A 12-year-old male presents with his father for a routine Whelchel visit. The father asked to speak to you privately, as he's concerned that his son is, quote, showing some body changes. Close quote during the visit, the child is alert, interactive with physical exam findings consistent with Tanner's Stage three sexual maturation. He remains on his growth curve for height and weight.

When discussing these findings with the father, which of the following is the most accurate statement?

A. These findings are normal for his age.

B. This is an unusual finding in a 12-year-old.

C. This signals he is likely nearly his adult height.

D. He just started puberty changes.

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A seven year old with a diagnosis of asthma since age to present with his parents for a new patient visit. He has cough, wheezing and shortness of breath 4 to 5 days per week and awakens with asthma symptoms about once weekly. His parents states when he's playing soccer, sometimes he needs to stop running because of his cough. So last visit with his prior PCP was about seven months ago when he was prescribed, according to his parents quote, "a pill to take every day to help control his cough". His last dose of this medication was about two months ago because the medication had no refills.

He's currently using albuterol as needed. Two puffs, about 3 to 4 times a day. About. Five days per week to help control his cough and shortness of breath. The medication, per his parent quote, "works pretty well most times". The child is currently feeling well without evidence of acute asthma exacerbation. He is alert oriented, talkative, and able to demonstrate adequate inhaler technique. Peak expiratory flow rate is approximately 60% a predictor.

Which of the following is an appropriate preferred treatment option for this child?

A. Continue current therapy as it is providing adequate symptom control.

B. They begin low dose ICS formoterol therapy, as maintenance and reliever therapy or marked therapy.

C. Begin daily montelukast albuterol as needed.

D. Begin nebulizer budesonide twice daily with nebulizer albuterol as needed.

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A healthy 12 month old child is scheduled for a routine well, child's visit and age appropriate immunizations in three days. The parent message is the nurse practitioner and ask, quote, my mother told me to give her some acetaminophen Tylenol before she gets her shots. That way she won't be uncomfortable afterwards. I want to check with you first. Is this a good idea?

A. Give acetaminophen about one hour before the appointment to relieve to prevent fever and injection site discomfort.

B. If she develops a fever or discomfort after the vaccines, you can give her an age and weight appropriate dose of acetaminophen as needed.

C. Give ibuprofen at the time of the vaccinations and continue it every six hours for the first 24 hours.

D. Try to avoid acetaminophen and ibuprofen for at least 48 hours after the vaccines, so that they can work as well as possible.

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According to the latest American College of Cardiology and American Heart Association dyslipidemia guidance, in which of the following patients is it most appropriate to obtain a lipoprotein A level?

A. A twenty-eight-year-old woman with obesity and polyendocrine metabolic ovarian syndrome, formerly known as PCOS, whose father had a myocardial infarction at age 48.

B. A 47-year-old man with well-controlled hypertension for the past five years, without a family history of early cardiovascular disease and an LDL cholesterol of 92

C. A 35-year-old woman with episodic migraine since age 12 and an LDL of 72 who exercises regularly.

D. A 52-year-old man with triglycerides of 320 related to uncontrolled type 2 diabetes.

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A 55-year-old man is seen in follow up six weeks post hospitalization for acute coronary syndrome with drug eluding stent placement, has a 40-pack-year cigarette smoking history and currently smokes two packs of cigarettes per day. His medical history is also significant for stage 3-A CKD, with current estimated GFR of 52. His medications include high-intensity statin therapy and ezetimibe or Zetia, along with standard post ACS and CKD therapies. He states he's feeling well and taking all his medications as advised without adverse effects. Laboratory results today reveal an LDL cholesterol of 98, HDL of 35, triglycerides of 154.

Which of the following is the most appropriate next step in lipid management?

A. As he is feeling well, an LDL cholesterol is post ACS goal. Continue current therapy.

B. Due to his GFR, discontinue Zetia and substitute with bempedoic acid.

C. Add a PCSK9 inhibitor to current regimen.

D. Advise that moderate intensity statin therapy is preferred in stage 3-A CKD.

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A 29-year-old patient presents with a genital lesion he first noted five days ago. The patient reports a new sex partner for the past four weeks with infrequent condom use. He denies dysuria, fever, urinary frequency, abdominal or scrotal pain, or penile discharge. Examination reveals a single well-defined ulcer on the shaft of the penis. The lesion is painless with a clear base and no purulent discharge. Mild non-tender inguinal lymphadenopathy is present. This clinical presentation is most consistent with:

A. genital herpes

B. primary syphilis

C. chancroid

D. Secondary syphilis

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A 75-year-old woman presents to the urgent care service of her primary care provider's practice for a sick visit with a chief complaint of a two-day history of dysuria, urinary frequency, and urgency. She denies fever, flank pain, nausea, or vomiting. Her past medical history includes hypertension, stage three ACKD, and dyslipidemia. Current medications include an ARB, thiazide diuretic, statin, and an SGLT2i. Vital signs are stable. Physical exam is unremarkable except for mild suprapubic tenderness. Laboratory results include the following: Urinalysis, positive for leukocyte esterase and nitrites. Reference lab is negative for those substances. Estimated GFR is 48, Serum potassium is 4.8.

Which of the following is the most appropriate treatment?

A. Trimethoprim sulfamethoxazole DS

B. Nitrofurantoin

C. Ciprofloxacin

D. Amoxicillin

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A 38-year-old woman presents for a sick visit with a two-day history of, "not feeling right. I've never felt like this before." Approximately four days ago, she self-discontinued a standard dose SSRI after taking this medication for the past 18 months, stating, "I feel like my depression had gotten much better." She denies alcohol or recreational drug use. When considering the diagnosis of antidepressant discontinuation syndrome, which of the following is most likely to be reported?

A. tremor, diaphoresis, tachycardia, hypertension, agitation

B. yawning, rhinorrhea, abdominal cramping, diarrhea, piloerection

C. dizziness, nausea, body aches, sleep disturbance, irritability, brief vibrating sensations

D. restlessness, sweating, diarrhea, tremor, fever, and involuntary muscle jerking

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