Practice Questions Flashcards
A 62-year-old man presents to the emergency
department (ED) with the chief concern of chest
pain that woke him from sleep and radiates to
his jaw. An electrocardiogram (ECG) reveals
ST-segment depression in leads II, III, and aVF.
His blood pressure is 112/62 mm Hg and heart rate
is 60 beats/minute. Cardiac enzymes have been
obtained, and the first troponin result was slightly
positive. Preparations are under way to take the
patient to the cardiac catheterization laboratory
for evaluation. Which medication regimen is most
appropriate for this patient at this time?
A. Aspirin 325 mg, clopidogrel 600-mg loading dose (LD), and unfractionated heparin
(UFH) infusion 80-unit/kg bolus, followed
by 18 units/kg/hour and metoprolol 5 mg
intravenously.
B. Aspirin 81 mg; prasugrel 60-mg LD; UFH
infusion 60-unit/kg bolus, followed by 12
units/kg/hour; and intravenous enalaprilat.
C. Aspirin 325 mg, ticagrelor 180-mg LD, and
UFH infusion 60-unit/kg bolus, followed by
12 units/kg/hour.
D. Aspirin 81 mg, prasugrel 60-mg LD, nitroglycerin infusion at 10 mcg/minute, and
bivalirudin 0.75-mg/kg bolus and 1.75-mg/kg/
hour infusion.
C
Acute Care Cardiology
An 81-year-old African American man (weight 90
kg) presents to the ED with chest pressure (10/10
on a pain scale). His ECG reveals ST-segment depression in the inferior leads. His medical history is significant for hypertension and chronic
kidney disease. Pertinent laboratory results are troponin 5.8 ng/L, serum creatinine (SCr) 3.7 mg/dL,
and estimated creatinine clearance (eCrCl) 20 mL/
minute. The patient has been given aspirin 325
mg single dose; a nitroglycerin drip, initiated at 5
mcg/minute, will be titrated to chest pain relief and
blood pressure. The patient consents for cardiac
catheterization after adequate hydration. Which
anticoagulation strategy is most appropriate to initiate in this patient?
A. Intravenous heparin 4000-unit intravenous
bolus, followed by a 1000-unit/hour continuous infusion.
B. Enoxaparin 90 mg subcutaneously every 12
hours.
C. Fondaparinux 2.5 mg subcutaneously daily.
D. Bivalirudin 67.5-mg bolus, followed by a 157-
mg/hour infusion.
Acute Care Cardiology
A
A 56-year-old man presents to the hospital with
the chief concern of chest pain that was unrelieved
at home with sublingual nitroglycerin. His ECG
reveals ST-segment depression and T-wave inversion. Cardiac markers show an elevated troponin I.
The cardiologist has requested that the patient go
to the cardiac catheterization laboratory for further
evaluation. The patient has a history of coronary
artery disease (CAD) and had a myocardial infarction (MI) about 6 months ago. During his previous
hospitalization, he was confirmed to have developed
heparin-induced thrombocytopenia (HIT) after his
platelet count (Plt) dropped to 40,000/mm3
and he
had a positive ELISA (enzyme-linked immunosorbent assay) upon serologic testing after his previous
catheterization. Given this patient’s diagnosis and
history, which treatment regimen would be most
appropriate during his cardiac catheterization?
A. Tirofiban.
B. Bivalirudin.
C. Enoxaparin.
D. Tenecteplase.
Acute Care Cardiology
B
A 62-year-old man presents to the ED after several hours of chest discomfort. His ECG reveals
a 1- to 2-mm ST-segment elevation with positive troponins. He has also had increasing shortness of
breath and lower-extremity swelling over the past
2–3 weeks. His medical history is significant for
tobacco use for 40 years, chronic obstructive pulmonary disease, diabetes, and hypertension. His
blood pressure is 102/76 mm Hg and heart rate is
111 beats/minute. He has rales in both lungs and
2–3+ pitting edema in his extremities. His echocardiogram reveals an ejection fraction of 25%.
After primary percutaneous coronary intervention
(PCI), he is transferred to the cardiac intensive
care unit. Which best describes the acute use of
β-blocker therapy in this patient?
A. Give 12.5 mg of oral carvedilol within the first
24 hours.
B. Give 5 mg of intravenous metoprolol at the
bedside.
C. Give 200 mg of oral metoprolol succinate at
discharge.
D. Give no β-blocker at this time.
Acute Care Cardiology
D
. A 60-year-old man (weight 75 kg) presents to
the ED with crushing substernal chest pain and
ST-segment elevations on ECG. He has a medical
history of diabetes and a 40 pack-year history of
smoking. He is taken immediately to the catheterization laboratory for primary PCI, and a drugeluting stent is placed in his left anterior descending artery. In addition to aspirin, which regimen
would best maintain this patient’s stent patency?
A. Clopidogrel 300-mg LD, followed by 75 mg
daily for 12 months.
B. Prasugrel 60-mg LD, followed by 10 mg daily
for 12 months.
C. Ticagrelor 180-mg LD, followed by 90 mg
twice daily for 6 months.
D. Clopidogrel 600-mg LD, followed by 75 mg
daily for 6 months.
Acute Care Cardiology
B
A 60-year-old woman with New York Heart
Association (NYHA) class IV heart failure (HF)
(heart failure with reduced ejection fraction
[HFrEF]) is admitted for increased shortness of
breath and dyspnea at rest. Her extremities appear
well perfused, but she has 3+ pitting edema in her
lower extremities. Her vital signs include blood
pressure 125/70 mm Hg, heart rate 92 beats/minute, and oxygen saturation (Sao2
) 89% on 100%
facemask. After initiating an intravenous diuretic,
which intravenous agent is best to rapidly treat this
patient’s pulmonary symptoms?
A. Dobutamine.
B. Milrinone.
C. Nitroglycerin.
D. Metoprolol.
Acute Care Cardiology
C
A 75-year-old woman admitted for pneumonia
has a history of several non–ST-segment elevation
myocardial infarctions (NSTEMIs). She had an
episode of sustained ventricular tachycardia (VT)
during this hospitalization. Her corrected QT (QTc)
interval was 380 milliseconds on the telemetry.
Her left ventricular ejection fraction (LVEF) was
found to be 25%. Her serum potassium and magnesium were 4.6 mEq/L and 2.2 mg/dL, respectively.
Which intravenous agent is most appropriate for
this patient’s ventricular arrhythmias?
A. Procainamide.
B. Metoprolol.
C. Magnesium.
D. Amiodarone.
Acute Care Cardiology
D
A 53-year-old woman is admitted to the hospital
after the worst headache she has ever had. Her
medical history includes exertional asthma, poorly
controlled hypertension, glaucoma, and hyperlipidemia. She is nonadherent to her medications
and has not taken her prescribed blood pressure
medications for 4 days. Vital signs include blood
pressure 220/100 mm Hg and heart rate 65 beats/
minute. She has retinal hemorrhaging on funduscopic examination. Which is most appropriate for
this patient’s hypertensive emergency?
A. Fenoldopam 0.1 mcg/kg/minute.
B. Nicardipine 5 mg/hour.
C. Labetalol 0.5 mg/minute.
D. Enalaprilat 0.625 mg intravenously every 6
hours.
Acute Care Cardiology
B
A 52-year-old woman has a witnessed cardiac
arrest in a shopping mall and is resuscitated with
an automatic external defibrillator device. On electrophysiologic study, she has inducible VT. Which is most appropriate for reducing the secondary
incidence of sudden cardiac death (SCD)?
A. Propafenone.
B. Amiodarone.
C. Implantable cardioverter-defibrillator (ICD).
D. Metoprolol.
Acute Care Cardiology
C
The Sudden Cardiac Death in Heart Failure trial
evaluated the efficacy of amiodarone or an ICD
versus placebo in preventing all-cause mortality
in ischemic and nonischemic patients with NYHA
class II and III HF. There was a 7.2% absolute risk
reduction and a 23% relative risk reduction in allcause mortality at 60 months with an ICD versus
placebo. Which best shows the number of patients
needed to treat with an ICD to prevent one death
versus placebo?
A. 1.
B. 4.
C. 14.
D. 43.
Acute Care Cardiology
C
A 66-year-old woman (weight 70 kg) with a history of MI, hypertension, hyperlipidemia, and diabetes mellitus presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike upper
chest pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her typical
angina was occurring with less exertion. Her ECG reveals ST-segment depression in leads II, III, and aVF and
hyperdynamic T waves and positive cardiac enzymes. Blood pressure is 150/90 mm Hg, and all laboratory
results are normal; SCr is 1.2 mg/dL. Home medications are aspirin 81 mg/day, simvastatin 40 mg every night,
metoprolol 50 mg twice daily, and metformin 1 g twice daily. Which regimen is best for this patient?
A. An early invasive approach with aspirin 325 mg, ticagrelor 180 mg one dose, and UFH 60-unit/kg bolus;
then 12 units/kg/hour titrated to 50–70 seconds.
B. An early invasive approach with aspirin 325 mg and enoxaparin 70 mg subcutaneously twice daily.
C. An ischemia-guided strategy with tirofiban 25 mcg/kg; then 0.15 mg/kg/minute plus enoxaparin 80 mg
subcutaneously twice daily, aspirin 325 mg, and clopidogrel 300 mg one dose; then 75 mg once daily.
D. An ischemia-guided strategy with aspirin 325 mg and ticagrelor 180 mg one dose; plus UFH 70-unit/kg
bolus; then 15 units/kg/hour.
Acute Care Cardiology
A
A 45-year-old patient underwent an elective percutaneous transluminal coronary angioplasty and drug-eluting
stent placement in the right coronary artery. Which best represents the minimum time DAPT should be continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.
Acute Care Cardiology
C
A 52-year-old man (weight 100 kg) with a history of hypertension and hypertriglyceridemia presents at a major
university teaching hospital with a cardiac catheterization laboratory. He has had 3 hours of crushing 10/10
substernal chest pain radiating to both arms that began while he was eating his lunch (seated), which is accompanied by nausea, diaphoresis, and shortness of breath. He has never before had chest pain of this character or
intensity. He usually can walk several miles without difficulty and smokes 1.5 packs/day of cigarettes. Home
medications are lisinopril 2.5 mg/day and aspirin 81 mg daily. Current vital signs include heart rate 68 beats/
minute and blood pressure 178/94 mm Hg. His ECG reveals a 3-mm ST-segment elevation in leads V2–V4, I,
and aVL. Serum chemistry values are within normal limits. The first set of cardiac markers shows positive
troponins, 0.8 mcg/L (normal defined as less than 0.1 mcg/L). Which regimen is best for this patient’s STEMI?
A. Reperfusion with primary PCI with stenting, clopidogrel 300 mg one dose, aspirin 325 mg one dose, and
tirofiban 25 mcg/kg followed by 0.15 mcg/kg/minute.
B. Reperfusion with a reteplase 10-unit bolus twice (30 minutes apart), clopidogrel 300 mg one dose, aspirin
325 mg one dose, and UFH 60 unit/kg followed by 12 unit/kg/hour.
C. Reperfusion with tenecteplase 25-mg intravenous push one dose, ticagrelor 180 mg one dose, aspirin 325
mg one dose, and bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.
D. Reperfusion with primary PCI with stenting, prasugrel 60 mg one dose, aspirin 325 mg one dose, and
bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.
Acute Care Cardiology
D
A 76-year-old male smoker (weight 61 kg) has a history of hypertension, benign prostatic hypertrophy, and
lower back pain. Three weeks ago, he began to have substernal chest pain with exertion (together with dyspnea), which radiated to both arms and was associated with nausea and diaphoresis. These episodes have
increased in frequency to four or five times daily; they are relieved with rest. He has never had an ECG. Today,
he awoke with 7/10 chest pain and went to the ED of a rural community hospital 2 hours later. He was acutely
dyspneic and had ongoing pain. Home medications are aspirin 81 mg/day for 2 months, doxazosin 2 mg/day,
and ibuprofen 800 mg three times daily. Vital signs include heart rate 42 beats/minute (sinus bradycardia) and
blood pressure 104/48 mm Hg. Laboratory results include blood urea nitrogen (BUN) 45 mg/dL, SCr 2.5 mg/
dL, and troponin 1.5 ng/L (normal value less than 0.1 ng/L). His ECG reveals a 3-mm ST-segment elevation.
Aspirin, ticagrelor, and sublingual nitroglycerin were given in the ED. The nearest hospital with a catheterization laboratory facility is 2½ hours away. Which regimen is best?
A. Give alteplase 15 units intravenously plus enoxaparin 30-mg intravenous bolus.
B. Use an ischemia-guided treatment strategy with UFH 4000-unit intravenous bolus, followed by 800 units
intravenously per hour.
C. Give tenecteplase 35 mg intravenously plus UFH 4000-unit intravenous bolus followed by 800 units intravenously per hour.
D. Transfer the patient to a facility for primary PCI.
Acute Care Cardiology
C
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
5. Which regimen is best for treating his ADHF?
A. Carvedilol 25 mg twice daily.
B. Sodium nitroprusside 0.1 mcg/kg/min via continuous infusion.
C. Furosemide 120 mg intravenously twice daily.
D. Milrinone 0.5 mcg/kg/minute
Acute Care Cardiology
C
A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day
After being initiated on intravenous loop diuretics with only minimal urinary output, the patient is transferred
to the coronary care unit for further management of diuretic-refractory decompensated HF. His Sao2
is now
87% on a 4-L nasal cannula, and an arterial blood gas is being obtained. His blood pressure is 110/75 mm
Hg and heart rate is 75 beats/minute. The patient’s SCr and K+
concentrations have begun to rise and are now
2.7 mg/dL and 5.4 mmol/L, respectively. In addition to a one-time dose of intravenous chlorothiazide, which
regimen is most appropriate for this patient?
A. Nitroglycerin 20 mcg/minute.
B. Sodium nitroprusside 0.3 mg/kg/minute.
C. Dobutamine 5 mcg/kg/minute.
D. Milrinone 0.5 mcg/kg/minute.
Acute Care Cardiology
A
72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
The patient initially responds with 2 L of urinary output overnight, and his weight decreases by 1 kg the next
day. However, by day 5, his urinary output has diminished again, and his SCr has risen to 4.3 mg/dL. He was
drowsy and confused this morning during rounds. His extremities are cool and cyanotic, blood pressure is
89/58 mm Hg, and heart rate is 98 beats/minute. It is believed that he is no longer responding to his current
regimen. A Swan-Ganz catheter is placed to determine further management. Hemodynamic values are cardiac
index 1.5 L/minute/m2
, SVR 2650 dynes/second/cm5
, and Pulmonary capillary wedge pressure 30 mm Hg.
Which regimen is most appropriate for his current symptoms?
A. Milrinone 0.2 mcg/kg/minute.
B. Dobutamine 10 mcg/kg/minute.
C. Sodium nitroprusside 0.1 mcg/kg/minute.
D. Phenylephrine 20 mcg/minute.
Acute Care Cardiology
A
A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots and
dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history includes
HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, diabetes, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glipizide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
8. Which is the best therapy to initiate for conversion of his sustained VT?
A. Amiodarone 150 mg intravenously for 10 minutes, then 1 mg/minute for 6 hours, then 0.5 mg/minute.
B. Sotalol 80 mg twice daily titrated to QTc of about 450 milliseconds.
C. Dofetilide 500 mcg twice daily titrated to QTc of about 450 milliseconds.
D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg.
Acute Care Cardiology
A
A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots and
dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history includes
HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, diabetes, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glipizide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
The patient presents to the ED 3 months after amiodarone maintenance initiation (he refused ICD placement)
after a syncopal episode, during which he lost consciousness for 30 seconds, according to witnesses. He also
has rapid heart rate episodes during which he feels dizzy and lightheaded. He feels very warm all the time (he
wears shorts, even though it is winter), cannot sleep, and has lost 3 kg in weight. He received a diagnosis of
hyperthyroidism caused by amiodarone therapy. On telemetry, he has runs of nonsustained VT. Which best
predicts the duration of amiodarone-associated hyperthyroidism in this patient?
A. 12 hours.
B. 1 month.
C. 6 months.
D. 18 months.
Acute Care Cardiology
C
A 64-year-old woman presents to the ED with the chief concern of palpitations. Her medical history includes
hypertension controlled with a diuretic and an inferior-wall MI 6 months ago. She is pale and diaphoretic but
can respond to commands. The patient’s laboratory values are within normal limits. Her vital signs include
blood pressure 95/70 mm Hg and heart rate 145 beats/minute; telemetry shows sustained VT. Despite chronic
use of β-blocker therapy, the patient has developed sustained VT that is successfully terminated with lidocaine. Subsequent electrophysiologic testing reveals inducible VT, and sotalol 80 mg orally twice daily is prescribed. Two hours after the second dose, the patient’s QTc is 520 milliseconds. Which regimen change would
be most appropriate for this patient?
A. Continue sotalol at 80 mg orally twice daily.
B. Increase sotalol to 120 mg orally twice daily.
C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.
D. Discontinue sotalol and initiate amiodarone 400 mg orally three times daily.
Acute Care Cardiology
D
A 68-year-old man with a history of stage 5 chronic kidney disease receiving hemodialysis, hypertension,
CAD post-MI, HFrEF, and gastroesophageal reflux disease presents with acute-onset shortness of breath and
chest pain. After his recent dialysis, he was nonadherent to medical therapy for 2 days and noticed he had
gained 2 kg in 24 hours. His baseline orthopnea worsened to sleeping sitting up in a chair for the 2 nights
before admission. He admits smoking cocaine within the past 24 hours and developed acute-onset chest tightness with diaphoresis and nausea, and his pain was 7/10. He went to the ED, where his blood pressure was
250/120 mm Hg. He had crackles halfway up his lungs on examination, and chest radiography detected bilateral fluffy infiltrates with prominent vessel cephalization. His ECG revealed sinus tachycardia, heart rate 122
beats/minute, and ST-segment depressions in leads 2, 3, and aVF. He was admitted for a hypertensive emergency. Laboratory results are as follows: BUN 48 mg/dL, SCr 11.4 mg/dL, BNP 2350 pg/mL, troponin T 1.5
ng/L (less than 0.1 mcg/L), creatine kinase 227 units/L, and creatine kinase-MB 22 units/L. Which medication
is best for this patient’s hypertensive emergency?
A. Intravenous nitroglycerin 5 mcg/minute titrated to a 25% reduction in MAP.
B. Labetalol 2 mcg/minute titrated to a 50% reduction in MAP.
C. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
D. Clonidine 0.1 mg orally every 2 hours as needed for a 50% reduction in MAP.
Acute Care Cardiology
A
A 56-year-old white woman with a long history of hypertension because of nonadherence and recently diagnosed HF (ejection fraction 35%) presents to the local ED with blood pressure 210/120 mm Hg and heart rate
105 beats/minute. She states that she felt a little lightheaded but that she now feels okay. She ran out of her
blood pressure medications (including hydrochlorothiazide, carvedilol, and lisinopril) 3 days ago. Her current
laboratory values are within normal limits. Which medication is best for this patient?
A. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
B. Labetalol 80 mg intravenously; repeat until blood pressure is less than 120/80 mm Hg.
C. Resumption of home medications; refer for follow-up within 2 days.
D. Resumption of home medications; initiate amlodipine 10 mg daily; refer for follow-up in 1 week.
Acute Care Cardiology
C
R.S., a 58-year-old woman with a history of hypertension (HTN), chronic coronary disease (CCD),
myocardial infarction (MI) 4 months ago, and dyslipidemia, presents to the clinic for a follow-up.
She has no worsening signs or symptoms of dyspnea or edema compared with her baseline. An
echocardiogram reveals a left ventricular ejection
fraction (LVEF) of 35%. She is in New York Heart
Association (NYHA) class III. Her medications
include aspirin 81 mg/day, metoprolol succinate
150 mg/day, and atorvastatin 40 mg/day at night.
Her vital signs include blood pressure (BP) 138/80
mm Hg and heart rate (HR) 58 beats/minute. Her
lungs are clear, and laboratory results are within
normal limits. Given her history and physical
examination, what is the most appropriate modification to R.S.’s current drug therapy?
A. Continue current therapy.
B. Initiate digoxin 0.125 mg/day.
C. Initiate vericiguat 2.5 mg/day.
D. Initiate sacubitril 24 mg/valsartan 26 mg twice
daily
Chronic Care Cardiology
D
J.O. is a 64-year-old woman with NYHA class II
nonischemic dilated cardiomyopathy (LVEF of
30%). She presents to the heart failure (HF) clinic
for a follow-up. She is euvolemic. Her medications
include enalapril 10 mg twice daily, furosemide
40 mg twice daily, and potassium chloride 20 mEq
twice daily. Her vital signs include BP 130/88 mm
Hg and HR 78 beats/minute. Her laboratory results
are within normal limits. What is the best way to
manage J.O.’s HF?
A. Continue current regimen.
B. Increase enalapril to 20 mg twice daily.
C. Initiate carvedilol 3.125 mg twice daily.
D. Initiate digoxin 0.125 mg/day
Chronic Care Cardiology
C
J.M. is a 65-year-old woman with a history of
HTN who presents to her primary care physician
with shortness of breath and markedly decreased
exercise tolerance. An echocardiogram reveals an LVEF of 65%, with diastolic dysfunction. J.M.
currently takes losartan 150 mg/day for HTN. Her
vital signs include BP 134/84 mm Hg and HR 68
beats/minute. Her lung fields are clear to auscultation, and there is no evidence of systemic congestion. Her laboratory results include SCr 1.1 mg/
dL and K 5.1 mEq/L. Which is the best change to
make to J.M.’s pharmacologic regimen today?
A. Add metoprolol succinate 50 mg/day.
B. Initiate furosemide 40 mg/day.
C. Add spironolactone 25 mg/day.
D. Add empagliflozin 10 mg/day.
Chronic Care Cardiology
D
B.W. is a 78-year-old man with a history of HTN,
peripheral arterial disease (PAD), gastroesophageal reflux disease, and asymptomatic atrial fibrillation (AF) for the past month. His therapy includes
aspirin 325 mg/day, lansoprazole 30 mg every
night, atenolol 50 mg/day, lisinopril 10 mg/day, and
atorvastatin 20 mg/day. His vital signs include BP
132/72 mm Hg and HR 68 beats/minute. Which is
the best therapy for B.W. at this time?
A. Add diltiazem and rivaroxaban.
B. Add digoxin and increase lisinopril to 20 mg/
day.
C. Discontinue atorvastatin and add warfarin.
D. Add apixaban and decrease aspirin to 81 mg/day.
Chronic Care Cardiology
D
Z.G. is a 61-year-old man with AF, HTN, and dyslipidemia. His medications include digoxin 0.125
mg/day, warfarin 5 mg/day, amlodipine 10 mg/day,
and pravastatin 20 mg every night. He comes to the
clinic with no complaints except for palpitations
and shortness of breath when doing yard work. His
vital signs include BP 138/80 mm Hg and HR 100
beats/minute. His international normalized ratio
(INR) is 2.4, and his digoxin concentration is 1.1
ng/mL. All other laboratory results are within normal limits. Which is the best option to help with
Z.G.’s symptoms?
A. Add metoprolol succinate 50 mg/day.
B. Increase digoxin to 0.25 mg/day.
C. Add verapamil 240 mg/day.
D. Continue current regimen and advise the patient
to avoid activitiesthat cause signs orsymptoms.
Chronic Care Cardiology
A
R.P. is an 69-year-old Hispanic man with a history
of HTN and gout. His medications include allopurinol 300 mg/day, amlodipine 10 mg/day, and aspirin 81 mg/day. His vital signs include BP 145/85
mm Hg and HR 82 beats/minute. His laboratory
values are normal and his 10-year atherosclerotic
cardiovascular disease (ASCVD) risk is 22.4%.
Which is the best therapy for R.P.?
A. Add hydrochlorothiazide 25 mg/day to achieve
a systolic blood pressure (SBP) goal of less
than 130 mm Hg.
B. Add lisinopril 40 mg/day and titrate to achieve
an SBP goal of less than 140.
C. Add losartan 25 mg/day to achieve an SBP less
than 130 mm Hg.
D. Make no changes to his current medications
because his SBP is at goal.
Chronic Care Cardiology
C
J.T. is a 58-year-old man who presents to his primary care provider for the first time in 10 years.
He has smoked 2 packs/day for the past 30 years
and takes no medication. A fasting lipid panel
shows total cholesterol (TC) 222 mg/dL, lowdensity lipoprotein cholesterol (LDL-C) 105 mg/dL,
triglycerides (TG) 330 mg/dL, and high-density
lipoprotein cholesterol (HDL-C) 51 mg/dL. His
vital signs include BP 140/75 mm Hg and HR 80
beats/minute. His pooled cohort equation reveals
a 10-year ASCVD risk of 14.6%. Which would be
the best pharmacologic therapy to initiate in J.T.?
A. Initiate simvastatin 20 mg/day and gemfibrozil
600 mg twice daily.
B. Initiate rosuvastatin 2.5 mg/day.
C. Initiate pravastatin 20 mg/day and fenofibrate
160 mg/day.
D. Initiate atorvastatin 20 mg/day
Chronic Care Cardiology
D
J.S. is a 43-year-old man with HTN who presents
for an annual physical examination. His family
history is significant for his father having HTN.
His only medication is lisinopril 10 mg/day. His
BP is 145/90 mm Hg. A fasting lipid profile shows
TC 238 mg/dL, TG 95 mg/dL, LDL-C 176 mg/dL,
and HDL-C 43 mg/dL. His calculated 10-year
ASCVD risk according to the pooled cohort equation is 3.9%. Which best describes the next step for
management in J.S.?
A. Initiate high-intensity statin therapy.
B. Initiate fenofibrate 130 mg/day.
C. Initiate moderate-intensity statin therapy.
D. Do not initiate statin therapy and reevaluate
risk in 4–6 years
Chronic Care Cardiology
D
J.C. is a 62-year-old man (height 177.8 cm, weight
135 kg [1 month ago 143 kg]) with a history of
diabetes, chronic kidney disease (CKD), bipolar
disorder, CCD, and hypertriglyceridemia that, in
the past, has resulted in pancreatitis. His family
history is significant for his father having CCD
and hypertriglyceridemia. He is not a smoker, but
admits drinking a 6-pack of beer daily. Pertinent
laboratory findings include a hemoglobin A1C of
11.6% and a serum creatinine (SCr) of 2.6 mg/dL.
He currently takes atorvastatin 40 mg every evening, aspirin 81 mg/day, metformin 1000 mg twice
daily, olanzapine 10 mg/day, metoprolol tartrate 50
mg twice daily, and coenzyme Q10 200 mg/day. His
fasting lipid profile is TC 402 mg/dL, LDL-C unable
to calculate, HDL-C 48 mg/dL, and TG 1500 mg/
dL. His other laboratory values are within normal
limits. Which best describes potential secondary
causes of elevated TG concentrations that should
be considered in J.C.?
A. Obesity, poorly controlled diabetes, olanzapine, metoprolol, coenzyme Q10.
B. Alcohol consumption, poorly controlled diabetes, weight loss, metoprolol.
C. Obesity, metformin, hyperthyroidism, alcohol
consumption.
D. Alcohol consumption, obesity, poorly controlled diabetes, olanzapine, metoprolol.
Chronic Care Cardiology
D
A.M. is a 32-year-old woman with type 1 diabetes
and HTN. Her current medication regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day,
amlodipine 10 mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg daily (for the past 2 years), and insulin
as directed. Her vital signs today include BP 145/83 mm
Hg, repeated BP 145/81 mm Hg; HR 82 beats/minute;
height 167.64 cm; weight 70 kg. A.M. presents to the
clinic for HTN management. She has no new concerns
but expresses that she would prefer not to take any more
drugs, if possible.
Which option is the best clinical plan for A.M.?
A. No change in therapy is currently warranted.
B. Advise weight loss and recheck her BP in
3 months.
C. Change chlorthalidone to hydrochlorothiazide.
D. Discuss changing her contraceptive method.
Chronic Care Cardiology
D
A.M. is a 32-year-old woman with type 1 diabetes
and HTN. Her current medication regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day,
amlodipine 10 mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg daily (for the past 2 years), and insulin
as directed. Her vital signs today include BP 145/83 mm
Hg, repeated BP 145/81 mm Hg; HR 82 beats/minute;
height 167.64 cm; weight 70 kg. A.M. presents to the
clinic for HTN management. She has no new concerns
but expresses that she would prefer not to take any more
drugs, if possible.
A.M. and her husband have decided they are ready
to have children. What is the best medication
option for A.M.?
A. No change in therapy is warranted.
B. Discontinue ramipril and replace with labetalol.
C. Increase chlorthalidone to 50 mg/day.
D. Discontinue all antihypertensive therapy
Chronic Care Cardiology
B
A 66-year-old African American man (height
177.8 cm, weight 91 kg) with AF and CCD (non–
ST-segment elevation MI and stent placement 3
years ago) presents with palpitations. Rate control
therapy, including trials of β-blockers and nondihydropyridine calcium channel blockers, has
been unsuccessful in controlling his symptoms.
He currently takes metoprolol succinate 50 mg/
day, aspirin 81 mg/day, atorvastatin 80 mg/day, lisinopril 5 mg/day, and warfarin 4 mg/day. His laboratory results show INR 2.2, potassium (K) 4.8
mEq/L, SCr 1.2 mg/dL. His BP is 110/70 mm Hg,
and his HR is 95 beats/minute. Which is the best
antiarrhythmic therapy for him?
A. Disopyramide.
B. Flecainide.
C. Propafenone.
D. Sotalol.
Chronic Care Cardiology
D
L.S. is a 48-year-old woman with alcohol-induced cardiomyopathy. Her most recent LVEF is 20%; her daily
activities are limited by dyspnea and fatigue (NYHA class III). Her medications include lisinopril 40 mg
daily, furosemide 40 mg twice daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg/day, and digoxin
0.125 mg/day. She has been stable on these doses for the past month. Her most recent laboratory results
include sodium (Na) 140 mEq/L, potassium (K) 4.0 mEq/L, chloride 105 mEq/L, bicarbonate 26 mEq/L,
blood urea nitrogen 12 mg/dL, SCr 0.8 mg/dL, glucose 98 mg/dL, calcium 9.0 mg/dL, phosphorus 2.8 mg/
dL, magnesium 2.0 mEq/L, and digoxin 0.7 ng/mL. She weighs 69 kg, and her vital signs include BP 112/70
mm Hg and HR 72 beats/minute. In the clinic today, she has concerns for increased shortness of breath and
fatigue. On physical examination, you note 2+ bilateral lower extremity pitting edema and hear crackles on
inspiration. What is the best approach for maximizing the management of her HF?
A. Increase carvedilol to 25 mg twice daily.
B. Increase lisinopril to 80 mg/day.
C. Add empagliflozin 10 mg/day.
D. Increase digoxin to 0.25 mg/day.
Chronic Care Cardiology
C
J.T. is a 62-year-old man (height 182.88 cm, weight 85 kg) with a history of CCD (MI 3 years ago), HTN,
depression, CKD (baseline SCr 2.8 mg/dL), PAD, osteoarthritis, hypothyroidism, and HF (LVEF of 25%).
His medications include aspirin 81 mg/day, atorvastatin 40 mg every night, enalapril 5 mg twice daily, metoprolol succinate 50 mg/day, furosemide 80 mg twice daily, cilostazol 100 mg twice daily, acetaminophen 650
mg four times daily, sertraline 100 mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP 128/74
mm Hg and HR 72 beats/minute. Pertinent laboratory results include K 4.1 mEq/L, SCr 2.8 mg/dL, and a
thyroid-stimulating hormone of 2.6 mIU/L. His HF is stable and considered NYHA class II. What is the best
approach for maximizing the management of his HF?
A. Discontinue metoprolol and begin carvedilol 12.5 mg twice daily.
B. Change enalapril to sacubitril/valsartan 24/26 mg orally twice daily.
C. Add spironolactone 25 mg/day.
D. Add digoxin 0.125 mg/day.
Chronic Care Cardiology
B
J.T. is a 62-year-old man (height 182.88 cm, weight 85 kg) with a history of CCD (MI 3 years ago), HTN,
depression, CKD (baseline SCr 2.8 mg/dL), PAD, osteoarthritis, hypothyroidism, and HF (LVEF of 25%).
His medications include aspirin 81 mg/day, atorvastatin 40 mg every night, enalapril 5 mg twice daily, metoprolol succinate 50 mg/day, furosemide 80 mg twice daily, cilostazol 100 mg twice daily, acetaminophen 650
mg four times daily, sertraline 100 mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP 128/74
mm Hg and HR 72 beats/minute. Pertinent laboratory results include K 4.1 mEq/L, SCr 2.8 mg/dL, and a
thyroid-stimulating hormone of 2.6 mIU/L. His HF is stable and considered NYHA class II.
Which drug that J.T. (from Patient Case 2) is currently taking would be best to discontinue because of his
HFrEF?
A. Acetaminophen.
B. Sertraline.
C. Cilostazol.
D. Levothyroxine.
Chronic Care Cardiology
C
P.M. is a 52-year-old man (height 177.8 cm, weight 116 kg) with a history of HTN and a transient ischemic
attack 2 years ago. He visits his primary care doctor with the chief concern of several weeks of a “fluttering” feeling in his chest on occasion. He thinks the fluttering is nothing; however, his wife insists he have it
checked. His current medications include metoprolol tartrate 50 mg twice daily and aspirin 81 mg/day. He is
adherent to this regimen and has health insurance, but he does not like to make the 3-hour trip to his primary
care provider. His laboratory data from his past visit were all within normal limits. His vitalsignstoday include
BP 130/78 mm Hg and HR 76 beats/minute. All laboratory values are within normal limits. An electrocardiogram
(ECG) reveals an irregularly irregular rhythm, with no P waves, and a HR of 74 beats/minute. A diagnosis of AF
is made. What is the best approach for managing his AF at this time?
A. Begin digoxin 0.25 mg/day.
B. Begin diltiazem CD 240 mg/day.
C. Begin warfarin 5 mg/day and titrate to a goal INR of 2.5.
D. Begin dabigatran 150 mg twice daily.
Chronic Care Cardiology
D
H.D. is a 67-year-old man with a history of HTN and AF for 4 years. His medications include ramipril 5 mg
twice daily, sotalol 120 mg twice daily, digoxin 0.125 mg/day, and warfarin 5 mg/day. He visits his primary
care physician after being discharged from the emergency department with increased fatigue on exertion
palpitations, and lower extremity edema. His vital signs today include BP 115/70 mm Hg and HR 88
beats/minute, and all laboratory results are within normal limits; however, his lower extremity edema has
worsened. His INR is 2.8. His ECG shows AF. An echocardiogram reveals an LVEF of 35%–40%. H.D.’s
physician would like to continue a rhythm control approach. What is the best treatment option for managing
his AF?
A. Discontinue sotalol and begin metoprolol succinate 12.5 mg/day.
B. Discontinue sotalol and begin dronedarone 400 mg twice daily.
C. Discontinue sotalol and begin amiodarone 400 mg twice daily, tapering to goal dose of 200 mg/day for the
next 6 weeks.
D. Continue sotalol and add metoprolol tartrate 25 mg twice daily
Chronic Care Cardiology
C
. W.D. is a 55-year-old woman who was recently admitted to the hospital with acute myocardial infarction
which was treated with a stent. She has a medical history of HTN and GERD. She is visiting your clinic
today for management of her cardiovascular medications. Her vitals today include BP 152/86 mm Hg and
HR 82 beats/minute. Her labs are all WNL, including Na 140 mEq/L, K 4.3 mEq/L, and SCr 1.0 mg/dL. Her
current medication regimen includes clopidogrel 75 mg daily, aspirin 81 mg daily, and atorvastatin 40 mg
daily. What is the most appropriate approach to manage her HTN?
A. Add carvedilol monotherapy
B. Add lisinopril and metoprolol
C. Add amlodipine and metoprolol
D. Add lisinopril monotherapy
Chronic Care Cardiology
D
T.J. is a 58-year-old African American woman presenting for routine follow-up of her chronic obstructive
pulmonary disease. She has no other medical history. Her blood pressure today (average of 2 readings) is
138/88 mm Hg. Her HR is 77 beats/minute. Her BP at her last visit was 136/86 mm Hg. Her current medications include tiotropium dry powder inhaler daily and an albuterol metered dose inhaler as needed. Her labs
include Na 140 mEq/L, K 4.0 mEq/L, Cl 102 mEq/L, bicarbonate 28 mEq/L, serum urea nitrogen 14 mg/dL,
and SCr 0.8 mg/dL. Her 10-year ASCVD risk is 12%. What is the best approach for managing her HTN?
A. Begin diet and lifestyle modifications only
B. Begin lifestyle modifications and add amlodipine 5 mg daily
C. Begin lifestyle modifications and add lisinopril 2.5 mg daily
D. Begin lifestyle modifications and add lisinopril 2.5 mg daily plus hydrochlorothiazide 12.5 mg daily
Chronic Care Cardiology
B
M.M. is a 63-year-old woman who just finished 6 months of diet and exercise for dyslipidemia. She has a history of hypertension, diabetes, and asthma. She smokes one pack of cigarettes and drinks three beers per day.
Her mother had HTN and suffered an MI at age 42 years. Her father had HTN and diabetes. Her medications
are albuterol metered dose inhaler, lisinopril, metformin, linagliptin, and calcium carbonate antacids. Her
vital signs include BP 134/84 mm Hg and HR 75 beats/minute. Her laboratory results are as follows: HDL-C
38 mg/dL, LDL-C 134 mg/dL, TG 186 mg/dL, TC 209 mg/dL, and hemoglobin A1C 8.6%. Her pooled cohort
equation estimates a 10-year ASCVD risk of 27.8%. What is the most appropriate next step for M.M.?
A. Initiate a low-intensity statin
B. Initiate a moderate-intensity statin
C. Initiate a high-intensity statin
D. Initiate a high-intensity statin plus ezetimibe
Chronic Care Cardiology
C
According to the ACC/AHA blood cholesterol guidelines, which is best described as a high-intensity statin dose?
A. Pravastatin 20 mg/day.
B. Lovastatin 20 mg/day.
C. Atorvastatin 40 mg/day.
D. Rosuvastatin 10 mg/day.
Chronic Care Cardiology
C
Which best describes a potential secondary cause of high TG concentrations?
A. Amiodarone.
B. Biliary obstruction.
C. Sirolimus.
D. Saturated fats
Chronic Care Cardiology
C
A 66-year-old man with a medical history of HTN and ACS with a drug-eluting coronary stent placement
14 months ago presents to the primary care clinic. Current medications include aspirin 81 mg/day, prasugrel
10 mg/day, nitroglycerin 0.4-mg sublingual tablets as needed for chest pain, metoprolol succinate 75 mg/day,
ramipril 10 mg/day, and atorvastatin 20 mg/day. He asks you how long he will need to take prasugrel. What
is the best answer?
A. Call your physician because you may be able to stop prasugrel now.
B. Your prasugrel should have been discontinued 6 months after ACS; discontinue it now.
C. You will need to take prasugrel indefinitely.
D. You will need to take prasugrel for at least 18 months after your MI and stent placement.
Chronic Care Cardiology
A
J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation
(AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension,
dyslipidemia, and depression. Her medications include
metoprolol tartrate 100 mg orally twice daily, enalapril
10 mg orally twice daily, and citalopram 20 mg orally
daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is
60 mL/minute; she has normal hepatic function.
Which best depicts J.M.’s CHA2DS2-VASc score
and HAS-BLED score?
A. CHA2DS2-VASc score 1; HAS-BLED score 1.
B. CHA2DS2-VASc score 3; HAS-BLED score 1.
C. CHA2DS2-VASc score 5; HAS-BLED score 4.
D. CHA2DS2-VASc score 3; HAS-BLED score 2.
Anticoagulation
B
J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation
(AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension,
dyslipidemia, and depression. Her medications include
metoprolol tartrate 100 mg orally twice daily, enalapril
10 mg orally twice daily, and citalopram 20 mg orally
daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is
60 mL/minute; she has normal hepatic function.
Which is the most appropriate stroke prevention strategy for J.M.? A. Aspirin 325 mg orally once daily. B. Rivaroxaban 20 mg orally once daily. C. Apixaban 2.5 mg orally twice daily. D. Edoxaban 30 mg orally once daily.
Anticoagulation
B
J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation
(AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension,
dyslipidemia, and depression. Her medications include
metoprolol tartrate 100 mg orally twice daily, enalapril
10 mg orally twice daily, and citalopram 20 mg orally
daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is
60 mL/minute; she has normal hepatic function.
J.M. was initiated on dabigatran and 3 months later
is involved in a motor vehicle accident resulting
in an intracranial hemorrhage. Which is the most
appropriate reversal strategy for J.M.?
A. Protamine.
B. Fresh frozen plasma (FFP).
C. Coagulation factor Xa [recombinant],
inactivated.
D. Idarucizumab.
Anticoagulation
D
B.T. is 68-year-old male (height 183 cm, weight 96 kg)
who recently underwent surgical aortic valve replacement with a bioprosthetic valve and is recovering well.
He also has hypertension, dyslipidemia, systolic heart failure, and a history of sustained ventricular tachycardia. His medications include carvedilol 25 mg orally
twice daily, lisinopril 10 mg orally daily, furosemide
40 mg orally daily, amiodarone 400 mg orally daily,
and atorvastatin 80 mg orally daily. His CrCl is 40 mL/
minute, hepatic function is normal, and other laboratory
data are within normal limits.
Which is the most appropriate antithrombotic regimen for B.T.?
A. Aspirin 81 mg orally daily.
B. Warfarin 7.5 mg orally daily to an INR of 2.5–3.5.
C. Apixaban 5 mg orally twice daily.
D. Dabigatran 150 mg twice daily
Anticoagulation
A
B.T. is 68-year-old male (height 183 cm, weight 96 kg)
who recently underwent surgical aortic valve replacement with a bioprosthetic valve and is recovering well.
He also has hypertension, dyslipidemia, systolic heart failure, and a history of sustained ventricular tachycardia. His medications include carvedilol 25 mg orally
twice daily, lisinopril 10 mg orally daily, furosemide
40 mg orally daily, amiodarone 400 mg orally daily,
and atorvastatin 80 mg orally daily. His CrCl is 40 mL/
minute, hepatic function is normal, and other laboratory
data are within normal limits.
Which best depicts how long B.T. should receive
therapy?
A. At least 1 month.
B. At least 3 months.
C. At least 1 year.
D. Indefinitely.
Anticoagulation
D
M.R. is a 51-year-old female (height 165 cm, weight 98
kg, BMI 36 kg/m2
) who presents to the ED with pain,
swelling, and redness in her right leg up into her thigh.
She also has some shortness of breath and pain in the
middle of her chest. She reports that she had a hysterectomy about 2 weeks ago and has not been moving much
at home in the past 2 weeks. On physical examination,
her right leg is warmer than her left and tender to the
touch. Her cardiac examination appears normal, with
vital signs consisting of a heart rate of 80 beats/minute, blood pressure 146/96 mm Hg, respiratory rate 20
breaths/minute, and Sao2 92% on room air. Her initial
laboratory information includes a positive D-dimer, a
negative troponin, and a CrCl of 65 mL/minute. Duplex
ultrasound detects a right femoral-popliteal deep
vein thrombosis (DVT), and CT reveals a pulmonary
embolism (PE). Her other conditions include hypertension, type 2 diabetes, and dyslipidemia. She has also
smoked 1 pack/day of cigarettes for the past 30 years.
Her medications include lisinopril 10 mg orally daily,
chlorthalidone 25 mg orally daily, metformin 1000 mg
orally twice daily, pravastatin 40 mg orally daily, and
hydrocodone 5 mg/acetaminophen 325 mg orally every
6 hours as needed for pain.
Which best depicts M.R.’s number of venous
thromboembolism (VTE) risk factors?
A. 3.
B. 4.
C. 5.
D. 6.
Anticoagulation
C
M.R. is a 51-year-old female (height 165 cm, weight 98
kg, BMI 36 kg/m2
) who presents to the ED with pain,
swelling, and redness in her right leg up into her thigh.
She also has some shortness of breath and pain in the
middle of her chest. She reports that she had a hysterectomy about 2 weeks ago and has not been moving much
at home in the past 2 weeks. On physical examination,
her right leg is warmer than her left and tender to the
touch. Her cardiac examination appears normal, with
vital signs consisting of a heart rate of 80 beats/minute, blood pressure 146/96 mm Hg, respiratory rate 20
breaths/minute, and Sao2 92% on room air. Her initial
laboratory information includes a positive D-dimer, a
negative troponin, and a CrCl of 65 mL/minute. Duplex
ultrasound detects a right femoral-popliteal deep
vein thrombosis (DVT), and CT reveals a pulmonary
embolism (PE). Her other conditions include hypertension, type 2 diabetes, and dyslipidemia. She has also
smoked 1 pack/day of cigarettes for the past 30 years.
Her medications include lisinopril 10 mg orally daily,
chlorthalidone 25 mg orally daily, metformin 1000 mg
orally twice daily, pravastatin 40 mg orally daily, and
hydrocodone 5 mg/acetaminophen 325 mg orally every
6 hours as needed for pain.
Which is the most appropriate treatment strategy
for M.R.?
A. Enoxaparin 100 mg subcutaneously every 12
hours and dabigatran 150 mg orally twice daily;
after 5 days, enoxaparin can be discontinued.
B. Rivaroxaban 15 mg orally twice daily for 7
days, followed by 20 mg orally once daily.
C. Enoxaparin 100 mg subcutaneously every 12
hours for 5 days; then initiate edoxaban 60 mg
orally once daily.
D. Unfractionated heparin (UFH) 4000-unit
bolus, followed by 1000 units/hour and warfarin 7.5 mg orally daily to an INR of 2.0–3.0,
discontinuing UFH when a therapeutic INR is
reached.
Anticoagulation
C
A male patient (height 186 cm, weight 125 kg) is
admitted for the treatment of a DVT with a PE. He
is administered a 10,000-unit bolus of UFH and
initiated on an infusion of 2000 units/hour. Twelve
hours into the infusion, he begins to vomit blood.
Which is the most appropriate protamine dose for
this patient?
A. 100 mg.
B. 50 mg.
C. 22.5 mg.
D. 11.25 mg
Anticoagulation
B
A female patient (height 163 cm, weight 65 kg)
has undergone a hip fracture surgery. She has normal renal and hepatic function. Which is the most
appropriate regimen for preventing VTE in this
patient?
A. Dabigatran 110 mg orally once 2 hours after
surgery, followed by 220 mg orally once daily.
B. Enoxaparin 30 mg subcutaneously once daily.
C. Fondaparinux 2.5 mg subcutaneously once daily.
D. Edoxaban 60 mg orally once daily.
Anticoagulation
C
B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a
history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications
include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol
succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine
10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values
include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL.
Which best depicts B.D.’s CHA2
DS2
-VASc score?
A. 2.
B. 3.
C. 4.
D. 5.
Anticoagulation
B
B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a
history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications
include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol
succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine
10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values
include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL.
Which is most accurate regarding DOAC therapy for reducing the risk of stroke in patients with nonvalvular
AF such as B.D.?
A. All the DOACs significantly reduced ischemic stroke in the phase III trials compared with warfarin.
B. All the DOACs significantly reduced hemorrhagic stroke in the phase III trials compared with warfarin.
C. Apixaban is more effective than rivaroxaban because apixaban was superior to warfarin in the
ARISTOTLE trial and rivaroxaban was only noninferior to warfarin in the ROCKET-AF trial.
D. Dabigatran was studied in patients with highest risk across the phase III trials and should not be used in
patients with a CHADS2 score less than 3.
Anticoagulation
B
B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a
history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications
include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol
succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine
10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values
include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL.
Which is the most appropriate regimen for reducing B.D.’s risk of stroke?
A. Dabigatran 75 mg orally twice daily.
B. Rivaroxaban 20 mg orally once daily.
C. Apixaban 5 mg orally twice daily.
D. Edoxaban 60 mg orally once daily
Anticoagulation
C
B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a
history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications
include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol
succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine
10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values
include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL.
Six months later, B.D. elects to undergo PCI for the management of his chronic coronary artery disease. He
has had no medication changes, and his vital signs and laboratory information remain consistent. Which is
the best available evidence-based approach to B.D.’s antithrombotic therapy?
A. Rivaroxaban 10 mg orally daily plus clopidogrel 75 mg orally daily.
B. Apixaban 2.5 mg orally twice daily plus clopidogrel 75 mg orally daily.
C. Adjusted-dose warfarin to an INR of 2.0–3.0 plus aspirin 81 mg orally daily plus clopidogrel 75 mg
orally daily.
D. Edoxaban 15 mg orally once daily plus aspirin 81 mg orally daily plus clopidogrel 75 mg orally daily
Anticoagulation
A
S.D. is a 62-year-old female (height 165 cm, weight 80 kg) with a history of significant primary mitral regurgitation. Her echocardiogram reveals significant leaflet flaring that is not amendable to mitral valve repair. She also has
a history of hypertension, dyslipidemia, and gout. Her medications include lisinopril 10 mg orally daily, hydrochlorothiazide 25 mg orally daily, simvastatin 40 mg orally daily, and allopurinol 300 mg orally daily. Her heart rate
is 68 beats/minute and blood pressure is 128/74 mm Hg. Her CrCl is 68 mL/minute. She is scheduled to undergo
valve replacement surgery and will receive a mechanical mitral valve. You are discussing the oral anticoagulant
postoperative plan with S.D.’s team
Which is the optimal regimen for preventing thrombosis?
A. Adjusted-dose warfarin to an INR goal of 2.5–3.5 plus aspirin 81 mg orally daily.
B. Adjusted-dose warfarin to an INR goal of 2.0–3.0 plus aspirin 81 mg orally daily.
C. Adjusted-dose warfarin to an INR goal of 2.0–3.0.
D. Adjusted-dose warfarin to an INR goal of 2.5–3.5.
Anticoagulation
D
S.D. is a 62-year-old female (height 165 cm, weight 80 kg) with a history of significant primary mitral regurgitation. Her echocardiogram reveals significant leaflet flaring that is not amendable to mitral valve repair. She also has
a history of hypertension, dyslipidemia, and gout. Her medications include lisinopril 10 mg orally daily, hydrochlorothiazide 25 mg orally daily, simvastatin 40 mg orally daily, and allopurinol 300 mg orally daily. Her heart rate
is 68 beats/minute and blood pressure is 128/74 mm Hg. Her CrCl is 68 mL/minute. She is scheduled to undergo
valve replacement surgery and will receive a mechanical mitral valve. You are discussing the oral anticoagulant
postoperative plan with S.D.’s team
Which best describes thrombotic risk in patients with valve replacement surgery?
A. Bioprosthetic valves carry a higher risk of thrombosis than mechanical valves.
B. The highest risk of thrombosis with bioprosthetic valve placement is during the first year after surgery.
C. All patients with mechanical heart valves require bridging therapy during invasive procedures.
D. Valve replacement in the mitral position carries a higher risk of thrombosis than in the aortic position
Anticoagulation
D
B.G. is a 62-year-old male (height 175 cm, weight 110 kg) hospitalized for a heart failure exacerbation. He has
symptoms when doing only limited exertion and has been out of bed only to use the bathroom for the past
3 days. His medical history also includes stable ischemic heart disease, hypertension, type 2 diabetes, and a
PE 2 years ago. He smokes 2 packs of cigarettes/day and drinks 1 glass of wine with dinner most evenings.
His medications include bisoprolol 5 mg orally daily, lisinopril 10 mg orally daily, aspirin 81 mg orally daily,
ranolazine 1000 mg orally twice daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and
metformin 1000 mg orally twice daily. His blood pressure today is 110/70 mm Hg and heart rate is 58 beats/
minute. His laboratory values are normal except for a BNP of 1498 ng/mL. Which is the most appropriate VTE
prevention strategy for B.G.?
A. Administer fondaparinux 5 mg subcutaneously daily.
B. Administer apixaban 2.5 mg orally twice daily.
C. Administer enoxaparin 40 mg subcutaneously daily.
D. His risk does not warrant prophylactic therapy.
Anticoagulation
C
A 48-year-old male (height 178 cm, weight 90 kg) presents to the ED with pain and swelling in his left leg.
On examination, his leg is warm to the touch and tender and has 3+ pitting edema below the knee. His
D-dimer is positive, and his duplex ultrasonography identifies a femoral-popliteal DVT. He understands
that he will need to receive anticoagulant therapy but wants to avoid any injections, if possible. He has good
insurance coverage. His other medical conditions are hypertension, HIV, and dyslipidemia. His medications
include benazepril 20 mg orally daily, ritonavir 100 mg orally daily, darunavir 800 mg orally daily, emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg orally daily, and atorvastatin 10 mg orally daily. His
vital signs are stable, and his CrCl is 78 mL/minute. Which is the most appropriate anticoagulant regimen to
initiate for this patient?
A. Rivaroxaban 15 mg orally twice daily for 21 days, followed by 20 mg orally daily.
B. Edoxaban 60 mg orally daily.
C. Warfarin 2.5 mg orally daily.
D. Apixaban 5 mg orally twice daily for 7 days, followed by 2.5 mg orally twice daily.
Anticoagulation
D
. A 49-year-old male (height 175 cm, weight 100 kg) was diagnosed with an idiopathic DVT 3 weeks ago. He
currently takes warfarin 8 mg orally daily. He missed his INR readings last week when he went on a short
vacation. Today, his INR is 10.4. He is not currently bleeding and has no risk factors for bleeding. In addition
to holding his warfarin dose, which is the best initial strategy for managing this patient’s high INR?
A. Hold warfarin only.
B. Hold warfarin and administer 4PCC 50 units/kg intravenously.
C. Hold warfarin and administer vitamin K 5 mg orally.
D. Hold warfarin and administer vitamin K 10 mg intravenously.
Anticoagulation
C
A 58-year-old male is receiving enoxaparin 40 mg subcutaneously daily for VTE prophylaxis. While trying
to shave himself at 6 p.m., he cuts his neck, and the medical team cannot stop the bleeding. His last enoxaparin dose was administered at 8 a.m. Which would be the most appropriate protamine dose (in milligrams) for
this patient?
A. 10.
B. 20.
C. 40.
D. 50
Anticoagulation
B
A 58-year-old woman remains intubated in the
intensive care unit (ICU) after a recent abdominal operation. In the operating room, she receives
more than 10 L of fluid and blood products, but has
received aggressive diuresis with furosemide postoperatively. In the past 3 days, she has generated
12 L of urine output, and her blood urea nitrogen
(BUN) and serum creatinine (SCr) have steadily
increased to 40 and 1.5 mg/dL, respectively. Her
urine chloride (Cl) concentration was 9 mEq/L
(24 hours after her last dose of furosemide). This
morning, her arterial blood gas (ABG) reveals pH
7.50, Paco2 46 mm Hg, and bicarbonate (HCO3
−
)
34 mEq/L. Her vital signs include blood pressure
85/40 mm Hg and heart rate 110 beats/minute.
Which action is best to improve her acid-base status?
A. 0.9% sodium chloride bolus.
B. 5% dextrose (D5
W) bolus.
C. Hydrochloric acid infusion.
D. Acetazolamide intravenously
Critical Care
A
A 21-year-old man (weight 80 kg) admitted 1
day ago after a gunshot wound to the abdomen
is receiving mechanical ventilation and is thrashing around in bed and pulling at his endotracheal
tube. His score is +3 on the Richmond AgitationSedation Scale (RASS). The patient is negative for
delirium according to the Confusion Assessment
Method for the ICU (CAM-ICU). His pulmonary
status precludes extubation, and the attending physician estimates that he will remain intubated for at
least 48 more hours. The medical team has decided
that his RASS goal should be between 0 and -1.
He is receiving a fentanyl infusion (150 mcg/hour),
which has been adequately controlling his pain
(Critical-Care Pain Observation Tool [CPOT] less
than 3 for 24 hours). Vital signs include blood pressure 110/70 mm Hg and heart rate 110 beats/minute. His baseline QTc interval is 460 milliseconds.
Which is the best intervention for achieving this
patient’s RASS goal?
A. Initiate a dexmedetomidine 1-mcg/kg loading
dose over 10 minutes, followed by 0.7 mcg/kg/
hour.
B. Initiate a lorazepam 3-mg intravenous load,
followed by a lorazepam 3-mg/hour infusion.
C. Initiate propofol at 5 mcg/kg/minute and
titrate by 5 mcg/kg/minute every 5 minutes as
needed.
D. Initiate haloperidol 1 mg intravenously, and
double the dose every 1 hour as needed.
Critical Care
C
A 62-year-old woman is admitted to the medical ICU for respiratory dysfunction necessitating
mechanical ventilation. She has no significant
medical history. Her chest radiograph reveals
bilateral lower lobe infiltrates, her white blood cell
count (WBC) is 21 × 103
cells/mm3
, lactate is 1.7
mmol/L, temperature is 103.3°F (39.6°C), blood
pressure is 82/45 mm Hg (normal for her is 115/70
mm Hg), heart rate is 110 beats/minute, and respiratory rate is 22 breaths/minute. After she is given
a diagnosis of community-acquired pneumonia,
she is empirically initiated on ceftriaxone 2 g/day
and azithromycin 500 mg/day intravenously. After
fluid resuscitation with 6 L of lactated Ringer solution, her blood pressure is unchanged. Dopamine
is initiated and titrated to 9 mcg/kg/minute, with a
resulting blood pressure of 96/58 mm Hg, and her heart rate is 138 beats/minute. She has made less
than 100 mL of urine during the past 6 hours, and
her SCr has increased from 0.9 mg/dL to 1.3 mg/
dL. Her serum albumin concentration is 2.7 g/dL.
Which therapy is best for this patient at this time?
A. Administer 5% albumin 500 mL intravenously over 1 hour and reassess mean arterial
pressure (MAP).
B. Initiate hydrocortisone 50 mg intravenously
every 6 hours.
C. Change dopamine to norepinephrine 0.01
mcg/kg/minute to maintain a MAP greater
than 65 mm Hg.
D. Reduce the dopamine infusion to 1 mcg/kg/
minute to maintain a urine output of at least 1
mL/kg/hour.
Critical Care
C
A 92-year-old woman (weight 51 kg) is admitted
to the ICU with urosepsis and septic shock. She
lives in a long-term care facility and has a medical history significant for coronary artery disease
and hypertension. Her blood pressure is 72/44 mm
Hg, central venous pressure (CVP) is 5 mm Hg,
heart rate 120 beats/minute, and oxygen saturation
(Sao2
) is 99%; her laboratory values are normal,
except for a BUN of 74 mg/dL and Cr of 2.7 mg/dL
(baseline of 1.5 mg/dL). Her urine output is about
20 mL/hour. Appropriate empiric antibiotics were
initiated. Which therapy is most appropriate to initiate next?
A. Norepinephrine 0.05 mcg/kg/minute.
B. Lactated Ringer solution 1500-mL bolus.
C. Dopamine 5 mcg/kg/minute.
D. Albumin 5% 500-mL bolus
Critical Care
B
46-year-old man had a witnessed cardiac arrest
in an airport terminal. After about 5 minutes, emergency medical services arrived, and defibrillator
pads were applied. The cardiac monitor showed
ventricular tachycardia (VT), and the patient had
no discernible pulse. He was defibrillated with
200 J without return of spontaneous circulation
(ROSC). He received an additional two shocks of
200 J with no improvement. Between shocks, the
patient received compressions. An intravenous line
was obtained, and an epinephrine 1-mg intravenous
push was given; chest compressions and artificial respirations were initiated. Within 1 minute, the
patient was reassessed. The cardiac monitor still
showed VT, and he remained pulseless; therefore,
another shock of 200 J, followed by an amiodarone
300-mg intravenous push, was administered. After
this, the patient was converted to a normal sinus
rhythm with a heart rate of 100 beats/minute. The
patient was then transported to the hospital, intubated and unresponsive. Which recommendation is
most likely to improve this patient’s outcomes?
A. Administer sodium bicarbonate 50 mEq
intravenously.
B. Administer vasopressin 40 unitsintravenously.
C. Administer a continuous infusion of heparin.
D. Initiate a targeted temperature management
protocol.
Critical Care
D
A 72-year-old man is admitted to the medical ICU
for post-cardiac arrest care with targeted temperature management. His body temperature was maintained at 91.4°F (33°C) for 24 hours, and the health
care team decides it is time to rewarm slowly at
0.5°C every hour. Which is most important to consider during the rewarming phase?
A. Frequent laboratory monitoring is necessary
to guide potassium supplementation because
of the risk of hypokalemia.
B. A vecuronium continuous infusion should be
administered to prevent shivering.
C. Phenytoin should be administered for seizure
prophylaxis.
D. Frequent blood glucose monitoring is necessary, given the risk of hypoglycemia.
Critical Care
D
A 65-year-old man with a history of hypothyroidism, heart failure, and myocardial infarction is
admitted to the ICU with severe community-acquired pneumonia. Six hours after admission, he
develops acute respiratory failure, hypotension,
and acute kidney injury from presumed sepsis. He
is placed on mechanical ventilation, and a nasogastric tube is placed, with no plans for extubation.
Which is most appropriate for this patient’s stress
ulcer prophylaxis (SUP)?
A. Administer sucralfate 1 g four times daily by
nasogastric tube.
B. Administer magnesium hydroxide 30 mL four
times daily by nasogastric tube.
C. Administer famotidine 20 mg intravenously
daily.
D. No prophylaxis is indicated for this patient
because he has no risk factors for SUP.
Critical Care
C
A 45-year-old man is admitted to the ICU with
H1N1 influenza causing respiratory failure. He is
intubated and sedated with fentanyl 200 mcg/hour
and propofol 25 mcg/kg/minute. He has received
4 L of lactated Ringer solution and 1 L of albumin and is currently receiving norepinephrine 0.15
mcg/kg/minute and vasopressin 0.03 unit/minute
for hemodynamic support. His current vital signs
are blood pressure 85/58 mm Hg, heart rate 99
beats/minute, and respiratory rate 18 breaths/minute. Which is the best plan for this patient’s steroid
therapy?
A. Initiate hydrocortisone 50 mg every 6 hours
intravenously.
B. Perform a cosyntropin stimulation test and
initiate hydrocortisone 50 mg every 6 hours
intravenously if the patient does not have an
increase greater than 9 mcg/dL from baseline.
C. Check a random cortisol and initiate
hydrocortisone 50 mg every 6 hours intravenously if the result is less than 10 mcg/dL.
D. Steroids are not indicated at this time.
Critical Care
A
A 19-year-old man (height 71 inches [180 cm],
weight 68 kg) is admitted to the ICU after ingesting
an unknown quantity of acetaminophen. After initial resuscitation and treatment with acetylcysteine,
the patient remains unresponsive and intubated.
The intensivist would like to start enteral nutrition
(EN) as soon as possible. Which is the best way to
calculate the patient’s caloric and protein needs?
A. Estimate caloric needs at 25 kcal/kg and protein at 1.2 g/kg.
B. Perform indirect calorimetry to estimate
caloric and protein needs.
C. Estimate caloric needs at 14 kcal/kg and protein at 2 g/kg.
D. Calculate caloric needs based on the Mifflin
equation, and order a prealbumin concentration
to assess protein needs.
Critical Care
A
A 57-year-old woman is admitted to the ICU with
injuries sustained after a fall from 12 feet. She has
traumatic brain injury and has been intubated for
airway protection. What is the best intervention
to prevent ventilator-associated pneumonia in this
patient?
A. Initiate pantoprazole 40 mg intravenously daily.
B. Perform selective digestive decontamination
with enteral polymyxin B sulfate, neomycin
sulfate, and vancomycin hydrochloride.
C. Maintain head of bed elevation at 20 degrees
at all times.
D. Start chlorhexidine 0.12% oral swabs twice
daily.
Critical Care
D
You are the critical care pharmacist for a 300-bed
hospital. The critical care committee wants to
institute an evidence-based glucose control protocol for the ICU. What is the best goal to implement
for patients who present with septic shock?
A. Check blood glucose every 6 hours and treat
with sliding scale protocol when greater than
180 mg/dL.
B. Initiate insulin infusion with a target of
110–140 mg/dL for two blood glucose values
greater than 140 mg/dL.
C. Initiate insulin infusion with a target of
140–200 mg/dL for two blood glucose values
greater than 180 mg/dL.
D. Initiate insulin infusion with a target blood
glucose of 80–110 mg/dL for two blood glucose values greater than 150 mg/dL.
Critical Care
C
Which is the most appropriate therapy to reduce
the risk of delayed ischemia and improve neurologic outcomes after an aneurysmal subarachnoid
hemorrhage (SAH)?
A. Clevidipine continuous infusion titrated to
maintain a systolic blood pressure (SBP) less
than 160 mm Hg.
B. Nimodipine 60 mg orally every 4 hours for 21
days.
C. Norepinephrine continuous infusion titrated
to maintain an SBP greater than 160 mm Hg.
D. Amlodipine 10 mg orally every 24 hours for 21
days.
Critical Care
B
A 62-year-old woman has been hospitalized in the ICU for several weeks. Her hospital stay has been complicated by aspiration pneumonia and sepsis, necessitating prolonged courses of antibiotics. For the past few
days, she has been having high temperatures, and her stool output has increased dramatically. Her most recent
stool samples have tested positive for Clostridioides difficile toxin, and her laboratory tests show serum sodium
138 mEq/L, K 3.5 mEq/L, Cl 115 mEq/L, HCO3
− 15 mEq/L, albumin 4.4 g/dL, pH 7.32, and Paco2
30 mm Hg.
Which is most consistent with this patient’s primary acid-base disturbance?
A. AG metabolic acidosis.
B. Non-AG metabolic acidosis.
C. Chloride-responsive metabolic alkalosis.
D. Acute respiratory acidosis.
Critical Care
B
A 32-year-old man with no pertinent medical history is admitted to the hospital after being “found down” in
his home with an empty bottle of alprazolam by his side. On arrival at the emergency department, he was neurologically unresponsive, with the following ABG values: pH 7.21, Paco2 58 mm Hg, Pao2 90 mm Hg, HCO3
−
24 mEq/L, and Sao2 86% on 2 L/minute of oxygen by nasal cannula. Which action is most appropriate?
A. Administer acetazolamide 500 mg intravenous push.
B. Administer 100% oxygen by face mask.
C. Give sodium bicarbonate 100 mEq intravenous push.
D. Provide urgent intubation.
Critical Care
D
A 55-year-old woman is admitted to the hospital after several days of worsening shortness of breath. Recently,
she was discharged from the hospital after a similar episode and was doing fine until 3 days before admission,
when she developed a productive cough, necessitating an increase in her home oxygen and more frequent use
of her metered dose inhalers. On admission to the medical ICU, she was anxious and markedly distressed, with
rapid, shallow breaths. She was hypertensive (160/80 mm Hg), tachycardic (140 beats/minute), and tachypneic
(respiratory rate 28 breaths/minute). Her ABG showed pH 7.30, Paco2 59 mm Hg, Pao2 50 mm Hg, HCO3
− 28
mEq/L, and Sao2 83% on 6 L/minute of oxygen by face mask, and she was immediately intubated. Her most
recent laboratory tests show serum sodium 142 mEq/L, K 3.8 mEq/L, Cl 109 mEq/L, HCO3
− 28 mEq/L, and
albumin 4.1 g/dL. Which primary acid-base disturbance is most consistent with this patient’s presentation and
laboratory data?
A. AG metabolic acidosis.
B. Non-AG metabolic acidosis
C. Respiratory acidosis.
D. Respiratory alkalosis.
Critical Care
C
A 65-year-old woman is admitted to cardiac surgery ICU after an aortic valve replacement. On hospital day 4,
she is hypotensive (blood pressure 80/50 mm Hg), tachycardic (heart rate 125 beats/minute), tachypneic (respiratory rate 30 breaths/minute), hypoxemic (Pao2 40 mm Hg), febrile (temperature 103.1°F [39.5°C]), and confused. The patient is given adequate boluses of lactated Ringer solution and is then intubated and initiated
on piperacillin/tazobactam and vancomycin for possible nosocomial pneumonia. After fluid boluses fail to
improve her hemodynamic and clinical status, a pulmonary artery catheter is placed, which reveals a PCWP
of 18 mm Hg, CI of 3.3 L/minute/m2
and SVR of 515 dynes/second/cm5
. Her chest radiograph reveals a left
lower lobe consolidation, and she still needs 100% fraction of inspired oxygen (FiO2). Which action is best?
A. Administer angiotensin II infusion titrated to achieve a MAP of at least 65 mm Hg.
B. Administer a dobutamine infusion titrated to achieve a MAP of at least 65 mm Hg.
C. Administer a norepinephrine infusion titrated to achieve a MAP of at least 65 mm Hg.
D. Administer a dopamine infusion titrated to achieve a MAP of at least 65 mm Hg
Critical Care
C
A patient (weight 75 kg) is to be initiated on a continuous infusion of norepinephrine for blood pressure support because of septic shock. The nurse has a 250-mL bag of normal saline containing 4 mg of norepinephrine.
Which rate is most appropriate to infuse the norepinephrine drip at a dose of 0.05 mcg/kg/minute?
A. 7 mL/hour.
B. 14 mL/hour.
C. 31.5 mL/hour.
D. 79 mL/hour
Critical Care
B
A 42-year-old man was found unresponsive at his group home covered in vomit. He was intubated by the
paramedics. On arrival at the emergency department, his blood pressure is 72/30 mm Hg and heart rate is 95
beats/minute. During the next few hours, he receives 5 L of lactated Ringer solution, 500 mL of 5% albumin,
and norepinephrine infusing at 0.5 mcg/kg/minute. With these interventions, his blood pressure is 87/56 mm
Hg and heart rate is 148 beats/minute. Pertinent laboratory values include WBC 20 × 103
cells/mm3
, lactic acid
1.5 mmol/L, aspartate aminotransferase 78 units/L, SCr 2.2 (baseline 1) mg/dL, platelet count 118,000 cells/
mm3
, international normalized ratio (INR) 1.4, and urine output about 45 mL/hour since arrival. Which is the
most appropriate intervention at this time?
A. Add hydrocortisone 50 mg intravenously every 6 hours.
B. Change norepinephrine infusion to phenylephrine infusion.
C. Change norepinephrine infusion to dopamine infusion.
D. Administer 1 L of lactated Ringer solution.
Critical Care
B
A 61-year-old woman collapses in front of her family members, who call 9-1-1 and begin CPR. The paramedics arrive and find the victim unresponsive, with an electrocardiogram revealing ventricular fibrillation,
and administer two additional rounds of CPR and two defibrillations, which are successful. In the emergency
department, the patient’s MAP is 68 mm Hg after fluids and norepinephrine, but the patient remains unresponsive. She is initiated on a TTM protocol. After 24 hours of TTM (body temperature 37°C), the patient is in the
ICU, and the rewarming process has recently begun. The pharmacist arrives in the ICU about 30 minutes into
the rewarming process. The patient has been receiving a continuous infusion of insulin throughout the period
of TTM at an average rate of 4 units/hour, with blood glucose testing every 3 hours. The patient has been
sedated with a continuous infusion of propofol and fentanyl and is receiving cisatracurium for neuromuscular
blockade. The patient’s vital signs are stable, and her laboratory values are normal. Which pharmacist recommendation is most appropriate at this time?
A. Increase blood glucose testing to now and every 1–2 hours during rewarming.
B. Adjust cisatracurium infusion to achieve a TOF of 0/4 impulses.
C. Discontinue propofol infusion to facilitate extubation.
D. Increase insulin infusion to prevent hyperkalemia
Critical Care
A
An older woman is admitted to the ICU for acute decompensated heart failure and acute kidney injury with
an ejection fraction of less than 30%. She is administered a continuous infusion of bumetanide; however, the
benefit is limited because of her acute-on-chronic kidney disease. She is intubated on ICU day 2 because of
worsening pulmonary edema and hypoxia. After intubation, her RASS score is 0, her CAM-ICU is negative,
and her CPOT score is 4. Her blood pressure is 120/70 mm Hg and heart rate is 88 beats/minute. Which is the
best recommendation for achieving her analgesia, sedation, and delirium goals?
A. Initiate morphine at 5 mg/hour and titrate as needed.
B. Administer haloperidol 5 mg intravenously as needed.
C. Administer fentanyl 25 mcg intravenously every hour as needed.
D. Initiate lorazepam 2 mg/hour and titrate as needed.
Critical Care
C
A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever,
chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg),
tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2
56 mm Hg, Pao2 49 mm Hg, HCO3
− 16 mEq/L, and Sao2
76% on 100% FiO2
. The only other significant laboratory
results are SCr 2.1 mg/dL and WBC 16 × 103
cells/mm3
. She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour.
After several nonpharmacologic attempts to improve her oxygenation fail, she is paralyzed, and her ventilator settings are adjusted accordingly. Which statement about neuromuscular blockade in this patient is most
appropriate?
A. Opioids should be discontinued to avoid prolonged neuromuscular weakness.
B. Vecuronium is the agent of choice.
C. Sedatives should be titrated to maintain a RASS goal of 0 to –2 during neuromuscular blockade.
D. Neuromuscular blockers should be titrated to the minimal dose necessary to achieve ventilator synchrony.
Critical Care
D
A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever,
chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg),
tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2
56 mm Hg, Pao2 49 mm Hg, HCO3
− 16 mEq/L, and Sao2
76% on 100% FiO2
. The only other significant laboratory
results are SCr 2.1 mg/dL and WBC 16 × 103
cells/mm3
. She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour.
The patient was initiated on neuromuscular blockade as instructed and synchronous with the ventilator, but
about 8 hours later, she began to move around violently in her bed. At this time, she was tachycardic (heart
rate 120 beats/minute) and appeared agitated; her Sao2 dropped to 80%. Which action is best?
A. Double the rate of the neuromuscular blocker every 5 minutes as needed until the patient stops moving.
B. Increase the propofol infusion rate as needed to achieve sedation goals.
C. Initiate a dexmedetomidine infusion.
D. Check the TOF.
Critical Care
B
A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever,
chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg),
tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2
56 mm Hg, Pao2 49 mm Hg, HCO3
− 16 mEq/L, and Sao2
76% on 100% FiO2
. The only other significant laboratory
results are SCr 2.1 mg/dL and WBC 16 × 103
cells/mm3
. She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour.
After that event, the patient did poorly the rest of the night. The patient was initiated on a norepinephrine infusion at 0.02 mcg/kg/minute to maintain an adequate blood pressure. Other medications initiated overnight included piperacillin/tazobactam, vancomycin, and gentamicin. By morning, her SCr has increased to 2.8 mg/dL, and the night shift nurse reports that the patient has had 0/4 twitches on TOF for the past 8 hours. Pertinent electrolyte values include K+ 4.9 mEq/L, calcium 9 mg/dL, and magnesium 2 mg/dL. What is most likely to potentiate the effects of the neuromuscular blocker? A. Piperacillin/tazobactam. B. Gentamicin. C. Norepinephrine. D. Potassium concentration.
Critical Care
B
A 73-year-old woman (weight 84 kg) is admitted to the ICU after a pneumonectomy and has been intubated for
4 days. Her blood pressure is 104/65 mm Hg, heart rate is 88 beats/minute, and Sao2 values are 98% on 40% FiO2
and positive end-expiratory pressure 5 cm H2
O; her Glasgow Coma Scale score is 11. Her other laboratory values
are normal. Her medications include simvastatin 20 mg every night, aspirin 81 mg/ day, metoprolol 25 mg twice
daily, heparin 5000 units subcutaneously every 8 hours, and 0.9% sodium chloride intravenously at 75 mL/hour
The surgeon would like to initiate SUP. Which is the best recommendation for this patient?
A. Administer famotidine 20 mg per tube every 12 hours.
B. Administer magnesium hydroxide 30 mL per tube four times daily.
C. Administer sucralfate 1 g per tube four times daily.
D. SUP is not indicated.
Critical Care
A
A 73-year-old woman (weight 84 kg) is admitted to the ICU after a pneumonectomy and has been intubated for
4 days. Her blood pressure is 104/65 mm Hg, heart rate is 88 beats/minute, and Sao2 values are 98% on 40% FiO2
and positive end-expiratory pressure 5 cm H2
O; her Glasgow Coma Scale score is 11. Her other laboratory values
are normal. Her medications include simvastatin 20 mg every night, aspirin 81 mg/ day, metoprolol 25 mg twice
daily, heparin 5000 units subcutaneously every 8 hours, and 0.9% sodium chloride intravenously at 75 mL/hour
One week later, the patient is extubated but still in the ICU. Her Glasgow Coma Scale score is 15, blood pressure is 112/70 mm Hg, and heart rate is 75 beats/minute, but her appetite is poor. Which statement is most
appropriate regarding SUP for this patient?
A. SUP should continue until the patient is discharged from the ICU.
B. SUP should be discontinued now.
C. Continue SUP until patient is eating.
D. SUP should be discontinued at hospital discharge.
Critical Care
B
A 75-year-old woman (height 65 inches [165 cm], weight 68 kg) who is intubated needs mechanical ventilation for
an acute exacerbation of chronic obstructive pulmonary disease. She has a medical history of heart failure and
hypertension. Her laboratory values are normal except for a creatinine level of 1.9 mg/dL
Which is the most appropriate recommendation to prevent VTE in this patient?
A. Initiate intermittent pneumatic compression.
B. Administer fondaparinux 2.5 mg subcutaneously once daily.
C. Administer enoxaparin 30 mg subcutaneously twice daily.
D. Administer heparin 5000 units subcutaneously three times daily
Critical Care
D
A 75-year-old woman (height 65 inches [165 cm], weight 68 kg) who is intubated needs mechanical ventilation for
an acute exacerbation of chronic obstructive pulmonary disease. She has a medical history of heart failure and
hypertension. Her laboratory values are normal except for a creatinine level of 1.9 mg/dL
Three days later, the patient continues to need mechanical ventilation. Enteral nutrition has been initiated through her nasogastric feeding tube and has gradually been increased to her goal of 45 mL/hour. Over the past day, her gastric residuals are consistently 300–350 mL. Which statement is most appropriate to optimize this patient’s nutrition support? A. Change to PN. B. Add metoclopramide 5 mg intravenously every 6 hours. C. Change feeds to a more concentrated formula. D. Decrease tube feeds to 10 mL/hour.
Critical Care
B
A 74-year-old woman (weight 72 kg) arrives in
the emergency department with a 3-day history
of cough, body temperature of 102°F (38.9°C),
and lethargy. She has the following vital signs and
laboratory values: blood pressure 72/40 mm Hg,
heart rate 115 beats/minute, urine output 10 mL/
hour, white blood cell count (WBC) 18 × 103
cells/
mm3
, hemoglobin 12.5 g/dL, and blood urea nitrogen (BUN)/serum creatinine (SCr) ratio of 28:1.7
mg/dL (baseline SCr 1.2 mg/dL), and blood glucose 82 mg/dL. After a 500-mL fluid bolus of 0.9%
sodium chloride, her blood pressure is 80/46 mm
Hg and her heart rate is 113 beats/minute. Her chest
radiograph is consistent with pneumonia. Her medical history includes coronary artery disease and
arthritis. Which is the most appropriate treatment
at this time?
A. Furosemide 40 mg intravenously.
B. 5% albumin 500 mL infused over 4 hours plus
norepinephrine titrated to maintain a systolic
blood pressure of 90 mm Hg or higher.
C. 1000-mL fluid bolus with 5% dextrose (D5
W)
and 0.9% sodium chloride.
D. 1000-mL fluid bolus with 0.9% sodium chloride.
Fluids, Electrolytes, Nutrition
D
An order has been received for 2% sodium chloride. Assume no commercially available product is
available. Using 0.9% sodium chloride and 23.4%
sodium chloride, first determine how much of each
is necessary to prepare 1 L of 2% sodium chloride.
Second, calculate the osmolarity of 2% sodium
chloride. Finally, determine whether the resultant
solution should be administered through a central or peripheral intravenous infusion (molecular
weight [MW] of sodium chloride is 58.5, osmotic
coefficient is 0.93).
A. Mix 951 mL of 0.9% sodium chloride plus
49 mL of 23.4% sodium chloride; osmolarity =
635 mOsm/L; peripheral intravenous infusion.
B. Mix 951 mL of 0.9% sodium chloride plus
49 mL of 23.4% sodium chloride; osmolarity
= 954 mOsm/L; central intravenous infusion.
C. Mix 850 mL of 0.9% sodium chloride plus
150 mL of 23.4% sodium chloride; osmolarity
= 954 mOsm/L; central intravenous infusion.
D. Mix 850 mL of 0.9% sodium chloride plus
150 mL of 23.4% sodium chloride; osmolarity
=513mOsm/L; peripheralintravenousinfusion.
Fluids, Electrolytes, Nutrition
A
A 68-year-old man is admitted to the hospital for
worsening shortness of breath during the past 2
weeks caused by heart failure. His serum sodium
concentration on admission was 123 mEq/L. Other
abnormal laboratory values include brain natriuretic peptide of 850 pg/mL and SCr of 1.7 mg/
dL. Chest radiography is consistent with pulmonary edema. The patient weighs 85 kg on admission, which is up 3 kg from his baseline weight.
The patient is not experiencing nausea, headache,
or mental status changes. The physician orders 3%
sodium chloride to treat the hyponatremia. Which
recommendation is best?
A. 3% sodium chloride is an appropriate choice
because the hyponatremia is probably acute.
B. A 250-mL bolus of 3% sodium chloride is
appropriate if used in combination with furosemide to prevent volume overload.
C. 3% sodium chloride is appropriate if the serum
sodium does not increase more than 10 mEq/L
in 24 hours.
D. The risks of 3% sodium chloride outweigh the
potential benefit for this patient
Fluids, Electrolytes, Nutrition
D
A 55-year-old man with diabetes and kidney disease has hyperkalemia. His laboratory values
include potassium (K+
) 7.2 mEq/L, calcium (Ca2+)
9 mg/dL, albumin 3.5 g/dL, and blood glucose 302
mg/dL. His electrocardiogram (ECG) is abnormal,
with peaked T waves. What is the best recommendation for initial treatment?
A. Regular insulin 10 units intravenously plus
50 g of dextrose intravenously.
B. 10% calcium gluconate 10 mL intravenously.
C. Sodium polystyrene sulfonate (Kayexalate)
15 g orally.
D. Sodium bicarbonate 50 mEq intravenously
over 5 minutes.
Fluids, Electrolytes, Nutrition
B
A 68-year-old woman (weight 60 kg) is admitted
to the hospital after a cardioembolic stroke. Her
medical history is significant for atrial fibrillation,
acute myocardial infarction, and diabetes. She has
been unconscious for 48 hours. The medical team
decides to start providing nutrition. All of her laboratory values, including glucose concentrations,
are normal. Although she currently has no enteral
access, she does have a peripheral intravenous
catheter. Which nutritional regimen is best for this
patient?
A. Insert a central intravenous catheter and initiate parenteral nutrition (PN) containing 60 g
of amino acids (AAs), 250 mL of 20% lipid
emulsion, 300 g of dextrose, standard electrolytes, multivitamins, and trace elements
in a volume of 2000 mL administered over
24 hours.
B. Insert a central intravenous catheter and initiate PN containing 40 g of AAs, 250 mL of
20% lipid emulsion, 200 g of dextrose, standard electrolytes, multivitamins, and trace
elements in a total volume of 2000 mL administered over 24 hours.
C. Insert a nasogastric (NG) or nasoduodenal
feeding tube and infuse an isotonic formula
(1 kcal/mL) starting at 25 mL/hour and
advance to a goal rate of 65 mL/hour.
D. Insert a percutaneous endoscopic gastrostomy
feeding tube and infuse an isotonic formula
(1 kcal/mL) starting at 25 mL/hour and
advance to a goal rate of 100 mL/hour.
Fluids, Electrolytes, Nutrition
C
A 70-year-old man is admitted to the hospital with
peritonitis caused by severe inflammatory bowel
disease. The patient has received adequate fluid
resuscitation, and he is prescribed appropriate
antibiotics. After several days of the patient being
unable to tolerate oral or enteral nutrition, the physician consults the pharmacist to recommend a PN
formula to be administered through a central line.
The patient is hemodynamically stable, with normal electrolyte concentrations. Weight is 55 kg,
BUN/SCr is 20/1.1 mg/dL, and WBC is 17 × 103
cells/mm3
. Assuming that appropriate electrolytes,
multivitamins, and trace elements are included,
which PN formula, when administered over 24
hours, will best provide this patient adequate calories, AAs, and lipids?
A. AAs 10% 700 mL, dextrose 30% 325 mL,
lipid 20% 500 mL.
B. AAs 10% 450 mL, dextrose 70% 400 mL,
lipid 20% 250 mL.
C. AAs 10% 800 mL, dextrose 70% 350 mL,
lipid 20% 250 mL
D. AAs 15% 900 mL, dextrose 50% 500 mL,
lipid 20% 250 mL.
Fluids, Electrolytes, Nutrition
C
A 59-year-old man has been admitted to the hospital after several days of vomiting and diarrhea.
In the emergency department, he had several
runs of nonsustained ventricular tachycardia. His
plasma potassium on admission is 2.8 mEq/L.
After 100 mEq of potassium chloride is infused
over 24 hours, his repeated K+
is 3.2 mEq/L, and he
continues to have runs of ventricular tachycardia.
Other laboratory values include Na+
143 mEq/L,
magnesium 1.4 mg/dL, phosphorus 3 mg/dL, Ca2+
9 mg/dL, and ionized Ca2+ 1.1 mmol/L. Which
treatment would be best to give next?
A. Administer potassium chloride 20 mEq intravenously over 1 hour each for 4 doses and
recheck K+
.
B. Administer magnesium sulfate as a 2 g slow
intravenous infusion over 2 hours.
C. Administer potassium phosphate 15 mmol
intravenously over 4 hours.
D. Administer calcium gluconate 2 g intravenously over 5 minutes.
Fluids, Electrolytes, Nutrition
B
Which nutritional strategy can best prevent
gut mucosal atrophy and subsequent bacterial
translocation?
A. PN enriched with glutamine.
B. PN enriched with branched-chain AAs.
C. Enteral nutrition (EN).
D. Zinc supplementation.
Fluids, Electrolytes, Nutrition
C
A female patient (weight 80 kg) in the intensive care
unit has developed acute kidney injury caused by
sepsis, and she requires intermittent hemodialysis
daily to maintain her BUN/SCr ratio at 49:2.5 mg/
dL. Currently, she is receiving appropriate antibiotics and is hemodynamically stable. She has also
been receiving PN providing 72 g of AAs per day.
What is the best recommendation for this patient’s
protein intake?
A. Reduce AAs to 40 g/day.
B. Reduce AAs to 64 g/day.
C. Increase AAs to 96 g/day.
D. Increase AAs to 160 g/day
Fluids, Electrolytes, Nutrition
C
A 65-year-old man (weight 80 kg) with a 3-day history of a body temperature of 102°F (38.9°C), lethargy, and
productive cough is hospitalized for community-acquired pneumonia. His medical history includes uncontrolled
hypertension and coronary artery disease. His vital signs include heart rate 104 beats/minute, blood pressure
112/68 mm Hg, and body temperature 101.4°F (38.6°C). His urine output is 10 mL/hour, K+ is 4 mEq/L, BUN is 46
mg/dL, SCr is 1.7 mg/dL, and WBC is 10.4 × 103
cells/mm3
. Other laboratory values are normal.
Which is most appropriate at this time?
A. Furosemide 40 mg intravenously.
B. Albumin 25% 100 mL intravenously over 60 minutes.
C. Lactated Ringer solution 1000 mL intravenously over 60 minutes.
D. D5
W/0.45% sodium chloride plus potassium chloride 20 mEq/L to infuse at 110 mL/hour
Fluids, Electrolytes, Nutrition
C
