NP Case Studies & Practical Application 3 — Questions and Answers
Question 1: A 55-year-old man with newly diagnosed hypertension also has stage 3 CKD and a urine albumin-to-creatinine ratio of 450 mg/g. Which antihypertensive class is most appropriate as first-line therapy?
- Calcium channel blocker (amlodipine)
- ACE inhibitor (lisinopril) (Correct answer)
- Beta-blocker (metoprolol)
- Thiazide diuretic (hydrochlorothiazide)
Correct answer: ACE inhibitor (lisinopril)
ACE inhibitors (or ARBs) are first-line in CKD with proteinuria because they reduce intraglomerular pressure and slow progression of kidney disease.
Question 2: A 40-year-old woman presents with palpitations, heat intolerance, 15-lb weight loss over 2 months, and a fine tremor. TSH is <0.01 mIU/L and free T4 is elevated. Radioactive iodine uptake scan shows diffuse increased uptake. What is the diagnosis?
- Toxic multinodular goiter
- Graves' disease (Correct answer)
- Subacute thyroiditis
- Toxic adenoma
Correct answer: Graves' disease
Graves' disease is characterized by diffuse increased RAI uptake due to TSH receptor antibodies stimulating the entire gland, unlike focal causes.
Question 3: A 67-year-old man on warfarin for atrial fibrillation presents after a mechanical fall with a head CT showing a small subdural hematoma. INR is 3.2. He is neurologically intact. What is the most urgent priority?
- Hold warfarin and recheck INR in 24 hours
- Reverse anticoagulation with 4-factor PCC and vitamin K (Correct answer)
- Switch to a direct oral anticoagulant
- Administer fresh frozen plasma only
Correct answer: Reverse anticoagulation with 4-factor PCC and vitamin K
An intracranial hemorrhage in an anticoagulated patient requires urgent reversal; 4-factor PCC provides faster and more complete reversal than FFP alone.
Question 4: A 19-year-old college student presents with 5 days of watery diarrhea (8 stools/day), crampy abdominal pain, and low-grade fever after returning from a camping trip where she drank from a mountain stream. Stool microscopy shows pear-shaped trophozoites. What is the treatment?
- Ciprofloxacin 500 mg twice daily for 3 days
- Metronidazole 250 mg three times daily for 5 days (Correct answer)
- Azithromycin 1 g single dose
- Supportive care only with oral rehydration
Correct answer: Metronidazole 250 mg three times daily for 5 days
Giardia lamblia (pear-shaped trophozoites) from contaminated water is treated with metronidazole or tinidazole.
Question 5: A 33-year-old woman at 10 weeks gestation presents with nausea, vomiting, and a uterus larger than expected for gestational age. Serum beta-hCG is markedly elevated and ultrasound shows a 'snowstorm' pattern without a fetal pole. What is the management?
- Prescribe ondansetron and schedule a repeat ultrasound in 4 weeks
- Perform suction curettage and monitor serial beta-hCG levels (Correct answer)
- Administer methotrexate intramuscularly
- Schedule cesarean section at 34 weeks
Correct answer: Perform suction curettage and monitor serial beta-hCG levels
Complete hydatidiform mole requires immediate suction curettage followed by serial beta-hCG monitoring to detect persistent gestational trophoblastic disease.
Question 6: A 70-year-old man with osteoporosis is being considered for bisphosphonate therapy. He has a GFR of 28 mL/min/1.73m². Which management is most appropriate?
- Start alendronate at the standard weekly dose
- Use denosumab instead, as it is safe in CKD (Correct answer)
- Defer treatment until GFR improves above 35
- Start zoledronic acid IV annually
Correct answer: Use denosumab instead, as it is safe in CKD
Oral and IV bisphosphonates are contraindicated when GFR <30–35 mL/min; denosumab is safe in CKD (though hypocalcemia monitoring is required).
Question 7: A 50-year-old man with no cardiac history presents with crushing substernal chest pain radiating to the left arm for 45 minutes. EKG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?
- Left anterior descending artery
- Right coronary artery (Correct answer)
- Left circumflex artery
- Left main coronary artery
Correct answer: Right coronary artery
Inferior STEMI (ST elevation in II, III, aVF) is most commonly caused by occlusion of the right coronary artery, which supplies the inferior wall.
NP Case Studies & Practical Application 3
A 55-year-old man with newly diagnosed hypertension also has stage 3 CKD and a urine albumin-to-creatinine ratio of 450 mg/g.
Which antihypertensive class is most appropriate as first-line therapy?