DHA GP EXAM

Answer: A. When a patient has chest pain and the etiology is not likely to be cardiac ischemia, a GI disorder such as GERD is the likely cause. Other common GI disorders associated with chest pain are ulcer disease, cholelithiasis, duodenitis, and gastritis. If a woman, age 48,has chest pain with no risk factors, ischemic heart disease is unlikely
to be the cause. By age 55–60, however, the protective effect of menstruation and naturally-occurring estrogen has worn off, and the rates of CAD will at least equal the rates in men. Menstruating women virtually never have myocardial infarction. Overall, more women will die of heart disease than men.

Explanation:

• Hypertensive urgency refers to a severely elevated blood pressure without current evidence of secondary organ damage, but if left untreated, it may lead to organ injury.

• Hypertensive emergency involves severely elevated blood pressure with evidence of target organ injury, necessitating immediate blood pressure reduction.

• Target organs involved typically include CNS, heart, kidney, and eyes.

Explanation:

• A systolic BP of 152 mmHg falls into Hypertension Stage-2, which is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.

• Hypertension Stage-1 is systolic BP between 130-139 mmHg or diastolic BP between 80-89 mmHg.

• Pre-hypertension is below these thresholds but elevated above normal.

• Severe hypertension usually refers to much higher BP or associated complications.

Explanation:

• Blood pressure should be measured after the patient is rested, as recent physical activity (like brisk walking) can temporarily elevate BP.

• Immediate treatment or investigation is not appropriate without confirming persistent hypertension under resting conditions.

• Proper diagnosis requires accurate measurement in a relaxed state to avoid misdiagnosis.

Explanation:

• The earliest symptom of left heart failure is exertional dyspnea, which occurs due to reduced cardiac output and pulmonary congestion during physical activity.

• Orthopnea and PND occur later as the condition progresses and pulmonary congestion worsens.

• Pedal edema is more commonly associated with right heart failure or advanced stages of cardiac failure.

Explanation:

• Sudden, severe chest and back pain in a hypertensive patient is classic for aortic dissection, a life-threatening tear in the aortic wall.

• Acute myocardial infarction typically causes chest pain but less often severe back pain.

• Pulmonary embolism causes chest pain and shortness of breath but is less linked to severe back pain.

• Muscular pain is less sudden and severe, and unlikely to present as an emergency.

Explanation:

• Clonidine withdrawal can cause rebound hypertension.

• Cocaine is a sympathomimetic that causes vasoconstriction and hypertension.

• Cyclosporine can induce hypertension through renal vasoconstriction and sodium retention.

• Therefore, all these drugs can cause or contribute to secondary hypertension.

Explanation:

• The Positive Chvostek sign is not a feature of hyperkalemia; it is a sign of nerve excitability seen in hypocalcemia.

• Hyperkalemia typically presents with peaked T waves, widened QRS complexes, nausea, vomiting, and can lead to cardiac arrest due to arrhythmias.

Explanation:

• In acute pericarditis, the typical early ECG change is diffuse, concave-upward ST elevation.

• This differs from myocardial infarction, which shows localized ST elevation with other ECG changes like Q waves.

• PR segment depression may also occur in pericarditis but is less prominent in the very first hour.

• T wave inversion and Q wave changes happen later or in other conditions.

Explanation:

• Methyldopa is the preferred first-line medication for managing mild hypertension in pregnancy due to its established safety profile for both mother and fetus.

• Diuretics, although sometimes used, are generally not first-line during pregnancy as they can reduce plasma volume and potentially impair placental perfusion.

• ACE inhibitors and ARBs are contraindicated in pregnancy because they can cause serious fetal complications such as renal dysplasia, oligohydramnios, and fetal death.

Explanation:
Cardiac catheterization is a diagnostic procedure that can assess multiple components of heart function and structure:

• It evaluates heart muscle function by measuring pressures inside the heart chambers and assessing contractility.

• It helps detect problems with heart valves by measuring pressure gradients across valves and visualizing blood flow.

• It is primarily used to examine the coronary arteries for blockages or narrowing (coronary artery disease).

Therefore, cardiac catheterization can be used to diagnose diseases related to heart muscle, valves, and coronary arteries.

Explanation:

• The left internal mammary artery (LIMA) is the most commonly used artery for grafting to the left anterior descending (LAD) coronary artery in CABG surgeries due to its superior long-term patency and durability compared to other graft options.

• The left subclavian artery is the source vessel for the LIMA but is not directly used as the graft.

• The right internal mammary artery (RIMA) and radial artery are sometimes used as alternative grafts but less commonly for the LAD compared to LIMA.

Explanation:

• Resistant hypertension is typically defined as blood pressure that remains above goal despite the use of three antihypertensive drugs including a diuretic.

• Initial treatment often involves 2 drugs plus a diuretic to help control blood pressure.

• If the goal is not met, treatment is usually escalated to include a third drug and sometimes beyond, but the foundational approach starts with combining two drugs plus a diuretic.

• The answer "2 drugs + diuretics" reflects an early step in therapy; more drugs may be added if needed based on clinical guidelines.

Explanation:

• Patients with permanent atrial fibrillation and risk factors such as age over 75 and hypertension have a significant risk of stroke.

• Warfarin is a well-established anticoagulant effective in reducing stroke risk in AF patients, especially those at moderate to high risk.

• Clopidogrel or aspirin alone are less effective for stroke prevention in AF compared to warfarin.

• Combined warfarin and aspirin increases bleeding risk and is not routinely recommended unless there's another indication.

• Not using anticoagulation in this high-risk patient increases stroke risk significantly.

• Therefore, warfarin remains the recommended anticoagulation for stroke prevention in this scenario.

Explanation:

• The history suggests angina (exertional chest pain relieved by rest), indicating possible coronary artery disease.

• A resting ECG may be normal between episodes; therefore, an exercise ECG is useful to provoke ischemic changes during stress.

• Chest X-ray and echocardiogram can help evaluate structural heart disease but are less useful initially in typical angina diagnosis.

• Repeating ECG later is not immediately helpful without symptom changes.

• Thallium scan is a more advanced nuclear imaging test, usually reserved if exercise ECG is inconclusive or if the patient cannot exercise.

Thus, an exercise treadmill test is the most appropriate next step.