GENERAL PRACTITIONER EXAM
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A male aged 63 years is receiving fluorouracil for colon cancer. Because of his profound nausea, he is prescribed aprepitant. The mechanism of action of this agent is which one of the following?
Lumbar region X-ray of the back of a 67 year old female reveals the presence of a compression fracture. Further examination shows a substantial decrease in the thickness of the other bones of the lower back. If investigations reveal normal levels of calcium, phosphorus, and parathyroid hormone, which drug would most likely worsen her condition?
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A young mother takes her infant to the pediatrician for the first time. The pediatrician notices the infant´s teeth are yellow. Which antibiotic mother most likely took during pregnancy?
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A new drug´s pharmacokinetic properties are being studied in normal volunteers during phase I clinical trials. The volume of distribution and clearance determined in the first subject are 80 L and 4 L/hr, respectively. The half-life of the drug in this subject is approximately which one of the following?
The half-life of a drug can be determined using the following equations:
1) CL=k x Vd
4L/h=k x 80L
or
k = 4/80 = 1/20 h-1
2) t1/2 = 0.7/k
t1/2=0.7 x 20h
t1/2= 14 h
IV midazolam is given to a 47 year old woman to supplement the local anesthetics that are injected into her foot during surgery. She suddenly becomes agitated and combative midway through the surgery and exhibits involuntary movements. The anesthesiologist determines that she is having a paradoxical reaction to the midazolam and immediately administers
Flumazenil is a benzodiazepine antagonist and has been approved to hasten the recovery from benzodiazepines used in anesthetic and diagnostic settings and to reverse the CNS depressant effects following an overdose with benzodiazepines Flumazenil can be used only for benzodiazepines or benzodiazepine receptor agonists, such as zolpidem and zaleplon; it is not useful in reversing the effects of other CNS depressants, such as barbiturates and ethanol.
Glucagon is an antidote for beta-blocker overdose. Naloxone, an opioid receptor antagonist, is an antidote for opioid overdose. Nitrite, or sodium nitrite, is an antidote for cyanide poisoning. Protamine is an antidote for heparin overdose.
A 49 year old smoker with deep venous thrombosis is given heparin. Heparin achieves its anticoagulant activity by binding to which one of the following substance?
Heparin, a highly negatively charged molecule, binds to the coagulation inhibitor antithrombin III, increasing its activity 100 to 1000 times.
Alpha2-antiplasmin binds plasmin. Plasmin functions to break down clots and the binding of alpha2-antiplasmin to plasmin acts to inhibit clot lysis. Alpha2 macroglobulin is a circulating antiprotease macromolecule that assists in preventing blood clotting by inhibiting the action of proteolytic coagulation factors. The remaining answer choices are all clotting factors. They do not interact with heparin.
A 34 year old patient with a history of asthma is being treated for symptoms of hypertension. The beta blockers would be an appropriate therapy for this patient is which one of the following?
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A 34 year old SLE patient abruptly stops taking her glucocorticoids because “she is well now and does not want to get fat.” After several days she goes to the ER because she “feels terrible.” The finding would be expected on investigations?
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The mechanism of action of low-molecular-weight heparin is which one of the following?
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Angina in a 56-year-old man was relieved by buccalglyceryltrinitrate (GTN) 5 mg. His discharge medication was isosorbidemononitrate (ISMN) 20 mg BD. Which factor is responsible for the dose difference between these two formulations?
Buccal GTN is quickly converted to di- and mono-nitrates which have half- lives of two hours. Its effective duration of action is 30 minutes. It is metabolised by the liver to inorganic nitrite.
ISMN is not subject to first pass metabolism in the liver. The overall half-life of isosorbidemononitrate is about five hours, and that of GTN is two hours. Thus, this would result in a reduced dose of ISMN being required if related to plasma clearance. The sublingual route (which avoids first pass effect and the need for gastrointestinal absorption) is the preferred route for achieving therapeutic effect quickly, as GTN is absorbed efficiently by this route. However, the total dose administered by this route must be limited to avoid excessive effects.
When a much longer duration is needed, oral preparations can be given that contain a sufficient amount of drug to result in sustained systemic blood levels.
A 45-year-old man presents with bilateral gynaecomastia. He has been diagnosed with Zollinger-Ellison syndrome in the last year. He underwent normal puberty at age 14. Which of the following drugs would be most likely to cause gynaecomastia?
The answer to this question is cimetidine which is an H2 receptor antagonist. Blockade of androgen-responsive receptors in the target organ appears to be the most likely mechanism involved. Research has shown that the other drugs listed above which may also be used as part of the treatment of Zollinger-Ellison syndrome have a much lower almost insignificant risk in the development of gynaecomastia.
Other drugs that can cause gynaecomastia include-spironolactone,digoxin, methylodopa, gonadotropins and cyproterone acetate Zollinger-Ellison syndrome The association of peptic ulcer with a gastrin-secreting pancreatic adenoma -50-60% is malignant. It occurs in approx 0.1% of patients with duodenal ulcer disease and is to be suspected in those with multiple peptic ulcers that are resistant to drugs.
A 46-year-old male takes Lithium for a bipolar affective disorder. Which of the following drugs would be contra-indicated in conjunction with Lithium?
Caution should be exercised when taking Lithium and diuretics as the latter may reduce renal clearance of lithium and increase serum lithium concentrations. NSAIDs also increase Lithium concentrations.
Metronidazole, ACEI´s and Calcium channel blockers also increase serum Lithium concentrations.
The best way to avoid benzodiazepine dependence is
Benzodiazepines have addictive properties. If a benzodiazepine with shorter half- life is used, there is more dependency since the patient will see the effect of the drug wear off faster. The better option is to counsel against long term use of such medicines. When prescribing benzodiazepines the following guidelines should be used:
Do not prescribe benzodiazepines in someone with a history of drug misuse and dependence.
Prescribe the lowest possible doses of benzodiazepines and only prescribe for a few weeks. It is important to remember that patients can get withdrawal symptoms between doses if they are given short- acting benzodiazepines.
Elderly patients are particularly prone to adverse effects of benzodiazepines therefore, need to be careful.
Which of the following micro-organisms is generally sensitive to benzylpenicillin?
Penicillin binds to specific penicillin-binding proteins (PBP´s) in the cell wall, mainly of gram positive organisms.
Penicillin resistance is usually due to production of altered PBPS or beta-lactamases which leave the…
Penicillin is mainly useful for group A Strep., Group B Strep., meningococcal and pneumococcal infections, though anthrax are also sensitive.
Pneumococci with modified PBPB are an increasing problem
A 72-year-old man is treated for chest infection. For past 6 months,he is receiving Warfarin for atrial fibrillation with normal INR. However, his most recent INR was 5.2 (<1.4).Which one of the following drugs is responsible?
Clarithromycin induces the anticoagulant effect of warfarin, whereas rifampicin would reduce the anticoagulant effect. Ciprof1oxacin and sulphonamides will also increase the anticoagulant effect of warfarin. Temazepam, digoxin and codeine have no appreciable effect.
Which of the following pharmacological agents acts through the opening of potassium channels?
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Which statement is true regarding gabapentin?
Gabapentin does not induce cytochrome P450 unlike other anticonvulsants such as phenytoin and phenobarbitone. Gabapentin is a structural analog of GABA, but it does not activate GABA receptors directly.
Vigabatrin may cause visual field defects, which may be irreversible rarely have visual disturbances been associated with gabapentin. Gabapentin is no use in petit mal and is used for add-on therapy in partial or generalized seizures.
A 91-year-old man with chronic leukemia presents with gout which his general practitioner treats with Allopurinol. How does Allopurinol prevent the accumulation of uric acid?
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The best way to avoid benzodiazepine dependence is
The benzodiazepine which has shortest half life is
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Addition of bupropion (Welbutrin) should be considered in a patient taking a selective serotonin reuptake inhibitor (SSRI) if he develops which one of the following side effects?
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A man aged 46 year is diagnosed pulmonary tuberculosis. Which one of the following investigations is essential prior to starting antituberculous therapy?
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A lady of age 56 years is on treatment for long-standing rheumatoid arthritis. She recently becomes dyspnoeic on mild exertion and developed a dry cough. The oxygen saturation was found to be 87% on air. A diffuse bilateral interstitial infiltrate was seen on chest X-ray. Screening for infection was negative and her symptoms were felt to be drug-induced. This adverse effect is most likely to be caused by which one of the following?
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A type 2 diabetic female of 50 years of age presents with a two month history of painful hands and feet. Diagnosis of sero-positive erosive rheumatoid arthritis is confirmed by investigations. She has some pain relief from NSAIDs. She currently takes metformin 500 mg tds and has good glycaemic control as reflected by an HbA1c of 6.7% (3.8-6.4). Which DMARD would be most appropriate as her initial therapy for early rheumatoid arthritis?
A 33 year old man presents with a history and findings that, satisfy DSM-IV criteria for bipolar disorder. Out of the following, which one is the most effective for long-term management of the majority of patients with this disorder?
A 27 year old homosexual male is diagnosed with tuberculosis and started on a regimen involving INH. Isoniazid interactions result in which one of the following vitamin deficiency?
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A 55 year old diabetic male is diagnosed with hypertension and prescribed a high dose of an antihypertensive associated with the development of a dry cough and angioedema. An adverse effect most likely to occur with this drug is
A 70 year old male has a blood pressure of 88/102mm Hg, edema in the scrotal region, and reddish urine. Lab findings are significant for hematuria and moderate proteinuria, as well as red cell casts and white cells in the urine. Additional test reveal abnormal complement levels (C3, C4, CH50) and anti-GBM antibodies as well as abnormal ANCA. Noncytotoxic treatment of this patient is likely to cause which of the following?
Acute glomerulonephritis is a relatively uncommon cause of acute renal failure, responsible for approximately 5% of all causes of intrinsic renal failure. In general, ANCA-associated and anti GBM associated acute glomerulonephritis can evolve to crescentic glomerulonephritis. The overall clinical outcome is poor unless treatment is started early. Those with acute glomerulonephritis are often hypertensive, edematous, and have an abnormal urinary sediment. The edema generally develops first in areas of the body with low tissue tension such as the periorbital and scrotal regions. Laboratory evaluation typically reveals hematuria, moderate proteinuria (usually < 2 g/d), and cellular elements such as red cells, red cell casts, and white cells. To confirm the etiology of the acute glomerulonephritis, complement levels (C3, C4, CH50), ASO titer, anti-GBM antibody levels, ANCAs, antinuclear antibody titres, cryoglobulins, hepatitis serologies, blood cultures and a renal ultrasound are often undertaken. Treatment measures generally consist of high dose corticosteroids and cytotoxic agents such as cyclophosphamide. The corticosteroids are generally associated with fluid and electrolyte imbalances such as hypernatremia fluid retention hypokalemia and hypocalcemia. Other adverse effects include muscle weakness muscle mass loss gastritis, hyperglycemia the appearance of a Cushingoid state immunosuppression, hypertension, steroid psychosis and osteoporosis. A lupus erythematosus like syndrome is a side effect of hydralazine, procainamide, and quinidine.
A 69 year old female is being evaluated for hip replacement surgery. She has hypertension that is well controlled. She is hospitalized and her cardiac rhythm shows second degree AV block. Which medication is the most likely cause of her arrhythmia?
A 56 year old man has nasal allergies. He also has nocturia and decreased force and caliber of his urinary stream. PSA level is 4.2. Rectal examination shows a diffusely enlarged prostate. What antihistamine would be most appropriate for him?
The patient is presenting with signs and symptoms highly suggestive of benign prostatic hyperplasia (BPH), which is a common disorder found in men and is often age related. BPH is characterized by a decreased force and caliber of the urinary stream, high postvoid residual urine volume, nocturia, and urinary retention on occasion. The PSA is just above the normal range (0-4 ng/mL); and the physical examination is suggestive of BPH. Anticholinergic agents are generally not used in patients with BPH because of their “anti-SLUDG” properties. These medications decrease salivation, lacrimation, urination, and the ability to defecate. Similarly, these medications act to slow down the gastrointestinal tract by exerting an antagonistic effect on acethylcholine M3 receptors in smooth muscle. However if a patient with BPH had to be prescribed an antihistamine the physician should choose one with low anticholinergic side effects such as cetirizine, fexofenadine or loratadine.
All of these agents produce reversible competitive antagonism of H1 receptors. The antihistaminic effects include inhibition of vascular, gastrointestinal, and respiratory smooth muscle contraction, decreased capillary permeability leading to decreased wheal, flare, and itching response; also anticholinergic effects lead to the “drying up” of mucus secretions. These agents are indicated for the relict of manifestations of immediate type hypersensitivity reactions, and to ameliorate the signs and symptoms of the common cold.
A 39 year old worker with constant back pain gets a prescription and takes the recommended drug dose. After 45 minutes, he begins to feel sleepy, has a dry mouth, and can feel his heart “racing.” Which drug was most likely given?
There are two major therapeutic groups of muscle relaxants: neuromuscular blockers and spasmolytics. Neuromuscular blockers act by interfering with transmission at the neuromuscular end plate, have no CNS activity, and often are used during surgical procedures and in intensive care and emergency medicine to cause paralysis. Spasmolytics, or “centrally acting” muscle relaxants, are used to alleviate musculoskeletal pain and spasms and to reduce spasticity in a variety of neurologic conditions. When patients present with either a muscle spasm or a “strained” muscle, a centrally acting skeletal muscle relaxant is typically prescribed. In addition to these agents, a nonsteroidal anti-inflammatory drug is often added for additional pain control. Although somnolence can be seen with any of the agents listed, xerostomia (dry mouth), mydriasis, and tachycardia are classic anticholinergic side effects. Cyclobenzaprine is a centrally acting skeletal muscle relaxant that is structurally related to tricyclic antidepressants, which are known for their strong anticholinergic side effects. Additional common anticholinergic side effects seen with this agent include blurred vision, urinary retention, and constipation. Less common side effects include agitation, respiratory depression disorientation, tachycardia, and widening of the QRS complex. Baclofen is a centrally acting skeletal muscle relaxant that produces muscle relaxation by inhibition of both monosynaptic and polysynaptic reflexes at the spinal level. This agent is indicated for the treatment of spasticity resulting from multiple sclerosis or secondary to spinal cord injuries; it has also been used in the treatment of trigeminal neuralgia. The most common side effects include transient drowsiness, fatigue, and hypotension. Diclofenac is a nonsteroidal anti-inflammatory drug indicated for the treatment of a variety of disorders associated with pain and inflammation. The most common side effects include dyspepsia, nausea, vomiting, abdominal cramps, and dizziness. Methocarbamol produces muscle relaxation by general CNS depression; it does not have a direct action on the contractile mechanism of striated muscle or nerve fibers. This agent is indicated as an adjunct to rest, physical therapy, and other measures for relief of discomfort in various musculoskeletal conditions. Reported side effects include dizziness, vertigo, ataxia, headache, irritability, bradycardia, hypotension, and syncope. Rofecoxib is a selective cyclooxygenase-2 (CDX-2) inhibitor with anti-inflammatory, analgesic, and antipyretic effects. This agent is used in adults for relief of pain and inflammation caused by osteoarthritis and rheumatoid arthritis, as well other inflammatory conditions. The most common side effects are nausea, vomiting, diarrhea, abdominal distress, flatulence, and anorexia.
A 63 year old man develops premature ventricular contraction (PVCs) while receiving digoxin for atrial fibrillation. He is taking several other medications for multiple problems. The likely cause of this new complication is
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An elderly patient diagnosed with erectile dysfunction is prescribed a drug that functions by preventing the breakdown of a compound essential for vascular smooth muscle relaxation, allowing increased blood flow to the penis. The enzyme that is involved in the synthesis of this endogenous compound is
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A 62 year old man with congestive heart failure and hypertension has new onset of anginal symptoms during periods of exertion. A calcium channel blocker is given for angina prophylaxis and for his hypertension. The drug that would be most likely to exacerbate the patient´s heart failure is
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Examination of a 78 year old type 2 diabetic woman with diabetic nephropathy, and hyperuricemia is remarkable for hypertension. Her blood pressure was also elevated on two prior visits. Which medication would be best for the initial treatment?
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A woman aged 87 years has multiple episodes of syncope and near syncope. She has history of coronary artery disease, asthma, hypothyroidism, diabetes, and hypertension. She states that she often forgets to take her medications, and will take higher doses to compensate for this. ECG reveals third degree block. Which drug overdose caused her arrhythmia?
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A 55 year old male´s cecal mass is resected and is found to be an invasive adenocarcinoma, with lymphatic involvement. 5 fluorouracil (5-FU) is added to control metastasis. 5-FU is an analog that substitutes for which compound in DNA synthesis?
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A 2 month old infant is brought with acute cardiovascular collapse. His mother gave him drug prescribed to her for salmonella gastroenteritis. Few days later he began to vomit, and began showing an ashen gray skin color. What is the mechanism of drug given to the child?
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A 59 year old man was previously taking aspirin to reduce pain of rheumatoid arthritis and gastric complications were developing. He is now taking an alternate drug that is relatively similar in potency to aspirin but is less likely to cause gastric irritation. This agent needs to be taken only once a day due to its long half life of 50 hours. Which drug is he now using to treat RA pain?
When used in recommended doses, piroxicam is similar in potency to aspirin and naproxen for pain relict associated with RA. Piroxicam competitively inhibits both cyclooxygenase (COX) isoenzymes, COX-1 and COX-2, resulting in analgesic, antipyretic, and anti-inflammatory effects. Because of the long half life, this drug needs to be taken only once a day, but it takes 2 weeks to reach therapeutic levels. Another advantage of piroxicam is the low risk of gastrointestinal reactions.
Ibuprofen, ketoprofen, and naproxen all produce dose- dependent gastric irritation. Ibuprofen and ketoprofen need to be taken every 2 hours, where is naproxen can be taken twice daily due to its relatively long half-life of 14 hours. Ketorolac is indicated for acute (<5 days) pain management.
A 34 year old woman goes to the physician for a minor outpatient procedure. Physician wants to use a long duration ester for a local anesthetic. The agent that should be used is which one of the following?
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A 28 year old drug abuser ingested 15 tablets of 10-mg dextroamphetamine 5 hours ago, and is brought to the emergency department in an agitated state. Which agent can hasten the elimination of the drug from this patient?
A 58 year old man with a history of MI has shortness of breath. On exam, his heart rate is 110/min, respiratory rate is 22/min and has peripheral edema. Auscultation reveals normal sinus rhythm with an S3 gallop. Ejection fraction is reduced. Which drug would alleviate his symptoms by reducing both the preload and afterload on the heart without affecting its isotropic state?
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A male aged 72 years with prostate cancer is treated with leuprolide. The mechanism of action of this drug is which one of the following?
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Metabolic alkalosis is associated with?
Diuretic therapy – loop diuretics and thiazides can both initially cause increase in chloride, but once stores are depleted, urine excretion will be below < 25 mEq/L. The loss of fluid from sodium excretion causes a contraction alkalosis.
Mineralocorticoid excess (Conn´s syndrome) is also associated with a metabolic alkalosis.
Metformin causes metabolic acidosis.
Salicylates are themselves acidic and produce a metabolic acidosis. Normal saline has a pH of 5 and may produce a mild metabolic acidosis with significant infusions.
A 63-year-old male has Benign Prostatic hyperplasia and he is commenced on Finasteride. Through which of the following mechanisms does Finasteride function?
Which one of the following is not associated with manic behavior?
Mania can occur by chance association during drug treatment, particularly in patients predisposed to mood disorder. Drugs with a definite propensity to cause manic symptoms include levodopa, corticosteroids and anabolic-androgenic steroids. Antidepressants of the tricyclic and monoamine oxidase inhibitor classes can induce mania in patients with pre-existing bipolar affective disorder.
Drugs which are probably capable of inducing mania, but for which the evidence is less scientifically secure, include other dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid, sympathomimetic drugs, chloroquine, cimetidine, baclofen, alprazolam, captopril, amphetamine and phencyclidine.
An 85 year old woman nursing-home resident with a primary diagnosis of Alzheimer´s disease develops a pattern of behavioral symptoms consisting of significant verbal and physical aggression toward stag and other residents on at least three occasions. She has also experienced hallucinations that have been very stressful to her. After other causes have been excluded, you decide to treat her abnormal behavior with a medicine. The most appropriate choice would be
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A 34 year old woman presents with restlessness, nausea and unstable vital signs. She has a history of depression. She was recently switched from sertraline (SSRI) to phenelzine (MAOI). On examination she is tachycardic and tachypneic and her blood pressure is 140/90 mmHg. Her neurological examination is normal aside from hyperreflexia and myoclonous. What is the most likely diagnosis?
With regard to poisoning /overdose:
Aspirin causes hyperventilation which may result in a respiratory alkalosis; massive overdose may cause a metabolic acidosis. Phenobarbitone and chlormethiazole both suppress the central nervous system causing hypoventilation, hypotension and hypothermia. Ethylene glycol causes a metabolic acidosis.
Methanol is metabolized to formaldehyde and formic acid.
The most helpful medication in a bulimic patient is
Bulimia nervosa is recurrent episodes of binge eating followed by self- induced vomiting, laxative or diuretic abuse, vigorous exercise, or fasting.
Most symptoms and physical complications result from purging. Self- induced vomiting leads to erosion of dental enamel of the front teeth and to painless salivary gland enlargement. Serious fluid and electrolyte disturbances, especially hypokalemia, occur occasionally.
The diagnosis is suspected when patients express marked concern about weight gain and have wide fluctuations in weight, especially with excessive laxative use or unexplained hypokalemia. Swollen parotid glands, scars on the knuckles (from induced vomiting), and dental erosion are danger signs.
Treatment is with psychotherapy and SSRIs, especially fluoxetine.
A 62 year old woman suffering from rheumatoid arthritis has been on long term therapy to control her disease. She now presents to you with history of increasing shortness of breath and a chest radiograph reveals “bilateral interstitial shadowing”. Investigations for infections were negative. Her symptoms are caused by which one of the following medications?
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A female of 80 years of age presents with bilaterally painful knees. There was no history of gastrointestinal diseases. Crepitus was present on examination but had a full range of movement of both knees. The initial therapy that is most appropriate for her painful knees is:
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A 45 year old male admitted to the psychiatric ward is given haloperidol. He then develops restlessness. Constantly gets up, then sits back down, and cannot sit still for any period of time. Which of the following side effects of haloperidol has the patient developed?
The side effects of antipsychotic medications are as follows: Parkinsonism: involves tremor, `increased muscle tone, bradykinesia or akinesia, drooling, postural instability, loss of spontaneity, micrographia, and seborrhea.
Akathisia: motor restlessness accompanied by a feeling of inner restlessness (sometimes described as anxiety), an urge to move, and an inability to sit still, patients may pace or continuously move their feet and legs. Dystonia: sustained contraction of muscles, twisting postures and may be visible only when the patient is moving. Neck and arm muscles are most commonly affected. Tardive dyskinesia: hyperkinesia, involuntary body movements most often of the muscles of the face, mouth, and tongue.
Which of the following medications may cause amnesia as a side effect?
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Patients who take digitalis are at increased risk for arrhythmias if they develop
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The pharmacologic agents that is most useful for treatment of generalized anxiety disorder is
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The drug of choice in the acute management of acetaminophen overdose is
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Bronchospasm is most likely caused by which one of the following antihypertensive agent?
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Resistance of bacteria to aminoglycosides CANNOT involve which one of the following mechanisms?
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A 60 year old man has altered mental status and an enlarged abdomen. Investigations reveal elevated ALT and AST as well as increased blood ammonia levels. A drug is administered to lower his blood ammonia levels. The mechanism of action of the medication he was most likely administered is
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A 31 year old female has a BMI of 35. She has been trying exercise regularly and eat smaller portion, but has not beenLOSING WEIGHT
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In the ER a 47 year old man presents with diffuse muscle weakness and palpitations. On examination tachycardia, mydriasis, and elevated body temperature are noted. All of this patient´s symptoms are most likely caused by
Botulism is caused by a protein toxin produced by the gram-positive, spore forming and obligate anaerobe Clostridium botulinum. The botulinum toxin selectively cleaves the docking proteins for ACh exocytosis. As a result, there is decreased ACh transmission in all parasympathetic neuroeffector junctions as well as decreased sympathetic cholinergic transmission in sweat glands and neuromuscular junctions. Tachycardia, mydriasis, and elevated body temperature are a result of decreased ACh activity on muscarinic receptors in parasympathetic neuroeffector junctions and sympathetic cholinergic innervation of sweat glands. Skeletal muscle weakness results from decreased ACh stimulation of nicotinic receptors in neuromuscular junctions. Atropine, a muscarinic receptor antagonist causes tachycardia, mydriasis, and elevated body temperature but does not cause muscle weakness. Ephedrine is an indirect sympathomimetic and would cause tachycardia, mydriasis, and possibly elevated body temperature from increased metabolic rate. However, it would not cause diffuse muscle weakness.
Which one of the following is most effective drug in reversing the paralysis of vecuronium?
A study is going on a new drug for the treatment of estrogen-sensitive breast cancer. Clinical trials show that it increases plasma levels of LH and FSH and decreases plasma estradiol levels. It also decreases endometrial proliferation. Which one of the following is most likely blocked by this drug?
Inhibition of aromatase decreases the synthesis of estradiol from testosterone. As a result of decreased estradiol, there is less stimulation of estrogen receptors on the breast. Decreased stimulation of estrogen receptors in the hypothalamus and anterior pituitary results in decreased negative feedback and an increase in the gonadotropins, LH and FSH. Also decreased estrogen receptor stimulation of the endometrium results in less proliferation.
Blocking androgen receptors would not cause the effects described above. Blocking estrogen receptors on the breast would help treat estrogen sensitive breast cancers. There would also be less negative feedback suppression of gonadotropins. Therefore, blocking estrogen receptors would increase circulating gonadotropins and estradiol. Blocking estrogen receptors on the uterus would decrease endometrial proliferation. Blocking 5 alpha-reductase, the enzyme responsible for converting testosterone to dihydrotestosterone (DHT), and blocking progesterone receptors would not have any of the effects described above.
A 45 year old man is admitted to the hospital emergency room after MI. Investigations reveal a two-fold elevation of his LDL cholesterol. Lovastatin is prescribed. It will inhibit which of the following enzymes?
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A 58 year old man is given antibiotic therapy for Pseudomonas aeruginosa with ceftazidime and gentamicin. Assuming that the half live of gentamicin is 3 hours in this patient, what percentage of the initial dose will most likely remain in his body after 6 hours?
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A patient is receiving Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) for Hodgkin disease. A drug is prescribed that blocks dopamine receptors to counteract a side effect of the ABVD regimen. The drug that was most likely prescribed is which one of the following?
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A 71 year old man presents with fatigue and exertional and nocturnal dyspnea. Examination is remarkable for rales and a gallop rhythm. CXR reveals cardiac enlargement. Which drug would delay the progress of his disorder?
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An elderly patient resident of a nursing home is diagnosed with Streptococcus pneumoniae pneumonia. She is treated with penicillin. Mechanism of action of this antibiotic is which one of the following?
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A patient is administered a continuous infusion (IV) of morphine at a dose of 0.1 mg/min in the ER. Half life of morphine is 1.9 hours and volume of distribution (Vd) is 230 L. The clearance (CL) for morphine is 60 L/h. What is the expected steady-state concentration that will be attained?
In the calculation of an appropriate dosing rate, drug clearance is the most important pharmacokinetic value to consider when determining a rational steady state drug dosage regimen. At steady-state, the dosing rate (“rate in”) must equal the rate of elimination (“rate out”).
Dosing rate = Css x CL. The equation can be rearranged to solve for Css such that Css = Dosing rate/CL = (0.1 mg/min)/1 L/min =0.1 mg/L.
A female aged 23 years presents with complaints of depressed mood and insomnia for the past two years. Amitriptyline is prescribed. This agent is believed to exert its antidepressant action by which mechanism?
Tricyclic antidepressants, such as amitriptyline, nortriptyline, and doxepin, possess three primary pharmacologic actions in varying degrees. These agents inhibit biogenic amine (norepinephrine and possibly serotonin) reuptake at the presynaptic neuron, (2) induce sedation, and (3) produce central and peripheral anticholinergic actions. The antidepressant effects are related to the inhibition of biogenic amine reuptake at the presynaptic neuron. Tricyclic antidepressants are indicated for the treatment of clinical depression, with or without anxiety and/or sleep disturbances. Medications that act as agonists at dopamine receptors are used in the treatment of Parkinson disease. Pharmacologic agents such as propranolol and metoprolol are known as beta-blockers, since they block beta-adrenergic receptors. Beta-blockers are indicated for the treatment of hypertension, angina pectoris, and various other cardiovascular conditions. Amphetamines act by increasing the release of norepinephrine from central noradrenergic neurons. They are indicated for the treatment of narcolepsy, attention deficit disorder with hyperactivity, and exogenous obesity.
A 54 year old male has tingling in his feet and recurrent blurry vision. He is obese, rarely exercises and eats an excessive amount of fatty, high caloric food. He takes no medications. A fasting plasma glucose level is 169 mg/dL on this visit and 172mg/dL on a subsequent visit. Which drug used in his condition´s treatment has no effect on the secretion of insulin?
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An 11 year old asthmatic is prescribed a cromolyn sodium inhaler to be administered prior to vigorous activity to prevent an attack. The mechanism of action of this drug is which one of the following?
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Angina in a 56-year-old man was relieved by buccalglyceryltrinitrate (GTN) 5 mg. His discharge medication was isosorbidemononitrate (ISMN) 20 mg BD. Which factor is responsible for the dose difference between these two formulations?
Out of the following, which drug would cause most concern in an overdose?
All of the following are symptoms of barbiturate withdrawal, except
Barbiturates are prescribed as anticonvulsants, sedatives, and general anesthetics. They can also mimic some of the characteristics of alcohol intoxication (including euphoria, elation, and uninhibited behavior), which make them candidates for abuse. These drugs depress the respiratory and nervous system functions, and because abusers rapidly build up a tolerance to the effects of the drug, fatal overdose or coma can easily occur.
Symptoms of withdrawal syndrome appear 12-20 hours after the last dose, they include anxiety, irritability, elevated heart and respiration rate, muscle pain, nausea, tremors, hallucinations, confusion, and seizures. Death is a possibility if the condition is left untreated. Major withdrawal symptoms (convulsions and delirium) may occur within 16 hours and last up to 5 days after abrupt cessation of these drugs.
A 50 year old female who has had low back pain for several years is admitted to the hospital because the pain has suddenly worsened. She is currently taking oxycodone, amitriptyline, perphenazine, fluoxetine and trazodone. On physical examination, the patient is 10% below her ideal body weight, pupils are constricted and skin turgor is poor. She seems sluggish and her speech is slow. Results of neurologic examination and radiographs of the lumbosacral spine are normal. Which of the following medication you suspect as the cause of her mental symptoms?
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The beta blocker that would be most useful for lowering blood pressure while minimizing bradycardia is
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Diuretic that may be ototoxic is which one of the following?
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A 29 year old HIV positive male presents with a recurrent whitish film that seems to grow on his tongue and oral mucosa. A sample of the material scrapped from the lesions reveals Candida albicans. What is the mechanism of action of the drug of choice for this infection?
Testing of a new antifungal medication is being conducted in phase I clinical trials. Examination of the drug´s pharmacokinetic properties reveals that the drug´s half life is 6 hours. If a continuous intravenous infusion of this drug were started on a research subject, how much time would it take to reach 75% of steady state?
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A man presents to the ER with chest pain, diaphoresis, and “a funny racing sensation in her chest.” An ECG is performed, that shows atrial fibrillation. After initial stabilization, which of the following medication should be given?
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A 65 year old male is diagnosed with chronic bacterial prostatitis and urosepsis. He is treated with large doses of broad spectrum antibiotics for an extended period of time. What complication would most likely develop?
To answer this question you have to identify two pieces of information. First, you have to recognize that the question is about vitamin deficiency acquired by antibiotic therapy (vitamin K is made by bacteria in the gut), and then you must recognize the deficiency syndrome that would be produced (bleeding tendency secondary to the inability to make clotting factors II, VII, IX, X, and proteins C and S). The other vitamin/syndrome associations are as follows:
Vitamin D deficiency can lead to bony abnormalities. Vitamin A deficiency can result in decreased night vision. Vitamin B12 and thiamine deficiency can lead to neurologic defects. Vitamin C deficiency can lead to scurvy.
A 48 year old patient with coronary artery disease undergoes surgery to insert a stent. To reduce the risk of an adverse cardiovascular disease, a combination of aspirin and a second medication that has the same Antiplatelet indications as aspirin is given. If this second medication is associated with rare cases of severe bone-marrow toxicity, which statement best describes this medication´s mechanism of action?
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A girl with a nonproductive cough, low grade fever, headache and noted to have a non-purulent otitis media is given an antibiotic that inhibits translocation of the growing peptide chain along the mRNA. Which antibiotic was prescribed?
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A 48 years old man is brought to the ER by his wife after obtaining a blood pressure reading of 234/142 mm Hg on a home blood pressure monitor. On arrival his blood pressure is 236/144 mm Hg. He has always had poorly controlled blood pressure. He also states he took medication for a migraine headache 2 hours earlier. He most likely took which medication?
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A patient is given an immunosuppressive drug that inhibits de novo purine synthesis and is myelosuppressive. Later dose reduction is needed because he is also taking Allopurinol. The drug likely used is
Azathioprine is converted to 6-mercaptopurine, which inhibits DNA synthesis and subsequent cell proliferation. Xanthine oxidase is instrumental in the metabolism of azathioprine metabolites, thus co-administration with allopurinol (an inhibitor of xanthine oxidase) can result in azathioprine toxicity.
Abatacept is as selective costimulation modulator that inhibits T-cell activation and is indicated for rheumatoid arthritis.
Cyclosporine and tacrolimus inhibit calcineurin mediated transcription of interleukin production, which reduces subsequent T-cell activation. Mycophenolate mofetil is converted to the active metabolite mycophenolic acid, which inhibits de novo guanine nucleotide synthesis and subsequent lymphocyte proliferation, these agents are both indicated for organ transplants but are not as likely to be affected by allopurinol.
On examination of a 77 year old man the blood pressure is found to be 200/100 mm Hg. He has history of coronary artery disease, hypercholesterolemia, and a coronary artery bypass graft surgery 2 years ago. Which drug is contraindicated in managing his hypertension?
Medications for hypertension are targeted at the four factors that affect systemic blood pressure, including heart rate, cardiac contractility, peripheral vascular resistance and volume status. However, in patients who are bradycardic, or who have an extensive cardiac history and likely congestive heart failure, the use of medications that can reduce cardiac contractility or heart rate is contraindicated. Thus, beta blockers such as propanolol should not be used in the patient described in this question. Enalapril is an ACE inhibitor that works primarily by preventing the conversion of angiotensin I to angiotensin II, increasing the secretion of aldosterone. The effect of enalapril on the heart is less than that of beta blockers. Furosemide is a loop diuretic, which is an effective treatment for hypertension by reducing renal fluid retention and the body´s fluid load. Hydralazine is a direct acting vasodilator that reduces peripheral vascular resistance via the nitric oxide pathway. Losartan is an angiotensin receptor antagonist that acts in a similar fashion to ACE inhibitors, and primarily reduces peripheral vascular resistance and body fluid status, with little effect on the heart.
A boy aged 14 years has been diagnosed with moderate persistent asthma. Recently his physician has decided to add an agent to the boy´s drug regimen that binds to free IgE. Which agent was likely prescribed?
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After a MI, a 53 year old male develops a life threatening ventricular arrhythmia and is treated with IV Lidocaine. He is then switched to an oral agent with mechanism of action similar to lidocaine. Which drug was likely prescribed?
A 35 year old man with IV opioid drug abuse presents complaining of arm pain. He is mildly febrile, and a tender, erythematous, fluctuant mass is observed on the patient´s right arm. The area is prepped and draped and copiously infiltrated with 2% lidocaine. When an incision is made to drain the abscess, the patient complains of severe pain. The failure of the local anesthesia is explained by which one of the following?
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A medical student is performing experiments on an anesthetized animal for her pharmacology lab. An arterial line is inserted to monitor blood pressure, and the animal is given an intravenous dose of epinephrine. The injection produces an increase in blood pressure. She then injects an unknown drug, followed fifteen minutes later by re-administration of epinephrine. The second administration of epinephrine now produces a decrease in blood pressure. The unknown drug belong to which class?
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A 23 year old man undergoes general anesthesia an inguinal hernia repair. Fentanyl, propofol, and midazolam are administered to achieve anesthesia. The surgeon quickly finishes the case, but the patient received too much fentanyl to breathe without assistance. The respiratory depression seen in this patient would be counteracted by which one of the following?
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A 67 year old female develops congestive heart failure secondary to left ventricular dysfunction. After discharge she is prescribed indapamide as part of her congestive heart failure treatment regimen. Which substance excretion would be decreased by this agent?
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A male aged 72 years is seen for a routine examination. His BP is 170/100 mm Hg. His physician prescribes Amlodipine. This agent exerts its mechanism of action by blocking which one of the following?
Amlodipine is calcium channel blocking agent indicated for the treatment of mild to moderate hypertension and angina. Amlodipine selectively blocks calcium ion influx across the membranes of cardiac and vascular smooth muscle cells without changing serum calcium concentrations. Terazosin is an example of an alpha 1 adrenergic receptor-blocking agent that is indicated for the treatment of hypertension and benign prostatic hypertrophy. Enalapril is an example of an angiotensin-converting enzyme (ACE) inhibitor indicated for the treatment of hypertension and congestive heart failure. When ACE is inhibited, it prevents the conversion of angiotensin I to angiotensin II, leading to decrease in aldosterone levels.
Propranolol is an example of a non-selective beta 1 receptor and beta-2 receptor blocking agent indicated for the treatment of hypertension. Beta-1 receptor blockade leads to negative inotropic and chronotropic effects on the heart. Beta-2 receptor blockade causes bronchoconstriction.
A 59 year old female arrives at her clinician´s office complaining of moderate anxiety. The drug that will help relieve her anxiety, with a minimum of unwanted sedative side effects is which one of the following?
Buspirone is a nonbenzodiazepine anxiolytic that is devoid of the sedative (or anticonvulsive and muscle relaxant) properties typically associated with the benzodiazepines. It is a partial agonist at 5-HT1A receptors.
Chlordiazepoxide and lorazepam are benzodiazepines. Although they are useful anxiolytics, they produce sedation. Trazodone is a very sedating atypical antidepressant. Zolpidem is a nonbenzodiazepine hypnotic used for the treatment of insomnia.
A male aged 34 years with a long history of asthma is referred to a pulmonologist. The physician decides to prescribe zileuton. Which one of the following is the mechanism of action of this drug?
A professor is teaching his class about the actions of different drugs on vessels. A certain drug produces vasodilation by increasing cGMP in the smooth muscle cells of arterioles. The drug that has this mechanism of action is
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A person who was drug abuser in past presents to ask for pain medication for a legitimate back pain. The physician takes the history of drug abuse into account. Which medication has the greatest potential for abuse?
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A 75 year old male has not been able to pass urine today, but had been able to do so normally the previous 2 days. Exam reveals a BP of 175/90 mm Hg. Lab data reveals creatinine of 4.5 mg/dL and BUN of 115 mg/dL. Urinalysis reveals a specific gravity of 1.01 mg/dL and an occasional white blood cell per high powered field. Which could be used to ameliorate his symptoms?
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