Back Pain Addiction

1
1

• Back Pain Addiction

2
SECTION ONE GENERAL TREATMENT APPROACHES TO LOW
BACK PAINYour patient with chronic back pain
returns for follow-up after having visited a
therapist who performed spinal manipulation. He
is happy with the result and asks about using
manipulation to prevent further pain episodes.
Which one of the following should you tell
him?  (check one) A. Evidence supports use of
spinal manipulation to prevent further episodes
of back pain.  B. Spinal manipulation is useful
for prevention only if performed by a
chiropractor.  C. Spinal manipulation is no more
effective than sham therapy and the benefit he
experienced is likely a placebo effect.  D.
Evidence does not support using spinal
manipulation to prevent exacerbations.  E.
Evidence supports prevention, but spinal
manipulation is not as effective as massage. 
3
Answer

•  D. Evidence does not support using spinal
  manipulation to prevent exacerbations. 
• Evidence does not support using spinal
  manipulation to prevent acute exacerbations in
  the setting of chronic back pain. See page 13.

4
SECTION ONE GENERAL TREATMENT APPROACHES TO LOW
BACK PAINWhich one of the following is the role
of exercise for patients with back pain?  (check
one) A. Improves overall fitness but has no
effect on back pain.  B. Reduces pain and
improves function in adults with chronic back
pain.  C. Reduces pain and improves function in
adults with acute back pain.  D. Exacerbates
pain in patients with back pain, so it should be
minimized.  E. Increases pain but improves
function in patients with acute and chronic back
pain. 
5
Answer

•  B. Reduces pain and improves function in adults
  with chronic back pain. 
• A Cochrane review concluded that exercise can
  reduce pain and improve function in adults with
  chronic back pain and is as effective as either
  no treatment or other conservative treatments for
  acute low back pain. See pages 13-14 and Table 1.

6
SECTION ONE GENERAL TREATMENT APPROACHES TO LOW
BACK PAINYour patient who works as a baker is
experiencing continued back pain since lifting a
heavy sack of flour 2 weeks ago. She finds
exercise too painful and asks about acupuncture
treatment recommended by a friend. Which one of
the following is true of acupuncture for this
patient?  (check one) A. It is not effective
for acute episodes of back pain.  B. It might be
effective but is associated with high rates of
adverse events.  C. It is not effective for any
type of back pain.  D. It is more effective than
sham acupuncture for chronic back pain.  E. It
has been proven to be effective for acute back
pain. 
7
Answer

•  A. It is not effective for acute episodes of
  back pain. 
• Although not shown to be effective in acute back
  pain, acupuncture appears to be an option for
  chronic back pain. See page 15.

8
SECTION ONE GENERAL TREATMENT APPROACHES TO LOW
BACK PAINYour patient who is a factory worker
e-mails you asking whether he should use a back
brace to prevent back pain. He has intermittent
episodes of low back pain and his employer has
encouraged him to use a brace. What advice should
you offer?  (check one) A. A back brace can
effectively prevent episodes of pain.  B. A back
brace may be effective for prevention but should
be professionally fitted.  C. Back braces only
show benefit for short-term pain reduction during
an episode of pain.  D. A back brace will be
effective in prevention and in managing painful
episodes.  E. Back braces are not effective for
pain prevention in patients with low back pain. 
9
Answer

• E. Back braces are not effective for pain
  prevention in patients with low back pain. 
• There is moderate evidence against use of bracing
  devices for preventing pain among patients with
  low back pain. See page 15.

10
SECTION ONE GENERAL TREATMENT APPROACHES TO LOW
BACK PAINWhich one of the following is a
conclusion of the American Society of
Interventional Pain Physicians regarding use of
opioids to treat chronic back pain?   (check
one) A. Opioid therapy is safe and effective
long term for most patients with chronic back
pain.  B. Opioid therapy should be provided with
caution and evidence is variable on the
effectiveness of long-term use.  C. If providing
opioid therapy, the strongest evidence supports
use of hydrocodone.  D. Family physicians who
use opioid therapy for patients with chronic back
pain can follow evidence-based guidelines to
select appropriate patients for therapy.  E.
Opioid drug use to treat chronic pain has
decreased in the past 10 years. 
11
Answer

•  B. Opioid therapy should be provided with
  caution and evidence is variable on the
  effectiveness of long-term use.
• Based on best evidence, the American Society of
  Interventional Pain Physicians stated that opioid
  therapy should be provided with caution and that
  evidence is variable on the effectiveness of
  long-term (6 months or more) opioid use in
  reducing pain and improving functional
  status. See page 16.

12
SECTION TWO ACUTE LUMBAR DISK PAINYour patient
returns for follow-up for persistent sciatica. He
underwent magnetic resonance imaging study last
week and the results indicate a lumbar disk
herniation. Which one of the following is true of
the association between disk herniation and
sciatica?  (check one) A. Most patients with
acute sciatica will have disk herniation on
imaging.  B. It is rare to find disk herniation
in an asymptomatic patient.  C. Most disk
herniations occur in patients older than 60 years
with sciatica.  D. Sciatica is more likely to be
due to a disk herniation if pain is worse in the
leg than in the back.  E. None of the above. 
13
Answer

•  D. Sciatica is more likely to be due to a disk
  herniation if pain is worse in the leg than in
  the back. 
• Three symptoms increase the specificity that the
  cause of the sciatica is from a lumbar disk
  herniation pain is worse in the leg as opposed
  to the back, neurologic symptoms (eg,
  paresthesias, numbness) follow a typical
  dermatome distribution, and pain worsens with the
  Valsalva maneuver. See page 17.

14
SECTION TWO ACUTE LUMBAR DISK PAINWhich one of
the following symptoms should trigger a clinician
to consider emergent/early referral for imaging
in a patient with sciatica?  (check one) A.
Pain for more than 2 weeks.  B. Bowel or bladder
dysfunction (ie, suspected cauda equina
syndrome).  C. Pain and numbness in the
foot.  D. New-onset pain with a history of
cancer.  E. Both B and D. 
15
Answer

•  E. Both B and D. 
• If cauda equina syndrome is suspected, emergent
  magnetic resonance imaging study should be
  performed with immediate surgical referral.
  Immediate erythrocyte sedimentation rate and
  x-ray should be obtained if major cancer risk
  (new-onset pain with history of cancer, multiple
  risk factors for cancer, or strong clinical
  suspicion of cancer) are present. See page 19 and
  Table 2.

16
SECTION TWO ACUTE LUMBAR DISK PAINWhile
pursuing a course of watchful waiting, your
patient with subacute sciatica telephones asking
for treatment for pain. She has heard about an
injection that might help. Which one of the
following should you tell her about epidural
steroid injection?  (check one) A. It may
improve short-term pain but not long-term
pain.  B. It may improve function and decrease
need for surgery.  C. Intradiscal steroid
injection may improve short-term pain.  D.
Intradiscal steroid injection may improve
function and decrease need for surgery.  E. It
is not associated with any benefit. 
17
Answer

• A. It may improve short-term pain but not
  long-term pain. 
• Epidural steroid injections may improve pain in
  the short term (less than 6 weeks) but they do
  not influence long-term pain relief, average
  impairment of function, or the need for
  surgery. See page 19.

18
SECTION TWO ACUTE LUMBAR DISK PAINYour patient
with sciatica for the past 4 weeks telephones to
ask about a referral to physical therapy (PT).
Which one of the following is true of formal PT
for sciatica?  (check one) A. It is effective
during acute episodes of sciatica.  B. It is
more effective than conservative care.  C. It is
more effective than manipulation.  D. It has not
been proven effective.  E. It increases pain and
delays healing during acute episodes of
sciatica. 
19
Answer

•  D. It has not been proven effective.
• Formal physical therapy programs directed by a
  physical therapist have not been proven effective
  for sciatica, and are no more cost-effective than
  conservative care without physical therapy. See
  page 19.

20
SECTION TWO ACUTE LUMBAR DISK PAINYour patient
with severe sciatica has not benefited from 6
weeks of conservative management and wants to
discuss surgical treatment options. He does not
have severe or progressive neuromotor deficits,
or cauda equina syndrome. Which one of the
following should you tell him about surgery for
sciatica?  (check one) A. He should consider
surgery now because over time the condition is
unlikely to improve without it.  B. Early
surgery is likely to improve his disability
scores and level of recovery at 1 year.  C.
Early surgery is likely to provide faster pain
relief and result in less disability at 1
year.  D. He should not pursue surgery because
it is too dangerous.  E. Early surgery has
potential for earlier relief but has similar
outcomes compared with nonsurgical treatment. 
21
Answer

•  E. Early surgery has potential for earlier
  relief but has similar outcomes compared with
  nonsurgical treatment. 
• For most patients with persistent sciatica, a
  discussion about surgical and nonsurgical
  treatment should include the severity of
  symptoms, the potential for earlier relief but
  similar long-term outcomes, patient aversion to
  surgical risks, and patient willingness to wait
  for spontaneous healing. See page 20.

22
SECTION THREE LUMBAR SPINAL STENOSISYour
78-year-old patient with intermittent back pain
presents with a worsening episode of back pain,
this time associated with bilateral burning leg
pain. You suspect lumbar spinal stenosis. Which
one of the following signs or symptoms, if
present, would most increase your suspicion of
this diagnosis?   (check one) A. Wide-based
gait.  B. Vibration deficit.  C. Pinprick
deficit.  D. Numbness in the lower
extremities.  E. Abnormal Romberg test result. 
23
Answer

•  A. Wide-based gait.
• Certain aspects of the history and physical
  examination can be used to support a diagnosis of
  lumbar spinal stenosis. The most suggestive
  features are a wide-based gait and absence of
  pain while seated. See page 21 and Table 3.

24
SECTION THREE LUMBAR SPINAL STENOSISA
68-year-old man presents with difficulty walking
as well as burning pain in the buttocks and
associated lower extremity numbness. To confirm
the diagnosis of lumbar spinal stenosis (LSS),
you consider obtaining x-rays of the lumbar
spine. Which one of the following describes the
role of x-rays in the diagnosis of LSS?  (check
one) A. They are useful for confirming the
diagnosis of LSS.  B. They are useful for
excluding diagnoses such as degenerative joint
disease.  C. They have no role in the evaluation
of LSS.  D. They are routinely recommended
before additional testing.  E. They are
recommended for medicolegal reasons. 
25
Answer

• B. They are useful for excluding diagnoses such
  as degenerative joint disease. 
• Although it might be reasonable to obtain an
  x-ray to exclude conditions in the differential
  diagnosis of lumbar spinal stenosis (eg,
  compression fractures, severe degenerative joint
  disease), in general, x-rays are not useful. See
  page 21.

26
Answer

•  B. They are useful for excluding diagnoses such
  as degenerative joint disease. 
• Although it might be reasonable to obtain an
  x-ray to exclude conditions in the differential
  diagnosis of lumbar spinal stenosis (eg,
  compression fractures, severe degenerative joint
  disease), in general, x-rays are not useful. See
  page 21.

27
SECTION THREE LUMBAR SPINAL STENOSISBased on
North American Spine Society recommendations,
which one of the following is the most
appropriate noninvasive test for imaging of
degenerative lumbar spinal stenosis?  (check
one) A. Computed tomography (CT) scan.  B.
Magnetic resonance imaging (MRI) study.  C.
X-ray.  D. Electromyogram.  E. Combination CT
scan and MRI study. 
28
Answer

•  B. Magnetic resonance imaging (MRI) study.
• The North American Spine Society recommends
  magnetic resonance imaging study as the most
  appropriate noninvasive test for imaging
  degenerative lumbar spinal stenosis. See page 21.

29
SECTION THREE LUMBAR SPINAL STENOSISYour
patient with lumbar spinal stenosis returns for
follow-up after no benefit from 1 month of
conservative treatment. He wishes to discuss
surgery. The patient is worried about surgical
risks but wants to know if he should go for
surgery and if there are risks in delaying
surgery to try alternative treatment. Which one
of the following should you advise?  (check
one) A. Early surgery is likely to improve
long-term outcomes.  B. Delaying surgery is
likely dangerous.  C. Early surgery may result
in early benefit, but delaying surgery is not
harmful.  D. Almost all patients do well with
medical treatment and few require surgery.  E.
Results of surgery are uniformly good, regardless
of when it is performed. 
30
Answer

•  C. Early surgery may result in early benefit,
  but delaying surgery is not harmful. 
• In cases of lumbar spinal stenosis, patients may
  achieve greater early benefit from surgery, but
  results are not uniformly good and delaying
  surgical treatment is unlikely to result in
  neurologic deterioration. See page 23.

31
SECTION THREE LUMBAR SPINAL STENOSISYour
patient is waiting for a surgical consultation
for lumbar spinal stenosis and asks about an
epidural steroid injection. Which one of the
following should you tell her?  (check one) A.
It is no more effective than sham injection.  B.
It is likely to provide long-term relief.  C. It
can be recommended based on strong evidence.  D.
It may provide short-term symptom relief.  E. It
is not effective for patients with mechanical
spinal nerve root compression. 
32
Answer

•  D. It may provide short-term symptom relief. 
• Steroid injections appear to provide short-term
  symptom relief, especially if there is a
  radiculopathy, for lumbar spinal stenosis. See
  page 23.

33
SECTION FOUR OSTEOPOROTIC VERTEBRAL
FRACTURESWhich one of the following describes
the current recommendations from the US
Preventive Services Task Force for osteoporosis
screening?  (check one) A. Screen all women
older than 50 years with dual-energy x-ray
absorptiometry (DXA).  B. The evidence is
insufficient to recommend screening.  C. Screen
only women with risk factors with DXA.  D.
Screen only women older than 65 years with
DXA.  E. Screen women 65 years and older and
younger women with risk factors. 
34
Answer

•  E. Screen women 65 years and older and younger
  women with risk factors. 
• Because screening for osteoporosis and preventive
  treatment may have a positive effect on fracture
  prevention, the US Preventive Services Task
  Force, the National Osteoporosis Foundation, and
  the American College of Obstetricians and
  Gynecologists recommend dual-energy x-ray
  absorptiometry screening for osteoporosis among
  women 65 years or older and for younger women
  with risk factors. See page 24.

35
SECTION FOUR OSTEOPOROTIC VERTEBRAL
FRACTURESYour patient presents after onset of
acute upper back pain. An x-ray shows a vertebral
compression fracture. Which one of the following
characteristics would help to confirm that this
is likely a recent fracture?   (check one) A.
Pain with forward flexion.  B. Pain with
extension.  C. Pain with side bending.  D. Pain
on percussion of the spine.  E. Pain when
sitting. 
36
Answer

•  D. Pain on percussion of the spine.
• Two characteristics that might help determine
  whether a fracture is old or new are pain on
  percussion of the spine (closed-fist percussion
  sign sensitivity 87.5, specificity 90,
  positive likelihood ratio LR 8.7, negative LR
  0.14) and inability to lie supine on a couch
  (sensitivity 81, specificity 93, positive
  LR 11.6, negative LR 0.20). See page 24. 

37
SECTION FOUR OSTEOPOROTIC VERTEBRAL FRACTURESA
74-year-old woman with upper back pain returns
for follow-up reporting continued pain despite
rest and acetaminophen. Neurologic examination
results are normal. You suspect an osteoporotic
compression fracture of the vertebra. Which one
of the following would you do to confirm the
diagnosis, based on the American College of
Radiology Appropriateness Criteria
guideline?  (check one) A. No further testing
is needed initiate treatment for
osteoporosis.  B. Obtain x-ray.  C. Obtain
x-ray and dual-energy x-ray absorptiometry
(DXA).  D. Obtain x-ray and consider computed
tomography scan and DXA.  E. Obtain magnetic
resonance imaging study. 
38
Answer

•  C. Obtain x-ray and dual-energy x-ray
  absorptiometry (DXA). 
• The American College of Radiology Appropriateness
  Criteria guideline recommends dual-energy x-ray
  absorptiometry and a spine x-ray for diagnosis of
  a suspected osteoporotic vertebral fracture in a
  patient with a clinical history, height loss, or
  steroid use. See page 24.

39
SECTION FOUR OSTEOPOROTIC VERTEBRAL
FRACTURESThe US Preventive Services Task Force
has found sufficient evidence that drug therapies
reduce facture risk in postmenopausal women with
osteoporosis detected on screening. Which one of
the following treatments, in addition to calcium
and vitamin D, would you consider for a woman
with osteoporosis but no fracture who is recently
menopausal?   (check one) A. Calcitonin.  B.
Hormone therapy.  C. A bisphosphonate.  D.
Denosumab.  E. B or C. 
40
Answer

•  E. B or C. 
• Estrogen/hormone therapy is approved for
  osteoporosis and fracture prevention as well as
  relief of menopause-associated vasomotor symptoms
  and vulvovaginal atrophy. Bisphosphonates have
  been shown to significantly reduce the incidence
  of new vertebral fractures. See page 27.

41
SECTION FOUR OSTEOPOROTIC VERTEBRAL
FRACTURESYour patient with a painful vertebral
compression fracture that occurred 2 weeks ago
has persistent severe pain despite use of oral
pain drugs and calcitonin. She asks about
surgery. Which one of the following should you
tell her about vertebroplasty?  (check one) A.
It is clearly of benefit for pain relief and
long-term function.  B. It is controversial,
with 2 trials showing no differences in
effectiveness of vertebroplasty and sham
control.  C. It is not of benefit, according to
all recent studies.  D. It is more effective
than kyphoplasty.  E. None of the above.
42
Answer

•  B. It is controversial, with 2 trials showing no
  differences in effectiveness of vertebroplasty
  and sham control. 
• In 2009, the use of this procedure was questioned
  when 2 randomized controlled trials using sham
  control groups showed no differences between
  treated and untreated patients. These studies
  sparked controversy regarding the efficacy of
  vertebroplasty and drew national media
  attention. See page 30

43
SECTION ONE ALCOHOL USE DISORDERSWhich one of
the following is most sensitive for detecting
alcohol use disorders?  (check one) A.
Carbohydrate-deficient transferrin.  B. Elevated
gamma-glutamyl transferase.  C. Macrocytosis on
hemogram.  D. Screening questionnaires. 
44
Answer

• D. Screening questionnaires. 

45
SECTION ONE ALCOHOL USE DISORDERSWhich one of
the following counts as 1 standard drink of
alcohol?  (check one) A. 12-oz bottle of malt
liquor.  B. 12-oz bottle of regular beer.  C. 2
shots of hard liquor.  D. 8-oz glass of wine. 
46
Answer

•  B. 12-oz bottle of regular beer. 

47
SECTION ONE ALCOHOL USE DISORDERSYou are
treating a patient for alcohol withdrawal. The
symptoms are severe enough to warrant
pharmacotherapy. The patient has been drinking
for years and has moderately impaired liver
function. Which one of the following drugs would
be preferred for this patient?  (check one) A.
Chlordiazepoxide.  B. Diazepam.  C.
Oxazepam.  D. Valproic acid.
48
Answer

•  C. Oxazepam. 
• Benzodiazepines are the first-line drugs for
  alcohol withdrawal for inpatient and outpatient
  treatment. Short-acting benzodiazepines (eg,
  lorazepam, oxazepam) are preferred in elderly
  patients or in patients with impaired liver
  function. See page 17.

49
SECTION ONE ALCOHOL USE DISORDERSWhich one of
the following statements is correct about
naltrexone for treatment of alcohol
dependence?   (check one) A. It is
contraindicated in patients with markedly
elevated liver function test results.  B. It
must be administered by injection.  C. The Food
and Drug Administration has not approved
naltrexone for treatment of alcohol
dependence.  D. The patient must stop drinking
before naltrexone can be started.
50
Answer

•  A. It is contraindicated in patients with
  markedly elevated liver function test results. 
• Naltrexone is contraindicated in patients with
  active liver disease, when liver function test
  results are greater than 3 times the upper limit
  of normal, and in patients requiring opioids. See
  page 18.

51
SECTION TWO PRESCRIPTIONSTIMULANT AND
METHAMPHETAMINE USE DISORDERSWhich one of the
following statements is correct about use of
prescription stimulants by undergraduate college
students?  (check one) A. More students have
reported nonmedical use than students reporting
medical use.  B. The leading source of illicit
stimulants is forged prescriptions.  C. The
majority of college students report nonmedical
use of stimulants at least once.  D. Use is
highest on the East Coast of the United States. 
52
Answer

•  A. More students have reported nonmedical use
  than students reporting medical use. 
• In an online survey of 9,161 undergraduate
  students at a Midwestern university, more
  students reported illicit use of prescription
  stimulants than students who reported medical use
  for attention-deficit/hyperactivity disorder. See
  page 21.

53
SECTION TWO PRESCRIPTIONSTIMULANT AND
METHAMPHETAMINE USE DISORDERSWhich one of the
following is a nonstimulant drug approved by the
Food and Drug Administration for treatment of
attention-deficit/hyperactivity disorder?  (check
one) A. Atomoxetine.  B. Methylphenidate.  C.
Dexmethylphenidate.  D. Bupropion. 
54
Answer

•  A. Atomoxetine. 

55
Answer

•  A. Atomoxetine. 
• Drugs for attention-deficit/hyperactivity
  disorder (ADHD) treatment that have lower abuse
  potential include nonstimulant drugs such as
  atomoxetine, bupropion, guanfacine, and
  clonidine. Atomoxetine and extended-release
  formulations of guanfacine and clonidine are Food
  and Drug Administration-approved for ADHD
  treatment, but bupropion is not. See page 22.

56
SECTION TWO PRESCRIPTIONSTIMULANT AND
METHAMPHETAMINE USE DISORDERSYour patient, a
long-term user of methamphetamine, presents to
your office seeking treatment for substance
abuse. Which one of the following statements is
correct about Food and Drug Administration
(FDA)-approved drugs for amphetamine
dependence?  (check one) A. Aripiprazole is
FDA-approved for treatment of amphetamine
dependence.  B. Modafinil is FDA-approved for
treatment of amphetamine dependence.  C.
Selective serotonin reuptake inhibitors are
FDA-approved for treatment of amphetamine
dependence.  D. Tricyclic antidepressants are
FDA-approved for treatment of amphetamine
dependence.  E. There are currently no drugs
approved by the FDA for treatment of amphetamine
dependence. 
57
Answer

•  E. There are currently no drugs approved by the
  FDA for treatment of amphetamine dependence. 
• . There are currently no drugs approved by the
  FDA for treatment of amphetamine dependence. 

58
SECTION THREE PRESCRIPTION OPIOID USE
DISORDERSWhich one of the following is the role
of urine drug screens when caring for a patient
who receives long-term opioid therapy for chronic
nonmalignant pain?  (check one) A. Routine
urine drug tests will detect all Food and Drug
Administration-approved opioids.  B. They are
not indicated if there is a good
patient-physician relationship.  C. They should
be performed at every visit if feasible, or
randomly.  D. Although many physicians perform
them, they are not recommended in the Federation
of State Medical Boards policy statement on
long-term opioid therapy.
59
Answer

•  C. They should be performed at every visit if
  feasible, or randomly. 
• If drug testing is not feasible at every patient
  visit, random drug testing can still be of
  benefit. See page 29.

60
FP Essentials - 383 - Connective Tissue
DiseasesQuestion 2 of 20Which statement is
correct regarding anticyclic citrullinated
peptide antibody testing in the evaluation of
patients with suspected rheumatoid arthritis
(RA)?   (check one) A. If results are positive,
it typically means the patient will have less
severe RA.  B. If results are negative, it
increases the likelihood that the patient does
not have RA.  C. The test has no value in the
evaluation of patients with suspected RA.  D.
The test results are typically positive later in
the course of RA. 
61
Answer

•  B. If results are negative, it increases the
  likelihood that the patient does not have RA.
• Anticyclic citrullinated peptide antibodies have
  similar sensitivity but higher specificity than
  rheumatoid factor in diagnosis of rheumatoid
  arthritis. See page 17 and Table 3.

62
A patient being evaluated for symptoms of a
connective tissue disease has a positive
anti-Smith antibody test result. Which one of
the following is the most likely diagnosis?
  (check one) A. Systemic lupus
erythematosus.  B. Polymyositis.  C.
Scleroderma.  D. Sjögren syndrome.
63
Answer

• A. Systemic lupus erythematosus. 
• The only highly specific tests for connective
  tissue disease detection are anti-double-stranded
  DNA (anti-dsDNA) and anti-Smith (anti-Sm)
  antibody, which are specific for systemic lupus
  erythematosus (SLE), and antiproteinase 3, which
  is specific for Wegener granulomatosis. Anti-Sm
  antibodies are present in approximately 40 of
  patients with SLE. But when present, anti-Sm
  antibodies are similar to anti-dsDNA antibodies
  in that they are highly specific for SLE. See
  pages 14, 18, and Table 3.

64
Your 76-year-old patient presented to the
emergency department, reporting axial pain,
stiffness, and weakness that has been present for
weeks. The emergency department physician
prescribed steroids. By the time the patient
visits your office 3 days later, the symptoms
have completely resolved. Which one of the
following is the likely diagnosis?  (check
one) A. Ankylosing spondylitis.  B.
Polymyalgia rheumatica.  C. Polymyositis.  D.
Vertebral rheumatoid arthritis.
65
Answer

• B. Polymyalgia rheumatica. 
• In polymyalgia rheumatica, an elderly patient
  with symptoms of axial pain, stiffness, or
  subjective weakness might experience complete
  symptom resolution within a few days of beginning
  daily therapy with 15 mg of prednisone, thus
  confirming the diagnosis. See page 20.

66
SLOWING GLOBAL WARMING BENEFITS FOR PATIENTS AND
THE PLANETWhich one of the following is a
recommendation that would mutually benefit
cardiovascular health and climate change?  (check
one) A. The target level of daily meat
consumption should be 12 oz.  B. Meat intake
should remain at current average levels of
consumption.  C. Average daily meat consumption
should decrease to 3 oz, and less than one-half
of that should be red meat.  D. The target level
of daily meat consumption should be 8
oz. Correct.
67
Answer

•  C. Average daily meat consumption should
  decrease to 3 oz, and less than one-half of that
  should be red meat. 

68
SLOWING GLOBAL WARMING BENEFITS FOR PATIENTS AND
THE PLANETWhich of the following health
conditions are likely to increase with expected
climate change?  (check all that apply) A.
Mental illness related to extreme weather
events.  B. Allergies.  C. Asthma.  D.
Vector-borne disease. 
69
Answer

•  A. Mental illness related to extreme weather
  events.  B. Allergies.  C. Asthma.  D.
  Vector-borne disease. 

70
Clinical recommendationEvidence ratingReferences

• Physicians should advise patients to reduce their
  dietary meat consumption, especially red meat, to
  improve individual health.
• C
• Physicians should advise patients to reduce their
  dietary meat consumption, especially red meat, to
  help reduce greenhouse gas emissions and improve
  public health.
• C
• Physicians should recommend that patients use
  more active transportation methods, such as
  walking and bicycling, to improve individual
  health.
• C
• Physicians should recommend that patients use
  more active transportation methods, such as
  walking and bicycling, to help reduce greenhouse
  gas emissions and improve public health.
• C

71
TREATMENT OF NONGENITAL CUTANEOUS WARTSWhich one
of the following statements about cryotherapy for
the treatment of cutaneous warts is
correct?  (check one) A. It is more effective
than salicylic acid.  B. It should not be used
for more than three months.  C. It should clear
hand warts with two freeze-thaw cycles.  D. It
requires more applications than salicylic acid. 
72
Answer

• B. It should not be used for more than three
  months

73
Nongenatial Warts

• Numerous treatments for nongenital cutaneous
  warts are available, although no single therapy
  has been established as completely curative.
• Watchful waiting is an option for new warts
  because many resolve spontaneously.
• However, patients often request treatment because
  of social stigma or discomfort.
• Ideally, treatment should be simple and
  inexpensive with low risk of adverse effects.
• Salicylic acid has the best evidence to support
  its effectiveness, but it is slow to work and
  requires frequent application for up to 12 weeks.
  
• Cryotherapy with liquid nitrogen is a favorable
  option for many patients, with cure rates of 50
  to 70 percent after three or four treatments.
• For recalcitrant warts, Candida or mumps skin
  antigen can be injected into the wart every three
  to four weeks for up to three treatments.
• More expensive treatments for recalcitrant warts
  are offered in many dermatology offices.
• Photodynamic therapy with aminolevulinic acid has
  the best evidence of effectiveness compared with
  pulsed dye laser, intralesional bleomycin, and
  surgical removal using curettage or cautery.

74
Nongenatial Warts

• Salicylic acid and cryotherapy with liquid
  nitrogen are first-line treatments for cutaneous
  warts.
• A
• Aggressive cryotherapy (10 to 30 seconds) is more
  effective than less aggressive cryotherapy.
• B
• Best results of cryotherapy can be achieved when
  the patient is treated every two or three weeks.
  There is no therapeutic benefit beyond three
  months.
• B
• When using cryotherapy for plantar warts, paring
  the wart before treatment can increase the
  clearance rate.
• B
• Intralesional injection with Candida or mumps
  skin antigen has moderate effectiveness for
  treatment of recalcitrant warts in patients with
  a positive skin antigen pretest.
• B
• Photodynamic therapy with aminolevulinic acid
  plus topical salicylic acid is a moderately
  effective option for treatment of recalcitrant
  warts.
• B
• Although preliminary studies were promising, duct
  tape is not effective for wart treatment.
• B
• Pulsed dye laser or intralesional injection with
  bleomycin can be considered for treatment of
  recalcitrant warts, although the effectiveness is
  unproven.
• B

75
TREATMENT OF NONGENITAL CUTANEOUS WARTSWhich one
of the following treatments for cutaneous warts
is usually administered by a dermatologist?  (chec
k one) A. Salicylic acid.  B.
Cryotherapy.  C. Photodynamic therapy.  D.
Topical fluorouracil. 
76
Answer

•  C. Photodynamic therapy.

77
TREATMENT OF NONGENITAL CUTANEOUS WARTSWhich of
the following statements about treatment of
asymptomatic warts are correct?  (check all that
apply) A. Paring plantar warts before
cryotherapy may be beneficial.  B. Pulsed dye
laser is the treatment of choice for plantar
warts.  C. Combining salicylic acid with
cryotherapy may be more effective than using
either treatment alone.  D. Watchful waiting is
reasonable for new warts. 
78
Answer

•  A. Paring plantar warts before cryotherapy may
  be beneficial.  C. Combining salicylic acid with
  cryotherapy may be more effective than using
  either treatment alone.  D. Watchful waiting is
  reasonable for new warts. 

79
DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN
ADULTSWhich one of the following is considered a
risk factor for constipation?  (check one) A.
Male sex.  B. High caloric intake.  C. Use of a
large number of medications.  D. High
educational level. 
80
Answer

•  C. Use of a large number of medications. 

81
DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN
ADULTSWhich one of the following statements
about the initial diagnostic evaluation of
patients with chronic constipation is
correct?  (check one) A. All patients should
have their thyroid-stimulating hormone level
measured.  B. Patients with alarm signs or
symptoms should undergo endoscopy to rule out
serious secondary causes of constipation.  C.
Patients with alarm signs or symptoms should
undergo abdominal computed tomography to rule out
malignancy.  D. All patients should undergo
manometric testing of pelvic floor function.
82
Answer

•  B. Patients with alarm signs or symptoms should
  undergo endoscopy to rule out serious secondary
  causes of constipation.

83
DIAGNOSTIC APPROACH TO CHRONIC CONSTIPATION IN
ADULTSWhich of the following statements about
slow transit constipation are correct?  (check
all that apply) A. Symptoms include an
infrequent call to stool, bloating, and
abdominal discomfort.  B. Prolonged colonic
transit time can be confirmed with radiopaque
markers that are delayed on motility study.  C.
Prolonged colonic transit time is defined as four
or more markers visible on a plain abdominal
radiograph taken 120 hours after ingesting one
Sitzmarks capsule.  D. Treatment with fiber
supplementation or laxatives is ineffective in
patients with severe slow transit constipation. 
84
Answer

•  A. Symptoms include an infrequent call to
  stool, bloating, and abdominal discomfort.  B.
  Prolonged colonic transit time can be confirmed
  with radiopaque markers that are delayed on
  motility study.  D. Treatment with fiber
  supplementation or laxatives is ineffective in
  patients with severe slow transit constipation.

85
Constipation

• A history and physical examination should be
  performed in patients with constipation to
  identify alarm signs or symptoms.
• C
• Routine use of blood tests, radiography, or
  endoscopy in patients with constipation who do
  not have alarm signs or symptoms is not
  recommended.
• C
• Patients with alarm signs or symptoms should
  undergo endoscopy to rule out malignancy.
• C
• The initial management of noncomplicated
  constipation should include a high-fiber diet,
  increased water intake, and exercise.
• B
• Biofeedback is recommended for treating symptoms
  of pelvic floor dysfunction.
• B

86
COCHRANE FOR CLINICIANS PUTTING EVIDENCE INTO
PRACTICESELF-MONITORING AND SELF-MANAGEMENT OF
ANTICOAGULATION THERAPYCompared with standard
care, self-monitoring of anticoagulation therapy
reduces the incidence of which of the following
outcomes?  (check all that apply) A.
Thromboembolism.  B. Minor hemorrhage.  C.
Major hemorrhage.  D. All-cause mortality.
87
Answer

•  A. Thromboembolism.  B. Minor hemorrhage.  C.
  Major hemorrhage.  D. All-cause mortality. 

88
GERIATRIC ASSISTIVE DEVICESA front-wheeled
walker has which one of the following advantages
over other walkers?  (check one) A. It is
lifted with each step.  B. It is the most stable
type of walker.  C. It has a small turning
arc.  D. It helps maintain a normal gait
pattern.
89
Answer

•  D. It helps maintain a normal gait pattern. 

90
GERIATRIC ASSISTIVE DEVICESCorrect use of a cane
involves which one of the following?  (check
one) A. With the patient standing upright with
arms relaxed at his or her sides, the handle
should be at the level of the patients elbow
crease.  B. A cane should be held contralateral
to a weak or painful lower extremity.  C. A cane
should be advanced alternating with movement of
the affected leg.  D. Patients should advance
the unimpaired extremity first when going down
stairs.
91
Answer

•  B. A cane should be held contralateral to a weak
  or painful lower extremity. 

92
GERIATRIC ASSISTIVE DEVICESWhich of the
following caveats should be considered when
recommending assistive devices?  (check all that
apply) A. They may cause osteoarthritis and
other musculoskeletal conditions.  B. They can
be destabilizing.  C. They have been associated
with worsening osteoporosis.  D. They may worsen
cardiorespiratory function. 
93
Answer

•  A. They may cause osteoarthritis and other
  musculoskeletal conditions.  B. They can be
  destabilizing.

94
Assistive Devices

• Assistive devices can be prescribed to
  improve balance, reduce pain, and increase
  mobility and confidence.
• C
• Because most patients obtain their assistive
  device without recommendations or instructions
  from a medical professional, assistive devices
  should be evaluated routinely for proper fit and
  use.
• C
• When only one upper extremity is needed for
  balance or weight bearing, a cane is preferred.
  If both upper extremities are needed, crutches or
  a walker is more appropriate.
• C
• The correct height of a cane or walker is at the
  level of the patient's wrist crease, as measured
  with the patient standing upright with arms
  relaxed at his or her sides. When holding the
  device at this height, the patient's elbow is
  naturally flexed at a 15- to 30-degree angle.
• C

95
Assistive devices

• Disability and mobility problems increase with
  age.
• Assistive devices such as canes, crutches, and
  walkers can be used to increase a patient's base
  of support, improve balance, and increase
  activity and independence, but they are not
  without significant musculoskeletal and metabolic
  demands.
• Most patients with assistive devices have never
  been instructed on the proper use and often have
  devices that are inappropriate, damaged, or are
  of the incorrect height.
• Selection of a suitable device depends on the
  patient's strength, endurance, balance, cognitive
  function, and environmental demands.
• Canes can help redistribute weight from a lower
  extremity that is weak or painful, improve
  stability by increasing the base of support, and
  provide tactile information about the ground to
  improve balance.
• Crutches are useful for patients who need to use
  their arms for weight bearing and propulsion and
  not just for balance.
• Walkers improve stability in those with lower
  extremity weakness or poor balance and facilitate
  improved mobility by increasing the patient's
  base of support and supporting the patient's
  weight.
• Walkers require greater attentional demands than
  canes and make using stairs difficult.
• The top of a cane or walker should be the same
  height as the wrist crease when the patient is
  standing upright with arms relaxed at his or her
  sides.
• A cane should be held contralateral to a weak or
  painful lower extremity and advanced
  simultaneously with the contralateral leg.
• Clinicians should routinely evaluate their
  patients' assistive devices to ensure proper
  height, fit, and maintenance, and also counsel
  patients on correct use of the device.

96
TREATMENT OPTIONS FOR LOCALIZED PROSTATE CANCERA
74-year-old man in the bottom quartile of health
has stage T2a prostate cancer with a Gleason
score of 6. His prostate-specific antigen (PSA)
level is 9 ng per mL (9 mcg per L). Which one of
the following treatment options would best align
with the recommendations of the National
Comprehensive Cancer Network?  (check one) A.
Active surveillance.  B. Surgery.  C. External
beam radiation therapy.  D. Brachytherapy.
97
Answer

• A. Active surveillance. 

98
TREATMENT OPTIONS FOR LOCALIZED PROSTATE
CANCERWhich of the following is part of the
Canadian protocol for active surveillance of
prostate cancer?  (check all that apply) A. PSA
testing and digital rectal examination every
three months for two years.  B. 10 to 12 core
biopsies one year after diagnosis, then every
three years until 80 years of age.  C.
Intervention if the PSA doubles in less than
three years.  D. Intervention for progression to
a Gleason score of 7 (43) or higher. 
99
Answer

•  A. PSA testing and digital rectal examination
  every three months for two years.  B. 10 to 12
  core biopsies one year after diagnosis, then
  every three years until 80 years of age.  C.
  Intervention if the PSA doubles in less than
  three years.  D. Intervention for progression to
  a Gleason score of 7 (43) or higher. 

100
Treatment for localized prostate cancer should be
recommended for higher-risk patients. Risk can be
estimated by using an index of cancer stage and
grade, prostate-specific antigen level, and
comorbidity-adjusted life expectancy.BPatients
can be counseled that surgery and external beam
radiation therapy are almost equally effective in
treating prostate cancer.BBrachytherapy is an
option for monotherapy in low-risk
patients.BActive surveillance is a reasonable
option for low-risk and very low-risk patients.B
101
EXERCISE-INDUCED BRONCHOCONSTRICTION DIAGNOSIS
AND MANAGEMENTA 21-year-old college basketball
player presents with symptoms suggestive of
exercise-induced bronchoconstriction (EIB). After
performing a workup, you confirm a diagnosis of
EIB and discuss treatment options with her. She
is concerned about choosing a treatment
prohibited by the National Collegiate Athletic
Association (NCAA). Which one of the following
drug classes requires proof of prescription under
NCAA regulations? (check one) A. Mast cell
stabilizers.  B. Inhaled corticosteroids.  C.
Leukotriene receptor antagonists.  D. Inhaled
beta2 agonists.
102

• Screening for abdominal aortic aneurysmThe USPSTF
  recommends one-time screening for abdominal
  aortic aneurysm (AAA) by ultrasonography in men
  aged 65 to 75 who have ever smoked.B