Snapshot A 44-year-old man presents to his primary care physician for an annual examination. He currently does not have any acute complaints. He has been attempting to increase the number of fruits and vegetables in his diet and has lost approximately 15 pounds over 6 months. His medical history is significant for type II diabetes mellitus and he is currently taking metformin. Physical examination is remarkable for a blood pressure of 155/103 mmHg and mildly decreased vibration and proprioception sense in his lower extremities. He returns to the clinic for two consecutive days to measure his blood pressure, which is 152/100 mmHg and 158/107 mmHg. He is started on lisinopril. Introduction Antihypertensive medications are used to manage hypertension in patients where conservative measures are ineffective there are four commonly used antihypertensive medications diuretics thiazides potassium-sparing diuretics sympatholytics β-blockers α-blockers vasodilators calcium channel blockers hydralazine minoxidil renin-angiotensin-aldosterone inhibitors angiotensin-converting enzyme (ACE) inhibitors angiotensin receptor blockers (ARBs) Diuretics Medications thiazides mechanism of action inhibits the NaCl transporter in the distal tubule vasodilation (mechanism is unclear) potassium-sparing diuretics mechanism of action promotes Na+ excretion in the distal nephron Sympatholytics Medications β-blockers mechanism decreases heart rate, which in turn, decreases cardiac output decreases renin release, which in turn, decreases total peripheral resistance notes can result in bronchospasm, impotence, and hyperglycemia e.g., metoprolol α-agonists mechanism central α2-agonist decreases the sympathetic outflow to blood vessels, heart, and kidneys by activating presynaptic α2-adrenoreceptors e.g., methyldopa and clonidine α-blockers mechanism α1-blockers blood vessel smooth muscle relaxation e.g., prazosin Vasodilators Medications hydralazine mechanism increases cGMP to cause direct vascular smooth muscle relaxation note this causes a reflex tachycardia; therefore, β-blockers are often given together minoxidil mechanism direct arteriolar smooth muscle relaxation calcium channel blockers mechanism decreases cardiac and vascular calcium influx, resulting in a decreased cardiac output and total vascular resistance Renin-Angiotensin-Aldosterone Inhibitors Medications angiotensin-converting enzyme (ACE) inhibitors mechanism inhibits ACE, which in turn, decreases circulating angiotensin II (AT-II) recall that AT-II causes vascular vasoconstriction increased aldosterone secretion from the adrenal gland (zona glomerulosa) notes decreases mortality in patients with acute myocardial infarction heart failure with decreased ejection fraction can result in a cough beneficial for patients with diabetes angiotensin receptor blockers (ARBs) mechanism directly blocks the AG-II receptor notes beneficial for patients with diabetes Antihypertensives in Pregnancy Medication options used to manage hypertension in pregnancy include hydralazine labetalol methyldopa nifedipine Antihypertensives in Hypertensive Emergencies Nitroprusside mechanism arteriole and venous dilation via cGMP notes is metabolized into cyanide, which can potentially lead to cyanide poisoning Fenoldopam mechanism a peripheral dopamine-1 receptor agonist notes maintains renal perfusion while the blood pressure is being decreased therefore, it is beneficial in patients with renal impairment Nicardipine and clevidipine mechanism decreases cardiac and vascular calcium influx Labetalol mechanism α- and β-blocker Antihypertensive Medications That Address Comorbid Conditions Individualizing Antihypertensive Therapy Condition Antihypertensive Medication Benign prostatic hyperplasia α-blockers Essential tremor β-blocker Hyperthyroidism β-blocker Migraine β-blocker Calcium channel blocker Osteoporosis Thiazide diuretics Raynaud phenomenon Dihydropyridine calcium channel blocker renin-angiotensin-aldosterone inhibitors
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M1.CV.139) A 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram. His vitals signs are stable, with blood pressure 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable. If this patient's cough is due to one of the medications he is taking, what would be the next step in management? Review Topic QID: 100655 1 Change citalopram to escitalopram 0% (0/23) 2 Change lisinopril to propanolol 9% (2/23) 3 Change lisinopril to amlodipine 4% (1/23) 4 Change atorvastatin to to lovastatin 0% (0/23) 5 Change lisinopril to losartan 87% (20/23) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (M1.CV.84) A 60-year-old woman presents to her primary care physician for a wellness checkup. She has a past medical history of hypertension and was discharged from the hospital yesterday after management of a myocardial infarction. She states that sometimes she experiences exertional angina. Her temperature is 99.5°F (37.5°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is within normal limits. Which of the following is the best next step in management? Review Topic QID: 100600 1 Atenolol 16% (25/157) 2 Furosemide 13% (21/157) 3 Hydrochlorothiazide 38% (59/157) 4 Nifedipine 8% (13/157) 5 Nitroglycerin 24% (38/157) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.90) A 67-year-old gentleman with a history of poorly controlled diabetes presents to his primary care physician for a routine examination. He is found to be hypertensive on physical exam and is started on a medication that is considered first-line therapy for his condition. What should the physician warn the patient about before the patient takes his first dose of the medication? Review Topic QID: 100606 1 Hypertensive episodes 0% (0/16) 2 Hypotensive episodes 81% (13/16) 3 Hyperthermic episodes 6% (1/16) 4 Hypothermic episodes 0% (0/16) 5 Anuric episodes 12% (2/16) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.CV.4753) A 45-year-old male with a history of diabetes and poorly controlled hypertension presents to his primary care physician for an annual check-up. He reports that he feels well and has no complaints. He takes enalapril and metformin. His temperature is 98.8°F (37.1°C), blood pressure is 155/90 mmHg, pulse is 80/min, and respirations are 16/min. His physician adds another anti-hypertensive medication to the patient’s regimen. One month later, the patient returns to the physician complaining of new onset lower extremity swelling. Which of the following medications was likely prescribed to this patient? Review Topic QID: 108864 1 Metoprolol 7% (7/94) 2 Verapamil 13% (12/94) 3 Nifedipine 59% (55/94) 4 Hydrochlorthiazide 13% (12/94) 5 Spironolactone 7% (7/94) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.85) A 72-year-old anthropologist with long-standing hypertension visits your office for a routine exam. You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene. What abnormality did you most likely find? Review Topic QID: 100601 1 Hypercalcemia 16% (4/25) 2 Hyperkalemia 72% (18/25) 3 Hypernatremia 4% (1/25) 4 Thrombocytopenia 4% (1/25) 5 Anemia 0% (0/25) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.93) A 67-year-old man with a history of diabetes mellitus type II and a previous myocardial infarction presents to your office for a routine examination. His blood pressure is found to be 180/100 mmHg. Which drug is the first-line choice of treatment for this patient's hypertension? Review Topic QID: 100609 1 Amlodipine 0% (0/8) 2 Hydrochlorothiazide 25% (2/8) 3 Lisinopril 75% (6/8) 4 Prazosin 0% (0/8) 5 Isoproterenol 0% (0/8) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3