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BP goal for patients <60? (w/ DM, CKD)
140/90
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Pt BP goal if >60 yrs old?
150/90
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Side effects of ACE inhibitor?
- Cough
- Angioedema
- Hyperkalemia
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Side effect of the use of diuretics?
Hypokalemia
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Calcium channel blockers is a good choice BP med for what patients?
Side effect?
Black Patients
Lower Extremity Edema
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Causes of secondary hypertension?
Renal, Vascular, Endocrine, Neurological, Pharmacological, Pregnancy after 20 weeks
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Elevated systolic with normal diastolic is known as what type of hypertension?
Isolated Systolic Hypertension (due to reduced vascular compromise in large arteries)
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What are he initial BP choices to start in black patient’s with/without DM?
- Thiazide Diuretic (mild HTN 5-8pts high)
- Ca Channel Blocker (severe >10pts high)
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What are the initial BP choices in non black patients with or without DM?
- Thiazide Diuretic (hctz)
- Ca Channel Blocker (-pine)
- ACE (-pril)
- ARB (-artan)
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Diagnosis for HTN?
Must have 2 elevated BPs on different occasions
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What BP medication should someone with lung problems never be placed on?
Beta Blocker
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A patient is already on a ACE inhibitor, what other BP medication should he never be started on with an ACE?
Arb - never start a patient on an ACE & ARB
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What causes a dry hacking cough in patients who are on an ACE inhibitor?
Bradykinin build up in the Lungs that trigger a cough (switch the ACE to an ARB)
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What type of Ca Channel Blockers do you want to use for hypertension?
DHPs (-end in pine) Doesn’t Hurt Pulse (non-DHPs such as diltiazam hurt pulse)
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Diltiazem & Verapamil are what type ofCa Channel Blockers?
Non-DHPs (decrease Heart Rate)
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A patient has a pulsitile abdominal mass on exam, what are you worried about as the provider and how should you follow up?
Aortic Aneurysm - order Abdominal Ultrasound/CT
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Insulin Insensitivity (DMII) is determined by what 2 lab values?
Increased Triglycerides & decreased HDL
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A patient has a history of gout and kidney problems, what BP medication should you not prescribe?
Thiazides (HCTZ)
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What is considered first line to treat hyperlipidemia?
Lifestyle modifications
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What class of medication has been shown to reduce morbidity & mortality in hyperlipidemia?
HMG Co-A reductase inhibitor (Statin Therapy)
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A patient who has been diagnosed with dyslipidemia complains of muscle pain, what are you concerned about and how should it be assessed?!
Concerned for Rhabdomylisis - check CPK level
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The valve most commonly affected by rheumatic heart disease is?
Mitral
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S/S of heart Failure?
- Tank 1 - heart (different sounds s3/4, tachycardia)
- Tank 2 - lungs (crackles, tachypnea)
- Tank 3 - peripheries (peripheral Edema)
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A patient has heart failure, what medication class should you not place the patient on?
Calcium Channel Blocker
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Diastolic Murmurs?
- Aortic Regurgitation
- Mitral Stenosis
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Systolic Murmurs?
- Mitral Regugitarion
- Physiologic Murmur
- Aortic Stenosis
- Mitral Valve Prolapse
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What murmurs are always abnormal?
Diastolic Murmurs
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Who are physiologic Murmurs most common in?
Younger patients (16 yr old growing athlete)
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The apex of the heart is the listening point for what murmur?
Mitral
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The turbulent noise you hear is in conjunction with the carotid pulse, what type of murmur is it?
Systolic Murmur
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Listening points: Aortic?
Right of Sternum - 2nd ICS
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Listening point: Pulmonic?
Left of sternum - 2nd ICS
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Listening point: Tricuspid?
Midsternal
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Listening point: Mitral?
Left of Sternum - 5th ICS (Apex)
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A patient has a sulfa allergy, which BP med should they never be placed on?
HCTZ (steven Johnson’s)
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Heart sound S2 is caused by? What 2 valves?
Closure of Semilunar Valves (aortic/pulmonic)
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CHF is accompanied by what 3 heart sounds?
S1 S2 & ***S3***
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Which systolic murmur is heard best at the apical area during auscultation of the chest, that’s the only murmur accompanied by a mid to late systolic CLICK?
Mitral Valve Prolapse (women of child bearing age complain of chest pain/palpitations)
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Which anti-hypertensive med is associated with erectile dysfunction?
HCTZ
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Subungual (splinter) hemorrhages on the nailbed, petechia on the palate, painful violet colored nodes on the fingers or feet (Osler nodes), and tender red spots on the palms/soles (Janeway lesions) are accompanied with what ? What
Bacterial Endocarditis
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Where is the apical impulse located?
5th ICS midclavicular line
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Heart sound S1 is made by? What 2 valves?
Closure of Atrioventricular Valves (mitral/tricuspid)
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Which heart sound is caused by increased resistance due to stiff left ventricle, left ventricular hypertrophy?
S4
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First time a thrill is present is what grade of murmur?
Grade IV
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All benign Murmurs occur when?
During Systole (S2)
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Which systolic mumur radiates to the axilla?
Mitral Regurgiation
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Which systolic murmur radiates to the neck?
Aortic Stenosis
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Simvastatin with amiodarone can cause what?
Rhabdomyolysis
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INR goal in patient with AFib?
2.0-3.0
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INR goal with patient who has synthetic/prosthetic valves?
2.5-3.5
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Patient complains of abrupt onset of palpitations, rapid pulse, lightheaded ness, soa, and anxiety. Heart rate is 150-250. What does the patient have and how should is be managed?
Paroxysmal Atrial Tachycardia - Valsalva Maneuvers
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How do you assess for pulsus paradoxus?
Inflate BP cuff on arm where the radial pulse can no longer be felt and the apical pulse should still be able to be heard
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What should you order with the INR in a patient who is on Coumadin and you suspect bleeding?
PT/PTT
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A patient is newly diagnosed HTN, what should be ordered as a baseline?
EKG & CXray
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Coarctation of the aorta is accompanied by what 2 physical exam findings?
- BP arms > legs
- Weak femoral pulses
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Spironolactone causes what major side effect?
Gynecomastia
(Hyperkalemia/GI)
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ACEs & ARBs are contraindicated in what disease?
Severe kidney disease
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Alpha-1 Blocker Agonist ends in what suffix?
What should pt be educated on?
Which types of patients is it indicated in?
- -zosin
- (First dose effect - lay down)
- Indicated in males with HTN & BPH
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Copper/Silver Wire arterioles & AC nicking are caused by what?
HTN
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Neovascularization, microaneurysms, hard exudates, and cotton wool spots are due to what?
Diabetic Retinopathy
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First line for Isolated systolic hypertension in elderly?
Next?
Thiazide diuretics
Add CCB or ACE/ARB
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How do you measure orthostatic HTN?
BP sitting and standing
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What are 3 side effects of thiazide diuretic?
- Hyperglycemia
- Hyperuricemia
- Hypertriglyceridemia
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The BP drug of choose for diabetics
ACE inhibitors
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Pt has renal artery Stenosis which BP med should they not be placed on and why?
ACE inhibitor because it can precipitate acute renal failure
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A female pt who has HTN & osteoporosis/osteopenia should recieve what type of BP med?
Thiazides because it helps bone loss by slowing down Ca loss and stimulating osteoclasts
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Homans sign?
Lower leg pain on dorsiflexion of the foot
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A patient who takes Coumadin has an INR of 3-5, how should this be managed?
Skip 1 dose, decrease maintenance and check INR in 1-2 days until normal
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A patient has an INR of 5-9, how should this be managed?
Give Vitamin K or omit next 1-2 doses of warfarin and monitor INR daily until normal
Decrease Coumadin dose
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Left heart failure results in symptoms where?
Lungs
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Right heart failure results in symptoms where?
GI tract (edema, spleenomegaly, anorexia, nausea, abdominal pain)
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Ordinary physical activity resulting in fatigue & exertional dyspnea is what class of heart failure?
Class II
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Chronic, recurrent episodes of color changes on fingertips that range from white (pallor), to blue (cyanosis), to red (reperfusion) is known as what conditions?
Reynauds Phenomenon
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What is the treatment for Reynauds phenomenon?
Ca Channel Blockers such as Amlodipine & Nifedipine
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Normal LDL?
<100 is optimal; <130 for low risk pt with less than 2 risk factors
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Normal Triglycerides?
<150
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Which should be treated first Triglycerides or LDL?
LDL unless Triglycerides are >500 then start the patient on tricor or niacin (high risk for acute pancreatitis)
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What HDL level is a risk factor for CHD even though total cholestorol, Triglycerides, & LDL are normal?
<40
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How should a patient be educated to reduce Triglycerides?
Reduce simple carbs, junk food, & fried foods
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Pts who have hypertension should limit their _____ intake.
Sodium
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What 2 things can a patient do to increase their HDL?
Increase aerobic Exercise & take Niacin
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Niacin and fibrates are best at lowering what?
Triglycerides
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Niacin can increase ______ enzymes.
Liver
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An elderly patient with isolated systolic hypertension should be started on what BP medication?
Calcium Channel Blocker
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An elderly patient with hypertension that is not isolated systolic HTN should be started on what type of BP medication?
Thiazide Diuretic
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Split S2 is best heard where?
2nd ICS - Left Sternal Border
Pulmonic Area
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What is pulsus paradoxus?
Decrease in SBP on inspiration
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What 2 medication classes have contraindications for drinking grape fruit juice?
Statins & CCBs
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A patient with stage 2 hypertension should be started on what?
2 BP medications
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What should be done about a fixed split ?
Always abnormal - refer
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