Medical Knowledge Self-Assessment Program
General Internal Medicine All New Content, Including 168 Multiple-Choice Questions
C u M u l aT I v e
INDEX
24 AMA PRA Category 1 Credits™ available until Dec. 31, 2015.
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Table of Contents
Interpretation of the Medical Literature
Professionalism and Ethics
Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Threats to Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Experimental Studies . . . . . . . . . . . . . . . . . . . . . . . . . 1 Observational Studies . . . . . . . . . . . . . . . . . . . . . . . . . 1 Other Study Designs. . . . . . . . . . . . . . . . . . . . . . . . . . 3 Statistical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Sources of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Decision-Making and Informed Consent . . . . . . . . . . . . . 24 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Assessing Decision-Making Capacity . . . . . . . . . . . . . 24 Advance Directives and Surrogate Decision-Making . 24 Withholding or Withdrawing Treatment . . . . . . . . . . . . . 25 Physician-Assisted Suicide and Euthanasia . . . . . . . . . . . . 25 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Medical Error Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . 26 Sexual Contact between Physician and Patient . . . . . . . . . 27 The Impaired Physician and Colleague Responsibility . . . 27
Routine Care of the Healthy Patient Important Health Care Initiatives and Trends . . . . . . . . . . 4 Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Screening During the History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Periodic Health Examination . . . . . . . . . . . . . . . . . . . 8 Specific Screening Tests. . . . . . . . . . . . . . . . . . . . . . . . 8 Family History and Genetic Testing . . . . . . . . . . . . . . . . . 11 Taking a Family History . . . . . . . . . . . . . . . . . . . . . . 11 Caveats to Genetic Testing . . . . . . . . . . . . . . . . . . . . 11 Referral for Genetic Counseling . . . . . . . . . . . . . . . . 11 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Vaccinations Recommended for All Adults . . . . . . . . 13 Vaccinations Recommended for Some Adults . . . . . . 13 Lifestyle Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Behavioral Counseling . . . . . . . . . . . . . . . . . . . . . . . 16 Diet and Physical Activity . . . . . . . . . . . . . . . . . . . . . 16 Substance Use Disorders. . . . . . . . . . . . . . . . . . . . . . 17 Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Patient Safety Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principles of Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . 19 Quality Improvement Models . . . . . . . . . . . . . . . . . . . . . 19 Measurement of Quality Improvement . . . . . . . . . . . 20 Sources of Error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Diagnostic Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Medication Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Transitions of Care . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Health Information Technology and Patient Safety . . . . . 22 National Patient Safety Goals . . . . . . . . . . . . . . . . . . . . . . 22
Palliative Care Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Deciding When Hospice Palliative Care Is Indicated . . . . 28 Assessment and Communication . . . . . . . . . . . . . . . . . . . 29 Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Nausea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Anorexia and Nutrition. . . . . . . . . . . . . . . . . . . . . . . 32 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Bereavement and Grief. . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Common Symptoms Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Chronic Noncancer Pain . . . . . . . . . . . . . . . . . . . . . . . . . 33 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Acute Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Subacute and Chronic Cough. . . . . . . . . . . . . . . . . . 37 Cough in the Immunocompromised Patient. . . . . . . 39 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Chronic Fatigue and Chronic Fatigue Syndrome . . . . . . . 39 Diagnosis and Evaluation of Chronic Fatigue . . . . . . 39 Management of Chronic Fatigue and Chronic Fatigue Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . 40 ix
Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Presyncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Dysequilibrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Nonspecific Dizziness . . . . . . . . . . . . . . . . . . . . . . . . 43 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Evaluation of Insomnia . . . . . . . . . . . . . . . . . . . . . . . 44 Management of Insomnia . . . . . . . . . . . . . . . . . . . . . 44 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Neurocardiogenic Syncope . . . . . . . . . . . . . . . . . . . . 45 Orthostatic Hypotension . . . . . . . . . . . . . . . . . . . . . 46 Cardiac Causes of Syncope . . . . . . . . . . . . . . . . . . . . 46 Diagnostic Evaluation of Syncope . . . . . . . . . . . . . . . 46 Risk Stratification and Management of Syncope . . . . 47 Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 47 Chest Pain and Decision to Hospitalize. . . . . . . . . . . 49 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Musculoskeletal Pain Acute Low Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 50 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Neck Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 52 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 53 Rotator Cuff Disorders . . . . . . . . . . . . . . . . . . . . . . . 54 Adhesive Capsulitis . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Acromioclavicular Joint Degeneration. . . . . . . . . . . . 56 Elbow Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 56 Epicondylitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Olecranon Bursitis . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Ulnar Nerve Entrapment . . . . . . . . . . . . . . . . . . . . . 56 Wrist and Hand Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Indications for Imaging . . . . . . . . . . . . . . . . . . . . . . 57 Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . 57 Other Causes of Wrist and Hand Pain. . . . . . . . . . . . 57 Hip Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 58 Specific Causes of Hip Pain. . . . . . . . . . . . . . . . . . . . 58 Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . 58 Degenerative Joint Disease . . . . . . . . . . . . . . . . . . . . 59 Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Patellofemoral Pain Syndrome . . . . . . . . . . . . . . . . . 59 Bursitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
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Iliotibial Band Syndrome . . . . . . . . . . . . . . . . . . . . . 60 Baker Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Ankle and Foot Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Ankle Sprains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Hind Foot Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Midfoot Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Forefoot Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Dyslipidemia Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Evaluation of Lipid Levels . . . . . . . . . . . . . . . . . . . . . . . . 62 LDL Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Triglycerides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 HDL Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Nonstandard Lipid Risk Factors . . . . . . . . . . . . . . . . 64 Management of Dyslipidemias . . . . . . . . . . . . . . . . . . . . . 64 Therapeutic Lifestyle Changes. . . . . . . . . . . . . . . . . . 64 Drug Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Combination Drug Therapy . . . . . . . . . . . . . . . . . . . 65 Management of Hypertriglyceridemia . . . . . . . . . . . . 66 Management of Low HDL Cholesterol . . . . . . . . . . 67 Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Epidemiology and Pathophysiology . . . . . . . . . . . . . 67 Management of Metabolic Syndrome . . . . . . . . . . . . 67 Dyslipidemia Management in Older Patients . . . . . . . . . . 68 Dyslipidemia Management and Stroke Prevention . . . . . . 69 Aspirin as an Adjunct to Dyslipidemia Management . . . . . 69
Obesity Definition and Epidemiology . . . . . . . . . . . . . . . . . . . . . . 69 Screening and Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 70 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Lifestyle Modification . . . . . . . . . . . . . . . . . . . . . . . . 72 Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . 72 Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Men’s Health Male Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 74 Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 74 Premature Ejaculation. . . . . . . . . . . . . . . . . . . . . . . . 76 Decreased Libido . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Androgen Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Benign Prostatic Hyperplasia . . . . . . . . . . . . . . . . . . . . . . 78 Acute Testicular and Scrotal Pain . . . . . . . . . . . . . . . . . . . 78 Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Epididymitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Hydrocele and Varicocele. . . . . . . . . . . . . . . . . . . . . . . . . 79 Epididymal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Acute and Chronic Prostatitis and Pelvic Pain . . . . . . . . . 80 Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Women’s Health Female Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . 81 Approach to the Patient . . . . . . . . . . . . . . . . . . . . . . 81 Classification of Female Sexual Disorders . . . . . . . . . 81 Evaluation of a Breast Mass . . . . . . . . . . . . . . . . . . . . . . . 82 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 83 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Breast Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 84 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Oral Contraceptive Pills . . . . . . . . . . . . . . . . . . . . . . 84 Long-Acting Contraceptives . . . . . . . . . . . . . . . . . . . 86 Intrauterine Devices . . . . . . . . . . . . . . . . . . . . . . . . . 86 Barrier Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Emergency Contraception . . . . . . . . . . . . . . . . . . . . 86 Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Preconception Counseling . . . . . . . . . . . . . . . . . . . . . . . . 86 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Management of Vasomotor Symptoms . . . . . . . . . . . 88 Management of Urogenital Symptoms . . . . . . . . . . . 89 Abnormal Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . . 90 Clinical Presentation and Evaluation . . . . . . . . . . . . . 90 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Dysmenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Chronic Pelvic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Vaginitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Clinical Presentation and Evaluation . . . . . . . . . . . . . 92 Bacterial Vaginosis . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Trichomoniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Vulvovaginal Candidiasis. . . . . . . . . . . . . . . . . . . . . . 93
Eye Disorders Red Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Subconjunctival Hematoma . . . . . . . . . . . . . . . . . . . 94 Corneal Conditions . . . . . . . . . . . . . . . . . . . . . . . . . 94 Episcleritis and Scleritis . . . . . . . . . . . . . . . . . . . . . . . 95 Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Blepharitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Macular Degeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pathophysiology and Clinical Presentation . . . . . . . . 96 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Primary Open Angle Glaucoma . . . . . . . . . . . . . . . . 96 Acute Angle Closure Glaucoma . . . . . . . . . . . . . . . . 97 Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Dry Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Excessive Tearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Retinal Detachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Retinal Vascular Occlusion . . . . . . . . . . . . . . . . . . . . . . . . 99 Central Retinal Vein Occlusion . . . . . . . . . . . . . . . . . 99 Central Retinal Artery Occlusion . . . . . . . . . . . . . . . 99 Eye Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Ear, Nose, Mouth, and Throat Disorders Evaluation of Hearing Loss . . . . . . . . . . . . . . . . . . . . . . 100 Tinnitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Otitis Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Cerumen Impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Upper Respiratory Tract Infections . . . . . . . . . . . . . . . . 103 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Nonallergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . 104 Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Oral Infections and Ulcers . . . . . . . . . . . . . . . . . . . 106 Dental Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Halitosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Tongue Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . 106 Burning Mouth Syndrome . . . . . . . . . . . . . . . . . . . 106 Temporomandibular Disorders . . . . . . . . . . . . . . . . . . . 106
Anorectal Disorders Approach to the Patient with Anorectal Disorders . . . . . 107 Hemorrhoids and Rectal Bleeding . . . . . . . . . . . . . . . . . 107 Anal Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Anorectal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Chronic Anorectal Pain . . . . . . . . . . . . . . . . . . . . . . . . . 108 Pruritus Ani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Mental and Behavioral Health Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Diagnosis of Depressive Disorders. . . . . . . . . . . . . . 108 Management of Depression . . . . . . . . . . . . . . . . . . 109 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Posttraumatic Stress Disorder . . . . . . . . . . . . . . . . . 111 Social Anxiety Disorder. . . . . . . . . . . . . . . . . . . . . . 111 Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . 111
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Intermittent Explosive Disorder. . . . . . . . . . . . . . . . . . . 112 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Somatoform Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 112 Clinical Presentation and Evaluation . . . . . . . . . . . . 112 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Types of Eating Disorders. . . . . . . . . . . . . . . . . . . . 113 Medical Complications of Eating Disorders. . . . . . . 114 Treatment of Eating Disorders . . . . . . . . . . . . . . . . 114 Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . 115 Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . 115 Difficult Patient Encounters. . . . . . . . . . . . . . . . . . . . . . 116
Geriatric Medicine Functional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Fall Prevention and Home Safety . . . . . . . . . . . . . . 117 Mild Cognitive Impairment and Dementia . . . . . . . 118 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 The Older Driver . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Levels of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Polypharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . 123 Prevention and Management . . . . . . . . . . . . . . . . . 123
xii
Perioperative Medicine General Recommendations . . . . . . . . . . . . . . . . . . . . . . 124 Perioperative Testing . . . . . . . . . . . . . . . . . . . . . . . 124 Perioperative Medication Management . . . . . . . . . . 125 Cardiovascular Perioperative Management . . . . . . . . . . . 125 Pulmonary Perioperative Management. . . . . . . . . . . . . . 128 Hematologic Perioperative Management . . . . . . . . . . . . 129 Venous Thromboembolism Prophylaxis . . . . . . . . . 129 Perioperative Management of Warfarin Therapy . . . 129 Perioperative Management of Antiplatelet Medications, Coagulopathies, and Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . 130 Perioperative Management of Anemia. . . . . . . . . . . 131 Perioperative Management of Endocrine Diseases . . . . . 132 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Adrenal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . 132 Perioperative Management of Kidney Disease . . . . . . . . 133 Perioperative Management of Liver Disease . . . . . . . . . . 133 Perioperative Management of Neurologic Disease . . . . . 134
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Self-Assessment Test . . . . . . . . . . . . . . . . . . . . . . . . 141 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
General Internal Medicine
Interpretation of the Medical Literature Study Design Threats to Validity Investigators attempt to infer validity, or “truth,” by comparing two groups of people in a well-designed study. Many factors can threaten a study’s validity, including errors in measurement, data collection, selection of subjects, or analysis. Internal validity refers to the degree to which the investigators’ conclusions (usually implying cause and effect) are supported by the study. External validity refers to the generalizability of the study. There is always some error in any research study. Error is typically shown in scientific publications by way of a confidence interval (CI), typically the 95% confidence interval, which signifies that the investigators can be 95% certain that the value derived from a study truly lies within that interval. If the CI is wide, the point estimate is said to have less certainty, or precision; this is often due to small sample size. A small sample size can also decrease the power of a study. Power is the probability of detecting a difference between two groups when a true difference exists. Random error due to chance alone can sometimes result in uneven distribution of patient characteristics, affecting study results. When error is not random, but is applied differentially to one group, it is called bias. Bias can occur in selection of patients, measurement, and analysis. Selection bias occurs when patients chosen for a study group have characteristics that can affect the results of the study. Bias can be minimized using carefully constructed research protocols that ensure that the comparison groups are selected, measured, and analyzed in the same way. Another major challenge in interpreting studies is confounding. A confounder is a third factor that influences both exposure (treatment) and outcome. For example, the false conclusion that smokeless tobacco in the form of snuff poses a greater risk for developing coronary artery disease (CAD) than cigarette smoking could occur because being male (the confounder, which is associated with CAD) is more likely among snuff users than among cigarette smokers. A failure to recognize the presence of a confounder distorts the causeeffect relationship. Confounding can be minimized by using a randomized study design or with statistical techniques if randomization is not possible.
Experimental Studies In an experimental study, patient selection, treatment, and analysis are determined from the outset to minimize error and bias. In addition, many experimental studies blind patients, treating physicians, and investigators to which treatment a patient is receiving in order to reduce bias, because knowledge of which treatment a patient receives can affect patient reporting and investigator assessment of outcomes. To minimize bias associated with measurement, assessors of clinical outcomes are typically blinded even if patients and treating physicians cannot be blinded. Various types of study designs are compared in Table 1. In a randomized controlled trial (RCT), randomization is performed in an effort to distribute all potential prognostic factors equally across both the experimental and the control groups, minimizing confounding and bias. Although historically, most RCTs compared a new intervention with a placebo, RCTs can also compare a new therapy with an existing one. The objective of these trials, which are often used when the new therapy is less costly or easier to use, is typically to prove that the new therapy is “noninferior” to accepted therapies. These studies require careful attention to the power of the study; studies with small numbers of patients can mask a true difference. Well-designed RCTs typically have a high degree of precision and internal validity. However, RCTs are typically conducted on patients with a narrow spectrum of disease and use treatment protocols that may be difficult to implement outside of a research setting. Therefore, many RCTs lack generalizability. Two other experimental study designs are used when randomization of individual patients is unfeasible or unethical (for example, evaluating a new patient safety initiative). In a quasiexperimental study design, data can be compared in the same group of patients both before and after an intervention. In cluster-randomized studies, groups of patients are randomized, rather than individual patients.
Observational Studies In an observational study, the investigator has no role in assigning individuals to interventions, but rather compares the effects of exposures or treatments among two or more observed groups. By their very nature, observational studies are more susceptible to bias and confounding than experimental studies. Strengths of observational studies, however, include their ability to include a broader spectrum of disease (and diseases or exposures that are rare) and that treatments 1
Interpretation of the Medical Literature
TA B L E 1 .
Types of Study Designs
Study Design
Description
Strengths
Weaknesses
Patients receive one of two interventions, often one being a placebo
Strongest design for Expensive, determining causation time-consuming, not practical for many clinical situations
Key Threats to Validity
Experimental Studies Randomized controlled trial (RCT)
Limited follow-up duration Limited number of outcomes that can be assessed
If randomization is ineffective If data are not analyzed according to initially assigned group If key individuals are aware of group assignment (not blinded) If follow-up is incomplete
Limited generalizability Cluster-randomized trial
Patients grouped by clusters (e.g., nursing unit) rather than assigned randomly
Quasi-experimental design Review of data collected before and after an intervention
Same as for RCTs
Same as for RCTs
Same as for RCTs
Can be used if randomization of patients is not ethical or feasible
Challenging to analyze If analysis does not account for clustering
Can be used if randomization of patients is not ethical or feasible
Patients not randomized
If no adjustment for possible confounding
Observational Studies Cohort study
Studies outcomes of groups using observed assignment
Able to detect Requires complicated associations, but these statistical techniques to are not always cause- minimize confounding effect relationships Prospective designs can Able to study multiple be expensive and take outcomes over a long many years before period of time results are available
Selection bias in cohort Bias in measurement of exposures and outcomes If important confounders not accounted for
Large sample size Case-control study
Compares past exposures in patients with and without disease
Useful for rare diseases or exposures Inexpensive
High risk for bias High risk for confounding Cannot assess incidence/prevalence
are administered in a “real-world� environment. Two types of observational studies are cohort studies and case-control studies. A cohort study compares the outcomes of groups with and without exposures or treatments not initiated by the investigator; for example, rates of lung cancer between smokers and nonsmokers. Cohorts are compared by following them forward in time (prospectively) or by looking backward in time (retrospectively); prospective design minimizes recall bias (inaccurate recall of past events). A case-control study retrospectively compares the experience of patients who have a disease with those who do not have the disease. For example, patients with and without lung cancer can be compared with respect to their exposure to asbestos. Case-control studies are particularly useful to study rare diseases or diseases that occur many years after specific exposures. These studies are highly susceptible to 2
Selection bias, especially in controls Measurement bias, especially recall bias
bias, especially recall bias, as patients with disease may be more likely to remember previous exposures. Careful attention is needed in both measurement of exposures and selection of controls. Other observational study designs are limited in their ability to establish causality but may be useful as relatively inexpensive means of generating hypotheses for future research or for determining estimates of prevalence of a disease. A cross-sectional study assesses for both exposure and disease at the same time point (rather than prospectively or retrospectively). A case series is a report of clinical outcomes in a group of patients; the absence of a control group prevents any conclusions about the effectiveness of the treatment. Epidemiologic studies compare outcomes, in aggregate, of two different populations (countries, socioeconomic groups). These studies are potentially subject to the ecologic fallacy,
This self-assessment test contains one-best-answer multiple-choice questions. Please read these directions carefully before answering the questions. Answers, critiques, and bibliographies immediately follow these multiple-choice questions. The American College of Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American College of Physicians designates MKSAP 16 General Internal Medicine for a maximum of 24 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Earn “Same-Day” CME Credits Online For the first time, print subscribers can enter their answers online to earn CME credits in 24 hours or less. You can submit your answers using online answer sheets that are provided at mksap.acponline.org, where a record of your MKSAP 16 credits will be available. To earn CME credits, you need to answer all of the questions in a test and earn a score of at least 50% correct (number of correct answers divided by the total number of questions). Take any of the following approaches: ‚ Use the printed answer sheet at the back of this book to record your answers. Go to mksap.acponline.org, access the appropriate online answer sheet, transcribe your answers, and submit your test for same-day CME credits. There is no additional fee for this service. ‚ Go to mksap.acponline.org, access the appropriate online answer sheet, directly enter your answers, and submit your test for same-day CME credits. There is no additional fee for this service. ‚ Pay a $10 processing fee per answer sheet and submit the printed answer sheet at the back of this book by mail or fax, as instructed on the answer sheet. Make sure you calculate your score and fax the answer sheet to 215-351-2799 or mail the answer sheet to Member and Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572, using the courtesy envelope provided in your MKSAP 16 slipcase. You will need your 10-digit order number and 8-digit ACP ID number, which are printed on your packing slip. Please allow 4 to 6 weeks for your score report to be emailed back to you. Be sure to include your email address for a response. If you do not have a 10-digit order number and 8-digit ACP ID number or if you need help creating a username and password to access the MKSAP 16 online answer sheets, go to mksap.acponline.org or email custserv@acponline.org. CME credit is available from the publication date of December 31, 2012, until December 31, 2015. You may submit your answer sheets at any time during this period.
141
Self-Assessment Test
General Internal Medicine Self-Assessment Test
Each of the numbered items is followed by lettered answers. Select the ONE lettered answer that is BEST in each case.
Item 1
Item 3
A 32-year-old man is evaluated during a routine examination. He is in good health, has no concerning symptoms, and takes no medications. He does not smoke, seldom drinks alcohol, and exercises 30 minutes daily 5 days per week. He ingests a heart-healthy diet. All of his immunizations are up to date. The patient has no symptoms or health problems.
A 40-year-old woman is evaluated for having difficulty at work. She is a nurse, and over the past 6 months she has become very zealous about avoiding infection. She washes her hands six or seven times before entering patients’ rooms and then again afterwards. She is having difficulty completing tasks on time. She showers multiple times daily and has scrubbed her skin raw in several areas. She recognizes that these actions are unreasonable but she no control over them. She has no history of psychiatric disease, bipolar disorder, or schizophrenia. On physical examination, vital signs are normal. Both hands are raw and there are several areas of denuded skin on her arms and legs.
Which of the following is the most reasonable next screening step for genetic disease in this patient? (A) (B) (C) (D)
Obtain a family history of disease Obtain a three-generation pedigree Refer for genetic counseling Screen for common genetic mutations
In addition to cognitive-behavioral therapy, which of the following is the most appropriate pharmacologic treatment?
Item 2 A 58-year-old woman is evaluated for a 7-week history of tingling pain involving the first, second, and third digits of the left hand. The pain is worse at night and radiates into the thenar eminence. The pain does not radiate into the proximal forearm. She has hypothyroidism and her only current medication is levothyroxine. On physical examination, the patient reports pain with plantar flexion at the wrist with the elbow extended. She also reports pain with percussion over the median nerve at the level of the wrist. There is no thenar or hypothenar eminence atrophy. Strength is 5/5 with thumb opposition. A hand diagram is completed (shown) demonstrating the location of the patient’s paresthesia.
(A) (B) (C) (D)
Fluoxetine Haloperidol Lorazepam Quetiapine
Item 4 A 24-year-old man is evaluated for a 2-hour history of epistaxis, which began after blowing his nose. The bleeding is controlled by placing pressure on the anterior portion of the nose for 3 minutes but then recurs. The bleeding is from the left nostril only. He has severe seasonal rhinitis that has been active recently. He has no history of bleeding, bruising, or clotting, and there is no family history of bleeding disorders. Current medications are loratadine and an intranasal corticosteroid. On physical examination, he is afebrile, blood pressure is 138/88 mm Hg, and pulse rate is 82/min. Blood pressure and pulse are without significant change from supine to standing positions. He is holding a tissue against his nose. Examination of the left naris with a nasal speculum after the removal of dried blood reveals a small oozing vessel in the septum in the Kiesselbach area. The right naris is clear of blood, and a skin examination demonstrates no petechiae or bruises. Which of the following is the most appropriate management of this patient?
In addition to avoidance of repetitive wrist motions, which of the following is the most appropriate initial treatment? (A) (B) (C) (D)
Local corticosteroid injection Oral ibuprofen Surgical intervention Wrist splinting
(A) (B) (C) (D) (E)
Arterial embolization Cauterization and nasal packing Complete blood count and coagulation studies Uninterrupted nasal pressure for 15 to 30 minutes Urgent otorhinolaryngology evaluation
Item 5 A 54-year-old woman is evaluated during a routine examination. She is very concerned by her lack of interest in 143
Self-Assessment Test
Directions
Answers and Critiques Answer:
A
Educational Objective: Identify appropriate genetic counseling strategies. The most appropriate screening step for genetic diseases in this patient is to inquire about any diseases that “run in the family” and, specifically, to inquire about family history of the more common and important inherited diseases, including breast, ovarian, prostate, and colon cancer, as well as early cardiovascular disease. A detailed family history should follow for those conditions identified through this preliminary questioning. Patient-reported family histories for first-degree relatives have been shown to be accurate and valuable for breast and colon cancer, but a negative family history for ovarian and endometrial cancer is less accurate. Although few diseases follow strict Mendelian genetics that allow for a relatively certain prediction of disease, knowledge regarding the frequency of disease occurrence in a given family cohort is helpful in assessing individual risk for developing specific disorders with a genetic predisposition. Genetic counseling with the option for testing should be offered when: (1) the patient has a personal or family history suggestive of a genetic susceptibility condition; (2) the genetic test can be adequately interpreted; and (3) the test results will aid in diagnosis or influence the medical or surgical management of the patient or family at hereditary risk. It is premature to refer for genetic counseling without first determining if there is concern for a genetic disorder. The process of taking a family history typically employed by medical genetics professionals is both laborand time-intensive. It typically involves a three-generation pedigree and may require hours to complete. Given the multiple demands on the internist during the clinical encounter, this degree of detail is not feasible. Although it is standard of care to perform genetic testing for certain mutations in unselected preconception, prenatal, and newborn populations, and direct-to-consumer genomic kits are commercially available, at least three important issues make it unwise to perform genetic testing in unselected populations seen by internists: (1) the clinical validity of such a test may be lacking, (2) there may be a high likelihood of falsepositive tests, and (3) the harms of performing a genetic test may outweigh any benefits. KEY POINT
• The most appropriate first screening step for genetic diseases is to inquire about any diseases that “run in the family” and to inquire specifically about family history of the more common and important inherited diseases, including breast, ovarian, prostate, and colon cancer, as well as early cardiovascular disease.
Bibliography Berg AO, Baird MA, Botkin JR, et al. National Institute of Health State-of-the-Science Conference Statement: Family History and Improving Health. Ann Intern Med. 2009; 151(12):872-877. [PMID: 19884615]
Item 2
Answer:
D
Educational Objective: Treat carpal tunnel syndrome. This patient has carpal tunnel syndrome, and the most appropriate initial treatment, in addition to the avoidance of repetitive wrist motions, is wrist splinting. Wrist splinting appears to be most effective when done in the neutral position compared with 20 degrees of extension. In one prospective study, full-time splinting was superior to nocturnal splinting at 6 weeks in terms of nerve latencies, although there was significant cross-over of patients between groups in this study. Nocturnal splinting has the advantage of being more convenient to patients in comparison with full-time splinting. Local corticosteroid injection has been shown to provide short-term (up to 3 months) pain relief, although the effect does not appear to be durable. Contraindications to local corticosteroid injections include thenar weakness and atrophy, profound sensory loss, and acute carpal tunnel syndrome. Owing to possible adverse effects, drug therapy should be reserved for patients in whom wrist splinting has failed. Although NSAIDs are frequently used as first-line therapy, evidence is lacking as to their effectiveness. Surgical intervention should be reserved for patients in whom both nonpharmacologic and pharmacologic conservative therapies have failed. Other indications include progressive sensory or motor deficits and moderate to severe findings on electrodiagnostic studies. In one randomized controlled trial of 116 patients, those with carpal tunnel syndrome who underwent surgical intervention had better outcomes (function and symptoms) than those who underwent nonsurgical management, although clinically, the benefit was modest. KEY POINT
• Initial therapy for carpal tunnel syndrome is wrist splinting and avoidance of repetitive wrist motions. Bibliography Jarvik JG, Comstock BA, Kliot M, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallelgroup trial. Lancet. 2009;374(9695):1074-1081. [PMID: 19782873]
181
Answers and Critiques
Item 1