AAFP Family Medicine| 533 Questions| WITH COMPREHENSIVE ANSWERS
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Kaplan University
Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on co...
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AAFP Family Medicine| 533 Questions| WITH
COMPREHENSIVE ANSWERS
Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated
by the development of heart failure. Caution is necessary when prescribing TZDs in patients with
known heart failure or other heart diseases, those with preexisting edema, and those on
concurrent insulin therapy Correct Answer: A 70yo M with h/o HTN and DM presents with a 2-
mo h/o increasing paroxysmal nocturnal dyspnea and SOB with minimal exertion. An
echocardiogram shows an ejection fraction of 25%. Which one of the patients current
medications should be discontinued?
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
Renal Parenchymal Disease
The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine
culture, and renal ultrasonography should be ordered for all children presenting with
hypertension. Correct Answer: What is the most common cause of hypertension in children
under 6 years of age?
Refer for cardiac resynchronization therapy (CRT)
Note: he's already on maximum doses of ACEI, loop diuretic, beta-blocker
Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously,
overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block.
These guidelines were refined by an April 2005 AHA Science Advisory, which stated that
optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis,
an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class
III or IV despite maximal medical therapy for heart failure. Correct Answer: A 72-year-old
African-American male with New York Heart Association Class III heart failure sees you for
follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his
medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice
daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood
pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings include a few
scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart,
and no edema on examination of the legs. An EKG reveals a left bundle branch block, and
echocardiography reveals an ejection fraction of 25%, but no other abnormalities. What's the
appropriate next step?
increase intake of omega 3 fatty acids
,Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild
vasodilators, and may have antiarrhythmic properties. The American Heart Association
guidelines state that omega-3 supplements may be recommended to patients with preexisting
disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like or
are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily
resulted in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with
particular decreases in the rate of sudden death. Correct Answer: What dietary change
recommended for the prevention and treatment of cardiovascular disease has been shown to
decrease the rate of sudden death?
Dx: aortic dissection
next step: Intravenous labetalol (Normodyne, Trandate)
Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest
level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below
60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg,
intravenous nitroprusside should be added. Without prior beta-blocade, vasodilation from the
nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased
ventricular contraction and increased shear stress on the aorta. Correct Answer: A 75-year-old
male presents to the emergency department with a several-hour history of back pain in the
interscapular region. His medical history includes a previous myocardial infarction (MI) several
years ago, a history of cigarette smoking until the time of the MI, and hypertension that is well
controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious,
but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110
beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest
radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a
dissecting aneurysm of the descending aorta that is distal to the proximal abdominal aorta but
does not involve the renal arteries. Which one of the following would be the most appropriate
next step in the management of this patient?
The guideline recommends one-time screening with ultrasonography for AAA in men 65-75
years of age who have ever smoked. No recommendation was made for or against screening
women. Men with a strong family history of AAA should be counseled about the risks and
benefits of screening as they approach 65 years of age. Correct Answer: According to the U.S.
Preventive Services Task Force, what are the screening recommendations for an abdominal
aortic aneurysm?
verapamil (Calan)
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can
usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails,
intravenous propafenone or flecainide may be necessary. It is also important to look for and treat
possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances.
Electrical cardioversion may be necessary if these measures fail to terminate the
,tachyarrhythmia. Correct Answer: A 36-year-old white female presents to the emergency
department with palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular
tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to
carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The
most appropriate next step would be to administer intravenous
BP goal: 130/80mmHg
Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients and to <130/80
mm Hg in diabetic patients is recommended. Lowering blood pressure may reduce stroke rates
by 40%-52% and cardiovascular morbidity by 18%-20% Correct Answer: The blood pressure
goal for a patient who has uncomplicated diabetes mellitus is
Diltiazem (Cardizem)
Monotherapy for hypertension in African-American patients is more likely to consist of diuretics
or calcium channel blockers than β-blockers or ACE inhibitors. It has been suggested that
hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in
Caucasians. Correct Answer: A 60-year-old African-American female has a history of
hypertension that has been well controlled with hydrochlorothiazide. However, she has
developed an allergy to the medication. Successful monotherapy for her hypertension would be
most likely with which one of the following?
A. Lisinopril (Prinivil, Zestril)
B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem)
Still's murmur
There are several benign murmurs of childhood that have no association with physiologic or
anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of
Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar
valves, or ventricular wall. Correct Answer: An asymptomatic 3-year-old male presents for a
routine check-up. On examination you notice a systolic heart murmur. It is heard best in the
lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not
radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the
examination is normal. What is the most likely diagnosis?
Enoxaparin
Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal
impairment the dosage must be significantly reduced. For some indications the dose normally
given every 12 hours is given only every 24 hours. Although some β-blockers require a dosage
adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage
adjustment in patients with renal failure. Clopidogrel is currently recommended at the standard
, dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are
given at the standard dosage in renal failure, although hemorrhagic complications are increased.
Correct Answer: A 57-year-old male with severe renal disease presents with acute coronary
syndrome. Which one of the following would most likely require a significant dosage adjustment
from the standard protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA)
2-dimensional echocardiography with Doppler
The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional
echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left
ventricular size, ventricular compliance, wall thickness, and valve function. The test should be
performed during the initial evaluation. Radionuclide ventriculography can be used to assess
LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest
radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in
all patients presenting with heart failure, but should not be used as the primary basis for
determining which abnormalities are responsible for the heart failure. Correct Answer: A 55-
year-old male who has a long history of marginally-controlled hypertension presents with
gradually increasing shortness of breath and reduced exercise tolerance. His physical
examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and
trace pitting edema. What study would be the preferred diagnostic tool for evaluating this
patient?
EKG
The symptom of an increased or abnormal sensation of one's heartbeat is referred to as
palpitations. This condition is common to primary care, but is often benign. Commonly, these
sensations have their basis in anxiety or panic. However, about 50% of those who complain of
palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the
evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for
signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a
prolonged QT interval. Correct Answer: A 23-year-old female sees you with a complaint of
intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel
lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never
passed out, had chest pain, or had difficulty with exertion. She is otherwise healthy, and a
physical examination is normal. What cardiac study should be ordered initially?
regular exercise
Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved by
rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with
peripheral vascular disease are asymptomatic. Initial treatment should consist of vigorous risk
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