1. Knowing that treatment for deep vein thrombosis (DVT) involves administration of anticoagulants,
which of the following patients can be safely
... [Show More] treated for DVT in the outpatient setting?
A. an 80-year-old woman who weighs 42 kg
B. a 22-year-old man who had an appendectomy 2 days ago
C. a 32-year-old woman with peptic ulcer disease
D. a 55-year-old man with lung cancer in remission
Most patients with DVT may be treated in the outpatient setting. However, there are multiple contraindications to outpatient
treatment, most involving increased bleeding risk, including: active peptic ulcer disease, recent surgery, and weight <55 kg for males
and <45 kg for females. Lung cancer or any other cancer that does not involve brain metastases is not a contraindication for outpatient
treatment.
Leavitt, A.D., & Minichiello, T. (2019). Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy. In M.A. Papadakis & S.J.
McPhee (Eds.), Current medical diagnosis and treatment 2019 (pp. 577-588). New York: McGraw-Hill Education.
2. The nurse practitioner is examining a 65-year-old man with a history of type 2 diabetes mellitus and a
complaint of cramping pain in his calves when walking. The patient reports the pain is alleviated with
rest but returns when the patient must walk again. The nurse practitioner expects to find all of the
following on exam consistent with the diagnosis of peripheral artery disease, except:
A. weak or absent dorsalis pedis pulses
B. large ulcerations at the medial ankles
C. bruits over the femoral arteries
D. an ABI of 0.6
Peripheral artery disease (PAD) causes intermittent claudication, pulses in the lower extremities to be faint or absent, may cause
bruits over the larger arteries, and usually results in an ABI of less than 0.9 (normal is 0.9-1.2). PAD can also cause ischemic and
arterial ulcers; however, these are generally found in the toes and feet. Large ulcers near the ankles are characteristic of venous ulcers
and chronic venous insufficiency.
Gasper, W.J., Rapp, J.H., & Johnson, M.D. (2019). Blood Vessel & Lymphatic Disorders. In M.A. Papadakis & S.J. McPhee (Eds.),
Current medical diagnosis and treatment 2019 (pp. 483-501). New York: McGraw-Hill Education.
3. A 43-year-old female presents with complaints of weight gain, constipation, memory fog, and fatigue.
Her labs reveal a TSH of 6.7 and Free T4 of 5. Your plan for this patient includes:
A. Her labs are within normal range, and no treatment is needed.
B. Start her on Synthroid at 1.6mcg/kg/day and recheck labs in 4-6 weeks.
C. Instruct her to take her Synthroid on a full stomach for best absorption.
D. Start her on Synthroid at 0.8mcg/kg/day and recheck labs in 2 weeks.
Normal TSH values are 0.4-4 mIU/L and normal FreeT4 is 10-27pmlol/L. This patient has both the symptoms and lab values for
hypothyroidism. Synthroid (synthetic levothyroxine) is the first line medication for hypothyroidism and starting dose is 1.6mcg/kg/day
based on ideal body weight. TSH and Free T4 should be rechecked every 4-6 weeks until euthyroid and normal lab values should
be obtained within 1-2 months of starting therapy.
Fitzgerald, P.A. (2019). Endocrine Disorders. In M.A. Papadakis & S.J. Mcphee (Eds.), Current medical diagnosis and treatment 2019
(pp.1134-1137). New York: McGraw-Hill Education.
4. Cigarette smoking may falsely increase the levels of:
A. gamma-glutamyl transpeptidase
B. sodium and potassium concentrations
C. hepatic enzymes
D. serum protein electrophoresis
Cigarette smoking may increase hepatic enzymes which in turn will reduce the levels of substances metabolized by the liver such as
theophylline.
Online: https://accessmedicine-mhmedicalcom.libproxy.usouthal.edu/content.aspx?bookid=2957§ionid=249389479#1175378669
5. A 75-year-old female patient who is healthy and active reports that she has recently been having
trouble getting to the bathroom on time to urinate and also has some leaks when she sneezes or
coughs. She reports having to wear an incontinence pad daily. She is very independent and is
embarrassed and worried that this is going to affect her lifestyle. As her provider, your best next steps
for this patient would be:
A. Refer her to urology, her symptoms will only get worse and she will more than likely need surgery
B. Suggest bladder training and pelvic floor muscle exercises (Kegel’s) to decrease incidences of stress
and urge incontinence
C. Prescribe an antimuscarinic agent such as oxybutynin immediately
D. Schedule the patient for insertion of a pessary
For women with mixed stress/urge incontinence, pelvic floor muscle exercises can be effective for decreasing this problem. The other
choices are more invasive and would not be first-line conservative treatments.
Harper, G. M., Johnston, C. B., & Landefeld, C. S. (2019). Geriatric Disorders. In M. A. Papadakis, & S. J. McPhee, Current Medical
Diagnosis and Treatment (pp. 65-67). McGraw-Hill Education.
6. A 40-year-old female waitress presents to the clinic complaining of pain, burning, and tingling in her
hands and fingers. She reports the symptoms are most bothersome at night. The NP has carpal tunnel
syndrome as a differential diagnosis. All of the following are used to rule in or out this diagnosis
EXCEPT:
A. Tinel test
B. Phalen test
C. Spurling test
D. Carpal compression test
A Tinel or Phalen sign may be positive. A Tinel sign is tingling or shock like pain on volar wrist percussion. The Phalen sign is pain or
paresthesia in the distribution of the median nerve when the patient flexes both wrists to 90 degrees for 60 seconds. The carpal
compression test, in which numbness and tingling are induced by the direct application of pressure over the carpal tunnel, may be
more sensitive and specific than the Tinel and Phalen tests.
Papadakis, M. A., McPhee, S. J. (2019). Sports medicine & outpatient orthopedics. In A. Luke, & C. B. Ma (Eds.), Current Medical
Diagnosis and Treatment 2019 (p. 1704). New York: McGraw-Hill Education.
7. A 66-year-old Hispanic female presents with a two-year history of detrusor overactivity or “urge
incontinence. She has been treated by a physical therapist with bladder training therapy for one year,
buts fail to provide appropriate relief. The next possible treatment would be:
A. Tolterodine 1-2 mg orally 2x daily
B. Oxybutynin 2.5 – 5mg orally 2-3x daily
C. Refer to OB/Gyn for a pessary fitting
D. All of the above
Antimuscarinic agents such as tolterodine or oxybutynin may provide additional benefit in stress incontinence issues. These
medications must be used with caution due to the side effects of dry mouth, urine retention, and delirium. A pessary may also be of
additional benefit but should be prescribed only by providers who are experienced in the selection, placement, and management
of these devices.
Harper G, & Johnston C, & Landefeld C (2021). Overview: geriatric disorders. Papadakis M.A., & McPhee S.J., & Rabow
M.W.(Eds.), Current Medical Diagnosis & Treatment 2021. McGraw-Hill. https://accessmedicine-mhmedicalcom.libproxy.usouthal.edu/content.aspx?bookid=2957§ionid=249362728
8. A 23-year-old male patient presents to the clinic with complaints of fever, irritative voiding symptoms,
and perineal/suprapubic pain for 2 days. On exam, the CBC shows leukocytosis and a left shift. UA is
positive for pyuria and bacteriuria. There is no CVA tenderness or painful scrotal enlargement. The NP
suspects the patient has which of the following diagnosis?
A. Acute Bacterial Prostatitis
B. Chronic Bacterial Prostatitis
C. Acute Epididymitis
D. Prostatodynia
Acute Bacterial Prostatitis presents with fever, irritative voiding symptoms, perineal and/or suprapubic pain, and a positive UA.
Chronic bacterial prostatitis does not present with fever or a positive UA. Acute epididymitis will present with painful scrotal
swelling due to enlargement of the epididymitis. Prostatodynia is a noninflammatory disorder presenting with a normal UA and no
fever (Papadakis & McPhee, 2019, p. 970-973).
Papadakis, M.A., McPhee, S.J. (2019). Urologic Disorders. In M.V., Wang, T.J., Walsh, & T.D.,
Chi (Eds.), Current medical diagnosis & treatment (58th ed., pp. 970 - 973). United States of America: McGraw-Hill Education.
9. A 24-year-old female who identifies as a lesbian, presents for her annual wellness visit. She has
multiple female sexual partners. She did not receive the HPV vaccine and has not had a cervical cancer
screening since she was 21 years old. Which of the following is not recommended in the treatment plan
for this patient?
A. HPV vaccination series
B. Papanicolaou (PAP) smear with HPV co-testing
C. Chlamydia trachomatis and Neisseria gonorrhea testing
D. Screen for Intimate Partner Violence (IPV)
Chlamydial infections were higher in 14- to 24-year-old women who reported same-sex behavior when compared with exclusively
heterosexual women. Untreated chlamydial infection places a woman’s future fertility at risk due to potential tubal occlusion. Some
women who have a chlamydia infection do not have symptoms. Secondary sequelae of chlamydia include intra-abdominal
abscesses, chronic pain, and the need for multiple surgeries. Regardless of sexual orientation, the CDC recommends
annual Chlamydia trachomatis (and Neisseria gonorrheae) screening from the age of first sexual activity to the age of 25 years for
all women. Compared to heterosexual women, lesbians and bisexual women have higher exposure to violence throughout their
lifetimes. The lifetime prevalence of sexual assault may be as high as 85%. It is essential to screen all women for IPV but especially
those in the LGBTQ community due to these alarming statistics. The primary prevention of cervical cancer is essential. All females
between the ages of 12 and 26 years should receive the HPV vaccine series even if they never have been or plan to be sexually
active with men. HPV is transmitted sexually between lesbian or heterosexual partners. The rate of HPV immunization among
lesbians is significantly less than for heterosexual women, which creates a health disparity that needs to be corrected. While she is
due for a PAP smear, the PAP with HPV co-testing is not recommended in women under the age of 30 years old.
Reference: Maliver, J. O., Robertson, P. A., Ard, K. L., Mayer, K. H., & Deutsch, M. B. (2019). Lesbian, Gay Bisexual, & Transgender
Health. In Papadakis, M. A., & McPhee, S. J. (Eds.) Current Diagnosis & Treatment 2019 (58th ed., pp. 1722-1742). McGraw-Hill
Education.
10. All of the following can help reduce the risk of adolescents developing STIs EXCEPT:
A. a monogamous sexual relationship with one partner
B. the use of a condom
C. abstinence
D. birth control
Abstinence, a monogamous sexual relationship with one partner, and proper condom use has shown to reduce the risk of adolescents
developing sexually transmitted infections. On the other hand, birth control only helps to prevent pregnancy and does not offer any
protection against STIs.
Reirden, D. H., & Nyquist, A. (2018). Sexually transmitted infections. In W. W. Hay, M. J. Levin, R. R. Deterding, & M. J. Abzug
(Eds.), Current diagnosis & treatment pediatrics (24th ed., pp. 1351-1372). McGraw Hill Education.
11. A 57-year-old female comes into the clinic with complaints of hot flashes and vaginal dryness. She is
a smoker and has hypertension. When giving her hormone replacement options, the NP informs her
best option is:
A. Oral estrogen
B. Oral estrogen with progesterone
C. Estradiol injections
D. Transdermal estrogen [Show Less]