Final exam student-made qs Flashcards
(58 cards)
A 60-year-old woman with a history of hypertension and type 2 diabetes presents for routine follow-up. Her blood pressure is 158/92 mmHg. Lifestyle modifications have been insufficient in controlling her blood pressure. Which of the following is the most appropriate initial pharmacologic treatment? Using AHA guidelines (ie, BP goals and compelling indications), what are the best two drugs to start at a low dose for treatment of this patient?
A. Beta-blocker (e.g., metoprolol)
B. Thiazide diuretic (e.g., hydrochlorothiazide)
C. ACE inhibitor (e.g., lisinopril)
D. Alpha-blocker (e.g., prazosin)
B. Thiazide diuretic (e.g., hydrochlorothiazide)
C. ACE inhibitor (e.g., lisinopril)
A 30-year-old woman, G1P0, at 32 weeks gestation presents to the ER with complaints of a persistent headache and blurry vision for the past 12 hours. Her blood pressure average is 162/108 mm Hg on two different readings. She has no history of hypertension. Urinalysis shows +1 protein, and labs show thrombocytopenia and elevated liver transaminases. There is no history of seizures or loss of consciousness. Which of the following is the most appropriate next step in management?
A) Begin oral methyldopa therapy and monitor outpatient
B) Administer IV hydralazine and prepare for delivery
C) Prescribe ACE inhibitor for blood pressure control
D) Monitor blood pressure and repeat labs in 24 hours
E) Administer oral labetalol and discharge home
B) Administer IV hydralazine and prepare for delivery
Which monitoring parameter is most critical within the first month of starting an ACE inhibitor or ARB?
a) Blood glucose levels b) Liver function tests c) Serum potassium and creatinine and blood pressure d) Thyroid panel
c) Serum potassium and creatinine and blood pressure
Morgan Wallen returns to your family medicine practice with complaints that you ruined his singing career. He says, “ever since you put me on this blood pressure medication, I have a cough that interrupts my singing voice.” What medication can cause this symptom, and what can you prescribe instead to lower Morgan’s blood pressure without interrupting his singing?
A) Spironolactone is causing the cough; give him losartan instead since ARBs do not have this symptom and can lower his BP.
B) Lisinopril is causing the cough; give him atorvastatin instead since statins do not have this symptom and can lower his BP.
C) Spironolactone is causing the cough; give him losartan instead since ACEi do not have this symptom and can lower his BP.
D) Lisinopril is causing the cough; give him losartan instead since ARBs do not have this symptom and can lower his BP.
D) Lisinopril is causing the cough; give him losartan instead since ARBs do not have this symptom and can lower his BP.
Which of the following medications has an adverse effect of tendon rupture?
a) Niacin b) Gemifibrozil c) Bempedoic Acid (Nexletol) d) Omega-3 polyunsaturated fatty acids
c) Bempedoic Acid (Nexletol)
Which of the following is not recommended by the FDA to be initiated at 80mg/day due to increased risk of myopathy and rarely rhabdomyolysis?
A. Simvastatin
B. Atorvastatin
C. Rosuvastatin
D. Pravastatin
A. Simvastatin
A 60 yo pt, has hx of ASCVD and LDL 125 mg /dL despite being on atorvastatin (Lipitor) 80mg qd & lifestyle changes. What is the next best step in management for this pt?
a. Add rosuvastatin (Crestor) 20mg PO qd
b. Add alirocumab (Praluent) 75 mg SUBQ q 2 weeks
c. Nothing, this is target level of LDL
d. Add lomitapide (Juxtapid) 5 mg PO qd
b. Add alirocumab (Praluent) 75 mg SUBQ q 2 weeks
A 64-year-old man with a history of hypertension and type 2 diabetes mellitus presents with stable exertional chest pain relieved by rest. His medications include metformin and lisinopril. His blood pressure is well controlled, and his LDL-C is 80 mg/dL despite being on a high-intensity statin. He reports 2–3 episodes of angina per week, which limit his ability to perform moderate physical activity. What is the most appropriate initial pharmacologic strategy to control his anginal symptoms?
A. Initiate sublingual nitroglycerin daily
B. Add a beta-blocker to his current regimen
C. Discontinue statin therapy and start ezetimibe
D. Add a calcium channel blocker as first-line monotherapy
B. Add a beta-blocker to his current regimen
What’s the patient’s HR and BP? What are the contraindications for beta-blockers? What warning do you give a patient with DM taking beta-blockers? Does the patient still need adjunct Zetia and PRN nitroglycerin?
Glorilla, a 25-year-old female, with a history of hypertension and hyperlipidemia presents with chronic stable angina diagnosed as stable ischemic heart disease (SIHD). She reports experiencing chest discomfort while she performs and runs around on stage (being her baddie self), but states that it resolves with rest. Her current medications include lisinopril, atorvastatin, and low-dose aspirin. Her blood pressure is 135/80 mmHg, and heart rate is 83 bpm.
Which of the following would be most appropriate to add to reduce these symptoms and improve exercise tolerance so she can perform pain free?
a) Metoprolol succinate
b) Amlodipine
c) Digoxin
d) Ranolazine
a) Metoprolol succinate
A 65-year-old male with a BMI of 34 comes into the ER w chest pain. Patient received SL NTG 0.4 mg in the ambulance. His past medical history includes a stroke 3 months ago and chronic GERD. Current medications include ramipril 10 mg PO QD, chlorthalidone 25 mg PO QAM, lovastatin 20 mg PO QHS, ASA 81 mg PO daily, and omeprazole 20 mg PO Qday one hour before other drugs or food. He smoked one pack of cigarettes daily for 20 years but quit smoking seven years ago. Findings on EKG show ST segment elevation. You perform a PCI at your facility. This patient requires dual platelet antiplatelet therapy.
Which is the best option for this patient?
a. Clopidogrel
b. Prasugrel
c. Ticagrelor
d. Cangrelor
c. Ticagrelor
68-year-old Sam Sung has a history of Afib, HTN, DM, and coronary artery disease with prior drug-eluting stent placement (2 months ago). Patient is taking clopidogrel 75 mg daily, ezetimibe 10 mg PO daily, ASA 81 mg PO qday, metoprolol succinate 50 mg daily, Farxiga 10 mg PO qday, and candesartan 32 mg daily. Mr. Sung is scheduled for elective laparoscopic cholecystectomy due to symptomatic cholelithiasis. How many days before his surgery should he stop his clopidogrel?
A. 7 days
B. Continue up until surgery
C. 5 days
D. 2 days
C. 5 days
A 70-year-old woman is admitted for ST-elevation myocardial infarction and undergoes successful PCI with a drug-eluting stent. She is started on aspirin, atorvastatin, carvedilol, and lisinopril. Her past medical history includes hypertension and GERD. Which of the following is the most appropriate additional medication to prescribe at discharge to reduce the risk of stent thrombosis?
a) Omeprazole b) Rivaroxaban c) Clopidogrel d) Dabigatran e) Nitroglycerin patch
c) Clopidogrel
Dr. Lewis notes:
1) After STEMI treated with PCI, DAPT with aspirin and a P2Y12 inhibitor is standard for at least 12 months to prevent stent thrombosis and recurrent ischemia.
2) Rivaroxaban and dabigatran are anticoagulants, not routinely used post STEMI unless AFIB or other thromboembolic risks exist.
3) Nitroglycerin patch helps with angina but doesn’t prevent stent thrombosis.
4) Use pantoprazole if GI protection is needed (omeprazole may inhibit clopidogrel metabolism)
Match the Alteplase dose for a patient with ACS & a patient with a stroke. Select 2 of the following.
a) ACS - 15 mg IVP over 1-2 minutes, then 0.75mg/kg (max 50 mg) IV over 30 minutes, then 0.5 mg/kg (max 35 mg) IV over 60 minutes, total dose not exceed 100 mg
b) ACS - 0.9 mg/kg IV (max 90 mg) total dose given as a 10% bolus over 1 minute, remaining given over 60 mins
c) Stroke - 15 IVP over 1-2 minutes, then 0.75mg/kg (max 50 mg) IV over 30 minutes, then 0.5 mg/kg (max 35 mg) IV over 60 minutes, total dose not exceed 100 mg
d) Stroke - 0.9 mg/kg IV (max 90 mg) total dose given as a 10% bolus over 1 minute, remaining given over 60 mins
a) ACS - 15 mg IVP over 1-2 minutes, then 0.75mg/kg (max 50 mg) IV over 30 minutes, then 0.5 mg/kg (max 35 mg) IV over 60 minutes, total dose not exceed 100 mg
d) Stroke - 0.9 mg/kg IV (max 90 mg) total dose given as a 10% bolus over 1 minute, remaining given over 60 mins
DK is a 67-year-old male who has just been diagnosed stable ischemic heart disease. He was prescribed sublingual nitroglycerin to use PRN for chest pain. Before he goes to pick it up, what are some patient counseling points that would be beneficial? Select all that apply.
a) Sit down when taking this prescription
b) Take with food
c) Take with orange juice (it increases absorption)
d) Store in its original dark glass container and avoid keeping it in humid areas like the bathroom
e) Avoid use with drugs like sildenafil or Levitra
a) Sit down when taking this prescription
d) Store in its original dark glass container and avoid keeping it in humid areas like the bathroom
e) Avoid use with drugs like sildenafil or Levitra
A 58-year-old man presents to your family medicine clinic for follow-up after a recent hospitalization for an ST-elevation myocardial infarction (STEMI). His past medical history includes type 2 diabetes mellitus, hypertension, and heart failure with reduced ejection fraction.
He appears visibly distressed and blurts out: “Doc, I think I’m turning into a woman! I swear I need to start shopping for a bra!”
He reports that over the past few weeks he has developed painful swelling beneath both nipples. On physical exam, he has bilateral tender gynecomastia.
His current medications include:
Metformin
Lisinopril
Atorvastatin
Metoprolol
Aspirin
Clopidogrel
Spironolactone
Laboratory values today are within normal limits. You review his medications and decide to make a substitution to address his new symptoms while maintaining cardioprotective benefits.
Which of the following is the most appropriate change to his medication regimen?
A. Discontinue spironolactone and do not replace it
B. Switch spironolactone to furosemide
C. Switch spironolactone to eplerenone
D. Switch spironolactone to hydrochlorothiazide
E. Continue spironolactone and initiate tamoxifen
C. Switch spironolactone to eplerenone
Dr Lewis notes: This patient developed gynecomastia, a known side effect of spironolactone, due to its antiandrogenic effects. Spironolactone blocks androgen receptors and increases peripheral conversion of testosterone to estradiol, leading to breast tissue development in males.
Additionally, epocrates drug interactions had a warning with spironolactone because of its interaction with lisinopril on kidney function, potassium, sodium and BP.
I usually ignore that last drug interaction warning. You’ll commonly see patients on spironolactone with an ACEi, ARB, ARNI, or potassium chloride. You’ll monitor their potassium and they will have lower potassium levels (especially if they are on thiazides and loops).
A 72-year-old man with a history of ischemic cardiomyopathy is brought to the emergency department after being found lethargic and short of breath at home. He is oriented but slow to respond, with cool extremities and poor capillary refill. He’s mumbling something about his girlfriend, Jenna Tolls, who broke his heart.
Vitals:
BP: 95/75 mmHg
HR: 108 bpm
RR: 22/min
O2 sat: 94% on 2L nasal cannula
Temp: 97.9°F
A right heart catheterization is performed and reveals:
Cardiac index: 1.8 L/min/m²
Pulmonary capillary wedge pressure (PCWP): 17 mmHg
Which of the following is the most appropriate next step in management?
A. Start IV fluids and recheck cardiac index in one hour
B. Initiate IV furosemide and IV nitroglycerin
C. Begin IV dobutamine and consider adding norepinephrine
D. Optimize chronic beta-blocker and ACE inhibitor therapy
C. Begin IV dobutamine and consider adding norepinephrine
This patient is showing signs of hypoperfusion (cold)with a low cardiac index (1.8)and low PCWP (17 mmHg). The diastolic BP is low. Clinically, he is cold and borderline wet/dry, suggesting he is in Subset III (cold and dry).
Match the stroke etiology to the treatment recommendation for secondary prevention:
a) Non-cardioembolic; antiplatelet therapy
b) Non-cardioembolic; anticoagulant therapy
c) Cardioembolic; antiplatelet therapy
d) Cardioembolic; insulin
a) Non-cardioembolic; antiplatelet therapy
Patients who had a stroke caused by a non-cardioembolic event are recommended to start antiplatelet therapy as a secondary preventative measure. These treatments can include Aspirin 50-325 mg qd, Aspirin 25 mg + ER dipyridamole 200 bid, or clopidogrel 75 mg qd.
b) Non-cardioembolic; anticoagulant therapy
Patients who had a stroke caused by a non-cardioembolic event are recommended to start antiplatelet therapy as a secondary preventative measure, not anticoagulant therapy.
c) Cardioembolic; antiplatelet therapy
Patients who had a stroke caused by a cardioembolic event are recommended to start anticoagulant therapy as a secondary preventative measure, not antiplatelet therapy.
d) Cardioembolic; insulin
Patients who had a stroke caused by a cardioembolic event are recommended to start anticoagulant therapy as a secondary preventative measure. Insulin is used to treat DM with an A1c >10.
Betty White, a 75-year-old woman is brought to the ER by EMS complaining that her heart has been “ racing and feeling kinda funny for a while” The paramedic reports states that a 12 lead EKG revealed she was in a fib and while on route she began to exhibit difficulties with her speech. Being the rockstar that you are, you get some STAT labs and a CT and diagnose her with ischemic stroke. It has been 3 hours since symptom onset, her BP is 200/116, and her INR is 1.0. Her daughter, when reached, says she’s already on some “a-statin med” for her cholesterol. What is your initial treatment and what other medications might you prescribe for secondary prevention. Select all that apply
A. Labetalol 10-20mg IV given over 1-2 min
B. Edoxaban 120 mg BID. This drug is the best.
C. Aspirin 25mg extended-release tablet
D. Alteplase 0.9 mg/kg IV with first 10% in a bolus and a max of 90 mg given over 60 minutes
E. Apixaban 5 mg BID
F. None of the above. The patient says to give her a shot of whiskey and some BC powder and let her go home. She’s got a hot date.
A. Labetalol 10-20mg IV given over 1-2 min
D. Alteplase 0.9 mg/kg IV with first 10% in a bolus and a max of 90 mg given over 60 minutes
E. Apixaban 5 mg BID
Which of the following is not a contraindication to tPA?
A) Previous stroke 1 year ago
B) Infective endocarditis
C) Active internal bleeding
D) GI malignancy
A) Previous stroke 1 year ago
Waldo is an 85-year-old male with a past medical history of atrial fibrillation. He had a cardioembolic stroke 7 days ago and was placed on apixaban (Eliquis) 5 mg PO BID. Given his weight of 83 kg and serum creatinine 2.0 mg/dL, should his apixaban be reduced, and if so what should the dosage be reduced to?
A. No, the patient should continue at the same dose.
B. Yes, it should be reduced to 5 mg PO QD.
C. Yes, it should be reduced to 2.5 mg PO BID.
D. Yes, it should be reduced to 2.5 mg PO QD
C. Yes, it should be reduced to 2.5 mg PO BID.
The patient’s apixaban should be reduced to 2.5 mg BID if two or more of the following:
○ Age ≥ 80 years old
○ Weight ≤ 60 kg
○ Serum creatinine ≥ 1.5 mg/dL
While on her clinical rotation, PA student Judith McSpanky emails Dr. Lewis (on break at Kroger, daydreaming about target doses) about a new ER admission:
Mr. Pickle T. Mamacita, 70 y/o male with HFrEF (EF 30%) and AFib, presents with dyspnea, 2+ edema, and HR 118 bpm.
Cardiac index is 2.5 and PCWP is 22; CrCl = 88 mL /min
Current medications include: Metoprolol succinate 25 mg Qday, furosemide 40 mg BID, lisinopril 10 mg Qday, digoxin 0.25 mg Qday, potassium chloride 20 MEQ daily
Judith McSpanky’s email states: “should I continue the furosemide or will my preceptor yell at me for that?’
What’s the most appropriate next step?
A. Add diltiazem for better rate control
B. Change to furosemide IV and consider adding HCTZ for loop resistance
C. Increase metoprolol dose and monitor response
D. Stop digoxin and start amiodarone
B. Change to furosemide IV and consider adding HCTZ for loop resistance
Is the patient taking the target dose of lisinopril and metoprolol?
Assume the patient is NHYA II, does the patient need spironolactone, Entresto, or Farxiga?
You’re tending a medieval herb garden as part of a very unconventional cardiology elective. While pulling weeds, your attending physician hands you a bouquet of purple flowers and says, “This one killed many cats.”
Suddenly, a messenger runs in from the castle infirmary:
“Your Majesty’s knight is weak and weary! His heart beats slow and his breath comes short! He’s been diagnosed with heart failure with reduced ejection fraction (HFrEF) and remains symptomatic despite standard treatment!”
You rush to the royal medicine chest and spot several options. Remembering your floral studies, you choose the one derived from purple foxglove—a medication known to reduce hospitalizations, but not mortality, and which requires careful dose monitoring due to its narrow therapeutic window.
Which medication do you choose for this knightly patient?
A. Carvedilol
B. Sacubitril/valsartan
C. Digoxin
D. Furosemide
E. Spironolactone
C. Digoxin
