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Terms in this set (50)

1. A patient with a long history of cardiovascular disease develops worsening ventricular arrhythmias. Which of the following drugs is most likely to be the cause of the arrhythmia?
(A) Quinidine
(B) Propanolol
(C) Dobutamine
(D) Methyldopa
(A) Quinidine
1. The answer is A. Quinidine is associated with QT interval prolongation and torsade de point arrhythmias. Propranolol can cause heart block. Dobutamine rarely causes ventricular
arrhythmias.
2. A patient is admitted into the emergency room and manifests ventricular tachycardia following an acute myocardial infarction (MI). This arrhythmia is life threatening and must be controlled immediately. Which of the following drugs would be best to quickly control the condition?
(A) Dobutamine
(B) Digitalis
(C) Quinidine
(D) Lidocaine
(E) Atropine
(D) Lidocaine
2. The answer is D. Lidocaine is the best agent for management of ventricular tachycardia associated with acute myocardial infarction (MI). Dobutamine, digitalis, quinidine, and atropine can all induce tachyarrhythmias. Lidocaine does not slow conduction and has little effect on atrial function.
3. A woman who is undergoing an endocrine work-up to diagnose the cause of a large multinodular goiter develops atrial fibrillation. Which of the following would be best to treat this arrhythmia?
(A) Verapamil
(B) Propranolol
(C) Digitalis
(D) Bretylium
(E) Tocainide
Propranolol
3. The answer is B. Hyperthyroidism apparently increases b-adrenoceptors. b-Adrenoceptor
antagonists such as propranolol can actually decrease symptoms of hyperthyroidism.
4. A 57-year-old man with atrial flutter is initially treated with quinidine to control the arrhythmia. He is released from the hospital, and while his condition Improves, sporadic arrhythmias continue. Which of the following drugs might be used as an adjunct to quinidine in the treatment of the atrial flutter?
(A) Digitalis
(B) Lidocaine
(C) Procainamide
(D) Nifedipine
(E) Propranolol
Digitalis
4. The answer is A. Quinidine acts to prolong refractoriness and slow conduction rather than as a negative inotropic agent. The ability of digitalis to decrease conduction through the atrioventricular (AV) node makes its effects compatible with quinidine to reduce atrial flutter. Lidocaine must be administered parenterally. The effects of procainamide are synergistic with quinidine, increasing the risk of toxicity; nifedipine has little antiarrhythmic effect.
5. A 16-year-old boy is brought to the hospital by ambulance following a car accident causing serious head injuries. His blood pressure is 220/ 170 mm Hg. Funduscopy reveals retinal damage, and you administer nitroprusside via infusion. Control of the hypertension requires 72 hours and you notice the patient becoming increasingly fatigued and nauseous. The mostly likely cause of these symptoms is
(A) Production of thiocyanate from
nitroprusside
(B) Negative inotropic activity of nitroprusside
(C) Renal precipitation of nitroprusside
(D) Accumulation of nitroprusside because of
its long half-life
(A) Production of thiocyanate from
nitroprusside
5. The answer is A. The toxicity of nitroprusside is caused by the release of cyanide and the accumulation of thiocyanate. Hydroxocobalamin is used to reduce the toxicity of nitroprusside through the formation of the less toxic cyanocobalamin.
6. A 66-year-old man presents to your office with a 5-month history of dry cough. He denies any other symptoms. His past medical history includes a recent myocardial infarction (MI), after which he was placed on several medications. He does not smoke, nor has he had a history of asthma. You decide that a medication side effect is the most likely cause of this patient's symptoms. Which medication might this be?
(A) Lisinopril
(B) Nitroglycerin
(C) Lovastatin
(D) Digoxin
(E) Quinidine
Lisinopril
6. The answer is A. Angiotensin-converting enzyme (ACE) inhibitors commonly cause dry nonproductive cough. Nitroglycerin can cause headaches. Lovastatin commonly causes liver dysfunction. Digoxin can cause arrhythmias, and quinidine is known to cause muscle weakness.
7. Since the side effects of the medication you prescribed preclude the patient in the above scenario from taking it, you switch him to therapy with an agent that is said to produce similar mortality benefits, while working via a slightly different mechanism of action. What agent is it?
(A) Furosemide
(B) Captopril
(C) Losartan
(D) Esmolol
(E) Ezetimibe
Losartan
7. The answer is C. Losartan is an angiotensin receptor blocker (ARB) that produces effects similar to those of angiotensin converting enzyme (ACE) inhibitors while causing less cough and angioedema. Furosemide is a loop diuretic that is used in congestive heart failure. Captopril is an example of another ACE inhibitor. Esmolol is an antiarrhythmic agent. Ezetimibe is a lipidlowering drug.
8. A 54-year-old woman is diagnosed with congestive heart failure (CHF). You prescribe captopril, a medication proven to reduce her mortality. This agent delivers several benefits to patients with CHF. Which of the following effects is caused by this drug?
(A) It has a high affinity for angiotensin II
receptors
(B) It promotes increased peripheral vascular
resistance
(C) It decreases cardiac output and increases
afterload
(D) It causes venodilation and induces
natriuresis
(E) It increases preload
(D) It causes venodilation and induces
natriuresis
8. The answer is D. Angiotensin converting enzyme (ACE) inhibitors cause venodilation and
induce natriuresis, thereby reducing preload. A high affinity for angiotensin II receptors represents the mechanism of action of angiotensin-receptor blockers. ACE inhibitors counteract increased peripheral resistance, increase cardiac output, and decrease afterload.
9. A 76-year-old man has suffered from atrial fibrillation for many years. This condition has been under good control with amiodarone and diltiazem until recently, when he started experiencing palpitations and came back to see you. You decide to start the patient on digoxin therapy. How does this medication work?
(A) It decreases intracellular sodium and
increases intracellular potassium
(B) It lowers intracellular calcium
(C) It decreases stroke volume and cardiac
output
(D) It diminishes elimination of sodium and
water
(E) It increases vagal activity and decreases
sympathetic tone
(E) It increases vagal activity and decreases
sympathetic tone
9. The answer is E. Digoxin, a cardiac glycoside, increases vagal activity, resulting in inhibition of the sinoatrial (SA) node and delayed conduction through the atrioventricular (AV) node. It also decreases sympathetic tone. Cardiac glycosides increase intracellular sodium while decreasing intracellular potassium; increase intracellular calcium; and increase stroke volume and therefore cardiac output. Cardiac glycosides enhance elimination of sodium and water.
10. A 47-year-old woman is admitted for treatment of acute myocardial ischemia. Her prior medication included digoxin for atrial fibrillation. She also suffers from hypertension, for which she is currently not taking anything. Before you discharge her home, you decide to add a medication that works well for hypertension. While she is still on the floor she develops a dangerous arrhythmia, which you are fortunately able to treat promptly. Which medication you added likely increased the effects of digoxin that this patient was already taking?
(A) Valsartan
(B) Hydrochlorothiazide
(C) Hydralazine
(D) Tadalafil
(E) Lovastatin
(B) Hydrochlorothiazide
10. The answer is B. Hydrochlorothiazide, a diuretic, is known to cause hypokalemia, a state in which the actions of digoxin can be potentiated to a dangerous level. Valsartan is generally not used as a sole agent for hypertension. Hydralazine lowers blood pressure, but it does not generally cause marked electrolyte disturbances. Tadalafil is an agent used for erectile dysfunction. Lovastatin is an HMG-CoA inhibitor, used for hypercholesterolemia.
11. A 55-year-old woman is admitted to the surgical intensive care unit after having a coronary artery bypass grafting of four of her coronary vessels. Overnight she develops hypotension, and her cardiac output, as measured by the Swan-Ganz catheter, is significantly lower than it had been post-surgery. You decide to give her a dose of milrinone. This results in an increase in her cardiac output. How does this medication work?
(A) It is a cholinergic agonist
(B) It reduces left ventricular filling pressure
(C) It potentiates cardiac phosphodiesterase
type 3
(D) It decreases cyclic AMP (cAMP)
(E) It decreases intracellular calcium
(B) It reduces left ventricular filling pressure
11. The answer is B. Milrinone reduces left ventricular filling pressure and thus enhances cardiac output. It is related to the anticholinergic agent biperiden. Milrinone inhibits cardiac phosphodiesterase type 3. It increases cyclic AMP (cAMP), and therefore intracellular calcium.
12. You are taking care of a 64-year-old man who had just undergone a right hemicolectomy for colon cancer. His blood pressure has been low, and you want to find out whether the shock that this patient is experiencing is related to a possible intraabdominal infection as a consequence of his surgery or is due to his preexisting congestive heart failure (CHF). After analyzing the Swan-Ganz catheter measurements, you deduce that the picture is most compatible with cardiogenic shock. You recall from your pharmacology class that dobutamine can be used successfully for such patients. Which of the following is true regarding dobutamine?
(A) It acts on dopamine receptors
(B) It activates a-receptors
(C) It activates cyclic AMP (cAMP)-related
pathways
(D) It increases peripheral resistance
(E) It produces bradycardia
(C) It activates cyclic AMP (cAMP)-related
pathways
12. The answer is C. Dobutamine increases cyclic AMP (cAMP)-mediated phosphorylation and the activity of calcium channels. It does not act on dopamine receptors or a-receptors; it only acts on b1-receptors. Dobutamine does not substantially affect peripheral resistance. This agent produces mild tachycardia.
13. A 75-year-old woman, who is admitted for management of her recent stroke, develops increased blood pressure, up to 195/105, with a heart rate of 95. Her physician is worried about the possibility of cerebral hemorrhage into the preexisting infarct and decides to administer a fast-acting vasodilating agent, which is also commonly used for severe decompensated congestive heart failure (CHF). Which medication did the doctor use?
(A) Nitroprusside
(B) Furosemide
(C) Dobutamine
(D) Losartan
(E) Digoxin
(A) Nitroprusside
13. The answer is A. Nitroprusside is a vasodilating agent that can be used in hypertensive emergencies. Furosemide is used for long-term treatment of congestive heart failure (CHF). Dobutamine does not significantly affect the vessels to produce vasodilation. Losartan is an
angiotensin converting enzyme (ACE) inhibitor that is used in long-term care of CHF. Digoxin is another long-term agent used in CHF and certain arrhythmias.
14. While doing your medicine clerkship, you
hear an announcement that a CPR team should
immediately report to the room of one of the
patients. Being an inquisitive student, you
decide to observe how the code team manages
this unfortunate patient's CPR. The rhythm
monitor displays ventricular fibrillation that is
quickly converted to atrial fibrillation with rapid
ventricular response. The senior resident orders
amiodarone to be administered to this patient.
Since you forgot how this agent works, you ask
one of the residents to explain how this medication
works. The resident replies that he is busy,
but tells you it is a class III antiarrhythmic agent.
What is the mechanism of action of this agent?
(A) It is a b-receptor antagonist
(B) It blocks fast sodium channels
(C) It decreases refractoriness
(D) It interferes with outward potassium
current
(E) It has a relatively short half-life
(D) It interferes with outward potassium
current
14. The answer is D. Amiodarone is a class III antiarrhythmic agent that interferes with outward potassium current. b-Receptor antagonists are considered class II antiarrhythmics. Class I antiarrhythmics block fast sodium channels. Amiodarone prolongs the effective refractory period. It has a rather long half-life, up to 100 days.
15. Although the rhythm is now under control
in the patient described in the question 14, his
rate is still rather high, into the 140s-150s. The
rhythm strip is consistent with supraventricular
tachycardia. The resident that was testing you
before is now less busy and asks you what medication
he should use next, given that he has in
mind an agent that can also be used as an antimalarial.
Which agent is it?
(A) Digoxin
(B) Propranolol
(C) Flecainide
(D) Verapamil
(E) Quinidine
15. The answer is E. Quinidine is used for supraventricular tachycardia and is used to maintain sinus rhythm after conversion of atrial fibrillation. It also has antimalarial properties. Digoxin can be used in long-term management of atrial fibrillation. Propranolol is a class II antiarrhythmic agent. Flecainide is a class IC agent that can be used for ventricular tachyarrhythmias. Verapamil is a class IV antiarrhythmic agent.
1. A patient is admitted to the hospital for gallbladder
surgery, and although the surgery is
successful, a case of ileus develops. This necessitates
feeding the patient parenterally for 8
days. A nurse observes that the surgical wound
and IV sites have begun to ooze small but constant
amounts of blood. Which of the following
would be the most appropriate treatment of this
patient?
(A) Ticlopidine
(B) Factor VIII concentrate
(C) Urokinase
(D) Vitamin K
(E) Folic acid
(D) Vitamin K
(The answer is D. After 6-7 days of parenteral feeding, vitamin K stores are depleted and clotting factor biosynthesis is impaired. Ticlopidine is an anticoagulant, and urokinase is a thrombolytic; both would be contraindicated in this circumstance. Folic acid would not improve the condition of the patient).
2. A man undergoing chemotherapy for lung
cancer complains of shortness of breath when
climbing stairs and generalized fatigue. An electrocardiogram
(ECG) appears normal, but his hematocrit level is 8.1.
Which of the following would be most appropriate for this patient?
(A) Erythropoietin
(B) Digoxin
(C) Ticlopidine
(D) Vitamin B6
(E) Enalapril
(The answer is A. Erythropoietin (EPO) stimulates the production of erythrocytes, which are frequently diminished as a consequence of anticancer therapy and correct the patient's hematocrit level. Digoxin is a cardiac glycoside that can improve contractility in impaired myocardium but would not be used in this circumstance. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that would have little effect on the patient's condition).
3. A 56-year old woman has a temporary loss of
peripheral vision and dizziness that lasts for
approximately 10 minutes. Her family history
reveals that her mother had thromboembolemic
disease, but her father was normal. Which
of the following would be the best outpatient
prophylactic regimen for this patient 2 days after
these symptoms appeared?
(A) Anistreplase
(B) Clopidogrel
(C) Heparin
(D) Abciximab
(E) Streptokinase
(The answer is B. The patient has symptoms consistent with a transient ischemic attack (TIA). Prophylactic antiplatelet therapy should be instituted while the diagnosis is confirmed. Heparin is not suitable for outpatient use. Anistreplase and streptokinase are thrombolytics that may be used within hours of a thrombotic stroke but not after 2 days after a possible TIA).
4. A 53-year-old obese woman is brought into
the emergency room by her concerned husband
approximately 1 hour after complaining of
constant abdominal pain, nausea, and shortness
of breath. An electrocardiogram (ECG) and
cardiac enzyme tests indicate a moderate myocardial
infarction (MI) due to occlusion of the
left descending coronary artery. Which of the
following would be the best course of treatment
for this patient?
(A) Reteplase
(B) Heparin
(C) Eptifibatide
(D) Lovastatin
(A) Reteplase
(The answer is A. Thrombolytics such as the recombinant tissue plasminogen activator (tPA)
reteplase reduce morbidity and mortality if used shortly after an acute myocardial infarction
(AMI). Heparin might be used after resolution of the AMI. If the patient is above recommended levels of low-density lipoprotein (LDL) cholesterol, she should be treated with a cholesterol-lowering drug such as lovastatin).
5. A young couple present to their primary
care physician stating that they are trying to
conceive. They would like to know if the
future mom-to-be needs to be on any
supplements. Along with recommending a
multivitamin with folic acid, the doctor also
suggests an iron supplement. Pregnant
women develop iron deficiency anemia
because of
(A) Increased bleeding tendency
(B) Increased dietary deficiency
(C) Malabsorption
(D) Increased iron demands
(E) Increased excretion
(D) Increased iron demands
(The answer is D. Pregnancy and lactation are the states of increased iron demands. While
increased bleeding tendency, dietary deficiency, and malabsorption are all true causes of iron deficiency anemia, they are not the culprits during pregnancy. Iron storage is regulated at the level of absorption, and very little of it is lost from the body).
6. A 65-year-old diabetic man develops endstage
renal disease. His glomerular filtration
capacity is now low enough to require dialysis.
His nephrologist also explains that the patient
will require weekly injections of synthetic erythropoietin
(EPO), since this protein is normally
produced by the kidney. What is the mechanism
of action of EPO?
(A) It increases proliferation of erythroid precursor
cells in the bone marrow
(B) It decreases the release of reticulocytes
from the bone marrow
(C) It decreases hemoglobin synthesis
(D) It is independent of the amount of iron
stored in the body
(E) It participates in the mitochondrial reaction
that produces succinyl-CoA
(The answer is A. Erythropoietin (EPO) increases the rate of proliferation and differentiation of erythroid precursor cells in the bone marrow. It increases the release of reticulocytes. It also increases hemoglobin synthesis. Erythropoietin requires adequate iron stores. Participation in the mitochondrial reaction that produces succinyl-CoA refers to the mechanism of action of one of the natural cobalamins, deoxyadenosylcobalamin).
7. A 47-year-old man with a history of
alcohol abuse presents to the urgent care
clinic complaining of lightheadedness and
dyspnea on exertion. His laboratory studies
indicate a low hemoglobin level. Peripheral
smear shows increased number of spherocytes.
What agent could be used to treat this patient's
anemia?
(A) Iron supplements
(B) Erythropoietin
(C) Vitamin B6
(D) Vitamin B12
(E) Folic acid
(The answer is C. Sideroblastic anemia may develop in alcoholics and patients undergoing antituberculin therapy. This condition is treated with vitamin B6 supplements (pyridoxine). Iron supplements are used in iron deficiency anemia. Erythropoietin is used in anemia caused by AIDS, chemotherapy, and renal failure. Vitamin B12 and folic acid are used for megaloblastic anemias caused by depletion of the vitamin).
(The answer is C. Sideroblastic anemia may develop in alcoholics and patients undergoing antituberculin therapy. This condition is treated with vitamin B6 supplements (pyridoxine). Iron supplements are used in iron deficiency anemia. Erythropoietin is used in anemia caused by AIDS, chemotherapy, and renal failure. Vitamin B12 and folic acid are used for megaloblastic anemias caused by depletion of the vitamin).
8. A 40-year-old morbidly obese woman undergoes
gastric bypass surgery to help her lose
weight. Her surgeon reminds her that now she
will have to get a monthly injection of vitamin
B12, since the part of her stomach responsible
for production of intrinsic factor has been
removed. Which of the following is true about
vitamin B12?
(A) Loss of vitamin B12 from the body is a rapid
process
(B) The molecule of vitamin B12 contains
copper
(C) Vitamin B12 is not required for fatty acid
metabolism
(D) A deficiency results in impaired DNA
replication
(E) Neurologic deficits are not seen with this
kind of anemia
(The answer is D. Deficiency of vitamin B12 results in impaired DNA replication. Loss of vitamin B12 is a very slow process, with hepatic stores being sufficient for up to 5 years. The molecule of vitamin B12 contains cobalt. Vitamin B12 is essential for normal fatty acid metabolism. Vitamin B12 deficiency causes irreversible neurologic disorders).
9. A 31-year-old pregnant woman presents to
her obstetrician for a routine visit. She has several
questions for her doctor, one of which has
to do with the supplements that she was advised
to take at her first prenatal visit. She stated she
leads a very busy lifestyle and sometimes forgets
to take all the pills she is supposed to take. She
wants to know the purpose of folic acid supplementation
in pregnancy.
(A) It increases oxygen-carrying capacity of the
blood
(B) It decreases the risk of neural tube defects
(C) It aids in bone growth of the maturing fetus
(D) It stimulates myelopoiesis of erythroid progenitor
cells
(E) It reduces blood viscosity during pregnancy
(The answer is B. Folic acid supplementation has been shown to decrease the incidence of neural tube defects. Increasing the oxygen-carrying capacity of the blood refers to a possible role of iron supplements. Calcium is helpful in adding bone growth. Stimulating myelopoiesis of erythroid progenitor cells refers to the mechanism of action of erythropoietin. Finally, reduction of blood viscosity during pregnancy refers to pentoxifylline; however, this medication is not recommended during pregnancy).
10. A 29-year-old African-American man
presents to the emergency department with a
chief complaint of severe pain in his arms and
legs. Since this has happened to him before, he
knows that what he is experiencing is a sickle
crisis. He states that since he does not have
medical insurance, he only comes to see a doctor
when he experiences these ''crises.'' Which
pain medication is the emergency physician
likely to prescribe?
(A) Indomethacin
(B) Hydrocodone
(C) Acetaminophen
(D) Celecoxib
(E) Hydroxyurea
(The answer is E. Hydroxyurea increases the production of fetal hemoglobin and has been shown to be effective in reducing painful episodes of sickle crisis. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for pain associated with rheumatoid arthritis. Hydrocodone is a narcotic pain reliever that is only recommended in cases of severe pain, such as that caused by surgery. Acetaminophen is unlikely to be helpful in this patient's situation, as this agent is useful for mild-to-moderate pain. Celecoxib is a COX-2 inhibitor used in a variety of inflammatory conditions.).
11. A 74-year-old woman who is undergoing
chemotherapy for advanced lung cancer
presents to the infusion center for her next
treatment. Before each treatment her white
count, hemoglobin, and platelet counts are
checked to make sure she is not experiencing
chemotherapy-related cytotoxicity. Her blood
sample is run in the analyzer, and her platelet
count is reported to be at a dangerously low
level. Which medication is her oncologist likely
to prescribe in this situation, along with a platelet
transfusion?
(A) Erythropoietin
(B) Oprelvekin
(C) Filgrastim
(D) Sargramostim
(E) Leucovorin
(The answer is B. Oprelvekin has been shown to reduce the need for platelet transfusions following myelosuppressive chemotherapy. Erythropoietin is used for anemia. Filgrastim and sargramostim are used for neutropenia. Leucovorin is used in patients undergoing treatment with methotrexate, to prevent some of its side effects).
12. A 55-year-old woman undergoes an open
cholecystectomy. She is admitted for postoperative
observation and started on subcutaneous
heparin treatment to prevent formation of deep
venous thrombosis, a major risk factor for pulmonary
embolism. Which of the following is
true regarding the mechanism of action of
heparin?
(A) Heparin increases activity of antithrombin
(B) Serine proteases of the clotting cascade are
deactivated
(C) Heparin catalyzes clotting in vitro
(D) Heparin aids sequestration of lipoproteins
(E) Clotting factor is activated
(The answer is A. Heparin increases the activity of antithrombin by 1,000-fold. Antithrombin, in turn, activates serine proteases of the clotting cascade. Heparin has a direct anticoagulant activity and can inhibit clotting in vitro. Heparin releases lipoprotein lipase from vascular beds, which accelerates clearing of lipoproteins from plasma. The clotting factor is inactivated, which releases heparin and allows it to be recycled).§
13. A 63-year-old man has a history of atrial fibrillation.
To reduce his risk of a stroke, his physician
had given him an anticoagulant medication. This agent, while being of tremendous
benefit to this patient, comes with its associated
risks, such as spontaneous hemorrhage.
To monitor the appropriateness of the current
dosage of the medication, the patient comes in
frequently to have the laboratory check his prothrombin
level. Which medication must this
patient be taking?
(A) Heparin
(B) Fragmin
(C) Lovenox
(D) Coumarin
(E) Protamine
(The answer is D. Coumarin is commonly used in patients with atrial fibrillation for prevention of thromboembolic events, such as stroke. Prothrombin times should be frequently monitored in patients taking coumarin, as bleeding is a common adverse effect. Heparin is monitored with partial thromboplastin time. Fragmin and Lovenox are low-molecular-weight derivatives of heparin that do not require laboratory monitoring. Protamine is an agent used for heparin reversal).
14. A 75-year-old man is brought to the emergency
department after being found on the floor
of his room. His wife tells you that his medical
history includes two prior strokes, for which he
is now taking a ''small pill that works on platelets.''
Your attending tells you that there are
newer agents now that work by preventing platelet
aggregation. He asks you if you know the
names of any such agents. You are very excited,
because you, in fact, had just reviewed your
pharmacology. Which answer do you give?
(A) Heparin
(B) Coumarin
(C) Clopidogrel
(D) Alteplase
(E) Dextran
(The answer is C. Clopidogrel works by inhibiting platelet aggregation. Heparin works by increasing the activity of antithrombin. Coumarin interferes with g-carboxylation of several clotting factors. Alteplase is a thrombolytic. Dextran impairs fibrin polymerization and platelet function).
1. A 35-year-old woman presents to your office
for a regular check-up. She has no complaints.
On examination, her blood pressure is slightly
elevated at 145/85. She is physically fit and follows
a healthy diet. You decide to start her on
antihypertensive therapy and prescribe hydrochlorothiazide.
How does this agent work?
(A) Inhibits reabsorption of sodium chloride in
the early distal convoluted tubule
(B) Decreases net excretion of chloride, sodium,
and potassium
(C) Increases excretion of calcium
(D) Inhibits reabsorption of sodium chloride in
the thick ascending limb of the loop of Henle
(E) Interferes with potassium secretion
(The answer is A. Thiazide diuretics inhibit active reabsorption of sodium chloride in the early distal convoluted tubule of the nephron by interfering with the Na/Cl cotransporter, resulting in net excretion of sodium and water. These agents increase net excretion of chloride, sodium, and potassium. They decrease excretion of calcium. Inhibiting reabsorption of sodium chloride in the thick ascending limb of the loop of Henle describes the mechanism of action of loop diuretics. Interfering with potassium secretion refers to mechanism of action of potassium-sparing Diuretics).
4. A 57-year-old man with a history of
heavy alcohol use is being admitted for a first
episode of congestive heart failure (CHF),
which likely resulted from untreated
alcoholic cardiomyopathy. The cardiologist
decides to start the patient on diuretic therapy.
Which class of diuretics is preferred in this
scenario?
(A) Loop diuretics, because they exert their
action at the distal convoluted tubule
(B) Loop diuretics, because the thick ascending
limb is an area of high capacity for NaCl
reabsorption
(C) Thiazide diuretics, because they exert their
action at the thick ascending limb of the
loop of Henle
(D) Thiazide diuretics, because they increase
cardiac output
(E) Thiazide diuretics, because they increase
peripheral vascular resistance
(The answer is B. Loop diuretics are used in cases of congestive heart failure (CHF) and pulmonary edema because they result in fast and significant diuresis. These agents exert their action at the thick ascending limb of the loop of Henle, which is the area of highest capacity for NaCl reabsorption. Thiazide diuretics actually decrease cardiac output initially, because of decrease blood volume. As well, thiazides decrease peripheral vascular resistance, because they relax arteriolar smooth muscle).
5. A 66-year-old woman suffers a myocardial
infarction while in the hospital and immediately
goes into respiratory distress. On examination
you realize the patient has flash pulmonary
edema as a result of her infarction. Along with
the management of the myocardial infarction,
you start the patient on furosemide therapy to
treat pulmonary edema. What is the mechanism
of action of this agent?
(A) Inhibition of action of aldosterone by binding
to its receptor in principal cells of the
collecting duct
(B) Reduction of bicarbonate reabsorption and
concomitant sodium uptake
(C) Inhibition of active reabsorption of sodium
chloride at the distal convoluted
tubule
(D) Alteration of the diffusion of water relative
to sodium, thereby reducing sodium
reabsorption
(E) Inhibition of active reabsorption of sodium
chloride at the thick ascending limb of the
loop of Henle
(The answer is E. Loop diuretics inhibit active NaCl reabsorption in the thick ascending limb of the loop of Henle by inhibiting a specific Na+/K+/2 Cl- cotransporter. Inhibition of action of aldosterone by binding to its receptor in principal cells of the collecting duct describes the mechanism of action of potassium-sparing diuretics. Reduction of bicarbonate reabsorption and concomitant sodium uptake refers to carbonic anhydrase inhibitors. Inhibition of active reabsorption of sodium chloride at the distal convoluted tubule describes thiazide diuretics. Finally, alteration of the diffusion of water relative to sodium, thereby reducing sodium reabsorption, refers to osmotic diuretics).
6. An 87-year-old woman who is taking multiple
medications for her ''heart disease'' is prescribed
gentamicin for diverticulitis. After a few
days of taking the antibiotic, she complains of
dizziness and tinnitus. What ''heart medication''
might she be on?
(A) Spironolactone
(B) Hydrochlorothiazide
(C) Mannitol
(D) Ethacrynic acid
(E) Urea
(The answer is D. Ototoxicity, as demonstrated by tinnitus and dizziness, is a common side effect of loop diuretics, especially ethacrynic acid. This effect is magnified when aminoglycoside antibiotics are added to the regimen. A common side effect of spironolactone is gynecomastia. Hydrochlorothiazide can cause gout in susceptible individuals. Mannitol and urea are osmotic diuretics and are not indicated in patients with heart disease, especially congestive heart failure (CHF)).
7. A 54-year-old man develops congestive heart
failure (CHF) after suffering his second myocardial
infarction. His physician puts him on a regimen
of several medications, including
furosemide. On follow-up, the patient is found
to have hypokalemia, likely secondary to furosemide
use. The addition of which medication
would likely resolve the problem of hypokalemia,
while helping to treat the underlying condition,
CHF?
(A) Allopurinol
(B) Hydrochlorothiazide
(C) Spironolactone
(D) Acetazolamide
(E) Ethacrynic acid
(The answer is C. Spironolactone is commonly added to the regimen of anti-congestive heart failure (CHF) medications, since it counteracts the loss of potassium caused by the loop diuretics such as furosemide. This agent is also effective in reducing the symptoms of refractory edema. Allopurinol is not used to treat CHF. Hydrochlorothiazide will exacerbate hypokalemia caused by the loop diuretics. Acetozolomide will not counteract hypokalemia. Ethacrynic acid is an example of another loop diuretic).
8. A 60-year-old previously healthy fit man
presents to your office with new-onset hypertension.
Since this is an unusual age to present
with essential hypertension, you order an extensive
work-up. The results show low levels of potassium,
high levels of aldosterone, and low
levels of renin. The patient is diagnosed with
Conn syndrome, or hyperaldosteronism. A
computed tomographic (CT) scan of the abdomen
reveals bilateral adrenal hyperplasia,
which renders this patient inoperable. You
decide to start the patient on spironolactone
therapy.
How does this medication work?
(A) It is an agonist of the mineralocorticoid
receptor
(B) It interferes with the action of the mineralocorticoid
receptor
(C) It promotes sodium reabsorption
(D) It increases the synthesis of sodium channels
in the principal cells
(E) It is only active when endogenous mineralocorticoids
are absent
(The answer is B. Sprironolactone interferes with the action of the mineralocorticoid receptor. Spironolactone prevents cellular events that regulate potassium and hydrogen secretion and sodium reabsorption. Spironolactone is an antagonist of mineralocorticoid receptors. It decreases the synthesis of sodium channels in the principal cells of the collecting ducts. This agent is only active when endogenous mineralocorticoids are present).
9. A 45-year-old woman with a long history of
alcohol abuse is being treated for cirrhosisassociated
ascites. Her internist decided to give
her amiloride, a diuretic helpful in edema
caused by cirrhosis. What common side effect
should be monitored in this patient?
(A) Hypernatremia
(B) Hypocalcemia
(C) Hyperphosphatemia
(D) Hypermagnesemia
(E) Hyperkalemia
(The answer is E. Hyperkalemia, a potentially life-threatening side effect, should be recognized as a possible result of amiloride use. Hyponatremia, not hypernatremia, can be observed with amiloride. This agent does not affect calcium or phosphorus balance to a significant degree. Triamterene, another potassium-sparing diuretic, can cause increased urinary excretion of magnesium; amiloride is not known to produce this effect).
1. A 17-year-old patient is brought to your
allergy practice complaining of chronic cough
that gets quite severe at times. The condition
occurs about twice a week and is beginning to
interfere with his studies. Which of the following
would be most appropriate treatment for
this patient?
(A) Oral prednisone
(B) Omalizumab
(C) Diphenhydramine
(D) Inhaled budesonide
(E) Theophylline
(The answer is D. This is a fairly classical presentation of asthma, which should be confirmed with further pulmonary testing. Mild persistent asthma can be treated several ways but inhaled glucocorticoids are very effective. Oral prednisone has many side effects, especially in a young person. Omalizumab is for patients who are refractory to other treatments and those with allergies. Antihistamines such as diphenhydramine are poorly effective in asthma, and theophylline is only moderately effective).
2. A woman who has asthma and is recovering
from a myocardial infarction is on several medications
including a baby aspirin a day. She complains
of large bruises on her arms and legs and
some fatigue. A standard blood panel reveals
markedly elevated alanine aminotransferase
(ALT). Which of the following is most likely responsible
for the increase in liver enzymes?
(A) Heparin
(B) Zileuton
(C) Zafirlukast
(D) Albuterol
(E) Aspirin
(The answer is B. Zileuton is a leukotriene synthesis inhibitor that can cause increases in hepatic enzymes and altered liver function. It decreases the rate of heparin metabolism, leaving patients prone to easy bruising. Zafirlukast and albuterol are antiasthmatic agents but do not alter liver enzymes. Aspirin might cause bleeding disorders, but the low dose this patient is taking is unlikely to be responsible for the liver enzyme abnormalities).
3. A 20-year-old college student participates in
several intramural athletic programs but is complaining
that his asthma, which you have been
treating for 5 years, is getting worse. In the last
month, he has used his albuterol inhaler at least
20 times following baseball practice, but he has
not been waking much at night. You elect to
change his treatment regimen. Which of the following
would be the best change in treatment
for this patient?
(A) Oral triamcinolone
(B) Zileuton
(C) Salmeterol
(D) Nedocromi
(The answer is C. The patient's asthma is worsening, especially in response to exercise or
increased allergen exposure, and the excessive of short-acting b2-agonists requires a change in medication. The best choice would be a long-acting b2-agonist like salmeterol. Oral glucocorticoids have many adverse effects, and zileuton and nedocromil are unlikely to be sufficiently efficacious in the worsening asthma).
4. Which of the following statements regarding
the pharmacokinetics of theophylline is correct?
(A) It is primarily metabolized by the kidney
(B) Its metabolism depends on age
(C) It is poorly absorbed after oral
administration
(D) It has a wide therapeutic index
(The answer is B. The metabolism of theophylline depends on age; the half-life of the drug in children is much shorter than in adults. The methylxanthines are all well absorbed and are metabolized in the liver).
5. Which of the following statements correctly
describes the action of theophylline?
(A) It stimulates cyclic AMP phosphodiesterase
(B) It is an adenosine-receptor antagonist
(C) It does not cross the blood-brain barrier
(D) It blocks the release of ACh in the bronchial
Tree
(The answer is B. Theophylline may have several mechanisms of action, but its adenosine-receptor antagonist activity and the inhibition of phosphodiesterase are the best understood).
6. Which of the following statements regarding opiate action is correct?
(A) It triggers a vagal reflex to suppress cough
(B) It can cause diarrhea
(C) Its expectorant action is caused by stimulation
of mucus production
(D) It acts centrally to suppress the medullary
cough center
((The answer is D. Opioids act centrally to decrease the sensitivity of the cough center; they also decrease propulsion in the bowel).
7. Which of the following statements about the
mechanism of action of ipratropium is correct?
(A) It acts centrally to decrease vagal ACh
release
(B) It inhibits pulmonary ACh receptors
(C) It decreases mast cell release of histamine
(D) It blocks the action of histamine at H1
Receptors
(The answer is B. Ipratropium is an ACh-receptor antagonist; it is poorly absorbed, so most of its effect is in the lung. It does not cross the blood-brain barrier and does not block mediator release or H1-receptors).
8. Zileuton is useful in the treatment of asthma
because it
(A) Inhibits prostaglandin biosynthesis
(B) Inhibits leukotriene synthesis
(C) Inhibits leukotriene receptors
(D) Inhibits 12-lipoxygenase
(The answer is B. By inhibiting 5-lipoxygenase, zileuton reduces leukotriene biosynthesis; it does not inhibit (and in fact it might increase) prostaglandin synthesis).
(The answer is B. By inhibiting 5-lipoxygenase, zileuton reduces leukotriene biosynthesis; it does not inhibit (and in fact it might increase) prostaglandin synthesis).
9. A 35-year-old Mexican-American man
presents to his family physician because his
mother has been visiting from Mexico and was
found to have tuberculosis (TB). The family
physician places a purified protein derivative
(PPD), which has negative results, but recommends
prophylaxis against TB. Which of the following
is indicated for TB prophylaxis in
exposed adult patients?
(A) Rifampin
(B) Ethambutol
(C) Isoniazid
(D) Streptomycin
(E) Pyrazinamide
(The answer is C. Isoniazid can be used alone for the prophylaxis of tuberculosis (TB) in the case of such exposure. All the other agents are important in the treatment of known TB infection and are often used in combination with isoniazid. Often rifampin, ethambutol, streptomycin, isoniazid, and pyrazinamide are used for months together, as many strains are multidrug resistant).
75. What should be given to correct coagulopathy
due to an overdose of warfarin in a
73-year-old man?
(A) Aminocaproic acid
(B) Vitamin K
(C) Heparin
(D) Vitamin D
(E) Oprelvekin
(The answer is B. Warfarin is an orally active inhibitor of vitamin K-dependent carboxylation of
various clotting factors. In the event of supratherapeutic doses of warfarin, the anticoagulation
can be reversed by giving vitamin K. Heparin is an intravenous preparation that is also an anticoagulation
agent. Aminocaproic acid inhibits plasminogen activation and is used in the treatment
of hemophilia. Vitamin D is used in cases of its deficiency or in the treatment of osteoporosis.
Oprelvekin is a recombinant form of interleukin-11 that stimulates platelet production and does
not affect the clotting factors).
52. Adverse effects seen with high blood levels
of theophylline include
(A) Seizures
(B) Arrhythmias
(C) Nervousness
(D) Nausea and vomiting
(E) All of the above
(E) All of the above
44. Which of the following is an antidote for
iron overdose?
(A) Protamine
(B) Deferoxamine
(C) Vitamin K
(D) Fresh frozen plasma
(E) Charcoal
Deferoxamine
43. Your resident asks you what the mechanism
of action of tPA is. What is your answer?
(A) It inhibits platelet aggregation
(B) It increases antithrombin activity
(C) It impairs fibrin polymerization
(D) It blocks GPIIa/IIIb
(E) It activates plasminogen bound to fibrin
(E) It activates plasminogen bound to fibrin
20. Which of the following would be useful in
the management of arrhythmia due to Wolf-
Parkinson-White syndrome?
(A) Digoxin
(B) Lidocaine
(C) Amiodarone
(D) Adenosine
(E) Atropine
(D) Adenosine
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