1 Inquire through: | Professional | Confidential Support
FM Shelf Questions and Answers (100% Correct
Answers)
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks
gestation. She complains of severe headaches and epigastric pain. She has had an
uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago.
Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained
5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate
management at this point would be: (check one)
A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
C. Admitting the patient to the hospital for bed rest and monitoring, and beginning
hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg
D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate,
and planning prompt delivery either vaginally or by cesarean section
Ans: D
This patient manifests a rapid onset of preeclampsia at term. The symptoms of
epigastric pain and headache categorize her preeclampsia as severe. These
symptoms indicate that the process is well advanced and that convulsions are
imminent. Treatment should focus on rapid control of symptoms and delivery of the
infant. Ref: Cunningham FG, Gant NF, Leveno KJ, et al: Williams Obstetrics, ed 21.
McGraw-Hill, 2001, pp 569-571, 591-592.
Which one of the following is the most common cause of hypertension in children
under 6 years of age? (check one)
A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caffeine use
Ans: C
Although essential hypertension is most common in adolescents and adults, it is
rarely found in children less than 10 years old and should be a diagnosis of
,2 Inquire through: | Professional | Confidential Support
exclusion. 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. Other secondary causes, such as
pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common,
and further testing and/or investigation should be ordered as clinically indicated.
Ref: Luma GB, Spiotta RT: Hypertension in children and adolescents. Am Fam
Physician 2006;73(9):1558-1566.
A 70-year-old male with a history of hypertension and type 2 diabetes mellitus
presents with a 2-month history of increasing paroxysmal nocturnal dyspnea and
shortness of breath with minimal exertion. An echocardiogram shows an ejection
fraction of 25%. Which one of the patients current medications should be
discontinued? (check one)
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)
Ans: B
According to the American Diabetes Association guidelines, 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 (SOR C). Older patients can be treated with the
same drug regimens as younger patients, but special care is required when
prescribing and monitoring drug therapy. Metformin is often contraindicated
because of renal insufficiency or heart failure. Sulfonylureas and other insulin
secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and
injecting it requires good visual and motor skills and cognitive ability on the part of
the patient or a caregiver. TZDs should not be used in patients with New York Heart
Association class III or IV heart failure.
Ref: American Diabetes Association: Standards of medical care in diabetes-2007.
Diabetes Care 2007;30(Suppl 1):S4-S41.
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
,3 Inquire through: | Professional | Confidential Support
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.
Which one of the following would be most appropriate at this time? (check one)
A. Increase the lisinopril dosage to 80 mg twice daily
B. Increase the carvedilol dosage to 50 mg twice daily
C. Increase the furosemide dosage to 160 mg daily
D. Refer for coronary angiography
E. Refer for cardiac resynchronization therapy
Ans: E
This patient is already receiving maximal medical therapy. The 2002 joint guidelines
of the American College of Cardiology, the American Heart Association (AHA), and
the North American Society of Pacing and Electrophysiology endorse the use of
cardiac resynchronization therapy (CRT) in patients with medically refractory,
symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS
interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55
mm, and a left ventricular ejection fraction (LVEF) ≤30%. 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.
Ref: Jarcho JA: Biventricular pacing. N Engl J Med 2006;355(3):288-294.
The American Heart Association recommends a goal blood pressure of ≤130/80 mm
Hg for patients with: (check one)
A. Heart failure
B. Pulmonary hypertension
C. Atrial fibulation
D. Angina pectoris
E. Chronic kidney disease
Ans: E
The American Heart Association recommends a goal blood pressure of 130/80 mm
Hg or less for the treatment of hypertension in patients with diabetes mellitus,
chronic kidney disease, or coronary artery disease.
, 4 Inquire through: | Professional | Confidential Support
Ref: Pflieger M, Winslow BT, Mills K, Dauber IM: Medical management of stable
coronary artery disease. Am Fam Physician 2011;83(7):819-826.
According to the U.S. Preventive Services Task Force, which one of the following
patients should be screened for an abdominal aortic aneurysm? (check one)
A. A 52-year-old male with type 2 diabetes mellitus
B. An asymptomatic 67-year-old male smoker with no chronic illness
C. A 72-year-old male with a history of chronic renal failure
D. A 69-year-old female with a history of coronary artery disease
E. A 75-year-old female with hypertension and hypothyroidism
Ans: B
The U.S. Preventive Services Task Force has released a statement summarizing
recommendations for screening for abdominal aortic aneurysm (AAA). 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. Ref: Upchurch GR,
Schaub TA: Abdominal aortic aneurysm. Am Fam Physician 2006;73(7):1198-1204.
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 (check one)
A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)
Ans: E
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
FM Shelf Questions and Answers (100% Correct
Answers)
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks
gestation. She complains of severe headaches and epigastric pain. She has had an
uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago.
Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained
5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate
management at this point would be: (check one)
A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
C. Admitting the patient to the hospital for bed rest and monitoring, and beginning
hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg
D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate,
and planning prompt delivery either vaginally or by cesarean section
Ans: D
This patient manifests a rapid onset of preeclampsia at term. The symptoms of
epigastric pain and headache categorize her preeclampsia as severe. These
symptoms indicate that the process is well advanced and that convulsions are
imminent. Treatment should focus on rapid control of symptoms and delivery of the
infant. Ref: Cunningham FG, Gant NF, Leveno KJ, et al: Williams Obstetrics, ed 21.
McGraw-Hill, 2001, pp 569-571, 591-592.
Which one of the following is the most common cause of hypertension in children
under 6 years of age? (check one)
A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caffeine use
Ans: C
Although essential hypertension is most common in adolescents and adults, it is
rarely found in children less than 10 years old and should be a diagnosis of
,2 Inquire through: | Professional | Confidential Support
exclusion. 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. Other secondary causes, such as
pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common,
and further testing and/or investigation should be ordered as clinically indicated.
Ref: Luma GB, Spiotta RT: Hypertension in children and adolescents. Am Fam
Physician 2006;73(9):1558-1566.
A 70-year-old male with a history of hypertension and type 2 diabetes mellitus
presents with a 2-month history of increasing paroxysmal nocturnal dyspnea and
shortness of breath with minimal exertion. An echocardiogram shows an ejection
fraction of 25%. Which one of the patients current medications should be
discontinued? (check one)
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)
Ans: B
According to the American Diabetes Association guidelines, 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 (SOR C). Older patients can be treated with the
same drug regimens as younger patients, but special care is required when
prescribing and monitoring drug therapy. Metformin is often contraindicated
because of renal insufficiency or heart failure. Sulfonylureas and other insulin
secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and
injecting it requires good visual and motor skills and cognitive ability on the part of
the patient or a caregiver. TZDs should not be used in patients with New York Heart
Association class III or IV heart failure.
Ref: American Diabetes Association: Standards of medical care in diabetes-2007.
Diabetes Care 2007;30(Suppl 1):S4-S41.
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
,3 Inquire through: | Professional | Confidential Support
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.
Which one of the following would be most appropriate at this time? (check one)
A. Increase the lisinopril dosage to 80 mg twice daily
B. Increase the carvedilol dosage to 50 mg twice daily
C. Increase the furosemide dosage to 160 mg daily
D. Refer for coronary angiography
E. Refer for cardiac resynchronization therapy
Ans: E
This patient is already receiving maximal medical therapy. The 2002 joint guidelines
of the American College of Cardiology, the American Heart Association (AHA), and
the North American Society of Pacing and Electrophysiology endorse the use of
cardiac resynchronization therapy (CRT) in patients with medically refractory,
symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS
interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55
mm, and a left ventricular ejection fraction (LVEF) ≤30%. 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.
Ref: Jarcho JA: Biventricular pacing. N Engl J Med 2006;355(3):288-294.
The American Heart Association recommends a goal blood pressure of ≤130/80 mm
Hg for patients with: (check one)
A. Heart failure
B. Pulmonary hypertension
C. Atrial fibulation
D. Angina pectoris
E. Chronic kidney disease
Ans: E
The American Heart Association recommends a goal blood pressure of 130/80 mm
Hg or less for the treatment of hypertension in patients with diabetes mellitus,
chronic kidney disease, or coronary artery disease.
, 4 Inquire through: | Professional | Confidential Support
Ref: Pflieger M, Winslow BT, Mills K, Dauber IM: Medical management of stable
coronary artery disease. Am Fam Physician 2011;83(7):819-826.
According to the U.S. Preventive Services Task Force, which one of the following
patients should be screened for an abdominal aortic aneurysm? (check one)
A. A 52-year-old male with type 2 diabetes mellitus
B. An asymptomatic 67-year-old male smoker with no chronic illness
C. A 72-year-old male with a history of chronic renal failure
D. A 69-year-old female with a history of coronary artery disease
E. A 75-year-old female with hypertension and hypothyroidism
Ans: B
The U.S. Preventive Services Task Force has released a statement summarizing
recommendations for screening for abdominal aortic aneurysm (AAA). 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. Ref: Upchurch GR,
Schaub TA: Abdominal aortic aneurysm. Am Fam Physician 2006;73(7):1198-1204.
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 (check one)
A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)
Ans: E
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
