Final exam questions 4 Flashcards
- Blood pressure screenings typically start at 3-year-old wellness visits, unless the patient has certain conditions that require blood pressure monitoring. Which of the following conditions would not require early blood pressure monitoring?
a. Recurrent urinary tract infections
b. Neurofibromatosis
c. Congenital heart disease
d. Asthma
d. Asthma
Rationale: Recurrent UTIs could indicate kidney disease, which is a common reason for hypertension in children.
Similarly, neurofibromatosis can cause renal artery stenosis, which would be diagnosed with renal
ultrasound.
Congenital heart disease warrants blood pressure monitoring due to defects like coarctation of
the aorta.
Asthma does not typically require blood pressure monitoring. However, if the patient was on
steroids for an asthma exacerbation, it would warrant blood pressure monitoring.
- A 57 y/o female presents to clinic for her annual wellness exam. She is a current smoker with a history of HTN. Lab evaluation revealed: total cholesterol = 246, LDL = 123, HDL = 27, triglycerides= 156. You determined her ASCVD risk is 16.7%. Which medication should be initiated to reduce the risk of a cardiac event?
a. Fibric acid
b. Niacin
c. HMG Co-A reductase inhibitor
d. Bile acid sequestriant
c. HMG Co-A reductase inhibitor
Rationale: The patient’s risk of a cardiac event includes: age 40-75 y/o, HTN, smoker, increased LDL, and an ASCVD score of 16.7%.
The initial recommended treatment for primary prevention includes lifestyle modifications and an HMG Co-A reductase inhibitor (a statin).
Statin therapy can significantly reduce elevated lipid levels which reduces the risk of a cardiac event. Other regimens can be added to treatment plan if statin therapy is not tolerated or not sufficient to lower the LDL.
- What is the medication of choice for acute management of Chronic Stable Angina Pectoris?
- What is the medication of choice for acute management of Chronic Stable Angina Pectoris?
a. Nitroglycerin
b. Metoprolol
c. Aspirin
d. Pravastatin
a. Nitroglycerin
Rationale: Chronic stable angina pectoris is chest pain usually precipitated by stress or exertion. It is rapidly
relieved by rest or nitrates.
Metoprolol is used in patients with CVD, Aspirin is an anticoagulant used to treat acute chest pain,
Pravastatin is used for management in patients with atherosclerotic disease.
- The following would be candidates for statin therapy EXCEPT:
a. 70-year-old male with LDL 98 mg/dL and CAC score 100
b. 77-year-old female with CAC score of zero
c. 42-year-old female with DM II
d. 28-year-old male with LDL 196 mg/dL
b. 77-year-old female with CAC score of zero
Rationales: According to the 2019 ACC/AHA Guidelines, statin therapy should be first-line treatment in patients with LDL at or above 190 mg/dL.
Statins should be initiated in those patients between 40-75 years of age with Diabetes Mellitus, and those aged 40-75 with LDL-C levels between 70-189.
CAC scores of zero do not favor statins unless the patient has a personal history of smoking or Diabetes Mellitus, or family history of premature coronary heart disease.
Clinical assessment and risk discussions with patients over the age of 75 are required.
- A 50-year-old male presents to the clinic for a follow-up on routine lab work. He has recently been diagnosed with HTN and DM Type 2. Based off his LDL of 150, smoking history and new diagnoses you calculate his ASCVD risk to be 25%. Which statin medication listed below would be the best to initiate on this patient?
a. Simvastatin 20mg
b. Atorvastatin 40mg
c. Rosuvastatin 5mg
d. Lovastatin 20mg
b. Atorvastatin 40mg
Rationale: This patient requires a high intensity statin to best manage his cholesterol and decrease his risk
for a CV event, which makes Atorvastatin 40mg the best option.
Simvastatin 20mg is a moderate intensity
statin and would not lower the LDL as effectively as the high intensity statin would.
Rosuvastatin 5mg is a moderate intensity statin as well, if we increased the dose to 20-40mg, we would call it high intensity.
Lovastatin 20mg is a low intensity statin and would have no benefit for this patient due to his extremely
high ASCVD risk.
- Your 50-year-old male patient comes in for BP follow up with consistent home readings of SBP in the 150’s for the past 3 weeks. His previous 2 office visits were 150/85 & 152/89 respectively. Today’s office BP reading is 153/86. What is the most effective, first line diuretic best utilized in mild-moderate hypertensive patients?
a. Furosemide
b. Spironolactone
c. Bumex
d. Hydrochlorothiazide
d. Hydrochlorothiazide
Rationale: Hydrochlorothiazide (HCTZ) thiazide diuretics have a solid research history which supports this class as the most reliable & effective diuretic to lower blood pressure. Blood pressure control can be achieved with single use diuretics in 50% of patients successfully with mild to moderate hypertension.
Furosemide is best utilized in patients with chronic kidney disease due to volume & electrolyte loss- also a
weak hypertensive.
Spironolactone & Bumex are not first line diuretics.
- A 72-year-old male is scheduled to follow up at your Family Clinic to discuss his lipid panel results. Upon review, the lipid panel revealed a total cholesterol of 180 and a LDL level of 98. The patient is already taking Atorvastatin 80mg daily and has maintained a low-fat diet. He has a past medical history of hypertension, hyperlipidemia, stable angina, and osteoporosis. Which action is the most appropriate for this patient?
a. Continue low-fat diet and recheck Lipid Panel in 1 month
b. Prescribe Ezetimibe (Zetia) 10mg by mouth daily
c. Nothing, these results are normal
d. Prescribe Fenofibrate (Tricor) 145mg by mouth daily
b. Prescribe Ezetimibe (Zetia) 10mg by mouth daily
Rationale: Ezetimibe (Zetia) is recommended as next step therapy for patients already on high intensity
statins, diagnosed with clinical ASCVD, in order to obtain a LDL level of <70. As indicated in the question,
the patient has already maintained a low-fat diet and has been unable to reach target LDL of <70 with this
intervention. The lipid results listed above in this question may be acceptable for some patients but not in those with clinical ASCVD, the goal is to have LDL of <70.
Fenofibrate should not be the first choice for this
patient due to its sparse effects on LDL.
- A 44-year-old female, with a history of hyperlipidemia, is taking a moderate intensity statin daily to lower her cholesterol. She asks the Family Nurse Practitioner how much her statin medication will lower her cholesterol. Which response by the practitioner is true?
a. “Your medication is estimated to lower your LDL levels by 30-50%”
b. “This medication will fix your cholesterol problem completely”
c. “Your medication can lower your LDL level by greater than 50%”
d. “Your medication may lower your cholesterol by 10-15%”
a. “Your medication is estimated to lower your LDL levels by 30-50%”
Rationale: Moderate intensity statins are estimated to decrease LDL levels by 30-50%. Statin medications
alone can bring cholesterol levels back within a normal range in some instances, however, it is best
achieved in combination with weight loss and dietary changes.
Only PCSK9 inhibitors are known to reduce
LDL levels beyond 50%.
Moderate intensity statins lower LDL levels more than 10-15%, making choice D incorrect.
- A healthy 51-year-old male presents to your clinic for his annual wellness exam. He has no concerns or complaints. Upon examination, you auscultate a systolic murmur in the 2nd right intercostal space preceded by an ejection click. It is harsh-sounding and you are also able to hear it radiate into the carotid artery. What valvular disorder do you suspect?
a. Mitral regurgitation
b. Aortic Stenosis
c. Aortic Regurgitation
d. Mitral Valve Prolapse
b. Aortic Stenosis
Rationale: Aortic stenosis is defined as narrowing of the aortic valve. This murmur is rough/harsh sounding
and occurs after s1 but stops before s2, classifying it a systolic murmur. It commonly is transmitted to the
carotid arteries.
The murmur heard with mitral regurgitation is systolic but has more of a blowing, high pitched
sound and does not have the ejection click. It commonly radiates to the left axilla.
The Aortic regurgitation murmur is a faint diastolic murmur heard best at the left sternal border.
MVP is uncommon in this age group and midsystolic click is usually what is heard on auscultation.
- Edward, a 68-year-old male who is one of your partner’s patient’s, is seeing you in the clinic for a routine follow up. He has a history of CAD with stent placement and DM Type 2. He is compliant with his Metoprolol, Plavix, Metformin, and Jardiance. You calculate his 10-yr ASCVD risk which is 8.9%. His recent LDL was 105. What is the top priority in your treatment plan?
a. Ensure he is following up with his cardiologist regularly.
b. Encourage him to exercise more.
c. Discuss starting him on Atorvastatin 20 mg PO daily.
d. Discuss starting him on Atorvastatin 40 mg PO daily.
d. Discuss starting him on Atorvastatin 40 mg PO daily.
Rationale: Given this patient’s 10-yr ASCVD risk of >7.5% in addition to his diagnosis of DM Type 2 & history
of CAD, he should be on a high-intensity statin (40-80 mg Atorvastatin or 20-40 mg Rosuvastatin) with goal
LDL of <70. Though it is important to discuss and encourage lifestyle modification such as exercise and
ensure follow up with his cardiologist, the top priority is statin therapy.
- Which of the following answers is FALSE regarding coronary artery calcium score?
a. It may help identify patients who will not benefit from cholesterol lowering therapy.
b. It is the best test for risk stratification.
c. It is a cardiac-gated CT scan
d. This test is recommended by the USPSTF and is an annual requirement for lipid screening in all persons over the age of 50
d. This test is recommended by the USPSTF and is an annual requirement for lipid screening in all persons over the age of 50
Rationale: This test is not recommended by the USPSTF and is not recommended annually. This test is
reserved for situations where additional information can change a therapeutic decision or will help to inform
shared decision making.
- What is your best response to the parent who asks why you are using a single eye chart with crowded bars around it when checking the visual acuity of a 4 years old child who presents for a well-child visit?
a. it is a matter of clinician preference. Children at this age cannot tell the difference
b. using single eye chart with crowding bars is most accurate in detecting reduced vision caused by conditions affecting normal vision development
c. the child at this age enjoys reading symbols and letters
d. using single eye chart without crowding bars is just as accurate in detecting reduced vision caused by conditions affecting normal vision development
b. using single eye chart with crowding bars is most accurate in detecting reduced vision caused by conditions affecting normal vision development
Rationale: Most accurate assessment is obtained when using charts with lines of optotypes or single
optotype with crowding bars around it. Using single optotypes without crowding bars around it can
overestimate visual acuity.
Crowding bars surrounding an optotype make individual letters more difficult to identify by an amblyopic eye, thus increasing the sensitivity to detect amblyopia.
- A new mother brings in her 1-month-old baby in for a check-up. She expresses concerns of some light brown marks that are oval shaped on her baby. On exam, you find these marks present in three areas. What do you tell the mother?
a. This is a very bad prognosis. Must refer to specialist right away.
b. Give antibiotic prescription.
c. This area needs to be removed today by cryotherapy.
d. There are called Café’ Au Lait macules. They are lesions that may persist through life but are not harmful. If there are more than 6 lesions that are greater than 0.5mm and/or unilateral and large, then it would be worrisome.
d. There are called Café’ Au Lait macules. They are lesions that may persist through life but are not harmful. If there are more than 6 lesions that are greater than 0.5mm and/or unilateral and large, then it would be worrisome.
Rationale: Café’ Au Lait macules may be found anywhere on the skin. This is not a worrisome finding, and they may increase with age. This finding could be on light or dark skin. If there were large, unilateral areas this might be indicative of McCune-Albright syndrome, which further testing would be needed
Although NF1 is the most common cause of multiple CALS, they are also a feature of other conditions including Legius syndrome, Noonan syndrome with multiple lentigines (formerly called LEOPARD syndrome), chromosome abnormalities, McCune-Albright syndrome, and others. Each of these conditions has features that overlap with NF1,
but other features that distinguish them. Rarely, multiple CALS can be seen as an isolated feature and not associated with an underlying condition.
A specialist in NF is often required to determine if multiple CALS are isolated or caused by a genetic condition
- A mother brought her 10-year-old boy into your clinic for an evaluation of a rash that he has had for 3 days. He reports intense itching on his arms and hands. The mother has tried over the counter anti-itch creams with little relief. He reports playing outside over the weekend and making a fort in the woods. He denies trauma or using new lotions, soaps, or medications. You would anticipate which of the following findings in your assessment?
a. Dermatitis-like areas with blisters in a linear pattern with oozing and crusting.
b. Scaly, large, cracked areas with erythematous borders
c. Erythematous papules and plaques with thick, white scales.
d. Numerous symmetrical coined shaped patches of dermatitis.
a. Dermatitis-like areas with blisters in a linear pattern with oozing and crusting.
Rationale: The cause of most cases of allergic dermatitis in children is poison ivy, poison oak, and poison
sumac. The presentation is typically acute dermatitis, pruritis, erythema, in a linear pattern with or without
blisters that are often oozing or crusting.
- A 2 year old presents to Peds clinic with mom for c/o cough. Mom states that he has been having a frequent non-productive cough since last week. She also reports decreased appetite and that he has been unable to tolerate solids and has been vomiting after he eats. Upon assessment the child is drooling, coughing, and has mild wheezing and decreased breath sounds on the left upper lung fields. Vital signs: BP 87/48, HR 118, RR 28, Temp 98.2 oral, 02 sat 98% As the NP what would be your highest differential for this child?
a. new onset asthma
b. pyloric stenosis
c. foreign body ingestion
d. pneumonia
c. foreign body ingestion
Rationale: Symptoms of foreign body ingestion are dysphagia, odynophagia, drooling, regurgitation, chest
discomfort, or abdominal pain. After 1 week a prominent cough is present for foreign bodies retained in the
esophagus. Foreign body ingestion should be highly considered with toddlers presenting with these
symptoms, even without witnessed ingestion.
