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Answers and Critiques Item 120 Answer: D TEY POIf,IS Ed u cati ona I Objective : Diagnose porphyria cutanea . Porphyria cutanea tarda is a photosensitive disorder tarda. that present with scarring and blistering on sun- exposed skin, most commonly on the dorsal hands. The most appropriate diagnostic test is plasma and urine porphyrin levels (Option D). This patient likely has por- . Porphyria cutanea tarda is most commonly associated phyria cutanea tarda (PCT), a photosensitive disorder with hepatitis C virus infection, alcohol-induced liver that presents clinically with scarring and blistering on disease, and hemochromatosis. sun-exposed skin, most commonly the dorsal hands. Hyperpigmentation of the skin and hypertrichosis of Bibliography the cheeks are also common. The photosensitivity is Bissell DM, Anderson KE, Bonkovsky HL. Porphyria. N Engl J Med. 2017 377 .862 72. [PMtD: 28854095] doi:10.1056/NEJMra1608634 caused by excess porphyrins deposited in the skin that are sensitive to visible light, particularly the blue-light tt (l, wavelength. PCT is the most common porphyria and Item 121 Answer: C ET typically presents in patients older than 40 years. Plasma Educational Objective: Manage pneumococcal and urine porphyrins should be measured to confirm the vaccination in a person older than 65 years. L' diagnosis of PCT to differentiate from pseudoporphyria, ?t which presents similarly clinically but has normal plasma The most appropriate vaccine to administer at this visit is the .! and urine porphyrin levels. Pseudoporphyria is com 13 valent pneumococcal conjugate vaccine (PCV13) (Option C). t {t monly caused by nonsteroidal anti-inflammatory drugs, According to the CDC Advisory Committee on Immunization Practices (ACIP), adults aged 65 years or older should receive UI tetracyclines, and diuretics. Although skin biopsy can = be performed, pathology can be nonspecific and is not the 23 valent pneumococcal polysaccharide vaccine (PPSV23). necessary. PCT is most commonly associated with hep Patients who initially received the PPSV23 before 65 years of age atitis C virus infection, alcohol induced liver disease, should receive a second dose at least 5 years after the initial vac- and hemochromatosis. Testing for other susceptibility cination. Adults aged 65 years or older who are not in high-risk factors, such as HIV and hemochromatosis, should also groups (immunocompromised, presence of a cochlear implant be considered. Treatment for PCT is phlebotomy or twice or cerebrospinal fluid leak) should be engaged in shared deci- week ly hydroxych loroquine. sion making regarding administration of the PCV13 in addition Bullous lupus erythematosus is an uncommon skin to the PPSV23. Patients who want to receive both pneumococ- manifestation of systemic lupus erythematosus. In this cal vaccines should receive the PCV13 flrst and the PPSV23 at condition, vesicles and bullae are localized to the neck least 1 year later. Given that this patient would like to receive and upper trunk and also unexposed skin. Direct immu any applicable vaccines, the most appropriate vaccine option nofluorescence testing of a skin biopsy is diagnostically in this patient is to administer the PCV13 now She should also helpful. Antinuclear antibody testing (Option A) is unlikely receive a second dose ofPPSV23 (Option D) 1 year later because she was initially vaccinated before the age of 65 years. to help in the evaluation of bullous conditions because of its lack of speciflcity. This patient's blistering disease is The ACIP recommends that adults aged 50 years or conflned to her hands and is not consistent with bullous older receive the two-dose recombinant herpes zoster vac- lupus erythematosus. cine (Option A) administered 2 to 6 months apart. Although Anti tissue transglutaminase antibody testing (Option this patient received her doses 7 months apart, this is not B) is the initial step in the diagnosis of dermatitis her- expected to decrease the efficacy ofthe vaccine series; a third petiformis, an intensely pruritic bullous disease most dose is not indicated for this patient. The tetanus and diphtheria toxoids (Td) vaccine (Option B) commonly found on the elbows, knees, and buttocks that is not indicated for this patient at this visit. The Td is indicated is associated with celiac disease. This patient's clinical flndings are not consistent with dermatitis herpetiformis, every 10 years, with at Ieast one dose replaced by the tetanus and anti tissue transglutaminase antibody testing is not toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. This patient received the Tdap vaccine 7 years ago and needed. The onset of bullous pemphigoid is usually in adults will not be due for her next Td vaccination until age 68 years. aged 60 years or older and presents with urticarial and xtv Porilrs eczematous lesions that progress to tense bullae on an o Adults aged 65 years or older who are not in high-risk erythematous base. The most common sites of involve groups (immunocompromised, presence of a cochlear ment are the trunk, extremity flexures, and axillary and implant or cerebrospinal fluid leak) should be engaged inguinal folds. Oral involvement is present in approx- in shared decision making regarding administration of imately 20% of patients. Antibody tests are helping for the 13-valent pneumococcal conjugate vaccine in addi- monitoring disease activity in patients with bullous pem phigoid. This patient's findings are not consistent with tion to the 23 valent pneumococcal polysaccharide bullous pemphigoid, and antibody testing (Option C) is vaccine. (Continued) not appropriate.

Item 120 Answer: D TEY POIf,IS Ed u cati ona I Objective : Diagnose porphyria cutanea . Porphyria cutanea tarda is a photosensitive disorder tarda. that present with scarring and blistering on sun- exposed skin, most commonly on the dorsal hands. The most appropriate diagnostic test is plasma and urine porphyrin levels (Option D). This patient likely has por- . Porphyria cutanea tarda is most commonly associated phyria cutanea tarda (PCT), a photosensitive disorder with hepatitis C virus infection, alcohol-induced liver that presents clinically with scarring and blistering on disease, and hemochromatosis. sun-exposed skin, most commonly the dorsal hands. Hyperpigmentation of the skin and hypertrichosis of Bibliography the cheeks are also common. The photosensitivity is Bissell DM, Anderson KE, Bonkovsky HL. Porphyria. N Engl J Med. 2017 377 .862 72. [PMtD: 28854095] doi:10.1056/NEJMra1608634 caused by excess porphyrins deposited in the skin that are sensitive to visible light, particularly the blue-light tt (l, wavelength. PCT is the most common porphyria and Item 121 Answer: C ET typically presents in patients older than 40 years. Plasma Educational Objective: Manage pneumococcal and urine porphyrins should be measured to confirm the vaccination in a person older than 65 years. L' diagnosis of PCT to differentiate from pseudoporphyria, ?t which presents similarly clinically but has normal plasma The most appropriate vaccine to administer at this visit is the .! and urine porphyrin levels. Pseudoporphyria is com 13 valent pneumococcal conjugate vaccine (PCV13) (Option C). t {t monly caused by nonsteroidal anti-inflammatory drugs, According to the CDC Advisory Committee on Immunization Practices (ACIP), adults aged 65 years or older should receive UI tetracyclines, and diuretics. Although skin biopsy can = be performed, pathology can be nonspecific and is not the 23 valent pneumococcal polysaccharide vaccine (PPSV23). necessary. PCT is most commonly associated with hep Patients who initially received the PPSV23 before 65 years of age atitis C virus infection, alcohol induced liver disease, should receive a second dose at least 5 years after the initial vac- and hemochromatosis. Testing for other susceptibility cination. Adults aged 65 years or older who are not in high-risk factors, such as HIV and hemochromatosis, should also groups (immunocompromised, presence of a cochlear implant be considered. Treatment for PCT is phlebotomy or twice or cerebrospinal fluid leak) should be engaged in shared deci- week ly hydroxych loroquine. sion making regarding administration of the PCV13 in addition Bullous lupus erythematosus is an uncommon skin to the PPSV23. Patients who want to receive both pneumococ- manifestation of systemic lupus erythematosus. In this cal vaccines should receive the PCV13 flrst and the PPSV23 at condition, vesicles and bullae are localized to the neck least 1 year later. Given that this patient would like to receive and upper trunk and also unexposed skin. Direct immu any applicable vaccines, the most appropriate vaccine option nofluorescence testing of a skin biopsy is diagnostically in this patient is to administer the PCV13 now She should also helpful. Antinuclear antibody testing (Option A) is unlikely receive a second dose ofPPSV23 (Option D) 1 year later because she was initially vaccinated before the age of 65 years. to help in the evaluation of bullous conditions because of its lack of speciflcity. This patient's blistering disease is The ACIP recommends that adults aged 50 years or conflned to her hands and is not consistent with bullous older receive the two-dose recombinant herpes zoster vac- lupus erythematosus. cine (Option A) administered 2 to 6 months apart. Although Anti tissue transglutaminase antibody testing (Option this patient received her doses 7 months apart, this is not B) is the initial step in the diagnosis of dermatitis her- expected to decrease the efficacy ofthe vaccine series; a third petiformis, an intensely pruritic bullous disease most dose is not indicated for this patient. The tetanus and diphtheria toxoids (Td) vaccine (Option B) commonly found on the elbows, knees, and buttocks that is not indicated for this patient at this visit. The Td is indicated is associated with celiac disease. This patient's clinical flndings are not consistent with dermatitis herpetiformis, every 10 years, with at Ieast one dose replaced by the tetanus and anti tissue transglutaminase antibody testing is not toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. This patient received the Tdap vaccine 7 years ago and needed. The onset of bullous pemphigoid is usually in adults will not be due for her next Td vaccination until age 68 years. aged 60 years or older and presents with urticarial and xtv Porilrs eczematous lesions that progress to tense bullae on an o Adults aged 65 years or older who are not in high-risk erythematous base. The most common sites of involve groups (immunocompromised, presence of a cochlear ment are the trunk, extremity flexures, and axillary and implant or cerebrospinal fluid leak) should be engaged inguinal folds. Oral involvement is present in approx- in shared decision making regarding administration of imately 20% of patients. Antibody tests are helping for the 13-valent pneumococcal conjugate vaccine in addi- monitoring disease activity in patients with bullous pem phigoid. This patient's findings are not consistent with tion to the 23 valent pneumococcal polysaccharide bullous pemphigoid, and antibody testing (Option C) is vaccine. (Continued) not appropriate. 233

Answers and Critiques f EY POI 1{TS {cortinued) XEY POI llIS (contlnued) . Patients who want to receive both pneumococcal . Patients with chronic bacterial prostatitis require an vaccines should receive the l3-valent pneumococcal extended course (at Ieast 4-6 weeks) of antimicrobial conjugate vaccine first and the 23 valent pneumococ- therapy that has good prostatic tissue penetration and cal polysaccharide vaccine at least 1 year later. covers the causative organism. Bibliography Bibliography F-reedman MS. Bernstein tl. Ault KA. Recommended adult immunization Cill BC. Shoskes DA. Bacterial prostatitis. Curr Opin lnfect Dis. 2016r29: schedule, United States. 2021. Ann Intern Med. 2021. [PMID: 33571011] 86 91. IPMID: 26555038] Oo"rO.,697rQCO.OOOOOOOO0OOO0222 doi:10.7326 M20-8080

Bibliography Bibliography F-reedman MS. Bernstein tl. Ault KA. Recommended adult immunization Cill BC. Shoskes DA. Bacterial prostatitis. Curr Opin lnfect Dis. 2016r29: schedule, United States. 2021. Ann Intern Med. 2021. [PMID: 33571011] 86 91. IPMID: 26555038] Oo"rO.,697rQCO.OOOOOOOO0OOO0222 doi:10.7326 M20-8080 Item 122 Answer: C Item 123 Answer: D Educational Objective: Treat a patient with chronic Educational Objective: Use shared decision making in r^ bacterial prostatitis. breast cancer screening discussions. (D = The most appropriate management is a 6 week course of Ut The most appropriate initial breast cancer screening man o, trimethoprim sulfamethoxazole (Option C). This patient agement strates/ for this patient is engagement in shared a has chronic bacterial prostatitis. Chronic bacterial prostati decision making (Option D). This patient is younger than a.| tis involves persistent prostate infection lasting longer than 50 years and is at average risk for breast cancer. Women at 3 months. It commonly manifests as recurrent lower urinary average risk include those without family history of breast .tt E (D tract infections (UTIs) with the same organism. On digital rec cancer or prior irradiation therapy to the chest region. Guide Ut tal examination, the prostate may be normal, tender, and/or lines from multiple specialty societies and the U.S. Preventive boggr. It is not uncommon for these patients to have a normal Services Task Force (USPSTF) unanimously encourage annual digital rectal examination, especially between UTI episodes or or biennial screening mammography in women beginning at during treatment. Patients with chronic bacterial prostatitis age 50 years. Although screening mammography in women require an extended treatment course (at least 4-6 weeks) of aged 40 to 49 years may reduce the risk for breast cancer antimicrobial therapy that has good prostatic tissue penetra death, the number of deaths averted is smaller than that in tion and covers the causative organism. This patient's urine older women and the number of false-positive results and cultures have repeatedly grown Escherichia coli sensitive to unnecessary biopsies is larger. In addition to false positive trimethoprim-sulfamethoxazole, which has excellent pros results and unnecessary biopsies, all women undergoing reg tatic tissue penetration and is an appropriate antibiotic choice ular screening mammography are at risk for the diagnosis for this patient. A fluoroquinolone, such as ciprofloxacin or and treatment of noninvasive and invasive breast cancer that levofloxacin, is also often a viable treatment option. would otherwise not have become a threat to their health. or CT of the prostate (Option A) is not indicated at this even apparent, during their lifetime (overdiagnosis). Begin time. CT is helpful in identifying prostate abscess in patients ning mammography screening at a younger age and screening with acute bacterial prostatitis in whom appropriate anti more frequently may increase the risk for overdiagnosis and microbial therapy has failed. This patient has improved with subsequent overtreatment. For patients younger than 50 years each course of antibiotics, making chronic bacterial prosta- who are interested in screening, shared decision making is a titis more likely than a prostate abscess. reasonable strate$/. Shared decision making includes consid Prostatic massage followed by urine culture (Option eration of the patient's level of risk, values, and preferences B) has diagnostic utility in patients with chronic bacterial that will help inform the screening decision. prostatitis because it may lead to identification of a causative Breast MRI (Option A) is not currently recommended organism when an organism cannot be identifled by standard as flrst line strategz for breast cancer screening because data urine culture. In this patient, urine culture has identifled E are limited to suggest it lowers breast cancer mortality when coli as the causative organism for each UTI episode, obviating utilized in women at average risk, such as this patient. the need for prostatic massage followed by urine culture. The USPSTF concludes that the current evidence is No additional treatment (Option D) will probably result insufficient to assess the benefits and harms of digital breast in a cycle of recurrent infections and is not the best strates/ tomosynthesis (Option B) as a primary screening method for for this patient. A prolonged treatment cycle with an antibi breast cancer, and digital breast tomosynthesis is therefore otic selected by culture sensitivity findings is recommended not a reasonable option for this patient. for patients with chronic bacterial prostatitis. Although mammography (Option C) is the imaging rtY Potilrs modality ofchoice for breast cancer screening in average-risk o Chronic bacterial prostatitis commonly manifests as patients, the beneflt and harms of screening are very flnely balanced in patients younger than 50 years. Before mam recurrent lower urinary tract infections with the same mography is offered, a shared decision making approach organism. should be undertaken with this young patient at average risk (Continued) for breast cancer.

Item 122 Answer: C Item 123 Answer: D Educational Objective: Treat a patient with chronic Educational Objective: Use shared decision making in r^ bacterial prostatitis. breast cancer screening discussions. (D = The most appropriate management is a 6 week course of Ut The most appropriate initial breast cancer screening man o, trimethoprim sulfamethoxazole (Option C). This patient agement strates/ for this patient is engagement in shared a has chronic bacterial prostatitis. Chronic bacterial prostati decision making (Option D). This patient is younger than a.| tis involves persistent prostate infection lasting longer than 50 years and is at average risk for breast cancer. Women at 3 months. It commonly manifests as recurrent lower urinary average risk include those without family history of breast .tt E (D tract infections (UTIs) with the same organism. On digital rec cancer or prior irradiation therapy to the chest region. Guide Ut tal examination, the prostate may be normal, tender, and/or lines from multiple specialty societies and the U.S. Preventive boggr. It is not uncommon for these patients to have a normal Services Task Force (USPSTF) unanimously encourage annual digital rectal examination, especially between UTI episodes or or biennial screening mammography in women beginning at during treatment. Patients with chronic bacterial prostatitis age 50 years. Although screening mammography in women require an extended treatment course (at least 4-6 weeks) of aged 40 to 49 years may reduce the risk for breast cancer antimicrobial therapy that has good prostatic tissue penetra death, the number of deaths averted is smaller than that in tion and covers the causative organism. This patient's urine older women and the number of false-positive results and cultures have repeatedly grown Escherichia coli sensitive to unnecessary biopsies is larger. In addition to false positive trimethoprim-sulfamethoxazole, which has excellent pros results and unnecessary biopsies, all women undergoing reg tatic tissue penetration and is an appropriate antibiotic choice ular screening mammography are at risk for the diagnosis for this patient. A fluoroquinolone, such as ciprofloxacin or and treatment of noninvasive and invasive breast cancer that levofloxacin, is also often a viable treatment option. would otherwise not have become a threat to their health. or CT of the prostate (Option A) is not indicated at this even apparent, during their lifetime (overdiagnosis). Begin time. CT is helpful in identifying prostate abscess in patients ning mammography screening at a younger age and screening with acute bacterial prostatitis in whom appropriate anti more frequently may increase the risk for overdiagnosis and microbial therapy has failed. This patient has improved with subsequent overtreatment. For patients younger than 50 years each course of antibiotics, making chronic bacterial prosta- who are interested in screening, shared decision making is a titis more likely than a prostate abscess. reasonable strate$/. Shared decision making includes consid Prostatic massage followed by urine culture (Option eration of the patient's level of risk, values, and preferences B) has diagnostic utility in patients with chronic bacterial that will help inform the screening decision. prostatitis because it may lead to identification of a causative Breast MRI (Option A) is not currently recommended organism when an organism cannot be identifled by standard as flrst line strategz for breast cancer screening because data urine culture. In this patient, urine culture has identifled E are limited to suggest it lowers breast cancer mortality when coli as the causative organism for each UTI episode, obviating utilized in women at average risk, such as this patient. the need for prostatic massage followed by urine culture. The USPSTF concludes that the current evidence is No additional treatment (Option D) will probably result insufficient to assess the benefits and harms of digital breast in a cycle of recurrent infections and is not the best strates/ tomosynthesis (Option B) as a primary screening method for for this patient. A prolonged treatment cycle with an antibi breast cancer, and digital breast tomosynthesis is therefore otic selected by culture sensitivity findings is recommended not a reasonable option for this patient. for patients with chronic bacterial prostatitis. Although mammography (Option C) is the imaging rtY Potilrs modality ofchoice for breast cancer screening in average-risk o Chronic bacterial prostatitis commonly manifests as patients, the beneflt and harms of screening are very flnely balanced in patients younger than 50 years. Before mam recurrent lower urinary tract infections with the same mography is offered, a shared decision making approach organism. should be undertaken with this young patient at average risk (Continued) for breast cancer. 234

Answers and Critiques f,[Y P0txrs fbr a lack ol response or clinical worsening. However, alier o Although screening mammography in women aged hospital discharge, evaluation tbr OSA is indicated. 40 to 49 years may reduce the risk for breast cancer Starting empiric antibiotics (Option E) is not inclicatecl because there is no evidence of infbction. Although bacterial death, the number of deaths averted is smaller than pnc'umonia can occur after surgery, it would not beconte that in older women and the number of false-positive clinically apparent in anesthesia recovery, and this patient results and unnecessary biopsies is larger. has no features cor-rsistent r.t,ith pneumonia. . For patients younger than 50 years who are interested I( EY PO I XIS in breast cancer screening, shared decision making that includes consideration of the patient's level of . All surgical patients should be screened preopera risk, values, and preferences is a reasonable strategr to tively for obstructive sleep apnea (OSA); a commonly inform the screening decision. used screening tool for OSA is the STOP-BANG score. . Initial perioperative risk-reduction strategies for a t o Bibliography patient at high risk for obstructive sleep apnea include 3 ET Siu AL: U.S. Preventi\€ Sen'ices Task l-orce. Screening for breast cancer: U.S. continuous pulse oximetry monitoring, elevation of Preventive Services Task Force recommendation statement. Ann Intem Med. 20161 16.1:279 96. [PMID: 267 5717 O) doi:10.7326/ M15 2886 the head of the bed, and limiting sedating medica- t, tions. EI .E la tr Item 124 Answer: B Educational Objective: Treat obstructive sleep apnea in Bibliography Chung F. Memtsoudis SG. Ramachandran SK. et al. Socieo, of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment q, UI = the postanesthesia care unit. of adult patients s,ith obstructive sleep apnea. Anesth Analg. 2016; 123 :452 73. IPMID : 274 1277 2l doi :10.1213 rANE.0OO000O000O0l4l6 The most appropriate management is to continue pulse oximetry monitoring, elevate the head of bed, and limit sedating medications (Option B). 'this hospitalized patient Item 125 Answer: A has oxyger-r desaturations tl-rat correspond with his physi- Educational Objective: Diagnose acute bacterial cal position and sleep status but no examination findings conjunctivitis. suggestive of a primary pulmonary process. Ile has sereral risk factors fbr obstructive sleep apnea (OSA). including The most likely diagnosis is acute bacterial conjunctivitis an elevated 1iN4t, hypertension, snoring. a large neck, and (Option A). In adults, Staphylococcus aureus is most com rnale sex. This clinical scenario is most consistent with OSA monly implicated. Bacterial conjunctivitis is highly contagious related desaturations in the setting olsupir.re positior.ring and and is usually spread by person to person contact or through somnolence due to recent anesthesia. OSA is exceedingly contact with contaminated surfaces. Patients most commonly conlnlon in botl.r men and wonlen older than 50 years. and present with several days of unilateral diffuse conjunctival it remains undiagnosed in the majority of patients u,ith the redness and discharge, although bilateral involvement may condition. Befbre surgery all patients should be screened occur. The discharge is frequently mucopurulent and accom for OSA. which is associated with adverse perioperative panied by eyelid debris and matting, which is worse upon outcomes. including cardiac events. pulmor.rary complica awakening. Patients, such as this one, may also have visual tions, and ICU admissions. r\ commonly used preoperative blurring that improves u,'ith blinking; ovefi changes in visual screening tool fbr OSA is the STOP BANG score (l poir.rt each acuity do not occur. for Snoring, 'liredness. Observed apneas, elevated blood Patients with blepharitis (Option B) typically present Pressure, BMI>35, Age >50 years, Neck circumfbrence >40 cm, with chronic symptoms characterized by red, swollen, or and male Gender). itchy eyelids; ocular grit[z sensation; and crusting of eye Although postoperative pulmonary embolism can lashes in the morning. Because of the accompanying disor- occur. this patient has neither consistent hyporernia nor dered tear composition, aflected patients may develop eye tachycardia and, most important. has an excellent alterna irritation and excessive tear production. This patient's pri tive explanation fbr his synrptoms. Chest CT angiography mary symptoms are acute eye redness and discharge without (Option A) should not be pursuecl unless clinical findings t<r eyelid involvement, which is not consistent with blepharitis. suggest pul nronary embolisrn emerge. Hyperacute bacterial conjunctivitis (Option C) is a Given the absence of wheezing on examination and potentially vision threatening condition caused by Neisserio no history of obstructive pnlmonary disease, there is no gonorrheainfection. It is characterized by rapid onset ofpro ir.rdication lbr a B-agonist bronchodilator. such i'rs illbuterol fuse purulent discharge and diffuse bright red conjunctival (Option C). hemorrhage. If untreated, it can progress to corneal ulcer Conlinuous or bilevel positive pressure therapy (Option ation. This patient's symptoms are relatively mild and do not D) is efl'ective for established OSA; however, there is objective support a diagnosis of hyperacute bacterial conjunctivitis. evidence that this patient rt,ill likely respond to conservative Although scleritis (Option D) causes diffuse eye red measures. Positive pressure ventilation should be resened ness, it is typically accompanied by severe eye pain, visual

f,[Y P0txrs fbr a lack ol response or clinical worsening. However, alier o Although screening mammography in women aged hospital discharge, evaluation tbr OSA is indicated. 40 to 49 years may reduce the risk for breast cancer Starting empiric antibiotics (Option E) is not inclicatecl because there is no evidence of infbction. Although bacterial death, the number of deaths averted is smaller than pnc'umonia can occur after surgery, it would not beconte that in older women and the number of false-positive clinically apparent in anesthesia recovery, and this patient results and unnecessary biopsies is larger. has no features cor-rsistent r.t,ith pneumonia. . For patients younger than 50 years who are interested I( EY PO I XIS in breast cancer screening, shared decision making that includes consideration of the patient's level of . All surgical patients should be screened preopera risk, values, and preferences is a reasonable strategr to tively for obstructive sleep apnea (OSA); a commonly inform the screening decision. used screening tool for OSA is the STOP-BANG score. . Initial perioperative risk-reduction strategies for a t o Bibliography patient at high risk for obstructive sleep apnea include 3 ET Siu AL: U.S. Preventi\€ Sen'ices Task l-orce. Screening for breast cancer: U.S. continuous pulse oximetry monitoring, elevation of Preventive Services Task Force recommendation statement. Ann Intem Med. 20161 16.1:279 96. [PMID: 267 5717 O) doi:10.7326/ M15 2886 the head of the bed, and limiting sedating medica- t, tions. EI .E la tr Item 124 Answer: B Educational Objective: Treat obstructive sleep apnea in Bibliography Chung F. Memtsoudis SG. Ramachandran SK. et al. Socieo, of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment q, UI = the postanesthesia care unit. of adult patients s,ith obstructive sleep apnea. Anesth Analg. 2016; 123 :452 73. IPMID : 274 1277 2l doi :10.1213 rANE.0OO000O000O0l4l6 The most appropriate management is to continue pulse oximetry monitoring, elevate the head of bed, and limit sedating medications (Option B). 'this hospitalized patient Item 125 Answer: A has oxyger-r desaturations tl-rat correspond with his physi- Educational Objective: Diagnose acute bacterial cal position and sleep status but no examination findings conjunctivitis. suggestive of a primary pulmonary process. Ile has sereral risk factors fbr obstructive sleep apnea (OSA). including The most likely diagnosis is acute bacterial conjunctivitis an elevated 1iN4t, hypertension, snoring. a large neck, and (Option A). In adults, Staphylococcus aureus is most com rnale sex. This clinical scenario is most consistent with OSA monly implicated. Bacterial conjunctivitis is highly contagious related desaturations in the setting olsupir.re positior.ring and and is usually spread by person to person contact or through somnolence due to recent anesthesia. OSA is exceedingly contact with contaminated surfaces. Patients most commonly conlnlon in botl.r men and wonlen older than 50 years. and present with several days of unilateral diffuse conjunctival it remains undiagnosed in the majority of patients u,ith the redness and discharge, although bilateral involvement may condition. Befbre surgery all patients should be screened occur. The discharge is frequently mucopurulent and accom for OSA. which is associated with adverse perioperative panied by eyelid debris and matting, which is worse upon outcomes. including cardiac events. pulmor.rary complica awakening. Patients, such as this one, may also have visual tions, and ICU admissions. r\ commonly used preoperative blurring that improves u,'ith blinking; ovefi changes in visual screening tool fbr OSA is the STOP BANG score (l poir.rt each acuity do not occur. for Snoring, 'liredness. Observed apneas, elevated blood Patients with blepharitis (Option B) typically present Pressure, BMI>35, Age >50 years, Neck circumfbrence >40 cm, with chronic symptoms characterized by red, swollen, or and male Gender). itchy eyelids; ocular grit[z sensation; and crusting of eye Although postoperative pulmonary embolism can lashes in the morning. Because of the accompanying disor- occur. this patient has neither consistent hyporernia nor dered tear composition, aflected patients may develop eye tachycardia and, most important. has an excellent alterna irritation and excessive tear production. This patient's pri tive explanation fbr his synrptoms. Chest CT angiography mary symptoms are acute eye redness and discharge without (Option A) should not be pursuecl unless clinical findings t<r eyelid involvement, which is not consistent with blepharitis. suggest pul nronary embolisrn emerge. Hyperacute bacterial conjunctivitis (Option C) is a Given the absence of wheezing on examination and potentially vision threatening condition caused by Neisserio no history of obstructive pnlmonary disease, there is no gonorrheainfection. It is characterized by rapid onset ofpro ir.rdication lbr a B-agonist bronchodilator. such i'rs illbuterol fuse purulent discharge and diffuse bright red conjunctival (Option C). hemorrhage. If untreated, it can progress to corneal ulcer Conlinuous or bilevel positive pressure therapy (Option ation. This patient's symptoms are relatively mild and do not D) is efl'ective for established OSA; however, there is objective support a diagnosis of hyperacute bacterial conjunctivitis. evidence that this patient rt,ill likely respond to conservative Although scleritis (Option D) causes diffuse eye red measures. Positive pressure ventilation should be resened ness, it is typically accompanied by severe eye pain, visual 23s

Answers and Critiques disturbance, photophobia, and watery discharge, which are Because of the asymmetry and color variation of this not present in this patient. patient's lesion, malignant melanoma (Option A) could be Viral conjunctivitis (Option E), most commonly caused considered in the differential diagnosis. However, the rolled by adenovirus, frequently occurs in the setting of upper borders ofthis patient's lesion and pearly translucent nature a respiratory tract symptoms. Patients with viral conjunctivitis of the tumor are features of BCC and stand in contrast to the often present with eye redness and clear, watery discharge berry like appearance of nodular melanoma (as shown). : that frequently begins unilaterally and eventually progresses to bilateral ocular involvement. On examination, preauricu- . lar lymphadenopathy is common. This patient has unilateral : purulent discharge, which is not consistent with viral con- junctivitis. ftY ?otrTs D a^ o Acute bacterial conjunctivitis, most commonly caused E (D by Staphylococcus aureus, typically presents with l,I several days of unilateral diffuse conjunctival redness o, and mucopurulent discharge. EL a'f . Hyperacute bacterial conjunctivitis is a potentially vision-threatening condition caused by Neisserio gon- lt orrhea infection and is characterized by rapid onset of .D profuse purulent discharge and diffirse bright red a conjunctival hemorrhage. Bibliography Varu DM, Rhee MK, Akpek EK, et al; American Academy of Ophthalmologr Preferred Practice Pattern Cornea and External Disease Panel. Conjunctivitis Preferred Practice Pattern'. Ophthalmolog. 20t9 ;t26 :P9 4 169. [PMID: 30366797) doi:10.1016/j.ophtha.2o18.10.020

ftY ?otrTs D a^ o Acute bacterial conjunctivitis, most commonly caused E (D by Staphylococcus aureus, typically presents with l,I several days of unilateral diffuse conjunctival redness o, and mucopurulent discharge. EL a'f . Hyperacute bacterial conjunctivitis is a potentially vision-threatening condition caused by Neisserio gon- lt orrhea infection and is characterized by rapid onset of .D profuse purulent discharge and diffirse bright red a conjunctival hemorrhage. Bibliography Varu DM, Rhee MK, Akpek EK, et al; American Academy of Ophthalmologr Preferred Practice Pattern Cornea and External Disease Panel. Conjunctivitis Preferred Practice Pattern'. Ophthalmolog. 20t9 ;t26 :P9 4 169. [PMID: 30366797) doi:10.1016/j.ophtha.2o18.10.020 Item 126 Answer: B Educational Objective: Diagnose pigmented basal cell Biopsy should be performed to conflrm the diagnosis. carcinoma. The most likely diagnosis in this patient, however, is a pig- The most likely diagnosis is pigmented basal cell carcinoma mented BCC. (BCC) (Option B). Nodular BCC tlpically presents as a pearly Seborrheic keratosis (Option C) is a benign skin growth, or translucent nodule or papule with arborizing telangiec- often on the trunk in older adults. It is usually hyperpig tasias. It may have a central depression or ulceration with a mented from brown to black in color. Unlike this patient's rolled waxy border. About 6'l. of BCCs are pigmented, such as lesion, seborrheic keratosis presents as a well circumscribed, this one, which has dark brown pigment along the superior keratotic, "stuck-on" papule. border of the tumor and a dot of pigment located at the mid- Squamous cell carcinoma (SCC) (Option D) of the skin dle of the inferior border. Pigmented BCCs are more common is the second most common skin cancer. SCC typically in patients with darker skin. Pigmented BCCs are a low risk presents as hyperkeratotic, indurated papules or plaques BCC subtype. However, they can mimic malignant melanoma, in sun-exposed areas. SCC does not typically have pigmen and biopsy is necessary to dillerentiate them. Although they tation or the rolled borders seen in this patient's lesion. have low mortality, signiflcant local tissue destruction can f,EY POIXIS occur if not treated. Mohs micrographic surgery is a sur- gical technique that enhances the ability to leave surgical o Nodular basal cell carcinoma typically presents as a margins free of tumor and at the same time minimize the pearly or translucent nodule or papule with arboriz- resection of normal tissue. Compared with standard excision, ing telangiectasias and may have a central depression Mohs micrographic surgery is associated with a reduced rate or ulceration with a rolled waxy border. of tumor recurrence. Mohs micrographic surgery is usually o A small portion of basal cell carcinomas contain pig- reserved for skin cancers that have a high risk for recurrence ment and can mimic a malignant melanoma; biopsy or for tumors located in areas where minimal destruction of is often needed to confirm the diagnosis. tissue is of cosmetic or functional importance. For the lesion on this patient's face near the eye, Mohs micrographic sur- Bibliography gery would be recommended for the best chance of complete Kim DP, Kus KJ, Ruiz E. Basal cell carcinoma review. Hematol Oncol Clin tumor eradication and cosmetic outcomes. North Am. 2019;33:13-24. [PMID: 3049Z6Z0) doit1.O.tO16/j.hoc.2018.09.004

Item 126 Answer: B Educational Objective: Diagnose pigmented basal cell Biopsy should be performed to conflrm the diagnosis. carcinoma. The most likely diagnosis in this patient, however, is a pig- The most likely diagnosis is pigmented basal cell carcinoma mented BCC. (BCC) (Option B). Nodular BCC tlpically presents as a pearly Seborrheic keratosis (Option C) is a benign skin growth, or translucent nodule or papule with arborizing telangiec- often on the trunk in older adults. It is usually hyperpig tasias. It may have a central depression or ulceration with a mented from brown to black in color. Unlike this patient's rolled waxy border. About 6'l. of BCCs are pigmented, such as lesion, seborrheic keratosis presents as a well circumscribed, this one, which has dark brown pigment along the superior keratotic, "stuck-on" papule. border of the tumor and a dot of pigment located at the mid- Squamous cell carcinoma (SCC) (Option D) of the skin dle of the inferior border. Pigmented BCCs are more common is the second most common skin cancer. SCC typically in patients with darker skin. Pigmented BCCs are a low risk presents as hyperkeratotic, indurated papules or plaques BCC subtype. However, they can mimic malignant melanoma, in sun-exposed areas. SCC does not typically have pigmen and biopsy is necessary to dillerentiate them. Although they tation or the rolled borders seen in this patient's lesion. have low mortality, signiflcant local tissue destruction can f,EY POIXIS occur if not treated. Mohs micrographic surgery is a sur- gical technique that enhances the ability to leave surgical o Nodular basal cell carcinoma typically presents as a margins free of tumor and at the same time minimize the pearly or translucent nodule or papule with arboriz- resection of normal tissue. Compared with standard excision, ing telangiectasias and may have a central depression Mohs micrographic surgery is associated with a reduced rate or ulceration with a rolled waxy border. of tumor recurrence. Mohs micrographic surgery is usually o A small portion of basal cell carcinomas contain pig- reserved for skin cancers that have a high risk for recurrence ment and can mimic a malignant melanoma; biopsy or for tumors located in areas where minimal destruction of is often needed to confirm the diagnosis. tissue is of cosmetic or functional importance. For the lesion on this patient's face near the eye, Mohs micrographic sur- Bibliography gery would be recommended for the best chance of complete Kim DP, Kus KJ, Ruiz E. Basal cell carcinoma review. Hematol Oncol Clin tumor eradication and cosmetic outcomes. North Am. 2019;33:13-24. [PMID: 3049Z6Z0) doit1.O.tO16/j.hoc.2018.09.004 236

lndex Note: Page numbers followed by f and t denote figure and table, respectively. Bariatric surgery 44 46, 46t, 47t, Q9, Q47 Test questions are indicated by Q. Bartonella quintono, 7ll Basal cell carcinoma, 123 124, 123f , l24f , Ql26 A Basal cell layer,82f ABCDEs, of melanoma, 124 Beau lines, 1161 Abdominal aortic aneurysm (AAA), 4, Q97 Bed bugs, 1111, 112f Acellular pertussis vaccine, 12, 16, Q40 Behavioral counseling, lT 18, Q105 Acne,83,96 98,97t 981, Q61 Behavioral therapy,44 Acne keloidalis nuchae, 114 U5, 115f Benign prcstatic hyperplasia (BPH), 29, 51-52, Q8 Acne vulgaris, 96-98,97f, 98t Benzoyl peroxide, 97-98 Acneiform eruptions, 96-100, 97t p Carotene, 19 Acral lentiginous melanoma, 125f Biologic therapy,4l Acrochordons, l2O, l21f Biopsy Actinic keratosis, 727 722, 722f endometrial,6l, Q45 Acute febrile neutrophilic dermatosis, 128-129 excisional, 841, 121, Q5 Acute generalized exanthematous pustulosis, 95, 95f punch,84l 84t Acute kidney injury (AKI),40 shave,84l 84t Acute otitis externa (AOE),77-78, Q112 Biotin, drug interactions with, l9 Acute otitis media(AOM),77 78 Black cohosh, 20t Acute pelvic pain, Q57 Blepharitis, T0 77,77f Acute sialadenitis, 80-81 Blue nails. u6t Acyclovir,110 Body mass index (BMl), 6, 42t. See olso Obesity Adenovirus, conjunctivitis and, 68 Bo rrelio recurrentis. ll7 Adrenal insufficienry, 39-40, 401, Q4 Bowen disease, 122 123,723f Age-related macular degeneration (AMDI, 73-74, 74f BRCA]/2 gene mutations, 11 Alcohol use disorder Q117 Breast Allergens, common,8Tt imaging, 55t Alopecia, 113-115 masses, Q49 management of, 1131 symptoms,55-56, Q90 nonscarring, 113-114, 1141 Q83 Breast cancer, 8-9, 8t, 9t, Q123 scarring, 114-115, 115f Breast Imaging and Reporting Data System (BI RADS), 9, 55, 55t a-Blockers,51 52 Bremelanotide, 65 Alprostadil,48 Breslow depth,125 Amoxicillin, drug eruptions and, 91 Bug bites, 83 Ampicillin, drug eruptions and, 91 Bullae, characteristics ol 83t Analgesic agents, perioperative, 30t Bullous impetigo. 105-106. l06f Androgen deficiency, 50, 501, Q113 Bullous pemphigoid, 102, 1021 103t Androgenic alopecia, 113-114, 1131, 114f Burns, classification ol 112, 112t, Q65 Anemia, perioperative management ol 38-39 Burrows, characteristics of, 83t Angle-closure glaucoma (ACG), 72,73f , Q37 Annual wellness visits, Medicare, 1 c Anogenital warts, 119f Calcineurin inhibitors, 87 Antibiotics, topical, 85t, 86, 97 Calcium, 18, 18t Anticoagulant therapy, 37-38, Q56, Q62, Q77, Q100 Call-outs,26t Antifungals, topical, 85 86, 85t Callus. 120 Antihistamines, Q66 Canadian Task Force on the Periodic Health Examination, 1 Antiparasitic medications, topical, 85t Cancer screening, 8 12 Antiplatelet medications, 38, Q100. See olso Anticoagulant therapy Condida olbicons, 65 Anxiety, screening fot 5 Candidiasis, 65-67, 66t, 108, 108f Aortic stenosis, Q41 Caprini score, 35, 36t Appendix testis torsion, 53t Cardiac arrhlthmia, 33 ARISCATscores,34 35 Cardiovascular agents, perioperative, 30t ASCVD, preventive use of aspirin for, 16 Cardiovascular disease (CVD) Aspiration, prevention of, 28 erectile dysfunction treatment in, 49t Aspirin, 16, 35, 38, Q46, Q77 perioperative evaluation for, 3l-33, 31f Athlete's foot (tinea pedis), 106 prevention of, Q46, Q114 Athletic pubalgia, 55 risk assessment for, Q22 Atopic dermatitis, 86-87, 86f screening for, 4-5 Atrial fibrillation, 37 social isolation in, Q52 Atrophy Carotid bruits. ausculation of, 5 skin, characteristics of, 83t Cataracts,51,72 vaginal, in menopause, 61, 61f Centor criteria, 80 Autoimmune blistering diseases, l03t Central retinal artery occlusion (CRAO), 74 Autoimmune bullous diseases, 102, Q34 Central retinal vein occlusion (CRVO), 74,75f Avanafil,48 Cephalexin, l06 Azelaic acid, 97 Cerebrovascular disease screening, 4 5 Cerumen impaction,78 B Cervical cancer screening, u, Q38 Bacitracin, allergenic properties ol 87-88 Check-backs.26t Bacterial prostatitis, Q122 Chemotherapy, topical, 85t Bacterial vaginosis, Q25 Chickenpox, l09f

Note: Page numbers followed by f and t denote figure and table, respectively. Bariatric surgery 44 46, 46t, 47t, Q9, Q47 Test questions are indicated by Q. Bartonella quintono, 7ll Basal cell carcinoma, 123 124, 123f , l24f , Ql26 A Basal cell layer,82f ABCDEs, of melanoma, 124 Beau lines, 1161 Abdominal aortic aneurysm (AAA), 4, Q97 Bed bugs, 1111, 112f Acellular pertussis vaccine, 12, 16, Q40 Behavioral counseling, lT 18, Q105 Acne,83,96 98,97t 981, Q61 Behavioral therapy,44 Acne keloidalis nuchae, 114 U5, 115f Benign prcstatic hyperplasia (BPH), 29, 51-52, Q8 Acne vulgaris, 96-98,97f, 98t Benzoyl peroxide, 97-98 Acneiform eruptions, 96-100, 97t p Carotene, 19 Acral lentiginous melanoma, 125f Biologic therapy,4l Acrochordons, l2O, l21f Biopsy Actinic keratosis, 727 722, 722f endometrial,6l, Q45 Acute febrile neutrophilic dermatosis, 128-129 excisional, 841, 121, Q5 Acute generalized exanthematous pustulosis, 95, 95f punch,84l 84t Acute kidney injury (AKI),40 shave,84l 84t Acute otitis externa (AOE),77-78, Q112 Biotin, drug interactions with, l9 Acute otitis media(AOM),77 78 Black cohosh, 20t Acute pelvic pain, Q57 Blepharitis, T0 77,77f Acute sialadenitis, 80-81 Blue nails. u6t Acyclovir,110 Body mass index (BMl), 6, 42t. See olso Obesity Adenovirus, conjunctivitis and, 68 Bo rrelio recurrentis. ll7 Adrenal insufficienry, 39-40, 401, Q4 Bowen disease, 122 123,723f Age-related macular degeneration (AMDI, 73-74, 74f BRCA]/2 gene mutations, 11 Alcohol use disorder Q117 Breast Allergens, common,8Tt imaging, 55t Alopecia, 113-115 masses, Q49 management of, 1131 symptoms,55-56, Q90 nonscarring, 113-114, 1141 Q83 Breast cancer, 8-9, 8t, 9t, Q123 scarring, 114-115, 115f Breast Imaging and Reporting Data System (BI RADS), 9, 55, 55t a-Blockers,51 52 Bremelanotide, 65 Alprostadil,48 Breslow depth,125 Amoxicillin, drug eruptions and, 91 Bug bites, 83 Ampicillin, drug eruptions and, 91 Bullae, characteristics ol 83t Analgesic agents, perioperative, 30t Bullous impetigo. 105-106. l06f Androgen deficiency, 50, 501, Q113 Bullous pemphigoid, 102, 1021 103t Androgenic alopecia, 113-114, 1131, 114f Burns, classification ol 112, 112t, Q65 Anemia, perioperative management ol 38-39 Burrows, characteristics of, 83t Angle-closure glaucoma (ACG), 72,73f , Q37 Annual wellness visits, Medicare, 1 c Anogenital warts, 119f Calcineurin inhibitors, 87 Antibiotics, topical, 85t, 86, 97 Calcium, 18, 18t Anticoagulant therapy, 37-38, Q56, Q62, Q77, Q100 Call-outs,26t Antifungals, topical, 85 86, 85t Callus. 120 Antihistamines, Q66 Canadian Task Force on the Periodic Health Examination, 1 Antiparasitic medications, topical, 85t Cancer screening, 8 12 Antiplatelet medications, 38, Q100. See olso Anticoagulant therapy Condida olbicons, 65 Anxiety, screening fot 5 Candidiasis, 65-67, 66t, 108, 108f Aortic stenosis, Q41 Caprini score, 35, 36t Appendix testis torsion, 53t Cardiac arrhlthmia, 33 ARISCATscores,34 35 Cardiovascular agents, perioperative, 30t ASCVD, preventive use of aspirin for, 16 Cardiovascular disease (CVD) Aspiration, prevention of, 28 erectile dysfunction treatment in, 49t Aspirin, 16, 35, 38, Q46, Q77 perioperative evaluation for, 3l-33, 31f Athlete's foot (tinea pedis), 106 prevention of, Q46, Q114 Athletic pubalgia, 55 risk assessment for, Q22 Atopic dermatitis, 86-87, 86f screening for, 4-5 Atrial fibrillation, 37 social isolation in, Q52 Atrophy Carotid bruits. ausculation of, 5 skin, characteristics of, 83t Cataracts,51,72 vaginal, in menopause, 61, 61f Centor criteria, 80 Autoimmune blistering diseases, l03t Central retinal artery occlusion (CRAO), 74 Autoimmune bullous diseases, 102, Q34 Central retinal vein occlusion (CRVO), 74,75f Avanafil,48 Cephalexin, l06 Azelaic acid, 97 Cerebrovascular disease screening, 4 5 Cerumen impaction,78 B Cervical cancer screening, u, Q38 Bacitracin, allergenic properties ol 87-88 Check-backs.26t Bacterial prostatitis, Q122 Chemotherapy, topical, 85t Bacterial vaginosis, Q25 Chickenpox, l09f 237