Exam Master 500-1000

A 10-year-old girl presents with chest pain and joint aches. Her mother says that about 2 weeks ago, her daughter had a sore throat with fevers and pus around her tonsils. She was prescribed a 14-day course of penicillin on the initial visit, but her mother stopped the medications after 2 days because the fever subsided. She also experienced chest pain and recurrence of fever. Her vital signs: blood pressure 120/80 mm Hg, heart rate 110 beats/min, temperature 102.3°F. On physical examination, normal S1/S2 and a II/VI short mid-diastolic murmur are heard. Her EKG shows a sinus tachycardia with a prolonged PR interval.

Antibiotic compliance

A 3-year old boy is brought to the pediatrician with a 2-week history of symptoms of an itchy, red "wound" on the right knee. The mother ignored the wound initially, assuming that the boy got injured while playing on the street, but it did not heal and seems to have worsened. On examination, there are a few intact vesicles and a few ruptured vesicles covered with honey-colored crusts. You suspect non-bullous impetigo.

Antibiotic ointment

A 72-year-old man presents with low-grade fever, nausea, confusion, and lethargy. His past medical history is significant for hypertension, hypercholesterolemia, and diabetes. He had sinusitis approximately 1 week ago; otherwise, he has been healthy. Laboratory workup shows a CSF with elevated opening pressure and low blood glucose levels. A Gram stain on the CSF shows gram-positive cocci. CBC shows an elevation of PMNs, but it is otherwise normal.

Antibiotic therapy

A 31-year-old female nurse who works at a local hospital presents with a purpuric rash covering her arms, legs, and abdomen, as well as fever, chills, nausea, abdominal tenderness, tachycardia, and generalized myalgias. Prior to the development of the rash, the patient noted that she had a headache, cough, and sore throat. Laboratory studies were positive for gram-negative diplococci in the blood, along with thrombocytopenia and an elevation in PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: BP 92/66, P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick contacts. She is admitted to the hospital and placed in respiratory isolation.

Antibiotics

A 44-year-old man starts to notice that his eyelids are drooping. Some time afterward, his jaw becomes weak. He has difficulty swallowing and experiences weakness in his limbs. He is quite embarrassed when he eats because he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs, but no sensory defects are present. A Tensilon test is done and is positive.

Antibodies to the acetylcholine receptor

An 18-year-old male high school dropout recently set a fire in his old school classroom because he was dared to do so by other students. He has been sent to you for evaluation. You interview him and find that he had a number of problems related to truancy and fighting in school; he has been found with liquor in his locker at school, and he always seems to feel that someone else is responsible for his having done something. When he was 10, the patient burned down a barn; last year, he and some friends threw rocks at passing cars on the expressway. Past medical history is non-contributory. He denies any recreational drug use.

Antisocial personality disorder

A 13-year-old girl presents with a painful reddened lesion on the inside of her cheek. She noticed this lesion a few days ago and it will not go away. Upon physical exam, the inside of her right cheek has a yellow-grey appearance with an erythematous halo surrounding the lesion. Patient overall feels well besides this specific issue, and no other rashes or lesions are noted. All laboratory findings are within normal limits. HSV-1 and HSV-2 are both negative.

Aphthous ulcers

A physician assistant arrives 45 minutes late to work due to traffic caused by a car collision. The PA forgot to notify the office of their tardiness. The PA arrives to find their first patient has been waiting 60 minutes in the examination room. The patient yells from the room, "This is how you treat your patients? Give me a different provider!"

Apologize to the patient and explain the delay.

A 6-month-old healthy male infant presents with an inability to sleep through the night. He has 3-4 nighttime awakenings, and his parents spend a long time getting him back to sleep. Both parents work, and their sleep remains disrupted, which affects their work performance the next day.

Approximately 25-50% of 6- to 12-month-olds have nighttime awakenings.

A 21-year-old man presents with acute onset of pleuritic chest pain accompanied by 2-3 days of fever, chills, arthralgias, and myalgias. Upon further questioning, the patient notes that he had a severe sore throat and fever 4 weeks ago, but he was not evaluated for these symptoms. Physical examination reveals a febrile patient in mild distress. A systolic murmur is noted in the left fourth/fifth intercostal space that radiates to the left axilla. A friction rub is also appreciated on exam. Laboratory results reveal an elevated erythrocyte sedimentation rate (ESR) and antistreptolysin antibodies.

Aspirin

A 30-year-old male presents for routine follow-up. He has a history of intermittent headaches, low back pain, knee pain, and dysuria over the last year. Additionally, he notes nausea, diarrhea, poor libido, and extremity numbness. He states he feels worthless. He admits to daily alcohol use in an attempt to feel better. Lab studies, urine testing, plain radiographs, CT scans, and MRIs are all unremarkable and show no explanation for his symptoms, but he is consumed by worry about his illness.

Associated personality disorders and depression are common.

A 5-year-old boy presents with an erythematous skin rash associated with intense itching. The boy's mother has noticed that her son's rash has been recurrent, with 3-4 episodes per year. The itching and rash increases after consumption of certain foods. On examination, erythematous raised papules are seen on the cheek, trunks, and upper arms.

Asthma

A 5-year-old boy presents because of concerns about his behavior. His mother notes he gets extremely distracted and can only focus for 1-2 minutes at a time. He cannot seem to sit still, and he displays extremely impulsive behavior at inappropriate times. She describes impulsive behavior recently at a funeral and at an older sibling's music recital. Because the mother works full time, the patient attends daycare after kindergarten. His kindergarten teacher and the daycare staff have expressed similar concerns.

Attention deficit hyperactivity disorder

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class, he is frequently in trouble for being disruptive, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are worsening. The teacher reports the patient often seems distracted. He rarely sits still at his desk, fidgets often, and blurts out comments without waiting his turn. Physical examination is remarkable for increased motor activity but is otherwise normal.

Attention deficit hyperactivity disorder Father reports similar symptoms into adulthood. Initiate stimulant medication.

An 18-month-old boy is brought in for a well-child visit. His mother states that he does not say any words, not even "mama" or "dada." He does have monosyllabic babble and points to objects that he wants. The remainder of the child's development is within normal limits, including gross and fine motor skills. He was born full-term via normal spontaneous vaginal delivery with no complications. He has always been healthy. He is currently not on any medications; he has no known drug allergies and all of his vaccinations are up to date. On observation, the child plays with the mother and makes good eye contact with her. The physical exam of the child is normal. The head circumference is normal. There is no cleft lip or palate, and the neurologic exam is within normal limits.

Audiology consultation for a hearing evaluation

Parents bring their 3-year-old son for evaluation of a recently diagnosed intellectual disability. The test for intellectual disability was performed primarily because of delayed speech. The mother states that her child started to babble at about 9 months of age and then learned a few words such as "dada" and "boo" at 18 months. Despite the efforts of his parents to stimulate his language (reading to him, singing, exposing him to sounds, teaching him to mimic their speech, etc.), his speech has remained far behind other children his age. He is not interested in playing with the other children, always looks serious, and behaves more independently than other children. His prenatal and past medical history is unremarkable; he was always healthy, and his immunizations are up to date, including MMR. While you are taking the anamnesis, he does not seem interested in the conversation. Instead, he started spinning himself, an activity that he enjoyed so much that he did not respond when parents tried to stop him. When asked, his parents left the room, but the child did not pay attention to them leaving. Then he saw fancy colored wooden sticks and started sorting them out by colors because nobody could interrupt him. Developmental screening today is impossible because he simply ignores you, so you decide to schedule a follow-up evaluation.

Autism spectrum disorder

A 35-year-old woman presents with a 2-month history of palpitation and nervousness. She mentions that she always feels hot, even if the weather is cold. Her menses have been irregular lately, and she has had no fevers recently. She was also told that her eyes are "weird-looking." On examination, blood pressure is 150/70 mm Hg, and pulse is 89 beats per minute. Her eyes show exophthalmos, and she has lid lag when looking down.

Autoimmune

A 12-year-old girl becomes comatose and is rushed to the hospital by her parents. She went to school feeling ill 2 days before the admission. She vomited that evening. Her vomiting persisted with only an 8-hour pause during sleep. She is breathing deeply and rapidly; her breath has a fruity odor. Her parents mention that her appetite has increased. She has also been drinking a lot of fluids; subsequently, she has been urinating more than normal. Urinalysis reveals 3+ glucose levels and 2+ ketone bodies.

Autoimmune destruction of B-cells of the pancreas

A 22-year-old woman presents due to clogging of the right ear, hearing loss, dizziness, ringing of the ear, and ear pain. She was scuba diving in Florida last week. A thorough ear exam was conducted. The eardrum appears slightly pushed outward from where it normally sits. Laboratory results showed no abnormal findings.

Barotrauma

An 85-year-old woman with active vascular dementia is brought into the emergency department by her son after a fall. She is only able to groan. Her son says that she "tripped over a cat." She has mobility issues and depends on her family for her activities of daily living. Vitals are within normal limits. Her arms exhibit bruises of various stages of healing, and she is malnourished.

Begin a physical exam.

An 80-year-old woman with metastatic bladder cancer presents to the office for review of her most recent imaging. Her computerized tomography (CT scan) reveals pelvic lymphadenopathy suspicious for metastasis. She requires oral narcotics for pain control and has become progressively weak with poor oral intake. She vocalizes she no longer wants to consider any further treatment.

Beginning after stopping treatment

An 18-year-old woman has been afraid of dogs ever since she was bitten as a child. You begin therapy by having the client do relaxation exercises while looking at the word "dog." Once the client is comfortable with this process, you have her do relaxation exercises while looking at a picture of a dog. The next step is to have the client do relaxation exercises while watching a dog from a distance. You then have the client do deep breathing exercises while sitting in the same room as a small dog. The final step is to have the client sit in the same room as a big dog while performing deep breathing exercises.

Behavioral therapy

A 37-year-old woman presents with a history of right-sided facial paralysis and periauricular discomfort since she awoke this morning. She is afebrile. She had a "cold sore" 1 week prior to her symptoms, but this resolved without complications. During her neurologic exam, she was discovered to have an inability to raise her right eyebrow and close her right eye completely. She also has drooping of the right corner of her mouth. The rest of her neurologic exam is normal. There are no masses or rashes evident. She denies history of prior CVA or neurologic illnesses. She does not take any medications.

Bell's palsy

A 61-year-old woman presents a 1-week history of intermittent episodes of feeling like she was spinning. She states the episodes are brief, but they occur 2-3 times per day. It is worse when she turns to her right side while lying in bed. Even when she is not dizzy, she feels off balance. She denies tinnitus, decreased hearing, fever, syncope, nausea, vomiting, diplopia, or any other related symptoms. During the Dix-Hallpike maneuver, the patient exhibits nystagmus, with her eyes beating laterally when the right ear is turned downward. The nystagmus diminished with each time the maneuver was performed.

Benign paroxysmal positional vertigo

A 65-year-old Caucasian man presents with a 3-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first 2 days of his illness but successfully eats breakfast on the day he is seen in the clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. The otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg and Fukuda testing indicate right-sided pathology. Other than a crisp left-beating nystagmus, cranial nerve examination is normal. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.

Benign positional vertigo

A 78-year-old woman presents with behavioral changes over the past few months. Her daughter feels that her mother is depressed, as she talks less frequently with her family members. She was a regular at various social gatherings, but the patient has been avoiding them lately due to some difficulty in communication. She has been spending more time painting portraits and has been watching television at a higher volume than usual. She has no suicidal thoughts. She is well oriented to time, place, and person; her mood today seems good. Ear examination and tests indicate sensorineural hearing loss. The rest of her physical examination is within normal limits.

Bilateral hearing aids

A 74-year-old man presents with a 90-minute history of severe pain and blurred vision in his left eye. He reports headache and some nausea along with halos surrounding lights. Upon examination, his left eye is erythematous with a steamy cornea and a poorly reactive mid-dilated pupil. An ophthalmologic consult is ordered and tonometry is completed, revealing an elevated intraocular pressure. Gonioscopy was used to confirm the diagnosis and examine the fellow eye, showing narrow anterior chambers in both eyes.

Bilateral laser peripheral iridotomy

A 60-year old woman has a history of stress-related migraine headaches. Many conventional treatments have failed.

Biofeedback

A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went "a little nuts" when she was a freshman; it was her first semester and the first time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought two computers and a whole new wardrobe with her father's credit card.

Bipolar I disorder

A 25-year-old woman is brought in by her sister. The woman has had increasingly frequent incidences of bizarre behavior, and her family is concerned. The most notable episodes occurred within the past week. She seemed sad and distant for a couple of days, then she left abruptly and returned home after being gone for 2 days. During that time, the woman told her sister that she had driven for 3 hours for no particular reason and spent much of her time partying and spending money. The normally intelligent woman was unable to remember where she had gone, and she could not explain why she left in the first place. After running out of money and sleeping in her car for 2 nights, she called her sister, who came and got her. Her sister found her dirty and speaking quickly about nothing in particular. She was brought home, and she now looks quite calm and seems a bit solemn. On examination, the woman's vital signs are within normal limits. Lab work reveals nothing abnormal. The patient did not display any unusual behavior. She was quite pleasant and cooperative. Her score on the mini-mental state exam was 29, but she does not seem to recall much about what happened a few days ago.

Bipolar disorder

A 32-year-old woman presents for magnetic resonance imaging of the head due to visual changes and galactorrhea. A mass is found in the sella turcica.

Bitemporal hemianopsia

A 22-year-old woman presents with a 1-year history of flaking and scaling around her lashes, along with itching and a burning sensation. She has also noted her lid margins are red, and some of her lashes are missing. Her history is significant for diabetes and for seborrheic dermatitis of the scalp, eyebrows, and external ears.

Blepharitis

A 52-year-old man presents with a burning sensation in both eyes. He denies recent trauma and contact with individuals who have similar symptoms. On examination, his eyelid margins are red and inflamed. His eyelashes are greasy and adherent with a surrounding dandruff-like scale. Conjunctivae are clear.

Blepharitis

A 65-year-old woman presents with weight gain, fatigue, and aching limbs that have been bothering her for 2 months. She has also been having intermittent runny noses, constipation, and dry skin. Physical exam reveals heart rate 56, respiratory rate 18, blood pressure 138/102, temperature 97.9°F, and weight 210 lb. On heart exam, there is a grade II systolic murmur heard best at the right sternal border, second intercostal space. Skin exam shows cool, dry, somewhat pale skin with scattered cherry angiomas.

Blood pressure of 138/102

A 23-year-old woman presents to the emergency department after a baseball hit her in the right eye. She has double vision, pain upon moving the right eye, and numbness of the cheek, nose, and right side of the eye. Upon physical exam, swelling, tenderness, numbness of the nose, and epistaxis are present.

Blowout fracture

A 60-year-old woman is referred to you for a bizarre fixation. She has become preoccupied with the issue of having breasts that are too small, and she has been shopping for plastic surgeons to fix the problem. She has become so fixated on her problem that she stays in the house, does not socialize with others, and tries to constantly hide the perceived problem by wearing clothes that enhance her breasts; sometimes, she even wears prosthetic breasts. She has become paranoid about what people are saying about her appearance.

Body dysmorphic disorder

A 30-year-old African American man is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He had been experiencing increased hearing loss in the right ear over the past few years. His mother had suffered from the same condition when she was in her 40s and had been successfully operated upon. You perform an assessment using the Weber and Rinne tests.

Bone conduction of the affected side is greater than air conduction.

A 19-year-old female student is referred for psychiatric assessment after an attempted suicide 2 days ago. On questioning, the patient informs that the precipitant to her attempted suicide was a recent breakup with her boyfriend. Her history is significant for multiple suicide attempts since the age of 12. On further questioning, the patient informs that she has a chronic feeling of emptiness and sometimes feels disconnected from reality. She also gets into fights with her boyfriends, as she has difficulty controlling her anger. The patient admits that she has had highly problematic relationships with men and that she falls quickly in and out of love. Examination reveals several cuts on the wrists and arms.

Borderline

A healthy mother with no known medical illnesses presents her 6-month-old male infant due to a 1-day history of poor feeding, lethargy, and weak cry. At first, the infant had difficulty sucking and swallowing and was not opening his eyes. This was followed by loss of head control, weakness of the trunk, arms, and then legs. The infant is constipated and has had decreased tears and saliva since yesterday. The infant was healthy before the onset of these symptoms. There is no history of fever, vomiting, cough, seizures, or difficulty in breathing. The infant has weak gag and pupillary reflexes, generalized hypotonia, loss of head control, ptosis, and diminished deep tendon reflexes. Blood counts and CSF examination are within normal limits.

Botulism

A 57-year-old white man presents to the emergency department reporting a syncopal spell 1 hour ago. He was in his normal state of health until approximately 7 days ago, when he developed acute diarrhea that lasted 4 days and then resolved. For the past 3 days, however, he has had progressively worsening nausea and vomiting. Past medical history is significant for congestive heart failure secondary to non-ischemic cardiomyopathy, atrial fibrillation, hypertension, chronic renal insufficiency (with baseline creatinine 2.0), and benign prostatic hypertrophy. Previous surgeries include laser surgery for a detached retina and transurethral retrograde prostatectomy. He has no known drug allergies but indicates an intolerance to diltiazem due to hypotension. Current medications include furosemide, digoxin, enalapril, carvedilol, and tamsulosin. Review of systems is as follows: General—Admits to decreased appetite for the past 3 days. Admits to fatigue and malaise. HEENT—Admits to visual disturbances for the past 3 days described as yellow and green halos around lights. Cardiovascular—Admits to chronic dyspnea on exertion at 3 blocks. A complete review of systems was otherwise negative. On physical examination, temp 98.8°F, pulse 40 and slightly irregular, respirations 16, blood pressure 108/60. The patient appears alert with nausea and some vomiting during interview and exam. Bradycardia is present with slightly irregular heart rhythm. Normal S1 and S2 without obvious rub, murmur, or gallop. Lungs fields are clear without rales, rhonchi, or wheezes. The remainder of complete physical examination is unremarkable. Lab: Notable for K+ of 5.8 mEq/L, BUN 40 mg/dL, creatinine 4.2 mg/dL, digoxin level 4.8 ng/mL. EKG demonstrates complete AV dissociation present, while CXR shows no acute disease and abdominal X-ray displays normal findings.

Bradycardia with complete AV block

A 55-year-old Caucasian man was brought to the emergency department for evaluation of sudden chest pain. He was at a barbecue eating ribs when he developed sudden substernal chest pain with nausea and left arm numbness. An EKG demonstrated 2 mm ST elevations in leads V3, V4, and V5. He was diagnosed with acute myocardial infarction. Cardiology was consulted and angioplasty was recommended. The procedure and potential risks were explained in detail to the patient. The patient declined angioplasty, opting for medical therapy alone. He is discharged and dies a few hours after discharge. His family sues the PA and cardiologist for malpractice.

Breach of duty

A 67-year-old man was cleaning out his garage and noticed a "bug" crawling on his leg. The bug bit him before the patient killed it. He discarded it and went about his business. 2 days later, he presents with pain, itching, and swelling of the affected leg. The bug had a violin-shaped pattern on its back.

Brown recluse spider

A 7-year-old girl was playing at a local playground near her home in Louisiana. She was playing kickball and retrieved the ball from a pile of rocks. After several minutes, she noticed a red lesion on her right forearm. She rushed home and told her mom. The mother looked at the lesion and noticed a small red area and sprayed the area with a local antiseptic that she had in her medicine cabinet. The child only noted that it burned. A few hours later, the mother looked at the area and noticed that a white area appeared. She thought nothing of it and placed a bandage over the bite. Before the child went to bed that night, she removed the bandage and noticed that the area had darkened. The mother then took the child to the ER for further evaluation.

Brown recluse spider

A 13-year-old girl has a history of being found by her mother consuming large amounts of high-calorie food on several occasions and then vomiting what she ate. For the past 2 days, the patient has experienced pain in her throat, which was diagnosed as esophagitis. Upon physical exam, the patient is dehydrated, has abnormal electrolyte imbalances, and appears to have eroding front teeth.

Bulimia nervosa

A 62-year-old woman well known to you presents with a severely itchy rash. The patient's medical history includes Parkinson's disease that was diagnosed around 7 years ago. The patient thought that the rash was just eczema initially, but the areas have morphed into severely tense, large blisters; they are extremely pruritic to the patient. On examination, you note multiple bullae 1-3 cm in size that are tense and appear to be sitting on an erythematous base. The bullae are located on the patient's lower abdomen in both lower quadrants and in the bilateral axillary and inguinal folds.

Bullous pemphigoid

An 8-month-old boy is admitted due to possible middle ear infection and chronic diarrhea. He has episodes of frequent loose stools since birth. He had two episodes of lower respiratory tract infection with bronchospasm, treated with intravenous antibiotics and bronchodilators. Parents are not related, and their firstborn died of pneumonia at age 8 months. The patient appears irritable, screams, shakes his head, and tries to rub the right ear. Signs of dehydration are noted. Weight is <5th percentile, height is 5th percentile, and head circumference is 50th percentile. Temperature is 38°C. Mucocutaneous changes suggestive of a fungal infection are noted. Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic otoscopy. Left tympanic membrane appears clear with good mobility. Throat is erythematous. Thyroid, heart, lungs, genitalia, and nervous system are within normal limits; abdomen is tender. You cannot palpate lymph nodes, and there are no signs of hepatosplenomegaly.

CBC with differential

A 1-year-old boy presents with a history of vomiting, lethargy, and respiratory distress of sudden onset; there is no prior illness or injury. The parents state that the boy is "always irritable" and he keeps them up all night. The parents have missed several well-baby visits; they both work and are unable to keep the appointments. Physical examination reveals red bruises on the boy's arms that appear in the shape of fingers, along with a full fontanel. Ophthalmologic exam demonstrates the presence of retinal hemorrhage.

CT scan of the brain and a skeletal survey

A 15-month-old toddler presents with sudden onset of generalized tonic and clonic convulsions for the last 30 minutes. Parents report that the patient was irritable in the minutes preceding the events, but there is no history of trauma, fever, or vomiting before the onset of convulsions. This is the first episode of seizure, and there is no history of convulsions in the family but the father has a history of cerebral aneurysm requiring surgical clipping. The patient's birth history, neonatal period, and developmental milestones are normal.

CT scan of the head

A 36-year-old man presents with nasal congestion, headache, fatigue, facial pain, and chronic post-nasal drip. He has had similar episodes in the past, occurring 2-3 times a year for the last several years. He has been diagnosed with acute sinusitis and antibiotics have been prescribed, providing him with relief for a brief period. This time, however, his symptoms have bothered him on and off for the last 3 months. He was given a 14-day course of antibiotics, but he experienced only partial relief. He is tired of the recurrent episodes and wants a cure. On exam, he is afebrile, nasal mucosa is inflamed, and there is mucopurulent secretion in the nasal cavity. The right maxillary sinus is tender on palpation. Lungs are clear.

CT scan of the sinuses

You have been working as a physician assistant with a neurosurgeon for several years and you have developed a strong professional relationship. Recently, the surgeon informed you their mother passed away. Since this disclosure, you have noticed the surgeon has become more withdrawn and less interactive with you and the staff. Despite this change, the surgeon continues to provide high-quality patient care. The two of you are scheduled to perform a lumbar laminectomy on a patient with significant spinal stenosis. Before the operation, the patient informs you they have been waiting over 6 months for this surgery. While preparing and draping the patient, you smell alcohol on the surgeon's breath. Upon questioning, the surgeon admits to having consumed a glass of whiskey in their office. The surgeon does not appear intoxicated and is conversing appropriately with you.

Cancel the surgery and report the surgeon for intoxication.

A 35-year-old woman who recently finished a round of oral antibiotics for pneumonia presents due to her tongue having "a thick white coating"; she adds that it is "also red and irritated." She is able to "scrape the white stuff off" some areas of her tongue, which she reports have become raw and more erythematous.

Candidiasis

A 27-year-old man underwent pre-employment urine drug testing of hospital employees after recently being hired for a full-time position. Although the patient admits to using both legal and recreational drugs in the past, he claims he has not used anything for at least 2 weeks. The urine test returns positive.

Cannabinoids

A 23-year-old man presents with burning on urination and a light greenish-yellow penile discharge. He is afebrile but otherwise well. He admits to having unprotected anal sex with a man.

Ceftriaxone 250 mg IM once and azithromycin 1 g now

A 60-year-old woman is awaiting surgery for an anterior pituitary tumor diagnosed several months ago. She has no other medical problems. Preoperatively, she is given no diuretics or contrast dye; her fasting blood glucose is 80 mg/dL. Urinalysis at that time indicates no glucose, cells, nitrate, blood, leukocyte esterase, or casts; the patient has ready access to fluids, but she is not aggressively hydrated intravenously.

Central diabetes insipidus

A 64-year-old African American man presents to the emergency department after he went blind in his right eye "out of the blue" 20 minutes ago. There is no pain associated with his symptoms and he is not nauseated. Past medical history is positive for type 2 diabetes mellitus for the past 10 years. The pupil reaction on the left side is normal with pressure of 17 mm Hg. Right pupil evaluation reveals no reaction to light or accommodation with pressure of 20 mm Hg. Right eye ophthalmoscopy reveals arteriolar narrowing, vascular stasis, and "boxcar" pattern.

Central retinal artery occlusion

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly man who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable.

Central retinal artery occlusion

A 24-year-old man presents with a painless, localized swelling of his left lower eyelid; it has developed over a period of weeks. He is seeking medical attention because it is now producing a foreign body sensation in his left eye; it is also hindering his path of vision. On physical examination, his visual acuity is normal; there is no evidence of injection or discharge. You palpate, and you observe a nontender, localized nodule on the lower eyelid.

Chalazion

A 42-year-old man presents with a firm painless bump on his left upper eyelid. On examination, you note a 5 mm mass within the tarsus of the left eye. The skin is freely movable over the mass. The remainder of the eye exam is unremarkable.

Chalazion

A 27-year-old unemployed Latina woman is living in California as an undocumented immigrant. She is married with 4 young children at home. Although her husband is employed, he is also an undocumented immigrant, and the family does not have health insurance. She describes herself as poor and requests your help in locating prenatal care. She states that she just took a home pregnancy test 2 days ago that indicated she is pregnant.

Children's Health Insurance Program

A 9-year-old boy presents with burning during urination and a creamy white penile discharge. The grandmother is concerned about sexual abuse by a female caregiver.

Chlamydia urethritis

A 55-year-old Caucasian man presents for yearly physical. On review of systems, he admits intermittent allergies that are worse with dust, weight loss, excessive hunger, intermittent back pain only with lifting, and new excessive frequent urination. His vitals are blood pressure 138/88, respirations 16, pulse 70, weight 258 lb, height 5'9", SpO2 96%, temperature 97.8°F. Labs show normal electrolytes, ALT of 10 U/L, AST of 18 U/L, and random glucose of 207 mg/dL. You check some additional labs, then explain his new diagnosis based on his lab work, telling him you are going to start him on a chronic medication for his condition. You want to make sure there are no contraindications.

Chronic kidney disease stage 3A

A 47-year-old Native American man presents to the Indian Health Service primary care clinic for evaluation of headache. His blood pressure is 165/75 mm Hg, weight 225 lb, heart rate 98 beats per minute, respiratory rate 18 respirations per minute, and temperature 98.7°F. He smokes 1 pack of cigarettes per day and drinks approximately 12 beers per week.

Chronic liver disease

An 8-year-old boy presents with left ear pain. His father reports that he had two ear infections as a baby, but he cannot remember which ear. The visit occurs during the summer months, and the father says that the patient has been swimming almost daily in a neighbor's pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema and pain with manipulation of the left pinna. No other physical examination findings are abnormal.

Ciprofloxacin/dexamethasone topical solution

A 29-year-old woman presents to an urgent care clinic due to abdominal pain and bloody diarrhea that has worsened in the last 36 hours. She also reports nausea, vomiting, and a low-grade temperature of 100.1°F. She attended a neighborhood block party 2 days ago and ate various home-cooked foods. She has no relevant past medical history. A physical exam reveals dry oral mucosa and epigastric pain upon deep palpation of the upper abdomen. Stool studies for bacteria, ova, and parasites were collected and sent for analysis. Several more people appear later in the week reporting similar symptoms.

City health department

A 15-year-old Caucasian boy presents with a 2-week history of recurrent breakouts on his face. His mother states that the condition is worse during football season. He currently uses over-the-counter products with no improvement. Examination of the face reveals a combination of inflammatory papules, pustules, and comedones on the face, with a concentration on the forehead and temples.

Clean football helmet after use.

A 27-year-old woman followed by your practice for several years has recently undergone genetic testing for von Hippel-Lindau disease. The test showed that she has a mutation in the VHL gene. She does not have von Hippel-Lindau disease yet, but she is at risk for developing it. The patient has a 24-year-old brother who was diagnosed with von Hippel-Lindau disease 6 months ago. The patient asks you where she might find information regarding ongoing investigational studies of patients with von Hippel-Lindau disease.

ClinicalTrials.gov

A 35-year-old man presents with recurrent headaches. They occur on one side of his head and feel like sharp stabbing pain just above his left eye. He notes eye redness and watering with the headaches. Each headache lasts for 2 hours, and they have been occurring daily for 2-3 weeks. He reports a similar pattern of headaches last year. He denies any known family history of headaches similar to his or migraines. Physical examination is within normal limits.

Cluster headache

A 45-year-old man goes to a party and enjoys several glasses of an alcoholic cocktail. His past medical history is significant for headaches. The drinks trigger a unilateral right-sided headache. The headache is behind his right eye and spreads to his forehead. He also notices that his right nostril has a watery discharge and his right eye is tearing. He describes the pain as if he were "being stabbed in my eye."

Cluster headache

A 53-year-old man presents with a 2-week history of severe headaches that occur primarily at night. The patient is pacing while he is talking. The pain surrounds one eye and lasts for 30-90 minutes. He also states that there is ipsilateral lacrimation, conjunctival injection, and nasal congestion during the attacks. The patient states that he has had these headaches once a day over the last week. He cannot point to any one thing that causes them. On examination, the patient has features of partial Horner's syndrome. His vital signs are temperature: 97.0°F, heart rate: 80/min, respiration 16/min, and blood pressure: 126/80 mm Hg.

Cluster headache

A 35-year-old man presents with headaches; he describes them as occurring on one side of his head with a sensation of a sharp stabbing pain just above his left eye. The episodes last for 2 hours, have occurred daily for 2-3 weeks, and have been presenting in this pattern every 3-4 months for the past 2 years. The patient describes his nose as feeling congested during these periods; his left eye also appears red. Aggravating factors appear to be alcohol and stressful situations. He denies any family history of migraines or headaches similar to his. Diagnostic and laboratory studies are pending.

Cluster headaches

The Framingham Heart Study is an ongoing cardiovascular research project centered around residents of Framingham, MA. It began in 1948 with 5209 adult participants. Since then, adult children, spouses of adult children, and grandchildren of the original participants and minority residents of the community have been added to the investigation. Before initiating this investigation, little was known regarding the epidemiology of atherosclerotic or hypertensive heart disease, such as the impact of smoking, diet, exercise, or aspirin use.

Cohort study

You have been employed as a PA for a hospitalist group for several years. You have recently been invited to serve on a hospital committee taskforce. The mission of this task force is to make recommendations regarding system-wide initiatives to improve patient satisfaction for the healthcare system.

Communication skills training for providers

A 35-year-old man presents with a 2-week history of constant burning and throbbing pain in his left hand. The pain also seems to affect his distant forearm. Contact with normal clothing and bed sheets worsen his hand pain. He also reports that his hand is swollen. He denies trauma to his hand, but he does report an uncomplicated left wrist fracture 3 months ago that resulted from a sports accident. By the time of cast removal at 7 weeks post-injury, he denied any pain or edema in the affected limb. He was instructed to return to normal activities, as tolerated. He was initially treated with ibuprofen and opioid pain pills. He discontinued all pain medicines within 2 weeks of the fracture. He now describes his hand pain as an 8/10. On physical exam, the left hand and forearm are noted to have some localized edema, warmer temperature, and increased hair growth compared to his right hand and forearm. No rash or skin lesions are noted. With even light palpation of the affected region, the patient cries out in pain. Range of motion is decreased, and reflexes are increased the left upper extremity (in comparison to the right). The rest of his exam is normal. X-ray of the left wrist and hand are normal, with good fracture resolution.

Complex regional pain syndrome

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she does admit to having a Colles fracture in this arm around 2 months ago. She denies any injury to her back, neck, or other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse, uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and cold; it does appear somewhat more swollen than her left arm. The patient is very upset; she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker. She does not drink, and she exercises 3 times a week. Physical examination conducted of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+) and ROM is limited. Radiograph studies are obtained and reveal spotty areas of apparent osteopenia of the right upper extremity.

Complex regional pain syndrome

The JUPITER trial ("Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein" New England Journal of Medicine 2008) was designed to evaluate if individuals with elevated high-sensitivity C-reactive protein (hs-CRP, specific biomarker of inflammation) without hyperlipidemia might benefit from statin treatment. The trial studied 17,802 apparently healthy individuals with LDL cholesterol <130 mg/dL and hs-CRP level ≥2.0 mg/L, half randomized to treatment with rosuvastatin 20 mg daily, half to placebo. The primary endpoint of the study was combined rate of MI, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular disease. The primary endpoint occurred in 142 of 8901 in the rosuvastatin cohort and 251 of 8901 in the control group (0.77 events per 100 person-years in the rosuvastatin group vs 1.36 events per 100 in control group; p-value <0.00001; hazard ratio 0.56, 95% confidence interval 0.46-0.69). Mean LDL cholesterol was reduced by 50% and mean hs-CRP was reduced by 37% in the cohort assigned to rosuvastatin. The study was terminated after a median follow-up of 1.9 years, at which time 75% of participants were taking their study pills. The study reported a 44% decrease in new cardiovascular events in patients treated with rosuvastatin compared to placebo.

Confidence interval has 95% chance of containing true hazard ratio.

A patient requests their medical records be forwarded to another provider. They also want to have a printed copy of the records. Your practice policy is that they pay a fee for the printed records and provide identification. Policy requires consent in an electronic patient portal to forward records. The patient must allow up to 7 days for the request to be completed.

Consent in an electronic portal

A 12-year-old boy presents for evaluation of short stature. His height is 54 in (136 cm, 5th percentile) and weight is 76 lb (35 kg, 25th percentile). He uses a nasal inhaler for seasonal allergies and denies other medications. He is physically active and an only child. His mother is 5'4" and his father is 5'10". He has healthy eating habits and denies constipation, fatigue, or any other digestive or urinary problems. His birth history was normal: full term, weight 7 lb 3 oz, height 20 in. On exam, he appears shorter than his stated age. He has normal-appearing facies. His heart, lung, and abdominal exams are all normal. He is at Tanner stage 1. His growth charts show him starting around the 50th percentile for height and weight; there is slow linear growth during the first 3 years of life, with both parameters crossing percentiles downward. Linear growth occurs at a near-normal rate below but parallel to the 5th percentile in the last couple of years. A bone age shows delayed skeletal maturation. Upper-to-lower body segment (U/L) ratio is proportionate.

Constitutional growth delay

You are a PA working in the emergency department of a community hospital. A 65-year-old man presents with left lower quadrant abdominal pain associated with nausea, vomiting, diarrhea, and fever for 3 days. Abdominopelvic computed tomography (CT) reveals sigmoid diverticulitis with microperforation. The patient is now comfortable after receiving intravenous (IV) fluids, morphine for pain control, and ondansetron for nausea.

Consult attending physician and on-call GI to request admission.

A 35-year-old woman presents to your outpatient clinic due to left knee pain. She slipped on ice and struck her knee several days ago; pain has persisted since her fall. Her physical exam is remarkable for a large knee effusion, tenderness to palpation, and decreased range of motion. As part of your investigation, you decide to obtain an X-ray of her left knee. When ordering her X-ray, you inadvertently order an X-ray of her right knee.

Contact the patient yourself and explain the imaging order error.

A 12-year-old boy presents with itching and redness between his toes. The mother notes that this is his second visit in 2 weeks, adding that her son had the same symptoms previously. She states that the child was prescribed an antifungal cream on the previous visit. They still have cream left. On examination, the interdigital spaces are macerated and erythematous.

Continue the antifungal cream and give health education advice.

A 72-year-old man—well known to your practice—presents with a severely itchy rash. His medical history includes Parkinson's disease for the past 10 years. At first, he thought the rash was just eczema, but the areas have progressed to significant hives, and itching has substantially worsened. On examination, you note multiple bullae that are 1-3 cm in size; they are tense, and they appear on an erythematous base. The bullae are noted to be located on the patient's trunk and the bilateral axillary and inguinal folds.

Corticosteroids

A 57-year-old Caucasian man is brought to the emergency department following an episode of palpitations and syncope. The patient is initially evaluated by the ED physician, then by a cardiology PA. While the PA is recording the patient's history and physical exam, the patient develops sustained monomorphic ventricular tachycardia at 120 beats per minute but with stable pulse and blood pressure. The PA contacts the on-call cardiologist, who arrives promptly. Intravenous anti-arrhythmic medication is initiated, but the patient remains in sustained monomorphic ventricular tachycardia. Two additional intravenous anti-arrhythmic medications are administered before the patient converts to normal sinus rhythm 45 minutes later. The patient is admitted to the hospital for further evaluation and treatment. The patient undergoes electrophysiology testing and an ablation procedure for ventricular tachycardia 2 days later; he is discharged from the hospital 4 days after admission.

Critical care services (CPT codes 99291 or 99292)

A 22-year-old man presents with a 3-month history of worsening diarrhea that comes and goes. While performing a comprehensive oral exam, you note two lesions on the buccal mucosa on the right side of the oral cavity. You document these lesions as two round lesions approximately 2 mm in diameter with a white-yellow center surrounded by a red halo. Pertinent positives also include a reduced appetite, abdominal pain, and cramping.

Crohn's disease

A 16-year-old boy presents for a physical. His mother is concerned that he is gaining weight but not growing taller. She has noticed his face is more round and he now has stretch marks on his abdomen. The physician notices a large amount of truncal fat and relatively thin limbs. The patient has acne on his cheeks bilaterally.

Cushing syndrome

A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally.

Daily cleaning with a damp cotton applicator and baby shampoo

A 36-year-old man with a history of diabetes and obesity presents with weakness and flu-like symptoms. His girlfriend reports that he had taken several caffeine pills the day before, but he denies a suicide attempt. During evaluation at the hospital, he experiences vomiting and seizures. A laboratory workup is within normal limits. He is admitted to the hospital and improves over the course of his 3-day admission. He is subsequently released with no lingering effects.

Decrease or stop caffeine intake

A 28-year-old woman presents for a routine follow-up. She has type 1 diabetes and is on a combination of glargine 40 units before bed and insulin lispro with meals. At her last visit, she mentioned having difficulties with her morning glucose levels. She has been tracking her glucose levels daily and brought along her log. Her pre-breakfast glucose averages 285 mg/dL. At dinnertime, it averages 95 mg/dL, and 68 mg/dL at 3 AM.

Decrease the evening dose of long-acting insulin.

A 25-year-old woman presents because she feels weak and tired all the time. She also reports that she has been amenorrheic for the past 3 months. Her past history is significant for transsphenoidal surgery followed by salvage radiation therapy for a pituitary macroadenoma 5 years earlier. On examination, she is not pale, but she appears fatigued. Her BP is 100/50 mm Hg, and a pregnancy test is negative.

Decreased axillary hair

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and tremor in her hands. Past medical history is non-contributory. She takes a multivitamin and drinks 1-2 cups of coffee daily. She denies any recreational drug use. Blood pressure is 110/70 mm Hg. Heart rate 105 bpm, regular. Respirations 16/minute. She appears anxious, and you note the presence of bulging eyes. Thyroid is diffusely enlarged. Cardiovascular exam reveals normal S1 and S2 without murmurs, rubs, or gallops. Normal breath sounds bilaterally.

Decreased thyroid-stimulating hormone

A 40-year-old man presents with stage 4 liver cancer. The patient, despite the diagnosis, continues to make business transactions over the hospital telephone and tells everyone he is fine. He gets angry with the nurses for thinking he is sick and giving him medicine.

Denial

A 35-year-old woman notices a change in the appearance of a mole on her neck. Physical examination reveals that the lesion is an irregular nodular superficial mass with a variegated appearance. Biopsy demonstrates a primary malignant tumor.

Depth

A 53-year-old man was recently diagnosed with a pituitary adenoma. He has been experiencing excessive thirst and large volume polyuria, as well as headaches and an increase in nocturia from once nightly to 3-4 times nightly.

Desmopressin acetate

A 60-year-old man presents with difficulty climbing stairs, dyspnea, and fatigue. He has gained 30 lb over the past year. On examination, he is found to have edema, pigmentation of the skin, palmar creases, and proximal muscle weakness. Chest X-ray shows an irregular mass in the right upper lobe. Lab values show an increase in evening cortisol levels and an increase in ACTH.

Dexamethasone suppression test

A 10-year-old boy has a history of problems at school and at home. Teachers report he rarely can focus on one task for longer than a few minutes, and they describe his behavior as chaotic. His mother states that he never gets tired of running, talking, and playing around the house; she usually has to repeat instructions over and over because he seems to not listen. She also reports that he failed at school and is now repeating the fourth grade. A psychostimulant, an indirect-acting adrenergic receptor agonist that centrally releases dopamine (DA), serotonin (5-HT), and norepinephrine (NE) to the synaptic cleft, is prescribed.

Dextroamphetamine

A 6-year-old boy's parents are concerned about their son's behavior. There have been complaints from his teachers that he is frequently fidgeting and disruptive in class. His parents state that he is extremely active at home and requires frequent discipline. After a complete history and physical exam, your suspected diagnosis is attention-deficit/hyperactivity disorder (ADHD).

Dextroamphetamine

A 66-year-old man presents to the office with polyuria and erectile dysfunction. He denies any other symptoms or significant past medical history. Physical examination reveals an obese male, Tanner stage 5 of the external genitalia, balanitis of an uncircumcised penis, and slightly enlarged symmetrical smooth prostate.

Diabetes mellitus

A 45-year-old man presents to the emergency department due to acutely worsened chronic low back pain. Pain is described as sharp with radiation to left knee, intensity reported as 15 on a scale of 1-10. He has previously been seen in your emergency department, where another provider prescribed him a short course of oxycodone. On review of your state's prescription drug monitoring system, you notice multiple recent prescriptions and fills for oxycodone. Prescriptions are from multiple providers and multiple local emergency departments. His most recent fill was 2 days ago for oxycodone 10 mg 30 tablets. Upon questioning, he states his pain was "so intense he took all 30 tablets in the past 48 hours." His urine drug screen is presumed positive for opioids.

Diagnose opioid use disorder and arrange for outpatient addiction management.

A 50-year-old man presents for a follow-up exam. He has a history of hypertension and morbid obesity. His routine labs reveal a hemoglobin A1c was 6.8%.

Diet modification only

An 11-year-old girl with no significant past medical history presents with an increase in the frequency of her nosebleeds. She has experienced 3 episodes in the last week. Her mother was able to control and stop the bleeding by applying direct pressure to her external nasal area. Past medical history shows no significant issues with bleeding discrepancies or coagulopathies; she had a tonsillectomy when she was 8 years old; there were not any postoperative complications. Physical examination reveals a raw and irritated anterior right nare; the presence of dried crusted blood is noted.

Digital trauma

A 62-year-old man who is well known to you presents with a severely itchy rash. The patient's medical history includes Parkinson's disease for the past decade. The patient felt the rash was just eczema at first, but the areas have progressed to significant hives; the itching has become far worse. On examination, you note multiple bullae that are 1 to 3 cm in size; they are tense and appear on an erythematous base. The bullae are noted to be located on the patient's trunk as well as the bilateral axillary and inguinal folds.

Direct immunofluorescence

A 4-year-old Caucasian boy is seen for a 2-week history of purulent nasal discharge. He has been afebrile and has had no respiratory symptoms. Past history is unremarkable except for his mother's assessment that "he gets into everything." Examination revealed only a right-sided purulent nasal discharge, which was greenish-brown in color and extraordinarily foul-smelling.

Direct visualization of the right nasal vestibule

A 5-year-old girl presents with a rash. The girl's mother states that she took the child to an urgent care center over the previous weekend; the patient was diagnosed with a urinary tract infection. The child was started on a 7-day course of sulfamethoxazole/trimethoprim and currently only has one more dose to take. The mother states the child has never taken this type of medication before. The rash in question was first noticeable 2 days ago; it has spread, worsened, and intensified, prompting the mother to bring the child in today. She denies any recent fevers, irritability, itching, or other significant symptoms. Her previous UTI symptoms have resolved. On physical examination, you note scattered lesions on the child. Each lesion appears to have three concentric circles of color change.

Discontinue sulfamethoxazole/trimethoprim; monitor symptoms.

You are evaluating a 24-year-old woman for bilateral eye pain. She describes red itching irritated eyelids for several weeks. She states she has had "several bouts" of similar symptoms over the last few years. Exam is consistent with blepharitis. She does not wear contacts, and she occasionally wears eye makeup. She denies any other infectious complaints.

Discuss good eye hygiene and eyelid scrubbing.

A 15-year-old male Jehovah's witness presents to the clinic for a follow-up appointment after he was notified about abnormal lab work. Labs demonstrated the following: Hemoglobin: Low Hematocrit: Low Bleeding time: Normal PT: Normal APTT: Prolonged He is advised to undergo subcutaneous injections to replace missing clotting factors. The patient does not give verbal consent due to his religious beliefs.

Discuss the risks and benefits of the procedure with the patient and his parents.

An 86-year-old man was recently admitted to the hospital for diastolic congestive heart failure exacerbation. His code status was not addressed before his admission. He was later intubated due to cardiogenic shock and his family was notified of his admission. A meeting was convened with the patient's hospitalist team, his close friend, and his family to discuss the patient's medical wishes. His recently divorced wife brought in his will expressing his wishes not to be intubated. His close friend brought a document expressing that the patient wants all lifesaving measures. His son expressed that the patient does not want to be intubated in past conversations. His daughter believes that the patient wants to be intubated to "live as long as he can."

Discuss with hospital ethics committee.

You are working at the Centers for Disease Control and Prevention, assigned to the National Center for Chronic Disease Prevention and Health Promotion. You are asked to prepare a report describing the impact of cardiovascular disease in the US. You learn that: Cardiovascular disease—including stroke and hypertension—caused 840,768 deaths in the US in 2016. 635,260 of these deaths were due to cardiac disease. The US population in 2016, according to the official government census, was approximately 323.4 million. In order to prepare the report, you make the following calculation: 635,260 deaths323,400,000 person-years=x100,000 person-years635,260 deaths323,400,000 person-years=x100,000 person-years x=635,260 deaths×100,000 person-years323,400,400 person-years=196 deathsx=635,260 deaths×100,000 person-years323,400,400 person-years=196 deaths Substituting the result in the original equation yields: 635,260 deaths323,400,000 person-years=196 deaths100,000 person-years635,260 deaths323,400,000 person-years=196 deaths100,000 person-years

Disease-specific mortality rate

A 22-year-old woman presents for psychiatric follow-up. During the visit, she begins to reveal what appear to be distinct personalities. Identities appear to repeatedly take control of the patient's behavior and affect. You know she is an incest survivor. She denies any drug or alcohol use.

Dissociative identity disorder

A 70-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. Past medical history is significant for chronic kidney disease stage III, obesity, diabetes mellitus, and hypertension.

Divalproex (Depakote)

An 80-year-old woman is diagnosed with dementia of the Alzheimer's type as a result of comprehensive testing. You believe she is in the very early stages of the disease and you want to try a medication to possibly slow disease progression.

Donepezil (Aricept)

A 19-year-old man with a family history of schizophrenia is receiving medical attention for his first presentation of psychosis. After ruling out organic causes and substance abuse as etiologies of his symptomatology, antipsychotic therapy with haloperidol is initiated. Within 48 hours, the patient begins to experience involuntary spasmodic contractions of the muscles in his face and neck.

Dopamine (D2)

A 34-year-old woman presents with worsening headaches. She says that the headaches are present throughout the day and that she has been feeling nauseous. She has also noticed difficulty in seeing vehicles on the freeway lately. She has had several close calls while driving due to this impairment. Her previously regular periods are now irregular, with heavy bleeding every 3-4 months. She has also noticed a milky discharge from both nipples. Her pregnancy test is negative. An MRI of the brain confirms the diagnosis.

Dopamine agonists

A 15-year-old girl presents due to a rash. She does not take any over-the-counter or prescription medications and she does not have any pertinent medical history or drug allergies. She denies known exposure to any sick contacts in the last several days, but she admits to traveling to Tennessee and hiking in the Smoky Mountains last week. Further questioning reveals that the patient admits to feeling feverish (although the patient has not formally taken her temperature), headache, lack of appetite, and muscle pain. Physical examination reveals a rash on her bilateral wrists, forearms, and bilateral ankles; it consists of numerous small flat pink macules that are non-pruritic and non-scaly.

Doxycycline

A 33-year-old woman presents to the office with multiple vesicles with associated intense itching on her hands and feet. Her past medical history is negative. The patient is a waitress who takes no medication and does not work with chemicals. The vesicles are tense with some scales. There is no erythema or initial incidence of itching. The vesicles have responded well to a limited treatment with a high steroid cream.

Dyshidrotic eczema

A 25-year-old Caucasian male landscaper presents with a 2-week history of generalized malaise and an "unusual rash" on his right thigh. The patient reports that this rash has been widening, but he denies any pruritus or pain in association with his complaints. In the past week, he has also noticed a constant headache and mild fever. The past medical history is unremarkable. The physical exam reveals vital signs within the normal limits, enlarged non-tender diffuse lymph nodes in cervical and inguinal areas, and an erythematous rash with central clearing and few satellite lesions.

Early localized

A 13-year-old boy diagnosed with autism spectrum disorder repeats phrases in a parrot-like fashion; he repeats whatever he hears, but comprehension is absent.

Echolalia

A 16-year-old Amish girl presents to an urgent care for evaluation of vaginal spotting. She has been experiencing it for the past 2 days and is concerned she may be pregnant. She has not experienced any nausea, vomiting, or fatigue. All vitals are within normal limits. Physical exam is normal. A urine pregnancy test is negative and urinalysis is unremarkable. The PA inquires if the patient uses birth control. She states that she is Amish and it is against her beliefs. "It does weird things to my body," she states.

Educate patient regarding physiology of vaginal spotting.

A 20-year-old woman presents to the emergency department (ED) for evaluation of amenorrhea. She has not menstruated for 7 weeks. A urine pregnancy test done in the ED is positive and confirmed with a transvaginal ultrasound revealing a viable intrauterine pregnancy. She is unemployed and uninsured, and she reports she could not afford a pregnancy test, contraception, or preventative care. She also expresses that she does not want to continue with this pregnancy. You refer her to the nearest free clinic for further management.

Elective termination of pregnancy

A 62-year-old man presents with vision problems and difficulty swallowing. Over the last week, he has had a constellation of symptoms; they began with numbness and tingling in his feet and progressed to weakness that now affects both lower and upper extremities. He has started to notice difficulty swallowing and double vision since yesterday. It feels difficult for him to take a big breath. His past medical history is non-contributory, and he takes no medications. Exam reveals bilateral absence of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis.

Elevated CSF protein content

A 33-year-old woman presents due to a 15-pound weight gain over 2 months; there is also muscle weakness, menstrual irregularities, amenorrhea, infertility, skin bruising, memory loss, and periods of depression. She denies any medication use or dietary changes; she has tried to lose weight unsuccessfully through increased exercise. She denies any headache, vision changes, hearing changes, chest pain, abdominal symptoms, polyuria, polydipsia, or breast discharge. Her physical exam reveals a blood pressure of 145/94 mm Hg. Her skin physical exam is remarkable for the findings in the image. Refer to the image.

Elevated urinary free cortisol (UFC) levels

A 7-year-old boy presents to the pediatrician's office with a 3-week history of clear nasal discharge, itchy eyes, and excessive sneezing. The family recently took in a stray cat, which sleeps with the boy. On examination of the nasal passage, you note swelling of the turbinates with clear drainage from the nares bilaterally. On examination of the oral cavity, you note slight pharyngeal erythema, post-nasal drip, and no tonsillar edema. He denies fevers, chills, nausea, and vomiting.

Eosinophils

A 37-year-old man fell from a ladder as he finished working on the roof of his house. The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he woke up with a headache, but he had no other complaints. A few hours later, the patient is brought to the emergency room by his neighbor because of an intense headache, confusion, and left hand hemiparesis. On examination, the patient has a bruise located over the right temporal region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar response. An emergency CT scan of the head without contrast reveals a lens-shaped hyper-density under the right temporal bone with mass effect and edema.

Epidural hematoma

A 3-year-old child presents with sudden onset of high-grade fever, sore throat, pain during swallowing, and drooling of saliva. There is no history of a cough. The child appears toxic and is dyspneic with inspiratory stridor. The child is sitting upright and leaning forward with chin up and mouth open. Suprasternal and intercostal retractions are present. Chest is clinically clear. Blood count shows polymorphonuclear leukocytosis. Lateral radiograph of upper airway shows "thumb sign."

Epiglottitis

A 10-year-old boy presents with swelling on his face that has been progressively increasing in size. He is an immigrant from East Africa. On examination, he has mild pallor and large swelling involving his right maxilla. A biopsy taken reveals a starry sky pattern of lymphocytes.

Epstein Barr virus (EBV)

A full-term Caucasian infant is a product of an uncomplicated pregnancy, labor, and delivery. Birth weight is 8 lb, length is 21 in, head circumference is 14 in. As you examine the newborn's mouth, you identify 6 raised yellowish-white raised lesions, each approximately 1 mm in size; these lesions are located along the mid-palatine raphe. The remainder of the physical examination is normal.

Epstein pearls

A 19-year-old woman presents with a 2-week history of rash. Other than a sore throat that she had last week, she reports being in good health; her sore throat was treated with penicillin. She does not believe that she has come in contact with any type of irritants or any individuals who are sick. On physical examination, you note several target-like lesions on the palms of her hands that are bilateral and symmetric. She indicates that she is on birth control medication.

Erythema multiforme

A 12-year-old girl is diagnosed using a quick antigen test as having a pharyngeal infection due to Streptococcus pyogenes. She also presents with a rash on the upper part of the chest and trunk.

Erythrogenic toxin

A 9-year-old girl presents with a sore throat. The parents state that she began a fever a few days ago, reporting that her throat hurt. On physical exam, you note a red throat, a red and beefy tongue, tonsillar exudates, and swollen anterior cervical lymph nodes. The parents report a history of a severe anaphylactic reaction to penicillin.

Erythromycin

During newborn nursery rounds, a young new mother tells you that there is a family history of eye problems that run on her dad's side. She is not sure what the problem is exactly, but many relatives have had to wear glasses. On exam, the infant's eyes seem to be deviated toward the nose. Corneal light reflex testing confirms your suspected diagnosis.

Esotropia

A 32-year-old woman with a history of a tremor presents seeking help. She has experienced emotional stress from work over the past 6 months. Upon physical exam, a tremor is observed in her right hand when hands are outstretched. Tremor is also present in her head. Laboratory findings showed no abnormal findings, but her family history reveals that her father was also diagnosed with a tremor around the same age.

Essential tremor

A 30-year-old man presents with a 2-month history of coughing and a 2-day history of coughing blood. He has been losing weight and sweating at night. On physical examination, the patient appears wasted and tachypneic with bronchial breath sounds in the right upper lobe and crepitations in the left upper lobe and right mid-zone. His direct sputum result comes back positive for acid-fast bacilli with Ziehl-Neelsen stain. His sputum is sent for culture and treatment is started for his condition. After starting the medication, he notices he is unable to distinguish between red and green colors.

Ethambutol

A 16-year-old girl has had acne breakouts since age 10, and both she and her mother have noted the breakouts worsening significantly every year. She notes worsening of her breakouts around her menses each month, but she states she has multiple lesions consistently throughout the month. She has a history of using diet modification, topical retinoids, benzoyl peroxide, and two types of oral antibiotics without improvement. Physical examination of the patient reveals extensive open and closed comedones on the forehead, cheeks, and chin. Painful cystic lesions are present throughout. Isotretinoin is now considered.

Every 4 weeks

A 53-year-old Caucasian man presents due to a bleeding mole on his left cheek that has been present for the past several years. In the last 3 months, it has started to spontaneously bleed. The patient denies any other moles with the same characteristics, and he just wants it taken care of so it is not as bothersome. The patient denies weight loss, night sweats, or fevers; he has no recent changes in his appetite or sleeping issues. He is a farmer, and he owns over 100 acres that he plants and harvests yearly; he has done so for the last 25 years. Physical examination reveals a 4 cm macule with irregular borders, at least 3 different shades of color, and small ulcer in the middle.

Excisional biopsy

A 38-year-old woman presents with a new tremor. She also reports weight loss and heat intolerance along with increased anxiety and palpitations. She has noticed swelling of her neck.

Exophthalmos

A routine EKG 5 weeks ago determined that a 59-year-old Caucasian man developed new-onset atrial fibrillation. It was asymptomatic, not associated with dizziness, palpitations, chest pain, or shortness of breath. He was started on warfarin 5 mg daily for anticoagulation. Cardioversion was scheduled as a subsequent elective outpatient procedure. PMH includes hypertension. Allergies: None. Usual medications: Hydrochlorothiazide 25 mg daily, metoprolol tartrate 50 mg b.i.d., warfarin 5 mg daily. He presents to the outpatient cath lab for planned cardioversion procedure, reporting no new medical problems or symptoms. He claims compliance to his medications. Review of lab work 3 days ago showed protime 16.2, INR 1.7. CBC and basic chemistry profile were normal. Today's lab work shows protime 19.2 seconds, INR 2.1. EKG shows atrial fibrillation with ventricular rate 87 bpm. Your supervising physician intends to proceed with the cardioversion procedure. You (PA) believe the cardioversion procedure is contraindicated based on lab work.

Express your concerns to your supervising physician privately.

A 24-year-old man is brought to the emergency room in shock. A quick history from his girlfriend reveals that he has had a "blister on his left foot" for the past couple of days. According to the girlfriend, the patient developed a fever earlier in the day; he felt weak and eventually collapsed. He last passed urine the evening prior to presentation. On examination, his BP is 70/40 and pulse is 130/minute; his hands feel cold and clammy. Except for a swollen left foot, systemic examination is normal. His lab values are as follows: Total WBC count: 21,000/mm3Neutrophils: 55%Lymphocytes: 25%Hemoglobin: 11.0 g/dLCRP: 165 mg/LSerum Creatinine: 2.3 mg/dLUrine Myoglobin: positiveSerum K: 5.9 Meq/dLSerum Na: 133 Meq/dLECG: sinus tachycardia

Extensive early surgical debridement

A 12-month-old girl presents with her parents after a 3-day history of intermittent episodes of strange behavior. A neurologist is consulted because the parents are concerned she is having some form of seizure activity. Her health history includes 2 episodes of otitis media, but she is otherwise healthy. Her initial vital signs and physical exam by the emergency room staff are all normal.

Eye deviation with facial twitching that lasts 1-2 minutes

You are employed as a PA in a large fast-paced high-volume hospitalist practice that employs several PAs. The practice's patients include a mix of 60% covered by commercial insurance, 30% by Medicare, 5% by Medicaid, and 5% uninsured. One of your primary responsibilities is performing initial assessments of new patients admitted to the hospital in collaboration with a physician whose documentation is sufficient to permit shared billing. Although you dictate or record the patient's admission history and physical exam, the collaborating/supervising physician submits and determines the billing charges for the hospital admission. The practice administrators have instructed all of the PAs to always perform a complete review of systems so that the physician is free to bill the H&P at the highest level of medical complexity, if merited. One of your colleagues admits that they seldom perform a complete review of systems, instead only asking the patient, "Do you have any other symptoms?" If the answer is "No", your PA colleague indicates in their written note/dictation that "Twelve systems were reviewed and found to be negative, except as detailed in the history of present illness and past medical history."

False or fraudulent claims

A 50-year-old African American man with no chronic medical conditions is overdue for an annual wellness visit. You call the patient to ask why he has not scheduled an appointment. He informs you that he no longer has health insurance and is concerned about how to pay for routine healthcare examinations. He is particularly concerned about how he will afford a screening colonoscopy that is due. His neighbor died from colon cancer as a result of failing to undergo screenings. You inform the patient that there are alternative screening tests for colorectal cancer, and there is a program at your clinic that covers the cost of annual wellness visits for uninsured patients, but it does not cover additional screening or diagnostic tests. He returns for an office visit, and you establish that he remains in an optimal state of health. You proceed to further discuss screening options.

Fecal occult blood testing

A 21-year-old Caucasian man reports symptoms of sneezing, runny nose, itchy nose and eyes, and occasional cough occurring intermittently. He describes his symptoms as mild and intermittent; they do not negatively impair his quality of life. He fractured his collarbone in childhood. No other significant past medical history. He does not use alcoholic beverages or recreational drugs. His only brother has asthma and eczema. The patient has occasional headaches and has dark circles under both eyes. Vitals: temperature 98.4°F, pulse 72 and regular, respirations 12, blood pressure 124/76. HEENT: Normocephalic. EOMs intact. PERRLA. Erythematous injection of the conjunctiva is noted. Pale boggy nasal mucosa is present. Oral mucosa is pink with a small amount of post-nasal drainage present. The remainder of the physical examination is unremarkable. Treatment options are discussed with the patient. He requests medication to treat his symptoms without affecting his daily activities.

Fexofenadine

A 24-year-old Muslim woman with no past medical history presents to establish care. She is dressed in a burka. She is given paperwork but does not fill it out. She enters the room and waits for the provider. A physician assistant enters the room several minutes later and introduces themselves. In presence of a nurse, the PA instructs the patient to change into a gown. The physician assistant returns several minutes later with the nurse and sees that the patient is still in her burka. She asks the patient why she did not change into the gown, but the patient does not respond.

Find an interpreter for the patient.

A 23-year-old woman presents to her psychiatrist's office for a follow up regarding her 2-year history of bulimia nervosa. Until this time, she has been undergoing cognitive behavioral therapy (CBT) several times per week. She has shown great improvement, but she would like to consider additional measures to control her disorder.

Fluoxetine (Prozac) 60 mg daily

A 6-month-old girl is brought in to the pediatrics clinic by her 15-year-old mother, and they are accompanied by the infant's grandmother. The pregnancy was uncomplicated, and the infant was born full-term by spontaneous vaginal delivery. The mother had prenatal care and has brought the infant to all scheduled appointments. The infant has received all age-appropriate vaccinations so far. She has been gaining weight appropriately and breastfeeding exclusively. She is meeting age-appropriate milestones, and the mother and grandmother have no concerns at this appointment. Your physical exam reveals no abnormalities. You discuss the risks and benefits of the vaccines due at this visit. The mother is able to restate these risks and benefits to demonstrate understanding, but she refuses to consent. She has been reading about vaccines online and is concerned about their safety. She requests that her infant is vaccinated on a delayed schedule. The infant's grandmother disagrees and would like the infant to receive the vaccinations per CDC guidelines. Despite a thorough conversation with the family, you are unable to reach an agreement.

Follow the 15-year-old mother's request.

A 3-year-old girl is presented by her mother with sinus problems. The mother has a history of airborne seasonal allergies. The patient has sneezed frequently for 4 days and has increased nasal congestion, nasal discharge, and irritability. The mother denies noticing shortness of breath, problems breathing, or fever; the child has not been in close contact with any sick contacts. Physical examination reveals unilateral purulent nasal drainage from the left nare and an obvious foul odor.

Foreign body

A 4-year-old girl presents to the emergency department with her mother due to pain and itching in her right ear. The patient denies hearing loss and dizziness. She came back from her grandmother's house yesterday and told her mom that her ear "really itched inside." There is some drainage noted on exam from the affected ear. There is no pain when manipulating the tragus or erythema on the pinna. The mother mentions the patient and her sister were playing dress up with earrings yesterday. The mother reports the patient was inside most of the weekend and did not go swimming.

Foreign body

A 14-year-old boy is brought to your medical office by his mother for a physical examination. According to the mother, the child was diagnosed with intellectual disability (intellectual developmental disorder) 2 years ago. They have just relocated from another state, and he requires a physician's clearance to start at a new special education school. She states that he has been in good physical health since birth. His past medical history includes a few mild headaches and upper respiratory tract infections, but no chronic conditions, hospitalizations, operations, or medications. The mother has brought his vaccination records with her, and they show all immunizations are current. Family history is positive for a maternal grandmother that developed dementia at age 55 and a maternal uncle with autism. Pertinent findings on the physical examination include an unusually narrow face, a prominent forehead, large protruding ears, a prominent jaw, and unusually large testes.

Fragile X syndrome

A 48-year-old Caucasian woman with multiple comorbidities presents with worsening hearing loss and tinnitus in her right ear. She states this first began about 3 months ago and was initially bearable; it has now progressed to where she cannot hear anything out of her right ear, and the tinnitus is unrelenting and constant. The patient is worried because she is now experiencing balance and coordination issues. An MRI is ordered, revealing an enhancing lesion of the right internal auditory canal.

Gamma Knife radiosurgery

A mother seeks medical attention for her 7-year-old son. For the last 8 months, he has not acted like his three older brothers. The mother indicates that her son has said on repeated occasions he wants to get rid of his male genitalia and he would prefer to be a girl. She has found him wearing his sister's clothing on numerous occasions. More history shows that he prefers to play with dolls and only spends time with female friends. Teachers relate that he turns down invitations from the boys in the class to join in sports activities. His male classmates are now teasing and embarrassing him in class, and it has begun to affect his schoolwork.

Gender dysphoria

A 27-year-old woman followed by your practice for several years tells you that her 24-year-old brother has been recently diagnosed with von Hippel-Lindau disease. She has been told it is a hereditary disease. She asks if she should undergo genetic testing for von Hippel-Lindau disease. You cannot immediately recall any details regarding the genetics, pathophysiology, or clinical manifestations of von Hippel-Lindau disease. Following your physical examination of the patient, you briefly step out of the exam room, intending to return in 5 minutes to conclude your office visit with her. During this break, you try to conduct online research for accurate information regarding this rare disease.

Genetic Testing Registry Online medical database

A 32-year-old woman presents with increasing irritability. She reports involuntary movements of her arms and increasing incoordination. Her husband is worried because she is having trouble remembering things. She was adopted, and her family history is unknown. Physical examination is remarkable for rapid involuntary movements of fingers bilaterally, impaired ability to concentrate, slurred and disorganized speech, and difficulty responding with appropriate words or phrases when prompted.

Genetic testing

A 34-year-old man presents for his first doctor's appointment. He had always neglected his health, but he finally sought medical attention at his wife's insistence. He explains that he was from an "unhealthy family" and that he was tired of being around doctors while growing up, so he avoided medical attention. His father died at the age of 30 of "very high blood pressure" and "heart failure." His older brother was recently operated on for the removal of a cancer from his neck. Prior to that, his brother had had surgery to remove a mass from his adrenal gland. He wants to know what he can do to be healthy. His blood pressure and BMI are within normal limits. He does not smoke or use alcohol, and he exercises regularly.

Genetic testing for possible familial cancer syndrome

A 43-year-old woman was diagnosed with type 2 diabetes mellitus 6 months ago. She presents for follow-up. She states she is feeling well and has no current symptoms. She currently receives oral hypoglycemics. The patient has no other significant medical history. Her glucose, acetone, lactate, and glycated hemoglobin are performed, and they are reported as follows:

Good glycemic control

A 35-year-old woman presents because of weight loss and palpitations. She lost 10 kg over 5 months despite having a good appetite. Her heart pounds and her hands tremble "all the time." She feels hot, is sweating profusely, and has difficulties going to sleep and maintaining sleep; the slightest stimulus wakes her. Her job is suffering because of her nervousness, and her supervisor became concerned because she uses the bathroom 3-4 times a day in a need to move her bowels. She thinks that poor sleep quality and frequent bowel movements make her weak; she cannot climb stairs anymore and has to take a rest every 10 steps or so. Physical examination reveals a slim anxious woman with pronounced stare, fine postural hand tremor at rest, and slight proximal weakness. Her thyroid is diffusely enlarged and non-tender; her pulse is 100/min; the rest of examination is within normal limits.

Grave's disease

A 16-year-old girl presents with sore throat and headache. She started feeling poorly when she woke up this morning. Her immunizations are current. Temperature is 102°F. Physical examination is remarkable for erythema in the posterior pharynx and palatal petechiae. She also has tender anterior cervical lymphadenopathy.

Group A Streptococcus

A 4-year-old girl is brought by her mother to the ED for swelling and redness of the left elbow. The mother tells you that the child fell onto the elbow 4 days ago and sustained a small abrasion. The child scratched and picked at the wound for 2 days and subsequently developed redness around the site and purulent drainage from the wound. Yesterday, the elbow became quite swollen and the child had a fever of 103°F. The mother states that the area of redness has increased rapidly over the past 24 hours.

Group A Streptococcus

An 8-year-old girl presents with a 3-day history of fever, generalized muscle weakness, bilateral knee pain, and chest pain. You suspect acute rheumatic fever (ARF).

Group A Streptococcus infection

A 20-year-old woman presents with a 3-day history of fever, sore throat, and enlarged glands in her neck. She denies any cough or runny nose, but she has malaise, body aches, and headaches. She has no other medical problems and does not take any medications. She works in a daycare center; she takes care of children 3-4 years old. On examination, she has a temperature of 101.5°F; pulse is 102/min, and BP 110/70 mm Hg. Oral exam reveals swollen tonsils with plenty of exudates. There is no nasal congestion, and lungs are clear. Cervical lymph nodes are enlarged bilaterally and tender. Abdomen is unremarkable. Throat swab is obtained by the physician.

Group A streptococcus

A 12-year-old girl presents with a 3-day history of progressive weakness and paresthesias in lower legs. Yesterday, she developed weakness in both upper extremities. She is unable to walk without assistance, so her mother brought her in. She had a sore throat 2 weeks ago. PMH is significant for measles and mumps. Because of religious beliefs, she has not had any immunizations. Physical examination reveals a well-developed well-nourished girl. She is awake, alert, and in no acute distress. Oral temperature 98.7°F, blood pressure 140/80 mm Hg, heart rate 84/min and regular, respirations 22/min and unlabored. Speech is moderately dysarthric. She can smile weakly but cannot raise her eyebrows against resistance. Pupillary responses are normal. There is mild upper extremity and severe lower extremity weakness, greater distally than proximally. Reflexes are hypoactive-to-absent. Sensation is intact, except for mildly impaired position and vibratory sensation in both feet.

Guillain-Barré syndrome

A 5-year-old girl presents with a rash of clear and grayish vesicles on a reddened base. Her hands and feet are affected, including her palms and soles. She reports sores in her mouth. There is no desquamation to the rash. Her heart and lungs are clear. She is febrile, and there is an accompanying tachycardia. Her blood pressure is normal. Her oral cavity shows ulcerations.

Hand-foot-mouth disease

A 32-year-old woman presents with constipation, weight gain, and dry skin. She has been experiencing the symptoms for a few months. Examination findings include dry rough skin, diffuse thyroid enlargement, bradycardia, and edema of hands and feet. A thyroid profile is performed and shows elevated thyroid-stimulating hormone (TSH) and the presence of thyroid autoantibodies (antithyroid peroxidase and antithyroglobulin).

Hashimoto's thyroiditis

A 35-year-old man presents with a 2-week history of recurrent swollen painful lips and a rash primarily affecting the arms and hands. His first episode occurred while in jail 6 months ago. He has had two additional episodes since then. He was treated with oral steroids each time, which improved his symptoms, but symptoms always returned. On examination, you notice several targetoid lesions on the dorsal hands and forearms, with darkening, swelling, and peeling of the lips.

Have you ever had fever blisters, cold sores, or genital herpes?

A 10-year-old boy is referred to you for being fidgety at school, even though he gets good grades. Prior history is unremarkable, and there has been no recent illness. The boy's father had a similar history as a child. While speaking with the patient, you notice that he clears his throat several times per minute. Examination is otherwise normal, except for rapid non-rhythmic jerking movements of the face, neck, and shoulders while at rest.

He has a condition that clusters in families.

An 8-year-old boy in third grade is referred to you by his school doctor to be evaluated for poor speaking and reading ability, failure to follow directions in class, and classroom disruptiveness. Despite these problems, he appears to be alert and interactive with other children and there is no demonstration of aggressive behavior or rage. He does not appear to be preoccupied with internal stimuli, and IQ testing results are within normal range.

Hearing impairment

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child's mother is concerned about the risk of hearing loss and its effects on development.

Hearing loss during OM may adversely affect cognition and language.

A 48-year-old Caucasian woman with a past medical history of hypertension and hypercholesterolemia was diagnosed recently with a cerebral aneurysm. The treatment plan for the aneurysm is endovascular coiling. Among other complications, this patient has an increased risk of thromboembolism postoperatively.

Heparin

A 32-year-old man is admitted to the hospital following loss of consciousness. The patient had been ill with fever and headache for several days, then developed double vision, confusion, and loss of consciousness. He has been otherwise healthy with no past medical conditions. Imaging reveals edema of the frontal lobe.

Herpes simplex virus

A 32-year-old man presents with a 2-day history of high fever and progressive severe headaches that are associated with blurred vision and increasing confusion. The patient is normally healthy, and he does not have a remarkable past medical history. He is married. He does not drink alcohol, smoke, or use recreational drugs. He has not had any blood transfusions and takes no medications. On physical examination, he appears ill and disorientated to time, place, and person. His pulse is 110 bpm, temperature 39°C (102°F), respirations 22/minute, and blood pressure 115/70 mm Hg. He is well-hydrated. He has no scleral icterus, pupils are equal and reactive, and fundi are normal. His cranial nerve examination is intact. He does not respond to pain stimuli appropriately. He can move all of his limbs. Deep tendon reflexes are normal; plantar reflexes are equivocal. His neck is supple and there is no palpable adenopathy. Skin exam is normal without rashes. His lab work includeswhite blood cell count (WBC) = 18x109/L with 70% polymorphonuclear neutrophils and 30% lymphocyteserythrocyte sedimentation rate = 90 mm/hour

Herpes simplex virus encephalitis

A 20-month-old boy presents with a 1-week history of fever up to 101°F and irritability. His mother noted sores in his mouth 4 days ago; she states that she has noticed him drooling and that his appetite is quite diminished. His past medical history is unremarkable. He has no medical allergies and his only current medication is acetaminophen. He is current on his immunizations. His physical exam reveals normal vital signs except for a temperature of 100.5°F. On examination of his oral cavity, you note swollen erythematous gingiva with ulcerations present mostly on the left of his mouth. The ulcerations appear yellowish-white and friable. White-gray lesions approximately 3 mm in diameter are seen on the anterior tongue. The tonsils appear erythematous without exudates. His lips are slightly cracked, and his mucous membranes are slightly tacky. Neck examination reveals bilateral anterior cervical adenopathy. He has no skin lesions. The remainder of his exam is normal. His strep test is negative.

Herpetic gingivostomatitis

A 21-year-old woman presents with recurrent painful nodules that form in her armpits. On physical examination, you note red inflammatory nodules that are very tender to palpation. Also noted are open comedones that seem to be paired. The patient indicates that these areas ultimately break down and drain a foul-smelling purulent material.

Hidradenitis suppurativa

A 35-year-old woman presents to the endocrinology clinic with results of a thyroid nodule fine needle aspiration (FNA) performed by a radiologist not associated with your practice. Upon review of her results, she is initially relieved to learn her needle aspirate is negative for thyroid cancer. After some thought, however, she begins to question her results and asks about the probability of a false negative test and that she does have thyroid cancer. You reassure her, stating with high probability her FNA results are truly negative.

High negative predictive value

A 4-year-old girl presents with her mother to discuss treatment of her atopic dermatitis. She was diagnosed as an infant, but her case appears to be getting worse despite frequent lubrication with thick emollient creams and medium-potency topical corticosteroid use. The mother states that the patient is itching a lot more, especially during the night. Large, single patches of erythematous scaly excoriations measuring about 3 cm x 4 cm are present in the flexor surfaces of both elbows.

High-potency topical corticosteroids

A 15-year-old girl presents with loss of consciousness. She is accompanied by her mother, who states that the patient initially fell ill several days ago with a headache, muscle aches, and fever. The patient developed a severe headache today, accompanied by double vision, difficulty speaking, confusion, and eventual loss of consciousness. She has not taken any medications aside from acetaminophen (Tylenol) for her fever. Her mother states that her daughter is usually active and had been playing soccer regularly until she became ill; the patient has been fairly healthy aside from occasional cold sores. Past medical history is significant for frequent ear infections as a toddler that were treated with tympanostomy tube placement at age 2. Brain imaging reveals edema of the temporal lobe.

History of cold sores

A 68-year-old man with a 50 pack-year smoking history presents to his primary care provider due to a 4-month-history of progressive dysphagia. His review of symptoms is notable for intermittent ear pain (especially upon swallowing), an involuntary weight loss of 12 lb over the past 4 weeks, and occasional hemoptysis. He denies chills, abdominal pain, shortness of breath, chest pain, vomiting, or skin changes. His physical exam is remarkable for non-tender immobile lymphadenopathy of the cervical nodes and stridor upon auscultation of the trachea. A nasopharyngoscope revealed complete replacement of the right true cord with a mass lesion.

Hoarseness

A 17-year-old boy comes into the urgent care clinic due to dysuria, frequency, urgency, and urethral discharge. His mother is present in the exam room during your interview. When asked, the patient says his mother can remain in the room for the interview but not for the exam. You conduct the interview, then ask the mother to step out. When she leaves, you ask the patient about his sexual history and discover he had consensual unprotected sex with a new partner just before the onset of these symptoms. He asks you to not discuss this information with his mother.

Honor the patient's wishes and do not disclose any information to the mother.

A 33-year-old man presents with a 1-day history of a painful left upper eyelid. He denies any change in vision, discharge, trauma, or foreign body. The pain started after the patient was cleaning out the garage. On physical exam, the visual acuity is OD/OS/OU = 20/20. The lateral aspect of the left upper eyelid is swollen, erythematous, and tender to palpation. The rest of the eye exam is normal.

Hordeolum

A 35-year-old woman presents with a painful swelling of her left eyelid. On physical exam, there is tenderness to palpation and erythematous swelling present on the lid margin involving the eyelashes.

Hordeolum

An 8-year-old child is brought to your office because of swelling of the left upper eyelid; the swelling is associated with redness and tolerable pain. No fever is noted. Physical examination shows a localized swelling and redness on the upper middle lid of the left eye; there is slight tenderness on palpation. Vital signs are within normal limits.

Hordeolum

A 38-year-old man with uncontrolled facial movements states that he has noticed himself over the last few months making expressions without even realizing it or being able to control it. Further questioning reveals that he also has noted an inability to intentionally move his eyes quickly without blinking. Very recently, he noted an inability to sustain physical movements, such as grasping objects with his hands. Physical examination reveals a puppet-like gait and obvious chorea. The patient admits that he does not know anything about his family history due to the fact that he was adopted when he was 4.

Huntington's disease

A 45-year-old man presents with concerns of uncontrollable movements that he has noticed for the past 2 months. He feels he cannot control these involuntary movements of his upper body. His wife reports that he appears irritable and impulsive. She feels that his personality has changed, but she is more concerned about the sudden jerking in his body. She shared that the patient's father passed away in his 50s with similar symptoms. Upon physical exam, the patient appears to have tics that are sudden and appear depressed. Additionally, Hoffmann's sign and Babinski's sign are normal. A CT scan shows cerebral atrophy and genetic testing from the lab is pending.

Huntington's disease

A 4-month-old female infant is presented for a well-child checkup. She was a spontaneous vaginal delivery at 39.5 weeks without complications. The mother notes she has been irritable and has not been eating well. No cough or fever. No one smokes at home. On exam, you note impaired extraocular movements, especially in the upward gaze, and a bulging anterior fontanel. There is increased tone of the legs. Skin exam is normal. Like her last visit, the length and weight are 50th percentile. Head circumference was formerly at the 75th percentile and is now above the 99th percentile.

Hydrocephalus

A 22-year-old woman presents with an 8-month history of amenorrhea. Further questions elicit additional pertinent positives of backaches, headaches, and acne. Physical examination reveals a female patient with a moon-shaped face, multiple purple striae, and significant central obesity (body mass index of 36).

Hypercortisolism

A 72-year-old woman presents with a 2-week history of fever, cough, and excessive diuresis. The woman has diabetes mellitus that is being treated with glimepiride (Amaryl). Her fluid and food intake have been poor during this time, as well. On physical examination, blood pressure is 98/58 mm Hg, pulse is 112/min, temperature is 100.6°F, and respirations are shallow and regular at 20/minute. On physical assessment, the patient is stuporous, skin and mucous membranes are dry, heart has a regular rate and rhythm without murmurs, and auscultation reveals rales in the left lung base. Her serum BG level is 602 and blood pH 7.35. She is diagnosed with pneumonia.

Hyperglycemic hyperosmolar state

A 73-year-old frail-appearing woman is brought in by her daughter who is concerned about her mother's increasingly poor memory. The mother reports fatigue and weakness so profound that "her bones hurt," as well as polyuria and chronic constipation. She is being treated for depression and osteoporosis, but she is otherwise in good health.

Hyperparathyroidism

A 38-year-old man had a total thyroidectomy for stage II papillary carcinoma yesterday.

Hypocalcemia

Daily cleaning with a damp cotton applicator and baby shampoo

Hyposensitization

A 22-year-old female college student presents because she does not eat properly and has missed several menstrual cycles. Her sorority sisters are certain she is not pregnant because she rarely, if ever, leaves their sorority house except to attend classes; she has not dated in more than 6 months. On examination, she is underweight. She walks unaided and her speech is clear and distinct. She has adequate vision, normal-appearing facial expressions, and adequate hearing. On her college entrance physical examination, her height was 5'7" and her weight was 130 lb. Her weight 1 year later is now 103 lb.

Hypothalamus

A 58-year-old Caucasian man presents to his primary care physician's office reporting lethargy. His heart rate is 44 bpm. The patient is sent to the emergency department where he is treated with atropine 0.5 mg x 1 dose. Heart rate then increases to 57 bpm, and the patient is admitted to the hospital for further evaluation. Cardiology consultation is requested. The patient reports no history of cardiac disease. He denies symptoms of chest pain or pressure but admits to intermittent lightheadedness and mild dyspnea on exertion with moderate activity in the last 2-3 months. He denies paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema, palpitations, and frank syncope. He admits fatigue and lethargy for 3 months. He had an exercise tolerance test 10 years ago that was reportedly normal. His last physician's office visit was 2 years ago. His past medical history is notable only for high cholesterol and history of tonsillectomy. He has no known drug allergies. His only daily medication is Lipitor 20 mg once daily. He does not smoke and does not use alcoholic beverages or recreational drugs. Review of systems reveals cold intolerance and episodes of constipation. Physical examination reveals an alert white man who is somewhat slow to speak and respond. His voice is moderately hoarse. He has coarse facial features and dry skin. Mild periorbital puffiness is noted. Deep tendon reflexes are delayed. 12-lead EKG reveals sinus bradycardia, rate 52, without evidence of prior myocardial infarction, ischemia, left ventricular hypertrophy, or bundle branch block. The EKG is otherwise within normal limits.

Hypothyroidism

A 32-year-old woman presents with malaise, excessive urination, and palpitations. Her symptoms began approximately 2 months ago and have been getting more pronounced with time. She finds herself craving ice-cold water and drinking on an almost continual basis. No matter how much she drinks, she never seems to satisfy her thirst. The patient had been very healthy until recently. She has no significant past medical or family history, with the exception of an auto accident approximately 2 years ago; she hit her head on the steering wheel and spent a night in the hospital for observation. She had no problems after she was discharged until now. She reports no deficits of vision and no history of syncope or seizures. On physical examination, the woman is anxious, pale, and appears dehydrated. Her vital signs are: blood pressure 100/54 mm Hg, temperature 99.8°F, pulse 112 beats per minute, respiratory rate of 24 per minute. Laboratory tests show dilute urine with a specific gravity of 1.000 and a urine osmolality of 198 mOsm/kg. Her plasma osmolality is 299 mOsm/kg.

Idiopathy

What is the most accurate statement concerning the treatment of migraine headache with sumatriptan?

If it is effective in the initial therapy, it is often effective in aborting a recurrence of symptoms.

A 39-year-old woman presents with a rash. The rash started 5 days ago; it is pruritic and located primarily on her arms and legs, with a few sores in her mouth. Her husband described the rash as like a "bullseye." She has felt mildly "flu-like," but she denies fevers. She denies any changes in soaps, detergents, or diet. She has not been around anyone with a similar condition, and she denies travel. Otherwise, she reports feeling better than usual, with more improved control of her migraines since her neurologist started her on topiramate about 3 weeks ago. She has not needed to use her sumatriptan for over 1 month. Her review of systems is negative. She suffers from migraines, but she has no other chronic health conditions. Her current medications are topiramate daily, with sumatriptan as needed. She is allergic to amoxicillin. She has regular menses; she had a tubal ligation as contraceptive. On physical exam, a few small oral lesions are noted. The lesions on the extremities are primarily on the dorsal surfaces, with a ringed appearance, similar to a target. The remainder of her exam is normal, including vital signs.

Immediate discontinuation of the new medication

A 48-year-old Caucasian man is evaluated for palpitations by a PA in an internal medicine clinic. He presents with a several-week history of episodes of irregular heartbeat and tachycardia. PMH: kidney stones, childhood asthma; lithotripsy 3 years ago. NKDA. No daily medications. Extensive travel for work and 1-2 alcoholic beverages a few times weekly. Denies recreational drugs. Review of systems negative for chest pain, shortness of breath, dizziness, or syncope. Pulse: 108 and irregular. Vitals otherwise stable. Heart: irregularly irregular, mild tachycardia. No murmurs. Lungs: clear to auscultation and percussion. Remainder of physical exam unremarkable. EKG: atrial fibrillation, rate 110. Patient is started on sotalol (Betapace AF) 80 mg twice daily, and Holter monitor is placed. Cardiologist appointment is scheduled for 2 weeks. 2 days later, the patient dies of sudden cardiac arrest wearing the Holter monitor, showing runs of torsades de pointes (form of polymorphic ventricular tachycardia). 2 months later, a wrongful death and medical practice lawsuit is filed against the PA and supervising physician on behalf of the family.

Immediate verbal discussion while patient still in office

A 36-year-old woman presents with fatigue and diplopia; symptoms started in the morning and worsened during her time at work. On examination, the patient has ptosis bilaterally and decreased ocular muscle power. A CT scan of the chest shows a thymoma.

Immune-mediated destruction of the acetylcholine receptor

A 5-year-old boy has three honey-colored crusted lesions with surrounding erythema on his legs. The swabs taken from the lesions were sent to the microbiology laboratory. The results show yellow colonies grown on blood agar with hemolysis. The colonies are coagulase-positive and mannitol-positive.

Impetigo

You have been employed as a PA for a hospitalist group for several years. You have recently been invited to serve on a hospital committee taskforce. The mission of this taskforce is to make recommendations regarding system-wide initiatives likely to improve patient outcomes and reduce costs for the healthcare system. These recommendations will be forwarded to the CEO of this large healthcare system. If the Board of Directors approves, it is fully expected that the initiatives will be funded and implemented.

Implementation of a telehealth program

You are working at the Centers for Disease Control and Prevention, assigned to the National Center for Chronic Disease Prevention and Health Promotion. You are asked to prepare a report describing the impact of atrial fibrillation in the US. You learn that: An estimated 4.4 million persons (estimate 2.7-6.1 million persons) had atrial fibrillation in the US in 2010. 1.2 million cases of these cases of atrial fibrillation were newly diagnosed in 2010. The US population in 2010, according to the official government census, was approximately 323 million. In order to prepare a table displaying measures of population morbidity of atrial fibrillation in 2010, you make the following calculation: 1.2 million new cases of atrial fibrillation323 million US population=0.0037=0.37%1.2 million new cases of atrial fibrillation323 million US population=0.0037=0.37%

Incidence proportion

A physician assistant sees 20 patients a day in a primary care clinic. These patients are all follow-up patients initially seen by the physician. The PA is supervised by a physician who is physically present in the office during the PA's clinic hours.

Incident-to services

A 28-year-old man presented 4 days ago for evaluation of a 101.8°F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat has worsened. He has not been able to drink fluids or eat, and he has excruciatingly severe pain when swallowing. You recognize the patient speaking with a muffled "hot potato" voice. Upon re-examination today, you identify a right medial deviation of the soft palate with 4+ right tonsillar swelling.

Incision and drainage

A 32-year-old man presents with a severe headache; he has had 2 similar headaches within the past week. He describes a burning, "hot poker" type of pain located primarily behind his right eye. He notes that his eye waters profusely with the headache. His nose is initially congested, then it starts running. Only his right side is affected. The headache is so severe that he cannot work or sleep through it, and he is unable to concentrate on anything else. The headaches have been unresponsive to over-the-counter pain medications. The episodes seem to last about 1 hour. He denies any other symptoms. This patient has no chronic medical conditions, and he takes no regular medications.

Increased trigeminal nerve and parasympathetic activity, leading to vasodilation

A 26-year-old woman has been trying to conceive over the last few months. She is married and has one child. She also has a history of one miscarriage. Her past medical history is significant for hypothyroidism, which is treated with levothyroxine (Synthroid) 125 mcg PO per day. Her last thyroid-stimulating hormone (TSH) level, performed 3 months ago, was normal. Today, she presents with a 6-week history of amenorrhea. A urine pregnancy test is positive. You estimate that she is 6 weeks pregnant.

Increasing levothyroxine dose

A 45-year old Caucasian woman complains of an oval growth on her forehead. She noticed the growth 2 weeks back, and it has gradually grown in size and now bleeds occasionally. She works as a secretary at a dentist's office. She often visits tanning parlors to get a tanned look. She has also had several cosmetic procedures done, including liposuctions in the past to treat her obesity. She gives a history of cocaine abuse in her 20s. She is a hypertensive on treatment with thiazides. On exam, there is an erythematous papule about 3 x 3 cm in size, which bleeds on touch. Her BMI is 30. Biopsy of the lesion reveals squamous cell carcinoma (SCC) of the skin.

Indoor tanning

A 4-year-old boy presents with skin eruptions, fever, and diarrhea. Skin eruptions developed 1 week ago after exposure to multiple mosquito bites that left weepy crusted areas. Over the past 2 days, the boy has become quiet, sleepy, and febrile and has had a few loose stools. His past medical history is non-contributory, and his immunizations are current. On examination, you find a child in a mild distress; his temperature is 39°C. Heart rate is 100/min, and respirations are 22/min. On the skin of the arms and trunk, you notice multiple excoriations: a few fragile thin-roofed flaccid transparent bullae with a clear yellow fluid that turns cloudy and dark yellow. Several bullae are ruptured, leaving behind rims of scales around erythematous moist bases, but no crusts. You also notice patches of skin of brown-lacquered appearance, with collarettes of scale and peripheral tube-like rims.

Inhibition of peptidoglycans synthesis

A 38-year-old Caucasian man with a long-standing diagnosis of acromegaly has come to you with a concern. He read some articles suggesting that patients with acromegaly have an increased incidence of developing colon cancer, and this has caused him tremendous worry. The patient has no known personal or family history of diverticular disease, colon polyps, or colon cancer. He had a successful selective transsphenoidal surgical resection of a pituitary microadenoma over 20 years ago and has had routine periodic serum insulin-like growth factor-1 (IGF-1) levels drawn that have always been within normal range.

Initial colonoscopy at age 40 and every 5 years

A 7-year-old boy presents for evaluation of behavior problems in school that have been occurring for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction. He does not finish his homework, and he often loses his homework, pencils, and books. The boy is often seen fidgeting at his desk. He blurts out answers and has difficulty waiting his turn. The parents tell you that they have seen similar traits at home, such as forgetting to do daily activities. For the past several years, he has been easily distracted. They view him as a happy, bright boy, and they report that he is very active. He has had normal vision and hearing screenings. The father self-reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he has never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams, has always met milestones, and has had normal exams. Today, he is quickly moving about the exam room. He looks at a book for a few moments, and then he looks out the window for a short time before interrupting his parents.

Initiate medication.

You are responsible for managing patients on a general medicine ward overnight. One of the patients under your care is a frail elderly woman with a history significant for advanced dementia admitted. She was admitted for hospital-acquired pneumonia, as she resides in a long-term memory care facility. Over the past several minutes, you have received numerous frantic pages from various nursing staff regarding this patient. Nursing reports this patient has become agitated, has had hallucinations, will not remain in bed, and has urinated on the floor. The nursing staff has requested you come and evaluate the patient.

Initiate non-pharmacologic management.

A 48-year-old man presents with fatigue, weakness, and nausea—symptoms progressively worsening over 6-8 months. He reports fatigue despite adequate sleep, overall feeling of muscle weakness, nausea with occasional vomiting, 12 lb weight loss, headaches, and muscle aches. His wife thinks he appears tan year-round, despite lack of sun exposure. He admits feeling anxious and irritable, but he denies any major psychosocial or traumatic events. Before symptom onset, he was healthy and active. Past medical history reveals no chronic medical conditions, medications, surgeries, or allergies. Family history is significant for thyroid disease in sister and mother, type 1 diabetes mellitus brother. He denies tobacco, alcohol, and recreational drugs. On physical exam, he is hypotensive and hyperpigmented. Remainder of his physical exam is normal.

Initiate steroids.

A 32-year-old Caucasian woman has a past medical history of Hashimoto's thyroiditis, type 1 diabetes mellitus, and pernicious anemia; she presents with a 2-year history of insidious and intermittent fatigue, anorexia, involuntary weight loss, nausea, abdominal pain, vomiting, and dizziness that is associated with position changes. Her physical exam is noteworthy for postural hypotension, with a maximum systolic blood pressure of 104 in the supine position. Additionally, she has a low-grade fever and a generalized pigment change to her skin.

Instructions on self-administration of IM hydrocortisone on an as-needed basis.

A 25-year-old woman presents due to sneezing episodes that have progressively worsened over the last few months. She has symptoms on most days, and it is affecting her daily life. The symptoms are worse in the spring and fall and improve in the winter. She also reports rhinorrhea, cough, and fatigue. Physical examination is remarkable for boggy nasal mucosa and pale nasal turbinates.

Intranasal corticosteroids

A 23-year-old man with no known significant past medical history is brought in by emergency medical services in an unconscious state. He was reported by friends to be out partying, carrying a prescription bottle. His father has a known history of severe spinal stenosis, for which he takes prescription opioid analgesics. His physical exam reveals slow and shallow respirations, bradycardia, hypotension, cyanosis, and miosis of both pupils. He is comatose, has diminished bowel sounds and distension with dullness to percussion over the suprapubic abdominal area, and has flaccid musculature.

Intravenous naloxone

You are a PA working with an international aid organization in sub-Saharan Africa. A local community has developed an outbreak of an apparently contagious illness with a high (approximately 50%) mortality rate. Symptoms of the illness include fever, weakness, headache, diarrhea, vomiting, abdominal pain, myalgias, and unexplained bleeding. Lab tests for Ebola virus coordinated through the country's health ministry and the World Health Organization report that the outbreak is due to Ebola.

Isolation of infected patients

A 30-year-old male immigrant worker presented 4 weeks ago with a chronic cough, blood-stained sputum, and night sweats. His PPD was 15 mm and pulmonary tuberculosis was diagnosed. Treatment was started at that time. Today, he is back for a checkup with the presenting problem of "pins and needles" sensation in his hands.

Isoniazid

An approximately 10-year-old Latinx boy is brought by paramedics to the emergency department after a motor vehicle accident. He is unconscious and has sustained severe trauma. He has a subdural hematoma, multiple fractures, contusions, and a tension pneumothorax. He is treated with needle thoracentesis and subsequent chest tube placement. A neurosurgeon is consulted regarding the subdural hematoma. The driver of the car, a Latinx woman in her mid-30s, did not survive the accident. Efforts are made to identify the boy and to locate his next-of-kin. The patient's father arrives at the hospital, but he does not speak English. The next day, the patient's sister (who speaks English) arrives and asks you why the family did not have to give consent before the chest tube was placed.

It was an emergency situation.

A 12-year-old boy presents with fatigue and jaundice. History obtained from the patient and his mother is negative for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On eye examination using a slit-lamp, you note brown-yellow rings encircling the iris in the rim of the cornea bilaterally. You order a serum ceruloplasmin level, which is reported as low.

Kayser-Fleischer rings

A 27-year-old woman presents at your family practice clinic for management of her anxiety. She reports that her home situation is unsafe, and she is afraid of her husband; he is physically and emotionally abusive to her and her children. She does not want this information shared; she fears he may retaliate for her telling anyone. She is also afraid that any diagnosis of psychiatric disease will affect her ability to have custody of her children.

Keep records electronically password protected.

A 48-year-old HIV-positive man starts to develop headaches. At first, he attributes the headaches to stress, but they persist and become worse over the next few weeks. He develops nausea and vomiting, and he thinks he has a fever. He starts to become confused, so he seeks medical attention. On physical examination, his temperature is 100°F.

Kernig's sign

A 38-year-old woman presents with a skin rash. She indicates that she has a history of psoriasis, but she has not had a serious outbreak for several years. You note salmon-pink papular lesions involving the flexor surfaces of the patient's wrist. The patient has no other lesions. The lesions appear to follow a linear pattern of distribution. She indicates that the lesion has been present about 3 days. You ask her if she was exposed to any type of agent, and she tells you that she scratched the area and then the lesions appeared the next days upon awakening.

Koebner phenomenon

A 2-year-old boy presents to your office. He is from a poor rural family and has not had regular healthcare since birth. He is experiencing a childhood exanthematous disease that involves a maculopapular rash and a fever. It started 7 days ago. He now has corneal ulcers and pneumonia.

Koplik's spots, coryza, fever, cough, and conjunctivitis

A 45-year-old African American man with no significant past medical history presents with a 1-hour history of left retro-orbital headache. The headache was of a sudden onset, and it began upon waking this morning. It is described as excruciating, stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any preceding infections, nausea, vomiting, fever, chills, focal weakness, numbness, tingling, hearing, gait, or speech changes. He recalls a similar episode several months ago; it lasted about 3 hours and dissipated without complications. His physical exam is remarkable for painful distress, nasal congestion with rhinorrhea, left ocular miosis, and left forehead flushing diaphoresis.

Lacrimation and conjunctival injection

A 56-year-old man presents with a history of persistent and progressive unrelenting hoarseness for the last few months. He is a 50 pack-year smoker but quit 1 year ago. Physical examination demonstrated a 2-cm firm non-tender right anterior cervical lymph node.

Laryngeal cancer

A 24-year-old man presents with head trauma received in a motor vehicle accident (MVA) 30 minutes ago. Paramedics relate that the patient experienced a loss of consciousness for 1 minute with a complete recovery. At the subsequent evaluation, the physical exam reveals a patient with a Glasgow Coma Scale (GCS) of 12, right hemiparesis, and a left fixed dilated pupil.

Left epidural hematoma

A 69-year-old woman suffered a massive stroke 6 weeks ago. She is now recovering from the stroke, but she has residual paralysis and sensory impairment of her right arm. She is also unable to speak and unable to turn her eyes to the right.

Left middle cerebral artery

A 74-year-old woman presents for management of an ischemic stroke. She reports difficulty seeing objects on her right side. You perform confrontational visual field testing as part of your neurological examination and you discover she has a right inferior homonymous quadrantanopsia.

Left parietal lobe

A 58-year-old Caucasian man presents to his primary care physician's office reporting lethargy. His heart rate is 44 beats per minute.The patient is sent to the emergency department where he is treated with atropine 0.5 mg x 1 dose. Heart rate then increases to 57 beats per minute, and the patient is admitted to the hospital for further evaluation. Cardiology consultation is requested. The patient reports no previous history of cardiac disease. He denies symptoms of chest pain or pressure but admits to intermittent lightheadedness and mild dyspnea on exertion with moderate activity in the last 2-3 months. He denies paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema, and palpitations. He denies frank syncope. He admits to fatigue and lethargy for approximately the past 3 months. He had an exercise tolerance test 10 years ago that was reportedly normal. His last physician's office visit was 2 years ago. His past medical history is notable only for high cholesterol and history of tonsillectomy. He has no known drug allergies. His only daily medication is Lipitor 20 mg once daily. He does not smoke, drink alcohol, or use recreational drugs. Review of systems reveals cold intolerance and episodes of constipation. Physical examination reveals an alert Caucasian man who is somewhat slow to speak and respond. His voice is moderately hoarse. He has coarse facial features and dry skin. Mild periorbital puffiness is noted. Deep tendon reflexes are delayed. 12-lead EKG reveals sinus bradycardia, rate 52, without evidence of prior myocardial infarction, ischemia, left ventricular hypertrophy, or bundle branch block. The EKG is otherwise within normal limits.

Levothyroxine Thyroid stimulating hormone and free T4 level

A young woman presents with her daughter, who appears to be about 6 years old. You note that the child's eyes are downcast and she is scratching her scalp. On closer inspection, you note a tiny white wingless insect and tiny eggs attached to the hair shafts. The child's mother also notes that the same insects are present in the girl's eyelashes.

Lice

A 30-year-old woman presents with a 2-week history of itchy pimples on her wrist. On examination, there are violaceous papules with a network of gray lines on their surface; they are found on the medial aspect of her right wrist.

Lichen planus

A 70-year-old woman presents after collapsing at work. She has a medical history significant for a mood disorder that causes her to have wild mood swings and reckless behavior. She was diagnosed with this disorder 1 year ago and has been taking her prescribed medication. She was recently hospitalized for acute gastroenteritis that was complicated for acute renal failure. Shortly after this, she reports experiencing nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevation in BUN and creatinine and elevated serum drug levels, but the results are otherwise normal.

Lithium

A 32-year-old man is brought to the emergency department after falling off a roof at a construction site. He is unresponsive and intubated, requiring mechanical ventilation. Computed tomography (CT) scan of the head reveals an uncal herniation and mass effect due to intracranial hemorrhage. Further testing reveals no brain activity. His girlfriend reports he wanted to donate his organs; no other family is present.

Living will

A 31-year-old man with a known generalized seizure disorder is brought to your emergency department. His friends tell you that the patient had a seizure and did not wake up. When he did not wake up after 30 minutes, his friends called 911. On examination, he is breathing and his heart is beating. He is warm, dry, and pink. His basic laboratory values are within normal limits, and the computerized axial tomography (CAT) scan of his brain is unremarkable. An emergency electroencephalogram (EEG) is not available. His only medications are phenytoin and phenobarbital.

Lorazepam (Ativan)

A 66-year-old man presents to the clinic with a complaint of not being able to hear the beeping of his microwave. Knowing that the beeping is high pitched and the age of the individual, you suspect hearing loss in this patient that is typically associated with aging.

Loss of cochlear hair cells

A 56-year-old woman presents with sudden onset of palpitations, trembling, sweating, anxiety, headache, and confusion that started 1 hour ago after a 5-mile early morning run. She has had similar episodes in the past, but never any symptoms this severe. Sometimes she wakes up in the morning with headaches and trembling, but they usually go away after she has gotten ready and has breakfast. On physical exam, she is found to have heart rate 114, blood pressure 125/86, respiration rate 18, weight 160 lb, and temperature 98.7°F. Patient is alert and appears somewhat anxious and diaphoretic but otherwise well. HEENT exam is unremarkable. Cranial nerves, cerebellar function, strength, sensation, deep tendon reflexes, and balance testing/Romberg are all normal. Patient is tachycardic, but S1 and S2 are normal with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. EKG shows sinus tachycardia. Lab work is significant for a glucose level of 36.

Low C-peptide levels

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills, and obsessive and compulsive characteristics; symptoms have been evident to his mother and multiple teachers at school. There have been numerous episodes. The patient has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last 4 months.

Low frustration tolerance

A 5-month-old male infant presents after a seizure involving all four limbs. His mother tells you that he was born full term without any complications, and he was well until 2 days ago when he developed a fever. He vomited multiple times yesterday and was irritable. He has not had diarrhea or a cough. He was given antipyretic medication for his fever. He has no known allergies. His immunizations are up to date. His developmental milestones have been in accordance with his age. On physical exam, temperature is 102.7°F, pulse is 154/min, BP is 90/50 mm Hg, RR is 20/min. He is lethargic and pale; there are no focal neurological deficits. Non-contrast CT of the head is unremarkable. You suspect that he has bacterial meningitis.

Lumbar puncture

A 70-year-old man with hypertension, diabetes, obesity, and coronary artery disease presents with a 3-day history of fever, headache, nausea, vomiting, lethargy, and myalgias. His wife states that the symptoms began the day after a summer evening walk around a lake. Today, his condition has worsened; he has developed a diminished level of consciousness, behavioral changes, and abnormal movements. His physical exam reveals a lethargic man with photophobia, cranial nerve deficiencies, neck stiffness, and abnormal extremity movements.

MRI of the brain

A 23-year-old man presents with a 2-week history of fever and back pain that radiates from the midline to one side. The patient also has a 1-week history of right lower limb weakness and urinary incontinence. The patient gives history of trauma to the back following a motor accident 1 month ago. Examination by touch and percussion demonstrates localized pain in the spine; you also note neurological losses on the right side of the body that include decreased sensation and weakness. The patient's temperature is 101°F, and his skin is moist.

Magnetic resonance imaging (MRI)

A 37-year-old woman was diagnosed as HIV-positive 3 years ago; she is unable to work and is physically debilitated, so she asks you to provide her with medications with which to take her own life.

Major depressive disorder

A patient presents with deteriorating work and feelings of worthlessness and hopelessness; symptoms have been worsening over the past month. The patient also gives history of excessive fatigue and loss of interest in pleasurable activities. They also have trouble eating and sleeping, and they are increasingly withdrawing from family and friends. These symptoms have been present for more than 2 months.

Major depressive disorder

A new female patient presents to your clinic to discuss upcoming travel plans. She was born in the Dominican Republic and emigrated the United States 10 years ago. She is planning on returning the Dominican Republic to visit relatives. She plans to spend some time outdoors trekking near her family's home. She is up-to-date on her influenza vaccination and other age-appropriate preventative health screenings and vaccinations. She is not pregnant or trying to become pregnant. She is otherwise healthy without any chronic medical conditions.

Malaria prophylaxis

A 5-year-old boy presents to his pediatrician's office due to a temperature of 103°F, cough, runny nose, and a rash for 5 days. His mother reports they are orthodox Jewish and traveled to Israel 2 weeks ago. Due to his religious beliefs, he is unvaccinated. His heart rate is 102 with a blood pressure of 100/65, pulse 102 beats per minute, and respiratory rate of 22 breaths per minute. On exam, he is lethargic and ill-appearing with a maculopapular rash on his face. He has clear nasal discharge and red conjunctiva. He has tiny white spots with bluish-white centers on a red background found inside the mouth on the inner lining of the cheek.

Measles, mumps, and rubella vaccine for all close contacts

A 3-year-old girl presents to her pediatrician with perianal itching that wakes her up at night. Her pediatrician performs an anal swab, and microscopic examination reveals eggs.

Mebendazole

A 33-year-old woman presents with tingling and numbness in the palms, thumbs, and index fingers bilaterally. Her symptoms are worse during the night. Recently, she noticed that she has difficulty grasping small objects. She works at a poultry farm and is involved in assembly packing. On examination, Tinel's sign and Phalen's test are positive.

Median nerve

A 25-year-old man is referred to you for evaluation. He has no history of psychiatric disturbance, and there is no family history of psychiatric illness. During the evaluation, he states that he has seen people following him and he has been having difficulty concentrating. He believes that he is in danger and that the people following him are FBI agents. When asked about the onset of the symptoms, he states that they began about 1 month ago and they have persisted ever since. The patient is not currently taking any psychiatric drugs, but he has been taking antihistamines to treat allergies for about 1 month.

Medication-induced psychotic disorder

A 45-year-old man presents with episodic attacks of headache, recurring bouts of palpitations, anxiety, and sweating. He also gives history of a severe attack 1 week ago while he was having wine and cheese with his wife. On further questioning, he comments that he gets lightheaded when he stands up too rapidly. He comments that his mother had similar problems. On physical examination, his blood pressure is 165/90 mm Hg and his heart rate is 80/min. A 24-hour collection of his urine tests positive for vanillylmandelic acid. Imaging studies showed bilateral adrenal medullary hyperplasia. Further workup showed hypercalcemia, hypophosphatemia, and increased parathyroid hormone levels.

Medullary carcinoma of the thyroid

A 16-year-old boy presents with acute onset of stiff neck, fever, headache, and vomiting. On exam, he appears lethargic, has limited range of motion of his neck, and a petechial rash is noted. Fever is 103°F. The patient's medical history is non-contributory.

Meningococcus

A 38-year-old male patient with HIV develops diabetes; he takes stavudine. What diabetes medication is most likely to exacerbate potential acid-base disorders of his antiviral therapy?

Metformin

A 50-year-old woman comes in for follow-up of newly diagnosed type 2 diabetes mellitus. She has no other contributory past medical history. She drinks alcohol rarely. She has been working on dietary changes over the last 6 months. Most recent A1c is 7.6%.

Metformin

A 21-year-old woman presents with urinary frequency. Her BMI is 41. A urinalysis is positive for glucose. Her random blood sugar is 257 mg/dL, hemoglobin A1c is 8.5%, and C-peptide is 1.5 ng/mL. She is diagnosed with type 2 diabetes; diet and exercise are recommended.

Metformin (Glucophage)

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home for several years, such as forgetting to do daily activities and being easily distracted. They view him as a bright happy boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents.

Methylphenidate

A 3-year-old girl presents with a 2-week history of a pruritic erythematous excoriated rash. Her past medical history is unremarkable. Her only medications include a topical steroid ointment and oral diphenhydramine. She has no known allergies. She lives on a farm on the outskirts of her town. She does not attend daycare and lives with three older siblings and her parents. There are cats and dogs in the house, which appear to be in good health. Her physical exam is significant for small red papules in her interdigital spaces, wrist flexors, anterior axillary folds, and forearms. Scattered red-brown nodules are found in her axillary region.

Microscopic examination of skin scrapings

An 18-year-old woman presents with a history of recurrent headaches that mainly occur above her right eye. She describes them as "throbbing" in quality. During these headaches, she gets bouts of nausea and vomiting. After a nap, she typically feels better. The headaches only last a few hours, and she experiences them roughly 2 times a month.

Migraine

A 22-year-old woman presents with headache. The pain is located on the right side of her head and is described as throbbing. The headache has lasted for approximately 10 hours and has been unrelieved by acetaminophen and ibuprofen. The pain worsens with movement, exposure to light, and loud noises. Neurological examination is within normal limits.

Migraine headache

A 74-year-old man presents to discuss difficulty with orientation, memory, and word-finding. The orientation problems are worse at night. His problems began with mood and behavioral changes 7-8 years ago, after his brother passed away. He reports no trouble with activities of daily living. The patient has only an elementary school education, stating that he was "not smart enough to go to college." There is no family history of dementia.

Mild cognitive impairment

A 76-year-old woman presents because her children are concerned that she might have dementia. She states that she is doing reasonably well, except that she sometimes sleeps less deeply and wakes up more often than she did several years ago. According to her children, she is slower than before, and her memory has been getting worse over the last 3 years; she has difficulties recalling the specific date of an event (although she can describe the event itself). She also has a great deal of trouble with names, but she can easily recognize people. She always says, "It is on the tip of my tongue, but..." Aside from hypertension that is under control, she does not have any other health problems. She has been a widow for about 10 years. Her older brother was diagnosed with dementia. Physical examination today is within normal limits for the age, and neurological examination is non-focal.

Mini-mental status examination

An 83-year-old woman is currently in a nursing home following a short hospitalization for a CVA. She experienced a thromboembolic stroke 2 weeks ago, which resulted in right hemiparesis and dysphagia. Other medical problems include congestive heart failure, atrial fibrillation, osteoarthritis, and depression. The nursing staff contacts you to reports a sacral pressure ulcer measuring 3 x 2 cm. On physical examination, there appears to be interruption of the epidermis with an abrasion. The lesion is clean; there is no cellulitis.

Moist dressing

A 35-year-old African American woman presents to urgent care with fatigue and intermittent vomiting of 2 weeks' duration. She recently came back from a month-long trip to Central America. She has also experienced symptoms of intermittent fevers, headaches, and brief "yellowing of her skin."

Mosquito

A 23-year-old woman presents with increasing fatigability and muscle weakness. On further questioning, she reveals that she has experienced difficulty swallowing over the past month, and there have been episodes of double vision as the day progresses. Several of her professors have expressed concern because she looks sleepy during the day. A CT of the chest reveals an anterior mediastinal mass.

Myasthenia gravis

A 65-year-old woman presents with general weakness for the past few days; it gets worse as the day progresses. She says she has been having double vision, and you notice she has poor posture. A blood test reveals the presence of antibodies to acetylcholine receptor. A repetitive nerve stimulation test showed a decremental response.

Myasthenia gravis

A 24-year-old man with HIV-positive status for 2 years presents due to an ongoing chronic cough for the past 8 months. He admits to a mild fever that comes and goes during that period. A 5 lb unintentional weight loss is also discovered since his last visit to your office, which was approximately 9 months ago. He states he has noted an increased amount of breathlessness with simple activities that were never bothersome before the cough began. The patient denies smoking, and his TB test is negative.

Mycobacterium avium complex

A 24-year-old man presents with a 2-day history of skin rash on his back. He notes pain in his joints and tiredness. He has just returned from a camping trip. Vital signs are normal. Examination reveals an expanding lesion with a concentric circle of erythema.

Myocarditis

A 40-year-old woman presents because of a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting but does admit to having a Colles' fracture in this arm around 2 months ago. She denies any injury to her back, neck, or other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse, uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and to cold, and it does appear somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker, does not drink, and exercises 3 times a week. Physical examination conducted of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+) and ROM is limited.

NSAIDs

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she does admit to having a Colles' fracture in this arm around 2 months ago. She denies any injury to her back, neck, or any other musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing; there is an extremely diffuse and uncomfortable aching accompanying it. She further states that this limb has become extremely sensitive to touch and cold, and it appears somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker, does not drink, and exercises 3 times a week. Physical examination of the extremity reveals a slightly cyanotic, mottled right arm with generalized pain of the entire extremity. Pulses are faint (1+), and ROM is limited.

NSAIDs

A 58-year-old woman presents for a follow-up accompanied by her adult daughter. A few months ago, the patient had gone to the emergency department via ambulance after the daughter discovered her mother confused and shaking at home. The patient underwent several days of inpatient treatment for alcohol withdrawal. Initial symptoms included hallucinations, tremor, nausea, anxiety, insomnia, and a seizure. The patient denies current symptoms and admits increased tolerance to greater amounts of alcohol and loss of control with a frequent need for the substance. Her work and home relationships suffer due to her condition. The patient has no other medical conditions, is menopausal, has had no surgeries, takes no medications, and has no allergies. The patient readily admits alcohol abuse and dependence with a desire to prevent relapse. She has not used any other substances, and has been abstinent of all substance use since hospital discharge. She is currently in individual and group programs to assist her in relapse prevention. She would like pharmacological help to maintain her sobriety.

Naltrexone (ReVia/Vivitrol)

A 40-year-old woman presents with a 7-day history of pain in her right arm. The patient denies any trauma or injury to this extremity just prior to the pain starting, but she admits to having a Colles fracture in this arm about 2 months ago. She denies any injury to her back, neck, or other components of the musculoskeletal system prior to the event of pain. She describes the pain as burning and throbbing with an extremely diffuse and uncomfortable ache accompanying it. She further states that this limb has become extremely sensitive to touch and cold; it appears somewhat more swollen than her left arm. The patient is very upset because she does not know why her arm is so painful when she has not done anything to it. She is a non-smoker. She does not drink alcohol, and she exercises 3 times a week. Physical examination of the extremity reveals a slightly cyanotic hue and generalized pain of the entire right upper extremity. Pulses are strong (2+), but due to the pain, the patient states ROM is limited.

Naprosyn 500 mg twice daily

A 13-year-old girl presents 2 weeks after an upper respiratory infection with diarrhea, sweating, and increased heart rate. Physical examination reveals a tremor and a swollen, tender, painful thyroid gland. Pulse rate is 110/min and blood pressure is 130/60 mm Hg.

Naproxen

A 19-year-old man presents for evaluation of excessive daytime sleepiness. Despite getting a full night's sleep, his coworkers have repeatedly noticed him suddenly dozing off at his desk, during meetings, and sometimes mid-conversation. Upon further questioning, the patient admits that he occasionally experiences nighttime episodes of feeling unable to speak or move. The remainder of the history and physical exam are unremarkable. Aside from the occasional ibuprofen for shoulder pain, he does not take any medications.

Narcolepsy

A 23-year-old man presents with a 2-day history of watery nasal discharge, malaise, sneezing, and nasal congestion. On examination, you notice inflammation of the nasal mucosa; pulse is 80/min, BP is 130/84 mm Hg; temperature is 98.8°F. The rest of the examination is normal.

Nasal decongestants and non-pharmacologic remedies

A 7-year-old boy presents to the ED with a 2-hour history of epistaxis. He has a history of several nosebleeds, which usually respond to pinching of the nose, but this episode has continued. The patient is known to pick his nose and has had some cold symptoms recently. He did not experience excessive bleeding at circumcision, and there is no family history of bleeding disorders. On exam, he is alert and responsive to questions. Heart rate 120 bpm; respiratory rate 20/min; blood pressure 105/64 mm Hg; oxygen saturation 97% on room air. There is continuous active bleeding from his left nostril. On examination of the nose, no obvious bleeding site can be visualized in the anterior part of the nasal cavity. He receives phenylephrine and nasal packing after the initial evaluation, and his bleeding finally stops.

Nasopharyngoscopy

A 20-year-old male college student presents with fever, chills, malaise, headache, photophobia, confusion, and numerous petechiae on his extremities and trunk. On examination, he has positive Brudzinski and Kernig's signs. A CT scan of the head is within reference limits. A lumbar puncture reveals increased leukocytes, particularly polymorphonuclear neutrophils, increased protein, and decreased glucose levels. Gram staining of the CSF reveals Gram-negative cocci in pairs.

Neisseria meningitidis

A 4-year-old boy currently hospitalized with pneumonia develops vomiting and stiff neck. The new symptoms are followed by a seizure. On physical examination, he is febrile and has signs of meningeal irritation. A lumbar puncture is done to determine if he has meningitis.

Neisseria meningitidis

A 43-year-old Caucasian man with a 20-year history of bipolar disorder presents for the first time with long-term polyuria and polydipsia. He previously took lithium for mood stabilization for 15 years before initiating divalproex sodium therapy. He stopped using lithium because of the polyuria, but he felt that the polyuria never fully subsided. His weight is stable, and he has no other urinary complaints. His blood pressure is 115/80 mm Hg, and his physical exam is normal. His urinalysis shows no blood, cells, protein, glucose, nitrate, casts, or crystals.

Nephrogenic diabetes insipidus

A 54-year-old man notices that he has very large urine output and he is constantly thirsty. In addition to urinating large volumes during the day, he awakens at night to urinate. He has a 25-year history of a bipolar disorder, which is treated effectively with lithium. His lab results are as follows:

Nephrogenic diabetes insipidus

A physician assistant has just joined a family medicine practice that has been around for more than a decade. This practice consists of a family medicine physician and a nurse practitioner. The physician assistant was asked to review two candidate applications for the position of receptionist. He notices that one candidate has the same last name as the physician. The candidates are both reviewed by the physician. The next morning, the new receptionist reveals that the physician is their cousin.

Nepotism

A 45-year-old woman is constantly thirsty and consumes large amounts of water. She has a history of sarcoidosis. In addition, her urine output is in the range of 7 liters per day; she wakes up several times a night to urinate. Upon administration of aqueous vasopressin, her urine osmolarity rises above the value of her plasma osmolarity.

Neurohypophysis

A 43-year-old woman with non-insulin dependent diabetes presents because the "sore on the bottom of my foot doesn't heal and gets my socks wet." The patient states that the "sore" presented gradually and has slowly worsened. The patient's past medical history is negative with the exception of type 2 diabetes. Physical exam of the right foot shows a 1 cm partial thickness ulcer present on the plantar aspect of the fifth MTPJ. The borders are well defined with white hyperkeratosis and clear serous drainage. There is no pain upon palpation.

Neurotrophic

A 24-month-old boy is brought in by his mother. Although he has been fairly healthy, she is concerned about his speech and language development. The mother says the boy's 4-year-old sister was talking in three- to four-word sentences and asking and answering questions with an extensive vocabulary when she was 2 years old.

No use of two-word phrases

You are evaluating a 17-year-old Caucasian boy on his high school's cycling team. He admits that he has been injecting himself with erythropoietin (EPO)—provided to him by a recent graduate from the team—once every 2 weeks for the past 3 months. While he is convinced that he has achieved the desired increase in endurance needed to win consistently, he is concerned by stories he has heard regarding the side effects of this drug. Past medical history is unremarkable and there is no history of tobacco, alcohol, or recreational drug use. Growth and development have been normal and immunizations are current. Vital signs are normal. The examination is unremarkable.

"Serious medical risks exist in connection with the use of this substance."

A 32-year-old woman presents for a follow-up visit. She was diagnosed with hyperthyroidism 2 weeks earlier, after presenting with tremors, heat intolerance, weight loss, and diarrhea. You prescribed propranolol for her, pending the results of her test during her last visit. She feels slightly better now. She denies any family history of thyroid disorder and has no drug allergies. She has a supportive husband. She does not smoke, drink alcohol, or use illicit drugs. Her physical examination is normal. She has been reading about management of hyperthyroidism; she prefers the 131I treatment.

"Take a pregnancy test prior to starting therapy."

A 21-year-old woman presents with a 3-month history of a black mole on her right calf. She tells you that the lesion is enlarging and expanding. It began to itch about 3 weeks ago, and it has bled 2 times. She thinks that there may have been a mole near the same spot previously, but she is not certain. Her general health is good; there is no history of chronic illness, hospitalizations, or surgeries. She works as a professional model for a large advertisement agency. She does not take any prescription medication; she does not use tobacco, alcohol, or recreational drugs. Although she has dark hair, she has a fair skin, and she says that she usually burns with even short sun exposure. She does occasionally use a tanning booth prior to modeling events and vacations. There is no family history of skin cancer. VS stable, she looks anxious, but she is otherwise well. There is a dark brown-black nodule on the right calf 1 cm in diameter. On the surface of the nodule, there is a tiny area of crusting. There are no hairs. The nodule is asymmetrical, and its border is sharply demarcated; the color is uniform, and the elevation is regular. There is a narrow (1-2 mm) rim of erythema around most of the nodule. She has a sprinkling (about 25-30 in all) of melanocytic nevi on her trunk and legs. There is no significant local or distal lymphadenopathy. The liver is not palpable. The remainder of the physical examination is unremarkable.

Nodular melanoma

A 48-year-old woman presents after a seizure. Before the seizure, she experienced confusion, disorientation, and poor coordination preceded by nausea, dizziness, flushing, and weakness. Symptoms appeared after bird watching several hours in her garden under the sun. Her medical history is significant for the presence of schizophrenia, for which she takes chlorpromazine at bedtime. Her temperature is 41°C, blood pressure 90/59, heart rate 110, respiratory rate 25; BUN, creatinine, and transaminases are elevated, and there is leukocytosis and lactic acidosis. There is normal urine myoglobin, PT, and PTT.

Non-exertional hyperthermia

A 30-year-old woman presents with episodic headache, palpitations, and sweating. She has had multiple episodes of approximately 20 minutes over the last few weeks. Her primary care physician noted hypertension on her last several visits, and her blood pressure today is 210/98 mm Hg. She has no past medical history.

Norepinephrine

A 32-year-old woman presents several hours after a grand mal seizure. Her husband states that she experienced headache, nausea, vomiting, fever, and "was not herself" a few days before the seizure. She is on glucocorticoid therapy due to a kidney transplant 1 year ago. On examination, you find a lethargic febrile (39°C) dysphasic patient; there is right-sided hemiparesis, and meningeal signs are present, but detailed examination cannot be performed because of lack of cooperation. EEG shows focal abnormalities over temporal lobes, and her CT is normal. A lumbar puncture is performed. Based on your suspected diagnosis, you initiate supportive care, anticonvulsants, and acyclovir. The patient improves over the following days.

Normal CSF: serum glucose ratio

An 82-year-old woman presents with her anxious daughter who lives with her. The daughter has noticed recent "lapses in memory" and feels that her mother has become forgetful lately. Her lapses in memory usually relate to people's names and recollection of past events and recent conversations. According to her, she is otherwise healthy; she takes calcium and vitamin D for osteoporosis, aspirin for her heart, and vitamin B complex. She has no history of trauma, strokes, or CNS infections. Her lapses in memory mostly affect short-term memory. She is able to carry out activities of daily living and is well oriented to time, place, and person. Her husband passed away 18 months ago, and she sometimes finds it difficult to sleep when she remembers his death. She feels "lonely" and "desperate" at times. Her BP is 130/80 mm Hg, and other vitals are normal. Neurological, cardiac, respiratory, and abdominal exam are normal. Her MMSE score is 28/30.

Normal aging

A 49-year-old woman presents for a consultation 1 month after her 22-year-old son was killed in a fall at a construction site near her home. The patient is upset, restless, and reports feeling lonely. She lies awake at night. She does not feel like eating. She cries easily when she looks at their family pictures around the house. She wishes she could talk to him again, and she reports she sometimes thinks she sees him walking just outside their home. She says she wishes she would have died instead of him, but she denies any thoughts or plan of harming herself.

Normal grief reaction

A 19-year-old woman presents with worsening headaches. She reports a multi-year history of episodic throbbing headaches. They have intensified, and she now misses classes and work periodically as a result. The headaches occur about 4-6 times per month recently, up from 1-2 per month when she first started experiencing them. Her headaches last 2-3 days and are accompanied by nausea, vomiting, and light sensitivity. After the headache resolves, she denies any residual symptoms. She denies neurologic symptoms, such as vision or taste changes, gait disturbances, and memory loss. She has tried multiple over-the-counter pain medications without relief. Her mother and maternal aunt experienced similar headaches. She reports some increased stressors and less sleep since recently starting college. Her past medical history is unremarkable, with no known medical conditions (except for the headaches), no surgeries, no chronic medications, and no drug allergies. She has never been sexually active and reports regular menses. She denies the use of tobacco, alcohol, and recreational drugs. On physical exam, the patient appears comfortable and reports no headache at this time. Her entire exam, including neurological, is normal.

Normal magnetic resonance imaging (MRI)

A 70-year-old woman is brought to your attention because of a slowly progressive gait disorder. She has also been experiencing forgetfulness and problems with micturition. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter. She occasionally forgets where she put things and she has forgotten to turn off the oven on 2 occasions. Over the last month, she has started experiencing urinary urgency, the need for frequent urination, and the involuntary leaking of urine. She is worried about these symptoms.

Normal pressure hydrocephalus

A 10-year-old boy presents due to a lesion on his gums. For the past 2 days, he has reported soreness around his teeth and inside his cheeks. When his mother looked closely in his mouth with a flashlight, she noted bright red areas and patches of white curd-like lesions. There are no ill contacts in the last few weeks. There has been no fever or shortness of breath. The patient's past medical history is positive for severe seasonal allergies and mild persistent asthma. Daily medications include: pediatric multivitamin, cetirizine hydrochloride 10 mg 1 tablet at bedtime, montelukast sodium 5 mg 1 chewable tablet in the morning, beclomethasone disproportionate HFA 40 mcg 2 puffs twice daily in the am and pm, and albuterol sulfate inhalation powder 2 inhalations every 4-6 hours as needed for wheezing and 15 minutes before physical activity. Examination reveals adherent thick white plaques with underlying erythematous tender mucosa on the gingival and buccal surfaces.

Nystatin suspension Beclomethasone dipropionate

A 4-year-old Caucasian boy is seen in the outpatient clinic with a 3-week history of generalized rash. Pruritus was minimal; it has resolved, and he has not had a fever. The mother noted that the rash began as a single lesion on the abdomen that grew in size as the rash progressed elsewhere. It is now the largest lesion present. Examination revealed an otherwise well and afebrile child with a generalized rash consisting of scaly reddish-pink plaques concentrated on the trunk in a Christmas tree pattern with the single largest lesion at the abdomen.

Observation

A 9-month-old female infant presents with an acute onset of a rash on her trunk. She has a 4-day history of fever up to 104°F, but the mother states her daughter has no fever today. She has had some diarrheal stools, but no vomiting. No coughing or nasal congestion has been noted. The child has previously been well. Her past medical history is unremarkable, and she is up to date on her immunizations. She attends daycare, and her mother notes that some children have been ill with non-specific febrile illnesses over the past 2 weeks. Her only medication has been ibuprofen for the fever. Physical exam shows a temperature of 98.8°F, pulse of 124 bpm, and respiratory rate of 28/min. She is alert and shows no other abnormalities. Her exam shows normal tympanic membranes in the ear and normal conjunctivae in the eye. The neck shows some shotty anterior cervical adenopathy; a normal appearing pharynx, and the skin appears with an erythematous maculopapular rash most pronounced on the trunk. Her chest is clear to auscultation, heart rhythm is regular without murmurs, abdomen is soft and non-tender, and her neurological exam is normal.

Observe the child and reassure the parent.

A 73-year-old man presents with a nosebleed that will not stop. The bleeding has been present for over 2 hours. The patient's nose began dripping blood at breakfast; there was no known trauma. He denies pain. He has tried applying nasal pressure and lying down to rest. Until the bleeding began, the patient had not been experiencing any nasal symptoms, such as congestion, impaired nasal patency, or rhinitis. Because he felt too dizzy to drive, his wife drove him to the emergency department. The patient has no diagnosed medical conditions and takes no medications. He denies prior episodes of severe nosebleeds, easy bruising, and any known bleeding disorder. The patient's vitals are shown in the table.

Obtain IV access and begin normal saline infusion. Blood type and Rh

A 7-week-old boy presents with a 12-hour history of lethargy. Physical exam reveals a child who cries and becomes irritable when examined. There is edema noted on the left side of the head. There is no papilledema, and his mother denies a history of the child vomiting. There is a single faint bruise on the upper lip. A CT of the head reveals a linear skull fracture of the left parietal bone; there is no evidence of intracranial injury. On further questioning, the mother states, "My baby rolled over from the sofa onto a carpeted floor 2 days ago."

Obtain skeletal survey to rule out child abuse.

A 73-year-old male presents reporting that his toenails are thick, hard to cut, discolored, and dystrophic. A KOH culture confirmed a fungal infection. What is the most likely diagnosis?

Onychomycosis

A man has had 4 diagnosed sinus infections in the last 5 months, so you order a CT scan of his sinuses. He does not believe that any of the episodes completely resolved. The patient has a long history of excessive seasonal allergies; he treats them with daily oral OTC anti-histamines and he has repeatedly declined beginning allergy immunotherapy. He also has a history of asthma that is well controlled with daily inhaled corticosteroids.

Opacification

A 14-year-old boy presents for a sports physical. History is significant for a high degree of myopia bilaterally first diagnosed at age 4 and a dislocated shoulder at age 10 that was easily reduced. Family history is significant for several unidentified ancestors having died in their 40s of an unidentified cardiovascular disorder. Physical examination reveals normal vital signs, height of 6'1", and weight 145 lb. The upper to lower segment ratio is 0.65 (decreased). Arm span is 76". The palate is highly arched. Mild pectus excavatum was present. A 2/6 early diastolic murmur is present best heard at the second intercostal space at the right sternal border. Arachnodactyly of the fingers and toes and generalized loose jointedness and pes planus are also present. Echocardiography reveals a tricuspid aortic valve with grade 1 (out of 4) aortic regurgitation with a normal aortic root diameter.

Ophthalmology evaluation

A mother brings her 5-year-old boy to the pediatrician due to multiple blisters on his cheek and nose. Physical examination is remarkable for numerous vesicles and crusted lesions containing light yellow fluid on both cheeks and around the nose. The child has similar lesions on his right wrist.

Oral dicloxacillin

A 15-year-old boy presents for follow-up for acne vulgaris. He has been using benzoyl peroxide and retinoic acid for the past 4 months. He returns for a re-evaluation, as his acne appears to have worsened. He states his diet has not changed significantly, and his past medical history is unremarkable. His mother had significant acne as an adolescent. Physical examination reveals large papules and pustules on the forehead, cheeks, chin, and upper back. No nodulocystic cystic lesions are noted.

Oral doxycycline

A 2-year-old boy is brought to your office by his mother after she noticed that he often scratches his head. She also notes patchy loss of hair on the top of his head. She has been sending him to a daycare center for the past 2 months. On examination, you note patchy loss of hair in the right parietal area and another area of "black dot" alopecia about 4 cm lateral to it. The area of hair loss shows a grayish ring-shaped scaly lesion. A KOH preparation demonstrates branching hyphae and spores.

Oral griseofulvin

A 42-year-old man presents for evaluation of a growth on his tongue. He thinks that the lesion has been present for a few months, and it has not changed, but he generally prefers to avoid healthcare, and he has not been concerned. He is only here at the urging of his family member. The patient denies oral symptoms and changes in taste sensation; he states that he generally feels fine. The patient denies the use of chewing tobacco and cigarettes. On physical exam, there is a white patch of tissue that does not scrape off; there is a "shaggy" appearance on the left lateral tongue. No erythema is noted. No other lesions are identified. The remainder of his exam is normal. A biopsy of the lesion is obtained. The pathology shows hyperkeratosis, "balloon" cells in the upper cell layer, and Epstein-Barr virus (EBV) in the basal epithelial cells.

Oral hairy leukoplakia

An 82-year-old man presents for evaluation of an itchy hive-like rash on his abdomen. He has had it for months. Over the last few days, the patient reports the character of the rash has changed; it now resembles blisters. Other than some skin irritation, he feels healthy. He has tried multiple over-the-counter topical treatments, but they have been unsuccessful in treating the rash. He denies any changes in soaps, lotions, laundry detergents, or anything else that may have come in contact with his skin. He also denies unusual travel, pets, or hobbies. No close contacts have reported a similar condition. He takes no medications, and he does not have any chronic illnesses. On physical exam, multiple clusters of bullae are noted across the trunk bilaterally, with some distribution on both anterior and posterior surfaces. There are still some remaining pink-red lesions; they are scattered among the bullae. The bullae are 1-3 cm in size; they are tense and do not easily rupture. They do not extend into normal skin with pressure. Pressure on the normal skin does not produce a blister. The remainder of his physical exam is normal.

Oral prednisone

An 18-year-old man presents with multiple painful vesicles on an erythematous base on the right side of his lower lip. He experienced similar symptoms a month ago with an associated sore throat. He has an oral temperature of 101°F and positive tender cervical lymphadenopathy.

Oral valacyclovir

A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable.

Order an outpatient MRI of the brain.

A 67-year-old woman presents; according to her, her husband says she never listens to anything he says. The patient states that occasionally she has to ask people to repeat themselves when sitting to her right. She denies any dizziness, headaches, or visual disturbances. Her current medication is furosemide. On physical examination, the Weber test reveals lateralization to the left ear. On the left ear, air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. On the right ear, air conduction lasted for 22 seconds and bone conduction lasted 10 seconds.

Ototoxicity

A newly graduated physician assistant is working in a vascular surgery practice. The PA is replacing a practitioner with 10 years of experience. The collaborating physician asks the PA to place a central line. The PA has done this once before, but the doctor states their previous PA did it all the time. The PA is uncomfortable doing this procedure.

PA's experience

A physician assistant is working in an emergency department. Their supervising physician requests a prescription for a sleeping pill because due to difficulty adjusting to shift work; the supervising physician has not been able to see their primary care provider.

PAs cannot prescribe medication to anyone who is not their patient.

A 28-year-old woman with a past medical history of well-controlled asthma presents with recurrent sneezing episodes, nasal itching, congestion, and headache. Her physical exam reveals post-nasal drip, a transverse nasal crease, and bilateral infraorbital cyanosis.

Pale bluish nasal mucosa upon speculum examination

A 22-year-old woman presents with a 2-month history of weight loss despite the woman having a good appetite. She also reports of having frequent bouts of diarrhea. On detailed questioning, she reveals a feeling of heat intolerance and menstrual irregularity. The right lobe of the thyroid is palpably enlarged, and further investigations confirm the suspected diagnosis.

Palpitations and tremors

A 23-year-old woman presents due to palpitations, numbness, shortness of breath, and sweating. She reports that these episodes have been occurring once or twice a week for the past several months and that she cannot discern any consistent pattern or trigger. Although the symptoms occur seemingly at random and independent of social situations, she reports that she has begun to limit her social activities for fear of having an episode while she is away from home. Physical exam and laboratory findings are within normal limits.

Panic disorder

A 43-year-old woman is found to have a palpable thyroid nodule that is 1.5 cm in size and located in the right lobe without regional lymphadenopathy. Upon questioning, the patient denies noticing this or any increase in the size of her thyroid. She denies hoarseness, a personal or family history of thyroid disease, and thyroid cancer.

Papillary

A 30-year-old man presents with a solitary firm thyroid nodule found on routine physical exam. He denies any heat or cold intolerance, palpitations, weight loss or gain, hoarseness, dysphagia, sore throat, or neck discomfort. The patient denies knowledge of previous head or neck irradiation. There is no cervical lymphadenopathy on examination. The remainder of HEENT exam is normal. TSH, thyroxine, thyroglobulin, and thyroid antibody levels are all within normal limits. Thyroid scanning with radioactive iodine reveals a 2 cm cold nodule in left lobe of the thyroid. Patient was sent for fine needle aspiration of the nodule.

Papillary carcinoma

A 6-year-old boy presents with a 2-day history of fever followed by cough, coryza, and conjunctivitis. He has also developed a rash that started behind the ear and is starting to spread downwards towards the trunk. On examination, you notice erythematous maculopapular blanching rash with coalescence in some areas. The palm and soles are spared. On oral examination, you notice 1-3 mm bluish lesions surrounded by an erythematous base. He is not up to date with his immunizations.

Paramyxovirus

A 25-year-old woman has a 2-month history of "episodes" that occur more than 3 times a week. She describes the episodes as a pounding heartbeat, breaking out in a sweat, and difficulty catching her breath. Occasionally, she will feel dizzy and faint with a "tingling" sensation throughout her body.

Paroxetine

A 39-year-old woman presents with a history of repeated short episodes of intensely anxious and fearful moments with physiologic manifestations, such as trembling, tachycardia, dizziness, sweating, and a smothering sensation. She has these episodes almost daily and feels they greatly impact her life when they occur. She denies symptoms of agitation, insomnia, and depression, and she states she does not have a history of recreational drug use. After an extensive workup, a diagnosis is made.

Paroxetine

You are a triage officer for your local jurisdiction's mass casualty response team. Your team has been activated to respond following a tornado with significant infrastructure damage and multiple injured. The nearest hospital is a small community hospital with limited medical resources 30 minutes away by ground ambulance. You are asked to evaluate the following patients: 17-year-old girl with 10 cm laceration on medial thigh; significant blood pooling is noticed on the ground around patient—alert and answers questions with some delay 27-year-old man with chest pain without visible injury or disability—alert and speaking on phone with family 34-year-old woman with leg pain and a visible large glass shard imbedded in lateral right thigh—alert and answering questions appropriately 45-year-old man with abdominal pain and visible wide spread ecchymosis on abdomen and pelvis—arousable to voice but answering questions inappropriately 75-year-old man on a stretcher with blood-stroked bandages wrapped around head—unarousable to stimulation

Patient D

A 54-year-old woman with history of type 2 diabetes mellitus presents with a new foot ulcer. She has minimal pain at the site. She noticed a small fissure on the ball of her foot about 2 weeks ago, and she discovered yesterday that the lesion had become larger and was draining purulent-smelling material. Her foot has also become swollen and red. She has been on hypoglycemic medication for the last 5 years; recently, her metformin dose was increased to 850 mg twice daily; it is combined with glipizide 10 mg twice daily. She is also on benazepril 10 mg daily for mild hypertension and microscopic proteinuria discovered at her annual physical earlier this year. Physical exam reveals a temperature of 99.1°F, pulse 72/min, and respirations 20/min; blood pressure is 123/84 mm Hg. The plantar surface of the right foot has a 2 cm shallow ulcer with a film of purulent, serous drainage. There is a 1 cm surrounding band of erythema around the ulcer margin, and her foot has 2 + edema. She has greatly decreased pinprick sensation in both feet, and she cannot feel vibration. Dorsalis pedis pulses are 4/5 bilaterally. Laboratory evaluation reveals a WBC count of 17.7 X 103/ìL, with 93% neutrophils. Her HbA1c is 8.8%, and glucose is 241 mg/dL.

Patient education and risk factor prevention

A 10-year-old girl presents with her mother and reports "really bad dandruff that itches like crazy." The child states that all of her friends at school have it too. Upon physical examination of the hair and scalp, you note numerous oval grayish-white sesame seed capsules 1-2 mm in size deposited on the hair shaft near the scalp. Small red bumps and sores on the scalp appear to be due to the patient scratching.

Pediculosis

An 18-year-old college student presents with a bright red rash on her left cheek area that has worsened since yesterday when it first appeared. It is now becoming more tender and she developed a temperature elevation of 100.2°F taken at home. She denies any new soaps or facial creams and wears occasional make-up. She denies any ill contacts. Vital signs are blood pressure of 110/72 mmHg, heart rate 86 bpm regular, respirations 18/min, and temperature of 100.4 °F. Your most likely diagnosis is erysipelas. She denies any medication allergies.

Penicillin VK 250 mg 4 times daily for 7 days

One of your patients, a sexually active gay man, asks you about pre-exposure prophylaxis for HIV (PrEP). He has been reading information regarding this prevention strategy online. One document he found on the CDC website references a study where participants were given PrEP. Study participants who were given PrEP medication were 44% less likely to get HIV, but it also mentions participants who took PrEP as directed reduced the risk of HIV up to 92%. He asks for your help in interpreting this study.

Per protocol

A 12-year-old Caucasian girl presents with a sore throat. The onset of symptoms was about 24 hours ago. The patient experiences pain in her throat, especially with talking or swallowing. She is fatigued because throat pain prevented her from sleeping last night. Throat lozenges have not been helpful. Several classmates have been out sick recently. She denies nasal congestion, rhinorrhea, and cough and is unsure of fevers. This patient has no chronic medical conditions, takes no medications, and has no known drug allergies. On physical exam, she appears slightly ill and fatigued. HEENT exam is positive for bilateral cervical lymphadenopathy and inflamed posterior oropharynx without exudate. She does have normal range of motion of the neck without eliciting pain. Her heart, lung, and abdominal exams are normal. No other lymph nodes are palpable. Weight 92 lb, height 4'8", pulse 95, BP 102/60, temperature 99.2°F/37.3°C.

Perform rapid antigen testing for group A streptococcus.

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8°F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids and he has excruciatingly severe pain with swallowing. You recognize the muffled "hot potato" voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling.

Peritonsillar abscess

A mother has brought her 9-year-old daughter to you because the child has been suffering from a 1-week history of intense itching on her scalp since she returned from a summer camp with a group of other children. Physical examination shows a number of nits attached to the hair shafts and a few full-grown lice on the scalp. Due to scratching, there are raw excoriated areas on the scalp with a few areas of pyoderma. Occipital group of lymph nodes are enlarged.

Permethrin 1% topical

A 3-year-old boy who weighs 14 kg presents with a 2-week history of severe itching all over the body that is more severe at night. Physical examination reveals gray thread-like serpentine lines with papules at the ends. There is a generalized papular and papulovesicular rash with few pustules. The lesions are more confluent between the webs of the fingers and toes and on the flexor surface of the wrists, axilla, genitalia, feet, and buttocks. Scrapings from the skin show an arthropod with four pairs of legs, hemispheric body, and brown spines and bristles on the dorsal surface.

Permethrin 5% cream

A 4-year-old boy presents with a rash on his feet, ankles, wrists, and gluteal areas; the rash is accompanied by severe itching, particularly at night. His 6-month-old sister has a similar rash on her neck and head. On examination, you find pruritic erythematous papular and papulopustular skin changes between the web spaces of the fingers; changes are also seen on the flexor aspects of the wrists and in the genital and gluteal areas. On superficial epidermis, you find several short elevated red tortuous lines; they have a small vesicle at the tip.

Permethrin cream

A 36-year-old woman presents because she has been feeling very tired and unhappy for the past 3 years; she thinks that she has no hope of better days in the future. She states that it is amazing her boss has not fired her yet because she is one of the company's worst employees. She cannot recall the last time she was excited about anything. She denies other symptoms. Her vital signs are stable. Her height and weight are within normal limits.

Persistent depressive disorder

A mother brings in her 6-year-old daughter because the girl's teacher is concerned about behaviors at school. The teacher has noticed the girl "staring off into space" frequently throughout the day; the teacher is able to get the girl's attention only occasionally. There are also periods when she appears to be talking to herself, but there is no sound coming from her mouth. The mother states that there are times when her daughter does not seem to be paying attention to what the mother is saying. Shortly after these episodes, the child engages in conversation without any problem, so the mother did not think the episodes were an issue. There is no concern about other abnormal behavior or discipline issues at home or at school.

Petit mal (absence) seizures

A 12-year-old girl presents with a 1-week history of a rash on her trunk. The patient has not been ill or exposed to anyone ill. On examination, there are scattered lesions on her trunk; they look like they form a Christmas tree. The girl states that the lesions are itchy at times, but they are generally not bothersome.

Pityriasis rosea

A 17-year-old girl presents with a rash. She states she noted a single oval patch several days before a more generalized rash erupted. She indicates that the rash mildly itches. On physical examination, the initial lesion appears as an erythematous (salmon-colored) plaque with a collarette on the trailing edge of the advancing border. You note a fawn-colored rash that follows the cleavage lines on the posterior trunk. This rash is most prevalent on the trunk, and the proximal upper and lower extremities.

Pityriasis rosea

A 25-year-old woman is admitted to the hospital with a 3-week history of headaches accompanied by palpitations and sweating. The episodes occur several times daily and last for 15 minutes. Heart rate is 125 beats/min and blood pressure is 220/100 mm Hg. Physical examination is remarkable for diaphoresis.

Plasma fractionated metanephrine

You are reviewing incoming test reports while your supervising physician (SP) is out of town. There are two reports for a 46-year-old man shown in the table.

Polyuria and polydipsia

A 25-year-old healthy male newly employed PA reports to the occupational health clinic for required testing. Based on his immunization history, it is recommended that he receive the full hepatitis B vaccine (Recombivax HB).

0, 1 month, 6 months

A 6-month-old infant is brought in for routine vaccination. The mother saw information about a measles outbreak online. There is no known measles outbreak in the state. The mother is asking for more information about this vaccine. She would like her child to receive it now.

12-15 months, 4-6 years

A 7-year-old boy presents to the emergency department with new-onset rash, fever, and coryza. It is determined that the patient has not received vaccinations since birth. To reduce the risk of transmission, he is placed in a negative pressure isolation room. The patient will be discharged home to remain under isolation for the next 4 days.

2 hours

A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of her evaluation, a tuberculin skin test (TST) is performed using 5 TU of purified protein derivative (PPD). The test site is examined 48 hours later and the skin reaction is measured.

5 mm

A 45-year-old Caucasian woman presents because she is worried she may have skin cancer. While interviewing the patient, you note the patient has an extremely fair complexion. When you examine the lesions that the patient is concerned about, you note the following description in your documentation: "5 papules that vary in diameter from 0.3-0.6 centimeters dispersed on the skin around the sternal angle. Lesions vary in color from flesh-toned to slightly hyperpigmented, and when palpated have a sandpaper texture."

5-fluorouracil cream

A 48-year-old obese woman presents to the emergency department with right upper quadrant pain. She also has nausea and right shoulder pain. She recently started a high-fat, low-carb diet. Her temperature is 100.2°F, pulse is 87 beats/min, and blood pressure is 129/84 mm Hg. Physical examination is remarkable for an ill-appearing female with right upper quadrant epigastric tenderness and a positive Murphy sign.

Abdominal ultrasound

A 28-year-old man presents with diplopia and the inability to move the right eye outwards. He was hit by a ball on the right side of his face while playing volleyball 2 hours ago. His symptoms are non-progressive. On examination, his visual acuity is normal in both eyes. Right eye is medially deviated and cannot be moved laterally; otherwise, there is no abnormality detected.

Abducens

A 42-year-old woman presents with a 1-month history of severe worsening pain in her right foot, ankle, and lower leg. The pain is constant and burning. She reports some initial swelling and warmth in the leg, which has lessened. Now, her right lower extremity is always cool to the touch. Hair growth has dramatically decreased on her right leg. She has tried multiple over-the-counter pain medications and topical analgesics with no relief. She denies trauma to the affected limb and reports her symptoms just "came out of the blue." Her sleep is poor, and she reports fatigue secondary to unrelenting pain, but she denies any other symptoms.

Abnormal autonomic nervous system activity

A 17-year-old male football player is being evaluated for fatigue and a sore throat. He denies coughing or fevers. He does not smoke or drink. In addition, he denies blood in his stool or urine and any dysuric symptoms. He practices safe sexual intercourse with his girlfriend. Physical exam demonstrates a blood pressure of 130/65 mm Hg, a pulse of 72/minute, respirations of 16/minute, and a temperature of 98°F (36.6°C). Lung and heart sounds are normal. There is no cervical adenopathy. When you look at the pharynx, there is tonsillar enlargement with evidence of exudates. The abdominal exam demonstrates a spleen tip that is easily palpable 1.5 cm below the left costal margin. Results of a Monospot test are positive.

Acetaminophen or NSAIDs

A 15-year-old boy is being treated at the dermatologist for lesions on his cheeks, forehead, chin, upper chest, and upper back with a history that has been progressively getting worse. Upon physical exam, open and closed comedones are present on the patient. Additionally, inflamed papules and some scarring are present. All labs are within normal limits.

Acne vulgaris

A 16-year-old boy presents to his primary care physician with skin lesions. The lesions are scattered over his forehead, nose, and chin. He denies facial flushing and pruritus. The following presentation is seen on examination.

Acne vulgaris

A 30-year-old man presents with excessive thirst for the past few days. He consumes 3-4 liters of water per day but is still thirsty. He has also been passing urine very frequently. He gives a history of a road traffic accident 1 month ago where he hit his head against the dashboard. Urine specific gravity and osmolality are 1.002 and 180 mOsm/kg, respectively. There is an increase in urine osmolality with exogenous antidiuretic hormone (ADH) administration.

Acquired central diabetes insipidus

A 65-year-old man is being treated at the dermatologist for a lesion on his face for the past 5 weeks that will not go away. Additionally, the patient has a history of staying out in the sun, as he lives in Florida. Upon physical exam, a 0.6 cm macule that appears flesh-colored and slightly hyperpigmented is present on his right cheek. Upon palpation, the macule feels like sandpaper and is tender to the patient. All labs are within normal limits.

Actinic keratoses

A 45-year-old woman presents with a skin lesion. She states she noticed a lesion on her cheek for the past few weeks and it will not go away. She has a history of laying out in the sun at her home in Florida since she was a teenager. Upon physical exam, the patient has a wart that appears to be elevated and pink with a sandpaper texture.

Actinic keratosis

A 40-year-old man presents with severe pain in his left eye, decreased vision, nausea, and abdominal pain. He denies recent trauma. He wears glasses for myopia. On examination, the patient's left pupil is moderately dilated and nonreactive. The cornea is "steamy" in appearance and the eye is red in general.

Acute angle-closure glaucoma

A 10-year-old boy presents with a 1-week history of progressing joint pain. The pain started in his ankles, and then progressed to his knees; his hips are now starting to hurt. His ankles feel slightly better. He had contact with someone who had strep throat within the past couple of weeks. The patient's heart rate is 130. On exam, there is erythema and edema over the knees and hips as well as minimal edema over the ankles. A high-pitched holosystolic murmur is noted over the apex and radiates to the axilla with a noted friction rub.

Acute rheumatic fever

A 5-year-old Latino boy with acute lymphoblastic leukemia presents with fever and rash. He is currently on induction chemotherapy that includes dexamethasone. He was exposed to a friend with varicella 2 weeks ago; he has never had the varicella vaccination and his mother cannot recall that he ever had a varicella infection. Blood tests prior to initiation of chemotherapy showed the absence of antibody to the varicella virus. He now has 10 small vesicles and several red macules on his face and chest. Temperature is 38.5°C. Exam is otherwise normal.

Acyclovir 500 mg/m2 IV every 8 hours

A 20-year-old man has had a 1-month duration second-line acne therapy; he now presents with skin that looks worse and has more inflammation and cystic development. This patient has now progressed to severe acne.

Add oral isotretinoin after stopping medication for 2 weeks.

A 31-year-old woman presents due to being "really tired." In addition to this extreme fatigue for the last several months, you note the patient has had unintentional weight loss of 20 lb, decreased appetite, salt cravings, nausea and mild vomiting, irritability, and loss of sexual interest. Physical examination reveals a hypotensive female patient who appears her stated age but fatigued. She has multiple areas of hyperpigmented skin located in her bilateral palmar creases, both axillary regions, and areas in the oral mucosa. She has noted thinning of body hair throughout.

Addison's disease

A 65-year-old man presents to his general surgeon's office with recurrent abdominal pain. He recently had an exploratory laparotomy 7 days ago. On exam, he is afebrile. Blood pressure is 136/78 mm Hg, heart rate of 80 bpm and regular, BMI of 45. He has a large incision in the abdomen with evidence of early dehiscence at the proximal incisional site with clear drainage noted.

Adipose tissue

A 3-day-old female newborn presents at your outpatient clinic with rapidly progressing bilateral conjunctivitis with white discharge. She was born full-term via precipitous vaginal delivery; her mother had no prenatal care. On exam, she is alert and active. The eye discharge is purulent and she has bilateral eyelid edema.

Admit to the hospital for IV antibiotics and evaluation.

A 25-year-old sexually active woman presents with a 2-day history of pain and swelling of her dorsal right wrist and fingers. For the past week, the pain and swelling have been in different joints of her body, including her left knee, left elbow, and right ankle. On exam, you note edema, effusion, and erythema over the dorsal right wrist with the wrist held in 15° of extension. It is very tender on palpation and has virtually no range of motion secondary to the pain. You aspirate synovial fluid for lab studies. The lab studies reveal the following information: Synovial fluid: WBCs - 57,000 cells/mcL Gram stain: too numerous to count WBCs with no bacteria seen Culture: pending

Admit to the hospital for IV ceftriaxone.

An obese 45-year-old woman is requesting medical weight loss therapy. She reports excessive weight gain of (37 kg) over the past 3 years. A detailed history also reveals easy bruising, oligomenorrhea, and increased hair growth on various parts of her body. A thorough examination shows hypertension (BP 180/110), truncal obesity with a buffalo hump, and moon face, along with hirsutism and pigmentation, with purple abdominal and lower leg striae. Lab reports confirm the most likely diagnosis.

Adrenocorticotropic hormone

A 32-year-old Gravida 4, Para 4, Ab 0 woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications. Vitals: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. The patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The next morning, the patient is found to be alert, oriented, and afebrile.

Albendazole with IV prednisolone

A 4-year-old boy has had intermittent rhinorrhea, nasal congestion, and cough for about 3 weeks. His mother says he had felt warm at night when his symptoms started, and he sneezes occasionally. He goes to a large daycare 4 days a week. Otherwise, he has been healthy except for an occasional dry itchy rash that he has had on and off for "a long time." Mom has been treating this with OTC moisturizers. On exam, his temperature is 98.4°F, respirations 24, pulse 86 beats/min. He appears somewhat tired, with dark circles under his eyes. There is slightly cloudy nasal drainage, turbinates seem a little boggy, lungs are clear, ears and throat are normal and his neck is supple without any lymphadenopathy. His skin exam reveals a fine roughened slightly hyperpigmented maculopapular rash in elbow creases with a few healing excoriations.

Allergic rhinitis

An 8-year-old girl presents with her mother to the pediatrician's office with persistent clear nasal drainage and nighttime cough for the past month. Her physical examination reveals clear rhinorrhea, dark circles under her eyes, and a transverse nasal crease.

Allergic rhinitis

A 19-year-old man presents with hair loss described as localized oval patches for the past month. Upon examination, the patches are sharply demarcated without tenderness, erythema, or scaling noted.

Alopecia areata

An 8-year-old girl presents with a 3-month history of hair loss. Except for usual minor childhood illnesses such as colds and ear infections, she has been in good health since birth. 3 months ago, her mother noted small bald areas developing on the girl's scalp when she brushed her hair. The child denies any pain or itching of the scalp, and she denies pulling at her hair. There have been no other symptoms. She has not taken any medications, and she has no known allergies. On exam, you find three round smooth silver dollar-sized areas of complete hair loss. The scalp is normal.

Alopecia areata

A 52-year-old woman recently diagnosed with acute myelocytic leukemia presents to her oncologist's office to discuss chemotherapy. She is hesitant to start chemotherapy, as she had an aunt pass away while undergoing chemotherapy for breast cancer. She is seen by the oncology physician assistant, who knows the patient well. Chemotherapy is discussed in detail.

Alternatives to chemotherapy

A 16-year-old previously healthy boy fell on a cemented surface while skateboarding 3 weeks ago. He lost consciousness for 2 minutes. He was not wearing a helmet. A CT scan showed no abnormalities. He is now back at school and has difficulty concentrating in class and has frequent spells of dizziness and headaches. His neurologic exam is normal.

Postconcussive syndrome

A 22-year-old postpartum woman presents with a loss of interest in eating, increased sleepiness, and fatigue at her first-week checkup. It was her first pregnancy. She has been happily married for 2 years; she has a stable job and good family support. Out of her hearing range, her husband reports that she seems more irritable, snapping at him for trivial things. She broke down sobbing when asked about her parents, who passed away in a car accident 1 year earlier.

Postpartum blues

A 27-year-old woman is brought to the ER by her husband because of bizarre behavior 4 days after the uncomplicated delivery of a full-term healthy boy. Her personal and family history of mental illness is negative. The second day after delivery, she accused her husband of poisoning her food. She has problems falling asleep, generally sleeping only 2-3 hours nightly and complaining of unpleasant smells waking her up. She started arranging toys and the newborn's things in a specific symmetrical order and became aggressive when someone moved them. She would stop the ongoing activity from time to time with a blank expression and was found several times staring at the wall and silently counting. Even simple tasks require the help of others, and she often forgets what she started doing. This makes her irritable and sometimes tearful. She feels guilty about being a terrible mother and states that she did not deserve to have a baby. The morning when her husband asked for your advice, she told him that she hears voices telling her to take her son and jump out the window.

Postpartum psychosis

A 22-year-old woman has a history of being involved in a bank robbery 8 months ago. Since then she noticed she has been having loss of memory, flashbacks, disruptive sleep and nightmares recalling the event, irritable moods, and difficulty concentrating. She denies any palpitations, tachycardia, or any chest pain. She denies any repetitive behaviors or feeling uncomfortable in social settings. She also denies any need for order or symmetry, unwanted intrusive thoughts, or scrupulosity. The patient does not mention any concerns about excessive worrying. Upon physical exam, the patient appears disheveled, with poor hygiene and flattened affect. She does not present with any hair loss or baldness. Upon lab results, everything is within normal limits.

Posttraumatic stress disorder

An 18-year-old woman presents with nausea, vomiting, drowsiness, and abdominal pain. She has Kussmaul respirations, ketotic breath, dry tongue, and loss of skin turgor. Her laboratory studies show the following results:

Potassium

A 21-year-old man presents with itchy skin changes. He works as a lifeguard. About a week ago, he noticed a round red patch on his belly that spread to his trunk and legs. He denies recent infections, allergies, and illnesses; he does not take any medications, and he admits that he occasionally smokes marijuana. The rest of his personal and family history is non-contributory. On examination, you find round annular scaly pruritic papulosquamous changes on his torso and legs. There are no changes on his mucosa, and the rest of physical examination is within normal limits.

Potassium hydroxide preparation

The 26-year-old HIV-positive man has a CD4 count <200. While he was in the hospital for the treatment of his miliary Tb, he developed smooth skin-colored umbilicated papules on his face. The lesions are asymptomatic, but they are spreading gradually to other parts of the body and causing cosmetic problems to the patient.

Poxvirus

A 16-year-old girl has moderate facial acne vulgaris that you plan to treat with topical retinoids.

Pregnancy

A 16-year-old girl presents with a history of severe nodulocystic acne. She has used topical benzoyl peroxide and topical tretinoin and has undergone numerous courses of oral tetracycline. The acne has not responded to any treatment. You decide to change her treatment plan and prescribe the appropriate next step in management to treat her condition.

Pregnancy test

A 19-year-old woman presents with a painful sore in her mouth that has been present for 3 days. She denies oral trauma. She describes a single painful lesion that feels like a bump between her cheek and gum line. She has not tried any treatments at home. She denies history of similar lesions. She has otherwise been feeling well and denies recent flu-like symptoms. Her past medical history is unremarkable, with no known medical conditions or history of surgery; she takes no medications and has no allergies. She lives in an apartment with her boyfriend; she works at a convenience store; and she denies the use of alcohol, tobacco (including chewing tobacco), and recreational drugs. On physical exam, her vitals are normal. A single tender lesion is identified on the buccal mucosa, just across from the lower right jaw. It is a small shallow ulcer approximately 3 mm diameter with a yellow-gray center surrounded by a red halo. The remainder of her exam is normal.

Prescribe topical corticosteroids.

A 75-year-old man with a history of dementia and chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. His condition deteriorates during his hospitalization, and he is now in respiratory failure and intubated. He has failed multiple attempts to wean off ventilatory support, and his prognosis is prolonged intubation and ventilation. Due to his history of COPD, dementia, and acute respiratory failure, there is concern about cognitive decline. His wife presents an advanced directive executed 7 years ago that states he does not want prolonged intubation and ventilation. His wife is uncomfortable giving consent to take him off of the ventilator despite her husband's advanced directive.

Present the case to the hospital ethics committee.

An 89-year-old man presents with pneumonia. You suspect lung cancer, which would require surgery and possibly chemotherapy. Upon hearing the news regarding his diagnosis, the patient becomes tearful and sad; he confides his thoughts of suicide. You notice the patient seems confused at times, not knowing the place and people who surround him. When the patient is asked to sign the informed consent for a scheduled thoracotomy, he vehemently refuses any and all treatments for his condition, stating that he is going to die anyway.

Principle of autonomy

A 29-year-old man presents with bouts of severe depression accompanied by suicidal thoughts. Although he is well-educated, he has been unable to get a job that fits his training because of his illegal status in this country. He has been doing odd jobs, and he has barely been making a living. His relationship with his girlfriend has become stormy over the last few months, and he confesses that he wants to kill his girlfriend. You believe his intent to kill his girlfriend to be serious and suspect that the underlying cause of his fury and homicidality, is untreated depression. For his own safety, you recommend he admit himself to a psychiatric hospital for further evaluation and treatment. He vehemently refuses.

Proceed with the procedure for involuntary hospitalization.

A 28-year-old woman presents because she has not gotten her period in 2 months. She is worried that she may be pregnant, but she is concerned because she and her boyfriend broke up about 2 months ago. She does not want to be a single mother. The patient mentions a discharge from both breasts. She denies any significant weight loss/gain or heat/cold intolerance. You order a urinary HCG, which is negative.

Prolactin level

A 48-year-old man presents with a 5-year history of hand tremor. The tremor was initially mild and has progressed over the last year. It diminishes at rest, but it intensifies with intentional movements and upon emotional stress and fatigue. He is unable to write or drink from a cup during stressful situations. He never drinks alcohol, and he does not currently take any drug except metformin for non-insulin-dependent diabetes mellitus. Family history is negative. Physical exam is unremarkable. His gait, speech, and posture are normal.

Propranolol

A 19-year-old man without significant past medical history presents to the ED with a 2 cm laceration on his right calf with several small flecks of organic material within the wound. The patient is a hospital volunteer who reports that he obtained this injury while accompanying a hospitalized patient on a walk through the hospital gardens. He is unsure of his specific vaccination record, but he has received all required childhood vaccinations and recently received Tdap (booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis) vaccination required for college admission.

Provide wound care alone.

A 30-year-old woman presents to the emergency room at 7 AM with severe pain and swelling of her right eye. She was awakened early the previous evening due to the discomfort and swelling of the surrounding conjunctiva. She found it difficult to sleep due to the discomfort. She planned on going to work, but the swelling had closed her eye shut, and she developed excruciating pain in the eye that radiated internally. The patient denies recent swimming and does not recollect any previous trauma or injury to the eye. She uses contact lenses, but they were not in use due to the condition of her eye. The contact lenses were stored in a small pillbox container with some fluid that she later described as tap water. She ran out of sterile cleaning and soaking solution for the contact lenses, so she has been using tap water as a substitute for approximately 5 days. She frequently sleeps with her contacts in. The patient is afebrile. Pulse is 70/min, and blood pressure is 135/80 mm Hg. Lungs are clear, and there is no evidence of lymphadenopathy. The eye has profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of conjunctivitis requires an ophthalmologist consult. The ophthalmologist obtains ocular fluid for culture and Gram stain. CBC results are unremarkable. The Gram stain reveals the following results (see image). Prompt and aggressive therapy is initiated.

Pseudomonas aeruginosa

A 70-year-old woman with long-standing type 2 diabetes mellitus presents due to pain in the left ear along with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal.

Pseudomonas aeruginosa

An 18-year-old female college student presents with a 2-day history of severe left ear pain. In the last 5 hours, the pain has become intolerable. Initially, the ear had an intense period of itchiness. Her history is significant for being a member of the college swim team. An examination of the ear canal is remarkable for the presence of edema and redness. A culture swab of the ear canal is performed. The patient is discharged with a course of treatment consisting of polymyxin with a steroid in an acid vehicle, and she is told to return if the symptoms do not subside within the next day. The next day, the microbiology laboratory isolates a gram-negative bacillus; it is oxidase positive and citrate positive. It does not ferment carbohydrates, and it produces a blue-green pigment.

Pseudomonas aeruginosa

A 56-year-old Caucasian man presents with a 3 mm papule on the left nostril that has a pearly appearance, is skin-colored with smooth surfaces, and displays well-defined smooth borders. It has been present for 8 months, but it has become more noticeable in the past 3 months. The patient denies any other lesions with the same characteristics and wants it taken care of so it is not as bothersome. He denies weight loss, night sweats, or fevers; there have been no sleeping issues or recent changes in his appetite.

Punch biopsy

A 16-year-old girl presents with a 4-hour history of loss of consciousness. Her older sister states that the patient has been depressed and was found with an empty bottle of tuberculosis medication. The patient has now begun having generalized tonic-clonic seizures. Examination reveals a developed teenage girl responsive only to painful stimuli; there are intermittent tonic-clonic movements of the extremities.

Pyridoxine

A 28-year-old woman presents because she is concerned about her children, ages 2, 4, 6. She is asymptomatic and there is nothing abnormal in her medical records, but her father was recently diagnosed with medullary thyroid cancer due to the presence of MEN 2A. She is asking if the condition is hereditary; if so, wants to know what can be done to prevent her children from developing the malignancy.

RET mutation test in the patient

A 62-year-old woman presents with excruciating pain, burning, and swelling in her left forearm and wrist. Symptoms began with a fracture 4 months ago, worsening despite strict adherence to instructions. She has continued using a sling and limiting left arm use to prevent exacerbation. Fabric touching her skin when wearing a jacket or long sleeves causes pain. She denies fevers, pain in other areas, new trauma, and urinary symptoms. Past medical history is unremarkable. No tobacco, alcohol, or recreational drug use. Physical exam is remarkable for mild left forearm edema, erythema, and tenderness to light touch. Distribution of findings is elbow to wrist, anterior and posterior surfaces. Left wrist strength and range of motion are decreased compared to right.

Radiograph showing callus formation

A 34-year-old African American woman presents with recurrent vaginal yeast infections. Over the past 2 years, she has had repeated episodes of similar infections that have been only partially responsive to over-the-counter treatments. She has not seen a physician in the 5 years since her last pregnancy, and she denies a history of any major medical illness. She has been moderately obese for most of her adult life; her maximal weight was 240 lb at a height of 5'1"; she has recently had a 15 lb unintentional weight loss. She also reports nocturia for the past several months. Examination reveals a blood pressure of 155/95 mm Hg, obesity, and findings consistent with vaginal candidiasis.

Random plasma glucose

You are a physician assistant assisting an orthopedic surgeon with a total knee arthroplasty (TKA). You reviewed the knee X-ray prior to the case and confirmed on the consent the correct side. A surgical time out was performed, and all agreed that the patient is having a left TKA. There is no mark on either leg by the surgeon to identify the correct leg. The surgery is completed, and the patient is transferred to the recovery room. Upon waking, the patient reports that they were supposed to have a right TKA. The consent is reviewed and does read as left.

Re-evaluate the consent procedure

A 3-year-old girl presents with a 5-day history of fever, coughing, sneezing, and watery nasal discharge. According to her mother, she passed out and began shaking yesterday. 1 hour before that, her temperature peaked at 40.1°C (104.2°F). The episode lasted for 1.5 minutes, and she remained drowsy for about 10 minutes afterward. She suffered a similar shaking episode during a bout of otitis media 1 year ago. The child reached all developmental milestones at appropriate ages, received all immunizations, and has no other relevant past medical or family history. Her only medication is acetaminophen. Vital signs: BP 110 / 70 mm Hg, HR 86 bpm, RR 20 rpm, and temperature 37.3°C (99.1°F). On physical examination, there is some wheezing in both lung fields. The remainder of the examination, including a full neurologic exam, is normal.

Reassure parents and discharge patient.

A 6-year-old boy is performing poorly in kindergarten. According to his teacher, he can perform some schoolwork and answer test questions, but he has difficulty understanding the instructions. He has to ask for detailed help regarding instructions, and his teacher sometimes has to demonstrate it to him with action so that he can proceed with his lessons. He is the second of three children. Except for language skills, developmental milestones are appropriate for his age. At 15 months, he could not respond to simple instructions like "no" and "give me." At the time, his mother thought, "He's just a little different from the other siblings." He has always had difficulty with school.

Receptive language dysfunction

A 15-year-old girl has been dieting for 6 months and has lost over 30 pounds. She tells you that she still feels fat. She is afraid to eat for fear of becoming obese. Her last menstrual period was 3 months ago. On physical exam, the patient is cachectic and slightly pale. Her heart rate is 50 beats/minute, her blood pressure is 90/60 mm Hg, and her temperature is 95.5°F. Her weight is 92 lb and her height is 5'6".

Reduced luteinizing hormone (LH)

A 42-year-old man with a known past medical history of schizophrenia has begun to demonstrate new and unusual behavior over the past 2 weeks. The patient has been compliant with taking risperidone 2 mg for the past year. The patient's son reports that his father has been acting "silly" and exhibiting inappropriate behavior, such as removing his clothes, repeating odd noises and gestures, and speaking incoherently with random loud and violent outbursts. This morning, the patient was observed to have used a knife to cut himself; his son stopped him.

Refer the patient to the hospital for inpatient monitoring.

A 41-year-old woman presents to the local emergency department with a 14-day history of nasal drainage, congestion, fever, and cheek pain. She was started on amoxicillin/clavulanate initially, but she was switched to levofloxacin 7 days ago due to no improvement in symptoms. After 7 days of levofloxacin therapy, she presents again, reporting that she is no better. The fever continues and she now has upper tooth pain. On exam, she is in mild distress, with thick purulent rhinorrhea and halitosis.

Refer to ENT for sinus aspiration

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. The patient's past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Referral for surgery

A 41-year-old man presents for evaluation of hearing loss. He states that he is having more difficulty in his right ear than his left. He began to notice this about 6 months ago when, while talking on his cell phone, he had to routinely switch to his left ear because of difficulty understanding the words while listening with his right ear. He states that he has had ear drainage for approximately 6 months. He also states that he was in the Navy for a few years and took up scuba diving as a recreational activity. He recalls multiple ear infections during his time in the Navy.

Referral to an otolaryngologist for surgical intervention

A physician assistant has just joined an internal medicine practice that has been around for more than 5 years. This practice consists of an internal medicine physician and a nurse practitioner. The patient population consists of >50% with Medicare insurance. While in orientation, the physician assistant overhears that all laboratory exam referrals go to a private laboratory that is owned exclusively by the internal medicine physician.

Referring to self-owned businesses

A 16-year-old slightly overweight girl presents because she wants to lose weight. She read online that drugs for ADD can help with weight loss. She is unsure of the name of the drug she read about but wonders if she can use them as diet pills instead. Since she was told that drugs like meth have similar properties, she also wants to know if these are safe to take for weight loss. She is told to avoid them because they can become habit-forming and their effectiveness is short-lived.

Releases dopamine and norepinephrine stores

A male postsurgical patient in the hospital reports an acute increase in the amount and frequency of bowel movements. Patient reports 3-4 loose stools each day for the past 2 days and diffuse abdominal discomfort. Upon review of his medical record, you discover he received perioperative antibiotics and a recent 7-day course of antibiotics 2 weeks ago prescribed for a skin infection. His medical history is significant for gastroesophageal reflux disease controlled with omeprazole 20 mg daily. You order stool toxin testing for Clostridium difficile (C. diff.), which quickly returns positive. Soon after, you start appropriate antibiotic treatment and place the patient in a private room.

Remove gloves and wash hands after patient contact.

A physician assistant recently joined a busy family medicine practice. The PA has noticed that their supervising physician is almost always late for work and is often late returning from lunch, at which times the PA has witnessed the supervising physician asleep in their car. The PA has also observed multiple irrational volatile outbursts by the physician while seeing patients in the clinic. He is concerned that the physician may have a substance abuse problem.

Report the physician's behavior.

A physician assistant is working the night shift in an emergency department and she notices that their boss comes in 3 hours late. The boss states that they had an emergency to deal with at home and did not notify the emergency department of their tardiness. The boss proceeds to the nurse's station and has difficulty with ambulation and trouble communicating with nursing staff, slurring some words.

Report them anonymously.

A 30-year-old man presents with recurrent vertigo. He gives a history of attacks when rising from bed in the morning and rolling over in bed that last <1 minute. He does not have headache, earache, hearing loss, tinnitus, nausea, or vomiting. He has no recent history of URI and has no other significant medical history. On examination, external auditory canals are normal. Dix-Hallpike maneuver produces nystagmus. Hearing tests are within normal limits. Pulse is 72/min, and blood pressure is 120/78 mm Hg. Central nervous system examination (including higher functions and mental status) is within normal limits.

Repositioning maneuvers

You are an emergency department (ED) physician assistant working in a Level 1 trauma center. You are notified by emergency medical services (EMS) that there was a mass casualty shooting at a night club and to anticipate a large number of patients arriving quickly for care. You activate the hospital policy for a trauma alert, including calling in additional staff and notifying the operating room to anticipate emergency cases.

Response

A 34-year-old pregnant woman presents with what she describes as "tingling in her right arm." She is at 34 weeks of gestation. This is her second pregnancy. It comes on along her palm, and it has been increasing in severity. She also notices it more at night and while attempting to carry her shopping bags. Her pain has been so bad lately that she has been losing sleep. Examination reveals a positive Phalen's test; there is no weakness or atrophy of the thenar muscles. She is not known to have diabetes or hypertension, and she is otherwise healthy. Her thyroid function is normal. Her primary care physician advised treating with NSAIDs and vitamin supplements, neither of which have worked after 3 months of regular use.

Rest and neutral splinting

The Nevada Test Site 65 miles northwest of Las Vegas was the site of 928 nuclear tests conducted by the US government between 1951 and 1992. These included 100 atmospheric tests and 828 underground tests. A spike in cancer rates was subsequently noted in a group of Mormon families (4125 people) residing in southwest Utah near the Nevada Test Site. A study comparing cancer rates in this group with those of all Utah Mormons was published in the Journal of the American Medical Association in January 1984.

Retrospective cohort study

A 42-year-old man presents with a 4-day history of worsening headache, stuffy nose, and clear-to-green nasal discharge. He admits to facial pain and a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a slight fever of 99.2°F taken orally, pulse 86/min, BP 120/76 mm Hg left arm sitting, and SPO2 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates.

Rhinovirus

A 42-year-old man presents with a 3-day history of "not being able to hear in my right ear." He is otherwise healthy and is not taking any medications. There is no history of trauma. On physical exam, the whisper test is decreased on his right, the Weber test lateralizes to the right ear, and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction.

Right ear conductive hearing loss, possibly due to cerumen impaction

A 10-year-old Latinx boy is brought by paramedics to the emergency department after a motor vehicle accident. He is unconscious and has sustained severe trauma. He has a subdural hematoma, multiple fractures, contusions, and a tension pneumothorax. He is treated with needle thoracentesis and subsequent chest tube placement. A neurosurgeon is consulted regarding the subdural hematoma. The driver of the car, a Latinx woman in her mid-30s, did not survive the accident. Efforts are made to identify the boy and to locate his next-of-kin. The patient's father arrives at the hospital, but he does not speak English.

Right to autonomy

The Tuskegee Syphilis Study conducted by the US Public Health Service followed 600 African American men—399 of whom had syphilis—over 40 years (1932-1972). The men were given free medical exams, free meals, and burial insurance in exchange for participating in the study. The patients were told that they were being treated for "bad blood." They were never explicitly told they had syphilis and were not treated for the disease, even after 1947 when penicillin had been proven effective as treatment. By the time the study was terminated in 1972, 40 of the men's wives had syphilis, and 19 of the children of study participants were born with congenital syphilis. This study is now infamous as an example of unethical research practices.

Right to informed consent

A 50-year-old woman has had a facial rash and a 10-year history of reddening of her face that comes and goes. On physical exam, you note erythema, telangiectasia, red papules, and tiny pustules on both cheeks.

Rosacea

A 13-month-old boy presents with a rash. The mother reports that he has had high fevers over the past 4 days, but he has not had a fever for the past 24 hours. The rash began 6 hours ago, startingt on his chest and back, spreading to his neck, face, and arms. The child does not appear to be itchy, and he has been acting normally since the fever subsided. The mother denies cough, runny nose, vomiting, and diarrhea. The only medication that the child has taken is acetaminophen. On examination, the child is happy and playful. The only physical finding is a blanching macular rash noted on the mentioned areas.

Roseola

A 35-year-old homeless man presents as a new patient. He received immunizations as a child and adolescent, but he has not received medical care for the last 10 years since becoming homeless. He is unemployed and spends the majority of his time among other individuals in community living shelters. In addition to obtaining a thorough history and physical examination and appropriate laboratory testing, you decide to update his immunizations.

Rotavirus

A 28-year-old woman with a 4-year history of end-stage renal disease secondary to diabetes has had intact parathyroid hormone (PTH) levels of 600-800 pg/mL (ref 150-300 pg/mL) for the past 15 months. She does not take prescribed phosphorus binders with meals and she routinely misses her dialysis treatments, during which she receives intravenous paricalcitol.

Rugger jersey spine

A 16-year-old boy presents with a general itching of his hands and wrists. It started a few weeks after he went to play in a high school soccer tournament. On physical exam, you note several wavy skin-colored ridges on his hands and wrists with excoriations. There are multiple small erythematous papules on flexor surface of wrists. You note that the intertriginous areas of the hands are involved.

Scabies

A 27-year-old woman presents with excruciating back pain. She states that the pain started earlier that morning and caused her to miss work. She has had similar pain like this before, but no doctor has ever found anything wrong. She is currently on fluoxetine for depression and periodic ibuprofen for pain. On physical exam, tissue texture changes are noted at L1 to L3, with no additional findings. The woman seems to be in an immense amount of pain, however, and she continues to insist that something is horribly wrong with her. Diagnostic results are negative, and a pain medication is prescribed. She returns later in the week with the same issue but no new findings. History shows episodes similar to this involving joint pain, abdominal pain, headaches, bloating, diarrhea, a "lump in the throat" feeling, and menstrual cramps.

Schedule frequent visits and involve her in the decision-making process

A 28-year-old man presents for a checkup. Medical records indicate a 3-year history of hospitalizations for mania and depression. The last admission occurred 7 months ago and was due to a suicide attempt after a major depression. The patient has been taking lithium since the last hospitalization; there have been no further mood disturbances, but his mother relates that the patient remains convinced that the "city officers" poisoned the water system over the last 2 months. He refuses to drink tap water. His mother heard him talking alone in his room, and she found several bottles of water under his bed. She reports he has not been very social with his friends over the last 6 months and is showing signs of depression. On examination, the patient appears disheveled; he experiences auditory hallucinations and persecutory delusions throughout the interview. His speech is disorganized.

Schizoaffective disorder

A 70-year-old woman has been refusing to leave her room at the nursing home facility where she resides. She says that people are following her, and she even refuses to go out with her daughter. She has a long history of mental illness; her ex-husband had her committed to a state hospital, where she had resided for over 30 years. On interview, it is difficult to obtain a history; her thinking is disordered and her speech is erratic. When asked why he committed her, she says that she believes her husband was trying to kill her.

Schizophrenia

Police officers found a 27-year-old man walking aimlessly and shouting the names of former presidents. Urine toxicology is negative, and the man appears to be oriented with respect to person, place, and time. He has had 5 similar admissions over the past year. Attempts to interview the patient are fruitless; he is easily derailed from his train of thought. A phone call to a friend listed in the chart provides the additional information that the man is homeless and unable to care for himself.

Schizophrenia

A 26-year-old African American man presents with a rash on his back. He first noticed the rash 3 weeks ago. He describes small whitish upper back lesions that are not painful and do not itch. He has no significant past medical history; he has no known drug or food allergies; he is not taking any medications. On physical examination, there are several small hypopigmented macules that coalesce on the upper third of his back. Fine scaling is produced on scratching. The remainder of the physical examination is unremarkable.

Scrape lesions and KOH stain.

An 8-month-old male infant presents with rashes over the scalp and eyebrows. Physical examination shows a dry scaly crusting lesion over the scalp, eyebrows, and nape area. He is comfortable, so his mother presumed that it was not itchy at all. He has been breastfed up to this point, and he started solid food at about 5 months. There are no other signs or symptoms noted. Bowel movement and urination are normal. Developmental milestones are consistent with age.

Seborrheic dermatitis

A 27-year-old man presents with the "flu." He says that he has felt feverish, tired, and mildly nauseated for the past few weeks. He mentions a headache and non-pruritic rash. He denies any past medical history or medication use. On exam, he is afebrile. Examination reveals diffuse mild lymphadenopathy with mild hepatosplenomegaly; his soft palate has a few scattered shallow ulcerations. The palmar and plantar surfaces have a scattered papular rash that is copper colored, with a few papules on the flexor surfaces of the arms, legs, and trunk. Laboratory evaluation reveals hemoglobin of 12.8 g/dL, hematocrit of 38%, and white blood cell count of 11.1 x 103/ìL.

Secondary syphilis

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, red and watery eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She most likely has allergic rhinitis.

Sedation

In order to maintain certification from the National Commission on the Certification of Physician Assistants (NCCPA), each PA is required to earn 100 hours of continuing medical education (CME) over their 2-year recertification cycle. The NCCPA awards additional CME credit hours (beyond the face value of earned CME credit hours) for certain types of CME activities.

Self-Assessment Category 1 CME

A 47-year-old man presents with numbness, tingling, and pain anterior and to the left side of his left thigh. Pain is provoked even with light touch, and tingling continues for several minutes after the touch. Symptoms started a couple of months ago and worsen when he wears a belt and walks down slopes and stairs, as well as after prolonged standing. Symptoms are relieved when he puts a pillow between his thighs. Patient also assumes hunched posture while standing to avoid unpleasant sensory symptoms. His BMI is 40, and he has a protruding pendulous abdomen.

Sensory loss in anterolateral thigh down to left upper knee

A 12-year-old girl presents with symptoms of anxiety. Her parents report she has always been anxious, but her anxiety levels have escalated during this school year. She frequently resists going to school in the morning. Once there, her symptoms often escalate enough to involve the school nurse. They are usually alleviated by telephone contact with her mother. Symptoms also occur on weekends when her mother has to work. The patient has a normal group of friends, but she prefers to be with them at her home rather than elsewhere. She has never slept away from home. She spends a considerable amount of time alone in her room, but she will often come out to "check up" on her mother.

Separation anxiety disorder

An 8-year-old girl is brought to your attention because she recently started refusing to go to school. When her mother tries to explain that she must go to school, the girl begins to report headaches and stomachaches. She does not want to sleep alone and is clingy around both of her parents. These symptoms have been present for 6 weeks. The parents are recently separated, and she has been having a hard time adjusting to the divorce. As a result, she has been acting out towards her teachers in the classroom. Her physical and laboratory findings, including drug tests, are normal.

Separation anxiety disorder

A 15-year-old boy presents for follow-up of previously diagnosed Asperger syndrome, now autism spectrum disorder. The patient is accompanied by his mother. He is considered high functioning. He attends public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions. The mother states she has noted a significant increase in the patient's anxiety symptoms that have become detrimentally disruptive to daily activities.

Sertraline

As part of a routine checkup, a 40-year-old man is evaluated by his family practitioner. He smokes 1/2 a pack of cigarettes a day, and he has an occasional glass of wine. For the past 5 years, he has been on SSRIs for mild depression. On general physical examination, his BP is 110/70, and his BMI is 25. The physician notes slight enlargement of his thyroid gland with a solitary left upper lobe nodule. Careful examination reveals cervical lymphadenopathy. An FNAC of the nodule shows large amounts of amyloid stroma and disorganized spindle-shaped cells with large vesicular nuclei.

Serum calcitonin levels

A 20-year-old woman presents to urgent care with diarrhea of 4 days' duration. She describes the stool as greasy and foul-smelling. She has also experienced nausea, mild weight loss, and abdominal cramps. She denies tenesmus, urgency, or bloody diarrhea. She has no relevant past medical history.

She drank stream water from a recent camping trip.

A 28-year-old man presents with a rash. The lesions, which are mildly pruritic, are located on his arms and legs. They have been present for about 3 days without change or resolution. He has tried over-the-counter anti-itch creams, but they have been ineffective. The patient reports that he was seen approximately 1 week ago for some blister-like lesions on his penis. He was given an antiviral medicine, and those lesions resolved. He is wondering if he was misdiagnosed and if the two rashes are related. He admits to feeling some malaise over the last 2 weeks, but he is otherwise healthy. He denies fevers, unusual travel, medication use (except for as listed above), and known allergies. He has no known chronic conditions. On physical exam, vitals are normal; the patient is in no apparent distress. A pink-to-red papular rash is observed on the backs of the hands and feet and extensor surfaces of the arms and legs. The individual lesions are quite distinct; they have a red center, and they are surrounded by a pale ring and then another outer ring of red, inflamed tissue. The remainder of his physical exam is normal.

Skin biopsy

A 7-year-old boy presents with a 3-day history of intense pruritus on his wrists, fingers, and antecubital fossae. It began on his fingers and has moved proximally. According to his mother, they are raised red eruptions and some have scabbed over. She states he has never had this before and it is keeping him up at night. He recently started at a new school.

Skin scraping with immersion oil

A 2-year-old boy presents because of his mother's concerns about his sleep. She notes that he is easy to put to sleep, and he has a regular bedtime of 7:30 PM. Most nights for the past 3 weeks, about 90 minutes after being put to sleep, he begins to thrash violently in bed, sometimes letting out bloodcurdling screams. He has his eyes open and seems to be talking, but he does not respond to either parent when spoken to. He sweats a lot. The episodes last about 15 minutes, and he then goes back to sleep; he seems fine in the morning. He naps for about an hour in the morning and an hour in the afternoon, but these episodes do not occur with naps.

Sleep terrors

A 33-year-old woman presents after being found unresponsive in her bedroom. She has a past medical history of depression, and her mother found an empty bottle of amitriptyline by her bedside. Otherwise, the patient has no other medical or surgical history. She is a non-smoker and does not drink alcohol. On physical exam, pulse 138/minute, blood pressure 80/60 mm Hg, temperature 101.2°F (38.4°C), respirations 6/minute. Her heart sounds are normal, and she has thready pulses. Her breath sounds are normal but with shallow effort. The abdomen is soft and non-tender. Neurologically, she moves her limbs from painful stimuli. Her skin is flushed; there are no needle marks. Her chest X-ray is normal, and the electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and hyperventilated.

Sodium bicarbonate

A 45-year-old woman presents with a lesion on her calf. She states that she has had it for a while and that it has not gotten bigger, but it does not heal and it bleeds occasionally. On exam, the lesion is a pink sharply demarcated scaling plaque.

Squamous cell carcinoma

A 68-year-old Irish farmer presents for his annual physical examination. He smokes 10 cigarettes per day. He has no complaints, but an erythematous scaly non-tender nodule measuring 0.5 cm is noted on his left lower lip. There are no surrounding telangiectasias. The nodule is firm, ill-defined, and fixed to the underlying tissue. It does not blanch with pressure.

Squamous cell carcinoma

You have recently been invited to serve on a hospital committee taskforce. The mission of this task force is to make cost-effective recommendations regarding system-wide initiatives to mitigate risk in the hospital. Potential risks to the hospital are ubiquitous and include:

Staff training in handoffs

A mother brings in her 5-year-old son due to papular and pustular lesions on his face. A serous honey-colored fluid exudes from the lesions. You suspect impetigo. A Gram stain reveals spherical gram-positive arrangements in irregular grape-like clusters.

Staphylococcus aureus

A 16-year-old girl is brought to the emergency room for evaluation of continuous seizures. The patient was first diagnosed with idiopathic epilepsy at age 10. She was started on valproic acid. Phenobarbital and carbamazepine (Tegretol) have been tried without success, and the phenobarbital resulted in transient severe personality changes. Two previous EEGs have been normal. This spell occurred abruptly at the dinner table without apparent warning. Past medical history has been normal. She saw her primary physician for nausea and vomiting 2 days ago. The physician believed she had the flu and started her on prochlorperazine, which relieved her nausea. Physical exam reveals a well-developed well-nourished young woman lying on a gurney; there is continuous but variable motor jerking of all four extremities. The jerking varies in intensity from side to side. The head intermittently turns from side to side. Eyes are closed tightly and cannot be passively opened. Deep tendon reflexes cannot be assessed. The response to plantar stimulation is withdrawal bilaterally. There are no signs of trauma to the head or elsewhere. Skin is warm and dry with normal color, and vitals are normal. The general medical exam is otherwise normal. Labs are done stat, and they include normal complete blood count and differential, normal chest X-ray, normal urinalysis on cath specimen, normal chemistry profile, and normal arterial blood gasses.

Stat electroencephalogram (EEG)

A 7-year-old boy presents because he is fidgety, impulsive, and unable to sit still. The patient is observed running around. There is no evidence of any hallucinations or delusions. The mother notes that the child speaks excessively and loudly, makes simple arithmetic errors, and has short-term memory deficiencies. He finds it difficult to wait in lines or wait his turn in games or group situations.

Stimulant medications are considered first-line pharmacologic therapy.

In 1965, in an article published in the Proceedings of the Royal Society of Medicine, Sir Austin Bradford Hill (Professor Emeritus of Medical Statistics, University of London) proposed a series of criteria for evaluating the likelihood of a cause-and-effect relationship between a specific exposure (risk factor) and a disease. If there is an association between the exposure and the disease, he recognized the following criteria: Strength of association Consistency of data Specificity Temporality Biological gradient Plausibility Coherence Experiment Analogy Hill qualified his endorsement of these criteria, however, by stating "None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required sine qua non."As a family practice PA, you routinely recommend HPV vaccine to boys and girls ages 11 and 12. Some parents are initially hesitant, so you have learned to make convincing arguments to the parents in favor of the vaccine based on the evidence that human papillomavirus (HPV) causes cervical cancer.

Strength of association

A 22-year-old woman presents because she developed a fever of 101°F this morning. She has a 2-week history of rhinorrhea, congestion, and headache. She states that her rhinorrhea was initially clear and actually improved after 5 days, but then it returned and developed into a green color. Her headache is felt in the forehead and cheeks, and it worsens when she bends over.

Streptococcus pneumoniae

A 42-year-old man is angry, frustrated, disillusioned, and disappointed with his wife's involvement with his best friend. He enrolls himself in a men's tennis club to relieve his negative emotions. What defense mechanism is he using?

Sublimation

A 25-year-old man has a long history of criminal behavior, and he has been in and out of prison for assaultive behavior, theft, armed robbery, and sexual assault. He shows no remorse for his behavior and states that he is the real victim. He also shows little emotion regarding his family history, and he prefers to brag about his sexual exploits. The patient denies a history of mood disorders or schizophrenia.

Substance use disorder

A consulting physician asks for a follow-up on a 35-year-old woman being treated for an acute migraine headache. Upon interview, she states that the physician gave her an injection about 20 minutes ago; she now has significant chest pain.

Sumatriptan

A nurse paged the on-call physician assistant regarding an 87-year-old woman reported to be agitated and experiencing auditory hallucinations. The physician assistant was busy with several new admissions and issued a verbal order to administer risperidone without reviewing the chart. The physician assistant informed the nurse of anticipated follow-up at the bedside 30 minutes later. The nurse administered the medication; the patient developed cardiac arrest and died. A retrospective chart review identified external medical records that had been electronically scanned— but not entered— into the hospital's electronic medical record system. The records included a diagnosis of Alzheimer's dementia and history of a prolonged QTc interval.

Supervising physician

A 25-year-old primigravida woman gave birth to a healthy male infant at 40 weeks gestation by normal spontaneous vaginal delivery (NSVD). She breastfeeds on demand and was doing well until day 4 postpartum. At that time, she developed insomnia, fatigue, and feelings of sadness and depression, which have been present for the last 3 weeks. She cries easily and feels guilty that she does not enjoy her baby as much as she had expected. She has not yet resumed any predelivery social activities and is often ready for bed when her spouse returns from work to assume care for the baby. Because she feels so tired, she wishes she had never begun breastfeeding.

Supportive psychotherapy

A 30-year-old woman presents to her primary care office with increasing polyuria of pale colorless urine, urinary frequency, enuresis, and nocturia. She has a past medical history of Sheehan's syndrome and a craniopharyngioma, for which she has followed up with her neurologist. She states that as a busy office worker, she finds it difficult to drink water throughout the day and has developed an "unquenchable thirst." She also finds that her sleep is disturbed and has mild daytime fatigue and somnolence as a result. She denies a family and personal history of diabetes mellitus, thyroid dysfunction, illicit drug use, smoking, and alcohol use. She denies fever, chills, polyphagia, weight changes, vaginal discharge, hematuria, or abnormal urinary odor.

Suprapubic distension

A 40-year-old man presents with fever, weakness, and pain in his right hand. Fever and weakness started this morning. 2 days ago, he noticed painful itching blisters on his hand. He thinks it might have been caused by a spider bite. He has type 2 diabetes mellitus and was treated in the ER for acute alcohol intoxication 2 times over the last month. His records show that he received a tetanus booster dose 5 years ago. On examination, he appears very ill; his blood pressure is 85/55 mm Hg, HR is 120/minute, and respiratory rate is 22/min. His hand is swollen and red; there is a small deep ulcer surrounded by a blue halo with preserved voluntary movements of the hand and fingers. You also notice crepitus and discharge of fluid that resembles "dishwater."

Surgical debridement

A 69-year-old woman with a 2-year history of asymptomatic hyperparathyroidism presents with a 1-week history of generalized anxiety and intermittent confusion. 6 months ago, she had normal results on serum and urine protein electrophoresis, mammography, radiography of the chest, and ultrasonography of the neck. The immunoreactive parathyroid hormone level was 5 times the normal level, and the ionized serum calcium level was also increased. She has no other major medical problems.

Surgical exploration of the neck

A 67-year-old woman is hospitalized because of lung cancer. During her stay in the hospital, she becomes obtunded. During a physical exam, she has a seizure. Soon thereafter, she goes into a coma. Lab results show that her urine is hypertonic. Additional laboratory results are as follows:

Syndrome of inappropriate ADH secretion

You are covering a weekend shift at a local inner-city free clinic. A 41-year-old woman presents with what she describes as "a cough." The patient states that this cough will not go away and has been present for several months, to the point that the patient is coughing up blood for the last 4 days. She admits to unintentionally losing about 10 pounds in the last 2 months. Progressively worsening fatigue, night sweats, and chills are also present. She is a non-smoker and lives in a rent-controlled apartment with 3 adults and 4 kids.

TB culture

A 32-year-old woman presents to the emergency department due to abdominal pain for the past 4 hours. The triage nurse reports she has had similar pain in the past that has resolved on its own, but the pain today is more severe. When you enter her room, she is sitting in bed comfortably and is fully covered in traditional clothing except for her eyes. Her husband is present and requests a female provider. In this scenario, you are a male provider responsible for this module today, but you have female colleagues working in other modules.

Take a brief history first to determine urgency.

A 29-year-old man presents 1 hour after stepping on a sharp nail. The nail penetrated deep into his foot; his last tetanus immunization was at age 6.

Tdap vaccine plus antibiotics

A 22-year-old woman is started on methimazole for the treatment of her hyperthyroidism. She has been diagnosed with Graves' disease and has been symptomatic for the last 6 months. She is otherwise healthy and does not take any other medications. You receive a call 2 weeks later from the patient; she tells you that she has had a mild sore throat for the past 2 days and has been feeling like she is coming down with the flu. She states that the symptoms of her hyperthyroidism are a little bit better.

Tell her to present ASAP for total and differential blood count.

A 20-year-old female college student presents to the student health center with a 1-week history of daily headaches. She has no significant past medical history. Upon further questioning, she admits to headaches occasionally over the past 2 years, but it is lasting longer this time. She classifies the pain as a 4/10 that is generalized, but is worse in the back of the head. The headaches are not debilitating or throbbing, and she describes it as an annoying pain. Acetaminophen helps somewhat but does not make the headache go away completely. On physical exam, there are no neurologic deficits, vision is 20/20 uncorrected, and vital signs are within normal limits. She does note tenderness upon palpation of the muscles of the head, neck, and shoulders.

Tension headache

A 23-year-old woman presents due to a headache that appears to be bilateral, and she describes it as a "tight" feeling around her head. She started physician assistant school 2 months ago and has been really stressed out. Upon physical exam, no abnormal findings are found. Additionally, all laboratory findings are within normal limits.

Tension headache

A 37-year-old Hispanic man presents with a 4-month history of mild-to-moderate headaches; on average, he gets them 3-4 days per week. He has tried over-the-counter analgesics with minimal relief. He is seeking care now because he had been promoted to store manager several months prior to presentation, and he is worried that his headaches are affecting his concentration. His headaches are generalized in location, described as starting at the base of his head and extending all over, feeling "tight" in nature. He denies memory loss, photophobia, nausea/vomiting, rhinorrhea, lacrimation, and upper respiratory symptoms associated with the headaches. He also denies seizures, syncope, incoordination, vertigo, weakness, and paresthesias. The patient mentions his concerns for his work several times. Although he enjoys his work, he admits to having some anxiety about being able to handle his new duties. His family history is negative for headache.

Tension headache

A 45-year-old woman presents with a 2-week history of daily headaches. She describes feeling as if a rubber band is around her temples, making it extremely hard to concentrate when trying to complete tasks at work or at home. Further questioning reveals that the patient is under a significantly increased amount of stress at work due to a new, extremely rigid boss who started last month. She denies any auras, nausea, vomiting, or specific neurological issues, but she does admit to some sensitivity to excessive noise and glaring lights. She has always treated these with two 500 mg tablets of acetaminophen as needed, but this current episode has had little or no relief with this regimen.

Tension headache

You are a PA employed on the evening shift by a 20-physician hospitalist practice in a 900-bed facility. You are responsible for admission H&P and initial orders on newly admitted patients, urgent consults, and phone calls from the various nursing floors regarding existing patients. You work until midnight every night, but your supervising physician typically departs from the hospital around 8 PM, remaining available by cell phone or pager. After the supervising physician departs, you are the practice's sole provider in the facility. At 11:30 PM one evening, you receive a phone call from a nurse regarding an inpatient who has begun vomiting up blood. The patient was admitted 2 days ago for pericarditis and has been treated with ibuprofen 600 mg every 8 hours and colchicine 0.5 mg every 12 hours. He has also been on apixaban (Eliquis) 5 mg b.i.d. for prevention of thromboembolism due to long-standing persistent atrial fibrillation. You order a stat GI consult. The GI consultant arrives 15 minutes later and makes arrangements for endoscopy at 6 AM the following morning. You depart the hospital at the end of your shift. The next morning, you learn that the patient expired prior to the endoscopy and that pre-endoscopy labwork obtained at 2 AM revealed a Hgb of 4.2. 4 months later, you learn that the patient's surviving spouse has filed a malpractice case that names the PA, the supervising physician, the attending physician, the gastroenterologist, and the hospital.

The PA was inadequately supervised.

A 65-year-old man was diagnosed with mild dementia 2 months ago. The laboratory evaluation, together with a several-year history of symptoms, is consistent with this diagnosis. Although this patient can no longer work as a physicist, he is still able to visit family and friends, play tennis and golf, enjoy church, and travel with his wife. He has lost the ability to keep track of the family finances, and his wife has taken over that responsibility. After obtaining a baseline Mini-Mental State Examination (MMSE) score, you start him on donepezil 5 mg once daily, which you subsequently increase to 10 mg daily after a period of 4 weeks without side effects. You also prescribed vitamin E, 400 IU, twice daily. The family does not note improvement despite 8 weeks of therapy, and they are encouraging the patient to stop taking donepezil, but there is no further deterioration of the patient's condition.

The current dose has shown cognition improvement and attenuation of further decline.

A 7-year-old boy presents with headaches, nausea, and lethargy. According to his parents, the boy has been consuming large amounts of fluids. He also urinates frequently. A previously healthy child, he has no significant past medical history. His symptoms began approximately 3 weeks ago. His parents thought that it was his increased activity level that led to his increased fluid intake. Over the past few days, however, he has been becoming more lethargic and is still consuming large amounts of water and juice. On physical exam, the boy appears thin, ill-appearing, and lethargic. His eyes appear sunken and his skin is dry. His vital signs are: blood pressure 100/54 mm Hg, temperature 99.0°F, pulse 120 beats per minute, respiratory rate of 22 per minute. Laboratory tests show dilute urine with a specific gravity of 1.002 and a urine osmolality of 199 mOsm/kg. His plasma osmolality is 296 mOsm/kg.

The idiopathic form is associated with destruction of cells in the hypothalamus.

You are employed by a cardiology practice as a PA; the majority of your responsibilities are in the hospital setting. As you are making hospital rounds one morning, your supervising physician asks you to remove the pericardial drain from one of the patients. The patient had a pericardiocentesis 2 days ago due to a large pericardial effusion with cardiac tamponade, and the catheter was left in place to facilitate continued drainage of fluid from the pericardial space. You locate supplies, including sterile gloves, needed to perform the procedure. Just before entering the patient's room, you decide not to proceed.

The procedure is not included in your hospital privileges.

A 75-year-old patient comes in with SOB, chest pain, and left lower extremity swelling. She recently went on a 5-hour plane trip to see family and returned yesterday. A bilateral lower extremity ultrasound reveals a left deep vein thrombosis. You are writing admission orders for this patient and prescribe heparin 80 u/kg IV once STAT followed by 18 u/kg/hr. The patient 2 hours later is noted to have hematuria, hemoptysis, and a nose bleed.

The use of u abbreviation

A 40-year-old man presents with burning and pain of his oral cavity; the burning and pain have been associated with a pruritic rash of the flexor aspect of his left wrist. He denies a history of smoking, drinking, or recreational drug use. The physical exam is remarkable for violaceous shiny polygonal papules arranged in lines and circles on his wrist. These papules range from 1 mm to 1 cm in diameter, and they have fine white lines on them. In the oral cavity, a reticular white lacy pattern is visualized.

This immune response is associated with hepatitis C.

A newborn presents for a 2-week physical exam. On exam, white plaques on the buccal mucosa and palate are noted. Upon trying to remove the plaques, there is an underlying erythematous base and small punctate areas of bleeding. The area appears to be quite tender to touch.

Thrush

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and a tremor in her hands for the past 3 months. She has also noted weight loss. You note the presence of bulging eyes.

Thyroid gland

A 10-year-old boy presents with a 1-week history of a rash on his scalp. His mother states that the boy has been scratching his head often, and she notes that there are areas where his hair appears to have fallen out. She attempted to treat it with over-the-counter preparations, but his condition has not improved. The boy is active and otherwise healthy. The rash appears as erythematous, circular, scaly patches. There are areas where the hairs have become brittle and broken off. A scraping of one of the patches is placed in potassium hydroxide solution and shows hyphae.

Tinea capitis

A 20-year-old Caucasian male college student comes in with a complaint of hypopigmented patches that appeared gradually during the summer. He reports no history of unprotected sex. Scaly patches are present, but no pruritus. On examination, he has hypopigmented patches over the face and chest, but no vesicles or pustules.

Tinea versicolor

A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 30 minutes ago. He notes seeing halos with his left eye. He is also experiencing nausea and vomiting. These symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His temperature is 36.9°C, pulse 90/min, BP 130/90 mm Hg, and respirations 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection.

Tonometry

A 35-year-old woman presents with intensely pruritic red papules over the anterior wrists. On close examination, the papules are shiny; they have a flat surface and there is occasional central umbilication. A red plaque is seen along the scratch line at the anterior forearm.

Topical corticosteroid

A 25-year-old man presents to his primary care provider with a 2-day history of acute pain in his mouth; he has no significant past medical history. He states that the pain is in a localized part of his inner cheek; it is aggravated by eating food, speaking, and smiling. He denies any history of smoking, risky sexual behavior, drug use, transfusions, trauma, fever, chills, otalgia, otorrhea, rhinitis, eye pain/discharge, halitosis, regurgitation, skin changes, swollen glands, sore throat, or headache. His physical exam is noteworthy for painful ulcerations of buccal and labial mucosa with yellowish base and red halos.

Topical corticosteroids

A 62-year-old man who you know well presents due to an itchy rash. His medical history includes Parkinson's disease for the past decade. The patient believed the rash was just a mosquito bite at first because it stayed small and confined to one space. This area has spread and now has characteristics of hives and intense itching. On examination, you note three 1-3 cm tense bullae that appear on an erythematous base. The bullae are located on the right trunk in a region that measures 5 cm in diameter. This patient states he came to you for treatment of this issue around 5 years ago.

Topical corticosteroids

A 28-year-old man presents with a 1-week history of an itchy scaly rash on his elbows. When he scratches it hard, scales come off and the rash bleeds. Examination reveals the elbows are affected bilaterally. The lesions appear as 3-4 cm annular whitish scales on an erythematous base that is irregular and well-demarcated. The antecubital fossae are unaffected.

Topical fluorinated glucocorticoids

A 19-year-old woman presents with a multi-year history of episodic throbbing headaches. They have intensified, and she now misses classes and work 4-6 times monthly. They last 2-3 days, accompanied by nausea, vomiting, and light sensitivity. She denies residual symptoms after headaches resolve. She denies neurologic symptoms such as vision or taste changes, gait disturbances, and memory loss. She has tried multiple over-the-counter pain medications without relief. Her mother and maternal aunt experienced similar headaches. She reports some increased stressors and less sleep since starting college. Past medical history is unremarkable, with no other known medical conditions, surgeries, chronic medications, or drug allergies. She has never been sexually active and reports regular menses. She denies tobacco, alcohol, and recreational drugs. Physical exam is unremarkable.

Topiramate

A 23-year-old man presents with an unspecified personality disorder; although his group and individual therapy sessions are going well, he wants to gain even more improvement with his diagnosis. He feels that his mood, self-image, and personal relationships have improved overall, but he specifically states he wants to have better anger management. When he becomes angry, for whatever reason, he still becomes extremely irritated, hostile, and even aggressive.

Topiramate

A 32-year-old woman is brought to the emergency room with sudden onset of fever, headache, sore throat, profuse watery diarrhea, vomiting, and lethargy; symptoms started in the morning. On physical examination, she is slightly confused; her temperature is 39°C (103°F), her blood pressure is 100/50 mm Hg, and she has diffuse sunburn like an erythematous rash. When the emergency doctor is trying to find out if she is pregnant, she mentions that her period started 2 days ago.

Toxic shock syndrome

A 20-year-old primigravida woman at 12 weeks gestation presents with a 2-day history of low-grade fever and swelling in her neck. She does not have any significant medical history and denies previous blood transfusion. On questioning, she states that she is not sexually promiscuous and that she is living with her husband and their pet cat. She is a homemaker and spends her free time gardening. She has received all immunizations, and they are up-to-date. She also states that she has abstained from sex since learning of her pregnancy 2 months ago. On examination, her vitals are temp 99°F, PR 88/min, BP 110/70 mm Hg, RR 20/min. She also has painless prominent cervical lymph nodes. Abdominal examination reveals a just-palpable uterus.

Toxoplasma gondii

A 28-year-old man presents with severe headaches. He states that they began a few weeks ago and that he has been taking over-the-counter medications with some relief. He reports that he has AIDS. You ask what the patient was doing prior to experiencing these headaches. He says that he was taking care of the neighbor's cat while they were on vacation. Concerned, you order a CT scan; it demonstrates multiple ring-enhanced lesions.

Toxoplasma gondii

You are working as a physician assistant caring for post orthopedic surgery patients. On review of your 36-year-male patient's routine 12-hour post-operative complete blood count, you notice their hemoglobin is 6.5 g/dL; preoperatively this patient's hemoglobin was 13.4 g/dL. The patient's intraoperative report mentions significant blood loss but adequate hemostasis was achieved prior to incision closure. This patient endorses fatigue postoperatively but denies any other acute complaints. Physical exam does not reveal increased erythema, edema, bandage strike through, or significant surgical site tenderness to palpation. Patient is hemodynamically well.

Transfuse one unit packed red blood cells for symptomatic anemia.

You are working as a physician assistant in a neurosurgical practice. You are called to the emergency department to evaluate an 85-year-old man with an acute epidural hematoma found on brain imaging. This patient is obtunded and you determine he will require emergent surgical intervention. His granddaughter—who found the patient unresponsive and is present in the exam room—states that her grandfather would want the surgery if he could consent. Upon review of the patient's medical record, you notice the patient has an advanced directive on file. In this document, you discover the patient previously stated that if he is found unresponsive, he would decline any life-prolonging measures or escalation in care apart from comfort measures. His wife, who is not present, is his power of attorney and cosigned his advanced directive document.

Transition to comfort care measures in accordance with the advanced directive.

A woman presents with her 6-year-old adopted daughter due to excessive scratching of the scalp and ears. The woman states that she washes the girl's hair frequently, but it hasn't been helpful; the woman is very frustrated for her daughter. On examination of the scalp, excessive excoriations are noted on the posterior neck and postauricular regions bilaterally. No cervical lymphadenopathy is noted. Nits are also observed on the shaft of the hair.

Treat with permethrin.

You are a PA in the emergency department (ED) of a community hospital. A 70-year-old woman comes in for evaluation of hematochezia for 1 day associated with dizziness. She is found to have a blood pressure of 100/55 mm Hg, heart rate 110 bpm. Her hemoglobin is 6.0 g/dL, and hematocrit is 20.1%. In the ED, she is observed to have several bloody bowel movements of hematochezia. She presents a durable power of attorney card that states she declines transfusion and identifies her as a Jehovah's Witness. After a lengthy discussion about the diagnosis of gastrointestinal (GI) bleed and the risk of death if she does not receive a transfusion, she still declines blood.

Treat with supportive measures.

A 16-year-old Caucasian girl presents with a 6-month history of blackheads and whiteheads on her face. On examination, there are a few papules and pustules on her cheeks; there are no nodules. Her mother reports having similar spots on her face at this age.

Tretinoin

A 32-year-old man with a past medical history of allergic rhinitis and asthma that is well-controlled complains of recurrent pruritus associated with an erythematous rash in the flexural areas of his elbows and knees. The lesions seem to become worse when he scratches them and when he is under stress. He denies any recent insect bites, travel, fever, chills, new clothing, or detergent use. Physical examination reveals rough-appearing erythematous plaques in the bilateral antecubital and popliteal fossae, with areas of excoriations within the lesions.

Triamcinolone 0.1% applied to the lesions once or twice daily

A 4-year-old boy presents with a 1-month history of weight loss, fevers, cough, and night sweats. He and his family moved to the United States from Africa 3 months ago. He is a thin pale boy in no acute distress. His heart rate and rhythm are regular, his lungs are clear to auscultation, and he has no organomegaly.

Tuberculin skin test

A 6-year-old boy presents due to lethargy, polyuria, nocturnal enuresis, and polydipsia. His mother tells you that he reports being tired and thirsty all the time. You note that he has lost 5 lb since his last visit 6 months ago.

Type 1 diabetes mellitus

A 44-year-old obese woman presents with increased nighttime urination. She has never had issues with having an increased urge to urinate nocturnally before, and it is extremely bothersome to her. She states that she has been waking up at least 3 times a night despite lifestyle modifications designed to help reduce this number. The patient admits to increased fatigue, worsening blurry vision, and two vaginal yeast infections in a span of 3 months.

Type 2 diabetes

A physician assistant is discharging a patient from the hospital when the electronic medical record system goes offline. The PA must resort to issuing handwritten prescriptions to this patient. What handwritten abbreviation has the highest risk of causing a medical error?

U (unit)

You are a physician assistant (PA) working on an inpatient medical service overnight. In the morning, you give verbal sign out to the PA taking over the day shift. You report to them that there was a 17-year-old patient admitted for appendicitis who received ceftriaxone intravenously and broke out in a rash. You prescribed diphenhydramine and documented the reaction in the progress note.

Update the allergy in the patient's medication reconciliation.

A 52-year-old man presents for a follow-up visit. He saw you about 2 weeks ago due to losing his voice. The diagnosis of acute laryngitis was made at that time, and supportive treatment was described to him. The patient returns a little worried today because he has had no improvement in getting his voice back since his last visit. The patient is a professor at a local university and desperately needs his voice to return in order to lecture properly. Social history reveals a 32 pack-year smoking history. Further questioning of the patient during your review of systems reveals unintentional weight loss of 5 lb since his last visit.

Urgent referral to an otolaryngologist

A 32-year-old woman presents for her annual health maintenance exam. She is concerned regarding weight gain. She states she has been watching her dietary intake closely but reports being hungry frequently. She has also had skin changes with frequent breakouts of acne and purple striae. Past medical history is noncontributory. She is not currently on any medications.

Urinary free cortisol level

A 23-year-old man diagnosed with type 1 diabetes 5 years ago presents for a regular examination. Upon physical examination, temperature is 98.1°F, blood pressure is 120/80 mm Hg, and there are no signs of edema. He explains that recently he has been noticing that his urine seems a little darker and foamy, but he has no discomfort while urinating. Blood tests indicate an A1c level of 6.7%.

Urine albumin measurement

A 20-year-old woman presents with a rapid onset of nausea, headaches, fast breathing, and dilated pupils. Her sister thinks that the patient is exhausted from staying up several nights to study for final exams. The patient refused food several times, arguing that she did not have time to spend on anything but her studying; she even became aggressive when her roommates insisted on her going out to dinner with them. Upon physical examination, the patient seems tired and has a dry mouth; her body temperature is 99.8°F and her blood pressure is 135/85. The patient states that she took 2 acetaminophen pills the night before and in the morning to get rid of her headaches.

Urine drug test

A 33-year-old Caucasian man presents with redness, itching, and burning on the back of his hands. He gives a history of clearing "weeds" on his farm yesterday. You ask him to describe the weeds, and he states that they had a cluster of three leaves. There are several tiny blisters with a linear distribution on both of his hands.

Urushiol

A 58-year-old man is admitted with an episode of acute diverticulitis. He will be started on ciprofloxacin, metronidazole, and morphine. He supplies a list of medications, including metoprolol, atorvastatin, aspirin, and tamsulosin. He reports he is on another medication but cannot recall the name. He describes it as a small white pill he thinks he takes for overactive bladder.

Use barcode-scanned medications only.

A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have become "dull." Over the past month, she has started having urinary urgency and involuntary leaking of urine. Besides multivitamins and local application of Timolol for glaucoma, she takes no other medications; there are no other symptoms.

Ventriculoperitoneal shunt

A 42-year-old man presents to the emergency department with a severe headache. He has been getting several of these headaches recently and has tried all over-the-counter pain relievers and headache medicines with no relief. His current headache started 15 minutes ago. He describes the pain as located next to and behind his left eye and "stabbing/excruciating" in nature. He feels like his left eye tears up profusely with these headaches. He reports he has been healthy otherwise, with no chronic medical conditions, no history of surgery, no medications, and no drug allergies. He denies recent stressors that may have caused his headaches. On physical exam, the patient appears slightly agitated and appears uncomfortable. His left eye's conjunctiva is mildly injected, and lacrimation is noted. His right eye is normal. Cranial nerves II-VII are intact, although the patient expresses discomfort when the light is shown in his left eye. Speech, gait, coordination, and reflexes are all normal. The remainder of his exam is normal. Head MRI is performed and reported as normal.

Verapamil

A 22-year-old woman with a history of gradual right-sided hearing loss presents seeking help. She has been experiencing some ringing in her right ear, vertigo, and a feeling of fullness in the ear. Upon physical exam, the patient appears frustrated and keeps tugging on her right ear. MRI displays a tumor that has developed in the right inner ear.

Vestibular schwannoma

A 22-year-old man presents with a temp of 101°F, a headache, stiff neck, and some limitation of flexion of his neck for the past 2 days. The patient also has generalized myalgia for the past 3 days. The patient was advised rest, adequate hydration, and treatment with antipyretics. The recommended treatment caused the resolution of symptoms.

Viral syndrome

A 50-year-old woman presents with a 4-month history of white patches on her skin. The patches of discoloration easily burn when exposed to sun but are not painful. Physical exam reveals well demarcated white macules on her face, neck and hands. There is no erythema, crusting, or drainage.

Vitiligo

An 18-year-old man presents to the emergency department due to right lower quadrant abdominal pain for 12 hours associated with nausea and vomiting. His temperature is 101°F, and he is hemodynamically stable. The patient has abdominal guarding, a positive Rovsing's sign and tenderness at McBurney's point. A computed tomography (CT) scan demonstrates a perforated appendix. General surgery is called and they request the patient be added on the OR schedule for emergency appendectomy.

Wait for the surgeon to obtain consent from the patient.

A 6-year-old girl is brought in by her mother and presents with sudden localized swelling of her left upper eyelid at the lid margin. Mom states this has never happened to the girl before. She denies discharge, fever, or trauma. There is mild pain on to palpation. The remainder of the eye exam is within normal limits.

Warm compresses

A 70-year-old man on vacation in the US presents for what appears to be suspicious skin lesion on his cheek. He has had a longstanding discolored patch; it has recently enlarged in size, and there is crusting. A biopsy confirms your suspected diagnosis. After undergoing treatment, he wants to take measures to prevent a recurrence.

Wear protective clothing and avoid midday sun.

A 24-year-old man with no significant past medical history presents with a 3-month history of progressive hearing loss of his left ear. He states that he has the greatest difficulty in hearing high-pitched sounds. He denies trauma, recent travel, sick contacts, pressure changes, headache, nausea, otorrhea, otalgia, fever, chills, vertigo, swollen glands, rashes, sore throat, vision changes, or rhinitis. He states that he enjoys listening to music on his personal music device and attends concerts frequently. An otoscopic speculum exam reveals no observable abnormalities.

Weber test

A 25-year-old man presents to you with an acute otitis media with serous otitis in the right ear. You perform the Weber and Rinne tests.

Weber—sound is heard louder in right ear; Rinne—bone conduction exceeds air conduction in right ear

A 58-year-old man presents for further evaluation after being brought in by the local police because of an unstable gait and disheveled appearance; his breathalyzer test is 0.08 g/dL. On exam, the man is gaunt and clearly malnourished; he is disoriented and confused and unable to respond to questioning. His right elbow and knee are bruised, but he appears to have no other significant injuries; however, his eye movements are uncoordinated and bounce from side to side. He is unable to fixate his gaze. Vital signs are as follows:

Wernicke's encephalopathy

A 17-year-old boy develops progressively abnormal muscle fatigability. He is diagnosedwith myasthenia gravis and is admitted to a hospital. In the course of his treatment with pyridostigmine, he develops increased weakness, nausea, vomiting, sweating, and bradycardia.

Withdraw pyridostigmine.

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. He also hears a ringing sound all the time. He denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. Past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and recreational drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Yearly head imaging

A physician assistant is triaging patients in California following a severe earthquake. The patient currently being evaluated by the PA has an open femur fracture without major hemorrhage.

Yellow

You are evaluating a 14-year boy for a pre-participation sports physical. He has been conditionally accepted as a wide receiver on his high school's football team. He was diagnosed with generalized tonic-clonic seizures at age 6. He is well-controlled on valproic acid, having had only 2 seizures in the past 3 years, associated with an intercurrent illness. There is no history of status epilepticus, head trauma, or other neurologic abnormalities, and he maintains a B+ average in school. Past medical history is otherwise unremarkable. Growth and development have been normal and immunizations are current. Vital signs are normal. Examination is unremarkable.

Yes; his seizure disorder is well-controlled.

A 43-year-old woman presents for possible seizures. She was having an argument with her supervisor at work when she slumped back in her chair, became pale, and had a 5- to 10-second spell of generalized tonic-clonic jerking. She was placed on the floor and began to rouse 15-30 seconds later. She has a history of generalized tonic-clonic seizures, and she has been on divalproex sodium (Depakote). At age 8, a repeat electroencephalogram was normal, and divalproex was discontinued. Seizures did not reoccur. Exam reveals a well-developed well-nourished woman; awake, alert, fully-oriented, and in no acute distress. Temperature is 98.8°F orally. Blood pressure is 129/85 mm Hg. Heart rate is 76/min and regular. Respirations are 14/min and unlabored. General neurological and medical exams are normal. Lab studies include a normal complete blood count and differential, blood chemistry panel, urinalysis, chest X-ray, and EKG. Portable electroencephalogram is normal.

Young (20-30) women with a history of sexual abuse