Exam 3
A common agent that causes contact dermatitis is:
Spider bite
Spicy foods
Exposure to cold
Exposure to nickel
Flat discoloration less than 1 cm in diameter
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Circumscribed area of skin edema
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Narrow linear crack into epidermis
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Vesicle like lesion w/ purulent content
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Flat discoloration > 1 cm in diameter
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Raised lesion > 1 cm, may be different color from surrounding skin
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Loss of epidermis and dermis
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Skin thickening, usually found over pruritic or friction areas
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
In a ring formation
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Raised flaking lesion
Pustule
Annular
Wheal
Fissure
Patch
Lichenification
Plaque
Scale
Ulcer
Macule
Which description is typical for a lesion suspicious for melanoma? The lesion is on the upper right back of a 62 year-old male, first noticed 2 weeks ago by his wife.
3mm x 3mm well circumscribed evenly pigmented symmetrical brown papule
oval shaped 1.5 cm x 2 cm brown plaque , symmetrical, evenly pigmented, warty surface and “stuck on” appearance.
New 1.5 cm x 2 cm lesion with varied color ranging from tan to dark brown and is asymmetrical
Pedunculated evenly pigmented tan lesion that is 1 cm in length and has a base 0.5 cm in diameter
A 79 year old female who is a resident in a long term care facility has night time sleep disturbance due to generalized intense pruritis. Her exam is consistent with scabies. What exam findings are typical of scabies?
Vesicular lesions in linear configuration
Excoriated papules in the interdigital areas
Honey colored crusting
Well demarcated red plaques on the knees
A common site for atopic dermatitis in an adult is
Neck
Face
Flexor surfaces
Dorsum of hand
A 54 year-old female presents with CC “painful bug-bites on my chest and back x 2 days”. The rash was preceded by a painful sensation described as "like a needle sticking me on that side". She has not seen any insects nor does she recall any specific stinging incidents. Exam reveals clusters of grouped vesicles on an erythematous base in a band like distribution right anterior and posterior trunk at her bra-line. These do not cross the midline. She has never had this before. What is the most likely diagnosis? Select the one best answer.
Cutaneous herpes simplex
Bullous impetigo
Herpes zoster
Contact dermatitis
Which presentation is typical for stable angina? Select the ONE best answer.
B. Exertional chest pain unrelieved by rest
C. Exertional chest pain unrelieved after SL nitroglycerin 0.4mg every 5 min x 3 doses.
D. Exertional chest pain relieved by morphine in the ED
A. Predictable chest pain for certain level of exertion that is relieved by rest or nitroglycerin
Which finding is more typical of NSTEMI?
Transmural infarct
Complete occlusion of major CA
Complications more severe
Partial occlusion of major CA
Which of the following are consistent w/ STEMI - select all
Complete occlusion of major CA
ST segment elevation on EKG
70% of all MI
Transmural infarction likely present
What drug should be avoided in a heart failure patient with reduced ejection fraction? Select the ONE best answer.
Lisinopril
Verapamil
Atorvastatin
Metoprolol
Which is true re. Hepatojugular reflux
A drop in JVP throughout manual compression of liver may indicate volume overload secondary to HF
A drop in JVP throughout manual compression of liver may indicate volume depletion in HF
A rise in JVP throughout manual compression of liver may indicate volume depletion secondary to HF
A rise in JVP throughout manual compression of liver may indicate volume overload secondary to heart failure
What are established invasive treatments for varicose veins? Select all that apply:
Endovascular obliteration of affected vessel
Vein stripping
Ligation of affected vessel
Surgical removal of affected vessel
Sx not typical for pericarditis
Pleuritic CP
Worse when lies flat
Chest pain radiates down bilateral arms
Sharp retrosternal pain
What is true re. Presentation of infarct in elderly
Less inpatient mortality than younger adults w/ MI
Thrombolytic therapy is best tx option
They almost always present w/ typical CP
Delay in dx due to LBBB is common
A 50 year old HTN DM pt. To urgent care w/ CP. Afebrile but tachycardic at 110. HR regular. EKG shows what finding to suggest pericarditis
Widespread ST elevation in most leads
Q wave in 2, 3, & AVF
T wave inversion in leads V1 and V2c
Depressed ST segments throughout all leads
Which of the following are appropriate pharmacologic treatments of peripheral vascular disease? Select all that apply.
Aspirin 75- 325 mg / day
Clopidrogel (Plavix) 75 mg/ day
ACE I
Statin
Which of the following findings is typical for NSTEMI, but not STEMI? Select the ONE best answer.
Elevated troponin
ST depression present/ no pathologic Q wave
Exertional CP
Pathologic Q wave/ ST elevation
Which one of the following is included as major criteria for the diagnosis of heart failure among the Framingham diagnostic criteria? Select the ONE best answer.
Rales
Ankle edema
DOE
Hepatomegaly
What is ABI
Ankle BP/ SBP
Ankle diameter/ SBP
Ankle diameter/ Brachial parameter
Bilateral ankle BP/ ankle circumference
How does unstable angina (UA) differ from NSTEMI? Select the ONE best answer.
C. Cardiac troponins do not elevate
A. The elevation of cardiac troponins is not as high as with NSTEMI
B. Chest pain of UA is never as severe as with NSTEMI
D. The ECG is always normal
If the left ventricle fills with 120 ml of blood and pumps out 40 ml, is the patient most likely to be in systolic or diastolic heart failure? Select the ONE best answer.
Diastolic because EF is preserved
Systolic bc EF is preserved
Diastolic bc EF is reduced
Systolic bc EF is reduced
Which of the following are symptoms of heart failure? Select all that apply.
Cough
Exertional dyspnea
Edema
Anorexia
Paroxysmal nocturnal dyspnea
Orthopnea
Fatigue
What medication is NOT recommended as a first line drug therapy for hypertension within JNC 8 guidelines for a 54 year-old black female who does not have diabetes or kidney disease?
Amlopdipine (CCB)
Verapamil (CCB)
Hydrochlorithiazide (thiazide diuretic)
Valsartan (ARB)
A 49 year-old white nondiabetic female who has healthy kidney function presents today seeking treatment for a sinus infection. Her BP today is 146/95 in both arms. What is the best next action?
Start nadolol 10 mg daily & f/u in 1 month
Recheck BP in one year
Recheck BP in one month
Start valsartain 80 mg daily. Recheck in 3 months
According to the new ACC/AHA 2013 Blood Cholesterol guideline, which of the following persons would NOT benefit from the addition of a nonstatin to statin therapy?
High risk pt. Who is completely statin intolerant
High risk pt who can't tolerate a less than recommended intensity statin
45 year old diabetic female w/ fasting LDL C 140, and 10 year ASVCD risk of 5%
High risk pt w/ less than anticipated response to statin therapy
Who does NOT need subacute bacterial endocarditis prophylaxis before a dental procedure?
Adult female w/ mild mitral valve prolapse
Adult female w/ prosthetic valve
Adult male w/ history of previous infective endocarditis
Adult male w/ heart transplant and valvular disease
What is an appropriate first line pharmacologic therapy for Stage I hypertension for a black diabetic male with chronic kidney disease?
Alpha blocker
ARB
Potassium sparing diuretic
Beta 1 selective BB
Which findings indicate end organ damage from long-standing hypertension?
Flame hemorrhages
Clotting d/o
Elevated creatine
LVH
Anemia
Lipid abnormalities
Hyperinsulinuremia
True or False? The major changes in the 2013 American College of Cardiology/American Heart Association Blood Cholesterol Guideline are based on the fact that achievement of LDL targets has NOT resulted in reduced atherosclerosis.
True
False
Mrs. Smith is a 54 year-old diabetic African–American female with Stage II hypertension and stage III chronic renal disease. According to JNC-8 guidelines, which of the following is an appropriate antihypertensive drug for Mrs. Smith? Select the one best answer:
Nadolol
Hydrochlorithiazide
Nifedipine
Valsartan
Afib > 7 days and requiring cardioversion to restore sinus rhythm is classified as what type
Permanent
Paroxsymal
Lone
Persistnet
Who most likely has secondary HTN
78 yo male w/ BP ranging from 170-189 / 80- 85 on 6 different occasions, 1-2 weeks apart
A 57 yo female w/ BP 160-189/ 95- 100 on 3 different occasions
47 yo female w/ 3 BP readings ranging from 135/80- 85
18 yo male w/ BP ranging from 160-168/ 95-110, checked x 3 week apart by school nurse
Which valvular problems produce a systolic murmur?
AS and AR
Mitral stenosis and aortic regurgiation
Mitral stenosis and mitral reguritation
Aortic stenosis and mitral regurgitation
45 yo male w/ HTN. Which finding is reccomeneded drug goal therapy
< 140/ 90 w/in 1 month
< 150/90 w/in 1 month
< 140/ 90 w/ in 1 year
< 120/ 80 w/ in 1 month
A 55 year old patient has a physiological split of S2, the NP notes that: Select the ONE best answer:
Heard best at base
Low frequency sound
This is always pathologic
Heard best left lying position
For patients with atrial fibrillation, which type of medication is usually started first, rate control or rhythm control?
Rate control meds bc fewer SE
Rate controlled bc rhythm controlled is best achieved w/ Cardioversion
Rhythm controlled bc less expensive
Rhythm controlled bc improve QOL and decrease morbidity/ mortality more effectively than rate controlled.
A 54 year-old female who presented with rhinosinusitis 3 weeks ago was found to have elevated blood pressures. She is here today to follow up. She is no longer taking nasal decongestants or ibuprofen. Her blood pressures over the past three weeks are as follows: 3 weeks ago: 154/95 (R), 155/96 (L) (while on decongestants and ibuprofen) 2weeks ago, by employee health RN, off all meds: BP 146/94 (R), 148/96 (L) 1 week ago, by employee health RN off all meds: BP 142/94 (R), 145/95 (L) Today, by medical assistant BP 144/96 (R), Recheck by NP: BP 144/90 (R), 142/94(L) What is the most appropriate diagnosis and plan?
C. Stage I Hypertension. Encourage heart-healthy lifestyle. Begin a thiazide diuretic and recheck BP within one month.
D. Stage II Hypertension Encourage heart healthy lifestyle. Begin a beta-1 selective beta blocker and recheck BP within one month.
B. Stage I hypertension. Encourage heart-healthy lifestyle and recheck BP in one month.
A. Prehypertension. Encourage heart-healthy lifestyle and recheck BP in one year.
A 72 year-old female has blood pressure readings on 4 different occasions ranging between 160-168/85-95. What is the correct diagnosis?
A. Normal blood pressure
D. Stage II hypertension
Prehypertension
C. Stage 1 hypertension
Who would benefit from estimation of 10-year risk of developing ASCVD?
B. 82 year-old female with unstable angina
A. 46 year-old male with fasting LDL-C of 196mg/dL
C. 54 year-old diabetic male with LDL-C= 140mg/dL
D. 63 year-old male who has already had CABG
Which isn't associated w/ AF
DM
OSA
ETOH excess
Caffiene
According to the November 2013 ACC/AHA Blood Cholesterol guidelines, which person would benefit from high intensity statin therapy (atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/da
C. 22 year-old diabetic male whose fasting LDL-C= 130mg/dL
A. 42 year-old female with fasting LDL-C = 200mg/dL
B. 82 year-old female with stable angina, and fasting LDL-C=160mg/dL
D. 63 year-old nondiabetic male with fasting LDL-C =140mg/dL, no clinical ASCVD history, and 10 year ASCVD risk=5%
Who should have 10 year ASCVD risk calculated
64 yo non diabetic w/ LDL C > 190
45 yo DM w/o ASCVD whose LDL C = 135 and has had mild stroke
60 yo non diabetic w/ stable angina and LDL < 70
64 yo non diabetic w/o ASCVD and LDL C = 160
Normal BP
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
PRE HTN
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
STAGE 1
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
STAGE II
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
ISOLATED SYSTOLIC HTN
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
ISOLATED DIASTOLIC HTN
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
HYPERTENSIVE URGENCY
120-139/ 80-89
> = 140/ < 90
> 160/ > 100
140- 159/ 90-99
< 140 / > = 90
> 180/ > 120
< 120/ < 80
Risk factors for Primary HTN - select all
Asain
Black
Parents w/ HTN
Oral contraceptives
Dyslipidemia
Overweight
Excess sodium
Drug use
Excess ETOH
Personality traits
Physical inactivity
Vit D deficiency
Renal disease
Conditions leading to secondary HTN - select all
Drug induced
DM
Primary renal disease
Pheochromocytoma
Oral contraceptives
Alcoholism
Primary aldosteronism
Renal vascular disease
COA
OSA
Cushings syndrome
80% length of bladder & 40% width of circumference for BP measurement? T/F
True
False
1st line tx for HTN w/ pts who do not have CKD
ACE
ARB
Thiazide diuretic
CCB
Routine tests to order in work up of HTN
CBC
Routine blood chem (Glucose, lytes, Cr.)
UA
Hct
Hgb
Lipid profile
Echo
EKG
TSH
If concern for LVH when working up HTN dx, what should be ordered
TEE
EKG
Echo
TTE
BP goals of drug therapy in adults < 60
< 130/ 80
< 140/90
< 150/90
< 120/ 80
What % of Americans die from heart disease and stroke
25%
33%
10%
50%
TRUE/ FALSE: Most heart disease and strokes are preventable
True
False
Which is not a factor contributing to atherosclerosis
Endothelial dysfunction
Cardiac risk factors (HTN, dysplipidemia, DM, smoking)
Plaque rupture
Cushings syndrome
Immunologic and inflammatory factors
Risk factors for increased risk of CHD. Select all
Low HDL
High LDL
Elevated triglycerides
Lipoprotein
Hs- CRP
High HDL
How do statins work?
Inhibit cholesterol biosynthesis by inhibiting HMG- COA reductase
Platelet aggregation and inhibition
What are the Big 4 in regards to Statin benefit group. Select all
Clinical ASVCD
LDL > = 190
40-75 w/ LDL 70-189 (w/ DM & w/o ASCVD)
W/o CV disease or DM, but have LDL 70-189 and 10 year risk of ASCVD > = 7.5%
What are clinical ASCVD. Select all
Acute coronary syndrome
MI
Stable, unstable angina
Coronary or other arterial revascularization
Stroke
TIA
Peripheral artery disease
DM
HF
Non fatal MI
CHD death
Nonfatal/ fatal stroke
Who is the 10 year ASCVD risk no appropriate to be calculated for?
In patients w/ clinical ASCVD
LDL > = 190
> 80 yo
A, B, C.
A & B
High intensity statin therapy
Lowers LDL 30-50%
Lowers LDL by < = 30%
Lowers LDL by > = 50%
Moderate intensity statin therapy
Lowers LDL 30-50%
Lowers LDL by < = 30%
Lowers LDL by > = 50%
Low intensity statin therapy
Lowers LDL 30-50%
Lowers LDL by < = 30%
Lowers LDL by > = 50%
Simvastatin should be titrated to 80 mg if pt is unable to reach target levels.
True
False
Statins are safe during pregnancy
True
False
When is it NOT ok to measure CK w/ statin therapy
Routinely
At baseline
If during statin therapy pt experiences muscle symptoms
When should ALT be measured. Select all
Baseline before initiating statin therapy
If muscle sx occur
If sx suggesting hepatatoxicity (fatigue, weakness, loss of appetite, abdominal pain, jaundice, dark urine)
Routinely
Niacin can cause
GI sx
Cough
Flushing
Increased triglycerides
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