ITE 2022

Question 1

How to treat outpatient diverticulitis

Answer 1

Clinical diagnosis, antibiotics and bowel rest; Treatments could be metro + a fluoroquinolone vs Augmentin; IF patient has watery diarrhea then maybe Doxym or Azithromycin for campylobacter or E coli

Question 2

PAtient with flutters in chest, on Holter shows 15% PVC burden, what is the next step

Answer 2

ECHO; patients with PVC > 10% are at risk for dilated cardiomyopathy; If patient has symptoms can treat with beta blockers or CCB

Question 3

Pain at heel that is most severe Immediately on standing in AM; what is first line intervention?

Answer 3

So this is plantar fasciitis; First line intervention is stretching exercises ; night splints use are inconclusive; Extracorporeal shock is Lower n possibilities

Question 4

18 month old comes to office, he was born at 28 weeks and had month long stay in NICU; Received palivizumab (synagis) monthly last year during RSV season; What is recommendation this year for chemoprophylaxis against RSV?

Answer 4

Palivizumab is recommended for all infants born before 29 weeks gestational age who are less than 1 year f age at beg of RSV season, OR for those less than 32 who develop chronic lung disease; After 1 year of age palivizumab is recommended for infants with chronic lung disease

Question 5

PAtient who does cycling an weightlifting presents for pain and parenthesis of 4th and fifth fingers, as well as erased sensation over hypothecate eminence and weakness in pincer grasp;

Answer 5

Issue with ulnar nerve; If it were auxiliary nerve, it would be parenthesis close to shoulder, and weakness with shoulder external rotation, abduction and extension; Median nerve issues would show up as parenthesis of first three fingers and the air muscle atrophy; Finally Radia nerve can cause parenthesis in posterior forearm and dorsal hand, and weakness in wrist and finger extensors

Question 6

Most common cause of septic arthritis in adults..

Answer 6

Staph aureus

Question 7

Outpatient therapy for pads community acquired Neuro is

Answer 7

Amoxicillin; paitients older than 7 Doxy is an alternative when an atypical bacteria is presumed likely

Question 8

Systolic murmur at the left lower eternal border with an intensity that changes along with changes to preload of the heart

Answer 8

Hypertrophic Cardiomyopathy, the more blood (the greater the preload), the quieter the murmur

Question 9

What kind of med is liraglutide ( Victoria)

Answer 9

It is a GLP 1 agonist, and helps weight loss`

Question 10

How long after a passive exposure to cannabis smoke can an otherwise cannabis naive person test positive for it on a drug screen?

Answer 10

Up to 24 hours

Question 11

diabetic patient with peripheral neuropathy and thickened toenails that lift easily from nailbeds…most effective treatment?

Answer 11

Terbinafine; American Academy of Dermatology recommendest testing that it is onychomycosis before treatment ; Of note oral antifungals are contraindicated in patient with chronic liver disease; Eficonazole is the most efective topical antifungal, but it is very expensive

Question 12

no foreign body in eye, BUT fluorescein staiing reveals a 3 mm corneal abrasion

Answer 12

Small (<4mm) uncomplicated abrasons typically heal within 1-2 days and respond to oral analgesics a or nsaids; Patching affected eye can actually delay healing

Question 13

Patient has positive anti HCV Ab test…next step

Answer 13

Basically is this infection active or past? You can determine by ordering HCV RNA polymerase

Question 14

in adolescents and adults what proportion of cases of uncomplicates acute bronchitis are caused by atypical organisms such as Mycoplasma pneumonia and Chlamydia

Answer 14

1. 1%; acute bronchitis is caused by a viral infection in 90-99%

Question 15

Bradycardia + pauses greater than 3 seconds w/ dizziness

Answer 15

sick sinus syndrome, abnormal initiation and propagation of electrical impulses from the SA node; Basically need a pacemaker, and if not willing to undergo this then maybe cilostazol

Question 16

A 43-year-old male sees you because of popping and clicking at the base of his index finger. On
examination you note a nodule on the palmar aspect of the metacarpophalangeal joint with the
finger flexed.

Answer 16

Trigger finger, which can be associated with diabetes mellitus, presents with locking, clicking, or popping
at the base of the finger or thumb. The finger may lock when flexed. Treatment consists of corticosteroid
injection or splinting, and surgery may be necessary

Question 17

A 60-year-old male with symptomatic low testosterone is started on a testosterone patch. You
should order specific periodic monitoring of his PSA level and

Answer 17

hematocrit; When testosterone therapy is started, baseline and periodic measurements of PSA and hematocrit should
be performed. If the hematocrit increases to >54% the testosterone dosage should be stopped or decreased
to avoid hemoconcentration. L

Question 18

after roux en y surgery, how often do you need to check labs for nutrition status

Answer 18

y. Evaluation for
nutritional deficiencies should be performed quarterly for the first year after surgery; after that, annual
checks are recommended.

Question 19

PAtient with htn is diagnosed with T2DM; Is on Metformin, and with labs her A1C is 7.6 while her GFR is 52; What other meds should she be on….

Answer 19

The American Diabetes Association and the Kidney Disease: Improving Global Outcomes group
recommend combination treatment with metformin and an SGLT2 inhibitor for patients with type 2 diabetes
and chronic kidney disease (CKD) with an estimated glomerular filtration rate >30 mL/min/1.73 m2
.
Metformin is first-line medical therapy for the majority of patients with type 2 diabetes. The addition of
an SGLT2 inhibitor limits the progression of kidney disease and improves cardiac outcomes (SOR A)

Insulin is not indicated in this patient as
oral hypoglycemics are first-line therapy unless the hemoglobin A1c is >10% or the patient is experiencing
persistent symptoms of hyperglycemia

Question 20

Initial evaluation of hemoptysis…

Answer 20

A chest radiograph is appropriate in the initial evaluation of hemoptysis (SOR C). If the chest radiograph
does not indicate a cause, then CT or CT angiography with intravenous contrast should be performed (SOR
C). CT has become the preferred modality over bronchoscopy because it is more effective in determining
the etiology. If CT does not identify the cause, bronchoscopy would be the next step. In addition, other
tests including a sputum Gram stain, acid-fast bacillus smear, or sputum cytology can be useful depending
upon the clinical situation.

Question 21

risk factors for neonatal early onset sepsis

Answer 21

Risk factors for neonatal EOS include
maternal GBS, prolonged rupture of membranes, intrauterine inflammation or infection, and the
combination of inflammation and infection, commonly known as maternal chorioamnionitis, or triple I.

Current guidelines recommend either categorical risk factor assessment, use of the neonatal EOS
calculator, or enhanced observation. However, categorical risk factor assessment, similar to 2002 and 2010
CDC guidelines, would result in blood cultures and administration of antibiotics to any newborn where
there was a maternal intrapartum fever.

Question 22

4-month-old female is brought to your clinic for a routine well child visit. She has not been
seen by a physician since 2 weeks of age due to parental concerns about seeking care during the
COVID-19 pandemic. Her growth and development appear to be normal.
Which vaccine is CONTRAINDICATED today?

Answer 22

Rotavirus; . Rotavirus vaccine has
age restrictions and should not be initiated after 14 weeks and 6 days of age. In addition, the rotavirus
series must be complete by 8 months of age. These age restrictions are intended to ensure the vaccine is
administered when it will be of maximal benefit to children given the slightly increased risk of
intussusception after vaccine administration

Question 23

guideline directed therapy for Peripheral Artery Disease

Answer 23

low dose aspirin, mod to high intensity statin, Ace inhibitor or Arb, structured exercise program and scmoking cessation

Question 24

A 68-year-old patient sees you for treatment of depression. When considering potential adverse
effects of antidepressants, which one of the following would be the most appropriate
pharmacotherapy for this patient?
A) Amitriptyline
B) Duloxetine (Cymbalta)
C) Nortriptyline (Pamelor)
D) Sertraline (Zoloft)
E) Venlafaxine (Effexor XR

Answer 24

Sertraline; A recent review from the Agency for Healthcare Research and Quality (AHRQ) found the frequency of
adverse events in older adults taking SSRIs such as sertraline and escitalopram was similar to placebo (SOR
B). SSRIs also have lower discontinuation rates than tricyclic antidepressants such as amitriptyline or
nortriptyline during treatment of up to 12 weeks (SOR B).
Evidence suggests that SNRIs including duloxetine and venlafaxine cause more adverse events and greater
discontinuation of therapy during treatment of up to 12 weeks when compared to placebo (SOR B). A
randomized, controlled trial involving duloxetine demonstrated an increased risk of treatment withdrawal
due to adverse events and an increased risk of falls over 12–24 weeks.
Venlafaxine was compared to no antidepressant use in a large cohort study that had a median treatment
period of 364 days and was associated with an increased risk of falls, fractures, and mortality.

Question 25

74-year-old male whom you have not seen for several years presents with fatigue, an 8-lb weight loss, and musculoskeletal pain for the last 6 months. He had been in good health before these symptoms started. He states that he has a “deep ache” in his lower back, hips, and shoulders that awakens him at night. Plain films of the lumbar spine ordered by an orthopedic surgeon revealed osteopenia and degenerative disease with osteophytes. A bone scan was within normal limits for his age. The only abnormalities you detect on a thorough physical examination are tenderness to percussion over the scapulae, lumbar vertebrae, and posterior pelvis, and a mildly enlarged but smooth prostate. Laboratory Findings Hematocrit 31% (N 40–50) Hemoglobin 10.3 g/dL (N 14.0–17.0) Mean corpuscular volume 90 μm 3(N 80–100) PSA 4.6 ng/mL (N 0.0–4.0) Calcium10.9 mg/dL (N 9.0–10.5) Phosphorus 4.2 mg/dL (N 3.0–4.5) Albumin 3.0 g/dL (N 3.5–5.5) Globulin 6.7 g/dL (N 2.0–3.5) Alkaline phosphatase 86 U/L (N 30–92) BUN 26 mg/dL (N 8–20) Creatinine 2.5 mg/dL (N 0.7–1.5

Answer 25

he combination of a high globulin-to-albumin ratio, anemia, renal insufficiency, and hypercalcemia in a patient with diffuse musculoskeletal pain is highly suggestive of multiple myeloma. Serum and urine immunoelectrophoresis would be the next test to order

Question 26

A 67-year-old male with a history of diabetes mellitus, hypertension, and heart failure with reduced ejection fraction has developed stage 5 chronic kidney disease. Which one of the following would be the best option for treatment of his diabetes? A) Glimepiride (Amaryl) B) Insulin glargine (Lantus) C) Metformin D) Pioglitazone (Actos)

Answer 26

Insulin; Glimepiride is a sulfonyurea and can cause hypoglycemia, metformin u need renal clearance of at least 30, and with stage 5 ur at 15, pioglitazone can cause fluid retention and worsening heart failure; so insulin is left of the choices

Question 27

complex regional pain syndrome is best diagnosed with which kind of study?

Answer 27

Complex regional pain syndrome (CRPS) usually develops after an injury, often a fracture, to a distal extremity, although it can present without prior injury. The diagnosis is made clinically using the history and physical examination. Its pathophysiology is poorly understood. Ultrasonography or MRI may be used to rule out other diagnoses but are not necessary for the diagnosis of CRPS. Nerve injury can be seen on nerve conduction testing with type 2 CRPS, also known as causalgia, but nerve injury is not always identified with type 1 CRPS, also known as reflex sympathetic dystrophy. Nerve conduction testing is not necessary for making the diagnosis, and both types of CRPS are treated with the same approach. A technetium 99m bone scan may reveal increased bone resorption at the site, but it is neither sensitive nor specific for CRPS.

Question 28

A patient sees you because of eye pain and swelling that have been present for a few days. A physical examination reveals a small, pink, tender area of the upper eyelid with an adjacent, slightly inflamed gland opening at the eyelid margin. Which one of the following would be the most appropriate initial treatment?

Answer 28

This patient has a hordeolum (stye). Typical first-line treatment is to apply warm compresses and perform gentle massage of the area to promote drainage of the occluded gland. Antibiotics and incision and drainage are not necessary unless surrounding cellulitis is present or there is failure to improve with initial therapy

Question 29

A 49-year-old male presents to the urgent care center with a fever, cough, and pleuritic chest pain. His medical history is unremarkable with no cardiac risk factors. The patient’s vital signs include a temperature of 39.0°C (102.2°F), a heart rate of 120 beats/min, a respiratory rate of 24/min, a blood pressure of 90/58 mm Hg, and an oxygen saturation of 95% on room air. The patient is awake and able to follow commands. An examination reveals warm skin with a capillary refill time of 2–3 seconds. The patient has normal heart sounds with a rapid peripheral pulse and no evidence of jugular vein distention. A chest radiograph is suggestive of pneumonia. Which one of the following would be the most appropriate next step in treatment?

Answer 29

This patient has an acute febrile illness and **meets criteria for systemic inflammatory response syndrome (SIRS) and decompensated shock.** Shock is a medical emergency requiring urgent treatment to prevent death or other complications. The four types of shock are differentiated based on clinical signs. Correct treatment hinges on accurate determination of the type of shock. This patient demonstrates high-output shock typical of septic shock. **Initial treatment of septic shock begins with fluid resuscitation using isotonic crystalloid by an intravenous or intraosseous route. Recent guidelines recommend a minimum of 30 mL/kg of isotonic crystalloid, with a preference for lactated Ringer’s solution over normal saline.** Hypotonic solutions, such as half-normal saline, should never be administered as a bolus. There is no indication for epinephrine or dobutamine in this patient. Norepinephrine can be indicated for septic shock that has not responded to fluid resuscitation

Question 30

what do you do with a nondisplaced radial head fracture

Answer 30

Current evidence supports a brief period of immobilization followed by early range-of-motion exercises to avoid decreased range of motion. This results in good outcomes in 85%–95% of patients. Immobilization for 6 weeks using either a long arm posterior splint or a long arm cast is not necessary

Question 31

A 4-year-old male is brought to your office by his parents because of a 2-day history of cough and a runny nose, but no fever. The child’s symptoms are not progressing. The patient has a history of wheezing when he has mild respiratory infections. The only findings on examination are yellow nasal discharge and mild wheezing. The appropriate management with the LEAST amount of risk would be treatment for 10 days with

Answer 31

For children up to 4 years of age who only have wheezing with respiratory infections, using an inhaled corticosteroid (IC) daily when a respiratory infection develops reduces exacerbations and the use of systemic corticosteroid therapy. It is uncertain if ICs affect growth, but they would be less likely to do so than systemic corticosteroids. Antibiotic therapy should be reserved for bacterial infections. Montelukast is indicated for the prevention of asthma and allergic rhinitis. The use of antihistamine decongestant preparations in children is not recommended due to potential side effects and minimal benefit. | DONT USE ANTIHISTAMINES!!!

Question 32

what vaccine is recommended for patients newly diagnosed with HIV?

Answer 32

The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a **two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV.** Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200 cells/ L. Hepatitis B vaccine is recommended but would not be necessary for patients such as this one with natural immunity or confirmed immunity from vaccination

Question 33

causes of acute altered mental status

Answer 33

****acute altered mental status. Delirium should always be considered in this setting because it is both common and frequently overlooked (SOR C). There are multiple potential causes of this patient’s acute altered mental status, including but not limited to **systemic infections, metabolic disturbances, medications, systemic conditions, and central nervous system insults such as ischemic stroke.**

Question 34

Which one of the following is true regarding acute gastroenteritis in children? A) Handwashing and general hygiene alone can prevent rotavirus infection B) Daily probiotics are recommended C) The majority of cases are caused by bacteria D) Oral rehydration is as effective as intravenous rehydration in mild to moderate dehydration E) Promethazine is the antiemetic of choice in patients with moderate dehydration and nausea

Answer 34

Oral rehydration therapy is as effective as intravenous rehydration in preventing hospitalizations and return emergency department visits in children with mild to moderate dehydration from acute gastroenteritis. Rotavirus infection cannot be prevented by handwashing and hygiene alone, and infants should receive the rotavirus vaccine to reduce the risk of rotavirus infection and associated complications. The benefit of probiotics for treatment of acute gastroenteritis is not yet clear.* The majority of acute gastroenteritis infections in children are caused by viruses, not bacteria.* **Ondansetron is the antiemetic of choice for children, as older antiemetics, including promethazine and metoclopramide, have higher rates of adver**se reactions.

Question 35

23-year-old female with a history of systemic lupus erythematosus presents to discuss contraceptive management. You note that she is no longer taking hydroxychloroquine (Plaquenil) and has not seen her rheumatologist in over a year. She reports generalized fatigue and intermittent joint pain. She is agreeable to obtaining laboratory studies at today’s visit. In addition to checking anti–double-stranded DNA, complement levels, an erythrocyte sedimentation rate, a C-reactive protein level, a CBC, and a comprehensive metabolic panel, which one of the following laboratory tests would be most helpful in monitoring her disease activity?

Answer 35

UA w/ microscopic exam; e majority of patients with systemic lupus erythematosus (SLE) follow a relapsing-remitting course, and management requires monitoring clinical symptoms and laboratory studies. Prolonged remission and persistently active disease are both infrequent. **In addition to monitoring anti–double-stranded DNA, complement levels, erythrocyte sedimentation rates, C-reactive protein levels, WBC counts, platelet counts, serum creatinine levels, and glomerular filtration rates, monitoring urine studies for proteinuria is important to assess disease activity over time**. *Lupus nephritis is a significant cause of morbidity and mortality associated with SLE *

Question 36

A 67-year-old male presents to your office with a 1-month history of fever with edema and erythema of his right foot. His medical history is significant for peripheral artery disease and poorly controlled type 2 diabetes with diabetic neuropathy. Significant vital signs include a temperature of 38.6°C (101.5°F), a blood pressure of 155/90 mm Hg, and a pulse rate of 85 beats/min. A physical examination is most notable for a draining ulcer on the ball of his right foot. The edema and erythema are limited to his right foot and he has no calf tenderness. Dorsalis pedis and posterior tibial artery pulses are present but diminished at the right ankle. Sensation to monofilament testing of his right foot is diffusely diminished, which is consistent with his baseline. The best initial imaging test of the foot ulcer would be...

Answer 36

osteomyelitis until proven otherwise; Need to check bone to make sure no osteo

Question 37

what sxs make a sinusitus more likely to be bacteria?

Answer 37

worsening fever, sxs for 10days or longer, signs of double sickening, unilateral facial and tooth pain, and cacosmia (perception of foul odor); plan for augmentin, since there is resistance against amoxicillin

Question 38

A 67-year-old male presents for follow-up of ongoing chest pain that he experiences when walking up hills. His medical history is significant for hypertension and coronary artery disease. Four months ago he had a positive exercise stress test and underwent coronary angiography, which showed **diffuse atherosclerotic disease but no lesions suitable for percutaneous intervention**. His current medications include aspirin, 81 mg; atorvastatin (Lipitor), 80 mg; and metoprolol succinate (Toprol-XL), 100 mg. His vital signs include a blood pressure of 120/66 mm Hg and a pulse rate of 68 beats/min. Recent laboratory studies are significant for an LDL-cholesterol level of 58 mg/dL, a triglyceride level of 120 mg/dL, and a troponin level of 0.05 ng/mL (N <0.04).

Answer 38

patient presents with stable angina and documented coronary atherosclerosis. His slight troponin elevation is a marker of elevated risk. The **addition of low-dose rivaroxaban to aspirin has been shown to decrease cardiac and all-cause mortality in patients with coronary artery disease (CAD) and may be offered** to this patient (SOR A). *Dual antiplatelet therapy with clopidogrel and aspirin is recommended for 1 year after stenting but is not recommended in patients with stable angina who do not have stents.* Colchicine has been associated with decreased cardiac events in patients with CAD but may increase all-cause mortality. Icosapent ethyl has been shown to decrease cardiac events but not mortality in patients with hypertriglyceridemia >150 mg/dL. Isosorbide mononitrate may be indicated to improve angina symptoms but does not improve mortality risk.

Question 39

a patient with hypothyroidism comes to you since she found out shes pregnant...next steps

Answer 39

patient with hypothyroidism require increased dosages of levothyroxine as early as the first 4 weeks of pregnancy; general recommendatio to to take an extra dose 2 days per week for a total of 9 weekly doses; TSH should be monitored every 4 weeks during pregnancy ; untreated hypothyroidism can lead to adverse effects such as spontaneous abortion, preterm bith, preeclampsia and placental abruption

Question 40

what is the most common causitive agent of abscess? how do u treat?

Answer 40

MRSA is the most common causative pathogen, so an antibiotic that provides coverage against MRSA, such as sulfamethoxazole/trimethoprim, doxycycline, or clindamycin, should be used as an empiric first-line agent for treatment of a skin abscess, pending culture results

Question 41

patient with diabetes, well controlled presents with perianal abscess...how do you treat?

Answer 41

**Incision and drainage of an abscess along with MRSA antibiotic coverage is recommended for all abscesses greater than 2×2 cm.** Incision and drainage of an abscess is almost always indicated and is a cornerstone of treatment. A wound culture with antibiotic sensitivity must be obtained in all cases to guide therapy. MRSA is the most common causative pathogen, so an **antibiotic that provides coverage against MRSA, such as sulfamethoxazole/trimethoprim, doxycycline, or clindamycin**, should be used as an empiric first-line agent for treatment of a skin abscess, pending culture results. *Additional anaerobic coverage is recommended when an abscess is located in the perirectal area or when an abscess occurs in an area where tissue ischemia is likely.*

Question 42

stress urinary incontinence advise for patients

Answer 42

1) appropriate fluid intake 2) weight loss 3) reduction of caffeine and carbonated beverages 4) timed voidings 5) pelvic floor muscle training

Question 43

in what kind of incontinence can u use pral antimuscairnirs and botox?

Answer 43

urge incontinence

Question 44

typical vision changes of glaucoma

Answer 44

patchy, peripheral vision blurring; elevated pressure in the eye pushes on the periphery of the ophthalmic nerve

Question 45

typical vision changes of macular degeneration

Answer 45

central vision loss with peripheral sparing

Question 46

typical vision changes of cataracts

Answer 46

halos and decreased night vision

Question 47

typical vision changes of retinal detachment

Answer 47

sudden scatered floaters/ curtain coming down eye

Question 48

A 51-year-old patient asks about recommended lung cancer screenings. The U.S. Preventive Services Task Force recommends annual lung cancer screening with low-dose CT for individuals starting at age

Answer 48

The primary risk factor for lung cancer is tobacco smoking, which accounts for 90% of all lung cancer cases. Lung cancer has a relatively poor prognosis, but early-stage lung cancer is more amenable to treatment and has a better prognosis. Low-dose CT has a reasonable specificity and high sensitivity for lung cancer in patients at high risk. The eligibility criteria were recently updated by the U.S. Preventive Services Task Force due to evidence of mortality benefit, with a recommendation for screening to begin at age 50 for patients with a 20-pack-year smoking history who are current smokers or have quit within the past 15 years.

Question 49

personality disorder is characterized by emotional dysregulation, unstable self-image, and instability in interpersonal relationships

Answer 49

borderline

Question 50

single most important determinant of the risk that a AAA will rupture

Answer 50

DIAMETER!!!! m. In men, aneurysm repair is recommended when the aneurysm reaches 5.5 cm in diameter. In women, whose aortas tend to be smaller, the recommended maximum diameter is 5.0 cm****

Question 51

After performing a thorough history and physical examination and appropriate laboratory studies you diagnose fibromyalgia. You explain to the patient that the initial treatment recommendation with the most proven efficacy is....

Answer 51

Aerobic exercise, a balanced diet, good sleep hygiene, and weight reduction are appropriate strategies for the management of fibromyalgia, and treatment goals should be focused on improving function and quality of life, along with managing symptoms. According to the 2017 European League Against Rheumatism, exercise is the strongest and most critical treatment for fibromyalgia

Question 52

You suspect primary ovarian insufficiency. Which one of the following combinations of FSH and LH levels is consistent with this diagnosis?

Answer 52

elevated fsh and lh; Ovarian insufficiency leads to low estrogen levels, which stimulate increased production of FSH in the pituitary in a feedback loop. In this scenario, LH levels are high but do not rise as much as FSH levels.

Question 53

A previously healthy 44-year-old female presents to the emergency department (ED) with severe, sharp, right upper quadrant abdominal pain and nausea that began shortly after eating dinner. On examination she is noted to have a low-grade fever with a positive Murphy sign. A laboratory analysis is notable for leukocytosis with a left shift and a mildly elevated total bilirubin level. A lipase level and liver transaminases are normal. Ultrasonography reveals several small gallstones, gallbladder wall thickening, and pericholecystic fluid. After receiving intravenous fluids, pain management, and antiemetic treatment in the ED, her symptoms improve. In addition to intravenous antibiotics, the most appropriate next step in management would be to offer....

Answer 53

Lap chole; While most patients with acute cholecystitis will have symptoms that improve with supportive care over 2–7 days, the risk of recurrent symptoms and complications increases with delayed surgical intervention. The Choosing Wisely initiative recommends that surgical treatment be offered to the patient during the initial hospitalization. The Society of American Gastrointestinal and Endoscopic Surgeons has found that laparoscopic cholecystectomy is safe and cost-effective in the immediate hospital setting. This stable, uncomplicated patient should be offered laparoscopic cholecystectomy during the current visit. s. Since she does not have signs of obstructive cholangitis such as elevated liver enzymes and jaundice, endoscopic retrograde cholangiopancreatography (ERCP) is not indicated.

Question 54

first line treatment for OSA

Answer 54

positive pressure ventilation;

Question 55

conditions associated with OSA

Answer 55

afrib, depression, heart failure, stroke