A 29-year-old otherwise healthy adult presents with a five-day history of nasal congestion, clear to white rhinorrhea, sore throat, and dry cough. She also denies dyspnea, pleuritic chest pain, GI upset, or fever. The patient is in no acute distress. Vital signs are temperature 99.2 Fahrenheit or 37.3 degrees centigrade. Respiratory rate is 16. O2 sat is 98 % on room air. Physical exam reveals mild pharyngeal erythema without exudate, no lymphadenopathy and tympanic membranes within normal limits. Lung resam is unremarkable except for occasional cough. The nurse practitioner diagnoses a viral URI or a common cold. The patient states, “I have trip coming up in five days, and I'm really worried that I might have the start of a sinus infection or pneumonia or a strep throat.”

The NP considers which of the following in addressing the patient's concerns?

A. if you start to cough up phlegm within the next day or so, this could indicate the start of a pneumonia

B. If your nasal discharge turns to green or dark yellow, this usually indicates that an antibiotic is needed

C. your cough could persist for a couple of weeks, which is quite common in a viral respiratory tract infection

D. if your sore throat persists for two to three more days, it means that a strep infection is starting

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A six-month, two-week-old infant who was born at 40.5 weeks gestation after an uneventful pregnancy is brought in for a well child visit. His parents mentioned, “his older sister was a really different baby. I think he's not quite where she was in his development at this age.” Which of the following would not be a red flag requiring further evaluation?

A. Inability to roll in either direction

B. Unable to transfer objects hand to hand

C. Reaches for objects with one hand

D. Ability to sit briefly without support

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Sarah, a healthy infant born at 40.5 weeks gestation after an uncomplicated pregnancy, is brought in for a four-month well child visit. Parents report the infant is feeding well, smiling frequently, and becoming more interactive with family members.

Which of the following is most consistent with a normal developmental exam for an infant of this age?

A. Rolls back to abdomen and transfers objects hand to hand

B. brings hands together and laughs out loud

C. Lifts head briefly when prone and startles to loud sounds

D. Increase babbling and sits without support

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A 24-year-old woman presents for a well-adult visit. Her health history includes the diagnosis of mitral valve prolapse without significant mitral regurgitation. She is feeling well, has no chief complaint, and denies activity intolerance, stating she plays tennis or pickleball for about one hour three to four times a week. Her only medication is an oral combined hormonal contraceptive and reports being pleased with her contraceptive method. She states that she read online that “I know I have a heart murmur and I'm worried about whether the birth control pill is safe for me.” The nurse practitioner considers the following when advising this patient

A. she should switch to a progestin only contraceptive method

B. if no other contraindications are present, she can continue to use combined hormonal contraception

C. in this clinical scenario, barrier contraceptive method is advised

D. she should be referred to cardiology for advice on contraceptive methods

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A 51 year old woman who works as a real estate agent presents for an office visit with a chief complaint of severe vasomotor symptoms reporting, "I can't sleep through the night without being drenched in sweat. I have at least four hot flashes a day. Sometimes while I'm working with clients. I need some help. What do you think about hormone therapy? " Her LMP was approximately 13 months ago and she's without chronic health problems.

When considering postmenopause hormone therapy, which of the following is the most accurate statement?

A. The use of hormone therapy post menopause is associated with a significant increase in cardiovascular and cancer risk.

B. The use of select low dose SSRIs for the management of vasomotor symptoms is as effective as hormone therapy.

C. Short duration lower dose hormone therapy offers an effective form of therapy for menopausal vasomotor symptoms.

D. Hormone therapy postmenopause offers an effective treatment for osteoporosis.

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Which of the following best describes the use of contraception for a 26 year old woman who has migraine without aura, usually three episodes per month controlled with high dose ibuprofen who is otherwise well states. "I want to get on some birth control that's really reliable for the next three years while I'm in graduate school."

A. All combined hormonal contraceptive forms are contraindicated with any type of migraine.

B. Combined hormonal contraception is acceptable for use in this clinical situation.

C. Progestin-only contraceptive methods should be avoided in migraine with or without aura due to the increased risk for elevated blood pressure.

D. Barrier contraceptive methods are preferred in this situation.

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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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