Health Assessment and Preventive Care Recommendations, Exams of Nursing

Download Health Assessment and Preventive Care Recommendations and more Exams Nursing in PDF only on Docsity! AQUIFER FAMILY MEDICINE 450 REAL EXAM QUESTIONS AND ACCURATELY VERIFIED ANSWERS WITH RATIONALES GRADED A+ 2024 Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely? A.) Abnormal gait B.) Increased pain with coughing C.) Loss of ankle jerk D.) Point tenderness on spinous processes E.) Spasm of paraspinous muscles - ANSWER- E.) Spasm of paraspinous muscles Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain that began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which additional physical exam finding would be consistent with this man's level of disc herniation? A. 2/5 strength on hip flexion B. Decreased range of motion on lumbar extension C. Decreased rectal tone D. Hypoactive ankle tendon reflex E. Positive Stoop test - ANSWER- D.) Hypoactive ankle tendon reflex Mr. Roberts is a 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension who presents lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of symptoms he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. He has never smoked. Vital signs: temperature is 38 C (100.4 F), blood pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15 breaths/minute. Given this history, which of the following physical exam maneuvers would be the most helpful in making the diagnosis? various stages of healing. He holds the knee in full extension. The knee is swollen, reddened, and tender, and it feels warm. Which of the following is the most appropriate next step? A. Knee aspiration B. Magnetic resonance imaging (MRI) of the knee C. Prescription for colchicine D. Prescription for full-dose acetaminophen E. X-ray of the knee, including sunrise and standing films - ANSWER- A. Knee aspiration You are seeing a 19-year-old female who suffered a knee injury playing soccer one day ago. The injury involved a sudden deceleration in which she planted her right foot in front of her while running, whereupon another athlete fell against her shin. She felt a pop and sudden pain. She had to be helped off the field and her knee swelled immediately. Today, she reports that she has considerable right knee pain with bearing weight and that her knee feels unstable at times. Her past medical history is unremarkable, and she takes no medications. On exam, her vital signs are perfectly normal. You conduct a knee exam. Which of the following exam maneuvers is most likely to be abnormal in this patient? A. Lachman test B. Laxity to valgus stress C. Laxity to varus stress D. McMurray test E. Posterior drawer test - ANSWER- A. Lachman test A 51-year-old female comes to you with acute pain and swelling of the knee. Joint fluid analysis confirms the diagnosis of acute gout. She has a past medical history of atrial fibrillation, hypothyroidism, hypertension, and prior treatment for H. pylori infection. Her current medications include losartan, warfarin, levothyroxine, and omeprazole. She is allergic to penicillin medications. Recent laboratory studies revealed normal hemoglobin and hematocrit, blood urea nitrogen, and creatinine levels. Which of the following information from her history would dissuade you from initiating NSAID therapy? A. Currently on warfarin B. Her age C. Hypothyroidism D. Penicillin allergy E. Previous H. pylori infection - ANSWER- A. Currently on warfarin You are seeing a 62-year-old male with a history of osteoarthritis in his knees and well-controlled hypertension and chronic constipation. His arthritic pain has been disabling in recent months, making it very difficult for him to do his work as a plumber. He has tried full dose acetaminophen in combination with diclofenac, but he still reports 8/10 pain and stiffness. He would like to pursue other treatment options. His current medications include chlorthalidone, diclofenac, acetaminophen, and methylcellulose. On exam, he is in no acute distress and his vital signs are normal. His knees show no warmth, erythema, or gross deformity. They are stable to varus and valgus stress. The Lachman test and McMurray test are both normal. There is moderate crepitus bilaterally. Which of the following would be the most appropriate next step in the management of his pain? A. Prescribe a glucosamine sulfate and chondroitin sulfate - ANSWER- D. Refer to physical therapy for strength and mobility training A 34-year-old cisgendered female who has no past medical problems and is not currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has a maternal aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children, aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago, and her other vital signs are stable. On breast exam, you note a mobile rubbery mass approximately 1 x 1cm that has regular borders and is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following puts this patient at increased risk for breast cancer? A. Age - ANSWER- E. Weight A 64-year-old cisgendered female who is overweight with well-controlled hypertension comes to your office with concerns of a lump in her breast that she noticed while showering. She reports having no pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 31 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer? A. Age B. Age at first birth C. Age at menarche D. Age at menopause E. Weight - ANSWER- D. Age at menopause A 63-year old cisgendered female comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago; both were normal. She has never had an abnormal Pap test. At the age of 45 she had a total hysterectomy for A. Influenza, meningococcal, and zoster B. Influenza, pneumococcal, and Tdap C. Influenza, zoster, and Tdap D. Meningococcal, pneumococcal, and Tdap E. Meningococcal, pneumococcal, and zoster - ANSWER- B. Influenza, pneumococcal, and Tdap A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? A. Ideal B. Morbidly (very severely) obese C. Obese D. Overweight E. Underweight - ANSWER- C. Obese A 55-year-old male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? A. Borders B. Color C. Diameter D. Location E. Symmetry - ANSWER- C. Diameter A 55-year-old male with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. He is a lifelong non-smoker, and he doesn't drink alcohol or use recreational drugs. Which of the following screening tests is given either a USPSTF A or B recommendation in favor of its routine use for patients such as this one? A. Colon cancer screening B. ECG screening for coronary artery disease C. Lung cancer screening D. Pancreatic cancer screening E. Prostate specific antigen (PSA) testing - ANSWER- A. Colon cancer screening Ms. Marcos is a 65-year-old woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5' 2" and weighs 250 lbs. When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly? A. Asymptomatic coronary artery disease B. Chronic sinusitis C. Hypoparathyroidism D. Pneumonia E. Sleep Apnea - ANSWER- E. Sleep Apnea Ms. Anderson is a 60-year-old woman who comes in to clinic as a walk in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn't know why but she has been very sad of late. She reports trouble falling asleep and staying asleep. She used to be the head of her Bridge club, but quit two weeks ago and doesn't feel like going out anymore. She also says she has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. She also says she feels weak and fatigued and no longer has the energy to do her gardening or shopping. She spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. She denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A and CT of th - ANSWER- B. Two weeks Mr. Jones is an 82-year-old man who presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; reports decreased enjoyment of his activities, such as playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He denies any suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife's voice while going to bed. He says he goes to church to pray. You are trying to determine if your patient's symptoms are normal grief or if you should diagnose and treat him for Major Depressive Disorder (MDD). Which feature of Mr. Jones' case would suggest MDD rather than a normal grief reaction? A. Change in appetite B. Fatigue C. Heari - ANSWER- D. Inability to experience any joy palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. What is the next best step in the management of this patient? A. Emergent surgical consultation B. Diagnostic imaging of right foot and ankle C. Immobilize leg and ankle with a cast D. Reassurance and icepacks q 2 hours E. Urgent EMG of the right lower extr - ANSWER- A. Emergent surgical consultation A 21-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing soccer a day prior to presentation to the family medicine ambulatory practice. She remembers immediate pain and swelling but was able to weight bear and limp off the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical examination reveals an edematous lateral right ankle with purplish hue and intact bilateral pulses. Sensation of the bilateral lower extremities is intact and symmetric motor function is preserved. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. There is mild tenderness to palpation of the anterior talofibular ligament and the calcaneofibular ligament. The anterior d - ANSWER- E. X-ray imaging of right ankle A 22-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing volleyball. The ankle quickly became edematous, but she used ice and was able to bear weight on the foot. When the patient presents at the family medicine ambulatory practice two days following her injury, minimal swelling is noted and motor functions and sensation are preserved. She has tenderness at the anterior lower lateral malleolus but not inferiorly or posteriorly. You diagnose her with an ankle sprain. You recommend continued relative rest and also tell the patient to keep it elevated and ice it several times during the day to help with the pain and swelling. You inform the patient that immobilization and compression is good for the conservative management of her condition. What is the best compression device to use in this situation? A. Compression stockings B. Elastic wrap C. - ANSWER- C. Semi-rigid ankle support A 20-year-old healthy female with no significant past history presents to your clinic with dysuria, lower abdominal discomfort, frequency, and urgency for one day. She notes an odor to her urine but denies any change in its appearance. She reports no vaginal discharge or fever. Review of systems is otherwise negative. The patient denies sexual activity and reports normal menses. There are no known allergies. Her examination is remarkable for mild suprapubic tenderness. Urinalysis: negative; urine HCG: negative. Which of the following would be the next best step in her clinical management? A. Await urine culture results before any treatment B. Initiate antibiotic treatment while awaiting urine culture results C. Insist that a pelvic exam and cervical DNA probe be performed today D. Reassure that this is not a urinary tract infection E. Urine DNA probe - ANSWER- B. Initiate antibiotic treatment while awaiting urine culture results A 53-year-old man has been experiencing three months of weight loss and palpitations. Work-up for hyperthyroidism, which is high on your differential, is pending. Which of the following symptoms is inconsistent with a diagnosis of hyperthyroidism? A. Tremor B. Insomnia C. Gynecomastia D. Constipation E. Fatigue - ANSWER- D. Constipation A 30-year-old male with PMH significant for one month of progressive hoarseness and fever presents with a painful neck mass. He reports increased sweating, racing heart, diarrhea, and fatigue. His vital signs are: Temperature: 39.5 Celsius Heart rate: 85 beats/minute Respiratory rate: 19 breaths/minute Blood pressure: 130/70 mmHg On physical exam, you palpate a hard, fixed, painless nodule on the left side of the thyroid gland. Bloodwork results show: TSH: decreased Free T4: increased Which of the following is correct about thyroid nodules? A. 25% of patients with hyperthyroidism are caused by thyroid nodules B. The majority of thyroid nodules symptomatic C. 4% to 5% of thyroid nodules are cancerous D. Older patients with thyroid nodules usually have solitary nodules E. Thyroid radioactive iodine uptake and scan is the best initial test to evaluate a new thyroid nodule - ANSWER- C. 4% to 5% of thyroid nodules are cancerous D. Complete blood count E. Glucose challenge test" - ANSWER- D. Complete blood count* " A 32-year-old female presents at your office for a preconception health visit. She is a G2P2, both deliveries were vaginal. Her first child was born with a neural tube defect. According to the USPSTF, what dosage of folate should this patient take daily before she gets pregnant? A. 1 mg B. 4 mg C. 8 mg D. 400 mcg E. 800 mcg" - ANSWER- B. 4mg* "A 24-year-old G1P0 patient at 14 weeks presents with vaginal bleeding and abdominal cramping. On examination her vital signs are: blood pressure 120/75 mmHg, pulse rate 74/minute, temperature 98.4 degrees F taken orally, respiratory rate 18/minute, and oxygen saturation 99% on room air. On pelvic examination, there is a small amount of blood in the vagina, the cervical os is open, and there is no cervical or adnexal tenderness noted. On pelvic ultrasound, an intrauterine gestational sac with a yolk sac is seen. What is her diagnosis? A. Complete abortion B. Threatened abortion C. Missed abortion D. Inevitable abortion E. Septic abortion" - ANSWER- D. Inevitable Abortion* "A 25-year-old female presents with vaginal bleeding and cramping. Her last normal menstrual period was six weeks ago. The patient's vital signs are stable. On speculum exam of the vagina, there is no bleeding from the cervix. A quantitative beta-human chorionic gonadotropin (beta-hCG) level is 1492 mIU/ml. The patient is sent home and told to return to the office in 48 hours. Her beta-hCG on the return visit is 3000 mIU/ml. What is the appropriate next step in the management of this patient? A. Surgery for ectopic pregnancy B. Methotrexate for ectopic pregnancy C. Ultrasound to confirm intrauterine pregnancy D. Dilation and curettage for non-viable pregnancy E. Progesterone level to confirm pregnancy" - ANSWER- C. Ultrasound to confirm intrauterine pregnancy* A 27-year-old G0P0 female presents to your office with abdominal pain, fever and vaginal discharge. The discharge has an abnormal odor. She reports a new, male, sexual partner. On pelvic exam, there is cervical motion tenderness and adnexal pain during the bimanual exam. A cervical culture is positive for Chlamydia trachomatis. What risk factor for chlamyida infection is present in this patient? A. Sexual orientation B. New sexual partner C. Age D. Nulliparity E. Race - ANSWER- B. New sexual partner A 40-year-old male presents to the clinic with dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He denies fever, but does report some continued shortness of breath. He is a smoker but only smokes 1-2 cigarettes a day for about six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis? A. COPD B. Foreign body aspiration C. Pneumonia D. Asthma E. Pulmonary embolism - ANSWER- D. Asthma A 15-year-old female with a history of allergic rhinitis presents to the clinic with a five day history of productive cough and wheezing that is worse at night. She denies any shortness of breath, chest pain, or fever. The patient states that she has had similar symptoms in the past, especially when seasons change. The only reported past medical history is atopic dermatitis which is well-controlled with an over-the-counter steroid cream. What is the best next step? A. Prescribe a short acting beta agonist inhaler with a short course of oral steroids B. Prescribe a long acting beta agonist inhaler C. Prescribe a daily corticosteroid inhaler D. Prescribe a daily corticosteroid and long acting beta agonist inhaler E. Prescribe antibiotic therapy - ANSWER- A. Prescribe a short acting beta agonist inhaler with a short course of oral steroids An 18-year-old non-smoking male comes to the clinic with cough, chest tightness, and difficulty breathing. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough primarily at night since he was 4 A. Fasting serum glucose concentration of 91 mg/dL B. Fasting serum glucose concentration of 112 mg/dL, and a one-hour serum glucose concentration of 128 mg/dL C. Fasting serum glucose concentration of 113 mg/dL, and a two-hour serum glucose concentration of 134 mg/dL D. Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 158 mg/dL D. Two-hour serum glucose concentration of 146 mg/dL - ANSWER- D. Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 150 mg/dL A 27-year old female, G2P1, returns to the clinic for her second prenatal visit. Her labs reveal that her blood type is A Rh-. She states she has done research online, and is concerned that this pregnancy will result in her baby dying if it has a different blood type than her own. To reassure the patient, you explain that her team of health care providers will: A. Perform a cesarean section to prevent fetal demise B. Treat the baby with Rhogam within the first 72 hours after delivery to prevent hemolytic anemia of the newborn C. Treat the mother with penicillin during labor to prevent transmission of gram- positive bacteria D. Treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum. E. Treat the mother with Rhogam when she is at 28-weeks gestation to - ANSWER- D. Treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies agains Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum. A 36-year-old female, G3P2 at 21 weeks gestation, returns to clinic for an ultrasound. She currently smokes a half pack of cigarettes per day. Her last two children were delivered by cesarean section. She reports no vaginal bleeding, no urinary symptoms, and no fluid leaking. She states her baby moves "all the time." Her vitals reveal a blood pressure of 130/74 mmHg, a temperature of 98.3o F, a pulse of 82, a respiration rate of 18, and a pulse oximetry of 98%. The ultrasound reveals no fetal abnormalities, but the location of the placenta is partially covering the cervical os. The diagnosis and treatment plan is: A. Placenta previa with admittance to the hospital for fetal and maternal monitoring B. Placenta previa with immediate cesarean section C. Placenta previa with reassurance that no additional monitoring is needed D. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or re - ANSWER- D. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution You are seeing a 32-year-old female at 34 weeks gestation for a routine prenatal visit. Her pregnancy has been uncomplicated, and she is up to date on her immunizations and screening. She is feeling well today, reporting regular fetal movement. She denies vaginal bleeding, leaking of fluid, and contractions. She plans to breastfeed after delivery. Her vital signs are all normal today. You engage in a discussion of postpartum contraception options with her. Which of the following would be recommended as a method of contraception? A. Combined oral contraceptive starting immediately postpartum B. Combined oral contraceptive starting six weeks postpartum C. Depo-levonorgestrel injections starting now, and every three months subsequently D. Etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) starting immediately postpartum E. Levonorgestrel intrauterine device (IUD) inserted immediately after delivery of the placenta - ANSWER- E. Levonorgestrel intrauterine device (IUD) inserted immediately after delivery of the placenta A 35-year-old man presents to clinic with acute onset of constant right upper quadrant abdominal pain. Additionally, he complains of ongoing nausea and vomiting. He denies any past abdominal surgeries or chronic diseases and his only medication is a multivitamin. His AUDIT-10 was positive. What lab(s) would you most likely expect to be abnormal to confirm your diagnosis of acute alcoholic hepatitis? A. GFR and INR B. CRP and alkaline phosphatase C. AST, ALT and total bilirubin D. AST, ALT, INR and WBC E. Lipase and amylase - ANSWER- C. AST, ALT and total bilirubin A 35-year-old man presents to clinic with acute onset of abdominal pain. On abdominal exam, you flex the patient's right hip to 90 degrees and take his right ankle in your right hand and with your left hand externally then internally rotate his hip by moving the knee back and forth. The patient denies any abdominal pain with this movement. What physical exam sign did you just perform and what disease is it ruling out? A. Psoas sign to rule out appendicitis B. Psoas sign to rule out cholecystitis C. Obturator sign to rule out appendicitis D. Murphy's sign to rule out appendicitis E. Obturator sign to rule out cholecystitis - ANSWER- C. Obturator sign to rule out appendicitis ANSWER- A. Breast self-examination increases the number of biopsies performed. A 47-year-old female presents to the clinic complaining of an ""itchy patch"" on her skin. On further examination, you note a solid, elevated 1.5cm lesion on the extensor surface of the right forearm. How would you best describe the lesion? A. Plaque B. Papule C. Patch D. Nodule E. Macule" - ANSWER- A. Plaque " A 12-year-old male is brought to the clinic with a pruritic, red, scaly rash in the creases of his elbows. He denies new topical exposures and generally feels well. He has a history of seasonal allergies. Which of the following is the most appropriate course of action? A. Biopsy the skin lesion B. Ask the patient to return to the clinic after three days C. Prescribe topical corticosteroids D. Prescribe oral antibiotics E. Prescribe oral corticosteroids" - ANSWER- C. Prescribe topical corticosteroids " A 26-year-old male professional football player comes to the clinic with the concern of hair loss. On examination, the scalp is scaly and erythematous, and certain regions are purulent. There are several circular spots where the hair follicles are no longer present. KOH of skin shows hyphae. What is the most appropriate next step in the management of this patient? A. Punch biopsy of lesion B. Topical griseofulvin C. Oral griseofulvin D. Oral prednisone E. Topical prednisone" - ANSWER- C. Oral griseofulvin " A 64-year-old male comes in for a routine physical examination. He notes that over the past few months he has had to get up to urinate in the middle of the night. Benign prostatic hypertrophy (BPH) is on your differential. What other symptom is consistent with BPH? A. Cloudy penile discharge B. Erectile dysfunction C. Hematuria D. Urinary urgency E. Dysuria" - ANSWER- D. Urinary urgency " A 57-year-old female comes in, concerned about a 1.5 cm dark multicolored mole lateral to her left eye that has been increasing in size over the past six months. A punch biopsy shows pathology indicative of squamous cell carcinoma. What is the most appropriate intervention? A. Three-month follow-up visits for the first year; then every six months B. Avoid artificial sources of UV light, such as indoor tanning C. Cryotherapy extending 4 mm beyond the lesion margins D. Mohs surgery E. Excisional biopsy extending 5 mm beyond lesional border" - ANSWER- D. Mohs surgery " A 53-year-old female with a past medical history of diet-controlled hypertension presents to the office with a two-month history of worsening hot flashes. Her menstrual cycles are regular, occurring every 30 to 32 days, but they have gradually lessened in duration, now lasting four to five days instead of the previous six to seven days. Vital signs and physical exam are normal. Which one of the following treatments is most likely to improve the patient's symptoms? A. Black cohosh B. Oral estrogen C. Venlafaxine D. Gabapentin E. Yoga" - ANSWER- B. Oral estrogen " A 56-year-old female with a past medical history significant for hypothyroidism and recurrent urinary tract infections presents to the office to discuss dyspareunia D. Endometrial ablation E. Referral for hysterectomy" - ANSWER- C. Transvaginal ultrasound " You are seeing a 56-year-old male who presents with daily headaches for the past two weeks. He describes them as an intense pressure behind both eyes that is throbbing in nature. He reports that lights and loud noises bother him some, but he has been able to tolerate his usual activities as a short-haul truck driver. The headaches tend to last all day. He has not had nausea, visual changes, fever, or chills. These symptoms have occurred in the context of him quitting tobacco, which he has found difficult. He read online about cluster headaches, and he thinks that is what he is experiencing. He would like you to prescribe oxygen treatment to help with the headaches. Which of the following characteristics is most typical of cluster headaches? A. Patients with them often complain of a pulsating quality of pain. B. The pain is typically periorbital and bilateral. C. They are associated with photophobia and phonophobia. - ANSWER- D. They are associated with rhinorrhea, lacrimation, miosis, and ptosis. " You are seeing a 33-year-old male who presents with several weeks of gradually- worsening headaches that he describes as severe and upsetting. They tend to occur three to four times per week and get worse as the day goes on. He describes them as feeling ""like a vice squeezing my whole head."" He has tried ibuprofen for them, and it has helped some. Unfortunately he never has ibuprofen with him at work where the headaches are more common, because his new boss does not allow medications to be kept at work without a doctor's note. He denies nausea, vomiting, lacrimosis, and photophobia. He is not awakened from sleep by the headaches. He appears mildly distressed, and his vital signs are normal. Examination of his head and neck, fundic discs, and cranial nerves is broadly normal. What is the most appropriate step in management of his headaches? A. Instruct him to discontinue ibuprofen, as he is having rebound headaches. - ANSWER- D. Prescribe ibuprofen to be taken as needed and provide a note for work. " You are seeing a 28-year-old female who presents with gradually worsening headaches. She has had headaches off and on since she was a teen, similar to her mother. She typically awakens with them, and they are associated with nausea and vomiting which can last for much of the day. The pain is throbbing and usually unilateral behind the right eye. Resting in a dark room often helps, and ibuprofen can help as well if she is able to take it at the onset of the headache. Recently, the headaches have become more common, happening two to three times per week. These have been interrupting her job as a paralegal, and she is worried she will be fired. She has tried yoga and mindfulness-based stress reduction, but these have not helped. She does not smoke, drink alcohol, or use illicit drugs. She recently stopped her oral contraceptive pills in an effort to get pregnant. Her vital signs and physical exam are perfectly normal. O - ANSWER- D. Prescribe amitriptyline nightly " A 35-year-old female with a history of headaches presents to your office with a headache that is not responsive to 400 mg Ibuprofen TID or 500 mg Tylenol TID. Upon gathering further history you find that in the past her headaches were controlled with these medications but recently have been worse with this same treatment. She complains of 4-5 headaches weekly that are often present on awakening. Which of the following is the best treatment for her disorder? A. Discontinue use of Ibuprofen and Tylenol B. Prescribe a calcium-channel blocker for headache prevention C. Prescribe a different NSAID to take for acute headaches D. Prescribe an opioid medication to take for acute headaches E. Prescribe sumatriptan to take as needed" - ANSWER- A. Discontinue use of Ibuprofen and Tylenol " A 68-year-old male with a past medical history significant for hypertension and diabetes presents to your office with a three month history of headaches. He describes a pain that has occasionally awoken him from sleep and is often worse in the morning. He denies any weakness or changes in vision. His exam shows 4+ reflexes in the right upper and lower extremities but is otherwise normal. What is the best next step in management for this patient? A. Initiate treatment with sumatriptan B. Neuroimaging C. Reassurance D. Referral to counselor for relaxation exercises E. Sleep study" - ANSWER- B. Neuroimaging " Ms. Smith is a 38-year-old female with a significant past medical history of hypercholesterolemia who presents to her primary care physician after four weeks of episodic epigastric discomfort. She reports a recurrent ache-like sensation in the epigastric region occurring about 10 minutes after eating and lasting for several hours. The pain does not appear to be associated with any particular food. She reports no odynophagia or dysphagia. Ms Smith is a smoker, with a 30-pack-year history. You are concerned about peptic ulcer disease. Which additional history finding would increase your level of concern? Choose the single best answer. C. Omeprazole twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily for 14 days D. Omeprazole daily, clarithromycin 500 mg twice daily, and tetracycline 500 mg three times daily for 14 days E. Omeprazole twice daily, tetracycline 500 mg three times daily, and metronidazole 500 mg twice daily for 10 days" - ANSWER- C. Omeprazole twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g twice daily for 14 days " Ms. Jones, a 35-year-old female with a significant past medical history of SLE who had been on NSAID therapy for the previous three months, presented four weeks ago with heartburn. At that time, she reported episodic, mealtime epigastric burning radiating to the throat for the past few months. She has had no surgeries. Serologic testing for H. pylori IgG was reported to be positive a few days after her visit and she was begun on triple therapy. She now returns to the office for follow- up. Today she reports no epigastric burning or tenderness. Physical exam is not significant. Which of the following is an accepted indication for performing repeat testing at this visit for H. pylori eradication? Choose the single best answer. A. Age below 40 years B. Documentation is required for all patients with confirmed H. pylori infection C. Positive serologic test prior to therapy D. Restarting of chronic NSAID therapy for SLE - ANSWER- D. Restarting of chronic NSAID therapy for SLE "Dr. Lee says, "Of course, these recommendations are based, in part, on the risk a patient will develop cervical cancer. So, now I have a question for you: What do you think are the risk factors for developing cervical cancer?" Select all that apply. A. Cigarette smoking. B. Early onset of sexual intercourse. C. Immunosuppressed patient. D. Multiple sexual partners. - ANSWER- A. Cigarette smoking. B. Early onset of sexual intercourse. C. Immunosuppressed patient. D. Multiple sexual partners. A 34-year-old male comes to the clinic complaining of recurrent abdominal pain. He says the pain has been bothering him for the past eight months. He reports episodes of diarrhea and constipation, with more episodes of constipation. He states he has noticed an increase in flatulence. He denies any nausea or vomiting. He has noticed mucus in his stools, but no blood. He states that he cannot recall if anything aggravates the pain, but admits to being under more stress than usual, due to his mother-in-law moving in with him and his wife. Vital signs show a blood pressure of 124/76 mmHg, pulse of 74, respirations of 16, a temperature of 97.9, and oxygen saturation of 98% on room air. Physical exam is unremarkable. The most appropriate initial step in management is: A. Scheduling the patient for a colonoscopy to look for colon cancer B. Discussing the patient's diet, and educating him about avoiding dairy products C. P - ANSWER- D. Offer behavioral therapies and exercise to help with symptoms " A 24-year-old female presents to the clinic complaining of a headache and arm pain. She is accompanied by her boyfriend, who insists on staying in the room with her during the visit. When asked to describe when she noticed the pain and how it occurred, the boyfriend states that the patient hit her head on the bathroom cabinet two days ago, and fell on her side afterwards, hitting her arm. The patient nods in agreement, while looking down at the floor. The next best step in obtaining an accurate history and physical exam is to: A. Direct all questions to the boyfriend, since it appears the patient does not want to discuss her situation with you B. Accuse the boyfriend of domestic abuse and call the police to report him C. Ask the boyfriend to leave the room so you can perform the physical exam, and explain that you always do that part of the exam with just the patient, and that he may join you after that part is com - ANSWER- C. Ask the boyfriend to leave the room so you can perform the physical exam, and explain that you always do that part of the exam with just the patient, and that he may join you after that part is completed " A 22-year-old female comes to the clinic complaining of frequent urination. She states she has noticed some increased frequency for the past week. She denies itching or pain in the vaginal area, but reports a burning sensation during urination that began a week ago. When asked if she has noticed blood in her urine, she admits to not paying attention to its color. She states that she has some abdominal pain in her pelvic area. She admits to being inconsistent with her birth control pills, and states she is sexually active with both men and women. She does not recall the date of her last menstrual period. Vital signs show a blood pressure of 126/78 mmHg, temperature of 98.2, respirations of 18, heart rate of 82, and oxygen saturation of 97%. Physical exam reveals suprapubic tenderness. She exhibits no costovertebral angle tenderness. Urine hCG test is negative. What is the most likely diagnosis? A. Pyelonephritis B. - ANSWER- D. Uncomplicated urinary tract infection A 42-year-old female presents for a visit after recently being diagnosed with Type 2 diabetes. She has made a plan to work on diet and exercise. Her A1C is found to be 8.0%. What is the best medicine to start at this time? A. A sulfonylurea B. An SGLT2 inhibitor C. GLP-1 receptor agonist D. Insulin E. Metformin Basal" - ANSWER- E. Metformin Basal " A 72-year-old female with a 30-year history of type 2 diabetes and hypertension returns to your office for a routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. She is on atorvastatin 40 mg daily and lisinopril 40 mg daily. She is on no other medications. Her A1C is 6.5% and her BP today is 145/90. She notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is the most appropriate next step to slow down the progression of diabetic retinopathy? A. Increase her insulin aspart from five units to seven units with meals. B. Increase her insulin glargine to 23 units every morning. C. Perform a fundoscopic examination and make no changes to her regimen today. D. Start her on a baby aspirin. E. Start her on a calcium channel blocker." - ANSWER- E. Start her on a calcium channel blocker. " A 65-year-old male with Type 2 diabetes mellitus and no other chronic health issues presents to the emergency department with altered mental status. The patient experienced no known head trauma. His vitals are: Temperature: 38.1 Celsius Heart rate: 102 beats/minute Respiratory rate: 16 breaths/minute Blood pressure: 90/74 mmHg He responds when you say his name, and he appears well nourished. His mucous membranes appear very dry. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis? A. Cardiac arrhythmia B. Cerebrovascular accident C. Diabetic ketoacidosis (DKA) D. Hyperosmolar hyperglycemic state (HHS) E. Thiamine deficiency" - ANSWER- D. Hyperosmolar hyperglycemic state (HHS) " A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1C was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient's blood pressure? A. Make no changes to her medications as her blood pressure is at goal. B. Start amlodipine daily. C. Start furosemide daily. D. Start lisinopril daily. E. Start metoprolol daily." - ANSWER- B. Start amlodipine daily. " A 65-year-old truck driver presents to your office complaining of right calf pain and swelling. He has recently returned from a four-day cross-country trip after which he had onset of his current symptoms. The patient reports that the week prior to his four-day trip, he was mostly in bed recovering from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25-pack-year smoking history. He denies having any chest pain or SOB. His physical exam shows 2+ pitting edema of his right leg. When measuring the circumference of his right leg, you note that it is 14 cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in diagnosis? A. D-dimer B. MRI C. Lower extremity Doppler D. CT angiography" - ANSWER- C. Lower extremity Doppler " A 45-year-old female presents to your office complaining of left calf pain and swelling. She reports first noticing the pain after her yoga class earlier in the week. She denies having any chest pain or shortness of breath. She has no significant PMH. Her physical exam is significant for tenderness to palpation over the left A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96 mmHg. You repeat the blood pressure in her other arm and get 148/92 mmHg. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76 mmHg. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. What is the most appropriate diagnosis at this time? A. Elevated blood pressure reading B. Secondary hypertension C. Stage 1 hypertension D. Stage 2 hypertension E. White coat hypertension" - ANSWER- A. Elevated blood pressure reading " A 68-year-old male was diagnosed with Stage 1 essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28 and mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94 mmHg. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. Which of the following is the most appropriate medication to begin in this patient? A. Beta-blocker B. Clonidine C. Loop diuretic D. Nitrate E. Thiazide diuretic" - ANSWER- E. Thiazide diuretic " A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vital signs today are blood pressure 138/88 mmHg, pulse 65 beats/min, respiratory rate 12 breaths/minute, afebrile, BMI 29 kg/m2. He does not smoke cigarettes or use illicit substances, and he does drink one or two glasses of wine most evenings. He currently jogs three times a week for approximately 30 minutes at a time. He and his partner order takeout food for supper twice per week and otherwise cook at home. He does not particularly like vegetables, but he tries to eat a piece of fruit every day. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is most likely to improve his cardiovascular risk? A. Alcohol cessation B. DASH eating plan C. Increased exercise D. Increasing dietary potassium - ANSWER- B. DASH eating plan " A 60-year-old male with a past medical history of chronic gout, depression, and stage 1 hypertension presents to your office for a follow-up visit. He has been attempting to reduce his blood pressure with behavioral changes, but has had difficulty maintaining the changes. Today, his vital signs are blood pressure is 144/90 mmHg, pulse is 78 beats/minute, respiratory rate is 12 breaths/minute, and temperature is 37.1 C (98.7 F). His recent basic metabolic panel was completely normal. As you consider starting a medication for his hypertension, which of the following medications is most likely to cause an adverse event in this patient? A. Amlodipine B. Hydrochlorothiazide C. Lisinopril D. Losartan E. Metoprolol" - ANSWER- B. Hydrochlorothiazide " A 62-year-old female presents for follow-up of her hypertension and diabetes. In general, her chronic diseases are well controlled and she has suffered no target organ damage. She has worked hard to begin exercising, and is walking vigorously five times a week. She has also worked hard on dietary changes, and has been following the DASH eating plan very seriously. She quit smoking three months ago. Her blood pressure today is 148/88 mmHg, pulse is 72 beats/minute, respiratory rate is 16 breaths/minute, temperature is 37.1 C (98.7 F), and BMI is 32 kg/m2. She is taking metformin 500 mg twice daily, simvastatin 20 mg daily and hydrochlorothiazide (HCTZ) 25 mg daily, and she is adherent with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the most appropriate? A. Add amlodipine 5 mg - ANSWER- A. Add amlodipine 5mg daily ">What are the risk factors for developing breast cancer in the general population? Select all that apply. A. Age B. Excessive alcohol intake C. Family history of breast cancer in first-degree relative D. Genetic factors E. Postmenopausal obesity F. Prolonged exposure to estrogen - ANSWER- A. Age B. Excessive alcohol intake C. Family history of breast cancer in first-degree relative D. Genetic factors E. Postmenopausal obesity F. Prolonged exposure to estrogen minutes each time. He has not passed out during these episodes, but he has felt the need to sit down when they come. Sitting calmly and waiting seems to make them go away. He denies chest pain, diaphoresis, jaw pain, or arm pain with these episodes. He has a past medical history of gout and hypertension, for which he takes daily allopurinol and losartan. He does not smoke or drink. He is not under any recent stresses at home or work. On exam, he is in no acute distress. His vital signs are completely normal as is his cardiopulmonary exam. A recent complete blood count and TSH were normal. Which of the following is the most appropriate next step? A. Transfer him to the emergency departme - ANSWER- D. Order a 48-hour Holter monitor. "Which of the following are risk factors for osteoporosis? Select all that apply. A. African American heritage B. BMI > 30 C. Early menopause D. History of previous fracture as an adult E. Sedentary lifestyle - ANSWER- C. Early menopause D. History of previous fracture as an adult E. Sedentary lifestyle A 13-year-old female comes to your clinic stating she has been having fever and chills for three days, and aching muscles for the last two days. She states she has also had a mild cough, but is not having any difficulty with breathing. She is up to date on vaccines and her only other medical history is having her tonsils and adenoids removed last year. On physical exam, you find her temperature is 39.2 C (102.6 F), pulse is 96 beats/minute, and her blood pressure is 108/62 mmHg. She has clear rhinorrhea and her oropharynx is mildly erythematous. The rest of her physical exam is normal, and a rapid strep test in the office is negative. What is the next best step in management? A. Albuterol B. Amantadine C. Aspirin D. Ibuprofen E. Zanamivir" - ANSWER- D. Ibuprofen " It is November and you are working in a small, rural emergency department serving a community that is currently going through a flu epidemic. Your next patient is a 4-year-old male who was brought in by his mother for a sore throat and fever that started the night prior. She says he has a cough and is reporting headaches as well. Since last night, he has had a decreased appetite and hasn't been his normal active self. She also wants you to know that he is allergic to eggs and latex and uses an inhaler once a month for asthma-like symptoms. On physical exam, he is tired-appearing but is not acutely dyspneic. His temperature is 39.2 C (102.6 F), pulse is 102 beats/minute, respiratory rate is 21 breaths/minute, and blood pressure is 108/62 mmHg. You note an erythematous throat with normal- sized tonsils without exudate, clear rhinorrhea, and normal-appearing tympanic membranes. His neck is supple without tender lymphaden - ANSWER- B. Order a rapid influenza test and a throat culture " A 7-year-old male is brought to your clinic with a fever of 38.9 to 39.4 C (102 to 103 F) for the past three days. He is up to date on all vaccinations and has no significant medical history. His mother notes that he has not had a cough but is eating and drinking less because ""it hurts to swallow."" On examination of his neck you notice tender cervical lymphadenopathy bilaterally, and auscultation of his back shows clear lung sounds on both sides. His oropharyngeal exam shows erythematous throat, but no tonsillar exudates. What would be the most appropriate next step? A. Chest x-ray B. Empiric levofloxacin (Levaquin) therapy C. Empiric oseltamivir (Tamiflu) therapy D. Empiric penicillin V therapy E. Rapid strep test" - ANSWER- E. Rapid strep test " A 48-year-old female with no smoking history comes to the emergency department with concerns of sore throat for the past two days. She does not have a thermometer at home, but states she has been feeling hot and her children have also been out from school with fever and sore throat. Her children are now staying with their father whom she is separated from, and he notified her yesterday that they were on antibiotics for their symptoms. She was holding off seeing a clinician because she wasn't coughing or having any problems with swallowing until breakfast this morning. You note that she has a fever of 38.6 C (101.5 F) measured by the nurse, and on physical exam you observe an erythematous throat with exudate, and bilateral cervical lymphadenopathy. Her lungs are clear to auscultation. What is the next best step? A. Chest x-ray B. Empiric levofloxacin (Levaquin) therapy C. Empiric oseltamivir (Tamiflu) therapy D. Emp - ANSWER- E. Rapid strep test " You are seeing a 6-year-old female in the family medicine office for a well-child exam. She and her parents have no concerns about her health today. She is A 36-month-old presents for a well child visit. The parents would like to know if the child's development is progressing appropriately. The child passed a hearing test at birth, and other than a few URIs, has been generally healthy. The child has not had any hospitalizations or serious illnesses. The child is able to run well, walk up stairs, walk slowly down stairs, uses more words than the parents are able to count, but can only use them in short, two or three-word sentences. The child's speech is understandable and the child can draw a circle, but not a cross. Neurological examination reveals normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the next best step in management of this child? A. Perform a brain-stem auditory evoked potential hearing screen B. Perform a screening exam for autism C. Reassure the parents that the boy's development appears n - ANSWER- C. Reassure the parents that the boy's development appears normal " Sammy is a healthy male child brought into your office by his mother for a well- child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy's age to be based upon his developmental milestones? A. 12 months B. 15 months C. 18 months D. 30 months E. 36 months" - ANSWER- C. 18 months " A 5-month-old male is brought to the urgent care clinic with a 3 day history of rhinorrhea and non-productive cough. At birth the baby was large for gestational age and exam at the time was notable for macrocephaly, macroglossia, and hypospadias. Vital signs are stable on physical exam at this time. There is copious nasal discharge, but lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A. Hepatoblastoma B. Renal cell carcinoma C. Teratoma D. Wilms' tumor" - ANSWER- D. Wilms' tumor " An asymptomatic, healthy 9-month-old is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? A. Children who are older than 12 months have a better prognosis than younger children B. Favorable histology does not play a role in prognosis C. Lymph node involvement is a poor prognostic factor D. Non-amplification of the n-myc gene is a favorable prognostic factor E. Prognosis of neuroblastoma is predictable" - ANSWER- D. Non-amplification of the n-myc gene is a favorable prognostic factor " A 9-month old comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference and is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? A. Hep B, DTaP, IPV B. Hep B, IPV, and MMR C. Influenza, Hep B, IPV D. Influenza, Hep B, IPV, DTaP E. Influenza, IPV" - ANSWER- C. Influenza, Hep B, IPV " A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A. Enlarged cells with intranuclear inclusion bodies B. Hypersegmented neutrophils C. Sheets of lymphocytes with interspersed macrophages D. Small round blue cells with dense nuclei forming small rosettes E. Stacks of RBCs" - ANSWER- D. Small round blue cells with dense nuclei forming small rosettes " " An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management? A. Do nothing, as this child's behavior is normal B.Find out more about his behavior at home and at school C. Prescribe a stimulant medication for ADHD D. Recommend group therapy for the child E. Suggest behavior modification for the child and parenting classes" - ANSWER- B. Find out more about his behavior at home and at school " An 8-year-old obese male with no past medical history is found to have a mildly elevated blood pressure during a routine health maintenance visit. Review of systems is negative. His physical exam is normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis? A. Coarctation of the aorta B. Hyperthyroidism C. Pheochromocytoma D. Primary hypertension E. Renal artery stenosis" - ANSWER- D. Primary hypertension " A 7-year-old male presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. He was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam, his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is the most likely cause of this patient's hypertension? A. Catecholamine excess B. Coarctation of the aorta C. Primary hypertension D. Renal insufficiency due to renal scarring E. Renal vascular disease" - ANSWER- A. Catecholamine excess " An 8-year-old female presents to your clinic for follow-up after being hospitalized for status asthmaticus. She is completing a five-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes daily use of inhaled fluticasone / salmeterol. She was also diagnosed with ADHD one year ago and was started on Adderall XR daily. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension? A. Medications B. Neurofibromatosis 1 C. Obesity D. Renal insufficiency E. The blood pressure cuff is too big" - ANSWER- A. Medications " A 7-year-old male frequently gets in trouble at school for being disruptive and talking inappropriately in class. He does not follow directions and does not work well with classmates during group exercises. His mother relates that at home, he is always on the go, sleeping only six to seven hours each night, and he does not follow the rules at home. He often skips his homework and sometimes puts himself in danger, such as by running away unaccompanied. Which of the following is the most likely diagnosis? A. Antisocial personality disorder B. Attention deficit hyperactivity disorder C. Bipolar mood disorder D. Functional neurologic symptom E. Rett syndrome" - ANSWER- B. Attention deficit hyperactivity disorder " A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A. Chest x-ray and tuberculin skin test B. CT of nasal sinuses C. Spirometry, before and after bronchodilator therapy D. Chest x-ray and methacholine challenge E. None needed, patient likely has habit cough" - ANSWER- A. Chest x-ray and tuberculin skin test "Which of the following are characteristics of a good screening test? Select all that apply. A. There should be a treatment for the condition being screened for. B. There should be a latent (asymptomatic) stage of the disease. C. The test should have low sensitivity and high specificity. D. The test should be acceptable to the population. E. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. - ANSWER- A. There should be a treatment for the condition being screened for.; B. There should be a latent (asymptomatic) stage of the disease.; D. The test should be acceptable to the population.; E. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. You are seeing a 72-year-old woman in a family medicine office who presents reporting having had a period of facial drooping and left upper extremity weakness that lasted approximately two hours the prior day. She currently has no symptoms. She has a past medical history of hypertension and Type 2 diabetes, for which she takes losartan and metformin daily. Her family history is positive for coronary artery disease in her father. She is a daily smoker, and she does not drink alcohol. On exam, she has normal vital signs including a blood pressure of 122/74 mmHg. Her cardiac exam reveals a regular rate without murmurs. Her neurological exam is completely normal. Which of the following is the most likely pathophysiology for her presenting symptoms? A.Hemorrhage of a cerebral vessel B. Transient hypotension leading to cerebral ischemia C. Hypertensive urgency that has since resolved D. Acute hypoglycemia E. Blood clot in - ANSWER- E. Blood clot in a cerebral vessel " A 57-year-old man presents for follow-up after suffering an ischemic stroke with residual weakness on the left. His past medical history includes type II diabetes. He smokes 1/2 pack per day of tobacco and he does not drink alcohol. He reports no medication allergies. He has at times found the costs of his medications and test strips to be a barrier to adherence. What pairing of an anti-platelet agent and its rational is the best choice for this patient? A. Aspirin 81 mg; more effective at preventing subsequent strokes than higher doses B. Aspirin 325 mg; more effective at preventing subsequent strokes than lower doses C. Aspirin 325 mg; fewer bleeding complications D. Aspirin 81 mg; fewer bleeding complications E. Clopidogrel 75 mg; optimal for patients with diabetes" - ANSWER- D. Aspirin 81 mg; fewer bleeding complications " You are seeing a 68-year-old woman who has presented to the emergency department with left sided facial droop, aphasia, and left sided weakness in her arm and leg. These symptoms began while she was having lunch two hours earlier. On exam, she is hypertensive and afebrile. Her neurologic exam reveals left-sided hemiparesis with expressive aphasia and left-sided hyperreflexia. When evaluating a person with a possible stroke, when might it be acceptable to administer t-PA? A. If onset of neurologic symptoms was < 8 hrs prior to presentation B. If emergent CT head shows a hemorrhagic stroke C. If onset of neurologic symptoms was < 4.5 hours prior to presentation D. If emergent CT head shows multilobar infarction E. If the patient awoke from an 8-hour sleep with stroke symptoms of uncertain duration" - ANSWER- C. If onset of neurologic symptoms was < 4.5 hours prior to presentation " Which of the following therapies are recommended as first-line therapy for secondary prevention of noncardioembolic TIA or noncardioembolic stroke? A. Aspirin B. Warfarin (Coumadin) C. Pravastatin (Pravachol) D. Recombinant tissue plasminogen activator (t-PA) E. Ticlopidine (Ticlid)" - ANSWER- A. Aspirin " A 71-year-old woman presents to the emergency department with acute headache and numbness of the left arm for the past six hours. Past history includes hypertension and diabetes. She takes amlodipine, chlorthalidone, metformin, and rosuvastatin, but ran out of all her medications recently. Her vitals are: Heart rate: 80 beats/minute Blood pressure: 205/110 mmHg Respirations: 16 per minute Body Mass Index: 30 kg/m2 An EKG reveals normal sinus rhythm with a rate of 82 and no ischemic changes. Which of the following is the most likely diagnosis A. Transient ischemic attack C. Rapid strep test - ANSWER- C. Rapid strep test and recommend immunizations today >Samantha and Joe bring in their newly adopted 5-year-old son, Matthew to your office with the chief concern of sore throat, without cough, that began two days ago. He was born in the United States and was neglected by his biological parents. Samantha and Joe believe Matthew lived in an old building and ate mostly non- nutritious meals. They are unsure if his immunizations are up to date. His immunization record is attached. Upon physical exam he is playful and interactive. His vital signs are: Temperature: 99.0 F; heart rate: 80; respiratory rate: 19; blood pressure: 95/63 mmHg. He has tender anterior cervical lymphadenopathy, tonsillar exudates and palatal petechiae.In addition to MMR and influenza, and Hep B, which other immunizations does Matthew need? A. Hib, DTaP, PCV, IPV B. RV, IPV, Hep A, varicella C. Varicella, meningococcal D. Varicella, HPV, DTaP E. Varicella, IPV, DTaP, Hep A - ANSWER- *E. Varicella, IPV, DTaP, Hep A "What history related to Mr. Reynolds' risk of cardiovascular disease do you want to obtain? Select all that apply. A. Exercise B. Tobacco use C. Stress D. Travel history E. Family history - ANSWER- A. Exercise B. Tobacco use C. Stress E. Family history F. History of leg pain with exercise G. History of chest pain with exercise H. Excess alcohol use 14-year-old Jennifer is brought to clinic by her mother who is concerned about ADHD. She states Jennifer lacks motivation, regularly does not clean her room, and has to be reminded to do chores around the house. She also is concerned Jennifer does not listen to her and avoids doing homework. Which of the following would most strongly support additional evaluation to assess for ADHD? A. A diagnosis of major depression B. A report card with good grades C. A teacher's report of inattentive behavior D. Fidgety behavior in the car when driving long distances E. Symptom onset with entry to high school" - ANSWER- C. A teacher's report of inattentive behavior " Ms. Jones is a first time mother who brings in her 5-day-old son Tommy for his first scheduled newborn visit. Upon reviewing Tommy's hospital records you note that mom's pregnancy was uncomplicated and that Tommy was born full term via spontaneous vaginal delivery and his birth weight was average for gestational age at 3000 grams. Per your discussion with mom, she has been breastfeeding successfully with good technique every two to three hours on demand since delivery. Tommy's physical exam is normal and largely unchanged from the hospital; he is at the 70th percentile for height and head circumference, but his weight has decreased to 2,750 grams. Mom is very concerned by this weight loss and wants to know what she should do. You should recommend: A. Continuing breast feeding with same frequency and return to clinic in 5-7 days B. Hospitalizing Tommy until he shows adequate weight gain for his age C. Increasing the - ANSWER- A. Continuing breast feeding with same frequency and return to clinic in 5-7 days " The Aronsen family bring their 3-week old newborn for an acute visit because his parents express worry that "something is not right."" They report vomiting, which seems more than the post-feeding "dribbles" they were used to with their prior children. The baby seems more irritable and less easily consoled. They deny stool changes, fever, rash, sick contacts, or decrease in frequency of feeds. They notice that he has fewer wet diapers overall. You are concerned that, on exam, the infant does not appear as well as one week prior when he underwent his routine 2-week well baby visit. His weight has increased slightly over the past week, but not as much as expected on the growth curve. He appears to be mildly dehydrated and lethargic, but you find no other distinct physical exam signs. What is the most likely diagnosis? A. Colic B. Failure to thrive C. Gastroesophageal reflux D. Intussusception E. Pyloric stenosis" - ANSWER- E. Pyloric stenosis " Ms. Kovacs is a first-time mother you are seeing on postpartum day two in the hospital, with her newborn son Christopher. Her pregnancy was uncomplicated and Christopher was born full-term via spontaneous vaginal delivery with no complications and a birth weight of 7 lbs, 0 oz (3,178 grams). Ms. Kovacs is getting ready to be discharged home today but is concerned because the baby now weighs 6.8 lbs (3,087 grams) and she hasn't been able to produce milk every time Christopher wants to feed. Upon receiving your recommendations, she has been attempting to breastfeed with good technique every two to three hours with strong latching and vigorous suckling. She is still concerned her baby isn't getting enough to eat. Which of the following would be the most appropriate advice for mom? Ms. Brady, a 78-year-old female prevents to your office after six months for follow-up. Her interval history is significant for a TIA three months ago. Today her Mini-Mental State Examination (MMSE) is 19. You note that six months ago her MMSE was 22, and nine months ago it was 26. Physical exam shows temperature of 98.8 Fahrenheit, blood pressure of 167/95 mmHg, heart rate of 76 beats/minute, respiratory rate of 14 breaths/minute, and BMI of 23. Chest: regular rate and rhythm, no murmurs; lungs: clear to auscultation; neuro: weakness in the right upper extremity; abdomen: soft, non-tender. She takes atorvastatin and aspirin. Lab studies show Hgb A1c: 5, TSH: 3, B12: 500 pg/mL. Which of the following is the most important recommendation to prevent further disability in this patient? A. Order a mammogram B. Start hydrochlorothiazide C. Start metformin D. Start vegetarian diet E. Weight loss" - ANSWER- B. Start hydrochlorothiazide " A 68-year-old male becomes confused and agitated on post-operative day three after open cholecystectomy. He does not recall his surgery or where he is, and he wants to leave the hospital. Physical exam shows temperature of 99.9 Fahrenheit, blood pressure of 143/89 mmHg, heart rate of 90 beats/minute, respiratory rate of 13 breaths/minute, and O2 sat of 98% on room air. He appears agitated and uncomfortable. He has a Foley catheter. His physical exam is unremarkable. Labs: WBC-11,000, Urinalysis: 2+ nitrites and 2+ leukocyte esterase, 10 WBC/hpf. Glucose finger stick: 80, ECG: normal sinus rhythm at 88 beats per minute. Which of the following is the best initial step to help relieve the patient's symptoms? A. Give IV ceftriaxone B. Give oral ceftriaxone C. Order urine culture D. Order urine gram stain E. Remove urine catheter" - ANSWER- E. Remove urine catheter " Ms. Michaels is an 80-year-old female with a past medical history of shingles. She comes to your office accompanied by her daughter Jennifer who reports that her mother is forgetting things. Jennifer explains that her mother will ask the same question several times throughout the day. Ms. Michaels also gets confused easily and is more passive than usual. Her memory problem was noticed two years ago after she forgot to pay her bills on multiple occasions. Jennifer now pays her mother's bills and cleans and cooks for her. Ms. Michaels' vital signs are temperature of 99.2 Fahrenheit, blood pressure of 118/70 mmHg, heart rate of 80 beats/minute, and respiratory rate of 12 breaths/minute. Her physical exam is significant for bilateral osteoarthritis hand deformities. She does not have a tremor, nor jerky uncontrolled movements. She is not on any chronic medications. She has no smoking history and does not drink alcohol. C - ANSWER- A. Alzheimer disease " You are seeing a 92-year-old male in the hospital. He was admitted after a fall in which he broke his hip. It is now post-op day two from surgery to repair the fracture. His children report that he has been very confused this morning, with varying levels of alertness. Yesterday, he had been recovering well and even participated in physical therapy. Today, he does now know where he is and is at times combative with his care team. His medical history is positive only for hypertension. His medications include amlodipine 5 mg daily and morphine 4 mg IV every 4 hours as needed for pain. His vital signs are all normal today, and his general exam is unremarkable except for expected post-operative changes to his hip. He is somnolent during the examination. Today's labs include a normal CBC and basic metabolic panel. A urinalysis reveals no leukocyte esterase and is nitrite negative. What is the most likely cause of his curr - ANSWER- B. Morphine " A 55-year-old female with exercise-induced asthma, but no other chronic health problems, presents to the office with left shoulder pain. She is a tennis player, left- handed, and notices pain serving the ball. When you suggest that it might be her rotator cuff your preceptor asks, ""what muscles make up the rotator cuff?"" A. Supraspinatus, infraspinatus, teres major, subscapularis B. Supraspinatus, infraspinatus, teres minor, subscapularis C. Supraspinatus, infraspinatus, teres minor, deltoid D. Supraspinatus, infraspinatus, teres major, teres minor E. Supraspinatus, infraspinatus, teres minor, rhomboid minor" - ANSWER- B. Supraspinatus, infraspinatus, teres minor, subscapularis " A 17-year-old male football player presents to the emergency department with acute onset of right-shoulder pain. The pain started approximately two hours ago when he was tackled during a game while carrying the football. Shoulder swelling and pain were present after injury. He is holding ice to a swollen shoulder, and on exam you notice severe bruising, pain on palpation over the lateral edge of the shoulder, and a raised bump over that same area. There is also severe tenderness over the coracoclavicular ligaments. You are seeing a 52-year-old male for a full physical at the local free clinic for patients who are uninsured. He has no concerns other than intermittent headaches, which are well controlled with ibuprofen. His family history is positive only for dementia in his mother and stroke in his father. He does not smoke tobacco, drink alcohol, or use illicit drugs. His general physical exam is normal aside from his being overweight. You mention that he is due for colon cancer screening, and he responds that his older brother has been pressuring him to get a colonoscopy. Unfortunately, he is unable to afford this test. There is a local program to provide free colonoscopies to patients at high risk for colon cancer, but your patient would not qualify on the basis of his lack of risk factors. What is the most appropriate next step with this patient regarding colon cancer prevention? A. Recommend yearly abdominal x-rays, which - ANSWER- B. Recommend annual fecal occult blood testing " You are seeing a 32-year-old female in the family medicine ambulatory practice who presents with concern of fatigue. She finds herself simply exhausted at various points of her day, particularly when she is sitting and having to focus on something. When she is busy and physically active, she notices the fatigue less. She reports no recent weight change, skin changes, temperature intolerance, tremulousness, or unusual bleeding. She uses a levonorgestrel IUD and does not have menses on a monthly basis. Her past medical history is positive for a history of seasonal allergies that are well-controlled with loratadine. She does not smoke, drink or use illicit substances. She works as an emergency department nurse at a local hospital, alternating between evening and over-night shifts. On exam, she is well-appearing and has normal vital signs and a BMI of 24 kg/m2. She has no conjunctival pallor. Her thyroid is non-palpable. - ANSWER- C. Sleep dysfunction due to alteration of her circadian rhythm. " You are seeing a 55-year-old female patient for follow-up who you met two weeks ago at her physical exam. Her review of systems and physical exam were only significant for fatigue. Her blood work shows iron deficiency anemia. She is post- menopausal x 2 years with no significant past medical history or family history but a 10 pack-year smoking history. Prior to establishing with you she hadn't seen a doctor since she was 18 years old. Which of the following would be the most appropriate next step in diagnosis? A. Prescribe oral iron supplementation and pursue no further workup if her fatigue improves B. Refer her for a colonoscopy C. Order a hemoglobin electrophoresis D. Order a pelvic ultrasound E. Recommend fecal occult blood testing now and every year moving forwards" - ANSWER- B. Refer her for a colonoscopy " Ms. Wicket is a 30-year-old female establishing with you as a new patient. Her past medical history is significant for hypothyroidism for which she has been without treatment for five years. She currently takes no medication and has no surgical or family history. She is single, with no children, drinks alcohol socially, and does not use tobacco or other recreational drugs. The only records she has are from blood work that she had done last month significant for a very elevated thyroid stimulating hormone (TSH). What constellation of symptoms would you expect to find on your review of systems? A. Dry skin, sensitivity to cold, constipation, and fatigue B. Palpitations, sweating,lightheadedness, and fatigue C. Depression, frequent bowel movements, sweating and increased appetite D. Tremor, hair changes, difficulty sleeping and heavy menses" - ANSWER- A. Dry skin, sensitivity to cold, constipation, and fatigue " You are seeing a 42-year-old established female patient in the office for her yearly physical. She has a past medical history of hypertension, and she has no significant family history. She is a teacher at a local high school, and she has three school- aged children. She does not drink alcohol or use illicit drugs, but she has smoked a pack and a half of tobacco for the past 20 years. She would like you to order a colonoscopy because a friend of hers was just diagnosed with colon cancer and has passed away from it. What combination of types of cancer screening all receive an A or B recommendation from the USPSTF for this patient? A. Cervical cancer screening, lung cancer screening, and breast cancer screening B. Cervical cancer screening and breast cancer screening C. Cervical cancer screening only D. Cervical cancer screening, breast cancer screening, and colon cancer screening E. Breast cancer screening and lung c - ANSWER- C. Cervical cancer screening only " A 68-year-old male with GOLD Stage 3, Group D, COPD requiring 2L of oxygen at nighttime presents to clinic complaining of increasing lower extremity edema over the past few weeks. He also thinks his nighttime cough might be worse. His D. Pulmonary rehabilitation program E. Tiotropium (Spiriva) inhaled daily" - ANSWER- A. Cessation of tobacco products " A 22-year-old male comes to the office for a physical before he graduates from college. He wants to know which cancer is most common in males in his age range. A. Follicular thyroid cancer B. Gastric cancer C. Pancreatic cancer D. Skin cancer E. Testicular cancer" - ANSWER- E. Testicular cancer " A 16-year-old male patient presents with dull, aching pain in his left scrotum. He says that the dull aching pain is more prominent upon standing. Which of the following the most likely diagnosis? A. Epididymitis B. Henoch-Schönlein purpura (HSP) C. Hydrocele D. Testicular torsion E. Varicocele" - ANSWER- E. Varicocele " Your 28-year-old male patient who presented with severe testicular pain has an exam consistent with a testicular torsion. Which of the following imaging studies is best for confirmation? A. Angiography B. Color Doppler US C. CT scan without contrast D. MRI E. X-ray" - ANSWER- B. Color Doppler US " Your 28-year-old male patient with testicular pain has been experiencing pain at a level of 8/10 for two hours. Within how many hours should surgery be performed on a patient with a diagnosed testicular torsion? A. 30 minutes B. 1 hour C. 6 hours D. 18 hours E. 24 hours" - ANSWER- C. 6 hours " A 21-year-old female comes into your family medicine office complaining of an abnormal discharge with a foul odor. She has been sexually active with four to five partners over the past year, and uses condoms inconsistently. Which of the following can be seen on a wet prep? A. Chlamydia B. Gonorrhea C. Herpes D. Syphilis E. Trichomonas" - ANSWER- E. Trichomonas " A 21-year-old G1P0 female present to clinic as a new patient to establish prenatal care. Which statement represents something that would not be expected to be a benefit of group prenatal care for this patient? A. Decreases the likelihood of preterm delivery B. Increases physician contact C. Increases support network D. Shared education between patients E. Increases adherence to techniques for pain management during labor" - ANSWER- E. Increases adherence to techniques for pain management during labor " A 24-year-old G1P0 female at 38 weeks gestation presents to ED complaining of strong lower abdominal contractions that are 10 minutes apart for the last hour. Subsequent cervical examination demonstrates that she is 2cm dilated. FHT are 140 and NST is non-reactive with early decelerations. What is the most appropriate management of this patient? You are seeing a 55-year-old female with a past medical history of hypertension, diabetes, and gout. She has no complaints today and is here to manage her chronic conditions. She is taking her medications, which include lisinopril 10 mg daily, metformin 500 mg twice daily, and allopurinol 100 mg daily. She is trying to focus on her diet in an effort to lose weight. She smokes a pack of cigarettes every day, and she is worried that quitting will make her gain weight and worsen her diabetes. Her family history is positive for a recent myocardial infarction in her father at age 78. Her vitals today include a blood pressure of 128/78 mmHg, pulse of 78 beats/minute, respirations of 14/minute and a BMI of 32 kg/m2. Her general exam is unremarkable today. Which of the following is not a risk factor for coronary artery disease in this patient? A. Hypertension B. Her family history C. Smoking D. Diabetes E. Obesity" - ANSWER- B. Her family history " 56-year old male with a past medical history of hypertension and type 2 diabetes mellitus presents with progressive dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and dependent edema over the prior 4 days. His social history is notable for a 30 pack-year tobacco history and occasional marijuana use. His family history is positive for bypass surgery in his mother at the age of 62. On exam, his vitals include a blood pressure of 166/86 mmHg, pulse of 98 beats/minute, respirations of 21/minute and a BMI of 32 kg/m^2. He appears mildly dyspneic. His neck reveals an elevated jugular venous pulse, his chest exam reveals bilateral crackles in the lower lung fields, and his cardiovascular exam reveals mild tachycardia, a regular rhythm, and no murmurs. His abdominal exam is unremarkable, and he has 2+ edema in his legs midway to his knees. An EKG reveals sinus tachycardia with a left axis deviation and Q waves - ANSWER- E. Ischemic cardiomyopathy " A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral crackles at the lung bases, and 2+ p - ANSWER- D. Electrocardiogram " You are seeing a 63-year-old male with hypertension, diabetes, and a history of an NSTEMI two years ago. His most recent echocardiogram reveals mild hypokinesis of the inferior wall of the left ventricle and a LV ejection fraction of 40%. Shortly after his MI, he was treated for symptoms of congestive heart failure, but he has not has any such symptoms since then. His exercise tolerance is excellent. Today his physical exam is completely unremarkable. The correct pairing of NYHA functional class and ACCF/AHA Stage of CHF is which of the following for this man? A. NYHA II / Stage C B. NYHA I / Stage A C. NYHA I / Stage B D. NYHA I / Stage C E. NYHA II / Stage B" - ANSWER- D. NYHA I / Stage C " You are seeing a 72-year-old female with a recent diagnosis of diastolic heart failure (HFpEF) with an ejection fraction of 60% on a recent echo. She was given a diuretic in the ER last week and told to follow up with you. She complains of mild new dyspnea on exertion, orthopnea and lower extremity edema. On exam, her vitals include a blood pressure of 142/86 mmHg, pulse of 84 beats/minute, respirations of 16/minute and oxygen saturation of 98% on room air. Pulmonary exam reveals mild bibasilar crackles, cardiac exam reveals a regular rate and rhythm with no murmurs, and her extremities have 1+ edema to the lower shins. Of the following, which would be the most appropriate choice of medication for this patient? A. Amlodipine B. Digoxin C. Metoprolol succinate D. Hydrochlorothiazide E. Spironolactone" - ANSWER- C. Metoprolol succinate " A 13-year-old female patient comes to your office for a physical. Her mother is concerned because she complains of menstrual cramps during her period each month. You determine that menarche was earlier that year and her periods have been mostly regular since that time. The pain is in her lower abdomen and is relieved with Ibuprofen and a heat pack. She has no other medical problems and her physical exam is normal.