ITE EXAM QUESTIONS AND ANSWERS
A 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 - Answers -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 - Answers -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.
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 - Answers -ANSWER: E
Counseling by a diabetic educator or team of educators for medical nutrition therapy
lowers hemoglobin
A1c by 0.2-0.8 percentage points in patients with type 2 diabetes. While a healthy
diabetic diet and regular
exercise are important, simply reminding the patient of that fact is not likely to be as
successful as
comprehensive diabetic education. According to the Society of General Internal
Medicine in the Choosing
Wisely campaign, patients with type 2 diabetes who are not on insulin therapy should
not check their blood
glucose level daily. An additional medication will likely decrease the hemoglobin A1c,
but this patient has
expressed a desire to avoid additional medication, is near goal, and is not currently
managing her diabetes
with adequate lifestyle changes, so it would be appropriate to respect her wishes and
pursue proven
interventions that do not require medication.
During a newborn examination the patient's mother asks what she can do to decrease
the risk
of food allergies in her newborn son. She tells you that there is no family history of
atopic
dermatitis or asthma but she has a cousin with a peanut allergy. The remainder of the
examination is unremarkable.
You tell her that food allergy risk can be reduced by
A) breastfeeding for at least 1 year
B) using soy-based formula instead of cow's milk-based formula
C) introducing peanut-containing foods when solids are started
D) avoiding all house pets
E) avoiding a day care setting - Answers -ANSWER: C
, Food allergy affects 4%-6% of children in the United States. Immunoglobulin E (IgE)-
mediated food
allergy is the best understood, and symptoms can range from rhinorrhea to anaphylaxis.
The two most
common allergens are cow's milk and peanuts. The onset of symptoms is usually within
2 hours of
exposure and they resolve within several hours.
The National Institute of Allergy and Infectious Diseases in 2017 recommended that
healthy infants without
known food allergy or who have mild to moderate eczema may be introduced to peanut-
containing foods
with other solid foods. If the parents are concerned about a reaction, introduction of
peanut-containing
foods may be done in the physician's office. Infants with severe eczema, egg allergy, or
both should
undergo peanut-specific IgE or skin-prick testing.
While breastfeeding may decrease atopic disease, there is insufficient evidence that it
reduces the likelihood
of food allergy, and using a soy-based formula will not prevent food allergy. If there is a
dog in the home
there is less risk of allergy to eggs. Children who are exposed to farm animals or who
attend day care are
less likely to develop atopic disease.
Which one of the following antihypertensive medications is LEAST likely to exacerbate
erectile
dysfunction?
A) Clonidine (Catapres)
B) Doxazosin (Cardura)
C) Hydrochlorothiazide
D) Losartan (Cozaar)
E) Metoprolol - Answers -ANSWER: D
Angiotensin receptor blockers (ARBs) such as losartan are least likely to cause or
exacerbate erectile
dysfunction. ARBs may have a favorable effect on erectile dysfunction by inhibiting
vasoconstriction
activity of angiotensin. Clonidine, -blockers, hydrochlorothiazide, and -blockers are more
likely to
negatively affect erectile function.
ARBS = cause vasodilation = increase blood flow = no erectile dysfunction
You are providing end-of-life care for a 53-year-old female with end-stage colon cancer.
Her
family reports that she is having significant abdominal pain, nausea, and vomiting, and
she is
A 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 - Answers -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 - Answers -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.
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 - Answers -ANSWER: E
Counseling by a diabetic educator or team of educators for medical nutrition therapy
lowers hemoglobin
A1c by 0.2-0.8 percentage points in patients with type 2 diabetes. While a healthy
diabetic diet and regular
exercise are important, simply reminding the patient of that fact is not likely to be as
successful as
comprehensive diabetic education. According to the Society of General Internal
Medicine in the Choosing
Wisely campaign, patients with type 2 diabetes who are not on insulin therapy should
not check their blood
glucose level daily. An additional medication will likely decrease the hemoglobin A1c,
but this patient has
expressed a desire to avoid additional medication, is near goal, and is not currently
managing her diabetes
with adequate lifestyle changes, so it would be appropriate to respect her wishes and
pursue proven
interventions that do not require medication.
During a newborn examination the patient's mother asks what she can do to decrease
the risk
of food allergies in her newborn son. She tells you that there is no family history of
atopic
dermatitis or asthma but she has a cousin with a peanut allergy. The remainder of the
examination is unremarkable.
You tell her that food allergy risk can be reduced by
A) breastfeeding for at least 1 year
B) using soy-based formula instead of cow's milk-based formula
C) introducing peanut-containing foods when solids are started
D) avoiding all house pets
E) avoiding a day care setting - Answers -ANSWER: C
, Food allergy affects 4%-6% of children in the United States. Immunoglobulin E (IgE)-
mediated food
allergy is the best understood, and symptoms can range from rhinorrhea to anaphylaxis.
The two most
common allergens are cow's milk and peanuts. The onset of symptoms is usually within
2 hours of
exposure and they resolve within several hours.
The National Institute of Allergy and Infectious Diseases in 2017 recommended that
healthy infants without
known food allergy or who have mild to moderate eczema may be introduced to peanut-
containing foods
with other solid foods. If the parents are concerned about a reaction, introduction of
peanut-containing
foods may be done in the physician's office. Infants with severe eczema, egg allergy, or
both should
undergo peanut-specific IgE or skin-prick testing.
While breastfeeding may decrease atopic disease, there is insufficient evidence that it
reduces the likelihood
of food allergy, and using a soy-based formula will not prevent food allergy. If there is a
dog in the home
there is less risk of allergy to eggs. Children who are exposed to farm animals or who
attend day care are
less likely to develop atopic disease.
Which one of the following antihypertensive medications is LEAST likely to exacerbate
erectile
dysfunction?
A) Clonidine (Catapres)
B) Doxazosin (Cardura)
C) Hydrochlorothiazide
D) Losartan (Cozaar)
E) Metoprolol - Answers -ANSWER: D
Angiotensin receptor blockers (ARBs) such as losartan are least likely to cause or
exacerbate erectile
dysfunction. ARBs may have a favorable effect on erectile dysfunction by inhibiting
vasoconstriction
activity of angiotensin. Clonidine, -blockers, hydrochlorothiazide, and -blockers are more
likely to
negatively affect erectile function.
ARBS = cause vasodilation = increase blood flow = no erectile dysfunction
You are providing end-of-life care for a 53-year-old female with end-stage colon cancer.
Her
family reports that she is having significant abdominal pain, nausea, and vomiting, and
she is
