A 72-year-old man presents to primary care for a sick visit, with the chief complaint of a one-day history of fever, projective cough with yellow sputum and increasing shortness of breath. He denies GI distress but states his appetite is not what it usually is. He has a history of hypertension, type 2 diabetes, and dyslipidemia at guideline-based goals. He is a former smoker, quitting about 10 years ago with approximately a 35-pack-year history and was diagnosed 5 years ago with COPD.  Clinical assessment confirms the diagnosis of community-acquired pneumonia, suitable for outpatient treatment.  Which of the following represents the most appropriate antimicrobial option?

A. Oral levofloxacin

B. Injectable ceftriaxone

C. Oral azithromycin

D. Oral amoxicillin
---
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A 9-year-old female presents for well child care with her parent. She is in the 4th grade, doing well academically, plays soccer on a local team, and reports, “I have 3 best friends”. Health history per parent and child reveals no concerns. On physical exam the clinician's notes the child is at about 40th percentile height and weight for age, and has breast budding and downy, straight, slightly pigmented pubic hair long the labia majora.

These physical findings are consistent with:

A. Precocious puberty

B. Early onset normative puberty

C. Age-appropriate pubertal findings

D. Concern for a GNrH producing lesion
---
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Esteban is an 18-month-old child who presents with his father for a sick visit. The child, who is typically healthy and UTD with immunizations and has no drug allergies, has had URI-like symptoms for the past 6 days with congested cough and clear to yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly reduced appetite and had a single episode of post tussive vomiting 3 days ago.  For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6 °F (39.2 °C), with father stating, “This is how he acted a few months ago when he had an ear infection.” Physical exam confirms the diagnosis of bilateral AOM. When prescribing an antimicrobial for this child, which of the following represents the first-line treatment option?

A. Oral azithromycin

B. Oral cefpodoxime

C. IM ceftriaxone

D. Oral amoxicillin
---
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An 18-month-old toddler, Estaban, presents with his father for a sick visit. The child, who is typically healthy and UTD with immunizations, has had URI-like symptoms for the past 6 days with congested cough and clear to yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly reduced appetite and had a single episode of post tussive vomiting 3 days ago.  For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6°F   (39.2°C), with the father stating, “This is how he acted a few months ago when he had an ear infection.”  Which of the two following findings are most suggestive in the diagnosis of acute otitis media in a toddler?

A. Bulging tympanic membrane

B. Cough

C. Evidence of ear discomfort

D. Bilateral cervical lymphadenopathy
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A 60 year old man presents with a chief complaint of a 6 month history of increasing fatigue despite adequate rest and sleep. He denies chest pain or difficulty breathing, and reports he is a non smoker. Concurrent history includes a 25 year history of alcohol used disorder, with daily intake of 5-7, occasionally more, 1.5 oz shots of whiskey, and chronic poor nutrition, reporting, “I eat chips and crackers a lot, I do not have the time to make a meal and I cannot afford to eat out. He is currently employed as a warehouse working, and states, “I get to work every day. The booze is really not  problem.”  On physical exam, mild pharyngeal redness without exudate, conjunctival pallor, and epigastric tenderness are present. The following lab results are noted.

Hgb = 9 g/dL (normal 14 to 16 g/dL)

Hct = 28.5% (normal 42% to 48%)

RBC = 3.4 million mm3 (normal 4.7 to 6.1 million mm3)

MCV = 108 fL (normal 81 to 96 fL)

MCHC = 33.2 g/dL (normal 31 to 37 g/dL)

RDW = 18.4% (normal 11-15%)

 These findings are most likely caused by:

A. iron deficiency anemia

B. Vitamin B12 deficiency anemia

C. Folic acid deficiency anemia

D. Anemia of chronic disease.
---
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A 45 year old woman with a 10 year history of hypothyroidism presents for follow up care. She's been taking levothyroxine 100 micrograms per day with excellent adherence. Stating "I take the medicine every morning on an empty stomach with a big glass of water.” She states she's generally feeling well, but notices increased fatigue over the past four months, which she attributes to the stress of starting her graduate studies while working full time. The results of today's laboratory testing include the following:

TSH is 2.3, the norm being .4 to 4, pre T4 15 with norm being 10 to 27.

The next step in her care is to:

A. continue on the same levothyroxine dose and obtain a repeat TSH in one year.

B. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in one month.

C. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in two months.

D. Repeat the TSH and free T4 today and provide counseling about taking the medication with breakfast.
---
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A 28-year-old woman presents with new onset worsening fatigue, present for approximately the last month. She is 28 weeks pregnant with her second child, has a 1.5-year-old healthy child at home, says she remembers being tired towards the end of her pregnancy with her first child, but states, “This is worse than with my last pregnancy”. She denies vaginal bleeding or discharge, abdominal pain, or other concerning issues, is sleeping about 7 hours per night, and has adequate access to nutritious food. She is not taking a prenatal vitamin, reporting, “I kept throwing up every time I took one.” During early pregnancy. PHQ-9 screening tool results are without concern.

Labs results are as follows.

Hemoglobin 9.2g per dl (NL=12-14)

Hct=27% (NL=36-42%)

Total RBC= 2.9 million (3.9 to 5.2 million cells per microliter (million/µL)

MCV 75 FL (NL=80-98)

MCH 22 PG (NL=27-33)

RDW 18% (NL=11.5-15%)

These results are most consistent with:

A. Pregnancy related hemodilution.
B. Folic acid deficiency anemia
C. Iron deficiency anemia.
D. Beta thalassemia minor.
---
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A 35 year old presents with chief complaint of “my sinus infection is not getting better”, with continued nasal and sinus congestion, yellow to white nasal discharge, and a feeling of sinus pressure particularly when he bends over. He denies sore throat headache, and GI symptoms, and previously reported fever prior to treatment is now resolved. The EMR documentation notes a prescription for dose-appropriate amoxicillin with clavulanate written 2 1/2 days ago when seen for a sick visit. Patient states he has taken the antibiotic as advised, staring the medicine on the day of his sick visit, and has not missed any doses. Physical exam reveals a no acute distress, mild tenderness to sinus palpation, and no fever. The next most appropriate step in this patient's treatment plan is to:

A. Advise the patient to continue his current course of therapy.
B. Switch his antimicrobial to moxifloxacin.
C. Order a CT of the sinuses.
D. Perform a posterior pharyngeal culture and sensitivity.
---
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Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick visit, stating, “My stomach has not been right for about 4  days. The illness began with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 24 h ago, last stool was around 4 h ago, reported as yellow-brown in color, small volume and without blood.  He has been tolerating  clear liquids for the past 24  h and voided a small amount around 2 h ago.  He feels “a little bit hungry but I am afraid to eat or I might throw up again. I still feel a little bit sick to my stomach.”  Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits  and denies dizziness with position change from supine to sit or stand. His mucous membranes are slightly dry, with intact skin turgor, and  mild diffuse abdominal tenderness without rebound.  With a working diagnosis of viral gastroenteritis, which of the two following clinical actions should be taken?

A. Obtain stool for culture and sensitivity.
B. Order a chem panel.
C. Provide information about a slowly progressive diet as tolerated.
D. Prescribe an antiemetic.
---
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Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 4 h ago, last stool was around 2 h ago, reported as yellow brown in color, small volume and without blood.  He has been tolerating a sips of clear liquids for the past 3 h and voided a small amount around 2 h ago. Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits and his mucous membranes are slightly dry. The most likely cause of Joseph’s clinical condition is:

A. Staphylococcal food poisoning
B. Clostridium difficile (C. diff) enteritis
C. Viral gastroenteritis
D. Gastric ulcer
---
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Sonia is a 15 year old teen who plays varsity basketball and is generally well and up-to-date with health maintenance.  She presents for an urgent care visit with a 6-h history of sudden onset nausea, with multiple episodes of vomiting, abdominal cramping and 2 episodes of diarrhea with stool described as light to dark brown without visible blood. Her VS are within normal limits and mucous membranes are slightly dry. She has slightly hyperactive bowel sounds and mild exceptional tenderness without rebound.  When considering a diagnosis of staphylococcal food poisoning, which would most likely be reported by Sonia?

A. "One after another, the people on my basketball team have been getting sick like this during the past week."

B. "My basketball team stopped at a restaurant today to get something to eat on our way home from a game. Practically all of us who got turkey sandwiches are sick like this.”

C. "I had an ear infection a couple of weeks ago, and I took about 5 days of an antibiotic."

D. "I have really bad cramps during my period, and I take a lot of ibuprofen to help out."
---
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The nurse practitioner sees a six week old with her parents for an urgent care visit. The family is of southeast Asian ancestry.  They voiced concern about “dark spots” over her lower back and buttocks that have developed over the past three weeks. The child was born after a full term pregnancy, went home with parents in 24 hours, has had an appropriate weight gain, and is meeting developmental milestones. On physical exam, the infant appears in no acute distress, and has blue to blue gray spots over the back, and the buttocks. The areas are flat with irregular shape and unclear edges and are noted in the areas that the parents report.  The areas of discoloration are 8 to 20 centimeters in diameter. Palpating the areas does not appear to elicit any discomfort in the child and the color does not blanch with pressure. The skin texture is within normal limits, and The physical exam is otherwise within normal limits. These findings are most consistent with:

A. cafe au lait spots
B. Congenital dermal melanocytosis
C. Port wine stain
D. Capillary Hemangioma
---
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A 40-year-old computer programmer presents for a sick visit with the chief complaint of a two-day history of low back pain. He reports the pain started after many hour stretch of doing yard work. The pain is described as a dull constant ache, worse with activity, better with rest, across the lower back, without radiation to the legs. He denies leg weakness, tingling, or numbness, and states he had similar pain in the past after doing extensive lifting. In considering the diagnosis of lumbar sacral strain, which of the following would most likely be noted on clinical assessment in this patient?

A. Diminished to absent lower extremity DTRs

B. Patient report of new-onset difficulty with voiding.

C. Paraspinal muscle tenderness

D. Positive straight leg raise test
---
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A three year old otherwise well child for a sick visit. Her caregivers report that the child has been well, with the exception of a number of small, new skin lesions on the chin and arms, present for about 3 days. The child will occasionally rub the lesions, but does not complain about pain, has no fever, no other symptoms. Exam is consistent with non bullous impetigo, with approximately 6 lesions, all less than two to three centimeters in diameter, scattered over the chin and both arms. The child is in no acute distress, and age appropriately resist the exam. Which of the following is the preferred treatment option?

A. Topical bacitracin, polymyxin and neomycin cream
B. Mupirocin ointment
C. Oral trimethoprim sulfamethoxazole
D. Triamcinolone cream
---
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A 5 year-old otherwise well child presents with a 4-day history of “a skin problem”. . She is without fever and in no acute distress. Her parent advises that other children in the child’s playgroup have developed  similar skin lesions. Considering the diagnosis of non bullous impetigo, the NP expects to find which of the following?

A : A four-centimeter, round, honey-crusted lesion surrounded by about a 0.5 centimeter area of erythema, localized to the chin. 

B: Multiple papular skin lesions about 0.25 centimeters in diameter, with burrow marks in a linear fashion on both arms. 

C : A generalized vesicular rash over the trunk and extremities.  

D. : Areas of lichenification in the antecubital fossa. 
---
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A 33 year-old who is pregnant with her 2d child presents for prenatal care. She does not have record of her immunizations, but states she has not had any vaccines in more than 1 year. She is without complaint, and exam is consistent with gestational age, with FHT= 140 BPM and visible fetal activity. Today which two vaccines are recommended?

A: Measles, mumps, rubella. 
B: Varicella. 
C: COVID 19. 
D: Tdap or tetanus-diphtheria-acellular pertussis. 
---
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Which of the following is consistent with the clinical presentation of placental abruption? 

a. A 38 year-old with primary HTN, who is now 28 weeks pregnant with her 6th child, presents with a 1-h history of sudden onset abdominal pain as well as dark red vaginal bleeding,dizziness,  tachycardia and BP= 88/ 55

b. A 32 year old who's pregnant with her eighth child, now 32 weeks pregnant presenting with A2 hour history of bright red vaginal bleeding stating she does not have abdominal pain.

c. 28 year old who states she had a positive home pregnancy test three days ago with last menstrual period six weeks ago. Normal timing and flow with an 8 hour history of intermittent bright red vaginal spot spotting with mild cramping.

d. A 26 year old with a past medical history of pelvic inflammatory disease who's now 8 weeks pregnant by LMP with A2 hour History of sudden onset. Severe left sided abdominal pain radiating to the shoulder, Small amount of bright red bleeding per vagina. Feeling lightheaded. Vital signs reveal tachycardia in ABP of 80 / 45.

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The nurse practitioner sees a six week old with her parents for an urgent care visit. The family is of southeast Asian ancestry.  They voiced concern about “dark spots” over her lower back and buttocks that have developed over the past three weeks. The child was born after a full term pregnancy, went home with parents in 24 hours, has had an appropriate weight gain, and is meeting developmental milestones. On physical exam, the infant appears in no acute distress, and has blue to blue gray spots over the back, and the buttocks. The areas are flat with irregular shape and unclear edges and are noted in the areas that the parents report.  The areas of discoloration are 8 to 20 centimeters in diameter. Palpating the areas does not appear to elicit any discomfort in the child and the color does not blanch with pressure. The skin texture is within normal limits, and The physical exam is otherwise within normal limits. These findings are most consistent with:

A.  Cafe au lait spots
B.  Congenital dermal melanocytosis
C.  Port wine stain
D.  Capillary Hemangioma

---
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A 56-year-old man with a 10-year history of hypertension (HTN) presents for a primary care visit, stating he has not taken his HTN medications, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the past 3 months due to “running out of the medication and not getting to the pharmacy.” Today, his blood pressure (BP) is 192/120, and he is without complaint, denying shortness of  breath, chest pain or visual changes.  He states, “ I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a ½ hour.”  His physical examination shows no acute distress, grade 1 HTN retinopathy, and S4 heart sound, neck veins WNL, chest is clear, no peripheral edema with resting HR= 73, RR=16. 12-lead ECG is WNL. BMI= 33. Which of the following is the next best step in this patient’s care?

A.  Administer in-office oral clonidine and reassess blood pressure in 1 hour.
B.  Activate EMS with prompt transfer to emergency department
C.  Restart prior blood pressure medications with follow-up within the next month
D.  Advise restricting dietary sodium and weight loss to help with BP control.

---
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A 56-year-old man with a 10-year history of hypertension (HTN) presents for a primary care visit, stating he has not taken his HTN medications, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the past 3 months due to “running out of the medication and not getting to the pharmacy.” Today, his blood pressure (BP) is 192/120, and he is without complaint, denying shortness of  breath, chest pain or visual changes.  He states, “ I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a ½ hour.”  His physical examination is normal with the exception of which of the following?

A. S4 heart sound
B. Grade 3 HTN retinopathy
C. Neck vein distension
D. Murmur of aortic regurgitation

---
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A 12-month-old is seen for well child care. He has been walking solo since age 11 months, and now waves “bye-bye”, searches for an item under a blanket as well as using “mama” and “dada” specifically. His physical examination is within normal limits. Laboratory evaluation reveals a mild microcytic hypochromic anemia with an elevated RDW.  The NP considers which of the following two are the most likely contributing causes of this anemia. 

A. Vitamin B 12 deficiency

B. Plumbism

C. Iron deficiency

D. Beta thalassemia minor

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Ariel is a 7 month old infant, born at 40 weeks gestation, with Apgar scores of 9 and 10. The baby is up-to-date for well child care and immunizations and has had 2 minor episodic illnesses at aged 4 and 6 months with full recovery.  Ariel rolled tummy to back, started to purposely bring hands together, and babble at around age 4 months, and has had a social smile since age 2 months. Ariel is the youngest of three children, and today, parents mention that they are concerned that, “She’s not sitting up by herself yet. Our older kids were all sitting by now. She tries but then falls over.” Physical exam reveals a highly interactive healthy appearing infant with excellent muscle tone, who age appropriately resists exam. The NP considers which of the following? 

A.  Refer the infant to an early intervention program for additional evaluation. 

B.  Discuss a referral for genetic counseling with the child’s parents. 

C.  Advise that the child’s clinical presentation is consistent with normal parameters for an infant of this age. 

D.  Order testing for plumbism and iron-deficiency anemia. 

---
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A 22-year-old woman presents with a chief complaint of a 4-day history of mild dysuria, described as, “It burns a bit when I urinate.” She denies fever, GI upset, urinary urgency and frequency. About 1 month ago, she entered a relationship with a male partner who is currently without symptoms. Clinical assessment reveals a friable cervix covered by a thick yellow discharge. Suprapubic, CVA and cervical motion tenderness are absent.  UA is positive for leukocytes and negative for nitrites, and microscopic examination of vaginal discharge reveals a large number of white blood cells (WBCs).  She is in no acute distress. Thie presentation is most consistent with:

A.  Pelvic inflammatory disease

B.  Lower urinary tract infection

C.  Genital herpes

D. Chlamydia trachomatis cervicitis. 

---
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A 22-year-old woman who is 20-weeks pregnant was treated for C. trachomatis 4 weeks ago with an appropriate antimicrobial. She presents today for a follow-up visit and reports she is currently without symptoms, that her partner was also treated,  “And we both took the medicine just as we were advised.” Which of the following represents next steps in this patient’s care?

Choose two that apply. 

A. Testing for C. trachomatis should be obtained at today’s visit.

B. A repeat of C. trachomatis testing should be conducted at 1 month postpartum.

C. Given she is without symptoms and her partner was also treated, no further C. trachomatis testing is advised. 

D. In the absence of new clinical findings, follow-up test is advised at around 28-32 weeks gestation. 

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Which of the following applies when considering issues in clinical testing in a target disease? 

A.  A false negative result identifies a person with the target disease 

B.  A true positive result identifies a person with the target disease.  

C.  A true negative result allows for the patient and clinician to discuss treatment 
options for the target disease. 

D.  A false positive result supports a patient and clinician to discussion on  the impact of the target disease on the patient’s overall health. 

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A 68-year-old woman presents for follow-up at her primary care provider with a chief complaint of “another urine infection”, stating she was seen 4 days ago at urgent care with new onset dysuria and urinary frequency. A review of her clinical record reveals that she has had 3 symptomatic, culture-confirmed UTIs in the past 8 months.  She is currently on day 4 of 5 of the antimicrobial prescribed and is without symptoms. Her concomitant health issues include HTN and dyslipidemia, both at treatment goals with lifestyle modification and medication.  When discussing with the patient efforts to prevent future UTIs, the NP considers which of the following will be appropriate?

A. Adding cranberry juice supplements to her diet daily.

B. Avoiding tub baths.

C. Initiating long-term antimicrobial prophylaxis

D. Regular use of a vaginal estrogen.

---
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A 28 year-old woman presents with a 2-day history of urinary frequency, urgency and dysuria, stating, “This feels like when I had a urine infection 4 years ago.” She denies fever or GI upset and otherwise feels well.  In consideration of the diagnosis of lower UTI/cystitis, a urinalysis is ordered.  Which of the following is the most sensitive and specific finding for UTI caused by  a Gram-negative organism?

A. Positive leukocyte esterase

B. Presence of bacteriuria

C. Proteinuria

D. Positive nitrite

---
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Which of the following examples represents a potential medical malpractice scenario?

A. A 25-year-old who is being treated for acute otitis media, reports penicillin allergy to the healthcare provider. An amoxicillin prescription is advised. The patient takes prescribed amoxicillin without adverse reaction.
B. A 40-year-old patient with acute bacterial sinusitis reports to his healthcare provider that his symptoms have not improved after 2 days of a dose-appropriate prescription for amox with clavulanate.
C. Before taking a medication, a 28-year-old patient realizes the wrong drug was dispensed at the pharmacy. She returned the prescription and the correct medication was dispensed.
D. A 50-year-old patient has an abnormal mammogram and was not advised by her healthcare providers about appropriate follow-up. A  mammogram  1 year later confirmed the prior findings, the HCP shared the findings and the patient was referred for further evaluation and breast biopsy.

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A 67-year-old man with a five-year history of heart failure with reduced ejection fraction presented to the ER approximately 7 days ago with worsening shortness of breath, and new onset orthopnea. He was hospitalized for two days, with medications adjusted, and states at that time his symptoms were significantly improved. The nurse practitioner now sees him in follow up. The patient states today that, “For the past day, I feel just like I did the day I was admitted to the hospital. I might even feel worse.”  The patient reports a 5 lb weight gain since arriving home from the hospital. He denies dietary indiscretion with high sodium foods and states he is taking all medications prescribed at hospital discharge as advised   On physical exam, he is sitting upright, slightly labored breathing,  BP=165/92, his resting heart rate=110 with S3 heart sound present, respiratory rate 26, neck veins to 8 cm, and bilateral crackles through the lung fields. The most appropriate next step in his care is to:

A. Perform medication reconciliation.
B. Obtain a detailed 48-hour dietary and fluid intake history.
C. Advise on the need for evaluation and treatment in the emergency department.
D. Ensure he has a cardiology follow-up within the next week.

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A 14-month-old is brought into the clinic for a well-child visit. Born at 39.5 weeks gestation, he has been healthy and is up-to-date with immunizations. The child started to walk at age 12 months and the parents note that “his feet look a little crooked when he stands and sometimes he will trip when he is trying to run because they curve in.”  The NP notes a mild inward curvature of the front half of the foot bilaterally,  with an intoeing positioning when he stands. The feet are flexible and the child walks with ease without evidence of discomfort during ambulation or on exam. There is no joint redness, heat, or swelling. This most likely represents: 

1. Pes planus. 
2. Club foot. 
3. Metatarsus adductus. 
4. Idiopathic juvenile arthritis. 

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YouTube: https://www.youtube.com/watch?v=NvjewWxJpUE

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A 68-year-old with atrial fibrillation is taking warfarin as part of therapy for the prevention of thromboembolic event.  His goal INR is 2-3, which is checked monthly and has been within acceptable range for the past 6 months. Today he presents with an INR=3.8. He denies bleeding events and reports, “I am taking my medicine just like I was told.” The NP considers that:

A. The INR should be repeated today.
B. A single dose of injectable vitamin K should be ordered.
C. His health history should be reviewed carefully, with a focus on interacting with medications and/or foods.
D.   His weekly warfarin dose should be increased by 15%.

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A 35-year-old woman presents for a well-woman exam. She is without complaint, with BMI=22, and reports that she runs about 28 miles per week, 4-5 miles with each run, and has excellent exercise tolerance. She states, “I am in great health.”  On physical examination, the NP notes a faint mid-systolic click followed by a grade 2/6  mid- to late-systolic murmur, best heard at the apex. No other abnormalities are noted.  These findings are most suggestive of

A. aortic stenosis
B. mitral stenosis
C. mitral regurgitation
D. mitral valve prolapse

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YouTube: https://www.youtube.com/watch?v=etnHh0ST5XY&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=46

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A 28-year-old woman who is breastfeeding her healthy 3-month-old term infant presents with a 48-hour history of generalized body aches, intermittent fever to 101.2 F, and localized pain on the upper aspect of her left breast. Nursing her child worsens the breast pain, while putting a cool compress on the area helps with pain control. She denies cough, GI symptoms or other skin alterations and does not have allergies to any medication. Physical exam is consistent with the diagnosis of lactation mastitis.  Which of the following represents the two best treatment options?

A. Discontinue breastfeeding on the affected side.
B. Prescribe an appropriate course of antimicrobial therapy.
C. Ensure that milk flow through the breast is encouraged via nursing as is tolerated or pumping.
D. Discard the milk from the affected breast.

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YouTube: https://www.youtube.com/watch?v=JravIOgsQm0&t=4s

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A nurse practitioner is newly licensed to practice. Which of the following best describes the NP’s ability to prescribe controlled substances?

A. Any NP who meets state-level requirements for a license to practice is able to prescribe controlled substances.
B. NPs are significantly restricted nationally from prescribing controlled substances.
C. NPs are able to prescribe controlled substances with significant physician oversight.
D. Controlled substance prescribing authority for NPs is regulated at the state and national level.

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YouTube: https://www.youtube.com/watch?v=I69XvssB_1k&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=44

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A 55-year-old man with a BMI of 40%, with the chief complaint of low back pain for the past two weeks. He describes the pain as originating in the lumbar sacral region, with radiation across the left buttock associated with numbness and tingling sensation in his left leg. The pain is worse with sitting and somewhat better with standing. He denies lower extremity weakness or a change in bowel or bladder function. He states, “I've tried ice, heat and ibuprofen and these just take the edge off. I've had back pain like this in the past. Usually just lasts a couple of days and it's not that bad. I'm going to try that again and it's not this bad.” This history of present illness is most consistent with:

A. Lumbar Radiculopathy

B. Spinal Stenosis

C. Vertebral Fracture

D. Lumbar Sacral Strain
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YouTube:https://www.youtube.com/watch?v=RayHhiD23iU&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=79

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The NP is seeing a 60-year-old woman with a 10 year history of T2DM. Her current medications include oral metformin and an oral SGLT2-I, and states she is feeling well, without report of blurred vision, excessive thirst or polyuria.  She has not had any laboratory tests done in the past 6 months.  Which of the following represents the best choice of test to determine her overall glucose control?

A. Fasting plasma glucose
B. Serum creatinine/ e GFR (estimated glomerular filtration rate)
C. Hemoglobin A1c
D. Random blood glucose

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A 21 year-old woman with a 15 year history of asthma. presents with acute bacterial rhinosinusitis; she is without fever and in no acute distress.  Her current medications include an ICS/LABA inhaler for reliever and prevention asthma therapy, and a LNG-IUD for contraception. She also reports being told by her parents that she has penicillin allergy, and states, “I had a pink rash on my face and body for a few days when I took penicillin at around 3 or 4 years-old.” In considering ABRS antimicrobial therapy for this patient, the preferred treatment option would be: 

A. Cefpodoxime
B. Azithromycin
C. Amoxicillin
D. Trimethoprim-sulfamethoxazole

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A 76 year-old man with a 20-year history of HTN presents for a sick visit in the primary care clinic, stating, “I do not think that new medicine agrees with me.”  Until recently, his BP was at goal with an ARB, but about 1 week ago, due to continued elevated readings, a second BP med, a thiazide diuretic, was added.  Which of the following is most likely to be reported by this patient?

A. “Since I started on the medicine, I passed out and woke up on the floor 4 times.”
B. “About 2 days after I started the new medicine, I started feeling lightheaded when I stand up quickly.”
C.” After starting the new medication, I feel like the room is spinning around me.”
D. “I’ve had chest pain and sweating off and on since I started the new medication.”

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A 60 year-old man who has a 10 year history of Parkinson disease presents with a chief complaint of “flaking skin that just does not go away, sometimes worse, sometimes better”, stating this problem has been present for > 6 years. Concurrent health issues include HTN, dyslipidemia and generalized anxiety disorder. The affected areas are occasionally itchy and will ache when particularly severe. He has used OTC hydrocortisone cream and skin moisturizers without seeing improvement. Physical exam reveals inflamed patches on the scalp, accompanied by greasy yellow scales. Similar lesions are noted in the nasolabial folds and behind the ears and into the ear canals. Which of the following is the most likely diagnosis?

A. Dandruff
B. Seborrheic dermatitis
C. Psoriasis
D. Atopic dermatitis

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YouTube: https://www.youtube.com/watch?v=VgCO_kpY208&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=39

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A 35-year-old man who is generally well was diagnosed with scabies 3 days ago presents with a chief complaint. “I do not think that skin medicine I was given worked. I am still really itchy and the rash looks the same”.  He reports using topical permethrin as advised. Physical exam reveals excoriated papules on the interdigital area and scattered similar areas in the axillary and groin regions.  Microscopic examination of skin scrapings supports the scabies diagnosis.  He is otherwise without new findings. The NP considers the following:

A. Another course of permethrin is advised, to be used as soon as possible.
B. A skin biopsy should be performed today.
C. Low dose topical corticosteroids and oral antihistamines should be prescribed.
D. A topical antibacterial is advised.

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A 28-year-old woman with a longstanding history of injection drug use presents with a 10-day history of malaise, nausea, and fatigue, and a two day “yellow eyes”.  Physical exam reveals scleral icterus and mild hepatomegaly with right upper quadrant tenderness. Considering the possibility of acute hepatitis B in the differential, the NP anticipates laboratory results will include. 

A. The presence of hepatitis B surface antibody (HBsAb)
B. Thrombocytosis. 
C. Leukocytosis. 
D. The presence hepatitis B surface antigen (HBsAg). 

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YouTube: https://www.youtube.com/watch?v=OGIvOMwCQCU&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=37

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A 22-year-old woman presents for follow-up after a recent clinic, requested STI screening. Testing for Chlamydia trachomatis was positive. She states, “I am really surprised, I feel fine.”  Her current medications include combined oral contraceptive and her LMP was about 10 days ago, with appropriate timing and a  3 day light flow. The NP considers which of the following is the best option?
A. Given she is asymptomatic, no further intervention is needed
B. Oral azithromycin as a single dose should be offered
C. Testing for C. trachomatis should be repeated today
D. A 7-day course of oral doxycycline is advised

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A 62-year-old woman with T2DM presents 2 days after noticing a “bug bite” on her left lower leg, stating, “I am not sure what bit me.” During this time, the area has increased in size and she reports discomfort in the region.  Examination reveals a tender warm, red, erythematous area with poorly demarcated borders, approximately 15 cm at its widest diameter on the anterior lower leg.  Calf circumference is equal bilaterally.  The patient is with no fever or additional complaints with no additional contributory history.  This most likely represents:
A. Deep vein thrombus
B. Erythema migrans
C. Cellulitis
D. Contact dermatitis 

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The NP sees a well, 18-month-old with a two-day history of clear nasal discharge, dry cough, intermittent fever to 101.4 or 38.5C, and mild crankiness. She's up to date with all recommended vaccination. Parents report everyone at home has this cold. Testing for RSV, COVID-19, influenza are all negative. She is alert, age appropriately resists the exam, which is consistent with viral URI.  Her father states, “We got her fever under control by giving her two different medicines around the clock.” He presents two medication bottles, one with liquid acetaminophen and one with liquid ibuprofen. The NP considers that alternating between ibuprofen and acetaminophen for a child with fever will:

 A. Result in additive effect in fever reduction.
B. Is encouraged in order to prevent febrile seizures.
C. Is only recommended in higher fever, such as when the fever is 100 degrees F or 38.8 degrees C or greater.
D. Is not recommended due to higher potential for adverse effects.

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YouTube: https://www.youtube.com/watch?v=3TwWdK5TnbM&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=34

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A 45-year-old adult presents for a sick visit, with the chief complaint of three-day history of low back pain. Clinical assessment is consistent with lumbar sacral strain. Which of the following represents the most appropriate next step in this person's care?

A. Advised three days of bed rest on a firm surface.

B. Apply ice or heat to the affected area based on clinical response.

C. Refer to neurology for further advice.

D. Order a lumbar sacral x ray to help confirm the diagnosis.
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YouTube: https://www.youtube.com/watch?v=bNQp-Vq4jds&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=78

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The NP is seeing a 35 year-old well woman for a health promotion and physical exam woman. She has not complaints, is a nonsmoker, a light social drinker with 1-2 glasses of wine per month, and exercises about 30 mins 5 days a week. Her BMI is 22 and vital signs are unremarkable with BP= 110/70. Which of the following is an anticipated finding on her funduscopic exam?

A. Retinal arteries wider than veins
B. Arteriovenous nicking
C. Physiologic cup-to-optic disc ratio of less than 0.5 
D. Blurred optic disc margins

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YouTube: https://www.youtube.com/watch?v=Vmb7IXP68m4&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=33

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A healthy 1 year old, accompanied by his mother, is in for a well child visit. He is due to receive routine immunizations for a child his age. His mother mentions that she is about 6 weeks pregnant and read that, “I know he should get the chickenpox and German measles vaccines today. Since I am pregnant, is this safe?” The NP considers the following:

A. Neither vaccine contain live virus and both can be given today.

B. Both vaccines contain live virus that the child will not shed, and he can receive these immunizations today.

C. The vaccines contain live virus and should be delayed until the mom is out of the first trimester of pregnancy.

D. Due to the mother’s pregnancy, these vaccines should be delayed until after she gives birth.

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YouTube: https://www.youtube.com/watch?v=HvjCBeUIXlc&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=32&t=6s

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A 78 year-old woman with well-controlled hypertension and dyslipidemia presents with a chief complaint of a many month history of pain, described as achiness, and stiffness in the joints both hands, particularly towards the end of the day. A part-time seamstress, she reports this discomfort is worse on work days.  She denies redness or heat in the affected regions and has no systemic complaints. Physical exam reveals Heberden and Bouchard nodes bilaterally. These findings are most consistent with a diagnosis of:

A. Rheumatoid arthritis
B. Systemic lupus erythematosus 
C. Osteoporosis
D. Osteoarthritis

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YouTube: https://www.youtube.com/watch?v=LXSE3bE7I30&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=31

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A 67-year-old man who is diagnosed with acute bacterial prostatitis presents with a chief complaint of a one-week history of constant perineal pain, arthralgia, irritative voiding symptoms, and intermittent fever. Which of the following is most consistent with anticipated findings on prostatic digital rectal exam (DRE) with this condition?

A. An enlarged prostate with obliterated median sulcus
B. A prostatic exam that reveals multiple firm, non tender nodular lesions
C. A tender, boggy prostate
D. A firm, non tender prostate

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YouTube: https://www.youtube.com/watch?v=fPoH6HNHh1U&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=30&t=302s

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