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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YouTube: https://www.youtube.com/watch?v=8ybH1qcskq8&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=124

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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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YouTube: https://www.youtube.com/watch?v=C-y2Ihr76nY&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=122

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A nurse practitioner receives a message from a neighbor, a 35-year-old woman who is asking for a prescription to treat a “urine infection”. The neighbor states she's had this condition occur in the past and does quite well if she gets on an antimicrobial quickly. The neighbor also mentions that she's going out of town on a business trip the next day and is unable to contact her personal healthcare provider nor get to urgent care. 

The NP considers the following in prescribing a medication to her neighbor.  

A. Given this is a request for a prescription that is not a controlled substance, the NP can provide the prescription as long as the patient can advise on what antimicrobials she has taken in the past. 

B. Providing this prescription would be a violation of federal law. 

C. In suspected UTI, an antimicrobial prescription should not be initiated until urine culture results are available.  

D. Since the NP does not have a patient provider relationship established with her neighbor, the request for an antimicrobial should be declined. 

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YouTube: https://www.youtube.com/watch?v=G1IN08Ioh74&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=121

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Which of the following best describes a disease that should be reported to the local or regional public health department?  

A. Diseases where public health intervention is needed to help prevent spread to the region or community.  

B. Diseases with significant rates of mortality and morbidity.  

C. Diseases that are most often noted among individuals with significant immunocompromise. 

D. Diseases where intervention in early life helps lead to improved health in adulthood.  

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YouTube: https://www.youtube.com/watch?v=oBvF5QT9RQE&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=120

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A 6-year-old presents with his parents, with a chief complaint of a 3 day history of sore throat, intermittent frontal headache and fever with a 1 day history of a non pruritic fine, raised rash, without N, V, D or C. He is able to take fluids without difficulty but has diminished appetite. The parents report that other children in their son’s kindergarten class have been sick with similar signs and symptoms. A rapid strep screen is positive. Clinical evaluation is consistent with scarlet fever. The child has no drug allergies. 

Which of the following is the most appropriate intervention?

A. IM penicillin

B. Oralamoxicillin

C. Topical triamcinolone

D. No specific therapy is needed.

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YouTube: https://www.youtube.com/watch?v=udyt2WeaoJo&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=119

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A 50 yo woman presents with a 6-month history of intermittent RUQ abdominal pain, bloating and nausea, particularly after eating fatty food, describing the discomfort as sharp, occasionally radiating to the right shoulder, usually lasting around 45 mins,  and accompanied by eructation.  She is currently without distress, stating that, “I cut back on food that I know bothers my stomach.  Physical exam reveals, BMI=35, no jaundice, mild RUQ abdominal tenderness and negative Murphy’s sign.  

Which of the following is the next step in her care?  

A. Provide a 1-month trial of proton pump inhibitor (PPI) therapy.

B. Refer to surgery for further evaluation.  

C. Order a RUQ ab for abdominal ultrasound and hepatic enzymes.

D. Obtain serum H. pylori testing.  

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YouTube: https://www.youtube.com/watch?v=qZSVLmpbTEA&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=118

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An 18-month-old toddler presents for a sick visit with a chief complaint of recent onset of fever and skin lesions.  Which of the following is most consistent with the presentation of measles (rubeola)? 

A. A 3-day history of anterior cervical lymphadenopathy, significant sore throat, fever with a 1-day history of a fine erythematous skin eruption.  

B. A 3-day history of fever, mild nasal congestion, 

and crankiness followed by resolution of elevated temperature and eruption of a fine pink rash 

C. A 3-day history of cough, conjunctivitis with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy and fever, followed by a new onset diffuse maculopapular rash 

D. A 2-day history of fever, mild sore throat, posterior cervical lymphadenopathy, and maculopapular skin lesions.  

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YouTube: https://www.youtube.com/watch?v=IWRqAkns1MQ&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=117

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A 28 year old assigned male at birth presents with the chief complaint of a "new problem in my private parts” He states he feels well otherwise. Which of the following would be most consistent with the clinical presentation of primary syphilis?

A. A three day history of purulent penile discharge with dysuria.

B. A one week history of a painless genital ulcer on the penile shaft.

C. A 5 day history of painful vesicular lesions over the penile glands, with some lesions now crusting over.

D. A one week history of N void dysuria without penile discharge.

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YouTube: https://www.youtube.com/watch?v=Jp-dk0BZ37o&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=116

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A 52-year-old man presents for an initial primary care visit at the nurse practitioners practice period he has not seen any health care providers since age 38, stating that he has been in good health. Social history, drinking approximately 2 beers per night over the weekend, two nights per week, has a 5 pack year cigarette smoking history, having taken up smoking when he was in college, and quit at age 22. He reports feeling well and without chief complaint or chronic health problems.  He asks about what kind of cancer screening he should have. The NP advisors which of the following?

A. Colonoscopy 

B. Prostate specific antigen (PSA) 

C. Low dose chest CT

D. Given his history, no routine cancer screening is advised. 

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YouTube: https://www.youtube.com/watch?v=qnKPe2EHgl4&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=115

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