A patient presents with a chief complaint of a gradual onset vision change, present for the past 6 months, while denying eye pain, redness or trauma. The funduscopic exam, extraocular movements and pupillary reactions are within normal limits. When considering a diagnosis of presbyopia, which of the following best describes patient presentation?

A. A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly".

B. A 75-year-old who states,"When I look at a bright light, I see a colored halo around it".

C. An 80-year-old who states, "I have a blurry spot in the middle of my eyesight".

D. A 17-year-old who states, "I went to get my driver’s license, but failed the distance vision exam".

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A 27-year-old woman presents as a new patient to your practice. She is without chief complaint. She asks to, “get a refill on my birth control pills” , having used combined oral contraceptives for the past 12 years without adverse effects. Social history reveals she is a nonsmoker, without recreational drug use, drinks approximately 1-2 mixed drinks per week, and runs 2-3 miles 5 days a week with reported excellent activity tolerance. Her health history is generally unremarkable, but with patient report of a “mild heart murmur that was picked up when I was a teenager during a physical I needed so I could run track. I was told not to worry about it.” Physical exam is unremarkable with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. The remainder of the cardiac exam is within normal limits.

These findings most likely represent which type of murmur?

A. Physiologic

B. Aortic stenosis

C. Mitral regurgitation

D. Mitral valve prolapse
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A 29-year-old who is 8 weeks pregnant presents with a chief complaint of nausea and vomiting. She states, “I’ve been like this for three weeks. I don’t know why this is called morning sickness since I feel sick to my stomach almost all the time”, reporting that she vomits 2-3 times nearly every day, stating, “I was worse 2-3 weeks ago, when I was throwing up 4-5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-h dietary recall reveals frequent low-fat meals and consistent sipping of liquids. She denies thirst or infrequent urination, and reports, “I’m just tired of feeling this way. I’ve missed so much work and can hardly keep up with my 3-year-old.” Physical exam reveals the following; Alert, appears fatigued, with moist mucous membranes, a 1 lb. weight loss since last visit 4 weeks ago, and minimal epigastric tenderness without rebound.

The NP considers advising on the following:

A. Initiate therapy with an oral 5HT-3 antagonist such as ondansetron (Zofran®).

B. Referral to high-risk for advise on further management.

C. Advise on the use of daily dose of oral vitamin B6 with doxylamine.

D. Increase fluid and fiber intake.
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