ITE 2020

Question 1

What benzo do you need to get confirmatory testing for if you get a negative testing?

Answer 1

Because of the importance of urine drug testing and the ramifications for patients, it is essential that physicians understand and properly interpret these results. The most appropriate next step in this case is to perform confirmatory testing for alprazolam. Immunoassays can have false-positive and false-negative results, and unexpected negative results must have confirmatory testing for verification (SOR C).

Question 2

How long do you keep people on bisphoshpnates

Answer 2

According to the National Osteoporosis Foundation, treatment is indicated for patients at high risk of fracture, including those with osteoporosis, defined as a T-score of –2.5 or less, or osteopenia, defined as a T-score of –1 to –2.5 and a 10-year probability of hip fracture of at least 3% using the FRAX tool. Bisphosphonates are considered first-line pharmacologic therapy. Treatment beyond 5 years in women who do not have a persistent T-score of –2.5 or less has not been shown to result in further decreases in rates of clinical vertebral fractures, nonvertebral fractures, or mortality (SOR C).

Question 3

When are ankle radiographs recommended per Ottowa rules?

Answer 3

ankle radiographs are indicated if there is any pain in the malleolar zone, plus one or more of the following:
1 bony tenderness over the distal 6 cm of the posterior lateral or medial malleolus (the areas of potential fracture)
2 or the inability to bear weight for four steps immediately after the injury and at the time of the examination.

Question 4

When are foot radiographs rec’d per Ottawa rules?

Answer 4

1. Foot radiographs are indicated if there is any pain in the mid-foot zone, plus one or more of the following:
2. bony tenderness at the base of the fifth metatarsal or
3. the navicular bone or the inability to bear weight for four steps immediately after the injury and at the time of the examination

Question 5

What is indication for PTH-ectomy?

Answer 5

Indications for surgery include a serum calcium level >1 mg/dL above the normal range, skeletal indications, renal indications, or age <50 years.

skeletal indications include either a previous vertebral fracture or a bone density more than 2.5 standard deviations below peak mean bone mass at the hip, lumbar spine, or distal radius.

Renal indications can include an estimated glomerular filtration rate <60 mL/min/1.73 m2; a 24-hour urinary calcium level >400 mg/day; or nephrolithiasis or nephrocalcinosis seen on a radiograph, ultrasound examination, or CT.

Question 6

What Fe supplement is best in CKD patients and those on HD?

Answer 6

Ferrous citrate.

Oral iron supplements, including ferrous fumarate, ferrous gluconate, and ferrous sulfate, are generally ineffective when used by hemodialysis patients and are only modestly effective when used by patients with non–dialysis-dependent chronic kidney disease. The one exception is ferric citrate, which is highly efficacious in all patients with chronic kidney disease

Question 7

Different tremors - what to think of and next step

Answer 7

essential - happens with any activity - BB blocker
resting - think PD, dopamine agents
postural intention — cerebellar! get MRI

Question 8

What are the Ottawa knee radiograph rules? (5 of them)

Answer 8

age 55 years
• isolated tenderness of the patella
• tenderness of the head of the fibula
• inability to flex the knee to 90°
• or the inability to bear weight for four steps both immediately after the injury and at the time of
the examination

Question 9

What age should trigger primary amenorrhea work up?

Answer 9

age 15

Question 10

What size stones do you use tamsulosin?

Answer 10

High-quality placebo-controlled studies have demonstrated a decreased time to clearance of kidney stones with the use of -blockers, including tamsulosin. For stones 6–10 mm in size, the mean time to clearance was reduced by almost 6 da

Question 11

What trial should what combination of meds for HTN to reduce CV events in DM and HTN patients?

Answer 11

The ACCOMPLISH trial demonstrated that an ACE inhibitor (ACEI) in combination with a calcium channel blocker (CCB) reduced both fatal and nonfatal cardiovascular events in patients with diabetes mellitus and hypertension.

Question 12

Name assocations of key auto-Ab?

Answer 12

Elevated anticyclic citrullinated peptide antibodies help confirm a diagnosis of rheumatoid arthritis.
Anti–smooth muscle antibodies are used to confirm autoimmune hepatitis, which can also cause an elevated ANA.
Anti-centromere antibodies, a subset of ANAs, are more closely associated with systemic sclerosis.
A positive HLA-B27 test is associated with the seronegative spondyloarthropathies, such as psoriatic arthritis.

Question 13

What do patients with significant valvular disese or a prosthetic valve need prior to dental procedure?

Answer 13

antibiotics!

Question 14

What causes trigger finger?

Answer 14

Trigger finger develops when there is scarring and inflammation of the A1 pulley, the first of a five-pulley system in the hand. Stenosis of the A1 canal or nodules on the tendon can produce locking, cracking, and pain when the digit is flexed.

Question 15

reticular brown hyperpigmented skin changes at the site of exposure to heat - name the condition

Answer 15

Erythema ab igne is characterized by reticular brown hyperpigmented skin changes at the site of exposure to heat, which this patient has developed due to regular use of a heating pad. Exposure to excess heat and humidity can predispose an individual to this condition.

Question 16

What is next step if HCV Ab test is positive?

Answer 16

If the anti-HCV antibody screen is positive, then a qualitative HCV RNA test is the next step (SOR C)

Question 17

What improves outcomes for meniscal tears?

Answer 17

A systematic review found that arthroscopic procedures for degenerative meniscal tears in middle-aged adults with little or no arthritis do not significantly improve long-term pain or function compared to conservative management consisting of physical therapy and a standardized exercise program

Question 18

What are parts of the STOP-Bang questionairre?

Answer 18

In the questionnaire S = snoring, T = tiredness, O = observed apnea, P = high blood pressure, B = BMI >35 kg/m2, A = age >50 years, N = neck circumference >40 cm, and G = male gender

Question 19

What is the one FDA approved treatment for explosive anger with conduct disorder AND co-morbid ADHD?

Answer 19

short term risperidone

Question 20

What antibiotic will increase the INR for patients on coumadin? By how much should coumadin dosing be decreased?

Answer 20

Trimethoprim/sulfamethoxazole is one of the antimicrobials most likely to increase the INR of a patient taking warfarin. If trimethoprim/sulfamethoxazole is used in a patient on warfarin, reducing the warfarin dosage by 25%–40% is recommended, with close monitoring of the INR. The patient’s INR should be checked within 3–5 days of starting or stopping any antimicrobial.

Question 21

Small- red brown macules that coalesce into larger partches - what is it? Tx?

Answer 21

Erythrasma is a superficial infection caused by Corynebacterium minutissimum. It presents as small, red-brown macules that may coalesce into larger patches with sharp borders. It fluoresces coral red on Wood’s lamp examination. Cutaneous erythrasma is treated with erythromycin (topical, twice daily until the rash resolves, or oral, 250 mg four times daily for 2 weeks).

Question 22

Symptoms of plantar fascitities?

Answer 22

Plantar fasciitis is the most common cause of heel pain in adults. It is characterized by stabbing pain over the anteromedial plantar aspect of the heel. It is usually worse with ambulation after a period of inactivity, such as the first steps of the day.

Question 23

Amblyopia - when should we screen in kiddos?

Answer 23

The U.S. Preventive Services Task Force recommends vision screening for all children at least once between 3 and 5 years of age to detect the presence of amblyopia or its risk factors (B recommendation).

Question 24

What should be done about preventing flu in pregnancy? Esp in case of exposure?

Answer 24

This patient has a young child who has been diagnosed with influenza, and she has two factors that place her in the high-risk category for complications from influenza: pregnancy and asthma. Pregnancy is an indication for influenza vaccine, not a reason to avoid it. In addition to influenza vaccine now, she should begin a 2-week course of chemoprophylaxis to allow time for the vaccine to become effective. The safety record for oseltamivir in pregnancy is good, and it is the preferred choice in this situation

Question 25

Concern for thyroid storm - what scale would you use to decide for admission?

Answer 25

Butch Warnofsky Score

Question 26

For recurrent C diff if vanc was used first time?

Answer 26

fidaxomicin is recommended for recurrent infection if vancomycin was prescribed for the initial episode (weak recommendation, moderate quality of evidence). If available, a prolonged tapered course of vancomycin could be used if a 10-day course was prescribed initially (weak recommendation, low quality of evidence). Vancomycin is only recommended for a first recurrent episode if metronidazole was used initially (weak recommendation, low quality of evidence)

Question 27

HTN assessment and mgmt in kiddos - what are the thresholds? what defines HTN? goal of tx? after 13 age?

Answer 27

Hypertension in children is defined as a blood pressure 95th percentile for age, sex, and height on three separate office visits.

Goal of tx: The goal for treatment should be to lower the systolic and diastolic blood pressures below the 90th percentile for age, sex, and height.

Once children are over 13 years of age, the target should be a blood pressure <130/80 mm Hg.

Question 28

What is one possible dx for PWID in terms of possible pulm diseases? Esp if slow development of symptoms?

Answer 28

Although persons who inject drugs are at high risk for a variety of pulmonary infectious diseases, this patient’s presentation, including the relatively slow development of symptoms, is most consistent with pulmonary foreign body granulomas. These result from the injection of crushed pills, talc, or other foreign substances, which are then deposited in the vasculature of the lungs.

Question 29

Cmmon viral disease in kids under 5 with rashes in mouth/hands

Answer 29

This patient has hand-foot-and-mouth disease frequently caused by enterovirus 71 or coxsackievirus A16. It is most common in children under 5 years of age and occurs most often in the fall and spring. It is characterized by painful maculopapular or papulovesicular lesions on the hands and feet, and in the oral cavity. Lesions can also appear on the genitals, trunk, or cheek. Management includes symptomatic treatment of pain and oral hydration. Antibiotics and antiviral treatment are not recommended. Laboratory testing is not appropriate for this condition.

Question 30

What is tx for female pattern hair loss at crown of head?

Answer 30

Hair thinning on the crown of the head with the presence of small, wispy hairs among the regular hair is characteristic of female pattern hair loss (FPHL). A family history of similar issues is often present but not necessary for the diagnosis.
Topical minoxidil is the mainstay of treatment for FPHL (SOR A). It is available in a 2% solution or 5% foam for women (the 5% solution is indicated only for men). Treatment for FPHL as well as the male equivalent, androgenic alopecia, must be continued long term. With treatment there is often an initial period of increased hair loss. Regrowth is noticeable around 6 months. Discontinuation of treatment results in loss of regrown hair.

Question 31

what is treatment to prevent fx if going on oral pred in elderly woman?

Answer 31

Calcium and vitamin D together have been shown to prevent decreases in bone mineral density with low-dose prednisone use but the effect with high doses is unknown. If a patient has an increased fracture risk, oral bisphosphonates should be started. It is not recommended that they be used empirically to reduce the risk of fracture

Question 32

What is the only situation in vit D screening is recommended?

Answer 32

The measurement of vitamin D levels is recommended only for patients with decreased kidney function, various skeletal diseases, or hypercalcemia (SOR C). Vitamin D deficiency is common in patients with chronic kidney disease.

Question 33

Common causes of RED EYE in primary care

Answer 33

Episcleritis is a self-limited condition that can be idiopathic and presents with mild discomfort and focal hyperemia.

Conjunctivitis is typically associated with a discharge that is clear in viral cases and mucopurulent in bacterial cases.

Iritis is associated with significant pain, a poorly reactive pupil, diminished vision, and photophobia.

This patient does not have changes in visual acuity, photophobia, or severe pain as seen in keratitis, which would also cause an abnormal fluorescein stain showing corneal ulceration.

Question 34

What is a potential treatment for chronic refractory cough?

Answer 34

In randomized, controlled trials, gabapentin has demonstrated benefit for treating a refractory chronic cough after 4 weeks of treatment (SOR C).

Question 35

What is a test for biceps tendonitis?

Answer 35

bicipital tendinitis, which causes pain with abduction and external rotation of the arm, and tenderness of the bicipital groove with palpation. Resisted supination of the hand with the elbow flexed to 90° is the Yergason test, and anterior shoulder pain with this maneuver is consistent with bicipital tendinitis

Question 36

What ovarian cysts seen on CT need pelvic US?

Answer 36

The American College of Radiology recommends that immediate ultrasonography be performed in the evaluation of simple-appearing cysts that are incompletely characterized by CT and are >5 cm in premenopausal women or >3 cm in postmenopausal women.