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Exam of 84 pages for the course ABFM ITE at ABFM ITE (ITE exam)
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ITE examA 67-year-old male sees you for a Medicare annual wellness visit. He tells you that his best friend had a stroke and he asks about his risk for stroke. He has no history of stroke, TIA, or neurologic symptoms. He has a family history of cardiovascular disease in his father, who had a myocardial infarction at age 65 and died from a thrombotic stroke at age 71. The patient exercises regularly and has a BMI of 27 kg/m2. His only current medical condition is hyperlipidemia, and his cholesterol level is at goal on rosuvastatin (Crestor), 10 mg daily. He
also takes aspirin, 81 mg daily. His blood pressure is 125/78 mm Hg.
Based on U.S. Preventive Services Task Force guidelines, which one of the following would be most appropriate at this time?
A) No additional testing for stroke risk
B) Auscultation for carotid bruits
C) Carotid duplex ultrasonography
D) Magnetic resonance angiography
E) CT angiography of the carotid arte - Answer- ANSWER: A
Carotid artery disease affects extracranial carotid arteries and is caused by atherosclerosis. This patient
is asymptomatic and has no history of an ischemic stroke, neurologic symptoms referable to the carotid
arteries such as amaurosis fugax, or TIA. He has risk factors for cardiovascular disease (age, male sex,
hyperlipidemia), but the U.S. Preventive Services Task Force recommends against specific screening for
asymptomatic carotid artery stenosis (D recommendation), which has a low prevalence in the general adult population. Stroke is a leading cause of disability and death in the United States, but asymptomatic carotid artery stenosis causes a relatively small proportion of strokes. Auscultation of the carotid arteries for bruits has been found to have poor accuracy for detecting carotid stenosis and is not a reasonable screening approach. Appropriate modalities for detecting carotid stenosis include carotid duplex ultrasonography, magnetic resonance angiography, and computed tomography, but these are not recommended for screening asymptomatic patients.
2. A 28-year-old female presents for evaluation of nasal congestion, sneezing, watery eyes, and postnasal drip. This has been an intermittent issue for her every spring and she would like to
manage it more effectively.
Which one of the following treatments has been shown to be the most effective and best
tolerated
first-line therapy for this patient's condition?
A) A leukotriene receptor antagonist
B) Intranasal corticosteroid monotherapy
C) Intranasal corticosteroids plus an oral antihistamine
D) Inhaled corticosteroids
E) Annual triamcinolone injections - Answer- ANSWER: B
This patient has seasonal allergic rhinitis. A joint guideline statement from the American Academy of
Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology Joint Task
Force on Practice Parameters recommends that monotherapy with intranasal corticosteroids should be
prescribed initially in patients 12 years of age rather than combined treatment with oral antihistamines
because data has not shown an additional benefit to adding the antihistamine. Higher patient adherence and
tolerance and fewer side effects were seen with the monotherapy regimen. High-quality evidence indicates
that intranasal corticosteroids were more effective than leukotriene receptor antagonists. Inhaled
corticosteroids and triamcinolone injections are not appropriate first-line options for the treatment of
seasonal allergic rhinitis.
3. A 68-year-old female presents with a 2-month history of watery diarrhea. She has not
had any
blood or pus in her stools, and the stools are not oily. She has not had any history of fever,
chills, or weight loss, and has not traveled recently. She smokes one pack of cigarettes per day.
Her medications include ibuprofen, sertraline (Zoloft), and pantoprazole (Protonix). A CBC,
metabolic panel, C-reactive protein level, IgA anti-tissue transglutaminase level, total IgA level,
and stool guaiac test are all normal.
Which one of the following tests would be most likely to yield a diagnosis?
A) Clostridioides (Clostridium) difficile toxin
B) Colonoscopy
C) Fecal calprotectin
D) A stool culture E) Stool examination for ova and parasites - Answer- ANSWER: B
In patients with chronic nonbloody diarrhea, the differential diagnosis includes microscopic (lymphocytic
or collagenous) colitis. The mucosa appears normal on colonoscopy but a biopsy will show lymphocytic
infiltration of the epithelium. The etiology of this is unknown but there are several risk factors to consider,
including older age, female sex, and smoking status. Drugs with a high level of evidence
for causing
microscopic colitis include NSAIDs, proton pump inhibitors, sertraline, acarbose, aspirin,
and ticlopidine.
Clostridioides (Clostridium) difficile should be suspected in individuals who have taken antibiotics in the past 3 months. Fecal calprotectin is elevated in inflammatory diarrhea such as Crohn's disease or ulcerative colitis. A stool culture would be indicated if there is suspicion of an infectious bacterial diarrhea such as Shigella or Salmonella, but these
bacteria tend to cause bloody diarrhea. Checking for a parasitic infection should be considered for patients with a history of recent travel or exposure to unpurified water.
A 23-year-old male with opioid use disorder requests buprenorphine therapy. He is still actively
using immediate-release oxycodone (Roxicodone) and he took a dose 2 hours ago.
This patient should begin buprenorphine induction
A) now
B) in 2 hours
C) 8-12 hours after his last opioid use
D) 24 hours after his last opioid use
E) 1 week after his last opioid use - Answer- ANSWER: C
Buprenorphine is a partial opioid agonist. In order to reduce the risk of precipitated withdrawal,
buprenorphine induction should begin once the patient is exhibiting signs of mild to moderate withdrawal,
usually 8-12 hours after the last opioid use. Waiting until a patient goes through full withdrawal increases
the chances that the patient will revert back to using opioids.
A 45-year-old left hand-dominant female presents to your office with a lump on her hand. She
first noticed the lump 2 weeks ago and thinks it has gotten bigger. She does not recall any injury.
She has not had any numbness, weakness, or tingling. She has minimal discomfort when she
presses on the lump, and it does not affect her activity. On examination her left wrist is
neurovascularly intact. You note the volar wrist mass shown below.
Which one of the following management options would you recommend? A) Re-examination if she develops numbness, weakness, or increased pain
B) Immobilization of the wrist for 6 weeks and then re-examination
C) Aspiration of the lesion
D) Aspiration and injection of the lesion with a corticosteroid
E) Referral for excision of the lesion - Answer- ANSWER: A
This patient has a ganglion cyst, which is common and resolves spontaneously in 50% of cases, and
watchful waiting would be most appropriate at this time. Treatment is indicated if the cyst is causing
significant symptoms such as pain, numbness, or weakness, or for cosmetic reasons. Aspiration of the
lesion is the initial treatment, although recurrence may occur in 85% of cases. Immobilizing the wrist with
a splint or brace is sometimes helpful in the short term if the patient is bothered by the symptoms, but
immobilization does not provide lasting relief and could cause muscle atrophy. Corticosteroid injections
have not shown any benefit. Referral for excision is appropriate if there has been no improvement. Patients
should be advised that there is a 10%-15% recurrence rate even after excision.
A 57-year-old female with diabetes mellitus comes to your office for a routine follow-up. Her
current medications include metformin (Glucophage), 1000 mg twice daily. She tells you
that
she does not exercise regularly and finds it difficult to follow a healthy diet. A hemoglobin A1c
today is 7.5%. She does not want to add medications at this time, but she does want to get her
hemoglobin A1c below 7%, which is the goal that was previously discussed.
Which one of the following would be the most effective way to improve glucose control for this
patient?
A) Discuss the components of a healthy diabetic diet and encourage her to follow it more
closely
B) Discuss the importance of regular exercise and encourage her to exercise 30-45 minutes
daily
C) Recommend that she check her glucose level 1-3 times daily to help determine what
adjustments need to be made
D) Start her on an additional medication
E) Refer her to a diabetes - Answer- ANSWER: E
Counseling by a diabetic educator or team of educators for medical nutrition therapy lowers hemoglobin
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