2023 In-Training Examination Critique Book PDF

American Board of Family Medicine 2023 IN-TRAINING EXAMINATION CRITIQUE BOOK This book contains the answers to each question in the In-Training Examination, as well as a critique that provides a rationale for the correct answer. Bib...

American Board of Family Medicine 2023 IN-TRAINING EXAMINATION CRITIQUE BOOK This book contains the answers to each question in the In-Training Examination, as well as a critique that provides a rationale for the correct answer. Bibliographic references are included at the end of each critique to facilitate any further study you may wish to do in a particular area. Copyright© 2023 The American Board of Family Medicine, Inc. All rights reserved. Item 1 ANSWER: E Because of the prevalence of cancer in the United States, it is important for family physicians to recognize oncologic emergencies. This patient presents with signs and symptoms related to superior vena cava syndrome, which is caused by compression of the superior vena cava. This is most often caused by lung cancer or lymphoma, but it can also be related to indwelling catheters, lymph nodes, or metastatic tumors. After ensuring that the patient is hospitalized and stable, the initial treatment options include intravenous corticosteroids, chemotherapy, radiation, and occasionally intravascular stenting. This condition is not the result of an infection, so antibiotics would not be appropriate. Hyperviscosity syndrome is another oncologic emergency associated with leukemia, multiple myeloma, and Waldenström macroglobulinemia. It is treated with chemotherapy and plasmapheresis. Echocardiography and bronchoscopy are not indicated in the initial management of superior vena cava syndrome. Ref: Higdon ML, Atkinson CJ, Lawrence KV. Oncologic emergencies: recognition and initial management. Am Fam Physician. 2018;97(11):741-748. 2) Zimmerman S, Davis M. Rapid fire: superior vena cava syndrome. Emerg Med Clin North Am. 2018;36(3):577-584. Item 2 ANSWER: B In the single maintenance and reliever therapy (SMART) approach for asthma control, combination therapy with an inhaled corticosteroid and a long-acting bronchodilator is used as both controller and rescue medication. SMART is recommended as the preferred therapeutic approach in steps 3 and 4 in the 2020 National Asthma Education and Prevention Program guidelines. Formoterol is the only medication available in the United States recommended for use in SMART therapy due to its rapid onset of action. Budesonide monotherapy, fluticasone/salmeterol, fluticasone/vilanterol, and tiotropium/olodaterol are not appropriate options for SMART in asthma control. Ref: Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF Jr, Pace W, Schatz M. Managing asthma in adolescents and adults: 2020 asthma guideline update from the National Asthma Education and Prevention Program. JAMA. 2020;324(22):2301-2317. Item 3 ANSWER: B Proton pump inhibitors (PPIs) are some of the most commonly used prescription or over-the-counter medications. However, many patients do not have a clear indication for their use, leading to situations in which the risks may outweigh the benefits. In 2022 the American Gastroenterological Association published 10 best practice statements to assist clinicians in addressing this issue. Key recommendations include regular review and documentation of the indication for any ongoing PPI use, and to consider discontinuing PPIs for any patient without a clear indication. Strategies for PPI discontinuation include tapering or abrupt discontinuation. Rebound acid hypersecretion can lead to a temporary increase in symptoms in either approach. If deprescribing is attempted but not tolerated, patients may reasonably be continued on the lowest effective dose. Possible risks, mostly reported in retrospective rather than prospective studies, include an increased incidence of chronic kidney disease, fractures, dementia, and respiratory infections, including COVID-19. 1 While many patients remain on long-term PPI therapy without a clear indication, in some situations the benefits of PPIs do clearly outweigh the risks. Such indications include Barrett esophagus, severe erosive esophagitis, eosinophilic esophagitis, and high risk for upper gastrointestinal (GI) bleeding. Risk factors for GI bleeding include prior ulcer, age >65, high-dose NSAID therapy, or concurrent use of aspirin, corticosteroids, or anticoagulants. Such patients should be advised to use PPIs indefinitely. PPIs are recommended for short-term use for eradication of Helicobacter pylori and treatment of NSAID-induced gastric ulcers. They may also be considered as adjunctive short-term therapy in Mallory-Weiss tears and after sclerotherapy or band ligation treatment of esophageal varices. None of these are indications for long-term use in the absence of other indications. Ref: Targownik LE, Fisher DA, Saini SD. AGA clinical practice update on de-prescribing of proton pump inhibitors: expert review. Gastroenterology. 2022;162(4):1334-1342. Item 4 ANSWER: A Dementia is a significant condition affecting 5 million adults and that number is likely to expand in the future due to the increasing number of individuals over age 65. The overall prevalence of dementia is around 5%, but it is 37% in those over age 90. Sixty percent to 80% of dementia is due to Alzheimer disease. The greatest risk factor for dementia is older age. Strong risk factors include diabetes mellitus, midlife obesity, a family history of dementia, a personal history of cardiovascular disease, cerebrovascular disease, use of anticholinergic medications, apolipoprotein E4 genotype, and a low education level. Other potential risk factors that lack strong evidence include atrial fibrillation, smoking, head trauma, substance abuse such as alcohol use disorder, and medications such as benzodiazepines and proton pump inhibitors. Ref: Falk N, Cole A, Meredith TJ. Evaluation of suspected dementia. Am Fam Physician. 2018;97(6):398-405. Item 5 ANSWER: C The initial first-line pharmacologic therapy for temporomandibular disorders is naproxen. Cyclobenzaprine may also be added if there is evidence of muscle spasm (A recommendation). If this is unsuccessful, other options include a trial of amitriptyline or gabapentin. Opioid therapy is not appropriate first-line treatment for temporomandibular disorders. Corticosteroid injections should be avoided due to potential cartilage damage (B recommendation). Ref: Matheson EM, Fermo JD, Blackwelder RS. Temporomandibular disorders: rapid evidence review. Am Fam Physician. 2023;107(1):52-58. 2 Item 6 ANSWER: B Thyroiditis, a general term for inflammation of the thyroid gland, is associated with thyroid gland dysfunction. It is classified based on clinical symptoms: painless or painful, acute or subacute, and underlying etiology (medication-induced, infection, radiation-induced, or autoimmune). The most common forms of thyroiditis include Hashimoto, subacute, and postpartum. Thyroiditis often results in a triphasic disease pattern of thyroid dysfunction: hyperthyroidism due to the release of preformed thyroid hormone from damaged thyroid cells followed by hypothyroidism when the thyroid stores are depleted. Eventually normal thyroid function is restored, or the patient develops permanent hypothyroidism. This patient presents with symptoms commonly seen in thyroid disease. Further testing reveals elevated TSH and thyroid peroxidase (TPO) levels. Elevated TPO levels are found in 95% of patients with Hashimoto thyroiditis. In addition, this patient’s family history includes rheumatoid arthritis, another autoimmune disease, making Hashimoto thyroiditis the most likely diagnosis. Treatment is lifelong thyroid hormone therapy. Several medications are linked to thyroiditis, including lithium, amiodarone, interferon-alfa, interleukin-2, immune checkpoint inhibitors, and tyrosine kinase inhibitors. However, there is no proven link between oral contraceptives and Hashimoto thyroiditis. Postpartum thyroiditis occurs within 1 year of delivery, miscarriage, or medical abortion, not 2–3 years. Subacute thyroiditis is self-limited and often occurs after upper respiratory infections, causing thyroid pain and dysphagia due to inflammatory destruction of thyroid follicles. Ref: Martinez Quintero B, Yazbeck C, Sweeney LB. Thyroiditis: evaluation and treatment. Am Fam Physician. 2021;104(6):609-617. Item 7 ANSWER: D Postpartum depression is common and patients who have given birth should be screened for a minimum of 1 year. A mother who knows what to feed an infant may have trouble executing it because of severe postpartum depression, leading to poor infant feeding practices. In this case, the provider will be more likely to successfully treat the child’s anemia by treating the mother’s postpartum depression. While mothers with depression often need encouragement and support, false reassurance is paternalistic and potentially harmful. Education of the mother is sometimes useful, but studies have demonstrated that the more likely barrier to implementing her knowledge is not a need for education on infant nutrition, but rather severe depression or other psychosocial barriers. It is ideal to involve all caretakers in efforts to support a child’s health, but a number of steps need to be taken prior to calling the father, including screening for domestic violence, checking on HIPAA consents, and asking about custody. Referring the mother to a psychiatrist may ultimately be helpful but puts unnecessary barriers in place for the testing and treatment of postpartum depression. Ref: Weinfield NS, Anderson CE. Postpartum symptoms of depression are related to infant feeding practices in a national WIC sample. J Nutr Educ Behav. 2022;54(2):118-124. 3 Item 8 ANSWER: A Although testicular cancer is the most common solid cancer in men ages 15–34, with effective treatment and an overall survival rate of 97%, the U.S. Preventive Services Task Force recommends against screening for testicular cancer in asymptomatic adolescent or adult males (D recommendation). A detailed history and physical examination should be obtained in symptomatic patients, followed by scrotal ultrasonography if there are positive findings on history and physical examination. Tumor markers and CT of the abdomen and pelvis are required for staging, treatment recommendations, and surveillance, but not for screening purposes. Ref: US Preventive Services Task Force. Final recommendation statement: testicular cancer: screening. Updated April 15, 2011. 2) Baird DC, Meyers GJ, Hu JS. Testicular cancer: diagnosis and treatment. Am Fam Physician. 2018;97(4):261-268. Item 9 ANSWER: D The first step in managing delirium in end-of-life care is to assess for any reversible or treatable causes, including uncontrolled pain, constipation, urinary retention, infections (e.g., urinary tract infections), and medication side effects. Antipsychotic medications, such as haloperidol and risperidone, are recommended if conservative measures fail to control the symptoms of delirium. Benzodiazepines should be used with caution as they can worsen delirium, especially in older patients. Melatonin is not indicated in the management of delirium. Ref: Albert RH. End-of-life care: managing common symptoms. Am Fam Physician. 2017;95(6):356-361. Item 10 ANSWER: E Patients with dark skin are at greater risk for postinflammatory hyperpigmentation, a reactive hypermelanosis. These are irregular hyperpigmented macules or patches that can occur after endogenous inflammation (e.g., acne vulgaris, pseudofolliculitis barbae, atopic dermatitis, lichen planus, psoriasis, contact dermatitis) and external injuries (e.g., insect bites, chemical peels, cryotherapy, laser surgery). This condition can occur at any age and is particularly noticeable in Fitzpatrick skin phototypes III, IV, V, and VI. Fitzpatrick skin phototype is used to classify the skin color spectrum and is based on an individual’s propensity for sunburn (photodermatitis). It is not a surrogate marker for race or ethnicity. Broad-spectrum, water-based sunscreen with SPF 30 should be used to prevent postinflammatory hyperpigmentation (SOR C). Sunscreen that blocks visible light such as iron oxide is also useful. Acanthosis nigricans, acne keloidalis nuchae, dermatosis papulosa nigra, and melasma are conditions that are also more common in skin of color. However, they are not related to external injuries such as insect bites. Acanthosis nigricans are usually on the posterior neck, axillae, and groin. These are velvety, irregularly defined, hyperpigmented patches. Acne keloidalis nuchae occur in the nuchal and occipital scalp. These are keloid-like papules, plaques, and cicatricial alopecia. Dermatosis papulosa nigra is usually on the face and neck. They are hyperpigmented, filiform, or sessile papules. Melasma are gray-brown patches that usually occur on the face. 4 Ref: Frazier WT, Proddutur S, Swope K. Common dermatologic conditions in skin of color. Am Fam Physician. 2023;107(1):26-34. Item 11 ANSWER: D Routine laboratory monitoring is required for patients with chronic kidney disease–bone mineral disorder (CKD-BMD) or secondary hyperparathyroidism due to renal disease. This patient has secondary hyperparathyroidism due to CKD, which interferes with normal calcium, phosphorus, and vitamin D regulation. Parathyroid hormone (PTH) stimulates bone resorption and increases serum calcium and phosphorus levels, and an elevated PTH level can result in significant hypercalcemia and hyperphosphatemia. Controlling these levels through diet and medication reduces fracture risk and mortality. Monitoring calcitonin, magnesium, and TSH levels on a routine basis is not useful for the management of CKD-BMD. PTH-related peptide is useful in diagnosing humoral hypercalcemia of malignancy but does not play a role in CKD-BMD monitoring. Ref: Sell J, Ramirez S, Partin M. Parathyroid disorders. Am Fam Physician. 2022;105(3):289-298. Item 12 ANSWER: B Of this patient’s medications, escitalopram is most likely to induce galactorrhea. SSRIs are responsible for 95% of medication-induced galactorrhea cases. The etiology of an elevated prolactin level 250 ng/mL). A normal physical examination, negative hCG level, and unremarkable TSH level, BUN level, creatinine level, and liver function tests further support a medication-induced etiology for this patient’s galactorrhea. Antihypertensives such as calcium channel blockers and methyldopa may cause galactorrhea, while diuretics such as hydrochlorothiazide and ACE inhibitors such as lisinopril are not known offenders. Neither atorvastatin nor metformin are common etiologies for medication-induced hyperprolactinemia, although atorvastatin can cause gynecomastia. Ref: Bruehlman RD, Winters S, McKittrick C. Galactorrhea: rapid evidence review. Am Fam Physician. 2022;106(6):695-700. Item 13 ANSWER: B Based on a large, randomized, multicenter trial with 17,187 participants, the administration of aspirin for suspected acute myocardial infarction (MI) saves one life for every 24 patients. Supplemental oxygen appears to have no benefit in patients with an oxygen saturation >94%. Excessive oxygen can be toxic to endothelial cells and may decrease coronary blood flow and increase systemic vascular resistance. -Blockers given immediately after MI do not decrease mortality, likely due to increased cardiogenic shock, although -blockers administered in the subacute period following the event do have benefit. Morphine does not appear to have benefit and may increase mortality. The use of nitroglycerin does not lower the risk of mortality. 5 Ref: Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE quality improvement initiative. Am Heart J. 2005;149(6):1043-1049. 2) Perez MI, Musini VM, Wright JM. Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event. Cochrane Database Syst Rev. 2009;(4):CD006743. 3) Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Magee K. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014;(6):CD003462. 4) Moss BJ, Sargsyan Z. Things we do for no reason: supplemental oxygen for patients without hypoxemia. J Hosp Med. 2019;14(4):242-244. Item 14 ANSWER: D This patient presents with symptoms and examination findings that are consistent with community-acquired pneumonia (CAP) with significant medical comorbidity, and he is stable for outpatient treatment. Medical comorbidities in this context include chronic heart, lung, liver, or kidney disease; diabetes mellitus; alcohol use disorder; cancer; or asplenia. One option for treatment in this situation is monotherapy with a respiratory fluoroquinolone, such as levofloxacin or moxifloxacin. Other options for outpatient treatment of CAP in adults with comorbidities include either the -lactam amoxicillin/clavulanate or a cephalosporin (specifically cefpodoxime, a third-generation cephalosporin, or cefuroxime, a second-generation cephalosporin), in combination with either doxycycline or a macrolide (SOR A). Of the available choices, only amoxicillin/clavulanate plus azithromycin would provide the appropriate spectrum of antimicrobial coverage. Amoxicillin or doxycycline monotherapy would be appropriate outpatient CAP treatment for an adult without a significant medical comorbidity. Another option in such a case is a macrolide such as azithromycin if the local pneumococcal resistance rate to macrolides is known to be less than 25% (SOR B). Oral cefuroxime would be appropriate in combination with either doxycycline or azithromycin in this scenario, but it would not provide broad enough coverage as monotherapy. Sulfamethoxazole/trimethoprim has encountered increasing pneumococcal resistance over the past several decades and therefore does not factor into current management for CAP, either alone or in combination with cephalexin, a first-generation cephalosporin that provides coverage against skin flora but not against typical CAP pathogens. Ref: Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. 2) Womack J, Kropa J. Community-acquired pneumonia in adults: rapid evidence review. Am Fam Physician. 2022;105(6):625-630. Item 15 ANSWER: A The National Osteoporosis Foundation supports treatment of postmenopausal women with low bone mass and a 10-year risk >20% for any major fracture or 3% for hip fracture. First-line treatment options include bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), teriparatide, and denosumab. These medications are considered first line due to their proven efficacy in reducing both hip and vertebral fractures. Hormonal treatment such as raloxifene and hormone replacement therapy is not recommended as first-line treatment due to associated risk and side effects as well as lack of evidence supporting efficacy in preventing hip fractures. Women with a 10-year fracture risk 45 mm Hg. Ninety percent of patients have coexistent obstructive sleep apnea (OSA). The pathogenesis is related to the increased physical demands on breathing caused by obesity. While decreased PaO2 or oxygen saturation is often present, it is not part of the diagnostic criteria. In obese patients with lower risk (often with lower BMIs), a serum HCO 3– level 38.5°C, confusion, delirium, and rigidity. Multiple classes of medications are associated with serotonin syndrome, including SSRIs/SNRIs, tricyclic antidepressants, antipsychotics, stimulants, triptans, and others. Changing to a different stimulant, or to a nonstimulant, would not help resolve serotonin syndrome, nor would symptomatic treatment with diphenhydramine or similar agents. Serotonin syndrome has been reported with 5-HT3 receptor antagonists such as ondansetron, particularly when used in combination with other serotonergic medications. Ref: Foong AL, Grindrod KA, Patel T, Kellar J. Demystifying serotonin syndrome (or serotonin toxicity). Can Fam Physician. 2018;64(10):720-727. 13 Item 35 ANSWER: A According to the American Geriatrics Society’s Choosing Wisely recommendations, oral handfeeding is no worse for outcomes such as aspiration pneumonia, patient comfort, and death compared to percutaneous feeding tube placement. Agitation and pressure ulcers may worsen with tube feeding. High-calorie shakes or supplements and appetite stimulants are not recommended as they may increase weight but do not improve patient-oriented outcomes such as functional status, quality of life, or survival. Furthermore, appetite stimulants such as megestrol acetate may increase the risk of thrombosis and edema, and hasten death. According to randomized, controlled trials, cholinesterase inhibitors may statistically improve cognitive testing results, but they do not produce meaningful improvement. This patient is approaching end-stage Alzheimer dementia and initiating a cholinesterase inhibitor will not improve functioning and may even worsen appetite, as a common side effect is gastrointestinal disturbance. Ref: American Geriatrics Society. Tip sheet: ten things clinicians and patients should question. ABIM Foundation Choosing Wisely campaign. Updated June 2017 2) Unwin BK, Bedsaul NB, Stubbs S. The physician's role in transitioning older adults into long-term care facilities. Am Fam Physician. 2022;106(6):714-717. Item 36 ANSWER: A Soft-tissue masses that are 5 cm in diameter carry a higher risk of malignancy and should prompt further evaluation with advanced imaging. Other features that raise concern for possible malignancy include rapid growth, sudden presentation without explanation, and lesions that are firm, deep, and adhere to surrounding structures. Both benign and malignant masses can be painless, but a lack of tenderness with palpation alone would not prompt the need for advanced imaging. Advanced imaging would also not be necessary for a mass that has a fluctuant texture, has grown persistently and slowly over several years, or is superficially located (above the fascia). Ref: Achar S, Yamanaka J, Oberstar J. Soft tissue masses: evaluation and treatment. Am Fam Physician. 2022;105(6):602-612. Item 37 ANSWER: C SGLT2 inhibitors are recommended for people with stage 3 or higher chronic kidney disease (CKD) and type 2 diabetes, as they slow CKD progression, reduce cardiovascular events, and reduce heart failure risk independent of glucose management. GLP-1 receptor agonists reduce the risk of cardiovascular disease events and hypoglycemia and appear to slow CKD progression. Biguanides (e.g., metformin), DPP-4 inhibitors, and thiazolidinediones have not been shown to reduce the progression of CKD in patients with type 2 diabetes (SOR B). Ref: ElSayed NA, Aleppo G, Aroda VR, et al. 9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes—2023. Diabetes Care. 2023;46(Suppl 1):S140-S157. 2) ElSayed NA, Aleppo G, Aroda VR, et al. 11. Chronic kidney disease and risk management: standards of care in diabetes—2023. Diabetes Care. 2023;46(Suppl 1):S191-S202. 14 Item 38 ANSWER: D Fluoride helps to prevent tooth decay and is an important aspect of good oral care. Family physicians can impact oral health, which directly affects overall health, by incorporating this into their routine practice. Fluoride varnish should be applied when the first primary tooth erupts. It should then be applied twice yearly in all infants and young children (SOR B). Also, if the patient’s primary water source is deficient in fluoride, then fluoride supplements should be prescribed for children beginning at 6 months of age. Ref: Silk H, McCallum W: Fluoride: The family physician's role. Am Fam Physician 2015;92(3):174-179. 2) Stephens MB, Wiedemer JP, Kushner GM: Dental problems in primary care. Am Fam Physician 2018;98(11):654-660. 3) US Preventive Services Task Force. Final recommendation statement: prevention of dental caries in children younger than 5 years: screening and interventions. Updated December 7, 2021. Item 39 ANSWER: C A lipid panel provides total cholesterol and HDL-cholesterol data, which are two of the components necessary to calculate the American College of Cardiology/American Heart Association 10-year atherosclerotic cardiovascular disease (ASCVD) event risk using the Pooled Cohort Equations. Other components required to compute the ASCVD event risk score include race, sex, age, systolic blood pressure level, smoking status, presence of diabetes mellitus, and antihypertension treatment. An ankle-brachial index, a high-sensitivity C-reactive protein level, and a coronary artery calcium score are not used in the Pooled Cohort Equations to calculate a patient’s 10-year ASCVD event risk. Ref: Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S49-S73. 2) US Preventive Services Task Force. Final recommendation statement: cardiovascular disease: risk assessment with nontraditional risk factors. Updated July 10, 2018. Item 40 ANSWER: D Autism spectrum disorder (ASD) is comprised of a range of neurodevelopment conditions that affect social communication and interaction and involve repetitive patterns of behavior, interests, or activities. Because early diagnosis and treatment can improve outcomes in affected patients and families, the American Academy of Pediatrics recommends universal screening for ASD with standardized autism-specific screening tools, such as the M-CHAT, at 18 and 24 months; regular developmental surveillance at all visits; and an appropriate response to family and caregiver concerns. An 18-month-old who does not point to show interest would be concerning for an increased risk for ASD, and further evaluation is warranted. A child who does not respond to his or her name by 12 months of age or engage in pretend play by 18–24 months of age would also be at risk for ASD. Clapping hands when excited is a normal milestone for a 15-month-old, and clapping is not considered a repetitive activity in this context. Looking at the parent’s face to see how to react, particularly in a new situation, is also a normal milestone for a 24-month-old. 15 Ref: Hyman SL, Levy SE, Myers SM; Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020;145(1):e20193447. 2) Autism spectrum disorder (ASD): signs and symptoms. Centers for Disease Control and Prevention. Reviewed March 28, 2022. 3) Learn the signs. Act early: milestones. Centers for Disease Control and Prevention. Reviewed June 6, 2023. Item 41 ANSWER: B This patient has obstructive sleep apnea (OSA) based on an apnea-hypopnea index (AHI) of 5 in the presence of symptoms and cardiovascular disease, such as hypertension. CPAP therapy is considered the most effective treatment for OSA if used correctly and consistently and is the first-line treatment recommendation. However, many patients struggle with tolerating CPAP, which results in poor adherence and undertreatment. An oral appliance may be tried for mild sleep apnea (an AHI of 5 to 40 kg/m 2 and are intolerant or unaccepting of CPAP (Strong Recommendation). It also recommends discussing referral to a bariatric surgeon with adult OSA patients with obesity (class II/III, BMI 35 kg/m2) who are intolerant or unaccepting of CPAP (Strong Recommendation). Discussing a referral does not necessarily have to result in a referral, but patients should be informed that other viable alternative treatments exist and can reduce disease burden. Ref: Semelka M, Wilson J, Floyd R. Diagnosis and treatment of obstructive sleep apnea in adults. Am Fam Physician. 2016;94(5):355-360. 2) Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(12):2499-2505. Item 42 ANSWER: A This patient meets diagnostic criteria for fibromyalgia, which is characterized by diffuse, chronic pain without evidence of inflammation, erythema, or joint deformities. Pharmacologic treatments for fibromyalgia include tricyclic antidepressants such as amitriptyline, SNRIs such as duloxetine and milnacipran, and gabapentinoids such as pregabalin. Evidence does not show benefit from NSAIDs such as celecoxib or naproxen or opioids such as hydrocodone. Hydroxychloroquine is a disease-modifying antirheumatic agent used to treat rheumatoid arthritis and malaria and is not appropriate for the treatment of fibromyalgia. Ref: Winslow BT, Vandal C, Dang L. Fibromyalgia: diagnosis and management. Am Fam Physician. 2023;107(2):137-144. 16 Item 43 ANSWER: E This patient has laboratory evidence of primary hyperparathyroidism, with hypercalcemia and an inappropriately elevated (as opposed to suppressed) parathyroid hormone (PTH) level. An elevated 24-hour urine calcium level further distinguishes primary hyperparathyroidism from familial hypocalciuric hypercalcemia. Treatment of primary hyperparathyroidism with parathyroidectomy has been shown to normalize PTH and calcium levels, decrease kidney stone production, and prevent declines in renal function and bone mineral density. Untreated primary hyperparathyroidism increases overall mortality as well as cardiovascular and cerebrovascular disease risk, in addition to increasing the risk of kidney stone production, renal function decline, and loss of bone mineral density. Parathyroidectomy is indicated in this patient based on her symptomatic hypercalcemia, age 1 mg/dL above the upper limit of normal. Other potential indications include the presence of osteoporosis, reduced kidney function, or other asymptomatic renal involvement, including silent nephrolithiasis on imaging, nephrocalcinosis, or hypercalciuria. Patients with primary hyperparathyroidism who are not candidates for surgery may be managed medically. Bisphosphonates may be used to increase bone mineral density. For this patient with a normal DEXA scan, surgical treatment would obviate the possible future need to treat her for bone density loss related to hyperparathyroidism. Thiazides may be used for treating certain hyperparathyroid states due to their impact on reducing calcium excretion and improving bone mineral density, although they are typically avoided in primary hyperparathyroidism because they can worsen hypercalcemia. Genetic evaluation would be warranted for a patient suspected of having multiple endocrine neoplasia type 1 or 2A, although this patient does not have any family history or presenting features to suggest involvement of either of these rare familial syndromes. Cystoscopy may be indicated in the setting of ureteral obstruction but is not necessary in this case. Ref: Insogna KL. Primary hyperparathyroidism. N Engl J Med. 2018;379(11):1050-1059. 2) Sell J, Ramirez S, Partin M. Parathyroid disorders. Am Fam Physician. 2022;105(3):289-298. Item 44 ANSWER: C The U.S. Preventive Services Task Force recommends that all adolescents and adults between the ages of 15 and 65 be screened for HIV (A recommendation). Screening for carotid stenosis and for testicular cancer is not recommended (D recommendation). The evidence for glaucoma screening and vitamin D deficiency is unclear and no recommendation has been made. Ref: US Preventive Services Task Force. Final recommendation statement: testicular cancer: screening. Updated April 15, 2011. 2) US Preventive Services Task Force. Final recommendation statement: human immunodeficiency virus (HIV) infection: screening. Updated June 11, 2019. 3) US Preventive Services Task Force. Final recommendation statement: asymptomatic carotid artery stenosis: screening. Updated February 2, 2021. 4) US Preventive Services Task Force. Final recommendation statement: vitamin D deficiency in adults: screening. Updated April 13, 2021. 5) US Preventive Services Task Force. Final recommendation statement: primary open-angle glaucoma: screening. Updated May 24, 2022. 17 Item 45 ANSWER: C This student athlete likely has a contusion to the radial nerve in the spiral groove of the distal humerus, resulting in the so-called “Saturday night palsy” after undue pressure on the distal upper arm. This could be the result of significant direct pressure over several hours, or such an injury could happen acutely, as in the described scenario. Findings include paresthesias and possible decreased light or sharp touch sensation on the back of the hand and extensor forearm. Motor findings include weakness of finger and wrist extension, best evaluated by testing while the examiner applies resistance to the actions. Thumb apposition is controlled by the median nerve and splaying out the fingers (lumbricals) is mainly an ulnar nerve function. Unless the nerve has been severed, the sensory loss and motor weakness typically resolve within days to weeks. Ref: Silver S, Ledford CC, Vogel KJ, Arnold JJ: Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 2021;103(5):275-285. Item 46 ANSWER: C Patients with moderately severe esophagitis require ongoing proton pump inhibitors (PPIs) to manage symptoms. There is a nearly 100% recurrence of symptoms at 6 months if a PPI is stopped. Lifelong omeprazole use would be the best choice for this patient. PPIs are recommended over H 2-blockers such as famotidine for maintenance and healing of erosive esophagitis. Prokinetic agents such as metoclopramide are not recommended for GERD unless gastroparesis is also present. Sucralfate is not recommended for GERD except in the case of pregnancy. Ref: Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27-56. Item 47 ANSWER: B The 2022 World Professional Association for Transgender Healthcare (WPATH) standards of care recommends that in eligible adolescents, pubertal suppression may begin at Tanner stage 2. Treatment prior to the onset of puberty is not recommended. Tanner stage 1 is prepubescent and Tanner stage 2 is the initial pubescent stage. It is not necessary and may be harmful to wait for further pubertal stages before initiating puberty blockers in an eligible transgender adolescent. Ref: Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. 18 Item 48 ANSWER: B Heart failure with preserved ejection fraction (HFpEF), defined as an EF 50%, has a relative paucity of evidence-based treatments leading to improved patient outcomes compared to heart failure with reduced ejection fraction (HFrEF), defined as an EF