Transcript 1 - RCRMC Family Medicine Residency

Internal Medicine Questions 2
Colorectal Cancer: Trends in Screening Prevalence, Incidence, and Mortality
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Screening continues to rise while new CRC cases and deaths continue to fall.
The latest data on colorectal cancer (CRC) screening prevalence, incidence, and
mortality in the U.S. population are now available. To evaluate trends over time,
researchers compiled data from the Behavioral Risk Factor Surveillance System
(BRFSS; a telephone-based health survey in the U.S.) and state-specific incidence and
mortality data.
BRFSS survey data were utilized to estimate the prevalence of CRC screening. In 2010,
236,186 individuals aged 50 to 75 responded to the BRFSS survey. Every 2 years since
2002, respondents aged 50 have been asked whether they have ever used a fecal occult
blood test (FOBT) kit or have ever received a screening endoscopy, and, if so, how long
ago. Self-reported use of FOBT within 1 year or endoscopy within 10 years was
considered current receipt of CRC screening. Incidence and mortality data in the U.S.
were respectively obtained from cancer registries and death certificates.
The prevalence of CRC screening overall increased from 52.3% in 2002 to 65.4% in
2010, and FOBT use declined from 21.1% to 11.8%. From 2003 to 2007, CRC
incidence and mortality declined by 13% and 12%, respectively — representing 66,000
fewer new CRC cases and 32,000 fewer CRC deaths than expected during that period
compared with 2002. CRC incidence decreased in 35 states, and mortality decreased in
49 states and the District of Columbia. The biggest reductions in incidence and mortality
typically occurred in states with the highest screening rates.
Comment: These findings add to recent encouraging evidence regarding colorectal
cancer incidence (JW Gastroenterol Jan 15 2010). The authors recommend development
of individual state-based programs to enhance screening service delivery systems and
further increase adherence.
PPIs Are the Most Effective Drugs to
Reduce Risk for Upper GI Bleeding
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Proton-pump inhibitors bested histamine-2–receptor antagonists and nitrates in patients taking gastrotoxic drugs and
in the general population.
Multiple studies have demonstrated the ability of proton-pump inhibitors (PPIs) to reduce the risk for upper
gastrointestinal bleeding (UGIB) in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or
clopidogrel. To determine if this effect is also seen in general practice, investigators conducted a nested, case-control
study involving 2049 patients with UGIB and 20,000 age- and sex-matched controls who were identified in The
Health Improvement Network UK primary care database between 2000 and 2007. Records were reviewed to
determine the use of drugs that increase the risk for UGIB as well as the use of acid-reduction therapy with PPIs,
histamine-2–receptor antagonists (H2RAs), or nitrates.
Current PPI use for >1 month versus nonuse was associated with a reduction in UGIB in the general population
(relative risk, 0.80; 95% confidence interval, 0.68–0.94) and in patients taking low-dose aspirin, clopidogrel, both
aspirin and clopidogrel, warfarin, and NSAIDs (RR, 0.58; 95% CI, 0.42–0.79). No significant effect was seen in
patients taking cyclooxygenase-2 inhibitors or steroids. The impact of H2RAs on the incidence of UGIB was smaller
than that of PPIs and was significant only for patients taking NSAIDs. Nitrate use had no effect on the risk for UGIB
in the general population or in gastrotoxic drug users.
Comment: This study adds 2 years of follow-up to a prior report that used the same database. The effectiveness of
PPI therapy to reduce risk for UGIB in patients taking gastrotoxic drugs confirms results from prior randomized trials.
That PPI use reduces the risk for UGIB in the general population suggests that some confounding risk factors for
bleeding that are affected by PPI therapy remain unidentified in the current analysis. One of these might be
Helicobacter pylori infection, which was not consistently reported. The relatively limited reduction in UGIB with
H2RA use is also consistent with other randomized trials, showing that these drugs are not as effective in preventing
UGIB. The broad confidence intervals seen in the study suggest that it might have been underpowered to identify a
small, but significant effect of H2RAs on bleeding risk. Nonetheless, PPIs seem to be the most effective drugs to
prevent UGIB in patients at risk.
Helicobacter pylori Therapy in Latin America:
Triple-Drug Regimen Still Best
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Standard 14-day triple-drug therapy — despite its suboptimal eradication rate — was more effective than shorterduration concomitant or sequential four-drug regimens.
Helicobacter pylori eradication rates with standard triple therapy are decreasing in Europe and Asia because of
antibiotic resistance. Little research has been done to determine the optimal therapeutic regimen in Latin America,
where H. pyloriinfection is endemic and antibiotic resistance patterns might be different. Now, investigators have
conducted an open trial at seven sites in Latin America to compare the effectiveness of three treatments.
Potentially eligible adults were recruited from the general population; H. pylori infection was confirmed using a urea
breath test. A total of 1463 participants were randomized to receive one of three therapy regimens using generic
drugs:
Standard (14 days of triple therapy with lansoprazole, amoxicillin, and clarithromycin)
Concomitant (5 days of lansoprazole, amoxicillin, clarithromycin, and metronidazole)
Sequential (5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and
metronidazole)
Assessment with a second urea breath test 6 to 8 weeks after randomization showed that the standard-therapy group
had the highest eradication rate (82.2%), followed by the sequential- and concomitant-therapy groups (76.5% and
73.6%, respectively). These results did not vary significantly by study site, sex, age, or presence of chronic dyspeptic
symptoms. The authors concluded that standard 14-day triple therapy is currently the preferred empirical treatment
for H. pylori infection in Latin America.
Comment: This study was undertaken with the aim of possible population-based H. pylori eradication to decrease the
incidence of gastric cancer in the region. The authors hypothesized that concomitant or sequential therapy would be at
least as effective as standard therapy and would provide a less -expensive alternative. However, the alternative
approaches proved inferior to standard therapy, perhaps because antibiotic exposure and resistance are less common
in Latin America than in previous study sites. It is important to note that even the standard therapy had a poor
eradication rate (82.2%). Further study is needed to evaluate the feasibility and advisability of empirical populationbased H. pylori eradication efforts. The study does not assess the frequency of recrudescence and reinfection. Authors
and an editorialist note the lack of definitive evidence that mass treatment would reduce incidence of gastric cancer.
The editorialist also cautions about potential consequences of population-wide treatment, including adverse drug
reactions and antibiotic resistance of H. pylori and other bacteria.
Sunscreen Is Expensive
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Sun-protective clothing and bulk buying can help reduce the cost.
Skin cancer incidence is rising in the Western world. Ultraviolet (UV) radiation is a known
carcinogen and sun-protection strategies, including sunscreen use, have long been advocated.
However, many individuals fail to use sunscreen adequately. Sunscreen cost may contribute to poor
compliance.
Investigators performed a cost analysis study of sunscreen needs in two scenarios: a family of four on
a 1-week beach vacation (4 hours/day in the sun, females in bikinis, males in swim trunks, reapplying
sunscreen twice for adults and 3 times for children, no other sun-protective measures taken), and a
transplant patient using sunscreen year round.
The researchers evaluated costs of 607 sunscreens from 17 Internet drugstores in seven countries
(Europe and North America). Median sunscreen price was US$1.70 per 10 g. Assuming that standard
sunscreen application recommendations (2 mg/cm2) were followed, the median cost to the family
varied from $178.20 per week (if children were 2-year-olds) to $238.40 per week (if children were
10-year-olds). The cost decreased by 33% if the family wore UV-protective T-shirts and by 41% if
large-volume bottles were used (price per gram was less for larger bottles) — both strategies
combined produced a 58% decrease in cost. The median cost to the transplant patient varied from
$245.30 to $292.30 per year.
The authors conclude that the cost of sunscreen for a weeklong vacation seems acceptable if sunprotective clothing is worn and larger-bottle sunscreens are purchased. Conversely, for sun-sensitive
individuals requiring year-round protection, the annual cost is relatively high, and patients may
require financial assistance to be compliant.
Comment: Sun-protection behaviors are complex, but there is no doubt — sunscreen is expensive.
Buying in bulk and wearing sun-protective clothing greatly decreases sunscreen cost. A sunprotective shirt also offers better protection than sunscreen alone during water sports — very few
individuals will interrupt their activity every 1 to 2 hours to reapply sunscreen. In addition, sunprotective shirts and hats can last more than one summer, making them money savers in the long run.
Cranberries vs. TMP-SMX to Prevent
Urinary Tract Infections
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Trimethoprim-sulfamethoxazole was better, at the expense of greater antibiotic
resistance.
Premenopausal women who experience recurrent urinary tract infections (UTIs) are
sometimes prescribed low-dose antibiotic prophylaxis. Growing concern about
antibiotic resistance, coupled with many patients' desire for nonpharmacologic remedies,
has led to renewed interest in cranberry consumption for UTI prophylaxis. The
presumed mechanism is prevention of bacterial adhesion to uroepithelial cells by
proanthocyanidins, a constituent of cranberries.
In a double-blind study, Dutch investigators randomized 221 women (median age, 35)
who reported having a median of 6 to 7 UTIs in the previous year to receive either
cranberry extract (500 mg twice daily) or trimethoprim-sulfamethoxazole (TMP-SMX;
480 mg nightly). During 12 months of treatment, cranberry-extract recipients had a
mean of 4 symptomatic UTIs compared with a mean of 1.8 in the TMP-SMX group — a
significant difference; the median time to first recurrence was 4 months in the cranberry
group and 8 months in the antibiotic group. Adverse events did not differ between
groups, but the dropout rate was about 50% in both.
Comment: Whereas cranberry extract recipients had fewer UTIs than they did in the
preceding year, TMP-SMX was more effective. However, antibiotic resistance to TMPSMX developed in >85% ofEscherichia coli strains in women taking the antibiotic,
compared with <30% in those taking cranberry extract. Unfortunately, cranberry juice
was no better than placebo for preventing UTIs in a recent study (JW Gen Med Jan 20
2011); whether cranberry or one of its constituents ultimately will prove to be clinically
useful remains unclear.
Regular Updates of Family History Can Change Cancer Screening
Recommendations
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Updates are recommended every 5 to 10 years.
Family history of cancer can influence screening recommendations, particularly for
colorectal, breast, and prostate cancers. Little is known about the value of regular
updates of family history. Researchers used a U.S. population-based registry of people
with personal or family histories of cancer to assess changes in family cancer history
retroactively (from birth to study enrollment in about 12,000 people) and prospectively
(from enrollment for a median of 8 years in a subset of about 2000 people).
Clinically relevant family history that would influence screening recommendations
increased with age for all three evaluated cancers. For example, as patients aged from 30
to 50, 5% had clinically significant changes in family histories of colorectal cancer, and
4% had changes for breast cancer. Roughly 2 to 4 per 100 women would have clinically
significant changes in family histories in each age decade (20–29, 30–39, and 40–49),
based on both retrospective and prospective assessments.
Comment: The full study provides additional helpful information, but the main point is
that clinically significant changes in a patient's family history of cancer occur with
sufficient frequency that clinicians should update family history on a regular basis —
the authors recommend every 5 to 10 years — particularly between the ages of 30 and
50. Once elevated risk has been identified, the challenge then is to overcome the many
barriers to appropriate screening.
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Physical Activity and Cognitive
Health, Revisited
Rx: 30 minutes of brisk walking daily to maintain cognition despite vascular risk factors
Cerebrovascular disease risk factors are known to be associated with cognitive decline. Recent
epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining
cognitive health. To assess the effect of physical activity on cognition in the setting of
cerebrovascular disease, researchers conducted a retrospective subgroup analysis of more than 2800
female health professionals (age 65) with at least three vascular risk factors (e.g., diabetes mellitus,
hypertension, hyperlipidemia, body-mass index 30, family history of premature myocardial
infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an
initial global cognitive evaluation. The cognitive evaluation was conducted via telephone; 81% of the
respondents completed at least three assessments at 2-year intervals. All instruments were previously
validated.
Women in the two highest quintiles of physical activity level — equivalent to brisk walking 30
minutes daily — had significantly slower rates of cognitive decline than those in the lowest quintile.
When the data were compared to an analysis of age-associated cognitive decline, participants in the
two highest quintiles of physical activity were cognitively 5 to 7 years "younger" than those in the
lowest quintile. A secondary analysis specific to walking showed a possible threshold effect, with at
least 30 minutes of brisk daily walking required for significant cognitive benefit.
Comment: This analysis adds to a growing body of literature emphasizing the role of physical
exercise throughout the life span as an important modifiable risk factor in maintaining cognitive
health, even in the context of cerebrovascular risk factors. Although the self-report of physical
activity is a potential confounder in this study, another study published in the same journal issue used
an objective measure of energy expenditure and showed similar results in a mixed-sex cohort (Arch
Intern Med 2011; 171:1251). On the basis of the accumulating evidence correlating physical exercise
with cognitive health, a prescription for a daily walk should quite literally be "just what the doctor
ordered."
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ABCD2 Score Might Be Poor
Predictor of Stroke Risk
Sensitivity of the score was poor in a cohort of emergency department TIA patients with
a 1.8% incidence of stroke at 7 days.
The ABCD2 score (Age, Blood pressure [BP], Clinical features,Duration of symptoms,
and Diabetes) was developed to predict which patients with transient ischemic attack
(TIA) might be at high risk for stroke, but it has not been prospectively validated in a
large study. In this prospective, multicenter Canadian study, researchers assessed the
accuracy of the ABCD2 score in 2056 patients (mean age, 68) with emergency
department diagnoses of TIA or minor stroke.
Physicians completed ABCD2 data forms and calculated the score for each patient. (The
score assigns 1 point each for age 60, BP 140/90 mm Hg, impaired speech without
weakness, duration of symptoms 10–59 minutes, and diabetes and assigns 2 points each
for unilateral weakness and duration of symptoms 60 minutes.)
The overall incidence of stroke at 7 days was 1.8%. An ABCD2 score >5 had a
sensitivity of 32% and a specificity of 87% for predicting stroke at 7 days. At the
American Heart Association recommended score cutoff of >2, sensitivity increased to
95% but specificity dropped to 13%.
Comment: In this study, no ABCD2 score cutoff reliably predicted TIA patients at risk
for stroke. A cutoff of >5 missed too many at-risk patients. Use of a lower cutoff
improved sensitivity, but the reduced specificity would lead to testing many patients
who are not at risk. In this population with a 1.8% overall incidence of stroke at 7 days,
the ABCD2 score was not an accurate screening tool.
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When LP Is Not Necessary to
Detect Subarachnoid Bleed
CT performed within 6 hours of symptom onset in neurologically intact patients had 100% negative
predictive value in this prospective multicenter study.
Standard teaching is that lumbar puncture (LP) is essential in patients with suspected subarachnoid
hemorrhage (SAH) despite normal head computed tomography (CT) scans. Researchers
prospectively enrolled 3132 consecutive neurologically intact patients older than 15 who underwent
head CT with third-generation multislice scanners to evaluate nontraumatic acute headache or
headache with syncope at 11 tertiary emergency departments in Canada from 2000 to 2009. LP was
performed at the discretion of the treating physician. Experienced radiologists who were blinded to
the study interpreted all CT scans. SAH was defined by subarachnoid blood on CT, aneurysm on
cerebral angiography, or xanthochromia in cerebrospinal fluid.
Mean headache peak pain severity was 8.7 on a 0–10 scale. LP was performed in 49% of patients
after negative CT scans. Overall, 240 patients (7.7%) were diagnosed with SAH. The sensitivity of
head CT for SAH was 92.9%, and the negative predictive value (NPV) was 99.4%. Emergency
physicians identified all but three cases of SAH; all three patients were scanned >6 hours after
headache onset. Among 953 patients who were scanned within 6 hours of symptom onset, head CT
had 100% sensitivity and 100% NPV. Follow-up at 1 and 6 months did not identify any cases of
missed SAH.
Comment: Because subarachnoid blood diffuses and hemolyzes within hours, CT might not be able
to distinguish cerebrospinal fluid from blood as time passes. Patients with histories that raise concern
for SAH should be prioritized to undergo CT within 6 hours of symptom onset. If CT is performed
with a modern scanner and is interpreted as negative for SAH by an experienced radiologist, LP is
unnecessary, unless it is being performed to detect other causes of headache.
Safety of Attention-Deficit/Hyperactivity Disorder
Medications in Children and Adolescents
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The absolute risk for cardiovascular events in stimulant users was low and did not differ
significantly from risk in nonusers.
The American Heart Association recommendation to obtain electrocardiograms in
children and adolescents taking stimulants for attention-deficit/hyperactivity disorder
(ADHD) raised concerns about the safety of these drugs (JW Pediatr Adolesc Med Apr
30 2008). In an industry-supported study, investigators analyzed data from two U.S.
administrative databases (1999–2006) to compare rates of severe cardiovascular events
(sudden death or ventricular arrhythmia, stroke, or myocardial infarction) among
241,417 children aged 3 to 17 years who received a first prescription for amphetamine,
atomoxetine, or methylphenidate and 945,668 nonusers (matched for data source, sex,
state, and age). Median follow-up was 135 days of active use for users and 609 days for
nonusers.
Rates of validated sudden death or ventricular arrhythmia and of all-cause mortality did
not differ significantly between users and nonusers of stimulants (hazard ratios, 1.60
[95% confidence interval, 0.19–13.60] and 0.76 [95% CI, 0.52–1.12], respectively). In
both users and nonusers, review and validation of cardiovascular events from medical
records was possible for only half the children (155 records).
Comment: These data suggest that ADHD medications do not confer increased risk for
severe cardiovascular events. Although review and validation of medical records was
possible for only half the children with cardiovascular events, the medical record
retrieval rate was similar in users and nonusers.
Stable Patients with Pulmonary Embolism
Can Be Treated as Outpatients
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In a randomized trial of outpatient versus inpatient care, outcomes did not differ
between groups.
Typically, diagnosis of pulmonary embolism (PE) means certain admission. Researchers
performed an open-label, randomized, noninferiority study to compare outcomes of
outpatient and inpatient treatment in consecutive adult patients who presented to 19
emergency departments in Europe and the U.S. with symptomatic PE and risk for death
less than 4% (based on the PE Severity Index; see table). Patients were excluded if they
had oxygen saturation <90% on room air, systolic blood pressure <100 mm Hg, chest
pain requiring opioids, active bleeding, or were at high risk for hemorrhage (recent
stroke or gastrointestinal bleeding or platelet count >75,000/mm3). All patients initially
received subcutaneous enoxaparin (1 mg/kg twice daily) followed by anticoagulation
with vitamin K antagonists for at least 90 days.
Overall, the study included 171 outpatients (mean age, 47) and 168 inpatients (mean
age, 49). Cancer prevalence was 1% and 2%, respectively. Within 90 days, one patient
in each group died, neither from PE. Recurrent venous thromboembolism occurred in
only one patient (outpatient group). Major bleeding occurred within 90 days in three
outpatients (intramuscular hematoma on day 3 and day 13 and menometrorrhagia on day
50) and no inpatients. At 14 days, more than 90% of patients in both groups were
satisfied or very satisfied with treatment.
Comment: These data suggest that stable low-risk patients with PE can be safely and
effectively treated as outpatients with low-molecular-weight heparin. The results might
not be applicable to older patients than those in this study or to patients with cancer.
Guidelines for Delirium
Prevention in At-Risk Adults
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U.K. national guidelines provide 13 specific recommendations for a multidisciplinary intervention.
Delirium, a common and costly problem among hospitalized elders, has been associated with longer hospital stays,
greater relative likelihood of being discharged to a nursing home, and risk for subsequent dementia and death. Now,
the U.K.'s National Institute for Health and Clinical Excellence (NICE) has published guidelines on the prevention of
delirium in both surgically and medically managed hospitalized adults; members of the guideline development group
provided a summary report.
The guidelines are based on a systematic review that ultimately identified eight studies of multicomponent
interventions to prevent delirium, although only two studies were of moderate or high quality. The guidelines contain
13 recommendations for interventions that could be tailored to individual patients at high risk for delirium, defined as
those older than 65 and those with cognitive impairment, severe illness, or hip fracture.
The recommendations emphasize a multidisciplinary, team–oriented approach that addresses cognitive impairment,
dehydration, hypoxia, infection, immobility, pain, poor nutrition, medication overuse, vision and hearing impairment,
and sleep deprivation. The authors conclude that this approach could reduce delirium incidence by one third. Results
of a cost-effectiveness analysis suggest that the approach would save £8180 per surgically treated patient and £2200
per medically treated patient.
Comment: The NICE clinical guidelines highlight relatively simple, holistic, patient-centered interventions that have
been shown to prevent delirium in at-risk hospitalized adults, albeit only in two relatively small, single-center studies
of moderate to high quality. At the same time, the guidelines highlight the paucity of data on delirium prevention,
despite the prevalence, adverse medical consequences, and economic impact of the condition. A large, multicenter
clinical trial is clearly needed to confirm the effectiveness of the recommended interventions; however, because they
pose little risk for harm and are likely to be cost-effective, it makes sense for hospitals to explore how to implement
them. The NICE guidelines potentially set the standard of care for delirium prevention; at the least, they represent a
roadmap for future multicenter studies. Regardless, they are a major step forward.
Triglycerides and Cardiovascular Disease: The Experts Speak
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Experts redefine an optimal triglyceride level and stress that lifestyle changes are required to reach it.
While debate continues about whether hypertriglyceridemia independently predicts coronary artery disease, mean
triglyceride levels in the U.S. are rising, along with rates of obesity and diabetes. In a new scientific statement, the
American Heart Association (AHA) outlines the scope of the problem and offers treatment recommendations.
Triglyceride levels directly influence high- and low-density lipoprotein metabolism, and hypertriglyceridemia can be
mediated genetically or acquired (e.g., in patients with hypothyroidism, diabetes, or renal disease).
The authors propose a "practical algorithm" for initial screening with nonfasting triglyceride measurement. If levels
are <200 mg/dL (corresponding to <150 mg/dL on a fasting sample), they suggest that patients continue with healthy
diet and activity levels. At levels 200 mg/dL, fasting lipoprotein measurement is advised, and suggested targets are
provided for weight loss and intake of dietary carbohydrates, sugars, and fats. Increased physical activity and intake
of -3 fatty acids also are advocated for their profound effects on elevated triglyceride levels. At the highest
triglyceride levels or in symptomatic patients, pharmacologic therapy can be useful (e.g., to lower risk for pancreatitis
in patients with triglycerides >500 mg/dL). At all triglyceride levels, the AHA recommends avoiding consumption of
trans fats, which raise triglyceride levels and atherogenic lipid particles. Finally, the guidelines set <100 mg/dL as an
optimal triglyceride level.
This statement summarizes what we know about triglycerides and their relation to disease and provides a framework
for treating the many patients with suboptimal triglyceride levels (see JW Cardiol Jul 13 2011 for additional
commentary from Harlan Krumholz). Patients should be advised that lifestyle changes in diet, weight loss, and
exercise are basic to treating most cases of hypertriglyceridemia, although tightening the definition of an optimal
triglyceride level could inadvertently invite additional prescribing.
— Kirsten E. Fleischmann, MD, MPH
AN ADDITIONAL PERSPECTIVE FROM the Journal Watch general medicine EDITOR-in-chief:
In this AHA-sponsored statement, the authors acknowledge that the evidence for triglycerides as an independent
predictor of cardiovascular events (i.e., after adjustment for other lipid fractions) remains controversial. They also
acknowledge the lack of convincing clinical-trial evidence to support triglyceride-lowering drug therapies,
independent of LDL-cholesterol–lowering or statin therapy; indeed, no benefit was seen in the recent AIM-HIGH
study. Hence, this statement is somewhat self-contradictory: If drugs are not indicated (except to lower risk for
pancreatitis when triglycerides are extremely elevated), and if lifestyle modifications that happen to lower
triglycerides are worthwhile regardless of triglyceride levels, why should we closely monitor triglyceride levels? I am
unaware of evidence that patients who track their triglyceride levels are more motivated to exercise, lose weight, and
eat a heart-healthy diet than are patients who receive similar counseling without following triglycerides. A move to
more-intense focus on triglyceride levels, and to a more stringent definition of "optimal" triglycerides, thus seems
unnecessary and misguided.
All the following are examples of
normal cognitive changes that
occur with aging, except:
A) Delayed recall
B) Disorientation
C) Difficulty finding words or
names
D) Slowed information
processing
Answer
• B) Disorientation
Which of the following is the
most likely diagnosis in a patient
with mild cognitive impairment
affecting memory only?
A) Depression
B) Vascular dementia
C) Frontal temporal dementia
D) Lewy body dementia
Answer
• A) Depression
Unsafe driving increases when
personality is characterized as:
A) Forgetful
B) Introverted
C) Aggressive
D) Anxious
Answer
• C) Aggressive
Which of the following is(are)
associated with increased risk for
unsafe driving?
A) Clinical rating score ≥0.5
B) Marginal or unsafe driving
rating given by caregiver
C) History of serious traffic
issues
D) All the above
Answer
• D) All the above
Falls occurring in women are less
likely to cause _______ and
twice as likely to cause _______
as those in men.
A) Death; fractures
B) Fractures; death
Answer
• A) Death; fractures
Which of the following statements about risk
of developing breast cancer is incorrect?
A) Breast cancer represents 26% of all
cancers (excluding skin cancer) in women
B) 40% of woman with breast cancer have a
family history of the disease
C) Breast-feeding for >1 yr is recommended
for risk reduction
D) Early child-bearing is associated with
reduced risk
Answer
• B) 40% of woman with breast cancer have
a family history of the disease
Studies on the effects of vitamin
E supplementation showed an
increase in which of the
following conditions?
A) Uterine and breast cancers
B) Colon and breast cancers
C) Breast cancer and macular
degeneration
D) Coronary artery disease and
congestive heart failure
Answer
• D) Coronary artery disease and congestive
heart failure
Aspirin has been shown to be
highly effective for preventing
myocardial infarction in women.
A) True
B) False
Answer
• B) False
Bilateral oophorectomy before
menopause increases the rate of
all the following, except:
A) Osteoporosis
B) Parkinson disease
C) Lung cancer
D) Breast cancer
Answer
• D) Breast cancer
Which of the following has not been
shown to be a benefit of drinking
one to two glasses of alcoholic
beverage each day?
A) Reduced risk for cardiovascular
disease
B) Reduced all-cause mortality
C) Reduced risk for breast cancer
D) Increased insulin sensitivity
Answer
• C) Reduced risk for breast cancer
CLINICAL TOPIC: FETAL ALCOHOL
SYNDROME
Which one of the following includes all 3 facial
abnormalities associated with fetal alcohol
syndrome? (check one)
A. Low-set ears, large eye openings, large forehead.
B. Small palpebral fissures, smooth philtrum, thin
vermilion border.
C. Large palpebral fissures, smooth philtrum, thin
vermilion border.
D. Large forehead, flattened cheeks, small eyes.
E. Thin vermilion border, distinct upper lip,
esotropia.
Answer
• B. Small palpebral fissures, smooth
philtrum, thin vermilion border.
CLINICAL TOPIC: FETAL ALCOHOL
SYNDROME
Which one of the following secondary disabilities is
experienced by individuals with fetal alcohol
syndrome? (check one)
A. Increased incidence of depression.
B. Decreased IQ.
C. Inability to live independently.
D. Increased likelihood to experience trouble with
the law.
E. All of the above.
Answer
• E. All of the above.
CLINICAL TOPIC: FETAL ALCOHOL
SYNDROME
Which one of the following provides a clue to
fetal alcohol effects? (check one)
A. Microcephaly.
B. Growth delays.
C. Cardiac defects.
D. Clinodactyly.
E. All of the above.
Answer
• E. All of the above.
CLINICAL TOPIC: FETAL ALCOHOL
SYNDROME
Which one of the following groups is at high
risk of fetal alcohol syndrome? (check one)
A. Individuals who flush when they ingest
alcohol.
B. Individuals with low socioeconomic
status.
C. Individuals with poor nutrition.
D. All of the above.
E. None of the above.
Answer
• D. All of the above.
CLINICAL TOPIC: FETAL ALCOHOL
SYNDROME
Which one of the following statements regarding
fetal alcohol syndrome (FAS) is true? (check one)
A. The US Preventive Services Task Force
recommends screening and behavioral interventions
to reduce alcohol misuse by adults, including
pregnant women, in primary care settings.
B. Alcohol use during the second trimester is
associated with spontaneous abortion.
C. FAS is associated with radioulnar synostosis.
D. All of the above.
E. None of the above.
Answer
• D. All of the above.
CLINICAL TOPIC: FETAL
ALCOHOL SYNDROME
There is a standard amount and
type of alcohol that is safe for
pregnant women to
consume. (check one)
A. True
B. False
Answer
• B. False
HYPERTENSION MANAGEMENT IN
OLDER PATIENTS
Hypertension is a major risk factor for which
one of the following conditions? (check one)
A. Myocardial infarction.
B. Stroke.
C. Congestive heart failure.
D. Atrial fibrillation.
E. All of the above.
Answer
• E. All of the above. Book said C online E
is correct and I agree. JD
HYPERTENSION MANAGEMENT IN
OLDER PATIENTS
Which one of the following statements most
accurately describes stovepipe
syndrome? (check one)
A. Reduction in renal function.
B. Rapid blood pressure elevation.
C. Rigidity of the blood vessels.
D. All of the above.
E. None of the above.
Answer
• C. Rigidity of the blood vessels.
HYPERTENSION MANAGEMENT IN
OLDER PATIENTS
The HYpertension in the Very Elderly Trial
(HYVET) study showed that management of
hypertension in elderly patients leads to which
one of the following outcomes? (check one)
A. Increases the relative risk of stroke.
B. Decreases cardiovascular-related
mortality.
C. Increases all-cause mortality.
D. All of the above.
E. None of the above.
Answer
• B. Decreases cardiovascular-related
mortality.
HYPERTENSION MANAGEMENT IN
OLDER PATIENTS
Which one of the following drugs is
associated with an elevated blood
pressure? (check one)
A. Nonsteroidal anti-inflammatory drugs.
B. Corticosteroids.
C. Bromocriptine.
D. Pseudoephedrine.
E. All of the above.
Answer
• E. All of the above.
HYPERTENSION
MANAGEMENT IN OLDER
PATIENTS
Individuals 65 years and older
have a 90% probability of
developing hypertension. (check
one)
A. True
B. False
Answer
• A. True
HYPERTENSION
MANAGEMENT IN OLDER
PATIENTS
Serum creatinine measurement is
a sensitive marker of reduced
renal function in older
patients. (check one)
A. True
B. False
Answer
• B. False
HYPERTENSION
MANAGEMENT IN OLDER
PATIENTS
Pet ownership is associated with
reduced blood pressure in elderly
patients. (check one)
A. True
B. False
Answer
• A. True
HYPERTENSION MANAGEMENT IN
OLDER PATIENTS
Increasing the dosage of hydrochlorothiazide
to 50 mg 2 times/day correlates with
improved blood pressure control in older
patients with stovepipe syndrome. (check
one)
A. True
B. False
Answer
• B. False
COLON CANCER SCREENING
Which one of the following is true for colon
cancer? (check one)
A. Capsule endoscopy detects 95% of colon cancers
detected by optical colonoscopy.
B. Family physicians who obtain colonoscopy
detect colon cancer at lower rates than
gastroenterology subspecialists.
C. The best predictor of being up-to-date for colon
cancer screening is having a personal healthcare
professional.
D. Crohn disease does not increase the risk of colon
cancer.
Answer
• C. The best predictor of being up-to-date
for colon cancer screening is having a
personal healthcare professional.
COLON CANCER
SCREENING
Patients with familial
adenomatous polyposis typically
develop colon cancer by age 40
years. (check one)
A. True
B. False
Answer
• A. True
COLD AND COUGH
MEDICATIONS; VITAMIN E
The voluntary withdrawal of cough and
cold medications for children younger
than 2 years has been associated with a
decrease in the number of adverse
effect–related emergency department
visits. (check one)
A. True
B. False
Answer
• A. True
COLD AND COUGH
MEDICATIONS; VITAMIN E
Vitamin E supplement use is
associated with a statistically
significant decrease in stroke
compared with placebo. (check
one)
A. True
B. False
Answer
• B. False
During the past decade, the rate
of obesity in the United States
has _______.
A) Increased
B) Decreased
C) Stabilized
D) Demonstrated no discernible
trend
Answer
• C) Stabilized
Normal exercise has been proven
to be an excellent short-term
weight-loss strategy.
A) True
B) False
Answer
• B) False
Which of the following diets has
been shown to produce weight
loss and health benefits superior
to those associated with the other
options?
A) High-protein
B) High-carbohydrate
C) Balanced macronutrient
D) None of the above
Answer
• D) None of the above
Which of the following is not
associated with successful longterm maintenance of weight loss?
A) One-half hour of moderate
exercise 3 days/wk
B) Regular self-monitoring of
weight
C) Consistent daily protocol
D) Grazing (ie, frequent small
meals)
Answer
• A) One-half hour of moderate exercise 3
days/wk
Medications for weight loss
generally produce a reduction in
weight of _______ of initial body
weight.
A) ≈2%
B) ≈5%
C) ≈10%
D) ≈15%
Answer
• B) ≈5%
During pregnancy, obese women
have an increased risk for:
A) Diabetes
B) Stillbirth
C) Wound complications
D) All the above
Answer
• D) All the above
At baseline, obese women have
an increased risk for unplanned
pregnancy, compared to
nonobese women.
A) True
B) False
Answer
• B) False
Which of the following
contraceptive methods is
contraindicated in obese women?
A) IUDs
B) Oral contraceptives
C) Hormone patch
D) None of the above
Answer
• D) None of the above
All the following are limitations of
current data on the efficacy of
contraception in obese women, except:
A) Obese women are often excluded
B) Most studies are observational
C) Most studies focus on barrier methods
of contraception
D) There is little pharmacokinetic data
Answer
• C) Most studies focus on barrier methods of
contraception
Of the following contraception
methods, which has been
associated with a 5-lb weight
gain during the first year of use?
A) Intrauterine devices (IUDs)
B) Etonogestrel implant
(Implanon)
C) Depot medroxyprogesterone
acetate (Depo-Provera)
D) Hormone patch
Answer
• C) Depot medroxyprogesterone acetate
(Depo-Provera)
A 46-year-old man has a 1-year history of almost daily
nonseasonal nasal congestion associated with a clear nasal
discharge but without sneezing or itchy eyes. Symptoms are
worse on humid days or days when the air quality is poor.
There is no relationship to spicy foods. The patient has not
had headache, facial pain or pressure, fatigue, malaise, fever,
sore throat, cough, or change in sense of smell. Oral
antihistamines do not relieve his symptoms, and he has not
used any nasal sprays. Medical history is significant for
hypertension managed with hydrochlorothiazide. There is no
family history of asthma or hay fever.
Vital signs, including temperature, are normal. Examination
of the nose shows only a clear mucoid discharge. The sclerae
are not erythematous. The lungs are clear to auscultation.
Which of the following is the most likely diagnosis?
AAllergic rhinitis
BChronic sinusitis
CChronic vasomotor rhinitis
DRhinitis medicamentosa
•
•
•
•
Chronic vasomotor rhinitis
This patient has chronic vasomotor (nonallergic) rhinitis, which is caused by increased
sensitivity to irritants in the air. The pathophysiology of vasomotor rhinitis is less clear
than that of allergic rhinitis, but the chemical mediators causing symptoms are similar in
both conditions. Symptoms of vasomotor rhinitis include nasal congestion and
rhinorrhea and may develop after exposure to odors, humidity, temperature change, and
alcohol. Sneezing and itching occur less often than in allergic rhinitis. Some experts
consider the diagnosis one of exclusion. Results of skin tests and radioallergosorbent
tests are normal in patients with vasomotor rhinitis and can be used to differentiate this
condition from allergic rhinitis. Some patients have both allergic and nonallergic
rhinitis. Chronic nonallergic rhinitis is less responsive to therapy than is allergic rhinitis.
Topical intranasal corticosteroids, topical intranasal antihistamine, and topical
ipratropium are the most consistently effective treatments.
Allergic rhinitis is unlikely in this patient because his symptoms are increased by
humidity and pollutants, and there is no seasonal variation in symptoms, no family
history of allergies, and no constitutional symptoms associated with allergic rhinitis. In
addition, most patients develop allergic rhinitis before 20 years of age.
Chronic sinusitis is unlikely in this patient because of the absence of mucopurulent nasal
drainage, facial pain or pressure, or decreased sense of smell.
Rhinitis medicamentosa refers to the syndrome of rebound nasal congestion after
discontinuing topical α-adrenergic decongestant sprays. Symptoms may occur after
using these sprays for 5 or more days and resolve with prolonged discontinuation of
these agents. However, this patient has not used nasal sprays. Rhinitis may be induced
by other drugs, as well. Medications generally associated with drug-induced rhinitis
include aspirin, NSAIDs, oral contraceptive agents, angiotensin-converting enzyme
inhibitors, prazosin, methyldopa, β-blockers, and chlorpromazine.
A 78-year-old man comes for a routine annual physical
examination. The patient feels well. He is accompanied by his
wife, who is concerned about his hearing. The review of
systems is normal, and the patient states that he does not have
any difficulty hearing.
Which of the following is the best way to screen this patient
for hearing impairment?
AAdminister the Screening Hearing Handicap Inventory
BPerform the Weber and Rinne tests
CPerform the whispered-voice test
DRefer for audiometric testing
ENo further evaluation is needed
C Perform the whispered-voice test
• Screening for hearing loss is important in elderly persons because
hearing impairment is prevalent but frequently underdiagnosed in this
population. In addition, significant hearing loss is still possible despite
a patient’s denial of having trouble hearing. A recent systematic review
evaluated the accuracy and precision of office clinical maneuvers for
diagnosing hearing impairment. The whispered-voice test is a quick
and easy assessment tool that has the best test characteristics among
the office maneuvers. This test assesses the ability to hear a whispered
voice with the examiner standing behind the patient 2 feet from the
patient’s ear while occluding and simultaneously rubbing the opposite
external auditory canal and whispering three numbers or letters. Using
a battery-powered handheld audioscope is an acceptable alternative
screening modality.
• The systematic review also found that the Screening Hearing Handicap
Inventory and the Weber and Rinne tests did not perform as well as the
whispered-voice test in detecting hearing impairment.
• Referring patients for formal audiometry, although the gold standard
for evaluating hearing loss, is expensive and time consuming. It is also
unnecessary to do routinely, since a normal result on the whisperedvoice test effectively rules out significant hearing loss.
A 36-year-old man is evaluated for follow-up after a recently obtained
fasting lipid profile that revealed a low HDL cholesterol level. He denies
chest pain. He currently smokes, and has a 10 pack-year smoking history.
He is overweight and does not exercise regularly. There is no family
history of coronary artery disease.
On physical examination, blood pressure is 133/82 mm/Hg and BMI is 29.
Heart examination reveals regular rhythm without murmur or gallop.
Fasting lipid levels are as follows: total cholesterol, 198 mg/dL (5.13
mmol/L); HDL cholesterol, 33 mg/dL (0.85 mmol/L); LDL cholesterol,
129 mg/dL (3.34 mmol/L); and triglycerides, 183 mg/dL (2.07 mmol/L).
Which of the following is the most appropriate management option for
this patient?
AExercise stress test
BGemfibrozil
CNicotinic acid
DPravastatin
ETherapeutic lifestyle modification
The most appropriate management option for this patient is therapeutic lifestyle
modification. This patient’s HDL cholesterol is low, total cholesterol is below 200
mg/dL (5.18 mmol/L), and triglyceride level is borderline high. HDL cholesterol
levels are inversely related to risk for the development of coronary artery disease
(CAD). Patients such as this one, who have low HDL cholesterol as the primary
lipid abnormality and who have no CAD, are managed with therapeutic lifestyle
modification. Because exercise, weight loss, and tobacco cessation raise HDL
cholesterol, physicians should counsel patients about these lifestyle changes.
Although this patient’s risk for the development of CAD is increased because of
his low HDL cholesterol level, his weight, his sedentary lifestyle, and his smoking
status, a cardiac stress test is not indicated because he has no complaints of chest
pain or CAD equivalents.
Medications such as gemfibrozil or nicotinic acid to treat isolated low HDL
cholesterol are only indicated in the setting of CAD. Although in practice,
nicotinic acid is often used for patients such as this one, therapeutic lifestyle
changes should be attempted first.
LDL cholesterol goal is based on the presence or absence of five cardiovascular
risk factors: smoking, hypertension (≥140/90 mm Hg or taking antihypertensive
medication), older age (men ≥45 years, women ≥55 years), low HDL cholesterol
(<40 mg/dL [1.04 mmol/L]), and family history of premature CAD (male firstdegree relative <55 years or female first-degree relative <65 years). This patient
has two major risk factors: cigarette smoking and low HDL cholesterol; therefore,
his LDL cholesterol goal is 130 mg/dL (3.37 mmol/L). A statin is not indicated
because his LDL cholesterol level is already below this goal.
A 21-year-old man is evaluated in the emergency department
1 hour after twisting his ankle while playing basketball. The
pain was immediate and has hurt constantly since. His coach
immediately wrapped his ankle in ice.
On physical examination, there is swelling in the ankle and
significant lateral bruising. It is tender on palpation, but not
on the medial or lateral malleolus. When the foot is inverted
by the examiner, there is no laxity of the calcaneofibular
ligament. The patient is able to ambulate 10 steps with pain.
Which of the following is the next most appropriate
management option?
AAnkle joint corticosteroid injection
BAnkle radiograph
CAnkle splint
DMRI of ankle
•
•
•
C Ankle splint
This patient’s ability to bear weight and the absence of instability on examination are
consistent with a grade I or II ankle sprain. Most patients with grade I sprains, which
involve stretching of a ligament with mild pain and swelling but no joint instability or
difficulty ambulating, do not seek medical care. Grade II sprains involve partial tears
and are accompanied by moderate pain and disability and some difficulty bearing
weight. Grade III sprains involve complete rupture of ligaments with significant
swelling, tenderness, and an inability to bear weight. Fifteen percent of patients with
sprains have complications involving fractures of the ankle or midfoot; however,
decisions about routine radiography should be guided by the Ottawa ankle rules. These
rules do not recommend a radiograph for an ankle injury unless there is bone tenderness
at the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or an
inability to bear weight. A systematic review has determined this instrument to be nearly
100% sensitive and able to reduce the number of unnecessary radiographs by 30% to
40%. Because this patient is able to bear weight and does not have tenderness on the
medial or lateral malleolus, neither plain film radiographs nor an MRI of the ankle
would be appropriate.
The initial management of a sprained ankle is to Protect, Rest, Ice, Compress, and
Elevate the injured ankle (PRICE treatment). The patient should have the PRICE
treatment for 3 days, and then the injury should be reassessed. If the patient does not
improve with conservative therapy, plain radiography may then be employed to look for
fractures that were not apparent on the initial examination.
While an ankle joint corticosteroid injection might be appropriate for certain
inflammatory arthropathies, it is not appropriate in an ankle sprain.
A 65-year-old man with a 2-year history of severe osteoarthritis of the right knee
is evaluated before undergoing total knee replacement surgery. Until 1 month ago,
the patient was able to walk four or more blocks and four flights of stairs but now
can only walk one block because of severe knee pain. He has a 3-year history of
occasional chest pain that occurs less than once each month and develops only
after walking too quickly. There has been no change in the severity or frequency
of the chest pain and no dyspnea. Medical history is significant for a myocardial
infarction 4 years ago, type 2 diabetes mellitus, and hypertension. Current
medications are metoprolol, fosinopril, atorvastatin, insulin glargine, metformin,
and aspirin.
Blood pressure is 140/80 mm Hg, pulse rate is 60/min. BMI is 30. There is no
jugular venous distention. The lungs are clear. There are no murmurs or gallops.
Serum creatinine is 1.5 mg/dL (132.6 µmol/L). An electrocardiogram shows
normal sinus rhythm with Q waves in leads II, III, and aVF; nonspecific ST-T
wave changes; and left ventricular hypertrophy. A chest radiograph is normal.
Which of the following is the most appropriate preoperative cardiac testing?
ACoronary angiography
BDobutamine stress echocardiography
CExercise (treadmill) thallium imaging
DResting two-dimensional echocardiography
ENo additional testing is indicated
E No additional testing is indicated
•
•
•
•
According to the American College of Cardiology/American Heart Association
guidelines, no further preoperative cardiac testing is indicated in a patient without
“active cardiac conditions” (unstable coronary syndrome, decompensated heart failure,
significant arrhythmia, or severe valvular heart disease) who has adequate exercise
capacity. This patient was able to walk four or more blocks until 1 month ago, when his
arthritis symptoms worsened, but he is still considered to have adequate exercise
capacity. Despite multiple cardiac risk factors, he has stable cardiac symptoms and is on
optimal medical therapy with good control of heart rate. A study of intermediatecardiac-risk patients randomized to testing or no testing found no benefit to noninvasive
cardiac testing if the heart rate was adequately controlled with β-blockers.
Coronary angiography is only indicated for patients with severe or unstable coronary
artery disease or significant ischemia detected by noninvasive testing.
The goal of noninvasive testing is to identify a high-risk subgroup of patients who may
benefit from coronary artery revascularization (patients with three or more cardiac risk
factors and five or more abnormal segments on dobutamine stress echocardiography).
Because this patient has adequate exercise capacity and only two clinical cardiac risk
factors (history of ischemic heart disease, diabetes mellitus), noninvasive testing with
dobutamine stress echocardiography would probably not alter management.
Even if the patient described here required cardiac testing, an exercise test (without a
pharmacologic stressor) with nuclear imaging would be inadequate in someone who can
only walk one block because he will not achieve 85% of his maximum heart rate. A
resting echo-cardiogram has not been found to predict ischemic complications, but may
be helpful in a patient with suspected valvular disease or heart failure, which this patient
does not have.
A 45-year-old woman is evaluated because of the gradual onset of rightsided hearing loss and a 3-year history of tinnitus. She does not have ear
pain or drainage, dizziness, or headache. There is no history of trauma to
the ear or excessive exposure to loud noises.
On examination, the patient is unable to hear numbers whispered 2 feet
from the right ear with the left auditory canal blocked. Examination of the
external auditory canals and tympanic membranes is normal. Neurologic
examination is normal. When a tuning fork is placed on the top of her
head, she reports that the sound is heard toward the left ear (Weber test).
Results of audiometry show normal hearing on the left and 45-decibel
high-frequency hearing loss on the right.
Which of the following is the most likely diagnosis?
AAcoustic neuroma
BCholesteatoma
CMeniere disease
DOtosclerosis
EPresbycusis
•
•
•
•
A Acoustic neuroma
This patient most likely has an acoustic neuroma, which is an important cause of
asymmetric sensorineural hearing loss that usually originates from the vestibular portion
of the acoustic nerve. The two major symptoms are hearing loss and tinnitus. Unilateral
hearing loss occurs in approximately 90% of patients with this disorder, but many
patients may be unaware of the deficit. Two thirds of patients have tinnitus. Both
hearing loss and tinnitus are present, on average, slightly more than 3 years prior to
diagnosis, although acoustic neuroma can cause sudden acute hearing loss. Other
symptoms include dizziness and headaches. MRI is the imaging modality of choice
because it is more sensitive than CT for detecting small tumors.
Cholesteatoma is a growth of desquamated, stratified, squamous epithelium within the
middle ear. Patients may present with otorrhea, pain, hearing loss, or neurologic
symptoms. Otosclerosis is a bony overgrowth that involves the footplate of the stapes,
eventually resulting in total fixation and inability to transmit vibration from the
tympanic membrane along the ossicular chain. Cholesteatomas and otosclerosis cause a
conductive hearing loss rather than a sensorineural loss.
Although Meniere disease also causes unilateral sensorineural hearing loss, this is most
often a low-frequency loss. Patients with Meniere disease usually have episodic vertigo
that lasts for several hours and is associated with tinnitus and a sensation of aural
fullness. Occasionally, patients experience episodic low-frequency hearing loss that
develops on a daily, weekly, or monthly basis and remits within 12 to 24 hours.
Presbycusis is the term used to describe sensorineural hearing loss associated with
aging. It is typically symmetric, starts in the high-frequency range, becomes more
noticeable in the sixth decade, and steadily progresses. Patients experience problems
understanding speech in a crowded or noisy environment and often have tinnitus.
Unilateral or asymmetric hearing loss is not typical for presbycusis and requires further
•
•
B “Get up and go” test
Risk factors for falling include lower extremity weakness, gait deficit, arthritis, impaired
activities of daily living, female sex, and age over 80 years. Other risk factors for falls
include balance deficits, impaired vision, depression, cognitive impairment,
psychotropic drug use, and use of an assistive device. Because falls often have multiple
causes and more than one predisposing risk factor, there is no standard diagnostic
evaluation for patients who fall or are at risk for falling. However, evaluations should
begin with balance and gait screening, such as the “get up and go” test. The “get up and
go” test is appropriate for screening because it is a quantitative evaluation of general
functional mobility. A strong association exists between performance on this test and a
person’s functional independence in activities of daily living. Persons are timed in their
ability to rise from a chair, walk 10 feet, turn, and then return to the chair. Most adults
can complete this task in 10 seconds, and most frail elderly persons, in 11 to 20 seconds.
Those requiring more than 20 seconds should undergo a fall evaluation. Typically, this
consists of a focused history and physical examination, much of which has already been
performed in this patient. Further evaluation, including measurement of 25hydroxyvitamin D levels, should be directed according to findings of the evaluation.
Interventions to prevent falls should be tailored to the patient’s needs.
A CT scan of the head, 24-hour electrocardiographic monitoring, and echocardiography
are not routine studies for fall evaluation and should not be done before balance and gait
screening.
A 58-year-old man is evaluated as a new patient. He
reports that he is healthy, he drinks one martini
before dinner, and has wine with dinner. There is no
family history of alcohol problems. He has recently
retired.
Which of the following is the best choice to screen
this patient for alcohol problems?
AAlanine and aspartate aminotransferase
concentrations
BCAGE questionnaire
CComplete blood count and mean corpuscular
volume
DEthanol level
•
•
•
•
•
•
•
•
•
B CAGE questionnaire
Alcohol abuse may be difficult to diagnose. Patients often present with complaints that may be
attributable to other medical conditions but actually are caused by alcohol consumption. These
problems might include depression, insomnia, injuries, gastroesophageal reflux disease, uncontrolled
hypertension, and important social problems. Other potential clues to alcohol misuse are recurrent
legal or marital problems, absenteeism or loss of employment, and committing or being the victim of
violence. The U.S. Preventive Services Task Force (USPSTF) recommends routine screening of
adults with either directed questioning or use of a standardized tool to identify persons whose alcohol
use puts them at risk. More likely to be at risk are those with prior alcohol problems, young adults,
and smokers. The USPSTF found good evidence that brief behavioral counseling interventions with
follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to
12-month periods or longer.
Although the optimal interval for screening is not known, screening at the time of an initial visit is
clearly important. There are multiple screening instruments; the CAGE questionnaire is one of the
most widely used. Two positive responses indicate that further assessment for alcohol misuse is
warranted.
C Have you ever felt you should cut down on your drinking?
A Have people annoyed you by criticizing your drinking?
G Have you ever felt bad or guilty about your drinking?
E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid
of a hangover?
The CAGE questionnaire has a reported sensitivity ranging from 43% to 94% and specificity ranging
from 70% to 97%.
Laboratory tests such as an elevated mean corpuscular volume (sensitivity 63%; specificity 48%) and
an elevated aspartate aminotransferase/alanine aminotransferase ratio (sensitivity 12%; specificity
91%) can be suggestive but are not diagnostic of alcohol abuse and dependence. Their relatively low
sensitivities make them unsuited for screening.
Because of the short half-life of ethanol, a random ethanol level should not be used to screen for
alcoholism.
A 75-year-old man treated with a fentanyl patch for chronic pain due to
spinal stenosis seeks advice regarding the use of alternative therapies to
help with pain relief. He does not want surgery but does not feel he has
been getting sufficient pain relief with the fentanyl, and did not like the
sedation that was associated with oral narcotics in the past. His medical
history is significant for atrial fibrillation, hypertension, hyperlipidemia,
and type 2 diabetes mellitus. Current medications are warfarin,
hydrochlorothiazide, and metformin. He denies anhedonia or feeling
down, depressed, or hopeless. On examination, there is no tenderness over
the spine or paraspinous muscles, and no tightness or spasm of the
paraspinous muscles is detected.
Which of the following is the best management option for this patient?
AGinkgo
BGraduated exercise program
CLocal application of ice
DSt. John’s wort (Hypericum)
ETraction
•
•
•
B
Graduated
exercise
program
A systematic review jointly conducted by the American Pain Society and the
American College of Physicians found that exercise is slightly to moderately
superior to no treatment for chronic low back pain for pain relief at earliest
follow-up. Several other reviews drew similar conclusions, and one review
identified reduced sick leave in the first year, as well as a higher percentage of
patients returning to work at 1 year. Other nonpharmacologic methods with
some evidence to support them include cognitive-behavioral therapy, spinal
manipulation, and interdisciplinary rehabilitation.
Ginkgo should be discouraged for this patient. While there are some studies of
debatable quality suggesting potential benefits with ginkgo in depression,
anxiety, and memory difficulties, there is very little evidence of efficacy in
chronic pain. More concerning for this particular patient is that ginkgo can
increase bleeding time or cause spontaneous hemorrhage.
There is some evidence of modest benefit with the local application of heat for
chronic low back pain, but none for ice. Although St. John’s wort is unlikely to
be harmful, it is also unlikely to be of significant benefit, as the only condition
for which it has some evidence of efficacy is mild to moderate depression. The
Cochrane review of therapies for low back pain found that traction was no
better than placebo, sham, or no treatment for any reported outcome.
A 57-year-old woman is seen following a stenting procedure
of the left main coronary artery. The patient has type 2
diabetes mellitus. Her father had a myocardial infarction at
age 62 years. Current medications are rosuvastatin, 40 mg/d;
aspirin, 81 mg/d; and glipizide, 10 mg/d.
On physical examination, blood pressure is 152/92 mm Hg.
Lungs are clear. Cardiac examination reveals no murmurs,
and the point of maximal impulse is not displaced. Fasting
lipid levels are as follows: total cholesterol, 200 mg/dL (5.18
mmol/L); HDL cholesterol, 42 mg/dL (1.09 mmol/L); LDL
cholesterol, 121 mg/dL (3.13 mmol/L); triglycerides, 183
mg/dL (2.07 mmol/L). Hemoglobin A1c is 6.9%.
Which of the following is the most appropriate treatment for
this patient?
AAdd a second lipid-lowering drug
BIncrease the dose of rosuvastatin
CSubstitute fenofibrate for rosuvastatin
DSubstitute metformin for glipizide
•
•
•
•
A Add a second lipid-lowering drug
LDL cholesterol should be less than 100 mg/dL (2.59 mmol/L) in patients with coronary artery
disease (CAD) or CAD-equivalent disease. In patients at very high risk, decreasing LDL cholesterol
to less than 70 mg/dL (1.81 mmol/L) is considered a therapeutic option. This patient is at very high
risk of future major cardiac events because she has diabetes mellitus and CAD. Most authorities
would recommend using more aggressive drug therapy by adding a second lipid-lowering drug to
further lower LDL cholesterol in patients such as this one.
Although increasing the statin dose for patients still above their LDL goal is a therapeutic option
often employed in practice, the incremental reduction in LDL cholesterol by increasing the dose of a
statin that is already near the maximal recommended dose is less than that which could be achieved
by using combination therapy. In this patient, rosuvastatin is already at the maximum recommended
dose. Adding a resin, nicotinic acid, or ezetimibe are reasonable options. Although the ENHANCE
trial did not show a benefit of adding ezetimibe to simvastatin when carotid intimal thickness was
used as the outcome, the American College of Cardiology Statement on the ENHANCE trial
(www.acc.org/enhance.htm ) concluded that major decisions could not be made on the basis of that
trial and that ezetimibe remains a reasonable option for patients who cannot tolerate statins or do not
reach goal with statins alone. Adding gemfibrozil in this patient would require lowering the dose of
rosuvastatin to reduce the risk of myopathy. Because fenofibrate does not interfere with statin
catabolism, there is less risk of myopathy if this is the fibrate chosen.
Substituting fenofibrate for rosuvastatin would further lower the triglyceride level, but, despite the
fact that this patient’s non-HDL cholesterol (158 mg/dL [4.09 mmol/L]) is above her goal of 130
mg/dL (3.37 mmol/L), LDL cholesterol lowering is the higher priority in this very-high-risk patient.
Substituting metformin for glipizide may have a beneficial effect on this patient’s diabetes control,
but her hemoglobin A1c is already less than 7%, and LDL cholesterol lowering is the higher priority.