at position 1 7.5 points Complaint: “My

at position 1 7.5 points Complaint: “My heartburn has been waking me up at night.” History: A 47-year-old male patient presents to the clinic with complaints of intermittent nocturnal gastroesophageal reflux. History reveals that he awakens experiencing burning pain substernally and in the back of his throat. This results in “my larynx closing down” and his being “almost unable to breathe.” As soon as he can breathe effectively, he swallows “a lot” of antacid and flushes it down with water. The entire episode is very frightening, and he is often afraid to go back to sleep. Because he already has a problem with mild sleep apnea, he is becoming increasingly tired and unable to function at work due to lack of sleep. He now sleeps only in his recliner. He is also concerned about the substernal pain because his father had a myocardial infarction at age 49 and required coronary artery bypass surgery. He is 5 feet 9 inches tall and weighs 220 pounds (body mass index [BMI] is 32.5), with much of his excess weight carried in his abdomen. He is not a smoker, “occasionally” has three or four beers with friends, and “often” has pizza or submarine sandwiches for lunch with a “diet cola.” He takes no drugs other than the antacid after a reflux episode. Assessment: A chest x-ray and electrocardiogram are negative for cardiopulmonary disease, and G.F. is diagnosed by history with gastroesophageal reflux disease (GERD). What would be included in the initial management plan for moderate GERD? Choose all that apply. · Begin omeprazole 20 mg daily. The addition of a proton pump inhibitor (PPI) will help to reduce gastric acid secretion. · Draw a complete blood count (CBC) for a baseline to assess for any potential future gastrointestinal bleeding. · Educate him that with nocturnal GERD, taking food and fluids no closer than 3 hours before bedtime can significantly reduce symptoms. · Draw a basic metabolic panel (BMP) for a baseline to assess for any potential future renal insufficiency caused by PPI’s. · Inform him that approximating his ideal body weight will reduce intra-abdominal pressure. Anti-reflux maneuvers and dietary changes will reduce total volume and acid content of the stomach. · Discuss lifestyle modifications with a focus on weight loss, antireflux maneuvers, and dietary changes. · Begin omeprazole 20 mg BID. The addition of a proton pump inhibitor (PPI) will help to reduce gastric acid secretion. · Consider H. pylori testing. Also, schedule a follow-up visit in 1 month to see how he is progressing after interventions. at position 2 5 points A year and a half later, G.F. experienced an acute STEMI with the identifiable culprit lesion of mid left anterior descending. He underwent a drug eluding stent (DES) to this coronary lesion and was initiated on clopidigrel (Plavix) 75mg daily after the initial load in the cardiac catheterization lab. He unfortunately now is intubated and sedated in the ICU due to cardiogenic shock complicated by acute HFrEF (heart failure with reduced ejection fraction). Additionally, he is coagulopathic with shock liver physiology. As the provider in the ICU, you review his medication reconciliation and notice aspirin 81mg daily, omeprazole 20mg PO daily, multivitamin daily. Upon review, you: Choose all that apply. (Hint, there are three correct answers) · Continue omperazole 20mg PO daily once enteral access with NGT or OGT (nasal or oral pharyngeal tube) is achieved. · Transition him to pantoprazole 40mg IV QD immediately to reduce the risk of erosive disease and GIB · Stop aspirin daily due to risk of GIB. · Continue clopidigrel due to recent DES placement. If you were his primary care provider, and if you deem his GERD is continuing after his acute illness resolves you can discuss with cardiology transition to another antiplatelet agent. You could also consider changing his PPI to an H2 blocker instead. · Realize famotidine has no interactions with clopidigrel and can serve as future alternative to a PPI. at position 3 7.5 points J.R, a 59-year-old female, who presents to you with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema 4 years ago and was placed on bronchodilator therapy. She has an 80 pack year history of smoking. “I feel short of breath when I walk, and my chest is sore.” She describes her chest soreness as mild pressure, rated as 2 on a 1-10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing “hard.” She states that she has had a nonproductive cough for 4 days and feels more fatigued than usual. Past medical history: She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had 2 exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully. Family history: Noncontributory. Social history: She lives with her husband who also smokes 2 packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory. Medications: Albuterol MDI, 90mcg/inhalation, 2 puffs as needed every 4-6 hours; ipratropium bromide MDI, 18 mcg/inhalation, 2 puffs 4 times/day; ibuprofen as needed for arthritic pain. Allergies: J.R. is allergic to Keflex and penicillin. General: J.R.is dyspneic at rest, sitting. Use of accessory muscles evident. Pursed lip breathing noted. Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; SpO2: 88. AP to transverse ratio is 1:1. Skin: Warm and dry. HEENT: Negative. Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedal pulses 2+/4+. Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on right and left anterior and lateral thorax from 2nd to 5th inter- costal spaces. PFT conducted 2 months prior to visit showed obstructive flow patterns and reduced FEV1/FVC. Abdomen: Soft, with bowel sounds; tympanic to percussion. Neurologic: Negative. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Choose the BEST options that apply to THIS visit. Remember, just because you can order it, doesn’t mean you should right now. · Echocardiogram · Spirometry · ECG · CT of the Chest · CXR · CBC · Arterial blood gas (ABG) at position 4 5 points Her diagnostic results are as follows: Diagnostic tests: · Spirometry: FEV1/FVC <.70; FEV1 50% predicted. · Chest X-Ray: Overdistention of lungs; flattened diaphragm; mild cardiomegaly. · CBC: WNL except slight elevation of RBCs. · ABGs: pH: 7.36; PCO2: 55; PO2: 60; HCO3: 29; SaO2: 89. · ECG: Sinus tachycardia; frequent PVCs; no ischemia; right axis deviation. For J.R., what is the most likely differential diagnosis? · Pneumonia · COPD exacerbation · Asthma · Pulmonary Neoplasm at position 5 5 points What is included in your plan of treatment for J.R? · There would be no consideration for oral glucocorticoid therapy to improve her recovery. · Educate her on smoking cessation. · A short-acting form of bronchodilator is all that is indicated in this patient's presentation. · Repeat spirometry and a clinical assessment of her lungs after initiation of regimen changes. · There is no need for education regarding smoking cessation due to her being educated many times before this encounter. · Change J.R.'s inhaled bronchodilator therapy to a long-acting form: salmeterol 12mcg (range 4.5-12). · Add beclomethasone dipropionate, 42mcg/inhalation MDI, 2 puffs 3-4 times per day. at position 6 7.5 points Complaint: "It hurts when I urinate." History: J.H is a 26-year-old female presents at clinic with symptoms of dysuria, frequency, and urgency. Further history yields 2 days of these symptoms but no fever, chills, or flank pain. She describes a burning discomfort during and immediately following urination and feeling the need to void every half hour. There is no vaginal discharge, itching, or odor. She uses a diaphragm and spermicide for birth control. She requests "a urine culture and some sulfa pills." When asked to explain, she says that she has had many "bladder infections" over the past 3 years and "sulfa pills usually work." She was evaluated approximately 5 years ago with an IV pyelography and cystogram, and "nothing was wrong." Assessment: A midstream urine specimen is collected for urinalysis and culture. A urine dipstick reveals 21 pyuria, 11 hematuria, and trace nitrates. Her pregnancy test is negative. She exhibits no costovertebral angle or abdominal tenderness. Her vital signs are within normal limits. J.H. looks essentially well. There are no symptoms suggestive of pyelonephritis or vaginal disorders. What would be the initial management plan for an adult woman with a simple uncomplicated urinary tract infection (UTI)? · An option is Ciprofloxacin 500mg TID for 7 days. · Do no culture the urine. · To correct her discomfort and burning with urination, prescribe phenazopyridine 200 mg bid. · An option is Nitrofurantoin 100 mg bid x 5 days. · Culture the urine. · An option is TMP-SMX (Bactrim) DS 1 tab PO BID for 3 days. · Consider Trimethoprim-sulfamethoxazole 80/400 mg 1 tablet single dose after intercourse. at position 7 7.5 points If J.H. were to present with + CVA tenderness, fever, nausea and/or vomiting how would your management change? Include all of the following that you would do: · Culture the urine and ensure susceptibilities are performed. · No further workup is necessary. I would not order any additional tests (CBC, BC, Urine culture with susceptibilities) · An option for inpatient treatment: ciprofloxaxin (Cipro) 400mg IV BID daily or Levaquin 750mg IV daily for 5-7 days. · An option for outpatient treatment: ciprofloxacin (Cipro) 500mg PO BID for 5-7 days or Rocephin 1 gram IM x 1 dose. · An option for outpatient treatment is NOT: TMP-SMX (Bactrim) DS 1 tab PO daily due to high failure rate. · Order a CBC and Blood Cultures x 2. · For outpatient treatment: ciprofloxaxin (Cipro) 400mg IV BID daily or Levaquin 750mg IV daily for 5-7 days. at position 8 5 points What education is needed when treating a patient with a UTI? · There is no need for postcoital suppression therapy unless pyelonephritis occurs. · Follow up in an urgent care or emergency room if symptoms recur. · Consideration will be given to postcoital suppression therapy if she continues to have these infections. · How to take the medication. Advised to complete the full course of antibiotics. · Increase fluids to 2,000 mL per day. · Follow up outpatient if symptoms recur. · Fluid restrict to 1,000 mL per day to promote decreased urine production while with active UTI.

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