HippoEd: Family Medicine

parental refusal of routine vaccinations

A 1-year-old boy is brought to the office by his mother because he has had fever and nonproductive cough for the past five days. Temperature is 39.0°C (102.2°F), pulse rate is 124/min, respirations are 42/min, and blood pressure is 80/64 mmHg. Oxygen saturation is 88% on room air. The patient appears ill. Physical examination shows increased work of breathing with mild intercostal retractions. Diminished breath sounds are heard over the right upper lobe. Pneumonia is suspected. Which of the following additional findings on history taking is most likely to increase this patient's risk for this invasive disease? A. Family history of a sibling with congenital heart disease B. Maternal history of sickle cell trait C. Parental refusal of routine vaccinations D. Personal history of asthma E. Personal history of chronic granulomatous disease

budesonide-formoterl as needed **asthma

A 12-year-old girl is brought to the clinic by her father because she has had episodes in which she has difficulty breathing during the past year. She says she has wheezing, coughing, and difficulty breathing when she is exposed to cats. These symptoms occur about once a month but more often during the winter months. She has no history of nighttime awakenings and has never been hospitalized or intubated. The family does not have any pets. The patient is currently asymptomatic since it is spring. Pulse rate is 90/min, and blood pressure is 110/78 mmHg. Physical examination shows no abnormalities. Results of spirometry are within normal limits. According to the 2019 GINA guidelines, which of the following is the most appropriate initial intervention? A. Albuterol as needed B. Budesonide-formoterol as needed C. Ipratropium as needed D. Methylprednisolone E. Montelukast daily

peritonsillar abscess **streptococcus pyogenes

A 14-year-old girl is brought to the clinic by her father because she has had a sore throat for the past four days. She also has had fever, chills, headache, and odynophagia. She has not had cough or dysphagia, and she has no sick contacts. Temperature is 38.5°C (101.3 °F), and blood pressure is 114/76 mmHg. On physical examination, the tonsils are erythematous and are grade 3+ with yellow exudate, bilaterally. But the uvula is midline, and the soft palate rises symmetrically. Painful anterior cervical lymphadenopathy is noted. Based on these findings, this patient is at increased risk for which of the following conditions? A. Lemierre syndrome B. Need for tonsillectomy in the future C. Nephrotic syndrome D. Peritonsillar abscess E. Pleural effusion

initiate enalapril therapy 10 mg twice daily

An 86-year-old woman comes for a follow-up appointment to discuss the results of echocardiography performed as part of a workup for peripheral edema. She has had 1+ edema of the legs bilaterally as well as hypertension with an average blood pressure of 146/95 mmHg. She has not had chest pain, palpitations, or decreased exercise tolerance. Medical history includes hypertension and hypothyroidism; current medications include hydrochlorothiazide 12.5 mg daily and levothyroxine 75 µg daily. Current pulse rate is 88/min, respirations are 16/min, and blood pressure is 160/92 mmHg. Oxygen saturation is 94%. Physical examination shows a laterally and inferiorly displaced apical pulse and a high-frequency decrescendo diastolic murmur along the left sternal border. Trace peripheral edema is noted to the shins bilaterally. Which of the following next steps is most appropriate to prevent disability from this condition? A. Discontinue levothyroxine therapy B. Increase hydrochlorothiazide therapy to 25 mg daily C. Initiate enalapril therapy 10 mg twice daily D. Initiate metoprolol XR therapy 25 mg daily E. Refer for aortic valve replacement surgery

intravenous antibiotics **orbital cellulitis

A 15-year-old girl is brought to the clinic by her father because she has had worsening pain and swelling in the right eye over the past two days. She says she has had bilateral frontal facial pressure for the past week but is currently more concerned about the symptoms in her right eye. She wears contact lenses but has not been able to use them for the past two days due to significant discomfort. The patient has blurry vision and pain with eye movements. Temperature is 38.0°C (100.4°F), and pulse rate is 98/min. Physical examination shows tenderness to palpation of the frontal sinus bilaterally with purulent drainage noted from the right nostril. The right eye is edematous and erythematous, and there is tenderness to palpation of the eye. Which of the following is the most appropriate initial intervention? A. Intravenous antibiotics B. Intravenous antifungals C. Oral antibiotics D. Topical ophthalmologic ointment E. Warm compresses and lubricating eye drops

posterior cervical lymphadenopathy

A 15-year-old patient is brought to the clinic because of fever and worsening sore throat over the past four days. They also have had profound fatigue, chills, nausea, and swollen glands. Medical history includes no chronic disease conditions, and they have no known sick contacts at school or home. Temperature is 38.0°C (100.4°F). On physical examination, the posterior oropharynx is erythematous with 3+ tonsillar enlargement, bilaterally. White exudate is noted on the tonsils. The lungs are clear to auscultation, and auscultation of the heart shows a regular rate and rhythm. Which of the following additional findings on physical examination is most likely? A. Bradycardia B. Hepatomegaly C. Posterior cervical lymphadenopathy D. Unilateral periorbital edema E. Vesicular rash

adductor longus **athletes who accelerate rapidly or change directions rapidly

A 20-year-old man comes to the clinic because he has had groin pain since he suddenly sprinted during a rugby game one day ago. He says he has pain in the left groin and proximal medial thigh. The patient does not have weakness or paresthesia. Medical history includes no chronic disease conditions, and he takes no medications. Pulse rate is 68/min, and blood pressure is 126/78 mmHg. On physical examination, ecchymoses are noted at the left proximal medial thigh, and there is tenderness to palpation at the site. Passive and active range of motion of the left hip and knee are within normal limits, and muscle strength of the hips, quadriceps, and hamstrings is 5/5 bilaterally. Which of the following is the most likely site of the injury? A. Adductor brevis B. Adductor longus C. Adductor magnus D. Gracilis E. Pectineus

no screening test is necessary

A 20-year-old man comes to the clinic for routine physical examination. He has no history of medical conditions, and physical examination shows no abnormalities. However, the patient is concerned because his friend was recently diagnosed with testicular cancer. He has never been screened for testicular cancer and insists that he begin screening now. The patient has not had testicular pain, swelling, or masses, and he has no history of cryptorchidism. Family medical history does not include testicular cancer. Which of the following is the most appropriate screening test for this patient? A. Alpha-fetoprotein level B. CT scan of the abdomen and pelvis C. MRI of the abdomen and pelvis D. No screening test is necessary E. Testicular ultrasonography

needle thoracotomy to the second intercostal space in the mid clavicular line **tension pneumothorax

A 21-year-old man comes to the emergency department because he has had dyspnea and chest pain since he sustained a gunshot wound in a firefight two minutes ago. Pulse rate is 170/min, and blood pressure is 104/64 mmHg. The patient appears distressed, is bleeding from the anterior chest, and is in respiratory distress. On physical examination, breath sounds are absent on the left. Which of the following is the most appropriate initial intervention? A. Administration of supplemental oxygen B. Needle thoracostomy to the second intercostal space in the mid clavicular line C. Placement of a three-sided occlusive dressing D. Simple aspiration E. Tube thoracostomy in the fifth intercostal space in the mid axillary line

supportive care **G6PD

A 21-year-old man who is of Asian descent comes to the clinic for a routine physical examination. His medical history includes no chronic disease conditions, and he says that he just got over a cold a few days ago. Pulse rate is 60/min, and blood pressure is 118/78 mmHg. Physical examination shows no abnormalities. On complete blood cell count, white blood cell count and platelet count are within normal limits. However, hemoglobin is 11.5 g/dL (N=13.5-17.0 g/dL). A peripheral blood smear shows Heinz bodies. Lactate dehydrogenase level, indirect bilirubin level, and reticulocyte count are elevated. Which of the following is the most appropriate treatment? A. B12 supplementation B. Blood transfusion C. Selenium supplementation D. Splenectomy E. Supportive care

mycoplasma pneumoniae

A 21-year-old transgender man who is a college student comes to the office because he has had fever, headache, myalgia, sore throat, and a nonproductive cough for the past seven days. Temperature is 38.0°C (100.4°F), pulse rate is 90/min, respirations are 18/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 97% on room air. On physical examination, the throat is erythematous, and no exudate is noted. The lungs are clear to auscultation. Chest x-ray study shows a patchy consolidation in the lower lungs, bilaterally. Which of the following organisms is the most likely cause? A. Klebsiella pneumoniae B. Legionella pneumoniae C. Mycoplasma pneumoniae D. Staphylococcus aureus E. Streptococcus pneumoniae

do you wear contact lenses? **corneal abrasion should have antibiotics to cover for pseudomonas

A 27-year-old man comes to the clinic because he has had pain, redness, and sensitivity to light in his left eye since his infant son accidentally scratched the eye a few hours ago while they were playing together. Pulse rate is 84/min, and blood pressure is 136/84 mmHg. Physical examination shows conjunctival injection and excessive lacrimation of the left eye. No hyphema or hypopyon is noted. Visual acuity is 20/30 bilaterally, and extraocular movements are intact bilaterally. Fluorescein staining of the eye shows a small linear area of uptake over the sclera. Which of the following is the most important question to ask this patient? A. Do you have an eye patch you can wear until the eye is healed? B. Do you prefer antibiotic drops or ointment? C. Do you wear contact lenses? D. Were the infant's hands clean when he scratched your eye? E. When was your last tetanus shot?

streptococcus pyogenes

A 27-year-old patient comes to the family medicine clinic because of a red, painful right shin. They recently returned from a five-day backpacking trip where their boot was rubbing against that part of the leg. Medical history includes no chronic disease conditions. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/85 mmHg. Oxygen saturation is 98% on room air. Physical examination shows erythema, mild edema, and moderate warmth of a 5 cm round area on the right anterior shin. Borders are poorly demarcated. Which of the following is the most likely causative organism? A. Candida albicans B. Methicillin-resistant Staphylococcus aureus C. Pasteurella multocida D. Pseudomonas aeruginosa E. Streptococcus pyogenes

pelvic sonography **secondary dysmenorrhea

A 27-year-old woman comes to the clinic because she has had painful menstrual cycles that have worsened over the past five years. She says her menstrual cycles last five days, and the flow is heavy. She also has had diarrhea and painful intercourse only during her menstrual cycles. She is sexually active with one male partner and has had a total number of six partners. She is currently taking an oral contraceptive and has never been pregnant. Body mass index is 19 kg/m². Blood pressure is 110/70 mmHg. Physical examination, including a pelvic examination, shows no abnormalities. Results of urine pregnancy test and urinalysis are negative, as are the results of sexually transmitted infection testing. Which of the following initial studies is most appropriate? A. CA-125 test B. Comprehensive metabolic panel C. Laparoscopic examination D. MRI of the pelvis E. Pelvic sonography

hemoglobin A1C

A 27-year-old woman comes to the clinic because she has had skin changes in her axilla and at the back of her neck for the past six months. She says the skin in these areas has become darker and thicker; it does not itch or hurt and does not appear to be spreading. Medical history includes irregular periods. The patient is sexually active with a male partner and takes oral contraceptive pills, which have helped her periods become regular. Weight is 220 lb, and height is 5 ft 3 in. Temperature is 36.9°C (98.5°F), pulse rate is 80/min, and blood pressure is 130/86 mmHg. The patient appears well and is not in any distress. Findings on examination of the skin are shown. The remainder of the physical examination shows no abnormalities. The result of which of the following laboratory studies is most likely to be abnormal in this patient? A. Erythrocyte sedimentation rate B. Hemoglobin A1C C. HIV antigen/antibody test D. Rheumatoid factor assay E. Tissue transglutaminase antibody test

reed-stern berg cells

A 28-year-old man comes to the clinic because he has had painless, enlarging lymph nodes over the past three months. He has not had fever, chills, or weight loss, but he says he has had a few episodes of soaking night sweats. Pulse rate is 80/min, and blood pressure is 116/74 mmHg. Physical examination shows painless anterior cervical and supraclavicular rubbery lymphadenopathy. Which of the following findings on histopathology is most likely? A. Auer rods B. Reed-Sternberg cells C. Rouleaux formation D. Smudge cells E. Starry sky pattern

hilar lymphadenopathy **primary tuberculosis

A 28-year-old man comes to the emergency department because he has had cough, fever, and night sweats for the past four months. He says the fever is worse during the day but improves at night and that sometimes he coughs up blood. He was recently released from prison and is currently living in a homeless shelter. The patient regularly uses intravenous heroin. Current temperature is 38.5°C (101.3°F), and blood pressure is 114/82 mmHg. The patient appears thin and fatigued. On physical examination, auscultation of the lungs shows diffuse crackling. A chest x-ray study is most likely to show which of the following? A. Dense nodules in the upper lobes with smaller nodules in the lower lobes B. Hilar lymphadenopathy C. Patchy consolidation to the apices D. Small nodular lesions that are diffuse E. Upper lobe cavitations

use a interpreting service

A 58-year-old woman comes to the clinic with her 10-year-old grandson because she has had a worsening sore throat over the past two days. The patient speaks Vietnamese only, but her grandson speaks English and Vietnamese. The grandson offers to translate, but the patient seems reluctant. One of the medical assistants speaks Vietnamese, but she has already left for the day. Blood pressure is 140/86 mmHg; she is afebrile. The patient appears comfortable and is in no acute distress. Which of the following is the most appropriate next step? A. Allow the grandson to translate B. Call the medical assistant to come back C. Reschedule the patient's appointment for a time when the medical assistant will be available D. Use a interpreting service E. Use the internet to translate

rales **pulmonary embolism

A 63-year-old man comes to the clinic because he has had worsening dyspnea that began suddenly 24 hours ago. The patient says that he usually has mild dyspnea with activity, but he now has it with rest. He says he also currently has chest pain, particularly with deep inspiration. His medical history includes chronic bronchitis and hypertension, and he smokes one pack of cigarettes every two days. Temperature is 37.1°C (98.8°F), pulse rate is 102/min, respirations are 22/min, and blood pressure is 148/98 mmHg. Oxygen saturation is 95% on room air. Body mass index is 38 kg/m². Which of the following findings is most likely to be present on physical examination of this patient? A. Abdominal pain B. Bradycardia C. Pain on palpation of chest wall D. Petechial rash on the lower extremities E. Rales

high dose oral corticosteroids

A 63-year-old woman comes to the clinic because she has had jaw pain for the past day. She says she has pain in her right jaw when chewing, and she had a 20-minute episode of painless loss of vision in the right eye yesterday that spontaneously resolved. The patient says she has long-standing fatigue and generalized muscle aches but attributes this to her diagnosis of polymyalgia rheumatica. Medical history is pertinent for osteopenia and anxiety well-controlled with sertraline 50 mg daily. Pulse rate is 90/min, and blood pressure is 134/84 mmHg. Visual and dental examinations show no abnormalities. Physical examination shows tenderness to palpation that is localized to the right scalp. Which of the following is the most appropriate initial intervention? A. Aspirin B. High-dose oral corticosteroids C. Methotrexate D. Tocilizumab E. Urgent inpatient admission

bladder neoplasm

A 64-year-old woman comes to the clinic because she has had intermittent episodes of blood in her urine during the past two months. She has been evaluated twice at the urgent care clinic and prescribed antibiotics for urinary tract infections during this time. The patient does not have fever, dysuria, hesitancy, urgency, or abdominal pain. Medical history includes stable hypertension for which she takes an angiotensin-converting enzyme inhibitor. She has smoked one pack of cigarettes per day for the past 40 years, rarely drinks alcoholic beverages, and does not use illicit drugs. The patient has been sexually active with one partner for the past 30 years. Physical examination shows no abnormalities. Clean-catch urinalysis shows 3+ blood and is negative for leukocytes, nitrates, and protein. Which of the following is the most likely explanation for these findings? A. Bladder neoplasm B. Chronic kidney disease C. Kidney stone D. Postmenopausal bleeding E. Urinary tract Infection

vitamin K deficiency

A 10-week-old male infant is brought to the emergency department with his parents via ambulance 15 minutes after he had an episode of seizure-like activity. The infant is lethargic and does not respond appropriately to verbal or physical stimuli. The mother received appropriate prenatal care and has been exclusively breastfeeding the patient. He was born at home via spontaneous vaginal delivery and has not yet been evaluated by a medical professional. Family medical history includes a maternal relative with a bleeding problem. Current temperature is 37.0°C (98.6°F), and respirations are 65/min. Physical examination shows shallow respirations and a petechial rash on the oral mucosa. On laboratory studies, platelet count and fibrinogen level are within normal limits, and international normalized ratio is 4. CT scan of the head shows intracranial hemorrhage. Which of the following is the most likely explanation for the findings in this patient? A. Child abuse B. Factor IX deficiency C. Factor V Leiden mutation D. Factor VIII deficiency E. Vitamin K deficiency

prescribe an epinephrine autoinjector

A 10-year-old boy is brought to the office by his parents because he had development of a rash after ingesting pecans for the first time earlier today. The rash is accompanied by tingling and itching around his mouth. The patient does not have a tight throat or difficulty breathing or swallowing. He does not have chest pain, shortness of breath, wheezing, abdominal pain, or nausea and vomiting. Temperature is 37.1°C (98.8°F), pulse rate is 100/min, respirations are 18/min, and blood pressure is 88/55 mmHg. The patient appears uncomfortable. Physical examination shows urticaria on the upper chest, abdomen, and forearms. No edema of the tongue or abnormalities in the posterior pharynx are noted. The remainder of the examination shows no abnormalities. Which of the following preventive measures is most appropriate to initiate at this time? A. Initiate a prednisone taper B. Initiate daily antihistamine therapy C. Initiate topical corticosteroid therapy D. Obtain radioallergosorbent testing E. Prescribe an epinephrine autoinjector

wolff-parkinson-white syndrome

A 16-year-old boy comes to the office for a follow-up two weeks after he was hospitalized for treatment of a cardiac arrest. When describing the incident, the patient says that he was playing basketball when he suddenly felt dizzy, felt like his heart was beating really fast, and then collapsed suddenly. An automated external defibrillator was used for resuscitation as well as cardiopulmonary resuscitation from a bystander; he was then transported to the hospital where he underwent additional workup and a cardiac ablation. Currently, he says he is feeling much better although his sternum hurts. Height is 5 ft 8 in, and weight is 160 lb. Pulse rate is 65/min, respirations are 14/min, and blood pressure is 100/62 mmHg. Physical examination shows moderate tenderness to palpation of the sternum but shows no other abnormalities. Electrocardiography obtained two weeks ago is shown. Which of the following is the most likely cause of the cardiac arrest in this patient? A. Acute pulmonary embolus B. Hypertrophic cardiomyopathy C. Long Q-T syndrome D. Myocardial infarction E. Wolff-Parkinson-White syndrome

post-streptococcal glomerulonephritis

A 16-year-old boy is brought to the family medicine clinic because he has had painless, reddish brown urine for the past two days. He also says that he has had headache, nausea, and malaise during this time. Medical history includes no chronic disease conditions, but he says that he had pharyngitis that resolved without antibiotics two and a half weeks ago. Temperature is 39.4°C (103.0°F), pulse rate is 80/min, respirations are 18/min, and blood pressure is 156/88 mmHg. Physical examination shows mild bilateral peripheral edema. Laboratory studies shows a serum creatinine level of 2.3 mg/dL. Urinalysis shows 2+ protein, red blood cells of 25 to 50/hpf with red blood cell casts, and white blood cells of 10 to 20/hpf. Which of the following is the most likely diagnosis? A. Goodpasture syndrome B. Hypertensive urgency C. IgA nephropathy D. Microscopic polyangiitis E. Post-streptococcal glomerulonephritis

add topical clindamycin gel daily to the current regimen

A 16-year-old boy is brought to the office by his mother because he has had acne on his face, chest, and back for the past two years that has been worsening over the past six months. He has tried using over-the-counter topical medications including a benzoyl peroxide rinse and adapalene gel 0.1% for 12 weeks, but this did not provide relief. Temperature is 37.0°C (98.6°F), pulse rate is 80/min, and blood pressure is 100/62 mmHg. During the interview, the patient says that he feels sad and embarrassed about his skin and does not want to go to school. Physical examination shows scattered papulopustular acne on the upper chest and upper back without scarring. A photograph of the patient's face is shown. Which of the following is the most appropriate next step in management? A. Add topical clindamycin gel daily to the current regimen B. Start oral isotretinoin once daily and stop topical medicines. C. Start oral minocycline twice daily and stop the topical medications D. Start spironolactone once daily in addition to the topical medications E. Stop the benzoyl peroxide and adapalene and switch to topical tretinoin cream

fluctuation in estrogen levels associated with menstruation

A 16-year-old girl is brought to the family medicine clinic by her mother because she has had new onset of headaches that seem to have occurred one to three days each month during the past six months. The patient says the headaches are intermittent, and the pain is sharp and occurs on one side of her forehead and eye. She has associated nausea without vomiting as well as light sensitivity. Sleep and nonsteroidal anti-inflammatory drugs provide relief. She says that the headaches worsen if she does schoolwork on her computer or exercises outside. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. The patient appears healthy. Physical examination, including neurologic examination, shows no abnormalities. Which of the following is the most likely trigger of headache in this patient? A. Fluctuation in estrogen levels associated with menstruation B. Increased intracranial pressure due to pseudotumor cerebri C. Mood disorder associated with development in adolescence D. Rebound headache caused by regularly taking nonsteroidal anti-inflammatory drugs E. Visual strain caused by excessive screen time

blepharitis

A 19-year-old woman comes to the clinic because she has had redness and irritation of the eyelids for the past month. She says that her eyelids are crusted together in the mornings, and her eyes itch and burn throughout the day. She wears contact lenses and says that she sometimes sleeps with them in. Medical history includes rosacea. Pulse rate is 80/min, and blood pressure is 116/84 mmHg. On physical examination, both eyelids are puffy and erythematous with crusting and flaking around the eyelashes. The conjunctiva are clear. Result of fluorescein staining is negative, bilaterally. Which of the following is the most likely diagnosis? A. Blepharitis B. Chalazion C. Dry eye disease D. Keratitis E. Trichiasis

tetanus, diphtheria and pertussis vaccine **all pregnant women should receive an update

A 19-year-old woman, gravida 1, para 0, who is at 10 weeks' gestation comes to the OB/GYN for an initial prenatal examination. She was not vaccinated as a child due to her family's religious beliefs but would like to be more proactive about her health. The patient asks which vaccinations she should get now. Medical history includes no chronic conditions, and her only medication is a prenatal vitamin. Which of the following vaccines is most appropriate to recommend? A. Human papilloma virus vaccine B. Live attenuated influenza vaccine C. Measles, mumps, and rubella vaccine D. Tetanus, diphtheria, and pertussis vaccine E. Varicella vaccine

coarctation of the aorta

A 2-week-old female infant is brought to the family medicine clinic by her parents for routine well-child examination. The patient was delivered vaginally at term and was feeding well at the time of discharge from the hospital. During the past week, the mother says that the patient has been increasingly fussy and irritable, is having difficulty feeding, and seems to be working hard to breathe. She has normal urine and stool output. She is at 90% of her birth weight. Pulse rate is 170/min, respirations are 45/min, and blood pressure is 107/70 mmHg. The patient appears pale. On physical examination, cardiac auscultation shows a systolic heart murmur in the left infraclavicular area. Brachial pulses are within normal limits, and femoral pulses are decreased. This patient most likely has which of the following congenital heart abnormalities? A. Coarctation of the aorta B. Hypoplastic left heart syndrome C. Tetralogy of Fallot D. Tricuspid atresia E. Ventricular septal defect

MRI of the brain **multiple sclerosis

A 22-year-old woman comes to the office because she has had episodes of intermittent tremor and associated leg weakness during the past 12 months. The episodes usually last a week and then resolve. However, during the past four weeks she says she has had numbness and weakness in both of her legs, has felt clumsy when she walks, and has occasionally fallen. The patient had an episode of bladder incontinence two days ago. Medical history includes no chronic disease conditions or surgical procedures. She does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. Temperature is 36.6°C (97.8°F), pulse rate is 75/min, and blood pressure is 108/72 mmHg. The patient appears tired. Neurologic examination shows abnormal tandem gait and mild resting tremor. Decreased sensation to light touch is noted in both legs and feet. Result of Romberg test is positive. Finger-nose-finger testing shows no abnormalities. Which of the following studies is most appropriate to determine the diagnosis? A. CT scan of the head B. Electroencephalography C. Electromyography of the bilateral lower extremities D. MRI of the brain E. X-ray studies of the lumbar spine

measure a 24 hour urine cortisol level

A 24-year-old woman comes to the office because she had sudden onset of weight gain primarily in her abdomen 6 months ago. She also has had development of wide stretch marks on her abdomen as well as facial acne during this time. She is certain that she is not pregnant because she has not been sexually active during the past 12 months. Medical history includes no chronic disease conditions. Height is 5 ft 2 in, and weight is 150 lb; body mass index is 26.6 kg/m². Temperature is 36.9°C (98.5°F), pulse rate is 64/min, and blood pressure is 110/78 mmHg. Physical examination shows central obesity with normal bowel sounds and no tenderness to palpation. Psychiatric examination shows no abnormalities. On laboratory studies, urine beta-human chorionic gonadotropin level is negative, and 24-hour urine cortisol level is 325 µg/dL. A photograph of the patient's abdomen is shown. Which of the following is the most appropriate next step? A. Measure a second 24-hour urine cortisol level B. Measure a serum quantitative beta-human chorionic gonadotropin level C. Measure afternoon adrenocorticotropic hormone level D. Obtain a CT scan of the abdomen E. Obtain an MRI of the brain

history of cataplexy

A 24-year-old woman comes to the office because she has had intense fatigue during the day for the past three months. She says the fatigue is so severe that she has fallen asleep in inappropriate situations such as during conversations or while driving and stopped at a red light. At times, the patient has experienced a feeling like she is "seeing things" as she falls to sleep but cannot wake herself in these situations. She knows these hallucinations are not real. Temperature is 37.0°C (98.6°F), pulse rate is 71/min, respirations are 16/min, and blood pressure is 98/62 mmHg. The patient appears healthy. Physical examination shows no abnormalities, and the airway is Mallampati class I. Which of the following additional findings is most likely to confirm the suspected diagnosis? A. History of cataplexy B. History of growing pains C. History of nocturnal enuresis D. History of sleep walking E. History of snoring

CT angiography of the chest

A 24-year-old woman has a 24-hour history of shortness of breath two weeks after she underwent repair of the anterior cruciate ligament. She also has pain in the right knee and lower leg, swelling, and decreased range of motion which has not changed since three days after the surgery. The patient does not have chest pain, palpitations, cough, or wheezing. Medications include oral norgestimate/ethinyl estradiol 0.25/0.035 mg daily. Temperature is 37.0°C (98.6°F), pulse rate is 102/min, respirations are 20/min, and blood pressure is 128/88 mmHg. Oxygen saturation is 92%. The patient appears anxious. Physical examination of the right lower extremity shows an incision that runs from two inches above the knee to two inches below the knee. The incision is closed; no drainage, warmth, or erythema is noted. The right knee is diffusely tender to palpation with decreased flexion and extension. Trace edema is noted in the right lower leg, and mild tenderness to palpation is noted in the posterior calf. An abnormal result on which of the following tests is most likely to determine the diagnosis? A. Chest x-ray study B. CT angiography of the chest C. D-dimer assay D. Electrocardiography E. Troponin test

history of genital herpes

A 25-year-old woman comes to the clinic for sexually transmitted disease (STD) testing. She is currently asymptomatic and requests STD testing before initiating sexual activity with a new partner. Medical history includes no chronic disease conditions, and she takes no medications. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. On laboratory studies, results of a hepatitis panel and rapid plasma reagin test are negative, but result of HIV assay is positive. Which of the following additional findings on history taking is most likely? A. History of blood transfusion B. History of employment as a phlebotomist C. History of genital herpes D. History of marijuana use E. History of regular plasma donation

start fiber supplementation and a low-FODMAP diet **IBS

A 26-year-old woman comes to the office because she has had intermittent diarrhea during the past 12 months since she started graduate school. She says she has episodes of loose, small-volume diarrhea sometimes accompanied by cramping abdominal pain about once per week. She often feels better after having a bowel movement. The patient has not had fever, nausea and vomiting, weight loss, or blood in the stool. She says she was recently evaluated by a gastroenterologist, and results of the workup, including blood, stool, and breath testing, were within normal limits. She says she has tried taking probiotics, but they seem to actually make the diarrhea worse with more frequent episodes. Family medical history does not include inflammatory bowel disease or colon cancer. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 100/66 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate initial intervention? A. Obtain a colonoscopy B. Obtain a CT scan of the abdomen with oral and intravenous contrast C. Start a regimen of intermittent fasting D. Start Fiber supplementation and a low-FODMAP diet. E. Start therapy with rifaximin

discharge to home with colchicine 1.2 mg once then 0.6 mg in one hour, and initiate losartan 25 mg once daily

A. Admit the patient to the hospital for a five-day methylprednisolone dose pack, and initiate intravenous esmolol and nitroglycerine B. Admit the patient to the hospital for intravenous corticosteroids, and initiate rapid blood pressure lowering with intravenous diltiazem titrated to normal blood pressure C. Discharge to home with colchicine 1.2 mg once then 0.6 mg in one hour, and initiate losartan 25 mg once daily D. Discharge to home with naproxen 500 mg every 12 hours for two days, and initiate lisinopril 10 mg once daily E. Discharge to home with prednisone 40 mg once daily for five days, and initiate hydrochlorothiazide 25 mg once daily

progesterone decreases the pulse frequency of gonadotropin-releasing hormone

A 28-year-old woman comes to the clinic because she is interested in obtaining contraception. She is currently using male condoms for contraception but would like to change to something else. Medical history does not include heart attack, stroke, migraine with aura, or blood clots. Pulse rate is 90/min, and blood pressure is 116/70 mmHg. Physical examination shows no abnormalities. Result of a urine pregnancy test is negative. After discussing all of the available options, the patient decides to begin using the combined oral contraceptive pill. Which of the following best explains the primary mechanism of action of this type of contraception? A. Both estrogen and progesterone cause an inflammatory response that is toxic to sperm B. Estrogen causes the cervical mucus to inhibit sperm moving through the cervix C. Estrogen facilitates the luteinizing hormone surge at mid cycle D. Progesterone decreases the pulse frequency of gonadotropin-releasing hormone E. Progesterone prevents implantation in the uterus by causing atrophy

between 26 and 28 weeks gestation and 72 hours after delivery

A 28-year-old woman who is pregnant for the first time comes to the OB/GYN for routine prenatal examination. The patient is Rh negative. Assuming there are no other complications during the pregnancy and the newborn is Rh positive, which of the following is the most appropriate time to administer Rho(D) immune globulin therapy to this patient? A. At 20 weeks' gestation and within 72 hours after delivery B. At 28 weeks' gestation C. Between 26 and 28 weeks' gestation and within 72 hours after delivery D. Rho(D) immune globulin therapy does not need to be administered to this patient E. Within 72 hours after delivery

nitrofurantion

A 28-year-old woman, gravida 1, para 0, who is at 14 weeks' gestation comes to the clinic for routine prenatal examination. She is doing well and has no symptoms. Results of a urine culture obtained one week ago shows >100,000 CFU/mL of Escherichia coli. Which of the following is the most appropriate treatment for this patient's condition? A. Chloramphenicol B. Levofloxacin C. Nitrofurantoin D. Tetracycline E. Trimethoprim-sulfamethoxazole

urine osmolality **SIADH

A 29-year-old man comes to the clinic because he has had weakness and has fallen frequently during the past two weeks. He says he went to the emergency department two nights ago for evaluation of these symptoms, and they told him that his sodium level was decreased and to follow-up with his primary care physician. Medical history includes medication-resistant depression, polysubstance abuse, and chronic pain. Current medications include sertraline 150 mg daily, aripiprazole 6 mg daily, and extended-release morphine 20 mg daily. He does not smoke cigarettes, intermittently drinks three to 10 alcoholic beverages daily, and occasionally uses marijuana, Ecstasy, and LSD. Temperature is 36.8°C (98.5°F), pulse rate is 66/min, respirations are 16/min, and blood pressure is 110/72 mmHg. The patient is alert but appears depressed and lethargic. He has mild confusion when asked to recount the timeline of his symptoms. The remainder of the examination show no abnormalities. Elevation of which of the following laboratory values is most likely to support the suspected diagnosis? A. Plasma glucose level B. Serum creatinine level C. Serum osmolality D. Thyroid-stimulating hormone level E. Urine osmolality

Galeazzi fracture

A 29-year-old patient comes to the urgent care clinic because of pain in their right arm for the past 30 minutes. The patient was sprinting for a ball in a pickup soccer game when they tripped and fell on an outstretched right hand. Pulse rate is 102/min and blood pressure is 146/90 mmHg. The patient appears uncomfortable. Physical examination shows tenderness to palpation of the right forearm and wrist. Neurologic examination shows no deficits. Plain film x-ray studies of the arm show a fracture of the distal third of the radius with a dislocation of the distal radioulnar joint. Which of the following best describes this type of fracture? A. Barton fracture B. Essex-Lopresti fracture C. Galeazzi fracture D. Monteggia fracture E. Smith fracture

renal ultrasonography **PCKD

A 29-year-old woman who has hypertension that was diagnosed one month ago comes to the office for follow-up. She has been otherwise healthy and has no history of surgical procedures. Current medications include lisinopril 30 mg daily, chlorthalidone 12.5 mg daily, and a daily oral contraceptive pill. Family medical history includes hypertension, polycystic kidney disease, hyperlipidemia, kidney stones in her father, and rheumatoid arthritis in her mother. She has smoked one-half pack of cigarettes daily for the past 10 years. She drinks alcoholic beverages occasionally and does not use illicit drugs. Weight is 160 lb, and height is 5 ft 10 in. Pulse rate is 80/min, respirations are 16/min, and blood pressure is 120/72 mmHg. Physical examination shows normal rate and rhythm and no rubs, murmurs, or gallops. No peripheral edema is noted. Which of the following studies is most likely to determine the underlying cause of the hypertension in this patient? A. CT scan of the abdomen B. MRI of the abdomen C. Renal ultrasonography D. Voiding cystourethrography E. X-ray studies of the kidneys, ureters, and bladder

rectal stool impaction **functional constipation

A 3-year-old boy is brought to the clinic by his parents because he has had constipation and abdominal pain during the past six months. The parents say that the patient had normal bowel movements up until six months ago when they started to work on toilet training. Since then, his stools have been hard and less frequent, and he has had intermittent abdominal pain. Medical history includes an uncomplicated vaginal birth, no abnormalities on newborn metabolic screening, and normal progression on growth charts. Height is 3 ft 5 in, and weight is 28 lb. Temperature is 37.1°C (98.7°F), pulse rate is 110/min, respirations are 18/min, and blood pressure is 80/55 mmHg. Physical examination shows mild tenderness to palpation in the right lower and left lower quadrants. No guarding or rebound tenderness is noted. Which of the following additional findings on physical examination is most likely? A. Decreased lower extremity reflexes and tone B. Empty Rectal Vault C. Evidence of weight loss on the growth chart. D. Presence of café au lait spots E. Rectal stool impaction

infective endocarditis

A 31-year-old man has had chronic low-grade fevers, fatigue, and cough for the past month. He says he has injected heroin daily during the past three months. The patient says he has no history of chronic disease conditions or heart murmur. Physical examination shows a 2/5 systolic heart murmur heard best along the left sternal border. Red-brown lines are noted under the fingernails. Which of the following is the most likely cause of the heart murmur in this patient? A. Ebstein anomaly B. Infective endocarditis C. Mitral valve prolapse D. Pulmonary hypertension E. Rheumatic fever

eating a diet that is higher in salt **vasovagal syncope

A 32-year-old man comes to the clinic because he has had multiple syncopal episodes during the past three months. He is a second-year physician assistant student and is completing his clinical rotations. The first episode occurred three months ago while he was watching an intrauterine device being placed during his OB/GYN rotation. The second episode occurred two weeks ago while he was assisting with a toenail removal during his dermatology rotation. He says he regained consciousness immediately after each event, and aside from feeling shaky, a little nauseous, and very embarrassed, he felt fine afterwards. The patient is very anxious because he is about to start his surgery rotation and wonders if he should just drop out of the program now. He has not had headaches, vision changes, chest pain, palpitations, or dizziness when he is in his normal state of health. He does not smoke cigarettes, drinks one to two alcoholic beverages per month, and does not use illicit drugs. The patient eats a raw food diet and drinks only water on most days. Height is 6 ft 2 in, and weight is 190 lb. Pulse rate is 70/min, respirations are 16/min, and blood pressure is 100/62 mmHg. Physical examination shows no abnormalities, and electrocardiography shows no abnormalities. Which of the following actions is most likely to prevent future syncopal episodes in this patient? A. Eating a diet that is higher in salt B. Take fluoxetine 20 mg daily C. Taking a beta-blocker before each clinical shift D. Taking fludrocortisone 0.1 mg daily to manage low blood pressure E. Use compression stockings

lipid panel

A 33-year-old man comes to the office for annual physical examination. He has no symptoms but asks about which laboratory studies and screening tests that he should undergo. Medical history includes exercise-induced bronchospasm. He takes no medications. Family history includes heart disease with an unknown specific diagnosis in his father and high blood pressure in his mother. He currently drinks two beers per day, does not smoke cigarettes, and does not use illicit drugs. The patient has gained weight over the past year and has had decreased exercise tolerance, which he attributes to being out of shape. Height is 6 ft, and weight is 230 lb; body mass index is 31.2 kg/m². Pulse rate is 72/min, respirations are 16/min, and blood pressure is 140/89 mmHg. The patient appears comfortable. Physical examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient? A. Chlamydia test B. Complete blood cell count C. Lipid panel D. Thyroid-stimulating hormone level E. Vitamin D level

worsened chest pain with movement **costochondritis

A 35-year-old man comes to the clinic because he has had worsening chest pain on deep inspiration over the past day. He has no history of trauma or sick contacts. Medical history includes no chronic disease conditions. Pulse rate is 84/min, and blood pressure is 136/84 mmHg. The patient appears well. On physical examination, auscultation of the heart shows a regular rate and rhythm with no murmurs, rubs, or gallops. Auscultation of the lungs shows clear lung sounds bilaterally. There is tenderness to palpation of the midline anterior chest. Which of the following additional findings on history taking is most likely? A. Dizziness B. Nausea C. Productive cough D. Shortness of breath E. Worsened chest pain with movement

doxycycline **mycoplasma

A 35-year-old man comes to the clinic because he has had worsening fatigue and dry cough over the past week. He says the cough is worse at night. He also has had a headache, sore throat, chills, and mild body aches. Temperature is 37.5°C (99.5°F), and blood pressure is 134/78 mmHg. On physical examination, the posterior oropharynx is erythematous. Auscultation of the lungs shows some rhonchi bilaterally. Plain film x-ray study of the chest shows bilateral patchy infiltrates. A gram stain is negative. Which of the following is the most appropriate initial intervention? A. Cefdinir B. Clindamycin C. Doxycycline D. Levofloxacin E. Trimethoprim-sulfamethoxazole

has the incongruence between your sex assigned at birth and your gender identity caused distress or impairment in social or occupational function?

A 35-year-old patient comes to the clinic to discuss questions about gender affirmation and hormones. The patient says that they were assigned female at birth, but they have identified as male since the age of 12 years. They had a strong aversion to female secondary sex characteristics when they began to develop. The patient prefers "he/him" pronouns and has identified as male in work and social settings for the past 10 years. Which of the following additional questions is most appropriate to ask to confirm the suspected diagnosis? A. Are you currently or have you ever taken hormone therapy to alter your gender assigned at birth? B. Do you have a history of depression, anxiety, or other mood disorders? C. Has anyone else in your family experienced gender incongruence? D. Has the incongruence between your sex assigned at birth and your gender identity caused distress or impairment in social or occupational function? E. To what sorts of people (male/female/other/both) are you sexually attracted?

small bowel

A 35-year-old patient with celiac disease comes to the clinic for routine follow-up. They have been adhering to a gluten-elimination diet most of the time but not all of the time. The patient reports occasional diarrhea and abdominal discomfort when they eat gluten-containing foods but say the diet is just too hard to stick to. It is most appropriate to counsel this patient to adhere to a gluten-free diet because persistent intake of gluten in a patient with celiac disease could cause inflammatory injury to which of the following structures? A. Anus B. Esophagus C. Peripheral nerves D. Small bowel E. Stomach

adequate hydration

A 35-year-old woman comes to the clinic because she has had a sore throat and cough for the past two days. She has not had hemoptysis, but the cough is productive of clear sputum. The patient has not had a fever, shortness of breath, or difficulty breathing. She says she has a history of similar symptoms about once a year with no known environmental triggers. Vital signs are all within normal limits. On physical examination, no abnormalities of the mucous membranes are noted. Auscultation of the lungs shows slight wheezing and rhonchi, both of which clear after coughing. No egophony or E to A changes are noted. The results of a complete blood cell count and basic metabolic panel are within normal limits. Chest x-ray study shows mild interstitial markings with no areas of consolidation. Which of the following is the most appropriate treatment for this patient's condition? A. Adequate hydration B. Azithromycin C. Codeine cough syrup D. Corticosteroids E. Ipratropium bromide

discuss treatment options for depression and avoid any information regarding the husband's appointment

A 36-year-old man comes to the primary care office because he has had painful genital blisters for the past two days. He says he has been married to his wife for 12 years but they have been having marital issues over the past several months. He says that he had a one-night stand with a new partner last weekend and did not use a condom. A diagnosis of herpes simplex virus infection is confirmed and acyclovir is prescribed. The patient is educated on the nature of this infection and is advised to discuss the diagnosis with his wife. He becomes upset and says that he is not ready to tell his wife. Later that day, the PA is assigned to evaluate the patient's wife for depression symptoms. She is unaware that her husband had an earlier appointment with the PA. Which of the following is the most appropriate course of action for the PA? A. Ask the wife if she is having any genitourinary symptoms and if she would like to be screened for sexually transmitted infections B. Disclose the husband's earlier diagnosis so that the wife does not become exposed to a herpes simplex virus infection C. Discuss treatment options for depression and avoid disclosing any information regarding the husband's appointment D. Inform the wife that her husband was evaluated earlier and do not disclose any other information E. Refer to a behavioral health specialist and offer a prescription for acyclovir

wearing compression stockings during the day

A 37-year-old woman comes to the office because she has a heavy, aching feeling in her lower legs with what she describes as "fat veins." She says these symptoms started three years ago during her second pregnancy but have worsened over the past year when she started working from home and sitting for prolonged periods. The symptoms worsen if she sits all day or if she stands for more than two hours. The patient has tried elevating her legs which does not seem to provide relief. She has not had redness or swelling of the calves. She has no history of calf pain with exercise that is alleviated with rest. She takes no medications. Vitals are normal. On physical examination, peripheral pulses are palpable in the legs, bilaterally. Examination of the lower legs shows subcutaneous veins dilated to 4 to 6 mm on both posterior calves. Skin color is normal. No leg edema is noted. Strength and range of motion are within normal limits in both legs. Venous Doppler ultrasonography shows no valvular reflux or deep vein thrombosis. Which of the following is the most appropriate next step in management? A. Sclerotherapy B. Superficial cryotherapy C. Surgery with ligation and stripping of the great or small saphenous vein D. Thermal ablation E. Wearing compression stockings during the day

borrelia burgdorferi

A 38-year-old patient who identifies as gender nonconforming comes to the clinic because of a low-grade fever, chills, and fatigue for the past four days. They work as a baker and have not had any sick contacts or known exposures. They just returned from a hunting trip last week. Temperature is 37.5°C (99.5°F), and a blood pressure is 126/84 mmHg. The patient appears fatigued. Physical examination shows a painless, nonpruritic erythematous patch with a ring of clearing to the left thoracic area. Which of the following is the most likely causative agent? A. Borrelia burgdorferi B. Epstein-Barr virus C. Herpes simplex virus D. Influenza virus E. Treponema pallidum

labetalol

A 38-year-old woman comes to the clinic to establish care as she recently moved to the area. She is at 7 weeks' gestation; this is her first pregnancy. She says that she has been feeling well overall, with mild nausea and vomiting. Medical history includes elevated blood pressure without a diagnosis of hypertension and migraine headaches. Current medications include a prenatal vitamin and acetaminophen as needed for migraine. Height is 5 ft 5 in, and weight is 135 lb. Pulse rate is 75/min, respirations are 14/min, and blood pressure is 166/92 mmHg. Three repeat measurements of blood pressure average 166/90 mmHg. Physical examination shows no abnormalities. Results of laboratory studies and urinalysis are within normal limits. A repeat blood pressure one week later is 155/92 mmHg. Which of the following is the most appropriate next step to prevent complications in this patient's pregnancy? A. Aspirin B. Home blood pressure monitoring and follow-up in 1 month C. Hydrochlorothiazide D. Labetalol E. Lisinopril

no testing is necessary until 44 years of age

A 40-year-old woman, gravida 3, para 3, comes to the clinic for a routine physical examination. She is currently sexually active with one male partner and has a total number of three partners in her lifetime. Her medical history includes an abnormal Pap smear result in her early 20s that showed low-grade dysplasia. All Pap smear results since, including one with HPV cotesting from a year ago, have been within normal limits. Body mass index is 32 kg/m². Blood pressure is 136/84 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate to suggest at this visit for this patient? A. Colposcopy B. Human papillomavirus test C. No testing is necessary until 44 years of age D. Pap smear E. Pap smear with human papillomavirus test

hydrochlorothiazide

A 41-year-old patient who identifies as gender nonconforming comes to the clinic because of excruciating pain in their right great toe since waking up this morning. The pain is so extreme that they are unable to put a sock or shoe. The patient has no history of trauma to the toe or recent fever or chills, and they have not had similar episodes in the past. Medical history includes a recent diagnosis of hypertension, for which they take an antihypertensive drug. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. On physical examination, the first metacarpophalangeal joint of the right foot is erythematous and exquisitely tender to touch. Aspiration of the joint shows negatively birefringent, needle-shaped urate crystals. Based on these findings, this patient is most likely taking which of the following antihypertensive medications? A. Diltiazem B. Hydrochlorothiazide C. Lisinopril D. Losartan E. Metoprolol

ulcerative colitis **anemia of chronic disease

A 42-year-old woman comes to the clinic because she has had fatigue for the past five months. She says that her menstrual cycles last four days and are moderately heavy. Body mass index is 32 kg/m². Blood pressure is 150/84 mmHg. Physical examination shows no abnormalities. Laboratory studies show a hemoglobin of 9.5 g/dL and a mean corpuscular volume of 90 µm³. Serum iron-binding capacity is decreased, but serum ferritin level is elevated. White blood cell count, platelet count, peripheral blood smear, and reticulocyte count are within normal limits. Which of the following additional findings on history taking is most likely? A. Alcohol use disorder B. Cyanocobalamin deficiency C. Hobby as a lead-figurine painter D. Thalassemia E. Ulcerative colitis

bupropion

A 42-year-old woman comes to the office with her partner because they think she had a seizure yesterday. She says she was working in her yard when she suddenly felt confused and fell to the ground. She lost consciousness and lost control of her bladder; when she woke up, she felt tired and confused. Her partner says that she saw her faint and then have jerking movements of the arms and legs with irregular breathing for about a minute before she regained consciousness. The patient has never had an episode like this before. Medical history includes depression, anxiety, and neck pain. Medications include fluoxetine 40 mg daily, bupropion 150 mg three times daily, amitriptyline 25 mg at bedtime, hydroxyzine 25 mg three times daily as needed, and naproxen 500 mg twice daily. Temperature is 37.1°C (98.7°F), pulse rate is 84/min, and blood pressure is 112/80 mmHg. Oxygen saturation is 96%. Physical examination shows no abnormalities. Results of laboratory and imaging studies are pending. Which of the following medications is most likely to have contributed to this patient's episode? A. Amitriptyline B. Bupropion C. Fluoxetine D. Hydroxyzine E. Naproxen

thyroid stimulating hormone secreting

A 43-year-old man comes to the family medicine clinic as a new patient to establish care. He says he has had unintentional weight loss and palpitations during the past year. The patient says he has a pituitary tumor that is supposed to be monitored, but he cannot recall the type or location of the tumor. Body mass index is within normal limits. Pulse rate is 110/min. The patient has normal stature. On physical examination, heart sounds are within normal limits and a mild resting tremor is noted. This patient most likely has which of the following types of pituitary adenoma? A. Adrenocorticotropic hormone-secreting B. Follicle-stimulating hormone-secreting C. Growth hormone-secreting D. Prolactin-secreting E. Thyroid-stimulating hormone-secreting

creatinine, bilirubin, and INR **3 of the 4 components of MELD score to predict disease severity with advanced liver disease

A 45-year-old man comes to the office because he has had swelling in his abdomen and legs as well as itchiness of his skin without a rash for the past week. He says he also has had intermittent constipation. The patient has not had abdominal pain, nausea and vomiting, chest pain, palpitations, shortness of breath, or cough. Medical history includes hypertension and anxiety. Current medications include lisinopril 30 mg daily, propranolol 20 mg twice daily, and clonazepam 0.5 mg twice daily. He does not smoke cigarettes, drinks four alcoholic beverages daily, and does not use illicit drugs. Height is 5 ft 8 in, and weight is 200 lb. Pulse rate is 98/min, respirations are 16/min, and blood pressure is 126/95 mmHg. Physical examination shows mild scleral icterus and pale skin with excoriations on the forearms. Bilateral 1+ pitting edema is noted to the knees. Abdominal examination shows a non tender, protuberant abdomen with a network of swollen veins around the umbilicus. Laboratory findings include the following: red blood cell count 4.23 million/mm³; hemoglobin 14.3 g/dL; mean corpuscular volume (MCV) 100.7 µm³; platelet count 92,000/mm³; sodium 130 mEq/L; potassium 4.0 mEq/L; urea nitrogen (BUN) 7 mg/dL; creatinine 0.68 mg/dL; bilirubin 2.3 mg/dL; alkaline phosphatase 220 U/L; aspartate aminotransferase (AST) 92 U/L; alanine aminotransferase (ALT) 27 U/L; brain natriuretic peptide (BNP) 114 pg/mL; and international normalized ratio (INR) 1.3. Which of the following laboratory values are the most important prognostic indicators for this patient? A. AST, ALT, and alkaline phosphatase B. BUN, platelet count, and BNP C. Creatinine, bilirubin, and INR D. Red blood cell count, hemoglobin, and MCV E. Sodium, potassium, and BUN

duloxetine **fibromyalgia

A 45-year-old woman comes to the clinic because she has had persistent fatigue and diffuse musculoskeletal pain for the past six months. She says she has significant fatigue and feels foggy despite sleeping 10 hours per night. Medical history includes episodic anxiety and panic attacks that are currently treated with lifestyle modifications, but the patient feels like she could use more treatment. Vitals are normal. The patient appears mildly anxious. Physical examination shows bilateral, symmetric tenderness to palpation at points on the trunk, upper extremities, and lower extremities. Results of laboratory studies including complete blood cell count, complete metabolic panel, thyroid-stimulating hormone level, iron level, antinuclear antibody assay, rheumatoid factor assay, C-reactive protein level, and erythrocyte sedimentation rate are within normal limits. Which of the following is the most appropriate initial intervention? A. Corticosteroids B. Diazepam C. Duloxetine D. Fluoxetine E. Tramadol

initiate escitalopram

A 47-year-old woman comes to the office because she has had emotional stress related to work. During the interview, she describes a confrontational telephone call with her boss this week during which she abruptly felt fearful and experienced physical symptoms including sweating, a feeling of choking, and nausea. When she hung up the phone, she felt like she was "going crazy." This morning, she was describing this episode to her spouse and developed all of those physical symptoms again. She usually takes alprazolam when she feels this way but tried with this episode and it only helped for a little while. The patient says she needs to go to work on Monday and is fearful about how she will react to the stress. Medical history includes anxiety, hypertension, and hypothyroidism. Medications include hydrochlorothiazide 25 mg daily, levothyroxine 75 µg daily, and alprazolam 0.25 mg daily, as needed. Temperature is 36.7°C (98.0°F), pulse rate is 64/min, and blood pressure is 153/82 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in medication management? A. Change alprazolam to clonazepam B. Change alprazolam to propranolol C. Initiate aripiprazole D. Initiate bupropion E. Initiate escitalopram

colonoscopy

A 47-year-old woman comes to the office because she has had rectal bleeding with most, but not all, of her bowel movements during the past seven days. She has not had abdominal pain or nausea and vomiting. Medical history includes alternating constipation and diarrhea with occasional associated right-sided abdominal pain for the past two years that she attributes to irritable bowel syndrome. She takes no medications. She has a 5-pack-year history of smoking cigarettes in her 20s, and she drinks approximately five alcoholic beverages per week. Vital signs are within normal limits. Physical examination shows conjunctival pallor. Abdominal examination shows mild diffuse tenderness to palpation in the lower abdomen. No rebound, guarding, or palpable masses are noted. Rectal examination shows no external hemorrhoids, and anoscopy shows no internal hemorrhoids. The result of a stool guaiac test is positive. Laboratory studies show mild normocytic anemia. Which of the following is the most appropriate next step in diagnosis? A. Barium enema x-ray study B. Colonoscopy C. CT scan of the abdomen and pelvis with and without contrast D. Fecal occult blood test E. Flexible sigmoidoscopy

viral hepatitis tests

A 47-year-old woman comes to the office for annual physical examination. She has no specific concerns but requests that she undergo annual laboratory analysis to make sure that she is healthy. Medical history includes obesity and prediabetes, and she takes no medications. Family medical history includes type 2 diabetes mellitus in both of her parents. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Height is 5 ft 3 in, and weight is 185 lb. Body mass index is 31.8 kg/m². Pulse rate is 74/min, respirations are 16/min, and blood pressure is 128/85 mmHg. Physical examination shows no abnormalities. Laboratory studies, including a complete metabolic panel, lipid panel, and hemoglobin A1c, show the following abnormal results: Alkaline phosphatase 174 U/L; aspartate aminotransferase 90 U/L; alanine aminotransferase 93 U/L; gamma-glutamyl transferase 313 U/L; triglycerides 182 mg/dL; hemoglobin A1C 6.1. Based on these results, which of the following laboratory studies is most important to order next? A. 2-Hour glucose tolerance test B. Complete blood cell count C. Epstein-Barr virus tests D. Serum copper test E. Viral hepatitis tests

naltrexone

A 49-year-old man comes to the office because he has had interpersonal stress with his partner due to his alcohol consumption over the past few months. He currently drinks a fifth of whisky every two to three days. He says that he does not need to drink in the morning to function, and he does not start to feel ill during the day when he is not drinking. He is able to work full-time but starts drinking every day when he returns home from work at 6 PM. The patient says that he is not ready to quit drinking alcohol, but he would like help with trying to cut back on his consumption. His only medication is a daily multivitamin. Height is 5 ft 8 in, and weight is 165 lb. Temperature is 36.9°C (98.5°F), pulse rate is 84/min, and blood pressure is 131/75 mmHg. Physical examination shows no abnormalities. Initiation of therapy with which of the following medications is most appropriate? A. Buprenorphine B. Bupropion C. Disulfiram D. Naltrexone E. Paroxetine

ankle brachial index test

A 50-year-old man comes to the primary care office because he has had leg pain when walking long distances during the past six months. He says the symptoms improve with rest. Medical history includes diabetes mellitus. He has a 20—pack-year history of cigarette smoking. Which of the following tests is most likely to determine the diagnosis? A. Ankle-brachial index test B. Arteriography C. Coronary calcium score test D. CT angiography E. Exercise stress test

basilar bullae

A 50-year-old woman comes to the clinic because she has had worsening dyspnea over the past eight years. She says she has dyspnea when walking as well as a cough and wheezing. The patient has worked at a rubber manufacturing plant for the past 30 years. She has a 2—pack-year history of smoking cigarettes but quit when she was 22 years of age. Medical history includes a diagnosis of asthma at 40 years of age, for which she takes budesonide/formoterol and montelukast. Pulse rate is 90/min, and blood pressure is 136/82 mmHg. The patient is thin and appears fatigued. On physical examination, auscultation of the lungs shows diffuse wheezing bilaterally. Cardiac auscultation shows no abnormalities. Which of the following findings is most likely on plain film x-ray studies? A. Basilar bullae B. Bilateral calcified pleural plaques C. Enlarged pulmonary arteries D. Reticular interstitial infiltrates E. Right paratracheal lymphadenopathy

have you exposed the skin to an irritant?

A 51-year-old patient comes to the office because of an itchy, painless rash on both hands and forearms for the past two weeks. The rash seems to be worse during the week when they are working at the office and is better on the weekends. The rash is not spreading. The patient used a topical antibiotic ointment, but this did not provide relief. Pulse rate is 71/min, and blood pressure is 135/82 mmHg. Physical examination shows erythema and scaly patches localized to both anterior forearms; mild excoriation is noted. The remainder of the examination shows no abnormalities. Which of the following is the most important question to ask this patient? A. Have you ever had/do you have food allergies? B. Have you exposed the affected skin to an irritant? C. Have you recently been ill with a viral infection? D. Have you recently started taking any new medications? E. Have you recently traveled?

excision biopsy

A 52-year-old woman comes to the office because she has had a mole that bleeds and crusts on her right medial thigh that has also seemed to be enlarging over the past three months. She does not know if the mole was present before these symptoms began. The patient grew up in Arizona and has a history of many blistering sun burns. Medical history includes Crohn disease and anxiety, for which she takes adalimumab and citalopram, respectively. The patient has a 25—pack-year history of cigarette smoking. Temperature is 37.1°C (98.8°F), pulse rate is 66/min, respirations are 14/min, and blood pressure is 110/62 mmHg. Physical examination shows fair skin and numerous freckles. A photograph of the skin lesion is shown. Which of the following is the most appropriate next step in diagnosis? A. Destruction with cryotherapy B. Excisional biopsy C. Initiation of topical corticosteroids D. Shave biopsy E. Watchful waiting and follow-up in three months

non-infectious meningitis

A 53-year-old woman comes to the emergency department because she has had fever and headache for the past 18 hours. She says she is almost finished taking a course of trimethoprim-sulfamethoxazole that she began taking one week ago for treatment of a two-week history of sinus pain that has since resolved. The patient does not have neck pain but she has sensitivity to light. She has no history of recent travel or sick contacts. Medical history includes systemic lupus erythematosus currently treated with hydroxychloroquine and ibuprofen. Temperature is 37.5°C (99.5°F), and blood pressure is 128/84 mmHg. The patient appears mildly uncomfortable. Physical examination, including neurologic examination, shows no abnormalities. Results of blood cultures are negative, and lumbar puncture shows an opening pressure of 100 mmH2O with a lymphocyte count of 15/mm³. Cerebrospinal fluid analysis shows a glucose level that is within normal limits and a mildly elevated protein level. Results of gram stain and culture are pending. Which of the following is the most likely diagnosis? A. Bacterial meningitis B. Cryptococcal meningitis C. Non-infectious meningitis D. Tuberculous meningitis E. Viral meningitis

daily morphine use **secondary hypogonadism

A 54-year-old man comes to the office because he has had fatigue, decreased strength, and erectile dysfunction during the past year. He has not had chest pain, palpitations, edema, dyspnea with exertion, sleep disturbance, polyuria, polydipsia, or depression. Medical history includes asthma as well as lumbar back pain secondary to spondylolisthesis and spinal stenosis. He says the back pain is stable with use of medication. Current medications include gabapentin 600 mg twice daily, diclofenac 50 mg three times daily, extended-release morphine 30 mg daily, baclofen 10 mg three times daily, and inhaled fluticasone 110 µg twice daily. He drinks two beers per week, does not smoke cigarettes, and smokes marijuana three times per week. Height 5 ft 7 in, and weight is 195 lb. Temperature is 36.9°C (98.5°F), pulse rate is 74/min, and blood pressure is 110/68 mmHg. Physical examination shows mild tenderness in the L4-L5 region of the low back. Forward flexion is decreased, and extension is within normal limits. Laboratory studies show the following abnormal results: hemoglobin A1C 5.9%, mean corpuscular volume 79 µm³, and total testosterone 165 ng/dL. Which of the following findings in this patient's history is most likely contributing to the adverse effects that he is experiencing? A. Alcohol use B. Daily morphine use C. Fluticasone dose D. Gabapentin dose E. Marijuana use

sensorineural hearing loss **acoustic trauma

A 55-year-old man comes to the clinic because he has had episodes of high-pitched ringing and roaring in both ears during the past eight years. He says the episodes are becoming more frequent and lasting for longer periods of time. Medical history includes hypertriglyceridemia that is not controlled with lifestyle modifications alone. The patient served in the military for 26 years, and he shoots guns as a hobby but always wears hearing protection. Pulse rate is 65/min and blood pressure is 124/84 mmHg. On physical examination, gross hearing to conversation is intact, and no subjective tinnitus is currently noted by the patient. The external auditory canal is clear bilaterally and the tympanic membrane is pearly gray. Which of the following is the most likely explanation for the findings in this patient? A. Aneurysm of the carotid artery B. Glomus tympanicum tumor C. Sensorineural hearing loss D. Stress E. Uncontrolled hypertriglyceridemia

EGD

A 55-year-old man with chronic alcohol use disorder comes to the office because he has had intermittent black, tarry stools during the past month. He also has had easy bruising, light-headedness, and fatigue. The patient has not had abdominal pain, nausea and vomiting, constipation, or diarrhea, but he says he has had abdominal bloating. He currently drinks 12 to 18 beers daily, does not smoke cigarettes, and does not use illicit drugs. Height is 6 ft 1 in, and weight is 195 lb. Temperature is 36.9°C (98.5°F), pulse rate is 108/min, and blood pressure is 100/57 mmHg. Oxygen saturation is 95%. Physical examination shows scleral icterus. The abdomen is distended, and the liver is palpable 2 cm below the costal margin. Which of the following is the most appropriate screening test at this time? A. Carcinoembryonic antigen test B. Colonoscopy C. Esophagogastroduodenoscopy D. Factor V Leiden deficiency testing E. Helicobacter pyloritesting

hyperparathyroidism

A 55-year-old woman comes to the office for annual follow-up of chronic depression. She says that she is still depressed but stable. The patient also has generalized pain which she describes as "in her bones." Medical history includes a kidney stone that was treated in the emergency department one month ago. Laboratory studies at that time showed an elevated serum calcium level; all other laboratory values were within normal limits. Medications include citalopram 40 mg daily and hydroxyzine 25 mg at bedtime as needed. Temperature is 36.9°C (98.5°F), pulse rate is 70/min, respirations are 16/min, and blood pressure is 132/81 mmHg. The patient's mood is depressed, and her affect is full. She does not have any suicidal ideation. On physical examination, no abnormalities are noted in strength or range of motion of the upper and lower extremities. No joint deformities are visible. Based on this patient's presentation, which of the following is the most likely diagnosis? A. Fibromyalgia B. Hyperparathyroidism C. Hypothyroidism D. Multiple myeloma E. Osteoarthritis

prednisone

A 56-year-old woman comes to the office because she has had daily headaches for the past two weeks. She says the headache is localized to her right temple. She also has had fatigue and discomfort in her jaw when she chews. Temperature is 37.5°C (99.5°F), pulse rate is 80/min, and blood pressure is 126/72 mmHg. Oxygen saturation is 99%. Physical examination shows a pale optic disc on the right. Tenderness to palpation is noted along the right temporal region of the head. No carotid bruits are noted. Laboratory studies show the following: red blood cell count 4.0 million/mm³; hematocrit 35%; hemoglobin level 11.9 g/dL; mean corpuscular volume 83 µm³; mean corpuscular hemoglobin level 30 pg/cell; and erythrocyte sedimentation rate 75 mm/hr. The results of a complete metabolic panel are within normal limits. Which of the following is the most appropriate treatment? A. Ketorolac B. Morphine C. Naproxen D. Prednisone E. Sumatriptan

low-dose CT scan of the chest annually

A 57-year-old woman comes to the clinic for an annual wellness visit. She also reports that she has had a sore throat for the past two days that is worse in the morning and improves throughout the day. She also has had sneezing, itchy eyes, and nasal congestion. The patient has no history of fever, chills, cough, hemoptysis, weight loss, or sick contacts. She has a 40-pack-year history of smoking cigarettes and quit smoking 10 years ago. Pulse rate is 84/min, and blood pressure is 128/90 mmHg. Physical examination shows an erythematous posterior oropharynx with postnasal drainage and a cobblestone appearance. The conjunctivae are watery and erythematous bilaterally. When discussing screening for lung cancer with this patient, which of the following is the most appropriate recommendation? A. Chest x-ray study annually B. Endobronchial ultrasonography every three years C. Low-dose CT scan of the chest annually D. No screening for lung cancer is necessary E. PET/CT scan of the chest every five years

sunlight exposure **pterygium

A 58-year-old man comes to the clinic because he has had a lesion on his left eye that has been slowly growing over the past three years. He says that vision in his left eye has become obstructed because of the lesion, and he feels like there is something in his eye. The patient works in construction and plays video games as a hobby. Medical history includes hypogonadism and depression. Pulse rate is 74/min, and blood pressure is 128/74 mmHg. Physical examination shows a triangular raised lesion extending from the nasal conjunctiva to the nasal cornea. Extraocular movements are intact. Which of the following additional findings on history taking is most likely to be present? A. Hypertension B. Recent diagnosis of conjunctivitis C. Sunlight exposure D. Uncontrolled diabetes mellitus E. Wearing of contact lenses

pneumococcal polysaccharide vaccine

A 59-year-old woman comes to the office for follow-up regarding newly diagnosed congestive heart failure. Currently, she says she feels well and does not have chest pain or palpitations. The patient says she has intermittent leg edema that improves when she sticks to a low-salt diet and avoids ibuprofen. Her exercise tolerance is fair, and she says her endurance has been improving. Medical history includes a myocardial infarction one month ago, hypertension, and breast cancer for which she underwent a double mastectomy. Current daily medications include lisinopril 20 mg, metoprolol 25 mg, furosemide 10 mg, and potassium chloride 10 mEq daily. Pulse rate is 65/min, respirations are 18/min, and blood pressure is 120/80 mmHg. Oxygen saturation is 96%. On physical examination, cardiac auscultation shows a regular rate and rhythm with no rubs, murmurs, or gallops. Trace edema is noted to the mid shin, bilaterally. Auscultation of the lungs shows normal breath sounds. Which of the following immunizations is most appropriate to administer at this time? A. Hepatitis B vaccine B. Human papillomavirus vaccine C. Meningococcal vaccine D. Pneumococcal polysaccharide vaccine E. Varicella vaccine

watchful waiting **molluscum contagiosum

A 6-year-old girl is brought to the office by her mother because she has had had an unsightly rash on her thigh for the past month. Initially, the patient had one to two bumps on her thigh, but now she has 10. The bumps are not painful or itchy. Application of hydrocortisone cream did not change the appearance of the rash. Temperature is 36.6°C (97.9°F), pulse rate is 92/min, and blood pressure is 94/54 mmHg. A photograph of the rash is shown. Which of the following is the most appropriate next step in treatment? A. Cryotherapy with liquid nitrogen B. Initiate therapy with acyclovir daily until the rash resolves C. Initiate therapy with topical imiquimod three days per week for 12 weeks D. Shave excision with a dermablade E. Watchful waiting

cholangitis

A 60-year-old man comes to the clinic because he has had abdominal pain, decreased appetite, fever, and chills for the past three days. He has not had nausea, vomiting, or changes in bowel habits or stool appearance. Medical history includes percutaneous placement of a biliary stent for treatment of gallstones 10 days ago; he says he felt much better after that procedure until his current symptoms began three days ago. Weight is 259 lb. Temperature is 38.4°C (101.1°F), pulse rate is 89/min, and blood pressure is 132/90 mmHg. The patient appears uncomfortable. On physical examination, auscultation of the chest shows no abnormalities. Mild jaundice is noted along with scleral icterus. Abdominal examination shows tenderness to palpation of the right upper quadrant, epigastric region, right lower quadrant, and periumbilical region. Which of the following acute conditions is the most likely cause of the findings in this patient? A. Appendicitis B. Cholangitis C. Cholelithiasis D. Pancreatitis E. Upper gastrointestinal bleed

hydroxyurea **polycythemia vera: hydroxyurea is 2nd line to phlebotomy due to IV drug use in the past

A 60-year-old man comes to the clinic because he has had generalized pruritus, fatigue, and headaches during the past three months. He says he also has had pruritus that worsens when he takes hot showers. Medical history includes obstructive sleep apnea treated with nightly use of a continuous positive airway pressure machine and hypertriglyceridemia treated with fenofibrate 160 mg daily. He used intravenous heroin for 20 years, but he has been taking methadone therapy for the past five years and has been stable. Pulse rate is 90/min, and blood pressure is 140/86 mmHg. Physical examination shows erythematous cheeks and splenomegaly. After significant difficulty in obtaining a blood sample, a complete blood cell count shows the following: white blood cell count 130,000/mm³ (N=3500-10,000/mm³); hemoglobin level 21.0 g/dL (N=13.5-17.0 g/dL); platelet count 485,000/mm³ (N=(130,000-400,000/mm³); and erythropoietin level is decreased. Results of genetic testing and bone marrow biopsy are pending. Which of the following initial interventions is most appropriate? A. Allopurinol B. High-dose aspirin C. Hydroxyurea D. Phlebotomy E. Ruxolitinib

ciprofloxacin

A 60-year-old man comes to the family medicine clinic because he has had fever, chills, dysuria, and lower abdominal pain for the past three days. He has not participated in any recent sexual activity. Temperature is 38.3°C (101.0°F), pulse rate is 80/min, respirations are 18/min, and blood pressure is 124/82 mmHg. Digital rectal examination shows a tender and enlarged prostate. Urinalysis shows pyuria and hematuria. Urine culture is pending. Which of the following is the most appropriate initial drug therapy? A. Ceftriaxone B. Ciprofloxacin C. Doxycycline D. Finasteride E. Tamsulosin

meloxicam

A 62-year-old man comes to the clinic for a follow-up examination one week after he was discharged from the hospital for treatment of an acute upper gastrointestinal bleed due to a gastric ulcer. He says he is feeling much better and currently does not have abdominal pain, nausea, or vomiting. His bowel movements have been normal. Medical history includes bilateral knee arthritis, GERD, and depression. Medications include meloxicam 15 mg daily, omeprazole 40 mg daily, and fluoxetine 20 mg daily. He drinks one to two beers per week, has smoked one pack of cigarettes per day for the past 30 years, and does not use illicit drugs. Vitals are stable. The patient appears pale and fatigued. Physical examination shows conjunctival pallor and angular cheilitis. Mild epigastric tenderness is noted on abdominal examination. No rigidity, guarding, rebound, or organomegaly is noted. Which of the following, had it been discontinued or avoided, would have prevented the development of this patient's upper gastrointestinal bleed? A. Alcohol use B. Cigarette smoking C. Fluoxetine D. Meloxicam E. Omeprazole

initiate anti platelet therapy **ASA or clopidogrel

A 62-year-old man comes to the office because he has had pain in the thighs and calves for the past six 6 months. He says the pain is worse when he is walking long distances and improves with rest. Medical history includes hypertension and erectile dysfunction, and current medications include chlorthalidone 25 mg daily and sildenafil 50 mg daily as needed. He has a 20—pack-year history of cigarette smoking, but he quit 10 years ago. Pulse rate is 66/min, respirations are 16/min, and blood pressure is 110/72 mmHg. Oxygen saturation is 96%. Physical examination of the skin shows hair loss on legs from the knee distally; otherwise, no abnormality in color or appearance is noted. Weak dorsalis pedis and posterior tibialis pulses are palpable. Strength and range of motion in the lower extremities is within normal limits. Ankle brachial index is 0.6 in the right lower extremity and 0.8 in the left lower extremity. Which of the following next steps is most appropriate to prevent disability from this condition? A. Initiate antiplatelet therapy B. Initiate leg compression therapy with graded compression stockings C. Initiate therapy with an additional antihypertensive agent D. Refer for endovascular procedures for revascularization E. Refer for surgical revascularization by popliteal bypass

aortic aneurysm screening

A 66-year-old man comes to the office for annual physical examination. He has no specific symptoms. Medical history includes hypertension, gout, and depression. Medications include enalapril 10 mg twice daily, allopurinol 100 mg daily, and paroxetine 10 mg daily. He has no history of surgery. Family history includes hypertension in both of his parents and colon cancer in his mother at age 80. He has a 10—pack-year history of smoking cigarettes, but he quit 20 years ago. He drinks one to two beers per week and does not use illicit drugs. He says he eats a moderately healthy diet and exercises with brisk walking for 40 minutes three days per week. Body mass index is 22 kg/m². Pulse rate is 74/min, respirations are 16/min, and blood pressure is 110/67 mmHg. Oxygen saturation is 95%. Health screenings completed one year ago included a colonoscopy which showed no abnormalities, lipid screening which was within normal limits, and diabetes screening which was negative; prostate-specific antigen level was within normal limits. Which of the following screening tests is most appropriate to recommend at this time? A. Aortic aneurysm screening B. CT scan to test for lung cancer C. Exercise stress test D. Fecal immunochemical test E. Hemoglobin A1C test

helicobacter pylori

A 66-year-old woman from Nepal has had burning abdominal pain, nausea, and abdominal bloating during the past two months. She says she recently relocated to the United States to be closer to her family. The patient lives with her daughter and son as well as both of their extended families. She takes medication for hypertension but is otherwise healthy. Which of the following is the most likely causative organism? A. Candida albicans B. Clostridium difficile C. Enterovirus D. Group A Streptococcus E. Helicobacter pylori

pneumococcal polysaccharide vaccine

A 67-year-old man comes to clinic because he has had productive cough for the past four months. He says he coughs up green sputum in the mornings and has had some difficulty breathing, particularly when going up the stairs to his apartment. He also has had occasional chest tightness and wheezing. The patient is unsure about his medical history because he has not been examined by a practitioner in 15 years. Pulse rate is 88/min, and blood pressure is 158/100 mmHg. The patient appears obese. On physical examination, auscultation of the lungs shows prolonged expiration and diffuse wheezing with rhonchi. Spirometry shows a ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FEV) of 0.5 with an FEV1 of 75%. Which of the following immunizations is most appropriate to administer at this time? A. Haemophilus influenzaetype B vaccine B. Meningococcal ACWY vaccine C. Pneumococcal conjugate vaccine D. Pneumococcal polysaccharide vaccine E. Tetanus, diphtheria, and pertussis vaccine

central retinal artery **retinal artery occlusion

A 67-year-old man comes to the clinic because he has had vision changes in the right eye for the past 20 minutes. He says he was playing outside with his grandchild when he noticed an abrupt, painless loss of vision in his right eye. Medical history includes hypertension, hyperlipidemia, and coronary artery disease controlled with losartan 50 mg, rosuvastatin 20 mg, and aspirin 81 mg daily. His pulse rate is 78/min, and blood pressure is 134/84 mmHg. On physical examination, visual acuity is 20/40 in the left eye and 20/200 in the right eye. Extraocular movements are intact. Both pupils constrict quickly when a light is shown in the left eye. But when a light is shown in the right eye, the right pupil constricts slowly. Funduscopic examination shows a pale right retina with a central red spot. A defect in which of the following structures is the most likely cause? A. Anterior ciliary artery B. Branch retinal artery C. Central retinal artery D. Cilioretinal artery E. Long posterior ciliary artery

enlarged, contender, firm and smooth prostate

A 68-year-old man comes to the family medicine clinic because he has had a variety of urinary symptoms during the past three months. He says he has had increased urinary frequency, difficulty initiating stream, a weak urinary stream, and post-void dribbling. He has no other symptoms or medical concerns. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Result of prostate-specific antigen measurement is pending. Urinalysis shows no abnormalities. Which of the following findings is most likely on digital rectal examination? A. Enlarged prostate with palpable seminal vesicles B. Enlarged, asymmetrical, and indurated prostate C. Enlarged, hard prostate with a unilateral nodule D. Enlarged, nontender, firm, and smooth prostate E. Enlarged, tender prostate with loss of the median groove

attention-deficit/hyperactivity disorder

A 7-year-old boy is brought to the clinic by his mother because he has been having difficulty at school for the past 9 months. The mother says that the patient has poor attention, distractibility, and poor academic performance, although his teachers find him to be pleasant. His behavior at home seems normal unless he is asked to sit and work on homework or complete a sustained task such as assembling a Lego project, in which case, she says he will have a meltdown. The patient has met all developmental milestones, and he has no chronic disease conditions or known social stressors. Which of the following behavioral disorders of childhood is most likely responsible for this patient's symptoms? A. Attention-deficit/hyperactivity disorder B. Autism spectrum disorder C. Bipolar disorder D. Learning disorder E. Oppositional defiant disorder

proximal bronchus **squamous cell carcinoma

A 72-year-old man comes to the clinic because he has had worsening cough and shortness of breath over the past three months. He is a retired uranium miner with a history of a myocardial infarction, hypertension, and hyperlipidemia, but he is not currently taking any medications because he "doesn't believe in them." The patient has a 50—pack-year history of smoking cigarettes, but he quit about three months ago because he was having financial difficulties and could no longer afford the cigarettes. Pulse rate is 74/min, and blood pressure is 178/100 mmHg. On physical examination, auscultation of the lungs shows wheezing. Cardiac auscultation shows a regular rate and rhythm with no murmurs, rubs, or gallops. Laboratory studies show hemoglobin level of 11 g/dL, calcium level of 11.5 mg/dL, and albumin level of 3.8 g/dL. Chest x-ray study of this patient is most likely to show a lesion in which of the following locations? A. Acinus B. Apex of the lung C. Base of the lung D. Pleura E. Proximal bronchus

acetaminophen **mild-moderate osteoarthritis

A 76-year-old woman who is overweight comes to the clinic because she has had worsening knee pain over the past four months. She says that both of her knees hurt and are stiff in the morning but generally feel better within 30 minutes. She has increased pain during the day with activity and has relief of pain when she rests. However, once she moves again, she feels stiff. She has no history of injuries, surgeries, or trauma to the knees. The patient is a retired postal worker who walked her route for over 20 years. She says she has gained significant weight since retiring 11 years ago. Medical history includes a gastrointestinal bleed when she was in her 40s. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows crepitus bilaterally with no redness or swelling. Plain x-ray studies of the knees show joint space narrowing and medial osteophytes. Which of the following is the most appropriate next step in management? A. Acetaminophen B. Ibuprofen C. Injections of hyaluronic acid D. Methotrexate E. Total knee replacement

decline the daughter's request

A 78-year-old woman is brought to the clinic by her daughter for a medication refill. The patient sustained a stroke two years ago and has residual Broca aphasia and left-sided weakness. Current medications include atorvastatin 80 mg daily, aspirin 81 mg daily, and lisinopril 20 mg daily. Pulse rate is 82/min, and blood pressure is 124/74 mmHg. Physical examination shows no new abnormalities. The patient's daughter is concerned about her mother and would like her mother to be declared incompetent and unable to make her own medical decisions. The patient becomes very upset when she hears this information. Which of the following is the most appropriate response? A. Administer the Montreal Cognitive Assessment test B. Agree with the daughter and declare the patient as incompetent C. Ask the patient if she is incompetent D. Decline the daughter's request E. Refer the patient to a psychiatrist for evaluation of incompetence

amoxicillin-clauvanic acid **otitis media and conjunctivitis will most likely have an infection with Haemophilus

A 9-year-old boy is brought to the clinic by his mother because he has had fever as well as redness and white-yellow discharge of both eyes for the past two days. The mother says the patient also has had right ear pain during this time. Temperature is 39.0°C (102.2°F). Physical examination shows a bulging tympanic membrane on the right. A photograph of the eye is shown. Which of the following is the most appropriate treatment? A. Amoxicillin-clavulanic acid B. Azithromycin C. High-dose amoxicillin D. Ofloxacin drops E. Supportive care only

initiate therapy with ursodeoxycholic acid

A 94-year-old woman comes to the office for follow-up three days after she was evaluated in the emergency department (ED) for upper abdominal pain. An abdominal ultrasonography obtained in the ED showed several gallstones. She says she felt much better after administration of fluids and analgesic medication. Currently, the patient still has some mild pain in the right upper quadrant, but it is much improved. She has not had fever, nausea and vomiting, or diarrhea. She has had chronic fatigue. Medical history includes atrial fibrillation, hypertension, sleep apnea, and a transient ischemic attack. Height is 5 ft 1 in, and weight is 145 lb. Temperature is 36.7°C (98.1°F), pulse rate is 75/min, and blood pressure is 140/85 mmHg. Oxygen saturation is 95%. Physical examination shows a soft abdomen with mild right upper quadrant and epigastric tenderness. Murphy sign is negative, and no hepatosplenomegaly is noted. Laboratory studies obtained in the ED show mild elevations in aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase levels. Imaging studies show cholelithiasis with multiple stones <5 mm in size; no thickening or obstruction of the gallbladder wall is noted. Which of the following is the most appropriate next step? A. Initiate therapy with naproxen B. Initiate therapy with rosuvastatin C. Initiate therapy with ursodeoxycholic acid D. Refer for endoscopic retrograde cholangiopancreatography E. Refer for laparoscopic cholecystectomy

what implicit biases do I have?

A physician assistant attends a diversity training seminar through her workplace in a hospital. The moderator discusses several health disparities such as economic stability, education, and the healthcare system. The moderator asks the attendees to think about implicit bias in healthcare and how it affects patients. Which of the following questions is most important for the physician assistant to ask herself regarding this subject? A. I am not racist, so why do I even need to question myself about this subject? B. I can't think of a time I was biased so doesn't that mean I treat everybody equally anyway? C. Should I attend every diversity seminar I can so I do not appear biased? D. Should I even see patients of a different culture because I might be biased? E. What implicit biases do I have?

inform all patients, colleagues, and institutions of his financial relationship

A physician assistant is beginning work at his first job in an outpatient family medicine clinic. He receives an invitation from a pharmaceutical representative for a presentation on a new medication at an upscale steak restaurant. He also receives a pecan pie from a local ophthalmologist's office at Christmas time. Finally, he has a financial relationship with a pharmaceutical company as a consultant. Which of the following must this provider do in order to maintain his ethical integrity? A. Accept all gifts regardless of cost B. Decline all invitations to non-CME presentations with meals C. Go to the presentation but do not accept any of the food or drink offered D. Inform all patients, colleagues, and institutions of his financial relationships E. Send the pecan pie back to the ophthalmologist's office

addend the note in the incorrect chart and document in the correct chart

A provider has a patient encounter with a 64-year-old woman and documents and signs the note while in the examination room. While doing chart review later, the provider realizes that they had the previous patient's chart pulled up in the examination room, and the documentation was accidentally entered into the chart of a 23-year-old woman. There is no information in the note that identifies the patient. Which of the following is the most appropriate next step? A. Addend the note in the incorrect chart and document in the correct chart B. Delete the erroneous note and document in the correct chart C. Immediately inform the patient about the mistake D. Inform the office manager about the mistake E. Leave everything as it is and make a mental note about the mistake for next time