Review Questions 1A

Front 1

What is the most valuable diagnostic tool for a bleeding disorder?

Back 1

Careful, comprehensive bleeding history.

The most valuable diagnostic test for a bleeding disorder is a careful, comprehensive bleeding history (Buttaro, 2008, p.1159)

Front 2

65 yr old male presents with complaints of dyspnea. Physical examination shows a loud second heart sound, decreased carotid pulse, and murmur of tricuspid regurgitation. What condition is this patient experiencing?

Back 2

Pulmonary Hypertension.

Findings include a loud second heart sound, decreased carotid pulse, evidence of right ventricular dilation, murmur of tricuspid regurgitation, and pulmonic insufficiency (Buttaro, 2008, p. 481)

Front 3

54 yr old male presents for annual physical exam with a blood pressure of 155/90. Patient admits to being a long-time smoker. He is not interested in quitting at this time. Labs show total cholesterol 220 mg/dl and LDL 130 mg/dl. What is the best way to manage his hyperlipidemia?

Back 3

3 month trial of lifestyle modification (diet and exercise) then repeat lipid profile.

For those patients with two or more risk factors but a 10-yr cardiac risk of less than 10%, the goal remains for LDL level of less than 100 mg/dl. It is reasonable to avoid the use of cholesterol-lowering medication unless the LDL level is 160 mg/dl or more (Buttaro, 2008, p.1105).

Front 4

A patient comes to you with no improvement in his/her LDL levels despite lifestyle modifications. This patient has 2 risk factors for CVD (i.e., smoking, hypertension) with a 10% chance of developing cardiovascular disease (CVD) in the next 10 years. How high should the LDL be before you consider starting lipid-lowering medication therapy for this patient?

Back 4

When the LDL is ≥160mg/dL.

A person with ≥2 risk factors for CVD with a 10-year risk of <10% should initiate medication therapy when the LDL ≥160mg/dL despite lifestyle modifications (Buttaro, 2013, pg. 1105).

Front 5

For patients in stage C heart failure, especially the elderly, what type of OTC medication should they particularly avoid?

Back 5

NSAIDs.

Nonsteroidal anti-inflammatory drugs and calcium channel blockers should be avoided in patients with stage C heart failure (Buttaro, 2013, p. 547). Because NSAIDs inhibits prostaglandin synthesis, renal prostaglandins (I2 and E2) are also inhibited which causes a sodium and water retention effect as well as blunting the effects of any diuretic therapy (Heerdink, Leufkens, Herings, Ottervanger, Stricker, & Bakker, 1998). NSAIDs also tend to antagonize the effectiveness of ACE inhibitors (Halter, Ouslander, Tinetti, Studenski, High, & Asthana, 2009, p. 306; Page &Henry, 2000). A study found that, “[t]he odds of a first admission to a hospital with CHF was positively related to the dose of NSAID consumed in the previous week…NSAIDs were responsible for approximately 19% of hospital admissions with CHF…NSAIDs should be used with caution in patients with a history of cardiovascular disease” (Page &Henry, 2000, p. 77).

Front 6

Which drug decreases systemic and pulmonary vascular resistance by preventing aldosterone and norepinephrine production while increasing bradykinin, a vasodilator?

Back 6

ACE inhibitor.

The end result is arterial vasodilation, decreased arteriolar resistance, improved left ventricular outflow, and augmented cardiac output and stroke volume (Buttaro, 2013, p. 547).

Front 7

Murmurs that have a crescendo-decrescendo sound in between the S1 and S2 heart sounds typically involve which valve(s)?

Back 7

Aortic and pulmonic.

At the closure of the mitral and tricuspid valve (S1), the ventricle is generating enough pressure to overcome the aortic and pulmonic arterial pressure. As this happens, the murmur intensifies as velocity increases and then decreases in intensity which occurs before S2 (the closure of the aortic and pulmonic valves). This murmur occurs with left ventricular outflow obstruction (i.e., rheumatic, calcific aortic stenosis, pneumonic stenosis) (Buttaro, 2013, p. 601).

Front 8

What lab value is most helpful in differentiating cardiac from pulmonary causes of dyspnea?

Back 8

B Natriuretic Peptide (BNP)

“BNP is secreted mainly in the left ventricle in response to elevated wall tension…The Breathing Not Properly trial revealed BNP to be most helpful in differentiating cardiac from pulmonary causes because values less than 100 have 100% sensitivity and 97.1% specificity, making this extremely useful in ruling out CHF” (Buttaro, 2013, p. 544).

Front 9

A 55 year old female presents to the clinic for annual exam with Pap today. The patient reports long history of hypertension and DMII. Today, you found that she has PMI @ 6th ICS, S3 and jugular vein distention. From above information, this patient would most likely reported current symptom of
A. Chest pain
B. Vertigo
C. Dyspnea
D. Unilateral leg pain

Back 9

C. Dyspnea

With long history of hypertension and DMII, PMI shift, S3 and jugular vein distention, this patient is likely having heart failure (Regan, 2008). One of the common symptoms of heart failure is dyspnea (Regan, 2008). Rest of the symptoms are not typical symptoms of heart failure. Chest pain is a typical symptom of acute coronary syndrome, cardiac attack (Capasso, Cox & Bouvier, 2008). Vertigo is a typical symptoms of tachyarrhythmia, volume depletion and hypoglycemia (Le, 2008). Unilateral leg pain is a typical symptom of pulmonary embolism and DVT (Campbell, 2008).

Front 10

A patient presents to the clinic with chest pain. The patient states the chest pain usually happens when he is exercising. The pain lasts for about 1-3 minutes and then he doesn’t have pain. He states he never has pain at rest. This description directs the provider to consider which diagnosis as the most probable?
A. Unstable angina requiring an emergent response.
B. Chronic stable angina requiring additional questions to assure the pain has not been progressing to unstable angina.
C. Acute ST-Segment elevation MI requiring an emergent angiogram.

Back 10

B. Chronic stable angina requiring additional questions to assure the pain has not been progressing to unstable angina.

Chronic stable angina last usually for 1 to minutes and has a predictable frequency, severity and duration. This syndrome can be best evaluated with a detailed history including associative factors such as fatigue, nausea, vomiting, dyspnea and diaphoresis. (Presti, 2013, p. 518).

Front 11

A patient comes to the clinic to see her primary NP. She states she read on the internet as she gets older she has a higher risk of having a abdominal aortic aneurysm. She has a family history of this AAA. What other parts of her health history would prompt the NP to order an abdominal US?
A. She has a history of breast CA and states her diet is suboptimal.
B. She has not been to her physician in five years and is age 50.
C. She currently smokes and has been having a hard time controlling her BP.

Back 11

C. She currently smokes and has been having a hard time controlling her BP.

Risk factors for developing a AAA include a family history, HTN, tobacco use, hypercholesterolemia, and being male. US is ordered most often to screen for AAA. Usually if asymptomatic screening is to be done, it would be for men over 65. (Moss, 2013, p. 494).

Front 12

Most HF patients will have beneficial effects from some sort of regular exercise and should be encouraged to participate according to Beggs and Sullivan (2013). What types of exercise are good to encourage in a patient with stable heart failure?

Back 12

Walking, stationary bicycles and water aerobics.

Regular walking programs are good for most patients except for those with orthopedic problems. Water aerobics and stationary bikes can help to decrease wear and tear on affected joints. Starting with frequent and short exercise sessions is best. The goal is 30 minutes of exercise five days a week. (Beggs & Sullivan, 2013, p. 551).

Front 13

Murmurs are best described by listing the intensity, pitch, location, radiation and timing of the murmur. If a murmur is easily heard, but the clinician is not able to palpate the vibrations on the chest, the murmur is what grade (I-VI)?

Back 13

Grade III

Grade III murmurs are “easily heard but without being able to palpate the vibrations on the chest wall” (McGhee, 2013, p. 601).

Front 14

A patient comes to see her NP. She is complaining of chest pain that has not alerted the provider to seek emergent care for the patient. The complaints are very non-specific. After physical examination, a harsh crescendo-decrescendo systolic murmur is noted. What diagnosis does this lead the NP to include in her differentials?
A. Aortic Stenosis
B. Tricuspid regurgitation
C. Mitral valve prolapse
D. Mitral regurgitation

Back 14

A. Aortic Stenosis

Auscultation of aortic stenosis reveals a harsh crescendo-decrescendo murmur after the S1 sound. It is loudest at the right sternal edge. It often radiates to the left lateral sternal border and to the carotids. The chest pain is often from increased oxygen demand, increased wall tension and decreased coronary blood supply to the heart. (McGhee, 2013, pp. 602-603).

Front 15

Although abdominal aortic aneurysm (AAA) is associated with considerable morbidity and mortality, there are identifiable risk factors such as race, gender, age, family history and personal history. As a primary care provider you understand the importance of screening certain individuals for this condition. For which patient would it most appropriate to perform a screening ultrasound for AAA?

Back 15

Men over the age of 65 with a past or current history of smoking.

The USPSTF recommends screening for AAA via ultrasound for men over the age of 65 who are current smokers or have a history of smoking (Buttaro, 2008, p. 497).

Front 16

Heart failure has two distinct subtypes, systolic dysfunction and diastolic dysfunction. Because treatment for each type is unique it is important to recognize their key features. Which set of features is a more classic presentation of systolic dysfunction?

Back 16

History of coronary artery disease and diabetes; physical exam reveals cardiomegaly, distant heart tones, edema and jugular venous distension; chest x-ray shows pulmonary congestion; echocardiogram shows low ejection fraction.

These are the differences in history, physical exam and diagnostics for systolic dysfunction (Buttaro,2008, p. 558).

Front 17

A 12-year-old male comes to your clinic with his mother after an injury at soccer practice. His mother is concerned because he seems to have some excessive bruising and bleeding of the left leg that will not resolve. You also note that he has joint pain in the left knee. X-rays and further exam for musculoskeletal origin are negative. When questioned about a family and personal history, you note that his family does not have a history of excessive bleeding or bruising but your patient often has difficulty with bleeding in the presence of minor injuries. What is the most likely diagnosis and plan of care?

Back 17

Hemophilia A or B; replacement of clotting factors or desmopressin, monitor for bleeding into joints and muscles, work with family to develop emergency care plan.

Hemophilia is x-linked and often presents with excessive bruising/bleeding and joint pain due to bleeding into joint and muscles. For the bleeding patient, replacement of clotting factors is necessary and desmopression can be used if the hemophilia is mild.

Front 18

A 57-year-old female presents to your office for her annual well-woman exam. She has no significant family history of cardiovascular disease but she does smoke and is on medication for hypertension. She has no other CVD risk factors or CVD risk equivalents. She is having her lipids drawn today and is curious what her goal LDL should be since she has many friends on medication for high cholesterol. What is the best response to her question?

Back 18

Because you are a female over the age of 55, a smoker and have hypertension, you have 3 risk factors for CVD. This places you in the moderately high-risk category. I would like your LDL to be less than 130 mg/dl and will start you on medication and lifestyle changes today if your LDL is greater than 130 mg/dl.

CVD risk factors include: male >45, female >55 or premature menopause, family hx of CVD, smoking, hypertension, HDL <40; CVD risk equivalents are diabetes, stroke, CVD, PVD or AAA. Having 2+ risk factors places her in the moderately high-risk category with a 10-year risk for CVD of 10-20%. LDL goal is <130mg/dl and both lifestyle changes and drugs can be initiated with an LDL > 130mg/dl (Buttaro, 2008, p. 1144).

Front 19

A 65-year-old man presents to your clinic with shortness of breath-especially at night, increasing activity intolerance, fatigue and states that his shoes no longer fit. On exam, you note some wheezing and crackles, jugular venous distension and a hepatojugular reflex. Though there are many important diagnostics for this patient, which test is the strongest predictor of outcomes for his condition?

Back 19

BNP (brain natriuretic peptide).

Secreted almost exclusively by ventricular myocardial cells in response to elevations in end-diastolic pressure and volume; strongest predictor of outcomes in heart failure.

Front 20

Mr. Lee is a 57 year-old patient who presents to the clinic today for a routine health maintenance exam. After completing his history and exam he asks you about abdominal aortic aneurysms. He is concerned because both his father and brother died before the age 60 from a ruptured AAA. He wonders if this is going to happen to him as well. After acknowledging his concerns, you explain to the patient the risk factors for the development of a AAA as being…

Back 20

Tobacco, high blood pressure, males, family history of AAA and high cholesterol.

Risk factors that have been identified as leading to the development of AAA are tobacco use, hypercholesterolemia, hypertension, male gender and family history of AAA(predominately male). The patients concerns are valid because 20% of patients with AAA also will have a first degree relative with a AAA (Moss, 2013).

Front 21

Mrs. Lee is 68 year old female who presents to the clinic for a post-hospitalization follow-up. She was admitted to the hospital for an acute CHF exacerbation, was given intravenous diuretics and released yesterday. Upon reviewing her chart, you note Mrs. Lee was placed in Class I in the New York Heart Association’s Functional Classification when she was last seen six months ago. You decide to re-evaluate Mrs. Lee’s symptoms. She states that she doesn’t have any shortness of breath or fatigue when she is sitting in her recliner but does notice it is hard to catch her breath when she gets up to go to the bathroom. Upon reviewing her symptoms the most appropriate class (NYHA) to place Mrs. Lee in would be?

Back 21

Class II.

Under the New York Heart Association’s Functional Classification system, Class II includes slight limitation in physical activity but no symptoms at rest. Because Mrs. Lee experiences dyspnea when she performs ordinary physical activity, her symptoms place her in Class II (Beggs & Sullivan, 2013).

Front 22

Mrs. Lee is a 68 year old female who presents to the clinic for a post-hospitalization follow-up. She was admitted to the hospital for an acute CHF exacerbation, was given intravenous diuretics and released yesterday. You decide to review her medications with her. You notice she is prescribed Furosemide 20 mg daily and Lisinopril 20 mg daily. Mrs. Lee tells you, “I don’t take the Lisinopril because it makes me cough all night”. Knowing the recommended treatment for the management of heart failure you decide to?

Back 22

Start Mrs. Lee on an angiotensin receptor blocker (ARB) instead of the Lisinopril.

In patients who are intolerant to ACE inhibitors because of side effects such as cough, an ARB should be initiated into their heart failure regimen instead of the ACE inhibitor as the two agents work similarly in their effects to decrease vasoconstriction (Beggs & Sullivan, 2013).

Front 23

Mr. Jones presents to the clinic today for his routine follow-up for heart failure. While taking Mr. Jones’s history he explains to you that his shortness of breath has been increasing and his shoes don’t fit anymore because of the swelling in his feet. He states that he has been taking his Lasix pill, 20mg once daily and watching his fluid and salt intake. His weight has increased 5 pounds since his last visit two months ago. You review his latest laboratory work and not his creatinine clearance to be 25 ml/min. You consider an appropriate medication adjustment to help with Mr. Jones’s symptoms as being?

Back 23

Increase his Lasix dose to 20 mg twice daily.

Appropriate dosing of Lasix can be 20-40mg daily to twice daily. Because his creatinine clearance is below 30 ml/min, he is not a candidate for thiazide diuretics. Loop diuretics, such as Lasix, are more potent than other diuretics and indicated for symptomatic heart failure, renal insufficiency and edema (Beggs & Sullivan, 2013).

Front 24

You are re-educating a patient who was diagnosed with chronic stable angina 10 years ago on how to use sublingual nitroglycerin tablets, as he has stated that the directions still continue to confuse him. What is an appropriate direction to give to this patient?

Back 24

You may take one tablet before physical activity that has previously caused angina.

Prophylactic use of sublingual nitroglycerin is recommended for patients before engagement in a stressful event of physical activity that has previously precipitated an angina event (Presti, 2013).

Front 25

A low-salt diet should be recommended for which condition:
A. Abdominal Aortic Aneurysm
B. Sarcoidosis
C. Pulmonary Hypertension
D. Mitral Stenosis
E. Peripheral Venous Insufficiency

Back 25

C. Pulmonary Hypertension

Front 26

Secondary prevention for patients with coronary artery disease includes which lifestyle modification goals?

Back 26

Smoking Cessation, Blood pressure <140/90 mm Hg, LDL <100 mg/dL, waist circumference <40 inches in men or <35 inches in women, Hemoglobin A1c <7%.

Front 27

Particularly true in women, myocardial ischemia can be experienced as what anginal equivalents?

Back 27

Dyspnea, Indigestion, Nausea, Numbness in the upper extremities, and/or Fatigue (Buttaro et al., 2013, p. 521).

Front 28

Murmurs are characterized by several factors: location, timing, intensity, pitch, and radiation; the most important of these is...

Back 28

“Timing delineates the critical division between systolic and diastolic murmurs as well as the relationship to the heart sounds” (Buttaro et al., 2013, p.601).

Front 29

A 73-year old man presents for his annual Medicare-sponsored wellness exam. He reveals he was a smoker for 10 years, and worked as a butcher for 50 years where meat was the staple of his diet. His mother had diabetes and hypertension, dying of pneumonia; while his dad died suddenly after several months of back and abdominal pain. What preventive screening test should you order?

Back 29

Duplex Ultrasound of the abdomen.

The Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act offers an ultrasound examination, paid by Medicare, to men and women aged 65 to 75 years who have smoked 100 cigarettes during their life and have a family history” (Buttaro et al., 2013, p.494).

Front 30

35 yr old female with history of hypertension presents with complaints of visual field disturbances and amenorrhea. She has multiple complaints as you begin to take her history. She states that she has been experiencing joint pain, headaches, weight gain, and excessive sweating. Upon physical exam, facial puffiness and broadening of the nose is noted. An IGF-1 and OGTT are ordered. What diagnosis do you suspect?

Back 30

Agromegaly.

Acromegaly develops insidiously. Signs and symptoms at diagnosis included enlargement of facial features or hands, joint pain, excessive sweating, headache, menstrual irregularity, snoring, vision problems, weight gain, deepening voice, hirsutism, and mood instability

Front 31

Which of the following is TRUE regarding chronic arterial insufficiency.
A. Less likely to occur in patients > 50 with history of diabetes or smoker
B. Pain that occurs in the legs at rest
C. Pain is always relieved by stopping the activity
D. The most useful diagnostic test is a CT scan

Back 31

C. Pain is always relieved by stopping the activity

Front 32

Symptoms of a pulmonary embolism include all of the following except:
A. Sudden onset of pleuritic chest pain
B. Grossly abnormal chest x-ray
C. Shortness of breath
D. Hypoxia

Back 32

B. Grossly abnormal chest x-ray

Chest x-ray is relatively normal, (Campbell, 2013)

Front 33

When screening for lipid disorders which of the following is the true?
A. Cholesterol screening is done every 2 years on adults over the age of 20.
B. A cholesterol of 200mg/dL and HDL-C of 35mg/dL is considered normal.
C. In patients with CVD a goal LDL-C is 80mg.dL or less
D. Diabetes and thyroid disease screening must be done if there are abnormalities in lipid profile

Back 33

A. Cholesterol screening is done every 5 years starting at age 20 (Young, 2013). B. A cholesterol of 200mg/dL and HDL-C of 35mg/dL is considered normal.

B. Cholesterol of 200-239 is borderline high and HDL of 40 or less is considered low (Young, 2013).

C. The goal LDL-C in this high risk group is 70 or less (Young, 2013)

**D. Diabetes and thyroid disease screening must be done if there are abnormalities in lipid profile

All patients with elevated lipids need to be screened for DM and thyroid disease (Young, 2013).

Front 34

In terms of cardiac function, pulmonary arterial hypertension (PAH) ultimately leads to what?

Back 34

Right sided heart failure.

PAH develops from restricted flow through pulmonary arterial circulation, leading to increased resistance across pulmonary vascular bed, leading ultimately to right sided heart failure (Whelan, 2013).

Front 35

Three aspects of cardiac function, pre-load, contractility and afterload, are altered in which type of heart failure?

Back 35

Systolic heart failure.

Systolic HF is affected by pre-load, contractility and afterload, leading to ventricular remodeling. In diastolic HF the underlying mechanism is increased ventricular stiffness, creating a rise in cardiac filling pressure during diastole (Beggs, 2013).

Front 36

When evaluating a patient with symptoms of sarcoidosis, it is most important to rule out what similarly presenting disease?

Back 36

Tuberculosis with tuberculine skin testing or mantoux.

Tuberculosis signs and symptoms and CXray may mimic sarcoidosis. For obvious public health reasons it must be ruled out (Sandberg-Cook, 2013)

Front 37

What type of angina exhibits similar symptoms to chronic stable angina but is more common in women and presents with rest pain, pain of longer duration and pain that is less responsive to nitroglycerin?

Back 37

Microvascular angina.

Also called syndrome X. Etiology is not clearly understood, some patients have been found to have an abnormal vasodilating response of their small or resistance vessels (Rosa Presti, 2013)

Front 38

A cause of heart failure that is a genetic cardiovascular disease; the most common cause of cardiac death in athletes and young adults.

Back 38

Hypertrophic cardiomyopathy.

Occurs more frequently than it is diagnosed. Characterized by enlargement of the septum between left and right ventricles, resulting in outflow obstruction. Patients are often asymptomatic. Family members should be screened (Beggs, 2013).

Front 39

A 45-year-old patient presents to the clinic with mild dyspnea, fatigue, chest discomfort and palpitations. She also notes anxiety with panic episodes. The valvular disorder most commonly presenting with these symptoms is:

Back 39

Mitral valve prolapse (MVP).

Although most patients are asymptomatic, patients with MVP can present with symptoms similar to panic disorder syndrome. This may be related to autonomic dysfunction in MVP.

Front 40

A 75 year old male presents to the clinic with chest discomfort, exercise intolerance, and dyspnea. Upon chest auscultation, you hear a harsh, systolic, crescendo-decrescendo murmur at the right sternal border. You also note a delayed carotid upstroke and a narrowed pulse pressure. What is the most likely diagnosis?

Back 40

Aortic Stenosis (AS).

A crescendo-decrescendo murmur is usually benign or caused by AS. The main difference is that AS is accompanied by chest pain, dyspnea, and exercise intolerance.

Front 41

When ordering therapeutic support stockings for those with venous insufficiency, the standard pressure recommendation is:

Back 41

30-40 mm Hg

30-40 mmHg is recommended for therapeutic purposes. 20-30 mm Hg may also be therapeutic but it provides less support. It may be better tolerated if patients cannot tolerate the 30-40 mm Hg stockings.

Front 42

Your patient returns for follow-up after being hospitalized with a new diagnosis of heart failure. He has a slight limitation in his daily activities due to symptoms but is comfortable at rest. He states he cannot mow his lawn anymore because it causes fatigue and fluttering in his chest. You expect that his heart failure classification according to the New York Heart Association Functional Classification System (I-IV) is:

Back 42

Class II

According to the New York Heart Association Functional Classification System, patients with class II heart failure are comfortable at rest but have a slight limitation in physical activity. Ordinary activity causes fatigue, shortness of breath, chest pain, or palpitations.

Front 43

Left ventricular systolic dysfunction is defined as an ejection fraction of less than:

Back 43

40%

Front 44

A 54 year old man presents to the clinic with complains of recurrent chest pain that has gotten progressively worse over the last few weeks. He reports that about a year ago the pain occasionally would occur when he was mowing his yard or walking with his dog, but that now the pain sometimes occurs while he is sitting in a chair at night reading a book. The pain, which localized over the sternum, lasts much longer now than it did a few months ago. What type of angina does his patient have at present? A. Atypical angina B. Heberden angina C. Stable angina D. Variant angina E. Unstable angina

Back 44

Unstable angina.

Classic angina (exertional angina or Heberden angina), is the most common form, is characterized by retrosternal pain that occurs with exercise, stress, or excitement. In contrast, unstable angina is characterized by increasing frequency of pain, increased duration of pain, or less exertion necessary to produce the chest pain (Schoen, 2004). This type of angina is important to recognize clinically because it indicates that a myocardial infarction may be near.

Front 45

Prinzmetal’s (Variant) angina is characterized by:
A. Chest pain on exertion
B. Chest pain at rest
C. Coronary embolism
D. Propranolol usually helps with symptoms

Back 45

B. Chest pain at rest

Variant angina, which is also referred to as Prinzmetal ‘s angina, characterized by episodes of angina pectoris, usually at rest and often between midnight and early morning, in association with ST-segment elevation. Patients sometimes note that beta-blockers exacerbate symptoms (Buttaro, 2011, p. 521)

Front 46

An 82 year old man with history of hypertension for many years complains of recent weight gain over 20 lbs and increased shortness of breath. Clinical findings include dyspnea, tachycardia, heart rate of 100 bmp, BP of 160/99 mm Hg, and 3+ pitting edema of the lower extremities. Digoxin is given for treatment of HF, and treatment with antihypertensive drug is continued. Which of the following medications causes hypokalemia and could potentiate the toxicity of Digoxin in this patient?
A. Hydrochlorothiazide
B. Lisinopril
C. Metoprolol
D. Verapamil

Back 46

Hydrochlorothiazide

Hydrochlorothiazide-induced electrolyte disturbances predispose patients to digoxin toxicity and can cause life-threatening arrhythmias. The electrolyte and renal status of each patient should be ascertained prior to initiating treatment and periodically thereafter. Hypokalemia, hypomagnesemia, and hypercalcemia exacerbate digoxin toxicity (Buttaro, 2011, p. 549)

Front 47

A 55 year old woman presents with complains of sudden onset shortness of breath with pain on inspiration. Two weeks ago she had a total knee replacement surgery and has been recovering without complications, although she has missed several of her prescribed physical therapy sessions. She takes oxycodone for pain management and hormone replacement therapy to control her peri-menopausal symptoms. VS’s: T 100.4 F, HR 125 bmp, RR 30, BP 110/70 mm Hg and O2 88% by pulse oximetry on room air. Chest X ray is normal. EKG shows sinus tachycardia without other abnormalities. What is the most likely diagnosis?

Back 47

Pulmonary Embolism (PE)

PE must be considered in a patient who presents with acute onset dyspnea and hypoxia. Clinical signs and symptoms associated with PE include pleuritic chest pain, hemoptysis, low-grade fever, rales, dyspnea, cough and tachycardia (Stein, 2007). Risk factors of PE/DVT include: immobilization, surgery within the last three months, stroke, paresis, paralysis, central venous instrumentation within the last three months, malignancy, chronic heart disease, autoimmune diseases, history of venous thromboembolism , hormone replacement therapy (Stein, 2007).

Front 48

A 40 years old woman presents to your clinic with complains of worsening fatigue and dyspnea. In the PMH you see that patient had rheumatic fever during childhood. Physical examination finds an early diastolic opening snap with a rumbling late diastolic murmur. Chest Xray shows an enlarged left atrium. What is the best diagnosis?

Back 48

Mitral Stenosis

The cardiac valve most often affected by chronic rheumatic fever is the mitral valve. Mitral stenosis is almost always caused by rheumatic heart disease (Buttaro, 2011). Clinically, mitral stenosis produces a rumbling late diastolic murmur with an opening snap.

Front 49

In pulmonary hypertension, when patients present with symptoms, what is the primary symptom that is presented?

Back 49

Dyspnea

In primary hypertension “60% of patients are initially seen with dyspnea” (Buttaro et al., 2013, p. 481).

Front 50

A 76 year old male patient presents to the clinic with exercise intolerance, dyspnea and angina. When you auscultate his heart you hear a harsh crescendo-decrescendo systolic murmur. What is your primary diagnosis for this patient?

Back 50

Aortic stenosis

Common symptoms of Aortic stenosis are “chest pain, syncope, exercise intolerance and dyspnea” (Buttaro et al., 2013, p. 602). The characteristic systolic murmur associated with aortic stenosis is a harsh crescendo-decrescendo murmur (Buttaro et al., 2013, p. 600).

Front 51

You are seeing a patient with stage 2 sarcoidosis who presents to the clinic with symptoms such as progressive dyspnea, worsening cough, fatigue and weight loss, who has a chest x-ray that shows bilateral hilar lymphadenopathy with pulmonary infiltrates. What medical treatment would you suggest for this patient?

Back 51

Corticosteroids

Patients with stage 2 sarcoidosis who are symptomatic or who have progressive impairment of lung function are treated with corticosteroids (Buttaro et al., 2013, p. 484-485).

Front 52

What is the diagnostic triad of a ruptured abdominal aortic aneurysm (AAA)?

Back 52

Hypotension, pulsatile abdominal mass, and abdominal or back pain.

“The classical diagnostic triad of a ruptured AAA is hypotension, pulsatile abdominal pain or back pain” (Buttaro et al., 2013, p. 494). This triad is only present in 50% of patients but a ruptured AAA should be suspected in any patient who presents with hypotension and atypical abdominal or back pain (Buttaro et al., 2013, p. 494).

Front 53

You are seeing a 35 year old patient in your clinic office. This patient is new to your care and had not had a primary care provider in the past. How often should this patient have a lipid profile checked according to the NCEP APT III guidelines?

Back 53

5 years

The NCEP APT III guideline recommends that lipid screening be performed every five years in all adult patients over the age of 20 (Buttaro et al., 2013, p. 1103).

Front 54

As defined by the ATP III guidelines, what would the LDL goal be for a healthy 21 year old male?

Back 54

<160

According to the ATP III guidelines, the goal for a person with 0-1 CHD risk factors is < 160, and you would not initiate drug therapy until LDL ≥ 190.

Front 55

Hypertension is more commonly associated with what type of heart failure?

Back 55

Diastolic

The pathology of diastolic heart failure involves increased ventricular stiffness and reduced LV compliance.

Front 56

What are the USPSTF screening recommendations for AAA?

Back 56

Males > 65 with smoking history.

75% of AAAs are asymptomatic, this high risk population should be screened once.

Front 57

What valvular disorder is strongly associated with advancing age?

Back 57

Aortic stenosis

A common cause of aortic stenosis is calcification of the valve over time. It is noted this process is similar to atherosclerosis.

Front 58

Estelle is a 68 year old female who comes to clinic for her yearly physical exam. On exam, you find her abdominal aorta is palpable and enlarged. Further testing shows that she has an abdominal aortic aneurysm (AAA), which measures 3.8cm. She reports no abdominal pain and shows no signs of lower extremity ischemia. You determine that her AAA is asymptomatic. Based on the current evidence, should this patient be referred to a vascular surgeon for elective AAA repair?

Back 58

No

The 2009 guidelines from the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery recommend observation for asymptomatic AAA less than 5.5cm. Also, since it is uncommon for AAAs smaller than 5cm to rupture, elective AAA repair is not recommended until the risk of rupture (AAA 5.5cm or greater) exceeds the risk associated with repair.

Front 59

Thomas is a 78 year old male. He was recently diagnosed with “mild” heart failure. He presents to clinic with the complaint of shortness of breath. On examination, you hear crackles at the lung bases. Thomas has not yet been started on diuretic therapy. Since you obtained a BMP in clinic today, you decide to calculate his creatinine clearance in order to determine which diuretic to prescribe him: A thiazine diuretic, such as HCTZ or a low-dose loop diuretic , such as lasix. You find is GFR is 25 mL/min. Based on Thomas’ creatinine clearance, which diuretic would be most appropriate?

Back 59

Low dose loop diuretic

A thiazine diuretic may be appropriate in mild heart failure if the creatinine clearance is greater than 30ml/min. A loop diuretic can be used in patients with a creatinine clearance of less than 30mL/min (Buttaro, 2013, p. 548).

Front 60

Mr. Jones is a 47 year od white male who presents to your office with complaints of worsening abdominal pain that is described as feeling “like someone is pushing something into my belly really forcefully and it is tearing something in there.” Mr. Jones does have a history of HTN and is a 2 pack a day smoker. Surgical history includes surgical repair of a groin hernia 5 years ago. He denies any chest pain or discomfort but does appear to be in some distress. He denies any abdominal trauma. Due to Mr. Jones health history and habits, what diagnosis should be included in your differential list?

Back 60

AAA

AAA risk factors include HTN, smoking, white race, male gender, history of hernias, family history of AAA, and presence of other aneurysms. Mr. Jones does have several of these risk factors. Also, AAA is often described as severe abdominal pain that is characterized as deep, boring, or tearing. Finally, AAA is considered a disease of older white men however, AAA repair is often performed for young patients (<50). (Buttaro, 2013).

Front 61

True or false, when assessing a patient for carotid bruits, if no bruit is heard is it a reassuring sign that there is no carotid stenosis in your patient.

Back 61

False

Because bruits are produced with turbulent flow, they may be pronounced with mild stenosis and less audible or non-detectable with severe or critical stenosis (Buttaro, 2013).

Front 62

A 65 year old patient presents to the clinic with shortness of breath and a weight gain of 8 kg the past month. You want to order a test to diagnose heart failure. True or False: A 12 lead EKG is the diagnostic test to diagnose heart failure.

Back 62

False

Due to the often nonspecific signs and symptoms of heart failure, a careful history and physical examination are needed. There is no single diagnostic test for heart failure. Current AHA guidelines support echocardiography as the preferred method to evaluate the cause of heart failure (Buttaro, 543).

Front 63

Your 55 year old patient presents to the clinic for an annual physical. He has a history of diabetes and renal disease. Your nurse reported his vitals as: blood pressure 138/88, heart rate 92, and respiratory rate 16. Are you concerned with any of these values?

Back 63

Yes

In patients over 55 with diabetes and/or renal failure, the recommended blood pressure is below 130/80 (JNC VII report, p. 25).

Front 64

Most patients with high blood pressure need more than diet and lifestyle modifications to reduce their blood pressure. What class of medication is recommended as the first line agent?

Back 64

Thiazide diuretics

Thiazide diuretics should be used as initial therapy for most patients in treatment of hypertension. Thiazide diuretics can also be tried in combination with other classes of medications (JNC VII, p.30).

Front 65

True or False: Women who are experiencing myocardial ischemia often have crushing chest pressure as a main symptom.

Back 65

False

Women who are experiencing myocardial ischemia often present with indigestion, nausea, and numbness in the upper extremities, fatigue and dyspnea (Buttaro, 2013. P. 520).

Front 66

What are the most effective, and therefore the first line of drugs for lowering LDL-C?

Back 66

Statins have been shown to be more effective in lowering LDL-C levels when compared to cholesterol-absorption inhibitors, bile acid sequestrates, nicotinic acid and cholesterol absorption inhibitors.

Front 67

In pulmonary hypertension, functional status and survival is most closely determined by what?

Back 67

The ability of the right ventricle to compensate for increased PA pressures.

While elevated PA numbers are diagnostic for pulmonary hypertension, it is the ability to the right heart to compensate for the increasing PA pressures that is the primary predictor of morbidity and mortality.

Front 68

Bilateral hilar lymphadenopathy noted on a chest x-ray is highly suggestive of

Back 68

Sarcoidosis

Chest radiographic changes including BHL and interstitial infiltrates in the upper and mid lung fields are seen in 90% of patients with sarcodoisis. Of these radiographic changes, BHL is most often the change that indicates sarcoidosis.

Front 69

Propranolol prescribed to an individual with Grave’s disease is being used to:

Back 69

Decrease tremor and tachycardia associated with hyperthyroidism.

Utilizing beta-blockers inhibits the alpha-adrenergic symptoms of hyperthyroidism.

Front 70

New onset, moderate to severe hypertension with systolic blood pressures above 170mmHg is a hallmark presentation of:

Back 70

Pheochromocytoma

Pheochromocytomas produce epinephrine and norepinephrine resulting in a profound increased in systolic blood pressure via sympathetic stimulation

Front 71

You are seeing a 65 y.o female patient in the heart failure clinic for routine disease management follow-up. She mentions to you that she has developed an annoying cough. You note that she has been on lisinopril for some time without prior mention of any problems. During your discussions you recommend stopping the lisinopril as the cough is likely due to the medication’s buildup of bradykinin. What medication(s), other than an ARB, might you use to replace the lisinopril?

Back 71

A combined hydralazine-isosorbide drug.

The updated 2009 ACC/AHA guidelines list hydralazine-isosorbide as an appropriate alternative for patients unable to tolerate ACEIs. The usefulness of this drug combination has proven to be especially beneficial to African-American heart failure patients who demonstrated significant reduction in mortality (Buttaro et al., 2013, p. 548).

Front 72

While completing the cardiovascular examination of a 75 year old male patient you hear a bruit on the right while auscultating both carotid arteries. The patient’s neuro exam is normal and he denies any symptoms of TIA or stroke, but you are aware that he has a PMH of CAD, PAD, and tobacco use (quit 10 years ago). Considering he has an asymptomatic bruit present, what test would are you most likely to recommend to your patient to determine the degree of stenosis present?

Back 72

Carotid duplex ultrasonography.

Carotid ultrasonography is the primary diagnostic tool used for determining the degree of stenosis due to its ability to measure the velocity of the blood flow in the carotid arteries. Additionally, it does not carry with it the costs or risks associated with catheter based angiography (Buttaro, 2013, p. 512).

Front 73

J. S. is a 67 year old patient presenting to your office today for his annual exam and routine surveillance of a known AAA measuring 3.5 cm. The AAA’s size has been stable over the last two years with medical management. Considering the size of J. S.’s aneurysm, stability, and continuing asymptomatic presentation, how often would you recommend ultrasound testing to reassess the size and state of his aneurysm?

Back 73

Annually

Abdominal aortic aneurysms measuring between 3.0 cm to 4.0 cm should be monitored annually by ultrasound to assess for possible enlargement or dilation.

Front 74

The American Heart Association has defined eight criteria for ideal cardiovascular health in women. Two of these criteria define ideal fasting blood glucose and lean body mass index levels. According to the AHA, what are the ideal values of the fasting blood glucose and lean body mass index?

Back 74

Fasting blood glucose less than 100 mg/dL, and lean body mass index less than 25 kg/m2.

Other criteria include no evidence of CVD, no smoking, more than 150 minutes of moderate physical activity per week, healthy diet such as a DASH diet, cholesterol of less than 200 mg/dL, and blood pressure of less than 120/80 (Presti, 2013).

Front 75

A 47 year old mother of four with a BMI of 29 has worked as a waitress for the past 20 years. She has noticed over the years that she has chronic swelling in her feet and ankles which she attributes to the long hours at work but presents now with a new concern that the skin overlying her ankles and calves has a brown discoloration. What condition is she most likely to have?

Back 75

Chronic venous stasis

Leg veins can distend during pregnancy causing valve incompetence that may not resolve completely after delivery leading to venous stasis in the legs. Being overweight can contribute to the problem. The stasis causes swelling in the foot/ankle especially when the patient is on their feet most of the day. Due to the high pressure created in her lower legs, blood cells can break down in the tiny venules which leads to deposition of hemosiderin under the skin and manifests as brown stains (Buttaro et al., 2013, p. 597).

Front 76

A 78 year old man visits your clinic with complaints of lightheadedness upon exertion that has developed over the last month. He denies chest pain or dyspnea. Exam findings uncover a murmur heard best at the right sternal border with a crescendo-decrescendo quality during systole that radiates to the neck. The findings are most suggestive of what?

Back 76

Aortic stenosis

Auscultation of an aortic stenosis “. . .reveals a harsh crescendo-decrescendo systolic ejection murmur that begins after the first heart sound. . .[and]. . .is loudest at the second right sternal edge and radiates to the left lateral sternal border and carotids” (Buttaro et al., 2013, p. 603).

Front 77

A 53-year old man with a history of hypertension has a new diagnosis of dyslipidemia. You would like to start him on a statin and have baseline liver function tests (LFT’s) drawn. Currently, the man is on amlodipine and hydrochlorothiazide for blood pressure control. Follow-up LFT’s are not elevated but the patient has started to complain of some muscle tenderness. An elevated ____ level indicates that statin therapy should be stopped.

Back 77

Creatine kinase (CK)

Patients who are on a statin and complain of new muscle pain need to have CK evaluated for evidence of muscle breakdown. If elevated, therapy should be discontinued and renal function should be monitored (Buttaro et al., 2013, p. 1109).

Front 78

When a patient with neuropathy and arterial insufficiency presents to your clinic, you assess his lower extremities. He c/o cramping pain, worse with movement, but it does get better with rest. You find his right lower extremity warm to touch. This is a sign that his circulation is improving. True or False?

Back 78

False

This is considered autonomic neuropathy. 30% of patients with neuropathy d/t arterial insufficiency have a condition where blood is diverted from the nutrient vessels to the skins surface. In reality his warm foot may be a sign that it is critically ischemic. (Buttaro, 2013, p. 592).

Front 79

Murmurs are characterized by a number of factors. Charting should include:

Back 79

Llocation, intensity, pitch, radiation and timing

Location is where it is heard best and should be noted. Intensity is graded 1 (barely audible) through 6 (heard without a stethoscope). Timing is considered the most important factor delineating when the murmur occurs between systole and diastole (Buttaro, 2013, p. 601).

Front 80

Which diagnostic test is considered the single most effective tool for the assessment of heart failure?

Back 80

Echocardiogram

The value of echocardiography is great in HF. It is considered to be the single most effective tool for the assessment of HF. Transthoracic Doppler Echocardiography is rapid and safe and provides information about the heart’s wall thickness, size of the chambers, heart wall abnormalities, and assesses the valvular functioning of the heart (Buttaro, 2013, p. 543).

Front 81

A blood pressure of 170/80 is considered to be what specific type of hypertension?

Back 81

Isolated systolic hypertension

Isolated systolic hypertension is defined as a systolic blood pressure above 160 mmHg with a diastolic blood pressure below 90 mmHg, so the correct answer is 170/80. ISH is associated with a 2-4 times higher risk of myocardial infarction, left ventricular hypertrophy, renal dysfunction, stroke, and cardiovascular mortality. Generally, the systolic reading more closely is correlated with cardiovascular risk (Egan, 2013).

Front 82

In diastolic murmurs, does the variation in intensity, the timing, or duration of the murmur correlate to the severity of stenotic obstruction?

Back 82

The duration of the murmur

The duration, not the intensity of the murmur correlates with the severity of the obstruction. Variation in intensity of the murmur with respiration is strongly associated with right sided abnormalities. Less severe stenosis will result in a shorter gradient across the stenotic valve and a shorter murmur. Timing delineates between systolic and diastolic murmur as well as the relationships to the heart sounds (McGhee, 2013).

Front 83

A 48-year-old female presents to clinic reporting worsening shortness of breath, chest pain with activity, and increasing fatigue. She denies recent cough or hemoptysis. Exam findings reveal loud second heart sound, murmur 5th intercostal space left sternal border, decreased carotid pulse, and lift at left sternal border. What is the most likely diagnosis?

Back 83

Pulmonary arterial hypertension

The most common presenting symptom in patients with pulmonary arterial hypertension (PAH) is dyspnea. Less common, but associated symptoms include fatigue, angina, syncope, cough, hemoptysis, Raynaud’s phenomenon, edema, and decreased exercise tolerance. Physical findings include loud second heart sound (pulmonic component), decreased carotid pulse, evidence of right ventricular dilation, murmur of tricuspid regurgitation and pulmonic insufficiency (Whelan & Polgar, 2013).

Front 84

A 76-year-old male with history of hypertension and hyperlipidemia presents with 5-day history of swollen upper lip. Currently the left side of his upper lip and his left cheek are swollen. No trauma. Current medications include atorvastatin calcium, lisinopril, aspirin and vitamin D3. You are concerned about adverse side effect of angioedema related to lisinopril and want to switch to an alternative antihypertensive. Would atenolol or diltiazem hydrochloride be more appropriate for this patient?

Back 84

Diltiazem would be the safer alternative.

All three chemical classes of calcium channel antagonists have been shown to be effective in treating older hypertensive patients. MOA — decreased peripheral vascular resistance, and lack of significant CNS or metabolic side effects make this class a good match for the geriatric population. Beta-receptor antagonists are no longer recommended as an appropriate choice for the initial antihypertensive drug, especially among older patients (Supiano, 2009).

Front 85

The risk factors of diabetes, hypertension, hyperlipidemia, hyperhomocysteinemia, and tobacco intake are the same for both chronic arterial insufficiency and coronary artery disease because of what condition?

Back 85

Atherosclerosis

A major cause of chronic arterial insufficiency and coronary artery disease is atherosclerosis. Numerous studies have confirmed that most patients with obstructive arterial disease have underlying coronary artery disease or diabetes.

Front 86

Tom is a 51-year-old male who presents to the clinic with 3 week history of vague, dull low back pain and abdominal pain. Lumbar spine exam is negative, abdomen is obese, soft, nontender, no visible pulsations, no aortic bruit. You are still concerned that he may be symptomatic of AAA. He has a history of smoking ½ pack cigarettes per day x 20 years, quit 10 years ago. His father is deceased at age 70 due to ruptured AAA. What screening test would you order for Tom?

Back 86

Ultrasound

There is strong evidence to suggest a genetic predisposition to AAA, suggesting importance of periodic ultrasound screening after the age of 50 in men. USPSTF recommends ultrasound screening for men older than 65 years because there is also evidence between smoking history and development of AAA.

Front 87

Your elderly patient takes omeprazole every morning before breakfast. You are writing a new prescription for levothyroxine to treat hypothyroidism. Your patient says, "That will be convenient. I will just take both drugs when I wake up in the morning." Should you tell her to go ahead with this plan?

Back 87

No @ Since proton-pump inhibitors prevent levothyroxine from being absorbed properly from the gastrointestinal tract, the two drugs should not be taken together (Hershman, Hassani, & Samuels, 2009, p. 1291). Your patient should take levothyroxine when she rises and omeprazole later, prior to breakfast.

Front 88

Your 50-year-old male patient is scheduled to undergo synchronized cardioversion for the treatment of atrial fibrillation with rapid ventricular response. He is going to have a transesophageal echocardiogram (TEE) prior to cardioversion. He asks you why he cannot go straight to cardioversion. What do you tell him?

Back 88

The transesophageal echocardiogram could detect a thrombus in the left atrium of his heart (DiMattia, 2008, p. 501).

If a thrombus is present, it is dangerous to cardiovert him due to the risk of stroke.

Front 89

Your patient was recently diagnosed with stage B systolic heart failure. You decide to start him on 40mg lisinopril PO daily (lisinopril is an ACE inhibitor). When do you want to follow-up with this patient and what would you like to check at that time?

Back 89

After 1 week, the patient’s blood pressure, renal function and serum potassium levels should be checked.

ACE inhibitors can lower blood pressure and alter serum chemistry (Beggs & Sullivan, 2013).

Front 90

A 56-year-old patient presents to the clinic with bilateral lower extremity edema, varicose veins, and an area of ulceration to the medial aspect of her right leg, just above the ankle. She also tells you that she had a DVT to the right leg five years ago. What is the most likely diagnosis?

Back 90

Chronic venous stasis.

This condition also results in chronic skin changes. Venous stasis ulcers occur most commonly around the medial side of the ankle and in those with a previous history of DVT (Buttaro, 2013, pp. 596-598).

Front 91

In regards to coagulation, a prolonged ____ lab value suggests abnormality in the intrinsic pathway, whereas a prolonged ___ lab value suggests abnormality in the extrinsic pathway.

Back 91

aPTT (activated partial thromboplastin time; PT (prothrombin time).

Abnormalities of the intrinsic pathway (entirely plasma derived) often are revealed through a prolonged PTT. Abnormalities of the extrinsic pathway (tissue factor initiated) often are revealed through a prolonged PT (Buttaro, 2013, p. 1158).

Front 92

Hypercoagulability (changes in the constitution of the blood), hemodynamic changes (alterations in blood flow), and endothelial injury (changes in the blood vessel walls) define the pathogenesis of a venous thromboembolism (VTE). This phenomenon is also known as ______ triad.

Back 92

Virchow’s

Virchow’s triad is a useful concept for recognizing the factors which contribute to thrombosis (Buttaro, 2013, p. 1164).

Front 93

While reviewing the chart of your next patient in clinic, you read a diagnosis of sarcoidosis. You know that 90% of people with sarcoidosis have involvement of which organ system?

Back 93

Pulmonary

Although sarcoidosis can affect any organ system, from renal to dermatologic, the large majority of patients have lung involvement with common symptoms of dyspnea, dry cough, and chest pain (Buttaro, 2013, p. 484).

Front 94

A 55-year-old man presents to the clinic with complaints of atypical abdominal pain. His BP reads 88/55. What is your “must not miss” differential diagnosis for this patient?

Back 94

Ruptured Abdominal Aortic Aneurysm (AAA)

A ruptured AAA should be suspected in any patient with hypotension who complains of abdominal or back pain that is atypical in nature. AAA also occur 6 times more frequently in males (Buttaro, 2013, pp. 493-494).

Front 95

A 48 year old non smoker, Diabetes Mellitus type II (well controlled), Caucasian female presents to your clinic for a follow up after a transient ischemic attack (TIA) 3 weeks ago. She reports no residual effects, has no pain, and no complaints. She is taking Aspirin daily but no other medications. Physical exam is benign; reveals a healthy woman, no neurological deficiencies. Vital Signs: heart rate 85 blood pressure 175/90 Respiratory rate 18 Temperature 98.2 Saturations 98% on room air. What is your top priority for this visit today?

Back 95

Decrease blood pressure

Systolic blood pressure greater than or equal to 160 mm Hg was the strongest independent predictor of carotid stenosis.

Front 96

True or False: ST segment depression on an ECG of 1 mm or more have a high likelihood of unstable angina.

Back 96

True

ST depression of .5 to 1 have an intermittent likelihood of unstable angina. ST changes are likely to return to normal after the ischemic event has resolved (p 524)

Front 97

A 40 year old male status post (ST elevation myocardial infarction ) STEMI with ACS (acute coronary syndrome) 2 weeks ago presents to your clinic for follow up. He was discharged in sinus rhythm (with no history of arrhythmias) normal left ventricular ejection fraction of 62% (no left ventricle dysfunction), normal blood pressure, and an elevated LDL of 200. You anticipate his medications to include. (Check all that apply). A. Acetylsalicylic acid (Aspirin) B. Beta blocker C. Statin D. Angiotensin converting enzyme inhibitor (ACEI) /or angiotensin converting blocker (ARB) E. Nitrates (as needed) F. Calcium channel blocker G. Thienopyridine (clopidogril)

Back 97

Acetylsalicylic acid, beta blocker, statin, nitrate, and thienopyridine

ACEI or ARB’s should be used in patients with LVEF less than 40% or DM, HTN, or CKD. ASA is to prevent the formation of additional clots and vascular endothelial cells. Thienopyridine mechanism of action is different than that of asa and is used for up to 12 months in patients after ACS. Beta blockers decrease the myocardial oxygen demand by decreasing HR, lowering blood pressure, and reducing myocardial contractility. Nitrates are given PRN for recurrent angina, they promote smooth muscle relaxation resulting in vessel dilation. Statin therapy is recommended to reduce the LDL as LDL reduction has been shown to lower the risk of mortality.

Front 98

True or False: Digoxin helps increase mortality in patients with systolic dysfunction heart failure.

Back 98

False

Digoxin has been showing to be effective in improving symptoms and reducing hospitalizations rates but there is no evidence to support an increase in mortality.

Front 99

A 75 year old patient with a history of diabetes mellitus type II, hyperlipidemia, and coronary artery disease is complaining of tightening and cramping muscle pain exacerbated by exercise and a large meal which is relieved by rest. He reports these symptoms have been present for the past six months. Upon clinical examination while the patient is supine you elevate his legs for 30 seconds they become pale. When they are placed in a neutral position, a dark red color insures at a sluggish rate. His lower extremities are also cool, and loss of hair is noted over the toes. These clinical findings are most indicative of:

Back 99

Chronic arterial insufficiency

Independent risk factors of chronic arterial insufficiency include diabetes, hyperlipidemia, and coronary artery disease. Chronic arterial insufficiency is presented by cladudication or tightening or cramping pain precipitated by exercise and relieved by rest. Other additive factors to claudication include incline, cold weather, or a recent meal. Muscle wasting, loss of hair, and reduced temperature to the affective limb may be noted. A physical sign can be helpful in the diagnosis of peripheral vascular disease is dependent rubor if the ischemic leg is elevated for 30 seconds. The longer the rubor takes to develop the worse the ischemia (Buttaro, 2008, p.589-590).

Front 100

In patients with chronic venous stasis, what is the most important non-pharmacologic method for controlling chronic venous insufficiency and preventing skin ulcers, such as venous stasis ulcers?

Back 100

Compression stockings and periodic leg elevation

With chronic venous stasis the diagnosis is based solely on the clinical history and physical findings. Compression stockings and periodic leg elevations are the most important methods for controlling chronic venous insufficiency and preventing skin ulcers. Careful monitoring is important when venous ulcers occur. Normal saline wet-to-dry dressing or topical antibiotics therapies are indicated. Ulcer infectious should also be treated with the appropriate antibiotic (Buttaro, 2008, p. 597).

Front 101

What diagnostic tool would a provider use to differentiate a diagnosis of systolic heart failure from diastolic heart failure in a 72 year old male patient presenting dyspnea, fatigue, lower extremity edema, and jugular venous distension?

Back 101

Echocardiogram

There is no single diagnostic test for heart failure because it is clinical spectrum that is based on a careful history and examination. The diagnostic evaluation should be aimed at those studies necessary to determine the type and degree of systolic or diastolic heart failure, to uncover correctable causes of cardiomyopathy, to determine prognosis, and to guide treatment. The echocardiocagram is key in diagnostic evaluation of suspected heart failure. The echocardiogram assists in evaluating the type of heart failure (Buttaro, 2008, p. 543).

Front 102

A 34 year old African American male presents to the clinic with dyspnea, chest pain, fever, and fatigue. He also complains of joint aches and a rash over his face and hair line. Upon auscultation of the lungs no adventitious lungs sounds were detected and he reports his chest pain at a 8/10. Apart from ruling out a cardiac cause of chest pain, an additional differential diagnosis indicative of this patient signs and symptoms suggest:

Back 102

Sarcoidosis

The incidence of sarcoidosis in the United states is higher in African Americans and in whites, with greater morbidity reported. Sarcoidosis may affect almost any organ system, however 90% of affected individuals have pulmonary involvement. Patients who are symptomatic with this disorder often have nonspecific pulmonary symptoms - dry cough, dyspnea, chest pain, fever, fatigue, anorexia, weight loss, and occasionally chills and night sweats. It is also unusual for adventitious lungs sounds to be detected on auscultation. Chest pain can also be severe and difficult to distinguish from cardiac chest pain. Skin lesions are seen in 20-30% of cases a maculopaprular rash over the face and hairline is the most common sub acute lesion (Buttaro, 2008, p. 484).

Front 103

_____ is a breakdown product of a fibrin clot that can be measured in the blood; it is almost always elevated in a patient with an acute thrombosis.

Back 103

D-dimer

Frequently performed in patients with suspected venous thromboembolism, a negative d-dimer test result is helpful for ruling out thromboembolism, but a positive test result does not rule it in, just means further testing must be done (Buttaro et al., 2008, p. 1164).

Front 104

A 70-year-old white male presents for a Wellness Exam. His history includes CAD, 55-pack year smoker, COPD, and HTN. Based on this you know it will be important to palpate his abdomen for:

Back 104

AAA

“Atherosclerotic vascular disease, white race, male gender, advanced age, hypertension, smoking, COPD, history of hernias, family history of AAA, and other aneurysms are the main risk factors for AAA.” Palpating the abdomen for a pulsating mass, AAA is detected 30-40% of the time, with percent decreasing as abdominal girth increases (Buttaro et al., 2008, p. 493-494).

Front 105

50% of ruptured AAA patients present with a classis triad of symptoms which include:

Back 105

Hypotension, pulsatile abdominal mass, abdominal/back pain.

“Ruptured AAA’s should be suspected in any patient who comes in with complaints of hypotension and atypical abdominal or back pain” (Buttaro et al., 2008, p. 494).

Front 106

A 55-year-old African American woman, unknown to clinic, with no past medical history presents to the clinic for a follow up visit. You discover she had a myocardial infarction and was hospitalized for 2 days. Upon discharge she was started on simvastatin 40mg po q HS. What are the goals for her lipid panel?

Back 106

LDL <100, Triglycerides <200

According the CARDIA study elevated LDL cholesterol is associated with coronary calcification (Buttaro et al., 2008, p. 518).

Front 107

A 55-year-old African American woman, unknown to clinic, with no past medical history presents for a follow up visit. You discover she had a myocardial infarction and was hospitalized for 2 days. Upon discharge she was started on simvastatin 40mg po q HS. In what amount of time can the response to drug therapy be assessed?

Back 107

12 weeks

If the patient’s goal has yet to be achieved in 12 weeks, more aggressive drug therapy and lifestyle analysis is needed. Once LDL goal is achieved, monitor every 4-6 months. If unable to reach goal refer to a specialist (Buttaro et al., 2008, p. 534).

Front 108

A 63-year-old African American female patient presents in clinic with increased shortness of breath and new onset of ankle edema. You suspect the cause is congestive heart failure. What laboratory test with high sensitivity and specificity can you order to support or refute your suspicion?

Back 108

B Natriuretic Peptide (BNP)

BNP values of less than 100 have 100% sensitivity and 97.1% specificity for ruling out CHF. Values of greater than 400 have high positive predictive values.

Front 109

A 52-year-old white male patient with a 30-pack-year smoking history presents with a blood pressure of 82/46 and acute onset of back pain. He should undergo emergent evaluation for what event?

Back 109

Ruptured Abdominal Aortic Aneurysm

Male gender, white race, and smoking history are risk factors for AAA. Additionally, the classic diagnostic triad for AAA consists of hypotension, pulsatile abdominal mass, and abdominal or back pain.

Front 110

A 42-year old female patient well known to your practice presents with new onset of hypertension (today’s BP is 195/90 compared to recent values in the 120s/70s). She reports daily headaches and heart palpitations. She denies any drug use and has recently quit drinking coffee since she thought that might be causing her palpitations. What is an endocrine disorder that may be causing these signs and symptoms?

Back 110

Pheochromocytoma

Classic intermittent symptoms of pheochromocytoma are headache, diaphoresis, and palpitations that occur as frequently as multiple times per day or as seldom as less than weekly. New onset of moderate to severe hypertension (SBP>170s) is a hallmark of these catecholamine-secreting tumors.

Front 111

While working in a walk-in clinic, a 17 year old male comes in complaining of a sore throat for a few days, painful swallowing, low-grade fever and chills, stating, “I think I have strep. I always feel like this when I have strep.” On exam you note marked erythema of the pharynx with tender, swollen anterior nodes. You suspect group-A streptococcal pharyngitis, but would like confirmation. The sensitivity and specificity of the rapid antigen detection test (RADT) has been reported as 64.6% and 96.79%, respectively (Gurol, et al, 2010). While this is a helpful test, the prudent clinician is aware that a false positive or false negative test is more likely?

Back 111

False-negative

Tests with very high sensitivity have a very low percentage of false-negative, results and tests very high specificity have a low percentage of false-positive results. The RADT demonstrates a great possibility of false-negatives due to the lower sensitivity.

Front 112

Angiotensin converting enzyme inhibitors (ACEI) are a necessary component in the management of heart failure. There are potential and absolute contraindications, however, which include:

Back 112

Prior adverse reactions, elevated serum potassium (i.e. >5.5 mEq/L), severe hypotension (i.e. <80 mmHg systolic), bilateral renal artery stenosis, elevated serum creatinine (i.e. > 3 mg/dL), angioedema, or pregnancy

ACEI decrease systemic and pulmonary vascular resistance by reducing vasoconstriction, restricting the neurohormonal contributing factors to heart failure. Patients must be able to benefit from this effect if at all possible.

Front 113

Jim, a 61 year old man with a BMI of 34.1 and central adiposity, has not been to the clinic in years. He reports a sedentary lifestyle and does not restrict sodium intake. Among his many risk factors, you note the potential for essential hypertension. Sure enough, his seated blood pressure reading is 168/94. You immediately start to consider guideline recommendations regarding diet and lifestyle modification, thiazide-type diuretics, or other treatments (Chobanian, et al., 2003). Nevertheless, it is crucial to consider potential secondary causes of hypertension in this older adult, including:

Back 113

Renovascular disease, medication effect (i.e. non-steroidal anti-inflammatory medication), sleep apnea, or pheochromocytoma

Though the majority of older adults will develop essential hypertension, secondary causes that may be responsive to treatment must also be ruled out.

Front 114

Mary, at 57 year old female smoker, is at your clinic for follow-up after a recent 3-day hospitalization due to a non-ST elevation myocardial infarction with stent placement. She is feeling well, but has a couple of questions about her on-going plan of care. She has committed to not smoking. Her discharge medications included aspirin 81mg daily by mouth, lisinopril 10mg daily by mouth, simvastatin 20mg daily by mouth, and clopidogrel 75mg daily by mouth. You closely review the records to see if there is a reason, or if it was an error, that she was not prescribed:

Back 114

A beta-blocker, such as metoprolol 25mg daily by mouth

Beta-blockers are a mainstay of pharmacologic treatment in coronary artery disease due to their broad benefits in reduced mortality and subsequent infarction (Buttaro, 2011).

Front 115

A patient comes in to the clinic with a non-healing lower extremity wound. The patient reports that he has been trying to keep it elevated but he finds that it makes it feel worse and that his leg becomes a little bit pale. This wound is likely due to what?

Back 115

Peripheral Arterial Insufficiency

In a patient with peripheral arterial insufficiency, elevation of the lower extremity causes it to become pale because blood is unable to flow uphill. Leg ulcers caused by ischemia are more painful on elevation. (Campbell, 2013)

Front 116

In a patient with suspected pulmonary hypertension, which procedure would you recommend for definitive diagnosis?

Back 116

Cardiac catheterization

In evaluating PH, a number of noninvasive and invasive studies are necessary; however, pulmonary capillary wedge pressures are necessary for a definitive diagnosis and are calculated during cardiac catheterization. (Whelan & Bailey, 2013)

Front 117

In sarcoidosis, staging is based on chest x-ray appearance. They usually demonstrate one or both of which patterns?

Back 117

Bilateral Hilar Lymphadenopathy and/or parenchymal interstitial infiltrates

90% of patients with sarcoidosis have abnormal chest x-rays. 50-80% of cases will have bilateral hilar lymphadenopathy and 25-50% will have parenchymal interstitial infiltrates. Some cases will demonstrate both. (Sandberg-Cook, 2013)

Front 118

Cardiac murmurs are identified based on five factors; what are they and which one is most important?

Back 118

Location, intensity, pitch, radiation, timing. Timing is most important.

Timing differentiates systolic and diastolic murmurs. (McGhee, 2013)

Front 119

A 73 year old long haul trucker comes in to the clinic complaining of left leg pain and swelling. He just got back from a week long road trip driving 12-14 hour days. He has a history of atrial fibrillation and is currently taking 2 mg of Coumadin daily. He tells you that he has just started the Coumadin a week ago, but has not had his INR checked since he started the Coumadin due to being on the road. He also tells you that he hurt his left knee a few days ago while pulling pallets off his truck. What is the most likely diagnosis?

Back 119

DVT

DVT is seen more commonly in people with atrial fibrillation and those who take long car rides (Buttaro, 2011). The fact that he is on Coumadin is a distractor, not sure if it is therapeutic dose.

Front 120

The characteristic symptoms of chronic stable angina have the following characteristics?

Back 120

The symptoms have predictable frequency, severity, duration, and provocation.

These symptoms occur with exertion, are relieved by rest, and last only 1-3 minutes. Also, nitroglycerin tablets relieve the symptoms.

Front 121

A 50 year old female with a history of smoking and family heart disease comes to the clinic for follow-up on lifestyle modification for her high LDL. Last visit her LDL was 160 and her HDL was 50. Today, her fasting lipid lab draws shows her LDL to be 140 and HDL was 60. What should you as her provider do regarding her cholesterol levels?

Back 121

Continue lifestyle modification

She has two risk factors for CVD so she is in the intermediate risk category. However, Buttaro (2011) states that it is reasonable to avoid the use of cholesterol lowering drugs for LDL’s < 160 for this group.

Front 122

You are reviewing Mrs. Smith’s lipid panel. Her HDL-C level is 35 mg/dl, total cholesterol level is 280 mg/dl, and triglyceride level is 220 mg/dl. Are these within normal limits?

Back 122

No. HDL-C is low. Both total cholesterol and triglyceride levels are high.

HDL-C levels at 40mg/dl or below are considered low. Total cholesterol level of 240mg/dl or more is considered high and triglyceride levels of 200 to 499mg/dl are considered high (Young, 2013).

Front 123

Mr. Meyer, a 57 year old, comes to your clinic for an annual wellness exam. He has documented carotid stenosis and is concerned about having a stroke. He states that it runs in his family and would like to know what he can do to minimize his risk. Identify modifiable risk factors you want to educate Mr. Meyer about.

Back 123

Hypertension, smoking, hyperlipidemia, diabetes, obesity, physical activity, heavy alcohol consumption and depression

Modifiable risk factors for patients with carotid stenosis to prevent ischemic stroke are: hypertension, smoking, hyperlipidemia, diabetes, obesity, physical activity, heavy alcohol use, depression, hyperhomocysteinemia (Capasso, Cox and Bouvier. 2013). Blood pressure >160, each increase of 10mm signifies a 30-45% increase in stroke risk (Capasso, Cox and Bouvier. 2013). A 25%-50% increase in stroke risk is seen in patients who smoke (Capasso, Cox and Bouvier. 2013).

Front 124

Name the most popular test to perform for an abdominal aortic aneurysm before repair.

Back 124

CT with IV contrast

CT with IV contrast is the most widely used due to the ability to detect inflammation, leakage, aortic ulcers, and horseshoe kidneys (Moss, 2013).

Front 125

While an LDL of <100 is optimal for most, what is the goal LDL for those with comorbidities like heart disease and diabetes?

Back 125

LDL of <70

An LDL of <70 is needed in people with comorbidities to reduce the risk of stroke and coronary problems.

Front 126

Diuretics are important in patients that have fluid retention related to congestive heart failure. For those patient taking loop diuretics such as Lasix, what are the main concerns when monitoring the patient?

Back 126

Electrolyte imbalance and dizziness.

According to Buttaro, the major side effects of loop diuretics are hypokalemia, hyperuricemia, and hypotension.

Front 127

A patient presents to the ER with dizziness and shortness of breath as the primary complaints. After an EKG is done, the patient is found to be in atrial fibrillation. Which medications should be used to treat the patient’s atrial fibrillation?

Back 127

Amiodarone

Amiodarone has been shown to be superior when compared to other antiarrhythmia agents for achieving a sinus rhythm. Despite this, it is not approved by the FDA for this use, but is widely used for this condition. Also, the patient should not start this medication until they have been on anticoagulation for 3 weeks. This is to prevent the throwing of a clot if the patient should convert to sinus rhythm.

Front 128

A patient with a triglyceride level of >400 should be managed with medication. Which class of medications is most useful in decreasing triglyceride levels?

Back 128

Fibric acids @ According to Buttaro, the fibric acids such as lopid can decrease triglyceride levels by 20-45% while increasing HDL levels. However, this class of drugs should not be used in those with liver or kidney dysfunction.

Front 129

A patient with atrial fibrillation is at greater risks for stroke due to potential clot formation from turbulent flow. What is a therapeutic INR for a patient with atrial fibrillation?

Back 129

INR should be 2 to 3

A therapeutic INR greatly reduces the risk of stroke for patient with atrial fibrillation. A therapeutic INR is most often achieved through the consistent dosing of warfarin. This requires frequent blood level monitoring.

Front 130

True or false: A loud bruit heard during auscultation of the carotid artery is strongly associated with severe carotid stenosis.

Back 130

False

Carotid bruits are produced by turbulent flow and therefore may be less pronounced in moderate to severe stenosis. They have poor diagnostic sensitivity in patients with carotid stenosis and all symptomatic patients require imaging of the arteries.

Front 131

Some patients are unable to tolerate statins, the most common LDL-cholesterol lowering-drug. This statin alternative is affordable and can lower LDL and triglycerides and raise HDLs, but can cause unpleasant side effects such as flushing, itching and rash.

Back 131

Nicotinic acid (niacin)

Niacin is an affordable and widely available alternative to statins, but some patients are unable to tolerate the common side effects of flushing, itching, rash, and GI upset.

Front 132

This systemic disease has no definitive cause, an unpredictable clinical course, and no cure. It should be included on the differential list for adults presenting with shortness of breath, especially patients younger than 40. What is the diagnosis?

Back 132

Sarcoidosis

Sarcoidosis has no clear cause despite ongoing research into genetics, immunology, environmental exposure, and microbials. It most commonly affects young adults (age 20-40) and the lungs are affected in 90% of cases (Lazarus, 2009).

Front 133

Initial drug treatment of most patients with hypertension should be with which drug class?

Back 133

Thiazide diuretics

Thiazide-type diuretics should be used as initial drug therapy in most patients with uncomplicated hypertension, either alone or in combination with other blood-pressure lowering drugs. (National Heart, Lung and Blood Institute, 2003).

Front 134

When determining the recommended treatment for your patient who is newly diagnosed with heart failure, what five questions must be answered first?

Back 134

1. What is the underlying etiology? 2. What are the precipitants? 3. What is the type of heart failure? 4. What stage of heart failure is the patient currently at? 5. What is the patient’s prognosis?

The answers to these questions determine what baseline diagnostic tests will be ordered and what treatment will be required (Yu, 2013).

Front 135

Your 55 year old patient presents to your same day clinic with sudden onset of pain in his lower extremity. He has a history of PVD in his chart. His leg is pale and slightly edematous. He has decreased capillary refill and his pulse is very difficult for you to find. What should you do?

Back 135

Send your patient to the emergency department and recommend that he be evaluated by a vascular surgeon immediately.

This patient could be dealing with acute arterial insufficiency which could result in either loss of limb or death (Cambell, 2013).

Front 136

You’ve been treating your patient who has congestive heart failure with the recommended ACE inhibitor, beta blocker and diuretic. She’s been stable for several years. She comes to you for her regular follow up appointment and shares that she has been experiencing increased weight gain, swelling in her lower extremities and mild shortness of breath. What is your intervention?

Back 136

Consult with a cardiologist.

Pts would benefit from cardiology consult when symptoms have been refractory to the standard therapies of diuretics, ACE inhibitors and beta blockers.

Front 137

List risk factors for Abdominal Aortic Aneurysm (AAA) development.

Back 137

Tobacco use, hypercholesterolemia, hypertension, male gender, family history (male predominance)

AAA is the result of loss of structural integrity of the walls of the aorta leading to dilation. Genetics, inflammation, tissue inhibitors all play a role in the risk factors.

Front 138

You are working at an urgent care clinic. You enter a room and evaluate a patient with the following symptoms: dry cough, dyspnea, chest pain, fever, fatigue, anorexia, weight loss and occasional chills and night sweats. On exam, his lungs sound clear. Given the nature of your patient’s symptoms, you order a chest x-ray and it comes back positive for bilateral hilar lymphadenopathy. The likely diagnosis is:

Back 138

Sarcoidosis

Sarcoidosis may affect almost any organ system; however, majority (90%) of patients has nonspecific pulmonary symptoms.

Front 139

A 55 year old male presents to the clinic complaining of LLE pain. He has a PMH of DM II and a 20 pack/year smoking history. Upon inspection you note hair loss on the LLE along with a decrease in muscle tone. He tells you that he is able to walk about 3 blocks before the leg pain begins and at the pain also wakes him from his sleep during the night. However, the pain is relieved by placing his legs over the edge of the bed in the dependent position. You explain to the patient that based on his assessment and history he suffers from Peripheral Arterial Insufficiency, but you would like to get some more tests. Which of the following tests would you NOT order for this patient? A. Doppler US with the use of a sphygmomanometer cuff B. Arteriography C. Exercise study with the measurement of ABIs D. High sensitivity CRB with Homocysteine

Back 139

B. Arteriography

Arteriography is ordered as needed in the case of Acute Arterial Insufficiency and is not required for a diagnoses of Peripheral Arterial Insufficiency. A, C & D are all used to diagnose Peripheral Arterial Insufficiency.

Front 140

A patient presents to the clinic with complaints of an ongoing dry cough, dyspnea, chest pain, fevers, fatigue, joint pain, and chills with occasional night sweats. He has also began to notice nodules appearing on his skin, some with a white-coating, along his hair line. He is diagnosed with Sarcoidosis via a CXR and lab testing. What would you use as your first line treatment? A. Prednisone 15mg/day B. NSAIDs with the use of Inhaled Corticosteroids C. Remicade D. No treatment, the patient will go into remission on his own

Back 140

B. NSAIDs with the use of Inhaled Corticosteroids.

In patients with complaints of fever, erythema nodosum, and joint pain NSAIDs should be administered along with the use of an inhaled corticosteroid to treat his symptoms of dyspnea, dry cough and chest pain. NSAIDs are used as a first line treatment, if there is no response to the treatment with NSAIDs, then Prednisone can be ordered to treat inflammatory side effects of the disease process. Oral corticosteroids are avoided in lieu of possible toxicity. However, oral corticosteroids may be effective. Remicade is a tumor-necrosis factor that is used if both first and second-line therapies have failed (2011, pp.485). Finally, the patient is not asymptomatic, therefore his symptoms should be treated. The disease may go into remission on its own, but the patient should not be left to suffer.

Front 141

What is the clinical presentation Microvascular angina?

Back 141

Similar to classic angina with atypical symptoms such as rest and prolonged pain, and pain that doesn’t lessen with the use of Nitroglycerin.

It’s similar to that of classic angina. However, it is more common to have atypical symptoms including rest pain, prolonged pain, and pain that is less responsive to Nitroglycerin.

Front 142

In elderly patients who suffer from isolated systolic hypertension without comorbid complications, which medication is not part of the first-line recommendation of medication to prescribe? A. Calcium Channel Blocker B. Thiazide Dieuretic C. Beta-Blocker D. Agiotensin II Receptor Blocker

Back 142

C. Beta Blocker

”Among elderly hypertensive patients who require antihypertensive medication and do not have an indication for a specific drug, we recommend monotherapy with a low-dose thiazide-type diuretic, an angiotensin converting enzyme (ACE) inhibitor/angiotensin II receptor blocker (ARBs), or a long-acting Calcium Channel Blocker.”

Front 143

A 32 year old male presents to the clinic for evaluation of dry cough, dyspnea, and chest pain that began one week ago. The patient reports increasing fatigue for the past two days and fever of 101.6 F. The patient’s CXR shows bilateral hilar lymphadenopathy (BHL). What is the most likely diagnosis?

Back 143

Sarcoidosis.

Although sarcoidosis may affect almost any organ system, 90% of affected individuals experience pulmonary involvement often presenting with nonspecific symptoms pulmonary symptoms with chest radiograph of BHL pattern in 50-80% of cases (Sandberg-Cook, 2013).

Front 144

A 70 year old male presents to the urgent care clinic with complaints of back pain and hypotension. The patient denies any recent musculoskeletal injury. On exam you note a pulsatile abdominal mass. What is the most likely diagnosis?

Back 144

Ruptured abdominal aortic aneurysm (AAA).

The classic triad of ruptured AAA is hypotension (42%), pulsatile abdominal mass (91%), and abdominal pain (58%) or back pain (70%), however only 50% of patients with ruptured AAA have the triad of symptoms (Moss, 2013).

Front 145

Ms. Johnson, 51 years old, comes to the clinic for an annual physical exam. Her PMH includes rheumatic heart disease. On auscultation you note low-pitched heart tones with a diastolic rumble at the apex with the patient in the left lateral position. There is no change in the murmur with the valsalva maneuver. ECG results show left atrial enlargement with right axis deviation. What is the most likely diagnosis?

Back 145

Mitral stenosis (MS).

The classic diastolic rumble of MS is heard with the bell of the stethoscope near the apex, can be more easily heard with patient lying in the left lateral position, and left atrial enlargement with right axis deviation is seen on ECG (McGhee, 2013).

Front 146

A 35 year old woman presents to you three weeks after having gone to the Emergency Department for an deep vein thrombus in her right calf. She is here today for follow-up. She states her calf feels “completely normal.” She states she is currently taking combined oral contraceptive pills and smokes occasionally when she is stressed out at work. Her physical exam is unremarkable. Her right leg is the same size as her left, with no erythema or tenderness. She has a negative homan’s sign. As an astute Nurse Practitioner, what plan would you make for this patient?

Back 146

Discontinue combined oral contraceptives, find an estrogen free birth control method that works for this patient, and aid patient in smoking cessation.

Birth control containing estrogen puts women, especially woman over 35 who smoke, at great risk for deep vein thrombus, (Buttaro,2013).

Front 147

A 37 year old woman comes to clinic highly distressed because she has noticed “unsightly” pooling of blood in her veins in both legs. She asks you to please “give her the piss she sees advertised on TV.” According to Buttaro, the nurse practitioner should provide what type of intervention to this distressed patient?

Back 147

Medical support stockings

There is no effective way to reduce venous pressure in the lower legs except with support stockings.

Front 148

A 64 year old man with known pulmonary hypertension comes to your clinic for a follow up visit. He wants you to explain to him why he has this condition. He states that his wife is an LPN and says it is because he had asthma as a child, which caused stress on his lungs. Do you think this is an accurate assessment? Why or why not?

Back 148

No. Asthma is an inflammatory disease of the lungs that often resolves in childhood. Pulmonary vascular resistance is directly related to cardiac function, (Buttaro,2013).

Front 149

A 73 year old man with chronic heart failure comes to clinic stating his, “muscles ache and are feeling all weak.“ You ask him to tell you what his current medication regimen is. He tells you he was “up 5 pounds” three days ago so he doubled his dose of his water pill. You look on the electronic medical record and see the patient is prescribed 25 mg of Hydrochlorothiazide daily. You suspect the symptoms he is experiencing are a result of what?

Back 149

Hypokalemia

Muscle aches and muscle weakness, along with heart palpitations, are all symptoms of hypokalemia. The patient is currently taking 50 mg of hydrochlorothiazide daily. This is twice the recommended dose of this medication, as such it puts this patient at high risk for hypokalemia, hypotension, and hyperuricemia, (Buttaro,2013).

Front 150

A healthy 19 year old male comes to see you for his annual physical. During the family history portion of the interview you discover that his dad, his uncle, and his paternal grandfather all have a significant cardiac history. His mother has type II Diabetes. The patient asks you, “what can I do to prevent these diseases in myself?” How would you respond?

Back 150

Maintain a healthy body weight. Eat a healthy balanced diet. Remain or become physically active, shoot for 60 minutes of moderate activity on most days. Do not start smoking, if you do smoke, quit. When you are 21 and older, do not drink alcohol excessively. Do not use street drugs.”

High BMI, tobacco use, physical inactivity, excessive etoh use, and certain illicit drugs are all risk factors for developing DMII or heart disease (Buttaro,2013).

Front 151

According to the Systolic Hypertension in the Elderly Program (SHEP), what is the strongest independent predictor or carotid stenosis (a major cause of ischemic strokes)?

Back 151

Systolic Blood Pressure >160 mm Hg

Furthermore, for every 10 mm Hg increase over 160 mm Hg, the risk for carotid stenosis grows by an additional 30-45% (Buttaro, 2013, p. 511). This is important because 20% of ischemic strokes are a direct result of carotid stenosis.

Front 152

What are the three most important influences on myocardial oxygen demand?

Back 152

Heart rate, Systemic Blood Pressure, and Left Ventricular Wall Tension

The heart rate and systemic blood pressure (peripheral vascular resistance) have an independent influence and impact myocardial oxygen demand directly.

Front 153

Your patient comes in complaining of chest pain. What descriptors would be most suspicious for a cardiac source of the pain?

Back 153

Pressure, heaviness, aching, constricting, tightness, squeezing, numbness, or burning.

Patients may use the motion of a squeezing fist over the sternum (Levine’s sign) to describe pain of a cardiac source. The pain is most often retrosternal, epigastric, or precordial and encompassing an area the size of a clenched fist.

Front 154

Your patient presents with 30 minutes of squeezing chest pain. What finding on the EKG would be strongly suggestive of acute ischemia and warrant immediate intervention?

Back 154

ST-segment depression of >1 mm with symmetrically inverted T waves.

These findings are usually present within minutes after a patient experiences an acute ischemic event such as unstable angina or NSTEMI.

Front 155

A patient presents with episodes of chest pain described as a burning or squeezing sensation that is predictable in duration, severity, frequency, and aggravation. Symptoms normally occur upon exertion, are relieved with rest, require no more than 1 nitroglycerin tablet, and last approximately 1-3 minutes. The patient last experienced an episode minutes before arriving in your office. The Advanced Practice nurse does the following:

Back 155

Determines that this sounds like a classic case of chronic stable angina, and orders a cardiac stress test to be conducted within 72 hours.

The patient is presenting with textbook chronic stable angina. Because the ECG is only useful for detecting ischemia during an actual episode, the cardiac stress test is ordered for both diagnostic and management reasons (Buttaro, 2013).

Front 156

A 70 y.o. Caucasian female diabetic patient presents to the clinic for her annual exam with no chief complaints. When palpating the abdomen, the Advanced Practice Nurse (APN) palpates the aorta with the patient supine and her knees flexed. The APN finds that the aorta is 1.96 inches in diameter. The APN:

Back 156

Knows that the sensitivity for an abdominal aortic aneurysm (AAA) increases to 76% in aortas > 1.96 inches in size, and orders an ultrasound to screen for an AAA.

75% of patients with an AAA are asymptomatic. When ruling out an AAA, an ultrasound allows for visualization of the halo effect of an inflammatory aneurysm, as well as anatomic markers, including the left renal vein, the origin of the superior mesenteric artery, and the iliac arteries (Buttaro, 2013).

Front 157

A 62 year old Caucasian male with a history of hyperlipidemia and tobacco use presents to the clinic complaining of cramping in his left calf. The cramping is relieved with rest, and exacerbated by exercise. The physical exam reveals dependent rubor, in which the leg becomes pale when elevated for 30 seconds, followed by a deep red color that ensues when the leg is again placed in the dependent position. What are the most useful tools for ruling out peripheral arterial insufficiency in the office?

Back 157

A portable Doppler instrument and a sphygmomanometer cuff.

These tools assist in evaluating the systolic pressure in the brachial artery, the dorsalis pedis, and the posterior tibial arteries. These results are used to calculate the ankle-brachial index, which is typically lower in the affected extremity.

Front 158

A 55 year old African-American female with a history of renal disease presents to the clinic for an annual wellness exam. During the physical exam, the provider takes note of xanthomas on the knees and elbows, as well as xanthelasmas on the eyelids. The Advanced Practice Nurse does the following:

Back 158

Orders a lipid screening to rule out hyperlipidemia.

The provider knows that renal disease affects lipid metabolism, and the physical exam findings are classic objective findings in a patient with hyperlipidemia.

Front 159

A 35 year-old Caucasian female presents to the clinic with chief complaints of dyspnea, angina, and a cough. The patient is taking dexfenfluramine. The patient’s lungs are clear, and a loud second heart sound is heard with cardiac auscultation. The Advanced Practice Nurse suspects that the patient is experiencing pulmonary hypertension. What are some the diagnostic tests commonly ordered to assist in making the diagnosis of pulmonary hypertension?

Back 159

An ECG, a chest x-ray, and a V/Q scan.

An ECG can show signs of right ventricular hypertrophy, a chest x-ray will allow of visualization of the size of the pulmonary arteries, and a V/Q scan will rule out an embolus.

Front 160

An established patient of your clinic presents with complaints of not feeling well. You are concerned and order orthostatic vital signs. What constitutes orthostatic changes?

Back 160

A drop in systolic blood pressure of at least 20 mm Hg or a fall in diastolic blood pressure of at least 10 mm Hg within 3 minutes of change in position.

Some variations in blood pressure are expected. A significant drop when going from a supine to a sitting or standing position is clinically significant.

Front 161

Ms. Green is 86 year old who fell down and broke her hip 6 days ago. She was admitted to the hospital and surgery a week ago. She was discharged home with outpatient rehab and follow up appointment with her primary care provider. She is in your clinic for follow up post hospitalization. During the history taking, Ms. Green tells you that since she was discharged from the hospital, she has been staying in bed most of the time because she is afraid to fall again and she does have pain when she attempts to get up. Ms. Green is at risk for what?

Back 161

Throboembolism

Ms. Green’s age puts her at a greater risk for thromboembolism because of her hip fracture, surgery, immobility and age.

Front 162

A 58 year old female presents for initial visit. Patient does not have any compliant. PE reveals BMI=39 and BP 144/100 and 132/88 today. The rest of PE is unremarkable. Patient is clinically stable with a one time reading of elevated BP. The next best action is to:
A. Start on 25mg HCTZ daily
B. Instruct patient to get additional BP readings within next 2 month
C. Check renal function
D. Advise restricting sodium intake.

Back 162

B. Instruct patient to get additional BP readings within next 2 month.

JNC 7 reports hypertension diagnosis as 2 abnormal readings on 2 occasion and confirm the diagnosis within 2 months. Thus, this patient would require additional BP readings to have hypertension diagnosis. The rest of the choices may be appropriate after diagnosis.

Front 163

What is Homan’s sign?

Back 163

Calf pain on dorsiflexion on the foot.

One of the classic sign of DVT

Front 164

In what population is Pulmonary Embolism the leading cause of death?

Back 164

Hospitalized elderly patients who had a hip fracture or orthopedic surgery

A particularly important risk factor for venous thromboembolism is recent surgery. A few other important risk factors are serious illness, heart failure, acute infections, and inflammatory bowel disease.

Front 165

Ed, your patient, is a 55 year old male with a past medical history of diabetes, recurrent gout, and hyperlipidemia. He also has newly diagnosed hypertension. Today, you will be starting him on an anti-hypertensive agent. Given his history of gout, which anti-hypertensive agent would you likely avoid?

Back 165

Thiazide diuretic, such as hydrochlorothiazide

Although thiazide diuretics are often recommended for the initial treatment of hypertension, studies have shown that thiazide diuretics can increase the risk of developing gout. Therefore, for this patient, it is more reasonable to choose and ARB or ACE inhibitor.

Front 166

A 50 year old African-American male patient with a past medical history of hypertension (he averages 140s/80s), mild renal insufficiency, and type 2 diabetes mellitus returns to you for follow up and to provide his second 24-hr urine analysis (UA). The first UA showed microalbuminuria (his results was 36mg/24 hr excretion). Today, the second UA showed 38mg/24 hour excretion. (Microalbuminuria is diagnostic when albumin to creatinine exceeds 30mg/24 hr excretion at two of three consecutive tests within a 3 to 6 month period.) His HbA1c today is 6.5% (decreased from 7%) and LDL is 95. So far, the patient is only taking hydrochlorothiazide for his hypertension and metformin 1,000mg daily for his diabetes. What other medication would you consider prescribing for him?
A. Simvastatin
B. ACE Inhibitor or ARB
C. Micronized Glyburide 1.5 mg by mouth daily
D. These are expected findings

Back 166

B. ACE inhibitor or ARB When microalbuminuria is confirmed, treatment with an ACE inhibitor or an ARB should be initiated.

In those with type 2 diabetes, hypertension, and microalbuminuria, an ACE inhibitor or an ARB has been shown to delay the progression to proteinuria. ARBs have been shown to delay the progression of nephropathy in those who have mild renal insufficiency.