A 70 year old man with a 35 year history of hypertension, dyslipidemia, and a 20 year history of type 2 diabetes presents. He was recently diagnosed with systolic heart failure, presenting with dyspnea on exertion and orthopnea. Prior clinical assessment revealed the murmur of mitral regurgitation. Which of the following would the NP anticipate finding on today’s physical exam?  

A. A mid to late systolic murmur that follows a mid systolic click. 

B. In early to mid systolic murmur harsh in quality, that radiates to the neck. 

C. A holosystolic murmur that radiates to the axilla.

D. A localized mid to late diastolic murmur.

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Which of the two following findings would be anticipated in the normal funduscopic exam of a healthy 40-year-old woman who is normotensive, generally in good health and without ocular complaint?  

A. Arteriovenous nicking

B. Optic cup to disc ratio < .0.5

C. Retinal arteries are brighter and narrower than veins  

D. Slight bulging of the optic disk

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Which of the following is most consistent with the clinical presentation of a person with folate-deficiency anemia? 

A. A 45-year-old woman with uterine fibroids, menorrhagia and a microcytic, hypochromic anemia with elevated RDW 

B. A 35-year-old woman with newly diagnosed systemic lupus and a normocytic, normochromic anemia with NL RDW 

C. A 40-year-old woman with alcohol use disorder who drinks 5-6 glasses of wine per day and a macrocytic normocytic anemia with an elevated RDW 

D. A 65 yo woman with a 20 year-history of hypothyroidism presenting with a 6-month history of stocking-glove neuropathy and a macrocytic, normochromic anemia with an elevated RDW.  

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A 70 year old man with a history of BPH, HTN and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past three years. He is alert, oriented and appears slightly uncomfortable while seated. Abdominal and scrotal exam are WNL, there is no penile discharge and digital rectal exam reveals a tender, enlarged prostate. UA reveals positive leukocyte esterase and > 10 WBCs per HPF. With a working diagnosis of acute bacterial prostatitis, which of the following is the most appropriate antimicrobial option in this clinical scenario?  

A. Ciprofloxacin PO x 10 days 

B. IM Ceftriaxone as a one-time dose with doxycycline PO BID X 10 days 

C. IV piperacillin with tazobactam for 5 days 

D. Nitrofurantoin PO BID x 5 days.  

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Which of the following clinical scenarios is most consistent with an older adult presenting with acute bacterial prostatitis?  

A. A 65  year old male who presents with a 6 month history of urinary frequency, occasional difficulty initiating urine stream, without dysuria or fever. GU exam within normal limits with the exception of prostate enlargement.  

B. A 50-year-old male with a 4 day history of increased urinary frequency, end-void dysuria, and intermittent fever. GU exam reveals suprapubic tenderness,  without  prostatic enlargement or scrotal abnormalities.  

C. A 70 year old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam WNL and digital rectal exam reveals a tender, enlarged prostate.  

D. A 78 year old man with a 3 month history of intermittent gross hematuria and urinary frequency without dysuria. GU exam is WNL with the exam of a nontender enlarged prostate with multiple nodular lesions.  

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The NP sees a 74-year-old woman with a BMI=30 kg/m2 who has a 30-year history of type 2 diabetes, HTN, and dyslipidemia. Pertinent social history includes the following: a retired elementary school teacher who lives in a 1-story home with her spouse and adult child, nonsmoker, drinks approximately 2, 5 oz glasses of wine per month, and walks approximately 2 miles per day. Her current medications include telmisartan, HCTZ, rosuvastatin, metformin, semaglutide and canagliflozin at optimized doses, and current A1c=9.2%. Her current A1c= 9.2% and is at HTN and lipid goal. Prior mediations have included sitagliptin, with patient stating, “That medication did not help my sugar at all.” She states she is adherent to her medications and dietary advice. Her eGFR is within acceptable parameters and she is feeling well. Physical exams are unremarkable. 

Which of the following is the most appropriate next step? 

A. Advise that her A1c is at an age-acceptable level.  

B. Add post-meal sliding scale rapid acting insulin 

C. Prescribe basal and pre meal insulin. 

D. Add oral glipizide.  

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Mrs. Mahem is a 68-year-old patient with a 25-year history of type 2 diabetes mellitus. In the past year, her A1c remains at around 8.5% with the use of the following medications: metformin, sitagliptin, and canagliflozin, at optimized doses and with adherence.  She states, “ I haven’t changed the way I eat and I walk about ½ h a day, just like I have for years”. Additional health issues include HTN and dyslipidemia, treated with medications and at therapeutic goal, and obesity with a BMI= 33. Her eGFR is 65. 

Which of the following is the most appropriate next step in the pharmacologic management of her diabetes?  

A. Add glyburide to enhance glycemic control.

B. Consider discontinuing metformin due to age and renal function.

C. Advise that her glycemic control is adequate for an older adult. 

D. Prescribe semaglutide to help her achieve A1c goal.  

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A patient presents with a chief complaint of a gradual onset vision change, present for the past 6 months, while denying eye pain, redness or trauma. The funduscopic exam, extraocular movements and pupillary reactions are within normal limits. When considering a diagnosis of presbyopia, which of the following best describes patient presentation? 

A. A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly". 

B. A 75-year-old who states,"When I look at a bright light, I see a colored halo around it".

C. An 80-year-old who states, "I have a blurry spot in the middle of my eyesight". 

D. A 17-year-old who states, "I went to get my driver’s license, but failed the distance vision exam".

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A 27-year-old woman presents as a new patient to your practice.  She is without chief complaint. She asks to, “get a refill on my birth control pills” , having used combined oral contraceptives for the past 12 years without adverse effects.  Social history reveals she is a nonsmoker, without recreational drug use, drinks approximately 1-2 mixed drinks per week, and runs 2-3 miles 5 days a week with reported excellent activity tolerance. Her health history is generally unremarkable, but with patient report of a “mild heart murmur that was picked up when I was a teenager during a physical I needed so I could run track. I was told not to worry about it.” Physical exam is unremarkable with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. The remainder of the cardiac exam is within normal limits. 

These findings most likely represent which type of murmur?

A. Physiologic

B. Aortic stenosis

C. Mitral regurgitation

D. Mitral valve prolapse
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A 29-year-old who is 8 weeks pregnant presents with a chief complaint of nausea and vomiting. She states, “I’ve been like this for three weeks. I don’t know why this is called morning sickness since I feel sick to my stomach almost all the time”, reporting that she vomits 2-3 times nearly every day, stating, “I was worse 2-3 weeks ago, when I was throwing up 4-5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-h dietary recall reveals frequent low-fat meals and consistent sipping of liquids. She denies thirst or infrequent urination, and reports, “I’m just tired of feeling this way. I’ve missed so much work and can hardly keep up with my 3-year-old.”  Physical exam reveals the following; Alert, appears fatigued, with moist mucous membranes,  a 1 lb. weight loss since last visit 4 weeks ago, and minimal epigastric tenderness without rebound.  

 The NP considers advising on the following:

A.  Initiate therapy with an oral  5HT-3 antagonist such as ondansetron (Zofran®).

B.  Referral to high-risk for advise on further management. 

C.  Advise on the use of daily dose of oral  vitamin B6  with doxylamine. 

D. Increase fluid and fiber intake.
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