Community and Public Health

Question 1

What should you do if you find a patient has a BP of over 140/90mmHg during a routine check up?

Answer 1

Take a second measurement, if different take a third measurement and record the lowest of the last 2 as their BP.

Question 2

How many BPs are needed to give the average for a patient who is using an ambulatory BP monitor?

Answer 2

14

Question 3

If a patient refuses ambulatory BP monitoring, what might you offer them?

Answer 3

Home BP monitoring

Question 4

How does the process of home BP monitoring work?

Answer 4

2 readings per day for a week, discard the first day and then take an average of the remaining days to diagnose/exclude HTN.

Question 5

When assessing a patient with a BP of over 180/100mmHg, what additional signs might lead you to refer to a specialist immediately?

Answer 5

• papilloedema
• retinal haemorrhages
• suggestion of phaeochromocytoma (labile/postural HTN, headaches, palpitations, pallor and diaphoresis)

Question 6

Which risk score might you use for a patient with HTN and give 3 components of it.

Answer 6

QRISK2
Three from…
Age, gender, ethnicity, post code, smoking status, diabetes, SBP, cholesterol/HDL ratio, BMI, CKD, CVD in 1st degree relative, BP medication, RA

Question 7

In a patient who is found to have hypertension, suggest 5 other investigations you might request?

Answer 7

• proteinuria, ACR and haematuria
• BM, U+E, creatinine, eGFR, serum total cholesterol and HDL
• fundoscopy (for retinopathy)
• 12 lead ECG

Question 8

A 48 year old, white male has been diagnosed with hypertension. Which is the most appropriate anti-hypertensive to prescribe?

a) amlodipine
b) bisoprolol
c) indapamide
d) ramipril
d) spironolactone

Answer 8

d) ramipril

Question 9

a 53 year old afro-Caribbean lady has been diagnosed with hypertension. Which is the most appropriate anti-hypertensive to prescribe?

a) amlodipine
b) bisoprolol
c) indapamide
d) ramipril
e) spironolactone

Answer 9

a) amlodipine

Question 10

A 65 year old, white woman still has uncontrolled hypertension having been prescribed one anti-hypertensive, which additional medication should be added now?

a) amlodipine
b) bisoprolol
c) indapamide
d) ramipril
e) spironolactone

Answer 10

d) ramipril

n. b. over 65 on one anti-HTN means she is most likely on a CCB i.e. amlodipine already.

Question 11

A 65 year old, afro-Caribbean woman still has uncontrolled hypertension having been prescribed one anti-hypertensive, which additional medication should be added now?

a) amlodipine
b) bisoprolol
c) candesartan
d) ramipril
e) spironolactone

Answer 11

c) Candesartan

Likely on a CCB already, in people of black ethnicity an ARB should be added instead of an ACE-I.

Question 12

A patient has been prescribed 2 anti-hypertensive agents already however they require a third for optimum control. Which is the most appropriate?

a) amlodipine
b) bisoprolol
c) indapamide
d) ramipril
e) spironolactone

Answer 12

c) indapamide (thiazide-like diuretic)

Question 13

If a patients BP is still over 140/90mmHg after the addition of a third anti-hypertensive to their prescription, which medication might you consider?

a) amlodipine
b) bisoprolol
c) candesartan
d) ramipril
d) spironolactone

Answer 13

d) spironolactone (at a low dose)

Question 14

A patient requires a 4th anti-hypertensive agent. What blood test are will be most informative to guide your treatment choice?

a) sodium
b) potassium
c) calcium
d) HDLs
e) cholesterol

Answer 14

b) potassium

Patient likely needs spironolactone which can cause hyperkalaemia therefore should only be prescribed if potassium levels are under 4.5mmol/L.

Question 15

A patient on spironolactone for HTN is found to have a low eGFR. What might you be concerned they will develop?

a) hyponatraemia
b) hypernatraemia
c) hypokalaemia
d) hyperkalaemia
e) hypercalcaemia

Answer 15

d) hyperkalaemia

Low GFR will increase a patients risk of this if they are on spironolactone

Question 16

A patient requires a 4th anti-hypertensive to try and control their BP however they have a slightly raised potassium and low GFR. Which is the most appropriate choice?

a) high dose amlodipine
b) high dose bisoprolol
c) high dose inapamide
d) high dose ramipril
d) spironolactone

Answer 16

c) high dose indapamide

The tests suggest hyperkalaemia and so this is the most appropriate choice as unlike spironolactone it does not cause hyperkalaemia

You might consider a B-blocker after this stage however you should make a referral and not start on a high dose.

Question 17

What QRISK Score indicates a patient should be prescribed a statin?

a) 5%>
b) 10%>
c) 15%>
d) 20%>
e) 25%>

Answer 17

b) 10%>

Question 18

What metabolic abnormality might be caused by thiazide diuretics?

Answer 18

hyponatraemia

Question 19

Why might an ACE-I cause hyperkalaemia and hyponatraemia?

Answer 19

Reduces the release of aldosterone and so increases potassium retention and sodium loss through the kidneys.

Question 20

Which class of medications should not be prescribed with ACE-Is and why?

Answer 20

NSAIDs as can affect kidney function.

Question 21

What three factors feed into behavioural change according to the Theory of Planned Behaviour?

Answer 21

Attitude, social pressure and perceived behavioural control.

Question 22

In the Theory of planned behaviour, give 5 things you may do to help an individual bridge the intention behaviour gap.

Answer 22

1) perceived control: help a patient to take ownership of the behaviour
2) anticipated regret: reflect on when things better/bad
3) preparatory actions: break the task into manageable chunks
4) implementation intentions: ‘if and then plan’
5) relevance to self: more likely behaviours for the patient.

Question 23

Give two positives and two negatives of the theory of planned behaviour.

Answer 23

+ve: effective across many behaviours, rational choice model, considers social and norm pressures + perceived control

-ve: no temporal/causal element, no affect or emotion considered, does not say how the 3 main aspects (attitude, social pressure and PBC) interact, habits and routines bypass cognitive deliberation, assumes 3 main aspects can be measured, relies on self-reported behaviour (at risk of patients lying).

Question 24

Which of the following conditions when treated with warfarin, aims for an INR of over 3?

a) mitral stenosis
b) short-term DVT prophylaxis
c) Atrial fibrillation
d) post-femur fracture repair
e) Prosthetic heart valves

Answer 24

e) prosthetic heart valves

a, c and d all are 2-3
b is 2-2.5