Urticaria
Which of the following is true regarding diagnostic testing in acute urticaria?
A. Routine laboratory testing is required
B. Imaging studies are recommended
C. Diagnostic testing is usually not required
D. Skin biopsy is first-line
Answer: C. Diagnostic testing is usually not required
Pearls
At what HBV DNA level during pregnancy should antiviral therapy be initiated to prevent perinatal transmission?
A. >20,000 IU/mL
B. >100,000 IU/mL
C. >200,000 IU/mL
D. Any detectable level
Answer: C. >200,000 IU/mL
Pearls
Which one of the following statements about the treatment of chronic HBV infection is correct? (check one)
A. Treatment is generally lifelong.
B. Treatment is only indicated in those with evidence of fibrosis.
C. Pegylated interferon alfa-2a (Pegasys) is first-line therapy for most patients.
D. Only patients with persistent hepatitis B DNA levels greater than 10,000 IU/mL require ongoing treatment.
Correct A
First-line treatment for hepatitis B is with nucleoside/nucleotide analogues and is generally lifelong. Patients with persistent hepatitis B DNA greater than 2,000 IU/mL should generally be offered treatment, as well as other subgroups based on age and clinical factors (such as those coinfected with HIV or hepatitis C virus, those with cirrhosis, or those who have had a liver transplant). Pegylated interferon alfa-2a is an alternative agent but has the disadvantages of being administered subcutaneously and causing multiple adverse effects, including myalgia, depression, and cytopenia. Fibrosis is not required for initiation of therapy.
What is the optimal treatment endpoint in chronic hepatitis B infection?
A. Normalization of ALT
B. Suppression of HBV DNA
C. HBeAg seroconversion
D. Loss of HBsAg with or without anti-HBs development
Answer: D. Loss of HBsAg with or without anti-HBs development
Compared with intermittent auscultation, continuous external fetal monitoring during labor decreases the risk of which one of the following outcomes? (check one)
A. Instrumental vaginal delivery.
B. Cesarean delivery.
C. Newborn seizures.
D. Neonatal intensive care unit admissions.
Correct C
A Cochrane review showed that compared with intermittent auscultation, continuous external fetal monitoring increased the risk of cesarean delivery and instrumental vaginal delivery. There was no difference in cord blood acidosis, hypoxic-ischemic encephalopathy, Apgar scores, or admission to the neonatal intensive care unit. Continuous external fetal monitoring decreases newborn seizure risk by one-half. The number needed to treat with continuous external fetal monitoring to prevent one seizure was 667, whereas that same number would cause 15 additional cesarean deliveries.
Which statement regarding antihistamine use in special populations with urticaria is correct?
A. First-generation antihistamines are preferred in breastfeeding patients
B. Omalizumab is contraindicated in pregnancy due to teratogenicity
C. Second-generation antihistamines are preferred in children and older adults due to better safety
D. All antihistamines equally cross into breast milk
Answer: C. Second-generation antihistamines are preferred in children and older adults due to better safety
What is the recommended vaccination schedule for an infant <2,000 g exposed to HBV?
A. 3-dose series at 0, 1, and 6 months
B. 2-dose series
C. 4-dose series starting at birth
D. Delay vaccination until weight >2,000 g
Answer: C. 4-dose series starting at birth
Pearl
<2 kg = 4 shots
≥2 kg = 3 shots
— both get vaccine + HBIG at birth
Which of the following is a noninvasive method to assess liver fibrosis in patients with chronic hepatitis B?
A. Liver biopsy only
B. Fibrosis-4 (FIB-4) score
C. Serum bilirubin
D. Prothrombin time
Answer: B. Fibrosis-4 (FIB-4) score
Pearl
Which of the following statements regarding monitoring in chronic hepatitis B patients on nucleos(t)ide analogue therapy is correct?
A. ALT flares early in therapy require immediate discontinuation
B. Patients should be monitored every 12 months until suppression
C. Monitoring is done every 3 months until viral suppression, then every 6 months
D. Viral suppression is defined as HBV DNA <2,000 IU/mL
Answer: C. Monitoring is done every 3 months until viral suppression, then every 6 months
Pearl
Which of the following methods is most accurate for detecting postpartum hemorrhage in vaginal deliveries?
A. Visual estimation of blood loss alone
B. Measuring hemoglobin levels only
C. Calibrated drape plus clinical observations (vital signs, uterine tone, blood flow)
D. Patient-reported bleeding
Answer: C. Calibrated drape plus clinical observations (vital signs, uterine tone, blood flow)
Which of the following is the preferred treatment for urticaria in pregnant or breastfeeding patients?
A. Diphenhydramine
B. Hydroxyzine
C. Cetirizine or loratadine
D. Avoid all antihistamines
Answer: C. Cetirizine or loratadine
Pearl:
1. Which group is routinely recommended to receive hepatitis B vaccination per updated guidelines?
A. Only high-risk adults
B. All adults 19–59 years
C. Only healthcare workers
D. Only patients with chronic liver disease
2. Which of the following is an indication for hepatitis B vaccination in adults ≥60 years?
A. Hypertension
B. Diabetes only
C. Injection drug use
D. Routine screening
Answer: C. Injection drug use
1. B. All adults 19–59 years
2. C. Injection drug use
Which of the following best defines a patient with active chronic hepatitis B infection who should be treated?
A. Normal ALT and undetectable HBV DNA
B. Elevated ALT with HBV DNA >2,000 IU/mL
C. Positive Anti-HBs with normal ALT
D. Isolated Anti-HBc positivity
Answer: B. Elevated ALT with HBV DNA >2,000 IU/mL
All four guidelines agree that patients with active disease (an elevated ALT level and HBV DNA measurement more than 2,000 IU/mL) should be treated, and those with cirrhosis and detectable viral load should receive NA therapy.
How often should ALT and HBV DNA be monitored in patients with chronic hepatitis B not receiving treatment?
A. Monthly
B. Every 3–6 months
C. Annually
D. Every 2 years
Answer: B. Every 3–6 months
Untreated HBV → monitor every 3–6 months to reassess need for therapy
Which of the following best describes the FAST mnemonic used for stroke recognition?
A. Fever, Ataxia, Seizure, Tremor
B. Face drooping, Arm weakness, Speech difficulty, Time to call 911
C. Fainting, Aphasia, Sensory loss, Tachycardia
D. Facial pain, Ataxia, Speech delay, Tingling
Answer: B. Face drooping, Arm weakness, Speech difficulty, Time to call 911
1. What is the primary pathophysiologic mechanism underlying most cases of urticaria?
A. Complement-mediated cytotoxicity
B. Mast cell activation with histamine release in the dermis
C. T-cell–mediated delayed hypersensitivity
D. Immune complex deposition
2. Which of the following mechanisms is responsible for NSAID-induced urticaria?
A. Direct IgE-mediated mast cell activation
B. Suppression of prostaglandin E2 leading to increased mast cell activation
C. Bradykinin-mediated vascular permeability
D. Immune complex deposition
1. B. Mast cell activation with histamine release in the dermis
2. B. Suppression of prostaglandin E2 leading to increased mast cell activation
Pearls
1. Which serologic pattern indicates immunity due to vaccination?
A. HBsAg (+), Anti-HBs (−), Anti-HBc (+)
B. HBsAg (−), Anti-HBs (+), Anti-HBc (−)
C. HBsAg (−), Anti-HBs (+), Anti-HBc (+)
D. HBsAg (+), Anti-HBs (+), Anti-HBc (+)
2. Which serologic pattern suggests past infection with immunity (natural infection)?
A. HBsAg (+), Anti-HBs (−), Anti-HBc (+)
B. HBsAg (−), Anti-HBs (+), Anti-HBc (+)
C. HBsAg (−), Anti-HBs (−), Anti-HBc (+)
D. HBsAg (+), Anti-HBs (+), Anti-HBc (−)
1. B. HBsAg (−), Anti-HBs (+), Anti-HBc (−)
2. B. HBsAg (−), Anti-HBs (+), Anti-HBc (+)
Pearls
1. What is the diagnostic criterion for chronic hepatitis B infection?
A. Presence of Anti-HBc IgM
B. Elevated ALT for >3 months
C. Presence of HBsAg for ≥6 months
D. Positive HBV DNA at any time
2. Which of the following noninvasive findings suggests cirrhosis (F4 fibrosis) in chronic HBV?
A. APRI >0.7
B. FIB-4 >1.45
C. Transient elastography >7 kPa
D. FIB-4 >3.25
1. Answer: C. Presence of HBsAg for ≥6 months
2. Answer: D. FIB-4 >3.25
Pearls
Which of the following is the preferred treatment approach for patients with chronic hepatitis B and HIV coinfection?
A. Peginterferon alfa-2a monotherapy
B. No treatment unless ALT is elevated
C. Use an HIV regimen including tenofovir plus emtricitabine or lamivudine
D. Treat HBV only after HIV is fully suppressed
Answer: C. Use an HIV regimen including tenofovir plus emtricitabine or lamivudine
Which of the following groups is empiric vitamin D supplementation recommended without measuring vitamin D levels for illness prevention?
Children aged 1–18 years, pregnant adults, individuals with prediabetes, and adults ≥75 years
1. What are the first-line pharmacologic treatments for chronic urticaria?
A. First-generation H1 antihistamines
B. Second-generation H1 antihistamines (daily dosing)
C. Oral corticosteroids
D. Cyclosporine
2. If symptoms persist on standard-dose second-generation H1 antihistamines, what is the next recommended step?
A. Add omalizumab
B. Increase dose up to four times the standard dose
C. Switch to first-generation antihistamines only
D. Start systemic steroids
3. Which of the following adjunct therapies may be added in Step 2 management?
A. Beta-blockers
B. Leukotriene receptor antagonists
C. Antibiotics
D. Antivirals
4. Which medication is preferred for refractory chronic urticaria requiring advanced therapy?
A. Diphenhydramine
B. Prednisone
C. Omalizumab
D. Loratadine
1.B. Second-generation H1 antihistamines (daily dosing)
2. B. Increase dose up to four times the standard dose
3. B. Leukotriene receptor antagonists
4. C. Omalizumab
1. What is the current CDC recommendation for hepatitis B screening in adults?
A. Screen only high-risk individuals
B. Screen all adults annually
C. One-time triple panel screening for all adults ≥18 years
D. Screen only pregnant women
2. Which tests are included in the hepatitis B triple panel screening?
A. HBsAg, anti-HBs, anti-HBc
B. HBsAg, ALT, AST
C. Anti-HBs, anti-HCV, HIV
D. HBeAg, viral load, ALT
1. C. One-time triple panel screening for all adults ≥18 years
2. A. HBsAg, anti-HBs, anti-HBc
Pearls
1. Which marker is typically detectable at the onset of symptoms in acute hepatitis B infection?
A. Anti-HBs
B. Anti-HBc IgM
C. Anti-HBe
D. Anti-HBc IgG
2. Which of the following best describes the timeline of hepatitis B core antibodies in acute infection?
A. Anti-HBc IgG appears first and disappears within months
B. Anti-HBc IgM appears at symptom onset and is replaced by lifelong Anti-HBc IgG
C. Anti-HBc IgM persists for life
D. Anti-HBc IgG is only present during acute infection
1. Answer: B. Anti-HBc IgM
2. Answer: B. Anti-HBc IgM appears at symptom onset and is replaced by lifelong Anti-HBc IgG
Pearls
Medications for Chronic Hepatitis B (HBV) Treatment
Medications for Chronic Hepatitis B (HBV) Treatment
First-line (preferred):
Alternative:
When should emergency medical services (EMS) be activated for a patient experiencing a seizure?
A. Any seizure lasting more than 1 minute
B. After a seizure lasting more than 5 minutes or if associated with breathing difficulty, injury, choking, or water immersion
C. Only if the patient has a history of epilepsy
D. Only if the seizure occurs during sleep
Answer: B. After a seizure lasting more than 5 minutes or if associated with breathing difficulty, injury, choking, or water immersion