MKSAP IM Wrong Q's

Oral Duloxetine. The most appropriate treatment for this patient with evidence of painful diabetic peripheral neuropathy and substantial neuropathic pain is initiation of oral duloxetine. Diabetes mellitus can cause various types of neuropathy. The most common pattern is symmetric distal sensory or sensorimotor. It is characterized by a stocking-glove distribution that ascends proximally. Diabetic sensorimotor neuropathy frequently presents as a sensation of numbness, tingling, burning, heaviness, pain, or sensitivity to light touch. The pain may worsen at night and with walking. Glycemic control and minimizing cardiovascular risk factors can slow the progression and improve the symptoms of diabetic neuropathy. Treatment of painful neuropathies is symptomatic. Tricyclic antidepressants (amitriptyline, nortriptyline), serotonin-norepinephrine reuptake inhibitors (venlafaxine, duloxetine), antiepileptic drugs (pregabalin, gabapentin, valproic acid), opioids (tapentadol), and topical capsaicin are commonly used. However, only pregabalin, duloxetine, and tapentadol (extended release) have FDA approval for painful diabetic neuropathy. Although duloxetine and gabapentinoids are considered first-line therapy, they are costly. The dosage of duloxetine is started at 20 mg/d or 30 mg/d and increased to a goal dosage of 60 mg/d. Dosages higher than 60 mg/d have not been shown to be more effective for analgesia.

A 67-year-old man is evaluated for a 2-year history of worsening pain in his feet. He describes the pain as long-standing aching and burning. The pain is persistent, sometimes waking him from sleep. Medical history is otherwise significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, insulin aspart, valsartan, aspirin, and simvastatin. On physical examination, vital signs are normal. The feet are insensate to monofilament testing, and vibratory sensation is absent in the feet and ankles. No evidence of skin breakdown is noted. What is the most appropriate treatment?

Vertebrobasilar Ischemia. The most likely diagnosis is vertebrobasilar ischemia. In patients with vertigo, it is crucial to differentiate central from peripheral causes, especially in patients with acute vertigo concerning for vertebrobasilar ischemia and other central causes. The Dix-Hallpike maneuver is an effective bedside test for this purpose. In this test, the examiner stands at the patient's side and rotates the patient's head 45 degrees; the examiner then moves the patient, whose eyes are open, from the seated to the supine ear-down position. The patient's neck is extended slightly so that the chin is pointed upward, and the patient is observed for nystagmus. During the test, the latency, duration, fatigability, and direction of nystagmus are noted. The maneuver is repeated with the patient's head turned in the opposite direction. Findings that indicate central vertigo are nystagmus with an immediate onset (no latency), longer duration (>1 minute), no fatigability, and vertical or horizontal directionality without a torsional component. With central vertigo, the direction of nystagmus may vary depending on the direction of the patient's gaze. Potentially life-threatening conditions associated with central vertigo include ischemia, infarction, or hemorrhage of the cerebellum or brainstem. Patients at high risk include those with hypertension, diabetes mellitus, hyperlipidemia, or advanced age. Vertebrobasilar stroke is usually, but not always, accompanied by dysarthria, dysphagia, diplopia, weakness, or numbness. Cerebellar infarct may present with gait or truncal ataxia or with vertigo alone. In a patient presenting with suspicion for a central cause of vertigo, brain MRI and magnetic resonance angiography of the posterior cerebral circulation are the preferred diagnostic studies.

A 67-year-old man is evaluated for a 3-hour history of episodic dizziness. He notes a room-spinning sensation started suddenly without antecedent trauma and has been accompanied by nausea. Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Medications are lisinopril, atorvastatin, and metformin. On physical examination, temperature is normal, blood pressure is 174/88 mm Hg, pulse rate is 101/min, and respiration rate is normal. The Dix-Hallpike maneuver evokes immediate nystagmus with no fatigability. The nystagmus is vertical without a torsional component, but the direction varies depending on the direction of the patient's gaze. The neurologic examination is limited but grossly nonfocal. What is the most likely diagnosis?

Binge Eating Disorder. This patient most likely has binge eating disorder (BED), which is characterized by impulsive overeating and feeling loss of control around food. The diagnosis of this disorder requires at least three of the following characteristics occurring at least once weekly for 3 months: abnormally rapid consumption, consuming large amounts of food when not hungry, eating alone due to embarrassment, eating until uncomfortably full, and feelings of guilt related to overconsumption. BED is more common than both anorexia and bulimia nervosa and is often accompanied by other psychiatric problems. The primary treatment is cognitive behavioral therapy.

A 17-year-old girl is seen for a health maintenance evaluation. She reports no health issues. In discussing dietary habits, she states that she frequently eats very large amounts of food until she is uncomfortably full. These episodes have occurred at least twice per week for the past year; during them, she feels a loss of control over her eating and guilt about her overconsumption. She often eats large amounts of food despite not being hungry, and she prefers eating alone because she is embarrassed of her eating. She does not take laxatives or induce vomiting after such episodes. She rarely exercises. BMI is 30. What is the most likely diagnosis?

Intravaginal Clotrimazole. The most appropriate treatment for this patient with symptoms of vulvovaginal candidiasis is intravaginal clotrimazole. Vulvovaginitis describes infectious and noninfectious conditions that cause vulvovaginal symptoms, including abnormal vaginal discharge, vulvar itching, burning, irritation, and malodor. When discharge is associated with abnormal findings, the differential diagnoses most commonly include bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. Vaginal irritation also may be caused by dermatologic conditions or allergic reactions, cervical infections, or genitourinary syndrome of menopause. A woman may have more than one type of infection at a time. The diagnosis of vulvovaginal candidiasis is suggested by the presence of vaginal discharge and vulvar pruritus, pain, irritation, and redness. Signs include vulvar edema; fissures; excoriations; and thick, white, curdy vaginal discharge. The diagnosis can be made when a saline or 10% potassium hydroxide wet mount of vaginal discharge shows hyphae, pseudohyphae, or yeast. Because the sensitivity of microscopy is low, empiric treatment of vulvovaginal candidiasis can be considered if symptoms are accompanied by characteristic findings. Several therapeutically equivalent topical and oral drugs are available; among the topically applied drugs, imidazoles (fluconazole, miconazole, clotrimazole) are the most effective. Evidence suggests that topical and oral agents have similar efficacy and that treatment preference should be based on cost, convenience, and patient preference.

A 23-year-old woman is evaluated for a 2-week history of persistent thick, white vaginal discharge; burning in the vulvar and vaginal regions; and vaginal itching. She has never had these symptoms before. She is in a monogamous sexual relationship. Medical history is otherwise unremarkable, and she takes no medications. On physical examination, vital signs are normal. Pelvic examination reveals vulvar edema with a few excoriations. Speculum examination demonstrates thick, white, curdy vaginal discharge. The remainder of the examination is unremarkable. Laboratory studies reveal a vaginal pH of 4.4; whiff test result is negative. Potassium hydroxide microscopy shows hyphae. Results of tests for Chlamydia trachomatis and Neisseria gonorrhoeae are negative. What is the most appropriate treatment?

Methylphenidate. The most appropriate treatment for this patient's depression is methylphenidate. Patients with a serious, life-threatening illness and untreated depression have poorer quality of life, which can lead to increased caregiver stress and burden. Diagnosing depression in terminally ill patients, however, is challenging. Although anticipatory grief is common in patients at the end of life and is considered a normal part of most end-of-life experiences, it can be distinguished from clinical depression by the patient's ability to find enjoyment and a fluctuating mood. Patients with depression at the end of life have symptoms that include hopelessness, pervasive guilt, and worthlessness. Depression in terminally ill patients responds well to both pharmacologic and nonpharmacologic treatments. Tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and mirtazapine are all effective agents. Prognosis should be taken into account because these medications take weeks to reach peak effect. This patient has symptoms consistent with clinical depression as well as a limited life expectancy. Methylphenidate is a rapid-acting psychostimulant that is well tolerated and may be effective in the treatment of depression; once initiated, results can be seen within 24 to 48 hours. Methylphenidate may also have the benefit of improving cancer-associated fatigue.

A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care. On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem. What is the Most Appropriate Tx ?

Cognitive Behavioral Therapy. The preferred initial treatment for this patient with obsessive-compulsive disorder (OCD) is cognitive behavioral therapy (CBT). OCD is an anxiety disorder in which patients experience obsessions (recurrent, intrusive thoughts, images, or impulses causing distress) and compulsions (repetitive behaviors done to alleviate obsession-related anxiety). Loss of time and disrupted social interactions from these thoughts and behaviors cause significant functional impairment. CBT is first-line treatment because it is more effective than pharmacotherapy alone. However, a combination of CBT and selective serotonin reuptake inhibitor (SSRI) therapy is useful for patients with severe symptoms or inadequate response to CBT. Although evidence is strongest for adjunctive therapy with SSRIs, more recent data support the adjunctive use of neuroleptics, deep-brain stimulation, and neurosurgical ablation for treatment-resistant OCD.

A 25-year-old man is evaluated during a new patient visit. He is experiencing severe anxiety about the start of a new job next month. Specifically, he is concerned about his ability to arrive on time because every morning before leaving his apartment, he feels compelled to perform multiple checks to ensure that all electronic devices are turned off and all windows and doors are locked. These activities consume approximately 1 hour of time. He performs these same activities each night before going to bed and often repeats them several times because of overwhelming feelings that he has forgotten something and his apartment will catch fire or be robbed. As a result of his anxieties, the patient rarely socializes outside of his home. When he is away from home, he uses a surveillance application to monitor his apartment 11 minutes after every hour. What is the most appropriate management?

Nucleic Acid Amplification Test For Chlamydia and Gonorrhea. The most appropriate screening strategy in this patient is nucleic acid amplification testing (NAAT) of urine, rectal, and pharyngeal specimens for Neisseria gonorrhoeae and Chlamydia trachomatis. Multiple studies have demonstrated an increased prevalence of genital and extragenital chlamydial and gonorrheal infections in men who have sex with men (MSM). In one study, prevalence rates of N. gonorrhoeae in MSM were 6.9% (rectal), 6% (urethral), and 9.2% (pharyngeal); for C. trachomatis, prevalence rates in MSM were 7.9% (rectal), 5.2% (urethral), and 1.4% (pharyngeal). Most infections are asymptomatic. The Centers for Disease Control and Prevention (CDC) recommends at least annual gonorrhea screening with NAAT of urethral, pharyngeal, and rectal specimens and at least annual screening for chlamydia with NAAT of urethral and rectal specimens. The CDC notes that commercially available NAATs have not been cleared by the FDA for some of these indications; however, these tests can be used by laboratories that have met all regulatory requirements for an off-label procedure. The CDC also recommends screening for syphilis and HIV at least annually in MSM. In contrast to the CDC, the U.S. Preventive Services Task Force has found insufficient evidence to recommend screening for chlamydia and gonorrhea in men.

A 26-year-old man is evaluated during a routine examination. He is asymptomatic. The patient is sexually active with men and has had multiple partners in the past year. He engages in both oral and anal sex, and he reports using condoms most of the time. He does not use illicit drugs. He is unsure about his vaccination status and has never been tested for HIV infection, syphilis, or infectious hepatitis. Medical history is unremarkable. He takes no medications. The physical examination, including vital signs, is normal. Screening is arranged for HIV infection, syphilis, and hepatitis A and B. What additional screening tests is most appropriate, as recommended by the Centers for Disease Control and Prevention?

Iliotibial Band Syndrome. The most likely diagnosis is iliotibial band syndrome (ITBS). ITBS is a common cause of lateral knee pain in runners and can also occur in patients with significant leg length difference, an excessively pronated foot, genu varum, or gluteal muscle weakness. Patients with ITBS have pain that is poorly localized to the lateral knee and distal thigh. Initially, the pain is present only after prolonged activity (such as running) that involves repeated knee flexion and extension. As the condition progresses, the pain occurs earlier in the course of activity and may eventually be present at rest. On examination, there is often tenderness to palpation 2 to 3 cm proximal to the lateral femoral condyle. Patients also frequently have weakness with hip abduction. Reproduction of the pain with knee extension from 90 degrees to 30 degrees with the examiner's thumb exerting pressure on the lateral femoral epicondyle (Noble test) supports the diagnosis of ITBS. Initial treatment consists of activity modification, ice application, and NSAIDs to reduce inflammation. Once inflammation subsides, stretching and then strengthening exercises are indicated.

A 26-year-old woman is evaluated for left lateral knee and distal thigh pain that began 6 weeks ago. She is a long-distance runner who trains 6 days per week. The pain began insidiously and has slowly worsened over time. The pain is worst when she is running downhill. She experiences no pain while resting. She has not had any knee trauma and reports no catching, grinding, or locking. On physical examination, vital signs are normal. On palpation, tenderness is noted 2 cm proximal to the lateral femoral condyle. With the patient supine, pain is reproduced with repeated flexion and extension of the knee as thumb pressure is applied to the lateral femoral epicondyle. There is weakness with left hip abduction. There is no joint line tenderness, joint effusion, or ligament laxity with applied stress. What is the most likely diagnosis?

Breast Ultrasonography. The most appropriate initial management of this patient is breast ultrasonography. Breast pain (mastalgia) is common and may be cyclic or noncyclic. Many younger women experience cyclic breast discomfort with the onset of menses. The discomfort is typically bilateral, lasts for several days, and varies in intensity. Noncyclic breast pain is more likely to be unilateral and may be caused by trauma, cysts, duct ectasia, mastitis, ligamentous stretching secondary to large breasts, or a breast mass. A thorough history with attention to type of pain, location, and relationship to menses and a careful physical examination are essential to rule out palpable masses or anatomic causes. All women should be up to date with screening mammography. Women with a palpable breast mass should be referred for diagnostic imaging. Women with noncyclic breast pain and no evidence of a breast mass should undergo targeted breast ultrasonography because approximately 1% of such patients may have breast cancer at the site of pain.

A 28-year-old woman is evaluated for persistent pain in the left upper outer breast of 9 weeks' duration. The pain is nonradiating and is not associated with aggravating factors or trauma. She has not noted breast lumps, fever, nipple discharge, or skin changes. Medical history is unremarkable, and she has no family history of breast or ovarian cancer. She takes no medications. On physical examination, vital signs are normal. BMI is 24. The breast tissue is dense, with no overlying skin changes or underlying masses. Focal tenderness is elicited on palpation of the upper quadrant of the left breast, but no mass or chest wall tenderness is present. There is no evidence of axillary, cervical, or supraclavicular lymphadenopathy. The remainder of the examination is unremarkable. What is the most appropriate management?

Cervical Cytology. This patient should be screened for cervical cancer with cytology (Pap testing) alone. Nearly all cases of cervical cancer are precipitated by persistent human papillomavirus (HPV) infection, and HPV (most commonly subtypes 16 and 18 [high-risk HPV]) is detected in most patients with cervical cancer. Immunization against HPV is thought to protect against 70% to 90% of cervical cancers depending on the type of vaccine received. However, in patients who have received the HPV vaccine series, routine cervical cancer screening is still strongly recommended. Recipients of the vaccine series may have been infected with HPV prior to immunization. Furthermore, HPV vaccination is not effective in clearing HPV infection and does not protect against all HPV types. The U.S. Preventive Services Task Force (USPSTF) has concluded that the benefits of screening for cervical cancer in women aged 21 to 29 years every 3 years with cytology alone substantially outweigh the harms.

A 29-year-old woman is evaluated during a routine examination. She is asymptomatic. Her last Pap smear was obtained 3 years ago and was normal. She completed the human papillomavirus (HPV) vaccine series at age 26 years. Medical and family histories are unremarkable. She takes no medications. What is the most appropriate cervical cancer screening strategy at this time?

Methylphenidate. In addition to cognitive behavioral therapy, methylphenidate is the best initial treatment for this patient with attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by persistent inattention and/or hyperactivity-impulsivity that disrupts functioning or development in at least two areas of a patient's life (such as work, home, or peer relationships). Some symptoms must be present since age 12 years; however, many patients are not formally diagnosed until adulthood, and up to 60% of children with ADHD continue to have symptoms as an adult. Although symptoms of hyperactivity and impulsivity often lessen over time, adults with ADHD may be easily distracted, disorganized, and restless. Many adults have comorbid psychiatric problems, such as anxiety, depression, sleep disorders, and substance use. Cognitive behavioral therapy alone or in combination with pharmacotherapy is effective for improving executive functioning in patients with ADHD. Stimulants, such as methylphenidate, are first-line pharmacologic therapy for ADHD. However, these drugs should not be prescribed to patients with recent substance use or at high risk for serious adverse effects (arrhythmia, hypertension). Atomoxetine, bupropion, and tricyclic antidepressants can be used when stimulants are contraindicated.

A 30-year-old man is evaluated for feeling "moody" and having persistent difficulty staying focused and keeping track of tasks. He reports often feeling restless and catching himself jumping between tasks before completing them. He describes himself as "hopelessly disorganized." As a result, he has lost or not paid home utility bills and has not always completed work tasks to the satisfaction of his supervisor. He recalls having these problems since childhood. He is otherwise well. He does not use coffee, alcohol, tobacco, or recreational drugs and does not take any medications. In addition to cognitive behavioral therapy, what is the most appropriate treatment?

Sertraline. The most appropriate long-term pharmacologic treatment for this patient with generalized anxiety disorder (GAD) is sertraline. GAD is characterized by excessive anxiety about activities or events (occupation, school) occurring more days than not for at least 6 months and causing significant functional impairment. Patients with GAD also experience difficulty concentrating, irritability, muscle tension, restlessness, and sleep disturbance. A useful tool for identifying and assessing the severity of GAD is the Generalized Anxiety Disorder 7-item scale (GAD-7) , which asks patients to rate seven items on a scale of 0 to 3 based on increasing severity. A score of 5 to 9 indicates mild anxiety, 10 to 14 moderate anxiety, and 15 to 21 severe anxiety. The GAD-7 can be used to monitor symptom severity over time, allowing clinicians to monitor treatment effectiveness.

A 30-year-old woman is evaluated for a 1-year history of severe anxiety about multiple aspects of her life, including her marriage, work, and health. She also reports irritability, poor sleep, and difficulty concentrating, and she finds it difficult to complete her daily home and occupational tasks. She has had multiple visits with her internist for various symptoms, including atypical chest pain, shortness of breath, palpitations, and intermittent diarrhea. She does not use alcohol, tobacco, or recreational drugs. She drinks one cup of coffee every morning. Her Generalized Anxiety Disorder 7-item scale score is 15, corresponding to severe anxiety. Laboratory studies reveal a normal serum thyroid-stimulating hormone level. What is the most appropriate long-term pharmacologic treatment?

The most appropriate management of this patient with pharyngitis is symptom control that might include an analgesic agent (such as an NSAID or acetaminophen), lozenges or topical sprays, and increased environmental humidity. Pharyngitis most commonly has viral causes; only 5% to 15% of pharyngitis cases are caused by bacteria, most often group A Streptococcus pyogenes (GAS). Clinicians must use clinical features to determine whether the patient meets the threshold for using a streptococcal rapid antigen detection test or throat culture. Several features are more predictive of a viral syndrome, and patients who present with a sore throat with accompanying features, such as conjunctivitis, cough, hoarseness, nasal congestion, and rhinorrhea, should not be tested for GAS pharyngitis. Additionally, the High Value Task Force of the American College of Physicians recommends that patients who meet fewer than three Centor criteria (fever by history, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough) need not be tested for GAS pharyngitis; these patients should be treated conservatively with symptom control.

A 30-year-old woman is evaluated for a 2-day history of sore throat and fatigue. She reports anorexia, chills, fever, rhinorrhea, and a dry persistent cough that keeps her awake at night. She works as a school bus driver. She has tried over-the-counter cough and cold products without benefit. Medical history is unremarkable, and she takes no medications. On physical examination, temperature is 37.2 °C (99.0 °F); all other vital signs are normal. She has nasal and pharyngeal erythema with sparse whitish exudate. There is no lymphadenopathy or rash. The remainder of the examination is normal. What is the most appropriate management?

Continue Fluoxetine as long term maintenance therapy. Long-term continuation of fluoxetine at the current dosage is appropriate for this patient with recurrent depression. Guidelines from the American Psychiatric Association (APA) recommend long-term maintenance therapy for patients with three or more episodes of major depressive disorder, persistent depressive disorder, or residual depressive symptoms. The same antidepressant and dosage that were effective in the treatment of acute depression should be continued for long-term maintenance.

A 31-year-old man is evaluated during a follow-up visit for depression. He previously experienced two episodes of major depressive disorder that were effectively treated with fluoxetine. Three months ago, he presented with recurrent symptoms of depression. His PHQ-9 score was 14, indicating moderate depression. Fluoxetine was initiated and uptitrated to an effective dosage. The patient now reports significant improvement in his symptoms. His PHQ-9 score is 6, indicating mild depression; he reports no adverse effects from the medication. What is the most appropriate next step in management?

Advice the Patient to Retire from driving. This patient should be advised to retire from driving. Driving assessments are qualitative and rely heavily on clinical judgment. The more risk factors for a motor vehicle accident that an older driver has, the higher the risk for an adverse event while driving. Drivers at highest risk should be counseled to retire from driving. This patient has multiple risk factors for unsafe driving, including cognitive impairment, self-restrictions in driving (does not drive after dark or on the interstate highway, drives within a 10-mile radius of home), minor accidents, and concerns from family members about driving safety. His other risk factors include impaired mobility, hearing decline, and medical conditions with increased risk for loss of consciousness. Physician advice to retire from driving is associated with older drivers appropriately discontinuing driving. Given the risk for depression and social isolation associated with driving retirement, however, this advice should be coupled with suggestions for alternate forms of transportation and follow-up assessment of his mood and quality of life.

An 82-year-old man is evaluated during a routine evaluation. He is accompanied to the visit by his son. The patient lives alone, and his son expresses reservations about his father continuing to drive. The patient no longer drives after dark or on the interstate highway. He limits his driving to within a 10-mile radius of his home and mainly drives for local errands and to church on Sundays. He has had no traffic accidents, but he had two recent incidents in which he misjudged the angle of his car in the grocery store parking lot and ran into the shopping cart stand. Medical history is significant for coronary artery disease, hypertension, and mild cognitive impairment. Medications are atorvastatin, aspirin, hydrochlorothiazide, lisinopril, and metoprolol. On physical examination, blood pressure is 132/82 mm Hg, and pulse rate is 64/min; other vital signs are normal. The patient appears frail with a pleasant demeanor. He wears eyeglasses and hearing aids, and he has impaired hearing as measured by the whispered voice test. On musculoskeletal examination, limited mobility of the cervical spine is noted. He scores 26/30 on the Mini-Mental State Examination. The remainder of the examination is unremarkable. What is the most appropriate management regarding this patient's driving?

Ibuprofen and Scrotal Support. This patient's history and physical examination findings support a clinical diagnosis of symptomatic varicocele, and the appropriate treatment is analgesic therapy (ibuprofen) and scrotal support. Varicoceles are common, occurring in 15% of men. Notably, they are believed to be a leading cause of infertility; 40% of men who are infertile have varicoceles. They are the result of dilation of the pampiniform plexus of spermatic veins and can have a presentation ranging from no symptoms to dull aching scrotal fullness. Examination reveals a left-sided (90%) soft scrotal mass with a "bag of worms" consistency that increases with standing and decreases while supine. Ultrasonography is used for confirmation. Management is usually conservative, including analgesic agents; scrotal support should be pursued in all patients and is considered first-line therapy. Unilateral right-sided varicoceles are uncommon and may be associated with a significant underlying abnormality, such as inferior vena cava obstruction due to tumor or thrombosis because the right gonadal vein directly empties into the inferior vena cava. Many experts recommend advanced imaging with CT for patients with right-sided varicoceles.

A 31-year-old man is evaluated for dull, aching, left-sided scrotal discomfort and fullness with intermittent swelling. His symptoms began 6 months ago. He is sexually inactive. On physical examination, vital signs are normal. Testicular size is normal bilaterally. On his left hemiscrotum, there are tenderness to palpation in the superolateral region and soft, compressible swelling along the spermatic cord, which increases with standing and the Valsalva maneuver. Transillumination and the Prehn sign (diminished scrotal discomfort with elevation) are negative. What is the most appropriate treatment?

Connect with The Ground Based Physician. The most appropriate next step in management is to connect with the ground-based physician. In-flight medical emergencies are relatively common during air travel, occurring in an estimated 1 of 600 flights. Airlines based in the United States are mandated by the Federal Aviation Administration to carry at least one automated external defibrillator; supplemental oxygen; and a medical kit that contains a stethoscope, sphygmomanometer, gloves, airway supplies, intravenous access supplies, and some basic medications. In the case of an in-flight emergency, the physician's role generally involves assessing the patient, establishing a diagnosis when possible, administering basic medical treatments, providing reassurance as appropriate, and recommending flight diversion if necessary. Physicians should practice within their scope of training, be mindful of patient privacy, and document the patient encounter. Although not a Federal Aviation Administration requirement, most airlines have contracts with 24-hour call centers with a ground-based physician to aid in the event of an in-flight emergency. Often, ground-based physicians trained in emergency or aerospace medicine can assist the on-board physician remotely and help direct care, which can be particularly helpful when the medical problem is outside the scope of the physician's practice.

A 32-year-old woman is evaluated during a domestic airline flight for an episode of weakness and lightheadedness. She is pregnant at 35 weeks' gestation. She has had several contractions since take-off but without regularity. She reports no abdominal pain. She has no medical problems, and her only medication is a prenatal vitamin. On physical examination, the patient appears weak. Temperature is normal, blood pressure is 105/60 mm Hg, pulse rate is 99/min, and respiration rate is 14/min. Her skin is clammy. Cardiovascular examination is unremarkable. Lungs are clear to auscultation. On abdominal examination, she has a gravid uterus. Oxygen, 2 L/min by nasal cannula, is started. An intravenous line is placed, and fluids are initiated. What is the most appropriate next step in management?

Advice use of Well-Fitting bra. The most appropriate next step in this patient's management is the use of a well-fitting bra. Breast pain is common among women and is categorized primarily as cyclic or noncyclic in relation to the menstrual cycle. This patient has cyclic mastalgia, which is bilateral and diffuse and worsens in the days before menses and then abates. Cyclic mastalgia is often related to hormonal changes that occur with ovulation. Because most symptoms of cyclic mastalgia are self-limited, management usually requires only education, reassurance, and appropriate breast support.

A 33-year-old woman is evaluated for a 10-month history of bilateral diffuse breast pain. The pain is severe in intensity, occurring about a week before her menstrual cycle and resolving afterward. She has generally lumpy breasts without a dominant mass and no nipple discharge. Her menstrual cycles are regular. She drinks a cup of coffee in the morning and another at noon. Medical history is otherwise unremarkable. She has no family history of breast cancer. On physical examination, vital signs are normal. BMI is 29. Examination of the breasts shows dense nodularity in the upper outer quadrant of both breasts and no skin changes. Tenderness is elicited on examination of the upper outer quadrants of the breasts. There is no evidence of cervical, supraclavicular, or axillary lymphadenopathy. What is the most appropriate next step in management?

Cognitive Behavioral Therapy. The most appropriate treatment for this patient with systemic exertion intolerance disease (SEID) is cognitive behavioral therapy. According to the Institute of Medicine (now the National Academy of Medicine), SEID is diagnosed by the presence of fatigue of at least 6 months' duration with substantial reduction in preillness activities, postexertional malaise, unrefreshing sleep, and either cognitive impairment or orthostatic intolerance (symptoms such as lightheadedness, dizziness, fatigue, cognitive deficits, and visual difficulties that worsen with upright posture and improve with recumbency). Patients with SEID benefit most from a structured, well-defined, multimodal approach that includes regularly scheduled office visits, which allow for discussion, educational opportunities, and longitudinal reassessment. There is evidence that cognitive behavioral therapy and graded exercise therapy may decrease fatigue and improve function, and these therapies should be offered to patients. Additionally, all patients should receive instruction on effective sleep hygiene. Other modalities that may be of benefit include physical therapy, occupational therapy, biofeedback therapy, massage therapy, acupuncture, yoga, tai chi, and stress management activities. Considering this patient's depression (which is likely a consequence of her chronic symptoms), cognitive behavioral therapy is an ideal treatment.

A 33-year-old woman is evaluated for a 16-month history of chronic fatigue, unrefreshing sleep, difficulty concentrating, and postexertional malaise. As a result of her symptoms, she has become isolated, restricting her social and personal activities. She has also taken sick days from work with increasing frequency in recent months. Medical and family histories are unremarkable. She takes no medications. On physical examination, the patient has depressed mood. Vital signs are normal. Neurologic examination and the remainder of the examination are normal. Her PHQ-9 score is 6, consistent with mild depression. After a careful evaluation, the patient is diagnosed with systemic exertion intolerance disease. In addition to a graded exercise program, What is the most appropriate treatment?

LMW heparin and Intermittent Pneumatic compression. Mechanical prophylaxis with intermittent pneumatic compression (IPC) and pharmacologic prophylaxis with low-molecular-weight heparin (LMWH) are appropriate for prevention of postoperative venous thromboembolism (VTE) in this patient undergoing nonorthopedic surgery. The American College of Chest Physicians (ACCP) antithrombotic guideline provides VTE prophylaxis recommendations for both orthopedic and nonorthopedic surgery populations. The ACCP guideline recommends using the Caprini score (https://venousdisease.com/dvt-risk-assessment-online/) to estimate risk for postoperative thrombosis in those undergoing general surgery, gastrointestinal surgery, urologic surgery, gynecologic surgery, bariatric surgery, vascular surgery, and plastic/reconstructive surgery (but not other types of surgeries). It includes weighted patient and surgery-related risk factors for VTE. A score of 0 defines very low risk for VTE (estimated VTE risk in the absence of prophylaxis, <0.5%); scores of 1 to 2 define low risk (VTE risk, 1.5%); scores of 3 to 4 define moderate risk (VTE risk, 3%); and scores of 5 or more define high risk (VTE risk, 6%). For patients at high risk for VTE, pharmacologic prophylaxis with LMWH or low-dose unfractionated heparin and the addition of mechanical prophylaxis are recommended. This patient has a high perioperative risk for VTE, with a Caprini score of 6 (1 point for history of inflammatory bowel disease, 2 points for major surgery >45 minutes, and 3 points for personal history of VTE). Therefore, IPC and LMWH are appropriate.

A 34-year-old woman is hospitalized for a small bowel resection due to multiple strictures. She has a 10-year history of Crohn disease. History is also significant for a provoked pulmonary embolism that occurred 5 years ago. Medications are azathioprine and certolizumab. On physical examination, vital signs are normal. The abdomen is soft. Mild diffuse pain without rebound or guarding is noted. The patient's Caprini risk score for venous thromboembolism is 6 (high risk). What is the most appropriate postoperative venous thromboembolism prophylaxis for this patient?

Discontinue Kava tea. This patient should be advised to discontinue drinking kava tea. Patients take dietary supplements for various reasons, such as to prevent illness, enhance health, and correct perceived deficiencies. In the United States, approximately 50% of adults report using vitamins or dietary supplements, with total consumer spending of more than $20 billion each year. Despite their prevalent use, the U.S. Preventive Services Task Force does not recommend multivitamins or herbal supplements for the prevention of cardiovascular disease or cancer. In addition to questionable efficacy, supplement use is associated with risk for considerable harms, including side effects; interactions with other drugs; and harms related to inclusion of unadvertised additives, compounds, or toxins. Despite the risks, many patients strongly believe in supplement use, and the role of the physician is to inform these patients of harmful supplements and suggest safer alternatives. This patient is taking kava, which is derived from Piper methysticum, a plant native to the western Pacific islands. It is often used to relieve stress and anxiety but has been associated with liver damage. In 2002, the FDA issued a consumer advisory regarding the potential risk for severe liver injury with kava use, especially in patients with liver disease or at risk for liver disease. Therefore, advising this patient with nonalcoholic steatohepatitis to discontinue kava tea would be the best management option.

A 35-year-old woman is evaluated during a follow-up visit for anxiety. Her symptoms have been well controlled with cognitive behavioral therapy, and she has been drinking kava tea every morning and practicing mindfulness daily. Medical history is significant for nonalcoholic steatohepatitis. Other supplements are folic acid and echinacea. On physical examination, vital signs are normal. BMI is 36. The remainder of the examination is unremarkable. What is the most appropriate recommendation for this patient?

Pregnancy Test. Pregnancy testing is the next step in this patient's management. Strategies to reduce unintended pregnancy require assessing pregnancy risk, counseling patients regarding contraceptive options, and ensuring correct and consistent use of contraceptives. Most women can start most contraceptive methods at any time. Available contraceptive methods include hormonal contraception; long-acting reversible preparations, including intrauterine devices; barrier contraceptives; and sterilization. Other than a thorough history and blood pressure and BMI measurements, few examinations or tests, if any, are needed before starting a contraceptive method. A pregnancy test should be obtained if more than 7 days have elapsed since the start of the last menses.

A 35-year-old woman is evaluated during a routine follow-up examination for hypothyroidism and requests a prescription for birth control pills. She is in a new sexual relationship. She has regular menstrual cycles, and her last menstrual period was 4 weeks ago. Her most recent Pap smear was obtained 2 years ago and was normal. Her only medical problem is hypothyroidism treated with levothyroxine. Her mother had breast cancer at age 67 years. On physical examination, vital signs are normal. BMI is 25. The remainder of the examination is unremarkable. What is the most appropriate next step in her management?

No further testing is recommended. No further diagnostic testing is required in this patient. She meets the diagnostic criteria for systemic exertion intolerance disease (SEID), which are fatigue of at least 6 months' duration accompanied by substantial reduction in preillness activities, postexertional malaise, unrefreshing sleep, and either cognitive impairment or orthostatic intolerance. Although the pathophysiology of SEID remains unclear, the phenomenon of central sensitization (the pathophysiologic dysregulation of the thalamus, hypothalamus, and amygdala) is gaining acceptance as a potential cause of SEID as well as of other highly prevalent comorbid conditions, including fibromyalgia, mood disturbances, irritable bowel syndrome, and interstitial cystitis. This patient's history, examination, and previous diagnostic test results point to central sensitization, as demonstrated by the constellation of such symptoms as diffuse arthralgia and myalgia, chronic fatigue, bowel and bladder irritability, chronic headaches, brain fog, paresthesias, and unrefreshing sleep. In patients with SEID, the history and physical examination should guide the choice of diagnostic tests. It is reasonable to obtain a complete blood count, creatine kinase (for myalgia), electrolyte panel, thyroid-stimulating hormone level, fasting glucose level, and kidney and liver chemistry tests; however, unnecessary laboratory, imaging, and invasive studies should be avoided because most patients will have unrevealing findings, which provide no lasting reassurance to patients. In this case, the diagnostic evaluation should be limited unless there is compelling new information to warrant further testing.

A 36-year-old woman is evaluated for a 3-year history of fatigue that worsens after activity and does not improve with rest. She also notes intermittent diffuse myalgia and arthralgia, constipation, dizziness, headaches, urinary urgency, memory problems, and paresthesias. Her musculoskeletal symptoms, dizziness, and headache worsen in the upright position and improve when she lies back down. She has almost entirely eliminated social activities. Medical history is significant for episodic migraine and irritable bowel syndrome. Medications are sumatriptan, polyethylene glycol, and hyoscyamine. On physical examination, vital signs are normal. BMI is 24. Neck circumference is 36 cm (14 in). The remainder of the examination is normal. Laboratory studies obtained 6 months ago showed a normal complete blood count, electrolyte levels, kidney function test results, liver chemistry test results, fasting glucose level, serum creatine kinase level, and serum thyroid-stimulating hormone level. What is the most appropriate diagnostic test to perform next?

Obtain All previous Medical Records. The most appropriate management of this patient with medically unexplained symptoms (MUS) is to avoid testing and obtain previous medical records. The most common symptoms in patients presenting with MUS are chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, and numbness. Frequently, patients have seen many primary care and subspecialty physicians over the course of many years and have undergone extensive laboratory testing, imaging studies, and procedures. Because patients with MUS present on a continuum of physical and mental health, a comprehensive, holistic approach is essential. Each presenting symptom merits a relevant history and physical examination. In most cases, prior records should be reviewed before repeating or extending the evaluation unless the patient's condition has changed substantially. Physicians must possess excellent patient-centered communication skills and listen carefully to the patient, validating concerns and responding to emotions. Additionally, the initial assessment should include specific questions to elicit the patient's concerns, underlying psychological status, and the degree of distress and disability attributable to the symptoms. Long-term management of the patient with MUS is challenging. A therapeutic alliance and a mutually respectful physician-patient relationship are key features in the successful management of the patient with MUS. In keeping with a patient-centered approach, the patient should be engaged fully in the plan, focusing on physical, psychological, and social aspects of health. The physician and patient should work together to create and maintain an atmosphere of mutual trust.

A 38-year-old man is evaluated during a new-patient visit for a 5-year history of fatigue, dizziness, nonexertional chest pain, intermittent and transient abdominal swelling, insomnia, and fleeting numbness of the extremities. He has been evaluated by two different internal medicine physicians, a gastroenterologist, a rheumatologist, and a pulmonologist. Despite extensive blood testing and imaging, a unifying diagnosis has never been established. Medical history is significant for depression, migraine, and cholecystectomy. He does not use tobacco, alcohol, or illicit drugs. Current medications are ibuprofen and sumatriptan as needed, acetaminophen, and citalopram. Physical examination, including vital signs, is normal. In addition to eliciting the patient's concerns, What is the most appropriate initial management?

optic neuritis. This patient with acute vision loss and eye pain unassociated with trauma has signs and symptoms suggestive of optic neuritis, including pain with eye movement, loss of color vision out of proportion to the vision loss, and an afferent pupillary defect. Two thirds of optic neuritis cases occur in women. The average age of onset is between 20 and 40 years, and it is often associated with multiple sclerosis. Most of these patients have a normal optic disc on funduscopy, but one third may have a swollen disc or papillitis. An urgent evaluation by an ophthalmologist is required; treatment usually involves high-dose intravenous glucocorticoids.

A 38-year-old woman is evaluated for a 2-day history of worsening eye pain and decreasing visual acuity in her left eye. The pain is worse with eye movement. She reports no fever or trauma. Vision loss is mostly central, and her ability to distinguish colors has diminished. She does not feel the sensation of a foreign body in the eyes. She wears contact lenses. Her medical history is otherwise unremarkable. On physical examination, vital signs are normal. Eye movement is intact but painful, with visual acuity of 20/20 in the right eye and 20/60 in the left. Afferent pupillary defect is noted in the left eye. There is no corneal injection or discharge, and the optic discs appear normal. What is the most likely diagnosis?

Non pharmacological Modalities. The most appropriate initial treatment of this patient's low back pain is nonpharmacologic therapy. According to a 2017 clinical practice guideline issued by the American College of Physicians, clinicians should choose nonpharmacologic treatments as first-line therapy for acute low back pain. Options include superficial heat, acupuncture, massage, and spinal manipulation. The quality of evidence supporting individual nonpharmacologic measures is moderate or low. Recommendations for their use are based on the fact that most patients with acute low back pain will improve over time (most within 4 weeks), regardless of the treatment chosen. Harms of nonpharmacologic interventions were seldom and minor. Superficial heat was associated with increased risk for skin flushing, and massage and spinal manipulation were associated with muscle soreness.

A 38-year-old woman is evaluated for low back pain that began 7 days ago when she bent over to pick up a piece of paper. She describes the pain as moderate aching that is localized to the right lower back. A sharp pain intermittently radiates down the lateral aspect of the right leg. She has not had bowel or bladder dysfunction, fevers, leg weakness, night sweats, saddle anesthesia, or weight loss. She has no history of trauma, and she does not use intravenous drugs. On physical examination, vital signs are normal. BMI is 21. Musculoskeletal and neurologic examinations are normal. What is the most appropriate initial treatment?

Morton Neuroma. This patient's symptoms are most likely due to a Morton neuroma, a condition that causes compression of the interdigital nerve. Common symptoms include paresthesias and the sensation of walking on a pebble. On examination, there are usually no obvious abnormalities, but some patients may have tenderness to direct palpation of the involved interspace. The cause is thought to be use of constricting footwear, such as high-heeled shoes. First-line therapy consists of wearing nonconstricting footwear and local padding. In patients who do not respond to these measures, a local glucocorticoid injection can be offered. For recalcitrant cases, sclerosing alcohol injections, radiofrequency ablation, and surgery (neurectomy) have been used with some success.

A 42-year-old woman is evaluated for a 2-month history of left foot pain between the third and fourth toes, accompanied by a burning sensation and the sensation of walking on a pebble. She has not experienced any trauma in the area, and she does not have edema or erythema. Symptom onset was insidious, and the pain only occurs when she is standing or walking. She works as a restaurant hostess and wears high-heeled shoes for her job. On physical examination, vital signs are normal. The left foot appears normal, with no palpable abnormalities or tenderness between the third and fourth toes. Sensation is intact throughout the foot, and posterior tibial and dorsalis pedis pulses are palpable. What is the most likely diagnosis?

Pregabalin. A trial of pregabalin is the most appropriate treatment for this patient with chronic pelvic pain syndrome (CPPS). CPPS is characterized by chronic pelvic pain and intermittent voiding symptoms without evidence of infection. Subtypes of this condition include inflammatory and noninflammatory forms. Treatment involves a multimodal approach; options include pharmacologic therapies (antibiotics, anti-inflammatory agents, α-blocking agents, 5α-reductase inhibitors, and neuromodulating agents) and nonpharmacologic strategies (biofeedback, cognitive behavioral therapy, and physical therapy). There is limited and conflicting evidence for thermal ablation therapies and direct surgical interventions. Despite these options, treatment can be challenging, with minimal rates of improvement. This patient has already attempted numerous medication regimens without symptomatic improvement. At this time, it would be most prudent to proceed with a neuromodulatory approach, with medications such as pregabalin, gabapentin, or nortriptyline. Nonpharmacologic options could also be recommended at this juncture.

A 44-year-old man is evaluated for a 6-year history of constant low-grade perineal pain with intermittent exacerbations and intermittent urinary symptoms of dysuria, frequency, and urgency. He had a documented case of acute bacterial prostatitis 6 years ago; since then, he has undergone extensive urologic evaluation during many of his exacerbations, all with negative findings. He has been treated numerous times with antibiotics, anti-inflammatory agents, and α-blockers without symptomatic benefit. He has no other medical problems and currently takes no medications. On physical examination, vital signs are normal. Prostate examination yields mild and poorly localized tenderness without masses or nodules. There is no penile discharge or scrotal pain on palpation. Results of previous laboratory studies reveal a normal erythrocyte sedimentation rate, C-reactive protein level, leukocyte count, serum creatinine level, electrolyte levels, and serum prostate-specific antigen level. A postvoid residual ultrasound was normal. What is the most appropriate pharmacologic treatment?

Ulnar Nerve Entrapment. This patient has symptoms consistent with ulnar neuropathy (fourth and fifth finger numbness and, more rarely, interosseous muscle weakness), making ulnar nerve entrapment the most likely diagnosis. Ulnar nerve entrapment, also known as cubital tunnel syndrome, is caused by impingement of the ulnar nerve at the elbow by bone spurs, fibrous tissue, ganglion cysts, or ulnar nerve subluxation. Elbow pain typically worsens with flexion. The diagnosis is usually made clinically and does not require imaging. Initial treatment consists of activity modification, splinting the elbow at night to prevent prolonged elbow flexion, and use of an elbow pad during the day to avoid direct trauma. Surgery is an option when conservative measures fail in the setting of significant or progressive symptoms.

A 44-year-old man is evaluated for right medial elbow pain that began 2 months ago with a dull ache and has gradually worsened. The pain is worse with elbow flexion, and his right fourth and fifth fingers are numb. On physical examination, vital signs are normal. Decreased sensation over the volar aspect of the right fourth and fifth fingers is noted, with adduction and abduction weakness of the fingers. The right elbow has full range of motion and no notable erythema, swelling, or tenderness. What is the most likely diagnosis?

Diagnostic Mammography and Ultrasonography. This patient's breast mass should be evaluated with both diagnostic mammography and ultrasonography. Any dominant mass in the breast warrants diagnostic imaging to determine the nature of the mass and the appropriate management. A clinical examination alone cannot differentiate between a cyst and a solid mass. In a woman aged 30 years or older, diagnostic mammography is recommended for evaluation of a palpable mass, to assess for a spiculated density or associated pleomorphic calcifications that may indicate malignancy. Diagnostic mammography may also include magnification views of the focal area of concern. In addition, targeted ultrasonography is needed to determine whether the mass is cystic or solid; however, ultrasonography is unnecessary in cases in which mammography shows a clearly benign correlate or a normal, fatty area of breast tissue in the location of the palpable finding. This diagnostic evaluation can help determine a benign finding from an indeterminate or suspicious finding requiring needle biopsy. For women aged 40 years or older, mammography, followed in most cases by ultrasonography, is recommended. For women aged 30 to 39 years old, ultrasonography or mammography may be performed first at the discretion of the radiologist or referring clinician.

A 44-year-old woman is evaluated for a breast lump she noticed 1 week ago. There is no nipple discharge. She birthed two children, the first at age 25 years, and her menstrual cycles are regular. She has no family members with breast or ovarian cancer. She has no other medical problems and takes no medications. On physical examination, vital signs are normal. BMI is 28. Examination of the breasts reveals dense tissue bilaterally and no skin changes. A mass is noted in the upper inner area of the right breast, measuring 1.8 cm; it is firm, mobile, and nontender, with ill-defined margins. There is no evidence of axillary, cervical, or supraclavicular lymphadenopathy. The remainder of the examination is unremarkable. What is the most appropriate diagnostic test to perform next?

Levonorgestrel-Containing Intrauterine Device. The most appropriate management of abnormal uterine bleeding in this patient is a levonorgestrel-containing intrauterine device (IUD). Abnormal uterine bleeding can generally be categorized into ovulatory and anovulatory patterns. Ovulatory abnormal uterine bleeding (menorrhagia) occurs at normal regular intervals but is excessive in volume or duration. Women with ovulatory bleeding have estrogen-mediated endometrial proliferation, produce progesterone, slough the endometrium regularly following progesterone withdrawal, and have a minimal risk for uterine cancer. Anovulatory cycles are characterized by unpredictable bleeding of variable flow and duration caused by the absence of normal cyclic hormonal flux. Without cyclic progesterone, the estrogen-mediated endometrium proliferates excessively, resulting in endometrial instability, erratic bleeding, and an increased risk for uterine cancer. For this perimenopausal patient who is anemic secondary to excessive menstrual blood loss and has contraindications to combination oral contraceptive use (previous deep venous thrombosis and current smoking), using a progestin-containing IUD would likely result in amenorrhea and prevent future blood loss. Managing anovulatory cycles involves the use of progestin to maintain endometrial stability to reduce the risk for endometrial cancer, which a levonorgestrel-containing IUD would do.

A 45-year-old woman is evaluated for heavy menstrual bleeding. She reports having heavy unpredictable bleeding of variable flow and duration for the past year. Her last period was 12 days ago. She has a history of provoked deep venous thrombosis 3 years ago following an intercontinental flight. She is a current smoker with a 10-pack-year history and does not wish to quit smoking at this time. She has never been pregnant and does not wish to become pregnant in the future. On physical examination, vital signs are normal. BMI is 24. Breast and pelvic examinations are normal. Laboratory studies reveal a hemoglobin level of 10.2 g/dL (102 g/L) and mean corpuscular volume of 68 fL. Pregnancy test result is negative. A subsequent evaluation for secondary causes of abnormal uterine bleeding, including endometrial cancer, was negative. In addition to oral iron supplements, What is the most appropriate management?

Medically Unexplained symptom. This patient most likely has a medically unexplained symptom. Such symptoms cannot be attributed to a specific medical cause after a thorough medical evaluation. Symptoms that are common in these patients include fatigue, headache, abdominal pain, musculoskeletal pain (back pain, myalgia, and arthralgia), dizziness, paresthesia, generalized weakness, transient edema, insomnia, dyspnea, chest pain, chronic facial pain, chronic pelvic pain, and chemical sensitivities. Symptoms can range from a minor nuisance to functional impairment. In this case, the patient's symptom does not appear to have a pathologic basis, and she is not excessively focused on or functionally limited by her symptom. As such, this patient would most appropriately be diagnosed with a medically unexplained symptom.

A 46-year-old woman is evaluated for a 3-day history of paresthesia of the right lateral nipple. She has experienced this symptom approximately three times per year for the past 7 years. The paresthesia generally lasts 7 to 10 days. She has no other right breast concerns and reports no milky or bloody discharge, fever, chills, or antecedent trauma. She has undergone extensive evaluation, including laboratory testing, mammography, breast ultrasonography, and dermatologic and neurologic examinations; all results have been normal. She has no other medical problems and takes no medications. She works full time, and her symptom has not limited her functioning. On physical examination, vital signs are normal. Breast examination is normal bilaterally. What is the most likely diagnosis?

Ibuprofen. Ibuprofen should be discontinued in this patient. This patient likely has patellofemoral pain syndrome, which is characterized by anterior knee pain that is usually gradual in onset and worsens with running, prolonged sitting, and climbing stairs. Applying direct pressure to the patella with the knee extended may reproduce the pain. Treatment generally includes activity modification and physical therapy. NSAIDs, acetaminophen, bracing, and patellar taping all have limited efficacy. Additionally, the use of NSAIDs in patients who have undergone bariatric surgery is associated with increased risk for internal bleeding; bleeding risk is increased at the sites of anastomoses and staple or suture lines in the early postoperative period, with increased risk of marginal or gastric ulceration in the later postoperative period. Therefore, ibuprofen and other NSAIDs should be avoided after bariatric surgery.

A 46-year-old woman is evaluated for knee pain. Seven months ago, she underwent sleeve gastrectomy for obesity. Before the procedure, her BMI was 36. She recently initiated a running program to enhance her weight loss and is now experiencing knee pain, which she treats with ibuprofen as needed. Medical history is significant for hypertension, obesity, and type 2 diabetes mellitus. Medications are atorvastatin, ibuprofen, lisinopril, and metformin. On physical examination, blood pressure is 118/64 mm Hg; other vital signs are normal. Knee examination is remarkable for tenderness with compression of the patella. There is no joint instability or tenderness along the medial or lateral joint lines. What medication should be discontinued in this patient?

Discontinue Sertraline and initiate bupropion. The most appropriate next step in management is to discontinue sertraline and initiate bupropion, which has a lower rate of sexual side effects. Cognitive behavioral therapy (CBT) or a second-generation antidepressant is an appropriate first choice for the treatment of major depressive disorder. Side effects, comorbid conditions, and cost are important considerations in the selection of therapy for a patient with depression. The most widely prescribed antidepressant drugs are selective serotonin reuptake inhibitors (SSRIs). SSRIs have excellent safety profiles compared with tricyclic antidepressants, but adverse sexual side effects (such as reduced libido, anorgasmia, or delayed orgasm) are common. Bupropion is an appropriate substitute agent for patients experiencing sexual side effects with an SSRI because it is an effective treatment with a low rate of sexual side effects. Bupropion can also be added to SSRI therapy to reduce SSRI-induced sexual side effects, but it is important to note that bupropion is contraindicated in patients with seizure disorders. Substituting CBT for antidepressant therapy in a patient experiencing sexual side effects of an SSRI is also an acceptable alternative.

A 47-year-old woman is evaluated during a follow-up visit for major depressive disorder that was diagnosed 2 months ago. At that time, she reported a 4-month history of anhedonia, depressed mood, decreased energy, insomnia, and weight loss. Her PHQ-9 score was 14, indicating moderate depression. She was prescribed sertraline, and her symptoms improved; her PHQ-9 score is now 9 (mild depression). However, she is distressed because she has had anorgasmia since starting sertraline. What is the most appropriate next step in management?

23-valent pneumococcal polysaccharide vaccine (PPSV23). This patient should be administered the 23-valent pneumococcal polysaccharide vaccine (PPSV23). Pneumococcal vaccination is recommended in all adults aged 65 years and older and adults aged 19 to 64 years with certain high-risk conditions. Two pneumococcal vaccines are available: PPSV23 and a 13-valent conjugate vaccine (PCV13). The Advisory Committee on Immunization Practices recommends administering PPSV23 alone to select immunocompetent patients aged 19 to 64 years, including those with chronic heart, liver, or lung disease; diabetes mellitus; cochlear implants; cerebrospinal fluid leak; alcoholism; or cigarette smoking. Because this patient is a current smoker, he should be given PPSV23.

A 48-year-old man is evaluated during a follow-up visit for hypertension. He has no symptoms. He received the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine 9 years ago and the influenza vaccine during the most recent influenza season. He is a current smoker with a 25-pack-year history. His only medication is chlorthalidone. On physical examination, vital signs are normal, and the remainder of the examination is unremarkable. What is the most appropriate vaccine to administer to this patient?

Total of 35 Days. The recommended postoperative duration of venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major orthopedic surgery is 35 days in patients who are not at increased bleeding risk and have not experienced perioperative bleeding complications. The American College of Chest Physicians (ACCP) antithrombotic guideline provides recommendations for VTE prophylaxis for both orthopedic and nonorthopedic surgery populations. The ACCP guideline identifies hip arthroplasty, knee arthroplasty, and hip fracture surgery as major orthopedic surgeries. These surgeries pose a high VTE risk, and both pharmacologic and mechanical VTE prophylaxis are recommended during hospitalization. The ACCP recommends LMWH over other pharmacologic agents, although there are other acceptable agents, including aspirin for those unable or unwilling to take heparin. For patients without increased bleeding risk, extended duration of postoperative prophylaxis for up to 35 days is recommended over shorter-duration prophylaxis of 10 to 14 days, which is the minimum recommended duration of pharmacologic VTE prophylaxis in orthopedic surgery. Randomized trials, systematic reviews, and meta-analyses have shown that compared with placebo, aspirin, and warfarin, extended prophylaxis up to 35 days with LMWH reduces the rate of VTE disease without excess bleeding in patients who undergo major orthopedic surgery. If bleeding risk is especially high, mechanical prophylaxis is recommended over no prophylaxis. In patients who decline LMWH injections or who are unable to tolerate LMWH, the oral direct thrombin inhibitor dabigatran, a factor Xa inhibitor (apixaban, rivaroxaban, edoxaban), or a vitamin K antagonist (warfarin) is recommended over alternate forms of prophylaxis. For this patient undergoing major orthopedic surgery, dual perioperative VTE prophylaxis with LMWH and intermittent pneumatic compression is recommended during hospitalization, with LMWH continued for up to 35 days.

A 49-year-old man is scheduled for total right knee arthroplasty. Medical history is otherwise unremarkable. He takes no medications. On physical examination, vital signs are normal. The right knee demonstrates bony hypertrophy and crepitus with passive movement. Low-molecular-weight heparin and intermittent pneumatic compression will be initiated and continued during the hospital stay. What is the recommended duration of low-molecular-weight heparin prophylaxis for this patient?

Advanced Static Mattress. An advanced static mattress is the most appropriate intervention to prevent pressure injuries (also known as pressure ulcers) in this patient. Pressure injuries are common in hospitals and long-term care settings. They can result in decreased quality of life, with associated depression, impaired mobility, and social isolation. The Centers for Medicare & Medicaid Services has selected the development of pressure ulcers as a sentinel health event (unexpected and preventable occurrence that results in serious patient injury) for health care facilities. Prevention of pressure injuries starts with identifying patients at risk. There are many standardized risk assessment tools, but evidence of whether these are superior to clinical judgment is inconclusive. Risk factors include advanced age, cognitive impairment, reduced mobility, sensory impairment, and comorbid conditions that affect skin integrity (such as low body weight, incontinence, edema, poor microcirculation, and hypoalbuminemia). Pressure redistribution is the most important factor in preventing pressure injuries through the use of pressure-reducing equipment and proper patient positioning. In 2015, the American College of Physicians (ACP) published a clinical practice guideline for risk assessment and prevention of pressure ulcers. The guideline recommends regular, structured risk assessment of patients and the use of an advanced static mattress or advanced static overlay for patients who are at increased risk. An advanced static mattress is made of specialized sheepskin, foam, or gel and is immobile when a patient lies on it, whereas an advanced static overlay is a pad composed of foam or gel that is secured to the top of a regular mattress.

A 49-year-old man was admitted to the ICU 3 days ago with sepsis secondary to health care-associated pneumonia. He is now being transferred to the general medical floor. Medical history is significant for spinal cord injury with associated lower extremity paralysis and neurogenic bladder. He is able to perform intermittent bladder catheterization. Medications are baclofen, enoxaparin, and levofloxacin. On physical examination, vital signs are normal. BMI is 19. Left lower lobe crackles are present on lung auscultation. There is flaccid paralysis of the lower extremities. Skin is intact without erythema over pressure points. What is the most appropriate intervention to prevent the development of a pressure injury?

Oral medical Cannabis Oil. A trial of oral medical cannabis oil would be a reasonable treatment in the management of this patient's chronic pain. Medical cannabis, although classified as a scheduled agent by the U.S. Drug Enforcement Administration on a federal level, has been approved by many states as a treatment for chronic pain. Current data on the effectiveness of medical cannabis for chronic pain are characterized by significant heterogeneity in both patient populations and cannabis preparations, although recent systematic reviews have demonstrated that cannabis has some efficacy in the treatment of chronic noncancer pain. Only two cannabinoid drugs (dronabinol and nabilone) are licensed for sale in the United States, and both drugs are available only in oral form. The pharmacokinetics of oral cannabis differ greatly from those of smoked cannabis, which has varying implications. Oral cannabis is slow in onset of action but produces more pronounced, and often unfavorable, psychoactive effects that last much longer than those experienced with smoking. On the other hand, smoked cannabis is quickly absorbed into the blood, and effects are immediate. However, examining the effects of smoked marijuana can be difficult because the absorption and efficacy of cannabis on symptom relief depend on subject familiarity with smoking and inhaling. This patient with end-stage kidney disease has a complex chronic pain syndrome that is unresponsive to multiple trials of nonpharmacologic and nonopioid analgesic therapies. If she resides in a state in which medical cannabis is available, oral medical cannabis oil would be a reasonable treatment option.

A 49-year-old woman is evaluated for a 3-year history of pelvic pain. An extensive evaluation has not found a clearly defined pathophysiologic or anatomic cause, and therapy has been targeted to general pain management lately. She has been a willing and cooperative participant in biofeedback, cognitive behavioral therapy, physical therapy, hypnosis, acupuncture, meditation, and stress-reduction techniques, without significant pain relief. Her pain has been unresponsive to multiple trials of nonopioid analgesics and antidepressants, and she has tried oral tapentadol and tramadol, which were also ineffective. She currently takes acetaminophen and gabapentin. Medical history is significant for end-stage kidney disease, for which she receives hemodialysis, and hypertension. Other medications are metoprolol succinate, amlodipine, intravenous iron, and an erythropoiesis-stimulating agent. What is the most reasonable treatment option for this patient's chronic pain?

Hormone Therapy with Estrogen and Progesterone. The most appropriate management is hormone replacement therapy with estrogen and progesterone. The hallmark symptoms of menopause vary greatly in duration, frequency, and severity, but they may include vasomotor symptoms (hot flushes, night sweats) and urogenital symptoms (dyspareunia, vaginal dryness). Symptoms generally resolve spontaneously within a few years, and treatment should be based on symptom severity. Hormone therapy is effective treatment for relief of vasomotor symptoms of menopause, and for women who are younger than 60 years and are within 10 years of menopause onset, the low absolute risk of adverse events supports the option to prescribe hormone therapy for women with moderate to severe vasomotor or urogenital symptoms who are at low risk for breast cancer, coronary heart disease, stroke, and thromboembolic disease. The clinician should prescribe the lowest effective dosage, titrating up if needed, for the shortest period of time needed to control symptoms. Use of hormone therapy in menopause should be reassessed every year; treatment duration is based on the continued presence of vasomotor symptoms. Estrogen-progesterone therapy taken for more than 5 years is associated with increased risk for breast cancer and requires that women receive individualized breast cancer risk evaluation. For this patient with an intact uterus and no contraindications, combination estrogen-progesterone therapy is the best choice.

A 49-year-old woman is seeking therapy for a 6-month history of increasing hot flushes, now occurring six to eight times per day. She also has night sweats that occur three to five times per night and result in disrupted sleep and daytime fatigue. Her last menstrual period was 14 months ago. She has no personal or family history of breast or ovarian malignancies. She takes no medications. On physical examination, vital signs are normal, as are pelvic and breast examinations. What is the most appropriate management?

Cancel Surgery and refer for liver transplant evaluation. The most appropriate preoperative management is to cancel surgery and refer the patient for liver transplant evaluation. Patients with cirrhosis but no complications are referred to as having compensated cirrhosis; they may be asymptomatic or may have nonspecific symptoms, such as fatigue, poor sleep, muscle cramps, feeling cold, or itching. Patients with complications of cirrhosis (hepatic encephalopathy, variceal hemorrhage, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, jaundice, or hepatocellular carcinoma) are referred to as having decompensated cirrhosis. Referral to a transplant center is indicated for patients with decompensation or a Model for End-stage Liver Disease (MELD) score of greater than 15. Patients with Child-Pugh class C disease or a MELD score greater than 20 are at high risk for death, and all but the most urgent and life-saving surgeries should be avoided until after liver transplantation. The MELD score is an equation that incorporates bilirubin, INR, and serum creatinine levels, and it accurately predicts 3-month survival. This patient, who has decompensated liver disease with a MELD score of 22, which confers a 30-day surgical mortality risk of more than 50%, should avoid elective surgery. Patients with decompensated liver disease have not only a higher perioperative mortality rate but also a significantly increased risk for other complications, including encephalopathy, electrolyte derangements, fluid imbalance, coagulopathy, infection, acute kidney injury, and hepatorenal syndrome. It is reasonable to refer patients at intermediate risk to a hepatologist before proceeding with surgery. Patients with compensated liver disease are often able to proceed with surgery with optimal medical management.

A 50-year-old man is seen for preoperative medical evaluation before left shoulder arthroplasty. History is significant for alcohol-related cirrhosis and osteoarthritis. Medications are lactulose, furosemide, and spironolactone. The patient stopped drinking alcohol 5 months ago but has difficulty with medication adherence. He reports increasing ascites and lower extremity edema. On physical examination, vital signs are normal. There is no jaundice or scleral icterus. Spider telangiectasias are noted on the face and chest. The abdomen is distended with flank dullness. There is 1+ pitting edema to the knees bilaterally. Mental status examination is normal. The calculated Model for End-stage Liver Disease (MELD) score is 22. The patient is instructed to increase his furosemide. What is the most appropriate preoperative management?

Physical Therapy. The most appropriate next step in treatment is physical therapy. This patient has a long-standing history of chronic pain that is most consistent with a diagnosis of fibromyalgia. All patients with chronic pain should be referred to a structured physical therapy program for evaluation and treatment. Physical therapy teaches patients safe, self-guided exercises to improve functional status, and there is a clear evidence base to support its use in all patients with chronic pain. Guided/progressive physical therapy programs are associated with a reduction in pain and, perhaps most importantly, improvement in function. No evidence suggests that a specific type of physical therapy is superior to another, and programs should be tailored to patient ability and adherence.

A 51-year-old woman is referred for evaluation. She has a 10-year history of chronic pain that she describes as head-to-toe aching, twisting, and sometimes burning that involves several large muscle groups. The pain is constant, and she rates the severity as a 6 on a 10-point scale. She is able to work despite the pain but is constantly fatigued. Her current regimen of oxycodone provides minimal relief. She has tried three other opioid medications as well as gabapentin and milnacipran, all of which provided only minimal improvement in her pain. Medical history is also significant for generalized anxiety disorder treated with sertraline. On physical examination, vital signs are normal. There is tenderness in multiple large muscle groups. The remainder of the physical examination is normal. In addition to slow tapering of oxycodone, What is the most appropriate next step in treatment?

Send the patient a letter warning that the relationship may be terminated. The most appropriate management is to send the patient a formal, written warning informing him that the patient-physician relationship may be terminated unless he is able to meaningfully participate in the plan of care. Physician-patient relationships are formed on the basis of mutual agreement. Rarely, the relationship fails to reach mutual goals and becomes unproductive. In some cases, the patient may not adhere to recommended therapies or may demonstrate inappropriate behavior with the physician or staff members, and it may be appropriate for the physician to terminate the relationship. After reasonable attempts to resolve differences have failed, the patient should be notified in writing that the relationship has been terminated and that care should be obtained from a different provider, usually with a several-week time frame for the patient to continue receiving urgent care. Terminations should occur only if the patient is medically stable and when alternative care is available. If a patient threatens a physician or staff member, the termination may be immediate.

A 52-year-old man fails to attend a scheduled appointment. He was initially evaluated for bilateral knee osteoarthritis 1 year ago, and treatment with weight loss, NSAIDs, and physical therapy was recommended. Over the past year, the patient missed three scheduled appointments, did not attend physical therapy, arrived for urgent care assessment twice with requests for stronger pain medications, and did not complete sufficient trials of oral nonopioid pharmacologic agents. Attempts to reach the patient by phone to discuss adherence to his care plan have not been successful. The visit today was scheduled to discuss the difficulties in his treatment and assess his barriers to care. Medical history is significant for bipolar disorder. In past visits, he has not appeared manic or suicidal. What is the most appropriate management?

Trimethoprim-Polymyxin B Ophthalmic Drops. The most appropriate treatment is trimethoprim-polymyxin B ophthalmic drops. This patient has acute, painless eye redness and several other signs of bacterial conjunctivitis. Studies have identified features that increase the probability of a bacterial cause of conjunctivitis, including redness of the conjunctival membrane obscuring the tarsal vessels, matting of both eyes in the morning, and purulent discharge. Inability to see redness of the eyes at 20 feet decreases the likelihood of a bacterial cause. Antibiotic treatment of bacterial conjunctivitis with topical trimethoprim-polymyxin B or erythromycin can shorten the duration of symptoms, but overall, bacterial conjunctivitis is a self-limited condition from which most patients recover within 2 weeks. Antibiotics should be enlisted when there is a higher risk for complications, such as in patients who wear contact lenses; immunocompromised patients, such as those with diabetes mellitus; and patients with copious, hyperpurulent discharge of the eye.

A 52-year-old man is evaluated for a 2-day history of painless red eye, which began on the right side and quickly spread to the left. He reports that his eyes have a thin mucopurulent discharge and that his eyelids are matted shut in the morning upon waking. He has had no photophobia, change in visual acuity, or itching in the eyes, but he has experienced some mild rhinorrhea. He does not use contact lenses. He is sexually monogamous. Medical history is significant for type 2 diabetes mellitus treated with metformin. On physical examination, vital signs are normal. There is redness of the sclerae bilaterally, with a white crust-like residue along the edges of the eyelids. The tarsal vessels are obscured by the conjunctival erythema. Visual acuity is intact, and there is no tenderness around the globes. What is the most appropriate treatment?

95%. This patient's posttest probability of ischemic coronary artery disease is approximately 95%. His pretest probability of ischemic coronary artery disease is estimated to be 50% based on clinical variables (including the nature of the chest pain, age, and sex). Likelihood ratios (LRs) are a statistical indicator of how much the result of a diagnostic test will increase or decrease the pretest probability of a disease in a specific patient. LRs may be determined from the sensitivity and specificity of a diagnostic test, and separate LRs are calculated for use when a test result is positive (LR+) or when a test result is negative (LR−). This patient has a positive result on a treadmill stress echocardiographic study, and the LR for a positive result on this test is approximately 10. Although very specific posttest probabilities may be calculated or estimated by using a nomogram, a clinical rule of thumb is that LR+ values of 2, 5, and 10 correspond to an increase in disease probability of 15%, 30%, and 45%, respectively. With a pretest probability of 50%, a positive result on treadmill stress echocardiography would increase the likelihood of disease by approximately 45%, leading to a posttest probability in the range of 95%; this information would be very useful clinically in making further treatment decisions.

A 52-year-old man is evaluated for substernal chest pain. The pain is not consistently associated with exertion, nor is it always relieved by rest; it sometimes occurs when he is eating or when he is anxious. He has a 30-pack-year smoking history, but he quit smoking 2 years ago. Medical history is significant for hypertension and hyperlipidemia, for which he takes lisinopril and rosuvastatin, respectively. On physical examination, vital signs and cardiovascular examination are normal. An electrocardiogram reveals left ventricular hypertrophy with associated ST-T-wave changes, findings that are unchanged from an electrocardiogram obtained 2 years ago. The patient's pretest probability of ischemic coronary artery disease is estimated to be 50%. Treadmill stress echocardiography is performed. This test has a positive likelihood ratio of 10.0 and a negative likelihood ratio of 0.1. The patient's stress test result is positive. What best approximates the patient's posttest probability of ischemic coronary artery disease?

Sudden Sensorineural Hearing Loss. The most likely diagnosis for this patient's acute, unilateral hearing loss is sudden sensorineural hearing loss (SSHL). The right-sided hearing loss and the finding of lateralization to the left ear on Weber testing support the diagnosis. Approximately 90% of cases of SSHL are idiopathic; however, viral infection, drug reactions, acoustic neuroma, multiple sclerosis, head injury, vascular issues, systemic immune-mediated conditions, and Meniere disease can all be causes. SSHL most commonly presents as unilateral tinnitus and ear fullness; vertigo occurs less often. Because this patient lacks other features to explain the acute hearing loss, she should undergo urgent referral to an otolaryngologist for audiometry, clinical assessment, and MRI to exclude tumors, multiple sclerosis, or vascular causes. Treatment involves oral glucocorticoids, although strong evidence of efficacy is lacking.

A 52-year-old woman is evaluated for acute onset of right-sided hearing loss that began yesterday. Soon afterward, she also noted a sensation of ear fullness and ringing in the same ear. She has no other focal neurologic symptoms. She reports no rhinorrhea, fever, pharyngitis, or ear pain. Medical history is significant for hypertension. She takes chlorthalidone. She has had no other exposures to medications or supplements. On physical examination, vital signs are normal. There is decreased hearing in the right ear; the Weber test lateralizes to the left ear, and air conduction is louder than bone conduction bilaterally. The ear canals are unobstructed, and the tympanic membranes are normal appearing. The neurologic examination is unremarkable. What is the most likely diagnosis?

Baseline Urine Drug Screening. Baseline urine drug screening is recommended before starting opioid therapy in this patient. Many guidelines, including the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, recommend initial and ongoing urine drug screening. Urine drug screening is used to test for adherence to current therapy, identify potential opioid diversion (by assessing whether the expected metabolite is present within an appropriate time frame), and evaluate for the presence of other controlled prescription and nonprescription drugs. Urine drug screening should be performed before opioids are prescribed for chronic pain and at least yearly during therapy. More frequent screening may be necessary in the setting of therapy changes or the presence of red flags (lost prescriptions, early refill requests, multiple concurrent opioid providers or "doctor shopping," consistently missed appointments, or erratic follow-up).

A 53-year-old man is evaluated for possible opioid therapy initiation for a several-year history of chest and back pain. Both types of pain significantly impair his ability to sleep, and he has not been able to work for the last 6 months. Over the past few years, he has undergone extensive evaluation, and no modifiable cause of the pain has been discovered. The patient has tried various nonpharmacologic interventions (acupuncture, cognitive behavioral therapy, exercise) and nonopioid pharmacologic therapies (duloxetine, gabapentin, ibuprofen), but he continues to have poor quality of life. These interventions are ongoing. He has no history of anxiety, depression, or substance use disorder. Results of screening tests for depression and anxiety disorders performed today are negative. His only medications are duloxetine, gabapentin, and ibuprofen. The risks and known benefits of long-term opioid therapy are reviewed with the patient. Treatment goals are discussed, and there is an understanding that opioid therapy will be stopped if the goals are not achieved or the risks exceed the benefit. A check with the state's prescription drug monitoring program confirms that the patient is not receiving opioids or benzodiazepine therapy. What is recommended before starting opioid therapy in this patient?

Labyrinthitis. The most likely diagnosis in this patient with vertigo is labyrinthitis. Patients with vertigo often describe a spinning or whirling sensation, which is frequently associated with concomitant nausea, vomiting, and sudden-onset fatigue. Once vertigo is suspected, the next important step is to distinguish central from peripheral causes. The Dix-Hallpike maneuver can help with this task but could not be performed in this patient. The identification of central vertigo is important because it can be associated with ischemia, infarction, or hemorrhage of the cerebellum or brainstem and may be life threatening. More than 80% of patients with central vertigo have focal neurologic signs, and many have experienced recurrent symptoms over days to weeks. In this patient's case, he has no risk factors for stroke (hypertension, diabetes mellitus), no focal signs, and a preceding upper respiratory tract infection, making central vertigo unlikely. Common causes of peripheral vertigo include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, labyrinthitis, and Meniere disease. Labyrinthitis is caused by postviral inflammation of both branches of the vestibulocochlear nerve (cranial nerve VIII), resulting in sudden-onset, severe, persistent vertigo and hearing loss. This patient has signs and symptoms consistent with labyrinthitis preceded by an acute viral infection, making it the most likely diagnosis.

A 55-year-old man is evaluated in the emergency department for a 2-day history of dizziness accompanied by nausea and vomiting. He works as an electrician, and his symptoms started suddenly while installing an overhead light fixture with his head tilted back for a prolonged period. He describes the dizziness as a constant whirling sensation that is unaffected by changes in position. He also reports symptoms of a recent upper respiratory tract infection but no fever. He has no other medical problems and takes no medications. On physical examination, temperature is normal, blood pressure is 155/84 mm Hg, pulse rate is 99/min, and respiration rate is normal. Hearing is diminished on the left side. Spontaneous combined horizontal and torsional nystagmus is noted but lessens with a fixed gaze. The patient declines further examination because of severe nausea. What is the most likely diagnosis?

Varenicline. The most effective treatment is varenicline. Although bupropion and nicotine replacement therapy (NRT) monotherapy are effective for tobacco cessation, varenicline has been shown to be more effective. Some studies, including a large meta-analysis, have raised concerns of an increased risk for cardiovascular events in patients taking varenicline compared with those taking placebo. However, a recent double-blind, randomized, placebo and active-controlled trial of varenicline, bupropion, and nicotine replacement therapy showed no evidence that the use of smoking cessation pharmacotherapies increased the risk of serious cardiovascular adverse events during or after treatment. FDA drug labeling information does not list recent cardiovascular events as a contraindication to varenicline therapy. The FDA recently removed the black box warning related to serious mental health adverse reactions with varenicline use after the risk for mental health effects was found to be lower than previously reported. Varenicline should be used with caution in patients with kidney failure.

A 55-year-old woman is evaluated during a routine examination. Medical history is significant for hypertension, hyperlipidemia, diabetes mellitus, and a non-ST-elevation myocardial infarction 2 weeks ago. She is a current smoker with a 35-pack-year smoking history. She is ready to stop smoking. Medications are metformin, rosuvastatin, aspirin, clopidogrel, metoprolol, and lisinopril. On physical examination, vital signs and other findings are normal. What is the most effective smoking cessation therapy for this patient?

MRI of the Internal Auditory Canal. The most appropriate management is MRI of the internal auditory canal. The assessment of tinnitus must differentiate more dangerous causes (such as neoplasms or cerebrovascular conditions) from more benign causes (such as infections or drugs). Most commonly, tinnitus is bilateral; unilateral tinnitus may indicate more serious pathology. Patients with unilateral tinnitus should undergo prompt hearing testing; if hearing loss is documented, as in this case, the patient should undergo MRI of the internal auditory canal to rule out an acoustic neuroma. It is important to note that patients who present with tinnitus may not report hearing loss that is subsequently revealed on audiologic testing.

A 55-year-old woman is evaluated for left-sided tinnitus that has gradually emerged over the last 6 months. She describes the tinnitus as a high-pitched continuous (nonpulsatile) buzzing. The patient reports no hearing loss, balance difficulties, dizziness, or headaches. Her medical history is otherwise unremarkable. On physical examination, vital signs are normal. Direct visualization of the external ear canals and tympanic membranes is unremarkable. Findings on Weber and Rinne testing suggest left sensorineural hearing loss. The whispered voice test suggests hearing loss on the left side. Results of the Romberg, cerebellar, and cranial nerve tests are all normal. Audiologic tests confirm mild to moderate left sensorineural hearing loss. What is the most appropriate management?

Genitourinary Syndrome of Menopause. The most likely diagnosis is genitourinary syndrome of menopause (vaginal atrophy). The clinical history and physical examination are most helpful for diagnosing genitourinary syndrome of menopause. Approximately 10% to 40% of menopausal women experience symptoms related to vaginal atrophy, including vulvar itching, vaginal dryness, and dyspareunia. On physical examination, pale and shiny vaginal walls, decreased rugae, and petechiae are characteristic findings. In contrast to menopausal vasomotor symptoms, which may last for a few years and resolve spontaneously, genitourinary syndrome of menopause is frequently progressive and often requires treatment. Mild to moderate symptoms can be treated with vaginal moisturizers and lubricants, but more severe symptoms, as experienced by this patient, are best treated with vaginal estrogen.

A 56-year-old woman is evaluated for severe vaginal itching and discomfort. Her symptoms have progressively worsened over the last 4 months. There is no associated vaginal discharge or vaginal odor. She is experiencing significant vaginal dryness, and intercourse has become painful despite the use of lubricants. She has been menopausal since age 53 years. She takes no medications. On physical examination, vital signs are normal. Physical examination reveals dry vaginal epithelium that is smooth and shiny. Blood vessels are visible beneath the pale vaginal mucosa, and increased friability is evident. Vaginal pH is 6.0. Wet mount shows occasional leukocytes. Whiff test result is negative. There are no clue cells and no hyphae on potassium hydroxide preparation. What is the most likely diagnosis?

Methylnaltrexone. The most appropriate treatment of this patient's constipation is methylnaltrexone. This patient presents with significant constipation refractory to enema therapy, osmotic laxatives (lactulose), and stimulants (bisacodyl, senna). There are several causes of this patient's constipation, but special attention must be paid to his opioid use for dyspnea palliation. In patients with laxative-refractory opioid-induced constipation, the American Gastroenterological Association (AGA) Institute recommends two peripherally acting µ-opioid receptor antagonists, oral naldemedine or subcutaneous methylnaltrexone, and naloxegol, a pegylated form of naloxone. By reversing μ-opioid receptor activation in the gut, methylnaltrexone can cause laxation in less than 60 minutes and does not reverse analgesic or antidyspneic effects of systemically administered opioids. It is contraindicated in patients with bowel obstruction.

A 58-year-old man is admitted to the hospital for a 2-week history of worsening constipation. He has end-stage heart failure (New York Heart Association functional class IV) and stage 3 chronic kidney disease. Medications include bisoprolol, furosemide, losartan, spironolactone, hydromorphone (for dyspnea palliation), bisacodyl, lactulose, senna, docusate, and tap water enema. On physical examination, respiration rate is 20/min; other vital signs are normal. Oxygen saturation is 92% breathing ambient air. Cardiac examination reveals an S3, jugular venous distention, and peripheral edema. Crackles are auscultated at the lung bases. Moderate abdominal distention is noted, with tenderness to palpation. What is the most appropriate treatment of this patient's constipation?

Ceftraixone and Levofloxacin. The most appropriate treatment is ceftriaxone and levofloxacin. This patient's history and physical examination findings (fever, erythema, and swelling of the hemiscrotum; tenderness to palpation near the epididymis; and urinary symptoms) are concerning for a diagnosis of acute epididymitis. Prehn sign, which is alleviation of pain with elevation of the testicle or scrotum, can clinically support this diagnosis. Infectious epididymitis has a bimodal distribution: men younger than 35 years and older than 55 years. In younger patients, sexually transmitted infections (chlamydia and gonorrhea) are the most likely cause. In older patients and those who practice insertive anal intercourse, Escherichia coli, Enterobacteriaceae, and Pseudomonas species should be considered. In older men and persons who practice insertive anal intercourse, infectious epididymitis should be treated with ceftriaxone and a fluoroquinolone, such as levofloxacin.

A 58-year-old man is evaluated in an urgent care center for a 3-day history of right-sided scrotal swelling, pain, and dysuria. He reports no antecedent trauma, nausea, or vomiting. He is sexually active with both men and women and uses condoms intermittently. He does not take any medications. On physical examination, temperature is 38.5 °C (101.3 °F), pulse rate is 101/min, and other vital signs are normal. The right hemiscrotum is edematous, with tenderness to palpation of the superolateral aspect. The scrotal pain lessens with elevation of the scrotum. There is no penile discharge. Results of nucleic acid amplification testing for chlamydia and gonorrhea are pending. What is the most appropriate treatment?

Perform Nasal Endoscopy. The most appropriate management is nasal endoscopy. Ninety percent of episodes of epistaxis occur in the anterior nasal septum in the Kiesselbach area. Anterior bleeding can be managed with compression for at least 15 minutes. Posterior epistaxis (behind the posterior middle turbinate, requiring a nasopharyngoscope for visualization) may be more difficult to manage and is more common in older patients. Common causes of epistaxis include topical intranasal medications (such as glucocorticoids or antihistamines), dehumidification, and self-induced digital trauma. Among patients with epistaxis serious enough to require hospitalization, almost half have a causal systemic condition, such as anticoagulation, hemophilia, hematologic malignancy, neoplasm, and acquired coagulopathies from kidney or liver disease. Recurrent unilateral epistaxis may represent a neoplasm; hence, this patient should be referred for nasal endoscopy.

A 59-year-old man is evaluated for recurring epistaxis over the last several months, usually on the right side. He has been able to stop the bleeding by applying pressure to the nares, but on one occasion, he required treatment in the emergency department. Typically, blood loss has been minimal. He does not use intranasal medications and reports no substance use. He has otherwise been well. There is no family history of epistaxis or rheumatologic or bleeding disorders. His only medication is low-dose aspirin. On physical examination, vital signs are normal. On nasal examination, there are no clear lesions, erythema, petechiae, scabs, telangiectasias, ulcers, or visible bleeding. What is the most appropriate management?

Withhold Clopidogrel now, Continue Aspirin. The most appropriate management of this patient's antiplatelet therapy is to withhold clopidogrel 5 to 7 days before surgery and continue aspirin. According to the 2016 American College of Cardiology/American Heart Association focused update on the duration of dual antiplatelet therapy (DAPT), perioperative management is based on surgical bleeding risk balanced with the risk for stent thrombosis. The risk for stent thrombosis is contingent on both the indication for coronary stent placement (stable ischemic heart disease [SIHD] or acute coronary syndrome [ACS]) and the amount of time that has passed from the time of stent placement.

A 61-year-old man is seen for medical evaluation before a pancreaticoduodenectomy for suspected pancreatic cancer scheduled in 7 days. He reports no recent chest pain or bleeding complications after undergoing drug-eluting stent placement to the left anterior descending artery for an ST-elevation myocardial infarction 5 months ago. He has been riding his bike 10 miles daily since recovering from the myocardial infarction. Medications are aspirin, clopidogrel, losartan, atorvastatin, and atenolol. On physical examination, vital signs are normal. Scleral icterus and jaundice are noted. Cardiac examination is normal, the lungs are clear, and the abdomen is nontender. There is no lower extremity edema. What is the most appropriate perioperative management of this patient's antiplatelet therapy?

Central Retinal Artery Occlusion. The most likely diagnosis for this patient's painless visual loss is central retinal artery occlusion (CRAO). This patient has several risk factors for this condition, including advanced age; male sex; and associated cardiovascular risk factors, such as hypertension and hyperlipidemia. Examination reveals an afferent pupillary defect and cherry red fovea (blue arrow) that is accentuated by a pale retinal background. Interruption of the venous blood columns may be recognized with the appearance of "boxcarring" rows of corpuscles separated by clear intervals seen in the vein just superior to the optic disc (white arrow). The most likely cause in this case is carotid atherosclerosis, but CRAO may also be caused by cardiogenic emboli; carotid artery dissection; hematologic conditions, such as sickle cell disease; or hypercoagulable states. The occlusion may be preceded by transient visual loss or a stuttering course. Retinal examination may demonstrate emboli. In an older patient who lacks emboli on examination, erythrocyte sedimentation rate and C-reactive protein level should be obtained to rule out giant cell arteritis, which is a rare but important cause of CRAO. Prognosis is based on visual acuity at presentation. Ischemia that lasts 4 hours or longer tends to result in irreversible vision loss. Treatment may include measures to lower intraocular pressure. Emergent ophthalmology consultation is required.

A 64-year-old man is evaluated in the emergency department for acute onset of vision loss in the left eye, which began 1 hour ago. He can barely see his own hands in front of his eye. He has no eye pain. One week ago, he had an episode of monocular vision loss in the left eye that resolved after 5 minutes. He has had no other recent medical concerns. He has no history of floaters, headaches, jaw claudication, muscular weakness, or weight loss. Medical history is significant for hyperlipidemia and hypertension. Medications are atorvastatin and lisinopril. On physical examination, vital signs are normal. There is loss of visual acuity in the left eye, and pupillary examination reveals an afferent pupillary defect. The optic disc is shown. There is no conjunctival erythema or scalp tenderness. Laboratory studies reveal an erythrocyte sedimentation rate of 22 mm/h. What is the most likely diagnosis?

Fecal immunochemical test. The most appropriate screening test for this patient is a fecal immunochemical test (FIT). The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in asymptomatic adults aged 50 to 75 years. For patients with average risk for colorectal cancer, several screening strategies are available, including fecal occult blood testing, direct endoscopic visualization, radiologic examination, and testing the blood for molecular markers of cancer. There is little head-to-head comparative evidence that any one recommended screening modality provides a greater benefit than the others. In addition, despite unequivocal evidence that colon cancer screening reduces mortality, an estimated one in three U.S. adults who are eligible for colon cancer screening has not been screened. Therefore, the USPSTF supports using the test that is most likely to result in completion of screening. Test selection should be guided by evidence, patient preferences, and local availability. Two fecal blood detection tests are available: a sensitive guaiac-based fecal occult blood test (gFOBT) and an FIT that uses antibodies to detect human hemoglobin. Sensitive gFOBT requires dietary restriction in order to reduce false-positive results, whereas FIT does not. The FDA has approved a third stool-based screening test that is combined with FIT and detects cancer DNA in the stool (the multitargeted stool DNA test). Mortality data for this screening strategy are not available. Because this patient would prefer not to modify his diet, FIT is the most appropriate screening option.

A 65-year-old man is evaluated during a visit to establish care. He is interested in colorectal cancer screening; however, he adamantly refuses to undergo colon preparation, and he does not want to modify his diet for screening. He has never undergone colorectal cancer screening. Medical and family histories are unremarkable. He takes no medications. Physical examination, including vital signs, is normal. After discussing the colon preparation process and dietary restrictions with the patient and exploring his concerns, he is steadfast in his refusal. What is the most appropriate screening test for this patient?

Obtain Results of the Last Cervical Cancer screening examination. The most appropriate screening strategy is to obtain the results of the patient's last cervical cancer screening examination. The U.S. Preventive Services Task Force recommends against cervical cancer screening in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Adequate screening is commonly defined as three consecutive negative cytology (Pap smear) results or two consecutive negative cytology plus human papillomavirus (HPV) test results within the last 10 years, with the most recent test occurring within 5 years. Data suggest that cervical cancer screening rates decline with increasing patient age; however, a Kaiser Permanente registry study found that 13% of 65-year-old women have not been adequately screened, with higher rates in patients without a primary physician or other health care provider. Other populations that are less likely to have received adequate screening include women with limited access to care, women from racial or ethnic minority groups, and women from countries where screening is not available. The study also documented that most cases of invasive cervical cancer in women older than age 65 years occurred among those who had not met criteria for stopping screening. The decision to stop screening at age 65 years should only be made after confirming that the patient has received adequate prior screening. In patients who do not meet the criteria for adequate prior screening, screening may be clinically indicated after age 65 years.

A 66-year-old woman is transitioning care after her previous physician retired and undergoes a new patient evaluation. She is asymptomatic. She is unclear when her last Pap smear was performed or the result. Medical history is unremarkable, and she takes no medications. The physical examination, including vital signs, is normal. What is the most appropriate cervical cancer screening strategy for this patient?

Hydromorphone. The most appropriate treatment of this patient's pain is hydromorphone. This patient's back pain is caused by progressive myeloma, and she requires rapid treatment of her pain with oral opioids initially. Given the concern for worsening back pain in the setting of malignancy, she requires an urgent MRI of her spine to rule out impending malignant spinal cord compression, and aggressive pain treatment while pursuing a diagnostic strategy is critical. Hydromorphone is a potent opioid agonist that is thought to be safer in patients with severe kidney impairment, such as this patient on hemodialysis.

A 67-year-old woman with multiple myeloma is evaluated for back pain. The pain began several months ago but has dramatically worsened in the past 2 weeks. It is located in the lumbar and thoracic spine with associated paraspinal muscle spasms. The pain does not radiate into the buttocks or legs, and there has been no change in gait or bowel or bladder function. She rates the pain as an 8 on a 10-point scale at its worst. Medical history is significant for multiple myeloma and end-stage kidney disease on hemodialysis. Medications are acetaminophen, amlodipine, aspirin, metoprolol, sertraline, bortezomib, dexamethasone, and lenalidomide. On physical examination, vital signs are normal. Palpation elicits tenderness over the thoracic and lumbar spine. The abdomen is not distended, and there are no palpable masses. Neurologic examination is normal. Restaging CT scans from 2 months ago reveal lytic lesions in the lumbar spine and left iliac crest. Spine MRI is scheduled. What is the most appropriate treatment of this patient's pain?

Dobutamine Stress Echo. Dobutamine stress echocardiography is indicated in this patient undergoing elective noncardiac surgery with an elevated cardiac risk, poor functional capacity, symptoms, and electrocardiographic findings concerning for possible silent ischemia. In patients undergoing noncardiac surgery, risk calculators, including the Revised Cardiac Risk Index (RCRI) and American College of Surgeons National Surgical Quality Improvement Program myocardial infarction and cardiac arrest calculator, can be used to determine the risk for a perioperative major adverse cardiac event (MACE). Asymptomatic patients at low risk (<1% risk for perioperative MACE) may proceed to surgery without preoperative cardiac stress testing, whereas patients with elevated risk (>1% risk for perioperative MACE) should undergo assessment of functional capacity. Metabolic equivalents (METs) are used to represent the patient's functional capacity based on the intensity of activity able to be performed. If the patient's functional capacity exceeds 4 METs, the patient may proceed to surgery without further testing. Cardiac stress testing should be considered in patients at elevated risk for MACE with a functional capacity of less than 4 METs or if functional capacity cannot be determined, but only if the results of stress testing will change perioperative management. In this case, the patient's RCRI score is 4 (pathologic Q waves on electrocardiogram, stroke, insulin-dependent diabetes mellitus, and preoperative creatinine >2.0 mg/dL [176.8 µmol/L]) corresponding to a MACE (cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest) risk of greater than 5.4%, and stress testing is indicated. Because of the elective nature of his scheduled surgery, he would be able to proceed with preoperative coronary angiography if indicated based on the results of stress testing.

A 68-year-old man is evaluated before elective left total hip arthroplasty. He reports left groin pain and new fatigue and dyspnea that limit ambulation to one flight of stairs and one block. Medical history is significant for type 2 diabetes mellitus, ischemic stroke, hypertension, hyperlipidemia, peripheral artery disease, degenerative joint disease, and chronic kidney disease. Medications are insulin glargine, insulin lispro, aspirin, lisinopril, simvastatin, and tramadol. On physical examination, temperature is normal, blood pressure is 145/85 mm Hg, pulse rate is 89/min, and respiration rate is 18/min. BMI is 35. Cardiopulmonary examination is normal. There is no lower extremity edema. Laboratory studies are notable for a serum creatinine level of 2.1 mg/dL (185.6 µmol/L). An electrocardiogram demonstrates Q waves in leads II and III. What is the most appropriate diagnostic test to perform next?

Trimethoprim-Sulphamethoxazole. This patient's history and physical examination findings indicate acute bacterial prostatitis, and the most appropriate treatment regimen is trimethoprim-sulfamethoxazole. Patient groups at high risk for acute bacterial prostatitis include those with diabetes mellitus, immunosuppression, or cirrhosis. Risk factors include unprotected sexual intercourse, urogenital instrumentation (chronic indwelling bladder catheterization, intermittent bladder catheterization, prostate biopsy), urinary tract manipulation (prostate resection), urinary stasis (obstruction), and benign prostatic hyperplasia. The most common infectious cause for acute bacterial prostatitis is Escherichia coli or other gram-negative bacilli. Diagnosis is typically established with urine Gram stain and culture in patients with a compatible history. The treatment of choice for acute bacterial prostatitis is a prolonged course of trimethoprim-sulfamethoxazole or ciprofloxacin. Data on treatment duration are sparse, but 6 weeks is reasonable and recommended by experts. Given the prolonged duration of antimicrobial therapy required in cases of acute bacterial prostatitis, it is most prudent to select an antibiotic with appropriate coverage, while also attempting to minimize the potential for serious adverse effects. Prolonged ciprofloxacin use has been associated with QT prolongation as well as tendinopathy/tendon rupture, especially in older adults. As such, given the treatment duration needed for acute bacterial prostatitis, trimethoprim-sulfamethoxazole would be the most appropriate choice.

A 68-year-old man is evaluated for fever, perineal pain, dysuria, frequency, and intermittent straining that began yesterday. Symptoms began 48 hours after a prostate biopsy due to an elevated prostate-specific antigen level detected during routine screening. On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 145/82 mm Hg, pulse rate is 105/min, and respiration rate is normal. The prostate is enlarged and boggy, and it is tender to gentle palpation. There is no penile discharge, and no scrotal pain occurs with palpation. Dipstick urinalysis is positive for leukocyte esterase and nitrates. Urine Gram stain reveals gram-negative rods. Urine culture is pending. What is the most appropriate treatment?

Post Void Residual Urine Volume Measurement. Obtaining a postvoid residual urine volume is the most appropriate next step in the management of this patient. This patient likely has neurogenic bladder with overflow incontinence, characterized by constant urine leaking and dribbling and a palpable bladder. Overflow incontinence is more commonly found in men with prostatic hyperplasia and bladder outlet obstruction. However, this patient has long-standing diabetes mellitus and evidence of autonomic neuropathy (resting tachycardia, dry feet, distended bladder) on physical examination. Postvoid residual bladder volume measurement with ultrasonography can confirm the presence of large volumes of urine in the bladder, supporting the clinical diagnosis.

A 68-year-old woman is evaluated for a 6-month history of incontinence typified by continuous leakage and dribbling. She reports no back pain, dysuria, or fever. Medical history is significant for a 30-year history of type 2 diabetes mellitus and a 10-year history of hypertension and hyperlipidemia. Medications include benazepril, metformin, and rosuvastatin. On physical examination, blood pressure is 147/76 mm Hg, and pulse rate is 92/min. On abdominal examination, the bladder is palpable just above the pubic symphysis. Foot examination demonstrates dry feet, loss of sensation to monofilament testing, and vibration up to the ankles. Lower extremity tendon reflexes are absent. Urinalysis results are normal. What is the most appropriate management?

Oral Hydromorphone. The most appropriate treatment is oral hydromorphone. This patient has severe chronic dyspnea that is refractory to maximal therapy for his underlying heart failure and COPD. Oral opioids, dosed appropriately, have been found to be both safe and efficacious in the treatment of dyspnea. Treatment efficacy is thought to be related to modulation of shared neural structures that are involved in the pathogenesis of both pain and dyspnea, as there are numerous μ-opioid receptors throughout the respiratory centers in the central nervous system. No evidence suggests that one opioid is superior to another in the treatment of dyspnea, and agent selection should be based on individual patient considerations, such as avoidance of morphine products in patients with reduced kidney function.

A 74-year-old man is evaluated for severe chronic shortness of breath. Medical history is significant for New York Heart Association functional class III heart failure and severe COPD. He was hospitalized 3 weeks ago for an exacerbation of his COPD. He has returned to his baseline oxygen requirements, but his continued shortness of breath is a significant impediment to his quality of life. The patient's goal is comfort. He does not desire any additional interventions for his heart failure or COPD. Medications are tiotropium, fluticasone propionate/salmeterol, albuterol, amlodipine, lisinopril, hydrochlorothiazide, and oxygen by nasal cannula. On physical examination, the patient is comfortable at rest but develops dyspnea while ambulating, with associated anxiety. Temperature is 36.9 °C (98.4 °F), blood pressure is 124/68 mm Hg, pulse rate is 98/min, and respiration rate is 32/min. Oxygen saturation is 93% breathing 4 L/min of oxygen by nasal cannula. Pulmonary examination reveals distant breath sounds and a prolonged expiratory phase; the lungs are otherwise clear to auscultation. The estimated central venous pressure is 6 cm H2O. Cardiac examination reveals an S4 but is otherwise normal. There is no peripheral edema. Chest radiograph shows evidence of hyperinflation but no signs of heart failure, pneumonia, or pneumothorax. What is the most appropriate treatment of this patient's dyspnea?

Timely discharge summary for the primary care physician. Communicating with and sharing the discharge summary with the primary care physician is recommended to improve patient safety and reduce rehospitalization in this patient. The evidence to support a reduction in hospital readmissions with completion of a discharge summary is mixed, most likely because of many complex factors that are difficult to control, such as timeliness, completeness, and quality of the discharge summary. However, the Institute for Healthcare Improvement identifies the lack of a timely discharge summary as a barrier to patient safety and prevention of early hospital readmission and therefore recommends a timely discharge summary as a key element in improving the transition of care from hospital to home. A discharge summary should include the evaluations performed, medication reconciliation, pending test results, required follow-up tests, and follow-up appointments and should be shared with the follow-up clinician. Timely follow-up with the primary care clinician is also important in ensuring that the transition goes smoothly. Another approach that has been successful in reducing hospitalization is the use of multiple team members, such as a nurse and pharmacist, to provide components of care.

A 75-year-old man is being discharged following treatment for acute decompensated heart failure. The patient and his wife are alerted to symptoms that indicate acute worsening of his heart failure and are informed of when he should seek immediate medical assistance. The discharge medication list and the side effects of these medications are reviewed, and the patient and his wife acknowledge an understanding. A nursing education visit regarding the hospital stay and evaluations is completed. A copy of the discharge summary is given to the patient, and a follow-up appointment is scheduled with his internist in 7 days. What is also recommended to improve patient safety and reduce rehospitalization in this patient?

Uretheral Bladder Catheterization. Bladder decompression with urinary catheterization is the most appropriate management of this patient who has developed postoperative urinary retention (POUR). POUR is a common complication in the postoperative setting and is characterized by the inability to spontaneously and adequately empty the bladder. Risk factors include type of surgery (incontinence and anorectal surgery, hernia repair, joint arthroplasty), longer surgery, use of regional anesthesia, administration of greater than 750 mL of intraoperative fluids, use of certain postoperative medications (opioids, anticholinergic agents), older age, constipation, pelvic organ prolapse, neurologic disease, history of urinary retention, and history of pelvic surgery. POUR is a urologic emergency. Symptoms of suprapubic pain and the finding of a palpable bladder are insensitive indicators of POUR. Patients may also present with frequent urination of small volumes and overflow incontinence. Reversible causes of POUR, such as medication use, should be addressed. Whenever possible, offending medications, including opioids, anticholinergics, antihistamines, antipsychotics, and calcium-blocking drugs, should be discontinued. Early removal of indwelling urinary catheters and voiding trials are recommended. Retrograde voiding trials are preferred to spontaneous voiding trials because they are more predictive of the need for continued catheterization. A retrograde voiding trial involves infusion of sterile saline, followed by the attempt to void. For patients in whom a voiding trial is unsuccessful, intermittent urinary catheterization should be considered in place of indwelling bladder catheterization. Results of a recent randomized controlled trial in patients undergoing total hip arthroplasty and total knee arthroplasty demonstrated that a catheterization threshold of 800 mL significantly reduced the need for postoperative urinary catheterization and did not increase urologic complications.

A 75-year-old woman underwent total hip arthroplasty 4 hours ago and is now evaluated because she has been unable to void since the operation. Bladder ultrasound reveals 900 mL of urine. Other than manageable postoperative pain, she has no symptoms. Current medications are acetaminophen, oxycodone, and enoxaparin. What is the most appropriate management?

No Additional Intervention. The most appropriate management of this patient's preoperative anticoagulation is to withhold warfarin without bridging anticoagulation. Anticoagulant therapy increases the risk for perioperative hemorrhage and should be discontinued in most patients before surgery. Bridging anticoagulation is the administration of therapeutic doses of short-acting parenteral therapy, usually heparin, when anticoagulant therapy is being withheld during the perioperative period in patients with elevated thrombotic risk. This patient is undergoing a procedure associated with elevated bleeding risk, and she has no history of stroke, transient ischemic attack (TIA), or intracardiac thrombus. Therefore, the risks of bridging anticoagulation outweigh the thrombotic risk, and the warfarin should be withheld without bridging anticoagulation.

A 77-year-old woman is seen for a preoperative medical evaluation before resection of the sigmoid colon for recurrent diverticulitis scheduled 5 days from now. She has nonvalvular atrial fibrillation and is receiving long-term warfarin, without a history of bleeding complications. She has no history of stroke, transient ischemic attack, or intracardiac thrombus. History is also significant for hypertension. Medications are warfarin, chlorthalidone, and metoprolol. The physical examination, including vital signs, is normal. The INR measurement is 2.3. Calculated CHADS2 score is 2, and CHA2DS2-VASc score is 4. In addition to withholding warfarin before surgery, What is the most appropriate management of this patient's perioperative anticoagulation?

Mini-Cog test. This patient would most benefit from evaluation with the Mini-Cog test or another validated screening test for cognitive function. Cognitive impairment is a progressive decline that impairs function in at least two areas: attention, executive function, language, memory, or visual-spatial function. Patients with signs and symptoms of cognitive impairment, such as this patient who reports difficulty with both memory and executive function, should undergo evaluation. A variety of validated tools are available to assess cognitive function. Among the free tools, the Montreal Cognitive Assessment and Mini-Cog test have been validated in primary care populations; these instruments screen for impairments in executive function. Self-administered instruments, such as the Self-Administered Gerocognitive Examination and Test Your Memory examination, have been validated in memory clinic populations to detect mild cognitive impairment and early dementia. Although the Mini-Mental State Examination has been the most extensively studied screening instrument, it is now proprietary, with a cost per use.

A 79-year-old woman is accompanied to the office by her son for an evaluation of her memory. The patient forgot to attend her last two scheduled appointments. The patient lives alone; her son visits her daily and sets up a weekly pillbox with her medications. The son reports that on several occasions lately, pills that his mother should have taken have been left in the compartments. The patient admits that she sometimes gets confused as to which section of the pillbox is the correct one for that day. Medical history is significant for hypothyroidism, hypertension, gastroesophageal reflux disease, and osteoarthritis. Medications are levothyroxine, amlodipine, omeprazole, vitamin D, and acetaminophen. On physical examination, vital signs are normal. The patient is pleasant and interactive. The physical examination is normal, including neurologic and gait assessment. Depression screening with PHQ-2 is negative. What is the most appropriate test to perform next?

Prompted Voiding. The most appropriate management is prompted voiding every 2 to 3 hours. There are four main classifications of urinary incontinence: urgency incontinence, stress incontinence, mixed incontinence, and overflow incontinence. Functional incontinence, which occurs in patients who cannot reach and use the toilet in a timely manner, may occur in patients with significant cognitive or mobility impairments. Classifying the type(s) of incontinence helps guide management. This patient demonstrates functional incontinence, in which decreased cognitive function limits her ability to recognize early signs of the need to void, and impaired mobility limits her ability to get to the bathroom when she does recognize the need. Providing assistance and scheduled toileting through prompting are effective for patients who have impaired cognition or mobility.

A 92-year-old woman is evaluated for urinary incontinence. Six months ago, the patient occasionally lost control of small amounts of urine, which was managed with an adult diaper. At present, the patient seems to have lost the ability to recognize that she needs to urinate until it is too late to reach the bathroom. There have been no recent noticeable changes in cognition. Medical history is significant for dementia treated with donepezil. On physical examination, vital signs are normal. The patient appears frail. She is not oriented to place or time. Gait is stable and narrow based. She is slow to rise from a chair, and she requires the arm rests to get up. What is the most appropriate treatment?

Lead-time Bias. Lead-time bias is most likely to threaten the validity of the authors' conclusions. Lead-time bias occurs when survival time (time from diagnosis to death) appears to be lengthened because the screened patient is diagnosed earlier during the preclinical phase but does not live longer in actuality. To guard against this bias, disease-specific mortality rates rather than survival time should be used as an outcome derived from randomized clinical trials.

A proposed new screening protocol for ovarian cancer involves universal pelvic ultrasonography for asymptomatic women starting at age 30 years. The protocol is based on a national study of randomly selected 30-year-old women. The authors of the study note that unilateral oophorectomy performed for suspicious lesions resulted in longer survival than oophorectomy performed for patients with symptoms, based on historical data. The study authors conclude that the screening protocol will reduce ovarian cancer-related deaths. What is most likely to threaten the validity of the authors' conclusions?

Autism Spectrum Disorder. This patient demonstrates behaviors most consistent with autism spectrum disorder. This is a heterogeneous group of disorders that share two diagnostic features: (1) repetitive, nonpurposeful behaviors and (2) deficiencies in communication and social interaction. Although the disorder may not be diagnosed until adulthood, the abnormal behaviors begin in childhood. The exact prevalence is debated, but it is estimated to affect 0.5% to 1% of the U.S. population. Early intervention with behavioral and educational interventions improves long-term functioning, but most patients require lifelong assistance.

An 18-year-old man is brought to the office by his mother, who is concerned about his behavior in school. Since age 6 years, the patient has had difficulty interacting with people and exhibits several unusual, repetitive behaviors, including tapping his fork three times with each bite of food. He has scored well on aptitude tests but has struggled in classroom activities that require working with other students. He has no friends, and his parents find it difficult to engage in conversation with him. On physical examination, the patient exhibits paucity of speech; he answers yes-or-no questions appropriately. There is no evidence of disordered thinking. What is the most likely diagnosis?

Consult with the hospital ethics committee. The most appropriate management is consultation with the hospital ethics committee. A recent policy statement from the Society of Critical Care Medicine recommends that appropriate treatment goals of ICU care include treatment that provides a reasonable expectation of survival outside of the acute care setting with sufficient cognitive ability to perceive benefits of treatment, or palliative care through the dying process in the ICU. Because conflicts between the desire to provide benefit to the patient and the desire to minimize the burden of treatment can be very difficult, one of the most important skills of the physician is the ability to communicate and negotiate a reasonable treatment plan with the patient's family. If these situations become intractable, many organizations recommend initiating a process to resolve the disagreement, including notifying surrogates of the process, seeking a second medical opinion, obtaining review by an interdisciplinary ethics committee, offering the surrogate the opportunity to seek care at another institution, and implementing the decision of the resolution process. This patient's family is requesting treatment that the care team does not think will achieve reasonable goals, and an ethics consultation may lead to conflict resolution.

An 81-year-old woman was admitted to the ICU 8 days ago for multisystem organ failure associated with a severe episode of multilobar pneumonia. She has required mechanical ventilation since admission. Efforts to wean the patient from mechanical ventilation have not succeeded, and the patient remains somnolent and unresponsive to verbal stimuli. Medical history is significant for dementia, diabetes mellitus, COPD, chronic kidney disease, and heart failure. The care team concludes and shares with the patient's family that she will not have a meaningful recovery; however, the patient's children request continued ICU-level care. The patient does not have an advance directive, and her wishes are unknown. After a family meeting with the care team to discuss the patient's prognosis, the children continue to request all treatment. What is the most appropriate management?

Rehabilitation at a long-term acute care hospital. The most appropriate discharge plan for this patient is rehabilitation at a long-term acute care hospital (LTACH). The patient requires continued mechanical ventilation but otherwise no longer requires hospitalization. LTACHs provide longer-term, higher-intensity medical treatment, such as complex wound care, mechanical ventilation weaning, and treatment with intravenous medications. Patients can also receive physical rehabilitation at such facilities.

An 82-year-old man is evaluated for discharge planning. He was hospitalized with community-acquired pneumonia complicated by respiratory failure and sepsis, which required prolonged mechanical ventilation. He eventually required a tracheostomy and remains on mechanical ventilation, but his respiratory status is otherwise stable. He is severely deconditioned and has been unable to participate even minimally in physical therapy. Although he is expected to require mechanical ventilation for at least several more weeks, he is medically stable for discharge. Medical history is significant for chronic kidney disease, heart failure, hypertension, and type 2 diabetes mellitus. Medications are insulin aspart, insulin glargine, carvedilol, furosemide, and lisinopril. On physical examination, the patient is alert and cooperative but appears frail on mechanical ventilation. Vital signs and the remainder of the examination are normal. What is the most appropriate discharge disposition for this patient?

Pulmonary Rehabilitation. The most appropriate treatment for this patient is pulmonary rehabilitation. Pulmonary rehabilitation is recommended for all symptomatic patients with an FEV1 less than 50% of predicted and specifically for those hospitalized with an acute exacerbation of COPD. These programs include education, functional assessment, nutrition counseling, and follow-up to reinforce behavioral techniques for change. They also include an exercise training component that has been shown to improve endurance, flexibility, and upper and lower body strength. Exercise training can provide sustained benefit for postexacerbation symptoms (such as breathlessness) following the completion of even a single rehabilitation program. When combined with other forms of therapy (medical therapy, smoking cessation, nutrition counseling, and education), pulmonary rehabilitation decreases patients' perceived intensity of breathlessness, reduces dyspnea and fatigue, facilitates increased participation in daily activities, and enhances health-related quality of life, including improvements in anxiety and depression.

An 82-year-old woman is evaluated for severe and progressive shortness of breath on ambulation. She has COPD and has been hospitalized only once in the past 18 months for an acute exacerbation. She has not experienced an acute worsening of her symptoms, and she has minimal nonproductive cough. She stopped smoking 15 years ago. She notes that her dyspnea is a substantial impediment to her quality of life. Medical history is otherwise significant for heart failure with preserved ejection fraction. Medications are umeclidinium/vilanterol and albuterol inhalers, lisinopril, and chlorthalidone. On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 128/78 mm Hg, pulse rate is 74/min, and respiration rate is 20/min. Oxygen saturation is 96% breathing 1 L/min of oxygen by nasal cannula and is maintained at 96% during a 6-minute walk test. Pulmonary examination reveals a prolonged expiratory phase and intermittent scattered rhonchi throughout her lung fields, with hyperresonance to percussion. Cardiac examination reveals an S4 but no murmur or jugular venous distention. Spirometry performed 2 months ago showed an FEV1 of 42% of predicted. What is the most appropriate treatment?

Symptom Explanation and Reassurance. This patient has audible posterior oropharyngeal secretions, which are most appropriately managed with family education and reassurance. Although several studies suggest that respiratory distress is not typically associated with these secretions, caregivers are often concerned by what is commonly referred to as the "death rattle." The first steps in management include caregiver education and anticipatory guidance. Additionally, repositioning often allows secretions to drain without pharmacologic intervention. Mouth hygiene with a sponge swab may also be helpful.

An 84-year-old woman in hospice care is evaluated for "death rattle" that is disturbing to family members. She is in the active phases of dying, and her family is distressed by her noisy respiratory secretions; they are worried that she is choking. Medications are haloperidol, hydromorphone, lactulose, and acetaminophen. On physical examination, respiration rate is 12/min. She is not responsive but does not appear uncomfortable. Extremities are cool. There are oropharyngeal secretions that produce a rattling and gurgling sound with inspiration. What is the most appropriate initial management?

Confounding. The most likely threat to the validity of this cross-sectional study is confounding. Cross-sectional studies evaluate the relationship between exposures and health outcomes in a population of interest. These studies are characterized by the measurement of factors and outcomes at a single point in time. The validity of cross-sectional studies is particularly susceptible to recall bias and confounding. Recall bias is a systematic error that is introduced into a study by differences in the accuracy of the recollections of study participants; participants who have unpleasant experiences may recall past events differently than those who do not have similar experiences. Because cross-sectional studies are observational and not experimental, there is also no opportunity to randomly distribute factors that might influence the relationship being studied. Although statistical techniques can be used to control for known potential confounders, unknown confounders remain a threat to the validity of the conclusions. As such, cross-sectional studies are best suited to identifying potentially significant associations that can be more rigorously tested in experimental studies. Finally, because there is no way to verify that the purported cause (statin therapy) preceded the effect (memory loss), cross-sectional studies cannot prove cause-and-effect relationships.

During a routine health examination, a patient asks about an article that recommended avoiding statin therapy because of the risk for memory loss. The findings were based on cross-sectional data analysis of a well-validated national health survey, which was conducted by random sampling of patients according to zip code of residence. The analysis showed that patients who self-reported memory loss were more likely to also report having taken statin drugs (odds ratio, 1.8; 95% CI, 1.2-2.7; P = 0.046). What is the most likely threat to the validity of this study?

Low dose Aspirin. The most appropriate measure to reduce this patient's atherosclerotic cardiovascular disease (ASCVD) risk is low-dose aspirin. The U.S. Preventive Services Task Force (USPSTF) recommends low-dose aspirin for the primary prevention of ASCVD and colorectal cancer in adults aged 50 to 59 years with a 10-year ASCVD risk of 10% or higher who do not have an increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. In those aged 60 to 69 years with a 10-year ASCVD risk of 10% or higher, the benefits of aspirin use for primary prevention are smaller but still outweigh the risk for bleeding, and the decision to initiate low-dose aspirin in this population should be individualized. In contrast to the USPSTF recommendations, the American Diabetes Association (ADA) recommends consideration of low-dose aspirin therapy as a primary prevention strategy in patients with type 1 or type 2 diabetes mellitus who are at increased cardiovascular risk. Similarly, the American College of Cardiology/American Heart Association suggest that low-dose aspirin might be considered in patients aged 40 to 70 years at higher risk for ASCVD who do not have an increased risk of bleeding. The decision to initiate low-dose aspirin should be informed by a holistic approach to ASCVD risk estimation that considers risk-enhancing factors, such as strong family history of premature myocardial infarction, smoking, albuminuria, or inability to achieve lipid, blood pressure, or glucose targets. The decision must take into account bleeding risk and patient preferences after careful assessment and a frank discussion of benefits and harms. For patients older than 70 years, aspirin appears to have a greater risk than benefit. The ADA does not recommend aspirin for patients younger than 50 years without major cardiovascular risk factors, although the American College of Cardiology/American Heart Association suggest considering therapy at age 40 years in those at higher ASCVD risk.

Qs 40 A 51-year-old woman is evaluated during a routine follow-up visit for diabetes mellitus. She also has hypertension and hyperlipidemia. Medications are metformin, enalapril, chlorthalidone, and high-intensity rosuvastatin. She has no drug allergies. On physical examination, blood pressure is 126/74 mm Hg. The remainder of the examination is unremarkable. Her 10-year risk for atherosclerotic cardiovascular disease is 11% according to the Pooled Cohort Equations. She has been instructed in intensive lifestyle modifications. What is the most appropriate preventive measure to reduce this patient's cardiovascular risk?

Harms and Cost of Treatment. The harms and cost of treatment are needed to conclude that treatment A is superior to treatment B. When assessing the clinical impact of an intervention, the number needed to treat (NNT) provides a quantifiable measure of the treatment effect that is easily understood by physicians and patients; it represents the number of patients who must receive a treatment to cause one additional patient to benefit. The acceptability of the NNT as a means of comparing one treatment with another depends on the risks associated with the condition, the cost and side effects of the treatment, and other treatments available. When comparing one treatment with another, head-to-head comparisons provide the best evidence of superiority. In this head-to-head comparison of two treatments, the absolute risk reduction for heart failure-related hospitalizations is 6% with treatment A compared with treatment B. This translates to 17 patients (NNT = 1/absolute risk reduction) who need to receive treatment A to result in 1 less heart failure-related hospitalization compared with treatment B. Although this information is informative, other data, such as cost and harms, must be evaluated before a conclusion that treatment A is superior to treatment B can be reached. If harms are more frequent or more severe with treatment A, the reduction in hospitalization for heart failure may become clinically meaningless.

Two new treatments for patients with heart failure with preserved ejection fraction were compared in a randomized controlled trial. The primary outcome was reduction in heart failure-related hospitalizations. Compared with treatment B, treatment A was associated with a statistically significant absolute risk reduction of 6%, and the number needed to treat to prevent one hospitalization was 17. What is needed to conclude that treatment A is superior to treatment B?