1. Hypertension
By Alaina darby

2. A patient has hypertension and suffers from migraines
A patient has hypertension and suffers from migraines. Which of the following agents could be used to manage both conditions?
A. Metoprolol
B. Atenolol
C. Propranolol
D. Lisinopril
E. Amlodipine C
Propranolol (Inderal LA, InnoPran XL) is a non-selective beta blocker and is highly lipophilic. It crosses the blood-brain barrier easily and is used for migraine headache prophylaxis, essential tremor, stage fright, hypertension and a few other conditions. 

3. History of Present Illness: TW, a 65 year old African American male, presents to the clinic to begin drug treatment for his high blood pressure. He has recently retired from construction work and is now able to focus more on his health.
Allergies: Bactrim (TMP-SMX) (rash)
Past Medical History: 
Diabetes mellitus type 2 
Newly diagnosed hypertension
Dyslipidemia
Current Medications:
Zocor (simvastatin) 40 mg PO QHS 
Metformin 1000 mg PO BID 
Tums 1-2 tablets Q4-6H PRN 
MVI daily   
Vitals: 
Height: 5'10"             Weight: 175 lbs 
BP: 158/94 mmHg   HR: 83 BPM       RR: 20 BPM 
Temp: 98.6ºF           Pain: 1/10   
1/10 Labs (2 months prior):
AST (units/L) = 24 ( ) 
ALT (units/L) = 21 ( ) 
TC (mg/dL) = 190 ( ) 
TG (mg/dL) = 160 (< 150) 
HDL (mg/dL) = 45 (> 40) 
LDL (mg/dL) = 101 (<100)
GLU (mg/dL) = 140 ( ) 
Na (mEq/L) = 141 ( )                       
K (mEq/L) = 3.6 ( )                             
Cl (mEq/L) = 100 ( )                         
HCO3 (mEq/L) = 28 ( )                       
BUN (mg/dL) = 22 (7 - 20)                           
SCr (mg/dL) = 1.1 ( ) 
Ca (mg/dL) = 9.5 ( ) 
Hgb A1C = 7.2 %
Urinalysis = albumin (-) and ketones (-)   

4. C. Angiotensin receptor blockers D. Calcium channel blockers
Which class of medications is most appropriate as initial therapy for TW? 
A. Beta blockers
B. ACE inhibitors
C. Angiotensin receptor blockers
D. Calcium channel blockers
E. Thiazide-type diuretics D
In black hypertensive patients, initial therapy should include a CCB or a thiazide-type diuretic according to JNC 8. Even though cross-reactivity is unlikely, thiazide-type diuretics are contraindicated in patient's with a sulfonamide allergy. TW is allergic to Bactrim.

5. What is TW's blood pressure goal according to JNC 8?
A. < 130/80 mmHg
B. < 140/90 mmHg
C. < 150/90 mmHg
D. < 120/80 mmHg 
E. < 130/70 mmHg B
Although TW is > 60 years of age, he has diabetes. All patients with diabetes have a goal BP of < 140/90 mmHg regardless of age.

6. A. His metformin dose will need to be reduced.
TW is started on amlodipine. Which of the following statements is correct?
A. His metformin dose will need to be reduced.
B. TW should stop taking Tums since amlodipine is a calcium channel blocker.
C. If kept on Zocor (simvastatin), the dose will need to be reduced.
D. Zocor (simvastatin) should be discontinued since TW does not have high cholesterol.
E. TW should be started on two drugs at the same time for his high blood pressure. C
The maximum dose of simvastatin for patients taking amlodipine is 20 mg. Two drugs can be considered for initial management of hypertension if the BP > 160/90 mmHg or > 20/10 mmHg above goal.

7. A. The patient needs an agent to lower her potassium level.
A patient is using chlorthalidone 25 mg daily has a reported potassium level of 4.6 mEq/L and a CrCl of 25 mL/min. Which of the following statements is correct?
A. The patient needs an agent to lower her potassium level.
B. Chlorthalidone works by blocking Na+ reabsorption in the proximal tubules of the nephron.
C. Chlorthalidone is also useful in treating dyslipidemia.
D. Chlorthalidone is ineffective when CrCl is less than 30 mL/min.
E. Chlorthalidone has been shown to be less effective than other thiazide-type diuretics. D

8. A 62 year-old female patient comes to the clinic for follow-up evaluation of her osteoporosis. Her BP last visit was 158/92 mmHg and 154/95 mmHg this visit. According to the JNC 8 guidelines, what is this patient's goal BP?
 A. < 140/90 mmHg
B. < 120/80 mmHg
C. < 150/90 mmHg
D. < 140/80 mmHg
E. < 130/80 mmHg C

9. What is the mechanism of action of clonidine?
A. Acts as an alpha-1 agonist, resulting in a decrease in norepinephrine release
B. Acts as an alpha-1 antagonist, resulting in an increase in norepinephrine release
C. Acts as an alpha-2 agonist, resulting in a decrease in norepinephrine release
D. Acts as an alpha-2 antagonist, resulting in a decrease in norepinephrine release
E. Acts as an alpha-1 and alpha-2 antagonist, resulting in an increase in norepinephrine release C
By acting as an alpha-2 receptor agonist, norepinephrine outflow is reduced. This is called reducing sympathetic outflow.

10. B. Adalat CC (nifedipine) C. Lotensin (metoprolol)
AK, a 68 year-old white male, is being treated at the clinic for hypertension. Today his BP is 147/93 mmHg. His PMH is significant for GERD, diabetes and gout. AK is currently taking Janumet XR (sitagliptin + metformin), Motrin, Hyzaar (HCTZ + losartan) and Zantac (ranitidine). Which of the following medications would be appropriate to add for better BP control according to JNC 8?
A. Chlorthalidone
B. Adalat CC (nifedipine)
C. Lotensin (metoprolol)
D. Coreg (carvedilol)
E. AK does not need additional BP lowering because he is > 60 years of age. B
AK is currently taking Hyzaar (losartan + HCTZ); therefore calcium channel blockers are the only other first line agents to consider according to JNC 8.

11. A. Lack of understanding of the need to take medicine
YP has hypertension. He states he feels fine and cannot believe he has to take medication but because his physician told him to, he began to take lisinopril 10 mg daily. He developed an irritating, dry cough and was switched to irbesartan. He took the irbesartan for awhile then stopped using it. Which of the following factors can contribute to poor medication adherence in patients with hypertension? (Select ALL that apply.)
A. Lack of understanding of the need to take medicine
B. Inability to afford the medications
C. Side effects from medications
D. Hypertension is asymptomatic; therefore, the patient does not experience any symptom relief
E. The patient does not believe in taking medicines
ABCDE

12. Which beta blocker also has alpha-1 receptor antagonistic activity?
A. Atenolol
B. Propranolol
C. Labetalol
D. Nebivolol
E. Esmolol C

13. A. The patient should be switched to Vasotec (enalapril) therapy.
A 55 year-old male patient with hypertension was started on lisinopril. He developed severe swelling of his mouth, with trouble breathing. Choose the correct statement:
A. The patient should be switched to Vasotec (enalapril) therapy.
B. The patient should be switched to Atacand (candesartan) therapy.
C. The patient should be switched to Lotrel (amlodipine + benazepril) therapy.
D. The patient should be switched to Exforge (amlodipine + valsartan) therapy.
E. None of the above. E
The patient developed angioedema from ACE inhibitor therapy so they should not use any other RAAS inhibitor. It would be best/safest to pick an agent outside of the RAAS inhibitor class.

14. A. Enalapril can retain potassium; potassium levels must be monitored.
Which of the following statements are true regarding enalapril? (Select ALL that apply.)
A. Enalapril can retain potassium; potassium levels must be monitored.
B. Enalapril is an angiotensin-converting enzyme inhibitor.
C. Enalapril comes in an oral and patch formulation.
D. Enalapril can cause a dry, hacking cough.
E. Enalapril has been shown to be beneficial in heart failure and renal protection in diabetes.
ABDE

15. A. Hydrochlorothiazide B. Enalapril C. Hydralazine D. Eplerenone
VC comes to the clinic for a follow up visit for his hypertension and diabetes management. He has been taking four medications to control his blood pressure for a long time. Today, the pharmacist notices a butterfly rash across VC's nose and upper cheeks. Which of the following medications is most likely to cause this side effect?
A. Hydrochlorothiazide
B. Enalapril
C. Hydralazine
D. Eplerenone
E. Verapamil C
Hydralazine can cause lupus-like syndrome which is dose and duration related.

16. A 35-year old female patient is started on hydrochlorothiazide 25 mg daily. Which of the following statements are correct? 
A. She should use birth control while taking this medication because it is teratogenic.
B. She has an increased risk for low bone density; calcium and vitamin D intake should be optimized.
C. She has an increased risk for hypokalemia and may need potassium supplements.
D. If she has headaches while using this medication, it is best to use over the counter ibuprofen.
E. If she misses a dose, she should can double the next dose to make sure her blood pressure doesn't get too high. C
Thiazides increase calcium so they can modestly increase bone density when taken long-term. Thiazides are not teratogenic. Hypokalemia is the primary side effect of hydrochlorothiazide. Patients with high blood pressure should avoid NSAIDs and should never double doses of medication.

17. C. Angiotensin receptor blockers D. Calcium channel blockers
JG is a white male patient who presents with high blood pressure on several visits. According to the JNC 8 guidelines, which class of medications are appropriate at initial therapy for JG? (Select ALL that apply.)
A. Beta blockers
B. ACE inhibitors
C. Angiotensin receptor blockers
D. Calcium channel blockers
E. Thiazide-type diuretics
BCDE
ACE inhibitors, ARBs, CCBs and thiazide-type diuretics can be used initially in this patient according to JNC 8.

18. A hospitalized patient was given sodium polystyrene sulfonate this morning. The pharmacist is reviewing her medications. Which of the following medications on the profile most likely needs to be discontinued?
A. Metoprolol
B. Chlorthalidone
C. Hydralazine
D. Clonidine
E. Spironolactone E
The patient was given sodium polystyrene sulfonate (Kayexalate), which is used to treat hyperkalemia. Antihypertensive agents that retain potassium include ACEIs, ARBs, direct renin inhibitors, potassium-sparing diuretics and the aldosterone blockers (aldosterone and eplerenone).

19. A. Calcium channel blockers B. Angiotensin receptor blockers
ZW has just been diagnosed with hypertension. His past medical history is significant for BPH and bilateral renal artery stenosis. Which of the following medications should not be used for treatment of his hypertension? (Select ALL that apply.)
A. Calcium channel blockers
B. Angiotensin receptor blockers
C. Direct renin inhibitors
D. Angiotensin converting enzyme inhibitors
E. Beta-blockers
BCD
ACE inhibitors, ARBs, and the direct renin inhibitor (aliskiren) should not be used in patients with bilateral renal artery stenosis.

20. A patient has high blood pressure, but a slow heart rate
A patient has high blood pressure, but a slow heart rate. The patient occasionally suffers from orthostatic hypotension and syncope. The physician is concerned and does not wish to use a blood pressure medication which can lower heart rate. Choose an agent that does not lower heart rate:
A. Clonidine
B. Amlodipine
C. Diltiazem
D. Verapamil
E. Atenolol B
Beta blockers (without ISA activity), clonidine and the non-dihydropyridine calcium channel blockers are anti-hypertensive agents that lower heart rate. This can be useful in a patient with a fast heart rate, or tachycardia. A normal heart rate ranges from BPM.

21. A. Lisinopril and hydrochlorothiazide B. Amlodipine and benazepril
SH, a 55 year-old white male, has just been diagnosed with hypertension. He has no other known medical conditions. His blood pressure runs between /97-99 mmHg. Choose an appropriate initial treatment regimen for this patient according to JNC 8? (Select ALL that apply.)
A. Lisinopril and hydrochlorothiazide
B. Amlodipine and benazepril
C. Ziac (HCTZ + bisoprolol)
D. Clorpres (clonidine + chlorthalidone)
E. Hydrochlorothiazide and labetalol AB
Two agents can be considered since his systolic blood pressure is > 160 mmHg. Beta blockers and clonidine are not considered first line for essential hypertension.

22. B. Lipitor (atorvastatin) C. Zestril (lisinopril) D. Losartan
A 32 year-old female patient has gone to see her primary care physician. The doctor is looking at her blood work, which includes the following parameters: total cholesterol 202 mg/dL, HDL 52 mg/dL, LDL 130 mg/dL, TG 96 mg/dL, BUN 18 mg/dL, SCr 0.8 mg/dL, hCG+, with a blood pressure of 148/88 mmHg. Which of the following medications can be safely administered?
A. Labetalol
B. Lipitor (atorvastatin)
C. Zestril (lisinopril)
D. Losartan
E. Tekturna (aliskiren) A
The patient is pregnant (hCG+). She cannot use statins, ACE inhibitors, angiotensin-receptor blockers, or direct renin inhibitors. These medications, if used, should be discontinued as soon as pregnancy is detected.

23. E. Pulmonary hypertension
A patient is prescribed Aldactone (spironolactone). What are the labeled indications for Aldactone? (Select ALL that apply.)
A. Hypertension
B. Heart failure
C. Diabetes
D. COPD
E. Pulmonary hypertension AB

24. What is the mechanism of action of Diovan (valsartan)?
A. Angiotensin converting enzyme inhibitor
B. Beta-1 selective adrenergic antagonist
C. Angiotensin receptor blocker
D. Calcium channel blocker
E. Alpha-2 receptor agonist C

25. A. Her new medication is safe in pregnancy.
A patient gave the pharmacist a prescription for Cozaar (losartan) she needed filled. Her other medication is Yaz contraceptive pills. The pharmacy is in a supermarket and the pharmacist notices the patient has Morton Salt Balance in her shopping cart, which contains potassium chloride. Which of the following are correct counseling statements for this patient? (Select ALL that apply.)
A. Her new medication is safe in pregnancy.
B. Yaz can increase potassium.
C. Her new medication can cause a dry, hacking cough.
D. Her new medication, and the salt substitute, can increase her potassium.
E. Her new medication can decrease the effectiveness of Yaz. BD

26. A patient with diabetes, hypertension, and peptic ulcer disease is on aspirin, glyburide, enalapril, metoprolol, chlorthalidone, and famotidine. Which of the patient's medications may block signs and symptoms of hypoglycemia?
A. Enalapril
B. Metoprolol
C. Aspirin
D. Chlorthalidone
E. Famotidine B
The physiologic response to hypoglycemia is mediated by sympathetic/adrenergic stimulation. Therefore, beta blockers can mask many signs and symptoms of hypoglycemia.

27. D. Myocardial infarction E. Stroke
The package labeling for aliskiren has a contraindication that warns not to use aliskiren in combination with ACE inhibitors or ARBs in patients with:
A. Diabetes
B. Hepatitis
C. Raynaud's syndrome
D. Myocardial infarction
E. Stroke A

28. A 54 year-old female has hypertension and COPD
A 54 year-old female has hypertension and COPD. She is already using a thiazide-type diuretic, a calcium channel blocker and an angiotensin receptor blocker but her blood pressure remains elevated at a range of / mmHg. She will be started on beta blocker therapy. Which of the following agents is most appropriate?
A. Carteolol
B. Carvedilol
C. Propranolol
D. Metoprolol
E. Timolol D
With a chronic breathing condition (asthma, COPD, emphysema), the non-selective beta blockers should be avoided.

29. A. Lopressor (metoprolol) B. Cardizem (diltiazem)
Which of the following antihypertensives should not be taken with grapefruit or grapefruit juice? (Select ALL that apply.)
A. Lopressor (metoprolol)
B. Cardizem (diltiazem)
C. Coreg (carvedilol)
D. Calan (verapamil)
E. Procardia (nifedipine)
BDE
All calcium channel blockers are substrates of CYP 3A4. Counsel patients to avoid grapefruit (the juice and the fruit), or try an alternative drug that does not interact. Separating the time a person drinks or eats grapefruit from the drug will not work.

30. A. Potassium can decrease B. Calcium can decrease
A patient has been started on hydrochlorothiazide. Which of the following statements are correct? (Select ALL that apply.)
A. Potassium can decrease
B. Calcium can decrease
C. Uric acid can increase
D. Sodium can increase
E. Magnesium can decrease
ACE
Thiazide diuretics can decrease potassium, sodium and magnesium and increase calcium, uric acid, blood glucose and cholesterol.

31. A. Take this medication by mouth four times daily.
A patient gave the pharmacist a prescription for Catapres TTS-1 (clonidine patch) #4. Choose the correct counseling statement for this medication. 
A. Take this medication by mouth four times daily.
B. The FDA recommends that this medication be disposed of by flushing in a sink or toilet. 
C. Replace the patch every morning.
D. Rotate the site where you place the patch.
E. This is the highest dose available of this medication. D
The clonidine patch is replaced every seven days. It is available in a higher dose.

32. History of Present Illness: AC is a 67-year old female who is brought to the urgent care clinic by her daughter with headache and confusion. After reviewing her information, the urgent care clinic sends AC to the emergency room.
Allergies: NKDA
Past Medical History:
Hypertension 
Mild COPD
Physical Exam/Vitals (at urgent care clinic):
BP 222/128 mmHg   HR 87 BPM     RR 18 BPM
Height: 5’ 5”       Weight: 144 pounds  
Home Medications (ran out of her blood pressure
medications 4 days ago):
Zestril (lisinopril) 20 mg PO daily
Hydrochlorothiazide 25 mg PO daily
Catapres (clonidine) 0.2 mg PO BID
Atrovent MDI 2 puffs Q6H PRN shortness of breath
Additional Notes (per daughter):
AC has no history of renal or hepatic impairment. She struggles keeping up with her medicines sometimes.
Labs (in emergency room):
Na (mEq/L) = 141 ( )                       
K (mEq/L) = 4.9 ( )                             
Cl (mEq/L) = 100 ( )                         
HCO3 (mEq/L) = 28 ( )                       
BUN (mg/dL) = 50 (7 - 20)                           
SCr (mg/dL) = 2.5 ( ) 
GLU (mg/dL) = 140 ( ) 
Ca (mg/dL) = 9.5 ( ) 
AST (units/L) = 30 ( ) 
ALT (units/L) = 28 ( ) 
Hgb A1C = 6.4 %
Urinalysis = albumin (+) and ketones (-)   

33. In addition to hydrochlorothiazide, AC is taking which of the following medications for high blood pressure? (Select ALL that apply.)
A. Lisinopril
B. Fosinopril
C. Amlodipine
D. Clonidine
E. Losartan AD

34. A. Hydrochlorothiazide B. Lisinopril C. Atrovent D. Clonidine
Of the medications AC stopped taking, which one has most likely caused her acute rise in blood pressure?
A. Hydrochlorothiazide
B. Lisinopril
C. Atrovent
D. Clonidine
E. None of her medications would cause an acute rise in blood pressure D
Clonidine causes rebound hypertension due to a sudden increase in sympathetic outflow. If discontinued, clonidine requires a slow taper to prevent this acute rise in blood pressure.

35. B. Discontinue all medications except hydrochlorothiazide.
After a few days, AC's blood pressure is at a safe level and she is to be discontinued on her home regimen. Which of the following pharmacist recommendations would help with AC's medication compliance?
A. Discontinue Zestril (lisinopril) and hydrochlorothiazide and start Zestoretic (lisinopril + HCTZ).
B. Discontinue all medications except hydrochlorothiazide.
C. Discontinue Zestril (lisinopril) and hydrochlorothiazide and start Tenoretic (atenolol)
D. Discontinue Catapres (clonidine) and start Catapres-TTS patch daily
E. Discontinue hydroclorothiazide and start Tekturna HCT (aliskiren + HCTZ) A
Zestoretic is the combination product containing lisinopril and hydrochlorothiazide. A combination drug may help with AC's compliance. A clonidine patch is another thing to consider but the patch is dosed weekly, not daily.

36. B. Hydrochlorothiazide C. Zestril (lisinopril) D. Atrovent
AC receives counseling on all of her home medications at discharge. The pharmacist tells her "this medication can cause dry mouth, constipation and fatigue". Which medication is the pharmacist referring to? 
A. Clonidine
B. Hydrochlorothiazide
C. Zestril (lisinopril)
D. Atrovent
E. Hydralazine A
Clonidine is not used first-line and has many side effects that make it a difficult drug for patients to tolerate, including constipation, dry mouth, fatigue, lethargy, aggravation of depression and sexual dysfunction/impotence.

37. Referring to the figure, which choice best represents the site where chlorthalidone exerts its mechanism of action? B
Chlorthalidone and other thiazide diuretics inhibit sodium reabsorption in the distal convoluted tubule.

38. A. Inhibitor of beta-1 and beta-2 adrenergic receptors
A cardiologist has ordered nebivolol 5 mg PO daily for a patient. Which of the following is a mechanism of action of nebivolol? 
A. Inhibitor of beta-1 and beta-2 adrenergic receptors
B. Inhibitor of beta-1 adrenergic receptors
C. Prevents nitric oxide-dependent vasoconstriction
D. Inhibitor of alpha-1 and alpha-2 adrenergic receptors
E. Inhibitor of alpha-1 adrenergic receptors B
Nebivolol is a beta-1 selective blocker that also has nitric-oxide dependent vasodilation.

39. History of Present Illness: KB, a 55 year old white male, is seen in clinic to get his blood pressure checked. He has no specific complaints today and does not think he needs to take any medications because he feels “just fine”.
Allergies: NKDA
Past Medical History: 
Hypertension
Gout
Current Medications:
Allopurinol 300 mg PO daily
Altace (ramipril) 10 mg PO daily
Norvasc (amlodipine) 10 mg PO daily
Vitals: 
Height: 6’ 2"                  Weight: 180 lbs 
BP: 149/90 mmHg         HR: 83 BPM            RR: 20 BPM 
Temp: 98.6ºF                 Pain: 0/10   
Labs (today):
Na (mEq/L) = 141 ( )                       
K (mEq/L) = 4.2 ( )                             
Cl (mEq/L) = 100 ( )                         
HCO3 (mEq/L) = 28 ( )                       
BUN (mg/dL) = 22 (7 - 20)                           
SCr (mg/dL) = 0.9 ( ) 
GLU (mg/dL) = 120 ( ) 
Ca (mg/dL) = 9.5 ( ) 

40. According to JNC 8, what is KB's blood pressure goal?
A. < 150/90 mmHg
B. < 140/90 mmHg
C. < 130/80 mmHg
D. < 130/70 mmHg
E. < 120/80 mmHg B
KB does not have diabetes or chronic kidney disease and is < 60 years of age; his BP goal is < 140/90 mmHg.

41. A. Increase Altace (ramipril) to 20 mg B. Add irbesartan
Which of the following options are appropriate to gain further control of KB's blood pressure? (Select ALL that apply.)
A. Increase Altace (ramipril) to 20 mg
B. Add irbesartan
C. Add chlorthalidone
D. Add aliskiren
E. Increase Norvasc (amlodipine) to 20 mg AC
Doses of current medications can be titrated to maximum tolerated doses or additional agents can be added. The max dose of Norvasc is 10 mg. When adding drugs, it is recommended to choose from one of the four preferred drug classes as long as an ACE inhibitor or ARB is not used together.

42. A. Blood glucose can decrease. B. Calcium can decrease.
KB is started on hydrochlorothiazide 25 mg daily. Which of the following statements are correct? 
A. Blood glucose can decrease.
B. Calcium can decrease.
C. It can worsen gout.
D. It can cause edema.
E. It can help cholesterol. C
Thiazide diuretics can decrease potassium, sodium and magnesium and increase calcium, uric acid, blood glucose and cholesterol.

43. Questions?
Content adapted from RxPrep