Cases 6-10

Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain, which began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which of additional physical exam finding would be consistent with this man's level of disc herniation? A. Hypoactive ankle tendon reflex B. Decreased range of motion on lumbar extension C. 2/5 strength on hip flexion D. Decreased rectal tone E. Positive Stoop test

A

A 55-year-old man presents to your office complaining of pain and stiffness in his knees. He used to play basketball three times a week with his friends but stopped about seven months ago because he was finding it difficult to keep up. His PMH is significant for hypertension, hyperlipidemia, and obesity. His BMI is 32. On exam, he is afebrile. There is no erythema or effusion of his knee joints but there is crepitus on movement of each joint. His range of motion of the knees is full. His x-rays show narrowed joint spaces and subchondral calcification. What is the most appropriate initial counseling for this patient? A. Instruct him to see an orthopedist for steroid injections. B. Refer him for knee replacement surgery. C. Develop a weight loss plan with the patient. D. Prescribe opioids for pain relief.

C

A 35 year old overweight woman in good health comes to the clinic for a routine physical. Which of the following screenings are recommended by the U.S. Preventative Services Task Force (USPSTF)? A. Complete blood count B. Thyroid stimulating hormone levels C. Cholesterol panel D. Blood pressure screening E. HbA1C

D

Which of the following patients is an appropriate candidate for a exercise stress test? A. A 58-year-old male who presents to the emergency room with constant substernal chest pressure, diaphoresis and shortness of breath B. A 44-year-old female with a BMI of 40 kg/m2 and history of asthma C. A 48-year-old female with a history of intermittent anginal episodes that have been controlled on medications. D. A 52-year-old female with new atypical chest pain with a history of elevated cholesterol, smoking and family history of coronary artery disease

D

Which of the following symptoms are most likely to be due to acute coronary syndrome? A. 23-year-old male with acute onset of difficulty breathing and hyperresonance upon lung auscultation B. 42-year-old woman with a pulsating pain in the center of her chest at night C. 35-year-old man with chest pain radiating down his left arm after falling off a ladder at work one week ago D. 59-year-old woman with palpitations that increase with exercise and are associated with nausea and vomiting E. 55-year-old woman with diffuse central chest pain that is worse when lying down

D

A 42-year-old female presents for a visit after recently being diagnosed with Type 2 diabetes. She has made a plan to work on diet and exercise. Her A1C is found to be 8.0%. What is the best medicine to start at this time? A. A sulfonylurea B. An SGLT2 inhibitor C. GLP-1 receptor agonist D. Insulin E. Metformin Basal

E

Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely? A. Increased pain with coughing B. Abnormal gait C. Point tenderness on spinous processes D. Loss of ankle jerk E. Spasm of paraspinous muscles

E

Working at your clinic, you receive a call from a patient of yours, Mr Smith, a 45-year-old male who was seen three days ago complaining of lower back pain. At that time he had no history of trauma, pain that improved while lying down and no neurologic deficits. He works as a truck driver. He was treated conservatively along with pharmacologic intervention with NSAIDs and muscle relaxants. He calls your office now due to only minimal improvement. And although his symptoms have not changed, he is frustrated with the slow progress, needs to get back to work as soon as possible, and is concerned this might be "something serious." Which of the following is the most appropriate next step in management? A. Obtain a plain film x-ray B. Order an MRI C. Ask him to double the dosage of his muscle relaxants D. Schedule him for an appointment immediately E. Reassure him and schedule a follow-up appointment in a few days

E

A 45-year-old female presents to your office complaining of left calf pain and swelling. She reports first noticing the pain after her yoga class earlier in the week. She denies having any chest pain or shortness of breath. She has no significant PMH. Her physical exam is significant for tenderness to palpation over the left calf. No edema or redness is present. The circumference of her left calf is 10 cm and the circumference of her right calf is 9 cm. What is the most appropriate next step in diagnosis? A. D-dimer B. MRI C. Lower extremity Doppler D. CT angiography

A

A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vital signs today are blood pressure 138/88 mmHg, pulse 65 beats/min, respirations 10/min, afebrile, BMI 29 kg/m2. He smokes 10 cigarettes per day, does not regularly exercise, and drinks one to two beers daily, four or five times a week. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is least likely to improve his cardiovascular risk? A. Alcohol cessation B. DASH eating plan C. Increased exercise D. Smoking cessation E. Weight loss

A

A 62-year-old female presents for follow-up of her hypertension and diabetes. In general, her chronic diseases are well controlled and she has suffered no target organ damage. She has worked hard to begin exercising, and is walking vigorously five times a week. She has also worked hard on dietary changes, and has been following the DASH eating plan very seriously. She quit smoking three months ago. Her blood pressure today is 148/88 mmHg, pulse is 72 and BMI is 32. She is taking metformin 500 mg twice daily, simvastatin 20 mg daily and hydrochlorothiazide (HCTZ) 25 mg daily, and she is adherent with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the most appropriate? A. Add amlodipine 5 mg daily B. Change her simvastatin from 10 mg to 20 mg C. Impress upon her the importance of making more lifestyle modifications D. Increase HCTZ to 50 mg daily E. Make no changes as she is at her treatment goals

A

A 60-year-old male with a past medical history of chronic gout, depression, and Stage 1 hypertension presents to your office for a follow-up visit. He has been attempting to reduce his blood pressure with behavioral changes, but has had difficulty maintaining the changes. Today, his vital signs are blood pressure 144/90 mmHg, pulse 78 beats/min, respirations 12/min, temperature 98.7 F. His recent basic metabolic panel was completely normal. As you consider starting a medication for his hypertension, which of the following medications is most likely to cause an adverse event in this patient? A. Amlodipine B. Hydrochlorothiazide C. Lisinopril D. Losartan E. Metoprolol

B

A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1C was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient's blood pressure? A. Make no changes to her medications as her blood pressure is at goal. B. Start amlodipine daily. C. Start furosemide daily. D. Start lisinopril daily. E. Start metoprolol daily.

B

A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96 mmHg. You repeat the blood pressure in her other arm and get 148/92 mmHg. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76 mmHg. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. What is the most appropriate diagnosis at this time? A. White coat hypertension B. Elevated blood pressure reading C. Stage 1 hypertension D. Stage 2 hypertension E. Secondary hypertension

B

Mr. Roberts is a 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension who presents lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of symptoms he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. Vital signs are temperature 100.2 F, blood pressure 135/75, pulse 76/min, and respiratory rate 15/min. Given this history, which of the following physical exam maneuvers are most helpful in making the diagnosis? Select all that apply. A. Abdominal palpation B. Costovertebral angle percussion C. Straight leg test D. Digital rectal exam E. Pinprick sensation of the legs

B,D

A 56-year-old male presents to your office for a six-month follow-up visit for DM Type 2 diagnosed at his previous visit with a HbA1C of 7.0%. At that visit, you discussed dietary modification including eliminating carbohydrates like rice from his diet. You also emphasized the importance of exercise and recommended he join a gym. On repeat testing of HbA1C today, you find that his HbA1C has increased to 7.5%. What might you do differently when counseling the patient at this visit? A. Suggest he get a personal trainer. B. Recommend he follow a more strict dietary protocol including elimination of meat from his diet. C. Find out from the patient whether barriers exist to his adherence to your previous suggestions. D. Tell him you are disappointed that he was not able to adhere to your previous recommendations.

C

A 65-year-old truck driver presents to your office complaining of right calf pain and swelling. He has recently returned from a four-day cross-country trip after which he had onset of his current symptoms. The patient reports that the week prior to his four-day trip, he was mostly in bed recovering from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25-pack-year smoking history. He denies having any chest pain or SOB. His physical exam shows 2+ pitting edema of his right leg. When measuring the circumference of his right leg, you note that it is 14 cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in diagnosis? A. D-dimer B. MRI C. Lower extremity Doppler D. CT angiography

C

A 65-year-old truck driver presents to your office complaining of right calf redness and swelling. He reports that he has had these symptoms off and on for some time but noticed that the redness and swelling on the right has worsened over the past few days and he also noticed fevers and chills. His PMH is significant for DM Type 2, COPD, and heart failure. He has a 25-pack-year smoking history. His physical exam shows a temperature of 101.1, 2+ pitting edema of his calves bilaterally, and dry, flaking skin over both calves. His right foot shows interdigital maceration and he has redness, warmth, and tenderness just inferior to the knee. When measuring the circumference of his right leg, you note that it is 12 cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in this patient's care? A. Initiate treatment with Low molecular weight heparin. B. Order a lower extremity Doppler. C. Initiate treatment with antibiotics. D. Check a D-dimer.

C

A 60-year-old female presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes one to two glasses of wine per week. Her vitals are: Heart rate: 70 beats/minute Blood pressure: 130/70 mmHg Body Mass Index: 30 kg/m2 Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows: Random plasma blood glucose: 205 mg/dL Creatinine: 0.8 mg/dL TSH: 2.1 U/L. What test is needed to diagnose diabetes mellitus? A. An oral glucose tolerance test B. Fasting blood glucose C. HgbA1C D. The random blood glucose is sufficient E. Urine microalbumin

D

A 65-year-old male with Type 2 diabetes mellitus and no other chronic health issues presents to the emergency department with altered mental status. The patient experienced no known head trauma. His vitals are: Temperature: 38.1 Celsius Heart rate: 102 beats/minute Respiratory rate: 16 breaths/minute Blood pressure: 90/74 mmHg He responds when you say his name, and he appears well nourished. His mucous membranes appear very dry. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis? A. Cardiac arrhythmia B. Cerebrovascular accident C. Diabetic ketoacidosis (DKA) D. Hyperosmolar hyperglycemic state (HHS) E. Thiamine deficiency

D

Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and recently completed a six-month steroid taper. She presents to her primary care physician after two weeks of lower lumbar back pain. She does not recall any trauma but began to feel a sharp pain after bending over to pick up laundry. The pain radiates bilaterally into her anterior abdomen. She has found no relief with over the counter NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2 region. There are no neurologic deficits and reflexes are intact. Which of the following is the most appropriate next step in management? A. Reassess in four weeks B. Refer to spine specialist C. Order complete blood count D. Order a plain x-ray E. Recommend conservative management

D

You are seeing a 55-year-old man who presents to the family medicine practice with a two-week history of daily episodes of sudden lightheadedness and palpitations. These seem to occur without provocation and last for approximately 5 minutes each time. He has not passed out during these episodes, but he has felt the need to sit down when they come. Sitting calmly and waiting seems to make them go away. He denies chest pain, diaphoresis, jaw pain, or arm pain with these episodes. He has a past medical history of gout and hypertension, for which he takes daily allopurinol and losartan. He does not smoke or drink. He is not under any recent stresses at home or work. On exam, he is in no acute distress. His vital signs are completely normal as is his cardiopulmonary exam. A recent complete blood count and TSH were normal. Which of the following is the most appropriate next step? A. Transfer him to the emergency department for admission to the hospital. B. Order an exercise stress test. C. Reassure him that his palpitations are likely benign and that he should focus on a healthy lifestyle. D. Order a 48-hour Holter monitor. E. Order an echocardiogram.

D

A 52-year-old woman with a history of diabetes and rheumatoid arthritis presents for her annual examination. She works in an office 10 hours a day, and rarely gets exercise. Her BMI is 23 and her blood pressure is 152/85. Her previous visit two months ago showed blood pressure of 148/82. Her father had a history of diabetes and her maternal grandmother died of rheumatic heart disease at the age of 42. She admits to marijuana drug use in the past and is a nonsmoker. Which of the following is a major risk factor for coronary heart disease (CHD) that this patient has? A. Age B. Family history C. Rheumatoid arthritis D. Obesity E. Hypertension

E

A 68-year-old male was diagnosed with Stage 1 essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28, mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94 mmHg. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. which of the following is the most appropriate medication to begin in this patient? A. Beta blocker B. Clonidine C. Loop diuretic D. Nitrate E. Thiazide diuretic

E

A 72-year-old female with a 30-year history of Type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. She is on atorvastatin 40 mg daily. She is on no other medications. Her A1c is 6.5%, and her BP today is 145/90. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is the most appropriate next step to slow down the progression of diabetic retinopathy? A. Increase her insulin aspart from five units to seven units with meals. B. Increase her insulin glargine to 23 units every morning. C. Perform a fundoscopic examination and make no changes to her regimen today. D. Start her on a baby aspirin. E. Start her on a calcium channel blocker.

E