A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he has not taken his high blood pressure medicines, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the last three months due to, quote, running out of medication and not getting to the pharmacy, close quote. Today's blood pressure is 192 over 120, and he's 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 half an hour." His physical exam shows no acute distress, grade one hypertensive retinopathy, and S4 heart sound. His neck veins are within normal limit, chest is clear, no peripheral edema with a resting heart rate of 73. Respiratory rate 16, 12 lead ECG is within normal limits. His BMI is 33.

Which of the following is the next best step in the 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 presents for a primary care visit, stating he's not taking his hypertension med, a calcium channel blocker, an angiotensin converting enzyme inhibitor, and a thiazide diuretic for the past three months due to "running out of the medication and not getting to the pharmacy." Today, his blood pressure is 192 over 120 and he has no 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 my blood pressure refills. I need to get back to work in a half an hour." When considering the diagnosis of asymptomatic markedly elevated blood pressure, the clinician would predict his physical exam 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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Which of the following two patients with asymptomatic bacteria, or abbreviated ABS, should receive antimicrobial therapy?

A. An 84‑year‑old woman who is a resident of a long‑term care facility with dementia, no new urinary symptoms, her urine is positive for nitrites, leukocytes, and culture reveals 100,000 colony forming units per ml of E. coli.

B. A 70‑year‑old man with an indwelling Foley catheter, no new urinary symptoms. His urine appears cloudy and foul‑smelling. His culture is 100,000 CFU of mixed flora.

C. A 30‑year‑old woman who is 10 weeks pregnant, no urinary symptoms, culture reveals 100,000 CFU per ml of E. coli.

D. A 72‑year‑old man scheduled for a transurethral prostate resection, a TURP, next week, no urinary symptoms. His culture reveals 100,000 CFU per ml of E. coli.

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A healthy seven‑month‑old boy presents with his parents for a well‑child visit. He was born at 39.5 weeks gestation via spontaneous vaginal delivery. After a pregnancy without complication, he and his mother went home after 24 hours. He is primarily breastfed with a small amount of solids and continues to be at the 50th percentile weight and 40th percentile length. The parents voice no concerns.

Which of the following is the most appropriate developmental milestone for this child's age?

A. sits briefly with support

B. is able to pull to stand

C. rolls front to back

D. uses pincher grasp to pick up a small object

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A 28‑year‑old male non‑smoker with no chronic health problems presents with a 10‑day history of persistent cough that's worse at night, stating, "I started with a head cold about two weeks ago. The cold moved into my chest." He reports mild chest discomfort with deep cough, rare production of small amounts of clear to white sputum, and feels tired because, "the cough keeps waking me up." He denies sore throat, fever, ear pain, shortness of breath, or GI symptoms. Objective temp 97.6, heart rate 72, respiratory rate 18, BP 112 over 68, SpO2 is 99%, no acute distress, mild pharyngeal redness, no lymphadenopathy, chest without crackles, occasional dry cough, abdominal exam is within normal limits.

Which of the following is the most appropriate next step?

A. Prescribe one week of oral amoxicillin.

B. Order a chest x-ray

C. Prescribe a five-day course of azithromycin

D. Provide advice about symptomatic care

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A 36 year old woman presents with a three month history of unintended weight loss, sensation of increased anxiety, heat intolerance, and reports, "I feel like my heart is going to beat right out of my chest." In addition, she reports a two-month history of increased frequency and looseness of stools. Physical exam reveals 3-4 plus Achilles and patella reflex response, mild exophthalmosis, bilateral fine tremor, and a diffusely enlarged non-tender thyroid. Heart rate 115 beats per minute at rest without murmur or other cardiac abnormalities.

Considering thyroid disorder as her working diagnosis, which of the following would be her anticipated lab results?

A. Elevated TSH with normal limit free T4

B. Low TSH with elevated free T4

C. Elevated TSH with a low free T4

D. Normal limit TSH

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A 62 year old man with a 60 pack year cigarette smoking history presents with a chief complaint of progressive dyspnea on exertion and a chronic productive cough over the past eight years. Significant contributing history include two episodes of being seen in urgent care in the past year for "bronchitis" and being told he should follow up with primary care.

When considering the diagnosis of COPD, which of the following is the most important diagnostic parameter?

A. patient report of progressive dyspnea and chronic productive cough

B. 60-pack year cigarette smoking history

C. FEV1 to FEC ratio of less than 0.7 post bronchodilator

D. FEV1 of less than 50 % of predicted

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A 72-year-old with a prosthetic aortic valve presents stating, "I was told I have to take a medicine before I have a deep dental cleaning." Concurrent health issues include hypertension, type 2 diabetes, and dyslipidemia, currently at treatment goals. Medications include metformin, hydrochlorothiazide, telmisartan, and rosuvastatin. She has no drug allergies. Which of the following is the most appropriate next step in her care?

A. amoxicillin 2 grams PO 30 to 60 minutes prior to the procedure

B. amoxicillin 2 grams PO 1 to 2 hours after the procedure

C. cephalexin 2 grams PO 30 to 60 minutes prior to the procedure

D. inform the patient that no antimicrobial prophylaxis is needed during dental care.

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