ITE 2022 Flashcards
A 50-year-old male presents with chronic abdominal pain. A workup leads you to suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small duodenal ulcer. The endoscopist also notes some small esophageal varices without red wale signs.
Further evaluation confirms that the patient has compensated cirrhosis in the setting of alcohol use disorder. He readily accepts this diagnosis and enters an Alcoholics Anonymous program. His ulcer symptoms resolve with antibiotic therapy for Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his esophageal varices would be
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1–2 years
ANSWER: E
Primary prevention of variceal hemorrhage is an important consideration in the management of patients with cirrhosis. Although this patient’s varices were diagnosed incidentally, patients with cirrhosis and clinically significant portal hypertension should be screened for varices every 2–3 years with esophagogastroduodenoscopy (EGD). EGD can be deferred in patients with platelet counts <150,000/mm3 and transient elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of bleeding. Findings associated with a high risk of bleeding include small varices in patients with decompensated cirrhosis, small varices with red wale signs (thinning of the variceal wall), and medium to large varices. Patients with small varices not meeting these criteria have a low risk of hemorrhage and do not require prophylaxis. They should be rescreened with EGD every 1–2 years.
For patients requiring treatment due to high-risk features, options for primary prophylaxis of hemorrhage include nonselective -blockers such as propranolol or endoscopic variceal ligation. Treatment decisions are based on patient preference, other potential contraindications, and local resources. The need for repeat endoscopy in these cases will depend on the clinical circumstances. If nonselective -blockers are used, they should be continued indefinitely. Octreotide is only given intravenously for acute hemorrhage. There is no evidence that omeprazole slows the progression of esophageal varices.
Once hemolysis is excluded, the most common cause of unconjugated hyperbilirubinemia is
A) alcoholic liver disease
B) biliary tract disease
C) fatty liver disease
D) Gilbert syndrome
E) Wilson disease
ANSWER: D
Unconjugated hyperbilirubinemia can be defined as an elevated indirect bilirubin level. While unconjugated hyperbilirubinemia is most commonly seen in hemolysis, another common cause is Gilbert syndrome, which stems from a genetic defect that affects how the liver processes bilirubin. Alcoholic liver disease, biliary tract disease, fatty liver disease, and Wilson disease do not lead to unconjugated hyperbilirubinemia.
A 27-year-old male presents to establish care after relocating to the community. He was diagnosed with β-thalassemia major at birth and has been transfusion-dependent since early childhood. His microcytic anemia is stable with blood transfusions every 4 weeks, but his most recent DEXA scan indicates an advancement from osteopenia to osteoporosis.
In addition to bisphosphonates, calcium, and vitamin D, which one of the following medications may improve his bone density?
A) Hydroxyurea (Hydrea)
B) Vitamin C
C) Zinc
D) Deferoxamine (Desferal)
E) Luspatercept (Reblozyl)
ANSWER: C
In addition to bisphosphonates, calcium, and vitamin D, zinc supplementation is recommended to improve bone density in patients with thalassemia and osteoporosis (SOR C). Though hydroxyurea is an indicated therapy to minimize the frequency of blood transfusions needed in transfusion-dependent thalassemia, it does not improve bone density (SOR C). Vitamin C supplementation does not improve bone health in patients with thalassemia and osteoporosis. Deferoxamine infusions are indicated when ferritin levels are >1000 ng/mL in patients with transfusion-dependent thalassemia to reduce iron overload (SOR C). Luspatercept reduced transfusion burden by 33% in a phase 3, randomized study but is not indicated to improve bone density.
An obese 40-year-old female with diabetes mellitus sees you for evaluation of painful, deep-seated nodules in both axillae. On examination you note nodules in the axillae with purulent drainage and associated scarring.
This condition is associated with which one of the following?
A) Amyotrophic lateral sclerosis
B) Crohn’s disease
C) Dermatitis herpetiformis
D) Systemic lupus erythematosus
E) Trauma
ANSWER: B
The patient has hidradenitis suppurativa, a chronic folliculitis affecting intertriginous areas in the axillae and the groin that may also occur around the anus and nipples. Treatment depends on severity and ranges from topical to systemic antibiotics. Hidradenitis suppurativa is associated with obesity, diabetes mellitus, Crohn’s disease, arthritis and spondyloarthropathy, metabolic syndrome, polycystic ovary syndrome, pyoderma gangrenosum, and trisomy 21. There are three stages: stage I is single or multiple abscesses without sinus tracts or scarring, stage II is abscess recurrence with sinus tracts and scarring and widely separated lesions, and stage III is diffuse abscesses with interconnecting sinus tracts. Amyotrophic lateral sclerosis has no typical skin manifestation. Dermatitis herpetiformis is associated with celiac disease and has clusters of pruritic lesions. Systemic lupus erythematosus has cutaneous manifestations of a malar rash and may involve subcutaneous lesions without scarring. Hidradenitis suppurativa is not associated with trauma.
A 43-year-old female with lifelong asthma asks if she would be a candidate for treatment with a biologic agent such as omalizumab (Xolair). A CBC reveals mild eosinophilia, indicating type 2 inflammatory asthma.
In which one of the following patient scenarios should biologic treatment for asthma be considered?
A) Any patient with poorly controlled, severe asthma
B) A patient with severe non–type 2 asthma that is poorly controlled despite adherence to
optimal therapy with long-term controller medication
C) A patient with type 2 inflammatory asthma that is poorly controlled despite therapy with
as-needed inhaled albuterol (Proventil, Ventolin) and low-dose inhaled corticosteroids
D) A patient with severe type 2 inflammatory asthma that is poorly controlled despite
adherence to optimal therapy with long-term controller medication
ANSWER: D
Biologic therapy for asthma targets type 2 inflammation pathways. According to the 2019 Global Initiative for Asthma (GINA) guidelines, diagnosis and management of severe asthma includes determination of the asthma phenotype to assess for type 2 inflammation. Type 2 asthma includes allergic and eosinophilic asthma. Non–type 2 asthma is driven by neutrophils and is associated with smoking and obesity. Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy. Biologic therapy may be considered in patients with severe type 2 inflammatory asthma who continue to have significant symptoms despite adherence to optimal therapy, including high-dose inhaled corticosteroids and a long-acting -agonist.
Cardiac stress testing would be most appropriate for which one of the following patients?
A) A 57-year-old female who is scheduled for a knee replacement and has dyspnea when walking up a few stairs
B) A 60-year-old male with diabetes mellitus who was admitted to the hospital for chest pain and acute stroke and has a normal EKG and troponin levels
C) A 66-year-old male with diabetes and hypertension without cardiac symptoms who would like to stratify his risk for heart disease
D) A 68-year-old female with coronary artery disease who is scheduled for a knee replacement and does not have cardiac symptoms when walking up a flight of stairs
E) A 79-year-old male who is scheduled for a transcatheter aortic valve replacement for severe aortic stenosis and has dyspnea when walking up a few stairs
ANSWER: A
In the setting of acute symptoms, cardiac stress testing is indicated when there is an intermediate probability of acute coronary syndrome. Cardiac stress testing is also indicated in a preoperative assessment when surgery is at least a moderate risk and the patient cannot reach 4 METs of exertion (climbing a single flight of stairs) without cardiac symptoms. Cardiac stress testing is contraindicated after a recent stroke or TIA and in patients with severe symptomatic aortic stenosis. It is not indicated in asymptomatic patients with no history of revascularization.
A 45-year-old male sees you for a routine visit. His medical history includes hypertension treated with hydrochlorothiazide, amlodipine (Norvasc), and losartan (Cozaar). He also has type 2 diabetes treated with metformin and empagliflozin (Jardiance). Laboratory findings are significant for an LDL-cholesterol level of 167 mg/dL and you prescribe simvastatin (Zocor), 80 mg daily. At a follow-up visit 3 months later he tells you that he stopped taking the simvastatin after a week due to muscle pain and weakness.
Which one of the following medications in this patient’s current regimen most likely contributed to his risk for developing statin-induced myopathy?
A) Amlodipine
B) Empagliflozin
C) Hydrochlorothiazide
D) Losartan E) Metformin
ANSWER: A
Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. In patients on statin therapy, concurrent use of other medications that are also metabolized by this system, including amiodarone, calcium channel blockers such as amlodipine, certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy. In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9), and this patient’s other medications are metabolized by different mechanisms (empagliflozin) or not significantly metabolized (hydrochlorothiazide and metformin).
A 12-year-old female is brought to your office for a routine well child examination. The U.S. Preventive Services Task Force recommends screening this patient for which one of the following?
A) Anemia
B) Depression
C) Diabetes mellitus
D) Dyslipidemia
E) HIV
ANSWER: B
The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents and adults starting at age 12. The USPSTF states that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children 6–24 months of age (I recommendation) and does not offer recommendations regarding other age groups. There are no USPSTF recommendations regarding universal screening for diabetes mellitus in children or adolescents. The American Academy of Pediatrics now recommends screening for dyslipidemia in children once between 9 and 11 years of age, but the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years of age (I recommendation). HIV screening is recommended in adolescents and adults 15–65 years of age (A recommendation).
A 70-year-old female who is an established patient at your practice calls you late on a Saturday afternoon. Earlier in the day she misjudged the location of a bench at a neighbor’s house and sat down hard on the porch floor. She felt immediate pain in her back. She went home and took naproxen, 440 mg, and sustained-release acetaminophen, 1300 mg, 3 hours ago. She still describes her pain as unbearable, rating it as 10 on a scale of 10. You agree to meet her in the emergency department, where you confirm an acute T12 vertebral compression fracture.
Of the following, the most appropriate treatment option for this patient’s acute pain is a short course of
A) prescription-strength NSAIDs
B) methadone
C) transdermal fentanyl
D) immediate-release oxycodone (Roxicodone)
ANSWER: D
The most appropriate treatment for this patient’s acute pain following a T12 vertebral compression fracture is round-the-clock class II narcotics. Subcutaneous calcitonin can also be useful for relieving pain from vertebral fractures. NSAIDs and acetaminophen are usually insufficient during the acute phase of a vertebral compression fracture, and this patient has already tried these. Methadone or transdermal fentanyl can be used, but plasma levels of methadone may take 5–7 days to stabilize and fentanyl takes 24–48 hours to take effect.
A 75-year-old male sees you for evaluation of a unilateral resting tremor of his right hand. The tremor resolves if he is touched on the hand by someone. His wife notes that he seems to drag his feet now, but he has no history of falls.
Which one of the following has been shown to delay progression of his disease?
A) No currently available pharmacologic agents
B) Amantadine
C) Carbidopa/levodopa (Sinemet)
D) Rasagiline (Azilect)
E) Ropinirole
ANSWER: A
There are no currently available medications that have been shown to delay progression of Parkinson’s disease. However, guidelines recommend initiating the treatment of motor symptoms when they begin to affect the functions of daily life or decrease the quality of life. The first-line treatment for motor symptoms is carbidopa/levodopa due to its effectiveness for tremors, rigidity, and bradykinesia. It is a myth that delaying the use of levodopa will prevent a lack of efficacy later in the course of the illness, as what appears to be a lack of efficacy actually represents progression of the disease.
Amantadine can be used for patients under 65 years of age who are only experiencing tremors. Monoamine oxidase inhibitors such as rasagiline and non-ergot dopamine agonists such as ropinirole are not as effective as carbidopa/levodopa for motor symptoms, but they do not cause the dyskinesias and motor fluctuations seen with levodopa. Monoamine oxidase inhibitors are considered first-line therapy for patients under age 65 with mild motor symptoms.
A 28-year-old female presents with a 2.5-cm pruritic, erythematous, oval macule on her left thigh. She was seen at an urgent care facility 2 days ago for a urinary tract infection (UTI) and was treated with sulfamethoxazole/trimethoprim (Bactrim). Her UTI symptoms have improved. She reports that she was called earlier this morning and told that her infection was caused by Escherichia coli. The patient reports a similar lesion in the same area about a year ago at the time of her last UTI.
You explain this is most likely secondary to
A) an immunologic reaction to E. coli
B) erythema multiforme
C) nummular eczema
D) the Shiga toxin sometimes produced by E. coli
E) the sulfamethoxazole/trimethoprim used to treat the infection
ANSWER: E
This is a typical history for a fixed drug eruption (FDE), which is an immunologic reaction that recurs upon re-exposure to the offending drug. It is most likely related to T-lymphocytes at the dermal-epidermal junction. Sulfonamides and anticonvulsants are the most frequently cited medications, but tetracycline and penicillins have also been reported to cause FDE. FDE is not caused by bacteria. Erythema multiforme does not present as an isolated, recurrent macule and generally has central clearing. Nummular eczema is a coin-shaped, very pruritic patch but does not fit this clinical scenario. Shiga toxin–producing Escherichia coli are rarely found in extra-intestinal sites.
A 72-year-old female presents with progressive hand pain and stiffness. She is a seamstress and is concerned because sewing has been more difficult over the past 6 months. She recalls that her mother’s hands were misshapen, but her mother never received a diagnosis. You examine her hands, which are shown below.
Which one of the following would be the most appropriate pharmacotherapy?
A) Colchicine (Colcrys)
B) Diclofenac (Zorvolex)
C) Hydroxychloroquine (Plaquenil)
D) Infliximab (Remicade) injections
E) Methotrexate (Trexall)
ANSWER: B
This patient presents with erosive osteoarthritis that involves the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints with sparing of the metacarpophalangeal (MCP) joints. The primary goals for treating osteoarthritis are to control symptoms such as pain and stiffness and optimize function in order to preserve quality of life. Topical or oral NSAIDs are the most appropriate pharmacotherapy for osteoarthritis of the hand. Colchicine and methotrexate have not been studied for the treatment of osteoarthritis and their use for this condition is not recommended. Colchicine is indicated for the treatment of gout, which is usually pauciarticular and asymmetrical, and methotrexate is effective for rheumatoid arthritis. Conventional synthetic and biologic disease-modifying medications such as hydroxychloroquine and infliximab have not been shown to be effective in the treatment of osteoarthritis. These medications are appropriate for the treatment of systemic lupus erythematosus and rheumatoid arthritis, which have examination findings that involve the MCP and PIP joints but spare the DIP joints.
Which one of the following medications for the treatment of type 2 diabetes has been associated with ketoacidosis?
A) Dapagliflozin (Farxiga)
B) Liraglutide (Victoza)
C) Metformin
D) Pioglitazone (Actos)
E) Sitagliptin (Januvia)
ANSWER: A
SGLT2 inhibitors such as dapagliflozin have increasingly been shown to be associated with diabetic ketoacidosis under certain circumstances. Liraglutide, metformin, pioglitazone, and sitagliptin are not associated with diabetic ketoacidosis.
A 48-year-old male with schizophrenia presents for a new patient visit after recently relocating to your area. He has been stable on clozapine (Clozaril) for the past 15 years and asks you to refill his prescription. He has been told the earliest available appointment with a local psychiatric provider is in 3 months.
Under the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program, which one of the following is required to prescribe clozapine to this patient?
A) A signed patient consent form
B) Serum clozapine levels
C) Creatinine levels
D) Neutrophil counts
E) Specialty training in psychiatry
ANSWER: D
Clozapine is a highly effective antipsychotic medication, but its use is limited due to its association with severe drug-induced neutropenia, also referred to as agranulocytosis. Patients must be enrolled in the national Clozapine Risk Evaluation and Mitigation Strategy (REMS) program to receive treatment, and all prescribers and pharmacies must be certified by this program in order to dispense clozapine. The patient’s absolute neutrophil count must be submitted at least every 30 days, or more frequently as determined by stability in treatment. A signed patient consent form should be obtained but is not a part of the Clozapine REMS monitoring system. Monitoring serum clozapine levels and creatinine levels may be appropriate but is not part of the Clozapine REMS program. Family physicians can prescribe clozapine if registered and certified in the Clozapine REMS program, which includes passing a brief knowledge assessment, but specialty training in psychiatry is not required.
A 32-year-old female comes to your office because of chronic diarrhea, abdominal cramping, and bloating. She has had these symptoms for many years but has never discussed them in depth with a physician. A thorough history and physical examination are most consistent with irritable bowel syndrome (IBS). You order IgA tissue transglutaminase (tTG) antibody and fecal calprotectin testing to rule out other conditions and both are negative. She has expressed an interest in nonpharmacologic measures as initial management of her IBS.
Which one of the following should you recommend initially, given that it has the best evidence of benefit for her condition?
A) A gluten-free diet
B) A low-FODMAP diet
C) Soluble fiber
D) Prebiotics
E) Probiotics
ANSWER: C
This patient has diarrhea-predominant irritable bowel syndrome (IBS-D) and may benefit from validation of her symptoms and a clear diagnosis that has several substantiated treatment options. A 2021 clinical guideline from the American College of Gastroenterology (ACG) is based on a systematic review performed by a committee of experts in this field. Based on this review, soluble fiber (but not insoluble fiber) has good evidence for the alleviation of global IBS symptoms and is recommended strongly as a first-line intervention. In contrast, a gluten-free diet has not been shown to be beneficial for IBS. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has low-quality evidence supporting its benefit but merits a trial in patients who do not have an adequate response to fiber supplementation. The ACG has not commented on prebiotics as a treatment for IBS. A 2018 systematic review concluded that while there are small individual studies suggesting benefit for prebiotics (and probiotics) there is inadequate long-term consistent evidence to support their routine use. Probiotics have mixed and low-quality evidence for benefit in IBS. Because of the inconsistent data the ACG recommends against their use.
Which one of the following disorders is caused by an underlying mechanism of osteochondrosis rather than apophysitis?
A) Legg-Calvé-Perthes disease
B) Osgood-Schlatter disease
C) Sever’s disease
D) Sinding-Larsen-Johansson syndrome
ANSWER: A
Osteochondrosis refers to degenerative changes in the epiphyseal ossification areas of growing bones. Legg-Calvé-Perthes disease is a type of osteochondrosis that affects the femoral head. Patients with Legg-Calvé-Perthes disease should be referred to an orthopedist and instructed to avoid all weight-bearing activities until reossification occurs. Osteochondrosis should be differentiated from apophysitis because the etiologies and management strategies differ. Apophysitis is a traction injury to the cartilage and bony attachments of tendons in growing children. Osgood-Schlatter disease, Sever’s disease, and Sinding-Larsen-Johansson syndrome are apophysitis disorders that affect the anterior tibial tubercle, posterior heel, and inferior patellar pole, respectively. Treatment of apophysitis involves stretching, activity modification, icing, and limited use of NSAIDs.
A 40-year-old female presents with several pruritic, thickened, scaly areas on her lower back, knees, and elbows. She says that when she tries to remove the scales they often bleed.
Which one of the following would be the most appropriate pharmacologic therapy for this patient?
A) Clobetasol propionate 0.05% lotion (Clobex)
B) Selenium sulfide 2.5% lotion
C) Permethrin cream (Nix)
D) Terbinafine cream 1%
E) Loratadine (Claritin), 10 mg daily
ANSWER: A
This patient has psoriasis that is characterized by plaques on her extensor extremities and limited bleeding with removal of the scales (Auspitz sign). First-line treatment for localized plaques is topical corticosteroid therapy, such as clobetasol propionate lotion. Antifungals such as selenium sulfide lotion and terbinafine cream are used to treat dermatophytosis infections including tinea pedis and tinea versicolor. Permethrin cream is indicated for treatment of scabies and lice. Loratadine, an oral antihistamine, is used to treat urticaria.
A 17-year-old cross country runner sees you to discuss the results of pulmonary function tests to evaluate his episodic shortness of breath and chest tightness. He had previously been diagnosed with exercise-induced asthma and prescribed albuterol (Proventil, Ventolin), which provided minimal relief. You tell him that the pulmonary function tests revealed normal expiratory findings including normal FEV1 and FVC and a flattened inspiratory flow loop.
The test most likely to confirm a diagnosis for this patient’s shortness of breath is
A) a sleep study
B) chest radiography
C) chest CT
D) esophagogastroduodenoscopy
E) nasolaryngoscopy
ANSWER: E
This patient has vocal cord dysfunction, sometimes called paradoxical vocal fold motion, a condition in which the vocal cords close during inspiration when they should be open. It is not entirely understood why this occurs but it is associated with other conditions including asthma, GERD, and anxiety disorders. It typically causes sudden, severe shortness of breath and often has a trigger such as exercise, gastroesophageal reflux, inhalation of an irritant, or stress. Symptoms may include chest or throat tightness, inspiratory stridor, and wheezing predominantly over the upper airway. In less severe situations the voice may be impacted, and patients sometimes also describe a chronic cough that occurs separately from more acute symptoms. Vocal cord dysfunction is confirmed by direct visualization of the vocal cords during inspiration via nasolaryngoscopy. Pulmonary function tests are often performed as part of the assessment for shortness of breath and, if performed while the patient is experiencing symptoms, will show a flattened inspiratory flow loop. Treatment is primarily focused on therapeutic breathing maneuvers and vocal cord relaxation techniques. A speech therapist may assist in instructing patients in these techniques. Associated conditions should also be treated to help prevent vocal cord dysfunction. A sleep study, chest radiography, chest CT, and esophagogastroduodenoscopy would not confirm a diagnosis of vocal cord dysfunction.
A 62-year-old male is found to have an alkaline phosphatase (ALP) level of 152 U/L (N 32–91). Laboratory studies performed last year showed an ALP level of 134 U/L. The review of systems today is negative, including for pain, nausea, and dyspnea. You note that his AST and ALT levels are in the normal range, and a gamma-glutamyl transaminase level is also normal.
Which one of the following would be the most appropriate next step in the evaluation?
A) Plain radiography of the skull, pelvis, and tibia
B) Right upper quadrant ultrasonography
C) A full-body CT scan
D) A HIDA scan
E) A radionuclide bone scan
ANSWER: A
Paget disease of bone is the second most common metabolic bone disorder after osteoporosis and has a lifetime prevalence of 1%–2% in the United States. Only 30%–40% of patients have symptoms such as bone pain at diagnosis. Most patients are diagnosed after an incidental finding of elevated alkaline phosphatase (ALP) on routine laboratory studies or by plain films performed for another reason. When an elevated ALP level is found in an asymptomatic patient, other liver function tests such as a gamma-glutamyl transaminase level should be performed to evaluate for hepatobiliary pathology. If negative, this should be followed by plain radiography of the skull and tibia, and an enlarged view of the pelvis to assess for lytic lesions and cortical thickening. If plain radiography is consistent with Paget disease of bone, a radionuclide bone scan is performed to assess the full extent of the disease. Bisphosphonates are the first-line treatment in active disease, which is signified by bone pain, hearing loss, and lytic lesions. Right upper quadrant ultrasonography, a full-body CT scan, and a HIDA scan would not be the most appropriate next step in the evaluation.
A 37-year-old male presents for a physical evaluation prior to starting a new job in a hospital. He recently immigrated from Uganda. An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) is positive. He is otherwise healthy. He has not had any cough, fever, unintended weight loss, or night sweats.
Which one of the following is the most appropriate next step?
A) Tuberculin skin testing
B) Inducing sputum for mycobacterial culture
C) Chest radiography
D) Proceeding with treatment for latent tuberculosis
E) Proceeding with treatment for active tuberculosis
ANSWER: C
This patient’s tuberculosis (TB) screening test is positive, and the next step in the evaluation involves determining whether he has a latent infection or active disease. Diagnosis of latent TB requires ruling out active disease by assessing the patient clinically with a history, physical examination, and chest radiograph. If this evaluation does not suggest active disease, sputum studies are not needed. Interferon-gamma release assays (IGRA), which are blood tests used to screen for TB infection, are more accurate than tuberculin skin testing, so a tuberculin skin test is not needed. Treatment should not be started until a determination of latent versus active TB is made.
An 11-year-old female is brought to your office by her parent who is concerned that the child’s spine might be curved. The most appropriate evaluation for scoliosis at this point is
A) comparing the length from the pelvic brim to the pelvic floor on the left and the right
B) scoliometer measurement with the patient bent over to 90°
C) scoliometer measurement with the patient upright and arms to her side
D) determination of the Cobb angle with the patient bent over to 90°
E) determination of the Cobb angle with the patient upright and arms to her side
ANSWER: B
The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°–7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis.
The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°.
A 69-year-old male with a history of diabetes mellitus presents to your clinic with concerns of mild vision problems. His brother lost his vision due to glaucoma and encouraged the patient to seek care.
Which one of the following is most consistent with the typical vision changes of glaucoma?
A) Central vision loss with peripheral sparing
B) Halos and decreased night vision
C) Intermittent complete blackening of the visual field
D) Patchy peripheral vision blurring
E) Sudden scattered floaters
ANSWER: D
Glaucoma and other common eye conditions cause a range of visual disturbances. Glaucoma is typically associated with blurring of peripheral vision as elevated pressure in the eye pushes on the periphery of the ophthalmic nerve. Central vision loss with peripheral sparing is classically seen with macular degeneration. Halos and decreased night vision are classic problems for patients with cataracts. Intermittent complete blackening of the visual field may be seen with ischemia associated with stroke or temporal arteritis. Sudden scattered floaters should raise concern for retinal detachment.
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).
The addition of which one of the following agents would decrease this patient’s all-cause mortality risk?
A) Clopidogrel (Plavix), 75 mg daily
B) Colchicine (Colcrys), 0.6 mg daily
C) Icosapent ethyl (Vascepa), 2 g twice daily
D) Isosorbide mononitrate, 30 mg daily
E) Rivaroxaban (Xarelto), 2.5 mg twice daily
ANSWER: E
This 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.
An 80-year-old female is brought to the emergency department after her family finds her on the floor at her home. They state that she has been confused and not acting like herself for the past 5–7 days. She lives independently and cares for herself, and she is active in a senior church group.
The patient is unable to explain why she was on the floor, so the history is obtained from the family. There are no other associated symptoms and no known inciting incident. There have been no recent medication changes and the family is unaware of any fever or chills. The patient has not had episodes like this in the past.
Her past medical history is notable for controlled blood pressure and a TIA several years ago with no residual neurologic deficit or impairment. A physical examination is negative except for her confusion, and there are no focal neurologic findings. Imaging shows no acute process.
Which one of the following is the most likely explanation for these findings?
A) Alzheimer’s disease
B) Delirium
C) Ischemic stroke
D) Mild neurocognitive disorder
E) Vascular dementia
ANSWER: B
This patient presents with 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. The clinical examination does not indicate the focal neurologic changes of a stroke, and this patient’s TIA was several years ago with no subsequent chronic cognitive changes.
The history and examination in this case do not suggest the presence of chronic cognitive changes indicative of conditions such as Alzheimer’s disease, mild neurocognitive disorder, or vascular dementia. Alzheimer’s disease has an insidious and gradual onset of cognitive symptoms. In vascular dementia, the symptoms begin after cerebrovascular events. Importantly, in the setting of acute mental status changes, the Choosing Wisely campaign recommends not presuming a diagnosis of dementia in an older adult with acute symptoms of confusion without first assessing for delirium.
