Case Studies & Practical Application Flashcards

A 77-year-old man with a history of MI is started on dual antiplatelet therapy (aspirin + clopidogrel) and also takes omeprazole. His cardiologist questions this combination. What is the clinical concern?

Answer: Omeprazole inhibits CYP2C19 and may reduce clopidogrel's antiplatelet effect

Omeprazole inhibits CYP2C19, reducing conversion of clopidogrel to its active metabolite and potentially diminishing its antiplatelet efficacy.

A 69-year-old woman presents with 3 weeks of constipation, decreased appetite, fatigue, and mild confusion. Labs show: serum calcium 11.9 mg/dL, PTH elevated. Which diagnosis best explains this picture?

Answer: Primary hyperparathyroidism

Elevated calcium with a simultaneously elevated PTH is the hallmark of primary hyperparathyroidism, not malignancy, which suppresses PTH.

An 85-year-old woman presents with a 2-month history of fatigue and is found to have a hemoglobin of 9.8 g/dL, MCV of 72 fL, and ferritin of 6 ng/mL. She denies blood in her stool. What is the priority next step?

Answer: Refer to gastroenterology for colonoscopy to identify the source of iron deficiency

Iron deficiency anemia in an older adult without an obvious source mandates GI evaluation to rule out occult colorectal malignancy before treating with iron alone.

A 73-year-old man presents after a near-syncope episode while exercising. He reports exertional chest pain and dyspnea for 3 months. On exam, a harsh systolic crescendo-decrescendo murmur is heard best at the right upper sternal border radiating to the carotids. What is the most likely diagnosis?

Answer: Aortic stenosis

The classic triad of angina, syncope, and exertional dyspnea with a crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids is diagnostic of aortic stenosis.

A 70-year-old woman with no prior cardiac history is found to have new-onset atrial fibrillation. Her CHA₂DS₂-VASc score is 4. She has no contraindications to anticoagulation. What is the recommended management?

Answer: Initiate a direct oral anticoagulant (DOAC) such as apixaban

A CHA₂DS₂-VASc score of ≥2 in women (≥3 if counting sex) with AFib warrants anticoagulation; DOACs are preferred over warfarin in eligible patients.

A 68-year-old man with well-controlled HIV (CD4 720, undetectable viral load) on antiretroviral therapy presents for routine age-appropriate cancer screening. Which screening is uniquely elevated in priority for this patient compared to the general population?

Answer: Anal Pap smear for anal squamous cell carcinoma

People living with HIV have significantly higher rates of anal HPV infection and anal cancer; anal Pap screening is recommended in this population.

A 74-year-old woman with a history of recurrent falls and polypharmacy presents with dizziness. Her medication list includes diphenhydramine, oxybutynin, amitriptyline, and lorazepam. Using the Beers Criteria, how many of her medications are potentially inappropriate for her age?

Answer: All four

All four medications — diphenhydramine (anticholinergic), oxybutynin (anticholinergic), amitriptyline (anticholinergic/TCA), and lorazepam (benzodiazepine) — are on the AGS Beers Criteria as potentially inappropriate for older adults.