Family Medicine Aquifer Cases

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

E

Mrs. Payne asks about the HPV vaccine. You tell her: Choose the single best answer. A. She is out of the approved age range to receive Gardasil 9. B. Due to her age she will need to receive three doses of Gardasil 9. C. If she has a history of HPV + co-testing she shouldn't receive the vaccine. D. If she gets the vaccine she should no longer have co-testing done E. TBD

B

67-year-old man comes to the clinic for a health maintenance visit. His past medical history is significant for chronic allergic rhinitis, severe chronic obstructive pulmonary disease (COPD), osteoporosis, psoriasis, atrial fibrillation, and benign prostatic hypertrophy. Vital signs show his temperature is 36.8C (98.2F), pulse is 76 beats/minute, respiratory rate is 12 breaths/minute, and blood pressure is 118/70 mmHg. His weight is 129.2 kg (285 lbs) and his body mass index (BMI) is 41. Which of his co-morbidities is most likely to be associated with his BMI? A. Atrial fibrillation B. Benign prostatic hypertrophy C. Chronic allergic rhinitis D. Osteoporosis E. Psoriasis

A

A 15-year-old female with a history of allergic rhinitis presents to the clinic with a five day history of productive cough and wheezing that is worse at night. She denies any shortness of breath, chest pain, or fever. The patient states that she has had similar symptoms in the past, especially when seasons change. The only reported past medical history is atopic dermatitis which is well-controlled with an over-the-counter steroid cream. What is the best next step? A. Prescribe a short acting beta agonist inhaler with a short course of oral steroids B. Prescribe a long acting beta agonist inhaler C. Prescribe a daily corticosteroid inhaler D. Prescribe a daily corticosteroid and long acting beta agonist inhaler E. Prescribe antibiotic therapy

A

A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy? A. Heroin B. Alcohol C. Marijuana D. Cocaine E. Tobacco

A

A 19-year-old female with no significant past medical history is the driver in a motor vehicle accident and is brought to the Emergency Department by EMS. She is complaining of severe pain in her right lower extremity that has worsened since the accident. In addition, she has started to notice what she describes as "burning and tingling" in her right foot. On physical exam, her right calf is edematous and tender with tense overlying skin. There is no swelling or tenderness of the right foot or ankle but the right dorsalis pedis and posterior tibial artery pulses are barely palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. What is the next best step in the management of this patient? A. Emergent surgical consultation B. Diagnostic imaging of right foot and ankle C. Immobilize leg and ankle with a cast D. Reassurance and icepacks q 2 hours E. Urgent EMG of the right lower extremity

A

A 63-year-old male with a past medical history significant for hypertension, COPD, and long-term tobacco use is accompanied by his wife to a hospital follow-up clinic appointment. She is very concerned about her husband's recent hospitalization for a COPD exacerbation and asks what can be done to improve her husband's health. Which of the following holds the greatest long-term health benefit for this patient? A. Cessation of tobacco products B. Immunization against pneumococcus C. Prednisone taken daily D. Pulmonary rehabilitation program E. Tiotropium (Spiriva) inhaled daily

A

A 20-year-old female G1P0 at 37 weeks gestation presents to the emergency department with the concern of a headache that has not gone away, despite taking acetaminophen 3 hours ago. She reports no visual changes, but admits to feeling nauseous and having stomach pain that she attributed to having a "bad case of heartburn." She states she went to her primary care physician that morning, and her blood pressure was elevated. She states she was asked to do a 24-hour urine collection when she left the clinic, but has not been able to use the restroom. Her vitals reveal a blood pressure of 182/106, a pulse of 92, a temperature of 98.2o F, a respiration rate of 20, and a pulse oximetry of 97%. What is the diagnosis and the best course of management? A. Severe gestational hypertension - admitting the patient to the hospital, with administration of magnesium-sulfate, management of hypertension, workup for preeclampsia, followed by possible induction or cesarean section B. Pharmacological management with 1 tablet metoprolol 50mg bid C. Admitting the patient to the hospital, and giving IV fluids and IV labetalol 20 mg, followed by close monitoring until a urinalysis is obtained D. Pharmacological management with Macrobid 100mg q12 hours x7 days E. Admitting the patient to the hospital, followed by pharmacologic management of Lopressor HCT 50/20 bid, and obtaining a urinalysis

A

A 24-year-old female presents to the clinic complaining of nausea and headache for the last week. She denies any fever, changes in bowel movements, or sinus symptoms. She is sexually active with one partner, and admits to not being consistent with her birth control pills. She does not remember the date of her last menstrual period, and reports a history of irregular menstrual cycles. She has not taken a home pregnancy test. Her vital signs reveal a blood pressure of 124/76 mmHg, a pulse of 78/min, respirations of 20/min, temperature of 98.1o F (taken orally), and an oxygen saturation of 98% on room air. The first most appropriate step in management is to: A. Obtain a urine hCG. B. Admit the patient to the hospital for monitoring. C. Obtain a serial serum hCG. D. Perform a pelvic exam to test for sexually transmitted infections. E. Ask the patient to return to the clinic after she has taken a home pregnancy test, and prescribe Zofran 8mg to control her nausea.

A

A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A. Chest x-ray and tuberculin skin test B. CT of nasal sinuses C. Spirometry, before and after bronchodilator therapy D. Chest x-ray and methacholine challenge E. None needed, patient likely has habitual cough

A

A 41-year-old male with no significant past medical history is brought to the Emergency Department after falling to the ground in the middle of a pick-up basketball game with friends. He did not lose consciousness nor hit his head when he fell. As he landed on the ball of his foot after having taken a shot, he recalls hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and tender to palpation. He is unable to plantarflex his right foot. What is the most likely diagnosis of his current condition? A. Achilles tendon rupture B. Ankle arthritis C. Ankle ligament sprain D. Ankle tendonitis E. Calcaneal fracture

A

A 52-year-old woman comes to the clinic to discuss weight loss. Her medical history is significant for obesity; her body mass index (BMI) is 41; hypertension; hyperlipidemia; and obstructive sleep apnea. She knows that losing weight will help her hypertension and hyperlipidemia, but she doesn't feel like these things bother her. Her only other concern is fatigue; she doesn't use her continuous positive airway pressure (CPAP) machine, because she doesn't like the mask. What additional information can you provide her to help motivate her weight loss? A. Her obstructive sleep apnea may improve with weight loss. B. Her risk of cardiovascular disease is similar to that of a woman with a normal BMI. C. Obesity is mainly a cosmetic issue. D. Surgery should be considered before diet and exercise.

A

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

A

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

A

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

A

A mother brings her 20-day-old male infant to your clinic for the child's first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends' infants. On exam, you note an eczematous rash and a musty odor to the infant's skin and urine. Which enzyme deficiency would you expect the infant to display? A. Phenylalanine hydroxylase B. Cystathionine synthase C. Sphingomyelinase D. Alpha-L-iduronidase E. Glucose-6-phosphatase

A

Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A. Wilms' tumor B. Teratoma C. Renal cell carcinoma D. Hepatoblastoma

A

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

A

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

A

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

A

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

A

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

A

Which of the following is a comorbid condition that needs to be controlled in order to improve asthma symptoms? A. High BMI B. Insomnia C. Atopic dermatitis D. Anxiety E. Anemia

A

A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A. Sheets of lymphocytes with interspersed macrophages B. Small round blue cells with dense nuclei forming small rosettes C. Hypersegmented neutrophils D. Stacks of RBCs E. Enlarged cells with intranuclear inclusion bodies

B

A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby? A. Tobacco exposure B. Alcohol exposure C. Congenital rubella D. Vertically transmitted HIV E. Congenital CMV infection

B

Mr. York is a 44-year-old man presenting for evaluation of an eyelid lesion (xanthelasma). He noticed the lesion about one year ago. There is no associated itching, discharge, or other bothersome symptoms. Which of the following is the next-best step in the management of the eyelid lesion? Eyelid lesion A. Low potency topical corticosteroid B. Measurement of serum cholesterol levels C. Measurement of serum uric acid levels D. No further management E. Skin biopsy

B

A 20-year-old healthy female with no significant past history presents to your clinic with dysuria, lower abdominal discomfort, frequency, and urgency for one day. She notes an odor to her urine but denies any change in its appearance. She reports no vaginal discharge or fever. Review of systems is otherwise negative. The patient denies sexual activity and reports normal menses. There are no known allergies. Her examination is remarkable for mild suprapubic tenderness. Urinalysis: negative; urine HCG: negative. Which of the following would be the next best step in her clinical management? A. Await urine culture results before any treatment B. Initiate antibiotic treatment while awaiting urine culture results C. Insist that a pelvic exam and cervical DNA probe be performed today D. Reassure that this is not a urinary tract infection E. Urine DNA probe

B

A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn? A. Hepatosplenomegaly B. Cardiac defects C. Absent red reflex D. Chorioretinitis E. Tremors

B

A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has an aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago and her other vital signs are stable. On breast exam, you note a mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following places this patient at increased risk for breast cancer? A. Age B. Weight C. Parity history D. Family history of cancer E. Age of menarche

B

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

B

A 52-year-old female presents for her third visit this year for productive cough. She has a 34-pack year history but has weaned down to only five cigarettes per day since she began to notice a cough. With her smoking history, you are concerned about the possibility of COPD. Which of the following criteria is included in the GOLD classification for diagnosis of COPD? A. Brain natriuretic peptide >500 B. Post-bronchodilator FEV1/FVC ratio of < 70% of predicted C. Flattened diaphragm on lateral chest film D. Left ventricular function <40% E. Oxygen saturation level of < 89%

B

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

B

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

B

A 61-year-old male with a history significant for COPD presents to the emergency department for shortness of breath. Upon exam you see a thin male with perspiration on his forehead. He is having a difficult time answering questions because "he just can't catch his breath." You order an arterial blood gas on the patient. The results are pH 7.22 (7.34-7.44) PaCO2 81 mmHg (35-45 mmHg) PaO2 55 mmHg (75-100 mmHg) . What is the next best step in diagnosis or management? A. Administer Rocephin B. Begin noninvasive mechanical ventilation C. Immunize against influenza D. Provide nicotine replacement patches E. Repeat the test in two hours

B

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

B

An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy? A. Only rescue inhaler PRN B. Low dose inhaled corticosteroids C. Medium dose inhaled corticosteroids and course of oral corticosteroids D. Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids E. Course of oral corticosteroids

B

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

B

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

B

Ms. H is a 68-year-old woman with a medical history significant for obesity, type II diabetes, hypothyroidism, hypertension, and recently diagnosed hyperlipidemia. Her most-recent lipoprotein (LDL), three months ago, was 197 mg/dL. At that time, atorvastatin was initiated. Other medications include metformin, insulin glargine, amlodipine, hydrochlorthiazide, and levothyroxine. Which of the following may be contributing to her elevated LDL? A. Amlodipine B. Hydrochlorthiazide C. Insulin glargine D. Levothyroxine E. Metformin

B

You are following a 32-year-old G2P1 female who is in active labor. Her pain is well managed with an epidural. Her vital signs are normal except for mild tachycardia. Her external fetal monitor tracing shows early decelerations which coincide with the beginning and end of a contraction. It is the characteristic "mirror image" of a contraction. What condition is the above tracing most consistent with? A. Cord compression B. Head compression C. Uteroplacental insufficiency D. Fetal bradycardia E. Fetal tachycardia

B

You are seeing a 55-year-old female with a past medical history of hypertension, diabetes, and gout. She has no complaints today and is here to manage her chronic conditions. She is taking her medications, which include lisinopril 10 mg daily, metformin 500 mg twice daily, and allopurinol 100 mg daily. She is trying to focus on her diet in an effort to lose weight. She smokes a pack of cigarettes every day, and she is worried that quitting will make her gain weight and worsen her diabetes. Her family history is positive for a recent myocardial infarction in her father at age 78. Her vitals today include a blood pressure of 128/78 mmHg, pulse of 78 beats/minute, respirations of 14/minute and a BMI of 32 kg/m2. Her general exam is unremarkable today. Which of the following is not a risk factor for coronary artery disease in this patient? A. Hypertension B. Her family history C. Smoking D. Diabetes E. Obesity

B

You are seeing a 92-year-old male in the hospital. He was admitted after a fall in which he broke his hip. It is now post-op day two from surgery to repair the fracture. His children report that he has been very confused this morning, with varying levels of alertness. Yesterday, he had been recovering well and even participated in physical therapy. Today, he does now know where he is and is at times combative with his care team. His medical history is positive only for hypertension. His medications include amlodipine 5 mg daily and morphine 4 mg IV every 4 hours as needed for pain. His vital signs are all normal today, and his general exam is unremarkable except for expected post-operative changes to his hip. He is somnolent during the examination. Today's labs include a normal CBC and basic metabolic panel. A urinalysis reveals no leukocyte esterase and is nitrite negative. What is the most likely cause of his current mental status? A. Acute stroke B. Morphine C. Residual effects of the anesthetic medications from his surgery D. Pneumonia E. Urinary tract infection

B

A 10-year-old boy comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup? A. Response to inhaled beta-agonist B. Hyperinflation in one lung field C. Alevolar consolidation in the RLL D. Positive PCR for pertussis E. Fluffy bilateral infiltrates and a large heart on chest x-ray

C

A 13-year-old female comes to your clinic stating she has been having fever and chills for three days, and aching muscles for the last two days. She states she has also had a mild cough, but is not having any difficulty with breathing. She is up to date on vaccines and her only other medical history is having her tonsils and adenoids removed last year. On physical exam, you find her temperature to be 102.6 degrees F, pulse 96, and her BP to be 108/62 mmHg. She has clear rhinorrhea and her oropharynx is mildly erythematous. The rest of her physical exam is normal, and a rapid strep test in the office is negative. What is the next best step in management? A. Zanamivir B. Aspirin C. Ibuprofen D. Amantadine E. Albuterol

C

A 22-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing volleyball. The ankle quickly became edematous, but she used ice and was able to bear weight on the foot. When the patient presents at the family medicine ambulatory practice two days following her injury, minimal swelling is noted and motor functions and sensation are preserved. She has tenderness at the anterior lower lateral malleolus but not inferiorly or posteriorly. You diagnose her with an ankle sprain. You recommend continued relative rest and also tell the patient to keep it elevated and ice it several times during the day to help with the pain and swelling. You inform the patient that immobilization and compression is good for the conservative management of her condition. What is the best compression device to use in this situation? A. Compression stockings B. Elastic wrap C. Semi-rigid ankle support D. Solid cast for eight weeks E. Tape

C

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

C

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

C

A 32-year-old female at 33 weeks and 5 days gestation (G2P1) presents to the clinic with headache and RUQ abdominal pain. Blood pressure is 172/121 mmHg on examination while seated. No visual changes noted. Edema is present in the hands, bilaterally. Urine dipstick demonstrated 4+ protein. FHT are 117. Which of the following is the most appropriate next step in the management of this patient? A. Twice-weekly non-stress testing B. Daily aspirin C. Expedited delivery of the premature fetus D. Lisinopril E. Strict bed rest until 37 weeks

C

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

C

A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? A. Ideal B. Morbidly (very severely) obese C. Obese D. Overweight E. Underweight

C

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

C

A 63-year old woman comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago was normal. She has never had an abnormal Pap smear. At the age of 45 she had a total hysterectomy for fibroids. You tell her she does not require a Pap smear today because: A. She has never had an abnormal Pap smear B. She is not sexually active C. She had a total hysterectomy for fibroids D. She is 63 years old E. She experienced menopause more than 10 years ago

C

A 67-year-old female with an 80 pack year smoking history presents to an urgent care for worsening shortness of breath. She also reports her chronic cough is more frequent and is producing greenish mucous throughout the day. She is using her inhaler every two hours and has been taking an antibiotic left over from a previous sinus infection. On exam there is a whistling noise when she exhales. What other treatment should you consider at this time? A. Digoxin B. Furosemide C. Prednisone D. Propranolol E. Theophylline

C

A 9-month old baby boy comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? A. Influenza, Hep B, IPV, DTaP B. Influenza, IPV C. Influenza, Hep B, IPV D. Hep B, DTaP, IPV E. Hep B, IPV, and MMR

C

A 9-year-old boy presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him? A. Oral antibiotics B. Short-acting beta agonist PRN C. Short-acting beta agonist PRN with low-dose inhaled corticosteroid D. Short-acting beta agonist PRN with medium-dose inhaled corticosteroid E. Long-acting beta agonist

C

A 9-year-old male who moved to the United States from Canada one year ago presents to your clinic with a three day history of fever, sore throat, and muscle aches. He lives at home with his parents who practice strict vegetarianism, and he does not eat meat of any kind. He is up to date on all vaccinations, and review of his medical records indicates that he has had several episodes of otitis media in the last five years. He was hospitalized twice in the past, once for a splenic rupture sustained in a MVA, and the second time was two months ago when he was diagnosed with Kawasaki disease for which he was put on daily aspirin. You suspect a viral infection and order the appropriate tests. Which of the following is the greatest risk factor for complications of your suspected diagnosis in this patient? A. Recent immigrant B. Splenectomy C. Long-term aspirin therapy D. Age < 10 E. Decreased Vitamin B-12

C

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

C

Mr. Rodriguez is a 32-year-old male who presents with three months of post-prandial epigastric burning. He reports no relief with antacid therapy. He has no allergies and no significant past medical history. He denies any hematemesis, odynophagia, dysphagia, hoarseness, or sore throat. Physical exam is unremarkable other than epigastric tenderness. H. pylori IgG serology is positive. Which of the following treatment regimens will most likely be successful in treating Mr. Rodriquez? A. Omeprazole daily for 8 weeks B. Omeprazole twice daily for 4 weeks C. Omeprazole twice daily, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily D. Omeprazole daily, clarithromycin 500mg twice daily, and tetracycline 500mg three times daily E. Omeprazole twice daily, tetracycline 500mg three times daily, and metronidazole 500mg twice daily

C

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

C

Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy's age to be based upon his developmental milestones? A. 12 months B. 15 months C. 18 months D. 30 months E. 36 months

C

You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? A. Perform a brain-stem auditory evoked potential hearing screen B. Perform a screening exam for autism C. Reassure the parents that the boy's development appears normal D. Refer the child to a developmental specialist for comprehensive evaluation E. Refer the child to a specialist for evaluation of his delayed motor development

C

You are seeing a 72-year-old female with a recent diagnosis of diastolic heart failure (HFpEF) with an ejection fraction of 60% on a recent echo. She was given a diuretic in the ER last week and told to follow up with you. She complains of mild new dyspnea on exertion, orthopnea and lower extremity edema. On exam, her vitals include a blood pressure of 142/86 mmHg, pulse of 84 beats/minute, respirations of 16/minute and oxygen saturation of 98% on room air. Pulmonary exam reveals mild bibasilar crackles, cardiac exam reveals a regular rate and rhythm with no murmurs, and her extremities have 1+ edema to the lower shins. Of the following, which would be the most appropriate choice of medication for this patient? A. Amlodipine B. Digoxin C. Metoprolol succinate D. Hydrochlorothiazide E. Spironolactone

C

A 28-year-old male comes to the Emergency Department with shortness of breath, cough and wheezing for the last 4 hours. He states that he was diagnosed with asthma recently, and is currently using inhaled corticosteroid with a long acting B2-agonist daily to control his symptoms. His RR is 34/min; Temp: 98.8 degrees F; O2sat: 88%; BP: 130/85 mmHg. What treatment should be given to this patient first? A. Albuterol breathing treatment using a nebulizer B. Intravenous corticosteroids C. Ipratropium breathing treatment using a nebulizer D. Oxygen E. Intravenous third generation cephalosporin

D

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

D

A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with? A. Does not awaken patient from sleep B. Paroxysmal C. Barking cough D. Worse at night E. Associated with crackles on exam

D

A 40-year-old male presents to the clinic with dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He denies fever, but does report some continued shortness of breath. He is a smoker but only smokes 1-2 cigarettes a day for about six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis? A. COPD B. Foreign body aspiration C. Pneumonia D. Asthma E. Pulmonary embolism

D

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

D

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

D

A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral crackles at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What diagnostic test would you perform first? A. Exercise stress test B. Pharmacologic stress test C. Echocardiogram D. Electrocardiogram E. Cardiac catheterization

D

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

D

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

D

An 18-year-old non-smoking male comes to the clinic with cough, chest tightness, and difficulty breathing. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough primarily at night since he was 4 years old. He has no past surgical history and no recent travel. On physical exam, you notice the patient appears in mild distress, has hunched shoulders, is using accessory muscles during respiration, and is only able to talk in two to three word sentences. His vitals are: Pulse 125/min, O2 sat 88%, BP 100/70 mmHg. On auscultation, you hear wheezing on inspiration and expiration throughout both lungs. You also notice a prolonged expiratory phase. What is the most likely diagnosis? A. Cystic Fibrosis B. CHF exacerbation C. Foreign body aspiration D. Severe asthma exacerbation E. Pulmonary embolism

D

It is November and you are working in a small, rural, emergency department serving a community who is currently going through a flu epidemic. Your next patient is a 4-year-old male who was brought in by his mother for a sore throat and fever that started two nights ago. She says he has a mild cough, and is complaining of headaches as well. Since last night, he has had a decreased appetite and hasn't been his normal, active self. She also wants you to know that he is allergic to eggs and latex, and uses an inhaler once a month for asthma like symptoms. On physical exam you note an erythematous throat, clear rhinorrhea, and rhonchi on auscultation. A rapid strep test was performed in the office and is negative. His last well child check was 14 months ago, and his mother says she knows he is due for another but her schedule has been too busy. What is the next best step in management? A. Flu Shot B. Amoxicillin therapy C. FluMist (influenza vaccine, live intranasal) D. Tamiflu (oseltamivir phosphate) E. Influenza test.

D

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

D

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

D

Ms Smith is a 38-year-old female with a significant past medical history of hypercholesterolemia who presents to her primary care physician after 4 weeks of episodic epigastric discomfort. She reports a recurrent ache-like sensation in the epigastric region occurring about 10 minutes after eating and lasting for several hours. The pain does not appear to be associated with any particular food. She denies any odynophagia or dysphagia. Ms Smith is a smoker, with a 30-pack year history. You are concerned about peptic ulcer disease. Which additional history finding would increase your level of concern? Choose the single best answer. A. Report of hoarseness B. Epigastric discomfort associated with recumbency or bending C. Bouts of recurrent laryngitis D. Return symptoms despite consistent use of antacids E. Sour or bitter taste in mouth

D

Ms. Tsvetanova is a 42-year-old woman with no significant past medical history presenting to establish care with her primary care physician. On review, she notes a weight gain of 14 kg (30 lbs) over the last three years. She attributes this mostly to her sedentary lifestyle, snacking, and difficulty with portion control. She works as a receptionist for a local physician's office and spends most of her day sitting. She denies constipation, low energy, cold intolerance, muscle weakness, depressed mood, easy bruisability, or other skin changes. On physical exam, vital signs reveal temperature is 36.8C (98.2F), pulse is 82 beats/minute, respiratory rate is 12 breaths/minute, blood pressure is 130/82 mmHg, weight is 81.6 kg (180 lbs), and height is 163 cm (64 in). The remainder of her physical exam is normal. Which of the following laboratory tests is most appropriate for the evaluation of this patient? A. 24-hour urine catecholamine levels B. 24-hour urine cortisol level C. Basic metabolic profile D. Lipid profile E. Thyroid stimulating hormone (TSH)

D

Sally is a generally healthy 27-year-old female graduate student who presented to your office twelve weeks ago with episodic post-prandial epigastric burning. This had been bothering her for nearly six months but she had been busy with her thesis and was unable to find the time necessary for an appointment. She reported this year has been particularly stressful, with limited time resulting in increased consumption of coffee and take-out fast food. At that time, she began an eight-week trial of omeprazole. She returns now with no improvement of her symptoms. She discontinued the omeprazole one month ago because she ran out of the medication. She has no additional symptoms and physical exam is unremarkable. Which of the following is the most appropriate next step in her management? A. Refer her for an upper gastrointestinal endoscopy B. Begin treatment with triple therapy of pantoprazole, clarithromycin, and azithromycin for 14 days C. Continue omeprazole for another 4 weeks with close follow up D. Administer a urea breath test E. Switch PPI from omeprazole to pantoprazole

D

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

D

You are seeing a 63-year-old male with hypertension, diabetes, and a history of an NSTEMI two years ago. His most recent echocardiogram reveals mild hypokinesis of the inferior wall of the left ventricle and a LV ejection fraction of 40%. Shortly after his MI, he was treated for symptoms of congestive heart failure, but he has not has any such symptoms since then. His exercise tolerance is excellent. Today his physical exam is completely unremarkable. The correct pairing of NYHA functional class and ACCF/AHA Stage of CHF is which of the following for this man? A. NYHA II / Stage C B. NYHA I / Stage A C. NYHA I / Stage B D. NYHA I / Stage C E. NYHA II / Stage B

D

56-year old male with a past medical history of hypertension and type 2 diabetes mellitus presents with progressive dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and dependent edema over the prior 4 days. His social history is notable for a 30 pack-year tobacco history and occasional marijuana use. His family history is positive for bypass surgery in his mother at the age of 62. On exam, his vitals include a blood pressure of 166/86 mmHg, pulse of 98 beats/minute, respirations of 21/minute and a BMI of 32 kg/m^2. He appears mildly dyspneic. His neck reveals an elevated jugular venous pulse, his chest exam reveals bilateral crackles in the lower lung fields, and his cardiovascular exam reveals mild tachycardia, a regular rhythm, and no murmurs. His abdominal exam is unremarkable, and he has 2+ edema in his legs midway to his knees. An EKG reveals sinus tachycardia with a left axis deviation and Q waves in leads II, III, and AVF. A BNP is measured and is found to be 510 pg/ml. Which of the following is the most likely cause of this patient's heart failure? A. Atrial fibrillation B. Non-ischemic cardiomyopathy C. Valvular disease D. Pulmonary embolism E. Ischemic cardiomyopathy

E

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

E

A 21-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing soccer a day prior to presentation to the family medicine ambulatory practice. She remembers immediate pain and swelling but was able to weight bear and limp off the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical examination reveals an edematous lateral right ankle with purplish hue and intact bilateral pulses. Sensation of the bilateral lower extremities is intact and symmetric motor function is preserved. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. There is mild tenderness to palpation of the anterior talofibular ligament and the calcaneofibular ligament. The anterior drawer test and squeeze test are both normal. What is the next best step in the management of this patient? A. Emergent surgical consultation B. Immobilize with cast C. Immobilize with a semi-rigid ankle support D. Rest, ice, ibuprofen, compression, and elevation (RICE) E. X-ray imaging of right ankle

E

A 31-year-old female, G1P0 at 26 weeks gestation, presents to the clinic for her gestational diabetes screening. Her pregnancy has been uncomplicated. Vital signs are stable. Which of the following would require a follow up three-hour glucose tolerance test? A. Fasting serum glucose concentration of 91 mg/dL B. Fasting serum glucose concentration of 112 mg/dL, and a one-hour serum glucose concentration of 128 mg/dL C. Two-hour serum glucose concentration of 146 mg/dL D. Fasting serum glucose concentration of 113 mg/dL, and a two-hour serum glucose concentration of 134 mg/dL E. Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 158 mg/dL

E

A 48-year-old female with no smoking history comes to the emergency department with a concern of sore throat for the last two days. She does not have a thermometer at home, but states she has been feeling hot and her children have also been out from school for a fever and sore throat. Her children are now staying with their father who she is separated from, and he notified her yesterday that they were on antibiotics for their symptoms. She was holding off coming to the doctor because she wasn't coughing or having any problems with swallowing until breakfast this morning. You note that she has a fever of 38.6 degrees Celsius measured by the nurse, and on physical exam you observe an erythematous throat with exudate, and bilateral cervical lymphadenopathy. What is the next best step? A. Amoxicillin therapy B. Levofloxacin (Levaquin) therapy C. Tamiflu therapy D. CXR E. Rapid Strep Test

E

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

E

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

E

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

E

A 68-year-old male with GOLD Stage 3, Group D, COPD requiring 2L of oxygen at nighttime presents to clinic complaining of increasing lower extremity edema over the past few weeks. He also thinks his nighttime cough might be worse. His physical exam reveals distant breath sound with scattered rhonchi, a normal cardiac exam, and 2+ bilateral pitting edema in his legs up to his mid shins. What is the most likely mechanism of disease underlying his lower extremity edema? A. Decreased blood flow to the lower extremities due to thromboembolism B. Hepatomegaly from infiltration of the liver with granulomas C. Irregular heart rate due to atrial fibrillation D. Overexpansion of lower extremity veins due to incompetent venous valves E. Pulmonary hypertension causing right heart failure

E

A 7-year-old male is brought to your clinic with a fever of 102-103° F (38.9-39.4° C) for the last three days. He is up-to-date on all vaccinations and has no significant medical history. His mother notes that he has not had a cough but is eating and drinking less because "it hurts to swallow." On examination of his neck you notice tender cervical lymphadenopathy bilaterally, and auscultation of his back shows clear lung sounds on both sides. His oropharyngeal exam shows erythematous throat, but no tonsillar exudates. What would be the most appropriate next step? A. Empiric Amoxicillin therapy B. Empiric Levofloxacin therapy C. Empiric Tamiflu therapy D. Chest x-Ray E. Rapid Strep Test

E

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

E

An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? A. Lymph node involvement is a poor prognostic factor B. Prognosis of neuroblastoma is predictable C. Children who are older than 12 months have a better prognosis than younger children D. Favorable histology does not play a role in prognosis E. Non-amplification of the n-myc gene is a favorable prognostic factor.

E

Mr Gill is a 27-year-old male who presents to his primary care physician with post-prandial epigastric burning. The burning is episodic, without associated hematemesis, dysphagia, or odynophagia. In the past, he has episodically used an OTC chewable calcium carbonate to provide relief. Over the past month, he has had to increase the frequency of its use to four times daily. His blood pressure is 120/71 mm Hg, heart rate at 75/min and regular. Physical exam reveals only minimal epigastric tenderness on palpation but is otherwise normal. Which of the following is the most appropriate next step in management? A. Upper endoscopy B. H. pylori IgG serologic testing C. Fecal immunochemical testing (FIT) D. Fecal occult blood testing (FOBT) E. 8 week trial of pantoprazole

E

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

E

Ms. Marcos is a 65-year-old woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5' 2" and weighs 250 lbs. When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly? A. Asymptomatic coronary artery disease B. Chronic sinusitis C. Hypoparathyroidism D. Pneumonia E. Sleep Apnea

E