ITE 2021

Question 1

best first line therapy for allergic rhinitis?

Answer 1

intra-nasal corticosteroids, not dual therapy

Question 2

ganglion cysts - evolution?

Answer 2

typically self-limiting

Question 3

what can help with bowel obstruction in end stage cancer patients?

Answer 3

Corticosteroids can help alleviate these symptoms, which is the focus in end-of-life care. Corticosteroids have numerous beneficial effects in these situations, such as central antiemetic, anti-inflammatory, antisecretory, and analgesic effects. Intravenous dexamethasone is generally recommended at a dosage of 4 mg 3–4 times daily for malignant bowel obstruction because it has much greater anti-inflammatory effect than methylprednisolone. Although octreotide is commonly used for this purpose, there is little evidence to support its use.

Question 4

what bug causes impetigo? what about bullous impetigo? tx for bullous impetigo?

Answer 4

Impetigo may be caused by Streptococcus pyogenes or Staphylococcus aureus, but bullous impetigo is caused exclusively by S. aureus. Oral trimethoprim/sulfamethoxazole is an appropriate treatment for skin infections caused by S. aureus, including susceptible cases of methicillin-resistant S. aureus (MRSA).

Question 5

are statins OK in pregnancy?

Answer 5

NO. Statins have been associated with fetal anomalies and are contraindicated during pregnancy and not recommended during breastfeeding

Question 6

presentation of bacterial tracheitis?

Answer 6

bacterial tracheitis, which includes a high fever, barking cough, respiratory distress, and rapid deterioration.

Question 7

acute onset of dysphagia, drooling, and high fever, along with anxiety and a muffled cough, and typically occurs in children 3–10 years of age.

Answer 7

epiglottitis

Question 8

what is little league shoulder? and usual treatment?

Answer 8

Little League shoulder, which is a stress injury to the proximal humeral physis in athletes with open growth plates. Tx: rest from throwing for ~3 months.

Question 9

identify a few criteria for diagnosing diabetes? fasting sugar? random sugar? 2-hr glucose test? a1c?

Answer 9

a hemoglobin A1c 6.5%, a fasting plasma glucose level 126 mg/dL, a 2-hour plasma glucose level 200 mg/dL on an oral glucose tolerance test, or a random plasma glucose level 200 mg/dL with classic symptoms of hyperglycemia.

Question 10

Weakness of the thumb and index finger pincer mechanism is indicative of what nerve injury?

Answer 10

ulnar nerve injury

Question 11

what stat do you need to calculate NNT?

Answer 11

absolute risk reduction.

The number needed to treat (NNT) is calculated as: 1/absolute risk reduction (ARR), where the ARR is expressed as a decimal. If the ARR is 5%, the NNT = 1/0.05 = 20

Question 12

what complication electrolyte related from TLS? Three levels go up - what are they – and what goes down (one electrolyte)

Answer 12

Tumor lysis syndrome is a common complication of chemotherapy in hematologic malignancies, such as acute leukemia. Homeostasis is overwhelmed with phosphorus, potassium, calcium, and uric acid released into the bloodstream due to acute cell lysis.

. Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome. Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream.

Question 13

Subclinical hypothyroidism? what are the benefits of tx?

Answer 13

Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4 level. It is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST (Thyroid Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of randomized, controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle strength, fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A), and up to 60% of cases resolve within 5 years without intervention in older adults.

Question 14

What is the treatment of distal phalanx injuries? called tuft fractures?

Answer 14

Tuft fractures are the most common type of distal phalanx fracture. They rarely require orthopedic referral but often result in up to 6 months of hyperesthesia, pain, and numbness. Treatment involves splinting the affected digit for 2–4 weeks, followed by range of motion and strengthening exercises. Symptomatic treatment may also be involved, but splinting is needed

Question 15

If you suspect Celiac disease but get a negative result and suspect false negative, what level should you check?

Answer 15

False-negative serologic results may occur in patients with an IgA deficiency, which includes up to 3% of patients with celiac disease. Therefore, when a diagnosis of celiac disease is strongly suspected despite a negative IgA TG2 antibody test, a total IgA level should be obtained. Diagnostic confirmation for patients with positive serologic testing is accomplished with endoscopic mucosal biopsy.

serum IgA transglutaminase-2 (TG2) antibody level,

Question 16

the only medication that improves persistent cough related to upper respiratory infection in adults.

Answer 16

Intranasal ipratropium

Question 17

surveillance rec for pts with asymptomatic severe aortic stenosis?

Answer 17

monitoring with serial echocardiography is recommended every 6–12 months.

Question 18

first line treatment of eczema?

Answer 18

The first-line treatment is liberal use of fragrance-free emollients, at least 1–2 times per day. Emollients with a high lipid-to-water ratio are the most effective; ointments have the highest ratios, followed by creams and then lotions.

A low-potency topical corticosteroid is an appropriate treatment for more significant flares, but in this case basic and consistent treatment with an emollient has not yet been tried.

Question 19

what med class is known to increase risk of GI bleed?

Answer 19

SSRIs such as citalopram increase the risk of upper gastrointestinal (GI) bleeding by 55%, according to meta-analysis studies including more than 1 million subjects (SOR A)

Question 20

natural history of ACE-inhibitor induced cough? when does it start? when does it resolve after stopping med?

Answer 20

onset of an ACE inhibitor–induced cough may occur within hours to months after the first dose. A proper evaluation of patients presenting with a chronic cough, which is defined in adults as a persistent cough lasting >8 weeks, begins with a careful history, with attention to smoking status, environmental exposures, and medication use. Identifying ACE inhibitor use is particularly important for a patient with hypertension and diabetes mellitus presenting with a persistent dry cough. If ACE inhibitor use is identified, consideration should be given to a trial of medication elimination, which is the only way to determine if the medication is the cause. If so, the cough should resolve within days, although resolution may take up to 3 months to occur.

Question 21

Sporotrichosis is a skin infection caused by the Sporothrix schenckii fungus. What’s the treatment?

Answer 21

Spontaneous resolution of sporotrichosis is rare. Uncomplicated small lesions of cutaneous sporotrichosis sometimes can be treated with the daily application of local heat for several weeks. More involved infections, such as this patient’s lymphocutaneous sporotrichosis, require systemic therapy. The initial treatment strategy is oral itraconazole for 3–6 months.

Question 22

what is the advantage of a albumin/cr ratio vs protein/cr ratio?

Answer 22

the spot albumin/creatinine ratio is able to detect lower levels of proteinuria as compared to the spot protein/creatinine ratio. The albumin/creatinine ratio indicates proteinuria, which is not specific to diabetes mellitus. Both protein/creatinine and albumin/creatinine ratios can be affected by exercise and menstruation.

Question 23

what is an association of atrophic glossitis? vitamin and med association?

Answer 23

The history and physical examination in this case are consistent with atrophic glossitis. Routine vitamin B12 monitoring or supplementation is appropriate for patients who take metformin chronically. A decline in vitamin B12 levels may be seen as early as 3–4 months after starting metformin.

Question 24

what is the only med that can prevent Seasonal affective disorder?

Answer 24

Bupropion is the only medication beneficial for prevention of SAD. Light therapy and SSRIs are helpful for treating this disorder but do not prevent it.

Question 25

sleeve gastrectomy has what common complication?

Answer 25

Sleeve gastrectomy is currently the most common bariatric procedure. The most common complication is development of GERD, which occurs in 20% of patients. Since this procedure does not produce a malabsorption component, complications such as cholelithiasis, dumping syndrome, and small bowel obstruction are not as likely as with other available procedures. A postoperative leak develops in <2% of cases.
A sleeve gastrectomy involves removing the majority of the greater curvature of the stomach, which creates a tubular stomach. Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch both combine volume restriction and nutrient malabsorption.

Question 26

what is the evidence for probiotics in IBS and preventing abx associated diarrhea?

Answer 26

For this 43-year-old patient, there is strong evidence based on Cochrane reviews that the use of probiotics may reduce the risk of both antibiotic-associated diarrhea more generally, and Clostridioides (Clostridium) difficile diarrhea specifically, when antibiotics are used (level of evidence A). Evidence is not as strong for their impact in adults over the age of 65. The preponderance of evidence for the effective use of probiotics is with diarrhea-predominant irritable bowel syndrome, and systematic reviews have generally supported their use for this condition. There is little evidence that probiotics decrease the incidence or recurrence of urinary tract infections. Topical, not oral, preparations of probiotics have good evidence for reducing the risk of recurrent bacterial vaginosis.

Question 27

What is a immunodeficiency that can present later in life?

Answer 27

Common variable immunodeficiency (CVID) is the only immunodeficiency condition listed that can present later in life, while severe combined immunodeficiency, DiGeorge syndrome, and Wiskott-Aldrich syndrome typically present prior to 6 months of age. CVID is a condition of impaired humoral immunity and thus should be considered in a patient this age in the setting of recurrent bacterial infections such as sinusitis or pneumonia.

Question 28

CKD diagnosis - duration and criteria to diagnose

Answer 28

CKD is defined by abnormal kidney structure or function lasting greater than 3 months, with associated implications for health. Diagnostic criteria include a persistent glomerular filtration rate <60 mL/min/1.73 m2, albuminuria, urine sediment abnormalities, renal imaging abnormalities, and serum acid-base or electrolyte abnormalities.

Question 29

Fourniers gangrene and what DM med are associated?

Answer 29

SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) are associated with a higher rate of genitourinary infections, including necrotizing fasciitis of the perineum (Fournier’s gangrene). While rare, this is a life-threatening infection associated with this class of medications that is being used more

Question 30

how to diagnose lymphoma?

Answer 30

An open lymph node biopsy is the preferred method for making the diagnosis of lymphoma. Although fine-needle aspiration and core needle biopsy are often part of the initial evaluation of any adenopathy, neither will provide adequate tissue for the diagnosis of lymphoma

Question 31

what drugs need follow on urine drug screens if suspect false negative

Answer 31

Immunoassay drug screenings can be performed at the point of care and are relatively inexpensive. Typical immunoassays can detect nonsynthetic opioids such as morphine and codeine, as well as illicit substances such as amphetamines, cannabinoids, cocaine, and phencyclidine. However, these immunoassays do not reliably detect synthetic or semisynthetic opioids such as oxycodone, oxymorphone, methadone, buprenorphine, and fentanyl, as well as many benzodiazepines.

Question 32

what is the blanching and blistering pattern for superficial vs partial thickness vs deep burns?

Answer 32

Superficial burns are red, painful, and blanching, and they do not blister. Superficial partial-thickness burns blister and blanch with pressure. Deep partial-thickness burns blister, but do not blanch with pressure. Full-thickness burns extend through the entire dermis and into the underlying tissues, and they are dry and leathery.

Question 33

how to prevent CAUTIs?

Answer 33

Prevention of catheter-associated urinary tract infections (CAUTIs) is important. The most important measure to prevent CAUTIs is routine cleaning of the meatal surface with soap and water while bathing or showering.

Question 34

car safety restraints for kids? age 4-8, and by size.

Answer 34

Children 4–8 years of age may be appropriately restrained in a car seat or booster seat, with a booster recommended when the child outgrows the forward-facing limit of the convertible or combination car seat. This child may still fit many car seats, though she is too large for rear-facing seats. Children can generally be safely restrained without a booster seat when their height reaches around 145 cm (57 in), though this lower limit can vary based on the specific vehicle. All children who ride in motorized vehicles should be restrained in the back seat until at least age 13 (SOR C).

Question 35

what med for hypertriglyceridemia when triglyceride levels are 500 mg/dL

Answer 35

Fibrates reduce the likelihood and recurrence of pancreatitis due to severe hypertriglyceridemia when triglyceride levels are 500 mg/dL, measured in a fasting or nonfasting state (SOR A). This patient’s risk of atherosclerotic cardiovascular disease is <7.5% and his LDL-cholesterol level is within normal range, so initiating a statin or ezetimibe is not indicated

Question 36

immediate treatment for acute rheumatic fever?

Answer 36

NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of acute rheumatic fever and would not be appropriate

Question 37

most specific for RA - ANCA or RF?

Answer 37

ANCA

Question 38

what’s the treatment after LAMA if more is needed for cOPD?

Answer 38

This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized, treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and has not had any recent exacerbations.

Question 39

What are the stone prevention steps for the most common type of stone?

Answer 39

prevent Ca stones

potassium citrate if lifestyle changes fails

Increasing fluid intake to 2.5–3 L/day is the most important lifestyle modification to prevent recurrent kidney stones. A diet rich in fiber and vegetables with normal calcium content (1–1.2 g/day), limited sodium intake (4–5 g/day), and limited animal protein intake (0.8–1 g/kg/day) is strongly encouraged. Reduction of BMI by dietary modification and increased exercise is also recommended.

Question 40

Risks of testosterone therapy?

Answer 40

Risks of testosterone therapy include more atherogenic lipid profiles, an increase in blood pressure, and erythrocytosis (rather than anemia). Severe liver dysfunction is unusual at therapeutic dosages but is a concern at dosages above the recommended therapeutic range. Testosterone therapy has not been associated with cervical cancer, kidney disease, or venous thromboembolism (VTE).

Question 41

stiff painful big toe that can be mistaken for gout

Answer 41

Hallux rigidus affects as many as 50% of women and 40% of men by the age of 70. It is usually due to osteoarthritis of the metatarsophalangeal (MTP) joint and presents as decreased range of motion, swelling, and pain. With progression of the condition, flare-ups become more frequent and more severe, and it can be mistaken for gout. Initial treatment is restriction of motion across the MTP joint.

Question 42

leading cause of death between 45-64 in the US

Answer 42

malignancy

Question 43

failed audiology test at newborn screening in hospital - what’s the follow up

Answer 43

For infants that fail the initial hearing screen in one or both ears, a repeat bilateral audiology evaluation should be performed before 3 months of age to ensure early identification of hearing loss and therefore maximize speech perception and development.

Question 44

what is the follow up work up once low testosterone is confirmed prior to treatment?

Answer 44

After confirming low testosterone with two morning laboratory tests, the next step is to attempt to determine the cause of the low testosterone. Checking LH and FSH levels is recommended to evaluate for primary hypogonadism. If primary hypogonadism is present, chromosomal studies should be considered. Before initiating testosterone therapy, checking the patient’s PSA level and performing a digital rectal examination are recommended, but in this case the initial workup is not yet complete.

Question 45

risk of patient with venous thoracic outlet syndrome - what testing should one get?

Answer 45

welling of the arm with associated pain strongly suggests obstruction of the subclavian vein. Paresthesias in the fingers and hand are common, likely due to swelling rather than nerve compression at the thoracic outlet. Venous thoracic outlet syndrome is easily identified by swelling, cyanosis, and distention of superficial veins in the arm. Due to the exceptionally high risk of developing a venous thrombosis, patients should undergo diagnostic evaluation with upper extremity venous duplex ultrasonography.

Question 46

bp goal in ischemic stroke in fisrt 480-72 hours?

Answer 46

Because patients with an acute ischemic stroke may require the increased perfusion pressure to limit ischemia, antihypertensive therapy should not be given during the first 48–72 hours as long as they are not candidates for, or recipients of, reperfusion therapy with alteplase or thrombectomy; do not have a comorbid condition requiring acute blood pressure lowering; and do not have a blood pressure >220/120 mm Hg.

Question 47

Ottawa knee rules

Answer 47

Criteria for imaging according to the Ottawa knee rule include any of the following: age >55, isolated tenderness of the patella, tenderness of the fibular head, inability to flex the knee to 90°, and inability to bear weight for four steps both immediately after the injury and at the time of the examination.

Question 48

ORS for viral gastro - what’s one option involving apple juice?

Answer 48

However, prescribing a formal oral rehydration solution is not necessary. A randomized, controlled trial has shown that initial rehydration with diluted apple juice followed by preferred fluids resulted in fewer treatment failures than use of a formal electrolyte solution.

Question 49

pericarditis that does not resolve with iniital NSAID like ibuprofen - what’s ttx?

Answer 49

In a patient with acute pericarditis, after determining that the patient is not at high risk for complications, does not have acute myocardial injury, and is an appropriate candidate for outpatient treatment, there are several options for treatment. Any of the NSAIDs alone are effective in many patients, but some patients do not respond sufficiently, so the addition of colchicine would be the treatment of choice. Colchicine alone is also an appropriate initial treatment, but in case of insufficient response to NSAIDs, the combination is the most effective treatment. Corticosteroids are best reserved for pericarditis related to a connective tissue disease, but they are not recommended in viral or idiopathic pericarditis or in pericarditis in patients with post–acute myocardial infarction pericarditis

Question 50

When should babies born before 37 weeks begin Fe supplementation?

Answer 50

Breastfed infants born before 37 weeks gestation should receive iron supplementation at 2 mg/kg/day after 1 month of life. This infant does have some physiologic reflux but since this infant appears asymptomatic, the parents should be counseled on behavioral techniques to reduce spitting up, as there is no clear long-term benefit to antireflux medication.

Question 51

unilateral foot swelling with mild or no erythema / warmth

Answer 51

Acute Charcot neuropathy is a commonly missed diagnosis, and the diagnosis is delayed in up to 25% of cases. The diagnosis should be considered in patients over age 40 with neuropathy and obesity who present with unilateral foot swelling. There may be associated erythema and warmth, and pain may be absent. In a patient with suspected acute Charcot neuropathy, bilateral weight-bearing radiographs are recommended to detect fractures of the midfoot. Acute Charcot neuropathy is frequently painless, and its consequences can be severe, so it would be inappropriate to counsel a patient that lack of pain means the absence of serious disease.

Question 52

prophylactic syphillis treatment - when should it be done?

Answer 52

He should be treated presumptively for early syphilis, even though the serologic test result is negative, because he had sexual contact within the past 90 days with a person who was diagnosed with secondary syphilis. same is true for primary or early latent syphilis during the same time period.

s a single dose of penicillin G benzathine, 2.4 million units

Question 53

hep C screening guidelines

Answer 53

The U.S. Preventive Services Task Force currently recommends that all asymptomatic adults, including pregnant women, between the ages of 18 and 79 without known liver disease should be screened for hepatitis C virus (B recommendation). Others at high risk, including anyone with past or current injection drug use, should also be screened for hepatitis C virus. The prior recommendation was to screen adults born between 1945 and 1965, as well as any other persons at high risk.

Question 54

thresholds for observation vs treatment for scoliosis? threshold for surgery?

Answer 54

Adolescent idiopathic scoliosis is generally defined as a lateral curvature of the spine or Cobb angle 10°. Cases with a Cobb angle <20° can generally be managed with observation. In this asymptomatic patient there would be no reason to suspend sports participation. Moreover, suspension of sports activity may worsen or contribute to psychologic distress experienced by those with this disorder. In a U.S. Preventive Services Task Force evidence report and systematic review, bracing did decrease progression of the Cobb angle but it did not improve patient-oriented outcomes and did have associated harms. Physical therapy does not have consistent evidence of benefit. Therefore, bracing and physical therapy should be reserved for more severe cases. Surgical evaluation is reserved for severe cases or those with a Cobb angle 40°

Question 55

what is a partial nicotinic receptor agonist?

Answer 55

Varenicline, an 4- 2 nicotinic receptor partial agonist, works to reduce nicotine withdrawal by activating the nicotine receptor and producing about 50% of the effect of nicotine. It also prevents tobacco smoke nicotine from binding to the receptor.

Question 56

prevention of migraines - what are potential treatments?

Answer 56

Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine prevention by consistent, good-quality evidence.

Question 57

first line treatment for hirsutism for PCOS?

Answer 57

Polycystic ovary syndrome (PCOS) accounts for 70% of cases with another 25% attributable to idiopathic hyperandrogenism and idiopathic hirsutism. First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production in the ovaries by decreasing LH levels