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A 58-year-old male has increasingly symptomatic osteoarthritis
of the knee. He says that acetaminophen no longer treats his
knee pain effectively, but he has tried ibuprofen, 600 mg three
times daily with food, and says that it works much better. He
does not want to have surgery because his construction firm
has a project with a deadline coming up in the next 3 months.
He does not have hypertension or chronic kidney disease and
does not take any other medications. He is up to date on all
health prevention measures and when he was seen for a
headache in the emergency department 3 months ago a
metabolic profile was normal. He is hesitant to get an injection
of his knee at this time. Which one of the following would be
most appropriate at this point?
Order a hemoglobin level so there is a baseline if he develops
gastrointestinal
bleeding
,Advise against ibuprofen and prescribe low-dose tramadol to
preserve kidney
functi - ANSWER
-C
Medical therapy for osteoarthritis should begin with full-
strength acetaminophen and topical therapy, then proceed to
NSAIDs and selectively to tramadol and other opioids. NSAIDs
and opioids may reduce pain and improve function but have
significant potential harms (SOR A). Based on meta-analyses of
randomized, controlled trials physicians should perform
laboratory screening for and eradicate Helicobacter pylori
before initiating long-term NSAID therapy in NSAID-naive
patients to reduce the risk of peptic ulcer disease (SOR A).
Because of that finding the American College of
Gastroenterology recommends testing for H. pylori infection
before initiating long-term NSAID therapy, and offering
eradication therapy to those with positive results (SOR A).
Physicians should also screen for and eradicate H. pylori
before initiating long-term NSAID therapy in patients with a
history of peptic ulcers (SOR B). Treatment with standard dose
H2-blockers is not effective for preventing peptic ulcers related
to long-term NSAID use.Low-dose tramadol would not be
recommended for this patient if other nonopioid medications
provide relief. Establishing a baseline hemoglobin level is not
necessary before starting NSAID treatment.
At a health maintenance visit, a 29-year-old male who only has
sex with men tells you that he ended a long-term relationship
,about 1 year ago and that he did not use condoms consistently
in that relationship because both he and his partner were
monogamous at the time. After a one-time sexual encounter 4
months ago he was diagnosed with a Chlamydia infection and
treated appropriately. His renal function, HIV, hepatitis B, and
hepatitis C tests were negative at that time. He is now dating a
new partner but has not been sexually active with that
person.In addition to recommending condom use, which one of
the following would be appropriate at this time?
Retesting for
Chlamydia
Retesting for
hepatitis C
A herpes simplex 2
antibody titer
Retesting for HIV and starting pre-exposure prophylaxis (PrEP)
- ANSWER -D
The U.S. Preventive Services Task Force (USPSTF)
recommends initiation of pre-exposure prophylaxis (PrEP) for
HIV in the following populations: Men who have sex with men,
are sexually active, and are in a sexual relationship with a
partner who is HIV positive, OR who use condoms
inconsistently during receptive or insertive anal sex, OR who
have had syphilis, gonorrhea, or a Chlamydia infection within
the past 6 months
Heterosexually active women and men who are in a sexual
relationship with a partner who is HIV positive, OR who use
, condoms inconsistently during sex with a partner whose HIV
status is unknown and who is at high risk, such as a person
who injects drugs or a man who has sex with men and women,
OR who have had syphilis or gonorrhea within the past 6
months
Persons who inject drugs and share drug-injection equipment,
OR who are at risk for sexual acquisition of HIV (see above)
Two medications have been approved for use as PrEP by the
FDA: emtricitabine/tenofovir disoproxil, 200 mg/300 mg once
daily, and emtricitabine/tenofovir alafenamide, 200 mg/25 mg
once daily.Studies have shown that daily PrEP reduces the risk
of HIV from sex by about 99%. In people who inject drugs, daily
PrEP reduces the risk of HIV by at least 74%. PrEP is much less
effective if it is not taken consistently.Recommending
abstinence alone is usually not sufficient. Using condoms
100% of the time will reduce transmission of HIV by 80%, and
will also reduce transmission of other sexually transmitted
infections (STIs). Since this patient had an STI 4 months ago,
PrEP therapy is indicated. Testing for herpes-virus antibodies
is not indicated and another test of cure for Chlamydia
infection is not needed. Hepatitis B status should be
determined before initiation of PrEP, but this patient has
recently been tested so testing is not necessar
A 32-year-old female who is new to your practice sees you for a
health maintenance visit. She does not take any medications
and exercises regularly. She does not have a family history of
coronary artery disease and does not recall having her
cholesterol levels measured in the past. On examination her