Accreditatie-vragen

Let op: u kunt de vragen slechts eenmalig beantwoorden.

Voor het beantwoorden van de toetsvragen van de andere delen selecteert u deze pagina.

Klik hier om uw resultaten te bekijken.

NephSAP Module 1 Hypertension Post toets

NephsapU heeft recht op 2 accreditatiepunten per module (totaal 6) indien u de Post toets volledig beantwoordt.

Feedback m.b.t. het resultaat kunt u direct na verzending inzien.
De NIV heeft GEEN inzage in het antwoordresultaat.

Indien u de toewijzing van uw accreditatiepunten wenst te bestendigen logt u na het beantwoorden van de vragen in. Dit scherm dient zich aan nadat u op "Verstuur" heeft geklikt. De punten zullen dan op uw conto worden bijgeschreven.


NephSAP is mede mogelijk gemaakt door financiële ondersteuning van
Sanofi-Aventis en Bristol Myers Squibb

1. A 36-year-old woman is referred to you from high-risk obstetrics because of new-onset edema and BP increase at 29 weeks of gestation. This is her third child, and she had preeclamptic pregnancies with both previous children. She has not been prescribed any restrictions on sodium in-take. Her examination shows BP of 128/88 mmHg and 2+ edema of both lower extremities. Her urine is positive for protein by dipstick at 2+. Her last creatinine (1 week ago) was 0.7 mg/dl.

Which ONE of the following would you recommend?

A. Start a 2000-mg/d Na+ diet
B. Hydralazine 25 mg three times a day
C. Hydrochlorothiazide 12.5 mg/d with instructions to hold if edema at midday is no longer present
D. Methyl-DOPA 250 mg twice a day
E. No medication changes at this visit, but weekly visits to monitor BP

2. A 59-year-old African American man visits you for an opinion about his clinical course. He brings an extensive set of records showing years of good BP control yet a gradual increase in creatinine from 1.4 seven years ago to 2.2 mg/dl currently. He has not had any known cardiovascular disease and three electrocardiograms (ECGs) are unremarkable aside from some "nonspecific ST-T wave changes in the lateral leads." He has a strong family history of kidney disease (three first-degree relatives died on dialysis). He takes no recreational drugs, does not smoke, and is on a statin that has reduced his LDL cholesterol level to 86 mg/dl. His current regimen is ramipril 10 mg/d, chlorthalidone 25 mg/d, and amlodipine 5 mg/d. His BPs, seated, were 126/70 and 124/70 mmHg. Standing values were 120/82 mmHg. Heart rate is 74 bpm seated and 76 bpm standing.
He is 174 cm tall and weighs 90.6 kg (body mass index [BMI] 29.9 kg/m2). His most recent basic chemistry panel shows the following: Sodium 138 mEq/L, potassium 3.9 mEq/L, chloride 98 mEq/L, bicarbonate 30 mEq/L; blood urea nitrogen 36 mg/dl, creatinine 2.20 mg/dl, and glucose 106 mg/dl. Urinalysis shows "+" protein. The spot urine protein is 28 mg/dl, and spot urine creatinine is 86 mg/dl.

Which ONE of the following would you add to his regimen to reduce his cardiovascular risk?

A. Candesartan 16 mg/d
B. Increase the amlodipine to 10 mg/d
C. Increase the ramipril to 20 mg/d
D. Aspirin 81 mg/d
E. Ergocalciferol 50,000 U once weekly for 8 weeks

3. A 56-year-old African American man consults you about his kidney function. His physicians have documented increase in creatinine from 1.6 mg/dl 4 years ago to 2.1 mg/dl currently. His BP seems to have been well controlled over the past 4 years. There is no known cardiovascular disease, and his cardiograms have been unremarkable. He had a cough on an angiotensin-converting enzyme inhibitor (ACEI) in the past. He has a family history of kidney disease. His current regimen is as follows: Irbesartan 300 mg/d, chlorthalidone 25 mg/d, and amlodipine
5 mg/d. His BPs, seated, averaged 127/79 mmHg, his heart rate is 74 bpm, and he has a BMI of 30.69 kg/m2. His most recent basic chemistry panel shows the following: Sodium 139 mEq/L, potassium 4.1 mEq/L, chloride 97 mEq/L, bicarbonate 31 mEq/L, creatinine 2.11 mg/dl, and glucose 100 mg/dl; urinalysis shows trace of protein.

According to the African American Study of Kidney Disease and Hypertension (AASK) cohort publication, which ONE of the following BEST reflects a possible cause of the creatinine increase despite good BP control?

A. IL-9 levels
B. Adiponectin levels
C. Serum bicarbonate concentration
D. Hematocrit
E. Nocturnal BP profile

4. An 84-year-old asymptomatic Caucasian woman is sent to you for "reduced kidney function." Her creatinine was 1.0 mg/dl, but the estimated GFR (eGFR) comment read "56 ml/ min per 1.73 m2 consistent with stage 3 CKD [chronic kidney disease]." A review of her previous laboratory records
indicates that her creatinine had been 0.9 mg/dl in 2002. The laboratory upgraded the chemistry analyzer in 2007, but she had not had a repeat value until recently. You assure her that she is likely to be fine, but you noticed that her BP was 164/74 mmHg today and that it has been ranging from 150 to 170 mmHg systolic for the past few years, although it has not been treated with medication to date. Her BMI is 22 kg/m2, and her examination is unremarkable except for a soft systolic murmur and venous varicosities in the lower extremities. She has no known cardiovascular disease. A urinalysis is negative for protein.

Which ONE of the following statements is CORRECT regarding this patient's clinical condition?

A. Treat her BP to <130/<80 mmHg per Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for CKD.
B. There are no data on managing BPs in this age range.
C. Treat her BP to <150 mmHg systolic with a regimen of ACEI and low-dosage diuretic.
D. Her diastolic BP (DBP) is at a level at which it is already un safe to lower it further.
E. An echocardiogram should be performed to rule out significant aortic stenosis before considering any therapy.

5. A 49-year-old man is referred for resistant hypertension. He currently takes an ACEI, a diuretic, and a calcium channel blocker (CCB) and uses topical clonidine weekly all at maximum recommended dosages. His BP has been difficult to control for years, and he has been treated with a variety of other antihypertensive agents, including β blockers, α blockers, and hydralazine.
He measures his BPs at home, and his device as checked by you today seems accurate. His history is remarkable for effort dyspnea and poor sleep with loud snoring reported by his wife. He does not smoke. He says that he does not add salt and has been counseled often about the need to restrict sodium intake. He is tired at work. He is 170 cm tall and weighs 101.4 kg (BMI 35 kg/m2). His waist circumference is 108 cm. His sitting BPs are 158/90 and 156/92 mmHg with a heart rate of 64 that is regular. His heart sounds are distant. The lungs sound clear. There are no bruits. He has modest pitting edema in both lower extremities. His creatinine level is 1.2 mg/dl (eGFR = 68 ml/min per 1.73 m2). His fasting blood glucose is 112 mg/dl. He has a fasting triglyceride level of 200 mg/dl, an HDL level of 46 mg/dl, and a potassium level of 4.2 mEq/L. His urinalysis shows trace protein on the dipstick, otherwise negative. You diagnose drug-resistant
hypertension.

Which ONE of the following interventions will BEST reduce his BP?

A. Eplerenone 50 mg once a day titrated to 100 mg/d in 1 month
B. Propranolol 160 mg/d titrated to 480 mg as tolerated
C. Ten minutes of treadmill activity daily at 2 mph
D. Continuous positive airway pressure with 10 cm of water pressure for 1 month
E. Irbesartan 150 mg/d titrated to 300 mg/d in 1 month

6. You are taking care of a 68-year-old woman who has hypertension and measures her BPs at home. She is compliant with her four-drug antihypertensive regimen. She takes her BP twice each time and averages these readings for a single entry and does this at least 4 d/wk at different times of the day. She enters the BP readings in a spreadsheet. You have witnessed her BP technique and are satisfied that her monitor is reasonably accurate. Her home BPs now average 132/77 mmHg. Her kidney function has been normal, and she has no known cardiovascular disease aside from hypertension. Her BP today in your office (average of three readings) is 153/81 mmHg.

Which ONE of the following statements BEST summarizes this situation?

A. Classic white-coat effect
B. Classic masked hypertension
C. Occult hypertension
D. Nondipping hypertension
E. Concordant hypertension

7. You are taking care of a 64-year-old man who has hypertension and measures his BPs at home. He is compliant with his three-drug antihypertensive regimen. He takes his BP twice at least 3 d/wk, mostly in the mornings between 7 and 10 am and in the evenings between 7 and 10 pm and maintains a log book of his values. You have monitored his BP technique are satisfied that he is doing the measurements properly. His home BPs average 127/74 mmHg. His kidney function is normal, and he has no known target organ damage from hypertension. His seated BP today in your office (average of three readings) is 152/88 mmHg.

In this patient which ONE of the following options would you recommend, supported by evidence of benefit?

A. Perform a 24-hour BP monitor.
B. Obtain a central aortic BP profile.
C. Obtain a 24-hour urine for sodium excretion.
D. Prescribe 0.5 mg lorazepam to take before each office visit.
E. Check yearly ECG, creatinine level, and urinalysis.

8. A patient is referred to you from the oncology group. He is 58 years old and is under treatment for metastatic colon cancer, stage C (regional nodes positive), and is on a protocol that uses the vascular endothelial growth factor inhibitor bevacizumab and the small molecule tyrosine kinase inhibitor erlotinib, which blocks intracellular vascular endothelial growth factor signaling. Before treatment, his BP had been in the range of 120 to 130/80 mmHg; now it is ranging from 140 to 150/90 mmHg on several weekly visits. It is anticipated that the protocol medications will continue for another 6 months; the level of BP increase is not sufficient to warrant dosage reduction, but the protocol does allow for (and actually recommends) treatment of intercurrent BP elevations. Aside from the chemo-therapy agents, he has no other medications except for those that are used intermittently to treat chemotherapy-related adverse effects such as nausea and diarrhea.

Which ONE of the following would you now recommend?

A. Start long-acting diltiazem 240 mg once daily
B. Start an ACEI
C. Start an angiotensin receptor blocker (ARB)
D. Perform a urinalysis to detect proteinuria
E. Start nebivolol 5 mg/d

9. A 49-year-old man is referred for resistant hypertension (same patient as in Question 5). He currently takes an ACEI, a diuretic, and a CCB and uses topical clonidine weekly all at maximum recommended dosages. His BP has been hard to control for years, and he has been treated with a variety of other antihypertensive agents, including β blockers, α blockers, and hydralazine. He measures his BPs at home, and his device as checked by you today seems accurate. His history is remarkable for effort dyspnea and poor sleep with loud snoring reported by his wife. He does not smoke. He says that he does not add salt and has been counseled often about the need to restrict sodium intake. He is tired at work. He is 170 cm tall and weighs 101.4 kg (BMI 35 kg/m2). His waist circumference is 108 cm. His sitting BPs are 158/90 and 156/92 mmHg with a heart rate of 64 that is regular. His heart sounds are distant. The lungs sound clear. There are no bruits. He has modest pitting edema in both lower extremities. His creatinine level is 1.2 mg/dl (eGFR = 68 ml/min per 1.73 m2). His fasting blood glucose is 112 mg/dl. He has a fasting triglyceride level of 200 mg/dl and an HDL level of 46 mg/dl. His urinalysis shows trace protein on the dipstick, otherwise negative. You diagnose drug-resistant hypertension.

Which ONE of the following statements is CORRECT regarding his sleep disturbance?

A. The presence of metabolic syndrome reduces the likelihood of finding significant apneic episodes on a poly somnogram (overnight sleep breathing test).
B. A sleep study on this patient is likely to show "moderate to severe sleep apnea."
C. Many people snore; therefore, there is little reason to pursue a sleep study for this patient.
D. Reducing his BP medicines would improve his effort dyspnea.
E. Treating sleep apnea, if it is present, is likely to increase his fasting blood glucose.