Clinical Practice Points
Patients with chronic neck pain often use complementary health care strategies, such
as acupuncture or the Alexander Technique, for treatment of their symptoms. In this
randomized, controlled trial, the long-term clinical effectiveness of acupuncture
or the Alexander Technique was compared with usual care for patients with chronic
Use this study to:
- Ask your learners what history and physical examination are appropriate when a patient
complains of neck pain.
- What is the differential diagnosis of chronic neck pain? When is testing appropriate,
and what kind?
- Ask your learners if they recommend “alternative” therapies (e.g., acupuncture,
chiropractic manipulation) for their patients with musculoskeletal complaints. Why
or why not? How do they know what does or does not work? Are there potential harms?
- Review the description of the Alexander Technique and the intervention used in this
trial presented in the article's Appendix. Ask your learners what the challenges are
in interpreting the results from educational and behavioral interventions. What might
affect the generalizability of the results?
In this study of add-on treatments to metformin, the addition of dipeptidyl peptidase-4
(DPP-4) inhibitors was associated with a lower risk for all-cause mortality, stroke,
and hypoglycemia compared with use of sulfonylureas. In contrast to prior studies,
there was no increased risk for myocardial infarction or hospitalization for heart
failure with DPP-4 inhibitor use.
Use this study to:
- Review the classes of drugs used for the treatment of type 2 diabetes mellitus. How
does each work? Use the information and tables in In the Clinic: Type 2 Diabetes.
- Ask your learners if they have prescribed DPP-4 inhibitors. What are the benefits
and potential harms? Are they reassured by this study regarding cardiovascular risks?
- Read the accompanying editorial, pointing out that with 6 drug classes to treat diabetes, there are 30 possible
2-agent combinations and 120 possible 3-agent combinations. In the absence of evidence
for each, how do we choose among these combinations when more than one drug is needed?
What variables do your learners consider when individualizing care?
- Ask why the lack of information regarding the patients' hemoglobin A1c levels is important. The editorialist discusses this issue.
- This study used a propensity score to “adjust” for differences between
the patients included in the study. Invite an expert in epidemiology and/or biostatistics
to review what such an approach can and cannot do. Use a short essay that discusses the potential utility and pitfalls of propensity score adjustments
to help frame your discussion. Consider combining this with the study below assessing
outcomes with emergency medical transport to create a teaching session about the importance
of potential confounders.
Humanism and Professionalism
This Annals Graphic Medicine video illustrates the challenges, failures, and successes of a patient
trying to manage his diabetes.
Use this Annals Graphic Medicine to:
- Watch the video with your learners.
- Ask if they got bored or impatient. Why? Might the authors have intended that to happen?
- Ask your learners if they grow impatient with patients who are not compliant with
your recommendations for management of their diabetes. Does watching this video alter
Hannah Breit tells us about how, as a medical student, her mirrored reflection changed
upon hearing she had cancer, and how it has since returned.
Use this essay to:
- Listen to an audio recording of this powerful essay, read by Dr. Michael LaCombe.
- Ask your learners what they think their response would have been to such news.
- What was their reaction to hearing about the wait to see a surgeon? Shocked? Appalled?
Was it surprising?
- Have your learners ever considered how the well-intentioned outreach by others to
patients with an illness might be a source of well-appreciated support, but also a
- How can such an essay make us better doctors? Better people?
A 56-year-old woman is evaluated in the emergency department for a 4-hour history
of nonproductive cough and shortness of breath. She does not have chest pain, hemoptysis,
or other localizing signs. She underwent laparoscopic cholecystectomy under general
anesthesia 6 weeks ago. Her medical history is notable for a childhood history of
asthma, but she has not had asthma symptoms as an adult. Her sister and daughter both
have asthma. She currently takes no medications.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure
is 140/86 mm Hg in both arms, pulse rate is 72/min and regular, and respiration rate
is 18/min; BMI is 33. Mild injection of the pharynx is noted. Cardiac examination
is normal. Pulmonary examination reveals rare scattered wheezes bilaterally over the
chest with no tenderness to palpation. Surgical incisions are healing well. The abdomen
is minimally tender, and bowel sounds are normal. There is no swelling or tenderness
of the legs.
Laboratory studies reveal a D-dimer level of less than 0.5 µg/mL (0.5 mg/L)
and a leukocyte count of 4,900/µL (4.9 × 109/L). Pulse oximetry is 93% breathing ambient air. Electrocardiogram and chest radiograph
Which of the following is the most appropriate next step in management?
A. Abdominal CT
B. CT angiography
C. Duplex ultrasonography of the legs
D. Peak flow measurement
D. Peak flow measurement
In clinically stable patients with a low pretest probability of pulmonary embolism
using the Wells or Revised Geneva scores, a normal D-dimer assay effectively excludes
an acute thrombotic process and eliminates the need for further testing.
Exclude pulmonary embolism with a D-dimer test in a low-risk patient.
The most appropriate next step in management is measurement of peak flow. This patient
has a strong family history of asthma and a remote personal history of asthma. She
has wheezing and pharyngeal injection on examination, which could reflect a viral
respiratory infection or reflux triggering bronchospasm as the cause of her dyspnea.
Thus, assessment for airflow obstruction is appropriate. Despite a history of recent
surgery and symptoms of acute onset of dyspnea, this patient's pulmonary embolism
(PE) risk score determined by either the Wells or Revised Geneva scoring systems suggests
a low probability of PE. Immunologic D-dimer assays are particularly sensitive for
detecting the presence of intravascular thrombosis. In this patient with a low PE
risk score, the normal D-dimer level effectively excludes PE; therefore, further testing
for PE, either by CT angiography or by duplex ultrasound of the legs (to identify
deep venous thrombosis as a source for PE), is not indicated.
Although abdominal surgery (particularly an open procedure) is associated with an
increased risk for perioperative pulmonary complications, there is no suggestion by
history or physical examination of an ongoing abdominal process as a cause of this
patient's respiratory symptoms that would indicate the need for abdominal imaging.
Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive
pulmonary embolism. Chest. 2011;140(2):509-518. PMID: 21813530
This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.