4/9/2017 8

2014HISHAMAWNYABDELMONIEM 10

1)0A87yearoldman(5'9",190lb)withamedicalhistorysignificantfortype2
diabetesmellitus(DM)andhypertension(HTN),presentstotheemergencydepartment
(ED)withsubsternalchestpressureand2mmSTsegmentdepressioninleadsV2V4.
Hisvitalsignsincludebloodpressure(BP)168/92mmHgandheartrate(HR)100
beats/minute.Hiscurrentmedicationsincludemetformin500mgorallytwicedailyand
lisinopril10mgorallydaily.PertinentlaboratoryresultsincludeSCr1.8mg/dL,
hemoglobin12.8g/dL,hematocrit38%,andtroponinI(TnI)4.7ng/mL(normal,less
than0.5ng/mL).

Whichmedicationregimenwouldbebesttoinitiateforthispatientuponadmissionto
thehospital,regardlessofwhetherhewillbegoingforpercutaneouscoronary
intervention(PCI)

1.Asprinclopidogrel,metoprolol,intravenousnitroglycerin,unfractionatedheparin,
andatorvastatin

2.Aspirin,clopidogrel,diltiazem,enoxaparin,andatorvastatin

3.Aspirin,prasugrel,metoprolol,enoxaparin,andlisinopril

4.Ticagrelor,metoprolol,intravenousnitroglycerin,unfractionatedheparin,and
atorvastatinirin

,answer:4becauseacctotimiscorehehasbleedingriskandasaplusclocombination
hashigherbleedingriskthanticagrelor

2)80yearoldambulatoryfemaleptwithhypertensionrecievinglisinopril20mgdaily
required2ndhypertensiveagentforoptimumbloodpressurecontrol..historyincludes
dietcontrolledDM,COPD.mildLVhypertrophyandmilddementia,secreatinine=2.5
mg/dl.BUN=30mg/dl..whichofthefollowingantihypert.agentshouldbeadded

a)valsartan

b)verapamil

c)metoprolol

d)HCT

answer:d)HCTisright

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3)Apatientisadmittedwithdecompensatedchronicheartfailure.Thepatientscurrent
medicationsincludelisinopril20mgdaily,furosemide40mgtwiceaday,metoprolol
CR/XL200mgdailydigoxin0.125mgdaily.Thepatienthasbeenstableonthesedoses
fortheprevious4months.Itisdecidedthatpositiveinotropictherapyisindicated,
alongwithIVdiuretics.Whichofthefollowingwouldyourecommend?

A)D/Cmetoprololandstartdopamine

b)D/Cmetoprololandstartdobutamine

C)Startdobutamine

D)Startmilrinone

answer:AnswerisDbecauseDobutamineisB1agonistsowecantuseinptalreadyonb
blockerandnoneedtostopmetoprololasptisstableonhismedicationsandwedon't
usedopamineasitneedsdosing

4)Whichchoicebestdescribesanabsolutecontraindicationtoblockertherapy?

A.Cardiogenicshock.

B.Type2diabetesmellitus.

C.Chronicobstructivepulmonarydisease(COPD).

D.SBPlessthan95mmHg.

answer:A

AlthoughsomepatientsmaybemaintainedonBlockersinthissituation,itshouldbe
doneonlybypersonnelhighlyexperiencedintreatingpatientswithHFinaclosely
monitoredsetting.Blockersarenotcontraindicatedinthesettingofdiabetes(educate
patientsthatBlockersmaymasksymptomsofhypoglycemiaandthatbloodglucose
controlshouldbemonitoredclosely)orCOPD(althoughtheymaybepoorlytoleratedin
reactiveairwaydisease)thus,AnswerBandAnswerCareincorrect.Inpatientswith
stageAHF,Blockersarenotcontraindicatedmoreover,theymaypreventthe
progressionofHF.ManypatientswithHFhavelowSBPandtoleratecertainBlockers
wellthus,AnswerDisincorrect.Aslongaspatientsarestableandnotincardiogenic
shock,BlockersareappropriateforpatientswithlownormalSBP

5)Thepatientisa74yearoldmanbeingpreparedfordischargefromthehospitalafter
sufferinganonSTsegmentelevationmyocardialinfarction(MI).Hehasahistoryof
type2diabetesmellitus,hypertension,andheartfailure(EFof35%).Hecurrentlytakes
lisinopril20mg/day,furosemide20mg2times/day,aspirin325mg/day,clopidogrel
75mg/day,simvastatin40mgatbedtime,andglipizide10mg/day.Hisbloodpressure
todayis130/80mmHg,andhisheartrateis70beats/minute.Whichofthefollowing
therapeuticstrategieswouldbestoptimizethispatientsoutcomes?

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A.Addmetoprolol.

B.Addezetimibe

.C.Addhydrochlorothiazide.

D.Adddigoxin.

answer:A

6)An80yearoldmanpresentswithdyspneaandisfoundtohaveCHFcausedby
systolicdysfunction.Healsohasmildrenalinsufficiency,withacreatininelevelof
1.4.WhichofthefollowingstatementsistrueregardingACEinhibitortherapyinthis
patient?

A.Itiscontraindicatedbecauseofhisage

B.Itiscontraindicatedbecauseofhisrenalinsufficiency

C.AngiotensinIIreceptorblockersarepreferredforCHFinelderlypatients

D.ACEinhibitortherapycanbestarted,provideditisaccompaniedbycareful
monitoringofhiscreatinineandpotassiumlevels

E.ACEinhibitortherapycanbestartedbutmustbediscontinuedifhiscreatinine
levelrisesaboveitscurrentlevel

answer:d

7)Youarethepharmacotherapyspecialistforaninpatientgeneralmedicineservice.You
haveageriatricpatientwhohasbeenadmittedfornewonsetatrialfibrillation.The
medicalteamisconsideringwhichtherapeuticstrategytoconsider.Basedonpublished
evidence,whichtherapeuticapproachandrationalewouldbethemostappropriateat
thistime?

A.Ratecontrolasithasbeenshowntobesuperiortorhythmcontrolformortality
reduction.

B.Rhythmcontrolasithasbeenshowntobesuperiortoratecontrolformortality
reduction.

C.Eitherrateorrhythmcontrolisacceptableasthereexistsnodifferenceinmortality
betweenthesetwostrategies

D.Rhythmcontrolasratesofhospitalizationareincreasedinpatientswhoreceiverate
control.

answer:c

8)A53yearoldwomanisadmittedtothehospitalaftertheworstheadacheshehas
everexperienced.Hermedicalhistoryincludesexertionalasthma,poorlycontrolled
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hypertension(HTN),andhyperlipidemia.Sheisnonadherenttohermedications,and
shehasnottakenherprescribedBPmedicationsfor4days.VitalsignsincludeBP
220/100mmHgandHR65beats/minute.Sheisfoundtohaveacerebrovascular
accident.Whichagentismostappropriateforthispatientshypertensiveemergency?

A.Fenoldopam0.1mcg/kg/minute.

B.Nicardipine5mg/hour.

C.Labetalol0.5mg/minute.

D.Enalaprilat0.625mgintravenouslyevery6hours

answer:B

9)A65yeoldwhitemaleisbeingevaluatedforstagech.f.heiscurrentlyexperiencing
shortnessofbreathandfatiguewithminimaldailyactivities,butissymptomfreeatrest,
hereports2pilloworthopneabutdeniespndorchestpain.hisphysicalexamis
unremarkablewithexceptionofstable,1+edemsbilaterallypastmedicalhistory:cad
s,pmih.f(lvef25%)hypertensiondyslipidemiacurrentmedications:enalapril10mg
twiceadaycarvedilol25mgtwiceadaydigoxin0.125mgdailykcl10meqdaily
torsemide40mgdailyrouvastatin10mgdailyaspirin81mgdailyvitalssigns:bp
124/24hr62wt185ibs(today)bp122/76hr60wt187ibs(4weeksagoatlastvisit)
labs:today:na138k4.3cl100co225bun15scr1.1glu854weeks:na140k4.2cl98
co296bun14scr1.1glu82digoxin1.0ng/mlwhichofthefollowingpharmacological
adjustmentwouldmostappropriateatthistime?

1initiateISOSORBIDEdinitrate/hydralazine20/37.5mgthreetimesaday

2increasedigoxin0.25mgdaily

3initatespironolactone25mgdaily

4increasetorsemideto60mgdaily

answer:3initatespironolactone25mgdailyisright

10)R.K.isa67yearoldmanwithchronicstableangina.Hehashadworseningchest
discomfortwithexerciseandhasbeenusinghisasneedednitroglycerinwithincreasing
frequency.Hismedicationsincludeaspirin81mg/day,atenolol100mg/day,
atorvastatin80mg/day,andlisinopril20mg/day.Today,hisvitalsignsincludeBP
136/80mmHgandHR60beats/minute.HislipidpanelisTC151mg/dL,TG58
mg/dL,HDLC68mg/dL,andLDLC68mg/dL.Duringexercise,hisHRtypically
increasesto85beats/minute.Whichwouldbethebestoptiontoimprovehisanginal
symptoms?

A.Addamlodipine10mg/day.

B.Discontinueatenololandbeginextendedreleasenifedipine90mg/day.

C.Addclopidogrel75mg/day.
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D.Addezetimibe10mg/day

answer:ADHPccbcausestrongVD....socoronaryvesselbloodflowdecsodecsupply
bloodtotheheartwhilenobbtodecdemandbydecHRsoincreasetheworkloadon
heart....Maypptischemia,ACS,MI

11)A55yearoldmalepresentswithuncontrolledhypertensionandiscurrently
receivinghydrochlorothiazide25mgdaily.Hismedicalhistoryissignificantfor
gastroesophagealrefluxdiseaseandhewasrecentlydiagnosedwithgout.

QuestionWhichantihypertensiveagentmaybeaddedandcouldreducehisuricacid
level?

AAmlodipine

BAtenolol

CHydralazine

DLosartan

answer:dLosartanisright

12)B.B.isa58yearoldwomanadmittedforacutedecompensatedheartfailure.At
baseline,shehasNewYorkHeartAssociationclassIIIheartfailurecausedbydiastolic
dysfunction.Duringthepast2weeks,shehasbeenexperiencingincreasedshortnessof
breathwithminimalactivitiesandisnowshortofbreathatrest.Sheisinitiatedon
intravenousloopdiureticsbuthasahistoryofdiureticresistance.B.B.sbaselinevital
signsincludeabloodpressureof85/60mmHgandheartrateof80beats/minute.
WhichoneofthefollowingisthenextbestoptionfortreatingB.B.sdecompensated
heartfailure?

A.Addingintravenouschlorothiazideororalmetolazone.

B.Initiatingintravenousvasodilatorymedications.

C.Initiatingintravenousinotropicmedications.

D.Switchingtoadifferentloopdiuretic

answer:c

13).A65yearoldwomanwithlongstandinghypertensionhasdyspneaassociatedwith
theclassicsymptomsandphysicalfindingsofCHF.Herchestxrayshowssignsof
pulmonaryedema.Herechocardiogram,however,showsslightlythickenedmyocardium
andanormalleftventricularejectionfraction.Adiagnosisofdiastolicdysfunctionis
madeWhichofthefollowingwouldimprovethispatient'ssymptoms?

A.Digoxin

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B.Furosemide

C.Enalapril

D.Metoprolol

E.Noneoftheabove

answer:B

14)R.S.,a58yearoldwomanwithahistoryofhypertension,coronaryarterydisease
(CAD),(myocardialinfarction[MI]4monthsago),anddyslipidemia,presentstothe
clinicforfollowup.Sheiswithoutcomplaintsandhasnosignsorsymptomsofdyspnea
oredema.Anechocardiogramrevealsaleftventricularejectionfraction(LVEF)of35%.
SheisNewYorkHeartAssociation(NYHA)classIII.Hermedicationsincludeaspirin81
mg/day,metoprololsuccinate150mg/day,andsimvastatin20mgeverynight.Hervital
signsincludeheartrate(HR)58beats/minuteandbloodpressure(BP)138/80mmHg.
Herlungsareclear,andlaboratoryresultsarewithinnormallimits.Givenherhistory
andphysicalexamination,whichisthemostappropriatemodificationtoR.S.scurrent
drugtherapy?

A.Continuecurrenttherapy.

B.Initiatedigoxin0.125mg/day.

C.Initiatespironolactone25mg/day.

D.Initiatelisinopril5mg/day

answer:D

15).A56yearoldmanwithahistoryofcoronaryarterydiseaseandadocumented
ejectionfractionof40%byechocardiographypresentsforfurtherdyspneaonexertion,
orthopnea,orlowerextremityedema.Hehasneverbeenadmittedtothehospitalfor
congestiveheartfailure(CHF)AccordingtothenewAmericanCollegeof
Cardiology/AmericanHeartAssociation(ACC/AHA)guidelinesfortheevaluationand
managementofheartfailure,inwhatstageofheartfailuredoesthispatientbelong?
A.StageA B.StageB C.StageC D.StageD

answer:B

16).A38yearoldmanwithstageCCHFremainssymptomaticinspiteofdiuretic
therapy.Youareconsideringaddingasecondandperhapsevenathirdagenttohis
regimen.Whichofthefollowingpharmacologicagentsusedinthemanagementof
heartfailurelackstrialdataindicatingamortalitybenefitanddoesnotprevent
maladaptiveventricularremodeling?

A.ACEinhibitorsorangiotensinreceptorblockers(ARBs)

B.Spironolactone

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C.Betablockers

D.Digoxin

ANSWER:D

17)Apatientisadmittedwithdecompensatedchronicheartfailure.Thepatients
currentmedicationsincludelisinopril20mgdaily,furosemide40mgtwiceaday,
metoprololCR/XL200mgdailydigoxin0.125mgdaily.Thepatienthasbeenstableon
thesedosesfortheprevious4months.Itisdecidedthatpositiveinotropictherapyis
indicated,alongwithIVdiuretics.Whichofthefollowingwouldyourecommend?

A)D/Cmetoprololandstartdopamine

b)D/Cmetoprololandstartdobutamine

C)Startdobutamine

D)Startmilrinone

answer:AnswerisDbecauseDobutamineisB1agonistsowecantuseinptalreadyonb
blockerandnoneedtostopmetoprololasptisstableonhismedicationsandwedon't
usedopamineasitneedsdosing

18)A54yearoldmanpresentstoyourclinictoestablishprimarycare.Hehasahistory
ofdiabetes,CHF,andhypertension.Hisbloodpressureis160/90mmHg,2+edemais
present,andmildcracklesareheardinthebasesofhislungs.Hetakesnomedication
Whichofthefollowingstatementsincorrectlycharacterizesattributesofthe
medicationstobeconsideredforthispatient?

A.Hydrochlorothiazidemayexacerbatehyperglycemia

B.Withoutaloadingdose,thebloodlevelofdigoxinwillplateauin7days

C.Oralbioavailabilityofloopdiureticsvarieslittlefromdrugtodrug

D.Spironolactonehasbeenassociatedwithgynecomastia

E.Nonsteroidalantiinflammatorydrugs(NSAIDs)maycausediuretic
Unresponsiveness

answer:CThiazidesmayprecipitateorexacerbatehyperglycemia,worsen
hyperuricemia,anddecreasesexualfunction.Thebloodlevelofdigoxinwillplateau7
days(fourtofivehalflives)afterinitiationofregularmaintenancedoseswithout
loading,makingthisapproachsatisfactoryforgraduallyincreasingthedigoxinlevelsof
outpatients.Theoralbioavailabilityoffurosemidevarieswidely(10%to100%),but
absorptionoftorsemideandbumetanideisnearlycomplete,rangingfrom80%to
100%.Ofthepotassiumsparingdiuretics,spironolactonehasbeenassociatedwith
gynecomastiaamiloridehasbeenassociatedwithimpotenceandtriamterenehas
beenassociatedwithkidneystones.Diureticunresponsivenessmaybecausedby
excessivesodiumintake,useofagentsthatantagonizetheireffects(NSAIDs),chronic
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renaldysfunction,orcompromisedrenalbloodflow.(Answer:C

Oralbioavailabilityofloopdiureticsvarieslittlefromdrugtodrug)

19)Whichoneofthefollowingistherecommendeddurationofdualantiplatelettherapy
afterplacementofadrugelutingcoronaryarterystent?

A)1week

1month

C)2months

D)3months

E)1year

answer:ANSWER:ETherecommendeddurationofdualantiplatelettherapyfollowing
placementofadrugelutingcoronaryarterystentis1year(SORC).Therecommended
dosagesofdualantiplatelettherapyareaspirin,162325mg,andclopidogrel,75mg,or
prasugrel,10mg.Ticlopidineisanoptionforpatientswhodonottolerateclopidogrel
orprasugrel.Theminimumrecommendeddurationofdualantiplatelettherapyis1
monthwithbaremetalstents,3monthswithsirolimuselutingstents,and6months
withotherdrugelutingstents

20)B.B.isa58yearoldwomanadmittedforacutedecompensatedheartfailure.At
baseline,shehasNewYorkHeartAssociationclassIIIheartfailurecausedbydiastolic
dysfunction.Duringthepast2weeks,shehasbeenexperiencingincreasedshortnessof
breathwithminimalactivitiesandisnowshortofbreathatrest.Sheisinitiatedon
intravenousloopdiureticsbuthasahistoryofdiureticresistance.B.B.sbaselinevital
signsincludeabloodpressureof85/60mmHgandheartrateof80beats/minute.
WhichoneofthefollowingisthenextbestoptionfortreatingB.B.sdecompensated
heartfailure?

A.Addingintravenouschlorothiazideororalmetolazone.

B.Initiatingintravenousvasodilatorymedications.

C.Initiatingintravenousinotropicmedications.

D.Switchingtoadifferentloopdiuretic.

answer:c

21)Apatienthasperiodicepisodesofparoxysmalsupraventricular

tachycardia(PSVT).Whichofthefollowingdrugswouldbemostsuitable
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foroutpatientprophylaxisoftheseworrisomeelectrophysiologicevents?

a.Adenosine

b.Lidocaine

c.Nifedipine

d.Nitroglycerin

e.Verapamil

answerise)

Verapamil,anondihydropyridine

calciumchannelblocker(CCB),depressesboththeSAnodeandthe

AVnodeandwouldbeeffectiveforprophylaxisofparoxysmalatrialor

supraventriculartachycardia.

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22)Weprescribea

adrenergicblockerforapatientwithchronicstable

(effortinduced)angina,andtheincidenceandseverityofanginalattacks

arereduced.Whichofthefollowingbestexplainsthepharmacologic

actionbywhichthe

bblockerdoesthis?

a.Decreasesmyocardialoxygendemand

b.Dilatesthecoronaryvasculature

c.Exertsantiplatelet/antithromboticeffects

d.Reducestotalperipheralresistance

e.SlowsAVnodalconductionvelocity

.answerisa)
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23)Yourpatientisa50yearoldmanwithwellcontrolledType2diabetes

andnormalrenalfunction(andnomicroalbuminuria).Whichofthe

followingdrugswouldbethemostrationalfirstchoiceforstartinghisantihypertensive

therapy?

a.Angiotensinconvertingenzyme(ACE)inhibitororangiotensinreceptorblocker

b.

adrenergicblocker

c.Nifedipine

d.Thiazidediuretic

e.Verapamilordiltiazem

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answerisa)

24)Wehavea50yearoldmanwithasymptomatichyperuricemia,and

weareabouttostarttherapyfornewlydiagnosedessentialhypertension

(BP136/90mmHg,basedonrepeatedmeasurementswiththepatient

supineandatrest).Whichofthefollowingantihypertensivedrugsismost

likelytoincreasehisserumuricacidlevelsfurther,andpossiblyprecipitate

agoutattack?

a.Captopril

b.Hydrochlorothiazide

c.Labetalol

d.Losartan

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e.Verapamil

answerisb)

25)Wevejustdiagnosedessentialhypertensionina58yearoldfemale

patient.Shetendstobetachycardic.Noteswrittenbyherophthalmologist

indicatethatshehaschronicopenangleglaucoma.Whichofthefollowing

drugswouldbethemostrationalchoiceforthiswoman,givenonlythe

informationpresentedinthisquestion?

a.Captopril

b.Diltiazem

c.Hydrochlorothiazide

d.Timolol

e.Verapamil

answerisd)

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26)Ournewlydiagnosedhypertensivepatienthasahistoryofvasospastic

angina.Whichofthefollowingdrugsordrugclasseswouldbethemost

rationalforstartingantihypertensivetherapybecauseitexertsantihypertensive

effects,directlylowersmyocardialoxygendemandandconsumption,

andalsotendstoinhibitcellularprocessesthatotherwisefavor

coronaryvasospasm?

a.Angiotensinconvertingenzyme(ACE)inhibitororangiotensinreceptor

blocker

b.

Adrenergicblocker

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c.Nifedipine

d.Thiazidediuretic

e.Verapamil(ordiltiazem)

answerise)

27)Wehaveapatientwithnewlydiagnosedessentialhypertension,and

startthemonacommonlyusedantihypertensivedrugatadosethatisconsidered

tobetherapeuticforthevastmajorityofpatients.Soonafterstarting

therapythepatientexperiencescrushingchestdiscomfort.EKG

changesshowmyocardialischemia.Studiesinthecardiaccathlabshow

episodesofcoronaryvasospasm,anditislikelytheantihypertensivedrug

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provokedthevasoconstriction.Whichofthefollowingantihypertensive

8
20

+

drugsordrugclassmostlikelycausedtheischemiaandtheangina?

a.Atenolol

b.Diltiazem

c.Hydrochlorothiazide

d.Losartan

e.Metolazone

answerisa)

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