NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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July 1, 2025
MKSAP 19 General Internal Medicine 1, Question 68
A 74-year-old man undergoes follow-up evaluation 4 weeks after an urgent care visit for benign paroxysmal positional vertigo. He is concerned about an upcoming trip and the possibility of falling. He has had no recent falls but did have a near fall. Medical history is significant for atrial fibrillation. Current medications are metoprolol, apixaban, and meclizine.
On physical examination, blood pressure and pulse rate are normal and without orthostatic changes. Cardiac examination reveals an irregular rhythm. Screening neurologic examination is normal.
The Timed Up and Go Test result is prolonged (16 seconds).
The patient undergoes canalith repositioning with the Epley maneuver.
Which of the following is the most appropriate additional management to reduce this patient's risk for falls?
A. Discontinue meclizine
B. Discontinue metoprolol
C. Prescribe a four-prong cane
D. Prescribe vitamin D
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Discontinue meclizine
Educational Objective:
Prevent falls in an elderly patient.
The most appropriate measure to reduce this patient's risk for falls is to discontinue meclizine (Option A). Meclizine is a centrally acting antihistamine associated with increased fall risk in elderly patients. Many health conditions, physical characteristics, and behaviors increase risk for falling, but the greatest increases are associated with cognitive impairment, psychoactive medications, gait/balance problems, and decreased lower extremity strength. The presence of multiple risk factors has an additive effect on fall risk. Even fear of falling in the absence of falls decreases self-rated health and hastens functional decline. The Timed Up and Go (TUG) test is used to help assess fall risk. This test involves asking the patient to rise from a chair with armrests, walk 10 feet, turn, return to the chair, and sit down. A TUG Test result of more than 12 seconds should prompt intervention to reduce fall risk.
Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo. Symptoms lead to increased risk for falls and a decline in functional status. First-line therapy for BPPV is canalith repositioning with the Epley maneuver, which is effective in up to 85% of patients. Medication is not useful in the treatment of BPPV except when the episodes are frequent and disabling. In that situation, the vestibular suppressant betahistine (not available in the United States) may be helpful along with the Epley maneuver. Meclizine probably contributed to this patient's near fall and fear of falling and is not especially helpful in controlling the symptoms of BPPV; it should be discontinued.
Discontinuing metoprolol (Option B) places the patient at increased risk for poor rate control of his atrial fibrillation and, in the absence of orthostatic hypotension, will not reduce his risk for falls.
Prescription of an assistive device, such as a cane (Option C), in the absence of a gait abnormality is not recommended.
Vitamin D supplementation (Option D) is not recommended for fall risk reduction. Meta-analysis of randomized controlled trials of community-dwelling elderly adults showed no reduction in fall or fracture risk in patients without osteoporosis or known vitamin D deficiency.
Key Point
Many health conditions, physical characteristics, and behaviors increase risk for falling, but the greatest increases are associated with cognitive impairment, psychoactive medications, gait/balance problems, and decreased lower extremity strength.
Bibliography
Grossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;319:1696-704. PMID: 29710141 doi:10.1001/jama.2018.3097
Copyright 2019, American College of Physicians.
June 17, 2025
MKSAP 19 Neurology, Question 60
A 78-year-old woman is evaluated in the hospital following treatment with intravenous alteplase 8 hours ago for acute ischemic stroke. CT angiogram showed no large vessel occlusion. The National Institutes of Health Stroke Scale (NIHSS) score before and 1 hour after treatment was 9. She has atrial fibrillation and hypertension. Outpatient medications were warfarin, enalapril, and amlodipine. At the time of hospital admission the INR was 1.0.
On physical examination, vital signs are normal. Oxygen saturation is 97% with the patient breathing ambient air. She has left facial weakness and dysarthria. The raised left arm and leg have a downward drift that contacts the bed, and there is a decreased sensitivity to pinprick on the left side. Heart rhythm is irregularly irregular.
Which of the following is the most appropriate next step in management?
A. Atorvastatin
B. Intravenous heparin
C. Oxygen by nasal cannula
D. Repeat head CT
E. Swallow evaluation
Responses Received from Members (728 Responses):
The Correct Answer is: E. Swallow evaluation
Educational Objective:
Manage acute ischemic stroke treated with thrombolysis.
The most appropriate next step is to perform a swallow evaluation (Option E) for dysphagia. She had an acute ischemic stroke treated appropriately with intravenous alteplase. She was not eligible for thrombectomy, given the absence of a large vessel occlusion. The patient's neurologic status has not changed since she received treatment, but she should continue to have neurologic checks and blood pressure monitoring once every hour for the first 24 hours. Any change in neurologic status should prompt repeat imaging to ensure that there is not symptomatic intracerebral hemorrhage, which would also require reversal. Oral medications can be considered after a formal dysphagia evaluation to minimize the risk of aspiration pneumonia.
Atorvastatin (Option A) and other statins have not been shown to reduce the risk of recurrent stroke when administered within 30 days but can be considered after a dysphagia evaluation has been completed, especially in those patients with an atherosclerotic stroke subtype. This patient most likely had a cardioembolic stroke, and the need for statin therapy will be determined by measurement of lipid levels.
Intravenous heparin (Option B) is not effective in acute ischemic stroke of cardioembolic etiology; in this patient it is contraindicated because she received thrombolysis. Oral anticoagulation in patients with atrial fibrillation can be restarted closer to hospital discharge if there are no hemorrhagic complications. A direct acting anticoagulant will be a better choice than restarting warfarin because of superior effectiveness, standard dosing, and lack of need for monitoring.
Oxygen supplementation (Option C) is not recommended in patients with acute medical or neurologic injury unless there is a decline in the oxygen saturation. Supplemental oxygen in patients with normal oxygen saturation increases mortality in patients with stroke and other acute illnesses.
Repeating head CT (Option D) is not appropriate because the patient has not had any change in
examination findings and has not yet reached the posttreatment time window of 24 hours, at which point repeat imaging is indicated.
Key Point
Any change in neurologic status following intravenous thrombolytic therapy for acute ischemic stroke should prompt repeat imaging to assess for intracerebral bleeding.
Patients with a stroke should receive a formal swallow evaluation before any oral intake.
Bibliography
Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110. PMID: 29367334 doi:10.1161/STR.0000000000000158
Copyright 2019, American College of Physicians.