Medical Knowledge Self-Assessment ProgramÂŽ
General Internal Medicine
36 AMA PRA Category 1 Credits™ available until December 31, 2021.
Welcome to the General Internal Medicine Section of MKSAP 18! In these pages, you will find updated information on routine care of the healthy patient; patient safety and quality improvement; professionalism and ethics; palliative medicine; common symptoms, including chronic pain, medically unexplained symptoms, dyspnea, cough, fatigue, dizziness, syncope, insomnia, and lower extremity edema; musculoskeletal pain; dyslipidemia; obesity; men’s and women’s health; eye disorders; ear, nose, mouth, and throat disorders; mental and behavioral health; geriatric medicine; perioperative medicine; and other clinical challenges. All of these topics are uniquely focused on the needs of generalists and subspecialists in internal medicine. The core content of MKSAP 18 has been developed as in previous editions—all essential information that is newly researched and written in 11 topic areas of internal medicine—created by dozens of leading generalists and subspecialists and guided by certification and recertification requirements, emerging knowledge in the field, and user feedback. MKSAP 18 also contains 1200 all-new peer-reviewed, psychometrically validated, multiple-choice questions (MCQs) for self-assessment and study, including 168 in General Internal Medicine. MKSAP 18 continues to include High Value Care (HVC) recommendations, based on the concept of balancing clinical benefit with costs and harms, with associated MCQs illustrating these principles and HVC Key Points called out in the text. Internists practicing in the hospital setting can easily find comprehensive Hospitalistfocused content and MCQs, specially designated in blue and with the symbol. If you purchased MKSAP 18 Complete, you also have access to MKSAP 18 Digital, with additional tools allowing you to customize your learning experience. MKSAP Digital includes regular text updates with new, practice-changing information, 200 new self-assessment questions, and enhanced custom-quiz options. MKSAP Complete also includes more than 1200 electronic, adaptive learning–enhanced flashcards for quick review of important concepts, as well as an updated and enhanced version of Virtual Dx, MKSAP’s image-based self-assessment tool. As before, MKSAP 18 Digital is optimized for use on your mobile devices, with iOS- and Android-based apps allowing you to sync between your apps and online account and submit for CME credits and MOC points online. Please visit us at the MKSAP Resource Site (mksap.acponline.org) to find out how we can help you study, earn CME credit and MOC points, and stay up to date. On behalf of the many internists who have offered their time and expertise to create the content for MKSAP 18 and the editorial staff who work to bring this material to you in the best possible way, we are honored that you have chosen to use MKSAP 18 and appreciate any feedback about the program you may have. Please feel free to send any comments to mksap_editors@ acponline.org. Sincerely,
Patrick C. Alguire, MD, FACP Editor-in-Chief Senior Vice President Emeritus Medical Education Division American College of Physicians
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Table of Contents High Value Care in Internal Medicine . . . . . . . . . . . . . . . 1 Interpretation of the Medical Literature Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Study Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Experimental Study Designs . . . . . . . . . . . . . . . . . . . . 2 Observational Study Designs. . . . . . . . . . . . . . . . . . . . 3 Systematic Reviews and Meta-Analysis. . . . . . . . . . . 3 Validity of a Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Statistical Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Sensitivity, Specificity, and Predictive Values. . . . . . . 4 Likelihood Ratios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Absolute and Relative Risk Reduction . . . . . . . . . . . . 4 Numbers Needed to Treat and Harm . . . . . . . . . . . . 6 Levels of Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . . . 10 Genetics and Genetic Testing. . . . . . . . . . . . . . . . . . . . . . . 17 Taking a Family History. . . . . . . . . . . . . . . . . . . . . . . 17 Genetic Tests and Testing Strategies . . . . . . . . . . . . . 17 Immunization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Vaccinations Recommended for All Adults . . . . . . . 19 Vaccinations Recommended for Some Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Vaccinations Recommended for Specific Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Aspirin as Primary Prevention . . . . . . . . . . . . . . . . . . . . . 23 Healthy Lifestyle Counseling. . . . . . . . . . . . . . . . . . . . . . . 24 Behavioral Counseling . . . . . . . . . . . . . . . . . . . . . . . . 24 Diet and Physical Activity. . . . . . . . . . . . . . . . . . . . . . 24 Supplements and Herbal Therapies . . . . . . . . . . . . . . . . . 25
Patient Safety and Quality Improvement Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Patient Safety and Quality Issues at the Clinician Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Diagnostic Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Medication Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Transitions of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Patient Safety and Quality Issues at the Systems Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Quality Improvement Models . . . . . . . . . . . . . . . . . . 29 Measurement of Quality Improvement . . . . . . . . . . . . . 30 Patient Safety and Quality Improvement Initiatives. . . 30 Patient-Centered Medical Home. . . . . . . . . . . . . . . 30 High Value Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Choosing Wisely . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 National Patient Safety Goals. . . . . . . . . . . . . . . . . . . 31 Health Information Technology and Patient Safety. . . . . 31 Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Professionalism and Ethics Professionalism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Primacy of Patient Welfare. . . . . . . . . . . . . . . . . . . . . . . . . 31 Appropriate Patient Relationships. . . . . . . . . . . . . . . 32 Challenging Physician-Patient Relationships. . . . . . 34 Requests for Interventions. . . . . . . . . . . . . . . . . . . . . 34 Conflicts of Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Respecting Patient Autonomy. . . . . . . . . . . . . . . . . . . . . . 35 Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Informed Consent and Refusal . . . . . . . . . . . . . . . . . 35 Advance Care Planning. . . . . . . . . . . . . . . . . . . . . . . . 35 Decision-Making Capacity. . . . . . . . . . . . . . . . . . . . 36 Surrogate Decision Making . . . . . . . . . . . . . . . . . . . . 37 Withholding or Withdrawing Treatment. . . . . . . . . 37 Physician-Assisted Suicide. . . . . . . . . . . . . . . . . . . . . 37 Justice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Medical Error Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Colleague Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Approaching Ethical Dilemmas. . . . . . . . . . . . . . . . . . . . . 38 Providing Care as a Physician Bystander . . . . . . . . . . . . . 38
Palliative Medicine Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Communicating with Patients with Serious Illness . . . 39 Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Nausea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Other Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ix
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Common Symptoms Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Chronic Noncancer Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 43 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Medically Unexplained Symptoms. . . . . . . . . . . . . . . . . . 47 Clinical Presentation and Evaluation . . . . . . . . . . . 48 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Dyspnea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Acute Cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Subacute and Chronic Cough . . . . . . . . . . . . . . . . . . 51 Cough in the Immunocompromised Patient. . . . . . 53 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Fatigue and Systemic Exertion Intolerance Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Approach to the Patient with Dizziness. . . . . . . . . . 55 Vertigo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Presyncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Disequilibrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Persistent Postural-Perceptual Dizziness . . . . . . . . 59 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Risk Stratification and Decision for Hospital Admission. . . . . . . . . . . . . . . . . . . . . . . . 61 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Lower Extremity Edema. . . . . . . . . . . . . . . . . . . . . . . . . . 63 Chronic Venous Insufficiency . . . . . . . . . . . . . . . . . 64 Common In-Flight Emergencies. . . . . . . . . . . . . . . . . . . 65
Musculoskeletal Pain Low Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Diagnosis and Evaluation. . . . . . . . . . . . . . . . . . . . . . 67 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Neck Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Diagnosis and Evaluation. . . . . . . . . . . . . . . . . . . . . 69 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Upper Extremity Disorders . . . . . . . . . . . . . . . . . . . . . . . . 71 Thoracic Outlet Syndrome. . . . . . . . . . . . . . . . . . . . . 71 Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Elbow Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Wrist and Hand Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 73 Lower Extremity Disorders . . . . . . . . . . . . . . . . . . . . . . . . 74 Hip Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Knee Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Ankle and Foot Pain. . . . . . . . . . . . . . . . . . . . . . . . . . 78
Dyslipidemia Evaluation of Lipid Levels. . . . . . . . . . . . . . . . . . . . . . . . . 79 LDL Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Triglycerides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 HDL Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Management of Dyslipidemia . . . . . . . . . . . . . . . . . . . . . 80 Therapeutic Lifestyle Changes. . . . . . . . . . . . . . . . . 80 Drug Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Management of Hypertriglyceridemia . . . . . . . . . . . 82 Management of Dyslipidemia in Special Populations . . . . . . . . . . . . . . . . . . . . . . . . 83 Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Epidemiology and Pathophysiology . . . . . . . . . . . . 84 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Obesity Definition and Epidemiology. . . . . . . . . . . . . . . . . . . . . . 84 Screening and Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 84 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Lifestyle Modification. . . . . . . . . . . . . . . . . . . . . . . . . 85 Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . 86 Bariatric Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Men’s Health Male Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 89 Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 89 Premature Ejaculation . . . . . . . . . . . . . . . . . . . . . . . 90 Decreased Libido. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Androgen Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Benign Prostatic Hyperplasia. . . . . . . . . . . . . . . . . . . . . . . 92 Acute Testicular and Scrotal Pain . . . . . . . . . . . . . . . . . . 94 Hydrocele, Varicocele, and Epididymal Cyst . . . . . . . . . 94 Acute and Chronic Prostatitis and Pelvic Pain. . . . . . . . 94 Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Women’s Health Breast Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Breast Mass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Breast Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Reproductive Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Preconception Care. . . . . . . . . . . . . . . . . . . . . . . . . . 99
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Menstrual Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Abnormal Uterine Bleeding. . . . . . . . . . . . . . . . . . . 101 Dysmenorrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Menopause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Chronic Pelvic Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Female Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . 104 Vaginitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Bacterial Vaginosis. . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Vulvovaginal Candidiasis . . . . . . . . . . . . . . . . . . . . . 106 Trichomoniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Eye Disorders Eye Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Red Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Keratitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Episcleritis and Scleritis. . . . . . . . . . . . . . . . . . . . . . 109 Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Subconjunctival Hemorrhage . . . . . . . . . . . . . . . . . 109 Blepharitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Dry Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Corneal Abrasion and Ulcer. . . . . . . . . . . . . . . . . . . . . . . 110 Cataracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Primary Open-Angle Glaucoma . . . . . . . . . . . . . . . 110 Angle-Closure Glaucoma. . . . . . . . . . . . . . . . . . . . . 110 Age-Related Macular Degeneration. . . . . . . . . . . . . . . . 110 Optic Neuritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Retinal Vascular Occlusion . . . . . . . . . . . . . . . . . . . . . . . 111 Retinal Artery Occlusion . . . . . . . . . . . . . . . . . . . . . 111 Retinal Vein Occlusion. . . . . . . . . . . . . . . . . . . . . . . 111
Ear, Nose, Mouth, and Throat Disorders Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Tinnitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Otitis Media and Otitis Externa. . . . . . . . . . . . . . . . . . . . 113 Cerumen Impaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Upper Respiratory Tract Infection. . . . . . . . . . . . . . . . . . 114 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Rhinitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Epistaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Oral Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Oral Infection and Ulcers. . . . . . . . . . . . . . . . . . . . . 115 Dental Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
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 Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . Tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personality Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . Somatic Symptom and Related Disorders . . . . . . . . . . . Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Complications. . . . . . . . . . . . . . . . . . . . . . . Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116 116 118 119 119 119 120 120 120 120 120 121 122 125 125 125 126 126 126 126 126 127
Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . 128 Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . . 128
Geriatric Medicine Comprehensive Geriatric Assessment . . . . . . . . . . . . . . 128 Functional Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Cognitive Function . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Fall Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Assessment of the Older Driver. . . . . . . . . . . . . . . . 130 Screening for Mistreatment. . . . . . . . . . . . . . . . . . . 131 Frailty Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Levels of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Polypharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Pressure Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
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Perioperative Medicine General Recommendations. . . . . . . . . . . . . . . . . . . . . . . Preoperative Laboratory Testing . . . . . . . . . . . . . . . Perioperative Medication Management . . . . . . . . . Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiovascular Perioperative Management. . . . . . . . . . Cardiovascular Risk Assessment. . . . . . . . . . . . . . . Cardiovascular Risk Management. . . . . . . . . . . . . . Pulmonary Perioperative Management . . . . . . . . . . . . . Pulmonary Risk Assessment. . . . . . . . . . . . . . . . . . Assessment of Underlying Lung Disease . . . . . . . . Perioperative Risk-Reduction Strategies. . . . . . . . . Hematologic Perioperative Management. . . . . . . . . . . . Venous Thromboembolism Prophylaxis. . . . . . . . . Perioperative Management of Anticoagulant Therapy. . . . . . . . . . . . . . . . . . . . . Perioperative Management of Antiplatelet Medications. . . . . . . . . . . . . . . . . . . . . Perioperative Management of Anemia, Coagulopathies, and Thrombocytopenia. . . . . . . .
137 137 137 137 139 139 141 142 142 142 143 143 143 143
Perioperative Management of Endocrine Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Thyroid Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Adrenal Insufficiency. . . . . . . . . . . . . . . . . . . . . . . . 148 Perioperative Management of Kidney Disease. . . . . . . . 149 Perioperative Management of Liver Disease. . . . . . . . . . 149 Perioperative Management of Neurologic Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Perioperative Management of the Pregnant Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Self-Assessment Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
147 147
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
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General Internal Medicine High Value Care in Internal Medicine Although the United States spends more on health care than all other developed nations, it has higher rates of medical care– related mortality and shorter life expectancy. Compared with other high-income countries, patients in the United States pay more for prescription drugs, undergo more diagnostic tests, and pay the highest hospital and physician prices for procedures. In response to this unsustainable spending, health policy organizations and other expert groups advocate implementing a high value approach to patient care. High value care is individualized care that delivers proven benefits while minimizing risks and unnecessary costs. It requires a careful evaluation to determine whether the benefits of a diagnostic test or intervention justify the harms and costs. Importantly, when determining value, clinicians should consider the benefits of a test or intervention before the cost. Focusing primarily on cost increases the tendency to avoid an expensive test or intervention regardless of outcome or to continue a low-cost intervention that provides no benefit. Notably, some costly or risky tests and interventions, such as screening colonoscopy, are high value because their benefits may be substantial. Similarly, some inexpensive and low-risk tests and interventions, such as routine daily laboratory testing in hospitalized patients, represent low value care. Examples of high value and low value care are provided in Table 1. Shared decision making is essential to high value care, particularly because perceived patient demand is one driver of inappropriate testing and interventions. Including patients in the decision-making process provides opportunities to educate patients on balancing benefits with potential harms and costs and to incorporate their values and preferences into the care process. Resources to help clinicians determine the value of common tests and interventions are available from the American College of Physicians (https://www.acponline.org/clinicalinformation/high-value-care), Alliance for Academic Internal Medicine, and Society of Hospital Medicine. In addition, the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation with medical specialty societies, has published specialty-specific lists of commonly used tests or procedures whose necessity should be questioned and discussed by clinicians and patients (www.choosingwisely.org). Consumer Reports works with many of the Choosing Wisely partners to develop patientfriendly materials from the lists of recommendations and to
Table 1. Examples of High Value and Low Value Care Interventions Intervention
Cost
Benefit
High-sensitivity D-dimer testing to exclude venous thromboembolism in patients with low likelihood of disease
Low
High negative predictive value
Influenza vaccination
Low
High benefit for reducing disease burden and complications
Antibiotic therapy in patients with upper respiratory tract infection
Low
No benefit for reducing duration or severity of illness
Carotid ultrasonography in patients with syncope
Intermediate
Low diagnostic value
Imaging studies in patients with low back pain in the absence of “red flag” findings (fever, involuntary weight loss, incontinence)
Intermediate
Low diagnostic value
High Value Care
Low Value Care
disseminate them to consumers through a network of Choosing Wisely consumer partners. Key Point
HVC
• High value care is individualized care that delivers proven benefits while minimizing risks and unnecessary costs.
Interpretation of the Medical Literature Introduction The science of medicine is constantly evolving, and peerreviewed literature is the primary means of disseminating new medical knowledge. The application of this information to patient-centered medical decision making requires an understanding of different study designs and how to interpret statistical tests for significance. Although research in the basic sciences (including pharmacology and physiology) provides the 1
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Routine Care of the Healthy Patient
mortality due to established disease, such as cardiac rehabilitation after myocardial infarction. Screening is appropriate for common conditions for which (1) early intervention can decrease morbidity and mortality and (2) safe, acceptable, widely available, and reasonably priced screening tests exist. Screening tests must also have adequate sensitivity and specificity to minimize false-positive and false-negative results. The effectiveness of screening tests in reducing morbidity and mortality is evaluated through clinical trials; however, studies of screening tests are problematic and subject to three types of bias. Lead-time bias occurs when early detection artificially leads to an increase in measured survival. The time between early detection and clinical diagnosis is mistakenly counted as survival time; however, only the measured time with diagnosed disease, not survival time, has increased (Figure 2). Using disease-specific mortality rates rather than survival time as the primary outcome in studies of screening tests can help minimize lead-time bias. Length-time bias occurs when screening detects more cases of disease with a prolonged asymptomatic phase than cases of disease with a short asymptomatic phase. Slowly progressive disease is more likely than aggressive disease to be detected with screening, leading to an overestimation of survival benefit in those with screen-detected disease. Overdiagnosis, or finding and treating illness that otherwise would not have become clinically apparent or caused harm in the patient’s lifetime, is an extreme example of length-time bias. Overdiagnosis is an increasingly recognized harm of breast and prostate cancer screening and may also occur with incidental detection of thyroid and kidney
cancers on imaging studies. Selection bias, also referred to as volunteer, referral, or compliance bias, occurs when patients who undergo screening tests are healthier and more interested in their health than nonadherent patients or the general population. Intention-to-treat analyses, in which patients are analyzed according to their original group assignment in randomized clinical trials regardless of intervention received, reduce selection bias.
Screening Recommendations for Adults The USPSTF and many specialty societies routinely aggregate and review available evidence to inform clinical practice guidelines for screening, counseling, and use of preventive medications. The American College of Physicians (ACP) has developed several different types of clinical recommendations, including clinical practice guidelines, clinical guidance statements, best practice advice, and recommendations regarding high value care, all of which are available at https://www. acponline.org/clinical-information/guidelines. Although there is much agreement among screening recommendations, guidelines often disagree when (1) sufficient evidence is lacking and expert opinion plays a larger role or (2) potential benefits and harms both exist and the balance depends on a person’s risk, preferences, and values. An additional resource to help clinicians identify appropriate screening tests and preventive services is the electronic Preventive Services Selector (ePSS) created by the Agency for Healthcare Research and Quality (available at epss.ahrq.gov in web-based or mobile application–based formats). With this tool, users can select USPSTF-recommended practices based
F i g u r e 2 . The effect of early detection (screening) on survival after diagnosis. (A) Screening is not implemented, and the disease takes its normal course. (B) Lead-time bias occurs when survival time appears to be lengthened because the screened patient is diagnosed earlier during the preclinical phase but does not live longer in actuality. (C) Screening effectively detects disease during the asymptomatic phase, and survival time is lengthened.
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Patient Safety and Quality Improvement
determine the magnitude of the effects. The Improve step involves implementation of tools to improve the process. Finally, in the Control phase, future processes are controlled to sustain the gains. Six Sigma may be applied to complex, multistep health care processes, such as the ordering and administration of high-risk medications like chemotherapy, to decrease medication errors.
Operational Excellence As its name suggests, Operational Excellence is a management system that focuses on the consistent and reliable operation of an institutional strategy. It also involves building and sustaining a culture in which each person is empowered and engaged, often by using aspects of Lean, Six Sigma, and other improvement methods. Operational Excellence can be used to improve quality by focusing key performance indicators on quality and safety metrics, such as timely completion of medication reconciliation. Key Points
HVC
• Successful quality improvement programs include a health care delivery system, the objective of meeting the needs and expectations of the patient, a team-based approach, and outcome assessment using both qualitative and quantitative data.
HVC
• The Model for Improvement, Lean, Six Sigma, and Operational Excellence are examples of quality improvement models that can be used in the health care setting.
Measurement of Quality Improvement Multiple organizations and payers now assess quality of care as a condition of accreditation or participation. For example, quality of care and patient safety are important elements in the Joint Commission accreditation process. The Joint Commission assesses a wide variety of quality metrics, such as timely provision of reperfusion therapy in acute myocardial infarction, the incidence of potentially preventable venous thromboembolic disease cases, and rates of immunization. Medicare also has a significant impact on measurement of health care quality. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) includes a new payment structure, the Merit-based Incentive Payment System (MIPS). MIPS consolidates previous quality-based programs and includes elements of the Physicians Quality Reporting System and Meaningful Use programs. More specifically, MIPS includes payment incentives and penalties related to quality and safety, value-based care, improvement activities, and meaningful use of the electronic health record (EHR). Clinicians will be required to report clinical quality metrics, participate in improvement activities (such as the patientcentered medical home), and continue to implement the EHR.
Medicare will adjust reimbursement, with bonuses and penalties based on overall performance, as determined by these measures. For American College of Physicians (ACP) resources on MACRA, see https://www.acponline.org/practice-resources/ business-resources/payment/medicare/macra.
Patient Safety and Quality Improvement Initiatives Patient-Centered Medical Home The patient-centered medical home is a model of providing health care in which the patient’s care is coordinated by a primary provider in a team-based practice. The functions of the patient-centered medical home include providing comprehensive care (including preventive, acute, and chronic care), supporting and partnering with patients to make care patient centered, coordinating care across settings with a specific focus on care transitions, delivering accessible services with extended clinician availability, and engaging in quality and safety improvement programs. Further information about the patient-centered medical home is available from AHRQ (www.pcmh.ahrq.gov/page/defining-pcmh). The concept of the patient-centered medical home has been expanded in the patient-centered medical neighborhood, which includes other clinicians and institutions involved in an individual patient’s care (such as specialists and hospitals).
High Value Care The ACP High Value Care initiative aims to improve health, avoid harms, and eliminate wasteful practices. This initiative addresses high value care broadly, offering learning resources for clinicians and medical educators, curricula, clinical guidelines, best practice advice, case studies, and patient resources on a wide variety of related topics (https://www.acponline. org/clinical-information/high-value-care). Some learning opportunities offer free Continuing Medical Education credits and Maintenance of Certification points. Components of the High Value Care initiative that are evident in MKSAP 18 include the identification of High Value Care key points in the text and a list of high value care recommendations assembled for each MKSAP section.
Choosing Wisely The Choosing Wisely initiative was developed by the American Board of Internal Medicine Foundation in collaboration with Consumer Reports to encourage discussions between clinicians and patients on selecting tests, treatments, and procedures that are evidence based and truly necessary, thereby avoiding unnecessary evaluations and treatments. More than 80 specialist organizations have participated to create lists of overused tests and treatments in their specialties (www.choosingwisely.org/ clinician-lists), and Consumer Reports has generated patient education materials based on these lists to engage and empower patients to participate in care discussions.
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Palliative Medicine
CONT.
or not tolerated, opioids are appropriate, with careful attention paid to dosing, frequency, and side effect profile. Table 30 outlines the most commonly used opioids in the treatment of pain resulting from a serious illness, as well as specific patient population concerns. Short-acting opioids should be titrated to achieve symptom relief. In patients using short-acting opioids who require longer-lasting relief, long-acting agents are appropriate; however, long-acting opioids should not be initiated in opioidnaĂŻve patients. Selection of a long-acting opioid should be based on underlying organ function and previous response to the equivalent short-acting formulation (for example, oxycodone immediate-release and controlled-release forms). Fentanyl patches are commonly used for long-acting pain relief, although they have a more complex pharmacokinetic profile than oral agents and are less easily titrated. Fentanyl patches must be used with caution in patients with a serious illness, especially those who lack adipose tissue or are subject to recurrent infections. Absence of adipose tissue may result in irregular transdermal absorption, whereas fever may cause increased absorption with a greater potential for adverse events. Orally administered transmucosal immediate-release fentanyl (TIRF) products are approved for the treatment of cancer-related pain. TIRF formulations are rapidly absorbed and offer immediate onset for patients who are not achieving adequate analgesia with high-dose morphine. Management of these medications is challenging because the dosing regimen, escalation, and frequency differ among brands. Additionally, clinicians require specialized education and certification (TIRF Risk Evaluation and Mitigation Strategy program) to initiate these medications. Methadone is another long-acting agent used to treat pain from a serious illness; however, its complex
dosing and variable half-life restrict its general use. Owing to their complicated management, TIRF formulations and methadone should be prescribed in collaboration with an expert in pain management or a palliative medicine specialist with experience in their use. Medical cannabis has long been used in the management of symptoms associated with serious illness. It has been studied for numerous clinical indications and is approved in many states for the treatment of cancer symptoms or symptoms associated with other terminal illnesses. Cannabis extracts, predominantly those containing higher concentrations of cannabidiol, have shown a moderate degree of benefit in the treatment of patients with chronic pain and patients with pain symptoms from spasticity in the setting of neurodegenerative disorders. However, given the lack of data on medical cannabis in managing complex cancer pain and the need for multimodal analgesic therapy in seriously ill patients, the role of medical cannabis for this indication remains unclear.
Constipation Constipation is a common symptom in patients with serious illness and negatively affects quality of life. Causes include opioids, dehydration, immobility, metabolic disturbances, and numerous nonopioid medications. More than 90% of patients with cancer who are receiving opioids experience constipation. Patients with constipation in the setting of serious illness should be educated on increasing their intake of fluids and dietary fiber. Patients taking opioids, however, should not receive supplemental fiber, owing to concerns for worsening constipation in the setting of opioid-reduced gastrointestinal motility. Pharmacologic therapy for constipation and for all patients taking scheduled opioids should include a stimulant laxative, such as senna or bisacodyl. Osmotic laxatives, such as
Table 30.  Opioids Commonly Used in Palliative Care Opioid
Protein Binding
Metabolism
Comments
Hydrocodone
Low
Liver enzyme CYP2D6
Variable efficacy; combination with acetaminophen limits use
Liver (glucuronidation)
Better choice if kidney disease is present
Liver enzymes CYP2D6/CYP3A4
Variable time to onset and analgesic efficacy in liver failure
Hydromorphone Tramadol
Low Low/moderate
Increased time to analgesic onset in liver failure Reduce dose and frequency in liver failure/cirrhosis Interactions with other serotonergic medications, potentially leading to serotonin syndrome (agitation, clonus, muscle rigidity, hyperreflexia)
Oxycodone
Moderate/high
Liver enzymes CYP2D6/CYP3A4
Increased half-life and variable onset in liver failure; if used, reduce dose and frequency
Morphine
Moderate/high
Liver (glucuronidation)
Avoid in liver failure/cirrhosis, kidney failure Increased bioavailability with liver failure Increased toxic metabolites with kidney failure
Fentanyl
High
Liver enzyme CYP3A4
Safest long-acting drug in kidney and liver failure Increased bioavailability with liver failure; start lower-dose patch in liver failure
CYP2D6 = cytochrome P-450 2D6; CYP3A4 = cytochrome P-450 3A4.
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Common Symptoms
F i g u r e 6 . Epley canalith-repositioning maneuver for the treatment of benign paroxysmal positional vertigo involving the right posterior semicircular canal. After resolution of the induced nystagmus with the use of the right-sided Dix-Hallpike maneuver (A, B, and C), the head is turned 90 degrees toward the unaffected left side (D), causing the otolithic debris to move closer to the common crus. The induced nystagmus, if present, would be in the same direction as that evoked during the Dix-Hallpike maneuver. The head is then turned another 90 degrees, to a face-down position, and the trunk is turned 90 degrees in the same direction, so that the patient is lying on the unaffected side (E); the otolithic debris migrates in the same direction. The patient is then moved to the sitting position (F), and the otolithic debris falls into the vestibule, through the common crus. Each position should be maintained until the induced nystagmus and vertigo resolve but always for a minimum of 30 seconds. Reproduced with permission from Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1144. [PMID: 24645946] doi:10.1056/NEJMcp1309481. Copyright 2014, Massachusetts Medical Society.
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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 (ACP) 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 18 General Internal Medicine for a maximum of 36 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of the CME activity, which includes participation in the evaluation component, enables the participant to earn up to 36 medical knowledge MOC points in the American Board of Internal Medicine’s Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
Earn Instantaneous CME Credits or MOC Points Online Print subscribers can enter their answers online to earn instantaneous CME credits or MOC points. You can submit your answers using online answer sheets that are provided at mksap.acponline.org, where a record of your MKSAP 18 credits will be available. To earn CME credits or to apply for MOC points, 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). Please note that if you are applying for MOC points, you must also enter your birth date and ABIM candidate number. Take either 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 or MOC points. 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 or MOC points. There is no additional fee for this service.
Earn CME Credits or MOC Points by Mail or Fax Pay a $20 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 enter your birth date and ABIM candidate number, 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 18 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 18 online answer sheets, go to mksap.acponline.org or email custserv@acponline.org. CME credits and MOC points are available from the publication date of December 31, 2018, until December 31, 2021. You may submit your answer sheet or enter your answers online at any time during this period. 157
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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 35-year-old woman is evaluated after laboratory test results showed an elevated LDL cholesterol level during routine screening. Family history is remarkable for myocardial infarction in her father at age 45 years. She takes no medications. On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is unremarkable. Laboratory studies: Alanine aminotransferase Thyroid-stimulating hormone Total cholesterol LDL cholesterol HDL cholesterol Triglycerides
30 U/L Normal 294 mg/dL (7.61 mmol/L) 195 mg/dL (5.05 mmol/L) 55 mg/dL (1.42 mmol/L) 220 mg/dL (2.49 mmol/L)
The patient is instructed in therapeutic lifestyle changes to lower her risk for atherosclerotic cardiovascular disease (ASCVD). According to the American College of Cardiology/American Heart Association cholesterol treatment guideline, which of the following is the most appropriate additional treatment for primary prevention of ASCVD in this patient? (A) Evolocumab (B) High-intensity rosuvastatin (C) Moderate-intensity atorvastatin (D) No additional treatment is necessary
On physical examination, vital signs are normal. The right knee demonstrates bony hypertrophy and crepitus with passive movement. Low-molecular-weight heparin and intermittent pneumatic compression will be initiated and continued during the hospital stay.
Self-Assessment Test
Directions
Which of the following is the recommended duration of low-molecular-weight heparin prophylaxis for this patient? (A) (B) (C) (D) (E)
Total of 10 days Total of 14 days Total of 35 days Until fully ambulatory Until hospital discharge
Item 4 A 67-year-old man is evaluated for a 2-year history of worsening pain in his feet. He describes the pain as long-standing aching and burning. The pain is persistent, sometimes waking him from sleep. Medical history is otherwise significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, insulin aspart, valsartan, aspirin, and simvastatin. On physical examination, vital signs are normal. The feet are insensate to monofilament testing, and vibratory sensation is absent in the feet and ankles. No evidence of skin breakdown is noted. Which of the following is the most appropriate treatment?
Item 2 A 40-year-old woman seeks advice on whether she should undergo breast cancer screening with mammography. Her family history is negative for breast and ovarian cancers, and she has no other risk factors for breast cancer. On physical examination, vital signs and the remainder of the examination are normal. The patient is engaged in a discussion of the potential benefits and harms of initiating mammography now, including the potential for false-positive results and overdiagnosis. After the discussion, she states that she is not overly concerned about her risk for breast cancer but is anxious about the potential harms associated with screening. Which of the following is the most appropriate screening test for this patient? (A) (B) (C) (D)
Breast self-examination Breast tomosynthesis Screening mammography No testing
Item 3 A 49-year-old man is scheduled for total right knee arthroplasty. Medical history is otherwise unremarkable. He takes no medications.
(A) (B) (C) (D) (E)
Oral duloxetine Oral hydromorphone Oral lamotrigine Oral tramadol Topical diclofenac
Item 5 A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care. On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem. 159
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Answers and Critiques Answer:
B
Educational Objective: Treat a patient with an LDL cholesterol level higher than 190 mg/dL (4.92 mmol/L). The most appropriate treatment for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in this patient is high-intensity statin therapy with rosuvastatin or atorvastatin. According to the American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol treatment guideline, patients aged 21 years or older with severe LDL cholesterol elevation (≼190 mg/dL [4.92 mmol/L]) should receive the maximum tolerated statin therapy for primary prevention of ASCVD, regardless of 10-year risk for ASCVD. High-intensity statin therapy is recommended unless there are contraindications to its use. It is reasonable to intensify statin therapy as tolerated to achieve an LDL cholesterol reduction of at least 50%. In contrast to the ACC/ AHA recommendation, the U.S. Preventive Services Task Force recommends initiating low- to moderate-intensity statin therapy in adults aged 40 to 75 years without a history of ASCVD who have one or more ASCVD risk factors (dyslipidemia, diabetes mellitus, hypertension, or smoking) and a calculated 10-year ASCVD event risk of 10% or higher. In the absence of familial hypercholesterolemia, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as alirocumab and evolocumab, are not indicated in primary prevention of ASCVD. Cost, treatment burden (injections), and absence of long-term safety data argue against their use in primary prevention. Such treatment might be considered if the patient cannot tolerate statin therapy or if LDL cholesterol cannot be sufficiently reduced in the highest-risk patients. In patients with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher, initial treatment with a moderate-intensity statin is less preferred; however, if the patient is unable to tolerate high-intensity therapy, down-titration to moderate-intensity therapy could be considered, especially if adequate LDL cholesterol reduction can be achieved. An evaluation for secondary causes of hyperlipidemia is also indicated in patients with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher. The most common secondary causes are obesity, hypothyroidism, biliary obstruction, and nephrotic syndrome. Medications can also increase LDL cholesterol level, and some of the most commonly implicated drugs include cyclosporine, HIV medications (such as protease inhibitors), glucocorticoids, and amiodarone. If a secondary cause is not identified, LDL cholesterol level elevation is considered primary, and family members should undergo screening because severe hypercholesterolemia is often genetically determined, as may be the case with this patient who has a first-degree relative with premature ASCVD.
Key Point
• The American College of Cardiology and American Heart Association recommend that patients aged 21 years or older with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher should receive high-intensity statin therapy for primary prevention of atherosclerotic cardiovascular disease.
Bibliography Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S145. [PMID: 24222016] doi:10.1161/01.cir.0000437738.63853.7a
Item 2
Answer:
Answers and Critiques
Item 1
D
Educational Objective: Use a shared decision-making approach to guide the initiation of breast cancer screening in a younger woman. This patient should not be screened for breast cancer at this time. In women aged 50 to 74 years, there is a clear benefit to screening mammography, and all breast cancer guidelines recommend screening mammography in this age group. Biennial screening mammography imparts most of the benefit of annual screening mammography with fewer harms, although the recommended screening frequency differs between guidelines. In women younger than 50 years or aged 75 years or older, the balance of benefits and harms is less clear, and screening recommendations vary widely. Most guidelines, including the recommendation statement of the U.S. Preventive Services Task Force (USPSTF), recommend individualized screening decisions for women aged 40 to 49 years based on patient context and values regarding specific benefits and harms. Compared with screening mammography in older women, the USPSTF concludes that, for women in their 40s, the number of women who benefit from screening mammography is smaller, and the harm is higher; however, the benefit still outweighs the harm. Therefore, the value the patient places on averting death from breast cancer compared with the importance she places on avoiding potential harms (false-positive results, anxiety, and overdiagnosis) can help guide her decision. This patient places more importance on avoiding potential harms and therefore should not pursue screening mammography or breast tomosynthesis at this time; no further testing is the best option. The USPSTF recommends against teaching breast self-examination (BSE), as BSE does not reduce breast cancer mortality and is associated with increased rates of breast biopsy. 193
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