Category Archives: Question Challeges


Sample Question – CVS- 2

A 53-year-old Afro-Caribbean gentleman is diagnosed with hypertension after having three blood pressure measurements greater than 160/100 mmHg. Past medical history is not significant. His BMI is 23, and he looks well. According to the NICE guidelines, which of the following is the most appropriate to prescribe first line for this patient?

(Please select the best option)

  1. Amlodipine Correct
  2. Atenolol
  3. Diltiazem
  4. Ramipril
  5. Valsartan

Patients of African origin are more likely to have low renin hypertension. This means that they are more likely to respond to initial therapy with either a calcium antagonist or diuretic, usually a thiazide. A number of studies have shown that amlodipine is more effective in reducing systolic and diastolic blood pressures

In contrast those patients of Caucasian origin who tend to have higher levels of renin respond much more readily to angiotensin-converting enzyme (ACE) inhibition, or if they fail to tolerate an ACE inhibitor because of cough, to an angiotensin receptor blocker. For these patients, ACE inhibition is seen by NICE as the first line treatment.

ACE inhibitor and calcium antagonist combination has been the one preferred by many clinicians.


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Sample Question CVS- 1

A 36-year-old patient with recent onset fatigue and prior hypertension presents to the endocrinology clinic as his potassium remains low despite oral supplements. He has no medical history of note.

A full endocrine profile is requested and pending, though the most recent available blood tests demonstrate ongoing hypokalaemia:

Full blood count          normal

Serum sodium 138 mmol/l      (132 – 144)

Serum potassium         2.6 mmol/l       (3.5 – 5.0)

Urea    6.4 mmol/l       (2.5 – 7.5)

Creatinine        70 μmol/l         (50 – 120)

What imaging would you advise now?

(Please choose the best answer)

  1. Abdominal x ray
  2. Barium swallow
  3. Chest x ray
  4. CT abdomen Correct
  5. CT brain

Low potassium with hypertension points toward the diagnosis of primary hyperaldosteronism, or Conn’s syndrome. A more complete biochemical profile would demonstrate alkalosis. The hypokalaemia is often refractory to supplements.

Liddle’s syndrome, a rare genetic abnormality of Na+channels, has a similar clinical presentation of fatigue, hypertension and hypokalaemia, but the sodium is usually higher.

Aldosterone levels are high in Conn’s syndrome and low-normal in Liddle’s syndrome.

CT or MRI of the abdomen identifies a secretory adrenal adenoma, which is usually not evident on abdominal x ray, subsequently managed by adrenalectomy.

CT brain may be indicated in hypokalaemia, with and without hyponatraemia (which may have been corrected too rapidly), to look for central pontine myelinolysis in the very different setting of alcoholic Korsakoff’s syndrome with vitamin and electrolyte deficiencies.



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