Diagnosis and Treatment of Chronic Pruritus

Diagnosis and Treatment of Chronic Pruritus

1. A 42-year-old female presents with a 3-month history of fatigue and pruritus localized to the palms and soles.

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Physical exam is negative for the presence of lesions. What is the most likely underlying etiology of pruritus?

a. Atopic dermatitis

b. Primary biliary cholangitis

c. Bullous pemphigoid

d. Drug-induced

2. Chronic pruritus associated with a recent history of night sweats, low-grade fevers, and recent weight loss

should raise suspicion for onset of:

a. Tuberculosis

b. Brachioradial pruritus

c. Lymphoma

d. Multiple sclerosis

3. A 28-year-old female with a history of childhood asthma presents with a 6-week onset of severe pruritus

localized to the popliteal fossae and ankles. Physical exam reveals dry, scaly, ill-defined plaques and mild

lichenification. What is the most likely diagnosis?

a. Atopic dermatitis

b. Psoriasis

c. Lichen planus

d. Xerosis

4. A 62-year-old male with complains of a 1-year history of severe pruritus most prominent on the neck and

extensor surfaces of the arms. Physical exam reveals excoriations in these body locations. Upon further

questioning, he states he was in a car accident three years ago which led to residual neck pain that still persists.

What is the best next step?

a. Observation and close monitoring

b. Perform a skin biopsy

c. Order cervical MRI

d. Order complete blood counts

5. A 54-year-old male with a longstanding history of hypertension presents with generalized pruritus for the past 5

months. It is not associated with a rash. He denies a history of constitutional symptoms, back pain, or psychiatric

disease. What is the best next step?Pancreatitis

a. Ask the patient to describe his bathing habits

b. Order a TSH level

c. Ask the patient what Prescribe triamcinolone ointment

d. medications he takes to treat his hypertension

6. A 44-year-old female with a past medical history of thoracic back pain presents with severe (10/10) generalized

itching. She is diagnosed with neuropathic pruritus based upon clinical history and positive MRI findings. What is

the best treatment regimen?

a. Topical corticosteroid

b. Gabapentin

c. Antihistamine

d. Topical calcineurin inhibitor

7. A 22-year-old patient with mild atopic dermatitis is started on crisaborole ointment. Which of the following side

effects should the patient be cautioned about?

a. Application-site burning.

b. Sedation

c. Development of urticaria

d. Temporary itch exacerbation

8. Patients with chronic pruritus should be advised to bathe with:

a. Bar soaps with a high pH

b. Bar soaps with a low pH

c. Liquid soap with a high pH

d. Liquid soap with a low pH

Lead ECG Interpretation

1) Mrs. Foster has a history of left ventricular hypertrophy. What axis deviation, if any, might be present on

her 12 lead ECG?

a. Left axis deviation

b. Right axis deviation

c. Right axis deviation in the inferior leads and left axis deviation in the precordial leads

d. No axis deviation

2) Mr. Adams is a 62-year-old new patient on your schedule today. He arrives for his annual physical and you

decide he should have an ECG since he can’t recall his last one and has a history of hypertension. You note

his QRS axis is +135 degrees. Which statement is accurate regarding his QRS axis?

a. His QRS axis is abnormal – it is extremely deviated to the right

b. His QRS axis is abnormal – it is deviated to the right

c. His QRS axis is abnormal – it is deviated to the left

d. His QRS axis is normal

3) You are precepting a student NP who wants to learn more about reading ECGs. Using the systematic

approach taught by the speaker of this presentation, which steps below are in the correct order for

interpreting an ECG?

a. Step 1: Determine axis. Step 2: Determine rhythms (presence of P wave, measure wave and

segment intervals, compute rate). Step 3: Assess for ventricular hypertrophy and conduction delay.

Step 4: Assess for Coronary Artery Disease (CAD)

b. Step 1: Determine rhythms (presence of P wave, measure wave and segment intervals, compute


Step 2: Assess for ventricular hypertrophy and conduction delay. Step 3: Assess for Coronary Artery

Disease (CAD). Step 4: Determine axis.

c. Step 1: Determine axis. Step 2: Assess for ventricular hypertrophy and conduction delay. Step 3:

Assess for Coronary Artery Disease (CAD). Step 4: Determine rhythms (presence of P wave,

measure wave and segment intervals, compute rate).

d. Step 1: Determine rhythms (presence of P wave, measure wave and segment intervals, compute

rate). Step 2: Determine axis. Step 3: Assess for ventricular hypertrophy and conduction delay.

Step 4: Assess for Coronary Artery Disease (CAD)

The following information is for the next two questions:

Your next patient is Mr. Smith who called earlier in the day for an appointment for “worsening indigestion.”

The medical assistant who brought him back informs you that Mr. Smith’s blood pressure is elevated at179/110, HR=105, Respirations 22, and temperature is 98.8. The patient is described to be “in discomfort and feels nauseated”. You immediately check on him and determine that an ECG should be done ASAP. While the ECG is being done, you review Mr. Smith’s electronic chart and note that he is a 47 y/o Caucasian male with a history of seasonal allergies, mild hypertension treated with a diuretic, and GERD treated with OTC proton pump inhibitors. He has no known drug allergies or other significant past medical history. He is a non-smoker,

rarely drinks alcohol, and his BMI from 3 months ago was 22.4. He has a family history of Coronary Artery Disease with his father passing away from an MI at age 55. The medical assistant brings you Mr. Smith’s office ECG for you to read. You note the following: Sinus rhythm with a HR of 115; QRS axis is -30, R wave in V5 = 15mm and the S wave in V2 = 6mm, the ST segment is significantly elevated in 3 leads, the QRS complex is .06 seconds, T wave is peaked in 2 leads.

4) What is your interpretation of Mr. Smith’s ECG?

a. He has sinus tachycardia with left Bundle Branch Block likely caused from anxiety over his  GERD


b. He has sinus tachycardic with left ventricular hypertrophy and is likely having an acute MI

c. He has sinus tachycardia with likely an old mild MI he was unaware of and right axis deviation

d. He has sinus tachycardia with left axis deviation and an acute injury most likely from a current MI

5) What should you do next for Mr. Smith?

a. Call a family member to pick him up and take him to the local emergency department

b. Call a cardiologist and request a same day office evaluation for an abnormal ECG

c. Call 911, have the defibrillator and code cart available for use, administer chewable aspirin to Mr.

Smith, calmly explain to him that he needs further emergency evaluation including cardiac

biomarkers and that you will continue to stay with him until the ambulance has arrived

d. Call 911, have the defibrillator and code cart available for use, give the patient clopidogrel and have

the patient wait in the waiting area where the receptionist can keep an eye on him and alert you of

any changes until the ambulance has arrived


  1. In addition to cervical cancer, what cancer type is commonly caused by the high-risk HPV variants that the HPV vaccine protects against (HPV-16 and HPV-18)?

a. Oropharyngeal cancer
b. Nonmelanoma skin cancer c. Gastrointestinal cancer
d. Non-Hodgkin lymphoma

  • What is one of the most important predictors of increasing HPV vaccination uptake? a. Recommendations from friends, family members, or other peer groups
    b. Access to information from trusted health organizations, such as the CDC
    c. Provision of patient brochures and materials

d. A high-quality recommendation from a health care provider

  • A 13-year-old female child presents for a wellness examination and routine vaccinations with her mother and father. Her parents agree to the Tdap and meningococcal vaccines but express hesitations about the HPV vaccine. When prompted, their concerns are that the vaccine could promote sexual activity in their daughter. What response from the NP is supported by available evidence?
    • “Although no studies have yet been performed, there is no evidence that HPV vaccination promotes sexual activity.”
    • “Studies show that there is a slight increase in sexual activity, but that risk is counterbalanced by the decreased incidence of cancer.”
    • “Studies show that HPV vaccination is not associated with younger age at first sexual intercourse or increasing number of sexual partners.”
    • “Although studies show that there is a slight increase in nonuse of contraception, there is no evidence that the HPV vaccination is associated with younger age at first sexual intercourse or increasing number of sexual partners.”

Cannabis meds

  1. Reflecting on the components of cannabis, which statement(s) is(are) most accurate?
    a. Marijuana has 0.3% or more THC while hemp has less than 0.3% THC
    b. The CB2 receptors are more widely used resulting in pharmacological effects of CBD
    c. Terpenes are responsible for the aroma of cannabis and may also have other unknown effects

d. (a), (b) & (c)

  1. Which statement(s) is(are) correct about the Endocannabinoid System?
    a. Receptor sites are only located in the brain affecting memory and cognition  .  b.Neurotransmitters within the system are only produced when needed
    c. Neurotransmitters are endogenous and the body stores what is not used
    d. (a), (b) & (c)
  2. Which of the following scenarios could reflect physiological effects from the Endocannabinoid System in a person who uses marijuana on a consistent basis?

a. Increased sensitivity to pain of a sprained ankle

b. Decreased appetite resulting in weight loss
c. Improved short-term memory before an exam

 d. More frequent upper respiratory illnesses

  1. A 32-year-old female new patient was seen by a non-NP provider last week and treated for bronchitis with clarithromycin and albuterol. The patient is back in the clinic on the NP’s schedule for complaints related to “side-effects” of clarithromycin. Although she is breathing better, she complains of “drowsiness on the antibiotic” and states she fell asleep at work yesterday. The NP reviews the social history on the new patient intake completed during the patient’s last visit and notes the patient smokes marijuana on weekends and some evenings to “de-stress”.

Which NP intervention is most appropriate for this patient?

  1.  Change antibiotic choice to erythromycin and advise patient to take a week off from work to rest. Educate that smoking marijuana can worsen bronchitis.
    1. Discontinue clarithromycin, add amoxicillin and educate that bronchitis takes at least 2 weeks to resolve. Advised to consider stopping marijuana.
    2. Educate patient that clarithromycin interacts with marijuana causing increased side-effects of marijuana. Discontinue marijuana, continue treatment plan and educate that smoking can worsen bronchitis.
    3. Educate patient that all components of cannabis interact with antibiotics resulting in side- effects of the antibiotic. Stopping marijuana will stop side-effects of clarithromycin.

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