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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August 25th, 2026
Pulmonary & Critical Care Medicine, Question 62
A 72-year-old man is evaluated for daytime sleepiness. His wife notes that he snores. He sleeps 8 hours each night. On most days of the week, he feels sleepy and will nap for 45 minutes. Medical history is significant for atrial fibrillation and heart failure. Medications are valsartan-sacubitril, metoprolol, furosemide, spironolactone, empagliflozin, and apixaban.
On physical examination, vital signs are normal. BMI is 27. Low-lying soft palate, irregularly irregular cardiac rhythm, normal central venous pressure, clear lung fields, and chronic venous stasis are present.
Transthoracic echocardiogram obtained 1 year ago showed left ventricular enlargement and left ventricular ejection fraction of 40%.
Which of the following is the most appropriate test?
A. Actigraphy
B. Home sleep apnea testing
C. Overnight oximetry
D. Polysomnography
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: D. Polysomnography
Educational Objective: Diagnose sleep apnea with polysomnography.
The most appropriate management is polysomnography in a sleep laboratory (Option D). Objective testing is required for a diagnosis of obstructive sleep apnea (OSA) and central sleep apnea (CSA). In- laboratory polysomnography is the gold standard test for mission-critical workers, patients with complicated OSA, and patients with comorbid conditions such as heart failure, neuromuscular disease, and advanced pulmonary disease in which diagnostic and treatment algorithms are more complex. This patient has risk factors for both OSA (male sex, snoring, overweight) and CSA (heart failure and atrial fibrillation). Once the type of apnea is clarified during the diagnostic portion of polysomnography, the technician may then use the most appropriate mode of positive airway pressure therapy and assess the response to treatment.
An actigraph (Option A), a small device worn on the wrist, uses an accelerometer and an ambient light sensor to objectively measure disrupted sleep patterns and sleep-wake cycles over multiple days and nights. Actigraphy is not a substitute for a home sleep study or polysomnography and cannot diagnose sleep apnea syndromes.
Home sleep apnea testing (Option B) should be used in patients without comorbid cardiopulmonary disease who are likely to have OSA of at least moderate severity, such as a middle-aged man with obesity who snores loudly, pauses breathing, and gasps during sleep.
Overnight pulse oximetry (Option C) is poorly discriminative to diagnose OSA, but in those who are asymptomatic with a low pretest probability, normal overnight oximetry might be reassuring and support the decision to avoid further testing. The patient has daytime sleepiness, which is a strong indication for treatment of sleep-disordered breathing. Further screening with overnight oximetry will not add reliably important diagnostic information, nor will it alter the decision to treat.
Key Point
- In-laboratory polysomnography is the gold standard sleep apnea test for mission-critical workers, patients with complicated obstructive sleep apnea, and patients with comorbid conditions such as heart failure, neuromuscular disease, and advanced pulmonary disease in which diagnostic and treatment algorithms are more complex.
Bibliography
Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13:479-504. PMID: 28162150 doi:10.5664/jcsm.6506
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.
August 11th, 2026
MKSAP 19 General Internal Medicine 1, Question 23
A 56-year-old man is evaluated during a routine follow-up appointment. He has schizophrenia treated with olanzapine. Currently, the patient experiences no hallucinations or delusions. He is otherwise healthy. Previous ECGs have been normal.
On physical examination, vital signs are normal. BMI is 27. The examination shows flat affect. Speech is normal, and thoughts appear organized.
A fasting blood glucose measurement is pending.
Which of the following should also be monitored in this patient?
A. Complete blood count
B. Lipid levels
C. Liver chemistries
D. Prolactin level
E. QT interval
Responses Received from Members (816 Responses):
The Correct Answer is: B. Lipid levels
Educational Objective: Monitor a patient taking antipsychotic medication.
Lipid levels (Option B), weight, and blood glucose level should be monitored in this patient who has schizophrenia and takes olanzapine, a second-generation antipsychotic medication. Schizophrenia is associated with an increased risk for diabetes mellitus, cardiovascular disease, and obesity, and undertreatment of medical disease is common in this population. Metabolic effects of antipsychotic therapy also can contribute to these conditions, which significantly increase mortality in patients with schizophrenia. The most common adverse effects of second-generation antipsychotic agents are weight gain (and sequelae of weight gain, such as hyperglycemia) and hyperlipidemia. The fasting blood glucose level should be measured upon initial medication initiation and at 3 months.
Thereafter, the fasting glucose level should be checked at least annually. More frequent monitoring can be considered in patients with risk factors for diabetes. Lipid monitoring should be performed at baseline, at 3 months, and at least every 5 years thereafter.
Complete blood count monitoring (Option A) is required for patients who take clozapine owing to its association with agranulocytosis. Routine complete blood count monitoring is not required with olanzapine use.
Periodic monitoring of liver chemistries (Option C) is required with use of some first-generation antipsychotics, such as fluphenazine, but it is not needed with olanzapine.
First-generation (typical) antipsychotic agents have a higher risk for extrapyramidal symptoms (parkinsonism, akathisia), tardive dyskinesia, and hyperprolactinemia than do second-generation (atypical) antipsychotic agents. Regardless of whether the patient is treated with typical or atypical agents, in the absence of side effects, such as nipple discharge, routine monitoring of the prolactin level (Option D) is not indicated.
Second-generation antipsychotic agents, including olanzapine, have been associated with a prolonged QT interval. However, the incidence of prolonged QT interval with olanzapine alone is less than 2%. When combined with other agents that can prolong the QT interval (quinidine, selective serotonin reuptake inhibitors, tricyclic antidepressants, ondansetron), QT should be monitored. In a patient with a previously normal QT interval and no new medications, routinely obtaining an ECG for QT interval monitoring (Option E) is not required.
Key Points
- The most common adverse effects of second-generation antipsychotic agents are weight gain (and sequelae of weight gain, such as hyperglycemia) and hyperlipidemia.
- Weight, blood glucose level, and lipid levels should be monitored in patients taking second- generation antipsychotic drugs.
Bibliography
American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601. PMID: 14747245 doi:10.2337/diacare.27.2.596
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.