flashes) at the lowest effective dosage for sion-making capacity must be performed first. the shortest time required. Discharging the patient (Option C) without appro- Oxybutynin (Option B) is a treatment for urge inconti- priately treating her disease (for example, with endoscopy nence when bladder training is only partially successful or and intravenous isotonic volume expansion) would violate has failed. It is not recommended for the treatment of stress the fiduciary physician-patient relationship. Patients with incontinence. decision-making capacity may refuse certain aspects of care Timed voiding (Option C) or bladder training comprises while participating in others. scheduled voiding attempts at intervals shorter than the Performing transfusion (Option D) against the patient’s usual time between incontinence episodes, regardless of the will is unethical. Should she lack capacity, a surrogate would urge to void, with a gradual increase in the time between be sought to make decisions for the patient in all but emer- voids. If an episode of urgency occurs before the designated gency situations. voiding time, patients are encouraged to use pelvic floor Petitioning the court for an evaluation of competence muscle contraction until the urge passes and then proceed (Option E) would be a lengthy process and would not be with voiding directly afterward. Timed voiding is a behav- appropriate in an urgent situation such as this one. In addi- ioral technique used for patients with urge incontinence tion, this patient may be able to make medical decisions for (urine leakage preceded by a sudden urge to void) and would herself. not be helpful in this patient with stress incontinence. ¢ Decision-making capacity includes the patient’s ability e For postmenopausal women with stress incontinence, to understand relevant information, consider treatment topical vaginal estrogen therapy may increase conti- options, appreciate the potential medical consequences nence compared with placebo. of their decision, and communicate a choice.

¢ Decision-making capacity includes the patient’s ability e For postmenopausal women with stress incontinence, to understand relevant information, consider treatment topical vaginal estrogen therapy may increase conti- options, appreciate the potential medical consequences nence compared with placebo. of their decision, and communicate a choice. ¢ Weight loss in women with overweight or obesity e Mental illness or cognitive impairment does not auto- improves urinary control in multiple types of matically invalidate a patient’s decision-making incontinence. capacity. 149

Answers and Critiques oo Bibliography Tilt-table testing (Option D) is recommended for Appelbaum PS. Clinical practice. Assessment of patients’ competence to patients suspected of having delayed orthostatic hypoten- consent to treatment. N EnglJ Med. 2007;357:1834-40. [PMID: 17978292] sion when the initial evaluation is not diagnostic. The diag- nosis of orthostatic hypotension is confirmed in this patient, and tilt-table testing is not indicated. Item 34 Answer: A

Bibliography Tilt-table testing (Option D) is recommended for Appelbaum PS. Clinical practice. Assessment of patients’ competence to patients suspected of having delayed orthostatic hypoten- consent to treatment. N EnglJ Med. 2007;357:1834-40. [PMID: 17978292] sion when the initial evaluation is not diagnostic. The diag- nosis of orthostatic hypotension is confirmed in this patient, and tilt-table testing is not indicated. Item 34 Answer: A Educational Objective: Treat medication-related orthostatic syncope. e The most common causes of orthostatic hypotension are autonomic failure, hypovolemia, medications, and The most appropriate management is adjusting the antihy- aging. pertensive medication dosage (Option A) in this patient with orthostatic syncope. The most common causes of orthostatic e Treatment of medication-induced orthostatic syncope syncope are autonomic failure, hypovolemia, medications, entails decreasing or stopping the offending agent. > and aging. The American Heart Association (AHA)/American —] “A College of Cardiology (ACC)/Heart Rhythm Society (HRS) Bibliography = @ syncope guideline recommends assessment for orthostatic Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for = the evaluation and management of patients with syncope: executive 7) hypotension in all patients with syncope. Orthostatic hypo- ry) summary: a report of the American College of Cardiology/American = tension is defined as a drop in systolic blood pressure of Heart Association Task Force on Clinical Practice Guidelines and the a Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] 20 mm Hg or greater or a drop in diastolic blood pressure oO doi:10.1161/CIR.0000000000000498 at of 10 mm Hg or greater upon assuming an upright pos- =. 2 ture. Immediate orthostatic hypotension is a transient blood t | @o pressure decrease within 15 seconds after standing. Classic Item 35 Answer: D wv orthostatic hypotension, as manifested by this patient, is Educational Objective: Treat premenstrual dysphoric characterized by a sustained reduction of systolic blood pres- disorder with a selective serotonin reuptake inhibitor. sure of 20 mm Hg or greater or diastolic blood pressure of 10 mm Hg or greater within 3 minutes of standing. Delayed This patient meets diagnostic criteria for premenstrual dys- orthostatic hypotension occurs after 3 minutes of stand- phoric disorder (PMDD), and a selective serotonin reuptake ing with a more gradual drop in blood pressure until the inhibitor (SSRI), such as sertraline (Option D), is appro- threshold for orthostatic hypotension is reached. The risk for priate. Diagnosis of PMDD requires the presence of at least medication-related syncope increases with age. Several drug one primary symptom: mood swings, irritability or anger, classes are implicated, including diuretics, vasodilators, feelings of hopelessness or depressed mood, and anxiety. In venodilators, negative chronotropes, and sedatives. The addition, a patient must have a total of at least five symptoms, AHA/ACC/HRS syncope guideline recommends reducing which may also include appetite changes; decreased interest or withdrawing medications that may cause hypotension. in usual activities; fatigue; difficulty concentrating; feelings Careful monitoring following medication adjustment is of loss of control; sleep disturbance; and physical symptoms important because supine hypertension may result from (breast tenderness, weight gain, bloating, myalgia). Symp- antihypertensive medication reduction or withdrawal. toms occur the week before menses and remit within 1 week Midodrine (Option B), a vasoactive drug, improves after and are present during most menstrual cycles. First- symptoms of neurogenic orthostatic hypotension, but its line therapy for PMDD includes the same second-generation effectiveness may be limited by supine hypertension and antidepressants used for major depressive disorder, with urinary retention. This patient most likely has medica- special emphasis on safety in pregnancy, because women tion-related orthostatic hypotension, and reducing or with- experiencing PMDD are typically of reproductive age. Most drawing his antihypertensive medications will be the best SSRIs are FDA pregnancy category C (except paroxetine, initial management step. which is category D). Neurogenic orthostatic hypotension is a subtype of Although cognitive behavioral therapy (CBT) (Option orthostatic hypotension caused by dysfunction of the auto- A) is an effective treatment for depression and anxiety dis- nomic nervous system (central or peripheral). Parkinson orders, data on its efficacy in women with PMDD are very disease and Lewy body dementia are common causes of limited and variable. CBT may benefit some women, but it is central neurogenic orthostatic syncope, whereas peripheral difficult to determine which patients will benefit most. CBT autonomic neuropathies due to diabetes mellitus and amy- can be considered as an adjunctive therapy to an SSRI. loidosis are the more common causes of peripheral neu- Benzodiazepines, such as lorazepam (Option B), can rogenic orthostatic syncope. Compressive garments, such be used as anxiolytic therapy. Although this patient reports as thigh-high compression hose (Option C) or garments anxiety as one of her symptoms, benzodiazepine therapy is that also bind the lower abdomen, are recommended for not indicated for treatment of PMDD. In addition, as-needed some patients with neurogenic orthostatic hypotension. therapy would not effectively reduce the likelihood of symp- Adjustment of antihypertensive medications is the pre- tom occurrence with each menstrual cycle. ferred initial management step for this patient with ortho- Oral contraceptives are considered second-line ther- static hypotension. apy for PMDD. In addition, in women with migraine with

Educational Objective: Treat medication-related orthostatic syncope. e The most common causes of orthostatic hypotension are autonomic failure, hypovolemia, medications, and The most appropriate management is adjusting the antihy- aging. pertensive medication dosage (Option A) in this patient with orthostatic syncope. The most common causes of orthostatic e Treatment of medication-induced orthostatic syncope syncope are autonomic failure, hypovolemia, medications, entails decreasing or stopping the offending agent. > and aging. The American Heart Association (AHA)/American —] “A College of Cardiology (ACC)/Heart Rhythm Society (HRS) Bibliography = @ syncope guideline recommends assessment for orthostatic Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for = the evaluation and management of patients with syncope: executive 7) hypotension in all patients with syncope. Orthostatic hypo- ry) summary: a report of the American College of Cardiology/American = tension is defined as a drop in systolic blood pressure of Heart Association Task Force on Clinical Practice Guidelines and the a Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] 20 mm Hg or greater or a drop in diastolic blood pressure oO doi:10.1161/CIR.0000000000000498 at of 10 mm Hg or greater upon assuming an upright pos- =. 2 ture. Immediate orthostatic hypotension is a transient blood t | @o pressure decrease within 15 seconds after standing. Classic Item 35 Answer: D wv orthostatic hypotension, as manifested by this patient, is Educational Objective: Treat premenstrual dysphoric characterized by a sustained reduction of systolic blood pres- disorder with a selective serotonin reuptake inhibitor. sure of 20 mm Hg or greater or diastolic blood pressure of 10 mm Hg or greater within 3 minutes of standing. Delayed This patient meets diagnostic criteria for premenstrual dys- orthostatic hypotension occurs after 3 minutes of stand- phoric disorder (PMDD), and a selective serotonin reuptake ing with a more gradual drop in blood pressure until the inhibitor (SSRI), such as sertraline (Option D), is appro- threshold for orthostatic hypotension is reached. The risk for priate. Diagnosis of PMDD requires the presence of at least medication-related syncope increases with age. Several drug one primary symptom: mood swings, irritability or anger, classes are implicated, including diuretics, vasodilators, feelings of hopelessness or depressed mood, and anxiety. In venodilators, negative chronotropes, and sedatives. The addition, a patient must have a total of at least five symptoms, AHA/ACC/HRS syncope guideline recommends reducing which may also include appetite changes; decreased interest or withdrawing medications that may cause hypotension. in usual activities; fatigue; difficulty concentrating; feelings Careful monitoring following medication adjustment is of loss of control; sleep disturbance; and physical symptoms important because supine hypertension may result from (breast tenderness, weight gain, bloating, myalgia). Symp- antihypertensive medication reduction or withdrawal. toms occur the week before menses and remit within 1 week Midodrine (Option B), a vasoactive drug, improves after and are present during most menstrual cycles. First- symptoms of neurogenic orthostatic hypotension, but its line therapy for PMDD includes the same second-generation effectiveness may be limited by supine hypertension and antidepressants used for major depressive disorder, with urinary retention. This patient most likely has medica- special emphasis on safety in pregnancy, because women tion-related orthostatic hypotension, and reducing or with- experiencing PMDD are typically of reproductive age. Most drawing his antihypertensive medications will be the best SSRIs are FDA pregnancy category C (except paroxetine, initial management step. which is category D). Neurogenic orthostatic hypotension is a subtype of Although cognitive behavioral therapy (CBT) (Option orthostatic hypotension caused by dysfunction of the auto- A) is an effective treatment for depression and anxiety dis- nomic nervous system (central or peripheral). Parkinson orders, data on its efficacy in women with PMDD are very disease and Lewy body dementia are common causes of limited and variable. CBT may benefit some women, but it is central neurogenic orthostatic syncope, whereas peripheral difficult to determine which patients will benefit most. CBT autonomic neuropathies due to diabetes mellitus and amy- can be considered as an adjunctive therapy to an SSRI. loidosis are the more common causes of peripheral neu- Benzodiazepines, such as lorazepam (Option B), can rogenic orthostatic syncope. Compressive garments, such be used as anxiolytic therapy. Although this patient reports as thigh-high compression hose (Option C) or garments anxiety as one of her symptoms, benzodiazepine therapy is that also bind the lower abdomen, are recommended for not indicated for treatment of PMDD. In addition, as-needed some patients with neurogenic orthostatic hypotension. therapy would not effectively reduce the likelihood of symp- Adjustment of antihypertensive medications is the pre- tom occurrence with each menstrual cycle. ferred initial management step for this patient with ortho- Oral contraceptives are considered second-line ther- static hypotension. apy for PMDD. In addition, in women with migraine with 150

_ Answers and Critiques aura, combination estrogen-progesterone agents (Option C) Bibliography should be avoided because of increased risk for stroke. Armstrong KA, Metlay JP. Annals clinical decision making: using a diagnostic test. Ann Intern Med. 2020;172:604-9. [PMID: 32311733] doi:10.7326/M19-1940 e Premenstrual dysphoric disorder consists of symptoms Item 37 Answer: C of mood disturbance that develop the week before menses, remit within a week after menses, and occur Educational Objective: Treat unexplained chronic cough.

e Premenstrual dysphoric disorder consists of symptoms Item 37 Answer: C of mood disturbance that develop the week before menses, remit within a week after menses, and occur Educational Objective: Treat unexplained chronic cough. with most menstrual cycles during a given year. Gabapentin (Option C) is the most appropriate additional e First-line therapy for premenstrual dysphoric disorder treatment for this patient’s cough. Unexplained chronic cough includes second-generation antidepressants with special is characterized by persistent cough symptoms with no identi- emphasis on safety in pregnancy. fiable cause after comprehensive evaluation. A multimodality speech pathology intervention has been shown to reduce cough wn Bibliography frequency, improve cough severity, and have a beneficial effect A =} Lanza di Scalea T, Pearlstein T. Premenstrual dysphoric disorder. Med Clin on cough-related quality of life in patients with unexplained = North Am. 2019;103:613-28. [PMID: 31078196] doi:10.1016/j.mcena. chronic cough. The intervention typically consists of two to 2019.02.007 i four sessions of education, cough suppression techniques, oO sc breathing exercises, and counseling. It is recommended by the = CHEST guideline and expert panel report on the treatment of c Item 36 Answer: B wn unexplained chronic cough. Gabapentin is a neuromodulatory eal rr) Educational Objective: Understand the relationship agent that may dampen the enhanced neural sensitization that = between prevalence and predictive values. wn is a key component of unexplained cough. Although it is not (= = At the peak of influenza season, the positive predictive value FDA approved for this indication, gabapentin can be an effec- of the new test will increase (Option B). Positive and nega- tive treatment for unexplained chronic cough. Gabapentin tive predictive values reflect the ability of a test to predict the carries significant risk for adverse effects, including dizziness, presence or absence of disease in a specific population. The disequilibrium, somnolence, weight gain, peripheral edema, positive predictive value is the proportion of persons with and cognitive difficulties. In this patient who is younger than a positive test result who have the disease. Stated another 65 years and otherwise healthy, a therapeutic trial of gabapen- way, the positive predictive value is the likelihood that a tin is reasonable if the potential harms and benefits are accept- person with a positive test result actually has the disease. able to the patient. After 6 months of treatment, harms and The negative predictive value is the proportion of persons benefits should be reassessed before continuing gabapentin. with a negative test result who are disease free; that is, the In adult patients with unexplained chronic cough and likelihood that a person who has a negative test result does negative results on testing for bronchial hyperresponsive- not have the disease. Predictive values are influenced by ness (spirometry) and nonasthmatic eosinophilic bronchi- disease prevalence: Positive predictive value increases as tis (sputum analysis for eosinophils), the CHEST guideline disease prevalence increases, and negative predictive value suggests that inhaled glucocorticoids, such as budesonide decreases (Option A) as disease prevalence increases. The (Option A), not be prescribed owing to ineffectiveness. converse of these is true as well. Because the prevalence of This patient’s cough did not respond to a previous trial

with most menstrual cycles during a given year. Gabapentin (Option C) is the most appropriate additional e First-line therapy for premenstrual dysphoric disorder treatment for this patient’s cough. Unexplained chronic cough includes second-generation antidepressants with special is characterized by persistent cough symptoms with no identi- emphasis on safety in pregnancy. fiable cause after comprehensive evaluation. A multimodality speech pathology intervention has been shown to reduce cough wn Bibliography frequency, improve cough severity, and have a beneficial effect A =} Lanza di Scalea T, Pearlstein T. Premenstrual dysphoric disorder. Med Clin on cough-related quality of life in patients with unexplained = North Am. 2019;103:613-28. [PMID: 31078196] doi:10.1016/j.mcena. chronic cough. The intervention typically consists of two to 2019.02.007 i four sessions of education, cough suppression techniques, oO sc breathing exercises, and counseling. It is recommended by the = CHEST guideline and expert panel report on the treatment of c Item 36 Answer: B wn unexplained chronic cough. Gabapentin is a neuromodulatory eal rr) Educational Objective: Understand the relationship agent that may dampen the enhanced neural sensitization that = between prevalence and predictive values. wn is a key component of unexplained cough. Although it is not (= = At the peak of influenza season, the positive predictive value FDA approved for this indication, gabapentin can be an effec- of the new test will increase (Option B). Positive and nega- tive treatment for unexplained chronic cough. Gabapentin tive predictive values reflect the ability of a test to predict the carries significant risk for adverse effects, including dizziness, presence or absence of disease in a specific population. The disequilibrium, somnolence, weight gain, peripheral edema, positive predictive value is the proportion of persons with and cognitive difficulties. In this patient who is younger than a positive test result who have the disease. Stated another 65 years and otherwise healthy, a therapeutic trial of gabapen- way, the positive predictive value is the likelihood that a tin is reasonable if the potential harms and benefits are accept- person with a positive test result actually has the disease. able to the patient. After 6 months of treatment, harms and The negative predictive value is the proportion of persons benefits should be reassessed before continuing gabapentin. with a negative test result who are disease free; that is, the In adult patients with unexplained chronic cough and likelihood that a person who has a negative test result does negative results on testing for bronchial hyperresponsive- not have the disease. Predictive values are influenced by ness (spirometry) and nonasthmatic eosinophilic bronchi- disease prevalence: Positive predictive value increases as tis (sputum analysis for eosinophils), the CHEST guideline disease prevalence increases, and negative predictive value suggests that inhaled glucocorticoids, such as budesonide decreases (Option A) as disease prevalence increases. The (Option A), not be prescribed owing to ineffectiveness. converse of these is true as well. Because the prevalence of This patient’s cough did not respond to a previous trial influenza increases during the peak of influenza season, of a proton pump inhibitor (PPI). A trial of a different PPI, positive predictive value will increase. such as esomeprazole (Option B), is unlikely to be effective Sensitivity and specificity reflect the accuracy of the in this patient with no symptoms of gastroesophageal reflux test. Sensitivity is the proportion of persons with the disease disease and normal ambulatory pH monitoring results. who have a positive test result; sensitive tests are those with Randomized controlled trials have demonstrated that low rates of false-negative results. Specificity is the propor- morphine (Option D) has positive effects on cough-specific tion of persons without the disease who have a negative test quality of life. However, this treatment failed to receive a

influenza increases during the peak of influenza season, of a proton pump inhibitor (PPI). A trial of a different PPI, positive predictive value will increase. such as esomeprazole (Option B), is unlikely to be effective Sensitivity and specificity reflect the accuracy of the in this patient with no symptoms of gastroesophageal reflux test. Sensitivity is the proportion of persons with the disease disease and normal ambulatory pH monitoring results. who have a positive test result; sensitive tests are those with Randomized controlled trials have demonstrated that low rates of false-negative results. Specificity is the propor- morphine (Option D) has positive effects on cough-specific tion of persons without the disease who have a negative test quality of life. However, this treatment failed to receive a result; specific tests are those with low rates of false-positive recommendation from the CHEST Expert Panel. Although results. Sensitivity and specificity do not change with disease no reason was given, it can be reasonably assumed that the prevalence (Options C, D). risk of chronic opioid use exceeds the benefit. ¢ The positive predictive value is the proportion of per- ¢ Patients with unexplained chronic cough should be sons with a positive test result who have the disease; referred for a multimodality speech pathology inter- the negative predictive value is the proportion of per- vention. sons with a negative test result who are disease free. ¢ Inselected patients with unexplained chronic cough e Positive predictive value increases as disease preva- that has not responded to other therapies, a 6-month lence increases, and negative predictive value trial of gabapentin is reasonable if the potential harms decreases as disease prevalence increases. and benefits are acceptable to the patient. 151

Answers and Critiques _ Bibliography Gibson P, Wang G, McGarvey L, et al; CHEST Expert Cough Panel. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. e Morphine is contraindicated in patients with end- Chest. 2016;149:27-44. [PMID: 26426314] doi:10.1378/chest.15-1496 stage kidney disease because of accumulation of active metabolites that can lead to neurotoxicity.

Bibliography Gibson P, Wang G, McGarvey L, et al; CHEST Expert Cough Panel. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. e Morphine is contraindicated in patients with end- Chest. 2016;149:27-44. [PMID: 26426314] doi:10.1378/chest.15-1496 stage kidney disease because of accumulation of active metabolites that can lead to neurotoxicity. Item 38 Answer: A Bibliography Educational Objective: Treat acute pain in a hospital Herzig SJ, Mosher HJ, Calcaterra SL, et al. Improving the safety of opioid use setting. for acute noncancer pain in hospitalized adults: a consensus statement from the Society of Hospital Medicine. J Hosp Med. 2018;13:263-71. [PMID: 29624189] doi:10.12788/jhm.2980 The most appropriate treatment is intravenous hydromor- phone (Option A) to control this patient’s acute severe somatic and neuropathic pain caused by calciphylaxis. Item 39 Answer: A > Hydromorphone is a p-opioid receptor agonist that is pri- = Educational Objective: Diagnose cervical myelopathy. wn marily metabolized by the liver and is also cleared during & hemodialysis, which gives it a more favorable safety pro- @ This patient most likely has cervical myelopathy (Option A), file than other opioids for patients with kidney disease or =e n a condition most commonly caused by degenerative cervical r<¥) on dialysis. Neuroexcitatory metabolites can accumulate spondylosis. Combined upper and lower motor neuron find- = 2. between dialysis treatments, and care still must be taken to ings indicate disease in the spinal cord, the only anatomic oO me prevent toxicity. Although the enteral route should be used location in the body where both segments are found together = whenever possible, parenteral opioids are appropriate for 2 and can be affected simultaneously. Lower motor neuron = immediate control of severe pain because of their rapid onset weakness originates at the level of compression, and upper @o wa of action, within 5 to 15 minutes. After intravenous hydro- motor neuron weakness occurs below it. Cervical spinal cord morphone administration, this patient’s underlying condi- compression produces lower motor weakness in the arms tion should be evaluated and treated, and the patient should or hands (atrophy, suppressed reflexes) and upper motor be rotated to oral opioid therapy once the acute severe pain is weakness in the legs (increased muscle tone, hyperreflexia, controlled. The state prescription drug monitoring database clonus, upgoing extensor reflexes in the toes). Lhermitte should be reviewed to identify previous prescriptions for sign, an electric shock-like pain radiating from the neck to the patient, which will help inform further treatment and the spine or the arms, can be produced by forward flexion of the eventual transition to oral medication. the neck, but it is insensitive for the presence of cervical cord Parenteral morphine (Option B) is contraindicated in disease. Clinical diagnosis of cervical myelopathy should be patients with end-stage kidney disease on hemodialysis confirmed with MRI. Treatment is surgical decompression. because of accumulation of active metabolites that can lead Cervical radiculopathy (Option B) is caused by spinal to neurotoxicity. nerve root compression resulting from degenerative spinal In this patient with acute severe pain, intravenous treat- changes or disk herniation. It manifests as neck pain radi- ment is preferable to oral medication, including oxycodone ating to the arm, paresthesia in a dermatomal distribution, (Option C) and tramadol (Option D), because of the slower decreased deep tendon reflexes, and diminished strength in onset of action through the oral route. Tramadol is a weak the affected extremity. This patient’s examination findings u-opioid receptor agonist with noradrenergic and serotoner- are not consistent with cervical radiculopathy. gic activity. Its active metabolites accumulate in the setting Cervical sprain (Option C) is a common musculoskele- of kidney failure, making it an inappropriate choice for this tal cause of neck pain. Typical symptoms include pain and patient. stiffness with movement and decreased cervical range of Because of its lack of clinically active metabolites in the motion. This patient’s abnormal neurologic findings rule out setting of kidney failure, fentanyl delivered via a transder- cervical sprain. mal patch (Option E) is a reasonable choice in patients with Myofascial neck pain (Option D) may be differentiated end-stage kidney disease on dialysis who have an established from other musculoskeletal causes by localized tenderness clinical need for basal analgesia and ongoing opioid therapy. and pain with palpation of “trigger points” on the neck and However, for this patient with acute pain, a fentanyl patch shoulder. The neurologic examination is normal in patients would not be an appropriate choice because the patient’s with myofascial neck pain. overall analgesic needs must be evaluated first, and the deliv- Whiplash injury (Option E) develops after trauma ery method of a transdermal patch takes effect more slowly involving abrupt acceleration and deceleration, leading to than intravenously administered medication. sudden neck flexion and extension. The physical examina- tion reveals pain and stiffness of the neck with decreased range of motion due to pain. The neurologic examination e Hydromorphone is cleared during hemodialysis, in patients with whiplash injury is normal as long as con- which gives it a more favorable safety profile for cussion was not a feature of the injury. Without a history patients on dialysis. of acceleration-deceleration trauma, whiplash injury is (Continued) unlikely in this patient.

Item 38 Answer: A Bibliography Educational Objective: Treat acute pain in a hospital Herzig SJ, Mosher HJ, Calcaterra SL, et al. Improving the safety of opioid use setting. for acute noncancer pain in hospitalized adults: a consensus statement from the Society of Hospital Medicine. J Hosp Med. 2018;13:263-71. [PMID: 29624189] doi:10.12788/jhm.2980 The most appropriate treatment is intravenous hydromor- phone (Option A) to control this patient’s acute severe somatic and neuropathic pain caused by calciphylaxis. Item 39 Answer: A > Hydromorphone is a p-opioid receptor agonist that is pri- = Educational Objective: Diagnose cervical myelopathy. wn marily metabolized by the liver and is also cleared during & hemodialysis, which gives it a more favorable safety pro- @ This patient most likely has cervical myelopathy (Option A), file than other opioids for patients with kidney disease or =e n a condition most commonly caused by degenerative cervical r<¥) on dialysis. Neuroexcitatory metabolites can accumulate spondylosis. Combined upper and lower motor neuron find- = 2. between dialysis treatments, and care still must be taken to ings indicate disease in the spinal cord, the only anatomic oO me prevent toxicity. Although the enteral route should be used location in the body where both segments are found together = whenever possible, parenteral opioids are appropriate for 2 and can be affected simultaneously. Lower motor neuron = immediate control of severe pain because of their rapid onset weakness originates at the level of compression, and upper @o wa of action, within 5 to 15 minutes. After intravenous hydro- motor neuron weakness occurs below it. Cervical spinal cord morphone administration, this patient’s underlying condi- compression produces lower motor weakness in the arms tion should be evaluated and treated, and the patient should or hands (atrophy, suppressed reflexes) and upper motor be rotated to oral opioid therapy once the acute severe pain is weakness in the legs (increased muscle tone, hyperreflexia, controlled. The state prescription drug monitoring database clonus, upgoing extensor reflexes in the toes). Lhermitte should be reviewed to identify previous prescriptions for sign, an electric shock-like pain radiating from the neck to the patient, which will help inform further treatment and the spine or the arms, can be produced by forward flexion of the eventual transition to oral medication. the neck, but it is insensitive for the presence of cervical cord Parenteral morphine (Option B) is contraindicated in disease. Clinical diagnosis of cervical myelopathy should be patients with end-stage kidney disease on hemodialysis confirmed with MRI. Treatment is surgical decompression. because of accumulation of active metabolites that can lead Cervical radiculopathy (Option B) is caused by spinal to neurotoxicity. nerve root compression resulting from degenerative spinal In this patient with acute severe pain, intravenous treat- changes or disk herniation. It manifests as neck pain radi- ment is preferable to oral medication, including oxycodone ating to the arm, paresthesia in a dermatomal distribution, (Option C) and tramadol (Option D), because of the slower decreased deep tendon reflexes, and diminished strength in onset of action through the oral route. Tramadol is a weak the affected extremity. This patient’s examination findings u-opioid receptor agonist with noradrenergic and serotoner- are not consistent with cervical radiculopathy. gic activity. Its active metabolites accumulate in the setting Cervical sprain (Option C) is a common musculoskele- of kidney failure, making it an inappropriate choice for this tal cause of neck pain. Typical symptoms include pain and patient. stiffness with movement and decreased cervical range of Because of its lack of clinically active metabolites in the motion. This patient’s abnormal neurologic findings rule out setting of kidney failure, fentanyl delivered via a transder- cervical sprain. mal patch (Option E) is a reasonable choice in patients with Myofascial neck pain (Option D) may be differentiated end-stage kidney disease on dialysis who have an established from other musculoskeletal causes by localized tenderness clinical need for basal analgesia and ongoing opioid therapy. and pain with palpation of “trigger points” on the neck and However, for this patient with acute pain, a fentanyl patch shoulder. The neurologic examination is normal in patients would not be an appropriate choice because the patient’s with myofascial neck pain. overall analgesic needs must be evaluated first, and the deliv- Whiplash injury (Option E) develops after trauma ery method of a transdermal patch takes effect more slowly involving abrupt acceleration and deceleration, leading to than intravenously administered medication. sudden neck flexion and extension. The physical examina- tion reveals pain and stiffness of the neck with decreased range of motion due to pain. The neurologic examination e Hydromorphone is cleared during hemodialysis, in patients with whiplash injury is normal as long as con- which gives it a more favorable safety profile for cussion was not a feature of the injury. Without a history patients on dialysis. of acceleration-deceleration trauma, whiplash injury is (Continued) unlikely in this patient. 152

_Answers and Critiques consistent with BPH. Furthermore, tamsulosin can cause weakness, low blood pressure, and blurry or hazy vision e¢ Combined upper and lower motor neuron findings and would not be a good option for this frail elderly patient indicate disease in the spinal cord. with dementia. © Cervical spinal cord compression produces lower motor weakness in the arms or hands (atrophy, suppressed reflexes) and upper motor weakness in the legs e Functional incontinence, or inability to reach the toilet (increased muscle tone, hyperreflexia, clonus, upgoing in time, is related to dementia and mobility disorders.

consistent with BPH. Furthermore, tamsulosin can cause weakness, low blood pressure, and blurry or hazy vision e¢ Combined upper and lower motor neuron findings and would not be a good option for this frail elderly patient indicate disease in the spinal cord. with dementia. © Cervical spinal cord compression produces lower motor weakness in the arms or hands (atrophy, suppressed reflexes) and upper motor weakness in the legs e Functional incontinence, or inability to reach the toilet (increased muscle tone, hyperreflexia, clonus, upgoing in time, is related to dementia and mobility disorders. extensor reflexes in the toes). e Ina patient with functional incontinence, behavioral therapy with prompted voiding is the appropriate Bibliography management. McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical spondylotic myelopathy: a guide to diagnosis and management. J Am n Board Fam Med. [PMID: 32179614] 2020;33:303-13. doi:10.3122/jabfm. Bibliography a 2020.02.190195 = Jachan DE, Miiller-Werdan U, Lahmann NA. Impaired mobility and urinary incontinence in nursing home residents: a multicenter study. J Wound = Ostomy Continence Nurs. 2019;46:524-9. [PMID: 31478987] doi:10.1097/ =) WON.0000000000000580 cs) cs Item 40 Answer: C = Ls] Educational Objective: Treat functional urinary wn Item 41 Answer: C Rom

extensor reflexes in the toes). e Ina patient with functional incontinence, behavioral therapy with prompted voiding is the appropriate Bibliography management. McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical spondylotic myelopathy: a guide to diagnosis and management. J Am n Board Fam Med. [PMID: 32179614] 2020;33:303-13. doi:10.3122/jabfm. Bibliography a 2020.02.190195 = Jachan DE, Miiller-Werdan U, Lahmann NA. Impaired mobility and urinary incontinence in nursing home residents: a multicenter study. J Wound = Ostomy Continence Nurs. 2019;46:524-9. [PMID: 31478987] doi:10.1097/ =) WON.0000000000000580 cs) cs Item 40 Answer: C = Ls] Educational Objective: Treat functional urinary wn Item 41 Answer: C Rom incontinence. o

extensor reflexes in the toes). e Ina patient with functional incontinence, behavioral therapy with prompted voiding is the appropriate Bibliography management. McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical spondylotic myelopathy: a guide to diagnosis and management. J Am n Board Fam Med. [PMID: 32179614] 2020;33:303-13. doi:10.3122/jabfm. Bibliography a 2020.02.190195 = Jachan DE, Miiller-Werdan U, Lahmann NA. Impaired mobility and urinary incontinence in nursing home residents: a multicenter study. J Wound = Ostomy Continence Nurs. 2019;46:524-9. [PMID: 31478987] doi:10.1097/ =) WON.0000000000000580 cs) cs Item 40 Answer: C = Ls] Educational Objective: Treat functional urinary wn Item 41 Answer: C Rom incontinence. o Educational Objective: Decrease risk for opioid overdose. = wn The most appropriate management is prompted voiding = The coadministration of lorazepam (Option C) with an opi- <= (Option C). This patient probably has functional incontinence due to dementia and decreased mobility. His dementia prevents oid, in this case morphine, poses the greatest risk for over- him from understanding when he needs to urinate, and his dose and death in this patient. Major risk factors for opioid mobility issues prevent him from reaching the toilet in time. overdose include receiving more than 50 morphine milli- In a patient with functional incontinence related to cognitive gram equivalents (MME) per day and receiving opioids and impairment, behavioral therapy with prompted voiding is the benzodiazepines concurrently. In this situation, the best risk appropriate management. With prompted voiding, the patient mitigation strategy is modifying the therapeutic regimen by is asked at regular intervals (every 2 to 4 hours) whether he tapering and then discontinuing lorazepam. If this cannot be needs to void, and assistance is provided in getting to the done or cannot be accomplished in a reasonable amount of toilet, as is positive reinforcement for urinating in the toilet. time, a naloxone reversal kit should be prescribed. Current Prompted voiding can promote improved bladder control. It recommendations are to prescribe naloxone to any patient reduces incontinence in older patients who have caregivers as who is receiving more than 50 MME per day, as well as well as in patients in assisted living or skilled nursing facilities. to patients receiving opioids and benzodiazepines concur- Patients with benign prostatic hyperplasia (BPH) may rently. Naloxone also should be considered for patients tak- experience lower urinary tract symptoms (LUTS). LUTS can ing opioids with risk factors for opioid-related harms, such be divided into symptoms that are obstructive (hesitancy, as elderly persons; patients with mental health conditions; weakened stream, straining, incomplete emptying, urinary and patients at risk for sleep-disordered breathing, such as retention, overflow incontinence) or irritative (frequency, those with heart failure, obstructive sleep apnea, or obesity. urgency, nocturia). 5a0-Reductase inhibitors (finasteride Household members should be informed about naloxone [Option A] and dutasteride) block the conversion of testos- administration and overdose prevention. terone to dihydrotestosterone; this leads to a reduction in There are no potential drug-drug interactions with prostate size and thus improvement in LUTS. Finasteride is amlodipine (Option A), bupropion (Option B), and mor- initiated when symptoms fail to respond to first-line ther- phine. The combined use of these drugs does not place the apy with a-blockers (tamsulosin, terazosin, doxazosin, alfu- patient at increased risk for overdose or death. zosin, silodosin) or the patient has a contraindication to The current total dose of morphine (Option D) is below a-blocker use. This patient with functional incontinence is the threshold associated with increased risk for overdose and unlikely to improve with the addition of finasteride. death (50 mg/d). It is the coadministration of opioids and Oxybutynin (Option B) is a reasonable second-line benzodiazepines that poses the greatest risk to this patient. therapy for urge incontinence after behavioral therapy has For most patients with chronic noncancer pain, been attempted. This patient’s urinary incontinence stems short-acting opioids are preferred. Extended-release or from his inability to understand the need to void and inabil- long-acting opioids are typically prescribed for use in pal- ity to maneuver to the bathroom. Oxybutynin and other liative care or to manage pain from cancer or other condi- anticholinergics can cause confusion and are not recom- tions characterized by persistent pain or disabling pain with mended in patients with cognitive impairment. significant functional impairment. The use of short-acting Tamsulosin (Option D) and other o-blockers are first- morphine (Option E) does not increase this patient’s risk for line therapy for BPH. This patient’s symptoms are not overdose compared with longer-acting preparations.

Educational Objective: Decrease risk for opioid overdose. = wn The most appropriate management is prompted voiding = The coadministration of lorazepam (Option C) with an opi- <= (Option C). This patient probably has functional incontinence due to dementia and decreased mobility. His dementia prevents oid, in this case morphine, poses the greatest risk for over- him from understanding when he needs to urinate, and his dose and death in this patient. Major risk factors for opioid mobility issues prevent him from reaching the toilet in time. overdose include receiving more than 50 morphine milli- In a patient with functional incontinence related to cognitive gram equivalents (MME) per day and receiving opioids and impairment, behavioral therapy with prompted voiding is the benzodiazepines concurrently. In this situation, the best risk appropriate management. With prompted voiding, the patient mitigation strategy is modifying the therapeutic regimen by is asked at regular intervals (every 2 to 4 hours) whether he tapering and then discontinuing lorazepam. If this cannot be needs to void, and assistance is provided in getting to the done or cannot be accomplished in a reasonable amount of toilet, as is positive reinforcement for urinating in the toilet. time, a naloxone reversal kit should be prescribed. Current Prompted voiding can promote improved bladder control. It recommendations are to prescribe naloxone to any patient reduces incontinence in older patients who have caregivers as who is receiving more than 50 MME per day, as well as well as in patients in assisted living or skilled nursing facilities. to patients receiving opioids and benzodiazepines concur- Patients with benign prostatic hyperplasia (BPH) may rently. Naloxone also should be considered for patients tak- experience lower urinary tract symptoms (LUTS). LUTS can ing opioids with risk factors for opioid-related harms, such be divided into symptoms that are obstructive (hesitancy, as elderly persons; patients with mental health conditions; weakened stream, straining, incomplete emptying, urinary and patients at risk for sleep-disordered breathing, such as retention, overflow incontinence) or irritative (frequency, those with heart failure, obstructive sleep apnea, or obesity. urgency, nocturia). 5a0-Reductase inhibitors (finasteride Household members should be informed about naloxone [Option A] and dutasteride) block the conversion of testos- administration and overdose prevention. terone to dihydrotestosterone; this leads to a reduction in There are no potential drug-drug interactions with prostate size and thus improvement in LUTS. Finasteride is amlodipine (Option A), bupropion (Option B), and mor- initiated when symptoms fail to respond to first-line ther- phine. The combined use of these drugs does not place the apy with a-blockers (tamsulosin, terazosin, doxazosin, alfu- patient at increased risk for overdose or death. zosin, silodosin) or the patient has a contraindication to The current total dose of morphine (Option D) is below a-blocker use. This patient with functional incontinence is the threshold associated with increased risk for overdose and unlikely to improve with the addition of finasteride. death (50 mg/d). It is the coadministration of opioids and Oxybutynin (Option B) is a reasonable second-line benzodiazepines that poses the greatest risk to this patient. therapy for urge incontinence after behavioral therapy has For most patients with chronic noncancer pain, been attempted. This patient’s urinary incontinence stems short-acting opioids are preferred. Extended-release or from his inability to understand the need to void and inabil- long-acting opioids are typically prescribed for use in pal- ity to maneuver to the bathroom. Oxybutynin and other liative care or to manage pain from cancer or other condi- anticholinergics can cause confusion and are not recom- tions characterized by persistent pain or disabling pain with mended in patients with cognitive impairment. significant functional impairment. The use of short-acting Tamsulosin (Option D) and other o-blockers are first- morphine (Option E) does not increase this patient’s risk for line therapy for BPH. This patient’s symptoms are not overdose compared with longer-acting preparations. 153

Answers and Critiques ee Bibliography Lim W. Le Gal G, Bates SM, et al. American Society of Hematology 2018 e Major risk factors for opioid overdose include receiving guidelines for management of venous thromboembolism: diagnosis of more than 50 morphine milligram equivalents per day venous thromboembolism. Blood Adv. 2018;2:3226-56. [PMID: 30482764] doi:10.1182/bloodadvances.2018024828 and receiving opioids and benzodiazepines concurrently. Bibliography Item 43 Answer: 8B Babu KM, Brent J, Juurlink DN. Prevention of opioid overdose. N EnglJ Med. 2019;380:2246-55. [PMID: 31167053] doi: 10.1056/NEJMral1807054 Educational Objective: Assess driving safety in an older adult. Item 42 Answer: C The most appropriate management is to recommend that

Bibliography Item 43 Answer: 8B Babu KM, Brent J, Juurlink DN. Prevention of opioid overdose. N EnglJ Med. 2019;380:2246-55. [PMID: 31167053] doi: 10.1056/NEJMral1807054 Educational Objective: Assess driving safety in an older adult. Item 42 Answer: C The most appropriate management is to recommend that Educational Objective: Diagnose deep venous this older patient with several previous motor vehicle colli- thrombosis. sions (MVCs) and cognitive impairment retire from driving P= aj (Option B). Drivers older than 65 years are associated with n The most appropriate management is testing for deep venous = more traffic fatalities than any other group of drivers older © thrombosis (Option C). In the case of acute unilateral lower = wn than 25 years. Older drivers are at risk for accumulating extremity edema, deep venous thrombosis (DVT) must be a deficits in multiple areas that affect driving safety, including J considered. The pretest probability of DVT is useful in deter- a vision, cognition, and mobility. However, driving is a highly (oe) mining the next steps for testing and treatment. The Wells valued instrumental activity of daily living, and cessation of =e score and modified Wells score are commonly used to deter- ae driving is associated with social isolation and depression. <2 mine pretest probability and are widely available. This patient = The decision to discontinue driving is thus a complex and @ has a moderate pretest probability of DVT based on the pres- wn somewhat subjective assessment that often requires part- ence of calf swelling at least 3 cm greater than the opposite leg, nering between the patient, family, and clinician. If modifi- and there is no alternative explanation for the symptoms that able risk factors for driving safety are present, interventions is more likely than DVT. If there is a high pretest probability of to address those risk factors with subsequent reassessment DVT, ultrasonography should be performed as the first step. may be an appropriate strategy. In this case, the patient has When there is a low or moderate pretest probability, D-dimer an abnormal result on the Mini-Cog test. The Mini-Cog is testing should be performed. If the D-dimer result is nega- sensitive (76%-100%) but not highly specific (54%-85%) in tive, no further testing needs to be completed. If the result is the diagnosis of dementia. On the basis of this patient’s his- positive or elevated, duplex ultrasonography to look for lower tory of MVCs and cognitive impairment, a recommendation extremity DVT should be performed. If ultrasonography find- to retire from driving is appropriate. This recommendation ings are positive, the patient should be treated for DVT. should be accompanied by a discussion of future transporta- Cellulitis is in the differential diagnosis of cutaneous tion, including resources that can be provided by the family erythema and leg swelling. However, cellulitis is painful and a referral to community resources that would allow her and warm to the touch and commonly associated with fever to live independently and continue participating in social and malaise, which are absent in this case. Treatment with activities that are important to her. an antibiotic, such as cephalexin (Option A), is not needed. Discontinuation of centrally acting medications can Compression therapy (Option B) is the recommended improve driving safety in older adults. Sertraline has been treatment for edema associated with chronic venous insuf- effective in treating this patient’s depression, however, so ficiency (CVI). However, edema due to CVI does not present discontinuation (Option A) would be inappropriate. Under- acutely; is typically bilateral; and is often associated with treated or untreated depression is also a risk factor associ- other findings of CVI, such as varicose veins and hyperpig- ated with MVCs in older adults. mentation, particularly on the medial aspect of the lower The presence of cataracts without significant impact on leg. This patient requires investigation for DVT rather than visual acuity would not necessarily be an indication for cat- compression therapy for CVI. aract removal (Option C). Visual acuity between 20/40 and Rest, ice, crutches, and elevation of the leg (Option D) 20/70 is not associated with increased MVC risk. would be helpful if the diagnosis were a pull or tear of the Many older drivers self-restrict to driving only in areas calf muscle. This cause of leg swelling is often associated with which they are familiar or during daytime hours. This with bruising around the ankle due to muscle bleeding. Calf patient has demonstrated unsafe driving on the basis of muscle tear may be identified at the time of ultrasonography. multiple MVCs. Combined with cognitive impairment, this makes her driving unsafe even with restrictions (Option D).

Educational Objective: Diagnose deep venous this older patient with several previous motor vehicle colli- thrombosis. sions (MVCs) and cognitive impairment retire from driving P= aj (Option B). Drivers older than 65 years are associated with n The most appropriate management is testing for deep venous = more traffic fatalities than any other group of drivers older © thrombosis (Option C). In the case of acute unilateral lower = wn than 25 years. Older drivers are at risk for accumulating extremity edema, deep venous thrombosis (DVT) must be a deficits in multiple areas that affect driving safety, including J considered. The pretest probability of DVT is useful in deter- a vision, cognition, and mobility. However, driving is a highly (oe) mining the next steps for testing and treatment. The Wells valued instrumental activity of daily living, and cessation of =e score and modified Wells score are commonly used to deter- ae driving is associated with social isolation and depression. <2 mine pretest probability and are widely available. This patient = The decision to discontinue driving is thus a complex and @ has a moderate pretest probability of DVT based on the pres- wn somewhat subjective assessment that often requires part- ence of calf swelling at least 3 cm greater than the opposite leg, nering between the patient, family, and clinician. If modifi- and there is no alternative explanation for the symptoms that able risk factors for driving safety are present, interventions is more likely than DVT. If there is a high pretest probability of to address those risk factors with subsequent reassessment DVT, ultrasonography should be performed as the first step. may be an appropriate strategy. In this case, the patient has When there is a low or moderate pretest probability, D-dimer an abnormal result on the Mini-Cog test. The Mini-Cog is testing should be performed. If the D-dimer result is nega- sensitive (76%-100%) but not highly specific (54%-85%) in tive, no further testing needs to be completed. If the result is the diagnosis of dementia. On the basis of this patient’s his- positive or elevated, duplex ultrasonography to look for lower tory of MVCs and cognitive impairment, a recommendation extremity DVT should be performed. If ultrasonography find- to retire from driving is appropriate. This recommendation ings are positive, the patient should be treated for DVT. should be accompanied by a discussion of future transporta- Cellulitis is in the differential diagnosis of cutaneous tion, including resources that can be provided by the family erythema and leg swelling. However, cellulitis is painful and a referral to community resources that would allow her and warm to the touch and commonly associated with fever to live independently and continue participating in social and malaise, which are absent in this case. Treatment with activities that are important to her. an antibiotic, such as cephalexin (Option A), is not needed. Discontinuation of centrally acting medications can Compression therapy (Option B) is the recommended improve driving safety in older adults. Sertraline has been treatment for edema associated with chronic venous insuf- effective in treating this patient’s depression, however, so ficiency (CVI). However, edema due to CVI does not present discontinuation (Option A) would be inappropriate. Under- acutely; is typically bilateral; and is often associated with treated or untreated depression is also a risk factor associ- other findings of CVI, such as varicose veins and hyperpig- ated with MVCs in older adults. mentation, particularly on the medial aspect of the lower The presence of cataracts without significant impact on leg. This patient requires investigation for DVT rather than visual acuity would not necessarily be an indication for cat- compression therapy for CVI. aract removal (Option C). Visual acuity between 20/40 and Rest, ice, crutches, and elevation of the leg (Option D) 20/70 is not associated with increased MVC risk. would be helpful if the diagnosis were a pull or tear of the Many older drivers self-restrict to driving only in areas calf muscle. This cause of leg swelling is often associated with which they are familiar or during daytime hours. This with bruising around the ankle due to muscle bleeding. Calf patient has demonstrated unsafe driving on the basis of muscle tear may be identified at the time of ultrasonography. multiple MVCs. Combined with cognitive impairment, this makes her driving unsafe even with restrictions (Option D). ¢ In the case of acute unilateral lower extremity edema, deep venous thrombosis must be considered. ¢ The decision to advise an older driver to retire from driv- ¢ When there is a low or moderate pretest probability of ing is qualitative, complex, and largely dependent on cli- deep venous thrombosis, D-dimer testing should be nician judgment; the evaluation should consider the performed as initial diagnostic testing. known risk factors and underlying medical conditions.

¢ In the case of acute unilateral lower extremity edema, deep venous thrombosis must be considered. ¢ The decision to advise an older driver to retire from driv- ¢ When there is a low or moderate pretest probability of ing is qualitative, complex, and largely dependent on cli- deep venous thrombosis, D-dimer testing should be nician judgment; the evaluation should consider the performed as initial diagnostic testing. known risk factors and underlying medical conditions. 154

Answers and Critiques Bibliography Aronson L. Don’t ruin my life — aging and driving in the 21st century. N Engl J Med. 2019;380:705-7. [PMID: 30786184] doi:10.1056/ e The treatment of severe alcohol withdrawal symptoms NEJMp1613342 is best managed by symptom-triggered administration of benzodiazepines.

Bibliography Aronson L. Don’t ruin my life — aging and driving in the 21st century. N Engl J Med. 2019;380:705-7. [PMID: 30786184] doi:10.1056/ e The treatment of severe alcohol withdrawal symptoms NEJMp1613342 is best managed by symptom-triggered administration of benzodiazepines. e In the treatment of severe alcohol withdrawal symp- Item 44 Answer: C toms, short-acting benzodiazepines are preferred to Educational Objective: Manage alcohol withdrawal in a long-acting benzodiazepines in patients with severe hospitalized patient. alcoholic hepatitis or cirrhosis. In this patient who is at risk for severe alcohol withdrawal, symptom-triggered chlordiazepoxide (Option C) is the Bibliography most appropriate treatment. Alcohol! withdrawal may cause Edelman EJ, Fiellin DA. In the clinic. Alcohol use. Ann Intern Med. 2016;164:ITC1-16. [PMID: 26747315] doi:10.7326/AITC201601050 minor symptoms, such as tremulousness, diaphoresis, and nn a palpitations, within 6 hours and hallucinosis and with- =] = drawal seizures within 12 to 48 hours of cessation of alcohol Item 45 Answer: 8B = use; symptoms may progress to severe withdrawal (delir- 1S) Educational Objective: Manage a patient’s discriminatory ium tremens), usually 48 to 96 hours after the last drink. s request for a different clinician. ba Predictors of severe alcohol withdrawal include a history cs wn of delirium tremens and baseline systolic blood pressure The most appropriate next step is to explore with the patient ems c<F) of 140 mm Hg or higher. No single symptom or sign is the reasons for his request for a new clinician (Option B). > wn associated with exclusion of severe alcohol withdrawal. In general, when faced with a perceived discriminatory & x The Clinical Institute Withdrawal Assessment for Alco- request, clinicians should (1) ensure that the patient is stable; hol, Revised (CIWA-Ar), is a commonly used standardized (2) assess decision-making capacity; and (3) determine the instrument to measure severity of alcohol withdrawal. The reason for the request before deciding whether to accom- CIWA-Ar includes 10 easily observable clinical findings that modate (Option D), negotiate, offer transfer, or set limits are summed to create a score. A score less than 8 indicates on unacceptable behavior. Although patients may refuse mild withdrawal, a score of 8 to 15 indicates moderate treatment from a specific clinician, patients do not have withdrawal, and a score greater than 15 indicates severe the right to demand or refuse clinically irrelevant clinician withdrawal. These scores can be used to guide changes in characteristics, because these demands result in unequal clinical status and medication management. Some patients working conditions for clinicians. Title VII of the Civil Rights can be managed safely in the outpatient setting with close Act of 1964 indicates that all health care employees have the follow-up, whereas patients at greater risk for severe alco- right to a workplace that is free from discrimination based hol withdrawal symptoms (e.g., history of delirium tre- on religion, race, color, sex, and national origin. mens or seizures, concomitant drug use, elderly persons) There may be clinically or ethically appropriate reasons should be hospitalized. to comply with a request that initially appears bigoted or Benzodiazepine therapy is the cornerstone of treat- racist, and it is the physician’s responsibility to determine ment for alcohol withdrawal. After initial dosing to control the rationale for the request. For example, the patient may acute symptoms, benzodiazepines should be administered have delirium, dementia, or psychosis, or he or she may lack using a symptom-triggered approach. Symptom-triggered decision-making capacity. For example, further discussion management of alcohol withdrawal in hospitalized patients may reveal that the patient fears triggering a posttraumatic results in a shorter course of therapy and less benzodiaze- flashback when interacting with clinicians of certain ethnic pine use. It is as efficacious as scheduled or scheduled plus background (e.g., a veteran of the Vietnam War interacting symptom-triggered management in managing symptoms. with a clinician of Asian ethnicity), and it may be appropri- Chlordiazepoxide has a very long half-life and is typically ate to accommodate his request. preferred in the treatment of alcohol withdrawal because Vocalizing or holding discriminatory beliefs does not it is associated with less frequent changes from agitated inherently mean that a patient lacks decision-making to sedated and a lower chance for recurrent withdrawal capacity, and such an assumption (Option A) should not or seizures. However, chlordiazepoxide may accumulate in be made. Assessment of decision-making capacity includes patients with severe alcoholic hepatitis and cirrhosis; ben- assessment of a patient’s ability to understand the relevant zodiazepines with a shorter half-life, such as lorazepam information, appreciate the medical consequences of the (Option A) and oxazepam (Option B), are preferred in these situation, consider various treatment options, and commu- patients. nicate a choice. Antipsychotics, such as haloperidol (Option D), should It is inappropriate and unprofessional to make accu- not be used in the treatment of alcohol withdrawal because sations against patients, including those of racism (Option they have not been shown to improve symptom burden. In C). In general, when faced with a racist or bigoted patient, addition, they may lower the seizure threshold in a patient setting firm expectations of behavior is more effective than at risk for withdrawal seizures. engaging in inflammatory dialogue. If exploration of the

e In the treatment of severe alcohol withdrawal symp- Item 44 Answer: C toms, short-acting benzodiazepines are preferred to Educational Objective: Manage alcohol withdrawal in a long-acting benzodiazepines in patients with severe hospitalized patient. alcoholic hepatitis or cirrhosis. In this patient who is at risk for severe alcohol withdrawal, symptom-triggered chlordiazepoxide (Option C) is the Bibliography most appropriate treatment. Alcohol! withdrawal may cause Edelman EJ, Fiellin DA. In the clinic. Alcohol use. Ann Intern Med. 2016;164:ITC1-16. [PMID: 26747315] doi:10.7326/AITC201601050 minor symptoms, such as tremulousness, diaphoresis, and nn a palpitations, within 6 hours and hallucinosis and with- =] = drawal seizures within 12 to 48 hours of cessation of alcohol Item 45 Answer: 8B = use; symptoms may progress to severe withdrawal (delir- 1S) Educational Objective: Manage a patient’s discriminatory ium tremens), usually 48 to 96 hours after the last drink. s request for a different clinician. ba Predictors of severe alcohol withdrawal include a history cs wn of delirium tremens and baseline systolic blood pressure The most appropriate next step is to explore with the patient ems c<F) of 140 mm Hg or higher. No single symptom or sign is the reasons for his request for a new clinician (Option B). > wn associated with exclusion of severe alcohol withdrawal. In general, when faced with a perceived discriminatory & x The Clinical Institute Withdrawal Assessment for Alco- request, clinicians should (1) ensure that the patient is stable; hol, Revised (CIWA-Ar), is a commonly used standardized (2) assess decision-making capacity; and (3) determine the instrument to measure severity of alcohol withdrawal. The reason for the request before deciding whether to accom- CIWA-Ar includes 10 easily observable clinical findings that modate (Option D), negotiate, offer transfer, or set limits are summed to create a score. A score less than 8 indicates on unacceptable behavior. Although patients may refuse mild withdrawal, a score of 8 to 15 indicates moderate treatment from a specific clinician, patients do not have withdrawal, and a score greater than 15 indicates severe the right to demand or refuse clinically irrelevant clinician withdrawal. These scores can be used to guide changes in characteristics, because these demands result in unequal clinical status and medication management. Some patients working conditions for clinicians. Title VII of the Civil Rights can be managed safely in the outpatient setting with close Act of 1964 indicates that all health care employees have the follow-up, whereas patients at greater risk for severe alco- right to a workplace that is free from discrimination based hol withdrawal symptoms (e.g., history of delirium tre- on religion, race, color, sex, and national origin. mens or seizures, concomitant drug use, elderly persons) There may be clinically or ethically appropriate reasons should be hospitalized. to comply with a request that initially appears bigoted or Benzodiazepine therapy is the cornerstone of treat- racist, and it is the physician’s responsibility to determine ment for alcohol withdrawal. After initial dosing to control the rationale for the request. For example, the patient may acute symptoms, benzodiazepines should be administered have delirium, dementia, or psychosis, or he or she may lack using a symptom-triggered approach. Symptom-triggered decision-making capacity. For example, further discussion management of alcohol withdrawal in hospitalized patients may reveal that the patient fears triggering a posttraumatic results in a shorter course of therapy and less benzodiaze- flashback when interacting with clinicians of certain ethnic pine use. It is as efficacious as scheduled or scheduled plus background (e.g., a veteran of the Vietnam War interacting symptom-triggered management in managing symptoms. with a clinician of Asian ethnicity), and it may be appropri- Chlordiazepoxide has a very long half-life and is typically ate to accommodate his request. preferred in the treatment of alcohol withdrawal because Vocalizing or holding discriminatory beliefs does not it is associated with less frequent changes from agitated inherently mean that a patient lacks decision-making to sedated and a lower chance for recurrent withdrawal capacity, and such an assumption (Option A) should not or seizures. However, chlordiazepoxide may accumulate in be made. Assessment of decision-making capacity includes patients with severe alcoholic hepatitis and cirrhosis; ben- assessment of a patient’s ability to understand the relevant zodiazepines with a shorter half-life, such as lorazepam information, appreciate the medical consequences of the (Option A) and oxazepam (Option B), are preferred in these situation, consider various treatment options, and commu- patients. nicate a choice. Antipsychotics, such as haloperidol (Option D), should It is inappropriate and unprofessional to make accu- not be used in the treatment of alcohol withdrawal because sations against patients, including those of racism (Option they have not been shown to improve symptom burden. In C). In general, when faced with a racist or bigoted patient, addition, they may lower the seizure threshold in a patient setting firm expectations of behavior is more effective than at risk for withdrawal seizures. engaging in inflammatory dialogue. If exploration of the 155

Answers and Critiques patient’s reasons uncovers a racist or bigoted perspective, a Although this patient has hypertriglyceridemia, a patient may be told, for example, “You will treat all members fibrate, such as gemfibrozil (Option B), is not indicated of your care team with respect and refrain from using exple- before intensifying statin therapy, lifestyle interventions, and tives or hurtful language.” addressing reversible factors. This patient does not have an indication for high- intensity statin therapy (Option C) because he is in the inter- ¢ When faced with a perceived discriminatory request mediate 10-year ASCVD risk category. In adults aged 40 to from a patient, clinicians should (1) ensure that the 75 years at high risk for ASCVD, high-intensity statin therapy patient is stable; (2) assess decision-making capacity; should be initiated for primary prevention to reduce LDL and (3) determine the reason for the request before cholesterol level by 50% or more. deciding whether to accommodate, negotiate, offer transfer, or set limits on unacceptable behavior. ¢ The American Heart Association/American College of bs = Cardiology recommend consideration of moderate- wn Bibliography = intensity statin therapy in adults at intermediate risk @ Paul-Emile K, Smith AK, Lo B, Fernandez A. Dealing with racist patients. N = EnglJ Med. 2016;374:708-11. [PMID: 26933847] doi:10.1056/NEJMp1514939 for atherosclerotic cardiovascular disease with risk- wn oy enhancing factors. = 2. Item 46 Answer: D e The U.S. Preventive Services Task Force recommends (=) = low- to moderate-intensity statin therapy for a Educational Objective: Prevent atherosclerotic 2 primary prevention in adults who have at least one < cardiovascular disease in an intermediate-risk patient @ with risk-enhancing factors. atherosclerotic cardiovascular disease (ASCVD) risk nn factor and a calculated 10-year ASCVD event risk of The most appropriate treatment is initiation of moderate- 10% or higher. intensity statin (e.g., atorvastatin) therapy (Option D). Adults aged 40 to 75 years without diabetes mellitus and with an LDL Bibliography cholesterol level of 70 mg/dL to 189 mg/dL (1.81-4.90 mmol/L) Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ should undergo risk assessment for primary prevention of ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management

patient’s reasons uncovers a racist or bigoted perspective, a Although this patient has hypertriglyceridemia, a patient may be told, for example, “You will treat all members fibrate, such as gemfibrozil (Option B), is not indicated of your care team with respect and refrain from using exple- before intensifying statin therapy, lifestyle interventions, and tives or hurtful language.” addressing reversible factors. This patient does not have an indication for high- intensity statin therapy (Option C) because he is in the inter- ¢ When faced with a perceived discriminatory request mediate 10-year ASCVD risk category. In adults aged 40 to from a patient, clinicians should (1) ensure that the 75 years at high risk for ASCVD, high-intensity statin therapy patient is stable; (2) assess decision-making capacity; should be initiated for primary prevention to reduce LDL and (3) determine the reason for the request before cholesterol level by 50% or more. deciding whether to accommodate, negotiate, offer transfer, or set limits on unacceptable behavior. ¢ The American Heart Association/American College of bs = Cardiology recommend consideration of moderate- wn Bibliography = intensity statin therapy in adults at intermediate risk @ Paul-Emile K, Smith AK, Lo B, Fernandez A. Dealing with racist patients. N = EnglJ Med. 2016;374:708-11. [PMID: 26933847] doi:10.1056/NEJMp1514939 for atherosclerotic cardiovascular disease with risk- wn oy enhancing factors. = 2. Item 46 Answer: D e The U.S. Preventive Services Task Force recommends (=) = low- to moderate-intensity statin therapy for a Educational Objective: Prevent atherosclerotic 2 primary prevention in adults who have at least one < cardiovascular disease in an intermediate-risk patient @ with risk-enhancing factors. atherosclerotic cardiovascular disease (ASCVD) risk nn factor and a calculated 10-year ASCVD event risk of The most appropriate treatment is initiation of moderate- 10% or higher. intensity statin (e.g., atorvastatin) therapy (Option D). Adults aged 40 to 75 years without diabetes mellitus and with an LDL Bibliography cholesterol level of 70 mg/dL to 189 mg/dL (1.81-4.90 mmol/L) Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ should undergo risk assessment for primary prevention of ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management atherosclerotic cardiovascular disease (ASCVD) by using of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. the Pooled Cohort Equations. The 10-year risk for ASCVD Circulation. 2019;139:e1082-1143. [PMID: 30586774] doi:10.1161/CIR. can be categorized as low (<5%), borderline (5% to <7.5%), 000000000000062540

atherosclerotic cardiovascular disease (ASCVD) by using of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. the Pooled Cohort Equations. The 10-year risk for ASCVD Circulation. 2019;139:e1082-1143. [PMID: 30586774] doi:10.1161/CIR. can be categorized as low (<5%), borderline (5% to <7.5%), 000000000000062540 intermediate (>7.5% to <20%), or high (20%). In adults at intermediate risk, the presence of risk-enhancing fac- Item 47 Answer: C tors may justify initiation of moderate-intensity statin ther- Educational Objective: Treat acute back pain with apy. This patient has two risk-enhancing factors: psoriatic nonpharmacologic therapy. arthritis (an inflammatory condition) and a family history of premature ASCVD. The American Heart Association/ This patient with nonspecific acute low back pain would American College of Cardiology recommendations for primary most likely benefit from a trial of nonpharmacologic treat- prevention of ASCVD support moderate-intensity statin ther- ments (Option C), which are first-line therapy for patients apy for this patient. The U.S. Preventive Services Task Force with acute low back pain. Potentially useful nonpharma- recommends low- to moderate-intensity statin therapy for cologic therapies for acute low back pain include local heat, primary prevention in adults who have at least one ASCVD risk massage, and acupuncture, although the evidence support- factor (dyslipidemia, diabetes, hypertension, or smoking) and ing these approaches is generally weak. Spinal manipulation a calculated 10-year ASCVD event risk of 10% or higher. The therapy has moderate evidence for modest pain reduction 2020 U.S. Department of Veterans Affairs/U.S. Department of and improvement in function. The harms of nonpharma- Defense cholesterol guideline recommends moderate-inten- cologic therapy are minimal, and the overall prognosis for sity statin therapy for primary prevention in patients with a nonspecific low back pain is excellent, with most patients 10-year cardiovascular risk of 12% or higher, an LDL choles- improving rapidly in the first month. terol level of 190 mg/dL (4.92 mmol/L) or greater, or diabetes. Bed rest (Option A) has been shown to increase pain Ezetimibe (Option A) in addition to maximally tolerated and decrease functional recovery. Patients with acute and statin therapy is indicated in very high-risk patients with subacute low back pain should be encouraged to maintain as ASCVD when the LDL cholesterol level remains 70 mg/dL many of their activities of daily living as possible. (1.81 mmol/L) or greater. Ezetimibe can be considered for Acute back pain (<4 weeks’ duration) without neuro- primary prevention of ASCVD in patients with an initial LDL logic or systemic findings, and without “red flag” symptoms, cholesterol level of 190 mg/dL (4.92 mmol/L) or greater in can be managed conservatively without imaging such as whom maximally tolerated statin therapy does not achieve MRI (Option B). Patients should be informed that most low a 50% reduction in LDL cholesterol. Ezetimibe monotherapy back pain is musculoskeletal in nature and resolves sponta- is not indicated for this patient. neously without imaging or intervention.

intermediate (>7.5% to <20%), or high (20%). In adults at intermediate risk, the presence of risk-enhancing fac- Item 47 Answer: C tors may justify initiation of moderate-intensity statin ther- Educational Objective: Treat acute back pain with apy. This patient has two risk-enhancing factors: psoriatic nonpharmacologic therapy. arthritis (an inflammatory condition) and a family history of premature ASCVD. The American Heart Association/ This patient with nonspecific acute low back pain would American College of Cardiology recommendations for primary most likely benefit from a trial of nonpharmacologic treat- prevention of ASCVD support moderate-intensity statin ther- ments (Option C), which are first-line therapy for patients apy for this patient. The U.S. Preventive Services Task Force with acute low back pain. Potentially useful nonpharma- recommends low- to moderate-intensity statin therapy for cologic therapies for acute low back pain include local heat, primary prevention in adults who have at least one ASCVD risk massage, and acupuncture, although the evidence support- factor (dyslipidemia, diabetes, hypertension, or smoking) and ing these approaches is generally weak. Spinal manipulation a calculated 10-year ASCVD event risk of 10% or higher. The therapy has moderate evidence for modest pain reduction 2020 U.S. Department of Veterans Affairs/U.S. Department of and improvement in function. The harms of nonpharma- Defense cholesterol guideline recommends moderate-inten- cologic therapy are minimal, and the overall prognosis for sity statin therapy for primary prevention in patients with a nonspecific low back pain is excellent, with most patients 10-year cardiovascular risk of 12% or higher, an LDL choles- improving rapidly in the first month. terol level of 190 mg/dL (4.92 mmol/L) or greater, or diabetes. Bed rest (Option A) has been shown to increase pain Ezetimibe (Option A) in addition to maximally tolerated and decrease functional recovery. Patients with acute and statin therapy is indicated in very high-risk patients with subacute low back pain should be encouraged to maintain as ASCVD when the LDL cholesterol level remains 70 mg/dL many of their activities of daily living as possible. (1.81 mmol/L) or greater. Ezetimibe can be considered for Acute back pain (<4 weeks’ duration) without neuro- primary prevention of ASCVD in patients with an initial LDL logic or systemic findings, and without “red flag” symptoms, cholesterol level of 190 mg/dL (4.92 mmol/L) or greater in can be managed conservatively without imaging such as whom maximally tolerated statin therapy does not achieve MRI (Option B). Patients should be informed that most low a 50% reduction in LDL cholesterol. Ezetimibe monotherapy back pain is musculoskeletal in nature and resolves sponta- is not indicated for this patient. neously without imaging or intervention. 156

eee ee ee For patients whose low back pain has not responded of sympathetic neural outflow and resultant venous to nonpharmacologic therapy, a trial of NSAIDs is first-line pooling associated with vasovagal syncopal. A meta-analysis pharmacologic therapy, and tramadol or duloxetine may suggests that midodrine can reduce recurrent vasovagal be considered as second-line therapy. Opioids, such as oxy- syncopal episodes by 43%. However, this patient has yet to codone (Option D), should only be considered in patients try less expensive, and presumably safer, nonpharmacologic for whom nonpharmacologic therapy as well as first- and options. second-line pharmacologic therapy has been ineffective. Trials of B-blockers for the prevention of vasovagal syn- Because of the addictive potential of opioids, physicians cope have, for the most part, been negative. However, some should prescribe them only after a discussion of the poten- studies have documented benefit with B-blocker therapy in tial harms and benefits of use. patients aged 42 years or older. It is unlikely that this young patient needs or will respond to B-blocker therapy, such as propranolol (Option D). e Nonpharmacologic treatments, such as superficial nn a heat, exercise, massage, acupuncture, and spinal s manipulation, are first-line therapy for patients with e Vasovagal syncope is treated with targeted education = acute low back pain. about avoiding triggers, such as prolonged standing = rs) and warm environments. e For patients whose low back pain has not responded <c = to nonpharmacologic therapy, NSAIDs are first-line e Physical counterpressure measures, such as squatting cs wn pharmacologic therapy. and leg crossing, as well as increased fluid and salt thes o intake, can decrease the risk for recurrent vasovagal = n Bibliography syncope. S <= Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from Bibliography the American College of Physicians. Ann Intern Med. 2017;166:514-30. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for [PMID: 28192789] doi:10.7326/M16-2367 the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] doi:10.1161/CIR.0000000000000498 Item 48 Answer: A Educational Objective: Treat vasovagal syncope.

For patients whose low back pain has not responded of sympathetic neural outflow and resultant venous to nonpharmacologic therapy, a trial of NSAIDs is first-line pooling associated with vasovagal syncopal. A meta-analysis pharmacologic therapy, and tramadol or duloxetine may suggests that midodrine can reduce recurrent vasovagal be considered as second-line therapy. Opioids, such as oxy- syncopal episodes by 43%. However, this patient has yet to codone (Option D), should only be considered in patients try less expensive, and presumably safer, nonpharmacologic for whom nonpharmacologic therapy as well as first- and options. second-line pharmacologic therapy has been ineffective. Trials of B-blockers for the prevention of vasovagal syn- Because of the addictive potential of opioids, physicians cope have, for the most part, been negative. However, some should prescribe them only after a discussion of the poten- studies have documented benefit with B-blocker therapy in tial harms and benefits of use. patients aged 42 years or older. It is unlikely that this young patient needs or will respond to B-blocker therapy, such as propranolol (Option D). e Nonpharmacologic treatments, such as superficial nn a heat, exercise, massage, acupuncture, and spinal s manipulation, are first-line therapy for patients with e Vasovagal syncope is treated with targeted education = acute low back pain. about avoiding triggers, such as prolonged standing = rs) and warm environments. e For patients whose low back pain has not responded <c = to nonpharmacologic therapy, NSAIDs are first-line e Physical counterpressure measures, such as squatting cs wn pharmacologic therapy. and leg crossing, as well as increased fluid and salt thes o intake, can decrease the risk for recurrent vasovagal = n Bibliography syncope. S <= Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from Bibliography the American College of Physicians. Ann Intern Med. 2017;166:514-30. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for [PMID: 28192789] doi:10.7326/M16-2367 the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] doi:10.1161/CIR.0000000000000498 Item 48 Answer: A Educational Objective: Treat vasovagal syncope. The most appropriate treatment is education about avoid- Item 49 Answer: A ance of triggers (Option A). This patient probably has vaso- Educational Objective: Evaluate the validity of a vagal syncope, which is provoked by noxious stimuli, fear, patient’s refusal of care. stress, or heat overexposure and is preceded by a prodrome of warmth, dizziness, and nausea. In cases of vasovagal The most appropriate next step in management is consulta- (reflex) syncope, explaining the diagnosis to the patient is tion with the hospital ethics committee (Option A). In most strongly recommended, along with targeted education about situations, adults with decision-making capacity have the avoiding triggers (e.g., prolonged standing, warm environ- legal and ethical right to accept or refuse medical treatments. ments) and how to cope with noxious events (e.g., blood This right is based on respect for the patient’s autonomy, draws). In addition, physical counterpressure measures, right to self-determination, and liberty. A patient’s refusal such as squatting and leg crossing, and increased fluid and of care should be explored thoughtfully and with empathy, salt intake can decrease the risk for recurrence of the synco- with attention to the spectrum of reasonable choices. How- pal event in selected patients. ever, for informed refusal to be considered valid, the patient Fludrocortisone (Option B) has mineralocorticoid must be able to make her own decisions and be free from activity that increases blood volume through sodium coercion. In this case, the care team has evidence that the and water retention. Hypertension and hypokalemia are patient may be being coerced to return home. The ethics expected adverse effects. Fludrocortisone might be con- committee should be consulted to determine the appropriate sidered for patients with vasovagal syncope not respond- course of action. ing to avoidance of triggers and physical counterpressure Discharging the patient home on oral antibiotics measures. Studies show a 31% non-statistically significant (Option B) is not appropriate given her tachycardia and reduction in recurrent syncope in patients with frequent hypoxia, as well as the report of potential coercion. vasovagal syncope after 2 weeks of therapy. Fludrocortisone It is inappropriate, and in opposition to the principles of is not indicated in this patient who has yet to try more autonomy and liberty, to hospitalize a patient with capacity effective means of syncope prevention that are associated against her will (Option C). Engaging the hospital ethics with fewer side effects. committee to determine whether coercion is preventing the Midodrine (Option C) is metabolized to a periph- patient from making a freely informed choice is the best erally active o-agonist that may counter the reduction next step.

The most appropriate treatment is education about avoid- Item 49 Answer: A ance of triggers (Option A). This patient probably has vaso- Educational Objective: Evaluate the validity of a vagal syncope, which is provoked by noxious stimuli, fear, patient’s refusal of care. stress, or heat overexposure and is preceded by a prodrome of warmth, dizziness, and nausea. In cases of vasovagal The most appropriate next step in management is consulta- (reflex) syncope, explaining the diagnosis to the patient is tion with the hospital ethics committee (Option A). In most strongly recommended, along with targeted education about situations, adults with decision-making capacity have the avoiding triggers (e.g., prolonged standing, warm environ- legal and ethical right to accept or refuse medical treatments. ments) and how to cope with noxious events (e.g., blood This right is based on respect for the patient’s autonomy, draws). In addition, physical counterpressure measures, right to self-determination, and liberty. A patient’s refusal such as squatting and leg crossing, and increased fluid and of care should be explored thoughtfully and with empathy, salt intake can decrease the risk for recurrence of the synco- with attention to the spectrum of reasonable choices. How- pal event in selected patients. ever, for informed refusal to be considered valid, the patient Fludrocortisone (Option B) has mineralocorticoid must be able to make her own decisions and be free from activity that increases blood volume through sodium coercion. In this case, the care team has evidence that the and water retention. Hypertension and hypokalemia are patient may be being coerced to return home. The ethics expected adverse effects. Fludrocortisone might be con- committee should be consulted to determine the appropriate sidered for patients with vasovagal syncope not respond- course of action. ing to avoidance of triggers and physical counterpressure Discharging the patient home on oral antibiotics measures. Studies show a 31% non-statistically significant (Option B) is not appropriate given her tachycardia and reduction in recurrent syncope in patients with frequent hypoxia, as well as the report of potential coercion. vasovagal syncope after 2 weeks of therapy. Fludrocortisone It is inappropriate, and in opposition to the principles of is not indicated in this patient who has yet to try more autonomy and liberty, to hospitalize a patient with capacity effective means of syncope prevention that are associated against her will (Option C). Engaging the hospital ethics with fewer side effects. committee to determine whether coercion is preventing the Midodrine (Option C) is metabolized to a periph- patient from making a freely informed choice is the best erally active o-agonist that may counter the reduction next step. 157

Answers and Critiques Physicians, in the course of routine clinical care, are able to evaluate decision-making capacity based on the CONT. e Patellofemoral pain syndrome is characterized by pain patient’s ability to understand information, appreciate the in the knee that can be localized to the patella or risks and benefits of treatment options, and communicate a behind the patella and classically occurs with activi- consistent choice in line with their stated values. A psychiat- ties that involve knee flexion. ric evaluation (Option D) is not needed. e The most effective long-term treatment for patel- lofemoral pain syndrome is physical therapy with an e Informed consent or refusal requires that the patient have exercise program designed to strengthen the quadri- decision-making capacity and be free from coercion. ceps muscles, hamstrings, and gluteus muscles.

Physicians, in the course of routine clinical care, are able to evaluate decision-making capacity based on the CONT. e Patellofemoral pain syndrome is characterized by pain patient’s ability to understand information, appreciate the in the knee that can be localized to the patella or risks and benefits of treatment options, and communicate a behind the patella and classically occurs with activi- consistent choice in line with their stated values. A psychiat- ties that involve knee flexion. ric evaluation (Option D) is not needed. e The most effective long-term treatment for patel- lofemoral pain syndrome is physical therapy with an e Informed consent or refusal requires that the patient have exercise program designed to strengthen the quadri- decision-making capacity and be free from coercion. ceps muscles, hamstrings, and gluteus muscles. Bibliography Bibliography Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights > Collins NJ, Barton CJ, van Middelkoop M, et al. 2018 Consensus statement on = Committee. American College of Physicians Ethics Manual: seventh edition. exercise therapy and physical interventions (orthoses, taping and man- nn Ann Intern Med. 2019;170:S1-32. [PMID: 30641552] doi:10.7326/M18-2160 ual therapy) to treat patellofemoral pain: recommendations from the 5th = @o International Patellofemoral Pain Research Retreat, Gold Coast, Australia, = i?) 2017. Br J Sports Med. 2018;52:1170-8. [PMID: 29925502] doi:10.1136/ rs¥) bjsports-2018-099397 J Item 50 Answer: D Qa (=) Educational Objective: Treat patellofemoral pain = Item 51 Answer: D = syndrome. 2 <= Educational Objective: Treat a pressure injury. The most appropriate treatment is physical therapy includ- Oo n ing strengthening exercises (Option D). This patient has Pressure offloading (Option D) is the most appropriate treat- patellofemoral pain syndrome, which is characterized by ment. Pressure injuries (also known as pressure ulcers) are pain in the knee that can be localized to the patella or localized injuries to the skin or soft tissue caused by pressure behind the patella and classically occurs with activities and shear forces. They may be classified by use of a staging that involve knee flexion. Common symptoms include system, with each stage distinguished by the amount of tissue pain with running and going up and down stairs. This loss. This patient has a stage 3 pressure injury characterized syndrome most commonly occurs in women and is a com- by full-thickness tissue loss with visible subcutaneous fat mon condition in runners. Weak quadriceps muscles may but no exposed bone, tendon, or muscle. Treatment of estab- contribute to the onset of patellofemoral pain syndrome. lished pressure injuries requires a multipronged manage- Diagnosis is based on the history and physical examination ment strategy that may include managing the causative con- findings, which include pain with flexion of the knee, such ditions; wound protection; surgical debridement and repair; as pain with squatting. Patellofemoral pain syndrome is and, in some cases, vacuum-assisted closure. Appropriate not associated with effusions or erythema. Further imag- treatment for this patient includes use of an air-fluidized ing or evaluation is not necessary. NSAIDs may help alle- mattress (or an advanced static mattress), local wound care viate symptoms in the acute setting but have not shown with hydrocolloid dressings, and pressure offloading. benefit in the long term. In the acute phase of injury, Some nutritional therapy, such as protein-containing modification of activity and cryotherapy (ice, ice water supplements, can improve wound healing, but ascorbic acid immersion) is recommended. In the recovery phase, the (vitamin C) supplementation (Option A) has not shown most effective treatment for patellofemoral pain syndrome benefit. In this patient with adequate nutritional status and is physical therapy with an exercise program designed to normal BMI, vitamin supplementation is not indicated. strengthen the quadriceps muscles, hamstrings, and glu- Hyperbaric oxygen therapy (Option B) is commonly teus muscles. Core strengthening exercises also may have used to treat pressure injuries in hospitalized patients; how- benefit. These strengthening exercises should be continued ever, evidence is insufficient to assess its safety and efficacy, after pain relief. and thus to support its use for this purpose. The underlying mechanism responsible for patellofem- Antibiotics, such as piperacillin-tazobactam (Option oral pain syndrome is weakness in one or more muscle C), do not have a role in managing pressure injuries without groups of the lower extremity. Arthroscopic surgery (Option signs of infection, and this patient has no evidence of infec- A) has no role in correcting these contributing factors for tion, such as fever, purulent drainage from the wound, or patellofemoral pain syndrome. Similarly, glucocorticoid surrounding erythema. In patients who develop abscesses injection (Option B) into the knee joint or periarticular associated with pressure injury, drainage is necessary. Osteo- structures is unlikely to improve symptoms and may cause myelitis can develop from advancing pressure injuries and harm to cartilage and tendons. often requires surgical debridement. Deep intraoperative Knee bracing (Option C), such as with kinesiology tape bone cultures guide the choice of antibiotic therapy in that or prepatellar bands, has not shown benefit in studies. The situation. use of foot orthoses may be beneficial and is a recommended Multiple studies have compared various dressing types adjunct to physical therapy. for pressure injuries. Hydrocolloid and foam dressings

Bibliography Bibliography Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights > Collins NJ, Barton CJ, van Middelkoop M, et al. 2018 Consensus statement on = Committee. American College of Physicians Ethics Manual: seventh edition. exercise therapy and physical interventions (orthoses, taping and man- nn Ann Intern Med. 2019;170:S1-32. [PMID: 30641552] doi:10.7326/M18-2160 ual therapy) to treat patellofemoral pain: recommendations from the 5th = @o International Patellofemoral Pain Research Retreat, Gold Coast, Australia, = i?) 2017. Br J Sports Med. 2018;52:1170-8. [PMID: 29925502] doi:10.1136/ rs¥) bjsports-2018-099397 J Item 50 Answer: D Qa (=) Educational Objective: Treat patellofemoral pain = Item 51 Answer: D = syndrome. 2 <= Educational Objective: Treat a pressure injury. The most appropriate treatment is physical therapy includ- Oo n ing strengthening exercises (Option D). This patient has Pressure offloading (Option D) is the most appropriate treat- patellofemoral pain syndrome, which is characterized by ment. Pressure injuries (also known as pressure ulcers) are pain in the knee that can be localized to the patella or localized injuries to the skin or soft tissue caused by pressure behind the patella and classically occurs with activities and shear forces. They may be classified by use of a staging that involve knee flexion. Common symptoms include system, with each stage distinguished by the amount of tissue pain with running and going up and down stairs. This loss. This patient has a stage 3 pressure injury characterized syndrome most commonly occurs in women and is a com- by full-thickness tissue loss with visible subcutaneous fat mon condition in runners. Weak quadriceps muscles may but no exposed bone, tendon, or muscle. Treatment of estab- contribute to the onset of patellofemoral pain syndrome. lished pressure injuries requires a multipronged manage- Diagnosis is based on the history and physical examination ment strategy that may include managing the causative con- findings, which include pain with flexion of the knee, such ditions; wound protection; surgical debridement and repair; as pain with squatting. Patellofemoral pain syndrome is and, in some cases, vacuum-assisted closure. Appropriate not associated with effusions or erythema. Further imag- treatment for this patient includes use of an air-fluidized ing or evaluation is not necessary. NSAIDs may help alle- mattress (or an advanced static mattress), local wound care viate symptoms in the acute setting but have not shown with hydrocolloid dressings, and pressure offloading. benefit in the long term. In the acute phase of injury, Some nutritional therapy, such as protein-containing modification of activity and cryotherapy (ice, ice water supplements, can improve wound healing, but ascorbic acid immersion) is recommended. In the recovery phase, the (vitamin C) supplementation (Option A) has not shown most effective treatment for patellofemoral pain syndrome benefit. In this patient with adequate nutritional status and is physical therapy with an exercise program designed to normal BMI, vitamin supplementation is not indicated. strengthen the quadriceps muscles, hamstrings, and glu- Hyperbaric oxygen therapy (Option B) is commonly teus muscles. Core strengthening exercises also may have used to treat pressure injuries in hospitalized patients; how- benefit. These strengthening exercises should be continued ever, evidence is insufficient to assess its safety and efficacy, after pain relief. and thus to support its use for this purpose. The underlying mechanism responsible for patellofem- Antibiotics, such as piperacillin-tazobactam (Option oral pain syndrome is weakness in one or more muscle C), do not have a role in managing pressure injuries without groups of the lower extremity. Arthroscopic surgery (Option signs of infection, and this patient has no evidence of infec- A) has no role in correcting these contributing factors for tion, such as fever, purulent drainage from the wound, or patellofemoral pain syndrome. Similarly, glucocorticoid surrounding erythema. In patients who develop abscesses injection (Option B) into the knee joint or periarticular associated with pressure injury, drainage is necessary. Osteo- structures is unlikely to improve symptoms and may cause myelitis can develop from advancing pressure injuries and harm to cartilage and tendons. often requires surgical debridement. Deep intraoperative Knee bracing (Option C), such as with kinesiology tape bone cultures guide the choice of antibiotic therapy in that or prepatellar bands, has not shown benefit in studies. The situation. use of foot orthoses may be beneficial and is a recommended Multiple studies have compared various dressing types adjunct to physical therapy. for pressure injuries. Hydrocolloid and foam dressings 158

_newers ang Critiques reduce ulcer size compared with gauze dressings; therefore, Bibliography ? use of hydrocolloid dressings should continue (Option E). Wald NJ, Morris JK. Two under-recognized limitations of number needed to CON treat [Editorial]. Int J Epidemiol. 2020;49:359-60. [PMID: 31965151] doi:10.1093/ije/dyz267 e Treatment of established pressure injuries requires a multipronged management strategy that may include managing the causative conditions, pressure offload- Item 53 Answer: 8B

reduce ulcer size compared with gauze dressings; therefore, Bibliography ? use of hydrocolloid dressings should continue (Option E). Wald NJ, Morris JK. Two under-recognized limitations of number needed to CON treat [Editorial]. Int J Epidemiol. 2020;49:359-60. [PMID: 31965151] doi:10.1093/ije/dyz267 e Treatment of established pressure injuries requires a multipronged management strategy that may include managing the causative conditions, pressure offload- Item 53 Answer: 8B ing, wound protection, and surgical debridement and Educational Objective: Diagnose bipolar 1 disorder. repair. The most likely diagnosis is bipolar 1 disorder (Option B). This patient’s impulsive behavior, decreased need for sleep, Bibliography increased goal-directed activity, and inflated mood suggest Ricci JA, Bayer LR, Orgill DP. Evidence-based medicine: the evaluation and mania, and the previous diagnosis of depression suggests treatment of pressure injuries. Plast Reconstr Surg. 2017;139:275e-86e. wn [PMID: 28027261] doi:10.1097/PRS.0000000000002850 the diagnosis of bipolar 1 disorder. Diagnostic criteria for @ a bipolar 1 disorder include symptoms of depression plus Zs = at least one episode of mania characterized by one or Ee Item 52 Answer: B more of the following: elevated mood, irritability, inflated tS) =] self-esteem, decreased need for sleep, increased talkative- = Educational Objective: Calculate the number needed to cs ness, flight of ideas, distractibility, or increased risk-taking treat. nn Baer behavior. Initial symptoms often present in the late teens 7) The number needed to treat for one patient to benefit from to early twenties. A careful history directed at identify- = n the new medication for fibromyalgia is 20 (Option B). Num- ing previous episodes of mania or hypomania should be = <= bers needed to treat (NNT) and harm (NNH) are a way to obtained when initially diagnosing depression; prescribing convey the clinical effect of an intervention. The NNT, or antidepressant monotherapy to a patient with bipolar dis- the number of patients who must receive a treatment to order may precipitate a manic episode. The Mood Disorder cause one patient to benefit, is the inverse of the absolute Questionnaire can be used to screen patients in the pri- risk reduction. Absolute risk reduction (ARR) is the abso- mary care setting. Bipolar 1 disorder should be managed by lute value of the difference in treatment effect between the a psychiatrist; in the setting of acute mania, urgent referral experimental and the control or comparison groups. The is appropriate. experimental and control effects are expressed as a rate, or Attention-deficit/hyperactivity disorder (ADHD) the number of patients who experienced the treatment effect (Option A) is characterized by persistent inattention and/ in the group divided by the total number of patients in that or hyperactivity-impulsivity that disrupt functioning or group. For this example, the experimental event rate is 0.30. development. ADHD is most frequently recognized in child- The control event rate is 0.25. Thus, the ARR is |0.30 - 0.25| = hood, but the diagnosis may be delayed until adulthood. 0.05. The NNT is the inverse of the ARR, calculated as 1/0.05 = This patient’s expansive mood, goal-directed behaviors, and 20; it is not 10 (Option A), 30 (Option C), or 40 (Option D). history of depression are not compatible with ADHD. The acceptability of the NNT depends on the risks asso- Personality disorders (Option C) involve consistent pat- ciated with the condition, the cost and side effects of the terns of interpersonal behavior and perceptions that are treatment, and other treatments available. Comparing the inflexible, diverge significantly from the behavioral stan- NNT with the NNH can assess the balance of treatment ben- dards of the person’s culture, and cause substantial func- efit versus treatment harms. NNH is calculated similarly to tional impairment and emotional distress. This patient’s NNT, by using the absolute risk increase (ARI), or the abso- behavior is not consistent with a personality disorder. lute difference in risk increase between the experimental Schizophrenia (Option D) is a heterogeneous psychi- and control groups. In this example, “risk” was the rate of atric disorder comprising both positive symptoms (hallu- adverse effects in each group. The experimental rate of risk cinations, disorganized thought, delusions) and negative is 15%. The control rate of risk is 5%. The ARI is |0.15 - 0.05| = symptoms (flattened affect, decreased activity). There is no 0.10, and the NNH (calculated as the inverse of the ARI) is evidence of these symptoms to support the diagnosis of 1/0.10 =10. schizophrenia in this patient.

ing, wound protection, and surgical debridement and Educational Objective: Diagnose bipolar 1 disorder. repair. The most likely diagnosis is bipolar 1 disorder (Option B). This patient’s impulsive behavior, decreased need for sleep, Bibliography increased goal-directed activity, and inflated mood suggest Ricci JA, Bayer LR, Orgill DP. Evidence-based medicine: the evaluation and mania, and the previous diagnosis of depression suggests treatment of pressure injuries. Plast Reconstr Surg. 2017;139:275e-86e. wn [PMID: 28027261] doi:10.1097/PRS.0000000000002850 the diagnosis of bipolar 1 disorder. Diagnostic criteria for @ a bipolar 1 disorder include symptoms of depression plus Zs = at least one episode of mania characterized by one or Ee Item 52 Answer: B more of the following: elevated mood, irritability, inflated tS) =] self-esteem, decreased need for sleep, increased talkative- = Educational Objective: Calculate the number needed to cs ness, flight of ideas, distractibility, or increased risk-taking treat. nn Baer behavior. Initial symptoms often present in the late teens 7) The number needed to treat for one patient to benefit from to early twenties. A careful history directed at identify- = n the new medication for fibromyalgia is 20 (Option B). Num- ing previous episodes of mania or hypomania should be = <= bers needed to treat (NNT) and harm (NNH) are a way to obtained when initially diagnosing depression; prescribing convey the clinical effect of an intervention. The NNT, or antidepressant monotherapy to a patient with bipolar dis- the number of patients who must receive a treatment to order may precipitate a manic episode. The Mood Disorder cause one patient to benefit, is the inverse of the absolute Questionnaire can be used to screen patients in the pri- risk reduction. Absolute risk reduction (ARR) is the abso- mary care setting. Bipolar 1 disorder should be managed by lute value of the difference in treatment effect between the a psychiatrist; in the setting of acute mania, urgent referral experimental and the control or comparison groups. The is appropriate. experimental and control effects are expressed as a rate, or Attention-deficit/hyperactivity disorder (ADHD) the number of patients who experienced the treatment effect (Option A) is characterized by persistent inattention and/ in the group divided by the total number of patients in that or hyperactivity-impulsivity that disrupt functioning or group. For this example, the experimental event rate is 0.30. development. ADHD is most frequently recognized in child- The control event rate is 0.25. Thus, the ARR is |0.30 - 0.25| = hood, but the diagnosis may be delayed until adulthood. 0.05. The NNT is the inverse of the ARR, calculated as 1/0.05 = This patient’s expansive mood, goal-directed behaviors, and 20; it is not 10 (Option A), 30 (Option C), or 40 (Option D). history of depression are not compatible with ADHD. The acceptability of the NNT depends on the risks asso- Personality disorders (Option C) involve consistent pat- ciated with the condition, the cost and side effects of the terns of interpersonal behavior and perceptions that are treatment, and other treatments available. Comparing the inflexible, diverge significantly from the behavioral stan- NNT with the NNH can assess the balance of treatment ben- dards of the person’s culture, and cause substantial func- efit versus treatment harms. NNH is calculated similarly to tional impairment and emotional distress. This patient’s NNT, by using the absolute risk increase (ARI), or the abso- behavior is not consistent with a personality disorder. lute difference in risk increase between the experimental Schizophrenia (Option D) is a heterogeneous psychi- and control groups. In this example, “risk” was the rate of atric disorder comprising both positive symptoms (hallu- adverse effects in each group. The experimental rate of risk cinations, disorganized thought, delusions) and negative is 15%. The control rate of risk is 5%. The ARI is |0.15 - 0.05| = symptoms (flattened affect, decreased activity). There is no 0.10, and the NNH (calculated as the inverse of the ARI) is evidence of these symptoms to support the diagnosis of 1/0.10 =10. schizophrenia in this patient. e The number needed to treat, or the number of patients e Diagnostic criteria for bipolar 1 disorder include symp- who must receive a treatment to cause one patient to toms of depression plus at least one episode of mania. benefit, is the inverse of the absolute risk reduction. e A careful history directed at identifying previous epi- e The number needed to harm, or the number of sodes of mania or hypomania should be obtained patients who must receive a treatment to cause one when initially diagnosing depression; prescribing patient harm, is the inverse of the absolute risk antidepressant monotherapy to a patient with bipolar increase. disorder may precipitate a manic episode.

e The number needed to treat, or the number of patients e Diagnostic criteria for bipolar 1 disorder include symp- who must receive a treatment to cause one patient to toms of depression plus at least one episode of mania. benefit, is the inverse of the absolute risk reduction. e A careful history directed at identifying previous epi- e The number needed to harm, or the number of sodes of mania or hypomania should be obtained patients who must receive a treatment to cause one when initially diagnosing depression; prescribing patient harm, is the inverse of the absolute risk antidepressant monotherapy to a patient with bipolar increase. disorder may precipitate a manic episode. 159

Anavenrs and Cheques Bibliography Item 55 Answer: E Koirala P, Anand A. Diagnosing and treating bipolar disorder in primary Educational Objective: Treat acute cough suggestive of care. Cleve Clin J Med. 2018;85:601-8. [PMID: 30102594] doi:10.3949 ccjm.85gr.18003 bronchitis.

Bibliography Item 55 Answer: E Koirala P, Anand A. Diagnosing and treating bipolar disorder in primary Educational Objective: Treat acute cough suggestive of care. Cleve Clin J Med. 2018;85:601-8. [PMID: 30102594] doi:10.3949 ccjm.85gr.18003 bronchitis. The most appropriate next step in management of this patient with symptoms consistent with acute bronchi- Item 54 Answer: A tis is education and reassurance (Option E). Acute cough Educational Objective: Treat delirium at the end of life. (<3 weeks’ duration) is most often caused by viral infec- tions involving the upper respiratory tract and bronchial air- The most appropriate next step in management is to add ways. Coronaviruses and rhinoviruses are the most common parenteral lorazepam (Option A) to the patient’s current medications. Delirium is an acute-onset disorder associ- causative pathogens, but influenza virus should be highly suspected in patients presenting with fever and myalgia, ated with fluctuation in mental status. It may manifest as > either inattention and agitation or hypoactivity. Termi- especially during influenza season (between autumn and = wn nally ill patients often experience delirium, and in elderly early spring). Treatment of acute cough is primarily symp- = tomatic and dependent on the underlying etiology. The o patients with cancer, delirium is associated with increased = mainstay of treatment of bronchitis is patient education and 2) morbidity. Regardless of the presentation of delirium, 9 reassurance that the cough usually resolves in 2 to 3 weeks. Ss diagnosis and treatment are indicated to ensure patient a. safety and to provide comfort to both patient and family. The use of albuterol (Option A) or another B-agonist for =] acute cough is not associated with a reduction in cough fre- me Potentially reversible causes of delirium, such as noise, =. medication side effects, pain, bladder distention, consti- quency or duration. 8-Agonist inhalers can be considered for 2 i= pation, and dehydration, should be addressed. There is patients with acute cough and wheezing on physical exam- @ wn very little evidence supporting the use of antipsychotics, ination. This patient’s cough is unlikely to improve with use

The most appropriate next step in management of this patient with symptoms consistent with acute bronchi- Item 54 Answer: A tis is education and reassurance (Option E). Acute cough Educational Objective: Treat delirium at the end of life. (<3 weeks’ duration) is most often caused by viral infec- tions involving the upper respiratory tract and bronchial air- The most appropriate next step in management is to add ways. Coronaviruses and rhinoviruses are the most common parenteral lorazepam (Option A) to the patient’s current medications. Delirium is an acute-onset disorder associ- causative pathogens, but influenza virus should be highly suspected in patients presenting with fever and myalgia, ated with fluctuation in mental status. It may manifest as > either inattention and agitation or hypoactivity. Termi- especially during influenza season (between autumn and = wn nally ill patients often experience delirium, and in elderly early spring). Treatment of acute cough is primarily symp- = tomatic and dependent on the underlying etiology. The o patients with cancer, delirium is associated with increased = mainstay of treatment of bronchitis is patient education and 2) morbidity. Regardless of the presentation of delirium, 9 reassurance that the cough usually resolves in 2 to 3 weeks. Ss diagnosis and treatment are indicated to ensure patient a. safety and to provide comfort to both patient and family. The use of albuterol (Option A) or another B-agonist for =] acute cough is not associated with a reduction in cough fre- me Potentially reversible causes of delirium, such as noise, =. medication side effects, pain, bladder distention, consti- quency or duration. 8-Agonist inhalers can be considered for 2 i= pation, and dehydration, should be addressed. There is patients with acute cough and wheezing on physical exam- @ wn very little evidence supporting the use of antipsychotics, ination. This patient’s cough is unlikely to improve with use such as haloperidol, in the treatment of delirium, but they of an albuterol inhaler. Empiric treatment of bronchitis with antibiotics, such are commonly prescribed. Benzodiazepines are typically avoided for patients at the end of life, primarily because of as azithromycin (Option B), is ineffective in most cases;

such as haloperidol, in the treatment of delirium, but they of an albuterol inhaler. Empiric treatment of bronchitis with antibiotics, such are commonly prescribed. Benzodiazepines are typically avoided for patients at the end of life, primarily because of as azithromycin (Option B), is ineffective in most cases; greater incidence of paradoxical reactions, including wors- increases bacterial antibiotic resistance; and may cause mul- ened delirium. However, recent evidence from clinical tri- tiple adverse effects, including Clostridioides difficile colitis. als showa potential benefit with the addition of lorazepam Antibiotics should be avoided unless pneumonia is prob- to haloperidol for agitated delirium in hospitalized patients able, and the lack of fever and dyspnea and normal lung at the end of life. In this case, the patient initially had a examination in this case argue against pneumonia. Patients positive response to parenteral haloperidol, but it is now suspected of having acute bronchitis should be counseled ineffective. Given that the goal of therapy is the patient’s to return if symptoms do not improve; further evaluation comfort, a trial of lorazepam and haloperidol would be and antibiotic therapy should be considered in patients with reasonable at this time. worsening or persistent symptoms. There is no evidence to suggest that second-generation Chest radiography (Option C) is not indicated for the antipsychotics, such as olanzapine, (Option B) are more evaluation of acute cough in the absence of abnormal vital effective than haloperidol in the management of patients signs (heart rate >100/min, respiration rate >24/min, tem- with agitated delirium. perature >38 °C [100.4 °F]) or abnormal lung examination Stopping haloperidol (Option C) should not be con- findings, unless there are other concerning clinical features

effective than haloperidol in the management of patients signs (heart rate >100/min, respiration rate >24/min, tem- with agitated delirium. perature >38 °C [100.4 °F]) or abnormal lung examination Stopping haloperidol (Option C) should not be con- findings, unless there are other concerning clinical features sidered until a trial of haloperidol and lorazepam can be (such as altered mental status). evaluated as a treatment for this patient’s agitated delirium. Antitussive agents, such as dextromethorphan (Option This patient was started on opioids to manage pain from D), have limited efficacy in treating cough and generally bony metastatic lung cancer as well as dyspnea refractory should be avoided in patients who take selective serotonin to medical management, two indications for which opioids reuptake inhibitors, particularly fluoxetine, because of are considered first-line therapy. In a patient receiving com- the possibility of increased serotonergic effects, including fort-directed care, pain management with morphine should serotonin syndrome. Serotonin syndrome is a hyperther- not be discontinued (Option D). mic reaction triggered by simultaneous use of two or more medications that affect release or reuptake of serotonin; it is usually associated with hyperreflexia and myoclonus. e Treatment with lorazepam and haloperidol may improve agitated delirium in patients at the end of e The mainstay of treatment of acute cough due to life. bronchitis is patient education and reassurance that Bibliography the cough usually resolves in 2 to 3 weeks.

not be discontinued (Option D). mic reaction triggered by simultaneous use of two or more medications that affect release or reuptake of serotonin; it is usually associated with hyperreflexia and myoclonus. e Treatment with lorazepam and haloperidol may improve agitated delirium in patients at the end of e The mainstay of treatment of acute cough due to life. bronchitis is patient education and reassurance that Bibliography the cough usually resolves in 2 to 3 weeks. Hui D, Frisbee-Hume S, Wilson A, et al. Effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced Bibliography cancer receiving palliative care: a randomized clinical trial. JAMA. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American 2017;318:1047-56. [PMID: 28975307] doi:10.1001/jama.2017.11468 College of Physicians and for the Centers for Disease Control and 160

; Answers and Critiques Prevention. Appropriate antibiotic use for acute respiratory tract infec- Item 57 Answer: C tion in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Educational Objective: Evaluate a patient with Intern Med. 2016;164:425-34. [PMID: 26785402] doi:10.7326/M15-1840 suspected osteomyelitis. The most appropriate management is urgent MRI of the lumbar spine (Option C). Spinal imaging for acute back pain Item 56 Answer: B should be limited to patients with “red flags” suggesting an Educational Objective: Treat a patient with mild to underlying process that requires intervention, such as a per- moderate depression with cognitive behavioral therapy. sonal history of cancer or symptoms concerning for cancer Cognitive behavioral therapy (CBT) (Option B) is the most (fever, persistent pain, vertebral tenderness, or weight loss) appropriate management. This patient’s symptoms are nega- or cauda equina syndrome (bowel or bladder dysfunction, tively affecting her quality of life and impairing her efforts at persistent or increasing lower motor neuron weakness, or chronic disease management. Initiation of treatment is rea- saddle anesthesia). In this case, the patient’s injection drug wn a sonable. Both CBT and second-generation antidepressants use and focal vertebral tenderness should heighten suspicion =

chronic disease management. Initiation of treatment is rea- saddle anesthesia). In this case, the patient’s injection drug wn a sonable. Both CBT and second-generation antidepressants use and focal vertebral tenderness should heighten suspicion = are appropriate first-line therapies for mild to moderate for an acute infection of the spine, such as epidural abscess, 4 diskitis, or osteomyelitis. MRI is considered the gold stan- = depressive disorders. The choice of therapy should be based o on patient preference, efficacy, and side effects. CBT meets dard in patients with suspected spinal infection, cancer, cord sc = a patient preference and is as effective as pharmacologic compression, or cauda equina syndrome. ©

are appropriate first-line therapies for mild to moderate for an acute infection of the spine, such as epidural abscess, 4 diskitis, or osteomyelitis. MRI is considered the gold stan- = depressive disorders. The choice of therapy should be based o on patient preference, efficacy, and side effects. CBT meets dard in patients with suspected spinal infection, cancer, cord sc = a patient preference and is as effective as pharmacologic compression, or cauda equina syndrome. © therapy. CT of the lumbar spine (Option A) would be appropri wn —s 7 Bupropion (Option A), a norepinephrine and dopa- ate if the patient were unable to undergo MRI (for example, = mine reuptake inhibitor, is often used as an alternative to because of hardware implantation). However, MRI allows wn = selective serotonin reuptake inhibitors (SSRIs) or serotonin- for better visualization of the soft tissue structures of the =< norepinephrine reuptake inhibitors. It has not been associ- lumbar spine and is therefore the preferred imaging modal-

therapy. CT of the lumbar spine (Option A) would be appropri wn —s 7 Bupropion (Option A), a norepinephrine and dopa- ate if the patient were unable to undergo MRI (for example, = mine reuptake inhibitor, is often used as an alternative to because of hardware implantation). However, MRI allows wn = selective serotonin reuptake inhibitors (SSRIs) or serotonin- for better visualization of the soft tissue structures of the =< norepinephrine reuptake inhibitors. It has not been associ- lumbar spine and is therefore the preferred imaging modal- ated with weight gain or sexual dysfunction and may help ity in patients who are candidates for either procedure. patients with impaired concentration. However, bupro- Patients with suspected osteomyelitis-related complica tions, such as severe sepsis, progressive neurologic deficits, pion is contraindicated in patients with a seizure disor- der or with certain conditions that increase seizure risk, spinal instability, or epidural abscess, should receive empir- such as anorexia nervosa or bulimia nervosa. Because this ical antibiotic therapy (Option B). Otherwise, initiation of patient has juvenile myoclonic epilepsy, she should not take antibiotic therapy for uncomplicated vertebral osteomyelitis bupropion. is based on culture results. Blood cultures should be per-

such as anorexia nervosa or bulimia nervosa. Because this ical antibiotic therapy (Option B). Otherwise, initiation of patient has juvenile myoclonic epilepsy, she should not take antibiotic therapy for uncomplicated vertebral osteomyelitis bupropion. is based on culture results. Blood cultures should be per- Paroxetine (Option C) is an SSRI that is appropriate as formed in all patients. Testing for Mycobacterium tuberculo- first-line therapy for major depressive disorder. However, sis infection (with tuberculin skin testing or an interferon- among SSRIs, paroxetine has the highest rate of sexual dys- y release assay), fungal blood cultures, and serologic tests function; a higher rate of weight gain; and the highest rate of for Brucella species are appropriate for patients at risk for discontinuation syndrome (dizziness, fatigue, headache, and these pathogens. Image-guided biopsy has a diagnostic yield nausea occurring after abruptly stopping or rapidly discon- of approximately 60% and should be used in patients with tinuing antidepressants). The adverse effects of weight gain negative blood culture results. and sexual dysfunction make paroxetine a less attractive Radiography (Option D) can be useful for detect- therapeutic option for this patient. ing pathology of the vertebral bodies, such as metastatic Depression that causes impairment in function, cancer or vertebral compression fractures. Because soft reduced quality of life, and worse health status or chronic tissue structures of the spine, such as the spinal canal and disease control should be treated. Reassurance (Option D) is disks, cannot be visualized on radiographs, MRI should not an appropriate strategy in this patient. be performed first in a patient with suspected vertebral infection.

disease control should be treated. Reassurance (Option D) is disks, cannot be visualized on radiographs, MRI should not an appropriate strategy in this patient. be performed first in a patient with suspected vertebral infection. e Both cognitive behavioral therapy and second-genera- tion antidepressants are appropriate first-line thera- e Urgent imaging of the spine is indicated for patients pies for mild to moderate depressive disorders. with low back pain and “red flag” symptoms suggest- e Selective serotonin reuptake inhibitors can cause ing an underlying process that requires intervention. reduced sexual desire, anorgasmia, and delayed e MRI is considered the gold standard in patients with orgasm; bupropion causes fewer sexual side effects suspected spinal infection, cancer, cord compression, but is contraindicated in patients with seizure or cauda equina syndrome. disorders. Bibliography Bibliography Smith DE, Siket MS. High-risk chief complaints III: neurologic emergencies. Park LT, Zarate CA Jr. Depression in the primary care setting. N EnglJ Med. Emerg Med Clin North Am. 2020;38:523-37. [PMID: 32336338] 2019:380:559-68. [PMID: 30726688] doi:10.1056/NEJMcp1712493 doi:10.1016/j.emc.2020.02.006 161

Answers and Critiques Item 58 Answer: A Item 59 Answer: B Educational Objective: Understand the process of Educational Objective: Diagnose generalized anxiety advance care planning. disorder. The patient and physician are engaging in the early stages of The most likely diagnosis is generalized anxiety disorder (GAD) advance care planning (Option A). Advance care planning (Option B). GAD is characterized by excessive anxiety about is the process by which a patient articulates preferences, activities or events (occupation, school) that a patient finds goals, and values regarding his or her future medical care. difficult to control and occurs more days than not for at least Advance care planning should consist of ongoing conversa- 6 months. The anxiety causes significant distress and func- tions between the patient, the physician, and loved ones to tional impairment. Diagnosis requires the presence of three inform decisions and direct medical care in the event that of the following physical symptoms: restlessness, being easily the patient loses decision-making capacity. These conver- fatigued, irritability, muscle tension, sleep disturbance, and

The patient and physician are engaging in the early stages of The most likely diagnosis is generalized anxiety disorder (GAD) advance care planning (Option A). Advance care planning (Option B). GAD is characterized by excessive anxiety about is the process by which a patient articulates preferences, activities or events (occupation, school) that a patient finds goals, and values regarding his or her future medical care. difficult to control and occurs more days than not for at least Advance care planning should consist of ongoing conversa- 6 months. The anxiety causes significant distress and func- tions between the patient, the physician, and loved ones to tional impairment. Diagnosis requires the presence of three inform decisions and direct medical care in the event that of the following physical symptoms: restlessness, being easily the patient loses decision-making capacity. These conver- fatigued, irritability, muscle tension, sleep disturbance, and Se sations should be a routine component of care and ideally difficulty concentrating. Patients with significant anxiety or a] multiple unexplained physical symptoms should be screened wn occur before an acute event or medical crisis. = In a living will (Option B), patients can outline specific for GAD using the GAD-7 screening tool. The shorter-form @o = wn preferences for treatment decisions (e.g., dialysis, mechan- GAD-2 can be administered in less time and may be equivalent <3) ical ventilation, nutritional support) in the event that the to the GAD-7 in screening for GAD in primary care popula- = a. patient is no longer able to direct his or her own medical tions. The GAD-2 asks patients how often they have been both- =) ered by “feeling nervous, anxious, or on edge” and “not being care. This patient’s conversation with his physician illus- pal = trates the process by which physicians can help patients able to stop or control worrying” over the previous 2 weeks. <2 t= articulate and eventually document their wishes for care. Attention-deficit/hyperactivity disorder (ADHD) @o wn However, this conversation does not constitute creation of (Option A) is characterized by persistent inattention and/or a living will. hyperactivity-impulsivity that disrupt functioning or devel- The execution of an advance directive (Option C) opment. Symptoms must interfere with at least two different involves completion of legal forms and notarization of settings (e.g., home and work), and some must have been signature. Completion of forms can be done online or with present since before 12 years of age. ADHD is most frequently the help of an attorney, but that step represents the end recognized in childhood, but the diagnosis may be delayed of the advance care planning process, which has not yet until adulthood. This patient’s symptoms are related more to occurred. worry than inattention. Advance care planning is also the process that allows Panic attacks (Option C) are characterized by the sud- patients to consider the selection of a health care proxy den onset and rapid escalation (within minutes) of extreme (Option D) who will be empowered to carry out the fear or anxiety, along with at least four of the following: fear wishes of the patient if he becomes incapacitated. The of dying, fear of losing control, palpitations, diaphoresis, health care proxy will be guided by the patient’s wishes tremor, dyspnea, sensation of choking, chest pain, nausea, articulated in the living will. If the patient fails to identify dizziness, chills or heat sensations, paresthesia, and dereal- a health care proxy, or the designated proxy refuses to ization (perception that the world is not real). This patient’s accept the role, most states have laws that provide a hier- symptoms do not have an abrupt onset and rapid escalation archy of preferred surrogates based on their relationship or the associated symptoms of panic attack. to the patient (typically in the sequence of spouse, adult Previously known as social phobia, social anxiety dis- child, parent, and adult sibling). Physicians should be order (Option D) is associated with excessive anxiety or fear familiar with laws regarding surrogate decision making of criticism or humiliation in social or performance situa- in the state in which they practice. Should this patient tions. Patients with social anxiety disorder may experience fail to assign a health care proxy, his daughter may be his palpitations, flushing, dyspnea, chest pain, or even panic legally designated surrogate. However, the patient should attacks in these situations. Patients avoid situations that may be advised to engage in advance care planning to desig- cause anxiety. To meet DSM-5 diagnostic criteria, symptoms nate the proxy that he wishes. In this case, that decision must be present for at least 6 months and cause significant has yet to be made. functional impairment. This patient has not expressed a fear of criticism or humiliation or displayed avoidance behavior.

Se sations should be a routine component of care and ideally difficulty concentrating. Patients with significant anxiety or a] multiple unexplained physical symptoms should be screened wn occur before an acute event or medical crisis. = In a living will (Option B), patients can outline specific for GAD using the GAD-7 screening tool. The shorter-form @o = wn preferences for treatment decisions (e.g., dialysis, mechan- GAD-2 can be administered in less time and may be equivalent <3) ical ventilation, nutritional support) in the event that the to the GAD-7 in screening for GAD in primary care popula- = a. patient is no longer able to direct his or her own medical tions. The GAD-2 asks patients how often they have been both- =) ered by “feeling nervous, anxious, or on edge” and “not being care. This patient’s conversation with his physician illus- pal = trates the process by which physicians can help patients able to stop or control worrying” over the previous 2 weeks. <2 t= articulate and eventually document their wishes for care. Attention-deficit/hyperactivity disorder (ADHD) @o wn However, this conversation does not constitute creation of (Option A) is characterized by persistent inattention and/or a living will. hyperactivity-impulsivity that disrupt functioning or devel- The execution of an advance directive (Option C) opment. Symptoms must interfere with at least two different involves completion of legal forms and notarization of settings (e.g., home and work), and some must have been signature. Completion of forms can be done online or with present since before 12 years of age. ADHD is most frequently the help of an attorney, but that step represents the end recognized in childhood, but the diagnosis may be delayed of the advance care planning process, which has not yet until adulthood. This patient’s symptoms are related more to occurred. worry than inattention. Advance care planning is also the process that allows Panic attacks (Option C) are characterized by the sud- patients to consider the selection of a health care proxy den onset and rapid escalation (within minutes) of extreme (Option D) who will be empowered to carry out the fear or anxiety, along with at least four of the following: fear wishes of the patient if he becomes incapacitated. The of dying, fear of losing control, palpitations, diaphoresis, health care proxy will be guided by the patient’s wishes tremor, dyspnea, sensation of choking, chest pain, nausea, articulated in the living will. If the patient fails to identify dizziness, chills or heat sensations, paresthesia, and dereal- a health care proxy, or the designated proxy refuses to ization (perception that the world is not real). This patient’s accept the role, most states have laws that provide a hier- symptoms do not have an abrupt onset and rapid escalation archy of preferred surrogates based on their relationship or the associated symptoms of panic attack. to the patient (typically in the sequence of spouse, adult Previously known as social phobia, social anxiety dis- child, parent, and adult sibling). Physicians should be order (Option D) is associated with excessive anxiety or fear familiar with laws regarding surrogate decision making of criticism or humiliation in social or performance situa- in the state in which they practice. Should this patient tions. Patients with social anxiety disorder may experience fail to assign a health care proxy, his daughter may be his palpitations, flushing, dyspnea, chest pain, or even panic legally designated surrogate. However, the patient should attacks in these situations. Patients avoid situations that may be advised to engage in advance care planning to desig- cause anxiety. To meet DSM-5 diagnostic criteria, symptoms nate the proxy that he wishes. In this case, that decision must be present for at least 6 months and cause significant has yet to be made. functional impairment. This patient has not expressed a fear of criticism or humiliation or displayed avoidance behavior. e Advance care planning allows patients with capacity to articulate preferences, goals, and values for future e Generalized anxiety disorder is characterized by medical care and to designate an individual or indi- excessive anxiety about activities or events that a viduals to carry out their wishes. patient finds difficult to control and occurs more days than not for at least 6 months. Bibliography Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights e The two-question screening tool for generalized anxiety Committee. American College of Physicians Ethics Manual: seventh edition. disorder (GAD-2) has high sensitivity and specificity. Ann Intern Med. 2019;170:S1-32. [PMID: 30641552] doi:10.7326/M18-2160

e Advance care planning allows patients with capacity to articulate preferences, goals, and values for future e Generalized anxiety disorder is characterized by medical care and to designate an individual or indi- excessive anxiety about activities or events that a viduals to carry out their wishes. patient finds difficult to control and occurs more days than not for at least 6 months. Bibliography Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights e The two-question screening tool for generalized anxiety Committee. American College of Physicians Ethics Manual: seventh edition. disorder (GAD-2) has high sensitivity and specificity. Ann Intern Med. 2019;170:S1-32. [PMID: 30641552] doi:10.7326/M18-2160 162

Answers and Critiques Bibliography DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170:ITC49-64. [PMID: 30934083] doi:10.7326/AITC201904020 ¢ Management of elevated triglyceride levels includes addressing lifestyle factors (obesity and metabolic syn- drome); managing secondary factors (diabetes melli- Item 60 Answer: C tus, chronic liver or kidney disease and/or nephrotic Educational Objective: Treat hypertriglyceridemia with syndrome, hypothyroidism); and avoiding medications therapeutic lifestyle interventions. that increase triglyceride levels (estrogens, B-blockers, glucocorticoids). The most appropriate management of this patient with mod- erate hypertriglyceridemia (fasting or nonfasting triglyceride Bibliography level of 175 to 499 mg/dL [1.98-5.65 mmol/L]) is therapeu- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ tic lifestyle modification (Option C). The American Heart ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management Association (AHA)/American College of Cardiology (ACC) of blood cholesterol: a report of the American College of Cardiology/ 4) fy American Heart Association Task Force on Clinical Practice Guidelines. = Guideline on the Management of Blood Cholesterol recom- Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. mends that moderate hypertriglyceridemia be treated by = 0000000000000625 a addressing lifestyle factors (obesity, metabolic syndrome); rs) managing secondary factors (diabetes mellitus, chronic liver cs = or kidney disease and/or nephrotic syndrome, hypothyroid- Item 61 Answer: B c wn ism); and avoiding medications that increase triglyceride be Educational Objective: Treat a patient with alcohol use iF) levels (estrogens, B-blockers, glucocorticoids). In addition = disorder. wn to adhering to a low-calorie diet, this patient should engage s 4 in physical activity. The AHA/ACC primary prevention Injectable naltrexone (Option B) is the most appropriate guideline recommends at least 150 min/wk of accumu- treatment for this patient. Naltrexone is an opioid receptor lated moderate-intensity physical activity or 75 minutes per antagonist that is thought to combat alcohol use disorder week of vigorous-intensity aerobic physical activity (or an through reduction of neuronal reward pathways associated equivalent combination of moderate and vigorous activ- with alcohol consumption. Naltrexone can be administered ity) to reduce risk for atherosclerotic cardiovascular disease as a once-daily oral medication (Option D) or as a monthly (ASCVD). injection, which may enhance patient adherence. It has Fibrate therapy (Option A) can be considered for been associated with a substantial decrease in 30-day read- patients with a triglyceride level higher than 500 mg/dL mission and emergency department visits when prescribed (5.65 mmol/L). Fibrates are effective at decreasing tri- to patients with alcohol dependence at the time of hospi- glyceride levels by 50% or more; however, these drugs tal discharge. This patient would benefit from initiation of are associated with muscle toxicity and multiple drug injectable naltrexone in addition to psychotherapeutic inter- interactions. ventions, such as referral to cognitive behavioral therapy Statin therapy (Option B) is reasonable in patients with or a 12-step facilitation program. Patients diagnosed with a triglyceride level of 500 mg/dL (5.65 mmol/L) or greater alcohol use disorder often require a multipronged approach and an ASCVD risk of 7.5% or higher, even in the absence with both psychotherapy and medication to ensure safety of other known risk factors or with concurrent initiation and minimize relapse. The American Psychiatric Association of lifestyle interventions. Statin therapy may be appropriate (APA) Practice Guideline for the Pharmacological Treatment in patients with moderate to severe hypertriglyceridemia of Patients with Alcohol Use Disorder recommends acam- (2175 mg/dL [1.98 mmol/L]) that has not responded to life- prosate as another first-line therapy for alcohol use disorder style modification alone and whose ASCVD risk is 7.5% or and suggests offering disulfiram, topiramate, or gabapentin higher. to patients with moderate to severe alcohol use disorder in Evidence of a beneficial effect for omega-3 fatty acid specific clinical circumstances. supplements (Option D) other than icosapent ethyl is Bupropion (Option A), an antidepressant that works lacking. Icosapent ethyl is a highly purified eicosapen- through mediation of dopaminergic/noradrenergic path- taenoic acid ethyl ester (fish oil). In patients with hyper- ways, is effective in the support of smoking cessation. triglyceridemia and ASCVD and in patients aged 50 years Although antidepressants may be useful in the manage- or older with hypertriglyceridemia, diabetes, and one ment of coexisting mood disorders, they are not supported additional ASCVD risk factor, treatment with a statin and as standalone treatment for alcohol use disorder. The APA icosapent ethyl was associated with a 25% relative risk guideline recommends that antidepressants not be used for reduction in the composite end point of cardiovascular treatment of alcohol use disorder unless there is evidence death, nonfatal myocardial infarction, nonfatal stroke, of a concomitant disorder for which an antidepressant is an coronary revascularization, and unstable angina. This indicated treatment. patient does not fall into one of the two high-risk groups Lorazepam (Option C) is a short- to moderate-acting that benefited from treatment with icosapent ethyl and benzodiazepine often used in the treatment of alcohol with- statin therapy. drawal syndrome, particularly in patients with liver disease

Bibliography DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170:ITC49-64. [PMID: 30934083] doi:10.7326/AITC201904020 ¢ Management of elevated triglyceride levels includes addressing lifestyle factors (obesity and metabolic syn- drome); managing secondary factors (diabetes melli- Item 60 Answer: C tus, chronic liver or kidney disease and/or nephrotic Educational Objective: Treat hypertriglyceridemia with syndrome, hypothyroidism); and avoiding medications therapeutic lifestyle interventions. that increase triglyceride levels (estrogens, B-blockers, glucocorticoids). The most appropriate management of this patient with mod- erate hypertriglyceridemia (fasting or nonfasting triglyceride Bibliography level of 175 to 499 mg/dL [1.98-5.65 mmol/L]) is therapeu- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ tic lifestyle modification (Option C). The American Heart ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management Association (AHA)/American College of Cardiology (ACC) of blood cholesterol: a report of the American College of Cardiology/ 4) fy American Heart Association Task Force on Clinical Practice Guidelines. = Guideline on the Management of Blood Cholesterol recom- Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. mends that moderate hypertriglyceridemia be treated by = 0000000000000625 a addressing lifestyle factors (obesity, metabolic syndrome); rs) managing secondary factors (diabetes mellitus, chronic liver cs = or kidney disease and/or nephrotic syndrome, hypothyroid- Item 61 Answer: B c wn ism); and avoiding medications that increase triglyceride be Educational Objective: Treat a patient with alcohol use iF) levels (estrogens, B-blockers, glucocorticoids). In addition = disorder. wn to adhering to a low-calorie diet, this patient should engage s 4 in physical activity. The AHA/ACC primary prevention Injectable naltrexone (Option B) is the most appropriate guideline recommends at least 150 min/wk of accumu- treatment for this patient. Naltrexone is an opioid receptor lated moderate-intensity physical activity or 75 minutes per antagonist that is thought to combat alcohol use disorder week of vigorous-intensity aerobic physical activity (or an through reduction of neuronal reward pathways associated equivalent combination of moderate and vigorous activ- with alcohol consumption. Naltrexone can be administered ity) to reduce risk for atherosclerotic cardiovascular disease as a once-daily oral medication (Option D) or as a monthly (ASCVD). injection, which may enhance patient adherence. It has Fibrate therapy (Option A) can be considered for been associated with a substantial decrease in 30-day read- patients with a triglyceride level higher than 500 mg/dL mission and emergency department visits when prescribed (5.65 mmol/L). Fibrates are effective at decreasing tri- to patients with alcohol dependence at the time of hospi- glyceride levels by 50% or more; however, these drugs tal discharge. This patient would benefit from initiation of are associated with muscle toxicity and multiple drug injectable naltrexone in addition to psychotherapeutic inter- interactions. ventions, such as referral to cognitive behavioral therapy Statin therapy (Option B) is reasonable in patients with or a 12-step facilitation program. Patients diagnosed with a triglyceride level of 500 mg/dL (5.65 mmol/L) or greater alcohol use disorder often require a multipronged approach and an ASCVD risk of 7.5% or higher, even in the absence with both psychotherapy and medication to ensure safety of other known risk factors or with concurrent initiation and minimize relapse. The American Psychiatric Association of lifestyle interventions. Statin therapy may be appropriate (APA) Practice Guideline for the Pharmacological Treatment in patients with moderate to severe hypertriglyceridemia of Patients with Alcohol Use Disorder recommends acam- (2175 mg/dL [1.98 mmol/L]) that has not responded to life- prosate as another first-line therapy for alcohol use disorder style modification alone and whose ASCVD risk is 7.5% or and suggests offering disulfiram, topiramate, or gabapentin higher. to patients with moderate to severe alcohol use disorder in Evidence of a beneficial effect for omega-3 fatty acid specific clinical circumstances. supplements (Option D) other than icosapent ethyl is Bupropion (Option A), an antidepressant that works lacking. Icosapent ethyl is a highly purified eicosapen- through mediation of dopaminergic/noradrenergic path- taenoic acid ethyl ester (fish oil). In patients with hyper- ways, is effective in the support of smoking cessation. triglyceridemia and ASCVD and in patients aged 50 years Although antidepressants may be useful in the manage- or older with hypertriglyceridemia, diabetes, and one ment of coexisting mood disorders, they are not supported additional ASCVD risk factor, treatment with a statin and as standalone treatment for alcohol use disorder. The APA icosapent ethyl was associated with a 25% relative risk guideline recommends that antidepressants not be used for reduction in the composite end point of cardiovascular treatment of alcohol use disorder unless there is evidence death, nonfatal myocardial infarction, nonfatal stroke, of a concomitant disorder for which an antidepressant is an coronary revascularization, and unstable angina. This indicated treatment. patient does not fall into one of the two high-risk groups Lorazepam (Option C) is a short- to moderate-acting that benefited from treatment with icosapent ethyl and benzodiazepine often used in the treatment of alcohol with- statin therapy. drawal syndrome, particularly in patients with liver disease 163

eae ane Se. or advanced age. It is not effective for the treatment of alco- Discharging this patient with only wound care (Option hol use disorder. The APA recommends that benzodiazepines D) to address the sacral wound ignores the concern for CONT. not be used in persons with alcohol use disorder unless neglect or abuse that may have contributed to its develop- treating acute alcohol withdrawal or a concomitant disorder ment. for which a benzodiazepine is an indicated treatment. e Findings suggestive of elder abuse or neglect should e Naltrexone, acamprosate, disulfiram, topiramate, and prompt additional investigation, most reliably by gabapentin are suggested by the American Psychiatric Adult Protective Services. Association guideline on alcohol use disorder as med- ications to be offered to patients with moderate to Bibliography severe alcohol use disorder. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373:1947-56. [PMID: 26559573] doi:10.1056/NEJMral404688 > e A monthly injection of naltrexone for the treatment of J wn alcohol use disorder may enhance patient adherence. = oO Item 63 Answer: A = wn Bibliography Educational Objective: Manage medically unexplained r.¥) = Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric 2. symptoms. Association Practice Guideline for the Pharmacological Treatment of a

e Findings suggestive of elder abuse or neglect should e Naltrexone, acamprosate, disulfiram, topiramate, and prompt additional investigation, most reliably by gabapentin are suggested by the American Psychiatric Adult Protective Services. Association guideline on alcohol use disorder as med- ications to be offered to patients with moderate to Bibliography severe alcohol use disorder. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373:1947-56. [PMID: 26559573] doi:10.1056/NEJMral404688 > e A monthly injection of naltrexone for the treatment of J wn alcohol use disorder may enhance patient adherence. = oO Item 63 Answer: A = wn Bibliography Educational Objective: Manage medically unexplained r.¥) = Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric 2. symptoms. Association Practice Guideline for the Pharmacological Treatment of a Patients With Alcohol Use Disorder. Am J Psychiatry. 2018;175:86-90. oe The most appropriate management is to acknowledge the [PMID: 29301420] doi:10.1176/appi.ajp.2017.1750101 = patient’s feelings (Option A). Medically unexplained symp- 2 < toms (MUS) are symptoms that cannot be attributed to a @ wn Item 62 Answer: A specific medical cause after a thorough medical evaluation. Common symptoms in patients with MUS include fatigue, Educational Objective: Manage mistreatment of an headache, abdominal pain, musculoskeletal pain (back elderly patient. pain, myalgia, arthralgia), dizziness, paresthesia, general- This older patient has findings suggestive of mistreatment, ized weakness, transient edema, insomnia, dyspnea, chest and it is most appropriate to make a referral to Adult Pro- pain, chronic facial pain, chronic pelvic pain, and chem- tective Services (Option A). Abuse and mistreatment occur ical sensitivities. A collaborative therapeutic relationship in up to 10% of older adults and can take the form of neglect is essential to providing care for patients with MUS. If an or physical, sexual, verbal/emotional, or financial abuse. underlying medical cause cannot be identified after an Women are at higher risk than are men. Other risk factors appropriately thorough evaluation, it is imperative that include dementia; low socioeconomic level; younger age; clinicians have an open and honest discussion with the poor social support; poor functional status; and shared living patient. This includes acknowledging the impact of the situations, especially in homes with multiple adults other symptoms and addressing concerns that the patient may than the spouse. Elder abuse is associated with increased be perceived as malingering or presenting with factitious risk for hospitalization and nursing home placement, as disease. Arranging for regular follow-up can strengthen the well as mood disorders and reduced quality of life. Findings therapeutic alliance. suggestive of abuse or neglect, whether thought to be inten- Malingering occurs whena patient feigns medical prob- tional or unintentional, should prompt additional investi- lems for gain, such as money, drugs, or time off from work. gation. Such investigation should ideally include a home Patients who malinger tend to avoid diagnostic testing. There assessment, which can be most reliably conducted under the is no evidence of malingering in this patient, and such an auspices of Adult Protective Services. assessment (Option B) is unnecessary. Enteral nutritional supplementation (Option B) is not The goals of management for patients with MUS are appropriate management of weight loss that is most likely functional restoration, decreased symptom focus, and acqui- the result of neglect. This patient will receive more benefit sition of coping mechanisms rather than abatement of symp- from an investigation of the home environment. toms. Cure is generally not possible. To assure the patient of The Hwalek-Sengstock Elder Abuse Screening Test a cure (Option C) is misleading and impairs achievement of (Option C) is a survey-based screening instrument for the more important goal of improvement in function. elder abuse. It is mostly reliant on patient self-report of Regularly scheduled follow-up visits and continuity of symptoms; therefore, its use is limited, particularly if the care are important when treating patients with MUS. Studies patient is afraid of reporting neglect or abuse. Patients suggest that regularly scheduled appointments with targeted who are willing and able to communicate should be inter- physical examination increase physical functioning. How- viewed separately from the suspected abuser, using indi- ever, scheduling visits only as new symptoms arise (Option rect questions (such as “Do you feel safe in your home?”). D) is counterproductive in patients with MUS because it is a It is doubtful that this patient would complete a self-report barrier to a healing therapeutic relationship with the clini- screening tool such as the Hwalek-Sengstock Elder Abuse cian. Clinicians can help patients by developing new short- Screening Test. term and long-term goals, showing preferential interest in

Patients With Alcohol Use Disorder. Am J Psychiatry. 2018;175:86-90. oe The most appropriate management is to acknowledge the [PMID: 29301420] doi:10.1176/appi.ajp.2017.1750101 = patient’s feelings (Option A). Medically unexplained symp- 2 < toms (MUS) are symptoms that cannot be attributed to a @ wn Item 62 Answer: A specific medical cause after a thorough medical evaluation. Common symptoms in patients with MUS include fatigue, Educational Objective: Manage mistreatment of an headache, abdominal pain, musculoskeletal pain (back elderly patient. pain, myalgia, arthralgia), dizziness, paresthesia, general- This older patient has findings suggestive of mistreatment, ized weakness, transient edema, insomnia, dyspnea, chest and it is most appropriate to make a referral to Adult Pro- pain, chronic facial pain, chronic pelvic pain, and chem- tective Services (Option A). Abuse and mistreatment occur ical sensitivities. A collaborative therapeutic relationship in up to 10% of older adults and can take the form of neglect is essential to providing care for patients with MUS. If an or physical, sexual, verbal/emotional, or financial abuse. underlying medical cause cannot be identified after an Women are at higher risk than are men. Other risk factors appropriately thorough evaluation, it is imperative that include dementia; low socioeconomic level; younger age; clinicians have an open and honest discussion with the poor social support; poor functional status; and shared living patient. This includes acknowledging the impact of the situations, especially in homes with multiple adults other symptoms and addressing concerns that the patient may than the spouse. Elder abuse is associated with increased be perceived as malingering or presenting with factitious risk for hospitalization and nursing home placement, as disease. Arranging for regular follow-up can strengthen the well as mood disorders and reduced quality of life. Findings therapeutic alliance. suggestive of abuse or neglect, whether thought to be inten- Malingering occurs whena patient feigns medical prob- tional or unintentional, should prompt additional investi- lems for gain, such as money, drugs, or time off from work. gation. Such investigation should ideally include a home Patients who malinger tend to avoid diagnostic testing. There assessment, which can be most reliably conducted under the is no evidence of malingering in this patient, and such an auspices of Adult Protective Services. assessment (Option B) is unnecessary. Enteral nutritional supplementation (Option B) is not The goals of management for patients with MUS are appropriate management of weight loss that is most likely functional restoration, decreased symptom focus, and acqui- the result of neglect. This patient will receive more benefit sition of coping mechanisms rather than abatement of symp- from an investigation of the home environment. toms. Cure is generally not possible. To assure the patient of The Hwalek-Sengstock Elder Abuse Screening Test a cure (Option C) is misleading and impairs achievement of (Option C) is a survey-based screening instrument for the more important goal of improvement in function. elder abuse. It is mostly reliant on patient self-report of Regularly scheduled follow-up visits and continuity of symptoms; therefore, its use is limited, particularly if the care are important when treating patients with MUS. Studies patient is afraid of reporting neglect or abuse. Patients suggest that regularly scheduled appointments with targeted who are willing and able to communicate should be inter- physical examination increase physical functioning. How- viewed separately from the suspected abuser, using indi- ever, scheduling visits only as new symptoms arise (Option rect questions (such as “Do you feel safe in your home?”). D) is counterproductive in patients with MUS because it is a It is doubtful that this patient would complete a self-report barrier to a healing therapeutic relationship with the clini- screening tool such as the Hwalek-Sengstock Elder Abuse cian. Clinicians can help patients by developing new short- Screening Test. term and long-term goals, showing preferential interest in 164

i aaermasiecnncccsiecsaeisin Oe oe RS the psychosocial aspects of the patient's story, and exploring In patients with orthostatic symptoms, such as light- its impact on symptoms. headedness with standing, discontinuation of a contributing medication, such as the B-blocker metoprolol (Option D), should be considered. However, this patient experienced a e A collaborative therapeutic relationship is essential to mechanical fall and has no orthostatic symptoms; therefore, providing care for patients with medically unexplained discontinuation of metoprolol is not the best choice in med- symptoms. ication management.

the psychosocial aspects of the patient's story, and exploring In patients with orthostatic symptoms, such as light- its impact on symptoms. headedness with standing, discontinuation of a contributing medication, such as the B-blocker metoprolol (Option D), should be considered. However, this patient experienced a e A collaborative therapeutic relationship is essential to mechanical fall and has no orthostatic symptoms; therefore, providing care for patients with medically unexplained discontinuation of metoprolol is not the best choice in med- symptoms. ication management. ¢ Regularly scheduled follow-up visits and continuity of care are important when treating patients with medi- e Physicians should review the medication list often, cally unexplained symptoms. especially during care transitions, and discontinue those that may be inappropriate for older patients. Bibliography 1) Olde Hartman TC, Rosendal M, Aamland A, et al. What do guidelines and ¢ The Beers Criteria for Potentially Inappropriate o systematic reviews tell us about the management of medically unex- = Medication Use in Older Adults lists medications that plained symptoms in primary care? BJGP Open. 2017;1:bjgpopen = 17X101061. [PMID: 30564678] doi:10.3399/bjgpopen17X101061 are problematic for elderly patients and provides rec- — ie

¢ Regularly scheduled follow-up visits and continuity of care are important when treating patients with medi- e Physicians should review the medication list often, cally unexplained symptoms. especially during care transitions, and discontinue those that may be inappropriate for older patients. Bibliography 1) Olde Hartman TC, Rosendal M, Aamland A, et al. What do guidelines and ¢ The Beers Criteria for Potentially Inappropriate o systematic reviews tell us about the management of medically unex- = Medication Use in Older Adults lists medications that plained symptoms in primary care? BJGP Open. 2017;1:bjgpopen = 17X101061. [PMID: 30564678] doi:10.3399/bjgpopen17X101061 are problematic for elderly patients and provides rec- — ie ommendations regarding drug interactions to avoid. So sc = c Item 64 Answer: C Bibliography wn od By the 2019 American Geriatrics Society Beers Criteria® Update Expert Educational Objective: Avoid medications on the Beers o Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for = Criteria list in a geriatric patient. potentially inappropriate medication use in older adults. J Am Geriatr 2) = Soc. 2019;67:674-94. [PMID: 30693946] doi:10.1111/jgs.15767 < Diphenhydramine should be discontinued in this patient (Option C). The patient had a nocturnal fall at home that resulted in a fracture, and she is at risk for future falls. Item 65 Answer: C Diphenhydramine is a first-generation antihistamine that Educational Objective: Diagnose neurogenic thoracic is highly anticholinergic. It is sold over the counter as a outlet syndrome. sedative-hypnotic; however, it can cause confusion, consti- pation, dry mouth, and increased risk for falls in geriatric This patient probably has neurogenic thoracic outlet syndrome populations. Although treatment of comorbid health con- (nTOS) (Option C). nTOS is caused by compression of the ditions in older adults often necessitates the use of several nerve roots of the brachial plexus in the interscalene triangle of medications, physicians should review the medication list the neck (bordered by the anterior and middle scalene muscles often, especially during care transitions, and discontinue and the first rib). Young, thin, active women with repetitive those that may be inappropriate for older patients. The 2019 overhead stress to an upper extremity are most likely to expe- Beers Criteria for Potentially Inappropriate Medication Use rience nTOS, which typically presents with nonradicular and in Older Adults from the American Geriatrics Society lists anatomically widespread symptoms (numbness, paresthesia, medications that are problematic for elderly patients and and pain) affecting the arm, neck, and shoulder. Atrophic provides recommendations regarding drug interactions to weakness of hand and arm muscles can occur but is typically a avoid. In addition to first-generation antihistamines, such late manifestation. Neck rotation, head tilting, arm abduction, as diphenhydramine, other commonly used medications and arm external rotation may provoke symptoms in some on the Beers Criteria list include tricyclic antidepressants, patients. Electrodiagnostic studies are frequently normal, and antipsychotics, and benzodiazepines. imaging may reveal an anomalous cervical rib, which predis- Although this patient was experiencing urinary urgency poses to this condition. First-line therapy for nTOS includes at the time of her fall, oxybutynin (Option A) is an anticho- physical therapy focusing on improving posture and strength- linergic medication that also has a propensity for side effects ening the shoulder girdle muscles. in geriatric patients. Oxybutynin is on the Beers Criteria Arterial TOS (aTOS) (Option A) is caused by subclavian list and would not be an appropriate medication in this artery compression, with or without thrombosis; it usually patient. Nonpharmacologic therapy is the preferred first-line occurs in the presence of an anomalous cervical rib. Symp- treatment for all types of urinary incontinence. In cases of toms include arm or hand pain (which may be exertional), urgency, recommended nonpharmacologic therapy includes weakness, paresthesia, coolness, and pallor. Some patients bladder training with timed voiding and gradually increas- may have blood pressure discrepancies between the arms ing the time between voids. or diminished pulses in the affected extremity. On occasion, The U.S. Preventive Services Task Force recommends a bruit may be auscultated over the ipsilateral subclavian against vitamin D supplementation (Option B) for fall preven- artery. This patient has no evidence of the arterial insuffi- tion in community-dwelling adults; these recommendations ciency that is characteristic of aTOS. do not apply to patients with osteoporotic fracture or vitamin Cervical radiculopathy (Option B) often presents with D deficiency. In this patient with no history of osteoporosis, constant neck and shoulder pain in a radicular distribu- vitamin D is unlikely to be beneficial for fall prevention. tion. The pain is aggravated by the position of the neck. The

ommendations regarding drug interactions to avoid. So sc = c Item 64 Answer: C Bibliography wn od By the 2019 American Geriatrics Society Beers Criteria® Update Expert Educational Objective: Avoid medications on the Beers o Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for = Criteria list in a geriatric patient. potentially inappropriate medication use in older adults. J Am Geriatr 2) = Soc. 2019;67:674-94. [PMID: 30693946] doi:10.1111/jgs.15767 < Diphenhydramine should be discontinued in this patient (Option C). The patient had a nocturnal fall at home that resulted in a fracture, and she is at risk for future falls. Item 65 Answer: C Diphenhydramine is a first-generation antihistamine that Educational Objective: Diagnose neurogenic thoracic is highly anticholinergic. It is sold over the counter as a outlet syndrome. sedative-hypnotic; however, it can cause confusion, consti- pation, dry mouth, and increased risk for falls in geriatric This patient probably has neurogenic thoracic outlet syndrome populations. Although treatment of comorbid health con- (nTOS) (Option C). nTOS is caused by compression of the ditions in older adults often necessitates the use of several nerve roots of the brachial plexus in the interscalene triangle of medications, physicians should review the medication list the neck (bordered by the anterior and middle scalene muscles often, especially during care transitions, and discontinue and the first rib). Young, thin, active women with repetitive those that may be inappropriate for older patients. The 2019 overhead stress to an upper extremity are most likely to expe- Beers Criteria for Potentially Inappropriate Medication Use rience nTOS, which typically presents with nonradicular and in Older Adults from the American Geriatrics Society lists anatomically widespread symptoms (numbness, paresthesia, medications that are problematic for elderly patients and and pain) affecting the arm, neck, and shoulder. Atrophic provides recommendations regarding drug interactions to weakness of hand and arm muscles can occur but is typically a avoid. In addition to first-generation antihistamines, such late manifestation. Neck rotation, head tilting, arm abduction, as diphenhydramine, other commonly used medications and arm external rotation may provoke symptoms in some on the Beers Criteria list include tricyclic antidepressants, patients. Electrodiagnostic studies are frequently normal, and antipsychotics, and benzodiazepines. imaging may reveal an anomalous cervical rib, which predis- Although this patient was experiencing urinary urgency poses to this condition. First-line therapy for nTOS includes at the time of her fall, oxybutynin (Option A) is an anticho- physical therapy focusing on improving posture and strength- linergic medication that also has a propensity for side effects ening the shoulder girdle muscles. in geriatric patients. Oxybutynin is on the Beers Criteria Arterial TOS (aTOS) (Option A) is caused by subclavian list and would not be an appropriate medication in this artery compression, with or without thrombosis; it usually patient. Nonpharmacologic therapy is the preferred first-line occurs in the presence of an anomalous cervical rib. Symp- treatment for all types of urinary incontinence. In cases of toms include arm or hand pain (which may be exertional), urgency, recommended nonpharmacologic therapy includes weakness, paresthesia, coolness, and pallor. Some patients bladder training with timed voiding and gradually increas- may have blood pressure discrepancies between the arms ing the time between voids. or diminished pulses in the affected extremity. On occasion, The U.S. Preventive Services Task Force recommends a bruit may be auscultated over the ipsilateral subclavian against vitamin D supplementation (Option B) for fall preven- artery. This patient has no evidence of the arterial insuffi- tion in community-dwelling adults; these recommendations ciency that is characteristic of aTOS. do not apply to patients with osteoporotic fracture or vitamin Cervical radiculopathy (Option B) often presents with D deficiency. In this patient with no history of osteoporosis, constant neck and shoulder pain in a radicular distribu- vitamin D is unlikely to be beneficial for fall prevention. tion. The pain is aggravated by the position of the neck. The 165

Answers and Critiques_ wide anatomic distribution and nonradicular nature of this Estimating pretest probability is useful in deciding whether patient’s symptoms make cervical nerve root compression to obtain a test, selecting among different tests, or decid- less likely. ing to start or withhold treatment with or without testing. Venous TOS (vTOS) (Option D) is caused by compression Incorrect estimation of the pretest probability (Option B) of the subclavian vein within the costoclavicular junction had little or nothing to do with this patient’s diagnostic where it passes anterior to the anterior scalene muscle. vTOS error. An underlying premise of estimating pretest proba- is characterized by substantial upper extremity swelling as bility is that the correct diagnosis has been established, a well as pain in the upper extremity, chest, and shoulder. condition that was not met in this case. Cyanosis may be present. vTOS is most common in young, Time management is the process of organizing and active men and often affects the dominant upper extremity. planning how to divide time between specific activities The absence of swelling or cyanosis and the presence of par- according to a system of priorities. Prioritizing the care of esthesia make vTOS unlikely in this patient. sicker patients should be a tenet of good time management,

wide anatomic distribution and nonradicular nature of this Estimating pretest probability is useful in deciding whether patient’s symptoms make cervical nerve root compression to obtain a test, selecting among different tests, or decid- less likely. ing to start or withhold treatment with or without testing. Venous TOS (vTOS) (Option D) is caused by compression Incorrect estimation of the pretest probability (Option B) of the subclavian vein within the costoclavicular junction had little or nothing to do with this patient’s diagnostic where it passes anterior to the anterior scalene muscle. vTOS error. An underlying premise of estimating pretest proba- is characterized by substantial upper extremity swelling as bility is that the correct diagnosis has been established, a well as pain in the upper extremity, chest, and shoulder. condition that was not met in this case. Cyanosis may be present. vTOS is most common in young, Time management is the process of organizing and active men and often affects the dominant upper extremity. planning how to divide time between specific activities The absence of swelling or cyanosis and the presence of par- according to a system of priorities. Prioritizing the care of esthesia make vTOS unlikely in this patient. sicker patients should be a tenet of good time management, P= but this can take place only within a system that minimizes = wn chaos, maximizes communication, and provides adequate = e Neurogenic thoracic outlet syndrome typically presents resources to manage multiple competing priorities simulta- oO = wn with nonradicular and anatomically widespread symp- neously (Option C). g toms (weakness, numbness, paresthesia, and pain) = a affecting the arm, neck, and shoulder; symptoms (2) e Diagnostic errors are usually multifactorial in cause, with =f, worsen with repetitive overhead activities. =A flaws in the individual clinician’s cognitive processes and 2 = Bibliography systems-level issues contributing to most errors. @ wa Kuhn JE, Lebus V GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015;23:222-32. [PMID: 25808686] doi:10.5435/JAAOS-D-13-00215 Bibliography McDonald KM, Matesic B, Contopoulos-loannidis DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Item 66 Answer: D Med. 2013;158:381-9. [PMID: 23460094] doi:10.7326/0003-4819-158-5- 201303051-00004 Educational Objective: Identify systems factors as a cause of diagnostic error. Item 67 Answer: B The fundamental basis for this diagnostic error is related to Educational Objective: Treat refractory chronic systems factors (Option D). Diagnostic error is often defined insomnia with pharmacotherapy. as diagnoses that are delayed, wrong, or missed. Diagnos- tic errors are usually multifactorial in cause; flaws in the The most appropriate treatment is doxepin (Option B). individual clinician’s cognitive processes and systems-level Chronic insomnia is diagnosed by the presence of symptoms issues contribute to most errors. Systems factors that con- that (1) cause substantial functional distress or impairment; tribute to diagnostic error include communication policies (2) occur at least 3 nights per week for at least 3 months; and and practices, resource availability, and practice structure. (3) are not associated with other sleep, medical, or mental Productivity pressures and administrative burden and their disorders. Multiple guidelines recommend cognitive behav- effect on clinician time with patients may also contribute to ioral therapy for insomnia (CBT-I) as the preferred therapy diagnostic errors. Chaos in a medical practice is associated for chronic insomnia because of its effectiveness and safety. with an increased risk for error and missed opportunities to However, some patients will not improve with CBT-I, and provide appropriate care. In this case, the patient has COPD others will decline to participate. In those situations, short- and pneumonia, but he did not receive treatment for his term pharmacologic therapy can be considered. Physicians pneumonia, which resulted in an adverse outcome. Cogni- should engage in a thorough shared decision-making pro- tive error, multiple competing demands with insufficient cess to decide whether to initiate pharmacologic therapy in resources to accommodate need, possible lack of commu- patients with refractory insomnia. Pharmacologic therapy nication during transitions of care, and chaos may have all can be associated with harms, including daytime drowsi- contributed to this diagnostic error. ness, increased risk for falls and hip fracture, and medica- An analytical, rule-based approach, such as hypothetico- tion-related hallucinations. The 2020 guideline from the deductive reasoning (Option A), is characterized by specific U.S. Department of Veterans Affairs and U.S. Department analysis of each diagnostic possibility, including the concor- of Defense recommends low-dose doxepin or nonbenzodi- dant and discordant aspects of the clinical presentation. In azepine benzodiazepine receptor agonists (e.g., zolpidem, this case, hypothetico-deductive reasoning probably did not zaleplon, eszopiclone) in this situation. Low-quality evi- occur; this reasoning process would probably have consid- dence shows improvement in subjective sleep latency, total ered pneumonia as a cause of the patient’s finding of fever, sleep time, and sleep quality outcomes in patients receiving cough, and confusion. doxepin compared with placebo. For short-term use, there Pretest probability is the probability of a patient having does not seem to be an increase in adverse events in patients a specific condition before diagnostic testing is performed. taking doxepin compared with placebo.

P= but this can take place only within a system that minimizes = wn chaos, maximizes communication, and provides adequate = e Neurogenic thoracic outlet syndrome typically presents resources to manage multiple competing priorities simulta- oO = wn with nonradicular and anatomically widespread symp- neously (Option C). g toms (weakness, numbness, paresthesia, and pain) = a affecting the arm, neck, and shoulder; symptoms (2) e Diagnostic errors are usually multifactorial in cause, with =f, worsen with repetitive overhead activities. =A flaws in the individual clinician’s cognitive processes and 2 = Bibliography systems-level issues contributing to most errors. @ wa Kuhn JE, Lebus V GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015;23:222-32. [PMID: 25808686] doi:10.5435/JAAOS-D-13-00215 Bibliography McDonald KM, Matesic B, Contopoulos-loannidis DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Item 66 Answer: D Med. 2013;158:381-9. [PMID: 23460094] doi:10.7326/0003-4819-158-5- 201303051-00004 Educational Objective: Identify systems factors as a cause of diagnostic error. Item 67 Answer: B The fundamental basis for this diagnostic error is related to Educational Objective: Treat refractory chronic systems factors (Option D). Diagnostic error is often defined insomnia with pharmacotherapy. as diagnoses that are delayed, wrong, or missed. Diagnos- tic errors are usually multifactorial in cause; flaws in the The most appropriate treatment is doxepin (Option B). individual clinician’s cognitive processes and systems-level Chronic insomnia is diagnosed by the presence of symptoms issues contribute to most errors. Systems factors that con- that (1) cause substantial functional distress or impairment; tribute to diagnostic error include communication policies (2) occur at least 3 nights per week for at least 3 months; and and practices, resource availability, and practice structure. (3) are not associated with other sleep, medical, or mental Productivity pressures and administrative burden and their disorders. Multiple guidelines recommend cognitive behav- effect on clinician time with patients may also contribute to ioral therapy for insomnia (CBT-I) as the preferred therapy diagnostic errors. Chaos in a medical practice is associated for chronic insomnia because of its effectiveness and safety. with an increased risk for error and missed opportunities to However, some patients will not improve with CBT-I, and provide appropriate care. In this case, the patient has COPD others will decline to participate. In those situations, short- and pneumonia, but he did not receive treatment for his term pharmacologic therapy can be considered. Physicians pneumonia, which resulted in an adverse outcome. Cogni- should engage in a thorough shared decision-making pro- tive error, multiple competing demands with insufficient cess to decide whether to initiate pharmacologic therapy in resources to accommodate need, possible lack of commu- patients with refractory insomnia. Pharmacologic therapy nication during transitions of care, and chaos may have all can be associated with harms, including daytime drowsi- contributed to this diagnostic error. ness, increased risk for falls and hip fracture, and medica- An analytical, rule-based approach, such as hypothetico- tion-related hallucinations. The 2020 guideline from the deductive reasoning (Option A), is characterized by specific U.S. Department of Veterans Affairs and U.S. Department analysis of each diagnostic possibility, including the concor- of Defense recommends low-dose doxepin or nonbenzodi- dant and discordant aspects of the clinical presentation. In azepine benzodiazepine receptor agonists (e.g., zolpidem, this case, hypothetico-deductive reasoning probably did not zaleplon, eszopiclone) in this situation. Low-quality evi- occur; this reasoning process would probably have consid- dence shows improvement in subjective sleep latency, total ered pneumonia as a cause of the patient’s finding of fever, sleep time, and sleep quality outcomes in patients receiving cough, and confusion. doxepin compared with placebo. For short-term use, there Pretest probability is the probability of a patient having does not seem to be an increase in adverse events in patients a specific condition before diagnostic testing is performed. taking doxepin compared with placebo. 166

Answers and Critiques The use of antihistamines, such as diphenhydramine for falls and a decline in functional status. First-line therapy (Option A), is not recommended for chronic insomnia. Anti- for BPPV is canalith repositioning with the Epley maneuver, histamines are often used off-label as a sleep aid due to their which is effective in up to 85% of patients. Medication is not sedating properties, but there are no data on their efficacy useful in the treatment of BPPV except when the episodes in treating chronic insomnia. In addition, because of their are frequent and disabling. In that situation, the vestibular well-known anticholinergic effects, antihistamines may be suppressant betahistine (not available in the United States) associated with adverse drug events, particularly in elderly may be helpful along with the Epley maneuver. Meclizine patients. probably contributed to this patient’s near fall and fear of Trazodone (Option C) is not recommended for patients falling and is not especially helpful in controlling the symp- with chronic insomnia. Data from a systematic review toms of BPPV; it should be discontinued. showed that trazodone improved the subjective measure of Discontinuing metoprolol (Option B) places the patient sleep quality compared with placebo; however, there was no at increased risk for poor rate control of his atrial fibrillation difference in objectively measured sleep onset latency, total and, in the absence of orthostatic hypotension, will not 4) a sleep time, or waking after sleep onset. reduce his risk for falls. =]

The use of antihistamines, such as diphenhydramine for falls and a decline in functional status. First-line therapy (Option A), is not recommended for chronic insomnia. Anti- for BPPV is canalith repositioning with the Epley maneuver, histamines are often used off-label as a sleep aid due to their which is effective in up to 85% of patients. Medication is not sedating properties, but there are no data on their efficacy useful in the treatment of BPPV except when the episodes in treating chronic insomnia. In addition, because of their are frequent and disabling. In that situation, the vestibular well-known anticholinergic effects, antihistamines may be suppressant betahistine (not available in the United States) associated with adverse drug events, particularly in elderly may be helpful along with the Epley maneuver. Meclizine patients. probably contributed to this patient’s near fall and fear of Trazodone (Option C) is not recommended for patients falling and is not especially helpful in controlling the symp- with chronic insomnia. Data from a systematic review toms of BPPV; it should be discontinued. showed that trazodone improved the subjective measure of Discontinuing metoprolol (Option B) places the patient sleep quality compared with placebo; however, there was no at increased risk for poor rate control of his atrial fibrillation difference in objectively measured sleep onset latency, total and, in the absence of orthostatic hypotension, will not 4) a sleep time, or waking after sleep onset. reduce his risk for falls. =] Pharmacotherapy for chronic insomnia is indicated in Prescription of an assistive device, such as a cane a a patients who have not responded to nonpharmacologic ther- (Option C), in the absence of a gait abnormality is not rec- Oo apies, such as sleep hygiene and cognitive behavioral ther- ommended. sc = apy, after a shared decision-making discussion of the risks Vitamin D supplementation (Option D) is not recom- c 2) and benefits. This patient has not responded to nonpharma- mended for fall risk reduction. Meta-analysis of random- Paces o cologic therapy and meets the criteria for pharmacotherapy ized controlled trials of community-dwelling elderly adults F wn (Option D). showed no reduction in fall or fracture risk in patients with- e out osteoporosis or known vitamin D deficiency. =

Pharmacotherapy for chronic insomnia is indicated in Prescription of an assistive device, such as a cane a a patients who have not responded to nonpharmacologic ther- (Option C), in the absence of a gait abnormality is not rec- Oo apies, such as sleep hygiene and cognitive behavioral ther- ommended. sc = apy, after a shared decision-making discussion of the risks Vitamin D supplementation (Option D) is not recom- c 2) and benefits. This patient has not responded to nonpharma- mended for fall risk reduction. Meta-analysis of random- Paces o cologic therapy and meets the criteria for pharmacotherapy ized controlled trials of community-dwelling elderly adults F wn (Option D). showed no reduction in fall or fracture risk in patients with- e out osteoporosis or known vitamin D deficiency. = ¢ For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or e Many health conditions, physical characteristics, and who decline to participate in CBT-I, either low-dose behaviors increase risk for falling, but the greatest doxepin or a nonbenzodiazepine benzodiazepine increases are associated with cognitive impairment, receptor agonist (e.g., zolpidem, zaleplon, eszopi- psychoactive medications, gait/balance problems, and clone) is recommended after a discussion of risks decreased lower extremity strength. and benefits. Bibliography Bibliography Grossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- Preventive Services Task Force recommendation statement. JAMA. nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. 2018;319:1696-704. [PMID: 29710141] doi:10.1001/jama.2018.3097 Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] doi:10.7326/M19-3575

¢ For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or e Many health conditions, physical characteristics, and who decline to participate in CBT-I, either low-dose behaviors increase risk for falling, but the greatest doxepin or a nonbenzodiazepine benzodiazepine increases are associated with cognitive impairment, receptor agonist (e.g., zolpidem, zaleplon, eszopi- psychoactive medications, gait/balance problems, and clone) is recommended after a discussion of risks decreased lower extremity strength. and benefits. Bibliography Bibliography Grossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- Preventive Services Task Force recommendation statement. JAMA. nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. 2018;319:1696-704. [PMID: 29710141] doi:10.1001/jama.2018.3097 Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] doi:10.7326/M19-3575 Item 69 Answer: C Item 68 Answer: A Educational Objective: Treat chronic venous Educational Objective: Prevent falls in an elderly patient. insufficiency with compression.

¢ For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or e Many health conditions, physical characteristics, and who decline to participate in CBT-I, either low-dose behaviors increase risk for falling, but the greatest doxepin or a nonbenzodiazepine benzodiazepine increases are associated with cognitive impairment, receptor agonist (e.g., zolpidem, zaleplon, eszopi- psychoactive medications, gait/balance problems, and clone) is recommended after a discussion of risks decreased lower extremity strength. and benefits. Bibliography Bibliography Grossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- Preventive Services Task Force recommendation statement. JAMA. nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. 2018;319:1696-704. [PMID: 29710141] doi:10.1001/jama.2018.3097 Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] doi:10.7326/M19-3575 Item 69 Answer: C Item 68 Answer: A Educational Objective: Treat chronic venous Educational Objective: Prevent falls in an elderly patient. insufficiency with compression. The most appropriate measure to reduce this patient’s risk for The most appropriate management is compression stockings falls is to discontinue meclizine (Option A). Meclizine is a cen- (Option C). This patient has chronic venous insufficiency, trally acting antihistamine associated with increased fall risk which has led to venous stasis changes. The underlying in elderly patients. Many health conditions, physical charac- cause of chronic venous insufficiency is venous hyperten- teristics, and behaviors increase risk for falling, but the greatest sion, which may develop as a result of obstruction to venous increases are associated with cognitive impairment, psychoac- flow (e.g., thrombus), dysfunction of venous valves (e.g., tive medications, gait/balance problems, and decreased lower congenital, after injury, venous thrombosis), and failure of extremity strength. The presence of multiple risk factors has an the “venous pump” (calf muscle constriction of deep veins). additive effect on fall risk. Even fear of falling in the absence of The increase in venous pressure within the deep venous falls decreases self-rated health and hastens functional decline. system is directed to the superficial venous system, caus- The Timed Up and Go (TUG) test is used to help assess fall risk. ing deleterious changes in the microcirculation (such as This test involves asking the patient to rise from a chair with recruitment of leukocytes, release of inflammatory medi- armrests, walk 10 feet, turn, return to the chair, and sit down. ators, and extravasation of proteins and erythrocytes into A TUG Test result of more than 12 seconds should prompt the extravascular space). Symptoms include aching, itch- intervention to reduce fall risk. ing, restlessness, heaviness, swelling, and pain in the legs.

The most appropriate measure to reduce this patient’s risk for The most appropriate management is compression stockings falls is to discontinue meclizine (Option A). Meclizine is a cen- (Option C). This patient has chronic venous insufficiency, trally acting antihistamine associated with increased fall risk which has led to venous stasis changes. The underlying in elderly patients. Many health conditions, physical charac- cause of chronic venous insufficiency is venous hyperten- teristics, and behaviors increase risk for falling, but the greatest sion, which may develop as a result of obstruction to venous increases are associated with cognitive impairment, psychoac- flow (e.g., thrombus), dysfunction of venous valves (e.g., tive medications, gait/balance problems, and decreased lower congenital, after injury, venous thrombosis), and failure of extremity strength. The presence of multiple risk factors has an the “venous pump” (calf muscle constriction of deep veins). additive effect on fall risk. Even fear of falling in the absence of The increase in venous pressure within the deep venous falls decreases self-rated health and hastens functional decline. system is directed to the superficial venous system, caus- The Timed Up and Go (TUG) test is used to help assess fall risk. ing deleterious changes in the microcirculation (such as This test involves asking the patient to rise from a chair with recruitment of leukocytes, release of inflammatory medi- armrests, walk 10 feet, turn, return to the chair, and sit down. ators, and extravasation of proteins and erythrocytes into A TUG Test result of more than 12 seconds should prompt the extravascular space). Symptoms include aching, itch- intervention to reduce fall risk. ing, restlessness, heaviness, swelling, and pain in the legs. Benign paroxysmal positional vertigo (BPPV) is the most This patient should wear compression stockings (providing common form of vertigo. Symptoms lead to increased risk 20-50 mm Hg of pressure) and be encouraged to walk or 167

perform heel lifts to facilitate the action of the venous pump. Cardiac monitoring (Option A) would be useful if the Leg elevation should be recommended to reduce edema, but ECG showed abnormalities or cardiac causes of syncope patient adherence is often difficult. Additional care recom- were strongly suspected despite normal ECG findings. Char- mendations include emollients to restore the skin barrier. acteristics associated with cardiac syncope include syncope The skin discoloration is caused by hemosiderin deposition while lying down, exertional syncope, lack of prodrome or from extravasated erythrocytes. a brief prodrome of palpitations, family history of sudden Antibiotics, such as cefadroxil (Option A), are not indi- cardiac death, age older than 60 years, and male sex. cated in this case. The swelling and skin changes are due to Advanced imaging of the head (Option B) is not indi- chronic venous insufficiency rather than cellulitis. Cellulitis cated in any patient without trauma during the syncopal also can present with swelling and erythema, but only rarely event or in the absence of focal neurologic findings. Such is it present in both legs. Cellulitis can be associated with unwarranted testing would not alter the management but systemic signs of infection, such as fever and pain, whereas would increase costs. > chronic venous insufficiency is not. If the patient had abnormalities on the physical exam- 7] rn Lower extremity deep venous thrombosis is in the dif- ination, such as a heart murmur, evaluation for structural = ferential diagnosis of unilateral swelling in a lower extrem- heart disease with echocardiography (Option D) could be Oo ity. This patient, however, has chronic bilateral swelling. = wn considered. This patient’s benign physical findings do not Q = Thus, compression duplex ultrasonography (Option B) is warrant echocardiography. a. not indicated. (=) = In the absence of such conditions as heart failure or a chronic kidney disease, patients with chronic venous insuf- e Syncope provoked by emotional stress, heat, noxious 2 = ficiency have normal intravascular volume. Diuretics, such stimuli, or prolonged standing, accompanied by a o wn as furosemide (Option D), primarily decrease intravascular prodrome of diaphoresis and nausea, is consistent

perform heel lifts to facilitate the action of the venous pump. Cardiac monitoring (Option A) would be useful if the Leg elevation should be recommended to reduce edema, but ECG showed abnormalities or cardiac causes of syncope patient adherence is often difficult. Additional care recom- were strongly suspected despite normal ECG findings. Char- mendations include emollients to restore the skin barrier. acteristics associated with cardiac syncope include syncope The skin discoloration is caused by hemosiderin deposition while lying down, exertional syncope, lack of prodrome or from extravasated erythrocytes. a brief prodrome of palpitations, family history of sudden Antibiotics, such as cefadroxil (Option A), are not indi- cardiac death, age older than 60 years, and male sex. cated in this case. The swelling and skin changes are due to Advanced imaging of the head (Option B) is not indi- chronic venous insufficiency rather than cellulitis. Cellulitis cated in any patient without trauma during the syncopal also can present with swelling and erythema, but only rarely event or in the absence of focal neurologic findings. Such is it present in both legs. Cellulitis can be associated with unwarranted testing would not alter the management but systemic signs of infection, such as fever and pain, whereas would increase costs. > chronic venous insufficiency is not. If the patient had abnormalities on the physical exam- 7] rn Lower extremity deep venous thrombosis is in the dif- ination, such as a heart murmur, evaluation for structural = ferential diagnosis of unilateral swelling in a lower extrem- heart disease with echocardiography (Option D) could be Oo ity. This patient, however, has chronic bilateral swelling. = wn considered. This patient’s benign physical findings do not Q = Thus, compression duplex ultrasonography (Option B) is warrant echocardiography. a. not indicated. (=) = In the absence of such conditions as heart failure or a chronic kidney disease, patients with chronic venous insuf- e Syncope provoked by emotional stress, heat, noxious 2 = ficiency have normal intravascular volume. Diuretics, such stimuli, or prolonged standing, accompanied by a o wn as furosemide (Option D), primarily decrease intravascular prodrome of diaphoresis and nausea, is consistent volume without diminishing extravascular fluid and edema. with vasovagal syncope.

perform heel lifts to facilitate the action of the venous pump. Cardiac monitoring (Option A) would be useful if the Leg elevation should be recommended to reduce edema, but ECG showed abnormalities or cardiac causes of syncope patient adherence is often difficult. Additional care recom- were strongly suspected despite normal ECG findings. Char- mendations include emollients to restore the skin barrier. acteristics associated with cardiac syncope include syncope The skin discoloration is caused by hemosiderin deposition while lying down, exertional syncope, lack of prodrome or from extravasated erythrocytes. a brief prodrome of palpitations, family history of sudden Antibiotics, such as cefadroxil (Option A), are not indi- cardiac death, age older than 60 years, and male sex. cated in this case. The swelling and skin changes are due to Advanced imaging of the head (Option B) is not indi- chronic venous insufficiency rather than cellulitis. Cellulitis cated in any patient without trauma during the syncopal also can present with swelling and erythema, but only rarely event or in the absence of focal neurologic findings. Such is it present in both legs. Cellulitis can be associated with unwarranted testing would not alter the management but systemic signs of infection, such as fever and pain, whereas would increase costs. > chronic venous insufficiency is not. If the patient had abnormalities on the physical exam- 7] rn Lower extremity deep venous thrombosis is in the dif- ination, such as a heart murmur, evaluation for structural = ferential diagnosis of unilateral swelling in a lower extrem- heart disease with echocardiography (Option D) could be Oo ity. This patient, however, has chronic bilateral swelling. = wn considered. This patient’s benign physical findings do not Q = Thus, compression duplex ultrasonography (Option B) is warrant echocardiography. a. not indicated. (=) = In the absence of such conditions as heart failure or a chronic kidney disease, patients with chronic venous insuf- e Syncope provoked by emotional stress, heat, noxious 2 = ficiency have normal intravascular volume. Diuretics, such stimuli, or prolonged standing, accompanied by a o wn as furosemide (Option D), primarily decrease intravascular prodrome of diaphoresis and nausea, is consistent volume without diminishing extravascular fluid and edema. with vasovagal syncope. Bibliography e The primary treatment of chronic venous insufficiency Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for is compression therapy. the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Bibliography Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] doi:10.1161/CIR.0000000000000498 Rabe E, Partsch H, Hafner J, et al. Indications for medical compression stockings in venous and lymphatic disorders: an evidence-based consen- sus statement. Phlebology. 2018;33:163-84. [PMID: 28549402] doi:10. 1177/0268355516689631 Item 71 Answer: D Educational Objective: Evaluate chronic cough ina Item 70 Answer: C stepwise fashion. Educational Objective: Manage vasovagal syncope. Spirometry (Option D) is the most appropriate next step in The most appropriate management is discharge home managing this patient’s cough. Evaluation of chronic cough (Option C). The history and physical examination are the should be performed in a stepwise fashion, beginning with most important diagnostic tools in determining the cause of a thorough history, physical examination, and chest radi- a syncopal event and can suggest a cause in at least half of ography, as well as cessation of ACE inhibitors and tobacco, cases. This patient’s description of events, prodrome of dia- if used. If the initial evaluation does not elicit the cause of phoresis and nausea, and normal physical examination and cough, a stepwise approach to management should start ECG are suggestive of vasovagal syncope. Vasovagal syncope with a trial of empiric treatment for upper airway cough is a type of neurally mediated syncope that is provoked by syndrome (UACS). Intranasal glucocorticoid therapy is first- noxious stimuli, fear, stress, or heat overexposure. It is typ- line treatment for allergic rhinitis-associated UACS; UACS ically characterized by a prodrome of diaphoresis, warmth, caused by nonallergic rhinitis is treated with first-generation nausea, and pallor. Patients with vasovagal syncope can be antihistamines and decongestants. Because this patient’s discharged from the emergency department without costly cough did not respond to treatment with fluticasone nasal testing or procedures. Patient education should be provided spray for UACS, the next step is evaluation for asthma with on the benign nature of the diagnosis, awareness and avoid- spirometry. Cough-variant asthma is diagnosed if spirom- ance of triggers (prolonged standing, warm environments), etry and/or bronchial hyperresponsiveness testing results and the need for adequate hydration. In addition, patients are abnormal, and symptoms should improve with standard with a prodrome should be educated on safety measures therapy for asthma, including inhaled glucocorticoids. (lying in a supine position to avoid injury) and counter- In patients with normal findings on evaluation and failed pressure measures that may abort an episode (leg crossing, empiric treatment for UACS and asthma, the most reasonable squatting, bending the knees when standing for a prolonged next step is to exclude nonasthmatic eosinophilic bronchitis period). (NAEB) with sputum analysis for eosinophils (Option E) or

Bibliography e The primary treatment of chronic venous insufficiency Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for is compression therapy. the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Bibliography Heart Rhythm Society. Circulation. 2017;136:e25-59. [PMID: 28280232] doi:10.1161/CIR.0000000000000498 Rabe E, Partsch H, Hafner J, et al. Indications for medical compression stockings in venous and lymphatic disorders: an evidence-based consen- sus statement. Phlebology. 2018;33:163-84. [PMID: 28549402] doi:10. 1177/0268355516689631 Item 71 Answer: D Educational Objective: Evaluate chronic cough ina Item 70 Answer: C stepwise fashion. Educational Objective: Manage vasovagal syncope. Spirometry (Option D) is the most appropriate next step in The most appropriate management is discharge home managing this patient’s cough. Evaluation of chronic cough (Option C). The history and physical examination are the should be performed in a stepwise fashion, beginning with most important diagnostic tools in determining the cause of a thorough history, physical examination, and chest radi- a syncopal event and can suggest a cause in at least half of ography, as well as cessation of ACE inhibitors and tobacco, cases. This patient’s description of events, prodrome of dia- if used. If the initial evaluation does not elicit the cause of phoresis and nausea, and normal physical examination and cough, a stepwise approach to management should start ECG are suggestive of vasovagal syncope. Vasovagal syncope with a trial of empiric treatment for upper airway cough is a type of neurally mediated syncope that is provoked by syndrome (UACS). Intranasal glucocorticoid therapy is first- noxious stimuli, fear, stress, or heat overexposure. It is typ- line treatment for allergic rhinitis-associated UACS; UACS ically characterized by a prodrome of diaphoresis, warmth, caused by nonallergic rhinitis is treated with first-generation nausea, and pallor. Patients with vasovagal syncope can be antihistamines and decongestants. Because this patient’s discharged from the emergency department without costly cough did not respond to treatment with fluticasone nasal testing or procedures. Patient education should be provided spray for UACS, the next step is evaluation for asthma with on the benign nature of the diagnosis, awareness and avoid- spirometry. Cough-variant asthma is diagnosed if spirom- ance of triggers (prolonged standing, warm environments), etry and/or bronchial hyperresponsiveness testing results and the need for adequate hydration. In addition, patients are abnormal, and symptoms should improve with standard with a prodrome should be educated on safety measures therapy for asthma, including inhaled glucocorticoids. (lying in a supine position to avoid injury) and counter- In patients with normal findings on evaluation and failed pressure measures that may abort an episode (leg crossing, empiric treatment for UACS and asthma, the most reasonable squatting, bending the knees when standing for a prolonged next step is to exclude nonasthmatic eosinophilic bronchitis period). (NAEB) with sputum analysis for eosinophils (Option E) or 168

Answers and Critiques exhaled nitric oxide testing. If test results are abnormal, ther- associated with decreased cardiovascular risk focus on con- apy with inhaled glucocorticoids should be initiated. sumption of fruits, vegetables, fiber, and monounsaturated Evaluation for gastroesophageal reflux disease (GERD) fats and minimize intake of saturated and trans fats, simple with an empiric trial of a proton pump inhibitor, such as carbohydrates, and red meats. Examples include the Med- omeprazole (Option C), is recommended for patients with iterranean diet (associated with an 18%-40% reduction in persistent cough who have negative evaluation findings and diabetes) and the Dietary Approaches to Stop Hyperten- have not responded to empiric treatment of UACS, asthma, sion (DASH) diet (associated with decreased blood pressure and NAEB. and LDL cholesterol level). In patients with elevated BMI, Ambulatory pH monitoring (Option A) is used to mea- such as this patient, moderate weight loss (=5%) is recom- sure acid exposure in the esophagus. It can be especially mended to decrease the incidence of diabetes by 30% to 60%. helpful in the diagnosis of GERD in patients unresponsive Weight loss will also lower blood pressure and lipid levels. In to acid-reducing therapy. In this patient, it should only be addition, the American Heart Association (AHA)/American considered after more common causes of chronic cough, College of Cardiology (ACC) recommend an active lifestyle wn ry such as asthma, have been ruled out. involving at least 150 minutes of moderate to vigorous phys- =

exhaled nitric oxide testing. If test results are abnormal, ther- associated with decreased cardiovascular risk focus on con- apy with inhaled glucocorticoids should be initiated. sumption of fruits, vegetables, fiber, and monounsaturated Evaluation for gastroesophageal reflux disease (GERD) fats and minimize intake of saturated and trans fats, simple with an empiric trial of a proton pump inhibitor, such as carbohydrates, and red meats. Examples include the Med- omeprazole (Option C), is recommended for patients with iterranean diet (associated with an 18%-40% reduction in persistent cough who have negative evaluation findings and diabetes) and the Dietary Approaches to Stop Hyperten- have not responded to empiric treatment of UACS, asthma, sion (DASH) diet (associated with decreased blood pressure and NAEB. and LDL cholesterol level). In patients with elevated BMI, Ambulatory pH monitoring (Option A) is used to mea- such as this patient, moderate weight loss (=5%) is recom- sure acid exposure in the esophagus. It can be especially mended to decrease the incidence of diabetes by 30% to 60%. helpful in the diagnosis of GERD in patients unresponsive Weight loss will also lower blood pressure and lipid levels. In to acid-reducing therapy. In this patient, it should only be addition, the American Heart Association (AHA)/American considered after more common causes of chronic cough, College of Cardiology (ACC) recommend an active lifestyle wn ry such as asthma, have been ruled out. involving at least 150 minutes of moderate to vigorous phys- = Chest CT (Option B) could be considered if evaluations ical activity per week. = i for asthma, NAEB, and GERD are unremarkable and cough Initial therapy for hypertriglyceridemia is lifestyle mod- cs) persists. However, CT should not be pursued now in the ification rather than pharmacologic therapy with fenofibrate a) = absence of “red flag” symptoms, such as unexplained weight (Option A). In patients with elevated ASCVD risk and hyper- c nn loss, abnormal pulmonary examination, or abnormal find- triglyceridemia, initiation of statin therapy is preferred over fees o ings on chest radiography. fenofibrate. = n Statin therapy (Option B) is not first-line therapy for a = patient who does not have diabetes and has a 10-year risk =< e The initial management of chronic cough includes for ASCVD of 4.3%. According to the AHA/ACC guideline tobacco cessation and discontinuation of ACE inhibi- on management of blood cholesterol, moderate-intensity tor therapy, followed by chest radiography if cough statin therapy could be considered in patients with a 10-year persists. ASCVD risk of 5% to less than 7.5% in the presence of ASCVD

Chest CT (Option B) could be considered if evaluations ical activity per week. = i for asthma, NAEB, and GERD are unremarkable and cough Initial therapy for hypertriglyceridemia is lifestyle mod- cs) persists. However, CT should not be pursued now in the ification rather than pharmacologic therapy with fenofibrate a) = absence of “red flag” symptoms, such as unexplained weight (Option A). In patients with elevated ASCVD risk and hyper- c nn loss, abnormal pulmonary examination, or abnormal find- triglyceridemia, initiation of statin therapy is preferred over fees o ings on chest radiography. fenofibrate. = n Statin therapy (Option B) is not first-line therapy for a = patient who does not have diabetes and has a 10-year risk =< e The initial management of chronic cough includes for ASCVD of 4.3%. According to the AHA/ACC guideline tobacco cessation and discontinuation of ACE inhibi- on management of blood cholesterol, moderate-intensity tor therapy, followed by chest radiography if cough statin therapy could be considered in patients with a 10-year persists. ASCVD risk of 5% to less than 7.5% in the presence of ASCVD e In patients with negative findings on chest radiograph risk enhancers, including metabolic syndrome. Other risk enhancers include family history of premature ASCVD; and persistence of cough after discontinuation of ACE chronic kidney disease; presence of inflammatory disease inhibitor therapy and tobacco, additional evaluation (e.g., rheumatoid arthritis, HIV infection, psoriasis); and proceeds in a stepwise fashion: (1) empiric treatment South Asian ethnicity. The USPSTF recommends selective for upper airway cough syndrome; (2) spirometry or consideration of low- to moderate-intensity statin therapy in empiric treatment for asthma; (3) sputum analysis for patients without ASCVD who have at least one ASCVD risk eosinophils or empiric treatment with inhaled gluco- factor (dyslipidemia, diabetes, hypertension, or smoking) corticoids; and (4) empiric treatment for gastroesoph- and a calculated 10-year ASCVD event risk of 7.5% to 10%. ageal reflux disease. This patient’s alcohol intake is moderate, not exceeding the acceptable range for men (two or fewer drinks per day). Bibliography Recommending decreased alcohol intake (Option C) is not Irwin RS, French CL, Chang AB, et al; CHEST Expert Cough Panel. the most appropriate treatment. Classification of cough as a symptom in adults and management algo- rithms: CHEST guideline and expert panel report. Chest. 2018;153:196- 209. [PMID: 29080708] doi:10.1016/j.chest.2017.10.016

e In patients with negative findings on chest radiograph risk enhancers, including metabolic syndrome. Other risk enhancers include family history of premature ASCVD; and persistence of cough after discontinuation of ACE chronic kidney disease; presence of inflammatory disease inhibitor therapy and tobacco, additional evaluation (e.g., rheumatoid arthritis, HIV infection, psoriasis); and proceeds in a stepwise fashion: (1) empiric treatment South Asian ethnicity. The USPSTF recommends selective for upper airway cough syndrome; (2) spirometry or consideration of low- to moderate-intensity statin therapy in empiric treatment for asthma; (3) sputum analysis for patients without ASCVD who have at least one ASCVD risk eosinophils or empiric treatment with inhaled gluco- factor (dyslipidemia, diabetes, hypertension, or smoking) corticoids; and (4) empiric treatment for gastroesoph- and a calculated 10-year ASCVD event risk of 7.5% to 10%. ageal reflux disease. This patient’s alcohol intake is moderate, not exceeding the acceptable range for men (two or fewer drinks per day). Bibliography Recommending decreased alcohol intake (Option C) is not Irwin RS, French CL, Chang AB, et al; CHEST Expert Cough Panel. the most appropriate treatment. Classification of cough as a symptom in adults and management algo- rithms: CHEST guideline and expert panel report. Chest. 2018;153:196- 209. [PMID: 29080708] doi:10.1016/j.chest.2017.10.016 ¢ The initial intervention for metabolic syndrome is intensive lifestyle modifications (diet and exercise). Item 72 Answer: D Educational Objective: Treat metabolic syndrome with Bibliography lifestyle interventions. Rosenzweig JL, Bakris GL, Berglund LF, et al. Primary prevention of ASCVD and T2DM in patients at metabolic risk: an Endocrine Society clinical The most appropriate treatment is to recommend an inten- practice guideline. J Clin Endocrinol Metab. 2019. [PMID: 31365087] doi:10.1210/jc.2019-01338 sive diet and exercise regimen (Option D). This patient meets the criteria for metabolic syndrome because of his large waist circumference, fasting glucose level, and triglyceride Item 73 Answer: 8B level. Metabolic syndrome is a marker of risk for future Educational Objective: Obtain genetic counseling for a atherosclerotic cardiovascular disease (ASCVD) and type patient who is at high risk for breast cancer. 2 diabetes mellitus. The recommended initial intervention is intensive lifestyle modifications to decrease risk. Guide- The most appropriate management of this patient’s breast lines from the Endocrine Society on primary prevention cancer risk is genetic counseling (Option B). Direct-to- of ASCVD and type 2 diabetes recommended prescribing consumer (DTC) genomic testing is a commercial service a cardiovascular-healthy diet. Diets that have been most that allows patients to obtain genetic information without a

¢ The initial intervention for metabolic syndrome is intensive lifestyle modifications (diet and exercise). Item 72 Answer: D Educational Objective: Treat metabolic syndrome with Bibliography lifestyle interventions. Rosenzweig JL, Bakris GL, Berglund LF, et al. Primary prevention of ASCVD and T2DM in patients at metabolic risk: an Endocrine Society clinical The most appropriate treatment is to recommend an inten- practice guideline. J Clin Endocrinol Metab. 2019. [PMID: 31365087] doi:10.1210/jc.2019-01338 sive diet and exercise regimen (Option D). This patient meets the criteria for metabolic syndrome because of his large waist circumference, fasting glucose level, and triglyceride Item 73 Answer: 8B level. Metabolic syndrome is a marker of risk for future Educational Objective: Obtain genetic counseling for a atherosclerotic cardiovascular disease (ASCVD) and type patient who is at high risk for breast cancer. 2 diabetes mellitus. The recommended initial intervention is intensive lifestyle modifications to decrease risk. Guide- The most appropriate management of this patient’s breast lines from the Endocrine Society on primary prevention cancer risk is genetic counseling (Option B). Direct-to- of ASCVD and type 2 diabetes recommended prescribing consumer (DTC) genomic testing is a commercial service a cardiovascular-healthy diet. Diets that have been most that allows patients to obtain genetic information without a 169

Answers and Critiques physician order or prescription. DTC tests are not diagnostic forms for ease of administration. Naloxone acts within tests. The FDA recommends confirmation with clinical test- minutes and has a very short half-life; its antidote effects ing before DTC test results are used in patient care. Clinical will usually wear off before the opioid effects are gone. genetic testing is indicated for patients with a personal or Patients should be observed for signs of opioid withdrawal family history suggesting inherited cancer susceptibility; (which is not fatal and requires only supportive care) and however, patients should undergo genetic counseling first for continued or recurrent signs of respiratory distress to guide decision making. The basic components of genetic (which may require repeated dosing of naloxone). Accord- counseling are education on the condition being tested, ing to the CDC opioid prescribing guideline, clinicians including the natural history, possible treatments, and pre- should offer naloxone to any patient at risk for opioid ventive measures; the risks and benefits of testing; alter- overdose. This includes patients with a history of overdose natives to testing, including the option to forgo testing; the or substance use disorder, patients taking benzodiazepines implications for the patient and family members; and costs, with opioids (which should be avoided whenever possible), > including the possibility of denial of coverage for disability, and those taking more than 50 morphine milligram equiv- = wn long-term care, and life insurance. alents per day. In addition, naloxone should be provided = This patient’s family history strongly suggests a hered- to patients taking opioids who have risk factors for opi- @ = wn itary breast cancer syndrome, such as a BRCA1/2 mutation, oid-related harms; such patients include elderly persons, gy = but clinical practice guidelines recommend that genetic patients with mental health conditions, and patients at risk Qa testing (Option A) begin with a relative affected by a BRCA- for sleep-disordered breathing (such as those with heart im} =e associated cancer. In this case, testing would ideally begin failure, obstructive sleep apnea, or obesity), regardless of =. with the patient’s sister. In addition, this patient should oral morphine equivalents prescribed. This patient with 2 = undergo genetic counseling before testing is pursued. a history of overdose should be prescribed naloxone and oO 17) MRI of the breast (Option C) would be a reasonable educated on its proper use and ways to prevent overdose. screening modality in selected patients with a high lifetime Friends, family members, and caretakers may also receive risk for breast cancer, such as those with known BRCA1/2 prescriptions and training in naloxone use. mutations, starting at age 25 years. It is not a substitute for Clonidine (Option B) is an antihypertensive agent genetic counseling and, potentially, BRCA gene testing. that can assist in the management of symptoms of drug Some commercially available DTCs examine for only withdrawal. Clonidine will not prevent death from opioid 3 of more than 1000 known BRCA1/2 variants. Results on overdose. DTCs should be confirmed with a clinical test before being Naltrexone (Option C) is an opioid blocker that can help used for medical decision making. In this case, relying on prevent relapse in patients with opioid use disorder when a negative DTC result to conclude that no further testing is used in combination with other treatment measures, which needed (Option D) would be inappropriate. may include cognitive behavioral therapy, psychosocial sup- port, and additional medications (such as buprenorphine). Naltrexone will not directly prevent death from opioid over- ¢ Positive results on direct-to-consumer genetic tests dose, and its use is contraindicated in patients who are still should be confirmed with a clinical test before being taking opioids, as this patient is. used for medical decision making. Buprenorphine (Option D) is a partial opioid agonist

physician order or prescription. DTC tests are not diagnostic forms for ease of administration. Naloxone acts within tests. The FDA recommends confirmation with clinical test- minutes and has a very short half-life; its antidote effects ing before DTC test results are used in patient care. Clinical will usually wear off before the opioid effects are gone. genetic testing is indicated for patients with a personal or Patients should be observed for signs of opioid withdrawal family history suggesting inherited cancer susceptibility; (which is not fatal and requires only supportive care) and however, patients should undergo genetic counseling first for continued or recurrent signs of respiratory distress to guide decision making. The basic components of genetic (which may require repeated dosing of naloxone). Accord- counseling are education on the condition being tested, ing to the CDC opioid prescribing guideline, clinicians including the natural history, possible treatments, and pre- should offer naloxone to any patient at risk for opioid ventive measures; the risks and benefits of testing; alter- overdose. This includes patients with a history of overdose natives to testing, including the option to forgo testing; the or substance use disorder, patients taking benzodiazepines implications for the patient and family members; and costs, with opioids (which should be avoided whenever possible), > including the possibility of denial of coverage for disability, and those taking more than 50 morphine milligram equiv- = wn long-term care, and life insurance. alents per day. In addition, naloxone should be provided = This patient’s family history strongly suggests a hered- to patients taking opioids who have risk factors for opi- @ = wn itary breast cancer syndrome, such as a BRCA1/2 mutation, oid-related harms; such patients include elderly persons, gy = but clinical practice guidelines recommend that genetic patients with mental health conditions, and patients at risk Qa testing (Option A) begin with a relative affected by a BRCA- for sleep-disordered breathing (such as those with heart im} =e associated cancer. In this case, testing would ideally begin failure, obstructive sleep apnea, or obesity), regardless of =. with the patient’s sister. In addition, this patient should oral morphine equivalents prescribed. This patient with 2 = undergo genetic counseling before testing is pursued. a history of overdose should be prescribed naloxone and oO 17) MRI of the breast (Option C) would be a reasonable educated on its proper use and ways to prevent overdose. screening modality in selected patients with a high lifetime Friends, family members, and caretakers may also receive risk for breast cancer, such as those with known BRCA1/2 prescriptions and training in naloxone use. mutations, starting at age 25 years. It is not a substitute for Clonidine (Option B) is an antihypertensive agent genetic counseling and, potentially, BRCA gene testing. that can assist in the management of symptoms of drug Some commercially available DTCs examine for only withdrawal. Clonidine will not prevent death from opioid 3 of more than 1000 known BRCA1/2 variants. Results on overdose. DTCs should be confirmed with a clinical test before being Naltrexone (Option C) is an opioid blocker that can help used for medical decision making. In this case, relying on prevent relapse in patients with opioid use disorder when a negative DTC result to conclude that no further testing is used in combination with other treatment measures, which needed (Option D) would be inappropriate. may include cognitive behavioral therapy, psychosocial sup- port, and additional medications (such as buprenorphine). Naltrexone will not directly prevent death from opioid over- ¢ Positive results on direct-to-consumer genetic tests dose, and its use is contraindicated in patients who are still should be confirmed with a clinical test before being taking opioids, as this patient is. used for medical decision making. Buprenorphine (Option D) is a partial opioid agonist * Clinical genetic testing is indicated for patients with a used to treat opioid use disorder by reducing cravings. It

physician order or prescription. DTC tests are not diagnostic forms for ease of administration. Naloxone acts within tests. The FDA recommends confirmation with clinical test- minutes and has a very short half-life; its antidote effects ing before DTC test results are used in patient care. Clinical will usually wear off before the opioid effects are gone. genetic testing is indicated for patients with a personal or Patients should be observed for signs of opioid withdrawal family history suggesting inherited cancer susceptibility; (which is not fatal and requires only supportive care) and however, patients should undergo genetic counseling first for continued or recurrent signs of respiratory distress to guide decision making. The basic components of genetic (which may require repeated dosing of naloxone). Accord- counseling are education on the condition being tested, ing to the CDC opioid prescribing guideline, clinicians including the natural history, possible treatments, and pre- should offer naloxone to any patient at risk for opioid ventive measures; the risks and benefits of testing; alter- overdose. This includes patients with a history of overdose natives to testing, including the option to forgo testing; the or substance use disorder, patients taking benzodiazepines implications for the patient and family members; and costs, with opioids (which should be avoided whenever possible), > including the possibility of denial of coverage for disability, and those taking more than 50 morphine milligram equiv- = wn long-term care, and life insurance. alents per day. In addition, naloxone should be provided = This patient’s family history strongly suggests a hered- to patients taking opioids who have risk factors for opi- @ = wn itary breast cancer syndrome, such as a BRCA1/2 mutation, oid-related harms; such patients include elderly persons, gy = but clinical practice guidelines recommend that genetic patients with mental health conditions, and patients at risk Qa testing (Option A) begin with a relative affected by a BRCA- for sleep-disordered breathing (such as those with heart im} =e associated cancer. In this case, testing would ideally begin failure, obstructive sleep apnea, or obesity), regardless of =. with the patient’s sister. In addition, this patient should oral morphine equivalents prescribed. This patient with 2 = undergo genetic counseling before testing is pursued. a history of overdose should be prescribed naloxone and oO 17) MRI of the breast (Option C) would be a reasonable educated on its proper use and ways to prevent overdose. screening modality in selected patients with a high lifetime Friends, family members, and caretakers may also receive risk for breast cancer, such as those with known BRCA1/2 prescriptions and training in naloxone use. mutations, starting at age 25 years. It is not a substitute for Clonidine (Option B) is an antihypertensive agent genetic counseling and, potentially, BRCA gene testing. that can assist in the management of symptoms of drug Some commercially available DTCs examine for only withdrawal. Clonidine will not prevent death from opioid 3 of more than 1000 known BRCA1/2 variants. Results on overdose. DTCs should be confirmed with a clinical test before being Naltrexone (Option C) is an opioid blocker that can help used for medical decision making. In this case, relying on prevent relapse in patients with opioid use disorder when a negative DTC result to conclude that no further testing is used in combination with other treatment measures, which needed (Option D) would be inappropriate. may include cognitive behavioral therapy, psychosocial sup- port, and additional medications (such as buprenorphine). Naltrexone will not directly prevent death from opioid over- ¢ Positive results on direct-to-consumer genetic tests dose, and its use is contraindicated in patients who are still should be confirmed with a clinical test before being taking opioids, as this patient is. used for medical decision making. Buprenorphine (Option D) is a partial opioid agonist * Clinical genetic testing is indicated for patients with a used to treat opioid use disorder by reducing cravings. It personal or family history suggesting inherited cancer must be administered by a certified physician as part of a

physician order or prescription. DTC tests are not diagnostic forms for ease of administration. Naloxone acts within tests. The FDA recommends confirmation with clinical test- minutes and has a very short half-life; its antidote effects ing before DTC test results are used in patient care. Clinical will usually wear off before the opioid effects are gone. genetic testing is indicated for patients with a personal or Patients should be observed for signs of opioid withdrawal family history suggesting inherited cancer susceptibility; (which is not fatal and requires only supportive care) and however, patients should undergo genetic counseling first for continued or recurrent signs of respiratory distress to guide decision making. The basic components of genetic (which may require repeated dosing of naloxone). Accord- counseling are education on the condition being tested, ing to the CDC opioid prescribing guideline, clinicians including the natural history, possible treatments, and pre- should offer naloxone to any patient at risk for opioid ventive measures; the risks and benefits of testing; alter- overdose. This includes patients with a history of overdose natives to testing, including the option to forgo testing; the or substance use disorder, patients taking benzodiazepines implications for the patient and family members; and costs, with opioids (which should be avoided whenever possible), > including the possibility of denial of coverage for disability, and those taking more than 50 morphine milligram equiv- = wn long-term care, and life insurance. alents per day. In addition, naloxone should be provided = This patient’s family history strongly suggests a hered- to patients taking opioids who have risk factors for opi- @ = wn itary breast cancer syndrome, such as a BRCA1/2 mutation, oid-related harms; such patients include elderly persons, gy = but clinical practice guidelines recommend that genetic patients with mental health conditions, and patients at risk Qa testing (Option A) begin with a relative affected by a BRCA- for sleep-disordered breathing (such as those with heart im} =e associated cancer. In this case, testing would ideally begin failure, obstructive sleep apnea, or obesity), regardless of =. with the patient’s sister. In addition, this patient should oral morphine equivalents prescribed. This patient with 2 = undergo genetic counseling before testing is pursued. a history of overdose should be prescribed naloxone and oO 17) MRI of the breast (Option C) would be a reasonable educated on its proper use and ways to prevent overdose. screening modality in selected patients with a high lifetime Friends, family members, and caretakers may also receive risk for breast cancer, such as those with known BRCA1/2 prescriptions and training in naloxone use. mutations, starting at age 25 years. It is not a substitute for Clonidine (Option B) is an antihypertensive agent genetic counseling and, potentially, BRCA gene testing. that can assist in the management of symptoms of drug Some commercially available DTCs examine for only withdrawal. Clonidine will not prevent death from opioid 3 of more than 1000 known BRCA1/2 variants. Results on overdose. DTCs should be confirmed with a clinical test before being Naltrexone (Option C) is an opioid blocker that can help used for medical decision making. In this case, relying on prevent relapse in patients with opioid use disorder when a negative DTC result to conclude that no further testing is used in combination with other treatment measures, which needed (Option D) would be inappropriate. may include cognitive behavioral therapy, psychosocial sup- port, and additional medications (such as buprenorphine). Naltrexone will not directly prevent death from opioid over- ¢ Positive results on direct-to-consumer genetic tests dose, and its use is contraindicated in patients who are still should be confirmed with a clinical test before being taking opioids, as this patient is. used for medical decision making. Buprenorphine (Option D) is a partial opioid agonist * Clinical genetic testing is indicated for patients with a used to treat opioid use disorder by reducing cravings. It personal or family history suggesting inherited cancer must be administered by a certified physician as part of a susceptibility. comprehensive treatment program for opioid use disorder and is most effective in combination with counseling ser-

personal or family history suggesting inherited cancer must be administered by a certified physician as part of a susceptibility. comprehensive treatment program for opioid use disorder and is most effective in combination with counseling ser- Bibliography vices. Buprenorphine will not directly prevent death from Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. opioid overdose. Risk assessment, genetic counseling, and genetic testing for BRCA- related cancer: US Preventive Services Task Force recommendation state- ment. JAMA. 2019;322:652-65. [PMID: 31429903] doi:10.1001/jama. 2019.10987 ¢ Naloxone is indicated for patients with a history of overdose or substance use disorder, as well as patients taking benzodiazepines with opioids, or more than 50 morphine milligram equivalents per day. Item 74 Answer: A Educational Objective: Prevent death from opioid ¢ Naloxone can be considered for patients taking opi-

Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. opioid overdose. Risk assessment, genetic counseling, and genetic testing for BRCA- related cancer: US Preventive Services Task Force recommendation state- ment. JAMA. 2019;322:652-65. [PMID: 31429903] doi:10.1001/jama. 2019.10987 ¢ Naloxone is indicated for patients with a history of overdose or substance use disorder, as well as patients taking benzodiazepines with opioids, or more than 50 morphine milligram equivalents per day. Item 74 Answer: A Educational Objective: Prevent death from opioid ¢ Naloxone can be considered for patients taking opi- overdose. oids who are older, have mental health disorders, or are at risk for sleep-disordered breathing. Intranasal naloxone (Option A) is the most appropriate pre- ventive measure for this patient. Naloxone is a nonselective and competitive opioid receptor blocker that reduces the Bibliography Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for risk for death from respiratory depression due to accidental chronic pain—United States, 2016. JAMA. 2016;315:1624-45. [PMID: opioid overdose. It is available in intranasal and injectable 26977696] doi:10.1001 /jama.2016.1464 170

Answers and Critiques Item 75 Answer: E Item 76 Answer: C Educational Objective: Treat cough secondary to ACE Educational Objective: Treat insomnia with brief inhibitor therapy. behavioral therapy for insomnia. Substituting amlodipine for lisinopril (Option E) is the most The most appropriate treatment for this patient is brief appropriate next step in management for this patient with behavioral therapy for insomnia (BBT-I) (Option C). Mul- subacute cough (3-8 weeks’ duration). Subacute cough is tiple guidelines now issue a strong recommendation that most often postinfectious after acute respiratory tract infec- cognitive behavioral therapy for insomnia (CBT-I) should be tion, particularly viral or Mycoplasma infection. It is usually the initial treatment for chronic insomnia; however, CBT-I is caused by postnasal drip or airway hyperreactivity. If infec- not available to many patients. The 2020 U.S. Department of tious causes of subacute cough are excluded, the evaluation Veterans Affairs and U.S. Department of Defense guidelines shifts to consideration of the causes of chronic cough. In the on the management of chronic insomnia disorder recom- absence of additional respiratory or constitutional symp- mend BBT-I as an alternative that may be more accessi- wn rt} toms, this patient’s cough is probably a side effect of the ble and less time consuming for patients. BBT-I focuses on r-

Substituting amlodipine for lisinopril (Option E) is the most The most appropriate treatment for this patient is brief appropriate next step in management for this patient with behavioral therapy for insomnia (BBT-I) (Option C). Mul- subacute cough (3-8 weeks’ duration). Subacute cough is tiple guidelines now issue a strong recommendation that most often postinfectious after acute respiratory tract infec- cognitive behavioral therapy for insomnia (CBT-I) should be tion, particularly viral or Mycoplasma infection. It is usually the initial treatment for chronic insomnia; however, CBT-I is caused by postnasal drip or airway hyperreactivity. If infec- not available to many patients. The 2020 U.S. Department of tious causes of subacute cough are excluded, the evaluation Veterans Affairs and U.S. Department of Defense guidelines shifts to consideration of the causes of chronic cough. In the on the management of chronic insomnia disorder recom- absence of additional respiratory or constitutional symp- mend BBT-I as an alternative that may be more accessi- wn rt} toms, this patient’s cough is probably a side effect of the ble and less time consuming for patients. BBT-I focuses on r- ACE inhibitor lisinopril. Up to 20% of patients who take an sleep restriction, stimulus control, and some sleep hygiene 3 ACE inhibitor develop a dry cough. Cough onset is usually techniques, whereas CBT-I also includes relaxation therapy, . s) within 2 weeks of ACE inhibitor initiation, but onset can counter-arousal strategies, and cognitive restructuring to a) < occur later in some patients. Cessation of lisinopril should address maladaptive thoughts or beliefs about sleep. These c relieve this patient’s cough within days, although the cough interventions can be delivered in person in an individual wn deo o can continue for weeks after the medication is stopped in or group setting, or via online or telephone-based mod- = a small number of patients. For patients who should con- ules. Data are insufficient to make recommendations on wn = tinue therapy with a renin-angiotensin system inhibitor, an the optimal delivery strategy, but most analyses have been =

ACE inhibitor lisinopril. Up to 20% of patients who take an sleep restriction, stimulus control, and some sleep hygiene 3 ACE inhibitor develop a dry cough. Cough onset is usually techniques, whereas CBT-I also includes relaxation therapy, . s) within 2 weeks of ACE inhibitor initiation, but onset can counter-arousal strategies, and cognitive restructuring to a) < occur later in some patients. Cessation of lisinopril should address maladaptive thoughts or beliefs about sleep. These c relieve this patient’s cough within days, although the cough interventions can be delivered in person in an individual wn deo o can continue for weeks after the medication is stopped in or group setting, or via online or telephone-based mod- = a small number of patients. For patients who should con- ules. Data are insufficient to make recommendations on wn = tinue therapy with a renin-angiotensin system inhibitor, an the optimal delivery strategy, but most analyses have been = angiotensin receptor blocker (ARB), such as losartan, can be performed on in-person interventions. substituted. Even in patients who have previously developed Certain environmental factors and patient behaviors, cough due to ACE inhibitor therapy, the use of an ARB is not such as daytime napping (Option A), may lead to difficulty associated with an increased incidence of cough. in falling asleep and poor sleep quality. Together, identi- Azithromycin (Option A) and erythromycin have anti- fication and correction of these factors and behaviors is neutrophil and antimicrobial effects. These agents have been known as sleep hygiene. Addressing sleep hygiene is part tested in patients with chronic productive cough with puru- of BBT-I and CBT-I. Evidence supporting sleep hygiene as lent sputum but are ineffective in treatment of subacute effective standalone therapy for chronic insomnia is not cough unrelated to bacterial infection. available. The 2020 U.S. Department of Veterans Affairs For subacute cough, chest imaging (Option B) would be and U.S. Department of Defense guidelines on chronic reasonable ifthe cough continues for a few weeks after lisinopril insomnia recommend against sleep hygiene education as a is stopped. In patients with acute cough (<3 weeks’ duration), standalone treatment for chronic insomnia, given this lack accompanying symptoms that are mostly respiratory and con- of evidence. stitutional suggest a lower respiratory tract infection, and chest Avoidance of watching television before attempting radiography may be warranted. Pneumonia is an unlikely cause sleep (Option B) is also recommended as part of a sleep of subacute cough, and chest radiography is not indicated in the hygiene program, although whether this factor contributes absence of abnormal vital signs or lung examination findings. to insomnia or poor sleep quality is unknown. This issue Protussives, such as guaifenesin (Option C), may may be addressed in patients who are participating in BBT-I, enhance mucus clearance in some patients experiencing but it should not be recommended as a single therapeutic productive cough but would be unlikely to improve a dry intervention for this patient. cough associated with an ACE inhibitor. Pharmacotherapy is second-line treatment for insomnia Spirometry (Option D) is useful for diagnosis of chronic and should be reserved for patients who have not responded cough (>8 weeks’ duration) as part of a stepped approach to nonpharmacologic therapies. There is limited evidence to diagnosis. Spirometry could be considered if the cough for efficacy of many over-the-counter sleep aids, including persists after discontinuation of lisinopril. melatonin (Option D). Sleep restriction therapy (Option E), which entails lim- iting the amount of time in bed to increase sleep efficiency, e Up to 20% of patients who take an ACE inhibitor is a component of BBT-I and CBT-I. Like improving sleep develop a dry cough, and stopping the offending hygiene, it is not recommended as a standalone therapy. medication usually relieves the cough within days.

angiotensin receptor blocker (ARB), such as losartan, can be performed on in-person interventions. substituted. Even in patients who have previously developed Certain environmental factors and patient behaviors, cough due to ACE inhibitor therapy, the use of an ARB is not such as daytime napping (Option A), may lead to difficulty associated with an increased incidence of cough. in falling asleep and poor sleep quality. Together, identi- Azithromycin (Option A) and erythromycin have anti- fication and correction of these factors and behaviors is neutrophil and antimicrobial effects. These agents have been known as sleep hygiene. Addressing sleep hygiene is part tested in patients with chronic productive cough with puru- of BBT-I and CBT-I. Evidence supporting sleep hygiene as lent sputum but are ineffective in treatment of subacute effective standalone therapy for chronic insomnia is not cough unrelated to bacterial infection. available. The 2020 U.S. Department of Veterans Affairs For subacute cough, chest imaging (Option B) would be and U.S. Department of Defense guidelines on chronic reasonable ifthe cough continues for a few weeks after lisinopril insomnia recommend against sleep hygiene education as a is stopped. In patients with acute cough (<3 weeks’ duration), standalone treatment for chronic insomnia, given this lack accompanying symptoms that are mostly respiratory and con- of evidence. stitutional suggest a lower respiratory tract infection, and chest Avoidance of watching television before attempting radiography may be warranted. Pneumonia is an unlikely cause sleep (Option B) is also recommended as part of a sleep of subacute cough, and chest radiography is not indicated in the hygiene program, although whether this factor contributes absence of abnormal vital signs or lung examination findings. to insomnia or poor sleep quality is unknown. This issue Protussives, such as guaifenesin (Option C), may may be addressed in patients who are participating in BBT-I, enhance mucus clearance in some patients experiencing but it should not be recommended as a single therapeutic productive cough but would be unlikely to improve a dry intervention for this patient. cough associated with an ACE inhibitor. Pharmacotherapy is second-line treatment for insomnia Spirometry (Option D) is useful for diagnosis of chronic and should be reserved for patients who have not responded cough (>8 weeks’ duration) as part of a stepped approach to nonpharmacologic therapies. There is limited evidence to diagnosis. Spirometry could be considered if the cough for efficacy of many over-the-counter sleep aids, including persists after discontinuation of lisinopril. melatonin (Option D). Sleep restriction therapy (Option E), which entails lim- iting the amount of time in bed to increase sleep efficiency, e Up to 20% of patients who take an ACE inhibitor is a component of BBT-I and CBT-I. Like improving sleep develop a dry cough, and stopping the offending hygiene, it is not recommended as a standalone therapy. medication usually relieves the cough within days. ¢ Brief behavioral therapy for insomnia is an alternative Bibliography to cognitive behavioral therapy for first-line treatment Irwin RS, French CL, Chang AB, et al; CHEST Expert Cough Panel. Classification of cough as a symptom in adults and management algo- of chronic insomnia. rithms: CHEST guideline and expert panel report. Chest. 2018;153:196- (Continued) 209. [PMID: 29080708] doi:10.1016/j.chest.2017.10.016

¢ Brief behavioral therapy for insomnia is an alternative Bibliography to cognitive behavioral therapy for first-line treatment Irwin RS, French CL, Chang AB, et al; CHEST Expert Cough Panel. Classification of cough as a symptom in adults and management algo- of chronic insomnia. rithms: CHEST guideline and expert panel report. Chest. 2018;153:196- (Continued) 209. [PMID: 29080708] doi:10.1016/j.chest.2017.10.016 171

Anewers end Ergues Bibliography Evens A, Vendetta L, Krebs K, et al. Medically unexplained neurologic symp- e Sleep hygiene may be used as a component of behav- toms: a primer for physicians who make the initial encounter. AmJ Med. ioral therapies for insomnia but has not been shown to 2015;128:1059-64. [PMID: 25910791] doi:10.1016/j.amjmed.2015.03.030 be effective as a standalone therapy for chronic insomnia.

Bibliography Evens A, Vendetta L, Krebs K, et al. Medically unexplained neurologic symp- e Sleep hygiene may be used as a component of behav- toms: a primer for physicians who make the initial encounter. AmJ Med. ioral therapies for insomnia but has not been shown to 2015;128:1059-64. [PMID: 25910791] doi:10.1016/j.amjmed.2015.03.030 be effective as a standalone therapy for chronic insomnia. Item 78 Answer: B Bibliography Educational Objective: Diagnose sciatica in a pregnant Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. patient. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] This patient most likely has radiculopathy of the sciatic nerve doi:10.7326/M19-3575 (Option B), commonly known as sciatica. One quarter to one third of women experience some hip pain during pregnancy; the most common causes are sciatica, sacroiliitis, and round Pa Item 77 Answer: A = ligament pain. Hip pain in pregnancy is caused by a combina- 7) Educational Objective: Evaluate new symptoms ina tion of factors, including an enlarging uterus, which increases = @o patient with medically unexplained symptoms. the mechanical load to the hip joints, and loosening or laxity of = wn a The most appropriate management is CT of the abdomen the ligaments of the sacroiliac joints due to relaxin and estro- = t= 5 and pelvis (Option A). This patient’s chronic gastrointestinal gens, which contribute to joint hypermobility and widening of oO symptoms have changed significantly. Further evaluation the symphysis pubis, which in turn alters the pelvic architec- ae =A with imaging is warranted. In patients with medically unex- ture. Sciatic nerve compression in the lumbosacral spine leads a =} to pain, tingling, and numbness that radiate into the leg. t= plained symptoms (MUS), each presenting symptom merits oO wn a relevant history and physical examination. In most cases, Hip osteoarthritis (Option A) causes pain that begins in previous records should be reviewed before the evaluation the hip joint and radiates to the groin, not the buttocks. Range

Item 78 Answer: B Bibliography Educational Objective: Diagnose sciatica in a pregnant Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. patient. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] This patient most likely has radiculopathy of the sciatic nerve doi:10.7326/M19-3575 (Option B), commonly known as sciatica. One quarter to one third of women experience some hip pain during pregnancy; the most common causes are sciatica, sacroiliitis, and round Pa Item 77 Answer: A = ligament pain. Hip pain in pregnancy is caused by a combina- 7) Educational Objective: Evaluate new symptoms ina tion of factors, including an enlarging uterus, which increases = @o patient with medically unexplained symptoms. the mechanical load to the hip joints, and loosening or laxity of = wn a The most appropriate management is CT of the abdomen the ligaments of the sacroiliac joints due to relaxin and estro- = t= 5 and pelvis (Option A). This patient’s chronic gastrointestinal gens, which contribute to joint hypermobility and widening of oO symptoms have changed significantly. Further evaluation the symphysis pubis, which in turn alters the pelvic architec- ae =A with imaging is warranted. In patients with medically unex- ture. Sciatic nerve compression in the lumbosacral spine leads a =} to pain, tingling, and numbness that radiate into the leg. t= plained symptoms (MUS), each presenting symptom merits oO wn a relevant history and physical examination. In most cases, Hip osteoarthritis (Option A) causes pain that begins in previous records should be reviewed before the evaluation the hip joint and radiates to the groin, not the buttocks. Range is repeated or extended unless the patient’s condition has of motion is usually limited, and even passive range of motion

Item 78 Answer: B Bibliography Educational Objective: Diagnose sciatica in a pregnant Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. patient. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] This patient most likely has radiculopathy of the sciatic nerve doi:10.7326/M19-3575 (Option B), commonly known as sciatica. One quarter to one third of women experience some hip pain during pregnancy; the most common causes are sciatica, sacroiliitis, and round Pa Item 77 Answer: A = ligament pain. Hip pain in pregnancy is caused by a combina- 7) Educational Objective: Evaluate new symptoms ina tion of factors, including an enlarging uterus, which increases = @o patient with medically unexplained symptoms. the mechanical load to the hip joints, and loosening or laxity of = wn a The most appropriate management is CT of the abdomen the ligaments of the sacroiliac joints due to relaxin and estro- = t= 5 and pelvis (Option A). This patient’s chronic gastrointestinal gens, which contribute to joint hypermobility and widening of oO symptoms have changed significantly. Further evaluation the symphysis pubis, which in turn alters the pelvic architec- ae =A with imaging is warranted. In patients with medically unex- ture. Sciatic nerve compression in the lumbosacral spine leads a =} to pain, tingling, and numbness that radiate into the leg. t= plained symptoms (MUS), each presenting symptom merits oO wn a relevant history and physical examination. In most cases, Hip osteoarthritis (Option A) causes pain that begins in previous records should be reviewed before the evaluation the hip joint and radiates to the groin, not the buttocks. Range is repeated or extended unless the patient’s condition has of motion is usually limited, and even passive range of motion significantly changed. If new symptoms arise or symptoms can reproduce pain. This patient’s normal range of motion and

Item 78 Answer: B Bibliography Educational Objective: Diagnose sciatica in a pregnant Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insom- nia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. patient. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172:325-36. [PMID: 32066145] This patient most likely has radiculopathy of the sciatic nerve doi:10.7326/M19-3575 (Option B), commonly known as sciatica. One quarter to one third of women experience some hip pain during pregnancy; the most common causes are sciatica, sacroiliitis, and round Pa Item 77 Answer: A = ligament pain. Hip pain in pregnancy is caused by a combina- 7) Educational Objective: Evaluate new symptoms ina tion of factors, including an enlarging uterus, which increases = @o patient with medically unexplained symptoms. the mechanical load to the hip joints, and loosening or laxity of = wn a The most appropriate management is CT of the abdomen the ligaments of the sacroiliac joints due to relaxin and estro- = t= 5 and pelvis (Option A). This patient’s chronic gastrointestinal gens, which contribute to joint hypermobility and widening of oO symptoms have changed significantly. Further evaluation the symphysis pubis, which in turn alters the pelvic architec- ae =A with imaging is warranted. In patients with medically unex- ture. Sciatic nerve compression in the lumbosacral spine leads a =} to pain, tingling, and numbness that radiate into the leg. t= plained symptoms (MUS), each presenting symptom merits oO wn a relevant history and physical examination. In most cases, Hip osteoarthritis (Option A) causes pain that begins in previous records should be reviewed before the evaluation the hip joint and radiates to the groin, not the buttocks. Range is repeated or extended unless the patient’s condition has of motion is usually limited, and even passive range of motion significantly changed. If new symptoms arise or symptoms can reproduce pain. This patient’s normal range of motion and change, clinicians should respond empathically and perform positive straight leg raise test make hip osteoarthritis unlikely.

is repeated or extended unless the patient’s condition has of motion is usually limited, and even passive range of motion significantly changed. If new symptoms arise or symptoms can reproduce pain. This patient’s normal range of motion and change, clinicians should respond empathically and perform positive straight leg raise test make hip osteoarthritis unlikely. an appropriately thorough investigation. This patient has Round ligament pain (Option C) is a common cause of new symptoms after a period of relative stability. The new hip pain during pregnancy, especially in the second trimester. symptoms are associated with a significant “red flag” of It is characterized by sharp pains in the abdomen, hip, and weight loss and should not be dismissed. Advanced imaging groin area, intensifying with rapid movements or changes in is a reasonable starting point in the evaluation of this patient. position. The pain does not radiate, and the straight leg raise Patients with MUS often have mental health comorbid- test is normal in patients with round ligament pain. ities, including a high prevalence of depression and anxiety. Sacroiliitis (Option D), or inflammation of the sacroiliac Screening for these disorders (Option B) is helpful because joints, may occur as an isolated musculoskeletal condition or appropriate treatment often improves patient symptoms and as part of a spondyloarthritis. Pregnancy, leg length discrep- function. However, onset of new abdominal pain after a period ancies, scoliosis, and lumbar fixation increase risk for sacro- of stability associated with abdominal tenderness to palpation iliitis. On physical examination, there is pain with palpation and weight loss signals the possibility of a condition other than of the sacroiliac joint; however, passive range of motion is depression, and additional investigation is required. unaffected, and straight and contralateral leg raise tests pro- A tenet of a healing therapeutic relationship is that the duce no pain. The diagnosis of sacroiliitis is more likely with

and weight loss signals the possibility of a condition other than of the sacroiliac joint; however, passive range of motion is depression, and additional investigation is required. unaffected, and straight and contralateral leg raise tests pro- A tenet of a healing therapeutic relationship is that the duce no pain. The diagnosis of sacroiliitis is more likely with physician helps the patient explore the relationship between a positive FABER test, in which pain is reproduced when the psychological stressors and symptoms (Option C), particu- hip is Flexed, ABducted, and Externally Rotated. larly symptoms that appear to be functional (i.e., without a clear understanding of the medical basis for the symptoms). e Sciatica is characterized by sciatic nerve compression This patient’s new symptom is probably not functional given in the lumbosacral spine, leading to pain, tingling, the history and physical findings, and a direct approach at and numbness that radiate into the leg. finding an underlying cause is of highest priority. Nortriptyline (Option D) is often prescribed for patients with chronic pain syndromes, including fibromyalgia, Bibliography Kesikburun S, Giizelkiiciik U, Fidan U, et al. Musculoskeletal pain and nonulcer dyspepsia, and irritable bowel syndrome. However, symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. this patient will benefit from a careful evaluation of the new 2018;10:229-34. [PMID: 30515249] doi:10.1177/1759720X18812449 pain before symptom-directed therapy is prescribed.

larly symptoms that appear to be functional (i.e., without a clear understanding of the medical basis for the symptoms). e Sciatica is characterized by sciatic nerve compression This patient’s new symptom is probably not functional given in the lumbosacral spine, leading to pain, tingling, the history and physical findings, and a direct approach at and numbness that radiate into the leg. finding an underlying cause is of highest priority. Nortriptyline (Option D) is often prescribed for patients with chronic pain syndromes, including fibromyalgia, Bibliography Kesikburun S, Giizelkiiciik U, Fidan U, et al. Musculoskeletal pain and nonulcer dyspepsia, and irritable bowel syndrome. However, symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. this patient will benefit from a careful evaluation of the new 2018;10:229-34. [PMID: 30515249] doi:10.1177/1759720X18812449 pain before symptom-directed therapy is prescribed. Item 79 Answer: D e Patients with medically unexplained symptoms should Educational Objective: Diagnose a labral tear. be evaluated carefully and appropriately when new This patient has a labral tear (Option D), specifically a tear of symptoms arise. the superior labrum anterior and posterior (SLAP). A SLAP 172

_Answers and Critiques tear is an injury to the glenoid labrum, the fibrocartilagi- activity. In patients with persistently debilitating symptoms nous rim around the margin of the glenoid cavity, leading despite maximal medical therapy, nonpharmacologic treat- to biceps tendon instability and a feeling of instability of ment strategies, such as pursed lip breathing, and devices the joint. SLAP tears are most common in patients older than that enhance airflow, such as a handheld fan, are the least 40 years who engage in repetitive overhead activities, such as invasive and easiest to administer to reduce the severity of weightlifting or throwing. Pain is often deep and difficult to dyspnea. localize and worsens with repetition of the overhead move- Chest physiotherapy (Option A) can assist with secre- ment. Patients report crepitus, catching of the joint with tion management in patients with lung diseases, such as movement, and overall joint instability. cystic fibrosis and bronchiectasis. Chest physiotherapy Acromioclavicular joint degeneration (Option A) causes would not relieve refractory dyspnea in a patient who is not poorly localized shoulder pain, although pain may be local- experiencing problematic secretions. ized to the acromioclavicular joint in some patients. Strength Monotherapy with a respiratory fluoroquinolone, such and range of motion are typically normal. Pain is reproduced as levofloxacin (Option C), is appropriate treatment for a 4] o with palpation of the joint, adduction of the arm across patient with evidence of a lower respiratory tract infection. =] the body (cross-arm test), and shoulder abduction beyond Presentation of infection would typically include dyspnea nH 120 degrees. with cough, increased sputum production, and fever. An - cs) Adhesive capsulitis (Option B), or frozen shoulder, is infectious process is unlikely in this patient, and an antibi- Zs another source of poorly localized deep or aching pain. It otic would not improve dyspnea in a patient with no infec- © Los} typically presents with decreased active and passive range tious signs or symptoms. 2 of motion and pain with movement in all directions. This Pulmonary rehabilitation (Option D) is an essential o = patient’s symptoms of joint instability, crepitus, clicking, and component of management of severe COPD. Patients with ” S pain with only specific movements are not consistent with refractory COPD symptoms should be encouraged to partici- et adhesive capsulitis. pate in pulmonary rehabilitation. The benefits of pulmonary Tendinopathy of the long head of the biceps (Option rehabilitation decline over time; however, the optimal role, C) can result from repetitive lifting and carrying. Biceps intensity, and timing of periodic retraining of patients to tendinopathy typically presents with pain localized to the sustain the initial gains have yet to be defined. This patient anterior shoulder, radiating toward the deltoid. As with a has recently participated in pulmonary rehabilitation with SLAP lesion, pain is elicited with overhead activities that a degree of improvement in symptoms. It is unlikely that put stress on the shoulder. On physical examination, pain is repeating pulmonary rehabilitation at this time would be reproduced by palpating the long head of the biceps tendon beneficial. in the bicipital groove or by placing the patient’s ipsilateral arm at his or her side while flexing the elbow to 90 degrees and supinating against resistance. ¢ In patients with persistently debilitating dyspnea despite maximal medical therapy, nonpharmacologic treatment strategies, such as pursed lip breathing, and e Superior labrum anterior and posterior (SLAP) lesions devices that enhance airflow are the least invasive and are often caused by repetitive overhead stress; patients easiest to administer to reduce severity of symptoms. present with deep anterolateral shoulder pain that

tear is an injury to the glenoid labrum, the fibrocartilagi- activity. In patients with persistently debilitating symptoms nous rim around the margin of the glenoid cavity, leading despite maximal medical therapy, nonpharmacologic treat- to biceps tendon instability and a feeling of instability of ment strategies, such as pursed lip breathing, and devices the joint. SLAP tears are most common in patients older than that enhance airflow, such as a handheld fan, are the least 40 years who engage in repetitive overhead activities, such as invasive and easiest to administer to reduce the severity of weightlifting or throwing. Pain is often deep and difficult to dyspnea. localize and worsens with repetition of the overhead move- Chest physiotherapy (Option A) can assist with secre- ment. Patients report crepitus, catching of the joint with tion management in patients with lung diseases, such as movement, and overall joint instability. cystic fibrosis and bronchiectasis. Chest physiotherapy Acromioclavicular joint degeneration (Option A) causes would not relieve refractory dyspnea in a patient who is not poorly localized shoulder pain, although pain may be local- experiencing problematic secretions. ized to the acromioclavicular joint in some patients. Strength Monotherapy with a respiratory fluoroquinolone, such and range of motion are typically normal. Pain is reproduced as levofloxacin (Option C), is appropriate treatment for a 4] o with palpation of the joint, adduction of the arm across patient with evidence of a lower respiratory tract infection. =] the body (cross-arm test), and shoulder abduction beyond Presentation of infection would typically include dyspnea nH 120 degrees. with cough, increased sputum production, and fever. An - cs) Adhesive capsulitis (Option B), or frozen shoulder, is infectious process is unlikely in this patient, and an antibi- Zs another source of poorly localized deep or aching pain. It otic would not improve dyspnea in a patient with no infec- © Los} typically presents with decreased active and passive range tious signs or symptoms. 2 of motion and pain with movement in all directions. This Pulmonary rehabilitation (Option D) is an essential o = patient’s symptoms of joint instability, crepitus, clicking, and component of management of severe COPD. Patients with ” S pain with only specific movements are not consistent with refractory COPD symptoms should be encouraged to partici- et adhesive capsulitis. pate in pulmonary rehabilitation. The benefits of pulmonary Tendinopathy of the long head of the biceps (Option rehabilitation decline over time; however, the optimal role, C) can result from repetitive lifting and carrying. Biceps intensity, and timing of periodic retraining of patients to tendinopathy typically presents with pain localized to the sustain the initial gains have yet to be defined. This patient anterior shoulder, radiating toward the deltoid. As with a has recently participated in pulmonary rehabilitation with SLAP lesion, pain is elicited with overhead activities that a degree of improvement in symptoms. It is unlikely that put stress on the shoulder. On physical examination, pain is repeating pulmonary rehabilitation at this time would be reproduced by palpating the long head of the biceps tendon beneficial. in the bicipital groove or by placing the patient’s ipsilateral arm at his or her side while flexing the elbow to 90 degrees and supinating against resistance. ¢ In patients with persistently debilitating dyspnea despite maximal medical therapy, nonpharmacologic treatment strategies, such as pursed lip breathing, and e Superior labrum anterior and posterior (SLAP) lesions devices that enhance airflow are the least invasive and are often caused by repetitive overhead stress; patients easiest to administer to reduce severity of symptoms. present with deep anterolateral shoulder pain that worsens with abduction and external rotation. Bibliography Barnes-Harris M, Allgar V, Booth S, et al. Battery operated fan and chronic

tear is an injury to the glenoid labrum, the fibrocartilagi- activity. In patients with persistently debilitating symptoms nous rim around the margin of the glenoid cavity, leading despite maximal medical therapy, nonpharmacologic treat- to biceps tendon instability and a feeling of instability of ment strategies, such as pursed lip breathing, and devices the joint. SLAP tears are most common in patients older than that enhance airflow, such as a handheld fan, are the least 40 years who engage in repetitive overhead activities, such as invasive and easiest to administer to reduce the severity of weightlifting or throwing. Pain is often deep and difficult to dyspnea. localize and worsens with repetition of the overhead move- Chest physiotherapy (Option A) can assist with secre- ment. Patients report crepitus, catching of the joint with tion management in patients with lung diseases, such as movement, and overall joint instability. cystic fibrosis and bronchiectasis. Chest physiotherapy Acromioclavicular joint degeneration (Option A) causes would not relieve refractory dyspnea in a patient who is not poorly localized shoulder pain, although pain may be local- experiencing problematic secretions. ized to the acromioclavicular joint in some patients. Strength Monotherapy with a respiratory fluoroquinolone, such and range of motion are typically normal. Pain is reproduced as levofloxacin (Option C), is appropriate treatment for a 4] o with palpation of the joint, adduction of the arm across patient with evidence of a lower respiratory tract infection. =] the body (cross-arm test), and shoulder abduction beyond Presentation of infection would typically include dyspnea nH 120 degrees. with cough, increased sputum production, and fever. An - cs) Adhesive capsulitis (Option B), or frozen shoulder, is infectious process is unlikely in this patient, and an antibi- Zs another source of poorly localized deep or aching pain. It otic would not improve dyspnea in a patient with no infec- © Los} typically presents with decreased active and passive range tious signs or symptoms. 2 of motion and pain with movement in all directions. This Pulmonary rehabilitation (Option D) is an essential o = patient’s symptoms of joint instability, crepitus, clicking, and component of management of severe COPD. Patients with ” S pain with only specific movements are not consistent with refractory COPD symptoms should be encouraged to partici- et adhesive capsulitis. pate in pulmonary rehabilitation. The benefits of pulmonary Tendinopathy of the long head of the biceps (Option rehabilitation decline over time; however, the optimal role, C) can result from repetitive lifting and carrying. Biceps intensity, and timing of periodic retraining of patients to tendinopathy typically presents with pain localized to the sustain the initial gains have yet to be defined. This patient anterior shoulder, radiating toward the deltoid. As with a has recently participated in pulmonary rehabilitation with SLAP lesion, pain is elicited with overhead activities that a degree of improvement in symptoms. It is unlikely that put stress on the shoulder. On physical examination, pain is repeating pulmonary rehabilitation at this time would be reproduced by palpating the long head of the biceps tendon beneficial. in the bicipital groove or by placing the patient’s ipsilateral arm at his or her side while flexing the elbow to 90 degrees and supinating against resistance. ¢ In patients with persistently debilitating dyspnea despite maximal medical therapy, nonpharmacologic treatment strategies, such as pursed lip breathing, and e Superior labrum anterior and posterior (SLAP) lesions devices that enhance airflow are the least invasive and are often caused by repetitive overhead stress; patients easiest to administer to reduce severity of symptoms. present with deep anterolateral shoulder pain that worsens with abduction and external rotation. Bibliography Barnes-Harris M, Allgar V, Booth S, et al. Battery operated fan and chronic Bibliography breathlessness: does it help?. BMJ Support Palliat Care. 2019;9:478-81. [PMID: 31068332] doi:10.1136/bmjspcare-2018-001749 Knesek M, Skendzel JG, Dines JS, et al. Diagnosis and management of supe- rior labral anterior posterior tears in throwing athletes. Am J Sports Med. 2013;41:444-60. [PMID: 23172004] doi:10.1177/0363546512466067

Bibliography breathlessness: does it help?. BMJ Support Palliat Care. 2019;9:478-81. [PMID: 31068332] doi:10.1136/bmjspcare-2018-001749 Knesek M, Skendzel JG, Dines JS, et al. Diagnosis and management of supe- rior labral anterior posterior tears in throwing athletes. Am J Sports Med. 2013;41:444-60. [PMID: 23172004] doi:10.1177/0363546512466067 Item 81 Answer: D Educational Objective: Diagnose urinary tract infection Item 80 Answer: B in a patient with acute urinary incontinence. Educational Objective: Treat refractory dyspnea in The most appropriate management is urinalysis (Option advanced lung disease. D). Acute-onset urinary incontinence may indicate the Use of a handheld fan (Option B) is the most appropriate presence of a transient, reversible cause. Common causes next step in treating this patient’s worsening dyspnea in of acute, transient incontinence include medications (e.g., the setting of severe COPD. Studies have shown that use of loop diuretics, sodium-glucose cotransporter-2 inhibitors, a handheld fan reduces breathlessness in this patient pop- o-blockers) and urinary tract infection (UTI). Additional ulation and has no adverse effects; a handheld fan should causes may include acute urine retention and overflow be considered in all patients with refractory dyspnea. In incontinence, excessively concentrated urine (a bladder some studies, up to 85% of patients report improvement in irritant), stool impaction, delirium, and impaired mobility. dyspnea and half of patients report an increase in physical UTI should be suspected in any individual with transient 173

Answers and Critiques incontinence, and urinalysis should be performed to rule out test, positive shoulder abduction test). Cervical radiculopa- infection. Although dysuria or hematuria can accompany thy may be managed conservatively as long as symptoms do UTI, absence of such symptoms does not exclude infection. not progress or become refractory. A multimodal approach Bladder training with timed voiding (Option A) is first- that is tailored to the individual patient should be pursued line treatment for urge incontinence, which is characterized and may include analgesic agents, range-of-motion exercise, by urine leakage preceded by a sudden urge to void. It com- and physical therapy. Symptoms generally improve in 6 to prises scheduled voiding attempts at intervals shorter than 8 weeks. the usual time between incontinence episodes, regardless of Use of a cervical collar (Option A) for neck pain should the urge to void, with a gradual increase in the time between be discouraged because it may delay improvement in neck voids. If an episode of urgency occurs before the designated pain and mobility. voiding time, patients are encouraged to use pelvic floor MRI of the cervical spine (Option B) provides anatomic muscle contraction until the urge passes and then pro- information about the spinal cord, nerve roots, intervertebral = ceed with voiding directly afterward. Although this patient’s disks, surrounding soft tissue, ligamentous structures, and = wn symptoms are consistent with urge incontinence, the acute vertebral arteries. It is indicated if myelopathy is suspected, = onset of incontinence suggests a transient, reversible cause, suspicion for cancer or infection is high, or neurologic @o = wn and infection must first be ruled out before any targeted symptoms progress despite conservative therapy. Given the my = therapies are prescribed. absence of red flag findings that raise suspicion for cancer Q. Pelvic floor muscle training (Kegel exercises) (Option B) or infection (e.g., trauma, fevers, chills, injection drug use, (=) =e is effective first-line therapy for stress incontinence, which or immunosuppression), MRI is unnecessary in this patient =. is typically characterized by incontinence after increased at this time. 2 © intra-abdominal pressure, such as that caused by sneezing, Oral and topical NSAIDs are first-line pharmacologic @o n laughing, bearing down, or coughing. This patient’s symp- therapy for neck pain. Owing to their potential for abuse, toms are not consistent with stress urinary incontinence. opioids, such as oxycodone (Option D), should be avoided Vaginal estrogen formulations (Option C) are a sec- in the treatment of musculoskeletal neck pain, especially in ond-line treatment for stress incontinence, particularly in a patient with a history of opioid use. women with additional genitourinary symptoms of meno- Radiography (Option E) is helpful in evaluating the bony pause, such as dryness and dyspareunia; however, UTI structures of the spine and is therefore useful in patients sus- should be ruled out before initiating therapies for any form pected of having a fracture, metastatic disease, osteomyelitis, of urinary incontinence. If a reversible cause is not iden- or diskitis. In this patient with cervical radiculopathy, there tified, behavioral therapy (pelvic floor muscle training or is no indication for radiography. bladder training) and weight loss, if appropriate, are first- line therapies for most causes of incontinence. ¢ Cervical radiculopathy is suggested by the finding of, singly or in combination, pain in the neck, shoulder, e Acute-onset urinary incontinence may indicate the or arms; upper extremity muscle weakness; reduced presence of a transient, reversible cause. reflexes; or paresthesia. ¢ Common causes of acute, transient urinary incontinence * Cervical radiculopathy may be managed conservatively include medications and urinary tract infection. with simple analgesia, exercises, and physical therapy as long as symptoms do not progress. Bibliography Vaughan CP, Markland AD. Urinary incontinence in women. Ann Intern Bibliography Med. 2020;172:ITC17-32. [PMID: 32016335] doi:10.7326/AITC202002040 Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev Musculoskelet Med. 2016;9:272-80. [PMID: 27250042] doi:10.1007/s12178-016-9349-4

incontinence, and urinalysis should be performed to rule out test, positive shoulder abduction test). Cervical radiculopa- infection. Although dysuria or hematuria can accompany thy may be managed conservatively as long as symptoms do UTI, absence of such symptoms does not exclude infection. not progress or become refractory. A multimodal approach Bladder training with timed voiding (Option A) is first- that is tailored to the individual patient should be pursued line treatment for urge incontinence, which is characterized and may include analgesic agents, range-of-motion exercise, by urine leakage preceded by a sudden urge to void. It com- and physical therapy. Symptoms generally improve in 6 to prises scheduled voiding attempts at intervals shorter than 8 weeks. the usual time between incontinence episodes, regardless of Use of a cervical collar (Option A) for neck pain should the urge to void, with a gradual increase in the time between be discouraged because it may delay improvement in neck voids. If an episode of urgency occurs before the designated pain and mobility. voiding time, patients are encouraged to use pelvic floor MRI of the cervical spine (Option B) provides anatomic muscle contraction until the urge passes and then pro- information about the spinal cord, nerve roots, intervertebral = ceed with voiding directly afterward. Although this patient’s disks, surrounding soft tissue, ligamentous structures, and = wn symptoms are consistent with urge incontinence, the acute vertebral arteries. It is indicated if myelopathy is suspected, = onset of incontinence suggests a transient, reversible cause, suspicion for cancer or infection is high, or neurologic @o = wn and infection must first be ruled out before any targeted symptoms progress despite conservative therapy. Given the my = therapies are prescribed. absence of red flag findings that raise suspicion for cancer Q. Pelvic floor muscle training (Kegel exercises) (Option B) or infection (e.g., trauma, fevers, chills, injection drug use, (=) =e is effective first-line therapy for stress incontinence, which or immunosuppression), MRI is unnecessary in this patient =. is typically characterized by incontinence after increased at this time. 2 © intra-abdominal pressure, such as that caused by sneezing, Oral and topical NSAIDs are first-line pharmacologic @o n laughing, bearing down, or coughing. This patient’s symp- therapy for neck pain. Owing to their potential for abuse, toms are not consistent with stress urinary incontinence. opioids, such as oxycodone (Option D), should be avoided Vaginal estrogen formulations (Option C) are a sec- in the treatment of musculoskeletal neck pain, especially in ond-line treatment for stress incontinence, particularly in a patient with a history of opioid use. women with additional genitourinary symptoms of meno- Radiography (Option E) is helpful in evaluating the bony pause, such as dryness and dyspareunia; however, UTI structures of the spine and is therefore useful in patients sus- should be ruled out before initiating therapies for any form pected of having a fracture, metastatic disease, osteomyelitis, of urinary incontinence. If a reversible cause is not iden- or diskitis. In this patient with cervical radiculopathy, there tified, behavioral therapy (pelvic floor muscle training or is no indication for radiography. bladder training) and weight loss, if appropriate, are first- line therapies for most causes of incontinence. ¢ Cervical radiculopathy is suggested by the finding of, singly or in combination, pain in the neck, shoulder, e Acute-onset urinary incontinence may indicate the or arms; upper extremity muscle weakness; reduced presence of a transient, reversible cause. reflexes; or paresthesia. ¢ Common causes of acute, transient urinary incontinence * Cervical radiculopathy may be managed conservatively include medications and urinary tract infection. with simple analgesia, exercises, and physical therapy as long as symptoms do not progress. Bibliography Vaughan CP, Markland AD. Urinary incontinence in women. Ann Intern Bibliography Med. 2020;172:ITC17-32. [PMID: 32016335] doi:10.7326/AITC202002040 Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev Musculoskelet Med. 2016;9:272-80. [PMID: 27250042] doi:10.1007/s12178-016-9349-4 Item 82 Answer: C

incontinence, and urinalysis should be performed to rule out test, positive shoulder abduction test). Cervical radiculopa- infection. Although dysuria or hematuria can accompany thy may be managed conservatively as long as symptoms do UTI, absence of such symptoms does not exclude infection. not progress or become refractory. A multimodal approach Bladder training with timed voiding (Option A) is first- that is tailored to the individual patient should be pursued line treatment for urge incontinence, which is characterized and may include analgesic agents, range-of-motion exercise, by urine leakage preceded by a sudden urge to void. It com- and physical therapy. Symptoms generally improve in 6 to prises scheduled voiding attempts at intervals shorter than 8 weeks. the usual time between incontinence episodes, regardless of Use of a cervical collar (Option A) for neck pain should the urge to void, with a gradual increase in the time between be discouraged because it may delay improvement in neck voids. If an episode of urgency occurs before the designated pain and mobility. voiding time, patients are encouraged to use pelvic floor MRI of the cervical spine (Option B) provides anatomic muscle contraction until the urge passes and then pro- information about the spinal cord, nerve roots, intervertebral = ceed with voiding directly afterward. Although this patient’s disks, surrounding soft tissue, ligamentous structures, and = wn symptoms are consistent with urge incontinence, the acute vertebral arteries. It is indicated if myelopathy is suspected, = onset of incontinence suggests a transient, reversible cause, suspicion for cancer or infection is high, or neurologic @o = wn and infection must first be ruled out before any targeted symptoms progress despite conservative therapy. Given the my = therapies are prescribed. absence of red flag findings that raise suspicion for cancer Q. Pelvic floor muscle training (Kegel exercises) (Option B) or infection (e.g., trauma, fevers, chills, injection drug use, (=) =e is effective first-line therapy for stress incontinence, which or immunosuppression), MRI is unnecessary in this patient =. is typically characterized by incontinence after increased at this time. 2 © intra-abdominal pressure, such as that caused by sneezing, Oral and topical NSAIDs are first-line pharmacologic @o n laughing, bearing down, or coughing. This patient’s symp- therapy for neck pain. Owing to their potential for abuse, toms are not consistent with stress urinary incontinence. opioids, such as oxycodone (Option D), should be avoided Vaginal estrogen formulations (Option C) are a sec- in the treatment of musculoskeletal neck pain, especially in ond-line treatment for stress incontinence, particularly in a patient with a history of opioid use. women with additional genitourinary symptoms of meno- Radiography (Option E) is helpful in evaluating the bony pause, such as dryness and dyspareunia; however, UTI structures of the spine and is therefore useful in patients sus- should be ruled out before initiating therapies for any form pected of having a fracture, metastatic disease, osteomyelitis, of urinary incontinence. If a reversible cause is not iden- or diskitis. In this patient with cervical radiculopathy, there tified, behavioral therapy (pelvic floor muscle training or is no indication for radiography. bladder training) and weight loss, if appropriate, are first- line therapies for most causes of incontinence. ¢ Cervical radiculopathy is suggested by the finding of, singly or in combination, pain in the neck, shoulder, e Acute-onset urinary incontinence may indicate the or arms; upper extremity muscle weakness; reduced presence of a transient, reversible cause. reflexes; or paresthesia. ¢ Common causes of acute, transient urinary incontinence * Cervical radiculopathy may be managed conservatively include medications and urinary tract infection. with simple analgesia, exercises, and physical therapy as long as symptoms do not progress. Bibliography Vaughan CP, Markland AD. Urinary incontinence in women. Ann Intern Bibliography Med. 2020;172:ITC17-32. [PMID: 32016335] doi:10.7326/AITC202002040 Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev Musculoskelet Med. 2016;9:272-80. [PMID: 27250042] doi:10.1007/s12178-016-9349-4 Item 82 Answer: C Educational Objective: Treat cervical radiculopathy Item 83 Answer: B with neck exercises. Educational Objective: Screen for depression in an elderly patient. The most appropriate treatment for this patient’s neck pain is conservative therapy with neck exercises (Option C). Radic- This older patient has symptoms suggestive of depression, ulopathy is the result of any pathologic process that affects and the most appropriate diagnostic test to perform next the nerve root. Cervical radiculopathy is suggested by the is depression assessment (Option B). Depression can pre- finding of, singly or in combination, pain in the neck, shoul- sent as cognitive impairment or worsening of preexisting der, or arms; upper extremity muscle weakness; reduced cognitive impairment. Symptoms of depression, includ- reflexes; or paresthesia. This patient probably has cervi- ing somatic symptoms; fatigue/low energy; and cognitive cal radiculopathy, on the basis of the history and physical symptoms, such as decreased concentration and psycho- examination findings (neck pain with radiation to the arm, motor agitation or retardation, are often misattributed to paresthesia in a dermatomal distribution, positive Spurling chronic illness or cognitive impairment. All patients being

Educational Objective: Treat cervical radiculopathy Item 83 Answer: B with neck exercises. Educational Objective: Screen for depression in an elderly patient. The most appropriate treatment for this patient’s neck pain is conservative therapy with neck exercises (Option C). Radic- This older patient has symptoms suggestive of depression, ulopathy is the result of any pathologic process that affects and the most appropriate diagnostic test to perform next the nerve root. Cervical radiculopathy is suggested by the is depression assessment (Option B). Depression can pre- finding of, singly or in combination, pain in the neck, shoul- sent as cognitive impairment or worsening of preexisting der, or arms; upper extremity muscle weakness; reduced cognitive impairment. Symptoms of depression, includ- reflexes; or paresthesia. This patient probably has cervi- ing somatic symptoms; fatigue/low energy; and cognitive cal radiculopathy, on the basis of the history and physical symptoms, such as decreased concentration and psycho- examination findings (neck pain with radiation to the arm, motor agitation or retardation, are often misattributed to paresthesia in a dermatomal distribution, positive Spurling chronic illness or cognitive impairment. All patients being 174

Saswers and Sriquae evaluated for cognitive impairment should also be screened affected side. Many examination maneuvers are available for for depression. Both the Geriatric Depression Scale and rotator cuff disease assessment. The painful arc test consists the PHQ-9 have acceptable sensitivity and specificity for of the patient performing full abduction of the arm; pain detecting depression in older patients. There are effective that occurs between 60 degrees and 120 degrees supports treatments for depression that can alleviate suffering and the diagnosis of rotator cuff tendinopathy. The painful arc improve functioning. test has the highest positive likelihood ratio (3.7) of all test- Formal neuropsychological testing (Option A) provides a ing maneuvers for rotator cuff tendinopathy. A rotator cuff more thorough assessment of cognitive function than office- tear should be suspected when the pain is complicated by based clinical assessments but is more time-consuming and weakness in external rotation or abduction or the patient costly. Detailed neuropsychological testing is especially use- is unable to lower the arm smoothly from a fully abducted ful for the following patients: those with milder cognitive position (positive drop arm test). Rotator cuff tendinopa- symptoms, to determine whether the cognitive difficulties thy is more common in patients older than 50 years who are within the realm of normal age-associated cognitive have repetitive overhead stress to the shoulder. Initial ther- wn rH} decline versus mild cognitive impairment; those with defi- apy includes rest, acetaminophen, and physical therapy to =

evaluated for cognitive impairment should also be screened affected side. Many examination maneuvers are available for for depression. Both the Geriatric Depression Scale and rotator cuff disease assessment. The painful arc test consists the PHQ-9 have acceptable sensitivity and specificity for of the patient performing full abduction of the arm; pain detecting depression in older patients. There are effective that occurs between 60 degrees and 120 degrees supports treatments for depression that can alleviate suffering and the diagnosis of rotator cuff tendinopathy. The painful arc improve functioning. test has the highest positive likelihood ratio (3.7) of all test- Formal neuropsychological testing (Option A) provides a ing maneuvers for rotator cuff tendinopathy. A rotator cuff more thorough assessment of cognitive function than office- tear should be suspected when the pain is complicated by based clinical assessments but is more time-consuming and weakness in external rotation or abduction or the patient costly. Detailed neuropsychological testing is especially use- is unable to lower the arm smoothly from a fully abducted ful for the following patients: those with milder cognitive position (positive drop arm test). Rotator cuff tendinopa- symptoms, to determine whether the cognitive difficulties thy is more common in patients older than 50 years who are within the realm of normal age-associated cognitive have repetitive overhead stress to the shoulder. Initial ther- wn rH} decline versus mild cognitive impairment; those with defi- apy includes rest, acetaminophen, and physical therapy to = nite dementia, diagnosed on the basis of clinical impression strengthen the rotator cuff muscles and improve flexibility. Pi 7 and results of screening cognitive tests, who have clinical Glucocorticoid injection (Option A) may provide short- oO features overlapping two or more underlying pathologic pro- term pain relief in patients with rotator cuff tendinopathy, sc = cesses; and those with cognitive symptoms whose clinical but repeated injections may cause tendon rupture or tear. ] wn picture is confounded by significant depression. However, Glucocorticoid injection combined with local anesthetic a o screening for and potentially treating depression should should be considered for significant pain that interferes with = ” occur before considering neuropsychological testing in this either sleep or function despite simple analgesia. ©

nite dementia, diagnosed on the basis of clinical impression strengthen the rotator cuff muscles and improve flexibility. Pi 7 and results of screening cognitive tests, who have clinical Glucocorticoid injection (Option A) may provide short- oO features overlapping two or more underlying pathologic pro- term pain relief in patients with rotator cuff tendinopathy, sc = cesses; and those with cognitive symptoms whose clinical but repeated injections may cause tendon rupture or tear. ] wn picture is confounded by significant depression. However, Glucocorticoid injection combined with local anesthetic a o screening for and potentially treating depression should should be considered for significant pain that interferes with = ” occur before considering neuropsychological testing in this either sleep or function despite simple analgesia. © patient. MRI of the shoulder (Option B) should be obtained if =

nite dementia, diagnosed on the basis of clinical impression strengthen the rotator cuff muscles and improve flexibility. Pi 7 and results of screening cognitive tests, who have clinical Glucocorticoid injection (Option A) may provide short- oO features overlapping two or more underlying pathologic pro- term pain relief in patients with rotator cuff tendinopathy, sc = cesses; and those with cognitive symptoms whose clinical but repeated injections may cause tendon rupture or tear. ] wn picture is confounded by significant depression. However, Glucocorticoid injection combined with local anesthetic a o screening for and potentially treating depression should should be considered for significant pain that interferes with = ” occur before considering neuropsychological testing in this either sleep or function despite simple analgesia. © patient. MRI of the shoulder (Option B) should be obtained if = MRI of the brain (Option C) supports the diagnosis of there is concern for an acute full-thickness rotator cuff tear, Alzheimer disease when it shows evidence of decreased which should be managed with immediate surgery. Chronic volume of the hippocampi out of proportion to rest of the or slowly progressive rotator cuff disease does not require brain. Advanced brain imaging should not be obtained in imaging in most cases. Given the subacute nature of this this patient before she is assessed for depression, a reversible patient’s presentation and lack of concerning examination cause of cognitive impairment. findings, it is appropriate to diagnose the patient without Vitamin B,, measurement (Option D) is reasonable in further testing. patients with new cognitive decline and other clinical symp- Immobilizing the shoulder (Option D) for nonoperative toms or examination findings consistent with this diagnosis. reasons can lead to adhesive capsulitis (frozen shoulder) and However, on the basis of the patient’s history of recently hav- therefore should be avoided. ing been widowed, plus symptoms of insomnia and anhe- donia, depression is more likely than vitamin B,, deficiency, and depression screening should occur first. e Pain that occurs between 60 degrees and 120 degrees during passive abduction of the arm (positive painful are test) has the highest positive likelihood ratio (3.7) e All patients being evaluated for cognitive impairment of all testing maneuvers for rotator cuff tendinopathy. should also be screened for depression. ¢ Initial management of rotator cuff tendinopathy includes e The Geriatric Depression Scale and the PHQ-9 have rest, acetaminophen, and physical therapy to strengthen acceptable sensitivity and specificity for detecting the rotator cuff muscles and improve flexibility. depression in older patients.

MRI of the brain (Option C) supports the diagnosis of there is concern for an acute full-thickness rotator cuff tear, Alzheimer disease when it shows evidence of decreased which should be managed with immediate surgery. Chronic volume of the hippocampi out of proportion to rest of the or slowly progressive rotator cuff disease does not require brain. Advanced brain imaging should not be obtained in imaging in most cases. Given the subacute nature of this this patient before she is assessed for depression, a reversible patient’s presentation and lack of concerning examination cause of cognitive impairment. findings, it is appropriate to diagnose the patient without Vitamin B,, measurement (Option D) is reasonable in further testing. patients with new cognitive decline and other clinical symp- Immobilizing the shoulder (Option D) for nonoperative toms or examination findings consistent with this diagnosis. reasons can lead to adhesive capsulitis (frozen shoulder) and However, on the basis of the patient’s history of recently hav- therefore should be avoided. ing been widowed, plus symptoms of insomnia and anhe- donia, depression is more likely than vitamin B,, deficiency, and depression screening should occur first. e Pain that occurs between 60 degrees and 120 degrees during passive abduction of the arm (positive painful are test) has the highest positive likelihood ratio (3.7) e All patients being evaluated for cognitive impairment of all testing maneuvers for rotator cuff tendinopathy. should also be screened for depression. ¢ Initial management of rotator cuff tendinopathy includes e The Geriatric Depression Scale and the PHQ-9 have rest, acetaminophen, and physical therapy to strengthen acceptable sensitivity and specificity for detecting the rotator cuff muscles and improve flexibility. depression in older patients. Bibliography Bibliography Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med. 2015;162:ITC1-15. [PMID:25560729] doi:10.7326/AITC201501060 Kok RM, Reynolds CF 3rd. Management of depression in older adults: a review. JAMA. 2017;317:2114-22. [PMID: 28535241] doi:10.1001/jama. 2017.5706 Item 85 Answer: C Educational Objective: Treat generalized anxiety Item 84 Answer: C disorder. Educational Objective: Treat rotator cuff tendinopathy. The most appropriate management is initiation of paroxetine This patient most likely has supraspinatus tendinopathy, (Option C). This patient has generalized anxiety disorder the most common type of rotator cuff tendinopathy, and (GAD), which is characterized by excessive anxiety about should undergo physical therapy (Option C). Pain from rota- activities or events (occupation, school) that a patient finds tor cuff disease is frequently localized to the upper arm near difficult to control and occurs more days than not for at least the deltoid insertion; is worsened with overhead activities; 6 months. These symptoms cause significant distress and and is often worse at night, particularly when lying on the functional impairment. Diagnosis also requires the presence

Bibliography Bibliography Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med. 2015;162:ITC1-15. [PMID:25560729] doi:10.7326/AITC201501060 Kok RM, Reynolds CF 3rd. Management of depression in older adults: a review. JAMA. 2017;317:2114-22. [PMID: 28535241] doi:10.1001/jama. 2017.5706 Item 85 Answer: C Educational Objective: Treat generalized anxiety Item 84 Answer: C disorder. Educational Objective: Treat rotator cuff tendinopathy. The most appropriate management is initiation of paroxetine This patient most likely has supraspinatus tendinopathy, (Option C). This patient has generalized anxiety disorder the most common type of rotator cuff tendinopathy, and (GAD), which is characterized by excessive anxiety about should undergo physical therapy (Option C). Pain from rota- activities or events (occupation, school) that a patient finds tor cuff disease is frequently localized to the upper arm near difficult to control and occurs more days than not for at least the deltoid insertion; is worsened with overhead activities; 6 months. These symptoms cause significant distress and and is often worse at night, particularly when lying on the functional impairment. Diagnosis also requires the presence 175

Gaswers aod Eritiquee: of three of the following physical symptoms: restlessness, doses, has controlled blood pressure and type 2 diabetes mel- being easily fatigued, irritability, muscle tension, sleep dis- litus, and has initiated lifestyle interventions to help decrease turbance, and difficulty concentrating. Clinicians must rule his risk for cardiovascular complications. Nonetheless, his out physiologic effects of another medical condition (e.g., LDL cholesterol level remains elevated. The American Heart hyperthyroidism; substance abuse; medication effect; and Association (AHA)/American College of Cardiology (ACC) symptom-driven anxiety, such as anxiety secondary to guideline on the management of blood cholesterol recom- dyspnea). Patients with significant anxiety or multiple unex- mends considering the addition of a PCSK9 inhibitor in plained physical symptoms should be screened for GAD by patients aged 40 to 75 years with a baseline LDL choles- using the GAD-7 screening tool. This patient’s GAD-7 score terol level of 220 mg/dL (5.70 mmol/L) or higher and who of 16 indicates severe anxiety. Cognitive behavioral therapy achieve an on-treatment LDL cholesterol level of 130 mg/dL (CBT), selective serotonin reuptake inhibitors (SSRIs), selec- (3.37 mmol/L) or higher while receiving maximally toler- tive serotonin-norepinephrine reuptake inhibitors (SNRIs), ated statin and ezetimibe therapy. The PCSK9 inhibitors are > buspirone, and tricyclic antidepressants are all effective monoclonal antibodies that bind to serine protease PCSK9, a J n treatment options for GAD, and CBT is often used in combi- liver enzyme that degrades hepatocyte LDL receptors. PCSK9 = nation with pharmacotherapy. SSRIs and SNRIs are preferred inhibitors reduce LDL cholesterol by 50% to 60%. According @ first-line agents because they have fewer side effects than tri- to AHA/ACC guidelines, this patient should continue sta- = ” fo cyclic antidepressants and are effective in treating comorbid tin therapy in addition to initiating PCSK9 inhibitor ther- = a. mood disorders when present. Paroxetine, an SSRI, is an apy. The 2020 U.S. Department of Veterans Affairs and U.S. (o) mae appropriate pharmacologic choice for this patient. Department of Defense cholesterol guideline, in contrast to =, Although often prescribed, benzodiazepines, such as AHA/ACC guidelines, does not recommend PCSK9 inhibitor 2 t alprazolam (Option A), should be used only for short-term therapy for primary prevention because of inconclusive evi- @ n control of severe anxiety symptoms during the initial treat- dence of benefit and high cost. ment phase of GAD. Adverse effects and risk for addiction Fenofibrate (Option A) is not effective at lowering LDL preclude longer-term use (>2-4 weeks). Benzodiazepines cholesterol levels and has no role as an adjunct to maximally should be avoided in patients with a history of substance use tolerated statin therapy for individuals at high risk for ath- disorder, such as this patient. erosclerotic cardiovascular disease (ASCVD). Tricyclic antidepressants, such as amitriptyline (Option Icosapent ethyl (Option B) is a highly purified eico- B), are an option for patients who cannot tolerate other sapentaenoic acid ethyl ester (fish oil). In patients with hyper- medications. However, these are not the best first choice triglyceridemia and ASCVD or in patients aged 50 years because of the potential for adverse effects (e.g., anticho- and older with hypertriglyceridemia, diabetes mellitus, and linergic effects; somnolence; and cardiac effects, such as one additional ASCVD risk factor, treatment with statins orthostatic hypotension and QT prolongation). and icosapent ethyl was associated with a 25% relative risk This patient meets diagnostic criteria for GAD with reduction in the composite end point of cardiovascular functional impairment and should receive treatment now death, nonfatal myocardial infarction, nonfatal stroke, coro- rather than undergoing repeat GAD-7 assessment in 1 month nary revascularization, or unstable angina. This patient does (Option D). not have an indication for icosapent ethyl therapy. Niacin (Option C) no longer has a role in dyslipidemia treatment. It has modest capacity to lower LDL cholesterol, e Preferred treatment options for generalized anxiety but evidence from randomized clinical trials does not sup- disorder include cognitive behavioral therapy, selective port its role as add-on therapy to statins. serotonin reuptake inhibitors, and selective serotonin- norepinephrine reuptake inhibitors. e The addition of a proprotein convertase subtilisin/kexin e Cognitive behavioral therapy can be used in combination type 9 (PCSK9) inhibitor for primary prevention of ath- with pharmacotherapy for generalized anxiety disorder. erosclerotic cardiovascular disease can be considered in patients aged 40 to 75 years with a baseline LDL choles- Bibliography terol level of 220 mg/dL (5.70 mmol/L) or higher and DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170:ITC49-64. [PMID: 30934083] doi:10.7326/AITC201904020 who achieve an on-treatment LDL cholesterol level of 130 mg/dL (3.37 mmol/L) or higher while receiving

of three of the following physical symptoms: restlessness, doses, has controlled blood pressure and type 2 diabetes mel- being easily fatigued, irritability, muscle tension, sleep dis- litus, and has initiated lifestyle interventions to help decrease turbance, and difficulty concentrating. Clinicians must rule his risk for cardiovascular complications. Nonetheless, his out physiologic effects of another medical condition (e.g., LDL cholesterol level remains elevated. The American Heart hyperthyroidism; substance abuse; medication effect; and Association (AHA)/American College of Cardiology (ACC) symptom-driven anxiety, such as anxiety secondary to guideline on the management of blood cholesterol recom- dyspnea). Patients with significant anxiety or multiple unex- mends considering the addition of a PCSK9 inhibitor in plained physical symptoms should be screened for GAD by patients aged 40 to 75 years with a baseline LDL choles- using the GAD-7 screening tool. This patient’s GAD-7 score terol level of 220 mg/dL (5.70 mmol/L) or higher and who of 16 indicates severe anxiety. Cognitive behavioral therapy achieve an on-treatment LDL cholesterol level of 130 mg/dL (CBT), selective serotonin reuptake inhibitors (SSRIs), selec- (3.37 mmol/L) or higher while receiving maximally toler- tive serotonin-norepinephrine reuptake inhibitors (SNRIs), ated statin and ezetimibe therapy. The PCSK9 inhibitors are > buspirone, and tricyclic antidepressants are all effective monoclonal antibodies that bind to serine protease PCSK9, a J n treatment options for GAD, and CBT is often used in combi- liver enzyme that degrades hepatocyte LDL receptors. PCSK9 = nation with pharmacotherapy. SSRIs and SNRIs are preferred inhibitors reduce LDL cholesterol by 50% to 60%. According @ first-line agents because they have fewer side effects than tri- to AHA/ACC guidelines, this patient should continue sta- = ” fo cyclic antidepressants and are effective in treating comorbid tin therapy in addition to initiating PCSK9 inhibitor ther- = a. mood disorders when present. Paroxetine, an SSRI, is an apy. The 2020 U.S. Department of Veterans Affairs and U.S. (o) mae appropriate pharmacologic choice for this patient. Department of Defense cholesterol guideline, in contrast to =, Although often prescribed, benzodiazepines, such as AHA/ACC guidelines, does not recommend PCSK9 inhibitor 2 t alprazolam (Option A), should be used only for short-term therapy for primary prevention because of inconclusive evi- @ n control of severe anxiety symptoms during the initial treat- dence of benefit and high cost. ment phase of GAD. Adverse effects and risk for addiction Fenofibrate (Option A) is not effective at lowering LDL preclude longer-term use (>2-4 weeks). Benzodiazepines cholesterol levels and has no role as an adjunct to maximally should be avoided in patients with a history of substance use tolerated statin therapy for individuals at high risk for ath- disorder, such as this patient. erosclerotic cardiovascular disease (ASCVD). Tricyclic antidepressants, such as amitriptyline (Option Icosapent ethyl (Option B) is a highly purified eico- B), are an option for patients who cannot tolerate other sapentaenoic acid ethyl ester (fish oil). In patients with hyper- medications. However, these are not the best first choice triglyceridemia and ASCVD or in patients aged 50 years because of the potential for adverse effects (e.g., anticho- and older with hypertriglyceridemia, diabetes mellitus, and linergic effects; somnolence; and cardiac effects, such as one additional ASCVD risk factor, treatment with statins orthostatic hypotension and QT prolongation). and icosapent ethyl was associated with a 25% relative risk This patient meets diagnostic criteria for GAD with reduction in the composite end point of cardiovascular functional impairment and should receive treatment now death, nonfatal myocardial infarction, nonfatal stroke, coro- rather than undergoing repeat GAD-7 assessment in 1 month nary revascularization, or unstable angina. This patient does (Option D). not have an indication for icosapent ethyl therapy. Niacin (Option C) no longer has a role in dyslipidemia treatment. It has modest capacity to lower LDL cholesterol, e Preferred treatment options for generalized anxiety but evidence from randomized clinical trials does not sup- disorder include cognitive behavioral therapy, selective port its role as add-on therapy to statins. serotonin reuptake inhibitors, and selective serotonin- norepinephrine reuptake inhibitors. e The addition of a proprotein convertase subtilisin/kexin e Cognitive behavioral therapy can be used in combination type 9 (PCSK9) inhibitor for primary prevention of ath- with pharmacotherapy for generalized anxiety disorder. erosclerotic cardiovascular disease can be considered in patients aged 40 to 75 years with a baseline LDL choles- Bibliography terol level of 220 mg/dL (5.70 mmol/L) or higher and DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170:ITC49-64. [PMID: 30934083] doi:10.7326/AITC201904020 who achieve an on-treatment LDL cholesterol level of 130 mg/dL (3.37 mmol/L) or higher while receiving Item 86 maximally tolerated statin and ezetimibe therapy. Answer: D Educational Objective: Treat statin-resistant dyslipid- emia with a proprotein convertase subtilisin/kexin type 9 Bibliography (PCSK9) inhibitor. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management The most appropriate treatment is a proprotein convertase of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. subtilisin/kexin type 9 (PCSK9) inhibitor (Option D). This Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. patient is receiving the maximum statin and ezetimibe 0000000000000625

Item 86 maximally tolerated statin and ezetimibe therapy. Answer: D Educational Objective: Treat statin-resistant dyslipid- emia with a proprotein convertase subtilisin/kexin type 9 Bibliography (PCSK9) inhibitor. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management The most appropriate treatment is a proprotein convertase of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. subtilisin/kexin type 9 (PCSK9) inhibitor (Option D). This Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. patient is receiving the maximum statin and ezetimibe 0000000000000625 176

Answers and Critiques Item 87 Answer: C low energy and activity levels, weakness, and slow walking speed. Frailty is associated with increased mortality, and Educational Objective: Assess a patient’s understanding many surgical and medical interventions have associated of his or her illnesses before eliciting goals of care. poor prognosis in patients with frailty. However, age is not The most appropriate next step in eliciting this patient’s goals synonymous with frailty. Frailty can be assessed with objec- of care is to inquire what she has been told about the status of tive measurement of walking speed and grip strength, but her current illnesses (Option C). This patient has significant several validated scales based on symptom self-report are functional decline, recurrent hospitalizations, and a progres- also available. Patients in a pre-frail stage may benefit from sive illness with an associated poor prognosis. The goal of optimization of nutrition and functional status. Strategies any further conversation is to better understand the patient’s include muscle strengthening, nutritional supplementation, goals, preferences, and values. This information will allow and addressing mood disorders and polypharmacy. The time her clinical team to make appropriate recommendations to benefit with these interventions can be weeks to months. about care plans and treatment recommendations to help Physical therapy with knee strengthening exercises wn a the patient accomplish these goals within the context of her (Option B) is often the best therapeutic intervention for =

Item 87 Answer: C low energy and activity levels, weakness, and slow walking speed. Frailty is associated with increased mortality, and Educational Objective: Assess a patient’s understanding many surgical and medical interventions have associated of his or her illnesses before eliciting goals of care. poor prognosis in patients with frailty. However, age is not The most appropriate next step in eliciting this patient’s goals synonymous with frailty. Frailty can be assessed with objec- of care is to inquire what she has been told about the status of tive measurement of walking speed and grip strength, but her current illnesses (Option C). This patient has significant several validated scales based on symptom self-report are functional decline, recurrent hospitalizations, and a progres- also available. Patients in a pre-frail stage may benefit from sive illness with an associated poor prognosis. The goal of optimization of nutrition and functional status. Strategies any further conversation is to better understand the patient’s include muscle strengthening, nutritional supplementation, goals, preferences, and values. This information will allow and addressing mood disorders and polypharmacy. The time her clinical team to make appropriate recommendations to benefit with these interventions can be weeks to months. about care plans and treatment recommendations to help Physical therapy with knee strengthening exercises wn a the patient accomplish these goals within the context of her (Option B) is often the best therapeutic intervention for = current and future medical reality. Identifying what patients osteoarthritis of the knee. However, physical therapy alone ACHE understand about their prognosis is critical to determining he would not be expected to restore the patient’s functional sta- cs) next steps for information sharing and prognostic disclosures. tus. Frailty assessment will identify needs and suggest inter- sc = Physician Orders for Life-Sustaining Treatment (POLST) ventions that go beyond addressing arthritis of a single joint. o

current and future medical reality. Identifying what patients osteoarthritis of the knee. However, physical therapy alone ACHE understand about their prognosis is critical to determining he would not be expected to restore the patient’s functional sta- cs) next steps for information sharing and prognostic disclosures. tus. Frailty assessment will identify needs and suggest inter- sc = Physician Orders for Life-Sustaining Treatment (POLST) ventions that go beyond addressing arthritis of a single joint. o and Medical Orders for Life-Sustaining Treatment (MOLST) The Timed Up and Go Test (Option C) is an assessment wn Cd o are order forms that allow clinicians to document the results intended to evaluate fall risk and is not a component of = of conversations about patient goals as well as the recom- frailty assessment. This patient does not report falls or fear wn = mendations for end-of-life care that result from these conver- of falling. <=

and Medical Orders for Life-Sustaining Treatment (MOLST) The Timed Up and Go Test (Option C) is an assessment wn Cd o are order forms that allow clinicians to document the results intended to evaluate fall risk and is not a component of = of conversations about patient goals as well as the recom- frailty assessment. This patient does not report falls or fear wn = mendations for end-of-life care that result from these conver- of falling. <= sations. It would not be appropriate to document the patient’s Knee replacement surgery (Option D) may ultimately preferences (Option A) until there is a better understanding be needed to maintain this patient’s mobility and indepen- of the patient’s goals in the context of her expected prognosis. dence if knee strengthening does not result in the desired Before moving forward with a conversation regarding outcome. However, a frailty assessment provides an oppor- care preferences and pathways, sharing prognostic infor- tunity to obtain valuable prognostic information and opti- mation (Option B) will be an important next step. After the mize nutritional and functional status to ensure the best patient is apprised of the prognosis, she can engage fully possible outcome for the patient in the event of surgery. in a conversation about care options. However, proceed- ing with disclosure without knowledge of what the patient understands about her illnesses and how much prognostic e Unintentional weight loss, low energy, low activity information she wishes to receive does not allow for a fully levels, weakness, and slow walking speed in an informed discussion. elderly patient could indicate the presence of frailty, It is important to discuss resuscitation preferences and frailty assessment should be performed. (Option D) with patients with serious illness; however, this discussion should occur after the clinician understands the Bibliography patient’s goals and prognostic information has been shared. Walston J, Buta B, Xue QL. Frailty screening and interventions: considera- tions for clinical practice. Clin Geriatr Med. 2018;34:25-38. [PMID: 29129215] doi:10.1016 /j.cger.2017.09.004

sations. It would not be appropriate to document the patient’s Knee replacement surgery (Option D) may ultimately preferences (Option A) until there is a better understanding be needed to maintain this patient’s mobility and indepen- of the patient’s goals in the context of her expected prognosis. dence if knee strengthening does not result in the desired Before moving forward with a conversation regarding outcome. However, a frailty assessment provides an oppor- care preferences and pathways, sharing prognostic infor- tunity to obtain valuable prognostic information and opti- mation (Option B) will be an important next step. After the mize nutritional and functional status to ensure the best patient is apprised of the prognosis, she can engage fully possible outcome for the patient in the event of surgery. in a conversation about care options. However, proceed- ing with disclosure without knowledge of what the patient understands about her illnesses and how much prognostic e Unintentional weight loss, low energy, low activity information she wishes to receive does not allow for a fully levels, weakness, and slow walking speed in an informed discussion. elderly patient could indicate the presence of frailty, It is important to discuss resuscitation preferences and frailty assessment should be performed. (Option D) with patients with serious illness; however, this discussion should occur after the clinician understands the Bibliography patient’s goals and prognostic information has been shared. Walston J, Buta B, Xue QL. Frailty screening and interventions: considera- tions for clinical practice. Clin Geriatr Med. 2018;34:25-38. [PMID: 29129215] doi:10.1016 /j.cger.2017.09.004 e Serious illness and end-of-life discussions should begin with an assessment of patients’ understanding Item 89 Answer: C of their health and prognosis before goals, preferences, and values are elicited. Educational Objective: Diagnose a personality disorder.

e Serious illness and end-of-life discussions should begin with an assessment of patients’ understanding Item 89 Answer: C of their health and prognosis before goals, preferences, and values are elicited. Educational Objective: Diagnose a personality disorder. Personality disorder (Option C) is the most likely diagnosis Bibliography in this patient. A personality disorder is characterized by Lakin JR, Block SD, Billings JA, et al. Improving communication about seri- persistent patterns of inner experiences and behaviors that ous illness in primary care: a review. JAMA Intern Med. 2016;176:1380-7. [PMID: 27398990] doi:10.1001/jamainternmed.2016.3212 digress substantially from the expectations of the affected person’s culture. Personality disorders are manifested by extreme behavior traits that cause clear difficulties in the Item 88 Answer: A lives and relationships of patients. These disorders can be divided into subtypes based on clusters of specific behav- Educational Objective: Screen for frailty to optimize iors. In this case, the patient describes multiple problematic clinical management. relationships (ex-spouse, roommate, former psychiatrist), The most appropriate management is to perform a frailty which is a clue to the diagnosis. assessment (Option A). Frailty is a multifactorial geriat- Bipolar disorder (Option A) is characterized by major ric syndrome characterized by unintentional weight loss, depressive episodes and periods of mania or hypomania. 177

ee eee Mania is clinically defined as an episode of at least 7 con- are poor metabolizers. Prodrugs require conversion to their secutive days of irritable, expansive, or elevated mood that active form; ultrarapid metabolizers will have increased drug interferes with social or occupational functioning and has levels, whereas poor metabolizers will have reduced levels. at least three of the following characteristics (four if the patient The most likely cause of this patient’s altered mental status reports irritable mood only): inflated self-esteem (grandiosity), is codeine toxicity. He has evidence of opioid toxicity on increased talkativeness, flight of ideas, distractibility, decreased physical examination, with miotic pupils and bradypnea sleep need, increased goal-directed activity, and excessive risk- that responded to naloxone. Codeine is a prodrug that is con- taking behaviors (promiscuity, spending sprees). This patient verted to morphine by the CYP2D6 enzyme; patients with does not fulfill any of the diagnostic criteria. a rapid or ultrarapid metabolizer phenotype, such as this Generalized anxiety disorder (Option B) is character- patient, are at increased risk for toxicity. Intake of CYP3A4 ized by excessive anxiety about activities or events (occu- inhibitors, such as diltiazem, ketoconazole, or grapefruit, pation, school) that a patient finds difficult to control and can also increase the risk for toxicity. > occurs more days than not for at least 6 months. The anxiety Polymorphisms in the thiopurine methyltransferase = wn causes significant distress and functional impairment. Diag- (TPMT) gene (Option B) are responsible for the metabolism = nosis requires the presence of three of the following physical of azathioprine and 6-mercaptopurine. Patients with low or @o = wn symptoms: restlessness, being easily fatigued, irritability, absent enzyme levels are at significantly increased risk for my muscle tension, sleep disturbance, and difficulty concen- bone marrow toxicity when prescribed these drugs. = on trating. The patient does not report any of these symptoms. Presence of the HLA-B*57:01 allele (Option C) is associ- a =e Schizophrenia (Option D) is a heterogeneous psychiat- ated with increased risk for hypersensitivity reaction when =. ric disorder composed of both positive symptoms (halluci- patients are prescribed abacavir; the FDA recommends test- 2 i=} nations, disorganized thought, and delusions) and negative ing before prescribing this drug. Oo an symptoms (flattened affect, decreased activity). The patient Presence of the HLA-B*58:01 allele (Option D) is asso- does not manifest the symptoms commonly associated with ciated with increased risk for severe cutaneous adverse reac- schizophrenia. tions when patients are prescribed allopurinol; the American College of Rheumatology conditionally recommends testing patients of Korean, Han Chinese, or Thai descent and Black e Personality disorders are manifested by extreme patients before prescribing allopurinol. behavior traits that cause clear difficulties in the lives and relationships of patients. ¢ Cytochrome P450 enzymes are primarily known for

Mania is clinically defined as an episode of at least 7 con- are poor metabolizers. Prodrugs require conversion to their secutive days of irritable, expansive, or elevated mood that active form; ultrarapid metabolizers will have increased drug interferes with social or occupational functioning and has levels, whereas poor metabolizers will have reduced levels. at least three of the following characteristics (four if the patient The most likely cause of this patient’s altered mental status reports irritable mood only): inflated self-esteem (grandiosity), is codeine toxicity. He has evidence of opioid toxicity on increased talkativeness, flight of ideas, distractibility, decreased physical examination, with miotic pupils and bradypnea sleep need, increased goal-directed activity, and excessive risk- that responded to naloxone. Codeine is a prodrug that is con- taking behaviors (promiscuity, spending sprees). This patient verted to morphine by the CYP2D6 enzyme; patients with does not fulfill any of the diagnostic criteria. a rapid or ultrarapid metabolizer phenotype, such as this Generalized anxiety disorder (Option B) is character- patient, are at increased risk for toxicity. Intake of CYP3A4 ized by excessive anxiety about activities or events (occu- inhibitors, such as diltiazem, ketoconazole, or grapefruit, pation, school) that a patient finds difficult to control and can also increase the risk for toxicity. > occurs more days than not for at least 6 months. The anxiety Polymorphisms in the thiopurine methyltransferase = wn causes significant distress and functional impairment. Diag- (TPMT) gene (Option B) are responsible for the metabolism = nosis requires the presence of three of the following physical of azathioprine and 6-mercaptopurine. Patients with low or @o = wn symptoms: restlessness, being easily fatigued, irritability, absent enzyme levels are at significantly increased risk for my muscle tension, sleep disturbance, and difficulty concen- bone marrow toxicity when prescribed these drugs. = on trating. The patient does not report any of these symptoms. Presence of the HLA-B*57:01 allele (Option C) is associ- a =e Schizophrenia (Option D) is a heterogeneous psychiat- ated with increased risk for hypersensitivity reaction when =. ric disorder composed of both positive symptoms (halluci- patients are prescribed abacavir; the FDA recommends test- 2 i=} nations, disorganized thought, and delusions) and negative ing before prescribing this drug. Oo an symptoms (flattened affect, decreased activity). The patient Presence of the HLA-B*58:01 allele (Option D) is asso- does not manifest the symptoms commonly associated with ciated with increased risk for severe cutaneous adverse reac- schizophrenia. tions when patients are prescribed allopurinol; the American College of Rheumatology conditionally recommends testing patients of Korean, Han Chinese, or Thai descent and Black e Personality disorders are manifested by extreme patients before prescribing allopurinol. behavior traits that cause clear difficulties in the lives and relationships of patients. ¢ Cytochrome P450 enzymes are primarily known for Bibliography their role in the oxidative metabolism of drugs. Combs G, Oshman L. Pearls for working with people who have personality e Significant pharmacokinetic alterations are most disorder diagnoses. Prim Care. 2016;43:263-8. [PMID: 27262006] doi:10. 1016/j.pop.2016.02.001 commonly caused by alleles in genes affecting the cytochrome P450 system.

Bibliography their role in the oxidative metabolism of drugs. Combs G, Oshman L. Pearls for working with people who have personality e Significant pharmacokinetic alterations are most disorder diagnoses. Prim Care. 2016;43:263-8. [PMID: 27262006] doi:10. 1016/j.pop.2016.02.001 commonly caused by alleles in genes affecting the cytochrome P450 system. Item 90 Answer: A Bibliography FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Educational Objective: Diagnose a pharmacogenetic Rheumatology guideline for the management of gout. Arthritis variant as a cause of an adverse drug reaction. Rheumatol. 2020;72:879-95. [PMID: 32390306] doi:10.1002/art.41247

Item 90 Answer: A Bibliography FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Educational Objective: Diagnose a pharmacogenetic Rheumatology guideline for the management of gout. Arthritis variant as a cause of an adverse drug reaction. Rheumatol. 2020;72:879-95. [PMID: 32390306] doi:10.1002/art.41247 Polymorphism of a cytochrome P450 gene (Option A) is most likely responsible for this patient’s adverse drug ltem 91 Answer: A reaction. Cytochrome P450 enzymes are primarily known Educational Objective: Treat systemic exertion for their role in the oxidative metabolism of drugs. Both intolerance disease. genetic and environmental factors can alter cytochrome P450 enzyme activity. Of the environmental factors, drug- A graded exercise program (Option A) is the most appropri- drug interactions are the most relevant to clinicians. Of ate treatment for this patient with symptoms consistent with the genetic factors, significant pharmacokinetic alterations systemic exertion intolerance disease (SEID), previously are most commonly caused by alleles in genes affecting known as chronic fatigue syndrome or myalgic encepha- the cytochrome P450 system, such as CYP2C19 or CYP2D6. lomyelitis. The diagnosis of SEID, based on criteria from Clinical phenotypes of these genetic variations are assigned the Institute of Medicine, requires the presence of fatigue on the basis of enzyme activity: poor metabolizer, inter- of at least 6 months’ duration with substantial reduction mediate metabolizer, extensive/normal metabolizer, rapid in pre-illness activities, postexertional malaise, unrefresh- metabolizer, and ultrarapid metabolizer. The effect of the ing sleep, and either cognitive impairment or orthostatic phenotype on a particular medication depends on whether intolerance. Although the pathophysiology of SEID remains the medication is an active drug or a prodrug. Levels of unclear, the phenomenon of central sensitization (the drugs taken in their active form are reduced in patients who pathophysiologic dysregulation of the thalamus, hypothal- are ultrarapid metabolizers and increased in patients who amus, and amygdala) is gaining acceptance as a potential

Polymorphism of a cytochrome P450 gene (Option A) is most likely responsible for this patient’s adverse drug ltem 91 Answer: A reaction. Cytochrome P450 enzymes are primarily known Educational Objective: Treat systemic exertion for their role in the oxidative metabolism of drugs. Both intolerance disease. genetic and environmental factors can alter cytochrome P450 enzyme activity. Of the environmental factors, drug- A graded exercise program (Option A) is the most appropri- drug interactions are the most relevant to clinicians. Of ate treatment for this patient with symptoms consistent with the genetic factors, significant pharmacokinetic alterations systemic exertion intolerance disease (SEID), previously are most commonly caused by alleles in genes affecting known as chronic fatigue syndrome or myalgic encepha- the cytochrome P450 system, such as CYP2C19 or CYP2D6. lomyelitis. The diagnosis of SEID, based on criteria from Clinical phenotypes of these genetic variations are assigned the Institute of Medicine, requires the presence of fatigue on the basis of enzyme activity: poor metabolizer, inter- of at least 6 months’ duration with substantial reduction mediate metabolizer, extensive/normal metabolizer, rapid in pre-illness activities, postexertional malaise, unrefresh- metabolizer, and ultrarapid metabolizer. The effect of the ing sleep, and either cognitive impairment or orthostatic phenotype on a particular medication depends on whether intolerance. Although the pathophysiology of SEID remains the medication is an active drug or a prodrug. Levels of unclear, the phenomenon of central sensitization (the drugs taken in their active form are reduced in patients who pathophysiologic dysregulation of the thalamus, hypothal- are ultrarapid metabolizers and increased in patients who amus, and amygdala) is gaining acceptance as a potential 178

cause of SEID. Central sensitization is often triggered by a bowel and bladder dysfunction, and erectile dysfunction. prodromal event, such as infection, physical or emotional On physical examination, decreased or absent distal reflexes trauma, a motor vehicle accident, surgery, medical illness, and decreased anal sphincter tone may be noted along with or prolonged stress. Comorbid conditions, including fibro- bilateral leg weakness. Cauda equina syndrome is most com- myalgia, mood disturbances, irritable bowel syndrome, and monly caused by disk herniation, degenerative changes, or interstitial cystitis, are often present. Treatment of SEID spondylosis, but it can also result from trauma, infection, or focuses on nonpharmacologic therapy. Evidence supports cancer (most commonly prostate cancer, lymphoma, or mul- the use of graded exercise programs, cognitive behavioral tiple myeloma). MRI of the lumbosacral spine can visualize therapy, sleep hygiene, and mindfulness interventions (such neurologic compromise of the cauda equina. as biofeedback therapy, massage therapy, acupuncture, yoga, Piriformis syndrome (Option B) is caused by compres- tai chi, and stress management activities). Pacing strategies, sion of the sciatic nerve by the piriformis muscle, leading in which specific limits are placed on the degree of exertion, to symptoms similar to those of sciatica. Pain, tingling, and are used to reduce the frequency of postexertional malaise. numbness occur in a unilateral distribution, with pain radi- wn rt} Pharmacologic therapies have not been shown to be ating into the leg. Piriformis syndrome does not typically =}

cause of SEID. Central sensitization is often triggered by a bowel and bladder dysfunction, and erectile dysfunction. prodromal event, such as infection, physical or emotional On physical examination, decreased or absent distal reflexes trauma, a motor vehicle accident, surgery, medical illness, and decreased anal sphincter tone may be noted along with or prolonged stress. Comorbid conditions, including fibro- bilateral leg weakness. Cauda equina syndrome is most com- myalgia, mood disturbances, irritable bowel syndrome, and monly caused by disk herniation, degenerative changes, or interstitial cystitis, are often present. Treatment of SEID spondylosis, but it can also result from trauma, infection, or focuses on nonpharmacologic therapy. Evidence supports cancer (most commonly prostate cancer, lymphoma, or mul- the use of graded exercise programs, cognitive behavioral tiple myeloma). MRI of the lumbosacral spine can visualize therapy, sleep hygiene, and mindfulness interventions (such neurologic compromise of the cauda equina. as biofeedback therapy, massage therapy, acupuncture, yoga, Piriformis syndrome (Option B) is caused by compres- tai chi, and stress management activities). Pacing strategies, sion of the sciatic nerve by the piriformis muscle, leading in which specific limits are placed on the degree of exertion, to symptoms similar to those of sciatica. Pain, tingling, and are used to reduce the frequency of postexertional malaise. numbness occur in a unilateral distribution, with pain radi- wn rt} Pharmacologic therapies have not been shown to be ating into the leg. Piriformis syndrome does not typically =} consistently effective in the treatment of SEID, and there are cause diminished distal reflexes. = Pelvic insufficiency fracture (Option C) can rarely occur x= no medications approved by the FDA for this disease. Stim- rs) ulants, such as modafinil (Option B), have not been shown after radiation to the pelvis and other bones during treat- sc = to improve postexertional malaise and may worsen cognitive ment for prostate cancer. Insufficiency fractures are a sub- c n dysfunction in patients with SEID. type of stress fracture that develops after normal stress to San o The characteristic clinical features of fibromyalgia are weakened bone. These fractures occur in approximately 5% = nn widespread chronic pain (including hypersensitivity to of patients who receive whole-pelvis radiation therapy for = painful stimuli), fatigue, and sleep disorders (both disrupted locally advanced prostate cancer. Most patients are also usu- =

consistently effective in the treatment of SEID, and there are cause diminished distal reflexes. = Pelvic insufficiency fracture (Option C) can rarely occur x= no medications approved by the FDA for this disease. Stim- rs) ulants, such as modafinil (Option B), have not been shown after radiation to the pelvis and other bones during treat- sc = to improve postexertional malaise and may worsen cognitive ment for prostate cancer. Insufficiency fractures are a sub- c n dysfunction in patients with SEID. type of stress fracture that develops after normal stress to San o The characteristic clinical features of fibromyalgia are weakened bone. These fractures occur in approximately 5% = nn widespread chronic pain (including hypersensitivity to of patients who receive whole-pelvis radiation therapy for = painful stimuli), fatigue, and sleep disorders (both disrupted locally advanced prostate cancer. Most patients are also usu- = and nonrestorative sleep). Although fibromyalgia and SEID ally receiving androgen deprivation therapy, which probably have many similar symptoms, the absence of pain makes the contributes to bone weakening. Fractures tend to occur in diagnosis of fibromyalgia unlikely. Pregabalin (Option C) is the sacrum and pubic bone. Patients develop symptoms of FDA approved for the treatment of fibromyalgia but has not low back pain or pelvic pain but do not develop neurologic been shown to be effective for treatment of SEID. findings consistent with cauda equina syndrome, as seen in Mood disorders are frequently encountered in patients this patient. with SEID, and pharmacotherapy may be beneficial for treat- Vertebral compression fracture (Option D) can cause ing those comorbidities. However, the absence of depressive low back pain and vertebral tenderness but does not typi- symptoms in this patient makes it unlikely that she will cally cause lower extremity weakness or diminished reflexes. benefit from a selective serotonin reuptake inhibitor such as sertraline (Option D). e The major finding associated with cauda equina syn- drome is bilateral leg weakness that may be associated e The treatment of systemic exertion intolerance disease with saddle anesthesia, bowel and bladder dysfunction, focuses on nonpharmacologic therapies, such as and erectile dysfunction. graded exercise programs, pacing strategies, cognitive ¢ Urgent MRI is indicated for patients with suspected behavioral therapy, sleep hygiene, and mindfulness cauda equina syndrome. interventions.

and nonrestorative sleep). Although fibromyalgia and SEID ally receiving androgen deprivation therapy, which probably have many similar symptoms, the absence of pain makes the contributes to bone weakening. Fractures tend to occur in diagnosis of fibromyalgia unlikely. Pregabalin (Option C) is the sacrum and pubic bone. Patients develop symptoms of FDA approved for the treatment of fibromyalgia but has not low back pain or pelvic pain but do not develop neurologic been shown to be effective for treatment of SEID. findings consistent with cauda equina syndrome, as seen in Mood disorders are frequently encountered in patients this patient. with SEID, and pharmacotherapy may be beneficial for treat- Vertebral compression fracture (Option D) can cause ing those comorbidities. However, the absence of depressive low back pain and vertebral tenderness but does not typi- symptoms in this patient makes it unlikely that she will cally cause lower extremity weakness or diminished reflexes. benefit from a selective serotonin reuptake inhibitor such as sertraline (Option D). e The major finding associated with cauda equina syn- drome is bilateral leg weakness that may be associated e The treatment of systemic exertion intolerance disease with saddle anesthesia, bowel and bladder dysfunction, focuses on nonpharmacologic therapies, such as and erectile dysfunction. graded exercise programs, pacing strategies, cognitive ¢ Urgent MRI is indicated for patients with suspected behavioral therapy, sleep hygiene, and mindfulness cauda equina syndrome. interventions. Bibliography Bibliography Babu JM, Patel SA, Palumbo MA, Daniels AH. Spinal emergencies in primary Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/ care practice. AmJ Med. 2019;132:300-6. [PMID: 30291829] doi:10.1016/j. Chronic Fatigue Syndrome, Board on the Health of Select Populations, amjmed.2018.09.022 Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: National Academies Press; 2015. [PMID: 25695122] Item 93 Answer: B Educational Objective: Assess risk before providing Item 92 Answer: A opioid therapy. Educational Objective: Diagnose cauda equina syndrome. Opioid risk assessment (Option B) is the most appropriate This patient’s presentation is most consistent with cauda next step in management. This patient has tried several equina syndrome (Option A) due to metastatic prostate can- different targeted interventions for her pain and currently cer. Emergent MRI of the lumbosacral spine, along with adheres to a reasonable nonopioid adjuvant strategy. Despite immediate neurosurgical evaluation, is indicated. Cauda these treatments, she continues to have persistent pain that equina syndrome classically presents with acute low back interferes with function. Consideration of opioid therapy pain radiating to the legs. The dominant finding is bilateral is not unreasonable. Assessment of opioid risk should be leg weakness that may be associated with saddle anesthesia, an initial step in the decision-making process between the

Bibliography Bibliography Babu JM, Patel SA, Palumbo MA, Daniels AH. Spinal emergencies in primary Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/ care practice. AmJ Med. 2019;132:300-6. [PMID: 30291829] doi:10.1016/j. Chronic Fatigue Syndrome, Board on the Health of Select Populations, amjmed.2018.09.022 Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: National Academies Press; 2015. [PMID: 25695122] Item 93 Answer: B Educational Objective: Assess risk before providing Item 92 Answer: A opioid therapy. Educational Objective: Diagnose cauda equina syndrome. Opioid risk assessment (Option B) is the most appropriate This patient’s presentation is most consistent with cauda next step in management. This patient has tried several equina syndrome (Option A) due to metastatic prostate can- different targeted interventions for her pain and currently cer. Emergent MRI of the lumbosacral spine, along with adheres to a reasonable nonopioid adjuvant strategy. Despite immediate neurosurgical evaluation, is indicated. Cauda these treatments, she continues to have persistent pain that equina syndrome classically presents with acute low back interferes with function. Consideration of opioid therapy pain radiating to the legs. The dominant finding is bilateral is not unreasonable. Assessment of opioid risk should be leg weakness that may be associated with saddle anesthesia, an initial step in the decision-making process between the 179

Answers and Critiques clinician and patient about whether to start opioids. The therapy. Studies comparing statins with placebo have shown process should include a discussion of treatment goals, the no difference in the incidence of persistently elevated ami- patient’s individualized risks, potential benefits of therapy, notransferase levels, despite this finding being commonly and ongoing monitoring strategies that will be part of the attributed to the initiation of statin therapy. If the ALT level treatment agreement. The Opioid Risk Tool is one example becomes elevated more than three times the upper limit of of a screening tool that can be administered in the office to normal when measured for clinically relevant indications, the help clinicians stratify a patient’s risk for opioid misuse as statin dose should be reduced or the drug should be discon- low, moderate, or high. tinued. It is not necessary to repeat aminotransferase mea- Calcitonin (Option A) may be considered for the man- surements during statin therapy in the absence of symptoms. agement of mild to moderate pain associated with acute Although the development of significant muscle injury osteoporotic fracture in patients with inadequate pain relief and rhabdomyolysis is a concern of many patients and pro- with oral analgesics, such as NSAIDs. Treatment may be con- viders, it is rare, occurring in less than 0.1% of the popula- Pd tinued for 2 to 4 weeks. The evidence of effectiveness is weak, tion. Muscle-related side effects, including muscle pain and = wn but calcitonin may be helpful as an adjuvant treatment in the weakness, are common and often require dose adjustment = context of acute vertebral fracture. This patient has chronic or changing medications. Measurement of creatine kinase @o = wn pain due to osteoporotic vertebral fractures, and calcitonin (Option B) before initiation of therapy is not useful. This test my = is not indicated. should be performed only when clinical signs and symptoms a Further imaging studies, such as thoracic and lumbar point to muscle injury. QO me radiography (Option C), are unlikely to be of value in decid- Statin therapy has been associated with an increase in =e ing whether to prescribe opioids as part of this patient’s new-onset type 2 diabetes mellitus. This effect tends to be 2 = multimodal analgesic plan. She has a long-standing history dose related and is often seen in patients with underlying @o 177) of chronic back pain as well as vertebral compression frac- metabolic syndrome or other risk factors for diabetes. The tures and has tried many treatments without satisfactory benefits of initiation of statin therapy in patients with ele- pain control. vated risk for atherosclerotic cardiovascular disease outweigh Urine drug screening (Option D) is an important moni- the small risk for diabetes associated with statin therapy. The toring strategy for patients receiving ongoing opioid therapy. American Diabetes Association recommends screening for Although optimal screening frequency has not been defined, type 2 diabetes with fasting blood glucose level (Option C) or patients on chronic opioid therapy should undergo urine hemoglobin A,, measurement in patients with hypertension drug screening at least yearly to ensure that they are taking but not as a prerequisite for starting statin therapy. medications as prescribed. This patient is asymptomatic and specifically reports no chest pain or shortness of breath with exertion. Therefore, he has a low pretest probability of clinically significant cor- e Assessment of opioid risk should be an initial step in onary artery disease requiring intervention, and treadmill the decision-making process between the clinician stress testing (Option D) is not indicated. and patient about whether to start opioids.

clinician and patient about whether to start opioids. The therapy. Studies comparing statins with placebo have shown process should include a discussion of treatment goals, the no difference in the incidence of persistently elevated ami- patient’s individualized risks, potential benefits of therapy, notransferase levels, despite this finding being commonly and ongoing monitoring strategies that will be part of the attributed to the initiation of statin therapy. If the ALT level treatment agreement. The Opioid Risk Tool is one example becomes elevated more than three times the upper limit of of a screening tool that can be administered in the office to normal when measured for clinically relevant indications, the help clinicians stratify a patient’s risk for opioid misuse as statin dose should be reduced or the drug should be discon- low, moderate, or high. tinued. It is not necessary to repeat aminotransferase mea- Calcitonin (Option A) may be considered for the man- surements during statin therapy in the absence of symptoms. agement of mild to moderate pain associated with acute Although the development of significant muscle injury osteoporotic fracture in patients with inadequate pain relief and rhabdomyolysis is a concern of many patients and pro- with oral analgesics, such as NSAIDs. Treatment may be con- viders, it is rare, occurring in less than 0.1% of the popula- Pd tinued for 2 to 4 weeks. The evidence of effectiveness is weak, tion. Muscle-related side effects, including muscle pain and = wn but calcitonin may be helpful as an adjuvant treatment in the weakness, are common and often require dose adjustment = context of acute vertebral fracture. This patient has chronic or changing medications. Measurement of creatine kinase @o = wn pain due to osteoporotic vertebral fractures, and calcitonin (Option B) before initiation of therapy is not useful. This test my = is not indicated. should be performed only when clinical signs and symptoms a Further imaging studies, such as thoracic and lumbar point to muscle injury. QO me radiography (Option C), are unlikely to be of value in decid- Statin therapy has been associated with an increase in =e ing whether to prescribe opioids as part of this patient’s new-onset type 2 diabetes mellitus. This effect tends to be 2 = multimodal analgesic plan. She has a long-standing history dose related and is often seen in patients with underlying @o 177) of chronic back pain as well as vertebral compression frac- metabolic syndrome or other risk factors for diabetes. The tures and has tried many treatments without satisfactory benefits of initiation of statin therapy in patients with ele- pain control. vated risk for atherosclerotic cardiovascular disease outweigh Urine drug screening (Option D) is an important moni- the small risk for diabetes associated with statin therapy. The toring strategy for patients receiving ongoing opioid therapy. American Diabetes Association recommends screening for Although optimal screening frequency has not been defined, type 2 diabetes with fasting blood glucose level (Option C) or patients on chronic opioid therapy should undergo urine hemoglobin A,, measurement in patients with hypertension drug screening at least yearly to ensure that they are taking but not as a prerequisite for starting statin therapy. medications as prescribed. This patient is asymptomatic and specifically reports no chest pain or shortness of breath with exertion. Therefore, he has a low pretest probability of clinically significant cor- e Assessment of opioid risk should be an initial step in onary artery disease requiring intervention, and treadmill the decision-making process between the clinician stress testing (Option D) is not indicated. and patient about whether to start opioids. e The decision to start opioids should include a discus- e Before initiation of statin therapy, aminotransferase sion of treatment goals, the patient’s individualized levels should be measured. risks, potential benefits of therapy, and ongoing moni- toring strategies. e Measurement of aminotransferase levels should not be repeated during statin therapy in the absence of

e The decision to start opioids should include a discus- e Before initiation of statin therapy, aminotransferase sion of treatment goals, the patient’s individualized levels should be measured. risks, potential benefits of therapy, and ongoing moni- toring strategies. e Measurement of aminotransferase levels should not be repeated during statin therapy in the absence of Bibliography symptoms of liver injury. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624-45. [PMID: Bibliography 26977696] doi:10.1001/jama.2016.1464 Newman CB, Preiss D, Tobert JA, et al; American Heart Association Clinical Lipidology, Lipoprotein, Metabolism and Thrombosis Committee, a Joint Committee of the Council on Atherosclerosis, Thrombosis and Vascular Item 94 Answer: A Biology and Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Educational Objective: Evaluate aminotransferase levels and Stroke Council. Statin safety and associated adverse events: a before initiating statin therapy. scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol. 2019;39:e38-81. [PMID: 30580575] doi:10.1161/ATV. 0000000000000073 The most appropriate test to perform before initiation of statin therapy is aminotransferase measurements (aspar- tate aminotransferase and alanine aminotransferase [ALT]) Item 95 Answer: C (Option A). Statins can cause asymptomatic, dose-related Educational Objective: Diagnose Meniere disease. elevations in aminotransferase levels in approximately 1% of patients. Rarely, the initiation of statin therapy can be This patient’s symptoms and examination findings are associated with severe liver injury (<0.001% of patients). consistent with Meniere disease (Option C). The onset When this occurs, it is often 3 to 4 months after initiation of of Meniere disease typically occurs between ages 20 and

Bibliography symptoms of liver injury. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624-45. [PMID: Bibliography 26977696] doi:10.1001/jama.2016.1464 Newman CB, Preiss D, Tobert JA, et al; American Heart Association Clinical Lipidology, Lipoprotein, Metabolism and Thrombosis Committee, a Joint Committee of the Council on Atherosclerosis, Thrombosis and Vascular Item 94 Answer: A Biology and Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Educational Objective: Evaluate aminotransferase levels and Stroke Council. Statin safety and associated adverse events: a before initiating statin therapy. scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol. 2019;39:e38-81. [PMID: 30580575] doi:10.1161/ATV. 0000000000000073 The most appropriate test to perform before initiation of statin therapy is aminotransferase measurements (aspar- tate aminotransferase and alanine aminotransferase [ALT]) Item 95 Answer: C (Option A). Statins can cause asymptomatic, dose-related Educational Objective: Diagnose Meniere disease. elevations in aminotransferase levels in approximately 1% of patients. Rarely, the initiation of statin therapy can be This patient’s symptoms and examination findings are associated with severe liver injury (<0.001% of patients). consistent with Meniere disease (Option C). The onset When this occurs, it is often 3 to 4 months after initiation of of Meniere disease typically occurs between ages 20 and 180

_ Answers and Critiques 40 years. Diagnosis requires two or more episodes of vertigo all adults aged 40 to 75 years should undergo lipid profile lasting 20 minutes to 12 hours and fluctuating or nonfluctu- measurement, followed by 10-year atherosclerotic cardiovas- ating sensorineural hearing loss, tinnitus, or ear pressure; the cular disease (ASCVD) risk estimation. The U.S. Preventive hearing loss often begins years before the vertigo. Meniere Services Task Force (USPSTF) concurs with this reeommenda- disease causes a peripheral vertigo, and nystagmus is present tion. Patients at low (<5%) 10-year risk for a major cardiovas- during episodes of vertigo. The Dix-Hallpike maneuver does cular event should consume a healthy diet that emphasizes the not always induce vertigo or nystagmus. HINTS (Head Impulse, intake of vegetables, fruits, nuts, whole grains, lean vegetable Nystagmus, and Test of Skew) examination results will be con- or animal protein, and fish and minimizes the intake of trans sistent with a peripheral cause of vertigo: catch-up saccades, fats, processed meats, refined carbohydrates, and sweetened unidirectional nystagmus, and absence of vertical skew. beverages. For patients with overweight, counseling and caloric Benign paroxysmal positional vertigo (BPPV) (Option restriction are recommended to achieve and maintain weight A) occurs when otoconia (calcium carbonate crystals) move loss. Adults should engage in at least 150 minutes of accumulated within the semicircular canals, causing peripheral ver- moderate-intensity physical activity per week or 75 minutes of wn cf tigo. As in Meniere disease, HINTS examination findings vigorous-intensity physical activity per week. =

40 years. Diagnosis requires two or more episodes of vertigo all adults aged 40 to 75 years should undergo lipid profile lasting 20 minutes to 12 hours and fluctuating or nonfluctu- measurement, followed by 10-year atherosclerotic cardiovas- ating sensorineural hearing loss, tinnitus, or ear pressure; the cular disease (ASCVD) risk estimation. The U.S. Preventive hearing loss often begins years before the vertigo. Meniere Services Task Force (USPSTF) concurs with this reeommenda- disease causes a peripheral vertigo, and nystagmus is present tion. Patients at low (<5%) 10-year risk for a major cardiovas- during episodes of vertigo. The Dix-Hallpike maneuver does cular event should consume a healthy diet that emphasizes the not always induce vertigo or nystagmus. HINTS (Head Impulse, intake of vegetables, fruits, nuts, whole grains, lean vegetable Nystagmus, and Test of Skew) examination results will be con- or animal protein, and fish and minimizes the intake of trans sistent with a peripheral cause of vertigo: catch-up saccades, fats, processed meats, refined carbohydrates, and sweetened unidirectional nystagmus, and absence of vertical skew. beverages. For patients with overweight, counseling and caloric Benign paroxysmal positional vertigo (BPPV) (Option restriction are recommended to achieve and maintain weight A) occurs when otoconia (calcium carbonate crystals) move loss. Adults should engage in at least 150 minutes of accumulated within the semicircular canals, causing peripheral ver- moderate-intensity physical activity per week or 75 minutes of wn cf tigo. As in Meniere disease, HINTS examination findings vigorous-intensity physical activity per week. = in BPPV are consistent with a peripheral cause of vertigo. The USPSTF recommends low-dose aspirin (Option B) = The Dix-Hallpike maneuver in BPPV would typically show for the primary prevention of ASCVD in adults aged 50 to ‘= rs) upbeat-torsional nystagmus and reproduction of vertigo 59 years with a 10-year ASCVD risk of 10% or higher who s < when the affected side is tested. do not have an increased risk for bleeding. The AHA and c

in BPPV are consistent with a peripheral cause of vertigo. The USPSTF recommends low-dose aspirin (Option B) = The Dix-Hallpike maneuver in BPPV would typically show for the primary prevention of ASCVD in adults aged 50 to ‘= rs) upbeat-torsional nystagmus and reproduction of vertigo 59 years with a 10-year ASCVD risk of 10% or higher who s < when the affected side is tested. do not have an increased risk for bleeding. The AHA and c Labyrinthitis (Option B) is associated with peripheral ACC suggest that low-dose aspirin might be considered wn Bes o vertigo and hearing loss, but it usually begins acutely after for ASCVD primary prevention in adults who are at higher = a viral infection, and the vertigo is typically constant. This ASCVD risk but not at increased bleeding risk. Low-dose wn S patient’s symptoms have persisted for years, which is not aspirin is not indicated in this patient. =<

Labyrinthitis (Option B) is associated with peripheral ACC suggest that low-dose aspirin might be considered wn Bes o vertigo and hearing loss, but it usually begins acutely after for ASCVD primary prevention in adults who are at higher = a viral infection, and the vertigo is typically constant. This ASCVD risk but not at increased bleeding risk. Low-dose wn S patient’s symptoms have persisted for years, which is not aspirin is not indicated in this patient. =< characteristic of labyrinthitis. This patient’s LDL cholesterol level is below the recom- Vertebrobasilar stroke (Option D) usually presents with mended level for starting a statin (190 mg/dL [4.9 mmol/L]), other neurologic findings in addition to vertigo. In patients and his calculated ASCVD risk falls below that for which with persistent vertigo, the HINTS examination can help guidelines recommend consideration of statin therapy differentiate between central and peripheral causes. The (>7.5%). Therefore, moderate-intensity statin therapy absence of catch-up saccades, presence of direction-changing (Option C) should not be initiated. nystagmus, or presence of skew deviation on the HINTS This patient is asymptomatic and has a low pretest prob- examination is suggestive of a central cause of vertigo. Ver- ability for significant cardiovascular disease; therefore, tread- tebrobasilar stroke typically occurs in patients with risk mill stress testing (Option D) is not warranted at this time. factors for vascular disease and would be visualized on MRI, effectively ruling out the diagnosis in this patient. Vestibular migraine (Option E) should always be con- e Adults aged 40 to 75 years should undergo fasting or sidered in patients with episodic vertigo and normal findings nonfasting plasma lipid profile measurement, followed on examination and imaging. However, vestibular migraine by estimation of 10-year atherosclerotic cardiovascular would not be associated with hearing loss, and patients typ- disease risk. ically have headache symptoms and/or a history of migraine. e Patients determined to be at low (<5%) 10-year risk for a major cardiovascular event should be advised to consume a healthy diet and should engage in at least e Diagnosis of Meniere disease requires two or more 150 minutes of accumulated moderate-intensity episodes of vertigo lasting 20 minutes to 12 hours and physical activity per week or at least 75 minutes of fluctuating or nonfluctuating sensorineural hearing vigorous-intensity physical activity per week. loss, tinnitus, or ear pressure.

characteristic of labyrinthitis. This patient’s LDL cholesterol level is below the recom- Vertebrobasilar stroke (Option D) usually presents with mended level for starting a statin (190 mg/dL [4.9 mmol/L]), other neurologic findings in addition to vertigo. In patients and his calculated ASCVD risk falls below that for which with persistent vertigo, the HINTS examination can help guidelines recommend consideration of statin therapy differentiate between central and peripheral causes. The (>7.5%). Therefore, moderate-intensity statin therapy absence of catch-up saccades, presence of direction-changing (Option C) should not be initiated. nystagmus, or presence of skew deviation on the HINTS This patient is asymptomatic and has a low pretest prob- examination is suggestive of a central cause of vertigo. Ver- ability for significant cardiovascular disease; therefore, tread- tebrobasilar stroke typically occurs in patients with risk mill stress testing (Option D) is not warranted at this time. factors for vascular disease and would be visualized on MRI, effectively ruling out the diagnosis in this patient. Vestibular migraine (Option E) should always be con- e Adults aged 40 to 75 years should undergo fasting or sidered in patients with episodic vertigo and normal findings nonfasting plasma lipid profile measurement, followed on examination and imaging. However, vestibular migraine by estimation of 10-year atherosclerotic cardiovascular would not be associated with hearing loss, and patients typ- disease risk. ically have headache symptoms and/or a history of migraine. e Patients determined to be at low (<5%) 10-year risk for a major cardiovascular event should be advised to consume a healthy diet and should engage in at least e Diagnosis of Meniere disease requires two or more 150 minutes of accumulated moderate-intensity episodes of vertigo lasting 20 minutes to 12 hours and physical activity per week or at least 75 minutes of fluctuating or nonfluctuating sensorineural hearing vigorous-intensity physical activity per week. loss, tinnitus, or ear pressure. Bibliography Bibliography Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the Basura GJ, Adams ME, Monfared A, et al. Clinical practice guideline: primary prevention of cardiovascular disease: a report of the American Ménieére’s disease. Otolaryngol Head Neck Surg. 2020;162(2_suppl):S1-55. College of Cardiology/American Heart Association Task Force on Clinical [PMID: 32267799] doi:10.1177/0194599820909438 Practice Guidelines. Circulation. 2019;140:e596-646. [PMID: 308797T55] doi:10.1161/CIR.0000000000000678

Bibliography Bibliography Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the Basura GJ, Adams ME, Monfared A, et al. Clinical practice guideline: primary prevention of cardiovascular disease: a report of the American Ménieére’s disease. Otolaryngol Head Neck Surg. 2020;162(2_suppl):S1-55. College of Cardiology/American Heart Association Task Force on Clinical [PMID: 32267799] doi:10.1177/0194599820909438 Practice Guidelines. Circulation. 2019;140:e596-646. [PMID: 308797T55] doi:10.1161/CIR.0000000000000678 Item 96 Answer: A Educational Objective: Prevent cardiovascular disease Item 97 Answer: A with risk reduction interventions. Educational Objective: Treat urge incontinence with bladder training. The most appropriate management is intensive diet and exer- cise counseling (Option A). The American Heart Association The most appropriate management is bladder training with (AHA)/American College of Cardiology (ACC) recommend that timed voiding (Option A). This patient probably has urge 181

Answers and Critiques incontinence, or overactive bladder with incontinence. Urge malnutrition, sensory loss, and reduced skin perfusion, which incontinence is urine leakage preceded by a sudden urge can occur with hypovolemia, hypotension, and systemic to void. First-line therapy for any urinary incontinence is vasoconstriction. The first step in pressure injury prevention behavioral training. For urge incontinence, behavioral train- is a comprehensive history and physical examination to assess ing consists of bladder training with timed voiding. Bladder risk. Regular, structured risk assessment should be performed training comprises scheduled voiding attempts at intervals to identify at-risk patients. Pressure redistribution through shorter than the usual time between incontinence episodes, pressure-reducing equipment and proper patient positioning regardless of the urge to void, with a gradual increase in the is of paramount importance in the prevention of pressure inju- time between voids. If an episode of urgency occurs before ries in at-risk patients. Advanced static mattresses or overlays the designated voiding time, patients are encouraged to use should be used in patients at increased risk. An advanced static pelvic floor muscle contraction until the urge passes and mattress is made of specialized sheepskin, foam, or gel and is then proceed with voiding directly afterward. immobile when a patient lies on it, whereas an advanced static

incontinence, or overactive bladder with incontinence. Urge malnutrition, sensory loss, and reduced skin perfusion, which incontinence is urine leakage preceded by a sudden urge can occur with hypovolemia, hypotension, and systemic to void. First-line therapy for any urinary incontinence is vasoconstriction. The first step in pressure injury prevention behavioral training. For urge incontinence, behavioral train- is a comprehensive history and physical examination to assess ing consists of bladder training with timed voiding. Bladder risk. Regular, structured risk assessment should be performed training comprises scheduled voiding attempts at intervals to identify at-risk patients. Pressure redistribution through shorter than the usual time between incontinence episodes, pressure-reducing equipment and proper patient positioning regardless of the urge to void, with a gradual increase in the is of paramount importance in the prevention of pressure inju- time between voids. If an episode of urgency occurs before ries in at-risk patients. Advanced static mattresses or overlays the designated voiding time, patients are encouraged to use should be used in patients at increased risk. An advanced static pelvic floor muscle contraction until the urge passes and mattress is made of specialized sheepskin, foam, or gel and is then proceed with voiding directly afterward. immobile when a patient lies on it, whereas an advanced static S If a patient is appropriately engaging in bladder train- overlay is a pad composed of foam or gel that is secured to | wn ing with scheduled voiding, pharmacologic therapy can the top of a regular mattress. Harms associated with overlays = be added as second-line therapy. For urge incontinence, include increased heat-related discomfort leading to removal @o anticholinergic drugs (oxybutynin [Option C], darifenacin, = “A of the overlay. pe) BS solifenacin, tolterodine, fesoterodine, trospium) reduce Alternating air mattresses (Option A) for pressure a. involuntary bladder contractions by blocking the muscarinic injury prevention are not recommended, primarily based (2) = cholinergic receptors. Another pharmacologic treatment for on cost considerations and lack of data demonstrating a clear = urge incontinence is mirabegron (Option B), a B-adrenergic advantage. ao] = agonist that enhances the inhibitory adrenergic signals to Repositioning every 3 hours compared with usual care oO wn the detrusor muscle. This patient might progress to need- has been shown to slightly reduce pressure injury formation, ing pharmacologic therapy for her urge incontinence, but but data from nursing homes assessing repositioning at 2-, she should attempt behavioral therapy first with bladder 3-, or 4-hour intervals showed no difference in the incidence training. of pressure injury. Repositioning every hour (Option B) has Pelvic floor muscle training (Option D) is a type of not been studied and would be burdensome for the patient behavioral therapy in which the patient performs sets of and nurse colleagues caring for this patient. contractions of the pelvic floor. Pelvic floor muscle train- Keeping the skin clean and free from maceration due to ing is five times more effective than no treatment for stress excess moisture, and possibly the application of emollients incontinence. Patients should be instructed to contract the (Option C) to chronically dry skin, may be useful adjunctive pelvic floor as if attempting to avoid urination and sustain therapy to pressure redistribution in the prevention of pres- the contraction for 10 seconds. Contractions should be per- sure injury. However, skin care alone has not been shown to formed in three or four sets of 10 daily. Pelvic floor exercises prevent pressure injury. are appropriate for stress incontinence and mixed stress and Data are insufficient to recommend the routine use of urge incontinence but will not be helpful for this patient dietary supplements (Option D) for pressure injury pre- who has only urge incontinence. vention. Nutritional supplementation has been studied in inpatients and nursing home residents, and five of six studies showed no difference in pressure injury risk. e First-line therapy for urge incontinence is bladder training with timed voiding. e Prevention of pressure injuries in hospitalized patients e Ifa patient with urge incontinence is appropriately requires regular risk assessment and pressure redis- engaging in bladder training with timed voiding, tribution through proper patient positioning and an pharmacologic therapy can be added as second-line advanced static mattress or overlay. therapy if symptoms fail to remit.

S If a patient is appropriately engaging in bladder train- overlay is a pad composed of foam or gel that is secured to | wn ing with scheduled voiding, pharmacologic therapy can the top of a regular mattress. Harms associated with overlays = be added as second-line therapy. For urge incontinence, include increased heat-related discomfort leading to removal @o anticholinergic drugs (oxybutynin [Option C], darifenacin, = “A of the overlay. pe) BS solifenacin, tolterodine, fesoterodine, trospium) reduce Alternating air mattresses (Option A) for pressure a. involuntary bladder contractions by blocking the muscarinic injury prevention are not recommended, primarily based (2) = cholinergic receptors. Another pharmacologic treatment for on cost considerations and lack of data demonstrating a clear = urge incontinence is mirabegron (Option B), a B-adrenergic advantage. ao] = agonist that enhances the inhibitory adrenergic signals to Repositioning every 3 hours compared with usual care oO wn the detrusor muscle. This patient might progress to need- has been shown to slightly reduce pressure injury formation, ing pharmacologic therapy for her urge incontinence, but but data from nursing homes assessing repositioning at 2-, she should attempt behavioral therapy first with bladder 3-, or 4-hour intervals showed no difference in the incidence training. of pressure injury. Repositioning every hour (Option B) has Pelvic floor muscle training (Option D) is a type of not been studied and would be burdensome for the patient behavioral therapy in which the patient performs sets of and nurse colleagues caring for this patient. contractions of the pelvic floor. Pelvic floor muscle train- Keeping the skin clean and free from maceration due to ing is five times more effective than no treatment for stress excess moisture, and possibly the application of emollients incontinence. Patients should be instructed to contract the (Option C) to chronically dry skin, may be useful adjunctive pelvic floor as if attempting to avoid urination and sustain therapy to pressure redistribution in the prevention of pres- the contraction for 10 seconds. Contractions should be per- sure injury. However, skin care alone has not been shown to formed in three or four sets of 10 daily. Pelvic floor exercises prevent pressure injury. are appropriate for stress incontinence and mixed stress and Data are insufficient to recommend the routine use of urge incontinence but will not be helpful for this patient dietary supplements (Option D) for pressure injury pre- who has only urge incontinence. vention. Nutritional supplementation has been studied in inpatients and nursing home residents, and five of six studies showed no difference in pressure injury risk. e First-line therapy for urge incontinence is bladder training with timed voiding. e Prevention of pressure injuries in hospitalized patients e Ifa patient with urge incontinence is appropriately requires regular risk assessment and pressure redis- engaging in bladder training with timed voiding, tribution through proper patient positioning and an pharmacologic therapy can be added as second-line advanced static mattress or overlay. therapy if symptoms fail to remit. Bibliography Bibliography Hajhosseini B, Longaker MT, Gurtner GC. Pressure injury. Ann Surg. Balk EM, Rofeberg VN, Adam GP, et al. Pharmacologic and nonpharmaco- 2020;271:671-79. [PMID: 31460882] doi:10.1097/SLA.0000000000003567 logic treatments for urinary incontinence in women: a systematic review and network meta-analysis of clinical outcomes. Ann Intern Med. 2019;170:465-79. [PMID: 30884526] doi:10.7326/M18-3227

Bibliography Bibliography Hajhosseini B, Longaker MT, Gurtner GC. Pressure injury. Ann Surg. Balk EM, Rofeberg VN, Adam GP, et al. Pharmacologic and nonpharmaco- 2020;271:671-79. [PMID: 31460882] doi:10.1097/SLA.0000000000003567 logic treatments for urinary incontinence in women: a systematic review and network meta-analysis of clinical outcomes. Ann Intern Med. 2019;170:465-79. [PMID: 30884526] doi:10.7326/M18-3227 Item 99 Answer: C Educational Objective: Provide patient education ltem 98 Answer: E regarding low back pain. Educational Objective: Prevent a pressure injury. In addition to nonpharmacologic treatment, patient edu- A static mattress overlay (Option E) is the best measure for cation is the most appropriate management (Option C). prevention of pressure injury in this high-risk patient. The Guidelines recommend that clinicians educate patients most important risk factors for pressure injury are immobility, on the favorable prognosis of acute low back pain with or 182

without sciatica, including the high probability of improve- shtml). Patients with positive or equivocal answers about ment in the first month. Clinicians should also educate suicidality require an immediate safety assessment and full patients about the expected course, advise them to remain mental health evaluation; this patient cannot leave until active, and provide effective self-care options. Shared deci- evaluated for safety. sion making should be used to select the most appropriate If initial monotherapy for depression fails to achieve treatment based on patient preferences, availability, harms, an adequate response, increasing the dosage of the cho- and costs. Support for patient education as a significant sen medication or adding psychotherapy (if not already therapeutic intervention comes from a systematic review used) may be appropriate. If no response is seen, switching and meta-analysis that reported moderate- to high-quality to another agent or adding a second agent with or with- evidence that patient education in primary care can pro- out psychotherapy is indicated. A second-line approach vide long-term reassurance for patients with acute or sub- is the addition of an antipsychotic drug. Approved anti- acute low back pain. Moderate-quality evidence showed that depressant-antipsychotic combinations include olanzapine patient education reduces low back pain-related primary (Option A) with fluoxetine and aripiprazole or quetiapine wn cH} care visits more than usual care. with any antidepressant. Before changes in therapy are ini- |

without sciatica, including the high probability of improve- shtml). Patients with positive or equivocal answers about ment in the first month. Clinicians should also educate suicidality require an immediate safety assessment and full patients about the expected course, advise them to remain mental health evaluation; this patient cannot leave until active, and provide effective self-care options. Shared deci- evaluated for safety. sion making should be used to select the most appropriate If initial monotherapy for depression fails to achieve treatment based on patient preferences, availability, harms, an adequate response, increasing the dosage of the cho- and costs. Support for patient education as a significant sen medication or adding psychotherapy (if not already therapeutic intervention comes from a systematic review used) may be appropriate. If no response is seen, switching and meta-analysis that reported moderate- to high-quality to another agent or adding a second agent with or with- evidence that patient education in primary care can pro- out psychotherapy is indicated. A second-line approach vide long-term reassurance for patients with acute or sub- is the addition of an antipsychotic drug. Approved anti- acute low back pain. Moderate-quality evidence showed that depressant-antipsychotic combinations include olanzapine patient education reduces low back pain-related primary (Option A) with fluoxetine and aripiprazole or quetiapine wn cH} care visits more than usual care. with any antidepressant. Before changes in therapy are ini- | In patients with acute or subacute low back pain, ace- tiated, suicidality must be assessed because that assessment = taminophen (Option A) does not appear to be effective at will dictate subsequent actions. i Oo improving pain outcomes versus placebo at 3 weeks. Other The Mood Disorder Questionnaire (Option B) is a=] = studies comparing acetaminophen with NSAIDs showed intended to screen for mania. Clinicians must assess patients bss]

In patients with acute or subacute low back pain, ace- tiated, suicidality must be assessed because that assessment = taminophen (Option A) does not appear to be effective at will dictate subsequent actions. i Oo improving pain outcomes versus placebo at 3 weeks. Other The Mood Disorder Questionnaire (Option B) is a=] = studies comparing acetaminophen with NSAIDs showed intended to screen for mania. Clinicians must assess patients bss] no difference in patient-related outcomes. Because this with depression for any history of elevated mood, which rn cal o patient is already taking an NSAID, adding acetaminophen is would suggest bipolar disorder; prescribing antidepressant F wn unlikely to have a substantial effect on the patient’s recovery. monotherapy to a patient with bipolar disorder may precip- S In an American College of Physicians systematic review itate a manic episode. This patient does not have any symp- _

no difference in patient-related outcomes. Because this with depression for any history of elevated mood, which rn cal o patient is already taking an NSAID, adding acetaminophen is would suggest bipolar disorder; prescribing antidepressant F wn unlikely to have a substantial effect on the patient’s recovery. monotherapy to a patient with bipolar disorder may precip- S In an American College of Physicians systematic review itate a manic episode. This patient does not have any symp- _ of the treatment of low back pain, evidence was insufficient toms concerning for mania, and the current crisis is related to determine the effectiveness of antidepressants, benzodi- to worsening depressive symptoms, not mania. azepines (such as lorazepam [Option B]), antiseizure med- Selective serotonin reuptake inhibitors—such as flu- ications, or opioids in patients with acute or subacute low oxetine, with which this patient is treated—are one of the back pain. four classes of second-generation antidepressants that are Low-quality evidence has indicated that systemic glu- considered first-line therapy for major depressive disorder. cocorticoids (Option D) are not effective in treating acute or Partial response to the initial dosage should be followed by subacute low back pain, and current guidelines recommend dosage titration. Although an increase in fluoxetine dosage against them. (Option C) may be required to treat this patient’s increased depressive symptoms, the time-to-effect of this dosage change would not be immediate and would be insufficient e Patient education in primary care can provide long-term to address suicidal ideation if present. reassurance for patients with acute or subacute low back pain and reduces low back pain-related primary care visits more than usual care. e Patients with depression must be specifically asked about suicidal ideation and behaviors.

of the treatment of low back pain, evidence was insufficient toms concerning for mania, and the current crisis is related to determine the effectiveness of antidepressants, benzodi- to worsening depressive symptoms, not mania. azepines (such as lorazepam [Option B]), antiseizure med- Selective serotonin reuptake inhibitors—such as flu- ications, or opioids in patients with acute or subacute low oxetine, with which this patient is treated—are one of the back pain. four classes of second-generation antidepressants that are Low-quality evidence has indicated that systemic glu- considered first-line therapy for major depressive disorder. cocorticoids (Option D) are not effective in treating acute or Partial response to the initial dosage should be followed by subacute low back pain, and current guidelines recommend dosage titration. Although an increase in fluoxetine dosage against them. (Option C) may be required to treat this patient’s increased depressive symptoms, the time-to-effect of this dosage change would not be immediate and would be insufficient e Patient education in primary care can provide long-term to address suicidal ideation if present. reassurance for patients with acute or subacute low back pain and reduces low back pain-related primary care visits more than usual care. e Patients with depression must be specifically asked about suicidal ideation and behaviors. Bibliography e Patients with positive or equivocal answers about sui- Traeger AC, Hiibscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect cidality require an immediate safety assessment and of primary care-based education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA Intern Med. full mental health evaluation. 2015;175:733-43. [PMID: 25799308] doi:10.1001/jamainternmed.2015.0217

Bibliography e Patients with positive or equivocal answers about sui- Traeger AC, Hiibscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect cidality require an immediate safety assessment and of primary care-based education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA Intern Med. full mental health evaluation. 2015;175:733-43. [PMID: 25799308] doi:10.1001/jamainternmed.2015.0217 Bibliography Item 100 Answer: D Fazel S, Runeson B. Suicide. N Engl J Med. 2020;382:266-74. [PMID: 31940700] doi:10.1056/NEJMra1902944 Educational Objective: Screen for suicidal ideation in a patient with major depressive disorder. Item 101 Answer: 8B This patient with acute worsening of previously controlled Educational Objective: Treat chronic pain with medical major depressive disorder should be assessed for suicidal cannabis. ideation (Option D). Nearly 40% of patients who attempt suicide report being seen by a physician within 1 week of the Medical cannabis (Option B) is most likely to improve this attempt; failing to inquire about suicidal ideation is a missed patient’s chronic pain related to multiple sclerosis. Her pain opportunity to intervene in a potentially life-threatening is long-standing and debilitating despite trials of multiple situation. Patients can be screened with validated instru- different opioid and nonopioid therapies. Cannabis (mari- ments, such as the Ask Suicide-Screening Questions tool juana) contains scores of pharmacologically active canna- (https://www.nimh.nih.gov/research/research-conducted- binoids. Among them, delta-9-tetrahydrocannabinol (THC) at-nimh/asq-toolkit-materials/asq-tool/asq-screening-tool. and cannabidiol (CBD) are most widely recognized. Unlike

Bibliography Item 100 Answer: D Fazel S, Runeson B. Suicide. N Engl J Med. 2020;382:266-74. [PMID: 31940700] doi:10.1056/NEJMra1902944 Educational Objective: Screen for suicidal ideation in a patient with major depressive disorder. Item 101 Answer: 8B This patient with acute worsening of previously controlled Educational Objective: Treat chronic pain with medical major depressive disorder should be assessed for suicidal cannabis. ideation (Option D). Nearly 40% of patients who attempt suicide report being seen by a physician within 1 week of the Medical cannabis (Option B) is most likely to improve this attempt; failing to inquire about suicidal ideation is a missed patient’s chronic pain related to multiple sclerosis. Her pain opportunity to intervene in a potentially life-threatening is long-standing and debilitating despite trials of multiple situation. Patients can be screened with validated instru- different opioid and nonopioid therapies. Cannabis (mari- ments, such as the Ask Suicide-Screening Questions tool juana) contains scores of pharmacologically active canna- (https://www.nimh.nih.gov/research/research-conducted- binoids. Among them, delta-9-tetrahydrocannabinol (THC) at-nimh/asq-toolkit-materials/asq-tool/asq-screening-tool. and cannabidiol (CBD) are most widely recognized. Unlike 183

Answers and Critiques THC, CBD does not produce intoxication or euphoria. Medical performed by having the patient lay supine, flexing the cannabis, predominantly in forms containing higher concen- knee fully, and externally rotating the tibia. The examiner’s trations of CBD, has shown some efficacy in the treatment of hand is over the medial joint line. The test is repeated with chronic noncancer pain. Systematic reviews have reported the tibia internally rotated. The test result is positive when that the pharmacologically active cannabinoids—nabiximols, snapping is detected over the joint line with extension of nabilone, dronabinol, oral cannabis extract, and THC—are the knee. The Thessaly test for meniscal tear is performed associated with modest improvements in patient-reported by holding the patient’s outstretched hands while the spasticity measures. When spasticity was measured using patient stands on the uninjured leg with the knee flexed to the clinician-based Ashworth spasticity scale, there was a 5 degrees; the other knee is flexed with the foot off the floor. trend toward improvement with use of cannabinoids, but The patient rotates the body internally and externally on the the effect was not statistically significant. Although canna- knee three times. The test is repeated with the knee flexed to bis is still classified as a schedule I agent by the U.S. Drug 20 degrees. This process is repeated with the injured knee. a Enforcement Administration, most states now allow patients Pain in the joint line is a positive test result. A growing body = wn to access cannabis products through state-administered of evidence supports managing degenerative meniscal tears = medical cannabis programs or recreationally. The potency conservatively with physical therapy and strengthening of @ aad nn and purity of non-FDA-approved cannabinoid products may the quadriceps and hamstring muscles. m@ i] vary from their labeled content. Studies show no functional benefit of arthroscopic sur- a. Hydrocodone/acetaminophen (Option A) is a combi- gical repair (Option A) over conservative measures, and con- (2) ie nation opioid product commonly prescribed to treat acute servative management costs less than surgical management. = and chronic pain, and buprenorphine (Option D) is a partial Pain scores do not differ between the two management 2 < opioid blocker with tight binding affinity and a long half-life options. In addition, surgical management is associated with Oo n that can be delivered in a transdermal patch applied every recovery time and time away from activities and work. The 7 days. Neuropathic pain is partially responsive to opioids, only definitive management is knee replacement. but this patient has tried numerous opioids without ben- Patients with degenerative meniscal disease can con- efit. There is no evidence to suggest that buprenorphine or tinue to perform their activities as tolerated without immo- hydrocodone products would be more effective than the bilization of the knee (Option B). Conservative measures can other opioids she has tried. help patients return to activities quickly, and protection of Topical capsaicin (Option C) has shown benefit in the the knee is unnecessary. treatment of focal neuropathic pain. It is unlikely to be Degenerative meniscal tears can be diagnosed on the beneficial for this patient with spasticity and a widespread basis of history and physical examination findings. Knee chronic pain syndrome. radiography is often unnecessary, and there is no role for advanced imaging, such as MRI (Option C).

THC, CBD does not produce intoxication or euphoria. Medical performed by having the patient lay supine, flexing the cannabis, predominantly in forms containing higher concen- knee fully, and externally rotating the tibia. The examiner’s trations of CBD, has shown some efficacy in the treatment of hand is over the medial joint line. The test is repeated with chronic noncancer pain. Systematic reviews have reported the tibia internally rotated. The test result is positive when that the pharmacologically active cannabinoids—nabiximols, snapping is detected over the joint line with extension of nabilone, dronabinol, oral cannabis extract, and THC—are the knee. The Thessaly test for meniscal tear is performed associated with modest improvements in patient-reported by holding the patient’s outstretched hands while the spasticity measures. When spasticity was measured using patient stands on the uninjured leg with the knee flexed to the clinician-based Ashworth spasticity scale, there was a 5 degrees; the other knee is flexed with the foot off the floor. trend toward improvement with use of cannabinoids, but The patient rotates the body internally and externally on the the effect was not statistically significant. Although canna- knee three times. The test is repeated with the knee flexed to bis is still classified as a schedule I agent by the U.S. Drug 20 degrees. This process is repeated with the injured knee. a Enforcement Administration, most states now allow patients Pain in the joint line is a positive test result. A growing body = wn to access cannabis products through state-administered of evidence supports managing degenerative meniscal tears = medical cannabis programs or recreationally. The potency conservatively with physical therapy and strengthening of @ aad nn and purity of non-FDA-approved cannabinoid products may the quadriceps and hamstring muscles. m@ i] vary from their labeled content. Studies show no functional benefit of arthroscopic sur- a. Hydrocodone/acetaminophen (Option A) is a combi- gical repair (Option A) over conservative measures, and con- (2) ie nation opioid product commonly prescribed to treat acute servative management costs less than surgical management. = and chronic pain, and buprenorphine (Option D) is a partial Pain scores do not differ between the two management 2 < opioid blocker with tight binding affinity and a long half-life options. In addition, surgical management is associated with Oo n that can be delivered in a transdermal patch applied every recovery time and time away from activities and work. The 7 days. Neuropathic pain is partially responsive to opioids, only definitive management is knee replacement. but this patient has tried numerous opioids without ben- Patients with degenerative meniscal disease can con- efit. There is no evidence to suggest that buprenorphine or tinue to perform their activities as tolerated without immo- hydrocodone products would be more effective than the bilization of the knee (Option B). Conservative measures can other opioids she has tried. help patients return to activities quickly, and protection of Topical capsaicin (Option C) has shown benefit in the the knee is unnecessary. treatment of focal neuropathic pain. It is unlikely to be Degenerative meniscal tears can be diagnosed on the beneficial for this patient with spasticity and a widespread basis of history and physical examination findings. Knee chronic pain syndrome. radiography is often unnecessary, and there is no role for advanced imaging, such as MRI (Option C). ¢ Medical cannabis has shown some efficacy in the treatment of chronic noncancer pain and may be con- e Degenerative meniscal tears are associated with diffuse sidered for patients whose pain has not responded to or medial knee pain; catching, locking, or inability to other therapies. extend the knee; and pain with flexion activities, such

¢ Medical cannabis has shown some efficacy in the treatment of chronic noncancer pain and may be con- e Degenerative meniscal tears are associated with diffuse sidered for patients whose pain has not responded to or medial knee pain; catching, locking, or inability to other therapies. extend the knee; and pain with flexion activities, such ¢ The potency and purity of non-FDA-approved cannab- as squatting. inoid products may vary from their labeled content. ¢ Degenerative meniscal tears can be managed conser- vatively with such strategies as physical therapy and Bibliography strengthening exercises. Cannabis and cannabinoids. Med Lett Drugs Ther. 2019;61:179-82. [PMID: 31770357] Bibliography Siemieniuk RA, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degen- erative knee arthritis and meniscal tears: a clinical practice guideline. Br Item 102 Answer: D J Sports Med. 2018;52:313. [PMID: 29449218] doi:10.1136/bjsports- Educational Objective: Treat a degenerative meniscal 2017-j1982rep tear.

inoid products may vary from their labeled content. ¢ Degenerative meniscal tears can be managed conser- vatively with such strategies as physical therapy and Bibliography strengthening exercises. Cannabis and cannabinoids. Med Lett Drugs Ther. 2019;61:179-82. [PMID: 31770357] Bibliography Siemieniuk RA, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degen- erative knee arthritis and meniscal tears: a clinical practice guideline. Br Item 102 Answer: D J Sports Med. 2018;52:313. [PMID: 29449218] doi:10.1136/bjsports- Educational Objective: Treat a degenerative meniscal 2017-j1982rep tear. The most appropriate management is physical therapy Item 103 Answer: E (Option D). This patient has a degenerative meniscal tear. Educational Objective: Diagnose somatic symptom Such tears are common in older individuals and can be a disorder. common source of knee pain in this patient population. The diagnosis can be made by the history and physical exam- This patient meets the diagnostic criteria for somatic symp- ination findings. Degenerative meniscal tears are associ- tom disorder (Option E): one or more somatic symptoms ated with diffuse or medial knee pain; catching, locking, or causing distress or interference with daily life: excessive inability to extend the knee; and pain with flexion activities, thoughts, feelings, and behaviors related to the somatic such as squatting. The McMurray test for meniscal tear is symptoms; and persistence of somatic symptoms for at least 184

Answers and Critiques 6 months. She has been extensively evaluated to exclude car- to achieve pain-free ambulation. Follow-up radiography at diac and other possible causes of her chest pain; therefore, 4 weeks can help document healing. Once the patient can somatic symptom disorder is most likely. When the main ambulate without pain and has no pain with provocative symptom is pain, the diagnosis is somatic symptom disorder maneuvers on examination, activity can be gradually rein- with predominant pain (previously termed pain disorder). troduced. Most patients with low-risk injuries can resume Cognitive behavioral therapy is the preferred treatment. running by 8 to 12 weeks. Conversion disorder (Option A) involves at least one In all cases of stress fracture, forces on the fracture site symptom of neurologic dysfunction (abnormal sensation must be reduced to permit pain-free ambulation and to or motor function) that is unexplained by a medical condi- facilitate healing. Common examples of protective devices tion and is not consistent with examination findings. These include a walking boot, leg splint, and hard-soled shoe. symptoms, which are functionally limiting, occur during Casting (Option A) is not required in the management of times of substantial physical, emotional, or psychological most stress fractures. stress. This patient does not have neurologic symptoms or Several treatment modalities of unproved benefit have +4] ® functional limitation consistent with conversion disorder. been suggested for patients with stress fracture, including =] 7 Factitious disorder (Option B) involves falsification of electrical stimulation (Option B), therapeutic ultrasonog- =

6 months. She has been extensively evaluated to exclude car- to achieve pain-free ambulation. Follow-up radiography at diac and other possible causes of her chest pain; therefore, 4 weeks can help document healing. Once the patient can somatic symptom disorder is most likely. When the main ambulate without pain and has no pain with provocative symptom is pain, the diagnosis is somatic symptom disorder maneuvers on examination, activity can be gradually rein- with predominant pain (previously termed pain disorder). troduced. Most patients with low-risk injuries can resume Cognitive behavioral therapy is the preferred treatment. running by 8 to 12 weeks. Conversion disorder (Option A) involves at least one In all cases of stress fracture, forces on the fracture site symptom of neurologic dysfunction (abnormal sensation must be reduced to permit pain-free ambulation and to or motor function) that is unexplained by a medical condi- facilitate healing. Common examples of protective devices tion and is not consistent with examination findings. These include a walking boot, leg splint, and hard-soled shoe. symptoms, which are functionally limiting, occur during Casting (Option A) is not required in the management of times of substantial physical, emotional, or psychological most stress fractures. stress. This patient does not have neurologic symptoms or Several treatment modalities of unproved benefit have +4] ® functional limitation consistent with conversion disorder. been suggested for patients with stress fracture, including =] 7 Factitious disorder (Option B) involves falsification of electrical stimulation (Option B), therapeutic ultrasonog- = symptoms, either attributed to the self or imposed on oth- raphy, prostacyclin analogs (such as iloprost), and extracor- = ws) ers, with no external benefit, whereas malingering (Option poreal shockwave therapy. Clinical trials have demonstrated =] S D) occurs whena patient feigns medical problems for gain. that electrical stimulation is no more effective than placebo bss] Patients with malingering tend to avoid diagnostic testing. in the healing of stress fracture and cannot be recommended. wn ca wo There is no evidence of factitious disorder or malingering for MRI (Option C) is more sensitive than radiography for = secondary gain in this patient. detection of stress fracture and can provide prognostic infor- wn > IlIness anxiety disorder (Option C) is characterized by mation about the risk for nonunion; it should be performed <x

symptoms, either attributed to the self or imposed on oth- raphy, prostacyclin analogs (such as iloprost), and extracor- = ws) ers, with no external benefit, whereas malingering (Option poreal shockwave therapy. Clinical trials have demonstrated =] S D) occurs whena patient feigns medical problems for gain. that electrical stimulation is no more effective than placebo bss] Patients with malingering tend to avoid diagnostic testing. in the healing of stress fracture and cannot be recommended. wn ca wo There is no evidence of factitious disorder or malingering for MRI (Option C) is more sensitive than radiography for = secondary gain in this patient. detection of stress fracture and can provide prognostic infor- wn > IlIness anxiety disorder (Option C) is characterized by mation about the risk for nonunion; it should be performed <x excessive concern about being or becoming ill. In contrast when plain radiographs are unrevealing but clinical prob- to somatic symptom disorder, no symptoms or only mild ability is high. Because this patient’s radiograph reveals a somatic symptoms are present. This patient’s presentation visible fracture in a low-risk location, MRI would not alter is symptom driven and not consistent with illness anxiety management at this point. disorder.

excessive concern about being or becoming ill. In contrast when plain radiographs are unrevealing but clinical prob- to somatic symptom disorder, no symptoms or only mild ability is high. Because this patient’s radiograph reveals a somatic symptoms are present. This patient’s presentation visible fracture in a low-risk location, MRI would not alter is symptom driven and not consistent with illness anxiety management at this point. disorder. e Stress fractures located at the base of the second met- e The diagnosis of somatic symptom disorder requires atarsal, fifth metatarsal diaphysis, and medial malleo- the presence of one or more somatic symptoms caus- lus are associated with a high risk for nonunion, and ing distress or interference with daily life; excessive orthopedic referral is recommended. thoughts, feelings, and behaviors related to the e Calcaneal fractures pose a low risk for nonunion and can somatic symptoms; and persistence of somatic symp- be managed with rest, crutches, a walking boot, and/or toms for at least 6 months. footwear padding to achieve pain-free ambulation. Bibliography Bibliography Kurlansik SL, Maffei MS. Somatic symptom disorder. Am Fam Physician. Tenforde AS, Kraus E, Fredericson M. Bone stress injuries in runners. Phys 2016;93:49-54. [PMID: 26760840] Med Rehabil Clin N Am. 2016;27:139-49. [PMID: 26616181] doi:10.1016/ j.pmr.2015.08.008

Bibliography Bibliography Kurlansik SL, Maffei MS. Somatic symptom disorder. Am Fam Physician. Tenforde AS, Kraus E, Fredericson M. Bone stress injuries in runners. Phys 2016;93:49-54. [PMID: 26760840] Med Rehabil Clin N Am. 2016;27:139-49. [PMID: 26616181] doi:10.1016/ j.pmr.2015.08.008 Item 104 Answer: D Educational Objective: Treat a calcaneal stress fracture. Item 105 Answer: A Educational Objective: Treat benign paroxysmal The most appropriate management is a walking boot (Option positional vertigo. D). The metatarsals, tarsals, and calcaneus are the most com- mon sites of stress fracture in the foot. Physical examination The canalith repositioning maneuver (Option A) is the most may reveal bony tenderness, pain with percussion, or pain appropriate next step in management. This patient has with hopping on a single leg. The calcaneal squeeze test may symptoms and examination findings (positive Dix-Hallpike elicit pain in patients with calcaneal fracture. Management maneuver) consistent with benign paroxysmal positional of foot and ankle stress fractures depends on the risk for vertigo (BPPV). BPPV, the most common form of vertigo, is nonunion, predominantly defined by the location of the characterized by dizziness, imbalance, nausea, and vom- fracture. Evaluation by an orthopedic surgeon is warranted iting that occur with positional changes of the head. The in fractures at high risk for nonunion. Such risk factors vertiginous symptoms are sudden in onset, recurrent, and include fracture at the base of the second metatarsal, fifth brief (usually <1 minute), with no focal neurologic findings. metatarsal diaphysis, and medial malleolus. Calcaneal frac- BPPV is caused by otoconia (calcium carbonate crystals) tures pose a low risk for nonunion and can be managed coming loose and moving within the fluid-filled semicircu- with rest, crutches, a walking boot, and/or footwear padding lar canals. The canalith repositioning (Epley) maneuver will

Item 104 Answer: D Educational Objective: Treat a calcaneal stress fracture. Item 105 Answer: A Educational Objective: Treat benign paroxysmal The most appropriate management is a walking boot (Option positional vertigo. D). The metatarsals, tarsals, and calcaneus are the most com- mon sites of stress fracture in the foot. Physical examination The canalith repositioning maneuver (Option A) is the most may reveal bony tenderness, pain with percussion, or pain appropriate next step in management. This patient has with hopping on a single leg. The calcaneal squeeze test may symptoms and examination findings (positive Dix-Hallpike elicit pain in patients with calcaneal fracture. Management maneuver) consistent with benign paroxysmal positional of foot and ankle stress fractures depends on the risk for vertigo (BPPV). BPPV, the most common form of vertigo, is nonunion, predominantly defined by the location of the characterized by dizziness, imbalance, nausea, and vom- fracture. Evaluation by an orthopedic surgeon is warranted iting that occur with positional changes of the head. The in fractures at high risk for nonunion. Such risk factors vertiginous symptoms are sudden in onset, recurrent, and include fracture at the base of the second metatarsal, fifth brief (usually <1 minute), with no focal neurologic findings. metatarsal diaphysis, and medial malleolus. Calcaneal frac- BPPV is caused by otoconia (calcium carbonate crystals) tures pose a low risk for nonunion and can be managed coming loose and moving within the fluid-filled semicircu- with rest, crutches, a walking boot, and/or footwear padding lar canals. The canalith repositioning (Epley) maneuver will 185

Answers and Critiques move otoconia from the semicircular canals back to the utri- The number needed to screen (Option A) is the num- cle, resolving symptoms in up to 85% of patients with BPPV. ber of patients who would need to undergo a screening Antihistamines, such as meclizine (Option B), can test to prevent one death or adverse event. It is calculated assist with symptom management in the setting of motion as the reciprocal of the absolute difference in deaths in the sickness or Meniere disease. This patient’s vertigo is most screened versus unscreened (or other comparator) popu- likely caused by canalith displacement, so the repositioning lation. This statistic is not applicable to situations in which maneuver is a more appropriate treatment than medication. diagnostic testing is indicated. MRI of the brain (Option C) would be appropriate if the The strongest experimental design is the randomized examination findings raised concern for central vertigo. In controlled trial. However, the level of evidence (Option C) is that case, examination would show a negative Dix-Hallpike not relevant in this situation because the fundamental flaw is maneuver, and HINTS (Head Impulse, Nystagmus, and the inappropriate use of a screening test in a population for Test of Skew) examination for central vertigo would show which it is not intended. > absence of catch-up saccades, bidirectional nystagmus, and Lead-time bias (Option D) is an artifactual increase in = w vertical skew. An abnormal result on any one of the three survival due to earlier diagnosis of disease from a screening = HINTS components suggests a central rather than peripheral test. Lead-time bias has no bearing on why a stool-based @o = wn cause of acute vertigo. The HINTS examination is most appli- colon cancer screening strategy is inappropriate for a high- re) = cable in patients with persistent rather than episodic vertigo. risk patient. a. Labyrinthitis can cause peripheral vertigo and hearing (2) =e loss, typically after a viral infection; it would typically cause =. constant dizziness instead of episodic dizziness, as seen in e External validity is the extent to which study results <= < this patient. Prednisone (Option D) would treat labyrinthi- can be applied to settings other than the study setting; © wn tis, but it has no role in the treatment of BPPV. it represents the generalizability of the study results. Vestibular and balance rehabilitation therapy (Option E) would be an option for vertiginous symptoms that persist Bibliography after appropriate treatment of the underlying cause. Metlay JP, Armstrong KA. Annals clinical decision making: weighing evi- dence to inform clinical decisions. Ann Intern Med. 2020;172:599-603. [PMID: 32311735] doi:10.7326/M19-1941

move otoconia from the semicircular canals back to the utri- The number needed to screen (Option A) is the num- cle, resolving symptoms in up to 85% of patients with BPPV. ber of patients who would need to undergo a screening Antihistamines, such as meclizine (Option B), can test to prevent one death or adverse event. It is calculated assist with symptom management in the setting of motion as the reciprocal of the absolute difference in deaths in the sickness or Meniere disease. This patient’s vertigo is most screened versus unscreened (or other comparator) popu- likely caused by canalith displacement, so the repositioning lation. This statistic is not applicable to situations in which maneuver is a more appropriate treatment than medication. diagnostic testing is indicated. MRI of the brain (Option C) would be appropriate if the The strongest experimental design is the randomized examination findings raised concern for central vertigo. In controlled trial. However, the level of evidence (Option C) is that case, examination would show a negative Dix-Hallpike not relevant in this situation because the fundamental flaw is maneuver, and HINTS (Head Impulse, Nystagmus, and the inappropriate use of a screening test in a population for Test of Skew) examination for central vertigo would show which it is not intended. > absence of catch-up saccades, bidirectional nystagmus, and Lead-time bias (Option D) is an artifactual increase in = w vertical skew. An abnormal result on any one of the three survival due to earlier diagnosis of disease from a screening = HINTS components suggests a central rather than peripheral test. Lead-time bias has no bearing on why a stool-based @o = wn cause of acute vertigo. The HINTS examination is most appli- colon cancer screening strategy is inappropriate for a high- re) = cable in patients with persistent rather than episodic vertigo. risk patient. a. Labyrinthitis can cause peripheral vertigo and hearing (2) =e loss, typically after a viral infection; it would typically cause =. constant dizziness instead of episodic dizziness, as seen in e External validity is the extent to which study results <= < this patient. Prednisone (Option D) would treat labyrinthi- can be applied to settings other than the study setting; © wn tis, but it has no role in the treatment of BPPV. it represents the generalizability of the study results. Vestibular and balance rehabilitation therapy (Option E) would be an option for vertiginous symptoms that persist Bibliography after appropriate treatment of the underlying cause. Metlay JP, Armstrong KA. Annals clinical decision making: weighing evi- dence to inform clinical decisions. Ann Intern Med. 2020;172:599-603. [PMID: 32311735] doi:10.7326/M19-1941 e Benign paroxysmal positional vertigo is characterized by sudden-onset, recurrent, and brief vertiginous Item 107 Answer: A symptoms that occur with positional changes of the head. Educational Objective: Evaluate chronic dyspnea with cardiopulmonary exercise testing. e Benign paroxysmal positional vertigo is treated with the canalith repositioning maneuver. Cardiopulmonary exercise testing (Option A) should be per- formed next. Cardiopulmonary exercise testing is helpful in Bibliography the evaluation of patients with chronic dyspnea without a Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: known cause after the completion of routine testing. It can benign paroxysmal positional vertigo (update). Otolaryngol Head Neck also aid in the evaluation of patients with multiple potential Surg. 2017;156:S1-47. [PMID: 28248609] doi:10.1177/0194599816689667 causes of dyspnea. Cardiopulmonary exercise testing is typi- cally performed using specialized equipment that allows for Item 106 Answer: B continuous cardiopulmonary assessment with ECG; blood pressure monitoring; pulse oximetry; and measurement of Educational Objective: Identify lack of external validity respiratory rate, tidal volume, oxygen consumption, carbon when applying the results of a study to a specific patient. dioxide production, and work output. Common indications Lack of external validity (generalizability) (Option B) is the for cardiopulmonary exercise testing include assessment of best explanation for why the stool-based test is not appro- undiagnosed exercise intolerance, measurement of exercise priate for this patient. External validity is the extent to which tolerance in patients with known cardiac or pulmonary dis- the study results can be applied to settings other than the ease, upcoming lung resection, and assessment of disability. study setting; it represents the generalizability of the study Testing can lead to physiologic understanding of the cause results. In this situation, the presence of hematochezia and of dyspnea (cardiovascular, ventilatory and gas exchange a significant family history increase the expected preva- response, metabolic issues), narrowing the differential diag- lence of colon cancer above what would be expected in an nosis, or it can support the diagnosis of deconditioning as a average-risk patient. This limits the ability to apply this test, cause of symptoms. which has acceptable performance in average-risk patients, Patients with pulmonary embolism may present with to patients with a higher pretest probability. Specifically, a chest pain, dyspnea, and tachypnea. For patients with symp- negative test result in this high-risk patient cannot reliably toms suggestive of an acute pulmonary embolism, validated exclude the presence of colon cancer as well as it could in an prediction rules that use D-dimer testing (Option B) to average-risk patient. effectively evaluate this condition, such as the Wells criteria,

e Benign paroxysmal positional vertigo is characterized by sudden-onset, recurrent, and brief vertiginous Item 107 Answer: A symptoms that occur with positional changes of the head. Educational Objective: Evaluate chronic dyspnea with cardiopulmonary exercise testing. e Benign paroxysmal positional vertigo is treated with the canalith repositioning maneuver. Cardiopulmonary exercise testing (Option A) should be per- formed next. Cardiopulmonary exercise testing is helpful in Bibliography the evaluation of patients with chronic dyspnea without a Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: known cause after the completion of routine testing. It can benign paroxysmal positional vertigo (update). Otolaryngol Head Neck also aid in the evaluation of patients with multiple potential Surg. 2017;156:S1-47. [PMID: 28248609] doi:10.1177/0194599816689667 causes of dyspnea. Cardiopulmonary exercise testing is typi- cally performed using specialized equipment that allows for Item 106 Answer: B continuous cardiopulmonary assessment with ECG; blood pressure monitoring; pulse oximetry; and measurement of Educational Objective: Identify lack of external validity respiratory rate, tidal volume, oxygen consumption, carbon when applying the results of a study to a specific patient. dioxide production, and work output. Common indications Lack of external validity (generalizability) (Option B) is the for cardiopulmonary exercise testing include assessment of best explanation for why the stool-based test is not appro- undiagnosed exercise intolerance, measurement of exercise priate for this patient. External validity is the extent to which tolerance in patients with known cardiac or pulmonary dis- the study results can be applied to settings other than the ease, upcoming lung resection, and assessment of disability. study setting; it represents the generalizability of the study Testing can lead to physiologic understanding of the cause results. In this situation, the presence of hematochezia and of dyspnea (cardiovascular, ventilatory and gas exchange a significant family history increase the expected preva- response, metabolic issues), narrowing the differential diag- lence of colon cancer above what would be expected in an nosis, or it can support the diagnosis of deconditioning as a average-risk patient. This limits the ability to apply this test, cause of symptoms. which has acceptable performance in average-risk patients, Patients with pulmonary embolism may present with to patients with a higher pretest probability. Specifically, a chest pain, dyspnea, and tachypnea. For patients with symp- negative test result in this high-risk patient cannot reliably toms suggestive of an acute pulmonary embolism, validated exclude the presence of colon cancer as well as it could in an prediction rules that use D-dimer testing (Option B) to average-risk patient. effectively evaluate this condition, such as the Wells criteria, 186

Answers and Critiques have been developed. D-dimer tests are highly sensitive but symptoms. However, benzodiazepines should be avoided in nonspecific in the diagnosis of pulmonary embolism, and patients with chronic pain because they do not appear to be false-positive results are common, including in individuals effective and present a risk for overuse and addiction. older than 50 years. A positive D-dimer result in this patient No evidence supports the use of long-term opioid ther- with chronic dyspnea and no other findings of pulmonary apy in patients with chronic noncancer pain, and opioids, embolism will probably be false-positive and fail to advance such as oxycodone (Option C), should not be considered the diagnosis of her dyspnea. first-line therapy in any patient with a chronic noncancer The 6-minute walk test (Option C) is helpful to assess pain syndrome. Evidence demonstrates that long-term opi- disability and prognosis in chronic lung conditions and may oid use is associated with poorer overall functional status, even predict mortality, but it does not provide information worse quality of life, and worse pain. on the physiologic cause of dyspnea and thereby narrow the Pregabalin (Option D), gabapentin, and duloxetine are differential diagnosis. first-line pharmacologic therapies for chronic neuropathic Progressive exertional dyspnea and exercise intolerance pain. Duloxetine is also effective in some patients with mus- w o are the most common symptoms of chronic thromboem- culoskeletal (somatic) pain, such as that which occurs with 3

have been developed. D-dimer tests are highly sensitive but symptoms. However, benzodiazepines should be avoided in nonspecific in the diagnosis of pulmonary embolism, and patients with chronic pain because they do not appear to be false-positive results are common, including in individuals effective and present a risk for overuse and addiction. older than 50 years. A positive D-dimer result in this patient No evidence supports the use of long-term opioid ther- with chronic dyspnea and no other findings of pulmonary apy in patients with chronic noncancer pain, and opioids, embolism will probably be false-positive and fail to advance such as oxycodone (Option C), should not be considered the diagnosis of her dyspnea. first-line therapy in any patient with a chronic noncancer The 6-minute walk test (Option C) is helpful to assess pain syndrome. Evidence demonstrates that long-term opi- disability and prognosis in chronic lung conditions and may oid use is associated with poorer overall functional status, even predict mortality, but it does not provide information worse quality of life, and worse pain. on the physiologic cause of dyspnea and thereby narrow the Pregabalin (Option D), gabapentin, and duloxetine are differential diagnosis. first-line pharmacologic therapies for chronic neuropathic Progressive exertional dyspnea and exercise intolerance pain. Duloxetine is also effective in some patients with mus- w o are the most common symptoms of chronic thromboem- culoskeletal (somatic) pain, such as that which occurs with 3 bolic pulmonary hypertension (CTEPH). More than 25% of fibromyalgia. Other pharmacologic options for neuropathic Pi a patients with CTEPH do not have a history of acute venous pain include capsaicin and topical lidocaine if pain genera- rs) thromboembolism. Ventilation/perfusion scanning (Option tors are focal and topically located. This patient has somatic a) < D) is the most sensitive indicator of CTEPH and should be pain, a subtype of nociceptive pain. Pregabalin is unlikely to G 4) performed in all patients in whom the diagnosis is sus- be effective in treating this patient’s pain, and nonpharma- ben o pected. However, the diagnosis of CTEPH would be unusual cologic management, with or without pharmacologic treat- = wn in a patient without findings suggesting pulmonary hyper- ment, should always be part of chronic pain management. = tension and with a normal cardiac and echocardiographic =<

bolic pulmonary hypertension (CTEPH). More than 25% of fibromyalgia. Other pharmacologic options for neuropathic Pi a patients with CTEPH do not have a history of acute venous pain include capsaicin and topical lidocaine if pain genera- rs) thromboembolism. Ventilation/perfusion scanning (Option tors are focal and topically located. This patient has somatic a) < D) is the most sensitive indicator of CTEPH and should be pain, a subtype of nociceptive pain. Pregabalin is unlikely to G 4) performed in all patients in whom the diagnosis is sus- be effective in treating this patient’s pain, and nonpharma- ben o pected. However, the diagnosis of CTEPH would be unusual cologic management, with or without pharmacologic treat- = wn in a patient without findings suggesting pulmonary hyper- ment, should always be part of chronic pain management. = tension and with a normal cardiac and echocardiographic =< examination. ¢ Nonpharmacologic multimodal programs improve pain and function in patients with chronic pain. ¢ Cardiopulmonary exercise testing is helpful in the evaluation of patients with chronic dyspnea without a Bibliography known cause after the completion of routine testing. Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharmacological treat- ment for chronic pain: a systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2018. [PMID: 30179389] Bibliography Datta D, Normandin E, ZuWallack R. Cardiopulmonary exercise testing in the assessment of exertional dyspnea. Ann Thorac Med. 2015;10:77-86. [PMID: 25829957] doi:10.4103/1817-1737.151438 Item 109 Answer: A Educational Objective: Treat a patient with familial hypercholesterolemia. Item 108 Answer: B The most appropriate treatment is high-intensity statin Educational Objective: Manage chronic pain with therapy (Option A). This patient has severe primary hyper- nonpharmacologic multimodal therapy. cholesterolemia with a strong family history of premature A multimodal approach (Option B) plays an important role atherosclerotic cardiovascular disease (ASCVD). The Amer- in the management of all pain subtypes, including acute and ican Heart Association criteria for the clinical diagnosis of chronic non-cancer-related pain. Patients with chronic pain familial hypercholesterolemia include an LDL cholesterol should be referred to a structured physical therapy program level of 190 mg/dL (4.92 mmol/L) or greater and either for evaluation and treatment aimed at improving functional a first-degree relative with an LDL cholesterol level of status. High-quality evidence suggests that physical ther- 190 mg/dL (4.92 mmol/L) or greater or with known prema- apy programs improve both pain and function in patients ture coronary heart disease, defined as occurring before age with debilitation due to pain. Continuation of physical ther- 55 years in men and before age 60 years in women. apy beyond 12 weeks should be based on iterative clinical In patients aged 20 to 75 years with an LDL cholesterol assessments and documented gains. Like physical therapy, level of 190 mg/dL (4.92 mmol/L) or greater, the American exercise programs improve pain and function in patients Heart Association/American College of Cardiology recom- with chronic pain, although no specific regimen has proved mend high-intensity statin therapy regardless of 10-year superior. Cognitive behavioral techniques, including cogni- ASCVD risk. Cholesterol levels should be remeasured in 4 to tive behavioral therapy, mindfulness practices, and biofeed- 12 weeks, with an LDL cholesterol goal of 100 mg/dL or less back, have been associated with reduced pain and improved and/or a 50% reduction in LDL cholesterol level. All patients overall function and mood. should be counseled on therapeutic lifestyle changes, such Benzodiazepines, such as lorazepam (Option A), are as exercise, weight reduction, and smoking cessation. If sometimes prescribed for patients with acute low back the LDL cholesterol level remains above goal with receipt of pain when other therapies have failed to adequately control maximally tolerated statin therapy, initiation of ezetimibe is

examination. ¢ Nonpharmacologic multimodal programs improve pain and function in patients with chronic pain. ¢ Cardiopulmonary exercise testing is helpful in the evaluation of patients with chronic dyspnea without a Bibliography known cause after the completion of routine testing. Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharmacological treat- ment for chronic pain: a systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2018. [PMID: 30179389] Bibliography Datta D, Normandin E, ZuWallack R. Cardiopulmonary exercise testing in the assessment of exertional dyspnea. Ann Thorac Med. 2015;10:77-86. [PMID: 25829957] doi:10.4103/1817-1737.151438 Item 109 Answer: A Educational Objective: Treat a patient with familial hypercholesterolemia. Item 108 Answer: B The most appropriate treatment is high-intensity statin Educational Objective: Manage chronic pain with therapy (Option A). This patient has severe primary hyper- nonpharmacologic multimodal therapy. cholesterolemia with a strong family history of premature A multimodal approach (Option B) plays an important role atherosclerotic cardiovascular disease (ASCVD). The Amer- in the management of all pain subtypes, including acute and ican Heart Association criteria for the clinical diagnosis of chronic non-cancer-related pain. Patients with chronic pain familial hypercholesterolemia include an LDL cholesterol should be referred to a structured physical therapy program level of 190 mg/dL (4.92 mmol/L) or greater and either for evaluation and treatment aimed at improving functional a first-degree relative with an LDL cholesterol level of status. High-quality evidence suggests that physical ther- 190 mg/dL (4.92 mmol/L) or greater or with known prema- apy programs improve both pain and function in patients ture coronary heart disease, defined as occurring before age with debilitation due to pain. Continuation of physical ther- 55 years in men and before age 60 years in women. apy beyond 12 weeks should be based on iterative clinical In patients aged 20 to 75 years with an LDL cholesterol assessments and documented gains. Like physical therapy, level of 190 mg/dL (4.92 mmol/L) or greater, the American exercise programs improve pain and function in patients Heart Association/American College of Cardiology recom- with chronic pain, although no specific regimen has proved mend high-intensity statin therapy regardless of 10-year superior. Cognitive behavioral techniques, including cogni- ASCVD risk. Cholesterol levels should be remeasured in 4 to tive behavioral therapy, mindfulness practices, and biofeed- 12 weeks, with an LDL cholesterol goal of 100 mg/dL or less back, have been associated with reduced pain and improved and/or a 50% reduction in LDL cholesterol level. All patients overall function and mood. should be counseled on therapeutic lifestyle changes, such Benzodiazepines, such as lorazepam (Option A), are as exercise, weight reduction, and smoking cessation. If sometimes prescribed for patients with acute low back the LDL cholesterol level remains above goal with receipt of pain when other therapies have failed to adequately control maximally tolerated statin therapy, initiation of ezetimibe is 187

Answers and Critiques reasonable. The 2020 U.S. Department of Veterans Affairs/ is no therapy for the purpura, but sun protection is recom- U.S. Department of Defense cholesterol guideline does not mended to prevent further damage. No additional testing or specifically address the treatment of familial hypercholester- treatment is required, and the patient should be reassured. olemia but would otherwise recommend moderate-intensity Other causes of purpuric lesions include immune statin therapy for primary ASCVD prevention in patients thrombocytopenic purpura and thrombotic thrombocyto- with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) penic purpura. These hematologic diseases require an initial or higher. Because statin therapy is contraindicated in preg- evaluation that includes complete blood count (Option A). nancy, this patient’s oral contraceptive should be continued. This patient’s current symptoms, time course, and physical Ezetimibe in addition to high-intensity statin therapy examination findings do not suggest a more sinister type of (Option B) is indicated for patients in whom high-intensity purpura, and laboratory testing should not be pursued. statin therapy alone fails to achieve goal LDL cholesterol Hydrochlorothiazide can contribute to photosensitiv- reduction, but it should not be initiated before a trial of ity and has rarely been associated with Stevens-Johnson > high-intensity statin therapy alone. syndrome/toxic epidermal necrolysis (SJS/TEN). Symptoms J nr Adding icosapent ethyl to high-intensity statin ther- of SJS/TEN typically develop within the first few weeks = apy (Option C) might be considered in patients who have after starting hydrochlorothiazide and include red or pur- @o = n persistently elevated fasting triglyceride levels greater than ple dusky macules on the trunk that progress to vesicles, mw 150 mg/dL (1.69 mmol/L) to reduce cardiovascular mor- erosion, and ulceration, with painful erosions in the mouth, = a. tality. However, this should not be considered before high- eyes, or genitals. Hydrochlorothiazide is not causing this oO ae intensity statin therapy is tried. patient’s actinic purpura, and discontinuation of this medi- =. Initiation of a proprotein convertase subtilisin/kexin cation (Option B) would not affect the rash. 2 <= type 9 (PCSK9) inhibitor (Option D) may be considered in The diagnosis of actinic purpura can be made on the o wn patients aged 40 to 75 years with a baseline LDL cholesterol basis of clinical findings alone. Skin biopsy (Option C) is not level of 220 mg/dL (5.70 mmol/L) or greater and in whom necessary.

reasonable. The 2020 U.S. Department of Veterans Affairs/ is no therapy for the purpura, but sun protection is recom- U.S. Department of Defense cholesterol guideline does not mended to prevent further damage. No additional testing or specifically address the treatment of familial hypercholester- treatment is required, and the patient should be reassured. olemia but would otherwise recommend moderate-intensity Other causes of purpuric lesions include immune statin therapy for primary ASCVD prevention in patients thrombocytopenic purpura and thrombotic thrombocyto- with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) penic purpura. These hematologic diseases require an initial or higher. Because statin therapy is contraindicated in preg- evaluation that includes complete blood count (Option A). nancy, this patient’s oral contraceptive should be continued. This patient’s current symptoms, time course, and physical Ezetimibe in addition to high-intensity statin therapy examination findings do not suggest a more sinister type of (Option B) is indicated for patients in whom high-intensity purpura, and laboratory testing should not be pursued. statin therapy alone fails to achieve goal LDL cholesterol Hydrochlorothiazide can contribute to photosensitiv- reduction, but it should not be initiated before a trial of ity and has rarely been associated with Stevens-Johnson > high-intensity statin therapy alone. syndrome/toxic epidermal necrolysis (SJS/TEN). Symptoms J nr Adding icosapent ethyl to high-intensity statin ther- of SJS/TEN typically develop within the first few weeks = apy (Option C) might be considered in patients who have after starting hydrochlorothiazide and include red or pur- @o = n persistently elevated fasting triglyceride levels greater than ple dusky macules on the trunk that progress to vesicles, mw 150 mg/dL (1.69 mmol/L) to reduce cardiovascular mor- erosion, and ulceration, with painful erosions in the mouth, = a. tality. However, this should not be considered before high- eyes, or genitals. Hydrochlorothiazide is not causing this oO ae intensity statin therapy is tried. patient’s actinic purpura, and discontinuation of this medi- =. Initiation of a proprotein convertase subtilisin/kexin cation (Option B) would not affect the rash. 2 <= type 9 (PCSK9) inhibitor (Option D) may be considered in The diagnosis of actinic purpura can be made on the o wn patients aged 40 to 75 years with a baseline LDL cholesterol basis of clinical findings alone. Skin biopsy (Option C) is not level of 220 mg/dL (5.70 mmol/L) or greater and in whom necessary. maximally tolerated statin and ezetimibe therapy does not Topical glucocorticoids, such as triamcinolone (Option achieve an LDL cholesterol level of 130 mg/dL (3.37 mmol/L) D), will not treat actinic purpura. The thinning action of or less. A PCSK9 inhibitor should not be initiated before chronic glucocorticoid application on the dermis and epi- high-intensity statin therapy is tried. In patients with a con- dermis is likely to worsen actinic purpura. firmed diagnosis of familial hypercholesterolemia, PCSK9 inhibitors are indicated if the LDL cholesterol remains greater than 100 mg/dL (2.59 mmol/L) despite statin and e Actinic purpura appears as purpuric macules or

maximally tolerated statin and ezetimibe therapy does not Topical glucocorticoids, such as triamcinolone (Option achieve an LDL cholesterol level of 130 mg/dL (3.37 mmol/L) D), will not treat actinic purpura. The thinning action of or less. A PCSK9 inhibitor should not be initiated before chronic glucocorticoid application on the dermis and epi- high-intensity statin therapy is tried. In patients with a con- dermis is likely to worsen actinic purpura. firmed diagnosis of familial hypercholesterolemia, PCSK9 inhibitors are indicated if the LDL cholesterol remains greater than 100 mg/dL (2.59 mmol/L) despite statin and e Actinic purpura appears as purpuric macules or ezetimibe therapy. patches, most commonly on the forearms and legs of older adults, and requires no testing or treatment. e High-intensity statin therapy is indicated in patients Bibliography aged 20 to 75 years with an LDL cholesterol level of Tobin DJ. Introduction to skin aging. J Tissue Viability. 2017;26:37-46. 190 mg/dL (4.92 mmol/L) or greater regardless of [PMID: 27020864] doi:10.1016/j.jtv.2016.03.002 10-year risk for atherosclerotic cardiovascular disease.

e High-intensity statin therapy is indicated in patients Bibliography aged 20 to 75 years with an LDL cholesterol level of Tobin DJ. Introduction to skin aging. J Tissue Viability. 2017;26:37-46. 190 mg/dL (4.92 mmol/L) or greater regardless of [PMID: 27020864] doi:10.1016/j.jtv.2016.03.002 10-year risk for atherosclerotic cardiovascular disease. Item 111 Answer: B Bibliography Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ Educational Objective: Diagnose greater trochanteric ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management pain syndrome. of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. The most likely diagnosis is greater trochanteric pain syn- Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. 0000000000000625 drome (GTPS) (Option B), formerly known as trochanteric bursitis. The most helpful diagnostic test for GTPS is to ask the patient to point to the location of the pain. If the patient

Item 111 Answer: B Bibliography Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ Educational Objective: Diagnose greater trochanteric ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management pain syndrome. of blood cholesterol: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. The most likely diagnosis is greater trochanteric pain syn- Circulation. 2019;139:e1082-143. [PMID: 30586774] doi:10.1161/CIR. 0000000000000625 drome (GTPS) (Option B), formerly known as trochanteric bursitis. The most helpful diagnostic test for GTPS is to ask the patient to point to the location of the pain. If the patient Item 110 Answer: E points to the lateral hip near the greater femoral trochanter, GTPS is the most likely diagnosis. The likely cause of GTPS is Educational Objective: Manage actinic purpura in an friction between the greater trochanter and iliotibial band, elderly patient. causing repetitive microtrauma of the gluteal tendons. The Reassurance (Option E) is the most appropriate next step in characteristic finding of tenderness over the greater tro- management of this elderly patient, who describes the classic chanter implies inflammation of the bursa, and more recent constellation of symptoms of actinic purpura. Actinic purpura studies have shown involvement of the gluteus minimus appears as purpuric macules or patches, most commonly on and medius tendons with similar frequency. Pain that wors- the forearms and anterior legs, after minor trauma, such as ens with lying on the affected side suggests GTPS; the pain scratching. It is caused by blood vessel fragility and dermal may also radiate to the buttock or knee if the iliotibial band atrophy from aging. With the passage of time, the macules is affected. The FABER (Flexion, ABduction, and External fade to a brown or tan color before resolving completely. There Rotation) test may cause lateral hip pain with GTPS. Most

Item 110 Answer: E points to the lateral hip near the greater femoral trochanter, GTPS is the most likely diagnosis. The likely cause of GTPS is Educational Objective: Manage actinic purpura in an friction between the greater trochanter and iliotibial band, elderly patient. causing repetitive microtrauma of the gluteal tendons. The Reassurance (Option E) is the most appropriate next step in characteristic finding of tenderness over the greater tro- management of this elderly patient, who describes the classic chanter implies inflammation of the bursa, and more recent constellation of symptoms of actinic purpura. Actinic purpura studies have shown involvement of the gluteus minimus appears as purpuric macules or patches, most commonly on and medius tendons with similar frequency. Pain that wors- the forearms and anterior legs, after minor trauma, such as ens with lying on the affected side suggests GTPS; the pain scratching. It is caused by blood vessel fragility and dermal may also radiate to the buttock or knee if the iliotibial band atrophy from aging. With the passage of time, the macules is affected. The FABER (Flexion, ABduction, and External fade to a brown or tan color before resolving completely. There Rotation) test may cause lateral hip pain with GTPS. Most 188

Answers and Critiques cases respond to conservative measures, including activity or heart failure because of the associated toxicity risks. modification, physical therapy, NSAIDs, and weight loss. Documented complications include hypotension and vol- Femoroacetabular impingement syndrome (FAIS) ume depletion, hyperphosphatemia, hypo- or hyperkalemia, (Option A) is a cause of anterior hip or groin pain attributed metabolic acidosis, severe hypocalcemia, kidney failure, and to abnormal contact of the femoral head-neck junction prolonged QT interval. against the acetabular rim of the hip joint with normal range Methylnaltrexone (Option D) is a peripherally act- of motion. Patients with FAIS describe an insidious onset of ing u-opioid receptor antagonist that does not cross the groin pain that is worse after sitting for a prolonged period blood-brain barrier and therefore can aid in the treatment and improves with standing. Movement is often associated of refractory opioid-induced constipation without revers- with pain. FAIS is associated with an aspherical femoral ing analgesia. Methylnaltrexone is often rapid acting, but head. FAIS is not responsible for this patient’s lateral hip it is contraindicated in patients with suspected bowel pain. obstruction. The American Gastroenterological Association Hip osteoarthritis (Option C) presents as groin or guideline for opioid-induced constipation provides a strong “A a buttock pain. Lateral hip pain that worsens with pressure, recommendation with at least moderate- to high-quality = = such as sleeping on the affected side, is not characteristic of evidence for two peripherally acting 1-opioid receptor antag 7 osteoarthritis. onists, naldemedine and naloxegol, for constipation refrac Ss) Meralgia paresthetica (Option D) causes upper outer tory to first-line treatment with laxatives. Methylnaltrexone sc = thigh paresthesia in the distribution of the lateral femo- has a conditional recommendation based on low-quality © wn ral cutaneous nerve; sensory disturbances are often found evidence. The best course of action for this patient is to pro- i o on examination. This patient’s hip pain is lateral, whereas ceed with a stimulant laxative and then reassess the need for = wv patients with meralgia paresthetica have pain that is more advanced therapies. = <= anterior. Finally, the patient’s sensory examination was nor- mal, making this diagnosis unlikely. ¢ Opioid-induced constipation requires prophylactic and ongoing pharmacologic therapy with an osmotic e The characteristic finding of greater trochanteric pain laxative, such as polyethylene glycol; stimulant laxatives syndrome is tenderness over the greater trochanter. are often needed in addition.

cases respond to conservative measures, including activity or heart failure because of the associated toxicity risks. modification, physical therapy, NSAIDs, and weight loss. Documented complications include hypotension and vol- Femoroacetabular impingement syndrome (FAIS) ume depletion, hyperphosphatemia, hypo- or hyperkalemia, (Option A) is a cause of anterior hip or groin pain attributed metabolic acidosis, severe hypocalcemia, kidney failure, and to abnormal contact of the femoral head-neck junction prolonged QT interval. against the acetabular rim of the hip joint with normal range Methylnaltrexone (Option D) is a peripherally act- of motion. Patients with FAIS describe an insidious onset of ing u-opioid receptor antagonist that does not cross the groin pain that is worse after sitting for a prolonged period blood-brain barrier and therefore can aid in the treatment and improves with standing. Movement is often associated of refractory opioid-induced constipation without revers- with pain. FAIS is associated with an aspherical femoral ing analgesia. Methylnaltrexone is often rapid acting, but head. FAIS is not responsible for this patient’s lateral hip it is contraindicated in patients with suspected bowel pain. obstruction. The American Gastroenterological Association Hip osteoarthritis (Option C) presents as groin or guideline for opioid-induced constipation provides a strong “A a buttock pain. Lateral hip pain that worsens with pressure, recommendation with at least moderate- to high-quality = = such as sleeping on the affected side, is not characteristic of evidence for two peripherally acting 1-opioid receptor antag 7 osteoarthritis. onists, naldemedine and naloxegol, for constipation refrac Ss) Meralgia paresthetica (Option D) causes upper outer tory to first-line treatment with laxatives. Methylnaltrexone sc = thigh paresthesia in the distribution of the lateral femo- has a conditional recommendation based on low-quality © wn ral cutaneous nerve; sensory disturbances are often found evidence. The best course of action for this patient is to pro- i o on examination. This patient’s hip pain is lateral, whereas ceed with a stimulant laxative and then reassess the need for = wv patients with meralgia paresthetica have pain that is more advanced therapies. = <= anterior. Finally, the patient’s sensory examination was nor- mal, making this diagnosis unlikely. ¢ Opioid-induced constipation requires prophylactic and ongoing pharmacologic therapy with an osmotic e The characteristic finding of greater trochanteric pain laxative, such as polyethylene glycol; stimulant laxatives syndrome is tenderness over the greater trochanter. are often needed in addition. e Peripherally acting p-opioid receptor antagonists are Bibliography recommended for opioid-induced constipation refrac- Hirschmann A, Falkowski AL, Kovacs B. Greater trochanteric pain syn- tory to first-line treatment with laxatives. drome: abductors, external rotators. Semin Musculoskelet Radiol. 2017; 21:539-46. [PMID: 29025184] doi:10.1055/s-0037-1606139

e Peripherally acting p-opioid receptor antagonists are Bibliography recommended for opioid-induced constipation refrac- Hirschmann A, Falkowski AL, Kovacs B. Greater trochanteric pain syn- tory to first-line treatment with laxatives. drome: abductors, external rotators. Semin Musculoskelet Radiol. 2017; 21:539-46. [PMID: 29025184] doi:10.1055/s-0037-1606139 Bibliography Crockett SD, Greer KB, Heidelbaugh JJ, et al; American Gastroenterological Association Institute Clinical Guidelines Committee. American Item 112 Answer: 8B Gastroenterological Association Institute guideline on the medical man- agement of opioid-induced constipation. Gastroenterology. 2019;156:218- Educational Objective: Treat opioid-induced 26. [PMID: 30340754] doi:10.1053/j.gastro.2018.07.016 constipation.

Bibliography Crockett SD, Greer KB, Heidelbaugh JJ, et al; American Gastroenterological Association Institute Clinical Guidelines Committee. American Item 112 Answer: 8B Gastroenterological Association Institute guideline on the medical man- agement of opioid-induced constipation. Gastroenterology. 2019;156:218- Educational Objective: Treat opioid-induced 26. [PMID: 30340754] doi:10.1053/j.gastro.2018.07.016 constipation. Senna (Option B) is the most appropriate treatment for this patient's constipation. The patient has developed opioid- Item 113 Answer: C induced constipation in the setting of opioid treatment for Educational Objective: Screen for HLA-B*58:01 in osteoporotic vertebral compression fractures, and the con- a patient of Asian descent before initiating allopurinol stipation has probably worsened because oflimited mobility therapy. due to the fractures. Most patients develop constipation with opioid use, and tolerance to this side effect typically does not The most appropriate initial management is HLA-B*58:01 improve over time, necessitating prophylactic and ongoing genotyping (Option C). Allopurinol is associated with severe pharmacologic therapy. Many patients can be managed with cutaneous adverse reactions, including toxic epidermal an osmotic laxative, such as polyethylene glycol, but stimu- necrolysis and StevensJohnson syndrome. Allopurinol- lant laxatives, such as senna, are often needed in addition to related severe cutaneous adverse reactions are rare, usually prevent constipation. occur in the presence of chronic kidney disease and diuretic Studies have evaluated the effectiveness of docu- use, and have a high mortality rate. The risk for severe cuta- sate sodium (Option A) in patients with constipation in neous adverse reactions is significantly increased in patients the setting of serious illness, and several trials found it to be with the HLA-B*58:01 haplotype, but these reactions still no better than placebo. Therefore, the addition of docusate occur infrequently. The use of allopurinol is contraindicated sodium is unlikely to help with this patient's constipation in patients with HLA-B*58:01 positivity. HLA-B*58:01 preva- symptoms. lence varies by race and ethnicity; rates are higher in Asian A sodium phosphate enema (Option C) is contraindi- (5.3%) and Black (3.8%) persons than in White persons (<1%). cated in elderly patients and in those with kidney failure The 2020 American College of Rheumatology Guideline for

Senna (Option B) is the most appropriate treatment for this patient's constipation. The patient has developed opioid- Item 113 Answer: C induced constipation in the setting of opioid treatment for Educational Objective: Screen for HLA-B*58:01 in osteoporotic vertebral compression fractures, and the con- a patient of Asian descent before initiating allopurinol stipation has probably worsened because oflimited mobility therapy. due to the fractures. Most patients develop constipation with opioid use, and tolerance to this side effect typically does not The most appropriate initial management is HLA-B*58:01 improve over time, necessitating prophylactic and ongoing genotyping (Option C). Allopurinol is associated with severe pharmacologic therapy. Many patients can be managed with cutaneous adverse reactions, including toxic epidermal an osmotic laxative, such as polyethylene glycol, but stimu- necrolysis and StevensJohnson syndrome. Allopurinol- lant laxatives, such as senna, are often needed in addition to related severe cutaneous adverse reactions are rare, usually prevent constipation. occur in the presence of chronic kidney disease and diuretic Studies have evaluated the effectiveness of docu- use, and have a high mortality rate. The risk for severe cuta- sate sodium (Option A) in patients with constipation in neous adverse reactions is significantly increased in patients the setting of serious illness, and several trials found it to be with the HLA-B*58:01 haplotype, but these reactions still no better than placebo. Therefore, the addition of docusate occur infrequently. The use of allopurinol is contraindicated sodium is unlikely to help with this patient's constipation in patients with HLA-B*58:01 positivity. HLA-B*58:01 preva- symptoms. lence varies by race and ethnicity; rates are higher in Asian A sodium phosphate enema (Option C) is contraindi- (5.3%) and Black (3.8%) persons than in White persons (<1%). cated in elderly patients and in those with kidney failure The 2020 American College of Rheumatology Guideline for 189

Answers and Critiques the Management of Gout conditionally recommends genetic vertigo arising from a peripheral cause, including unidi testing before prescribing allopurinol for patients of East rectional nystagmus with the Dix Hallpike maneuver and Asian (e.g., Han Chinese, Korean, Thai) descent and for Black catch-up saccades with head impulse testing. Labyrinthitis patients. is caused by postviral inflammation of both branches of the Urate-lowering therapy (Options A, B) is recommended vestibulocochlear nerve (cranial nerve VIII). resulting in for patients with gout plus any of the following: (1) stage 2 or sudden-onset, severe, persistent vertigo and hearing loss. greater chronic kidney disease; (2) two or more acute attacks This patient's symptoms and her recent viral upper respira per year; (3) one or more tophi; or (4) uric acid nephrolithi- tory tract infection are consistent with the diagnosis of lab asis. Allopurinol is the recommended first-line choice for yrinthitis. Labyrinthitis is usually treated with prednisone. urate-lowering therapy. During initiation of urate-lowering Benign paroxysmal positional vertigo (BPPV) (Option therapy, mobilization of uric acid crystals from the joints and A) is a common cause of peripheral vertigo. However, it soft tissues can provoke acute attacks. Accordingly, patients typically causes brief episodes of vertigo provoked by posi > starting urate-lowering therapy should receive anti-inflam- tion change, rather than the continuous vertigo described = wn matory prophylaxis to prevent flares. Choices include col- by this patient. BPPV is not typically associated with hear = chicine, low-dose NSAIDs, or low-dose glucocorticoids. In ing loss. @ - wn this patient, initiation of urate-lowering therapy (allopurinol Symptoms of Meniere disease (Option C) typically re) with colchicine or prednisone) is not appropriate until the include episodic vertigo with insidious onset of both sen = a. results of genetic testing are known. sorineural hearing loss and tinnitus; the hearing loss and (=) =e Thiopurine methyltransferase (TPMT), a key enzyme tinnitus occur sometimes years before the vertigo. Meniere =. involved in the metabolism of azathioprine and 6-mercap- disease would cause examination findings consistent with 2 = topurine (6-MP), exhibits a population polymorphism that peripheral vertigo, but it would be uncommon for Meniere 1] wn greatly increases the risk for bone marrow toxicity with disease to present with constant vertigo that worsens rapidly. use of these agents. Therefore, before initiation of thiopu- Ramsay Hunt syndrome (herpes zoster infection involv rine therapy, testing for the TPMT genotype or phenotype ing cranial nerve VII) (Option D) causes peripheral vertigo (enzyme activity) (Option D) is recommended to help pre- but has clinical features unlike this patient’s; it usually pre vent toxicity by identifying individuals with low or absent sents with ear pain and vesicles in the auditory canal. It can TPMT enzyme activity. Allopurinol can inhibit TPMT activity also cause unilateral facial paralysis (from cranial nerve VII and is contraindicated in patients taking azathioprine or involvement), taste loss or dysgeusia (from cranial nerve VII 6-MP. Low or absent TPMT activity will not increase the risk branch chorda tympani involvement), and altered hearing for adverse reactions in this patient. (if cranial nerve VIII is involved). Ramsay Hunt syndrome is usually seen in young immunosuppressed persons (such as those with AIDS) or in adults older than 50 years. e Allopurinol is associated with severe cutaneous adverse In vertebrobasilar ischemia (Option E), physical exam reactions; the risk for hypersensitivity is significantly ination findings are consistent with central ischemia (neg increased in patients with the HLA-B*58:01 haplotype. ative Dix-Hallpike maneuver and absence of catch-up sac

testing before prescribing allopurinol for patients of East rectional nystagmus with the Dix Hallpike maneuver and Asian (e.g., Han Chinese, Korean, Thai) descent and for Black catch-up saccades with head impulse testing. Labyrinthitis patients. is caused by postviral inflammation of both branches of the Urate-lowering therapy (Options A, B) is recommended vestibulocochlear nerve (cranial nerve VIII). resulting in for patients with gout plus any of the following: (1) stage 2 or sudden-onset, severe, persistent vertigo and hearing loss. greater chronic kidney disease; (2) two or more acute attacks This patient's symptoms and her recent viral upper respira per year; (3) one or more tophi; or (4) uric acid nephrolithi- tory tract infection are consistent with the diagnosis of lab asis. Allopurinol is the recommended first-line choice for yrinthitis. Labyrinthitis is usually treated with prednisone. urate-lowering therapy. During initiation of urate-lowering Benign paroxysmal positional vertigo (BPPV) (Option therapy, mobilization of uric acid crystals from the joints and A) is a common cause of peripheral vertigo. However, it soft tissues can provoke acute attacks. Accordingly, patients typically causes brief episodes of vertigo provoked by posi > starting urate-lowering therapy should receive anti-inflam- tion change, rather than the continuous vertigo described = wn matory prophylaxis to prevent flares. Choices include col- by this patient. BPPV is not typically associated with hear = chicine, low-dose NSAIDs, or low-dose glucocorticoids. In ing loss. @ - wn this patient, initiation of urate-lowering therapy (allopurinol Symptoms of Meniere disease (Option C) typically re) with colchicine or prednisone) is not appropriate until the include episodic vertigo with insidious onset of both sen = a. results of genetic testing are known. sorineural hearing loss and tinnitus; the hearing loss and (=) =e Thiopurine methyltransferase (TPMT), a key enzyme tinnitus occur sometimes years before the vertigo. Meniere =. involved in the metabolism of azathioprine and 6-mercap- disease would cause examination findings consistent with 2 = topurine (6-MP), exhibits a population polymorphism that peripheral vertigo, but it would be uncommon for Meniere 1] wn greatly increases the risk for bone marrow toxicity with disease to present with constant vertigo that worsens rapidly. use of these agents. Therefore, before initiation of thiopu- Ramsay Hunt syndrome (herpes zoster infection involv rine therapy, testing for the TPMT genotype or phenotype ing cranial nerve VII) (Option D) causes peripheral vertigo (enzyme activity) (Option D) is recommended to help pre- but has clinical features unlike this patient’s; it usually pre vent toxicity by identifying individuals with low or absent sents with ear pain and vesicles in the auditory canal. It can TPMT enzyme activity. Allopurinol can inhibit TPMT activity also cause unilateral facial paralysis (from cranial nerve VII and is contraindicated in patients taking azathioprine or involvement), taste loss or dysgeusia (from cranial nerve VII 6-MP. Low or absent TPMT activity will not increase the risk branch chorda tympani involvement), and altered hearing for adverse reactions in this patient. (if cranial nerve VIII is involved). Ramsay Hunt syndrome is usually seen in young immunosuppressed persons (such as those with AIDS) or in adults older than 50 years. e Allopurinol is associated with severe cutaneous adverse In vertebrobasilar ischemia (Option E), physical exam reactions; the risk for hypersensitivity is significantly ination findings are consistent with central ischemia (neg increased in patients with the HLA-B*58:01 haplotype. ative Dix-Hallpike maneuver and absence of catch-up sac e Genetic testing for the HLA-B*58:01 haplotype is rec- cades on the head impulse test). Vertebrobasilar ischemia

testing before prescribing allopurinol for patients of East rectional nystagmus with the Dix Hallpike maneuver and Asian (e.g., Han Chinese, Korean, Thai) descent and for Black catch-up saccades with head impulse testing. Labyrinthitis patients. is caused by postviral inflammation of both branches of the Urate-lowering therapy (Options A, B) is recommended vestibulocochlear nerve (cranial nerve VIII). resulting in for patients with gout plus any of the following: (1) stage 2 or sudden-onset, severe, persistent vertigo and hearing loss. greater chronic kidney disease; (2) two or more acute attacks This patient's symptoms and her recent viral upper respira per year; (3) one or more tophi; or (4) uric acid nephrolithi- tory tract infection are consistent with the diagnosis of lab asis. Allopurinol is the recommended first-line choice for yrinthitis. Labyrinthitis is usually treated with prednisone. urate-lowering therapy. During initiation of urate-lowering Benign paroxysmal positional vertigo (BPPV) (Option therapy, mobilization of uric acid crystals from the joints and A) is a common cause of peripheral vertigo. However, it soft tissues can provoke acute attacks. Accordingly, patients typically causes brief episodes of vertigo provoked by posi > starting urate-lowering therapy should receive anti-inflam- tion change, rather than the continuous vertigo described = wn matory prophylaxis to prevent flares. Choices include col- by this patient. BPPV is not typically associated with hear = chicine, low-dose NSAIDs, or low-dose glucocorticoids. In ing loss. @ - wn this patient, initiation of urate-lowering therapy (allopurinol Symptoms of Meniere disease (Option C) typically re) with colchicine or prednisone) is not appropriate until the include episodic vertigo with insidious onset of both sen = a. results of genetic testing are known. sorineural hearing loss and tinnitus; the hearing loss and (=) =e Thiopurine methyltransferase (TPMT), a key enzyme tinnitus occur sometimes years before the vertigo. Meniere =. involved in the metabolism of azathioprine and 6-mercap- disease would cause examination findings consistent with 2 = topurine (6-MP), exhibits a population polymorphism that peripheral vertigo, but it would be uncommon for Meniere 1] wn greatly increases the risk for bone marrow toxicity with disease to present with constant vertigo that worsens rapidly. use of these agents. Therefore, before initiation of thiopu- Ramsay Hunt syndrome (herpes zoster infection involv rine therapy, testing for the TPMT genotype or phenotype ing cranial nerve VII) (Option D) causes peripheral vertigo (enzyme activity) (Option D) is recommended to help pre- but has clinical features unlike this patient’s; it usually pre vent toxicity by identifying individuals with low or absent sents with ear pain and vesicles in the auditory canal. It can TPMT enzyme activity. Allopurinol can inhibit TPMT activity also cause unilateral facial paralysis (from cranial nerve VII and is contraindicated in patients taking azathioprine or involvement), taste loss or dysgeusia (from cranial nerve VII 6-MP. Low or absent TPMT activity will not increase the risk branch chorda tympani involvement), and altered hearing for adverse reactions in this patient. (if cranial nerve VIII is involved). Ramsay Hunt syndrome is usually seen in young immunosuppressed persons (such as those with AIDS) or in adults older than 50 years. e Allopurinol is associated with severe cutaneous adverse In vertebrobasilar ischemia (Option E), physical exam reactions; the risk for hypersensitivity is significantly ination findings are consistent with central ischemia (neg increased in patients with the HLA-B*58:01 haplotype. ative Dix-Hallpike maneuver and absence of catch-up sac e Genetic testing for the HLA-B*58:01 haplotype is rec- cades on the head impulse test). Vertebrobasilar ischemia ommended before prescribing allopurinol in Asian commonly occurs in patients with risk factors for vascular disease and often presents with other neurologic findings in patients, particularly those of Han Chinese, Thai, and addition to vertigo, such as dysarthria, dysphagia, diplopia, Korean descent. weakness, or numbness.

ommended before prescribing allopurinol in Asian commonly occurs in patients with risk factors for vascular disease and often presents with other neurologic findings in patients, particularly those of Han Chinese, Thai, and addition to vertigo, such as dysarthria, dysphagia, diplopia, Korean descent. weakness, or numbness. Bibliography Saito Y, Stamp LK, Caudle KE, et al; Clinical Pharmacogenetics Implementation Consortium. Clinical Pharmacogenetics Implementation ¢ Labyrinthitis is caused by postviral inflammation of Consortium (CPIC) guidelines for human leukocyte antigen B (HLA-B) the vestibulocochlear nerve (cranial nerve VIII), genotype and allopurinol dosing: 2015 update. Clin Pharmacol Ther. resulting in sudden-onset, severe, persistent vertigo 2016;99:36-7. [PMID: 26094938] doi:10.1002/cpt.161 and hearing loss. ¢ Labyrinthitis is treated with prednisone. C) Item 114 Answer: B Educational Objective: Diagnose labyrinthitis. Bibliography Zwergal A, Dieterich M. Vertigo and dizziness in the emergency room. Labyrinthitis (Option B) is the most likely diagnosis. This Curr Opin Neurol. 2020;33:117-25. [PMID: 31743236] doi:10.1097/WCO. patient has symptoms and examination findings suggesting 0000000000000769 190