A 77-year-old man is in for a routine follow up visit. He has its twenty-year history of type 2 diabetes and hypertension as well as a 5-year history of stage 3B chronic kidney disease, or CKB. At this visit, his A1C is 8.4% and his estimated GFR is 42 mL per minute. His BP is 128/76. He states he's feeling well and denies headache, visual changes, dizziness and hypoglycemic episodes. His medications include metformin, amlodipine, lisinopril and rosuvastatin. In reviewing his current medication, the NP considers which of the following options?

A. Prescribe glipizide

B. Add pioglitazone

C. Continue on his current medication without adjustment

D. Initiate therapy with Canagliflozin

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A 72-year-old woman with a 20-year history of hypertension and dyslipidemia-- both at EBP goals with appropriate drug therapy, as well as a remote history of peptic ulcer disease-- presents for follow up. She is a nonsmoker, drinks about 1- 2 glasses of wine per week and denies the use of other substances. Her daily routine includes a 2- 3 mile walk and she denies history of acute coronary syndrome or other ASCVD related conditions. She mentions that one of her friends takes an aspirin a day to “prevent a heart attack or a stroke”, and further states, “I live alone, and I need to maintain my independence.” According to the latest recommendations from US Preventative Services Task Force, which of the following is the most appropriate advice regarding low dose aspirin use in this patient?

A. Start low dose aspirin therapy 81 mg daily as the vascular benefits outweigh the risk.

B. Best evidence for primary prevention of ASCBT event is with higher dose aspirin at 325 mg a day.

C. The risks associated with aspirin therapy in this patient outweigh the potential benefits.

D. Start aspirin therapy only if the patient has a family history of heart disease and 1st degree relatives.
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YouTube: https://www.youtube.com/watch?v=9uK3CINTFOg&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=91

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A 57-year-old man presents for a routine physical exam during history taking. He reports that he drinks approximately 7-to-8 12-ounce beers nightly and denies other substance use, including tobacco. His physical examination is unremarkable except for mild pharyngeal erythema without exudate. In consideration of his health history, which of the following lab results would be anticipated?

A. Elevated platelets

B. Macrocytosis

C. Lymphocytosis

D. Elevated sed rate
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YouTube: https://www.youtube.com/watch?v=57EyxtFcUUY&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=90

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Which of the following are the most common features of skin changes noted in areas of the feet affected by tinea pedis?

A. Widely distributed with consistently raised with areas of hyperpigmentation.

B. Localized to the dorsal aspect with central clearing and a raised border

C. Involving plantar crusting and interdigital fissures

D. Remains stable in size over time with lateral lichenification.
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YouTube: https://www.youtube.com/watch?v=D70UTIMym6w&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=89

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Mrs. Martinez is a 64-year-old woman with 10 year-history of type 2 diabetes mellitus, HTN, and dyslipidemia. Her current medications include metformin, an SGLT-2 inhibitor, statin, ARB and thiazide diuretic. She is at EBP-advised goals including recent A1c=6.9%. Today, she reports she is feeling well. Her history and physical examination are unremarkable. She mentions that, for the past year, in addition to her prescribed medications, she drinks a special tea blend that her sister makes, taking this each day to help “draw out the sugar” in her blood. She states, “I feel much better when I take it.” Your most appropriate response is:

A. “I don’t believe the tea is helpful in controlling your blood sugar.”

B. "Please stop using the tea until I can look into its contents."

C. "Homemade teas might interact with your medicines”

D. “Tell me more about how the tea draws out the sugar.”

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A 76-year-old woman with presbycusis presents for a follow-up visit on HTN and dyslipidemia, treated with an ARB, thiazide diuretic and a statin, and at treatment goal. Which of the following is she likely to report?

A. Occasional difficulty with speech discrimination

B. Need to use her prescription eyeglasses to read

C. Altered sense of smell

D. Diminished sense of touch
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YouTube: https://www.youtube.com/watch?v=cj_Qj5hOvS4&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=87

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A 24-year-old adult, assigned female at birth, presents to your practice chief complaint of bilateral lower abdominal pain for the past three days, worsening over this time frame. She describes the pain as a heavy pressure like feeling, accompanied by intermittent fever , mild dysuria, yellow vaginal discharge, as well as nausea without vomiting nausea without vomiting. She is tolerating fluids well and has a markedly decreased appetite. Additional history of present illness includes recent LMP, ending about three days ago with normal timing and normal flow, she is sexually active with two male partners, and describes that the last episode of coitus six days ago was painful for deep pelvic discomfort. The physical exam reveals a temp of 100.4 Fahrenheit, rest of vital signs within normal limits, mild lower abdominal discomfort to light and deep palpation without rebound, yellow vaginal discharge and cervical motion tenderness without palpable pelvic mass. This clinical presentation is most consistent with:

A. Acute Appendicitis

B. Pelvic Inflammatory Disease

C. Ovarian Cyst

D. Ectopic Pregnancy
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YouTube: https://www.youtube.com/watch?v=hS0zWLA9b_A&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=86

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A 14 yo presents with a 4 h history of sudden onset LLQ abdominal and scrotal pain, described as a pulling, burning sensation. He denies vomiting, diarrhea or constipation, and reports mild nausea and is taking fluids without difficulty. HPI is negative for recent trauma to the region, dysuria, penile discharge, genital lesions or fever. He reports milder, similar episodes during the past 3 months, “that just went away.” Physical exam reveals loss of the cremasteric reflex, negative Blumberg sign and a high riding left testicle.

A. Testicular Neoplasia

B. Acute Epididymitis

C. Incarcerated Inguinal Hernia

D. Testicular Torsion
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YouTube: https://www.youtube.com/watch?v=cGczKmYTdVU&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=85

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