Preparing for Your Recertication Exams? 9 Helpful Hints for Busy Physicians

o What red flags suggest that there’s something more going on than “just” a headache?
o What’s the treatment of choice for a corneal ulcer?
o Can you safely clear a patient for laparoscopic surgery if her asthma isn’t completely controlled?

I decided to attend an Internal Medicine Board Review recently.¹ Although I am not recertifying this year, I found the practical guidance offered valuable. For general internal medicine knowledge, there was a section with sample questions under the heading, “Multidisciplinary Skills for the Internist.”² The questions were multiple choice and answers and discussion followed each one. I will summarize a few that succinctly (and painlessly) taught me some important clinical points that will not only help you when you take your recertifying examinations, but also in your daily practice. I have italicized key words and connections that help with problem solving.

A 50-year-old woman has

mild headaches

. The headaches are new. They have no pattern. They respond to

aspirin

but return when the analgesic wears off. Her past history, medication history, general examination, and mental status are all normal. A detailed screening neurological examination is positive for

left pronator drift

and

extinction

of left simultaneous sensory stimulation.

You are offered choices as to the next step. Two are “business as usual”-essentially doing nothing further or treating “depression.” In an era of cost consciousness, 2 are imaging choices (CT or MRI).

Answer: CT of the head without contrast.

Clinical Points³
1. One of the most important historical features of a headache is a change in quality as in this patient. She did not have headaches before at all and now she does. This presentation is not “business as usual” even if the headaches are mild.
2. A response to analgesics does not guarantee benign headaches.
3. Your neurological examination is important!

What is most important is that the History and Physical-what a primary care physician lives and dies by-transcends all other (more expensive) facts. The exam added one-sided upper motor neuron signs to what at first glance was just another headache. That means these headaches are not routine.

A 20-year-old college student comes to see you for eye pain. She has been cramming for finals and has issues with her right eye and contact lens. She can’t wear the lens now because of the eye pain, swelling, and photophobia. She swims regularly and wears her contacts during her workouts. She asks if you can give her drops and an eye patch. You have difficulty with the exam, but notice an area of cloudiness in her right cornea. You call an ophthalmologist and after culture in his office, a pseudomonal corneal ulcer is diagnosed.

I grew up in an era of “patching” any and all ambulatory corneal pathology.⁴ Patching was still a choice; no treatment versus broad-spectrum antibiotic therapy were the 2 other choices.

This is an era of soft contact lenses. Most corneal ulcers today are caused by infections, the risk of which is increased 10-fold by extended-wear lenses.  

Answer: Corneal cultures and sensitivities

Clinical Points
4. Corneal ulcers are analogous to other infections anywhere in the body-know what “bug” you are treating by culture.
5. Swimming with extended-wear lenses can lead to pseudomonal infections of the cornea.
6. The assistance of an ophthalmologist is necessary and has to be immediate.

You see a 48-year-old woman before a planned laparoscopic cholecystectomy. She has asthma. On your physical examination, she has moderate wheezing. She has been treated with theophylline and an albuterol inhaler. It may seem that adding an inhaler, like salmeterol, or a corticosteroid, for example, may fix things. Since she is not all that compromised and her surgery is laparoscopic, she may do well as is. Can you safely “clear” her for elective surgery?

⁵

Answer: The correct (and safest) answer is to cancel surgery until she has her asthma controlled.

This patient is at increased risk for postoperative pulmonary complications with any asthma activity that is unchecked before surgery.  

Clinical Points

7. Asthma activity increases the risk for post-op pulmonary complications: the best option is to defer elective surgery until the airways are under control.

8. Again, when the clinical information provided contains physical exam findings, USE THEM!
9. Elective surgery is elective: you have time to correct morbidities that can negatively affect risk.

References:

1. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014.
2. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:29.
3. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:30.
4. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:38-39.
5. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:40.