Which of the following beta-blockers is cardio selective?
A. Nadolol
B. Propanolol
C. Atenolol
D. Penbutolol - correct answer C.
... [Show More] Atenolol
Explanation: Of the beta blockers listed, atenolol is the most cardioseletive. Cardioselective refers to the ability to affect predominately beta 1 receptors rather than beta 2 receptors. Beta 1 receptors are located mainly in the heart and mediate the sympathetic nervous system's direct effects on the heart. Beta 2 receptors are located predominately in the peripheral vascular system and other organs like the lungs. Although all beta-blockers affect beta receptors, some affect subsets of receptors differently. This has a significan consequences in terms of side effects, as beta-blockers are know to cause extra-cardiac symptoms such as worsened bronchospasms in in asthmatics.
Nadolol, propanolol, and penbutolol are non-selective beta-blocker
For the initial pharmacological treatment of essential hypertension, which of the following statements is true?
A. Diuretics should be the first consideration because of their effectiveness, cost, and low side-effect profile.
B. ACE inhibitors speed the progression of moderately increased albuminuria independent of blood pressure control in diabetic patients.
C. Alpha-blockers are of particular benefit for the treatment of hypertension in patients with ischemic cardiomyopathy.
D. Angiotensin receptor blockers should not be used in place of ACE inhibitors in patients who develop a cough after initiating an ACE inhibitor. - correct answer A. Diuretics should be the first considered because of their effectiveness, cost, and low side-effect profile.
Explanation: There is no evidence that alpha-blockers are of particular benefit for the treatment of hypertension in patients with ischemic cardiomyopathy. The JNC 8 guidelines state that in the general non-black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide type diuretic or CCB. Initial treatment with a thiazide-type diuretic was more effective than CCB or an ACEI.
A 30-year-old G1 P0 female at 35 weeks gestation complains of a headache at her routine prenatal visit. Her blood pressure is 140/90 mmHg and urinalysis reveals 1+ protein. Which of the following is the most appropriate step in management of this patient?
A. Emergent cesarean section delivery
B. Close follow-up of urinary protein and serum creatinine.
C. Pitocin
D. Methylopa (Aldomet) to reduce blood pressure - correct answer B. Close followup of urine protein and serum creatinine.
Explanation: The patient has evidence of preeclampsia. Symptoms of preeclampsia include headache, and blurred vision. Preeclampsia is characterized by hypertension, proteinuria, and edema that occur after 20 weeks' gestation. Two blood pressures readings should be measured at least 6 hours apart. Systolic blood pressure than than or equal to 140 mm Hg or diastolic blood blood pressure greater than or equal to 90 mm Hg is consistent with preeclampsia, for which the cure is delivery of the fetus and placenta. Patients will demonstrate greater than 0.3 grams of protein in a 24-hour urine specimen and frequently gain weight rapidly, from two to five lbs per week. RUQ pain may also herald development of HELLP syndrome, characterized by hemolysis, elevated liver enzymes, and low platelets. Preeclampsia can cause multi-organ damage, including stroke, acute renal failure, pulmonary edema, hepatic rupture, DIC, and fetal or maternal death. If seizures develop, the condition is known as eclampsia. Recommendations for management of preeclampsia include bed rest with bathroom privileges: monitor platelets, urine and serum protein, and serum creatinine: and monitor weight and blood pressure. Oral antihypertensives are not the first line of treatment.
A 55 yo female patient with a history of hypertension controlled with HCTZ 25 mg q day presents for a routine wellness examination. Her BMI is 30kg/m3 and her total cholesterol is 230 g/dL. How many risk factors does this patient have for CAD?
A. 2
B. 3
C. 4
D. 5 - correct answer C. 2
Explanation: The patient has 4 risk factors for CAD: women aged 55 and older; hypertension; hyperlipidemia; and obesity. Risk factors for CAD include HTN, family history of premature heart disease; DM; dyslopidemia; HDL cholesterol <40 mg/dL; age older than 45 years in men or 55 years in women; cigarette smoking; obesity (BMI > or = to 30); microalbuminuria; carotid artery disease; peripheral arterial disease. Some patients without CAD are at an increased risk of MI as the result of other conditions. Patients with the following conditions have greater than 20% chance of developing coronary heart disease in ten years:
CAD, PAD, abdominal aortic aneurysm, CKD, diabetes, and cigarette smoking. These conditions are known as coronary risk equivalents and patients with these conditions should be treated as though they have preexisting CAD.
A 54 yo male is discharged from the hospital after experiencing an MI. Past medical history includes asthma, HTN, hyperlipidemia, and DM. He presents to PCP for an intial followup and complains of increasing wheezing and SOB. Cardiovascular exam shows a regular rate and rhytms without murmur/gallp/rubs and no elevated JVD. Pulmonary exam shows wheezing in all lung fields and a prolonged expiratory phase. Which of the patient's medications are likely to blame?
A. Lisinopril
B Rosuvastatin
C. Clopidogrel
D. Metoprolol tartrate - correct answer D. Metoprolol tartrate
Explanation: This patient has likely experienced a side effect of a new cardiac medication. His wheezing on exam could be cardiac wheezing if he was volume overloaded, but he shows no signs of this condition. The most likely explanation is that his known asthma has flared. Medications that induce bronchoconstriction can do this, and the mostly likely is metoprolol tartrate. This patient's beta-blocker dose should be adjusted, or he should e trialed on a different beta-blocker.
A 45 yo man's lipid profile results are sent to the NP. They are as follows: total cholesterol= 287; HDL= 30; LDL= 165. The NP interperts these results as:
A. Abnormal; the elevated triglyceride levels is often the most concern.
B. Borderline; this is considered to a borderline risk lipid profile.
C. Abnormal; the total cholesterol and LDL levels are elevated and the HDL is too low.
D. Normal; these results are of no concern; follow up with client in 1 year. - correct answer C. Abnormal; the total cholesterol and LDL levels are elevated, and the HDL is too low.
Explanation: Desired levels for lipid profile re total cholesterol <200, HDL > 35, LDL < 130, and triglycerides < 150.
Which of the following diagnostic-inclusion is criterion is included in both the TIMI risk score and the GRACE risk score for acute coronary syndrome mortality?
A. Blood pressure
B. Gender
C. Troponin measurements
D. Heart rate - correct answer C. Troponin measurements
Explanation: The TIMI and GRACE risk scores are mortality rates for patients with acute coronary syndrome. The TIMI risk score is used to estimate mortality for patients with unstable angina and non-ST elevation MIs. Depending on the risk-factor inclusion and exclusion criteria, a score is given that determines whether the patient needs urgent revascularization. The criteria include 7 factors: age greater than or equal to age 65, 3 or more CAD risk factors, known CAD with at least 50% stenosis, aspirin use within the past 5 days, 2 episodes of angina within 24/hr, EKG changes >0.5 mm, and positive cardiac markers. the TIMI score was established in 2000, and the GRACE score is more recent and has updated criteria.
Which answer correctly identifies the effect profile of direct beta-adrenergic stimulation on the cardiovascular system?
A. Increased heart rate, contractility, and systemic vascular resistance
B. Increased heart rate and contractility with decreased systemic vascular resistance
C. Decreased heart rate and systemic vascular resistance with increased contractility
D. Decreased heart rate, contractility, and systemic vascular resistance - correct answer B. Increased heart rate and contractility with decreased systemic vascular resistance.
Explanation: There are 2 beta-adrenergic receptors: beta 1 and beta 2. Beta 1 receptors are the primary cardiac beta receptor, while beta 2 receptors in the peripheral vasculature are stimulated, this triggers smooth muscle dilation and subsequent vasodilation. This causes a decrease in overall systemic vascular resistance (SVR). In contrast, the stimulation of cardiac beta 1 receptors triggers both increased heart rate and increased myocyte contractility. Both beta-receptor subtypes act vi G-protein-coupled receptors. Thus, global beta-receptor stimulation will yield increased heart rate and contractility with decreased SVR.
A 77 yo female presents to her PCP complaining of a left foot ulcer. She has mild pain that is relieved with elevation of the leg. On physical exam, the ulcer is located on the medial malleolus, has an irregular border and has a pink base with granulation tissue. What is the likely cause of this patient's ulcer?
A. Peripheral neuropathy
B. Venous insufficiency
C. PAD
D. Diabetic neuropathy - correct answer B. Venous insufficiency
Explanation:The patient has a classic venous insufficiency ulcer. Neurotrophic ulcers due to neuropathy occur where there is pressure or trauma, usually on the sole of the foot. Neurotrophic ulcers are usually deep, frequently infected, and usually not painful because loss of sensation. Ulcers from PAD usually are more painful, discrete, circumscribed with regular borders, and frequently located on the great toe.
A 69 yo, African American male patient presents for a well visit. He takes atorvastatin (Lipitor) for dyslipidemia as well as hydrochlorothiazide and enalapril (Vasotec) for HTN. He does not drink and stopped smoking 10 years ago.He reports some difficulty "getting moving" in the morning because his joints are stiff, but otherwise reports that he feels well. He has no history of abdominal surgeries and his last colonoscopy was one year ago. All systems are WNL, except he has a pulsatile periumbilical, non-reducing mass. What screening test do you want to run?
A. X-ray
B. Doppler ultrasound
C. CT scan
D. Abdominal ultrasound - correct answer D. Abdominal ultrasound
Explanation: The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasound in men ages 65 to 75 years who have ever smoked (over 100 lifetime cigarettes).
A 54 yo female with CKD and known proteinuria is started on lisinopril 2- mg daily. Her serum creatinine before starting the medication is 1.7. About 1 month later, it is 2.0. Her blood pressure at this time is 129/70. What is the next step in the management of this patient?
A. Stop lisinopril
B. Decrease lisinopril dosage and add amlodipine
C. Decrease lisinopril dosage
D. Make no changes to her regimen. - correct answer D. Make no changes to her regimen
Explanation: This patient is being treated with an ACE inhibitor for proteinuria. ACE inhibitors decrease proteinuria in those with CKD and help with blood pressure control. Unfortunately, this patient has experienced an increase in serum creatinine from 1.7 to 2. In most cases situations, this would be a cause for alarm. However, adding an ACE inhibitor for patients with known CKD commonly results in an increased serum creatinine. The improvement in proteinuria happens despite this effect. Thus, it is standard practice to accept up to 30% increase in serum creatinine before considering discontinuation of ACE inhibitor in this patient, that would be a serum creatinine of >2.2). This patient should continue lisinopril and have her kidney function checked regularly.
The mechanism by which thiazide and thiazide-like diuretics lower blood pressure is incompletely understood, but the decrease in blood pressure appears to be a response to initial volume loss. This fall in blood pressure is initially blunted by the action of the renin-angiotesin system, but the blood pressure will still remain low or continue to fall slowly over as long as 12 weeks. Which mechanism explains this continued blood pressure lowering after urinary sodium returns to normal?
A. Parasympathetic activation
B. Sympathetic inactivation
C. Upregulation of the renin-angiotensin system with decreased peripheral vascular resistance
D. Decreased cardiac contractility - correct answer C. Upregulation of the renin-angiotensin system with decreased peripheral vascular resistance.
Explanation: Immediately after the initiation of a thiazide diuretic, patients experience diuresis and reduction in blood pressure due to volume loss. This response is blunted by hypovolemia-induced activation of the renin-angiotensin system. Diuresis decreases within a few week. This decrease in diuresis is secondary to a return to baseline of the renin-angiotensisn-aldosterone system. The plasma volume and cardiac output partially rise toward the baseline level, while the systemic vascular resistance falls. This secondary effect is more pronounced with long-acting thiazide diuretics. The mechanism for this vasodilatory effect is unclear. The maintenance of reduction in blood pressure is due to this small, secondary vasodilatory effect that is characterized by decreased peripheral vascular resistance. Overall, expect a drop of about 10 mm Hg with thiazide diuretics.
A cigarette smoker with a history of lower-extremity claudication is started on an ACE-inhibitor for HTN that failed to improve with lifestyle modifications. His serum Cr doubled after the initiation of the ACE inhibitor. This is suggestive of which finding?
A. Significant bilateral renal artery stenosis
B. Pheochromocytoma
C. Primary aldosteronism
D. Atherosclerotic emboli from the aorta. - correct answer A. Significant bilateral renal artery stenosis
Explanation: in bilateral renal artery stenosis, GFR is preserved by the actions of angiotensisn II, afferent arteriolar vasodilation, and efferent arteriolar vasoconstriction. ACE inhibitors and angiotensin II receptor blockers blunt these responses, resulting in a decrease in GFR and an increase in serum Cr. Thiazide diuretics and CCB are better choices for hypertensive patients with bilateral renal artery stenosis.
A 46 yo man presents to your office for an annual well-check. He has HTN and takes amlodipine. His vital signs and physical exam findings are all within normal limits at this visit. [Show Less]