Self-Evaluation Process Update in Internal Medicine

Self-Evaluation Process. 2014 Update in Internal Medicine
Self-Evaluation Process Update in Internal Medicine Module C0Q Version 14-1 WARNING: This Self-Evaluation Process (SEP) is copyrighted work under the Federal Copyright Act. It is a federal criminal offense to copy or reproduce this work in any manner or to make adaptations of this work. It is also a crime to knowingly assist someone else in the infringement of a copyrighted work. No part of this work may be reproduced by any means or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the American Board of Internal Medicine. The making of adaptations from this work also is strictly forbidden. In addition to criminal penalties, the Copyright Act, 17 U.S.C.§§101, et seq., provides a number of remedies for the infringement of a copyright, including injunctive relief, the award of statutory and actual damages, the award of attorney fees and costs, and confiscation and destruction of infringing works and materials. It is the policy of the Board to strictly enforce its rights to this copyrighted work.

Disclosures (ACP) Bill Weppner, MD, MPH: None Chris Knight, MD:
Full disclosure – Chris Knight (and Moe Hagman) are the true brains behind this review; I will try to do justice to their presentation (originally presented at Washing ACP Chapter in November 2014)

Let's get started Must be registered for MOC with American Board of Internal Medicine (ABIM) Order the module at Log in Select "2014 Update in Internal Medicine Module" choose "Work on module" 30 question (3 slides per = 90 minutes???) Worth 10 MOC points (towards 100) Also worth 1 CME hour Need to get 24+ of 30 questions right

Question 1 A 78-year-old man is evaluated for memory loss. Over the past year, the patient has had more difficulty remembering names. His wife also reports that he has trouble with short- term memory. The patient remains fully independent in his activities of daily living. Medical history is remarkable only for osteoarthritis. Neurologic examination is normal except for a score of 26/30 on the Montreal Cognitive Assessment; he missed four points on short-term word recall. However, the patient was fully oriented and performed the executive function, attention, and naming tasks without difficulty. Normal results were obtained for complete blood count, comprehensive metabolic panel, and serum thyroid-stimulating hormone. © 2014 ABIM

Question 1 - continued Which of the following is the most appropriate management strategy for this patient? (A) No pharmacologic therapy at this time (B) Start donepezil (C) Start ginkgo biloba (D) Start memantine © 2014 ABIM

Question 1 - Answer Correct answer: A Key teaching point:
Drugs don’t work for mild cognitive impairment (MCI) Rationale: Cholinesterase inhibitors not helpful, possibly harmful Ddx includes depression Gingko has been debunked Weak evidence for exercise, low dose lithium

Question 2 An 88-year-old man who has hypertension and Alzheimer's disease sees you for a follow-up evaluation. He was found to have cognitive impairment six years ago, and it has gradually worsened. One year ago, his wife brought him to see you because he started having "behavioral problems" beginning later in the day, including worsened disorientation, fidgeting, and calling out for his mother. At that time, his Mini-Mental State Examination score was 14/30, and he had no other significant findings on physical examination. Risperidone (1 mg daily at 6 PM) was started for the agitation. Today, his wife reports that the patient is doing well. She says that he only has occasional outbursts in the evening and is easily redirected. She describes the risperidone as a "wonder drug" for his behavior. Other current medications are chlorthalidone (25 mg daily), donepezil (10 mg nightly), and memantine (10 mg twice a day). © 2014 ABIM

Question 2 - continued Temperature is 36.8 C (98.2 F), pulse rate is 67 per minute, respirations are 16 per minute, and blood pressure is 125/64 mm Hg. Cardiopulmonary, abdominal, and neurologic examinations are normal, with the exception of a Mini-Mental State Examination score of 11 and mild cogwheeling about the left elbow. In addition to reinforcing caregiver education in appropriate strategies for redirection and management of environmental stimuli, which of the following is the most appropriate next step in the management of this patient's behavioral problems? (A) Increased dosage of donepezil to 23 mg daily (B) Addition of carbidopa–levodopa, 25/100 three times daily (C) Trial discontinuation of risperidone after tapering (D) Continuation of current therapy © 2014 ABIM

Question 2 - Answer Correct answer: C Key teaching point:
Avoid antipsychotics in elderly patients with dementia Rationale: Growing body of evidence that antipsychotics increase risk of CV disease, AKI in older patients Also can cause parkinsonism Consider temporary use if pt is danger to self or others

Question 3 A 90-year-old man who lives in a nursing home fell after tripping over his walker in the dining room. He struck his right forehead on the corner of a table and sustained a 1-cm laceration, but he never lost consciousness. The patient reported pain on the right side of his forehead. His primary care physician called his partner who was making rounds at the facility to evaluate the need for sutures. The patient has mild dementia, osteoarthritis, and hypertension. Current medications are aspirin (81 mg), donepezil, acetaminophen, and hydrochlorothiazide. A focused physical examination revealed a 1-cm superficial laceration, with good approximation of wound borders above the right eyebrow. The evaluating physician determined that no sutures were necessary and treated the wound with adhesive strips. © 2014 ABIM

Question 3 - continued Twenty-four hours later, the patient is difficult to arouse. He is sent to the emergency department and is found to have a large, right-sided frontal subdural hematoma with a mass effect. Urgent evacuation by a neurosurgeon is scheduled. Which of the following most likely led to the failure to diagnose this patient's subdural hematoma during his initial evaluation? (A) Clinical complexity of the presentation (B) Use of availability heuristic (C) Framing (D) Health system error © 2014 ABIM

Many diagnostic errors result from cognitive bias Rationale: Framing: “look at this” ignoring big picture Availability: “last time I saw this it was…” Anchoring: “I still think it’s…” Confirmation: only “seeing” data that confirms hypothesis Review:

Question 4 A 62-year-old man is admitted to the hospital because of worsening shortness of breath during the past two days due to an exacerbation of chronic obstructive pulmonary disease. He has not had fever but reports increased sputum production. The patient is in respiratory distress with some accessory muscle usage. Temperature is 37.1 C (98.8 F), pulse rate is 92 per minute, respirations are 18 per minute, and blood pressure is 110/74 mm Hg. Pulmonary examination reveals minimal air movement, but no crackles are heard. Arterial blood studies (with the patient breathing 6 L/min oxygen by nasal cannula) are pH of 7.35 [7.38–7.44], PCO2 of 80 mm Hg [38–42], and PO2 of 74 mm Hg [75–100]. Chest radiograph is clear. Antibiotics and intravenous corticosteroids are started. © 2014 ABIM

Question 4 - continued Which of the following is the safest and most effective method of managing this patient's respiratory status? (A) Continued monitoring on 6 L/min oxygen by nasal cannula (B) Noninvasive mechanical ventilation (C) Invasive mechanical ventilation (D) 100% Nonrebreathing mask © 2014 ABIM

Question 4 - Answer Correct answer: B Key teaching point:
NIV/NIPPV/BPAP beneficial in COPD exacerbation Rationale: NIV has been studied in both COPD and CHF exacerbations Shorter LOS, lower mortality, reduced risk of intubation Treatment of choice in cooperative patient

Question 5 A 45-year-old man is evaluated for heartburn with water brash, usually occurring at bedtime. He notes worsening of symptoms when lifting weights, but he is asymptomatic during his routine 5-km run. He has not had dysphagia, bleeding, vomiting, or weight loss. He has been taking nonprescription omeprazole once daily for the past two weeks. BMI is 32. Vital signs and physical examination are normal. Complete blood count, serum electrolytes, and electrocardiogram are normal. © 2014 ABIM

Question 5 - continued Which of the following should you recommend?
(A) An increase of omeprazole dosage to twice daily (B) Exercise stress test (C) Computed tomography of the abdomen (D) Ultrasonography of the abdomen (E) Esophagogastroduodenoscopy © 2014 ABIM

Save EGD for red flag symptoms (dysphagia, bleeding, anemia, weight loss and recurrent vomiting) or pts who don’t respond to BID PPI Rationale: ACP practice guideline

Question 6 A 42-year-old man comes to your office at the urging of his wife after having not seen a physician in 10 years. Physical examination and laboratory studies reveal hypertension. Medical history and immunization records are unavailable. The patient has no recollection of his vaccination status since childhood but says that he received required vaccinations for school. Ten years ago, he sustained multiple fractures of his right leg and underwent splenectomy after a motor vehicle collision. Healed incisions are noted along the midline of the abdomen and the right lower leg. © 2014 ABIM

Question 6 - continued In addition to influenza, tetanus-diphtheria-acellular pertussis, and meningococcal vaccinations, which of the following should you recommend now? (A) Pneumococcal conjugate (PCV13) vaccine now and pneumococcal polysaccharide (PPSV23) vaccine at least eight weeks later (B) Pneumococcal polysaccharide (PPSV23) vaccine now and every five years until age 65 (C) Herpes zoster vaccine (D) Human papillomavirus vaccine © 2014 ABIM

Pneumococcal conjugate vaccine (PCV13, Prevnar) now indicated for immunocompromised adults Rationale: ACIP recommends for all over 65 Numeric - PCV13 first, PPSV23 (Pneumovax) 8 weeks later

Question 7 A 73-year-old man is evaluated because of recurrent diverticulitis. He has depression, hypertension, and hyperlipidemia. Current medications are lisinopril, chlorthalidone, atorvastatin, citalopram, and aspirin. The patient is ordered to receive nothing by mouth and undergoes partial colectomy. Postoperative antibiotics and deep vein thrombosis prophylaxis are begun. On postoperative day 1, pulse rate is 76 per minute, and blood pressure is 132/74 mm Hg. The abdomen is soft and is not distended. Bowel sounds are absent. The incision site is clean, dry, and intact. © 2014 ABIM

Question 7 - continued Which of the following medications should be restarted now in order to reduce this patient's risk of postoperative mortality? (A) Aspirin (B) Atorvastatin (C) Chlorthalidone (D) Citalopram (E) Lisinopril © 2014 ABIM

Statin withdrawal for as little as a few days may increase risk of perioperative MI Rationale: Evidence is of moderate quality ACC/AHA guidelines recommend continuing statins or resuming ASAP Low-dose aspirin increases bleeding without reducing risk

Discussion 10,010 patients at risk of CVD randomized to start/continue aspirin vs placebo within 24h of surgery and for 7 days after New starts stayed on low dose (100 mg) aspirin for 30 days post-op; continuation patients took 100 mg for 1 week 30% h/o CVD, 37% diabetes, 85% hypertension No difference in death/nonfatal MI (7.0 vs 7.1%) Increased major bleeding in aspirin group (4.6 vs 3.8, NNT 13)

Question 8 A 40-year-old man has had typical sciatic pain radiating down his left leg to just below the knee for one week. The pain worsens after heavy lifting. Nonsteroidal anti- inflammatory drugs provide minimal relief. Medical history and review of systems are negative. Straight leg-raising test is positive on the left. Gait is antalgic. The remainder of the physical examination and laboratory studies are normal. He has read about the possibility of getting an epidural corticosteroid injection and requests that you refer him for the procedure. © 2014 ABIM

Question 8 - continued You should advise the patient that epidural corticosteroid injections will provide which of the following? (A) Small, short-term improvement of leg pain but no long-term improvement (B) No short-term or long-term improvement of leg pain (C) Long-term improvement of leg pain, but therapy will exacerbate the pain initially (D) Both short-term and long-term improvement of leg pain © 2014 ABIM

Epidural steroids offer only short term benefit in sciatica Rationale: Annals 2012 meta-analysis Recent NEJM article: no benefit in spinal stenosis either

Question 9 Compared with central venous catheters, peripherally inserted central catheters are associated with which of the following? (A) Lower patient satisfaction (B) Lower cost effectiveness (C) Greater risk of bloodstream infection (D) Greater risk of deep vein thrombosis © 2014 ABIM

Question 9 - Answer Correct answer: D Key teaching point:
PICCs have higher DVT risk (2.7%, OR 2.55) than CVC Rationale: Generally PICCs are more cost-effective, better tolerated, and have lower infection risk Be cautious in patients with high risk of DVT (cancer, critical illness

Question 10 A 55-year-old woman comes to your office for a routine health evaluation. She feels well. Last menstrual period was one year ago. She has occasional hot flushes, which sometime interfere with sleep and are lessening. She has never received corticosteroids. She does not smoke cigarettes, and she drinks alcoholic beverages rarely. Her parents are healthy and in their 80s; they both have osteoarthritis with no history of fractures. Family history of cancer is negative. BMI is 25. Vital signs and physical examination are normal. © 2014 ABIM

CDC recommends HCV screening for US adults born Rationale: FSH doesn’t add much No risk factors for early DEXA Ovarian ultrasound not recommended for screening

Question 11 A healthy 45-year-old man comes to your office for a periodic health evaluation. He currently exercises daily and runs half-marathons. He does not smoke cigarettes or drink alcoholic beverages. Medical history is unremarkable. He started taking a variety of antioxidant health supplements, including vitamin E, vitamin C, vitamin B-complex, vitamin B12, selenium, and vitamin A after friends told him about their health benefits. Vital signs, physical examination, and serum lipid panel are normal. © 2014 ABIM

Question 11 - continued What would be your best evidence-based advice regarding this patient's use of supplements? (A) Antioxidant supplements will not decrease cardiovascular events or mortality (B) Antioxidant supplements decrease cardiovascular events but not mortality (C) Antioxidant supplements decrease cardiovascular events and lower mortality (D) Antioxidant supplements decrease cardiovascular events but increase all-cause mortality © 2014 ABIM

Antioxidants don’t have major impact on any outcome Rationale: Some data suggest that vitamin E may increase rates of lung and prostate cancer but not mortality

Question 12 A 75-year-old man who has erectile dysfunction comes to your office as a new patient. He takes sildenafil one to two times weekly with satisfactory results. Libido is normal. He has noted increased fatigue during the past several years, but he is otherwise asymptomatic. Review of his medical record confirms his drug regimen. Blood pressure is 130/85 mm Hg. Cardiac and vascular examinations, testicular size, and hair pattern are normal, as is the remainder of the physical examination. Serum total cholesterol is 185 mg/dL [desirable: less than 200], HDL cholesterol is 42 mg/dL [low: less than 40], and LDL cholesterol is 93 mg/dL [optimal: less than 100]. No record of serum testosterone level is noted. © 2014 ABIM

Question 12 - continued Which of the following should you recommend now? (A) Initiation of a six-month trial of testosterone replacement therapy (B) Measurement of serum testosterone; if low, discontinuation of sildenafil and addition of testosterone (C) Measurement of serum testosterone; if normal or low, continuation of sildenafil and addition of testosterone (D) No change in therapy © 2014 ABIM

Males with hypogonadism usually have symptoms or signs—no need to “screen” even with ED Rationale: Sildenafil is more effective than testosterone for ED even in men with low testosterone

Discussion T benefits Grip strength, muscle mass Bone mineral density
Increased libido T harms Polycythemia BPH back to baseline risk T questions Prostate cancer risk Fracture risk

Question 13 A 58-year-old woman who has a history of symptomatic bradycardia is scheduled to undergo an elective placement of a permanent pacemaker. The patient reports that she had a rash after taking penicillin as a child. Vital signs and physical examination are normal. Which of the following should you do to minimize the risk of surgical site infection in this patient? (A) Perform penicillin skin testing; if negative, administer preoperative cephalexin (B) Administer preoperative vancomycin (C) Administer preoperative cephalexin (D) Administer preoperative trimethoprim–sulfamethoxazole © 2014 ABIM

Many penicillin “allergies” are not. Rationale: Cross reactivity between cephalosporins and penicillins is low—but cephalexin is one of the worst

Question 14 A 75-year-old woman underwent several free screening procedures at a local health fair. She was told that she had 35% to 45% narrowing of the right carotid artery. She has no symptoms and feels well. She has hypertension and hyperlipidemia; current medications are indapamide, atorvastatin, and enalapril. Medical history and review of systems are normal. The patient volunteers at a local hospital. Blood pressure is 130/80 mm Hg; physical examination is otherwise normal. Fasting blood glucose is 90 mg/dL [70–99], serum electrolytes are normal, and serum LDL cholesterol is 95 mg/dL [optimal: less than 100]. © 2014 ABIM

Question 14 - continued Which of the following should you recommend based on this patient's screening results? (A) No further testing at this time (B) Confirmation with magnetic resonance angiography (C) Referral for vascular intervention (D) Repeat carotid ultrasonography in one year © 2014 ABIM

No value to screening for asymptomatic carotid artery stenosis (ACAS) Rationale: Even with high grade stenosis and carefully selected surgeons, the benefit is only slightly greater than harms

Question 15 A 42-year-old man comes to your office for the first time because of palpitations and difficulty with sleeping. He also has a rash on the dorsum of his hands which worsens with sun exposure. Medical history is notable for splenectomy for treatment of idiopathic thrombocytopenic purpura. Heart rate and rhythm are normal at 85 per minute. On physical examination, the lymph nodes are not enlarged. The thyroid gland is slightly enlarged. A well-healed incision is noted over the left upper abdomen. A rash is noted on the dorsum of the hands, consistent with porphyria cutanea tarda. The remainder of the skin examination is normal. © 2014 ABIM

Question 15 - continued Laboratory studies: Serum electrolytes Normal
Serum bilirubin Slightly elevated Serum thyroid-stimulating hormone 0.3 μU/mL [0.5–4.0] Serum free thyroxine (T4) 3.0 ng/dL [0.8–1.8] Serum aminotransferases ALT 80 U/L [10–40] AST 82 U/L [10–40] Urinalysis © 2014 ABIM

Question 15 - continued Which of the following is the best explanation of this patient's clinical presentation? (A) Sarcoidosis (B) Granulomatosis with polyangiitis (Wegener's) (C) Renal cell carcinoma (D) Hepatitis C infection © 2014 ABIM

Extrahepatic HCV can include porphyria cutanea tarda, autoimmune thyroiditis and ITP Rationale: Thrombocytopenia in pt with HCV can be ITP or cirrhosis Other diagnoses don’t fit the overall picture

Question 16 A 54-year-old woman who has obesity and mild hypertension sees you to discuss smoking cessation. She has smoked one-half to one pack of cigarettes daily for the past 25 years. You counsel her on smoking cessation, including trigger control. She declines a prescription for a pharmacologic aid and prefers to try to quit "cold turkey." Which of the following is the best advice you should provide this patient regarding smoking cessation? (A) Abrupt smoking cessation is more effective than gradual reduction of smoking (B) Gradual and abrupt cessation methods are equally effective (C) Gradual smoking cessation is more effective than abrupt reduction due to increased patient adherence © 2014 ABIM

When quitting smoking, cold turkey=taper Rationale: Systematic review shows similar outcomes Support whatever the patient thinks will work

Question 17 An 80-year-old woman has had myalgia, fatigue, and brown urine for three days. She has hypertension, coronary artery disease, heart failure, osteoporosis, and gout. One year ago, she had a stroke and was found to have atrial fibrillation, at which time simvastatin, metoprolol, and warfarin were started. Current medications are simvastatin (40 mg daily), warfarin, metoprolol (50 mg daily), enalapril (10 mg daily), alendronate (35 mg weekly), allopurinol (100 mg daily), and acetaminophen. She completed a 10-day course of esomeprazole, amoxicillin, and clarithromycin last month for Helicobacter pylori infection. She has not traveled recently. Physical examination reveals no changes from her last examination three months ago. The mucous membranes are moist. © 2014 ABIM

Question 17 - continued Laboratory studies (three months ago):
Serum creatinine 1.3 mg/dL [0.7–1.5] eGFR 39 mL/min/1.73 m2 Serum electrolytes Normal Laboratory studies (today): Hemoglobin 11 g/dL [12–16] Leukocyte count 8000/μL [4000–11,000] Differential Normal Laboratory studies continued on next slide © 2014 ABIM

Question 17 - continued Laboratory studies continued:
INR 3.5 Serum creatinine 3.2 mg/dL [0.7–1.5] eGFR 14 mL/min/1.73 m2 Serum potassium 5.8 mEq/L [3.5–5.0] Serum uric acid Normal Serum creatine kinase 800 U/L [30–135] Urinalysis is notable for positive blood on dipstick examination, but no crystals, RBCs, WBCs, or casts are noted. © 2014 ABIM

Question 17 - continued Which of the following is the most likely cause of this patient's symptoms? (A) Warfarin overdose (B) Simvastatin toxicity (C) Uric acid nephropathy (D) ACE inhibitor-induced kidney failure © 2014 ABIM

Clarithromycin inhibits simvastatin metabolism, increases levels & toxicity Rationale: Similar concerns with amlodipine, fibrates, azole antifungals

Question 18 A 20-year-old man who has a lesion on his penis is found to have genital warts. He has not received human papillomavirus vaccination. Which of the following should you recommend? (A) No vaccination (B) Inactivated bivalent human papillomavirus (HPV2) vaccination (C) Inactivated quadrivalent human papillomavirus (HPV4) vaccination (D) Viral culture for high-risk human papilloma virus infection © 2014 ABIM

Males should be immunized against HPV with quadrivalent HPV vaccine (HPV4, Gardasil) Rationale: HPV2 (Cervarix) protects against carcinogenic strains but not warts HPV2 only approved for women, but I’m not sure why you would use it with anyone

Question 19 An 82-year-old woman who has had type 2 diabetes mellitus for five years is evaluated for hypoglycemia. Her diabetes had been well controlled on metformin (1000 mg twice daily) until six months ago when she was seen in an urgent care clinic for elevated blood glucose (higher than 300 mg/dL two hours after eating her evening meal [abnormal: greater than 125]). Insulin glargine (10 units at bedtime) was started with sliding-scale regular insulin for blood glucose levels higher than 150 mg/dL (minimum dosage was 2 units; maximum dosage was 10 units for blood glucose levels higher than 400 mg/dL). © 2014 ABIM

Question 19 - continued The patient checks her blood glucose levels before meals and two hours after her evening meal or when she is symptomatic. Since her visit six months ago, her glucose levels have not been higher than 250 mg/dL. However, on two or three occasions, glucose has been lower than 70 mg/dL each week, usually in the morning. The patient also occasionally awakens feeling jittery and nervous in the middle of the night, and glucose checks confirm hypoglycemia. She drinks orange juice, and symptoms resolve. She reports no other symptoms. Today, vital signs and physical examination are normal. © 2014 ABIM

Question 19 - continued Laboratory studies: Hemoglobin A1C
7.9% [4.0–6.1] (six months ago 9.3%) Blood urea nitrogen 18 mg/dL [8–20] Serum creatinine 0.7 mg/dL [0.7–1.5] eGFR Greater than 60 mL/min/1.73 m2 © 2014 ABIM

Question 19 - continued Which of the following should be the initial step to improve this patient's diabetes control and reduce the risk of hypoglycemia? (A) Reduce insulin glargine by 50% (B) Reduce sliding-scale regular insulin by 50% (C) Discontinue sliding-scale insulin (D) Discontinue metformin (E) Discontinue all insulin and start glyburide © 2014 ABIM

Sliding scale insulin is bad Rationale: This is a weird question: it looks like she is having fasting hyperglycemia, but it’s probably delayed action of reg SSI Basal alone or basal + pre-meal insulin (preferably ultra- short) would be better, reduce risk of hypoglycemia

Question 20 A 72-year-old woman who was found to have depression two months ago sees you for an evaluation. The patient had the onset of anhedonia, hypersomnolence, weight gain, increased appetite, and intermittent anxiety 12 weeks ago, but she had no suicidal or homicidal ideations. Two months ago, she was started on citalopram (10 mg daily), which was titrated to 20 mg daily two weeks ago. At the time of diagnosis, complete blood count and serum thyroid-stimulating hormone and comprehensive metabolic panel levels were normal. The patient was treated for depression at age 65 when she retired from her job as a bank teller, but her symptoms completely resolved after one year. Her husband of 37 years is very supportive of her. She does not drink alcoholic beverages, smoke cigarettes, or use recreational drugs. © 2014 ABIM

Question 20 - continued Today she reports feeling slightly more energetic, and she has not had suicidal or homicidal ideations. However, she still feels depressed and wants to know what else can be done for her. Which of the following should you recommend now? (A) Continue current treatment (B) Increase citalopram to 40 mg daily (C) Add mirtazapine, 15 mg nightly (D) Add alprazolam, 0.5 mg every 6 hours as needed for anxiety (E) Refer for cognitive behavioral therapy © 2014 ABIM

Question 20 - Answer Correct answer: E Key teaching point:
Good evidence for psychotherapy + medications for depression Rationale: Citalopram 40 mg increases risk of long QT Mirtazepine increases risk of weight gain, serotonin syndrome Alprazolam is evil, evil, evil

Question 21 A 74-year-old man who has mild dementia, hypertension, and type 2 diabetes mellitus is admitted to the hospital with pneumonia, and antibiotics are started. Later that night, the nursing staff calls you stating that the patient is confused. He is calling for his deceased wife and believes that he is back at his home. He is repeatedly trying to get out of his bed despite nurses' attempts to keep him lying down. He accused a nurse of trying to kidnap him and attempted to hit her. Temperature is 37.9 C (100.2 F); physical examination is unchanged from admission. Leukocyte count is 12,400/μL [4000–11,000]; laboratory studies are otherwise normal. © 2014 ABIM

Question 21 - continued In addition to attempts at reorientation strategies and reducing environmental stimuli, which of the following is the most appropriate initial step in the management of this patient's symptoms? (A) Wrist restraints to prevent the patient from falling (B) Haloperidol, 5 mg intravenously (C) Haloperidol, 1 mg intramuscularly (D) Olanzapine, 10 mg intramuscularly (E) Risperidone, 1 mg intramuscularly © 2014 ABIM

Low-dose haloperidol as effective as atypical antipsychotics, less expensive Rationale: Another weird question IV haloperidol associated with long QT Physical restraints associated with prolonged delirium Prevention is the best approach

Question 22 For the past week, a 67-year-old man has had elbow pain that began after he was working on a project at his home that required repetitive use of a screwdriver. The patient reports the pain as 5/10 in intensity. It is exacerbated by extension of the arm, lasts a few minutes at a time, and is present over the lateral epicondyle. Physical examination confirms tenderness over the right lateral epicondyle but full range of motion in the right elbow. You prescribe ibuprofen (600 mg three times daily) and avoidance of the activities that precipitated the symptoms. The patient returns eight weeks later with continued pain. He completed a 10-day course of the ibuprofen with some initial improvement, but the pain has persisted. © 2014 ABIM

Question 22 - continued Which of the following treatment strategies is most appropriate now? (A) Physiotherapy (B) Elbow counterforce bracing (C) Oral corticosteroids (D) Local corticosteroid injection © 2014 ABIM

Steroids not optimal for chronic epicondylitis Rationale: Randomized placebo-controlled trial showed higher recurrence rates with steroid injection Evidence for PT not strong but probably the best option Bracing has only been studied for short term use

Question 23 A 65-year-old woman who has osteoarthritis is evaluated for a history of borderline blood pressure readings. BMI is 27. Blood pressure has measured 135/75 mm Hg three times in previous office visits during the past six weeks. Blood pressure readings at home have ranged from 135/85 mm Hg to 140/80 mm Hg. Laboratory studies: Fasting blood glucose 95 mg/dL [70–99] Serum creatinine 1.3 mg/dL [0.7–1.5] eGFR 41 mL/min/1.73 m2 Urine albumin-to-creatinine ratio 400 mg/g [less than 30] © 2014 ABIM

Question 23 - continued In addition to the DASH diet, which of the following should you recommend now? (A) Amlodipine (B) Enalapril (C) Chlorthalidone (D) Metoprolol (E) Monitoring of blood pressure; no treatment at this time © 2014 ABIM

CKD + proteinuria = ACE/ARB Rationale: Any questions?

Question 24 A 56-year-old white man asks for your advice regarding methods to reduce his risk of coronary disease. He has hypertension and depression. Current medications are sertraline (50 mg daily), aspirin (162 mg daily), and lisinopril (10 mg daily). He does not use tobacco. BMI is 34. Pulse rate is 74 per minute, and blood pressure is 115/74 mm Hg. © 2014 ABIM

Question 24 - continued Serum lipids:
Cholesterol Total 205 mg/dL [desirable: less than 200] HDL 41 mg/dL [low: less than 40] LDL 118 mg/dL [optimal: less than 100] Triglycerides 229 mg/dL [normal: less than 150] The patient's 10-year risk for atherosclerotic cardiovascular disease is 7.2%. © 2014 ABIM

Question 24 - continued In addition to recommending weight loss, which of the following should you do to reduce this patient's risk of cardiovascular events? (A) Begin simvastatin, 40 mg daily (B) Increase of aspirin dosage to 325 mg daily (C) Addition of metoprolol, 25 mg twice daily (D) Addition of omega-3 fatty acids, 1.5 g daily (E) No changes are indicated at this time © 2014 ABIM

ACC/AHA 10 year risk cutoff for statins is 7.5% Rationale: Omega-3 pills don’t work No value to beta blockers for primary prevention Aspirin helpful but probably equivalent

Question 25 A 50-year-old woman comes to your office for an initial evaluation. She feels well. She has type 2 diabetes mellitus, hypertension, anxiety, osteoarthritis, and chronic constipation. Simvastatin was started but was discontinued when myalgias developed; symptoms subsequently resolved. No blood tests were performed during the episodes of myalgias, and she did not have any other symptoms. Current medications are enalapril, metformin, paroxetine, and a psyllium fiber supplement. Recent screening colonoscopy was normal. The patient smokes five cigarettes daily. Vital signs and physical examinations are normal, as is electrocardiogram. © 2014 ABIM

Question 25 - continued Laboratory studies:
Hemoglobin A1C 7.2% [4.0–6.1] Serum electrolytes Normal Serum cholesterol HDL 40 mg/dL [low: less than 40] LDL 122 mg/dL [near optimal: 100–129] Which of the following should you do now? (A) Add colesevelam (B) Add pravastatin (C) Add gabapentin and restart simvastatin (D) Discontinue paroxetine and restart simvastatin © 2014 ABIM

Over 90% of patients can tolerate statins when rechallenged; different statin is slightly better Rationale: Pravastatin has lower rates of myopathy Colesevalam causes constipation (and doesn’t help) No interaction between paroxetine and simvastatin

Question 26 A 59-year-old man is evaluated before undergoing placement of an automatic implantable cardiac converter defibrillator next week. He underwent mechanical mitral valve replacement ten years ago due to mitral stenosis; his other problems include rate-controlled atrial fibrillation, coronary artery disease, and heart failure. Echocardiogram performed two weeks ago showed a left ventricular ejection fraction of 25% and a well- functioning mechanical mitral valve. Current medications are low-dose aspirin, extended-release metoprolol, warfarin, lisinopril, spironolactone, and furosemide. Today, the patient feels well. Pulse rate is 66 per minute and irregular, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination reveals an irregularly irregular heart beat and a mechanical S1; the lungs are clear. Trace edema is noted in the extremities. INR is 2.9. © 2014 ABIM

Question 26 - continued Which of the following is the most appropriate strategy to reduce the risk of bleeding complications during the procedure in this patient? (A) Continue warfarin, with a target INR of 3.5 or less on the day of the procedure (B) Discontinue warfarin five days before the procedure and resume the day after the procedure (C) Discontinue warfarin five days before the procedure and bridge with an unfractionated heparin infusion (D) Discontinue warfarin five days before the procedure and bridge with low-molecular-weight heparin (1 mg/kg/twice daily) © 2014 ABIM

At least for pacer/ICD placement, continuing warfarin is MUCH safer than heparin bridging Rationale: Multicenter RCT (BRUISE CONTROL) Pocket hematoma 3.5% with warfarin, 16.5% with heparin Other complications rare, 2 in each group

Question 27 A 63-year-old man is admitted to the hospital because of hematemesis. He has gastroesophageal reflux disease and atrial fibrillation; he takes warfarin. He had felt well until this morning when nausea developed after eating. He vomited blood once and was brought to the hospital. Temperature is normal. Pulse rate is 84 per minute and irregular, and blood pressure is 110/72 mm Hg. Abdominal examination is normal. Hemoglobin is 11.8 g/dL [14–18], serum creatinine is 0.9 mg/dL [0.7–1.5], and eGFR is greater than 60 mL/min/1.73 m2. Intravenous isotonic saline (500 mL) is given, and nasogastric lavage is subsequently performed. Upper endoscopy reveals a duodenal ulcer, which is successfully cauterized. Warfarin is discontinued, and intravenous pantoprazole is begun. No additional bleeding is noted, and the patient is prepared for discharge. © 2014 ABIM

Question 27 - continued How long after the bleeding episode can this patient's warfarin be safely restarted? (A) One week (B) One month (C) Six weeks (D) Three months (E) Warfarin should not be restarted © 2014 ABIM

Restarting warfarin early after GI bleed associated with reduced mortality Rationale: 442 patients with A. fib (50%), prior VTE (25%), prosthetic valve (10%) analyzed based on when they restarted Restarting warfarin within a week associated with small increase in recurrent GIB, large decrease in mortality

Question 28 A 32-year-old woman is evaluated for fatigue and malaise. In an effort to lose weight, she has been exercising more aggressively during the past several weeks; she runs seven to 10 miles daily, which is an increase from her daily routine of two to three miles. She has been adhering to a diet prescribed by a weight-loss center, which consists of a greater intake of animal proteins and complex carbohydrates and vitamin D supplements (600 IU daily). She has also purchased supplements on the internet; including mu tong, St. John's wort, and coenzyme Q10. She has lost 9.1 kg (20 lb) in the past year. Medical history and review of systems are negative. BMI is 27. Physical examination is normal. © 2014 ABIM

Question 28 - continued Laboratory studies: Hemoglobin 8 g/dL [12–16]
Serum iron studies Normal Serum creatinine 1.7 mg/dL [0.7–1.5] eGFR 35 mL/min/1.73 m2 Serum creatine kinase Urinalysis Protein 1+ Blood 2+ RBC 1/hpf Casts None Ketones Negative © 2014 ABIM

Question 28 - continued Which of the following is the most likely explanation of this patient's clinical presentation? (A) Rapid weight loss (B) Vitamin D toxicity (C) Coenzyme Q10 toxicity (D) St. John's wort toxicity (E) Mu tong toxicity © 2014 ABIM

Aristolochic acid (e.g. mu tong) causes irreversible, progressive nephropathy

Aristolochic acid comes from genus Aristolochia
Mu Tong, Fang Ji Fibrotic renal disease that continues to progress after cessation of AA products High risk of urothelial cancers

Question 29 A 57-year-old white woman comes to your office for a periodic health evaluation. She has a 15-pack-year history of cigarette smoking but no other significant medical history. Her father has coronary artery disease, and her mother has type 2 diabetes mellitus. BMI is 32. Pulse rate is 72 per minute, and blood pressure is 144/92 mm Hg. © 2014 ABIM

Question 29 - continued Laboratory studies:
Fasting plasma glucose 104 mg/dL [borderline: 100–125] Serum cholesterol Total 218 mg/dL [high: greater than 239] HDL 52 mg/dL [low: less than 50] LDL 140 mg/dL [high: 160–189] Serum triglycerides 129 mg/dL [normal: less than 150] The patient's 10-year risk for atherosclerotic cardiovascular disease is 8%. Because of her family history, the patient would like to reduce her risk for heart disease. © 2014 ABIM

Question 29 - continued In addition to smoking cessation, which of the following would be most effective in the prevention of coronary events in addition to all-cause mortality in this patient? (A) Aspirin (B) Atorvastatin (C) Ezetimibe (D) Metoprolol (E) Niacin © 2014 ABIM

ACC/AHA 10 year risk cutoff for statins is 7.5% Rationale: Statins more potent than aspirin for risk reduction Niacin adds little to statins Ezetimibe highly questionable value

Question 30 A 47-year-old woman who is gravida 3, para 3 comes to your office for a periodic health evaluation. Papanicolaou tests have been normal at regular intervals, and she has no history of sexually transmitted infections or new sexual partners. Her menstrual periods typically occurred every 28 days; but during the past six months, they occur every 12 to 30 days. She takes an iron supplement regularly. BMI is 38. Blood pressure is 120/70 mm Hg. Genitourinary examination reveals a normal cervix. Bimanual examination is normal; no adnexal masses are noted, and the uterus is not enlarged. The abdomen is round and nontender with active bowel sounds. Laboratory studies are normal. © 2014 ABIM

(A) Measurement of serum follicle-stimulating hormone and serum luteinizing hormone (B) Magnetic resonance imaging of the pelvis (C) Ultrasonography in six months if intermenstrual bleeding continues (D) Referral for endometrial biopsy © 2014 ABIM

Perform endometrial biopsy in women over 45 with intermenstrual bleeding Rationale: 7% of endometrial CA diagnosed under 50 ACOG recommends EMB in women over 45 with intermenstrual bleeding US less useful in premenopausal women

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Self-Evaluation Process Update in Internal Medicine

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