Mixed Deck — All ITE Topics Flashcards

A 55-year-old female ex-smoker with COPD (FEV1 45% predicted) has had 3 exacerbations in the past year requiring hospitalization. Her current regimen is LAMA + LABA. What additional therapy has shown mortality benefit in this patient?

Answer: Inhaled corticosteroid (ICS)

Adding ICS to LAMA+LABA (triple therapy) reduces exacerbations and has shown mortality benefit in COPD patients with frequent exacerbations, particularly those with elevated eosinophils.

A patient with a mechanical mitral valve prosthesis becomes pregnant. Which anticoagulation strategy is associated with the lowest risk of valve thrombosis?

Answer: Warfarin throughout pregnancy

Warfarin throughout pregnancy offers the most reliable anticoagulation for mechanical valves and the lowest thrombosis risk, though it carries fetal risks (especially in the first trimester).

A 61-year-old woman presents with acute chest pain. ECG shows ST depression in V1-V4 and ST elevation in aVR. Troponin is rapidly rising. She is hemodynamically stable. Emergent coronary angiography shows 90% stenosis of the left main coronary artery with TIMI-2 flow and 70% mid-LAD lesion. Her SYNTAX score is 38. Which revascularization strategy is MOST appropriate?

Answer: Emergency CABG with left internal mammary artery to LAD and saphenous vein graft to circumflex

A SYNTAX score ≥33 in the setting of left main disease identifies patients who derive significantly greater survival benefit from CABG versus PCI (SYNTAX trial, NOBLE trial, EXCEL trial long-term data). With a score of 38 and a two-vessel disease pattern (left main + LAD), CABG with LIMA-to-LAD provides a proven long-term survival advantage and lower rates of repeat revascularization. PCI of left main in complex disease (SYNTAX ≥33) is associated with higher MACCE rates. In a hemodynamically stable patient, emergent CABG is feasible and preferred. Deferring the LAD or using medical management alone with rising troponin and high-grade left main disease is inappropriate. FFR assessment should not delay definitive revascularization in this acute high-risk presentation.

A 74-year-old man with EF of 25% is on optimal HFrEF therapy. He has NYHA class III symptoms. His ICD was implanted 2 years ago. QRS is 110 ms. What additional therapy should be considered to reduce hospitalization?

Answer: SGLT2 inhibitor (dapagliflozin or empagliflozin)

SGLT2 inhibitors (dapagliflozin, empagliflozin) reduce HF hospitalization and cardiovascular death in HFrEF independent of diabetes status.

A 45-year-old man with MEN1 undergoes resection of a gastrinoma. Post-operatively, he develops hypocalcemia with Ca 7.1 mg/dL, phosphorus 3.0 mg/dL, PTH 890 pg/mL (markedly elevated), and 25-OH vitamin D 8 ng/mL. He is on proton pump inhibitor therapy. Which of the following best explains his biochemical picture?

Answer: Vitamin D deficiency causing secondary hyperparathyroidism with PTH-resistance at the skeletal level

This patient has profound vitamin D deficiency (25-OH vitamin D 8 ng/mL), likely worsened by PPI-associated malabsorption and possibly prior achlorhydria from the gastrinoma itself. Severe vitamin D deficiency impairs intestinal calcium absorption, leading to hypocalcemia that drives compensatory secondary hyperparathyroidism — hence the markedly elevated PTH. The normal-to-low phosphorus (not high, as seen in hypoparathyroidism) confirms PTH is biologically active. Hungry bone syndrome occurs post-parathyroidectomy in the setting of pre-existing hyperparathyroidism; the PTH here is elevated, not suppressed. Hypomagnesemia causes functional hypoparathyroidism (low PTH despite hypocalcemia). Pseudohypoparathyroidism presents with high PTH AND high phosphorus.

A 60-year-old man with cirrhosis presents with acute upper GI bleeding. Endoscopy reveals esophageal varices with active oozing. In addition to endoscopic band ligation, which medication should be started immediately?

Answer: Octreotide

Octreotide (somatostatin analogue) reduces portal pressure by causing splanchnic vasoconstriction and is given alongside endoscopic therapy for variceal bleeding.

Which test is most useful in the diagnosis of primary hyperparathyroidism?

Answer: Serum calcium and PTH levels

The most useful diagnostic test for primary hyperparathyroidism involves measuring both serum calcium and parathyroid hormone (PTH) levels. In primary hyperparathyroidism, there is typically hypercalcemia (high calcium) accompanied by inappropriately elevated or normal PTH levels. This combination confirms autonomous PTH secretion, which is characteristic of the condition.

A 52-year-old woman undergoing workup for hypertension is found to have a 3.2 cm right adrenal incidentaloma. Labs reveal: 24-hour urine metanephrines normal, aldosterone-to-renin ratio normal, low-dose dexamethasone suppression test (1 mg overnight) shows cortisol of 3.8 mcg/dL. Which of the following is the most accurate statement about her management?

Answer: She likely has mild autonomous cortisol secretion and should be evaluated for metabolic comorbidities and cardiovascular risk

A post-dexamethasone cortisol of 1.8–5.0 mcg/dL (using the 1 mg overnight DST) defines 'possible autonomous cortisol secretion' (formerly called 'subclinical Cushing's syndrome'), per the European Society of Endocrinology guidelines. This is distinguished from 'confirmed autonomous cortisol secretion' (>5.0 mcg/dL). The clinical significance lies in the associated increased risk of hypertension, type 2 diabetes, dyslipidemia, osteoporosis, and cardiovascular events. Management involves treating these cardiometabolic comorbidities; adrenalectomy may be considered in younger patients with progressive comorbidities, but is not reflexively indicated. CRH stimulation is used in the differential of ACTH-dependent hypercortisolism, not for adrenal incidentalomas.

A 40-year-old woman with myelodysplastic syndrome has a del(5q) as the sole cytogenetic abnormality, transfusion-dependent anemia, and platelet count of 450,000/μL. Which agent is specifically indicated?

Answer: Lenalidomide

Lenalidomide is specifically approved for transfusion-dependent MDS with isolated del(5q) and produces high rates of transfusion independence.

A 72-year-old woman is admitted with confusion and fatigue. Labs: Na 118 mEq/L, K 3.8 mEq/L, BUN 8 mg/dL, creatinine 0.7 mg/dL, serum osmolality 248 mOsm/kg, urine osmolality 520 mOsm/kg, urine Na 68 mEq/L. She takes escitalopram and hydrochlorothiazide. Thyroid and cortisol are normal. She has no edema and appears euvolemic. Which feature would MOST reliably distinguish SIADH from the cerebral salt-wasting syndrome (CSWS) as the etiology?

Answer: Clinical assessment of extracellular fluid (ECF) volume status

The definitive distinguishing feature between SIADH and CSWS is extracellular fluid (ECF) volume status: SIADH is characterized by normal-to-expanded ECF (euvolemic or mildly hypervolemic), whereas CSWS is a salt-wasting nephropathy leading to true hypovolemia with volume depletion. Both conditions share elevated urine sodium (>40 mEq/L), urine osmolality > serum osmolality, and even low serum uric acid (both cause fractional uric acid excretion >12%). In CSWS, fluid restriction (SIADH treatment) worsens the condition, while volume and sodium replacement is correct. In practice, CVP measurement or careful clinical volume assessment (orthostatic BP, skin turgor, mucous membranes, weight trend) is the key differentiator. This distinction is critical because CSWS commonly occurs after subarachnoid hemorrhage.

A 29-year-old MSM presents with painful genital ulcers, tender inguinal lymphadenopathy, and a reactive RPR 1:64 with confirmatory TPPA. He reports a prior syphilis infection treated 3 years ago with benzathine penicillin G, with documented fourfold RPR decline to 1:4. His current neurological exam is normal, and LP is deferred. Which treatment is most appropriate?

Answer: Benzathine penicillin G 2.4 million units IM once (primary syphilis)

This patient has secondary syphilis (painful ulcer at primary site plus lymphadenopathy plus RPR 1:64 representing a fourfold or greater rise from documented nadir of 1:4). Secondary syphilis represents early syphilis (<1 year duration) and is treated with a single dose of benzathine penicillin G 2.4 million units IM — not the 3-dose regimen, which is reserved for late latent or latent syphilis of unknown duration. The 1:64 titer compared to a documented nadir of 1:4 (fourfold rise = 1:16 → 1:64) confirms reinfection rather than treatment failure. With a normal neurological exam and no ocular symptoms, LP is not required. IV penicillin is reserved for confirmed neurosyphilis.

Which of the following is the most common cause of hyperthyroidism?

Answer: Graves' disease

Graves' disease is the most common cause of hyperthyroidism, an autoimmune disorder where the body produces antibodies that stimulate the thyroid gland to produce excessive thyroid hormones. This leads to symptoms such as weight loss, heat intolerance, and palpitations. It is characterized by diffuse thyroid enlargement and often ophthalmopathy.

A 55-year-old man is being treated for DKA. His blood glucose has decreased from 500 mg/dL to 220 mg/dL, his anion gap has closed, and his pH is 7.35. He is now tolerating oral intake. The insulin infusion is stopped. What is the most appropriate next step to prevent the recurrence of ketoacidosis?

Answer: Administer subcutaneous long-acting insulin 1-2 hours before stopping the insulin infusion.

To prevent the recurrence of hyperglycemia and ketoacidosis, it is crucial to have an overlap between the intravenous insulin infusion and the initiation of a subcutaneous insulin regimen. Long-acting (basal) insulin should be administered 1-2 hours before the IV insulin is discontinued to ensure a continuous supply of insulin. Stopping the infusion without this overlap can lead to a rapid return to a catabolic state.

A patient with MEN1 syndrome is found to have a gastrinoma. Which finding would be expected?

Answer: Elevated fasting serum gastrin with acid hypersecretion

Gastrinomas cause Zollinger-Ellison syndrome, characterized by elevated fasting gastrin (>1000 pg/mL) and recurrent peptic ulcers from gastric acid hypersecretion.

A patient with Cushing's disease undergoes transsphenoidal surgery. Post-operatively, serum cortisol is 2 mcg/dL. What does this indicate?

Answer: Adrenal insufficiency requiring glucocorticoid replacement

Very low post-operative cortisol indicates successful tumor removal but requires exogenous glucocorticoid replacement until the HPA axis recovers.

A 65-year-old man with bicuspid aortic valve has severe AR with LVEF 55% and LVESD 52 mm but no symptoms. What is the most appropriate management?

Answer: Surgical aortic valve replacement

In severe AR, surgery is indicated when LVESD ≥50 mm (Class IIa) or ≥55 mm (Class I) even in asymptomatic patients to prevent irreversible LV dysfunction.

A 22-year-old African American man with known sickle cell disease presents with severe bilateral leg bone pain, fever of 38.4°C, and WBC 12,500/μL. His Hgb is 6.9 g/dL compared to a baseline of 7.1 g/dL. What is the most likely diagnosis?

Answer: Vaso-occlusive (pain) crisis

Severe bone pain with near-baseline hemoglobin and no respiratory symptoms is characteristic of a vaso-occlusive pain crisis.

A 26-year-old woman with type 1 diabetes presents with recurrent DKA episodes despite good outpatient compliance. She has celiac antibodies positive on screening. How does undiagnosed celiac disease contribute to DKA in type 1 diabetes?

Answer: Malabsorption leads to unpredictable glucose-insulin matching

Celiac disease-related malabsorption causes erratic carbohydrate absorption, making glucose-insulin matching unpredictable and precipitating hypoglycemia or hyperglycemia and DKA.

A 55-year-old man with idiopathic pulmonary fibrosis (IPF) has FVC 65% predicted and DLCO 48% predicted. Honeycombing is present on HRCT. Which medication has been shown to slow FVC decline in IPF?

Answer: Nintedanib 150 mg twice daily

Nintedanib (and pirfenidone) are the only FDA-approved antifibrotic agents that slow FVC decline in IPF; corticosteroids and azathioprine increase mortality in IPF.

A 48-year-old woman presents with progressive proximal muscle weakness and difficulty rising from a chair. CK is 3500 U/L. ANA is positive. What is the most likely diagnosis?

Answer: Polymyositis

Polymyositis presents with symmetric proximal muscle weakness, elevated CK, and positive ANA; EMG and muscle biopsy confirm the diagnosis.