3P APEA EXAM
Cardiovascular System
1. Differentiating Varicose Veins and Arteriosclerosis
Affected Vessel:
o Arteriosclerosis primarily affects arteries.
o Varicose veins primarily affect veins.
2. Point of Maximal Impulse (PMI) in Hypertension
A patient with poorly controlled hypertension for over 10 years is likely to
develop left ventricular hypertrophy.
Left ventricular hypertrophy causes the heart to enlarge, displacing the
PMI.
Most Likely PMI Position: The PMI would most likely be palpated
inferiorly and laterally to the typical location (5th intercostal space, left of
the midclavicular line). Therefore, it would be more than the 5th ICS, left
of MCL.
3. Diastolic Mitral Stenosis Murmur
A 43-year-old Hispanic male with an audible diastolic mitral stenosis
murmur, best heard at the mitral listening point, and no audible click, likely
has a murmur that is chronic and stable, given it has been monitored for the
past two years without significant change.
The absence of a click suggests no significant calcification or immobility
of the mitral valve leaflets.
4. Peripheral Arterial Disease (PAD) Symptoms
A patient with diabetes experiencing calf muscle pain during walking that
resolves with rest is exhibiting classic symptoms of intermittent
claudication, a hallmark of PAD.
Likely Patient Report: When specifically asked about the pain, the patient
will likely report pain that occurs with exertion and is relieved by rest.
,5. Contraindicated Medication with Sulfa Allergy
The patient has a history of a severe allergic reaction ("sloughing of skin"
requiring hospitalization) to a sulfa antibiotic.
Contraindicated Medication: Hydrochlorothiazide (HCTZ) is a
sulfonamide derivative and is contraindicated in patients with a documented
severe sulfa allergy due to the risk of cross-reactivity.
6. Worsening Symptoms of Aortic Stenosis
Aortic stenosis can remain asymptomatic for a long period.
Symptoms Indicating Worsening Aortic Stenosis: The NP should inform
the patient that worsening stenosis can manifest as:
o Shortness of breath (dyspnea)
o Syncope (fainting)
o Chest pain (angina)
These symptoms indicate a significant reduction in cardiac output.
7. Nonmodifiable Risk Factor for Peripheral Arterial
Disease (PAD)
Risk Factors for PAD: Both modifiable (e.g., smoking, diabetes) and
nonmodifiable (e.g., age, genetics) factors contribute to PAD.
Important Nonmodifiable Risk Factor: Among the options provided
(diabetes is listed but it is modifiable), age is a significant nonmodifiable
risk factor for PAD. The 74-year-old patient's age increases his risk.
8. Benazepril and Pregnancy
Benazepril is an ACE inhibitor.
Contraindication in Pregnancy: ACE inhibitors are known teratogens and
can cause serious harm to the developing fetus.
Action Upon Pregnancy: Benazepril should be discontinued immediately
if pregnancy occurs.
9. Aortic Regurgitation Characteristics
Aortic regurgitation often has a long asymptomatic period.
, Progression of Symptoms: Symptoms typically progress as the condition
worsens:
o Initially, exercise intolerance may develop.
o Later, dyspnea at rest can occur, indicating significant left
ventricular dysfunction.
10. Deep Vein Thrombosis (DVT) Classic Symptoms
Classic Symptoms of DVT: The classic triad of DVT symptoms includes:
o Swelling (edema) of the lower extremity.
o Pain or tenderness in the affected leg.
o Discoloration (redness or cyanosis) of the lower extremity.
11. Characteristic of ACE Inhibitor-Induced Cough
ACE Inhibitor-Induced Cough: A common side effect of ACE inhibitors
is a dry, persistent cough.
Typical Onset: This cough usually begins within two weeks of starting
therapy.
16. Medications Used to Treat Heart Failure (HF)
A common combination of medications used to manage heart failure may
include:
o Fosinopril: An ACE inhibitor.
o Hydrochlorothiazide (HCTZ): A thiazide diuretic.
o Verapamil: A calcium channel blocker (less commonly used as a
primary HF medication and requires careful consideration due to
potential negative inotropic effects).
17. Warfarin Management for Chronic Atrial
Fibrillation (A-fib)
The patient has chronic A-fib and an elevated INR of 4.0 while taking
warfarin.
Management of Elevated INR: The NP should advise the patient to stop
the warfarin today and repeat the INR tomorrow to assess the rate of
decline. Further management will depend on the subsequent INR value.
Cardiovascular System
1. Differentiating Varicose Veins and Arteriosclerosis
Affected Vessel:
o Arteriosclerosis primarily affects arteries.
o Varicose veins primarily affect veins.
2. Point of Maximal Impulse (PMI) in Hypertension
A patient with poorly controlled hypertension for over 10 years is likely to
develop left ventricular hypertrophy.
Left ventricular hypertrophy causes the heart to enlarge, displacing the
PMI.
Most Likely PMI Position: The PMI would most likely be palpated
inferiorly and laterally to the typical location (5th intercostal space, left of
the midclavicular line). Therefore, it would be more than the 5th ICS, left
of MCL.
3. Diastolic Mitral Stenosis Murmur
A 43-year-old Hispanic male with an audible diastolic mitral stenosis
murmur, best heard at the mitral listening point, and no audible click, likely
has a murmur that is chronic and stable, given it has been monitored for the
past two years without significant change.
The absence of a click suggests no significant calcification or immobility
of the mitral valve leaflets.
4. Peripheral Arterial Disease (PAD) Symptoms
A patient with diabetes experiencing calf muscle pain during walking that
resolves with rest is exhibiting classic symptoms of intermittent
claudication, a hallmark of PAD.
Likely Patient Report: When specifically asked about the pain, the patient
will likely report pain that occurs with exertion and is relieved by rest.
,5. Contraindicated Medication with Sulfa Allergy
The patient has a history of a severe allergic reaction ("sloughing of skin"
requiring hospitalization) to a sulfa antibiotic.
Contraindicated Medication: Hydrochlorothiazide (HCTZ) is a
sulfonamide derivative and is contraindicated in patients with a documented
severe sulfa allergy due to the risk of cross-reactivity.
6. Worsening Symptoms of Aortic Stenosis
Aortic stenosis can remain asymptomatic for a long period.
Symptoms Indicating Worsening Aortic Stenosis: The NP should inform
the patient that worsening stenosis can manifest as:
o Shortness of breath (dyspnea)
o Syncope (fainting)
o Chest pain (angina)
These symptoms indicate a significant reduction in cardiac output.
7. Nonmodifiable Risk Factor for Peripheral Arterial
Disease (PAD)
Risk Factors for PAD: Both modifiable (e.g., smoking, diabetes) and
nonmodifiable (e.g., age, genetics) factors contribute to PAD.
Important Nonmodifiable Risk Factor: Among the options provided
(diabetes is listed but it is modifiable), age is a significant nonmodifiable
risk factor for PAD. The 74-year-old patient's age increases his risk.
8. Benazepril and Pregnancy
Benazepril is an ACE inhibitor.
Contraindication in Pregnancy: ACE inhibitors are known teratogens and
can cause serious harm to the developing fetus.
Action Upon Pregnancy: Benazepril should be discontinued immediately
if pregnancy occurs.
9. Aortic Regurgitation Characteristics
Aortic regurgitation often has a long asymptomatic period.
, Progression of Symptoms: Symptoms typically progress as the condition
worsens:
o Initially, exercise intolerance may develop.
o Later, dyspnea at rest can occur, indicating significant left
ventricular dysfunction.
10. Deep Vein Thrombosis (DVT) Classic Symptoms
Classic Symptoms of DVT: The classic triad of DVT symptoms includes:
o Swelling (edema) of the lower extremity.
o Pain or tenderness in the affected leg.
o Discoloration (redness or cyanosis) of the lower extremity.
11. Characteristic of ACE Inhibitor-Induced Cough
ACE Inhibitor-Induced Cough: A common side effect of ACE inhibitors
is a dry, persistent cough.
Typical Onset: This cough usually begins within two weeks of starting
therapy.
16. Medications Used to Treat Heart Failure (HF)
A common combination of medications used to manage heart failure may
include:
o Fosinopril: An ACE inhibitor.
o Hydrochlorothiazide (HCTZ): A thiazide diuretic.
o Verapamil: A calcium channel blocker (less commonly used as a
primary HF medication and requires careful consideration due to
potential negative inotropic effects).
17. Warfarin Management for Chronic Atrial
Fibrillation (A-fib)
The patient has chronic A-fib and an elevated INR of 4.0 while taking
warfarin.
Management of Elevated INR: The NP should advise the patient to stop
the warfarin today and repeat the INR tomorrow to assess the rate of
decline. Further management will depend on the subsequent INR value.
