ITE 2019

Question 1

What are the presenting characteristics of alpha-one antitrypsin deficiency?

Answer 1

Symptoms of COPD, airflow limitation/obstruction on spirometry with FEV1/FVC <0.7, younger age, lack of tobacco smoke or occupational exposure, and panlobular basal emphysema on CXR.

Question 2

What would L heart failure look like on CXR/PFT?

Bronchiectasis?

Interstitial lung disease?

Diffuse pan-bronchiolitis?

Answer 2

Pulmonary edema and volume restriction on PFT

Bronchial dilation and wall thickening.

Reticular or increased interstitial markings.

Diffuse small centrilobular nodular opacities and hyperinflation

Question 3

What are the symptoms of low T / hypogonadism? What lab test should be next?

Answer 3

Fatigue, decreased libido, erectile dysfunction

FSH and LH to distinguish primary and secondary hypogonadism.

Secondary = low or inappropriately normal FSH/LH, then test prolactin and serum iron levels / total iron binding capacity to determine cause. Consider MRI pituitary.

Primary = … … karyotype for Klinefelter’s

Question 4

How to treat flexible metatarsus adductus?

Rigid metatarsus adductus?

Answer 4

Flexible = most common congenital foot deformity, can be observed for spontaneous resolution by age 1.

Rigid should be treated with serial casting or adjustable shoes (less expensive)

Surgical correction reserved for older children who are walking or that is resistant to casting.

Question 5

TREMORS!!

Describe psychogenic tremor.

Cerebellar? Which test / imaging is helpful?
Parkinsonian?

Essential?

Enhanced physiologic?

Answer 5

Psychogenic:
Abrupt onset, spontaneous remission, changing characteristics, and extinction with distraction.

Cerebellar:
Intention tremor with ipsilateral involvement on the side of the lesion. Testing will show past-pointing on finger-nose test -> CT or MRI brain is diagnostic.

Parkinsonian:
Resting tremor, asymmetric, decreases with voluntary movement. Bradykinesia, rigidity, and postural instability. Dx with single-photon emission CT ir OET, Tx carbidopa/levodopa.

Essential:
Symmetric, fine tremors that involves hands, wrists, head, voice, or lower extremities. May improve with small amount of EtOH. No specific test. Tx propranolol or primidone.

Enhanced physiologic:
Postural tremor of low amplitude exacerbated by medication, usually with a history of caffeine use or anxiety.

Question 6

At what degree of contracture is surgical release of Dupuytren’s indicated?

Answer 6

30 degrees MCP, or any contracture of the PIP

Question 7

What are high-risk markers that would suggest benefit from inpatient admission?

Answer 7

Risk of mortality increases with RR 30 or more, hypoTN, confusion/disorientation, BUN 20 or greater, age >65, male, or heart failure / COPD

Question 8

Which is more sensitive, PHQ2 or PHQ9? Which is more specific?

Answer 8

PHQ2 has similar sensitivity to PHQ9, but PHQ9 is more specific

Question 9

What are the risks associated with anemia?

Answer 9

Increased morbidity / mortality in older adults

Question 10

What are the common causes of anemia?

Answer 10

nutritional deficiencies
CKD
occult blood loss (GI malignancies)
chronic inflammation
idiopathic

Question 11

What lab to order with normocytic or microcytic anemia?

Answer 11

serum ferritin level

Question 12

What problem is associated with low ferritin level?

Answer 12

iron deficiency, but order a serum transferrin-receptor-ferritin index if ferritin level is between 46-100 to distinguish between iron def and other types.

Question 13

Which med can be added to improve antidepressant-related sexual arousal dysfunction?

Answer 13

Bupropion (Wellbutrin)

Question 14

What is black cohosh good for?

Answer 14

Alternative for menopausal vasomotor symptoms.

Question 15

What is the medication for dyspareunia related to vulvar / vaginal atrophy from menopause?

Answer 15

Ospemifene

Question 16

What is Henoch-Schonlein purpura, and what does it look like?

Answer 16

IgA vasculitis, dx clinically, presents as palpable purpura of lower extremities without thrombocytopenia or coagulopathy.

Associated with arthralgia / arthritis, abd pain, renal dysfunction

self-limited, supportive tx only

Question 17

What does erythema infectiosum (fifth disease) look like?

Answer 17

erythematous rash on the cheeks and a lacy reticular rash on the extremities

Question 18

What does Gianotti-Crosti syndrome look like?

Answer 18

sudden papular or papulovesicular eruption on the extensor surfaces of arms, legs, buttocks, and face.

Question 19

What does HUS look like?

Answer 19

Classic triad of hemolytic anemia, thrombocytopenia, and kidney injury.

Question 20

Which markers are the best predictors for the severity of pancreatitis, and therefore how aggressive management should be?

Answer 20

Hct, BUN, and Cr levels because they reflect the degree of intravascular volume depletion.

Question 21

What are the classic facial dysmorphologies associated with fetal alcohol syndrome?

Answer 21

smooth philtrum
shortened palpebral fissures
thin vermilion border of upper lip

Question 22

What are the most common causes of HTN in preadolescent children? Best diagnostic test?

When to suspect primary hyperaldosteronism? Best diagnostic test?

When to suspect pheochromocytomas? Best dx?

When to suspect renal aa stenosis? Best dx?

Answer 22

Renal parenchymal diseases
- glomerulonephritis
- congenital abnormalities
- reflux nephropathy
Should be evaluated by renal US

Unexplained hypokalemia, evaluate with renin / aldosterone levels.

Rare, triad of headache / palpitations / sweating. Eval with 24-hour urinary fractionated metanephrines and normetanephrines.

Patients with coronary or peripheral atherosclerosis or young adults esp women 19-39 y/o who are more at risk for renal aa stenosis due to fibromuscular dysplasia. Eval with doppeler US of renal aa.

Question 23

Which med increases risk of kidney stones?

Answer 23

Topiramate, carbonic anhydrase inhibitor, induces metabolic acidosis -> hypercalciuria -> calcium phosphate stones

Question 24

When to treat nondisplaced tuberosity fracture with compressive dressing with weight bearing / ROM exercises as tolerated, vs ortho referral?

Answer 24

Minimally displaced <3mm vs >3mm

Question 25

Which abx for cat bite?

Answer 25

Augmentin

if penicillin allergy, clinda plus levo of moxifloxacin

Question 26

How to give previously unvaccinated kids the flu shot?

Answer 26

at 6 months to 8 years, two dose of trivalent or quadrivalent vaccine separated by one month

Question 27

How frequently to check breast cancer survivors?

Answer 27

H&P q 3-6 months for first 3 years following tx. 6-12 months q 2 years, then annually.

PAP recommendation does not change.

Mammo no more than yearly. No breast MRI unless there is high risk for recurrence, significant family history of breast/ovarian cancer, or personal history of Hodgkin’s disease.

Question 28

How to treat severe CAP?

What if there is risk for anaerobic infection, ie aspiration or alcoholism?

Answer 28

CS - improve length of stay, duration of abx, and risk of ARDS

Abx - {B-lactam (ceftriaxone, cefotaxime) OR amp/sulbactam} + macrolide alone OR macrolide + fluoroquinolone.

Anaerobic -> clindamycin

Question 29

Diagnostic criteria for PCOS?

Answer 29

hyperandrogenism, ovulatory dysfunction *oligomenorrhea), and polycystic ovary on US

Question 30

Which meds are associated with osteoporosis and increased fracture risk?

Answer 30

Antiepileptics
long-term heparin
cyclosporine
tacrolimus
aromatase inhibitors
glucocorticoids
gonadotropin-releasing hormone agonists
thiazolidinediones
high dose levothyroxine
PPI
SSRI
parenteral nutrients
medroxyprogesterone contraception
methotrexate
aluminum antacids

Question 31

Risk factors for AAA?

Who to screen?

Answer 31

history of smoking
advanced age
above-average height
first degree FHx
atherosclerosis
high cholesterol
HTN

screen males age 65 - 75 with smoking history

Question 32

What risks are increased with Turner syndrome?

Answer 32

endometrial cancer
celiac disease
structural heart defects

Question 33

What are the most common causes of chronic cough in adults?

Answer 33

upper airway cough syndrome
tobacco use
GERD 
asthma
ACEi

Question 34

What electrolyte disturbance can HCTZ cause?

Answer 34

hypercalcemia

high vitamin D can also do this

Question 35

Prednisone dose for COPD exacerbation?

Answer 35

40mg daily for 5 days

can improve FEV1, oxygenation, shorten recovery time, and reduce hospital LOS

oral is as good as IV

Question 36

Hair loss:

1. What does androgenetic alopecia look like?
2. Alopecia areata?
3. Anagen effluvium?
4. Tinea capitis?
5. Trichorrhexis nodosa?

Answer 36

1. Bitemporal thinning of frontal and vertex scalp in men, but in women frontal hairline is spared and thinning most apparent at the vertex.
2. acute patchy hair loss
3. diffuse hair loss days - weeks after chemotherapy
4. dermatophyte infection of hair shaft and follicles -> patchy hair loss
5. breaks in hair due to trauma or fragile hair ie excessive brushing, heat application, hairstyles that pull on hair

Question 37

What to do if AST/ALT are persistently mildly elevated for 3+ months?

Answer 37

Rule out uncommon but not rare causes of liver disease ie viral hepatitis, iron studies (hemochromatosis), serum albumin, CBC

Consider NAFLD fibrosis score for liver biopsy eval

Question 38

What causes B12 deficiency? What does it’s anemia look like?

Answer 38

deficiency of intrinsic factor produced by gastric mucosa, necessary for absorption of vitamin B12 in terminal ileum.

Appears as megaloblastic macrocytic anemia with hypersegmented (usually 5+) polymorphonuclear WBCs

Vit B12 levels are low with high methylmalonic acid level to confirm diagnosis

Risk factors: PPI, chronic metformin, malnutrition due to alcohol, chronic gastritis, PUD; diseases of terminal ileum ie Crohn’s; gastric bypass surgery

Question 39

What does iron deficiency anemia appear as?

Answer 39

microcytic, hypochromin RBCs

Question 40

What red cell abnormality is caused by lead toxicity?

Answer 40

Basophilic stippling

Question 41

What is praxis? Gnosia?

Answer 41

Praxis - ability to carry out intentional motor acts

Apraxia - inability to carry out specific motor tasks

Gnosia - ability to name objects and their function

Question 42

What is the preferred serology for celiac disease dx?

Answer 42

IgA tissue transglutaminase Ab

Question 43

COPD treatment

Answer 43

COPD dx FEV1/FVC <0.7

GOLD criteria

Question 44

Dx IBS?

Answer 44

Rome IV criteria:

recurrent abd pain at least 1 day per week for 3 months

+ at least two:
abd pain related to defecation
change in stool form
change in stool frequency

Alarm symptoms:
+ FHx colon cancer
rectal bleeding without hemorrhoids or fissures
unintentional weight loss