Transcript Self-Evaluation Process 2014 Update in Internal Medicine

Self-Evaluation Process
2014 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:
 None
 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 https://www.abim.org/ONLINE/rqsep.aspx
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 shortterm 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
Question 3 - Answer
Correct answer:
C
Key teaching point:
 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: http://pmid.co/23802513
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
Question 5 - Answer
Correct answer:
A
Key teaching point:
 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
Question 6 - Answer
Correct answer:
A
Key teaching point:
 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
Question 7 - Answer
Correct answer:
B
Key teaching point:
 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 antiinflammatory 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
Question 8 - Answer
Correct answer:
A
Key teaching point:
 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
Question 10 - continued
Which of the following should you recommend?
 (A) Bone density scan
 (B) Measurement of serum follicle-stimulating hormone
 (C) Screening for hepatitis C
 (D) Ultrasonography of the ovaries
© 2014 ABIM
Question 10 - Answer
Correct answer:
C
Key teaching point:
 CDC recommends HCV screening for US adults born
1945-1965
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
Question 11 - Answer
Correct answer:
A
Key teaching point:
 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
Question 12 - Answer
Correct answer:
D
Key teaching point:
 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
Question 13 - Answer
Correct answer:
A
Key teaching point:
 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
Question 14 - Answer
Correct answer:
A
Key teaching point:
 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
Normal
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
Question 15 - Answer
Correct answer:
D
Key teaching point:
 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
Question 16 - Answer
Correct answer:
B
Key teaching point:
 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
Question 17 - Answer
Correct answer:
B
Key teaching point:
 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
Question 18 - Answer
Correct answer:
C
Key teaching point:
 Males 11-26 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
Question 19 - Answer
Correct answer:
C
Key teaching point:
 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 ultrashort) 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
Question 21 - Answer
Correct answer:
C
Key teaching point:
 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
Question 22 - Answer
Correct answer:
A
Key teaching point:
 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
Question 23 - Answer
Correct answer:
B
Key teaching point:
 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
Question 24 - Answer
Correct answer:
E
Key teaching point:
 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 75-325 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
Question 25 - Answer
Correct answer:
B
Key teaching point:
 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 wellfunctioning 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
Question 26 - Answer
Correct answer:
A
Key teaching point:
 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
Question 27 - Answer
Correct answer:
A
Key teaching point:
 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
Normal
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
Question 28 - Answer
Correct answer:
E
Key teaching point:
 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
Question 29 - Answer
Correct answer:
B
Key teaching point:
 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
Question 30 - continued
Which of the following should you recommend?
 (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
Question 30 - Answer
Correct answer:
D
Key teaching point:
 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
Thanks for joining us!