Aquifer Family Medicine

A 30-year-old male with PMH significant for one month of progressive hoarseness and fever presents with a painful neck mass. He reports increased sweating, racing heart, diarrhea, and fatigue. His vital signs are: Temperature: 39.5 Celsius Heart rate: 85 beats/minute Respiratory rate: 19 breaths/minute Blood pressure: 130/70 mmHg On physical exam, you palpate a hard, fixed, painless nodule on the left side of the thyroid gland. Bloodwork results show: TSH: decreased Free T4: increased Which of the following is correct about thyroid nodules? A. 25% of patients with hyperthyroidism are caused by thyroid nodules B. The majority of thyroid nodules symptomatic C. 4% to 5% of thyroid nodules are cancerous D. Older patients with thyroid nodules usually have solitary nodules E. Thyroid radioactive iodine uptake and scan is the best initial test to evaluate a new thyroid nodule

C. 4% to 5% of thyroid nodules are cancerous Four percent to 5% of thyroid nodules are cancerous. Only 5% cases of hyperthyroidism are due to nodules (A). Most thyroid nodules are asymptomatic and are found by physical exam or imaging done for another purpose (B). Older patients are more likely to have multinodular disease, and younger patients solitary nodules (D). The best initial imaging for a thyroid nodule is thyroid ultrasound (E). The patient in this case could either have an ultrasound or fine needle biopsy as this case is consistent with thyroid cancer, probably papillary.

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 severe) C. Obese D. Overweight E. Underweight

C. Obese With a BMI of 31.6, this patient is considered obese. The categories of weight, according to BMI measurements, are as follows: Underweight: BMI < 18.5 Ideal: BMI 18.5 to 25 Overweight: BMI 25 to 30 Obese: BMI 30 to 40 Morbidly (very severely) Obese: BMI > 40.

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. 9 His APGAR is calculated as follows: One point for "Appearance" (color); two points each for "Activity," "Pulse," "Grimace" and "Respiration." The APGAR scoring is done at one minute and five minutes of life. It is a tool that helps to predict early infant mortality.

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

D. Age at menopause The patient experienced menopause at the age of 44, which shortens her time of estrogen exposure, thereby reducing her risk of breast cancer. Factors associated with decreased breast cancer risk include pregnancy at an early age (20 or younger), late menarche (13 or older), early menopause (45 or younger), high parity, and medications such as selective estrogen receptor modulators along with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in a first-degree relative, prolonged estrogen exposure (menarche before age 12, menopause after 55, advanced age at first pregnancy, obesity after menopause), female sex, genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age), increased breast density and certain exposures (diethylstilbestrol, hormone or radiation therapy, smoking).

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

D. Precontemplation Based on this man's response, it appears he has not actively considered quitting smoking despite his family's concern. All options refer to different stages in the Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses.

A 66-year-old male presents to his primary care provider with concern for intermittent chest pain. He describes several episodes a week of pressure under his sternum that comes on with exertion, lasts for about 5 to 10 minutes and is improved with rest, over the last two weeks. He notes some shortness of breath with the pain, but denies any associated diaphoresis, nausea, or jaw pain. He has a history of hypertension and hyperlipidemia treated with lisinopril, simvastatin, and aspirin. He exercises at a gym for 30 minutes, two to three times per week. Physical examination shows his pulse is 78 beats/minute, respiratory rate is 16 breaths/minute, and blood pressure is 145/80 mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity edema. His electrocardiogram (ECG) is normal. Which of the following is the most-appropriate next step in his workup? A. Cardiac catheterization B. CT scan C. Echocardiogram D. Pharmacologic stress test with imaging E. Treadmill stress test without imaging

A. Cardiac catheterization The patient should proceed directly for a cardiac catheterization. His symptoms meet the criteria for angina (substernal chest discomfort with a characteristic duration and features, exertional in nature and relieved with rest or nitroglycerin) and since it is relatively new and started within the month, it should be considered unstable angina. In addition, he has considerable risk factors, thus his pretest probability is high for cardiac disease and cardiac catheterization is recommended. A CT scan is not the first line for diagnosing angina. An echo alone would not be sufficient to diagnose coronary artery disease, or determine its severity and the need for treatment. Pharmacologic stress tests with imaging should be reserved for patients who are not able to exert themselves. If he had been experiencing symptoms for more than six weeks, he would be considered intermediate probability and a treadmill stress test without imaging would be indicated given his normal ECG and ability to exercise.

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. Achilles tendon rupture This is a classical description of an acute rupture of the Achilles tendon. Middle-aged males are more commonly affected than other groups. The mechanism does not describe inversion injury, which makes an ankle ligament sprain (C) less likely, and there is no direct trauma, making calcaneal fracture (E) less likely. There is no history of overuse or chronicity making tendonitis (D) and arthritis (B) less likely.

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 beats/minute, respiratory rate is 16 breaths/minute, temperature is 37.1 C (98.7 F), and BMI is 32 kg/m2. She is taking metformin 500 mg twice daily, simvastatin 20 mg daily and hydrochlorothiazide (HCTZ) 25 mg daily, and she is adherent with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the most appropriate? A. Add amlodipine 5 mg daily B. Change her simvastatin from 20 mg to 40 mg C. Impress upon her the importance of making more lifestyle modifications D. Increase HCTZ to 50 mg daily E. Make no changes as she is at her treatment goals

A. Add amlodipine 5 mg daily The goal blood pressure for patients with hypertension is 130/80 mmHg, and this patient has not met this goal with HCTZ and major lifestyle changes. Increasing the dose of HCTZ from 25 to 50 does not improve blood pressure further, so adding a second medication would be more beneficial. While commending her on her lifestyle changes is important, counseling about intensifying them is not likely to be realistic nor helpful given all that she has already done. There is no need to change her statin, however, calculating her ASCVD risk to determine whether she is on the appropriate dose would be helpful. The current cholesterol guidelines recommend a moderate intensity statin for patients with diabetes. For simvastatin, a dose of 20 mg represents a moderate-intensity dose. Increasing this to 40 mg would likely decrease her cardiovascular risk, though it may not decrease the risk more than further blood pressure lowering would.

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. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized. The USPSTF recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks. The purpose of the PHQ -2 is not to establish a final diagnosis, but rather to screen for depression as a "first-step" approach. Patients who screen positive should be evaluated by the PHQ-9 to determine whether they meet the criteria for depression. Another screening tool which can be used is the Geriatric Depression Scale - Short Form (GDS-SF) which includes a series of 15 questions. Specifically related to suicide in the geriatric population: Elderly persons attempting suicide are more likely to be WIDOW(ER)S, AND LIVE ALONE; Elderly persons attempting suicide have REDUCED sleep quality; Suicidal behaviors DO NOT increase with age, but rates of completed suicides DO. Drug overdose is the most common means of suicide in the elderly.

A 58-year-old female presents to the clinic with concern for chest pain over the past three months. She describes the pain as sharp and stabbing, in the mid-sternal region, lasting for one to two minutes, occurring a few times a day. The pain can come on at rest or with exertion and resolves on its own. It has not become worse since it began. There is no associated diaphoresis, shortness of breath, nausea, jaw pain, or pain with movement, eating, or laying supine. She has a 10-year history of obesity and hypertension for which she takes chlorthalidone and lisinopril. She was recently diagnosed with diabetes that has been controlled by diet. Physical examination shows her pulse is 86 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 135/85 mmHg. Her lungs are clear, heart sounds are normal, and there is no chest wall tenderness to palpation or abdominal tenderness. There is no peripheral edema. How would you best characterize her chest pain? A. Atypical angina B. GERD C. Musculoskeletal D. Stable angina E. Unstable angina

A. Atypical angina This patient is experiencing atypical angina. She does not meet the criteria for angina which includes substernal chest discomfort with characteristic duration and features, is exertional in nature and relieved with rest or nitroglycerin. This is considered atypical angina because the pain does not follow the classic pattern of angina; however, it is still possible that the pain is cardiac in origin, especially since atypical features are more common in women and patients with diabetes. Gastroesophageal reflux typically occurs after meals or while laying flat and is often described as having a burning quality. Musculoskeletal pain is typically worse with certain movements and associated with chest wall tenderness. Stable angina would meet the criteria and follow a predictable pattern with exertion. Unstable angina is characterized by chest pain at rest or with progressively less exertion. Angina with worsening features or new within the past four to six weeks is also considered unstable.

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. CBC, CMP, and TSH CMP can be used to detect electrolyte, renal and hepatic problems. TSH can be used to rule out hypo- or hyperthyroidism. CBC can be helpful to detect anemia and vitamin deficiencies. In addition, ESR can be used to test for rheumatologic disease. An ECG should be done if the patient is using drugs that might alter cardiac conductivity, such as TCAs.

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. Cessation of tobacco products This is a key intervention in all patients with COPD who continue to smoke and can reduce the rate of FEV1 decline. The pneumococcal vaccine is recommended for COPD patients ≥ 65 years old or < 65 years old and for all smokers or patients with chronic lung disease. While important to prevent complications from COPD (pneumonia), it is not as fundamental as smoking cessation. Long-term monotherapy with oral corticosteroids is not recommended. Pulmonary rehabilitation may improve dyspnea, walking distance, and quality of life but does not have as much supporting evidence as tobacco cessation. Tiotropium is a medication for COPD, which may be used to decrease symptoms and/or complications, but no medication for COPD has been shown to modify long-term decline in lung function.

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. Colon cancer screening The USPSTF gives colon cancer screening an A recommendation for people age 50 to 75 years due to clear evidence of benefit. Lung cancer screening is given a B recommendation for 55-year-old men with a 30 pack-year tobacco history and who have smoked in the past 15 years. This patient is a non-smoker. Pancreatic cancer screening and ECG screening are both given D recommendations (against their use). PSA screening is given a C recommendation, indicating that doctors and patients should make individualized decisions about the use of this test.

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

A. Elevated blood pressure reading To diagnose hypertension, two separate readings greater than 130/80 mmHg each time—taken a week or more apart—are needed. Furthermore, ideally home blood pressure readings in the hypertensive range would be needed to confirm that she does not have white coat hypertension. Because this patient has had elevated blood pressure documented on only one occasion (today), the most appropriate current diagnosis is elevated blood pressure. If she has a second similarly elevated reading, stage 2 hypertension may be diagnosed. Stage 1 hypertension refers to blood pressures between 130-139/80-89 mmHg. This patient has not yet been diagnosed with hypertension, so neither B, C, D, nor E is appropriate.

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. Emergent surgical consultation This clinical scenario describes acute compartment syndrome which is a vascular emergency. Emergent fasciotomy is the treatment of choice to relieve pressure in the calf. If not performed, the limb could be lost due to acute ischemia. While emergent radiographs of the tibia and fibula are appropriate to evaluate for co-existent fracture, x-rays of the foot and ankle are not indicated. Also, imaging should not delay surgical consultation in this case. Reassurance and ice packs (D), urgent EMG (E), and immobilization (C) are all incorrect treatments and place the patient at risk of serious permanent adverse outcome.

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. 1 week B. 2 weeks C. 4 weeks D. 5 weeks E. 8 weeks

B. 2 weeks Depressed mood or anhedonia and at least five of the following eight criteria must have been present for two weeks or longer. (Mneumonic = SIG E CAPS) Sleep: Insomnia or hypersomnia nearly every day Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) Energy (decreased): Fatigue or loss of energy nearly every day Concentration (decreased): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) Appetite (increased or decreased) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

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. Begin noninvasive mechanical ventilation This patient is in respiratory distress as evidenced by his dyspnea, physical exam, and ABG. He has a respiratory acidosis as his pH is low and he is retaining CO2. His PaO2 is also low. Initially you would want to improve his respiratory status with some type of mechanical ventilation such as nasal cannula, facemask, bipap, or even intubation if indicated by worsening of respiratory status such as decreasing oxygen saturation, confusion and drowsiness. After stabilizing the patient, you might consider giving an antibiotic such as Rocephin if he was diagnosed with pneumonia or possibly a COPD exacerbation. Immunizing against the flu and providing tobacco cessation counseling are always good steps in patients with COPD, but would not be the initial step in this scenario. You might want to repeat the ABG after the patient is placed on mechanical ventilation to ensure improvement in his oxygenation status.

A 42-year-old female presents to the emergency department with concern for mild chest pain lasting three to four minutes with vigorous exercise, three times over the past week. She has no past medical history and is not taking any medications or supplements. She has no family history of cardiac or pulmonary disorders. She follows a vegetarian diet, exercises regularly, and is training for a half-marathon. Physical examination shows her pulse is 66 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 110/70 mmHg. Her lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Which of the following is the most likely laboratory study in the acute setting to assist with the diagnosis? A. BNP B. CBC C. Hemoglobin A1c D. LDL E. Triglycerides

B. CBC Although cardiac causes of chest pain should be considered, it is important to consider other sources of pain. Anemia may cause chest pain by decreasing oxygen carrying capacity. BNP should be ordered when congestive heart failure is suspected; however heart failure is unlikely in this case, given her clear lungs, lack of edema, and lack of risk factors. Hemoglobin A1c would be helpful for the diagnosis of insulin resistance and diabetes, which are significant risk factors for cardiac disease, but do not cause chest pain on their own. LDL and triglycerides would be helpful to characterize her cardiac risk, but would not help determine the source of her symptoms

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. Metformin basal Metformin (E) is the best first medication to choose in this case. Sulfonylureas (A), GLP-1 receptor agonists (C), and SGLT2 inhibitors (B), DPP-4 inhibitors, thiazolidinediones, or insulin (D) may be used as second-line agents, depending on key patient factors including a) important comorbidities such as ASCVD, chronic kidney disease, and heart failure, b) hypoglycemia risk, c) effects on body weight, d) side effects, e) costs, and f) patient preferences.

A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vital signs today are blood pressure 138/88 mmHg, pulse 65 beats/min, respiratory rate 12 breaths/minute, afebrile, BMI 29 kg/m2. He does not smoke cigarettes or use illicit substances, and he does drink one or two glasses of wine most evenings. He currently jogs three times a week for approximately 30 minutes at a time. He and his partner order takeout food for supper twice per week and otherwise cook at home. He does not particularly like vegetables, but he tries to eat a piece of fruit every day. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is most likely to improve his cardiovascular risk? A. Alcohol cessation B. DASH eating plan C. Increased exercise D. Increasing dietary potassium E. Supplementation with vitamin D

B. DASH eating plan Of all of these interventions, the DASH diet has been demonstrated to reduce blood pressure by the most (~11 mm/Hg) and is associated with reductions in cardiovascular risk. Moderate alcohol consumption, such as this patient demonstrates, has been associated with cardiovascular benefits in observational studies. He is unlikely to reduce his risk by abstaining from alcohol. He does not exercise as much as is currently recommended (150 minutes per week of moderate to strenuous exercise), but he gets some benefit from the exercise he is doing. Increasing his exercise would be beneficial, but not as much as improving his diet. Dietary potassium may lower his blood pressure slightly (average of 4-6 mm/Hg), but it is not associated with reductions in cardiovascular disease outcomes. Vitamin D has no role in cardiovascular disease prevention.

You are seeing a 6-year-old female in the family medicine office for a well-child exam. She and her parents have no concerns about her health today. She is developing normally and is thriving in first grade. She has no significant medical history, and she is up to date on her immunizations. On exam, she is well-appearing with normal vital signs except for a BMI of 19.2 kg/m2, placing her at the 96th percentile for her age. The remainder of her examination is normal. Which of the following would be the most appropriate next step? A. Advise diet and exercise with a goal of a 5% weight loss B. Encourage healthy behaviors with a goal of maintaining her current weight C. Order a TSH D. Reassure her parents that since the remainder of her exam is normal, her weight is not a concern E. Referral to a multidisciplinary weight-management program

B. Encourage healthy behaviors with a goal of maintaining her current weight This child meets the criteria for being overweight. As she shows no complications of her weight currently, there is no need to initiate more serious interventions such as referral to a multidisciplinary clinic (E) or suggesting weight loss (A). The American Academy of Pediatrics recommends that younger overweight children without complications be advised to maintain their weight (B), which will result in a decreased BMI as they grow taller. Childhood weight problems are associated with obesity in adulthood and increased risks of chronic illnesses such as diabetes and hypertension, so minimizing concerns about her weight (D) is not appropriate. Ordering a TSH (C) would not be appropriate without other findings to suggest thyroid illness.

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. Daily aspirin B. Expedited delivery of the premature fetus C. Lisinopril D. Strict bed rest until 37 weeks E. Twice-weekly non-stress testing

B. Expedited delivery of the premature fetus Expedited delivery of the fetus is the best treatment for severe preeclampsia. (Note: severe preeclampsia is not necessarily an indication for a C-section, however.) Twice-weekly non-stress testing combined with assessment of amniotic fluid volume (or twice-weekly biophysical profiles) is part of the management of preeclampsia without severe features. This would not be appropriate in this case. Aspirin is used in the second and third trimesters among patients at risk of developing preeclampsia and those with pregestational hypertension. This patient has severe preeclampsia and needs expedited delivery, not preventive therapy. Lisinopril is contraindicated in pregnancy. In the third trimester, it can cause oligohydramnios. Strict bed rest is not encouraged in the management of preeclampsia.

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 is 144/90 mmHg, pulse is 78 beats/minute, respiratory rate is 12 breaths/minute, and temperature is 37.1 C (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. HCTZ Hydrochlorothiazide (HCTZ) (B) can cause hyperuricemia and therefore should be used with caution in patients with gout. Metoprolol (E) is not a first-line choice for the management of blood pressure, but there is no particular reason to expect this patient to experience an adverse drug event due to a beta-blocker. While all of the other medications listed are appropriate first-line anti-hypertensives, many clinicians would select one of the other options over HCTZ for this patient given his history of gout.

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. Her family history Hypertension, smoking, and diabetes (along with elevated lipid levels, obesity, and sedentary lifestyle) are modifiable risk factors for CAD. Non-modifiable risk factors include older age (men>45 and women >55), family history of CAD in a first-degree relative at a young age, and male sex

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

B. Increases adherence to techniques for pain management during labor Clear, health literate communication about options for pain management are a benefit of group prenatal care, not adherence to a particular pain management plan. Answer choices A, C, D and E are benefits of group prenatal care. Advantages of group prenatal visits: Increase prenatal knowledge, labor preparedness, support network, shared education between patients, and patient satisfaction Provide more time for prenatal education and anticipatory guidance Improve provider efficiency Preterm delivery less likely (more significant for African-American women) -preterm birth is the number one cause for neonatal death in African-American infants Increased birth weight of preterm infants (a significant survival determinant) Combat racial disparities Used for a variety of medical conditions, including diabetes and chronic pain.

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. Influenza, pneumococcal, and Tdap Because this patient has a diagnosis of COPD and smokes cigarettes, both pneumococcal and annual influenza vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time Tdap is recommended. At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. Zoster vaccine is recommended to all adults at age 50 or older.

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. Initiate antibiotic treatment while awaiting urine culture results The presence of multiple urinary tract symptoms in young women who present without vaginal symptoms is suggestive of a urinary tract infection. The constellation of typical symptoms outweighs a normal urinalysis. In this case scenario, treatment would be initiated for an uncomplicated urinary tract infection. Consideration for antibiotics could include trimethoprim/sulfamethoxazole, nitrofurantoin, or fosfomycin. Antibiotic choice would be dictated by the individual's health profile and regional antibiotic resistance profiles. It is not unreasonable to send urine for culture but management does not need to wait (A) till that result is available. While it is always prudent to consider the possibility of sexually transmitted infection in this age group, based on the information presented about an established patient, it would be inappropriate to insist on a pelvic exam (C) or await results of a urine DNA (E) probe in the face of such strong UTI symptoms.

It is November and you are working in a small, rural emergency department serving a community that 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 the night prior. She says he has a cough and is reporting 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, he is tired-appearing but is not acutely dyspneic. His temperature is 39.2 C (102.6 F), pulse is 102 beats/minute, respiratory rate is 21 breaths/minute, and blood pressure is 108/62 mmHg. You note an erythematous throat with normal-sized tonsils without exudate, clear rhinorrhea, and normal-appearing tympanic membranes. His neck is supple without tender lymphadenopathy, and there are scattered rhonchi on auscultation. A rapid strep test was performed 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. Administer an influenza vaccine B. Order a rapid influenza test and a throat culture C. Order a rapid influenza test alone D. Prescribe oseltamivir (Tamiflu) E. Prescribe penicillin V

B. Order a rapid influenza test and a throat culture This child likely has influenza, given his presentation during a local influenza outbreak. His Modified Centor score is 2, so testing for strep is also appropriate. In children, a negative rapid strep test should always be followed by a throat culture because the post-test probability of strep infection remains too high after a negative rapid test. Thus, ordering both an influenza test and a throat culture is the most appropriate step (B). Prescribing oseltamivir (D) would be appropriate treatment for influenza in this child, but given his mildly ill appearance, history of asthma, and lung findings, it would be appropriate to confirm a diagnosis of influenza with a rapid test first. Prescribing penicillin V (E) would be appropriate treatment for strep throat, but one should not make the diagnosis of strep throat without a positive test for it. This child likely has not received the influenza vaccine (A) and would be a candidate for it. His egg allergy complicates this option, as there is a theoretical risk of an allergic reaction to the egg used in the development of the vaccine. Current evidence shows that most egg-allergic patients may be given the influenza vaccine, but this should be done in a controlled, monitored environment in a healthy patient. It would not be appropriate to give the vaccine to this child now.

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% C. Flattened diaphragm on lateral chest film D. Left ventricular function <40% E. Oxygen saturation level of < 89%

B. Post-bronchodilator FEV1/FVC ratio of < 70% Spirometry (pulmonary function tests) is the gold standard for diagnosing COPD. If the FEV1 to FVC ratio is less than 70%, then the patient has COPD. Brain natriuretic peptide levels >500 are suggestive of congestive heart failure. Flattened diaphragm on a lateral chest film may be suggestive of advanced COPD but is not diagnostic. Left ventricular function <40% is seen with systolic heart failure. Oxygen saturation levels <89% may be seen in those with COPD but is very nonspecific.

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

B. She had a total hysterectomy for fibroids The patient described above underwent a total hysterectomy (total removal of the uterus and cervix with or without oophorectomy) for benign reasons (fibroids). USPSTF guidelines recommend against continued cervical cancer screening in patients whose uterus has been removed for benign disease. Evidence has shown cytologic screening to be low yield in detecting vaginal cancers or improving health outcomes in females after hysterectomy for benign disease. Cervical cancer screening should begin at the age of 21. Females between the ages of 65 and 70 who have had three or more normal Pap tests or two negative co-tests (Pap and HPV) in the past 10 years may choose to stop cervical cancer screening. Not being sexually active, age 63, only having had normal Pap tests, and years since menopause are not reasons to stop screening for cervical cancer.

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. Start amlodipine daily. According to the 2017 AHA/ACC blood pressure guidelines, this patient's blood pressure goal should be 130/80 mmHg. She is clearly above that, and she should have a blood pressure medication added (or in a highly motivated patient, dramatic behavioral changes with close follow up). There is no preference for a first-line treatment for blood pressure in diabetic patients without albuminuria, although many providers start with an ACE inhibitor or ARB because diabetes is a risk factor for chronic kidney disease. Furosemide and metoprolol are not among the four major classes of medications for blood pressure management (ACEIs, ARBS, calcium channel blockers, and thiazides), so (C) and (E) are not acceptable choices. Lisinopril (D) is an acceptable first-line choice, but it should not be combined with an ARB. Since this patient is taking losartan (an ARB), adding an ACEI is contraindicated. Amlodipine is a good choice for this patient.

A 68-year-old male presents with concern for substernal chest pressure with exertion lasting five minutes and alleviated with rest. He has a remote history of a myocardial infarction (MI). He recently presented with angina symptoms and had a cardiac catheterization which did not reveal any concerning areas of stenosis. He has not been taking his medications. Physical examination shows his pulse is 88 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 130/80 mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Which of the following is the best treatment to manage the chest pain? A. ACEi B. Baby aspirin C. Beta blocker D. CCB E. Statin

C. Beta blocker This patient has stable angina and should be treated with a beta blocker. The beta blocker will reduce angina by slowing his heart rate and decreasing his blood pressure, thus decreasing myocardial oxygen consumption. Although studies have shown that calcium channel blockers may reduce angina, beta blockers are the first line since data suggests an improved survival rate. Aspirin and statins are indicated for secondary prevention of cardiovascular disease (CVD), but will not treat angina. There is conflicting data as to whether or not ACE inhibitors reduce angina symptoms and these are not recommended by the American College of Cardiology/American Heart Association guidelines for specific management of angina.

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. Diameter Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is > 6 mm, which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma.

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. Expectant management Expectant management is the most appropriate management at this time. ** Patient is currently not in active labor. Active labor is defined as cervical dilation > 6 cm in the presence of contractions. Contractions are normally 3-5 minutes apart. Fetus is not in distress at this time. Early decelerations are indicative of head compression and are not especially concerning. It is not generally advised to induce patients prior to 39 weeks if there are no complications and fetus is not in distress. C-section would not be indicated in this case because both mother and baby are stable and not in distress. Immediate vacuum delivery is not indicated in this case. Vacuum delivery is indicated only during the second stage of labor, which is the beginning of pushing to the delivery of the baby.

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

C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23) The pneumococcal polysaccharide vaccine (PPSV23) is recommended for adults who smoke (like this patient); have chronic heart, lung, or liver illness; have alcohol use disorder; and have diabetes. The pneumococcal conjugate vaccine (PCV13) is not routinely recommended for adults, though it can be given to some patients at the age of 65.

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. HCTZ E. Spironolactone

C. Metoprolol succinate Beta blockers are part of the first-line treatment for diastolic heart failure. Treatment guidelines for diastolic CHF include the use of beta-blockers and ace inhibitors, similar to systolic CHF. There is no role for digoxin or potassium-sparing diuretics in diastolic failure. HCTZ may help with BP control (important in diastolic CHF) but does not improve the ventricular filling as the chronotropic effects of beta-blockers do.

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. Prednisone This patient meets the criteria for a COPD exacerbation as she has increased dyspnea, increased sputum volume and increased sputum purulence. Inhaled bronchodilators (albuterol) and oral glucocorticosteroids such as prednisone are effective treatments with or without an antibiotic. Digoxin is commonly used for patients with congestive heart failure or atrial fibrillation. Furosemide is a diuretic used for a number of things including volume overload. Propranolol is a beta-blocker used for hypertension and coronary artery disease. Theophylline is an oral methylxanthine that antagonizes adenosine receptors and increases cAMP. It can be used in asthma and COPD but would not be the initial choice of drug in this case.

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. Semi-rigid ankle support This patient has a ligamentous injury to her anterior talofibular ligament. In recommending the RICE mnemonic, a semi-rigid ankle support (C) (such as an Air Stirrup) provides protection from repeat inversion injury while allowing the patient to actively dorsi- and plantar-flex her foot, which aids recovery. Compression stockings (A) and elastic wrap (B) do not provide adequate support. A solid cast (D) completely immobilizes the ankle and delays recovery. Evidence in support of ankle taping (E) is lacking.

A 35-year-old woman has been diagnosed with Graves disease and has decided to go for treatment with radioactive iodine (RAI). She has had good relief from taking propranolol for her palpitations. What is the best way to counsel this patient about what to do after her treatment? A. Tell her to stop her propranolol a week after she gets the RAI. B. Check her TSH level two weeks after her treatment with RAI. C. Describe the symptoms of hypothyroidism to her and tell her to expect to become symptomatic within one month. D. Check her TSH levels two to three months after her treatment and treat as necessary.

D. Check her TSH levels two to three months after her treatment and treat as necessary. The RAI takes several months to destroy the overactive thyroid cells. There is no point in checking the TSH after only two weeks and since she may still be symptomatic from her hyperthyroidism for several months there is no reason to stop her propranolol until she becomes euthyroid. It generally takes a number of months to notice symptoms of hypothyroidism, so while it is important to let her know what to expect in the future you do not want her to have unrealistic expectations.

A 53-year-old man has been experiencing three months of weight loss and palpitations. Work-up for hyperthyroidism, which is high on your differential, is pending. Which of the following symptoms is inconsistent with a diagnosis of hyperthyroidism? A. Tremor B. Insomnia C. Gynecomastia D. Constipation E. Fatigue

D. Constipation The other answer choices are typically associated with hyperthyroidism, while constipation is usually seen with hypothyroidism. Gynecomastia seen in 10% to 40% of patients with Graves disease and is thought to be because of sex hormone binding globulins being increased in Graves disease. Fatigue is common in both hyper- and hypothyroidism.

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. Ischemic cardiomyopathy This patient, with several major risk factors for CAD (hypertension, diabetes, smoking, and a family history in his mother), is most likely to be presenting with heart failure due to ischemic heart disease. While we do not have information about his echocardiogram or cardiac stress testing, his risk factors make E the most likely diagnosis. Atrial fibrillation can cause CHF, but his exam and EKG showing sinus rhythm make this less likely. Non-ischemic cardiomyopathy is also a possible diagnosis, but it is less common than ischemic cardiomyopathy. Valvular disease is less likely in the patient with no audible murmurs. Pulmonary embolism can cause dyspnea and dependent edema due to right heart failure. In such patients, pulmonary edema does not usually occur unless there is also a history of left sided heart failure. The crackles on this patient's exam makes PE less likely.

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. Electrocardiogram An ECG can quickly help determine whether the patient is in sinus rhythm, whether there is ischemia or infarction, or whether there is left ventricular hypertrophy. These findings may help you determine the etiology of this patient's congestive heart failure. Other tests (especially an echocardiogram) may be indicated at some point during the patient's work-up, but may not be appropriate first tests to order. Specifically, cardiac stress testing and cardiac catheterization are more useful in ascertaining the diagnosis and prognosis of coronary artery disease than those of congestive heart failure, although they are often a concurrent part of an extensive workup.

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 decels. What condition is the above tracing most consistent with? A. Cord compression B. Fetal bradycardia C. Fetal tachycardia D. Head compression E. Uteroplacental insufficiency

D. Head compression The external fetal monitoring tracing shows early decelerations which indicate head compression. Early decelerations coincide with the beginning and end of a contraction. It is the characteristic "mirror image" of a contraction. Cord compression is indicated by variable decelerations which are a decrease in fetal heart rate that vary in timing, duration, and intensity. It often looks like the letter "V" and does not necessarily correspond to contractions. Uteroplacental insufficiency is indicated by late decelerations which are decreases in fetal heart rate after the peak of a contraction. It is often caused by decreased uterine blood flow or placental insufficiency that can be related to postdate gestation, preeclampsia, chronic hypertension and diabetes mellitus. Late decelerations are worrisome and require further evaluation. Fetal bradycardia is a baseline fetal heart rate of < 120 bpm. Severe prolonged bradycardia of less than 80 bpm that lasts for three minutes or longer is an ominous finding indicating severe hypoxia and is often a terminal event. Fetal tachycardia is a baseline fetal heart rate > 160 bpm. Tachycardia > 180 bpm is severe. Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia or congenital anomalies.

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 is 38.1 C (100.6 F) Pulse is 102 beats/minute Respiratory rate is 16 breaths/minute Blood pressure is 90/74 mmHg He responds when you say his name, and he appears well nourished. His mucous membranes appear very dry. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis? A. Cardiac arrhythmia B. Cerebrovascular accident C. Diabetic ketoacidosis (DKA) D. Hyperosmolar hyperglycemic state (HHS) E. Thiamine deficiency

D. Hyperosmolar hyperglycemic state (HHS) HHS (D) is seen typically in patients with type 2 diabetes. It includes very high sugars > 600; ph > 6.4; dehydration; and lack of ketones in the urine and blood. Diabetic ketoacidosis is more common in type 1 diabetes, and the patient will have ketone bodies in the urine. Thiamine deficiency can cause Korsakoff syndrome, and is typically seen in alcoholics with alcohol use disorder with severe malnutrition, however, this patient is not a known alcoholic and doesn't appear malnourished. Despite the confusion in this patient, stroke is an unlikely diagnosis in this case given the lack of focal deficits on exam. Cardiac arrhythmia can cause dizziness, but is less likely to cause prolonged altered mental status.

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 is 39.2 C (102.6 F), pulse is 96 beats/minute, and her blood pressure is 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. Albuterol B. Amantadine C. Aspirin D. Ibuprofen E. Zanamivir

D. Ibuprofen Since this patient is presenting outside of the 48-hour window, she should be treated supportively with rest, hydration, and ibuprofen (D) or Tylenol for pain/fever. However, aspirin is an important exception (C). Aspirin is associated with a risk of Reye syndrome in children. Therefore, you should not give aspirin to a child or teen unless specifically directed by a clinician. While this patient's presentation is strongly suspicious for influenza infection, antivirals such as zanamivir (E), oseltamivir, amantadine (B), and rimantadine only decrease the duration of the infection by 24 hours, and are generally not efficacious outside of 48 hours from the beginning of symptoms. This patient also does not appear to require hospitalization at this time, which would be another reason to consider initiating antiviral therapy. Albuterol (A) would be unhelpful as there is no history of difficulty breathing and no wheezing on exam

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. Inability to experience any joy The loss of a loved one can be a traumatic event and it is normal to experience a period of grief. DSM-5 states that MDD can be diagnosed during a period of grief as long as the criteria are met. Grief can be difficult to distinguish from major depression with symptoms of sadness, fatigue, changes in appetite, sleep disruption, and decreased concentration. Since your patient is also exhibiting diminished pleasure with normally enjoyable activities, this may indicate the patient has MDD, as pervasive unhappiness and misery are rarely a part of the normal grieving process. Other features that differentiate MDD from grief include: - Guilt about things other than actions taken or not taken at the time of death - Thoughts of death other than feeling that he or she would be better off dead or should have died with the deceased person - Morbid preoccupation with worthlessness - Marked psychomotor retardation - Prolonged and marked functional impairment - Hallucinatory experiences other than hearing the voice of, or transiently seeing the image of, the deceased person

A 24-year-old previously healthy female has been exhibiting some new concerning symptoms over the past four months. From her history, you gather that she's been having increased diarrhea, tremors, palpitations, and fatigue over this time. Your physical exam reveals a fine tremor in the bilateral upper extremities, sweaty palms, and a smooth, mildly enlarged thyroid gland. You determine that serum testing is warranted. Of the following lab results, which would best support the diagnosis of Graves disease? A. Low TSH, normal free T4, high free T3 B. Low TSH, normal free T4, normal free T3 C. Low TSH, low free T4, low radioactive iodine uptake, low thyroglobulin D. Low TSH, high free T4; high, diffuse radioactive iodine uptake E. Low TSH, high free T4; high, nodular radioactive iodine uptake F. High TSH, high free T4

D. Low TSH, high free T4; high, diffuse radioactive iodine uptake The diagnostic algorithm of the AAFP for hyperthyroidism can be found by clicking on the following weblink: http://www.aafp.org/afp/2005/0815/p623.html. As can be intuited from the answer choices, the first step is to check if serum TSH is low or high and if serum T4 is low or high. If TSH is low and T4 is high, primary hyperthyroidism is diagnosed, and a radioactive iodine uptake scan is next.

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. NYHA I / Stage C This patient has no current physical limitations from his CHF, so his NYHA class is I, but he has a history of symptomatic CHF, thus his ACCF/AHA stage is C. NYHA relies purely on someone's current functional status. Thus a person with known CHF but who has no symptoms or limitations (such as this one) is NYHA class I. The ACCF/AHA Staging is based on the stage of illness. Any person who has ever had symptoms or physical findings of CHF is at least Stage C. If their symptoms are unable to be controlled, they are Stage D. Stage A indicates a patient at risk of developing CHF, but with no known findings or symptoms. Stage B is for patients with evidence of decreased cardiac function (eg. decreased ejection fraction) but who have never experiences symptoms of congestive heart failure

A 46-year-old female presents to her primary care provider to discuss her risk of cardiovascular disease. She notes that her mother had a heart attack at age 66. She denies any recent symptoms of chest pain or shortness of breath. She has a history of hypertension, hyperlipidemia, and obesity. She is a never smoker and drinks a glass of wine daily. Current medications are 10mg amlodipine daily, and 40mg atorvastatin daily. Her pulse is 78 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 154/80 mmHg. Her lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Her electrocardiogram (ECG) is normal. A recent fasting lipid profile obtained 2 weeks prior to this visit shows a total cholesterol of 173mg/dL, an HDL of 45mg/dL, and an LDL of 105mg/dL. Which of the following is the most appropriate management to lower her risk of cardiovascular disease? A. Limit alcohol intake B. Limit polyunsaturated fats C. Start a beta blocker D. Start a thiazide diuretic E. Take an aspirin daily

D. Start a thiazide diuretic This patient should have her blood pressure medication titrated upward to optimize her risk reduction. Thiazide diuretics are first-line antihypertensive agents and should be added to her regimen to achieve goal blood pressure value < 130/80. One serving of alcohol daily in women has been shown to lower the risk of cardiovascular disease (CVD). In addition, she should be counseled on lifestyle modification to reduce her risk of developing coronary heart disease. Polyunsaturated fats have been shown to reduce the risk of CVD and should not be limited. Beta blockers have been shown to lower mortality for secondary prevention of CVD, but not for primary prevention. A low dose aspirin daily is recommended by the United States Preventive Services Task Force (USPSTF) 2016 guidelines for individuals over 50 years old who have a 10% or greater risk of CVD, have no bleeding risk, and at least a 10-year life expectancy. Those guidelines found insufficient evidence to support daily aspirin use for primary prevention in patients < 50 years. A 2018 expert analysis by the American College of Cardiology that has incorporated more recent studies of aspirin for primary prevention recommend use of daily low dose aspirin for nondiabetic patients 40-70 years if 10-year risk of CVD is 20% of higher who do not have a high bleeding risk. This patient's 10-year risk based on ASCVD score is < 10% so daily aspirin would not be recommended.

A 60-year-old female presents to the office complaining of increased frequency of urination and fatigue for the past several months. She reports no fever, dysuria, back pain, diarrhea or 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 nonsmoker and consumes one to two glasses of wine per week. Her vitals are: Pulse is 70 beats/minute Blood pressure is 130/70 mmHg Body mass index is 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 is the next most appropriate step in establishing a diagnosis of diabetes mellitus in this patient? A. An oral glucose tolerance test B. Fasting blood glucose C. HgbA1C D. The random blood glucose is sufficient E. Urine microalbumin

D. The random blood glucose is sufficient Diabetes can be diagnosed with either an HbA1C > 6.5%, a fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l), a plasma glucose ≥ 200 mg/dl (11.1 mmol/l) two hours after a 75 g glucose load, or symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dl (11.1 mmol/l). Answers (A), (B), (C), and (E) are incorrect, as the diagnosis of diabetes can be made in this patient based on her symptoms and random blood glucose (> 200 mg/dl with symptoms). It would be reasonable to order an A1C for management of her diabetes, but this is not necessary to establish the diagnosis. It would also be reasonable to order a urine microalbumin in this particular case, but this would also be useful for management of her diabetes, not for diagnosis.

A 45-year-old woman presents to the ED with two weeks of abdominal pain, progressive weakness and palpitations. She notes an unexplained 3-lb weight loss as well as black, sticky diarrhea. Her vital signs are: Temperature: 99.1 Fahrenheit Heart rate: 117 beats/minute Respiratory rate: 22 breaths/minute Blood pressure: 92/67 mmHg She appears pale and diaphoretic. Her neck is supple and non-tender. Lungs are clear to auscultation bilaterally. Cardiac exam reveals elevated heart rate and a diastolic murmur. Her abdominal exam is notable for diffuse epigastric pain and hyperactive bowel sounds. Which of the following additional lab values might you expect? A. PaO2 of 60 B. Elevated LDH C. Free T4 of 15 mcg/dL (nml range 4.5-11.2 mcg/dL) D. TSH of 0.3 uU/mL (nml range 0.5-5.0 uU/mL E. Hgb of 8.4 g/dL (nml range 12.0-16.0 g/dL) F. Platelet count of 530,000 /mm3 (nml range 150,000-400,000/mm3)

E. Hgb of 8.4 g/dL (nml range 12.0-16.0 g/dL) This woman appears to be suffering from anemia due to GI losses, as evidenced by her abdominal pain, weakness, tachycardia, diastolic murmur, and tar-like stools. There is some evidence of exam of hyperthyroidism (C), like tachycardia and diarrhea, but the other aspects of her presentation point to loss of blood. PaO2 is not impacted in blood loss (A), nor is platelet count (F). LDH is elevated in hemolytic anemia.

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. Pulmonary hypertension causing right heart failure Chronic hypoxia causes pulmonary vasoconstriction that increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention. Given this patient's history of advanced COPD, E is the most likely cause. Thromboembolism would cause painful necrotic areas in the distal extremities but is not a common cause of peripheral edema. Hepatomegaly can cause venous congestion, but there is nothing in this patient's history to suggest this is likely. New onset atrial fibrillation can cause left-sided heart failure and dependent edema. This patient's cardiac exam is described as normal which indicates he is not in atrial fibrillation currently (though he could have paroxysmal AFib). He also does not present with lung findings suggestive of pulmonary edema such as crackles. His lung findings are typical for a patient with COPD. Venous stasis from incompetent venous valves is a common cause of dependent edema. This is frequently the result of a deep vein thrombosis, and thus is more typically unilateral. In this patient with advanced COPD, pulmonary hypertension is a much more likely explanation.

A 7-year-old male is brought to your clinic with a fever of 38.9 to 39.4 C (102 to 103 F) for the past 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. CXR B. Empiric levofloxacin (Levaquin) therapy C. Empiric oseltamivir (Tamiflu) therapy D. Empiric penicillin V therapy E. Rapid strep test

E. Rapid strep test In addressing this child presenting with fever, symptoms of pharyngitis (sore throat), and the absence of cough, the clinician needs to consider the possibility of strep throat. Predictive scoring tools such as the Modified Centor criteria are useful in determining which patients need testing for strep, but should not be used to make a positive diagnosis of strep throat. This child would have a score of 4 (one each for fever, absence of cough, high-risk age group, and tender cervical lymphadenopathy) and should be tested for strep using a rapid strep test (E). Empiric antibiotics (B, D) are not appropriate here. In the case of a positive strep test, penicillin V (D) would be an appropriate choice, but levofloxacin (B) would not. Influenza often presents with fever and sore throat, but typically involves cough as a prominent symptom, therefore empiric treatment with oseltamivir (C) is not indicated. This patient has no lung findings on exam, so a chest x-ray (A) is unlikely to be of benefit.

A 48-year-old female with no smoking history comes to the emergency department with concerns of sore throat for the past 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 with fever and sore throat. Her children are now staying with their father whom she is separated from, and he notified her yesterday that they were on antibiotics for their symptoms. She was holding off seeing a clinician 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 C (101.5 F) measured by the nurse, and on physical exam you observe an erythematous throat with exudate, and bilateral cervical lymphadenopathy. Her lungs are clear to auscultation. What is the next best step? A. CXR B. Empiric levofloxacin (Levaquin) therapy C. Empiric oseltamivir (Tamiflu) therapy D. Empiric penicillin V therapy E. Rapid strep test

E. Rapid strep test The Modified Centor criteria may be used as a tool to identify which patients (both adults and children) should undergo rapid strep testing. Current guidelines suggest that all adults who score three or more points using these criteria should be tested for strep. This patient gets a score of three: 1 point each for fever, absence of cough, tonsillar exudates, and cervical lymphadenopathy, as well as minus one point for her age group (age >= 45). Given her score of 3 using the Modified Centor criteria, a rapid strep test is appropriate in this case (E). Empiric antibacterials (B, D) would not be appropriate, as strep throat should not be diagnosed without a positive test for strep (either rapid strep test or throat culture). Empiric treatment for influenza with oseltamivir (C) would not be appropriate without first ruling out strep throat. During an influenza outbreak, empiric treatment for influenza might be appropriate, but strep throat would need to be ruled out first in this case. In this patient with no lung findings, a chest x-ray is unlikely to be of benefit and would be inappropriate (A).

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. Sleep apnea Sleep apnea occurs in 20% to 70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep. Some of the other most common causes of insomnia in the elderly are: Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep. Drugs, Alcohol, and Caffeine such as over-the-counter, alternative, and certain recreational drugs. Parasomnias such as restless leg syndrome/periodic leg movements/REM sleep behavior disorder. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively. Disturbances in the sleep-wake cycle such as jet lag or shift work. Psychiatric disorders such as primary depression and anxiety Symptomatic cardiorespiratory disease (asthma, COPD, heart failure) Pain or pruritus Gastroesophageal reflux disease (GERD) due to heartburn, throat pain or breathing problems. Hyperthyroidism The elderly frequently do not present with typical symptoms such tachycardia or weight loss, and therefore further laboratory studies may be required to detect this problem.

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

E. Start at age 50 and every 2 years thereafter Mammography has a sensitivity of 60% to 90% for detecting breast cancer and decreases breast cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not routinely indicated for females younger than 50 except as based on patient context (history) and beliefs about risks/benefits. The USPSTF recommends biennial testing for females between the ages of 50 and 74. There is insufficient evidence to assess the benefits versus risk of screenings in females after the age of 75. The American Cancer Society (ACS) recommends yearly mammograms starting at age 45, and American College of Obstetricians and Gynecologists (ACOG) recommends engaging in shared decision-making about mammograms starting at age 40. They also recommend that all females at age 50 commence annual or biennial mammography.

A 72-year-old female with a 30-year history of type 2 diabetes and hypertension returns to your office for a routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. She is on atorvastatin 40 mg daily and lisinopril 40 mg daily. She is on no other medications. Her A1C is 6.5% and her BP today is 145/90. She notes blurry vision for the past several months and a few days of dark spots in her vision. She reports no headaches or nausea. What is the most appropriate next step to slow down the progression of diabetic retinopathy? A. Increase her insulin aspart from five units to seven units with meals. B. Increase her insulin glargine to 23 units every morning. C. Perform a fundoscopic examination and make no changes to her regimen today. D. Start her on a baby aspirin. E. Start her on a calcium channel blocker.

E. Start her on a calcium channel blocker. The patient's symptoms describe diabetic retinopathy, which affects 40% of people with diabetes who are on insulin after five years (25% of those on oral agents). Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Patients with diabetes need to see an ophthalmologist regularly for a dilated retina exam and should not rely on an undilated fundoscopic exam by a primary care physician (C) as effective screening. Increasing either her mealtime insulin (A) or her basal insulin (B) would be inappropriate, as her hemoglobin A1C is at target. Aspirin (D) has not been demonstrated to have an impact on diabetic retinopathy. This patient's blood pressure is above her target of 130/80 mmHg. Starting her on any of the first-line options for blood pressure management, such as a calcium channel blocker (E), would be appropriate. There is fair evidence that in addition to decreasing cardiovascular risk, blood pressure control may prevent progression of diabetic retinopathy.

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

E. Thiazide diuretic This patient now meets criteria for stage 2 hypertension as indicated by a systolic BP 140 to 159 mmHg and diastolic BP 90 to 99 mmHg. The ACC/AHA guidelines recommend thiazide diuretics (E), ACE inhibitors, angiotensin II receptor blockers, or calcium channel blockers as first-line treatment for most patients with newly diagnosed hypertension, with a slight preference for chlorthalidone in the diuretic class. The other options are not first-line treatments for hypertension.

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

E. Weight With a BMI of 32, obesity is the one risk factor for this patient based on the information given. Other risk factors for breast cancer include family history of breast cancer in a first-degree relative (mother or sister—not aunt), prolonged estrogen exposure (menarche before age 12, menopause after 45, advanced age at first pregnancy), genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age, and this patient is relatively young), female sex, increased breast density and certain exposures (diethylstilbestrol, hormone or radiation therapy, heavy smoking). Breast cancer risk also decreases with increasing parity. With three children, this patient's risk is slightly reduced.

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. X-ray imaging of right ankle Based on the Ottawa Ankle Rules, tenderness of the lower 6 cm of the posterior lateral malleolus may predict fracture and justifies X-ray imaging of the ankle. Tenderness of the lower anterior lateral malleolus is common in ligamentous injury but this finding alone does not require x-rays. Immobilization with a cast (B) may be indicated, but imaging should be obtained first. If the x-ray is negative, it would be appropriate to diagnose a sprain and manage with a semi-rigid ankle support (C), as well as rest, ice, compression, and elevation (D). Since this patient has normal sensation and distal pulses, compression syndrome is unlikely and a surgical consultation is not indicated (A).