So You Want to Be a Board-Certified Physician

1. So You Want to Be a Board-Certified Physician Jonathan Birnberg MD 4/19/10

2. Objectives • How to Study • Evidence-Based Medicine • Preventive Medicine • Screening • Common Symptoms • Obesity

3. How to Study • When to Begin? • How much? • What to use • MKSAP • Medstudy

4. Evidence-Based Medicine

5. A 23-year-old woman is evaluated for chronic migraine headaches. She is experiencing five migraine headaches per month, which are negatively affecting her quality of life. She wants to start a prophylactic medication regimen but has responded poorly to β-blockers and amitriptyline in the past. She wonders whether gabapentin medication is likely to help her. The remainder of the patient's history and physical examination is normal. Which of the following sources of information is most likely to provide reliable information for answering this patient's clinical question? A Randomized clinical trial B Case report C Case-controlled studies D Systematic review E Drug information inserts

6. A 23-year-old woman is evaluated for chronic migraine headaches. She is experiencing five migraine headaches per month, which are negatively affecting her quality of life. She wants to start a prophylactic medication regimen but has responded poorly to β-blockers and amitriptyline in the past. She wonders whether gabapentin medication is likely to help her. The remainder of the patient's history and physical examination is normal. Which of the following sources of information is most likely to provide reliable information for answering this patient's clinical question? A Randomized clinical trial B Case report C Case-controlled studies D Systematic review E Drug information inserts

7. Clinical Studies • RCT: Randomization, blinding, and placebo maximize validity. • Limitations: Generalizability, feasibility. Ex: Pap Smear • Cohort studies • Large with long follow-up. Try to control for patient variables. • Case–control : Hypothesis-Generating • Systematic Reviews: Inclusion criteria. Combine effects to maximize power.

8. A 53-year-old man with chronic obstructive pulmonary disease and cor pulmonale has recently transferred his medical care to the city in which his daughter lives. His current medications include albuterol and corticosteroid inhalers, hydrochlorothiazide, digoxin, and supplemental oxygen. After considering whether to discontinue the digoxin, the physician reads a systematic review on the use of digoxin in heart failure. Which of the following best guards against the inclusion of biased information in the review? A Calculating the number needed to harm B Calculating the number needed to treat C Specifying criteria for selection of reviewed articles D Grading the quality of evidence

9. A 53-year-old man with chronic obstructive pulmonary disease and cor pulmonale has recently transferred his medical care to the city in which his daughter lives. His current medications include albuterol and corticosteroid inhalers, hydrochlorothiazide, digoxin, and supplemental oxygen. After considering whether to discontinue the digoxin, the physician reads a systematic review on the use of digoxin in heart failure. Which of the following best guards against the inclusion of biased information in the review? A Calculating the number needed to harm B Calculating the number needed to treat C Specifying criteria for selection of reviewed articles D Grading the quality of evidence

10. Bias • Systematic error that tends to skew the findings of a study. • Selection, Information • Systemic reviews: • Inclusion Criteria • RCT: • Randomization • Cohort: • Treat control and case the same • Case-Control: Match cases with controls

11. Healthy Patient

12. A 52-year-old man is evaluated during a routine examination that includes a discussion of health maintenance issues. After discussing screening for colorectal cancer, he refuses colonoscopy because of lack of insurance coverage. He is willing to consider other options for screening and states that if an abnormality is found, he would be willing to undergo colonoscopy. There is no family history of colorectal cancer, and no previous colonoscopy. On physical examination, vital signs and the heart, lungs, and abdomen are normal. Which of the following is the most appropriate colorectal cancer screening strategy for this patient? A Annual home fecal occult blood testing B Annual office rectal examination and fecal occult blood testing C Double-contrast barium enema every 10 years D Flexible sigmoidoscopy every 10 years

13. A 52-year-old man is evaluated during a routine examination that includes a discussion of health maintenance issues. After discussing screening for colorectal cancer, he refuses colonoscopy because of lack of insurance coverage. He is willing to consider other options for screening and states that if an abnormality is found, he would be willing to undergo colonoscopy. There is no family history of colorectal cancer, and no previous colonoscopy. On physical examination, vital signs and the heart, lungs, and abdomen are normal. Which of the following is the most appropriate colorectal cancer screening strategy for this patient? A Annual home fecal occult blood testing B Annual office rectal examination and fecal occult blood testing C Double-contrast barium enema every 10 years D Flexible sigmoidoscopy every 10 years

14. Colon Cancer Screening • Colonoscopy every 10 years • Flexible sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years. • Double-contrast barium enema every 5 years • Annual home high-sensitivity FOBT. If positive, colonoscopy. • Annual rectal examination with office FOBT not recommended

15. A 38-year-old man is evaluated at a routine appointment with a new primary care physician. There is no history of major illnesses. There is no family history of coronary artery disease or diabetes mellitus. His only current medication is a multivitamin. On physical examination, blood pressure is 126/78 mm Hg and pulse rate is 72/min. BMI is 24. The remainder of the examination is normal. Which of the following is the most appropriate screening test in the management of this patient? A Chest radiograph B Complete blood count C Comprehensive metabolic profile D Fasting blood sugar E Fasting lipid profile

16. A 38-year-old man is evaluated at a routine appointment with a new primary care physician. There is no history of major illnesses. There is no family history of coronary artery disease or diabetes mellitus. His only current medication is a multivitamin. On physical examination, blood pressure is 126/78 mm Hg and pulse rate is 72/min. BMI is 24. The remainder of the examination is normal. Which of the following is the most appropriate screening test in the management of this patient? A Chest radiograph B Complete blood count C Comprehensive metabolic profile D Fasting blood sugar E Fasting lipid profile

17. Cholesterol Screening • Men should be screened for dyslipidemia starting at age 35 years. • Screening for dyslipidemia is recommended by the (USPSTF) for all men > 35 years regardless of risk factors. In addition, men and women > 20 years who have other risk factors for cardiovascular disease

18. Cardiometabolic Screening

19. A 40-year-old male college professor is planning a week-long bicycle trip involving cycling 20 miles daily. He has a sedentary lifestyle, with his most vigorous activity being walking on campus to classes. He wants to know if it is safe for him to go on the bike trip. His medical history is unremarkable, he takes no medications, there is no family history of early coronary artery disease, and he does not smoke cigarettes. His blood pressure is 124/82 mm Hg and his BMI is 32. Heart and lung examinations are normal. Recent cholesterol test results included total cholesterol, 182 mg/dL (4.71 mmol/L); HDL cholesterol, 45 mg/dL (1.17 mmol/L); and LDL cholesterol, 127 mg/dL (3.29 mmol/L). Which of the following is the most appropriate evaluation strategy for this patient? A Carotid intimal medial thickness measurement B Coronary artery calcium scoring C Electrocardiographic treadmill stress test D Nuclear stress test E No testing

20. A 40-year-old male college professor is planning a week-long bicycle trip involving cycling 20 miles daily. He has a sedentary lifestyle, with his most vigorous activity being walking on campus to classes. He wants to know if it is safe for him to go on the bike trip. His medical history is unremarkable, he takes no medications, there is no family history of early coronary artery disease, and he does not smoke cigarettes. His blood pressure is 124/82 mm Hg and his BMI is 32. Heart and lung examinations are normal. Recent cholesterol test results included total cholesterol, 182 mg/dL (4.71 mmol/L); HDL cholesterol, 45 mg/dL (1.17 mmol/L); and LDL cholesterol, 127 mg/dL (3.29 mmol/L). Which of the following is the most appropriate evaluation strategy for this patient? A Carotid intimal medial thickness measurement B Coronary artery calcium scoring C Electrocardiographic treadmill stress test D Nuclear stress test E No testing

21. Stress Test • Asymptomatic adults at low risk for coronary artery disease (CAD) don’t need to consult with a physician prior to beginning . • According to the U.S. Preventive Services Task Force and AHA, no need for routine stress test before exercise program. • ACSM men > 45 years women >55 years and in persons with >2 two or more major cardiac risk factors; signs or symptoms of CAD; or those with cardiac, pulmonary, or metabolic .

22. Common Symptoms

23. A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and became diaphoretic and lightheaded. She sat on the ground and then lost consciousness. According to her son, she was unconscious for less than a minute and exhibited some twitching movements when she first lost consciousness. She had no incontinence or symptoms of confusion upon awakening. She had no further symptoms upon regaining consciousness. She has a history of hypertension and hyperlipidemia. Current medications are lisinopril and lovastatin. On physical examination, temperature is normal, blood pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine) and 92/min (standing), and respiration rate is 14/min. BMI is 35. Cardiac and neurologic examinations are normal. An electrocardiogram is normal.

24. Which of the following is the most appropriate management option for this patient? A Echocardiogram B Electroencephalogram C Exercise stress test D Tilt-table testing E No further testing

25. Which of the following is the most appropriate management option for this patient? A Echocardiogram B Electroencephalogram C Exercise stress test D Tilt-table testing E No further testing

27. Red Flags for Hospitalization

28. An 89-year-old woman is evaluated for dizziness that she has had for the past year, mainly while standing and ambulating. The dizziness is described as a sense of unsteadiness. The symptoms can last for minutes to hours, and she has at least 4 to 5 episodes per day. There are no reproducible activities that cause the dizziness. She does not describe hearing loss, headache, diplopia, or other motor or sensory symptoms. Medical history is remarkable for a 15-year history of type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, and mild dementia. Current medications are hydrochlorothiazide, ramipril, simvastatin, metformin, insulin glargine, low-dose aspirin, and donepezil. She has not started any new medications recently, and she has no known drug allergies. Vital signs are normal; there is no evidence of orthostasis. BMI is 27. A cardiopulmonary examination is normal. The patient has a positive Romberg sign and is unsteady on tandem gait. Rapid alternating movements are slowed. The patient has a corrected visual acuity of 20/50 in the right eye and 20/70 in the left eye. Vibratory sense and light touch are diminished in a stocking pattern in the lower extremities, and ankle jerk reflexes are 1+. The patient’s Mini-Mental State Examination score is 26/30 (normal ≥24/30), unchanged from 1 year ago. She has no motor abnormalities and no cranial nerve abnormalities. A Dix-Hallpike maneuver does not elicit vertigo or nystagmus.

29. A complete blood count, metabolic profile, and thyroid function studies are normal. Which of the following management options is the best choice for this patient? A. Brain MRI B. Meclizine C. Physical therapy D. Replace aspirin with aspirin/extended-release dipyridamole

30. A complete blood count, metabolic profile, and thyroid function studies are normal. Which of the following management options is the best choice for this patient? A. Brain MRI B. Meclizine C. Physical therapy D. Replace aspirin with aspirin/extended-release dipyridamole

31. Dizziness • Pre-syncope • Vertigo • Unsteadiness/Dysequlibrium • Non-specific

32. A 54-year-old woman is evaluated for a 4-day history of an acute headache that has been gradually worsening and is located diffusely on the left side of her head. The patient is nauseous but does not have photophobia, fever, chills, history of tick exposures, trauma, stiff neck, muscle weakness, parasthesias, or bowel or bladder problems. She awakens with the headache and it gradually worsens during the day, and she experiences slight relief with acetaminophen and ibuprofen. She has a family history of migraines and, as a teenager and in her mid-30s, had a few migraine headaches that were more severe than her current episode and were associated with photophobia and severe fatigue. However, since those episodes, she had been headache free until now. Her medical history includes hypertension, diabetes mellitus, breast cancer for which she underwent lumpectomy 4 years ago, and osteoarthritis. Current medications include atenolol, metformin, tamoxifen, and enteric-coated aspirin. On physical examination, the patient appears to be in mild distress, but vital signs are normal. The neurologic evaluation is significant for decreased vibratory and monofilament perception in the bilateral lower extremities in a stocking distribution.

33. Which of the following is the most appropriate management option for this patient? A MRI of the head B Lumbar puncture and cerebrospinal fluid analysis C Bone scan D Enzyme-linked immunosorbent assay for Borrelia E Sumatriptan therapy

34. Which of the following is the most appropriate management option for this patient? A MRI of the head B Lumbar puncture and cerebrospinal fluid analysis C Bone scan D Enzyme-linked immunosorbent assay for Borrelia E Sumatriptan therapy

35. History Danger Signs • Sudden onset • Severe persistent headache that reaches maximum intensity in seconds to minutes • Focal neurologic symptoms other than visual or sensory aura • Fever • Changes in MS • History of cancer

36. Physical Exam Warning Signs • Fever • Neck Stiffness • Altered mental status • Papilledema • Focal neurologic signs

37. Bad Headaches • Mass Lesion • Vascular abnormality • Infection • Pseudotumor Cerebri

38. Common Headache • Tension: Bilateral, no associated symptoms • Cluster: Unilateral, eye lacrimation and redness, rhinorrhea • Migraine: Bilateral or unilateral, associated N/V, photophobia aura

39. Obesity

40. A 44-year-old obese man is evaluated at a follow-up of chronic medical problems. He has been trying to follow a restricted-calorie Mediterranean-style diet for the past year after being unable to comply with a low-carbohydrate, high-protein diet the year before. He has been on sibutramine to lose weight for the past 2 years and has attended a medically supervised weight loss clinic. The patient initially lost 4.5 kg (10 lb) but gained 2.3 kg (5 lb) back. Efforts to increase aerobic activity have been difficult owing to right knee osteoarthritis. He also has type 2 diabetes mellitus, hyperlipidemia, and hypertension. Current medications are hydrochlorothiazide, lisinopril, atorvastatin, aspirin, metformin, insulin glargine, sibutramine, and acetaminophen. On physical examination, temperature is normal, blood pressure is 144/78 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 43. Hemoglobin A1c is 8.2%, and random plasma glucose is 186 mg/dL (10.32 mmol/L). Laboratory results, including complete blood count, hepatic enzymes, and serum chemistry studies, are otherwise normal.

41. Which of the following is the most appropriate management option for this patient? A . Bariatric surgery B. Begin a very-low-calorie diet (800 kcal/d) C. Continue sibutramine D. Discontinue sibutramine and prescribe orlistat

42. Which of the following is the most appropriate management option for this patient? A . Bariatric surgery B. Begin a very-low-calorie diet (800 kcal/d) C. Continue sibutramine D. Discontinue sibutramine and prescribe orlistat

43. A 44-year-old woman is evaluated during a routine appointment. She has been trying to lose weight over the past 3 years. The patient has tried several diets and has also attempted to increase her physical activity. Medical history is remarkable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications are lisinopril, simvastatin, aspirin, metformin, and glipizide. On physical examination, temperature is normal, blood pressure is 138/90 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. BMI is 34. Her hemoglobin A1c is 6.9%. In addition to encouraging continued efforts at dieting and exercise, which of the following is the most appropriate management option for this patient? A Add orlistat B Add sibutramine C Discontinue glipizide, initiate insulin glargine D Refer for bariatric surgery

44. A 44-year-old woman is evaluated during a routine appointment. She has been trying to lose weight over the past 3 years. The patient has tried several diets and has also attempted to increase her physical activity. Medical history is remarkable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications are lisinopril, simvastatin, aspirin, metformin, and glipizide. On physical examination, temperature is normal, blood pressure is 138/90 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. BMI is 34. Her hemoglobin A1c is 6.9%. In addition to encouraging continued efforts at dieting and exercise, which of the following is the most appropriate management option for this patient? A Add orlistat B Add sibutramine C Discontinue glipizide, initiate insulin glargine D Refer for bariatric surgery

45. A 30-year-old woman is evaluated during a routine appointment. She has no symptoms other than fatigue, which she attributes to long work hours. She denies daytime somnolence and a history of snoring. She is a lawyer and, owing to stress at work, she finds it difficult to eat healthy foods and get exercise. She gained 9.1 kg (20 lb) with the birth of her first child last year and has been unable to lose the weight. The patient had gestational diabetes. She states that her menstrual periods are normal. She is taking no medications. Vital signs are normal. She is 177.8 cm (70 in) tall. BMI is 32. Her thyroid examination is normal. She has normal hair distribution and normal skin color with no evidence of striae. In addition to a fasting plasma glucose, lipid panel, and thyroid-stimulating hormone assay, which of the following should be done next? A 24-Hour urine cortisol B Pelvic ultrasonography C Serum insulin-like growth factor 1 (IGF-1) concentration D Waist circumference measurement

46. A 30-year-old woman is evaluated during a routine appointment. She has no symptoms other than fatigue, which she attributes to long work hours. She denies daytime somnolence and a history of snoring. She is a lawyer and, owing to stress at work, she finds it difficult to eat healthy foods and get exercise. She gained 9.1 kg (20 lb) with the birth of her first child last year and has been unable to lose the weight. The patient had gestational diabetes. She states that her menstrual periods are normal. She is taking no medications. Vital signs are normal. She is 177.8 cm (70 in) tall. BMI is 32. Her thyroid examination is normal. She has normal hair distribution and normal skin color with no evidence of striae. In addition to a fasting plasma glucose, lipid panel, and thyroid-stimulating hormone assay, which of the following should be done next? A 24-Hour urine cortisol B Pelvic ultrasonography C Serum insulin-like growth factor 1 (IGF-1) concentration D Waist circumference measurement