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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September 22nd, 2026
MKSAP 19 Rheumatology, Question 24
A 66-year-old woman is evaluated for a 10-year history of pain in the hands and knees. She has tried occupational therapy, with minimal benefit; she is enrolled in a weight loss program. She has hypertension and chronic kidney disease. Current medications are lisinopril and amlodipine.
On physical examination, Heberden and Bouchard nodes are present and there is carpometacarpal joint tenderness. The medial joint line of each knee is tender to palpation. There is bony enlargement of the medial knees, with crepitus on range of motion.
Laboratory evaluation shows a serum creatinine level of 2.2 mg/dL (194.5 μmol/L) and an estimated glomerular filtration rate of 45 mL/min/1.73 m2.
Which of the following is the most appropriate treatment?
A. Hydrocodone
B. Meloxicam
C. Topical capsaicin
D. Topical diclofenac
E. Topical lidocaine
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: D. Topical diclofenac
Educational Objective: Treat osteoarthritis of the knees and hands with a topical NSAID.
The most appropriate treatment is topical diclofenac (Option D). Topical NSAIDs, such as diclofenac, are safe and effective for treatment of knee and hand osteoarthritis (OA). For OA in those locations, the 2019 American College of Rheumatology (ACR)/Arthritis Foundation (AF) guideline suggests that topical NSAIDs should be considered before oral NSAIDs because of fewer safety concerns. Topical NSAIDs are not effective for hip OA and have limited efficacy in OA of other sites.
There is minimal benefit of opioid therapy, including hydrocodone (Option A), for chronic pain control in patients with OA. Opioids pose a high risk for toxicity and dependence and should not be used to treat OA.
Oral NSAIDs, such as meloxicam (Option B), are an ACR/AF guideline–recommended first-line treatment for hand, knee, and hip OA. However, they should be used cautiously in patients older than age 50 years and avoided in those with comorbidities, such as a history of peptic ulcer disease or gastrointestinal bleeding, and in patients with hypertension, cardiovascular disease, or chronic kidney disease, as in this patient.
The ACR/AF guideline conditionally recommends topical capsaicin (Option C) for patients with knee OA and conditionally recommends against topical capsaicin in patients with hand OA. The guideline notes limited data supporting the efficacy of topical capsaicin for knee OA. No direct evidence supports topical capsaicin in the treatment of hand OA, and eye contamination is possible when it is used on the hands.Other topical agents are available, such as lidocaine (Option E) and methyl salicylate preparations, but they are not as well studied or as efficacious as topical NSAIDs. They may be used as adjunctive measures.
Key Points
- Topical NSAIDs are safe and effective for treatment of knee and hand osteoarthritis and should be considered before oral NSAIDs.
- Oral NSAIDs are recommended for the treatment of hand, knee, and hip osteoarthritis but should be avoided in patients with comorbidities, such as peptic ulcer disease, cardiovascular disease, and chronic kidney disease.
Bibliography
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72:220-233. PMID: 31908163 doi:10.1002/art.41142
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
September 8th, 2026
MKSAP 19 Pulmonary & Critical Care Medicine, Question 48
A 29-year-old woman was hospitalized 24 hours ago with hypoxemic respiratory failure due to influenza pneumonia. She was intubated and placed on mechanical ventilation. Treatment includes lactated Ringer solution, intravenous peramivir, propofol, fentanyl, and norepinephrine.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 109/59 mm Hg, pulse rate is 90/min, and respiration rate is 24/min. The arterial PO2 is 60 mm Hg on FIO2 of 0.65, and positive end-expiratory pressure is 10 cm H2O. Tidal volume is 6 mL/kg ideal body weight, and plateau pressure is 27 cm H2O. The patient is sedated but wakes to touch and is calm. Pulmonary rhonchi are present bilaterally.
Chest radiograph shows bilateral opacities. Echocardiogram reveals normal cardiac function and chamber size.
Which of the following is the most appropriate intervention to improve oxygenation?
A. Increase level of sedation
B. Perform recruitment maneuver
C. Prone positioning
D. Start diuretics
Responses Received from Members (565 Responses):
The Correct Answer is: C. Prone positioning
Educational Objective: Treat acute respiratory distress syndrome with prone positioning.
The most appropriate management is prone positioning (Option C). The patient has severe acute respiratory distress syndrome (ARDS) due to influenza pneumonia (arterial PO2/FIO2 = 92). Prone positioning reduces compression of portions of the lung behind the cardiac and mediastinal structures and improves ventilation/perfusion matching in patients with ARDS. Prone positioning for at least 12 to 16 hours daily should be considered for patients with moderate to severe ARDS with persistent hypoxemia despite use of low tidal volume ventilation and plateau pressure less than 30 cm H2O. The indications for prone positioning have been variably defined, but entry criteria in a pivotal clinical trial that showed benefit included: arterial PO2/FIO2 <150; FIO2 ≥0.60 on positive end- expiratory pressure >5 cm H2O. Study participants were intubated for less than 48 hours before initiating prone positioning. Although the patient is also meeting goals for lung protective ventilation, randomized trials show that the addition of prone positioning improves mortality in those patients.
The sedation level should not be increased (Option A). The patient is meeting goals for sedation and is calm and easily arousable. Light-sedation protocols or daily awakening trials are associated with decreased length of mechanical ventilation and length of ICU stay.
In patients with refractory hypoxemia, a recruitment maneuver (Option B)—applying a high level of CPAP to open collapsed alveoli (e.g., continuous pressure to 35 cm H2O for 40 seconds)—has been conditionally recommended. However, a randomized control trial demonstrated that recruitment maneuvers in patients with moderate to severe ARDS was associated with increased risk for barotrauma, pneumothorax, and death compared with standard care. The FACCT trial suggested that excessive fluid resuscitation is harmful to ARDS patients.
This trial compared conservative with liberal fluid strategies based on central venous pressure and pulmonary artery occlusion pressure (a surrogate for left atrial pressure) in patients with ARDS. Although mortality did not differ between groups, patients who were treated with conservative fluid management showed improved oxygenation and decreased time on the ventilator and in the ICU. In patients who are hemodynamically stable and do not have end-organ hypoperfusion, minimizing fluid administration is warranted. This patient still requires norepinephrine blood pressure support; diuresis is not indicated at this time (Option D).
Key Point
- Prone positioning for at least 12 hours daily should be considered for patients with acute respiratory syndrome and arterial PO2/FIO2 <150 mm Hg, FIO2 ≥0.60 on positive end- expiratory pressure >5 cm H2O, who have been intubated for less than 48 hours.
Bibliography
Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377:562-572. PMID: 28792873 doi:10.1056/NEJMra1608077
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.