Osteoporosis Weight Problems.
You'll hear lots of buzz about Brilinta, a new antiplatelet drug. Brilinta (ticagrelor) will compete with Plavix (clopidogrel) and Effient(prasugrel)...for acute coronary syndrome or after a stent. Plavix will still lead the pack...for a while. It was the first one approved and is used the most. But it's not perfect. Plavix has a delayed onset and variable response...because it has to be activated by cytochrome P450 enzymes in the liver. Effient is more effective than Plavix...but causes more bleeding. That's why it's not for patients with a prior stroke or TIA, or over 75. Brilinta seems to be more effective than Plavix for acute coronary syndrome...and usually doesn't cause any more major bleeding. For every 1000 patients with acute coronary syndrome treated for a year, Brilintaprevents 11 more CV deaths, 11 more MIs, and at least 6 more stent thromboses compared to Plavix. But these stats are affected by the dose of aspirin that is used with Brilinta. Aspirin over 100 mg/day makes Brilinta LESS effective. Watch that patients onBrilinta take only 81 mg/day of aspirin. Brilinta has a faster onset than Plavix or Effient...because it's not a prodrug. It also wears off faster because it binds to platelets REVERSIBLY...instead of permanently like Plavix and Effient. You'll hear this fast offset is an advantage in case a patient needs CABG or other surgery. But both Brilinta and Plavix should be stopped 5 days before surgery...andEffient at least 7 days beforehand. Brilinta's short duration may be a disadvantage in the long run because it has to be taken twice a day...instead of once like the others. Expect to see Plavix's price drop when the generic comes out next year. If you thought that there was already a generic Plavix, good memory. There WAS. But it got withdrawn...and will soon return. If a patient is on Brilinta, avoid using strong 3A4 inhibitors or inducers...clarithromycin, ketoconazole, rifampin, etc. Don't exceed 40 mg/day for simvastatin or lovastatin...and monitor digoxin levels when starting or stopping Brilinta. Keep in mind that Brilinta can cause dyspnea...especially the first week. Consider switching to Plavix or Effient if needed.
A.It's less effective than clopidogrel for acute coronary syndrome. B.It should be used with 81 mg/day of aspirin. C.It can be stopped just 2 days before surgery. D.It's an irreversible platelet inhibitor.
You'll see a new ORAL anticoagulant called Xarelto (zuh-REL-toe). It's initially approved to prevent thrombosis after hip or knee replacement surgery. It'll also likely be approved to prevent stroke in patients with atrial fibrillation. Xarelto (rivaroxaban) is the first ORAL factor Xa inhibitor. It has a fast onset and doesn't need coagulation monitoring. Xarelto is more effective than enoxaparin 40 mg once daily after knee replacement. One more major blood clot is prevented for every 62 patients treated with Xarelto...with a similar bleeding risk. Xarelto also costs about $8 a day...compared to $25 to $50 a day for generic enoxaparin. Patients will take Xarelto 10 mg once daily for 35 days after a hip replacement...or for 12 days after knee replacement surgery. Watch for drug interactions when patients are on Xarelto. Don't combine it with drugs that significantly DECREASE CYP3A4 and p-glycoprotein elimination, such as ketoconazole or ritonavir. Also try not to combine Xarelto with drugs that INCREASE its elimination, such as phenytoin, carbamazepine, and rifampin. If the combo is unavoidable, increase the dose to Xarelto 20 mg/day. Don't give Xarelto to patients with severe renal impairment...or moderate to severe hepatic impairment.
Reps will promote Staxyn (STAX-in), a new orally disintegrating tablet version of vardenafil (Levitra). Think of it as the same as Levitra. The new formula gives it a new marketing angle...but no significant clinical advantage. You may hear it works faster than Levitra...but it doesn't. Orally disintegrating tabs dissolve in the mouth...but they're still swallowed and primarily absorbed in the GI tract like oral meds. This also means that these tabs DON'T avoid the first-pass effect. One advantage is that Staxyn costs less. It costs about $14/tab...compared to $19 for Levitra. Tell patients to take Staxyn an hour before sexual activity...just like with Levitra.
VITAMIN B12Is it ever necessary to give vitamin B12 by injection? Only rarely. This is being brought up now by the recent shortage of injectable B12 (cyanocobalamin) due to manufacturing delays. Many patients have trouble absorbing B12 from food due to reduced gastric acidity or lack of intrinsic factor. We used to think that these patients needed B12 by injection...but in many cases supplements can be given orally instead. About 1% of the B12 in oral supplements is absorbed passively...even in patients without gastric acid or intrinsic factor. Feel comfortable using ORAL B12 for treating mild to moderate deficiencies...or for maintenance therapy. The key is to give enough. Recommend 1000 to 2000 mcg/day of oral or sublingual B12 for mild to moderate deficiencies. Steer patients away from sustained-release B12 supplements...because their absorption might not be adequate. Consider using B12 nasal spray (Nascobal) if another option is needed...but it costs much more than oral or injectable B12. Continue to use injectable B12 for initial treatment of more severe deficiencies...especially if there are neurologic symptoms. Also use the injectable for patients who can't take or adhere to oral meds...or those who may not absorb it due to diarrhea, vomiting, inflammatory bowel disease, or bowel resection.
POST-TRAUMATIC STRESS DISORDERNew VA guidelines for post-traumatic stress disorder discourage using benzodiazepines and encourage treating acute pain aggressively. PTSD is a problem for about 13% of our returning war veterans. It also affects people after assaults, rapes, disasters, and other traumas. Psychotherapy and an SSRI or SNRI antidepressant are first-line. If two trials of an SSRI or SNRI are not helpful, try switching to mirtazapine (Remeron, etc) and then a tricyclic. Cautiously add other drugs if needed for specific symptoms...agitation, nightmares, insomnia, pain, etc. Atypical antipsychotics (risperidone, etc) can be added to an antidepressant to decrease hyperarousal and re-experiencing symptoms. But explain they DON'T seem to help when used alone. Prazosin can help reduce nightmares associated with PTSD. Start with prazosin 1 mg at bedtime and slowly titrate to 6 to 10 mg if needed and tolerated. Caution about possible syncope. Benzodiazepines are often used for insomnia and anxiety...but try not to use them. There's no evidence they help core PTSD symptoms...and they may worsen fear response and slow recovery from trauma. They can also be very hard to discontinue due to withdrawal symptoms. Use trazodone or a non-benzo hypnotic (zolpidem, etc) for sleep. Anticonvulsants (topiramate, etc) overall don't seem effective either as monotherapy or when used as adjuncts to other drugs. Analgesics should be used aggressively for acute pain due to traumatic injuries. Explain that adequately treating pain may reduce the risk of developing PTSD. But follow the usual precautions to limit opioid abuse...especially if they are used chronically. Propranolol seemed promising for lessening the memory of traumatic events. But don't count on it...the latest evidence suggests it's not effective for preventing PTSD.
SMOKING CESSATION People will worry about new warnings about Chantix and an increased risk of cardiac events in patients with heart disease. FDA says there MIGHT be a higher risk...but this is controversial. Any cardiac risk is likely to be small...if it exists at all. Continue to prescribe Chantix (varenicline) when appropriate. Chantix is more effective than other monotherapies for smoking cessation...and FAR less dangerous than continuing to smoke. Patients with heart disease who stop smoking lower their risk of death by 36% within 3 to 7 years. Continue to advise Chantix patients to report serious psychiatric effects...but keep in mind that some psych problems get attributed to Chantix when they're really due to nicotine withdrawal. Use nicotine replacement therapy or bupropion (Zyban, etc) for patients who don't tolerate Chantix. If monotherapy isn't enough, try combining nicotine replacement therapies. Combining the patch plus gum or nasal spray can work at least as well as Chantixto help people quit smoking. Here's a neat new opportunity for you: You can listen to a brief audio snippet of our staff discussing/debating this with our experts during one of our working sessions.
A.Varenicline (Chantix) is less effective than other smoking cessation therapies. B.Combining a nicotine patch and gum can work as well as varenicline. C.Nicotine replacement should never be combined with varenicline. D.Varenicline increases cardiac risk more than smoking.
A patient with a T score of -1.5 based on dual-energy x-ray absorptiometry (DEXA) at the spine and hip is classified as having: A) Normal bone mass B) Low bone mass C) Osteoporosis D) Severe osteoporosis
The Fracture Risk Assessment Tool is not validated for which of the following? A) Femoral neck bone mineral density (BMD) B) Total hip BMD C) Spine BMD D) Use in patients who have never taken pharmacotherapy for osteoporosis
According to the American Society for Bone and Mineral Research: A) Numerous large studies show increased risk for cardiovascular events associated with calcium and vitamin D supplementation B) Calcium supplements should be taken by all patients >65 yr of age, regardless of dietary calcium intake C) Most recent osteoporosis treatment studies suggest adequate vitamin D required for efficacy of antifracture therapy D) Calcium supplements recommended only for patients with T score <-1.5
Choose the correct statement about atypical subtrochanteric and diaphyseal femoral fractures. A) Use of bisphosphonates most common cause B) Usually due to serious trauma C) No risk associated with glucocorticoids or proton pump inhibitors D) Observational data suggest risk after 9 yr of treatment similar to that of stopping treatment after 3 mo
Which of the following agents used to treat osteoporosis may be associated with increased risk for serious infections of the skin, abdomen, urinary tract, or ear? A) Denosumab B) Raloxifene C) Teriparatide D) Alendronate
Use of estrogen plus progestin for the treatment of menopausal symptoms is associated with increased risk for: A) Breast cancer B) Stroke C) Kidney stones D) All the above
A study found all the following were associated with improvements in hot flushes, except: A) Physical activity B) Weight loss C) Decrease in body mass index D) Decrease in abdominal circumference
Choose the correct statement about the treatment of vaginal dryness. A) Usually resolves over time with no treatment B) Regular use of lubricants more effective than as-needed use C) Systemic hormone therapies more effective than local hormone therapies D) Can be treated with transdermal testosterone
All the following are required for a diagnosis of metabolic syndrome, except: A) Patient on medication for low high-density lipoprotein B) Waistline ≥30 in C) High blood pressure D) High fasting blood sugar
The IDF consensus worldwide definition of the metabolic syndrome (2006)Central obesity (defined as waist circumference# with ethnicity specific values)AND any two of the following:Raised triglycerides: > 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality.Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormalityRaised blood pressure: systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension.Raised fasting plasma glucose :(FPG)>100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes. If FPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tolerance test is strongly recommended but is not necessary to define presence of the Syndrome.# If BMI is >30 kg/m², central obesity can be assumed and waist circumference does not need to be measured
NCEPThe US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 36 inches(female)dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dl)dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)blood pressure ≥ 130/85 mmHgfasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)
Body mass index (BMI) is often _______ in muscular patients and _______ in elderly patients. A) Underestimated; overestimated B) Overestimated; underestimated
Tools for enabling weight loss include: A) 24-hour dietary recall B) Increase in fiber intake to ≥25 g per day C) Exercise prescription D) All the above
Identify the incorrect statement about the 24-hr dietary recall. A) Done at every visit of patient being treated for hypertension, diabetes, or other weight-related problem B) Patient reports food intake from day immediately preceding visit C) Takes about 15 min D) Physician should look for patterns
According to the most recent National Institutes of Health guidelines (1991), obesity surgery is indicated in patients with which of the following? A) BMI >40 or BMI >35 and comorbid illness B) History of failed sustained weight loss on supervised weight-reduction program(s) C) No substance abuse, psychoses, or uncontrolled depression D) All the above
Which of the following is key for successful bariatric surgery? A) Patient age <50 yr B) Absence of comorbidities C) Performance in centers with high volume of bariatric surgery D) Use of the gastric band
An 83-year-old woman who is recuperating from hip replacement surgery was evaluated on the orthopedic floor of a hospital when she became confused and was found on the floor of her room at about 3 am. Her assessment found no sign of injury, and vital signs were normal. The patient was released from the hospital without further incident 2 days later. The patient’s medical history is significant for osteoporosis and hypothyroidism. A geriatric assessment within the past year revealed a Mini–Mental State Examination score of 29/30 (normal ≥24/30) and full activity of daily living capability. Current medications are hydrocodone, levothyroxine, diphenhydramine, aspirin, and fondaparinux. The patient’s records show that hydrocodone was ordered on a routine schedule, and an additional hydrocodone order was to be given for breakthrough pain. The patient had received the two doses of hydrocodone during the 6 hours prior to the incident. Diphenhydramine was ordered as a routine sleep aid. Which of the following system-level interventions will be most helpful in preventing future falls in other patients in similar circumstances? ABegin collecting adverse drug event prevalence dataBImplement a fall-risk prediction tool for newly admitted patientsCRe-engineer the hospital room architecture to decrease fall riskDStandardize protocols for management of opiate medications
A 62-year-old woman is evaluated during a follow-up visit for hypertension. She has no complaints and is monogamous with her husband of 35 years. Her only current medication is hydrochlorothiazide. On physical examination, blood pressure is 136/72 mm Hg and weight is 62 kg (136 lb). Physical examination is normal. Total cholesterol is 188 mg/dL (4.87 mmol/L) and HDL cholesterol is 54 mg/dL (1.40 mmol/L). She received an influenza vaccination 3 months ago and a herpes zoster vaccination 1 year ago. Her last Pap smear was 14 months ago and it was normal, as were the previous three annual Pap smears. Which of the following is the most appropriate health maintenance option for this patient?AAbdominal ultrasonographyBDual-energy x-ray absorptiometryCPap smearDPneumococcal vaccine
A 22-year-old woman is evaluated in the office for feelings of sadness and guilt 6 weeks after an uncomplicated delivery of twins. Her symptoms have been present for 3 weeks but have worsened over the past week, and she cannot sleep, is preoccupied about the babies’ health, and has discontinued all social activities. She says that her husband is supportive and that they have no marital problems. She is willing to start treatment for her disorder, but she is concerned about the potential impact of medication because she is breastfeeding, and is interested in alternative treatments. Which of the following is the best treatment option for this patient?AFluoxetineBPsychotherapyCReassurance with follow-up in 2 weeksDSt. John’s wort
A 36-year-old woman presents with a 12- to 14-month history of persistent pelvic pain. She reports no relation to dietary factors or bowel movements and denies diarrhea, constipation, melena, hematochezia, dysuria, or hematuria. She has had negative evaluations by multiple providers, with normal colonoscopy, ultrasonography and CT of the abdomen and pelvis, and cystoscopy. She underwent a hysterectomy and salpingo-oophorectomy for possible endometriosis 9 months ago, without relief of her symptoms. Her medical history is significant for chronic migraine headaches and chronic lower back pain. She is taking estrogen replacement therapy. She has two children, and has not been sexually active since her divorce from her husband more than 2 years ago. Her BMI is 30. Mild nonfocal tenderness is present on abdominal and pelvic examinations, with normal bowel sounds, no rebound, no masses, and no vaginal bleeding or discharge. Which of the following is the most appropriate management for this patient?ACognitive-behavioral therapyBNaproxenCReassurance with follow-up at 3 to 4 weeksDSertraline
A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and became diaphoretic and lightheaded. She sat on the ground and then lost consciousness. According to her son, she was unconscious for less than a minute, exhibited some twitching movements when she first lost consciousness, but had no incontinence or symptoms of confusion upon awakening. She had no further symptoms upon regaining consciousness. She has a history of hypertension and hyperlipidemia. Current medications are lisinopril and lovastatin. On physical examination, temperature is normal, blood pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine) and 92/min (standing), and respiration rate is 14/min. BMI is 35. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?AEchocardiogramBElectroencephalogramCExercise stress testDTilt-table testingENo further testing
A 64-year-old woman is evaluated for a urinary tract infection. She has had three urinary tract infections in the past 2 years. She is not sexually active. She has no other medical problems and takes no medications. A pelvic examination reveals pale, dry vaginal epithelium that is smooth and shiny with loss of most rugation. Urinalysis reveals 2+ leukocyte esterase, leukocytes too numerous to count, and 10 to 20 erythrocytes/hpf. Urine culture grows Escherichia coli. In addition to treating the current urinary tract infection, which of the following is the most reasonable management option for this patient? AContinuous antibiotic prophylaxisBCT imaging of the abdomen and pelvisCTopical estrogen therapyDVaginal lubricants
A 75-year-old man has a 1-month history of intermittent nosebleeds that occur from either naris. Last night, he experienced a more severe episode. There is no history of trauma to the nose, bleeding disorders, recent upper respiratory tract infections, or recent use of nasal decongestants. The patient uses tissues to remove scabs and mucus from his nares. He has been using his home heater more often because of unusually cold weather. Medical history is significant for hypertension. Current medications are hydrochlorothiazide, atenolol, and low-dose aspirin. Vital signs are normal. No bleeding site is identified in either naris, and examination of the ears, nose, and throat is normal.Which of the following is the best treatment?ACauterization of the anterior septum bilaterallyBIntranasal fluticasoneCOxymetazoline sprayDPacking of one or both anterior naresETopical petrolatum and home humidification
A 34-year-old man is evaluated at the urging of his wife because of a 3-month history of nightmares, increased irritability, outbursts of anger, and social isolation. He recently returned from reserve duty in Iraq. The nightmares are especially frequent and troubling around the time of his monthly weekend reserve duty, and he has started to drink heavily at these times to try to block out the dreams. The patient has lost interest in his usual activities, does not play with his children, spends much time alone, won’t watch the news on television, and is very uncomfortable in crowded places, such as restaurants. He has avoided repeated efforts by his wife to talk about his experiences in Iraq. Findings on physical examination are unremarkable. Which of the following is the most effective treatment for this patient?APrescribe fluoxetineBPrescribe zolpidem and alcohol counselingCProvide brief counseling for the patient and his wifeDRefer for cognitive-behavioral therapyERefer for psychodynamic therapy
A 42-year-old man has a 15-day history of a cough that was initially associated with rhinorrhea, nasal congestion, and a sore throat. All symptoms have resolved except the cough, which is productive of purulent sputum. The patient has not had fever, malaise, dyspnea, pleuritic chest pain, myalgia, paroxysms of coughing, or posttussive vomiting. Medical history is unremarkable, and he takes no medications. On physical examination, vital signs, including temperature, are normal. There is no pharyngeal erythema or exudate and no lymphadenopathy. The lungs are clear to auscultation. Which of the following is the best initial management?AAlbuterol inhalerBAzithromycinCChest radiographDNasopharyngeal swab for influenza virus cultureESymptomatic treatment
A 72-year-old woman is evaluated for a 4-month history of insomnia, with difficulty falling asleep. The patient was the major caretaker for her husband, who had advanced heart failure and died suddenly 4 months ago. She has lost 3.6 kg (8 lb) and does not have much of an appetite. The patient used to volunteer at the hospital, but she does not enjoy going there any longer. She also does not have much energy. The patient is tearful and says that nearly everything reminds her of her husband. Medical history is otherwise unremarkable. The physical examination is unremarkable. Which of the following is the most appropriate management option for this patient?ABegin dextroamphetamineBBegin mirtazapine at bedtimeCBegin zolpidem at bedtimeDReassure the patient and schedule a follow-up appointment in 3 months
An 18-year-old male college freshman is brought for evaluation by his parents because of difficulty focusing and completing tasks during his first college semester. The patient did fairly well in high school but now reports being unable to concentrate, especially in his dormitory, where he is easily distracted by music, television, and other students’ conversations. He also has difficulty completing assignments on time. Both parents had to supervise the patient in high school to make sure that he remained focused. His elementary school teachers reported that he was very bright but had difficulty paying attention and following directions. The patient drinks socially on weekends and does not use illicit drugs. He enjoys playing his guitar and attending fraternity parties. He does not feel depressed or anxious, other than worrying about his grades. Medical history is unremarkable, and he takes no medications. He is alert and oriented to person, place, and time, and physical examination is normal. Which of the following is the most likely diagnosis?AAttention-deficit/hyperactivity disorderBGeneralized anxiety disorderCMajor depressionDParanoid schizophrenia
A 64-year-old man is evaluated at a follow-up appointment. He had a left inguinal hernia diagnosed 6 months ago and has since had mild intermittent pain that is tolerable and does not interfere with his daily activities. He has not had previous hernia surgery, and he has had no episodes of bowel obstruction. The patient is reluctant to have surgery. He had a myocardial infarction 9 months ago, but has had no chest pain or other cardiopulmonary symptoms since then. Current medications are tamsulosin, aspirin, metoprolol, pravastatin, and lisinopril. On physical examination, the prostate is enlarged, and there is a left inguinal hernia that arises above the inguinal ligament and moves toward the scrotum with the Valsalva maneuver. Which of the following is the most appropriate management option for this patient?ADefer surgery and monitorBLaparoscopic hernia repairCOpen surgical hernia repairDPrescribe a hernia truss
A 30-year-old woman is evaluated during a routine appointment. She has no symptoms other than fatigue, which she attributes to long work hours. She denies daytime somnolence and a history of snoring. She is a lawyer and, owing to stress at work, she finds it difficult to eat healthy foods and get exercise. She gained 9.1 kg (20 lb) with the birth of her first child last year and has been unable to lose the weight. The patient had gestational diabetes. She states that her menstrual periods are normal. She is taking no medications. Vital signs are normal. She is 177.8 cm (70 in) tall. BMI is 32. Her thyroid examination is normal. She has normal hair distribution and normal skin color with no evidence of striae. In addition to a fasting plasma glucose, lipid panel, and thyroid-stimulating hormone assay, which of the following should be done next? A24-Hour urine cortisolBPelvic ultrasonographyCSerum insulin-like growth factor 1 (IGF-1) concentrationDWaist circumference measurement
A 64-year-old woman is evaluated during a health maintenance examination. She has hypertension and hypercholesterolemia. She has no symptoms to report. She is a current smoker, with a 20 pack-year history. Current medications are atenolol and hydrochlorothiazide. Vital signs are normal. BMI is 28. Funduscopic examination reveals bright, yellow, refractile deposits scattered in the retina of the right eye, with approximately five deposits seen on direct ophthalmoscopy. The left fundus appears normal. On visual acuity testing, near vision is 20/20 with reading glasses, and distance vision is 20/25 for both eyes. The remainder of the physical examination is normal. A lipid panel obtained prior to today’s visit reveals a total cholesterol of 190 mg/dL (4.92 mmol/L); LDL cholesterol of 120 mg/dL (3.11 mmol/L); HDL cholesterol of 40 mg/dL (1.04 mmol/L); and triglycerides of 150 mg/dL (1.70 mmol/L). Which of the following is the most effective management option for this patient’s ocular findings?AAntioxidant supplementsBAtorvastatinCLower blood pressure to below 130/85 mm HgDSmoking cessation
A 62-year-old man is evaluated for a syncopal event two nights ago. On his way to the bathroom during the night, he felt very dizzy and the next thing he remembered was waking up on the floor in the hallway to the bathroom. He went back to bed, and the symptoms did not recur the following morning. He notes that he often feels a little dizzy when he stands up. Medical history is remarkable for hypertension, benign prostatic hyperplasia, and hyperlipidemia. Two weeks ago, he started doxazosin, 2 mg before bedtime, for benign prostatic hyperplasia. Other current medications are lisinopril, atenolol, and atorvastatin. On physical examination, temperature is normal, blood pressure is 142/78 mm Hg (supine) and 106/64 mm Hg (standing), pulse rate is 74/min (supine) and 80/min (standing), and respiration rate is 16/min. He experiences lightheadedness when he stands up. BMI is 31. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?AAdmit to hospital for cardiovascular evaluationBBrain MRICDiscontinue doxazosinD24-Hour ambulatory electrocardiographic monitoring
A 54-year-old woman is evaluated for pain in the right posterior hip and pelvic area that she noticed upon awakening 3 days ago. She had been moving and lifting boxes the day before the onset of pain. She has experienced similar pain several times over the last 2 years, but it has never lasted so long. On physical examination, BMI is 30. The FABER test (Flexion, ABduction, and External Rotation of the hip) elicits pain in the right posterior pelvis. There is tenderness on palpation over the right posterior pelvic girdle. Flexing the hip is painful. There is no tenderness in the right groin, the right trochanter, or the right gluteal notch. Passive range of motion of the right hip reveals no pain. Straight-leg-raising test is negative, and deep tendon reflexes are normal. Which of the following is the most likely diagnosis?AOsteoarthritis of the right hipBPiriformis syndromeCRight L5 radiculitisDRight sacroiliitisERight trochanteric bursitis