Page 1

MKSAP® 17

Medical Knowledge Self-Assessment Program®

General Internal Medicine

General Internal Medicine

General Internal Medicine

150591010 150591010

28 AMA PRA Category 1 Credits™ available until December 31, 2018.


Table of Contents High Value Care in Internal Medicine . . . . . . . . . . . . . . . 1 Interpretation of the Medical Literature Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Study Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Experimental Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Observational Studies. . . . . . . . . . . . . . . . . . . . . . . . . . 2 Systematic Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Validity of a Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Statistical Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Confidence Intervals and P Values. . . . . . . . . . . . . . . . 4 Calculations for Diagnostic Tests and Medical Therapeutics. . . . . . . . . . . . . . . . . . . . . . 4 Levels of Evidence and Recommendations . . . . . . . . . . . 6

Routine Care of the Healthy Patient History and Physical Examination . . . . . . . . . . . . . . . . . . 6 Periodic Health Examination. . . . . . . . . . . . . . . . . . . 6 Routine History and Physical Examination. . . . . . . . 7 Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Principles of Screening. . . . . . . . . . . . . . . . . . . . . . . . . 8 Screening Recommendations for Adults . . . . . . . . . 9 Specific Screening Tests. . . . . . . . . . . . . . . . . . . . . . . 9 Genetics and Genetic Testing. . . . . . . . . . . . . . . . . . . . . . . 14 Taking a Family History. . . . . . . . . . . . . . . . . . . . . . . 14 Genetic Tests and Testing Strategies . . . . . . . . . . . . . 15 Referral for Genetic Counseling. . . . . . . . . . . . . . . . . 15 Immunization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Vaccinations Recommended for All Adults . . . . . . . 17 Vaccinations Recommended for Some Adults. . . . . 18 Immunization Recommendations for Specific Populations. . . . . . . . . . . . . . . . . . . . . . . 21 Healthy Lifestyle Counseling. . . . . . . . . . . . . . . . . . . . . . . 21 Behavioral Counseling . . . . . . . . . . . . . . . . . . . . . . . . 22 Diet and Physical Activity. . . . . . . . . . . . . . . . . . . . . . 22 Supplements and Herbal Therapies . . . . . . . . . . . . . . . . . 22

Patient Safety and Quality Improvement Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Direct Patient Care–Related Safety and Quality Issues. . . . . 25 Diagnostic Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Medication Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Transitions of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Systems Patient Care–Related Safety and Quality Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Quality Improvement Models . . . . . . . . . . . . . . . . . . 27 Additional Quality Improvement Tools . . . . . . . . . . 28 Measurement of Quality Improvement . . . . . . . . . . . . . . 28 Patient-Centered Medical Home. . . . . . . . . . . . . . . . . . . . 29 Health Information Technology and Patient Safety. . . . . 29 National Patient Safety Goals. . . . . . . . . . . . . . . . . . . . . . . 29

Professionalism and Ethics Professionalism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Primacy of Patient Welfare. . . . . . . . . . . . . . . . . . . . . . . . . 31 Appropriate Physician-Patient Relationships. . . . . . 31 Challenging Physician-Patient Relationships. . . . . . 31 Conflicts of Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Respecting Patient Autonomy. . . . . . . . . . . . . . . . . . . . . . 32 Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Decision-Making Capacity. . . . . . . . . . . . . . . . . . . . . 32 Advance Care Planning. . . . . . . . . . . . . . . . . . . . . . . . 33 Surrogate Decision-Making. . . . . . . . . . . . . . . . . . . . 33 Withholding or Withdrawing Treatment. . . . . . . . . 33 Physician-Assisted Death. . . . . . . . . . . . . . . . . . . . . . 33 Requests for Interventions. . . . . . . . . . . . . . . . . . . . . 34 Justice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Medical Error Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Colleague Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Approaching Ethical Dilemmas. . . . . . . . . . . . . . . . . . . . . 35

Palliative Care Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Dyspnea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Nausea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Anorexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Common Symptoms Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Chronic Noncancer Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 41 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 ix

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Medically Unexplained Symptoms. . . . . . . . . . . . . . . . . 44 Clinical Presentation and Evaluation . . . . . . . . . . . 44 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Acute Cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Subacute and Chronic Cough . . . . . . . . . . . . . . . . . 48 Cough in the Immunocompromised Patient. . . . . 50 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Fatigue and Systemic Exertion Intolerance Disease . . . 50 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Approach to the Patient with Dizziness. . . . . . . . . . 52 Vertigo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Presyncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Disequilibrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Nonspecific Dizziness and Chronic Subjective Dizziness. . . . . . . . . . . . . . . . . . . . . . . . . . 55 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Diagnosis and Evaluation. . . . . . . . . . . . . . . . . . . . . 59 Risk Stratification and Decision for Hospital Admission. . . . . . . . . . . . . . . . . . . . . . . 60 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Lower Extremity Edema. . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Chronic Venous Insufficiency . . . . . . . . . . . . . . . . . . 61

Musculoskeletal Pain Low Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Diagnosis and Evaluation. . . . . . . . . . . . . . . . . . . . . . 62 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Neck Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Diagnosis and Evaluation. . . . . . . . . . . . . . . . . . . . . 66 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Upper Extremity Disorders . . . . . . . . . . . . . . . . . . . . . . . 68 Thoracic Outlet Syndrome. . . . . . . . . . . . . . . . . . . . 68 Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Elbow Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Wrist and Hand Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 71 Lower Extremity Disorders . . . . . . . . . . . . . . . . . . . . . . . . 72 Hip Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Knee Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Ankle and Foot Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 75

Dyslipidemia Evaluation of Lipid Levels. . . . . . . . . . . . . . . . . . . . . . . . . 77 LDL Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Triglycerides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 HDL Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Nonstandard Lipid Risk Factors. . . . . . . . . . . . . . . . . 78 Management of Dyslipidemias . . . . . . . . . . . . . . . . . . . . . 78 Therapeutic Lifestyle Changes. . . . . . . . . . . . . . . . . . 78 Drug Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Management of Hypertriglyceridemia . . . . . . . . . . . 81 Dyslipidemia Management in Unique Populations. . . . . 82 Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Epidemiology and Pathophysiology . . . . . . . . . . . . . 82 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Obesity Definition and Epidemiology. . . . . . . . . . . . . . . . . . . . . . . 83 Screening and Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . 83 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Lifestyle Modification. . . . . . . . . . . . . . . . . . . . . . . . 84 Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . . 85 Bariatric Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Men’s Health Male Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 88 Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 88 Premature Ejaculation . . . . . . . . . . . . . . . . . . . . . . . 89 Decreased Libido. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Androgen Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Benign Prostatic Hyperplasia. . . . . . . . . . . . . . . . . . . . . . 90 Acute Testicular and Scrotal Pain . . . . . . . . . . . . . . . . . . . 91 Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Epididymitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Hydroceles, Varicoceles, and Epididymal Cysts. . . . . . . . 92 Hydroceles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Varicoceles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Epididymal Cysts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Acute and Chronic Prostatitis and Pelvic Pain. . . . . . . . . 92 Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Women’s Health Abnormal Uterine Bleeding. . . . . . . . . . . . . . . . . . . . . . . 94 Clinical Presentation. . . . . . . . . . . . . . . . . . . . . . . . . 94 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Breast Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Clinical Presentation. . . . . . . . . . . . . . . . . . . . . . . . . 95 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Breast Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Clinical Presentation. . . . . . . . . . . . . . . . . . . . . . . . . 96 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Chronic Pelvic Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

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Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Hormonal Contraception. . . . . . . . . . . . . . . . . . . . . . 97 Barrier Contraceptive Methods . . . . . . . . . . . . . . . . 99 Sterilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Emergency Contraception . . . . . . . . . . . . . . . . . . . . 99 Dysmenorrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Female Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . 100 Classification of Female Sexual Disorders . . . . . . . 100 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Menopause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Management of Vasomotor Symptoms. . . . . . . . . . 101 Management of Genitourinary Symptoms. . . . . . . 102 Nonhormonal Therapy. . . . . . . . . . . . . . . . . . . . . . . 102 Preconception Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Vaginitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Bacterial Vaginosis. . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Vulvovaginal Candidiasis . . . . . . . . . . . . . . . . . . . . . 105 Trichomoniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Eye Disorders Red Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Episcleritis and Scleritis. . . . . . . . . . . . . . . . . . . . . . 106 Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Blepharitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Subconjunctival Hemorrhage . . . . . . . . . . . . . . . . . 108 Corneal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Primary Open Angle Glaucoma. . . . . . . . . . . . . . . . 108 Acute Angle Closure Glaucoma. . . . . . . . . . . . . . . . 109 Age-Related Macular Degeneration. . . . . . . . . . . . . . . . 109 Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Dry Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Retinal Vascular Occlusion . . . . . . . . . . . . . . . . . . . . . . . 111 Retinal Artery Occlusion . . . . . . . . . . . . . . . . . . . . . 111 Retinal Vein Occlusion. . . . . . . . . . . . . . . . . . . . . . . 111 Eye Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Ear, Nose, Mouth, and Throat Disorders Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Tinnitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Otitis Media and Otitis Externa. . . . . . . . . . . . . . . . . . . . 114 Cerumen Impaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Upper Respiratory Tract Infections. . . . . . . . . . . . . . . . . 115 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Rhinitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Epistaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Oral Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oral Infections and Ulcers. . . . . . . . . . . . . . . . . . . . Dental Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Halitosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Temporomandibular Disorders. . . . . . . . . . . . . . . . . . . .

118 118 118 118 118

Mental and Behavioral Health Mood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Depressive Disorders. . . . . . . . . . . . . . . . . . . . . . . . . Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Generalized Anxiety Disorder. . . . . . . . . . . . . . . . . Panic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . Posttraumatic Stress Disorder. . . . . . . . . . . . . . . . . Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . Substance Abuse Disorders . . . . . . . . . . . . . . . . . . . . . . . Tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personality Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . Somatic Symptom and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Complications. . . . . . . . . . . . . . . . . . . . . . . Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . .

118 118 121 122 122 122 122 122 123 123 123 123 125 126 126 127 127 127 127 127 128 128

Geriatric Medicine Comprehensive Geriatric Assessment . . . . . . . . . . . . . . 128 Functional Assessment. . . . . . . . . . . . . . . . . . . . . . . 128 Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Cognitive Function . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Fall Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Assessment of the Older Driver. . . . . . . . . . . . . . . . 132 Levels of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Polypharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Clinical Presentation. . . . . . . . . . . . . . . . . . . . . . . . . 136 Prevention and Management. . . . . . . . . . . . . . . . . . 136

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Perioperative Medicine General Recommendations. . . . . . . . . . . . . . . . . . . . . . . 136 Preoperative Testing . . . . . . . . . . . . . . . . . . . . . . . . . 137 Perioperative Medication Management . . . . . . . . . 137 Cardiovascular Perioperative Management. . . . . . . . . . 137 Cardiovascular Risk Assessment. . . . . . . . . . . . . . . 137 Cardiovascular Risk Management. . . . . . . . . . . . . . 140 Pulmonary Perioperative Management . . . . . . . . . . . . . 141 Hematologic Perioperative Management. . . . . . . . . . . . 142 Venous Thromboembolism Prophylaxis. . . . . . . . . 142 Perioperative Management of Anticoagulant Therapy. . . . . . . . . . . . . . . . . . . . . . . 142 Perioperative Management of Antiplatelet Medications. . . . . . . . . . . . . . . . . . . . . 145 Perioperative Management of Anemia, Coagulopathies, and Thrombocytopenia. . . . . . . . 145

Perioperative Management of Endocrine Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . Thyroid Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adrenal Insufficiency. . . . . . . . . . . . . . . . . . . . . . . . Perioperative Management of Kidney Disease. . . . . . . . Perioperative Management of Liver Disease. . . . . . . . . . Perioperative Management of Neurologic Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . .

145 145 146 146 147 147 147

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Self-Assessment Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

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General Internal Medicine High Value Care in Internal Medicine An economically unsustainable amount of money is spent on health care in the United States—18% of the U.S. gross domestic product—leaving less money to pay for other essential services such as public health and safety, infrastructure, and education. Despite spending more on health care than any other country, the United States has health outcomes, including mortality, survival, and life expectancy, that rank at or near the bottom when compared with other high-income countries. Misuse and overuse of medical interventions contribute significantly to this untenable health care spending. Physicians are uniquely positioned to take the lead in addressing these problems by partnering with patients and other health care providers to reduce the use of medical interventions (tests and treatments) that offer minimal or no benefit and may lead to unintended harm. High value care is care that balances the clinical benefit of a given medical intervention with its harms and costs, with the goal of improving patient outcomes. High value care represents a paradigm shift away from the belief that more care is better care toward the idea that evidence-based, individualized care is better care. High value care places patients and their outcomes, values, and concerns at the center of every major clinical decision, using cost-effective and low-risk tools (for example, history and physical examination) and patientcentered communication to improve patient outcomes. This approach helps lay a foundation for dealing with the psychological burden that accompanies diagnostic uncertainty and allows both patients and physicians to be more comfortable with a conservative course of care. New drugs, devices, procedures, and tests are the primary drivers of increased health care spending; however, it is critical that physicians use testing and medical technology judiciously and selectively assess whether potential benefits justify the costs. The Alliance for Academic Internal Medicine and the American College of Physicians (ACP) have developed a simple stepwise framework to help providers incorporate high value care into daily practice (Table 1). The ACP has also developed clinical recommendations and physician resources to help physicians practice high value care (available at http://hvc. acponline.org/index.html). Additionally, over 72 medical specialty societies and Consumer Reports (an independent product testing organization) have participated in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, which promotes stewardship of medical resources

Table 1.  High Value Care Framework: Steps Toward High Value Care Step 1: Understand the benefits, harms, and relative costs of the interventions that you are considering. Step 2: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful. Step 3: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative effectiveness and cost-effectiveness data). Step 4: Customize a care plan with patients that incorporates their values and addresses their concerns. Step 5: Identify system-level opportunities to improve outcomes, minimize harms, and reduce health care waste. Reprinted with permission from Smith CD; Alliance for Academic Internal Medicine– American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum. Ann Intern Med. 2012 Aug 21;157(4):284-6. [PMID: 22777503]

by asking societies to create evidence-based lists of tests and procedures whose necessity should be questioned. The Choosing Wisely lists and accompanying patient educational information are available at www.choosingwisely.org. Key Point

• High value care is care that balances the clinical benefit of a given medical intervention with its harms and costs, with the goal of improving patient outcomes.

Interpretation of the Medical Literature Introduction Physicians must be familiar with an ever-expanding knowledge base that is founded on published research. Consequently, physicians must understand the basic principles of research to be able to independently interpret the literature, remain current in their medical knowledge, and apply the results of studies to provide high value care for their patients.

Study Designs Many research study designs exist, and it is important to recognize the strengths and weaknesses of each and the appropriate application of information derived from these studies to clinical situations. 1

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Interpretation of the Medical Literature

Experimental Studies CONT.

In an experimental study, subjects and interventions are determined at the study outset, and investigators and subjects are often blinded to the intervention to minimize biased outcomes. In the most common type of experimental study, a randomized controlled trial (RCT), subjects are randomly assigned to either an intervention or control group to equally distribute predictive factors and minimize confounding among the groups. Although RCTs are considered the most rigorous study design and have the greatest ability to draw causal inferences, these studies usually involve detailed protocols and patients with a narrow disease spectrum—conditions that are challenging to replicate in ordinary practice settings. Consequently, RCTs often have limited generalizability. A variation of an RCT is a clusterrandomized trial, in which groups (or clusters) of study subjects are randomized to a treatment or control group; this design is helpful in evaluating interventions directed toward specific groups of people instead of individual patients. A less rigorous experimental design is the quasi-experimental study, in which investigators assign patients to intervention and control groups in a nonrandom manner. This type of design is typically used when randomization would be impractical or unethical. The different types of experimental studies and observational studies are compared in Table 2.

Observational Studies An observational study does not employ interventions or patient assignment to groups; alternatively, researchers compare two or more naturally existing groups. Observational studies are often less rigorous than experimental studies, thus reducing the ability to draw causal inferences. Advantages of observational studies include the capacity to utilize natural practice settings and to involve patients with wider ranges of illnesses and exposures. A disadvantage of observational studies is that they are more subject to confounding and bias than experimental studies. Observational designs include cohort studies, casecontrol studies, cross-sectional studies, and case series. A cohort study investigates the outcomes of groups (cohorts) with or without certain exposures or treatments. An example is a study that examines the rates of type 2 diabetes mellitus among patients with high socioeconomic status versus patients with low socioeconomic status. In prospective cohort studies, patients are observed for outcomes going forward in time, whereas retrospective cohort studies look at patients’ histories, often after an outcome has occurred. Prospective cohort studies are more rigorous than retrospective cohort studies because they reduce bias by selecting patients and statistical methods a priori. The standard outcome measure for a cohort study is relative risk. A case-control study, which is usually retrospective, compares the outcomes of patients with a disease (cases) to those without a disease (controls). For instance, patients with and without type 2 diabetes could be compared with respect to exposure to high-calorie, fast-food diets. Case-control studies

can be particularly valuable in the study of rare diseases. To reduce bias in case-control studies, investigators carefully match selected cases to controls in terms of demographic and prognostic factors. Additionally, investigators often increase statistical power by recruiting more controls than cases. For casecontrol studies, the standard estimate of risk is the odds ratio. Cross-sectional studies examine associations between diseases and exposures within a group of patients at one point in time. This study design is most commonly used to determine disease prevalence and infer causation. Survey studies are generally cross-sectional studies. Case series include only patients with the condition of interest. These patients are evaluated, either prospectively or retrospectively, to identify exposures or outcomes. Cross-sectional and case series designs are limited, based on the absence of control groups.

Systematic Reviews Systematic reviews provide a comprehensive summary, synthesis, and analysis of the literature that pertains to a focused research question. Systematic reviews involve exhaustive literature searches, systematic data abstraction, multiple reviewers, and a narrative summary regarding the strengths and limitations of the analysis. Systematic reviews minimize error by combining results from many studies. They may also include meta-analysis, which involves the statistical analysis of pooled data from the studies identified in a systematic review meeting certain predefined criteria for adequacy. The purpose of meta-analysis is to draw conclusions using a greater amount of data than is available in each of the individual studies. The limitations of systematic reviews and meta-analysis result from variability in the identification and selection of studies and from the inclusion of weak studies. However, a systematic review with meta-analysis that is based on the rigorous selection of numerous, high-quality RCTs could be considered the highest level of evidence. Key Points

• In a randomized controlled trial, subjects are randomly allocated to an intervention or control group, and investigators and subjects are often blinded to the intervention to minimize biased outcomes. • Observational designs include cohort studies, casecontrol studies, cross-sectional studies, and case series; patients are not randomly allocated to an intervention or control group, thus reducing the ability to draw causal inferences. • A systematic review provides a comprehensive summary, synthesis, and analysis of the literature that pertains to a focused research question and may or may not include meta-analysis; systematic reviews minimize errors by combining results from many studies but may be limited by variability in the identification and selection of studies and from the inclusion of weak studies.

2

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Routine Care of the Healthy Patient

number needed to treat (NNT), and if detrimental, the number needed to harm (NNH). Numbers needed are useful indicators of the clinical impact of an intervention because they provide a sense of magnitude expected from the intervention. Numbers needed are calculated by taking the reciprocal of the change in absolute risk. For example, for the two interventions previously discussed, the NNT in the first case is 5 (1/0.2) and in the second case 50 (1/0.02) (see Table 4). Key Points

• Confidence intervals provide more information than P values because they reveal the plausible range of an event, allowing clinical significance to be estimated. • Statistical significance does not equal clinical importance, especially for large studies with uncommon outcomes.

HVC

• Relative risk comparisons tend to exaggerate outcomes relative to absolute risk measures; whenever possible, absolute risk should be used when explaining risk to patients.

HVC

• Numbers needed are estimates of the number of patients who must receive an intervention to cause one patient to experience the outcome being studied; numbers needed are useful indicators of the clinical impact of an intervention by providing a sense of magnitude of benefit/harm expected from the intervention.

HVC

Levels of Evidence and Recommendations F i g u r e 1 . Nomogram for interpreting diagnostic test results. In this nomogram, a straight line drawn from a patient’s pretest probability of disease (which is estimated from experience, local data, or published literature) through the likelihood ratio for the test result will point to the posttest probability of disease. Reprinted with permission from Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975 Jul 31;293(5):257. [PMID: 1143310] Copyright 1975, Massachusetts Medical Society.

CONT.

rates of events, such as death or complications, in two study groups using measures that include relative risk, odds ratios, and hazard ratios (Table 4). Absolute comparisons, on the other hand, represent absolute (that is, total) differences in outcomes between two groups. A disadvantage of relative comparisons is the potential for exaggerated outcomes, especially if the outcomes are uncommon. For instance, interventions that reduce the rate of a disease from 40% to 20% and 4% to 2% each have a relative risk reduction of 50%. However, the absolute risk reduction (ARR) for the first case is 20%, whereas the ARR for the second case is 2%.

Numbers Needed Numbers needed are estimates of the number of patients who must receive an intervention to cause one patient to experience the outcome being studied; if beneficial, it is termed the

Physicians make clinical decisions about patients by interpreting evidence from the published literature; however, not all evidence is developed with the same rigor. Therefore, the U.S. Preventive Services Task Force has identified levels of evidence that reflect the rigor of methods used in a study (Table 5). Additionally, grades of recommendations for providing a clinical service were created by balancing the level of evidence with the risk versus benefit of the service (Table 6).

Routine Care of the Healthy Patient History and Physical Examination Periodic Health Examination Although the periodic health examination has been associated with increased delivery of preventive services, multiple studies have failed to show a beneficial effect of the periodic health examination on morbidity or mortality; however, many of these trials were older, limited in scope, and assessed out-of-date interventions. Many physicians argue that the periodic health examination builds physician-patient relationships, which may promote improved adherence to physician recommendations.

6

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This self-assessment test contains one-best-answer multiple-choice questions. Please read these directions carefully before answering the questions. Answers, critiques, and bibliographies immediately follow these multiple-choice questions. The American College of Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Self-Assessment Test

General Internal Medicine Self-Assessment Test

The American College of Physicians designates MKSAP 17 General Internal Medicine for a maximum of 26 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Earn “Instantaneous” CME Credits Online Print subscribers can enter their answers online to earn CME credits instantaneously. You can submit your answers using online answer sheets that are provided at mksap.acponline.org, where a record of your MKSAP 17 credits will be available. To earn CME credits, you need to answer all of the questions in a test and earn a score of at least 50% correct (number of correct answers divided by the total number of questions). Take any of the following approaches: ➢ Use the printed answer sheet at the back of this book to record your answers. Go to mksap.acponline.org, access the appropriate online answer sheet, transcribe your answers, and submit your test for instantaneous CME credits. There is no additional fee for this service. ➢ Go to mksap.acponline.org, access the appropriate online answer sheet, directly enter your answers, and submit your test for instantaneous CME credits. There is no additional fee for this service. ➢ Pay a $15 processing fee per answer sheet and submit the printed answer sheet at the back of this book by mail or fax, as instructed on the answer sheet. Make sure you calculate your score and fax the answer sheet to 215-351-2799 or mail the answer sheet to Member and Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572, using the courtesy envelope provided in your MKSAP 17 slipcase. You will need your 10-digit order number and 8-digit ACP ID number, which are printed on your packing slip. Please allow 4 to 6 weeks for your score report to be emailed back to you. Be sure to include your email address for a response. If you do not have a 10-digit order number and 8-digit ACP ID number or if you need help creating a username and password to access the MKSAP 17 online answer sheets, go to mksap.acponline.org or email custserv@acponline.org. CME credit is available from the publication date of December 31, 2015, until December 31, 2018. You may submit your answer sheets at any time during this period.

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Each of the numbered items is followed by lettered answers. Select the ONE lettered answer that is BEST in each case.

Item 1 A 58-year-old woman is evaluated during a routine examination. She is asymptomatic. Medical history is unremarkable. She smoked cigarettes socially in her 20s but is currently a nonsmoker. Family history is significant for her mother who had a hip fracture in her 70s and two cousins who have hypothyroidism. She takes no medications. On physical examination, temperature is normal, blood pressure is 118/72 mm Hg, and pulse rate is 72/min. BMI is 24. The remainder of the physical examination is normal. A lipid panel and fasting plasma glucose level obtained 1 year ago were normal. Pap smear and human papillomavirus testing performed 3 years ago were negative. Her Fracture Risk Assessment Tool (FRAX) score indicates a 13% risk for major osteoporotic fracture over the next 10 years. Which of the following is the most appropriate screening test for this patient? (A) (B) (C) (D) (E)

Dual-energy x-ray absorptiometry scan Fasting lipid panel Fasting plasma glucose level Pap smear Thyroid-stimulating hormone level

Item 2 A 38-year-old woman is evaluated during a routine examination. She is a mother of two children and works full time at a high-stress job. She smokes 10 cigarettes daily, eats fast food three times per week, and drinks two alcoholic beverages most nights. She does not exercise. Family history is noncontributory. She takes no medications. On physical examination, the patient is afebrile, blood pressure is 122/76 mm Hg, and pulse rate is 80/min. BMI is 26. The remainder of the physical examination is normal.

She had a similar episode several years ago. Medical history is remarkable for osteoporosis. Her medications are alendronate, calcium, and vitamin D. On physical examination, the patient is afebrile, blood pressure is 137/84 mm Hg and pulse rate is 78/min without orthostasis, and respiration rate is 13/min. BMI is 25. Tympanic membranes, external auditory canals, and gross auditory acuity are normal. Cardiopulmonary and neurologic examinations are normal. The Dix-Hallpike maneuver results in mild vertigo with nausea, and after 10 seconds, there are five beats of upbeat nystagmus with a rotatory component with the upper pole of the eyes beating toward the lower ear. The nystagmus lasts for 10 seconds and then abates. Which of the following is the most appropriate next step in management? (A) Diazepam (B) Epley maneuver (C) Meclizine (D) Vestibular rehabilitation therapy

Item 4 A 52-year-old woman is seen for preoperative evaluation for open total abdominal hysterectomy. She is an active smoker with a 30-pack-year smoking history but no cough, dyspnea, or chest pain. She reports no daytime fatigue and has never been told she snores or stops breathing in her sleep. She exercises by running for 2 miles on a treadmill every other day. She takes no medications. On physical examination, respiration rate is 14/min. Oxygen saturation on pulse oximetry is 98% with the patient breathing ambient air. BMI is 28. Cardiovascular examination is normal. Lungs are clear to auscultation and percussion. There is no clubbing or cyanosis of the digits.

Which of the following interventions will have the largest impact on this patient’s health?

In addition to smoking cessation counseling, which of the following is the most appropriate diagnostic test to perform next?

(A) (B) (C) (D) (E)

(A) Chest radiography (B) Chest radiography and spirometry (C) Chest radiography, spirometry, and arterial blood gas analysis (D) No further diagnostic tests

Decrease alcohol consumption Exercise 30 minutes daily, 5 days per week Healthful diet including fruits and vegetables Smoking cessation Stress management and relaxation techniques

Self-Assessment Test

Directions

Item 3

Item 5

A 62-year-old woman is evaluated for a 4-hour episode of dizziness. Upon arising from bed in the morning, she noted the abrupt onset of a spinning sensation and imbalance. She has moderate nausea but no vomiting. Symptoms are markedly accentuated when she positions her head backward or forward, such as when bending down to tie her shoe. She reports no dysarthria, diplopia, dysphagia, weakness, numbness, tinnitus, headache, recent head trauma, otalgia, or recent upper respiratory tract infection.

A 42-year-old woman is evaluated for a 6-day history of right elbow pain that started after lifting a heavy box. The pain is often worse at night and sometimes radiates to the wrist. Her medical and family histories are unremarkable. Her only medication is ibuprofen as needed for the elbow pain, and she has no allergies. On physical examination, vital signs are normal. There is tenderness over the right lateral epicondyle, but there is normal elbow range of motion and no elbow swelling. 155

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Item 1

Answer:

A

Educational Objective: Screen for osteoporosis in a patient with risk factors. This patient should be screened for osteoporosis with dual-energy x-ray absorptiometry (DEXA). The U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis by measurement of bone mineral density in women aged 65 years and older and in younger women who have a fracture risk equal to or higher than a 65-yearold white woman (9.3%). The Fracture Risk Assessment Tool (FRAX) (available at www.shef.ac.uk/FRAX/) can be used to determine if the 10-year fracture risk for younger women is greater than or equal to 9.3%. Risk factors that can increase the FRAX score include a first-degree relative with a history of hip fracture, alcohol abuse, smoking, low body mass, and glucocorticoid use. Although this patient is younger than 65 years, her parental history of hip fracture increases her risk of fracture to 13%; therefore, she should be screened for osteoporosis using DEXA. The USPSTF suggests screening for lipid disorders every 5 years in all men 35 years of age and older and all women 45 years of age and older who are at increased risk of coronary heart disease. This interval should be tailored to individual risk. Since this patient’s lipid panel was normal when tested last year, screening in this patient would not be appropriate. Although the optimal screening interval for diabetes mellitus is unknown, the American Diabetes Association recommends screening for diabetes every 3 years in adults 45 years and older and adults younger than 45 years with a BMI of 25 or higher and one risk factor for diabetes. In 2008, the USPSTF recommended screening for type 2 diabetes only in asymptomatic adults with sustained blood pressure higher than 135/80 mm Hg. An updated draft guideline, issued in October 2014, recommends screening for abnormal blood glucose and type 2 diabetes in adults with risk factors, including age 45 years or older, obesity or overweight, first-degree relative with diabetes, history of gestational diabetes or polycystic ovary syndrome, and certain high-risk ethnic backgrounds (African Americans, American Indians/Alaska Natives, Asian Americans, Hispanics/Latinos, and Native Hawaiians/Pacific Islanders). This patient was screened for diabetes last year, and therefore, she does not need to be screened again now. A combination of cytology (Pap smear) and human papillomavirus (HPV) testing can be performed every 5 years in women aged 30 to 65 years to screen for cervical cancer. Screening with a Pap smear alone every 3 years is also acceptable. This patient had a normal Pap smear and HPV test 3 years ago. The USPSTF concludes that there is insufficient evidence to recommend for or against screening for thyroid

disease. The American College of Physicians recommends screening women over age 50 years who have at least one symptom that can be attributed to thyroid disease. The American Thyroid Association and the American Association of Clinical Endocrinologists recommend measuring thyroid-stimulating hormone (TSH) level in individuals with risk factors for hypothyroidism (for example, personal history of autoimmune disease, neck radiation, or thyroid surgery) and consideration of TSH testing in adults age 60 years and older. This patient does not have any symptoms of thyroid disease and therefore should not be screened. Key Point

• Women aged 65 years and older and younger women who have a fracture risk of 9.3% or higher should be screened for osteoporosis.

Answers and Critiques

Answers and Critiques

Bibliography U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2011 Mar 1;154(5):356-64. [PMID: 21242341]

Item 2

Answer:

D

Educational Objective: Identify the relatively large impact of smoking cessation on improving health. This patient would most benefit from smoking cessation counseling. Cigarette smoking increases the risk of cancer, heart disease, stroke, and lung disease and is the leading preventable cause of death in the United States. Quitting smoking is the single most important thing that smokers can do to improve their quality and quantity of life. Smoking cessation before age 40 years reduces the risk of death associated with continued tobacco use by approximately 90%. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users. Behavioral counseling for smoking cessation in primary care settings has been found to improve quit rates and sustained abstinence at 1 year. Even minimal in-office interventions, defined as less than 3 minutes in duration, are effective in improving smoking cessation rates. A meta-analysis suggested that women who consume an average of two or more alcoholic drinks per day had an increased mortality rate compared with nondrinkers; therefore, this patient may benefit from counseling regarding reducing her alcohol consumption. Nonetheless, the benefit of brief intervention for smoking cessation is still likely to be more impactful in this patient. Exercising and eating a healthful diet both have a significantly positive impact on health and have been strongly linked with decreased incidence of cardiovascular disease. 195

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Answers and Critiques

However, the effect of behavioral counseling in promoting healthful diet and physical activity in adults without known cardiovascular disease, hypertension, hyperlipidemia, or diabetes is small. Given small potential effect, time limitations, and opportunity costs, the USPSTF recommends offering dietary and exercise behavioral counseling based only on individual patient circumstances. In this patient, smoking cessation counseling will have a greater benefit than counseling that promotes a healthful diet and physical activity. Stress reduction and relaxation techniques have the potential to improve this patient’s health; however, the health benefits of smoking cessation are likely to be greater.

Answers and Critiques

Key Point

• The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users.

pressants (such as diazepam), and antiemetics, may help symptoms transiently but, in general, is ineffective for longterm management or cure. Vestibular rehabilitation therapy, when delivered by trained physical or occupational therapists, is beneficial in patients with peripheral vertigo, particularly those with recurrent or refractory symptoms; however, the initial management of this patient presenting with BPPV is to perform the Epley maneuver. Key Point

• Benign paroxysmal positional vertigo can be effectively treated with the Epley maneuver, which is performed to reposition otoliths from the semicircular canal into the vestibule of the ear.

Bibliography Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20;370(12):1138-47. [PMID: 24645946]

Bibliography Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013 Jan 24;368(4):341-50. [PMID: 23343063]

Item 3

Answer:

B

Educational Objective: Treat a patient with benign paroxysmal positional vertigo. The Epley maneuver should be performed in this patient presenting with symptoms of benign paroxysmal positional vertigo (BPPV). In patients with vertigo, the Dix-Hallpike maneuver can assist in distinguishing peripheral from central causes. In peripheral vertigo, the maneuver will result in nystagmus that begins after a brief period of latency (2-40 seconds) and lasts less than 1 minute. With repeated trials, the nystagmus may not be further provoked. In vertigo of central origin, the nystagmus is not associated with latency, typically lasts longer than 1 minute, and does not fatigue with repeated trials. BPPV is the most common cause of vertigo and is attributed to debris (canalithiasis), usually in the posterior semicircular canal, perturbing labyrinthine sensory receptors and resulting in the erroneous perception of angular head acceleration. BPPV is characterized by abrupt episodes of vertigo that last less than 1 minute and is provoked by a sudden change in head position. The Epley maneuver, which is performed to reposition otoliths from the semicircular canal into the vestibule, can be curative in patients with BPPV. The maneuver involves sequentially positioning the patient to encourage movement of the otoliths, and modified versions of the procedure allow patients to perform the maneuver themselves for recurrent episodes. A meta-analysis demonstrated that patients with BPPV who were treated with the Epley maneuver had significantly higher rates of improvement in symptoms compared with those who received sham treatment (odds ratio [OR] 4.4; 95% CI, 2.6-7.2). Pharmacologic therapy for BPPV, including centrally acting antihistamines (such as meclizine), vestibular sup-

Item 4

Answer:

D

Educational Objective: Evaluate pulmonary risk in a preoperative patient. No further diagnostic studies are needed for this asymptomatic patient scheduled for surgery. For patients with no history of cardiopulmonary disease and no cardiac or respiratory symptoms, preoperative pulmonary diagnostic testing is not beneficial. Moreover, these studies add considerable cost and potential risk (for example, radiation exposure with chest radiography). Although smoking is a risk factor for postoperative pulmonary complications, a history of smoking without other evidence of disease is not an indication for chest radiography, spirometry, or arterial blood gas analysis in the general or preoperative setting. Several studies have demonstrated that these studies do not offer improved prognostic value beyond clinical assessment alone and rarely alter management. Chest radiography may be considered in patients with known cardiopulmonary disease or symptoms. Spirometry assessment is frequently done prior to cardiothoracic surgery, but its value is limited for other types of surgery. For nonthoracic surgery, spirometry should be performed for the same reasons as in a nonoperative situation (for example, evaluation of dyspnea or hypoxia). Similarly, preoperative arterial blood gas analysis may identify hypercapnia in patients at risk for carbon dioxide retention, but studies have not shown an incremental diagnostic benefit with this testing. Key Point

• For patients with no history of cardiopulmonary disease and no cardiac or respiratory symptoms, preoperative pulmonary diagnostic testing is not beneficial.

Bibliography Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays. Can J Anaesth. 2005 Jun-Jul;52(6):568-74. [PMID: 15983140]

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MKSAP 17 - General Internal Medicine  

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