A 45 year old woman who works as a professional baker, with a specialty in birthday and wedding cakes, is diagnosed today with carpal tunnel syndrome. Her history of present illness include a four month history of numbness and tingling of the thumb, index and middle finger of her dominant hand. Physical exam reveals normal grip strength and decreased sensation along the median nerve distribution. Thenar atrophy is absent. 

Which of the following is the most appropriate next step?

A. referral for carpal tunnel surgical decompression

B. arranging for carpal tunnel corticosteroid injection

C. advice on the use of neutral position wrist splinting

D. obtain a TSH and an A1C

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A 45-year-old woman who works as a professional baker with a specialty in birthday and wedding cakes presents with a six-month history of progressive numbness and tingling in the thumb, index, and middle fingers of her right hand. She noticed that her symptoms are worse at night and are accompanied by hand weakness and reports being right hand dominant. She denies any injury to the area and states "This is getting in the way of my work. I'm having a much harder time holding the tools that I need to use to decorate a cake." Her concurrent health history includes a five-year history of type 2 diabetes, hypertension, and dyslipidemia, obesity with a BMI of 38. Her current meds include Metformin and an SGLT2I, and ARB with a thiazide diuretic and a statin. 

When considering the diagnosis of carpal tunnel syndrome, which of the following would be one of the earliest physical exam findings?

A. Pain reproduced with forced wrist flexion held for 60 seconds

B. Diminished radial pulse

C. thenar atrophy

D. tingling of the fingers when tapping on the median nerve

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A 28-year-old woman who is breastfeeding her healthy six-week-old term infant presents with a four-day history of generalized body aches, intermittent fever to 101.2 degrees Fahrenheit, and localized pain on the upper aspect of her left breast. She states that she's been attempting to nurse her infant as tolerated and pumps the affected breast when unable to nurse. Physical exam is consistent with lactation-associated mastitis. 

Which of the following is the most appropriate next steps? 

A. advise continued expressing of milk on the affected breast through pumping or nursing as tolerated

B. initiate antimicrobial therapy with oral cephalexin for five to seven days.

C. advise discontinuing breastfeeding on the left breast and apply ice packs to the affected area.

D. initiate antimicrobial therapy with oral ciprofloxacin for 10 days. 

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A 35-year-old woman presents for a periodic physical exam with Pap and HPV testing. She states she's feeling well without complaint and has excellent exercise tolerance, running about 30 miles per week. Her current medications include an levonagestrel IUD for contraception. Physical exam includes vital signs within normal limits, a BMI of 23, and no unusual findings, save for a mid-systolic click followed by a grade two, mid to late systolic murmur with a honking quality. The murmur moves forward into systole with position change from supine to standing and does not radiate beyond the precordium. These findings most likely represent:

A. A physiologic murmur

B. The murmur of aortic stenosis

C. The murmur of mitral valve prolapse

D. The murmur related to tricuspid valve incompetency

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A 35-year-old man presents with a one-week history of new onset fatigue, nausea, as well as reporting his urine looks like, quote, ice tea. He also reports, feel like someone kicked me right underneath my ribs on the right. He denies recent travel, contact with individuals with similar signs and symptoms, and reports a new sex partner for the past six months, stating, quote, we sometimes use condoms. 

In considering the diagnosis of acute hepatitis B, which of the following laboratory profiles would be noted?

A. Hep B surface antigen positive, anti-HBs negative, or Hep B surface antibody. ALT markedly elevated at 1390. AST similarly elevated at 1100. Total bilirubin markedly elevated at 4.8

B. Hep B surface antigen positive, anti-HBs, HBS- or Hep B surface antibody ALT modestly elevated at 68 as is AST total bilirubin .9 within normal limits

C. Hep B surface antigen negative, anti-HBS- or Hep B surface antibody, ALT 24, AST 22 and a total bilirubin of 0.6

D. Hep B surface antigen negative, anti-HPS negative, ALT 150, AST 140, total bilirubin 0.7 within normal limits

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A 73-year-old female with a 20-year history of hypertension, type 2 diabetes, dyslipidemia, and stage 3B CKD, typically at treatment goals with oral medications, is being seen. She was discharged yesterday after being hospitalized for three days with community-acquired pneumonia and is here for a follow-up visit.

She states she's feeling much better with less shortness of breath, diminished cough, and sputum production, and is without fever. She mentions that while she was in the hospital that, quote, they changed my diabetes medicine and gave me insulin four times a day to keep my sugar controlled, close quote. A review of her discharge note reveals that rapid acting insulin was given according to blood glucose levels without scheduled basal insulin and this was used from admission to discharge. 

Random glucose today is at 220. The patient asks, should I start back up on those insulin shots? I've never used them before. The NP considers with which of the following.

A. given her random blood glucose is elevated, the use of a sliding scale insulin should be continued for the next week

B. the use of a sliding scale insulin potentially results in wide glucose excursions

C. sliding scale insulin is helpful as it mimics physiologic insulin secretion

D. the sliding scale insulin regimen should now be replaced with a basal insulin

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A 60-year-old male with documented ASCVD, obesity with BMI of 34, and type 2 diabetes presents for care. The patient reports he's currently feeling well without episodes of hypoglycemia. Current laboratory assessment includes the following. A1C is 8.6 % and his estimated GFR is at 62. Current medications include metformin at optimized dose and a sulfonyl urea.

Which of the following represents the nurse practitioner's next best action?

A. continue on current therapy and arrange for a three month follow up

B. discontinue the metformin and add a DPP4 inhibitor

C. add a GLP-1 inhibitor and discontinue the sulfonyl urea

D. add basal insulin and titrate to fasting glycemic goals

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A 17 yo male presents for follow up on a “fainting” episode that occurred during football practice at the end of a running exercise. He states, “I do not know what happened. We finished a set of running sprints and next thing I knew, I was on the ground.” He denies injury from the event and history of prior episodes. His physical examination reveals a crescendo-decrescendo systolic murmur heart best at the apex, increasing in intensity with position change from supine to standing position.  

This most likely represents: 

A. Mitral regurgitation 

B. Physiologic murmur 

C. Hypertrophic cardiomyopathy

D. Aortic stenosis 

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A 40 year-old accountant presents for advice on measles prevention. He reports disembarking from an airplane approximately 40 hours ago, and now being notified that one of the passengers on the plane has been diagnosed with measles today. He denies any chronic health problems, states he received “all the shots I should have” when he was a child. However, he is unable to produce documentation of childhood vaccinations. 

Which of the following represents the most appropriate action? 

A. This is an example of a low risk rubeola exposure without need for specific prophylactic action.  

B. Obtain rubeola IgG titers and provide appropriate prophylaxis based on results.  

C. Administer a single dose of MMR vaccine now with advice to contact the practice if there are concerning signs and symptoms.  

D. Order a dose of immunoglobulin and arrange for MMR vaccination update.

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