,Course Code: NR 601
Course Name: Primary Care of the Maturing and Aged Family Practicum
QUESTIONS AND ANSWERS WITH RATIONALE REVIEW
1. A 72-year-old male with a 45-pack-year smoking history and a diagnosis of moderate COPD
(GOLD Stage 2) presents to your clinic with a 3-week history of progressive dyspnea on
exertion, a new productive cough with purulent sputum, and subjective fevers. He has had
three similar exacerbations in the past year requiring oral corticosteroids and antibiotics. He
reports that his baseline oxygen saturation is 94% on room air, but today it is 88%. On lung
auscultation, you note distant breath sounds with diffuse expiratory wheezing and coarse
crackles at the bases. He is using accessory muscles to breathe. His chest X-ray reveals
hyperinflation but no new infiltrate. What is the most appropriate next step in the
management of this acute exacerbation?
A. Prescribe a 7-day course of oral doxycycline and continue his home maintenance inhalers.
B. Initiate a 5-day course of systemic corticosteroids and prescribe azithromycin, while arranging
for a same-day pulmonary function test.
C. Admit the patient to the hospital for IV antibiotics, IV corticosteroids, and BiPAP therapy given
his hypoxia and severity of symptoms.
D. Increase his home supplemental oxygen to 4 L/min via nasal cannula and schedule a follow-
up visit in 48 hours.
Correct Answer: C. Admit the patient to the hospital for IV antibiotics, IV corticosteroids, and
BiPAP therapy given his hypoxia and severity of symptoms.
Rationale: This patient is experiencing a severe acute exacerbation of COPD, as evidenced by his
hypoxia (SpO2 88%), use of accessory muscles, and history of frequent exacerbations. According
to the GOLD guidelines, patients who present with severe dyspnea, respiratory failure, or new-
onset hypoxia require inpatient management. IV corticosteroids reduce airway inflammation
more rapidly than oral routes in severe cases, and IV antibiotics are indicated given the purulent
sputum and systemic symptoms. BiPAP is the standard of care for acute hypercapnic or hypoxic
respiratory failure in COPD to prevent intubation and reduce work of breathing. Sending him
home with antibiotics and steroids is unsafe given his clinical instability, and a PFT is
contraindicated during an active exacerbation.
,2. A 78-year-old female with a history of stage 3 chronic kidney disease (eGFR 45 mL/min) and
hypertension presents with progressive fatigue, anorexia, and generalized pruritus that is
worse at night. Her labs reveal a hemoglobin of 9.2 g/dL, serum creatinine of 2.4 mg/dL, BUN
of 42 mg/dL, calcium of 8.0 mg/dL, and phosphorus of 5.8 mg/dL. Her intact PTH is 220
pg/mL. She is not on any phosphate binders or vitamin D supplements. What is the most
appropriate initial pharmacological intervention to address her metabolic bone disease and
pruritus?
A. Initiate oral calcium carbonate as a phosphate binder and prescribe calcitriol to suppress
PTH.
B. Start ferrous sulfate 325 mg TID to treat her anemia and improve her energy levels.
C. Begin sevelamer carbonate to control hyperphosphatemia and add an oral antihistamine for
pruritus.
D. Prescribe a low-protein diet and initiate erythropoietin-stimulating agents for her anemia.
Correct Answer: A. Initiate oral calcium carbonate as a phosphate binder and prescribe
calcitriol to suppress PTH.
Rationale: This patient has secondary hyperparathyroidism (SHPT) due to CKD-Mineral and
Bone Disorder (CKD-MBD), as evidenced by her hyperphosphatemia, hypocalcemia, and
elevated PTH. The standard initial therapy is to control hyperphosphatemia with a phosphate
binder and provide active vitamin D (calcitriol) to suppress PTH secretion, which will also help
alleviate uremic pruritus. Calcium carbonate is a cost-effective phosphate binder that also
provides elemental calcium to correct hypocalcemia. Sevelamer is another option but is
typically used if calcium levels are already high or if the patient has vascular calcification.
Treating her anemia with iron or ESA is important but secondary to the immediate electrolyte
and bone mineral imbalances that are causing her symptoms.
3. A 65-year-old male with a 10-year history of type 2 diabetes (HbA1c 8.9%) and
hypertension presents with a 6-month history of bilateral burning pain, tingling, and
numbness in his feet that is worse at night. He reports that the pain is severe enough to
interfere with his sleep and his ability to walk. He is currently on metformin 1000 mg BID and
glipizide 10 mg BID. His monofilament test is abnormal in both feet, and his ankle reflexes are
absent. What is the most comprehensive initial management strategy for this patient's painful
diabetic neuropathy?
A. Start gabapentin 100 mg at bedtime and titrate slowly, while optimizing glycemic control and
initiating a daily walking program.
B. Prescribe duloxetine 60 mg daily and add an over-the-counter NSAID for breakthrough pain.
C. Increase the glipizide dose to achieve tighter glycemic control and start physical therapy for
, gait training.
D. Start amitriptyline 25 mg at bedtime and refer the patient to a podiatrist for custom
orthotics.
Correct Answer: A. Start gabapentin 100 mg at bedtime and titrate slowly, while optimizing
glycemic control and initiating a daily walking program.
Rationale: Painful diabetic neuropathy requires a multimodal approach. First-line pharmacologic
therapy includes gabapentinoids (gabapentin or pregabalin) or SNRIs (duloxetine). Gabapentin is
highly effective for neuropathic pain and is started at a low dose (100-300 mg at bedtime) and
titrated slowly to minimize sedation. Optimizing glycemic control is the cornerstone of
preventing further nerve damage, as hyperglycemia directly contributes to neuronal injury. A
daily walking program improves circulation and can reduce neuropathic symptoms.
Amitriptyline is effective but carries significant anticholinergic risks in older adults. NSAIDs are
generally ineffective for neuropathic pain and carry renal and GI risks.
4. A 71-year-old female with a history of coronary artery disease, atrial fibrillation (on
warfarin with a therapeutic INR of 2.8), and well-controlled hypertension presents to the
emergency department with a sudden onset of severe, tearing chest pain that radiates to her
back and into her left shoulder. Her blood pressure is 165/95 mmHg in her right arm and
130/80 mmHg in her left arm. Her heart rate is 110 bpm. An ECG shows sinus tachycardia
without ischemic changes. What is the most appropriate initial diagnostic study to confirm
the suspected diagnosis and what is the immediate medical therapy?
A. Obtain a CT angiography of the chest and abdomen; initiate IV esmolol to reduce heart rate
and blood pressure.
B. Order a transesophageal echocardiogram; start IV nitroprusside to rapidly lower blood
pressure.
C. Perform a high-sensitivity troponin I and a standard chest X-ray; begin IV heparin for possible
pulmonary embolism.
D. Order a bedside echocardiogram to assess for pericardial effusion; start IV morphine for pain
control and await cardiology consult.
Correct Answer: A. Obtain a CT angiography of the chest and abdomen; initiate IV esmolol to
reduce heart rate and blood pressure.
Rationale: The patient's presentation of acute, severe, tearing chest pain radiating to the back
with a significant blood pressure differential between arms is classic for an acute aortic
dissection. CT angiography is the gold standard for confirming the diagnosis with high sensitivity
and specificity. Immediate medical management focuses on reducing the force of left
ventricular ejection (dP/dt) to prevent propagation of the dissection, which is achieved with IV
Course Name: Primary Care of the Maturing and Aged Family Practicum
QUESTIONS AND ANSWERS WITH RATIONALE REVIEW
1. A 72-year-old male with a 45-pack-year smoking history and a diagnosis of moderate COPD
(GOLD Stage 2) presents to your clinic with a 3-week history of progressive dyspnea on
exertion, a new productive cough with purulent sputum, and subjective fevers. He has had
three similar exacerbations in the past year requiring oral corticosteroids and antibiotics. He
reports that his baseline oxygen saturation is 94% on room air, but today it is 88%. On lung
auscultation, you note distant breath sounds with diffuse expiratory wheezing and coarse
crackles at the bases. He is using accessory muscles to breathe. His chest X-ray reveals
hyperinflation but no new infiltrate. What is the most appropriate next step in the
management of this acute exacerbation?
A. Prescribe a 7-day course of oral doxycycline and continue his home maintenance inhalers.
B. Initiate a 5-day course of systemic corticosteroids and prescribe azithromycin, while arranging
for a same-day pulmonary function test.
C. Admit the patient to the hospital for IV antibiotics, IV corticosteroids, and BiPAP therapy given
his hypoxia and severity of symptoms.
D. Increase his home supplemental oxygen to 4 L/min via nasal cannula and schedule a follow-
up visit in 48 hours.
Correct Answer: C. Admit the patient to the hospital for IV antibiotics, IV corticosteroids, and
BiPAP therapy given his hypoxia and severity of symptoms.
Rationale: This patient is experiencing a severe acute exacerbation of COPD, as evidenced by his
hypoxia (SpO2 88%), use of accessory muscles, and history of frequent exacerbations. According
to the GOLD guidelines, patients who present with severe dyspnea, respiratory failure, or new-
onset hypoxia require inpatient management. IV corticosteroids reduce airway inflammation
more rapidly than oral routes in severe cases, and IV antibiotics are indicated given the purulent
sputum and systemic symptoms. BiPAP is the standard of care for acute hypercapnic or hypoxic
respiratory failure in COPD to prevent intubation and reduce work of breathing. Sending him
home with antibiotics and steroids is unsafe given his clinical instability, and a PFT is
contraindicated during an active exacerbation.
,2. A 78-year-old female with a history of stage 3 chronic kidney disease (eGFR 45 mL/min) and
hypertension presents with progressive fatigue, anorexia, and generalized pruritus that is
worse at night. Her labs reveal a hemoglobin of 9.2 g/dL, serum creatinine of 2.4 mg/dL, BUN
of 42 mg/dL, calcium of 8.0 mg/dL, and phosphorus of 5.8 mg/dL. Her intact PTH is 220
pg/mL. She is not on any phosphate binders or vitamin D supplements. What is the most
appropriate initial pharmacological intervention to address her metabolic bone disease and
pruritus?
A. Initiate oral calcium carbonate as a phosphate binder and prescribe calcitriol to suppress
PTH.
B. Start ferrous sulfate 325 mg TID to treat her anemia and improve her energy levels.
C. Begin sevelamer carbonate to control hyperphosphatemia and add an oral antihistamine for
pruritus.
D. Prescribe a low-protein diet and initiate erythropoietin-stimulating agents for her anemia.
Correct Answer: A. Initiate oral calcium carbonate as a phosphate binder and prescribe
calcitriol to suppress PTH.
Rationale: This patient has secondary hyperparathyroidism (SHPT) due to CKD-Mineral and
Bone Disorder (CKD-MBD), as evidenced by her hyperphosphatemia, hypocalcemia, and
elevated PTH. The standard initial therapy is to control hyperphosphatemia with a phosphate
binder and provide active vitamin D (calcitriol) to suppress PTH secretion, which will also help
alleviate uremic pruritus. Calcium carbonate is a cost-effective phosphate binder that also
provides elemental calcium to correct hypocalcemia. Sevelamer is another option but is
typically used if calcium levels are already high or if the patient has vascular calcification.
Treating her anemia with iron or ESA is important but secondary to the immediate electrolyte
and bone mineral imbalances that are causing her symptoms.
3. A 65-year-old male with a 10-year history of type 2 diabetes (HbA1c 8.9%) and
hypertension presents with a 6-month history of bilateral burning pain, tingling, and
numbness in his feet that is worse at night. He reports that the pain is severe enough to
interfere with his sleep and his ability to walk. He is currently on metformin 1000 mg BID and
glipizide 10 mg BID. His monofilament test is abnormal in both feet, and his ankle reflexes are
absent. What is the most comprehensive initial management strategy for this patient's painful
diabetic neuropathy?
A. Start gabapentin 100 mg at bedtime and titrate slowly, while optimizing glycemic control and
initiating a daily walking program.
B. Prescribe duloxetine 60 mg daily and add an over-the-counter NSAID for breakthrough pain.
C. Increase the glipizide dose to achieve tighter glycemic control and start physical therapy for
, gait training.
D. Start amitriptyline 25 mg at bedtime and refer the patient to a podiatrist for custom
orthotics.
Correct Answer: A. Start gabapentin 100 mg at bedtime and titrate slowly, while optimizing
glycemic control and initiating a daily walking program.
Rationale: Painful diabetic neuropathy requires a multimodal approach. First-line pharmacologic
therapy includes gabapentinoids (gabapentin or pregabalin) or SNRIs (duloxetine). Gabapentin is
highly effective for neuropathic pain and is started at a low dose (100-300 mg at bedtime) and
titrated slowly to minimize sedation. Optimizing glycemic control is the cornerstone of
preventing further nerve damage, as hyperglycemia directly contributes to neuronal injury. A
daily walking program improves circulation and can reduce neuropathic symptoms.
Amitriptyline is effective but carries significant anticholinergic risks in older adults. NSAIDs are
generally ineffective for neuropathic pain and carry renal and GI risks.
4. A 71-year-old female with a history of coronary artery disease, atrial fibrillation (on
warfarin with a therapeutic INR of 2.8), and well-controlled hypertension presents to the
emergency department with a sudden onset of severe, tearing chest pain that radiates to her
back and into her left shoulder. Her blood pressure is 165/95 mmHg in her right arm and
130/80 mmHg in her left arm. Her heart rate is 110 bpm. An ECG shows sinus tachycardia
without ischemic changes. What is the most appropriate initial diagnostic study to confirm
the suspected diagnosis and what is the immediate medical therapy?
A. Obtain a CT angiography of the chest and abdomen; initiate IV esmolol to reduce heart rate
and blood pressure.
B. Order a transesophageal echocardiogram; start IV nitroprusside to rapidly lower blood
pressure.
C. Perform a high-sensitivity troponin I and a standard chest X-ray; begin IV heparin for possible
pulmonary embolism.
D. Order a bedside echocardiogram to assess for pericardial effusion; start IV morphine for pain
control and await cardiology consult.
Correct Answer: A. Obtain a CT angiography of the chest and abdomen; initiate IV esmolol to
reduce heart rate and blood pressure.
Rationale: The patient's presentation of acute, severe, tearing chest pain radiating to the back
with a significant blood pressure differential between arms is classic for an acute aortic
dissection. CT angiography is the gold standard for confirming the diagnosis with high sensitivity
and specificity. Immediate medical management focuses on reducing the force of left
ventricular ejection (dP/dt) to prevent propagation of the dissection, which is achieved with IV
