MSN 622 final
A middle-aged patient with type 2 diabetes mellitus has been diagnosed with heart failure. He is worried about developing further complications from untreated diabetes. What does the American Heart Association recommend should be the target A1c goal when treating such patients?
7%
A 65-year-old man presents with complaints of chest pain on exertion, which is relieved on rest. The patient was diagnosed with asymptomatic coronary artery disease 6 months ago. However, the patient has been noncompliant with his medication. The patient's coronary arteries are most likely occluded by which of the following?
70%
A 72-year-old man with a recent history of a large anterior wall myocardial infarction complains of dyspnea on exertion, orthopnea, and increasing pedal edema. There is concern about congestive heart failure. Which of the following would support the diagnosis?
A S3 gallop
A 33-year-old White female patient presents with body pain. She reports diffuse body pain as well as pain in the shoulder and neck area. She reports stiffness in the whole body in the morning time which gets slightly better in the afternoon but does not resolve. She also reports increased fatigue and an inability to concentrate. She has a history of Sjogren syndrome and uses artificial tear drops and lozenges for dryness of eyes and mouth, respectively. She has had a history of migraine since childhood, and she reports worsening headaches for the last month. She has no visual symptoms. She has a family history significant of polymyalgia rheumatica in her 82-year-old grandmother who is doing well on a low dose corticosteroid. Her examination reveals tender points with no joint tenderness or muscle weakness. Her complete blood count, metabolic profile, thyroid-stimulating hormone, creatine phosphokinase, and erythrocyte sedimentation rate are within normal range. What further management should be suggested for the patient?
A moderate exercise program
A 17-year-old, previously healthy girl presents with an acute flu-like illness, fever, myalgias, shortness of breath, and chest pain. Her ECG shows sinus tachycardia. Her labs show elevated white blood cells and an abnormally elevated troponin. Her chest x-ray shows mild pulmonary edema, with findings consistent with congestive heart failure. What is her likely diagnosis?
Acute myocarditis
A 56-year-old man was admitted to the hospital for new-onset atrial fibrillation. After failed attempts of pharmacologic therapy to return his heart to normal sinus rhythm, the decision was made to perform a transesophageal echocardiogram (TEE) and cardioversion. When performing the TEE, he was found to have a left atrial appendage thrombus, so the cardioversion was aborted. He was then started on rivaroxaban. When should cardioversion be considered again?
After he has been taking rivaroxaban for 3 to 4 weeks
A 65-year-old male presents to the clinic with difficulty staying up during the day. He works as a sales representative and often finds himself dozing off during meetings with clients. He feels irritable, and reports decreased concentration and memory problems. He also states that his loud snoring is causing problems as his wife prefers sleeping in a different room. His medical history is significant for ischemic heart disease and diabetes mellitus type 2. Vital signs show blood pressure 135/90 mmHg, pulse 92/min, temperature 37 C (97.6 F), and respiratory rate 17/min. His body mass index is 33 kg/m2. Physical examination shows no significant findings. Polysomnography is done, confirming the likely diagnosis. What is the treatment of choice for this patient?
Aggressive weight reduction
A 17-year-old female presents to the emergency department after having an episode of syncope. She was out watching fireworks during the day and drinking alcohol. She reports that she took ibuprofen earlier in the day for a mild headache. Her vital signs are normal, and she has no symptoms at this time. Which of the following is a risk factor for what happened to the patient?
Alcohol consumption
A 30-year-old woman comes to the emergency department at midnight. She is tearful and upset and complains of abdominal pain. She is disheveled and confides in the provider that she was assaulted. Her examination is unremarkable, and she agrees to testing. The testing kit is obtained, and the patient is moved to a quiet room. There are stains on her garments that look like blood. She agrees to submit them as evidence. She removes her jeans and places them on a sheet on the floor. The clinician then collects the item in a labeled bag. Which of the following steps is essential during the processing of the item?
Allowing it to air dry on a table
A patient has just developed type 2 diabetes mellitus. He is obese and also has hypertension. He sincerely wants to control his diabetes mellitus to avoid complications. The primary care provider recommends that he carefully count his carbohydrate intake. Which of the following is a major benefit of such a dietary approach to diabetes mellitus?
Allows for better glycemic control
A middle-aged patient with diabetes mellitus is referred to the clinic by his primary care provider to diagnose heart failure. The patient states that he does not have any documentation or labs from his previous medical encounters. Which of the following is the most significant and earliest sign of heart failure?
An S3 gallop
Which of the following findings indicates critical peripheral arterial disease?
An ankle-brachial index <0.3
A 67-year-old woman is newly diagnosed with type 2 diabetes mellitus. Her blood pressure is above 140/90 mmHg on 3 separate occasions, 2 weeks apart. Laboratory tests show a BUN of 15 mg/dL, creatinine of 1.1 mg/dL, and spot urine microalbumin of 100 mcg/mg creatinine. Which of the following medications would be most appropriate?
Angiotensin-converting enzyme (ACE) inhibitor
A 65-year-old female patient complains of joint stiffness and swelling in both hands. The stiffness worsens upon waking up in the morning and gradually improves after two to three hours. She further reports having had more trouble opening her pill bottles in the past few weeks. Which one of the following is going to be the most specific for reaching a diagnosis in this patient?
Anti-citrullinated protein antibodies (ACPA)
A 48-year-old woman presents with pain in her hand joints for about 4 months. A history of present illness reveals joint stiffness in the mornings usually lasting for 2 hours. A review of systems is positive for swelling of the hand joints over the past 2 months. She denies pain, swelling, or stiffness of the shoulders, elbows, knees, and ankles. On physical examination, she has swelling, stiffness, and tenderness of the second and third metacarpophalangeal (MCP) joints of the right hand. Laboratory testing shows an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Which of the following is the most specific diagnostic test?
Anti-cyclic citrullinated peptide antibody
A 32-year-old woman presents to the healthcare provider with six months of fatigue. She also reports joint pains, chest pain, and a 3 kg weight loss ever since the fatigue started. She denies recent travel, fever, or new sexual partners. She has no past medical history and takes no medications. She is sexually active with her husband of five years. Her mother has rheumatoid arthritis. Vitals include a blood pressure of 123/80 mmHg, a heart rate of 81/min, a respiratory rate of 18/min, and oxygen saturation of 99% on room air. On examination, she has a rash over her nose and an ulcer on her hard palate. The chest examination reveals decreased air entry in her right lung base. Her abdomen is soft, and there is no hepatosplenomegaly. Neurological examination is within normal limits. Which of the following antibody titers most likely correlates with the disease activity in this patient?
Anti-double-stranded DNA antibodies
A 45-year-old woman presents to the office with complaints of easy fatiguability, lethargy, and constipation for the past 6 months. The patient states, ''she feels tired all the time and was fired from her job for being too clumsy.'' The patient also reports a 6 kg weight gain. On examination, the patient has dry skin, brittle nails, and swelling of the pretibial area of both lower limbs. A midline neck swelling is also noted. Laboratory analysis reveals a raised TSH level and a decrease in T3 and T4 levels. A biopsy of the swelling is performed, and the histopathology is shown in the figure. Which of the following additional lab findings is most likely to be present in this patient?
Anti-thyroid peroxidase antibodies
A 75-year-old male presents with a complaint of palpitations for the past 1 week. He denies any associated symptoms. He has a past medical history of hypertension and diabetes mellitus type 2, for which he takes lisinopril and metformin at home. He smokes 1 pack of cigarettes per day and drinks 1-2 beers daily. On physical exam, his blood pressure is 158/90 mmHg, his pulse is irregularly irregular with a rate of 110/min, his respirations are 16/min, his temperature is 99.4°F (37.4 °C), and his pulse oximetry is 97% on room air. A rhythm strip from his examination is provided. A complete blood count (CBC) and thyroid function tests are normal. A bedside echocardiogram shows no structural abnormalities. Which of the following treatments is most appropriate at this time to prevent adverse effects from his arrhythmia?
Apixaban
A 78-year-old patient with a history of hypertension, coronary artery disease, New York Heart Association (NYHA) Functional Class 2, diabetes mellitus type 2, and Parkinson disease presents with intermittent claudication of the left leg. The arterial brachial index is decreased on the left. The patient is refractory to non-invasive therapy of full-dose aspirin and cilostazol. Angiography shows stenosis in the superficial femoral artery. What is the next best step in management?
Attempt endovascular revascularization
Which of the following is the next step in managing a patient with claudication who has failed smoking cessation, cilostazol, and walking-trial therapy?
CT angiography
A 40-year-old obese man with a body mass index of 35 kg/m2 presents to the clinic for follow-up with his primary care provider. The patient is in good health, maintains a healthy diet consisting of vegetables and fruits. He does physical exercise 3-4 times a week. On the patient's last lipid panel, his low-density lipoprotein (LDL) was 80 mg/dl. What is the next step in therapy?
Calculate 10-year atherosclerotic cardiovascular disease risk
A 37-year-old woman presents to the clinic a few days after being sexually assaulted and has concerns about contracting HIV from her assailant. She has no significant medical history and has never had a sexually transmitted infection. Her vital signs are within normal limits. Her physical examination is unremarkable as well. Which of the following is the recommended empiric therapy against sexually transmitted infections, excluding HIV and hepatitis B in this case?
Ceftriaxone 500 mg IM, doxycycline 100 mg PO twice a day for seven days, and metronidazole or tinidazole 2 g PO
Which of the following may be the initial presentation of long-term hypertension?
Cerebrovascular accident
A 54-year-old man with a history of rheumatoid arthritis presents to the clinic for a regular follow-up appointment. He has remained stable on methotrexate 15 mg every week, folic acid 1 mg daily, and etanercept 50 mg every week. His examination is unremarkable, with no joint tenderness or swelling. Routine labs are within normal limits. The patient does mention some pain along his spine. Involvement of which of the following spinal segments is associated with the worst morbidity in this patient?
Cervical spine
A 72-year-old man presents to the clinic for pre-operative evaluation. His past medical history is significant for a joint condition, and he was prescribed medications for which he would have to do blood tests regularly. He was not interested in doing regular blood tests and seeing a clinician regularly so was not treated. On physical examination, he has bilateral ulnar deviation and subluxation of the metacarpophalangeal (MCP) joints. Hand X-ray shows erosions of the MCP and proximal interphalangeal (PIP) joints. Rheumatoid factor (RF) and anti-CCP antibodies are positive. Which of the following is the next best step in management?
Cervical spine x-rays
A 75-year-old man with a 15-year history of type 2 diabetes mellitus presents to the clinic for follow-up. He complains of numbness and tingling in both feet. Which of the following is the best initial step in the evaluation of this patient?
Check the pressure sensation using the monofilament test
A 59-year-old female with a past medical history of coronary artery disease, hypertension, hyperlipidemia, obesity, gastroesophageal reflux disease, and alcohol dependence presents to the emergency department with acute onset shortness of breath for one day. She has dry cough and nausea. Vitals shows heart rate of 138/min, respiratory rate 32/min, temperature 99 F, and blood pressure is 142/92 mmHg. Oral mucosa is dry, and her breath smells of alcohol. Lungs exam reveals fine bibasilar crackles and the neck exam is unremarkable. Also, the EKG shows an irregularly irregular rhythm. Labs indicate a raised blood alcohol level and TSH is 0.36 mU/L. Diltiazem infusion is initiated along with fluids. Which of the following is the best management plan for this patient?
Continue diltiazem drip, IV fluids, and consult cardiology
A 55-year-old asymptomatic, female smoker, with an extensive family history of premature coronary artery disease, presents to the office for further cardiovascular risk stratification. Her 10-year ASCVD risk score by the pool cohort equation is 5.3%, and she is concerned about testing for further risk stratification as she is reluctant to take medications. Which of the following is most appropriate to order to assist in treatment decision making?
Coronary artery calcium scoring
Which of the following immunotherapies can be used to treat acute systemic lupus erythematosus?
Cyclophosphamide
A woman with diabetes mellitus type 2 gave birth to a baby boy. After the birth, how will the dosage of her medication change?
Decrease
A 65-year-old man presents to the emergency department with chest pain, palpitations, and dyspnea. The client has a past medical history significant for hypertension and hyperthyroidism. An electrocardiogram (EKG) is performed, as shown in the figure. Initial medical management is initiated. Which of the following is the most appropriate initial objective of this patient's treatment?
Decrease the ventricular rate below 100/min
A 65-year-old female patient presents with complaints of progressive dyspnea on exertion for the past two weeks. The patient has a past medical history of hypertension. She has a 25-year smoking history but quit smoking 4 years ago. The patient reveals further that she initially had dyspnea only on moderate exertion, but now it occurs with activities like showering. The patient denies chest pain, cough, or wheezing. Her medications include metformin, amlodipine, and simvastatin. The patient appears comfortable at rest. Currently, she is afebrile and hemodynamically stable. Physical examination reveals bibasilar crackles. The patient's troponin-T level is normal. What changes are more likely to be seen on an electrocardiogram (ECG) if this patient is a suspected case of unstable angina?
Deep, symmetric T-wave inversions in V2 and V3 accompanied by flat ST-segment
An adult female visits a provider at a clinic with complaints of swelling and pain in the joints of her hands for three months. The client has also noticed stiffness in the joints in the early morning. What would the nurse expect in the physical examination?
Deformity and tenderness of the PIP and MCP joints
A 2-month-old male is brought to the emergency department in distress. He had a normal birth history. He had a history of viral illness 4 weeks ago, which resolved with time. His vital signs are a heart rate of 180 beats per minute, a blood pressure of 85/52 mmHg, a respiratory rate of 50 breaths per minute, and a temperature of 37 C (98.6 F). Physical examination reveals a pale-looking infant. The heart sounds are distant, and there is a gallop. A chest x-ray shows an enlarged cardiac shadow. The electrocardiogram has low voltage. Which of the following explains his presentation?
Dilated cardiomyopathy secondary to myocarditis
A 70-year-old man with chronic non-ischemic cardiomyopathy and hypertension presents to the emergency department with shortness of breath that started 2 days ago. His last known ejection fraction is 40%. His vitals are blood pressure 110/60 mmHg, heart rate 125 bpm, respiratory rate 20 breaths/min, and oxygen saturation 94% on ambient air. An ECG rhythm strip is shown below. What is the most appropriate treatment for this patient's arrhythmia at this time?
Diltiazem
A 33-year-old woman is brought to the emergency department with chest pain for the past day. Her chest pain is left-sided and worse with activities and breathing. She has also noted dyspnea. Her past medical history is significant for systemic lupus erythematosus (SLE), diagnosed ten years ago. She has had a malar rash, oral ulcers, pleuritis, and joint pains due to her condition. She was also diagnosed with lupus nephritis class III 6 years ago and was treated with high-dose corticosteroids and mycophenolate mofetil, which was eventually tapered off two years ago. She is currently taking hydroxychloroquine for her SLE, which has been quiescent for six months. She also has a history of hypertension and hyperlipidemia. Her other current medications include lisinopril and glipizide. On exam, the patient is in distress due to pain and is sweating. Vital signs show pulse rate 110/min, blood pressure 118/73 mmHg, and temperature 98.6 F. The physical exam is otherwise unremarkable. Which of the following is the next best step in managing this patient?
Electrocardiography
A 19-year-old woman is brought to the hospital by the police after being sexually assaulted four hours ago. She reports that the assailant performed vaginal penetration without a condom. She believes that the assailant ejaculated. The patient did not know her assailant and is concerned about sexually transmitted infections. She received the HPV vaccine as a teenager and the hepatitis B vaccination when she started nursing school last fall. She has no past medical history or medication allergies. Which of the following combinations of medications is most appropriate for this patient?
Emergency contraception, ceftriaxone, doxycycline, raltegravir, tenofovir, emtricitabine, and metronidazole
A 65-year-old male presents to the clinic with complaints of increased frequency of urination and thirst. He says he wakes up multiple times at night to urinate which makes it difficult to wake up on time the next morning. It has been going on for the past three months and he is really distressed. He is a businessman by profession and drinks alcohol socially. He has a history of hypertension being treated with a calcium channel blocker. His physical exam is unremarkable. His blood work reveals HbA1c of 7.4, BUN 30 mg/dL, Cr 1.1 mg/dL and LDL 200 mg/dl. He is educated about his illness and some medications are started. In the absence of active kidney disease, how often should serum creatinine levels be monitored in this patient?
Every year, regardless of the presence of urine albumin excretion
A 65-year-old male presents to the clinic with complaints of increased frequency of urination and thirst. He says he wakes up multiple times at night to urinate, which makes it difficult to wake up on time the next morning. It has been going on for the past three months, and he is distressed. He is a businessman by profession and drinks alcohol socially. He has a history of hypertension being treated with a calcium channel blocker. His physical exam is unremarkable. His blood work reveals a hemoglobin (Hb) A1c of 7.4, BUN 30 mg/dL, serum creatinine 1.1 mg/dL and LDL 200 mg/dL. He is educated about his illness, and some medications are started. In the absence of active kidney disease, how often should serum creatinine levels be monitored in this patient?
Every year, regardless of the presence of urine albumin excretion.
A 16-year-old man presents to the emergency department due to a 3-day history of polyuria, vomiting, and extreme thirst. He had an upper respiratory infection starting 2 days prior and now presents with a temperature of 101.2 °F (38.4 °C). Physical exam shows decreased skin turgor and dry mucous membranes, and urine analysis is positive for ketones. He has a blood glucose level of 935 mg/dL. What structures are commonly affected by microvascular damage from this disease?
Eyes, gums, feet, and kidneys
A 24-year-old woman presents with diffuse aching and stiffness, worsened by cold weather and stress. Her history is significant for Lyme disease 2 years ago treated with doxycycline 100 mg twice a day for 4 weeks. Her joints show no tenderness or synovitis, but she is tender over points bilaterally at the occiput, trapezius, lateral epicondyle, gluteals, and knee. What is the most probable diagnosis?
Fibromyalgia
A 44-year-old man comes to the clinic for a follow-up. The patient was found to have elevated blood pressure on his annual physical exam last week. He was thus asked to keep a blood pressure diary for one week. Today, the diary reveals an average blood pressure of between 125-135/80-85 mmHg over the past week. Which of the following the best advice to this patient by the nurse?
Get about 150 minutes of moderate-intensity exercise per week
A 44-year-old female presents to your clinic with fatigue and weakness. She states that over the past 2 years she has been feeling increasingly tired and having difficulty with her everyday tasks. She also has gained 15 pounds (7 kg) despite trying to lose weight. Her past medical history is significant for Sjogren syndrome, which was diagnosed 20 years ago and has been treated medically. On physical exam, she has dry skin, notable hair loss, and nonpitting lower extremity edema. Her neck exam reveals a rubbery, non-tender goiter. Her thyroid-stimulating hormone levels are increased. What is the most likely diagnosis?
Hashimoto thyroiditis
A young woman is seen in the clinic after being diagnosed with subclinical hypothyroidism. The provider orders additional blood work, which reveals the presence of serum anti-thyroid peroxidase antibodies. Which of the following is most likely to develop?
Hashimoto thyroiditis
A 23-year-old male presents with penile discharge for three days. He also reports urinary urgency and cloudy urine. When asked about his sexual history, the patient reports that he was recently sexually assaulted but did not report the assault. He worried that his girlfriend would not understand and think he had cheated on her. He has no past medical history. His vitals indicate a temperature of 100.1 F (37.8 C), a pulse of 75 beats per minute, blood pressure of 115/77 mmHg, and 16 respirations per minute. On physical examination, there is discharge at the urethral meatus that is collected for analysis. The specimen is viewed under wet prep microscopy, and an organism with a single flagellum is seen. What precautions should this patient take about the medication used in his treatment?
He should avoid taking it with alcohol
A 14-year-old girl is brought to the emergency department by her parents. Her parents state that she was playing outside during a softball game when she developed nausea and started complaining of fatigue and mild headache. Further evaluation reveals that she has a heart rate of 120 beats/min and a temperature of 103 degrees Fahrenheit. However, she has no mental status changes or muscle fasciculations but is sweating profusely. What is the most likely diagnosis?
Heat exhaustion
A 16-year-old girl presents to the emergency department after being raped by two men. After initial stabilization, the patient consents to the forensic exam by the sexual assault nurse examiner (SANE). The patient is counseled by the SANE on receiving sexually transmitted infection prophylaxis. The patient is uncertain about her immunization history. On discharge which of the following vaccines should be administered to this patient?
Hepatitis B vaccine
A 16-year-old girl presents to the office for a follow-up exam two weeks following sexual assault. The patient was administered emergency contraception only, as she denied prophylaxis against sexually transmitted infections. The patient's last immunization was at the age of 5. Laboratory analysis reveals the presence of anti-Hbs antibodies only. Which of the following vaccines should be administered to the patient, given her recent history of sexual assault?
Human papillomavirus vaccine
A 50-year-old man presents to the clinic for recurrent headaches. His office blood pressure has been consistently found to be elevated. He is not on any hypertensive agent. Home blood pressure diary measurements reveal an average systolic blood pressure (SBP) of 135 mm Hg and diastolic blood pressure (DBP) of 85 mm Hg over 3 weeks. The chemistry panel and electrocardiogram are normal. What is the best initial step in the management of this patient?
Hydrochlorothiazide
A 25-year-old woman presents with complaints of a facial rash that started a few months ago and has worsened. She states that the rash is often itchy and worsens when she goes out in the sun. In the last few days, she has noticed generalized aches all over her body. She denies any trauma, allergies, or recent travel. She did try several over-the-counter products, but nothing helped. The appearance of her rash is shown in the image. Which of the following is the first-line drug in managing her rash?
Hydroxychloroquine
A 35-year-old woman arrives to seek help regarding a medical illness that caused a characteristic butterfly rash and joint pains, leading to a systemic illness. She was compliant with her medication but stopped taking it before becoming pregnant. She is now approaching 17 weeks of gestation. Her current medications are low-dose aspirin and prenatal vitamins. Unfortunately, her rash and joint pains have returned. Which of the following is the most appropriate drug to treat her symptoms?
Hydroxychloroquine
An 18-year-old football player presents to the emergency department (ED) complaining of nausea after a training session at high heat. His coach was concerned because he was very warm to the touch and was sweating profusely. A couple of minutes after arrival at the ED, the patient has an episode of vomiting. His uniform and padding are quickly removed as he is laid on a stretcher. His vital signs demonstrate a core temperature 102.2 °F (38.9 °C), heart rate 118 bpm, blood pressure 119/82 mmHg, and respiration rate 22 breaths/min. His point-of-care glucose was 80 mg/dL, and his skin remains very sweaty. Which of the following is the most appropriate treatment to initiate now?
IV fluids with normal saline
A 76-year-old male comes into the emergency department with a complaint of chest pain. The patient was placed on telemetry monitoring that showed an abnormal rhythm at a rate of 160 beats per minute. A 12 lead EKG was performed showing an irregularly irregular rhythm. He has a history of atrial fibrillation and has been taking rivaroxaban for the past four months. The patient soon becomes diaphoretic, unresponsive, and hypotensive. What is the next best step?
Immediate cardioversion
A patient diagnosed with rheumatoid arthritis 3 months ago is being treated with methotrexate 15 mg per week, hydroxychloroquine 200 mg twice a day, and prednisone, which has been tapered from 20 mg a day to 5 mg a day. Despite some improvement, the patient still has morning stiffness, swelling, and tenderness of several metatarsophalangeal joints. She still cannot open a jar. Which of the following would be most appropriate?
Increase methotrexate to 25 mg a week and refer the patient to rheumatology.
A 75-year-old man with a history of hypertension presents to the emergency department with dizziness, lightheadedness, and palpitations that started this morning. He reports occasional palpitations at home while climbing stairs or doing heavy work, but these episodes do not last more than a few minutes. His blood pressure is 95/70 mm Hg, heart rate 125 bpm, respiratory rate 22 breaths/min, and oxygen saturation 95% on room air. The physical examination findings are unremarkable. An electrocardiogram is negative for ST-segment changes or T-wave abnormalities. A rhythm strip is shown below. What is the best next step in the management of this patient?
Intravenous fluid bolus followed by intravenous metoprolol
A patient presents with the complaint of polyphagia and polydipsia. After the relevant tests, he is diagnosed with diabetes mellitus. Which is the most appropriate nursing diagnosis?
Knowledge deficit
A patient presents with the complaint of polyphagia and polydipsia. After the relevant tests, he is diagnosed with diabetes mellitus. Which of the following is the most appropriate nursing diagnosis?
Knowledge deficit
A 70-year-old patient comes to the clinic with complaints of increased blood pressure. He was diagnosed with hypertension 10 years ago. His other problems include osteoporosis and hyperlipidemia. His readings range from systolic 160 mmHg to 170 mmHg while diastolic falling in between 70 mmHg to 90 mmHg. His current blood pressure is 160/80 mmHg. His medications include lisinopril, amlodipine, atorvastatin, calcium and vitamin D supplements, and bisphosphonates. He does not exercise and smokes a pack of cigarettes daily. He drinks two glasses of beer every day. Family history is significant for stroke in father and MI in his sister. Which of the following is the most likely effect of increased blood pressure on his heart?
Left ventricular (concentric) hypertrophy
A woman presents with chronic fatigue and trouble breathing. Upon inspection, there is peripheral edema and significant jugular venous pressure. She has had longstanding hypertension with exertional fatigue, which has been worsening over the past several years. She has not been adherent to medications. What is the most common cause of her symptoms?
Left-sided heart failure
A 30-year-old female presents with weakness, weight loss, heart palpitations, and nervousness. Physical examination shows a restless woman with warm, moist skin, and a resting pulse rate of 110 beats/min. The neck exam reveals a diffusely enlarged thyroid. Her skin has an orange peel color and texture in the pretibial areas, and onycholysis is noted in her fifth fingernail bilaterally. Which of the following would likely be seen in the suspected disorder?
Low TSH, elevated T4 and T3, and increased radioactive iodine uptake
A 65-year-old man presents with an enlarging, painless thyroid nodule. Laboratory testing shows an elevated thyroid stimulating hormone level and a positive anti-thyroid peroxidase and anti-thyroglobulin antibodies. Histological exam shows dense lymphoplasmacytic infiltrate with the formation of lymphoid follicles. What is this patient at risk for developing?
Lymphoma
A 35-year-old woman presents for a pregnancy test and sexually transmitted infection screening. She tearfully admits that she went out with friends 10 days ago and was sexually assaulted. On exam, vital signs are within normal limits. No physical signs of trauma are noted. An appropriate workup has been ordered. Which of the following is the next best step in the treatment of this patient?
Mental health evaluation
A 65-year-old female is admitted to the hospital with palpitations and shortness of breath. Her past medical history includes congestive heart failure with an ejection fraction of 28%, hypertension, and asthma. She reports smoking 4 to 5 cigarettes a day but no illicit drug use. She takes amlodipine 10 mg once a day, lisinopril 10 mg a day and uses an albuterol inhaler about once a month in the spring and fall). Physical exam reveals blood pressure 140/80 mmHg, heart rate 164 bpm, irregular, respiratory rate 20. EKG results are shown. What is an appropriate rate control medication for her that would also be useful for her congestive heart failure?
Metoprolol
A 21-year-old female presents to the office five days after being sexually assaulted. The patient was raped by a student at her college. Before discharge, the patient was given emergency contraception and prophylaxis against sexually transmitted infections. She states since starting the medications, she has developed a metallic taste. Which of the following drugs is most likely responsible for the patient's complaint?
Metronidazole
A 65-year-old man presents with palpitations and dyspnea without chest pain or lightheadedness. His medical history is significant for hypertension and hyperthyroidism. A 12-lead ECG is shown below. What is the mechanism of this patient's arrhythmia?
Micro-reentry
A 65-year-old man presents with complaints of palpitations, dyspnea, and chest discomfort. The patient has hypertension and diabetes mellitus. His blood pressure is 140/90 mmHg, heart rate 120/min, and respiratory rate 23/min. An electrocardiogram is performed, which is shown in the image. Which of the following valvular diseases is associated with this patient's condition?
Mitral stenosis
A 45-year-old man presents for a two-month history of worsening dyspnea. He denies a history of fever and sore throat with joint pain during childhood. On examination, he is found to have displaced, thrusting apex beats and a systolic murmur. His echocardiographic images are shown below. What is the definitive management for this patient's condition?
Mitral valve repair or replacement
A 65-year-old man presents to the emergency department with palpitations, lightheadedness, and chest discomfort. He has a history of hypertension and mitral stenosis. His vital signs include a heart rate of 141/minute, blood pressure of 110/78 mm Hg, and oxygen saturation of 97% on room air. A 12-lead electrocardiogram is shown. Which of the following best describes the rate of atrial activity associated with this patient's condition?
More than 350/minute
A 32-year-old woman presents for examination, evidence collection, and treatment after being sexually assaulted by her golf instructor. For which of the following bacterial infections should she be routinely tested before beginning prophylaxis?
No routine testing indicated
A 50-year-old man complains of a lack of energy. He nods off during the day, usually when reading or watching television. He goes to bed at 11 pm and wakes up at 8 am. He has no medical illnesses and takes no medication. He drinks a glass of wine daily, usually with dinner, and denies smoking. He states that his wife complains about his snoring. His vital signs show blood pressure of 130/85 mmHg, heart rate of 67 beats/minute, respiratory rate of 16 breaths/minute, and body mass index of 27 kg/m^2. Which of the following is the gold standard test for diagnosing this patient's condition?
Nocturnal polysomnography
Which of the following abnormal types of respirations is seen in patients with heart failure?
Paroxysmal nocturnal dyspnea
A 42-year-man with a past medical history of mitral stenosis due to rheumatic heart disease dies during open-heart surgery. Autopsy findings were consistent with mitral valve stenosis. Addtitionionally, it also revealed the presence of heart failure cells. What is the most probable explanation for the presence of these cells?
Passive congestion of pulmonary parenchyma
A 65-year-old man is diagnosed with ACC/AHA stage A heart failure. This stage is characterized by which of the following?
Patients at high risk for heart failure but have no symptoms or structural heart disease
A 65-year-old man presents with complaints of palpitation, dizziness, and dyspnea for the past 2 hours. The patient has a past medical history significant for hypertension, diabetes mellitus, and hyperthyroidism. An electrocardiogram (ECG) is shown. After initial stabilization, the patient is discharged with a Holter monitor and asked to return after 7 days. At his next visit, ECG tracings show similar findings as seen on his first visit. The patient's condition can be classified as which of the following?
Persistent atrial fibrillation
A 52-year-old is being evaluated for Roux-en-Y gastric bypass. He reports feeling tired during the day and often falls asleep mid-conversation. His wife says she often snores very loudly at night and stops breathing. His BMI is 39 kg/m2, and his neck circumference is 19 inches (48.26 cm). Which of the following is the next best step in evaluating this patient?
Polysomnography
A 6-year-old boy is brought to the outpatient department by his parents due to snoring during his sleep. They state that his snoring has progressively gotten worse over three months. They have also noticed that their son randomly stops breathing during the night. These episodes of absent breathing last 10 to 15 seconds before he gasps and resumes his normal breathing. They also claim that their child has become more irritable and less social over the past few months. He has no significant past medical history other than the occasional sore throat and flu. His family history is positive for diabetes mellitus type 1 in an elder brother and diabetes mellitus type 2 in his father. His vaccinations are up to date, and his vital signs are normal. On examination, the abdomen is soft and non-tender with no organomegaly, S1 and S2 are audible with no added sounds, and the pulse has a normal volume, character, and rhythm. Examination of the head and neck reveals enlarged tonsils. What is the best diagnostic modality for this disease?
Polysomnography
A home health provider has been assigned the task of screening high-risk patients within a community for diabetes. Which of the following are the most classic symptoms among subsets of patients with Type 1 diabetes?
Polyuria, polydipsia, and polyphagia
A 32-year old African-American woman, who is 26 weeks pregnant, presents to the emergency department with dyspnea, lower extremity edema, and fatigue. This is her first pregnancy. She has a history of systemic lupus erythematosus (SLE), which was diagnosed four years ago when she had a malar rash, oral ulcers, joint pains, and pleurisy along with a positive ANA anti-Smith, and anti-DS-DNA antibodies. Her last flare of SLE was ten months before conception when she was treated with oral steroids, and since then, her SLE has been in remission. She is currently on hydroxychloroquine. Vital signs show blood pressure 170/100 mmHg, pulse 102/min, and temperature of 98 F. She has a maculopapular rash on her upper torso but no oral ulcers. She has 2+ pitting edema in the lower extremities. The cardiac and pulmonary exam is normal. No synovitis is appreciated on the joint exam. Laboratory evaluation reveals CBC with hemoglobin 11.5 mg/dL and normal WBC and platelet counts. Liver function tests and serum creatinine are normal. Serum uric acid is 9.0 mg/dL. Urinalysis shows the presence of protein but no casts. The urine protein/creatinine ratio is 1.0. Anti-DS-DNA and ANA are positive. C3 and C4 ar
Pre-eclampsia
A patient presents with shortness of breath. Rales are heard in the lower lung fields. There is an S4. Hepatojugular reflux is present. The chest x-ray shows cardiomegaly and enlargement of the mediastinal veins. Congestive heart failure is suspected. Reduced bloodflow in the ascending aorta would not cause decreased blood flow in which of the following arteries?
Pulmonary artery
A 55-year-old woman presents to the clinic for a follow-up. Her past medical history is significant for hypertension and type 2 diabetes mellitus. She is currently taking lisinopril and metformin. She reports feeling well and exercising 3-4 times per week. She has changed her diet plan and reports a 5-pound (2.2 kg) weight loss in the last 2 months. Her last hemoglobin A1c was obtained 2 weeks ago at the time of her diagnosis. It was 8.6% at the time. Her home glucose readings show adequate control. Her vital signs and physical examination, including the foot exam, are unremarkable. What is the next step in the management?
Refer to an ophthalmologist
A 65-year-old woman with claudication symptoms for the last six months presents to the clinic for evaluation. The patient has a history of diabetes and hypertension. She denies smoking. Physical exam shows palpable pulses on the bilateral lower extremities. Ankle-brachial index done at bedside shows a 1.1 on the right and 1.0 on the left lower extremity. What is the next best step in the management of this patient?
Repeat ankle-brachial index after exercise
A 16-year-old girl presents to the emergency department to be evaluated after being sexually assaulted the night prior. Once in the exam room with the sexual assault nurse examiner (SANE), the patient tearfully exclaims that she does not want anyone to know, but she wants to make sure she's not pregnant. Which of the following is the next most appropriate course of action?
Report the incident to the relevant authorities
A patient has type 2 diabetes that is poorly controlled. He is obese and also has hypertension. He sincerely wants to control his diabetes to avoid complications. The provider recommends he start insulin and carefully count the carbohydrate intake. Which of the following is a major benefit of such a dietary approach to diabetes?
Requires less insulin compared to fixed meal dosing
A 39-year-old man is accompanied by his wife to the clinic. The wife says her husband has episodes of passing out during the daytime, even when doing important work. She states that the patient has reduced attentiveness and has become more irritable over the past few months. The patient and his wife have also stopped sharing a bed because of his loud snoring. On further questioning the patient after sending his wife out of the office, the patient confirms everything. He further adds that he is embarrassed about his behavior and wishes that there was something he could do to fix everything. He admits to falling asleep even during office meetings and describes these episodes as involuntary. His body mass index is 35 kg/m2. His vitals are blood pressure 135/88 mmHg, pulse 95/min, and respiratory rate 19/min. A nighttime arterial blood sample is sent for acid-base analysis. What abnormality is most likely to be seen in an arterial blood gas report?
Respiratory acidosis
A 47-year-old woman presents with swelling in both knees, morning stiffness lasting more than an hour, and pain when walking. Associated symptoms include bilateral hand and wrist pain. These symptoms are present for about 3 months and are gradually progressing. The patient tried over-the-counter acetaminophen without relief from the symptoms. A review of systems is positive for fatigue and a low-grade fever. She denies rashes, oral ulcers, chest pain, and difficulty breathing. On physical examination, she demonstrates synovitis of both knees and metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints bilaterally. X-rays of the hands do not show joint damage. Laboratory test results for rheumatoid factor (RF), anti-CCP, and ANA are negative. What is the most likely diagnosis?
Rheumatoid arthritis
What heart sound would one hear in a patient with systolic congestive heart failure (CHF)?
S3 heart sound
A 66-year-old woman presents with extreme fatigue and muscle pain that has troubled her for the past 9 months. On physical examination, she has many tender points on her upper body. Laboratory tests are normal. Which combination of the following medications is helpful in a patient not responding to initial therapy?
SNRI and anticonvulsants.
A 65-year-old male patient with a medical history of hypertension, diabetes mellitus, and coronary artery disease is being evaluated for chronic stable anginal symptoms. He was prescribed sublingual nitroglycerin as needed for chest pain. Which of the following medications should be avoided in this patient due to this drug?
Sildenafil
A 54-year-old female presented for evaluation at the outpatient clinic. She was diagnosed with rheumatoid arthritis two years ago. She has been closely followed up and found to have low-level disease activity. Currently, she is managed with NSAIDs and has never received disease-modifying antirheumatic drugs (DMARDs). In patients with established disease, the American College of Rheumatology recommends what type of treatment?
Start monotherapy with a DMARD
A 49-year-old otherwise healthy male with no past medical history apart from hypertension well controlled with medications presents to the emergency department with a friend after having an episode in which he lost consciousness. The patient stated that they were outside taking their dog for a walk at a local dog park when he got dizzy, sat on the ground, and then passed out. The friend states the patient was out for about 30 seconds. The patient is currently feeling normal. He does admit he hasn't been drinking much water today. Which of the following will help prevent this from happening in the future?
Staying well hydrated during periods of heat exposure
A patient is admitted with acute appendicitis. He is to receive nothing by mouth (NPO). The patient says, "I am supposed to take glyburide 5 mg by mouth daily." His glucose level on admission is 362 mg/dlL He is to receive 10 units of regular human insulin subcutaneously without delay. Which of the following explanations should be given to the patient?
Subcutaneous insulin is only temporary while the patient is NPO.
A 42-year-old male is brought to the emergency department after routine evening exercise with chest tightness and severe pain radiating down the left arm. His blood pressure is 130/90 mmHg, and his heart rate is 102 beats per minute. The patient receives a medication that improves his symptoms immediately. Which of the following medications was most likely given to the patient?
Sublingual nitroglycerin
Which of the following is the most likely presentation of new-onset rheumatoid arthritis (RA)?
Symmetric polyarthritis of the hands, wrists, and feet
A 32-year-old woman presents to a clinic with complaints of pain and stiffness in small joints of the hand and wrist for two months duration. After a laboratory and imaging evaluation, the provider diagnoses rheumatoid arthritis, and medication is started. Which structure of the joint is affected in this client?
Synovium
A 73-year-old patient presents with a 6-month history of progressive fatigue, with difficulty climbing stairs and brushing her hair. These symptoms are different than her usual symptoms. Her medical history is significant for rheumatoid arthritis diagnosed 15 years ago. During this time, the patient has tried multiple biological agents with most of these medications discontinued because of adverse effects or loss of efficacy. The patient declined to try rituximab and requested to continue steroids. She has been on 10 mg of prednisone daily for about 10 years. Her dose is increased to 15 mg daily when the patient experiences an increase in joint pain, which happens about twice a month. What is the most likely etiology of the patient's symptoms?
The patient probably has proximal muscle weakness secondary to corticosteroids.
A 60-year-old woman with obesity and congestive heart failure (CHF) presents with a complaint of increased abdominal girth. She has noticed this occur over the last week, making her self-conscious about her appearance. She reports shortness of breath, constipation, and abdominal discomfort but denies nausea and vomiting or any changes in appetite. She also reports a history of cholecystectomy and frequently experiences constipation. Physical examination reveals jugular venous distension, pulmonary crackles, a non-tender distended abdomen, and bulging flanks. The liver is non-palpable. Which of the following is the best assessment of this patient?
There is a pathologic buildup of fluid in her peritoneum due to abnormal changes in her hydrostatic pressure due to a CHF exacerbation. Her serum albumin is 4 g/dL, and ascitic fluid albumin is 2 g/dL.
A 65-year-old man presents with a 4-hour history of progressively worsening left chest pain that radiates to his left neck. A history of present illness reveals minor episodes of transient chest pain over the last 6 months after climbing 2 flights of stairs or running. His past medical history includes hypertension, type 2 diabetes mellitus, and hyperlipidemia. His vital signs are oxygen saturation 98% on room air, respiratory rate 18 breaths/min, heart rate 91 bpm, blood pressure 131/91 mm Hg, and temperature 98.6 °F (37 °C). A 12-lead electrocardiogram (ECG) demonstrates ST depressions in leads V5, V6, and aVL. The patient is administered oxygen, morphine, nitroglycerin, and aspirin. What is the principle behind giving this patient nitroglycerin?
To dilate the venous system and decrease cardiac preload.
What is the most appropriate goal while treating a patient with atrial fibrillation?
To reduce the ventricular response rate below 100 beats/minute
A 16-year-old girl is brought to the hospital for a facial wound. She says a friend hit her in the face at a party. Upon further evaluation, she revealed that she was assaulted by her boyfriend, who forced himself on her. He did not use protection. Emergency contraception, ceftriaxone, doxycycline, and metronidazole are given. Prophylaxis against which of the following possible infections is the primary objective of giving this patient metronidazole?
Trichomoniasis
A 65-year-old woman presents with intermittent, sudden-onset chest pain and shortness of breath, which radiates to her left jaw and arm. A history of present illness reveals that the pain initially occurred with activity, but now it occurs throughout the day. A review of systems is positive for tiring easily with mild physical activity. Her medical history is significant for hypertension and type 2 diabetes mellitus. An electrocardiogram (ECG) and cardiac enzyme markers are ordered. Which of the following tests will be most helpful in differentiating unstable angina from a non-ST segment elevation myocardial infarction (NSTEMI)?
Troponin I
