ITE 2023 Flashcards
A 22-year-old male presents for follow-up of moderate persistent asthma. After discussing his treatment options, you decide to use a single maintenance and reliever therapy (SMART) approach.
Which one of the following daily inhaled therapies is appropriate to prescribe in this setting?
A) Budesonide (Pulmicort)
B) Budesonide/formoterol (Symbicort)
C) Fluticasone/salmeterol (Advair Diskus)
D) Fluticasone/vilanterol (Breo Ellipta)
E) Tiotropium/olodaterol (Stiolto Respimat)
ANSWER: B
In the single maintenance and reliever therapy (SMART) approach for asthma control, combination therapy with an inhaled corticosteroid and a long-acting bronchodilator is used as both controller and rescue medication. SMART is recommended as the preferred therapeutic approach in steps 3 and 4 in the 2020 National Asthma Education and Prevention Program guidelines. Formoterol is the only medication available in the United States recommended for use in SMART therapy due to its rapid onset of action. Budesonide monotherapy, fluticasone/salmeterol, fluticasone/vilanterol, and tiotropium/olodaterol are not appropriate options for SMART in asthma control.
You are co-managing a 59-year-old female with stage 3b chronic kidney disease (CKD) and secondary hyperparathyroidism resulting in osteoporosis. Due to transportation issues, she has been unable to see her specialist and requests that you take over her laboratory surveillance for CKD–bone mineral disorder.
In addition to serum calcium, parathyroid hormone, vitamin D, and creatinine levels and the estimated glomerular filtration rate, which one of the following laboratory values should be routinely monitored?
A) Calcitonin
B) Magnesium
C) Parathyroid hormone–related peptide
D) Phosphorus
E) TSH
ANSWER: D
Routine laboratory monitoring is required for patients with chronic kidney disease–bone mineral disorder (CKD-BMD) or secondary hyperparathyroidism due to renal disease. This patient has secondary hyperparathyroidism due to CKD, which interferes with normal calcium, phosphorus, and vitamin D regulation. Parathyroid hormone (PTH) stimulates bone resorption and increases serum calcium and phosphorus levels, and an elevated PTH level can result in significant hypercalcemia and hyperphosphatemia. Controlling these levels through diet and medication reduces fracture risk and mortality. Monitoring calcitonin, magnesium, and TSH levels on a routine basis is not useful for the management of CKD-BMD. PTH-related peptide is useful in diagnosing humoral hypercalcemia of malignancy but does not play a role in CKD-BMD monitoring.
A 42-year-old premenopausal female presents to your office with new-onset bilateral nipple discharge for the past 4 weeks. She describes the discharge as green and nonbloody. She has a past medical history of diabetes mellitus, dyslipidemia, hypertension, and depression. Her current medications include the following:
Atorvastatin (Lipitor) Escitalopram (Lexapro) Hydrochlorothiazide Lisinopril (Zestril) Metformin
Her vital signs are unremarkable. A physical examination is significant for nonbloody green fluid expressed from the nipples. A TSH level, comprehensive metabolic panel, and CBC are all within normal range, and a serum hCG test is negative. A prolactin level is elevated at 85 ng/mL (N <30 in nonpregnant premenopausal females).
Which one of her medications is most likely to cause galactorrhea?
A) Atorvastatin
B) Escitalopram
C) Hydrochlorothiazide
D) Lisinopril E) Metformin
ANSWER: B
Of this patient’s medications, escitalopram is most likely to induce galactorrhea. SSRIs are responsible for 95% of medication-induced galactorrhea cases. The etiology of an elevated prolactin level <100 ng/mL is commonly medication, systemic pathology, or a microadenoma. Macroadenomas are associated with higher prolactin levels (>250 ng/mL). A normal physical examination, negative hCG level, and unremarkable TSH level, BUN level, creatinine level, and liver function tests further support a medication-induced etiology for this patient’s galactorrhea. Antihypertensives such as calcium channel blockers and methyldopa may cause galactorrhea, while diuretics such as hydrochlorothiazide and ACE inhibitors such as lisinopril are not known offenders. Neither atorvastatin nor metformin are common etiologies for medication-induced hyperprolactinemia, although atorvastatin can cause gynecomastia.
A 73-year-old female with a history of obesity, essential hypertension, hyperlipidemia, and well-controlled type 2 diabetes presents to the emergency department (ED) with severe, crushing chest pain. She has a blood pressure of 115/64 mm Hg, a pulse rate of 90 beats/min, a respiratory rate of 15/min, a temperature of 37.2°C (99.0°F), and an oxygen saturation of 95% on room air. A point-of-care troponin level is 1.0 ng/mL (N <0.04) and an EKG is normal, and you diagnose a non–ST-elevation myocardial infarction.
Which one of the following interventions in the ED has the greatest benefit with regard to decreasing mortality in this patient?
A) Supplemental oxygen
B) Aspirin
C) Metoprolol
D) Morphine
E) Nitroglycerin
ANSWER: B
Based on a large, randomized, multicenter trial with 17,187 participants, the administration of aspirin for suspected acute myocardial infarction (MI) saves one life for every 24 patients. Supplemental oxygen appears to have no benefit in patients with an oxygen saturation >94%. Excessive oxygen can be toxic to endothelial cells and may decrease coronary blood flow and increase systemic vascular resistance.
-Blockers given immediately after MI do not decrease mortality, likely due to increased cardiogenic shock, although -blockers administered in the subacute period following the event do have benefit. Morphine does not appear to have benefit and may increase mortality. The use of nitroglycerin does not lower the risk of mortality.
A healthy 78-year-old female with no history of osteoporosis has a family history of hip fracture. Bone density screening reveals a lumbar T-score of –2.0 and a right hip T-score of –1.5. Her FRAX score is calculated at a 20% risk of major osteoporotic fracture and an 11% risk of hip fracture. She is concerned about the possibility of breaking her hip.
Which one of the following interventions would be most appropriate?
A) Initiating treatment with a bisphosphonate
B) Initiating treatment with combined estrogen/progesterone
C) A repeat bone density scan in 1 year
D) A repeat bone density scan in 3 years
E) A repeat bone density scan in 5 years
ANSWER: A
The National Osteoporosis Foundation supports treatment of postmenopausal women with low bone mass and a 10-year risk >20% for any major fracture or 3% for hip fracture. First-line treatment options include bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), teriparatide, and denosumab. These medications are considered first line due to their proven efficacy in reducing both hip and vertebral fractures. Hormonal treatment such as raloxifene and hormone replacement therapy is not recommended as first-line treatment due to associated risk and side effects as well as lack of evidence supporting efficacy in preventing hip fractures. Women with a 10-year fracture risk <20% but who have osteopenia and/or risk factors for bone loss can be monitored with periodic bone density scans, though the optimal intervals for repeat evaluation have not been definitively established.
Which one of the following tests has the highest negative predictive value to rule out celiac disease?
A) An antigliadin antibody test
B) A C-reactive protein level
C) A fecal calprotectin level
D) Genetic testing for HLA-DQ2 and HLA-DQ8
E) An IgA tissue transglutaminase (tTG) antibody test
ANSWER: D
Celiac disease occurs almost exclusively in people with HLA-DQ2 or HLA-DQ8 genotypes. Though not routinely performed, a negative result has more than a 99% negative predictive value for the disease. A positive IgA tissue transglutaminase (tTG) antibody test is helpful in making a diagnosis if symptoms are present and has 95% sensitivity and specificity for active disease, but a negative IgA tTG test does not rule out future risk. A negative antigliadin antibody test has lower sensitivity and specificity than IgA tTG, and is used to diagnose the disease in the presence of symptoms rather than to rule out future risk. Negative C-reactive protein and fecal calprotectin levels make active inflammatory bowel disease less likely.
An unhoused 63-year-old male is brought to the emergency department in a state of agitation and confusion. He is found to be hypothermic with a body temperature of 31.1°C (88.0°F). He has a blood pressure of 90/70 mm Hg and a heart rate of 120 beats/min.
While undergoing warming, which one of the following should be given to this patient?
A) Normal saline at room temperature
B) Normal saline that has been warmed
C) Lactated Ringer solution at room temperature
D) Lactated Ringer solution that has been warmed
E) 50% dextrose in water at room temperature
ANSWER: B
When fluid resuscitation is necessary in hypothermia, normal saline is preferred because hypothermic patients cannot metabolize lactate. The fluid should be warmed to 38°C–42°C (100.4°F–107.6°F.) Lactated Ringer solution and 50% dextrose in water would not be appropriate.
A 69-year-old male presents 30 hours after the onset of difficulty speaking, right-sided facial droop, and marked weakness in his right arm and leg, with the arm more affected than the leg. You diagnose an ischemic stroke of the left middle cerebral artery (MCA). Noncontrast CT of the head reveals hypodensity in the area of the brain supplied by that artery, and CT angiography reveals occlusion of the left proximal MCA.
Which one of the following treatments would be indicated at this time?
A) Aspirin daily
B) Clopidogrel (Plavix) plus aspirin
C) Intravenous alteplase (Activase)
D) Intravenous tenecteplase (TNKase)
E) Thrombectomy of the MCA
ANSWER: A
The benefit of interventions for the treatment of acute ischemic stroke is time dependent. A 21-day course of clopidogrel plus aspirin, followed by clopidogrel alone is indicated for patients with mild, non-debilitating stroke who do not require other interventions. Intravenous alteplase is most beneficial if given within 4.5 hours after the onset of stroke symptoms. In some selected patients, this time window may extend up to 9 hours. Tenecteplase is still experimental. Thrombectomy should be performed within 6 hours if possible, although select patients may benefit from thrombectomy up to 24 hours after onset of symptoms. This patient meets none of the above criteria, so he should be started on daily aspirin.
A 35-year-old female with a history of heavy menstrual bleeding is found to have a hemoglobin level of 10.4 g/dL (N 12.0–15.0). An elevated blood level of which one of the following biomarkers would be most consistent with iron deficiency anemia in this patient?
A) Ferritin
B) Hepcidin
C) Reticulocyte count
D) Total iron-binding capacity
E) Transferrin saturation
ANSWER: D
Patients with iron deficiency anemia have an increase in total iron-binding capacity. All the other listed biomarkers, including ferritin and hepcidin levels, reticulocyte count, and transferrin saturation, are decreased in the setting of iron deficiency anemia. Other laboratory findings with iron deficiency anemia include a low mean corpuscular volume, a low mean corpuscular hemoglobin, a high red cell distribution width on a CBC, and a low serum iron level.
A 68-year-old female presents for evaluation of low back pain. Which one of the following signs or symptoms would be most consistent with a diagnosis of spinal stenosis syndrome?
A) Pain improvement when moving from sitting to standing
B) Pain improvement with lumbar extension
C) Pain worsened by bending forward at the waist
D) Poor balance
E) Urinary incontinence
ANSWER: D
A diagnosis of lumbar spinal stenosis is characterized by the narrowing of a neural foramen or the spinal canal, which causes impingement of the nerve roots. It is most often caused by disc protrusion/herniation or degenerative changes. Degenerative changes cause ligamentous hypertrophy and development of osteophytes that cause symptoms by impinging on spinal roots. Compression of the posterior columns of the spinal canal can impact the awareness of position sense (proprioception). A report of balance problems by patients with low back pain is 70% sensitive for spinal stenosis syndrome, and the patient may exhibit a positive Romberg test and a wide-based gait. Spinal stenosis pain is increased by movements of lumbar extension such as standing upright and improved by forward flexion such as bending over a shopping cart or while sitting. Severe impingement as in cauda equina syndrome causes urinary retention and not incontinence.
A 71-year-old male who resides at sea level travels to Colorado for a vacation. He spends the first night in a resort at 2700 m (8858 ft) above sea level. He notes a headache and sleeps poorly. The next morning he is somewhat nauseated and lightheaded, but feels well enough to proceed with his plans and ascends to his campsite at 4000 m (13,123 ft). During the first evening at the campsite, friends note that he is confused and having difficulty with his balance.
Which one of the following diagnoses best explains his symptoms at the campsite?
A) Acute mountain sickness
B) High-altitude cerebral edema
C) High-altitude headache
D) High altitude–induced central sleep apnea
E) High-altitude pulmonary edema
ANSWER: B
This patient likely had a high-altitude headache on arrival, central sleep apnea during his first night in the hotel, and acute mountain sickness by the next morning. None of these conditions are life-threatening, and proper acclimatization would have been helpful. The addition of ataxia and confusion to his symptom list points to high-altitude cerebral edema, which can progress to coma and death. Immediate descent is indicated. Symptoms of high-altitude pulmonary edema include cough with pinkish sputum, respiratory distress, and cyanosis.
A 62-year-old male presents with daytime fatigue, sleepiness, snoring at night, and a BMI of 41 kg/m2. You are concerned that he may have obesity hypoventilation syndrome (OHS) in addition to possible obstructive sleep apnea.
Which one of the following tests is most appropriate for establishing a diagnosis of OHS?
A) Daytime awake serum HCO3–
B) Daytime awake PaCO2
C) Daytime awake PaO2
D) Nighttime serial measurement of peripheral oxygen saturation during sleep
E) Nighttime serum HCO3– within 2 minutes of awakening
ANSWER: B
Obesity hypoventilation syndrome (OHS) is characterized by obesity and alveolar hypoventilation while awake, which is defined by an awake PaCO2 level >45 mm Hg. Ninety percent of patients have coexistent obstructive sleep apnea (OSA). The pathogenesis is related to the increased physical demands on breathing caused by obesity. While decreased PaO2 or oxygen saturation is often present, it is not–part of the diagnostic criteria. In obese patients with lower risk (often with lower BMIs), a serum HCO3 level <27 mmol/L may obviate the need for an arterial blood gas measurement as OHS becomes very unlikely. If the HCO3– level is 27 mmol/L (a renal compensatory mechanism for hypoventilation-induced acidosis), a PaCO2 measurement should be obtained to establish the diagnosis. The first-line treatment for ambulatory patients with this condition is CPAP. Nighttime measurement of peripheral oxygen saturation during sleep is a key component of sleep studies that are used to diagnose OSA, but it is not used to diagnose OHS.
You are caring for a 21-year-old female with previously diagnosed bipolar II disorder, generalized anxiety disorder, attention-deficit/hyperactivity disorder, and insomnia. The patient presents for a same-day appointment with new symptoms of chills, excess sweating, flushing, and nausea of approximately 2 hours’ duration. The patient felt normal upon awakening, took methylphenidate (Ritalin), 5 mg with breakfast, and went to work. She began to feel shaky around lunchtime and took a second dose of methylphenidate, 5 mg. Thirty minutes later she began having agitation, chills, sweating, flushing, and nausea and had to leave work. Her current medications include the following:
Desvenlafaxine (Pristiq), 50 mg daily Doxepin, 10 mg daily at bedtime Methylphenidate, 5 mg twice daily Ziprasidone (Geodon), 40 mg twice daily
An examination reveals an alert and anxious patient with damp skin, a temperature of 38.1°C (100.6°F), and a heart rate of 110 beats/min. The pupils are slightly dilated and briskly reactive. A neurologic examination reveals a mild tremor and hyperreflexia without clonus.
Which one of the following would you recommend for this patient?
A) Discontinuing all current medications until her symptoms subside
B) Replacing methylphenidate with atomoxetine (Strattera)
C) Replacing methylphenidate with amphetamine salts such as
dextroamphetamine/amphetamine (Adderall)
D) Symptomatic treatment with diphenhydramine (Benadryl Allergy)
E) Symptomatic treatment with ondansetron
ANSWER: A
Serotonin syndrome is a serious condition that can be life-threatening. This patient is taking multiple serotonergic medications and displays features suggestive of serotonin syndrome. Signs and symptoms of serotonin syndrome include mental status changes (e.g., agitation, hallucinations, delirium, coma), autonomic instability (e.g., hyperthermia, tachycardia, labile blood pressure, diaphoresis, dizziness, flushing), neuromuscular changes (e.g., tremor, rigidity, hyperreflexia), and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). A timely diagnosis and immediate discontinuation of serotonergic medications can help prevent worsening of the condition. Supportive care, sometimes in a hospital or intensive-care setting depending on severity, is the mainstay of treatment. Severe symptoms that necessitate hospital management include a temperature >38.5°C, confusion, delirium, and rigidity. Multiple classes of medications are associated with serotonin syndrome, including SSRIs/SNRIs, tricyclic antidepressants, antipsychotics, stimulants, triptans, and others. Changing to a different stimulant, or to a nonstimulant, would not help resolve serotonin syndrome, nor would symptomatic treatment with diphenhydramine or similar agents. Serotonin syndrome has been reported with 5-HT3 receptor antagonists such as ondansetron, particularly when used in combination with other serotonergic medications.
A 24-year-old male presents for evaluation of a soft-tissue mass on his arm. Which one of the following features, if present, should prompt further evaluation with advanced imaging?
A) Diameter 5 cm
B) Fluctuant texture
C) Lack of tenderness with palpation
D) Persistent, slow growth over several years
E) Superficial location (above the fascia)
ANSWER: A
Soft-tissue masses that are 5 cm in diameter carry a higher risk of malignancy and should prompt further evaluation with advanced imaging. Other features that raise concern for possible malignancy include rapid growth, sudden presentation without explanation, and lesions that are firm, deep, and adhere to surrounding structures. Both benign and malignant masses can be painless, but a lack of tenderness with palpation alone would not prompt the need for advanced imaging. Advanced imaging would also not be necessary for a mass that has a fluctuant texture, has grown persistently and slowly over several years, or is superficially located (above the fascia).
A 35-year-old female presents with a 4-month history of pain in her neck, chest, mid and lower back, hip, and right leg. She has difficulty falling asleep at night and does not feel refreshed upon awakening in the morning. She feels like she is not as mentally sharp as she used to be and feels mildly depressed at times. A physical examination is notable for multiple soft-tissue tender points without evidence of joint deformity, inflammation, or erythema.
Which one of the following would be appropriate first-line pharmacologic therapy for this patient’s condition?
A) Amitriptyline
B) Celecoxib (Celebrex)
C) Hydrocodone
D) Hydroxychloroquine (Plaquenil)
E) Naproxen
ANSWER: A
This patient meets diagnostic criteria for fibromyalgia, which is characterized by diffuse, chronic pain without evidence of inflammation, erythema, or joint deformities. Pharmacologic treatments for fibromyalgia include tricyclic antidepressants such as amitriptyline, SNRIs such as duloxetine and milnacipran, and gabapentinoids such as pregabalin. Evidence does not show benefit from NSAIDs such as celecoxib or naproxen or opioids such as hydrocodone. Hydroxychloroquine is a disease-modifying antirheumatic agent used to treat rheumatoid arthritis and malaria and is not appropriate for the treatment of fibromyalgia.
A 55-year-old male sees you because of heartburn and dysphagia. Esophagogastroduodenoscopy shows moderately severe esophagitis.
Which one of the following is the most appropriate long-term pharmacologic management for this condition?
A) Famotidine (Pepcid), 10 mg daily
B) Metoclopramide (Reglan), 10 mg before meals
C) Omeprazole, 40 mg daily
D) Sucralfate (Carafate), 1 g twice daily
ANSWER: C
Patients with moderately severe esophagitis require ongoing proton pump inhibitors (PPIs) to manage symptoms. There is a nearly 100% recurrence of symptoms at 6 months if a PPI is stopped. Lifelong omeprazole use would be the best choice for this patient. PPIs are recommended over H2-blockers such as famotidine for maintenance and healing of erosive esophagitis. Prokinetic agents such as metoclopramide are not recommended for GERD unless gastroparesis is also present. Sucralfate is not recommended for GERD except in the case of pregnancy.
A 12-year-old transgender female accompanied by her mother comes to your office to discuss persistent gender dysphoria. The patient has been in counseling for 2 years along with her family, who is supportive of her gender identity. The patient’s mother asks about puberty blockers.
In discussing GnRH analogs with her, you note that the current recommendation for beginning this medication is when she is at which Tanner stage of development?
A) 1 B) 2 C) 3 D) 4 E) 5
ANSWER: B
The 2022 World Professional Association for Transgender Healthcare (WPATH) standards of care recommends that in eligible adolescents, pubertal suppression may begin at Tanner stage 2. Treatment prior to the onset of puberty is not recommended. Tanner stage 1 is prepubescent and Tanner stage 2 is the initial pubescent stage. It is not necessary and may be harmful to wait for further pubertal stages before initiating puberty blockers in an eligible transgender adolescent.
A 63-year-old female with a history of obesity and hypertension sees you for evaluation of shortness of breath on exertion and lower extremity edema. Echocardiography shows grade 2 diastolic dysfunction and an ejection fraction of 50%. You diagnose heart failure with preserved ejection fraction.
Which one of the following medications has the best evidence to reduce hospitalization due to heart failure or cardiovascular death in patients such as this?
A) Carvedilol (Coreg)
B) Empagliflozin (Jardiance)
C) Lisinopril (Zestril)
D) Sacubitril/valsartan (Entresto)
E) Spironolactone (Aldactone)
ANSWER: B
Heart failure with preserved ejection fraction (HFpEF), defined as an EF 50%, has a relative paucity of evidence-based treatments leading to improved patient outcomes compared to heart failure with reduced ejection fraction (HFrEF), defined as an EF <40%. While all of the options listed have good evidence of benefit in HFrEF, only the SGLT2 inhibitor empagliflozin has been shown to improve the composite outcome of hospitalization due to heart failure or cardiovascular death in HFpEF. The 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America guideline for the management of heart failure recommends SGLT2 inhibitors as having the best evidence of benefit in HFpEF.
-Blockers such as carvedilol may be used for rate control in patients with atrial fibrillation and HFpEF but are not clearly beneficial otherwise. Clinical trials of ACE inhibitors such as lisinopril and angiotensin receptor blockers such as valsartan have not shown improved outcomes for patients with HFpEF. Sacubitril/valsartan similarly did not achieve the primary end point of improvement in time to HF hospitalization or cardiovascular death in this patient population. The mineralocorticoid antagonist spironolactone is associated with improved diastolic function in patients with HFpEF and was found to improve hospitalizations but not cardiovascular death as a primary outcome.
A 46-year-old female comes to your office because of left hip pain. After a thorough evaluation you make a diagnosis of osteoarthritis, likely associated with congenital hip dysplasia.
In addition to nonpharmacologic therapies, including physical exercise, which one of the following medications has the best evidence of treating her pain effectively?
A) Topical diclofenac
B) Topical lidocaine
C) Oral acetaminophen
D) Oral naproxen
E) Oral tramadol
ANSWER: D
Symptomatic osteoarthritis of the hip is estimated to affect 10% of U.S. adults. Nonpharmacologic measures are the cornerstone of treatment and include physical activity, including strength training, aerobic exercise, tai chi, and yoga; weight loss for those who are overweight; and education in self-management. When these interventions are not adequate to manage pain, medications should be considered. In patients without contraindications, oral NSAIDs such as naproxen should be considered as first-line management. The hip joint is less amenable to topical therapies than the knee joint and topical NSAIDs such as diclofenac do not have evidence of benefit for hip osteoarthritis. Topical lidocaine is similarly without evidence of benefit at the hip joint. Those with risk factors for gastrointestinal toxicity should receive prophylaxis with proton pump inhibitors when treated with oral NSAIDs. Acetaminophen is less effective than NSAIDs but may be considered for use. Tramadol should not be used as a first-line treatment for pain due to osteoarthritis of the hip.
A 39-year-old male with no known previous medical history sees you for follow-up of recently diagnosed depression. He works as a home renovation contractor and does not smoke. A physical examination is normal other than a BMI of 36 kg/m2. Laboratory studies reveal a normal TSH level and a hemoglobin level of 17.4 g/dL (N 13.3–16.2).
You suspect that which one of the following is a cause of his polycythemia?
A) Alcohol use
B) Hemochromatosis
C) Hereditary spherocytosis
D) Lead exposure
E) Obstructive sleep apnea
ANSWER: E
Secondary polycythemia, or elevation of red blood cells, can have multiple causes. Conditions that affect oxygenation such as obstructive sleep apnea may cause secondary polycythemia. While hemochromatosis causes elevation of iron levels, it does not typically cause polycythemia. Hereditary spherocytosis causes hemolytic anemia. Smoking cigarettes is a common cause of secondary polycythemia, but alcohol use is often associated with macrocytic anemia. This patient may be at risk for lead toxicity, which can lead to anemia.
Which one of the following medications commonly causes hyponatremia in the elderly?
A) Amlodipine (Norvasc)
B) Amoxicillin
C) Atorvastatin (Lipitor)
D) Escitalopram (Lexapro)
E) Spironolactone (Aldactone)
ANSWER: D
A possible side effect of SSRIs is hyponatremia, which is more pronounced in the elderly. This fact is particularly pertinent in elderly patients with poorly controlled psychiatric illness who are more inclined to psychogenic polydipsia, which also leads to hyponatremia. Amlodipine is known to cause peripheral edema, dizziness, and medication-induced hepatitis. Amoxicillin causes eosinophilia and ALT and AST elevations. Atorvastatin causes elevations in ALT, AST, and creatine kinase levels. Spironolactone causes hyperkalemia and hyperuricemia, but it is not known to cause hyponatremia.
A 16-year-old female sees you because she has not yet started her menses and has noticed little breast development. Both her mother and her older sister started menstruating at age 13. She has never been sexually active and has not had any abdominal pain, vaginal discharge, nipple discharge, appetite changes, or urinary symptoms. She does not take any medications and does not use tobacco, alcohol, or illicit substances. Her weight has been stable. She walks to and from school daily and plays recreational basketball during the winter season, but otherwise does not get regular exercise.
On examination the patient appears well. She has a blood pressure of 110/70 mm Hg and a heart rate of 70 beats/min, and she is in the 5th percentile for height and 50th percentile for weight. Cardiovascular, pulmonary, abdominal, and skin examinations are all normal. Her breast development is Tanner stage 2 and her genitourinary development is Tanner stage 4, with normal external genitalia and a normal-appearing nulliparous cervix. There is no edema to the extremities.
Laboratory studies include a normal TSH level, prolactin level, and basic metabolic panel. A urine pregnancy test is negative. Pelvic ultrasonography reveals a normal uterus and the ovaries are nonvisualized.
Which one of the following is the most likely diagnosis?
A) Congenital adrenal hyperplasia
B) Cushing syndrome
C) Functional hypothalamic amenorrhea
D) Polycystic ovary syndrome
E) Turner syndrome
ANSWER: E
Turner syndrome is the most likely cause of this patient’s primary amenorrhea. Turner syndrome is characterized by a lack of normal X chromosome gene expression (45,X karyotype) and is estimated to occur in 1/3000 births. Females with Turner syndrome have ovarian sex hormone insufficiency, which leads to delayed puberty. Delayed diagnosis of Turner syndrome is common, and short stature and delayed puberty are sometimes the only symptoms. Diagnosis is made via karyotyping.
Individuals with congenital adrenal hyperplasia would most likely have other signs, including clitoromegaly. Similarly, individuals with Cushing syndrome will have other features such as a dorsocervical fat pad and a rounded, swollen facial appearance. There is nothing in this patient’s history or physical examination to suggest functional hypothalamic amenorrhea given that her weight is normal and has not changed recently. Polycystic ovary syndrome more typically presents with oligomenorrhea rather than primary amenorrhea.
In a patient with hyperuricemia with an elevated uric acid level but no prior episodes of acute gout, which one of the following is recommended?
A) No urate-lowering medication
B) Allopurinol (Zyloprim), 100 mg daily
C) Febuxostat (Uloric), 40 mg daily
D) Naproxen, 250 mg three times daily
E) Probenecid, 100 mg twice daily
ANSWER: A
Uric acid–lowering treatment is recommended for all patients with an elevated uric acid level who have had two or more gout flareups per year. Consider starting it in patients with a second flareup occurring more than 1 year later, those without an attack but who are at high risk, such as in those with kidney stones, patients with a uric acid level 9.0 mg/dL, or patients with stage 3 or greater chronic kidney disease.
There is no benefit for urate lowering in asymptomatic patients with an elevated uric acid level who have never had an acute episode of gout, thus allopurinol, febuxostat, and probenecid would not be appropriate. NSAIDs, colchicine, or corticosteroids are recommended for gout prophylaxis for the first 3–6 months after initiating urate-lowering therapy to prevent acute flares, but this patient has no history of acute gout. Additionally, vitamin C is not effective.
A 75-year-old male with long-standing diabetes mellitus, tobacco use, and venous insufficiency presents to your office with bilateral leg heaviness and recent oozing from his left leg. A physical examination reveals venous stasis dermatitis, edema of both legs, and a well-circumscribed 3×4-cm area of superficial ulceration on the left medial shin with a thin layer of purulent exudate overlying a pink base. The surrounding skin has no erythema, warmth, or tenderness. Pedal pulses are nonpalpable bilaterally.
In addition to smoking cessation counseling and local wound care, which one of the following would be the most appropriate next step?
A) An ankle-brachial index
B) A medical-grade compression stocking
C) A zinc oxide–impregnated Unna boot
D) A wound culture specimen
E) A skin biopsy of the ulcer
ANSWER: A
This patient’s presentation is typical for a venous ulcer resulting from long-standing venous hypertension. Patients with venous disease may have leg heaviness, pain, and swelling that worsens throughout the day. Common physical manifestations of venous disease include leg edema, varicose veins, and venous stasis dermatitis. Ulcers also may develop, often over a bony prominence in the lower leg, such as the medial malleolus. Venous ulcers are typically shallow with an exudative appearance over a granulating base and well-defined borders.
The mainstay treatment of venous ulcers is compression, which may be accomplished through various methods that are often used in combination. Options include elastic sleeves, compression stockings, non-elastic wraps such as Unna boots, and intermittent pneumatic compression. However, when underlying significant peripheral arterial disease is also present, compression therapy may further compromise distal circulation and cause unintentional harm. Therefore, patients with suspected arterial disease should have distal pulses evaluated and ankle-brachial indexes (ABIs) measured prior to starting compression therapy. When noninvasive testing suggests underlying arterial disease, consultation with a vascular surgeon is indicated. This patient has several risk factors for peripheral arterial disease, including an abnormal pedal pulse examination, and therefore should be evaluated further with ABI measurements before treating his ulcer with either a medical-grade compression stocking or an Unna boot. Although ulcers are often colonized with bacteria, antibiotics are not indicated in the absence of infection. This patient does not have symptoms or signs to suggest active infection and a culture swab would have no impact on his present management. Obtaining a biopsy of a skin ulcer may be indicated in the setting of suspected connective tissue disease, vasculitis, or malignancy but is not indicated in this situation.
A healthy 23-year-old presents for a physical examination required for entrance to nursing school. The patient’s vital signs and a physical examination are unremarkable. To complete the immunization requirements, you administer Tdap and varicella vaccines. The nursing school requests tuberculosis (TB) test results.
Which one of the following would be most appropriate regarding TB testing?
A) No testing because the patient is asymptomatic
B) A sputum culture
C) A tuberculin skin test
D) An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold)
E) A chest radiograph
ANSWER: D
Initial tuberculosis screening is recommended for all health care providers upon hire and extends to health care students. Recommended tests for initial screening include the interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) and tuberculin skin testing (TST). TST can be affected by live virus vaccines given within the previous 4 weeks. Since this patient received a live virus vaccine (varicella), a TST may be falsely negative. The IGRA, which is not affected by prior live vaccines, would be most appropriate for this patient. Additional advantages to the assay test include higher sensitivity and specificity than the TST, the need for only one visit, and objective results. While the TST is less expensive, there is risk for subjective or misread results and a requirement of two clinic visits. A sputum culture and a chest radiograph are only indicated in the setting of positive screening results with the above-mentioned tests.
A 70-year-old male presents for evaluation of an itchy rash (shown below) that started a few weeks ago in the interdigital areas of both feet. The rash has since extended to his dorsal feet and ankles. He has tried using a topical moisturizing lotion and hydrocortisone 1% cream without improvement.
Based on the extent of skin involvement, you offer him an oral medication to treat the infection. He is concerned about the risk of gastrointestinal side effects and asks if he could use a different topical medication instead.
Of the
A) B) C) D) E)
following options, which one is most likely to resolve his symptoms?
Clotrimazole/betamethasone dipropionate (Lotrisone) cream Mupirocin cream
Nystatin cream
Nystatin ointment
Terbinafine cream
ANSWER: E
Tinea infections, such as the tinea pedis seen in this patient, are caused by dermatophytes, which include the three genera Trichophyton, Microsporum, and Epidermophyton. The rash of tinea pedis is often limited to the webspace between the toes and/or the plantar aspect of the foot but infections may also involve the dorsum of the foot, even into the ankle region. This patient’s more proximal involvement displays the classic “ringworm” pattern with an active border that is red, raised, and scaly. Cases in which the diagnosis is in doubt may be confirmed by a potassium hydroxide skin scraping that demonstrates the presence of hyphae. Most cases of tinea pedis respond well to topical therapy. Systemic treatment may be indicated in cases with widespread skin involvement, immunocompromise, failed topical treatment, or the chronic moccasin pattern marked by plantar and lateral foot hyperkeratosis, erythema, and silvery-white scale. Of the available oral options, ketoconazole is the most hepatotoxic and therefore should be avoided for the treatment of any tinea infection; however, itraconazole, fluconazole, and terbinafine are all suitable alternatives.
In this case, the patient has reasonably requested a trial of topical treatment. Newer fungicidal agents, such as butenafine and terbinafine, work more effectively and require a shorter treatment course than older fungistatic alternatives such as clotrimazole. Combination products that include corticosteroids, such as clotrimazole/betamethasone, should be avoided because they can aggravate fungal infections. Mupirocin is an antibiotic used for limited skin infections caused by Staphylococcus aureus or Streptococcus pyogenes but does not play a role in treatment of tinea infections without bacterial superinfection. This patient has a classic appearance of a tinea infection without evidence of superimposed cellulitis or abscess; therefore, an antibacterial medication is not indicated. Nystatin is useful for treating cutaneous Candida infections, but is ineffective for dermatophyte infections.
You see a 5-year-old female for the first time for a new patient visit. Her mother notes that she tires easily and sometimes cannot keep up with other children her age. Laboratory studies reveal the following:
WBCs RBCs Hemoglobin Hematocrit Platelets Meancorpuscularvolume Meancorpuscularhemoglobin Mean corpuscular hemoglobin
concentration Redcelldistributionwidth Ferritin Transferrinsaturation
6500/mm3 (N5000–14,500) 5.6million/mm3 (N3.90–5.30) 9.1g/dL(N11.5–15.5) 27%(N34–40)
220,000/mm3 (N150,000–450,000) 68 m3 (N75–87)
28 pg/cell (N 24–30)
34g/dL(N32–36) 11%(N11.5–15.0) 150 ng/mL (N 7–140) 40%(N15–50)
A peripheral smear shows target cells, microcytic cells, red cell fragments, teardrop cells, and nucleated RBCs.
Which one of the following is the most likely etiology of this patient’s anemia?
A) Aplastic anemia
B) Iron deficiency
C) Megaloblastic anemia
D) Myelofibrosis
E) Thalassemia minor
ANSWER: E
This patient most likely has thalassemia minor and will need further genetic testing to confirm the diagnosis. Thalassemia minor is associated with microcytic anemia. Thalassemia can be differentiated from iron deficiency based on low red cell distribution width (RDW), elevated reticulocyte count, normal or slightly elevated RBC count, slightly elevated ferritin, and nucleated RBCs on peripheral smear. Aplastic anemia is associated with a poor reticulocyte response and low counts. Iron deficiency is associated with an elevated RDW; a low reticulocyte count; and low RBC, ferritin, and transferrin saturation levels. Megaloblastic anemia is typically associated with an elevated mean corpuscular volume. Myelofibrosis is associated with bone marrow failure and pancytopenia.
