ITE 2021 Flashcards
A 23-year-old male with opioid use disorder requests buprenorphine therapy. He is still actively using immediate-release oxycodone (Roxicodone) and he took a dose 2 hours ago.
This patient should begin buprenorphine induction
A) now
B) in 2 hours
C) 8–12 hours after his last opioid use
D) 24 hours after his last opioid use
E) 1 week after his last opioid use
ANSWER: C
Buprenorphine is a partial opioid agonist. In order to reduce the risk of precipitated withdrawal, buprenorphine induction should begin once the patient is exhibiting signs of mild to moderate withdrawal, usually 8–12 hours after the last opioid use. Waiting until a patient goes through full withdrawal increases the chances that the patient will revert back to using opioids.
A 57-year-old female with diabetes mellitus comes to your office for a routine follow-up. Her current medications include metformin (Glucophage), 1000 mg twice daily. She tells you that she does not exercise regularly and finds it difficult to follow a healthy diet. A hemoglobin A1c today is 7.5%. She does not want to add medications at this time, but she does want to get her hemoglobin A1c below 7%, which is the goal that was previously discussed.
Which one of the following would be the most effective way to improve glucose control for this patient?
A) Discuss the components of a healthy diabetic diet and encourage her to follow it more closely
B) Discuss the importance of regular exercise and encourage her to exercise 30–45 minutes daily
C) Recommend that she check her glucose level 1–3 times daily to help determine what adjustments need to be made
D) Start her on an additional medication
E) Refer her to a diabetes educator for medical nutrition therapy
ANSWER: E
Counseling by a diabetic educator or team of educators for medical nutrition therapy lowers hemoglobin A1c by 0.2–0.8 percentage points in patients with type 2 diabetes. While a healthy diabetic diet and regular exercise are important, simply reminding the patient of that fact is not likely to be as successful as comprehensive diabetic education. According to the Society of General Internal Medicine in the Choosing Wisely campaign, patients with type 2 diabetes who are not on insulin therapy should not check their blood glucose level daily. An additional medication will likely decrease the hemoglobin A1c, but this patient has expressed a desire to avoid additional medication, is near goal, and is not currently managing her diabetes with adequate lifestyle changes, so it would be appropriate to respect her wishes and pursue proven interventions that do not require medication.
Which one of the following antihypertensive medications is LEAST likely to exacerbate erectile dysfunction?
A) Clonidine (Catapres)
B) Doxazosin (Cardura)
C) Hydrochlorothiazide
D) Losartan (Cozaar)
E) Metoprolol
ANSWER: D
Angiotensin receptor blockers (ARBs) such as losartan are least likely to cause or exacerbate erectile dysfunction. ARBs may have a favorable effect on erectile dysfunction by inhibiting vasoconstriction activity of angiotensin. Clonidine, -blockers, hydrochlorothiazide, and -blockers are more likely to negatively affect erectile function.
A 3-year-old male has developed multiple large areas of bullous impetigo on the legs, buttocks, and trunk after being bitten numerous times by ants. Which one of the following would be the most appropriate treatment?
A) Topical mupirocin ointment
B) Oral azithromycin (Zithromax)
C) Oral tetracycline
D) Oral trimethoprim/sulfamethoxazole (Bactrim)
E) Intramuscular penicillin G benzathine (Bicillin L-A)
ANSWER: D
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). Topical mupirocin ointment is not practical in very widespread cases or in cases with large bullae. Neither azithromycin nor penicillin is a preferred treatment for impetigo, due to a high rate of treatment failure. Tetracycline should be avoided in children under 8 years of age due to a propensity to cause permanent staining of the teeth.
A 60-year-old male with diabetes mellitus and hypertension sees you for routine follow-up. He has no acute health concerns during today’s visit. His current medications include metformin (Glucophage), lisinopril (Prinivil, Zestril), and hydrochlorothiazide. He smokes cigarettes and has a 40-pack-year smoking history. His vital signs and a physical examination are normal. An in-office dipstick urinalysis reveals 1+ blood and trace protein but is otherwise normal.
Which one of the following would be the most appropriate follow-up?
A) Repeat dipstick urinalysis in 3 months
B) Microscopic urinalysis
C) Renal ultrasonography
D) CT urography
E) Referral for cystoscopy
ANSWER: B
Microscopic hematuria, also known as microhematuria, is defined as 3 RBCs/hpf on microscopy. Dipstick analysis alone is insufficient to diagnose microscopic hematuria, as blood that is seen on dipstick analysis may represent a false-positive result caused by myoglobinuria, hemoglobinuria, dehydration, exercise, menstrual blood, or povidone-iodine, as opposed to true hematuria. Thus, when the presence of blood is suggested by dipstick urinalysis, confirmation with microscopic analysis should be obtained. The current guideline from the American Urological Association (AUA) stratifies further workup for microscopic hematuria based on the patient’s overall risk of genitourinary malignancy, rather than automatic referral for cystoscopy and CT urography for all adults 35 years old with microhematuria, as was recommended in the previous AUA guideline. According to the current guideline, further evaluation may include renal ultrasonography, CT urography, and/or cystoscopy, depending on the patient’s level of risk. Patients who are at low risk also may be given the option to repeat a urinalysis in 6 months. For this patient the next step would be microscopic urinalysis to determine the presence of hematuria, and, if present, to quantify it. If microscopic urinalysis confirms the presence of hematuria, then CT urography and cystoscopy would be indicated, as his age, male sex, and smoking history place him at increased risk of malignancy. Repeating the dipstick analysis in 3 months would be inappropriate in this situation, as the presence or absence of true microscopic hematuria needs to be clarified because of his high-risk history.
A 33-year-old gravida 2 para 1 presents to the hospital at 35 weeks estimated gestation with premature rupture of membranes. A decision is made to manage the pregnancy expectantly and delay delivery unless signs of infection or fetal distress are noted.
Based on current evidence, expectant management rather than immediate delivery increases the risk of which one of the following complications?
A) Cesarean delivery
B) Antepartum or postpartum maternal hemorrhage
C) Time spent in the neonatal intensive-care unit
D) Neonatal sepsis
E) Perinatal or infant mortality
ANSWER: B
While historically the optimal management of premature rupture of membranes between 34 and 36 weeks has been unclear, based on the PPROMT (Preterm Pre-labour Rupture of the Membranes close to Term) trial published in 2015, expectant management appears to be associated with better neonatal outcomes. Expectant management decreases the risk of cesarean delivery, neonatal respiratory distress, mechanical ventilation, time spent in the neonatal intensive-care unit, and time spent in the hospital. Expectant management did increase the risk of maternal antepartum or postpartum hemorrhage and intrapartum fever. No differences were found between immediate delivery and expectant management in the risk of neonatal sepsis, pneumonia, or perinatal or infant mortality.
A 57-year-old male recently diagnosed with acute lymphoblastic leukemia presents to the emergency department with intractable nausea, vomiting, and myalgias. His first chemotherapy infusion was administered earlier in the day.
Which one of the following electrolyte disturbances would be consistent with tumor lysis syndrome?
A) Hypocalcemia B) Hypokalemia C) Hyponatremia
D) Hypophosphatemia E) Hypouricemia
ANSWER: A
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. Sodium electrolyte levels are not as likely to be affected.
Which one of the following is needed to calculate the number needed to treat (NNT)?
A) Number needed to harm
B) Pretest probability
C) Absolute risk reduction
D) Relative risk reduction
E) Likelihood ratio
The number needed to treat (NNT) is calculated as: 1/absolute risk reduction (ARR),
A 30-year-old male comes to your office for evaluation of hand weakness. On examination you detect weakness when he tries to bring his thumb and index finger together. For confirmation you ask him to try to hold on to a piece of paper between his thumb and index finger while you try to pull it away. He is unable to resist when you pull on the paper.
The most likely explanation for these findings is an injury to the
A) brachial plexus
B) median nerve
C) musculocutaneous nerve
D) radial nerve
E) ulnar nerve
ANSWER: E
Initial general neurovascular assessment of an upper extremity injury includes evaluating for radial pulse and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism is indicative of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential brachial plexus injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index finger, and long finger. Weakness of supination of the forearm would indicate a potential musculocutaneous nerve injury. Weakness of active wrist extension would indicate a potential radial nerve injury.
A 70-year-old female sees you for a Medicare annual wellness visit. Her past medical history includes hypertension treated with enalapril (Vasotec). She states that she “couldn’t be better” and says that she has no new symptoms or health concerns. She has a blood pressure of 159/90 mm Hg, a temperature of 36.7°C (98.1°F), a heart rate of 76 beats/min, a respiratory rate of 17/min, and an oxygen saturation of 98% on room air. On examination you note a new harsh systolic murmur that is heard best at the second right intercostal space and can also be heard over the right carotid artery. A transthoracic echocardiogram reveals severe aortic stenosis.
Which one of the following should you recommend for this patient?
A) Antibiotic prophylaxis for dental procedures
B) Transesophageal echocardiography
C) Repeat echocardiography in 6 months
D) Referral for aortic valve replacement
ANSWER: C
This patient has severe aortic stenosis that is asymptomatic. Watchful waiting is recommended for most asymptomatic patients. In asymptomatic patients with severe aortic stenosis, monitoring with serial echocardiography is recommended every 6–12 months. Antibiotic prophylaxis is not indicated unless the patient has undergone aortic valve replacement or has a history of endocarditis. Transesophageal echocardiography is not indicated in this situation. Aortic valve replacement is indicated to decrease mortality in patients with symptomatic aortic stenosis.
After a thorough history and examination you determine that a 30-year-old male has an upper respiratory infection with a persistent cough. He is afebrile and is otherwise healthy.
The best treatment for symptomatic relief of his persistent cough would be intranasal
A) antibiotics
B) antihistamines
C) corticosteroids
D) ipratropium (Atrovent)
E) saline
ANSWER: D
Upper respiratory tract infections are the most common acute illness in the United States. Symptoms are self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise, and a low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis, antitussives and expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics, antihistamines, corticosteroids, and saline would not improve this patient’s cough.
A 20-year-old male presents with a painful second finger after his right hand was stepped on 3 days ago while he was playing basketball. He has marked pain as well as numbness of the distal finger. There are no open wounds and the skin color and nail appear normal other than moderate edema of the fingertip. A radiograph reveals a distal phalanx fracture.
Which one of the following would be the most appropriate next step?
A) Treat symptomatically with ice and an anti-inflammatory medication
B) Tape the first and second digits together until symptoms resolve
C) Splint the affected digit for 2–4 weeks
D) Remove the nail to evaluate for a nail bed injury
E) Refer to a hand surgeon
ANSWER: C
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. Taping digits would likely not provide enough stability for the second digit distal phalanx, which extends beyond the first digit. Patients with distal finger injuries need careful physical examination to evaluate for a nail bed injury, but in this case there is no evidence of nail bed damage or laceration.
A 72-year-old female with a history of type 2 diabetes and hypertension presents to your clinic because of fatigue and depression for the last 5–6 months. She has gained about 7 kg (15 lb) and now has a BMI of 32 kg/m2. A physical examination is otherwise unremarkable. Laboratory studies reveal a TSH level of 8.2 U/mL (N 0.4–4.0). A repeat test 1 month later shows a TSH level of 7.4 U/mL and a free T4 level of 1.6 ng/dL (N 0.8–2.8).
Treatment of this patient with L-thyroxine
A) has no proven benefit
B) can increase grip strength
C) can increase her energy level
D) can help improve depression symptoms
E) can reduce her BMI
ANSWER: A
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.
Appropriate management of an elevated TSH level includes repeat testing in 1–3 months along with a free T4 level. If SCH is diagnosed, levels should be monitored yearly. Only 2%–4% of patients with SCH develop overt hypothyroidism.
A 72-year-old male with a history of hypertension, heart failure, and chronic kidney disease sees you for evaluation of gradually worsening lumbar pain. The pain worsens with walking but improves when he sits. He says that the pain radiates to the buttocks and down the right leg, especially with activity. He has not had any fevers, chills, or new urinary symptoms. MRI indicates severe degenerative changes resulting in moderate to severe canal stenosis at the L4-L5 level.
Which one of the following would be most appropriate at this point?
A) Oral diclofenac, 75 mg twice daily
B) Oral pregabalin (Lyrica), 75 mg twice daily
C) Physical therapy
D) Referral to an orthopedic surgeon for elective surgical resolution
E) Referral to a neurosurgeon for urgent surgical resolution
ANSWER: C
Lumbar spinal stenosis is a common cause of low back pain in older adults, with varying reports of prevalence but at least 10% in most studies. It is the most common reason for lumbar spinal surgery in the United States. Management of this condition is delayed due to the lack of strong evidence for definitively efficacious nonsurgical approaches, and by high rates of major complications with surgical approaches. Focused physical therapy has the best evidence for initial management. Given this patient’s cardiac and renal comorbidities, chronic use of oral NSAIDs is likely to cause significant harm. While some oral pain medications may be considered, pregabalin has not been found to be any more effective than placebo. Both orthopedic and neurosurgical subspecialists perform lumbar spinal surgeries across the United States. In this case, there is no indication for urgent or emergent surgical management. Given the high complication rate, elective surgical management should be considered only after more conservative options have been found ineffective.
A 28-year-old female presents with a depressed mood and sleep disturbance. She tells you that this has occurred for the past 4 years but only during the winter months. Her past medical history and a physical examination are unremarkable.
Which one of the following interventions has the strongest evidence for preventing recurrence of her condition?
A) Exercise
B) Light therapy
C) Cognitive-behavioral therapy
D) Bupropion (Wellbutrin XL)
E) Fluoxetine (Prozac)
ANSWER: D
This patient has seasonal affective disorder (SAD) that has recurred and is likely to continue to recur. 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. Exercise and cognitive-behavioral therapy are beneficial adjuncts to treatment but would not prevent recurrence.
A 69-year-old male sees you for a routine examination and asks about lung cancer screening. He smoked one pack of cigarettes per day for about 35 years but quit 11 years ago.
According to the U.S. Preventive Services Task Force and the American College of Chest Physicians, which one of the following should you recommend?
A) No screening
B) An annual history and examination focusing on lung symptoms
C) Annual chest radiography
D) Annual low-dose chest CT
ANSWER: C
This patient most likely has peroneal tendinopathy, which is a degeneration of the peroneal tendon that involves pain or tenderness in the lateral calcaneus below the ankle along the path to the base of the fifth metatarsal. Initial treatment options include activity modification, decreasing pressure to the affected area, anti-inflammatory or analgesic medications, and eccentric exercises. Calcaneal apophysitis, or Sever’s disease, is a common growth-related injury that typically affects adolescents between 8 and 12 years of age. Symptoms often present after a growth spurt or starting a new high-impact sport or activity, and common examination findings include tight heel cords and a positive calcaneal squeeze test. A calcaneal stress fracture, which most commonly occurs immediately inferior and posterior to the posterior facet of the subtalar joint, involves pain that intensifies with activity and often worsens to include pain at rest. It typically follows an increase in weight-bearing activity or a switch to running or walking on a hard surface. Plantar fasciitis is characterized by sharp, shooting pain in the arch and medial aspect of the foot that often is worse upon arising and taking the first few steps of the morning. Examination of the foot reveals tenderness at the site and pain with dorsiflexion of the toes. Tarsal tunnel syndrome involves entrapment of the posterior tibial nerve and causes a burning, tingling, or shooting pain and numbness that radiates into the plantar aspect of the foot, often into the toes. The pain associated with tarsal tunnel syndrome typically worsens with activity and is relieved with rest.
A 30-year-old female with type 2 diabetes and obesity sees you for follow-up. She has experienced several episodes of symptomatic hypoglycemia, and because of this she stopped all of her medications except metformin (Glucophage). Her hemoglobin A1c has increased to 8.4%.
Which one of the following would be the best additional treatment for this patient?
A) Basal insulin (Lantus)
B) Rapid-acting insulin (Humalog)
C) Exenatide (Byetta)
D) Glipizide (Glucotrol)
E) Repaglinide
A 69-year-old male sees you for a routine examination and asks about lung cancer screening. He smoked one pack of cigarettes per day for about 35 years but quit 11 years ago.
According to the U.S. Preventive Services Task Force and the American College of Chest Physicians, which one of the following should you recommend?
A) No screening
B) An annual history and examination focusing on lung symptoms
C) Annual chest radiography
D) Annual low-dose chest CT
A 43-year-old female comes to your clinic for a routine health maintenance examination. She has a past medical history of diarrhea-predominant irritable bowel syndrome (IBS-D), recurrent urinary tract infections (UTIs), and bacterial vaginosis. She has no new health concerns today. She does not take any medications on a regular basis, and states that she prefers natural supplements to prescription medications. She says that she has heard that oral probiotics are beneficial and asks if they might be the right choice for her.
Which one of the following is the best evidence-based approach to counseling her about oral probiotics?
A) There is no evidence that they will improve her IBS
B) There is no evidence that they will decrease the risk of Clostridioides (Clostridium)
difficile diarrhea when she is treated for a UTI
C) There is strong evidence that they will decrease the risk of antibiotic-associated diarrhea
when she is treated for a UTI
D) There is strong evidence that they will decrease the risk of UTI recurrence
E) There is strong evidence that they will decrease the risk of bacterial vaginosis recurrence
ANSWER: C
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.
A 70-year-old female with a history of coronary artery disease, a femorofemoral bypass 3 years ago, and hypertension sees you for a follow-up visit. She has intermittent right arm pain that is worse with exercise. The pain increases with all arm exercises and improves with rest. The patient’s blood pressure is 140/70 mm Hg in the left arm and 120/64 mm Hg in the right arm.
Which one of the following would be the most appropriate next step?
A) Radiographs of the right shoulder
B) Arterial duplex ultrasonography of the upper extremities
C) MR angiography
D) No imaging, and referral to physical therapy
ANSWER: B
This patient has peripheral artery disease (PAD) of the right arm. PAD of the upper extremities is characterized by pain with exertion and can cause gangrene and ulceration. It is more common in patients who have had lower extremity occlusive disease. A blood pressure differential of 15 mm Hg between arms suggests stenosis and warrants further testing. Initial testing in symptomatic patients includes arterial duplex ultrasonography of the upper extremities. CT angiography and MR angiography may be appropriate to clarify the diagnosis or plan intervention. Neither radiography nor physical therapy would be appropriate.
Which one of the following has been shown to be an appropriate therapeutic intervention for nonspecific low back pain?
A) Bed rest
B) A lumbar brace
C) Muscle relaxants
D) Shoe insoles
E) Yoga
ANSWER: E
Nonspecific low back pain is a condition with no distinct etiology to explain the patient’s associated symptoms. Physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention in the treatment of nonspecific low back pain. The Choosing Wisely campaign states that bed rest should not be recommended for low back pain, and lumbar supports or braces should not be prescribed for the long-term treatment or prevention of low back pain. Studies have consistently shown that NSAIDs combined with muscle relaxants have no benefit over NSAIDs alone. Interventions such as shoe insoles have shown little benefit.
An otherwise healthy 21-year-old male sees you for follow-up after a hospitalization for pneumonia. This was his second pneumonia infection of the year. He reports a history of multiple sinus infections and upper respiratory infections over the years that were treated with antibiotics on an outpatient basis. Laboratory studies reveal a normal CBC and a decreased IgA level. A trial of pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) reveals no measurable response.
This presentation is most consistent with
A) selective IgA deficiency
B) common variable immunodeficiency
C) severe combined immunodeficiency
D) DiGeorge syndrome
E) Wiskott-Aldrich syndrome
ANSWER: B
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. The blunted response to a vaccination challenge implies impaired IgG antibody response, which differentiates CVID from a selective IgA deficiency. Because severe combined immunodeficiency is associated with significant abnormalities of both T-cell and B-cell function, it presents very early in life with multiple severe, opportunistic infections, and failure to thrive. DiGeorge syndrome is associated with multiple other physical abnormalities such as cardiac malformations and dysmorphic facial features. Wiskott-Aldrich syndrome is linked to the X chromosome (primarily affecting males) and associated with eczema and thrombocytopenia.
A 55-year-old female with type 2 diabetes sees you because of early satiety, nausea, vomiting, bloating, and postprandial fullness that is sometimes accompanied by upper abdominal pain. Since these symptoms have developed she has also noted increasing difficulty with blood glucose control.
Which one of the following would be the best study for confirming the most likely diagnosis?
A) Gastric emptying scintigraphy with a solid meal
B) Hepatobiliary scintigraphy (HIDA)
C) An upper gastrointestinal series with small-bowel follow-through
D) Abdominal ultrasonography
E) Abdominal CT
ANSWER: A
Gastroparesis is a complication of diabetes mellitus, and presents with nausea, vomiting, early satiety, bloating, postprandial fullness, and/or upper abdominal pain. Gastric emptying scintigraphy with a solid meal is the first-line study for confirming the diagnosis. Hepatobiliary scintigraphy (HIDA) is used to evaluate biliary dyskinesia and is not indicated in this patient. An upper gastrointestinal radiographic series, abdominal ultrasonography, and CT of the abdomen can help to rule out obstructive pathology, biliary tract disease, and other gastrointestinal conditions but would not confirm the diagnosis. The patient should also undergo esophagogastroduodenoscopy to exclude obstruction.
The administrator in your practice recently attended a quality improvement conference. He would like to start a clinic-wide program to focus on lead screening in asymptomatic children 5 years of age and younger.
After reviewing U.S. Preventive Services Task Force guidelines, which one of the following should you tell the practice administrator?
A) There is insufficient evidence to recommend for or against lead screening in children 5 years of age and younger
B) All children 5 years of age and younger should undergo lead screening
C) All children who live in housing built before 1978 should undergo lead screening
D) There are accurate and reliable screening questionnaires to guide lead screening
ANSWER: A
The U.S. Preventive Services Task Force (USPSTF) has found adequate evidence that questionnaires and other clinical prediction tools to identify asymptomatic children with elevated blood lead levels are inaccurate. The USPSTF went on to conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years of age and younger. Although children living in older housing with lead-based paint are at higher risk of elevated blood lead levels than those living in housing built after 1978, the USPSTF does not recommend routine screening in asymptomatic children based on this risk factor.
A 3-year-old male is brought to your office by his mother because he stepped on a large wooden splinter that broke off at the surface of his left foot and since then he has been avoiding walking on that foot. On examination the bottom of the left heel is red and inflamed.
Which one of the following would be most appropriate initially to visualize the splinter?
A) Radiography
B) Fluoroscopy
C) Ultrasonography
D) CT E) MRI
ANSWER: C
Foreign bodies can be challenging to both detect and remove, especially in younger children. Ultrasonography is good for detecting radiolucent material such as wood or vegetation. MRI can also be used but is more expensive and not as readily available, and may be dangerous if metal is present. There is no radiation exposure with either of these modalities. Plain radiography creates minimal exposure to radiation and can detect radiopaque materials such as glass and metal but cannot detect vegetative materials. Fluoroscopy would be an option to detect radiopaque materials, but not a wooden splinter. CT would not be used for initial evaluation given the cost and high level of radiation exposure. In addition, like plain radiography, CT does not adequately detect radiolucent material.
A 55-year-old male sees you because of a second flare of gout. He has also had an elevated blood pressure at the last few visits to your clinic and is hypertensive again today.
In addition to treating his gout flare, which one of the following would be the most appropriate agent to treat his hypertension in light of his presenting problem?
A) Atenolol (Tenormin)
B) Hydralazine
C) Hydrochlorothiazide
D) Lisinopril (Prinivil, Zestril)
E) Losartan (Cozaar)
ANSWER: E
The 2020 American College of Rheumatology guideline for the management of gout generated numerous recommendations, including the management of concurrent medications in patients with gout. In such patients, losartan is the preferred antihypertensive agent when possible (SOR C). Hydrochlorothiazide should typically be changed to another agent, such as losartan, when feasible in patients with gout (SOR C). Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations, with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril as antihypertensive treatment in patients with gout.
Which one of the following is the preferred method of diagnosing lymphoma in a 60-year-old male who presents with weight loss, unexplained fever, and axillary adenopathy?
A) CT of the chest, pelvis, and abdomen pre- and post-contrast
B) A PET-CT scan
C) A bone scan
D) A bone marrow aspiration and biopsy
E) An open lymph node biopsy
ANSWER: E
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. A PET-CT scan may be used for staging. A bone scan or CT alone is not part of the usual diagnostic evaluation
A 30-year-old female who is an established patient calls your office to request a test for COVID-19. The patient spent several hours inside the home of another individual who just received a positive COVID-19 test result. She states that her sense of taste seems diminished, but she has no respiratory symptoms and otherwise feels well.
Which one of the following is the typical incubation period for COVID-19?
A) 1day
B) 5 days
C) 14 days
D) 30 days
ANSWER: B
SARS-CoV-2 is a respiratory coronavirus that is responsible for COVID-19. Knowledge of the natural history of the viral infection will inform testing strategies and many other aspects of counseling of patients. The incubation period measures the time from exposure to symptom onset. The typical incubation period for COVID-19 is approximately 4–5 days, though it can range from 1–14 days.
