Board Review: General Internal Medicine

Friday, July 17

Question 1
A 60-year-old man is evaluated for a 3-month history of persistent left lower facial pain in the mandibular region that has worsened and been unresponsive to treatment with acetaminophen, 4 g four times daily, over the past 3 weeks. He describes the pain as electrical in nature, often triggered by dental manipulation or extreme temperature exposure.

Question 1
His dentist found no oral or dental cause for the pain but treated him with a 14-day course of amoxicillin for presumptive sinusitis without improvement. The physical examination, including a complete neurologic evaluation, is normal. Laboratory studies and CT of the sinuses are normal.

Question 1
Which of the following is the most costeffective and efficacious treatment for this patient? A. Narcotic analgesia B. Gabapentin C. Tricyclic antidepressants D. Carbamazepine E. Tetrahydrocannabinol analogue

Answer 1
Which of the following is the most costeffective and efficacious treatment for this patient? A. Narcotic analgesia B. Gabapentin C. Tricyclic antidepressants D. Carbamazepine E. Tetrahydrocannabinol analogue

Answer 1
This patient has trigeminal neuralgia. Although there is little evidence on efficacious therapies for this disorder, in a meta-analysis of three placebocontrolled studies, carbamazepine was associated with a number needed to treat of 2.5 for improvement of pain (typically a 50% reduction in pain), without any higher incidence of major adverse events compared with placebo. No other anticonvulsant agent has been adequately studied in randomized, placebo-controlled trials for treatment of this disorder.

Answer 1
Narcotic analgesia is only modestly effective at treating neuropathic pain and should be reserved only for patients whose pain is recalcitrant to non-narcotic treatments. Although gabapentin is increasingly being used for patients with neuropathic pain, there is no clinical trial evidence for its efficacy in treating trigeminal neuralgia. In addition, compared with carbamazepine, gabapentin has not been found to be superior in treating other neuropathic syndromes, is considerably more expensive, and requires more frequent dosing.

Answer 1
Tricyclic antidepressants are efficacious in treating several neuropathic pain syndromes, although these agents have not been studied in patients with trigeminal neuralgia. Cannabinoids are the natural constituents of marijuana (cannabis) and consist of delta-9tetrahydrocannabinol (THC), cannabinol, and cannabidiol. Cannabinoids are currently being studied as treatment for chronic pain but have not yet been proved efficacious in patients with neuropathic pain syndromes.

Question 2
A 23-year-old woman is evaluated because her mother, who has accompanied her, is concerned that she is too thin. The patient reports that she has lost 8.6 kg in the past 6 months from her baseline of 48.08 kg. Her current BMI is 14.9. Her daily dietary intake usually consists of a yogurt for breakfast and a salad or bagel with a double-espresso coffee for dinner. She says that she feels full and bloated after eating anything, and she thinks her stomach looks big.

Question 2
Although she feels tired, she drinks two to three caffeinated diet beverages per day to maintain her energy level. Sometimes, when she stands up quickly, she feels lightheaded. Her last menstrual period was 2 months ago. She denies bingeing, laxative use, vomiting, depression, or anhedonia.

Question 2
On physical examination, she is a very thin, wellgroomed woman, in no apparent distress. She is orthostatic and tachycardic, but her other vital signs are normal. Her hair is thin and brittle, and her integument dry. The remainder of the physical examination is unremarkable. Laboratory studies include a serum potassium level of 3.1 meq/L, and a serum phosphorus level of 2.2 mg/dL.

Question 2
Which of the following is the best initial management option for this patient? A. Citalopram B. Immediate hospitalization C. Outpatient psychiatric referral D. Olanzapine E. Nutrition consultation

Answer 2
Which of the following is the best initial management option for this patient? A. Citalopram B. Immediate hospitalization C. Outpatient psychiatric referral D. Olanzapine E. Nutrition consultation

Answer 2
This patient has anorexia nervosa and should be immediately hospitalized. Criteria for hospitalization of these patients include severe malnutrition or dehydration, electrolyte disturbances, cardiac arrhythmias, physiologic instability, failure of outpatient treatment, acute food refusal, uncontrollable bingeing and purging, acute medical complication of malnutrition, suicidal ideation, and the presence of comorbid problems interfering with treatment.

Answer 2
This patient requires hospitalization because she is orthostatic, severely malnourished, and has hypokalemia and hypophosphatemia. She is at high risk for the refeeding syndrome and could become profoundly hypophosphatemic because malnourished patients have depleted intracellular phosphate stores; this condition can worsen as patients switch from fat to carbohydrate metabolism.

Answer 2
Although patients with anorexia nervosa commonly have psychiatric comorbidities, pharmacologic antidepressants, such as citalopram, are not indicated as monotherapy. In patients who can be managed on an outpatient basis, referral to a psychiatrist that specializes in eating disorders or management by a multidisciplinary team, including a nutritionist, mental health worker, and internist, are both acceptable treatment options; however, the results of this patient's physical examination and laboratory studies indicate the need for in-hospital care. Although there have been a few case reports suggesting olanzapine to be effective in patients with anorexia nervosa, its widespread use cannot be recommended until better clinical trials have established its efficacy.

Question 3
A 54-year-old man is evaluated for a 3-day history of nasal congestion, rhinorrhea, scratchy throat, and nonproductive cough. He has had no obvious contact with ill patients and does not have a history of allergic rhinitis. He is otherwise healthy except for a history of hypertension well controlled with hydrochlorothiazide and lisinopril. On physical examination, the temperature is 37.3 C (99.2 F). There is no conjunctival erythema, pharyngeal exudate, cervical lymphadenopathy, or adventitious lung sounds.

Question 3
Which of the following treatments is supported by evidence for improving symptoms in patients with this syndrome? A. Echinacea B. Antihistamines C. Pseudoephedrine D. Zinc E. Vitamin C

Answer 3
Which of the following treatments is supported by evidence for improving symptoms in patients with this syndrome? A. Echinacea B. Antihistamines C. Pseudoephedrine D. Zinc E. Vitamin C

Answer 3
This patient has symptoms of a viral upper respiratory infection (URI), for which there are a myriad of treatments available, although relatively few have been proven effective at improving symptoms or modifying the course of the illness. Effective therapies with good evidence for patients with viral URIs include pseudoephedrine, ipratropium nasal inhaler, cromolyn sodium nasal inhaler, and humidified air; however, their efficacy is based largely on their effect of reducing nasal congestion severity and not the course of the illness itself.

Answer 3
Pseudoephedrine is safe for use in patients with hypertension whose blood pressure is adequately controlled, because the increase in blood pressure and heart rate caused by this agent, on average, is only slightly higher than that of placebo. Therapies with insufficient evidence to support their use in patients with viral URI symptoms include vitamin C, zinc, antihistamines, and antitussives. There is sufficient randomized trial evidence indicating that echinacea is not effective for viral URI symptoms or illness duration. New antiviral agents targeting the rhinovirus genus are being actively studied.

Question 4
A 76-year-old man is evaluated for a syncopal episode that occurred as he was stepping into his truck; he is accompanied by his wife. He reports experiencing palpitations before the episode occurred. His wife states he looked suddenly sweaty and ashen before passing out. On regaining consciousness approximately 1 minute later, he appeared slightly dazed but was oriented and mentating normally. He reports remembering nothing prior to the syncope except for a sense of his heart racing. There was no bowel or bladder incontinence.

Question 4
His medical history is significant for coronary artery disease and stable angina, diabetes mellitus, hypertension, and hyperlipidemia, for which he takes atenolol, fosinopril, metformin, simvastatin, and aspirin. On physical examination, pulse rate is 64/min, and blood pressure is 126/74 mm Hg. The remainder of the examination, including cardiac and neurologic evaluation, is unremarkable. Results of electrocardiography are consistent with his most recent electrocardiogram, with evidence of an old bifascicular block.

Results from 24-hour ambulatory electrocardiography, exercise stress testing, and echocardiography are normal.

Question 4
Which of the following is the most appropriate next step in diagnosis? A. Electrophysiologic testing B. 72-Hour ambulatory electrocardiography C. Cardiac catheterization D. Tilt-table testing E. External or implanted continuous loop recorder

Answer 4
Which of the following is the most appropriate next step in diagnosis? A. Electrophysiologic testing B. 72-Hour ambulatory electrocardiography C. Cardiac catheterization D. Tilt-table testing E. External or implanted continuous loop recorder

Answer 4
True syncope is an abrupt, transient loss of consciousness caused by global cerebral hypoperfusion without focal neurologic deficit and with spontaneous recovery. Rates of 1-year cardiac mortality and sudden death are higher for patients with cardiac syncope than noncardiac or idiopathic syncope. Arrhythmia is strongly suspected in this patient because of his known coronary artery disease and bifascicular block. Long-term ( 30 days) event monitoring with external or implantable continuous-loop recorders is recommended when suspicion of arrhythmia remains after inpatient telemetry and ambulatory electrocardiographic monitoring are nondiagnostic.

Answer 4
Continuous-loop recorders require that patients activate the monitoring when symptoms occur. After activation, readings are captured for the preceding several minutes and 1 minute longer. Subcutaneously implanted recorders can now monitor for events up to 18 months. Electrophysiologic testing would be performed as a last step in diagnosis or if patients cannot self-activate a continuous-loop recorder.

Answer 4
Increasing ambulatory electrocardiographic monitoring to 72 hours will not increase the diagnostic yield. Cardiac catheterization is not the appropriate next step in this patient given the negative results on exercise stress testing. Tilt-table testing is indicated for patients with unexplained syncope in the absence of coronary artery disease or after a cardiac cause has been excluded.

Question 5
A 23-year-old woman is evaluated for abdominal pain of several years' duration and a 5.4-kg (12-lb) weight loss occurring over the past few months. The pain is diffuse, although mostly occurring in the lower abdomen, and is crampy in nature and so severe at times that it doubles her over. She does not experience an increase or relief of pain with oral intake. The pain is frequently associated with diarrhea, especially when she is under stress, or intermittent constipation, although on most days she has a normal, formed bowel movement.

Question 5
Currently, she reports having up to six bowel movements daily, consisting of loose, watery, and foul-smelling stools, but without blood or mucous. She gets some relief of pain with defecation but denies fecal urgency. She has taken loperamide, with relief, for her diarrhea. She has never sought care for her abdominal problems in the past but seeks help now because the pain has become more severe and is interfering with her activities of daily living. Her family history is remarkable for irritable bowel syndrome.

Question 5
Recent laboratory studies indicated that she has mild anemia, for which she takes a daily iron supplement. On physical examination, she is a thin-appearing, fatigued woman in mild distress. Temperature is 36.9 C (98.4 F), respiration rate is 12/min, and blood pressure is 114/53 mm Hg. The height is 162.56 cm (64 in), and weight is 57.6 kg (127 lb). The abdominal examination reveals normal bowel sounds and no hepatosplenomegaly, and the abdomen is diffusely tender without guarding, rebound, or rigidity. No palpable masses are appreciated. The remainder of the examination, including pelvic and rectal examination, is unremarkable.

Question 5
Which of the following is the best diagnostic option for this patient? A. CT of the abdomen B. Colonoscopy C. Flexible sigmoidoscopy D. Abdominal ultrasonography E. Fecal calprotectin analysis

Answer 5
Which of the following is the best diagnostic option for this patient? A. CT of the abdomen B. Colonoscopy C. Flexible sigmoidoscopy D. Abdominal ultrasonography E. Fecal calprotectin analysis

Answer 5
Although irritable bowel syndrome (IBS) occurs very commonly in patients in this age group, and many features of this patient's presentation suggest this syndrome, including the chronicity of the problem, its association with stress, and the pattern of alternating diarrhea and constipation. She also has two alarm symptoms, weight loss of greater than 4.5 kg (10 lb), and anemia; therefore, she should undergo colonoscopy.

Answer 5
In patients with tenesmus or hematochezia, disease is likely distal, and flexible sigmoidoscopy may be sufficient. Crohn's disease is frequently characterized by skip areas (that is, areas of normal-appearing bowel interrupted by large areas of diseased bowel) and often is associated with terminal ileitis, diagnosable with a colonoscopy; however, a small-bowel followthrough is sometimes required to find disease that does not extend to the colon. If the patient were febrile, a CT of the abdomen might be necessary to identify fistulas and abscesses, which can occur in Crohn's disease.

Answer 5
Fecal calprotectin is a zinc- and calciumbinding protein derived mostly from neutrophils and monocytes, and although initial studies suggest that measuring levels of this protein may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea, its test characteristics are not yet sufficiently defined for routine clinical use.

Answer 5
Rome II criteria for IBS require the presence of 3 (not-necessarilyconsecutive) months of pain relieved with defecation and onset associated with change in stool frequency or consistency. In clinical practice, these criteria have a positive predictive value of 98%. Because most clinicians are unaware of these criteria, the American College of Gastroenterology recommends diagnosis of IBS based on abdominal discomfort associated with altered bowel habits.

However, both of these clinical diagnostic rules should be applied only to patients who have no alarm symptoms suggesting a potentially serious underlying condition, such as hematochezia, weight loss greater than 4.5 kg (10 lb), family history of colon cancer, recurring fever, anemia, or chronic severe diarrhea.

Question 6
A 35-year-old man is evaluated for red eye and acute onset of right eye pain. He wears contact lenses daily. Fluorescein staining is positive for corneal abrasion without a dendritic, or branching, pattern. He is instructed to stop wearing the contact lenses until the abrasion is healed. He calls the next day to report that the pain has worsened, even though he has not worn his contact lenses. On examination, compared with the previous day's findings, the patient appears to be in more pain, visual acuity of the right eye is worse with Snellen's test, and the abrasion is larger on fluorescein staining. The eye remains red, and there is a mucopurulent discharge.

Question 6
Which of the following is the most likely diagnosis? A. Hypopyon B. Infectious keratitis C. Herpetic keratitis D. Anterior uveitis

Answer 6
Which of the following is the most likely diagnosis? A. Hypopyon B. Infectious keratitis C. Herpetic keratitis D. Anterior uveitis

Answer 6
Corneal abrasion associated with hard or soft contact lenses is especially susceptible to infectious keratitis. The eye is red and painful; vision loss is not usually immediately present, but it may occur as the corneal abrasion progresses or with infectious keratitis. Permanent vision loss may occur. There is an increased risk for fulminant keratitis caused by Pseudomonas sp.

Answer 6
With hypopyon (white or yellowish-white accumulation of purulence in the anterior chamber) and hyphema (blood in the anterior chamber), gravity causes inferior pooling. Both conditions are associated with acute anterior uveitis (red and painful eye with decreased visual acuity) and corneal trauma, infiltrate, or ulcer. Anterior uveitis also presents with red, painful eye, blurred vision, and vision loss, usually in young or middle-aged persons, but is not associated with contact lens use, corneal abrasion, or foreign-body sensation. There is diffuse erythema prominent at the limbus, light reflex is sluggish to unreactive, and the pupil is constricted in patients with anterior uveitis. in 1 to 2 days. Diagnosis of this condition usually requires slit-lamp examination, and hypopyon or hyphema may be visible at the base of the anterior chamber.

Answer 6
Herpetic keratitis is associated with watery discharge and dendritic, or branching, pattern on fluorescein staining, and may have branching opacities. Hypopyon, infectious keratitis associated with corneal abrasion, and anterior uveitis require emergency referral to an ophthalmologist; viral keratitis should be evaluated by an ophthalmologist

Question 7
A 19-year-old college student is evaluated for left testicle pain that began 3 to 4 days earlier. He is newly sexually active. The symptoms started slowly, but now the left testicle is painful even when he walks. He has had no dysuria, urinary frequency, penile discharge, or ulcerations. He reports no fever or chills. On examination, temperature is normal. He has an area of tenderness at the superior pole of the left testicle, with normal-sized testes, smooth surface, and negative transillumination. There is no evidence of urethral discharge. Urinalysis in the office shows leukocytes (7/hpf) and erythrocytes (5/hpf). DNA amplication is performed. Urethral swabs are sent for culture.

Question 7
Which of the following is the best empiric treatment for this patient? A. Doxycycline B. Ceftriaxone and doxycycline C. Amoxicillin D. Trimethoprim--sulfamethoxazole

Answer 7
Which of the following is the best empiric treatment for this patient? A. Doxycycline B. Ceftriaxone and doxycycline C. Amoxicillin D. Trimethoprim--sulfamethoxazole

Answer 7
This patient's symptoms suggest acute bacterial epididymitis. In sexually active young adults, it is frequently caused by sexually transmitted pathogens, including Chlamydia trachomatis or Neisseria gonorrhoeae. It can also be caused by enteric pathogens in men who engage in receptive anal intercourse. In men 35 years or older, nonsexually transmitted epididymitis is associated with urinary tract infections, recent genitourinary instrumentation or surgery, indwelling catheters, or anatomic abnormalities of the urinary tract. Urine culture is usually positive in epididymitis, but urethral swab for gonococcus and Chlamydia can provide valuable additional information.

Answer 7
Treatment of acute bacterial epididymitis includes bed rest and scrotal elevation with oral antibiotics. The Centers for Disease Control and Prevention recommend ceftriaxone and doxycycline in combination for treatment of epididymitis most likely caused by gonococcal or chlamydial infection. Fluoroquinolone monotherapy (ofloxacin or levofloxacin) is recommended in patients in whom enteric organisms are more likely, in those who are allergic to cephalosporins and tetracyclines, and in those older than 35 years. Doxycycline alone is effective against C. trachomatis but does not adequately treat N. gonorrhoeae. Amoxicillin has no activity against either of these pathogens. Trimethoprimsulfamethoxazole has adequate gram-negative coverage but is not effective against the pathogens most likely causing this patient's symptoms.

Answer 7
Any health care episode possibly related to sexually transmitted disease is an opportunity to educate patients about safe sex practices and to screen for other sexually transmitted infections, specifically HIV infection and syphilis. When patients have confirmed or suspect infection with N. gonorrhoeae or C. trachomatis, they should be instructed to refer their sexual partners for evaluation and treatment and to avoid sexual intercourse until they and their sexual partners are cured (or therapy is completed with no further symptoms).

Question 8
A 45-year-old black man is evaluated for concerns about prostate cancer. A good friend was recently diagnosed with extensive disease and has a poor prognosis. The patient asks if he should have a screening test for this disease. He reports once-nightly nocturia but has no hesitancy, urinary frequency, or dribbling.

Question 8
Which of the following is the most appropriate course of action for this patient? A. Prostate-specific antigen (PSA) measurement B. PSA measurement and digital rectal examination C. Transrectal ultrasonography D. Transrectal ultrasonography with random biopsies E. Discussion of benefits and harms of PSA testing

Answer 8
Which of the following is the most appropriate course of action for this patient? A. Prostate-specific antigen (PSA) measurement B. PSA measurement and digital rectal examination C. Transrectal ultrasonography D. Transrectal ultrasonography with random biopsies E. Discussion of benefits and harms of PSA testing

Answer 8
The patient described in this scenario is asymptomatic and needs to be told the benefits and harms of prostate-specific antigen (PSA) testing before any other diagnostic tests are performed. Screening for prostate cancer continues to be controversial owing to the poor sensitivity and specificity of serum PSA testing. With a cutoff of 4 ng/mL (4 g/L), a single PSA assay has a sensitivity of 70% to 80% and a specificity of 60% to 70%. In asymptomatic patients, it has a positive predictive value of 30%, meaning that fewer than one in three men with an elevated PSA level actually has prostate cancer.

Answer 8
Levels can be normal in the presence of prostate cancer or elevated without cancer present. There are age and racial differences in normal values, although use of these values is not recommended for clinical use. The U.S. Preventive Services Task Force cites the level of evidence for screening with PSA as insufficient for determining whether the benefits outweigh the harms because of mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with frequent false-positive results, unnecessary anxiety, biopsies, and complications associated with treatment of some cancers that may never have affected the patient's health.

Answer 8
Digital rectal examination is unreliable, because physicians have relatively low inter-rater agreement on findings. The combination of PSA and digital rectal examination provides an overall rate of cancer detection higher than either test alone. However, this strategy should be preceded by adequate discussion with the patient about its benefits and harms. Several tools have been developed to assist providers in this discussion. Transrectal ultrasonography with biopsy is an invasive test used in the workup of an established problem, such as a palpable nodule or a rising PSA level. Given its low sensitivity and low positive predictive value, it is a poor screening test and not feasible in most practices.

Question 9
A 27-year-old woman is evaluated for abdominal pain and discomfort occurring intermittently over the past 2 years. She describes the pain as crampy, occurring diffusely in the lower quadrant. She experiences some relief with defecation. The abdominal pain is usually associated with 3 to 5 days of loose, watery stools. Between episodes, she feels fine and has normal, formed stools. She has not had fecal urgency, hematochezia, weight loss, fever, arthralgia, or rashes. Her medical history includes depression occurring after the death of her father when she was aged 22 years, for which she received 6 months of antidepressant therapy with good response. She is not currently depressed. Her family history is negative for colon cancer and inflammatory bowel disease.

Question 9
On physical examination, she is well developed and appears well nourished. Vital signs, including temperature and blood pressure, are normal. The remainder of her examination is unremarkable. Laboratory studies obtained within the past 6 months, including complete blood count, renal function and liver chemistry tests, and serum thyroid-stimulating hormone, electrolyte, and calcium levels, were normal.

Which of the following treatment options is most appropriate for this patient? A) Nortriptyline B) Sertraline C) Loperamide D) Alosetron E) Psyllium

Which of the following treatment options is most appropriate for this patient?

C Loperamide

Answer 9
This patient meets Rome II criteria for irritable bowel syndrome (IBS). Treatment for IBS is largely symptomatic. For diarrhea-predominant IBS, loperamide has been found effective. Antidepressants, both tricyclic agents and selective serotonin reuptake inhibitors, have been shown to improve overall well being and pain levels, but have no impact on other IBS symptoms. Alosetron is Food and Drug Administration approved for diarrheapredominant IBS; however, its use should be restricted to patients with severe, diarrhea-predominant IBS who have not responded to other symptomatic measures, because it has been associated with ischemic colitis in approximately 1 in 700 patients who take this drug. Physicians who prescribe alosetron must register with the manufacturer, and patients must sign a consent form before beginning therapy.

Answer 9
Adding fiber to the diet is a common approach to treating IBS. Although safe, fiber was found to be no more beneficial in treating global IBS symptoms than placebo in a recent metaanalysis. Finally, although clinical trials suggest that antispasmodic agents, such as dicyclomine and hyoscyamine, may be helpful in managing pain in patients with IBS, a recent meta-analysis suggests the benefit is weak.

Question 10
A 43-year-old woman is evaluated during an initial visit. She has brought with her a written list of health problems, including headaches, muscle pain and weakness, abdominal pain, diarrhea, sinusitis, and frequent urinary tract infection. She also reports problems with sexual intimacy. For the past 4 years, her health problems have interfered with her ability to work. Previous treatments for headache have included venlafaxine, verapamil, propranolol, and gabapentin. For each of these, she reports no relief or an intolerance to the medication.

Question 10
Previous evaluation by a neurologist, gastroenterologist, and rheumatologist yielded no diagnosis of her medical problems. Previous laboratory studies, including complete blood count; erythrocyte sedimentation rate; serum B-12/folate, electrolyte, creatinine, blood urea nitrogen, and thyroid-stimulating hormone levels; liver chemistry tests; serum lipid panel; serum rheumatoid factor and antinuclear antibody assays; heterophile antibody testing; and urinalysis, were normal.

Question 10
Results of MRI of the head, colonoscopy, and CT of the abdomen were negative. She has not had any tick exposures or bites nor any memory of experiencing an expanding red rash. The patient describes health problems in response to each portion of the general review of systems. When she is asked if she feels depressed, she becomes visibly angry. The physical examination, including vital signs, is normal.

Which of the following is the most appropriate management option for this patient?

A) Repeated MRI of the head B) Cognitive behavioral therapy C) Enzyme-linked immunosorbent assay for Borrelia burgdorferi D) Lumbar puncture and cerebral fluid analysis E) Switch from nortriptyline to venlafaxine

Which of the following is the most appropriate management option for this patient?

B) Cognitive behavioral therapy

Answer 10
This patient has a somatization disorder, for which the optimal initial management strategy is cognitive behavioral therapy (CBT). Somatization disorder criteria include several years of many physical complaints beginning before age 30 years that result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. To meet the criteria for this disorder, patients must have experienced two gastrointestinal tract symptoms, one sexual symptom, and one pseudoneurologic symptom, none of which can be explainable by another medical diagnosis.

Answer 10
Although there is some evidence that CBT is helpful in treating patients with somatization disorder, these patients often are reluctant to undergo CBT. Reorienting them by suggesting that CBT may help them cope better by allowing them to live more productively with their symptoms can be helpful, particularly when patients trust that their physicians do not believe the problems to be in their heads.

Answer 10
Because recent results of exhaustive diagnostic tests have been negative, repeated testing is not indicated in this patient at this time. Venlafaxine and nortriptyline both inhibit uptake of norepinephrine; therefore, it is unlikely that switching from one agent to another with a similar mechanism of action will provide relief to this patient.

Question 11
A 54-year-old woman is evaluated for a 5-day history of sore throat, nonproductive cough, and low-grade fever. She has not had any contact with persons who are ill. She takes no prescription medications and has no drug allergies. The remainder of the medical history is noncontributory. On physical examination, the patient is not in any acute distress, and the temperature is 37.3 C (99.2 F). Pulmonary examination is normal. The oropharynx is erythematous without exudates. She has no cervical lymphadenopathy.

Which of the following is the most appropriate management of this patient? A) Oral amoxicillinclavulanate B) Oral penicillin C) Rapid streptococcal detection test D) Throat culture E) Symptomatic treatment

Which of the following is the most appropriate management of this patient?

E) Symptomatic treatment

Answer 11
Pharyngitis is one of the most common symptoms in adult primary care, but the prevalence of GABHS is only 5% to 15%. However, approximately 75% of adults presenting with pharyngitis receive a prescription for antibiotics, most targeting GABHS. Consequently, clinical-prediction rules have been developed to efficiently guide antibiotic treatment and testing for GABHS. The validated Centor prediction score assigns one point to each of four clinical findings: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, or absence of cough. The probability of GABHS in the original study of adults evaluated in an urban emergency room was 2.5% for a Centor score of 0, 6.5% for a score of 1, 15% for a score of 2, 32% for a score of 3, and 56% for a score of 4.

Answer 11
This patient is at very low risk for group A hemolytic streptococcus (GABHS) because her Centor score is 1 (based on the presence of a fever). Conservative management to reduce her symptoms is sufficient. Antibiotic treatment is recommended for patients with GABHS pharyngitis to prevent rheumatic fever, acute glomerulonephritis, and suppurative complications and to reduce contagion and symptom duration.

Answer 11
Although a narrow-spectrum antibiotic such as penicillin is more appropriate than a broad-spectrum antibiotic such as amoxicillinclavulanate for treating GABHS, empirical antibiotic therapy and further diagnostic testing (rapid streptococcal testing or throat culture) are inappropriate in this case because the probability of GABHS is so low.

Question 12
A 60-year-old man is evaluated for a 1-month history of bilateral lower-extremity pain. He describes the pain as an ache in both calves and upper legs that worsens after exercise and at night, but he denies predictable occurrence while active. His medical history includes hypercholesterolemia, hypertension, and osteoarthritis for which he takes fluvastatin, atenolol, and aspirin. His family history is negative for coronary artery disease. On physical examination, blood pressure is 140/85 mm Hg. Dorsalis pedis pulses and sensation to light touch bilaterally are normal. The remainder of the examination is unremarkable.

Laboratory Studies Serum creatinine kinase Serum total cholesterol Serum triglycerides Serum low-density lipoprotein cholesterol Normal 215 mg/dL (5.56 mmol/L) 300 mg/dL (3.39 mmol/L) 120 mg/dL (3.1 mmol/L)

Serum high-density lipoprotein cholesterol 35 mg/dL (0.91 mmol/L)

Which of the following is the most appropriate next step in the management of this patient? A) Cholestyramine B) Fibric acid derivative C) Further lifestyle changes D) Pentoxifylline E) Substitution of another statin for fluvastatin

Which of the following is the most appropriate next step in the management of this patient?

E) Substitution of another statin for fluvastatin

Answer 12
This patient is likely experiencing myalgias from fluvastatin, but he may not have the same problem with another statin or when taking fluvastatin at a lower dose. If the patient's muscle symptoms were tolerable, he would not need to change his medication. Because his symptoms are bothersome, it is advisable to discontinue the fluvastatin and, after he becomes completely asymptomatic, try another statin.

Answer 12
Common dose-related muscle symptoms that can occur with the use of statins include in 1% to 5% of cases focal or diffuse myalgia and creatine kinase (CK) elevations that are less than 10 times the upper limit of normal levels. Myopathy, indicated by a serum CK level more than 10 times the upper limit of normal, occurs in 0.1% to 0.5% of patients treated with statins in clinical trials. Some medications increase the risk of statin-associated myopathy, including fibrates, cyclosporine, macrolide antibiotics, various antifungal drugs, and cytochrome P-450 inhibitors. The Medical Letter consultants recommend measuring CK levels before starting a statin and again on development of muscle pain. However, other expert panels do not recommend this approach. In general, the statin should be discontinued if the CK value is more than 3 to 10 times the upper limit of the normal range.

Answer 12
Cholestyramine is not recommended in this patient because it might increase his serum triglyceride level, which is already elevated. Although a fibric acid derivative would lower his triglyceride level, the more important objective is to lower his serum low-density lipoprotein cholesterol level to reduce his risk for coronary artery disease. Pentoxifylline may help treat symptoms of vascular disease, but this patient's symptoms are not likely caused by vascular disease. He does not have exerciseinduced leg symptoms, and physical examination indicates normal peripheral pulses.