Unit 2 Part 1

Question 1

Which type of headache often requires further investigations due to its association with underlying medical conditions?
a. Tension-type headache
b. Cluster headache
c. Migraine with aura
d. Secondary headache

Answer 1

D
Secondary headaches are symptoms of underlying medical conditions and often require further investigations to identify and treat the root cause.

Question 2

What distinguishes migraine with aura from migraine without aura?
a. Presence of nausea
b. Location of pain
c. Duration of headache
d. Presence of neurological symptoms

Answer 2

D
Migraine with aura is characterized by specific neurological symptoms (such as visual disturbances) that precede or accompany the headache, whereas migraine without aura does not have these warning signs.

Question 3

A patient reports recurrent headaches occurring 1 or 2 times per month that generally occur with weather changes or when sleep patterns are disrupted. They are described as severe, with throbbing on one side of the head and sometimes accompanied by nausea. What is the recommended abortive treatment for this type of headache?
a. Gabapentin
b. Propranolol
c. Ergotamine tartrate
d. Topiramate

Answer 3

C
This patient describes migraine headache without aura and has fewer than 4 per month. An abortive medication, such as ergotamine tartrate, is recommended. The other medications are preventive medications and are used for patients having more than 4 per month.

Question 4

A patient has recurrent cluster headaches and asks about abortive therapy. Which therapy is effective for most patients with cluster headaches?
a. Lithium
b. NSAIDs
c. Oxygen
d. Verapamil

Answer 4

C
Oxygen works as abortive therapy for cluster headaches in 75% of patients and should be inhaled at the start of an attack. Lithium and verapamil work well as preventive medications for cluster headaches but are not given for abortive treatment. NSAIDs are not useful.

Question 5

Which medications may be useful in treating tension-type headache? (Select all that apply.)
a. Triptan drugs
b. Lithium
c. Muscle relaxants
d. NSAIDs
e. Oxygen

Answer 5

A, C, D
Triptan drugs, muscle relaxants, and NSAIDs may all be used to treat tension-type headaches. Lithium and oxygen are not used.

Question 6

Which headache type is characterized by severe throbbing pain, often unilateral, and is frequently associated with nausea, vomiting, and sensitivity to light and sound?

A. Tension headache
B. Cluster headache
C. Migraine
D. Red-flag headache

Answer 6

C
Migraines typically present with severe throbbing pain, often on one side of the head, and are associated with additional symptoms like nausea, vomiting, and sensitivity to light and sound.

Question 7

Which headache type is characterized by excruciating pain around the eye, tearing, and nasal congestion, often occurring in clusters multiple times a day for weeks to months?

A.Tension headache
B. Cluster headache
C. Migraine
D. Red-flag headache

Answer 7

B
Cluster headaches are known for their severe, stabbing pain around the eye and occur in clusters, with multiple attacks per day for a defined period.

Question 8

A patient presents with a gradual onset of a mild to moderate, steady, band-like headache that is usually bilateral and not aggravated by physical activity. Which type of headache is most likely?

A. Tension headache
B. Cluster headache
C. Migraine
D. Red-flag headache

Answer 8

A
Tension headaches typically present with a steady, band-like headache that is usually bilateral and not aggravated by physical activity.

Question 9

In the context of secondary headaches, which feature should raise concerns and prompt further evaluation?

A. Gradual onset
B. Neurological deficits
C. Bilateral pain
D. Mild intensity

Answer 9

B
Neurological deficits. Any unusual neurological symptoms should raise concerns and prompt further evaluation to rule out serious underlying causes of secondary headaches.

Question 10

What is a non-pharmacological approach commonly recommended for managing tension headaches?

A. Oxygen therapy
B. Stress management
C. Triptans
D. Muscle relaxants

Answer 10

B
Stress management. Non-pharmacological approaches for tension headaches often include stress management techniques, relaxation exercises, and lifestyle modifications.

Question 11

What is the recommended approach for managing rebound headaches caused by overuse of pain medications?

A. Continue the current medications
B. Gradually taper off the offending medications
C. Increase the dosage of pain medications
D. Switch to a different class of pain medications

Answer 11

B
Gradually taper off the offending medications. Rebound headaches caused by overuse of pain medications are best managed by gradually tapering off the offending medications under medical supervision.

Question 12

A 35-year-old patient reports suddenly experiencing an asymmetric smile along with drooping and tearing in one eye. The patient has a history of a recent viral illness but is otherwise healthy. During the exam, the provider notes that there is unilateral full-face paralysis on the right side. What is the initial intervention for this patient?
a. Perform confirmatory diagnostic tests.
b. Prescribe oral corticosteroids.
c. Recommend wearing an eye patch.
d. Refer the patient to a neurologist.

Answer 12

B
Steroids are highly effective and increase the probability of complete nerve recovery and should be started within 72 hours of onset. There are no confirmatory diagnostic tests, but other tests may be performed to rule out certain causes. Patients may be instructed to tape the eye closed at night, but eye patches are not recommended. A neurology referral is needed only if patients have an atypical presentation or other comorbid conditions.

Question 13

What is recommended to prevent ophthalmic complications in patients with Bell’s palsy?
a. Acupuncture
b. Lubricating eye drops
c. Patching of the eye
d. Sunglasses

Answer 13

B
Exposure keratitis from drying of the eye can result in blindness. Lubricating eye drops should be used every 2 hours. Acupuncture has not been sufficiently studied. Patching is not recommended. Protective eyewear to prevent moisture loss is recommended.

Question 14

Which symptoms may occur with Bell’s palsy? (Select all that apply.)
a. Alteration in taste
b. Decreased hearing
c. Drooling
d. Inability to open the eye
e. Tinnitus

Answer 14

A, C, E
Bell’s palsy may cause altered taste, drooling, and tinnitus. It causes increased sensitivity to noises and an inability to close the eye.

Question 15

A patient reports paroxysms of burning, shock-like pain on both sides of the face usually triggered by chewing or talking. The provider suspects trigeminal neuralgia. Based on these presenting symptoms, what testing is indicated?
a. Autoimmune laboratory panel
b. Inflammatory markers
c. Magnetic resonance imaging (MRI)
d. Plain radiographs

Answer 15

C
Trigeminal neuralgia is a clinical diagnosis. Pain on both sides of the face raises a suspicion for multiple sclerosis and MRI is done to corroborate the presence of MS. Autoimmune laboratory pane is performed if alternative diagnoses are suspected. Inflammatory markers are not diagnostic. Plain radiographs are not indicated.

Question 16

A patient is diagnosed with trigeminal neuralgia and reports having paroxysms several times each day. What is the initial treatment for this patient?
a. A combination of baclofen, lamotrigine, and phenytoin
b. A high dose of carbamazepine with subsequent titration downward
c. Botox injections or intranasal lidocaine as needed
d. Low doses of anticonvulsants with gradual increase as needed

Answer 16

B
Anticonvulsants are first-line treatments for trigeminal neuralgia – carbamazepine is started at the maximum therapeutic dose and titrated down to the lowest effective dose. Combination drug therapy is begun if the initial treatment is not effective or if the single drug regimen has intolerable side effects. Botox injections and intranasal lidocaine are used as adjuncts to anticonvulsants for acute pain relief.

Question 17

A patient diagnosed with trigeminal neuralgia has tried several medication regimens to control pain without success. What is the next step in management for this condition?
a. Consultation with a psychiatrist
b. Education about alternative treatments
c. Recommending a pain center
d. Referral to a neurosurgeon

Answer 17

D
Referral to a neurosurgeon is indicated after medical therapies have been exhausted. The other options may be included in long-term care, but a neurosurgery referral is warranted.

Question 18

What is a characteristic feature of Trigeminal Neuralgia?

a. Facial weakness
b. Recurrent stabbing pain in the face
c. Difficulty closing the eye
d. Ear pain

Answer 18

B
Trigeminal Neuralgia is known for sudden-onset, severe, stabbing pain along the trigeminal nerve distribution. Options a, c, and d are not typical of Trigeminal Neuralgia.

Question 19

Why is early intervention important in Bell’s Palsy?

a. To prevent corneal damage and protect the eye
b. To reduce facial swelling
c. To minimize ear pain
d. To prevent facial asymmetry

Answer 19

A
Early intervention in Bell’s Palsy helps protect the affected eye from complications like corneal abrasions. Options b, c, and d are not the primary reasons for early intervention in Bell’s Palsy.

Question 20

What is a common first-line treatment for Trigeminal Neuralgia?

a. Oral steroids
b. Antibiotics
c. Anticonvulsant medications
d. Surgical decompression

Answer 20

C
Anticonvulsants, such as carbamazepine, are commonly used as a first-line treatment for Trigeminal Neuralgia.

Question 21

Which patient would benefit from a polysomnography evaluation to assess a potential sleep disorder?
a. A child with enlarged tonsils who has daytime sleepiness
b. A patient with gastroesophageal reflux disease (GERD) who has difficulty falling asleep
c. A shift worker who has trouble adjusting to new schedules
d. An elderly woman with osteoarthritis who has difficulty staying asleep

Answer 21

A
The child with enlarged tonsils is likely to have obstructive sleep apnea and would benefit from polysomnography (PSG) to help diagnose this problem. The other patients have sleep disorders related to other conditions that interfere with comfort or circadian rhythms and would not benefit from PSG.

Question 22

A patient who has excessive daytime sleepiness tells the practitioner that he goes to bed and gets up at the same time each day but still wakes up tired. The spouse reports that the patient snores so much she has had to move to another bedroom. The patient is otherwise healthy and does not take any medications or drink alcohol. Which diagnostic test may be performed for this patient?
a. Full overnight polysomnography (PSG)
b. Multiple sleep latency test (MSLT)
c. Overnight pulse oximetry
d. Unattended out of center sleep testing (OCST)

Answer 22

D
This patient has a high probability of OSA without significant comorbidities or use of medications that may cause central sleep apnea, so this test, which has more limited measures than a full PSG, may be performed. Full overnight PSG is used when the cause of sleep apnea is less certain to help determine whether there is a central cause. The multiple sleep latency test is used to test EDS symptoms. Overnight pulse oximetry is not sufficiently sensitive to be a reliable screening for sleep apnea.

Question 23

A patient is diagnosed with mild restless leg syndrome (RLS) which occasionally interferes with sleep. Which initial treatment will be helpful?
a. A continuous positive airway pressure (CPAP) devices
b. A dopaminergic agonist
c. Hot baths and exercise
d. Supplemental iron

Answer 23

C
Patients with mild restless leg syndrome (RLS) may benefit from massage, hot baths, exercise, and good sleep hygiene. CPAP is used for obstructive sleep apnea. Dopaminergic agonists are useful medications but have a risk of rebound or augmentation of effects.
Supplemental iron is used in patients with low ferritin levels.

Question 24

A patient is noted to have prolonged bleeding after an intravenous needle is removed. A subsequent laboratory test reveals a prolonged activated partial thromboplastin (aPTT) time with a normal prothrombin time (PT). Based on this result, the provider may suspect alteration in function of which factor?
a. Factor V
b. Factor VII
c. Factor VIII

Answer 24

C
Factor VIII is part of the intrinsic system, which aPTT measures. The other factors are part of the extrinsic system, which is measured by PT.

Question 25

A male patient has a history of recurrent epistaxis. Prior to a scheduled surgery, the provider asks about a family history of bleeding disorders. The patient reports no female relatives who had excessive bleeding episodes, but states that a maternal uncle and his maternal grandfather both had postsurgical complications related to bleeding. Based on this history, which diagnosis is possible?
a. Hemophilia
b. Thrombocytopenia
c. Thrombophilia
d. Von Willebrand disease

Answer 25

A
Hemophilia is an X-linked recessive disorder affecting only males and carried by females. A family history of maternal males with bleeding disorders should clue the provider that this disorder is likely. Thrombocytopenia is usually an acquired disorder. Thrombophilia causes clots and thrombi, not bleeding. Von Willebrand disease is an autosomal genetic disorder affecting both males and females.

Question 26

A patient has type 1 Von Willebrand disease (vWD). What treatment is generally effective to prevent and treat bleeding episodes in this patient?
a. Coagulation factor
b. Desmopressin
c. Heparin
d. Vitamin K

Answer 26

B
Desmopressin may be useful in patients with type 1 vWD. Coagulation factor is used in most patients with hemophilia. Heparin is an anticoagulant. Vitamin K is used to counter warfarin overdose.

Question 27

A patient who has chronic lower back pain reports increased difficulty sleeping unrelated to discomfort, along with a desire to quit working. What will the provider do?
a. Ask the patient about addiction issues.
b. Consult with a social worker.
c. Increase the dosage of prescribed pain medications.
d. Order radiographic studies of the lower spine.

Answer 27

B
Patients who exhibit poor sleep and poor coping may be developing mental defeat as a result of chronic pain and should be evaluated and treated early for this to prevent further disability and improve functionality. Substance abuse may be a part of mental defeat and should be evaluated based on assessment findings. Unless the symptoms are related to pain, increasing the dose of analgesics and ordering diagnostic studies are not indicated.
2. A patient with chronic leg pain describes the pain as “stabbing” and “throbbing.”

Question 28

A patient with chronic leg pain describes the pain as “stabbing” and “throbbing.” This is characteristic of which type of pain?
a. Neuropathic pain
b. Referred pain
c. Somatic pain
d. Visceral pain

Answer 28

C
Somatic pain is caused by the activation of nociceptors in the peripheral tissues, including skin, bones, muscles, and soft tissue and is usually well-localized and characterized as stabbing, aching, or throbbing. Neuropathic pain occurs from injury to or disease of the nervous system and is described as burning, shooting, or tingling. Referred pain is a kind of visceral pain that is localized, but not attributable to the involved organ. Visceral pain is related to an organ and is often referred and poorly localized.

Question 29

A patient develops a dry, nonproductive cough and is diagnosed with bronchitis. Several days later, the cough becomes productive with mucoid sputum. What may be prescribed to help with symptoms?
a. Antibiotic therapy
b. Antitussive medication
c. Bronchodilator treatment
d. Mucokinetic agents

Answer 29

B
Antitussive medications are occasionally useful for short-term relief of coughing. Antibiotic therapy is generally not needed and should be avoided unless a bacterial cause is likely.
Bronchodilator medications show no demonstrated reduction in symptoms and are not recommended. Mucokinetic agents have no evidence to support their use.

Question 30

An adult patient who had pertussis immunizations as a child is exposed to pertussis and develops a runny nose, low-grade fever, and upper respiratory illness symptoms without a paroxysmal cough. What is recommended for this patient?
a. A prescription for a macrolides
b. Isolation if paroxysmal cough develops
c. Pertussis vaccine booster
d. Symptomatic care only

Answer 30

A
Adults previously immunized against pertussis may still get the disease without the classic whooping cough sign seen in children and are contagious from the beginning of the catarrhal stage of runny nose and common cold symptoms. Macrolide antibiotics are useful for reducing symptoms and for decreasing shedding of bacteria to limit spread of the disease.
Patients should be isolated for 5 days from the start of treatment. Pertussis vaccine booster will not alter the course of the disease once exposed. Symptomatic care only will not reduce symptoms or decrease disease spread.

Question 31

A 35-year old patient develops acute viral bronchitis. Which is the focus for the management of symptoms in this patient?
a. Trimethoprim-sulfamethoxazole therapy
b. Antibiotic therapy
c. Supportive care
d. Antitussive therapy

Answer 31

C
The mainstay of treatment in acute bronchitis is directed toward symptom reduction and supportive care. Data suggest that 85% of patients diagnosed with acute bronchitis will improve without specific treatment. Trimethoprim-sulfamethoxazole is prescribed for pertussis when macrolides are not an option. Antibiotic therapy is not effective in treating viral acute bronchitis.

Question 32

A patient presents to an emergency department reporting chest pain. The patient describes the pain as being sharp and stabbing and reports that it has been present for several weeks. Upon questioning, the examiner determines that the pain is worse after eating. The patient reports getting relief after taking a friend’s nitroglycerin during one episode. What is the most likely cause of this chest pain?
a. Aortic dissection pain
b. Cardiac pain
c. Esophageal pain
d. Pleural pain

Answer 32

C
Pain that is constant for weeks or is sharp and stabbing is not likely to be cardiac in origin. Both esophageal and cardiac causes will be attenuated with sublingual nitroglycerin. Aortic dissection will cause an abrupt onset with the greatest intensity at the beginning of the pain. Pleural pain is usually related to deep breathing or cough.

Question 33

When a patient reports experiencing chronic chest pain that occurs after meals, the provider suspects gastroesophageal reflux disease (GERD) and prescribes a proton pump inhibitor. After 2 months the patient reports improvement in symptoms. What is the next action in treating this patient?
a. Wean patient from proton pump inhibitor (PPI)
b. Order esophageal pH monitoring.
c. Refer the patient to a gastroenterologist.
d. Schedule an upper endoscopy.

Answer 33

A
Often the effectiveness of treatment with a PPI is diagnostic and is equal to or better than more invasive and expensive testing. If the patient continues to show improvement, the patient is weaned off of the PPI. Most patients do well and there is no need to order tests or refer for evaluation. If patients do not do well, further testing is needed.

Question 34

A high school athlete reports recent onset of chest pain that is aggravated by deep breathing and lifting. A 12-lead electrocardiogram in the clinic is normal. The examiner notes localized pain near the sternum that increases with pressure. What will the provider do next?
a. Order a chest radiograph.
b. Prescribe an antibiotic.
c. Recommend an NSAID.
d. Refer to a cardiologist.

Answer 34

C
This patient has symptoms consistent with chest wall pain because chest pain occurs with specific movement and is easily localized. Since the ECG is normal, there is no need to refer to a cardiologist. The patient does not have symptoms of pneumonia, so a radiograph or antibiotic is not needed. NSAIDs are recommended for comfort.

Question 35

A patient presents with a cough and fever. The provider auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient’s pneumonia?
a. A virus
b. Mycoplasma
c. S. pneumoniae
d. Tuberculosis

Answer 35

B
Atypical pneumonias, such as those caused by mycoplasma, often present with headache and sore throat and will have larger areas of infiltrate on chest radiograph. Viral pneumonias show more diffuse radiographic findings. S. pneumonia will have high fever and cough and distinct areas of infiltration.

Question 37

A young, previously healthy adult clinic patient reports symptoms of pneumonia including high fever and cough. Auscultation reveals rales in the left lower lobe. A chest radiograph is normal. The patient is unable to expectorate sputum. Which treatment is recommended for this patient?
a. A B-lactam antibiotic plus a fluoroquinolone
b. A respiratory fluoroquinolone antibiotic
c. Empirical treatment with a macrolide antibiotic
d. Hospitalization for intravenous antibiotics

Answer 37

C
This patient likely has community-acquired pneumonia. The patient has typical symptoms and, even though the chest radiograph is normal, will require outpatient treatment. For community-acquired pneumonia in a previously healthy individual, treatment with a macrolide antibiotic is the recommended first-line therapy. B-lactam plus fluoroquinolone therapy is used for patients in the ICU. Respiratory fluoroquinolones are used for patients with underlying disorders who develop pneumonia. Hospitalization is not necessary.

Question 38

Which risk assessment for coronary artery disease is recommended for all female patients?
a. Coronary artery calcium score
b. Electrocardiogram
c. Exercise stress test
d. Framingham risk score

Answer 38

D
The Framingham risk score is a quick method for identifying potential risk for CAD and can
guide providers in choosing subsequent tests based on risk level. The ECG is performed on women with risk factors. The exercise stress test is useful in symptomatic women who have a normal ECG. The CACS may be used if moderate risk is present.

Question 38

A patient was initially treated as an outpatient for pneumonia and then after 2 weeks was hospitalized after no improvement was evident. The patient continues to show no improvement after several antibiotic regimens have been attempted. What is the next step in managing this patient?
a. Administration of the pneumonia vaccine
b. Increasing the dose of the antibiotics
c. Open lung biopsy
d. Performing diagnostic bronchoscopy

Answer 38

D
Patients who do not respond to antibiotic therapy may have opportunistic fungal or other infections, bronchogenic carcinoma, or other diseases. Bronchoscopy can exclude or confirm these. The pneumonia vaccine is preventative for pneumococcal causes and will not help this patient. Increasing the dose of the antibiotics is not recommended. Open lung biopsy may be performed if a bronchoscopy is inconclusive.

Question 39

A patient reports recurrent chest pain that occurs regardless of activity and is not relieved by rest. The provider administers a nitroglycerin tablet which does not relieve the discomfort. What is the next action?
a. Administer a second nitroglycerin tablet.
b. Give the patient a beta blocker medication.
c. Prescribe a calcium channel blocker mediation.
d. Start aspirin therapy and refer the patient to a cardiologist.

Answer 39

B
Patient with these symptoms who do not respond to nitroglycerin is likely to have microvascular angina. Treatment is effective with beta blockers. These symptoms are not characteristic of acute MI, so aspirin is not given. A second nitroglycerin tablet is used for classic angina. Calcium channel blockers are not indicated.

Question 40

A patient is brought to an emergency department with symptoms of acute ST-segment elevation MI (STEMI). The nearest hospital that can perform percutaneous coronary intervention (PCI) is 3 hours away. What is the initial treatment for this patient?
a. Administer heparin.
b. Give the patient an oral beta blocker.
c. Initiate fibrinolytic treatment
Transfer to the PCI-capable facility

Answer 40

C
Fibrinolytic therapy should be administered to any patient with evolving STEMI within 30 minutes of the time of first medical contact. Patients more than 120 minutes away from a PCI-capable hospital should be given fibrinolytic therapy since PCI should be performed within 90 minutes if possible. Giving heparin or beta blockers is not helpful.

Question 41

A patient who has been diagnosed with heart failure for over a year reports being comfortable while at rest but experiences palpitations and dyspnea when walking to the bathroom. Which classification of heart failure is appropriate based on these symptoms?
a. Class I
b. Class II
c. Class III
d. Class IV

Answer 41

Patients with Class II heart failure (HF) will have slight limitation of activity and will be comfortable at rest with symptoms occurring with ordinary physical activity. Patients with Class I HF do not have limitations and ordinary physical activity does not produce symptoms. With Class III HF, less than usual activity will produce symptoms. With Class IV HF, symptoms are present even at rest and all physical activity worsens symptoms.

Question 42

Which patient meets the criteria for statin therapy to help prevent atherosclerotic cardiovascular disease? (Select all that apply.)
a. A 55-year old with a history of congestive health failure (CHF)
b. A 70-year old nondiabetic with a 10-year risk score of 7.5% with an LDL-C of 80 mg/dL
c. An otherwise healthy 25-year old with a low-density lipoprotein (LDL-C) level of 196 mg/dL
d. A 45-year old diabetic with an LDL-C of 150 mg/dL
e. A 60-year old with a history of myocardial infarction

Answer 42

B, C, D, E
Adults with a history of known cardiovascular disease, including stroke, caused by atherosclerosis; those with LDL-C level of greater than 190 mg/dL; adults 40 to 75 years, with diabetes; adults 40 to 75 years, with LDL-C level of 70 to 189 mg/dL and a 5% to 19.9%
10-year risk of developing cardiovascular disease from atherosclerosis, with risk enhancing factors; adults 40 to 75 years, with LDL-C level of 70 to 189 mg/dL and a 20% or greater 10-year risk of developing cardiovascular disease from atherosclerosis.

Question 43

A patient experiencing heart failure with reduced ejection fraction will have which symptoms?
a. Dyspnea and fatigue without volume overload
b. Impairment of ventricular filling and relaxation
c. Mild, exertionally related dyspnea
d. Pump failure from left ventricular systolic dysfunction

Answer 43

D
Heart failure with reduced ejection fraction results in pump failure from ventricular systolic dysfunction. Heart failure with preserved ejection fraction may have milder symptoms and is associated with impairment of ventricular filling and relaxation.

Question 44

A patient who has Class II heart failure is taking an ACE inhibitor and reports a recurrent cough that does not interfere with sleep or activity. What will the provider do initially to manage this patient?
a. Assess serum potassium and sodium immediately
b. Discontinue the ACE inhibitor and prescribe an ARB
c. Provide reassurance that this is a benign side effect
d. Withhold the drug and evaluate renal and pulmonary function

Answer 44

C
Cough occurs in about 20% of patients who take ACE inhibitors and is not dangerous. The patient should be reassured that this is the case. If the cough is annoying, alternate therapy with an ARB may be considered. It is not necessary to evaluate electrolytes, renal function, or pulmonary function.