Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 5 — Questions and Answers
Question 1: 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?
- Omeprazole increases clopidogrel bioavailability, causing bleeding risk
- Omeprazole inhibits CYP2C19 and may reduce clopidogrel's antiplatelet effect (Correct answer)
- Aspirin blocks omeprazole's gastroprotective effect
- The combination causes QT prolongation
Correct 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.
Question 2: 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?
- Malignancy-associated hypercalcemia
- Primary hyperparathyroidism (Correct answer)
- Vitamin D toxicity
- Milk-alkali syndrome
Correct answer: Primary hyperparathyroidism
Elevated calcium with a simultaneously elevated PTH is the hallmark of primary hyperparathyroidism, not malignancy, which suppresses PTH.
Question 3: 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?
- Start iron supplementation and recheck CBC in 6 weeks
- Refer to gastroenterology for colonoscopy to identify the source of iron deficiency (Correct answer)
- Order bone marrow biopsy to evaluate for myelodysplasia
- Start erythropoietin-stimulating agent
Correct 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.
Question 4: 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?
- Hypertrophic obstructive cardiomyopathy (HOCM)
- Mitral regurgitation
- Aortic stenosis (Correct answer)
- Pulmonary stenosis
Correct 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.
Question 5: 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?
- Aspirin 81 mg daily is sufficient anticoagulation
- Rate control only without anticoagulation since she is asymptomatic
- Initiate a direct oral anticoagulant (DOAC) such as apixaban (Correct answer)
- Refer for immediate cardioversion before starting anticoagulation
Correct 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.
Question 6: 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?
- Annual chest X-ray for lung cancer
- Anal Pap smear for anal squamous cell carcinoma (Correct answer)
- Annual PSA testing beginning at age 45
- Annual skin biopsy of pigmented lesions
Correct 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.
Question 7: 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?
- One
- Two
- Three
- All four (Correct answer)
Correct 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.
Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 5
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?