Rosh Boost: Family Medicine

oral hydration and ciprofloxacin **shigella

A 46-year-old man presents to the urgent care with 4 days of diarrhea and abdominal cramps. He states he started to feel fatigued and had a low-grade fever when he got back from his Costa Rica trip. He then noticed abdominal cramping and explosive watery diarrhea that has now turned into bloody diarrhea. He reports around eight episodes of diarrhea per day. Vital signs today include HR of 92 bpm, BP of 132/81 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 100.4°F. Upon physical exam, inspection and percussion of the abdomen is unremarkable. Auscultation reveals hyperactive bowel sounds. Mild tenderness to deep palpation of all four quadrants is elicited. A stool culture is obtained and is positive for Shigella. What is the best next step in the management of this patient's condition? AOral hydration alone BOral hydration and ciprofloxacin COral hydration and loperamide DOral hydration and rifaximin

E. coli **acute epididymitis

A 46-year-old man with a medical history of hypertension, for which he takes chlorthalidone, presents to the urgent care with 2 days of right testicular pain and swelling. The patient reports no history of trauma. He reports that he is in a long-term monogamous relationship with his partner. Vital signs include a BP of 120/80 mm Hg, HR of 85 bpm, RR of 20/minute, oxygen saturation of 99% on room air, and T of 98.6°F. On physical examination, the patient has posterior right testicular tenderness, intact cremasteric reflexes bilaterally, and no penile discharge. The patient reports improvement in the pain when the testicle is raised. Which of the following is the most common pathogen to cause the suspected condition in this patient? AChlamydia trachomatis BEscherichia coli CNeisseria gonorrhoeae DProteus mirabilis

diabetes mellitus **gastroparesis

A 47-year-old woman presents to urgent care with a 5-week history of appetite loss. Over-the-counter therapeutics have not improved her symptoms. She is accustomed to small meals and snacks but finds that she feels full or bloated all day. If she tries to eat at those times, she feels nauseous or even vomits. She has had no surgery except for wisdom teeth removal. Bowel movements occur every other day. Vital signs are BP of 116/80 mm Hg, HR of 80 bpm, RR of 18 bpm, oxygen saturation of 97% on room air, T of 97.8°F, and BMI of 20.5 kg/m2. Oral mucosal tissues are dry. Abdominal exam reveals mild distention and diminished bowel sounds but no tenderness or guarding. Abdominal X-ray shows air-fluid levels including a distended stomach. What is the most common underlying cause of this condition? ADiabetes mellitus BMultiple sclerosis CParkinson disease DScleroderma

neovascularization **proliferative diabetic retinopathy

A 50-year-old man presents to the clinic for a routine ophthalmologic examination. He reports no changes in visual acuity. Vital signs include an HR of 80 bpm, BP of 125/80 mm Hg, RR of 20/minute, oxygen saturation of 99% on room air, and T of 98.6°F. The patient has a hemoglobin A1C of 10.5 g/dL. Which of the following findings on ophthalmoscopic examination is suggestive of advanced proliferative disease in this patient? AArteriovenous nicking BCotton wool spots CMicroaneurysms DNeovascularization

lisinopril

A 50-year-old man with a history of type 2 diabetes presents to the clinic for his yearly physical. His vital signs include a blood pressure of 165/85 mm Hg, heart rate of 85 beats per minute, respiratory rate of 18 breaths per minute, oxygen saturation of 98% on room air, and temperature of 98°F. Physical exam reveals normal cardiac exam with regular rate and rhythm, clear lungs to auscultation, and abdominal exam with no distension, no hepatomegaly, and no masses. He has 2+ radial and distal pedal pulses bilaterally. No lower extremity swelling is noted. You note the patient's blood pressure at his last visit was 160/80 mm Hg. He did not follow-up as asked at his last visit. BMP shows fasting glucose 101 mg/dL, calcium level 9 mg/dL, potassium 3.7 mEq/L, sodium 138 mEq/L, and creatinine 1.3 mg/dL. Hemoglobin A1C is 7%. What is the most appropriate first-line pharmacologic therapy according to the ACC/AHA hypertension guidelines? AAmlodipine BCarvedilol CHydrochlorothiazide DLisinopril

order low-dose chest CT **ages 50-80 with 20 pack year smoking history

A 51-year-old man presents to his family clinician for his annual wellness check. His colonoscopy 1.5 years ago detected two noncancerous polyps, which were removed. His history includes smoking one pack of cigarettes per day from age 18-50. Medications include lisinopril and allopurinol. Vital signs are BP of 120/80 mm Hg, HR of 70 bpm, RR of 16/min, T of 97.8°F, and BMI of 28 kg/m2. His lipid profile shows an LDL of 110 mg/dL, HDL of 55 mg/dL, and total cholesterol of 215 mg/dL, for a calculated total 10-year atherosclerotic cardiovascular disease risk of 4%. CMP values are within normal limits. Uric acid is 7 mg/dL. His heart has a regular rate and rhythm, lungs are clear to auscultation, bowel sounds are active, and prostate is smooth and walnut sized. What is the best next step in management? AOrder abdominal US BOrder low-dose chest CT CPrescribe a statin DSchedule a colonoscopy

vagal maneuvers **supraventricular tachycardia

A 52-year-old man with a medical history of diabetes mellitus and hyperthyroidism, for which he takes metformin and methimazole, presents to the urgent care with palpitations for the past hour. The patient reports he feels lightheaded and fatigued, but he has not experienced any chest pain or shortness of breath. Vital signs include a HR of 195 bpm, BP of 120/80 mm Hg, RR of 20/minute, SpO2 of 95% on room air, and T of 98.6°F. Physical examination reveals a tachycardic and regular rate with no murmurs and lungs that are clear to auscultation. The patient has no peripheral edema and has 2+ pulses in all extremities. The patient's ECG is shown above. Which of the following is the most appropriate next step? AAdenosine BCardioversion CVagal maneuvers DVerapamil

continuous positive airway pressure **OSA

A 55-year-old man presents to the clinic with his spouse for his annual physical. When asked about sleep, his spouse mentions the patient often snores loudly, and the spouse has witnessed the patient stop breathing in his sleep. The patient also reports daytime sleepiness. Vital signs are a blood pressure of 134/82 mm Hg, heart rate of 76 bpm, respiratory rate of 16/min, oxygen saturation of 95% on room air, and temperature of 98.6°F. Physical exam reveals a Mallampati score of 3 and a waist circumference of 40 cm. The remainder of the physical exam is unremarkable. Polysomnography is ordered and reveals an apnea-hypopnea index of > 15 events per hour. What is the best next step in management? AContinuous positive airway pressure BOral appliances COxybutynin trial DUpper airway surgery

demolition of an attic covered with bird droppings **histoplasmosis

A 55-year-old man who works as a farmer presents to the clinic with a cough and shortness of breath that have been gradually worsening over the past 3 weeks. He reports associated fever, chills, and headaches. The patient has a medical history of diabetes mellitus and has not been adhering to his treatment recently. Vital signs include an HR of 110 bpm, BP of 120/80 mm Hg, RR of 24/minute, oxygen saturation of 95% on room air, and T of 100.6°F. Physical examination reveals rales and dullness to percussion in the right lower lobe and no meningeal signs. Chest X-ray reveals hilar adenopathy. You are concerned for the most common endemic fungal infection in the United States. Which of the following is considered a risk factor for this fungal infection? AClose proximity to goats and sheep BDemolition of an attic covered with bird droppings CHistory of HIV infection with recent CD4 count of 200 cells/μL DResidence in Arizona

acute gastritis

A 55-year-old woman, who is otherwise healthy, presents to the clinic with abdominal pain. She notes pain intermittently over the past 2 weeks. She also notes feelings of fullness and bloating. She feels it is worse after eating. She reports no chest discomfort or burning, cough, nausea, vomiting, diarrhea, or constipation. She has no significant weight loss or weight gain. The patient states she drinks one to two glasses of wine per night. Vital signs show a heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 118/75 mm Hg, temperature of 98°F, and oxygen saturation of 100% on room air. Abdominal exam reveals normoactive bowel sounds and mild tenderness to palpation in the epigastric region and right upper quadrant without rebound tenderness, guarding, or rigidity. Urine shows negative leukocytes or nitrites. There is no hematuria. CBC and CMP results are within normal limits. What is the most likely diagnosis? AAcute cholecystitis BAcute gastritis CAcute pancreatitis DGastroesophageal reflux disease

transfer to nearest hospital facility **MI

A 56-year-old man presents to the urgent care clinic with chest pain that started approximately 30 minutes ago. The patient was at rest when the pain started. He describes the pain as crushing and radiating to the left shoulder. His vital signs are a BP of 140/84 mm Hg, HR of 66 bpm, RR of 26/min, SpO2 of 95% on room air, and a T of 98.8°F. Upon physical examination, the patient is noted to be diaphoretic. Cardiac examination is within normal limits, and lungs are clear to auscultation bilaterally. The remainder of the physical examination is unremarkable. An electrocardiogram is shown above. What is the best next step in the management of this patient's condition? AAdminister alteplase BAdminister morphine CAdminister oxygen DTransfer to nearest hospital facility

improvement with small amounts of ethanol **essential tremor

A 57-year-old man presents to the office for evaluation of tremor. The patient reports that the tremor has been present for the past 20 years. The severity of the tremor has progressed and is now interfering with his day-to-day functioning. He is debating leaving his job as a heating, ventilation, and cooling technician, as he cannot handle the tools effectively. His medical history is pertinent for hyperlipidemia, which is currently managed with simvastatin. He reports a family history of a similar tremor in his mother. Vital signs reveal a blood pressure of 142/78 mm Hg, heart rate of 82 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 98%. The patient is afebrile. Physical examination reveals a high-frequency, low-amplitude tremor of both hands. A subtle yes-yes tremor of the head is also observed. There are no gait abnormalities or bradykinesia. Given the most likely diagnosis, what other tremor characteristic would you anticipate? AAmelioration with dopamine-containing compounds BAssociation with cogwheeling rigidity CImprovement with small amounts of ethanol DWorsening with caffeine intake

interstitial lung disease **silicosis

A 57-year-old man who works as a quartz miner presents to the clinic with shortness of breath and dry cough for 9 months. His medical history includes essential hypertension and benign prostatic hyperplasia. Current vital signs are heart rate 86 bpm, blood pressure 130/88 mm Hg, respiratory rate 18/minute, oxygen saturation 95% on room air, and temperature 98.7°F. Physical examination reveals regular rate and rhythm, soft and nontender abdomen, no respiratory distress, crackles over bilateral lower lung fields, no wheezing, and no stridor. Pulmonary function testing reveals an FEV1/FVC of 85%, FVC of 65%, and total lung capacity of 70%. Which of the following is the most likely diagnosis? AAsthma BEmphysema CInterstitial lung disease DPulmonary hypertension

internal hemorrhoid

A 57-year-old man with a medical history of hypertension treated with losartan 25 mg daily presents to the clinic with rectal bleeding and a few episodes of mild fecal incontinence gradually worsening over the past 3 months. He describes the blood as bright red and notices it on the toilet paper after wiping and also notes a small amount of blood in the toilet bowl after having a bowel movement. He reports one bowel movement per day recently, compared to his usual two to three per day. Vital signs include a heart rate of 76 bpm, blood pressure of 132/82 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 98.4°F. On physical exam, normal-appearing perianal skin is observed with no erythema or protrusions. A digital rectal examination is performed and no abnormalities are palpated. Anoscopy shows bulging purple-blue veins in the anal canal and distal rectum. What is the most likely diagnosis? AAnal fissure BExternal hemorrhoid CInternal hemorrhoid DProctitis

amoxicillin-clavulanate and azithromycin **community acquired pneumonia

A 57-year-old man with a medical history of hypertension, for which he takes amlodipine, diabetes mellitus, for which he takes metformin and sitagliptin, and an abdominal aortic aneurysm presents to the urgent care with fever and cough for the past 2 days. He reports mild shortness of breath but no chest pain. Vital signs include HR of 105 bpm, BP of 125/80 mm Hg, RR of 20/minute, oxygen saturation of 95% on room air, and T of 101.2°F. Physical examination reveals the patient to be alert and oriented with a regular rate and rhythm and rales in the left lower lung field. The patient has a chest X-ray performed that is pictured above. Which of the following is the recommended initial treatment for this patient? AAmoxicillin-clavulanate and azithromycin BAzithromycin CLevofloxacin DSend the patient to the emergency department for admission

non-ST elevation myocardial infarction

A 58-year-old man with hypertension controlled by lisinopril and hyperlipidemia controlled by atorvastatin presents to the emergency department with acute chest pain that began 1 hour ago. The pain is described as tightness that radiates to the left shoulder. Vital signs are a blood pressure of 100/60 mm Hg, heart rate of 86 bpm, respiratory rate of 30/min, oxygen saturation of 93% on room air, and temperature of 98.6°F. Physical examination reveals a diaphoretic and anxious patient. Cardiac examination reveals tachycardia without murmurs, gallops, or rubs. Lungs are clear to auscultation bilaterally. The remainder of the physical examination is within normal limits. Laboratory examination reveals a cardiac troponin of 1 ng/mL. An ECG is obtained and is shown above. What is the most likely diagnosis? ANon-ST elevation myocardial infarction BPericarditis CST elevation myocardial infarction DUnstable angina

alcohol consumption **breast cancer

A 58-year-old woman presents to primary care with a lump in her left breast. She noticed it about 2 months ago while in the shower. She has no medical history and is on no medications. She reports no nipple retraction, edema, nipple discharge, or redness of her left breast. Her vital signs include a T of 97.8°F, BP of 120/78 mm Hg, RR of 13/min, HR of 90 bpm, and oxygen saturation of 100% on room air. Examination reveals a single, nontender, hard mass with ill-defined margins. No skin changes or lymphadenopathy are present. Her mammogram reveals clustered microscopic calcifications. Which of the following is a risk factor for her disease? AAlcohol consumption BEarly menopause CMenarche at age 14 DMultiparity

monofilament testing **they need a dilated eye exam as well

A 58-year-old woman with hypertension controlled by lisinopril and type 2 diabetes mellitus controlled by metformin presents to the clinic for her annual physical exam. Her vital signs are a BP of 126/82 mm Hg, HR of 76 bpm, RR of 16/min, SpO2 of 99% on room air, and a T of 98.6°F. Physical examination reveals lungs clear to auscultation and a heart with regular rate and rhythm. The abdomen is soft and nontender, and cranial nerves are intact. The remainder of the physical examination is within normal limits. A hemoglobin A1C is 8.2%. What is the best test to assess for complications of this patient's conditions? AExercise stress testing BFundoscopic exam CMonofilament testing DUrinalysis

bladder ultrasound **acute urinary retention due to BPH

A 60-year-old man with benign prostatic hyperplasia controlled by alfuzosin presents to the urgent care clinic with an inability to urinate for the past 12 hours. He states that he did not have any discomfort with urination prior to his inability to urinate, and he did not notice any blood in his urine. His vital signs are a BP of 128/88 mm Hg, HR of 90 bpm, RR of 20/min, SpO2 of 99% on room air, and a T of 98.8°F. Upon abdominal examination, the urinary bladder is palpable anteriorly, and pain is elicited from the patient upon deep abdominal palpation. The remainder of the physical examination is within normal limits, and the patient does not appear to be in acute distress. What is the best next step in the management of this patient's condition? ABladder ultrasound BReferral to urologist CTransfer to emergency department DUrinary catheter

pain relieved by hanging the foot off the side of the bed **peripheral artery disease -this allows extra perfusion to ischemic areas due to gravity

A 60-year-old woman who currently smokes and has a history of hypertension, type 2 diabetes, and hyperlipidemia presents to the clinic with concerns for left lower extremity pain upon with walking. She states the pain has been occurring for about 6 months. She takes lisinopril 10 mg daily and atorvastatin 40 mg daily. On a physical exam, her vital signs show a heart rate of 80 beats per minute, blood pressure of 140/80 mm Hg, temperature of 96.8°F, respiratory rate of 20 bpm, and oxygen saturation of 99% on room air. The cardiac exam reveals normal rate and rhythm. Lungs are clear to auscultation. Her abdomen is soft, nondistended, with no masses. Vascular exam reveals 2+ bilateral femoral pulses and 1+ distal pedal pulses in bilateral lower extremities. There is a 1 × 1 cm ulceration along the left lateral malleolus. The skin is slightly thin and shiny on the left lower extremity. What other aspects of this patient's history would support the most likely diagnosis? AAching leg pain that is worse at the end of the day BElevation of the legs relieves swelling CPain is improved by elevating the feet DPain relieved by hanging the foot off the side of the bed

intraperitoneal adhesions **small bowel obstruction

A 60-year-old woman with a history of a hysterectomy 2 years prior and hypertension presents to the urgent care with a chief concern of abdominal pain and vomiting. She states the abdominal pain began 3 days prior and vomiting began the day of presentation. On the exam, she has HR of 120 bpm, BP of 130/90 mm Hg, T of 98°F, and oxygen saturation of 98% on room air. She is slightly ill appearing. The cardiac exam reveals tachycardia and normal rhythm without murmur. Her lungs are clear to auscultation in all fields. The abdomen is mildly distended with hyperactive and high-pitched bowel sounds. An abdominal X-ray is shown above. What is the most common cause associated with the most likely diagnosis? ACrohn disease BIncarcerated umbilical hernia CIntraperitoneal adhesions DMalignancy

alcohol consumption **oral leukoplakia

A 62-year-old man presents to the clinic after noticing a white area on the inside of his mouth. He reports he has not had any associated pain or bleeding. The patient has a history of hypertension for which he takes amlodipine. He has used smokeless tobacco for the past 45 years. Vital signs include an HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination reveals a small white area on his labial mucosa that does not scrape with gauze. Which of the following is a risk factor for the suspected condition? AAlcohol consumption BNonsteroidal anti-inflammatory drug use CRed meat consumption DSedentary lifestyle

unstable angina **new increase and frequency in chest pain

A 62-year-old man with a medical history of hypertension, hyperlipidemia, and diabetes mellitus, which are untreated due to medication nonadherence, presents to the emergency department with worsening intermittent and substernal chest pressure for the past week. The pain has occurred while playing tennis and resolves with 15 minutes of rest. It radiates to his left arm and is associated with nausea and diaphoresis. The duration of the episodes of chest pain has increased during the past week. The patient reports having no shortness of breath, back pain, or leg swelling. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, SpO2 of 99% on room air, and T of 98.6°F. The patient's chest X-ray shows no acute cardiopulmonary process. The patient's initial troponin, 2-hour troponin, and 6-hour troponin are 0.1 ng per mL. The patient's chest pain resolves with nitroglycerin, and his initial and repeat ECG are unchanged. The ECG is shown above. Which of the following is the suspected diagnosis? ANon-ST elevation myocardial infarction BST elevation myocardial infarction CStable angina DUnstable angina

vaginal moisturizers and lubricants

A 62-year-old woman presents to her primary care office with concerns about vaginal dryness. She has not had a menstrual cycle for the past 4 years. She states she has experienced dyspareunia for the past 1-2 years. Her vital signs are HR of 70 bpm, RR of 17/min, BP of 120/76 mm Hg, T of 98.2°F, oxygen saturation of 100% on room air, and BMI of 23.2 kg/m2. Consent for a pelvic exam is obtained, and a pelvic exam is performed. On exam, the vaginal epithelium is pale, dry, and shiny. Which of the following is the most appropriate management for this patient's condition? AIntravaginal clotrimazole BIntravaginal estrogen CSystemic estrogen and progesterone DVaginal moisturizers and lubricants

Ethambutol

A 62-year-old woman presents to hospital-associated urgent care reporting a productive cough for the past 6 months. She also reports fever, night sweats, fatigue, and weight loss. She reports losing her job during the COVID-19 pandemic and is currently without housing. She has not had regular medical care since losing her health insurance after the loss of her job. She has been sleeping in a crowded tent in a community. She presented to the urgent care because her cough recently began producing blood-tinged sputum. Physical examination reveals posttussive apical rales. Chest X-ray shows small unilateral infiltrates, hilar and paratracheal lymph node enlargement, and segmental atelectasis. Sputum culture is obtained and sent to the laboratory for culture. While awaiting results of the sputum culture, red-green color vision testing should be completed when considering initiating which of the following medications? AEthambutol BIsoniazid CPyrazinamide DRifampin

Hydroxymethylglutaryl-coenzyme A reductase inhibitor **statin

A 62-year-old woman with type 2 diabetes mellitus controlled by metformin and empagliflozin and hypertension controlled by lisinopril presents to the primary care clinic for her annual physical exam. Vital signs are blood pressure of 128/88 mm Hg, heart rate of 86 bpm, respiratory rate of 16/min, oxygen saturation of 98% on room air, and temperature of 98.8°F. A physical examination reveals lungs that are clear to auscultation bilaterally. A cardiac exam reveals a regular rate and rhythm with no murmurs, gallops, or rubs. The abdomen is soft and nontender. The rest of the physical exam is unremarkable. Laboratory examination reveals a total cholesterol of 220 mg/dL, LDL of 170 mg/dL, HDL of 29 mg/dL, and triglycerides of 308 mg/dL. Medication is prescribed to treat the lab results that are outside the normal range. What is the mechanism of action of the medication? ACholesterol absorption inhibitorYour Answer BHydroxymethylglutaryl-coenzyme A reductase inhibitor CPeroxisome proliferator-activated receptor-alpha agonist DProprotein convertase subtilisin-kexin type 9 inhibitor

acetylsalicylic acid **stable angina

A 63-year-old man with a history of stable angina presents for his routine health check. He reports being able to walk 1 mile without stopping to rest. In the past 3 months, he has had no episodes requiring sublingual nitroglycerin and has cut back on smoking and fast food consumption. Vital signs are BP of 122/80 mm Hg, HR of 66 bpm, RR of 14/min, SpO2 of 97% on room air, T of 98.0°F, and BMI of 29 kg/m2. His laboratory results came back with total cholesterol of 240 mg/dL, HDL of 45 mg/dL, LDL of 120 mg/dL, and A1C of 5%. Other labs are unremarkable. Kidney function is within normal limits. The echocardiologist report from 6 months ago indicated a left ventricular ejection fraction of 59%. No murmurs or bruits are detected on exam, and lungs are clear to auscultation. Which of the following pharmacological therapies has been associated with a decreased risk of cardiovascular events in patients like this one? AAcetylsalicylic acid BAmlodipine CIsosorbide dinitrate DLisinopril

colchicine and ibuprofen **pericarditis

A 64-year-old man with a medical history of hypertension on hydrochlorothiazide 25 mg daily presents to the urgent care with chest pain since this morning. He describes the pain as sharp, constant, and worse with inspiration. He reports the chest pain happens at rest and does not worsen with exertion. He reports the pain radiates to his left shoulder. Vital signs today include HR of 100 bpm, BP of 132/81 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 98.4°F. On physical exam, a pericardial friction rub is heard at the end of expiration. The chest wall is symmetric, without deformity, and atraumatic in appearance. No tenderness to palpation of the chest wall is noted. An electrocardiogram is shown above. An echocardiogram is also taken and the results are unremarkable. What is the best management for this patient's condition? AColchicine and aspirin BColchicine and ibuprofen CPericardial drainage DPrednisone

abdominal ultrasound

A 65-year-old man with a medical history of hypertension and hyperlipidemia, for which he takes amlodipine and atorvastatin, presents to the clinic for an annual wellness examination. He has smoked a pack of cigarettes per day for 44 years. Vital signs include a HR of 80 bpm, BP of 130/80 mm Hg, RR of 20/minute, SpO2 of 99% on room air, and T of 98.6°F. Physical examination findings include a regular rate and rhythm, lungs clear to auscultation bilaterally, no carotid bruits, an abdominal bruit at the umbilicus, 2+ distal pulses in all extremities, and a soft and nontender abdomen with bowel sounds present in all four quadrants and no pulsatile masses. Which of the following diagnostic studies is recommended for this patient? AAbdominal ultrasound BAbdominal X-ray CCT angiography of the abdomen and pelvis DMRI of the abdomen

rivaroxaban for 12 weeks **venous thromboembolism

A 66-year-old woman with hypertension controlled by lisinopril and hyperlipidemia controlled by atorvastatin presents to the urgent care clinic with pain in her left calf that started 2 hours ago. She notes that her left calf is warm to the touch and swollen. Her vital signs are a BP of 122/86 mm Hg, HR of 80 bpm, RR of 16/min, SpO2 of 93% on room air, T of 99.1°F, and a BMI of 36 kg/m2. Upon physical examination, tenderness is noted in the left calf and the area is erythematous and edematous. Cardiac examination is within normal limits, and lung exam is unremarkable. An ultrasound of the left lower extremity is obtained and reveals noncompressibility of the left posterior tibial vein. What is the best next step in the management of this patient's condition? ANo anticoagulation indicated BPlacement of an inferior vena cava filter CRivaroxaban for 12 weeks DWarfarin for 12 weeks

chronic venous insufficiency

A 67-year-old man with a history of obesity and hypertension presents to the clinic for bilateral lower extremity swelling and a new wound. He has not been seen in the clinic for over a year. He reports no chest pain, shortness of breath, or orthopnea. He notes he has had some leg heaviness that is worse in the evening. Pain and swelling are improved with elevation of his legs. Vital signs show heart rate of 80 beats per minute, respiratory rate of 19 breaths per minute, temperature of 98°F, blood pressure of 150/85 mm Hg, and oxygen saturation of 98% on room air. Cardiac exam reveals normal rate and rhythm without murmur. Pulmonary exam reveals bilateral lungs clear to auscultation without rales or crackles. The patient has 1+ pitting edema with darkening of skin of bilateral lower extremities. A wound is noted on his right lower extremity above the medial malleolus. It is shallow, weeping, erythematous, and has irregular borders. Which of the following is the most likely diagnosis? ACellulitis BChronic venous insufficiency CLymphatic obstruction DPeripheral artery disease

postural instability **Parkinsons disease

A 67-year-old woman presents to the office with concerns of a tremor in her right hand. The tremor has been present for approximately 6 months and only seems to occur when her hand is at rest. She notes difficulty with buttoning her buttons when getting dressed in the morning. Her medical history is pertinent for osteoporosis. She currently takes alendronate. Vital signs include a blood pressure of 128/74 mm Hg, heart rate of 68 beats per minute, respiratory rate of 14 breaths per minute, and oxygen saturation of 100%. She is afebrile. Physical examination demonstrates a pill-rolling tremor, cogwheeling rigidity, and a slow shuffling gait with loss of arm swing. Based on the suspected diagnosis, which of the following is considered a cardinal feature of the disease? ADementia BMasked facies CMicrographia DPostural instability

fenofibrate **hypertriglyceridemia

A 67-year-old woman with a history of depression, diabetes mellitus type 2, hypertriglyceridemia, and gout presents to the primary care clinic for a routine checkup. She takes escitalopram 10 mg daily, metformin 500 mg bid, fenofibrate 160 mg daily, and allopurinol 200 mg daily. She reports having muscle weakness in her shoulders, arms, and thighs that has gradually worsened over the past few months. Vital signs include a heart rate of 82 bpm, blood pressure of 132/84 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.4°F. On physical exam, the shoulders and arms have no obvious bony deformities, inflammation, or tenderness in the rotator cuff, biceps tendon, or acromioclavicular joint. Full range of motion and strength are noted in the shoulders upon adduction, abduction, and internal and external rotation. Strength of 5/5 is noted in the hip flexors and extensors and adductors and abductors. Patellar reflex is noted to be 2+ bilaterally. Lab results include a creatine kinase level of 45 U/L. Which of the following is the most likely causative agent for this patient's presentation? AAllopurinol BEscitalopram CFenofibrate DMetformin

CT scan of the abdomen and pelvis **diverticulitis

A 67-year-old woman with a medical history of hyperlipidemia treated with atorvastatin 20 mg daily presents to the urgent care with abdominal pain. She reports left-sided abdominal pain that started last night and has been gradually worsening. She describes the pain as achy and constant. She reports slight nausea but no vomiting. She had one bowel movement last night and one this morning, which appeared normal for her. She reports she has never experienced this pain in the past. Vital signs include a heart rate of 98 bpm, blood pressure of 128/74 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 99.8°F. On physical exam, there is tenderness to palpation of the left lower quadrant. Bowel sounds are normal. Murphy sign is negative, no tenderness is noted at the McBurney point, and no rebound guarding is noted. Which of the following is the best next step in diagnosis for this patient's condition? AAbdominal radiograph BBarium enema CColonoscopy DCT scan of the abdomen and pelvis

thyroid-stimulating hormone **atrial fibrillation

A 68-year-old woman presents to her primary care clinician with concerns about "palpitations" that come and go. She first noticed them after "living it up" with friends and family over the holiday season but otherwise notices no pattern to the episodes. When asked if she feels the palpitations now, she states she is not sure. She has been feeling tired. She has hypertension, for which she takes lisinopril, and she smokes one-half of a pack of cigarettes a day. Vital signs are BP of 122/78 mm Hg, HR of 64 bpm, RR of 18/min, oxygen saturation of 96% on room air, T of 98.0°F, and BMI of 26 kg/m2. She appears well without pallor, flushing, or trembling of extremities. Pupilar are equal, round, and reactive to light. Physical exam reveals an irregularly irregular pulse, and no murmurs or rubs on the cardiac exam. Auscultation of lungs is normal. ECG is shown above. Which of the following diagnostic tests is indicated in the initial workup of the most likely diagnosis? AChest X-ray BCT pulmonary angiography CThyroid-stimulating hormone DUrine toxicology

Alzheimer disease -dementia with Lewy bodies: hallucinations, Parkinson symptoms, rapid eye movement withs sleep -frontotemporal dementia: behavior change with compulsions and impulsivity -vascular dementia: history of stroke

A 68-year-old woman presents to the office with a family member for evaluation of memory loss. While the patient reports no problems with her memory, the family member notes the patient has been increasingly forgetful over the past 9 months. She calls family members multiple times per day to ask the same question. She has been less sociable. She recently got lost when driving home from the post office, which is less than a mile from her home. The patient's medical history is pertinent for well-controlled hypertension, for which she is prescribed losartan. Vital signs show a blood pressure of 118/60 mm Hg, heart rate of 64 beats per minute, respiratory rate of 18 breaths/minute, and oxygen saturation of 97%. The patient is afebrile. Physical examination is without focal neurologic findings, but a Mini-Mental State Examination results in a score of 18. What is the most likely diagnosis? AAlzheimer disease BDementia with Lewy bodies CFrontotemporal dementia DVascular dementia

prescribe a cephalosporin **pharyngitis -this is because they do not have an anaphylactic reaction to penicillin

A 7-year-old boy presents to the clinic with his parents for fever and sore throat that started suddenly yesterday. He also reports pain with swallowing, fatigue, and nausea but no cough, joint aches, myalgias, or abdominal pain. His medical history includes seasonal allergies to tree pollen, and he takes OTC cetirizine daily but no other medications. He is allergic to penicillin (rash). His vital signs today include T of 101.1°F, BP of 105/75 mm Hg, RR of 18/min, HR of 104 bpm, and oxygen saturation of 100% on room air. His physical exam reveals tender anterior cervical lymphadenopathy, and tonsils are red and edematous with exudates present on the pharynx and tonsils. Skin is warm, without rashes or lesions, and abdomen is soft, nontender, and without organomegaly. Sinuses are nontender, and tympanic membranes are pearly gray with no erythema bilaterally. Which of the following is the most appropriate therapy in this patient? APrescribe a cephalosporin BPrescribe a fluoroquinolone CPrescribe amoxicillin DSymptomatic treatment with acetaminophen

double balloon catheter **posterior epistaxis

A 71-year-old man with a history of ischemic stroke and hypertension presents to the emergency department for nasal bleeding. He takes clopidogrel 75 mg daily, hydrochlorothiazide 50 mg daily, and lisinopril 40 mg daily. He reports the bleeding started this morning while he was watching the news. He reports the amount of blood filled up a small bowl he was holding under his nose until the ambulance came to pick him up. He reports no prior history of nosebleeds. Vital signs today include HR of 99 bpm, BP of 164/94 mm Hg, RR of 18/min, oxygen saturation of 98% on room air, and T of 98.4°F. Upon physical exam, the patient is alert and oriented × 3, airway is open but blood is noted in the posterior pharynx. He appears pale. Which of the following will most likely control his epistaxis? ACauterize with silver nitrate BDouble balloon catheter CNasal pressure and oxymetazoline DNasal tampon

weight loss and low-impact exercise **osteoarthritis

A 72-year-old man presents to the office with left knee pain, which has been slowly worsening over the past year. He has pain when he gets up in the morning that improves once he starts moving but worsens toward the end of the day. He has decreased his activity due to the pain. On physical examination, he has a body mass index of 35 kg/m2. He walks with an antalgic gait on the left. He has mild varus alignment of the left knee. He has no effusion in the knee and mild tenderness over the medial joint line. He has 120° of flexion compared with 135° on the right and no instability to ligament testing. X-ray is shown above. Which of the following is the most appropriate initial treatment? AArthroscopic debridement BGlucocorticoid injection CGlucosamine and chondroitin supplements DWeight loss and low-impact exercise

legionella pneumophila

A 72-year-old man presents to urgent care reporting fever, cough, shortness of breath, and chest pain that worsens during breathing. He also reports associated nausea, vomiting, and diarrhea. His medical history includes COPD. His medications include tiotropium, fluticasone, and albuterol. He currently smokes tobacco and has been smoking 1 pack per day for 50 years. He reports that he flew to New York City for a science fiction convention 2 weeks ago, stayed at the hotel where the convention was being held, spent most of his time indoors due to a heat wave, and took public transportation when he went out. Chest X-ray shows focal patchy infiltrates. Lab work reveals WBC 14,000 µL, sodium 131 mEq/L, phosphorous 2.7 mg/dL, alanine transaminase (ALT) 42 U/L, aspartate transaminase (AST) 45 U/L, and creatine kinase 185 U/L. Sputum Gram stain shows polymorphonuclear leukocytes with no organisms. Which of the following is the most likely causative agent of the patient's symptoms? ALegionella pneumophila BMycobacterium tuberculosis CMycoplasma pneumoniae DStreptococcus pneumoniae

captopril **HFrEF

A 72-year-old man with a history of hyperlipidemia and type 2 diabetes presents to the clinic. He reports several weeks of progressive shortness of breath, dyspnea on exertion, and fatigue. When questioned further, he states that he has been sleeping in his reclining chair, as he feels he is unable to breathe when lying flat. His current medications include metformin and rosuvastatin. His vital signs are a temperature of 37°C, blood pressure of 125/80 mm Hg, heart rate of 76 bpm, respirations of 18/min, and oxygen saturation of 98% on room air. On exam, the patient appears fatigued but not in acute distress. His cardiac exam reveals an S3 heart sound. He has 1+ pitting lower extremity edema bilaterally and an elevated jugular venous pressure. The remainder of his physical exam is normal. Lab results reveal white blood cells 5,000/µL, hemoglobin 14 g/dL, platelets 200,000/µL, and a B-type natriuretic peptide 900 pg/mL. An echocardiogram is performed and shows left ventricular systolic dysfunction and an ejection fraction of 40%. Which of the following medications is indicated as first-line therapy to reduce mortality in the suspected diagnosis? ACaptopril BFurosemide CLosartan DSpironolactone

discomfort of the jaw and tongue during eating **giant cell (temporal) arteritis

A 72-year-old woman presents to the office with concerns regarding a headache. The headache has been ongoing for 2 days and is located at the right temple. She reports no history of similar headaches. In the days prior to the headache, she experienced low-grade fever and fatigue. Her medical history is pertinent for osteoarthritis of the knees. She takes acetaminophen on an as-needed basis for pain. Vital signs demonstrate a blood pressure of 142/82 mm Hg, heart rate of 86 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 98%. The patient's temperature is 99.6°F. A weight loss of 4 pounds is noted since the patient's last visit. On physical examination, the patient's scalp is tender over the temporal artery. What other clinical manifestation is associated with the suspected disease? AConjunctival injection of the right eye with tearing BDiscomfort of the jaw and tongue during eating CStabbing paroxysms of pain with brushing the teeth or touching the face DVesicles in the distribution of the ophthalmic branch of the trigeminal nerve

low-dose polyethylene glycol

A 75-year-old man with a medical history of hypertension, for which he takes amlodipine, presents to the clinic with lumpy and hard stools. He reports that he has to strain during bowel movements and has bowel movements only once per week. He has had these symptoms for years, and the symptoms have not improved with increased water and fiber intake. The patient has also been taking psyllium without improvement. Vital signs include HR of 80 bpm, BP of 130/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.2°F. Physical examination findings include a soft and nontender abdomen with bowel sounds in all four quadrants. Which of the following is the best next step in management? ADocusate BLactulose CLow-dose polyethylene glycol DSodium phosphate enema

Spoken "E" heard as "A" on auscultation **community acquired pneumonia

A 75-year-old woman presents to the clinic from the nursing home facility with fatigue, a productive cough, malaise, and chest pain for 1 week. Her medical history includes hypertension and dementia. Vital signs today include heart rate of 105 bpm, blood pressure of 132/86 mm Hg, respiratory rate of 24/minute, oxygen saturation of 95% on room air, and temperature of 100.8°F. Chest X-ray is shown above. Which of the following physical examination findings is most consistent with the suspected diagnosis? ADecreased tactile fremitus BHyperresonance to percussion CSpoken words muffled and indistinct on auscultation DSpoken "E" heard as "A" on auscultation

intra-articular glucocorticoid injection to the knee **pseudogout

A 75-year-old woman presents to the office with right knee pain and swelling, which has been worsening over the past 5 days. She has no history of injury or unusual activity, and she is generally healthy. She walks for exercise daily and has not changed her routine. On physical examination, she walks with a cane. The right knee has an effusion and feels warm to touch. She has limited range of motion compared with the left knee. X-rays show mild degenerative changes and calcification of the menisci. Aspiration of the joint is performed, and cloudy, yellow fluid is obtained. Analysis of the synovial fluid reveals a white blood cell count of 30,000 cells/mm3 and rhomboid-shaped weakly birefringent crystals. Gram stain of the fluid shows polymorphonuclear leukocytes and no organisms. Which of the following is the most appropriate initial treatment for this patient's condition? AAllopurinol 100 mg orally daily BArthroscopic drainage and irrigation of the knee CDoxycycline 100 mg orally twice daily for 10 days DIntra-articular glucocorticoid injection to the knee

salmonella enteritidis **gastroenteritis -yersinia is in pigs and raw/undercooked pork

A 10-year-old boy presents to urgent care early on a Sunday morning. The patient developed severe cramps and diarrhea at around midnight that kept him up all night and forced the family to end their camping trip early. The diarrhea is described as greenish in color. The day before, the boy and his brother waded in the creek and caught tadpoles to use for fish bait. They caught a large catfish, which the family grilled for supper, but the patient only ate hot dogs. No one else in the family is sick. Vital signs are BP of 100/60 mm Hg, HR of 90 bpm, RR of 20 bpm, oxygen saturation of 97% on room air, and T of 100.6°F. His face is pale, and his oral membranes are tacky. The abdomen is soft though the patient describes it as sore. What is the most likely causative agent? ACampylobacter jejuni BSalmonella enteritidis CShigella sonnei DYersinia enterocolitica

switch to a low-dose budesonide plus formoterol inhaler

A 13-year-old boy with a history of asthma presents to his family clinician for his annual physical. It has been 1 year since he had an acute asthma attack requiring ED treatment. He reports sleeping well and sometimes goes 3 weeks without using his short-acting beta-2 agonist inhaler, as long as he is careful about contact with his allergens, especially pet dander. His caregiver confirms regular and proper use of medications. Current medications are a medium-dose budesonide plus formoterol inhaler once daily for maintenance control and an albuterol inhaler for as-needed relief of symptoms. Vital signs are BP of 110/60 mm Hg, HR of 70 bpm, RR of 14/min, T of 97.4°F, and SpO2 of 98% on room air. His growth chart shows a growth spurt with a gain of 3 inches and 25 pounds, putting his ranking in both stature and weight close to the 50% lines. On a pulmonary function test, the patient gets his highest score ever and is close to 80% of the expected function. No wheezing is detected on auscultation. What is the best next step in the management of this patient's asthma? AChange the maintenance inhaler to medium-dose formoterol only BMake no change in the regimen CSwitch to a high-dose budesonide plus formoterol inhaler DSwitch to a low-dose budesonide plus formoterol inhaler

sitting to standing **hypertrophic cardiomyopathy causing left ventricular hypertrophy

A 14-year-old boy presents to your clinic for a sports physical. His parent notes that he has become increasingly short of breath with exertion. He has no history of early cardiac death in the family. On the exam, the patient is well appearing and at an appropriate weight for age. Vital signs show HR of 80 bpm, oxygen saturation of 99%, BP of 117/78 mm Hg, and T of 97°F. Cardiac exam reveals a harsh systolic crescendo-decrescendo murmur at the left lower sternal border. The patient has 2+ radial and distal pedal pulses with no lower extremity swelling. His lungs are clear to auscultation in all fields. The abdomen is soft and nondistended, with no hepatosplenomegaly. For the suspected diagnosis, what maneuver can be performed to increase murmur intensity? APassive elevation of legs BPerform a handgrip CSitting to standing DStanding to squatting

begin oral iron therapy

A 14-year-old girl visits her clinician for a sports physical for cross country. She has been training over the summer and recently adopted a vegan lifestyle. She reports feeling very tired in her first few days at school but otherwise feels fine. She underwent menarche 12 months ago and has no concerns about her periods or her weight. Vital signs are BP of 100/65 mm Hg, HR of 90 bpm, RR of 12 bpm, oxygen saturation of 98% on room air, T of 98.4°F, and BMI of 20.5 kg/m2. Physical examination is normal. A screening CBC reveals a hemoglobin of 10.5 g/dL, WBC of 5,000/μL, and ferritin of 11 μg/L. Which clinical intervention should be recommended for this patient? ABegin oral iron therapy BIncrease intake of red meat and vegetables CPerform stool guaiac test DRepeat CBC in 1 month

reassurance and follow-up in 1-2 months **fibroadenomas are benign breast tumors

A 16-year-old girl presents to the office with her parent for evaluation of a lump in her breast. She discovered it in the past month when she was experiencing discomfort in her right breast a few days before her menses. Her medical history includes a humerus fracture at age 6 that was surgically repaired. Her first menstrual period was at 11 years of age, and her most recent menstrual period was 2 weeks ago. Vital signs reveal a blood pressure of 110/74 mm Hg, heart rate of 78 beats per minute, respiratory rate of 18 breaths/minute, and oxygen saturation of 100%. The patient is afebrile. On physical examination, there is a well-circumscribed, nontender, round, rubbery, mobile 1 cm × 1.5 cm nodule in the upper outer quadrant of the right breast. No nipple discharge is appreciated. No axillary lymphadenopathy is palpated. What is the preferred intervention for the patient's suspected condition? AFine-needle aspiration BPhysical support and oral analgesics CReassurance and follow-up in 1-2 months DUltrasound of the breast

atrophic mucosa with complete loss of villi **celiac disease

A 17-year-old girl presents to the office with reports of abdominal pain, diarrhea, and weight loss over the past 6 months. The patient is well developed and well nourished. On physical exam, her temperature is 98.6°F, blood pressure is 112/64 mm Hg, heart rate is 84 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. She has a slightly distended abdomen that is nontender to palpation and has normoactive bowel sounds. She has a hemoglobin level of 11.8 g/dL and an elevated anti-tissue transglutaminase immunoglobulin A. Which of the following findings will most likely be found on a duodenal biopsy? AAtrophic mucosa with complete loss of villi BFoamy macrophages with periodic acid-Schiff-positive inclusions CNoncaseating granulomas DTrophozoites on the duodenal surface

surgical eradication of the mass **cholesteatoma is a complication of otitis media

A 19-year-old man with a history of chronic ear infections presents to his primary care office for evaluation of a brown discharge from his right ear for the past 4 days. He also noticed some difficulty hearing from the associated ear. The patient reports no pain associated with his ear or any other symptoms such as fever or nasal congestion. His vital signs are HR of 78 bpm, RR of 19/min, BP of 127/80 mm Hg, T of 98.8°F, oxygen saturation of 100% on room air, and BMI of 31.6 kg/m2. On exam, there is a thick mass of keratin-like debris in his right ear canal with a largely perforated tympanic membrane. Which of the following is the most appropriate management for this patient's condition? ANo additional intervention needed BOral amoxicillin for 10 days CSurgical eradication of the mass DTopical ciprofloxacin with hydrocortisone drops

doxycycline 100 mg orally twice daily for 7 days **chlamydia cervicitis

A 19-year-old woman presents to the clinic with increased vaginal discharge, painful urination, and pain during intercourse. She is sexually active with multiple partners and does not always use condoms. Pelvic exam shows unremarkable external vaginal exam, but upon swabbing the cervix, you note that the endocervix and surrounding areas bleed easily. A bimanual exam is performed and is negative for cervical motion tenderness. Her pregnancy test is negative. Which of the following is the treatment of choice for the most common bacterial sexually transmitted infection in the United States? AAzithromycin 1 g orally in a single dose BCeftriaxone 250 mg intramuscularly in a single dose CDoxycycline 100 mg orally twice daily for 7 days DLevofloxacin 500 mg once daily for 7 days

leukopenia **anorexia nervosa -Russell sign is calluses on hand -leukopenia -metabolic alkalosis -hypokalemia -hypochloremia - elevated sodium bicarbonate

A 19-year-old woman presents to your office for her yearly physical exam. She states she has not had a menstrual cycle in the past 4 months, and she is concerned about gaining 2 pounds over the past 3 months. Urine pregnancy test result is negative. Vital signs reveal an HR of 52 bpm, RR of 17 breaths/minute, BP of 96/72 mm Hg, SpO2 of 99% on room air, T of 98.7°F, and BMI of 16.3 kg/m2. Physical exam reveals pale skin, thin hair, and calluses on her knuckles. Which of the following laboratory results would be most consistent with the suspected diagnosis? ADecreased blood urea nitrogen BElevated thyroxine hormone CHyperkalemia DLeukopenia

10 minute warm soaking bath once a day using soap-free cleansers **atopic dermatitis (eczema) then add emollient

A 2-year-old boy presents to the clinic with an itchy rash that has waxed and waned for the past year. Vital signs include a BP of 100/60 mm Hg, HR of 115 bpm, RR of 28/minute, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination reveals a dry and scaly rash on the posterior arms, anterior legs, and bilateral cheeks. Which of the following is the most appropriate bathing advice for patients with the suspected condition? A10 minute warm soaking bath once a day using soap-free cleansers B5 minute hot baths followed by immediate emollient application CDry the skin well with a towel followed by immediate emollient application DWarm soaking bath weekly with addition of bath emollient

vaginal pH > 4.5 **bacterial vaginosis -milky vaginal discharge -fishy odor -positive whiff test -clue cells

A 21-year-old woman presents to the office due to increased foul-smelling vaginal discharge over the past 3 days. On physical exam, her temperature is 97.6°F, blood pressure is 114/68 mm Hg, heart rate is 78 bpm, oxygen saturation is 99% on room air, and respiratory rate is 19/minute. A physical exam reveals the presence of runny and milky discharge that has a fishy odor. Clue cells are identified on wet mount microscopy. Which additional finding will most likely be present, based on the most likely diagnosis? ACervical motion tenderness BHyphae and spores on wet mount microscopy CRed macular lesions on the cervix DVaginal pH > 4.5

lid lag **hyperthyroidism -lid lag is when the eyelids stay up when looking down

A 21-year-old woman presents to the office for a routine physical examination. She states that she has been feeling a little more anxious lately and is not sure why. On physical exam, her temperature is 98.6°F, blood pressure is 112/64 mm Hg, heart rate is 105 bpm, oxygen saturation is 98% on room air, and respiratory rate is 22/minute. Her body mass index is 23 kg/m². The patient appears very hyperactive and nervous and is constantly moving around while speaking. Laboratory studies show a TSH of 0.1 µU/mL and a T4 level of 17.2 µg/dL. Which of the following findings will most likely be found on a physical exam? ADry and flaky skin BHyporeflexia CLid lag DNarrow pulse pressure

painless cervical lymphadenopathy **hodgkin lymphoma

A 22-year-old man with no medical history presents to the clinic with fatigue, pruritus, night sweats, and unintended weight loss over the past 2 months. Vital signs include a BP of 120/80 mm Hg, HR of 104 bpm, RR of 20/minute, oxygen saturation of 99% on room air, and T of 100.6°F. Physical examination reveals palpable and nontender lymphadenopathy. The patient undergoes a lymph node biopsy, which shows cells with a bilobed nucleus and prominent nucleoli. Which of the following is the most common clinical manifestation of the suspected diagnosis? AFatigue and pruritus BPainless axillary lymphadenopathy CPainless cervical lymphadenopathy DWeight loss

history of cryptorchidism **testicular cancer

A 23-year-old man presents to the clinic due to a mass on his right testicle for the past few months. He reports a painless, palpable mass on the underside of his right testicle along with a sense of heaviness. He reports no swelling, pain, abnormal discharge, or skin changes. He is sexually active with one partner and uses condoms for protection. He is otherwise healthy and takes no medication. His vital signs include a T of 98.8°F, BP of 112/72 mm Hg, RR of 13/min, HR of 72 bpm, and oxygen saturation of 100% on room air. Physical examination reveals a 1.2 cm discrete mass on the underside of the right testicle. The mass is hard and nontender. Abdominal exam reveals no masses or organomegaly. What is the biggest risk factor for the most likely diagnosis? AFamily history of testicular cancer BHistory of cryptorchidism CHistory of hypospadias DRecent sexually transmitted infection

cervical motion tenderness **pelvic inflammatory disease

A 23-year-old woman presents to urgent care with vaginal discharge, lower abdominal pain, nausea, and vomiting. She is sexually active with multiple partners. She is on an oral contraceptive pill and does not use condoms. She has no significant medical or surgical history. Vital signs today include a temperature of 101.2°F, blood pressure of 126/82 mm Hg, heart rate of 96 bpm, respiratory rate of 16/minute, and oxygen saturation of 98% on room air. A point-of-care pregnancy test result is negative. Which of the following physical exam findings is most specific for the suspected diagnosis? ACervical motion tenderness BMucopurulent vaginal discharge CSuprapubic tenderness DTemperature of 101.2°F

oxygen and transfer to the nearest facility for observation **apical pneumothorax

A 24-year-old man with no significant medical history presents to the urgent care with dyspnea and chest pain for the past 2 hours. He reports the chest pain started suddenly and is localized to the left side of his chest. He has also developed a slight cough. Vital signs include a heart rate of 112 bpm, blood pressure of 126/81 mm Hg, respiratory rate of 22/minute, oxygen saturation of 96% on room air, and temperature of 98.4°F. On physical exam, S1 and S2 heart sounds are noted in regular rhythm with no murmurs. No lifts, heaves, or thrills are noted. The chest wall is symmetric, without deformity, and atraumatic in appearance. There is no tenderness to palpation of the chest wall. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezing. Resonance is normal upon percussion of all lung fields. A chest radiograph is shown above. Which of the following is the most appropriate management for this patient's condition? ANeedle thoracostomy BOxygen and transfer to the nearest facility for observation CPigtail catheter aspiration DTube thoracostomy

mobile trichomonads **vaginal trichomoniasis

A 24-year-old woman presents to the office with a 3-day history of increased vaginal discharge and painful urination. She is sexually active and uses oral contraceptives. On physical exam, her temperature is 98.8°F, blood pressure is 118/70 mm Hg, heart rate is 84 bpm, oxygen saturation is 100% on room air, and respiratory rate is 21/minute. A physical exam reveals the presence of copious, frothy greenish-yellow vaginal discharge that is malodorous. Her cervix is erythematous and edematous with the appearance of punctate hemorrhages. Which additional findings on wet mount microscopy will also help to confirm the diagnosis? AClue cells BHyphae and spores CMotile trichomonads DRound parabasal cells

1-hour glucose tolerance test **screened at 24-28 weeks

A 25-year-old G1P0 woman at 27 weeks gestation presents to her obstetrician for a prenatal appointment. She reports no nausea, headaches, vaginal bleeding, or seizures. She has no significant medical history, and her only medication is a prenatal vitamin. She drinks one cup of coffee in the morning but reports no alcohol, smoking, or illicit drug use. Her vital signs include a T of 97.8°F, BP of 112/70 mm Hg, RR of 13/min, HR of 80 bpm, and oxygen saturation of 100% on room air. What is the most appropriate screening test for her at this time? A1-hour oral glucose tolerance test BRhD typing and antibody screen CSerum quadruple marker DSwab for group B beta-hemolytic Streptococcus

administer a single dose of doxycycline 200 mg **Lyme disease

A 25-year-old woman presents to the clinic with a spot on her arm that she noticed this morning when she was getting dressed. The patient states she was hiking 2 days ago in Massachusetts. She reports feeling well. Vital signs include an HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination reveals an orange-reddish 5 mm insect with a dark-brown oval-shaped structure at the superior aspect. You are able to remove the insect with forceps. The patient's urine pregnancy test is negative. Which of the following is the most appropriate next step for this patient? AAdminister a single dose of doxycycline 200 mg BAdminister amoxicillin 100 mg twice daily for 5 days CPerform serologic testing for Borrelia burgdorferi DReassure and provide education to return for treatment if symptoms develop

aspiration of the mass **ganglion cyst

A 25-year-old woman presents to your office with a bump over her right wrist, which she first noticed 6 months ago. It was not initially painful, and she saw her primary clinician, who recommended observation. Since that time, it has enlarged slightly, and she now has pain when she puts weight on her hand, such as when doing a push-up. On physical examination, there is a 1.5 cm subcutaneous mass over the dorsum of her right wrist at the scapholunate joint. It is well circumscribed, mobile, and slightly tender. She has pain with maximum dorsiflexion of her wrist. X-rays of the wrist are normal. Which of the following is the most appropriate intervention? AAspiration of the mass BGlucocorticoid injection CReassurance and continued observation DSurgical excision of the mass

intermittent obstruction of the cystic duct **uncomplicated gallstone disease

A 25-year-old woman with obesity presents to the clinic with intermittent episodes of right upper abdominal pain for the past 2 months. The patient reports the pain tends to occur after she eats pizza and lasts for about 4 hours. She has associated nausea and vomiting but no fever. The patient is currently not experiencing abdominal pain. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.2°F. Physical examination findings include a soft and nontender abdomen with bowel sounds present in all four quadrants. You order an outpatient right upper quadrant ultrasound that is shown above. Which of the following is the suspected underlying pathophysiology of the condition causing the patient's symptoms? AIntermittent obstruction of the cystic duct BObstruction of the common bile duct CObstruction of the common bile duct with secondary infection DObstruction of the pancreatic duct

supportive care **E. coli

A 27-year-old woman with a medical history of depression treated with fluoxetine 20 mg daily presents to the urgent care with diarrhea for the past 2 days. She reports four episodes of diarrhea per day with associated abdominal cramping, nausea, and one episode of vomiting. She returned from Costa Rica yesterday. She reports no bloody or mucoid stools. Vital signs include a heart rate of 98 bpm, blood pressure of 128/82 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 98.4°F. On physical examination, slight tenderness to palpation is noted throughout all four quadrants of the abdomen. No distention or peritoneal findings are noted. Which of the following is the most appropriate management for this patient's condition? AAzithromycin BExamine stool for ova and parasites CStool culture DSupportive care

ecchymosis over the plantar surface of the mid foot **lisfranc injury

A 28-year-old man presents to the urgent care department after he injured his right foot yesterday evening. He was playing rugby on a turf field and caught the toe of his shoe as he was running. He fell with his foot forcibly plantar flexed. He was unable to continue playing and had to be helped off the field. He applied ice and elevated the foot overnight but today notes increased pain and swelling in the foot. On physical examination, he has difficulty bearing weight on the foot and is unable to do a toe rise. He has diffuse swelling over the foot and tenderness over the dorsal midfoot. X-ray is shown above. Which of the following additional findings is most likely to be present on physical examination? AAbsence of ankle plantar flexion when the calf is squeezed BEcchymosis over the plantar surface of the midfoot CPain with axial loading of the second metatarsal DPain with forced extension of the first metatarsophalangeal joint

noncaseating granuloma on lung biopsy **sarcoidosis

A 28-year-old woman presents to the clinic with 2 months of fatigue, dry cough, blurred vision, rash, and weight loss. She has no significant medical or surgical history. She was adopted and does not know her family history. Vital signs today are heart rate 82 bpm, blood pressure 116/78 mm Hg, respiratory rate 18/minute, oxygen saturation 97% on room air, and temperature 98.4°F. On physical examination, the patient has erythema surrounding the cornea, cervical lymphadenopathy, regular rate and rhythm, clear lungs to auscultation bilaterally, soft and nontender abdomen, and tender nodules on the bilateral lower legs. Chest X-ray is shown above. Additional diagnostic studies are performed. What diagnostic finding is most consistent with the suspected diagnosis? ACaseating granuloma on lung biopsy BElevated sweat chloride test result CNoncaseating granuloma on lung biopsy DPositive acid-fast bacillus culture

lichen planus simplex

A 28-year-old woman with no significant medical history presents to her primary care office for evaluation of an ongoing rash on the right hand. She notes the rash has been there for many months and waxes and wanes in severity. A photo of the rash is shown above. Her vital signs are HR of 88 bpm, RR of 17/min, BP of 124/86 mm Hg, T of 97.8°F, oxygen saturation of 99% on room air, and BMI of 25.6 kg/m2. Which of the following is the most likely diagnosis? ALichen planus BLichen simplex chronicus CNummular dermatitis DPsoriasis

serum thyrotropin **generalized anxiety disorder; thyrotropin is TSH

A 29-year-old woman presents to her primary care clinician reporting nervousness, worrying, rapid heart rate, occasional tremor, and frequent sweating for the past 8 months. Vital signs reveal an HR of 114 bpm, RR of 17 breaths/minute, BP of 118/74 mm Hg, SpO2 of 99% on room air, T of 98.7°F, and BMI of 20.3 kg/m2. Physical exam reveals tachycardia and moist skin. Before making the most likely diagnosis, what testing should the clinician order? AEstrogen levels BHepatic panel CSerum thyrotropin DUrine pregnancy test

Factor VIII infusion **hemophilia A

A 3-year-old boy presents to the clinic with a painful and swollen right ankle. His parent accompanying him to the visit states there was no trauma or injury. The patient has had two prior episodes of similar symptoms that occurred without trauma. Vital signs include an HR of 95 bpm, BP of 95/70 mm Hg, RR of 22/minute, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination reveals an effusion of the right ankle, and the patient is not moving his right lower extremity. Radiographs of the right ankle show soft tissue swelling but no acute bony abnormality. The patient's laboratory studies include: White blood cell count: 10,000/µL Platelet count: 250,000/µL Prothrombin time: 13 sec Activated partial thromboplastin time: 55 sec Von Willebrand factor antigen: 125 IU/dL Which of the following is the recommended treatment? AAircast splint placement BAnalgesics and ice packs CFactor VIII infusion DTranexamic acid

inadequate personal hygiene **balanoposthitis is the inflammation of the glans penis from poor hygiene

A 3-year-old boy presents to the clinic with his parents for itching and pain in his genital area for the past day. His parents report he seems uncomfortable and has a groin rash but no fever or recent illness. The patient is an uncircumcised male whose only medical problem is allergic rhinitis. He takes over-the-counter loratadine but no other medications. His vital signs include a T of 98.8°F, BP of 105/65 mm Hg, RR of 20/min, HR of 102 bpm, and oxygen saturation of 100% on room air. Physical examination reveals swelling, tenderness to palpation, and erythema of the glans penis upon retraction of the foreskin. Inguinal lymphadenopathy is also present, but no urethral discharge is noted upon gentle palpation of the meatus. The foreskin is tight, but the clinician is able to reduce it. An erythematous rash is noted on his groin. The abdomen is soft and nontender with positive bowel sounds. What is the most likely cause of the most likely diagnosis? ACandidal infection BInadequate personal hygiene CNummular eczema DScabies infection

papilledema

A 31-year-old woman with a medical history of polycystic ovary syndrome presents to the clinic with intermittent nausea, vomiting, headache, and blurred vision for 3 weeks. Vital signs today are heart rate 72 bpm, blood pressure 140/92 mm Hg, oxygen saturation 97% on room air, respiratory rate 16/minute, and temperature 98.5°F. Physical examination reveals no neurological deficits and intact strength and sensation. Pupils are equal and reactive to light bilaterally, and funduscopic findings are shown above. Which of the following is the most likely diagnosis? ACentral retinal vein occlusion BPapilledema CRetinal detachment DVitreous hemorrhage

advise patient to wear a well-fitting bra and take an over-the-counter oral analgesic **fibrocystic breast disease

A 32-year-old woman presents to the office due to increasing breast pain and tenderness that has gotten worse over the past year. She states the pain peaks about 1 week before her period and improves after her period ends. She notices her breasts feel heavy and extremely tender, especially with physical activity. On physical exam, her temperature is 98.6°F, blood pressure is 112/64 mm Hg, heart rate is 84 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. She has a body mass index of 24 kg/m². Upon palpation, the breasts are dense and moderately tender to palpation with a rope-like texture bilaterally. Which of the following is the best next step for the treatment of her condition? AAdvise patient to wear a well-fitting bra and take an over-the-counter oral analgesic BAdvise patient to wear a well-fitting bra and take oral tamoxifen COrder a bilateral breast ultrasound DProvide reassurance without intervention and make a follow-up in 2 months

thyroid-stimulating hormone

A 33-year-old woman presents to the office with increasing fatigue, depression, and weight gain over the past year. She also states that she has had heavier bleeding during her periods and that her menstrual cycles have become more irregular and unpredictable. On physical exam, her temperature is 97.2°F, blood pressure is 110/62 mm Hg, heart rate is 72 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. She is found to have a free thyroxine level of 0.2 ng/dL, a free triiodothyronine level of 0.09 ng/dL, a thyroid-stimulating hormone level of 9.2 µU/mL, and a positive thyroid peroxidase antibody on her laboratory findings. She is prescribed levothyroxine and is scheduled to follow up in 6 weeks. Which of the following lab tests should be ordered to monitor the patient's response to therapy? AFree thyroxine BFree triiodothyronine CThyroid-stimulating hormone DThyroxine-binding globulin

oral amoxicillin-clavulanate **sinus infection

A 34-year-old man with a history of asthma and seasonal allergies presents to his primary care office for evaluation of persistent thick nasal congestion and facial pressure. The patient thought his symptoms were initially caused by seasonal allergies, but he is now concerned as they have persisted for over 2 weeks. He takes cetirizine daily and uses his albuterol inhaler as needed. His vital signs are HR of 92 bpm, RR of 19/min, BP of 122/86 mm Hg, T of 100.8°F, oxygen saturation of 99% on room air, and BMI of 28.1 kg/m2. On exam, his nasal turbinates are enlarged with thick yellow discharge and he has bilateral maxillary tenderness. His bilateral tympanic membranes are clear with good light reflexes. The patient reports no known allergies to medications. Which of the following is the most appropriate management for this patient's condition? AIntranasal steroids BOral amoxicillin-clavulanate COral doxycycline DOral nasal decongestants

resisted wrist extension with the elbow in extension **lateral epicondylitis

A 35-year-old man presents to his primary care clinician reporting 3 months of worsening right elbow pain. He reports he has always been a regular tennis player but increased his activity 6 months ago when he joined a local competitive league. He localizes the pain to the lateral aspect of the elbow. He reports the pain is most severe when he performs a backhanded swing. Which of the following exam findings would you expect to reproduce pain for this patient? APalpation of the medial epicondyle BPassive wrist extension with the elbow in extension CResisted wrist extension with the elbow in extension DResisted wrist flexion with the elbow in extension

malassezia **tinea versicolor

A 35-year-old man presents to his primary care with a skin rash on his chest and back for the past week. He first noticed it after he returned from a weekend at the beach. He reports no itch, fever, pain, or burning. He reports no significant medical history, and he takes no medications. He drinks two beers a night but reports no tobacco or illicit drug use. In office, his vital signs include a T of 98.8°F, BP of 114/74 mm Hg, RR of 13/min, HR of 72 bpm, and oxygen saturation of 100% on room air. On physical examination, he has tanned skin with numerous hypopigmented white macules over the chest and back. The lesions are nontender and have a slight scaly texture. The potassium hydroxide preparation reveals hyphae and spores. What is the most likely common cause of his condition? ACandida BLack of melanin in the skin CMalassezia DTrichophyton

interferon-gamma release assay

A 35-year-old man presents to the clinic for occupational tuberculosis screening. The patient is an emergency medicine nurse and reports that he received the Bacille Calmette-Guérin vaccine when he was 5 years old before he started school in South America. He has not had a cough, fever, or shortness of breath recently. Vital signs include HR of 80 bpm, BP of 130/80 mm Hg, RR of 20/minute, oxygen saturation of 97% on room air, and T of 98.2°F. The patient's lungs are clear to auscultation bilaterally on physical examination. Which of the following is the recommended method of tuberculosis screening in this patient? AAcid-fast bacilli smear of sputum samples BChest X-ray CInterferon-gamma release assay DTuberculin skin test

perifollicular hyperkeratotic papules **vitamin C deficiency scurvy

A 35-year-old man with a history of alcohol use disorder presents to your clinic with concern for bleeding gums and a new rash. He currently drinks approximately five drinks per day. He does not eat much, but when he does, it is mainly fast food. He began noticing symptoms about 2 weeks ago. His gums bleed mainly with teeth brushing. His vital signs show a heart rate of 89 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 120/80 mm Hg, oxygen saturation of 97% on room air, and temperature of 98°F. The patient appears underweight. Oral exam reveals no active bleeding but swollen gums with increased erythema. What additional physical exam finding is most likely to be seen based on the patient's most likely diagnosis? ADermatitis around the eyes BDestruction of hair follicles CPerifollicular hyperkeratotic papules DPsoriasiform dermatitis of the perioral area

Clarithromycin

A 35-year-old woman has cardiac indications for antibiotic prophylaxis for dental care and is referred to your clinic to gain preoperative clearance and medication instructions for dental surgery. Her vital signs are a BP of 110/76 mm Hg, HR of 76 bpm, RR of 16/min, SpO2 of 97% on room air, T of 98.0°F, and BMI of 21 kg/m2. While you take her history, she reports she has had hives and difficulty breathing in response to sulfa drugs and penicillins but no prior incidents with anesthesia. Her gums show moderate swelling and significant recession. Which of the following antibiotic regimens would be recommended as prophylaxis in this patient? AAmoxicillin BCephalexin CClarithromycin DClindamycin

age **according to ADA start at 35

A 36-year-old woman presents as a new patient to the primary care office. She has no concerns today and is here for a routine physical and blood work. Vital signs include HR of 82 bpm, BP of 135/85 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, T of 98.4°F, and a BMI of 24 kg/m2. The patient states her maternal grandfather had diabetes mellitus type 2. Which of the following is a requirement for this patient to be screened for diabetes mellitus type 2 per the American Diabetes Association guidelines? AAge BBlood pressure CBMI DFamily history of diabetes

lifestyle modification and histamine H2-receptor antagonist **start with H2 in GERD and then PPI if they fail

A 38-year-old man presents to the clinic to discuss chest pain. The pain has been present about once weekly for the past 3 weeks, and the patient describes it as a burning sensation in the center of his chest. He has noticed that the pain is worse after meals. Vital signs are a blood pressure of 122/82 mm Hg, heart rate of 68 bpm, respiratory rate of 16/min, oxygen saturation of 98% on room air, temperature of 98.7°F, and BMI of 32 kg/m2. A cardiac examination reveals a regular rate and rhythm with no murmurs, gallops, or rubs. The patient's lungs are clear to auscultation bilaterally. Upon abdominal examination, he reports pain to palpation in the epigastric region. The remainder of the physical examination is within normal limits. An ECG is obtained and is unremarkable. What is the best next step in management? ALifestyle modification and antacid BLifestyle modification and histamine H2-receptor antagonist CLifestyle modification and proton pump inhibitor DReferral for upper endoscopy

morning stiffness that improves with movement **rheumatoid arthritis

A 39-year-old woman presents to her primary care clinician reporting progressive multi-joint pain over the past 5 years. The most notable symptoms are in her hands and involve her wrists, metacarpophalangeal joints, and proximal interphalangeal joints. She reports she had a few children in close succession and assumed her symptoms were from standard childcare activities. Her children are now older, but her symptoms have continued and worsened. Physical exam reveals decreased range of motion, swelling with a boggy feeling over the joints, and reduced grip strength. Inspection of her hands reveals ulnar deviation of the digits. Which of the following additional symptoms would you expect her to confirm based on the most likely diagnosis? AAfternoon and evening pain and stiffness following activity BImprovement in symptoms with reduction of alcohol and meat intake CMorning stiffness that improves with movement DRadial-sided wrist pain with lifting

coccidioidomycosis

A 40-year-old man with a history of HIV presents to the clinic with fever, cough, chest pain, and shortness of breath for 6 days. He was on antiretroviral therapy but stopped treatment 6 months ago. His recent travel includes a trip to Arizona 3 weeks ago, and he has no known sick contacts. Vital signs include a heart rate of 84 bpm, blood pressure of 114/78 mm Hg, respiratory rate of 26/minute, oxygen saturation of 94% on room air, and temperature of 100.4°F. Physical examination reveals regular rate and rhythm, mild respiratory distress, no stridor, rales and dullness to percussion over the right lung field, and soft, nontender abdomen. Point-of-care CD4 test results are 210 cells/mm3. CXR is obtained, as shown above. Which of the following is the most likely diagnosis? AAsbestosis BCoccidioidomycosis CMycobacterium avium complex infection DPneumocystis pneumonia

heartburn and regurgitaton **hiatal hernia

A 40-year-old woman with a history of obesity presents to your clinic with a chief concern of cough. She notes a dry cough for 1 month without shortness of breath or chest pain. The patient is well appearing on exam. Vital signs show HR of 80 bpm, oxygen saturation of 98%, BP of 120/82 mm Hg, and T of 97.3°F. The patient has a normal heart rate and rhythm without murmur. Her lungs are clear to auscultation in all fields. The abdomen is soft with no tenderness to palpation and no hepatosplenomegaly. You order a chest X-ray, which is shown above. What are the most common clinical manifestations in patients with this disorder? ADysphagia to liquids and solids BHeartburn and regurgitation CHoarseness DNausea and retching

Quadruple therapy with a proton pump inhibitor, bismuth, tetracycline, and metronidazole for 14 days

A 42-year-old man presents to the office with several months of pain to the upper abdomen that wakes him up at least once or twice per week. He was treated for pneumonia about a month ago but has no other significant medical history and takes no medications. The pain is described as gnawing and achy and improves with over-the-counter calcium carbonate. On physical exam, his temperature is 97.4°F, blood pressure is 122/84 mm Hg, heart rate is 92 bpm, oxygen saturation is 98% on room air, and respiratory rate is 20/minute. A physical exam is unremarkable. Laboratory findings reveal a hemoglobin of 14.3 g/dL and a gastrin level of 82 pg/mL. A urea breath test is positive. Which of the following is the best treatment for this patient? ADual therapy with a proton pump inhibitor and clarithromycin for 14 days BMonotherapy with a proton pump inhibitor for 8 weeks CQuadruple therapy with a proton pump inhibitor, bismuth, tetracycline, and metronidazole for 14 days DTriple therapy with a proton pump inhibitor, clarithromycin, and amoxicillin for 14 days

an asymmetric dark skin lesion with irregular borders **malignant melanoma

A 42-year-old woman presents to the clinic with a lesion on her chest. She first noticed the lesion about a year ago, but it has gotten larger and darker since then. She reports no other lesions, pain, or itching. She states she does not use sunblock regularly and occasionally goes to tanning beds during the winter months. Her medical history includes several moderately dysplastic nevi, and her only medication is a combination oral contraceptive. She does not smoke. Her vital signs include a T of 98.8°F, BP of 118/72 mm Hg, RR of 13/min, HR of 75 bpm, and oxygen saturation of 100% on room air. A skin biopsy of the skin lesion is performed, and pathology results show melanocytes with hyperchromatic nuclei and nests of melanocytes along the dermal-epidermal junction. Which of the following clinical presentations is most consistent with the suspected diagnosis? AA pearly-colored lesion with rolled borders and central umbilication BA scaly red patch with a rough surface CA waxy brown lesion that is slightly raised DAn asymmetric dark skin lesion with irregular borders

labyrinthitis

A 42-year-old woman presents to urgent care with a chief concern of persistent dizziness, which started abruptly yesterday morning. She reports nausea and vomiting. The dizziness is severe enough to interfere with driving, walking, and her ability to go to work. She has not noted an association with any posture, and there is no tinnitus. She reports difficulty hearing out of her right ear. Medical history is pertinent for asthma, which is managed with a short-acting beta-agonist inhaler on an as-needed basis. She notes she was sick with an upper respiratory infection in the past week and needed her inhaler twice. Vital signs demonstrate a blood pressure of 118/74 mm Hg, heart rate of 84 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 99%. She is afebrile. On physical examination, the patient's gait appears unstable, but she is able to ambulate. Horizontal nystagmus, suppressible with visual fixation, is observed, with the fast component beating toward the left ear. A Weber test lateralizes to the left side. There is no evidence of sensory loss, facial droop, limb weakness, or speech abnormality. What is the most likely diagnosis? ALabyrinthitis BLateral medullary infarction CMénière disease DVestibular neuritis

avoiding the location of the accident **PTSD

A 43-year-old man presents to establish care after moving to the area. His medical history is significant for nerve damage from a major burn wound after a workplace accident 4 years ago. He reports trouble sleeping due to nightmares and unwanted memories about his accident. Vital signs reveal an HR of 72 bpm, RR of 19 breaths/minute, BP of 126/85 mm Hg, SpO2 of 98% on room air, T of 98.7°F, and BMI of 21.6 kg/m2. Physical exam and laboratory results are within normal limits. Based on the most likely diagnosis, what other reported symptom would the patient most likely have? AAvoiding the location of the accident BCompulsive thoughts to check locked doors CFrequent headaches DVisual hallucinations

bruises of different color patterns **intimate partner violence

A 43-year-old woman presents to the office, after two missed appointments, with a chief concern of frequent headaches. She also reports frequent abdominal discomfort and insomnia. Her medical history is significant for frequent sexually transmitted infection treatment and two prior elective abortions. The patient appears withdrawn and has poor eye contact. Vital signs reveal an HR of 90 bpm, RR of 18 breaths/minute, BP of 115/75 mm Hg, SpO2 of 99% on room air, T of 98.7°F, and BMI of 21.6 kg/m2. Which of the following physical exam findings would the clinician most likely observe? AAbdominal distention BBruises of different color patterns CDiffuse lymphadenopathy DMaculopapular rash

sexual dysfunction

A 45-year-old man presents to the clinic 3 months after his father's death. He describes feeling hopeless most days of the week and having insomnia, decreased appetite, and trouble concentrating at work. He has been seeing an outpatient therapist but states it has not helped as much as he thought it would. Laboratory results from his yearly physical were within normal limits. Vital signs reveal an HR of 65 bpm, RR of 18 breaths/minute, BP of 125/82 mm Hg, SpO2 of 99% on room air, T of 98.7°F, and BMI of 22.5 kg/m2. Physical exam is within normal limits. Based on the most likely diagnosis, you decide to begin first-line pharmacological therapy. Which of the following is a common side effect you should educate the patient about? AAbnormal facial movements BDizziness CHypertension DSexual dysfunction

resolved hepatitis B infection -acute=surface antigen/IgM -chronic=surface antigen/IgG -vaccine=anti-surface

A 45-year-old man presents to the clinic for follow-up of recent laboratory testing. Blood tests detect the presence of hepatitis B core antibody IgG and hepatitis B surface antibody, while hepatitis B surface antigen and hepatitis B e antigen are both negative. Which of the following correlates with the above laboratory findings? AAcute hepatitis B infection BImmunity by hepatitis B vaccination CNo history of hepatitis B vaccination or infection DResolved hepatitis B infection

local wound care **brown recluse spider bite

A 45-year-old man presents to the office with severe pain, redness, and swelling to the top of the left thigh that appeared after he was doing some work in his shed about 2 days ago. He thinks he got bit by a brown spider. He felt a burning sensation to the thigh and noticed a red bump, but as the day went on, the area became more and more painful. This morning, he noticed that a blister formed and the area has become increasingly inflamed and seems to be spreading. On physical exam, his temperature is 99.6°F, blood pressure is 142/84 mm Hg, heart rate is 99 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. He is mildly anxious. There is a 2 cm round, blood-filled blister located at the top of the thigh with a red halo surrounding it that appears to be spreading outward peripherally. His last tetanus vaccination was 3 years ago. Which of the following is the most appropriate management of this condition? AAntibiotic therapy BAntivenom CDapsone DLocal wound care

inadequate adherence to hypertensive therapy

A 45-year-old man with hypertension, for which he takes hydrochlorothiazide and lisinopril, and treatment-resistant major depression, for which he takes selegiline, presents to the urgent care clinic with a headache that started 2 days ago. He describes the pain as throbbing and not localized. He states that he is not having any visual disturbances or confusion. He also states that he has not had any nausea or vomiting. His vital signs are a BP of 180/120 mm Hg, HR of 70 bpm, RR of 16/min, SpO2 of 98% on room air, and a T of 98.4°F. Upon physical examination, the lungs are clear to auscultation, and upon cardiac examination, there is a regular rate and rhythm with no murmurs, gallops, or rubs. Cranial nerves are intact, the abdomen is soft and nontender, and the remainder of the physical exam is within normal limits. Which of the following is the most common cause of this patient's condition? AInadequate adherence to hypertensive therapy BMonoamine oxidase inhibitor use CPheochromocytoma crisis DRenal artery stenosis

insulin resistance **acanthosis nigricans

A 45-year-old woman presents to the clinic for a skin rash she has had for the past few months. She noticed brown lesions in her axilla and neck a few months ago but has not had it evaluated until now. She reports no itching, pain, redness, fever, or recent illness. Her medical history includes obesity, hypertension, and high cholesterol. She currently takes lisinopril 20 mg daily and atorvastatin 40 mg at night. Her vital signs include a T of 97.8°F, BP of 126/76 mm Hg, RR of 13/min, HR of 85 bpm, BMI of 32 kg/m2, and oxygen saturation of 100% on room air. Physical exam reveals symmetric dark brown velvety plaques in both the axilla and the flexural areas on her posterior neck. The lesions are nontender to palpation. No other skin lesions are identified. What is the most likely etiology of her skin lesions? AAdrenal insufficiency BCushing disease CGraves disease DInsulin resistance

patient education and reassurance **acute bronchitis

A 45-year-old woman with a medical history of hypothyroidism, for which she takes levothyroxine, presents to the clinic with a cough for the past 2 weeks. The patient reports that she initially had rhinorrhea and nasal congestion but these symptoms resolved with the cough persisting. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.2°F. On physical examination, her lungs are clear to auscultation bilaterally without rales, rhonchi, or wheezing. She has no erythema or exudate on oropharyngeal exam. The patient's chest X-ray is pictured above. Which of the following is the recommended treatment in addition to symptomatic measures for the cough? AAmoxicillin BAzithromycin CPatient education and reassurance DPrednisone

A 54-year-old woman with a body mass index of 23 kg/m2 and recent distal radius fracture from a fall at home

Which of the following patients is most appropriate for osteoporosis screening using dual-energy X-ray absorptiometry scanning? AA 45-year-old woman with a body mass index of 25 kg/m2 and maternal history of a hip fracture BA 54-year-old woman with a body mass index of 23 kg/m2 and recent distal radius fracture from a fall at home CA 59-year-old woman with a body mass index of 26 kg/m2, remote smoking history (quit 30 years ago), and recent 10-day course of glucocorticoids for asthma exacerbation DA 62-year-old woman with a body mass index of 27 kg/m2 and recent fifth metatarsal fracture while playing soccer

creates nitric oxide, which stimulates guanylate cyclase **angina with nitroglycerin

A 79-year-old man under your treatment for hypertension presents with concerns about tightness in his chest after follow-up with his cardiologist. He first noticed the tightness when he was climbing the stairs at a football stadium last month, but the tightness resolved when he sat down. He also noticed chest pain lasting 5 minutes while he prepared the quarterly tax report for his store. His current medications include lisinopril and a multivitamin. Vital signs are BP of 126/80 mm Hg, HR of 70 bpm, RR of 18/min, SpO2 of 95% on room air, T of 98.0°F, and BMI of 25.5 kg/m2. Heart and lung auscultation are normal. The patient feels no pain upon palpation of the anterior ribs. An ECG is obtained and shown above. His cardiologist prescribed a sublingual medication to be taken as needed at the first sign of chest pain and suggests the patient also try using it before heavy exertion. Which of the following is the mechanism of action of the prescribed medication? AActivates central alpha-2 receptors BCreates nitric oxide, which stimulates guanylate cyclase CInhibits entry of calcium ions into "slow" channels of the myocardium DOpens potassium channels in arteriolar smooth muscle cells