Question 1. (2 pts): Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend:
a. testosterone therapy.
b. estrogen-only therapy.
c. nonhormonal drugs for osteoporosis.
d. estrogen-progesterone therapy for 1 to 2 years.
Question 2. (2 pts): A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe:
a. aprepitant (Emend).
b. ondansetron (Zofran).
c. scopolamine transdermal.
d. prochlorperazine (Compazine).
Question 3. (2 pts): A 75-year-old patient who has cardiovascular disease reports insomnia and vomiting for several weeks. The primary care NP orders thyroid function tests. The tests show TSH is decreased and T4 is increased. The NP should consult with an endocrinologist and order:
Question 4.(2pts): A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should:
a. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.
b. perform a careful cardiovascular physical assessment.
c. counsel the patient about dietary and lifestyle changes.
d. order a urinalysis and creatinine clearance and begin therapy with a b-blocker.
Question 5. (2 pts): A patient reports fatigue, weight loss, and dry skin. The primary care nurse practitioner (NP) orders thyroid function tests. The patient’s thyroid stimulating hormone (TSH) is 40 microunits/mL, and T4 is 0.1 ng/mL. The NP should refer the patient to an endocrinologist and prescribe:
Question 6. (2 pts): When prescribing a medication for a chronic condition, the primary care NP should tell the patient:
a. to contact the pharmacy whenever refills are needed.
b. that it is necessary to return to the clinic for each monthly refill of the medication.
c. about the frequency of clinic visits necessary for the number of refills authorized.
d. to ask the pharmacist to supply several months' worth of the medication at a time.
Question 7. (2 pts): A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child weighs 15 kg. The primary care NP sees the child for a 3-year-old check-up. The NP should consult with a pediatric endocrinologist to discuss:
a. increasing the dose to 90 mcg/day.
b. decreasing the dose to 30 mcg/day.
c. stopping the medication and checking TSH and T4 in 4 weeks.
d. discussing the need for lifetime replacement therapy with the child's parents.
Question 8. (2 pts): A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend:
a. 25 g of fiber each day.
b. avoiding gluten and lactose in the diet.
c. increasing water intake to eight to ten glasses per day.
d. beginning aerobic exercise, such as running, every day.
Question 9. (2 pts): A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and:
a. take one cycle of COCPs.
b. take a home pregnancy test.
c. use condoms for the next 7 days.
d. contact the clinic if she misses a period.
Question 10. (2 pts): A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe:
a. mesalamine (Asacol).
b. dicyclomine (Bentyl).
c. simethicone (Phazyme).
d. metoclopramide (Reglan).
Question 11. (2 pts): A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, “Dispense as Written.” The NP should explain that a different brand of this drug:
a. may cause different adverse effects.
b. does not necessarily have the same therapeutic effect.
c. is likely to be less safe than the brand specified in the prescription.
d. may vary in the amount of drug that reaches the site of action in the body.
Question 12. (2 pts): A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The primary care NP notes thready, rapid pulses and 3-second capillary refill. An ECG reveals a heart rate of 198 beats per
a. administer intravenous fluids and obtain serum electrolytes.
b. administer amiodarone in the clinic and observe closely for response.
c. order digoxin and verapamil and ask the patient to return for a follow-up examination in 1 week.
d. send the patient to an emergency department for evaluation and treatment.
Question 13. (2 pts): An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary care NP that she likes the fact that she won’t have to deal with pills or periods. The primary care NP should tell her that she:
a. should consider another form of contraception after 1 year.
b. may have irregular bleeding, especially in the first month or so.
c. will need to take calcium and vitamin D every day while using this method.
d. will have to take oral contraceptive pills in addition to Depo-Provera when she takes antibiotics.
Question 14. (2 pts): A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss:
a. changing to amlodipine.
b. ordering renal function tests.
c. increasing the dose of nifedipine.
d. evaluation of left ventricular function.
Question 15. (2 pts): A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest, determined to be from long QT syndrome. The NP should:
a. schedule a treadmill stress test.
b. order genetic testing for this patient.
c. discontinue the trimethoprim-sulfamethoxazole.
d. refer the patient to a cardiologist for further evaluation.
Question 16. (2 pts): A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order:
a. a b-blocker.
b. an angiotensin-converting enzyme inhibitor.
c. a thiazide diuretic.
d. dietary and lifestyle changes.
Question 17. (2 pts): A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to:
a. order LH and FSH levels.
b. order a serum prolactin level.
c. prescribe testosterone replacement.
d. obtain a morning serum testosterone level.
Question 18. (2 pts): A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone (Phazyme), and a TCA. She reports having continued severe diarrhea. The primary care NP should:
a. order diphenoxylate (Lomotil).
b. prescribe alosetron after ruling out pregnancy.
c. refer her to a gastroenterologist for endoscopy.
d. increase the fiber in her diet to 30 g per day.
Question 19. (2 pts): A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pyloriis still present. The NP should order:
a. continuation of the PPI for 4 to 8 weeks.
b. a PPI, amoxicillin, and metronidazole for 14 days.
c. a PPI, clarithromycin, and amoxicillin for 14 more days.
d. a PPI, bismuth subsalicylate, tetracycline, and metronidazole.
Question 20. (2 pts): A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme:
Question 21. (2 pts): The primary care NP sees a new patient who has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. The patient’s blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should:
a. order a b-blocker.
b. add an angiotensin-converting enzyme inhibitor.
c. continue the current drug regimen.
d. change to an aldosterone antagonist medication.
Question 22. (2 pts): A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the clinic after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP should:
a. obtain a stool specimen and order vancomycin.
b. order testing for Clostridium difficile and consider metronidazole therapy.
c. prescribe diphenoxylate (Lomotil) to provide symptomatic relief.
d. reassure the patient that diarrhea is a common side effect of antibiotic therapy.
Question 23. (2 pts): The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should:
a. compromise with the parents and order a nasogastric tube for feedings.
b. initiate a discussion with the parents about the potential outcomes of each possible action.
c. refer the family to a case manager who can help guide the parents to the best decision.
d. understand that the child's parents have a right to make choices that override those of the medical team.
Question 24. (2 pts): The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen?
a. "I have to take a pill only every 3 months."
b. "I should expect to have only four periods each year."
c. "I will need to use condoms for only 7 more days."
d. "This type of pill has fewer side effects than other types."
Question 25. (2 pts): The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma. The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes. The NP should:
a. provide pharmaceutical company samples of the medication for the patient.
b. inform the patient that the drug must be paid for out of pocket because it is not covered.
c. order the closest formulary-approved approximation of the drug and monitor effectiveness.
d. write a letter of medical necessity to the insurer to explain the need for this particular medication.
Question 26. (2 pts): A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL cholesterol. The NP should:
a. order LFTs.
b. order CK-MM tests.
c. consider decreasing the dose of the medication.
d. reassure the patient that this side effect is common.
Question 27. (2 pts): A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary care NP should counsel the patient to:
a. report wheezing and shortness of breath, which may occur with these drugs.
b. take care when getting out of bed or a chair after the first dose of the ACE inhibitor.
c. discuss taking an increased dose of the thiazide diuretic with the cardiologist.
d. minimize fluid intake for several days when beginning therapy with the ACE inhibitor.
Question 28. (2 pts): A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe:
a. estrogen-only HT now.
b. estrogen-only HT in 5 years.
c. estrogen-progesterone HT now.
d. estrogen-progesterone HT in 5 years.
Question 29. (2 pts): A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to:
a. dissolve atheromatous lesions.
b. relax vascular smooth muscle.
c. prevent catecholamine release.
d. reduce C-reactive protein levels.
Question 30. (2 pts): A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days. The patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of greater than 3 seconds. The NP should:
a. obtain a complete blood count and serum electrolytes.
b. prescribe a rectal antiemetic medication.
c. admit to the hospital for intravenous (IV) rehydration.
d. encourage the patient to take small, frequent sips of Gatorade.
Question 31. (2 pts): A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should:
a. prescribe cimetidine (Tagamet).
b. prescribe omeprazole (Prilosec).
c. teach the patient about a bland diet.
d. change the NSAID to a corticosteroid.
Question 32. (2 pts): A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to:
a. obtain an electrocardiogram.
b. administer oxygen at 2 L/minute.
c. give 325 mg of chewable aspirin.
d. call EMS.
Question 33. (2 pts): A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. decrease the dose of the diuretic to prevent further dehydration.
b. obtain a serum potassium level to assess for hyperkalemia.
c. hold the ACE inhibitor until the patient's blood pressure stabilizes.
d. obtain a digoxin level before the patient takes the next dose of digoxin.
Question 34. (2 pts): A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to:
a. avoid foods that are high in vitamin K for several days.
b. take a double dose of the medication the next morning.
c. refill the prescription and take today's dose immediately.
d. skip today's dose and resume a regular dosing schedule in the morning.
Question 35. (2 pts): A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10 lb in the first month but reports that the drug does not seem to be suppressing appetite as much as before. The NP should:
a. discontinue the phentermine.
b. increase the dose of phentermine.
c. continue the phentermine at the same dose.
d. change to a combination of phentermine and topiramate.
Question 36. (2 pts): A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend:
a. 30 minutes of aerobic exercise daily.
b. taking 81 to 325 mg of aspirin daily.
c. beginning therapy with a statin medication.
d. starting a thiazide diuretic to treat hypertension.
Question 37. (2 pts): A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. order serum electrolytes.
b. obtain renal function tests.
c. consider prescribing a B-blocker.
d. call the patient's cardiologist to discuss adding digoxin to the patient's regimen.
Question 38. (2 pts): A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP should:
a. prescribe a TCA.
b. discontinue the antidiarrheal medication.
c. encourage the patient to increase water intake.
d. lower the dose of the antispasmodic medication.
Question 39. (2 pts): A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are:
a. not curative and may prolong the illness.
b. useful in cases of acute infection with elevated temperature.
c. most beneficial when symptoms persist longer than 2 weeks.
d. useful when other symptoms, such as hematochezia, develop.
Question 40. (2 pts): A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to:
a. amlodipine (Norvasc).
b. isradipine (DynaCirc).
c. verapamil HCl (Calan).
d. short-acting nifedipine (Procardia).
Question 41. (2 pts): A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not working as well as it did initially. The primary care NP should:
a. recommend a reduced potassium intake.
b. increase the dose of digoxin to 0.5 mg daily.
c. hold the next dose of digoxin and obtain a serum digoxin level.
d. contact the patient's pharmacy to ask if generic digoxin was dispensed.
Question 42. (2 pts): A patient is taking spironolactone and comes to the clinic complaining of weakness and tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute and a blood pressure of 100/58 mm Hg. The NP should:
a. obtain a serum drug level.
b. order an electrocardiogram (ECG) and serum electrolytes.
c. change the medication to a thiazide diuretic.
d. question the patient about potassium intake.
Question 43. (2 pts): The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should:
a. prescribe a thiazide diuretic.
b. consider treatment with an angiotensin-converting enzyme inhibitor.
c. reassure the patient that these findings are normal.
d. counsel the patient about dietary and lifestyle changes.
Question 44. (2 pts): A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should:
a. recommend supplements of omega-3 along with the atorvastatin.
b. change the atorvastatin dose to 15 mg twice daily.
c. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.
d. change the patient’s medication to cholestyramine
Question 45. (2 pts): The primary care NP is seeing a patient for a hospital follow-up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them.” The NP’s initial response should be to:
a. ask the patient to describe the medication regimen.
b. ask the patient to make a list of questions about the medications.
c. determine what the patient understands about coronary artery disease.
d. give the patient information about drug effects and any adverse reactions.
Question 46. (2 pts): A primary care NP sees a 5-year-old child who is morbidly obese. The child has an elevated hemoglobin A1c and increased lipid levels. Both of the child’s parents are overweight but not obese, and they tell the NP that they see nothing wrong with their child. They both state that it is difficult to refuse their child’s requests for soda or ice cream. The NP should:
a. suggest that they give the child diet soda and low-fat frozen yogurt.
b. understand and respect the parents' beliefs about their child's self-image.
c. initiate a dialogue with the parents about the implications of the child's laboratory values.
d. suggest family counseling to explore ways to improve parenting skills and limits.
Question 47. (2 pts): A primary care NP is developing a handout to give to patients who will begin self-administering insulin. When developing this handout, the NP should:
a. provide detailed descriptions of each step in the process of injecting insulin.
b. use correct medical terminology when describing insulin self-administration.
c. provide as much factual information as possible about insulin administration.
d. address one or two educational objectives that describe what the patient will learn.
Question 48. (2 pts): A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend:
a. a daily bulk laxative.
b. long-term docusate sodium.
c. a saline laxative as needed.
d. glycerin suppositories as needed.
Question 49. (2 pts): A patient who has heart failure has been treated with furosemide and an ACE inhibitor. The patient’s cardiologist has added digoxin to the patient’s medication regimen. The primary care NP who cares for this patient should expect to monitor:
a. serum electrolytes.
b. blood glucose levels.
c. serum thyroid levels.
d. complete blood counts (CBCs).
Question 50. (2 pts): A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should:
a. tell her that starting HT now may reduce her risk of breast cancer.
b. advise a short course of HT now that may decrease her risk for CHD.
c. tell her that HT will not help control her symptoms during postmenopause.
d. recommend herbal supplements for her symptoms to avoid HT side effects.
Question 51. (2 pts): A primary care NP is performing a previsit health history on a new patient. The patient reports taking vitamins every day. The NP should:
a. ask the patient to bring all vitamin bottles to the clinic appointment.
b. recommend natural vitamin products over synthetic vitamin products.
c. reassure the patient that vitamins that are high in folic acid are safe to take.
d. tell the patient that some vitamins, such as vitamin C, are safe in large doses.
Question 52. (2 pts): An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:
a. calcium carbonate (Tums).
b. aluminum hydroxide (Amphojel).
c. sodium bicarbonate (Alka-Seltzer).
d. magnesium hydroxide (Milk of Magnesia).
Question 53. (2 pts): A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should:
a. prescribe estrogen-only therapy.
b. initiate oral contraceptive pills now.
c. discuss using bioidentical HT.
d. plan to use estrogen-progesterone therapy when menopause begins.
Question 54. (2 pts): A patient who has breast cancer has been taking toremifene for 2 weeks. She tells her primary care NP that she thinks her tumor has grown larger. The NP should:
a. schedule her for a breast ultrasound.
b. reassure her that this is common and will subside.
c. tell her she may need an increased dose of this medication.
d. contact her oncologist to discuss adding another medication.
Question 55. (2 pts): A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe:
Question 56. (2 pts): The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe:
a. albuterol metered-dose inhaler.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. chlorthalidone (Zaroxolyn).
Question 57. (2 pts): A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe:
a. estrogen-only HT.
b. low-dose oral contraceptive therapy.
c. selective serotonin reuptake inhibitor therapy until menopause begins.
d. estrogen-progesterone HT.
Question 58. (2 pts): A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she:
a. is having vomiting or diarrhea.
b. delays taking a pill by 5 or 6 hours.
c. takes nonsteroidal antiinflammatory drugs several days in a row.
d. has recurrent headaches or insomnia.
Question 59. (2 pts): A patient who has had a new onset of AF the day prior will undergo cardioversion that day. The primary care NP will expect the cardiologist to:
a. give clopidogrel after administering cardioversion.
b. administer cardioversion without using anticoagulants.
c. give warfarin and aspirin before attempting cardioversion.
d. give low-dose aspirin before administering cardioversion.
Question 60. (2 pts): A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is:
a. the relation of the pain to stools.
b. what time of day the pain occurs.
c. whether the pain is sharp or diffuse.
d. the age of the patient when the pain began.