Table Of Content*MKSA
@
ACP
lVle# i*eI Hr-#=lrl**g* Self-A,=s*s*rrrffi nt Frmilr#ffi re
General lnternal
Medicine
2
@ACP
American College of Physicians@
Leading lnternal Medicine, lmproving Lives
Welcome to the General lnternal
Medicine 2 Section of MKSAP 19!
To address the ever-growing role ofgeneralists and the broad and comprehensive spectrum ofillnesses they treat, General
Internal Medicine has been expanded into tvvo sections for MKSAP 19. In these pages, you will find updated information
on routine care of the healthy patient; patient safety and quality improvement; hospital medicine principles: perioperative
medicine; obesity; men's and women's health; eye, ear, nose, mouth, and throat disorders; and dermatologic conditions. The
General Internal Medicine 1 section, published in MKSAP 19 Part A, features content on clinical decision making and inter
preting the medical literature, medical ethics and professionalism, common symptoms, pain, palliative medicine. common
musculoskeletal problems, dyslipidemia, mental and behavioral health, geriatric medicine, and genetics' All of these topics
are uniquely focused on the needs of generalists and subspecialists in internal medicine'
MKSAP 19 strives to provide the clinical knowledge its learners need to navigate their longitudinal learning paths. MKSAP l9's
core content contains essential, newly researched information in 11 subspecialty areas of internal medicine created by dozens
of expert generalists and subspecialists. Development of MKSAP 19's syllabus and its 1200 all-new peer reviewed. psychomet
rically validated multiple choice questions (MCQs) has been informed by ABIM Certification and Maintenance of Certification
(MOC) requirements, emerging internal medicine knowledge, and our learners' feedback. MKSAP 19 continues to include
High Value Core (HVC) recommendations and MCQs, based on the concept of balancing clinical benefit with costs and harms.
Hospital-based internists can continue to trust that MKSAP's comprehensive hospitalist content, integrated throughout the syl
labus, and hospitalist focused MCQs, specially designated with the blue hospitalist icon (E), continue to align with the ABIM's
Focused Practice in Hospital Medicine MOC exam blueprint and enhance learning for hospital based practitioners.
More than ever before, MKSAP 19 Digital focuses on individualized learning and convenience. In addition to custom quizzes
and interlinked questions and syllabus sections, MKSAP 19 Digital's new learning dashboard enables users to create a self-
directed learning plan, with topic-specific links to resources within MKSAP and ACP Online. Multimedia formats, including
whiteboard animations and clinical videos, will benefit our audiovisual learners, while MKSAP's Earn-as-You-Go CME/MOC
feature now allows subscribers to earn CME/MOC as they answer individual questions. In addition to Extension Questions and
New Info Updates, MKSAP 19 Complete and Complete Green continue to offer Virtual Dx and Flashcards and non,offer brand
new enhancements: MKSAP Quick Qs, a set of concise questions mapped to high frequency/high-importance areas of the
ABIM blueprint mirroring boards-style MCQs, and an embedded digital version of Board Basics for easy-access exam prep.
Language can be imprecise and imperfect, but MKSAP 19's Editors and contributors commit to using language and images
that support ACP's commitment to being an anti racist organization that supports diversi$, equity, and inclusion through
out health care and health education. ACP also continues to ensure diversity among MKSAP's physician-contributors. When
appropriate, the MKSAP Editors also rely on MKSAP 19 Digital's expanded use of multimedia enhancements, including video
and audio, to explore and more fully explain issues surrounding the presentation of MKSAP 19 clinical content as it relates to
race and ethnicity. MKSAP 19 users are encouraged to contact the Editors at mksap_editors6racponline.org to help us identiff
opportunities for improvement in this area.
On behalf of the many internists and editorial staff who have helped us create our new edition, we are honored that y,ou have
chosen to use MKSAP 19 to meet your lifelong learning needs.
Sincerely,
Davoren Chick, MD, FACP
Editor in Chief
Senior Vice President
Medical Education Division
Amcrican C<-rllege of Physicians
ll
General lnternal Medicine 2
Committee AmyTuWang, MD, FACP
Associate Professor of Medicine
Kurt Pfeifer, MD, FACE Section Editor
David Geffen School of Medicine at UCLA
Professor of Medicine
Los Angeles, California
Division of General lnternal Medicine
Associate Program Director, Internal Medicine Residency
Medical College ol' Wisconsin
Medical Director, Employee Health
Milwaukee, Wisconsin
Department of Medicine
Amy H. Farkas, MD, MS Harbor UCLA Medical Center
Assistant Professor of Medicine Torrance. California
Division of General Internal Medicine
Medical College of Wisconsin Editor-in-Chief
Clement J. Zablocki VA Medical Center
Davoren Chick, MD, FACP
Milwaukee, Wisconsin
Senior Vice President. Medical Education
Galen Foulke, MD American College of Physicians
Assistant Professor Philadelphia. Pennsylvania
Department of Dermatologr
University of North Carolina Senior Deputy Editor
Chapel Hill. North Carolina
Patrick C. Alguire, MD, EACP
Scott Herrle, MD, MS, FACP American College ol Physicians
Associate Prof'essor of Medicine Phi ladelphia, Pennsylvania
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Deputy Editor
Jeremy Jackson, MD
Robert L. Trowbridge, Jr., MD, FACP
Associate Professor
Department of Medicine
l)epartment of Dermatologz
Maine Medical Center
University of Mississippi Medical Center
Portland. Maine
Jackson, Mississippi
Tufts University School of Medicine
Heather E. Nye, MD, PhD Boston, N4assachusetts
Professor of Medicine and Pediatrics
Department of Medicine General lnternal Medicine 2 Reviewers
University of California, San Francisco
Bhavin Adhyaru, MD, MS, FACP
Associate Chiel oI Medicine
I\4egan Berman, MD, FACP
Director of Co Management and Consult Medicine Services
John Cox. MD
Director of Veterans' Integrated Perioperative (VlP) Clinic
Elie G. Dib. MD
San Francisco VA Health Care System
Doug Einstadter, I\4D, MPH, FACP
San Francisco, California
Gairy Hall, MD, FACP
Eric I. Rosenberg, MD, MSPH, FACP Heather Henri, MD, FACP
Professor and Chief Alan T. Kaell, MD, FACP
Division of General Internal Medicine Ketevan Kobaidze, MD, PhD, FACP
Department of Medicine Shailaja Nair, MD, FACP
University of Florida College of Medicine Ateeq Rehman, MD, FACP
Associate Chief Medical Officer Kavitha Subramoney, MD, FACP
UF Health Shands Hospital Bright Thilagar, MD, FACP
Gainesville. Florida Cynthia Wong, MD, FACP
llr
Opting in for MOC found with the list of contributors' names and those of ACP
principal staff listed in the beginning of this book.
MKSAP 19 users can opt in for simultaneous submission of
CME and MOC points as they answer self assessment ques-
Language Reflecting Diversity, Equily,
tions. To opt in, users will be required to complete a form
and lnclusion Within MKSAP 19
requesting their name, date of birth, and ABIM number. The
MOC Opt-in Form will be presented during a user's first MKSAP 19's Editors and contributors commit to using
CME submission and needs to be completed only once. language and images that support ACP's commitmellt to
being an anti racist organization that supports diversify,
ABIM Maintenance of Certification equity, and inclusion throughout health care and health
Successful completion of the CME activiry which includes education. ACP also continues to ensure diversity among
participation in the evaluation component, enables the par MKSAP's physician contributors. When appropriate,
ticipant to earn up to 300 medical knowledge MOC points in the MKSAP Editors will also rely on MKSAP 19 Digital's
the ABIM's MOC program. It is the CME activity provider's expanded use of multimedia enhancements. including video
responsibility to submit participant completion information and audio, to explore and more fully explain issues sur-
to ACCME for the purpose of granting MOC credit. rounding the presentation of MKSAP 19 clinical content as it
relates to race and ethnicity. MKSAP 19 users are encouraged
Disclosure Policy to contact the Editors at mksap-editors6lacponline.org to
help us identi$z opporhrnities for improvement in this area.
It is the policy of the American College of Physicians (ACP)
to ensure balance, independence, objectivity, and scientific Hospital-Based Medicine
rigor in all of its educational activities. To this end, and con
sistent with the policies of the ACP and the Accreditation For the convenience of subscribers who provide care itr
Council for Continuing Medical Education (ACCME), con hospital settings, comprehensive hospital focused content
tributors to all ACP continuing medical education activities aligned with the ABIM Focused Practice in tJospital Mt:dicine
are required to disclose all relevant financial relationships blueprint is integrated throughout the syllabus, and self
with any entity producing, marketing, re selling, or dis assessment questions that are specific to the hospital setting
tributing health care goods or services consumed by, or are specially designated with the blue hospitalist icon tlEl).
used on, patients. Contributors are required to use generic
names in the discussion of therapeutic options and are High Value Care Key Points
required to identify any unapproved, off-label, or inves Key Points in the text that relate to High Value Care concepts
tigative use of commercial products or devices. Where a (that is, concepts that discuss balancing clinical benefit with
trade name is used, all available trade names for the same costs and harms) are designated by the HVC icon [HVC].
product type are also included. If trade name products
manufactured by companies with whom contributors have
Educational Disclaimer
relationships are discussed, contributors are asked to pro-
vide evidence based citations in support ofthe discussion. The editors and publisher ol MKSAP 19 recognize that the
The information is reviewed by the committee responsible development of new material offers many opportunities
for producing this content. If necessary adjustments to for error. Despite our best eflforts, some errors may prersist
topics or contributors' roles in content development are in print. Drug dosage schedules are, we believe, accurate
made to balance the discussion. A11 relevant relationships and in accordance with current standards. Readers eLre
are mitigated. Readers of this content are asked to evaluate advised, however, to ensure that the recommended dos
it for evidence of commercial bias and send any relevant ages in MKSAP 19 concur with the information provided
comments to mksap-editors6lacponline.org so that future in the product information material. This is especialJy
decisions about content and contributors can be made in important in cases of new, infrequently used, or higltly
light ol this inlormation. toxic drugs. Application of the information in MKSAP 19
remains the professional responsibility of the practitioner.
Mitigation of Conflicts
The primary purpose of MKSAP 19 is educational.
To mitigate all conflicts of interest and influences of vested Information presented, as well as publications, technologies,
interests, ACP's content planners used best evidence and products, and/or services discussed, is intended to infcrrm
updated clinical care guidelines in developing content, subscribers about the knowledge, techniques, and exp,sri-
when such evidence and guidelines were available. All ences ofthe contributors. A diversity ofprofessional opinion
content underwent review by external peer reviewers not exists, and the views of the contributors are their own and
on the committee to ensure that the material was balanced not those of the ACP. Inclusion of any material in the pro-
and unbiased. Contributors' disclosure information can be gram does not constitute endorsement or recommendration
vl
I
by the ACP. The ACP does not warrant the safety, reliability, not set up MKSAP CME/MOC accounts for purchasers of
accuracy, completeness, or usefulness of and disclaims any MKSAP sold by unauthorized sellers (e.g., Amazon, eBay),
and all liability for damages and claims that may result from with whom ACP has no relationship. We do not honor
the use of information, publications, technologies, products, third party sales. CME credits and MOC points cannot be
and/or services discussed in this program. awarded to those purchasers who have purchased the pro
gram from non-authorized sellers.
Permission for Use of Figures Shown in
MKSAP 19 General lnternal Medicine 2 Unauthorized Use of This Book ls
Multiple-Choice Ouestions Against the Law
Figure shown in the critique of Self-Assessment Test Unauthorized reproduction of this publication is unlaw-
Item 37 is reprinted with permission from Walker HK, ful. ACP prohibits reproduction of this publication or any
\ Hall WD, Hurst JW, Editors. Clinical Methods: The of its parts in any form either for individual use or for
History, Physical, and Laboratory Examinations, third distribution.
:\ edition. Chapter 118, Tonometry. Boston: Butterworth
ACP will consider granting an individual permission to
t Heinemann, 1990. Gl 1990 Butterworth Heinemann. reproduce only limited portions of this publication for
: his or her own exclusive use. Send requests in writing to
\ Publisher's lnformation
MKSAP- Permissions, American College of Physicians, 190 N
it Copyright Et 2022 American College of Physicians. All Independence Mall West, Philadelphia, PA 19106 7572, or
't rights reserved. email your request to mksap-editors6racponline.org.
This publication is protected by copyright. No part of MKSAP 19 ISBN: 978-l-938245-75-6
I
this publication may be reproduced, stored in a retrieval General Internal Medicine 2 ISBN: 978 1 938245-83-1
tI system, or transmitted in any form or by any means, elec- Printed in the United States of America.
t tronic or mechanical, including photocopy, without the
It
express consent of the ACP. MKSAP 19 is for individual For order information in the U.S. or Canada, call 800-ACP-
it use only. Only one account per subscription will be per- 1915. In all other countries, call 215-351-2600 (Monday
mitted for the purpose of earning CME credits and MOC to Friday, 9 eu-S prvr ET). Fax inquiries lo 215-351-2799 or
tt
points and for other authorized uses of MKSAP 19. email to [email protected].
L
Disclaimer Regarding Direct Purchases Errata and Revisions
t
L from Online Retailers
Errata and Revisions for MKSAP 19 will be available
I\
CME and/or MOC for MKSAP 19 is available only to custom- through MKSAP 19 Digital at mksaplg.acponline.org as
tI ers who purchase the program directly from ACP. ACP will new information becomes known to the editors.
,
t
i
t
t
t
t
t]
t\
I
t\
It
I
t
t
\,
tI
t
t
t
i
tI vll
t
L
t
:
Table of Contents
Routine Care of the Healthy Patient Perioperative Medicine
H istory and Physical Exantinatior-r .1 General Responsibilities. . . . . 28
Periodic Health Examinatior.r. .1 Preoperative Laboratory'l'esting 28
....
Routine History and Physical Examination . . .1 PerioperativeMedication Management . 29
Screening .2 Postoperative Care. . . 29
Principles of Screening. ,2 CardiovascularPerioperative Management .. . ... 31
Screening Recommendations fbr Adults . . . . .3 Cardiovascular Risk Assessnlent. . . 31
Specific Screening l'ests . . ,4 Cardiovascular Risk Management. . 33
lmmunization 12 Pulmonary Perioperative Management 34
Vaccinations Recommended tbr All Adults . . t2 Pulmonary Risk Assessment . . . 34
Vaccinations Recommended lbr Some Adults 13 Perioperative Risk Reduction Strategies. . . . . 35
Vaccinations Recommended for Hematologic Perioperative Management 35
Specific Populations 15 Venous Thromboembolism Prophylaxis. . . . . 35
Aspirin tbr Primary Prevention 16 Perioperative Management of
Healthy Lit'estyle Counseling t6 Anticoagulant Therapy ,1
Wellness 17 Perioperative Management of Antiplatelet
Behavioral Counseling 17 Medications 38
Nutrition. 18 Perioperative Management of Anemia,
Physical Activity 1B Coagulopathies, and'l'hrombocytopenia . . . . 3B
Perioperative Management of Endocrine Diseases 39
Supplements and Herbal Therapies 1B
Diabetes Mellitus 39
Thyroid Disease 39
Patient Safety and Ouality lmprovement
lntroduction. .......19 Adrenal Insufficiency 39
Perioperative Management ol Kidney Disease. . . . 40
Patient Saf'ety and Quality Issues
attheClinicianlevel .......19 Perioperative Management of Liver Disease. . . . . . 40
MedicationErrors. .....19 Perioperative Management of Neurologic Disease. 47
MedicationAdherence .........27 Rheumatologic Perioperative Management. . . . . . 41
'l'ransitionsof Care .....22 Perioperative Management During
Disease Modifying Antirheumatic
Patient Safbty and Quality lssues at the Systems Level. . . 22 Drug and Biologic Therapy. 4t
Models ..........
Qualitylmprovement 22 Perioperative Management ol Special Populations 4t
MeasurementofQualitylmprovement ...... 23 Geriatric Patients. 4t
Patient Safety and Quality Improvement Initiatives . . . 23 Pregnant Patients 42
Home. .......23
Patient CenteredMedical
HighValueCare... .....23
0besity
ChcrosingWisely .......24
Defi nition and Epidemiologr 42
Goals
National Patient Saf'ety . . . .24 Screening and Evaluation. . . 43
Health Infbrmation Technology and Patient Safety. . . . 24 'freatment. 43
Healthliteracy .....24
Lifestyle Modification . . 43
Pharmacologic Therapy 44
Hospital Medicine Principles Bariatric Surgery. . . . .. 44
nterprofessional Communication and
I
'l'eam BasedCare. . . 25 Men's Health
Consultation and Co management. . . 25 Male Sexual Dysfunction 46
Hospital Based Prevention Strategies . 27 Erectile Dysfunction 46
lx
1
..
l
.....
Premature Ejaculation OpticNeuritis 74
:
Decreased Libido. Retinal Detachment 74 I
Reproductive Counseling and Male Retinal Vascular Occlusion . 74
I
Sterilization Retinal Artery Occlusion 74
:
Androgen Deficiency Retinal Vein Occlusion . 74 I
Benign Prostatic Hyperplasia.
Acute Testicular and Scrotal Pain . . Ear, Nose, Mouth, and Throat Disolders
Hydrocele, Varicocele, and Epididymal Cyst . Hearing Loss . . 7S
Acute and Chronic Prostatitis and Pelvic Pain
Tinnitus 77
Hernias.
Otitis Media and Otitis Externa. 77
Cerumen Impaction 7B
Women's Health
Epistaxis 7B
Breast Symptoms. . . Upper RespiratoryTract Infection. . . . . . 79
Breast Mass. The Common Cold . . 79
Breast Pain
Sinusitis 79
Reproductive Health Rhinitis. 79
Contraception
Pharyngitis. 79
Preconception Care. . . . . . . Epiglottitis BO
Postpartum Care . . Salivary Gland Disorders . . . 80
Menstrual Disorders
Oral Health. 81
Abnormal Uterine Bleeding
Dental Disease and Infections . . . . . 81
Dysmenorrhea...........
Menopause.
Dermatologic Disorders
Diagnosis
Approach to the Patient With Dermatologic
Management
Disease 82
Pelvic Pain
Morphologr 82
Acute PelvicPain. . ... . . . . Physical Examination 82
Chronic Pelvic Pain......
. Diagnostic Tests. . B3
Female Sexual Dysfunction . . .. Therapeutic Principles in Dermatolory . . . . B4
Vaginitis
General Considerations. . . . . . B4
Bacterial Vaginosis.
Topical Glucocorticoids . . . . 85
Vulvovaginal Candidiasis . . Topical Antifungal Agents 85
..........
Trichomoniasis
Topical Immunomodulators B6
Topical Retinoids 86
Eye Disorders
Topical Antibiotics. 86
EyeEmergencies....
Dermatitis B6
Red Eye. AtopicDermatitis...
Conjunctivitis ..... B6
Contact Dermatitis 87
Keratitis
HandDermatitis... 88
Episcleritis andScleritis. . . . . . Seborrheic Dermatitis. BB
Uveitis.
Nummular Dermatitis 89
Subconjunctival Hemorrhage
. Intertrigo 89
Blepharitis
Venous Stasis Dermatitis . . . 90
DryEye.
Urticaria. 90
CornealAbrasions andUlcers . . . . ., DrugEruptions....
9T
Cataracts.
Exanthematous (Morbilliform) . . . . . . . 9l
Glaucoma.
Fixed Drug Eruption. 97
Primary Open Angle Glaucoma
Drug-Induced Hypersensitivity
Angle Closure Glaucoma. . . . . . Syndrome (ORESS Syndrome) 9T
Age-Related Macular Degeneration. . Hypersensitivity Vasculitis 93
x
Stevens-Johnson Syndrome and Nail Disorders . 115
Toxic Epidermal Necrolysis Infection. . tr6
Acute Generalized Exanthematous Pustulosis, Inflammatory Nail Disorders. . . ..tt7
Pruritus IngrownToenail .... . .lt7
Acneiform Eruptions . . Melanonychia . 118
Acne Vulgaris Squamous Cell Carcinoma. . . . . . 118
Rosacea. Benign Nodules and Tumors . 119
Hidradenitis Suppurativa Seborrheic Keratosis . tLg
Pigment Disorders Warts, Corns, and Skin Tags. . . . . 119
Vitiligo Dermatofibroma ... . t20
Nevi... . L20
Autoimmune Bullous Diseases DysplasticNevi ....... ....... . r2l
Pemphigus Vulgaris Premalignant and Malignant Tumors . t2t
Bullous Pemphigoid Actinic Keratosis . 127
Photo- or LightJnduced Dermatoses. . . . . Squamous Cell Carcinoma and
Porphyria Cutanea Tarda . Keratoacanthoma. . t22
Phototoxic and Photoallergic Conditions. . . . . Basal Cell Carcinoma t23
Polymorphous Light Eruption. Melanoma L24
Superficial Skin Infections. . . . . . Inflammatory Dermatoses 126
Bacterial Skin Infections. . . . . . Psoriasis 126
....
Dermatophytes Lichen Planus 126
Yeast .. Erythema Multiforme 127
Viral Skin Infections and Exanthems . . . . . . . . Erythema Nodosum t27
Ectoparasites Erythroderma ..... t28
Lice... SweetSyndrome... t28
Scabies
Bed Bugs. Bibliognphy t29
Burns
.
Alopecia
lelf.AssesmentTest. 135
Nonscarring Localized and
Generalized Alopecia
Scarring Localized and Generalized Alopecia lndex 237
xt
I
1
I
1
I
1
I
1
I
I
l
General lnternal Medicine
2
High Value Care Recommendations
r
The American College of Physicians, in collaboration with Preoperative ECG should not be performed in patients
multiple other organizations, is engaged in a worldwide undergoing low-risk procedures.
initiative to promote the practice of High Value Care o Patients with coronary artery disease should not undergo
(HVC). The goals of the HVC initiative are to improve routine coronary angiography or revascularization before
health care outcomes by providing care ofproven benefit surgery exclusively to reduce perioperative events.
r
and reducing costs by avoiding unnecessary and even Chest radiography, arterial blood gas analysis, or spirom
harmful interventions. The initiative comprises several etry is not routinely indicated in the preoperative evalua
programs that integrate the important concept of health tion of patients with chronic lung disease (see Item 23).
care value (balancing clinical benefit with costs and o There is no benefit of incentive spirometry with or with
harms) for a given intervention into a broad range of out deep breathing exercises, in preventing postoperative
educational materials to address the needs of trainees. pulmonary complications (see Item 111).
.
practicing physicians, and patients. Patients with untreated, asymptomatic mild hypothy
roidism may proceed to surgery without further testing
HVC content has been integrated into MKSAP 19 in sev
or treatment.
eral important ways. MKSAP 19 includes HVC-identified r
Pregnant patients should undergo the same preoperative
key points in the text, HVC-focused multiple-choice ques-
medical evaluation as nonpregnant patients; additional
tions, and, in MKSAP Digital, an HVC custom quiz. From
diagnostic testing is unnecessary.
the text and questions, we have generated the following .
There is little evidence that over-the-counter weight loss
list of HVC recommendations that meet the definition
supplements are effective.
below ofhigh value care and bring us closer to our goal .
Aspirin should be used infrequently in primary prevention
of improving patient outcomes while conserving finite
of atherosclerotic cardiovascular disease (see Item 77).
resources. r
Routine screening for abdominal aortic aneurysm (AAA)
High Value Care Recommendation: A recommendation to in women who have never smoked and who have no
choose diagnostic and management strategies for patients family history of AAA is not recommended (see Item 97).
r
in specific clinical situations that balance clinical benefit Do not screen for coronary artery disease with either
with cost and harms with the goal of improving patient resting or exercise ECG in asymptomatic patients at low
outcomes. risk (see Item 22).
r
Clinicians should not use clinical breast examination to
Below are the High Value Care Recommendations for the
screen for breast cancer.
General Internal Medicine 2 section of MKSAP 19. .
Ultrasonography is preferred to mammography in the
r
The ordering ofexcessive tests and procedures to avoid evaluation of a breast mass in women younger than
malpractice litigation leads to waste and potential harm 30 years.
through unnecessary testing and treatment (see Item 84). o Routine laboratory testing for the diagnosis of menopause
o Routine testing beyond the history and physical exam- is not recommended.
ination is not necessary in the preparticipation physical o Nonhormonal therapies are preferred to topical vaginal
examination (see Item 87). estrogen as first-line treatments for genitourinary syn-
o The use of B-carotene or vitamin E supplements for the drome of menopause (see Item 1).
.
prevention of cardiovascular disease or cancer is not The preferred colorectal screening strate$/ is the one
recommended. most likely to be completed by the patient (see Item 67).
. Urinalysis is not indicated before joint arthroplasty in o Clinicians should not screen men for prostate cancer
asymptomatic patients (see Item 30). unless they express a preference for screening (see
o Patients whose Iaboratory test results in the past 4 months Item 106).
were normal and whose clinical status is stable do not o Observation is recommended for uncomplicated acute
need repeat testing before surgery (see Item 30). otitis media in adults and children.
o Patients with less than 1% risk for perioperative major r Antibiotic therapy is ineffective in the treatment for the
adverse cardiac event may proceed to surgery without common cold or acute rhinosinusitis and is not recom
additional testing. mended (see Item 42).
xltl
