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(Updated May 2024)

 

Invalidated MKSAP 19 Questions

The following questions have been invalidated as a result of postpublication analysis and/or new data that are relevant to the question: , , , and from Cardiovascular Medicine; , and from Endocrinology and Metabolism; from Gastroenterology and Hepatology; and from General Internal Medicine 1; , and from Infectious Disease; , , , , , and from Nephrology; and from Pulmonary and Critical Care Medicine.

 

Cardiovascular Medicine

 

Epidemiology and Risk Factors

: The text has been revised to acknowledge that the significant racial and ethnic disparities in the prevalence of cardiovascular disease in the United States are driven by multiple factors, including structural social factors and inequitable access to care. Many calculators of cardiovascular risk, including the Pooled Cohort Equations recommended by the U.S. Preventive Services Task Force, the Society of Thoracic Surgeons Adult Cardiac Surgery Risk Calculator, and the Multi-Ethnic Study of Atherosclerosis risk score, include race as a variable in estimating cardiovascular risk. The inclusion of race as a predictor of risk is problematic, and guidelines are likely to evolve to better reflect individualized risk.

In addition, the text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Coronary Artery Disease

: Risk Stratification. The URL for the GRACE score has been updated to www.mdcalc.com/calc/1099/grace-acs-risk-mortality-calculator. (Added May 2023)

 

Heart Failure

: Screening. The text has been revised to acknowledge that inclusion of race as a variable in calculating risk for heart failure is likely a flawed approach. (Added March 2022)

: Heart Failure With Reduced Ejection Fraction. The text, including the Figure 13 legend, has been revised to acknowledge that race-based heart failure treatment recommendations are under scrutiny. (Added March 2022)

: Black Patients. The text has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)

 

Valvular Heart Disease

: Clinical Presentation and Evaluation. In the last sentence of the first paragraph, "non-Hodgkin" was changed to "Hodgkin." (Added January 2022)

 

Diseases of the Aorta

: Treatment. In the second sentence, the expansion rate necessitating repair of an aortic abdominal aneurysm was changed from >0.5 cm/year to >0.5 cm/6 months. (Added May 2023)

 

Pregnancy and Cardiovascular Disease

: Peripartum Cardiomyopathy. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Cardiovascular Medication Use During Pregnancy. The link to the Drugs and Lactation Database (LactMed) has been updated to www.ncbi.nlm.nih.gov/books/NBK501922. (Added May 2023)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Add isosorbide dinitrate–hydralazine" to "Add digoxin." In addition, the second paragraph of the critique has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the last paragraph of the stem, the word “atypical” in “atypical chest pain” was deleted. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Isosorbide dinitrate–hydralazine" to "Ivabradine." In addition, the fourth paragraph of the critique has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from “Switch esmolol to metoprolol” to “Switch nitroprusside to amlodipine.” Accordingly, the fourth paragraph of the critique now states, “Although control of blood pressure and shear forces remains an important objective, the focus in this patient should be on urgent surgical intervention rather than changing the nitroprusside to amlodipine (Option D). Furthermore, the abrupt discontinuation of nitroprusside may lead to rebound hypertension and the blood pressure–lowering effect of amlodipine may be delayed for several days, making this an inappropriate change in antihypertensive therapy. (Added May 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn CME/MOC credit for this question. The item has been excluded because the lack of direct comparison between dual antiplatelet therapy and aspirin plus a direct oral anticoagulant makes clinical recommendations challenging, and information in this question may be misleading to learners without advanced training in cardiovascular diseases. (Added July 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first sentence of the stem, the patient’s recent diagnosis was changed to nonischemic dilated cardiomyopathy. (Added November 2023)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option B has been changed to “Discontinue aspirin and clopidogrel,” and the critique has been revised accordingly. (Added May 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn CME/MOC credit for this question. This item has been excluded because the educational objective is no longer relevant on the basis of new guidelines from the American College of Cardiology. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first paragraph of the stem, coronary artery disease was removed from the patient's history. (Added January 2023)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question. This item has been excluded because new guidelines specifically eliminate the terms typical and atypical angina. (Added May 2022)

 

: In the first sentence of the third paragraph of the critique, “NYHA functional class II to IV heart failure” was changed to “NYHA functional class II to III heart failure.” (Added May 2023)

 

: The first paragraph of the critique was revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

: The first paragraph of the critique was revised to acknowledge that the inclusion of race as a predictor of cardiovascular risk is problematic and that the guidelines are likely to evolve to better reflect individualized risk. (Added March 2022)

 

: The first paragraph of the critique was amended as follows: The second sentence was revised to read “He has hyponatremia and worsening kidney function that may be related to heart failure, has had recurrent hospitalizations for heart failure, and has a reduction in his functional capacity.” The sixth sentence was revised to state “Acceptable candidates for transplantation are generally younger than 65 to 70 years with no medical contraindications (e.g., diabetes mellitus with end-organ complications, malignancies within 5 years, irreversible kidney dysfunction with an estimated glomerular filtration rate less than 30 mL/min/1.73 m², or other chronic illnesses that will decrease survival) and have good social support and adherence.” A sentence was added to the end of the first paragraph: “This patient meets these criteria and should be evaluated for transplantation.” In the second sentence of the second paragraph of the critique, the word poor was changed to compromised. (Added November 2022)

 

: The second to last sentence in the fourth paragraph of the critique was changed to “However, the risk for angioedema is higher with valsartan-sacubitril than with ACE inhibitor or ARB therapy, and valsartan-sacubitril is contraindicated in patients who have had angioedema while receiving an ACE inhibitor.” (Added July 2022)

 

: In the first sentence of the third paragraph of the critique, “adults aged 50 to 59 years” was changed to “adults aged 40 to 59 years.” (Added May 2023)

 

: In the last sentence of the critique, "0.50 cm/year" was changed to "0.50 cm/6 months." (Added May 2023)

 

: In the critique, the fourth paragraph was amended to read “In the short term, the focus should be on hemodynamic support in the hopes of improving cardiac function over the next 48 hours with revascularization. Transplant is not an option because the patient is too old (Option D).” The fifth paragraph was amended to read “Vasopressin (Option E) may be added to norepinephrine to further raise blood pressure or reduce the dose of norepinephrine in patients with vasodilatory shock. In general, vasopressin should not be used in cardiogenic shock.” (Added November 2022)

 

Endocrinology and Metabolism

 

Disorders of Glucose Metabolism

: Idiopathic Type 1 Diabetes Mellitus. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Table 3. Under "advantages" in the first row, "Not altered by conditions such as illness or stress" was changed to "Relatively unaltered by conditions such as illness or stress." Under "disadvantages" in the first row, language was updated to remove race-based screening information that is under scrutiny; the corresponding footnote was also removed. (Added May 2023)

: Table 6. In the eighth row of the table, exenatide was removed from the list of glucagon-like peptide 1 receptor agonists. (Added May 2023)

: Therapy for Type 2 Diabetes Mellitus. In the sixth paragraph, the following text has been added after the third sentence: “Renal dose adjustment is required for all SGLT2 inhibitors. The GLP-1 RAs exenatide and lixisenatide should be avoided in patients with an eGFR less than 30 mL/min/1.73 m².” (Added January 2022)

: Table 10. In the second row, tolbutamide, chlorpropamide, and gliclazide were removed from the first column because they are no longer available in the United States. In the first column of the fifth row, rosiglitazone was removed because it is no longer available. Drugs that were listed twice in the first column of the ninth row were removed; that cell now reads "GLP-1 receptor agonists (exenatide, liraglutide, lixisenatide, dulaglutide, semaglutide)." In the first column of the twelfth row, "quick release" was removed. (Added May 2024)

: Hypoglycemia in Patients With Diabetes Mellitus. The third paragraph has been changed to: "Hypoglycemia can also occur with the use of oral antidiabetic agents (especially sulfonylureas or meglitinides) because of incorrect dosages, drug-drug interactions, and intercurrent illnesses that alter the metabolism or excretion of drugs." (Added January 2022)

 

Disorders of the Adrenal Glands

: In the second row beneath "Pheochromocytoma/Paraganglioma," "unenhanced CT >10 HU" has been changed to "unenhanced CT ≥10 HU." (Added November 2022)

: Table 25. The case detection indications for primary aldosteronism were revised. The row "Hypertension in the setting of family history of hypertension onset age <40 years" was removed. Rows were added for the following: "Controlled blood pressure on four or more antihypertensives including a diuretic," "Hypertension and sleep apnea," and "Hypertension with a family history of either early-onset hypertension or cerebrovascular accident before age 40 years." "On three separate occasions" was added to the first row; it now reads "Untreated hypertension with sustained BP >150/100 mm Hg on three separate occasions." (Added May 2023)

: Primary Aldosteronism. In the third sentence of the third paragraph, the text “a non-suppressed plasma renin level rules out mineralocorticoid excess” was removed; the sentence now reads “If the PRA is suppressed, the likelihood of primary aldosteronism is high and a PAC/PRA should be performed.” (Added November 2022)

: Primary Aldosteronism. The second key point has been changed to “In patients taking an ACE inhibitor or an angiotensin receptor blocker, a simple initial test for primary aldosteronism is a plasma renin activity (PRA) measurement; if the PRA is suppressed, the likelihood of primary aldosteronism is high and a plasma aldosterone concentration/PRA should be performed.” (Added January 2023)

: In the third column of the third row, "Density >10 HU (usually >30)" was changed to "Density ≥10 HU (usually >30).” (Added November 2022)

: Pheochromocytoma and Paraganglioma. In the second sentence of the seventh paragraph, "multiple endocrine neoplasia type 1" has been changed to "multiple endocrine neoplasia type 2." (Added May 2022)

: Adrenal Mass. In the second sentence in the second paragraph, "and for pheochromocytoma if the unenhanced CT attenuation is greater than 10 HU" was changed to "and for pheochromocytoma if the unenhanced CT attenuation is greater than or equal to 10 HU." The Key Point was revised accordingly. (Added November 2022)

: "Catecholamines" and its corresponding test text was moved from the "All patients" box to the "Select patients" box, and the text "Who: HU ≥10" was added beneath it. Footnote d was removed from the figure and legend, and the existing footnote e was changed to d. (Added November 2022)

: Figure 8: In the "Select patients" box, under "Aldosterone," "PRA/PAC" has been changed to "PAC/PRA." (Added May 2023)

 

Disorders of the Thyroid Gland

: Thyroid Examination. The last sentence, "With either approach, it is important for the examiner's fingers to curve along the tracheal surface posteriorly (i.e., the examiner's right hand evaluates the patient's left lobe and vice versa)," was removed. (Added January 2024)

: Figure 9. In the figure legend, "See Table 30 for additional information" has been corrected to "See Table 33 for additional information." (Added November 2023)

: Other Causes. The first sentence was revised to clarify that thionamides are another treatment option for a toxic adenoma or toxic multinodular goiter. The sentence now reads “First-line therapy for a toxic adenoma or toxic MNG is thionamides, ¹³¹I therapy, or thyroid surgery.” (Added November 2023)

: Management. In the third paragraph, the threshold for treatment of subclinical hypothyroidism has been changed from 20 μU/mL (20 mU/L) to 10 μU/mL (10 mU/L). The first sentence now reads “Treatment of subclinical hypothyroidism with a TSH greater than 10 μU/mL (10 mU/L) should be initiated with levothyroxine at 25 to 50 μg/day.” The second sentence was revised from “Treating patients with TSH values 5 to 20 μU/mL (5-20 mU/L) results in unclear benefits and potential harm” to “Treating asymptomatic patients with TSH values 5 to 10 μU/mL (5-10 mU/L) results in unclear benefits.” The third sentence, “A recent study showed no benefit to treatment of subclinical hypothyroidism in patients older than 65 years with TSH levels between 4.6 and 20 μU/mL (4.6-20 mU/L), although outcomes were assessed at 2 years, potentially before cardiovascular benefits could emerge,” was removed. The last sentence now reads “Treatment for subclinical hypothyroidism with TSH less than 10 μU/mL (10 mU/L) should be considered in younger patients, those attempting to become pregnant, or if significant symptoms are present.” The third Key Point has been updated accordingly. (Added November 2022)

 

Reproductive Disorders

: Evaluation of Hyperandrogenism. In the third sentence of the second paragraph, "Serum dehydroepiandrosterone (DHEA)" was changed to "Serum dehydroepiandrosterone sulfate (DHEAS)." In the third paragraph, "DHEA" was changed to "DHEAS" throughout, and "18.9 μmol/L" was changed to "19.0 μmol/L" in the second sentence. (Added May 2023)

: Management. In the second paragraph, the following information has been added to clarify the risk for cardiovascular events in men receiving certain testosterone therapies: "However, two products (oral testosterone undecanoate and subcutaneous testosterone enanthate) have boxed warnings regarding the potential for increased blood pressure, which can increase the risk for major adverse cardiovascular events." (Added March 2022)

: Table 42. Recommended Testosterone Replacement Therapy. This table has been updated to add information on testosterone undecanoate. (Added March 2022)

 

Calcium and Bone Disorders

: Primary Hyperparathyroidism. In the third sentence of the fourth paragraph, the units were changed from "ng/dL" to "ng/mL." The sentence now reads "Repletion is recommended for patients with levels less than 20 ng/mL (50 nmol/L) with a goal range of 20 to 30 ng/mL (50-75 nmol/L)." (Added May 2023)

: Pathophysiology. A second paragraph has been added, as follows: "Glucocorticoids are a well-recognized cause of significant bone loss, and risk is increased in older patients, larger doses, and longer duration of therapy. Patients taking glucocorticoids should be on the lowest dose possible for the shortest duration necessary." (Added January 2022)

: Bisphosphonates. In the third paragraph, "glomerular filtration rate <35 mL/min/1.73 m²" was removed; it has been replaced with "creatinine clearance <30-35 mL/min, depending on the bisphosphonate." (Added May 2023)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The details of the patient’s medical history and medications have been updated, and the Critique has been revised accordingly. (Added November 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The characteristics of the patient's adrenal mass have been changed in the Stem, and the correct answer and Critique have been updated accordingly. (Added May 2024)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The patient's serum estradiol level was changed to 10 pg/mL (37 pmol/L). (Added May 2024)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Order dual-energy x-ray absorptiometry scan" to "Discontinue teriparatide, start abaloparatide." In addition, the fourth paragraph of the critique has been removed. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the Stem, the patient's plasma dehydroepiandrosterone sulfate level was changed from "4 μg/mL (11 μmol/L)" to "400 μg/dL (10.9 μmol/L)." In the third sentence of the second paragraph of the Critique, "DHEAS is typically greater than 700 μg/dL (7 μg/L)" has been changed to "DHEAS is typically greater than 700 μg/dL (19.0 μmol/L)." (Added May 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the fifth sentence of the first paragraph of the Stem, the upper limit of the patient's morning fasting glucose levels was changed from "180 mg/dL (10.0 mmol/L)" to "130 mg/dL (7.2 mmol/L)"; the sentence now states "Fasting levels most mornings are between 110 mg/dL (6.1 mmol/L) and 130 mg/dL (7.2 mmol/L)." Additionally, the first and fourth paragraphs of the Stem have been revised to reflect updated American Diabetes Association recommendations. (Added May 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first paragraph of the Stem, “1 year ago” has been changed to “6 months ago.” Additionally, “intermediate to high risk” has been changed to “high risk” throughout the Critique and Key Points. (Added January 2023)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn CME/MOC credit for this question. This item has been excluded because option C (Adrenocorticotropin hormone stimulation test) is a logical step next in the evaluation of this patient and is therefore a correct answer. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the Stem, the size of the thyroid nodule has been changed to 2.5 cm; the Critique has been updated accordingly. (Added May 2024)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The plasma free metanephrines result was removed from the laboratory studies in the Stem. Additionally, mention of pheochromocytoma was removed from the second sentence of the Critique and from the first Key Point. The third paragraph of the Critique was changed to "Testing for pheochromocytoma with a 24-hour urine total metanephrine measurement (Option C) is unnecessary in this patient because the adrenal nodule has a density of less than 10 Hounsfield units." (Added November 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question. The item has been excluded because the most appropriate pathway in evaluating hypercalcemia in general involves ruling out other potential causes first. Additionally, according to the relevant literature, alkaline phosphatase levels may be variable and may not corroborate the diagnosis. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The question stem has been revised, and Option D has been changed from "13-Valent pneumococcal conjugant" to "23-Valent pneumococcal polysaccharide vaccine." In addition, the first, second, and fourth paragraphs of the Critique have been revised. The first Key Point has been removed, and the second Key Point has been revised. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The patient's immunization history has been updated, and the lead-in was changed to "With shared decision making, which of the following is the most appropriate vaccination to recommend at this time?" (Added May 2024)

 

: Albiglutide was removed from the list of glucagon-like peptide 1 receptor agonists in the sixth sentence of the first paragraph of the Critique because it is no longer on the market. (Added November 2022)

 

: In the sixth sentence of the first paragraph of the Critique, dapagliflozin was removed from the list of sodium-glucose cotransporter 2 inhibitors with established cardiovascular disease benefit. (Added May 2023)

 

: In the third sentence of the Critique, "screening for pheochromocytoma is indicated if the unenhanced CT attenuation is greater than 10 Hounsfield units" was changed to "screening for pheochromocytoma is indicated if the unenhanced CT attenuation is greater than or equal to 10 Hounsfield units." (Added November 2022)

 

: The bibliographic reference was changed to "American Diabetes Association Professional Practice Committee. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47:S52-S76. [PMID: 38078591] doi:10.2337/dc24-S004." (Added May 2024)

 

: The fourth paragraph of the Critique has been revised to clarify the evaluation of hypogonadism and why thyroid-stimulating hormone level measurement is not the most appropriate diagnostic test for this patient scenario. The paragraph now reads “The most appropriate first step in the evaluation of suspected hypogonadism is to measure a morning testosterone level. If hypogonadism is confirmed and subsequent LH and follicle-stimulating hormone levels are low or inappropriately normal, suggesting secondary hypogonadism, then an evaluation for possible secondary causes (e.g., hyperprolactinemia, infiltrative disorders, and possibly hypothyroidism) is appropriate. Conversely, hyperthyroidism is unlikely in this patient as he does not have suggestive clinical features (palpitations, tachycardia, tremors, sweating, weight loss, hyperdefecation). Therefore, a thyroid-stimulating hormone level (Option E) is not the most appropriate diagnostic step at this time.” (Added November 2023)

 

: In the second paragraph of the Critique, the second sentence has been changed to “Although liothyronine has not been found to be a teratogen, maternal supplementation with liothyronine does not provide the fetus with sufficient concentrations of T₄.” A third sentence was added: “Therefore, liothyronine is not the preferred treatment of hypothyroidism in pregnancy.” (Added January 2023)

 

: The fifth paragraph of the Critique was incorporated into the third paragraph to address the methimazole (Option B) and propylthiouracil (Option D) options together. Additionally, the text has been clarified to indicate that thionamides are used to treat other conditions in addition to Graves disease. The paragraph now reads “Because this patient does not demonstrate excessive thyroid hormone production (i.e., Graves disease, toxic nodular disease, or a toxic multinodular goiter), methimazole (Option B) or propylthiouracil (Option D) is not indicated.” (Added November 2023)

 

: In the second sentence of the Critique, pembrolizumab was removed from the list of anti-cytotoxic T-lymphocyte-associated protein-4 antibodies. (Added May 2024)

 

: In the first sentence of the second paragraph of the Critique, “TSH less than 20 μU/mL (20 mU/L)” has been changed to “TSH less than 10 μU/mL (10 mU/L).” The sentence now reads “Initiating levothyroxine (Option A) for subclinical hypothyroidism with TSH less than 10 μU/mL (10 mU/L) should be considered in younger patients, those attempting to become pregnant, or if severe symptoms are present.” (Added November 2022)

 

: In the second Key Point, "normal menstrual cycles" has been changed to "irregular menstrual cycles." (Added November 2022)

 

: In the fourth sentence of the first paragraph of the Critique, “if PRA is elevated, hyperaldosteronism is ruled out” was removed; the sentence will now read “If PRA is suppressed, the likelihood of primary aldosteronism is high and then PAC/PRA should be calculated.” In the second Key Point, “an elevated serum renin level excludes hyperaldosteronism” was revised to “a suppressed PRA is a strong predictor of primary hyperaldosteronism.” (Added November 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn CME/MOC credit for this question.

This item has been excluded because the best pharmacologic agent to treat type 2 diabetes mellitus in this patient with stage 4 chronic kidney disease, a glucagon-like peptide 1 receptor agonist (GLP-1 RA) such as liraglutide, was not included in the option list. GLP-1 RAs improve cardiovascular outcomes and reduce albuminuria. The dosage of these agents can be adjusted in patients with chronic kidney disease, although exenatide and lixisenatide should be avoided in patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m². (Added January 2022)

 

: In the second paragraph of the Critique, "screening patients with overweight or obesity between age 40 and 70 years for diabetes" has been changed to "screening for diabetes in patients aged 35 to 70 years with overweight or obesity" based on updated USPSTF guidance on screening for prediabetes and type 2 diabetes. The related Key Point has also been revised accordingly. (Added May 2022)

 

: In the second sentence of the third paragraph of the Critique, “glyburide” has been corrected to “glipizide.” (Added January 2023)

 

Gastroenterology

 

Disorders of the Esophagus

: Achalasia and Pseudoachalasia. The third full paragraph has been revised so that upper endoscopy is listed as the first test used in making a diagnosis of achalasia, in accordance with American College of Gastroenterology guidelines. (Added November 2022)

 

Disorders of the Small and Large Bowel

: History and Physical Examination. In the last sentence of the second paragraph, "age 50 years" has been changed to "age 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

: Additional Testing. In the last sentence of the sixth paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

: Small Intestinal Bacterial Overgrowth. The third sentence of the second paragraph has been revised to "The glucose breath test offers better sensitivity, and the lactulose breath test offers better specificity for diagnosing SIBO. Compared with small bowel aspirates culture the glucose breath test has a sensitivity of 20% to 93% and specificity of 30% to 86%. The lactulose breath test demonstrates a sensitivity of 31% to 68% and a specificity of 44% to 100%." (Added November 2023)

: Evaluation. In the third sentence of the first paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

: Health Care Considerations. The fifth sentence of the third paragraph has been revised to include more detailed information on bone mineral density testing criteria for patients with inflammatory bowel disease taking oral glucocorticoids. (Added July 2023)

: Perianal Disorders. In the last sentence of the first paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

 

Colorectal Neoplasia

: Risk Factors. In the first sentence of the first paragraph, the "≥50 years" has been changed to "≥45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. The same change has been made in the related key point. (Added January 2022)

: Risk Factors. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Table 24: Screening for Colorectal Cancer in Individuals at Elevated Risk. The colorectal cancer screening interval for patients with inflammatory bowel disease in the last row has been changed from “repeat every 1-2 years” to “repeat every 1-3 years.” (Added April 2024)

: Table 26: Surveillance for Colorectal Cancer After Screening or Polypectomy. The third type of adenomatous polyp described in the third row has been revised from “adenoma with high-grade dysplasia” to “any adenoma with villous or tubulovillous histology and/or high-grade dysplasia.” (Added April 2024)

 

Disorders of the Liver

: Drug-Induced Liver Injury. In the first paragraph, the last sentence has been changed to "Use of the Web-based tool LiverTox () from the National Institutes of Health can help assess risk for hepatotoxicity." (Added August 2021)

: Hepatitis D. The last sentence has been changed to "HDV-infected patients with evidence of progressive liver disease should receive 48 weeks of pegylated interferon treatment; cure rates are 25% to 45%." (Added November 2023)

: Pyogenic Liver Abscesses. The third and fourth sentences have been changed to "Successful treatment of a pyogenic liver abscess includes broad-spectrum antibiotics and percutaneous drainage." (Added May 2023)

: Focal Nodular Hyperplasia. The last sentence has been changed to "In women with FNH who continue to use oral contraceptives, annual liver ultrasonography should be performed for a period of 2 to 3 years to assess the lesion for growth." (Added July 2023)

 

Disorders of the Gallbladder and Bile Ducts

: The text in the top box has been revised to "Gallbladder polyp of any size associated with gallstones or biliary colic." (Added November 2023)

 

Gastrointestinal Bleeding

: Table 43. In the fifth row, ">50" in the "Patient Age" column has been changed to ">45" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

Questions

 

: Under "Laboratory studies" in the question stem, "Hepatitis E antigen" and "Hepatitis E IgG antibody" have been changed to "Hepatitis B e antigen" and "Hepatitis B e IgG antibody," respectively. (Added January 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn CME/MOC credit for this question. The item has been invalidated because the judgment on drainage of hepatic abscesses (small or large) is clinician dependent. (Added May 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The total IgA level in the question stem has been changed to “less than 5 mg/dL (0.05 g/L).” (Added January 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the question stem, data regarding platelet count have been added to allow a Fibrosis-4 calculation to be performed. In addition, the first paragraph of the Critique has been revised. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the question stem, in the laboratory studies table, the level of hemoglobin has been changed to 86 g/L. (Added May 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first sentence of the Stem, the age of the patient has been changed to 76 years. In the second sentence of the Stem, diabetes and mild congestive heart failure have been added as comorbid conditions. (Added July 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Broad-spectrum antibiotics" to "Standard-dose esomeprazole and broad-spectrum antibiotics". Option B has been changed from "Esomeprazole, intravenously twice daily" to "High-dose esomeprazole". Option C has been changed from "Octreotide, intravenously by continuous infusion" to "High-dose esomeprazole and octreotide". Option D has been changed from "Omeprazole, orally once daily" to "Standard-dose esomeprazole". In addition, the first and fourth paragraphs of the Critique have been revised. (Added May 2022)

 

: In the first paragraph of the critique, the second sentence has been revised as follows: "This patient most likely has primary biliary cholangitis (PBC), a diagnosis that is best established by imaging with ultrasound or magnetic resonance cholangiopancreatography to exclude extrahepatic obstruction and by positive results for AMA." (Added January 2022)

 

: In the second sentence of the first paragraph of the critique, “A 3-year colonoscopy interval is appropriate for patients with larger adenomas (≥10 mm), 5 to 10 tubular adenomas less than 10 mm, adenomas with tubulovillous or villous histology, or adenomas with high-grade dysplasia,” has been revised to “A 3-year colonoscopy interval is appropriate for patients with larger adenomas (≥10 mm), 5 to 10 tubular adenomas less than 10 mm, or any adenoma with tubulovillous or villous histology and/or high-grade dysplasia.” (Added April 2024)

 

: In the first paragraph of the critique and in the related key point, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

 

: The penultimate sentence of the first paragraph in the critique, "Glucose breath tests are approximately 80% sensitive but only 40% specific for diagnosing SIBO," has been revised to, "Glucose breath tests have a sensitivity of 20% to 93% and specificity of 30% to 86% in diagnosing SIBO." (Added November 2023)

 

: In the second paragraph of the critique, "age 50 years or older" has been changed to "age 45 years or older" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)

 

: In the first paragraph of the critique, text was revised to better reflect the risk factors for gastric cancer identified by the American Gastroenterological Association. (Added March 2022)

 

: In the first sentence of the second paragraph of the critique, “cholecystitis” has been changed to “cholangitis.” The sentence now reads, “Surgical drainage of the biliary tree, either open or laparoscopic (Option A), is reserved for patients with acute cholangitis who cannot undergo ERCP or in whom ERCP has failed.” (Added January 2022)

 

General Internal Medicine 1

 

Clinical Decision Making and Interpreting the Literature

: Application of Study Results; Table 8. In the third row of the table (Absolute and relative risk reduction), the relative risk reduction in the example was changed from 17% to 15.6%. (Added April 2024)

 

Common Symptoms

: Acute Cough. In the third sentence of the third paragraph, the phrase "the most current" was changed to "additional." The sentence now reads, "For additional information on SARS-CoV-2, see COVID-19: An ACP Physician's Guide (/clinical-information/clinical-resources-products/coronavirus-disease-2019-covid-19-information-for-internists)." (Added January 2022)

: Evaluation. The first sentence in the second to last paragraph was revised to read: “Although the pathophysiology of SEID remains unclear, central sensitization may contribute.” The following sentence was added to the last paragraph: “Comorbid conditions, such as fibromyalgia, irritable bowel syndrome, and interstitial cystitis, are common.” (Added March 2022)

: Management. The second sentence in the first paragraph was changed to: “In patients with SEID, treatment is supportive and focuses on treatment of symptoms and comorbid conditions.” The sentence “Cognitive behavioral therapy (CBT) may decrease fatigue and improve function” was deleted. The second sentence in the second paragraph was changed to: “Medical therapy is therefore typically limited to the treatment of symptoms and comorbid conditions.” The second sentence in the last paragraph was changed to: “It depends on many factors, including patient age, formal education level, severity and duration of symptoms, decline in functional status relative to premorbid level of functioning, presence of other symptoms, comorbid conditions, and availability of resources.” (Added March 2022)

: Management. In the fourth sentence of the first paragraph, the phrases "and graded exercise therapy" and "and these therapies should be offered to all patients" were deleted. The sentence now reads, "Cognitive behavioral therapy (CBT) may decrease fatigue and improve function." In the second key point, the phrase "cognitive behavioral therapy and graded exercise therapy may decrease fatigue and improve function and should be offered to all patients" was deleted. The key point now states, "Patients with systemic exertion intolerance disease benefit most from a structured, multimodal approach that includes regularly scheduled office visits." (Added January 2022)

 

Dyslipidemia

: Table 40. Ranges have been added for moderate-intensity statin dosages: atorvastatin, 10-20 mg/d; rosuvastatin, 5-10 mg/d; pravastatin, 40-80 mg/d; and lovastatin, 40-80 mg/d. (Added November 2023)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In both the stem and the educational objective, the study design was changed from case-control to cohort. The last paragraph of the critique was revised to read as follows: “The cohort study is an observational study in which participants are initially classified or enrolled according to the presence of an exposure—in this case, the new treatment for catastrophic antiphospholipid syndrome. Those with the exposure are compared against participants who do not have the exposure or, in this case, patients who received usual treatment. Because sample size is a critical determinant of study power, or the ability to detect differences between groups, a cohort study design is an optimal way to collect enough cases of a rare exposure, in this case patients with catastrophic antiphospholipid syndrome who were exposed to the new treatment, to enable adequate power to allow meaningful conclusions to be drawn (Option D).” (Added November 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first paragraph of the stem, “He has no other medical conditions and takes no other medications.” was replaced with “He has hypertension and chronic kidney disease; his most recent estimated glomerular filtration rate was 28 mL/min/1.73 m². His only other medication is amlodipine.” In the second paragraph of the critique, “It is not an approved therapy for major depressive disorder. This patient reports no symptoms of mania that would justify the use of this therapy.” was replaced with “It may be used as augmentation therapy for resistant depression. However, it is not recommended in patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m² so would not be an appropriate choice for this patient.” (Added July 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The lead-in was changed to “Which of the following is the most appropriate management?” The correct option was changed to “Refer to psychiatry for intranasal esketamine” and is now Option D. The other three options were re-tagged to maintain alphabetical order. The first sentence of the critique was changed to “The most appropriate management is to refer the patient to psychiatry for intranasal esketamine (Option D).” (Added November 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The fifth sentence in the stem was changed to “Medical history is significant for migraine with aura, for which she takes sumatriptan as needed, fewer than two doses per month.” (Added November 2023)

 

: In the second paragraph of the stem, the fourth sentence was corrected to state that the patient’s left leg calf is 4 cm larger than the right. (Added January 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The lead-in was changed to “After initial dosing to control acute symptoms, which of the following is the most appropriate treatment?” (Added November 2023)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The first paragraph of the stem was revised to convey that the patient's race is reported for the purposes of calculating risk for atherosclerotic cardiovascular disease. (Added March 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C to earn CME/MOC credit for this question.

This item has been excluded because the history and examination findings described in the stem may be insufficient to make the correct diagnosis. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The first paragraph of the stem was revised to convey that the patient's race is reported for the purposes of calculating risk for atherosclerotic cardiovascular disease. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the lead-in question, “another overdose” was changed to “an overdose-related death.” (Added March 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question.

This item has been excluded because there is more than one correct answer. Option B (knee strengthening exercises) is not an unreasonable answer for this patient who also has limiting knee osteoarthritis. (Added January 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Graded exercise program" to "Pacing strategies." (Added March 2022)

 

: In the second sentence of the second paragraph of the stem, "The Dix-Hallpike maneuver shows unidirectional nystagmus on the right side" was changed to "There is horizontal nystagmus that is suppressed with visual fixation." In the second sentence of the first paragraph of the critique, "unidirectional nystagmus with the Dix-Hallpike maneuver" was changed to "horizontal nystagmus that is suppressed with visual fixation." In the first sentence of the fifth paragraph of the critique, "negative Dix-Hallpike maneuver" was changed to "e.g., nystagmus not suppressed with visual fixation." (Added April 2024)

 

: In the third paragraph of the critique, pemoline was deleted from the parenthetical list of psychostimulants because it has been discontinued. (Added May 2022)

 

: The reference was updated to: Fowler JR, Hughes TB. Scaphoid fractures. Clin Sports Med. 2015;34:37-50. [PMID: 25455395] doi:10.1016/j.csm.2014.09.011. The previous reference--Mawdsley MJ, Harrison J. Conservative interventions for treating scaphoid fractures in adults. Cochrane Database Syst Rev. 2018;2018:CD010713. doi:10.1002/14651858.CD010713.pub2—was removed from the Cochrane Library and is no longer accessible. (Added March 2022)

 

: In the next to last sentence in paragraph 1 of the critique, “ways to prevent overdose” was changed to “ways to reverse overdose and prevent overdose death.” (Added March 2022)

 

: The critique and key point have been revised to reflect the current evidence for systemic exertion intolerance disease therapies. (Added March 2022)

 

General Internal Medicine 2

 

Routine Care of the Healthy Patient

: Screening for Chronic Diseases. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Obesity

: Screening and Evaluation. The first sentence of the first paragraph was revised to, "Multiple organizations, including the American College of Cardiology, American Heart Association, and The Obesity Society, recommend annual screening of adults with BMI and waist circumference measurements." (Added March 2022)

 

Women's Health

: Contraception. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Eye Disorders

: Glaucoma. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Ear, Nose, Mouth, and Throat Disorders

: Upper Respiratory Tract Infection/Sinusitis. Sentence three in paragraph one was revised to, “It is usually self-limited; therapies that may relieve symptoms include systemic decongestants, saline nasal irrigation, and intranasal glucocorticoids, all targeted to the patient's specific symptoms.” (Added March 2022)

: Legend for Figure 30: In the first sentence, “loss or diminution of the interdental papilla, and necrotic sloughing of the gingiva” was revised to “loss or diminution of the interdental papilla (green arrow), and necrotic sloughing of the gingiva (blue arrow).” (Added January 2022)

 

Dermatologic Disorders

: Table 74. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "23-Valent pneumococcal polysaccharide vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the second sentence of the question stem and the first and third paragraphs of the critique have been revised. (Added May 2022)

 

: In the seventh sentence of the stem, “FVC/FEV₁” has been corrected to “FEV₁/��հ�.” (Added January 2023)

 

: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option B has been changed from "13-Valent pneumococcal conjugate vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the second sentence of the question stem and the first and third paragraphs of the critique have been revised. (Added May 2022)

 

: In the sixth sentence of the question stem, "and recently completed the hepatitis B vaccine series" was added. (Added May 2022)

 

: In paragraph 3 of the critique, the first three sentences were revised to read, “The possibility of infection with unusual or resistant organisms should be considered when there is persistence of symptoms despite appropriate antibiotic therapy. Because this patient did not previously receive antibiotics, obtaining cultures is not necessary. When concern for infection with resistant organisms exists, it is important to obtain bacterial and/or fungal cultures directly from the sinus via nasal endoscopy or by sinus puncture.” (Added May 2023)

 

: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)

 

: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)

 

: In the third sentence of the question stem, "and has additionally completed the hepatitis B vaccine series" was added. In addition, the third paragraph of the critique has been revised. (Added May 2022)

 

: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In paragraph two of the question stem, "BMI is 22 kg/m²." has been added after the second sentence. In addition, the second paragraph of the critique has been revised. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "13-Valent pneumococcal conjugate vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the first paragraph of the critique has been revised. (Added May 2022)

 

Hematology

 

Approach to Nonmalignant Leukopenia and Leukocytosis

: Lymphopenia and Neutropenia. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Lymphopenia and Neutropenia: The term "benign ethnic neutropenia" has been revised to "Duffy-null associated neutrophil count." The sentence, "BEN is more common among certain demographics, including those of African descent," has been removed and replaced with, "Absence of the Duffy antigen, which is the receptor for Falciparum ovale, provides protection against malaria. DANC is more common among certain demographics, particularly those where malaria is endemic, including those of sub-Saharan African or Middle Eastern descent," to better describe this condition. (Added July 2023)

 

Erythrocyte Disorders

: α-Thalassemia. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Sickle Cell Syndromes. The discussion has been revised to clarify that sickle cell disease is most common in patients from sub-Saharan Africa, India, the Middle East, the Caribbean, and Central and South America. (Added March 2022)

 

Iron Overload Syndromes

: Primary/Hereditary Hemochromatosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Primary/Hereditary Hemochromatosis. In the fourth paragraph, the final sentence beginning, “Pituitary injury leads to androgen deficiency…” the word “melatonin” should be “melanin.” (Added July 2022)

 

Thrombotic Disorders

: Inherited Thrombophilias. The discussion has been revised to clarify that some inherited thrombophilias (heterozygous factor V Leiden, prothrombin G20210A mutation, and heterozygous methylene tetrahydrofolate reductase polymorphisms) are most commonly found in patients of European ancestry. (Added March 2022)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The pneumococcal vaccine formulation has been updated from “13-valent pneumococcal conjugate” to “20-valent pneumococcal conjugate”. (Added May 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The laboratory studies table has been updated to include a von Willebrand factor (vWF) antigen assay result and a Ristocetin cofactor activity:vWF antigen ratio. Option D has also been revised from "von Willebrand antigen assay" to "Fibrinogen level." The Critique has been updated to remain consistent with the revised Stem and answer option. (Added November 2022)

 

: In the third paragraph of the Critique, the sentence, “As such, an elevated concentration of methylmalonic acid is a more sensitive indicator of vitamin B12 deficiency” has been altered to replace “sensitive” with “specific.” (Added November 2022)

 

: The Critique has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

: The third Critique paragraph has been revised to clarify that heterozygous factor V Leiden is most commonly found in patients of European ancestry. (Added March 2022)

 

: In the final Critique paragraph, the first sentence has been revised to, "A low vitamin B₁₂ level is associated with intramedullary hemolysis because of ineffective erythropoiesis and resultant elevated LDH and bilirubin (indirect) and decreased haptoglobin levels, which are normal in this patient (Option D)." The sentence previously stated, "...elevated LDH, haptoglobin, and bilirubin (indirect) levels..." (Added July 2022)

 

: The epidemiologic information regarding hereditary hemochromatosis in the first Critique paragraph has been revised. (Added March 2022)

 

: The epidemiologic information regarding glucose-6-phosphate dehydrogenase deficiency in the first Critique paragraph has been revised. (Added March 2022)

 

Infectious Disease

 

Central Nervous System Infection

: Table 2. Under "Empiric Antibiotic Regimen" for patients >50 years or with altered cell-mediated immunity, the phrase “or cefotaxime” has been added as an alternative treatment instead of ceftriaxone. “In countries with ceftriaxone resistance rate >1%, such as the United States” has been moved to the footnotes section. (Added January 2022)

 

Community-Acquired Pneumonia

: Complications. In the final paragraph, the word "without" should be "with." The sentence should read, "Glucocorticoids are not routinely recommended and should be reserved for patients with documented adrenal insufficiency or refractory septic shock." (Added January 2022)

 

Tick-Borne Diseases

: Early Disseminated Disease. In the paragraph beginning, "Neurologic infection occurs…," the sentence on lumbar puncture has been revised to, "Serum antibody testing, rather than polymerase chain reaction or culture of either cerebrospinal fluid or serum, is recommended for the diagnosis of Lyme disease involving the peripheral or central nervous system." This change makes the content more consistent with current guidelines. (Added January 2022)

 

Mycobacterium tuberculosis Infection

: Management, Drug-Resistant Tuberculosis. The last sentence and the Key Point box have been clarified concerning treatment duration and culture conversion. Both sentences now state, "…the recommendation is to use five drugs in the intensive phase of treatment and four drugs in the continuation phase of treatment. The recommended intensive-phase duration is between 5 and 7 months after culture conversion, with the total duration between 15 and 21 months after culture conversion." (Added January 2022)

 

Nontuberculous Mycobacterial Infection

: Mycobacterium avium Complex Infection. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Fungal Infections

: Coccidioidomycosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Viral Infections

: Human Herpesvirus Infections, Epstein-Barr Virus. In the third sentence (“Patients present with…”), the word “exudative” has been removed. The same change has been applied to the first Key Point for the section. Acute Epstein-Barr virus infection may be associated with either exudative or nonexudative pharyngitis. (Added November 2022)

Questions

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C to earn CME/MOC credit for this question. (Added July 2023)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn CME/MOC credit for this question. (Added November 2023)

 

: The patient's history has been revised to indicate meningococcal meningitis as a child; the family history has been removed. (Added March 2022)

 

: The sentence, "An interferon-γ release assay is negative," has been removed from the Stem and replaced with, "Nucleic acid amplification testing for Mycobacterium tuberculosis is negative." In addition, the first and third Critique paragraphs have been revised consistent with this change. (Added July 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question. (Added August 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option E has been changed from “Clindamycin and gentamicin” to “Cefotetan and doxycycline.” In addition, the associated Critique paragraph has been revised. (Added May 2022)

 

: The first Critique paragraph has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

: In the final Critique paragraph, the first sentence, "Hepatitis B vaccination and immune globulin are used to prevent HBV infection in nonimmune persons (negative surface antigen and positive surface antibody)," the parenthetical note should indicate "negative surface antigen and negative surface antibody." (Added March 2022)

 

: In the first Critique paragraph, following the sentence that reads, "In countries such as the United States with a prevalence of greater than 1% of ceftriaxone-resistant pneumococcus, …provide coverage for possible Listeria monocytogenes (Option A)," a sentence has been added, indicating, "Cefotaxime is also effective against pneumococcus and may be given instead of ceftriaxone." The first Key Point has also been revised to state, "Empiric therapy for bacterial meningitis should include vancomycin, ceftriaxone or cefotaxime, and ampicillin in adult patients older than 50 years." (Added January 2022)

 

: In the last sentence in the first paragraph of the Critique, "oral" has been removed. The sentence should read, "Ertapenem has an advantage over the other carbapenems with once-daily dosing, but some ESBL-producing organisms are resistant to it." Ertapenem does not have oral dosing. (Added March 2022)

 

: In the third sentence of the first paragraph of the Critique (“Mononucleosis typically presents with...”), the word "nonexudative" has been removed. The same change has been applied to the first Key Point for the question. Acute Epstein-Barr virus infection may be associated with either exudative or nonexudative pharyngitis. (Added November 2022)

 

: The last sentence of the first Critique paragraph was revised to state, "A tuberculin skin test or interferon-γ release assay cannot be reliably used to exclude a diagnosis of tuberculosis and should not be used in the evaluation of patients with suspected active tuberculosis." (Added May 2023)

 

: In the first sentence of the Critique, Heartland virus is classified as a Phlebovirus. The taxonomy of Heartland virus was recently revised, and the virus is now classified as part of the new genus Bandavirus. (Added January 2022)

 

: The last Critique paragraph has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Nephrology

 

Clinical Evaluation of Kidney Function

: Assessment of Kidney Function. The text has been revised to acknowledge that inclusion of race in glomerular filtration rate (GFR) calculation may lead to inaccurately higher GFR estimates for Black patients, which could subsequently translate into delayed or inequitable care in some cases. In addition, epidemiologic information that is irrelevant to the discussion has been removed. (Added February 2022)

: Estimation of Glomerular Filtration Rate. In September 2021, the Task Force of the National Kidney Foundation and the American Society of Nephrology recommended the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refit to estimate glomerular filtration rate without a race variable. Based on this recommendation, the following revisions have been made:

In the first paragraph, sentence 2, "These formulas take into account" has been replaced with "These formulas may take into account."

In the second paragraph, sentence 2 has been replaced with: "To estimate GFR, the National Kidney Foundation and the American Society of Nephrology recommend using the CKD-EPI Creatinine Equation (2021) (), which has been refit to estimate kidney function without a race variable (see Table 1). CKD-EPI equations presume standard body surface area and therefore require adjustment for very large or small persons. Combining filtration markers (creatinine and cystatin C) into the CKD-EPI creatinine-cystatin C equation is more accurate and informs clinical decision making better than either marker alone." (Added October 2021)

: Estimation of Glomerular Filtration Rate, Table 1. Methods for Estimating Kidney Function. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refit to estimate glomerular filtration rate without a race variable, Table 1 was revised as follows:

• Row 3, column 1. Column heading was revised to "CKD-EPI Creatinine (2021)." In sentence 1, the term "race" was deleted.
• Row 3, column 3. Sentence 2 was deleted.
• Row 5, column 3. "The most accurate formula for estimating GFR in most situations" was added.
• (Added October 2021)

: Estimation of Glomerular Filtration Rate, Key Points. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refit to estimate glomerular filtration rate without a race variable, the second Key Point was revised to, "To estimate glomerular filtration rate, the National Kidney Foundation and the American Society of Nephrology recommend using Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation (2021), which has been refit to estimate kidney function without a race variable." (Added October 2021)

 

Fluids and Electrolytes

: Hypokalemia. In the last row of the algorithm, in the sixth box from the left, "diuretics" was added, as hypokalemia due to diuretics can occur with or without metabolic alkalosis. (Added May 2022)

 

Acid-Base Disorders

: Diagnostic Approach to Normal Anion Gap Metabolic Acidosis: In column three, row two, “or decreased” was added after “Normal.” (Added July 2023)

 

Hypertension

: The text has been revised to acknowledge that race-based antihypertensive prescribing recommendations are under scrutiny. In addition, epidemiologic information that is irrelevant to the discussion has been removed. (Added February 2022)

: Primary Hyperaldosteronism. Sentence three of paragraph one was revised to read, "Screening is recommended in patients with sustained hypertension of >150/100 mm Hg on three separate measurements, resistant hypertension (uncontrolled hypertension on a three-drug regimen inclusive of a diuretic), controlled blood pressure on four or more antihypertensives (one of which is a diuretic), hypertension with hypokalemia (either spontaneous or diuretic induced), hypertension and an incidentally discovered adrenal mass, or a family history of early-onset hypertension or stroke at age <40 years." (Added May 2023)

 

Glomerular Diseases

: The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)

 

Genetic Disorders and Kidney Disease

: Apolipoprotein L1 Nephropathy. The text has been revised to acknowledge the multifactorial reasons for disparities in the incidence of kidney failure. (Added February 2022)

 

Acute Kidney Injury

: Tumor Lysis Syndrome. In sentence three of the second paragraph, "80 to 100 mL/kg/h" has been changed to "80 to 100 mL/h." (Added July 2022)

 

Kidney Stones

: Overview. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)

 

Chronic Kidney Disease

: Diagnosis. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refit to estimate glomerular filtration rate without a race variable, the equation in sentence 1 has been revised to "Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation (2021)." (Added October 2021)

: Dyslipidemia. In paragraph one, a new sentence seven was added, "In persons with diabetes and CKD, a high-intensity statin can be considered. KDIGO also recommends statin therapy for all patients older than age 40 years with diabetes and non-dialysis–dependent CKD." (Added May 2023)

: Non-Dialytic Palliative Therapy. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)

Questions

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn CME/MOC credit for this question. This item has been excluded because there is more than one correct answer. Recent evidence from the Chronic Hypertension and Pregnancy trial and subsequent recommendations from the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists note that pregnant patients with chronic hypertension should be treated with antihypertensive therapy to a target blood pressure of <140/90 mm Hg. Therefore, the original answer to this item (option D, Clinical monitoring) regarding a pregnant patient with chronic hypertension is no longer correct. Options B (Start hydrochlorothiazide) and C (Start labetalol) could be considered for management of this patient’s hypertension. (Added November 2022)

 

: The lead-in, Which of the following is the most appropriate test?, has been edited to Which of the following is the most appropriate diagnostic test? to provide clarification. (Added February 2024)

 

: This question has been revised to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)

 

: In the first sentence of the second paragraph of the critique, “aged 50” has been changed to “age 45”; in the fourth sentence, “50 years of age” has been changed to “45 years of age.” (Added November 2022)

 

: In the first Key Point of the critique, “23-valent pneumococcal conjugate vaccine” has be changed to “23-valent pneumococcal polysaccharide vaccine.” (Added November 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added February 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added February 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C to earn CME/MOC credit for this question. The item has been excluded because the data is insufficient to include the answer (Option C), potassium citrate, as a potential option for prevention of kidney stones. (Added May 2023)

 

: In sentence two of the first paragraph of the stem, "150/90 mm Hg" was changed to "145/90 mm Hg" and in sentence six, "atenolol" was removed. In sentence one of paragraph two of the stem, "150/96 mm Hg" was changed to "148/96 mm Hg." In the critique, paragraph two (Option B explanation) was revised. Sentence two was revised to read, "Primary hyperaldosteronism should be suspected in patients with sustained hypertension of >150/100 mm Hg on three separate measurements, resistant hypertension (uncontrolled hypertension on a three-drug regimen inclusive of a diuretic), controlled blood pressure on four or more antihypertensives (one of which is a diuretic), hypertension with hypokalemia (either spontaneous or diuretic induced), hypertension and an incidentally discovered adrenal mass, or a family history of early-onset hypertension or stroke at age <40 years. If adding a diuretic does not lead to improved blood pressure control, a subsequent work-up for primary hyperaldosteronism would be appropriate." (Added May 2023)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. CME credit and ABIM MOC points will be honored for this invalidated question. Please select option D for CME and MOC credit. This item has been excluded because there is more than one correct answer. Option B (mycophenolate mofetil) can cause tremor. Therefore, both options B and D are correct. (Added July 2022)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer E to earn CME/MOC credit for this question. The item has been excluded based on the NOSTONE trial that significantly affects the evidence base for using hydrochlorothiazide. The NOSTONE trial evaluated the use of hydrochlorothiazide in the prevention of kidney stone recurrence. The trial demonstrated that once daily hydrochlorothiazide (at a dose of 12.5 mg, 25 mg, or 50 mg) did not reduce the risk of recurrent calcium-containing stones as compared with placebo. (Added May 2023)

 

: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added February 2022)

 

: The critique of this question has been updated to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)

 

: . In paragraph two of the critique, the second sentence, "In this case, the urine anion gap will be positive, reflecting increase urinary excretion of hydrogen ions," has been replaced with "In these types of cases, the urine anion gap will be negative, reflecting increased urinary excretion of hydrogen ions." (Added July 2022)

 

: The critique of this question has been updated to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)

 

: The Educational Objective, "Manage end-stage kidney disease with non-dialytic palliative therapy," has been replaced with "Manage advanced chronic kidney disease with non-dialytic palliative therapy." (Added July 2022)

 

Neurology

 

Stroke

: Cardioembolic Stroke. The last sentence of the second paragraph has been changed to "For further details on anticoagulation criteria in atrial fibrillation, see MKSAP 19 Cardiovascular Medicine." An additional sentence has been added, stating, "For recommendations regarding percutaneous PFO closure to prevent a secondary stroke, see MKSAP 19 Cardiovascular Medicine." (Added May 2023)

: Subarachnoid Hemorrhage Treatment. In the second sentence of the first paragraph, “and maintenance of a blood pressure of less than 140/80 mm Hg is required” has been replaced with “and blood pressure control are required.” The sentence “Most guidelines recommend maintaining systolic blood pressure values below 160 mm Hg; in clinical practice, a goal of 140/80 mm Hg is frequently used” has been added immediately after. The first key point has been revised accordingly. (Added January 2023)

: Primary Prevention. In the first sentence of the first paragraph, the cross-reference should be: MKSAP 19 General Internal Medicine 2. (Added August 2021)

 

Cognitive Impairment

: Figure 16. Footnote a was removed from the figure. (Added January 2024)

 

Multiple Sclerosis

: Lifestyle Modifications and General Health Care. In the third sentence of the fifth paragraph, "Although the risk of relapse is increased slightly in the first 3 months of pregnancy" has been changed to "Although the risk of relapse is increased slightly in the first 3 months postpartum." (Added May 2023)

 

Neuromuscular Disorders

: Paraproteinemic Neuropathy. The cross-reference at the end of the third sentence of this paragraph should be: (See MKSAP 19 Hematology.) (Added August 2021)

: Toxic Myopathy. In the last sentence, “hydroxymethylglutaryl–coenzyme A receptor” has been changed to “hydroxymethylglutaryl–coenzyme A reductase.” The sentence now states “These patients have a serum antibody to hydroxymethylglutaryl–coenzyme A reductase and may respond to immunosuppression.” (Added November 2023)

 

Neuro-oncology

: Table 53. In the second row of the table, "thymoma" has been added to the "Associated Cancers" column. (Added July 2022)

Questions

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The fifth sentence of the first paragraph of the question stem has been revised to read as follows: "Her sister, brother, mother, and maternal aunt have similar muscle, neurologic, and multiorgan symptoms, but her father and a second brother do not." (Added March 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The patient's current medications have been removed from the first paragraph of the Stem; a fifth paragraph on medical therapy has been added. The first and third paragraphs of the Critique have been revised. Additionally, in the second paragraph of the Critique the answer options were incorrectly listed as "Options A-C"; this has been corrected to "Options A, B, D." The answer option in the third paragraph has been updated to "Option C." (Added November 2022)

 

: In the question stem, the second sentence of the second paragraph should read: "She has right facial weakness, dysarthria, and right arm and leg weakness with a downward drift, with the leg not touching the examination table." (Added August 2021)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the third paragraph of the Stem, "right internal carotid artery stenosis of 60% to 80%" was revised to "right internal carotid artery stenosis of 60%." Additionally, the Critique has been revised. (Added November 2022)

 

: The third sentence of the fourth paragraph of the Stem, “Transthoracic echocardiogram shows an ejection fraction of 50% with no wall motion abnormalities, left atrial dilation, valvular regurgitation, or stenosis,” was changed to “Transthoracic echocardiogram shows an ejection fraction of 50% with left atrial dilation but no wall motion abnormalities, valvular regurgitation, or valvular stenosis.” (Added April 2024)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Recombinant herpes zoster vaccine" to "Varicella vaccine." In addition, the first and fourth paragraphs of the Critique have been revised accordingly. (Added May 2022)

 

: After the third sentence of the first paragraph of the critique, the following text was inserted: “Offspring of affected fathers do not inherit these diseases, but all offspring regardless of sex are at equal risk for inheriting the disease when a mother possesses the mutation. Each cell carries multiple copies of the mitochondrial genome and deleterious mutations usually affect some but not all copies of the mitochondrial genome. The expression of disease due to mitochondrial DNA depends on the relative proportions of normal and abnormal mitochondrial DNA. This means that there can be substantial variation in the likelihood of developing the disease and the disease severity. In this case, three of the offspring are affected because of this variable expression of disease. ” In addition, the last sentence of the first paragraph should read: “In this patient, fluctuating weakness, ophthalmoplegia, multiorgan symptoms, and family history should prompt consideration of mitochondrial myopathy.” Finally, the Key Point should read: “Mitochondrial myopathy is associated with fluctuating weakness, ophthalmoplegia, multiorgan symptoms, and maternal inheritance.” (Added March 2022)

 

: In the first sentence of the second paragraph of the Critique, "previously known as complex partial seizures" was revised to "previously known as simple partial seizures." Additionally, the abbreviation "JME" was spelled out as "juvenile myoclonic epilepsy" in the last sentence of the second paragraph. (Added November 2022)

 

: The third sentence of the first paragraph of the critique should read: "He is receiving the most appropriate medical therapy, including aspirin and a high-intensity statin." (Added January 2022)

 

: The first sentence of the fifth paragraph of the Critique was revised to “Vitamin E deficiency (Option E) can cause myelopathy and peripheral neuropathy, but myopathy with proximal weakness is not typical of this condition.” (Added July 2023)

 

: The bibliographic reference was changed to "Hoh BL, Ko NU, Amin-Hanjani S, et al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2023;54:e314-e370. [PMID: 37212182] doi:10.1161/STR.0000000000000436.” (Added April 2024)

 

: In the first paragraph of the critique, after the 11th sentence, the following text was added: "The Infectious Disease Society of America recommends careful observation rather than antimicrobial treatment in older patients with functional and/or cognitive impairment with bacteriuria and delirium and without local genitourinary symptoms or other systemic signs of infection (strong recommendation, very low-quality evidence). The next sentence should read “In this patient who cannot give a symptom history, a urinalysis seems a reasonable initial management step." (Added January 2022)

 

Oncology

 

Breast Cancer

: Epidemiology and Risk Factors. The first sentence of the second paragraph has been changed from “Patients with deleterious BRCA1 or BRCA2 gene mutations have a 50% to 85% lifetime risk of breast cancer,” to “Patients with deleterious BRCA1 or BRCA2 gene mutations have a 45% to 75% lifetime risk of breast cancer.” (Added July 2023)

: Ductal Carcinoma in Situ: The last sentence of the third paragraph should read: "Following bilateral mastectomy, adjuvant endocrine therapy is not indicated." (Added January 2022)

: Ductal Carcinoma in Situ. The last sentence of the third paragraph should read: “If bilateral mastectomy is performed, the risks of local recurrence and of a new contralateral breast cancer are both extremely low, and adjuvant endocrine therapy is not indicated.” (Added January 2023)

: Adjuvant Endocrine Therapy. The second sentence in the third paragraph should read: “Extended aromatase therapy up to 10 years increases disease-free survival in patients with high-risk features but does not have an impact on overall survival.” (Added March 2022)

 

Gastroenterological Malignancies

: Colon Cancer: The fourth key point should read: "Patients with stage II colon cancer that is microsatellite stable and lacks high-risk features are unlikely to benefit from adjuvant chemotherapy." (Added January 2022)

 

Genitourinary Cancer

: Epidemiology and Risk Factors. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Lymphoid Malignancies

: Hairy Cell Leukemia. The fourth sentence of the second paragraph has been revised from "Relapses can be treated with the alternate purine nucleoside agent, rituximab and the anti-CD22 immunoconjugate moxetumomab pasudotox-tdfk" to "Relapses can be treated with the alternate purine nucleoside agent, followed by rituximab." (Added April 2024)

 

Effects of Cancer Therapy and Survivorship

: Survivorship Care Plan. The last two sentences of the second paragraph have been changed from, "Screening MRI, mammography, or a combination of both modalities is recommended for these patients beginning at age 25 years or 8 years after completing radiation therapy, whichever occurs last," to, "For women who receive chest radiation before age 30 years, annual breast cancer screening is recommended to begin 8 to 10 years post-therapy or at age 25 years, whichever comes last. The National Comprehensive Cancer Network guideline recommends annual breast MRI from ages 25 to 29 years, and mammography in addition to MRI beginning at age 30 years." (Added May 2023)

Questions

 

: The first sentence of the stem should read: "A 50-year-old woman is evaluated for heaviness and swelling of her right breast of 3 weeks' duration." (Added March 2022)

 

: The second sentence of the stem should read: “After radiation treatment, his prostate-specific antigen (PSA) level dropped to a nadir of 1.5 ng/mL (1.5 µg/L); it had remained stable until it rose to 2 ng/mL (2 µg/L) 1 year ago and is currently 3.7 ng/mL (3.7 µg/L).” The fifth sentence of the critique should read: “This patient had a nadir PSA of approximately 1.5 ng/mL (1.5 µg/L) and now has a PSA of 3.7 ng/mL (3.7 µg/L) 9 years after treatment.” (Added July 2023)

 

: The next to last sentence in the first paragraph of the critique should read: "Annual breast cancer screening is recommended to begin 8 to 10 years post-therapy or at age 25 years, whichever comes last. The National Comprehensive Cancer Network (NCCN) guideline recommends annual breast MRI from ages 25 to 29 years, and mammography in addition to MRI beginning at age 30 years." The first key point should read: "For women survivors of Hodgkin lymphoma who received chest irradiation between age 10 and age 30, annual breast cancer screening with MRI is recommended to begin 8 to 10 years posttherapy or at age 25 years, whichever comes last, with mammography in addition to MRI beginning at age 30 years." (Added May 2023)

 

: The second and third sentences of the critique should read: “After bilateral mastectomy for DCIS, the risks of local recurrence and of a new contralateral breast cancer are both extremely low at 1%. In this setting, neither radiation therapy nor hormonal therapy provides benefit.” (Added January 2023)

 

Pulmonary and Critical Care Medicine

 

Pulmonary Diagnostic Tests

: Pulmonary Function Testing. The text has been updated to acknowledge that the use of race as a variable in establishing predicted values for pulmonary function tests is inappropriate and that alternate means of describing norms have been proposed. (Added March 2022)

 

Airways Disease

: Epidemiology and Natural History. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: The figure has been revised. The updated version includes only the National Asthma Education and Prevention Program guidelines for a stepwise approach to asthma therapy. The recommendations for asthma therapy from the Global Initiative for Asthma can be found in Table 72. (Added November 2022)

: Controller Medications: In the first full sentence at the top of page 14, the eosinophil counts given in SI units in parentheses have been corrected from "0.15 x 109/L" and "0.4 x 109/L" to "0.15 x 10⁹/L" and "0.4 x 10⁹/L." (Added January 2022)

: Other Agents. In the first sentence of the first paragraph, the word "inflammatory" has been changed to "anti-inflammatory." (Added March 2022)

 

Diffuse Parenchymal Lung Disease

: Sarcoidosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

 

Common ICU Conditions

: Epidemiology of Sepsis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Management of Sepsis: In the first paragraph, "time-based metrics" has been changed to "the development of separately created time-based performance improvement metrics." The fourth sentence has been revised to read as follows: "In 2018, the 3- and 6-hour bundles were combined into a single 1-hour performance improvement bundle." Under the subheading "Initial Resuscitation," the first two sentences of the second paragraph have been revised to read as follows: "The Surviving Sepsis Campaign guidelines recommend early and aggressive fluid resuscitation for sepsis-induced hypoperfusion or shock with an initial bolus of 30 mL/kg of crystalloid fluid given within the first 3 hours of resuscitation. The 1-hour performance improvement bundle indicates that fluid bolus should be initiated within the first hour of presentation." (Added January 2022)

Questions

 

: In the second sentence of the second paragraph of the critique, the following text has been removed: “however, there are criteria for patient selection, and the procedure is not recommended for patients with a BMI greater than 32. This patient's BMI of 34 would exclude him from candidacy.” At the end of the same paragraph, the following text was added: “who is beginning a weight loss program and is primarily in need of an option to use when traveling.” (Added April 2024)

 

: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn CME/MOC credit for this question. The item has been excluded because the recommendations of the guidelines on which it was based (the Global Initiative for Asthma and the National Asthma Education and Prevention Program) now conflict with one another. (Added November 2022)

 

: In the fourth sentence of the first paragraph of the stem, "21-pack-year history" has been changed to "15-pack-year history." (Added March 2022)

 

: In the third sentence of the first paragraph of the critique, the word “hyperthermia” has been changed to “hypothermia.” (Added November 2022)

 

: In the third sentence of the fourth paragraph of the stem, "7.6 U/L" has been changed to "7.6 g/dL (76 g/L)." (Added January 2023)

 

: In the second sentence of the first paragraph of the stem, “On the day of admission,” has been changed to “Prior to admission” (Added May 2022)

 

: In the first sentence of the fourth paragraph of the critique, the word "performed" has been changed to "initiated." (Added January 2022)

 

Rheumatology

 

Systemic Vasculitis

: In Table 41, seventh row, second column, “(10%-15%)” has been added after "tracheal/subglottic stenosis". (Added November 2022)

 

Other Rheumatologic Diseases

: Adult-Onset Still Disease: In the fourth sentence of the second paragraph, sore throat has been added to the list of minor Yamaguchi criteria. (Added May 2023)

Questions

 

: The descriptions of the blue and red arrows in the critique figure have been switched. The fifth and sixth sentences in the first paragraph of the critique now read: “The blue arrow, pointing to the humeral head, illustrates aggressive bone destruction at the glenohumeral junction. The red arrow illustrates distended subacromial/subdeltoid bursa with fluid and calcific debris.” (Added November 2022)

 

: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "Quadrivalent influenza" to "Recombinant influenza," and option E has been changed from "13-Valent pneumococcal conjugate" to "15-Valent pneumococcal conjugate". (Added May 2022)

 

: In the last paragraph of the stem, the FVC value has been changed from 82% to 75%. (Added May 2023)

 

: In the third paragraph of the critique, the sentence "However, GPA involvement of the lungs is typically parenchymal and does not involve the trachea" has been changed to "However, GPA involvement of the lungs is typically parenchymal, and tracheal involvement is much less common (10%-15% of patients) than in relapsing polychondritis (about 50% of patients). In addition, inflammatory involvement of the helix of the ear is uncommon." (Added November 2022)

 

: In the first key point, the percentage of cases of acute anterior uveitis due to spondyloarthritis in the United States has been changed from 85% to 40%. (Added January 2023)

 

Board Basics

Cardiovascular Medicine

: Chronic Stable Angina, Treatment. In the paragraph on cardioselective β-blockers, the term "reactive airways disease" has been changed to "asthma." (Added July 2023)

: Study Table: Treatment of HFrEF. Some table content has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Cardiac Physical Diagnosis, Heart Murmurs. The highlighted sentence beginning, "Signs of serious cardiac disease include..." has been revised to, "Signs of possible significant cardiac disease include..." (Added May 2022)

Endocrinology and Metabolism

: Diabetes Mellitus, Type 2 Diabetes Mellitus. Under “Screening for Type 2 Diabetes,” the first sentence has been revised to, “The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 35 to 70 years who have overweight or obesity.” (Added May 2023)

: Diabetes Mellitus, Type 2 Diabetes, Study Table: Treatment of Diabetes Complications. In the row for "Diabetes and average cardiovascular risk," the "Goal or Indication" cell has been revised to state only, "Age >40 years and diabetes." The 10-year ASCVD risk has been deleted, because the ACC/AHA guideline recommendation is regardless of risk. (Added November 2022)

: Hypoglycemia in Patients Without Diabetes, Test Yourself. This scenario has been rewritten as follows: “A previously healthy 28-year-old man is found unconscious on the ward where he works. His plasma glucose level is 28 mg/dL. He regains consciousness following IV glucose administration. Serum insulin level is elevated, and serum C-peptide level is low.

For diagnosis, select surreptitious use of insulin.” (Added November 2023)

: Pheochromocytoma, Don’t Be Tricked. The second sentence of this bullet point has been corrected to, “β-Adrenergic blockade before adequate α-adrenergic blockade can result in severe paroxysmal hypertension.” (Added July 2022)

Gastroenterology and Hepatology

: Achalasia, Testing. The order of diagnostic evaluation has been revised to better demonstrate how these three tests are complementary in making the diagnosis of achalasia. The text now reads:

Diagnostic evaluation:

• Upper endoscopy rules out structural causes such as esophagitis, stricture, ring, or adenocarcinoma
• Esophageal manometry confirms diagnosis by documenting absence of peristalsis and incomplete relaxation of the LES with swallows
• Barium esophagography is likely to demonstrate “bird's beak” narrowing of the GE junction (Added November 2022)

 

: Chronic Pancreatitis, Diagnosis. The last bullet point in the list should read “endocrine pancreatic insufficiency (diabetes mellitus)” not “exocrine.” (Added July 2022)

General Internal Medicine

: Systemic Exertion Intolerance Disease, Diagnosis & Treatment. The first sentence under "Diagnosis" has been revised to state, "Systemic exertion intolerance disease (SEID) is defined as an impairment or reduction in the ability to engage in pre-illness activities lasting more than 6 consecutive months that is accompanied by fatigue and not alleviated by rest." The second sentence under "Treatment" has been revised to state, "Patients with SEID benefit most from a structured, multimodal approach that includes regularly scheduled office visits and that focuses on symptom and comorbid disease management." (Added March 2022)

: Perioperative Medicine, Pulmonary Perioperative Management. The last sentence in the section, "Select early mobilization and lung expansion maneuvers (deep breathing exercises, incentive spirometry) to prevent pulmonary complications" has been deleted. The evidence behind incentive spirometry in preventing perioperative pulmonary complications, although a low-risk intervention, is not convincing. (Added April 2024)

: Eye Disorders, Study Table: Causes and Treatment of Red Eye. In the first row of the table regarding bacterial conjunctivitis, the cell in the "Do This…" column has been revised to clarify treatment in content lens wearers. The cell now indicates, "Topical trimethoprim-polymyxin B or erythromycin for immunocompromised patients and health care workers; topical fluoroquinolone therapy for contact lens wearers; otherwise, withhold." (Added May 2024)

Hematology

: Thrombophilia, Inherited Thrombophilia. The discussion has been revised to clarify that factor V Leiden mutation is the most common hereditary thrombophilia in those of European ancestry. (Added March 2022)

Infectious Disease

: Ehrlichiosis and Anaplasmosis, Figure. The title of the figure has been revised from "Human Granulocytic Ehrlichiosis" to "Ehrlichiosis and Anaplasmosis." (Added May 2023)

: Rocky Mountain Spotted Fever, Treatment. The sentence stating, "In patients who are pregnant, choose chloramphenicol," has been removed. (Added July 2023)

: Study Table: Prophylaxis for Patients With HIV Infection. In the row on MAC infection, when to provide prophylaxis has been clarified to indicate, “CD4 cell count <50/μL and patient not receiving ART.” (Added November 2022)

Oncology

: Lung Cancer, Screening and Prevention. In the second paragraph, starting "Annual screening...” the recommendation has been updated to "patients aged 50 to 80 years (guidelines vary) who have a 20-pack-year history of smoking, including those who quit smoking in the preceding 15 years..." (Added May 2023)

Nephrology

: Approach to Acid-Base Problem Solving, Delta-Delta. In "Problem 2," the PCO₂ has been revised to 21 mm Hg. (Added November 2023)

: Study Table: Presentation and Treatment of Alcohol Poisoning. For the row on "Ethanol," the Anion Gap should indicate "Possible" rather than "No." (Added March 2022)

: Hypertension, Treatment. The text has been revised to acknowledge that race-based antihypertensive prescribing recommendations are under scrutiny. (Added February 2022)

: Hypertension, Treatment. The "Don't Be Tricked" point, "Thiazide diuretics are not effective in patients with kidney disease (GFR <30 mL/min/1.73 m²); select a loop diuretic" has been revised to, "Choose a loop diuretic rather than a thiazide diuretic for patients with GFR <30 mL/min/1.73 m²." (Added May 2022)

: Study Table: Common Causes of the Nephrotic Syndrome. The table has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)

: Nephrolithiasis, Study Table: Kidney Stone Risk Factors and Therapy. In the last row of the table, the word "cysteine" under Risk Factors has been corrected to "cystine." (Added May 2023)

Pulmonary and Critical Care Medicine

: Solitary Pulmonary Nodule, Test Yourself. In this scenario, the nodule description has been revised from "subsolid" to "pure ground glass," and the follow-up CT timing has been changed from "1 year" to "6-12 months." (Added November 2023)

Rheumatology

: Study Table: Vasculitis Diagnosis. Some table content has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)

: Vasculitis, Don't Be Tricked. The second Don't be Tricked point has been revised for consistency. The point now reads, "Polyarteritis nodosa kidney disease does not involve the glomerulus (no urine erythrocyte casts, but hematuria and proteinuria may occur)." (Added May 2022)

: Vasculitis, Test Yourself. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)