Board review from medscape Case-Based Internal Medicine Self-Assessment Questions pdf

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Case-Based Internal Medicine

Self-Assessment Questions

CLINICAL ESSENTIALS

CARDIOVASCULAR MEDICINE

DERMATOLOGY

ENDOCRINOLOGY

GASTROENTEROLOGY

HEMATOLOGY

IMMUNOLOGY/ALLERGY

INFECTIOUS DISEASE

INTERDISCIPLINARY MEDICINE

METABOLISM

NEPHROLOGY

NEUROLOGY

ONCOLOGY

PSYCHIATRY

RESPIRATORY MEDICINE

RHEUMATOLOGY

BOARD REVIEW FROM MEDSCAPE

Case-Based Internal Medicine

Self-Assessment Questions

BOARD REVIEW FROM MEDSCAPE

Case-Based Internal Medicine

Self-Assessment Questions

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EDITORIAL BOARD

Editor-in-Chief

David C. Dale, M.D., F.A.C.P.

Professor of Medicine, University of Washington

Medical Center, Seattle, Washington

(Hematology, Infectious Disease, and General Internal

Medicine)

Founding Editor

Daniel D. Federman, M.D., M.A.C.P.

The Carl W. Walter Distinguished Professor of Medicine

and Medical Education and Senior Dean for Alumni

Relations and Clinical Teaching, Harvard Medical

School, Boston, Massachusetts

Associate Editors

Karen H. Antman, M.D.

Deputy Director for Translational and Clinical Science,

National Cancer Institute, National Institutes of Health,

Bethesda, Maryland

(Oncology)

John P. Atkinson, M.D., F.A.C.P.

Samuel B. Grant Professor and Professor of Medicine

and Molecular Microbiology, Washington University

School of Medicine, St. Louis, Missouri

(Immunology)

Christine K. Cassel, M.D., M.A.C.P.

President, American Board of Internal Medicine,

Philadelphia, Pennsylvania

(Ethics, Geriatrics, and General Internal Medicine)

Mark Feldman, M.D., F.A.C.P.

William O. Tschumy, Jr., M.D., Chair of Internal

Medicine and Clinical Professor of Internal Medicine,

University of Texas Southwestern Medical School of

Dallas; and Director, Internal Medicine Residency

Program, Presbyterian Hospital of Dallas, Dallas, Texas

(Gastroenterology)

Raymond J. Gibbons, M.D.

Director, Nuclear Cardiology Laboratory, The Mayo

Clinic, Rochester, Minnesota

(Cardiology)

Brian Haynes, M.D., Ph.D., F.A.C.P.

Professor of Clinical Epidemiology and Medicine and

Chair, Department of Clinical Epidemiology and

Biostatistics, McMaster University Health Sciences

Centre, Hamilton, Ontario, Canada

(Evidence-Based Medicine, Medical Informatics, and General

Internal Medicine)

Janet B. Henrich, M.D.

Associate Professor of Medicine and Obstetrics and

Gynecology, Yale University School of Medicine, New

Haven, Connecticut

(Women’s Health)

William L. Henrich, M.D., F.A.C.P.

Professor and Chairman, Department of Medicine,

University of Maryland School of Medicine, Baltimore,

Maryland

(Nephrology)

Michael J. Holtzman, M.D.

Selma and Herman Seldin Professor of Medicine, and

Director, Division of Pulmonary and Critical Care

Medicine, Washington University School of Medicine,

St. Louis, Missouri

(Respiratory Medicine)

Mark G. Lebwohl, M.D.

Sol and Clara Kest Professor and Chairman, Department

of Dermatology, Mount Sinai School of Medicine, New

York, New York

(Dermatology)

Wendy Levinson, M.D., F.A.C.P.

Vice Chairman, Department of Medicine, The

University of Toronto, and Associate Director, Research

Administration, Saint Michael’s Hospital, Toronto,

Ontario, Canada

(Evidence-Based Medicine and General Internal Medicine)

D. Lynn Loriaux, M.D., Ph.D., M.A.C.P.

Professor of Medicine and Chair, Department of

Medicine, Oregon Health Sciences University, Portland,

Oregon

(Endocrinology and Metabolism)

Shaun Ruddy, M.D., F.A.C.P.

Elam C. Toone Professor of Internal Medicine,

Microbiology and Immunology, and Professor Emeritus,

Division of Rheumatology, Allergy and Immunology,

Medical College of Virginia at Commonwealth

University, Richmond, Virginia

(Rheumatology)

Jerry S. Wolinsky, M.D.

The Bartels Family Professor of Neurology, The

University of Texas Health Science Center at Houston

Medical School, and Attending Neurologist, Hermann

Hospital, Houston, Texas

(Neurology)

EDITORIAL BOARD

PREFACE

CLINICAL ESSENTIALS

Ethical and Social Issues 1

Reducing Risk of Injury and Disease 2

Diet and Exercise 3

Adult Preventive Health Care 7

Health Advice for International Travelers 7

Quantitative Aspects of Clinical Decision Making 11

Palliative Medicine 12

Symptom Management in Palliative Medicine 15

Psych osocial Issues in Term in al Illn essc 17

Complementary and Alternative Medicine 20

1 CARDIOVASCULAR MEDICINE

Heart Failure 1

Hypertension 7

Atrial Fibrillation 12

Supraventricular Tachycardia 14

Pacemaker Therapy 15

Acute Myocardial Infarction 18

Chronic Stable Anginai 25

Unstable Angina/Non–ST Segment Elevation MI 30

Diseases of the Aorta 31

Pericardium, Cardiac Tumors, and Cardiac Trauma 35

Congenital Heart Disease 39

Peripheral Arterial Disease 43

Venous Thromboembolism 45

2 DERMATOLOGY

Cutaneous Manifestations of Systemic Diseases 1

Papulosquamous Disorders 3

CONTENTS

Psoriasis 5

Eczem atous Disorders, Atopic Derm atitis, Ich th yoses an d 9

Contact Dermatitis and Related Disorders 11

Cutaneous Adverse Drug Reactions 13

Fungal, Bacterial, and Viral Infections of the Skin 17

Parasitic Infestations 19

Vesiculobullous Diseases 21

Malignant Cutaneous Tumors 23

Benign Cutaneous Tumors 26

Acne Vulgaris and Related Disorders 29

Disorders of Hair 31

Diseases of the Nail 33

Disorders of Pigmentation 35

3 ENDOCRINOLOGY

Testes and Testicular Disorders 1

The Adrenal 3

Calcium Metabolism and Metabolic Bone Disease 5

Genetic Diagnosis and Counseling 8

Hypoglycemia 13

Obesity 15

4 GASTROENTEROLOGY

Esophageal Disorders 1

Peptic Ulcer Diseases 2

Diarrheal Diseases 5

Inflammatory Bowel Disease 6

Diseases of the Pancreas 8

Gallstones and Biliary Tract Disease 11

Gastrointestinal Bleeding 16

Malabsorption and Maldigestion 17

Diverticulosis, Diverticulitis, and Appendicitis 21

Enteral and Parenteral Nutritional Support 22

Gastrointestinal Motility Disorders 24

Liver and Pancreas Transplantation 25

5 HEMATOLOGY

Approach to Hematologic Disorders 1

Red Blood Cell Function and Disorders of Iron Metabolism 4

Anemia: Production Defects 5

Hemoglobinopathies and Hemolytic Anemia 10

The Polycythemias 15

Nonmalignant Disorders of Leukocytes 17

Transfusion Therapy 22

Hematopoietic Cell Transplantation 26

Hemostasis and Its Regulation 31

Hemorrhagic Disorders 33

Thrombotic Disorders 35

6 IMMUNOLOGY/ALLERGY

Innate Immunity 1

Histocompatibility Antigens/Immune Response Genes 3

Immunogenetics of Disease 5

Immunologic Tolerance and Autoimmunity 7

Allergic Response 8

Diagnostic and Therapeutic Principles in Allergy 10

Allergic Rhinitis, Conjunctivitis, and Sinusitis 11

Urticaria, Angioedema, and Anaphylaxis 14

Drug Allergies 16

Allergic Reactions to Hymenoptera 18

Food Allergies 21

7 INFECTIOUS DISEASE

Infections Due to Gram-Positive Cocci 1

Infections Due to Mycobacteria 8

Infections Due to Neisseria 14

Anaerobic Infections 16

Syphilis and Nonvenereal Treponematoses 21

E. coli and Other Enteric Gram-Negative Bacilli 24

Campylobacter, Salmonella, Shigella, Yersinia, Vibrio, Helicobacter 27

Haemophilus, Moraxella, Legionella, Bordetella, Pseudomonas 30

Brucella, Francisella, Yersinia Pestis, Bartonella 33

Diseases Due to Chlamydia 36

Antimicrobial Therapy 40

Septic Arthritis 45

Osteomyelitis 50

Rickettsia, Ehrlichia, Coxiella 52

Infective Endocarditis 54

Bacterial Infections of the Upper Respiratory Tract 57

Pneumonia and Other Pulmonary Infections 64

Peritonitis and Intra-abdominal Abscesses 72

Vaginitis and Sexually Transmitted Diseases 75

Urinary Tract Infections 77

Hyperthermia, Fever, and Fever of Undetermined Origin 79

Respiratory Viral Infections 82

Herpesvirus Infections 84

Enteric Viral Infections 88

Measles, Mumps, Rubella, Parvovirus, and Poxvirus 90

Viral Zoonoses 93

Human Retroviral Infections 96

HIV and AIDS 98

Protozoan Infections 103

Bacterial Infections of the Central Nervous System 105

Mycotic Infections 108

8 INTERDISCIPLINARY MEDICINE

Management of Poisoning and Drug Overdose 1

Bites and Stings 5

Cardiac Resuscitation 7

Preoperative Assessment 9

Bioterrorism 12

Assessment of the Geriatric Patient 15

Disorders in Geriatric Patients 18

Rehabilitation of Geriatric Patients 24

9 METABOLISM

Diagnosis and Treatment of Dyslipidemia 1

The Porphyrias 3

Diabetes Mellitus 4

10 NEPHROLOGY

Renal Function and Disorders of Water and Sodium Balance 1

Disorders of Acid-Base and Potassium Balance 3

Approach to the Patient with Renal Disease 5

Management of Chronic Kidney Disease 8

Glomerular Diseases 11

Acute Renal Failure 14

Vascular Diseases of the Kidney 16

Tubulointerstitial Diseases 21

Chronic Renal Failure and Dialysis 24

Renal Transplantation 28

Benign Prostatic Hyperplasia 31

11 NEUROLOGY

The Dizzy Patient 1

Diseases of the Peripheral Nervous System 3

Diseases of Muscle and the Neuromuscular Junction 7

Cerebrovascular Disorders 10

Traumatic Brain Injury 14

Neoplastic Disorders 16

Anoxic, Metabolic, and Toxic Encephalopathies 19

Headache 21

Demyelinating Diseases 23

Inherited Ataxias 27

Alzh eim er Disease an d Oth er Dem en tin g Illn esses Major 27

Epilepsy 31

Disorders of Sleep 34

Pain 38

Parkinson Disease and Other Movement Disorders 41

Acute Viral Central Nervous System Diseases 43

Central Nervous System Diseases Due to Slow Viruses and Prions 45

12 ONCOLOGY

Cancer Epidemiology and Prevention 1

Molecular Genetics of Cancer 2

Principles of Cancer Treatment 4

Colorectal Cancer 8

Pancreatic, Gastric, and Other Gastrointestinal Cancers 10

Breast Cancer 13

Lung Cancer 18

Prostate Cancer 20

Gynecologic Cancer 26

Oncologic Emergencies 29

Sarcomas of Soft Tissue and Bone 32

Bladder, Renal, and Testicular Cancer 34

Chronic Lymphoid Leukemias and Plasma Cell Disorders 36

Acute Leukemia 38

Chronic Myelogenous Leukemia and Other Myeloproliferative Disorders 42

Head and Neck Cancer 45

13 PSYCHIATRY

Depression and Bipolar Disorder 1

Alcohol Abuse and Dependency 4

Drug Abuse and Dependence 6

Schizophrenia 9

Anxiety Disorders 11

14 RESPIRATORY MEDICINE

Asthma 1

Chronic Obstructive Diseases of the Lung 5

Focal and Multifocal Lung Disease 14

Chronic Diffuse Infiltrative Lung Disease 16

Ventilatory Control during Wakefulness and Sleep 20

Disorders of the Chest Wall 22

Respiratory Failure 26

Disorders of the Pleura, Hila, and Mediastinum 29

Pulmonary Edema 32

Pulmonary Hypertension, Cor Pulmonale, and Primary Pulmonary Vascular Diseases 35

15 RHEUMATOLOGY

Introduction to the Rheumatic Diseases 1

Rheumatoid Arthritis 3

Seronegative Spondyloarthropathies 9

Systemic Lupus Erythematosus 13

Scleroderma and Related Diseases 15

Idiopathic Inflammatory Myopathies 16

Systemic Vasculitis Syndromes 20

Crystal-Induced Joint Disease 22

Osteoarthritis 26

Back Pain and Common Musculoskeletal Problems 31

Fibromyalgia 33

PREFACE

The idea behind the creation of this book is to provide time-pressed physicians with a con￾venient way to measure and sharpen their medical knowledge across all of the topics in adult

internal medicine, possibly with preparation for recertification as a final goal.

With this idea in mind, we have collected 981 case-based questions and created Board Review

from Medscape. The list of topics is comprehensive, providing physicians an extensive review

library covering all of adult internal medicine, as well as such subspecialties as psychiatry, neu￾rology, dermatology, and others. The questions present cases of the kind commonly encountered

in daily practice. The accompanying answers and explanations highlight key educational con￾cepts and provide a full discussion of both the correct and incorrect answers. The cases have

been reviewed by experts in clinical practice from the nation’s leading medical institutions.

Board Review from Medscape is derived from the respected ACP Medicine CME program. A

continually updated, evidence-based reference of adult internal medicine, ACP Medicine is also

the first such comprehensive reference to carry the name of the American College of Physicians.

At the end of each set of questions, we provide a cross-reference for further study in ACP

Medicine. You can learn more about this publication on the Web at www.acpmedicine.com.

This review ebook has been produced in a convenient PDF format to allow you to test your

medical knowledge wherever you choose. You are free to print out copies to carry with you, or

just leave the file on your computer or handheld device for a quick look during free moments.

This format also allows you to buy only the sections you need, if you so choose.

I hope you find this ebook helpful. Please feel free to send any questions or comments you

might have to [email protected]. You will help us improve future editions.

Daniel D. Federman, M.D., M.A.C.P.

Founding Editor, ACP Medicine

The Carl W. Walter Distinguished Professor of Medicine

and Medical Education and Senior Dean for Alumni Relations and Clinical Teaching

Harvard Medical School

Ethical and Social Issues

1. An 81-year-old woman recently became ill and is now dying of metastatic cancer. She wishes to have her

life preserved at all costs. Her physician is concerned that such an effort would be medically futile and

extremely costly. Until recently, the patient had an active social life, which included regular participa￾tion in many church activities. Her closest relatives are two nieces, whom she does not know well.

At this time, it would be most appropriate for which of the following groups to become involved in

decisions about this patient?

❏ A. Social workers

❏ B. The patient's family

❏ C. Clergy

❏ D. Ethics committee

❏ E. Risk management personnel

Key Concept/Objective: To understand that the patient's beliefs and support systems can often

guide health care providers in engaging others in support of the patient

The patient's active involvement in church activities may mean that she will be receptive

to the involvement of clergy. Communication regarding prolongation of suffering by

aggressive measures to preserve life at all costs and discussion of spiritual dimensions may

help this patient resolve the issue. Although courts have generally upheld the wishes of

individuals regardless of issues involving the utilization of resources, the appropriate use

of resources continues to be a legitimate and difficult problem. (Answer: C—Clergy)

2. An 80-year-old woman presents with severe acute abdominal pain. She is found to have bowel ischemia,

severe metabolic acidosis, and renal failure. She has Alzheimer disease and lives in a nursing home.

Surgical consultation is obtained, and the surgeon feels strongly that she would not survive surgery.

When you approach the patient's family at this time, what would be the best way to begin the

discussion?

❑ A. Explain that DNR status is indicated because of medical futility

❑ B. Find out exactly what the family members know about the patient's

wishes

❑ C. Explain that the patient could have surgery if the family wishes but

that the patient would probably not survive

❑ D. Discuss the patient's religious beliefs

❏ E. Explain to the family that the patient is dying and tell them that you

will make sure she is not in pain

Key Concept/Objective: To understand the duties of the physician regarding the offering of choic￾es to patients and families in urgent situations when the patient is dying

Although the issues underlying each of these choices might be fruitfully discussed with the

family, ethicists have affirmed the duty of physicians to lead and guide such discussions

CLINICAL ESSENTIALS 1

CLINICAL ESSENTIALS

2 BOARD REVIEW

on the basis of their knowledge and experience. Health care providers should not inflict

unrealistic choices on grieving families; rather, they should reassure them and describe the

efficacy of aggressive palliative care in relieving the suffering of patients who are dying. In

this case, a direct approach involving empathy and reassurance would spare the family of

having to make difficult decisions when there is no realistic chance of changing the out￾come. (Answer: E—Explain to the family that the patient is dying and tell them that you will make

sure she is not in pain)

3. An 86-year-old man with Alzheimer disease is admitted to the hospital for treatment of pneumonia. The

patient has chronic obstructive pulmonary disease; coronary artery disease, which developed after he

underwent four-vessel coronary artery bypass grafting (CABG) 10 years ago; and New York Heart

Association class 3 congestive heart failure. His living will, created at the time of his CABG, calls for full

efforts to resuscitate him if necessary. A family meeting is scheduled for the next morning. At 2 A.M., a

nurse discovers that the patient is blue in color and has no pulse; the nurse initiates CPR and alerts you

regarding the need for emergent resuscitation. An electrocardiogram shows no electrical activity.

What should you do at this time?

❏ A. Proceed with resuscitation because of the patient's living will

❏ B. Proceed with resuscitation until permission to stop resuscitation is

obtained from the family

❏ C. Decline to proceed with resuscitation on the basis of medical futility

❏ D. Continue resuscitation for 30 minutes because the nurse initiated CPR

❏ E. Decline to proceed with resuscitation because the patient's previous living

will is void, owing to the fact that it was not updated at the time of

admission

Key Concept/Objective: To understand the concept of medical futility as the rationale for not per￾forming CPR

It would be medically futile to continue CPR and attempts at resuscitation, given the

absence of ECG activity. In this case, the patient's likelihood of being successfully resusci￾tated is less than 1%, owing to his multiple medical conditions. (Answer: C—Decline to pro￾ceed with resuscitation on the basis of medical futility)

For more information, see Cassel CK, Purtilo RB, McParland ET: Clinical Essentials: II

Contemporary Ethical and Social Issues in Medicine. ACP Medicine Online (www.

acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, July 2001

Reducing Risk of Injury and Disease

4. A 26-year-old woman presents to clinic for routine examination. The patient has no significant medical

history and takes oral contraceptives. She smokes half a pack of cigarettes a day and reports having had

three male sexual partners over her lifetime. As part of the clinic visit, you wish to counsel the patient

on reducing the risk of injury and disease.

Of the following, which is the leading cause of loss of potential years of life before age 65?

❏ A. HIV/AIDS

❏ B. Motor vehicle accidents

❏ C. Tobacco use

❏ D. Domestic violence

Key Concept/Objective: To understand that motor vehicle accidents are the leading cause of loss

of potential years of life before age 65

Motor vehicle accidents are the leading cause of loss of potential years of life before age 65.

Alcohol-related accidents account for 44% of all motor vehicle deaths. One can experience

a motor vehicle accident as an occupant, as a pedestrian, or as a bicycle or motorcycle

rider. In 1994, 33,861 people died of injuries sustained in motor vehicle accidents in the

United States. The two greatest risk factors for death while one is driving a motor vehicle

are driving while intoxicated and failing to use a seat belt. The physician's role is to iden￾tify patients with alcoholism, to inquire about seat-belt use, and to counsel people to use

seat belts and child car seats routinely. In one study, 53.5% of patients in a university inter￾nal medicine practice did not use seat belts. Problem drinking, physical inactivity, obesi￾ty, and low income were indicators of nonuse. The prevalence of nonuse was 91% in peo￾ple with all four indicators and only 25% in those with no indicators. Seat belts confer con￾siderable protection, yet in one survey, only 3.9% of university clinic patients reported that

a physician had counseled them about using seat belts. Three-point restraints reduce the

risk of death or serious injury by 45%. Air bags reduce the risk of death by an additional

9% in drivers using seat belts. Because air bags reduce the risk of death by only 20% in

unbelted drivers, physicians must tell their patients not to rely on air bags. (Answer: B—

Motor vehicle accidents)

For more information, see Sox HC Jr.: Clinical Essentials: III Reducing Risk of Injury and

Disease. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds.

WebMD Inc., New York, July 2003

Diet and Exercise

5. A 78-year-old woman with hypertension presents for a 3-month follow-up visit for her hypertension. A

year ago, she moved to a retirement community, where she began to eat meals more regularly; during

the past year, she has gained 15 lb. She is sedentary. She weighs 174 lb, and her height is 5 ft 1 in. She

is a lifelong smoker; she smokes one pack of cigarettes a day and has repeatedly refused to receive coun￾seling regarding smoking cessation. She has occasional stiffness on waking in the morning. Her blood

pressure is 120/80 mm Hg. She reports taking the prescribed antihypertensive therapy almost every day.

She is concerned about her weight gain because this is the most she has ever weighed. She has reported

that she has stopped eating desserts at most meals and is aware that she needs to reduce the amount of

fat she eats. She has never exercised regularly, but her daughter has told her to ask about an aerobic exer￾cise program. She has asked for exercise recommendations, although she does not know whether it will

make much difference.

Which of the following would you recommend for this patient?

❏ A. Attendance at a structured aerobic exercise program at least three times a

week

❏ B. Membership in the neighborhood YMCA for swimming

❏ C. Walking three times a week, preferably with a partner

❏ D. Contacting a personal trainer to develop an individualized exercise

program

❏ E. No additional exercise because she has symptoms of osteoarthritis

Key Concept/Objective: To recognize that even modest levels of physical activity such as walking

and gardening are protective even if they are not started until midlife to late in life

Changes attributed to aging closely resemble those that result from inactivity. In sedentary

patients, cardiac output, red cell mass, glucose tolerance, and muscle mass decrease.

Systolic blood pressure, serum cholesterol levels, and body fat increase. Regular exercise

appears to retard these age-related changes. In elderly individuals, physical activity is also

associated with increased functional status and decreased mortality. Although more stud￾ies are needed to clarify the effects of exercise in the elderly, enough evidence exists to war￾rant a recommendation of mild exercise for this patient, along with counseling concern￾ing the benefits of exercise at her age. Walking programs increase aerobic capacity in indi￾viduals in their 70s with few injuries. Although structured exercise is most often recom￾mended by physicians, recent studies demonstrate that even modest levels of physical

activity such as walking and gardening are beneficial. Such exercise is protective even if it

is not started until midlife or late in life. Because this patient is used to a sedentary lifestyle

CLINICAL ESSENTIALS 3

4 BOARD REVIEW

and is not strongly motivated to begin exercising, compliance with exercise recommen￾dations may be an issue. Lifestyle interventions appear to be as effective as formal exercise

programs of similar intensity in improving cardiopulmonary fitness, blood pressure, and

body composition. Exercise does not appear to cause or accelerate osteoarthritis. However,

counseling concerning warm-ups, stretches, and a graded increase in exercise intensity can

help prevent musculoskeletal problems as a side effect of exercise. (Answer: C—Walking three

times a week, preferably with a partner)

6. A 50-year-old woman presents for a follow-up visit to discuss the laboratory results from her annual

physical examination and a treatment plan. Her total serum cholesterol level is 260 mg/dl, which is up

from 200 mg/dl the previous year. Her blood pressure is 140/100 mm Hg, which is up from 135/90 mm

Hg; she weighs 165 lb, a gain of 12 lb from the previous year. Results from other tests and her physical

examination are normal. Her height is 5 ft 3 in. She is postmenopausal and has been receiving hormonal

replacement therapy for 2 years. You discuss her increased lipid levels and increased blood pressure in

the context of her weight gain and dietary habits. When asked about her dietary habits, she says that

she has heard that putting salt on food causes high blood pressure. She asks if she should stop putting

salt on her food because her blood pressure is high.

How would you describe for this patient the relationship between sodium and hypertension?

❏ A. Tell her that reducing sodium intake usually leads to significant reduc￾tions in blood pressure

❏ B. Tell her that reducing intake of sodium and fats while increasing intake

of fruits, vegetables, and whole grains usually leads to significant reduc￾tions in hypertension

❏ C. Explain to her that decreasing sodium is only important in elderly patients

❏ D. Tell her that research studies are unclear about the role of sodium in

hypertension

❏ E. Explain to her that antihypertensive medication is effective in reducing

hypertension, making sodium reduction unnecessary

Key Concept/Objective: To understand current evidence that supports the relationship between

sodium and hypertension

The Dietary Approaches to Stop Hypertension (DASH) trial1 demonstrated that the combi￾nation of eating fruits, vegetables, and whole grains along with reducing fat and sodium

levels can lower systolic blood pressure an average of 11.5 mm Hg in patients with hyper￾tension. Reductions in dietary sodium can contribute to substantial reductions in the risk

of stroke and coronary artery disease. In addition, for this patient, a reduction in sodium

intake will decrease urinary calcium excretion and thus reduce her risk of osteoporosis.

Because the patient has asked about putting salt on food, she should also be counseled that

80% of dietary sodium comes from processed food. It is important to review these hidden

sources of salt with patients who would benefit from sodium restriction. The average

American diet contains more than 4,000 mg of sodium a day. There is no recommended

daily allowance for sodium, but the American Heart Association (AHA) recommends that

daily consumption of sodium not exceed 2,400 mg, with substantially lower sodium

intake for patients with hypertension. (Answer: B—Tell her that reducing intake of sodium and

fats while increasing intake of fruits, vegetables, and whole grains usually leads to significant reductions

in hypertension)

1. Sacks FM, Svetkey LP, Vollmer WM, et al: Effects on blood pressure of reduced dietary sodium and the Dietary

Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 344:3,

2001

7. A 64-year-old man comes to your clinic for a routine visit. He has a history of myocardial infarction,

which was diagnosed 1 year ago. Since that time, he has been asymptomatic, and he has been taking all

his medications and following an exercise program. His physical examination is unremarkable. He has

been getting some information on the Internet about the use of omega-3 polyunsaturated fatty acids as

part of a cardioprotective diet.