AAFP Family Medicine Questions
with Correct Answers
A 70yo M with h/o HTN and DM presents with a 2-mo h/o increasing paroxysmal
nocturnal dyspnea and SOB with minimal exertion. An echocardiogram shows an
ejection fraction of 25%. Which one of the patients current medications should be
discontinued?
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL) - ✔✔- ANS: Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can
be complicated by the development of heart failure. Caution is necessary when
prescribing TZDs in patients with known heart failure or other heart diseases,
those with preexisting edema, and those on concurrent insulin therapy
What is the most common cause of hypertension in children under 6 years of
age? - ✔✔- ANS: Renal Parenchymal Disease
The most common cause of hypertension is renal parenchymal disease, and a
urinalysis, urine culture, and renal ultrasonography should be ordered for all
children presenting with hypertension.
A 72-year-old African-American male with New York Heart Association Class III
heart failure sees you for follow-up. He has shortness of breath with minimal
exertion. The patient is adherent to his medication regimen. His current
medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol
(Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood
pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular.
Findings include a few scattered bibasilar rales on examination of the lungs, an
S3 gallop on examination of the heart, and no edema on examination of the legs.
An EKG reveals a left bundle branch block, and echocardiography reveals an
ejection fraction of 25%, but no other abnormalities. What's the appropriate next
step? - ✔✔- ANS: Refer for cardiac resynchronization therapy (CRT)
,Note: he's already on maximum doses of ACEI, loop diuretic, beta-blocker
Using a pacemaker-like device, CRT aims to get both ventricles contracting
simultaneously, overcoming the delayed contraction of the left ventricle caused
by the left bundle-branch block. These guidelines were refined by an April 2005
AHA Science Advisory, which stated that optimal candidates for CRT have a
dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a
QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or
IV despite maximal medical therapy for heart failure.
What dietary change recommended for the prevention and treatment of
cardiovascular disease has been shown to decrease the rate of sudden death? -
✔✔- ANS: increase intake of omega 3 fatty acids
Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), which inhibit the inflammatory immune response
and platelet aggregation, are mild vasodilators, and may have antiarrhythmic
properties. The American Heart Association guidelines state that omega-3
supplements may be recommended to patients with preexisting disease, a high
risk of disease, or high triglyceride levels, as well as to patients who do not like or
are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA
and DHA daily resulted in decreased rates of mortality, nonfatal myocardial
infarction, and stroke, with particular decreases in the rate of sudden death.
A 75-year-old male presents to the emergency department with a several-hour
history of back pain in the interscapular region. His medical history includes a
previous myocardial infarction (MI) several years ago, a history of cigarette
smoking until the time of the MI, and hypertension that is well controlled with
hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious,
but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate
is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute
changes. A chest radiograph shows a widened mediastinum and a normal aortic
arch, and CT of the chest shows a dissecting aneurysm of the descending aorta
that is distal to the proximal abdominal aorta but does not involve the renal
arteries. Which one of the following would be the most appropriate next step in
the management of this patient? - ✔✔- ANS: Dx: aortic dissection
,next step: Intravenous labetalol (Normodyne, Trandate)
Initial management should reduce the systolic blood pressure to 100-120 mm Hg
or to the lowest level tolerated. The use of a β-blocker such as propranolol or
labetalol to get the heart rate below 60 beats/min should be first-line therapy. If
the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside
should be added. Without prior beta-blocade, vasodilation from the nitroprusside
will induce reflex activation of the sympathetic nervous system, causing
increased ventricular contraction and increased shear stress on the aorta.
According to the U.S. Preventive Services Task Force, what are the screening
recommendations for an abdominal aortic aneurysm? - ✔✔- ANS: The guideline
recommends one-time screening with ultrasonography for AAA in men 65-75
years of age who have ever smoked. No recommendation was made for or
against screening women. Men with a strong family history of AAA should be
counseled about the risks and benefits of screening as they approach 65 years of
age.
A 36-year-old white female presents to the emergency department with
palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular
tachycardia with a narrow complex QRS and no apparent P waves. The patient
fails to respond to carotid massage or to two doses of intravenous adenosine
(Adenocard), 6 mg and 12 mg. The most appropriate next step would be to
administer intravenous - ✔✔- ANS: verapamil (Calan)
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the
tachycardia can usually be terminated by the administration of intravenous
verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may
be necessary. It is also important to look for and treat possible contributing
causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical
cardioversion may be necessary if these measures fail to terminate the
tachyarrhythmia.
The blood pressure goal for a patient who has uncomplicated diabetes mellitus is
- ✔✔- ANS: BP goal: 130/80mmHg
, Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients
and to <130/80 mm Hg in diabetic patients is recommended. Lowering blood
pressure may reduce stroke rates by 40%-52% and cardiovascular morbidity by
18%-20%
A 60-year-old African-American female has a history of hypertension that has
been well controlled with hydrochlorothiazide. However, she has developed an
allergy to the medication. Successful monotherapy for her hypertension would be
most likely with which one of the following?
A. Lisinopril (Prinivil, Zestril)
B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem) - ✔✔- ANS: Diltiazem (Cardizem)
Monotherapy for hypertension in African-American patients is more likely to
consist of diuretics or calcium channel blockers than β-blockers or ACE
inhibitors. It has been suggested that hypertension in African-Americans is not as
angiotensin II-dependent as it appears to be in Caucasians.
An asymptomatic 3-year-old male presents for a routine check-up. On
examination you notice a systolic heart murmur. It is heard best in the lower
precordium and has a low, short tone similar to a plucked string or kazoo. It does
not radiate to the axillae or the back and seems to decrease with inspiration. The
remainder of the examination is normal. What is the most likely diagnosis? -
✔✔- ANS: Still's murmur
There are several benign murmurs of childhood that have no association with
physiologic or anatomic abnormalities. Of these, Still's murmur best fits the
murmur described. The cause of Still's murmur is unknown, but it may be due to
vibrations in the chordae tendinae, semilunar valves, or ventricular wall.
A 57-year-old male with severe renal disease presents with acute coronary
syndrome. Which one of the following would most likely require a significant
dosage adjustment from the standard protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
with Correct Answers
A 70yo M with h/o HTN and DM presents with a 2-mo h/o increasing paroxysmal
nocturnal dyspnea and SOB with minimal exertion. An echocardiogram shows an
ejection fraction of 25%. Which one of the patients current medications should be
discontinued?
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL) - ✔✔- ANS: Pioglitzaone
thiazolidinediones (TZDs) are associated with fluid retention, and their use can
be complicated by the development of heart failure. Caution is necessary when
prescribing TZDs in patients with known heart failure or other heart diseases,
those with preexisting edema, and those on concurrent insulin therapy
What is the most common cause of hypertension in children under 6 years of
age? - ✔✔- ANS: Renal Parenchymal Disease
The most common cause of hypertension is renal parenchymal disease, and a
urinalysis, urine culture, and renal ultrasonography should be ordered for all
children presenting with hypertension.
A 72-year-old African-American male with New York Heart Association Class III
heart failure sees you for follow-up. He has shortness of breath with minimal
exertion. The patient is adherent to his medication regimen. His current
medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol
(Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood
pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular.
Findings include a few scattered bibasilar rales on examination of the lungs, an
S3 gallop on examination of the heart, and no edema on examination of the legs.
An EKG reveals a left bundle branch block, and echocardiography reveals an
ejection fraction of 25%, but no other abnormalities. What's the appropriate next
step? - ✔✔- ANS: Refer for cardiac resynchronization therapy (CRT)
,Note: he's already on maximum doses of ACEI, loop diuretic, beta-blocker
Using a pacemaker-like device, CRT aims to get both ventricles contracting
simultaneously, overcoming the delayed contraction of the left ventricle caused
by the left bundle-branch block. These guidelines were refined by an April 2005
AHA Science Advisory, which stated that optimal candidates for CRT have a
dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a
QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or
IV despite maximal medical therapy for heart failure.
What dietary change recommended for the prevention and treatment of
cardiovascular disease has been shown to decrease the rate of sudden death? -
✔✔- ANS: increase intake of omega 3 fatty acids
Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), which inhibit the inflammatory immune response
and platelet aggregation, are mild vasodilators, and may have antiarrhythmic
properties. The American Heart Association guidelines state that omega-3
supplements may be recommended to patients with preexisting disease, a high
risk of disease, or high triglyceride levels, as well as to patients who do not like or
are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA
and DHA daily resulted in decreased rates of mortality, nonfatal myocardial
infarction, and stroke, with particular decreases in the rate of sudden death.
A 75-year-old male presents to the emergency department with a several-hour
history of back pain in the interscapular region. His medical history includes a
previous myocardial infarction (MI) several years ago, a history of cigarette
smoking until the time of the MI, and hypertension that is well controlled with
hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious,
but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate
is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute
changes. A chest radiograph shows a widened mediastinum and a normal aortic
arch, and CT of the chest shows a dissecting aneurysm of the descending aorta
that is distal to the proximal abdominal aorta but does not involve the renal
arteries. Which one of the following would be the most appropriate next step in
the management of this patient? - ✔✔- ANS: Dx: aortic dissection
,next step: Intravenous labetalol (Normodyne, Trandate)
Initial management should reduce the systolic blood pressure to 100-120 mm Hg
or to the lowest level tolerated. The use of a β-blocker such as propranolol or
labetalol to get the heart rate below 60 beats/min should be first-line therapy. If
the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside
should be added. Without prior beta-blocade, vasodilation from the nitroprusside
will induce reflex activation of the sympathetic nervous system, causing
increased ventricular contraction and increased shear stress on the aorta.
According to the U.S. Preventive Services Task Force, what are the screening
recommendations for an abdominal aortic aneurysm? - ✔✔- ANS: The guideline
recommends one-time screening with ultrasonography for AAA in men 65-75
years of age who have ever smoked. No recommendation was made for or
against screening women. Men with a strong family history of AAA should be
counseled about the risks and benefits of screening as they approach 65 years of
age.
A 36-year-old white female presents to the emergency department with
palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular
tachycardia with a narrow complex QRS and no apparent P waves. The patient
fails to respond to carotid massage or to two doses of intravenous adenosine
(Adenocard), 6 mg and 12 mg. The most appropriate next step would be to
administer intravenous - ✔✔- ANS: verapamil (Calan)
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the
tachycardia can usually be terminated by the administration of intravenous
verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may
be necessary. It is also important to look for and treat possible contributing
causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical
cardioversion may be necessary if these measures fail to terminate the
tachyarrhythmia.
The blood pressure goal for a patient who has uncomplicated diabetes mellitus is
- ✔✔- ANS: BP goal: 130/80mmHg
, Aggressive control of blood pressure to <135/85 mm Hg in hypertensive patients
and to <130/80 mm Hg in diabetic patients is recommended. Lowering blood
pressure may reduce stroke rates by 40%-52% and cardiovascular morbidity by
18%-20%
A 60-year-old African-American female has a history of hypertension that has
been well controlled with hydrochlorothiazide. However, she has developed an
allergy to the medication. Successful monotherapy for her hypertension would be
most likely with which one of the following?
A. Lisinopril (Prinivil, Zestril)
B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem) - ✔✔- ANS: Diltiazem (Cardizem)
Monotherapy for hypertension in African-American patients is more likely to
consist of diuretics or calcium channel blockers than β-blockers or ACE
inhibitors. It has been suggested that hypertension in African-Americans is not as
angiotensin II-dependent as it appears to be in Caucasians.
An asymptomatic 3-year-old male presents for a routine check-up. On
examination you notice a systolic heart murmur. It is heard best in the lower
precordium and has a low, short tone similar to a plucked string or kazoo. It does
not radiate to the axillae or the back and seems to decrease with inspiration. The
remainder of the examination is normal. What is the most likely diagnosis? -
✔✔- ANS: Still's murmur
There are several benign murmurs of childhood that have no association with
physiologic or anatomic abnormalities. Of these, Still's murmur best fits the
murmur described. The cause of Still's murmur is unknown, but it may be due to
vibrations in the chordae tendinae, semilunar valves, or ventricular wall.
A 57-year-old male with severe renal disease presents with acute coronary
syndrome. Which one of the following would most likely require a significant
dosage adjustment from the standard protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
