EXAMPREPCONNECT (LEIK) QUESTION PRACTICE Flashcards

Question

When might referral to an otolaryngologist be necessary?

Answer 1

In severe cases with concern for complications or if the infection does not respond to initial antibiotic therapy.

Answer 2

Antibiotic ear drops.

Answer 3

Antibiotic ear drops, such as ofloxacin.

Answer 4

Systemic oral antibiotics to effectively target the middle ear infection.

Answer 5

Cerumenolytic agents are used to soften or dissolve earwax.

Answer 6

The standard method involves using cerumenolytic agents followed by gentle irrigation.

Answer 7

Symptoms include hearing loss, sensation of fullness, and discomfort.

Answer 8

It is typically recommended as the first line of treatment for uncomplicated cases of cerumen impaction in the primary care setting.

Answer 9

Referral may be considered if the cerumen impaction does not respond to initial treatment, if there are complications, or if there is a contraindication to irrigation.

Answer 10

No, antibiotics are not indicated because cerumen impaction is not caused by an infection.

Answer 11

It is not recommended due to the risk of pushing the wax further into the ear canal, potentially exacerbating impaction or causing damage.

Answer 12

A curet is typically used to draw the cerumen out of the canal.

Answer 13

A painless, firm nodule on the eyelid resulting from the blockage of a meibomian gland.

Answer 14

The initial management includes the application of warm compresses several times a day followed by gentle lid massage.

Answer 15

They help to facilitate drainage and resolution of the lesion.

Answer 16

Most chalazia resolve within a few weeks.

Answer 17

It is considered for chalazia that do not respond to conservative treatment, significantly obstruct vision, or for cosmetic reasons after several months.

Answer 18

No, antibiotics are not required as a chalazion is not primarily an infectious condition.

Answer 19

firm nodule on the eyelid is characteristic of a chalazion

Answer 20

Persistent facial pain and pressure, purulent nasal discharge, diminished sense of smell, and mild fever.

Answer 21

Antibiotic therapy is recommended for patients with moderate illness, immunocompromise, or unresolved symptoms after 7 days.

Answer 22

Oral amoxicillin-clavulanate.

Answer 23

It is effective against common pathogens and can counteract beta-lactamase-producing bacteria.

Answer 24

Oral antihistamines and avoidance of allergens. NOTE: If patient have used OTC Antihistamine and the symptom persist, impacting life, sleep and daily activities, intranasal corticosteroids are needed. B. Intranasal corticosteroids Intranasal corticosteroids are the first-line treatment for mild to moderate allergic rhinitis because of their efficacy in reducing inflammation and controlling a wide range of symptoms, including nasal congestion, sneezing, and itchy eyes. They are recommended for long-term use and provide comprehensive symptom relief. Oral corticosteroids are not advised for the routine, long-term management of allergic rhinitis due to potential systemic side effects. They may be reserved for short-term use in severe exacerbations. While potentially beneficial as a supportive treatment, nasal saline irrigation is unlikely to be as effective as intranasal corticosteroids in controlling the underlying inflammation and the full spectrum of allergic rhinitis symptoms. Oral decongestants may temporarily relieve nasal congestion but do not address the underlying inflammation, and they are not recommended for long-term use due to potential side effects like hypertension and insomnia.

Answer 25

They are used in the management of asthma and allergic rhinitis to reduce inflammation.

Answer 26

They may provide temporary relief from nasal congestion but will not address the infection.

Answer 27

The duration should be limited to 3 days due to the risk of rebound congestion.

Answer 28

severe sore throat

Answer 29

Sudden-onset high fever, severe sore throat, difficulty swallowing, muffled voice, preference for sitting upright in a 'tripod' position, drooling, and difficulty speaking.

Answer 30

A life-threatening condition characterized by inflammation and swelling of the epiglottis, leading to potential airway obstruction.

Answer 31

To manage the risk of airway obstruction.

Answer 32

It may cause sore throat, fever, and difficulty swallowing, but does not lead to acute airway compromise or the characteristic posture seen in epiglottitis.

Answer 33

Sore throat and fever, but generally not severe airway obstruction symptoms or urgent presentation.

Answer 34

Drooling and the need to adopt a 'tripod' position.

Answer 35

It leads to voice changes and difficulty swallowing but typically presents more gradually and does not cause acute onset of symptoms.

Answer 36

Gradual loss of peripheral vision, history of elevated intraocular pressure, and optic disc cupping. ## Footnote This form of glaucoma progresses slowly and is often asymptomatic in its early stages.

Answer 37

Family history of glaucoma.

Answer 38

Sudden increase in intraocular pressure due to a narrow or closed anterior chamber angle, leading to rapid onset of eye pain, redness, blurred vision, and sometimes nausea or vomiting.

Answer 39

Blurred vision, difficulty with glare, halos around lights, and faded colors. ## Footnote Cataracts often present with cloudiness of the eye upon examination.

Answer 40

Cataracts do not cause elevated intraocular pressure or optic disc cupping.

Answer 41

Sudden appearance of floaters, flashes of light, and a shadow or 'curtain' descending over the field of vision.

Answer 42

Topical permethrin cream is effective in eliminating mites and eggs.

Answer 43

No, antibiotics such as doxycycline are not effective against scabies.

Answer 44

No, antifungals such as terbinafine are not effective against scabies.

Answer 45

No, while it may provide relief for itching, it will not eradicate the mites and eggs.

Answer 46

A lesion on the lower lip that has not healed for more than 2 months.

Answer 47

As a persistent rough patch that sometimes bleeds while eating.

Answer 48

The patient has a history of spending extensive time outdoors.

Answer 49

A flat, scaly area with slightly raised edges that does not extend beyond the border of the lip.

Answer 50

B. Squamous cell carcinoma (SCC) ## Footnote The description of a persistent, rough patch on the lip that bleeds, coupled with significant sun exposure history, strongly suggests SCC.

Answer 51

BCC typically presents as a pearly or waxy bump, often with visible blood vessels, on sun-exposed areas. ## Footnote BCC typically presents as a pearly or waxy bump, often with visible blood vessels, on sun-exposed areas of the body. it is less likely to occur on the lips than SCC and usually does not present as a flat, scaly patch.

Answer 52

Melanoma is known for its rapid changes and aggressive behavior, often identified by the ABCDE criteria. ## Footnote (Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolution). While melanoma can occur on the lip, the described lesion does not exhibit these typical characteristics. Actinic keratosis is a precancerous skin condition that appears as rough, scaly patches on sun-exposed areas of the skin. While it can potentially progress to SCC, the presence of a persistent lesion that bleeds makes SCC a more likely diagnosis.

Answer 53

A precancerous skin condition that appears as rough, scaly patches on sun-exposed areas of the skin.

Answer 54

Inject the anesthetic intradermally around the borders of the foreign body. ## Footnote This creates a field block, numbing the immediate area while preserving tactile sensation.

Answer 55

It can cause more pain and complications. ## Footnote Superficial procedures do not require deep muscle anesthesia.

Answer 56

They may not provide sufficient depth of anesthesia. ## Footnote Topical anesthetics only numb the skin's surface.

Answer 57

No, it is not a standard practice. ## Footnote Intravenous administration is not used for numbing localized areas.

Answer 58

The patient has a history of atopic dermatitis since infancy.

Answer 59

The patient has tried high-potency topical corticosteroids, topical calcineurin inhibitors, and diligent moisturizing routines.

Answer 60

The lesions are widespread, covering more than 30% of the body, with significant lichenification, excoriation, and occasional weeping.

Answer 61

The patient's quality of life is severely impacted, with sleep disturbances, frequent work absences, and social withdrawal.

Answer 62

Laboratory tests reveal a recent history of recurrent bacterial skin infections.

Answer 63

A. Dupilumab subcutaneously every 2 weeks after a loading dose ## Footnote For a patient with severe, refractory atopic dermatitis, biologic therapy such as dupilumab can be considered.

Answer 64

Dupilumab is a monoclonal antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling.

Answer 65

Patients receive a weight-based loading dose followed by injections every 2 weeks (or 4 weeks for patients weighing less than 30 kg).

Answer 66

Methotrexate is an immunosuppressive drug that may increase the risk of further infections due to the patient's history of recurrent bacterial skin infections.

Answer 67

No, isotretinoin is primarily used for severe acne and is not a standard treatment for atopic dermatitis.

Answer 68

A continuous 3-month antibiotic regimen could lead to antibiotic resistance, disruption of normal skin and gut microbiota, and other potential side effects.

Answer 69

Effectively managing the underlying atopic dermatitis with appropriate therapies can help reduce the risk of secondary bacterial infections. ## Footnote A young adult patient with a history of atopic dermatitis since infancy presents to the clinic. Despite multiple interventions, including high-potency topical corticosteroids, topical calcineurin inhibitors, and diligent moisturizing routines, the patient continues to experience severe flare-ups. The lesions are widespread, covering more than 30% of the body, with significant lichenification, excoriation, and occasional weeping. The patient's quality of life is severely impacted, with sleep disturbances, frequent work absences, and social withdrawal. Laboratory tests reveal a recent history of recurrent bacterial skin infections. Given the refractory nature of the atopic dermatitis and the patient's clinical presentation, which of the following treatment regimens would be most appropriate to consider next? A. Dupilumab subcutaneously every 2 weeks after a loading dose B. Methotrexate 15 mg once weekly C. Isotretinoin 0.5 mg/kg per day D. Continuous oral antibiotics for 3 months Answer: A. Dupilumab subcutaneously every 2 weeks after a loading dose For a patient with severe, refractory atopic dermatitis, especially one who has not responded to conventional treatments, biologic therapy such as dupilumab can be considered. Dupilumab is a monoclonal antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling and has been approved for moderate-to-severe atopic dermatitis in adolescents and adults. Patients receive a weight-based loading dose followed by injections every 2 weeks (or 4 weeks for patients weighing less than 30 kg). Methotrexate is an immunosuppressive drug that can be used for atopic dermatitis, but given the patient's history of recurrent bacterial skin infections, immunosuppressive therapy may increase the risk of further infections. Isotretinoin is primarily used for severe acne and is not a standard treatment for atopic dermatitis. While secondary bacterial infection requires treatment, a continuous 3-month antibiotic regimen would be unusually long and could lead to antibiotic resistance, disruption of normal skin and gut microbiota, and other potential side effects. Moreover, effectively managing the underlying atopic dermatitis with appropriate therapies can help reduce the risk of secondary bacterial infections.

Answer 70

A small, flesh-colored, slightly raised bump that is smooth to the touch.

Answer 71

Several years.

Answer 72

It has remained stable in size and appearance, is not painful or itchy.

Answer 73

Approximately 5 mm.

Answer 74

Dermatofibroma ## Footnote The description strongly suggests a dermatofibroma, which is a benign skin lesion.

Answer 75

BCC typically presents as a pearly or waxy bump, often with visible blood vessels, on sun-exposed areas.

Answer 76

SCC often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.

Answer 77

Melanoma is known for its rapid changes and aggressive behavior, often identified by the ABCDE criteria. ## Footnote An adult patient comes to the clinic with a skin lesion on the back that has been present for several years. The lesion has remained stable in size and appearance. The patient describes it as a small, flesh-colored, slightly raised bump that is smooth to the touch. It is not painful or itchy. The patient has no significant past medical history and no history of extensive sun exposure. On examination, the lesion measures approximately 5 mm in diameter, is well-circumscribed, and has a pearly appearance. Based on this presentation, which of the following is the most likely diagnosis? A. Basal cell carcinoma (BCC) B. Squamous cell carcinoma (SCC) C. Melanoma D. Dermatofibroma Answer: D. Dermatofibroma The description of a small, flesh-colored, slightly raised bump that has remained stable in size and appearance over several years and is smooth to the touch strongly suggests a dermatofibroma. Dermatofibromas are benign skin lèsions that are commonly found on the extremities or trunk. BCC typically presents as a pearly or waxy bump, often with visible blood vessels, on sun-exposed areas of the body. While the patient's lesion has a pearly appearance, the stability over several years without changes in size or symptoms is not characteristic of BCC. SCC often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface. Melanoma is known for its rapid changes and aggressive behavior, often identified by the ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolution).

Answer 78

The patient has had a persistent wart for the past 6 months.

Answer 79

The patient has tried over-the-counter salicylic acid treatments with no significant improvement.

Answer 80

The wart is a well-defined, 1-cm, thickened, rough lesion on the weight-bearing area of the sole with black pinpoint dots.

Answer 81

The patient mentions that it is painful when they walk.

Answer 82

The patient is eager to find a solution that will provide relief and is open to more aggressive treatment options.

Answer 83

Recommend cryotherapy with liquid nitrogen. ## Footnote Cryotherapy can be effective for warts that have not responded to other treatments and is especially useful for thicker warts on the soles of the feet.

Answer 84

Duct tape occlusion has inconsistent efficacy and is likely not the best choice for a wart that has been resistant to other treatments.

Answer 85

No, high-potency topical corticosteroids are not typically used for the treatment of warts.

Answer 86

Surgical excision is usually reserved for warts that have resisted all other treatments and is not the first-line option due to the risk of scarring and potential complications. ## Footnote An adult patient reports a persistent wart on the sole of the foot for the past 6 months. They have tried over-the-counter salicylic acid treatments with no significant improvement. Examination reveals a well-defined, 1-cm, thickened, rough lesion on the weight-bearing area of the sole with black pinpoint dots. The patient mentions that it is painful when they walk. The patient is eager to find a solution that will provide relief and is open to more aggressive treatment options. Given the location, size, and resistance to initial treatment, which of the following interventions would be the most appropriate next step? A. Apply a duct tape occlusion for 6 weeks B. Recommend cryotherapy with liquid nitrogen C. Prescribe a high-potency topical corticosteroid D. Advise surgical excision Answer: B. Recommend cryotherapy with liquid nitrogen The presentation is consistent with a plantar wart. Given its location on a weight-bearing area, its size, and its resistance to over-the-counter treatments, cryotherapy with liquid nitrogen is a suitable option. Cryotherapy can be effective for warts that have not responded to other treatments and is especially useful for thicker warts on the soles of the feet. Duct tape occlusion is a home remedy that has been suggested for warts, but its efficacy is inconsistent, and it is likely not the best choice for a wart that has been resistant to other treatments. High-potency topical corticosteroids are not typically used for the treatment of warts and are more appropriate for inflammatory skin conditions. Surgical excision is usually reserved for warts that have resisted all other treatments and is not the first-line option due to the risk of scarring and potential complications.

Answer 87

The patient is employed as a dental hygienist.

Answer 88

The patient reported a painful lesion that is swollen and red with small vesicles filled with clear fluid.

Answer 89

The patient treated an individual who reported an oral herpes outbreak the day after treatment.

Answer 90

B. Herpetic whitlow

Answer 91

Herpetic whitlow is a viral infection caused by the herpes simplex virus (HSV), presenting as painful vesicular lesions on the fingers or thumbs.

Answer 92

It presents with painful vesicular lesions on an erythematous base.

Answer 93

Bacterial paronychia is characterized by redness, swelling, and tenderness around the nail bed, often with pus collection, while herpetic whitlow has vesicles filled with clear fluid.

Answer 94

Contact dermatitis presents with erythema, itching, and possibly vesicles in response to contact with an allergen or irritant.

Answer 95

Fungal infections (tinea manuum) typically present with scaly, itchy patches and may involve the nails but do not present with acute vesicular lesions. ## Footnote An adult patient presents with a painful lesion on their thumb. The patient, who is employed as a dental hyglenist, reports the onset of symptoms a few days after accidentally pricking the thumb with a dental instrument. The lesion is swollen and red and has small vesicles filled with clear fluid. The patient denies any recent fever, malaise, or respiratory symptoms. There is no history of similar lesions in the past. When asked to provide details about occupational exposure risks, the patient mentions recently treating an individual who reported an oral herpes outbreak the day after treatment. What is the most likely diagnosis? A. Bacterial paronychia B. Herpetic whitlow C. Contact dermatitis D. Fungal infection Answer: B. Herpetic whitlow Herpetic whitlow is a viral infection caused by the herpes simplex virus (HSV), presenting as painful vesicular lesions on the fingers or thumbs. It can occur in individuals with a history of HSV infection due to direct inoculation of the virus into the skin of the digit. The patient's risk of occupational exposure helps support the diagnosis of herpetic whitlow. The characteristic vesicles on an erythematous base are typical of this condition. Bacterial paronychia is an infection of the periungual skin and is characterized by redness, swelling, and tenderness around the nail bed, often with pus collection. While occupational exposure could predispose to bacterial infection, the presence of vesicles filled with clear fluid is more indicative of a viral etiology than a bacterial etiology. Contact dermattis presents with erythema, itching, and possibly vesicles in response to contact with an allergen or irritant. However, it typically does not present with localized vesicular lesions and is less likely to be as acutely painful as herpetic whitlow. Also, the patient does not have a clear history of exposure to new substances. Fungal infections of the hand (tinea manuum) typically present with scaly, itchy patches and may involve the nails (onychomycosis, but they do not typically present with acute vesicular lesions.

Answer 96

Itchy, red sores on the face and arms that began as small blisters and progressed to yellow-crusted patches.

Answer 97

One of the child's classmates recently had a similar skin issue.

Answer 98

Honey-colored crusts surrounded by erythema.

Answer 99

The child has no fever and no history of recent illness or medication changes.

Answer 100

Topical mupirocin ## Footnote The patient's presentation is suggestive of impetigo, characterized by honey-colored crusts. Mupirocin ointment is first-line for localized infections.

Answer 101

For severe cases or when the infection is widespread.

Answer 102

Viral infections, such as herpes simplex virus.

Answer 103

Fungal infections. ## Footnote 6-year-old patient presents with complaints of itchy, red sores on their face and arms. The caregiver indicates that the lesions began as small blisters and have progressed to form yellow-crusted patches over the past few days. They also report that one of the child's classmates recently had a similar skin issue. On examination, the nurse practitioner notes the presence of honey-colored crusts surrounded by erythema. The child has no fever, and there is no history of recent illness or medication changes. Based on this presentation, which of the following is the most likely treatment? A. Oral amoxicillin B. Oral acyclovir C. Topical clotrimazole D. Topical mupirocin Answer: D. Topical mupirocin The patient's presentation is suggestive of impetigo, a common skin infection that is characterized by its distinct appearance of honey-colored crusts. For localized infections, the first-line treatment is mupirocin ointment. It is effective against the bacteria typically responsible for the condition, including Staphylococcus aureus and Streptococcus pyogenes, and directly targets the infection site. While oral amoxicillin might be used for severe cases of impetigo or when the infection is widespread, the patient's presentation suggests a localized infection, making topical treatment with mupirocin more appropriate. Oral acyclovir is an antiviral medication used to treat viral infections, such as herpes simplex virus. Topical clotrimazole is an antifungal.

Answer 104

It is an acute skin condition often triggered by infections or medications. ## Footnote EM presents as target-like lesions on the skin.

Answer 105

No, it is not a chronic condition; it is self-limited and mild cases typically resolve on their own.

Answer 106

It is frequently triggered by viral infections, especially herpes simplex virus, or by certain medications.

Answer 107

Hospitalization may be required for more severe cases, but it is not needed in almost all cases.

Answer 108

No, while infections are a common trigger, viral infections, especially with herpes simplex virus, are most commonly associated with the condition. ## Footnote learn more. Which of the following statements accurately describes erythema multiforme (EM)? A. It is a chronic skin condition that persists throughout life. B. It is a skin condition primarily caused by bacterial infection. C. It is an acute skin condition often triggered by infections or medications. D. It is a skin condition that requires hospitalization in almost all cases. Answer: C. It is an acute skin condition often triggered by infections or medications. EM is an acute, immune-mediated skin condition that often presents as target-like lesions on the skin. It is frequently triggered by viral infections, especially herpes simplex virus, or by certain medications. EM is not a chronic condition; it is self-limited, and mild cases typically resolve on their own. For more severe cases, corticosteroids or, occasionally, hospitalization may be required. While infections are a common trigger for EM, viral infections, especially with herpes simplex virus, are most commonly associated with the condition, not bacterial infections.

Answer 109

A new skin lesion on the right shoulder.

Answer 110

Over the past 6 months.

Answer 111

1 cm. ## Footnote Melanoma diameter is greater than 6 mm and here it is 1 cm. 1cm is greater than 6 mm.

Answer 112

Irregular borders, varies in color from tan to dark brown, and occasionally bleeds.

Answer 113

Significant sun exposure without adequate sun protection in past years.

Answer 114

It is asymmetrical, has a diameter of 1 cm, and exhibits color variegation.

Answer 115

Melanoma ## Footnote The lesion exhibits asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolution over time.

Answer 116

Asymmetry, Border irregularity, Color variation, Diameter > 6mm, Evolution.

Answer 117

As a pearly or waxy bump, often with visible blood vessels.

Answer 118

As a firm, red nodule or a flat lesion with a scaly, crusted surface.

Answer 119

A precancerous skin lesion that appears as a rough, scaly patch on sun-exposed skin. ## Footnote An older adult patient presents to the clinic with concerns about a new skin lesion on the right shoulder. The patient reports that the lesion has been growing in size over the past 6 months. It is now approximately 1 cm in diameter, has irregular borders, varies in color from tan to dark brown, and occasionally bleeds. The patient admits to significant sun exposure without adequate sun protection in past years. On physical examination, the lesion is asymmetrical, with a diameter of 1 cm, and exhibits color variegation. Based on this presentation, which of the following is the most likely diagnosis? A. Basal cell carcinoma (BCC) B. Squamous cell carcinoma (SCC) C. Melanoma D. Actinic keratosis Answer: C. Melanoma The patient's lesion exhibits several characteristics that align with melanoma, including asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolution over time. These features are summarized by the ABCDE criteria for melanoma (Asymmetry, Border irregularity, Color variation, Diameter > 6mm, Evolution). The history of significant sun exposure and the lesion's tendency to bleed further support the likelihood of melanoma. BCC typically presents as a pearly or waxy bump, often with visible blood vessels, and may ulcerate but usually does not exhibit the same degree of color variation or rapid evolution as melanoma. SCC often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface. While it can grow and evolve, the specific description of color variation and the ABCDE criteria more strongly suggest melanoma. Actinic keratosis is a precancerous skin lesion that appears as a rough, scaly patch on sun-exposed skin. While it can potentially progress to SCC, its presentation does not typically include the significant color variation seen in this patient.

Answer 120

B. Punch biopsy ## Footnote A punch biopsy removes a cylindrical core of tissue, including the epidermis, dermis, and superficial fat.

Answer 121

A punch biopsy captures a full-thickness sample of skin, including the epidermis, dermis, and superficial fat.

Answer 122

A shave biopsy involves shaving off the top layers of the skin and may not capture the full depth of certain lesions.

Answer 123

Fine-needle aspiration is used mainly for sampling cells from masses or cysts.

Answer 124

The scraping technique is often used for superficial skin infections like fungal conditions. ## Footnote An adult patient presents with an atypical mole on the lower back that has been gradually changing in appearance over the last few months. The patient consents to a skin biopsy for further examination. What technique is most appropriate for a full-thickness, definitive biopsy of this lesion? A. Shave biopsy B. Punch biopsy C. Fine-needle aspiration D. Scraping technique Answer: B. Punch biopsy A punch biopsy is the recommended method for obtaining a full-thickness, definitive biopsy of an atypical skin lesion. This technique removes a cylindrical core of tissue, which includes the epidermis, dermis, and superficial fat, making it ideal for diagnosing various skin conditions, especially when the depth of the lesion is clinically relevant. Shave biopsy, on the other hand, typically involves shaving off the top layers of the skin and might not capture the full depth of certain lesions. Fine-needle aspiration is used mainly for sampling cells from masses or cysts and would not provide a full-thickness skin sample. The scraping technique is often used for superficial skin infections like fungal conditions, and it is not appropriate for a definitive biopsy of a skin lesion.

Answer 125

The condition is consistent with pityriasis rosea.

Answer 126

The patient reports itching and slight fatigue.

Answer 127

Recommend over-the-counter hydrocortisone cream and oral antihistamines. ## Footnote This treatment helps alleviate symptoms, especially itching.

Answer 128

Pityriasis rosea typically resolves within 6 to 8 weeks.

Answer 129

A topical antifungal cream would be inappropriate.

Answer 130

Tinea corporis (ringworm) is treated with a topical antifungal cream.

Answer 131

Tinea corporis presents as a circular, red, raised rash with a clear center.

Answer 132

Topical antibiotic ointment is used for bacterial skin infections, such as impetigo.

Answer 133

Impetigo can manifest as honey-colored crusts on the skin.

Answer 134

No, oral antivirals are not among the typical treatment options for pityriasis rosea. ## Footnote An adult patient reports discovering a single large, oval-shaped, salmon-colored patch on their trunk a week ago. The patient now presents with a "Christmas tree" pattern of smaller similar lesions on the back. The patient reports itching and slight fatigue but has no other systemic symptoms. Which of the following treatment strategies would be most appropriate for the suspected condition? A. Prescribe a topical antifungal cream B. Recommend over-the-counter hydrocortisone cream and oral antihistamines C. Advise the application of an over-the-counter topical antibiotic ointment D. Initiate a course of oral antiviral medication Answer: B. Recommend over-the-counter hydrocortisone cream and oral antihistamines The patient's presentation is consistent with pityriasis rosea, a self-limiting rash that typically resolves on its own within 6 to 8 weeks. The primary goal of treatment is to alleviate symptoms, especially itching. Over-the-counter hydrocortisone cream and oral antihistamines can help manage the itchiness associated with pityriasis rosea. Exposure to ultraviolet light may also be helpful. A topical antifungal cream would be more appropriate for conditions like tinea corporis (ringworm), which presents as a circular, red, raised rash with a clear center. Topical antibiotic ointment is used for bacterial skin infections, such as impetigo, which can manifest as honey-colored crusts on the skin. Although some research has supported viral exposure as the cause of pityriasis rosea, oral antivirals are not among the typical treatment options.

Answer 135

Persistent facial redness, flushing, papules, and pustules on the cheeks and nose.

Answer 136

Consumption of spicy food and exposure to sun or high temperatures.

Answer 137

Central facial erythema, visible blood vessels, and several papules and pustules without comedones.

Answer 138

Topical metronidazole ## Footnote This is effective in reducing inflammation, erythema, and papulopustular lesions associated with rosacea.

Answer 139

Their side effects generally make them poor choices for initial management.

Answer 140

They can exacerbate facial redness and lead to worsening of the condition over time. ## Footnote The nurse practitioner is managing the care of an adult who presents with persistent facial redness, flushing, and the presence of papules and pustules on the cheeks and nose. The patient reports that the symptoms worsen with consumption of spicy food and exposure to sun or high temperatures. Physical examination reveals central facial erythema, visible blood vessels, and several papules and pustules without comedones. Which of the following treatments is the most appropriate initial approach to managing the condition? A. Oral clindamycin B. Oral isotretinoin C. Topical metronidazole D. High-potency topical corticosteroid Answer: C. Topical metronidazole The patient's presentation of central facial erythema, papules, pustules, and telangiectasias, aggravated by specific triggers, is suggestive of rosacea. Topical metronidazole is effective in reducing inflammation, erythema, and the papulopustular lesions associated with this condition, making it an appropriate first-line treatment. Oral antibiotics and oral isotretinoin are sometimes prescribed for more severe cases that do not respond to more conservative measures, but their side effects generally make them poor choices for initial management. High-dose topical corticosteroids can exacerbate facial redness and lead to worsening of the condition over time, especially in conditions like rosacea.

Answer 141

A tender, swollen, and red area on the forearm that began as a small insect bite.

Answer 142

The lesion is fluctuant, approximately 2.5 cm in diameter, with a central area of purulence, and the overlying skin is warm and erythematous.

Answer 143

Perform incision and drainage and prescribe oral antibiotics.

Answer 144

It removes the purulent material, provides relief, and addresses the infection directly.

Answer 145

Oral antibiotics to address surrounding cellulitis and prevent further spread of the infection.

Answer 146

Topical antibiotics are not sufficient for treating a skin abscess of this size and depth.

Answer 147

It would not address the underlying infection and could potentially exacerbate the condition by suppressing local immune responses. ## Footnote An adult patient presents with a 5-day history of a tender, swollen, and red area on the forearm. The patient reports that it began as a small insect bite but has since grown in size. The patient has been afebrile, but the lesion has become increasingly painful. On examination, the lesion is fluctuant, measures approximately 2.5 cm in diameter, and appears to have a central area of purulence. The overlying skin is warm and erythematous. Given the clinical presentation and the size of the abscess, which of the following is the most appropriate initial treatment step? A. Prescribe oral antibiotics and advise warm compresses B. Perform incision and drainage and prescribe oral antibiotics C. Prescribe topical antibiotics and advise warm compresses D. Apply a steroid cream to reduce inflammation and swelling Answer: B. Perform incision and drainage and prescribe oral antibiotics The patient's presentation is consistent with a skin abscess. For abscesses of this size, especially in a location like the forearm where there is potential for spread, the mainstay of treatment is incision and drainage to remove the purulent material. This not only provides relief but also addresses the infection directly. Given the erythema and warmth surrounding the abscess, oral antibiotics are also appropriate to address any surrounding cellulitis and prevent further spread of the infection. Prescribing only oral antibiotics without addressing the abscess directly through incision and drainage may not effectively treat the localized collection of pus. Topical antibiotics are not sufficient for treating a skin abscess of this size and depth. Applying a steroid cream would not address the underlying infection and could potentially exacerbate the condition by suppressing local immune responses.

Answer 148

Dry, itchy skin and recurrent rashes on the flexor surfaces of the arms and behind the knees.

Answer 149

The symptoms have been ongoing for the past 2 years.

Answer 150

During the colder months.

Answer 151

Atopic dermatitis. ## Footnote Atopic dermatitis is characterized by chronic dry skin, itching, and rashes, especially in areas like the flexor surfaces of the arms and behind the knees.

Answer 152

Urticaria, also known as hives, presents as raised, itchy welts on the skin, often in response to allergens.

Answer 153

Contact dermatitis is a reaction to an external irritant or allergen, typically associated with exposure to a specific substance.

Answer 154

Tinea corporis, also known as ringworm, is a fungal infection that presents as a ring-shaped rash. ## Footnote An adult patient presents with dry, itchy skin and recurrent rashes on the flexor surfaces of the arms and behind the knees. The patient reports that these symptoms have been ongoing for the past 2 years and seem to intensify during the colder months. Which condition is the patient most likely exhibiting? A. Urticaria B. Atopic dermatitis C. Contact dermatitis D. Tinea corporis Answer: B. Atopic dermatitis Atopic dermatitis is characterized by chronic dry skin, itching, and rashes, especially in areas like the flexor surfaces of the arms and behind the knees. The chronic nature and the exacerbation during colder months further support the diagnosis of atopic dermatitis. Urticaria, also known as hives, presents as raised, itchy welts on the skin, often in response to allergens, but it does not typically involve chronic dry skin. Contact dermatitis is a reaction to an external irritant or allergen and would typically be associated with exposure to a specific substance. Tinea corporis, also known as ringworm, is a fungal infection that presents as a ring-shaped rash.

Answer 155

13 years old

Answer 156

A slowly expanding, itchy rash on the arm for the past 2 weeks

Answer 157

A well-defined, annular lesion with a raised, erythematous border and central clearing, with fine scales along the periphery.

Answer 158

Calamine lotion

Answer 159

The family recently adopted a kitten from a local animal shelter.

Answer 160

Tinea corporis

Answer 161

Terbinafine cream applied twice daily for 2 to 4 weeks

Answer 162

It reduces inflammation but does not treat the underlying fungal infection and can exacerbate the condition.

Answer 163

It is not effective against a fungal infection.

Answer 164

They can help reduce itching but do not resolve the underlying fungal infection. ## Footnote A 13 year old patient is brought to the clinic by their parent with a complaint of a slowly expanding, itchy rash on the patient's arm for the past 2 weeks. Examination reveals a well-defined, annular lesion with a raised, erythematous border and central clearing. There are fine scales along the periphery of the lesion. The parent reports that they initially applied calamine lotion, thinking it was an insect bite or allergic reaction, but the rash continued to grow. The family recently adopted a kitten from a local animal shelter. Given the clinical presentation and the patient's history, which of the following would treat the underlying cause? A. Clobetasol propionate cream 0.05% applied once daily for 2 weeks B. Terbinafine cream applied twice daily for 2 to 4 weeks C. Neomycin antibiotic ointment applied three times daily for 10 days D. Cetirizine 10 mg orally once daily for 14 days Answer: B. Terbinafine cream applied twice daily for 2 to 4 weeks The patient's clinical presentation is consistent with tinea corporis, a superficial fungal infection of the skin. The annular lesion with central clearing and scaling at the periphery is characteristic of this condition. The recent adoption of a kitten, which could be a sourc of dermatophyte infection, further supports this diagnosis. Terbinafine antifungal cream is an appropriate first-line treatment for localized tinea corporis. A high-potency topical corticosteroid such as clobetasol propionate can reduce inflammation and itching but does not treat the underlying fungal infection and can potentially exacerbate the condition by suppressing local immunity. A topical antibiotic ointment would not be effective against a fungal infection. Oral antihistamines like cetirizine can help reduce itching but do not resolve the underlying fungal infection.

Answer 165

Multiple small, tender, red bumps around hair follicles on the back of the neck and upper back.

Answer 166

The employer recently issued protective clothing that is hot and tends to trap sweat.

Answer 167

Some pustules centered around hair follicles in the affected areas.

Answer 168

There are no signs of systemic infection, and the patient is afebrile.

Answer 169

Folliculitis.

Answer 170

Recommend over-the-counter benzoyl peroxide wash. ## Footnote Benzoyl peroxide wash is effective for mild cases of bacterial folliculitis due to its antibacterial properties.

Answer 171

It is more appropriate for fungal infections, not bacterial folliculitis.

Answer 172

For viral skin infections, like herpes simplex virus.

Answer 173

They could exacerbate bacterial infections. ## Footnote An adult patient presents with multiple small, tender, red bumps around hair follicles on the back of the neck and upper back. The patient reports that their employer recently issued protective clothing that is hot and tends to trap sweat. Physical examination reveals some pustules centered around hair follicles in the affected areas. There are no signs of systemic infection, and the patient is afebrile. Given the clinical presentation and history, which of the following treatment strategies would be most appropriate for the suspected condition? A. Prescribe an oral antifungal medication B. Recommend over-the-counter benzoyl peroxide wash C. Advise the application of a topical antiviral cream D. Initiate a course of oral corticosteroids Answer: B. Recommend over-the-counter benzoyl peroxide wash The patient's presentation is consistent with folliculitis, which is often caused by bacterial infection, particularly with Staphylococcus aureus. Benzoyl peroxide wash is an over-the-counter treatment that can be effective for mild cases of bacterial folliculitis because it has antibacterial properties. An oral antifungal medication would be more appropriate for fungal infections, not bacterial folliculitis. A topical antiviral cream would be used for viral skin infections, like herpes simplex virus, but it is not appropriate for bacterial folliculitis. Oral corticosteroids are not typically used for uncomplicated folliculitis and could exacerbate bacterial infections.

Answer 174

22 years old

Answer 175

Persistent itching between the toes for the past 3 weeks.

Answer 176

Macerated, white skin between the toes, with areas of erythema and scaling.

Answer 177

An over-the-counter moisturizer.

Answer 178

Tinea pedis, commonly known as athlete's foot.

Answer 179

Clotrimazole cream ## Footnote Clotrimazole antifungal cream is used twice daily for 2 to 4 weeks.

Answer 180

Topical antifungals are effective for localized infections and have a lower risk of systemic side effects.

Answer 181

Clobetasol can reduce inflammation and itching but does not treat the fungal infection.

Answer 182

Mupirocin is a topical antibiotic and would not treat a fungal infection. ## Footnote A 22 year old 22-year-old patient presents with reports of persistent itching between the toes for the past 3 weeks. On examination, the nurse practitioner observes macerated, white skin between the toes of both feet, with some areas showing erythema and scaling. The patient reports that they initially tried an over-the-counter moisturizer, thinking it was just dry skin, but the condition worsened. The patient is active in sports and often wears closed-toe shoes for extended periods. Given the clinical presentation and the patient's history, which of the following treatment approaches would be most appropriate? A. Oral terbinafine B. Topical clobetasol C. Mupirocin ointment D. Clotrimazole cream Answer: D. Clotrimazole cream The patient's clinical presentation is consistent with tinea pedis, commonly known as athlete's foot. Given the localized nature of the infection, clotrimazole antifungal cream (twice daily for 2 to 4 weeks) is the most appropriate first-line treatment. Topical antifungals are effective for most localized tinea infections and have a lower risk of systemic side effects compared with oral antifungals. Oral terbinafine is typically reserved for severe or extensive cases or for when topical treatment has failed. Clobetasol, a potent corticosteroid, can reduce inflammation and itching, but it does not treat the underlying fungal infection and can potentially exacerbate the condition by suppressing local immunity. A topical antibiotic ointment such as mupirocin would not be effective against a fungal infection and could potentially exacerbate the condition if there is no bacterial superinfection present

Answer 183

Amoxicillin-clavulanate orally for 7 days ## Footnote This treatment is effective against Pasteurella multocida and other organisms associated with cat bites.

Answer 184

Erythema, swelling, and purulence ## Footnote These symptoms indicate a potential infection requiring treatment.

Answer 185

Amoxicillin-clavulanate provides specific coverage against Pasteurella multocida, which cephalexin lacks. ## Footnote Cephalexin is used for skin infections but is not effective against this specific organism.

Answer 186

Azithromycin or clindamycin ## Footnote Azithromycin is generally a secondary option, while clindamycin is specifically for those allergic to penicillin.

Answer 187

13 years old

Answer 188

Small white particles attached to the hair shafts near the scalp and tiny moving organisms.

Answer 189

Pediculosis capitis (head lice infestation)

Answer 190

Topical permethrin 1% lotion applied to damp hair and rinsed off after 10 minutes.

Answer 191

Seborrheic dermatitis, which presents with dandruff and sometimes red skin.

Answer 192

Psoriasis, which can present with thick scales on the scalp.

Answer 193

Various inflammatory skin conditions, including mild cases of eczema or dermatitis. ## Footnote 13-year-old patient presents with intense itching on the scalp. On examination, the nurse practitioner identifies small white particles attached to the hair shafts near the scalp and some tiny moving organisms. Which of the following is the most appropriate treatment? A. Topical ketoconazole shampoo left on for 5 minutes and then rinsed B. Topical coal tar shampoo left on for 10 minutes and then rinsed C. Topical hydrocortisone 1% cream applied to the scalp nightly D. Topical permethin 1% lotion applied to damp hair and rinsed off after 10 minutes Answer: D. Topical permethrin 1% lotion applied to damp hair and rinsed off after 10 minutes The presentation of intense itching on the scalp, along with the identification of small white particles (nits) and tiny moving organisms (live lice), is indicative of pediculosis capitis (head lice infestation). The recommended first-line treatment for pediculosis capitis is topical permethin 1% lotion. It is applied to damp hair and rinsed off after 10 minutes. Topical ketoconazole shampoo is a treatment for seborrheic dermatitis, which presents with dandruff and sometimes red skin but not with live organisms. Coal tar shampoo is often used for psoriasis, which can present with thick scales on the scalp, but not with nits or live lice. Topical hydrocortisone 1% cream is a mild corticosteroid used for various inflammatory skin conditions, including mild cases of eczema or dermatitis, but it is not effective against lice.

Answer 194

This presentation suggests a partial-thickness (second-degree) burn.

Answer 195

Apply a topical antibiotic and a sterile dressing. ## Footnote This helps prevent infection and promotes healing.

Answer 196

Referral to the ED is not likely required unless the burn covers extensive areas or is a full-thickness burn.

Answer 197

Aloe vera is commonly recommended for minor burns due to its soothing properties, but this burn requires more than just aloe vera gel.

Answer 198

Cold compresses or immersion in cool water are appropriate for minor burns, but partial-thickness burns require wound cleaning and infection prevention. ## Footnote An adult patient presents after sustaining a burn injury to the right forearm. The burn area is approximately 2 inches in length and 1.5 inches in width, located on the dorsal surface of the forearm. The injured skin appears red and blistered and is extremely painful, especially when touched. There are no signs of charring or white, leathery skin. The patient is alert and oriented. Based on this presentation, which of the following is the most appropriate management of this patient's burn injury? A. Immediately refer the patient to the ED B. Recommend applying aloe vera gel at home C. Suggest applying cold compresses for periods of 10 to 15 minutes D. Apply a topical antibiotic and a sterile dressing Answer: D. Apply a topical antibiotic and a sterile dressing A burn that is red, blistered, and painful, without signs of charring or white, leathery skin, suggests a partial-thickness (second-degree) burn. The appropriate initial management includes cleaning the wound, applying a topical antibiotic to prevent infection, and covering it with a sterile dressing to protect the area and promote healing. Pain management is also appropriate. Referral to the ED is not likely required in this case, although it may be warranted for partial-thickness burns that cover extensive portions of the body, and is necessary for full-thickness (third-degree) burns. While aloe vera is commonly recommended for minor burns due to its soothing properties, the severity of this burn requires more than just applying aloe vera gel at home. Similarly, a cold compress or immersion in cool water is appropriate for minor burns, but a partial-thickness burn requires measures for wound cleaning and infection prevention

Answer 199

A progressively enlarging, erythematous, warm, and tender patch on their forearm.

Answer 200

A minor scrape in the area a week ago while working in the garden.

Answer 201

Approximately 10 cm in diameter.

Answer 202

Poorly defined border, mild pain, no fever, chills, or systemic symptoms.

Answer 203

No abscess formation or purulent discharge.

Answer 204

Oral cephalexin.

Answer 205

Cellulitis.

Answer 206

Redness, warmth, swelling, and tenderness of the affected area.

Answer 207

First-generation cephalosporins, such as cephalexin.

Answer 208

Staphylococcus aureus (including methicillin-susceptible strains) and Streptococcus pyogenes.

Answer 209

They are ineffective against bacterial infections.

Answer 210

Impetigo or eradicating nasal colonization of MRSA.

Answer 211

Its coverage against the most common pathogens causing cellulitis is not as broad or reliable as that of cephalexin. ## Footnote An adult patient presents to the clinic with a 5-day history of a progressively enlarging, erythematous, warm, and tender patch on their forearm. The patient reports a minor scrape in the area a week ago while they were working in their garden. The lesion is now approximately 10 cm in diameter with a poorly defined border, and while the patient reports mild pain, they do not have fever, chills, or any other systemic symptoms. The overlying skin shows no abscess formation or purulent discharge. What is the most appropriate initial treatment for this patient? A. Topical clotrimazole cream B. Oral cephalexin C. Topical mupirocin ointment D. Oral azithromycin Answer: B. Oral cephalexin The patient's clinical presentation is consistent with cellulitis, a bacterial skin infection that typically occurs following a break in the skin, such as a minor scrape. Cellulitis is characterized by redness, warmth, swelling, and tenderness of the affected area. First-line treatments for mild cases include first-generation cephalosporins, such as cephalexin, that are effective against the most common causative organisms of cellulitis-namely, Staphylococcus aureus (including methicillin-susceptible strains) and Streptococcus pyogenes. Other treatment options include penicillin or clindamycin. Antifungals such as clotrimazole cream are ineffective against bacterial infections. Mupirocin ointment is primarily used for impetigo or for eradicating nasal colonization of methicillin-resistant Staphylococcus aureus (MRSA). It is not typically used as a primary treatment for cellulitis, especially without abscess formation or purulent discharge. Azithromycin's coverage against the most common pathogens causing cellulitis is not as broad or reliable as that of cephalexin.

Answer 212

A pruritic, circular rash on the thigh that has been present for 2 weeks.

Answer 213

It began as a small red area but expanded outward, leaving a clearer center and developing a ring-like appearance.

Answer 214

The lesion is annular, with a scaly, raised border and some central clearing.

Answer 215

Topical clotrimazole ## Footnote This is the first-line treatment for localized tinea corporis.

Answer 216

Tinea corporis, a common fungal skin infection caused by dermatophytes.

Answer 217

For more extensive or refractory cases of fungal infections, not for initial treatment of localized tinea corporis.

Answer 218

It can worsen the infection by suppressing the immune system.

Answer 219

No, they are ineffective against fungal infections. ## Footnote An adult patient presents to the clinic with a 2-week history of a pruritic, circular rash on the thigh. The patient mentions that the rash began as a small red area but has expanded outward, leaving a clearer center and thus developing a ring-like appearance. The patient has no significant past medical history and takes no medications. On examination, the lesion is annular, with a scaly, raised border and some central clearing. There are no other similar lesions on the body. Based on this presentation, which of the following is the most appropriate treatment? A. Topical clotrimazole B. Oral fluconazole C. Oral prednisone D. Topical neomycin Answer: A. Topical clotrimazole The description of the lesion as annular, with a scaly, raised border and central clearing, is suggestive of tinea corporis, a common fungal skin infection caused by dermatophytes. Topical antifungals, such as clotrimazole, are the first-line treatment for localized tinea infections. They are effective, have minimal side effects, and can be applied directly to the affected area. Oral fluconazole is typically reserved for more extensive or refractory cases of fungal infections, not for initial treatment of localized tinea corporis. It is used when the infection covers a large area, involves the hair or nails, or has not responded to topical treatments. Prednisone is not an appropriate treatment for fungal infections and can actually worsen the infection by suppressing the immune system. Antibiotics like topical neomycin are ineffective against fungal infections.

Answer 220

A 29 years old male patient.

Answer 221

The patient has a BMI of 24.

Answer 222

Family history of atherogenic cardiovascular disease before age 60 in father and paternal uncle, colon cancer at age 60 in maternal great-grandfather, and type 2 diabetes mellitus in mother and maternal grandfather.

Answer 223

He has not had any prior blood testing performed to his knowledge.

Answer 224

The review of symptoms is negative today for any concerning symptoms.

Answer 225

A. Obtaining a fasting lipid panel today ## Footnote For a 28-year-old male patient with a family history of early-onset cardiovascular disease, it is appropriate to obtain a fasting lipid panel to screen for familial hypercholesterolemia, particularly if the patient was not screened as an adolescent.

Answer 226

No, there is no indication to start screening at an earlier age than currently recommended for average-risk individuals.

Answer 227

Current recommendations are to start at age 45 years or at an age 10 years earlier than the age of diagnosis of colon cancer in a first-degree relative.

Answer 228

No, HGA1C screening is not recommended by the American Diabetes Association for asymptomatic patients in their twenties without an elevated BMI and at least one additional risk factor.

Answer 229

Prostate cancer screening is recommended to start at age 45 to 50 years. ## Footnote The range is due to discrepancies between societies' recommendations.

Answer 230

A fasting lipid panel is a blood test used to measure different types of fats in the blood, helping assess cardiovascular health and the risk of conditions like heart disease and stroke. The test requires 8-12 hours of fasting before blood is drawn.

Answer 231

1. Total Cholesterol 2. High-Density Lipoprotein (HDL) 3. Low-Density Lipoprotein (LDL) 4. Triglycerides

Answer 232

Total Cholesterol measures the overall amount of cholesterol in the blood, including HDL and LDL. ## Footnote Normal range: <200 mg/dL

Answer 233

HDL is known as 'Good' Cholesterol, which helps remove excess cholesterol from the bloodstream and reduces heart disease risk. ## Footnote Optimal range: >60 mg/dL (protective), <40 mg/dL (low and increased risk)

Answer 234

LDL is known as 'Bad' Cholesterol, contributing to plaque buildup in arteries, increasing cardiovascular risk. ## Footnote Optimal range: <100 mg/dL; Borderline high: 130-159 mg/dL; High: 160-189 mg/dL; Very high: ≥190 mg/dL

Answer 235

Triglycerides are a type of fat stored in the body from excess calories. High levels are linked to metabolic syndrome and cardiovascular disease. ## Footnote Normal range: <150 mg/dL; Borderline high: 150-199 mg/dL; High: 200-499 mg/dL; Very high: ≥500 mg/dL

Answer 236

Elevated LDL and total cholesterol indicate an increased risk of atherosclerosis, heart attack, and stroke.

Answer 237

Low HDL indicates a higher risk of heart disease.

Answer 238

High triglycerides are associated with metabolic syndrome, diabetes, and pancreatitis.

Answer 239

Adults every 4-6 years starting at age 20, or more frequently if at risk, including those with diabetes, hypertension, obesity, smoking history, or family history of cardiovascular disease.

Answer 240

Patients on cholesterol-lowering medications should get a lipid panel to monitor treatment effectiveness. ## Footnote A fasting lipid panel (or lipid profile) is a blood test used to measure different types of fats in the blood, which helps assess cardiovascular health and the risk of conditions like heart disease and stroke. The test requires 8-12 hours of fasting (no food or drinks except water) before blood is drawn. Components of a Fasting Lipid Panel 1. Total Cholesterol * Measures the overall amount of cholesterol in the blood, including HDL and LDL. * Normal range: <200 mg/dL 2. High-Density Lipoprotein (HDL) – “Good” Cholesterol * Helps remove excess cholesterol from the bloodstream and reduces heart disease risk. * Optimal range: >60 mg/dL (protective), <40 mg/dL (low and increased risk) 3. Low-Density Lipoprotein (LDL) – “Bad” Cholesterol * Contributes to plaque buildup in arteries, increasing cardiovascular risk. * Optimal range: <100 mg/dL * Borderline high: 130-159 mg/dL * High: 160-189 mg/dL * Very high: ≥190 mg/dL 4. Triglycerides * Type of fat stored in the body from excess calories. High levels are linked to metabolic syndrome and cardiovascular disease. * Normal range: <150 mg/dL * Borderline high: 150-199 mg/dL * High: 200-499 mg/dL * Very high: ≥500 mg/dL Clinical Significance * Elevated LDL & total cholesterol → Increased risk of atherosclerosis, heart attack, and stroke. * Low HDL → Higher risk of heart disease. * High triglycerides → Associated with metabolic syndrome, diabetes, and pancreatitis. Who Should Get a Lipid Panel? * Adults every 4-6 years starting at age 20, or more frequently if at risk. * Patients with diabetes, hypertension, obesity, smoking history, or family history of cardiovascular disease. * Those on cholesterol-lowering medications (e.g., statins) to monitor treatment effectiveness.

Answer 241

A. Dyspnea ## Footnote Dyspnea is more commonly associated with mitral stenosis due to pulmonary congestion.

Answer 242

Dyspnea is shortness of breath.

Answer 243

A buildup of pressure in the left atrium and lungs.

Answer 244

No, abdominal distension is not a direct symptom.

Answer 245

Palpitations, atypical chest pain, and sometimes dyspnea. ## Footnote The dyspnea in mitral valve prolapse is generally less severe.

Answer 246

135/85 mmHg and 138/88 mmHg

Answer 247

Less than 10%

Answer 248

The patient does not smoke, has a low stress level, and engages in approximately 100 minutes of moderate-intensity activity each week.

Answer 249

The patient reports a reasonable amount of fruits and vegetables but admits to eating out often and not consciously avoiding high-sodium meals.

Answer 250

C. Recommend lifestyle modifications ## Footnote For patients with newly diagnosed stage 1 hypertension who do not have a history of cardiovascular disease and have a low 10-year ASCVD risk (<10%), current guidelines recommend starting with lifestyle modifications as the initial management strategy.

Answer 251

Systolic murmur heard best at the aortic listening point and associated chest pain ## Footnote Aortic stenosis is a systolic murmur that is best heard at the aortic listening point (right second intercostal space near the sternum). Associated symptoms can include chest pain, syncope, or heart failure symptoms due to increased left ventricular pressure and decreased cardiac output.

Answer 252

It is more suggestive of mitral valve prolapse. ## Footnote A systolic murmur heard best at the mitral listening point (the apex of the heart or the left fifth intercostal space at the midlavicular line) and associated palpitations.

Answer 253

It would be more indicative of aortic regurgitation.

Answer 254

It could suggest mitral stenosis or regurgitation, not aortic stenosis. ## Footnote A Deep Dive into ASCVD Risk Assessment & Management What is ASCVD? Atherosclerotic Cardiovascular Disease (ASCVD) refers to conditions caused by plaque buildup in the arteries, leading to events such as: * Myocardial infarction (MI, heart attack) * Stroke (ischemic stroke, transient ischemic attack - TIA) * Coronary artery disease (CAD) * Peripheral arterial disease (PAD) Assessing a person’s 10-year risk of ASCVD helps guide preventive strategies, including lifestyle modifications, pharmacologic interventions (e.g., statins, antihypertensives, aspirin), and other risk-reducing measures. ⸻ ASCVD Risk Assessment: How is it Calculated? The ASCVD Risk Calculator (Pooled Cohort Equations, PCE) estimates the 10-year risk of a first ASCVD event (heart attack or stroke) in adults aged 40-79 years. Risk Factors Considered in the ASCVD Calculator 1. Age & Sex * Older adults and males have higher ASCVD risk. 2. Race * Black individuals often have a higher baseline risk. 3. Total Cholesterol & HDL-Cholesterol (Lipid Panel) * High LDL increases risk. * Low HDL is a risk factor. 4. Blood Pressure (Systolic BP) * Elevated BP (≥130/80 mmHg) increases risk. 5. Smoking Status * Current smokers have a significantly higher risk. 6. Diabetes Mellitus * Diabetics have a much higher baseline ASCVD risk. 7. Use of Antihypertensive Therapy * Medication use affects risk estimates. ASCVD Risk Categories & Interpretation See chart Who Should Get an ASCVD Risk Assessment? * All adults aged 40-79 years without ASCVD should have their risk assessed. * Younger individuals (<40 years) with risk factors (e.g., diabetes, hypertension, smoking, obesity) can undergo a lifetime ASCVD risk assessment. * Reassessment is recommended every 4-6 years for low-risk individuals and more frequently for those with high risk. ⸻ Management of ASCVD Risk Based on Risk Category 1. Low-Risk (<5%) ✅ Recommendations: * Lifestyle modifications (DASH diet, exercise, weight loss, smoking cessation). * Reassess risk in 4-6 years. 💊 Medications? * No statin therapy recommended. * Blood pressure and diabetes management as per guidelines. ⸻ 2. Borderline Risk (5-7.4%) ✅ Recommendations: * Lifestyle modifications as the primary approach. * Consider statins if risk enhancers are present (see below). 💊 Medications? * Statins may be considered if the patient has additional risk-enhancing factors: * Family history of premature ASCVD (men <55, women <65). * LDL ≥160 mg/dL. * Metabolic syndrome. * Chronic kidney disease (CKD). * Chronic inflammatory conditions (e.g., rheumatoid arthritis, lupus). * High-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L. * Elevated coronary artery calcium (CAC) score (>100 Agatston units). ⸻ 3. Intermediate Risk (7.5-19.9%) ✅ Recommendations: * Moderate-intensity statin therapy to reduce LDL by 30-49%. * Lifestyle modifications remain important. 💊 Medications? * Statin therapy is recommended for most patients. * If uncertain about statins, consider a coronary artery calcium (CAC) score: * CAC = 0 → Delay statin therapy unless other high-risk features exist. * CAC 1-99 → Consider statins, especially if age >55. * CAC ≥100 or ≥75th percentile → Statin therapy indicated. ⸻ 4. High Risk (≥20%) ✅ Recommendations: * High-intensity statin therapy to reduce LDL by ≥50%. * Aggressive lifestyle modifications. * Consider aspirin therapy in select patients (e.g., prior MI or stroke). 💊 Medications? * High-intensity statins (atorvastatin 40-80 mg, rosuvastatin 20-40 mg). * Ezetimibe or PCSK9 inhibitors may be added if LDL remains ≥70 mg/dL. * Blood pressure and diabetes should be aggressively managed. ⸻ Special Considerations in ASCVD Prevention 1. Role of LDL Reduction in ASCVD Prevention * Primary Prevention: * In intermediate-to-high-risk patients, lowering LDL to <70 mg/dL reduces the risk of first-time heart attacks and strokes. * Secondary Prevention (Patients with Established ASCVD): * Goal: LDL <55 mg/dL in high-risk individuals. 2. Coronary Artery Calcium (CAC) Score: When to Use? * Uncertain about statin use? Consider a CAC scan to guide decisions. * CAC = 0? Statins may be delayed in some cases. * CAC >100? Strong indication for statin therapy. 3. Aspirin in Primary Prevention * No longer routinely recommended for primary prevention in low-risk patients due to bleeding risks. * Consider aspirin (81 mg daily) in high-risk patients (e.g., diabetes with high ASCVD risk, strong family history, elevated CAC score). 4. Diabetes & ASCVD Risk * Diabetes itself is a major risk factor, so statin therapy is usually indicated in diabetics aged 40-75 regardless of ASCVD risk score. * SGLT2 inhibitors (e.g., empagliflozin) and GLP-1 receptor agonists (e.g., liraglutide) reduce cardiovascular risk in diabetics with high ASCVD risk.

Answer 255

ARF and RHD are immune-mediated complications following untreated Group A Streptococcus (GAS) pharyngitis, primarily affecting the heart, joints, CNS, and skin. ## Footnote RA is a chronic autoimmune disease with progressive joint destruction.

Answer 256

ARF is a systemic inflammatory disease that develops 2-4 weeks after a Group A Streptococcus (GAS) pharyngeal infection, resulting from a misdirected immune response.

Answer 257

The major criteria include: 1. Joint involvement (Migratory polyarthritis) 2. Carditis (Pancarditis) 3. Nodules (subcutaneous, firm, and painless) 4. Erythema marginatum 5. Sydenham chorea.

Answer 258

The minor criteria include: Fever (≥38.5°C), Arthralgia, Elevated inflammatory markers (ESR, CRP), Prolonged PR interval (ECG finding).

Answer 259

Management includes: A. Antibiotic Therapy (Benzathine penicillin G, Oral penicillin V, Azithromycin for penicillin allergy) B. Anti-inflammatory Treatment (Aspirin, NSAIDs, Corticosteroids) C. Secondary Prophylaxis (IM benzathine penicillin G every 3-4 weeks).

Answer 260

RHD is the chronic valvular damage resulting from recurrent or severe episodes of ARF, primarily affecting the mitral and aortic valves.

Answer 261

Common manifestations include Mitral Stenosis, Mitral Regurgitation, and Aortic Stenosis or Regurgitation, leading to symptoms like dyspnea and heart failure.

Answer 262

Diagnosis involves echocardiography (gold standard), ECG, and chest X-ray to assess valve thickening, calcification, and cardiomegaly.

Answer 263

RA is a chronic autoimmune inflammatory disorder that primarily affects synovial joints, leading to progressive joint destruction and systemic complications.

Answer 264

Articular symptoms include symmetric polyarthritis, morning stiffness, and joint deformities such as ulnar deviation and Swan-neck deformity.

Answer 265

Diagnosis includes serology tests for rheumatoid factor (RF) and anti-CCP antibodies, as well as imaging studies like X-ray and MRI.

Answer 266

Management includes Disease-Modifying Anti-Rheumatic Drugs (DMARDs) like Methotrexate, symptomatic treatment with NSAIDs, and physical therapy.

Answer 267

ARF and RHD are post-infectious immune responses related to GAS infection, while RA is an autoimmune disease affecting joints and systemic organs.

Answer 268

A congenital cardiac anomaly characterized by an abnormal opening in the interventricular septum, allowing blood to shunt between the left and right ventricles.

Answer 269

Approximately 25-30% of all congenital heart defects.

Answer 270

VSDs are classified based on anatomical location within the interventricular septum: Perimembranous, Muscular, Outlet, and Inlet VSDs.

Answer 271

Perimembranous VSD, accounting for about 70% of cases.

Answer 272

It leads to left-to-right shunting, volume overload, and potential pulmonary hypertension.

Answer 273

Asymptomatic; may be incidentally detected with a harsh holosystolic murmur at the left lower sternal border.

Answer 274

Mild to moderate symptoms such as dyspnea, feeding difficulty, and failure to thrive.

Answer 275

Severe symptoms in infancy, including heart failure signs, failure to thrive, and recurrent respiratory infections.

Answer 276

A condition that occurs when untreated large VSD leads to pulmonary hypertension and right-to-left shunting, resulting in cyanosis and clubbing.

Answer 277

Echocardiography, which defines size, location, and hemodynamic impact.

Answer 278

Diuretics, ACE inhibitors, nutritional support, and monitoring for spontaneous closure.

Answer 279

Large VSD with symptoms of heart failure, persistent left-to-right shunt causing pulmonary hypertension, and failure of medical therapy.

Answer 280

Congestive heart failure, pulmonary hypertension, endocarditis, aortic regurgitation, and arrhythmias.

Answer 281

Excellent prognosis; most close spontaneously.

Answer 282

Endocarditis prophylaxis, early detection and management, and avoiding pregnancy if Eisenmenger syndrome develops.

Answer 283

Most common congenital heart defect; left-to-right shunt leads to pulmonary overcirculation; small VSDs often asymptomatic; large VSDs can cause heart failure; echocardiography is the gold standard for diagnosis.

Answer 284

Mitral regurgitation (MR) is a valvular heart disease characterized by backflow of blood from the left ventricle (LV) into the left atrium (LA) due to an incompetent mitral valve.

Answer 285

Untreated MR can lead to left atrial dilation, left ventricular hypertrophy, and ultimately heart failure.

Answer 286

MR is one of the most common valvular heart diseases.

Answer 287

The etiology can be primary (degenerative) due to valve pathology or secondary (functional) due to LV dysfunction.

Answer 288

Chronic MR leads to left-sided heart failure, atrial fibrillation, and pulmonary hypertension.

Answer 289

MR results in volume overload, leading to left atrial dilation, left ventricular dilation, pulmonary congestion, and reduced forward cardiac output.

Answer 290

Mild MR: RF < 30%, Moderate MR: RF 30-50%, Severe MR: RF > 50%.

Answer 291

Mitral Valve Prolapse (MVP) is the most common cause.

Answer 292

Rheumatic Heart Disease is the most common cause.

Answer 293

Causes include papillary muscle rupture (post-MI), endocarditis, and chordae tendineae rupture.

Answer 294

Symptoms include left-sided heart failure (orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema) and right-sided heart failure (peripheral edema, hepatomegaly, JVD).

Answer 295

Echocardiography is the gold standard for diagnosis.

Answer 296

Findings include left atrial enlargement, left ventricular hypertrophy, and atrial fibrillation.

Answer 297

Medical therapy includes diuretics, vasodilators, beta-blockers, anticoagulation, and digoxin.

Answer 298

Indications include severe symptomatic MR, LV dysfunction, atrial fibrillation, or pulmonary hypertension.

Answer 299

Mitral Valve Repair is preferred if feasible.

Answer 300

Complications include heart failure, atrial fibrillation, pulmonary hypertension, and endocarditis.

Answer 301

Chronic MR has a long compensated phase, but early surgical intervention is crucial once symptoms or LV dysfunction develop.

Answer 302

A holosystolic murmur is heard at the apex, radiating to the axilla.

Answer 303

Aortic regurgitation (AR), also known as aortic insufficiency, is a valvular disorder where the aortic valve fails to close properly during diastole, causing backflow of blood from the aorta into the left ventricle (LV). This leads to LV volume overload, progressive ventricular dilation, and eventually heart failure if left untreated.

Answer 304

Less common than aortic stenosis but still a significant cause of morbidity.

Answer 305

Can be due to valve pathology (primary AR) or aortic root disease (secondary AR).

Answer 306

Leads to LV dilation, eccentric hypertrophy, reduced ejection fraction (EF), and heart failure.

Answer 307

Aortic regurgitation creates a volume and pressure overload on the left ventricle, leading to increased LV end-diastolic volume (LVEDV), eccentric hypertrophy, increased stroke volume, and increased myocardial oxygen demand.

Answer 308

RF = (Regurgitant Volume / LV Stroke Volume) ## Footnote Mild AR: RF < 30%, Moderate AR: RF 30-50%, Severe AR: RF > 50%

Answer 309

Infective endocarditis, aortic dissection, trauma, prosthetic valve dysfunction, and rheumatic fever.

Answer 310

Aortic Valve Disease (Primary AR) includes bicuspid aortic valve, rheumatic heart disease, infective endocarditis, and congenital defects. Aortic Root Disease (Secondary AR) includes Marfan syndrome, aortic aneurysm, aortic dissection, syphilitic aortitis, and inflammatory disorders.

Answer 311

Severe dyspnea, pulmonary edema, hypotension, cardiogenic shock, weak pulses, and cool extremities.

Answer 312

Palpitations, exertional dyspnea, and fatigue.

Answer 313

Paroxysmal nocturnal dyspnea (PND), orthopnea, angina, and heart failure symptoms.

Answer 314

High-pitched, blowing early diastolic murmur best heard at the left sternal border in end-expiration with the patient leaning forward. Austin Flint Murmur is a low-pitched, mid-diastolic murmur at the apex due to regurgitant jet.

Answer 315

Corrigan’s Pulse, Quincke’s Sign, Musset’s Sign, Duroziez’s Sign, and Traube’s Sign.

Answer 316

Echocardiography ## Footnote Severe AR Criteria: Regurgitant fraction >50%, regurgitant volume >60 mL, dilated LV (End-diastolic diameter >65 mm).

Answer 317

LV hypertrophy (LVH), left atrial enlargement, and ST-T changes in advanced heart failure.

Answer 318

Acute AR shows pulmonary congestion with normal heart size, while chronic AR shows LV dilation and a boot-shaped heart.

Answer 319

Medical therapy includes afterload reduction with ACE inhibitors, ARBs, or nifedipine, diuretics, and beta-blockers in select cases.

Answer 320

Severe symptomatic AR, asymptomatic but LV dysfunction (EF < 50%), and LV end-diastolic diameter > 65 mm.

Answer 321

Aortic Valve Replacement (AVR) with mechanical or bioprosthetic valve, aortic root surgery, and Transcatheter Aortic Valve Replacement (TAVR).

Answer 322

Heart failure, atrial fibrillation, endocarditis, and sudden cardiac death.

Answer 323

Chronic AR is well tolerated for years, but once symptoms develop, surgical intervention is critical. Acute AR has a high mortality if untreated.

Answer 324

Blowing early diastolic murmur at the left sternal border, wide pulse pressure with bounding peripheral pulses, echocardiography as the gold standard, and urgent surgical intervention for severe symptomatic AR.

Answer 325

Aortic stenosis (AS) is a valvular heart disease characterized by narrowing of the aortic valve, leading to obstruction of blood flow from the left ventricle (LV) to the aorta.

Answer 326

Untreated AS can lead to progressive left ventricular hypertrophy (LVH), increased myocardial oxygen demand, and eventually heart failure.

Answer 327

Aortic stenosis is the most common valvular heart disease in the elderly.

Answer 328

Etiologies include degenerative (calcific), congenital (bicuspid aortic valve), or rheumatic.

Answer 329

Severe AS leads to exertional dyspnea, angina, syncope, and heart failure.

Answer 330

AS causes increased LV pressure, decreased LV compliance, fixed cardiac output, and increased myocardial oxygen demand.

Answer 331

Normal AVA is 3-4 cm².

Answer 332

Severe AS is defined as AVA < 1.0 cm².

Answer 333

Congenital Bicuspid Aortic Valve (BAV) is the most common cause.

Answer 334

The classic triad includes exertional dyspnea, angina, and exertional syncope.

Answer 335

Late symptoms include resting dyspnea, atrial fibrillation, and sudden cardiac death.

Answer 336

A harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border.

Answer 337

Echocardiography is the gold standard for diagnosis.

Answer 338

Mild: AVA > 1.5 cm²; Moderate: AVA 1.0-1.5 cm²; Severe: AVA < 1.0 cm².

Answer 339

Indications include severe symptomatic AS, severe AS with LV dysfunction, and asymptomatic AS with LV dilation.

Answer 340

Options include Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR).

Answer 341

Complications include heart failure, sudden cardiac death, atrial fibrillation, and endocarditis.

Answer 342

50% of asymptomatic severe AS patients become symptomatic within 5 years.

Answer 343

Aortic valve replacement (AVR) significantly improves survival if performed at the right time.

Answer 344

Pulsus parvus et tardus (delayed, weak carotid upstroke) is a hallmark feature.

Answer 345

Aortic stenosis produces a harsh, crescendo-decrescendo systolic murmur due to turbulent blood flow across a narrowed aortic valve.

Answer 346

The murmur is best heard at the right upper sternal border (2nd intercostal space).

Answer 347

The murmur radiates to the carotid arteries.

Answer 348

The quality is described as harsh, rough, or 'mechanical'.

Answer 349

The murmur has a crescendo-decrescendo pattern, increasing and then decreasing in intensity during systole.

Answer 350

It increases with squatting and leg raising (↑ preload) and decreases with Valsalva and standing (↓ preload).

Answer 351

The classic triad includes exertional dyspnea, angina, and exertional syncope.

Answer 352

Exertional dyspnea is due to diastolic dysfunction and increased left ventricular end-diastolic pressure.

Answer 353

Resting dyspnea and pulmonary edema are late symptoms indicating poor prognosis.

Answer 354

Findings include a harsh, crescendo-decrescendo systolic murmur, paradoxically split S2, diminished S2, and S4 gallop.

Answer 355

Pulsus parvus et tardus, which is a weak and delayed carotid pulse.

Answer 356

Echocardiography is the gold standard for diagnosis.

Answer 357

Mild AS: >1.5 cm², Moderate AS: 1.0 - 1.5 cm², Severe AS: <1.0 cm².

Answer 358

Aortic valve replacement (AVR) is the definitive treatment for severe symptomatic AS.

Answer 359

Options include Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR).

Answer 360

50% of asymptomatic severe AS patients become symptomatic within 5 years.

Answer 361

Aortic stenosis murmur is a harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border and radiates to the carotids.

Answer 362

Aortic stenosis produces a harsh, crescendo-decrescendo systolic murmur due to turbulent blood flow across a narrowed aortic valve during systole. ## Footnote The murmur is best heard at the right upper sternal border (2nd intercostal space) and radiates to the carotid arteries.

Answer 363

The murmur occurs during systole as the left ventricle (LV) contracts, forcing blood through the narrowed aortic valve, creating a crescendo-decrescendo murmur. ## Footnote The murmur increases in intensity, peaks in mid-systole, then decreases.

Answer 364

The murmur is harsh or 'rough', low-pitched in mild cases, and higher-pitched in severe AS due to increased pressure gradient.

Answer 365

The murmur is louder with increased preload (e.g., squatting, leg raise) and softer with decreased preload (e.g., Valsalva, standing).

Answer 366

The murmur is best heard at the right 2nd intercostal space, near the sternum, because the aortic valve is anatomically closest to this site.

Answer 367

The murmur radiates to the carotid arteries as turbulent flow transmits sound along the ascending aorta and carotids. ## Footnote This differentiates AS from other systolic murmurs: MR radiates to the axilla, and HOCM radiates to the left lower sternal border.

Answer 368

In severe AS, A2 is delayed due to prolonged LV systole, leading to paradoxical splitting of S2 or a single S2 if the valve is severely calcified. ## Footnote A2 may disappear entirely, making it softer or absent.

Answer 369

S4 is a low-pitched heart sound occurring just before S1, caused by left ventricular hypertrophy (LVH) making the LV stiff, leading to forceful contraction of the left atrium. ## Footnote S4 is a sign of diastolic dysfunction and differentiates severe AS from mild-moderate cases.

Answer 370

Heart sounds are produced by the closing of heart valves, turbulent blood flow, and myocardial vibrations during the cardiac cycle.

Answer 371

The two primary heart sounds are S1 and S2.

Answer 372

S1 represents the closure of the mitral and tricuspid valves at the beginning of systole.

Answer 373

S1 is loudest at the apex (Mitral area – 5th ICS, midclavicular line).

Answer 374

Loud S1 can be caused by mitral stenosis, shortened PR interval, and hyperdynamic states.

Answer 375

Soft S1 can be caused by mitral regurgitation, prolonged PR interval, and severe heart failure.

Answer 376

S2 represents the closure of the aortic and pulmonary valves at the beginning of diastole.

Answer 377

S2 is loudest at the base of the heart (Aortic area – 2nd ICS, right sternal border).

Answer 378

Physiological splitting of S2 occurs during inspiration when increased venous return delays pulmonary valve closure.

Answer 379

Wide splitting of S2 can be caused by right bundle branch block, pulmonary hypertension, and pulmonary stenosis.

Answer 380

S3, known as 'Ventricular Gallop', occurs during early diastole and is associated with rapid ventricular filling.

Answer 381

Pathologic S3 is associated with heart failure, dilated cardiomyopathy, and severe mitral regurgitation.

Answer 382

S4, known as 'Atrial Gallop', occurs in late diastole and is caused by atrial contraction against a stiff ventricle.

Answer 383

S4 is associated with left ventricular hypertrophy, hypertrophic cardiomyopathy, and acute myocardial infarction.

Answer 384

A Mid-Systolic Click is caused by mitral valve prolapse and occurs in mid-systole.

Answer 385

An Opening Snap occurs in early diastole in mitral stenosis and is best heard at the apex.

Answer 386

A Pericardial Friction Rub is a scratching, high-pitched sound indicative of pericarditis.

Answer 387

Key takeaways include: S1 & S2 are normal heart sounds, S3 indicates volume overload, S4 indicates ventricular stiffness, and pathological murmurs often accompany abnormal heart sounds.

Answer 388

Splitting of S1 and S2 provides critical diagnostic clues about underlying cardiac physiology and pathology due to differences in timing of valve closure between the right and left sides of the heart.

Answer 389

S1 is produced by the closure of the mitral (M1) and tricuspid (T1) valves at the beginning of systole.

Answer 390

S1 is normally heard as a single sound because mitral valve closure precedes tricuspid closure by only ~20 milliseconds, which is usually undetectable.

Answer 391

Split S1 occurs when the tricuspid valve closes significantly later than the mitral valve.

Answer 392

Right Bundle Branch Block (RBBB) is a common cause, leading to delayed tricuspid valve closure.

Answer 393

Wide splitting of S1 suggests right ventricular conduction delay or tricuspid valve pathology.

Answer 394

S2 is produced by the closure of the aortic (A2) and pulmonary (P2) valves at the beginning of diastole.

Answer 395

Normal splitting of S2 occurs when A2 closes before P2, with P2 being delayed during inspiration.

Answer 396

Wide splitting of S2 is caused by delayed right ventricular systole, leading to a late P2.

Answer 397

Fixed splitting of S2 occurs when A2 and P2 remain widely split throughout inspiration and expiration.

Answer 398

Atrial Septal Defect (ASD) is the hallmark condition associated with fixed splitting of S2.

Answer 399

Paradoxical splitting of S2 occurs when P2 occurs before A2, splitting is heard only during expiration.

Answer 400

Paradoxical splitting is caused by delayed left ventricular systole, leading to a late A2.

Answer 401

1. Listen at the pulmonary area to determine if S2 is single or split. 2. Observe changes with inspiration and expiration. 3. Assess associated murmurs.

Answer 402

Loud P2 suggests pulmonary hypertension.

Answer 403

S1 splitting is rare but indicates right ventricular conduction delays. Physiologic S2 splitting is normal and increases with inspiration. Wide S2 splitting suggests delayed pulmonary valve closure. Fixed S2 splitting is a hallmark of ASD. Paradoxical S2 splitting indicates delayed A2 closure.

Answer 404

Shortness of breath, epigastric abdominal pain, nausea, and vomiting for 12 hours.

Answer 405

Prior myocardial infarction, hyperlipidemia, and hypertension.

Answer 406

81 mg of aspirin, 20 mg of rosuvastatin, and 10 mg of lisinopril.

Answer 407

Heart rate: 89 beats/min, blood pressure: 145/86 mmHg, oxygen saturation: 96% on room air, respiratory rate: 18 breaths/min, temperature: 98.8°F (37.1°C).

Answer 408

Normal sinus rhythm of 89 beats/min, PR interval of 180 ms, QRS complex of 110 ms, QT interval of 475 ms, and corrected QT interval (QTc) of 579 ms.

Answer 409

Giving 8 mg of ondansetron intravenously. ## Footnote Ondansetron has a known adverse reaction of prolonged QT interval, which could precipitate a ventricular arrhythmia in this patient with a coexisting prolonged QT interval.

Answer 410

It helps differentiate the presence of myocardial injury, as a myocardial infarction is part of the differential for her symptoms.

Answer 411

To test for electrolyte imbalances that can cause prolonged QT interval, especially in patients who have been vomiting.

Answer 412

It would be appropriate to give aspirin immediately. ## Footnote Case Analysis This case presents an older adult female with shortness of breath, epigastric pain, nausea, and vomiting, symptoms that could indicate multiple possible diagnoses, including: * Acute coronary syndrome (ACS) * Electrolyte disturbances * Gastrointestinal disorders (e.g., gastritis, peptic ulcer disease) * Medication-induced effects (e.g., QT prolongation) The patient’s history includes: * Prior myocardial infarction (MI) → Higher risk for another cardiac event. * Hyperlipidemia and hypertension → Major cardiovascular risk factors. * Current medications: * Aspirin (81 mg daily) → Cardioprotective. * Rosuvastatin (20 mg daily) → Lipid-lowering agent. * Lisinopril (10 mg daily) → Antihypertensive agent, could cause hyperkalemia. Key ECG Findings * QT interval = 475 ms (borderline prolonged). * Corrected QT interval (QTc) = 579 ms (prolonged, normal for women is <460 ms). * No ST-T wave changes → No clear evidence of an acute MI. Diagnosis and Management Approach 1. Differential Diagnosis * Myocardial infarction (MI) / Acute coronary syndrome (ACS) * Electrolyte disturbances (Hypokalemia, Hypocalcemia, Hypomagnesemia) * Drug-induced QT prolongation * Autonomic dysfunction or nausea from an underlying cause (e.g., cardiac ischemia, vagal response, metabolic issues) 2. Evaluation Steps * High-sensitivity cardiac troponin test → Rule out myocardial injury. * Basic metabolic panel (BMP) → Assess electrolytes (K+, Mg2+, Ca2+) and renal function. * Medication review → Identify QT-prolonging drugs. ⸻ Why Ondansetron is Contraindicated? Correct Answer: C. Giving 8 mg of Ondansetron intravenously 1. QT Prolongation Risk * Ondansetron (Zofran) is known to prolong the QT interval. * This patient already has a prolonged QTc of 579 ms, which puts her at risk for torsades de pointes (TdP), a life-threatening ventricular arrhythmia. * Other risk factors for QT prolongation include: * Female gender. * Electrolyte imbalances (vomiting-induced hypokalemia, hypomagnesemia, hypocalcemia). * Underlying cardiac disease. 2. Safer Alternative Anti-Emetics * Metoclopramide (Reglan): Low risk of QT prolongation but can cause extrapyramidal symptoms. * Prochlorperazine (Compazine): Can be used with caution. * Promethazine (Phenergan): Minimal QT effect but should be used cautiously. ⸻ Why Are Other Options Correct? A. Obtaining a High-Sensitivity Cardiac Troponin Test * Essential in any patient with dyspnea, epigastric pain, and nausea, especially with a history of prior MI. * Women often present with atypical MI symptoms, such as: * Epigastric pain, nausea, and fatigue instead of chest pain. * Troponin helps differentiate between ischemic and non-ischemic causes. B. Obtaining a Basic Metabolic Panel (BMP) * Key in evaluating QT prolongation causes, especially: * Hypokalemia * Hypocalcemia * Hypomagnesemia * Vomiting could lead to electrolyte depletion. * Lisinopril (ACE inhibitor) can cause hyperkalemia, which should also be checked. D. Giving Chewable Aspirin if the Patient Has Not Taken It Yet * ACS is high on the differential. * Aspirin reduces thrombus formation in MI. * Contraindications: Active bleeding or aspirin allergy (neither present in this case). ⸻ Management Summary 1. Obtain High-Sensitivity Troponin → Rule out myocardial infarction. 2. Obtain BMP (Electrolytes, Renal Function) → Check for metabolic causes of QT prolongation. 3. Avoid QT-Prolonging Medications (Ondansetron, Certain Antiarrhythmics, Fluoroquinolones, Macrolides). 4. Provide Alternative Anti-Emetics (Metoclopramide, Prochlorperazine, Promethazine). 5. Administer Aspirin If ACS Suspected (unless contraindicated). 6. Consider Magnesium and Potassium Repletion if Low. ⸻ Key Takeaways * QTc prolongation (>500 ms) increases risk for torsades de pointes (TdP). * Ondansetron prolongs the QT interval and is contraindicated in this patient. * Women with ACS may present with atypical symptoms (epigastric pain, nausea, dyspnea). * Always check electrolytes in patients with vomiting and QT prolongation. * Avoid QT-prolonging drugs and consider alternative anti-emetics.

Answer 413

A normal electrocardiogram (ECG) represents electrical conduction through the heart in a structured manner.

Answer 414

P waves present before each QRS complex, regular rate (60-100 bpm), PR interval between 120-200 ms, QRS complex duration ≤120 ms.

Answer 415

HR < 60 bpm, regular rhythm, normal PR interval. ## Footnote Causes include physiologic (athletes, sleep), increased vagal tone, hypothyroidism, inferior MI.

Answer 416

Atropine 0.5 mg IV, repeat every 3-5 min (max 3 mg).

Answer 417

HR > 100 bpm, regular rhythm. ## Footnote Causes include fever, pain, dehydration, hyperthyroidism.

Answer 418

Identify and treat underlying cause (e.g., fluids, beta-blockers for hyperthyroidism).

Answer 419

Irregularly irregular rhythm, no distinct P waves, fibrillatory waves. ## Footnote Causes include hypertension, valvular disease, CAD.

Answer 420

Stroke, heart failure.

Answer 421

Rate control (Beta-blockers, CCBs), anticoagulation (CHA2DS2-VASc score), cardioversion for unstable patients.

Answer 422

Sawtooth atrial waves, atrial rate ~300 bpm, ventricular rate ~150 bpm.

Answer 423

Narrow QRS tachycardia (HR 150-250 bpm), regular rhythm, absent P waves. ## Footnote Management includes vagal maneuvers and adenosine.

Answer 424

Wide QRS complex (>120 ms), regular rate > 100 bpm. ## Footnote Management includes Amiodarone for stable VT and synchronized cardioversion for unstable VT.

Answer 425

Chaotic, irregular deflections with no P waves or organized QRS. ## Footnote Requires immediate defibrillation.

Answer 426

ST elevation ≥1 mm in ≥2 contiguous leads, new LBBB in symptomatic patient. ## Footnote Management includes MONA-BASH.

Answer 427

ST depression or T-wave inversions, elevated troponins without ST elevation.

Answer 428

Similar to STEMI but no fibrinolysis, early invasive strategy for high-risk patients.

Answer 429

Similar to NSTEMI but NO troponin elevation, ST depressions or T-wave inversions.

Answer 430

Wide QRS (>120 ms), 'Rabbit ears' in V5-V6.

Answer 431

Wide QRS (>120 ms), RSR’ (Rabbit ears) in V1-V2.

Answer 432

PR >200 ms (one large box).

Answer 433

Progressive PR prolongation, then dropped QRS.

Answer 434

Fixed PR, then dropped QRS (more dangerous).

Answer 435

No communication between P waves & QRS.

Answer 436

Identify life-threatening rhythms first (VT, VF, STEMI), recognize key arrhythmias (AF, SVT, heart blocks), differentiate ischemic changes (STEMI, NSTEMI, unstable angina), know electrolyte-related ECG changes, and understand bundle branch blocks significance. ## Footnote Normal and Abnormal ECG Interpretation: A Deep Dive for the FNP AANP/ANCC Board Exam Electrocardiogram (ECG/EKG) interpretation is an essential skill for Family Nurse Practitioners (FNPs), especially for the AANP and ANCC board exams. Understanding normal ECG findings and recognizing abnormal patterns can help diagnose cardiac conditions early and improve patient outcomes. ⸻ 1. Basics of ECG Interpretation A 12-lead ECG records electrical activity in different planes of the heart, helping identify arrhythmias, ischemia, infarction, hypertrophy, electrolyte imbalances, and conduction abnormalities. A. ECG Leads and Heart Views Common ECG Abnormalities for the AANP/ANCC Exam Recognizing critical ECG abnormalities is crucial for diagnosing cardiac emergencies, electrolyte disturbances, and conduction disorders. Approach to ECG Interpretation (Stepwise) 1. Check Rate & Rhythm: * Normal sinus rhythm: Regular P waves before every QRS. * Bradycardia (<60 bpm), Tachycardia (>100 bpm). 2. Evaluate Intervals: * PR interval (should be 120-200 ms). * QRS duration (should be <120 ms). * QT interval (prolonged if >460 ms in women, >450 ms in men). 3. Examine ST Segment & T Waves: * ST elevation → STEMI. * ST depression → Ischemia/NSTEMI. * T wave inversion → Ischemia, Wellens syndrome. 4. Look for Blocks and Bundle Branch Defects: * Prolonged PR → AV block. * Wide QRS → RBBB or LBBB. 5. Compare with Prior ECGs (if available). ⸻ 5. Key Takeaways for the AANP/ANCC Exam ✅ Recognize STEMI vs. NSTEMI & localize infarction. ✅ Identify life-threatening arrhythmias (VT, VF, AFib with RVR). ✅ Know conduction abnormalities (AV blocks, BBB). ✅ Electrolyte abnormalities can alter ECG findings.

Answer 437

B) Tall R waves in V5-V6

Answer 438

B) Inferior wall MI

Answer 439

B) Atrial fibrillation

Answer 440

B) First-degree AV block

Answer 441

A) Hyperkalemia

Answer 442

A) Left bundle branch block (LBBB)

Answer 443

D) Third-degree (Complete) AV block

Answer 444

Irregularly irregular rhythm, no distinct P waves, narrow QRS complexes. ## Footnote Diagnosis: Atrial fibrillation (AFib). Management: Rate control (Beta-blockers, calcium channel blockers), Anticoagulation (based on CHA₂DS₂-VASc score)

Answer 445

ST-elevation in V2-V4, reciprocal ST depression in leads II, III, aVF. ## Footnote Diagnosis: STEMI (Anterior Wall MI - LAD occlusion). Management: Aspirin, P2Y12 inhibitors (Clopidogrel), Heparin, Urgent PCI or fibrinolysis if PCI unavailable.

Answer 446

Polymorphic VT with “twisting” QRS complexes. ## Footnote Diagnosis: Torsades de Pointes. Management: IV magnesium sulfate, Correct electrolyte imbalances.

Answer 447

Common conditions like: Normal Sinus Rhythm, Atrial Fibrillation, STEMI, Torsades de Pointes. ## Footnote Answers to the ECG Quiz Questions ⸻ Basic ECG Interpretation 1. Which of the following findings suggests left ventricular hypertrophy (LVH)? B) Tall R waves in V5-V6 * Explanation: LVH is characterized by tall R waves in the left-sided leads (V5, V6) and deep S waves in V1-V2. The Sokolow-Lyon criteria for LVH include S wave in V1 + R wave in V5/V6 ≥ 35 mm. 2. What is the most common cause of ST-elevation in leads II, III, and aVF? B) Inferior wall MI * Explanation: ST elevation in leads II, III, and aVF suggests an inferior myocardial infarction, typically caused by occlusion of the right coronary artery (RCA). 3. A patient with a known history of mitral stenosis presents with palpitations. ECG shows an irregularly irregular rhythm without distinct P waves. What is the most likely diagnosis? B) Atrial fibrillation * Explanation: Atrial fibrillation (AFib) is characterized by an irregularly irregular rhythm with no distinct P waves. It is common in mitral stenosis due to left atrial dilation. 4. A prolonged PR interval (>200 ms) without dropped QRS complexes is characteristic of which conduction disorder? B) First-degree AV block * Explanation: First-degree AV block is diagnosed when the PR interval is >200 ms but all P waves are conducted (no dropped beats). ⸻ Advanced ECG Interpretation 5. Which electrolyte imbalance is most likely to cause peaked T waves and a widened QRS? A) Hyperkalemia * Explanation: Hyperkalemia leads to tall, peaked T waves, followed by widened QRS complexes, and can progress to sine-wave ECG (pre-arrest state). 6. A wide QRS complex (>120 ms) with an RSR’ pattern in V1 (“bunny ears”) is diagnostic for which condition? B) Right bundle branch block (RBBB) * Explanation: RBBB presents as a wide QRS complex (>120 ms) with an RSR’ pattern (“bunny ears”) in V1-V2. 7. A 55-year-old male with a history of uncontrolled hypertension presents with syncope. ECG shows an HR of 36 bpm, P waves unrelated to QRS complexes, and a regular escape rhythm. What is the most likely diagnosis? D) Third-degree (Complete) AV block * Explanation: Third-degree (complete) AV block occurs when P waves and QRS complexes are completely dissociated. A ventricular escape rhythm maintains a slow heart rate (~30-40 bpm). Pacemaker placement is required. ⸻ Summary of Key ECG Concepts ✅ LVH: Tall R waves in V5-V6, deep S waves in V1-V2 ✅ Inferior MI: ST elevation in II, III, aVF (RCA occlusion) ✅ Atrial Fibrillation: Irregularly irregular rhythm, no P waves ✅ First-Degree AV Block: PR interval >200 ms, no dropped QRS ✅ Hyperkalemia: Peaked T waves, wide QRS, risk of cardiac arrest ✅ RBBB: Wide QRS, “bunny ears” in V1-V2 ✅ Third-Degree AV Block: P waves independent of QRS, pacemaker required Would you like more board-style practice questions, additional case studies, or another ECG interpretation topic to focus on? Let me know how I can help with your AANP/ANCC exam preparation!

Answer 448

Hypertension is a persistent elevation in blood pressure (BP) readings, measured on at least two separate visits.

Answer 449

Hypertensive Urgency: ≥180/≥120 mmHg with no target organ damage. Hypertensive Emergency: ≥180/≥120 mmHg with signs of end-organ damage.

Answer 450

Primary Hypertension accounts for 90-95% of cases and has no identifiable cause.

Answer 451

Non-modifiable: Age, family history, race (higher risk in African Americans). Modifiable: Obesity, high sodium diet, sedentary lifestyle, smoking, alcohol, stress.

Answer 452

Secondary Hypertension accounts for 5-10% of cases and is caused by an underlying condition.

Answer 453

1. Renal Disease (Chronic Kidney Disease, Renal Artery Stenosis). 2. Endocrine Disorders (e.g., Hyperaldosteronism, Pheochromocytoma, Cushing’s Syndrome). 3. Medications (e.g., NSAIDs, decongestants, steroids). 4. Sleep Apnea. 5. Coarctation of the Aorta.

Answer 454

Most patients are asymptomatic. If symptomatic, they may experience headache, dizziness, visual changes, epistaxis, chest pain, or dyspnea.

Answer 455

Patient should be seated, back supported, feet flat, arm at heart level. No caffeine, smoking, or exercise 30 min prior. Use average of 2+ readings on at least 2 separate visits.

Answer 456

ABPM is the gold standard for differentiating white coat HTN from masked HTN. Hypertension is diagnosed if the 24-hour average is ≥130/80 mmHg.

Answer 457

Lifestyle modifications are the first-line treatment for elevated BP and Stage 1 HTN.

Answer 458

The best initial HTN medications include Thiazides, ACE inhibitors/ARBs, and Calcium Channel Blockers.

Answer 459

Resistant Hypertension may require medications such as Spironolactone for hyperaldosteronism or Alpha-blockers like Doxazosin for BPH & HTN.

Answer 460

A Hypertensive Emergency is characterized by the need for IV medications and the presence of organ damage.

Answer 461

HTN Diagnosis: ≥130/80 mmHg (Stage 1), ≥140/90 mmHg (Stage 2).

Answer 462

White Coat HTN is when office BP is high, but home BP is normal.

Answer 463

Primary Hypertension has no identifiable cause, while Secondary Hypertension is due to renal, endocrine, sleep apnea, or medications.

Answer 464

A 36-year-old male patient.

Answer 465

The patient's body mass index is 23.

Answer 466

Total cholesterol 450 mg/dL, HDL-C 45 mg/dL, LDL-C 360 mg/dL, triglycerides 112 mg/dL.

Answer 467

The patient's father, paternal uncle, and paternal grandfather had hyperlipidemia and early-onset atherogenic cardiovascular disease.

Answer 468

The patient was unable to tolerate any statin medications at low doses due to severe myalgias.

Answer 469

A. Start a PCSK9 inhibitor injection

Answer 470

They are appropriate for patients with familial hypercholesterolemia who cannot tolerate statins or are not at their LDL-C goal with maximally tolerated statins and lifestyle changes.

Answer 471

PCSK9 inhibitors can result in dramatic reductions in LDL-C of up to 70%.

Answer 472

The patient has already tried three moderate- to high-intensity statins and is unlikely to tolerate a fourth.

Answer 473

It is chemically similar to lovastatin and would have the same risks of myalgias as statins.

Answer 474

No, there is no evidence supporting its use for familial hypercholesterolemia. ## Footnote Familial Hypercholesterolemia (FH) & Hyperlipidemia: Deep Dive for the FNP AANP/ANCC Board Exam 1. Overview Hyperlipidemia refers to elevated cholesterol and/or triglyceride levels, which increase the risk of atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease (CAD), stroke, and peripheral artery disease (PAD). A. Primary vs. Secondary Hyperlipidemia * Primary (Genetic) Hyperlipidemia: Inherited disorders leading to high cholesterol levels, e.g., Familial Hypercholesterolemia (FH). * Secondary Hyperlipidemia: Due to lifestyle, metabolic, or medication-induced causes. ⸻ 2. Familial Hypercholesterolemia (FH) FH is a genetic disorder that results in extremely high LDL cholesterol levels, often leading to early-onset ASCVD. A. Pathophysiology * Autosomal dominant disorder caused by mutations in the LDL receptor (LDLR) gene. * Leads to reduced clearance of LDL-C from circulation, resulting in elevated LDL-C levels from birth. Diagnosis of Familial Hypercholesterolemia 1. Clinical Criteria FH is diagnosed using Dutch Lipid Clinic Network (DLCN) criteria, which considers: * LDL-C levels * Family history of hyperlipidemia and ASCVD * Presence of tendon xanthomas or corneal arcus * Genetic testing (not required for diagnosis but confirms FH) Risk Stratification for ASCVD The AHA/ACC guidelines recommend assessing ASCVD risk to guide lipid-lowering therapy. A. ASCVD Risk Enhancers * Family history of premature ASCVD * LDL-C ≥190 mg/dL (suggestive of FH) * Chronic kidney disease * Diabetes mellitus * Smoking, hypertension, metabolic syndrome B. ASCVD Risk Calculator (Pooled Cohort Equation) Used for primary prevention in patients aged 40-75 years to determine statin therapy eligibility. ⸻ 4. Treatment of Hyperlipidemia & FH A. Lifestyle Modifications (For All Patients) However, lifestyle changes alone are insufficient for FH, requiring pharmacologic therapy. Statin Intolerance & Alternative Treatments A. Statin Myopathy & Intolerance * Statins are first-line agents for LDL-lowering but can cause: * Myalgias (muscle pain) * Rhabdomyolysis (rare) * Elevated liver enzymes (AST/ALT) * Management of Statin Intolerance: * Try a different statin (pravastatin, fluvastatin are lower risk) * Alternate-day dosing of atorvastatin or rosuvastatin * Use non-statin agents if intolerance persists B. Non-Statin Therapies Answer Analysis: Why PCSK9 Inhibitor Is Correct A. Case Summary * 36-year-old male with severely elevated LDL-C (360 mg/dL). * Family history of early-onset ASCVD. * Tendinous xanthomas (hallmark of FH). * Intolerance to multiple statins (severe myalgias). B. Why PCSK9 Inhibitor (Answer A) Is Correct * PCSK9 inhibitors (Alirocumab, Evolocumab) reduce LDL by up to 70%. * Best option for patients with FH who cannot tolerate statins. C. Why Other Choices Are Incorrect Key Takeaways for AANP/ANCC Exam ✅ LDL-C >190 mg/dL = Possible Familial Hypercholesterolemia (FH) ✅ FH is an autosomal dominant disorder causing early CAD and tendon xanthomas ✅ First-line treatment for FH = High-intensity statin (unless intolerant) ✅ PCSK9 inhibitors are highly effective in statin-intolerant patients ✅ Ezetimibe can be added for additional LDL lowering but is not as potent as PCSK9 inhibitors

Answer 475

Prevents thromboembolism (stroke, PE, DVT) Reduces mortality in high-risk patients Minimizes complications of AFib-related embolism

Answer 476

To estimate the annual stroke risk in non-valvular atrial fibrillation and determine the need for anticoagulation.

Answer 477

C) Apixaban 5 mg BID ## Footnote CHA₂DS₂-VASc ≥2 in men (high stroke risk) = anticoagulation required. DOACs (e.g., Apixaban) are preferred over warfarin for non-valvular AFib.

Answer 478

C) Warfarin ## Footnote Severe CKD (CrCl <30 mL/min) = Warfarin is preferred. Dabigatran & Edoxaban are contraindicated in CKD.

Answer 479

CHA₂DS₂-VASc Score ≥2 (men) or ≥3 (women) = Anticoagulation Required

Answer 480

DOACs (Apixaban, Rivaroxaban) are preferred over warfarin.

Answer 481

For mechanical heart valves, mitral stenosis, severe CKD.

Answer 482

Helps assess bleeding risk but does not automatically stop anticoagulation.

Answer 483

Andexanet alfa (Xa inhibitors), Idarucizumab (Dabigatran), Vitamin K (Warfarin).

Answer 484

Mitral Valve Prolapse (MVP) is a common valvular abnormality affecting 2-3% of the population, particularly young women. It occurs when the mitral valve leaflets bulge into the left atrium during systole, sometimes leading to mitral regurgitation (MR).

Answer 485

Key features include: • 27-year-old woman, young & active. • Asymptomatic – No signs of heart failure, chest pain, or dyspnea. • History of a heart murmur detected in adolescence.

Answer 486

Physical exam findings include: • Mid-systolic click → Classic hallmark of MVP. • Mid-to-late systolic murmur (Grade II) following the click → Associated with mitral regurgitation due to valve prolapse.

Answer 487

The mitral valve leaflets have redundant, myxomatous degeneration. During systole, the valve 'parachutes' backward into the left atrium. The sudden tensing of chordae tendineae causes the mid-systolic click. If the leaflets fail to close completely, a late systolic murmur follows due to mitral regurgitation.

Answer 488

Mitral Valve Prolapse (MVP) is a common valvular abnormality affecting 2-3% of the population, particularly young women. It occurs when the mitral valve leaflets bulge into the left atrium during systole, sometimes leading to mitral regurgitation (MR).

Answer 489

Key features include: • 27-year-old woman, young & active. • Asymptomatic – No signs of heart failure, chest pain, or dyspnea. • History of a heart murmur detected in adolescence.

Answer 490

Physical exam findings include: • Mid-systolic click → Classic hallmark of MVP. • Mid-to-late systolic murmur (Grade II) following the click → Associated with mitral regurgitation due to valve prolapse.

Answer 491

The mitral valve leaflets have redundant, myxomatous degeneration. During systole, the valve 'parachutes' backward into the left atrium. The sudden tensing of chordae tendineae causes the mid-systolic click. If the leaflets fail to close completely, a late systolic murmur follows due to mitral regurgitation.

Answer 492

A murmur is an abnormal heart sound caused by turbulent blood flow due to: • Valve stenosis (narrowing) • Valve regurgitation (insufficiency) • Septal defects or shunts (VSD, ASD) • Increased blood flow (pregnancy, hyperthyroidism, fever, anemia)

Answer 493

Harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border (RUSB) and radiates to the carotids. ## Footnote Classic triad: Angina, syncope, heart failure.

Answer 494

Valsalva ## Footnote MVP click moves earlier & murmur gets louder with decreased preload (Valsalva, standing).

Answer 495

Grade I-VI murmur classification (thrills start at Grade IV).

Answer 496

Yes, diastolic murmurs are ALWAYS pathologic.

Answer 497

Aortic stenosis has a harsh murmur with carotid radiation, while mitral regurgitation has a blowing murmur with axilla radiation.

Answer 498

MVP has a mid-systolic click & late murmur that gets louder with standing.

Answer 499

Maneuvers include Valsalva, squatting, and handgrip.

Answer 500

Frequent respiratory infections and noticeable fatigue during physical activities.

Answer 501

The patient became short of breath after brief exertion and had a soft systolic murmur at the upper left sternal border.

Answer 502

An echocardiogram.

Answer 503

Atrial septal defect (ASD).

Answer 504

ASDs can lead to increased pulmonary blood flow, manifesting as the patient's clinical presentation.

Answer 505

Abnormal blood flow between the atria.

Answer 506

VSD is more commonly associated with a louder, harsher murmur over the lower left sternal border.

Answer 507

A continuous 'machinery' murmur caused by blood flow between the aorta and pulmonary artery.

Answer 508

It includes four anatomical heart defects and is usually associated with cyanosis and tet spells.

Answer 509

Acute bacterial rhinosinusitis (ABRS).

Answer 510

An ICS/LABA inhaler for asthma therapy and a LNG-IUD for contraception.

Answer 511

Penicillin allergy.

Answer 512

A pink rash on her face and body for a few days.

Answer 513

Cefpodoxime.

Answer 514

It is effective for ABRS and safe given her penicillin allergy history.

Answer 515

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Answer 516

It has poor activity against Streptococcus pneumoniae, leading to a high risk of treatment failure.

Answer 517

It is a penicillin and the patient has a reported penicillin allergy.

Answer 518

It has limited activity against the ABRS organisms.

Answer 519

Choose a therapy that is both safe and effective for the patient.

Answer 520

72 years old

Answer 521

One day history of fever, productive cough with yellow sputum, and increasing shortness of breath

Answer 522

Temp 99.8 °F (37.6 °C), BP 140/85, heart rate 98 bpm, respiratory rate 22, O2 saturation 94% on room air

Answer 523

Hypertension and type 2 diabetes, both at guideline-based goals

Answer 524

Former smoker, quit 35 years ago, with a 25-pack year history

Answer 525

Crackles in right lower lung fields, no wheezing, can speak in complete sentences, moist mucous membranes

Answer 526

Reported voiding approximately 1 hour ago

Answer 527

Denies GI distress but states appetite is not what it usually is

Answer 528

Lives in a single-story home with spouse and adult child

Answer 529

Mild leukocytosis, renal function within normal limits, no evidence of anemia

Answer 530

Right lower lobe infiltrate consistent with pneumonia

Answer 531

At home with careful follow-up ## Footnote The correct answer is B. “Keep in mind, with the exception of the worst years of the COVID-19 pandemic, pneumonia has remained the number one cause of infectious disease death. Period. Full stop.” “Community-acquired pneumonia is defined as an infection of the bronchi and the lungs per increment acquired while residing in the community and usually in a patient who can be treated in the outpatient setting. What is often not appreciated by health care providers whose experience is largely reflective of inpatient hospital care, the community is the most common location for pneumonia care, and hence why, in part, it's called community-acquired pneumonia, AKA CAP.” “One of the most important parts of treating a person with CAP is to determine whether the patient is able to be safely and effectively treated as an outpatient for this potentially fatal disease. A number of factors figure into this, including the patient's GI function, presence of a helpful caregiver at home, health literacy, ability for clinical follow-up, and relatively stable vital signs, as well as knowing concerning clinical findings, including lab and x-ray. In addition, a number of clinical predictive tools have been developed to help determine where the patient would be best treated.” From NP Certification Q&A: Pneumonia Treatment, Jul 1, 2024 “Some of the more commonly used tools include the CURB65 and the PSI, or the Pneumonia Severity Index. For those of you who practice in the inpatient setting, you are probably familiar with the PSI, and it includes more data that can be added to it than CURB65.” From NP Certification Q&A: Pneumonia Treatment, Jul 1, 2024 “You should know that there are standardized scales for seeing where a person would be best treated for community acquired pneumonia.” From NP Certification Q&A: Pneumonia Treatment, Jul 1, 2024 .

Answer 532

A 35-year-old woman.

Answer 533

15+ year history of recurrent cramping abdominal pain.

Answer 534

The pain is often relieved with defecation.

Answer 535

Bloating and a change in stool frequency and form.

Answer 536

Symptoms occur particularly when 'I eat certain foods.'

Answer 537

Bloody or tarry stools, nausea, vomiting, or fever.

Answer 538

The patient's weight is stable, and there is no evidence of anemia.

Answer 539

Irritable bowel syndrome. ## Footnote The most likely diagnosis here then will actually be option A.

Answer 540

35 years old

Answer 541

Defecation

Answer 542

Bloating and a change in stool frequency and form

Answer 543

Eating certain foods

Answer 544

Bloody or tarry stools, nausea, vomiting, or fever

Answer 545

It is stable

Answer 546

No evidence of anemia

Answer 547

Irritable bowel syndrome ## Footnote Other options include Paralytic ileus, Peptic ulcer disease, and Ulcerative colitis.