Can't Breathe with No Air
A 58-year-old male with 20 pack year smoking history presents for well exam. States he quit smoking 1 year ago, but has not seen a physician in over 20 years.
According to USPSTF, patient is due for this screening exam.
Hepatitis C screening
An 85-year-old female with a previous history of diabetes mellitus, hypertension, dementia, and peptic ulcer disease has been in a skilled nursing facility for 4 weeks for rehabilitation after a hip fracture repair secondary to a fall during an ischemic stroke. She is transported to the emergency department today when she develops confusion, shortness of breath, and diaphoresis. Her blood pressure is 172/98 mm Hg, her heart rate is 122 beats/min with an irregular rhythm, and her respiratory rate is 22/min. An EKG demonstrates atrial fibrillation and 0.2 mV ST-segment elevation compared to previous EKGs. Her first troponin level is elevated.
This condition in this patient is considered an ABSOLUTE contraindication to fibrinolytic therapy?
Ischemic stroke
A healthy 2-month-old female is brought to your office for a routine well baby examination by both of her parents. They refuse routine recommended vaccines because of their personal beliefs.
You decide to follow the CDC recommendations by
having the parents sign a refusal to vaccinate form
A 25-year-old female sees you because of irregular menses, hirsutism, and moderate acne. She is sexually active in a monogamous relationship with a male, has never been pregnant, and prefers not to become pregnant at this time.
This is considered first-line therapy.
Levonorgestrel/ethinyl estradiol (hormonal contraception)
A 15-year-old female presents with a 3-month history of intermittent abdominal pain and headaches. She does not have any associated weight loss, fever, nausea, change in bowel habits, or other worrisome features. An examination is unremarkable. She does report being stressed at school and has a PHQ-2 score of 4.
This intervention would be most appropriate at this point.
Further evaluation for depression
A 29-year-old male smoker presents with a 10-day history of a cough, 2 day history of low grade fever, 3-4 days of productive cough with green sputum and mild rhinorrhea. Hasn't tried any medications. PE notable for rhinorrhea with clear lungs.
This is the most appropriate management recommendation at this time.
Supportive care only
A 42-year-old male with hypertension and hyperlipidemia sees you for well exam. His blood pressure is 185/105 mm Hg. ROS is negative. He is adherent to his current medication regimen, which includes lisinopril (Prinivil, Zestril), 10mg daily, and simvastatin (Zocor), 20 mg at night. A thorough history and physical examination are both unremarkable.
This would be the would be the most appropriate next step in management.
A 30-minute rest period followed by a repeat blood pressure reading
2-week-old infant presents for a well child check. Infant is primarily breastfed with formula supplementation. Mom is insisting on starting vitamin supplement. You advise her that this is the correct vitamin, dose, and frequency.
He should be given 400 IU of supplemental vitamin D daily
A 30-year-old female with anovulatory uterine bleeding asks about treatment options. An examination is normal and blood testing is negative. She is unmarried and is undecided about having children.
This contraception method would be the most appropriate treatment for this patient.
A levonorgestrel-releasing IUD
You are initiating pharmacologic therapy for a 75-year-old patient with depression.
Between Amitriptyline, Escitalopram, Imipramine, and Paroxetine, which medication would be the most appropriate for this patient.
Escitalopram (Lexapro)
A 7-month-old male is admitted to the hospital for respiratory syncytial virus bronchiolitis. His temperature is 37.9°C (100.2°F), pulse rate 160 beats/min, respiratory rate 70/min, and oxygen saturation 92% on room air. Auscultation of the lungs reveals diffuse wheezing and crackles accompanied by nasal flaring and retractions.
This intervention would most likely be beneficial.
Nasogastric fluids
A 50-year-old male with hypertension who is not at increased risk for gastrointestinal bleeding should begin low-dose aspirin at this 10-year risk level for cardiovascular disease.
10%
At the initial exam of a newborn male born via NSVD at 37w 6d EGA, you note that the infant’s upper lip is thin and the philtrum is somewhat flat. The additional finding of clinodactyly is associated with this condition.
fetal alcohol syndrome
A 29-year-old gravida 2 para 1 comes to the hospital for scheduled induction of labor. Her last delivery was a spontaneous vaginal delivery without complications. Her pregnancy has been uneventful. Oxytocin (Pitocin) is used during induction according to the hospital protocol and her labor progresses without difficulty.
This "routine" procedure should be AVOIDED to minimize the risk of postpartum hemorrhage in this patient.
Routine episiotomy
A 24-year-old female with a history of bulimia nervosa sees you for treatment of depression. She is currently receiving cognitive-behavioral therapy. You decide that she requires medication to treat her depression.
This medication has been associated with an increased risk of seizures in patients with bulimia nervosa.
Bupropion (Wellbutrin)
A 48-year-old female presents with dyspnea with exertion. She has never smoked. A physical examination is normal, including vital signs and pulse oximetry. A CXR reveals mild hyperexpansion of the chest, and pulmonary function testing reveals an FEV1/FVC ratio of 0.67, unchanged after bronchodilator use. An EKG and stress echocardiogram are normal. You suspect COPD.
This is the most likely underlying cause of this patient’s pulmonary disease?
Alpha 1-Antitrypsin deficiency
A 50-year-old female sees you for follow-up of her hypertension. At her last visit 4 weeks ago you started her on lisinopril (Prinivil, Zestril), 10 mg daily, because of a blood pressure of 158/92 mm Hg and confirmed hypertension on ambulatory blood pressure monitoring.
She is tolerating the medication well and has no side effects. She does not take any other medications. Today her blood pressure is 149/90 mm Hg, which you confirm on repeat BP. This is also consistent with her home measurements. At her last visit a BMP was normal.
You repeat a basic metabolic panel today and the results are normal except for a BUN of 25 mg/dL (N 8–23) and a creatinine level of 1.5 mg/dL (N 0.6–1.1). At her last visit her BUN was 12 mg/dL and her creatinine level was 0.7 mg/dL.
This is the most appropriate management of her medications at this time.
Discontinue lisinopril and begin either thiazide or calcium channel blockers.
A 4-year-old male with no PMHx presents for well exam. Mom reports new skin lesions: nonerythematous flesh-colored, dome-shaped papules with a central indentation, on the lower back and popliteal fossa. Patient reports itchiness.
VS & PE otherwise within normal. You recommend this initial management.
Observation only
A 33-year-old gravida 2 para 2 presents with a 1-year history of amenorrhea, hot flashes, and vaginal dryness. She previously had normal menses and takes no medications. Her PMHX ans PSHX are negative. The patient is 178 cm (70 in) tall and her BMI is 22.0 kg/m2. Her vital signs are normal. A physical examination is normal except for vaginal dryness. Laboratory studies reveal a negative urine pregnancy test, normal TSH and prolactin levels, and elevated LH and FSH levels.
This is the most likely diagnosis.
primary ovarian insufficiency
When deciding between traditional psychotherapy, cognitive-behavioral therapy, psychoanalysis, and psychodynamic therapy, this is the most appropriate psychotherapy for patients with obsessive-compulsive disorder.
Cognitive-behavioral therapy
A 35-year-old white female presents with recurrent wheezing and coughing over the past few weeks, and recent production of brown sputum plugs. Has a long history of asthma and multiple allergies. She has been treated four times in the last 3 months for asthma exacerbations and generally feels better the first day she takes her corticosteroid, but any attempt at tapering leads to a recurrence of symptoms. She previously had good control of her asthma, although she has required regular use of a high-dose inhaled corticosteroid and a long-acting -agonist. In spite of just completing a course of levofloxacin (Levaquin) for suspected pneumonia she returns today with a recurrence of the same symptoms.
A physical examination is unremarkable with the exception of diffuse expiratory wheezing.
She has no fever or other abnormal vital signs. A chest radiograph shows opacities in the upper and middle lobes and a CBC is concerning for eosinophilia.
This is the most likely diagnosis.
Allergic bronchopulmonary aspergillosis
A 21-year-old female is being evaluated for secondary causes of refractory hypertension.
This imaging modality is the most specific for fibromuscular dysplasia.
Magnetic resonance angiography of the renal arteries
An 18-month-old male is brought to your office for a well child check. He is walking only with assistance. You and the parents are concerned about gross motor delay.
This physical exam finding would be most suggestive of muscular dystrophy in this patient
Head lag when sitting up
A 27-year-old female with a past medical history of polycystic ovary syndrome (PCOS) would like to become pregnant.
This treatment for PCOS is associated with greater live-birth and ovulation rates?
Letrozole (Femara)
You see a 26-year-old male for the first time. He has a history of major depression over the past 4–5 years. He currently does not take any medications. His psychiatric history reveals at least two episodes of mania, most recently 1 year ago when he was hospitalized during the episode.
This class of drugs is CONTRAINDICATED as monotherapy in treating this patient’s depression at this time.
SSRI