During a new office visit your 70 year-old patient complains of being easily short of breath and is often tired.  He has been a smoker for 50 years.  On exam you hear decreased breath sounds bilaterally , hyperresonance and hypertrophied accessory muscles.  His hematocrit it elevated and his pulmonary function test shows increased total lung capacity with FEV1 of 60%.  His mMRC is 3. How would you treat him?

A 45 year old female with significant past medical history of fibromyalgia, chronic pain, high cholesterol and hypertension comes into the office for depression. She currently takes HCTZ 25mg, Lisinopril 20mg and atorvastatin 40mg and tylenol 500mg daily. After your assessment, you determine she would benefit from treatment of her depression. What is the best medication choice for her?

A 27 year old new married patient comes to your office for elevated blood pressure. She notes that she was seen at a health fair and her blood pressure was 160/85 so they told her to come to the office. She has a long family history of hypertension in her mother, father, brother and grandparents. She is planning to get pregnant in the next year and wants to know what would be the best blood pressure medication to use. Which of the following shows evidence of being the safest for a pregnant patient?

Side effects of SSRI’s include the following: nausea, vomiting, GI upset and sexual dysfunction.

A 57 year old male presents to the office for a physical and lab review. You note that his blood pressure is 180/90. He indicates that he has been very stressed out lately and that he has been having daily headaches. A repeat blood pressure in the office shows the patient continues to be elevated at 182/96. His last office visit showed his blood pressure to be 150/88 and at that time you counseled him on diet, exercise and weight loss. His most recent labs show elevated creatinine at 2.0 with a decrease in GFR to 55. His urine dipstick is negative for ketone, glucose and bilirubin but positive for protein. What is the most appropriate next step for him?

A 64 year old woman presents to the office with concerns regarding her “joint problem”. She does not recall the name of her condition, but reports that she has had several flares in her big toe over the past 2 years.  A doctor once told her it causes crystals to get stuck in her joints and this causes pain, swelling, and redness. She has a significant past medical history for HTN, hyperlipidemia, and asthma. She takes the following medications: hydrochlorothiazide, simvastatin, aspirin, and prn albuterol. As her PCP you include all of the following in your plan for her “joint problem” (choose all that apply) :

A 72 year old patient with diabetes, hypertension and high cholesterol presents to the office for a follow-up to his osteoarthritis knee pain. He started taking tylenol for the pain but reports that this has not been helpful. His current medications are insulin, losartan, asprin and simvastatin. His creatinine is 2.4 and A1c is 6.3%. His vital signs are all normal. All of the following would be acceptable treatment options except which?

A 32 year old female presents to the office for complaints of dysuria, incomplete bladder emptying and blood in urine. On exam you note a fever of 101.4 and CVA tenderness. The remainder of her vitals and exam are stable. She is allergic to sulfa. Her urine is positive for blood, +leukocytes and +nitrates. How would you treat her?

A 18 year old female presents to the office complaining of diffuse abdominal pain, fever, nausea and vomiting.  On exam you note a fever of 101.6 and heart rate of 116, but the remainder of her vital signs are normal. On examination, she has guarding and rebound tenderness. She has abdominal pain when passively extending her thigh lying on her side with knees extended and with active flexion of her thigh. What dose she have and what are your recommendations?

A 24 year old obese female presents to the office for evaluation of hypertension. She indicates she recently has been having headaches and asked the nurse at work to check her blood pressure which was 145/92. You review her chart and note that the last two readings were 145/92 and 148/90. Today she presents and her blood pressure is 144/92. The remainder of her vital signs and exam are normal. She indicates that she was recently married and they are trying to start a family, but thought perhaps all the recent changes have been too stressful and increased her blood pressure. What are your recommendations for her?