Hypertension

Chapter 25 Hypertension




Clinical Case Problem 1: An Obese 47-Year-Old Man with Hypertension


A 47-year-old man presents to your office for a yearly checkup. He is 5 foot 10 inches tall, weighs 250 pounds, smokes two packs of cigarettes a day, and “slams down” 12 ounces of whiskey a day. He is a truck driver and is on the road a lot. He frequently eats at “fast-food joints.”


On physical examination, you find his blood pressure to be 180/105   mm Hg. His point of maximal impulse is detected in the sixth intercostal space in the anterior axillary line. His funduscopic examination findings are normal. He has no carotid bruits.



Select the best answer to the following questions




1. Which of the following statements about this patient’s blood pressure is false?


a. a single blood pressure reading of diastolic 105   mm Hg is satisfactory for a diagnosis of hypertension

b. this patient’s alcohol intake may be a significant contributing factor to his elevated blood pressure

c. the patient should have his blood pressure rechecked after a period of rest in the office

d. the patient should return for reassessment of his blood pressure in 1   week

e. the patient’s cigarette smoking may be a significant contributing factor to his elevated blood pressure

2. Which of the following blood pressure values meet(s) the definition of prehypertension in the seventh report the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)?


a. 122/82   mm Hg

b. 140/90   mm Hg

c. 118/78   mm Hg

d. 135/85   mm Hg

e. a and d

3. The minimum goal in hypertension therapy is to reduce his blood pressure to a level less than which of the following?


a. 150/90   mm Hg

b. 140/90   mm Hg

c. 130/90   mm Hg

d. 120/80   mm Hg

e. 110/70   mm Hg

4. A week later, the patient returns to your office with blood pressure measurements taken by his company’s nurse. They are as follows: 148/95, 144/92, and 150/90   mm Hg. At this time, you would prescribe


a. a thiazide diuretic

b. a beta blocker

c. a calcium channel blocker

d. an angiotensin-converting enzyme (ACE) inhibitor

e. none of the above

5. What is the first-line pharmacologic therapy now recommended for most patients with hypertension?


a. a beta blocker

b. a thiazide diuretic

c. a calcium channel blocker

d. an ACE inhibitor

e. any of the above

6. Which of the following statements is false?


a. in chronic congestive heart failure, ACE inhibitors, beta blockers, and aldosterone inhibitors have been shown to decrease morbidity and mortality

b. recurrent strokes are decreased by a combination of ACE inhibitors and thiazide diuretics

c. calcium channel blockers are beneficial in reducing cardiovascular disease and stroke in patients with diabetes mellitus

d. hypertension in older individuals is best treated with calcium channel blockers

e. ACE inhibitors should be avoided in women of childbearing age or pregnant women

7. Which statement(s) is (are) true regarding the use of antihypertensive drugs with other comorbidities?


a. thiazide diuretics are useful in slowing demineralization in osteoporosis

b. beta blockers are useful in prophylactic treatment of migraine headache

c. beta blockers are useful in the comanagement of Raynaud’s phenomenon

d. a and b

e. all of the above

8. The initial diagnostic workup of a patient with hypertension should include which of the following?


a. electrolytes

b. blood urea nitrogen (BUN), creatinine

c. electrocardiogram (ECG)

d. 24-hour urine collection for vanillylmandelic acid (VMA) and metanephrines

e. all of the above

9. Based on the patient’s history and physical examination, which of the following statements concerning his hypertensive complications is most likely true?


a. this patient is unlikely to have any hypertensive complications

b. this patient is likely to have hypertensive retinopathy

c. this patient is likely to have cardiac hypertrophy

d. this patient is likely to have hypertensive renal failure

e. none of the above

10. Which of the following statements accurately apply(ies) to mild hypertension?


a. the term is no longer considered appropriate in defining hypertension

b. mild hypertension describes a systolic level of 140 to 159   mm Hg

c. mild hypertension describes a diastolic level of 90 to 104   mm Hg

d. b and c

e. none of the above

11. Which of the following statements regarding the treatment of hypertensive emergencies and urgencies is (are) false?


a. patients with marked blood pressure elevations and acute target organ damage require hospitalization

b. patients with marked blood pressure elevations without target organ damage should receive immediate combination oral hypertensive therapy

c. the oral medication of choice for hypertensive urgencies is sublingual nifedipine

d. all of the above

e. none of the above


Clinical Case Problem 2: A 50-Year-Old Man with Resistant Hypertension


A 50-year-old man is being treated for hypertension with a low-salt diet; hydrochlorothiazide, 25   mg/day; and propranolol, 120   mg twice daily. His blood pressure is currently 180/100   mm Hg.



12. Which of the following would be a reasonable third-line agent for the treatment of this patient’s blood pressure?


a. atenolol

b. metoprolol

c. labetalol

d. furosemide

e. enalapril

13. What is the most common side effect of ACE inhibitors?


a. cough

b. constipation

c. headache

d. rash

e. depression

14. What is the recommended starting dose for hydrochlorothiazide?


a. 25   mg

b. 50   mg

c. 75   mg

d. 100   mg

e. none of the above

15. Which of the following prescribing considerations concerning hydrochlorothiazide is true?


a. it can be used without concern in patients taking digoxin

b. it is safe for use in patients with uric acid metabolism disorders

c. it can cause hyperkalemia

d. it can be associated with osteoporosis development

e. its use should be avoided in patients allergic to sulfonamides

16. Based on the history and physical examination of the patient described in Clinical Case Problem 1, which of the following additional investigations should be undertaken?


a. digital subtraction angiography

b. intravenous pyelography (IVP)

c. echocardiography

d. retinal ultrasonography

e. renal ultrasonography

17. Which medication would be the least optimal in a patient with asthma?


a. hydrochlorothiazide

b. propranolol

c. lisinopril

d. nifedipine

e. prazosin

18. Which antihypertensive medication is best avoided in chronic kidney disease?


a. lisinopril

b. furosemide

c. amlodipine

d. triamterene

e. atenolol

19. Which medication is contraindicated in gout?


a. atenolol

b. hydrochlorothiazide

c. lisinopril

d. nifedipine

e. prazosin

20. The 47-year-old male patient described in Clinical Case Problem 1 is admitted to the hospital a few months later for an acute myocardial infarction. He has disregarded your previously prescribed therapies. What medications would you now prescribe for his blood pressures that average 160/90   mm Hg?


a. metoprolol

b. amlodipine

c. lisinopril

d. a and c

e. a, b, and c


Clinical Case Problem 3: A 49-Year-Old Obese Postmenopausal Woman with Type 2 Diabetes Mellitus


The next day, the wife of the patient described in Clinical Case Problem 2, a teacher, sees you in your office. She is a 49-year-old postmenopausal obese woman with type 2 diabetes mellitus. She brings in a record of blood pressures taken by the school nurse during the past 3 months. The blood pressure readings average 136/86   mm Hg.



21. Your approach to this clinical case problem may be to do which of the following?


a. recommend lifestyle changes and a return visit in 3 months

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Hypertension

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