Family Med Aquifer Questions (2021)

A 55-year-old male with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35-pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" Which stage of change best describes this patient at this time? A. Action B. Contemplation C. Maintenance D. Precontemplation E. Preparation

D. Precontemplation

You are seeing a 28-year-old female who presents with gradually worsening headaches. She has had headaches off and on since she was a teen, similar to her mother. She typically awakens with them, and they are associated with nausea and vomiting, which can last for much of the day. The pain is throbbing and usually unilateral behind the right eye. Resting in a dark room often helps, and ibuprofen can help as well if she is able to take it at the onset of the headache. Recently, the headaches have become more common, happening two to three times per week. These have been interrupting her job as a paralegal, and she is worried she will be fired. She has tried yoga and mindfulness-based stress reduction, but these have not helped. She does not smoke, drink alcohol, or use illicit drugs. She recently stopped her oral contraceptive pills in an effort to get pregnant. Her vital signs and physical exam are perfectly normal. Of the following, which would be the most appropriate next step in managing this patient? A. Advise her to continue the ibuprofen as it has been helpful B. Discontinue the ibuprofen and prescribe acetaminophen instead C. Order a CT scan of her head D. Prescribe propranolol nightly E. Prescribe sumatriptan as needed

D. Prescribe propranolol nightly

A 17-year-old male football player presents to the emergency department with acute onset of right-shoulder pain. The pain started approximately two hours ago when he was tackled during a game while carrying the football. Shoulder swelling and pain were present after injury. He is holding ice to a swollen shoulder, and on exam, you notice severe bruising, pain on palpation over the lateral edge of the shoulder, and a raised bump over that same area. There is also severe tenderness over the coracoclavicular ligaments. What is the most likely diagnosis? A. AC joint sprain B. Rotator cuff tear C. Rotator cuff tendonitis D. Subacromial bursitis E. Subacromial impingement

A. AC joint sprain

A 62-year-old female presents for follow-up of her hypertension and diabetes. In general, these 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 beats/minute, respiratory rate is 16 breaths/minute, and BMI is 32 kg/m2. 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 20 mg to 40 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. Add amlodipine 5 mg daily

A 72-year-old female presents to the clinic one year after having suffered a stroke that left her with some residual left-sided weakness/paralysis. On exam, the left shoulder demonstrates a severe decrease in both active and passive ROM and significant pain. The patient has a history of hypertension, hyperlipidemia, and diabetes. What is the most likely diagnosis? A. Adhesive capsulitis B. Biceps tendonitis C. Osteoarthritis D. Rotator cuff tear E. Subacromial bursitis

A. Adhesive capsulitis

Ms. McSally is a generally healthy 27-year-old female graduate student who presented to your office twelve weeks ago with episodic postprandial epigastric burning. This had been bothering her for nearly six months but she had been busy with her thesis and was unable to find the time necessary for an appointment. She reported this year has been particularly stressful, with limited time resulting in increased consumption of coffee and takeout fast food. At that time, she began an eight-week trial of omeprazole. She returns now with no improvement of her symptoms. She discontinued the omeprazole one month ago because she ran out of the medication. She has no additional symptoms and physical exam is unremarkable. Which of the following is the most appropriate next step in her management? Choose the single best answer. A. Administer a urea breath test B. Begin treatment with triple therapy of pantoprazole, clarithromycin, and azithromycin for 14 days C. Continue omeprazole for another four weeks with close follow-up D. Refer her for an upper gastrointestinal endoscopy E. Switch PPI from omeprazole to pantoprazole

A. Administer a urea breath test

Ms. Michaels is an 80-year-old female with a past medical history of shingles. She comes to your office accompanied by her daughter Jennifer who reports that her mother is forgetting things. Jennifer explains that her mother will ask the same question several times throughout the day. Ms. Michaels also gets confused easily and is more passive than usual. Her memory problem was noticed two years ago after she forgot to pay her bills on multiple occasions. Jennifer now pays her mother's bills and cleans and cooks for her. Ms. Michaels' vital signs are: temperature of 37.3 C (99.2 F), blood pressure of 118/70 mmHg, pulse of 80 beats/minute, and respiratory rate of 12 breaths/minute. Her physical exam is significant for bilateral osteoarthritis hand deformities. She does not have a tremor, nor jerky uncontrolled movements. She is not on any chronic medications. She has no smoking history and does not drink alcohol. CT head shows mild atrophy of the hippocampus. Her MMSE is 20. Which of the following is the most likely diagnosis? A. Alzheimer disease B. Huntington disease C. Lewy bodies D. Prion protein E. Vascular disease

A. Alzheimer disease

A 75-year-old was found unresponsive in her house by her neighbor who had come over to help clean her house. An empty unlabeled pill container was found next to her on the bathroom floor. She was rushed to the ER, stabilized, and is now in ICU on a mechanical ventilator. Which of the following are true regarding suicide in the elderly? A. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized. B. Elderly persons attempting suicide are more likely to be married and living with their spouse. C. Elderly persons attempting suicide usually report good sleeping habits. D. Firearms are the most common means of suicide in the elderly. E. Suicidal behaviors increase with age, but rates of completed suicides don't.

A. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized.

A 40-year-old male presents to the clinic with a dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He reports no fever but does report some continued shortness of breath. He has smoked 1-2 cigarettes a day for the past six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis? A. Asthma B. COPD C. Foreign body aspiration D. Pneumonia E. Pulmonary embolism

A. Asthma

A 34-year-old overweight female in good health comes to the clinic for a routine physical. Which of the following screenings are recommended by the U.S. Preventive Services Task Force (USPSTF)? A. Blood pressure screening B. Cholesterol panel C. Complete blood count D. HbA1C E. Thyroid stimulating hormone levels

A. Blood pressure screening

This 45-year-old has never been to a primary care provider. She presents today to establish care and get her health in order. Her concerns today are fatigue, weakness, numbness, insomnia, feeling sad at times, anhedonia, increased appetite, weight gain, dry skin, and increasing hair loss within the past month. Her vital signs are: Pulse is 78 beats/minute Respiratory rate is 18 breaths/minute Oxygen saturation is 95% Blood pressure is 152/84 mmHg Weight is 147 kg (325 lbs) Body Mass Index is 41 kg/m2 Today, her physical exam is significant for thinning hair, poor dentition, a systolic murmur heard at the left upper sternal border, an obese abdomen, and bilateral knee stiffness and pain on range of motion exam. Remainder of the physical exam is within normal limits. Which laboratory tests or studies can be done to rule out medical causes of insomnia, fatigue, and depression? A. CBC, CMP, and TSH B. Chest-X Ray C. CT head without contrast D. HgbA1c, lipid panel, urine microalbumin E. MRI brain with contrast

A. CBC, CMP, and TSH

A 55-year-old male with no significant past medical history and generally healthy behaviors presents to the clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. He is a lifelong non-smoker, and he doesn't drink alcohol or use recreational drugs. Which of the following screening tests is given either a USPSTF A or B recommendation in favor of its routine use for patients such as this one? A. Colon cancer screening B. ECG screening for coronary artery disease C. Lung cancer screening D. Pancreatic cancer screening E. Prostate specific antigen (PSA) testing

A. Colon cancer screening

Ms. Kovacs is a first-time mother you are seeing on postpartum day two in the hospital, with her newborn son Christopher. Her pregnancy was uncomplicated and Christopher was born full-term via spontaneous vaginal delivery with no complications and a birth weight of 7 lbs, 0 oz (3,178 grams). Ms. Kovacs is getting ready to be discharged home today but is concerned because the baby now weighs 6.8 lbs (3,087 grams) and she hasn't been able to produce milk every time Christopher wants to feed. Upon receiving your recommendations, she has been attempting to breastfeed with good technique every two to three hours with strong latching and vigorous suckling. She is still concerned her baby isn't getting enough to eat. Which of the following would be the most appropriate advice for mom? A. Continue to attempt breastfeeding B. Request a lactation consultation to ensure the baby gains weight C. Remain in the hospital until Christopher is having full and consistent feeds with breast milk D. Stop attempting to breastfeed and begin formula E. Switch from breast milk to formula for a few days to allow mom's body to produce more milk, and then attempt breastfeeding again

A. Continue to attempt breastfeeding

Ms. Jones is a first time mother who brings in her 5-day-old son Tommy for his first scheduled newborn visit. Upon reviewing Tommy's hospital records you note that mom's pregnancy was uncomplicated and that Tommy was born full term via spontaneous vaginal delivery and his birth weight was average for gestational age at 3000 grams. Per your discussion with mom, she has been breastfeeding successfully with good technique every two to three hours on demand since delivery. Tommy's physical exam is normal and largely unchanged from the hospital; he is at the 70th percentile for height and head circumference, but his weight has decreased to 2,750 grams. Mom is very concerned by this weight loss and wants to know what she should do. You should recommend: A. Continuing breast feeding with same frequency and return to clinic in 5-7 days B. Hospitalizing Tommy until he shows adequate weight gain for his age C. Increasing the frequency of breastfeeding until Tommy starts gaining weight D. Refer Ms. Jones and Tommy to a lactation consultant E. Supplementing breast milk with 1-2 oz of baby formula until Tommy starts gaining weight

A. Continuing breast feeding with same frequency and return to clinic in 5-7 days

A 51-year-old female comes to you with acute pain and swelling of the knee. Joint fluid analysis confirms the diagnosis of acute gout. She has a past medical history of atrial fibrillation, hypothyroidism, hypertension, and prior treatment for H. pylori infection. Her current medications include losartan, warfarin, levothyroxine, and omeprazole. She is allergic to penicillin medications. Recent laboratory studies revealed normal hemoglobin and hematocrit, blood urea nitrogen, and creatinine levels. Which of the following information from her history would dissuade you from initiating NSAID therapy? A. Currently on warfarin B. Her age C. Hypothyroidism D. Penicillin allergy E. Previous H. pylori infection

A. Currently on warfarin

A 35-year-old female with a history of tension-type headaches presents to your office with a headache that is not responsive to 400 mg Ibuprofen TID or 500 mg Tylenol TID. Upon gathering further history you find that in the past her headaches were controlled with these medications but recently have been worse with this same treatment. She complains of 4-5 headaches weekly that are often present on awakening. Which of the following is the best treatment for her disorder? A. Discontinue use of Ibuprofen and Tylenol B. Prescribe a different NSAID to take for acute headaches C. Prescribe an opioid medication to take for acute headaches D. Prescribe propranolol for headache prevention E. Prescribe sumatriptan to take as needed

A. Discontinue use of Ibuprofen and Tylenol

Mr. Gill is a 27-year-old male who presents to his primary care physician with post-prandial epigastric burning. The burning is episodic, without associated hematemesis, dysphagia, or odynophagia. In the past, he has episodically used an OTC chewable calcium carbonate to provide relief. Over the past month, he has had to increase the frequency of its use to four times daily. His blood pressure is 120/71 mm Hg. His pulse is 75 beats/minute and regular. Physical exam reveals minimal epigastric tenderness on palpation but is otherwise normal. Which of the following is the most appropriate next step in management? Choose the single best answer. A. Eight-week trial of pantoprazole once a day B. H. pylori IgG serologic testing C. Fecal immunochemical testing (FIT) D. Fecal occult blood testing (FOBT) E. Upper endoscopy with biopsy

A. Eight-week trial of pantoprazole once a day

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. Elevated blood pressure reading B. Secondary hypertension C. Stage 1 hypertension D. Stage 2 hypertension E. White coat hypertension

A. Elevated blood pressure reading

A 59-year-old patient comes to the local ER with a swollen, tender knee that started yesterday. He returned home two days ago from a five-day hike on the Appalachian Trail. He reports no recent or previous injury to the knee and any history of previous inflammatory joint disease. Vital signs: temperature is 36.5 C (97.7 F), pulse is 80 beats/minute, blood pressure is 139/75 mmHg, and respiratory rate is 22 breaths/minute. His lower extremities are marked with abrasions in various stages of healing. He holds the knee in full extension. The knee is swollen, reddened, and tender, and it feels warm. Which of the following is the most appropriate next step? A. Knee aspiration B. Magnetic resonance imaging (MRI) of the knee C. Prescription for colchicine D. Prescription for full-dose acetaminophen E. X-ray of the knee, including sunrise and standing films

A. Knee aspiration

You are seeing a 19-year-old female who suffered a knee injury playing soccer one day ago. The injury involved a sudden deceleration in which she planted her right foot in front of her while running, whereupon another athlete fell against her shin. She felt a pop and sudden pain. She had to be helped off the field and her knee swelled immediately. Today, she reports that she has considerable right knee pain with bearing weight and that her knee feels unstable at times. Her past medical history is unremarkable, and she takes no medications. On exam, her vital signs are perfectly normal. You conduct a knee exam. Which of the following exam maneuvers is most likely to be abnormal in this patient? A. Lachman test B. Laxity to valgus stress C. Laxity to varus stress D. McMurray test E. Posterior drawer test

A. Lachman test

A 52-year-old female with no past medical history presents to your office with amenorrhea. The patient states that her menstrual cycles previously occurred approximately every 28 to 34 days. However, she has not had a menstrual cycle for the last 10 months. She also reports insomnia and intermittent dysuria. She reports no headaches, abdominal pain, constipation or diarrhea, changes in hair distribution, or easy bruising. She has lost 15 pounds since her last visit eight months ago, which she attributes to improving her diet and beginning regular exercise. Which of the following tests or pairs of tests is used to confirm menopause? A. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) B. Prolactin and Thyroid Stimulating Hormone (TSH) C. Prothrombin time (PT) and international normalized ratio (INR) D. Testosterone and dehydroepiandrosterone sulfate (DHEA-S) E. Thyroid-stimulating hormone (TSH) and free T4

A. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)

A 26-year-old professional football player comes to the clinic with the concern of hair loss. On examination, the scalp is scaly and erythematous, and certain regions are purulent. There are several circular spots where the hair follicles are no longer present. KOH of skin shows hyphae. What is the most appropriate next step in the management of this patient? A. Oral griseofulvin B. Oral prednisone C. Punch biopsy of lesion D. Topical griseofulvin E. Topical prednisone

A. Oral griseofulvin

You are seeing a 55-year-old male 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 five minutes each time. He has not passed out during these episodes, but he has felt the need to sit down when they occur. Sitting calmly and waiting seems to make them go away. He reports no 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. Order a 48-hour Holter monitor B. Order an echocardiogram C. Order an exercise stress test D. Reassure him that his palpitations are likely benign and that he should focus on a healthy lifestyle E. Transfer him to the emergency department for admission to the hospital

A. Order a 48-hour Holter monitor

A 38-year-old female with a past medical history of sarcoidosis and recent completion of a six-month steroid taper 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. Order a plain x-ray B. Order complete blood count (CBC) C. Reassess in four weeks D. Recommend conservative management E. Refer to spine specialist

A. Order a plain x-ray

Mr. and Mrs. Thomas are first-time parents who have brought their 5-day-old newborn son into your office for his first visit. Mom's pregnancy, baby birth, and today's physical exam are all normal. Both parents are sharing the duties of feeding, cleaning, holding, and watching their son without any problems. When Mrs. Thomas steps out of the room to use the restroom, Mr. Thomas asks to speak with you privately. He wants to know if you can prescribe some antidepressant medication for his wife because since giving birth she hasn't been the same. She has been having mood swings multiple times a day, he has found her crying in bed at night after putting their son in his crib, and she gets very irritated and yells at her parents any time they try to help with the baby. What would be the most appropriate advice to give Mr. Thomas? A. This is known as the "postpartum blues"; is quite common for new moms; and is very likely to self-resolve. B. This behavior is very common and a mild antidepressant can help most women get through it. C. The behavior is uncommon at five days postpartum and mental health counseling should be considered. D. This behavior sounds dangerous and hospitalization is in order. E. You should challenge Mr. Thomas on whether he is helping enough with child care.

A. This is known as the "postpartum blues"; is quite common for new moms; and is very likely to self-resolve.

A 32-year-old female presents at your office for a preconception health visit. She is a G2P2, both deliveries were vaginal. Her first child was born with a neural tube defect. According to the USPSTF, what dosage of folate should this patient take daily before she gets pregnant? A. 1 mg B. 4 mg C. 8 mg D. 400 mcg E. 800 mcg

B. 4 mg

A 24-year-old G1P0 patient at 14 weeks presents with vaginal bleeding and abdominal cramping. On examination her vital signs are: blood pressure 120/75 mmHg, pulse 74/minute, temperature 36.9 C (98.4 F) taken orally, respiratory rate 18/minute, and oxygen saturation 99% on room air. On pelvic examination, there is a small amount of blood in the vagina, the cervical os is open, and there is no cervical or adnexal tenderness noted. On pelvic ultrasound, an intrauterine gestational sac with a yolk sac is seen. What is her diagnosis? A. Complete abortion B. Inevitable abortion C. Missed abortion D. Septic abortion E. Threatened abortion

B. Inevitable abortion (cervical os is open or dilated, bleeding in early pregnancy)

You are seeing a 34-year-old cisgender female with a history of eczema, seasonal allergies, and asthma. She is presenting for a follow-up of her asthma, which has been bothersome in the past four months. She has been needing her albuterol rescue inhaler several times per week, and she had a recent visit to the emergency department for an asthma exacerbation. She currently takes a moderate-potency inhaled corticosteroid twice daily and uses an albuterol metered-dose inhaler as needed. She demonstrates proper technique for self-administering these medications with a spacer. She also takes loratadine and intranasal fluticasone for her allergic rhinitis. She does not smoke, drink alcohol, or use illicit substances. She works as a bank teller and lives with her partner, who also does not smoke. They have no pets. On exam, her vitals are normal, her head and neck exams are normal, and she has very mild expiratory wheezing diffusely. Of the following, which is the most appropriate next step? A. Add a leukotriene receptor antagonist B. Add a long-acting beta agonist to her twice-daily inhaled corticosteroid C. Add theophylline D. Change the delivery of her inhaled medications from metered-dose inhalers to nebulized delivery. E. Refer her to an allergist for allergy testing and possible immunotherapy

B. Add a long-acting beta agonist to her twice-daily inhaled corticosteroid

A 61-year-old G4P4 female presents to a local emergency room with vaginal bleeding. The bleeding began two days ago and is described as spotting. She began her menses at age 16 and had regular menstrual cycles until the age of 59. She reports smoking ½ pack per day for the last 23 years and drinks 1-2 glasses of wine with dinner every evening. She reports no abdominal pain or dysuria. On exam, she has a blood pressure of 124/76 mmHg and a BMI of 18.2 kg/m2. Her pelvic exam reveals a small amount of dried blood in the vaginal vault and mildly atrophic vaginal mucosa. Which one of the following characteristics of this patient increases her risk of endometrial cancer? A. Age of menarche B. Age of menopause C. Body habitus D. Multiparity E. Smoking

B. Age of menopause

A 33-year-old G0P0 female presents to your clinic for her first prenatal visit. Her home pregnancy test was positive, she has been experiencing mild nausea for two weeks. Her last normal menstrual period was six weeks ago. What test should her initial prenatal visit include? A. Abdominal ultrasound B. Complete blood count C. Complete metabolic panel D. Glucose challenge test E. Quad screen

B. Complete blood count

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, respiratory rate 12 breaths/minute, BMI 29 kg/m2. He does not smoke cigarettes or use illicit substances, and he does drink one or two glasses of wine most evenings. He currently jogs three times a week for approximately 30 minutes at a time. He and his partner order takeout food for supper twice per week and otherwise cook at home. He does not particularly like vegetables, but he tries to eat a piece of fruit every day. 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 most likely to improve his cardiovascular risk? A. Alcohol cessation B. DASH eating plan C. Increased exercise D. Increasing dietary potassium E. Supplementation with vitamin D

B. DASH eating plan

A 32-year-old patient at 34 weeks and 5 days gestation (G2P1) presents to the clinic with headache and RUQ abdominal pain. Blood pressure is 172/121 mmHg on examination while seated. No visual changes noted. Edema is present in the hands, bilaterally. Urine dipstick demonstrated 4+ protein. FHT are 117. Which of the following is the most appropriate next step in the management of this patient? A. Daily aspirin B. Expedited delivery of the premature fetus C. Lisinopril D. Strict bed rest until 37 weeks E. Twice-weekly non-stress testing SUBMIT

B. Expedited delivery of the premature fetus

A 60-year-old female with a past medical history of chronic gout, depression, and stage 1 hypertension presents to your office for a follow-up visit. She has been attempting to reduce her blood pressure with behavioral changes but has had difficulty maintaining the changes. Today, her vital signs are blood pressure 144/90 mmHg, pulse 78 beats/minute, respiratory rate 12 breaths/minute. Recent basic metabolic panel was completely normal. As you consider starting a medication for her 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. Spironolactone

B. Hydrochlorothiazide

A 21-year-old G1P0 patient presents to the clinic as a new patient to establish prenatal care. Which statement represents something that would not be expected to be a benefit of group prenatal care for this patient? A. Decreases the likelihood of preterm delivery B. Increases adherence to techniques for pain management during labor C. Increases physician contact D. Increases support network E. Shared education between patients

B. Increases adherence to techniques for pain management during labor

A 48-year-old male with a past medical history that includes hypertension, chronic obstructive pulmonary disease (COPD), and hyperlipidemia presents to the clinic as a new patient in October for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently nonadherent with his medications. A review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient? A. Influenza, meningococcal, and zoster B. Influenza, pneumococcal, and Tdap C. Influenza, zoster, and Tdap D. Meningococcal, pneumococcal, and Tdap E. Meningococcal, pneumococcal, and zoster

B. Influenza, pneumococcal, and Tdap

A 55-year-old female with exercise-induced asthma, but no other chronic health problems, presents to the office with left shoulder pain. She is a tennis player, left-handed, and notices pain serving the ball. When you suggest that it might be her rotator cuff your preceptor asks, "what muscles make up the rotator cuff?" A. Supraspinatus, infraspinatus, teres major, subscapularis B. Supraspinatus, infraspinatus, teres minor, subscapularis C. Supraspinatus, infraspinatus, teres minor, deltoid D. Supraspinatus, infraspinatus, teres major, teres minor E. Supraspinatus, infraspinatus, teres minor, rhomboid minor

B. Supraspinatus, infraspinatus, teres minor, subscapularis

You are seeing a 92-year-old male in the hospital. He was admitted after a fall in which he broke his hip. It is now post-op day two from surgery to repair the fracture. His children report that he has been very confused this morning, with varying levels of alertness. Yesterday, he had been recovering well and even participated in physical therapy. Today, he does not know where he is and is at times combative with his care team. His medical history is positive only for hypertension. His medications include amlodipine 5 mg daily and morphine 4 mg IV every 4 hours as needed for pain. His vital signs are all normal today, and his general exam is unremarkable except for expected postoperative changes to his hip. He is somnolent during the examination. Today's labs include a normal CBC and basic metabolic panel. A urinalysis reveals no leukocyte esterase and is nitrite negative. What is the most likely cause of his current mental status? A. Acute stroke B. Morphine C. Pneumonia D. Residual effects of the anesthetic medications from his surgery E. Urinary tract infection

B. Morphine

A 68-year-old male with a past medical history significant for hypertension and diabetes presents to your office with a three-month history of headaches. He describes a pain that has occasionally awoken him from sleep and is often worse in the morning. He reports no weakness or changes in vision. His exam shows 4+ reflexes in the right upper and lower extremities but is otherwise normal. What is the best next step in management for this patient? A. Initiate treatment with sumatriptan B. Neuroimaging C. Reassurance D. Referral to counselor for relaxation exercises E. Sleep study

B. Neuroimaging

A 27-year-old G0P0 female presents to your office with abdominal pain, fever and vaginal discharge. The discharge has an abnormal odor. She reports a new, male, sexual partner. On pelvic exam, there is cervical motion tenderness and adnexal pain during the bimanual exam. The strings from her IUD, placed two years ago, are seen coming from the os. A cervical culture is positive for Chlamydia trachomatis. What risk factor for chlamydia infection is present in this patient? A. Age B. New sexual partner C. Nulliparity D. IUD E. Sexual orientation

B. New sexual partner

A 63-year old cisgender female comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago; both were normal. She has never had an abnormal Pap test. At the age of 45 she had a total hysterectomy for fibroids. Of the details provided about this patient, which is an appropriate reason to explain why she does not need a Pap test today? A. She experienced menopause more than 10 years ago B. She had a total hysterectomy for fibroids C. She has never had an abnormal Pap test D. She is 63 years old E. She is not sexually active

B. She had a total hysterectomy for fibroids

A 61-year-old patient 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.

B. Start amlodipine daily.

Ms. Brady, a 78-year-old female presents to your office after six months for follow-up. Her interval history is significant for a TIA three months ago. Today her Montreal Cognitive Assessment (MoCA) is 19. You note that six months ago her MoCA was 22, and nine months ago it was 26. Physical exam shows temperature of 37.1 C (98.8 F), blood pressure of 167/95 mmHg, pulse of 76 beats/minute, respiratory rate of 14 breaths/minute, and BMI of 23. Chest: regular rate and rhythm, no murmurs; lungs: clear to auscultation; neuro: weakness in the right upper extremity; abdomen: soft, non-tender. She takes atorvastatin and aspirin. Lab studies show Hgb A1c: 5, TSH: 3, B12: 500 pg/mL. Which of the following is the most important recommendation to prevent further disability in this patient? A. Order a mammogram B. Start hydrochlorothiazide C. Start metformin D. Start vegetarian diet E. Weight loss

B. Start hydrochlorothiazide

A 60-year-old comes into the clinic for a walk-in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn't know why but she has been very sad of late. Reports trouble falling asleep and staying asleep. Used to be the head of her Bridge club, but quit two weeks ago and doesn't feel like going out anymore. She has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. Feels weak and fatigued and no longer has the energy to do her gardening or shopping. Spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. Denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A, and CT of the head were all within normal limits. How long do the above symptoms need to be present in order to make the diagnosis of Major Depressive Disorder? A. One week B. Two weeks C. Four weeks D. Five weeks E. Eight weeks

B. Two weeks

A 47-year-old patient presents to the clinic complaining of an "itchy patch" on her skin. On further examination, you note a solid, elevated, flat-topped, 1.5 cm lesion on the extensor surface of the right forearm. How would you best describe the lesion? A. Nodule B. Macule C. Papule D. Patch E. Plaque

E. Plaque

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

C. A 52-year-old female with new atypical chest pain with a history of elevated cholesterol, smoking and family history of coronary artery disease

14-year-old Jennifer is brought to the clinic by her mother who is concerned about ADHD. She states Jennifer lacks motivation, regularly does not clean her room and has to be reminded to do chores around the house. She also is concerned Jennifer does not listen to her and avoids doing homework. Which of the following would most strongly support additional evaluation to assess for ADHD? A. A diagnosis of major depression B. A report card with good grades C. A teacher's report of inattentive behavior D. Fidgety behavior in the car when driving long distances E. Symptom onset with entry to high school

C. A teacher's report of inattentive behavior

Ms. Martinez, a 74-year-old female, is brought to your clinic by her husband. He is concerned because his wife, who used to take pride in keeping the house in good shape, has stopped cleaning and caring for her appearance. She recently went shopping and left the stove on. She frequently misplaces her car keys and checkbook. Ms. Martinez reports trouble concentrating and does not have much energy. She has a poor appetite and no longer enjoys knitting. Her Montreal Cognitive Assessment (MoCA) is 28/30. Physical exam: General appearance: well-nourished, appears stated age; HEENT: pupils equal, round and reactive to light, moist mucous membranes; chest: normal S1 and S2, no murmurs; lungs: clear to auscultation bilaterally; abdomen: soft, nontender, non-distended; extremities: no cyanosis, no clubbing; neurologic: no focal deficits; psychiatric: flat affect. Labs: TSH: 2; WBC: 6.0; HgbA1c: 4.5. Which of the following is the most likely diagnosis? A. Delirium B. Dementia C. Depression D. Hypoglycemia E. Normal bereavement

C. Depression

A 55-year-old male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back that appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? A. Borders B. Color C. Diameter D. Location E. Symmetry

C. Diameter

A 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension presents with lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of systems, he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. He has never smoked. Vital signs: temperature is 38 °C (100.4 °F), blood pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15 breaths/minute. Given this history, which of the following physical exam maneuvers would be the most helpful in making the diagnosis? A. Abdominal palpation B. Auscultation for an abdominal bruit C. Digital rectal exam D. Pinprick sensation of the legs E. Straight leg test

C. Digital rectal exam

A 24-year-old G1P0 patient at 38 weeks gestation presents to ED complaining of strong lower abdominal contractions that are 10 minutes apart for the last hour. Subsequent cervical examination demonstrates that she is 2cm dilated. FHT is 140 and NST is non-reactive with early decelerations. What is the most appropriate management of this patient? A. Augment labor with oxytocin (Pitocin) B. C-section C. Expectant management D. Immediate vacuum delivery E. Rupture membranes to increase labor

C. Expectant management

A 25-year-old patient presents to the office for follow-up on anxiety and tobacco dependence. She reports she is doing well on her new medication to help with both her mood and smoking, though she continues to smoke. She recently started her first sexual relationship with a new female partner. She received a tetanus vaccine at the age of 18, and she received her flu vaccine this year. Her blood pressure is 122/70, and her physical exam is within normal limits. You review her recent Pap test, which was negative. Which of the following indicates the vaccines she should receive today? Choose the single best answer. A. HPV vaccine alone B. HPV vaccine and pneumococcal conjugate vaccine (PCV13) C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23) D. HPV vaccine and Zoster vaccine E. No vaccines are needed

C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23)

A 52-year-old female with a history of diabetes and rheumatoid arthritis presents for a health maintenance visit. 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 a 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 artery disease (CAD) that this patient has? A. Age B. Family history C. Hypertension D. Obesity E. Rheumatoid arthritis

C. Hypertension

A 42-year-old patient 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. Basal insulin B. GLP-1 receptor agonist C. Metformin D. SGLT2 inhibitor E. Sulfonylurea

C. Metformin

A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 177.8 cm (70 in) and weighs 99.8 kgs (220 lbs), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? A. Ideal B. Morbidly (very severely) obese C. Obese D. Overweight E. Underweight

C. Obese

Mr. Rodriguez is a 32-year-old male who presents with three months of postprandial epigastric burning. He reports no relief with antacid therapy. He has no allergies and no significant past medical history. He reports no hematemesis, odynophagia, dysphagia, hoarseness, or sore throat. Physical exam is unremarkable other than epigastric tenderness. H. pylori IgG serology is positive. Which of the following treatment regimens will most likely be successful in treating Mr. Rodriquez? Choose the single best answer. A. Omeprazole daily for eight weeks B. Omeprazole twice daily for four weeks C. Omeprazole twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily for 14 days D. Omeprazole daily, clarithromycin 500 mg twice daily, and tetracycline 500 mg three times daily for 14 days E. Omeprazole twice daily, tetracycline 500 mg three times daily, and metronidazole 500 mg twice daily for 10 days

C. Omeprazole twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily for 14 days

A 31-year-old patient, G1P0 at 26 weeks gestation, presents to the clinic for her gestational diabetes screening. Her pregnancy has been uncomplicated. Vital signs are stable. Which of the following would require a follow up three-hour glucose tolerance test? A. Fasting serum glucose concentration of 91 mg/dL B. One-hour serum glucose concentration of 128 mg/dL C. One-hour serum glucose concentration of 158 mg/dL D. Two-hour serum glucose concentration of 134 mg/dL E. Three-hour serum glucose concentration of 136 mg/dL

C. One-hour serum glucose concentration of 158 mg/dL

A 53-year-old female with a past medical history of diet-controlled hypertension presents to the office with a two-month history of worsening hot flashes. Her menstrual cycles are regular, occurring every 30 to 32 days, but they have gradually lessened in duration, now lasting four to five days instead of the previous six to seven days. Vital signs and physical exam are normal. Which one of the following treatments is most likely to improve the patient's symptoms? A. Black cohosh B. Gabapentin C. Oral estrogen D. Venlafaxine E. Yoga

C. Oral estrogen

A 56-year-old female with a past medical history significant for hypothyroidism, breast cancer, and recurrent urinary tract infections presents to the office to discuss dyspareunia and hot flashes that began approximately one year ago. Her last menstrual cycle was 14 months ago, and her family history is significant for a deep vein thrombosis in her sister, diagnosed at the age of 47. She has become increasingly bothered by the frequency of her hot flashes and has stopped attending social events with her friends due to these symptoms. Her past surgical history includes a left lumpectomy. She smokes one pack per day of cigarettes and drinks alcohol only on special occasions. Which one of the following recommendations to address her menopausal symptoms would be most appropriate for this patient? A. Combined oral estrogen and progesterone daily. B. Oral estrogen daily. C. Oral venlafaxine daily. D. Oral venlafaxine daily and vaginal estrogen cream twice per week E. Vaginal estrogen cream alone.

C. Oral venlafaxine daily.

You are seeing a 33-year-old male who presents with several weeks of gradually worsening headaches that he describes as severe and upsetting. They tend to occur three to four times per week and get worse as the day goes on. He describes them as feeling "like a vice squeezing my whole head." He has tried ibuprofen for them, and it has helped some. Unfortunately, he never has ibuprofen with him at work where the headaches are more common, because his new boss does not allow medications to be kept at work without a doctor's note. He reports no nausea, vomiting, lacrimosis, or photophobia. He is not awakened from sleep by the headaches. He appears mildly distressed, and his vital signs are normal. Examination of his head and neck, fundic discs, and cranial nerves is broadly normal. What is the most appropriate step in management of his headaches? A. Instruct the patient to discontinue ibuprofen, as it is causing medication overuse headaches. B. Order a CT scan of the patient's head to rule out intracranial pathology. C. Prescribe ibuprofen to be taken as needed and provide a note for work. D. Prescribe propranolol to be taken as migraine prophylaxis. E. Prescribe sumatriptan as needed and provide a note for work.

C. Prescribe ibuprofen to be taken as needed and provide a note for work.

James is brought in by his mother and father today for a well-child visit. His mother had a normal term pregnancy and uncomplicated spontaneous vaginal delivery. Thus far James has been meeting all his developmental milestones. Today James can feed himself, easily pedal a tricycle, uses three-five word sentences, can be understood by strangers 75% of the time, can copy a square, takes turns in games, and engages in fantasy play with his siblings. At what developmental age is James? A. 1 year B. 18 months C. 2 years D. 3 years E. 6 years

D. 3 years

A 28-year-old, G2P1 patient delivers a 6 lb., 7oz. baby boy at 39 weeks gestation. At one minute, the baby has blue extremities and a pink body; his arms and legs are flexed and he is moving them vigorously with prompt response to stimulation; HR is 118 bpm and he is coughing and crying vigorously as well. What would his APGAR score be at one minute? A. 6 B. 7 C. 8 D. 9 E. 10

D. 9

A 64-year-old cisgender female who is overweight with well-controlled hypertension comes to your office with concerns of a lump in her breast that she noticed while showering. She reports having no pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 31 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer? A. Age B. Age at first birth C. Age at menarche D. Age at menopause E. Weight

D. Age at menopause

A 65-year-old patient 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 is 38.1 °C (100.6 °F) Pulse is 102 beats/minute Respiratory rate is 16 breaths/minute Blood pressure is 90/74 mmHg He responds when you say his name, and he appears well-nourished. His mucous membranes appear very dry. A 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. Hyperosmolar hyperglycemic state (HHS)

A 37-year-old male who drives a delivery truck presents to your clinic after acute onset of severe lower back pain that 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 additional physical exam finding would be consistent with this man's level of disc herniation? A. 2/5 strength on hip flexion B. Decreased range of motion on lumbar extension C. Decreased rectal tone D. Hypoactive ankle tendon reflex E. Positive Stoop test

D. Hypoactive ankle tendon reflex

An 82-year-old presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; reports decreased enjoyment of his activities, such as playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He reports no suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife's voice while going to bed. He says he goes to church to pray. You are trying to determine if your patient's symptoms are normal grief or if you should diagnose and treat him for Major Depressive Disorder (MDD). Which feature of Mr. Jones' case would suggest MDD rather than a normal grief reaction? A. Change in appetite B. Fatigue C. Hearing wife's voice D. Inability to experience any pleasure E. Insomnia

D. Inability to experience any pleasure

A 36-year-old patient, G3P2 at 21 weeks gestation, returns to the clinic for an ultrasound. She currently smokes a half pack of cigarettes per day. Her last two children were delivered by cesarean section. She reports no vaginal bleeding, no urinary symptoms, and no fluid leaking. She states her baby moves "all the time." Her vitals reveal a blood pressure of 130/74 mmHg, a temperature of 36.8 oC (98.3 oF), a pulse of 82, a respiration rate of 18, and a pulse oximetry of 98%. The ultrasound reveals no fetal abnormalities, but the location of the placenta is partially covering the cervical os. The diagnosis and treatment plan is: A. Placenta previa with admittance to the hospital for fetal and maternal monitoring B. Placenta previa with immediate cesarean section C. Placenta previa with reassurance that no additional monitoring is needed D. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution E. Uncomplicated pregnancy

D. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution

A 57-year-old patient comes in, concerned about a 1.5 cm dark multicolored mole lateral to her left eye that has been increasing in size over the past six months. A punch biopsy shows pathology indicative of squamous cell carcinoma. What is the most appropriate intervention? A. Avoid artificial sources of UV light, such as indoor tanning B. Cryotherapy extending 4 mm beyond the lesion margins C. Excisional biopsy extending 5 mm beyond lesional border D. Mohs surgery E. Three-month follow-up visits for the first year; then every six months

D. Mohs surgery

A 24-year-old patient presents to the clinic complaining of nausea and headache for the last week. She reports no fever, changes in bowel movements, or sinus symptoms. She is sexually active with one partner and admits to not being consistent with her birth control pills. She does not remember the date of her last menstrual period and reports a history of irregular menstrual cycles. She has not taken a home pregnancy test. Her vital signs reveal a blood pressure of 124/76 mmHg, a pulse of 78/min, respirations of 20/min, temperature of 36.7 oC (98.1 oF, taken orally), and an oxygen saturation of 98% on room air. The first most appropriate step in management is to: A. Admit the patient to the hospital for monitoring. B. Ask the patient to return to the clinic after she has taken a home pregnancy test and prescribe Zofran 8mg to control her nausea. C. Obtain a serial serum hCG. D. Obtain a urine hCG. E. Perform a pelvic exam to test for sexually transmitted infections.

D. Obtain a urine hCG.

Samantha and Joe bring in their newly adopted 5-year-old son, Matthew, to your office with the chief concern of a sore throat, that began two days ago. He was born in the United States and was neglected by his biological parents. Samantha and Joe believe Matthew lived in an old building and ate mostly non-nutritious meals. He is behind on routine immunizations. Upon physical exam, he is playful and interactive but is frequently coughing. His vital signs are: Temperature: 37.2 °C (99.0 °F); pulse: 80; respiratory rate: 19, blood pressure: 95/63 mmHg. He has tender anterior cervical lymphadenopathy, tonsillar exudates, and palatal petechiae. Which pairing contains the most appropriate next steps in the management of this patient? A. Empiric antibiotic treatment and do NOT recommend immunizations today B. Empiric antibiotic treatment and recommend immunizations today C. Rapid strep test and do NOT recommend immunizations today D. Rapid strep test and recommend immunizations today E. Reassurance and follow-up in one week

D. Rapid strep test and recommend immunizations today

Working at your clinic, you receive a call from a patient of yours, 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. Ask him to double the dosage of his muscle relaxants B. Obtain a plain film x-ray C. Order an MRI D. Reassure him and schedule a follow-up appointment in a few days E. Schedule him for an appointment immediately

D. Reassure him and schedule a follow-up appointment in a few days

Ms. Smith is a 38-year-old female with a significant past medical history of hypercholesterolemia who presents to her primary care physician after four weeks of episodic epigastric discomfort. She reports a recurrent ache-like sensation in the epigastric region occurring about 10 minutes after eating and lasting for several hours. The pain does not appear to be associated with any particular food. She reports no odynophagia or dysphagia. Ms Smith is a smoker, with a 30-pack-year history. You are concerned about peptic ulcer disease. Which additional history finding would increase your level of suspicion? Choose the single best answer. A. Report of hoarseness B. Epigastric discomfort associated with recumbency or bending C. Bouts of recurrent laryngitis D. Recurrent symptoms despite consistent use of antacids E. Sour or bitter taste in mouth

D. Recurrent symptoms despite consistent use of antacids

You are seeing a 62-year-old male with a history of osteoarthritis in his knees and well-controlled hypertension and chronic constipation. His arthritic pain has been disabling in recent months, making it very difficult for him to do his work as a plumber. He has tried full dose acetaminophen in combination with diclofenac, but he still reports 8/10 pain and stiffness. He would like to pursue other treatment options. His current medications include chlorthalidone, diclofenac, acetaminophen, and methylcellulose. On exam, he is in no acute distress and his vital signs are normal. His knees show no warmth, erythema, or gross deformity. They are stable to varus and valgus stress. The Lachman test and McMurray test are both normal. There is moderate crepitus bilaterally. Which of the following would be the most appropriate next step in the management of his pain? A. Prescribe a glucosamine sulfate and chondroitin sulfate combination pill B. Prescribe amitriptyline nightly C. Prescribe oxycodone after reviewing a pain management agreement and performing a urine drug screen D. Refer to physical therapy for strength and mobility training E. Schedule for bilateral intra-articular hyaluronic acid (viscosupplementation) injections

D. Refer to physical therapy for strength and mobility training

Ms. Jones, a 35-year-old female with a significant past medical history of SLE who had been on NSAID therapy for the previous three months, presented four weeks ago with heartburn. At that time, she reported episodic, mealtime epigastric burning radiating to the throat for the past few months. She has had no surgeries. Serologic testing for H. pylori IgG was reported to be positive a few days after her visit and she was begun on triple therapy. She now returns to the office for follow-up. Today she reports no epigastric burning or tenderness. Physical exam is not significant. Which of the following is an accepted indication for performing repeat testing at this visit for H. pylori eradication? Choose the single best answer. A. Age below 40 years B. Documentation is required for all patients with confirmed H. pylori infection C. Positive serologic test prior to therapy D. Restarting of chronic NSAID therapy for SLE E. Treatment with triple rather than quadruple therapy

D. Restarting of chronic NSAID therapy for SLE

A 41-year-old male presents to the clinic with left shoulder pain after a fall where he caught himself with his left arm. To assess the injury the patient's arms were placed in 30 degrees of horizontal forward flexion and his shoulders were abducted to 90 degrees. The patient attempted to resist downward pressure and was unable to do so. This test assesses the integrity of the: A. Biceps tendon B. Deltoid muscle C. Infraspinatus muscle D. Supraspinatus muscle E. Teres minor muscle

D. Supraspinatus muscle

You are seeing a 56-year-old male who presents with daily headaches for the past two weeks. He describes them as an intense pressure behind both eyes that is throbbing in nature. He reports that lights and loud noises bother him some, but he has been able to tolerate his usual activities as a short-haul truck driver. The headaches tend to last all day. He has not had nausea, visual changes, fever, or chills, though he has reported rhinorrhea. These symptoms have occurred in the context of him quitting tobacco, which he has found difficult. He read online about cluster headaches, and he thinks that is what he is experiencing. He would like you to prescribe oxygen treatment to help with the headaches. What aspect of this patient's story is most typical of cluster headaches? A. His pain is periorbital and bilateral. B. His photophobia and phonophobia. C. The throbbing quality of his pain. D. They are associated with rhinorrhea E. They typically last all day

D. They are associated with rhinorrhea

An otherwise healthy 57-year-old G2P2 female presents to your office with vaginal bleeding that began one week ago. She began her menses at age 13 and had regular menstrual cycles until the age of 49. She reports no tobacco or alcohol use. Further review of systems is negative. Her vital signs are normal, and her BMI is 27.8 kg/m2. Her pelvic exam reveals a small amount of dried blood in the vaginal vault and mildly atrophic vaginal mucosa. Which of the following is the most appropriate next step? A. Endometrial ablation B. Reassurance C. Referral for hysterectomy D. Transvaginal ultrasound E. Trial of oral contraceptives

D. Transvaginal ultrasound

A 27-year old patient, G2P1, returns to the clinic for her second prenatal visit. Her labs reveal that her blood type is A Rh-. She states she has done research online and is concerned that this pregnancy will result in her baby dying if it has a different blood type than her own. To reassure the patient, you explain that her team of health care providers will: A. Perform a cesarean section to prevent fetal demise B. Treat the baby with Rhogam within the first 72 hours after delivery to prevent hemolytic anemia of the newborn C. Treat the mother with penicillin during labor to prevent transmission of gram-positive bacteria D. Treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum. E. Treat the mother with Rhogam when she is at 28-weeks gestation to prevent thalassemia in the newborn, and if it is determined the neonate is Rh+ the mother will receive a second dose of Rhogam postpartum

D. Treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum.

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. 35-year-old male with chest pain radiating down his left arm after falling off a ladder at work one week ago C. 42-year-old female with a pulsating pain in the center of her chest at night D. 55-year-old female with diffuse central chest pain that is worse when lying down E. 59-year-old female with palpitations that increase with exercise and are associated with nausea and vomiting

E. 59-year-old female with palpitations that increase with exercise and are associated with nausea and vomiting

You are seeing a 32-year-old patient at 34 weeks gestation for a routine prenatal visit. Her pregnancy has been uncomplicated, and she is up to date on her immunizations and screening. She is feeling well today, reporting regular fetal movement. She reports no vaginal bleeding, leaking of fluid, and contractions. She plans to breastfeed after delivery. Her vital signs are all normal today. You engage in a discussion of postpartum contraception options with her. Which of the following would be recommended as a method of contraception? A. Combined oral contraceptive starting immediately postpartum B. Combined oral contraceptive starting six weeks postpartum C. Depo-levonorgestrel injections starting now, and every three months subsequently D. Etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) starting immediately postpartum E. Levonorgestrel intrauterine device (IUD) inserted immediately after delivery of the placenta

E. Levonorgestrel intrauterine device (IUD) inserted immediately after delivery of the placenta

A 15-year-old female with a history of allergic rhinitis presents to the clinic with a five-day history of productive cough and wheezing that is worse at night. She reports no shortness of breath, chest pain, or fever. The patient states that she has had similar symptoms in the past, especially when seasons change. The only reported past medical history is atopic dermatitis, which is well-controlled with an over-the-counter steroid cream. Her vitals are: temperature is 36.8 C (98.2 F), pulse is 96 beats/minute, respiratory rate is 20 breaths/minute, oxygen saturation is 98%, blood pressure is 110/72 mmHg. She is in no acute distress and is breathing comfortably. On auscultation, there are some mild wheezes on expiration but air movement is good. What is the best next step? A. Prescribe a daily corticosteroid and long-acting beta agonist inhaler B. Prescribe a daily corticosteroid inhaler C. Prescribe a long-acting beta agonist inhaler D. Prescribe antibiotic therapy E. Prescribe a short-acting beta agonist inhaler with a short course of oral steroids

E. Prescribe a short-acting beta agonist inhaler with a short course of oral steroids

A 12-year-old patient is brought to the clinic with a pruritic, red, scaly rash in the creases of his elbows. He reports no new topical exposures and generally feels well. He has a history of seasonal allergies. Which of the following is the most appropriate course of action? A. Ask the patient to return to the clinic after three days B. Biopsy the skin lesion C. Prescribe oral antibiotics D. Prescribe oral corticosteroids E. Prescribe topical corticosteroids

E. Prescribe topical corticosteroids (sounds like eczema)

The Aronsen family bring their 3-week old newborn for an acute visit because his parents express worry that "something is not right." They report vomiting, which seems more than the post-feeding "dribbles" they were used to with their prior children. The baby seems more irritable and less easily consoled. They deny stool changes, fever, rash, sick contacts, or decrease in frequency of feeds. They notice that he has fewer wet diapers overall. You are concerned that, on exam, the infant does not appear as well as one week prior when he underwent his routine 2-week well baby visit. His weight has increased slightly over the past week, but not as much as expected on the growth curve. He appears to be mildly dehydrated and lethargic, but you find no other distinct physical exam signs. What is the most likely diagnosis? A. Colic B. Failure to thrive C. Gastroesophageal reflux D. Intussusception E. Pyloric stenosis

E. Pyloric stenosis

You are on call over the weekend for the pediatric clinic and a concerned mother calls in. She has three children at home, her youngest being a 5-week-old. She's very busy and about to leave town on Monday to visit relatives out of state. She tells you that for the last week her two oldest children have had a cough, runny nose, and one or two fevers as high as 38.4 C (101.2 F), but these symptoms have improved in both children with Tylenol. Her youngest child is now having the same symptoms and has a temperature of 38.1 C (100.5 F). Because they're about to go out of town, the mother wants to know if you can call in something stronger like an antibiotic so her youngest can feel better sooner. What is the most appropriate step in managing this child? A. Call in a prescription for amoxicillin as this will cover the likely causative organisms for this infection B. Call in a prescription for a cough syrup so both child and mom can get more sleep. C. Continue to use Tylenol as needed for fevers and supportive care D. Educate mom that this is likely a viral infection and it will have to run its course E. Recommend that the infant be evaluated immediately in your office or the nearest emergency department

E. Recommend that the infant be evaluated immediately in your office or the nearest emergency department

A 68-year-old male becomes confused and agitated on post-operative day three after open cholecystectomy. He does not recall his surgery or where he is, and he wants to leave the hospital. Physical exam shows a temperature of 37.7 C (99.9 F), blood pressure of 143/89 mmHg, pulse of 90 beats/minute, respiratory rate of 13 breaths/minute, and O2 sat of 98% on room air. He appears agitated and uncomfortable. He has a Foley catheter. His physical exam is unremarkable. Labs: WBC-11,000, Urinalysis: 2+ nitrites and 2+ leukocyte esterase, 10 WBC/hpf. Glucose finger stick: 80, ECG: normal sinus rhythm at 88 beats per minute. Which of the following is the best initial step to help relieve the patient's symptoms? A. Give IV ceftriaxone B. Give oral ceftriaxone C. Order urine culture D. Order urine gram stain E. Remove urine catheter

E. Remove urine catheter

You are seeing one of your regular patients, a 65-year-old female, for a follow-up appointment for intractable knee pain from osteoarthritis. The knee pain has not responded to ibuprofen or acetaminophen. She has a past medical history that also includes obesity, diabetes, hypertension, and depression. Her current medications include aspirin, HCTZ, metformin, and duloxetine. You are considering prescribing tramadol. She has never taken any kind of opioid medication in the past. Which of the following potential problems should you inquire about when adding tramadol? A. Hypercoagulability B. Hypotension C. Rash D. Recent hyperglycemia E. Seizures

E. Seizures

An 18-year-old nonsmoking male comes to the clinic with cough, chest tightness, and difficulty breathing that has gradually worsened over the proceeding three days. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough, primarily at night, since he was four years old. He has no past surgical history and no recent travel. On physical exam, you notice the patient appears in mild distress, has hunched shoulders, is using accessory muscles during respiration, and is only able to talk in two to three-word sentences. His vitals are: temperature is 36.9 C (98.4 F), pulse is 125 beats/minute, respiratory rate is 28 breaths/minute, oxygen saturation is 88%, blood pressure is 100/70 mmHg. On auscultation, you hear wheezing on inspiration and expiration throughout both lungs. You also notice a prolonged expiratory phase. What is the most likely diagnosis? A. CHF exacerbation B. Cystic Fibrosis C. Foreign body aspiration D. Pulmonary embolism E. Severe asthma exacerbation

E. Severe asthma exacerbation

A 65-year-old with a past medical history of type 2 diabetes, hypertension, and hypercholesterolemia presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. Her height is 157 cm (62 in), and weight is 113 kg (250 lbs), BMI = 45.8 kg/m2. When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly? A. Asymptomatic coronary artery disease B. Chronic sinusitis C. Hypoparathyroidism D. Pneumonia E. Sleep Apnea

E. Sleep Apnea

A 42-year-old male accountant with a significant past medical history of obesity 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 reports no 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. Abnormal gait B. Increased pain with coughing C. Loss of ankle jerk D. Point tenderness on spinous processes E. Spasm of paraspinal muscles

E. Spasm of paraspinal muscles

A 47-year-old cisgender female comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34, and the remainder of her physical exam is within normal limits. Her vaccinations are up to date, and she has a Pap test today and will have labs drawn. According to USPSTF, which of the following is the best recommendation to give her concerning mammography? A. Should have started at age 40 and every year thereafter B. Should have started at age 40 and every two years thereafter C. Should have started at age 45 and every year thereafter D. Start at age 50 and every year thereafter E. Start at age 50 and every two years thereafter

E. Start at age 50 and every two years thereafter

A 72-year-old patient with a 30-year history of type 2 diabetes and hypertension returns to your office for a 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 and lisinopril 40 mg daily. She is on no other medications. Her A1C is 6.5% and her BP today is 145/90. She notes blurry vision for the past several months and a few days of dark spots in her vision. She reports no 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. Start her on a calcium channel blocker.

Tim is a 15-year-old who comes to the clinic with his father, who is concerned Tim has Strep throat. Tim has felt tired for the past day, has a sore throat, scratchy eyes, and dry cough. On exam, his temperature is 38.6 °C (101.5 °F), pulse 75, respiratory rate 14, and blood pressure 110/65 mmHg. His pupils are equal, round, and reactive and his conjunctivae are clear. He has increased tearing in both eyes. His nares are patent with mild erythema. His oropharynx is erythematous without tonsillar enlargement or exudate. He does not have tender or swollen anterior cervical lymph nodes. What is the most appropriate course of action? A. Empiric antibiotic therapy for Strep pharyngitis B. Heterophile antibody test for infectious mononucleosis C. Rapid Antigen Detection Test for Strep pharyngitis D. Strep throat culture E. Symptomatic management without further testing

E. Symptomatic management without further testing

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 and 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 class of medication to begin in this patient? A. Alpha agonist B. Beta-blocker C. Loop diuretic D. Nitrate E. Thiazide diuretic

E. Thiazide diuretic

A 25-year-old female presents with vaginal bleeding and cramping. Her last normal menstrual period was six weeks ago. The patient's vital signs are stable. On speculum exam of the vagina, there is no bleeding from the cervix. A quantitative beta-human chorionic gonadotropin (beta-hCG) level is 1492 mIU/ml. The patient is sent home and told to return to the office in 48 hours. Her beta-hCG on the return visit is 3000 mIU/ml. What is the appropriate next step in the management of this patient? A. Dilation and curettage for non-viable pregnancy B. Methotrexate for ectopic pregnancy C. Progesterone level to confirm pregnancy D. Surgery for ectopic pregnancy E. Ultrasound to confirm intrauterine pregnancy

E. Ultrasound to confirm intrauterine pregnancy

A 64-year-old patient comes in for a routine physical examination. He notes that over the past few months he has had to get up to urinate in the middle of the night. Benign prostatic hypertrophy (BPH) is on your differential. What other symptom is consistent with BPH? A. Cloudy penile discharge B. Dysuria C. Erectile dysfunction D. Hematuria E. Urinary urgency

E. Urinary urgency

You are seeing a 27-year-old cisgender male with a past medical history of acne and generalized anxiety disorder who presents for a follow-up visit for one year of gradually worsening dyspnea, cough, and wheezing. At his prior visit, his physical exam revealed mild diffuse expiratory wheezing. He was prescribed an albuterol inhaler, and pulmonary function tests (PFTs) were ordered. Today he reports feeling no better. The inhaler has not seemed to improve his symptoms. He is a non-smoker, and he does not use alcohol or illicit substances. On exam, he is mildly anxious, has normal vitals, has a normal head and neck exam, and has mild diffuse wheezing. His recent PFTs reveal mild flattening of the inspiratory portion of the flow-volume loop, a normal FEV1/FVC ratio, and no reversibility of findings with the administration of albuterol. Of the following, which is the most likely diagnosis? A. Asthma, mild intermittent B. Asthma, moderate persistent C. Chronic sinusitis D. Upper airway cough syndrome E. Vocal cord dysfunction

E. Vocal cord dysfunction

A 34-year-old cisgender female who has no past medical problems and is not currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has a maternal aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children, aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago, and her other vital signs are stable. On breast exam, you note a mobile rubbery mass approximately 1 x 1cm that has regular borders and is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following puts this patient at increased risk for breast cancer? A. Age B. Age of menarche C. Family history of cancer D. Parity history E. Weight

E. Weight

A 23-year-old epileptic male presents to the emergency department after a generalized tonic-clonic seizure. You notice that the patient is holding his right shoulder and that his arm is adducted and internally rotated. What is the best imaging modality for this type of injury? A. CT scan B. MRI C. PET scan D. Ultrasound E. X-ray

E. X-ray