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Answers
Here are the answers to all the questions from your images:
Q1. From the listed below which belongs to the primary prevention:
- a. Prescribe Aspirin to patients with Stable Angina
- b. Patient education about getting Calcium rich food and physical activity
- c. Measuring blood Glucose level periodically to detect Diabetes
- d. Hearing screening for newborns
ANS: B - Patient education about calcium-rich food and physical activity is primary prevention (promoting health before disease occurs). Options a & c are secondary/tertiary; d is secondary (screening).
Q2. Which is the example of tertiary prevention?
- a. Prescribe aspirin to patients with Stable Angina to prevent heart attack
- b. Patient education about Osteoporosis
- c. Measuring blood Glucose level periodically to detect Diabetes Mellitus
- d. Immunization
ANS: A - Prescribing aspirin to a patient with existing Stable Angina to prevent a heart attack = tertiary prevention (managing established disease to prevent complications). Immunization (d) = primary; blood glucose measurement (c) = secondary screening.
Q3. From the listed below which belongs to the tertiary prevention?
- a. Prescribe Folic acid to prevent NTDs
- b. Pharmacological treatment and modification of risk-factors for Arterial Hypertension
- c. Mammography for women older than 45 years
- d. Pap test to detect cervical cancer
ANS: B - Treating an already-diagnosed hypertensive patient with drugs AND managing risk factors = tertiary prevention (controlling an established disease). Folic acid (a) = primary; mammography (c) and Pap test (d) = secondary (screening).
Q4. From the listed below which belongs to the secondary prevention:
- a. Prescribe folic acid before 12 weeks for pregnancy women to prevent NTDs
- b. Pharmacological treatment for Arterial Hypertension + modification of risk-factors
- c. Mammography with intervals for women over 45
- d. Anti-tobacco propaganda in healthy population
ANS: C - Mammography screening in asymptomatic women = secondary prevention (early detection of pre-clinical disease). Option a & d = primary; option b = tertiary (treating established disease).
Q5. Which is correct from the listed below (about Screening)?
- a. Screening is a synonym for secondary prevention - means asymptomatic patient examination to determine existence/absence of disease
- b. Screening is a synonym for primary prevention
- c. Screening is a synonym for tertiary prevention
ANS: A - Screening IS secondary prevention; it involves examining asymptomatic individuals to detect pre-clinical disease early.
Q6. Secondary Prevention means:
- a. Avoiding the development of a disease, implementing healthy lifestyle, reducing risk-factors
- b. Avoiding the complications of a disease or disability
- c. Early diagnostics of pre-clinical stage of a disease
ANS: C - Secondary prevention = early diagnosis of pre-clinical (asymptomatic) stage of disease. Option a = primary; option b = tertiary.
Q7. Pharmacological treatment for arterial hypertension + advice about modification of risk-factors is:
- a. Primary prevention
- b. Secondary prevention
- c. Tertiary prevention
ANS: C - Managing an already diagnosed hypertensive patient = tertiary prevention (preventing complications/disability of an established disease).
Q8. From the listed statements below which is true about prevention:
- a. Tertiary prevention means avoiding development of diseases
- b. Primary prevention means avoiding complications and disability
- c. Screening of asymptomatic diseases = secondary prevention = early diagnostics of pre-clinical stage
ANS: C - This is the only true statement. Tertiary = avoiding complications (not a); Primary = avoiding disease development (not b).
Q9. The 52-year-old woman with breast cancer - what will you do?
- a. Inform the patient while her son is with her in the hall
- b. Talk to son first, then decide together
- c. Inform both patient and son in the consultation room
- d. Tell patient I need to share important news, invite her to consultation room, ask if she wants her son present, and if she agrees invite the son too
ANS: D (already shown in image) - This respects patient autonomy, confidentiality, and the right to choose who is present.
Q10. From the listed statements about informing a patient - which do you disagree with?
- a. A doctor's duty is to treat; the doctor should decide what's best, avoid discussing complicated medical issues with patients who lack competence
- b. Giving complete information is a main part of medicine; patients should be aware of their health issues
- c. A patient should be an active member in making decisions; the doctor should explain clearly and confirm the patient understood
ANS: A - Statement a is paternalistic and violates the principles of informed consent and patient autonomy. Modern medical ethics requires shared decision-making (options b and c are correct principles).
Q11. Which is the correct combination?
- a. Primary prevention - Avoid trauma (e.g. use seatbelts)
- b. Secondary prevention - Modification of risk-factors
- c. Tertiary prevention - Colonoscopy
ANS: A - Using seatbelts to avoid trauma is a correct example of primary prevention (preventing disease/injury before it occurs). Option b is wrong (modifying risk factors in healthy people = primary; in sick people = tertiary). Option c is wrong (colonoscopy = secondary prevention/screening, not tertiary).
Q12. Which is an example of primary prevention from the listed below?
- a. Prescribe Aspirin to patients with Stable Angina to prevent heart attack
- b. Patient education about osteoporosis
- c. Measuring blood Glucose periodically to detect Diabetes Mellitus
- d. Hearing screening for newborns
ANS: B - Patient education about osteoporosis (before disease develops) = primary prevention. Options c & d = secondary (screening); option a = tertiary.
Quick Reference Summary
| Level | Goal | Examples |
|---|---|---|
| Primary | Prevent disease before it starts | Education, seatbelts, folic acid, anti-tobacco campaigns, calcium/exercise advice |
| Secondary | Early detection of pre-clinical disease | Mammography, Pap smear, glucose screening, hearing screening, colonoscopy |
| Tertiary | Manage established disease, prevent complications | Aspirin for Stable Angina, antihypertensives + risk factor modification |
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Answers
Here are the answers to all the clinical case questions from your images:
Question 1 - 43 y.o. Male, Routine Physical
Case: 43M, no symptoms, no PMH. FH: DM and HTN in 2 first-degree relatives. BP 134/86 → repeat 126/76 and 128/78. BMI 32. Normal Cr and plasma glucose.
What is his BP classification and what should you do next?
ANS: His repeat BPs (126/76, 128/78) are normal/elevated (not hypertensive). The initial 134/86 was likely white-coat effect. However, given his strong family history of HTN and DM, plus BMI 32 (obese):
- BP classification: Normal (repeat values < 130/80)
- Management: Counsel on lifestyle modifications - weight loss, DASH diet, aerobic exercise, sodium restriction
- Screen for DM (fasting glucose/HbA1c given FH)
- Recheck BP at next visit in 1 year
- No antihypertensive medication needed yet
Question 2 - 57 y.o. African American Male, Newly Diagnosed HTN
Case: 57 y.o. African American M, newly diagnosed HTN. PMH: HLD on moderate-dose simvastatin. BP 151/94, HR 72, BMI 28. Fasting glucose 104, K+ 4.5. Urine dipstick: no blood or protein.
ANS: Best initial antihypertensive = Thiazide diuretic OR Calcium Channel Blocker (CCB)
Reasoning:
- In African American patients, clinical guidelines (JNC 8 / ACC/AHA) recommend thiazide diuretics or CCBs as first-line (ACE inhibitors/ARBs are less effective as monotherapy in this population)
- BP is Stage 1 HTN (140-159/90-99) → start pharmacotherapy + lifestyle changes
- Fasting glucose 104 = impaired fasting glucose (pre-diabetes) → avoid thiazides at high dose if possible; CCB (e.g. amlodipine) may be preferred
- No proteinuria, so no mandatory ACEi/ARB indication
- Best answer: Amlodipine (CCB) as first-line for African American patient with pre-diabetes
Question 3 - 48 y.o. Woman, Follow-up for Newly Diagnosed HTN
Case: 48F, newly diagnosed HTN confirmed by multiple measurements. PMH: HLD on atorvastatin. Lifestyle mods recommended. BP 160/92, HR 64, BMI 32. Fasting glucose 114, K+ 4.0. Urine dipstick: no blood or protein.
ANS: Start antihypertensive medication - ACE inhibitor or ARB preferred
Reasoning:
- BP 160/92 = Stage 2 HTN → pharmacotherapy is required (lifestyle alone is insufficient)
- Fasting glucose 114 = pre-diabetes (100-125) → ACE inhibitor (e.g. lisinopril) or ARB preferred: renoprotective, metabolically neutral, may delay progression to DM
- Already on atorvastatin for HLD - no interaction concern
- K+ 4.0 = normal, ACEi safe
- No proteinuria yet, but ACEi/ARB provides extra renal protection given metabolic risk
- Best answer: Start ACE inhibitor (e.g. lisinopril) + continue lifestyle modifications
Question 4 - 51 y.o. Male, HTN + Diabetes
Case: 51M, newly diagnosed HTN + DM. On lifestyle modifications for DM, no anti-HTN meds yet. BP 148/92, HR 76, BMI 33. Cr 1.5, K+ 4.2. Urine dipstick: no hematuria/proteinuria. Spot urine protein-creatinine ratio: 50 mg/g.
ANS: Start ACE inhibitor (or ARB)
Reasoning:
- Patient has DM + HTN + elevated Cr 1.5 (reduced kidney function) + microalbuminuria (urine PCR 50 mg/g = microalbuminuria range 30-300 mg/g)
- ACEi or ARB is mandatory in diabetic patients with CKD/microalbuminuria - they reduce proteinuria and slow CKD progression
- BP target in DM + CKD: < 130/80 mmHg
- K+ 4.2 is acceptable for starting ACEi, but monitor closely (Cr 1.5 suggests CKD stage ~2-3)
- Do NOT use thiazide as sole agent; avoid CCB alone without RAAS blockade
- Best answer: Start ACE inhibitor (e.g. lisinopril) or ARB (e.g. losartan) + lifestyle modifications for both HTN and DM
Q8 (from first image with ANS: B) - 26 y.o. Woman Planning Pregnancy
Case: Healthy 26F, planning a family soon, never been pregnant. Which intervention has been shown to have a clear beneficial outcome?
- a. Blood typing and antibody testing
- b. Screening for HIV
- c. Screening for Chlamydia
ANS: B - Screening for HIV
Reasoning:
- Pre-conception HIV screening is a USPSTF Grade A recommendation for all women aged 15-65 (and all pregnant women)
- Early detection allows treatment to prevent mother-to-child transmission and protect maternal health
- Blood typing (a) is done at first prenatal visit, not pre-conception
- Chlamydia screening (c) is recommended for sexually active women under 25, but the "clear beneficial outcome" evidence is stronger for HIV in the pre-conception context as tested here
Q16 (from document image with ANS: D) - 64 y.o. Former Smoker with COPD
Case: 64M former smoker, increasing dyspnea, barrel chest, pursed-lip breathing, tripod positioning, decreased breath sounds, distant heart sounds. Concerned about COPD. Which spirometry measurement is most sensitive to diagnose COPD?
- a. Total lung capacity (TLC)
- b. Forced vital capacity (FVC)
- c. Forced expiratory volume in 1 second (FEV1)
- d. FEV1/FVC ratio
ANS: D - FEV1/FVC ratio (already shown in image)
Reasoning:
- COPD diagnosis requires confirmation by spirometry showing post-bronchodilator FEV1/FVC < 0.70 (GOLD criteria)
- This ratio is the defining criterion for obstructive airflow limitation
- FEV1 alone (c) tracks severity but is not the diagnostic criterion
- TLC increases in COPD (hyperinflation) but is not the diagnostic standard
- FVC may be reduced but is not specific for obstruction
Answer Slide - Sulfonylureas (Question C explanation)
ANS: C - Sulfonylureas have long half-lives and can cause prolonged hypoglycemia in elderly patients and those with renal insufficiency. In such patients, insulin may be more appropriate, with a less-intensive HbA1c target of 8% instead of 7%.
This applies to a case involving an elderly or renally impaired diabetic patient where a sulfonylurea was being considered - the correct answer is C because it accurately describes the risk and provides the appropriate alternative (insulin, relaxed HbA1c goal).
Answers
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"Most effective drug for hypertension in pregnancy is?" A, ACE inhibitors. B, Angiotensin receptor blockers. C, Diuretics. D, Methyl-dopa.
ANS: D - Methyldopa
Methyldopa is the drug of choice for hypertension in pregnancy.
Why Methyldopa?
- It has the longest safety record in pregnancy, with decades of use and no evidence of fetal harm
- It is a centrally acting alpha-2 agonist that reduces sympathetic outflow, lowering BP without reducing uteroplacental blood flow
- Considered safe in all trimesters
- Recommended by WHO, JNC, and most obstetric guidelines as first-line for chronic hypertension in pregnancy
Why the others are WRONG (and dangerous):
| Drug | Reason Avoided |
|---|---|
| ACE Inhibitors | Contraindicated - cause fetal renal dysgenesis, oligohydramnios, skull hypoplasia, fetal death (especially 2nd/3rd trimester) |
| ARBs | Contraindicated - same fetotoxic mechanism as ACEi (block fetal RAAS), cause fetal renal failure |
| Diuretics | Generally avoided - reduce plasma volume, which is already physiologically expanded in pregnancy; can compromise uteroplacental perfusion |
Other safe options in pregnancy (for reference):
- Labetalol (beta + alpha blocker) - widely used, especially IV for acute severe HTN
- Nifedipine (CCB) - also commonly used, especially for acute management
- Hydralazine - used IV for hypertensive emergencies in pregnancy
Bottom line: For the exam, Methyldopa = drug of choice for chronic hypertension in pregnancy. ACEi and ARBs are absolutely contraindicated.
A 45-year-old obese Hispanic woman present for follow-up of her diabetes. She currently takes glipizide, which is sulfonylurea, 10 mg twice per day, and her fasting morning glucose runs approximately 170 to 200 mg/dL. Her last HbA1c was 7.9. She states that she con- consistently follow her diet and that she walks 30 minutes to one hour daily. Which of the following is the best next step in her care? A, add an insulin pump. B, add metformin. C, add thiazolidinediones. And D, hospitalize her urgently.
ANS: B - Add Metformin
Why Metformin?
This patient has inadequately controlled T2DM on maximum-dose glipizide (10mg BID is the max dose) with HbA1c 7.9% (goal < 7%). She is compliant with diet and exercise, so the next step is adding a second agent rather than switching.
Metformin is the ideal add-on because:
- It is the first-line agent for T2DM per ADA guidelines and should be added whenever monotherapy fails
- Works by a different mechanism (reduces hepatic glucose output / improves insulin sensitivity) - complementary to sulfonylurea which stimulates insulin secretion
- Especially beneficial in obese patients - weight neutral to modest weight loss effect
- Reduces cardiovascular mortality (UKPDS data)
- Low cost, well-tolerated, no hypoglycemia risk on its own
- Particularly appropriate in Hispanic patients who have high rates of insulin resistance
Why the others are wrong:
| Option | Why Not |
|---|---|
| A - Insulin pump | Way too aggressive as a next step; pumps are for T1DM or highly refractory T2DM; she is not at that stage |
| C - Thiazolidinediones (TZDs) | e.g. pioglitazone - these are third-line agents; also cause weight gain (already obese), fluid retention, fracture risk, and possible bladder cancer risk; not the best next step |
| D - Hospitalize urgently | No indication - she is not in DKA or hyperosmolar crisis; glucose 170-200 is elevated but not an emergency |
Clinical Pearl:
Her HbA1c of 7.9% means she is about 0.9% above goal. Adding metformin typically lowers HbA1c by 1-1.5%, which would bring her to target. This is a textbook step-up therapy scenario.
Bottom line: Add metformin to her existing glipizide. If she still fails to reach goal after 3 months, the next step would be adding a third agent (GLP-1 agonist, SGLT-2 inhibitor, or insulin).
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