1. A 35-year-old man is for a physical examination.Labs reveal an HIV test that is positive. He undergoes counseling regarding his diagnosis. His CD4 count is 125, and viral load is 36,000; he is Toxoplasma gondii IgG po
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1. A 35-year-old man is for a physical examination.Labs reveal an HIV test that is positive. He undergoes counseling regarding his diagnosis. His CD4 count is 125, and viral load is 36,000; he is Toxoplasma gondii IgG positive. His hepatitis panel shows hepatitis B surface antibody positive and hepatitis C antibody negative. He had a tuberculin skin test (TST) reaction measuring 4 mm. Which of the following prophylaxis treatments for opportunistic infections should you offer?
2. Which of the following is a risk factor for urinary tract infection in sexually active women?
3. A 39-year-old female presents with anxiety and frequent “panic attacks.” She was seen 2 weeks ago, and her examination was unremarkable. The patient is referred to a therapist for a psychological evaluation. She returns today while experiencing a panic attack. She is diaphoretic with a heart rate of 101, blood pressure of 150/90, and papilledema. The patient denies chest pain or dyspnea. She states this is a typical episode. Which of the following tests is the next best step in establishing a diagnosis?
4. Which of the following is true of management goals in sepsis?
5. A patient presents with the lesion shown below. Which of the following drugs should be given as post-exposure prophylaxis (PEP) for this disease?
6. A 45-year-old white woman with clinical findings suggestive of Cushing syndrome has 2 elevated late night salivary cortisol levels and 2 elevated urinary free-cortisol tests of 220 and 300 (normal 2-50mg/24 hour); her ACTH level is 55 (normal 5-50pg/mL), and her pituitary MRI shows a 3mm adenoma. Which of the followings is the best next course of action?
7. A female patient with primary hypothyroidism has been stable (normal TSH) on replacement LT4 (dose 1.6μg/kg of body weight) for several years. On annual follow-up, the following laboratory tests are obtained: T4 = 14.1μg/dL (normal 5.0-10.5) and TSH = 23.4μU/mL (normal 0.4-5.5). Which is the most likely diagnosis?
8. Which of the following is the organism most frequently implicated in toxic shock syndrome in women who are using tampons?
9. Rocky Mountain spotted fever is caused by which of the following?
10. A 36-year-old female presents to a primary healthcare provider with a history of irregular menstrual cycles and secondary amenorrhea. She had no problem conceiving her first child at age 24, but she has been trying unsuccessfully to become pregnant for the past 2 years. She also reports a weight gain of about 5kg, increasing fatigue, a puffy face, and marked cold intolerance. CBC reveals an Hb of 11.1 and an MCV of 90. Physical exam reveals a moderate-sized diffuse enlargement of the thyroid gland. Which of the following thyroid profiles is most likely present in this woman?
11. A 40-year-old white woman with a history of severe asthma and Hashimoto thyroiditis reports 2 months of fatigue, anorexia, nausea, weight loss, and myalgia. Examination is remarkable only for a BP of 98/60 mmHg and a pulse of 98 beats/minute without orthostasis. She shows no hyperpigmentation. Lab values are as follows: sodium 130 mEq/L, potassium 4.5 mEq/L, chloride 105 mEq/L, and bicarbonate 24 mEq/L. ACTH stimulation testing shows an AM cortisol level of 5.8 μg/dL at T0 (normal is 10-20 μg/dL) and 13.2 μg/dL (normal 18 μg/dL) at T60 (60 minutes after administration of ACTH). Which of the following is correct?
12. Which of the following is the first line treatment for gonorrheal infections?
13. A 59-year-old woman presents to the ED feeling generally unwell with 2 months of worsening lethargy, nausea, generalized abdominal pain, and constipation. She is a heavy smoker and has hypertension, high cholesterol, and chronic bronchitis. She takes amlodipine 5mg daily and atorvastatin 40mg daily with no recent changes in doses or frequency. The patient has lost 15lbs despite a normal appetite over this period. There has been no recent exacerbation of her chronic cough. She had a few episodes of minimal hemoptysis a few months ago but none since.Vital signs are within normal limits. Auscultation of the lungs reveals mild decreased air entry throughout and no adventitious sounds. Mild generalized abdominal tenderness to palpation is noted. Physical examination is otherwise unremarkable. Laboratory investigations are notable for a Cr of 0.8 and Ca of 12.1. Albumin is 3.8. Chest radiograph shows a discrete mass in the right hilum that is approximately 10mm in diameter; otherwise, lung fields are clear without collapse or consolidation. What is the best initial management of this patient?
14. A 26-year-old man has had a painless penile lesion for several weeks and new swelling in the groin. On examination, a single nontender penile ulcer and bilateral palpable nontender inguinal lymph nodes are present. Rapid plasma reagin test results are negative. What is the most likely diagnosis?
15. A 60-year-old male patient is evaluated in the emergency department for mental status changes. He has a history of COPD and a 40 pack year history of tobacco use. Laboratory results reveal:
16. Which of the following is a characteristic of acromegaly
17. Which of the following oral antimicrobials should a nurse practitioner prescribe for outpatient treatment of community acquired methicillin resistant Staphylococcus aureus infection?
18. An 85-year-old male nursing care resident with Alzheimer disease is brought to the emergency department with diarrhea and vomiting for 3 days. His nurse-aid reports that the patient has been unable to eat or drink for the past 24 hours and appears more lethargic than usual. His vitals at the time of admission are temperature 37.0 degrees C (98.6 degrees F), blood pressure 90/60 mmHg, heart rate 138/min, and respiratory rate 19/min. The patient's mucous membranes are dry.
19. Which of the following is true of urinary tract infections associated with indwelling urinary catheters?
20. Which of the following medications is the first line treatment for Grave’s disease?
21. A 60-year-old woman is referred for a positive Venereal Disease Research Laboratory (VDRL) test result. She is asymptomatic. She recalls having syphilis as a teenager but never receiving treatment. Cerebrospinal fluid (CSF) examination shows no white blood cells, normal protein, and normal glucose; CSF VDRL is nonreactive. How should the patient be managed?
22. A 70-year-old female complains of fever, myalgias, and headache over 3 days. She began coughing today, but her cough is not productive. She has a past medical history significant for hypertension and osteoarthritis. Vital signs include T 102.8 F; RR 20/min; pulse 100/min; and blood pressure 110/70 mm Hg. Exam reveals watery red eyes, warm dry skin, and a dry cough with clear lungs. Influenza is confirmed by use of a QuickVUe Influenza A+B test. Local epidemiological data show a cluster of influenza B cases locally. Which of the following is true?
23. A 28-year-old female patient complains of vaginal discharge associated with burning, irritation, and pruritus. She is sexually active with one partner and her last menstrual period was 2 weeks earlier. On examination, her vulva is erythematous with edema. She has a thick white adherent discharge and no cervical motion tenderness or uterine tenderness is noted. Which of the following is the most common infectious cause of vulvovaginal pruritus?
24. A 50-year-old male patient presents with a wound on the bottom of his foot, which he sustained by stepping on a nail. He was wearing tennis shoes. Which of the following is true?
25. A 58-year-old female presents with chronic, agonizing pain. For the past 3 years, she has been experiencing an intermittent "burning" pain in her legs that occasionally becomes sharp and shooting. The pain is not responsive to OTC pain medications, but she reports mild relief with a combination of hydrocodone and acetaminophen. The pain seems unrelated to exertion and does not resolve with rest. Besides this pain, the patient appears to be fairly well.Her past medical history is significant for diabetes mellitus type 2, complicated by retinopathy, diabetic gastroparesis, and a myocardial infarction 8 years ago. Although her blood sugar is largely under control, she admits to poor glycemic control. Her hemoglobin A 1c levels have been 10-14% for most of her life. Which of the following medications will be most effective for this patient’s leg pain?
26. A nurse practitioner is treating a patient who has had four recent bouts of cystitis. She states on this visit that she has had symptoms of urgency, dysuria, and frequency for 7 days. Which of the following statements by the patient suggest that her symptoms may be due to something more than cystitis?
27. A 32-year-old woman is seen for primary infertility and irregular menses. Menarche was at age 14. Her periods have always been irregular, and she has about 8 or 9 periods each year. She has used birth control pills in the past to induce regular cycles. Her mother and maternal aunt have type 2 DM. On physical examination, she is overweight (BMI 25.1 kg/m2) and has facial hirsutism. Workup for infertility includes a pelvic ultrasound, which reveals increased ovarian volume bilaterally.
28. A 23-year-old Caucasian woman is seen for polyuria and increased thirst. She craves icy cold water. She denies headaches or visual changes. She has no significant past medical history and denies using any medications. Family history is unremarkable. On physical examination, her blood pressure is 110/70 mmHg and heart rate is 78 beats/minute. She weighs 50 kg.
Lab results are as follows:
29. A patient presents with headache and stuffy nose for a week. She relates pain over her cheek that radiates to the teeth when she bends down. Her temperature is 100.9 F. Exam reveals tenderness over the maxillary sinus with palpation and edematous and boggy nasal mucosa. Which of the following is first line therapy for this patient?
30. Which of the following secretes aldosterone?
31. A 70-year-old man is brought to the ER after being found unresponsive by his wife. His past medical history is significant for HTN, coronary artery disease, ischemic cardiomyopathy, and arthritis. He had been seen recently by his primary care physician for weight loss and diarrhea. The patient's wife reports that his diarrhea has been occurring periodically for several months. In the ER, his BP is 75/40, HR is 120, T is 39°C, and RR is 24. He is brought to the ICU and started on broad-spectrum antibiotics for presumed sepsis. Blood cultures drawn in the ER grow Clostridium septicum. The patient is eventually stabilized and transferred to the regular nursing floor. What do you recommend to complete this patient’s workup?
32. A 35-year-old woman reports dysuria. Other than a minor back pain, for which she is taking ibuprofen, she has generally been healthy. Her vital signs and physical examination are normal. A urine dipstick test reveals 2+ leukocyte esterase. Urine is sent immediately to the laboratory for culture and sensitivity. She is told that she has a urinary tract infection and is given a prescription for trimethoprim-sulfamethoxazole. Two days later, the urine culture report indicates no bacterial growth. In interpreting this report, what should you consider?
33. Which of the following infections is most likely to affect the cervix, endometrial lining, fallopian tubes, and pelvic cavity?
34. Which of the following diseases require mandatory reporting to the Centers for Disease Control and Prevention?
35. A 35-year-old man is for a physical examination. He states that he has been healthy except for having a bout of pneumonia a year ago and an abnormal taste in his mouth for several months. His medications include vitamin E, Flonase, and occasional ibuprofen for muscle aches. Labs reveal an HIV test that is positive. His CD4 count is 125, and viral load is 36,000. Which of the following prophylaxis treatments for opportunistic infections should you offer?
36. A 19-year-old male college student presents with fever, headache, and a petechial rash. A lumbar puncture is performed. Gram stain of his cerebral spinal fluid shows gram negative diplococci. Which of the following organisms is the cause of his symptoms?
37. Which of the following is true of antibiotic management in a patient with sepsis?
38. A 31-year-old female with a family history of thyroid disease presents for a thyroid evaluation after finding out she was 8 weeks pregnant. She is feeling well besides some mild nausea. Because of her family history of thyroid disease, she had thyroid function tests checked in the past, and her thyroid peroxidase antibodies have been positive. This is her third pregnancy. She has 2 healthy children and no history of miscarriages. She denies weight gain, cold intolerance, and constipation.On physical exam, her weight is 143lbs, height is 5’3”, blood pressure is 118/76 mmHg, and heart rate is 76bpm. Thyroid is slightly firm to palpation but normal in size. Uterus size consistent with an 8-week pregnancy. Physical exam otherwise unremarkable. Labs are as follows: TSH 1.4mIU/L (first trimester 0.1-2.5mIU/L) and Free T4 1.4ng/dL (0.7-2.0ng/dL). What is the next step in managing this patient, in addition to referral to an obstetrician?
39. Which of the following signs is consistent with hypothyroidism?
40. A 45-year-old female with a history of sarcoidosis, pulmonary fibrosis, and hyperlipidemia is admitted for community-acquired pneumonia. The day after admission, she suddenly develops confusion and hypotension. The patient's blood pressure is 80/45, and her heart rate is 105 bpm. Fingerstick testing indicates a glucose level of 40. She is immediately given 1 amp D50 and is started on IV fluids, but her BP remains the same after a 2L infusion. She is still hypotensive after norepinephrine is initiated. What is the next step in treatment?
41. Which of the following stabilizes the cardiac membrane in treatment of hyperkalemia?
42. The NP is seeing a patient for depression who recently had a thyroidectomy for a large, benign goiter. The patient states she has been experiencing "numbness and tingling of fingers, toes and circumoral region. Which of the laboratory values would support the NP's suspicions that the patient's parathyroid was removed during the thyroidectomy?
43. A 68-year-old man presents for evaluation of a 2.5 cm adrenal mass. History and physical examination are negative for malignancy and overproduction of any adrenal hormones. A biochemical evaluation for pheochromocytoma is negative. No data are present regarding CT attenuation value and MRI opposed-phase imaging is not available.Which of the following would you recommend?
44. A 52-year-old woman is referred by her urologist for a 3cm right adrenal mass detected on abdominal CT. Her weight has been stable, and she has generally felt well. She has not noted hirsutism, acne, proximal myopathy, or easy bruising, but she has felt depressed lately. She also has had diaphoresis and occasional headaches but no palpitations. Her last menstrual period was 6 months earlier. She has a 2-year history of DM that is well controlled by diet. Her last mammogram 8 months earlier was negative, and no breast masses are present. She smokes 1 pack of cigarettes daily. BP is 135/85 mmHg; pulse = 95 beats/minute; and weight = 174 pounds. She has no buffalo hump, supraclavicular fat, or abdominal striae. Proximal muscle strength is normal. Stool is negative for occult blood. Complete blood cell count and chemistry profile are normal. Which of the following would you do first?
45. A 48-year-old female with no known medical history presents for periodic "attacks" of headaches, sweating, and palpitations over the past 4 months. These episodes are associated with nausea and chest pain and do not seem to be related to exercise or exertion. Each episode lasts for 1-5 minutes and resolves without intervention. Her vital signs, physical examination, and electrocardiogram are normal. Which of the following is the most appropriate test to establish the correct diagnosis?
46. Which of the following is the most commonly identified bacterial cause of community acquired pneumonia?
47. A 32-year-old man is seen at the clinic with a 1-week history of swelling, erythema, pain, and tenderness in his right upper arm. He has also been having fevers and chills. He went to the ER previously, was diagnosed with cellulitis, and was given cephalexin. However, his arm has gotten worse. He is otherwise healthy, although he admits using cocaine occasionally. He denies intravenous drug use.
On physical examination, his upper arm is markedly edematous with erythema and severe tenderness. MRI of the right upper extremity shows a large area of edema and cellulitis along the medial aspect of the arm with a discrete abscess in the soft tissues at the mid-arm. The patient is admitted and undergoes incision and drainage. Cultures grow methicillin-resistant Staphylococcus aureus (MRSA). Which of the following is correct about community-acquired MRSA?
48. A 74-year-old white woman presents for evaluation of her bone health. Her neighbor just "broke her hip," so she wants to know how to improve her bone health. She has no personal history of fractures but remembers her mother had kyphosis in her 70s. The patient has not lost height or noticed back pain. She takes calcium carbonate 600mg twice daily with vitamin D and a multivitamin daily. She does not take any prescriptions medications and denies smoking or significant alcohol use. The patient belongs to a walking club and exercises several times per week. Physical exam is as follows: weight 153lb (69.4kg), height 63" (160.0cm), BMI 27.1kg/m^2, BP 114/78 mmHg, and HR 68bpm. Exam is otherwise unremarkable. Lab tests including a complete blood count, liver function tests, and creatinine are within the reference range. DXA scan shows a femoral neck T-score of –1.7 and a lumbar spine T-score of –1.0. What is the next step in management?
49. A 35-year-old female with a history of GERD and asthma is admitted with a fever and severe headache. She is 30 weeks pregnant. She is allergic to penicillin with a history of anaphylaxis. History is notable for exposure to an outdoor dog. She lives in a wooded area in Massachusetts and denies known tick bites. On exam, the patient is afebrile and looks comfortable. Heart has a regular rate and rhythm with no murmurs. Bilateral clear breath sounds are heard. Abdomen is obese due to pregnancy but otherwise benign. An erythematous rash is noted on her left thigh that is typical of Erythema migrans. Complete neurological exam is unremarkable except for Bell's palsy. Workup for Babesia and Anaplasma is negative. LP shows clear CSF with normal opening pressure, neutrophils 3, lymphocytes 22, glucose 70, and protein 23. What is the best treatment option?
50. A 50-year-old female with a history of migraine headaches presents for evaluation of a productive cough and fever. She was in her usual state of health until 2 days ago, when she noticed nasal congestion and a mild sore throat. At that time, she had a cough that produced some clear sputum, but this morning she began to experience fever and chills. Sputum is yellow and thick.On exam, her temperature is 101.2 F, RR 18/minute, HR 90/minute, and blood pressure is 105/70 mm Hg. Oxygen saturation is 94% on room air and examination reveals rales in the right lung base. Her chest x-ray demonstrates a right lower lobe consolidation and laboratory studies are significant for a white blood cell count of 13,000 cells/mm^3 with 11% bands. BUN and creatinine are within normal limits.Which of the following is appropriate for initial treatment of this patient?
51. A 34-year-old man presents to the ER with a 4-day history of generalized malaise, low-grade fevers, chills, and myalgias. He works at a textile mill and had to miss work for the past few days because he felt like he had the flu. His temperature on admission is 39°C, BP is 120/72, RR is 18, and saturation is 96% on room air. He is admitted for further workup. Ceftriaxone and azithromycin are started empirically for possible community-acquired pneumonia. The next day, the patient deteriorates rapidly, becomes hypotensive, and is saturating only 86% on room air. He is visibly dyspneic and has stridor on physical examination. A chest x-ray is shown below. What is the treatment of choice?
52. A 19-year-old man is seen in an urgent care center. He reports dysuria for the past 2 days and admits to 2 sexual partners in the past 3 weeks. Physical examination reveals an otherwise healthy man with a purulent urethral discharge. A gram-stained smear of the discharge reveals intracellular gram-negative diplococci. Along with appropriate counseling and serologic testing, which of the following would be the most appropriate treatment?
53. A 45-year-old African American woman presents to the emergency department with fever, productive cough, and shortness of breath. She was well until approximately 5 days ago. Her vital signs reveal that she is febrile, normotensive, and tachycardic. She appears in mild respiratory distress. On examination of her lungs, decreased breath sounds and egophony are heard in the left lower base, and dullness to percussion is present in the same region. All the following regarding the diagnosis of community-acquired pneumonia (CAP) in this patient are true, EXCEPT:
54. Which of the following signs would a nurse practitioner expect to see in a patient with meningitis?
55. A 77-year-old male with COPD on 2L oxygen at home with activity was recently admitted for fever and treated with vancomycin for MRSA bacteremia from a line infection 5 weeks ago. He presents to the ER with shortness of breath, a mildly productive cough, a fever to 102°F, and chest pain. On exam, the patient is alert, oriented x3, and mildly tachycardic with no murmurs. Exam is significant for left base crackles with an occasional inspiratory wheeze. CXR is consistent with developing retrocardiac opacity on the left. Initial blood cultures show no growth, and Gram stain shows no organisms. He is allergic to meropenem and piperacillin/tazobactam. Which initial antibiotics should be chosen?
56. Which of the following is the most common cause of bacterial meningitis in the United States?
57. Which of the following CSF (cerebrospinal fluid) findings is most likely in a patient with bacterial meningitis?
58. A patient presents with the lesion shown below. Which of the following drugs should be given as post-exposure prophylaxis (PEP) for this disease?
59. A 44-year-old male presents reporting a 45lb weight gain over the past year. Physical examination reveals a 280lb, 5’11” male with central obesity. Physical exam reveals fat accumulation in the interscapular area and prominent vertical purple striae on the abdomen. Fasting blood glucose is 208mg/dL. Plasma levels of ACTH and cortisol are increased compared to reference ranges. TSH levels are normal. An overnight high-dose dexamethasone test produces 75% suppression of cortisol levels. This patient most likely has which of the following conditions?
60. A 59-year-old female hairdresser presents with 4 days of a worsening, painless, pruritic punctuate lesion with surrounding edema on the dorsal surface of her right hand. The lesion started to change in color from red to a deep purple. She reports nausea but no other symptoms. The patient is worried that she might have been exposed to something at work. She was treated for herpetic whitlow 1 year ago on her index finger.Otherwise, she has no significant past medical history, no known drug allergies, and takes a regular multivitamin. She lives in a rural area and has a hobby farm with her husband. They raise cows, sheep, goats, a dog, and a cat. The animals are not sickly, and her husband is well. Which investigation(s) would establish a diagnosis?
61. A 45-year-old male presents to his primary care physician with complaints of frequent episodes of severe headaches and visual field defects. CT scan demonstrates a 5.5cm mass involving the optic chiasm and sella turcica. The mass is resected via a trans-sphenoidal approach. Postoperatively, there is concern about possible anterior pituitary insufficiency. Which of the following pairs of hormones is most important to replace immediately, before life-threatening symptoms develop?
62. A patient is evaluated by a nurse practitioner in an ambulatory care setting, for a severe sore throat, difficulty swallowing, fever, and chills. His voice is muffled. He has a temperature of 101 degrees F and on exam, there is asymmetric swelling of the soft palate with deviation of the uvula away from the mass. Which of the following is indicated?
63. A 65-year-old male presents for evaluation of palpitations and weight loss. He has a history of recurrent bladder cancer, and began treatment with BCG with interferon-alpha 4 months ago. For the past 4 weeks, he has noticed palpitations and has lost 2-3 lbs. On review of labs from a year ago, the patient's TSH was normal. A physical exam reveals the following: weight 190 lbs, height 6’2”, BMI 24.2 kg/m^2, BP 122/80, and HR 90 bpm. The exam is otherwise unremarkable except for a mild lid lag and fine resting tremor of outstretched hands. Which test should be ordered to evaluate these symptoms?
64. A 23-year-old woman with newly diagnosed DM is referred to your practice. She presents with an 8 lb weight loss over the last 2-3 months, random blood glucose values over 200 mg/dL on several occasions, and a hemoglobin A1C of 9%. Her medical history is significant for cystic fibrosis and numerous hospitalizations for lung infections. Her current medications include several inhalers, pancreatic enzyme pills, multivitamin, and ciprofloxacin. Her BMI is 19 kg/m2. Digital clubbing is noted. Her lungs have coarse vesicular sounds.She tries medical nutrition therapy. After 6 weeks, home glucose-monitoring results show that her blood glucose remains elevated. Which of the following is the best therapeutic option at this time?
65. A 70-year-old man is admitted to the hospital from a skilled nursing facility for altered mental status and a fever of 102°F. On physical exam, he is unable to tuck his chin to his chest due to neck stiffness. A head CT is negative for any abnormality. A lumbar puncture is performed, and CSF studies show the following results: Opening pressure 30 cm H20, Glucose 20, Leukocyte count 1500 with neutrophil predominance, Protein 300, and CSF culture species pending. The patient is started on empiric therapy. Which medication(s) should be initiated?
66. Which of the following is the cause of hypocalcemia in patients with end stage renal disease?
67. A 54-year-old female was diagnosed with a cervicofacial abscess. The abscess is drained, and cultures are taken. Gram stain is compatible with Actinomyces israelii. What is the treatment?
68. An 88-year-old man with poorly controlled diabetes, coronary artery disease status post 2 stents, chronic kidney disease with baseline Cr 2.3, and a chronic suprapubic catheter due to neurogenic bladder presents to the ED from an extended care facility with altered mentation and a rectal temperature of 100 degrees Fahrenheit. He was discharged from the hospital a month ago after being treated for syncope. Heart rate is 100-110 beats per minute, RR is 12 breaths per minute, O2saturation is 98% on room air, and blood pressure is 88/60 mmHg.On exam, the patient is confused and unable to provide any details. Cardiac exam shows no murmur, rub, or gallop. Lungs are clear to auscultation but with poor inspiratory effort. Urinalysis shows cloudy urine with 30-50 WBC, positive leukocyte esterase and positive nitrites. Chest x-ray is shown below.Which of the following empiric antibiotic(s) should be initiated in the ED?
69. A 68-year-old female with type 2 diabetes (T2DM) presents for follow-up. She was diagnosed with T2DM 9 years ago and is on metformin, a DPP-4 inhibitor, and basal insulin. Basal insulin was started 1 year ago, and she checks her fasting blood glucose a few times per week. Her basal insulin dose has been titrated at every visit, and she is currently on glargine 60 units at bedtime. Fasting blood glucose values since her last visit have been 70-120mg/dL. She occasionally feels shaky if she delays eating breakfast. Physical exam reveals the following: weight 180lbs (81.8kg), height 5’3” (160cm), BMI 32kg/m2, BP 132/84 mmHg, and HR 72bpm. Labs are pertinent for an HbA1c of 8.2%. What is the next step in this patient's diabetes management?
70. A 24-year-old woman with a PMH of gonorrhea and stress fracture of the foot presents with knee pain that has been occurring for 1 month. She is a volleyball player and denies any trauma or recent injury to the knee. She complains of deep pain in the knee and chills and sweats occasionally at night. The pain has no relation to temperature or time of day, and it is not mitigated or exacerbated by anything.The patient’s temperature = 100.5°F, HR = 100, RR = 14, and BP = 100/60. Physical exam shows pain upon palpation of anterior knee and swelling and skin lesions throughout the body. Examination of all other joints is normal. What is the most likely diagnosis?
71. A 34-year-old female mother of 3 reports complaints of restlessness, agitation, palpitations, sweating, and a weight loss of 8lbs (without any dietary or exercise interventions). Lab investigations reveal low levels of TSH and an increased radioactive iodine uptake. A diagnosis of Graves' disease is made, and possible treatment options are discussed. If the patient chooses radioactive iodine therapy, what is a possible long-term complication?
72. A 24-year-old woman with a PMH of gonorrhea and stress fracture of the foot presents with knee pain that has been occurring for 1 month. She is a volleyball player and denies any trauma or recent injury to the knee. She complains of deep pain in the knee and chills and sweats occasionally at night. The pain has no relation to temperature or time of day, and it is not mitigated or exacerbated by anything.The patient’s temperature = 100.5°F, HR = 100, RR = 14, and BP = 100/60. Physical exam shows pain upon palpation of anterior of the knee with swelling and skin lesions throughout the body. Examination of all other joints is normal. What is the best treatment for her condition?
73. A nurse practitioner is examining a patient with a history of chronic allergic rhinitis who is complaining of ear pain and muffled hearing in the right ear. The patient is afebrile. On exam, his nasal mucosa is erythematous and edematous. The tympanic membrane is not red, but it is bulging and a fluid level is noted. What is the correct diagnosis?
74. A 76-year-old male who recently recovered from pneumonia presents to the ER with multiple episodes of diarrhea. He has no prior history of C. difficile infection and no other significant past medical history. On exam, he is dehydrated and tachycardic to 102. Temperature is 99°F. Physical exam is unremarkable. Lab values are notable for WBCs of 13000 and a Cr of 0.8. Blood and urine cultures are taken, stool for C. difficile is sent, and results are pending. What is the next step in management?
75. A 58-year-old male patient who is sexually active with several partners presents with purulent penile discharge and he is diagnosed with gonorrheal urethritis. He should be also be treated for which of the following sexually transmitted infections?
76. Which of the following is caused by Epstein Barr virus infection?
77. A 45-year-old female presents with weight gain and abnormal menstrual cycles over the past few months. She also reports feeling moderately depressed and fatigued all the time. Laboratory testing reveals normal thyroid-stimulating hormone (TSH) and thyroid hormone levels but elevated cortisol levels. If the patient's symptoms and laboratory studies are the result of adrenal dysfunction, which of the following may also be present?
78. A 75-year-old white man is evaluated for weakness and asthenia. The history obtained from his wife revealed that he was well until 6 months ago before this admission. He has had a 30 lb weight loss with a poor appetite since then. He does not take any medications and has no history of radiation exposure. On physical examination, he is afebrile; he looks cachectic and has no features of infiltrative eyelid changes. Thyroid gland is prolapsed but is palpated upon swallowing. Pulse rate is irregular at 120 beats/minute. Serum T4 is 19.7μg/dL (normal 5.0-10.5), with a serum TSH <0.02μU/mL (normal 0.4-5.5). The next step in diagnosis is to order:
79. A 45-year-old woman with AIDS and disseminated histoplasmosis complains of profound weakness, easy fatigability, anorexia, weight loss, and diarrhea. Laboratory investigation reveals a serum sodium of 132mEq/L, serum potassium of 5.8mEq/L, and pH of 7.32. Skin hyperpigmentation is noted on physical examination. Which of the following is the most likely diagnosis?
80. A 19-year-old female patient complains of rhinorrhea and cough. On examination, the nurse practitioner notices a painless bony protuberance midline on the roof of her mouth. The overlying skin has no erythema or exudate. Which of the following is true?
81. Which of the following is characteristic of Grave’s disease
82. A 20-year-old student presents to the ED with palpitations, a low-grade fever, and anxiety for 2 months. She reports feeling irritable and experiencing severe mood swings that are interfering with her sleep and relationships. She admits to crying spells and frequent fights with friends and family. The patient has also lost 12lbs in the past 2 months with no apparent alteration in her diet or physical activity (although she is happy with her weight loss). She denies any past medical problems, but her friends have always been worried that she "eats too little."The patient's temperature is 38.0°C (100.4°F), blood pressure is 148/62 mmHg, pulses are 122/min and regular, and respiratory rate is 28/min. Examination reveals a bruit heard over the anterior neck, a fine tremor of the hands, and warm, moist skin. Her eyes and eyelids do not move together during a finger following test (with steady head). Laboratory work is sent, including a thyroid panel, but will not be available until tomorrow morning. Which of the following is most appropriate medication for initial management?
83. A 45-year-old previously healthy male is admitted with florid diarrhea for 3 days. He was treated with clindamycin 2 weeks ago for a dental abscess. He is afebrile. HR is 98, RR is 16, saturation on room air is 98%, and BP is 110/86. Exam is significant only for mild abdominal tenderness. C. diff toxin and Ag are positive, and he is started on metronidazole treatment. Which of the following precautions must be taken to prevent the spread of C. diff infection in the hospital? I. Wash hands with soap and water before and after seeing the patient. II. Use bleach to clean the equipment and room. III. Use antiseptic hand spray in and out of the room (no need to wash hands). IV. Use airborne precautions. V. Wear gloves and gown when entering the room.
84. A 39-year-old MSM presents after sexual intercourse with a new partner for evaluation of a possible STD. The patient and his partner have been together for 6 months. His partner revealed that he was treated for syphilis 2 months ago after developing a solitary penile lesion. The patient has no symptoms and denies penile lesions. He does not have any fevers, chills, or associated symptoms. On physical exam, the patient has no abnormalities, and his vital signs are within normal limits. Results of HIV, hepatitis, and rapid plasma reagent tests are negative. What should you recommend next?
85. Which of the following abnormalities is most likely in a patient with lung cancer and syndrome of inappropriate antidiuretic hormone?
86. A 20-year-old female college student is seen in the school infirmary for a hacking cough and runny nose. Her cough produces a small amount of clear sputum. She has no past medical problems and takes only an oral contraceptive. Her vital signs are: T 100.1 F; respirations: 16/minute; HR 92/minute. Her blood pressure is 110/70 mm Hg and exam reveals some bilateral basilar crackles in her lungs. Chest x–ray reveals diffuse infiltrate in the right lower lobe and her laboratory studies are significant for a white blood cell count of 10,800 cells/mm^3. Which of the following is the most likely diagnosis?
87. A 22-year-old woman presents with dysuria and foul-smelling urine for 24 hours. No fever or suprapubic or flank pain is present. She had a similar episode in the past year. She uses spermicide-coated condoms and diaphragms for contraception. Her examination is normal. Besides treatment, what should be done for the patient?
88. A nurse practitioner is evaluating a 50-year-old patient with a laceration sustained when cleaning out a vacant lot. He cut his right hand on a rusty lawn mower blade that had been discarded in the grass. His last tetanus shot was 8 years ago. Which of the following is true?
89. What is the organism most commonly associated with acute prostatitis?What is the organism most commonly associated with acute prostatitis?
90. Which of the following is consistent with a diagnosis of diabetes according the criteria set by the American Diabetes Association (ADA)?
91. A 68-year-old female patient presents for evaluation of a cat bite received yesterday while visiting her grandchildren. She has a small puncture wound and no signs of systemic infection. Which of the following is the preferred antibiotic for prophylactic treatment?
92. A 28-year-old male student from India is seen in an urgent care facility. He reports that his friend’s dog bit his hand 1 hour ago. The dog is apparently in good health. Examination of the affected hand reveals small, superficial puncture wounds. He does not have any allergies. He does not recall any childhood immunizations. What is the most appropriate management for this patient?
93. A 30-year-old female is diagnosed with Hashimoto’s thyroiditis. Which of the following characterizes this disorder?
94. A 30-year-old healthy woman presents with non-bloody diarrhea that has persisted for 24 hours. She has nausea and abdominal cramping but no fever or tenesmus. No recent travel is noted, and her examination is normal. What is the best course of action?
95. A 58-year-old male patient is admitted to intensive care and a central line is placed. He develops sepsis. If the cause of sepsis is an infection of his central line, when considering initiation of empiric therapy, which organism is most likely to be cultured from his blood?
96. A 35-year-old man presents to the emergency department with abdominal cramping, tenesmus, and sudden onset of bloody diarrhea. On examination, he is toxic-appearing with a temperature of 40°C, normal blood pressure, and normal respiratory rate. He is mildly tachycardic and slightly tender in the right lower quadrant. A presumptive diagnosis is made after examining the stool for fecal leukocytes and is confirmed by rectal-swab culture. Which of the following is true?
97. A 27-year-old woman comes to the office because her boyfriend was recently diagnosed with genital herpes. She is sexually active and does not use condoms. She is asymptomatic, and her pelvic examination is normal. She is requesting an evaluation for herpes.Which of the following is the best next step?
98. A 62-year-old man with end-stage renal disease (ESRD) on hemodialysis, DM, and HTN is admitted for low-grade fevers and chills for the past 3 days occurring especially during dialysis. His admitting vital signs include a temperature of 38.0°C, BP of 140/87, HR of 92bpm, RR of 18, and saturation of 97% on room air. On physical examination, he is alert and oriented and looks well. He has anicteric sclerae without conjunctival hemorrhages, good dentition, a clear chest on auscultation, and a regular heart rhythm without murmurs or ectopy. 2 out of 2 blood cultures drawn at the ER grow gram-positive cocci (GPC) in clusters. Empiric antibiotics are started. GPCs in the blood are identified as methicillin-sensitive Staphylococcus aureus (MSSA). His hemodialysis catheter is pulled out and replaced with a new one. After 24 hours in the hospital, he is afebrile, and his follow-up blood cultures are all negative. An echo is negative for endocarditis. Which of the following statements is true regarding this case?
99. You are evaluating a 30-year-old female patient with confusion and decreased level of consciousness. She has no significant past medical history except for a record of recent treatment for a urinary tract infection. Her temperature is 102 degrees F and her heart rate is 105/minute with blood pressure of 94/60 mm Hg. Respiratory rate is 24/minute. Which of the following criteria is used in the qSOFA evaluation for diagnosis of SEPSIS?
100. A 35-year-old woman presents with a rapid onset of fever, nausea, vomiting, and painful lower abdomen and groin. She started feeling unwell overnight and noticed a painful, macular rash extending from her groin and lower abdomen. She recently had hair removal in the area, as she normally does, but this time complained of scattered pustular folliculitis that started 3 days ago. The patient denies vaginal discharge, frequency, urgency, or dysuria. Her last menstrual period was 2 weeks ago. She has no significant past medical history. The patient appears acutely unwell and restless due a painful lower abdomen. Her vital signs are as follows: temperature 104.1°F, regular pulse rate 110bpm, and blood pressure 104/68. Laboratory investigations confirm multi-organ failure with coagulopathy. Blood cultures, skin swabs, and throat swabs are sent for gram stain, culture, and sensitivities. Urinalysis shows proteinuria and hematuria. Chest radiograph shows widespread bilateral infiltrates. What is the most likely primary diagnosis?
101. Which of the following is a clinical sign indicative of hypocalcemia?
102. A 55-year-old man presents with complaints of generalized fatigue and an unintentional weight loss of 8 lb over 6 months. He denies any palpitations or sleep disturbances. On physical examination, his skin is warm and moist. When his hand is outstretched, a fine tremor is noted. Eye examination is unremarkable. His thyroid is asymmetrically enlarged (right left) and firm, with a palpable nodule in the right lower lobe that measures 3 cm at the greatest dimension. His trachea is in the midline. TSH is <0.01 mU/mL (normal 0.5-5 mU/mL), and free thyroxine T4 is 2.6 ng/dL (normal 0.9-2.4 ng/dL). What is the next step in the management of this patient?\
103. A 25-year-old patient asks the nurse practitioner about the purpose of a recommended HPV screening test. The NP replies that it is used to screen for risk of which of the following?
104. Which of the following organisms causes syphilis?
105. A 26-year-old man presents because he was informed that a previous female partner was diagnosed with gonorrhea. He denies any present complaints or medical problems. He is not on any medication. He has had 3 new partners in the past 2 months and does not use condoms consistently. His last sexual activity was 2 weeks ago. On examination, he has small bilateral inguinal nodes that are nontender and purulent urethral discharge. He is also found to have flat-topped lesions in his perianal area and whitish plaques on his tongue. Urethral Gram stain is not available, but urine and blood tests are sent to the lab. His tongue is pictured below. Which of the following should this patient receive for therapy?
106. A 47-year-old male started experiencing fatigue and malaise, followed by a 7lb weight loss over 2 months. He also reported watery diarrhea and occasional nausea after meals but denies any vomiting or dysphagia. Vital signs are unremarkable. Physical examination suggests a soft abdomen with mild epigastric tenderness. Laboratory studies on serum show: Calcium 11.7mg/dL, Phosphate 2.2mg/dL, Magnesium 1.6mEq/dL, Albumin 3.9g/dL, Total protein 7.4g/dL, TSH 3.4 IU/mL, Prolactin 262ng/mL, Insulin-like growth factor-1 (IGF-1) Normal, and Fasting glucose 65mg/dL. Abdominal computed tomography (CT) scan shows a lesion in the head of the pancreas. The blood level of which of the following hormones is most likely to be decreased?
107. Which of the following is incorrect regarding screening for sexually transmitted diseases (STDs)?
108. A 58-year-old woman presents with a 3-week history of nonproductive cough, hoarseness, and a temperature of 100.4°F. She is not short of breath and has no chills or sweats. She has a smoking history of 20 packs per year but quit 20 years ago. She lives at home with her husband, who is asymptomatic. She has had several antibiotics in the past week, of which she comments, “I felt a little better after the clarithromycin, but not much, so my doctor changed me to cefuroxime, and I felt worse.”On examination, she appears healthy. She has a low-grade fever of 100.4°F, but her vital signs are otherwise normal. Physical examination is unremarkable. Laboratory evaluation is notable only for a normal white blood cell count with a mild left shift. Chest radiograph reveals a subtle right-sided infiltrate. What is the most appropriate next step in the care of this patient?
109. A 65-year-old man with a history of a nonfunctional pituitary macroadenoma develops severe retro-orbital headache, nausea, and vomiting with change in mental status. On examination, right third nerve palsy with stiff neck is present. An emergency MRI of the brain shows hemorrhage in the pituitary adenoma, which is enlarged in size. What is the best next course of action?
110. A 37-year-old French-Canadian man presents to the preventive cardiology clinic after routine cholesterol levels were abnormal. His father died of a myocardial infarction at age 45. You notice arcus cornea on his physical examination. His fasting lipid profile is as follows: LDL 285 mg/dL, TG 110 mg/dL, and HDL 45 mg/dL. What is the most likely diagnosis?
111. Which of the following is the treatment of choice for prevention of neurologic complications in patients with bacterial meningitis?
112. A 68-year-old male presents for evaluation of a purified protein derivative test 2 days after it was administered. He has a history of rheumatoid arthritis and is treated with methotrexate and corticosteroids. Which of the following is the minimal criteria to be considered a positive test in this patient?
113. A 44-year-old man has had a painful penile ulcer and tender inguinal lymph nodes on the right side for several weeks. He had a negative HIV test 1 year before but had frequent encounters with prostitutes. He saw several physicians, apparently without a diagnosis. On examination, the lymph nodes are fluctuant and have a fistula with pus. Which of the following would be effective treatment?
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