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Answers and Critiques Item 1 Answer: D XEY POl lll5 (continued) Educational Objective: Treat genitourinary syndrome o If nonhormonal treatments are not effective in the of menopause. treatment of genitourinary syndrome of menopause, guidelines recommend the use of low dose topical The most appropriate initial treatment is daily topical vaginal moisturizer (Option D). This patient has genitourinary syn vaginal estrogen therapy rather than systemic estro- drome of menopause (GSM). Vaginal symptoms are common gen therapy for patients whose only symptoms are in menopause and can include sexual symptoms, such as related to vaginal atrophy. a (l, dyspareunia; vaginal dryness, burning, and itching; and uri ET nary symptoms, such as dysuria and frequent urinary tract Bibliography infections. The North American Menopause Society recom The NAMS 2017 hormone therapy position statement advisory panel. The 2017 hormone therapy position statement of the North American t, mends initiating nonhormonal therapies as first line treat Menopause Society. Menopatse. 2017:24:728-53. [PMID: 28650869] =l E ment lbr GSM betbre considering other therapies, including doi: lo. I 097i GME. 00000000OO000921 .E UI topical vaginal estrogen therapy. Nonhormonal approaches o include as needed vaginal lubricants for intercourse and vag inal moisturizers that can alleviate vaginal dryness and irrita Item 2 Answer: B cta= tion when used regularly. A daily topical vaginal moisturizer Educational Objective: Treat hidradenitis suppurativa. may improve this patient's symptoms of vaginal dryness and itching and pain with sexual intercourse. Adalimumab (Option B), a tumor necrosis factor-a inhibitor, lf nonhormonal treatments are not ell'ective, guidelines is the most appropriate additional treatment. It is the only recommend the use of low dose topical vaginal estrogen FDA approved therapy for hidradenitis suppurativa and is therapy rather than systemic estrogen therapy for patients indicated lor use in patients with moderate to severe dis whose only symptoms are related to vaginal atrophy. Sys ease. Moderate to severe disease is defined by the presence of temic estrogen therapy (Option A) is associated with higher multiple recurring nodules or the development of scarring. risk fbr complications, such as venous thromboembolism, Hidradenitis suppurativa is an inflammatory skin disorder compared with low dose topical vaginal estrogen therapy. of the apocrine glands. This disease tends to occur more Ospemifene (Option B) is a selective estrogen receptor commonll,in women and tlpically begins after puberty. The modulator that is FDA approved tbr the treatment of moder pathogenesis of hidradenitis begins with follicular occlusion, ate to severe GSM. However, its use is limited by its side efl'ect but not infection or inflammation of the apocrine glands. profile, which includes hot flashes and an increased risk lbr After occlusion, secretions build up in the follicular duct and venous thromboembolism. A daily topical vaginal moistur result in rupture and a subsequent inflammatory reaction that izer is a more appropriate flrst line therapy. resembles a bacterial abscess. An acute inflammatory reaction 'lbpical vaginal estrogen therapy (Option C) is a treatment is then triggered in the surrounding tissue. The role ofbacteria option fbr GSM, but the North American Menop:ruse Society rec is controversial and is likely a secondary colonization, because ommends the use olnonhonnonal therapies as initial treatment. lesions are initially sterile and antibiotics are not entirely Women with urinary slmptoms ol GSM, which this patient efI'ective in preventing new lesions. The chronic and recurrent does not have, may benefit more fiom topical estrogen therapy nature of hidradenitis suppurativa helps distinguish it from because there is some evidence that topical estrogen therapy can other inlectious causes. Areas frequently aflected are inter help reduce urinary slmptoms, including frequent urinary tract triginous areas, such as the axilla, groin, and underneath the infections. Topical vaginal estrogen is available in three prepara breasts. The condition is characterizrd by comedones, painful tions (cream, tablet, or ring) and is not associated with the same nodules, abscesses, draining sinuses, and scarring. Risk fac risks as systemic estrogen therapy. l,brwomen with breast cancer tors include obesity, metabolic syndrome, cigarette smoking, (past or current), topical vaginal estrogen therapy should only be and family history. For this reason, weight loss and smoking oflbred in consultation with their or.rcologist. cessation are an essential part of the treatment plan. Hi dradenitis suppurativa is extremely difficult to treat. No single I(EY POITIS treatment has been eflective for all patients; however, several . The North American Menopause Society recommends options are available. Decolonization with dilute bleach baths initiating nonhormonal therapies, such as daily vagi and chlorhexidine washes may be used in addition to topical nal moisturizer and vaginal lubricants, as first line clindamycin as initial therapy. For more extensive or resistant treatments fbr genitourinary syndrome of menopause disease, common systemic treatments include oral antibiotics, before considering topical vaginal estrogen therapy. such as tetracyclines or the combination of clindamycin and (Continued) rifampin. This patient with several active lesions and scarring

Answers and Critiques Item 1 Answer: D XEY POl lll5 (continued) Educational Objective: Treat genitourinary syndrome o If nonhormonal treatments are not effective in the of menopause. treatment of genitourinary syndrome of menopause, guidelines recommend the use of low dose topical The most appropriate initial treatment is daily topical vaginal moisturizer (Option D). This patient has genitourinary syn vaginal estrogen therapy rather than systemic estro- drome of menopause (GSM). Vaginal symptoms are common gen therapy for patients whose only symptoms are in menopause and can include sexual symptoms, such as related to vaginal atrophy. a (l, dyspareunia; vaginal dryness, burning, and itching; and uri ET nary symptoms, such as dysuria and frequent urinary tract Bibliography infections. The North American Menopause Society recom The NAMS 2017 hormone therapy position statement advisory panel. The 2017 hormone therapy position statement of the North American t, mends initiating nonhormonal therapies as first line treat Menopause Society. Menopatse. 2017:24:728-53. [PMID: 28650869] =l E ment lbr GSM betbre considering other therapies, including doi: lo. I 097i GME. 00000000OO000921 .E UI topical vaginal estrogen therapy. Nonhormonal approaches o include as needed vaginal lubricants for intercourse and vag inal moisturizers that can alleviate vaginal dryness and irrita Item 2 Answer: B cta= tion when used regularly. A daily topical vaginal moisturizer Educational Objective: Treat hidradenitis suppurativa. may improve this patient's symptoms of vaginal dryness and itching and pain with sexual intercourse. Adalimumab (Option B), a tumor necrosis factor-a inhibitor, lf nonhormonal treatments are not ell'ective, guidelines is the most appropriate additional treatment. It is the only recommend the use of low dose topical vaginal estrogen FDA approved therapy for hidradenitis suppurativa and is therapy rather than systemic estrogen therapy for patients indicated lor use in patients with moderate to severe dis whose only symptoms are related to vaginal atrophy. Sys ease. Moderate to severe disease is defined by the presence of temic estrogen therapy (Option A) is associated with higher multiple recurring nodules or the development of scarring. risk fbr complications, such as venous thromboembolism, Hidradenitis suppurativa is an inflammatory skin disorder compared with low dose topical vaginal estrogen therapy. of the apocrine glands. This disease tends to occur more Ospemifene (Option B) is a selective estrogen receptor commonll,in women and tlpically begins after puberty. The modulator that is FDA approved tbr the treatment of moder pathogenesis of hidradenitis begins with follicular occlusion, ate to severe GSM. However, its use is limited by its side efl'ect but not infection or inflammation of the apocrine glands. profile, which includes hot flashes and an increased risk lbr After occlusion, secretions build up in the follicular duct and venous thromboembolism. A daily topical vaginal moistur result in rupture and a subsequent inflammatory reaction that izer is a more appropriate flrst line therapy. resembles a bacterial abscess. An acute inflammatory reaction 'lbpical vaginal estrogen therapy (Option C) is a treatment is then triggered in the surrounding tissue. The role ofbacteria option fbr GSM, but the North American Menop:ruse Society rec is controversial and is likely a secondary colonization, because ommends the use olnonhonnonal therapies as initial treatment. lesions are initially sterile and antibiotics are not entirely Women with urinary slmptoms ol GSM, which this patient efI'ective in preventing new lesions. The chronic and recurrent does not have, may benefit more fiom topical estrogen therapy nature of hidradenitis suppurativa helps distinguish it from because there is some evidence that topical estrogen therapy can other inlectious causes. Areas frequently aflected are inter help reduce urinary slmptoms, including frequent urinary tract triginous areas, such as the axilla, groin, and underneath the infections. Topical vaginal estrogen is available in three prepara breasts. The condition is characterizrd by comedones, painful tions (cream, tablet, or ring) and is not associated with the same nodules, abscesses, draining sinuses, and scarring. Risk fac risks as systemic estrogen therapy. l,brwomen with breast cancer tors include obesity, metabolic syndrome, cigarette smoking, (past or current), topical vaginal estrogen therapy should only be and family history. For this reason, weight loss and smoking oflbred in consultation with their or.rcologist. cessation are an essential part of the treatment plan. Hi dradenitis suppurativa is extremely difficult to treat. No single I(EY POITIS treatment has been eflective for all patients; however, several . The North American Menopause Society recommends options are available. Decolonization with dilute bleach baths initiating nonhormonal therapies, such as daily vagi and chlorhexidine washes may be used in addition to topical nal moisturizer and vaginal lubricants, as first line clindamycin as initial therapy. For more extensive or resistant treatments fbr genitourinary syndrome of menopause disease, common systemic treatments include oral antibiotics, before considering topical vaginal estrogen therapy. such as tetracyclines or the combination of clindamycin and (Continued) rifampin. This patient with several active lesions and scarring 155

Answers and Critiques is experiencing moderate to severe disease. and treatment require dosage adjustn-rent in patients with advanced kid with adalimumab is indicated. ney disease because decreased kidney clearance of these An oral retinoid, such as acitretin (Option A), is an medications may be associated with adverse events. The excellent treatment option for hidradenitis suppurativa CDS system r.rotifled the physician of the contraindication that fails to respond to initial therapy with topical or oral to use full dose rivaroxaban ir.r this patient and prevented antibiotics and other adjunctive therapies. Nonadherence the potential harn-r. is common due to side effects. However, coadministration Electronic transmission ol prescriptions (Option B) with doxycycline poses an unacceptable high risk for the has reduced delays in obtaining prescriptions and elimi- patient to develop idiopathic intracranial hypertension and nates errors due to prescription legibilitf issues. This process is therefore not the best choice fbr additional therapy. improles the likelihood that a r.nedication is disper.rsed as Methotrexate (Option C) has not been shown to be intended but is unlikely to result in a change in the rnedica efficacious in hidradenitis suppurativa and should not be tion prescribed. prescribed. When applied to medication prescritring, best practice t^ Narrow band ultraviolet B phototherapy (Option D) is alerts or advisories typically provide infbrmation on how o a powerful tool in the treatment of psoriasis vulgaris and best to institute and monitor specific rnedications. The1, = tt other conditions. such as mycosis fungoides, atopic derma rnal' provide guidance on appropriate lab<,rratory ntonitoring o, titis, and vitiligo, but has no role in treatment of hidradenitis (Option C) or duration of therapy. They usually are distinct CL suppurativa. fiom a contraindicaticln alert. n Patient inlbrmation fact sheets (Option D) are t1'picalll' TEY POIIIIT provided by the pharmacy upolr medication dispensing and lt o Hidradenitis suppurativa is associated with smoking, provide information regarding medication administration. .D t/l obesity, and metabolic syndrome, and these condi- erpected medication effects. and potential adverse events. tions should be addressed. Their provision typically $'ould not result in a change in o Adalimumab is FDA approved for moderate to severe rnedication. hidradenitis, defined by the presence ofdiffuse nodules IEY POIilI or scar formation. o Computerized clinical decision support can high- light potential contraindications to diagnostic tests, Bibliography specify dose recommendations. identify potential Coldburg SR. Strober B[. Payette MJ. Hidradenitis suppurativa: current and emerging treatments. J Am Acad Dermatol. 2020:82:lo6l 82. LPMII): drug interactions, and suggest modifications to 316041001 doi:10.101 6rj.jaad.2019.08.089 drug dosage in patients with kidney or liver dysfunction.

is experiencing moderate to severe disease. and treatment require dosage adjustn-rent in patients with advanced kid with adalimumab is indicated. ney disease because decreased kidney clearance of these An oral retinoid, such as acitretin (Option A), is an medications may be associated with adverse events. The excellent treatment option for hidradenitis suppurativa CDS system r.rotifled the physician of the contraindication that fails to respond to initial therapy with topical or oral to use full dose rivaroxaban ir.r this patient and prevented antibiotics and other adjunctive therapies. Nonadherence the potential harn-r. is common due to side effects. However, coadministration Electronic transmission ol prescriptions (Option B) with doxycycline poses an unacceptable high risk for the has reduced delays in obtaining prescriptions and elimi- patient to develop idiopathic intracranial hypertension and nates errors due to prescription legibilitf issues. This process is therefore not the best choice fbr additional therapy. improles the likelihood that a r.nedication is disper.rsed as Methotrexate (Option C) has not been shown to be intended but is unlikely to result in a change in the rnedica efficacious in hidradenitis suppurativa and should not be tion prescribed. prescribed. When applied to medication prescritring, best practice t^ Narrow band ultraviolet B phototherapy (Option D) is alerts or advisories typically provide infbrmation on how o a powerful tool in the treatment of psoriasis vulgaris and best to institute and monitor specific rnedications. The1, = tt other conditions. such as mycosis fungoides, atopic derma rnal' provide guidance on appropriate lab<,rratory ntonitoring o, titis, and vitiligo, but has no role in treatment of hidradenitis (Option C) or duration of therapy. They usually are distinct CL suppurativa. fiom a contraindicaticln alert. n Patient inlbrmation fact sheets (Option D) are t1'picalll' TEY POIIIIT provided by the pharmacy upolr medication dispensing and lt o Hidradenitis suppurativa is associated with smoking, provide information regarding medication administration. .D t/l obesity, and metabolic syndrome, and these condi- erpected medication effects. and potential adverse events. tions should be addressed. Their provision typically $'ould not result in a change in o Adalimumab is FDA approved for moderate to severe rnedication. hidradenitis, defined by the presence ofdiffuse nodules IEY POIilI or scar formation. o Computerized clinical decision support can high- light potential contraindications to diagnostic tests, Bibliography specify dose recommendations. identify potential Coldburg SR. Strober B[. Payette MJ. Hidradenitis suppurativa: current and emerging treatments. J Am Acad Dermatol. 2020:82:lo6l 82. LPMII): drug interactions, and suggest modifications to 316041001 doi:10.101 6rj.jaad.2019.08.089 drug dosage in patients with kidney or liver dysfunction. tr Item 3 Answer: A Educational Objective: Use clinical decision support to Bibliography Billstein Leber M, Carrilk) CJ. Cassano ,\1. et al. .\SIIP guidelines on pre improve medication safety. Venting medication er()rs in hospitrls. Am J tlerlth S).st Pharnt. 201tt: 75:1,193 517. IPMTD:302578-1-11 doi:10.21 16 aihplT08ll Computerized clir.rical decision support (CDS) (Option A) is the feature ot the electronic health record (EHR) that rnost likely accounts for tl.re physician's decisiort to mod ify the patient's prescription. The EIIR is a computer- ized system that encompasses patient record reviert, and Item 4 Answer: A Educational Objective: Manage perioperative tr glucocorticoids. treatment ordering lunctionality fbr clinicians. The EilR enables the timely sharing of patient information by mul The most appropriate preoperative gluc<-rcorticoid manage tiple users, resulting in in-rproved communication and care ment is to plan for administration of stress-dose gluco efficiency. Computerized physician order entry (CPOF.) is corticoids perioperatively (Option A) to avoid an adrenal a system by w'hich clinicians electronically enter medica crisis. Patients receiving long term glucocorticoid therapy tion, radiology, and iaboratory orders, thereby reducing may be at risk fbr secclndary adrenal insulficiency (Al) and errors and delays related to illegible handu'ritir.rg. Comput perioperative adrenal crisis. Historicall\l increased gluco erized CDS is the use of intbrmation technology to facilitate corticoid doses (stress dosing) n'ere administered liberally clinical decision making. When integrated into a CPOE in the perioperative period to mimic the natural response system, CDS can highlight potential contraindications to of'the adrenal glands t<-r phy'siologic stress. However. studies diagnostic tests, specify dose recommendations. identily have shorvn that stress dosing n.ray not be required in n.ran1' potential drug interactit-rns, and suggest modifications to patients receiving low dose and short course glucocorti drug dosage in patients r,,r,ith kidney or liver dysfunction. coid therapy. When managing a patient u'ith glucocorticoid In this case. the physician u'as going to prescribe this patient exposure rvithin the past year, considerations include the lull d<lse rivaroxaban to reduce the risk for stroke caused by type of surgery (low intermediate, or high risk) and the atrial librillation. However. many direct oral anticoagulants dose and duration of glucocorticoid therapy. Patients on

tr Item 3 Answer: A Educational Objective: Use clinical decision support to Bibliography Billstein Leber M, Carrilk) CJ. Cassano ,\1. et al. .\SIIP guidelines on pre improve medication safety. Venting medication er()rs in hospitrls. Am J tlerlth S).st Pharnt. 201tt: 75:1,193 517. IPMTD:302578-1-11 doi:10.21 16 aihplT08ll Computerized clir.rical decision support (CDS) (Option A) is the feature ot the electronic health record (EHR) that rnost likely accounts for tl.re physician's decisiort to mod ify the patient's prescription. The EIIR is a computer- ized system that encompasses patient record reviert, and Item 4 Answer: A Educational Objective: Manage perioperative tr glucocorticoids. treatment ordering lunctionality fbr clinicians. The EilR enables the timely sharing of patient information by mul The most appropriate preoperative gluc<-rcorticoid manage tiple users, resulting in in-rproved communication and care ment is to plan for administration of stress-dose gluco efficiency. Computerized physician order entry (CPOF.) is corticoids perioperatively (Option A) to avoid an adrenal a system by w'hich clinicians electronically enter medica crisis. Patients receiving long term glucocorticoid therapy tion, radiology, and iaboratory orders, thereby reducing may be at risk fbr secclndary adrenal insulficiency (Al) and errors and delays related to illegible handu'ritir.rg. Comput perioperative adrenal crisis. Historicall\l increased gluco erized CDS is the use of intbrmation technology to facilitate corticoid doses (stress dosing) n'ere administered liberally clinical decision making. When integrated into a CPOE in the perioperative period to mimic the natural response system, CDS can highlight potential contraindications to of'the adrenal glands t<-r phy'siologic stress. However. studies diagnostic tests, specify dose recommendations. identily have shorvn that stress dosing n.ray not be required in n.ran1' potential drug interactit-rns, and suggest modifications to patients receiving low dose and short course glucocorti drug dosage in patients r,,r,ith kidney or liver dysfunction. coid therapy. When managing a patient u'ith glucocorticoid In this case. the physician u'as going to prescribe this patient exposure rvithin the past year, considerations include the lull d<lse rivaroxaban to reduce the risk for stroke caused by type of surgery (low intermediate, or high risk) and the atrial librillation. However. many direct oral anticoagulants dose and duration of glucocorticoid therapy. Patients on 156

Answers and Critiques tr CONI, high doses ol glucocorticoids fbr cxtended periods (equiva lent of >20 nrgid prednisone fbr >3 lreeks) arc at high risk for AI and should receive stress dosing u,hen undergoing lclrenal insufficiency: Guidelines Irorn the Association of Anaesthetists, the Royal College of Physicians and the Society fbr lrndocrinologlr UK. Anaesthesia. 2O2O :75:654 63. IPM] D: 32017012|r doi: l 0. l111, anae. l,l96:l intermediate to high-risk surgery. These patients may not need glucocorticoid support fbr a low risk proccclure, such as cataract surgery. Patients at low risk fbr AI (those taking Item 5 Answer: B lor,r, doses ol glucocorticoicls lirr shorter periods) can gen- erally proceed to surgery ol any risk lerel r.t,ithout stress- Educational Objective: Diagnose malignant dose glucocorticoids. Patients at moderate risk fttr AI may melanoma with an excisional biopsy. require testing to assess firr the presence of adrcnal insuffi- The most appropriate management is excisional biopsy ciency belore determining best pcrioperative management, (Option B) in this patient who most likely has a malignant although newer guidelines suggest treating empirically with melanoma. Melanoma is the leading cause of skin cancer stress dose glucocorticoids ftrr a large proportion of this related deaths, and early detection and diagnosis are t/l (l, intermediate risk group. this patient is at moclerate risk for imperative. Skin biopsy is required fbr definitive diagno ET AI because she receired rnorc than 5 mgrfl ol prcdnisone sis. An excisional biopsy, a technique in which the entire during thc past year: previously required supplemcntal glu lesion is removed using 1- to 2 mm peripheral margins. (J cocorticoids during another nlajor operation; and is under- is the most appropriate biopsy technique. For localized going total l<nce arthroplasty. which is an intermediate risk =, melanomas, prognosis is related to the depth of invasion, |g procedure. Continuing her baseline glucocorticoids alone UI either by Clark level (l to V) or by Breslow depth. A high (Option B) r.r,ould not be suflicient to avoid a potential o mitotic rate, lymphovascular invasion, and the presence t adrenal crisis. of bleeding or ulceration are poor prognostic signs. As = Nlornir.rg measurement of serum cortisol (Option C) the depth of invasion increases, the risk for nodal and can be usecl to screen for adrenal suppression in patients ultimately distant metastasis increases. Lesion depth also with less clear risk. If the B:00 ,rv morning corlisol level infbrms the nature of definitive excision. A margin of I cm is less than ll pg/dl (82.8 nnrol/1.) in the absence of glu is acceptable for lesions that are less than 1 mm in thick cocorticoid rcplacement for 24 hours, the aclrenal gland ness. Melanomas between 1 mm and 2 mm in thickness is supprcssccl and perioperative glucocorticoid stress dos should be resected with a 2 cm margin, provided that ing is indicatcd. An B:00 ,rvr cortisol level greater than a skin graft is not required for closure. Lesions that are 15 pgrdt- (+t+ nmolll) indicates normal adrenal function greater than 2 mm in thickness should also be resected and no nccd fbr stress dosing. Values of 3 to la pg/dl with 2-cm margins. (83-386 nrnol/L) require additional evaluation, such as a Cryotherapy (Option A) or other destructive therapies, corticotropin (ACTH) stimulatior-r test or glucocorticoid such as electrodesiccation and curettage, should not be used stress dosir.rg, according the physician's best juclgment. to treat pigmented lesions that are suspicious for malig Prior eviclence of adrenal insufliciency and glucocorti nant melanoma. Destructive therapies of this llpe remove coid use of greater than 5 mgld make adrenal axis testing the ability to determine the depth of the lesion, which is unnecessary in this patient. impofiant for determining prognosis and planning surgical Because of the risk fbr adrenal suppression and dis- excision. ln addition, destroying the tumor removes the ease flare. prcdnisone should not be u,ithheld (Option D). ability assess for genetic mutations that may guide f'uture Studies clemonstrate that only glucocorlicoid doscs greater therapy. than l5 mgrcl are associated with signiflcant increases in the Survival in malignant melanoma is dependent on early risk for post arthroplasty inlection in patients with rheu diagnosis. This lesion exhibits all of the ABCDE criteria fbr matoid arthritis. Continuing low daily glucocorticoicl doses diagnosing melanoma: Asymmetry, Border irregularity, throughout the perioperative period is unlikely to result in Color variation, Diameter greater than 6 mm, and Evolution complications in this patient. or change over time. Because of the importance of early detection and diagnosis of malignant melanoma, reevalua XEV POII{IS tion in 3 months (Option C) is not appropriate. . Perioperative glucocorticoid stress dosing may not be Superflcial shave biopsies (Option D) should be required in many patients receiving low dose and avoided in most pigmented lesions because there is risk short-course glucocorticoid therapy. fbr transecting a melanoma and preventing true stag . Patients at moderate risk for adrenal insufficiency ing of the lesion. A deep shave (scoop or saucerization) may require testing to determine perioperative man- biopsy to a depth below the lesion is also adequate but agement, although treating empirically with stress is best performed by dermatologists, who have more doses of glucocorticoids may be reasonable. experience with this procedure. However, an excisional biopsy is most appropriate because it enables the entire lesion to be examined by the pathologist fbr an accurate Bibliography \ bodcock T. Barker P, Daniel S, et al. Guidelines for the ntrnrgement of Breslow depth measurement, the most important factor in glucocorticoids during the peri operative period ti)r patients \\'ith determining prognosis.

tr CONI, high doses ol glucocorticoids fbr cxtended periods (equiva lent of >20 nrgid prednisone fbr >3 lreeks) arc at high risk for AI and should receive stress dosing u,hen undergoing lclrenal insufficiency: Guidelines Irorn the Association of Anaesthetists, the Royal College of Physicians and the Society fbr lrndocrinologlr UK. Anaesthesia. 2O2O :75:654 63. IPM] D: 32017012|r doi: l 0. l111, anae. l,l96:l intermediate to high-risk surgery. These patients may not need glucocorticoid support fbr a low risk proccclure, such as cataract surgery. Patients at low risk fbr AI (those taking Item 5 Answer: B lor,r, doses ol glucocorticoicls lirr shorter periods) can gen- erally proceed to surgery ol any risk lerel r.t,ithout stress- Educational Objective: Diagnose malignant dose glucocorticoids. Patients at moderate risk fttr AI may melanoma with an excisional biopsy. require testing to assess firr the presence of adrcnal insuffi- The most appropriate management is excisional biopsy ciency belore determining best pcrioperative management, (Option B) in this patient who most likely has a malignant although newer guidelines suggest treating empirically with melanoma. Melanoma is the leading cause of skin cancer stress dose glucocorticoids ftrr a large proportion of this related deaths, and early detection and diagnosis are t/l (l, intermediate risk group. this patient is at moclerate risk for imperative. Skin biopsy is required fbr definitive diagno ET AI because she receired rnorc than 5 mgrfl ol prcdnisone sis. An excisional biopsy, a technique in which the entire during thc past year: previously required supplemcntal glu lesion is removed using 1- to 2 mm peripheral margins. (J cocorticoids during another nlajor operation; and is under- is the most appropriate biopsy technique. For localized going total l<nce arthroplasty. which is an intermediate risk =, melanomas, prognosis is related to the depth of invasion, |g procedure. Continuing her baseline glucocorticoids alone UI either by Clark level (l to V) or by Breslow depth. A high (Option B) r.r,ould not be suflicient to avoid a potential o mitotic rate, lymphovascular invasion, and the presence t adrenal crisis. of bleeding or ulceration are poor prognostic signs. As = Nlornir.rg measurement of serum cortisol (Option C) the depth of invasion increases, the risk for nodal and can be usecl to screen for adrenal suppression in patients ultimately distant metastasis increases. Lesion depth also with less clear risk. If the B:00 ,rv morning corlisol level infbrms the nature of definitive excision. A margin of I cm is less than ll pg/dl (82.8 nnrol/1.) in the absence of glu is acceptable for lesions that are less than 1 mm in thick cocorticoid rcplacement for 24 hours, the aclrenal gland ness. Melanomas between 1 mm and 2 mm in thickness is supprcssccl and perioperative glucocorticoid stress dos should be resected with a 2 cm margin, provided that ing is indicatcd. An B:00 ,rvr cortisol level greater than a skin graft is not required for closure. Lesions that are 15 pgrdt- (+t+ nmolll) indicates normal adrenal function greater than 2 mm in thickness should also be resected and no nccd fbr stress dosing. Values of 3 to la pg/dl with 2-cm margins. (83-386 nrnol/L) require additional evaluation, such as a Cryotherapy (Option A) or other destructive therapies, corticotropin (ACTH) stimulatior-r test or glucocorticoid such as electrodesiccation and curettage, should not be used stress dosir.rg, according the physician's best juclgment. to treat pigmented lesions that are suspicious for malig Prior eviclence of adrenal insufliciency and glucocorti nant melanoma. Destructive therapies of this llpe remove coid use of greater than 5 mgld make adrenal axis testing the ability to determine the depth of the lesion, which is unnecessary in this patient. impofiant for determining prognosis and planning surgical Because of the risk fbr adrenal suppression and dis- excision. ln addition, destroying the tumor removes the ease flare. prcdnisone should not be u,ithheld (Option D). ability assess for genetic mutations that may guide f'uture Studies clemonstrate that only glucocorlicoid doscs greater therapy. than l5 mgrcl are associated with signiflcant increases in the Survival in malignant melanoma is dependent on early risk for post arthroplasty inlection in patients with rheu diagnosis. This lesion exhibits all of the ABCDE criteria fbr matoid arthritis. Continuing low daily glucocorticoicl doses diagnosing melanoma: Asymmetry, Border irregularity, throughout the perioperative period is unlikely to result in Color variation, Diameter greater than 6 mm, and Evolution complications in this patient. or change over time. Because of the importance of early detection and diagnosis of malignant melanoma, reevalua XEV POII{IS tion in 3 months (Option C) is not appropriate. . Perioperative glucocorticoid stress dosing may not be Superflcial shave biopsies (Option D) should be required in many patients receiving low dose and avoided in most pigmented lesions because there is risk short-course glucocorticoid therapy. fbr transecting a melanoma and preventing true stag . Patients at moderate risk for adrenal insufficiency ing of the lesion. A deep shave (scoop or saucerization) may require testing to determine perioperative man- biopsy to a depth below the lesion is also adequate but agement, although treating empirically with stress is best performed by dermatologists, who have more doses of glucocorticoids may be reasonable. experience with this procedure. However, an excisional biopsy is most appropriate because it enables the entire lesion to be examined by the pathologist fbr an accurate Bibliography \ bodcock T. Barker P, Daniel S, et al. Guidelines for the ntrnrgement of Breslow depth measurement, the most important factor in glucocorticoids during the peri operative period ti)r patients \\'ith determining prognosis. 167

Answers and Critiques XEY POIXT aged 50 years or older should receive the recombinant (inac tivated) herpes zoster vaccine. o For suspected malignant melanoma, excisional biopsy, a technique in which the entire lesion is removed TEY POIXIS using 1 to 2-mm peripheral margins, is used for both . Adults aged 50 years or older should receive the diagnosis and determination of Breslow depth. recombinant herpes zoster vaccine regardless of a his- tory of herpes zoster vaccination with the live attenu Bibliography ated vaccine or a previous episode of herpes zoster. Swetter SM,'Isao H, Bichakjian CK. et al. Guidelines of care for the manage ment of primary cutaneous melanoma. J Am Acad Dermatol. 2019: . The Advisory Committee on Immunization Practices 80:208 50. IPMID: 30392755J doi:10.1016rj.jaad.2018.08.055 provides no recommendation regarding use of the recombinant herpes zoster vaccine in immunocom promised patients or patients with HIV infection. D Item 6 Answer: B (a (D Ed u cati o na I Objective : Vaccinate with recombinant Bibliography = (inactivated) herpes zoster vaccine. I.'reedman \lS. Bernsteir.l tl. Ault KA. Reconrmended adult immunization Ut schedule. United Strtes, 2021. Ann lntern l\'led. 2021. [PI!{lD: 33571011] q, doi:10.71126 \12O SOUO The most appropriate vaccine to administer to this patient is EL the recombinant (inactivated) herpes zoster vaccine (Option r.| B). Adults aged 50 years or older should receive the recom- Item 7 Answer: C lt binant (inactivated) herpes zoster vaccine to reduce the inci Educational Objective: Screen and monitor for (D dence ofzoster and postherpetic neuralgia. The recombinant UI hypertension in a young adult. vaccine is administered intramuscularly in two doses, with an interval of 2 to 6 months between doses. This patient's The most appropriate next step in management is to repeat previous episode of herpes zoster does not provide immunity blood pressure measurement annually (Option C). This against future episodes and should not preclude additional patient has received appropriate screening for hypertension zoster vaccination. In addition, persons who received the at a routine wellness examination. She has no signs or symp live attenuated herpes zoster vaccine, such as this patient, toms ofcardiovascular disease and her blood pressure at this should be oflered the recombinant herpes zoster vaccine visit is in the high normal range, according to the U.S. Pre given its increased efficacy; the recombinant vaccine has ventive Services Task Force (USPSTF). The USPSTF supports shown 97"/,, efficacy in persons aged 50 to 69 years and 91"/,, screening all adults beginning at age 18 years for hyperten efficacy in persons aged 70 years or older. Patients who have sion (grade A). Screening should occur annually in adults received the live attenuated vaccine should wait at least aged 40 years or older and in younger adults at increased 8 weeks before receiving the recombinant vaccine. The Advi risk, including patients with high normal blood pressure. sory Committee on Immunization Practices has not made a patients who are overweight or obese, and Black patients. recommendation regarding the recombinant herpes zoster On the basis ol this patient's blood pressure reading today vaccine in immunocompromised patients or patients with (129178 mm Hg) and her having obesity (BMI of 30), she HIV infection, regardless of CD4 cell count. should have repeated blood pressure measurement annually. The quadrivalent meningococcal conjugate vac patients who are overweight or obese. and Black patients. cine (Option A) is recommended to be given at age 11 to On the basis of this patient's blood pressure reading today 12 years, with a booster dose at age 16 years. Adults who are (130/85 mm Hg) and her having obesity (BMI of 30), she at increased risk for meningococcal disease should undergo should have repeated blood pressure measurement annually. primary vaccination if they never received age-appropriate The 2017 American College of Cardiolog,iAmerican Heart vaccination. Increased risk is deflned as persistent comple Association blood pressure guideline recommends repeated ment component deflciencies or patients taking eculizumab; annual blood pressure measurement fbr adults with a nor functional or anatomic asplenia (including sickle cell dis mal pressure reading. ease); HIV infection; microbiologists routinely exposed to This patient does not meet criteria for initiation of Neisserio meningitidis; a meningococcal disease outbreak; antihypertensive medication (Option A). Before treatment and travel or residence in countries with hyperendemic or is initiated, when possible and in the absence of severe epidemic meningococcal disease. This patient has no indica- hypertension or end organ damage, the diagnosis should tion for the quadrivalent meningococcal conjugate vaccine. be conflrmed with blood pressure measurements outside of For healthy patients who are nonsmokers, the 23-valent the clinical setting by using ambulatory or home blood pres pneumococcal polysaccharide vaccine (Option C) is recom sure monitoring. This patient with high normal blood pres mended at age 65 years. This 64 year-old patient who is a sure reading can be reassessed in 1 year without initiating nonsmoker with no significant medical history does not treatment. need to receive the vaccine early. Left ventricular hypertrophy (LVH) is commonly mea Providing no vaccines is not the best strateS/ (Option sured by ECG andror echocardiography (Option B). Assess D). In the absence ofspecific contraindications, all patients ment for LVH is not universally recommended during

XEY POIXT aged 50 years or older should receive the recombinant (inac tivated) herpes zoster vaccine. o For suspected malignant melanoma, excisional biopsy, a technique in which the entire lesion is removed TEY POIXIS using 1 to 2-mm peripheral margins, is used for both . Adults aged 50 years or older should receive the diagnosis and determination of Breslow depth. recombinant herpes zoster vaccine regardless of a his- tory of herpes zoster vaccination with the live attenu Bibliography ated vaccine or a previous episode of herpes zoster. Swetter SM,'Isao H, Bichakjian CK. et al. Guidelines of care for the manage ment of primary cutaneous melanoma. J Am Acad Dermatol. 2019: . The Advisory Committee on Immunization Practices 80:208 50. IPMID: 30392755J doi:10.1016rj.jaad.2018.08.055 provides no recommendation regarding use of the recombinant herpes zoster vaccine in immunocom promised patients or patients with HIV infection. D Item 6 Answer: B (a (D Ed u cati o na I Objective : Vaccinate with recombinant Bibliography = (inactivated) herpes zoster vaccine. I.'reedman \lS. Bernsteir.l tl. Ault KA. Reconrmended adult immunization Ut schedule. United Strtes, 2021. Ann lntern l\'led. 2021. [PI!{lD: 33571011] q, doi:10.71126 \12O SOUO The most appropriate vaccine to administer to this patient is EL the recombinant (inactivated) herpes zoster vaccine (Option r.| B). Adults aged 50 years or older should receive the recom- Item 7 Answer: C lt binant (inactivated) herpes zoster vaccine to reduce the inci Educational Objective: Screen and monitor for (D dence ofzoster and postherpetic neuralgia. The recombinant UI hypertension in a young adult. vaccine is administered intramuscularly in two doses, with an interval of 2 to 6 months between doses. This patient's The most appropriate next step in management is to repeat previous episode of herpes zoster does not provide immunity blood pressure measurement annually (Option C). This against future episodes and should not preclude additional patient has received appropriate screening for hypertension zoster vaccination. In addition, persons who received the at a routine wellness examination. She has no signs or symp live attenuated herpes zoster vaccine, such as this patient, toms ofcardiovascular disease and her blood pressure at this should be oflered the recombinant herpes zoster vaccine visit is in the high normal range, according to the U.S. Pre given its increased efficacy; the recombinant vaccine has ventive Services Task Force (USPSTF). The USPSTF supports shown 97"/,, efficacy in persons aged 50 to 69 years and 91"/,, screening all adults beginning at age 18 years for hyperten efficacy in persons aged 70 years or older. Patients who have sion (grade A). Screening should occur annually in adults received the live attenuated vaccine should wait at least aged 40 years or older and in younger adults at increased 8 weeks before receiving the recombinant vaccine. The Advi risk, including patients with high normal blood pressure. sory Committee on Immunization Practices has not made a patients who are overweight or obese, and Black patients. recommendation regarding the recombinant herpes zoster On the basis ol this patient's blood pressure reading today vaccine in immunocompromised patients or patients with (129178 mm Hg) and her having obesity (BMI of 30), she HIV infection, regardless of CD4 cell count. should have repeated blood pressure measurement annually. The quadrivalent meningococcal conjugate vac patients who are overweight or obese. and Black patients. cine (Option A) is recommended to be given at age 11 to On the basis of this patient's blood pressure reading today 12 years, with a booster dose at age 16 years. Adults who are (130/85 mm Hg) and her having obesity (BMI of 30), she at increased risk for meningococcal disease should undergo should have repeated blood pressure measurement annually. primary vaccination if they never received age-appropriate The 2017 American College of Cardiolog,iAmerican Heart vaccination. Increased risk is deflned as persistent comple Association blood pressure guideline recommends repeated ment component deflciencies or patients taking eculizumab; annual blood pressure measurement fbr adults with a nor functional or anatomic asplenia (including sickle cell dis mal pressure reading. ease); HIV infection; microbiologists routinely exposed to This patient does not meet criteria for initiation of Neisserio meningitidis; a meningococcal disease outbreak; antihypertensive medication (Option A). Before treatment and travel or residence in countries with hyperendemic or is initiated, when possible and in the absence of severe epidemic meningococcal disease. This patient has no indica- hypertension or end organ damage, the diagnosis should tion for the quadrivalent meningococcal conjugate vaccine. be conflrmed with blood pressure measurements outside of For healthy patients who are nonsmokers, the 23-valent the clinical setting by using ambulatory or home blood pres pneumococcal polysaccharide vaccine (Option C) is recom sure monitoring. This patient with high normal blood pres mended at age 65 years. This 64 year-old patient who is a sure reading can be reassessed in 1 year without initiating nonsmoker with no significant medical history does not treatment. need to receive the vaccine early. Left ventricular hypertrophy (LVH) is commonly mea Providing no vaccines is not the best strateS/ (Option sured by ECG andror echocardiography (Option B). Assess D). In the absence ofspecific contraindications, all patients ment for LVH is not universally recommended during 158

Answers and Critiques evaluation and management of hypertension. Assessment a clinical beneflt. S-ARIs can be initiated when cr-blocker for LVH is most useful in adults with conflrmed hyperten- therapy alone does not control symptoms or if a patient is sion who are young (<18 years of age) or have evidence of intolerant of maximum dose cx blocker therapy. secondary hypertension, chronic uncontrolled hyperten- Scheduled or timed voiding (Option B) is a technique sion, or a history of symptoms of heart failure. Echocardi to manage urge urinary incontinence, not LUTS associ- ography is not indicated in this patient with normal physical ated with BPH. This behavioral strateg/ includes scheduled examination findings and a high-normal blood pressure. voiding attempts at intervals shorter than the usual time According to the USPSTF, for patients younger than between incontinence episodes, regardless of the urge to 40 years with normal initial blood pressure and no risk void, with a gradual increase in the time between voids. factors for atherosclerotic cardiovascular disease, screen ln patients with cognitive impairment related functional ing should occur at 3 to 5 year intervals (Option D). This urinary incontinence, timed voiding with prompting by the patient is at increased risk for hypertension, and annual caregiver may also be useful. This patient does not report blood pressure measurement is recommended. incontinence. ,a {l, Urodynamic testing (Option D) is not indicated for KEY POIilTS E patients who have not yet attempted pharmacotherapy and . The U.S. Preventive Services Task Force supports have no evidence of urinary retention or urinary inconti- L,, screening all adults for hypertension beginning at age nence, as is the case for this patient. -E, 18 years. .E f,EY POIilT5 UI . Hypertension screening should occur annually in . cr-Blockers, such as tamsulosin, are first line therapy ttt adults aged 40 years or older and in younger adults at ,h for lower urinary tract symptoms secondary to benign = increased risk, including patients with high-normal prostatic hyperplasia; symptom improvement can be 4 blood pressure (130 to 139/85 to 89 mm Hg), patients seen within 48 hours of initiation. who are overweight or obese, and Black patients. o So-Reductase inhibitors, such as finasteride, are Bibliography second line therapy for lower urinary tract symptoms Siu AL; U.S. Preventi\e Services Task Force. Screening for high blood pres secondary to benign prostatic hyperplasia; clinical srrre in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:778 86. [PMID: 26458123] doi:]0. improvement is not seen for several months. 7:t26 M15-2223 Bibliography Item 8 Answer: C Bortnick E, Brown C, Simma Chiang V Kaplan SA. Modern best practice in the management of benign prostatic hyperplasia in the elderly. Ther Educational Objective: Treat lower urinary tract A<lv Urol. 2020;12:7756287220929 486. IPMID : 32547 6421 doi: 10.1177l 17562A7220929486 symptoms secondary to benigrr prostatic hyperplasia.

evaluation and management of hypertension. Assessment a clinical beneflt. S-ARIs can be initiated when cr-blocker for LVH is most useful in adults with conflrmed hyperten- therapy alone does not control symptoms or if a patient is sion who are young (<18 years of age) or have evidence of intolerant of maximum dose cx blocker therapy. secondary hypertension, chronic uncontrolled hyperten- Scheduled or timed voiding (Option B) is a technique sion, or a history of symptoms of heart failure. Echocardi to manage urge urinary incontinence, not LUTS associ- ography is not indicated in this patient with normal physical ated with BPH. This behavioral strateg/ includes scheduled examination findings and a high-normal blood pressure. voiding attempts at intervals shorter than the usual time According to the USPSTF, for patients younger than between incontinence episodes, regardless of the urge to 40 years with normal initial blood pressure and no risk void, with a gradual increase in the time between voids. factors for atherosclerotic cardiovascular disease, screen ln patients with cognitive impairment related functional ing should occur at 3 to 5 year intervals (Option D). This urinary incontinence, timed voiding with prompting by the patient is at increased risk for hypertension, and annual caregiver may also be useful. This patient does not report blood pressure measurement is recommended. incontinence. ,a {l, Urodynamic testing (Option D) is not indicated for KEY POIilTS E patients who have not yet attempted pharmacotherapy and . The U.S. Preventive Services Task Force supports have no evidence of urinary retention or urinary inconti- L,, screening all adults for hypertension beginning at age nence, as is the case for this patient. -E, 18 years. .E f,EY POIilT5 UI . Hypertension screening should occur annually in . cr-Blockers, such as tamsulosin, are first line therapy ttt adults aged 40 years or older and in younger adults at ,h for lower urinary tract symptoms secondary to benign = increased risk, including patients with high-normal prostatic hyperplasia; symptom improvement can be 4 blood pressure (130 to 139/85 to 89 mm Hg), patients seen within 48 hours of initiation. who are overweight or obese, and Black patients. o So-Reductase inhibitors, such as finasteride, are Bibliography second line therapy for lower urinary tract symptoms Siu AL; U.S. Preventi\e Services Task Force. Screening for high blood pres secondary to benign prostatic hyperplasia; clinical srrre in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:778 86. [PMID: 26458123] doi:]0. improvement is not seen for several months. 7:t26 M15-2223 Bibliography Item 8 Answer: C Bortnick E, Brown C, Simma Chiang V Kaplan SA. Modern best practice in the management of benign prostatic hyperplasia in the elderly. Ther Educational Objective: Treat lower urinary tract A<lv Urol. 2020;12:7756287220929 486. IPMID : 32547 6421 doi: 10.1177l 17562A7220929486 symptoms secondary to benigrr prostatic hyperplasia. The most appropriate management is tamsulosin, an o blocker (Option C). This patient has lower urinary tract Item 9 Answer: A symptoms (LUTS). His age, physical examination findings, Educational Objective: Treat obesity with and normal urinalysis suppoft benign prostatic hyperplasia bariatric surgery. (BPH) as the cause of LUTS. BPH is a histologic diagnosis that is found in more than B0'/o of men aged 70 years or older. The The most appropriate management of this patient's obesity American Urological Association Symptom Index (AUA SI) is bariatric surgery (Option A). Bariatric surgery is indicated is a validated seven item questionnaire that can be used to for motivated individuals with BI\41 of 40 or greater or BMI of objectively assess LUTS severity and subsequently deter 35 or greater and at least one serious weight related comor mine appropriate treatment and treatment response. For bid condition, such as obstructive sleep apnea, osteoarthritis patients with bothersome symptoms, such as this patient, of the hip or knee, or type 2 diabetes. Additional criteria pharmacologic treatment is warranted. o Blockers, such for bariatric surgery include sustained unsuccessful weight as tamsulosin, are flrst line therapy for LUTS secondary loss attempts using high intensity lifestyle modiflcation programs, sttrrctured meal plans, and/or pharmacotherapy' to BPH. s Blockers function by promoting smooth muscle relaxation in the prostate. Symptom improvement can be Bariatric surgery reliably results in weight loss and may also produce improvements in diabetes control, blood pressure' seen within 48 hours of initiation, with maximum response and iipid proflles. Cardiovascular and overall mortality may within several weeks. also be improved in patients with severe obesity' It may also Scr Reductase inhibitors (5 ARls), such as flnasteride (Option A), are second line therapy for LUTS secondary to durably improve or reverse some of the medical compli cations associated with obesity, such as obstructive sleep BPH. 5 ARIs function by preventing the conversion of testos apnea and osteoarthritis. Patients should have acceptable terone to dihydroxl'testosterone, inhibiting prostate growth' operative risk, understand the necessity of iifelong dietary These agents are eflective only in patients who have an ,r-rA Ut.ttyt" measures for sustained weight loss' and be prostate enlarged prostate; efficacy increases with increasing should willing to adhere to lifelong follow-up' Candidates size. S-ARls require several months' use before showing 169

Answers and Critiques not have psychological conditions that impede adherence to inrpractical. ancl slstemic glucocorticoid therapl' mav be these requirements. required. Regular exercise (Option B) has many important health I)rug inducecl lty persensitivitl sl'ndrome (DlllS) beneflts. However. exercise alone or combined r.t,ith calorie (Option A). fbrnrerll cirlled dmg rcilction rlith eosinophilia restriction results in additional weight loss of no more than lncl systemic s)'nlplonts (DRESS). is a severe lile threatening 3 kg (o.o lb). This will not result in the weight loss required rleclicatior-r reaction. S1'mptoms begin r'vith f'ever and flu by this patient, and it is unlikely that he can comply owing lil<c symptoms. n'hich are quickll follou'ed b1' burning to his hip and knee osteoarthritis. skir.r pain irnd rlsh. The rash is t1 picllll' a morbillifirrnt Of all the weight loss medications. phentermine- exanthem that strrts on the tace and upper trllnk xnd topiramate (Option C) has the highest probability of achiev- spreads distalll: lrventuallli patie nts clcve lop striking facill ing a 5'1, weight loss. Howeveq contraindications include edema and redness. a l-rallmark o{ this condition. as shou'n. nephrolithiasis, uncontrolled hypertension, or resting tachy D cardia. A 5'1, weight loss will not be sufficient to treat this ar! patient's many comorbid conditions. Finally, he is already taking a weight loss medication (liraglutide) and has resting = .D gr tachycardia; therefore, phentermine topiramate is contra- q, indicated. a Recommending a very-low-calorie diet (Option D) for f.l this patient is unrealistic because he reports having not lt had success with other dietary interventions. lt is unlikely (D that diet therapy alone will result in the weight loss that is UI needed to address his obesity related complications.

not have psychological conditions that impede adherence to inrpractical. ancl slstemic glucocorticoid therapl' mav be these requirements. required. Regular exercise (Option B) has many important health I)rug inducecl lty persensitivitl sl'ndrome (DlllS) beneflts. However. exercise alone or combined r.t,ith calorie (Option A). fbrnrerll cirlled dmg rcilction rlith eosinophilia restriction results in additional weight loss of no more than lncl systemic s)'nlplonts (DRESS). is a severe lile threatening 3 kg (o.o lb). This will not result in the weight loss required rleclicatior-r reaction. S1'mptoms begin r'vith f'ever and flu by this patient, and it is unlikely that he can comply owing lil<c symptoms. n'hich are quickll follou'ed b1' burning to his hip and knee osteoarthritis. skir.r pain irnd rlsh. The rash is t1 picllll' a morbillifirrnt Of all the weight loss medications. phentermine- exanthem that strrts on the tace and upper trllnk xnd topiramate (Option C) has the highest probability of achiev- spreads distalll: lrventuallli patie nts clcve lop striking facill ing a 5'1, weight loss. Howeveq contraindications include edema and redness. a l-rallmark o{ this condition. as shou'n. nephrolithiasis, uncontrolled hypertension, or resting tachy D cardia. A 5'1, weight loss will not be sufficient to treat this ar! patient's many comorbid conditions. Finally, he is already taking a weight loss medication (liraglutide) and has resting = .D gr tachycardia; therefore, phentermine topiramate is contra- q, indicated. a Recommending a very-low-calorie diet (Option D) for f.l this patient is unrealistic because he reports having not lt had success with other dietary interventions. lt is unlikely (D that diet therapy alone will result in the weight loss that is UI needed to address his obesity related complications. XEY POITT o Bariatric surgery is indicated for motivated individu- als with BMI of 40 or greater or BMI of 35 or greater with obesity associated comorbid complications Orll mucosal invohernent is cornntor-r. Ur-rlike other severe who have not responded to behavioral treatment or meclicltion reactions. the orlset ot svnrptoms in DIIIS is pharmacotherapy. cicllled. often 2 to 6 uleeks irtler erposure. The rash onsct lltcr 9 clal's and l:rcl< of systernic synrptorns in this patient Bibtiography irre inconsistent n'ith DItlS. Tsai AC, Bessesen DH. Obesit_ri Ann Intern Med. 20191170:lTC33 .18. [PN{ID: 308315931 doi: 10.7326'AlTC20l9O3050 ,\ flxed dmg emption (Option C) presents \\'ith one to several duskl purple pink nracules or plirques. rlost cor.ttrt.tonlv on tlie lips, tace. {ingers. ancl genitals. Thel rnl1, Item 1O tr Answer: B Educational Objective: Diagnose exanthematous occur u,ithin the tirst 2.,.r,eeks of stirrting a causativc nrccl icltion but are locirlized. inclucling u,hen tl.re1' recur Llpon re exposure. The clif luse rash in this prrtier-rt is inconsistent (morbilliform) drug eruption. u'ith a fired drug rcaction. The rnost likell, diagnosis is erirnthematous clrug eruption H]'persensilivit) \'asculitis (Option D) also occurs (Option B). 'lhis patiellt preseltts u'ith a rrorbillifbrrn rash 'nvithin 2 u'eeks ol clrug erposure but rnirnilests as palpirble 9 days after stirrting sultamethorazole trinrethoprim, a purpura and not thc clifluse rash seen in this patient. frequent ciruse of medication reactions. Eranthentatous or morbillifirrm (n.reasles like) emptions are the most com XEY POIIIIS rnon fbrm ot cutaneous drug reactions. most likely rep o Exanthematous or morbillifbrm (measles-like) erup- resenting a t),pe IV delalecl hYpersensitivitr.relction. The tions are the most common form of cutaneous drug rasl-r lr1-tpclrs during the first or secor-rd r,r'eek after drug reactions, usually appearing within the first or second exposure. rrlthough subsequent exposures can produce a week of drug exposure. I reactior.r ntuch more quicl<ly piitients develop erythem o An exanthematous rash begins as erythematous pap atous paltules and macules that coalesce svntmetricallv to fornr plaques. beginning on the trunk :rncl ltrogressing ules and macules that coalesce symmetrically to form plaques. beginning on the trunk and progressing dis- distalll across the lirnbs irnd usualll' sparing the pahns and soles. '[he papules arc olten dense irncl ntonontor tally across the limbs and usually sparing the palms phic and arc accompaniecl I-r_\, r,iirr,ing clegrees of pruritus. and soles. l-ymph:rdenopathy is ltot uncontmon. Treatmcnt involves cessation of the causative agent. use ofpotent topical glu Bibliography cocorticoids. and oral FI, antil-ristamines. A u,iclespread Kroshins\' D. Adverse cutaneous reactions to medications IEditorial]. Clin Dermatol. 2020:38:605 6. IPMID: 333.11194] doi:10.1016/j.clinderniltol. rash may rnake the topical irpplication of glucocorticoids 2(020.06.o17

XEY POITT o Bariatric surgery is indicated for motivated individu- als with BMI of 40 or greater or BMI of 35 or greater with obesity associated comorbid complications Orll mucosal invohernent is cornntor-r. Ur-rlike other severe who have not responded to behavioral treatment or meclicltion reactions. the orlset ot svnrptoms in DIIIS is pharmacotherapy. cicllled. often 2 to 6 uleeks irtler erposure. The rash onsct lltcr 9 clal's and l:rcl< of systernic synrptorns in this patient Bibtiography irre inconsistent n'ith DItlS. Tsai AC, Bessesen DH. Obesit_ri Ann Intern Med. 20191170:lTC33 .18. [PN{ID: 308315931 doi: 10.7326'AlTC20l9O3050 ,\ flxed dmg emption (Option C) presents \\'ith one to several duskl purple pink nracules or plirques. rlost cor.ttrt.tonlv on tlie lips, tace. {ingers. ancl genitals. Thel rnl1, Item 1O tr Answer: B Educational Objective: Diagnose exanthematous occur u,ithin the tirst 2.,.r,eeks of stirrting a causativc nrccl icltion but are locirlized. inclucling u,hen tl.re1' recur Llpon re exposure. The clif luse rash in this prrtier-rt is inconsistent (morbilliform) drug eruption. u'ith a fired drug rcaction. The rnost likell, diagnosis is erirnthematous clrug eruption H]'persensilivit) \'asculitis (Option D) also occurs (Option B). 'lhis patiellt preseltts u'ith a rrorbillifbrrn rash 'nvithin 2 u'eeks ol clrug erposure but rnirnilests as palpirble 9 days after stirrting sultamethorazole trinrethoprim, a purpura and not thc clifluse rash seen in this patient. frequent ciruse of medication reactions. Eranthentatous or morbillifirrm (n.reasles like) emptions are the most com XEY POIIIIS rnon fbrm ot cutaneous drug reactions. most likely rep o Exanthematous or morbillifbrm (measles-like) erup- resenting a t),pe IV delalecl hYpersensitivitr.relction. The tions are the most common form of cutaneous drug rasl-r lr1-tpclrs during the first or secor-rd r,r'eek after drug reactions, usually appearing within the first or second exposure. rrlthough subsequent exposures can produce a week of drug exposure. I reactior.r ntuch more quicl<ly piitients develop erythem o An exanthematous rash begins as erythematous pap atous paltules and macules that coalesce svntmetricallv to fornr plaques. beginning on the trunk :rncl ltrogressing ules and macules that coalesce symmetrically to form plaques. beginning on the trunk and progressing dis- distalll across the lirnbs irnd usualll' sparing the pahns and soles. '[he papules arc olten dense irncl ntonontor tally across the limbs and usually sparing the palms phic and arc accompaniecl I-r_\, r,iirr,ing clegrees of pruritus. and soles. l-ymph:rdenopathy is ltot uncontmon. Treatmcnt involves cessation of the causative agent. use ofpotent topical glu Bibliography cocorticoids. and oral FI, antil-ristamines. A u,iclespread Kroshins\' D. Adverse cutaneous reactions to medications IEditorial]. Clin Dermatol. 2020:38:605 6. IPMID: 333.11194] doi:10.1016/j.clinderniltol. rash may rnake the topical irpplication of glucocorticoids 2(020.06.o17 170

Answers and Criti que: Item 11 Answer: B Item 12 Answer: E EI Ed ucatio na I Objective: Manage antirheumatic therapy Educational Objective: Treat seborrheic during the perioperative period. dermatitis.

Item 11 Answer: B Item 12 Answer: E EI Ed ucatio na I Objective: Manage antirheumatic therapy Educational Objective: Treat seborrheic during the perioperative period. dermatitis. Jhe most appropriatc periopcrative rnnnagenlcnt of this The most appropriate treatment is zinc pyrithione shampoo patient's antirheunratic reginrcr-r is to cor-ttinue nrethcl (Option E). This patient has a classic presentation of seb trexilte ancl hold lclalinrunrab lirr 2 rveeks belbre and after orrheic dermatitis, a common condition characterized by surgery (Option B). O'ur,ing to both their cliseitse and its greasy, scaly, yellow to erythematous patches in seborrheic trertment, patients rvith rlteutnrttologic disease undcr areas (scalp, face, ears, upper chest, axillae, and inguinal going elective surgerv rrrc rrt highcr risk tirr pcrioperrtive folds). On the face, speciflc areas of involvement include inlectious conrplicittions. it.tcltttling risk firr peri the eyebrows, medial aspects of the cheeks, inter eyebrow prosthetic joint inlcctiou in totitl joir.rt rtrthroplasties ol the region, and nasal ala. Topical antifungal treatments are first hip and knee. Appropriatc lxrrrlilgenrerrt ol lntirheunratic line treatment. Over the counter medications, such as zinc ut (l, rnedication in the perioperrltive periocl rnitigates this risk. pyrithione and selenium sulflde shampoos, are the most ET Elective surgery shoukl bc dclayed until the undcrly cost eflective treatment options to use first. Ketoconazole ing disease is controllecl irncl preterably in renrission, shampoo and cream are also effective. Patients should apply TJ because this is associated with rccluccd inf'ection risk and the shampoo on the skin and allow it to sit for .5 minutes T' improved oLitconles. All nonbiukrgic cliscase nrodilyittg before rinsing it off. Seborrheic dermatitis is believed to be E (g antirheurtatic drugs (l)MAItl)s) should bc continued caused by heightened sensitivity to yeasts, such as Molos lrl througlrout the periolrerative period in luticnts under sezia. lt is more common in patients with neurologic dis o B vt going elective j<linl relrlacenrent. l,lvidence sllggests that orders. such as Parkinson disease and Alzheimer dementia. continuing t)l\4ARI)s is r.rssociatecl with a krwer risk ltrr Low potency topical glucocorticoids can be used in combi infections vcrsus discorltinuing l)MAltl)s at the tinre of nation with antifungal treatments when severe inflamma surgery. Diseasc flrres itrc also less fiec;uent rlter surgcry tion is present. Often, a low-potency topical glucocorticoid in patients who continue I)MAltl)s periopcrativc'ly. Bio' is added for flares. logic agents. such irs lclalimunrrtb (Option A), should be Clindamycin lotion (Option A) is often used to treat withhelil fbr one closing cycle bcftrrc the surgery, witl.t acne and folliculitis, which are characterized by inflam surgery pertbrnrecl at the cncl of thc clrclc. Jarrus kinase matory papules and pusfules; these are not present in this inhibitors. such as tofacitinib. shoulcl bc withheld ftlr at patient. Clindamycin is not efl'ective for seborrheic derma least 7 clays bclilrc sul-gcry. Once thc' opcralive wound titis. shows evidcncc of hellirrg (typicxlly arour.tcl 14 days), Clobetasol ointment (Option B) is an ultra high agellts that hirve been u,ithhel(l sl'roulcl bc rcsurned irt the potency topical glucocorticoid and would not be appropri previously' establishccl dosc. ate treatment for this patient's seborrheic dermatitis. Fur this patient has rvell controllcd disease. and procced thermore, use of ultra high-potency topical glucocorticoids 'lhe ing u,ith elective knee replacenrcrlt surgery is acceptable. increases the risk for skin atrophy and should not be used DMARI) lrethotrexate (Options C, D) shoulcl be contiuued on the face. A low potency topical glucocorticoid, such as throughout the periopcrativc pc'riod, atrd adalinturnab, a hydrocortisone or desonide, can be used in combination biologic usually dosetl every 2 wccl<s, should be ltcld fbr with topical antifungal agents for treatment of seborrheic 2 rveeks befbre the surgery itncl resut.tred rtpproximately dermatitis flares. 2 rvceks after sulger),. 5 Fluorouracil cream (Option C) is used to treat actinic keratosis and is not appropriate treatment fbr this f,EY POIf,IS patient. 5 Fluorouracil cream often exacerbates seborrheic . All nonbiologicdisease-modiffingantirheumatic dermatitis. drugs should be continued throughout the periopera- Oral ketoconazole (Option D) is not an appropriate tive period in patients with rheumatologic disease treatment for seborrheic dermatitis or any superlicial fun undergoing elective arthroplasty. gal infection. In 2016, the FDA issued a boxed warning lor . Biologic agents should be withheld for one dosing ketoconazole due to risk of liver and adrenal toxicity and cycle preoperatively, before arthroplasty, with surgery interactions with other medications. The use of systemic performed at the end of the cycle and resumed when ketoconazole is limited to the treatment of susceptible systemic fungal infections (blastomycosis, histoplasmosis, the wound shows evidence of healing. paracoccidioidomycosis, coccidioidomycosis, and chro momycosis) in patients in whom other, saf'er antifungal Bibliography therapies have failed or who are intolerant to such ther- Goodman SM, Springer B, Guyatt (i, et al. 2017 American College of apies. Rarely, in refractory cases of seborrheic dermatitis, Rheumatolops//American Association of Hip and Knee Surgeons guide line fbr the perioperative mrnagement of antirheumatic medication in oral antifungals can be considered; in these cases, flu patients witlr rheumatic diseases undergoing elective-total hip or total conazole would be preferred because of the lower risk for inee arthroplasry Arthritis Rheumatol. 2oi7;69:1538 51. [PMID: 286209481 doi:10.1O02/art.40149 side effects.

Jhe most appropriatc periopcrative rnnnagenlcnt of this The most appropriate treatment is zinc pyrithione shampoo patient's antirheunratic reginrcr-r is to cor-ttinue nrethcl (Option E). This patient has a classic presentation of seb trexilte ancl hold lclalinrunrab lirr 2 rveeks belbre and after orrheic dermatitis, a common condition characterized by surgery (Option B). O'ur,ing to both their cliseitse and its greasy, scaly, yellow to erythematous patches in seborrheic trertment, patients rvith rlteutnrttologic disease undcr areas (scalp, face, ears, upper chest, axillae, and inguinal going elective surgerv rrrc rrt highcr risk tirr pcrioperrtive folds). On the face, speciflc areas of involvement include inlectious conrplicittions. it.tcltttling risk firr peri the eyebrows, medial aspects of the cheeks, inter eyebrow prosthetic joint inlcctiou in totitl joir.rt rtrthroplasties ol the region, and nasal ala. Topical antifungal treatments are first hip and knee. Appropriatc lxrrrlilgenrerrt ol lntirheunratic line treatment. Over the counter medications, such as zinc ut (l, rnedication in the perioperrltive periocl rnitigates this risk. pyrithione and selenium sulflde shampoos, are the most ET Elective surgery shoukl bc dclayed until the undcrly cost eflective treatment options to use first. Ketoconazole ing disease is controllecl irncl preterably in renrission, shampoo and cream are also effective. Patients should apply TJ because this is associated with rccluccd inf'ection risk and the shampoo on the skin and allow it to sit for .5 minutes T' improved oLitconles. All nonbiukrgic cliscase nrodilyittg before rinsing it off. Seborrheic dermatitis is believed to be E (g antirheurtatic drugs (l)MAItl)s) should bc continued caused by heightened sensitivity to yeasts, such as Molos lrl througlrout the periolrerative period in luticnts under sezia. lt is more common in patients with neurologic dis o B vt going elective j<linl relrlacenrent. l,lvidence sllggests that orders. such as Parkinson disease and Alzheimer dementia. continuing t)l\4ARI)s is r.rssociatecl with a krwer risk ltrr Low potency topical glucocorticoids can be used in combi infections vcrsus discorltinuing l)MAltl)s at the tinre of nation with antifungal treatments when severe inflamma surgery. Diseasc flrres itrc also less fiec;uent rlter surgcry tion is present. Often, a low-potency topical glucocorticoid in patients who continue I)MAltl)s periopcrativc'ly. Bio' is added for flares. logic agents. such irs lclalimunrrtb (Option A), should be Clindamycin lotion (Option A) is often used to treat withhelil fbr one closing cycle bcftrrc the surgery, witl.t acne and folliculitis, which are characterized by inflam surgery pertbrnrecl at the cncl of thc clrclc. Jarrus kinase matory papules and pusfules; these are not present in this inhibitors. such as tofacitinib. shoulcl bc withheld ftlr at patient. Clindamycin is not efl'ective for seborrheic derma least 7 clays bclilrc sul-gcry. Once thc' opcralive wound titis. shows evidcncc of hellirrg (typicxlly arour.tcl 14 days), Clobetasol ointment (Option B) is an ultra high agellts that hirve been u,ithhel(l sl'roulcl bc rcsurned irt the potency topical glucocorticoid and would not be appropri previously' establishccl dosc. ate treatment for this patient's seborrheic dermatitis. Fur this patient has rvell controllcd disease. and procced thermore, use of ultra high-potency topical glucocorticoids 'lhe ing u,ith elective knee replacenrcrlt surgery is acceptable. increases the risk for skin atrophy and should not be used DMARI) lrethotrexate (Options C, D) shoulcl be contiuued on the face. A low potency topical glucocorticoid, such as throughout the periopcrativc pc'riod, atrd adalinturnab, a hydrocortisone or desonide, can be used in combination biologic usually dosetl every 2 wccl<s, should be ltcld fbr with topical antifungal agents for treatment of seborrheic 2 rveeks befbre the surgery itncl resut.tred rtpproximately dermatitis flares. 2 rvceks after sulger),. 5 Fluorouracil cream (Option C) is used to treat actinic keratosis and is not appropriate treatment fbr this f,EY POIf,IS patient. 5 Fluorouracil cream often exacerbates seborrheic . All nonbiologicdisease-modiffingantirheumatic dermatitis. drugs should be continued throughout the periopera- Oral ketoconazole (Option D) is not an appropriate tive period in patients with rheumatologic disease treatment for seborrheic dermatitis or any superlicial fun undergoing elective arthroplasty. gal infection. In 2016, the FDA issued a boxed warning lor . Biologic agents should be withheld for one dosing ketoconazole due to risk of liver and adrenal toxicity and cycle preoperatively, before arthroplasty, with surgery interactions with other medications. The use of systemic performed at the end of the cycle and resumed when ketoconazole is limited to the treatment of susceptible systemic fungal infections (blastomycosis, histoplasmosis, the wound shows evidence of healing. paracoccidioidomycosis, coccidioidomycosis, and chro momycosis) in patients in whom other, saf'er antifungal Bibliography therapies have failed or who are intolerant to such ther- Goodman SM, Springer B, Guyatt (i, et al. 2017 American College of apies. Rarely, in refractory cases of seborrheic dermatitis, Rheumatolops//American Association of Hip and Knee Surgeons guide line fbr the perioperative mrnagement of antirheumatic medication in oral antifungals can be considered; in these cases, flu patients witlr rheumatic diseases undergoing elective-total hip or total conazole would be preferred because of the lower risk for inee arthroplasry Arthritis Rheumatol. 2oi7;69:1538 51. [PMID: 286209481 doi:10.1O02/art.40149 side effects. 171

Answers and Critiques XEY POITTS for treating ED, tadalafil therapy should not be initiated o Cost effective treatment of seborrheic dermatitis, a in this patient without flrst tapering sertraline, a possible causative agent, because there are no contraindications to common condition characterized by greasy, yellow doing so. scaly, yellow to erythematous patches in seborrheic areas, includes zinc pyrithione or selenium sulfide r(EY POtl{TS shampoos. . All patients with erectile dysfunction (ED) must have r Oral ketoconazole is not an appropriate treatment for a thorough medication history performed to deter- any superficial fungal infection. mine whether any medications may be contributing to or causing the ED. l

XEY POITTS for treating ED, tadalafil therapy should not be initiated o Cost effective treatment of seborrheic dermatitis, a in this patient without flrst tapering sertraline, a possible causative agent, because there are no contraindications to common condition characterized by greasy, yellow doing so. scaly, yellow to erythematous patches in seborrheic areas, includes zinc pyrithione or selenium sulfide r(EY POtl{TS shampoos. . All patients with erectile dysfunction (ED) must have r Oral ketoconazole is not an appropriate treatment for a thorough medication history performed to deter- any superficial fungal infection. mine whether any medications may be contributing to or causing the ED. l Bibliography o Selective serotonin reuptake inhibitors are commonly Piquero Casals J, Hexsel D. Mir Bonaf'e lF, et al. Topical non pharmacologi- associated with decreased libido and erectile cal trertment for facial seborrheic dermatitis. Dermatol Ther (Heidelb). D 2019:9:469 77. [PMID:31396944] doi;10.1007/sl:1555 019 00319 0 dysfunction. tr € (D Bibliography ut q, Item 13 Answer: D Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;2oo:633-41. I PMID, 297468581doi:10.1o16/j.juro.2018.0.5.004 EL Educational Objective: Treat medication-induced a.l erectile dysfunction. Item 14 Answer: C tt The most appropriate management is to taper sertraline Educational Objective: Provide contraceptive care for a .D (Option D), a selective serotonin reuptake inhibitor (SSRI). lrt patient with migraine with aura. All patients with erectile dysfunction (ED) must have a thor ough medication history performed to determine whether The most appropriate contraceptive option for this patient a medication is contributing to or causing the ED. SSRIs are is the levonorgestrel releasing intrauterine device (lUD) commonly associated with decreased libido and ED, both of (Option C). this patient has a history of migraine with aura, which this patient reports. For patients with depression, the which is a contraindication to estrogen owing to increased American Psychiatric Association recommends continua risk for stroke. Women with contraindications to estrogen tion therapy (treatment after resolution of a major depres should be prescribed either a progesterone-only or a non sive episode) for 4 to 9 months in patients who responded to hormonal contraceptive option. For this patient, proges acute therapy for a flrst episode ofdepression. Antidepres terone only contraceptive options include the levonorge sant medications can then be gradually tapered. Because this strel-releasing IUD, subdermal progestin implant, depot patient reports no depressive symptoms and has been treated medroxyprogesterone acetate injection, or progesterone only for 8 months, the most appropriate step is a trial taper of ser oral contraceptive pill. A nonhormonal contraceptive option traline. If his mood worsens when the sertraline is tapered, is the copper IUD. The patient's history of multiple sexual initiation of the dopamine/norepinephrine reuptake inhib male partners and being nulliparous are not a contrain- itor bupropion could be considered. Bupropion is typically dication to IUD use. IUDs are well tolerated. Changes in not associated with ED but can rarely (<1'l.) be associated menstrual bleeding patterns are the most common adverse with ejaculatory disorders. In addition to antidepressants, effect. Complications include expulsion (3"/,,-6% in the first other medications commonly implicated in ED are antihy year) and uterine perforation (approximately 0.1')6 of inser- pertensive medications, such as p-blockers, spironolactone, tions). Contraindications to IUD placement include preg thiazide diuretics, and clonidine. nancy; anatomic uterine abnormalities with distortion of Psychotherapy with or without sex therapy counseling the uterine cavity; and acute untreated pelvic infection. (Option A) with a certified therapist is an effective treatment Risk for pelvic infection with IUD placement is low and for patients with psychogenic ED. These patients commonly prophylactic antibiotics are not recommended during the have preserved early morning and nocturnal erections and procedure. frequently report a depressed mood and psychosocial stress- Estrogen-containing contraception, including the com- ors; these factors are not consistent with this patient's pre bined hormonal (estrogen-progesterone) contraceptive pill sentation. Without evidence of psychogenic ED, a referral for (Option A), is contraindicated in patients with a history of psychotherapy or sex therapy counseling is not the correct migraine with aura, such as this patient. Othercontraindica management. tions to estrogen-containing contraception include a history According to a 2018 guideline from the American Uro- of breast cancer, venous thromboembolic disease, uncon- logical Association, all patients with ED should have an early trolled hypertension, and smoking more than 15 cigarettes a morning serum total testosterone measurement, which is nor day for women older than 35 years. mal in this patient. There is no role for testosterone therapy A combined hormonal (estrogen progesterone) vagi (Option B) in patients with ED who are not androgen deflcient. nal ring (Option B) is a flexible device approximately S cm Although phosphodiesterase-5 inhibitors, such as tada in diameter and 4 mm thick that is inserted vaginally by lafll (Option C), are considered flrst Iine pharmacotherapy the patient and worn fbr 3 weeks and then removed and

Bibliography o Selective serotonin reuptake inhibitors are commonly Piquero Casals J, Hexsel D. Mir Bonaf'e lF, et al. Topical non pharmacologi- associated with decreased libido and erectile cal trertment for facial seborrheic dermatitis. Dermatol Ther (Heidelb). D 2019:9:469 77. [PMID:31396944] doi;10.1007/sl:1555 019 00319 0 dysfunction. tr € (D Bibliography ut q, Item 13 Answer: D Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;2oo:633-41. I PMID, 297468581doi:10.1o16/j.juro.2018.0.5.004 EL Educational Objective: Treat medication-induced a.l erectile dysfunction. Item 14 Answer: C tt The most appropriate management is to taper sertraline Educational Objective: Provide contraceptive care for a .D (Option D), a selective serotonin reuptake inhibitor (SSRI). lrt patient with migraine with aura. All patients with erectile dysfunction (ED) must have a thor ough medication history performed to determine whether The most appropriate contraceptive option for this patient a medication is contributing to or causing the ED. SSRIs are is the levonorgestrel releasing intrauterine device (lUD) commonly associated with decreased libido and ED, both of (Option C). this patient has a history of migraine with aura, which this patient reports. For patients with depression, the which is a contraindication to estrogen owing to increased American Psychiatric Association recommends continua risk for stroke. Women with contraindications to estrogen tion therapy (treatment after resolution of a major depres should be prescribed either a progesterone-only or a non sive episode) for 4 to 9 months in patients who responded to hormonal contraceptive option. For this patient, proges acute therapy for a flrst episode ofdepression. Antidepres terone only contraceptive options include the levonorge sant medications can then be gradually tapered. Because this strel-releasing IUD, subdermal progestin implant, depot patient reports no depressive symptoms and has been treated medroxyprogesterone acetate injection, or progesterone only for 8 months, the most appropriate step is a trial taper of ser oral contraceptive pill. A nonhormonal contraceptive option traline. If his mood worsens when the sertraline is tapered, is the copper IUD. The patient's history of multiple sexual initiation of the dopamine/norepinephrine reuptake inhib male partners and being nulliparous are not a contrain- itor bupropion could be considered. Bupropion is typically dication to IUD use. IUDs are well tolerated. Changes in not associated with ED but can rarely (<1'l.) be associated menstrual bleeding patterns are the most common adverse with ejaculatory disorders. In addition to antidepressants, effect. Complications include expulsion (3"/,,-6% in the first other medications commonly implicated in ED are antihy year) and uterine perforation (approximately 0.1')6 of inser- pertensive medications, such as p-blockers, spironolactone, tions). Contraindications to IUD placement include preg thiazide diuretics, and clonidine. nancy; anatomic uterine abnormalities with distortion of Psychotherapy with or without sex therapy counseling the uterine cavity; and acute untreated pelvic infection. (Option A) with a certified therapist is an effective treatment Risk for pelvic infection with IUD placement is low and for patients with psychogenic ED. These patients commonly prophylactic antibiotics are not recommended during the have preserved early morning and nocturnal erections and procedure. frequently report a depressed mood and psychosocial stress- Estrogen-containing contraception, including the com- ors; these factors are not consistent with this patient's pre bined hormonal (estrogen-progesterone) contraceptive pill sentation. Without evidence of psychogenic ED, a referral for (Option A), is contraindicated in patients with a history of psychotherapy or sex therapy counseling is not the correct migraine with aura, such as this patient. Othercontraindica management. tions to estrogen-containing contraception include a history According to a 2018 guideline from the American Uro- of breast cancer, venous thromboembolic disease, uncon- logical Association, all patients with ED should have an early trolled hypertension, and smoking more than 15 cigarettes a morning serum total testosterone measurement, which is nor day for women older than 35 years. mal in this patient. There is no role for testosterone therapy A combined hormonal (estrogen progesterone) vagi (Option B) in patients with ED who are not androgen deflcient. nal ring (Option B) is a flexible device approximately S cm Although phosphodiesterase-5 inhibitors, such as tada in diameter and 4 mm thick that is inserted vaginally by lafll (Option C), are considered flrst Iine pharmacotherapy the patient and worn fbr 3 weeks and then removed and 172

Answers and Critiques discarded. A new vaginal ring is inserted I week later. The interviewing can be particularly effective in establishing a vaginal ring is as eflective as combined oral contraceptive partnership to create lifestyle changes and may be highly pills in preventing pregnancy. The combined hormonal relevant in this patient, who is currently not motivated to (estrogen progesterone) vaginal ring is not an appropriate make lifestyle changes. option because estrogen is contraindicated in this patient. It may be desirable to increase this patient's medica Although barrier contraceptive methods, such as male tions for diabetes in an attempt to lower the hemoglobin A,. condoms (Option D), are safe fbr women who cannot take level. However, addressing only the pharmacologic aspects estrogen and can provide protection fiom sexually transmit of this patient's care will not resolve the underlying issue ted infections, when used alone they are considered one of of an unhealthy diet, lack of exercise, and ambivalence to the least effective lorms of contraception. change. ln addition, pioglitazone (Option A), a drug that increases the peripheral uptake of glucose, is associated rEY POII{TS with weight gain and is not the best choice for this patient. o Contraindications to estrogen-containing contracep- Behavioral counseling with motivational interviewing and tt €, tives include migraine with aura, history of breast increasing the dose of metformin or liraglutide, if possible, ET cancer, venous thromboembolic disease, uncontrolled are better choices. hypertension, or smoking more than 15 cigarettes a Using a multidisciplinary team of health care profes (J day for women older than 35 years. sionals (dietitians, nurses, and psychologists) can be help ?r r Non estrogen hormonal contraception options are ful when available. However, in the absence of motivation |E to change, referring the patient to a dietitian or supervised vt levonorgestrel-releasing intrauterine devices (lUDs), (l, subdermal progestin implant, depot medroxlproges exercise program (Options C, D) is unlikely to be success ful in achieving a healthier lif'estyle in this ambivalent vt = terone acetate injection, and progesterone only oral patient. contraceptive pills; a copper IUD is a nonhormonal option. f,EY POttrs o Motivational interviewing is a counseling approach Bibliography that uses directive, patient-centered techniques; its Woodhams EJ, Gilliam M. Contraceptbn. Ann lntern Med.2019;170:lTCl8 32. I PMID, 307167581 doi:10.7326lAl'l'C201902050 overall goal is to assist patients in addressing and changing unhealthy behaviors. o Foundational to motivational interviewing is an Item 15 Answer: B attempt by the physician to understand the patient's perspectives, followed by having the patient reflect on Ed u catio n a I O bj ective: Use motivational interviewing to help patients make lifestyle changes. the need for change by highlighting the discrepancy between the patient's current and desired behavior. The most appropriate initial management step is behav ioral counseling that includes motivational interviewing Bibliography (Option B). The basic elements in motivational interview Mifsud lL, Galea J, Garside J, et al. Motivational interviewing to support ing include engagement, focusing, evoking, and planning. modifiable risk factor change in individuals at increased risk of cardio vascular disease: a systematic review and meta analysis. PLoS One. Motivational interviewing is a counseling approach that 202O;15:e0241193. [PMID: 331758491 doi:10.1371/journal.pone.0241l93 uses directive, patient centered techniques. Its overall goal is to assist patients in addressing and changing unhealthy Item 16 behaviors. Motivational interviewing capitalizes on the patient's intrinsic motivation to change and identifles rea- sons fbr ambivalence to change and discusses them without Answer: D Ed ucational Objective: Diagnose Stevens-Johnson tr syndrome toxic epidermal necrofsis overlap syndrome. directly confronting the patient. Foundational to motiva- tional interviewing is the physician's attempt to understand Stcvcns Johnson synclrorne (S.lS) and toxic epidcnnril the patient's perspectives, followed by having the patient necrolysis (TEN) (Option D) are thc rnost sL'vere ar-rcl deaclly reflect on the need for change by highlighting the discrep of'the cutaneous adverse clrug rcactions. SJS/TEN overlup ar.rcy between the patient's current and desired behavior. sl,nclronre rcfers to patients r,t,itlt lo'X, to 30'li, body surlircc The physician attempts to build rapport and engage the arca aflected. Symptonrs bcgirt usr-rally lvithin 1 to 3 r,r'ccks patient with a supportive, nonjudgmental attitude. The phy of erposure to iln inciting rgenl. such its carbantitzepitte. sician elicits ideas and feelings about current behaviors u'ith fever and r.nalaise ftrllou'ed [.l1 skin pain. grittiness or and how they match the patient's desires and values, and sirrrd like irritatioll of thc eyes. anci rtcll'nopl-ragia. Shortll' has the patient reflect on the possibility of better options thereatter. p.rtients devclop rcd or purple dus\'macules on compared with current behaviors. The conversation allows the trunk that progress to vcsicles. erosiort. and ulcerirti<tn. identification of speciflc changes important to the patient. l'}ainlul erosions delelop in thc tnouth. e),es. or genitirls itt as ln a process known as change talk, the physician elicits the nttny as 95')1, of patients. Mortllity is high, rvith 5')1, to 10'){, of' patient's own reasons and rationale for change. Motivational SJS cases being fatal.

discarded. A new vaginal ring is inserted I week later. The interviewing can be particularly effective in establishing a vaginal ring is as eflective as combined oral contraceptive partnership to create lifestyle changes and may be highly pills in preventing pregnancy. The combined hormonal relevant in this patient, who is currently not motivated to (estrogen progesterone) vaginal ring is not an appropriate make lifestyle changes. option because estrogen is contraindicated in this patient. It may be desirable to increase this patient's medica Although barrier contraceptive methods, such as male tions for diabetes in an attempt to lower the hemoglobin A,. condoms (Option D), are safe fbr women who cannot take level. However, addressing only the pharmacologic aspects estrogen and can provide protection fiom sexually transmit of this patient's care will not resolve the underlying issue ted infections, when used alone they are considered one of of an unhealthy diet, lack of exercise, and ambivalence to the least effective lorms of contraception. change. ln addition, pioglitazone (Option A), a drug that increases the peripheral uptake of glucose, is associated rEY POII{TS with weight gain and is not the best choice for this patient. o Contraindications to estrogen-containing contracep- Behavioral counseling with motivational interviewing and tt €, tives include migraine with aura, history of breast increasing the dose of metformin or liraglutide, if possible, ET cancer, venous thromboembolic disease, uncontrolled are better choices. hypertension, or smoking more than 15 cigarettes a Using a multidisciplinary team of health care profes (J day for women older than 35 years. sionals (dietitians, nurses, and psychologists) can be help ?r r Non estrogen hormonal contraception options are ful when available. However, in the absence of motivation |E to change, referring the patient to a dietitian or supervised vt levonorgestrel-releasing intrauterine devices (lUDs), (l, subdermal progestin implant, depot medroxlproges exercise program (Options C, D) is unlikely to be success ful in achieving a healthier lif'estyle in this ambivalent vt = terone acetate injection, and progesterone only oral patient. contraceptive pills; a copper IUD is a nonhormonal option. f,EY POttrs o Motivational interviewing is a counseling approach Bibliography that uses directive, patient-centered techniques; its Woodhams EJ, Gilliam M. Contraceptbn. Ann lntern Med.2019;170:lTCl8 32. I PMID, 307167581 doi:10.7326lAl'l'C201902050 overall goal is to assist patients in addressing and changing unhealthy behaviors. o Foundational to motivational interviewing is an Item 15 Answer: B attempt by the physician to understand the patient's perspectives, followed by having the patient reflect on Ed u catio n a I O bj ective: Use motivational interviewing to help patients make lifestyle changes. the need for change by highlighting the discrepancy between the patient's current and desired behavior. The most appropriate initial management step is behav ioral counseling that includes motivational interviewing Bibliography (Option B). The basic elements in motivational interview Mifsud lL, Galea J, Garside J, et al. Motivational interviewing to support ing include engagement, focusing, evoking, and planning. modifiable risk factor change in individuals at increased risk of cardio vascular disease: a systematic review and meta analysis. PLoS One. Motivational interviewing is a counseling approach that 202O;15:e0241193. [PMID: 331758491 doi:10.1371/journal.pone.0241l93 uses directive, patient centered techniques. Its overall goal is to assist patients in addressing and changing unhealthy Item 16 behaviors. Motivational interviewing capitalizes on the patient's intrinsic motivation to change and identifles rea- sons fbr ambivalence to change and discusses them without Answer: D Ed ucational Objective: Diagnose Stevens-Johnson tr syndrome toxic epidermal necrofsis overlap syndrome. directly confronting the patient. Foundational to motiva- tional interviewing is the physician's attempt to understand Stcvcns Johnson synclrorne (S.lS) and toxic epidcnnril the patient's perspectives, followed by having the patient necrolysis (TEN) (Option D) are thc rnost sL'vere ar-rcl deaclly reflect on the need for change by highlighting the discrep of'the cutaneous adverse clrug rcactions. SJS/TEN overlup ar.rcy between the patient's current and desired behavior. sl,nclronre rcfers to patients r,t,itlt lo'X, to 30'li, body surlircc The physician attempts to build rapport and engage the arca aflected. Symptonrs bcgirt usr-rally lvithin 1 to 3 r,r'ccks patient with a supportive, nonjudgmental attitude. The phy of erposure to iln inciting rgenl. such its carbantitzepitte. sician elicits ideas and feelings about current behaviors u'ith fever and r.nalaise ftrllou'ed [.l1 skin pain. grittiness or and how they match the patient's desires and values, and sirrrd like irritatioll of thc eyes. anci rtcll'nopl-ragia. Shortll' has the patient reflect on the possibility of better options thereatter. p.rtients devclop rcd or purple dus\'macules on compared with current behaviors. The conversation allows the trunk that progress to vcsicles. erosiort. and ulcerirti<tn. identification of speciflc changes important to the patient. l'}ainlul erosions delelop in thc tnouth. e),es. or genitirls itt as ln a process known as change talk, the physician elicits the nttny as 95')1, of patients. Mortllity is high, rvith 5')1, to 10'){, of' patient's own reasons and rationale for change. Motivational SJS cases being fatal. 173

Answers and Critiques tr CONI, Acute generalizecl exanthemiltoLls pustulosis (ACEI)) (Option A) refers to the rapicl onset ol a pustular rash af ter a nreclication exposurc. C)r'rsct nray be as soon as 1 day alicr Treatment may reduce transmissibility. 1he choice of antibiotic is usually empiric. Because a course of a broad- spectrum topical antibiotic is usually effective, the most con cxl)osllre to the nrcdication rlr a fcw clays at most. Patients venient or least expensive option can be selected; there is no present with fever and crythcnril and eventually devekrp clinical evidence suggesting the superiority of any particular dense non {blliculocentric pustules, primarily in skin firkls antibiotic. Although there are no data supporting the cost- and on the trunk. lhe onsct ol this patient's rash 12 days eflectiveness of using antibiotics in mild bacterial conjunctivitis, illier initiation of carbirmazcpinc irnd lack of pustules arguc the shortened morbidity associated with their use makes against ACEP choice of therapy an individual decision. Trimethoprim I)rug induced hvpcrscnsitivity' syndrome (l)lllS) polymyxin ophthalmic solution is an appropriate antibi (Option B) is also a severc litc thrcatening medication rclc otic option for patients, such as this one, who do not wear tion. Unlike other scvcrc rnedication rcaclions. the onsct contact lenses. Other reasonable options are erythromy D ol symptoms is delayed. oltcn 2 to 6 wecks after exllosurc. cin or bacitracin-polymyxin ophthalmic ointments. Lack UI Symptoms begin with fcvcr and flulikc synrptoms. cluickly of symptom improvement or symptom worsening within { .D filllowecl by burning skin pain arrcl rash. Palienls typically several days of initiation of an appropriate topical antimi UI clcvelop a morbillilbrnr exanthenr that starts on thc facc crobial should prompt ophthalmology referral. 9, ancl upper trunk and sprcads <listally. l'iventually. the patient Because of concern about antibiotic resistance and CL clcvelops striking facial eclenrir ancl redness, a hallmark of' higher cost, ofloxacin ophthalmic solution (Option A) rl I)lllS. Oral nrucosal involvenrerrt is common.'[he onset ol should be reserved for patients who wear contact lenses, ll this pirtient's rash l2 da-vs lller initiation of carbamazepinc which increases the risk for pseudomonal infection. and lack of a morbilliftrrnr rash ancl fircial edema trrgue Topical antihistamines, such as olopatadine (Option B), o UI agrrinst DIHS. have no role in the treatment of acute bacterial conjunctivi lrrytl.rroderma (Option C) is clcfined as diffuse erythenra tis. Olopatadine is commonly used in patients with allergic covcring B0')1, to 90'7, bocly surllce arca and is comnronly conjunctivitis, who typically present with bilateral eye red associated with pruritus, pcripheral eclema, erosions, scal ness, pruritus, watery discharge, and eyelid swelling. ing, and lymphadenoprrthy. 'lhe lrost common causes flrc Topical ophthalmologic glucocorticoids, such as pred idiopathic (up to 40'X,). exacerbrrtion of a preeristing rash. or nisolone alone (Option C) or in combination with an anti mcdicatior.r rcaction. liris 1'uticnt's illr.ress is not manifcstccl biotic. do not have a role in the treatment of acute bacterial l.ry widespread erythcma. conjunctivitis. When given to patients with either bacterial or viral keratitis, they can lead to corneal damage, including f,EY POIilI perloration and scarring. o Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome begins 1 to 3 weeks after exposure t(tY PoltTS to an inciting agent and is characterized by a wide r Mild bacterial conjunctivitis is typically a self-limited spread mucocutaneous reaction that progresses to condition, but topical antibiotic treatment may vesicles, erosions, and ulcerations. shorten the duration of symptoms and transmissibil- ity and is a reasonable option in some patients. Bibliography o The choice of a topical broad spectrum antibiotic for Noe Mll, Micheletti RG. Diagnosis and management of Stevens Johnson bacterial conjunctivitis is usually empiric; the most syndrome/toxic epidermal necrolysis. Clin Dermatol. 2020)8:607 12. I PMID: 333411951 doi:10.lol6lj.clindermak)1.2020.06.016 convenient or least expensive option can be selected.

tr CONI, Acute generalizecl exanthemiltoLls pustulosis (ACEI)) (Option A) refers to the rapicl onset ol a pustular rash af ter a nreclication exposurc. C)r'rsct nray be as soon as 1 day alicr Treatment may reduce transmissibility. 1he choice of antibiotic is usually empiric. Because a course of a broad- spectrum topical antibiotic is usually effective, the most con cxl)osllre to the nrcdication rlr a fcw clays at most. Patients venient or least expensive option can be selected; there is no present with fever and crythcnril and eventually devekrp clinical evidence suggesting the superiority of any particular dense non {blliculocentric pustules, primarily in skin firkls antibiotic. Although there are no data supporting the cost- and on the trunk. lhe onsct ol this patient's rash 12 days eflectiveness of using antibiotics in mild bacterial conjunctivitis, illier initiation of carbirmazcpinc irnd lack of pustules arguc the shortened morbidity associated with their use makes against ACEP choice of therapy an individual decision. Trimethoprim I)rug induced hvpcrscnsitivity' syndrome (l)lllS) polymyxin ophthalmic solution is an appropriate antibi (Option B) is also a severc litc thrcatening medication rclc otic option for patients, such as this one, who do not wear tion. Unlike other scvcrc rnedication rcaclions. the onsct contact lenses. Other reasonable options are erythromy D ol symptoms is delayed. oltcn 2 to 6 wecks after exllosurc. cin or bacitracin-polymyxin ophthalmic ointments. Lack UI Symptoms begin with fcvcr and flulikc synrptoms. cluickly of symptom improvement or symptom worsening within { .D filllowecl by burning skin pain arrcl rash. Palienls typically several days of initiation of an appropriate topical antimi UI clcvelop a morbillilbrnr exanthenr that starts on thc facc crobial should prompt ophthalmology referral. 9, ancl upper trunk and sprcads <listally. l'iventually. the patient Because of concern about antibiotic resistance and CL clcvelops striking facial eclenrir ancl redness, a hallmark of' higher cost, ofloxacin ophthalmic solution (Option A) rl I)lllS. Oral nrucosal involvenrerrt is common.'[he onset ol should be reserved for patients who wear contact lenses, ll this pirtient's rash l2 da-vs lller initiation of carbamazepinc which increases the risk for pseudomonal infection. and lack of a morbilliftrrnr rash ancl fircial edema trrgue Topical antihistamines, such as olopatadine (Option B), o UI agrrinst DIHS. have no role in the treatment of acute bacterial conjunctivi lrrytl.rroderma (Option C) is clcfined as diffuse erythenra tis. Olopatadine is commonly used in patients with allergic covcring B0')1, to 90'7, bocly surllce arca and is comnronly conjunctivitis, who typically present with bilateral eye red associated with pruritus, pcripheral eclema, erosions, scal ness, pruritus, watery discharge, and eyelid swelling. ing, and lymphadenoprrthy. 'lhe lrost common causes flrc Topical ophthalmologic glucocorticoids, such as pred idiopathic (up to 40'X,). exacerbrrtion of a preeristing rash. or nisolone alone (Option C) or in combination with an anti mcdicatior.r rcaction. liris 1'uticnt's illr.ress is not manifcstccl biotic. do not have a role in the treatment of acute bacterial l.ry widespread erythcma. conjunctivitis. When given to patients with either bacterial or viral keratitis, they can lead to corneal damage, including f,EY POIilI perloration and scarring. o Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome begins 1 to 3 weeks after exposure t(tY PoltTS to an inciting agent and is characterized by a wide r Mild bacterial conjunctivitis is typically a self-limited spread mucocutaneous reaction that progresses to condition, but topical antibiotic treatment may vesicles, erosions, and ulcerations. shorten the duration of symptoms and transmissibil- ity and is a reasonable option in some patients. Bibliography o The choice of a topical broad spectrum antibiotic for Noe Mll, Micheletti RG. Diagnosis and management of Stevens Johnson bacterial conjunctivitis is usually empiric; the most syndrome/toxic epidermal necrolysis. Clin Dermatol. 2020)8:607 12. I PMID: 333411951 doi:10.lol6lj.clindermak)1.2020.06.016 convenient or least expensive option can be selected. Bibliography Item 17 Answer: D Varu DM, Rhee MK, Akpek EK, et al;American Academyof Ophthalmologr Preferred Practice Pattern Cornea and External Disease Panel. Educational Objective: Treat acute bacterial Conjunctivitis Preferred Practice Pattern . Ophthalmology. 2019; conjunctivitis with a topical antibiotic. 126:P94 169. [PMID: 303667971 doi:l0.l0l 6/j.ophtha.2018.1O.O2O

Bibliography Item 17 Answer: D Varu DM, Rhee MK, Akpek EK, et al;American Academyof Ophthalmologr Preferred Practice Pattern Cornea and External Disease Panel. Educational Objective: Treat acute bacterial Conjunctivitis Preferred Practice Pattern . Ophthalmology. 2019; conjunctivitis with a topical antibiotic. 126:P94 169. [PMID: 303667971 doi:l0.l0l 6/j.ophtha.2018.1O.O2O Trimethoprim polymyxin ophthalmic solution is the most appropriate topical treatment (Option D). This patient pre Item 18 sents with acute unilateral conjunctival redness accompa nied by mucopurulent discharge, which is consistent with Answer: E Educational Objective: Provide culturally sensitive care tr to a transgender patient. acute bacterial conjunctivitis. According to the 2019 American Academy of Ophthalmologr guideline, mild bacterial con lhe most appropriate next step in patient management is junctivitis is usually self limited, and it typically resolves expectant managenrent (Option E). [n general. examina spontaneously without specific treatment in immuno tion of an organ systenr should be related to the patient's competent adults. Use of topical antibacterial therapy is symptoms. associated with earlier clinical and microbiological remis This patient's gcnder identity is not relevant to sion compared with placebo in days 2 to 5 of treatment. the reason for the visit; therefbre, obtaining a detailecl 174

Answers and Critiques l'll gender related history (hormonal, surgical, social, andsexual) Actinic keratosis (Option A) is a precancerous lesion (Ontions A, B) and perfgrming a genital examinarion lff '"''' (Option C) are unnecessary. ln acldition, these interventions that can potentially develop into squamous cell carcinoma. It presents as a thin papule or plaque with scale that is often may make this patient feel uncomfortable and potentially more easily felt than seen. This patient's rapidly evolving dissuade him from returning fbr important ongoing health papule with a keratin-fllled center is not compatible with care. A comprehensive history of a transgender person is actinic keratosis. usually not possible to obtain in one visit; it is best obtained Basal cell carcinoma (Option B) is a malignant neo over time in order to build rapport with the patient. In plasm arising from the basal layer of the epidermis. There general, history taking lor transgender persons is the same are different histologic subtypes, including superflcial, as for all patients and includes fantily, reproductive, sexual, pigmented, sclerotic, and nodular, that result in varying psychiatric, and social histories. Elernents of the history that clinical appearance. Nodular basal cell carcinoma is the most are unique to the transgender population are hormonal and common type, classically appearing as pearly papules with surgical therapies related to gender transition. rolled borders and arborizing telangiectasias. Frequently, a ur Recommendations fbr sexually transmitted infection central ulceration may appear that is similar in appearance o (STl) screening (Option D) are the same fbr transgender to the crater seen in keratoacanthoma (as shown). ET patients as fbr all patients. Screening should account fbr the patient's anatomy and sexual history. Just as it would be U !, inappropriate to perform STI screening in a nontransgender .g patient during a first time visit fbr unrelated episodic care. tt it would also be inappropriate to screen this patient today. (l, STI screening is important ancl shouid be performed; how v! = E ever, it can wait until patient rapport has been established and a more detailed history has been obtained to guide screening. Many online resources are available fbr learning about transgender persons and providing culturally sensitive medical care. The University of' Califbrnia, San Francisco, has published guidelines fbr primary and gender-affirming I care of transgender and gender nonbinary persons at http:// transhealth.ucsfledu/protocols. ln addition, the National Lesbian, Gay, Bisexual, and 1'ransgender (LGBT) Health However, basal cell carcinomas do not have the keratin- Eclucation Center, a program of the Fenway Institute, pro filled center and typically do not develop as rapidly as this vides learning modules at wwwlgbthealtheducation.org/ patient's lesion. lgbt educationiiearning modules/. Pyoderma gangrenosum (Option D) presents with I an exquisitely tender papule, pustule, or nodule. The area o Physicians should provide care for all patients in a quickly enlarges and begins to ulcerate in a cribriform pat- sensitive, respectful, and affirming manner. tern, with intervening strands of epithelium. There is a char- t acteristic violaceous border with an overhanging epithelium Bibliography around the central exudative ulcer, which is often described I

l'll gender related history (hormonal, surgical, social, andsexual) Actinic keratosis (Option A) is a precancerous lesion (Ontions A, B) and perfgrming a genital examinarion lff '"''' (Option C) are unnecessary. ln acldition, these interventions that can potentially develop into squamous cell carcinoma. It presents as a thin papule or plaque with scale that is often may make this patient feel uncomfortable and potentially more easily felt than seen. This patient's rapidly evolving dissuade him from returning fbr important ongoing health papule with a keratin-fllled center is not compatible with care. A comprehensive history of a transgender person is actinic keratosis. usually not possible to obtain in one visit; it is best obtained Basal cell carcinoma (Option B) is a malignant neo over time in order to build rapport with the patient. In plasm arising from the basal layer of the epidermis. There general, history taking lor transgender persons is the same are different histologic subtypes, including superflcial, as for all patients and includes fantily, reproductive, sexual, pigmented, sclerotic, and nodular, that result in varying psychiatric, and social histories. Elernents of the history that clinical appearance. Nodular basal cell carcinoma is the most are unique to the transgender population are hormonal and common type, classically appearing as pearly papules with surgical therapies related to gender transition. rolled borders and arborizing telangiectasias. Frequently, a ur Recommendations fbr sexually transmitted infection central ulceration may appear that is similar in appearance o (STl) screening (Option D) are the same fbr transgender to the crater seen in keratoacanthoma (as shown). ET patients as fbr all patients. Screening should account fbr the patient's anatomy and sexual history. Just as it would be U !, inappropriate to perform STI screening in a nontransgender .g patient during a first time visit fbr unrelated episodic care. tt it would also be inappropriate to screen this patient today. (l, STI screening is important ancl shouid be performed; how v! = E ever, it can wait until patient rapport has been established and a more detailed history has been obtained to guide screening. Many online resources are available fbr learning about transgender persons and providing culturally sensitive medical care. The University of' Califbrnia, San Francisco, has published guidelines fbr primary and gender-affirming I care of transgender and gender nonbinary persons at http:// transhealth.ucsfledu/protocols. ln addition, the National Lesbian, Gay, Bisexual, and 1'ransgender (LGBT) Health However, basal cell carcinomas do not have the keratin- Eclucation Center, a program of the Fenway Institute, pro filled center and typically do not develop as rapidly as this vides learning modules at wwwlgbthealtheducation.org/ patient's lesion. lgbt educationiiearning modules/. Pyoderma gangrenosum (Option D) presents with I an exquisitely tender papule, pustule, or nodule. The area o Physicians should provide care for all patients in a quickly enlarges and begins to ulcerate in a cribriform pat- sensitive, respectful, and affirming manner. tern, with intervening strands of epithelium. There is a char- t acteristic violaceous border with an overhanging epithelium Bibliography around the central exudative ulcer, which is often described I l-ewis EB, Vincent B, Brett A, Gibson S, Walsh U. I am your trans patient. as a "wet ulcer." This patient's keratin filled papule is not tsMl. 2077 ;357 :j2963. IPMID: 286670101 doi:1O.1136/bmj.j2963 compatible with the diagnosis of pyoderma gangrenosum. L Sporotrichosis (Option E) is a rare fungal infection I caused by Sporothrix schenckii. Also known as "rose han- Item 19 Answer: C dler's disease," it is commonly associated with minor cuts I I Ed ucationa I Objective : Diagnose keratoacanthoma. caused by working with vegetation, such as rose bushes or I mosses. Sporotrichosis can appear as a subcutaneous nodule 5 The most likely diagnosis is keratoacanthoma (Option C), that may ulcerate. Typically, multiple nodules will appear which typically presents as a pink nodule with a keratin-fllled I

l-ewis EB, Vincent B, Brett A, Gibson S, Walsh U. I am your trans patient. as a "wet ulcer." This patient's keratin filled papule is not tsMl. 2077 ;357 :j2963. IPMID: 286670101 doi:1O.1136/bmj.j2963 compatible with the diagnosis of pyoderma gangrenosum. L Sporotrichosis (Option E) is a rare fungal infection I caused by Sporothrix schenckii. Also known as "rose han- Item 19 Answer: C dler's disease," it is commonly associated with minor cuts I I Ed ucationa I Objective : Diagnose keratoacanthoma. caused by working with vegetation, such as rose bushes or I mosses. Sporotrichosis can appear as a subcutaneous nodule 5 The most likely diagnosis is keratoacanthoma (Option C), that may ulcerate. Typically, multiple nodules will appear which typically presents as a pink nodule with a keratin-fllled I t along the Iymphatic tracts. Sporotrichosis does not present center, giving it a "volcaniforrn" appearance. Keratoacantho- with a keratin fllled crater. mas grow rapidly (within 4-6 weeks) and are frequently pain- ! ful. They are considered by many to be a variant of squamous IIY POIII t !

t along the Iymphatic tracts. Sporotrichosis does not present center, giving it a "volcaniforrn" appearance. Keratoacantho- with a keratin fllled crater. mas grow rapidly (within 4-6 weeks) and are frequently pain- ! ful. They are considered by many to be a variant of squamous IIY POIII t ! cell carcinoma. After rapid growth, some keratoacanthomas o Keratoacanthomas present as a pink nodule with tend to involute. Because keratoacanthomas are difficult to a keratin-filled center ("volcaniform" appearance), i differentiate from cutaneous squamous cell carcinoma, they are rapidly growing and frequently painful, and I are often treated with surgical excision. For this patient with are considered a variant of squamous cell a lesion on the dorsal right hand, Mohs micrographic surgery carcinoma. would most likely be performed. 175 l L

Answers and Critiques Bibliography f,tY POlt{TS (sninaedt Kwiek B, Schwartz RA. Keratoacanthoma (KA): an update and review. J Am Acad Dermatol. 2016;74:1220 33. [PMID: 26853179] doi:10'1016/j' . In addition to the 23-valent pneumococcal polysac- jaad.2015.11.o33 charide vaccine, administration of the 13-valent pneu- mococcal conjugate vaccine is recommended in indi- viduals with certain high-risk conditions, including Item 20 Answer: B immunocompromise, asplenia, hemoglobinopathies, Educational Objective: Vaccinate a patient at increased cerebrospinal fluid leaks, and cochlear implants. risk for pneumococcal disease. The most appropriate vaccine to administer to this patient Bibliogpphy Freedman MS. Bernstein H, Ault KA. Recommended adult immunization is the 13 valent pneumococcal coniugate vaccine (PCV13) schedule. United States. 2021. Ann Intern Med. 2021. [PMID: 33571011] (Option B). Pneumococcal vaccination is recommended in doi:1O.7326/M20 8080 all adults aged 65 years or older and in adults aged 19 to ut 64 years with certain high risk conditions. Two pneumococ { (D ut q, cal vaccines are available: the 23-valent polysaccharide vac- cine (PPSV23) and the 13 valent conjugate vaccine (PCV13)' PPSV23 is favored over PCV13 as the primary vaccine. This Item 21 Answer: C Educational Obiective: Screen for frailty in a tr El. preoperative geriatric patient. patient received the PPSV23 four years ago, but because she n has chronic kidney disease and is at increased risk for pneu A frailtl' assessment (Option C) l,rould best predict surge$r mococcal disease, she should additionally receive the PCV13 related morbidity and morlality and should be perfbnned in .l! at this time. The Advisory Committee on Immunization Prac this patient to identify incteased risk. Frailtf is a rnultilactorial tD la tices (ACIP) no longer recommends the PCV13 to all individu- state ofdecreased physiologic resenres and incrcased vulnera als but instead only to those who are considered at increased bility to stressors. [n persons older than 65 1ears. the estirnated risk, such as patients with immunocompromising conditions, incidence of i'railtf is 10')i, to 20'r;, alld increases u'ith each including chronic kidney disease, HIV infection, solid organ decade. Standardized indices to objectirell' nleasure frailtl' transplants, malignancy, or use of immunosuppressive med include the Frailty Index. tl-re frailtl' pheno['pe. the FRAIL ications. Other groups requiring PCV13 vaccination include (Fatigue, Resistance. Ambulation. Illness. irnd Loss of ueight) those with functional or anatomic asplenia and hemoglo scale, and the Osteoporotic Fractures Frailtl'Scale. The FRAIt. binopathies, such as sickle cell disease. Finally, immuno scale is the easiest to administer and score. ln the perioperative competent patients with cerebrospinal fluid leaks or cochlear period. frailty is associated with l-righer rates of complications. implants should also be vaccinated with PCV13. Shared deci- prolonged hospital stays. and increased rates of morbidi4'' and sion making should be used as the basis for administering lnortaliry Fraih-v* is a risk lactor for poor surgical outcomes. PCV13 in patients older than 65 years without one of these and thus it is impofiant to engage the Iiail patient and fan.t risk factors. PCV13 should be given at least 1 year after prior i1y in conversations arcur.rd decision making before electire PPSV23 administration. surgeries. A frailtl,assessment may inforn.r discussions with All adults should receive a tetanus and diphtheria the patient and fan-rily regarding surgical techr.riques. pre and toxoids (Td) or the tetanus toxoid, reduced diphtheria postoperative strategies to minirnize risk. and likely outcomes. toxoid, and acellular pertussis (Tdap) booster every 10 years. Screening chest radiography (Option A) is generally not This patient received Tdap vaccine 2 years ago and does not recommended for patients undergoing surgery r.rnless there are require a Td booster (Option A) at this time. nert signs and symptoms suggestire ot undiagr.rosed or progrcs- Although most patients receive the 23-valent pneu- sir,e pulmonary disease. Multiple studies hare sholr,n that chest mococcal vaccine (Option C) at age 65 years, this patient radiographs are usualll' not etibctire at predicting postopera- received the vaccine early because ol her increased risk. She tive outcomes or changing perioperati"e managet.nent. \\t'hen will require revaccination in 5 years; she received the vaccine abnomal findings are noted. thel'g'picalll'could l.rare been 4 years ago and does not require it at this time. The ACIP predicted through history and ptrysical examinatior.r. makes no recommendation for continued booster doses after Preoperatire ECG (Option B) is reasonable in patier.rts the initial revaccination. with knou'n coronary artery disease. arrhytl-rmia. peripheral Given this patient's history of chronic kidney disease, artery disease, cerebror,,ascular disease, or structural heart and thus increased risk for pneumococcal disease, oIfer- disease undergoing moderate to high risk surgeries. Horv- ing no vaccines at this time would not be the best strategz ever, ECG abnonr.ralities ir.r older patients are common. r,r,ith (Option D). a prevalence of 75')1, in one observational studlt but are not xtY PorilTs associated rvith cardiac er,ents and do not predict perioper ative morbidity or mortaliry Risk scores. such the Revised o Pneumococcal vaccination is recommended in all Cardiac Risk Index score and others. do predict perioperatire adults aged 65 years or older and in adults aged 19 to morbidit-v and mortaliry 64 years with certain high-risk conditions. Spirometry (Option D) is not useful fbr predicting (Continued) surgical risk and should n<tt be routinely ordered for

Bibliography f,tY POlt{TS (sninaedt Kwiek B, Schwartz RA. Keratoacanthoma (KA): an update and review. J Am Acad Dermatol. 2016;74:1220 33. [PMID: 26853179] doi:10'1016/j' . In addition to the 23-valent pneumococcal polysac- jaad.2015.11.o33 charide vaccine, administration of the 13-valent pneu- mococcal conjugate vaccine is recommended in indi- viduals with certain high-risk conditions, including Item 20 Answer: B immunocompromise, asplenia, hemoglobinopathies, Educational Objective: Vaccinate a patient at increased cerebrospinal fluid leaks, and cochlear implants. risk for pneumococcal disease. The most appropriate vaccine to administer to this patient Bibliogpphy Freedman MS. Bernstein H, Ault KA. Recommended adult immunization is the 13 valent pneumococcal coniugate vaccine (PCV13) schedule. United States. 2021. Ann Intern Med. 2021. [PMID: 33571011] (Option B). Pneumococcal vaccination is recommended in doi:1O.7326/M20 8080 all adults aged 65 years or older and in adults aged 19 to ut 64 years with certain high risk conditions. Two pneumococ { (D ut q, cal vaccines are available: the 23-valent polysaccharide vac- cine (PPSV23) and the 13 valent conjugate vaccine (PCV13)' PPSV23 is favored over PCV13 as the primary vaccine. This Item 21 Answer: C Educational Obiective: Screen for frailty in a tr El. preoperative geriatric patient. patient received the PPSV23 four years ago, but because she n has chronic kidney disease and is at increased risk for pneu A frailtl' assessment (Option C) l,rould best predict surge$r mococcal disease, she should additionally receive the PCV13 related morbidity and morlality and should be perfbnned in .l! at this time. The Advisory Committee on Immunization Prac this patient to identify incteased risk. Frailtf is a rnultilactorial tD la tices (ACIP) no longer recommends the PCV13 to all individu- state ofdecreased physiologic resenres and incrcased vulnera als but instead only to those who are considered at increased bility to stressors. [n persons older than 65 1ears. the estirnated risk, such as patients with immunocompromising conditions, incidence of i'railtf is 10')i, to 20'r;, alld increases u'ith each including chronic kidney disease, HIV infection, solid organ decade. Standardized indices to objectirell' nleasure frailtl' transplants, malignancy, or use of immunosuppressive med include the Frailty Index. tl-re frailtl' pheno['pe. the FRAIL ications. Other groups requiring PCV13 vaccination include (Fatigue, Resistance. Ambulation. Illness. irnd Loss of ueight) those with functional or anatomic asplenia and hemoglo scale, and the Osteoporotic Fractures Frailtl'Scale. The FRAIt. binopathies, such as sickle cell disease. Finally, immuno scale is the easiest to administer and score. ln the perioperative competent patients with cerebrospinal fluid leaks or cochlear period. frailty is associated with l-righer rates of complications. implants should also be vaccinated with PCV13. Shared deci- prolonged hospital stays. and increased rates of morbidi4'' and sion making should be used as the basis for administering lnortaliry Fraih-v* is a risk lactor for poor surgical outcomes. PCV13 in patients older than 65 years without one of these and thus it is impofiant to engage the Iiail patient and fan.t risk factors. PCV13 should be given at least 1 year after prior i1y in conversations arcur.rd decision making before electire PPSV23 administration. surgeries. A frailtl,assessment may inforn.r discussions with All adults should receive a tetanus and diphtheria the patient and fan-rily regarding surgical techr.riques. pre and toxoids (Td) or the tetanus toxoid, reduced diphtheria postoperative strategies to minirnize risk. and likely outcomes. toxoid, and acellular pertussis (Tdap) booster every 10 years. Screening chest radiography (Option A) is generally not This patient received Tdap vaccine 2 years ago and does not recommended for patients undergoing surgery r.rnless there are require a Td booster (Option A) at this time. nert signs and symptoms suggestire ot undiagr.rosed or progrcs- Although most patients receive the 23-valent pneu- sir,e pulmonary disease. Multiple studies hare sholr,n that chest mococcal vaccine (Option C) at age 65 years, this patient radiographs are usualll' not etibctire at predicting postopera- received the vaccine early because ol her increased risk. She tive outcomes or changing perioperati"e managet.nent. \\t'hen will require revaccination in 5 years; she received the vaccine abnomal findings are noted. thel'g'picalll'could l.rare been 4 years ago and does not require it at this time. The ACIP predicted through history and ptrysical examinatior.r. makes no recommendation for continued booster doses after Preoperatire ECG (Option B) is reasonable in patier.rts the initial revaccination. with knou'n coronary artery disease. arrhytl-rmia. peripheral Given this patient's history of chronic kidney disease, artery disease, cerebror,,ascular disease, or structural heart and thus increased risk for pneumococcal disease, oIfer- disease undergoing moderate to high risk surgeries. Horv- ing no vaccines at this time would not be the best strategz ever, ECG abnonr.ralities ir.r older patients are common. r,r,ith (Option D). a prevalence of 75')1, in one observational studlt but are not xtY PorilTs associated rvith cardiac er,ents and do not predict perioper ative morbidity or mortaliry Risk scores. such the Revised o Pneumococcal vaccination is recommended in all Cardiac Risk Index score and others. do predict perioperatire adults aged 65 years or older and in adults aged 19 to morbidit-v and mortaliry 64 years with certain high-risk conditions. Spirometry (Option D) is not useful fbr predicting (Continued) surgical risk and should n<tt be routinely ordered for 176

Answers and Critiques [l lrreoperatirr cvlluatior.r. ir.rcluding in pltients rt,ith COp]) recommends against screening low-risk and asymptomatic lfl (,rs is the cirsc lirr this pltient). I,'urthermorc, eviclence adults with resting or exercise ECG. CoNI d1;er not support :i spirontetric thresholcl below which the Cardiovascular disease is the leading cause of morbidity risk of surgery is unacccptable ar.rcl spironletrv is rl poor and mortality in the United States, accounting for 1 of every predictor of ntorl)idit), or ntortalilri Spirometry ntight be 3 deaths among adults. The rationale for calculating cardio helpful in patierrts with oltstructive airways disease il there vascular risk is that some asymptomatic individuals between is suspicion that the patient is not optimally trcated; the 40 and 75 years of age without a history of cardiovascular presence of reversible airfkx,r,obstruction suggests tlte need disease may have undetected atherosclerotic changes and ftrr nrore aggressive therapv may be candidates for preventive interventions. Assessing XEY POIilTS cardiovascular risk to identi$r persons that will beneflt from prevention strategies is reasonable (Option E). . Frailty is a multifactorial state of decreased physio- logic reserves and increased vulnerability to stressors. f,tY P0rtTs (^ r Frailty is associated with perioperative complications, . The U.S. Preventive Services Task Force recommends o prolonged hospital stays, and increased mortality. calculating the cardiovascular disease risk in adults ET aged 40 to 75 years using the Pooled Cohort rr, Bibliography Equations. !, Alvarez Nebreda ML, tsentov N, Urman RD, et .rl. Recommendations for o The U.S. Preventive Services Task Force does not rec- |g preoperative mtnagement ol tiailty from the Society fbr perioperative tt Assessment and Quality lmprovement (SpAel). J Clin Anesth. 2018;47: ommend screening for coronary artery disease with (l, il:l 42. IPMtD: 29550619] doi: 10. l0l6/j.jc1inane.2018.02.011 either resting or exercise ECG in asymptomatic patients t! = at low risk. tr

[l lrreoperatirr cvlluatior.r. ir.rcluding in pltients rt,ith COp]) recommends against screening low-risk and asymptomatic lfl (,rs is the cirsc lirr this pltient). I,'urthermorc, eviclence adults with resting or exercise ECG. CoNI d1;er not support :i spirontetric thresholcl below which the Cardiovascular disease is the leading cause of morbidity risk of surgery is unacccptable ar.rcl spironletrv is rl poor and mortality in the United States, accounting for 1 of every predictor of ntorl)idit), or ntortalilri Spirometry ntight be 3 deaths among adults. The rationale for calculating cardio helpful in patierrts with oltstructive airways disease il there vascular risk is that some asymptomatic individuals between is suspicion that the patient is not optimally trcated; the 40 and 75 years of age without a history of cardiovascular presence of reversible airfkx,r,obstruction suggests tlte need disease may have undetected atherosclerotic changes and ftrr nrore aggressive therapv may be candidates for preventive interventions. Assessing XEY POIilTS cardiovascular risk to identi$r persons that will beneflt from prevention strategies is reasonable (Option E). . Frailty is a multifactorial state of decreased physio- logic reserves and increased vulnerability to stressors. f,tY P0rtTs (^ r Frailty is associated with perioperative complications, . The U.S. Preventive Services Task Force recommends o prolonged hospital stays, and increased mortality. calculating the cardiovascular disease risk in adults ET aged 40 to 75 years using the Pooled Cohort rr, Bibliography Equations. !, Alvarez Nebreda ML, tsentov N, Urman RD, et .rl. Recommendations for o The U.S. Preventive Services Task Force does not rec- |g preoperative mtnagement ol tiailty from the Society fbr perioperative tt Assessment and Quality lmprovement (SpAel). J Clin Anesth. 2018;47: ommend screening for coronary artery disease with (l, il:l 42. IPMtD: 29550619] doi: 10. l0l6/j.jc1inane.2018.02.011 either resting or exercise ECG in asymptomatic patients t! = at low risk. tr Item 22 Answer: A Bibliography Educational Objective: Assess cardiovascular Bibbins-Domingo K, Grossman DC, Curry Sl, et al; US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease risk. disease in adults: US Preventive Services'Iask Force recommendation statement. JAMA. 2016;31 6:1 997 -2OO7. [PMI D: 27838723 I doi:10.1001 / The U.S. Preventive Services Task Force (USPSTF) recom jama.2016.15450 mends calculating the cardiovascular disease risk (Option A) in adults aged 40 to 75 years using the Pooled Cohort Equations. This requires measurement of serum lipid lev els to determine risk tbr an atherosclerotic cardiovascular disease (ASCVD) event. The USPSTF recommendation has Item 23 Answer: D Educationa I O bjective: Perform perioperative tr pulmonary assessment in a patient with COPD. shifted away from routine measurement of serum lipid lev els and toward identiffing adults with a lO-year risk for a No further testing is required fbr- tl.ris patient (Option D). cardiovascular event that is 10'2, or greater. For adults 40 to Perioperative pulmonary cclmplicatior-rs includc pneunroniu, 75 years of age, the American College of Cardiologz/American respiratory flilure, and exacerbation ot underl-v''ing lung dis Heart Association also recommends routine assessment of ease. There is a lirnited roie fbr nrutine perioperative pul traditional cardiovascular risk factors and calculation of the n1onary testing in patients with COPI). Patients with COPI) 10 year risk for ASCVD by using the Pooled Cohort Equations. should be screened preoperatively fbr signs und symptoms The USPSTF does not recommend screening for carotid ol COPD exacerbation. Patients shoulcl also be screened fbr artery stenosis, such as carotid artery ultrasonography obstmctive sleep apnea. rvhich is associatecl u'ith adr'erse (Option B), in the general adult population. The rationale perioperative outcolres, including cirrcliac events, pulmonary for this recommendation is based on the very low prevalence complications, and ICU ldmissions. A validatccl screening of carotid stenosis (0.5%-l'U,) and the resulting high rate of tool for OSA is the 8 itenr STOP BANG questionruire. One false-positive results yielded by commonly used ultrasonog- pclir.rt is assignecl fbr each "les" response about Snoring, Tired raphy. Auscultation of the neck for carotid bruits is ineflective ness, Obscrved apneas, elcvated blood Pressure. BMI >35. Age fbr screening as well. Screening for carotid stenosis in asymp- >50 years, Neck circumference >40 cnr, and nrale Gender. tomatic patients could lead to harm as a result of complications Cumulative points dc'termine the risk fbr OSA: lon,risk, 0 t<r lrom unnecessary angiographic studies or endarterectomy. 2 pointsr ir.rtermediate risk, :l to 5 poir.rts: high risk. 5 points. The USPSTF does not recommend screening for cor Eviclence for the bene{it of preoperative arterial blood onary artery disease with either resting or exercise ECG gas analysis (Option A) is lacking. 'lhe results are rirrely help (Options C, D) in asymptomatic patients at Iow risk, deflned ful in managing paticnts with stable chronic lung disease or by the USPSTF as a lO-year cardiovascular event risk less predicting clinical outcomes. than l0% using the Pooled Cohort Equations. In patients at Routinc preoperative chest radiography (Option B) is intermediate or high risk for such events, evidence was inad not reconrmended in patients with chronic lung disease equate to assess the relative beneflts and harms ofscreening unless clinical exarninatiot.t or hisktry suggests a change in (l statement). Similarly, the American College of Physicians pulmonary status. In ru.rly approximately 2'X, of cases does

Item 22 Answer: A Bibliography Educational Objective: Assess cardiovascular Bibbins-Domingo K, Grossman DC, Curry Sl, et al; US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease risk. disease in adults: US Preventive Services'Iask Force recommendation statement. JAMA. 2016;31 6:1 997 -2OO7. [PMI D: 27838723 I doi:10.1001 / The U.S. Preventive Services Task Force (USPSTF) recom jama.2016.15450 mends calculating the cardiovascular disease risk (Option A) in adults aged 40 to 75 years using the Pooled Cohort Equations. This requires measurement of serum lipid lev els to determine risk tbr an atherosclerotic cardiovascular disease (ASCVD) event. The USPSTF recommendation has Item 23 Answer: D Educationa I O bjective: Perform perioperative tr pulmonary assessment in a patient with COPD. shifted away from routine measurement of serum lipid lev els and toward identiffing adults with a lO-year risk for a No further testing is required fbr- tl.ris patient (Option D). cardiovascular event that is 10'2, or greater. For adults 40 to Perioperative pulmonary cclmplicatior-rs includc pneunroniu, 75 years of age, the American College of Cardiologz/American respiratory flilure, and exacerbation ot underl-v''ing lung dis Heart Association also recommends routine assessment of ease. There is a lirnited roie fbr nrutine perioperative pul traditional cardiovascular risk factors and calculation of the n1onary testing in patients with COPI). Patients with COPI) 10 year risk for ASCVD by using the Pooled Cohort Equations. should be screened preoperatively fbr signs und symptoms The USPSTF does not recommend screening for carotid ol COPD exacerbation. Patients shoulcl also be screened fbr artery stenosis, such as carotid artery ultrasonography obstmctive sleep apnea. rvhich is associatecl u'ith adr'erse (Option B), in the general adult population. The rationale perioperative outcolres, including cirrcliac events, pulmonary for this recommendation is based on the very low prevalence complications, and ICU ldmissions. A validatccl screening of carotid stenosis (0.5%-l'U,) and the resulting high rate of tool for OSA is the 8 itenr STOP BANG questionruire. One false-positive results yielded by commonly used ultrasonog- pclir.rt is assignecl fbr each "les" response about Snoring, Tired raphy. Auscultation of the neck for carotid bruits is ineflective ness, Obscrved apneas, elcvated blood Pressure. BMI >35. Age fbr screening as well. Screening for carotid stenosis in asymp- >50 years, Neck circumference >40 cnr, and nrale Gender. tomatic patients could lead to harm as a result of complications Cumulative points dc'termine the risk fbr OSA: lon,risk, 0 t<r lrom unnecessary angiographic studies or endarterectomy. 2 pointsr ir.rtermediate risk, :l to 5 poir.rts: high risk. 5 points. The USPSTF does not recommend screening for cor Eviclence for the bene{it of preoperative arterial blood onary artery disease with either resting or exercise ECG gas analysis (Option A) is lacking. 'lhe results are rirrely help (Options C, D) in asymptomatic patients at Iow risk, deflned ful in managing paticnts with stable chronic lung disease or by the USPSTF as a lO-year cardiovascular event risk less predicting clinical outcomes. than l0% using the Pooled Cohort Equations. In patients at Routinc preoperative chest radiography (Option B) is intermediate or high risk for such events, evidence was inad not reconrmended in patients with chronic lung disease equate to assess the relative beneflts and harms ofscreening unless clinical exarninatiot.t or hisktry suggests a change in (l statement). Similarly, the American College of Physicians pulmonary status. In ru.rly approximately 2'X, of cases does 177

Answers and Critiques to the deep red color with fine lamellar scale seen in this ]!t screening chest radiography lead to changes in perioper- El 21ivg management. ancl abnormal findings can usually be patient. Although lichen planus can afi'ect the nail, it tends to coNl preclicted on the basis of clinical examination. lt rnay be cause thinner, atrophic nails with red streaks or pterygiunl reasonable. but not necessary. to obtain chest radiographs unguis (dorsal pterygiurn). wl.ricl.r mirnifests as a triangular in patients older than 70 vears rt'ith chronic cardiopulmo- plate d1'strophl: nary disease if they have not had chest radiograplly in the Pemphigus vulgirris (Option D), an autoimmune blis previons 6 months. Preoperative chest radiography may be tering disease. presents with erosions rather than the scaly indicated in patients unclergoing thoracic or nlediastinal plaques seen in this patient. In acldition. pemphigus vulgaris surgery which this patlent is not. aln'ays involves the or:.r1 mucosil: this patient's nlucosa is Although spirometry (Option C) may help delineate normal. progression of airflow obstruction due to worsening COPD. Stevens-Johnson syndrome/toxic epidennal necrolysis results do not change perioperative nlanagement in patients (SlS TEN) (Option E) preser-rts as purple duskl' macules on such as this <,rne. There is no absolute value of FEV, or FEV, the trunk that progress to vesicles, erosions. ar.rd ulceration. ut t VC that precludes surgery. nor do these values help predict Painlul nrucosal erosions develop in as nlanl' as 95'1, of € .D perioperative pulmonary complications. patients. This patient's diltuse erythroderma is inconsistent t \\'ith SJS ]'EN. o, TEY EL 'OIXII . Patients with COPD should be screened preopera- TEY POIilIS n tively for signs and symptoms of COPD exacerbation. . Erlthroderma describes the condition of erythema . Chest radiography, arterial blood gas analysis, or covering greater than 80% body surface area. .lt E (D spirometry is not routinely indicated in the preopera . Up to 40% of cases of erythroderma are idiopathic; UI tive evaluation of patients with chronic lung disease. exacerbation of a preexisting rash (e.g., psoriasis, atopic dermatitis) and medication reaction are other Bibliography common etiologies. Misk<.rvic A. Lunrb AB. Postoperative pulmonary complications. Br J Anaesth. 2017:tl8:317 34. IPMID: 28186222ldoi:10.1093rbjaiaexoo2 Bibliography Inamadar AC, Ragunatha S.'l'he rash that becomes an erythrodermJ. Clin Dermat(r. 2019:37:88 98. [PMID: 30981298] doi:10.1O16 j.clindermatol. 201 8.12.002 Item 24 Answer: B tr Eduqational Objective: Diagnose erythroderma. Item 25 Answer: D '[he most likely diagnosis is erythroclerma (Option B). spe Ed ucati o na I O bjective : Treat bacterial vaginosis. cifically erythrodermic psoriiisis. Erythroderma is l clescrip tive term firr erythema covering greater than B0')1, body The most appropriate management is oral metronidazole surface area. Up to 40'X, ofcases are idiopathic; exacerbation (Option D) fbr bacterial vaginosis. Bacterial vaginosis is the of a preexisting rash (e.g., psoriasis, atopic dernratitis) and most common cause ol vaginitis. It results fiom the loss of rnedication reaction are other common etioiogies. Psoriasis the normal hydrogen peroxide-producing lactobacilli in the can flare violently to erythrodermic psoriasis after exposure vagina, with an increase in the vaginal pH that contributes to systemic glucocorticoicls; fbr this reason, systrmic cor to an overgrowth of Gardnerella uaginalis and other anaer ticosteroids are very rarely used fbr treatment of psoriasis. obes. Anaerobic overgrowth results in the production of llowever. patients receiving glucocorticoids lor other con amines, causing the characteristically malodorous discharge. ditions may clevelop arr erythrodermic flare. Erythrodermic Diagnosis of bacterial vaginosis is based on the Amsel crite psoriasis can be fatal, with mortality resulting fiom fluid ria, which requires presence of three of the fbllowing four loss, high output heart failure, intection. I.rypothermia, or criteria: vaginal pH greater than 4.5; thin. homogeneous hypoc:rlcemia (because calcium is consumed during tl.re vaginal discharge; a positive amine (whifl) test result in rapid turnover of keratinocytes). which application ol 10% potassium hydroxide (KOH) to Drug-irrduced hypersensitivity syndrome (DIHS) vaginal secretions results in a flshy odor; and at least 20',{, (Option A) riccurs 2 to 6 r,reeks after exposure to a medica clue cells on saline wet mount. This patient meets all four tion. It is characterized by poly'morphous macules papules Amsel criteria and can begin treatment for bacterial vagino or plaques and the developntent olpronounced facial edema sis. Treatment of bacterial vaginosis includes metronidazole and lymphadenopathy. Nail changes are not typical of DIHS. (oral or vaginal gel), clindamycin (vaginal cream), tinidazole '[he time course and appearance of nearly total body ery (oral), or secnidazole (oral). Oral agents are preferred during thema in this patient make DIHS an unlikell,'diagnosis. pregnancy. Lichen planus (Option C) typically presents ils pur Although a nucleic acid ampliflcation test (NAA1') ple flat topped pruritic papules that ntay exhibit a clilfuse, (Option A) can confirm the diagnosis of bacterial vaginosis, hypertropl.ric fbrm. The papules are typically purple or it is not required to make the diagnosis when the Amsel hyperpigmented and with thicker crusting scale, in contrast criteria are satisfled. Although NAAT and rapid antigen tests

to the deep red color with fine lamellar scale seen in this ]!t screening chest radiography lead to changes in perioper- El 21ivg management. ancl abnormal findings can usually be patient. Although lichen planus can afi'ect the nail, it tends to coNl preclicted on the basis of clinical examination. lt rnay be cause thinner, atrophic nails with red streaks or pterygiunl reasonable. but not necessary. to obtain chest radiographs unguis (dorsal pterygiurn). wl.ricl.r mirnifests as a triangular in patients older than 70 vears rt'ith chronic cardiopulmo- plate d1'strophl: nary disease if they have not had chest radiograplly in the Pemphigus vulgirris (Option D), an autoimmune blis previons 6 months. Preoperative chest radiography may be tering disease. presents with erosions rather than the scaly indicated in patients unclergoing thoracic or nlediastinal plaques seen in this patient. In acldition. pemphigus vulgaris surgery which this patlent is not. aln'ays involves the or:.r1 mucosil: this patient's nlucosa is Although spirometry (Option C) may help delineate normal. progression of airflow obstruction due to worsening COPD. Stevens-Johnson syndrome/toxic epidennal necrolysis results do not change perioperative nlanagement in patients (SlS TEN) (Option E) preser-rts as purple duskl' macules on such as this <,rne. There is no absolute value of FEV, or FEV, the trunk that progress to vesicles, erosions. ar.rd ulceration. ut t VC that precludes surgery. nor do these values help predict Painlul nrucosal erosions develop in as nlanl' as 95'1, of € .D perioperative pulmonary complications. patients. This patient's diltuse erythroderma is inconsistent t \\'ith SJS ]'EN. o, TEY EL 'OIXII . Patients with COPD should be screened preopera- TEY POIilIS n tively for signs and symptoms of COPD exacerbation. . Erlthroderma describes the condition of erythema . Chest radiography, arterial blood gas analysis, or covering greater than 80% body surface area. .lt E (D spirometry is not routinely indicated in the preopera . Up to 40% of cases of erythroderma are idiopathic; UI tive evaluation of patients with chronic lung disease. exacerbation of a preexisting rash (e.g., psoriasis, atopic dermatitis) and medication reaction are other Bibliography common etiologies. Misk<.rvic A. Lunrb AB. Postoperative pulmonary complications. Br J Anaesth. 2017:tl8:317 34. IPMID: 28186222ldoi:10.1093rbjaiaexoo2 Bibliography Inamadar AC, Ragunatha S.'l'he rash that becomes an erythrodermJ. Clin Dermat(r. 2019:37:88 98. [PMID: 30981298] doi:10.1O16 j.clindermatol. 201 8.12.002 Item 24 Answer: B tr Eduqational Objective: Diagnose erythroderma. Item 25 Answer: D '[he most likely diagnosis is erythroclerma (Option B). spe Ed ucati o na I O bjective : Treat bacterial vaginosis. cifically erythrodermic psoriiisis. Erythroderma is l clescrip tive term firr erythema covering greater than B0')1, body The most appropriate management is oral metronidazole surface area. Up to 40'X, ofcases are idiopathic; exacerbation (Option D) fbr bacterial vaginosis. Bacterial vaginosis is the of a preexisting rash (e.g., psoriasis, atopic dernratitis) and most common cause ol vaginitis. It results fiom the loss of rnedication reaction are other common etioiogies. Psoriasis the normal hydrogen peroxide-producing lactobacilli in the can flare violently to erythrodermic psoriasis after exposure vagina, with an increase in the vaginal pH that contributes to systemic glucocorticoicls; fbr this reason, systrmic cor to an overgrowth of Gardnerella uaginalis and other anaer ticosteroids are very rarely used fbr treatment of psoriasis. obes. Anaerobic overgrowth results in the production of llowever. patients receiving glucocorticoids lor other con amines, causing the characteristically malodorous discharge. ditions may clevelop arr erythrodermic flare. Erythrodermic Diagnosis of bacterial vaginosis is based on the Amsel crite psoriasis can be fatal, with mortality resulting fiom fluid ria, which requires presence of three of the fbllowing four loss, high output heart failure, intection. I.rypothermia, or criteria: vaginal pH greater than 4.5; thin. homogeneous hypoc:rlcemia (because calcium is consumed during tl.re vaginal discharge; a positive amine (whifl) test result in rapid turnover of keratinocytes). which application ol 10% potassium hydroxide (KOH) to Drug-irrduced hypersensitivity syndrome (DIHS) vaginal secretions results in a flshy odor; and at least 20',{, (Option A) riccurs 2 to 6 r,reeks after exposure to a medica clue cells on saline wet mount. This patient meets all four tion. It is characterized by poly'morphous macules papules Amsel criteria and can begin treatment for bacterial vagino or plaques and the developntent olpronounced facial edema sis. Treatment of bacterial vaginosis includes metronidazole and lymphadenopathy. Nail changes are not typical of DIHS. (oral or vaginal gel), clindamycin (vaginal cream), tinidazole '[he time course and appearance of nearly total body ery (oral), or secnidazole (oral). Oral agents are preferred during thema in this patient make DIHS an unlikell,'diagnosis. pregnancy. Lichen planus (Option C) typically presents ils pur Although a nucleic acid ampliflcation test (NAA1') ple flat topped pruritic papules that ntay exhibit a clilfuse, (Option A) can confirm the diagnosis of bacterial vaginosis, hypertropl.ric fbrm. The papules are typically purple or it is not required to make the diagnosis when the Amsel hyperpigmented and with thicker crusting scale, in contrast criteria are satisfled. Although NAAT and rapid antigen tests 178

Answers and Criti ques can be helpful in clinical settings in which there is no access the sinus via nasal endoscopy or by sinus puncture. Nasal to microscopy, such testing is not necessary in this situation. swabs (Option C) are inadequate because they do not accu Oral azithromycin (Option B) is the appropriate treat- rately predict the infecting organism and cannot be used to ment fbr chlamydia. However, results of this patient,s exam- guide therapy. This patient has no indication for bacterial ination do not suggest cervicitis; her cervix was normal and/or fungal culture at this time. Findings on CT may sug_ appearing, and no purulence was noted at the os. gest the need for more aggressive evaluation. Oral fluconazole (Option C) is an appropriate treat Plain radiography of the sinuses (Option D) may show ment for vaginal candidiasis but not fbr bacterial vaginosis. changes suggestive of chronic sinusitis, including sinus Patients with vaginal yeast infections typically present with opaciflcation and mucosal thickening. These findings, how itching and a thick white discharge. The diagnosis is con_ ever, are nonspecific. Furthermore, plain radiography lacks firmed when KOH wet mount of the discharge demonstrates sufficient sensitivity to determine the presence or extent of yeast, hyphae, and pseudohyphae. potential bony erosion by infection. t(tY P0tilIs xtY Potl{IS vt (u o Diagnosis of bacterial vaginosis is based on the pres_ . Patients with chronic sinusitis, characterized by nasal CT ence of at least three of the four Amsel criteria: vagi_ congestion, purulent rhinorrhea, and headache for nal pH greater than 4.5; thin, homogeneous vaginal more than 12 weeks, should undergo either nasal U discharge; a positive amine (whifl) test result in which t endoscopy or CT ofthe sinuses for diagnostic application of10% potassium hydroxide to vaginal ll, purposes. tn secretions results in a fishy odor; and at least 20% clue (u o In patients with chronic sinusitis, the findings cells on saline wet mount. 3 (a most commonly seen on CT include mucosal . Treatment of bacterial vaginosis includes metronida- thickening, sinus ostial obstruction, polyps, and zole (oral or vaginal gel), clindamycin (vaginal cream), sinus opacification. tinidazole (oral) or secnidazole (oral). Bibliography Bibliography Kwah JH. Itters AT. Nasal polyps tnd rhinosinusitis. Allergr Asthma proc. Paavonen J. Brunhant RC. Bacterial vaginosis and clesqurmative inllanlnta 2019:.10:380 4. IPMII): 316903751 doi:10.2500,'aap.2 O19.tO. 2S2 tory vaginitis. N Engl J Med. 2Ot8t379:2216 54. [pMlD:30575452] doi:10. 1056/NllJMral80u4 l8 Item 27 Answer: B Educational Objective: Manage premature ejaculation. Item 26 Answer: A Educational Objective: Evaluate a patient with The most appropriate management is paroxetine (Option B). This patient has premature ejaculation, which is deflned suspected chronic sinusitis. as ejaculation with minimal stimulation that occurs earlier The most appropriate diagnostic test to perform next is CT than desired. Premature ejaculation that causes self reported ol'the sinuses (Option A). Chronic sinusitis manifests with psychological distress in the patient or partner is an indica at Ieast 12 weeks of nasal congestion with purulent drainage, tion for treatment. The diagnosis of premature ejaculation is diminished sense of smell, or facial pain/pressure. It may be solely based on history. Clinicians should obtain a thorough associated with nasal polyposis (with a strong association sexual history (frequency of premature ejaculation, anteced- with asthma). Demonstration of mucosal involvement by ent sexual activities, aggravating and alleviating factors, nasal endoscopy or imaging (typically CT) is necessary fbr the impact of premature ejaculation, and any concomitant diagnosis. The flndings most commonly seen on CT scan erectile dysfunction). Assessment for an underlying mood include mucosal thickening, sinus ostial obstruction, polyps, condition is also imperative, given the association between and sinus opacification. Treatment includes glucocorticoids premature ejaculation and development of poor self esteem and antibiotics. CT without contrast is the most commonly and depression. Although the speciflc pathophysiologic used imaging modality for the diagnosis of chronic sinusitis. mechanism of premature ejaculation is unknown, dysfunc Although mucosal disease can be demonstrated with tion of 5 hydroxytryptamine (5 HT) receptors and penile MRI (Option B), CT has higher resolution and better diag- hypersensitivity are believed to be involved. Paroxetine and nostic accuracy for mucosal disease and sinus ostial occlu- other selective serotonin reuptake inhibitors (SSRIs) are sion. In addition, MRI is more costly than CT and does not considered flrst line therapy and are the most appropri- provide a more accurate diagnosis. MRI should be consid ate pharmacologic management option for this patient. A ered when there is suspicion for infection or inflammation meta analysis of available trials suggests that paroxetine may that extends beyond the sinus cavities. be the most effective SSRL Complete therapeutic response The possibility of infection with unusual or resistant typically occurs within 2 to 3 weeks of continuous use. organisms is suggested by the persistence of symptoms Owing to upregulation of 5 HT receptors, therapeutic ben- despite previous antibiotic therapy. In this case, it is impor eflt may decline after 6 to 12 months. The combination of a tant to obtain bacterial and/or fungal cultures directly from SSRI plus a phosphodiesterase 5 inhibitor may be the most

can be helpful in clinical settings in which there is no access the sinus via nasal endoscopy or by sinus puncture. Nasal to microscopy, such testing is not necessary in this situation. swabs (Option C) are inadequate because they do not accu Oral azithromycin (Option B) is the appropriate treat- rately predict the infecting organism and cannot be used to ment fbr chlamydia. However, results of this patient,s exam- guide therapy. This patient has no indication for bacterial ination do not suggest cervicitis; her cervix was normal and/or fungal culture at this time. Findings on CT may sug_ appearing, and no purulence was noted at the os. gest the need for more aggressive evaluation. Oral fluconazole (Option C) is an appropriate treat Plain radiography of the sinuses (Option D) may show ment for vaginal candidiasis but not fbr bacterial vaginosis. changes suggestive of chronic sinusitis, including sinus Patients with vaginal yeast infections typically present with opaciflcation and mucosal thickening. These findings, how itching and a thick white discharge. The diagnosis is con_ ever, are nonspecific. Furthermore, plain radiography lacks firmed when KOH wet mount of the discharge demonstrates sufficient sensitivity to determine the presence or extent of yeast, hyphae, and pseudohyphae. potential bony erosion by infection. t(tY P0tilIs xtY Potl{IS vt (u o Diagnosis of bacterial vaginosis is based on the pres_ . Patients with chronic sinusitis, characterized by nasal CT ence of at least three of the four Amsel criteria: vagi_ congestion, purulent rhinorrhea, and headache for nal pH greater than 4.5; thin, homogeneous vaginal more than 12 weeks, should undergo either nasal U discharge; a positive amine (whifl) test result in which t endoscopy or CT ofthe sinuses for diagnostic application of10% potassium hydroxide to vaginal ll, purposes. tn secretions results in a fishy odor; and at least 20% clue (u o In patients with chronic sinusitis, the findings cells on saline wet mount. 3 (a most commonly seen on CT include mucosal . Treatment of bacterial vaginosis includes metronida- thickening, sinus ostial obstruction, polyps, and zole (oral or vaginal gel), clindamycin (vaginal cream), sinus opacification. tinidazole (oral) or secnidazole (oral). Bibliography Bibliography Kwah JH. Itters AT. Nasal polyps tnd rhinosinusitis. Allergr Asthma proc. Paavonen J. Brunhant RC. Bacterial vaginosis and clesqurmative inllanlnta 2019:.10:380 4. IPMII): 316903751 doi:10.2500,'aap.2 O19.tO. 2S2 tory vaginitis. N Engl J Med. 2Ot8t379:2216 54. [pMlD:30575452] doi:10. 1056/NllJMral80u4 l8 Item 27 Answer: B Educational Objective: Manage premature ejaculation. Item 26 Answer: A Educational Objective: Evaluate a patient with The most appropriate management is paroxetine (Option B). This patient has premature ejaculation, which is deflned suspected chronic sinusitis. as ejaculation with minimal stimulation that occurs earlier The most appropriate diagnostic test to perform next is CT than desired. Premature ejaculation that causes self reported ol'the sinuses (Option A). Chronic sinusitis manifests with psychological distress in the patient or partner is an indica at Ieast 12 weeks of nasal congestion with purulent drainage, tion for treatment. The diagnosis of premature ejaculation is diminished sense of smell, or facial pain/pressure. It may be solely based on history. Clinicians should obtain a thorough associated with nasal polyposis (with a strong association sexual history (frequency of premature ejaculation, anteced- with asthma). Demonstration of mucosal involvement by ent sexual activities, aggravating and alleviating factors, nasal endoscopy or imaging (typically CT) is necessary fbr the impact of premature ejaculation, and any concomitant diagnosis. The flndings most commonly seen on CT scan erectile dysfunction). Assessment for an underlying mood include mucosal thickening, sinus ostial obstruction, polyps, condition is also imperative, given the association between and sinus opacification. Treatment includes glucocorticoids premature ejaculation and development of poor self esteem and antibiotics. CT without contrast is the most commonly and depression. Although the speciflc pathophysiologic used imaging modality for the diagnosis of chronic sinusitis. mechanism of premature ejaculation is unknown, dysfunc Although mucosal disease can be demonstrated with tion of 5 hydroxytryptamine (5 HT) receptors and penile MRI (Option B), CT has higher resolution and better diag- hypersensitivity are believed to be involved. Paroxetine and nostic accuracy for mucosal disease and sinus ostial occlu- other selective serotonin reuptake inhibitors (SSRIs) are sion. In addition, MRI is more costly than CT and does not considered flrst line therapy and are the most appropri- provide a more accurate diagnosis. MRI should be consid ate pharmacologic management option for this patient. A ered when there is suspicion for infection or inflammation meta analysis of available trials suggests that paroxetine may that extends beyond the sinus cavities. be the most effective SSRL Complete therapeutic response The possibility of infection with unusual or resistant typically occurs within 2 to 3 weeks of continuous use. organisms is suggested by the persistence of symptoms Owing to upregulation of 5 HT receptors, therapeutic ben- despite previous antibiotic therapy. In this case, it is impor eflt may decline after 6 to 12 months. The combination of a tant to obtain bacterial and/or fungal cultures directly from SSRI plus a phosphodiesterase 5 inhibitor may be the most 179

Answers and Critiques effective treatment for premature ejaculation but is associ- low dose CT scan for persons aged 50 years to 80 years with ated with more side ellects than monotherapies. at least a 2O-pack-year smoking history and who are still Clomipramine (Option A), a tricyclic antidepressant smoking or who quit within the past 15 years. Screening (TCA) with serotonergic activity, is effective for premature should be discontinued once a person has not smoked for ejaculation. It is considered second line therapy, however, 15 years or develops a health problem that substantially because TCAs have more side effects than SSRIs. Clomip limits life expectancy or the ability or willingness to have ramine can be used when SSRIs are either ineffective or not curative lung surgery. Shared decision making, including tolerated, but it would be inappropriate to initiate clomip providing patients with information about radiation expo ramine in this patient before a trial of paroxetine. sure with CT, risk for false positive diagnoses, and anxiety The squeeze or start stop technique (Options C, D) related to surveillance of slow growing lung nodules, is a should not be considered in place of starting fluoxetine. crucial element in making the decision to screen. Screening The squeeze technique involves squeezing the glans of alone cannot prevent most lung cancer related deaths, and the penis when nearing orgasm until the urge to ejac- smoking cessation is essential. This patient has a significant vt ulate subsides. Developed in the 1950s, the start-stop smoking history within the past 15 years and should be E technique involves stimulating the penis until the patient ollered screening. .D t feels the urge to ejaculate and then stopping until the urge Chest radiography (Option A) is not an effective means q, subsides. This process is repeated multiple times until of screening for lung cancer. Multiple studies have investi CL ejaculation. Although initial studies suggested that both gated chest radiography screening in patients at risk for lung ft methods were effective, subsequent evidence has been cancer, and none has demonstrated a mortality benefit. less convincing. One time screening with low dose CT (Option C) is not lt C .D A topical anesthetic agent (Option E) made of 2.5't the optimal strate$/ because continued annual screening Ut prilocaine and lidocaine is an eII'ective therapy, resolving is associated with the discovery ol cancers that were not premature ejaculation more quickly than an SSRI, and can detected on the initial screen. Most guidelines recommend be used on an as needed basis for patients who do not want annual screening until at least the age of 74 years or until to take a daily oral medication. However, in this patient with at least 15 years has passed since the patient quit smoking. depressive symptoms, paroxetine is a better choice. Not screening this patient for lung cancer is not the best t(tY Pot ltTs strates/ (Option D). Annual screening with low-dose CT in patients with a significant past or current smoking history o Premature ejaculation is defined as ejaculation with results in a 20'1, to 24'l. reduction in lung cancer mortality. minimal stimulation that occurs earlier than desired: treatment is indicated if associated with psychological f,EY POIIITI distress. . The U.S. Preventive Services Task Force recommends o Paroxetine monotherapy or combined with a phos- lung cancer screening with an annual low-dose CT of phodiesterase 5 inhibitor is considered first-line the chest for persons aged 50 years to 8O years with at treatment for premature ejaculation; complete thera least a 20-pack-year smoking history who are still peutic effect is reached within 2 to 3 weeks of use. smoking or who quit within the past lS years. t o Screening alone cannot prevent most lung cancer- Bibliography related deaths, and smoking cessation is essential. l Liu H, Zhang M, tJuang M, et al. Comparative efficacy and safety of drug treatment for premature ejaculation: a systemic review and-Bayesian network meta-analysis. Andrologia. 2020:52:el3806. [pMtO, ffegZaZq] Bibliography doi: 10.1 111/and. 13806 Krist AH, Davidson KW Mangione CM, et al: US preventive Services Task Force. Screening for lung cancer: US preventive Services Task Force rec ommendation statement. JAMA. 2021:32S:qOZ ZO. [pMIO, 336g7470] doi:10.1001/jama .2O2t.1|7 Item 28 Answer: B Educational Objective: Screen for lung cancer in at_risk patients. Item 29 Answer: C The most appropriate lung cancer screening strates/ for Educational Objective: Diagnose nail psoriasis. this patient is annual low dose CT of the chest (Option B). The most likely diagnosis is nail psoriasis (Option C). Nail Smoking is the most important risk factor for the devel_ psoriasis is characterized by dystrophic nails with opment of lung cancer, and risk increases with additional vellow_red (oil stain) discoloration caused by inflammation of the nail years oftobacco exposure and age. Lung cancer has a poor bed; pitting caused by inflammation of the nail matrix: and prognosis, and nearly 90%, ofpersons with lung cancer die distal onycholysis (separation of nail plate from the nail of the disease. However, early-stage non-small cell lung can_ bed). Other findings include nail plate thickening, distal nail cer has a better prognosis and can be treated with surgical plate crumbling, and splinter hemorrhages. Nail psoriasis resection. The U.S. preventive Services Task Force guide more commonly affects the fingernails than the toenails. lines recommend lung cancer screening with an annual Nail psoriasis typically occurs in patients with psoriasis, but

effective treatment for premature ejaculation but is associ- low dose CT scan for persons aged 50 years to 80 years with ated with more side ellects than monotherapies. at least a 2O-pack-year smoking history and who are still Clomipramine (Option A), a tricyclic antidepressant smoking or who quit within the past 15 years. Screening (TCA) with serotonergic activity, is effective for premature should be discontinued once a person has not smoked for ejaculation. It is considered second line therapy, however, 15 years or develops a health problem that substantially because TCAs have more side effects than SSRIs. Clomip limits life expectancy or the ability or willingness to have ramine can be used when SSRIs are either ineffective or not curative lung surgery. Shared decision making, including tolerated, but it would be inappropriate to initiate clomip providing patients with information about radiation expo ramine in this patient before a trial of paroxetine. sure with CT, risk for false positive diagnoses, and anxiety The squeeze or start stop technique (Options C, D) related to surveillance of slow growing lung nodules, is a should not be considered in place of starting fluoxetine. crucial element in making the decision to screen. Screening The squeeze technique involves squeezing the glans of alone cannot prevent most lung cancer related deaths, and the penis when nearing orgasm until the urge to ejac- smoking cessation is essential. This patient has a significant vt ulate subsides. Developed in the 1950s, the start-stop smoking history within the past 15 years and should be E technique involves stimulating the penis until the patient ollered screening. .D t feels the urge to ejaculate and then stopping until the urge Chest radiography (Option A) is not an effective means q, subsides. This process is repeated multiple times until of screening for lung cancer. Multiple studies have investi CL ejaculation. Although initial studies suggested that both gated chest radiography screening in patients at risk for lung ft methods were effective, subsequent evidence has been cancer, and none has demonstrated a mortality benefit. less convincing. One time screening with low dose CT (Option C) is not lt C .D A topical anesthetic agent (Option E) made of 2.5't the optimal strate$/ because continued annual screening Ut prilocaine and lidocaine is an eII'ective therapy, resolving is associated with the discovery ol cancers that were not premature ejaculation more quickly than an SSRI, and can detected on the initial screen. Most guidelines recommend be used on an as needed basis for patients who do not want annual screening until at least the age of 74 years or until to take a daily oral medication. However, in this patient with at least 15 years has passed since the patient quit smoking. depressive symptoms, paroxetine is a better choice. Not screening this patient for lung cancer is not the best t(tY Pot ltTs strates/ (Option D). Annual screening with low-dose CT in patients with a significant past or current smoking history o Premature ejaculation is defined as ejaculation with results in a 20'1, to 24'l. reduction in lung cancer mortality. minimal stimulation that occurs earlier than desired: treatment is indicated if associated with psychological f,EY POIIITI distress. . The U.S. Preventive Services Task Force recommends o Paroxetine monotherapy or combined with a phos- lung cancer screening with an annual low-dose CT of phodiesterase 5 inhibitor is considered first-line the chest for persons aged 50 years to 8O years with at treatment for premature ejaculation; complete thera least a 20-pack-year smoking history who are still peutic effect is reached within 2 to 3 weeks of use. smoking or who quit within the past lS years. t o Screening alone cannot prevent most lung cancer- Bibliography related deaths, and smoking cessation is essential. l Liu H, Zhang M, tJuang M, et al. Comparative efficacy and safety of drug treatment for premature ejaculation: a systemic review and-Bayesian network meta-analysis. Andrologia. 2020:52:el3806. [pMtO, ffegZaZq] Bibliography doi: 10.1 111/and. 13806 Krist AH, Davidson KW Mangione CM, et al: US preventive Services Task Force. Screening for lung cancer: US preventive Services Task Force rec ommendation statement. JAMA. 2021:32S:qOZ ZO. [pMIO, 336g7470] doi:10.1001/jama .2O2t.1|7 Item 28 Answer: B Educational Objective: Screen for lung cancer in at_risk patients. Item 29 Answer: C The most appropriate lung cancer screening strates/ for Educational Objective: Diagnose nail psoriasis. this patient is annual low dose CT of the chest (Option B). The most likely diagnosis is nail psoriasis (Option C). Nail Smoking is the most important risk factor for the devel_ psoriasis is characterized by dystrophic nails with opment of lung cancer, and risk increases with additional vellow_red (oil stain) discoloration caused by inflammation of the nail years oftobacco exposure and age. Lung cancer has a poor bed; pitting caused by inflammation of the nail matrix: and prognosis, and nearly 90%, ofpersons with lung cancer die distal onycholysis (separation of nail plate from the nail of the disease. However, early-stage non-small cell lung can_ bed). Other findings include nail plate thickening, distal nail cer has a better prognosis and can be treated with surgical plate crumbling, and splinter hemorrhages. Nail psoriasis resection. The U.S. preventive Services Task Force guide more commonly affects the fingernails than the toenails. lines recommend lung cancer screening with an annual Nail psoriasis typically occurs in patients with psoriasis, but 180

Answers and Critiques occasionally the nail changes may precede the skin changes. Item 30 Answer: B A family history of psoriasis can be helpful, as can a through physical examination looking for "hidden" areas of plaque Educational Objective: Obtain appropriate preoperative EI laboratory testing. psoriasis in the gluteal cleft, periumbilically, in the concha of the ear, and on the scalp. Nail psoriasis is strongly associated Ihe most appropriate preoperative laboratory testing fbr this with psoriatic arthritis. Patients with psoriasis, particularly patient is hemitglobin and serum creatinine lreasurement involving the nails, should be screened for psoriatic arthritis (Option B). Preoperative laboratury testing is primarity driven at diagnosis and follow up. by patient related factors. Overtesting in tl-re preoperative Paronychia (Option A) is an infection of the nail fold. period is comnton and leads to higher costs and additional Acute paronychia is characterized by painful swelling of the downstream testing, which can cause harm. Preoperative nail fold, most commonly caused by Staphylococcus eureus. hemoglobin testing is indicated in r patient with signs or It typically affects only one nail. Chronic paronychia tends to symptoms suggestive ot' :rnemia, recent blood loss, use of' be more insidious and involve multiple flngers. In adults, it is medications tl.rat could aflbct hematopoiesis, or anticipated rtt q, most often seen in those with frequent hand immersion in significant blood loss. Patient relatecl f'actors that may drive water. There is tender swelling in the nail folds, with missing preoperilti\e semm creatinine testing include hypertension, or dystrophic cuticles. Chronic paronychia can cause ridg- chronic kidney disease, diabetes, cardiac disease. ancl mecl ing of the nail plate. These flndings are not present in this ications that afl'ect kidney function. Total hip arthroplasty t, T' patient, making chronic paronychia an unlikely diagnosis. is associated with significant btood loss. and establishing r! Lichen planus (Option B) can affect the nails in about the patient's baseline hentoglobin level will be helpful. This tn 10'2, ofcases. It causes nail plate dystrophy, including longi- patient has hypertension and is taking lisinopril, both ol {t

occasionally the nail changes may precede the skin changes. Item 30 Answer: B A family history of psoriasis can be helpful, as can a through physical examination looking for "hidden" areas of plaque Educational Objective: Obtain appropriate preoperative EI laboratory testing. psoriasis in the gluteal cleft, periumbilically, in the concha of the ear, and on the scalp. Nail psoriasis is strongly associated Ihe most appropriate preoperative laboratory testing fbr this with psoriatic arthritis. Patients with psoriasis, particularly patient is hemitglobin and serum creatinine lreasurement involving the nails, should be screened for psoriatic arthritis (Option B). Preoperative laboratury testing is primarity driven at diagnosis and follow up. by patient related factors. Overtesting in tl-re preoperative Paronychia (Option A) is an infection of the nail fold. period is comnton and leads to higher costs and additional Acute paronychia is characterized by painful swelling of the downstream testing, which can cause harm. Preoperative nail fold, most commonly caused by Staphylococcus eureus. hemoglobin testing is indicated in r patient with signs or It typically affects only one nail. Chronic paronychia tends to symptoms suggestive ot' :rnemia, recent blood loss, use of' be more insidious and involve multiple flngers. In adults, it is medications tl.rat could aflbct hematopoiesis, or anticipated rtt q, most often seen in those with frequent hand immersion in significant blood loss. Patient relatecl f'actors that may drive water. There is tender swelling in the nail folds, with missing preoperilti\e semm creatinine testing include hypertension, or dystrophic cuticles. Chronic paronychia can cause ridg- chronic kidney disease, diabetes, cardiac disease. ancl mecl ing of the nail plate. These flndings are not present in this ications that afl'ect kidney function. Total hip arthroplasty t, T' patient, making chronic paronychia an unlikely diagnosis. is associated with significant btood loss. and establishing r! Lichen planus (Option B) can affect the nails in about the patient's baseline hentoglobin level will be helpful. This tn 10'2, ofcases. It causes nail plate dystrophy, including longi- patient has hypertension and is taking lisinopril, both ol {t tudinal roughness and ridging, nail thinning, red streaking, which can alter kidney function, and serum creatinine mea rn = and pterygium unguis formation (scarring of the proximal suremellt is indicated. nail fold and matrix), as shown. ln all patients undergoing surgery, a careiul preopera tive bleeding history. including a farnily history. should be obtained. Coagulation studies (Option A) are indicated in patients taking anticoagulants, those with known or sus pected liver dysfunction, or those with a personal or family history suggestive of abnormal bleeding. A platelet count is reasonable in patients with a history olbleecling cliathe sis, those with a myeloprolilerative disorder, those taking myclotoxic medications. or those with cirrhosis.'Ihis patient does not have indications fbr coagulation studies or platelet count. This patient has been receiving thyroid hormone replacement, ar-rd her thyroid-stimulating hormone (TSH) level was normal 2 months ago. Patients whose test results in the past 4 months were normal and have a stable clinical sta tus do not need repeated testing befbre surgeryi a fiee serum This patient's findings are inconsistent with nail lichen thyroxine level is Llnnecessary in a patient with a normal planus. TStl level and on a stable dose of levothynrxine (Option C). In patients with onychomycosis (Option D), the toenails There is little evidence that treatment of asymptonl are more commonly affected than fingernails. This patient's atic bacteriuria will prevent postsurgical prosthetic joit.tt toenails are not involved. Nail pitting is not seen in onycho infection, and it is not indicated. Inappropriate treatment of mycosis but is present in this patient's nails. At times, it can asymptomatic bacteriuria is a ntajor driver of antimicrobial be difficult to exclude onychomycosis by physical examina resistance, particularly in health care facilities. 'l'reatment o1 tion alone. In such cases, potassium hydroxide preparation, asymptonlatic bacteriuria is, however, indicated in patients periodic acid-Schiffstaining, or f'ungal culture is indicated. scheduled to undergo an invasive procedure inv<tlving the urinary tract. Urinalysis (Option D) in this asymptomatic f,EY POIilT patient undergoing orthopedic surgery is unnecessary. . Nail psoriasis, which more commonly affects the fin gernails than toenails, is characterized by dystrophic f,tY POlf,rs nails with yellow-red (oil stain) discoloration, pitting, . Urinalysis is not indicated before joint arthroplasty in and distal onycholysis. asymptomatic patients.

tudinal roughness and ridging, nail thinning, red streaking, which can alter kidney function, and serum creatinine mea rn = and pterygium unguis formation (scarring of the proximal suremellt is indicated. nail fold and matrix), as shown. ln all patients undergoing surgery, a careiul preopera tive bleeding history. including a farnily history. should be obtained. Coagulation studies (Option A) are indicated in patients taking anticoagulants, those with known or sus pected liver dysfunction, or those with a personal or family history suggestive of abnormal bleeding. A platelet count is reasonable in patients with a history olbleecling cliathe sis, those with a myeloprolilerative disorder, those taking myclotoxic medications. or those with cirrhosis.'Ihis patient does not have indications fbr coagulation studies or platelet count. This patient has been receiving thyroid hormone replacement, ar-rd her thyroid-stimulating hormone (TSH) level was normal 2 months ago. Patients whose test results in the past 4 months were normal and have a stable clinical sta tus do not need repeated testing befbre surgeryi a fiee serum This patient's findings are inconsistent with nail lichen thyroxine level is Llnnecessary in a patient with a normal planus. TStl level and on a stable dose of levothynrxine (Option C). In patients with onychomycosis (Option D), the toenails There is little evidence that treatment of asymptonl are more commonly affected than fingernails. This patient's atic bacteriuria will prevent postsurgical prosthetic joit.tt toenails are not involved. Nail pitting is not seen in onycho infection, and it is not indicated. Inappropriate treatment of mycosis but is present in this patient's nails. At times, it can asymptomatic bacteriuria is a ntajor driver of antimicrobial be difficult to exclude onychomycosis by physical examina resistance, particularly in health care facilities. 'l'reatment o1 tion alone. In such cases, potassium hydroxide preparation, asymptonlatic bacteriuria is, however, indicated in patients periodic acid-Schiffstaining, or f'ungal culture is indicated. scheduled to undergo an invasive procedure inv<tlving the urinary tract. Urinalysis (Option D) in this asymptomatic f,EY POIilT patient undergoing orthopedic surgery is unnecessary. . Nail psoriasis, which more commonly affects the fin gernails than toenails, is characterized by dystrophic f,tY POlf,rs nails with yellow-red (oil stain) discoloration, pitting, . Urinalysis is not indicated before joint arthroplasty in and distal onycholysis. asymptomatic patients. Bibliography r Patientswhose laboratorytest results in thepast 4 months were normal and whose clinical status is stable do not Hinshaw MA, Rubin A. Inflammatory diseases of the nail unit. Semin Cutan Med Surg. 2015;34:109 16. [PMlD, 261762891 doi:10.12788/i.sder. need repeat testing before surgery. 2015.0132

Bibliography r Patientswhose laboratorytest results in thepast 4 months were normal and whose clinical status is stable do not Hinshaw MA, Rubin A. Inflammatory diseases of the nail unit. Semin Cutan Med Surg. 2015;34:109 16. [PMlD, 261762891 doi:10.12788/i.sder. need repeat testing before surgery. 2015.0132 181

Answers and Critiques Bibliography Bibliography Edwards AF. R)rest DJ. Preoperative laboratory testing. Anesthesiol Clin. Arterburn D. \\rellman R. Emiliano A, et al: PCORneI Bariatric Stud) 2018::16:493 507. IPMID: 303907711 doi:10.1016/i.anclin.20l8.07.002 Collaboratire. Comparative effectiveness and salety of bariatric proce dures fbr $eight loss: a PCORnet cohort stud): Ann Intern l!4ed' 2018: 169 :7 41 50. [PM D : 301]831391 doi: Io.7 326 t Ml7 27 86 I

Bibliography Bibliography Edwards AF. R)rest DJ. Preoperative laboratory testing. Anesthesiol Clin. Arterburn D. \\rellman R. Emiliano A, et al: PCORneI Bariatric Stud) 2018::16:493 507. IPMID: 303907711 doi:10.1016/i.anclin.20l8.07.002 Collaboratire. Comparative effectiveness and salety of bariatric proce dures fbr $eight loss: a PCORnet cohort stud): Ann Intern l!4ed' 2018: 169 :7 41 50. [PM D : 301]831391 doi: Io.7 326 t Ml7 27 86 I Item 3! Answer: D Educational Objective: Treat obesity with sleeve gastrectomy. Item 32 Answer: A Educational Objective: Evaluate a patient with tr pulmonary hypertension prior to surgery. The most appropriate treatment for this patient is sleeve gastrectomy (Option D). Guidelines recommend bariatric The most appropriate preoperative management of this surgery for patients with a BMI of 40 or greater or for those patient is to cancel surgery (Option A) and refer the patient with a BMI ol 35 or greater who have at least one serious for eraiuation by a pulmonary hypertension (PH) specialist. weight related comorbid condition, such as type 2 diabetes In the perioperative period. PH. defined as pulmonary artery UI E mellitus, obstructive sleep apnea, or knee or hip osteoar pressure (PAP) greater than 25 mm Hg, is associated uith (D (/r thritis. Sleeve gastrectomy is accomplished by excising the mortaliry rates of 4')1, to 2,1')1, and significant morbidi[.in up o, part of the stomach along the greater curvature, creating to 42"/.' ol patients. Potential complications ol PH include CL an approximately 85')(, reduction in size of the stomach. It m1'ocardial infarction. arrhl'thmias. right ventricular (R\') r.l results in restriction of caloric intake via early satiety with failure. venous thromboembolism. and pulmonary failure. a smaller stomach and hormonal (glucagon like peptide I Patients rvith high risk PH features. including group 1 PH st and related hormones) appetite suppression. The smaller (pulmonary arterial hypertension), PAP greater than 70 mn.t (D gastric surface area als<-r results in less production of ghrelin, t^ Hg. and moderate or selere RV dysfunction. should undergo an appetite stimulant. Roux-en Y gastric bypass (RYGB) a thorough preoperative risk assessment by a PH specialist. surgery has the most efficacy data and remains superior to Surgery should generally be avoided in patients n'ith severe other procedures for weight loss. but it also has the highest PH. This patient has severe COPD and heart failure nith rate of early postoperative complications. RYGB consists of reduced eiection fraction with evidence of PH and moder- creating a small proximal gastric pouch separate from the ate to severe right ventricular dystunction. She should be distal stomach and creating a biliopancreatic limb that con referred to a PH specialist for evaluation prior to the electire nects the Roux limb to the gastrojejunostomy. The weight procedure. loss with sleeve gastrectomy is less than RYGB surgery. Although increasing this patient's furosernide (Option Sleeve gastrectomy, however, is associated with f'ewer major B) may be indicated for heart iailure and volume overload. surgical complications at 30 days than other fbrms of bar changes to the medication regimen should be made as part iatric surgery. After 5 years, the two bariatric procedures do of an overall treatment strate$,' and not as part of a preop not differ in regard to health related quality of lif'e or major erative evaluation. Decisions regarding medication manage complications. ment in the perioperative period in this patient should be Gastric banding (Option A) is often complicated by made in conjunction with a Pt{ specialist. band erosion and slippage. Due to complications and poor Most cases of PH are caused by left-sided heart disease efficacy, sleeve gastrectomy is preferred. and hypoxic respiratory disorders. Treatment is directed The FDA has approved intragastric balloons (Option B) toward the underlying disorder. Patients n'ith group 1 PH and vagal blockade devices, which resulted in modest weight (u'hich includes idiopathic and heritable pulmonary arterial loss in trials. However, long-term safety and elficacy data hlpertension, and disease related to drugs and toxins. connec are lacking, and most insurance companies classiff these tive tissue diseases. HIV infection, schistosomiasis. and portal devices as i nvest igationill. hypertension) may be treated n,ith a calcium channel blocker This patient is taking liraglutide. which promotes or \asodilator therapli such as tadalafil (Option C) tbllou'ing weight loss, and has tried two different weight loss medi \asoreactivity testing. Starting tadalafil is not indicated. cations with modest initial success but experienced weight Chronic hypoxia $,ith resultant pulmonary \asocon gain upon their discontinuation. 'this is common fbr patients striction may be a major contributor to a patient's PH. but who take weight loss medications. Orlistat (Option C) is less further evaluation is necessary prior to instituting continu eflective in achieving target weight loss than the weight loss ous orygen therapl' (Option D). medications that this patient has already tried. Provided that this patient has no contraindications to bariatric surgery TEY POITI sleeve gastrectomy is an appropriate choice. . Patients with high-risk pulmonary hypertension undergoing noncardiac surgery have high risk for I(EY POITT complications, including myocardial ischemia, venous o Sleeve gastrectomy is associated with less weight loss thromboembolism, cardiogenic shock, and dysrhyth compared with Roux-en Y gastric bypass but fewer mias, and should be evaluated by a pulmonary hyper- 30-day postoperative complications. tension specialist before undergoing surgery.

Item 3! Answer: D Educational Objective: Treat obesity with sleeve gastrectomy. Item 32 Answer: A Educational Objective: Evaluate a patient with tr pulmonary hypertension prior to surgery. The most appropriate treatment for this patient is sleeve gastrectomy (Option D). Guidelines recommend bariatric The most appropriate preoperative management of this surgery for patients with a BMI of 40 or greater or for those patient is to cancel surgery (Option A) and refer the patient with a BMI ol 35 or greater who have at least one serious for eraiuation by a pulmonary hypertension (PH) specialist. weight related comorbid condition, such as type 2 diabetes In the perioperative period. PH. defined as pulmonary artery UI E mellitus, obstructive sleep apnea, or knee or hip osteoar pressure (PAP) greater than 25 mm Hg, is associated uith (D (/r thritis. Sleeve gastrectomy is accomplished by excising the mortaliry rates of 4')1, to 2,1')1, and significant morbidi[.in up o, part of the stomach along the greater curvature, creating to 42"/.' ol patients. Potential complications ol PH include CL an approximately 85')(, reduction in size of the stomach. It m1'ocardial infarction. arrhl'thmias. right ventricular (R\') r.l results in restriction of caloric intake via early satiety with failure. venous thromboembolism. and pulmonary failure. a smaller stomach and hormonal (glucagon like peptide I Patients rvith high risk PH features. including group 1 PH st and related hormones) appetite suppression. The smaller (pulmonary arterial hypertension), PAP greater than 70 mn.t (D gastric surface area als<-r results in less production of ghrelin, t^ Hg. and moderate or selere RV dysfunction. should undergo an appetite stimulant. Roux-en Y gastric bypass (RYGB) a thorough preoperative risk assessment by a PH specialist. surgery has the most efficacy data and remains superior to Surgery should generally be avoided in patients n'ith severe other procedures for weight loss. but it also has the highest PH. This patient has severe COPD and heart failure nith rate of early postoperative complications. RYGB consists of reduced eiection fraction with evidence of PH and moder- creating a small proximal gastric pouch separate from the ate to severe right ventricular dystunction. She should be distal stomach and creating a biliopancreatic limb that con referred to a PH specialist for evaluation prior to the electire nects the Roux limb to the gastrojejunostomy. The weight procedure. loss with sleeve gastrectomy is less than RYGB surgery. Although increasing this patient's furosernide (Option Sleeve gastrectomy, however, is associated with f'ewer major B) may be indicated for heart iailure and volume overload. surgical complications at 30 days than other fbrms of bar changes to the medication regimen should be made as part iatric surgery. After 5 years, the two bariatric procedures do of an overall treatment strate$,' and not as part of a preop not differ in regard to health related quality of lif'e or major erative evaluation. Decisions regarding medication manage complications. ment in the perioperative period in this patient should be Gastric banding (Option A) is often complicated by made in conjunction with a Pt{ specialist. band erosion and slippage. Due to complications and poor Most cases of PH are caused by left-sided heart disease efficacy, sleeve gastrectomy is preferred. and hypoxic respiratory disorders. Treatment is directed The FDA has approved intragastric balloons (Option B) toward the underlying disorder. Patients n'ith group 1 PH and vagal blockade devices, which resulted in modest weight (u'hich includes idiopathic and heritable pulmonary arterial loss in trials. However, long-term safety and elficacy data hlpertension, and disease related to drugs and toxins. connec are lacking, and most insurance companies classiff these tive tissue diseases. HIV infection, schistosomiasis. and portal devices as i nvest igationill. hypertension) may be treated n,ith a calcium channel blocker This patient is taking liraglutide. which promotes or \asodilator therapli such as tadalafil (Option C) tbllou'ing weight loss, and has tried two different weight loss medi \asoreactivity testing. Starting tadalafil is not indicated. cations with modest initial success but experienced weight Chronic hypoxia $,ith resultant pulmonary \asocon gain upon their discontinuation. 'this is common fbr patients striction may be a major contributor to a patient's PH. but who take weight loss medications. Orlistat (Option C) is less further evaluation is necessary prior to instituting continu eflective in achieving target weight loss than the weight loss ous orygen therapl' (Option D). medications that this patient has already tried. Provided that this patient has no contraindications to bariatric surgery TEY POITI sleeve gastrectomy is an appropriate choice. . Patients with high-risk pulmonary hypertension undergoing noncardiac surgery have high risk for I(EY POITT complications, including myocardial ischemia, venous o Sleeve gastrectomy is associated with less weight loss thromboembolism, cardiogenic shock, and dysrhyth compared with Roux-en Y gastric bypass but fewer mias, and should be evaluated by a pulmonary hyper- 30-day postoperative complications. tension specialist before undergoing surgery. 182

Answers and Critiques Bibliography Bibliography Aguirre MA, Lynch I, Hardman B. Perioperative management of pulmonary American College of Obstetricians and Gynecologists. ACOC crrmmittee opin hypertension and right ventricular failure during noncardiac surgery Adv ion no. 762 summary: prepregnancy counseling. Obstet Gynecol. 2019; Anesth. 2018;36:201 30. IPMID: 30414638] doi:10.1016/j.aan.2018.07.011 133:228 30. IPMID: 30s7s672] doi:10.1097/AOC.0000000000003014

Bibliography Bibliography Aguirre MA, Lynch I, Hardman B. Perioperative management of pulmonary American College of Obstetricians and Gynecologists. ACOC crrmmittee opin hypertension and right ventricular failure during noncardiac surgery Adv ion no. 762 summary: prepregnancy counseling. Obstet Gynecol. 2019; Anesth. 2018;36:201 30. IPMID: 30414638] doi:10.1016/j.aan.2018.07.011 133:228 30. IPMID: 30s7s672] doi:10.1097/AOC.0000000000003014 Item 33 Answer: D Educational Objective: Provide preconception care for Item 34 Answer: C Educational Obiective: Diagnose pemphigus vulgaris. tr an average-risk woman. The most likely diagnosis is pemphigus vulgaris (Option C), an autoimmune bullous disease (ABD). ABDs are caused by The most appropriate management is to obtain a varicella antibodies interfering with cohesion between keratinorytes antibody titer (Option D). All women considering pregnancy of the epidermis (desmosomes) or between the epidermis should be assessed for immunity to varicella and rubella. and dermis (basement membrane zone). ABDs can be sub- v! This patient reports receiving the measles, mumps, and (u divided into intraepidermal and subepidermal disorders. rubella vaccine during childhood but is unsure whether she ET Intraepidermal ABDs present with flaccid vesicles that rup had varicella (chickenpox). She should have a varicella anti- .= ture easily, whereas subepidermal ABDs show intact, tense rr, body titer test. If she is not immune to varicella, she should bullae. Pemphigus vulgaris is the most common intraepi receive the varicella vaccine and be instructed to wait 4 weeks =t dermal ABD, and its incidence increases with age. It presents lE before attempting to conceive. If an already pregnant woman UI with flaccid oral or other mucosal bullae that rupture easily is not immune to either varicella or rubella, these vaccines (u and leave erosions. Lesions heal with pigment change but should be administered after delivery but before hospital la otherwise do not scar. This patient has an acute onsct of a = discharge. Immunizations to be avoided during pregnancy blistering disorder. Pemphigus vulgaris always involves the include Iive vaccines (varicella, rubella, measles, mumps, oral mucosa and may affect the skin in varying degrees. live attenuated influenza, live attenuated herpes zoster) and Bullous pemphigoid (Option A) is an ABD that f'eatures human papillomavirus (HPV) vaccine. tense bullae. Although bullae may rupture and result in All pregnant women should receive a tetanus toxoid, erosions, typically several bullae are present on examina- reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine (Option A) between 27 weeks' and 36 weeks' gesta tion (as shown). Pruritus is the predominant symptom in bullous pemphigoid. tion with each pregnancy, helping to ensure immunity to the child upon birth. Administering Tdap during pregnancy is recommended regardless of when a patient received her last tetanus vaccination. This patient is currently not pregnant and should not receive the Tdap vaccine at this visit because she is otherwise current with this vaccination. A nucleic acid amplification test for chlamydia (Option B) is not indicated for this patient. Chlamydia screening of all sex ually active women younger than 25 years is recommended. Women aged 25 years or older should be screened if they have sexually transmitted infection (STI) risk factors, such as new or multiple sex partners, sex partners who have multiple other partners, no or inconsistent condom use (outside a monoga mous partnership), previous STI, current STI, or exchanging sex for money or drugs. This patient is not high risk, and although screening for STIs is considered routine during preg nancy, it is not necessary during preconception care. A Pap smear is not indicated (Option C). the patient's Dermatitis herpetiformis (Option B) presents with last Pap smear was obtained 1 year ago and was normal; HPV clustered fragile vesicles that break down quickly, leaving testing was negative. Women aged 30 to 39 years who have small erosions on the elbows, knees, or buttocks. It intensely a normal Pap smear and a negative HPV test result do not pruritic and does not involve the oral mucosa. require another Pap smear for 5 years. Although Stevens Johnson syndrome (SJS) (Option D) and toxic epidermal necrolysis (TEN) (Option E) should IEY be considered in any patient with desquamative lbaturcs r AII'OIilIs women considering pregnancy should be assessed in the acute setting, several aspects ol this patient's pre for immunit5r to varicella and rubella. sentation make these life threatening conditions unlikely. o If an already pregnant woman is not immune to either Patients with SIS and TFIN present with significant skin pain (even in unaffected areas), malaise, and fever and typ varicella or rubella, these vaccines should be adminis- ically appear toxic. Furthermore, patients with SJS and l'EN tered after delivery and before hospital discharge. present with two mucosal surfhces involved, whereas this

Item 33 Answer: D Educational Objective: Provide preconception care for Item 34 Answer: C Educational Obiective: Diagnose pemphigus vulgaris. tr an average-risk woman. The most likely diagnosis is pemphigus vulgaris (Option C), an autoimmune bullous disease (ABD). ABDs are caused by The most appropriate management is to obtain a varicella antibodies interfering with cohesion between keratinorytes antibody titer (Option D). All women considering pregnancy of the epidermis (desmosomes) or between the epidermis should be assessed for immunity to varicella and rubella. and dermis (basement membrane zone). ABDs can be sub- v! This patient reports receiving the measles, mumps, and (u divided into intraepidermal and subepidermal disorders. rubella vaccine during childhood but is unsure whether she ET Intraepidermal ABDs present with flaccid vesicles that rup had varicella (chickenpox). She should have a varicella anti- .= ture easily, whereas subepidermal ABDs show intact, tense rr, body titer test. If she is not immune to varicella, she should bullae. Pemphigus vulgaris is the most common intraepi receive the varicella vaccine and be instructed to wait 4 weeks =t dermal ABD, and its incidence increases with age. It presents lE before attempting to conceive. If an already pregnant woman UI with flaccid oral or other mucosal bullae that rupture easily is not immune to either varicella or rubella, these vaccines (u and leave erosions. Lesions heal with pigment change but should be administered after delivery but before hospital la otherwise do not scar. This patient has an acute onsct of a = discharge. Immunizations to be avoided during pregnancy blistering disorder. Pemphigus vulgaris always involves the include Iive vaccines (varicella, rubella, measles, mumps, oral mucosa and may affect the skin in varying degrees. live attenuated influenza, live attenuated herpes zoster) and Bullous pemphigoid (Option A) is an ABD that f'eatures human papillomavirus (HPV) vaccine. tense bullae. Although bullae may rupture and result in All pregnant women should receive a tetanus toxoid, erosions, typically several bullae are present on examina- reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine (Option A) between 27 weeks' and 36 weeks' gesta tion (as shown). Pruritus is the predominant symptom in bullous pemphigoid. tion with each pregnancy, helping to ensure immunity to the child upon birth. Administering Tdap during pregnancy is recommended regardless of when a patient received her last tetanus vaccination. This patient is currently not pregnant and should not receive the Tdap vaccine at this visit because she is otherwise current with this vaccination. A nucleic acid amplification test for chlamydia (Option B) is not indicated for this patient. Chlamydia screening of all sex ually active women younger than 25 years is recommended. Women aged 25 years or older should be screened if they have sexually transmitted infection (STI) risk factors, such as new or multiple sex partners, sex partners who have multiple other partners, no or inconsistent condom use (outside a monoga mous partnership), previous STI, current STI, or exchanging sex for money or drugs. This patient is not high risk, and although screening for STIs is considered routine during preg nancy, it is not necessary during preconception care. A Pap smear is not indicated (Option C). the patient's Dermatitis herpetiformis (Option B) presents with last Pap smear was obtained 1 year ago and was normal; HPV clustered fragile vesicles that break down quickly, leaving testing was negative. Women aged 30 to 39 years who have small erosions on the elbows, knees, or buttocks. It intensely a normal Pap smear and a negative HPV test result do not pruritic and does not involve the oral mucosa. require another Pap smear for 5 years. Although Stevens Johnson syndrome (SJS) (Option D) and toxic epidermal necrolysis (TEN) (Option E) should IEY be considered in any patient with desquamative lbaturcs r AII'OIilIs women considering pregnancy should be assessed in the acute setting, several aspects ol this patient's pre for immunit5r to varicella and rubella. sentation make these life threatening conditions unlikely. o If an already pregnant woman is not immune to either Patients with SIS and TFIN present with significant skin pain (even in unaffected areas), malaise, and fever and typ varicella or rubella, these vaccines should be adminis- ically appear toxic. Furthermore, patients with SJS and l'EN tered after delivery and before hospital discharge. present with two mucosal surfhces involved, whereas this 183

Answers and Critiques fiE prrticnt has onll'one involr,ed mucosal surface: the mouth. The Weber test, because it bypasses the tympanic 515 or TEN occurs secondary to medication or infectior.r. membrane and ossicles, tests sensorineural hearing. In this coNr typically within 2 weeks ol adrninistration, usually shorter. patient, the Weber test lateralized to the right ear (sound was Although this patient has a history <tf doxycycline use, it louder in the right ear); this ear has normal sensorineural wirs started 6 months ago. not rt,ithin the 2 week wir.rdow function (Option D). The sound was heard less well in the typical fbr SJS and TEN. ear with impaired sensorineural flunction, the left ear. f,EY POITTS TEY POITI' . Pemphigoid lrrlgaris is an autoimmune blistering dis . Hearing loss is categorized according to the anatomic order that presents with flaccid oral or other mucosal deficit: conductive, sensorineural, or mixed. bullae that rupture easily and leave erosions. o Conductive hearing loss is more often associated with o Bullous pemphigoid is an autoimmune blistering dis pain or ear drainage, whereas sensorineural hearing ease that features tense bullae with pruritus as the loss is more often accompanied by tinnitus or vertigo. t^ predominant symptom. E .E Bibliography la Bibliography Cunningham LL, Tucci DL. Hearing loss in adults. N Engl J Med. 2017;377: tr, 2465 73. IPMID: 292622741 doi: lO.l056/N FlJMral6l6601 Kridin K. Pemphigus group: overview epidemiolory, mortality, and comor CL bidities. Immunol Res. 2018;66:255 70. [PMID: 29479654) doi:10.1007/ a.l s12026 018 8986 7

f,EY POITTS TEY POITI' . Pemphigoid lrrlgaris is an autoimmune blistering dis . Hearing loss is categorized according to the anatomic order that presents with flaccid oral or other mucosal deficit: conductive, sensorineural, or mixed. bullae that rupture easily and leave erosions. o Conductive hearing loss is more often associated with o Bullous pemphigoid is an autoimmune blistering dis pain or ear drainage, whereas sensorineural hearing ease that features tense bullae with pruritus as the loss is more often accompanied by tinnitus or vertigo. t^ predominant symptom. E .E Bibliography la Bibliography Cunningham LL, Tucci DL. Hearing loss in adults. N Engl J Med. 2017;377: tr, 2465 73. IPMID: 292622741 doi: lO.l056/N FlJMral6l6601 Kridin K. Pemphigus group: overview epidemiolory, mortality, and comor CL bidities. Immunol Res. 2018;66:255 70. [PMID: 29479654) doi:10.1007/ a.l s12026 018 8986 7 lt Item 36 Answer: B Educational Obiective: Treat herpes zoster. tr (E vf Item 35 lnswer: C -lhe most appropriate treatnrent is val:rcyclovir (Option B) for Ed u cationa I Objective : Diagnose sensorineural hearing this patient lvith herpes zoster infbction. lnitiation oi systen-ric loss. antiviral therapy (acyclovir. valacyclovir, or famciclovir) can The most likely cause of hearing loss in this patient is senso help attenuate the duration ol rash and symptoms during a rineural hearing loss of the left ear (Option C). Hearing Ioss herpes zoster outbreak and reduce the risk for postherpetic is categorized according to the anatomic deflcit: conductive, ncuralgia if administered n,ithin the first 72 hours after onset sensorineural, or mixed. Conductive hearing loss is more of symptoms. Valacyclovir and famciclovir are often preti:rred often associated with pain or ear drainage, whereas senso- because of possible increased efficacy and decreased fre rineural hearing loss is more often accompanied by tinnitus quency of dosing compared with acyclovir. This eflbct is best or vertigo. In patients with hearing loss, physical examina established in patients older than .50 years. Varicella zoster tion should include otoscopic examination as well as the vims is :r DNA virus that causes varicella (cl-rickenpox). r,r'hich Weber and Rinne tests. The Weber test assesses sensorineural is irn ncute illness u,ith fbver and an eruption of 'nesicles on an hearing. In the Weber test, a 256 Hz vibrating tuning fork is crythematous base that is transmittecl by respiratory droplets. applied to the midline forehead, bridge of the nose, or teeth. Alier primary infection. the vims remains latent in the dorsal A normal result is no lateralization of loudness of the sound root or cranial ganglia. Reactivatir-rn causes hetpes zoster. (sound loudness equal in both ears). In the presence ofsen Proclromal symptoms, such as trurning. stinging, or tingling, sorineural hearing loss, the sound lateralizes (is louder) in the ollen occur in a localized regior.r, firllowed by a dermatonral uninvolved ear. In this patient, the sound was louder in the emption of'grouped vesicles or pustules on an erythenlatous right ear; thus, the left ear is impaired. The Rinne test assesses birse. The most common dernrator-nes afl'ected are in the tho conductive hearing. In this test, the patient is asked to identiff racic region. With inohenrer.rt of'the first division of the tri whether the tuning fork sound is louder when placed on the gen.rinal nen'e (forehead extending or,er upper elelid, or n:rsal mastoid process (bone conduction) or when placed in front of tip invol'uement). ophthalnrologic evaluation is mandatory the extemal auditory canal (air conduction). A normal test is beciruse herpes zoster opl.rthalmicus and possible blir.rdness associated with air conduction louder than bone conduction. can result. If vesicles are noted in the e.xternal ear canal. This patient, with a Weber test that lateralizes to the right ear evaluation by an otolaryngologist may be required because (the "good ear") and normal conduction in the left ear (air peripheral facial paralysis and auclitoryivestibular symptonrs conduction greater than bone conduction) has sensorineural ciln occur (Ramsay Hunt syndrome). hearing loss of the Ieft ear. The most concerning condition Whereas systemic acvclovir is an eff'ective option fbr causing chronic unilateral sensorineural hearing loss with shortening symptoms ancl decreasing the likelihood ot tinnitus is an acoustic neuroma. The flrst diagnostic step is postherpetic neuralgia. topical ircyclovir (Option A) or confirmation of the hearing loss with audiometry followed by topical penciclovir is ineflective and should not be used. MRI of the internal auditory meatus. Gabapentin may be useful in alleviating the pain associ This patient has normal conductive hearing in both the atcd lvith post-herpetic neuralgia once it has become estab right and left ears (Options A, B) as confirmed by the bilat lished, but there is no evidence that gabapentin plus an erally normal Rinne test (air conduction greater than bone antiviral decreases (Option C) the likelihood of developing conduction). postherpetic neuralgia. As is the casc with glucocorticoicls,

lt Item 36 Answer: B Educational Obiective: Treat herpes zoster. tr (E vf Item 35 lnswer: C -lhe most appropriate treatnrent is val:rcyclovir (Option B) for Ed u cationa I Objective : Diagnose sensorineural hearing this patient lvith herpes zoster infbction. lnitiation oi systen-ric loss. antiviral therapy (acyclovir. valacyclovir, or famciclovir) can The most likely cause of hearing loss in this patient is senso help attenuate the duration ol rash and symptoms during a rineural hearing loss of the left ear (Option C). Hearing Ioss herpes zoster outbreak and reduce the risk for postherpetic is categorized according to the anatomic deflcit: conductive, ncuralgia if administered n,ithin the first 72 hours after onset sensorineural, or mixed. Conductive hearing loss is more of symptoms. Valacyclovir and famciclovir are often preti:rred often associated with pain or ear drainage, whereas senso- because of possible increased efficacy and decreased fre rineural hearing loss is more often accompanied by tinnitus quency of dosing compared with acyclovir. This eflbct is best or vertigo. In patients with hearing loss, physical examina established in patients older than .50 years. Varicella zoster tion should include otoscopic examination as well as the vims is :r DNA virus that causes varicella (cl-rickenpox). r,r'hich Weber and Rinne tests. The Weber test assesses sensorineural is irn ncute illness u,ith fbver and an eruption of 'nesicles on an hearing. In the Weber test, a 256 Hz vibrating tuning fork is crythematous base that is transmittecl by respiratory droplets. applied to the midline forehead, bridge of the nose, or teeth. Alier primary infection. the vims remains latent in the dorsal A normal result is no lateralization of loudness of the sound root or cranial ganglia. Reactivatir-rn causes hetpes zoster. (sound loudness equal in both ears). In the presence ofsen Proclromal symptoms, such as trurning. stinging, or tingling, sorineural hearing loss, the sound lateralizes (is louder) in the ollen occur in a localized regior.r, firllowed by a dermatonral uninvolved ear. In this patient, the sound was louder in the emption of'grouped vesicles or pustules on an erythenlatous right ear; thus, the left ear is impaired. The Rinne test assesses birse. The most common dernrator-nes afl'ected are in the tho conductive hearing. In this test, the patient is asked to identiff racic region. With inohenrer.rt of'the first division of the tri whether the tuning fork sound is louder when placed on the gen.rinal nen'e (forehead extending or,er upper elelid, or n:rsal mastoid process (bone conduction) or when placed in front of tip invol'uement). ophthalnrologic evaluation is mandatory the extemal auditory canal (air conduction). A normal test is beciruse herpes zoster opl.rthalmicus and possible blir.rdness associated with air conduction louder than bone conduction. can result. If vesicles are noted in the e.xternal ear canal. This patient, with a Weber test that lateralizes to the right ear evaluation by an otolaryngologist may be required because (the "good ear") and normal conduction in the left ear (air peripheral facial paralysis and auclitoryivestibular symptonrs conduction greater than bone conduction) has sensorineural ciln occur (Ramsay Hunt syndrome). hearing loss of the Ieft ear. The most concerning condition Whereas systemic acvclovir is an eff'ective option fbr causing chronic unilateral sensorineural hearing loss with shortening symptoms ancl decreasing the likelihood ot tinnitus is an acoustic neuroma. The flrst diagnostic step is postherpetic neuralgia. topical ircyclovir (Option A) or confirmation of the hearing loss with audiometry followed by topical penciclovir is ineflective and should not be used. MRI of the internal auditory meatus. Gabapentin may be useful in alleviating the pain associ This patient has normal conductive hearing in both the atcd lvith post-herpetic neuralgia once it has become estab right and left ears (Options A, B) as confirmed by the bilat lished, but there is no evidence that gabapentin plus an erally normal Rinne test (air conduction greater than bone antiviral decreases (Option C) the likelihood of developing conduction). postherpetic neuralgia. As is the casc with glucocorticoicls, 184

Answers and Critiques tr CONI. gabaper-rtin may be used as an adjunctive therapy in patients with severe pain with acute neuritis. Although commonly prescribed in the past. evidence is Attacks ol acute ACG more commonly occur in the evening. lthen lower light Ievels cause mydriasis and fold ing back ofthe iris. blocking the narrow angle. Risk factors insulflcient to support the addition ol glucocorticoids. such for acute ACG include older ager lemale sex; hyperopirr: as prednisone (Option D), to antiviral therapy to reduce the Asian ethnicity; and receipt ofcertain drugs, such as selec synrptonls of herpes zoster or the incidence of postherpetic tive serotonin reuptake inhibitors. Common examination neuralgia. Postherpetic neuralgia is defined as chronic neunr findings include a mid dilated, minimally responsive pathic pain that persists for 3 months or more after tl.re initial pupil; conjunctivaI injection; decreased visual acuity; and onset of herpes zoster. Glucocorticclids mly be consiclered as globe tenderness kr palpation. l.'unduscopic examination adjunctivc therapy in patients with severe acnte neuritis. but reveals an increascd cup to disc ratio if chronic ACG is this is not necessary in this patient with mild to nroderate pain. also present. Ophthalmology referral within 1 hour ol presentation is necessirrl, 1o minirnize risk for permanent TEY POIXIS visual loss. U! q, r A dermatomal eruption of grouped vesicles or pus- Bacterial keratitis (Option B) is rnost commonly seen tules on an erythematous base is consistent with the ET in patients ruho r-rsc contilct lcnses and u,ear their lenses diagnosis of herpes zoster. overnight or improperly nash the lenses with nonsterile |., o Oral acyclovir, valaryclovir, or famciclovir is effective water. Patients with bacterill kcratitis have eye pain. red E for treating herpes zoster if initiated within 72 hours of ness, floreign body scnsation. :rnd difficulty keeping the t! aflected eye open. lhey do not see halos around lights or vt presentation and can shorten the disease course as well (l, I as decrease the likelihood ofpostherpetic neuralgia. have nausea. vomiting. or periorbital heiidache, as seen in t this patient. = Bibliography Orbital cellulitis (Option C) is an infection of the Schmader K. Herpes zoster. Ann Intern Med. 2018;169:l'ICl9 31. IPMID globe, ocular fat, ;rncl ocular muscles of the orbit that can 3008371 8l doi:10.7326lAITC201808070 be both vision' and life threatening because of potential spread into tl-rc brain. Pllicnts with orbital cellulitis fre : quently have ophtl.ralmoplcgia and proptosis and not the ! Item 37 Answer: A clouded cornea and irupillary changes seen in this patient. Orbital cellulitis warrunts hospitalization for intravenous \ Educational Objective: Diagnose acute angle closure antibiotics. glaucoma. Patients with scleritis (Option D) present n,ith a painful 'lhe nrost lil<ely diagnosis is acute trngle closurc glaucoma red eye accompanied by visual disturbance and photopho (ACG) (Option A). Acute ACG presents with unilaterirl visual bia. The cardinal sign of scleritis is edema of the sclera, o{ten : disturbancc and seeing halos around lights. often accompanied associated with a violaceous discoloration of the underlying t by scvcrc eye pain, eye redness, nausea, vontiting, and head. sclera and intensc dilatior.r of episcleral blood vessels. Ten ache. Patients with ACG have narrow anterior chamber angles, derness is invariably present.'lhese findings are not present which inhibit drainage of the aqueous fluid; see imagc shown. in this patient.

tr CONI. gabaper-rtin may be used as an adjunctive therapy in patients with severe pain with acute neuritis. Although commonly prescribed in the past. evidence is Attacks ol acute ACG more commonly occur in the evening. lthen lower light Ievels cause mydriasis and fold ing back ofthe iris. blocking the narrow angle. Risk factors insulflcient to support the addition ol glucocorticoids. such for acute ACG include older ager lemale sex; hyperopirr: as prednisone (Option D), to antiviral therapy to reduce the Asian ethnicity; and receipt ofcertain drugs, such as selec synrptonls of herpes zoster or the incidence of postherpetic tive serotonin reuptake inhibitors. Common examination neuralgia. Postherpetic neuralgia is defined as chronic neunr findings include a mid dilated, minimally responsive pathic pain that persists for 3 months or more after tl.re initial pupil; conjunctivaI injection; decreased visual acuity; and onset of herpes zoster. Glucocorticclids mly be consiclered as globe tenderness kr palpation. l.'unduscopic examination adjunctivc therapy in patients with severe acnte neuritis. but reveals an increascd cup to disc ratio if chronic ACG is this is not necessary in this patient with mild to nroderate pain. also present. Ophthalmology referral within 1 hour ol presentation is necessirrl, 1o minirnize risk for permanent TEY POIXIS visual loss. U! q, r A dermatomal eruption of grouped vesicles or pus- Bacterial keratitis (Option B) is rnost commonly seen tules on an erythematous base is consistent with the ET in patients ruho r-rsc contilct lcnses and u,ear their lenses diagnosis of herpes zoster. overnight or improperly nash the lenses with nonsterile |., o Oral acyclovir, valaryclovir, or famciclovir is effective water. Patients with bacterill kcratitis have eye pain. red E for treating herpes zoster if initiated within 72 hours of ness, floreign body scnsation. :rnd difficulty keeping the t! aflected eye open. lhey do not see halos around lights or vt presentation and can shorten the disease course as well (l, I as decrease the likelihood ofpostherpetic neuralgia. have nausea. vomiting. or periorbital heiidache, as seen in t this patient. = Bibliography Orbital cellulitis (Option C) is an infection of the Schmader K. Herpes zoster. Ann Intern Med. 2018;169:l'ICl9 31. IPMID globe, ocular fat, ;rncl ocular muscles of the orbit that can 3008371 8l doi:10.7326lAITC201808070 be both vision' and life threatening because of potential spread into tl-rc brain. Pllicnts with orbital cellulitis fre : quently have ophtl.ralmoplcgia and proptosis and not the ! Item 37 Answer: A clouded cornea and irupillary changes seen in this patient. Orbital cellulitis warrunts hospitalization for intravenous \ Educational Objective: Diagnose acute angle closure antibiotics. glaucoma. Patients with scleritis (Option D) present n,ith a painful 'lhe nrost lil<ely diagnosis is acute trngle closurc glaucoma red eye accompanied by visual disturbance and photopho (ACG) (Option A). Acute ACG presents with unilaterirl visual bia. The cardinal sign of scleritis is edema of the sclera, o{ten : disturbancc and seeing halos around lights. often accompanied associated with a violaceous discoloration of the underlying t by scvcrc eye pain, eye redness, nausea, vontiting, and head. sclera and intensc dilatior.r of episcleral blood vessels. Ten ache. Patients with ACG have narrow anterior chamber angles, derness is invariably present.'lhese findings are not present which inhibit drainage of the aqueous fluid; see imagc shown. in this patient. Normal Abnormal

tr CONI. gabaper-rtin may be used as an adjunctive therapy in patients with severe pain with acute neuritis. Although commonly prescribed in the past. evidence is Attacks ol acute ACG more commonly occur in the evening. lthen lower light Ievels cause mydriasis and fold ing back ofthe iris. blocking the narrow angle. Risk factors insulflcient to support the addition ol glucocorticoids. such for acute ACG include older ager lemale sex; hyperopirr: as prednisone (Option D), to antiviral therapy to reduce the Asian ethnicity; and receipt ofcertain drugs, such as selec synrptonls of herpes zoster or the incidence of postherpetic tive serotonin reuptake inhibitors. Common examination neuralgia. Postherpetic neuralgia is defined as chronic neunr findings include a mid dilated, minimally responsive pathic pain that persists for 3 months or more after tl.re initial pupil; conjunctivaI injection; decreased visual acuity; and onset of herpes zoster. Glucocorticclids mly be consiclered as globe tenderness kr palpation. l.'unduscopic examination adjunctivc therapy in patients with severe acnte neuritis. but reveals an increascd cup to disc ratio if chronic ACG is this is not necessary in this patient with mild to nroderate pain. also present. Ophthalmology referral within 1 hour ol presentation is necessirrl, 1o minirnize risk for permanent TEY POIXIS visual loss. U! q, r A dermatomal eruption of grouped vesicles or pus- Bacterial keratitis (Option B) is rnost commonly seen tules on an erythematous base is consistent with the ET in patients ruho r-rsc contilct lcnses and u,ear their lenses diagnosis of herpes zoster. overnight or improperly nash the lenses with nonsterile |., o Oral acyclovir, valaryclovir, or famciclovir is effective water. Patients with bacterill kcratitis have eye pain. red E for treating herpes zoster if initiated within 72 hours of ness, floreign body scnsation. :rnd difficulty keeping the t! aflected eye open. lhey do not see halos around lights or vt presentation and can shorten the disease course as well (l, I as decrease the likelihood ofpostherpetic neuralgia. have nausea. vomiting. or periorbital heiidache, as seen in t this patient. = Bibliography Orbital cellulitis (Option C) is an infection of the Schmader K. Herpes zoster. Ann Intern Med. 2018;169:l'ICl9 31. IPMID globe, ocular fat, ;rncl ocular muscles of the orbit that can 3008371 8l doi:10.7326lAITC201808070 be both vision' and life threatening because of potential spread into tl-rc brain. Pllicnts with orbital cellulitis fre : quently have ophtl.ralmoplcgia and proptosis and not the ! Item 37 Answer: A clouded cornea and irupillary changes seen in this patient. Orbital cellulitis warrunts hospitalization for intravenous \ Educational Objective: Diagnose acute angle closure antibiotics. glaucoma. Patients with scleritis (Option D) present n,ith a painful 'lhe nrost lil<ely diagnosis is acute trngle closurc glaucoma red eye accompanied by visual disturbance and photopho (ACG) (Option A). Acute ACG presents with unilaterirl visual bia. The cardinal sign of scleritis is edema of the sclera, o{ten : disturbancc and seeing halos around lights. often accompanied associated with a violaceous discoloration of the underlying t by scvcrc eye pain, eye redness, nausea, vontiting, and head. sclera and intensc dilatior.r of episcleral blood vessels. Ten ache. Patients with ACG have narrow anterior chamber angles, derness is invariably present.'lhese findings are not present which inhibit drainage of the aqueous fluid; see imagc shown. in this patient. Normal Abnormal Cornea

tr CONI. gabaper-rtin may be used as an adjunctive therapy in patients with severe pain with acute neuritis. Although commonly prescribed in the past. evidence is Attacks ol acute ACG more commonly occur in the evening. lthen lower light Ievels cause mydriasis and fold ing back ofthe iris. blocking the narrow angle. Risk factors insulflcient to support the addition ol glucocorticoids. such for acute ACG include older ager lemale sex; hyperopirr: as prednisone (Option D), to antiviral therapy to reduce the Asian ethnicity; and receipt ofcertain drugs, such as selec synrptonls of herpes zoster or the incidence of postherpetic tive serotonin reuptake inhibitors. Common examination neuralgia. Postherpetic neuralgia is defined as chronic neunr findings include a mid dilated, minimally responsive pathic pain that persists for 3 months or more after tl.re initial pupil; conjunctivaI injection; decreased visual acuity; and onset of herpes zoster. Glucocorticclids mly be consiclered as globe tenderness kr palpation. l.'unduscopic examination adjunctivc therapy in patients with severe acnte neuritis. but reveals an increascd cup to disc ratio if chronic ACG is this is not necessary in this patient with mild to nroderate pain. also present. Ophthalmology referral within 1 hour ol presentation is necessirrl, 1o minirnize risk for permanent TEY POIXIS visual loss. U! q, r A dermatomal eruption of grouped vesicles or pus- Bacterial keratitis (Option B) is rnost commonly seen tules on an erythematous base is consistent with the ET in patients ruho r-rsc contilct lcnses and u,ear their lenses diagnosis of herpes zoster. overnight or improperly nash the lenses with nonsterile |., o Oral acyclovir, valaryclovir, or famciclovir is effective water. Patients with bacterill kcratitis have eye pain. red E for treating herpes zoster if initiated within 72 hours of ness, floreign body scnsation. :rnd difficulty keeping the t! aflected eye open. lhey do not see halos around lights or vt presentation and can shorten the disease course as well (l, I as decrease the likelihood ofpostherpetic neuralgia. have nausea. vomiting. or periorbital heiidache, as seen in t this patient. = Bibliography Orbital cellulitis (Option C) is an infection of the Schmader K. Herpes zoster. Ann Intern Med. 2018;169:l'ICl9 31. IPMID globe, ocular fat, ;rncl ocular muscles of the orbit that can 3008371 8l doi:10.7326lAITC201808070 be both vision' and life threatening because of potential spread into tl-rc brain. Pllicnts with orbital cellulitis fre : quently have ophtl.ralmoplcgia and proptosis and not the ! Item 37 Answer: A clouded cornea and irupillary changes seen in this patient. Orbital cellulitis warrunts hospitalization for intravenous \ Educational Objective: Diagnose acute angle closure antibiotics. glaucoma. Patients with scleritis (Option D) present n,ith a painful 'lhe nrost lil<ely diagnosis is acute trngle closurc glaucoma red eye accompanied by visual disturbance and photopho (ACG) (Option A). Acute ACG presents with unilaterirl visual bia. The cardinal sign of scleritis is edema of the sclera, o{ten : disturbancc and seeing halos around lights. often accompanied associated with a violaceous discoloration of the underlying t by scvcrc eye pain, eye redness, nausea, vontiting, and head. sclera and intensc dilatior.r of episcleral blood vessels. Ten ache. Patients with ACG have narrow anterior chamber angles, derness is invariably present.'lhese findings are not present which inhibit drainage of the aqueous fluid; see imagc shown. in this patient. Normal Abnormal Cornea Trabecular Angle Trabecular network network I Canal of Canal of Normal I Closed Schlemm Schlemm I

Trabecular Angle Trabecular network network I Canal of Canal of Normal I Closed Schlemm Schlemm I Iris Lens - 185 i

Answers and Critiques a cervical lesion is strongly suspected. It has no role as a pri- . Acute angle-closure glaucoma presents with sudden mary screening modality. Discontinuing cervical screening is not the correct onset of unllateral visual disturbance, which fre- stratery (Option D). This patient has incomplete records to quently indudes seeing halos around lights, accompa- substantiate previous cervical cancer screening. Therefore, nied by swere eye pain, eye redness, nausea, vomiting, cervical cancer screening should be initiated until criteria and headache. for discontinuation are met. o Patients with angle-closure glaucoma have narrow anterior chamber angles, which inhibit drainage of the aqueous fluid. . Routine screening for cervical cancer can be discon- tinued at age 65 years in non-high-risk women, pro- Bibliograptry vided that the patient has undergone adequate prior Jonas JB, Aung T, Bourne RR, et a]. Glaucoma. t-ancet. 20U;390:2183-93. screening. vt IPMID: 28s28601 doi:10.1016/50140-6736(77)31469 -r . The U.S. Preventive Services Task Force defines ade- (D = quate prior screening as three consecutive negative ta o, Item 38 Angwer: B cytologr results or two consecutive negative cytolory tests plus human papillomavirus test lesults within g- Educational Obiective: Screen for cervical cancer in older adults. the past l0 years, with the most recent test occurring =. within 5 years. lt The most appropriate cervical cancer screening strategr for a this patient is cervical rytologr with human papillomavi- Bibliography tt rus (HPV) testing (Option B). Routine screening for cer- Curry Sl Krist AH, Owens DK, et al; US Preventive Services Task Force. vical cancer can be discontinued at age 65 years in non- Screening for cervical cancer: US Preventive Services Task Force recom- mendation statement. JAMA. 2018:320:674-86. [PMID: 30140884] doi:lo. high-risk women, provided that the patient has undergone 1001ijama.2018.10897 adequate prior screening. The U.S. Preventive Services Task Force (USPSTF) defines adequate prior screening as three consecutive negative cytolory resuls or tvvo consecutive neg- Item 39 Answer: C ative cytolory tests plus negative HPV test results within the Educational Objective: Diagnose nodular melanoma. past 10 years, with the most recent test occurring within 5 years. Recommendations from the American Cancer Society The most likely diagnosis is nodular melanoma (Option C). (ACS) are similar and state that screening can be discontinued In general, the ABCDE identi$ing characteristics (Asymme- at age 65 years in patients who have appropriate negative try, irregular Border, multiple C-olors, Diameter >6 mm, and screening in the preceding 10 years and who do not have a Evolution or change over time) can help diagnose melanoma. history of cervical intraepithelial neoplasia grade 2 or more However, nodular melanomas do not always fulfill the ABCDE signiflcant disease in the preceding past 25 years. Women diagnostic criteria. As seen in this patient, nodular melano- older than 65 years who have never been screened or in mas may be uniform in color and have regular, qrmmetric whom the adequacy ofprior screening cannot be conflrmed, borders, making them difficult to diagnose until a later stage. zuch as this patient, should undergo screening. There is up Some nodular melanomas may be amelanotic or have a pink Io a74o/o mortalrty reduction from cervical cancer in women hue (as shown), adding to the diagnostic dfficulty. who have neverbeen screened. Currently, two FDA-approved primary HPV tests are available for cervical cancer screening, and both are approved as standalone cervical screening tests beginning at age 25 years. Five HPV tests are FDA-approved for co-testing (HPV testing plus cytolory). The USPSTF recom- mends screening with cytolory every 3 years, primary high- risk HPV testing every 5 years, or or-testing wery 5 years. The ACS favors primary HPV testing er/ery 5 years. When primary HPV testing is unaailable, the ACS recommends HPV co-testing wery 5 years or, altematively, rytolory alone wery 3 years. Upon inspection ofthe cervix, lesions that are raised, bleed, or have a wart-like appearance should be biopsied, regardless of previous rytolory results. Biopsy (Option A) is not a screening method for cervical cancer and should not be done in this patient without an acceptable indication. Colposcopy (Option C) provides an illuminated, magni- Most nodular melanomas are smooth, but others are fled view ofthe cervix, vagina, vulva, or anus. Colposcopy is eroded and have a particularly poor prognosis. Nodular used for patients with abnormal Pap smear results in which melanomas grow rapidly (fulfllling the Evolution diagrrostic

. Acute angle-closure glaucoma presents with sudden mary screening modality. Discontinuing cervical screening is not the correct onset of unllateral visual disturbance, which fre- stratery (Option D). This patient has incomplete records to quently indudes seeing halos around lights, accompa- substantiate previous cervical cancer screening. Therefore, nied by swere eye pain, eye redness, nausea, vomiting, cervical cancer screening should be initiated until criteria and headache. for discontinuation are met. o Patients with angle-closure glaucoma have narrow anterior chamber angles, which inhibit drainage of the aqueous fluid. . Routine screening for cervical cancer can be discon- tinued at age 65 years in non-high-risk women, pro- Bibliograptry vided that the patient has undergone adequate prior Jonas JB, Aung T, Bourne RR, et a]. Glaucoma. t-ancet. 20U;390:2183-93. screening. vt IPMID: 28s28601 doi:10.1016/50140-6736(77)31469 -r . The U.S. Preventive Services Task Force defines ade- (D = quate prior screening as three consecutive negative ta o, Item 38 Angwer: B cytologr results or two consecutive negative cytolory tests plus human papillomavirus test lesults within g- Educational Obiective: Screen for cervical cancer in older adults. the past l0 years, with the most recent test occurring =. within 5 years. lt The most appropriate cervical cancer screening strategr for a this patient is cervical rytologr with human papillomavi- Bibliography tt rus (HPV) testing (Option B). Routine screening for cer- Curry Sl Krist AH, Owens DK, et al; US Preventive Services Task Force. vical cancer can be discontinued at age 65 years in non- Screening for cervical cancer: US Preventive Services Task Force recom- mendation statement. JAMA. 2018:320:674-86. [PMID: 30140884] doi:lo. high-risk women, provided that the patient has undergone 1001ijama.2018.10897 adequate prior screening. The U.S. Preventive Services Task Force (USPSTF) defines adequate prior screening as three consecutive negative cytolory resuls or tvvo consecutive neg- Item 39 Answer: C ative cytolory tests plus negative HPV test results within the Educational Objective: Diagnose nodular melanoma. past 10 years, with the most recent test occurring within 5 years. Recommendations from the American Cancer Society The most likely diagnosis is nodular melanoma (Option C). (ACS) are similar and state that screening can be discontinued In general, the ABCDE identi$ing characteristics (Asymme- at age 65 years in patients who have appropriate negative try, irregular Border, multiple C-olors, Diameter >6 mm, and screening in the preceding 10 years and who do not have a Evolution or change over time) can help diagnose melanoma. history of cervical intraepithelial neoplasia grade 2 or more However, nodular melanomas do not always fulfill the ABCDE signiflcant disease in the preceding past 25 years. Women diagnostic criteria. As seen in this patient, nodular melano- older than 65 years who have never been screened or in mas may be uniform in color and have regular, qrmmetric whom the adequacy ofprior screening cannot be conflrmed, borders, making them difficult to diagnose until a later stage. zuch as this patient, should undergo screening. There is up Some nodular melanomas may be amelanotic or have a pink Io a74o/o mortalrty reduction from cervical cancer in women hue (as shown), adding to the diagnostic dfficulty. who have neverbeen screened. Currently, two FDA-approved primary HPV tests are available for cervical cancer screening, and both are approved as standalone cervical screening tests beginning at age 25 years. Five HPV tests are FDA-approved for co-testing (HPV testing plus cytolory). The USPSTF recom- mends screening with cytolory every 3 years, primary high- risk HPV testing every 5 years, or or-testing wery 5 years. The ACS favors primary HPV testing er/ery 5 years. When primary HPV testing is unaailable, the ACS recommends HPV co-testing wery 5 years or, altematively, rytolory alone wery 3 years. Upon inspection ofthe cervix, lesions that are raised, bleed, or have a wart-like appearance should be biopsied, regardless of previous rytolory results. Biopsy (Option A) is not a screening method for cervical cancer and should not be done in this patient without an acceptable indication. Colposcopy (Option C) provides an illuminated, magni- Most nodular melanomas are smooth, but others are fled view ofthe cervix, vagina, vulva, or anus. Colposcopy is eroded and have a particularly poor prognosis. Nodular used for patients with abnormal Pap smear results in which melanomas grow rapidly (fulfllling the Evolution diagrrostic 186

Answers and Critiques criterion), particularly vertical growth, and are more aggres l9 years or older who did not receive the Tdap vaccine at sive than other subtlpes. Because of the increased thick age 11 years or older should receive one dose of the Tdap ness of the melanoma at diagnosis and eggressive behavior. vaccine. All adults should receive a tetanus and diphthe_ prompt identification, biopsy, and treatment are imperative. ria toxoids (Td) or Tdap booster every 10 years. pregnant All suspicious pigmented lesions must be biopsied. The pre women should receive at least one dose of the Tdap vaccine ferred method to biopsy a pigmented lesion is an excisional between 27 weeks' and 36 weeks' gestation with every biopsy with a t to 3-mm margin to obtain the entire lesion pregnancy. Pregnant women who had not previously been and prevent sampling error. fully vaccinated against tetanus and diphtheria should also A hemangioma (Option A) is a fypically red or pink receive a Td series. , benign vascular tumor. Int'antile hemangiomas are com Patients should be administered the human papilloma mon but resolve before adulthood. Cherry hemangiomas are virus (HPV) vaccine series (Option A) at age 11 or 12 years I common in adults and typically increase in number with or between the ages of 13 and 26 years if not given previ age. Aithough hemangiomas can be blue or purple, they ously. In unvaccinated patients aged 27 to 45 years, vacci Ut (l, would not have the black appearance or rapid growth of this nation can be considered on the basis of risk using a shared patient's nodular melanoma. ET decision making process. Vaccination is not recommended A keratoacanthoma (Option B) has a distinct appear. during pregnancy, although no harmful effects have been (J ance and clinical course. It appears rapidly (within noted when inadvertently given to pregnant women and 4-6 weeks) as a round pink nodule with a central, kera q =, pregnancy testing is not necessary before vaccination. This .E tin filled crater, giving it a "volcaniform" appearance. After patient is up to date on her immunizations, and repeating UI (t, its rapid growth, some keratoacanthomas tend to involute in HPV vaccination during pregnancy is neither recommended 6 months. Because keratoacanthomas are difficult to differ nor necessary. UI = entiate from squamous cell carcinoma, they are often treated Influenza revaccination (Option B) is necessary each with surgical excision. The lack of a keratin filled center and year, owing to frequent genetic changes in the influenza uniform black pigmentation of this patient's skin lesion dif: virus (antigenic drift). Annual vaccination is recommended ferentiates it from a keratoacanthoma. for all individuals aged 6 months or older. All women who A pigmented basal cell carcinoma (BCC) (Option D) are pregnant or might be pregnant during the influenza sea typically has features ofa nodular BCC, such as rolled, pearly, son should receive standard dose influenza vaccination as translucent borders and arborizing telangiectasias. Use of soon as it becomes available, regardless ofthe stage ofpreg dermoscopy can help distinguish pigmented BCC from mel- nancy. Revaccinating this patient who received the vaccine anoma clinically, and skin biopsy conflrms the diagnosis. just before conception is not necessary. This patient's lesion is pigmented but has no other features No vaccination (Option D) fbr this patient is incorrect. ofa nodular BCC. Routine vaccinations for pregnant women include 'ldap vaccination and influenza vaccination during influenza t(EY P0r1{TS season. r Nodular melanomas do not always fulfill the ABCDE I(EY POITTS diagnostic criteria; they may be uniform in color (or amelanotic) and have regular, symmetric borders, . Pregnant women should receive one dose of the teta- making them difficult to diagnose until a later stage. nus toxoid, reduced diphtheria toxoid, and acellular . All suspicious pigmented lesions must be biopsied. pertussis vaccine befween 27 weeks' and 36 weeks' gestation with every pregnancy.

criterion), particularly vertical growth, and are more aggres l9 years or older who did not receive the Tdap vaccine at sive than other subtlpes. Because of the increased thick age 11 years or older should receive one dose of the Tdap ness of the melanoma at diagnosis and eggressive behavior. vaccine. All adults should receive a tetanus and diphthe_ prompt identification, biopsy, and treatment are imperative. ria toxoids (Td) or Tdap booster every 10 years. pregnant All suspicious pigmented lesions must be biopsied. The pre women should receive at least one dose of the Tdap vaccine ferred method to biopsy a pigmented lesion is an excisional between 27 weeks' and 36 weeks' gestation with every biopsy with a t to 3-mm margin to obtain the entire lesion pregnancy. Pregnant women who had not previously been and prevent sampling error. fully vaccinated against tetanus and diphtheria should also A hemangioma (Option A) is a fypically red or pink receive a Td series. , benign vascular tumor. Int'antile hemangiomas are com Patients should be administered the human papilloma mon but resolve before adulthood. Cherry hemangiomas are virus (HPV) vaccine series (Option A) at age 11 or 12 years I common in adults and typically increase in number with or between the ages of 13 and 26 years if not given previ age. Aithough hemangiomas can be blue or purple, they ously. In unvaccinated patients aged 27 to 45 years, vacci Ut (l, would not have the black appearance or rapid growth of this nation can be considered on the basis of risk using a shared patient's nodular melanoma. ET decision making process. Vaccination is not recommended A keratoacanthoma (Option B) has a distinct appear. during pregnancy, although no harmful effects have been (J ance and clinical course. It appears rapidly (within noted when inadvertently given to pregnant women and 4-6 weeks) as a round pink nodule with a central, kera q =, pregnancy testing is not necessary before vaccination. This .E tin filled crater, giving it a "volcaniform" appearance. After patient is up to date on her immunizations, and repeating UI (t, its rapid growth, some keratoacanthomas tend to involute in HPV vaccination during pregnancy is neither recommended 6 months. Because keratoacanthomas are difficult to differ nor necessary. UI = entiate from squamous cell carcinoma, they are often treated Influenza revaccination (Option B) is necessary each with surgical excision. The lack of a keratin filled center and year, owing to frequent genetic changes in the influenza uniform black pigmentation of this patient's skin lesion dif: virus (antigenic drift). Annual vaccination is recommended ferentiates it from a keratoacanthoma. for all individuals aged 6 months or older. All women who A pigmented basal cell carcinoma (BCC) (Option D) are pregnant or might be pregnant during the influenza sea typically has features ofa nodular BCC, such as rolled, pearly, son should receive standard dose influenza vaccination as translucent borders and arborizing telangiectasias. Use of soon as it becomes available, regardless ofthe stage ofpreg dermoscopy can help distinguish pigmented BCC from mel- nancy. Revaccinating this patient who received the vaccine anoma clinically, and skin biopsy conflrms the diagnosis. just before conception is not necessary. This patient's lesion is pigmented but has no other features No vaccination (Option D) fbr this patient is incorrect. ofa nodular BCC. Routine vaccinations for pregnant women include 'ldap vaccination and influenza vaccination during influenza t(EY P0r1{TS season. r Nodular melanomas do not always fulfill the ABCDE I(EY POITTS diagnostic criteria; they may be uniform in color (or amelanotic) and have regular, symmetric borders, . Pregnant women should receive one dose of the teta- making them difficult to diagnose until a later stage. nus toxoid, reduced diphtheria toxoid, and acellular . All suspicious pigmented lesions must be biopsied. pertussis vaccine befween 27 weeks' and 36 weeks' gestation with every pregnancy. Bibliography o All women who are pregnant or might be pregnant \,lrrr VJ. Chamberlain AJ. Kelly JW. et al. Clinical prirctice guidelines fbr the during the influenza season should receive standard diagnosis ancl management of melanoma: melanomas th:lt lack clrtssicrtl dose influenza vaccination as soon as it becomes clinical ['atures. Med J Aust. 20171207::].18 50. IPMII): zsozoSsl] available, regardless of the stage of pregnancy.

Bibliography o All women who are pregnant or might be pregnant \,lrrr VJ. Chamberlain AJ. Kelly JW. et al. Clinical prirctice guidelines fbr the during the influenza season should receive standard diagnosis ancl management of melanoma: melanomas th:lt lack clrtssicrtl dose influenza vaccination as soon as it becomes clinical ['atures. Med J Aust. 20171207::].18 50. IPMII): zsozoSsl] available, regardless of the stage of pregnancy. Item 40 Answer: C Bibliography Freedman MS. Bernstein tl. Atllt KA. Recommended adult immuniziltion Educational Objective: Provide tetanus toxoid, reduced schcdule, United States, 2021. Ann Intern Med. 2021:171:'374 84. JPMII): diphtheria toxoid, and acellular pertussis vaccination $sziottl doi:10.7326lM20 8080 during pregnancy.

Item 40 Answer: C Bibliography Freedman MS. Bernstein tl. Atllt KA. Recommended adult immuniziltion Educational Objective: Provide tetanus toxoid, reduced schcdule, United States, 2021. Ann Intern Med. 2021:171:'374 84. JPMII): diphtheria toxoid, and acellular pertussis vaccination $sziottl doi:10.7326lM20 8080 during pregnancy. The most appropriate vaccination is tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) (Option C). Primary vaccination against tetanus, diph Item 41 Answer: A Educational Objective: Treat severe aortic stenosis with tr valve replacement prior to elective noncardiac surgery. theria, and acellular pertussis consists of a five dose vac- cine series administered during childhood. Persons aged 'lhc nrost approprirlte recotntltt'ntlittion regartling sttrgerY 11 to 18 years who have completed the primary series is aortic vllve replacenlellt prior to itort<lfetltlrirl byllass should receive one dose of the Tdap vaccine' Adults aged (Option A). lhc 201.1 Atrericitn Grllege of CardioloSt i\mericau 187

Answers and Critiques I I cough, headache. nasal congestion, and malaise in the tr CONT, lleart Association guideline fbr the managenlent of patiellts rvith v:rlvr-rlar heart disease recommends that uhen valvu lar [.reart ciisease is diagnosecl in paticllts being considered absence of fever, as well as the findings on physical exam- ination. are consistent with an acute upper respiratory tract fbr elcctive noncardiac stlrgery. the first step is to review infection (URI), or the common cold. URIs are caused by a the standard criteria fbr intervention of the specific valve large variety of viruses, most commonly rhinovims' Virus lesion. If the patient meets standard criteria for intenen transmission is via inhalation or direct contact with secre- tiol1. it is prudent to deler the elective tloncarcliac proce tions infected with viral particles. The overproduction of : dure and proceed to valvc intervention instead. ln patients mucosal secretions is caused by infection of epithelial cells r,r,ith significant asynlptomatic valve disease who clo not responsible for the mucociliary layer within the respiratory i meet stancl:rrd criteria for inten'ention. the risk of the non tract and oropharynx. Symptoms of an uncomplicated URI l cardiirc procedure can be tninintized by l) har:ing al-l accu may persist for up to 2 weeks after initial infection, and rate diagnosis of the tlrpe and severitl' ol valve d1'sfunction. cough may persist even after resolution of the acute illness. l

dure and proceed to valvc intervention instead. ln patients mucosal secretions is caused by infection of epithelial cells r,r,ith significant asynlptomatic valve disease who clo not responsible for the mucociliary layer within the respiratory i meet stancl:rrd criteria for inten'ention. the risk of the non tract and oropharynx. Symptoms of an uncomplicated URI l cardiirc procedure can be tninintized by l) har:ing al-l accu may persist for up to 2 weeks after initial infection, and rate diagnosis of the tlrpe and severitl' ol valve d1'sfunction. cough may persist even after resolution of the acute illness. l D 2) choosing an anesthetic approach appropriate to the valve Treatment for the common cold focuses on symptom man UI lesion. and 3) er.rsuring a l.rigl.rer level of intri]operative agement, including reducing severity of discomfort caused :

dure and proceed to valvc intervention instead. ln patients mucosal secretions is caused by infection of epithelial cells r,r,ith significant asynlptomatic valve disease who clo not responsible for the mucociliary layer within the respiratory i meet stancl:rrd criteria for inten'ention. the risk of the non tract and oropharynx. Symptoms of an uncomplicated URI l cardiirc procedure can be tninintized by l) har:ing al-l accu may persist for up to 2 weeks after initial infection, and rate diagnosis of the tlrpe and severitl' ol valve d1'sfunction. cough may persist even after resolution of the acute illness. l D 2) choosing an anesthetic approach appropriate to the valve Treatment for the common cold focuses on symptom man UI lesion. and 3) er.rsuring a l.rigl.rer level of intri]operative agement, including reducing severity of discomfort caused : E morlitoring. by lrequent coughing, sneezing, headache, sore throat, and ) .D l,I This patier,t has severe :rortic stenttsis that meets cri malaise. Analgesics may help with myalgia and headache. o, teria fbr surgical intervention. uhich is a lif'e prokrnging whereas nasal symptoms may respond to intranasal cromo- CL surgery. Aortof'emoral bypass (Option B) is an effective lyn, intranasal ipratropium, or combination decongestantr n intervention fbr improving symptoms, increasing func antihistamines. tional capacity'. and impror,ing n,ound healing in paticnts Antibiotic therapy, such as amoxicillin (Option B). is lt r,r,ith internrittent claudication or critical limb ischemia: inellective in the treatment for the common cold and is not .D lrt hor,r,ever, the procedure is not lif'e exter.rding lnd can be recommended for either shortening duration of symptoms postponed until the patient recovers from his aortic valve or preventing bacterial superinfection. Not prescribing anti replacement. biotics is supported by multiple guidelines as a means of Aortic valve replacenrent is the prelbrred treatnrent fbr decreasing health care costs, antibiotic resistance, and the patients with aortic stenosis meeting the criteria fbr inter potential adverse eflects of antibiotics. vention. Percutaneous balloon aortic valvotomy (Options There is little evidence to support the use of expecto C, D) is not a substitute for valvc' replacement. It prorricles rants and mucolytics, such as guaifenesin (Option C), in the only tcmporary irnprovement in'r,alve function. hirs a high treatment of the common cold. Although the adverse effects rate o[ coraplications, and is not lifesavir.rg. Percutane of these agents are minimal, they should not be recom ous balloon aortic valvulotoml, might be considerecl in mended because of the lack of beneflcial effect. patients with severe aortic stenosis and pulnronary edcma Although there is some evidence that zinc lozenges may or cardiogenic shock unresponsivc to standard therapl,: decrease the duration of URI symptoms, adverse effects, This patient has no indication frrr pcrcutaneous aortic bal including nausea and bad taste, are common. Zinc-containing Ioon valvulotom),. intranasal products (Option D) in particular should be avoided owing to the risk for permanent anosmia. XEY POII{T5 o When valvular heart disease is diagnosed in patients TEV POITIS being considered for elective noncardiac surgery the . Treatment for the common cold locuses on symptom first step is to review the standard criteria for inter- management. vention of the specific valve lesion. o Antibiotic therapy is ineffective in the treatment for r If a patient meets standard criteria for valvular inter- the common cold and not recommended for either vention, it is prudent to defer the elective noncardiac shortening duration of symptoms or preventing bac- procedure and proceed to valve intervention instead. terial superinfection.

E morlitoring. by lrequent coughing, sneezing, headache, sore throat, and ) .D l,I This patier,t has severe :rortic stenttsis that meets cri malaise. Analgesics may help with myalgia and headache. o, teria fbr surgical intervention. uhich is a lif'e prokrnging whereas nasal symptoms may respond to intranasal cromo- CL surgery. Aortof'emoral bypass (Option B) is an effective lyn, intranasal ipratropium, or combination decongestantr n intervention fbr improving symptoms, increasing func antihistamines. tional capacity'. and impror,ing n,ound healing in paticnts Antibiotic therapy, such as amoxicillin (Option B). is lt r,r,ith internrittent claudication or critical limb ischemia: inellective in the treatment for the common cold and is not .D lrt hor,r,ever, the procedure is not lif'e exter.rding lnd can be recommended for either shortening duration of symptoms postponed until the patient recovers from his aortic valve or preventing bacterial superinfection. Not prescribing anti replacement. biotics is supported by multiple guidelines as a means of Aortic valve replacenrent is the prelbrred treatnrent fbr decreasing health care costs, antibiotic resistance, and the patients with aortic stenosis meeting the criteria fbr inter potential adverse eflects of antibiotics. vention. Percutaneous balloon aortic valvotomy (Options There is little evidence to support the use of expecto C, D) is not a substitute for valvc' replacement. It prorricles rants and mucolytics, such as guaifenesin (Option C), in the only tcmporary irnprovement in'r,alve function. hirs a high treatment of the common cold. Although the adverse effects rate o[ coraplications, and is not lifesavir.rg. Percutane of these agents are minimal, they should not be recom ous balloon aortic valvulotoml, might be considerecl in mended because of the lack of beneflcial effect. patients with severe aortic stenosis and pulnronary edcma Although there is some evidence that zinc lozenges may or cardiogenic shock unresponsivc to standard therapl,: decrease the duration of URI symptoms, adverse effects, This patient has no indication frrr pcrcutaneous aortic bal including nausea and bad taste, are common. Zinc-containing Ioon valvulotom),. intranasal products (Option D) in particular should be avoided owing to the risk for permanent anosmia. XEY POII{T5 o When valvular heart disease is diagnosed in patients TEV POITIS being considered for elective noncardiac surgery the . Treatment for the common cold locuses on symptom first step is to review the standard criteria for inter- management. vention of the specific valve lesion. o Antibiotic therapy is ineffective in the treatment for r If a patient meets standard criteria for valvular inter- the common cold and not recommended for either vention, it is prudent to defer the elective noncardiac shortening duration of symptoms or preventing bac- procedure and proceed to valve intervention instead. terial superinfection. Bibliography Bibliography Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Harris AM, Hicks LA. Qaseem A: High \hlue Care Task Force of the American Cardiologr. 20i4 ACC/AHA guideline on perioperati\€ cardiovascular College of Physicians and for the Centers for Disease Control and evaluation and management of patients undergoing noncardiac surgery: Prevention. Appropriate antibiotic use for acute respiratory tract infec- a report of the American College of Cardiologr/American Heart tion in adults: advice for high lalue care from the American College of Association Task Force on practice guidelines. I Am Coll Cardiol. 2014; Physicians and the Centers fbr Disease Control and prevention. Ann 64:e77 737. [PMID: 25091544] doi:10.1016/j.jacc.2}t4.O7.944 Intern Med. 2016;764:425-34. IPMID:26785a02] doi:10.7326 MtS 1840

Bibliography Bibliography Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Harris AM, Hicks LA. Qaseem A: High \hlue Care Task Force of the American Cardiologr. 20i4 ACC/AHA guideline on perioperati\€ cardiovascular College of Physicians and for the Centers for Disease Control and evaluation and management of patients undergoing noncardiac surgery: Prevention. Appropriate antibiotic use for acute respiratory tract infec- a report of the American College of Cardiologr/American Heart tion in adults: advice for high lalue care from the American College of Association Task Force on practice guidelines. I Am Coll Cardiol. 2014; Physicians and the Centers fbr Disease Control and prevention. Ann 64:e77 737. [PMID: 25091544] doi:10.1016/j.jacc.2}t4.O7.944 Intern Med. 2016;764:425-34. IPMID:26785a02] doi:10.7326 MtS 1840 Item 42 Answer: A Item 43 Answer: A Educational Objective: Treat the common cold. Educational Obiective: Screen for hepatitis C virus. The most appropriate treatment is acetaminophen The most appropriate infectious disease screening test for this (Option A). This patient's presentation of sore throat, patient is hepatitis C virus (HCV) antibody assay (Option A). 188

Answers and Critiques Patients at highest risk for HCV include individuals who Item 44 Answer: A engage in high risk sexual behavior (such as having multi- Educational Obiective: Diagnose lichen planus. ple partners), practice unhealthy drug use, have been incar cerated, or are receiving hemodialysis. One time screening The most likely diagnosis is lichen planus (Option A). Some, for HCV should be completed in all patients aged 18 to but not all, studies have shown an increased prevalence of 79 years. The U.S. Preventive Services Task Force (USPSTF) hepatitis C virus infection in patients with lichen planus. does not promote screening in patients older than 79 years, Lichen planus is a relatively common T cell-mediated dis- although the CDC does not specify an upper age limit. ease presenting with pruritic purple papules that are often Patients with risk factors should also be retested regard- flat topped and have a polygonal appearance. Papules char- Iess of age. Screening is accomplished by testing for HCV acteristically erupt on the low back, volar wrists, elbows, antibody, followed by HCV RNA quantification if results ofl knees, and ankles. Othervariants include nail, genital, bul- antibody testing are positive. Conventional Iiver chemistry lous, atrophic, and hypertrophic Iichen planus. Mucosal testing is not sufficiently sensitive to exclude chronic HCV lesions have lacy white streaks (Wickham striae), as shown r^ (l, infection. in this patient, or erosions and ulcerations. 3 ET According to the USPSTF, screening for chlamydia and gonorrhea (Option B) should be performed in all sexually t, active women aged 24 years or younger because ofincreased T' prevalence in this population. The USPSTF believes repeat ru screening is reasonable in patients whose sexual history la (l, reveals new or persistent risk factors since the last negative t^ test result. There is no indication to screen this patient for = sexually transmitted infections. The USPSTF recommends screening for syphi lis (Option C) in persons who are at increased risk for infection. Men who have sex with men (MSM) and men and women living with HIV have the highest risk for syphilis; 67% of cases of primary and secondary syphilis occurred among MSM, and approximately one half of all MSM diagnosed with syphilis were also coinfected with HIV. Other factors associated with increased risk that clinicians should consider include history of incarcera tion, history of commercial sex work, and well-described Lichen planus also exhibits the Koebner phenome- regional variations. non, which describes its occurrence in areas of trauma, Not screening for HCV infection is inappropriate such as those caused by scratching. Lichen planus is typi (Option D). HCV is the most common chronic bloodborne cally treated with topical glucocorticoids or ultraviolet light pathogen in the United States and is a leading cause of com- therapy. Lichen planus tends to resolve over the course of plications from chronic liver disease. HCV infection is asso, 1 to 2 years, although oral and nail lichen planus are more ciated with more deaths than the top 60 other reportable persistent. infectious diseases combined, including HIV Effective and Pityriasis rosea (Option B) begins as a single annu- safe treatment is available for patients with HCV infection, lar patch or plaque with fine scaling (the herald patch), and screening for HCV should be performed and treatment typically on the trunk, followed by numerous smaller provided to prevent complications of chronic liver disease skin-colored to pink papules and plaques erupting along and premature death. skin cleavage lines. As a result of the Koebner phenome I(EY POIXIS non, scratching the lichen planus on the lower back can result in a linear-appearing rash, mimicking the appearance . One-time screening for hepatitis C virus should be of pityriasis rosea. However, Iichen planus is signiflcantly completed in all patients aged 18 to 79 years. more purple in color than pityriasis rosea and tends to . Patients with risk factors for hepatitis C, such as indi erupt on the lower back, whereas pityriasis rosea tends to viduals who engage in high-risk sexual behavior, erupt on the upper and mid back. This patient also has rash practice unhealthy drug use, have been incarcerated, on her volar wrists, which would be an unusual flnding in or are receiving hemodialysis, should be retested pityriasis rosea. regardless of age. Psoriasis (Option C) has many clinical presentations, the most common being plaque psoriasis. Plaque psoriasis Bibliography typicaly presents with thick, well-demarcated erythem- Owens DK, Davidson KW Krist AH, et al; US Preventive Services Task Force. atous plaques with overlying silvery scale. Nail psoriasis Screening lbr hepatitis C virus infection in adolescents and adults: US presents with nail pitting, onycholysis (separation of the Preventive Services Task Force recommendation statement. JAMA. 2O2O:323:97O 5. [PMID: 327190761 doi:10.1001 /jama.2O2O.1123 nail plate from the nail bed), and "oil spots." Other less

Patients at highest risk for HCV include individuals who Item 44 Answer: A engage in high risk sexual behavior (such as having multi- Educational Obiective: Diagnose lichen planus. ple partners), practice unhealthy drug use, have been incar cerated, or are receiving hemodialysis. One time screening The most likely diagnosis is lichen planus (Option A). Some, for HCV should be completed in all patients aged 18 to but not all, studies have shown an increased prevalence of 79 years. The U.S. Preventive Services Task Force (USPSTF) hepatitis C virus infection in patients with lichen planus. does not promote screening in patients older than 79 years, Lichen planus is a relatively common T cell-mediated dis- although the CDC does not specify an upper age limit. ease presenting with pruritic purple papules that are often Patients with risk factors should also be retested regard- flat topped and have a polygonal appearance. Papules char- Iess of age. Screening is accomplished by testing for HCV acteristically erupt on the low back, volar wrists, elbows, antibody, followed by HCV RNA quantification if results ofl knees, and ankles. Othervariants include nail, genital, bul- antibody testing are positive. Conventional Iiver chemistry lous, atrophic, and hypertrophic Iichen planus. Mucosal testing is not sufficiently sensitive to exclude chronic HCV lesions have lacy white streaks (Wickham striae), as shown r^ (l, infection. in this patient, or erosions and ulcerations. 3 ET According to the USPSTF, screening for chlamydia and gonorrhea (Option B) should be performed in all sexually t, active women aged 24 years or younger because ofincreased T' prevalence in this population. The USPSTF believes repeat ru screening is reasonable in patients whose sexual history la (l, reveals new or persistent risk factors since the last negative t^ test result. There is no indication to screen this patient for = sexually transmitted infections. The USPSTF recommends screening for syphi lis (Option C) in persons who are at increased risk for infection. Men who have sex with men (MSM) and men and women living with HIV have the highest risk for syphilis; 67% of cases of primary and secondary syphilis occurred among MSM, and approximately one half of all MSM diagnosed with syphilis were also coinfected with HIV. Other factors associated with increased risk that clinicians should consider include history of incarcera tion, history of commercial sex work, and well-described Lichen planus also exhibits the Koebner phenome- regional variations. non, which describes its occurrence in areas of trauma, Not screening for HCV infection is inappropriate such as those caused by scratching. Lichen planus is typi (Option D). HCV is the most common chronic bloodborne cally treated with topical glucocorticoids or ultraviolet light pathogen in the United States and is a leading cause of com- therapy. Lichen planus tends to resolve over the course of plications from chronic liver disease. HCV infection is asso, 1 to 2 years, although oral and nail lichen planus are more ciated with more deaths than the top 60 other reportable persistent. infectious diseases combined, including HIV Effective and Pityriasis rosea (Option B) begins as a single annu- safe treatment is available for patients with HCV infection, lar patch or plaque with fine scaling (the herald patch), and screening for HCV should be performed and treatment typically on the trunk, followed by numerous smaller provided to prevent complications of chronic liver disease skin-colored to pink papules and plaques erupting along and premature death. skin cleavage lines. As a result of the Koebner phenome I(EY POIXIS non, scratching the lichen planus on the lower back can result in a linear-appearing rash, mimicking the appearance . One-time screening for hepatitis C virus should be of pityriasis rosea. However, Iichen planus is signiflcantly completed in all patients aged 18 to 79 years. more purple in color than pityriasis rosea and tends to . Patients with risk factors for hepatitis C, such as indi erupt on the lower back, whereas pityriasis rosea tends to viduals who engage in high-risk sexual behavior, erupt on the upper and mid back. This patient also has rash practice unhealthy drug use, have been incarcerated, on her volar wrists, which would be an unusual flnding in or are receiving hemodialysis, should be retested pityriasis rosea. regardless of age. Psoriasis (Option C) has many clinical presentations, the most common being plaque psoriasis. Plaque psoriasis Bibliography typicaly presents with thick, well-demarcated erythem- Owens DK, Davidson KW Krist AH, et al; US Preventive Services Task Force. atous plaques with overlying silvery scale. Nail psoriasis Screening lbr hepatitis C virus infection in adolescents and adults: US presents with nail pitting, onycholysis (separation of the Preventive Services Task Force recommendation statement. JAMA. 2O2O:323:97O 5. [PMID: 327190761 doi:10.1001 /jama.2O2O.1123 nail plate from the nail bed), and "oil spots." Other less 189

Answers and Critigues common subtypes include guttate psoriasis (commonly seen This patient's changes in menstrual bleeding may be related in pediatric patients), palmoplantar psoriasis (frequently to perimenopausal hormone changes. However. FSH levels with pustules as the primary lesion). and inverse psoriasis vary during the menstrual cycle in premenopausal women (often seen without scale in the intertriginous areas). This and may not be indicative of perimenopause. patient's purple papules do not resemble the red plaques Obtaining a Pap smear (Option B) is not appropriate with thick scale of psoriasis. management. Women older than 30 years rt,ith a normal The rash of secondary syphilis (Option D) is more Pap smear and a negative human papillomavirus (HPV) test brownish red in color compared with the purple papules result require screening every 5 years. This patient's last Pap of lichen planus. Secondary syphilis also typically involves smear was obtained 3 year ago and was normal: HPV testing the trunk and extremities, often including the palms and was negative. soles. Involvement of the palms and soles and general, Although oral contraceptive pills (Option D) are an ized lymphadenopathy favor the diagnosis of secondary option to manage abnormal uterine bleeding, this patient D syphilis. requires further assessment and the exclusion of endome tt trial cancer before initiating treatment. E TEY POIilT o o Lichen planus is a T cell-mediated disease classically TEY POtilIS t/t o, presenting with pruritic purple papules that are often o Risk factors for endometrial cancer include obesity CL flat topped and characteristically erupt on the low back, (BMI >30); a history of unopposed estrogen (e.g., poly n volar wrists, elbows, knees, and ankles. cystic ovary syndrome, obesity)l or genetic syndromes, such as Lynch or Cowden syndrome. lt o Bibliography . When presenting with abnormal uterine bleeding. t^ Ioannides D. Vakirlis E. Kemen!'l-. et al. European Sl guidelines on the women aged 45 years and older or those younger than management of lichen planus: a cooperation of the l.]uropean Dermatolory Forum u,ith the Iiuropean Academy of Dermatolog'and 45 years who are at increased risk for endometrial Venereolopy. J Eur Acad Dermatol Venereol. 202o::l{:1.10:l l-1. IPMID: cancer should undergo endometrial biopsy. 326785131 doi:10.1111, jdv16.16.1

common subtypes include guttate psoriasis (commonly seen This patient's changes in menstrual bleeding may be related in pediatric patients), palmoplantar psoriasis (frequently to perimenopausal hormone changes. However. FSH levels with pustules as the primary lesion). and inverse psoriasis vary during the menstrual cycle in premenopausal women (often seen without scale in the intertriginous areas). This and may not be indicative of perimenopause. patient's purple papules do not resemble the red plaques Obtaining a Pap smear (Option B) is not appropriate with thick scale of psoriasis. management. Women older than 30 years rt,ith a normal The rash of secondary syphilis (Option D) is more Pap smear and a negative human papillomavirus (HPV) test brownish red in color compared with the purple papules result require screening every 5 years. This patient's last Pap of lichen planus. Secondary syphilis also typically involves smear was obtained 3 year ago and was normal: HPV testing the trunk and extremities, often including the palms and was negative. soles. Involvement of the palms and soles and general, Although oral contraceptive pills (Option D) are an ized lymphadenopathy favor the diagnosis of secondary option to manage abnormal uterine bleeding, this patient D syphilis. requires further assessment and the exclusion of endome tt trial cancer before initiating treatment. E TEY POIilT o o Lichen planus is a T cell-mediated disease classically TEY POtilIS t/t o, presenting with pruritic purple papules that are often o Risk factors for endometrial cancer include obesity CL flat topped and characteristically erupt on the low back, (BMI >30); a history of unopposed estrogen (e.g., poly n volar wrists, elbows, knees, and ankles. cystic ovary syndrome, obesity)l or genetic syndromes, such as Lynch or Cowden syndrome. lt o Bibliography . When presenting with abnormal uterine bleeding. t^ Ioannides D. Vakirlis E. Kemen!'l-. et al. European Sl guidelines on the women aged 45 years and older or those younger than management of lichen planus: a cooperation of the l.]uropean Dermatolory Forum u,ith the Iiuropean Academy of Dermatolog'and 45 years who are at increased risk for endometrial Venereolopy. J Eur Acad Dermatol Venereol. 202o::l{:1.10:l l-1. IPMID: cancer should undergo endometrial biopsy. 326785131 doi:10.1111, jdv16.16.1 Bibliography Item 45 Answer: C Anrerican Collcge of Obstetricians and G)necologists. ACOC committee opinion n{). 557: Management of acute ;rbnormirl uterine bleeding in Educational Objective: Evaluate a patient for nonpregn:rnt reprotluctile-aged nomen. Obstet G!'necol. 201:l;121:891 6. endometrial cancer. lPl!{lD: 2:16:ls7o6l doi:10.1097 01.AOG.0000128616.67925.9^

Bibliography Item 45 Answer: C Anrerican Collcge of Obstetricians and G)necologists. ACOC committee opinion n{). 557: Management of acute ;rbnormirl uterine bleeding in Educational Objective: Evaluate a patient for nonpregn:rnt reprotluctile-aged nomen. Obstet G!'necol. 201:l;121:891 6. endometrial cancer. lPl!{lD: 2:16:ls7o6l doi:10.1097 01.AOG.0000128616.67925.9^ The most appropriate management is to obtain an endome trial biopsy (Option C). When presenting with abnormal Item 46 Answer: C uterine bleeding, premenopausal women aged 45 years or Educational Objective: Prevent cardiovascular disease older or those younger than 45 years who are at increased with low dose aspirin. risk for endometrial cancer should undergo endometrial biopsy. Risk factors for endometrial cancer include obesity The most appropriate antithrombotic therapy for this patient (BMI >30); a history of unopposed estrogen (e.g., polycystic is low dose aspirin (Option C). Daily low-dose aspirin may ovary syndrome, obesity)l or genetic syndromes, such as be considered for primary prevention of atherosclerotic car Lynch or Cowden syndrome. Failure of medical manage diovascular disease (ASCVD) events, but the potential benefit ment for abnormal uterine bleeding is another indication must be balanced against the increased risk for bleeding. for endometrial biopsy. Because this patient is 39 years old The American College of Cardiolopy/American Heart Asso and obese. she is at increased risk fbr endometrial cancer ciation guidelines recommend that aspirin should be used and should undergo endometrial biopsy to evaluate for infrequently in the routine primary prevention of ASCVD hyperplasia or malignancy. In postmenopausal women with because of a lack of net beneflt; specifically, low dose aspi- abnormal uterine bleeding, transvaginal ultrasonography rin may be considered for primary prevention of ASCVD in can be used to evaluate the thickness of the endometrial adults aged 40 to 70 years who are at higher ASCVD risk but lining; an endometrial thickness greater than 4 mm may not at increased bleeding risk. This patient is not at high risk indicate hyperplasia or malignancy and biopsy is indicated. for bleeding but is at high risk for ASCVD. making low dose However, in premenopausal women, endometrial thickness aspirin an appropriate choice. is not a reliable indicator because it varies with the men Dual antiplatelet therapy (DAPT), such as the combina strual cycle. Although transvaginal ultrasonography may tion of aspirin and clopidogrel (Option A) , plays an essential be appropriate to evaluate for structural causes of abnormal role in the treatment of established ASCVD. It is particu bleeding, it does not substitute for an endometrial biopsy larly important after myocardial infarction and in prevent and biopsy is usually performed regardless of the ultra ing thrombotic events after percutaneous intervention for sound flndings. coronary artery disease. Because of the increased risk for Obtaining a follicle stimulating hormone (FSH) Ievel bleeding, however, DAPT does not have a role in the primary (Option A) would not assist in the evaluation of this patient. prevention of ASCVD events.

The most appropriate management is to obtain an endome trial biopsy (Option C). When presenting with abnormal Item 46 Answer: C uterine bleeding, premenopausal women aged 45 years or Educational Objective: Prevent cardiovascular disease older or those younger than 45 years who are at increased with low dose aspirin. risk for endometrial cancer should undergo endometrial biopsy. Risk factors for endometrial cancer include obesity The most appropriate antithrombotic therapy for this patient (BMI >30); a history of unopposed estrogen (e.g., polycystic is low dose aspirin (Option C). Daily low-dose aspirin may ovary syndrome, obesity)l or genetic syndromes, such as be considered for primary prevention of atherosclerotic car Lynch or Cowden syndrome. Failure of medical manage diovascular disease (ASCVD) events, but the potential benefit ment for abnormal uterine bleeding is another indication must be balanced against the increased risk for bleeding. for endometrial biopsy. Because this patient is 39 years old The American College of Cardiolopy/American Heart Asso and obese. she is at increased risk fbr endometrial cancer ciation guidelines recommend that aspirin should be used and should undergo endometrial biopsy to evaluate for infrequently in the routine primary prevention of ASCVD hyperplasia or malignancy. In postmenopausal women with because of a lack of net beneflt; specifically, low dose aspi- abnormal uterine bleeding, transvaginal ultrasonography rin may be considered for primary prevention of ASCVD in can be used to evaluate the thickness of the endometrial adults aged 40 to 70 years who are at higher ASCVD risk but lining; an endometrial thickness greater than 4 mm may not at increased bleeding risk. This patient is not at high risk indicate hyperplasia or malignancy and biopsy is indicated. for bleeding but is at high risk for ASCVD. making low dose However, in premenopausal women, endometrial thickness aspirin an appropriate choice. is not a reliable indicator because it varies with the men Dual antiplatelet therapy (DAPT), such as the combina strual cycle. Although transvaginal ultrasonography may tion of aspirin and clopidogrel (Option A) , plays an essential be appropriate to evaluate for structural causes of abnormal role in the treatment of established ASCVD. It is particu bleeding, it does not substitute for an endometrial biopsy larly important after myocardial infarction and in prevent and biopsy is usually performed regardless of the ultra ing thrombotic events after percutaneous intervention for sound flndings. coronary artery disease. Because of the increased risk for Obtaining a follicle stimulating hormone (FSH) Ievel bleeding, however, DAPT does not have a role in the primary (Option A) would not assist in the evaluation of this patient. prevention of ASCVD events. 190

Answers and Critiques ln the secondary prevention of ASCVD events, clopi has diabetes, she should continue therapy with atorvastatin dogrel is recommended fbr patients who are aspirin intol (Option A) regardless ol weight loss. erant. 'lhere is no indicatior.r that this patient is irspirin 'l'he American Diabetes Associatior-r hypertension intolerant. and there is no recommendation to substitute treatment goal for most persons rvith diabetes is less clopidogrel (Option B) tbr aspirin for the primary preven than 140/90 mm Hg. 'l'hose persons with known ASCVD tion of'ASCVD. or at high risk (10-year ASCVD risk >15'1,) should l.rave a Anticoagulation has no role in the prirnary prevention blood pressure target less than 130/80 mm Hg. Guide of ASCVD. ln patients with peripheral artery disease. the use lines f rom the American College of Cardiologyi'American of low dose rivaroxaban (Option D) plus aspirin compared Heart Association :rdvocate fbr a treatment target below with aspirin alone has been associated with a significant 130/80 n.rm Hg for most patients with diabetes. l'his decrease in cardiovascular mortality (t.Z')(, vs. ).2"/,,) and patient is asymptomatic and, although her blood pressure stroke (0.7'X, vs. 1.,1'){,) but a higher incidence of gastrointes should be carelully r.r.ronitored, she can continue lisino tinal bleeding. This patient does not have an indicatior.r ft-rr pril (Option C) because her blood pressure remains well Ut low dose rivaroxaban. o controlled on current medications. ET Not recommending lurther management is inct-rr Metfbrmin (Option D) does not cause hypoglycemia rect (Option E). Adding low dose aspirin to his medica and sl.rould be continued, particularly if insulin glargine is (J tion regimen is an appropriate choice fbr this patient in to be discor.rtinued. 'lhe primary sites ol vitamin D absorption are the jeju -,E light of his high risk fbr ASCVD and acceptable bleeding r! risk. num and ileum. and deficiencies ol vitamin D and other vt (u fat soluble vitamins occur regularly after RYGB surgery. Cal 3 I(EV POI ilT . Aspirin may be considered in adults aged 40 to cium absorption is dependent on the presence of vitamin D. tUI Patients require lif'elong vitamin D and calcium supplemen 70 years who are at higher atherosclerotic cardiovas tation (Option E) alter most bariatric surgical procedures. cular disease risk and are not at increased bleeding and they sl.rouid not be discontinued. risk. I(EY POIilT5

ln the secondary prevention of ASCVD events, clopi has diabetes, she should continue therapy with atorvastatin dogrel is recommended fbr patients who are aspirin intol (Option A) regardless ol weight loss. erant. 'lhere is no indicatior.r that this patient is irspirin 'l'he American Diabetes Associatior-r hypertension intolerant. and there is no recommendation to substitute treatment goal for most persons rvith diabetes is less clopidogrel (Option B) tbr aspirin for the primary preven than 140/90 mm Hg. 'l'hose persons with known ASCVD tion of'ASCVD. or at high risk (10-year ASCVD risk >15'1,) should l.rave a Anticoagulation has no role in the prirnary prevention blood pressure target less than 130/80 mm Hg. Guide of ASCVD. ln patients with peripheral artery disease. the use lines f rom the American College of Cardiologyi'American of low dose rivaroxaban (Option D) plus aspirin compared Heart Association :rdvocate fbr a treatment target below with aspirin alone has been associated with a significant 130/80 n.rm Hg for most patients with diabetes. l'his decrease in cardiovascular mortality (t.Z')(, vs. ).2"/,,) and patient is asymptomatic and, although her blood pressure stroke (0.7'X, vs. 1.,1'){,) but a higher incidence of gastrointes should be carelully r.r.ronitored, she can continue lisino tinal bleeding. This patient does not have an indicatior.r ft-rr pril (Option C) because her blood pressure remains well Ut low dose rivaroxaban. o controlled on current medications. ET Not recommending lurther management is inct-rr Metfbrmin (Option D) does not cause hypoglycemia rect (Option E). Adding low dose aspirin to his medica and sl.rould be continued, particularly if insulin glargine is (J tion regimen is an appropriate choice fbr this patient in to be discor.rtinued. 'lhe primary sites ol vitamin D absorption are the jeju -,E light of his high risk fbr ASCVD and acceptable bleeding r! risk. num and ileum. and deficiencies ol vitamin D and other vt (u fat soluble vitamins occur regularly after RYGB surgery. Cal 3 I(EV POI ilT . Aspirin may be considered in adults aged 40 to cium absorption is dependent on the presence of vitamin D. tUI Patients require lif'elong vitamin D and calcium supplemen 70 years who are at higher atherosclerotic cardiovas tation (Option E) alter most bariatric surgical procedures. cular disease risk and are not at increased bleeding and they sl.rouid not be discontinued. risk. I(EY POIilT5 Bibliography o At'ter bariatric surgery as patients lose weight, Arnett [)K. l]lumenthal RS. r\lbert MA. et al. 2019 ACO A tlA guidelinc 0n t he frequent reassessment of medications is required. primrr\ prevention of clnliorascular diserst: r report ol tlte Antcri('rt] College ol Cardiolog, ,\nrerican Heirrt Associirtion tirsk force on clinicill r After bariatric surgery, in patients with diabetes pructicc guidelines. Circulltion. 2019:1,10:e.596 6,16. IPMID: 308791]551 mellitus, preemptive lowering of hypoglycemic agents doi: 10. I I (rl rC1R.00000000OO000678 is recommended to prevent the development of hypoglycemia. Item 47 Answer: B Educational Objective: Manage medication for diabetes Bibliography O'Kane M. Nutritional consequences of brrirtric surgery prevention. following bariatric surgery. detection and managcmcnt. (lLlrr Opin Cxstn)entcrol. 2027:37:135 .11. IPMl t), 33332915] doi:10. 1097/MOG.O0OOO00O(XX)00707 The most appropriate medication to discontinue is insulin glargine (Option B). Weight loss is rapid during the first lbw months after bariatric surgery. Following Roux en Y gastric Item 48 Answer: B bypass (RYGB) surgery patients lose or.r average 4.5 to 7 kg Ed ucationa I Objective: Diagnose superficial fungal (10 15 lb) per month, xnd at 6 months, the average weight infections using potassium hydroxide preparation. loss is as much as 36 kg (80 lb). Weight should be monikrred closely in the early postoperative period. As patients lose A potassium hydroxide (KOH) preparation of skin scraping weight, fiequent reassessnlent of medications is required. In (Option B) is the most appropriate diagnostic test fbr this patients with diabetes r.r.rellitus, symptonrs of hypoglycemia patierlt with a superficial fungal infbction. This patier.rt has an should be sought. Because of the potential harmful eflbcts ar.rnular erythematous plaque with scale at the border, which of hypoglycemia, preen.rptive lowering or discontinuatior.r of' is characteristic of tinea corporis. The rash is likely worsening some hypoglycemic agents is recommended to prevent the because ofthe patient's use ofclobetasol, a potent topical glu devekrprlent of hypoglycen.ria. Discontinuing this patient's cocorticoid. Microscopic examination r,rf skin scrapings using bas:rl insulin now- is reasonable considering her near normal a KOH preparation is inexpensive and results are yielded fasting blood glucose levels. quickly, typically within the time lrame of the patient's visit. Patients aged 40 to 75 years with cliabetes should be 'the edge ol a glass slide or 15 blade is uscd to scrape the scale started on a moderate intensity statin. If additional athcm onto a glass slide. Two to three drops <-r1'KOH are then placed sclerotic cardiovascular disease (ASCVI)) risk f'actors are on the scale, and a coverslip is applied. l)iagnosis of'tinea is present. the Pooled Cohort Equations can be used to cal confin.ned by the presence of branching hyphae under the culate the 10 year ASCVD risk to determine whether high rnicroscope, typically at 10 or 20 power magnification, as intensity statin therapy is indicated. Because this patient shown (see top of next page).

Bibliography o At'ter bariatric surgery as patients lose weight, Arnett [)K. l]lumenthal RS. r\lbert MA. et al. 2019 ACO A tlA guidelinc 0n t he frequent reassessment of medications is required. primrr\ prevention of clnliorascular diserst: r report ol tlte Antcri('rt] College ol Cardiolog, ,\nrerican Heirrt Associirtion tirsk force on clinicill r After bariatric surgery, in patients with diabetes pructicc guidelines. Circulltion. 2019:1,10:e.596 6,16. IPMID: 308791]551 mellitus, preemptive lowering of hypoglycemic agents doi: 10. I I (rl rC1R.00000000OO000678 is recommended to prevent the development of hypoglycemia. Item 47 Answer: B Educational Objective: Manage medication for diabetes Bibliography O'Kane M. Nutritional consequences of brrirtric surgery prevention. following bariatric surgery. detection and managcmcnt. (lLlrr Opin Cxstn)entcrol. 2027:37:135 .11. IPMl t), 33332915] doi:10. 1097/MOG.O0OOO00O(XX)00707 The most appropriate medication to discontinue is insulin glargine (Option B). Weight loss is rapid during the first lbw months after bariatric surgery. Following Roux en Y gastric Item 48 Answer: B bypass (RYGB) surgery patients lose or.r average 4.5 to 7 kg Ed ucationa I Objective: Diagnose superficial fungal (10 15 lb) per month, xnd at 6 months, the average weight infections using potassium hydroxide preparation. loss is as much as 36 kg (80 lb). Weight should be monikrred closely in the early postoperative period. As patients lose A potassium hydroxide (KOH) preparation of skin scraping weight, fiequent reassessnlent of medications is required. In (Option B) is the most appropriate diagnostic test fbr this patients with diabetes r.r.rellitus, symptonrs of hypoglycemia patierlt with a superficial fungal infbction. This patier.rt has an should be sought. Because of the potential harmful eflbcts ar.rnular erythematous plaque with scale at the border, which of hypoglycemia, preen.rptive lowering or discontinuatior.r of' is characteristic of tinea corporis. The rash is likely worsening some hypoglycemic agents is recommended to prevent the because ofthe patient's use ofclobetasol, a potent topical glu devekrprlent of hypoglycen.ria. Discontinuing this patient's cocorticoid. Microscopic examination r,rf skin scrapings using bas:rl insulin now- is reasonable considering her near normal a KOH preparation is inexpensive and results are yielded fasting blood glucose levels. quickly, typically within the time lrame of the patient's visit. Patients aged 40 to 75 years with cliabetes should be 'the edge ol a glass slide or 15 blade is uscd to scrape the scale started on a moderate intensity statin. If additional athcm onto a glass slide. Two to three drops <-r1'KOH are then placed sclerotic cardiovascular disease (ASCVI)) risk f'actors are on the scale, and a coverslip is applied. l)iagnosis of'tinea is present. the Pooled Cohort Equations can be used to cal confin.ned by the presence of branching hyphae under the culate the 10 year ASCVD risk to determine whether high rnicroscope, typically at 10 or 20 power magnification, as intensity statin therapy is indicated. Because this patient shown (see top of next page). 191

Answers and Critiques Bibliography \\'insett FT. Prtcl SCi. Kelll B(i. Bedside clirgnostics li)r intections: .l guide for tlermaro)ogisrs. .\m J Clin l)ermalol. 2020:21:697 709. IP\lll): 3]5622011 tkri:10.i007 slO257 020 00526-v o Item 49 Answer: A Educational Obiective: Evaluate a breast mass in a woman younger than 30 years.

Bibliography \\'insett FT. Prtcl SCi. Kelll B(i. Bedside clirgnostics li)r intections: .l guide for tlermaro)ogisrs. .\m J Clin l)ermalol. 2020:21:697 709. IP\lll): 3]5622011 tkri:10.i007 slO257 020 00526-v o Item 49 Answer: A Educational Obiective: Evaluate a breast mass in a woman younger than 30 years. The most appropriate nlanagement is ultrirsonographl of the o8 o o 6.a ., rigl.rt breast (Option A). Although breast cancer shor'rld be considered in all patients, most breast nlitsses. particularl)' in u'omen )'ounger than 30 yeilrs, are benign conditions. D such as c1,sts. fibroadenomas, fat necrosis. or liponlas. Eral vt uation requires consideration ol breast cancer risk tactors. o = o including firmily history of breast or ovarian cancer: previ -t UI ous breast biopsies: hormonal risk iactors: and a detailed o, history of thc mass, inctuding onset. changes u'ith the men CL stmirl c1cle. irssociated symptonls. and overlf ing skin nipple rl rt changes. \\bnren )rounger than ll0 years uto present \\'ith a brcast mass should first be evaluated with breast ultrasonog 4t c(D raphy: Younger women ha.ue increased breast densi\: u'hich l^ decreases the sensitivity of mantntographl: Ultrasontlgraphl is also the preferred imiiging modaliry'in pregnant \\'omen to a'",oid radiation exposure. Breast ultrasound results are catego rized b1' Breast Imaging irnd Reporting Data Sl stem (BI RADS) criteria. Biopsf is recommended ttrr category'-1 and 5 findings. A In addition. any suspicious findings. inclucling a l.rard. fired. or heterogenous mass on clinical breast exantination (CBE). Scabies presents lr,ith lr.r extrenrely pruritic rash char should be evaluated b1'biopsll er"en if imtrging is negative. acterized by erythen.ratous papules and burrorts, ."r'hich are Diagnostic mamn.rography (Option B) is an appropriate commonly on the wrist. interdigital web spaces. axillae. ancl first test in l ltoman irged 30 )'ears or olcler u,ho presents waistline. Diagnosis is made b1' microscopic identification \\'ith a breast mass. Mantmographl mal'demclnstrate a nlass. of the mites, eggs, or feces ir.r skin scrapings prepared u ith asymmetric densiry or abnonral pleomoqtl.ric calcifications mineral oil (Option A). Scabies does not present as annullr potentially indicating breast cancer. For patients $'ith a focal plaques with scalc as seen in this patient. and testing lbr abnorrnalitl, noted on nlammofJnlm. targeted ultrasonographl' scabies is not indicated. can clariS'tl'rc size of the mass. cletermine u'hether the mass is Sl.rave biopsy (Option C) is commonly perlbrmecl t<r solid or cystic. and identify the margins as smooth or irregular. diagnose both neoplastic and inflammatory skin conditions. llouerer. this patient is 28 )€ars old. and therefore she should Shave biopsy can be perforn.red to diagnose tirrel infections. har,e a breast ultrasonography to e\aluate the right breast mass. but it is more expensive thirn KOH preparation and it mity Al1 r,r,omen presenting with a bre:lst mass should be take 1 to 2 ciays to receive results. In addition, skin biopsy has evaluated bf imaging even if their CBE lacks concerning poter.rtial morbidity; such its scarring and risk for infection. A Ieirtures. Findings on CBE ma! suggest a benign (sn.rooth. KOH examinatior.r shouid be performed first ancl. ilr-regative. n.robile. regular) process. such as seen ir.t this patient. or a a culture (preferred) or shavc biopsy could be considered. malignant (fixed. hard. heterogeneous) process. Houever. the A Wood lanrp is a handheld ultraviolet light source predictir-e value of CBE is poor. and all uomen require fur used to diagnose pigment clisorders. such as vitiligo. and tl.rer er,aluati<,rn r,r,'ith imaging ar.rd or biopsli U,'aiting 6 rveeks may also be used to diagnose the skin fluorescence seen in to perform ir repeat CBE is not the best option (Option C). erythrasma. Although Woocl lamp eramination (Option D) rr-ray be useful in diagnosing tinea capitis. it is not helpful in \o further er,irluirtion is inappropriate (Option D). Because thc patient is younger than 30 years, breast ultra diagnosing t inea tr rrporis. sonography is required to lurther er,aluate the breast mass KEY POIilTS dcspite l CBE that is relssuring. . Tinea corporis is characterized by annular erythema I(EY POIl{T5 tous plaques with scale at the border. . Ultrasonography is the pref'erred imaging modalit)'fbr o Diagnosis of tinea corporis is made by examination of evaluation of a breast mass in \\omen 1'ounger than the scale with potassium hydroxide; the presence of 30 years. branching hyphae is diagnostic. (Continued)

The most appropriate nlanagement is ultrirsonographl of the o8 o o 6.a ., rigl.rt breast (Option A). Although breast cancer shor'rld be considered in all patients, most breast nlitsses. particularl)' in u'omen )'ounger than 30 yeilrs, are benign conditions. D such as c1,sts. fibroadenomas, fat necrosis. or liponlas. Eral vt uation requires consideration ol breast cancer risk tactors. o = o including firmily history of breast or ovarian cancer: previ -t UI ous breast biopsies: hormonal risk iactors: and a detailed o, history of thc mass, inctuding onset. changes u'ith the men CL stmirl c1cle. irssociated symptonls. and overlf ing skin nipple rl rt changes. \\bnren )rounger than ll0 years uto present \\'ith a brcast mass should first be evaluated with breast ultrasonog 4t c(D raphy: Younger women ha.ue increased breast densi\: u'hich l^ decreases the sensitivity of mantntographl: Ultrasontlgraphl is also the preferred imiiging modaliry'in pregnant \\'omen to a'",oid radiation exposure. Breast ultrasound results are catego rized b1' Breast Imaging irnd Reporting Data Sl stem (BI RADS) criteria. Biopsf is recommended ttrr category'-1 and 5 findings. A In addition. any suspicious findings. inclucling a l.rard. fired. or heterogenous mass on clinical breast exantination (CBE). Scabies presents lr,ith lr.r extrenrely pruritic rash char should be evaluated b1'biopsll er"en if imtrging is negative. acterized by erythen.ratous papules and burrorts, ."r'hich are Diagnostic mamn.rography (Option B) is an appropriate commonly on the wrist. interdigital web spaces. axillae. ancl first test in l ltoman irged 30 )'ears or olcler u,ho presents waistline. Diagnosis is made b1' microscopic identification \\'ith a breast mass. Mantmographl mal'demclnstrate a nlass. of the mites, eggs, or feces ir.r skin scrapings prepared u ith asymmetric densiry or abnonral pleomoqtl.ric calcifications mineral oil (Option A). Scabies does not present as annullr potentially indicating breast cancer. For patients $'ith a focal plaques with scalc as seen in this patient. and testing lbr abnorrnalitl, noted on nlammofJnlm. targeted ultrasonographl' scabies is not indicated. can clariS'tl'rc size of the mass. cletermine u'hether the mass is Sl.rave biopsy (Option C) is commonly perlbrmecl t<r solid or cystic. and identify the margins as smooth or irregular. diagnose both neoplastic and inflammatory skin conditions. llouerer. this patient is 28 )€ars old. and therefore she should Shave biopsy can be perforn.red to diagnose tirrel infections. har,e a breast ultrasonography to e\aluate the right breast mass. but it is more expensive thirn KOH preparation and it mity Al1 r,r,omen presenting with a bre:lst mass should be take 1 to 2 ciays to receive results. In addition, skin biopsy has evaluated bf imaging even if their CBE lacks concerning poter.rtial morbidity; such its scarring and risk for infection. A Ieirtures. Findings on CBE ma! suggest a benign (sn.rooth. KOH examinatior.r shouid be performed first ancl. ilr-regative. n.robile. regular) process. such as seen ir.t this patient. or a a culture (preferred) or shavc biopsy could be considered. malignant (fixed. hard. heterogeneous) process. Houever. the A Wood lanrp is a handheld ultraviolet light source predictir-e value of CBE is poor. and all uomen require fur used to diagnose pigment clisorders. such as vitiligo. and tl.rer er,aluati<,rn r,r,'ith imaging ar.rd or biopsli U,'aiting 6 rveeks may also be used to diagnose the skin fluorescence seen in to perform ir repeat CBE is not the best option (Option C). erythrasma. Although Woocl lamp eramination (Option D) rr-ray be useful in diagnosing tinea capitis. it is not helpful in \o further er,irluirtion is inappropriate (Option D). Because thc patient is younger than 30 years, breast ultra diagnosing t inea tr rrporis. sonography is required to lurther er,aluate the breast mass KEY POIilTS dcspite l CBE that is relssuring. . Tinea corporis is characterized by annular erythema I(EY POIl{T5 tous plaques with scale at the border. . Ultrasonography is the pref'erred imaging modalit)'fbr o Diagnosis of tinea corporis is made by examination of evaluation of a breast mass in \\omen 1'ounger than the scale with potassium hydroxide; the presence of 30 years. branching hyphae is diagnostic. (Continued) 192

Answers and Critiques f,EY POaXTS (wdnwdl vasculitis, which burn and sting and with individual wheals . All women presenting with a breast mass should be persisting longer than 24 hours. Angioedema (Option B) is a transient, Iocalized subcu evaluated by imaging even if their clinical breast taneous or submucosal form ofurticaria caused by extrav- examination is without concerning features. asation of fluid into interstitial tissues. Angioedema may occur with or without urticaria and can be a component Bibliography of anaphylaxis. The margins of the affected areas are often Moy L, Heller SL, Bailey L, et al; Expert Panel on Breast Imaging. ACR Appropriateness Criteria- palpable breast masses. J Am Coll Radiol. indistinct, and the skin may be a normal hue or faintly pink. 2017;14:S203 24. [PMID: 28473077] doi:10.1016/j.jacr.2017.02.033 The localized swelling, indistinct margins, and normal or faint color of angioedema are distinct from the flndings in urticaria. Item 50 Answer: D Urticarial drug reaction (Option C) is an unlikely diag Ed ucationa I O bjective : Diagnose urticarial vasculitis. nosis, given that this patient has no history of new medi- t,t o cations with the exception of acetaminophen, which was The most likely diagnosis is urticarial vasculitis (Option D), EF initiated after she developed systemic symptoms from the which is characterized by individual urticarial lesions lasting urticarial vasculitis. frt longer than 24 hours; symptoms of burning and stinging tE, more common than itch; wheals that resolve with hyperpig TEY POITIS .E mentation (as shown); and associated systemic symptoms, o Urticarial vasculitis is characterized by urticarial UI such as fever and joint pain. lesions that last longer than 24 hours and that burn c, and sting rather than itch; wheals that resolve with tt = hyperpigmentation; and associated systemic symp- toms, such as fever and joint pain. . If urticarial vasculitis is suspected, skin biopsy is helpful diagnostical ly.

f,EY POaXTS (wdnwdl vasculitis, which burn and sting and with individual wheals . All women presenting with a breast mass should be persisting longer than 24 hours. Angioedema (Option B) is a transient, Iocalized subcu evaluated by imaging even if their clinical breast taneous or submucosal form ofurticaria caused by extrav- examination is without concerning features. asation of fluid into interstitial tissues. Angioedema may occur with or without urticaria and can be a component Bibliography of anaphylaxis. The margins of the affected areas are often Moy L, Heller SL, Bailey L, et al; Expert Panel on Breast Imaging. ACR Appropriateness Criteria- palpable breast masses. J Am Coll Radiol. indistinct, and the skin may be a normal hue or faintly pink. 2017;14:S203 24. [PMID: 28473077] doi:10.1016/j.jacr.2017.02.033 The localized swelling, indistinct margins, and normal or faint color of angioedema are distinct from the flndings in urticaria. Item 50 Answer: D Urticarial drug reaction (Option C) is an unlikely diag Ed ucationa I O bjective : Diagnose urticarial vasculitis. nosis, given that this patient has no history of new medi- t,t o cations with the exception of acetaminophen, which was The most likely diagnosis is urticarial vasculitis (Option D), EF initiated after she developed systemic symptoms from the which is characterized by individual urticarial lesions lasting urticarial vasculitis. frt longer than 24 hours; symptoms of burning and stinging tE, more common than itch; wheals that resolve with hyperpig TEY POITIS .E mentation (as shown); and associated systemic symptoms, o Urticarial vasculitis is characterized by urticarial UI such as fever and joint pain. lesions that last longer than 24 hours and that burn c, and sting rather than itch; wheals that resolve with tt = hyperpigmentation; and associated systemic symp- toms, such as fever and joint pain. . If urticarial vasculitis is suspected, skin biopsy is helpful diagnostical ly. Bibliography Davis MD, van der Hilst JC. Mimickers of urticaria: urticarial vasculitis and autoinflammatory diseases. J Allerry Clin Immunol Pract. 2018; 6:1762-70. IPMID: 298717971 doi:10.1016/j.jaip.2o18.05.006

Bibliography Davis MD, van der Hilst JC. Mimickers of urticaria: urticarial vasculitis and autoinflammatory diseases. J Allerry Clin Immunol Pract. 2018; 6:1762-70. IPMID: 298717971 doi:10.1016/j.jaip.2o18.05.006 Item 51 Answer: D Educational Objective: Treat erectile dysfunction in a patient with coronary artery disease. When urticarial vasculitis is accompanied by decreased semm complement (C3 or C4), it is classifled as The most appropriate management is oral sildenafll (Option hypocomplementemic urticarial vasculitis; these cases are D). Ihis patient with erectile dysfunction (ED) has a history strongly associated with systemic lupus erythematosus and of previously revascularized coronary artery disease. He is glomerulonephritis. The cause of urticaria is investigated currently without cardiovascular symptoms and exercises primarily by history and physical examination. Diagnostic regularly. According to the Third Princeton Consensus Con- evaluation for urticaria is not recommended unless history ference guidelines on the safety of ED treatment in patients suggests a speciflc cause. If symptoms persist, laboratory with cardiovascular disease, this patient is low risk and can tests, including a complete blood count with differential, be treated pharmacologically. Phosphodiesterase-S (PDE 5) urinalysis, ery.throcyte sedimentation rate or C reactive inhibitors, such as sildenafll, tadalafll, and vardenafll, are protein, thyroid-stimulating hormone, and liver chem- flrst-line pharmacotherapy for ED. All PDE-S inhibitors have istry tests, can be considered. If associated with systemic similar efficacy and are FDA approved for on-demand use. symptoms or suspicion of urticarial vasculitis, skin biopsy Tadalafll, which has a long halfJife, is also FDA approved for is helpful. daily use. It is essential to instruct patients who are prescribed Typical urticaria lesions itch and are transient, and PDE 5 inhibitors on proper use: The medication should be wheals appear and disappear within minutes to a few hours. taken 30 to 60 minutes before sexual activity, and efficacy Although individual urticarial lesions should resolve in less may be decreased if taken after consumption of a high-fat than 24 hours, recurrent crops of hives may last for weeks. meal. PDE-S inhibitors should not be prescribed to patients Most cases of urticaria resolve spontaneously, and the cause on nitrates because of the risk for hypotension. Similarly, they is never determined (idiopathic). If the episodes last longer should be used with caution in the setting of concomitant than 6 weeks, the condition is classifled as chronic (Option cr-blocker therapy. All patients with ED should also be coun A). the features ofchronic idiopathic urticaria are inconsis- seled on exercising regularly, minimizing stress, losing weight tent with this patient's urticarial vasculitis, a small vessel if overweight, and smoking cessation.

Item 51 Answer: D Educational Objective: Treat erectile dysfunction in a patient with coronary artery disease. When urticarial vasculitis is accompanied by decreased semm complement (C3 or C4), it is classifled as The most appropriate management is oral sildenafll (Option hypocomplementemic urticarial vasculitis; these cases are D). Ihis patient with erectile dysfunction (ED) has a history strongly associated with systemic lupus erythematosus and of previously revascularized coronary artery disease. He is glomerulonephritis. The cause of urticaria is investigated currently without cardiovascular symptoms and exercises primarily by history and physical examination. Diagnostic regularly. According to the Third Princeton Consensus Con- evaluation for urticaria is not recommended unless history ference guidelines on the safety of ED treatment in patients suggests a speciflc cause. If symptoms persist, laboratory with cardiovascular disease, this patient is low risk and can tests, including a complete blood count with differential, be treated pharmacologically. Phosphodiesterase-S (PDE 5) urinalysis, ery.throcyte sedimentation rate or C reactive inhibitors, such as sildenafll, tadalafll, and vardenafll, are protein, thyroid-stimulating hormone, and liver chem- flrst-line pharmacotherapy for ED. All PDE-S inhibitors have istry tests, can be considered. If associated with systemic similar efficacy and are FDA approved for on-demand use. symptoms or suspicion of urticarial vasculitis, skin biopsy Tadalafll, which has a long halfJife, is also FDA approved for is helpful. daily use. It is essential to instruct patients who are prescribed Typical urticaria lesions itch and are transient, and PDE 5 inhibitors on proper use: The medication should be wheals appear and disappear within minutes to a few hours. taken 30 to 60 minutes before sexual activity, and efficacy Although individual urticarial lesions should resolve in less may be decreased if taken after consumption of a high-fat than 24 hours, recurrent crops of hives may last for weeks. meal. PDE-S inhibitors should not be prescribed to patients Most cases of urticaria resolve spontaneously, and the cause on nitrates because of the risk for hypotension. Similarly, they is never determined (idiopathic). If the episodes last longer should be used with caution in the setting of concomitant than 6 weeks, the condition is classifled as chronic (Option cr-blocker therapy. All patients with ED should also be coun A). the features ofchronic idiopathic urticaria are inconsis- seled on exercising regularly, minimizing stress, losing weight tent with this patient's urticarial vasculitis, a small vessel if overweight, and smoking cessation. 193

Answers and Critiques According to the Third Princeton Consensus Conference to cardiovascular risk. The eIlect ol artificial sweeteners guidelines, cardiac testing, such as an ECG (Option A) or an on health is uncertain. Some studies indicate that artificial exercise stress test (Option B), is not required for patients sweeteners may cause weight gain and have effects on bowel at low cardiovascular risk befbre initiating pharmacologic health and the gut n.ricrobiome. Although artificial sweet therapy fbr ED. This patient has Iow cardiovascular risk, and eners have been associated with increased risk for cancer cardiac testing is therefbre not warranted. in animal models. the association has not been fbund in Acc<-rrding to the 2018 American Urological Associa humans. Artiflcially sweetened beverages are often recom tion guideline statement, all patients with ED should have mended as a transition from sugar sweetened beverages to an early morning serum total testosterone measurement water and can also decrease dental caries in these cases. (Option C). This patient's early morning testosterone level is this patient's once weekly consumption of red n.reat normal. There is no role fbr testosterone supplementation in (Option C) is unlikely to be a significant contributor to patients with ED who are not androgen deficient. cardiovascular risk. Many studies have shown that liequent D XEY POIXIS consumption of red meat results in a modest increased risk ta for cancer; diabetes; cardiovascular disease: and. in some E (D . Phosphodiesterase-S inhibitors, such as sildenafil, studies, mortality. Efl'ect sizes are generally small and incon Ut tadalafil, and vardenafil, are considered first-line sistent, and no randomized controlled trial data conflrm this. o, pharmacotherapy fbr erectile dysfunction and can be This patient's red meat consumption is quite minimal and is CL used by patients with known cardiovascular disease unlikely to contribute to cardiovascular risk. n after assessment of cardiovascular risk. XEV POITT lt . Phosphodiesterase-s inhibitors should not be pre- o Evidence supports that loneliness and social isolation o la scribed to patients on nitrates because ofthe risk fbr are significant risk factors for cardiovascular disease hypotension and should be used with caution in the and death. setting of concomitant a-blocker therapy.

According to the Third Princeton Consensus Conference to cardiovascular risk. The eIlect ol artificial sweeteners guidelines, cardiac testing, such as an ECG (Option A) or an on health is uncertain. Some studies indicate that artificial exercise stress test (Option B), is not required for patients sweeteners may cause weight gain and have effects on bowel at low cardiovascular risk befbre initiating pharmacologic health and the gut n.ricrobiome. Although artificial sweet therapy fbr ED. This patient has Iow cardiovascular risk, and eners have been associated with increased risk for cancer cardiac testing is therefbre not warranted. in animal models. the association has not been fbund in Acc<-rrding to the 2018 American Urological Associa humans. Artiflcially sweetened beverages are often recom tion guideline statement, all patients with ED should have mended as a transition from sugar sweetened beverages to an early morning serum total testosterone measurement water and can also decrease dental caries in these cases. (Option C). This patient's early morning testosterone level is this patient's once weekly consumption of red n.reat normal. There is no role fbr testosterone supplementation in (Option C) is unlikely to be a significant contributor to patients with ED who are not androgen deficient. cardiovascular risk. Many studies have shown that liequent D XEY POIXIS consumption of red meat results in a modest increased risk ta for cancer; diabetes; cardiovascular disease: and. in some E (D . Phosphodiesterase-S inhibitors, such as sildenafil, studies, mortality. Efl'ect sizes are generally small and incon Ut tadalafil, and vardenafil, are considered first-line sistent, and no randomized controlled trial data conflrm this. o, pharmacotherapy fbr erectile dysfunction and can be This patient's red meat consumption is quite minimal and is CL used by patients with known cardiovascular disease unlikely to contribute to cardiovascular risk. n after assessment of cardiovascular risk. XEV POITT lt . Phosphodiesterase-s inhibitors should not be pre- o Evidence supports that loneliness and social isolation o la scribed to patients on nitrates because ofthe risk fbr are significant risk factors for cardiovascular disease hypotension and should be used with caution in the and death. setting of concomitant a-blocker therapy. Bibliography Bibliography Hakulinen C. Pulkki Raback L, Virtanen M, et xl. Social isolation and loneli Burnett AL, Nchra A, Breau RI l. ct al. Erectile dysfunction: AUA guidrline. J ness ls risk lactors lbr nryocardial infarction, stroke and mortality: UK Urol. 2018:200:633 41. I PM l l): 29746858] doi: l0. l0l6ij.juro.20l8.0s.oo4 tsiobank cohort study o1 ,179 05.1 men and women. I leart. 2018:104:1536 42. I l'}M ll): 295883291 doi: 10.1136, heartjnl 2017 l]12663

Bibliography Bibliography Hakulinen C. Pulkki Raback L, Virtanen M, et xl. Social isolation and loneli Burnett AL, Nchra A, Breau RI l. ct al. Erectile dysfunction: AUA guidrline. J ness ls risk lactors lbr nryocardial infarction, stroke and mortality: UK Urol. 2018:200:633 41. I PM l l): 29746858] doi: l0. l0l6ij.juro.20l8.0s.oo4 tsiobank cohort study o1 ,179 05.1 men and women. I leart. 2018:104:1536 42. I l'}M ll): 295883291 doi: 10.1136, heartjnl 2017 l]12663 Item 52 Answer: D Educational Objective: Evaluate social isolation as risk factor for cardiovascular disease. Item 53 Answer: D Educational Objective: Diagnose retinal detachment. tr In addition to the patient's age, sex, and hypertension, a The nrost likely diagr.ursis is retinal cletachment (Option D). contributing Iactor fbr tuture cardiovascular disease ir.r this which is causing a painless visual fielcl defbct. Hcr syntlt patient is scicial isolation (Option D). Tl.rere is increasing evi toms ol visual loss. Ilashing lights, and floaters should raise dence supporting loneliness and specifically social isolation suspicion fbr this diagnosis, which can be conflrmecl by ln as risk lactors for cardiovascular disease and death. A study ophthalmologist using indirect ophthalmoscopy or rvide field of over 450,000 patients demonstrated that social isolation retinal photography Indirect ophthalnroscopy using a cor.t was associated with a 1.43 (957, CI, 1.3 1.55) increased risk densing lens provides the ophthahnologist a u,ide field ot for incident acute myocardial infarction (AMI) and 1.39 (95'1, vision ot the retina and three'dimensional viert's showing ele' CI, 1.25 1.54) increased risk for stroke. Some, but not all, of valirin ancl depth. Bccluse retinal detachn.rent typically occurs these eflbcts were attenuated by correction for traditional risk f'ar into the periphery. oftice-based direct ophthalmoscopy factors lbr cardiovascular disease and stroke. Social isolation lvill likely be normal or ilt least nondiagnostic. Floaters ma1' was also associated with a 25'7, increase in n-rortality after AMI be clescribed by patients as a -cobr,rcb" and represent accon.r and a 32'X, increase in nrortality after stroke. par.rying posterior vitreous detachment (PVD). This patient this patient's level of'alcohol consumption (Option A) likely developed a PVt) in the days preceding her presen is considered lower risk. The 2020 Dietary Guidelines indi tation, which led to a retinal tear. I,lashing lights represent cate that irdults should limit consumption of alcohol to no vitreoretinal attachments stimulating retinal depolarization more than one drink per day for nonpregnant women and as they pull anay'fionr the retina. l-xrger retinal detachnlents two drinks per day fbr men. Studies have shown that this causc rrore severe visual disturbances. Risk factors ftrr retinal amount of alcohol consumption may reduce the risk fbr Ml. detachnrent include increasing age, nryopia. and recent cat However, it is generally agreed that individuals who prefer aract surgery. This patient requires imrnediate ophthalnrol- not to drink alcohol should not initiate alcohol consumption ogr referral for diagnosis and treatment to prevent thrthcr for the purposes of cardiovascular risk reduction. vision krss. This patient's consumption ot' artificially sweetened Age related macular degeneration (AMD) (Option A) is soda (Option B) is unlikely to be a significant contributor often lsymptomatic in its earliest stages. I)ry AMD typically

Item 52 Answer: D Educational Objective: Evaluate social isolation as risk factor for cardiovascular disease. Item 53 Answer: D Educational Objective: Diagnose retinal detachment. tr In addition to the patient's age, sex, and hypertension, a The nrost likely diagr.ursis is retinal cletachment (Option D). contributing Iactor fbr tuture cardiovascular disease ir.r this which is causing a painless visual fielcl defbct. Hcr syntlt patient is scicial isolation (Option D). Tl.rere is increasing evi toms ol visual loss. Ilashing lights, and floaters should raise dence supporting loneliness and specifically social isolation suspicion fbr this diagnosis, which can be conflrmecl by ln as risk lactors for cardiovascular disease and death. A study ophthalmologist using indirect ophthalmoscopy or rvide field of over 450,000 patients demonstrated that social isolation retinal photography Indirect ophthalnroscopy using a cor.t was associated with a 1.43 (957, CI, 1.3 1.55) increased risk densing lens provides the ophthahnologist a u,ide field ot for incident acute myocardial infarction (AMI) and 1.39 (95'1, vision ot the retina and three'dimensional viert's showing ele' CI, 1.25 1.54) increased risk for stroke. Some, but not all, of valirin ancl depth. Bccluse retinal detachn.rent typically occurs these eflbcts were attenuated by correction for traditional risk f'ar into the periphery. oftice-based direct ophthalmoscopy factors lbr cardiovascular disease and stroke. Social isolation lvill likely be normal or ilt least nondiagnostic. Floaters ma1' was also associated with a 25'7, increase in n-rortality after AMI be clescribed by patients as a -cobr,rcb" and represent accon.r and a 32'X, increase in nrortality after stroke. par.rying posterior vitreous detachment (PVD). This patient this patient's level of'alcohol consumption (Option A) likely developed a PVt) in the days preceding her presen is considered lower risk. The 2020 Dietary Guidelines indi tation, which led to a retinal tear. I,lashing lights represent cate that irdults should limit consumption of alcohol to no vitreoretinal attachments stimulating retinal depolarization more than one drink per day for nonpregnant women and as they pull anay'fionr the retina. l-xrger retinal detachnlents two drinks per day fbr men. Studies have shown that this causc rrore severe visual disturbances. Risk factors ftrr retinal amount of alcohol consumption may reduce the risk fbr Ml. detachnrent include increasing age, nryopia. and recent cat However, it is generally agreed that individuals who prefer aract surgery. This patient requires imrnediate ophthalnrol- not to drink alcohol should not initiate alcohol consumption ogr referral for diagnosis and treatment to prevent thrthcr for the purposes of cardiovascular risk reduction. vision krss. This patient's consumption ot' artificially sweetened Age related macular degeneration (AMD) (Option A) is soda (Option B) is unlikely to be a significant contributor often lsymptomatic in its earliest stages. I)ry AMD typically 194

L t l Answers and Critiques L t t tr CONT. presents with gradual onset of vision loss that is most notice- able when driving or with a scotoma (blind spot). Wet AMD can present acutely with change or loss in central vision show absence of melanocytes. Treatment can be challeng- ing and prolonged, with suboptimal results. Potent topical glucocorticoids, topical calcineurin inhibitors (tacrolimus or t resulting from subretinal swelling and hemorrhage. Neither pimecrolimus), and phototherapy are common treatments. t is typically associated with flashing lights or floaters. Repigmentation often occurs first in perifollicular areas (as Patients with central retinal artery occlusion (CRAO) shown). t (Option B) present with abrupt, painless vision loss in one f eye. The vision loss is profound, and afiected patients can typically visualize only gross movements, although there L may be a small area of vision in the temporal field. A com- t plete or relative afferent pupillary defbct is present, and L funduscopic examination will reveal retinal paleness due to t ischemic changes. These lindings are absent in this patient. tl(l, CRAO is most commonly associated with ipsilateral carotid t artery atherosclerotic disease. ET

t t tr CONT. presents with gradual onset of vision loss that is most notice- able when driving or with a scotoma (blind spot). Wet AMD can present acutely with change or loss in central vision show absence of melanocytes. Treatment can be challeng- ing and prolonged, with suboptimal results. Potent topical glucocorticoids, topical calcineurin inhibitors (tacrolimus or t resulting from subretinal swelling and hemorrhage. Neither pimecrolimus), and phototherapy are common treatments. t is typically associated with flashing lights or floaters. Repigmentation often occurs first in perifollicular areas (as Patients with central retinal artery occlusion (CRAO) shown). t (Option B) present with abrupt, painless vision loss in one f eye. The vision loss is profound, and afiected patients can typically visualize only gross movements, although there L may be a small area of vision in the temporal field. A com- t plete or relative afferent pupillary defbct is present, and L funduscopic examination will reveal retinal paleness due to t ischemic changes. These lindings are absent in this patient. tl(l, CRAO is most commonly associated with ipsilateral carotid t artery atherosclerotic disease. ET Patients with central retinal vein occlusion (CRVO) i (Option C) present with sudden onset of unilateral vision L' .E, i

Patients with central retinal vein occlusion (CRVO) i (Option C) present with sudden onset of unilateral vision L' .E, i t loss. On examination, an allerent pupillary defect may be = .E present. The most common funduscopic findings are scat t^ i tered, ditfuse retinal hemorrhages sometimes accompanied o by optic disc edema, none of which are present in this tt = patient. Most commonly, CRVO is due to primary thrombus fbrmati<-rn. Risk flactors include increasing age, hypertension, tobacco use, and diabetes mellitus.

t loss. On examination, an allerent pupillary defect may be = .E present. The most common funduscopic findings are scat t^ i tered, ditfuse retinal hemorrhages sometimes accompanied o by optic disc edema, none of which are present in this tt = patient. Most commonly, CRVO is due to primary thrombus fbrmati<-rn. Risk flactors include increasing age, hypertension, tobacco use, and diabetes mellitus. o Retinal detachment is an ocular emergency that causes painless vision loss, unilateral flashing lights, floaters, and visual field defect. . Retinal detachment is confirmed by indirect ophthal- moscopy or wide-field retinal photo$aphy by an ophthalmologist. Vitiligo is associated with several autoimmune diseases, Bibliography with autoimmune thyroid disease being the most common, Kwok JM, Yu CW, Christakis PG. Retinal detachment. CMAJ. 2020;792:8312. present in about 20% of patients. Both Hashimoto thyroid- IPMID: 323925141 doi:10.1503/cmaj.191337 itis and Graves disease are associated with vitiligo and risk increases with age. Other autoimmune disorders associated with vitiligo include alopecia areata, type 1 diabetes mellitus, Item 54 Answer: D pernicious anemia, rheumatoid arthritis, and polyglandu- lar autoimmune syndrome. Additional autoantibody testing Educational Objective: Evaluate for thyroid disease in a may be reasonable based on the patient's personal and fam- patient with vitiligo. ily history. Thyroid-stimulating hormone measurement (Option D) Antinuclear antibody (ANA) tests (Option A) are often should be obtained next to assess this patient's skin flnd positive in patients with vitiligo. However, ANA testing ings. this patient has vitiligo, an autoimmune skin condi- should be performed only if the patient's clinical presenta- tion characterized by depigmented patches due to loss of tion is suggestive of systemic lupus erythematosus or other function or absence of melanocy'tes. Its onset is insidious systemic connective tissue disease. This patient has no other and asymptomatic, starting as smaller macules that gradually symptoms of connective tissue disease, and ANA, even if enlarge. It tends to be more visible in persons with darker skin positive, will not be helpful diagnostically. types or in sun exposed areas, as the surrounding skin with Hepatitis C virus infection (Option B) is associated with preserved and functional melanocltes becomes darker with some cutaneous diseases, such as lichen planus, porphyria sun exposure. Vitiligo can be diagnosed clinically and pre- cutanea tarda, and leukocytoclastic vasculitis; however, it is sents as depigmented, well demarcated symmetric macules not associated with vitiligo. Universal screening for hepatitis or patches without scale that appear most commonly on the C is recommended for all adults aged 18 to 79 years. hands, extensor surfaces, and perioriflcial areas. Wood lamp HIV infection (Option C) is associated with conditions examination showing intense whiteness can help conflrm such as pruritus, molluscum contagiosum, and seborrheic the diagnosis. Skin biopsies are often unnecessary but will dermatitis; however, HIV is not associated with vitiligo.

o Retinal detachment is an ocular emergency that causes painless vision loss, unilateral flashing lights, floaters, and visual field defect. . Retinal detachment is confirmed by indirect ophthal- moscopy or wide-field retinal photo$aphy by an ophthalmologist. Vitiligo is associated with several autoimmune diseases, Bibliography with autoimmune thyroid disease being the most common, Kwok JM, Yu CW, Christakis PG. Retinal detachment. CMAJ. 2020;792:8312. present in about 20% of patients. Both Hashimoto thyroid- IPMID: 323925141 doi:10.1503/cmaj.191337 itis and Graves disease are associated with vitiligo and risk increases with age. Other autoimmune disorders associated with vitiligo include alopecia areata, type 1 diabetes mellitus, Item 54 Answer: D pernicious anemia, rheumatoid arthritis, and polyglandu- lar autoimmune syndrome. Additional autoantibody testing Educational Objective: Evaluate for thyroid disease in a may be reasonable based on the patient's personal and fam- patient with vitiligo. ily history. Thyroid-stimulating hormone measurement (Option D) Antinuclear antibody (ANA) tests (Option A) are often should be obtained next to assess this patient's skin flnd positive in patients with vitiligo. However, ANA testing ings. this patient has vitiligo, an autoimmune skin condi- should be performed only if the patient's clinical presenta- tion characterized by depigmented patches due to loss of tion is suggestive of systemic lupus erythematosus or other function or absence of melanocy'tes. Its onset is insidious systemic connective tissue disease. This patient has no other and asymptomatic, starting as smaller macules that gradually symptoms of connective tissue disease, and ANA, even if enlarge. It tends to be more visible in persons with darker skin positive, will not be helpful diagnostically. types or in sun exposed areas, as the surrounding skin with Hepatitis C virus infection (Option B) is associated with preserved and functional melanocltes becomes darker with some cutaneous diseases, such as lichen planus, porphyria sun exposure. Vitiligo can be diagnosed clinically and pre- cutanea tarda, and leukocytoclastic vasculitis; however, it is sents as depigmented, well demarcated symmetric macules not associated with vitiligo. Universal screening for hepatitis or patches without scale that appear most commonly on the C is recommended for all adults aged 18 to 79 years. hands, extensor surfaces, and perioriflcial areas. Wood lamp HIV infection (Option C) is associated with conditions examination showing intense whiteness can help conflrm such as pruritus, molluscum contagiosum, and seborrheic the diagnosis. Skin biopsies are often unnecessary but will dermatitis; however, HIV is not associated with vitiligo. 195

Answers and Critiques Universal screening for HIV infection is recommended for in healthy populations; however, testing for deficiency is adolescents and adults aged 15 to 65 years. appropriate in groups at high risk or in patients presenting with low bone mass, fractures, hypocalcemia, or hyper f,tY POtllT parathyroidism. This patient has not met an indication for o Vitiligo, an autoimmune skin condition characterized vitamin D measurement (Option D). by depigmented patches, is associated with autoim- I(EY POITI mune thyroid disease; thyroid-stimulating hormone measurement should be performed at time of diagnosis. . The U.S. Preventive Services Task Force recommends screening for osteoporosis in all women aged 65 years Bibliography or older and in women younger than 65 years who are 'Iaieb A, Alomar A, Bohm M, et al; Vitiligo European Task Force (VETF). at increased risk for osteoporosis, as determined by a Guidelines for the management of vitiligo: the European Dermatolory formal clinical risk assessment tool. Forum consensus. Br J Dermatol. 2013;168:5 19. [PMID: 228606211 D doi:10.1111/j.1365 2133.2012.11197.x Ut Bibliography € (D Curry SJ, Krist AH. Owens DK, et al; US Preventive Services'lhsk Force. Screening fbr osteoporosis to prevent I'ractures: US Preventive Services l,t Item 55 Answer: A Task Force recommendation statement. JAMA. 2018:319:2521 31. IPMID: o, 299 467 351 doi:10. I 001 /iama.20l 8.7498 TL Educational Objective: Assess fracture risk in a woman n at high risk for osteoporosis.

Universal screening for HIV infection is recommended for in healthy populations; however, testing for deficiency is adolescents and adults aged 15 to 65 years. appropriate in groups at high risk or in patients presenting with low bone mass, fractures, hypocalcemia, or hyper f,tY POtllT parathyroidism. This patient has not met an indication for o Vitiligo, an autoimmune skin condition characterized vitamin D measurement (Option D). by depigmented patches, is associated with autoim- I(EY POITI mune thyroid disease; thyroid-stimulating hormone measurement should be performed at time of diagnosis. . The U.S. Preventive Services Task Force recommends screening for osteoporosis in all women aged 65 years Bibliography or older and in women younger than 65 years who are 'Iaieb A, Alomar A, Bohm M, et al; Vitiligo European Task Force (VETF). at increased risk for osteoporosis, as determined by a Guidelines for the management of vitiligo: the European Dermatolory formal clinical risk assessment tool. Forum consensus. Br J Dermatol. 2013;168:5 19. [PMID: 228606211 D doi:10.1111/j.1365 2133.2012.11197.x Ut Bibliography € (D Curry SJ, Krist AH. Owens DK, et al; US Preventive Services'lhsk Force. Screening fbr osteoporosis to prevent I'ractures: US Preventive Services l,t Item 55 Answer: A Task Force recommendation statement. JAMA. 2018:319:2521 31. IPMID: o, 299 467 351 doi:10. I 001 /iama.20l 8.7498 TL Educational Objective: Assess fracture risk in a woman n at high risk for osteoporosis. lr .D UI The most appropriate next step is to assess fracture risk with a clinical assessment tool (Option A). The U.S. Preventive Services Task Force (USPSTF) recommends screening for oste- Item 56 Answer: C Ed u catio na I O bjective: Manage warfarin anticoagulation tr in the perioperative period. oporosis in all women aged 65 years or older and in women younger than 65 years who are at increased risk for osteopo The most appropriate perioperative management of this rosis, as determined by a formal clinical risk assessment tool. patient's warlarin is to withhold warfarin .5 days prior to This patient presents with several risk factors for osteoporosis suryery anci to restart in 12 to 2.1 hours aftcr suryery (Option C). and, most important, bone fracture. This patient's risk factors Wartarin shoulcl be withheld a ntinitnum <tf 5 days befbre include low body weight (BMI of 21), cigarette smoking, and surgery to nornulize the patient's INR. I he timing rll narlarin family history of hip fracture. The Fracture Risk Assessment discontinuatirin is based on its 116' to 42 hour hal{'lifb and (FRAX) is a commonly used clinical risk assessment tool clinicai studies docuntenting the time lbr thc INR to return (available at ww w.shef.ac.uk/FRAX). Women with a 10 year to normal tbllowing cliscontinuation. In general, 2 to 3 days FRAX risk for major osteoporotic fracture equal to or higher are required fbr the INR kr clrop belou'2 ancl .4 to 6 days fbr than that of a 65 year old White woman without additional the INR to nomrirlizc. Somc physicians obtain an INR on clay risk factors (10 year risk of 8.4'1,) should undergo screen- .1 and intcn'ene u,ith vitanrir-r K supplementation if necessary ing for osteoporosis. Screening can be accomplished with for persistentlv elevated INRs. Postoperative re initiation of bone mineral density (BMD) measurement, most commonly anticoagulation shoukl be guidecl by'the patient's thrombotic with dual-energr x ray absorptiometry of the hip and lumbar and bleeding risk and cleterrninecl in collaboratirm with the spine. surgical team. Owing to i1s delayed eftbct. the first dose of BMD measurement (Option B) is not indicated in this r,rartlrin is typically rrdn.rinistered 12 ttl')4 hours alter surgery. patient unless a fracture risk assessment with a formal risk pencling adequate henrostasis ancl barring any surgical con.t assessment tool (e.g., FRAX) indicates an increased risk for plicutions that rnay increase the risk firr bleedir-rg. It usually fracture. takcs 5 to 6 days to achieve a therapeutic INR. The U.S. National Osteoporosis Foundation recommends Withholding wartarin f'ur only 2 days prior to surgery pharmacologic treatment for patients with osteoporosis- (Option A) increascs the risk firr surgical bleedittg or,r'ittg related hip or spine fracturesl those with a BMD T-score of to the long hall life of wirrfarin. Many paticnts r,vould har,e -2.5 or less; and those with a BMD T score between -1 and an INR ol lpprorimltely 2 lbllou,ing only 2 clal's ol warfarin 2.5 with a 10 year risk of 3'l" or greater for hip fracture or discontinuation. Starting wart'arin 2 or 5 days after surgery 20'1, risk or greater for major osteoporosis-related fracture (Option I)) is unneccssarily delaycd, considering 5 to 6 duys as estimated by the FRAX tool. This patient has yet to meet are requireci lbr fLll rrnticoagulation. an indication for treatment with a bisphosphonate, such as Withholding wurfarin lbr .5 days ar.rcl bridging n,ith alendronate (Option C). lorv molecular g,eigfit heparin (Option B) is not ir.rdicated The National Academy of Medicine recommends cal because this may increase bleeding risk r,rdtl.rout of icring any cium intake of 1000 to 1200 mg/d, ideally from dietary adclitional lntithr-ombotic bcnefits in the perioperatire period. sources. A calcium supplement may be used for patients This ilaticnt has a CI IATDS, VASc score of 5 (fi:nrale, hyperten- whose diets are insufficient but should not be recommended sion. diabctes mellitus. age) '"r,ithout adclitional risk lactors lor independent of dietary assessment and intervention. Rou- bleeding and is :rt moderatc to high risk firr stroke with atrial tine screening for vitamin D deflciency is not recommended flbrillation o\er the long tenn (l .'1"t, ttl"t, annually). Bridging

lr .D UI The most appropriate next step is to assess fracture risk with a clinical assessment tool (Option A). The U.S. Preventive Services Task Force (USPSTF) recommends screening for oste- Item 56 Answer: C Ed u catio na I O bjective: Manage warfarin anticoagulation tr in the perioperative period. oporosis in all women aged 65 years or older and in women younger than 65 years who are at increased risk for osteopo The most appropriate perioperative management of this rosis, as determined by a formal clinical risk assessment tool. patient's warlarin is to withhold warfarin .5 days prior to This patient presents with several risk factors for osteoporosis suryery anci to restart in 12 to 2.1 hours aftcr suryery (Option C). and, most important, bone fracture. This patient's risk factors Wartarin shoulcl be withheld a ntinitnum <tf 5 days befbre include low body weight (BMI of 21), cigarette smoking, and surgery to nornulize the patient's INR. I he timing rll narlarin family history of hip fracture. The Fracture Risk Assessment discontinuatirin is based on its 116' to 42 hour hal{'lifb and (FRAX) is a commonly used clinical risk assessment tool clinicai studies docuntenting the time lbr thc INR to return (available at ww w.shef.ac.uk/FRAX). Women with a 10 year to normal tbllowing cliscontinuation. In general, 2 to 3 days FRAX risk for major osteoporotic fracture equal to or higher are required fbr the INR kr clrop belou'2 ancl .4 to 6 days fbr than that of a 65 year old White woman without additional the INR to nomrirlizc. Somc physicians obtain an INR on clay risk factors (10 year risk of 8.4'1,) should undergo screen- .1 and intcn'ene u,ith vitanrir-r K supplementation if necessary ing for osteoporosis. Screening can be accomplished with for persistentlv elevated INRs. Postoperative re initiation of bone mineral density (BMD) measurement, most commonly anticoagulation shoukl be guidecl by'the patient's thrombotic with dual-energr x ray absorptiometry of the hip and lumbar and bleeding risk and cleterrninecl in collaboratirm with the spine. surgical team. Owing to i1s delayed eftbct. the first dose of BMD measurement (Option B) is not indicated in this r,rartlrin is typically rrdn.rinistered 12 ttl')4 hours alter surgery. patient unless a fracture risk assessment with a formal risk pencling adequate henrostasis ancl barring any surgical con.t assessment tool (e.g., FRAX) indicates an increased risk for plicutions that rnay increase the risk firr bleedir-rg. It usually fracture. takcs 5 to 6 days to achieve a therapeutic INR. The U.S. National Osteoporosis Foundation recommends Withholding wartarin f'ur only 2 days prior to surgery pharmacologic treatment for patients with osteoporosis- (Option A) increascs the risk firr surgical bleedittg or,r'ittg related hip or spine fracturesl those with a BMD T-score of to the long hall life of wirrfarin. Many paticnts r,vould har,e -2.5 or less; and those with a BMD T score between -1 and an INR ol lpprorimltely 2 lbllou,ing only 2 clal's ol warfarin 2.5 with a 10 year risk of 3'l" or greater for hip fracture or discontinuation. Starting wart'arin 2 or 5 days after surgery 20'1, risk or greater for major osteoporosis-related fracture (Option I)) is unneccssarily delaycd, considering 5 to 6 duys as estimated by the FRAX tool. This patient has yet to meet are requireci lbr fLll rrnticoagulation. an indication for treatment with a bisphosphonate, such as Withholding wurfarin lbr .5 days ar.rcl bridging n,ith alendronate (Option C). lorv molecular g,eigfit heparin (Option B) is not ir.rdicated The National Academy of Medicine recommends cal because this may increase bleeding risk r,rdtl.rout of icring any cium intake of 1000 to 1200 mg/d, ideally from dietary adclitional lntithr-ombotic bcnefits in the perioperatire period. sources. A calcium supplement may be used for patients This ilaticnt has a CI IATDS, VASc score of 5 (fi:nrale, hyperten- whose diets are insufficient but should not be recommended sion. diabctes mellitus. age) '"r,ithout adclitional risk lactors lor independent of dietary assessment and intervention. Rou- bleeding and is :rt moderatc to high risk firr stroke with atrial tine screening for vitamin D deflciency is not recommended flbrillation o\er the long tenn (l .'1"t, ttl"t, annually). Bridging 196

t Answers and Critiques t i i i ffi cln be consiclerecl fbr patients at l.righest risk titr dev,astirt Although transvaginal ultrasonogrlrphl, (Option D) can be lll 111g thromlloembolic cliscirse (rccent pulnronary embolism, valuable in thc assessment of acute pelvic 1rain. a pregnancy coNT t priu. stroke. high thrornbotic risk mechanical heart valve. test should be obtaincd first. Transvaginal ultrasonography can CtIA,t)S2 \ASc score >7). ilssess fbr ectopic pregnanc'!! orarian cyst. ovarian torsion. and 1 appenclicitis; C'l'is more sensitive lor appendicitis. xtY PorilTs . In patients undergoing major surgery warfarin should r(lY POrilrS 1 be withheld a minimum ol5 days before surgery to o A pregnancy test should be obtained for all women of normalize the INR. reproductive age presenting with acute pelvic pain to . In patients on chronic warfarin therapy, warfarin rule out an ectopic pregnancy before considering ' should be restarted within 12 to 24 hours of surgery other diagnoses. pending adequate hemostasis. . In women with acute pelvic pain, transvaginal ultra- :

appenclicitis; C'l'is more sensitive lor appendicitis. xtY PorilTs . In patients undergoing major surgery warfarin should r(lY POrilrS 1 be withheld a minimum ol5 days before surgery to o A pregnancy test should be obtained for all women of normalize the INR. reproductive age presenting with acute pelvic pain to . In patients on chronic warfarin therapy, warfarin rule out an ectopic pregnancy before considering ' should be restarted within 12 to 24 hours of surgery other diagnoses. pending adequate hemostasis. . In women with acute pelvic pain, transvaginal ultra- : sonography can assess for ectopic pregnancy, ovarian vt C, I Bibliography cyst, ovarian torsion, and appendicitis. E I-ip G\'. Banerjee A, Boriani C, et al. Antithrombotic therapy fi)r atrial fibril lation: CHEST guideline and expert panel report. Chest. 2018;154:U21 201. f PMID: 30144 4 l9l doi: 10.101 6/j.chest.2018.07.040 Bibliography L., Bhosale PR. lavitt MC, Atri M. et al. ACR Appropriateness Criteria' acute -, pelvic pain in the reproductive age group. Ultrasound Q. 2016;32:108 15. ag IPMID: 26s88104J doi:10.1097/RUQ.0000000000000200 tt Item 57 tr Answer: C Educational Objective: Evaluate acute pelvic pain in a o ut = g reproductive age woman. Item 58 Answer: A 'lhe most appropriate initial diagnostic test is a pregnancy test Educational Objective: Treat impetigo. (Option C). Ilelorc consiclering other cliagnoses. it pregnincy The most appropriate treatment is mupirocin ointment test should be obtair-red tbr all r,r,omen ol reproductive age, (Option A). This patient has typical nonbullous impetigo, inclucling \\,rlnlen using contrlception, r,vho present n,itl-r characterized by eroded erythematous papules or plaques acute pelvic pain k) assess the possibility ol an ectopic preg with honey-colored crust. Impetigo is a superflcial infection nancl: Although the use of'an intrauterine ctevice (lUI)) does of the epidermis most commonly caused by Staphylococ not increasc the risk fbr ectopic pregrlancy. it is the fbrm of cus aureus or group A streptococci. Impetigo is classifled as tailecl contraception most associirtecl u,ith ectopic pregnanc),1 bullous or nonbullous; ecthyma is a deeper ulcerative form. II ir woman with acLlte ltelvic pain ckres lrave a positive preg Impetigo is most commonly seen in children but can present nanc), test rcsult, quantitative p huntan chorionic gonado in adults. Bullous impetigo is usually caused by S. cureus, tropin, t-vpe and screen, ancl transvaginal ultrlsonographl, which produces exfoliative toxins targeting the adhesion mol- sl.tottlcl be obtained imn.recliatell,, a1,r* *.,,,r consultation rvith ecule desmoglein-1 between keratinocfies. This results in an oltstetricianrgrnecologist. Women with eck4ric pregnan localized blister formation (as shown). cies nlly unclergo surgical nlaltagelnent or meclical nran agelxelrl with methotrexate, as directed by an obstetriciani g..necologist. *-*u C'l'of the abdomen and pelvis (Option A) ntay be appro priate in tlre assessment olacute pelvic pain. particularly if' the clinical picture is suggestive of appendicitis, but orrly alter obtair.rir.rg a negative pregnanc_v test result. Ilowerer, CT is l second-line test in the evaluatiou of acute pelvic pain lrec;rusc ultrasonography' provicles bctter visualization to assess the likelihood of'ovlrian torsion dltd other pelvic prtl.rolog' Although this paticlrt has right lor,r,er quadrant t)ain, which is concerniug fbr appendicitis, she hls no other findings, snch as rlituser. vonliting, or leukocytosis, to sug gest the diagnosis. 'l'esting fbr sexuirlll' triulsmitted irrfections (S'l ls). inch.rcling r.rucleic acid amplification test firr chhmyclir and Nonbullous impetigo is more common and can be gonorrhea (Option B). rnay be inclicatecl in ',rornen pre caused by S. oureus or group A streptococci, or both. Sat senting with acute pelvic pain. liowever, a pregnancy test ellite lesions are common. Nonbullous impetigo occurs sl.rould be obtained first. h.r addition, this patiellt dicl not on normal skin but can appear at areas of inflammatory report any signs or synrptonrs suggestive of an S'l'1. She conditions, such as atopic dermatitis. Impetigo is typically rcports no vaginal dischurge. lncl no purulent dischargc r,vas minimally symptomatic but is cosmetically distressing and seen on pelvic exarxination. easily spread to other family members. Treatment consists

sonography can assess for ectopic pregnancy, ovarian vt C, I Bibliography cyst, ovarian torsion, and appendicitis. E I-ip G\'. Banerjee A, Boriani C, et al. Antithrombotic therapy fi)r atrial fibril lation: CHEST guideline and expert panel report. Chest. 2018;154:U21 201. f PMID: 30144 4 l9l doi: 10.101 6/j.chest.2018.07.040 Bibliography L., Bhosale PR. lavitt MC, Atri M. et al. ACR Appropriateness Criteria' acute -, pelvic pain in the reproductive age group. Ultrasound Q. 2016;32:108 15. ag IPMID: 26s88104J doi:10.1097/RUQ.0000000000000200 tt Item 57 tr Answer: C Educational Objective: Evaluate acute pelvic pain in a o ut = g reproductive age woman. Item 58 Answer: A 'lhe most appropriate initial diagnostic test is a pregnancy test Educational Objective: Treat impetigo. (Option C). Ilelorc consiclering other cliagnoses. it pregnincy The most appropriate treatment is mupirocin ointment test should be obtair-red tbr all r,r,omen ol reproductive age, (Option A). This patient has typical nonbullous impetigo, inclucling \\,rlnlen using contrlception, r,vho present n,itl-r characterized by eroded erythematous papules or plaques acute pelvic pain k) assess the possibility ol an ectopic preg with honey-colored crust. Impetigo is a superflcial infection nancl: Although the use of'an intrauterine ctevice (lUI)) does of the epidermis most commonly caused by Staphylococ not increasc the risk fbr ectopic pregrlancy. it is the fbrm of cus aureus or group A streptococci. Impetigo is classifled as tailecl contraception most associirtecl u,ith ectopic pregnanc),1 bullous or nonbullous; ecthyma is a deeper ulcerative form. II ir woman with acLlte ltelvic pain ckres lrave a positive preg Impetigo is most commonly seen in children but can present nanc), test rcsult, quantitative p huntan chorionic gonado in adults. Bullous impetigo is usually caused by S. cureus, tropin, t-vpe and screen, ancl transvaginal ultrlsonographl, which produces exfoliative toxins targeting the adhesion mol- sl.tottlcl be obtained imn.recliatell,, a1,r* *.,,,r consultation rvith ecule desmoglein-1 between keratinocfies. This results in an oltstetricianrgrnecologist. Women with eck4ric pregnan localized blister formation (as shown). cies nlly unclergo surgical nlaltagelnent or meclical nran agelxelrl with methotrexate, as directed by an obstetriciani g..necologist. *-*u C'l'of the abdomen and pelvis (Option A) ntay be appro priate in tlre assessment olacute pelvic pain. particularly if' the clinical picture is suggestive of appendicitis, but orrly alter obtair.rir.rg a negative pregnanc_v test result. Ilowerer, CT is l second-line test in the evaluatiou of acute pelvic pain lrec;rusc ultrasonography' provicles bctter visualization to assess the likelihood of'ovlrian torsion dltd other pelvic prtl.rolog' Although this paticlrt has right lor,r,er quadrant t)ain, which is concerniug fbr appendicitis, she hls no other findings, snch as rlituser. vonliting, or leukocytosis, to sug gest the diagnosis. 'l'esting fbr sexuirlll' triulsmitted irrfections (S'l ls). inch.rcling r.rucleic acid amplification test firr chhmyclir and Nonbullous impetigo is more common and can be gonorrhea (Option B). rnay be inclicatecl in ',rornen pre caused by S. oureus or group A streptococci, or both. Sat senting with acute pelvic pain. liowever, a pregnancy test ellite lesions are common. Nonbullous impetigo occurs sl.rould be obtained first. h.r addition, this patiellt dicl not on normal skin but can appear at areas of inflammatory report any signs or synrptonrs suggestive of an S'l'1. She conditions, such as atopic dermatitis. Impetigo is typically rcports no vaginal dischurge. lncl no purulent dischargc r,vas minimally symptomatic but is cosmetically distressing and seen on pelvic exarxination. easily spread to other family members. Treatment consists 197

Answers and Critiques of washing with soap and water and removal of the crust. patients undergoing chemotherapy, the vaccine should ide Topical antibiotic treatment with mupirocin or retapamulin ally be administered at least 2 weeks before initiation of is effective in most cases of impetigo. chemotherapy or 1 week after administration of chemother- Topical antibiotics are as effective as oral antibiotics in apy if befween cycles. However, some studies ha've shown the treatment of impetigo. There is no evidence to support no dillerence in immunogenic response at different time the combined use of a topical and an oral antibiotic for impe points during chemotherapeutic cycles. tigo. Systemic antibiotics. such as cephalexin (Option B) and Def'erring influenza vaccination until completion of doxycycline (Option C), are helpful in cases of widespread chemotherapy (Option A) is not an appropriate option. bullous impetigo or when methicillin resistant S. oureus is Immunocompromised pctients are especially prone to suspected or confirmed. However, this patient has localized severe influenza infection, and a priority must be placed on nonbullous impetigo, and topical antibiotics, such as mupi preventing inf'ections, if possible. Although chemotherapy rocin oinlment. are eflective. may potentially blunt the immune response to vaccination, The classic presentation of cutaneous herpes simplex is the vaccine should still be administered. UI a group of painful, small vesicles on an erythematous base. High dose quadrivalent influenza vaccine (Option B) € (D transitioning to pustules and subsequent crusting of' the became a'uailable in the 2020-2021 influenza season and is ut lesior-rs over time. The diagnosis is typically made on clinical an option for people aged 65 years or older. The previous o, grounds. Oral antiviral agents (acyclovir valacyclovir, or f'am high-dose trivalent vaccine was 24'2, more efl'ective than its CL ciclovir) (Option D) car.r be used to treat primary infbctions standard dose counterpart. Estinlates of relative efficacy or n and episodic or secondary recurrences, and as suppression or eflectiveness of the quadrivalent high dose vaccine com prophylaxis fbr patients with six or more recurrences perlear. pared with standarcl dose quadrivalent vaccine are not avail- lt Topical glucocorticoids, such as triamcinolone cream able. This patient is younger than 65 years and would not o t^ (Option E), will most likely cause tl.ris localized inf'ection beneflt fiom the high-dose fornrulation. to enlarge. Topicirl glucocorticoids :rre used for their anti The nasal spray influenza vaccine (Option C) is a live inflammatory efl'ects arrd are most commonly indicated in attenuated vaccine and should not be given to patients with patients with eczematous dermatosis; they should not be active cancer or who are undergoing chemotherapy. The live applied to patients with bacterial, viral. or fungal infections. attenuated influenza vaccine is contraindicated in immu nocompromised patients and additionally should be used XEY PO I ]IT with caution in patients with significant medical conditions, r Nonbullous impetigo, characterized by eroded erythe- including cardiovascular, pulmonary. or liver disease; dialysis- matous papules or plaques with honey colored crust, dependent end stage kidney disease; or diabetes mellitus. can be treated with topical antibiotics, such as mupi lhis live attenuated vaccine should not be given to members of rocin or retapamulin. tl.ris patient's housel.rold. The nasal spray vaccination is other- wise an option for some individuals aged 2 through 49 years. Bibliography t(EY POiltTS Kosar L. l.aubscher'1. l\4anagement of impetigo ancl cellulitis: simple consid errtions for promoting appropriate antibiotic use in skin infections. Can o In patients with active cancer, annual vaccination Fam Physician. 2017:63:615 8. LPMID: 288079581 with the standard dose inactivated influenza vaccine should be administered at least 2 weeks before initia tion of chemotherapy or 1 week after administration Item 59 Answer: D of chemotherapy if between cycles. Educational Objective: Prevent influenza in patients o The live attenuated influenza vaccine is contraindi- who are immunocompromised. cated in immunocompromised patients, including The most appropriate vaccination strategv for this patient those with active cancer or who are undergoing is to administer the standard-dose inactivated influenza chemotherapy. vaccine (Option D). Annual influenza vaccination is rec ommended for all individuals aged 6 months or older. The Bibliography influenza vaccine should be administered as soon as it l.reedmrrr.r MS. Ilernstein H. Ault KA. Recommended ildult immunization becomes available, pref'erably by October. but can be given schedule. United States, 2021. 1\nn Intern Merl. ')02l:171:37.1 8.1. [PMID: 335710111 ckri:10.7326rM20 8080 at any time during the influenza season. lmmunocompro- mised patients, including patients with cancer and those undergoing chemotherapy, are at risk lbr influenza and may be more likely to develop complications. Successful immunization requires a competent immune system to Item 60 Answer: E Educational Objective: Prevent harm in patients using tr generate antibodies; althougl.r this response may be atten dietary supplements. uated in immunocompromised patients, vaccination is still lhe most appropriate recommendation is to stop all dietary indicated. Members of this patient's immediate household supplements (Option E). Dietary supplcments. including vita should also receive the inactivated influenza vaccine. In nrins, minerals, botanicals, herbals, metabolites. and amino

of washing with soap and water and removal of the crust. patients undergoing chemotherapy, the vaccine should ide Topical antibiotic treatment with mupirocin or retapamulin ally be administered at least 2 weeks before initiation of is effective in most cases of impetigo. chemotherapy or 1 week after administration of chemother- Topical antibiotics are as effective as oral antibiotics in apy if befween cycles. However, some studies ha've shown the treatment of impetigo. There is no evidence to support no dillerence in immunogenic response at different time the combined use of a topical and an oral antibiotic for impe points during chemotherapeutic cycles. tigo. Systemic antibiotics. such as cephalexin (Option B) and Def'erring influenza vaccination until completion of doxycycline (Option C), are helpful in cases of widespread chemotherapy (Option A) is not an appropriate option. bullous impetigo or when methicillin resistant S. oureus is Immunocompromised pctients are especially prone to suspected or confirmed. However, this patient has localized severe influenza infection, and a priority must be placed on nonbullous impetigo, and topical antibiotics, such as mupi preventing inf'ections, if possible. Although chemotherapy rocin oinlment. are eflective. may potentially blunt the immune response to vaccination, The classic presentation of cutaneous herpes simplex is the vaccine should still be administered. UI a group of painful, small vesicles on an erythematous base. High dose quadrivalent influenza vaccine (Option B) € (D transitioning to pustules and subsequent crusting of' the became a'uailable in the 2020-2021 influenza season and is ut lesior-rs over time. The diagnosis is typically made on clinical an option for people aged 65 years or older. The previous o, grounds. Oral antiviral agents (acyclovir valacyclovir, or f'am high-dose trivalent vaccine was 24'2, more efl'ective than its CL ciclovir) (Option D) car.r be used to treat primary infbctions standard dose counterpart. Estinlates of relative efficacy or n and episodic or secondary recurrences, and as suppression or eflectiveness of the quadrivalent high dose vaccine com prophylaxis fbr patients with six or more recurrences perlear. pared with standarcl dose quadrivalent vaccine are not avail- lt Topical glucocorticoids, such as triamcinolone cream able. This patient is younger than 65 years and would not o t^ (Option E), will most likely cause tl.ris localized inf'ection beneflt fiom the high-dose fornrulation. to enlarge. Topicirl glucocorticoids :rre used for their anti The nasal spray influenza vaccine (Option C) is a live inflammatory efl'ects arrd are most commonly indicated in attenuated vaccine and should not be given to patients with patients with eczematous dermatosis; they should not be active cancer or who are undergoing chemotherapy. The live applied to patients with bacterial, viral. or fungal infections. attenuated influenza vaccine is contraindicated in immu nocompromised patients and additionally should be used XEY PO I ]IT with caution in patients with significant medical conditions, r Nonbullous impetigo, characterized by eroded erythe- including cardiovascular, pulmonary. or liver disease; dialysis- matous papules or plaques with honey colored crust, dependent end stage kidney disease; or diabetes mellitus. can be treated with topical antibiotics, such as mupi lhis live attenuated vaccine should not be given to members of rocin or retapamulin. tl.ris patient's housel.rold. The nasal spray vaccination is other- wise an option for some individuals aged 2 through 49 years. Bibliography t(EY POiltTS Kosar L. l.aubscher'1. l\4anagement of impetigo ancl cellulitis: simple consid errtions for promoting appropriate antibiotic use in skin infections. Can o In patients with active cancer, annual vaccination Fam Physician. 2017:63:615 8. LPMID: 288079581 with the standard dose inactivated influenza vaccine should be administered at least 2 weeks before initia tion of chemotherapy or 1 week after administration Item 59 Answer: D of chemotherapy if between cycles. Educational Objective: Prevent influenza in patients o The live attenuated influenza vaccine is contraindi- who are immunocompromised. cated in immunocompromised patients, including The most appropriate vaccination strategv for this patient those with active cancer or who are undergoing is to administer the standard-dose inactivated influenza chemotherapy. vaccine (Option D). Annual influenza vaccination is rec ommended for all individuals aged 6 months or older. The Bibliography influenza vaccine should be administered as soon as it l.reedmrrr.r MS. Ilernstein H. Ault KA. Recommended ildult immunization becomes available, pref'erably by October. but can be given schedule. United States, 2021. 1\nn Intern Merl. ')02l:171:37.1 8.1. [PMID: 335710111 ckri:10.7326rM20 8080 at any time during the influenza season. lmmunocompro- mised patients, including patients with cancer and those undergoing chemotherapy, are at risk lbr influenza and may be more likely to develop complications. Successful immunization requires a competent immune system to Item 60 Answer: E Educational Objective: Prevent harm in patients using tr generate antibodies; althougl.r this response may be atten dietary supplements. uated in immunocompromised patients, vaccination is still lhe most appropriate recommendation is to stop all dietary indicated. Members of this patient's immediate household supplements (Option E). Dietary supplcments. including vita should also receive the inactivated influenza vaccine. In nrins, minerals, botanicals, herbals, metabolites. and amino 198

Alswers and Critiques tr CONT, aci(ls, are categorized es tbods by thc FDA. Thercfbre, man ufacturers are not requircd to demonstrate e{Icacy or safety of their products unless the supplerner.rt ir-rcludcs ingredients Item 61 Answer: D Educational Objective: Manage acne in an adult woman.

tr CONT, aci(ls, are categorized es tbods by thc FDA. Thercfbre, man ufacturers are not requircd to demonstrate e{Icacy or safety of their products unless the supplerner.rt ir-rcludcs ingredients Item 61 Answer: D Educational Objective: Manage acne in an adult woman. thirt were introduced aftcr 199.1. As ir result. the cflicacl' ol The most appropriate management is to start spironolac nrrist supplemcnts has not been subject to rigorous evalua tone (Option D). This patient has adult female type acne, tion. ln addition to qucstionable ef liclcl,i supplcrncnt use is characterized by papules and nodules on the lower half of :lssociilted \\,ith risk fbr both direct ancl indirect hru'nrs. Dircct the face with marked presence on the jawline. Adult acne is harms include side eflbctsr interactions r,r,ith other dmgsr more common in women and, when present, results from ancl hanns related to inclusion ol unadvertiscd additives. an abnormal response to physiologic levels of androgens. It cornpounds. or toxins. lndirect harms occur rthen dietar] typically presents along the jawline and often flares with the supplement use replaces or dela1's strrndard trcrtnlents that menstrual cycle. Although considered second line therapy, have clemonstrated efficacy: When counscling paticnts usir.rg oral contraceptives or spironolactone (aldosterone receptor supplements, thc physician's role is to in[brm these patients of' blocker with antiandrogen activity) can be added to other v, (u potential sidc eftbcts ancl benefits, if l<nown. treatments in women with moderate to severe acne. Spi- ET Biotin (Option A), a common over-the counter sup ronolactone is an excellent choice for adult female acne plcment, has no kno'"r,n toric eft'ects. Hovvever. pitients tak for which topical therapies have failed. Spironolactone is a (, ing thyroid rcplacement xnd also tll<ing morc than 5 to pregnancy category C (risk cannot be ruled out), and con !, l0 mgrd ol biotin should discontinuc it entirely or at least 2 traception is recommended when used in premenopausal tg to 5 days befbre thyroid firnction testing. l]iotin interf'erencc women for the treatment of conditions such as hirsutism .A (l, caLrses falsely high levels ol fiee thyroxine (T r). fie c triiodo and acne. thyronine (T,), total T.,, and total 'l'., and a lirlsely low thy Obtaining hormone measurements (Option A), such = a

thirt were introduced aftcr 199.1. As ir result. the cflicacl' ol The most appropriate management is to start spironolac nrrist supplemcnts has not been subject to rigorous evalua tone (Option D). This patient has adult female type acne, tion. ln addition to qucstionable ef liclcl,i supplcrncnt use is characterized by papules and nodules on the lower half of :lssociilted \\,ith risk fbr both direct ancl indirect hru'nrs. Dircct the face with marked presence on the jawline. Adult acne is harms include side eflbctsr interactions r,r,ith other dmgsr more common in women and, when present, results from ancl hanns related to inclusion ol unadvertiscd additives. an abnormal response to physiologic levels of androgens. It cornpounds. or toxins. lndirect harms occur rthen dietar] typically presents along the jawline and often flares with the supplement use replaces or dela1's strrndard trcrtnlents that menstrual cycle. Although considered second line therapy, have clemonstrated efficacy: When counscling paticnts usir.rg oral contraceptives or spironolactone (aldosterone receptor supplements, thc physician's role is to in[brm these patients of' blocker with antiandrogen activity) can be added to other v, (u potential sidc eftbcts ancl benefits, if l<nown. treatments in women with moderate to severe acne. Spi- ET Biotin (Option A), a common over-the counter sup ronolactone is an excellent choice for adult female acne plcment, has no kno'"r,n toric eft'ects. Hovvever. pitients tak for which topical therapies have failed. Spironolactone is a (, ing thyroid rcplacement xnd also tll<ing morc than 5 to pregnancy category C (risk cannot be ruled out), and con !, l0 mgrd ol biotin should discontinuc it entirely or at least 2 traception is recommended when used in premenopausal tg to 5 days befbre thyroid firnction testing. l]iotin interf'erencc women for the treatment of conditions such as hirsutism .A (l, caLrses falsely high levels ol fiee thyroxine (T r). fie c triiodo and acne. thyronine (T,), total T.,, and total 'l'., and a lirlsely low thy Obtaining hormone measurements (Option A), such = a roicl stimulatir.tg hon.none level, mirnicking thyrotoxicosis. as follicle stimulating hormone, luteinizing hormone, and l]iotin also interferes u'ith serum tl-oponin testing. resultilltj free testosterone levels, is not indicated. The patient has no in falsely lor,r, lcvels. which conlcl leird to difficulty in the features that suggest hyperandrogenism, such as hirsutism, dirrgnosis of acutc coronary syndronre. l)epencling on the muscle mass gain, deepening of the voice, or clitoromegaly. assay used. biotin can also interfere u,ith the nreasuremeut Rapid onset of acne combined with other signs of hyperan- of digoxin. IL'rritin, testoslcrorle. brlin natriuretic pepticle. drogenism warrants consideration of polycystic ovary syn- ancl progesterone. drome, congenital adrenal hyperplasia, or an underlying l'}atients w]ro are snrokers and those exposcd to asbestos adrenal or ovarian tumor. should avoid p carotene (Option B) because eviclcnce has Pelvic ultrasonography (Option B) might be indicated linkeci B carotene'uvith increased risk tbr lung cancer (but in patients with findings suspicious for polycystic ovary not rt,ith other cancers) in these p<;pu lations. F-or this patient syndrome. However, this patient has no features of polycystic who continues 1o smokc, discontinuation ol B carotene is ovary syndrome, such as hirsutism or oligo /anovulation, recommended. and pelvic ultrasonography is not indicated. Both fish oil andvitamin E (Options C, D) nrrrl increirsc Progesterone eluting intrauterine devices (Option C), as thc risk fbr blccding in patients tirking anticoagular.rts. This well as any other progesterone based hormonal contracep patient shoulcl be adviscd to stop taking fish oil ancl vitanrin tion, can exacerbate acne and would not be recommended. E because he is taking rivaroxabln fbr atrial tibrillation. Combined estrogen and progesterone oral contraceptives are Beciiuse this patient has contraindic:rtions fur [i carotenc, effective treatments for inflammatory acne in women with- f ish oil, and vitamin E ancl biotin nlay compromise the abil out evidence of hyperandrogenism and would be an option ity to monitor his thyroid disease, all supplenrer.rts shoulcl be for this patient. discontinuecl. Topical antibiotics are helpful in inflammatory acne because they target Cutibacterium ocnes and have anti KEY POIIIIS inflammatory effects. It is recommended that topical anti o Dietary supplements have questionable efficacy in biotics be combined with topical benzoyl peroxide in improving health, and their use is associated with risk treatment for mild. moderate. or severe acne to avoid for both direct and indirect harms; the physician's antibiotic resistance. The common topical antibiotics clin- role is to inform patients of potential side effects. damycin and erythromycin are pregnancy category B, . In patients taking anticoagulants, vitamin E and fish whereas topical benzoyl peroxide is pregnancy category C. Topical metronidazole cream (Option E) is a flrst line oil increase the risk for bleeding; p-carotene increases treatment for rosacea but not for acne. the risk for lung cancer in cigarette smokers; and biotin interferes with several biological assays. XEY POIilT5 . Spironolactone andcombined oral contraceptives can Bibliography be used for adult female acne in patients in whom Incze M. Vitamins and nutritional supplements: what do I need to know? topical therapies have failed. JAMA Intern Med. 2019;179:460. [PMII): 306150201 tloi:10.1001r (Continued) jamainternmed.2018.588O

roicl stimulatir.tg hon.none level, mirnicking thyrotoxicosis. as follicle stimulating hormone, luteinizing hormone, and l]iotin also interferes u'ith serum tl-oponin testing. resultilltj free testosterone levels, is not indicated. The patient has no in falsely lor,r, lcvels. which conlcl leird to difficulty in the features that suggest hyperandrogenism, such as hirsutism, dirrgnosis of acutc coronary syndronre. l)epencling on the muscle mass gain, deepening of the voice, or clitoromegaly. assay used. biotin can also interfere u,ith the nreasuremeut Rapid onset of acne combined with other signs of hyperan- of digoxin. IL'rritin, testoslcrorle. brlin natriuretic pepticle. drogenism warrants consideration of polycystic ovary syn- ancl progesterone. drome, congenital adrenal hyperplasia, or an underlying l'}atients w]ro are snrokers and those exposcd to asbestos adrenal or ovarian tumor. should avoid p carotene (Option B) because eviclcnce has Pelvic ultrasonography (Option B) might be indicated linkeci B carotene'uvith increased risk tbr lung cancer (but in patients with findings suspicious for polycystic ovary not rt,ith other cancers) in these p<;pu lations. F-or this patient syndrome. However, this patient has no features of polycystic who continues 1o smokc, discontinuation ol B carotene is ovary syndrome, such as hirsutism or oligo /anovulation, recommended. and pelvic ultrasonography is not indicated. Both fish oil andvitamin E (Options C, D) nrrrl increirsc Progesterone eluting intrauterine devices (Option C), as thc risk fbr blccding in patients tirking anticoagular.rts. This well as any other progesterone based hormonal contracep patient shoulcl be adviscd to stop taking fish oil ancl vitanrin tion, can exacerbate acne and would not be recommended. E because he is taking rivaroxabln fbr atrial tibrillation. Combined estrogen and progesterone oral contraceptives are Beciiuse this patient has contraindic:rtions fur [i carotenc, effective treatments for inflammatory acne in women with- f ish oil, and vitamin E ancl biotin nlay compromise the abil out evidence of hyperandrogenism and would be an option ity to monitor his thyroid disease, all supplenrer.rts shoulcl be for this patient. discontinuecl. Topical antibiotics are helpful in inflammatory acne because they target Cutibacterium ocnes and have anti KEY POIIIIS inflammatory effects. It is recommended that topical anti o Dietary supplements have questionable efficacy in biotics be combined with topical benzoyl peroxide in improving health, and their use is associated with risk treatment for mild. moderate. or severe acne to avoid for both direct and indirect harms; the physician's antibiotic resistance. The common topical antibiotics clin- role is to inform patients of potential side effects. damycin and erythromycin are pregnancy category B, . In patients taking anticoagulants, vitamin E and fish whereas topical benzoyl peroxide is pregnancy category C. Topical metronidazole cream (Option E) is a flrst line oil increase the risk for bleeding; p-carotene increases treatment for rosacea but not for acne. the risk for lung cancer in cigarette smokers; and biotin interferes with several biological assays. XEY POIilT5 . Spironolactone andcombined oral contraceptives can Bibliography be used for adult female acne in patients in whom Incze M. Vitamins and nutritional supplements: what do I need to know? topical therapies have failed. JAMA Intern Med. 2019;179:460. [PMII): 306150201 tloi:10.1001r (Continued) jamainternmed.2018.588O 199

Answers and Critiques I EY P0lrdlS (continud) Withholding rivaroxaban for 7 da1,s befbre surgery (Option D) is unlikell, to provide additional bcnefit from a . Topical antibiotics are helpful in inflammatory acne bleeding standpoint ilnd may increase thc risk fbr tl.rrombo because they target Cutibacterium ocnes and have sis by lengthening the tirne the patient is ofi anticoagulatior.r. anti-inflammatory effects; they should be combined with topical benzoyl peroxide. I(EY POITIS . In patients with normal kidney function, withholding Bibliography a direct oral anticoagulant for four half-lives (2-3 days) Zaenglein AL. Acne vulgaris. N Engl J Med. 2018;379:1343 52. [PMID' reduces anticoagulant levels to approximately 6.25%, 302819821 doi:10.1056/NEIM cplT 02493 resulting in near-normal bleeding risk. . Direct oral anticoagulants have a rapid onset and F UI tr Item 62 Answer: B Ed ucatio na I Obiective : Manage direct oral anticoagrrlant short half-life; thus, bridging anticoagulation is not needed.

I EY P0lrdlS (continud) Withholding rivaroxaban for 7 da1,s befbre surgery (Option D) is unlikell, to provide additional bcnefit from a . Topical antibiotics are helpful in inflammatory acne bleeding standpoint ilnd may increase thc risk fbr tl.rrombo because they target Cutibacterium ocnes and have sis by lengthening the tirne the patient is ofi anticoagulatior.r. anti-inflammatory effects; they should be combined with topical benzoyl peroxide. I(EY POITIS . In patients with normal kidney function, withholding Bibliography a direct oral anticoagulant for four half-lives (2-3 days) Zaenglein AL. Acne vulgaris. N Engl J Med. 2018;379:1343 52. [PMID' reduces anticoagulant levels to approximately 6.25%, 302819821 doi:10.1056/NEIM cplT 02493 resulting in near-normal bleeding risk. . Direct oral anticoagulants have a rapid onset and F UI tr Item 62 Answer: B Ed ucatio na I Obiective : Manage direct oral anticoagrrlant short half-life; thus, bridging anticoagulation is not needed. € therapy for an elective surgical procedure. o Bibliography t/l The most appropriate perioperative managernent of the Lip GY, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibril- o, patient's ri'v'aroxaban is to withhold fbr 3 clays before surgery lation: CHEST guideline and expert panel report. Chest. 2018;15,1:1121- EL 201. IPMID: 301.14419] doi:10.1016'j.chest.2018.07.040 (Option B). Befbre elective surgery,; management decisions n ab<lut anticoagulant therapy are made on the basis of'surgi lt cal bleeding risk, thrombotic risk ofl'anticoagulants, kidney Item 63 Answer: C E function, and type of dmg. In this case, tl.re patient is taking .D t^ Educational Objective: Manage vaccination of a health rivaroxaban, a direct oral anticoagulant (DOAC), lcrr atrial care worker. fibrillation. She has a moderate high CHArDS.,,-\ASc score of 4 (hypertension. age. vascular disease, fbmale) ancl normal The most appropriate vaccine to administer to this health kidney function and is undergoing a surgery rvith moderate care worker is the tetanus toxoid, reduced diphtheria toxoid, bleeding risk. Because ofthe bleeding risl<, she should not be and acellular pertussis (Tdap) vaccine (Option C). Health anticoagulated at the time of surgcry. In patients with nor- care workers are at increased risk lor acquiring and trans mal kidney function.l,r,ithholding a DOAC for four half lives mitting pertussis and should receive a dose of the Tdap vac- (2 3 days) rcduces anticoagulant levels to approximately cine regardless ofwhen they received their last tetanus and 6.25'){,, resulting in near normal bleeding risk. Thus. with diphtheria toxoids (Td) vaccine. Because this patient received holding rivaroxaban 3 days befbre surgery in this patient is only a Td vaccine, a Tdap vaccine is required at this time. rccommended. Health care workers are also at increased risk for infection Although anticoagulation can be continued until the with influenza, hepatitis B, measles, mumps, rubella, and day of surgery for select minor procedures (e.g., cataract or varicella viruses; this patient was previously vaccinated for dental surgery), patients undergoing surgery with signifi these viruses and has documented immunity to hepatitis B, cant blceding risk must have anticoagulation withheld long rubella, and varicella. enough to ensure adequate drug clcarance and normaliza- Hepatitis A vaccination (Option A) is not indicated for tion of coagulation. Continuing rivaroxaban until the day this patient because health care workers are not considered of surgery (Option A) places this patient at an unacceptable to be at increased risk for hepatitis A virus infection unless bleeding risk perioperatively. working in high-risk venues. Hepatitis A vaccination is rec Patients u,ho are at especially' high risk fbr thrombo ommended for adults who request it or those at increased sis r.thile ofl'anticoagulants may neecl a pre or postop risk for infection or complications of infections, including erative anticoagulant bridge r,r,ith lolr,, molecular weight travelers to endemic areas, individuals with chronic liver heparin to limit tirne ofI anticoagulation. This is most rel disease, men who have sex with men, users of illicit drugs, evant lor drugs with a delaycd onset ol action and longer homeless persons, persons who conduct hepatitis A related half'life. such as rvarfarin. t)OACs. hor,r,ever, have a rapid research, household or close contacts of children adopted onset and short half lif'e; thus, bridging anlicoagulation from endemic areas, and those who work in settings of is not needed. The BRII)GE trial demonstrated r.ro difler possible exposure (group homes, nonresidential day_care ence in thrombotic events in patients on warfarin with facilities for developmentally disabled persons, and health atrial fibrillation r,l,ho were bridged perioperatively but did care programs serving patients with unhealthy drug use). observe a higher rate of bleeding in this group. Iherefore. Health care workers are not considered to be at increased bridging anticoagulatior.r is rarely recommencled, except risk for meningococcal disease, and thus the quadrivalent in the setting of very high throntbosis risk off r,r,arfarin meningococcal conjugate vaccine (MenACWy) (Option B) is therapy, such as atrial fibrillation with a mechanical heart not indicated for this patient. The MenACWy vaccine is recom_ valve. lhis patient is not at very high risk for thrombosis mended for adults considered to be at increased risk, includ and is not or.r warfarin: thereforc, bridging is not war ing first year college students living in dormitories; travelers ranted (Options C, E). to endemic areas; microbiologists with ongoing exposure to

€ therapy for an elective surgical procedure. o Bibliography t/l The most appropriate perioperative managernent of the Lip GY, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibril- o, patient's ri'v'aroxaban is to withhold fbr 3 clays before surgery lation: CHEST guideline and expert panel report. Chest. 2018;15,1:1121- EL 201. IPMID: 301.14419] doi:10.1016'j.chest.2018.07.040 (Option B). Befbre elective surgery,; management decisions n ab<lut anticoagulant therapy are made on the basis of'surgi lt cal bleeding risk, thrombotic risk ofl'anticoagulants, kidney Item 63 Answer: C E function, and type of dmg. In this case, tl.re patient is taking .D t^ Educational Objective: Manage vaccination of a health rivaroxaban, a direct oral anticoagulant (DOAC), lcrr atrial care worker. fibrillation. She has a moderate high CHArDS.,,-\ASc score of 4 (hypertension. age. vascular disease, fbmale) ancl normal The most appropriate vaccine to administer to this health kidney function and is undergoing a surgery rvith moderate care worker is the tetanus toxoid, reduced diphtheria toxoid, bleeding risk. Because ofthe bleeding risl<, she should not be and acellular pertussis (Tdap) vaccine (Option C). Health anticoagulated at the time of surgcry. In patients with nor- care workers are at increased risk lor acquiring and trans mal kidney function.l,r,ithholding a DOAC for four half lives mitting pertussis and should receive a dose of the Tdap vac- (2 3 days) rcduces anticoagulant levels to approximately cine regardless ofwhen they received their last tetanus and 6.25'){,, resulting in near normal bleeding risk. Thus. with diphtheria toxoids (Td) vaccine. Because this patient received holding rivaroxaban 3 days befbre surgery in this patient is only a Td vaccine, a Tdap vaccine is required at this time. rccommended. Health care workers are also at increased risk for infection Although anticoagulation can be continued until the with influenza, hepatitis B, measles, mumps, rubella, and day of surgery for select minor procedures (e.g., cataract or varicella viruses; this patient was previously vaccinated for dental surgery), patients undergoing surgery with signifi these viruses and has documented immunity to hepatitis B, cant blceding risk must have anticoagulation withheld long rubella, and varicella. enough to ensure adequate drug clcarance and normaliza- Hepatitis A vaccination (Option A) is not indicated for tion of coagulation. Continuing rivaroxaban until the day this patient because health care workers are not considered of surgery (Option A) places this patient at an unacceptable to be at increased risk for hepatitis A virus infection unless bleeding risk perioperatively. working in high-risk venues. Hepatitis A vaccination is rec Patients u,ho are at especially' high risk fbr thrombo ommended for adults who request it or those at increased sis r.thile ofl'anticoagulants may neecl a pre or postop risk for infection or complications of infections, including erative anticoagulant bridge r,r,ith lolr,, molecular weight travelers to endemic areas, individuals with chronic liver heparin to limit tirne ofI anticoagulation. This is most rel disease, men who have sex with men, users of illicit drugs, evant lor drugs with a delaycd onset ol action and longer homeless persons, persons who conduct hepatitis A related half'life. such as rvarfarin. t)OACs. hor,r,ever, have a rapid research, household or close contacts of children adopted onset and short half lif'e; thus, bridging anlicoagulation from endemic areas, and those who work in settings of is not needed. The BRII)GE trial demonstrated r.ro difler possible exposure (group homes, nonresidential day_care ence in thrombotic events in patients on warfarin with facilities for developmentally disabled persons, and health atrial fibrillation r,l,ho were bridged perioperatively but did care programs serving patients with unhealthy drug use). observe a higher rate of bleeding in this group. Iherefore. Health care workers are not considered to be at increased bridging anticoagulatior.r is rarely recommencled, except risk for meningococcal disease, and thus the quadrivalent in the setting of very high throntbosis risk off r,r,arfarin meningococcal conjugate vaccine (MenACWy) (Option B) is therapy, such as atrial fibrillation with a mechanical heart not indicated for this patient. The MenACWy vaccine is recom_ valve. lhis patient is not at very high risk for thrombosis mended for adults considered to be at increased risk, includ and is not or.r warfarin: thereforc, bridging is not war ing first year college students living in dormitories; travelers ranted (Options C, E). to endemic areas; microbiologists with ongoing exposure to 200

t Answers and Critiques Neisserio meningitidis; military recruits; those at increased routine use of oral contraceptives. This method also requires risk because of an outbreak; and patients with anatomic or a repeat dose at 12 hours. Combined oral contraceptive pills functional asplenia, complement deflciencies, or HIV infection. are less eflective and are associated with higher rates of side Because health care workers are considered at effects compared with FDA approved emergency contra increased risk for pertussis, not offering this the Tdap vac ceptive methods. Some experts will suggest this method cine (Option D), regardless of when he received his last Td to patients when cost is an issue or when quick access to vaccine, is not the best strategr. FDA approved emergency contraception is limited. Either the copper IUD or oral ulipristal acetate would be recom- f,EY POIilTS mended as the most appropriate method for this patient. . Health care workers are at increased risk for pertussis The levonorgestrel oral contraceptive pill (Option B) is and should receive the tetanus toxoid, reduced diph available over the counter (without age restriction), and a theria toxoid, and acellular perhlssis vaccine regard single dose is eflective for emergency contraception within less ofwhen they received their last tetanus and diph- the 3 days after intercourse. Like ulipristal acetate, Ievo ut (l, theria toxoids vaccine. norgestrel delays ovulation. The effectiveness of levonorge- CT r In addition to pertussis, health care workers are also strel declines in women with a BMI greater than 26 and at increased risk for influenza, hepatitis B, measles, would not be recommended for this patient. (J mumps, rubella, and varicella viruses and should The subdermal contraceptive implant (Option C) is not an eflective form of emergency contraception and would =, receive the appropriate vaccinations. l9 therefore not be appropriate for this patient. |a o Bibliography XEY POIilIS 3 t/l Freedman MS, Bernstein H, Ault KA. Recommended adult immunization schedule, United States, 2021. Ann Intern Med. 2021. [pMIt): 33571011] r Oral ulipristal acetate is an effective oral emergency doi:10.71126/M20 8080 contraception option for women with a BMI greater than 26. Item 64 Answer: D . The copper intrauterine device is the most effective Educational Objective: Provide emergency form ofemergency contraception option and can contraception. reduce the risk for pregnancy by 99'/. if placed within 5 days of unprotected sexual intercourse. The most appropriate emergency contraceptive option for this patient is the ulipristal acetate oral contraceptive pill (Option Bibliography D). Emergency contraception refers to postcoital contracep Woodhams EJ, Gilliam M. Contraception. Ann lntern Med. 2019;l7O:lTCt8 tion using a device or medication to prevent pregnancy after 32. IPMID: 307167 s9l doi:10.7326 /AITC20l 902050 inadequately protected intercourse. All forms of emergency contraception work by disrupting ovulation or preventing fertilization of an egg. Emergency contraceptives are not abortion inducing interventions. FDA approved options for emergency contraception include oral ulipristal acetate, oral Item 65 Answer: B Educational Objective: Classiff the severity of a burn. tr levonorgestrel, or a copper intrauterine device (lUD). New 'lhe classificrtion <;f this patient's burn is second clegree, data suggest that the 52 mg levonorgestrel IUD is noninferior superficial partial thickness (Option B), which in'uolves the to the copper IUD for emergency contraception, but it is not entire epidennis and penetrtrtes inb, bnt not through. thc currently FDA approved for this indication. Ulipristal acetate clcrtnis. l]ecause thc epidermal layer is lost, the wound fbrrns delays ovulation. It is the preferred oral contraceptive option a blister or n'eeps illterstitial f luid. The rn,ouncl blanchcs rvith for women with a BMI greater than 26, such as this patient. pressurc and is painful to air. tenlperatrlre, and pressure A single oral dose of ulipristal acetate is eft'ective for up to because thc vesscls ancl nerve of the dernris are still intact. 5 days after unprotected sexual intercourse. Although a pre- unlike the case with second degrec, cleep pafiial thickness scription is required for oral ulipristal acetate, an in person burns lnd third clegree burns. Ilealing occurs through medical visit is not required to provide this form of emer re epitlrclialization. Wound care lilr second clcgrce, par gency contraception. The copper IUD is FDA approved for use tial thickr.ress burns includes cleaning the rtottt.tcl ruith soap as emergency contraception and is the most effective fbrm and water and applying a topical antibiotic ointnlent. Spc ofemergency contraception; it can reduce the risk for preg ciirlized wound dr-essit.tg will nraintlin a t.lloist environment nancy by 99% if placed within 5 days of unprotected sexual and rnay renrain in place fbr several clays after thc injuryL intercourse. Copper IUDs prevent fertilization by unknown Surgical excision and skir-r grafting shoulcl be consiclered ftrr mechanisms and require a clinic visit fbr insertion. rtouncls that clo not re epithelialize after 2 kr 3 rt'eeks. Emergency contraception can be provided with off A tirst degrec, ttr superficial, bttrn (Option A) dtles not label use of combined oral contraceptive pills (Option A) penetrrte through the epiderrnis ancl presetlts rvith recl. containing ethinyl estradiol or either norgestrel or levo- tender skin but no blistering or rt'eeping. Minimirl or no norgestrel, but the dosing schedule is very different from the trcirtment is requircd.

Neisserio meningitidis; military recruits; those at increased routine use of oral contraceptives. This method also requires risk because of an outbreak; and patients with anatomic or a repeat dose at 12 hours. Combined oral contraceptive pills functional asplenia, complement deflciencies, or HIV infection. are less eflective and are associated with higher rates of side Because health care workers are considered at effects compared with FDA approved emergency contra increased risk for pertussis, not offering this the Tdap vac ceptive methods. Some experts will suggest this method cine (Option D), regardless of when he received his last Td to patients when cost is an issue or when quick access to vaccine, is not the best strategr. FDA approved emergency contraception is limited. Either the copper IUD or oral ulipristal acetate would be recom- f,EY POIilTS mended as the most appropriate method for this patient. . Health care workers are at increased risk for pertussis The levonorgestrel oral contraceptive pill (Option B) is and should receive the tetanus toxoid, reduced diph available over the counter (without age restriction), and a theria toxoid, and acellular perhlssis vaccine regard single dose is eflective for emergency contraception within less ofwhen they received their last tetanus and diph- the 3 days after intercourse. Like ulipristal acetate, Ievo ut (l, theria toxoids vaccine. norgestrel delays ovulation. The effectiveness of levonorge- CT r In addition to pertussis, health care workers are also strel declines in women with a BMI greater than 26 and at increased risk for influenza, hepatitis B, measles, would not be recommended for this patient. (J mumps, rubella, and varicella viruses and should The subdermal contraceptive implant (Option C) is not an eflective form of emergency contraception and would =, receive the appropriate vaccinations. l9 therefore not be appropriate for this patient. |a o Bibliography XEY POIilIS 3 t/l Freedman MS, Bernstein H, Ault KA. Recommended adult immunization schedule, United States, 2021. Ann Intern Med. 2021. [pMIt): 33571011] r Oral ulipristal acetate is an effective oral emergency doi:10.71126/M20 8080 contraception option for women with a BMI greater than 26. Item 64 Answer: D . The copper intrauterine device is the most effective Educational Objective: Provide emergency form ofemergency contraception option and can contraception. reduce the risk for pregnancy by 99'/. if placed within 5 days of unprotected sexual intercourse. The most appropriate emergency contraceptive option for this patient is the ulipristal acetate oral contraceptive pill (Option Bibliography D). Emergency contraception refers to postcoital contracep Woodhams EJ, Gilliam M. Contraception. Ann lntern Med. 2019;l7O:lTCt8 tion using a device or medication to prevent pregnancy after 32. IPMID: 307167 s9l doi:10.7326 /AITC20l 902050 inadequately protected intercourse. All forms of emergency contraception work by disrupting ovulation or preventing fertilization of an egg. Emergency contraceptives are not abortion inducing interventions. FDA approved options for emergency contraception include oral ulipristal acetate, oral Item 65 Answer: B Educational Objective: Classiff the severity of a burn. tr levonorgestrel, or a copper intrauterine device (lUD). New 'lhe classificrtion <;f this patient's burn is second clegree, data suggest that the 52 mg levonorgestrel IUD is noninferior superficial partial thickness (Option B), which in'uolves the to the copper IUD for emergency contraception, but it is not entire epidennis and penetrtrtes inb, bnt not through. thc currently FDA approved for this indication. Ulipristal acetate clcrtnis. l]ecause thc epidermal layer is lost, the wound fbrrns delays ovulation. It is the preferred oral contraceptive option a blister or n'eeps illterstitial f luid. The rn,ouncl blanchcs rvith for women with a BMI greater than 26, such as this patient. pressurc and is painful to air. tenlperatrlre, and pressure A single oral dose of ulipristal acetate is eft'ective for up to because thc vesscls ancl nerve of the dernris are still intact. 5 days after unprotected sexual intercourse. Although a pre- unlike the case with second degrec, cleep pafiial thickness scription is required for oral ulipristal acetate, an in person burns lnd third clegree burns. Ilealing occurs through medical visit is not required to provide this form of emer re epitlrclialization. Wound care lilr second clcgrce, par gency contraception. The copper IUD is FDA approved for use tial thickr.ress burns includes cleaning the rtottt.tcl ruith soap as emergency contraception and is the most effective fbrm and water and applying a topical antibiotic ointnlent. Spc ofemergency contraception; it can reduce the risk for preg ciirlized wound dr-essit.tg will nraintlin a t.lloist environment nancy by 99% if placed within 5 days of unprotected sexual and rnay renrain in place fbr several clays after thc injuryL intercourse. Copper IUDs prevent fertilization by unknown Surgical excision and skir-r grafting shoulcl be consiclered ftrr mechanisms and require a clinic visit fbr insertion. rtouncls that clo not re epithelialize after 2 kr 3 rt'eeks. Emergency contraception can be provided with off A tirst degrec, ttr superficial, bttrn (Option A) dtles not label use of combined oral contraceptive pills (Option A) penetrrte through the epiderrnis ancl presetlts rvith recl. containing ethinyl estradiol or either norgestrel or levo- tender skin but no blistering or rt'eeping. Minimirl or no norgestrel, but the dosing schedule is very different from the trcirtment is requircd. 201

Answers and Critiques tr CONI A second-degree, deep partial thickness bum (Option C) involves destruction of the epidermis and the dermis. It presents as a wet or dry u,ound that is painful only to patient given the degree of his symptoms. Topical agents in this category include olopatadine, alcaftadine, bepotastine, azelas tine hydrochloride, cetirizine, epinastine, ketotifen fumarate, pressure. The wound may be any color most commonly and emedastine. Generic ketotifen fumarate does not require white. yellor.l', or red. llealing is less likely to occur rvith re, a prescription. Although the full effect of these agents may take epithelialization, and surgical evaluation may be necessary. days, some effect is seen immediately. An advantage of this This patient's burn is painful rtithout pressure. so a deep class of drugs is that it is administered only once or twice daily, partial-thickness burn is incorrect. depending on the speciflc formulation. The most common side In a third degree, or full-thickness. burn (Option D), the eflect is buming and stinging with application, which may be entire epidermis. dermis. and lat are destroyed. These wounds mitigated by using refrigerated agents. are dry and often black in color (as shown) and cause minimal Topical antibiotics (Option A), such as trimethoprim- pain because the nenes of the dermis have been destroyed. polymyxin B, have no role in the treatment of uncompli- Excision and skin grafting are required for treatment. cated allergic conjunctivitis. This class of drug is effective for vt treating acute bacterial conjunctivitis in patients who do not € {f-,q (D wear contact lenses. Factors favoring bacterial conjunctivi- vt tis include glued eyes in the morning, redness completely o, obscuring the tarsal vessels, purulent discharge, and a red ct eye observed at 20 feet. Absence of a purulent discharge n makes bacterial conjunctivitis very unlikely. Topical glucocorticoids (Option C), such as prednis lt (D olone, are eflective for allergic conjunctivitis but are asso vt ciated with serious potential side ellects, including vision loss; glaucoma; corneal damage; and, with prolonged use, cataracts. They should be reserved for patients who have refractory symptoms and administered only under close supervision of an ophthalmologist for short periods. They would therefore be inappropriate to use in this patient. A mast cell-stabilizing agent (Option D), such as cromo- lyn, is eflective therapy for allergic conjunctivitis. However, it needs to be used for up to 14 days before complete efficacy is reached and requires administration four times daily, which may decrease adherence. Therefore, use is reserved for those o Second-degree, superficial partial-thickness burns patients in whom other therapies have failed. present as blisters or weeping wounds that blanch Topical NSAIDs (Option E) function by blocking the with pressure and are painful to air, temperature, and breakdown of thromboxane. Although topical NSAIDs have pressure. some efficacy in the treatment of allergic conjunctivitis com- . Wound care for second-degree, partial-thickness pared with placebo, they are less effective than antihista- burns includes cleaning the wound with soap and mines and are not a flrst-line treatment. water and applying a topical antibiotic ointment fol- lowed by an appropriate dressing. rit'?otf,lt .:':, ',,' o Perennial allergic conjunctivitis presents with bilat- Bibliography eral eye redness, pruritus, and watery discharge. Greenhalgh DG. Management ofburns. N Engl J Med. 2019;380:2349 59 o Topical antihistamines with mast cell-stabilizing IPMID: 311890381 doi:10.1056/NEJM ral$O7 442 effects are first-line therapies for uncomplicated allergic conjunctivitis. Item 66 Answer: B Ed ucationa I Obiective: Treat allergic conjunctivitis. Bibliography Bielory L, Delgado L, Katelaris CH, et al. ICON: diagnosis and management An antihistamine with mast cell-stabilizing properties is the of allergic conjunctivitis. Ann Allerry Asthma Immunol. 2020:124:ll8 34. IPMID: 31759180] doi:10.1016,,j.anai.2019.11.014 most appropriate topical treatment (Option B). This patient presents with bilateral eye redness, pruritus, and watery dis- charge, which are characteristic ofperennial allergic conjunc- Item 67 Answer: A G_ tivitis. Allergic conjunctMtis is due to IgE-mediated mast cell degranulation, with the resultant release of histamine and Educational Objective: Screen for colorectal cancer in a other inflammatory mediators. In addition to basic eye care, person who does not prefer colonoscopy. including cold compresses, and avoiding eye rubbing and An annual fecal immunochemical test (FIT) (Option A) known allergens, topical pharmacotherapy is indicated for this is the most appropriate colorectal screening test for this

tr CONI A second-degree, deep partial thickness bum (Option C) involves destruction of the epidermis and the dermis. It presents as a wet or dry u,ound that is painful only to patient given the degree of his symptoms. Topical agents in this category include olopatadine, alcaftadine, bepotastine, azelas tine hydrochloride, cetirizine, epinastine, ketotifen fumarate, pressure. The wound may be any color most commonly and emedastine. Generic ketotifen fumarate does not require white. yellor.l', or red. llealing is less likely to occur rvith re, a prescription. Although the full effect of these agents may take epithelialization, and surgical evaluation may be necessary. days, some effect is seen immediately. An advantage of this This patient's burn is painful rtithout pressure. so a deep class of drugs is that it is administered only once or twice daily, partial-thickness burn is incorrect. depending on the speciflc formulation. The most common side In a third degree, or full-thickness. burn (Option D), the eflect is buming and stinging with application, which may be entire epidermis. dermis. and lat are destroyed. These wounds mitigated by using refrigerated agents. are dry and often black in color (as shown) and cause minimal Topical antibiotics (Option A), such as trimethoprim- pain because the nenes of the dermis have been destroyed. polymyxin B, have no role in the treatment of uncompli- Excision and skin grafting are required for treatment. cated allergic conjunctivitis. This class of drug is effective for vt treating acute bacterial conjunctivitis in patients who do not € {f-,q (D wear contact lenses. Factors favoring bacterial conjunctivi- vt tis include glued eyes in the morning, redness completely o, obscuring the tarsal vessels, purulent discharge, and a red ct eye observed at 20 feet. Absence of a purulent discharge n makes bacterial conjunctivitis very unlikely. Topical glucocorticoids (Option C), such as prednis lt (D olone, are eflective for allergic conjunctivitis but are asso vt ciated with serious potential side ellects, including vision loss; glaucoma; corneal damage; and, with prolonged use, cataracts. They should be reserved for patients who have refractory symptoms and administered only under close supervision of an ophthalmologist for short periods. They would therefore be inappropriate to use in this patient. A mast cell-stabilizing agent (Option D), such as cromo- lyn, is eflective therapy for allergic conjunctivitis. However, it needs to be used for up to 14 days before complete efficacy is reached and requires administration four times daily, which may decrease adherence. Therefore, use is reserved for those o Second-degree, superficial partial-thickness burns patients in whom other therapies have failed. present as blisters or weeping wounds that blanch Topical NSAIDs (Option E) function by blocking the with pressure and are painful to air, temperature, and breakdown of thromboxane. Although topical NSAIDs have pressure. some efficacy in the treatment of allergic conjunctivitis com- . Wound care for second-degree, partial-thickness pared with placebo, they are less effective than antihista- burns includes cleaning the wound with soap and mines and are not a flrst-line treatment. water and applying a topical antibiotic ointment fol- lowed by an appropriate dressing. rit'?otf,lt .:':, ',,' o Perennial allergic conjunctivitis presents with bilat- Bibliography eral eye redness, pruritus, and watery discharge. Greenhalgh DG. Management ofburns. N Engl J Med. 2019;380:2349 59 o Topical antihistamines with mast cell-stabilizing IPMID: 311890381 doi:10.1056/NEJM ral$O7 442 effects are first-line therapies for uncomplicated allergic conjunctivitis. Item 66 Answer: B Ed ucationa I Obiective: Treat allergic conjunctivitis. Bibliography Bielory L, Delgado L, Katelaris CH, et al. ICON: diagnosis and management An antihistamine with mast cell-stabilizing properties is the of allergic conjunctivitis. Ann Allerry Asthma Immunol. 2020:124:ll8 34. IPMID: 31759180] doi:10.1016,,j.anai.2019.11.014 most appropriate topical treatment (Option B). This patient presents with bilateral eye redness, pruritus, and watery dis- charge, which are characteristic ofperennial allergic conjunc- Item 67 Answer: A G_ tivitis. Allergic conjunctMtis is due to IgE-mediated mast cell degranulation, with the resultant release of histamine and Educational Objective: Screen for colorectal cancer in a other inflammatory mediators. In addition to basic eye care, person who does not prefer colonoscopy. including cold compresses, and avoiding eye rubbing and An annual fecal immunochemical test (FIT) (Option A) known allergens, topical pharmacotherapy is indicated for this is the most appropriate colorectal screening test for this 202

Answers and Critiques patient. There is significant variation among colorec Bibliography tal cancer screening guidelines. The American College of Qrrsccm A, Crandlll CJ. Mustxlx RA. Hicks l-A, Wilt TJr Clinical Guidelines (bmmittee of the American (lollege of Physicians. Screening for cokrrec Physicians suggests colonoscopy every 10 years. flexible tlll cilncer in asymptomatic average risk trdults: a guidlnce statement sigmoidoscopy every 10 years plus FIT every 2 years, or FIT liom the Amcrican College ol l)hysicians. Ann Intern Mecl. 2019:171:6.1:l or high sensitivity guaiac based fecal occult blood testing 5.1. IPMID: 316ti32901 doi:10.7::t26lM19 0642

patient. There is significant variation among colorec Bibliography tal cancer screening guidelines. The American College of Qrrsccm A, Crandlll CJ. Mustxlx RA. Hicks l-A, Wilt TJr Clinical Guidelines (bmmittee of the American (lollege of Physicians. Screening for cokrrec Physicians suggests colonoscopy every 10 years. flexible tlll cilncer in asymptomatic average risk trdults: a guidlnce statement sigmoidoscopy every 10 years plus FIT every 2 years, or FIT liom the Amcrican College ol l)hysicians. Ann Intern Mecl. 2019:171:6.1:l or high sensitivity guaiac based fecal occult blood testing 5.1. IPMID: 316ti32901 doi:10.7::t26lM19 0642 every 2 years as acceptable screening regimens. In con trast. the U.S. Multi SocietyTask Force on Colorectal Cancer Item 68 Answer: D (MSTF), an initiative of'U.S. gastroenterology societies, has Educational Objective: Diagnose menopause. ranked colorectal cancer screening tests in tiers based on the available evidence. cost effectiveness, test availability, The most appropriate management is no further evaluation and several other factors. The MSTF recommends colon (Option D). Menopause is a clinical diagnosis made retro oscopy every 10 years or annual FIT as flrst tier tests; CT spectively when a woman has not experienced a menstrual colonography every 5 years, FIT f'ecal DNA testing every period for 12 months. Menopause occurring in women older ta o, 3 years. or flexible sigmoidoscopy every 5 to 10 years as sec than 40 years. such as this patient, requires no additional ET ond tier tests; and capsule colonography every 5 years as a lirboratory or diagnostic evaluation. Menopause occurring third tier test. Screening would be most appropriate among in women younger than 40 years should be evaluated fbr adults who (t) are healthy enough to undergo treatment if premature ovarian insufficiency and other disorders by t, E colorectal cancer is detected and (2) do not have comorbid obtaining fol licle stimulating hormone (FSH), serum thyroid E .u conditions that would signiflcantly limit their life expec stimulating hormone (TSH), and prolactin levels; on the UI tancy. Because there are no head to head comparisons of basis of results of these studies, additional evaluation may c, 3 the various screening modalities fbr colorectal cancer, the be required. Symptoms of menopause include vasomotor Ut E U.S. Preventive Services Task Force makes a practical rec symptoms (hot flushes, night sweats). Ilot flushes generally ommendation that the best screening modality is the one start in the perimenopausal period and can last for a few the patient is willing to complete. For this patient, FIT may years to lifelong. Women may experience other symptoms, h:rve certain desirable aclvantages. FIT has improved accu such as depression, anxiety, and irritability, but it is unclear racy compared with guaiac fecal occult blood test and does whether these symptoms can be attributed to menopause. not require bowel preparation, anesthesia, or transportation Genitourinary syndrome of menopause results from estro to and from the screening examination. gen deficiency and is characterized by vaginal symptoms, The recommended interval for CT colonography is every such as burning or irritation; sexual symptoms, such as dys 5 years, not every 10 years (Option B). Like colonoscopy, CT pareunia or sexual dysfunction; or urinary symptoms, such colonography requires bowel preparation, and this imaging as clysuria or recurrent urinary infections. test is not associated with the ability to remove polyps or Although serum FSH levels (Option A) are elevated biopsy. Extracolonic findings of undetermined significance in nrenopausal woman, measurement of FSH levels is not are common. required to diagnosis menopause in this patient. In a woman The serum circulating methylated SFIP'I'9 DNA test older than 40 years who has not had a menstrual period in (Option C) is an FDA approved screening strategy that more than 1 year and has a negative result on pregnancy test, I.rolds promise because blood tests may result in increased the clinical diagnosis of menopause can be made without adherence. However, this test's sensitivity tbr detecting additional laboratory evaluation. colorectal cilncer is only 4B'1,, and the MSTF does not rec A serum prolactin level (Option B) is appropriate man ommend its use. agement in the evaluation of early menopause and amen Flexible sigmoidoscopy every 2 years (Option D) orrhea. but it is not required to diagnose menopause in a is not a recommended colorectal screening strategy. patient older than 40 years. Flexible sigmoidoscopy is recommended every 5 to Obtaining a serum TSH level (Option C) can be helpful in l0 years when used alone, or every 5 years when com- evaluating a woman younger than 40 years with absent men bined with annual FIT. Although flexible sigmoidoscopy ses or a woman presenting with abnormal uterine bleeding, does require bowel preparation, it is limited compared but it is not required for the routine diagnosis of menopause. with colonoscopy. XEY POIIITS I(EY POITIS . Menopause is a clinical diagnosis made retrospectively o Colorectal cancer screening would be most appropri- when a woman has not experienced a menstrual ate among adults who (1) are healthy enough to period for 12 months, and routine laboratory testing undergo treatment if colorectal cancer is detected and for the diagnosis is not recommended. (2) do not have comorbid conditions that would sig- o Patients with possible early menopause (age <40 years) nificantly limit their life expectancy. should have pregnancy excluded and undergo meas- r The preferred colorectal screening strates/ is the one urement of follicle-stimulating hormone, thyroid most likely to be completed by the patient. stimulating hormone, and prolactin.

every 2 years as acceptable screening regimens. In con trast. the U.S. Multi SocietyTask Force on Colorectal Cancer Item 68 Answer: D (MSTF), an initiative of'U.S. gastroenterology societies, has Educational Objective: Diagnose menopause. ranked colorectal cancer screening tests in tiers based on the available evidence. cost effectiveness, test availability, The most appropriate management is no further evaluation and several other factors. The MSTF recommends colon (Option D). Menopause is a clinical diagnosis made retro oscopy every 10 years or annual FIT as flrst tier tests; CT spectively when a woman has not experienced a menstrual colonography every 5 years, FIT f'ecal DNA testing every period for 12 months. Menopause occurring in women older ta o, 3 years. or flexible sigmoidoscopy every 5 to 10 years as sec than 40 years. such as this patient, requires no additional ET ond tier tests; and capsule colonography every 5 years as a lirboratory or diagnostic evaluation. Menopause occurring third tier test. Screening would be most appropriate among in women younger than 40 years should be evaluated fbr adults who (t) are healthy enough to undergo treatment if premature ovarian insufficiency and other disorders by t, E colorectal cancer is detected and (2) do not have comorbid obtaining fol licle stimulating hormone (FSH), serum thyroid E .u conditions that would signiflcantly limit their life expec stimulating hormone (TSH), and prolactin levels; on the UI tancy. Because there are no head to head comparisons of basis of results of these studies, additional evaluation may c, 3 the various screening modalities fbr colorectal cancer, the be required. Symptoms of menopause include vasomotor Ut E U.S. Preventive Services Task Force makes a practical rec symptoms (hot flushes, night sweats). Ilot flushes generally ommendation that the best screening modality is the one start in the perimenopausal period and can last for a few the patient is willing to complete. For this patient, FIT may years to lifelong. Women may experience other symptoms, h:rve certain desirable aclvantages. FIT has improved accu such as depression, anxiety, and irritability, but it is unclear racy compared with guaiac fecal occult blood test and does whether these symptoms can be attributed to menopause. not require bowel preparation, anesthesia, or transportation Genitourinary syndrome of menopause results from estro to and from the screening examination. gen deficiency and is characterized by vaginal symptoms, The recommended interval for CT colonography is every such as burning or irritation; sexual symptoms, such as dys 5 years, not every 10 years (Option B). Like colonoscopy, CT pareunia or sexual dysfunction; or urinary symptoms, such colonography requires bowel preparation, and this imaging as clysuria or recurrent urinary infections. test is not associated with the ability to remove polyps or Although serum FSH levels (Option A) are elevated biopsy. Extracolonic findings of undetermined significance in nrenopausal woman, measurement of FSH levels is not are common. required to diagnosis menopause in this patient. In a woman The serum circulating methylated SFIP'I'9 DNA test older than 40 years who has not had a menstrual period in (Option C) is an FDA approved screening strategy that more than 1 year and has a negative result on pregnancy test, I.rolds promise because blood tests may result in increased the clinical diagnosis of menopause can be made without adherence. However, this test's sensitivity tbr detecting additional laboratory evaluation. colorectal cilncer is only 4B'1,, and the MSTF does not rec A serum prolactin level (Option B) is appropriate man ommend its use. agement in the evaluation of early menopause and amen Flexible sigmoidoscopy every 2 years (Option D) orrhea. but it is not required to diagnose menopause in a is not a recommended colorectal screening strategy. patient older than 40 years. Flexible sigmoidoscopy is recommended every 5 to Obtaining a serum TSH level (Option C) can be helpful in l0 years when used alone, or every 5 years when com- evaluating a woman younger than 40 years with absent men bined with annual FIT. Although flexible sigmoidoscopy ses or a woman presenting with abnormal uterine bleeding, does require bowel preparation, it is limited compared but it is not required for the routine diagnosis of menopause. with colonoscopy. XEY POIIITS I(EY POITIS . Menopause is a clinical diagnosis made retrospectively o Colorectal cancer screening would be most appropri- when a woman has not experienced a menstrual ate among adults who (1) are healthy enough to period for 12 months, and routine laboratory testing undergo treatment if colorectal cancer is detected and for the diagnosis is not recommended. (2) do not have comorbid conditions that would sig- o Patients with possible early menopause (age <40 years) nificantly limit their life expectancy. should have pregnancy excluded and undergo meas- r The preferred colorectal screening strates/ is the one urement of follicle-stimulating hormone, thyroid most likely to be completed by the patient. stimulating hormone, and prolactin. 203

Answers and Critiques Bibliography XEY POIilIS Burger HG. Unpredictable endocrinologr of the menopause transition: clinical, diagnostic and management implications. Menopause Int. 2011; . Melasma is a hyperpigmentation disorder that 17:153 4. IPMID: 22120939] doi:1O.1258/mi.2011.011026 occurs mostly on the sun exposed areas on the face; it most commonly affects women of childbearing age. Item 69 Answer: D o The first-line treatment for melasma is strict sun Educational Objective: Treat melasma with sun protection with sun avoidance, sunscreen, and avoidance and protection. sun-protective clothing. The most appropriate management is sun protection (Option D). This patient has melasma, also known as Bibliography chloasma, or the mask of pregnancy. Melasma is a hyper Ogbechie Godec OA, Fllbuluk N. Melasnra: an up to date comprehensive revieui Dermatol 'Iher (Heidelb). 201717::105 18. [PMID: 287262121 pigmentation disorder resulting in tan to dark brown retic- doi:10.1007/s13555 017 019.1-1 =t u ulated patches, mostly on the sun exposed areas on the face (malar, mandibular, and centrofacial regions, including the = .D UI o, forehead) and the upper extremities. It is exacerbated with Item 70 Answer: B sun exposure. Melasma most commonly affects women of CL Educational Objective: Frevent human childbearing age; it occurs more frequently and is more f'f papillomavirus infection with appropriate noticeable in patients with darker skin. Causes of melasma immunization. 4t are hormonal factors (pregnancy, use of oral contracep- .D tives), ultraviolet (UV) light, and genetic predisposition. The most appropriate vaccination strates/ for this patient t^ The most essential element of management of melasma is is to administer the human papillomavirus (HPV) vaccine strict sun protection with sun avoidance, use ofsunscreen, series (Option B). HPV vaccination prevents persistent HPV and wearing sun protective clothing. Melasma can occa- infection, which can lead to cervical, anogenital, and naso sionally resolve after pregnancy or with cessation of oral pharyngeal cancers. The vaccine should be administered contraceptive use but may persist or recur with UV light belween age 11 and 12 years or between the ages of 13 and exposure. Treatment is challenging and, in addition to strict 26 years if not given previously. Individuals younger than sun protection and avoidance, involves topical depigment 15 years can receive a tvvo-dose series, whereas those aged ing agents, such as hydroquinone. Laser therapy; chemical 15 years or older, such as this patient, should receive a three peels; and oral agents, such as tranexamic acid, are other dose series. A history of HPV infection or an abnormal Pap treatment options. It may take months to years for pigmen smear does not change the recommendation for vaccination. tation to normalize. The HPV vaccine is considered safe lor individuals aged 27 to Hydrocortisone cream (Option A) is a low potency glu 45 years; unvaccinated individuals in this age group should cocorticoid. When combined with tretinoin and hydroqui participate in shared decision making with their physician none, topical glucocorticoids have shown some efncacy in about the beneflts and risks of vaccination. Vaccination is the treatment of melasma. Monotherapy with topical gluco- not recommended during pregnancy, although no harmful corticoids for melasma is not recommended and would not effects have been noted when inadvertently given to preg be the correct management in this patient. Long term use of nant women and pregnancy testing is not necessary before topical glucocorticoids on the face additionally increases the vaccination. risk for skin atrophy. Administration of a second dose of quadrivalent Monobenzyl ether of hydroquinone (Option B) is a meningococcal conjugate vaccine (MenACWY) (Option A) depigmenting topical medication used for the treatment is not indicated for this patient. The Advisory Committee of vitiligo. It may be used for permanent depigmenta on Immunization Practices recommends routine vaccina tion in patients with greater than 50% body surface area tion with MenACWY for adolescents aged 11 or 12 years, affected by vitiligo but is not appropriate for treatment of with a booster dose at age 16 years. Eight weeks should melasma. elapse between primary vaccination and booster. If the first Oral tranexamic acid (Option C) is an antifibrinolytic dose was administered after age 16 years, such as in this approved for the treatment of heavy menstrual bleed- patient, a booster is not required. College freshmen living ing. Tranexamic acid inhibits melanin synthesis and has in resident halls should receive the vaccine within 5 years been used off label to treat refractory melasma. Because of enrollment. of its potential increased risk for thromboembolic events, For healthy nonsmokers with no high risk medical tranexamic acid would not be first line treatment for this conditions, such as this patient. the 23-valent pneumococ patient. cal polysaccharide vaccine (Option C) is not indicated until Although an association of melasma with thyroid age 65 years. abnormalities has been reported, routine measurement Because individuals betr,veen age 11 and 26 years should of thyroid stimulating hormone level (Option E) is not receive HPV vaccination, not offering the HPV vaccine series indicated. to this patient is not the best strategz (Option D).

Bibliography XEY POIilIS Burger HG. Unpredictable endocrinologr of the menopause transition: clinical, diagnostic and management implications. Menopause Int. 2011; . Melasma is a hyperpigmentation disorder that 17:153 4. IPMID: 22120939] doi:1O.1258/mi.2011.011026 occurs mostly on the sun exposed areas on the face; it most commonly affects women of childbearing age. Item 69 Answer: D o The first-line treatment for melasma is strict sun Educational Objective: Treat melasma with sun protection with sun avoidance, sunscreen, and avoidance and protection. sun-protective clothing. The most appropriate management is sun protection (Option D). This patient has melasma, also known as Bibliography chloasma, or the mask of pregnancy. Melasma is a hyper Ogbechie Godec OA, Fllbuluk N. Melasnra: an up to date comprehensive revieui Dermatol 'Iher (Heidelb). 201717::105 18. [PMID: 287262121 pigmentation disorder resulting in tan to dark brown retic- doi:10.1007/s13555 017 019.1-1 =t u ulated patches, mostly on the sun exposed areas on the face (malar, mandibular, and centrofacial regions, including the = .D UI o, forehead) and the upper extremities. It is exacerbated with Item 70 Answer: B sun exposure. Melasma most commonly affects women of CL Educational Objective: Frevent human childbearing age; it occurs more frequently and is more f'f papillomavirus infection with appropriate noticeable in patients with darker skin. Causes of melasma immunization. 4t are hormonal factors (pregnancy, use of oral contracep- .D tives), ultraviolet (UV) light, and genetic predisposition. The most appropriate vaccination strates/ for this patient t^ The most essential element of management of melasma is is to administer the human papillomavirus (HPV) vaccine strict sun protection with sun avoidance, use ofsunscreen, series (Option B). HPV vaccination prevents persistent HPV and wearing sun protective clothing. Melasma can occa- infection, which can lead to cervical, anogenital, and naso sionally resolve after pregnancy or with cessation of oral pharyngeal cancers. The vaccine should be administered contraceptive use but may persist or recur with UV light belween age 11 and 12 years or between the ages of 13 and exposure. Treatment is challenging and, in addition to strict 26 years if not given previously. Individuals younger than sun protection and avoidance, involves topical depigment 15 years can receive a tvvo-dose series, whereas those aged ing agents, such as hydroquinone. Laser therapy; chemical 15 years or older, such as this patient, should receive a three peels; and oral agents, such as tranexamic acid, are other dose series. A history of HPV infection or an abnormal Pap treatment options. It may take months to years for pigmen smear does not change the recommendation for vaccination. tation to normalize. The HPV vaccine is considered safe lor individuals aged 27 to Hydrocortisone cream (Option A) is a low potency glu 45 years; unvaccinated individuals in this age group should cocorticoid. When combined with tretinoin and hydroqui participate in shared decision making with their physician none, topical glucocorticoids have shown some efncacy in about the beneflts and risks of vaccination. Vaccination is the treatment of melasma. Monotherapy with topical gluco- not recommended during pregnancy, although no harmful corticoids for melasma is not recommended and would not effects have been noted when inadvertently given to preg be the correct management in this patient. Long term use of nant women and pregnancy testing is not necessary before topical glucocorticoids on the face additionally increases the vaccination. risk for skin atrophy. Administration of a second dose of quadrivalent Monobenzyl ether of hydroquinone (Option B) is a meningococcal conjugate vaccine (MenACWY) (Option A) depigmenting topical medication used for the treatment is not indicated for this patient. The Advisory Committee of vitiligo. It may be used for permanent depigmenta on Immunization Practices recommends routine vaccina tion in patients with greater than 50% body surface area tion with MenACWY for adolescents aged 11 or 12 years, affected by vitiligo but is not appropriate for treatment of with a booster dose at age 16 years. Eight weeks should melasma. elapse between primary vaccination and booster. If the first Oral tranexamic acid (Option C) is an antifibrinolytic dose was administered after age 16 years, such as in this approved for the treatment of heavy menstrual bleed- patient, a booster is not required. College freshmen living ing. Tranexamic acid inhibits melanin synthesis and has in resident halls should receive the vaccine within 5 years been used off label to treat refractory melasma. Because of enrollment. of its potential increased risk for thromboembolic events, For healthy nonsmokers with no high risk medical tranexamic acid would not be first line treatment for this conditions, such as this patient. the 23-valent pneumococ patient. cal polysaccharide vaccine (Option C) is not indicated until Although an association of melasma with thyroid age 65 years. abnormalities has been reported, routine measurement Because individuals betr,veen age 11 and 26 years should of thyroid stimulating hormone level (Option E) is not receive HPV vaccination, not offering the HPV vaccine series indicated. to this patient is not the best strategz (Option D). 204

Answers and Critiques XEY POITIS value when the diagnosis is in doubt owing to equivrlcal physical examination tindings. . Individuals aged 1t to 26 years should receive human papillomavirus vaccination, ideally administered XEY POII'It between age 11 and 12 years or between age 13 and o Testicular torsion, a surgical emergency, presents 26 years if not given previously. with acute onset of moderate to severe testicular o A history of human papillomavirus infection or an pain. abnormal Pap smear does not change the recommen- r Patients with testicular torsion have profound testicu- dation for human papillomavirus vaccination. lar tenderness and swelling, elevation of the involved testicle, and an absent cremasteric reflex. Bibliography Freedman MS. Bernstein ll. Ault KA. Recommended adult immunization Bibliography schedule, United States,2021. Ann lntern Med. 2021. IPMID: 33571011] UI doi:10.7326lM20 8080 Bourke MM, Silverberg JZ. Acute scrotal emergencies. Emerg Med Clin North o Am. 2019;37:593 610. IPMID: 31563197] doi:10.1016/i.emc.2019-07.002 ET

XEY POITIS value when the diagnosis is in doubt owing to equivrlcal physical examination tindings. . Individuals aged 1t to 26 years should receive human papillomavirus vaccination, ideally administered XEY POII'It between age 11 and 12 years or between age 13 and o Testicular torsion, a surgical emergency, presents 26 years if not given previously. with acute onset of moderate to severe testicular o A history of human papillomavirus infection or an pain. abnormal Pap smear does not change the recommen- r Patients with testicular torsion have profound testicu- dation for human papillomavirus vaccination. lar tenderness and swelling, elevation of the involved testicle, and an absent cremasteric reflex. Bibliography Freedman MS. Bernstein ll. Ault KA. Recommended adult immunization Bibliography schedule, United States,2021. Ann lntern Med. 2021. IPMID: 33571011] UI doi:10.7326lM20 8080 Bourke MM, Silverberg JZ. Acute scrotal emergencies. Emerg Med Clin North o Am. 2019;37:593 610. IPMID: 31563197] doi:10.1016/i.emc.2019-07.002 ET tr Item 71 Answer: A Educational Objective: Treat testicular torsion. Item72 Answer: C Educational Objective: Recommend timing of surgery tr (J ?, a! following a stroke. UI The most appropriate management is immediate surgical (l, exploration (Option A). This patient has a classic prescnta 'lhe most appropriate recomnrendation is to dclay surgery t,l = tion of testicular torsion, a twisting of the spermatic cord fbr at lcast 9 n.ronths fbllowing this patient's stroke (Option contcnts resulting in testicular ischcrnia. Testicular torsion C). Prior stroke or transient ischemic attack (TIA) is a is nlost comnron in children and your.rg adults and prcsents significant risk factor for recurrent stroke ir.r general and as acute unilateral scrotal pain and swelling. Examination during the perioperative peririd and also increases the risk reveirls elevation olthe im'olved scrotum ancl an absent cre- for a n.rajor adverse cardiac evcnt. Historically, it has beer-r mirsteric ref lex (failure of the testis to elevate when the ipsi recomnrended to delxy elective noncardiac surgery fbr a lateral inner thigh is stroked). I)ecreasecl bloocl flow seen on minimum of 3 montl.ts lbllowing stroke clr TIA owing to ! Doppler ultrasound is typical. l'esticular torsiorr is a surgical unacceptably high risk fbr recurrent stroke and impaired emergenc),,, ancl this patient should undergo immediatc sur- cerebral autoregulatior.r during that time franrc. However, gical exploration. The time fiont symptom onset to surgical more recent data show that this excecdingly high risk fbr t exploration is the most important determining f:rctor of tes recurrent stroke persists longer than il montl.rs, graclually ticular viability. If surgical exploratior.r is pertbrmed within returrring to a new baseline 9 to 12 months after the event, 6 hours of'sympton.r onset, the testis remains viable in 90'1, at r,rftich point it still remains elevated cclrnpared r.r,ith to 100')1, of cases. Testicular viabilit_v drops to 50',r, if surgery persons who never had :r strokc or TIA. Although surgeries is not performed until 12 hours after presentation and to less deen.rcd morc time sensitive or urgent may proceed af'ter than 10',{, if pertbrn.red 2,1 hours or more afler presentation. 3 months, it is nrost prudent to rt,ait at least 6 nronths alter I{ surgery is not reaclily available, an attempt to untwist the a priur stroke, and possibly as long as 9 months prior to testicle manually is warranted. hven iI successtul, folktw up elective proccdures. It is also important to notc that sec sulgery is typically required. ondary stroke prophylaxis with antiplatelet agents is ofler.r Iiimpiric antimicrobial therapy with intran.ruscular ccttri held Ibr prokrnged periods befbre and after spine surgery axor.rc and oral doxyclaline and scrotal eleration (Options B, owing to bleeding risks. rendering the patient at cven C) are both appropriate management fbr epididymitis and greatcr risk for recurrcnt strokc. epidiclymo orchitis in men younger thar.r 35 years, but not fbr Waiting 9 to 12 months for the risk for perioperative a patient with suspected testicular torsicl.r. Epididymitis and stroke to reduce to baseline is ideal. although the risk tbr epicliclymo rlrcl.ritis typically h:l,e a slou,er or.rsct and cause recurrent stroke remains elevated. Avoidir-rg surgery (Option less severe painl on physical examinatior.r, there is an intact A) is r.rot absolutely neccssary and after the bencfits and risks crenrasteric rellex ancl the involred testicle is not elevated. hare bcen weighed, surgery can be planned with appropri Ilecause of'the very high likelihood of tcsticular tor ate risk mitigation after an appropriate interval after stroke sion and tlre urgency fbr surgical exploratior.r in testicular or TlA. torsion, sLlrgery should not be delayed to obtain irnrg Stroke or TIA witl-rin 30 days of planned surgery ing studies. Although ultrasonography of'the scrotum (Options B, D) significantly increases the risk fbr perioper- (Option D) is highly sensitive (89'1,) and highly specilic ative stroke; cluring this period. electivc surgeries should be (99')1,) and hiis a false-negative rate of approximately 1'L avoidecl. Patients with stroke involving a large brain volume fbr diagnosing testicular torsion, it is not mandatory or with a reccnt hemorrhagic stroke also are at risk for cere- or nccessary in patients with a supportive l.ristory and bral hemorrhage if placed on cardiopulrnonary bypass and/ unequivclcal physical examination findings. iis exernpli or anticoagulation. If possible, nonemergency r.najor cardiac fied by this patient. Scrotal ultrasonography is of most proccdures should be avoided.

tr Item 71 Answer: A Educational Objective: Treat testicular torsion. Item72 Answer: C Educational Objective: Recommend timing of surgery tr (J ?, a! following a stroke. UI The most appropriate management is immediate surgical (l, exploration (Option A). This patient has a classic prescnta 'lhe most appropriate recomnrendation is to dclay surgery t,l = tion of testicular torsion, a twisting of the spermatic cord fbr at lcast 9 n.ronths fbllowing this patient's stroke (Option contcnts resulting in testicular ischcrnia. Testicular torsion C). Prior stroke or transient ischemic attack (TIA) is a is nlost comnron in children and your.rg adults and prcsents significant risk factor for recurrent stroke ir.r general and as acute unilateral scrotal pain and swelling. Examination during the perioperative peririd and also increases the risk reveirls elevation olthe im'olved scrotum ancl an absent cre- for a n.rajor adverse cardiac evcnt. Historically, it has beer-r mirsteric ref lex (failure of the testis to elevate when the ipsi recomnrended to delxy elective noncardiac surgery fbr a lateral inner thigh is stroked). I)ecreasecl bloocl flow seen on minimum of 3 montl.ts lbllowing stroke clr TIA owing to ! Doppler ultrasound is typical. l'esticular torsiorr is a surgical unacceptably high risk fbr recurrent stroke and impaired emergenc),,, ancl this patient should undergo immediatc sur- cerebral autoregulatior.r during that time franrc. However, gical exploration. The time fiont symptom onset to surgical more recent data show that this excecdingly high risk fbr t exploration is the most important determining f:rctor of tes recurrent stroke persists longer than il montl.rs, graclually ticular viability. If surgical exploratior.r is pertbrmed within returrring to a new baseline 9 to 12 months after the event, 6 hours of'sympton.r onset, the testis remains viable in 90'1, at r,rftich point it still remains elevated cclrnpared r.r,ith to 100')1, of cases. Testicular viabilit_v drops to 50',r, if surgery persons who never had :r strokc or TIA. Although surgeries is not performed until 12 hours after presentation and to less deen.rcd morc time sensitive or urgent may proceed af'ter than 10',{, if pertbrn.red 2,1 hours or more afler presentation. 3 months, it is nrost prudent to rt,ait at least 6 nronths alter I{ surgery is not reaclily available, an attempt to untwist the a priur stroke, and possibly as long as 9 months prior to testicle manually is warranted. hven iI successtul, folktw up elective proccdures. It is also important to notc that sec sulgery is typically required. ondary stroke prophylaxis with antiplatelet agents is ofler.r Iiimpiric antimicrobial therapy with intran.ruscular ccttri held Ibr prokrnged periods befbre and after spine surgery axor.rc and oral doxyclaline and scrotal eleration (Options B, owing to bleeding risks. rendering the patient at cven C) are both appropriate management fbr epididymitis and greatcr risk for recurrcnt strokc. epidiclymo orchitis in men younger thar.r 35 years, but not fbr Waiting 9 to 12 months for the risk for perioperative a patient with suspected testicular torsicl.r. Epididymitis and stroke to reduce to baseline is ideal. although the risk tbr epicliclymo rlrcl.ritis typically h:l,e a slou,er or.rsct and cause recurrent stroke remains elevated. Avoidir-rg surgery (Option less severe painl on physical examinatior.r, there is an intact A) is r.rot absolutely neccssary and after the bencfits and risks crenrasteric rellex ancl the involred testicle is not elevated. hare bcen weighed, surgery can be planned with appropri Ilecause of'the very high likelihood of tcsticular tor ate risk mitigation after an appropriate interval after stroke sion and tlre urgency fbr surgical exploratior.r in testicular or TlA. torsion, sLlrgery should not be delayed to obtain irnrg Stroke or TIA witl-rin 30 days of planned surgery ing studies. Although ultrasonography of'the scrotum (Options B, D) significantly increases the risk fbr perioper- (Option D) is highly sensitive (89'1,) and highly specilic ative stroke; cluring this period. electivc surgeries should be (99')1,) and hiis a false-negative rate of approximately 1'L avoidecl. Patients with stroke involving a large brain volume fbr diagnosing testicular torsion, it is not mandatory or with a reccnt hemorrhagic stroke also are at risk for cere- or nccessary in patients with a supportive l.ristory and bral hemorrhage if placed on cardiopulrnonary bypass and/ unequivclcal physical examination findings. iis exernpli or anticoagulation. If possible, nonemergency r.najor cardiac fied by this patient. Scrotal ultrasonography is of most proccdures should be avoided. 205

Answers and Critiques IEY POIilTS . Patients at the highest risk for perioperative stroke include those with a history of prior stroke or tran sient ischemic attack. o Elective surgery should ideally be delayed at least 6 months after a prior stroke, and possibly as long as 9 months following stroke or transient ischemic attack. Bibliography Benesch C, Glance LG. Derde),n CP. r,t rli American Heart .\ssociation Stroke (iruncil: Council on i\rteriosclerosis. Throntbosis and \irscular Biolop5 r (iruncil on Cardiovirscular and Stroke Nursing: Council on Clinical Crrdiolo[X/l Council on lipidemiokr!l/ and Prevention. Perioperative neu rological elaluation and management to los,er the risk ofacute stroke in UI prtients undergoing noncardiac. nonneurokrgical surgery': ir scientific statement liom the Anrerican l{eart Association Americirn Stroke = .D Association. (lirculation. 2021:CIR00000000OO0O0968. IPMID: 33827230] UI q, doi: I 0.11 6l rCI R.00OOO000OOOOO968

Bibliography Benesch C, Glance LG. Derde),n CP. r,t rli American Heart .\ssociation Stroke (iruncil: Council on i\rteriosclerosis. Throntbosis and \irscular Biolop5 r (iruncil on Cardiovirscular and Stroke Nursing: Council on Clinical Crrdiolo[X/l Council on lipidemiokr!l/ and Prevention. Perioperative neu rological elaluation and management to los,er the risk ofacute stroke in UI prtients undergoing noncardiac. nonneurokrgical surgery': ir scientific statement liom the Anrerican l{eart Association Americirn Stroke = .D Association. (lirculation. 2021:CIR00000000OO0O0968. IPMID: 33827230] UI q, doi: I 0.11 6l rCI R.00OOO000OOOOO968 a r.l Item 73 Answer: D .lt Educational Objective: Diagnose scabies. tr Because of the lower mite burden in the typical presen o UI The most likely diagnosis is scabies (Option D), an intensely tation of scabies, the scabies preparation may be negatire: pruritic skin condition that presents with papules and bur diagnosis, however, can be made on the basis of the history rows on the fingers and web spaces. Other common areas of (itch. close contact with individuals with similar lesions or involvement are the breasts, wrists, axillae, waistline. geni- itch) and distribution of lesions. Treatment is topical perme talia, and ankles. Scabies typically spares the face and scalp thrin or oral ivermectin. in adults. Pruritus is usually worse at night. Scabies is caused Bed bug bites (Option A) present as erythematous pap- by Sorcoptes scobiei. which lives in the human epidermis. ules, typically in a linear pattern, on exposed areas ofthe skin. Skin to skin contact, including sexual transmission, is the Bites occur at night when the bed bug. Cimex lectulorius, primary mode of transmission. Outbreaks are common in typically feeds. Bites have characteristically linearly arranged families, institutional settings, and the homeless population urticarial papules ("breakfast. lunch. and dinner") and are due to its highly contagious nature. Crusted scabies, a form usually fewer in number than seen in this patient. Bed bug of scabies with a significantly higher mite load (thousands bites are not consistent with this patient's skin findings. versus 5 15 mites in typical scabies), presents lvith wide Dyshidrosis (Option B). or dyshidrotic eczema. is a form spread psoriasiform and hyperkeratotic lesions; it is more of hand dermatitis characterized by vesicles on the hands common in immunocompromised patients. The skin find and fingers; it is also common on the feet. Dyshidrosis is ings of crusted scabies are shown. often exacerbated by irritants, such as u,ater and detergents, and is more common in patients with atopic clermatitis. It does not present u,ith burrows, as seen in this patient. lmpetigo (Option C) is a bacterial infection of the skin most commonly caused by Stophylococcus oureus. group A streptococci. or both. Impetigo presents as honey colored crusted erosions or bullae, commonly on the face. This patient's skin findings are not consistent with impetigo.

a r.l Item 73 Answer: D .lt Educational Objective: Diagnose scabies. tr Because of the lower mite burden in the typical presen o UI The most likely diagnosis is scabies (Option D), an intensely tation of scabies, the scabies preparation may be negatire: pruritic skin condition that presents with papules and bur diagnosis, however, can be made on the basis of the history rows on the fingers and web spaces. Other common areas of (itch. close contact with individuals with similar lesions or involvement are the breasts, wrists, axillae, waistline. geni- itch) and distribution of lesions. Treatment is topical perme talia, and ankles. Scabies typically spares the face and scalp thrin or oral ivermectin. in adults. Pruritus is usually worse at night. Scabies is caused Bed bug bites (Option A) present as erythematous pap- by Sorcoptes scobiei. which lives in the human epidermis. ules, typically in a linear pattern, on exposed areas ofthe skin. Skin to skin contact, including sexual transmission, is the Bites occur at night when the bed bug. Cimex lectulorius, primary mode of transmission. Outbreaks are common in typically feeds. Bites have characteristically linearly arranged families, institutional settings, and the homeless population urticarial papules ("breakfast. lunch. and dinner") and are due to its highly contagious nature. Crusted scabies, a form usually fewer in number than seen in this patient. Bed bug of scabies with a significantly higher mite load (thousands bites are not consistent with this patient's skin findings. versus 5 15 mites in typical scabies), presents lvith wide Dyshidrosis (Option B). or dyshidrotic eczema. is a form spread psoriasiform and hyperkeratotic lesions; it is more of hand dermatitis characterized by vesicles on the hands common in immunocompromised patients. The skin find and fingers; it is also common on the feet. Dyshidrosis is ings of crusted scabies are shown. often exacerbated by irritants, such as u,ater and detergents, and is more common in patients with atopic clermatitis. It does not present u,ith burrows, as seen in this patient. lmpetigo (Option C) is a bacterial infection of the skin most commonly caused by Stophylococcus oureus. group A streptococci. or both. Impetigo presents as honey colored crusted erosions or bullae, commonly on the face. This patient's skin findings are not consistent with impetigo. IEY POIlIII o Scabies is a skin infestation with Sorcoptes scobiei characterized by papules and burrows on the fingers and web spaces, breasts, wrists, axillae, waistline, genitalia, and ankles; it is transmitted by skin to skin contact and can be treated with topical permethrin or oral ivermectin. o Crusted scabies is a form of scabies with a high mite Diagnosis of scabies is conflrmed using :r mineral oil load that presents with widespread psoriasiform and preparation of skin scraping for microscopic identification hyperkeratotic lesions; it is more common in immu- of mites, eglls, or feces under the microscope. as shown (see nocompromised patients. top of next column).

IEY POIlIII o Scabies is a skin infestation with Sorcoptes scobiei characterized by papules and burrows on the fingers and web spaces, breasts, wrists, axillae, waistline, genitalia, and ankles; it is transmitted by skin to skin contact and can be treated with topical permethrin or oral ivermectin. o Crusted scabies is a form of scabies with a high mite Diagnosis of scabies is conflrmed using :r mineral oil load that presents with widespread psoriasiform and preparation of skin scraping for microscopic identification hyperkeratotic lesions; it is more common in immu- of mites, eglls, or feces under the microscope. as shown (see nocompromised patients. top of next column). 206

Answers and Critiques Bibliography l(EY PO I 1{I5 (ointinued) 'Ihomas C. Coates SJ. I:ngelman I). et al. Ectoparasites: scabies. J Am Acad Dermatol. 2020;82:533 48. ll)MID: 313108,101 doi:10.1016,j.jaad.2019. o Patients with compensated cirrhosis who have Model 05.109 for End-stage Liver Disease (MELD) scores below 8 to 10 may proceed with most surgeries with optimal

Bibliography l(EY PO I 1{I5 (ointinued) 'Ihomas C. Coates SJ. I:ngelman I). et al. Ectoparasites: scabies. J Am Acad Dermatol. 2020;82:533 48. ll)MID: 313108,101 doi:10.1016,j.jaad.2019. o Patients with compensated cirrhosis who have Model 05.109 for End-stage Liver Disease (MELD) scores below 8 to 10 may proceed with most surgeries with optimal tr Item 74 Answer: A Educational Objective: Assess risk in a patient with medical management; a MELD score greater than 20 precludes all but the most urgent surgeries for life threatening illness. cirrhosis before elective surgery. 'lhe mt.rst appropriate perioperati\e ntanagemeltt is to coun Bibliography se1 the patient r-rn increasecl surgical risk as it relates k) his Northup l'(;. l.riedmln I-S. Kantath PS. AGA clinical practice updatc on diagnosis of'cirrltosis (Option A). Dr-rring the perioperative surgical risk assessntent and perioperative nranagement in cirrhosis: expert review. Clin (lastroentcRrl IIepatol. 2019;17:59.5 606. IPMII]: period, prtients with cirrhosis arc rrt significar-rtly greater 302737Sll doi:10. l0l 6/j.cgh.20l t].09.043 t risk fbr electrol_vte abnormllities. Iluid imbalance, deliriurn. q, kidnel, failure. r.r'orsening liver dl,stunction. impaired clear ET ance ol nlcdiciltiorls, ir.rf'ection. bleecling, clotting, and death. Item 75 Answer: A 'lhe likelihood of poor outcontes increases rt,ith the extent of Educational Objective: Treat obesity with (J lirer disease as rncasured by \,lodel tbr End stirge I-iver L)is pharmacotherapy. -, .g case (r\,1il.1)) or Child Turcotte-Pugh score. 'lhe MELD score 'lhe most appropriate management is liraglutide (Option A), UI ir-rcorporates the INR. serunt total bilirubin level, and serun-r c, a glucagon like peptide 1 (GLP-1) receptor agonist. Phar creatinine lerels. A progressiYe increase in perioperative ntrtr UI macotherapy is an option in the treatment ol obesity and = E talitl' lirr all proccdures is <tbsencd as MELD scores rise. overweight for patients with BMI of 30 or greater or fbr [)atients who have MEI.D scores below B to l0 generally do those with BMI of 27 or greater and at least one obesity- uell pcrioperativell, pr-oviciecl that their lir,.er clisease is stable associated comorbid conditiorl (such as diabetes, hyper iit-td contpensated, and it is reasonable to proceed rtith rlost tension, or obstructive sleep apnea) who have not achieved surgerics with optimal medical milnxgcment. When a MEI-t) weight loss goals with a trial of at least 3 to 6 months of score is greater than 20. mortalit!' rates increase to a dcgree lilbstyle modiflcation. Pharmacotherapy is contraindicated that prcclucles all but the most urgerlt surgerics fbr lite thrcat- in pregnancy, and women of childbearing age should be ening illness. A M ELD score ot 14 (as this patient has) inclicates advised to avoid pregnancy while using these medications. intermecliate risl< ftrr surgcry related complications. ancl the The goal of pharmacotherapy is weight loss of 5'7, or more risks and benefits of tl-re allticipated clecti'"e surgerl shoulcl be during the first 3 to 6 months. If this target is not reached, discussecl r,vith tl.rc patient al'ter the perioper:rtive evaluation. use of the medication should be discontinued. Weight is In patients r,r'ith cirrhosis ancl asymptom;itic clev:r typically regained once pharmacotherapy is discontinued, tior.t of the prothron.rbin tinre or INR, prophy'lactic trcat- which underscores the importance of concomitant lifestyle ment nrith either plasma or cryoprecipitate (Option B) is changes. '[he potential weight loss beneflt of pharmacother not indic'ated. 'lhcre is no cvidence of benefit with these apy should be balanced against risk fbr adverse events and intervclrtions and there is evidence of harnr. particularly cost. Liraglutide in an injectable agent that acts to decrease the risks fbr transfusion reactions xnd volunte overlotd. gastric emptying, thereby increasing satiety, and has been Patients n'ith cirrhosis ilnd platelet counts o1'50.0001pI- associated with weight loss ot'5.2 kg (11.6 lb) compared with (50 x 10" L) or grcater do not requirc platelet transfusior.rs placebo. Contraindications include a history of medullary prior to surger),. thyroid carcinoma and family history of multiple endocrine In the abscnce of'dccompensatecl liver clisease (vari neoplasia type 2, and it should be used cautiously in patients ceal hcrnorrh:rgc. ascites, encephlkrpathl') ir NlELD score with pancreatitis. Of the pharmacologic treatment options, lcss than 15 clocs not mect criteria firr lir.er transplantation liraglutide is the weight loss medication most likely to be (Option C). 'lhis patient is at increilsecl risl< for srlrgery rclated well tolerated in this patient. Naltrexone bupropion (Option B) is an opioid antag corxplicxtions. Before proceeding r,r'ith surgery in such onist and norepinephrine dopamine uptake inhibitor that patients. it is impurtant to cliscuss w,ith theur the poterl suppresses appetite. It has a higher discontinuation rate tiiil risks and benefits of hip artl.rroplastl, (Option D). compared with other pharnlacologic options. The most com inclucling alternative therapics that do not in\'ohre sLlrgical mon adverse eflbcts include nausea, dizziness, changes in intervclrtioll. bowel habits, and insomnia. Contraindications include sei- I(EY PO I XTI zure disorders. eating disorders, any current opiate use or o A progressive increase in perioperative mortality for withdrawal, or any risky alcohol use. Because this patient has insomnia, this drug combination would be a poor choice. all procedures is observed as Model for End stage Orlistat (Option C) is an intraluminal lipase inhibitor Liver Disease scores rise. (Continued) that induces weight loss by decreasing triglyceride absorp tion. Although safb, it causes gastrointestinal side efl'ects,

tr Item 74 Answer: A Educational Objective: Assess risk in a patient with medical management; a MELD score greater than 20 precludes all but the most urgent surgeries for life threatening illness. cirrhosis before elective surgery. 'lhe mt.rst appropriate perioperati\e ntanagemeltt is to coun Bibliography se1 the patient r-rn increasecl surgical risk as it relates k) his Northup l'(;. l.riedmln I-S. Kantath PS. AGA clinical practice updatc on diagnosis of'cirrltosis (Option A). Dr-rring the perioperative surgical risk assessntent and perioperative nranagement in cirrhosis: expert review. Clin (lastroentcRrl IIepatol. 2019;17:59.5 606. IPMII]: period, prtients with cirrhosis arc rrt significar-rtly greater 302737Sll doi:10. l0l 6/j.cgh.20l t].09.043 t risk fbr electrol_vte abnormllities. Iluid imbalance, deliriurn. q, kidnel, failure. r.r'orsening liver dl,stunction. impaired clear ET ance ol nlcdiciltiorls, ir.rf'ection. bleecling, clotting, and death. Item 75 Answer: A 'lhe likelihood of poor outcontes increases rt,ith the extent of Educational Objective: Treat obesity with (J lirer disease as rncasured by \,lodel tbr End stirge I-iver L)is pharmacotherapy. -, .g case (r\,1il.1)) or Child Turcotte-Pugh score. 'lhe MELD score 'lhe most appropriate management is liraglutide (Option A), UI ir-rcorporates the INR. serunt total bilirubin level, and serun-r c, a glucagon like peptide 1 (GLP-1) receptor agonist. Phar creatinine lerels. A progressiYe increase in perioperative ntrtr UI macotherapy is an option in the treatment ol obesity and = E talitl' lirr all proccdures is <tbsencd as MELD scores rise. overweight for patients with BMI of 30 or greater or fbr [)atients who have MEI.D scores below B to l0 generally do those with BMI of 27 or greater and at least one obesity- uell pcrioperativell, pr-oviciecl that their lir,.er clisease is stable associated comorbid conditiorl (such as diabetes, hyper iit-td contpensated, and it is reasonable to proceed rtith rlost tension, or obstructive sleep apnea) who have not achieved surgerics with optimal medical milnxgcment. When a MEI-t) weight loss goals with a trial of at least 3 to 6 months of score is greater than 20. mortalit!' rates increase to a dcgree lilbstyle modiflcation. Pharmacotherapy is contraindicated that prcclucles all but the most urgerlt surgerics fbr lite thrcat- in pregnancy, and women of childbearing age should be ening illness. A M ELD score ot 14 (as this patient has) inclicates advised to avoid pregnancy while using these medications. intermecliate risl< ftrr surgcry related complications. ancl the The goal of pharmacotherapy is weight loss of 5'7, or more risks and benefits of tl-re allticipated clecti'"e surgerl shoulcl be during the first 3 to 6 months. If this target is not reached, discussecl r,vith tl.rc patient al'ter the perioper:rtive evaluation. use of the medication should be discontinued. Weight is In patients r,r'ith cirrhosis ancl asymptom;itic clev:r typically regained once pharmacotherapy is discontinued, tior.t of the prothron.rbin tinre or INR, prophy'lactic trcat- which underscores the importance of concomitant lifestyle ment nrith either plasma or cryoprecipitate (Option B) is changes. '[he potential weight loss beneflt of pharmacother not indic'ated. 'lhcre is no cvidence of benefit with these apy should be balanced against risk fbr adverse events and intervclrtions and there is evidence of harnr. particularly cost. Liraglutide in an injectable agent that acts to decrease the risks fbr transfusion reactions xnd volunte overlotd. gastric emptying, thereby increasing satiety, and has been Patients n'ith cirrhosis ilnd platelet counts o1'50.0001pI- associated with weight loss ot'5.2 kg (11.6 lb) compared with (50 x 10" L) or grcater do not requirc platelet transfusior.rs placebo. Contraindications include a history of medullary prior to surger),. thyroid carcinoma and family history of multiple endocrine In the abscnce of'dccompensatecl liver clisease (vari neoplasia type 2, and it should be used cautiously in patients ceal hcrnorrh:rgc. ascites, encephlkrpathl') ir NlELD score with pancreatitis. Of the pharmacologic treatment options, lcss than 15 clocs not mect criteria firr lir.er transplantation liraglutide is the weight loss medication most likely to be (Option C). 'lhis patient is at increilsecl risl< for srlrgery rclated well tolerated in this patient. Naltrexone bupropion (Option B) is an opioid antag corxplicxtions. Before proceeding r,r'ith surgery in such onist and norepinephrine dopamine uptake inhibitor that patients. it is impurtant to cliscuss w,ith theur the poterl suppresses appetite. It has a higher discontinuation rate tiiil risks and benefits of hip artl.rroplastl, (Option D). compared with other pharnlacologic options. The most com inclucling alternative therapics that do not in\'ohre sLlrgical mon adverse eflbcts include nausea, dizziness, changes in intervclrtioll. bowel habits, and insomnia. Contraindications include sei- I(EY PO I XTI zure disorders. eating disorders, any current opiate use or o A progressive increase in perioperative mortality for withdrawal, or any risky alcohol use. Because this patient has insomnia, this drug combination would be a poor choice. all procedures is observed as Model for End stage Orlistat (Option C) is an intraluminal lipase inhibitor Liver Disease scores rise. (Continued) that induces weight loss by decreasing triglyceride absorp tion. Although safb, it causes gastrointestinal side efl'ects, 207

Answers and Critiques including oily stools, increased defecation, and fecal urgency infections have more signiflcant erythema, tenderness, and or incontinence in as many as 30'/, of patients. Contraindi often exudative drainage. This patient has pruritus and a cations include malabsorption syndromes and cholestasis. classic presentation of allergic contact dermatitis. and thus This patient has irritable bowel syndrome with diarrhea, and mupirocin is not the best treatment option. it is unlikely that she will tolerate the gastrointestinal side Prednisone (Option C) can be used for severe systemic eflects of orlistat. drug reactions, such as a systemic reaction to an antibiotic, Phentermine-topiramate (Option D) is a noradren but it would not be appropriate for treating this localized l

including oily stools, increased defecation, and fecal urgency infections have more signiflcant erythema, tenderness, and or incontinence in as many as 30'/, of patients. Contraindi often exudative drainage. This patient has pruritus and a cations include malabsorption syndromes and cholestasis. classic presentation of allergic contact dermatitis. and thus This patient has irritable bowel syndrome with diarrhea, and mupirocin is not the best treatment option. it is unlikely that she will tolerate the gastrointestinal side Prednisone (Option C) can be used for severe systemic eflects of orlistat. drug reactions, such as a systemic reaction to an antibiotic, Phentermine-topiramate (Option D) is a noradren but it would not be appropriate for treating this localized l ergic y-aminobutyric acid receptor activator and AMPA contact dermatitis. Systemic drug reactions are typically glutamate receptor inhibitor. Contraindications include morbilliform, widespread, and symmetric. This patient has glaucoma, hyperthyroidism, and nephrolithiasis. Caution is no indication of a systemic drug reaction to the course advised in patients with hypertension or resting tachycardia. of amoxicillin he had received, and prednisone is not Because this patient has a history of nephrolithiasis, phen warranted. D termine-topiramate is contraindicated. TEY POIXIS 3 tt € XEY POIt{I . Contact dermatitis is an eczematous eruption that .D UI o Pharmacotherapy is an option in the treatment of occurs at the site of allergen contact with the skin and o, obesity and overweight for patients with BMI of 30 or is characterized by pruritic, erythematous patches or EL greater or for those with BMI of 27 or greater and at plaques that may show vesicles and weeping acutely, a't Ieast one obesity-associated comorbid condition who or dry scaling and lichenification at later stages.

ergic y-aminobutyric acid receptor activator and AMPA contact dermatitis. Systemic drug reactions are typically glutamate receptor inhibitor. Contraindications include morbilliform, widespread, and symmetric. This patient has glaucoma, hyperthyroidism, and nephrolithiasis. Caution is no indication of a systemic drug reaction to the course advised in patients with hypertension or resting tachycardia. of amoxicillin he had received, and prednisone is not Because this patient has a history of nephrolithiasis, phen warranted. D termine-topiramate is contraindicated. TEY POIXIS 3 tt € XEY POIt{I . Contact dermatitis is an eczematous eruption that .D UI o Pharmacotherapy is an option in the treatment of occurs at the site of allergen contact with the skin and o, obesity and overweight for patients with BMI of 30 or is characterized by pruritic, erythematous patches or EL greater or for those with BMI of 27 or greater and at plaques that may show vesicles and weeping acutely, a't Ieast one obesity-associated comorbid condition who or dry scaling and lichenification at later stages. a=. have not achieved weight loss goals with a trial of at . Bacitracin, polymyxin B, and neomycin are common E least 3 to 6 months of lifestyle modification. topical antibiotics used to treat or prevent wound o Ut infections and are commonly associated with allergic Bibliography contact dermatitis. Khera R. Murad MH. Chandar AK. et al. Association ol pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta analysis. JAMA. 2016;315:2424 34. IPMID: 272996181 Bibliography doir10.1001 /jama.2016.7 602 Bonamonte D. De Marco A, Giufliida R. et al. Topical antibiotics in the der matological clinical practice: indications. eflicacl. and adrerse effects. Dermatol Ther. 2020r:13:e13824. IPMID: 325:]11051 doi:10.1 lll dth.l3821

a=. have not achieved weight loss goals with a trial of at . Bacitracin, polymyxin B, and neomycin are common E least 3 to 6 months of lifestyle modification. topical antibiotics used to treat or prevent wound o Ut infections and are commonly associated with allergic Bibliography contact dermatitis. Khera R. Murad MH. Chandar AK. et al. Association ol pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta analysis. JAMA. 2016;315:2424 34. IPMID: 272996181 Bibliography doir10.1001 /jama.2016.7 602 Bonamonte D. De Marco A, Giufliida R. et al. Topical antibiotics in the der matological clinical practice: indications. eflicacl. and adrerse effects. Dermatol Ther. 2020r:13:e13824. IPMID: 325:]11051 doi:10.1 lll dth.l3821 Item 76 Answer: D Ed u cationa I O bjective : Treat allergic contact Item 77 Answer: D dermatitis. Educational Objective: Avoid aspirin for primary prevention in patients on anticoagulation. The most appropriate treatment is to add triamcinolone cream (Option D). This patient developed allergic contact Aspirin is not recommended (Option D) fbr patients at dermatitis to bacitracin ointment. Contact dermatitis is higher risk for bleeding, such as this patient taking rivarox an eczematous eruption that occurs at the site of allergen aban. The U.S. Preventive Services Task Force recommends contact with the skin and is characterized by pruritic, ery- low-dose aspirin for the primary pievention of atheroscle thematous patches or plaques that may show vesicles and rotic cardiovascular disease (ASCVD) and colorectal can- weeping acutely. or dry scaling and lichenification at later cer in willing adults aged 50 to 59 years with a 1O-year stages. Although the patient discontinued using bacitracin ASCVD risk of 10'X, or higher, a life expectancy of at least 3 days before presenting, erythema and pruritus persist and 10 years, and no increased risk for bleeding. This patient has would be best treated with a topical glucocorticoid, such as a 10 year ASCVD risk greater than 10'){, and may be consid triamcinolone cream. Bacitracin, polymlxin B, and neomy ered for aspirin therapy lor primary prevention of ASCVD. cin are common topical antibiotics used to treat or prevent Tempering the recommendation lor primary prevention of wound infections and are fiequently associated with allergic ASCVD with aspirin are multiple trials, including ASCEND. contact dermatitis. For clean wounds, such as a skin surgical ARRIVE, and ASPREE. and a 2019 meta-analysis showing site, the application of plain petrolatum is recommended no net mortalify benefit with aspirin; reductions in nonfatal over the use oftopical antibiotics. myocardial infarction and ischemic stroke were offset by Candida infections are rare in clean surgical wounds, an increased risk for major bleeding, including intracranial and treatment with ketoconazole cream (Option A) is not hemorrhage. Factors that increase risk for bleeding include indicated for this patient. Candido infections occur more increasing age, male sex, concurrent anticoagulant or NSAID commonly in intertriginous areas and are characterized by use, history of gastrointestinal bleeding, upper gastrointesti erythema with satellite papules or pustules. This patient's nal pain, uncontrolled hypertension, chronic kidney disease, skin flndings have no features of Candida infection. and thrombocytopenia. Because of these data, the American Although mupirocin ointment (Option B) is less likely College of Cardiologr and the American Heart Association than bacitracin to cause allergic contact dermatitis, there recommended that aspirin should be used infrequently in is no indication of wound infection in this patient. Wound primary prevention of ASCVD and that low-dose (81 mg/d)

Item 76 Answer: D Ed u cationa I O bjective : Treat allergic contact Item 77 Answer: D dermatitis. Educational Objective: Avoid aspirin for primary prevention in patients on anticoagulation. The most appropriate treatment is to add triamcinolone cream (Option D). This patient developed allergic contact Aspirin is not recommended (Option D) fbr patients at dermatitis to bacitracin ointment. Contact dermatitis is higher risk for bleeding, such as this patient taking rivarox an eczematous eruption that occurs at the site of allergen aban. The U.S. Preventive Services Task Force recommends contact with the skin and is characterized by pruritic, ery- low-dose aspirin for the primary pievention of atheroscle thematous patches or plaques that may show vesicles and rotic cardiovascular disease (ASCVD) and colorectal can- weeping acutely. or dry scaling and lichenification at later cer in willing adults aged 50 to 59 years with a 1O-year stages. Although the patient discontinued using bacitracin ASCVD risk of 10'X, or higher, a life expectancy of at least 3 days before presenting, erythema and pruritus persist and 10 years, and no increased risk for bleeding. This patient has would be best treated with a topical glucocorticoid, such as a 10 year ASCVD risk greater than 10'){, and may be consid triamcinolone cream. Bacitracin, polymlxin B, and neomy ered for aspirin therapy lor primary prevention of ASCVD. cin are common topical antibiotics used to treat or prevent Tempering the recommendation lor primary prevention of wound infections and are fiequently associated with allergic ASCVD with aspirin are multiple trials, including ASCEND. contact dermatitis. For clean wounds, such as a skin surgical ARRIVE, and ASPREE. and a 2019 meta-analysis showing site, the application of plain petrolatum is recommended no net mortalify benefit with aspirin; reductions in nonfatal over the use oftopical antibiotics. myocardial infarction and ischemic stroke were offset by Candida infections are rare in clean surgical wounds, an increased risk for major bleeding, including intracranial and treatment with ketoconazole cream (Option A) is not hemorrhage. Factors that increase risk for bleeding include indicated for this patient. Candido infections occur more increasing age, male sex, concurrent anticoagulant or NSAID commonly in intertriginous areas and are characterized by use, history of gastrointestinal bleeding, upper gastrointesti erythema with satellite papules or pustules. This patient's nal pain, uncontrolled hypertension, chronic kidney disease, skin flndings have no features of Candida infection. and thrombocytopenia. Because of these data, the American Although mupirocin ointment (Option B) is less likely College of Cardiologr and the American Heart Association than bacitracin to cause allergic contact dermatitis, there recommended that aspirin should be used infrequently in is no indication of wound infection in this patient. Wound primary prevention of ASCVD and that low-dose (81 mg/d) 208

Answers and Critiques aspirin (Option A) might be considered for primary preven- Recommending l pitl box (Option B) and selecting an tion of ASCVD only in some individuals aged 40 to 70 years anticoagulant rvith the lowest copayment (Option D) are who are at high risk for ASCVD but do not have an increased recognized strategies [o increase meclication adherence. Both bleeding risk. methods are usually acceptable to patients. Selecting ir med I The addition of a proton pump inhibitor, such as icrrtion with the lowcst copayment is challenging Llecause omeprazole (Option B), is recommended by the American it requires physicians to maintain knowledge of various College of Cardiologr for patients with established ASCVD rnd shifting copayments with a hrge uurnber oi'insurauce disease who require treatment with two or more antithrom conrparries and is tin-re intensive. anci its inrpact is unkuort,n. botic agents. These patients should also avoid NSAIDs. How- More important. it appears that the primary reason ft)r this ever, this patient should not take aspirin and therefore does patient's nonadherence r,ras lack of trnderslanding ol the not need to take a proton pump inhibitor. prolonged treatment duration tbr deep venous thrombo Higher doses of aspirin, such as 325 mg (Option C), have sis. Patient education is more likely kl increase meclication not been shown to be more effective in primary prevention adherence than either a pill bor or lowest copaymerlt. t o of ASCVD than low-dose aspirin and are associated with Scr-eening lbr klrv health literacy (Option C) may uncover \ increased risk for bleeding. Ifaspirin were indicated as a pri health literacy pnrblems but u,ill not impror,e adherence to ET

aspirin (Option A) might be considered for primary preven- Recommending l pitl box (Option B) and selecting an tion of ASCVD only in some individuals aged 40 to 70 years anticoagulant rvith the lowest copayment (Option D) are who are at high risk for ASCVD but do not have an increased recognized strategies [o increase meclication adherence. Both bleeding risk. methods are usually acceptable to patients. Selecting ir med I The addition of a proton pump inhibitor, such as icrrtion with the lowcst copayment is challenging Llecause omeprazole (Option B), is recommended by the American it requires physicians to maintain knowledge of various College of Cardiologr for patients with established ASCVD rnd shifting copayments with a hrge uurnber oi'insurauce disease who require treatment with two or more antithrom conrparries and is tin-re intensive. anci its inrpact is unkuort,n. botic agents. These patients should also avoid NSAIDs. How- More important. it appears that the primary reason ft)r this ever, this patient should not take aspirin and therefore does patient's nonadherence r,ras lack of trnderslanding ol the not need to take a proton pump inhibitor. prolonged treatment duration tbr deep venous thrombo Higher doses of aspirin, such as 325 mg (Option C), have sis. Patient education is more likely kl increase meclication not been shown to be more effective in primary prevention adherence than either a pill bor or lowest copaymerlt. t o of ASCVD than low-dose aspirin and are associated with Scr-eening lbr klrv health literacy (Option C) may uncover \ increased risk for bleeding. Ifaspirin were indicated as a pri health literacy pnrblems but u,ill not impror,e adherence to ET mary prevention measure in this patient, low dose aspirin tl.re required ar.rticoagulation plan. C.lirricians can adclress rJ would be appropriate. low lrealth literacy by using techniques b improve patient understanding, such as rcpeating inlirrnration and supplying =, XEY POITIIS l! the patient with eclucational materirls writtel-r in plain lan UI . Aspirin should be used infrequently in primary pre- guage. the teach back method, rn,herein the clinician asks (l, vention of atherosclerotic cardiovascular disease but patients kl describe their understzrncling of instructior.rs in U! = should not be used in patients at increased risk for their ou.n worcls, is especially helpfLrl in rlpidly identilying bleeding. a potential health literacy problern beftrre a patient leaves . Low-dose aspirin may be considered for primary pre- a mcdical setting. Ihe teach back nrethod coupled with vention of atherosclerotic cardiovascular disease eclucation about the prtient's medical pniblem and need fbr (ASCVD) in some individuals aged 40 to 70 years who prolonged treatmelrt is more likely to increase nredication are at high risk for ASCVD and do not have an aclhcrence than is screening for lort' health literacy alone.

mary prevention measure in this patient, low dose aspirin tl.re required ar.rticoagulation plan. C.lirricians can adclress rJ would be appropriate. low lrealth literacy by using techniques b improve patient understanding, such as rcpeating inlirrnration and supplying =, XEY POITIIS l! the patient with eclucational materirls writtel-r in plain lan UI . Aspirin should be used infrequently in primary pre- guage. the teach back method, rn,herein the clinician asks (l, vention of atherosclerotic cardiovascular disease but patients kl describe their understzrncling of instructior.rs in U! = should not be used in patients at increased risk for their ou.n worcls, is especially helpfLrl in rlpidly identilying bleeding. a potential health literacy problern beftrre a patient leaves . Low-dose aspirin may be considered for primary pre- a mcdical setting. Ihe teach back nrethod coupled with vention of atherosclerotic cardiovascular disease eclucation about the prtient's medical pniblem and need fbr (ASCVD) in some individuals aged 40 to 70 years who prolonged treatmelrt is more likely to increase nredication are at high risk for ASCVD and do not have an aclhcrence than is screening for lort' health literacy alone. increased bleeding risk. I(EY POITT o The factors most strongly associated with medication Bibliography adherence include strong provider-patient relationships Arnett DK. Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention ofcardiovascular disease: a report of the American and patients' understanding of their medical conditions. College of Cardiolos,/American Heart Association task lbrce on clinical practice guidelines. Circulation. 2019;140:e596 646. [PMID: 3O8ZSSSS] doi:10. I I 6l /Cl R.0OOOOO00OOOO067tt Bibliography Yen PH. Leasure AR. Use and etlectiveness of the teach-back method in patient education and health outcomes. l'ed Pract. 2019:36:284 9. IPMID:312583221

increased bleeding risk. I(EY POITT o The factors most strongly associated with medication Bibliography adherence include strong provider-patient relationships Arnett DK. Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention ofcardiovascular disease: a report of the American and patients' understanding of their medical conditions. College of Cardiolos,/American Heart Association task lbrce on clinical practice guidelines. Circulation. 2019;140:e596 646. [PMID: 3O8ZSSSS] doi:10. I I 6l /Cl R.0OOOOO00OOOO067tt Bibliography Yen PH. Leasure AR. Use and etlectiveness of the teach-back method in patient education and health outcomes. l'ed Pract. 2019:36:284 9. IPMID:312583221 tr Item 78 Answer: A Educational Objective: Provide patient education to promote medication adherence.

increased bleeding risk. I(EY POITT o The factors most strongly associated with medication Bibliography adherence include strong provider-patient relationships Arnett DK. Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention ofcardiovascular disease: a report of the American and patients' understanding of their medical conditions. College of Cardiolos,/American Heart Association task lbrce on clinical practice guidelines. Circulation. 2019;140:e596 646. [PMID: 3O8ZSSSS] doi:10. I I 6l /Cl R.0OOOOO00OOOO067tt Bibliography Yen PH. Leasure AR. Use and etlectiveness of the teach-back method in patient education and health outcomes. l'ed Pract. 2019:36:284 9. IPMID:312583221 tr Item 78 Answer: A Educational Objective: Provide patient education to promote medication adherence. Patient education (Option A) at this visit is imporlant to Item 79 Answer: C Educational Objective: Prevent deep venous tr thromboembolism in a patient with cancer undergoing promote meclication adherence. 'lhis patient did not under major surgery. stand the neecl to continue his anticoagulant meclicatiot't beyond the l4 clay course he was provided. lf patients do 'lhe nr<ist appropriate additional venous thromboembtilisnt not comprehcnd medical instructiot.ts, as in the case of'this (V'l'Fi) prophylaxis firr this patient is adr-ninistration of'subcu patient, nonadherence rvitl-r resultant adrcrse evertts. such as tiineolls lor,v molecular rteight heparin (LMWH) fbr 130 dlys rehospitalization or mortality may occur. Medication adher (Option C).The 2019 Arnerican Society of Clinical Onctllogy- ence is defined as the degree to which a paticnt ldheres kr (ASCO) guideline itrr V'IE prophylaxis in patients with can the dosage and interval ol'their prescribed pharnracologic cer recommencls phunnacol<tgic prophylaxis lbr hospitalizecl regimen. Nonadherence. typically clefined as failure to take patients with active clttcer in the absence of bleeding or at least 80')1, of a prescribed medication t-egimen. has been other contrainclici.ttions. Patients shoulci be offerecl phar associated r,r'ith increased health care utilizatitln, poor out rnacologic thron.rboprophylaxis with cither unfiactionated comes, and increased costs. Mcclication adherence is a com I.reparin or I-MWII. l']rophylaxis shottlcl commencc in thc plex behavior that is influenced by tl.re patient, systenr, and hours imtrediately prcceding surgery and may be combincd provider. 'lhe factors most strottgly associated with rnedica with mechanicirl mcthods. such as intermittent pneumatic tion adherence include stror.rg ltrovider patient relationships conrpression. A combined regimen ol pharmacologic lncl and a patient's understanding o1'their medical cotrclitiot-ts. nrechanical prophylaxis may be superior. especially in the

Patient education (Option A) at this visit is imporlant to Item 79 Answer: C Educational Objective: Prevent deep venous tr thromboembolism in a patient with cancer undergoing promote meclication adherence. 'lhis patient did not under major surgery. stand the neecl to continue his anticoagulant meclicatiot't beyond the l4 clay course he was provided. lf patients do 'lhe nr<ist appropriate additional venous thromboembtilisnt not comprehcnd medical instructiot.ts, as in the case of'this (V'l'Fi) prophylaxis firr this patient is adr-ninistration of'subcu patient, nonadherence rvitl-r resultant adrcrse evertts. such as tiineolls lor,v molecular rteight heparin (LMWH) fbr 130 dlys rehospitalization or mortality may occur. Medication adher (Option C).The 2019 Arnerican Society of Clinical Onctllogy- ence is defined as the degree to which a paticnt ldheres kr (ASCO) guideline itrr V'IE prophylaxis in patients with can the dosage and interval ol'their prescribed pharnracologic cer recommencls phunnacol<tgic prophylaxis lbr hospitalizecl regimen. Nonadherence. typically clefined as failure to take patients with active clttcer in the absence of bleeding or at least 80')1, of a prescribed medication t-egimen. has been other contrainclici.ttions. Patients shoulci be offerecl phar associated r,r'ith increased health care utilizatitln, poor out rnacologic thron.rboprophylaxis with cither unfiactionated comes, and increased costs. Mcclication adherence is a com I.reparin or I-MWII. l']rophylaxis shottlcl commencc in thc plex behavior that is influenced by tl.re patient, systenr, and hours imtrediately prcceding surgery and may be combincd provider. 'lhe factors most strottgly associated with rnedica with mechanicirl mcthods. such as intermittent pneumatic tion adherence include stror.rg ltrovider patient relationships conrpression. A combined regimen ol pharmacologic lncl and a patient's understanding o1'their medical cotrclitiot-ts. nrechanical prophylaxis may be superior. especially in the 209

Answers and Critiques tr CONI. highest risk patients. Pharmacologic thromboprophylaxis fbr patients undergoir.rg nrajor surgery for cancer should be continued for at least 7 to 10 days. Extended prophy'1axis present \\-ith acute onset ol local symptonls (d)'suria. uri nary tiequencl' and urgcncy, sr-rprapubic and or perineal pain) and s!'stemic symptonls (i'evers. chills. nausea r,om with LMWH for up to ,1 weeks postoperativell,' is reconr iting, rnalaise). Most cases of acute bacterial prostatitis are mended for patients unclergoing n.rajor open or laparoscol.ric caused by' gram negative bacteria, including Escherichict abdominal or pelvic surgery ltlr cancer rvho have high risk coli arrd Klebsiello, Enterobacter, Proteus, and Serrotio Ieatures. such as restricted rnobilitl,. obesitl,l or history of species. Oral trimethoprinr suliamethoxazole has both VTE. or have additional risk factors. This patient is excellent co\:erage of grarn negative bacteria and prostatic "vho undergoing high-risk surgery and has obesiS' as an addi tissue penetration. lt is a reasonable empiric antibiotic tional risk fbr VTE, and extended prophylaxis is u'arranted. choice in patients able to tolL'rate oral intake. A fluoro- 'Ihe ASCO and other guidelincs assert that there is ntr quinolone antibiotic (ciprofloxacin. ler,ofloracin) is also role fbr inferior vena cava (l\tC) filter insertion (Option A) an appropriate empiric antibiotic choice. Antibiotic ther fbr VTE prophylaxis ou,ing to collcerns about its long-term apy should be initiated after a urine sample is obtained UI harm. IVC filter placement may be considered in patients fbr ar.rall'sis and culture and should be continued for 2 to .D with absolute contraindicatiorls to anticoagulant therapy in 4 r,r,eeks: some experts recornrnertd up to 6 r,reeks. Treatntent = ut the acute treatment setting olV'l'E if the thron-rbus burden is can be modified on the basis of results of the urine culture. o, considered life-threatening. CT or MRI of the prostate (Option A) is not indicated fbr EL Prophylaxis n,ith LMWH fbr 7 days (Option B) is patients with symptoms and pl.rysical examination findings n unlikely to provide adeqrlate prophylaxis for this patient ol.acute bacterial prostatitis. CT can be obtained if there is st with cancer undergoing rrajor surgery Registry data have diagnostic uncertainB' or if the patient does not improre (D documented that postoperative VTE is detected after hospital atter appropriate antibiotic theraplr because antibiotic f,ail art discharge in 54')1, of cases. n,itl.r the highest risk correspor.rd ture raises the suspicion for prostate abscess. ir.rg to colorectal and genitourinary cancer surgery Studies Although nitrofurantoin (Option B) is appropriate for have demonstrated that administriition of LMWH for 30 clays uncornplicated cystitis, it has poor penetration into prostatic after the day of surgery reduccs tl.re risk for VTE rvitl.rout tissue. lt is not indicated fbr a patient with acute bacterial increasing the risk for bleeding cornplicatior.rs. prostatitis. No additional prophylaxis is not appropriate therapy Although prostatic nlassage follorved by urine culture (Option D). The 2019 ASCO guideline for VTE propl.rylaxis (Option C) has a role in patients rvith suspected chronic in patients u,ith cancer recommends pharmacologic pro bacterial prostatitis. it should be avoided in patients u,ith phylaxis fbr hospitalized patients u,ith active cancer in the acute bacterial prostatitis because it can potentialll,cause absence olbleeding or other contraindications. bacteremia and sepsis. Placement of a urinary catheler (Option E) is neces TEY POITITS sary in patients lr,'ith prostatitis experiencing acute urirrlry' o Pharmacologic venous thromboembolismprophy rctention. Acute urinary retention is usually associated n,ith laxis is recommended for hospitalized patients with inability to urinate and lolr,er arbdon.rir.ral and or suprapubic active cancer in the absence of bleeding or other discomfbrt. Although this patient has obstructive urinar-r' contraindications. svmptoms, he has no evidence olacute urinary retention. o Extended venous thromboembolism (VTE) prophy f,EY POIXTS laxis with lowmolecular-weight heparin for up to 4 weeks postoperatively is recommended for patients . Bacterial prostatitis is associated with acute onset of local symptoms (dysuria, urinary frequency and undergoing major open or laparoscopic abdominal or urgency, suprapubic and/or perineal pain) and systemic pelvic surgery for cancer who have high-risk features, symptoms (fevers, chills, nausea/vomiting, malaise). such as restricted mobility, obesity, or history of VTE, or who have additional risk factors. o Oral trimethoprim-sulfamethoxazole or an oral fluo- roquinolone (ciprofloxacin, levofloxacin) is an appro Bibliography priate empiric antibiotic for acute bacterial prostatitis. Key NS, Khorana AA, Kuderer NM, et tl. Venous thromboembolism prophy laxis and treatment in patients with c:]ncer: ASCO clinical practice Bibliography guideline update. J CIin Oncol. 2020:38:496 520. IPMID: 31381464] doi:10.1200/JCO.19.01461 Gill BC. Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis. 2016:29: 86 91. IPMID: 26555038] doi:lO.lO97 QCO.OOOOO0000o000222

tr CONI. highest risk patients. Pharmacologic thromboprophylaxis fbr patients undergoir.rg nrajor surgery for cancer should be continued for at least 7 to 10 days. Extended prophy'1axis present \\-ith acute onset ol local symptonls (d)'suria. uri nary tiequencl' and urgcncy, sr-rprapubic and or perineal pain) and s!'stemic symptonls (i'evers. chills. nausea r,om with LMWH for up to ,1 weeks postoperativell,' is reconr iting, rnalaise). Most cases of acute bacterial prostatitis are mended for patients unclergoing n.rajor open or laparoscol.ric caused by' gram negative bacteria, including Escherichict abdominal or pelvic surgery ltlr cancer rvho have high risk coli arrd Klebsiello, Enterobacter, Proteus, and Serrotio Ieatures. such as restricted rnobilitl,. obesitl,l or history of species. Oral trimethoprinr suliamethoxazole has both VTE. or have additional risk factors. This patient is excellent co\:erage of grarn negative bacteria and prostatic "vho undergoing high-risk surgery and has obesiS' as an addi tissue penetration. lt is a reasonable empiric antibiotic tional risk fbr VTE, and extended prophylaxis is u'arranted. choice in patients able to tolL'rate oral intake. A fluoro- 'Ihe ASCO and other guidelincs assert that there is ntr quinolone antibiotic (ciprofloxacin. ler,ofloracin) is also role fbr inferior vena cava (l\tC) filter insertion (Option A) an appropriate empiric antibiotic choice. Antibiotic ther fbr VTE prophylaxis ou,ing to collcerns about its long-term apy should be initiated after a urine sample is obtained UI harm. IVC filter placement may be considered in patients fbr ar.rall'sis and culture and should be continued for 2 to .D with absolute contraindicatiorls to anticoagulant therapy in 4 r,r,eeks: some experts recornrnertd up to 6 r,reeks. Treatntent = ut the acute treatment setting olV'l'E if the thron-rbus burden is can be modified on the basis of results of the urine culture. o, considered life-threatening. CT or MRI of the prostate (Option A) is not indicated fbr EL Prophylaxis n,ith LMWH fbr 7 days (Option B) is patients with symptoms and pl.rysical examination findings n unlikely to provide adeqrlate prophylaxis for this patient ol.acute bacterial prostatitis. CT can be obtained if there is st with cancer undergoing rrajor surgery Registry data have diagnostic uncertainB' or if the patient does not improre (D documented that postoperative VTE is detected after hospital atter appropriate antibiotic theraplr because antibiotic f,ail art discharge in 54')1, of cases. n,itl.r the highest risk correspor.rd ture raises the suspicion for prostate abscess. ir.rg to colorectal and genitourinary cancer surgery Studies Although nitrofurantoin (Option B) is appropriate for have demonstrated that administriition of LMWH for 30 clays uncornplicated cystitis, it has poor penetration into prostatic after the day of surgery reduccs tl.re risk for VTE rvitl.rout tissue. lt is not indicated fbr a patient with acute bacterial increasing the risk for bleeding cornplicatior.rs. prostatitis. No additional prophylaxis is not appropriate therapy Although prostatic nlassage follorved by urine culture (Option D). The 2019 ASCO guideline for VTE propl.rylaxis (Option C) has a role in patients rvith suspected chronic in patients u,ith cancer recommends pharmacologic pro bacterial prostatitis. it should be avoided in patients u,ith phylaxis fbr hospitalized patients u,ith active cancer in the acute bacterial prostatitis because it can potentialll,cause absence olbleeding or other contraindications. bacteremia and sepsis. Placement of a urinary catheler (Option E) is neces TEY POITITS sary in patients lr,'ith prostatitis experiencing acute urirrlry' o Pharmacologic venous thromboembolismprophy rctention. Acute urinary retention is usually associated n,ith laxis is recommended for hospitalized patients with inability to urinate and lolr,er arbdon.rir.ral and or suprapubic active cancer in the absence of bleeding or other discomfbrt. Although this patient has obstructive urinar-r' contraindications. svmptoms, he has no evidence olacute urinary retention. o Extended venous thromboembolism (VTE) prophy f,EY POIXTS laxis with lowmolecular-weight heparin for up to 4 weeks postoperatively is recommended for patients . Bacterial prostatitis is associated with acute onset of local symptoms (dysuria, urinary frequency and undergoing major open or laparoscopic abdominal or urgency, suprapubic and/or perineal pain) and systemic pelvic surgery for cancer who have high-risk features, symptoms (fevers, chills, nausea/vomiting, malaise). such as restricted mobility, obesity, or history of VTE, or who have additional risk factors. o Oral trimethoprim-sulfamethoxazole or an oral fluo- roquinolone (ciprofloxacin, levofloxacin) is an appro Bibliography priate empiric antibiotic for acute bacterial prostatitis. Key NS, Khorana AA, Kuderer NM, et tl. Venous thromboembolism prophy laxis and treatment in patients with c:]ncer: ASCO clinical practice Bibliography guideline update. J CIin Oncol. 2020:38:496 520. IPMID: 31381464] doi:10.1200/JCO.19.01461 Gill BC. Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis. 2016:29: 86 91. IPMID: 26555038] doi:lO.lO97 QCO.OOOOO0000o000222 Item 80 tr Answer: D Educational Objective: Treat acute bacterial prostatitis. Item 81 Answer: A Ed ucation a I O bj ective : Treat infl amed seborrheic keratoses. lhe most appropriate next step in management is en.rpiric trirnethoprim-sulfamethoxazole (Option D). This patient The most appropriate treatment is cryotherapy (Option A). has acute bacterial prostatitis. These patients typically This patient has seborrheic keratoses, the most common

Item 80 tr Answer: D Educational Objective: Treat acute bacterial prostatitis. Item 81 Answer: A Ed ucation a I O bj ective : Treat infl amed seborrheic keratoses. lhe most appropriate next step in management is en.rpiric trirnethoprim-sulfamethoxazole (Option D). This patient The most appropriate treatment is cryotherapy (Option A). has acute bacterial prostatitis. These patients typically This patient has seborrheic keratoses, the most common 210

Answers and Critiques benign skin tumors in adults. Typically occurring after mid be tested for rubella immuni[2, and those who lack immunity dle age, seborrheic keratoses present as warI/, "stuck on" should be ollered the MMR vaccine; women should avoid papuies or plaques, most commoniy on the trunk; they conceiving for at least 4 weeks after vaccination. If a woman involve only the epidermis. Seborrheic keratoses range in lacks immunity to rubella but is already pregnant, she should size from a few millimeters to several centimeters, are usu- receive the MMR vaccine aller delivery but before leaving the ally hyperyigmented, and range in color from tan to brown hospital or at the time of pregnancy termination. The MMR or black. The sign of Leser Trdlat is the sudden eruption of vaccine is a live virus vaccine and should not be administered numerous seborrheic keratoses and is associated with an to immunocompromised individuals or pregnant women. internal malignancy. Diagnosis of seborrheic keratoses can Patients should be administered the human papilloma usuallybe made clinically, but shave biopsy can be conflrma virus (HPV) vaccine series (Option A) at age 11 or 12 years tory when there is concern for melanoma or squamous cell or between 13 and 26 years of age if not given previously. In carcinoma. Reassurance is typically the appropriate manage unvaccinated patients aged 27 to 45 years, vaccination can ment. but seborrheic keratoses are often treated if irritated be considered on the basis of risk using a shared decision tn (l, or pruritic, such as in this patient, or for cosmetic reasons. making process. If administered before 15 years of age, a 3 CT Seborrheic keratosis usually become irritated and inflamed two dose series is recommended. whereas a three-dose owing to chronic friction from clothing, but inflammation series is recommended in older individuals. Vaccination is U of seborrheic keratoses may occur during chemotherapy; not recommended during pregnancy, although no harmful "!El C cytarabine and docetaxel are the most implicated drugs. effects have been noted when inadvertently given to preg- .E UI When indicated, the most common treatment is cryother- nant women and pregnancy testing is not necessary before apy with liquid nitrogen, but rinly if the diagnosis is certain. vaccination. This patient received two doses of the HPV o 3 ut Otherwise, a shave removal and submission for histologic vaccine befbre 15 years ofage and does not need a third dose. evaluation is most appropriate. Other destructive therapies All pregnant women should receive the tetanus toxoid, include curettage, electrodessication, or laser therapy. reduced diphtheria toxoid, and acellular perhrssis (Tdap) vac Mupirocin ointment (Option B) is effective in treat cine (Option C) during each pregnancy between 27 weeks' ing superflcial skin infections typically caused by gram and 36 weeks'gestation. This patient is currently not preg positive bacteria (staphylococci and streptococci). There is no nant and her Tdap vaccination is up to date. In patients who indication of inf'ection in this patient, and mupirocin is not have previously received the Tdap vaccine, booster vaccina appropriate treatment. tion with either tetanus and diphtheria toxoids (Td) or Tdap Topical 5 fluorouracil (Option C) is an approved treat- booster is recommended every 10 years. Patients who have ment for actinic keratoses. It can also be used to treat super not yet received the Tdap vaccine can receive it as one ofthe ficial basal cell carcinomas and squamous cell carcinoma in scheduled booster vaccinations. This patient should wait until situ. Topical 5 fluorauracil would not be appropriate man the appropriate time interval to receive the Tdap or Td vaccine. agement for a seborrheic keratosis. Because the patient is planning pregnancy and does not Topical glucocorticoids, such as triamcinolone aceton have immunity to rubella, not offering the MMR vaccine is ide (Option D), have no role in the treatment of seborrheic not the best strategz (Option O). keratoses because they are ineffective and over time may XEY POITITS thin the normal surrounding skin. . Women who are planning pregnanry and do not have I(EY POIl{T immunity to rubella should receive the measles, mumps, . Seborrheic keratoses, the most common benign skin and rubella vaccine before conceiving and shottld'nait at tumors in adults, present as "stuck on" papules or least 4 weeks after vaccination to conceive. plaques; removal, most commonly with cryotherapy, . The measles, mumps, and rubella vaccine is a live is considered if the keratoses are irritated or pruritic, virus vaccine and should not be administered to or fbr cosmetic reasons. immunocompromised individuals or pregnant women. Bibliography Ranasinghe GC, Friedman AJ. Managing seborrheic keratoses: evolving strategies for optimizing patient outcomes. J Drugs Dermatol. 2017; Bibliography 16:106,1 8. [pMtD: 29141054] Freedman MS, Bernstein H. Ault KA. Recommended adult immunization schedule. United States. 2021. Ann lntern Med. 2021. IPMID, 33571011] doi:10.7326lM20 8080

benign skin tumors in adults. Typically occurring after mid be tested for rubella immuni[2, and those who lack immunity dle age, seborrheic keratoses present as warI/, "stuck on" should be ollered the MMR vaccine; women should avoid papuies or plaques, most commoniy on the trunk; they conceiving for at least 4 weeks after vaccination. If a woman involve only the epidermis. Seborrheic keratoses range in lacks immunity to rubella but is already pregnant, she should size from a few millimeters to several centimeters, are usu- receive the MMR vaccine aller delivery but before leaving the ally hyperyigmented, and range in color from tan to brown hospital or at the time of pregnancy termination. The MMR or black. The sign of Leser Trdlat is the sudden eruption of vaccine is a live virus vaccine and should not be administered numerous seborrheic keratoses and is associated with an to immunocompromised individuals or pregnant women. internal malignancy. Diagnosis of seborrheic keratoses can Patients should be administered the human papilloma usuallybe made clinically, but shave biopsy can be conflrma virus (HPV) vaccine series (Option A) at age 11 or 12 years tory when there is concern for melanoma or squamous cell or between 13 and 26 years of age if not given previously. In carcinoma. Reassurance is typically the appropriate manage unvaccinated patients aged 27 to 45 years, vaccination can ment. but seborrheic keratoses are often treated if irritated be considered on the basis of risk using a shared decision tn (l, or pruritic, such as in this patient, or for cosmetic reasons. making process. If administered before 15 years of age, a 3 CT Seborrheic keratosis usually become irritated and inflamed two dose series is recommended. whereas a three-dose owing to chronic friction from clothing, but inflammation series is recommended in older individuals. Vaccination is U of seborrheic keratoses may occur during chemotherapy; not recommended during pregnancy, although no harmful "!El C cytarabine and docetaxel are the most implicated drugs. effects have been noted when inadvertently given to preg- .E UI When indicated, the most common treatment is cryother- nant women and pregnancy testing is not necessary before apy with liquid nitrogen, but rinly if the diagnosis is certain. vaccination. This patient received two doses of the HPV o 3 ut Otherwise, a shave removal and submission for histologic vaccine befbre 15 years ofage and does not need a third dose. evaluation is most appropriate. Other destructive therapies All pregnant women should receive the tetanus toxoid, include curettage, electrodessication, or laser therapy. reduced diphtheria toxoid, and acellular perhrssis (Tdap) vac Mupirocin ointment (Option B) is effective in treat cine (Option C) during each pregnancy between 27 weeks' ing superflcial skin infections typically caused by gram and 36 weeks'gestation. This patient is currently not preg positive bacteria (staphylococci and streptococci). There is no nant and her Tdap vaccination is up to date. In patients who indication of inf'ection in this patient, and mupirocin is not have previously received the Tdap vaccine, booster vaccina appropriate treatment. tion with either tetanus and diphtheria toxoids (Td) or Tdap Topical 5 fluorouracil (Option C) is an approved treat- booster is recommended every 10 years. Patients who have ment for actinic keratoses. It can also be used to treat super not yet received the Tdap vaccine can receive it as one ofthe ficial basal cell carcinomas and squamous cell carcinoma in scheduled booster vaccinations. This patient should wait until situ. Topical 5 fluorauracil would not be appropriate man the appropriate time interval to receive the Tdap or Td vaccine. agement for a seborrheic keratosis. Because the patient is planning pregnancy and does not Topical glucocorticoids, such as triamcinolone aceton have immunity to rubella, not offering the MMR vaccine is ide (Option D), have no role in the treatment of seborrheic not the best strategz (Option O). keratoses because they are ineffective and over time may XEY POITITS thin the normal surrounding skin. . Women who are planning pregnanry and do not have I(EY POIl{T immunity to rubella should receive the measles, mumps, . Seborrheic keratoses, the most common benign skin and rubella vaccine before conceiving and shottld'nait at tumors in adults, present as "stuck on" papules or least 4 weeks after vaccination to conceive. plaques; removal, most commonly with cryotherapy, . The measles, mumps, and rubella vaccine is a live is considered if the keratoses are irritated or pruritic, virus vaccine and should not be administered to or fbr cosmetic reasons. immunocompromised individuals or pregnant women. Bibliography Ranasinghe GC, Friedman AJ. Managing seborrheic keratoses: evolving strategies for optimizing patient outcomes. J Drugs Dermatol. 2017; Bibliography 16:106,1 8. [pMtD: 29141054] Freedman MS, Bernstein H. Ault KA. Recommended adult immunization schedule. United States. 2021. Ann lntern Med. 2021. IPMID, 33571011] doi:10.7326lM20 8080 Item 82 Answer: B Educational Objective: Provide measles, mumps, and rubella vaccination in a woman planning pregnancy. Item 83 Answer: A Educational Objective: Diagnose alopecia areata. The measles, mumps, and rubella (MMR) vaccine (Option B) is the most appropriate vaccine for this patient who iacks immu- This patient has alopecia areata (Option A), which results nity to rubella. AII women in the preconception period shouid in well-circumscribed patches of nonscarring hair loss

Item 82 Answer: B Educational Objective: Provide measles, mumps, and rubella vaccination in a woman planning pregnancy. Item 83 Answer: A Educational Objective: Diagnose alopecia areata. The measles, mumps, and rubella (MMR) vaccine (Option B) is the most appropriate vaccine for this patient who iacks immu- This patient has alopecia areata (Option A), which results nity to rubella. AII women in the preconception period shouid in well-circumscribed patches of nonscarring hair loss 211

Answers and Critiques without scale. Alopecia areata aflects men and women TEY POIXIS equally and most commonly presents before the age of . Alopecia areata is nonscarring hair loss that results in 30 years. It can progress to complete loss of scalp hair (alo smooth, hairless patches of skin, most commonly pecia totalis) and all ofthe body (alopecia universalis). Other appearing on the scalp. than the hair loss, alopecia areata is usually asymptomatic. On examination, "exclamation point" hairs, which are small . "Exclamation point" hairs, which are small broken broken hairs at the edges of the hair loss that are thicker hairs at the edges ofthe hair loss that are thicker at the at the top and thinner near the scalp, can be observed; top and thinner near the scalp, are pathognomonic of these are a pathognomonic indicator ofalopecia areata. The alopecia areata. pathogenesis ofalopecia areata is not fully understood, but an autoimmune process is postulated. Alopecia areata can Bibliography be associated with atopic dermatitis, asthma, thyroid dis- Strazzulla LC. Wang EH, Avila L, et al. Alopecia areata: disease characteris ease, and tlpe 1 diabetes mellitus. Patients with mild disease tics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatol. 2018;78:1 12. IPMID: 29241771) doi:10.1016 j.jaad.2ol7. tt will often have spontaneous hair regrowth. More extensive 04.1141 E involvement at onset has a poorer prognosis. Treatment .D includes potent topical or intralesional glucocorticoids for ut o, CL limited disease. Androgenic alopecia (Option B), or patterned bald Item 84 Answer: B Educational Objective: IdentiS high value care. tr r.l ness, is due to the postpubertal terminal hair replace- The American College of Physicians (ACP) High \hlue Care lr ment, first with miniaturized follicles and eventually with initiative (Option B) ainrs to improve health. aroid harms. atrophic follicles. It is seen in both men and women. The irnd elinrinate r,rasteful practices. This initiatire addresses .D .A onset begins after puberty and can be gradual. In men, it high r,alue care broadlyl olt'ering leirrning resources for clini presents as bitemporal hairline recession, followed by ver- cians and medical educators. curricula. clinical guidelines. tex thinning and then baldness (as shown). This patient's best practice advice, case studies. and patient resources on circumscribed hair loss is not compatible with androgenic a wide variety of related topics. ACP believes that it is thc alopecia. responsibility of the medical prof'ession to become cost conscious and decrease unnecessary care that does not ben cfit patients. ACP has developed r five step framer,','ork to assist ph1'sicians in delir,ering high value care: (1) understand the benefits. harms. and relative costs of the intenentions that being considered: (2) decrease or eliminate the use of inter ventior.rs that provide r.ro benefits ancl or may be harmtulr (3) choose interventions and carc settings that manimize bene fits. rninimize harms. and reduce costs (using conlparative eff'ectiveness and cost eflectiveness data); (,1) customize lr care plan nith the patient that incorporates their values and addresses their concerns: rrnd (5) identify systenr level opportunities to improve outcomes. rninimize harms, and reduce health care \^,aste. Not perfbrming unnecessary test ing, as shorvn in this case. is an erample ol high lalue care. The practice of defensive medicine (Option A). thc Discoid lupus erythematosus (DLE) (Option C) is ordering of excessire tests and procedures b1- ph1,-sicians to a scarring alopecia that presents with erythematous avoid malpractice litigation. is the irr.rtithesis of high raluc plaques with areas of scarring; it often occurs in the care. 'Ihe prevalence ol defbnsive medicine is a challenge absence of systemic disease. The conchal bowls of the ears to the provision of high laluc care. Remedies that include and other areas of the face are often involved. The absence ernphasizing patient saf'ety. pronroting a culture ol quality of erythema and scarring in this patient is inconsistent improvement and coordinated care, and training physicians with DLE. in best practices to ar,oid errors and reduce risk rvill pre Tinea capitis (Option D) is most commonly caused vent harm and reduce the rvaste associated $,ith defensive by Trichophyton and Microsporum species and typically medicine. presents with pruritic single or multiple scaly patches. [-ean is a quality intproventent model (Option C) that It is a common cause of hair loss in children but a less aims to maximize value and minimize lvaste by closely common cause in adults. Severe cases may present with a examining a system's processes ancl eliminating non kerion, an inflammatory plaque with pustules and drain- value added activities uithin the system. High ralue care age. Cervical lymphadenopathy is common. The age of this may be an outcome of the Lean qualiry- improvement pro patient and lack of pruritus or scaling make tinea capitis cess, but this physician's uppropriate decision to forgo an unlikely diagnosis. unnecessary testing is more indicative of'high value care.

without scale. Alopecia areata aflects men and women TEY POIXIS equally and most commonly presents before the age of . Alopecia areata is nonscarring hair loss that results in 30 years. It can progress to complete loss of scalp hair (alo smooth, hairless patches of skin, most commonly pecia totalis) and all ofthe body (alopecia universalis). Other appearing on the scalp. than the hair loss, alopecia areata is usually asymptomatic. On examination, "exclamation point" hairs, which are small . "Exclamation point" hairs, which are small broken broken hairs at the edges of the hair loss that are thicker hairs at the edges ofthe hair loss that are thicker at the at the top and thinner near the scalp, can be observed; top and thinner near the scalp, are pathognomonic of these are a pathognomonic indicator ofalopecia areata. The alopecia areata. pathogenesis ofalopecia areata is not fully understood, but an autoimmune process is postulated. Alopecia areata can Bibliography be associated with atopic dermatitis, asthma, thyroid dis- Strazzulla LC. Wang EH, Avila L, et al. Alopecia areata: disease characteris ease, and tlpe 1 diabetes mellitus. Patients with mild disease tics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatol. 2018;78:1 12. IPMID: 29241771) doi:10.1016 j.jaad.2ol7. tt will often have spontaneous hair regrowth. More extensive 04.1141 E involvement at onset has a poorer prognosis. Treatment .D includes potent topical or intralesional glucocorticoids for ut o, CL limited disease. Androgenic alopecia (Option B), or patterned bald Item 84 Answer: B Educational Objective: IdentiS high value care. tr r.l ness, is due to the postpubertal terminal hair replace- The American College of Physicians (ACP) High \hlue Care lr ment, first with miniaturized follicles and eventually with initiative (Option B) ainrs to improve health. aroid harms. atrophic follicles. It is seen in both men and women. The irnd elinrinate r,rasteful practices. This initiatire addresses .D .A onset begins after puberty and can be gradual. In men, it high r,alue care broadlyl olt'ering leirrning resources for clini presents as bitemporal hairline recession, followed by ver- cians and medical educators. curricula. clinical guidelines. tex thinning and then baldness (as shown). This patient's best practice advice, case studies. and patient resources on circumscribed hair loss is not compatible with androgenic a wide variety of related topics. ACP believes that it is thc alopecia. responsibility of the medical prof'ession to become cost conscious and decrease unnecessary care that does not ben cfit patients. ACP has developed r five step framer,','ork to assist ph1'sicians in delir,ering high value care: (1) understand the benefits. harms. and relative costs of the intenentions that being considered: (2) decrease or eliminate the use of inter ventior.rs that provide r.ro benefits ancl or may be harmtulr (3) choose interventions and carc settings that manimize bene fits. rninimize harms. and reduce costs (using conlparative eff'ectiveness and cost eflectiveness data); (,1) customize lr care plan nith the patient that incorporates their values and addresses their concerns: rrnd (5) identify systenr level opportunities to improve outcomes. rninimize harms, and reduce health care \^,aste. Not perfbrming unnecessary test ing, as shorvn in this case. is an erample ol high lalue care. The practice of defensive medicine (Option A). thc Discoid lupus erythematosus (DLE) (Option C) is ordering of excessire tests and procedures b1- ph1,-sicians to a scarring alopecia that presents with erythematous avoid malpractice litigation. is the irr.rtithesis of high raluc plaques with areas of scarring; it often occurs in the care. 'Ihe prevalence ol defbnsive medicine is a challenge absence of systemic disease. The conchal bowls of the ears to the provision of high laluc care. Remedies that include and other areas of the face are often involved. The absence ernphasizing patient saf'ety. pronroting a culture ol quality of erythema and scarring in this patient is inconsistent improvement and coordinated care, and training physicians with DLE. in best practices to ar,oid errors and reduce risk rvill pre Tinea capitis (Option D) is most commonly caused vent harm and reduce the rvaste associated $,ith defensive by Trichophyton and Microsporum species and typically medicine. presents with pruritic single or multiple scaly patches. [-ean is a quality intproventent model (Option C) that It is a common cause of hair loss in children but a less aims to maximize value and minimize lvaste by closely common cause in adults. Severe cases may present with a examining a system's processes ancl eliminating non kerion, an inflammatory plaque with pustules and drain- value added activities uithin the system. High ralue care age. Cervical lymphadenopathy is common. The age of this may be an outcome of the Lean qualiry- improvement pro patient and lack of pruritus or scaling make tinea capitis cess, but this physician's uppropriate decision to forgo an unlikely diagnosis. unnecessary testing is more indicative of'high value care. 212

Answers and Critiques tr CONI. i\,ledical rttioning (Option D), dcfinecl by the allocatiorr of scarcc nteclical resources to ir sclcctecl group of'patients, lelcls kr uncleruse of potentially lltltrrrpriirtc care. I Iigh valuc Topical metronidazole vaginal gel (Option D), 5 g daily fbr 5 days, is an eflective option for the treatment of bacterial vaginosis. This form of metronidazole, however, care uclv<lcates for rational clrc thirt is cl'uracterized by care is not curative and is inferior to a single 2 g dose of oral that is clinically ellective, thus avoidilrg overuse or misuse ol' metronidazole or tinidazole for the treatment of tricho carc that is inappropriate and wastcfirl. moniasis. TIY POITTS t(EY POll{rS o The aim of high value care is to improve health, avoid . Vaginal trichomoniasis is a sexually transmitted infec harms, and eliminate wasteful practices. tion that can be asymptomatic or present with pale . The practice of defensive medicine, the ordering of yellow, green, or gray frothy vaginal discharge with excessive tests and procedures by physicians to avoid itching and burning; it is best treated with a single 2-g malpractice litigation, is the antithesis of high value dose of oral metronidazole or tinidazole. Ut q, care and leads to waste and potential harm through . Women treated for trichomoniasis should be retested GT unnecessary testing and treatment. in 3 months with a nucleic acid amplification test. TJ Bibliography Bibliography E Carnrll AE. The high costs of unnecessary care. JAMA. 2017;318:1748 9 Workowski KA, Bolan GA; Centers tbr Disease Control and Prevention. |! IPM I D: 29136432] doi:10.1001 ijama.2017.16193 Sexually transmitted diseases treatment guidelines, 2015. MMWR u! Recomm Rep. 2015;64:1 137. IPMlD, 260.12815] o UI = Item 86 Answer: D Item 85 Answer: C Educational Objective: Treat trichomoniasis. Educational Objective: Avoid preoperative testing for tr low-risk surgery. The most appropriate treatment is a single 2 g dose of oral metronidazole (Option C). Vaginal trichomoniasis is a sexu No testing is indicated (Option D) ftrr this patient belirre ally transmitted infection (STI). Patients can be asymptom ciltaract surgery. Preoperative testing can help define risks atic or present with pale yellow, green, or gray frothy vaginal bcfirre undergoing a procedure and is intended to guide discharge with itching and burning. Although trichomonia- lnanrgerrent. Hou,ever, there is considerable overuse of pre sis can be diagnosed with microscopy when motile tricho operativc testing. particularl-v- in lorn, risk procedures. When monads are noted on wet mount, nucleic acid amplification rletcrnrinir.rg appropriate preoperativc testir.rg ltrr electivc testing (NAAT) is recommended because it can be dilflcult to procedures. the first branch point is detcrmining the risk establish the diagnosis with a wet mount. Because trichomo ol surgeryi ln general, low risk surgeries (such as skin sur niasis is sexually transmitted, patients should be screened for gcrics, hernia repair. cataract sLlrgery and arthroscopy) are other STIs, including chlamydia, gonorrhea, HIV, and syph- o{ shorter duration. involve klcirI anestlretics. incur minimal ilis. A single 2 g dose ofl oral metronidazole (or tinidazole) is blrxrd loss, and are associated with fl'w contplications (<1'X, efl'ective treatment for established Trichomonas infection. It rnujor artverse cardiac evenls). Multiple studies have shown is also important to treat the patient's partner to help prevent that preoperative testir.rg has little value ir.r low' risk proce reinf'ection and spread of infection to other sexual contacts. clurcs. Even when patients have substantial comorbidities, Patients should also be retested for Trichomonos in 3 months such as this patient, chest radiography, echocardiography, with NAAT because of high reinf.ection rates. and UCG do not predict carclilc complications. Therefbre, A single 1-g dose of oral azithromycin (Option A) is provided rnedical issues are stable, preoperative testiug is not appropriate treatment for chlamydia but does not treat rec<lnrnrended tbr low risk pr<-rcedurcs. trichomoniasis. Testing for chlamydia is appropriate in this Although this patient has cardiopulmonary disease, setting because trichomoniasis is a STI, but treatment should inclucling COPD, her sylxptonls arc stable and chest radi be limited to patients with established chlamydia infection. ography (Option A) results will n<-rt change perioperative Fluconazole (Option B), 150 mg orally, is an appropriate nlilrlagement. Preoperative chest radiography in nontho treatment for vulvovaginal candidiasis but is not appropriate racic surgery is indicated only in patients with new sigrrs for the treatment of trichomoniasis. Vulvovaginal candidi- or sylxptoms of pulmonary illr.ress or unclerlying cardiac or asis is typically characterized by vaginal itching, irritation, pulmonary disease with new or unstable symptoms. and discharge. Examination reveals vulvar edema and exco Civen the low rates of cardiovascular complicatior.rs riation, with thick, white, curdy vaginal discharge. Diagnos and minimal preciicti'n'e value they provide, screenitrg I tic testing involves 10'7, potassium hydroxide wet mount of I')CC (Option B) is not helpful prior to lort' risk proce the discharge showing yeast, hyphae, or pseudohyphae or a clures. Cardiac testing prior to ltx,r, risk surgery should positive NAAT. Vulvovaginal candidiasis is not an STI; there be obtained only if the prrtient has nert, symptoms sug is no need to treat partners of women diagnosed with vulvo gcstive ol cardiac disease (palpitations, chest pain, short vaginal candidiasis. ncss olbreath).

tr CONI. i\,ledical rttioning (Option D), dcfinecl by the allocatiorr of scarcc nteclical resources to ir sclcctecl group of'patients, lelcls kr uncleruse of potentially lltltrrrpriirtc care. I Iigh valuc Topical metronidazole vaginal gel (Option D), 5 g daily fbr 5 days, is an eflective option for the treatment of bacterial vaginosis. This form of metronidazole, however, care uclv<lcates for rational clrc thirt is cl'uracterized by care is not curative and is inferior to a single 2 g dose of oral that is clinically ellective, thus avoidilrg overuse or misuse ol' metronidazole or tinidazole for the treatment of tricho carc that is inappropriate and wastcfirl. moniasis. TIY POITTS t(EY POll{rS o The aim of high value care is to improve health, avoid . Vaginal trichomoniasis is a sexually transmitted infec harms, and eliminate wasteful practices. tion that can be asymptomatic or present with pale . The practice of defensive medicine, the ordering of yellow, green, or gray frothy vaginal discharge with excessive tests and procedures by physicians to avoid itching and burning; it is best treated with a single 2-g malpractice litigation, is the antithesis of high value dose of oral metronidazole or tinidazole. Ut q, care and leads to waste and potential harm through . Women treated for trichomoniasis should be retested GT unnecessary testing and treatment. in 3 months with a nucleic acid amplification test. TJ Bibliography Bibliography E Carnrll AE. The high costs of unnecessary care. JAMA. 2017;318:1748 9 Workowski KA, Bolan GA; Centers tbr Disease Control and Prevention. |! IPM I D: 29136432] doi:10.1001 ijama.2017.16193 Sexually transmitted diseases treatment guidelines, 2015. MMWR u! Recomm Rep. 2015;64:1 137. IPMlD, 260.12815] o UI = Item 86 Answer: D Item 85 Answer: C Educational Objective: Treat trichomoniasis. Educational Objective: Avoid preoperative testing for tr low-risk surgery. The most appropriate treatment is a single 2 g dose of oral metronidazole (Option C). Vaginal trichomoniasis is a sexu No testing is indicated (Option D) ftrr this patient belirre ally transmitted infection (STI). Patients can be asymptom ciltaract surgery. Preoperative testing can help define risks atic or present with pale yellow, green, or gray frothy vaginal bcfirre undergoing a procedure and is intended to guide discharge with itching and burning. Although trichomonia- lnanrgerrent. Hou,ever, there is considerable overuse of pre sis can be diagnosed with microscopy when motile tricho operativc testing. particularl-v- in lorn, risk procedures. When monads are noted on wet mount, nucleic acid amplification rletcrnrinir.rg appropriate preoperativc testir.rg ltrr electivc testing (NAAT) is recommended because it can be dilflcult to procedures. the first branch point is detcrmining the risk establish the diagnosis with a wet mount. Because trichomo ol surgeryi ln general, low risk surgeries (such as skin sur niasis is sexually transmitted, patients should be screened for gcrics, hernia repair. cataract sLlrgery and arthroscopy) are other STIs, including chlamydia, gonorrhea, HIV, and syph- o{ shorter duration. involve klcirI anestlretics. incur minimal ilis. A single 2 g dose ofl oral metronidazole (or tinidazole) is blrxrd loss, and are associated with fl'w contplications (<1'X, efl'ective treatment for established Trichomonas infection. It rnujor artverse cardiac evenls). Multiple studies have shown is also important to treat the patient's partner to help prevent that preoperative testir.rg has little value ir.r low' risk proce reinf'ection and spread of infection to other sexual contacts. clurcs. Even when patients have substantial comorbidities, Patients should also be retested for Trichomonos in 3 months such as this patient, chest radiography, echocardiography, with NAAT because of high reinf.ection rates. and UCG do not predict carclilc complications. Therefbre, A single 1-g dose of oral azithromycin (Option A) is provided rnedical issues are stable, preoperative testiug is not appropriate treatment for chlamydia but does not treat rec<lnrnrended tbr low risk pr<-rcedurcs. trichomoniasis. Testing for chlamydia is appropriate in this Although this patient has cardiopulmonary disease, setting because trichomoniasis is a STI, but treatment should inclucling COPD, her sylxptonls arc stable and chest radi be limited to patients with established chlamydia infection. ography (Option A) results will n<-rt change perioperative Fluconazole (Option B), 150 mg orally, is an appropriate nlilrlagement. Preoperative chest radiography in nontho treatment for vulvovaginal candidiasis but is not appropriate racic surgery is indicated only in patients with new sigrrs for the treatment of trichomoniasis. Vulvovaginal candidi- or sylxptoms of pulmonary illr.ress or unclerlying cardiac or asis is typically characterized by vaginal itching, irritation, pulmonary disease with new or unstable symptoms. and discharge. Examination reveals vulvar edema and exco Civen the low rates of cardiovascular complicatior.rs riation, with thick, white, curdy vaginal discharge. Diagnos and minimal preciicti'n'e value they provide, screenitrg I tic testing involves 10'7, potassium hydroxide wet mount of I')CC (Option B) is not helpful prior to lort' risk proce the discharge showing yeast, hyphae, or pseudohyphae or a clures. Cardiac testing prior to ltx,r, risk surgery should positive NAAT. Vulvovaginal candidiasis is not an STI; there be obtained only if the prrtient has nert, symptoms sug is no need to treat partners of women diagnosed with vulvo gcstive ol cardiac disease (palpitations, chest pain, short vaginal candidiasis. ncss olbreath). 213

Answers and Critiques Echocardiography (Option C) should not be routinely Echocardiography (Option B) is not indicated as a com Fl lfl perlbrmed preoperatively and cerlainly not before lou, risk ponent of the preparticipation physical examination unless t0*' ,r.g".y. Specific indications lbr cchocardiography befbre there is known or suspected cardiac disease. Although surgery that is other than lou'risk include the presence ol hypertrophic cardiomyopathy may very rarely present as dyspnea of unknown origin. heart tailure with worsening sudden death in the young athlete, the prevalence of the clyspnca or change in clinical status. known left rentricular disease is so low that routine echocardiography is not an dysfunction u,ithout echocarcliographic assessment in the ell'ective screening strates/. Findings that would prompt lasl year. and know'n or suspected nloderate to severe val echocardiography include exertional syncopei family history vular stenosis or regurgitation u'itl.tout echocardiographic ofsudden death; and physical findings suggestive ofcardiac assessment in the past year or u'ith a change in clinical disease. including an unexplained murmur. This patient has status. none of these flndings, and echocardiography is not nec- essary. An ECG is clearly indicated if the patient has unex I(EY POI ilI plained syncope; palpitations; or a family history of sudden t,l o In patients undergoing low risk surgery preoperative death that is suggestive ofa congenital abnormality, such as E (D screening tests seldom predict perioperative compli- long QT syndrome. Although some guidelines suggest rou aa cations and are not indicated even in patients with tine ECG, the Americat.r College of Cardiology and American A, substantial comorbidities. Heart Association do not. EL n Bibliography I(EY POIIITS (jrhn SL. I)reoperative e\aluation firr nor]clrtliirc surgery: Ann lntern Med. . Routine testing beyond the history and physical lt 2016:165:lTC81 96. [PN,llD:')7919097)doi:10.7:]26 AITC201612060 examination is not necessary in the preparticipation (D la physical examination unless concerning symptoms and physical findings are uncovered. Item 87 Answer: D o Mandatory components olthe preparticipation physi Educational Objective: Evaluate a patient for cal examination include evaluating for exertional preparticipation physical examination. symptoms, family history of premature or sudden There is no indication lor testing (Option D). Prepartici cardiac death, and presence of a heart murmur. pation physical examination is often required for adoles cents and young adults befbre participation in organized Bibliography sports. The goal of a preparticipation physical evaluation Nlirlbelli l\,1H. Devine MJ. Singh J. et xl. 'lhe preparticipation sports evtluil is to determine an individual's safe participation in sports, tion. Am Fxm Physician.2015r92:il7l 6. It'MID,26371570l although studies have not fbund that the preparticipation screening examination prevents morbidity and mortal ity associated with sports. Advocates claim that it may Item 88 Answer: D detect conditions that predispose the athlete to injury Educational Objective: Diagnose squamous cell or illness, which then may guide advice or intervention. carcinoma. lhe examination should not be a barrier to competitive sports participation, and unnecessary testing should be Squamous cell carcinoma (SCC) (Option D), the second most avoided owing to its attendant costs and unintended con common skin cancer, is a malignant neoplasm of keratino sequences, such as downstream testing fbr incidental flnd cytes. It usually presents as pink, scaly, indurated plaques, ings. Mandatory components include evaluating fbr exer papules, or nodules that can ulcerate, bleed, or become crusty. tional symptoms, family history ol premature or sudden SCCs tend to retain their surlace scale. and as an SCC accumu cardiac death, and presence of a heart murmur. Routine lates a large amount of scale, it is called a cutaneous horn. Risk testing beyond the history and physical examination is factors are exposure to UV light, ionizing radiation, or chem not necessary unless concerning symptoms and physical ical carcinogens (coal tar, soot, and arsenic); viruses (human findings are uncovered. This patient has exercise-induced papillomavirus); and immunosuppression (organ transplant, bronchospasm but an unlimited exercise capacity and no hematologic malignancies, HIV infection). SCC on the central other concerning symptoms or physical flndings. There is face, lips, or ear, as seen in this patient, is considered high no indication for testing. risk and should be treated with Mohs micrographic surgery. Chest radiography and spirometry (Options A, C) are Mohs micrographic surgery is a highly specialized surgical not indicated for a preparticipation physical examination technique that combines pathologz and surgery for complete in a patient with either well controlled asthma or exercise margin control and tissue conservation. It is appropriately induced bronchospasm. as is the case fbr this patient. The used fbr cancers in the head and neck region, those that are indications for these tests are the same as those in other large or recurrent, or those in areas where tissue-sparing is patients, specifically a suspicion of pulmonary disease on critical for function. the basis of symptoms or abnormal flndings on pulmo- Basal cell carcinoma (BCC) (Option A) is the most com nary examination. mon skin cancer. It commonly presents as a pink, pearly

Echocardiography (Option C) should not be routinely Echocardiography (Option B) is not indicated as a com Fl lfl perlbrmed preoperatively and cerlainly not before lou, risk ponent of the preparticipation physical examination unless t0*' ,r.g".y. Specific indications lbr cchocardiography befbre there is known or suspected cardiac disease. Although surgery that is other than lou'risk include the presence ol hypertrophic cardiomyopathy may very rarely present as dyspnea of unknown origin. heart tailure with worsening sudden death in the young athlete, the prevalence of the clyspnca or change in clinical status. known left rentricular disease is so low that routine echocardiography is not an dysfunction u,ithout echocarcliographic assessment in the ell'ective screening strates/. Findings that would prompt lasl year. and know'n or suspected nloderate to severe val echocardiography include exertional syncopei family history vular stenosis or regurgitation u'itl.tout echocardiographic ofsudden death; and physical findings suggestive ofcardiac assessment in the past year or u'ith a change in clinical disease. including an unexplained murmur. This patient has status. none of these flndings, and echocardiography is not nec- essary. An ECG is clearly indicated if the patient has unex I(EY POI ilI plained syncope; palpitations; or a family history of sudden t,l o In patients undergoing low risk surgery preoperative death that is suggestive ofa congenital abnormality, such as E (D screening tests seldom predict perioperative compli- long QT syndrome. Although some guidelines suggest rou aa cations and are not indicated even in patients with tine ECG, the Americat.r College of Cardiology and American A, substantial comorbidities. Heart Association do not. EL n Bibliography I(EY POIIITS (jrhn SL. I)reoperative e\aluation firr nor]clrtliirc surgery: Ann lntern Med. . Routine testing beyond the history and physical lt 2016:165:lTC81 96. [PN,llD:')7919097)doi:10.7:]26 AITC201612060 examination is not necessary in the preparticipation (D la physical examination unless concerning symptoms and physical findings are uncovered. Item 87 Answer: D o Mandatory components olthe preparticipation physi Educational Objective: Evaluate a patient for cal examination include evaluating for exertional preparticipation physical examination. symptoms, family history of premature or sudden There is no indication lor testing (Option D). Prepartici cardiac death, and presence of a heart murmur. pation physical examination is often required for adoles cents and young adults befbre participation in organized Bibliography sports. The goal of a preparticipation physical evaluation Nlirlbelli l\,1H. Devine MJ. Singh J. et xl. 'lhe preparticipation sports evtluil is to determine an individual's safe participation in sports, tion. Am Fxm Physician.2015r92:il7l 6. It'MID,26371570l although studies have not fbund that the preparticipation screening examination prevents morbidity and mortal ity associated with sports. Advocates claim that it may Item 88 Answer: D detect conditions that predispose the athlete to injury Educational Objective: Diagnose squamous cell or illness, which then may guide advice or intervention. carcinoma. lhe examination should not be a barrier to competitive sports participation, and unnecessary testing should be Squamous cell carcinoma (SCC) (Option D), the second most avoided owing to its attendant costs and unintended con common skin cancer, is a malignant neoplasm of keratino sequences, such as downstream testing fbr incidental flnd cytes. It usually presents as pink, scaly, indurated plaques, ings. Mandatory components include evaluating fbr exer papules, or nodules that can ulcerate, bleed, or become crusty. tional symptoms, family history ol premature or sudden SCCs tend to retain their surlace scale. and as an SCC accumu cardiac death, and presence of a heart murmur. Routine lates a large amount of scale, it is called a cutaneous horn. Risk testing beyond the history and physical examination is factors are exposure to UV light, ionizing radiation, or chem not necessary unless concerning symptoms and physical ical carcinogens (coal tar, soot, and arsenic); viruses (human findings are uncovered. This patient has exercise-induced papillomavirus); and immunosuppression (organ transplant, bronchospasm but an unlimited exercise capacity and no hematologic malignancies, HIV infection). SCC on the central other concerning symptoms or physical flndings. There is face, lips, or ear, as seen in this patient, is considered high no indication for testing. risk and should be treated with Mohs micrographic surgery. Chest radiography and spirometry (Options A, C) are Mohs micrographic surgery is a highly specialized surgical not indicated for a preparticipation physical examination technique that combines pathologz and surgery for complete in a patient with either well controlled asthma or exercise margin control and tissue conservation. It is appropriately induced bronchospasm. as is the case fbr this patient. The used fbr cancers in the head and neck region, those that are indications for these tests are the same as those in other large or recurrent, or those in areas where tissue-sparing is patients, specifically a suspicion of pulmonary disease on critical for function. the basis of symptoms or abnormal flndings on pulmo- Basal cell carcinoma (BCC) (Option A) is the most com nary examination. mon skin cancer. It commonly presents as a pink, pearly 214

An s w9_11_11 { !_1 11 iq y e s

An s w9_11_11 { !_1 11 iq y e s papule with rolled borders and arborizing telangiectasias. epiglottitis are less likely than chilclren to progress to air Patients commonly report bleeding of BCCs with any manip way clbstruction, if acute epiglottitis is suspected and air ulation, such as shaving or washing the face. BCC does not way obstruction is a consideration, airway management is a present as hyperkeratotic lesions, as seen in this patient. priorily. Patients rarely require intubation or tracheostomy; Similar to SCC, BCC is usually treated with surgical excision. however, hospital admission is recommended, often to an ICU Mohs micrographic surgery is appropriate for BCC in the setting and with surgical cor.rsultation, to ensure close mon head and neck region. itoring of the airway. Parenteral antibiotic therapy directed SCC in situ is referred to as Bowen disease (Option B). toward common respiratory pathogens is additionally indi ln this condition, malignant keratinocytes are conflned to -fypical cirted. choices tbr empiric thcrapy include ceftriaxone the epidermis. Bowen disease appears as larger scaly pink or tcfolaxime and rantomlr'irr. and tan plaques with well defined borders and does not Although parenteral glucocorticclids. such methylpred resemble this patient's hyperkeratotic nodule. Small lesions nisolone (Option B), are somctimes used to minimize lir can be excised for cure; larger lesions may be more amenable way inflammation in acutc epiglottis, there is little evidence t (l, to destructive therapies, such as curettage and electrodesic supporti ng eflectiveness. Other measures, including airway ET cation or cryotherapy. management and initiation of parenteral antibiotics, arc ol Seborrheic keratoses (Option C) are benign pigmented far greater urgency. U neoplasms of keratinoclte origin that are common in adults. FLtsobacterium necrophorum inf'ection can cause They are "stuck-on" papules and plaques that occur any Lemierre syndrome. a rare suppllrative complication of =, .E where on the body but are most common on the trunk and pharyngitis caused by local spread of inf'ection with resul t,l spare the palms, soles, and mucous membranes. Usually tant septic thrombosis of the internal jugr-rlar vein. Clinicians o UI they are brown, but they can range in color from tan to sl-roulcl suspect Lemierre synclronre in patients with severe = black. When seborrheic keratoses are symptomatic, they pharlrngitis and neck pain that do not respond to :rpprcr may be treated with cryotherapy or shave removal. This priate antibiotics. Diagnosis is made with neck CI' with patient's hyperkeratotic nodule on the ear is most consistent contrast (Option C). In patients with suspected epiglottitis. with SCC. radiographic imaging with ultrasonography or plain racliog raphy may be helpful in gauging the severity of'neck tissue KEY POI lIIS inflammation and predicting likctihood of progression. ltrr . Cutaneous squamous cell carcinoma presents as pink, this patient, CT of the ncck is nnwarrantecl and would delay scaly, indurated plaques, papules, or nodules that can hcr transf'er to the ICU fbr carcful aint':ry monitoring ancl ulcerate, bleed, or become crusty. inten ention if required. . Squamous cell carcinoma on the central face, lips, or Although a rapid antigen detection test (RADT) (Option ear is considered high risk and should be treated with D) is a reasonable test lor gronp A streptococcal pharyngitis, Mohs micrographic surgery. this patier-rt has acute epiglottitis r,r,ith possible ainvay com promise and there is no role lor IIAI)T. Bibliography r(EY P0t1{rs Kim JY, Kozlow JH, Mittal B, et al; W)rk Croup. Cuidelines of care for the management of cutaneous squamolls cell ctrrcinoma. J Am Acad . Patients with epiglottitis typically appear seriously i11, Dermatol. 2018;78:560 78. Il,MIl): 293313861 doi.l0.l0161j.jaad. with excessive salivation and drooling, tachypnea, 2017.1 o.o07 stridor, and severe pharyngitis and dysphagia. . If severe acute epiglottitis is suspected and airway Item 89 Answer: A obstruction seems imminent, airway control should precede diagnostic evaluation. Educational Objective: Manage a patient with suspected epiglottitis. Bibliography The most appropriate next stcp in management is admission Klein MR. Infections of the orophlrynx. limerg Med Clin North Am '2019:37:69 80. IPMI D: 30454781 ] doi:10.1016/i.emc.2018.09.002 to the ICU (Option A). this prtient likely has acute epiglotti tis. Epiglottitis is a severe and rare inflammatory response to a respiratory infection that requires emergent identification and treatment, r.tith close attention tcl airway management. Item 9O Answer: D Although viral causes are common, epiglottitis may also be Educational Objective: Manage cyclic breast pain. caused by Streptococcus pneumotiioe and other bacterial respiratory pathogens. Betbre universal vaccination. Hae The most appropriate management is patient education and rrroplrilus influenzae type B accounted fbr most infections. reassurance (Option D). This patient has bilateral cyclic breast Patients n,ith epiglottitis may present with flndings of sep pain. Most common in women aged 20 to 39 years, cyclic sis, including fever. tachycarclia, severe sore throat, drooling breast pain is often diffuse and bilateral, occurs during the that suggests difficulty managing normal secretions, striclor, premenstrual phase, and resolves with onset of menstruation; and inability to open the mouth. Although adults with acutc it is usually associated with hormonal changes and is typically

papule with rolled borders and arborizing telangiectasias. epiglottitis are less likely than chilclren to progress to air Patients commonly report bleeding of BCCs with any manip way clbstruction, if acute epiglottitis is suspected and air ulation, such as shaving or washing the face. BCC does not way obstruction is a consideration, airway management is a present as hyperkeratotic lesions, as seen in this patient. priorily. Patients rarely require intubation or tracheostomy; Similar to SCC, BCC is usually treated with surgical excision. however, hospital admission is recommended, often to an ICU Mohs micrographic surgery is appropriate for BCC in the setting and with surgical cor.rsultation, to ensure close mon head and neck region. itoring of the airway. Parenteral antibiotic therapy directed SCC in situ is referred to as Bowen disease (Option B). toward common respiratory pathogens is additionally indi ln this condition, malignant keratinocytes are conflned to -fypical cirted. choices tbr empiric thcrapy include ceftriaxone the epidermis. Bowen disease appears as larger scaly pink or tcfolaxime and rantomlr'irr. and tan plaques with well defined borders and does not Although parenteral glucocorticclids. such methylpred resemble this patient's hyperkeratotic nodule. Small lesions nisolone (Option B), are somctimes used to minimize lir can be excised for cure; larger lesions may be more amenable way inflammation in acutc epiglottis, there is little evidence t (l, to destructive therapies, such as curettage and electrodesic supporti ng eflectiveness. Other measures, including airway ET cation or cryotherapy. management and initiation of parenteral antibiotics, arc ol Seborrheic keratoses (Option C) are benign pigmented far greater urgency. U neoplasms of keratinoclte origin that are common in adults. FLtsobacterium necrophorum inf'ection can cause They are "stuck-on" papules and plaques that occur any Lemierre syndrome. a rare suppllrative complication of =, .E where on the body but are most common on the trunk and pharyngitis caused by local spread of inf'ection with resul t,l spare the palms, soles, and mucous membranes. Usually tant septic thrombosis of the internal jugr-rlar vein. Clinicians o UI they are brown, but they can range in color from tan to sl-roulcl suspect Lemierre synclronre in patients with severe = black. When seborrheic keratoses are symptomatic, they pharlrngitis and neck pain that do not respond to :rpprcr may be treated with cryotherapy or shave removal. This priate antibiotics. Diagnosis is made with neck CI' with patient's hyperkeratotic nodule on the ear is most consistent contrast (Option C). In patients with suspected epiglottitis. with SCC. radiographic imaging with ultrasonography or plain racliog raphy may be helpful in gauging the severity of'neck tissue KEY POI lIIS inflammation and predicting likctihood of progression. ltrr . Cutaneous squamous cell carcinoma presents as pink, this patient, CT of the ncck is nnwarrantecl and would delay scaly, indurated plaques, papules, or nodules that can hcr transf'er to the ICU fbr carcful aint':ry monitoring ancl ulcerate, bleed, or become crusty. inten ention if required. . Squamous cell carcinoma on the central face, lips, or Although a rapid antigen detection test (RADT) (Option ear is considered high risk and should be treated with D) is a reasonable test lor gronp A streptococcal pharyngitis, Mohs micrographic surgery. this patier-rt has acute epiglottitis r,r,ith possible ainvay com promise and there is no role lor IIAI)T. Bibliography r(EY P0t1{rs Kim JY, Kozlow JH, Mittal B, et al; W)rk Croup. Cuidelines of care for the management of cutaneous squamolls cell ctrrcinoma. J Am Acad . Patients with epiglottitis typically appear seriously i11, Dermatol. 2018;78:560 78. Il,MIl): 293313861 doi.l0.l0161j.jaad. with excessive salivation and drooling, tachypnea, 2017.1 o.o07 stridor, and severe pharyngitis and dysphagia. . If severe acute epiglottitis is suspected and airway Item 89 Answer: A obstruction seems imminent, airway control should precede diagnostic evaluation. Educational Objective: Manage a patient with suspected epiglottitis. Bibliography The most appropriate next stcp in management is admission Klein MR. Infections of the orophlrynx. limerg Med Clin North Am '2019:37:69 80. IPMI D: 30454781 ] doi:10.1016/i.emc.2018.09.002 to the ICU (Option A). this prtient likely has acute epiglotti tis. Epiglottitis is a severe and rare inflammatory response to a respiratory infection that requires emergent identification and treatment, r.tith close attention tcl airway management. Item 9O Answer: D Although viral causes are common, epiglottitis may also be Educational Objective: Manage cyclic breast pain. caused by Streptococcus pneumotiioe and other bacterial respiratory pathogens. Betbre universal vaccination. Hae The most appropriate management is patient education and rrroplrilus influenzae type B accounted fbr most infections. reassurance (Option D). This patient has bilateral cyclic breast Patients n,ith epiglottitis may present with flndings of sep pain. Most common in women aged 20 to 39 years, cyclic sis, including fever. tachycarclia, severe sore throat, drooling breast pain is often diffuse and bilateral, occurs during the that suggests difficulty managing normal secretions, striclor, premenstrual phase, and resolves with onset of menstruation; and inability to open the mouth. Although adults with acutc it is usually associated with hormonal changes and is typically 215

Answers and Critiques benign. If flndings on clinical breast examination (CBE) are patches involving most of the soles in a "moccasin" distribu normal, additional screening for malignancy beyond age- tion. "Two feet one hand" tinea is a characteristic pattern of appropriate screening is not required. Cyclic breast pain should involvement. Tinea pedis can have a more acute form, with be managed conservatively with education, reassurance regard 1- to 2 mm vesicles, and can be extremely pruritic. The inter- ing the absence of malignanry, and wearing a supportive and digital variant of tinea pedis shows flssures and maceration well-fltting bra. Although some patients beneflt from topical in the folds (as shown). NSAID therapy pain resolves spontaneously for most women. There is a lack of evidence to support limiting caffeine intake or using vitamin E as a means of mitigating the pain. Breast ultrasonography (Option A) is not indicated for this patient. Women with cyclic diffuse breast pain and a normal CBE do not require additional imagrng. For women younger than 30 years who have focal breast pain or an abnor (,t mal CBE, breast ultrasonography is appropriate for further evaluation. This patient is 33 years old; if indicated, mammog- = .D !n raphy would be the appropriate diagnostic modality. o, Danazol (Option B) is the only FDA-approved agent for EL cyclic breast pain, but its use is limited because of side effects, at including amenorrhea, hirsutism, and adverse changes in st lipid proflle. It should be considered only in women with severe pain in whom conservative management has failed. This patient's plaques with serpiginous and arcuate scaly (D tl Ir4ammography (Option C) is not indicated. Given this borders in a moccasin distribution should raise suspicion for patient's age, she does not qualify for routine screening dermatophy.te infection. Tinea should be treated to prevent mammography, and her family history does not suggest a skin breakdor.r,n, which can be an entry port for bacterial hereditary cancer syndrome that would quali$r for early infection. Dermatophytosis of non hair bearing skin with screening. Mammography would be the most appropriate Iimited involvement can be treated topically with the use of management in patients older than 30 years who present topical terbinaflne or imidazole creams, such as miconazole, with noncyclic focal breast pain or have an abnormal CBE. clotrimazole, and ketoconazole, applied once to twice daily for Noncyclic breast pain is often caused by medication use 2 to 4 weeks, ensuring that the application extends a few cen- (contraceptive agents, hormone replacement therapy, psy- timeters beyond the advancing border. Combined antifungals chiatric medications), underlying breast disease (flbrocys- and topical glucocorticoids should be avoided because they tic disease, infection, trauma, cancer), or stretching of the can lead to increased recurrences and treatment failures. Cooper Iigaments (connective tissue that maintains breast Adalimumab (Option A) and clobetasol (Option B) are structural integrity). not helpful in the treatment of dermatophytosis but are effec tive in the treatment of psoriasis, which can affect the soles of the feet and nails. Psoriasis appears as discrete, sharply . If a clinical breast examination is normal, manage- marginated red plaques with silvery lamellar scale. The arcu ment of bilateral cyclic breast pain is conservative and ate and serpiginous scale and the dull brown red color of this includes education, reassurance regarding the patient's skin flndings are not consistent with the presenta absence of malignancy, wearing a supportive and tion ofpsoriasis. well-fitting bra, and topical NSAID therapy. Topical nystatin cream (Option C) is beneflcial in the . Danazol is the only FDA approved agent for cyclic treatment of cutaneous candidiasis, but it is not effective in the treatment of dermatophyte infections, such as tinea pedis. breast pain but should be considered only in women Although systemic antifungal agents, such as itracon with severe pain in whom conservative management azole (Option D), can be beneflcial in the treatment of ony- has failed. chomycosis, this patient reports she is not concerned with treating her toenails. Furthermore, itraconazole is rarely BibHography used for the treatment of onychomycosis due to its side Salzman B, Collins E, Hersh L. Common breast prcblems. Am Fam Physician. 2019;99:505-14. [PMlD, 30990294] effect proflle. Systemic terbinaflne or fluconazole are more commonly utilized.

benign. If flndings on clinical breast examination (CBE) are patches involving most of the soles in a "moccasin" distribu normal, additional screening for malignancy beyond age- tion. "Two feet one hand" tinea is a characteristic pattern of appropriate screening is not required. Cyclic breast pain should involvement. Tinea pedis can have a more acute form, with be managed conservatively with education, reassurance regard 1- to 2 mm vesicles, and can be extremely pruritic. The inter- ing the absence of malignanry, and wearing a supportive and digital variant of tinea pedis shows flssures and maceration well-fltting bra. Although some patients beneflt from topical in the folds (as shown). NSAID therapy pain resolves spontaneously for most women. There is a lack of evidence to support limiting caffeine intake or using vitamin E as a means of mitigating the pain. Breast ultrasonography (Option A) is not indicated for this patient. Women with cyclic diffuse breast pain and a normal CBE do not require additional imagrng. For women younger than 30 years who have focal breast pain or an abnor (,t mal CBE, breast ultrasonography is appropriate for further evaluation. This patient is 33 years old; if indicated, mammog- = .D !n raphy would be the appropriate diagnostic modality. o, Danazol (Option B) is the only FDA-approved agent for EL cyclic breast pain, but its use is limited because of side effects, at including amenorrhea, hirsutism, and adverse changes in st lipid proflle. It should be considered only in women with severe pain in whom conservative management has failed. This patient's plaques with serpiginous and arcuate scaly (D tl Ir4ammography (Option C) is not indicated. Given this borders in a moccasin distribution should raise suspicion for patient's age, she does not qualify for routine screening dermatophy.te infection. Tinea should be treated to prevent mammography, and her family history does not suggest a skin breakdor.r,n, which can be an entry port for bacterial hereditary cancer syndrome that would quali$r for early infection. Dermatophytosis of non hair bearing skin with screening. Mammography would be the most appropriate Iimited involvement can be treated topically with the use of management in patients older than 30 years who present topical terbinaflne or imidazole creams, such as miconazole, with noncyclic focal breast pain or have an abnormal CBE. clotrimazole, and ketoconazole, applied once to twice daily for Noncyclic breast pain is often caused by medication use 2 to 4 weeks, ensuring that the application extends a few cen- (contraceptive agents, hormone replacement therapy, psy- timeters beyond the advancing border. Combined antifungals chiatric medications), underlying breast disease (flbrocys- and topical glucocorticoids should be avoided because they tic disease, infection, trauma, cancer), or stretching of the can lead to increased recurrences and treatment failures. Cooper Iigaments (connective tissue that maintains breast Adalimumab (Option A) and clobetasol (Option B) are structural integrity). not helpful in the treatment of dermatophytosis but are effec tive in the treatment of psoriasis, which can affect the soles of the feet and nails. Psoriasis appears as discrete, sharply . If a clinical breast examination is normal, manage- marginated red plaques with silvery lamellar scale. The arcu ment of bilateral cyclic breast pain is conservative and ate and serpiginous scale and the dull brown red color of this includes education, reassurance regarding the patient's skin flndings are not consistent with the presenta absence of malignancy, wearing a supportive and tion ofpsoriasis. well-fitting bra, and topical NSAID therapy. Topical nystatin cream (Option C) is beneflcial in the . Danazol is the only FDA approved agent for cyclic treatment of cutaneous candidiasis, but it is not effective in the treatment of dermatophyte infections, such as tinea pedis. breast pain but should be considered only in women Although systemic antifungal agents, such as itracon with severe pain in whom conservative management azole (Option D), can be beneflcial in the treatment of ony- has failed. chomycosis, this patient reports she is not concerned with treating her toenails. Furthermore, itraconazole is rarely BibHography used for the treatment of onychomycosis due to its side Salzman B, Collins E, Hersh L. Common breast prcblems. Am Fam Physician. 2019;99:505-14. [PMlD, 30990294] effect proflle. Systemic terbinaflne or fluconazole are more commonly utilized. 'fitrI'POlXttt., r :,' .

benign. If flndings on clinical breast examination (CBE) are patches involving most of the soles in a "moccasin" distribu normal, additional screening for malignancy beyond age- tion. "Two feet one hand" tinea is a characteristic pattern of appropriate screening is not required. Cyclic breast pain should involvement. Tinea pedis can have a more acute form, with be managed conservatively with education, reassurance regard 1- to 2 mm vesicles, and can be extremely pruritic. The inter- ing the absence of malignanry, and wearing a supportive and digital variant of tinea pedis shows flssures and maceration well-fltting bra. Although some patients beneflt from topical in the folds (as shown). NSAID therapy pain resolves spontaneously for most women. There is a lack of evidence to support limiting caffeine intake or using vitamin E as a means of mitigating the pain. Breast ultrasonography (Option A) is not indicated for this patient. Women with cyclic diffuse breast pain and a normal CBE do not require additional imagrng. For women younger than 30 years who have focal breast pain or an abnor (,t mal CBE, breast ultrasonography is appropriate for further evaluation. This patient is 33 years old; if indicated, mammog- = .D !n raphy would be the appropriate diagnostic modality. o, Danazol (Option B) is the only FDA-approved agent for EL cyclic breast pain, but its use is limited because of side effects, at including amenorrhea, hirsutism, and adverse changes in st lipid proflle. It should be considered only in women with severe pain in whom conservative management has failed. This patient's plaques with serpiginous and arcuate scaly (D tl Ir4ammography (Option C) is not indicated. Given this borders in a moccasin distribution should raise suspicion for patient's age, she does not qualify for routine screening dermatophy.te infection. Tinea should be treated to prevent mammography, and her family history does not suggest a skin breakdor.r,n, which can be an entry port for bacterial hereditary cancer syndrome that would quali$r for early infection. Dermatophytosis of non hair bearing skin with screening. Mammography would be the most appropriate Iimited involvement can be treated topically with the use of management in patients older than 30 years who present topical terbinaflne or imidazole creams, such as miconazole, with noncyclic focal breast pain or have an abnormal CBE. clotrimazole, and ketoconazole, applied once to twice daily for Noncyclic breast pain is often caused by medication use 2 to 4 weeks, ensuring that the application extends a few cen- (contraceptive agents, hormone replacement therapy, psy- timeters beyond the advancing border. Combined antifungals chiatric medications), underlying breast disease (flbrocys- and topical glucocorticoids should be avoided because they tic disease, infection, trauma, cancer), or stretching of the can lead to increased recurrences and treatment failures. Cooper Iigaments (connective tissue that maintains breast Adalimumab (Option A) and clobetasol (Option B) are structural integrity). not helpful in the treatment of dermatophytosis but are effec tive in the treatment of psoriasis, which can affect the soles of the feet and nails. Psoriasis appears as discrete, sharply . If a clinical breast examination is normal, manage- marginated red plaques with silvery lamellar scale. The arcu ment of bilateral cyclic breast pain is conservative and ate and serpiginous scale and the dull brown red color of this includes education, reassurance regarding the patient's skin flndings are not consistent with the presenta absence of malignancy, wearing a supportive and tion ofpsoriasis. well-fitting bra, and topical NSAID therapy. Topical nystatin cream (Option C) is beneflcial in the . Danazol is the only FDA approved agent for cyclic treatment of cutaneous candidiasis, but it is not effective in the treatment of dermatophyte infections, such as tinea pedis. breast pain but should be considered only in women Although systemic antifungal agents, such as itracon with severe pain in whom conservative management azole (Option D), can be beneflcial in the treatment of ony- has failed. chomycosis, this patient reports she is not concerned with treating her toenails. Furthermore, itraconazole is rarely BibHography used for the treatment of onychomycosis due to its side Salzman B, Collins E, Hersh L. Common breast prcblems. Am Fam Physician. 2019;99:505-14. [PMlD, 30990294] effect proflle. Systemic terbinaflne or fluconazole are more commonly utilized. 'fitrI'POlXttt., r :,' . Item 91 Answer: E o The chronic form of tinea pedis presents as mildly Educational Objective: Treat tinea pedis. pruritic scaly patches involving most of the soles in a "moccasin' distribution; the interdigital variant of The most appropriate treatment for this patient's rash is ter- tinea pedis shows flssures and maceration in the folds. binaflne cream (Option E). This patient has tinea pedis. The (Continued) chronic form of tinea pedis presents as mildly pruritic scaly

Item 91 Answer: E o The chronic form of tinea pedis presents as mildly Educational Objective: Treat tinea pedis. pruritic scaly patches involving most of the soles in a "moccasin' distribution; the interdigital variant of The most appropriate treatment for this patient's rash is ter- tinea pedis shows flssures and maceration in the folds. binaflne cream (Option E). This patient has tinea pedis. The (Continued) chronic form of tinea pedis presents as mildly pruritic scaly 216

Answers and Critiques f EY POI{IS (cortirraedl XEY POITIS . Recommended treatment of localized tinea on non . Treatment of postoperative ileus consists of minimiz- hair bearing skin is terbinafine or imidazole creams, ing the use ofopioids, hydration, bowel rest, electro such as miconazole, clotrimazole, and ketoconazole. lyte repletion, postoperative ambulation, and use of chewinggum. Bibliography . Minimally invasive surgical approaches, multimodal Aizenberg DJ. Common complaints of the hands and feet. Med Clin North Am. 2021;105:187 97. [PMID: 33246518] doi:10.1016/j.mcna.2020.08.016 analgesia techniques, prophylactic bowel regimens, and early ambulation may help to prevent postopera- tive ileus.

f EY POI{IS (cortirraedl XEY POITIS . Recommended treatment of localized tinea on non . Treatment of postoperative ileus consists of minimiz- hair bearing skin is terbinafine or imidazole creams, ing the use ofopioids, hydration, bowel rest, electro such as miconazole, clotrimazole, and ketoconazole. lyte repletion, postoperative ambulation, and use of chewinggum. Bibliography . Minimally invasive surgical approaches, multimodal Aizenberg DJ. Common complaints of the hands and feet. Med Clin North Am. 2021;105:187 97. [PMID: 33246518] doi:10.1016/j.mcna.2020.08.016 analgesia techniques, prophylactic bowel regimens, and early ambulation may help to prevent postopera- tive ileus. tr Item 92 Answer: B Educational Obiective: Manage postoperative ileus. Bibliography Vilz TO, Stoffels B, Strassburg C, et al. Ileus in adults. Dtsch Arztebl lnt. a (l, 2017;114:508 18. IPMIDT 28818187] doi:10.3238/ailtebI.2017.0508 The nrost appropriate managentent is to decrease the ET patient's opioid use (Option B). This patient likely has a postoperative ileus (POI). POI is common after both intra abdominal and nonabdominal surgery. It is caused by a com bination of intraperitoneal inflammation, neuroinhibition ol Item 93 Answer: C Educational Objective: IdentiS overdiagnosis as a carrse tr 1., It .u ofharm due to screening. rrl the sympathetic nenzous system, and medications (such as (, opioids and anesthesia). There is no specific therapy for post Overdiagnosis (Option C) is most likely responsible for the UI operative ileus other than supportive. Supportive therapy small reduction in cancer related deaths and increase in = consists of minimizing the use of opioids, hydration, bowel harm. Length-time bias occurs when screening detects more rest, electrolyte repletion, postoperative ambulation, and use cases of disease with a prolonged asymptomatic phase than of chewing gum. Minimally invasive surgical approaches, aggressive cases of disease with a shorl asymptomalic phase. multimodal analgesia techniques, prophylactic bowel regi- Slowly progressive disease is more likely than aggressive dis mens, and early ambulation may help to prevent POI. ease to be detected with screening, leading to an overesti- Plain radiography is usually adequate to diagnose POl mation of survival benefit in patients with screen-detected and to distinguish it fiom small bowel obstruction. CT of disease. Overdiagnosis, or finding and treating illness that the abdomen (Option A) is indicated if any suspicion fbr otherwise would not have become clinically apparent or small bowel obstruction remains. particularly if the ileus is caused harm in the patient's litbtime, is an extreme example prolonged beyoncl 3 to 4 days. There is no indication for CT of length time bias. Overdiagnosis not uncommonly leads to for this patient at this time. harm due to overtesting and unnecessary treatments. In patients receiving long-standing opioid therapy and All-cause mortality (Option A) rather than cancer who have severe constipation. a peripherally acting p-opioid specilic moftality has been proposed as a pref'erable end receptor antagonist, such as methylnaltrexone, can be eflec point in randomized controlled trials on the basis of possible tive in improving bowel motility. Althotigh opioids may be biases in assignment of cause of death. I\{isassignment can contributing to this patient's POI, they are unlikely to be falsely elevate or decrease cancer related deaths. All-cause the only cause and methylnaltrexone therapy (Option C) is mortality is a less ambiguous assignment and reduces bias unlikely to be successful in reversing the ileus. and does not account for the results of this study. Gastric decompression with a nasogastric tube (Option Lead time bias (Option B) occurs when early detection D) is indicated for patients with significant vomiting, bowel arlificially results in an increase in measured survival. The distention, or abdominal pain. These indications are not time between early detection and clinical diagnosis is mis- present. takenly counted as survival time; howevel only the mea Acute colonic pseudo-obstruction (Ogilvie syn- sured time with diagnosed disease, not survival time, has drome) is characterized by acute dilatation of the colon in increased. Using moftality rates rather than survival time the absence of a mechanical obstruction. This condition as the prin-rary outcome in studies of screening tests in ran- i is usually found in severely i1l hospitalized patients or domized controlled trials can help minimize lead time bias. after surgery that is complicated by a metabolic distur This randomized controlled trial used a specific disease bance or medications that inhibit peristalsis. Patients related end point as well as overall mortality. The risk for have abdominal distention with pain, anorexia, nausea. lead time bias is low in this studv and cannot account fbr and vomiting. Plain radiography docunrents a dilated the results. colon. The initial management is supportive care, but Selection bias (Option D) occurs when patients who treatment with neostigmine is often attempted in patients undergo screening tests are healthier and more interested in r,r,hom conservative therapy has failed. On the basis of in their health than the general population. Intention-to findings on this patient's radiograph, she does not have treat analyses, in which patients are analyzed according acute colonic pseudo obstruction and does not require to their original group assignment in randomized clinical neostigmine (Option E). trials regardless ofintervention received, reduce the risk for

tr Item 92 Answer: B Educational Obiective: Manage postoperative ileus. Bibliography Vilz TO, Stoffels B, Strassburg C, et al. Ileus in adults. Dtsch Arztebl lnt. a (l, 2017;114:508 18. IPMIDT 28818187] doi:10.3238/ailtebI.2017.0508 The nrost appropriate managentent is to decrease the ET patient's opioid use (Option B). This patient likely has a postoperative ileus (POI). POI is common after both intra abdominal and nonabdominal surgery. It is caused by a com bination of intraperitoneal inflammation, neuroinhibition ol Item 93 Answer: C Educational Objective: IdentiS overdiagnosis as a carrse tr 1., It .u ofharm due to screening. rrl the sympathetic nenzous system, and medications (such as (, opioids and anesthesia). There is no specific therapy for post Overdiagnosis (Option C) is most likely responsible for the UI operative ileus other than supportive. Supportive therapy small reduction in cancer related deaths and increase in = consists of minimizing the use of opioids, hydration, bowel harm. Length-time bias occurs when screening detects more rest, electrolyte repletion, postoperative ambulation, and use cases of disease with a prolonged asymptomatic phase than of chewing gum. Minimally invasive surgical approaches, aggressive cases of disease with a shorl asymptomalic phase. multimodal analgesia techniques, prophylactic bowel regi- Slowly progressive disease is more likely than aggressive dis mens, and early ambulation may help to prevent POI. ease to be detected with screening, leading to an overesti- Plain radiography is usually adequate to diagnose POl mation of survival benefit in patients with screen-detected and to distinguish it fiom small bowel obstruction. CT of disease. Overdiagnosis, or finding and treating illness that the abdomen (Option A) is indicated if any suspicion fbr otherwise would not have become clinically apparent or small bowel obstruction remains. particularly if the ileus is caused harm in the patient's litbtime, is an extreme example prolonged beyoncl 3 to 4 days. There is no indication for CT of length time bias. Overdiagnosis not uncommonly leads to for this patient at this time. harm due to overtesting and unnecessary treatments. In patients receiving long-standing opioid therapy and All-cause mortality (Option A) rather than cancer who have severe constipation. a peripherally acting p-opioid specilic moftality has been proposed as a pref'erable end receptor antagonist, such as methylnaltrexone, can be eflec point in randomized controlled trials on the basis of possible tive in improving bowel motility. Althotigh opioids may be biases in assignment of cause of death. I\{isassignment can contributing to this patient's POI, they are unlikely to be falsely elevate or decrease cancer related deaths. All-cause the only cause and methylnaltrexone therapy (Option C) is mortality is a less ambiguous assignment and reduces bias unlikely to be successful in reversing the ileus. and does not account for the results of this study. Gastric decompression with a nasogastric tube (Option Lead time bias (Option B) occurs when early detection D) is indicated for patients with significant vomiting, bowel arlificially results in an increase in measured survival. The distention, or abdominal pain. These indications are not time between early detection and clinical diagnosis is mis- present. takenly counted as survival time; howevel only the mea Acute colonic pseudo-obstruction (Ogilvie syn- sured time with diagnosed disease, not survival time, has drome) is characterized by acute dilatation of the colon in increased. Using moftality rates rather than survival time the absence of a mechanical obstruction. This condition as the prin-rary outcome in studies of screening tests in ran- i is usually found in severely i1l hospitalized patients or domized controlled trials can help minimize lead time bias. after surgery that is complicated by a metabolic distur This randomized controlled trial used a specific disease bance or medications that inhibit peristalsis. Patients related end point as well as overall mortality. The risk for have abdominal distention with pain, anorexia, nausea. lead time bias is low in this studv and cannot account fbr and vomiting. Plain radiography docunrents a dilated the results. colon. The initial management is supportive care, but Selection bias (Option D) occurs when patients who treatment with neostigmine is often attempted in patients undergo screening tests are healthier and more interested in r,r,hom conservative therapy has failed. On the basis of in their health than the general population. Intention-to findings on this patient's radiograph, she does not have treat analyses, in which patients are analyzed according acute colonic pseudo obstruction and does not require to their original group assignment in randomized clinical neostigmine (Option E). trials regardless ofintervention received, reduce the risk for 217

Answers and Critiques l[ selection bias. Participants in tiris study nere randonlized A single dose of intramuscular celtriarone and a 10 da-v- E inle the lwo anns olthe studv and the results'utere analvzed course oloral levofloxacin (Option C) is appropriate empiric -""' according to their original group assignment; risk fbr selec CONT, therapl, for patients with acute epididl'mitis ulto prac tior, bias was thus reduced. and such bias cannot account tice insertive anal intercourse because it provides coverage for the results. against coliform bacteria. N. gonorrhoerie, and C. tracho' motis. This regimen is not indicated fbr this patient u'ho is XEY POIIITS sexualll' active onl!' with his wif'e. . Overdiagnosis is finding and treating illness that oth- erwise would not have become clinically apparent or IEY POITTS caused harm in the patient's lifetime and is often . Enteric bacteria are the most commonly implicated associated with patient harm. pathogens causing epididyrnitis in men older than . Lead-time bias occurs when early detection artifi- 35 years and at low risk for sexually transmitted

l[ selection bias. Participants in tiris study nere randonlized A single dose of intramuscular celtriarone and a 10 da-v- E inle the lwo anns olthe studv and the results'utere analvzed course oloral levofloxacin (Option C) is appropriate empiric -""' according to their original group assignment; risk fbr selec CONT, therapl, for patients with acute epididl'mitis ulto prac tior, bias was thus reduced. and such bias cannot account tice insertive anal intercourse because it provides coverage for the results. against coliform bacteria. N. gonorrhoerie, and C. tracho' motis. This regimen is not indicated fbr this patient u'ho is XEY POIIITS sexualll' active onl!' with his wif'e. . Overdiagnosis is finding and treating illness that oth- erwise would not have become clinically apparent or IEY POITTS caused harm in the patient's lifetime and is often . Enteric bacteria are the most commonly implicated associated with patient harm. pathogens causing epididyrnitis in men older than . Lead-time bias occurs when early detection artifi- 35 years and at low risk for sexually transmitted F cially results in an increase in measured survival. infections. t!) . ChlamAdia trachomatis and Neisseria gonorrhoeae 4, (D Bibliography are the most commonly implicated pathogens causing vt Berry DA. Failure ofresearchers, reyiewers. editors, and the media to under epididymitis in patients aged 35 years or younger o, stand flaws in cancer screening studies: application to an article in and in those at high risk for sexually transmitted CL Cancer. Cancer. 2074;120:2781 91. [PMID: 219253151 doi: 10.1002"cncr. a1 24795 infections.

F cially results in an increase in measured survival. infections. t!) . ChlamAdia trachomatis and Neisseria gonorrhoeae 4, (D Bibliography are the most commonly implicated pathogens causing vt Berry DA. Failure ofresearchers, reyiewers. editors, and the media to under epididymitis in patients aged 35 years or younger o, stand flaws in cancer screening studies: application to an article in and in those at high risk for sexually transmitted CL Cancer. Cancer. 2074;120:2781 91. [PMID: 219253151 doi: 10.1002"cncr. a1 24795 infections. .€t Bibliography (D ur tr Item 94 Answer: D Ed ucationa I Objective : Manage acute epididymitis McConaghy JR, Panchal B. Epididymitis: an oven-ie\-. Am Fam Ph]'sician. 2Q16:94:723 6. IPMID: 27929213)

.€t Bibliography (D ur tr Item 94 Answer: D Ed ucationa I Objective : Manage acute epididymitis McConaghy JR, Panchal B. Epididymitis: an oven-ie\-. Am Fam Ph]'sician. 2Q16:94:723 6. IPMID: 27929213) in an older man. The most appropriate management is oral levofloxacin Item 95 Answer: C (Option D). This patient has acute epididymitis characterized Educational Objective: Diagnose phototoxic reaction to by unilateral scrotal pain of gradual onset that u,orsens o\,€r a doxycycline. period of days. In men older than 35 years and in those u,ho are at lorar risk fbr sexually translxitted infections (STIs). the The most likely diagnosis is phototoxic drug reaction (Option most likely pathogen is an enteric bacterium. such as Esche C). This patient presents with the characteristic erythema richia coli. The most appropriate therapy is ar-r empiric 10 day and blistering ofa phototoxic drug reaction. Phototoxic drug course of oral levofloxacin. Other important management reactions usually present as exaggerated sunburn due to direct measures include rest. NSAIDs. and scrotal suppofl. At the cellular injury. Unlike photoallergic reactions, they are not time of presentation, urinall,sis should be obtained: if results immunologically mediated and do not require prior sensi are abnormal, urine culture should be performed. Hor,rerer. tization; reactions occur minutes to hours after sun expo- antimicrobial therapy should not be delaled rvhile ar,raiting sure. Tetracyclines, including doxycycline, are one of the most culture results. common causes of phototoxic drug reactions. In addition Acute epididymitis is a clinical diagnosis. Doppler ultra- to exaggerated sunburn, tetracycline induced phototoxic- sonography ol the scrotum (Option A) is not indicated in lty may present with photo onycholysis (separation of the patients who present with both historical and eramination nail from the nail bed) and pseudoporphyria. Minocycline flndings consistent with acute epididymitis (as is the case for may cause less photosensitization than other tetracyclines. this patient) . Doppler ultrasonography is helpful r,t hen there Other common causes of phototoxic reactions include sul is diagnostic uncertainty; Doppler findings suggestir,e of fonamides, hydrochlorothiazide, fluoroquinolones, antima- acute epididymitis include increased epididymal blood flon' Iarials, amiodarone, and voriconazole. Discontinuation of the and swelling. Lack of blood florv r,r,ould indicate a urologic photosensitizing drug and sun avoidance measures will lead emergency, such as testicular torsion. r,r,hich is unlikely in to resolution of the reaction. Topical glucocorticoids can be the presence ofan intact cremasteric reflex. used for symptomatic treatment. A single dose of intramuscular ceftriarone and a 10 day Bullous pemphigoid (Option A) is a pruritic autoim- course of oral doxycycline (Option B) is appropriate empiric mune blistering disorder that presents most commonly in antimicrobial therapy in patients r,r,ith acute epididyntitis elderly persons. It does not present acutely after sun expo who are 35 years of age or younger and in men are at high sure and is a very unlikely diagnosis in this young patient. risk for STIs. In these cases, common causatir,e organisms A photoallergic drug reaction (Option B) is a type IV include l{eisserio gonorrlrceae and Chlamydia tracho- hypersensitivity reaction that is less common than photo- mofis; nucleic acid ampliflcation testing for these organ toxic drug reactions and occurs in patients with prior sen isms should be obtained. This regimen is not indicated for sitization to the offending drug. This type of drug reaction patients who are older than 35 years and in those at lor,v [zpically presents more than24 hours after exposure. It clin risk for STls. ically presents as eczematous dermatitis and less commonly

in an older man. The most appropriate management is oral levofloxacin Item 95 Answer: C (Option D). This patient has acute epididymitis characterized Educational Objective: Diagnose phototoxic reaction to by unilateral scrotal pain of gradual onset that u,orsens o\,€r a doxycycline. period of days. In men older than 35 years and in those u,ho are at lorar risk fbr sexually translxitted infections (STIs). the The most likely diagnosis is phototoxic drug reaction (Option most likely pathogen is an enteric bacterium. such as Esche C). This patient presents with the characteristic erythema richia coli. The most appropriate therapy is ar-r empiric 10 day and blistering ofa phototoxic drug reaction. Phototoxic drug course of oral levofloxacin. Other important management reactions usually present as exaggerated sunburn due to direct measures include rest. NSAIDs. and scrotal suppofl. At the cellular injury. Unlike photoallergic reactions, they are not time of presentation, urinall,sis should be obtained: if results immunologically mediated and do not require prior sensi are abnormal, urine culture should be performed. Hor,rerer. tization; reactions occur minutes to hours after sun expo- antimicrobial therapy should not be delaled rvhile ar,raiting sure. Tetracyclines, including doxycycline, are one of the most culture results. common causes of phototoxic drug reactions. In addition Acute epididymitis is a clinical diagnosis. Doppler ultra- to exaggerated sunburn, tetracycline induced phototoxic- sonography ol the scrotum (Option A) is not indicated in lty may present with photo onycholysis (separation of the patients who present with both historical and eramination nail from the nail bed) and pseudoporphyria. Minocycline flndings consistent with acute epididymitis (as is the case for may cause less photosensitization than other tetracyclines. this patient) . Doppler ultrasonography is helpful r,t hen there Other common causes of phototoxic reactions include sul is diagnostic uncertainty; Doppler findings suggestir,e of fonamides, hydrochlorothiazide, fluoroquinolones, antima- acute epididymitis include increased epididymal blood flon' Iarials, amiodarone, and voriconazole. Discontinuation of the and swelling. Lack of blood florv r,r,ould indicate a urologic photosensitizing drug and sun avoidance measures will lead emergency, such as testicular torsion. r,r,hich is unlikely in to resolution of the reaction. Topical glucocorticoids can be the presence ofan intact cremasteric reflex. used for symptomatic treatment. A single dose of intramuscular ceftriarone and a 10 day Bullous pemphigoid (Option A) is a pruritic autoim- course of oral doxycycline (Option B) is appropriate empiric mune blistering disorder that presents most commonly in antimicrobial therapy in patients r,r,ith acute epididyntitis elderly persons. It does not present acutely after sun expo who are 35 years of age or younger and in men are at high sure and is a very unlikely diagnosis in this young patient. risk for STIs. In these cases, common causatir,e organisms A photoallergic drug reaction (Option B) is a type IV include l{eisserio gonorrlrceae and Chlamydia tracho- hypersensitivity reaction that is less common than photo- mofis; nucleic acid ampliflcation testing for these organ toxic drug reactions and occurs in patients with prior sen isms should be obtained. This regimen is not indicated for sitization to the offending drug. This type of drug reaction patients who are older than 35 years and in those at lor,v [zpically presents more than24 hours after exposure. It clin risk for STls. ically presents as eczematous dermatitis and less commonly 218

Answers and Cr ues as exaggerated sunburn. Although many drugs can cause Transvaginal ultrasonography (Option D) is not both a phototoxic and photoallergic drug reaction, doxycy- required to diagnose or treat dysmenorrhea in the setting of cline is not known to cause a photoallergic drug reaction. a normal physical examination. Even if there is a concern for Porphyria cutanea tarda (pCT) (Option D) is a blistering a secondary cause ofdysmenorrhea, such as endometriosis, disorder that presents most commonly in persons older empiric treatment is recommended before initiating diag than 40 years, usually on the dorsal hands. It is associated nostic studies. with hepatitis C virus infection, alcohol-related liver dis ease, hemochromatosis, and HIV infection. Although pCT is XEY POII{TS a photosensitive blistering disorder, it is not the most likely . Management options for primary or secondary dys diagnosis in this young woman taking doxycycline. menorrhea include empiric treatment with either combined hormonal contraceptives or progesterone- XEY POI]IT only methods. . Phototoxic reactions present as exaggerated sunburn r NSAIDs are an effective treatment for dysmenorrhea, UI within minutes to hours of sun exposure; tetracy- (l, acting by reducing the release of prostaglandins and clines are a common inciting agent. ET thereby helping to reduce cramping and menstrual

as exaggerated sunburn. Although many drugs can cause Transvaginal ultrasonography (Option D) is not both a phototoxic and photoallergic drug reaction, doxycy- required to diagnose or treat dysmenorrhea in the setting of cline is not known to cause a photoallergic drug reaction. a normal physical examination. Even if there is a concern for Porphyria cutanea tarda (pCT) (Option D) is a blistering a secondary cause ofdysmenorrhea, such as endometriosis, disorder that presents most commonly in persons older empiric treatment is recommended before initiating diag than 40 years, usually on the dorsal hands. It is associated nostic studies. with hepatitis C virus infection, alcohol-related liver dis ease, hemochromatosis, and HIV infection. Although pCT is XEY POII{TS a photosensitive blistering disorder, it is not the most likely . Management options for primary or secondary dys diagnosis in this young woman taking doxycycline. menorrhea include empiric treatment with either combined hormonal contraceptives or progesterone- XEY POI]IT only methods. . Phototoxic reactions present as exaggerated sunburn r NSAIDs are an effective treatment for dysmenorrhea, UI within minutes to hours of sun exposure; tetracy- (l, acting by reducing the release of prostaglandins and clines are a common inciting agent. ET thereby helping to reduce cramping and menstrual Bibliography blood Ioss. L' tt Monteiro AF, Rato M, Martins C. Drug induced photosensitivity: photoal lergic and phototoxic reactions. Clin Dermatol. 2016;34:571-81. [pMID: Bibliography ag ')76381351 doi:1 0.1016 lj.clindermarol.20l 6.05.006 tt Kho KA. Shields JK. Diagnosis and management ol primary dysmenorrhea. 6, JAMA. 20201323:268-9. [PMID: 31855238] doi:10.1001 ijama.2019.16921 UI = Item 96 Answer: B Educational Objective: Treat dysmenorrhea. Item 97 Answer: C Educational Objective: Screen for abdominal aortic The most appropriate management is a combined hormonal aneurysm. oral contraceptive pill (Option B). Dysmenorrhea is charac terized by pain and cramping during menstruation and can The most appropriate screening test is abdominal ultrasonog be associated with low back pain, nausea, headache, and gas raphy (Option C). This patient has a 50 pack year smoking trointestinal symptoms. Dysmenorrhea is classified as either history. According to the U.S. Preventive Services Task Force primary when there is no identified cause, or secondary (USPSTF), one time abdominal ultrasonography is the pre for which endometriosis is the most common cause. Many ferred screening modality for abdominal aortic aneurysm women with dysmenorrhea have symptoms severe enough (AAA) in men aged 65 to 75 years who have smoked at least to result in missed school, work, or other activities. Whether five packs of cigarettes in their lifetime (grade B). Screening primary or secondary dysmenorrhea, empiric treatment with with ultrasonography is noninvasive, is simple to perform, either combined hormonal contraceptives (pill, patch, or ring) has high sensitivity (94"/,, lOO"/,,) and speciflcity (98%-100')(,) or progesterone only methods (pill, injection, implant, or for detecting AAA, and does not expose patients to radiation. intrauterine device [lUD]) are appropriate options. Before Abdominal ultrasonography screening can also be performed prescribing a combined hormonal contraceptive, it is impor selectively in men in the same age range who have not smoked tant to assess for contraindications to estrogen, including a but are at increased risk for peripheral vascular disease or history of venous thromboembolism or migraine with aura. who have a flrst-degree relative who had an AAA (grade C). In this patient without contraindications and a need for more The USPSTF assessed the benefits of screening for AAA in eflective contraceptive therapy, a combined hormonal oral women aged 65 to 75 years who have ever smoked as uncer contraceptive pill is a reasonable option. tain and makes no recommendation regarding screening in Acetaminophen (Option A) is often used for the treat this population (l statement). The USPSTF speciflcally recom- ment of dysmenorrhea; it may be more effective than pla mends against routine screening in women who have never cebo but is not as effective as NSAIDs. NSAIDs reduce the smoked and who have no family history of AAA (grade D). release of prostaglandins and thereby help reduce cramps Smoking cessation and treatment of hypertension can prevent and menstrual blood loss. Because of this patient's need for the development of aneurysmal disease. more effective contraception, a combined hormonal oral Auscultation of the abdomen for bruits and palpation contraceptive is a more attractive option than either acet (Option A) to detect pulsatile enlargement of the aorta have aminophen or NSAIDS. low sensitivity (39'/. 68'1,,) and speciflcity (zs%) for AAA and A copper IUD (Option C) would not improve the are not recommended for screening, especially in patients patient's dysmenorrhea. Some women report heavier men with obesi[2, such as this patient with a BMI of 35. strual bleeding and increased cramping with use of the Abdominal CT (Option B) is an accurate tool for identi copper IUD. Levonorgestrel releasing IUDs, however, are an fying AAA; however, it is not recommended as a screening effective treatment modality for women with dysmenorrhea method because of the expense and potential for harms who are interested in long acting contraceptive options. from radiation exposure. Once an AAA is identifled, CT can

Bibliography blood Ioss. L' tt Monteiro AF, Rato M, Martins C. Drug induced photosensitivity: photoal lergic and phototoxic reactions. Clin Dermatol. 2016;34:571-81. [pMID: Bibliography ag ')76381351 doi:1 0.1016 lj.clindermarol.20l 6.05.006 tt Kho KA. Shields JK. Diagnosis and management ol primary dysmenorrhea. 6, JAMA. 20201323:268-9. [PMID: 31855238] doi:10.1001 ijama.2019.16921 UI = Item 96 Answer: B Educational Objective: Treat dysmenorrhea. Item 97 Answer: C Educational Objective: Screen for abdominal aortic The most appropriate management is a combined hormonal aneurysm. oral contraceptive pill (Option B). Dysmenorrhea is charac terized by pain and cramping during menstruation and can The most appropriate screening test is abdominal ultrasonog be associated with low back pain, nausea, headache, and gas raphy (Option C). This patient has a 50 pack year smoking trointestinal symptoms. Dysmenorrhea is classified as either history. According to the U.S. Preventive Services Task Force primary when there is no identified cause, or secondary (USPSTF), one time abdominal ultrasonography is the pre for which endometriosis is the most common cause. Many ferred screening modality for abdominal aortic aneurysm women with dysmenorrhea have symptoms severe enough (AAA) in men aged 65 to 75 years who have smoked at least to result in missed school, work, or other activities. Whether five packs of cigarettes in their lifetime (grade B). Screening primary or secondary dysmenorrhea, empiric treatment with with ultrasonography is noninvasive, is simple to perform, either combined hormonal contraceptives (pill, patch, or ring) has high sensitivity (94"/,, lOO"/,,) and speciflcity (98%-100')(,) or progesterone only methods (pill, injection, implant, or for detecting AAA, and does not expose patients to radiation. intrauterine device [lUD]) are appropriate options. Before Abdominal ultrasonography screening can also be performed prescribing a combined hormonal contraceptive, it is impor selectively in men in the same age range who have not smoked tant to assess for contraindications to estrogen, including a but are at increased risk for peripheral vascular disease or history of venous thromboembolism or migraine with aura. who have a flrst-degree relative who had an AAA (grade C). In this patient without contraindications and a need for more The USPSTF assessed the benefits of screening for AAA in eflective contraceptive therapy, a combined hormonal oral women aged 65 to 75 years who have ever smoked as uncer contraceptive pill is a reasonable option. tain and makes no recommendation regarding screening in Acetaminophen (Option A) is often used for the treat this population (l statement). The USPSTF speciflcally recom- ment of dysmenorrhea; it may be more effective than pla mends against routine screening in women who have never cebo but is not as effective as NSAIDs. NSAIDs reduce the smoked and who have no family history of AAA (grade D). release of prostaglandins and thereby help reduce cramps Smoking cessation and treatment of hypertension can prevent and menstrual blood loss. Because of this patient's need for the development of aneurysmal disease. more effective contraception, a combined hormonal oral Auscultation of the abdomen for bruits and palpation contraceptive is a more attractive option than either acet (Option A) to detect pulsatile enlargement of the aorta have aminophen or NSAIDS. low sensitivity (39'/. 68'1,,) and speciflcity (zs%) for AAA and A copper IUD (Option C) would not improve the are not recommended for screening, especially in patients patient's dysmenorrhea. Some women report heavier men with obesi[2, such as this patient with a BMI of 35. strual bleeding and increased cramping with use of the Abdominal CT (Option B) is an accurate tool for identi copper IUD. Levonorgestrel releasing IUDs, however, are an fying AAA; however, it is not recommended as a screening effective treatment modality for women with dysmenorrhea method because of the expense and potential for harms who are interested in long acting contraceptive options. from radiation exposure. Once an AAA is identifled, CT can 219

Answers and Critiques provide precise information on its size and location, which RADT has comparable sensitivity and speciflcity to is needed to plan surgery. throat culture (Option C). ln patients who are at high risk for Although magnetic resonance angiography (MRA) complications (immunocompromised, high-risk contacts or (Option D) of the abdomen would detect an AAA, it is environment), a negative RADT result should be confirmed expensive and time consuming compared with ultrasonog by throat culfure; otherwise, it is unnecessary. Results of raphy. Like CT, MRA is typically reserved for surgical plan throat culture generally take 24 to 48 hours. Empiric treat ning, if indicated. ment with antibiotics while results are pending is not rec ommended because short delays in therapy have not been TEY POIIIIS associated with higher complication rates. . According to the U.S. Preventive Services Task Force, No testing or therapy is inappropriate (Option D). one-time abdominal ultrasonography is the preferred Because this patient meets four Centor criteria, placing him screening modality for abdominal aortic aneurysm in at risk for streptococcal pharyngitis, RADT is needed to men aged 65 to 75 years who have smoked at least five guide therapy. UI packs of cigarettes in their lifetime. t(tY PorilIs = .D . The U.S. Preventive Services Task Force specifically o The Centor criteria (fever, tonsillar exudates, tender UI recommends against routine screening for abdominal o, anterior cervical lymphadenopathy, and absence of aortic aneurysm (AAA) in women who have never CL cough) can used to guide the need for testing (rapid n smoked and who have no family history of AAA. antigen detection test) for group A streptococcal pharyngitis. 4t Bibliography E (D O\\,ens DK, Davidson KW. Krist AH, et ali US Preventive Services Task ljorce. . Patients presenting with acute pharyngitis and two UI Screening for abdominal aortic aneurysm: US Preventi\e Senices'l-ask or fewer Centor criteria do not need to be tested for I.orce recommendation statement. JAI\,1A. 2019:322:2211 8. IPMID: 318214371 doi:10.1001ijama.2019.18928 group A Streptococcus.

provide precise information on its size and location, which RADT has comparable sensitivity and speciflcity to is needed to plan surgery. throat culture (Option C). ln patients who are at high risk for Although magnetic resonance angiography (MRA) complications (immunocompromised, high-risk contacts or (Option D) of the abdomen would detect an AAA, it is environment), a negative RADT result should be confirmed expensive and time consuming compared with ultrasonog by throat culfure; otherwise, it is unnecessary. Results of raphy. Like CT, MRA is typically reserved for surgical plan throat culture generally take 24 to 48 hours. Empiric treat ning, if indicated. ment with antibiotics while results are pending is not rec ommended because short delays in therapy have not been TEY POIIIIS associated with higher complication rates. . According to the U.S. Preventive Services Task Force, No testing or therapy is inappropriate (Option D). one-time abdominal ultrasonography is the preferred Because this patient meets four Centor criteria, placing him screening modality for abdominal aortic aneurysm in at risk for streptococcal pharyngitis, RADT is needed to men aged 65 to 75 years who have smoked at least five guide therapy. UI packs of cigarettes in their lifetime. t(tY PorilIs = .D . The U.S. Preventive Services Task Force specifically o The Centor criteria (fever, tonsillar exudates, tender UI recommends against routine screening for abdominal o, anterior cervical lymphadenopathy, and absence of aortic aneurysm (AAA) in women who have never CL cough) can used to guide the need for testing (rapid n smoked and who have no family history of AAA. antigen detection test) for group A streptococcal pharyngitis. 4t Bibliography E (D O\\,ens DK, Davidson KW. Krist AH, et ali US Preventive Services Task ljorce. . Patients presenting with acute pharyngitis and two UI Screening for abdominal aortic aneurysm: US Preventi\e Senices'l-ask or fewer Centor criteria do not need to be tested for I.orce recommendation statement. JAI\,1A. 2019:322:2211 8. IPMID: 318214371 doi:10.1001ijama.2019.18928 group A Streptococcus. Bibliography Item 98 Answer: B Mustafa Z, Ghaffari M. Diagnostic methods, clinical guidelines, and antibi otic treatment for group A streptococcal pharyngitis: a narrative review. Educational Objective: Evaluate a patient with acute trront Cell Infect Microbiol. 2020:10:563627. [PMID: 33178623] doi:10. pharyngitis. :ll]891fcimb.2020.563627

Bibliography Item 98 Answer: B Mustafa Z, Ghaffari M. Diagnostic methods, clinical guidelines, and antibi otic treatment for group A streptococcal pharyngitis: a narrative review. Educational Objective: Evaluate a patient with acute trront Cell Infect Microbiol. 2020:10:563627. [PMID: 33178623] doi:10. pharyngitis. :ll]891fcimb.2020.563627 The most appropriate next step in management is a rapid Item 99 antigen detection test (RADT) for group A Streptococcus (GAS) (Option B). Acute pharyngitis symptoms typically last less than 1 week. Most cases are viral in etiologr, and Ed ucationa I Objective Answer: C : Treat Stevens-Johnson tr syndromeitoxic epidermal necrolysis. only 5'1, to 15% of pharyngitis cases are caused by bacteria, most frequently GAS. The Centor criteria (fever, tonsillar 'lhe nrost appropriate lnilrirgelrent is to cliscontinue sultamc exudates, tender anterior cervical lymphadenopathy, and tlroxazole trimethoprim (Option C). lhis patient likely hrs absence of cough) can help guide the need for testing for Stcvens Johnson synclronre (SlS)itoric epidermal necrolvsis bacterial pharyngitis. The Centor criteria have a low posi- ('ll1N) that is seconclary to sttlfitnrethoxazole trintethoprint. tive predictive value for determining the presence of GAS SJS ancl 'll--N are a spectrum ot severc mucocutaneous reilc infection and are best used to exclude infection. Patients tions cletined by' thc crtcnl of aflbcted BSA inrolred u'ith with two or fewer Centor criteria are very unlikely to have ir.t-trttune rnediated clltilncolls nccrosis. It 10'ri, kr 30'li, lroclv GAS pharyngitis and do not need to be tested or treated surflce area is afl'ected. rs in this p.ltient. the reaction is with antibiotics. Patients with three or more Centor criteria terrnecl SJS TE\ overlirp svnclrornc. S-r'nrptoms of SIS 'l L\ should be tested by using a RADT for GAS pharyngitis. This usually begin u,ilhin I to ll u,cclis of erposttre to the inciting patient presents with four Centor criteria, placing him at agent. Ferer. malaise, ancl s1,'nrpton-rs of upper respiratorl risk for streptococcal pharyngitis, and a RADT is needed to infbction are fbllou,ccl by skin pilirl, grittiness or sancl like guide therapy. irritation ol the eyes, and riclynr4rl.tirgirt. Within se, ,entl ditys Antibiotic therapy with penicillin (Option A) or amox of symptom onset. patients clcvckrl.r rcd or purple dusl<y rnirc icitlin is indicated for GAS pharyngitis to reduce the like ulcs on the tr-unl< thirt progrcss to resicles. erosions. rrnrl lihood of cardiac complications, such as valvular damage ulceratior-r. Painful erosions clcvclr4r in tl-re mor-rth. e)'es. or from rheumatic fever; lower the risk fbr pharyngeal abscess; genitals in as rnan1, xs g5'lr, ot pxtigrts. \\'hen SJS 'I'EN is con and reduce the duration of symptoms and transmission of siclered to be a possible cliagnosis. the lrost important first inf.ection. Even with multiple findings suggestive of a bacte stcp is to irnrnecliatell' discor-rtinuc lll nonessentitrl nrcclicrr rial etiologr, a viral cause is still reasonably likely, and RADT tions because cor-rtinuecl cxposuft' to the ollending agent c'rllr should be completed to conlirm GAS pharyngitis before \\()rscn outcomes. 'lhe importlncc ol imrnedi:rte clmg u'ith antibiotic treatment. No guideline recommends empiric dralr,al in patients r,t,itl.r SJSi'['I]N r,vas highlighted in a l0 yclr treatment without testing. obscrvirtional study thxt suggcstccl drug withdrau'al reduccd

The most appropriate next step in management is a rapid Item 99 antigen detection test (RADT) for group A Streptococcus (GAS) (Option B). Acute pharyngitis symptoms typically last less than 1 week. Most cases are viral in etiologr, and Ed ucationa I Objective Answer: C : Treat Stevens-Johnson tr syndromeitoxic epidermal necrolysis. only 5'1, to 15% of pharyngitis cases are caused by bacteria, most frequently GAS. The Centor criteria (fever, tonsillar 'lhe nrost appropriate lnilrirgelrent is to cliscontinue sultamc exudates, tender anterior cervical lymphadenopathy, and tlroxazole trimethoprim (Option C). lhis patient likely hrs absence of cough) can help guide the need for testing for Stcvens Johnson synclronre (SlS)itoric epidermal necrolvsis bacterial pharyngitis. The Centor criteria have a low posi- ('ll1N) that is seconclary to sttlfitnrethoxazole trintethoprint. tive predictive value for determining the presence of GAS SJS ancl 'll--N are a spectrum ot severc mucocutaneous reilc infection and are best used to exclude infection. Patients tions cletined by' thc crtcnl of aflbcted BSA inrolred u'ith with two or fewer Centor criteria are very unlikely to have ir.t-trttune rnediated clltilncolls nccrosis. It 10'ri, kr 30'li, lroclv GAS pharyngitis and do not need to be tested or treated surflce area is afl'ected. rs in this p.ltient. the reaction is with antibiotics. Patients with three or more Centor criteria terrnecl SJS TE\ overlirp svnclrornc. S-r'nrptoms of SIS 'l L\ should be tested by using a RADT for GAS pharyngitis. This usually begin u,ilhin I to ll u,cclis of erposttre to the inciting patient presents with four Centor criteria, placing him at agent. Ferer. malaise, ancl s1,'nrpton-rs of upper respiratorl risk for streptococcal pharyngitis, and a RADT is needed to infbction are fbllou,ccl by skin pilirl, grittiness or sancl like guide therapy. irritation ol the eyes, and riclynr4rl.tirgirt. Within se, ,entl ditys Antibiotic therapy with penicillin (Option A) or amox of symptom onset. patients clcvckrl.r rcd or purple dusl<y rnirc icitlin is indicated for GAS pharyngitis to reduce the like ulcs on the tr-unl< thirt progrcss to resicles. erosions. rrnrl lihood of cardiac complications, such as valvular damage ulceratior-r. Painful erosions clcvclr4r in tl-re mor-rth. e)'es. or from rheumatic fever; lower the risk fbr pharyngeal abscess; genitals in as rnan1, xs g5'lr, ot pxtigrts. \\'hen SJS 'I'EN is con and reduce the duration of symptoms and transmission of siclered to be a possible cliagnosis. the lrost important first inf.ection. Even with multiple findings suggestive of a bacte stcp is to irnrnecliatell' discor-rtinuc lll nonessentitrl nrcclicrr rial etiologr, a viral cause is still reasonably likely, and RADT tions because cor-rtinuecl cxposuft' to the ollending agent c'rllr should be completed to conlirm GAS pharyngitis before \\()rscn outcomes. 'lhe importlncc ol imrnedi:rte clmg u'ith antibiotic treatment. No guideline recommends empiric dralr,al in patients r,t,itl.r SJSi'['I]N r,vas highlighted in a l0 yclr treatment without testing. obscrvirtional study thxt suggcstccl drug withdrau'al reduccd 220

Answers and Critiques tr CONT, nrortalit, lry 30'1, fbr each clay the dmg r,.,as absent before the dcvclopmerrt ol blisters and erosions. 'lhis observation did not holcl true frrr cl-ugs r,r,ith prokrnged hall lives. Decisions regarding perioperative a ntiplatelet tl.rerapy are inft)rmed in part by a ranclomized controlled study of patients with previous coronary ar1ery stenting who subse- 'freatrnent fbr SJS, TEN orerlap s)'ndrome rernlins con quently lrad surgery. 'lhe data suggested that patients lvho troversial. Intrirvenous glucocorticoicls (Option A) or intra continued aspirin throughout the perioperative period had venous immunoglobulin (Option B) are likely the most the lowcst rate of a major cardiac aclverse event. Withholding crirnmonlv used treatments. but neither is su1-rported Iry perioperative aspirin eitherwith oru,ithout ir P2Y1, inhibitor strong eviclence. Regarclless, initiating therapy r,r,ith eithcr (Options C, D) is not recommencled. Withholding both aspi intravenolls glucocorticoicls or intravenous imrnune globtr rin ancl clopidogrel may be reasonable if the risk for bleeding lins is secondary in importance to discontinuing the poten is extreme or the consequences catastrophic, such as those tial ofl'ending agent. associated with neurosurgeryr Skin biopsy (Option D) may be indicated in the evalua Surgery is associated with proinflamnratory eflects that tion of possible SJSI'I'EN overlap syndnrrne if the diugnosis is may increase the risk lbr thronrbosis, prrticularly coronary tt not conclusivc hased on clinical flndings. When the possibil o artery thrombosis and stent thrombosis. Aspirin, clopido ET it1'oISJS TIIN is present. however, skin biopsy is secondary grel. and otl.rer P2Y,, inhibitors are antiplatelet agents. n hich in impofiancc to immediate discontinuation of the possible can mitigate this risk. Balancing the risk fbr bleeding and t, oflending agent. thronrbosis is key, and continuation of both agents may lead =, to unacceptable bleeding risk. In general, bleeding risl< with IE rEY POTXT UI aspirin is lor,rer than that r.l,ith clopidogrcl in the perioper o The most important first step in preventing progres- (, ative period, so colltinuing aspirin alone is recommended sion of Stevens Johnson syndrome/toxic epidermal during this time fiame. vt = E necrolysis is to immediately discontinue any potential XEY POIlII' inciting medications. o In patients with coronary stents, guidelines recom- Bibliography mend that dual antiplatelet therapy should be contin- ll'lustafa SS, Ostrov D. Yerly D. Severe cutaneous adverse drug reactions: ued uninterrupted for 14 to 30 days after bare metal presentation, risk factors, and management. Curr Allergl Asthma Rep. stent placement and a minimum of 3 to 6 months 2018118:26. [PMID: 29574562] doi:10.1007rs11882 OIA 0778 6 after drug eluting stent placement. . In patients with an urgent need for surgery discontin- Item 100 Answer: B tr Educational Objective: Manage perioperative dual uation of a P2Y,, inhibitor can be considered after a minimum of 3 months in patients with a drug-eluting antiplatelet therapy for a patient undergoing urgent stent; aspirin should be continued ifat all possible. noncardiac surgery. 'lhe most appropriate preoperative management of this Bibliography Banerjee S. Angiolillo DJ. Boden WE, et al. Use ofantiplatelet therxpy/DAPT patient's dual antiplatelet therapy (DAP'f) is to continue aspi for post PCI patients undergoing noncardiac surgery. J Am Coll Cardiol. rin and withhold clopiclogrel (Option B). In patients with 2017 ;69 :1 867 70. I PM I D : 2838531 5] doi 1 0.1016/i.iacc .2077 .O2.O 12 :

tr CONT, nrortalit, lry 30'1, fbr each clay the dmg r,.,as absent before the dcvclopmerrt ol blisters and erosions. 'lhis observation did not holcl true frrr cl-ugs r,r,ith prokrnged hall lives. Decisions regarding perioperative a ntiplatelet tl.rerapy are inft)rmed in part by a ranclomized controlled study of patients with previous coronary ar1ery stenting who subse- 'freatrnent fbr SJS, TEN orerlap s)'ndrome rernlins con quently lrad surgery. 'lhe data suggested that patients lvho troversial. Intrirvenous glucocorticoicls (Option A) or intra continued aspirin throughout the perioperative period had venous immunoglobulin (Option B) are likely the most the lowcst rate of a major cardiac aclverse event. Withholding crirnmonlv used treatments. but neither is su1-rported Iry perioperative aspirin eitherwith oru,ithout ir P2Y1, inhibitor strong eviclence. Regarclless, initiating therapy r,r,ith eithcr (Options C, D) is not recommencled. Withholding both aspi intravenolls glucocorticoicls or intravenous imrnune globtr rin ancl clopidogrel may be reasonable if the risk for bleeding lins is secondary in importance to discontinuing the poten is extreme or the consequences catastrophic, such as those tial ofl'ending agent. associated with neurosurgeryr Skin biopsy (Option D) may be indicated in the evalua Surgery is associated with proinflamnratory eflects that tion of possible SJSI'I'EN overlap syndnrrne if the diugnosis is may increase the risk lbr thronrbosis, prrticularly coronary tt not conclusivc hased on clinical flndings. When the possibil o artery thrombosis and stent thrombosis. Aspirin, clopido ET it1'oISJS TIIN is present. however, skin biopsy is secondary grel. and otl.rer P2Y,, inhibitors are antiplatelet agents. n hich in impofiancc to immediate discontinuation of the possible can mitigate this risk. Balancing the risk fbr bleeding and t, oflending agent. thronrbosis is key, and continuation of both agents may lead =, to unacceptable bleeding risk. In general, bleeding risl< with IE rEY POTXT UI aspirin is lor,rer than that r.l,ith clopidogrcl in the perioper o The most important first step in preventing progres- (, ative period, so colltinuing aspirin alone is recommended sion of Stevens Johnson syndrome/toxic epidermal during this time fiame. vt = E necrolysis is to immediately discontinue any potential XEY POIlII' inciting medications. o In patients with coronary stents, guidelines recom- Bibliography mend that dual antiplatelet therapy should be contin- ll'lustafa SS, Ostrov D. Yerly D. Severe cutaneous adverse drug reactions: ued uninterrupted for 14 to 30 days after bare metal presentation, risk factors, and management. Curr Allergl Asthma Rep. stent placement and a minimum of 3 to 6 months 2018118:26. [PMID: 29574562] doi:10.1007rs11882 OIA 0778 6 after drug eluting stent placement. . In patients with an urgent need for surgery discontin- Item 100 Answer: B tr Educational Objective: Manage perioperative dual uation of a P2Y,, inhibitor can be considered after a minimum of 3 months in patients with a drug-eluting antiplatelet therapy for a patient undergoing urgent stent; aspirin should be continued ifat all possible. noncardiac surgery. 'lhe most appropriate preoperative management of this Bibliography Banerjee S. Angiolillo DJ. Boden WE, et al. Use ofantiplatelet therxpy/DAPT patient's dual antiplatelet therapy (DAP'f) is to continue aspi for post PCI patients undergoing noncardiac surgery. J Am Coll Cardiol. rin and withhold clopiclogrel (Option B). In patients with 2017 ;69 :1 867 70. I PM I D : 2838531 5] doi 1 0.1016/i.iacc .2077 .O2.O 12 : coronary stents. guidelines reconlmend that DAPT shor-rld be continued unir.rtemrptecl for 14 to 130 days after bare metal Item 1Ol Answer: C stent placement and ll kt 6 montl.rs after drug-eluting stent Ed u cati o na I O bj ective : Manage vasomotor symptoms placenrent. Elective surgery should be ltostponed cluring these of menopause with hormone therapy. time frames. llowever, il the risk ol surgical clclay exceeds the risk fbr ster.rt thrombosis. discontinuation of the P2Y,, The most appropriate treatment is transdermal estrogen inhibitor can lre considered after a minimum of 3 nlonths in (Option C). Although associated with risk, hormone therapy prtients \{ith a drug ehlting stent. l.ow dose aslririn should is the most eflective medication for vasomotor symptoms be continuecl if at all possible. and Dr\PT sl.rould bc restafiecl associated with menopause (hot flashes, night sweats). This ils soon as bleecling risk has suflicienlly diminishecl. Clopido patient is experiencing symptoms severe enough to result grel should be withheld 5 clays before surgery. in missed work, which warrants hormone therapy. Before Precise data on the risk fbr serious DAPT related bleed initiating therapy, patients should be assessed for contraindi ing are lacking except in patients undergoing coronary cations, including unexplained vaginal bleeding, liver disease, irrtcry bypass gralt surgery. Studies have shown that DAP'I' coronary artery disease, stroke, thromboembolic disease, and in these patients iucreases the inciclence of bleedir.rg, reop breast or endometrial cancer. This patient has no risk factors eration. and transf'usion. On the basis ol these clrta, experts for complications of hormonal therapy. Her only other health rcconrmencl cliscontinuation of P2Y,, receptor blockers at condition is controlled hypertension, and her mammogram lcirst 5 days bclbre surgery fbr clopidogrel, 7 days lirr prasu obtained 1 year ago was negative. The lowest dose ofestrogen grel, and 3 to 5 days fbr tic:rgrelor. (br.rtinuing both aspirin therapy needed to manage symptoms should be used, and :rnd a P2Y,., ir.rhibitor (Option A) is not recommcnded. vasomotor symptoms and risk factors should be assessed

coronary stents. guidelines reconlmend that DAPT shor-rld be continued unir.rtemrptecl for 14 to 130 days after bare metal Item 1Ol Answer: C stent placement and ll kt 6 montl.rs after drug-eluting stent Ed u cati o na I O bj ective : Manage vasomotor symptoms placenrent. Elective surgery should be ltostponed cluring these of menopause with hormone therapy. time frames. llowever, il the risk ol surgical clclay exceeds the risk fbr ster.rt thrombosis. discontinuation of the P2Y,, The most appropriate treatment is transdermal estrogen inhibitor can lre considered after a minimum of 3 nlonths in (Option C). Although associated with risk, hormone therapy prtients \{ith a drug ehlting stent. l.ow dose aslririn should is the most eflective medication for vasomotor symptoms be continuecl if at all possible. and Dr\PT sl.rould bc restafiecl associated with menopause (hot flashes, night sweats). This ils soon as bleecling risk has suflicienlly diminishecl. Clopido patient is experiencing symptoms severe enough to result grel should be withheld 5 clays before surgery. in missed work, which warrants hormone therapy. Before Precise data on the risk fbr serious DAPT related bleed initiating therapy, patients should be assessed for contraindi ing are lacking except in patients undergoing coronary cations, including unexplained vaginal bleeding, liver disease, irrtcry bypass gralt surgery. Studies have shown that DAP'I' coronary artery disease, stroke, thromboembolic disease, and in these patients iucreases the inciclence of bleedir.rg, reop breast or endometrial cancer. This patient has no risk factors eration. and transf'usion. On the basis ol these clrta, experts for complications of hormonal therapy. Her only other health rcconrmencl cliscontinuation of P2Y,, receptor blockers at condition is controlled hypertension, and her mammogram lcirst 5 days bclbre surgery fbr clopidogrel, 7 days lirr prasu obtained 1 year ago was negative. The lowest dose ofestrogen grel, and 3 to 5 days fbr tic:rgrelor. (br.rtinuing both aspirin therapy needed to manage symptoms should be used, and :rnd a P2Y,., ir.rhibitor (Option A) is not recommcnded. vasomotor symptoms and risk factors should be assessed 221

Answers and Critiques annually. All women receiving hormone therapy should also commonly unilateral than bilateral. Nodular variants of epi receive individualized breast cancer risk assessments. This scleritis also occur. Although most causes of episcleritis are patient does not have a flrst degree relative with breast can idiopathic, it can be associated with systemic conditions, cer or other markers of elevated risk fbr breast cancer. but including rheumatoid arthritis, vasculitis, and inflammatory she should be advised that hormone therapy is associated bowel disease. Women are more commonly afl'ected than with an increased risk for breast cancer in a dose-dependent men, with most cases occurring in those who are young or fashion; estrogen therapy alone is lower risk than estrogen middle aged. Use ofa topical vasoconstrictor, such as phenyl plus progesterone (Option A). When hormonal therapy is ephrine, results in improvement in eye redness and can help indicated, transdermal estrogen may be preferable to oral confirm the diagnosis. estrogen because it is associated with less thromboembolic Although herpes simplex keratitis (Option B) is in the risk. However, this is based on Iimited observational data, differential diagnosis of red eye, it typically causes signifl and head to head comparisons are lacking. Guidelines are in cant eye pain. photophobia, and visual blurring, which are general agreement in recommending transdermal estrogen not present in this patient. Herpes simplex keratitis can lead UI in patients with moderate risk for coronary artery disease, to vision loss due to corneal damage and, when suspected, increased risk fbr venous thromboembolism, hypertriglyceri should prompt immediate referral to an ophthalmologist. = .D UI demia, or high or intermediate risk for breast cancer. Scleritis (Option C), inflammation of the sclera, is an q, Oral gabapentin (Option B) taken nightly can be an unlikely diagnosis for this patient because it causes intense. CL effective nonhormonal option for the management of vaso boring eye pain and photophobia. The cardinal sign ofscleri n motor symptoms of menopause. However, it is less effec tis is edema of the sclera often associated with a violaceous tive than hormonal therapy, and given the severity of this discoloration ofthe underlying sclera and intense dilation of a patient's symptoms and the absence of contraindications, the episcleral blood vessels accounting for the red eye. o vt she should be offered transdermal estrogen. Uveitis (Option D) is a potentially vision threatening Transdermal or oral estrogen plus oral progesterone condition that typically causes severe ocular pain and photo (Option D) is not appropriate treatment. A progestin is only phobia, both of which are absent in this patient. In addition. needed for patients with a uterus to prevent estrogen related the eye redness observed with uveitis is most prominent at endometrial proliferation and hyperplasia. This patient pre- the boundary between the iris and sclera, a pattern termed viously underwent hysterectomy. When used, progestins can ciliary flush. In some patients, a collection of leukocytes be dosed either continuously or cyclically. Women receiving (hypopyon) is seen pooling in the inf'erior aspect of the ante progestins cyclically may experience withdrawal bleeding. rior chamber. Viral conjunctivitis (Option E) is an unlikely diagnosis I(EY POII{TS because it causes diffuse eye redness, as opposed to the . Hormone therapy is the most effective treatment for localized redness seen in this patient. Symptoms of viral vasomotor symptoms associated with menopause. conjunctivitis classically start in one eye before spreading to . Transdermal estrogen is recommended for patients the other eye. Eye redness is Szpically accompanied by watery with moderate risk for coronary artery disease. discharge, and the tarsal conjunctiva may appear bumpy. Pre increased risk for venous thromboembolism, hyper auricular lymphadenopathy is commonly present. triglyceridemia, or high or intermediate risk for breast XEY POIlIIS cancer. r The classic presentation ofepiscleritis is an abrupt onset of unilateral eye redness due to dilated episcle- Bibliography ral blood vessels, irritation, and tearing, with no pain, The NAMS 2017 Hormone Therap! Position Statement Advisory Panel. The 2017 hormonc therapy position statement ol the North American photophobia, or change in vision. Menopause Society. Menopause. 2017;2.1:728 53. [PMlD, 28650869] doi :l 0.1097/Cl\4 F].000000000ooo0921 . The cardinal sign of scleritis is edema of the sclera often associated with an underlying violaceous dis coloration of the sclera and intense dilation of the Item 102 Answer: A episcleral blood vessels, accounting for the red eye. Ed ucationa I Objective: Diagnose episcleritis. Bibliography lhe most likely diagnosis is episcleritis (Option A), or inflam 'larff A. Behrens A. Ocular emergencies: red e1e. Med Clin North Am. mation of the episclera, the highly vascularized connective 2017rl01:61.5 39. IPMID: 283727771 doi:10.1016/i.mcna.2016.12.013 tissue layer that lies between the conjunctiva and sclera. This patient has a classic presentation of episcleritis, r.r'ith abrupt onset of unilateral eye redness, irritation, and tearing. Pain, Item 103 Answer: D photophobia, and vision changes are typically absent. Exam Educational Objective: Diagnose erythrasma. ination shows dilation of superflcial episcleral blood ves sels. with normal sclera visualized between the blood vessels. Wood lamp evaluation (Option D) is the most appropriate Redness can be localized or diffuse: involvement is more diagnostic test to perform nexl. This patient has ery,.thrasma,

annually. All women receiving hormone therapy should also commonly unilateral than bilateral. Nodular variants of epi receive individualized breast cancer risk assessments. This scleritis also occur. Although most causes of episcleritis are patient does not have a flrst degree relative with breast can idiopathic, it can be associated with systemic conditions, cer or other markers of elevated risk fbr breast cancer. but including rheumatoid arthritis, vasculitis, and inflammatory she should be advised that hormone therapy is associated bowel disease. Women are more commonly afl'ected than with an increased risk for breast cancer in a dose-dependent men, with most cases occurring in those who are young or fashion; estrogen therapy alone is lower risk than estrogen middle aged. Use ofa topical vasoconstrictor, such as phenyl plus progesterone (Option A). When hormonal therapy is ephrine, results in improvement in eye redness and can help indicated, transdermal estrogen may be preferable to oral confirm the diagnosis. estrogen because it is associated with less thromboembolic Although herpes simplex keratitis (Option B) is in the risk. However, this is based on Iimited observational data, differential diagnosis of red eye, it typically causes signifl and head to head comparisons are lacking. Guidelines are in cant eye pain. photophobia, and visual blurring, which are general agreement in recommending transdermal estrogen not present in this patient. Herpes simplex keratitis can lead UI in patients with moderate risk for coronary artery disease, to vision loss due to corneal damage and, when suspected, increased risk fbr venous thromboembolism, hypertriglyceri should prompt immediate referral to an ophthalmologist. = .D UI demia, or high or intermediate risk for breast cancer. Scleritis (Option C), inflammation of the sclera, is an q, Oral gabapentin (Option B) taken nightly can be an unlikely diagnosis for this patient because it causes intense. CL effective nonhormonal option for the management of vaso boring eye pain and photophobia. The cardinal sign ofscleri n motor symptoms of menopause. However, it is less effec tis is edema of the sclera often associated with a violaceous tive than hormonal therapy, and given the severity of this discoloration ofthe underlying sclera and intense dilation of a patient's symptoms and the absence of contraindications, the episcleral blood vessels accounting for the red eye. o vt she should be offered transdermal estrogen. Uveitis (Option D) is a potentially vision threatening Transdermal or oral estrogen plus oral progesterone condition that typically causes severe ocular pain and photo (Option D) is not appropriate treatment. A progestin is only phobia, both of which are absent in this patient. In addition. needed for patients with a uterus to prevent estrogen related the eye redness observed with uveitis is most prominent at endometrial proliferation and hyperplasia. This patient pre- the boundary between the iris and sclera, a pattern termed viously underwent hysterectomy. When used, progestins can ciliary flush. In some patients, a collection of leukocytes be dosed either continuously or cyclically. Women receiving (hypopyon) is seen pooling in the inf'erior aspect of the ante progestins cyclically may experience withdrawal bleeding. rior chamber. Viral conjunctivitis (Option E) is an unlikely diagnosis I(EY POII{TS because it causes diffuse eye redness, as opposed to the . Hormone therapy is the most effective treatment for localized redness seen in this patient. Symptoms of viral vasomotor symptoms associated with menopause. conjunctivitis classically start in one eye before spreading to . Transdermal estrogen is recommended for patients the other eye. Eye redness is Szpically accompanied by watery with moderate risk for coronary artery disease. discharge, and the tarsal conjunctiva may appear bumpy. Pre increased risk for venous thromboembolism, hyper auricular lymphadenopathy is commonly present. triglyceridemia, or high or intermediate risk for breast XEY POIlIIS cancer. r The classic presentation ofepiscleritis is an abrupt onset of unilateral eye redness due to dilated episcle- Bibliography ral blood vessels, irritation, and tearing, with no pain, The NAMS 2017 Hormone Therap! Position Statement Advisory Panel. The 2017 hormonc therapy position statement ol the North American photophobia, or change in vision. Menopause Society. Menopause. 2017;2.1:728 53. [PMlD, 28650869] doi :l 0.1097/Cl\4 F].000000000ooo0921 . The cardinal sign of scleritis is edema of the sclera often associated with an underlying violaceous dis coloration of the sclera and intense dilation of the Item 102 Answer: A episcleral blood vessels, accounting for the red eye. Ed ucationa I Objective: Diagnose episcleritis. Bibliography lhe most likely diagnosis is episcleritis (Option A), or inflam 'larff A. Behrens A. Ocular emergencies: red e1e. Med Clin North Am. mation of the episclera, the highly vascularized connective 2017rl01:61.5 39. IPMID: 283727771 doi:10.1016/i.mcna.2016.12.013 tissue layer that lies between the conjunctiva and sclera. This patient has a classic presentation of episcleritis, r.r'ith abrupt onset of unilateral eye redness, irritation, and tearing. Pain, Item 103 Answer: D photophobia, and vision changes are typically absent. Exam Educational Objective: Diagnose erythrasma. ination shows dilation of superflcial episcleral blood ves sels. with normal sclera visualized between the blood vessels. Wood lamp evaluation (Option D) is the most appropriate Redness can be localized or diffuse: involvement is more diagnostic test to perform nexl. This patient has ery,.thrasma, 222

Answers and cll"igues a superficial skin infection secondary to Corynebacterium microscopic identification of the mites, eggs, or f'eces in skin minutissimum infection. Symptoms, limited to pruritus, are scrapings prepared with mineral oil. The patient's presenta minimal in most patients. Efihrasma manifests as thin, atro tion is not typical for dermatophytes, Candida, or scabies. phic, flnely wrinkled pink brown plaques in the intertrigi- t(EY POl]tTS nous areas, such as the axillae or inguinal or gluteal fblds, or less commonly in the interdigital or intramammary regions. . Erlthrasma, a superficial skin infection, manifests as The skin is often described as having "cigarette paper" appear thin, atrophic, finely wrinkled pink brown plaques ance. A Wood lamp evaluation reveals a soft coral red or in the intertriginous areas; Wood lamp evaluation pink fluorescence, as shown in this patient with interdigital reveals a soft coral red or pink fluorescence. erythrasma. . Symptoms of erythrasma are limited to mild pruritus, and treatment for localized disease is topical erythro- mycin. vt q, Bibliography ET Irorouzan P, Cohen PR. Erythmsma revisited: diagnosis, diflerential diagno ses, ancl comprehensive review' ol treatment. Cureus. 2020;12:e10733. IPMID: l]:ll45l38l doi:10.7759, cureus.l073ll t, E t! vt L o Item 104 Answer: D Educational Objective: Manage perioperative tr t = medications. 'I he most appropriate perioperative nreclicatior-r rn:lnagement is to colltinue all meclications (Option D). tligh quality evi Treatment is with oral or topical erythromycin (preferred dence kr gr.ride perioperative mediclrtion lxanrgement is lack fbr localized disease). Typical skin flndings plus fluorescence ing. Reconrnrendatiorrs are. largely derived fr<trn tlreoretical with Wood lamp illumination conflrms the diagnosis; addi drug interirctions ancl expert consensus. Althor-rgh nrost nted tional testing is not needed. ications are tolertrtecl thnrughout thc perioperxtile perioil. Acanthosis nigricans can appear in the axillae as thick- there arc some importlnt exceptions. Fbr exirmple, the Amer ened, hypertrophic velvety hyperpigmented plaques. In ican College ol Rheumatolog; reconrnrends that biologic patients with acanthosis nigricans, it is important to obtain medications should be u,ithheld as closc. to one d<tsing cyclc a hemoglobin A,. measurement (Option A) to evaluate for ls schedr.rling permits belbre elective hip ancl l<nee arthro the presence of diabetes mellitus or glucose intolerance. plasty and restarted after evidence oI wor-rnd healing, typically The plaques on this patient are atrophic rather than hyper- l4 days. N<lnbiologic discase.modifying :intirhcumatic drugs trophic; a Wood lamp evaluation is the most appropriate (l )\lARt)s) (nrethotrexatc. sulfasalazine. hldrrxl,cl.rl,rroquinc. initial test. lellunomirle) rnay be continued throughout the periopcrl Examination of a potassium hydroxide preparation tive periocl. Meth<ltrcxatc is administcrcd or.rce weekly, mtist of'skin scrapings (Option B) can show fungal elements in commonll, bv oral or subcutaneous routcs. Studies in patients the case of dermatophytes or yeast, whereas mineral oil u'ith rheurnatoid arthritis have denronstrated thirt continuir.rg preparation (Option C) can highlight ectoparasites, such as I)MARDs. includir-tg nrethotrexate. thnrugh the lterioperative Sorcoptes scobiei or Demodex species. However, the charac period is safb without an increase in infbction ratc (Option teristic clinical presentation oftinea corporis is annular scaly A), er,en with prosthetic irr.rplantation, and rc'duces the risk patches with central clearing and varying degrees of inflam tor disease fllres. mation; microscopic examination of a potassium hydrox- Accorcling to the 201.'l Americln College ol C:rrdiology ide preparation will show branching hyphae in the scale. A mericir n He:rrt Associ :rtion pcrioperative carcl i ovasculirr Intertrigo is an inflammatory skin disease that involves the guidelinc. p:rtients on B blocker therapy, such as meto axillae, inframammary and inguinal folds. Condido is the prolol. sl.rould c<lntinue therapt' in the perioperative period most common secondary inf'ection in intertrigo, with obe (Options B. C). Cessirtion ot thesc ilgents may cause rebound sity being an important risk factor. It presents as erythema tachycardiu and pronrote dysrhythmias in thc periopcrri tous patches with satellite pustules that are often macerated. tive perirxl because of the elevatcd adrenergic tone fronr Diagnosis is fiequently made on clinical grounds alone, pain, strcss. :rnd volunre shifts. l)reoperative initiation ol but a potassium hydroxide preparation can show spores B blockers is generalll' reserved tbr pirlients n'ith a Rer,isetl and pseudohyphae. Scabies infestation is characterized by Cardiac Risk lndex score of 3 or mol'e without contraindi intensely pruritic, crusted papules, nodules, and burrows cxtions (such :rs reslilrs bradycarclia or hypotcnsion) ar-rcl that develop in the interdigital spaces, wrists, ankles, breasts, who havc enough tir-t're bclore sllrgcry to trial n'reclications periumbilical area, and genitals. Diagnosis is performed by (>l r,r'eek) to ensure satety ancl tolerribility

a superficial skin infection secondary to Corynebacterium microscopic identification of the mites, eggs, or f'eces in skin minutissimum infection. Symptoms, limited to pruritus, are scrapings prepared with mineral oil. The patient's presenta minimal in most patients. Efihrasma manifests as thin, atro tion is not typical for dermatophytes, Candida, or scabies. phic, flnely wrinkled pink brown plaques in the intertrigi- t(EY POl]tTS nous areas, such as the axillae or inguinal or gluteal fblds, or less commonly in the interdigital or intramammary regions. . Erlthrasma, a superficial skin infection, manifests as The skin is often described as having "cigarette paper" appear thin, atrophic, finely wrinkled pink brown plaques ance. A Wood lamp evaluation reveals a soft coral red or in the intertriginous areas; Wood lamp evaluation pink fluorescence, as shown in this patient with interdigital reveals a soft coral red or pink fluorescence. erythrasma. . Symptoms of erythrasma are limited to mild pruritus, and treatment for localized disease is topical erythro- mycin. vt q, Bibliography ET Irorouzan P, Cohen PR. Erythmsma revisited: diagnosis, diflerential diagno ses, ancl comprehensive review' ol treatment. Cureus. 2020;12:e10733. IPMID: l]:ll45l38l doi:10.7759, cureus.l073ll t, E t! vt L o Item 104 Answer: D Educational Objective: Manage perioperative tr t = medications. 'I he most appropriate perioperative nreclicatior-r rn:lnagement is to colltinue all meclications (Option D). tligh quality evi Treatment is with oral or topical erythromycin (preferred dence kr gr.ride perioperative mediclrtion lxanrgement is lack fbr localized disease). Typical skin flndings plus fluorescence ing. Reconrnrendatiorrs are. largely derived fr<trn tlreoretical with Wood lamp illumination conflrms the diagnosis; addi drug interirctions ancl expert consensus. Althor-rgh nrost nted tional testing is not needed. ications are tolertrtecl thnrughout thc perioperxtile perioil. Acanthosis nigricans can appear in the axillae as thick- there arc some importlnt exceptions. Fbr exirmple, the Amer ened, hypertrophic velvety hyperpigmented plaques. In ican College ol Rheumatolog; reconrnrends that biologic patients with acanthosis nigricans, it is important to obtain medications should be u,ithheld as closc. to one d<tsing cyclc a hemoglobin A,. measurement (Option A) to evaluate for ls schedr.rling permits belbre elective hip ancl l<nee arthro the presence of diabetes mellitus or glucose intolerance. plasty and restarted after evidence oI wor-rnd healing, typically The plaques on this patient are atrophic rather than hyper- l4 days. N<lnbiologic discase.modifying :intirhcumatic drugs trophic; a Wood lamp evaluation is the most appropriate (l )\lARt)s) (nrethotrexatc. sulfasalazine. hldrrxl,cl.rl,rroquinc. initial test. lellunomirle) rnay be continued throughout the periopcrl Examination of a potassium hydroxide preparation tive periocl. Meth<ltrcxatc is administcrcd or.rce weekly, mtist of'skin scrapings (Option B) can show fungal elements in commonll, bv oral or subcutaneous routcs. Studies in patients the case of dermatophytes or yeast, whereas mineral oil u'ith rheurnatoid arthritis have denronstrated thirt continuir.rg preparation (Option C) can highlight ectoparasites, such as I)MARDs. includir-tg nrethotrexate. thnrugh the lterioperative Sorcoptes scobiei or Demodex species. However, the charac period is safb without an increase in infbction ratc (Option teristic clinical presentation oftinea corporis is annular scaly A), er,en with prosthetic irr.rplantation, and rc'duces the risk patches with central clearing and varying degrees of inflam tor disease fllres. mation; microscopic examination of a potassium hydrox- Accorcling to the 201.'l Americln College ol C:rrdiology ide preparation will show branching hyphae in the scale. A mericir n He:rrt Associ :rtion pcrioperative carcl i ovasculirr Intertrigo is an inflammatory skin disease that involves the guidelinc. p:rtients on B blocker therapy, such as meto axillae, inframammary and inguinal folds. Condido is the prolol. sl.rould c<lntinue therapt' in the perioperative period most common secondary inf'ection in intertrigo, with obe (Options B. C). Cessirtion ot thesc ilgents may cause rebound sity being an important risk factor. It presents as erythema tachycardiu and pronrote dysrhythmias in thc periopcrri tous patches with satellite pustules that are often macerated. tive perirxl because of the elevatcd adrenergic tone fronr Diagnosis is fiequently made on clinical grounds alone, pain, strcss. :rnd volunre shifts. l)reoperative initiation ol but a potassium hydroxide preparation can show spores B blockers is generalll' reserved tbr pirlients n'ith a Rer,isetl and pseudohyphae. Scabies infestation is characterized by Cardiac Risk lndex score of 3 or mol'e without contraindi intensely pruritic, crusted papules, nodules, and burrows cxtions (such :rs reslilrs bradycarclia or hypotcnsion) ar-rcl that develop in the interdigital spaces, wrists, ankles, breasts, who havc enough tir-t're bclore sllrgcry to trial n'reclications periumbilical area, and genitals. Diagnosis is performed by (>l r,r'eek) to ensure satety ancl tolerribility 223

Answers and Critiques tr CONT. Sufficient evidence has demonstrated benelits ot sta- tin agents, such as atorvastatin, during the periopcrative period. Pleiotropic effects of these agents are belie\ed to Reviewing the benefits of a healthy diet and exercise (Options B, C) is necessary but not sufficient to help this patient achieve healthy lifestyle goals. Behavioral change be responsiblc Ibr numerous benefits in major surgeries. counseling that includes motivational interviewing and presumably due to anti inflanlmabry properties. Statins introduction to behavioral change techniques as well as have been consistently associated with lower risk Ibr car goal setting is more likely to achieve the desired end than diovascular c<lmplications in both cardiac and noncardiac solely providing information about the benefits of diet surgery In surgeries u'ith highest cardiovascular risk (major and exercise. The USPSTF notes that there is adequate vascular. cardiothoracic). it is reasonable to start :l statin evidence that counseling interventions reduce overall preoperatir,ely if the patient is not already taking one. T1-tis CVD events (myocardial infarction and stroke); improve recommendation does not apply fbr patients ur.rdergoing blood pressure, lipid and fasting blood glucose levels. noncardiac sllrger):. as is this case firr this patient: il a and body weight/adiposity; and improve healthy eating D patient has bcen on long tcnn statin therapll it sl.rould be habits. t^ continued. Although it is important that patients understand the E long term complications of their diseases (Option D), pro .D f,EY POIXTS t viding a stronger means of supporting behavioral change. o, . Nonbiologic disease-modifying antirheumatic such as a behavioral counseling program, is more likely to CL drugs (DMARDs) can be continued throughout the make a signiflcant impact. n perioperative period; biologic DMARDs should be I(EY PO I XI discontinued and restarted after evidence ofwound tt o The U.S. Preventive Services Task Force recom healing. .D UT o Patients on p blocker and statin medications should mends behavioral counseling to promote a healthy diet and physical activity for adults aged 18 years or continue therapy in the perioperative period. older who are at increased risk for cardiovascular disease. Bibliography Coodman SM. Springer B, Guyatt G, et al. 2017 American College of Rheumatolos//American Association of Hip irnd Knee Surgeons guide Bibliography line for the perioperative management of antirheumatic medication in Krist AH. Davidson KW. Mangione CM. et irl: US Preventive Sen'ices Task patients with rheumatic diseases undergoing elective total hip or total Force. Behavioral counseling intenentions to promote a healthy diet and knee arthroplasty. Arthritis Crre Res (Hoboken). 2017:69)111 2.1. [PMID: physical activity for cardiovascular disease pre\ention in adults u'ith 286209171 doi: I 0. 1002/acr.2327.1 cardiovascular risk factors: US Preventive Services Task Force recom mendation statement. JAMA. 2020;32.1:2069-75. IPMID: 332316701 doi:l0.lo0l jrm3.2020.21ilq Item 105 Answer: A Educational Objective: Provide counseling for behavioral change. Item 106 Answer: D Educational Objective: Avoid prostate cancer The most appropriate management is counseling for behav screening in a patient who does not express a preference ioral change (Option A). Behavioral counseling is an inte for screening. gral part of helping patients attain a healthy lifestyle. The U.S. Preventive Services Task Force (USPSTF) recommends The most appropriate prostate cancer screening stratery behavioral counseling to promote a healthy diet and phys for this patient is no screening (Option D). Screening for ical activity for adults aged 18 years or older who are at prostate cancer in asymptomatic. average risk men has increased risk for cardiovascular disease (CVD). Patients been controversial, and recommendations among profes at increased risk for CVD are identified by the USPSTF as sional organizations continue to evolve. The U.S. Preven patients with hypertension or elevated blood pressure; tive Services Task Force (USPSTF) recommends that for dyslipidemia; or mixed or multiple risk factors, such as the men aged 55 to 69 years, the decision to undergo periodic metabolic syndrome or an estimated 10 year atherosclerotic prostate speciflc antigen (PSA) based screening for CVD risk of 7.5'1, or higher. The USPSTF provides suggestions prostate cancer should be an individual decision. Before for behavioral change implementation, including a median deciding whether to be screened. men should have an of 12 contacts. with an estimated 6 hours of contact over opportunity to discuss the potential benefits and harms 12 months; some one-on one time with an interventionist; of screening with their clinician and to incorporate their and use of motivational interviewing and behavioral change values and preferences in the decision. Screening offers techniques, such as goal setting, active use of self monitoring, a small potential benefit of reducing the chance of death and addressing barriers related to diet, physical activity, or from prostate cancer in some men that is estimated to weight change. The USPSTF suggests that counseling for be a reduction in one prostate cancer related death for behavioral change can be done in person or referred to out every 1000 men screened for 10 years. However, many men side counseling services, or patients can be informed about will experience potential harms of screening, including media based interventions. false-positive results that require additional testing and

tr CONT. Sufficient evidence has demonstrated benelits ot sta- tin agents, such as atorvastatin, during the periopcrative period. Pleiotropic effects of these agents are belie\ed to Reviewing the benefits of a healthy diet and exercise (Options B, C) is necessary but not sufficient to help this patient achieve healthy lifestyle goals. Behavioral change be responsiblc Ibr numerous benefits in major surgeries. counseling that includes motivational interviewing and presumably due to anti inflanlmabry properties. Statins introduction to behavioral change techniques as well as have been consistently associated with lower risk Ibr car goal setting is more likely to achieve the desired end than diovascular c<lmplications in both cardiac and noncardiac solely providing information about the benefits of diet surgery In surgeries u'ith highest cardiovascular risk (major and exercise. The USPSTF notes that there is adequate vascular. cardiothoracic). it is reasonable to start :l statin evidence that counseling interventions reduce overall preoperatir,ely if the patient is not already taking one. T1-tis CVD events (myocardial infarction and stroke); improve recommendation does not apply fbr patients ur.rdergoing blood pressure, lipid and fasting blood glucose levels. noncardiac sllrger):. as is this case firr this patient: il a and body weight/adiposity; and improve healthy eating D patient has bcen on long tcnn statin therapll it sl.rould be habits. t^ continued. Although it is important that patients understand the E long term complications of their diseases (Option D), pro .D f,EY POIXTS t viding a stronger means of supporting behavioral change. o, . Nonbiologic disease-modifying antirheumatic such as a behavioral counseling program, is more likely to CL drugs (DMARDs) can be continued throughout the make a signiflcant impact. n perioperative period; biologic DMARDs should be I(EY PO I XI discontinued and restarted after evidence ofwound tt o The U.S. Preventive Services Task Force recom healing. .D UT o Patients on p blocker and statin medications should mends behavioral counseling to promote a healthy diet and physical activity for adults aged 18 years or continue therapy in the perioperative period. older who are at increased risk for cardiovascular disease. Bibliography Coodman SM. Springer B, Guyatt G, et al. 2017 American College of Rheumatolos//American Association of Hip irnd Knee Surgeons guide Bibliography line for the perioperative management of antirheumatic medication in Krist AH. Davidson KW. Mangione CM. et irl: US Preventive Sen'ices Task patients with rheumatic diseases undergoing elective total hip or total Force. Behavioral counseling intenentions to promote a healthy diet and knee arthroplasty. Arthritis Crre Res (Hoboken). 2017:69)111 2.1. [PMID: physical activity for cardiovascular disease pre\ention in adults u'ith 286209171 doi: I 0. 1002/acr.2327.1 cardiovascular risk factors: US Preventive Services Task Force recom mendation statement. JAMA. 2020;32.1:2069-75. IPMID: 332316701 doi:l0.lo0l jrm3.2020.21ilq Item 105 Answer: A Educational Objective: Provide counseling for behavioral change. Item 106 Answer: D Educational Objective: Avoid prostate cancer The most appropriate management is counseling for behav screening in a patient who does not express a preference ioral change (Option A). Behavioral counseling is an inte for screening. gral part of helping patients attain a healthy lifestyle. The U.S. Preventive Services Task Force (USPSTF) recommends The most appropriate prostate cancer screening stratery behavioral counseling to promote a healthy diet and phys for this patient is no screening (Option D). Screening for ical activity for adults aged 18 years or older who are at prostate cancer in asymptomatic. average risk men has increased risk for cardiovascular disease (CVD). Patients been controversial, and recommendations among profes at increased risk for CVD are identified by the USPSTF as sional organizations continue to evolve. The U.S. Preven patients with hypertension or elevated blood pressure; tive Services Task Force (USPSTF) recommends that for dyslipidemia; or mixed or multiple risk factors, such as the men aged 55 to 69 years, the decision to undergo periodic metabolic syndrome or an estimated 10 year atherosclerotic prostate speciflc antigen (PSA) based screening for CVD risk of 7.5'1, or higher. The USPSTF provides suggestions prostate cancer should be an individual decision. Before for behavioral change implementation, including a median deciding whether to be screened. men should have an of 12 contacts. with an estimated 6 hours of contact over opportunity to discuss the potential benefits and harms 12 months; some one-on one time with an interventionist; of screening with their clinician and to incorporate their and use of motivational interviewing and behavioral change values and preferences in the decision. Screening offers techniques, such as goal setting, active use of self monitoring, a small potential benefit of reducing the chance of death and addressing barriers related to diet, physical activity, or from prostate cancer in some men that is estimated to weight change. The USPSTF suggests that counseling for be a reduction in one prostate cancer related death for behavioral change can be done in person or referred to out every 1000 men screened for 10 years. However, many men side counseling services, or patients can be informed about will experience potential harms of screening, including media based interventions. false-positive results that require additional testing and 224

t t I Answers and Critiques t possible prostate biopsy; overdiagnosis and overtreatment; including erythrotelangiectatic (as shown), papulopustu- and treatment complications, such as incontinence and lar, phymatous, and ocular rosacea. L erectile dysfunction. In determining whether this service I is appropriate in individual cases, patients and clinicians t should consider the balance ofbeneflts and harms on the i basis of family history race/ethnicity, comorbid medical I conditions, patient values about the beneflts and harms I t of screening and treatment specific outcomes, and other I health needs. Clinicians should not screen men who do not lr express a preference for screening. i Conducting a digital rectal examination (Options A, B) i as part of prostate cancer screening is not recommended by i the USPSTF because there is no evidence that it adds beneflt U! o i to the PSA assay. I ET Because the patient has not expressed a preference for i screening, obtaining a PSA measurement (Option C) is not (J t I indicated. If the decision is made to proceed with screening, 'El ) the American Urological Association (AUA) recommends .g choosing less frequent screening intervals (>2 years), which UI The papulopustular variant of rosacea can be confused may reduce overdiagnosis and the number of false,positive with acne, but rosacea does not present with comedonal o results while preserving most of the screening benefit. The rn lesions. Telangiectasias are seen in the erythrotelangiec = AUA also recommends that the interval for rescreening tatic subtype. Most patients also have frequent flushing in may be based on the baseline PSA level. Screening is not response to triggers, such as stress, alcohol consumption, recommended for men with less than a 10 to lS-year life heat, and excessive sunlight. Ihe erythema of the cheeks expectancy. can mimic the malar rash of systemic lupus erS,thematosus. IEY POITII Unlike lupus, however, the erythema of rosacea includes the nasolabial folds. Ocular rosacea may present in isola- . For men aged 55 to 69 years, the U.S. Preventive tion or with associated skin flndings. In ocular rosacea, the Services Task Force recommends that clinicians conjunctiva appears injected, and patients often describe a engage in a discussion ofthe potential benefits versus "gritty sensation." In phymatous rosacea, severe sebaceous harms ofscreening for prostate cancer before ordering hyperplasia and chronic inflammation lead to flbrous over- testing. growth of the skin, creating a nodular, tumor-like deforma- . The U.S. Preventive Services Task Force recom tion of the facial structures. Rhinophyma is the form most mends that clinicians should not screen men for frequently encountered, and it is almost exclusively found prostate cancer unless they express a preference for in men. Treatment for rosacea is targeted toward the most screening. prominent signs and symptoms in each patient. Topical metronidazole is a reasonable flrst-line option for patients Bibliography with predominant papulopustular variant of rosacea as seen Crossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. in this patient. Other effective topical agents include sodium Screening for prostate cancer: US Preventive Services Task Force recom sulfacetamide/sulfur, azelaic acid, topical calcineurin inhib- mendation statement. JAMA. 2018;319:1901 13. [PMID: 29801017] doi:10.1001/jama.2018.3710 itors (pimecrolimus, tacrolimus), and ivermectin. Oral anti- biotics, such as low-dose doxycycline, have been shown to help control inflammation in ocular and papulopustular Item 107 Answer: C rosacea. Most patients will also beneflt from avoidance of identifled triggers, proper use ofsun protection, and use of Educational Objective: Treat rosacea. gentle skin cleansers. The most appropriate treatment is topical metronidazole Chloroquine (Option A) can be very helpful in the cream (Option C). This patient's rash consists of red mac- treatment of cutaneous and systemic lupus erythematosus. ules with pustules and telangiectasias within the rash, However, this patient has rosacea and chloroquine is not which after exposure to certain triggers becomes more indicated. prominent with stinging, burning, and itching. These Topical clobetasol cream (Option B) is a glucocorticoid flndings are most consistent with rosacea. This condition and may exacerbate existing rosacea or cause rosacea de is deflned by chronic inflammation of the pilosebaceous novo on the face. It is not a treatment for rosacea. units with increased vascular reactivity; it is most com- Although topical tacrolimus cream (Option D) can mon among patients of Irish and English descent with treat inflammatory variants of rosacea, such as perioriflcial light complexions, usually in the third to sixth decades of dermatitis, topical metronidazole cream is a flrst-line agent life. Ihere are a variety ofclinical presentations ofrosacea, for rosacea.

possible prostate biopsy; overdiagnosis and overtreatment; including erythrotelangiectatic (as shown), papulopustu- and treatment complications, such as incontinence and lar, phymatous, and ocular rosacea. L erectile dysfunction. In determining whether this service I is appropriate in individual cases, patients and clinicians t should consider the balance ofbeneflts and harms on the i basis of family history race/ethnicity, comorbid medical I conditions, patient values about the beneflts and harms I t of screening and treatment specific outcomes, and other I health needs. Clinicians should not screen men who do not lr express a preference for screening. i Conducting a digital rectal examination (Options A, B) i as part of prostate cancer screening is not recommended by i the USPSTF because there is no evidence that it adds beneflt U! o i to the PSA assay. I ET Because the patient has not expressed a preference for i screening, obtaining a PSA measurement (Option C) is not (J t I indicated. If the decision is made to proceed with screening, 'El ) the American Urological Association (AUA) recommends .g choosing less frequent screening intervals (>2 years), which UI The papulopustular variant of rosacea can be confused may reduce overdiagnosis and the number of false,positive with acne, but rosacea does not present with comedonal o results while preserving most of the screening benefit. The rn lesions. Telangiectasias are seen in the erythrotelangiec = AUA also recommends that the interval for rescreening tatic subtype. Most patients also have frequent flushing in may be based on the baseline PSA level. Screening is not response to triggers, such as stress, alcohol consumption, recommended for men with less than a 10 to lS-year life heat, and excessive sunlight. Ihe erythema of the cheeks expectancy. can mimic the malar rash of systemic lupus erS,thematosus. IEY POITII Unlike lupus, however, the erythema of rosacea includes the nasolabial folds. Ocular rosacea may present in isola- . For men aged 55 to 69 years, the U.S. Preventive tion or with associated skin flndings. In ocular rosacea, the Services Task Force recommends that clinicians conjunctiva appears injected, and patients often describe a engage in a discussion ofthe potential benefits versus "gritty sensation." In phymatous rosacea, severe sebaceous harms ofscreening for prostate cancer before ordering hyperplasia and chronic inflammation lead to flbrous over- testing. growth of the skin, creating a nodular, tumor-like deforma- . The U.S. Preventive Services Task Force recom tion of the facial structures. Rhinophyma is the form most mends that clinicians should not screen men for frequently encountered, and it is almost exclusively found prostate cancer unless they express a preference for in men. Treatment for rosacea is targeted toward the most screening. prominent signs and symptoms in each patient. Topical metronidazole is a reasonable flrst-line option for patients Bibliography with predominant papulopustular variant of rosacea as seen Crossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. in this patient. Other effective topical agents include sodium Screening for prostate cancer: US Preventive Services Task Force recom sulfacetamide/sulfur, azelaic acid, topical calcineurin inhib- mendation statement. JAMA. 2018;319:1901 13. [PMID: 29801017] doi:10.1001/jama.2018.3710 itors (pimecrolimus, tacrolimus), and ivermectin. Oral anti- biotics, such as low-dose doxycycline, have been shown to help control inflammation in ocular and papulopustular Item 107 Answer: C rosacea. Most patients will also beneflt from avoidance of identifled triggers, proper use ofsun protection, and use of Educational Objective: Treat rosacea. gentle skin cleansers. The most appropriate treatment is topical metronidazole Chloroquine (Option A) can be very helpful in the cream (Option C). This patient's rash consists of red mac- treatment of cutaneous and systemic lupus erythematosus. ules with pustules and telangiectasias within the rash, However, this patient has rosacea and chloroquine is not which after exposure to certain triggers becomes more indicated. prominent with stinging, burning, and itching. These Topical clobetasol cream (Option B) is a glucocorticoid flndings are most consistent with rosacea. This condition and may exacerbate existing rosacea or cause rosacea de is deflned by chronic inflammation of the pilosebaceous novo on the face. It is not a treatment for rosacea. units with increased vascular reactivity; it is most com- Although topical tacrolimus cream (Option D) can mon among patients of Irish and English descent with treat inflammatory variants of rosacea, such as perioriflcial light complexions, usually in the third to sixth decades of dermatitis, topical metronidazole cream is a flrst-line agent life. Ihere are a variety ofclinical presentations ofrosacea, for rosacea. 225

Answers and Critiques TEY POITTS weight loss. Saxagliptin, linagliptin. and alogliptin are . Topical metronidazole cream is a reasonable first-line other drugs within this class. Other pharmacologic agents for diabetes that are weight neutral include metformin option for patients with predominant papulopustular and the a glucosidases (acarbose, miglitol). variant of rosacea. This patient's seizures are well controlled on topi o Most patients with rosacea will benefit from avoid- ramate (Option E), a medication that does not promote ance ofidentified triggers, proper use ofsun protection, weight gain, and thus her antiseizure regimen should and use ofgentle skin cleansers. not be changed. Many other anticonvulsant medications, including carbamazepine, valproate, and gabapentin, are Bibliography associated with weight gain, whereas topiramate and zoni Marson JW, Baldwin HE. Rosacea: a wholistic review and update from samide typically cause weight loss. Phenytoin is weight pathogenesis to diagnosis and therapy. Int J Dermatol. 2020;59:e175 82. neutral. IPMID: 318803271 doi:1o.1111/ijd.14757 D I EY PO I TITS (a € r Insulin, sulfonylureas, thiazolidinediones, and megli- .D Item 108 Answer: C tinides are associated with weight gain. UI o, Educational Objective: Manage medications that o Glucagon-like peptide-l receptor agonists, sodium- CL promote weight loss and weight gain. glucose transporter-2 inhibitors, and amylin mimetics ..) The medication change most likely to promote weight are associated with weight loss. lt loss in this patient is to switch glimepiride to liraglutide .D (Option C). For this patient with an inability to Iose weight Bibliography ta despite pursuing healthy lifestyle choices, a thorough Tsai AC, Bessesen DH. Obesity. Ann lntern Med. 2019:170:lTC33 +e. IPMID, medication review is necessary to identify medications 308315931 doi:10.73261AITC20190305O

TEY POITTS weight loss. Saxagliptin, linagliptin. and alogliptin are . Topical metronidazole cream is a reasonable first-line other drugs within this class. Other pharmacologic agents for diabetes that are weight neutral include metformin option for patients with predominant papulopustular and the a glucosidases (acarbose, miglitol). variant of rosacea. This patient's seizures are well controlled on topi o Most patients with rosacea will benefit from avoid- ramate (Option E), a medication that does not promote ance ofidentified triggers, proper use ofsun protection, weight gain, and thus her antiseizure regimen should and use ofgentle skin cleansers. not be changed. Many other anticonvulsant medications, including carbamazepine, valproate, and gabapentin, are Bibliography associated with weight gain, whereas topiramate and zoni Marson JW, Baldwin HE. Rosacea: a wholistic review and update from samide typically cause weight loss. Phenytoin is weight pathogenesis to diagnosis and therapy. Int J Dermatol. 2020;59:e175 82. neutral. IPMID: 318803271 doi:1o.1111/ijd.14757 D I EY PO I TITS (a € r Insulin, sulfonylureas, thiazolidinediones, and megli- .D Item 108 Answer: C tinides are associated with weight gain. UI o, Educational Objective: Manage medications that o Glucagon-like peptide-l receptor agonists, sodium- CL promote weight loss and weight gain. glucose transporter-2 inhibitors, and amylin mimetics ..) The medication change most likely to promote weight are associated with weight loss. lt loss in this patient is to switch glimepiride to liraglutide .D (Option C). For this patient with an inability to Iose weight Bibliography ta despite pursuing healthy lifestyle choices, a thorough Tsai AC, Bessesen DH. Obesity. Ann lntern Med. 2019:170:lTC33 +e. IPMID, medication review is necessary to identify medications 308315931 doi:10.73261AITC20190305O that may contribute to weight gain. Many medications are associated with weight gain, including some antide- pressants, anticonvulsants, lithium, clozapine, olanzapine, Item 109 Answer: B depot progesterone, depot leuprolide acetate, glucocor Educational Objective: Screen for diabetes in women ticoids, and antiretroviral therapies. Medications used to with a history of gestational diabetes. treat diabetes mellitus have differing effects on weight. Sulfonylureas, insulin, thiazolidinediones (rosiglitazone, The most appropriate management is a hemoglobin A,. pioglitazone), and meglitinides (repaglinide, nateglinide) test (Option B). Women with a history of gestational dia- typically cause weight gain, whereas glucagon like betes, such as this patient, are at high risk for developing peptide 1 (GLP-I) receptor agonists (liraglutide, exenatide, diabetes in the future. These patients should be screened albiglutide, lixisenatide, dulaglutide, semaglutide), sodium- with either a fasting blood glucose level or 2 hour, 75 g glucose cotransporter-2 (SGLI 2) inhibitors (canagliflozin, oral glucose tolerance test between 6 and 12 weeks post dapagliflozin, empagliflozin, ertugliflozin), and amylin partum and then screened every 1 to 3 years with a mimetics (pramlintide) have been associated with weight hemoglobin A," measurement. These patients should also Ioss. These agents produce weight Ioss by various mecha be counseled on the importance of achieving a healthy nisms. GLP 1 receptor agonists and amylin mimetics slow weight and dietary and exercise interventions to prevent gastric emptying and increase satiety. SGLI-2 inhibitors diabetes. increase kidney excretion ofglucose. In this patient's case, Cervical cytologz and human papillomavirus (HPV) replacing glimepiride, a sulfonylurea, with liraglutide will testing (Option A) are not indicated. This patient had a result in weight loss. normal Pap smear 1 year ago; she does not need additional Switching bupropion to either paroxetine or venla screening at this time. According to the U.S. Preventive faxine (Options A, B) will not result in weight loss. Bupro- Services Task Force, women younger than 30 years require pion is the antidepressant medication most associated with a Pap smear every 3 years but do not require co testing for weight loss and should be continued, especially because HPV. Women aged 30 years or older should be screened the patient's depression is currently well controlled. every 5 years with a Pap smear and HPV co testing. If Among other antidepressants, venlafaxine, nefazodone, HPV co testing is unavailable, patients can be screened and fluoxetine are weight neutral. Paroxetine, however, every 3 years with Pap testing only. The American Cancer has been associated with weight gain, as have citalopram, Society recommends that individuals with a cervix initi- escitalopram, sertraline, duloxetine, mirtazapine, and ate cervical cancer screening at age 25 years and undergo amitriptyline. HPV testing every 5 years through age 65 years; if primary Switching glimepiride to sitagliptin (Option D) will HPV testing is not available, then individuals aged 25 to not be as ellective in reducing weight as switching to 65 years should be screened with co testing (HPV testing liraglutide. Sitagliptin, a dipeptidyl peptidase-4 inhibi in combination with cytolory) every 5 years or cytology tor, is weight neutral and unlikely to result in significant alone every 3 years.

that may contribute to weight gain. Many medications are associated with weight gain, including some antide- pressants, anticonvulsants, lithium, clozapine, olanzapine, Item 109 Answer: B depot progesterone, depot leuprolide acetate, glucocor Educational Objective: Screen for diabetes in women ticoids, and antiretroviral therapies. Medications used to with a history of gestational diabetes. treat diabetes mellitus have differing effects on weight. Sulfonylureas, insulin, thiazolidinediones (rosiglitazone, The most appropriate management is a hemoglobin A,. pioglitazone), and meglitinides (repaglinide, nateglinide) test (Option B). Women with a history of gestational dia- typically cause weight gain, whereas glucagon like betes, such as this patient, are at high risk for developing peptide 1 (GLP-I) receptor agonists (liraglutide, exenatide, diabetes in the future. These patients should be screened albiglutide, lixisenatide, dulaglutide, semaglutide), sodium- with either a fasting blood glucose level or 2 hour, 75 g glucose cotransporter-2 (SGLI 2) inhibitors (canagliflozin, oral glucose tolerance test between 6 and 12 weeks post dapagliflozin, empagliflozin, ertugliflozin), and amylin partum and then screened every 1 to 3 years with a mimetics (pramlintide) have been associated with weight hemoglobin A," measurement. These patients should also Ioss. These agents produce weight Ioss by various mecha be counseled on the importance of achieving a healthy nisms. GLP 1 receptor agonists and amylin mimetics slow weight and dietary and exercise interventions to prevent gastric emptying and increase satiety. SGLI-2 inhibitors diabetes. increase kidney excretion ofglucose. In this patient's case, Cervical cytologz and human papillomavirus (HPV) replacing glimepiride, a sulfonylurea, with liraglutide will testing (Option A) are not indicated. This patient had a result in weight loss. normal Pap smear 1 year ago; she does not need additional Switching bupropion to either paroxetine or venla screening at this time. According to the U.S. Preventive faxine (Options A, B) will not result in weight loss. Bupro- Services Task Force, women younger than 30 years require pion is the antidepressant medication most associated with a Pap smear every 3 years but do not require co testing for weight loss and should be continued, especially because HPV. Women aged 30 years or older should be screened the patient's depression is currently well controlled. every 5 years with a Pap smear and HPV co testing. If Among other antidepressants, venlafaxine, nefazodone, HPV co testing is unavailable, patients can be screened and fluoxetine are weight neutral. Paroxetine, however, every 3 years with Pap testing only. The American Cancer has been associated with weight gain, as have citalopram, Society recommends that individuals with a cervix initi- escitalopram, sertraline, duloxetine, mirtazapine, and ate cervical cancer screening at age 25 years and undergo amitriptyline. HPV testing every 5 years through age 65 years; if primary Switching glimepiride to sitagliptin (Option D) will HPV testing is not available, then individuals aged 25 to not be as ellective in reducing weight as switching to 65 years should be screened with co testing (HPV testing liraglutide. Sitagliptin, a dipeptidyl peptidase-4 inhibi in combination with cytolory) every 5 years or cytology tor, is weight neutral and unlikely to result in significant alone every 3 years. 226

Answers and Critiques Because this patient has no vaginal concerns, a nucleic acid ampliflcation test for chlamydia (Option C) is not indicated. The CDC recommends annual screening for chlamydia in women aged 25 years or younger or those with risk factors, such as having multiple sexual partners. Any woman reporting symptoms or requesting screening for sexually transmitted infections should be ollered testing. The copper intrauterine device (lUD) (Option D) is approved for 10 years of use, and thus the patient does not need her IUD replaced at this time. Levonorgestrel releasing IUDs are FDA approved for 3 to 5 years ofuse, depending on the brand. UI (u f,tY POlilrs ET o Women with a history of gestational diabetes are at IJ high risk for developing diabetes in the future. o Women with a history of gestational diabetes require =, .E Ut screening with either a fasting blood glucose level or (l, 2-hour, 75-g oral glucose tolerance test between 6 to B UI 12 weeks postparhrm, followed by screening every 1to 3 years with hemoglobin A1" measurement.

Because this patient has no vaginal concerns, a nucleic acid ampliflcation test for chlamydia (Option C) is not indicated. The CDC recommends annual screening for chlamydia in women aged 25 years or younger or those with risk factors, such as having multiple sexual partners. Any woman reporting symptoms or requesting screening for sexually transmitted infections should be ollered testing. The copper intrauterine device (lUD) (Option D) is approved for 10 years of use, and thus the patient does not need her IUD replaced at this time. Levonorgestrel releasing IUDs are FDA approved for 3 to 5 years ofuse, depending on the brand. UI (u f,tY POlilrs ET o Women with a history of gestational diabetes are at IJ high risk for developing diabetes in the future. o Women with a history of gestational diabetes require =, .E Ut screening with either a fasting blood glucose level or (l, 2-hour, 75-g oral glucose tolerance test between 6 to B UI 12 weeks postparhrm, followed by screening every 1to 3 years with hemoglobin A1" measurement. Bibliography American College of Obstetricians and Cynecologists. ACOG committee opinion no. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018; 131 :e140 50. doi:10.1097iAOG.0000000000002633

Because this patient has no vaginal concerns, a nucleic acid ampliflcation test for chlamydia (Option C) is not indicated. The CDC recommends annual screening for chlamydia in women aged 25 years or younger or those with risk factors, such as having multiple sexual partners. Any woman reporting symptoms or requesting screening for sexually transmitted infections should be ollered testing. The copper intrauterine device (lUD) (Option D) is approved for 10 years of use, and thus the patient does not need her IUD replaced at this time. Levonorgestrel releasing IUDs are FDA approved for 3 to 5 years ofuse, depending on the brand. UI (u f,tY POlilrs ET o Women with a history of gestational diabetes are at IJ high risk for developing diabetes in the future. o Women with a history of gestational diabetes require =, .E Ut screening with either a fasting blood glucose level or (l, 2-hour, 75-g oral glucose tolerance test between 6 to B UI 12 weeks postparhrm, followed by screening every 1to 3 years with hemoglobin A1" measurement. Bibliography American College of Obstetricians and Cynecologists. ACOG committee opinion no. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018; 131 :e140 50. doi:10.1097iAOG.0000000000002633 Item 110 Answer: A Educational Objective: Diagnose a dysplastic Pigmented actinic keratoses (Option B) are a rare skin nevus. condition that can have a similar presentation as dysplastic nevi, but they may have erythema and scale and occur more The most likely diagnosis is a dysplastic nevus (Option A). commonly in patients with darker skin. There is no scale or Dysplastic nevi are melanocytic nevi that are often asymmet- erythema in this patient's lesion. ric, irregularly bordered, have more than one shade of brown, Pigmented basal cell carcinoma (BCC) (Option C) is a and may be quite large in diameter. Many have a "fried egg" subtype of BCC that typically presents with f'eatures of a appearance, with an eccentric dark brown papular center and nodular BCC, including a translucent, rolled border with surrounding light brown ring. Dysplastic nevi can display one overlying telangiectasias. Pigmented BCC also has pigment or more of the identifiiing characteristics of melanoma (asym deposition, ranging from dark brown to black. This patient's metry irregular border, multiple colors, diameter >6 mm, lesion is pigmented, but it is a macular lesion with irregular evolution over time), making an accurate clinical diagnosis borders, making it distinctly different than a pigmented impossible; excisional skin biopsy to remove the entire lesion BCC. shouid be performed for diagnosis. The lesion seen on this Seborrheic keratosis (Option D) is a benign skin patient shows minimal color variability, so the most likely growth, often occurring on the trunk in older adults. Unlike diagnosis is a dysplastic nevus. Although the potential for this patient's lesion, seborrheic keratosis presents as a well an individual dysplastic nevus to develop into melanoma is circumscribed, keratotic, "stuck on" papule. low, patients with dysplastic nevi are at increased risk for KEY POIXIS developing a melanoma. Patients with multiple dysplastic nevi are also at risk for developing melanoma and should . Dysplastic nevi are melanocytic nevi that are often be monitored closely Some of these patients have dysplastic asymmetric, irregularly bordered, and multicolored, nevus syndrome. Criteria fbr this syndrome include a history and may be large in diameter (>6 mm); biopsy is used of melanoma in one or more flrst or second degree rela to differentiate between a dysplastic nevus and a tives; the presence of a large number olnevi (>s0), as shown melanoma. (see top olnext column); multiple nevi having atlpical clinical o Patients with multiple dysplastic nevi are at risk for fbatures; and multiple nevi that have atypical histologic fea- developing melanoma and should be monitored tures. lhese patients are at increased risk for melanoma and closely. should have yearly full-skin examinations.

Item 110 Answer: A Educational Objective: Diagnose a dysplastic Pigmented actinic keratoses (Option B) are a rare skin nevus. condition that can have a similar presentation as dysplastic nevi, but they may have erythema and scale and occur more The most likely diagnosis is a dysplastic nevus (Option A). commonly in patients with darker skin. There is no scale or Dysplastic nevi are melanocytic nevi that are often asymmet- erythema in this patient's lesion. ric, irregularly bordered, have more than one shade of brown, Pigmented basal cell carcinoma (BCC) (Option C) is a and may be quite large in diameter. Many have a "fried egg" subtype of BCC that typically presents with f'eatures of a appearance, with an eccentric dark brown papular center and nodular BCC, including a translucent, rolled border with surrounding light brown ring. Dysplastic nevi can display one overlying telangiectasias. Pigmented BCC also has pigment or more of the identifiiing characteristics of melanoma (asym deposition, ranging from dark brown to black. This patient's metry irregular border, multiple colors, diameter >6 mm, lesion is pigmented, but it is a macular lesion with irregular evolution over time), making an accurate clinical diagnosis borders, making it distinctly different than a pigmented impossible; excisional skin biopsy to remove the entire lesion BCC. shouid be performed for diagnosis. The lesion seen on this Seborrheic keratosis (Option D) is a benign skin patient shows minimal color variability, so the most likely growth, often occurring on the trunk in older adults. Unlike diagnosis is a dysplastic nevus. Although the potential for this patient's lesion, seborrheic keratosis presents as a well an individual dysplastic nevus to develop into melanoma is circumscribed, keratotic, "stuck on" papule. low, patients with dysplastic nevi are at increased risk for KEY POIXIS developing a melanoma. Patients with multiple dysplastic nevi are also at risk for developing melanoma and should . Dysplastic nevi are melanocytic nevi that are often be monitored closely Some of these patients have dysplastic asymmetric, irregularly bordered, and multicolored, nevus syndrome. Criteria fbr this syndrome include a history and may be large in diameter (>6 mm); biopsy is used of melanoma in one or more flrst or second degree rela to differentiate between a dysplastic nevus and a tives; the presence of a large number olnevi (>s0), as shown melanoma. (see top olnext column); multiple nevi having atlpical clinical o Patients with multiple dysplastic nevi are at risk for fbatures; and multiple nevi that have atypical histologic fea- developing melanoma and should be monitored tures. lhese patients are at increased risk for melanoma and closely. should have yearly full-skin examinations. 227

Answers and Critiques Bibliography IEY POIf,TS (milnucd) Farber MJ, Heilman ER, Friedman RI. Dysplastic nevi. Dermatol Clin. 2012;30:389 404. IPMID: 228005471 doi:10.1016/i.det.2012.O4.OO4 . There is no benefit of incentive spirometry with or without deep breathing exercises, in preventing post tr Item 1t 1 Answer: A Ed u cationa I Obj ective : Prevent postoperative operative pulmonary complications.

Bibliography IEY POIf,TS (milnucd) Farber MJ, Heilman ER, Friedman RI. Dysplastic nevi. Dermatol Clin. 2012;30:389 404. IPMID: 228005471 doi:10.1016/i.det.2012.O4.OO4 . There is no benefit of incentive spirometry with or without deep breathing exercises, in preventing post tr Item 1t 1 Answer: A Ed u cationa I Obj ective : Prevent postoperative operative pulmonary complications. Bibliography pulmonary complications. Odor PM. Bampoe S, Gilhooly D, et al. Perioperati\e interventions for pre Perioperative prophvlactic respirator)' ph1'siritl.rerapl' \€ntion of postoperative pulmonary complications: s),stematic review and meta analysis. BMJ. 2020;368:m540. [PMID: 32161042] doi:10.1136 (Option A) that includes increased r.nobilit-r. sputunl bmj.m540 clearance, deep breathing erercise, and inspiratitn' mus cle training is consistentl! sho$,n to reduce pulntonan, complications ,fter surgery A 2020 s)'stematic revieu'and Item 112 Answer: A D meta-analysis cvaluated intenentions to reduce tl're inci Educational Objective: Treat acute otitis externa. U! € dence of postoperati\e pulmonary complications in patients o undergoing noncardiac surgery Postoperatire pulmonary The most appropriate additional treatment for this patient UI with moderate severity acute otitis externa (AOE) (swimmer's o, con.rplications u,ere defincd as a contposite of respiraton ir.tfbction, respiratory failure, pleurirl eflusion. atclectasis, or ear) is ciprofloxacin dexamethasone otic drops (Option A). CL n pneumothorax. Perioperative (either bcfilre or afler surgery AOE is diffuse inflammation of the external ear canal and may involve the pinna and tragus. In 987, of cases of AOE, the or both) prophylactic respiratory. phl,siotherapl' shou'ed an ll cause is bacterial infection, most commonly with Pseudomo- overall benefit (risk ratio. 0.55: 95'll, CI. 0.32 0.911) in reduc' .D ing the development o{ postoperative pulmonary compli nos or Stophulococcus oureus. Symptoms include otalgia, (a cations. Other intenentions :rssociated with a reduccd risk pruritus, and ear fullness. The history should include assess fbr postoperative puimonan' complications inclucled lung ment for risk factors, including swimming/water activities, protecti\,e int raoperatire vcntilation. goal directecl hemod)' trauma/injury associated skin conditions (including contact namic therapics. epidural irnalgesia (replacing opioid anal- dermatitis, eczema, and psoriasis), immunocompromising gesia), prophylactic mucolytics. and postoperative continu- conditions (such as diabetes mellitus, HIV infection, or can- ous positive pressure ventilation. All intcnentious sho\fing cer chemotherapy), history of radiation, and tympanostomy benefit \tere associated rvith lou- qualit] er,idence. tubes or perforation of the tympanic membrane, which may Although incentir,e spirornetry, (Option B) is olten alter choice of treatment. On physical examination, the classic included in postoperativc management, moderatc qualit_v sign of AOE is tendemess with pushing on the tragus or pull- evidence shons no benelit in pre\€nting postoperative pul ing on the pinna. Topical treatments, including antibiotics, glucocorticoids, antiseptics (acetic acid), and combination n1onary complications (risk ratio. 1.06: 95'1,, CI. 0.85 1.31). Otl.rer recent systematic revielvs concur u'ith this finding. therapies, are flrst line management for uncomplicated AOE. Routine use of nasogastric tubes (Option C) is not rec In this patient with moderate severity disease characterized ommended lor the prerentitnt of postoperatir,e pulmonary' by pain and occlusion olthe ear canal with debris (cerumen, complications. Sl,stematic revierrs and meta anall'sis hare desquamated cells, purulent material), a topical antibiotic/ concluded that the routine use of'a nasogastric tube lo clecon.r glucocorticoid combination is reasonable after cleaning out prcss the stornach followirrg abdominal surgery is associated the debris from the ear canal. Patients should be instructed u,ith an increased risk lor pulmonary.complications. includ on proper technique for instillation of ear drops, including ing pneumonia and atelcctasis. \asogtstric tubes do hare a cleaning excess debris before instilling the drops and then role in patients rvitl.r postoperati\,e gastric distention or in the lying down with the affected ear facing upward, remaining in treatment of nausea and v<tmiting. but nrutine use fitllou,ing this position for 3 to 5 minutes. abdominal surgery is not recontmended. In most patients with AOE, systemic antibiotics. Maxintizing oral h1'eiene u-ith preoperativc use o1' such as intravenous ceftriaxone (Option B), are ineffec chlorhexidir.rc ntouth$'ash (Option D) reduces thc risk for tive and should be avoided. However, immunocompro- postoperative pneumonia in patients undergoing cardiac mised patients require topical and systemic therapy and surgeryi the ef licacy in patients undergoing noncardiac tho are at increased risk flor deeper infections, including bone racic surgery or abdominal surgery, is less clear. involvement (malignant otitis externa), which if present requires urgent referral to an otolaryngologist and intrave I(EY POITTS nous antibiotics. o Perioperative prophylactic respiratory physiotherapy Fungal infection of the external ear canal is uncom that includes increased mobility, sputum clearance, mon and is usually suspected when appropriate treat- deep breathing exercise, and inspiratory muscle train ment for AOE fails. The use of topical antibiotics can be a ing reduces the incidence of postoperative pulmonary predisposing factor for fungal external otitis. Treatment complications. includes meticulous cleaning of the external ear canal (Continued) and application of a topical antifungal agent, such as clotrimazole (Option C).

Bibliography pulmonary complications. Odor PM. Bampoe S, Gilhooly D, et al. Perioperati\e interventions for pre Perioperative prophvlactic respirator)' ph1'siritl.rerapl' \€ntion of postoperative pulmonary complications: s),stematic review and meta analysis. BMJ. 2020;368:m540. [PMID: 32161042] doi:10.1136 (Option A) that includes increased r.nobilit-r. sputunl bmj.m540 clearance, deep breathing erercise, and inspiratitn' mus cle training is consistentl! sho$,n to reduce pulntonan, complications ,fter surgery A 2020 s)'stematic revieu'and Item 112 Answer: A D meta-analysis cvaluated intenentions to reduce tl're inci Educational Objective: Treat acute otitis externa. U! € dence of postoperati\e pulmonary complications in patients o undergoing noncardiac surgery Postoperatire pulmonary The most appropriate additional treatment for this patient UI with moderate severity acute otitis externa (AOE) (swimmer's o, con.rplications u,ere defincd as a contposite of respiraton ir.tfbction, respiratory failure, pleurirl eflusion. atclectasis, or ear) is ciprofloxacin dexamethasone otic drops (Option A). CL n pneumothorax. Perioperative (either bcfilre or afler surgery AOE is diffuse inflammation of the external ear canal and may involve the pinna and tragus. In 987, of cases of AOE, the or both) prophylactic respiratory. phl,siotherapl' shou'ed an ll cause is bacterial infection, most commonly with Pseudomo- overall benefit (risk ratio. 0.55: 95'll, CI. 0.32 0.911) in reduc' .D ing the development o{ postoperative pulmonary compli nos or Stophulococcus oureus. Symptoms include otalgia, (a cations. Other intenentions :rssociated with a reduccd risk pruritus, and ear fullness. The history should include assess fbr postoperative puimonan' complications inclucled lung ment for risk factors, including swimming/water activities, protecti\,e int raoperatire vcntilation. goal directecl hemod)' trauma/injury associated skin conditions (including contact namic therapics. epidural irnalgesia (replacing opioid anal- dermatitis, eczema, and psoriasis), immunocompromising gesia), prophylactic mucolytics. and postoperative continu- conditions (such as diabetes mellitus, HIV infection, or can- ous positive pressure ventilation. All intcnentious sho\fing cer chemotherapy), history of radiation, and tympanostomy benefit \tere associated rvith lou- qualit] er,idence. tubes or perforation of the tympanic membrane, which may Although incentir,e spirornetry, (Option B) is olten alter choice of treatment. On physical examination, the classic included in postoperativc management, moderatc qualit_v sign of AOE is tendemess with pushing on the tragus or pull- evidence shons no benelit in pre\€nting postoperative pul ing on the pinna. Topical treatments, including antibiotics, glucocorticoids, antiseptics (acetic acid), and combination n1onary complications (risk ratio. 1.06: 95'1,, CI. 0.85 1.31). Otl.rer recent systematic revielvs concur u'ith this finding. therapies, are flrst line management for uncomplicated AOE. Routine use of nasogastric tubes (Option C) is not rec In this patient with moderate severity disease characterized ommended lor the prerentitnt of postoperatir,e pulmonary' by pain and occlusion olthe ear canal with debris (cerumen, complications. Sl,stematic revierrs and meta anall'sis hare desquamated cells, purulent material), a topical antibiotic/ concluded that the routine use of'a nasogastric tube lo clecon.r glucocorticoid combination is reasonable after cleaning out prcss the stornach followirrg abdominal surgery is associated the debris from the ear canal. Patients should be instructed u,ith an increased risk lor pulmonary.complications. includ on proper technique for instillation of ear drops, including ing pneumonia and atelcctasis. \asogtstric tubes do hare a cleaning excess debris before instilling the drops and then role in patients rvitl.r postoperati\,e gastric distention or in the lying down with the affected ear facing upward, remaining in treatment of nausea and v<tmiting. but nrutine use fitllou,ing this position for 3 to 5 minutes. abdominal surgery is not recontmended. In most patients with AOE, systemic antibiotics. Maxintizing oral h1'eiene u-ith preoperativc use o1' such as intravenous ceftriaxone (Option B), are ineffec chlorhexidir.rc ntouth$'ash (Option D) reduces thc risk for tive and should be avoided. However, immunocompro- postoperative pneumonia in patients undergoing cardiac mised patients require topical and systemic therapy and surgeryi the ef licacy in patients undergoing noncardiac tho are at increased risk flor deeper infections, including bone racic surgery or abdominal surgery, is less clear. involvement (malignant otitis externa), which if present requires urgent referral to an otolaryngologist and intrave I(EY POITTS nous antibiotics. o Perioperative prophylactic respiratory physiotherapy Fungal infection of the external ear canal is uncom that includes increased mobility, sputum clearance, mon and is usually suspected when appropriate treat- deep breathing exercise, and inspiratory muscle train ment for AOE fails. The use of topical antibiotics can be a ing reduces the incidence of postoperative pulmonary predisposing factor for fungal external otitis. Treatment complications. includes meticulous cleaning of the external ear canal (Continued) and application of a topical antifungal agent, such as clotrimazole (Option C). 228

Answers and Critiques Herpes zoster infection involving the ear may present less costly than transdermal formulations and has similar with vesicles around the external ear canal and may be com- efflcacy and safety. plicated by peripherai facial nerve paralysis and auditory/ Oral phosphodiesterase 5 (PDE 5) inhibitors, such vestibular symptoms (Ramsay Hunt syndrome). These as sildenafll (Option E), are first-line medical therapy fbr patients require antiviral therapy, such as valacyclovir erectile dysfunction and are safe and effective in most (Option D), and referral to an otolaryngologist. Inspection of patients. Testosterone therapy may also be indicated in this patient's ear and ear canal does not suggest the presence cases of confirmed androgen deflciency. When prescribed of vesicles, and treatment for herpes zoster with valacyclovir fbr hypogonadal men with erectile dysfunction, testos is not indicated. terone therapy will enhance the efficacy of PDE 5 inhib I(EY POITTS itors. However, neither PDE 5 inhibitors nor testosterone therapy is indicated until the patient is fully evaluated fbr o The classic sign of acute otitis externa is tendemess hypogonadism. with pushing on the tragus or pulling on the pinna. ta r First-line treatment of acute otitis externa includes rtY PortTS c,

Herpes zoster infection involving the ear may present less costly than transdermal formulations and has similar with vesicles around the external ear canal and may be com- efflcacy and safety. plicated by peripherai facial nerve paralysis and auditory/ Oral phosphodiesterase 5 (PDE 5) inhibitors, such vestibular symptoms (Ramsay Hunt syndrome). These as sildenafll (Option E), are first-line medical therapy fbr patients require antiviral therapy, such as valacyclovir erectile dysfunction and are safe and effective in most (Option D), and referral to an otolaryngologist. Inspection of patients. Testosterone therapy may also be indicated in this patient's ear and ear canal does not suggest the presence cases of confirmed androgen deflciency. When prescribed of vesicles, and treatment for herpes zoster with valacyclovir fbr hypogonadal men with erectile dysfunction, testos is not indicated. terone therapy will enhance the efficacy of PDE 5 inhib I(EY POITTS itors. However, neither PDE 5 inhibitors nor testosterone therapy is indicated until the patient is fully evaluated fbr o The classic sign of acute otitis externa is tendemess hypogonadism. with pushing on the tragus or pulling on the pinna. ta r First-line treatment of acute otitis externa includes rtY PortTS c, topical antibiotics, glucocorticoids, antiseptics (acetic o The diagnosis of androgen deficiency should be made ET only when a patient has two separate early morning .= acid), and combination therapies. IJ (B:OO arr,t) serum total testosterone levels less than -ts Bibliography 300 ng/dl (10.41 nmoudl) combined with suggestive .E symptoms and/or signs. UI Ilajioli t), l\,4acKeith S. Otitis externa. BMJ (llin Evid.2015;2015. IPl\.4ID: L (, 260741)11 . Free and bioavailable testosterone measurements UI should be reserved for patients with total testosterone = E levels in the low-normal range and for patients sus- Item 113 Answer: C pected of having alterations in sex hormone-binding Ed ucationa I Objective: Diagnose androgen deficiency. globulin levels.

topical antibiotics, glucocorticoids, antiseptics (acetic o The diagnosis of androgen deficiency should be made ET only when a patient has two separate early morning .= acid), and combination therapies. IJ (B:OO arr,t) serum total testosterone levels less than -ts Bibliography 300 ng/dl (10.41 nmoudl) combined with suggestive .E symptoms and/or signs. UI Ilajioli t), l\,4acKeith S. Otitis externa. BMJ (llin Evid.2015;2015. IPl\.4ID: L (, 260741)11 . Free and bioavailable testosterone measurements UI should be reserved for patients with total testosterone = E levels in the low-normal range and for patients sus- Item 113 Answer: C pected of having alterations in sex hormone-binding Ed ucationa I Objective: Diagnose androgen deficiency. globulin levels. The most appropriate management is repeat measurement Bibliography of the 8:00 AM serum total testosterone level (Option C). The i\l Sharefi A. Quinton R. Current national and international guidelines fbr diagnosis of androgen deficiency should be made only when the management of male hypogonadism: helping clinicians to navigtlte a patient has trruo separate ear$ morning (B'00 rnr) serum variation in diagnostic criteri:l and treatment recontmendations. Endocrinol Metab (Seoul). 2020:115:526 .1o. IPMID: 32981295] doi:10. total testosterone levels less than 300 ng/dl (tO.+t nmol/dL) 3803 EnNI.2020.760 combined with suggestive symptoms and/or signs. This patient has an B:00 AM serum total testosterone level of 200 ng/dl Item 114 Answer: E (6.94 nmol/L) and symptoms of sexual dysfunction (decreased Educational Objective: Avoid recommending vitamins libido and erectile dysfunction), suggesting androgen defl- for the prevention ofcardiovascular disease. ciency. 'lhe most appropriate management at this time is to repeat the 8:00 .,rv serum total testosterone measurement to No vitamin or supplement (Option E) can be recommended conflrm this diagnosis. to prevent cardiovascular disease. Overall, the U.S. Preventive Obtaining a serum free testosterone level (Option A) Services Task Force (USPSTF) lbund inadequate evidence on can be helpfui when alterations in sex hormone binding the benefits of supplementation with multivitamins to reduce globulin (SHBG) levels may be causing serum total testoster the risk lbr cardiovascular disease. In addition, the USPSTF one ievels to be unreliable. Alterations in SHBG levels occur found inadequate evidence on the benefits of supplementa- in older men with obesity; men with advanced liver disease. tion with individual vitamins or minerals or functional pairs diabetes, or insulin resistance; and men who use glucocorti in healthy populations without known nutritional deflcien coids. There is no concern that this patient has an alteration cies to reduce the risk for cardiovascular disease. Although in his SHBG level, and obtaining a serum lree testosterone these interventions lack proof of eflicacy in the prevention level is not indicated. ofcardiovascular disease, they appear to be without harm if An elevated luteinizing hormone (LH) level (Option taken in recommended doses. B) with simultaneous low testosterone indicates primary The USPSTF reviewed five studies of vitamin A (Option (testicular) hypogonadism. A low or normal LH level with A) supplementation in healthy patients without deficiencies. simultaneous low testosterone indicates secondary hypo None of the studies reported cardiovascular disease inci- gonadism. Confirming the presence of hypcigonadism is dence. Trno trials reported all cause mortality, but no signif necessary before assessment with LH measurement. icant dillerence was observed between the interrrention and Starting intramuscular testosterone therapy (Option D) control groups. before obtaining a second, conflrmatory B:00 au serum total The USPSTF cited two studies that reported the eflects testosterone level is not recommended. If the second serum of vitamin C (Option B), either alone or in combination with total testosterone level is low, intramuscular testosterone other supplements, and lbund no statistically significant therapy can be considered. Intramuscular testosterone is effect on cardiovascular disease or all cause morlality.

The most appropriate management is repeat measurement Bibliography of the 8:00 AM serum total testosterone level (Option C). The i\l Sharefi A. Quinton R. Current national and international guidelines fbr diagnosis of androgen deficiency should be made only when the management of male hypogonadism: helping clinicians to navigtlte a patient has trruo separate ear$ morning (B'00 rnr) serum variation in diagnostic criteri:l and treatment recontmendations. Endocrinol Metab (Seoul). 2020:115:526 .1o. IPMID: 32981295] doi:10. total testosterone levels less than 300 ng/dl (tO.+t nmol/dL) 3803 EnNI.2020.760 combined with suggestive symptoms and/or signs. This patient has an B:00 AM serum total testosterone level of 200 ng/dl Item 114 Answer: E (6.94 nmol/L) and symptoms of sexual dysfunction (decreased Educational Objective: Avoid recommending vitamins libido and erectile dysfunction), suggesting androgen defl- for the prevention ofcardiovascular disease. ciency. 'lhe most appropriate management at this time is to repeat the 8:00 .,rv serum total testosterone measurement to No vitamin or supplement (Option E) can be recommended conflrm this diagnosis. to prevent cardiovascular disease. Overall, the U.S. Preventive Obtaining a serum free testosterone level (Option A) Services Task Force (USPSTF) lbund inadequate evidence on can be helpfui when alterations in sex hormone binding the benefits of supplementation with multivitamins to reduce globulin (SHBG) levels may be causing serum total testoster the risk lbr cardiovascular disease. In addition, the USPSTF one ievels to be unreliable. Alterations in SHBG levels occur found inadequate evidence on the benefits of supplementa- in older men with obesity; men with advanced liver disease. tion with individual vitamins or minerals or functional pairs diabetes, or insulin resistance; and men who use glucocorti in healthy populations without known nutritional deflcien coids. There is no concern that this patient has an alteration cies to reduce the risk for cardiovascular disease. Although in his SHBG level, and obtaining a serum lree testosterone these interventions lack proof of eflicacy in the prevention level is not indicated. ofcardiovascular disease, they appear to be without harm if An elevated luteinizing hormone (LH) level (Option taken in recommended doses. B) with simultaneous low testosterone indicates primary The USPSTF reviewed five studies of vitamin A (Option (testicular) hypogonadism. A low or normal LH level with A) supplementation in healthy patients without deficiencies. simultaneous low testosterone indicates secondary hypo None of the studies reported cardiovascular disease inci- gonadism. Confirming the presence of hypcigonadism is dence. Trno trials reported all cause mortality, but no signif necessary before assessment with LH measurement. icant dillerence was observed between the interrrention and Starting intramuscular testosterone therapy (Option D) control groups. before obtaining a second, conflrmatory B:00 au serum total The USPSTF cited two studies that reported the eflects testosterone level is not recommended. If the second serum of vitamin C (Option B), either alone or in combination with total testosterone level is low, intramuscular testosterone other supplements, and lbund no statistically significant therapy can be considered. Intramuscular testosterone is effect on cardiovascular disease or all cause morlality. 229

Answers and Critiques The USPSTF reported on two trials that studied the burning after application. Both drugs have been associated effects of vitamin D on cardiovascular disease and found no with an increased risk for viral skin infections, such as her effect on disease incidence or mortality. The USPSTF lound pes simplex and varicella zoster. These medications have a only one trial that reported cardiovascular disease incidence black box warning fbr the rare development of'skin cancer and mortality and all cause mortaliry with combined use and cutaneous lymphoma. Replacing clobetasol cream with of vitamin D and calcium (Option C). and it fbund no ellect tacrolimus ointment is the most appropriate choice to con- after 7 years of lbltow up. tinue to treat this patient's atopic dermatitis in the setting The USPSTF found adequate evidence that supple- of glucocorticoid atrophy. mentation with p carotene or vitamin E (Option D) in Calcipotriene cream (Option A) is a vitamin D analogue healthy populations without known nutritional deflcien used fbr the treatment of psoriasis. Although adding calcipo- cies does not reduce the risk for cardiovascular disease. triene cream would not worsen this patient's skin atrophy. it The USPSTF recommends against the use of p-carotene or is not effective for treating atopic dermatitis. Regardless, this D vitamin E supplements for the prevention ol cardiovascu patient should discontinue clobetasol cream, which is the U! lar disease. cause ol her skin atroPhY. Ketoconazole cream (Option B) is effective for treating = .D rEY PO!TIT superficial fungal infections. l{owever, the annular plaques t^ o, . No vitamin or supplement can be recommended to and scale of tinea are not seen in this patient. and keto CL prevent cardiovascular disease due to lack of evidence conazole would not be efl'ective in treating this patient's skin n for efficacy. atrophy, striae, and telangiectasias. . The U.S. Preventive Services Task Force recom Triamcinolone cream (Option D) is a mid potency 4t E mends against the use of B-carotene or vitamin E topical glucocorticoid. Although it is effective in treating .D ta supplements for the prevention of cardiovascular atopic dermatitis and is Iess potent than clobetasol cream, disease because of evidence demonstrating lack of it can potentially exacerbate the current atrophy, striae, and telangiectasias seen in this patient's skin. Topical glu- efficacy. cocorticoids are frequently commercially combined with topical antifungal agents (clotrimazole betamethasone). Bibliography These combinations should also be avoided. The use of a N{oyer \A: U.S. Prcvcnti\,e Senices'lask Forcc. Vitirmin. mineral. and mul tivitlnrin supplements Ibr the primary prevention ot cardiovirscular combination drug can worsen some tinea inf'ections and diseasc lnd cancer: U.S. Preventive Services'lhsk Forcr recommendation when used in the groin area has a high risk fbr causing statement. Ann lntern Med. 201.1:160:558 6.1. IPMII): 21566,174] doi:10. 7326 l\,ll-1 0198 striae.

The USPSTF reported on two trials that studied the burning after application. Both drugs have been associated effects of vitamin D on cardiovascular disease and found no with an increased risk for viral skin infections, such as her effect on disease incidence or mortality. The USPSTF lound pes simplex and varicella zoster. These medications have a only one trial that reported cardiovascular disease incidence black box warning fbr the rare development of'skin cancer and mortality and all cause mortaliry with combined use and cutaneous lymphoma. Replacing clobetasol cream with of vitamin D and calcium (Option C). and it fbund no ellect tacrolimus ointment is the most appropriate choice to con- after 7 years of lbltow up. tinue to treat this patient's atopic dermatitis in the setting The USPSTF found adequate evidence that supple- of glucocorticoid atrophy. mentation with p carotene or vitamin E (Option D) in Calcipotriene cream (Option A) is a vitamin D analogue healthy populations without known nutritional deflcien used fbr the treatment of psoriasis. Although adding calcipo- cies does not reduce the risk for cardiovascular disease. triene cream would not worsen this patient's skin atrophy. it The USPSTF recommends against the use of p-carotene or is not effective for treating atopic dermatitis. Regardless, this D vitamin E supplements for the prevention ol cardiovascu patient should discontinue clobetasol cream, which is the U! lar disease. cause ol her skin atroPhY. Ketoconazole cream (Option B) is effective for treating = .D rEY PO!TIT superficial fungal infections. l{owever, the annular plaques t^ o, . No vitamin or supplement can be recommended to and scale of tinea are not seen in this patient. and keto CL prevent cardiovascular disease due to lack of evidence conazole would not be efl'ective in treating this patient's skin n for efficacy. atrophy, striae, and telangiectasias. . The U.S. Preventive Services Task Force recom Triamcinolone cream (Option D) is a mid potency 4t E mends against the use of B-carotene or vitamin E topical glucocorticoid. Although it is effective in treating .D ta supplements for the prevention of cardiovascular atopic dermatitis and is Iess potent than clobetasol cream, disease because of evidence demonstrating lack of it can potentially exacerbate the current atrophy, striae, and telangiectasias seen in this patient's skin. Topical glu- efficacy. cocorticoids are frequently commercially combined with topical antifungal agents (clotrimazole betamethasone). Bibliography These combinations should also be avoided. The use of a N{oyer \A: U.S. Prcvcnti\,e Senices'lask Forcc. Vitirmin. mineral. and mul tivitlnrin supplements Ibr the primary prevention ot cardiovirscular combination drug can worsen some tinea inf'ections and diseasc lnd cancer: U.S. Preventive Services'lhsk Forcr recommendation when used in the groin area has a high risk fbr causing statement. Ann lntern Med. 201.1:160:558 6.1. IPMII): 21566,174] doi:10. 7326 l\,ll-1 0198 striae. t(tY P0 t t{T Item 115 Answer: C . Topical tacrolimus and pimecrolimus are immu Educational Objective: Treat inflammatory skin nomodulators (calcineurin inhibitors) that can be disorders with topical immunomodulators. effective in treating atopic dermatitis without the risk The most appropriate treatment is to replace clobetasol for skin atrophy, striae, and telangiectasias that can cream with tacrolimus ointment (Option C). This patient occur with topical glucocorticoid use. has signs of skin atrophy, telangiectasias, and striae caused by overuse of clobetasol cream, a high-potency topical glu- Bibliography cocorticoid. Side effects are most fiequently seen when l)rugs lbr iltopic dermatitis. Med l.ett Drugs Ther 2020:62:89 96. IPMID: 325ssl22l higher potencies are used lbr longer periods or when used under occlusion, and they can appear as soon as 2 weeks Answer: E after initiation of therapy. Use of glucocorticoids around the eyes can exacerbate glaucoma and cause cataracts. Skin atrophy is more likely to occur in intertriginous areas, the Item 116 Educational Objective: Prevent venous tr thromboembolism in a hospitalized patient. face, and often in the popliteal or antecubital fossa. Topical glucocorticoids rnay also cause easy bruising. Although The most appropriate management lbr prever.rting venolls this patient has signs ofskin atrophy. she continues to have thromboembolism (VTE) in this I.rospitalized patient is flares ot her atopic dermatitis requiring treatment. Topical lou,molecular rveight l.reparin (LMWII) (Option E). Rates tacrolimus and pimecrolimus are immunomodulators (cal of VTE (both pulmonary embolism and deep vcnous thron.r cineurin inhibitors) that can be effective in treating atopic bosis) are elevated in acutely i1l medical patients. Acutely dermatitis, having similar efflcacl' to low to medium ill medical patients are putients hospitalized fbr a n.redical potency glucocorticoids. Topical calcineurin inhibitors can illness. Irr acutely ill medical patients, the 2018 American be used on the face and intertriginous areas without the Society of Hematologr (AStl) guideline suggcsts parenteral risk fbr skin atrophy, telangiectasias, and striae that can anticoagulation using LNIWH. unfractionated heparin (UFH). occur with topical glucocorticoid use. The most common or fbndaparinux to prevent V'l'E. In critically ill patients. the side effect of topical calcineurin inhibitors is stinging or ASI{ guicleline prefers LI\{WH to UFH.

t(tY P0 t t{T Item 115 Answer: C . Topical tacrolimus and pimecrolimus are immu Educational Objective: Treat inflammatory skin nomodulators (calcineurin inhibitors) that can be disorders with topical immunomodulators. effective in treating atopic dermatitis without the risk The most appropriate treatment is to replace clobetasol for skin atrophy, striae, and telangiectasias that can cream with tacrolimus ointment (Option C). This patient occur with topical glucocorticoid use. has signs of skin atrophy, telangiectasias, and striae caused by overuse of clobetasol cream, a high-potency topical glu- Bibliography cocorticoid. Side effects are most fiequently seen when l)rugs lbr iltopic dermatitis. Med l.ett Drugs Ther 2020:62:89 96. IPMID: 325ssl22l higher potencies are used lbr longer periods or when used under occlusion, and they can appear as soon as 2 weeks Answer: E after initiation of therapy. Use of glucocorticoids around the eyes can exacerbate glaucoma and cause cataracts. Skin atrophy is more likely to occur in intertriginous areas, the Item 116 Educational Objective: Prevent venous tr thromboembolism in a hospitalized patient. face, and often in the popliteal or antecubital fossa. Topical glucocorticoids rnay also cause easy bruising. Although The most appropriate management lbr prever.rting venolls this patient has signs ofskin atrophy. she continues to have thromboembolism (VTE) in this I.rospitalized patient is flares ot her atopic dermatitis requiring treatment. Topical lou,molecular rveight l.reparin (LMWII) (Option E). Rates tacrolimus and pimecrolimus are immunomodulators (cal of VTE (both pulmonary embolism and deep vcnous thron.r cineurin inhibitors) that can be effective in treating atopic bosis) are elevated in acutely i1l medical patients. Acutely dermatitis, having similar efflcacl' to low to medium ill medical patients are putients hospitalized fbr a n.redical potency glucocorticoids. Topical calcineurin inhibitors can illness. Irr acutely ill medical patients, the 2018 American be used on the face and intertriginous areas without the Society of Hematologr (AStl) guideline suggcsts parenteral risk fbr skin atrophy, telangiectasias, and striae that can anticoagulation using LNIWH. unfractionated heparin (UFH). occur with topical glucocorticoid use. The most common or fbndaparinux to prevent V'l'E. In critically ill patients. the side effect of topical calcineurin inhibitors is stinging or ASI{ guicleline prefers LI\{WH to UFH. 230

Answers and Critiques tr CON], In acutelv ill medical patients requiring V'l'l.l chemo prophylaris. thc ASH and othcr guidelines recommend use of parentcral anticoagulants over oral anticorrgullnts. Direct preventable death in the United States. Individuals with unhealthy alcohol use often interact with the health care system but rarely receive appropriate treatment. Screen oral ar.rticoagulants (Option A) are increasingly uscd as the ing instruments to identiflz harmful drinking include the agent of choice for postsurgicrl VTE prophylaxis. and in the Alcohol Use Disorders Identiflcation Test (AUDIT), AUDIT 2019 ASll VTFI guideline, clirect oral anticoagulants are pre Consumption (AUDIT C), and Single Alcohol Screening lerred over LMWH for postopcrrtive VTE prophylaxis in total Question (SASQ). The AUDIT is a validated 10 item screen knee and hip arthroplastl. ing test that takes approximately 2 to 3 minutes to admin ln ircutclv or criticalll, ill ntedical patients. the ASH ister; the AUDIT C is a briefer (three item) version of the guideline suggests using pharntacologic VTE pr<tphylaxis AUDIT. With single item screening, the clinician asks, "llow over mechanical VTE prophylaxis, such as intcrnlittent many times in the past year have you had five [four fbr pneumatic compression (lPC) (Option B) or gradient women and persons aged >65 years] or more drinks in stockir.rgs. IPC is indicatecl lirr a patient at incrcased risk 1 day?" Patients with a positive screening result should be tl fbr VTF. arld at high risl< fttr n.rajor bleecling or expe- o evaluated for alcohol use disorder and medical complica ET riencing bleeding on prophylactic dose anticoagulants. tions ofexcessive alcohol intake. It is also vcry unlikely tl.rat this patient u,ith exter.rsive The USPSTF recommends screening for diabetes ntel (., cellulitis r,r,ould tolerate the cliscomfbrt of IPC or gradient litus (Option A) in adults aged 40 to 70 years who are over stockings. weight or obese. The American Diabetes Association (ADA) =, .E In acutcly ill medicll patients. the ASf t guiclclinc panel recommends that screening be perfbrmed in patients of l^ q, does uot suggest combined use of lPC devices ancl paren- any age who are overweight or obese and have one or ta teral anticoagulation prophl,laxis over parenterul anticoag- more risk factors fbr diabetes. The ADA also recomnlends = ulation rlolle (Options C, D).-[his recommendation is based screening all adults beginning at age 45 years, regardless on lor,r, quality evidence bccrusc there are no trials com of risk factors. This patient has no indication for diabetes paring both strategies in this population. The AStl guide- screening. line recommends combined mechanical and pharnracologic According to the USPSTF, evidence is insufficient to prophylaris over pharmacologic prophylaxis alone in the assess the balance of benefits and harms of screening fbr hospitalizecl surgical patient. obstructive sleep apnea (Option C) in asymptomatic adults with the currently available tools. t(EY P0tltIt The USPSTF concludes that evidence is insufficient to . In acutely ill medical patients, parenteral anticoagula- recommend for or against screening fbr thyroid dystunc tion using low-molecular-weight heparin, unfraction tion (Option D). The American Thyroid Association and the ated heparin, or fondaparinux is suggested to prevent American Association of Clinical Endocrinologists, however, venous thromboembolism. recommend measuring thyroid-stimulating hormone in o In acutely ill medical patients, parenteral anticoagu- individuals at risk for hypothyroidism (e.g.,personal history Iation to prevent venous thromboembolism is sug- of autoimmune disease, neck radiation, or thyroid surgery); gested over oral anticoagulants and over mechanical they additionally suggest considering screening in adults prophylaxis. aged 60 years or older. This patient has no indication fbr thyroid function screening. Bibliography f,EY POIlIIS Schtinemann llJ, Cushman M. Burnett AE, et al. Americirn Society of tlematolos, 2018 guidelines fbr mrnagement ol venous thromboembo . The U.S. Preventive Services Task Force recommends lism: prophylaxis for hospitalized and nonhospitalized nredical patients. screening for unhealthy alcohol use in primary care Blood Atlv 2018;2:3198-225. IPMID: 30482763] doi:10.1182/bloodad \ances.20l 8O2295,1 settings in adults aged 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol Item 117 Answer: B use. Educational Objective: Screen a patient for hazardous drinking. . Screening instruments to identify unhealthy alcohol use include the Alcohol Use Disorders Identiflcation The most appropriate screening is for hazardous alcohol Test (AUDIT), AUDlT-Consumption (AUDIT C), and drinking (Option B). The U.S. Preventive Services Task Single Alcohol Screening Question (SASQ). Force (USPSTF) recommends screening for unhealthy alco hoi use in primary care settings in adults aged 18 years or Bibliography older, including pregnant women, and providing persons (lurry SJ, Krist AH, Owens DK, et al; US Preventive Services Task I'irrce. engaged in risky or hazardous drinking with brief behav- Screening and behavioral counseling interventions to reduce unhellthy alcohol use in adolescents and adults: US I'r€'ventive Seruices lhsk lbrce ioral counseling interventions to reduce unhealthy alcohol recommendation statement. JAMA. 2018:320:1 899 909. IPMID: 304221 99] use. Unhealthy alcohol use is the third Ieading cause of doi :1 0.1001 ijama-2018. I 6789

tr CON], In acutelv ill medical patients requiring V'l'l.l chemo prophylaris. thc ASH and othcr guidelines recommend use of parentcral anticoagulants over oral anticorrgullnts. Direct preventable death in the United States. Individuals with unhealthy alcohol use often interact with the health care system but rarely receive appropriate treatment. Screen oral ar.rticoagulants (Option A) are increasingly uscd as the ing instruments to identiflz harmful drinking include the agent of choice for postsurgicrl VTE prophylaxis. and in the Alcohol Use Disorders Identiflcation Test (AUDIT), AUDIT 2019 ASll VTFI guideline, clirect oral anticoagulants are pre Consumption (AUDIT C), and Single Alcohol Screening lerred over LMWH for postopcrrtive VTE prophylaxis in total Question (SASQ). The AUDIT is a validated 10 item screen knee and hip arthroplastl. ing test that takes approximately 2 to 3 minutes to admin ln ircutclv or criticalll, ill ntedical patients. the ASH ister; the AUDIT C is a briefer (three item) version of the guideline suggests using pharntacologic VTE pr<tphylaxis AUDIT. With single item screening, the clinician asks, "llow over mechanical VTE prophylaxis, such as intcrnlittent many times in the past year have you had five [four fbr pneumatic compression (lPC) (Option B) or gradient women and persons aged >65 years] or more drinks in stockir.rgs. IPC is indicatecl lirr a patient at incrcased risk 1 day?" Patients with a positive screening result should be tl fbr VTF. arld at high risl< fttr n.rajor bleecling or expe- o evaluated for alcohol use disorder and medical complica ET riencing bleeding on prophylactic dose anticoagulants. tions ofexcessive alcohol intake. It is also vcry unlikely tl.rat this patient u,ith exter.rsive The USPSTF recommends screening for diabetes ntel (., cellulitis r,r,ould tolerate the cliscomfbrt of IPC or gradient litus (Option A) in adults aged 40 to 70 years who are over stockings. weight or obese. The American Diabetes Association (ADA) =, .E In acutcly ill medicll patients. the ASf t guiclclinc panel recommends that screening be perfbrmed in patients of l^ q, does uot suggest combined use of lPC devices ancl paren- any age who are overweight or obese and have one or ta teral anticoagulation prophl,laxis over parenterul anticoag- more risk factors fbr diabetes. The ADA also recomnlends = ulation rlolle (Options C, D).-[his recommendation is based screening all adults beginning at age 45 years, regardless on lor,r, quality evidence bccrusc there are no trials com of risk factors. This patient has no indication for diabetes paring both strategies in this population. The AStl guide- screening. line recommends combined mechanical and pharnracologic According to the USPSTF, evidence is insufficient to prophylaris over pharmacologic prophylaxis alone in the assess the balance of benefits and harms of screening fbr hospitalizecl surgical patient. obstructive sleep apnea (Option C) in asymptomatic adults with the currently available tools. t(EY P0tltIt The USPSTF concludes that evidence is insufficient to . In acutely ill medical patients, parenteral anticoagula- recommend for or against screening fbr thyroid dystunc tion using low-molecular-weight heparin, unfraction tion (Option D). The American Thyroid Association and the ated heparin, or fondaparinux is suggested to prevent American Association of Clinical Endocrinologists, however, venous thromboembolism. recommend measuring thyroid-stimulating hormone in o In acutely ill medical patients, parenteral anticoagu- individuals at risk for hypothyroidism (e.g.,personal history Iation to prevent venous thromboembolism is sug- of autoimmune disease, neck radiation, or thyroid surgery); gested over oral anticoagulants and over mechanical they additionally suggest considering screening in adults prophylaxis. aged 60 years or older. This patient has no indication fbr thyroid function screening. Bibliography f,EY POIlIIS Schtinemann llJ, Cushman M. Burnett AE, et al. Americirn Society of tlematolos, 2018 guidelines fbr mrnagement ol venous thromboembo . The U.S. Preventive Services Task Force recommends lism: prophylaxis for hospitalized and nonhospitalized nredical patients. screening for unhealthy alcohol use in primary care Blood Atlv 2018;2:3198-225. IPMID: 30482763] doi:10.1182/bloodad \ances.20l 8O2295,1 settings in adults aged 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol Item 117 Answer: B use. Educational Objective: Screen a patient for hazardous drinking. . Screening instruments to identify unhealthy alcohol use include the Alcohol Use Disorders Identiflcation The most appropriate screening is for hazardous alcohol Test (AUDIT), AUDlT-Consumption (AUDIT C), and drinking (Option B). The U.S. Preventive Services Task Single Alcohol Screening Question (SASQ). Force (USPSTF) recommends screening for unhealthy alco hoi use in primary care settings in adults aged 18 years or Bibliography older, including pregnant women, and providing persons (lurry SJ, Krist AH, Owens DK, et al; US Preventive Services Task I'irrce. engaged in risky or hazardous drinking with brief behav- Screening and behavioral counseling interventions to reduce unhellthy alcohol use in adolescents and adults: US I'r€'ventive Seruices lhsk lbrce ioral counseling interventions to reduce unhealthy alcohol recommendation statement. JAMA. 2018:320:1 899 909. IPMID: 304221 99] use. Unhealthy alcohol use is the third Ieading cause of doi :1 0.1001 ijama-2018. I 6789 231

Answers and Critiques Item 118 Answer: D Bibliography Workou,ski KA. Bolan GAr Centers fbr Diselse Control and Prevention. Educational Objective: Evaluate a vaginal discharge. Sexually transmitted diseases treatment guidelines. 2015. MMWR Recomm Rep. 2015;64:l 1117. [PMID: 26042815] The most appropriate management is microscopic evalua tion of saline and potassium hydroxide (KOH) wet mounts of the vaginal discharge (Option D). Vaginitis describes con- Item 119 Answer: B ditions associated with vulvovaginal symptoms that may EX Educational Objective: Manage transition of care at include vaginal discharge, burning, itching, or odor. Vaginal hospital discharge. discharge can be physiologic. related to ovulation or preg 'llre factor ir.r this patient's hospitirl tlischarge proccss that nancy, or infectious, most commonly bacterial vaginosis, candidiasis, or trichomoniasis. Other causes of vaginal dis is lundarnental to a successful trar.rsition of care is explicit charge include irritation from use ofdouches, atrophic vag communication with the primary care physician (Option initis, malignancy, or a foreign body. Physical examination B). Poor comnrunicrtion between inpatient and outpatient includes assessment of the vulva and vagina for erythema, clinicians and between clinicians and pirtients is associated t) E edema. excoriation, papillomas, and the type ol discharge. n'ith increaseci risk tilr hospital relclntission. During trittt .D However, clinical flndings do not sulflciently distinguish sitions, physicians should strive to provide clear. concise. UI q, among the common causes of vaginitis, and laboratory test and accurate patient records to sultseqttent clinicians. ['h1' CL ing is necessary to establish a diagnosis. Diagnostic testing sicilns must adclitionally educate prltiellts and families on n includes assessment of vaginal pH; amine (whiff) test; and the expected course and red flag symptoms that necessitrltL' microscopic evaluation of the specimen to look for clue cells reevaluation. 4t A multidisciplinarv team approach to clischarge plitn on the wet mount and yeast, hyphae, and pseudohyphae on (D UI the KOH preparation. Occasionally, motile trichomonads ning should clecrcase this patient's risk tbr readmission. 'l'ransitions of clre are enhanced lr,hen rnultidisciplinrtrl, can be visualized on a wet preparation, suggesting tricho moniasis; in these cases, antigen testing is recommended tearns, including those r,vith a dedicatccl case managcr. arc because it can be difflcult to diagnose trichomoniasis on usecl fbr hospitaI clischarge plannilrg. l)ischarge planning Lly microscopy alone. If microscopy is unavailable, nucleic acid the hospital physician (Option A) is an inlportant ancl nec ampliflcation testing for the common pathogens can assist essary element of successiul transitions ot care but b1 itsclf with the diagnosis. is olten not suflicient. Intravaginal clotrimazole (Option A) and oral flucon- Accurate meclicatior.r reconcili:rtion, although time con azole (Option B) are appropriate treatments for a vaginal suming, is pamnrount to decreasing the likelihood ol rcad yeast infection. Although history and physical examination nrission because meclication errors tiecluc'ntly occur rvith are important, the diagnosis should be conflrmed. Vaginal tr;msitions of care. Il4eclication reconciliatior-r during this yeast infections are confirmed by the presence of yeast, patient's discharge process is a crucill fhctor in reducing hyphae, or pseudohyphae on KOH wet mounts. the risk fbr subsequent readmission. 'lhis ma1'be per{brrned Oral metronidazole (Option C) is appropriate treat by the discharging clinician or phirrnracist: several stuclies ment for bacterial vaginosis and trichomoniasis, although have shown that medication reconciliation is nrost eflective the dose and duration diff'er. Bacterial vaginosis is diag- when performe'd by a pharmacist. Medicltion reconciliation nosed using the Amsel criteria, which requires presence of pertirrmed by the patient's daughter alone (Option C) r.nisses three of the following four criteria: vaginal pH greater than the opportunity ftrr best practices associatecl with rcclLlcirlg 4.51 thin. homogenous vaginal discharge; positive whifftest, l)renrrlure hospilrrl rcildm ission. and at least 20'l,, clue cells on saline wet mount. Patients The simple orderlr.rg of laboratory tests is not flncla with trichomoniasis typically present with increased discol mental to a succcssful transition of care. l.aboratorl tests ored vaginal discharge, dyspareunia, itching, and postcoital may not be necessary in the immecliate postdischarge pcriod bleeding. The diagnosis of trichomoniasis is most secure (Option D). particul:rrly if predischrtrge laborabry vulues after a positive saline wet mount and nucleic acid amplifl- r,r,ere norntal. cation test. XEY POIITS

Item 118 Answer: D Bibliography Workou,ski KA. Bolan GAr Centers fbr Diselse Control and Prevention. Educational Objective: Evaluate a vaginal discharge. Sexually transmitted diseases treatment guidelines. 2015. MMWR Recomm Rep. 2015;64:l 1117. [PMID: 26042815] The most appropriate management is microscopic evalua tion of saline and potassium hydroxide (KOH) wet mounts of the vaginal discharge (Option D). Vaginitis describes con- Item 119 Answer: B ditions associated with vulvovaginal symptoms that may EX Educational Objective: Manage transition of care at include vaginal discharge, burning, itching, or odor. Vaginal hospital discharge. discharge can be physiologic. related to ovulation or preg 'llre factor ir.r this patient's hospitirl tlischarge proccss that nancy, or infectious, most commonly bacterial vaginosis, candidiasis, or trichomoniasis. Other causes of vaginal dis is lundarnental to a successful trar.rsition of care is explicit charge include irritation from use ofdouches, atrophic vag communication with the primary care physician (Option initis, malignancy, or a foreign body. Physical examination B). Poor comnrunicrtion between inpatient and outpatient includes assessment of the vulva and vagina for erythema, clinicians and between clinicians and pirtients is associated t) E edema. excoriation, papillomas, and the type ol discharge. n'ith increaseci risk tilr hospital relclntission. During trittt .D However, clinical flndings do not sulflciently distinguish sitions, physicians should strive to provide clear. concise. UI q, among the common causes of vaginitis, and laboratory test and accurate patient records to sultseqttent clinicians. ['h1' CL ing is necessary to establish a diagnosis. Diagnostic testing sicilns must adclitionally educate prltiellts and families on n includes assessment of vaginal pH; amine (whiff) test; and the expected course and red flag symptoms that necessitrltL' microscopic evaluation of the specimen to look for clue cells reevaluation. 4t A multidisciplinarv team approach to clischarge plitn on the wet mount and yeast, hyphae, and pseudohyphae on (D UI the KOH preparation. Occasionally, motile trichomonads ning should clecrcase this patient's risk tbr readmission. 'l'ransitions of clre are enhanced lr,hen rnultidisciplinrtrl, can be visualized on a wet preparation, suggesting tricho moniasis; in these cases, antigen testing is recommended tearns, including those r,vith a dedicatccl case managcr. arc because it can be difflcult to diagnose trichomoniasis on usecl fbr hospitaI clischarge plannilrg. l)ischarge planning Lly microscopy alone. If microscopy is unavailable, nucleic acid the hospital physician (Option A) is an inlportant ancl nec ampliflcation testing for the common pathogens can assist essary element of successiul transitions ot care but b1 itsclf with the diagnosis. is olten not suflicient. Intravaginal clotrimazole (Option A) and oral flucon- Accurate meclicatior.r reconcili:rtion, although time con azole (Option B) are appropriate treatments for a vaginal suming, is pamnrount to decreasing the likelihood ol rcad yeast infection. Although history and physical examination nrission because meclication errors tiecluc'ntly occur rvith are important, the diagnosis should be conflrmed. Vaginal tr;msitions of care. Il4eclication reconciliatior-r during this yeast infections are confirmed by the presence of yeast, patient's discharge process is a crucill fhctor in reducing hyphae, or pseudohyphae on KOH wet mounts. the risk fbr subsequent readmission. 'lhis ma1'be per{brrned Oral metronidazole (Option C) is appropriate treat by the discharging clinician or phirrnracist: several stuclies ment for bacterial vaginosis and trichomoniasis, although have shown that medication reconciliation is nrost eflective the dose and duration diff'er. Bacterial vaginosis is diag- when performe'd by a pharmacist. Medicltion reconciliation nosed using the Amsel criteria, which requires presence of pertirrmed by the patient's daughter alone (Option C) r.nisses three of the following four criteria: vaginal pH greater than the opportunity ftrr best practices associatecl with rcclLlcirlg 4.51 thin. homogenous vaginal discharge; positive whifftest, l)renrrlure hospilrrl rcildm ission. and at least 20'l,, clue cells on saline wet mount. Patients The simple orderlr.rg of laboratory tests is not flncla with trichomoniasis typically present with increased discol mental to a succcssful transition of care. l.aboratorl tests ored vaginal discharge, dyspareunia, itching, and postcoital may not be necessary in the immecliate postdischarge pcriod bleeding. The diagnosis of trichomoniasis is most secure (Option D). particul:rrly if predischrtrge laborabry vulues after a positive saline wet mount and nucleic acid amplifl- r,r,ere norntal. cation test. XEY POIITS r(EY PO t 1{TS . Poor communication between inpatient and outpatient clinicians and between providers and patients is asso- r Clinical findings do not sufficiently distinguish among ciated with increased risk for hospital readmission. the common causes olvaginitis, and laboratory testing is necessary to establish a diagnosis. . A multidisciplinary team approach to discharge plan ning decreases the risk for readmission. o Diagnostic testing for vaginitis includes assessment of vaginal pH; amine (whiffl test; and microscopic evalu- ation of the specimen to look for clue cells on the wet Bibliography Kamermayer AK, Leasure AR, Anderson L. 'l-he eflbctiveness of transitions mount and yeast, hyphae, and pseudohyphae on the of care interventk)ns in reducing hospital readmissions and mortality: potassium hydroxide preparation. , systematic review. Dimens Crit Care Nurs. 2017:36:311 6. IPMID: '289764801 doi : 10. 1097i DCC.OO0000oooooo0266

r(EY PO t 1{TS . Poor communication between inpatient and outpatient clinicians and between providers and patients is asso- r Clinical findings do not sufficiently distinguish among ciated with increased risk for hospital readmission. the common causes olvaginitis, and laboratory testing is necessary to establish a diagnosis. . A multidisciplinary team approach to discharge plan ning decreases the risk for readmission. o Diagnostic testing for vaginitis includes assessment of vaginal pH; amine (whiffl test; and microscopic evalu- ation of the specimen to look for clue cells on the wet Bibliography Kamermayer AK, Leasure AR, Anderson L. 'l-he eflbctiveness of transitions mount and yeast, hyphae, and pseudohyphae on the of care interventk)ns in reducing hospital readmissions and mortality: potassium hydroxide preparation. , systematic review. Dimens Crit Care Nurs. 2017:36:311 6. IPMID: '289764801 doi : 10. 1097i DCC.OO0000oooooo0266 232