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1
Back Pain Addiction
SECTION ONE: GENERAL TREATMENT
APPROACHES TO LOW BACK PAIN
Your patient with chronic back pain returns for follow-up
after having visited a therapist who performed spinal
manipulation. He is happy with the result and asks about
using manipulation to prevent further pain episodes. Which
one of the following should you tell him? (check one)
A. Evidence supports use of spinal manipulation to prevent
further episodes of back pain.
B. Spinal manipulation is useful for prevention only if
performed by a chiropractor.
C. Spinal manipulation is no more effective than sham
therapy and the benefit he experienced is likely a placebo
effect.
D. Evidence does not support using spinal manipulation to
prevent exacerbations.
E. Evidence supports prevention, but spinal manipulation is
not as effective as massage.
Answer
• D. Evidence does not support using spinal
manipulation to prevent exacerbations.
• Evidence does not support using spinal
manipulation to prevent acute exacerbations
in the setting of chronic back pain. See page
13.
SECTION ONE: GENERAL TREATMENT
APPROACHES TO LOW BACK PAIN
Which one of the following is the role of exercise for
patients with back pain? (check one)
A. Improves overall fitness but has no effect on
back pain.
B. Reduces pain and improves function in adults
with chronic back pain.
C. Reduces pain and improves function in adults
with acute back pain.
D. Exacerbates pain in patients with back pain, so it
should be minimized.
E. Increases pain but improves function in patients
with acute and chronic back pain.
Answer
• B. Reduces pain and improves function in
adults with chronic back pain.
• A Cochrane review concluded that exercise
can reduce pain and improve function in
adults with chronic back pain and is as
effective as either no treatment or other
conservative treatments for acute low back
pain. See pages 13-14 and Table 1.
SECTION ONE: GENERAL TREATMENT
APPROACHES TO LOW BACK PAIN
Your patient who works as a baker is experiencing continued
back pain since lifting a heavy sack of flour 2 weeks ago. She
finds exercise too painful and asks about acupuncture
treatment recommended by a friend. Which one of the
following is true of acupuncture for this patient? (check one)
A. It is not effective for acute episodes of back pain.
B. It might be effective but is associated with high rates of
adverse events.
C. It is not effective for any type of back pain.
D. It is more effective than sham acupuncture for chronic
back pain.
E. It has been proven to be effective for acute back pain.
Answer
• A. It is not effective for acute episodes of
back pain.
• Although not shown to be effective in acute
back pain, acupuncture appears to be an
option for chronic back pain. See page 15.
SECTION ONE: GENERAL TREATMENT
APPROACHES TO LOW BACK PAIN
Your patient who is a factory worker e-mails you asking
whether he should use a back brace to prevent back pain. He
has intermittent episodes of low back pain and his employer
has encouraged him to use a brace. What advice should you
offer? (check one)
A. A back brace can effectively prevent episodes of pain.
B. A back brace may be effective for prevention but should
be professionally fitted.
C. Back braces only show benefit for short-term pain
reduction during an episode of pain.
D. A back brace will be effective in prevention and in
managing painful episodes.
E. Back braces are not effective for pain prevention in
patients with low back pain.
Answer
• E. Back braces are not effective for pain
prevention in patients with low back pain.
• There is moderate evidence against use of
bracing devices for preventing pain among
patients with low back pain. See page 15.
SECTION ONE: GENERAL TREATMENT
APPROACHES TO LOW BACK PAIN
Which one of the following is a conclusion of the American
Society of Interventional Pain Physicians regarding use of
opioids to treat chronic back pain? (check one)
A. Opioid therapy is safe and effective long term for most
patients with chronic back pain.
B. Opioid therapy should be provided with caution and
evidence is variable on the effectiveness of long-term use.
C. If providing opioid therapy, the strongest evidence
supports use of hydrocodone.
D. Family physicians who use opioid therapy for patients
with chronic back pain can follow evidence-based guidelines
to select appropriate patients for therapy.
E. Opioid drug use to treat chronic pain has decreased in the
past 10 years.
Answer
• B. Opioid therapy should be provided with
caution and evidence is variable on the
effectiveness of long-term use.
• Based on best evidence, the American
Society of Interventional Pain Physicians
stated that opioid therapy should be
provided with caution and that evidence is
variable on the effectiveness of long-term (6
months or more) opioid use in reducing pain
and improving functional status. See page
16.
SECTION TWO: ACUTE LUMBAR DISK PAIN
Your patient returns for follow-up for persistent sciatica. He
underwent magnetic resonance imaging study last week and
the results indicate a lumbar disk herniation. Which one of the
following is true of the association between disk herniation
and sciatica? (check one)
A. Most patients with acute sciatica will have disk herniation
on imaging.
B. It is rare to find disk herniation in an asymptomatic
patient.
C. Most disk herniations occur in patients older than 60 years
with sciatica.
D. Sciatica is more likely to be due to a disk herniation if
pain is worse in the leg than in the back.
E. None of the above.
Answer
• D. Sciatica is more likely to be due to a
disk herniation if pain is worse in the leg
than in the back.
• Three symptoms increase the specificity
that the cause of the sciatica is from a
lumbar disk herniation: pain is worse in the
leg as opposed to the back, neurologic
symptoms (eg, paresthesias, numbness)
follow a typical dermatome distribution,
and pain worsens with the Valsalva
maneuver. See page 17.
SECTION TWO: ACUTE LUMBAR
DISK PAIN
Which one of the following symptoms should
trigger a clinician to consider emergent/early
referral for imaging in a patient with
sciatica? (check one)
A. Pain for more than 2 weeks.
B. Bowel or bladder dysfunction (ie,
suspected cauda equina syndrome).
C. Pain and numbness in the foot.
D. New-onset pain with a history of cancer.
E. Both B and D.
Answer
• E. Both B and D.
• If cauda equina syndrome is suspected,
emergent magnetic resonance imaging
study should be performed with immediate
surgical referral. Immediate erythrocyte
sedimentation rate and x-ray should be
obtained if major cancer risk (new-onset
pain with history of cancer, multiple risk
factors for cancer, or strong clinical
suspicion of cancer) are present. See page
19 and Table 2.
SECTION TWO: ACUTE LUMBAR DISK PAIN
While pursuing a course of watchful waiting, your patient
with subacute sciatica telephones asking for treatment for
pain. She has heard about an injection that might help. Which
one of the following should you tell her about epidural steroid
injection? (check one)
A. It may improve short-term pain but not long-term pain.
B. It may improve function and decrease need for surgery.
C. Intradiscal steroid injection may improve short-term pain.
D. Intradiscal steroid injection may improve function and
decrease need for surgery.
E. It is not associated with any benefit.
Answer
• A. It may improve short-term pain but not
long-term pain.
• Epidural steroid injections may improve
pain in the short term (less than 6 weeks)
but they do not influence long-term pain
relief, average impairment of function, or
the need for surgery. See page 19.
SECTION TWO: ACUTE LUMBAR DISK
PAIN
Your patient with sciatica for the past 4 weeks
telephones to ask about a referral to physical therapy
(PT). Which one of the following is true of formal
PT for sciatica? (check one)
A. It is effective during acute episodes of sciatica.
B. It is more effective than conservative care.
C. It is more effective than manipulation.
D. It has not been proven effective.
E. It increases pain and delays healing during acute
episodes of sciatica.
Answer
• D. It has not been proven effective.
• Formal physical therapy programs directed
by a physical therapist have not been proven
effective for sciatica, and are no more costeffective than conservative care without
physical therapy. See page 19.
SECTION TWO: ACUTE LUMBAR DISK PAIN
Your patient with severe sciatica has not benefited from 6
weeks of conservative management and wants to discuss
surgical treatment options. He does not have severe or
progressive neuromotor deficits, or cauda equina syndrome.
Which one of the following should you tell him about surgery
for sciatica? (check one)
A. He should consider surgery now because over time the
condition is unlikely to improve without it.
B. Early surgery is likely to improve his disability scores and
level of recovery at 1 year.
C. Early surgery is likely to provide faster pain relief and
result in less disability at 1 year.
D. He should not pursue surgery because it is too dangerous.
E. Early surgery has potential for earlier relief but has similar
outcomes compared with nonsurgical treatment.
Answer
• E. Early surgery has potential for earlier
relief but has similar outcomes compared
with nonsurgical treatment.
• For most patients with persistent sciatica, a
discussion about surgical and nonsurgical
treatment should include the severity of
symptoms, the potential for earlier relief but
similar long-term outcomes, patient
aversion to surgical risks, and patient
willingness to wait for spontaneous
healing. See page 20.
SECTION THREE: LUMBAR SPINAL
STENOSIS
Your 78-year-old patient with intermittent back pain
presents with a worsening episode of back pain, this
time associated with bilateral burning leg pain. You
suspect lumbar spinal stenosis. Which one of the
following signs or symptoms, if present, would most
increase your suspicion of this diagnosis? (check
one)
A. Wide-based gait.
B. Vibration deficit.
C. Pinprick deficit.
D. Numbness in the lower extremities.
E. Abnormal Romberg test result.
Answer
• A. Wide-based gait.
• Certain aspects of the history and physical
examination can be used to support a
diagnosis of lumbar spinal stenosis. The
most suggestive features are a wide-based
gait and absence of pain while seated. See
page 21 and Table 3.
SECTION THREE: LUMBAR SPINAL STENOSIS
A 68-year-old man presents with difficulty walking as well as
burning pain in the buttocks and associated lower extremity
numbness. To confirm the diagnosis of lumbar spinal stenosis
(LSS), you consider obtaining x-rays of the lumbar spine.
Which one of the following describes the role of x-rays in the
diagnosis of LSS? (check one)
A. They are useful for confirming the diagnosis of LSS.
B. They are useful for excluding diagnoses such as
degenerative joint disease.
C. They have no role in the evaluation of LSS.
D. They are routinely recommended before additional
testing.
E. They are recommended for medicolegal reasons.
Answer
• B. They are useful for excluding diagnoses
such as degenerative joint disease.
• Although it might be reasonable to obtain
an x-ray to exclude conditions in the
differential diagnosis of lumbar spinal
stenosis (eg, compression fractures, severe
degenerative joint disease), in general, xrays are not useful. See page 21.
Answer
• B. They are useful for excluding diagnoses
such as degenerative joint disease.
• Although it might be reasonable to obtain
an x-ray to exclude conditions in the
differential diagnosis of lumbar spinal
stenosis (eg, compression fractures, severe
degenerative joint disease), in general, xrays are not useful. See page 21.
SECTION THREE: LUMBAR SPINAL
STENOSIS
Based on North American Spine Society
recommendations, which one of the following is the
most appropriate noninvasive test for imaging of
degenerative lumbar spinal stenosis? (check one)
A. Computed tomography (CT) scan.
B. Magnetic resonance imaging (MRI) study.
C. X-ray.
D. Electromyogram.
E. Combination CT scan and MRI study.
Answer
• B. Magnetic resonance imaging (MRI)
study.
• The North American Spine Society
recommends magnetic resonance imaging
study as the most appropriate noninvasive
test for imaging degenerative lumbar spinal
stenosis. See page 21.
SECTION THREE: LUMBAR SPINAL STENOSIS
Your patient with lumbar spinal stenosis returns for follow-up
after no benefit from 1 month of conservative treatment. He
wishes to discuss surgery. The patient is worried about
surgical risks but wants to know if he should go for surgery
and if there are risks in delaying surgery to try alternative
treatment. Which one of the following should you
advise? (check one)
A. Early surgery is likely to improve long-term outcomes.
B. Delaying surgery is likely dangerous.
C. Early surgery may result in early benefit, but delaying
surgery is not harmful.
D. Almost all patients do well with medical treatment and
few require surgery.
E. Results of surgery are uniformly good, regardless of when
it is performed.
Answer
• C. Early surgery may result in early
benefit, but delaying surgery is not
harmful.
• In cases of lumbar spinal stenosis, patients
may achieve greater early benefit from
surgery, but results are not uniformly good
and delaying surgical treatment is unlikely
to result in neurologic deterioration. See
page 23.
SECTION THREE: LUMBAR SPINAL STENOSIS
Your patient is waiting for a surgical consultation for lumbar
spinal stenosis and asks about an epidural steroid injection.
Which one of the following should you tell her? (check one)
A. It is no more effective than sham injection.
B. It is likely to provide long-term relief.
C. It can be recommended based on strong evidence.
D. It may provide short-term symptom relief.
E. It is not effective for patients with mechanical spinal nerve
root compression.
Answer
• D. It may provide short-term symptom
relief.
• Steroid injections appear to provide shortterm symptom relief, especially if there is a
radiculopathy, for lumbar spinal
stenosis. See page 23.
SECTION FOUR: OSTEOPOROTIC VERTEBRAL FRACTURES
Which one of the following describes the current recommendations from
the US Preventive Services Task Force for osteoporosis
screening? (check one)
A. Screen all women older than 50 years with dual-energy x-ray
absorptiometry (DXA).
B. The evidence is insufficient to recommend screening.
C. Screen only women with risk factors with DXA.
D. Screen only women older than 65 years with DXA.
E. Screen women 65 years and older and younger women with risk
factors.
Answer
• E. Screen women 65 years and older and younger
women with risk factors.
• Because screening for osteoporosis and preventive
treatment may have a positive effect on fracture
prevention, the US Preventive Services Task
Force, the National Osteoporosis Foundation, and
the American College of Obstetricians and
Gynecologists recommend dual-energy x-ray
absorptiometry screening for osteoporosis among
women 65 years or older and for younger women
with risk factors. See page 24.
SECTION FOUR: OSTEOPOROTIC
VERTEBRAL FRACTURES
Your patient presents after onset of acute
upper back pain. An x-ray shows a vertebral
compression fracture. Which one of the
following characteristics would help to
confirm that this is likely a recent
fracture? (check one)
A. Pain with forward flexion.
B. Pain with extension.
C. Pain with side bending.
D. Pain on percussion of the spine.
E. Pain when sitting.
Answer
• D. Pain on percussion of the spine.
• Two characteristics that might help
determine whether a fracture is old or new
are pain on percussion of the spine (closedfist percussion sign; sensitivity = 87.5%,
specificity = 90%, positive likelihood ratio
[LR] = 8.7, negative LR = 0.14) and
inability to lie supine on a couch (sensitivity
= 81%, specificity = 93%, positive LR =
11.6, negative LR = 0.20). See page 24.
SECTION FOUR: OSTEOPOROTIC VERTEBRAL
FRACTURES
A 74-year-old woman with upper back pain returns for
follow-up reporting continued pain despite rest and
acetaminophen. Neurologic examination results are normal.
You suspect an osteoporotic compression fracture of the
vertebra. Which one of the following would you do to
confirm the diagnosis, based on the American College of
Radiology Appropriateness Criteria® guideline? (check one)
A. No further testing is needed; initiate treatment for
osteoporosis.
B. Obtain x-ray.
C. Obtain x-ray and dual-energy x-ray absorptiometry
(DXA).
D. Obtain x-ray and consider computed tomography scan and
DXA.
E. Obtain magnetic resonance imaging study.
Answer
• C. Obtain x-ray and dual-energy x-ray
absorptiometry (DXA).
• The American College of Radiology
Appropriateness Criteria® guideline
recommends dual-energy x-ray
absorptiometry and a spine x-ray for
diagnosis of a suspected osteoporotic
vertebral fracture in a patient with a clinical
history, height loss, or steroid use. See page
24.
SECTION FOUR: OSTEOPOROTIC VERTEBRAL
FRACTURES
The US Preventive Services Task Force has found sufficient
evidence that drug therapies reduce facture risk in
postmenopausal women with osteoporosis detected on
screening. Which one of the following treatments, in addition
to calcium and vitamin D, would you consider for a woman
with osteoporosis but no fracture who is recently
menopausal? (check one)
A. Calcitonin.
B. Hormone therapy.
C. A bisphosphonate.
D. Denosumab.
E. B or C.
Answer
• E. B or C.
• Estrogen/hormone therapy is approved for
osteoporosis and fracture prevention as well
as relief of menopause-associated
vasomotor symptoms and vulvovaginal
atrophy. Bisphosphonates have been shown
to significantly reduce the incidence of new
vertebral fractures. See page 27.
SECTION FOUR: OSTEOPOROTIC VERTEBRAL
FRACTURES
Your patient with a painful vertebral compression fracture
that occurred 2 weeks ago has persistent severe pain despite
use of oral pain drugs and calcitonin. She asks about surgery.
Which one of the following should you tell her about
vertebroplasty? (check one)
A. It is clearly of benefit for pain relief and long-term
function.
B. It is controversial, with 2 trials showing no differences in
effectiveness of vertebroplasty and sham control.
C. It is not of benefit, according to all recent studies.
D. It is more effective than kyphoplasty.
E. None of the above.
Answer
• B. It is controversial, with 2 trials showing
no differences in effectiveness of
vertebroplasty and sham control.
• In 2009, the use of this procedure was
questioned when 2 randomized controlled
trials using sham control groups showed no
differences between treated and untreated
patients. These studies sparked controversy
regarding the efficacy of vertebroplasty and
drew national media attention. See page 30
SECTION ONE: ALCOHOL USE
DISORDERS
Which one of the following is most sensitive
for detecting alcohol use disorders? (check
one)
A. Carbohydrate-deficient transferrin.
B. Elevated gamma-glutamyl transferase.
C. Macrocytosis on hemogram.
D. Screening questionnaires.
Answer
• D. Screening questionnaires.
SECTION ONE: ALCOHOL USE
DISORDERS
Which one of the following counts as 1
standard drink of alcohol? (check one)
A. 12-oz bottle of malt liquor.
B. 12-oz bottle of regular beer.
C. 2 shots of hard liquor.
D. 8-oz glass of wine.
Answer
• B. 12-oz bottle of regular beer.
SECTION ONE: ALCOHOL USE DISORDERS
You are treating a patient for alcohol withdrawal.
The symptoms are severe enough to warrant
pharmacotherapy. The patient has been drinking for
years and has moderately impaired liver function.
Which one of the following drugs would be
preferred for this patient? (check one)
A. Chlordiazepoxide.
B. Diazepam.
C. Oxazepam.
D. Valproic acid.
Answer
• C. Oxazepam.
• Benzodiazepines are the first-line drugs for
alcohol withdrawal for inpatient and
outpatient treatment. Short-acting
benzodiazepines (eg, lorazepam, oxazepam)
are preferred in elderly patients or in
patients with impaired liver function. See
page 17.
SECTION ONE: ALCOHOL USE DISORDERS
Which one of the following statements is correct
about naltrexone for treatment of alcohol
dependence? (check one)
A. It is contraindicated in patients with markedly
elevated liver function test results.
B. It must be administered by injection.
C. The Food and Drug Administration has not
approved naltrexone for treatment of alcohol
dependence.
D. The patient must stop drinking before naltrexone
can be started.
Answer
• A. It is contraindicated in patients with
markedly elevated liver function test
results.
• Naltrexone is contraindicated in patients
with active liver disease, when liver
function test results are greater than 3 times
the upper limit of normal, and in patients
requiring opioids. See page 18.
SECTION TWO: PRESCRIPTION
STIMULANT AND METHAMPHETAMINE
USE DISORDERS
Which one of the following statements is correct
about use of prescription stimulants by
undergraduate college students? (check one)
A. More students have reported nonmedical use than
students reporting medical use.
B. The leading source of illicit stimulants is forged
prescriptions.
C. The majority of college students report
nonmedical use of stimulants at least once.
D. Use is highest on the East Coast of the United
States.
Answer
• A. More students have reported nonmedical
use than students reporting medical use.
• In an online survey of 9,161 undergraduate
students at a Midwestern university, more
students reported illicit use of prescription
stimulants than students who reported
medical use for attentiondeficit/hyperactivity disorder. See page 21.
SECTION TWO: PRESCRIPTION
STIMULANT AND
METHAMPHETAMINE USE
DISORDERS
Which one of the following is a nonstimulant
drug approved by the Food and Drug
Administration for treatment of attentiondeficit/hyperactivity disorder? (check one)
A. Atomoxetine.
B. Methylphenidate.
C. Dexmethylphenidate.
D. Bupropion.
Answer
• A. Atomoxetine.
Answer
• A. Atomoxetine.
• Drugs for attention-deficit/hyperactivity
disorder (ADHD) treatment that have lower
abuse potential include nonstimulant drugs
such as atomoxetine, bupropion,
guanfacine, and clonidine. Atomoxetine and
extended-release formulations of guanfacine
and clonidine are Food and Drug
Administration-approved for ADHD
treatment, but bupropion is not. See page
22.
SECTION TWO: PRESCRIPTION
STIMULANT AND METHAMPHETAMINE USE DISORDERS
Your patient, a long-term user of methamphetamine, presents to your
office seeking treatment for substance abuse. Which one of the following
statements is correct about Food and Drug Administration (FDA)approved drugs for amphetamine dependence? (check one)
A. Aripiprazole is FDA-approved for treatment of amphetamine
dependence.
B. Modafinil is FDA-approved for treatment of amphetamine
dependence.
C. Selective serotonin reuptake inhibitors are FDA-approved for
treatment of amphetamine dependence.
D. Tricyclic antidepressants are FDA-approved for treatment of
amphetamine dependence.
E. There are currently no drugs approved by the FDA for treatment of
amphetamine dependence.
Answer
• E. There are currently no drugs approved
by the FDA for treatment of amphetamine
dependence.
• . There are currently no drugs approved by
the FDA for treatment of amphetamine
dependence.
•
SECTION THREE: PRESCRIPTION OPIOID USE
DISORDERS
Which one of the following is the role of urine drug screens
when caring for a patient who receives long-term opioid
therapy for chronic nonmalignant pain? (check one)
A. Routine urine drug tests will detect all Food and Drug
Administration-approved opioids.
B. They are not indicated if there is a good patient-physician
relationship.
C. They should be performed at every visit if feasible, or
randomly.
D. Although many physicians perform them, they are not
recommended in the Federation of State Medical Boards
policy statement on long-term opioid therapy.
Answer
• C. They should be performed at every visit
if feasible, or randomly.
• If drug testing is not feasible at every
patient visit, random drug testing can still
be of benefit. See page 29.
FP Essentials - #383 - Connective Tissue Diseases
Question 2 of 20
Which statement is correct regarding anticyclic
citrullinated peptide antibody testing in the
evaluation of patients with suspected rheumatoid
arthritis (RA)? (check one)
A. If results are positive, it typically means the
patient will have less severe RA.
B. If results are negative, it increases the likelihood
that the patient does not have RA.
C. The test has no value in the evaluation of patients
with suspected RA.
D. The test results are typically positive later in the
course of RA.
Answer
• B. If results are negative, it increases the
likelihood that the patient does not have
RA.
• Anticyclic citrullinated peptide antibodies
have similar sensitivity but higher
specificity than rheumatoid factor in
diagnosis
of rheumatoid arthritis. See page 17 and
Table 3.
A patient being evaluated for symptoms of a
connective tissue disease has a positive antiSmith antibody test result.
Which one of the following is the most likely
diagnosis? (check one)
A. Systemic lupus erythematosus.
B. Polymyositis.
C. Scleroderma.
D. Sjögren syndrome.
Answer
• A. Systemic lupus erythematosus.
• The only highly specific tests for connective tissue disease
detection are anti-double-stranded DNA (anti-dsDNA) and
antiSmith (anti-Sm) antibody, which are specific for systemic
lupus erythematosus (SLE), and antiproteinase 3, which is
specific for Wegener granulomatosis. Anti-Sm antibodies
are present in approximately 40% of patients with SLE.
But
when present, anti-Sm antibodies are similar to antidsDNA antibodies in that they are highly specific for
SLE. See pages
14, 18, and Table 3.
Your 76-year-old patient presented to the emergency
department, reporting axial pain, stiffness, and
weakness that has been present for weeks. The
emergency department physician prescribed steroids.
By the time the patient visits your office 3 days later,
the symptoms have completely resolved. Which one
of the following is the likely diagnosis? (check one)
A. Ankylosing spondylitis.
B. Polymyalgia rheumatica.
C. Polymyositis.
D. Vertebral rheumatoid arthritis.
Answer
• B. Polymyalgia rheumatica.
• In polymyalgia rheumatica, an elderly
patient with symptoms of axial pain,
stiffness, or subjective weakness might
experience complete symptom resolution
within a few days of beginning daily
therapy with 15 mg of prednisone, thus
confirming the diagnosis. See page 20.
SLOWING GLOBAL WARMING: BENEFITS FOR
PATIENTS AND THE PLANET
Which one of the following is a recommendation that would
mutually benefit cardiovascular health and climate
change? (check one)
A. The target level of daily meat consumption should be 12
oz.
B. Meat intake should remain at current average levels of
consumption.
C. Average daily meat consumption should decrease to 3 oz,
and less than one-half of that should be red meat.
D. The target level of daily meat consumption should be 8
oz.
Correct.
Answer
• C. Average daily meat consumption should
decrease to 3 oz, and less than one-half of
that should be red meat.
SLOWING GLOBAL WARMING:
BENEFITS FOR PATIENTS AND THE
PLANET
Which of the following health conditions are
likely to increase with expected climate
change? (check all that apply)
A. Mental illness related to extreme weather
events.
B. Allergies.
C. Asthma.
D. Vector-borne disease.
Answer
• A. Mental illness related to extreme
weather events.
B. Allergies.
C. Asthma.
D. Vector-borne disease.
Clinical recommendationEvidence ratingReferences
• Physicians should advise patients to reduce their dietary meat
consumption, especially red meat, to improve individual health.
• C
• Physicians should advise patients to reduce their dietary meat
consumption, especially red meat, to help reduce greenhouse gas
emissions and improve public health.
• C
• Physicians should recommend that patients use more active
transportation methods, such as walking and bicycling, to improve
individual health.
• C
• Physicians should recommend that patients use more active
transportation methods, such as walking and bicycling, to help reduce
greenhouse gas emissions and improve public health.
• C
TREATMENT OF NONGENITAL
CUTANEOUS WARTS
Which one of the following statements about
cryotherapy for the treatment of cutaneous warts is
correct? (check one)
A. It is more effective than salicylic acid.
B. It should not be used for more than three
months.
C. It should clear hand warts with two freeze-thaw
cycles.
D. It requires more applications than salicylic acid.
Answer
• B. It should not be used for more than three
months
Nongenatial Warts
•
•
•
•
•
•
•
•
•
Numerous treatments for nongenital cutaneous warts are available,
although no single therapy has been established as completely curative.
Watchful waiting is an option for new warts because many resolve
spontaneously.
However, patients often request treatment because of social stigma or
discomfort.
Ideally, treatment should be simple and inexpensive with low risk of
adverse effects.
Salicylic acid has the best evidence to support its effectiveness, but it is
slow to work and requires frequent application for up to 12 weeks.
Cryotherapy with liquid nitrogen is a favorable option for many patients,
with cure rates of 50 to 70 percent after three or four treatments.
For recalcitrant warts, Candida or mumps skin antigen can be injected
into the wart every three to four weeks for up to three treatments.
More expensive treatments for recalcitrant warts are offered in many
dermatology offices.
Photodynamic therapy with aminolevulinic acid has the best evidence of
effectiveness compared with pulsed dye laser, intralesional bleomycin, and
surgical removal using curettage or cautery.
Nongenatial Warts
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Salicylic acid and cryotherapy with liquid nitrogen are first-line treatments for cutaneous warts.
A
Aggressive cryotherapy (10 to 30 seconds) is more effective than less aggressive cryotherapy.
B
Best results of cryotherapy can be achieved when the patient is treated every two or three weeks.
There is no therapeutic benefit beyond three months.
B
When using cryotherapy for plantar warts, paring the wart before treatment can increase the
clearance rate.
B
Intralesional injection with Candida or mumps skin antigen has moderate effectiveness for treatment
of recalcitrant warts in patients with a positive skin antigen pretest.
B
Photodynamic therapy with aminolevulinic acid plus topical salicylic acid is a moderately effective
option for treatment of recalcitrant warts.
B
Although preliminary studies were promising, duct tape is not effective for wart treatment.
B
Pulsed dye laser or intralesional injection with bleomycin can be considered for treatment of
recalcitrant warts, although the effectiveness is unproven.
B
TREATMENT OF NONGENITAL
CUTANEOUS WARTS
Which one of the following treatments for
cutaneous warts is usually administered by a
dermatologist? (check one)
A. Salicylic acid.
B. Cryotherapy.
C. Photodynamic therapy.
D. Topical fluorouracil.
Answer
• C. Photodynamic therapy.
TREATMENT OF NONGENITAL
CUTANEOUS WARTS
Which of the following statements about treatment
of asymptomatic warts are correct? (check all that
apply)
A. Paring plantar warts before cryotherapy may be
beneficial.
B. Pulsed dye laser is the treatment of choice for
plantar warts.
C. Combining salicylic acid with cryotherapy may
be more effective than using either treatment alone.
D. Watchful waiting is reasonable for new warts.
Answer
• A. Paring plantar warts before cryotherapy
may be beneficial.
C. Combining salicylic acid with
cryotherapy may be more effective than
using either treatment alone.
D. Watchful waiting is reasonable for new
warts.
DIAGNOSTIC APPROACH TO
CHRONIC CONSTIPATION IN
ADULTS
Which one of the following is considered
a risk factor for constipation? (check
one)
A. Male sex.
B. High caloric intake.
C. Use of a large number of
medications.
D. High educational level.
Answer
• C. Use of a large number of medications.
DIAGNOSTIC APPROACH TO CHRONIC
CONSTIPATION IN ADULTS
Which one of the following statements about the initial
diagnostic evaluation of patients with chronic constipation is
correct? (check one)
A. All patients should have their thyroid-stimulating
hormone level measured.
B. Patients with alarm signs or symptoms should undergo
endoscopy to rule out serious secondary causes of
constipation.
C. Patients with alarm signs or symptoms should undergo
abdominal computed tomography to rule out malignancy.
D. All patients should undergo manometric testing of pelvic
floor function.
Answer
• B. Patients with alarm signs or symptoms
should undergo endoscopy to rule out
serious secondary causes of constipation.
DIAGNOSTIC APPROACH TO CHRONIC
CONSTIPATION IN ADULTS
Which of the following statements about slow transit
constipation are correct? (check all that apply)
A. Symptoms include an infrequent “call to stool,” bloating,
and abdominal discomfort.
B. Prolonged colonic transit time can be confirmed with
radiopaque markers that are delayed on motility study.
C. Prolonged colonic transit time is defined as four or more
markers visible on a plain abdominal radiograph taken 120
hours after ingesting one Sitzmarks capsule.
D. Treatment with fiber supplementation or laxatives is
ineffective in patients with severe slow transit constipation.
Answer
• A. Symptoms include an infrequent “call to
stool,” bloating, and abdominal discomfort.
B. Prolonged colonic transit time can be
confirmed with radiopaque markers that are
delayed on motility study.
D. Treatment with fiber supplementation or
laxatives is ineffective in patients with
severe slow transit constipation.
Constipation
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A history and physical examination should be performed in patients with
constipation to identify alarm signs or symptoms.
C
Routine use of blood tests, radiography, or endoscopy in patients with
constipation who do not have alarm signs or symptoms is not recommended.
C
Patients with alarm signs or symptoms should undergo endoscopy to rule out
malignancy.
C
The initial management of noncomplicated constipation should include a highfiber diet, increased water intake, and exercise.
B
Biofeedback is recommended for treating symptoms of pelvic floor
dysfunction.
B
COCHRANE FOR CLINICIANS: PUTTING
EVIDENCE INTO PRACTICE
SELF-MONITORING AND SELFMANAGEMENT OF ANTICOAGULATION
THERAPY
Compared with standard care, self-monitoring of
anticoagulation therapy reduces the incidence of
which of the following outcomes? (check all that
apply)
A. Thromboembolism.
B. Minor hemorrhage.
C. Major hemorrhage.
D. All-cause mortality.
Answer
• A. Thromboembolism.
B. Minor hemorrhage.
C. Major hemorrhage.
D. All-cause mortality.
GERIATRIC ASSISTIVE DEVICES
A front-wheeled walker has which one of the
following advantages over other
walkers? (check one)
A. It is lifted with each step.
B. It is the most stable type of walker.
C. It has a small turning arc.
D. It helps maintain a normal gait pattern.
Answer
• D. It helps maintain a normal gait pattern.
GERIATRIC ASSISTIVE DEVICES
Correct use of a cane involves which one of the
following? (check one)
A. With the patient standing upright with arms
relaxed at his or her sides, the handle should be at
the level of the patient’s elbow crease.
B. A cane should be held contralateral to a weak or
painful lower extremity.
C. A cane should be advanced alternating with
movement of the affected leg.
D. Patients should advance the unimpaired
extremity first when going down stairs.
Answer
• B. A cane should be held contralateral to a
weak or painful lower extremity.
GERIATRIC ASSISTIVE DEVICES
Which of the following caveats should be considered
when recommending assistive devices? (check all
that apply)
A. They may cause osteoarthritis and other
musculoskeletal conditions.
B. They can be destabilizing.
C. They have been associated with worsening
osteoporosis.
D. They may worsen cardiorespiratory function.
Answer
• A. They may cause osteoarthritis and other
musculoskeletal conditions.
B. They can be destabilizing.
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Assistive
Devices
Assistive devices can be prescribed to improve balance, reduce pain,
and increase mobility and confidence.
C
Because most patients obtain their assistive device without
recommendations or instructions from a medical professional, assistive
devices should be evaluated routinely for proper fit and use.
C
When only one upper extremity is needed for balance or weight
bearing, a cane is preferred. If both upper extremities are needed,
crutches or a walker is more appropriate.
C
The correct height of a cane or walker is at the level of the patient's
wrist crease, as measured with the patient standing upright with arms
relaxed at his or her sides. When holding the device at this height, the
patient's elbow is naturally flexed at a 15- to 30-degree angle.
C
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Assistive devices
Disability and mobility problems increase with age.
Assistive devices such as canes, crutches, and walkers can be used to increase a patient's base of
support, improve balance, and increase activity and independence, but they are not without
significant musculoskeletal and metabolic demands.
Most patients with assistive devices have never been instructed on the proper use and often
have devices that are inappropriate, damaged, or are of the incorrect height.
Selection of a suitable device depends on the patient's strength, endurance, balance, cognitive
function, and environmental demands.
Canes can help redistribute weight from a lower extremity that is weak or painful, improve
stability by increasing the base of support, and provide tactile information about the ground to
improve balance.
Crutches are useful for patients who need to use their arms for weight bearing and propulsion
and not just for balance.
Walkers improve stability in those with lower extremity weakness or poor balance and
facilitate improved mobility by increasing the patient's base of support and supporting the
patient's weight.
Walkers require greater attentional demands than canes and make using stairs difficult.
The top of a cane or walker should be the same height as the wrist crease when the patient is
standing upright with arms relaxed at his or her sides.
A cane should be held contralateral to a weak or painful lower extremity and advanced
simultaneously with the contralateral leg.
Clinicians should routinely evaluate their patients' assistive devices to ensure proper height, fit,
and maintenance, and also counsel patients on correct use of the device.
TREATMENT OPTIONS FOR LOCALIZED
PROSTATE CANCER
A 74-year-old man in the bottom quartile of health has stage
T2a prostate cancer with a Gleason score of 6. His prostatespecific antigen (PSA) level is 9 ng per mL (9 mcg per L).
Which one of the following treatment options would best
align with the recommendations of the National
Comprehensive Cancer Network? (check one)
A. Active surveillance.
B. Surgery.
C. External beam radiation therapy.
D. Brachytherapy.
Answer
• A. Active surveillance.
TREATMENT OPTIONS FOR LOCALIZED
PROSTATE CANCER
Which of the following is part of the Canadian protocol for
active surveillance of prostate cancer? (check all that apply)
A. PSA testing and digital rectal examination every three
months for two years.
B. 10 to 12 core biopsies one year after diagnosis, then every
three years until 80 years of age.
C. Intervention if the PSA doubles in less than three years.
D. Intervention for progression to a Gleason score of 7 (4+3)
or higher.
Answer
• A. PSA testing and digital rectal
examination every three months for two
years.
B. 10 to 12 core biopsies one year after
diagnosis, then every three years until 80
years of age.
C. Intervention if the PSA doubles in less
than three years.
D. Intervention for progression to a
Gleason score of 7 (4+3) or higher.
Treatment for localized prostate cancer should be
recommended for higher-risk patients. Risk can be estimated
by using an index of cancer stage and grade, prostate-specific
antigen level, and comorbidity-adjusted life expectancy.
B
Patients can be counseled that surgery and external beam
radiation therapy are almost equally effective in treating
prostate cancer.
B
Brachytherapy is an option for monotherapy in low-risk
patients.
B
Active surveillance is a reasonable option for low-risk and
very low-risk patients.
B
EXERCISE-INDUCED BRONCHOCONSTRICTION:
DIAGNOSIS AND MANAGEMENT
A 21-year-old college basketball player presents with
symptoms suggestive of exercise-induced
bronchoconstriction (EIB). After performing a workup, you
confirm a diagnosis of EIB and discuss treatment options with
her. She is concerned about choosing a treatment prohibited
by the National Collegiate Athletic Association (NCAA).
Which one of the following drug classes requires proof of
prescription under NCAA regulations? (check one)
A. Mast cell stabilizers.
B. Inhaled corticosteroids.
C. Leukotriene receptor antagonists.
D. Inhaled beta2 agonists.
• Screening for abdominal aortic
aneurysmThe USPSTF recommends onetime screening for abdominal aortic
aneurysm (AAA) by ultrasonography in
men aged 65 to 75 who have ever smoked.B