Cases Flashcards by Stacey Chu

Ob-Gyn patient, s/p episiotomy – during suturing, very little bleeding, and no complaints of pain. Pt becomes disoriented, mumbling, barely responsive. Warm, flushed diaphoretic, P 140 reg, BP 70/40. H/o - 23yo female, first deliver, no PMH, no meds. Had had an amniocentesis 7d earlier, PROM (30h earlier).

How would you treat this patient?
What was the issue?
Pathophysiology?
Drugs?

How would you treat this patient? – Stabilize. Start IV, fluids (NS). Trendelenberg position.

What was the issue? – Chorioamnionitis (RF’s - amnio, PROM).

Pathophysiology? – GI/GU/urethral [GNR, anaerobes – Bacteroides, Prevotella, Enterobacteracea, C. trachomatis, Group A,B strep]; skin [Staph, Strep]

Drugs? – Doxycycline (for Chlamydia)+ Pip/Tazo OR Clinda + Gentamicin (or ceftriaxone)

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65yo male requires hand surgery, but has extensive CAD and severe HTN. Decided to provide regional IV anaesthesia with lidocaine (what is this?)

Regional IV anaesthesia
1 ) Nerve block
2) Venous then arterial tourniquet [45min] + numbing of nerves – Lidocaine +/- epinephrine

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65yo male requires hand surgery, but has extensive CAD and severe HTN. What is the problem with giving him IV epinephrine.

Arrhythmia –> sinus tach –> V tach, V fib

Hypertensive crisis

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26yo female in clinic - acute onset of dysruia, freq, urgency, slight hematuria (no fever, chills, abd pain, back pain, flank pain). PE: T 37.5, P 80, BP nml, R 12, very mild suprapubic tenderness, no CVA tenderness. U/A dipstick pos for WBCs, blood. What do you do?

Dx?
Pathophysiology?
Drugs?

Dx - UTI (cystitis)

Pathophysiology - (1) E. coli; (2) Enterobacter, Serratia, Staph saprophyticus, Enterococcus

Drugs - Nitrofurantoin, TMP/SMX, Ciprofloxacin, Cephalexin
–> Phnazopyridine for symptomatic relief of dysuria

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In treating an uncomplicated UTI, what are the usual drugs, and which would be problematic with the following?

1) known hives to penicillin
2) known G6PD deficiency
3) She lived in an area with >25% E. coli resistant to co-trimoxazole
5) She had known liver disease
6) She was known to be pregnant
7) She was treated for a UTI one week earlier

Nml drugs = Nitrofurantoin, TMP/SMX, Ciprofloxacin, Cephalexin

1) known hives to penicillin - Cephalexin
2) known G6PD deficiency - TMP/SMX
3) lived in an area with >25% E. coli resistance - TMP/SMX (–> Nitrofurantoin)
4) She had known renal disease
5) She had known liver disease - Ciprofloxacin
6) She was known to be pregnant - Nitrofurantoin in the in T3 or during labor; TMP/SMX 2 wks before EDC (d/t potential increase in kernicterus)
7) She was treated for a UTI one week earlier

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A 60-year old man was admitted to evaluate double vision and weakness. His hypertension had been well controlled for 15 years on HCTZ. Six months ago he was placed on penicillamine for refractory rheumatoid arthritis. In retrospect, he feels he has not felt “right” since starting that drug. He mentioned that the double vision was not present on waking, but progressed throughout the day. His PE demonstrated weakness of several extra-ocular muscles. When he received edrophonium 2 mg IV there was prompt resolution of his ocular problems for several minutes. How would you proceed?

Penicillamine: rare side effect of MG
(improved with edorphonium = acetylcholinase inhibitor - short-acting)

Penicillamine mimics acetylcholine antibody –> attacking the Nm receptors on the NMJ end-plates

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A 68-year old man received two weeks of intravenous mezlocillin and gentamicin in the hospital to treat a severe pseudomonal external otitis media. He was discharged home to receive the same drugs for another four weeks (iv home administration by his wife through a PICC line). Five days after he went home, at about 9 PM, his wife presented to a local ER with a severe allergic reaction. She had acutely developed diffuse skin itching with classic urticarial lesions, then wheezing and shortness of breath. She received diphenhydramine and prednisone )no Epi???) in the ER, and her symptoms resolved over the next few hours. What happened to the patient’s wife?

Immediate allergic rxn in penicillin-sensitive wife of pt receiving parenteral mezlocillin ==> high seminal level in wife.

Timing == it was 5 days after (first time they had had vaginal sex), she had been mixing the drug previously without problems.

Type I rxn == should have gotten diphenhydramine + prednisone + Epi (if really having breathing problems).

Possible that could have dripped on hand – but have to assume that can be absorbed transcutaneously

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A patient with known chronic stable angina is admitted to the CCU with new onset unstable angina and pancreatitis. His usual outpatient medications include nitroglycerin 0.4 mg SL when necessary for chest pain, hydrochlorothiazide 25 mg by mouth once daily for hypertension, and prompt release metoprolol 25 mg by mouth thrice daily to control hypertension and chronic angina. In the CCU, you wish to continue (or possibly increase) his metoprolol to prevent withdrawal (or “rebound”) worsening of his angina, but the surgical consultant insists that he remain “NPO” with an NG tube to put the pancreas at rest.
Write specific orders in the chart for giving this man his metoprolol.

Cannot stop metoprolol abruptly = rebound

Can convert metoprolol PO –> IV
2.5:1

F = 1/2.5 == 40%

Metoprolol = 75mg/d PO ==> 30mg/d IV

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You admit a 70-year old alcoholic man to the hospital to treat a large carbuncle, and he begins to demonstrate signs and symptoms of alcohol withdrawal. To prevent the development of delirium tremens, you begin treatment with diazepam 5 mg by mouth four times daily. After three days, the patient seems quieter and less agitated, and you decide to continue the drug. He is discharged on the fourth hospital day, with strict instructions to continue his diazepam and oral antibiotic as ordered. The patient was apparently very scared during this admission, and promises that he will take his drugs faithfully; his daughter states that he will be staying with her for the next two weeks, and promises to make sure that he takes his medicines as ordered.

One week later (10 days after starting the diazepam), his daughter brings the patient back to your clinic, saying that he keeps falling asleep and can barely stay awake to eat or dress himself. She says that she can’t care for him in this state, and you will have to either admit him, or place him in a nursing home. Also, she is worried because she has never seen him like this before, except when he has been drinking heavily. She is sure this is not the case, because she has no alcohol of any kind in the house. How do you explain this patient’s course based upon pharmacokinetic principles?

Diazepam is very lipid-soluble ( can stop a seizure in 2-4min)

==> if lipid-soluble ==> metabolized by the liver

Pt could also have alcoholic fatty liver / cirrhosis

t 1/2 of elimination in healthy liver (diazepam) = 24h
Steady-state concentration @ 3.5d

t 1/2 of elimination in cirrhotic liver (diazepam) = 72h
Steady-state concentration @ 10-12d

He was discharged at 3-4days at 5mg of diazepam ==> reaching steady state at 10-12d later –> he should have been kept longer, or given a lower amt.

t(1/2) = 0.7 * Vd/Cl

b/c the pt is likely cirrhotic == increased t (1/2) –> decreased clearance of the drug.

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When epinephrine is added to a 1% lidocaine solution to be used as a local anesthetic, the main therapeutic goal is to:

A. Help prevent vasovagal syncope with the local injection
B. Reduce the initial pain from the local injection/infiltration
C. Prolong the duration of action of the local anesthetic with local infiltration
D. Buffer the pH of the solution to prolong the shelf life of the local anesthetic
E. Help maintain the patient’s blood pressure during the procedure

C. constricts the blood flow, decreasing the uptake of the drug – increasing its duration of action.

bupiviaine is better for reducing bleeding (specifically)

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You are treating a woman for a case of cystitis, and the gram stain of her urine reveals lots of PMN’s and plump gram negative rods. She tells you that she has been healthy prior to this acute problem, but she does know from a prior drug experiences that with her Mediterranean background, she is deficient in the enzyme glucose-6-phosphate dehydrogenase. Which one of the following possible oral antibiotics that you are considering prescribing would be most strongly contraindicated for use in this patient?

A. 	Ampicillin
B.	Cefuroxmine
C.	Doxycycline
D.	Nitrofurantoin
E.	Ciprofloxacin

D. nitrofurantoinn == on the DANGER list of drugs NOT to give people with G6PD deficiency.

quinolones are on the “likely do not give”

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A fourth-year medical student is planning to go into a general surgery residency, and then pursue further training in plastic surgery. Why is it important for that student to learn about the advantages and disadvantages of the newer or atypical antipsychotic drugs (such as quetiapine) as compared to the older drugs of this class like haloperidol or chlorpromazine?

A. One of the intern’s post-op patients may develop an acute dystonic reaction after receiving Compazine™ (prochlorperazine), given for post-op nausea and vomiting
B. One of the intern’s plastic surgery patients may develop post-op ICU psychosis, and may require treatment with an optimal neuroleptic drug in the ICU
C. Step 3 (at the end of internship) will test the intern’s knowledge in this area
D. The intern may become concerned about potential anesthesia/drug interactions with one of these newer drugs
E. All answers are correct
F. One of the intern’s plastic surgery patients may be on one of these newer drugs preoperatively

E. the 2nd generation / atypical antipsychotics are more likely to cause extrapyramidal sxs.

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In this course, when we discuss a particular medication, we will always refer to that drug with its generic name, and often with its brand name as well. It’s useful for you to learn both names for a drug primarily because:

A. On board examinations, all drugs will be referred to by their generic names
B. In most states, you can order a drug by either its generic name or its brand name
C. Some smaller pharmacies will stock only one version of a drug, sometimes generic, sometimes branded
D. In most states, if you prescribe a drug by its generic name, the pharmacist will dispense the generic version of the drug
E. You will usually want to prescribe the drug by its generic name, but patients and doctors often remember the brand name better

E. Best answer - “you will usually want to prescribe the drug in generic form”

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In his 2015 paper in The Lancet, Dr. Simon Maxwell discussed the importance of every medical school in Great Britain making sure that its graduates received adequate training the the knowledge and skills necessary for their graduates to become safe and effective prescribers when they became new interns. They also developed a national on-line exam that could be taken (and is now required to be taken) by all senior medical students in the UK, prior to graduation, and passing the exam prior to beginning their internships. This national effort involving all UK medical schools, and all UK teaching hospitals, was motivated in part by the earlier discovery that some percentage of prescriptions (or drug orders) written by newly graduated doctors in UK teaching hospitals contained errors ranging from minor to life-threatening. How large was this problem, according to his paper?

A.	10%
B.	15%
C.	30%
D.	20%
E.	5%

A. 7-10% of prescriptions written by interns are incorrect

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A 32-year-old Caucasian female needs analgesia after oral surgery for a root canal/ tooth implant preparation. She is prescribed PO tramadol 37.5 mg combined with acetaminophen 325 mg two tablets twice a day. She contacts her dentist the following morning saying she is still in significant pain and the dentist increases her dose to two tablets every six hours. A day later she goes to see his PCP still complaining of severe tooth and jaw pain on the side of her dental surgery. Oral examination shows edema and inflammation at the surgical site. Altered activity of which of the following enzymes is MOST LIKELY responsible for the therapeutic failure of the analgesic regimen in this patient?

A.  Prostaglandin synthase 
B.  CYP 450 3A4 
C.  CYP450 2D6 
D.  Cyclo-oxygenase-1 &amp; 2 
E.  CYP450 2C9 
F.  Cyclo-oxygenase 3

C. Acetaminophen and tramadol metabolized by both Cyp450 3A4 and 2D6

Tramadol esp. a substrate for 2D6

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74 year old male with congestive heart failure and atrial fibrillation is well controlled on the following drug regimen, furosemide, spironolactone, lisinopril, carvedilol and warfarin. His most recent INR is 2.6 and has been stable on his current warfarin dose of 3 mg/ day. The patient develops a community acquired pneumonia, which has progressed over 5 days despite azithromycin treatment, and requires hospitalization. Concomitant prescription of which of the following as part of combination drug therapy to treat his refractory pneumonia will necessitate an INCREASE in warfarin dose to maintain anti-coagulation?

A.  Piperacillin/tazobactam 
B.  Azithromycin 
C.  levofloxacin 
D.  cefoperazone 
E.  rifampin

E. Rifampin is the only one of the group that is a Cyp inducer

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A 55-year-old liver transplant patient is on cyclosporine as part of his immunosuppressive therapeutic regimen. His trough cyclosporine concentrations have been stable at 200-250 mcg/L (therapeutic range 150-300 mcg/L). He develops what was treated as a lower respiratory tract infection and received a course of antibiotics. Several days after starting the antibiotic he noted bilateral hand tremor and was taken to the ED having sustained a self-limiting seizure. A random cyclosporine concentration done in the ED was 775 mcg/L. Which of the following drugs was he MOST LIKELY prescribed, that caused this adverse outcome?

A.  Minocycline 
B.  Amoxicillin/clavulanate 
C.  Clarithromycin 
D.  Doxycycline 
E.  Cefditoren

C. Clarithromycin is the only of the group that is a Cyp inhibitor

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A 52 year old man is admitted to hospital with a one week history of dark urine and pale stools. On examination he is jaundiced without physical signs of chronic liver disease. His total bilirubin is 14.9 mg/dL (direct bilirubin is 13.5 mg/dL) ALT and AST are 45 and 39 iu/L respectively and the Alk phosphatase is 90 iu/L . His prothrombin time is 18 seconds (INR 2.0). Further investigation does not identify an extra hepatic anatomical/viral/toxicological or immunological cause for his elevated bilirubin. His comorbidities, CAD and mild CHF are well controlled on his current drug therapy. Which of the following drugs this patient is taking is the MOST LIKELY cause of his jaundice?

A.  Eplerenone 
B.  Atenolol 
C.  Clopidogrel 
D.  Lisinopril 
E.  Rosuvastatin

C. Clopidogrel

+ Rosuvastatin
==> intrahepatic cholestasis

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A 25-year-old healthy man who weighs about 70 kg goes into a bar at 6 PM (mostly empty stomach). While he is there he drinks 3 beers, and 4 shots of vodka.
He leaves the bar at 8 PM, and drives to his girlfriend’s house
He drives for about ½ hour, and then arrives at her town
As he is driving down the street, at about 8:30 PM he strikes an elderly man with a cane who is crossing the street. He does not see him, and does not stop.
The next day, he sees blood on his front fender, and a large dent, and vaguely remembers something from the night before. He learns that there was a hit-and-run accident the night before two blocks from his girlfriend’s house.
He turns himself into the police that next morning, and his BAC is zero at that time. The police determine that his car is the one that hit and killed the little old man in the crosswalk.

What was his approximate BAC at the time of the accident? Was he driving “under the influence”?

3 beers
4 shots of vodka

BEER: 12oz * 3 * 14g ethanol = 42g EtOH
VODKA: 1oz * 4 * 14g ethanol = 46g EtOH
==> 98g EtOH

Vd = 0.6 L/kg == 42L

Cp(max) = 98g/42L == 2.3g/L == 2300mg/L
(if he absorbed all of it without clearing it)

legal limit of alcohol == 800 mg/L

LIVER METABOLISM = 120mg/kg/h
==> 120mg/70/h
== 8.4g/h * 2h
== 16.8g cleared by the time he left the bar

98g EtOH - 16.8g == 81.2g EtOH left in his system

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Which of the following drugs is CORRECTLY paired with the urological tract adverse effect it is MOST often associated with?

A. Sulfamethoxazole + Trimethoprim/nephrolithiasis
B. Ketorolac/ureteric strictures
C. Omeprazole/increased tubular reabsorption of sodium
D. Atenolol/reduced renal efferent arteriolar resistance
E. Dobutamine/acute tubular necrosis

A. Sulfa drugs cause obstructive uropathy (post-renal)

not very soluble

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An 81 year old man has been noted to have blood pressure recordings of between 185/110 and 175/100 mm Hg for the last three visits to his PCP’s office. His home blood pressure monitoring revealed a BP average of 168/102 mm Hg. He is not overweight, does not smoke cigarettes or imbibe ethanol. His serum creatinine is normal for his age but his eCrCl is 45 mL/min (eGFR 50 ml/min/1.73 m2). His PCP initiates therapy with hydrochlorothiazide 12.5 mg daily. In this patient which of the following effects would this therapy MOST LIKELY cause?

A.  Hypomagnesemia 
B.  Hyperphosphaturia 
C.  Hyperoxaluria 
D.  Hypo-osmolar urine 
E,  Hypocalcemia

A. Hypomagnesemia

–> hypercalcemia == leading to stones

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In patients with normal renal function, 80 % of the administered dose of a newly FDA approved H2 receptor antagonist (pergeiseldine) is excreted unchanged in the urine. In patients with normal renal function, the standard persgeiseldine dose is 100 mg PO q 12h. Your patient who is 84 years old and has an estimated creatinine clearance (eCrCL) of 25 mL/min (~ 1/4 of normal). What dose of pergeiseldine would you give 12 hourly to achieve the same average serum steady state concentration (Css-av) as a patient with normal renal function?

A.  40 mg 
B.  10 mg 
C.  25 mg 
D.  75 mg 
E.  60 mg 
F.  85 mg

A. 40mg

Consider nml clearance = 100mL/min
80% - kidneys ==> 100mL/min
20% - liver

Consider pt’s clearance = 25mL/min (25%)
(1/4) 80% - kidneys ==> 20mL/min
20% - liver==> 20mL/min

== 40mL/min cleared

If given 40mg,

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• A 21-year old woman sees you in the clinic, complaining of 4 days of dysuria, frequency, and urgency. Over the last 12 hours she has noted shaking chills, fever, nausea, vomiting, malaise, and right flank pain. She had several urinary tract infections in high school, but none in the last few years. She is taking no other meds. Her last period was one week ago. She says that when she last received ampicillin several years ago, she passed out and required epinephrine because of a breathing problem. On exam, she is a fit young woman lying uncomfortably on the stretcher who appears warm, diaphoretic, and flushed. Her temperature is 103 F orally, BP 95/60 (lying) and 85/50 (sitting), pulse 120, respirations 16. There is marked right costovertebral angle tenderness, mild right flank tenderness, and moderate suprapubic tenderness. Pelvic and rectal exams are unremarkable except for some bladder tenderness. Urinalysis reveals many white cells and bacteria; gram stain of the unspun urine reveals many WBCs and many plump gram negative rods per high-power field. Creatinine is 0.7 mg/dl. Approach this case using the framework that we discussed in class. Discuss the diagnosis, and present your detailed plans for management.

o Dx – pyelonephritis, with concern for distributive sepsis
o Pathology – GNRs = likely E. coli (she is young, prior hx of UTIs)
o Typical methods of treatment = Outpatient (Ciprofloxacin 500mg BID, Levofloxacin 750mg q24h, Ofloxacin 400mg BID x5-7d); Inpatient (Ciprofloxacin 400mg IV q12h; Ampicillin 2gm IV q6h + Gentamicin 5mg/kg q24h OR Ceftriaxone 1-2g IV q24h OR Piperacillin-Tazobactam 3.375g IVq4-6h)
o Tx for this pt - she is an outpatient, but she likely need to be admitted for concerns of sepsis, and she had an anaphylactic/anaphylactoid rxn to ampicillin so no penicillins or cephalosporins if other good regimens exist – Get cultures/sensitivities + empiric Ciprofloxacin 400mg IV q12h x5-7 days.

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• A 68 year-old Caucasian woman with no significant past medical history, was unwell with a non productive cough, intermittent fevers and muscle and joint aches for over a week. She lost her appetite during this period, and had been taking extra strength acetaminophen (Tylenol) two 650 mg tablets every 6-8 hours most days during this illness, to relieve her symptoms. Over the prior 24-36h she noticed her urine had become dark and her skin rather yellow. Her bilirubin was 4.2 mg/dL, AST and ALT were 1350 and 1140 U/L respectively; Alk. Phos. - 230 u/L; Tot. Protein - 7.2 g/dL and Albumin - 3.2 g/dL; PT - 19 seconds (INR 2.2). Plasma acetaminophen conc. = 13 mg/L (therapeutic range 10-20 mg/L). What is the diagnosis and how would you manage this patient? How could this clinical situation have been prevented?

o Dx: acetaminophen-induced acute liver injury
o Risk factors for drug-induced acute liver injury (DILI): female (likely d/t smaller size); alcohol abuse; malnutrition.
o Prevention:
1) improved nutrition
2) advice on cautious use of acetaminophen use. The recommended limit of acetaminophen is 3000mg per day (she was taking 1300mg every 6-8h, so ranging from 3900-5200mg).
3) Review of other medications – if she was concurrently taking medications for what may have been a flu, she may have taken a Cyp inhibitor, which would have lead to accumulated, toxic levels of acetaminophen (though the serum level was not supratherapeutic).

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• A 58 year old man with moderately severe coronary artery disease and is being treated with metoprolol 100 mg bid, diltiazem SR 160 mg bid and sublingual nitrates prn. He takes atorvastatin 40 mg at night for hypercholesterolemia. He comes to your office complaining that he feels tired and depressed since started on the combination anti-anginal therapy, though his angina is well controlled. You decide his symptoms are, in part, drug induced but also in part due to depression. Treatment with nefazodone 100 mg bid (a non-SSRI antidepressant) is begun. Two weeks later the patient says he feels no better, the nefazodone dose is increased to 200 mg bid. When reviewed one week later he complains that for the past week his muscles have been aching especially after some exercise and that his legs feel weak. What assessments/labs should you perform? What is the etiology of this problem? What precipitants should he avoid? What genetic test may show him to be predisposed to this? How would you manage the patient clinically?

``` o Assessment: The major point from his history was the increase in his nefazodone, which is a Cyp3A4 inhibitor. His current symptoms mimic statin toxicity, as statins are as well metabolized through the liver. It is likely that higher doses of nefazodone led to decreased Cyp3A4 activity, causing accumulated statin levels. o Labs: Assessment of his liver, since nefazodone toxicity can cause acute liver injury – AST, ALT, Alk phos, Tbili, DBili. o Avoid: Any Cyp inhibitors. If he continues to require the nefazodone, he should also avoid drugs that are metabolized by the liver. However, it is more likely that he would be switched to a different antidepressant since he will require the statins for his moderately severe CAD. o Genetic test: Cytochrome p450 3A4 mutation panel and Cytochrome p450 3A5 DNA test – since 5% of those of European origin have a slow-acting, intermediate metabolizer form of Cyp3A4. o Management: 1) Gradual taper of nefazodone over weeks to months as tolerated 2) Start on an alternative anti-depressant. Bupropion is in the similar class of non-SSRI antidepressants. Bupropion is a Cyp450 2D6 inhibitor, but statins are processed through the Cyp450 3A4 pathway, so this is a potentially safer option than SSRIs, which are processed through Cyp450 3A4. ```

• Write a complete prescription for yourself for a ten-day course of ampicillin for a UTI. This is legal, but what are you “missing” if you go this route??? What are the eight essential parts of this Rx, and why are they important?

o Ampicillin will cover most of the gram-positives, but would miss some of the gram negatives (E.coli, Klebsiella that are the common culprits of UTIs) and beta-lactamase producing bacteria (which would be better covered by a regimen of Amoxicillin-Clavulanate). o Prescription 1) Date: 01/30/2018 2) Name: Stacey T Chu 3) Rx: Augmentin 4) Formulation: Amoxicillin-Clavulanate 875/125mg tablets 5) Dispense: #14 tablets 6) Label: Take 1 tablet, twice daily, for 7 days for urinary tract infection 7) Renewal: none 8) Prescriber contact info: Stacey T Chu, (818)470-8414

• A 60-yo man (otherwise in good health, creatinine 1.6 mg/dl) developed acute, severe pustular psoriasis. After several weeks of not responding to topical treatments, he was referred to a dermatologist. He decided that the most appropriate treatment given the severity and acuity of the disease would be oral methotrexate (MTX). He explained this to the patient (regimen Monday 8 PM, Tuesday 8 AM and 8 PM), handed him a pamphlet about use of MTX in psoriasis, and gave him a prescription for o Methotrexate 2.5 mg tablets o Dispense #60 o Label: Take 2 tablets every 12 hours 3x/week. o Patient was instructed to have CBCs checked every Monday morning for weeks 1,2,4, and 6, and to return to Derm clinic in week 6. Patient was seen in drop-in clinic 3 days after beginning this regimen for complaints of burning of his skin, and some worsening of his skin lesions. CBC and LFTs were checked because of his history of having been recently started on oral MTX; all were normal. He was discharged on antihistamines. Four days later he was admitted with sepsis and severe pancytopenia. Any thoughts?

o Per UptoDate: methotrexate dosing is 15mg-25mg/week (maximum), with absorption of oral methotrexate reduced at higher doses – such that subcu or IM administration is preferred. This patient was 2*2.5*2 = 10mg per day, 30mg per week, which is an incredibly high dose.  Dermatologic toxicity: His symptoms of skin burning and worsened skin lesions is likely a result of methotrexate toxicity, which can cause a dermatologic toxicity ranging from a nonspecific morbilliform drug rash to a bullous formation or desquamation. A secondary bacterial infectious over these bullae or desquamated areas may have led to his sepsis  Hematologic toxicity: methotrexate toxicity can lead to myelosuppression and thus his severe pancytopenia. o While the major problem is with the initial dosage, I wonder if folate repletion may have helped with his problem. o 90% of methotrexate is cleared by the kidneys. With the patient’s eCrCl = (140-60)/1.6 = 50, he has roughly 50% of the expected clearance. Renal dosing would have required that the dose be given at 50% of normal (for CrCl 10-50 mL/min).

• What are four important factors that the FDA considers in deciding whether a given drug preparation can be safely sold over the counter without a prescription?

1) Adequate labeling so that consumers with low literacy can understand and so that the consumer can self-diagnose, self-treat, and self-manage the condition being treated 2) No health practitioner is needed for the safe and effect use of the product. 3) Drugs have low potential for misuse and abuse 4) Safety margin such that OTC availability benefits > risks.

When you write an order for a drug to be given “prn” or “as needed” in the hospital chart or EMR, you must also supply what further bit of information that is most often forgotten by the prescriber? ``` A. Interval of dosing B. Dose of drug C. Indication for repeat dosing D. Name of drug E, DEA number ```

C. Indication for repeat dosing Need both interval AND indication (indication is most often forgotten)

In 1906 when the first legislation about the FDA was passed in Congress during the “Progressive Era”, the actual bill stated that in order for drugs to be approved by the FDA, they had to be proven to be: A. Accurately labeled in terms of content and purity of ingredients B. Safe C. Effective D. More effective than previous treatments for the same condition E. Non-addicting

A. Pure Food & Drug Act of 1906 - prohibited mislabeling and adulteration of drugs

Nowadays, most new drugs are first approved for prescription use only, and then later, the FDA might make a decision to allow the drug, often at the lower end of the dose range, to be sold over-the-counter and without a prescription. Recently we have seen such a pathway with drugs such as several antihistamines, several H2 blockers, several PPIs, etc. When the FDA makes the decision to allow a relatively new drug to be sold over the counter without a prescription, they usually are paying close attention to all of the following factors EXCEPT which one? A. Lack of severe toxicity when the drug is taken as directed (e.g. acetaminophen) B. Evidence that the drug is not habit-forming or addicting, or regulated by the DEA C.Cost of the drug D. The ability of the patient to make an accurate self-diagnosis (e.g. GERD) E. The ability of a typical patient with 8th grade reading ability to understand the necessary safety information printed on the box

C. cost of the drug -yes, they're usually cheaper, but the FDA is not interested in that These OTC are for drugs that can reasonably help pt's self-diagnose (not like cancer drugs, etc.)

In 2009, three faculty members at DMS (Drs. Lisa Schwartz, Steven Woloshin, and Gil Welch) published a paper advocating that direct-to-consumer ads about prescription drug typically fail to provide fundamental information that consumers need to make informed decisions about how well a particular drug might work for them. They proposed that providing patient a drug facts box—a carefully formatted table quantifying important outcomes with and without the drug (or comparing one drug with a second drug)—could improve patient knowledge and affect patient judgments about prescription medications. The authors concluded that the specially formatted drug facts box, when present in such direct-to-consumer advertisements: A. All answers are correct B. Helped consumers appreciate how well each of the drugs actually worked C. Resulted in better choices by consumers between two drugs for current symptoms D. Corrected overestimation of drug benefit in the setting of drugs used for prevention

A. of course all of these are correct dummy

Which one of the following is the most important way that an allergic drug reaction (such as red macular rash from penicillin) differs from the more common type of pharmacologic adverse drug reactions (such as hypokalemia from hydrochlorothiazide)? A. Allergic drug reactions are usually more severe than pharmacologic drug reactions B. Drug allergies are more common than pharmacologic adverse drug reactions C. Allergic drug reactions are usually easier to predict in advance by using skin testing D. Allergic drugs reactions are not related to the usual pharmacodynamic properties of the drug E. Allergic drug reactions are usually easier to treat than are pharmacologic drug reactions

D. allergic rxn are not expected from the pharmacodynamic properties

A 54-year-old woman previously in good health presents to the ER with the sudden onset 30 minutes earlier of severe pain in her left flank, which radiates down to her left groin. This pain comes in waves every few minutes. At its worst, she says it is 10 out of 10, subsiding back down to 2/10, but not going away completely. She has not noticed any other symptoms. Her vital signs and abdominal exam are normal except for a tachycardia of 110/min. Her basic lab studies are normal, except for her urinalysis, which is positive for a pink color and is dipstick 2+ positive for blood. She is given ketorolac intravenously for her pain , and that seems to have helped a bit. 30 minutes later she undergoes a CT of the abdomen with IV contrast (Renografin™, or sodium meglumine diatrizoate) in an effort to identify the location of her stone. A few seconds after receiving the iv bolus of contrast (Renografin™), she says she feels warm and flushed all over her body. A few seconds after that, she begins to break out in hives all over her thorax and arms. She then begins to wheeze, and her blood pressure falls from 130/80 on admission to 90/54. She says that she feels woozy and lightheaded, and that her lips feel puffy to her, but she is still alert and oriented. She has most likely experienced: A. An anaphylactoid reaction to ketorolac B. An anaphylactoid reaction to Renografin™ C. A Type III reaction to ketorolac D. An anaphylactic reaction to ketorolac E. An anaphylactic reaction to Renografin™

B. An anaphylactoid reaction to Renografin™ Anaphylactoid are clinically indistinguishable from anaphylaxis --> but usually are d/t: - contrast - morphine - aspirin (induced bronchospasm)

A 54-year-old woman previously in good health presents to the ER with the sudden onset 30 minutes earlier of severe pain in her left flank, which radiates down to her left groin. This pain comes in waves every few minutes. At its worst, she says it is 10 out of 10, subsiding back down to 2/10, but not going away completely. She has not noticed any other symptoms. Her vital signs and abdominal exam are normal except for a tachycardia of 110/min. Her basic lab studies are normal, except for her urinalysis, which is positive for a pink color and is dipstick 2+ positive for blood. She is given ketorolac intravenously for her pain , and that seems to have helped a bit. 30 minutes later she undergoes a CT of the abdomen with IV contrast (Renografin™, or sodium meglumine diatrizoate) in an effort to identify the location of her stone. A few seconds after receiving the iv bolus of contrast (Renografin™), she says she feels warm and flushed all over her body. A few seconds after that, she begins to break out in hives all over her thorax and arms. She then begins to wheeze, and her blood pressure falls from 130/80 on admission to 90/54. She says that she feels woozy and lightheaded, and that her lips feel puffy to her, but she is still alert and oriented. , which one of the following treatments is most important to deliver to her immediately at this point in her case? A. Diphenhydramine 50 mg PO stat B. Cimetidine 150 mg IV stat C. Normal saline 100 ml IV stat D. Epinephrine 0.4 mg IM stat E. Methylprednisolone hemisuccinate 125 mg IV stat

D. Epinephrine 0.4 mg IM stat Esp. if she is hypotensive should also give diphenhydramine for the hives and swelling --> but not AS important as her BP crashing

Two pseudo-allergic reactions to ACE inhibitors are cough and angioedema. Cough, which occurs in 15-30% of patients on ACE inhibitors, seems to be mediated by bradykinin, and such patients are often switched to angiotension-receptor blockers, usually with good results. However, 0.2-1.0% of patients taking ACE inhibitors develop angioedema, again thought to be related to the toxic effects of excessive bradykinin. Such patients may benefit from being switched from their ACE inhibitor to an ARB drug, but there is concern about the recurrence of angioedema after such patients are switched to an ARB. If you were faced with such a patient (one who had developed angioedema while taking an ACE inhibitor), what would be your advice to the patient? ``` A. Such patients should virtually never be switched to an ARB because the risk of developing angioedema is simply too high B. Before switching such a patient to an ARB, the patient should first be switched to a different ACE inhibitor, since angioedema may not be a class effect. C. Such patients may be switched to an ARB, but only if the need for such a drug is great, and appears to outweigh the possible risk of angioedema D. Clinical studies have shown that when such patients are switched from an ACEI to an ARB, the risk of having another episode of angioedema is around 25-50%. E. If such a patient is switched from an ACE inhibitor to an ARB, then the patient should also carry an Epi-PEN in case angioedema recurs. F. If such a patient is switched to an ARB, and if angioedema recurs while on the ARB, then the angioedema that develops on the ARB is usually more severe than the first episode while taking the ACE inhibitor. ```

C. Such patients may be switched to an ARB, but only if the need for such a drug is great, and appears to outweigh the possible risk of angioedema usually good to be cautious At most, cross-reactivity at 10% This IS a class effect - do not give her another ACE-I!

A patient is undergoing anesthesia induction in preparation for a 3-hour abdominal surgical procedure, a complex resection of part of the colon involved with colorectal cancer, with exploration and removal of regional lymph nodes. The patient is premedicated with midazolam and fentanyl, but general anesthesia is induced with intravenous thiopental given as a slow IV push. Once the patient becomes totally unresponsive, the anesthesiologist quickly acts to paralyze the patient, secure the airway by endotracheal intubation, and initiate ongoing general anesthesia with sevoflurane. The anesthesiologist knows that he must complete these tasks within a few minutes because the general anesthetic effects of this bolus of thiopental will end after about 10 minutes because: A. t ½ alpha is about 3-4 minutes B. t ½ beta is about 1 hour C. the drug redistributes quickly from blood into bone D. the liver clears the drug very quickly E. the kidneys eliminate the drug very quickly

A. For "this bolus of thiopental to end after 10min" -- the t 1/2 of redistribution must be about 3-4 min (for steady state to be reached in about 10min) Thiopental redistribution from its site of action (the highly perfused brain) into other tissues (e.g. the poorly perfused adipose tissue) NOT BONE

Sometimes when we look up information about a loading dose of a drug, the information that we find is confusing. For example, when we look up a loading dose of gentamicin, the reference books say something like LD = 2 mg/kg, which doesn’t look like the numbers we discussed in class. That number would be correct if it was based on: A. Our target Cp is 8 mg/L, and Vd=0.25 L/kg B. Our target Cp is 4 mg/L, and Vd = 0.6 L/kg C. Our target Cp is 1 mg/L, and Vd = 1.5 L/kg D. Our target Cp is 10 mg/L, and Vd = 4 L/kg E. Our target Cp is 20 mg/L, and Vd = 0.5 L/kg

LD = Cw desired * Volume A. LD = 8mg/L * 0.25L/kg == 2 mg/kg

Sometimes patients present to the ER with an intentional drug overdose, but often they present with an unintentional drug overdose. According to literature describing deaths from unintentional drug overdoses from 2000 to 2007, these have almost quadrupled. The drug during this period mostly responsible for this sharp increase in the death rate per 100,000 population over this time period was: ``` A. Heroin B. Benzodiazepines C. Opioid analgesics D. Cocaine E. Barbiturates ```

C. Opioid analgesics > cocaine > heroin

In the last 10 years or so (2007-2017), there has been a further sharp increase in deaths due to unintentional drug overdoses. In this more recent time period, the drug found (by medical examiners’ postmortem drug testing) to be primarily responsible for this sharp increase in drug overdose deaths has been: ``` A. Oxycodone B. Hydromorphone C. Heroin D. Fentanyl E. OxyContin™ ```

D. Fentanyl cutting bags of heroin with fentanyl

When balancing the potential benefits and risks of administering a slurry of activated charcoal to a patient with a recent (< 2 hours ago) intentional drug overdose, the largest potential risk in this situation would be is: A. Precipitation of torsades de pointes by the charcoal B. The drug ingested does not adsorb to the activated charcoal C. Anaphylaxis from the activated charcoal D. Aspiration of the charcoal slurry E. Severe diarrhea from the cathartic agent given with the charcoal (e.g. sorbitol)

D. Aspiration of the charcoal slurry esp. if have seizure and vomit --> then aspirate

A 17 yo high school student runs away from home with his girlfriend. After a few days, she decides to return to North Carolina, and he becomes very depressed. He decides to ingest a bottle of mercuric chloride, which he had stolen from his high school chemistry lab back in NC before he drove to NH. You call your poison information center, and find that this chemical is very likely to cause severe acute renal failure, and sloughing of the lining of the GI tract, as well as other toxic effects related to absorption of the inorganic form of Hg++. Which of the following antidotes would be indicated in this particular overdose case? ``` A. Flumazenil iv B. Desferoxamine iv C. Naloxone iv D. Desferoxamine po E. Calcium disodium EDTA iv F. Dimercaptosuccinic acid (DMSA) po ```

F. Dimercaptosuccinic acid (DMSA) po Flumazenil - Benzos Desferoamine - Iron Naloxone - Opioids

Over the last two years, in both NH and VT, we have seen a sharp increase in deaths related to use of heroin. This recent increase has been termed a crisis in both states, and has led to legislation to permit broader distribution of naloxone to doctors, users, and first responders likely to witness such events. The main factor which has led to heroin use to be associated with so many more ER visits and deaths in the last two years or so appears to be: A. As bags of heroin have become much less expensive, users are buying and then injecting larger and larger doses of heroin B. Increasing but unknown amounts of fentanyl have been added to heroin powder to make it appear to be more potent to users C. The heroin is cut by levamisole, which itself is acutely toxic D. Drug dealers are distributing heroin in a more pure and therefore potent form E. As drug cartels in Mexico have changed recently, heroin for intravenous use has become more contaminated with endotoxin, which is highly toxic

B. Increasing but unknown amounts of fentanyl have been added to heroin powder to make it appear to be more potent to users

You are Medical Director for the development of a novel compound with new mechanism of action in treating diabetic ulcers. You are working with your development team to design the first in human study of this compound. Which of the following clinical trial characteristics is MOST important in the trial design? A. The study provides categorical data on the therapeutic efficacy of the vaccine B. A phase 0 study must be performed prior to the dose escalation study C. The study cohorts do not treat normal healthy volunteers D. The study cohorts receive sequentially escalating doses of the vaccine E. The study does not have subjects treated with placebo

D. The study cohorts receive sequentially escalating doses of the vaccine Phase I (first in human) - no need for therapeutic efficacy - phase 0 is optiona - normal healthy volunteers - escalating doses - placebo controlled

Novel chemical entity (drug) new drug applications (NDAs) may not be approved by regulatory agencies, such as the FDA. What is the MOST COMMON reason for FDA give this opinion? A. Inhibits the IKr in in vitro HERG channel studies B. Absence of a drug formulation that has an oral bioavailability of > 5% C. Absence of a pediatric development plan D. Minimal or absence of clear therapeutic efficacy E. Inhibits the metabolism of drugs metabolized by CYP3A4 and CYP2D6

D. Minimal or absence of clear therapeutic efficacy ``` #1 - efficacy #2 - safety ```

A novel biological monoclonal antibody is being developed to treat multiple sclerosis. Based on its mechanism of action it has the potential to cause progressive multifocal leukoencephalopathy (PML) but rarely. Initial estimates suggest PML is likely to occur in only between 1-3 /10,000 patients on treatment. At which point during the clinical development of this agent is it MOST likely to define that it is associated with the development of PML? A. At the completion of phase I studies B. At the completion of phase III studies C. At the completion of phase IV studies D. At the completion of phase II studies E. At the completion of phase 0 studies

C. At the completion of phase IV studies because PML is so rare - you wouldn't see it at the end of phase I --> more likely when have n = 1000s.

Which of the following properties of all of the infliximab biosimilars is REQUIRED for them to be approved by the FDA as a biosimilar to the innovator product, Remicade™? A. They must be less immunogenic than the innovator product B. They must have the same number of and sequence of amino acids as the innovator product C. They must be manufactured in the same recombinant cell line as the innovator product D. They must be prescribed at different doses to the innovator product. E. They must have the same excipients as the innovator product

B. They must have the same number of and sequence of amino acids as the innovator product They have to have "all of the same essential components" The recombinant cell line is likely proprietary.

A 70-year-old woman is being followed for long-time essential hypertension, moderate mitral regurgitation, CAD s/p stenting six months earlier, asthma, and GERD. Her long-term outpatient medications include lisinopril, clopidogrel, aspirin, an albuterol inhaler prn (she uses several days per month), and Mylanta 30 ml po q2h prn burning from GERD. She also has a prescription for nitroglycerin sublingual tablets prn, but fortunately she has not needed them since her stent was placed 6 months earlier. A few days ago, she developed acute onset atrial fibrillation, which made her quite uncomfortable with the sensation of palpitations and slight shortness of breath, and which was associated with a rapid ventricular response (of about 130-140 bpm). In the ER, she converted to normal sinus rhythm with the second loading dose of intravenous diltiazem, given to slow down her ventricular response. She was continued on oral diltiazem to try to prevent recurrence of the atrial fib. There was no clot evident in the LA on echo, and she was not started on an anticoagulant. When she was discharged, the intern did start her on omeprazole, to better treat her GERD symptoms. Now several days later, her primary care physician is considering her long-term management, and which drug would be optimal in her case trying to prevent a recurrence of her atrial fibrillation. He is considering chronic treatment by continuing her on oral diltiazem (which she is still on), or switching her to propranolol or sotalol. (They do not consider using amiodarone at this point, after just one episode of atrial fibrillation.)

Problems - HTN, essential, chronic - moderate MR - CAD, MI s/p stenting 6mo earlier, no recent angina - mild episodic asthma - GERD - Acute episode of atrial fibrillation, lasting several hours, terminated during infusion of diltiazem Meds - Lisinopril (long-term) - aspirin + clopidogrel (x6mo past - DAPT) - albuterol MDI prin - Mylanta chronically - Omeprazole recently added 3 days earlier - Nitroglycerin - Diltiazem - Omeprazole (possible) - propanolol, sotalol Assessment = 1 episode of Afib (x1h), likely contributed to by her MR 1) Keep LIsinopril b/c also good for MR and HTN 2) Don't need full anti-coagulation for one instance of A-fib; CHADsVASc doesn't apply unless she is currently in A-fib 3) Keep albuterol 4)

A 52 year old woman comes to see you in your office stating that she has stopped taking any prescription or other drugs and over the past 48h and has noticed increased agitation, anxiety, stomach cramps and nausea. Physical examination reveals no abnormal signs and her heart rate was 74/min. regular and BP was 118/68 mm Hg. Which ONE of the following drugs/agents is this patient most likely to be WITHDRAWING from? ``` A. Zolpidem B. Lysergic acid C. L-tryptophan D. Cocaine E. Cathinones (bath salts) ```

A. zolpidem w/d from non-benzo

24-year-old male presents to the emergency room and is wildly and aggressively striking out at the nurses and shouting that they are ISIS terrorists. On examination he has temperature of 38oC and is diaphoretic. He has a sinus tachycardia of 120/min and BP 180/115 mmHg, his pupils are 6 mm diameter, equal in size, and reactive, with no nystagmus. He is disorientated to time and place, but has no myoclonus or muscle rigidity or focal neurological signs. His girlfriend tells you that he is a recreational drug abuser. Which of the following drug or drug combinations has this patient most LIKELY ingested? A. Diphenhydramine B. Methyl- 4 acetoxy-butanoate C. Lorazepam plus diamorphine (heroin) D. Fluoxetine plus dextromethorphan E. Methylenedioxymethylamphetamine-MDMA (ecstasy) F. Buprenorphine plus naloxone

E. Methylenedioxymethylamphetamine-MDMA (ecstasy) ==> the only one to cause such agitation The rest would cause more depressive sxs B = GHB

A 23 year old caucasian male presents to the ED completely obtunded with non-focal response to pain and no gag reflex, he is bradycardic and bradypneic, he is intubated and ventilated. There was NO improvement in his clinical condition after he was given IV glucose, thiamine, naloxone and flumazenil. An urgent CT scan, LP, and BUN and electrolytes were all normal. He had no detectable salicylates or acetaminophen in his blood, blood ethanol concentration was 800 mg/L and his routine urine toxicology screen was all negative. Co-ingestion of which of the following is MOST LIKELY to have caused this presentation? ``` A. LSD combined with marijuana B. Diamorphine (heroin)/fentanyl C. Phencyclidine D. Gamma hydroxybutyrate (GHB) E. Ecstasy (MDMA) combined with ketamine ```

D. Gamma hydroxybutyrate (GHB) The one that looks like a benzo with negative UTox

A 26 year-old homeless man was found slumped over on a park bench by police. When attended by EMS he was noted to be slow to respond to command and had a blank stare. On arrival at the ED he was lethargic, diaphoretic with normal vital signs. Pupils were equal and 4 mm in diameter. His pulse was 88/min regular, BP 101/88 mmHg and Sp02 -95% with a respiratory rate of 21/min. There were no other abnormal signs on cardiovascular/respiratory or abdominal exam. CNS exam showed no focal localizing signs but he would periodically have intermittent transient episodes of groaning with slow mechanical movements of his arm and legs. His GCS was 13. Further intensive work up revealed no hematologic/biochemical cause. His serum ethanol was < 100 mg/L, urine toxicology was negative and head CT was normal. He was observed for the next 8-10 hours and his lethargy resolved and mental status improved back to baseline for him. At this point he told the medical team that he had inhaled some dust like material from a small packet which he had been given. This clinical presentation was MOST LIKELY caused by ingestion of which of the following chemicals? ``` A. Amb-funica B. Phencyclidine (PCP) C. Lysergic acid (LSD) D. Fentanyl E. Carfentanil ```

A. Amb-funica == synthetic cannabinoid not found on Utox Fentanyl & cartafentanil would be found on Utox

Which one of the following medications is MOST appropriate to help prevent a relapse of ethanol dependence in a patient with cirrhosis, esophageal varices and acute alcoholic hepatititis? ``` A. Propranolol B. Fomepizole C. Naltrexone D. Disulfiram E. Acamprosate ```

Can't give disulfiram to someone with liver problems ==> will worsen E. Acamprosate [off alcohol] == maintain abstinence (via NMDA receptors)

A 78 year old Caucasian female has back pain due to an acute T12 vertebral collapse fracture secondary to osteoporosis. She is currently taking PO naproxen 225 mg bid, PO oxycodone CR 15 mg bid and PO oxycodone 5 mg prn for breakthrough pain. Which of the following if added to her current analgesic regimen would make her analgesia regimen less effective? ``` A. Tramadol B. Buprenorphine C. Ketamine D. Bupivacaine E. Fentanyl ```

B. Buprenorphine partial agonist that would decrease effectiveness & precipitate W/D

A 58 year old Welsh man weighs 320 lbs and is 5 feet 4 inches tall. He undergoes laparotomy and right hepatic lobectomy for hepatocellular carcinoma. On post-operative day 1 and 2 he requires an average of 80 mg IV morphine via PCA /24h for adequate analgesia. He is now taking oral fluids and light diet you are planning to convert her to an oral morphine analgesic regimen. What total daily dose of oral morphine would you prescribe initially to maintain adequate analgesic control if he was being treated with opioid therapy? ``` A. 240 mg B. 160 mg C. 320 mg D. 135 mg E. 360 mg F. 80 mg ```

A. 240 mg 80mg IV / 24h morphine for 145kg  *3-5  240-400mg PO / 24h Start at the lower dose

A 28 year old Caucasian female injures her right arm in a motor vehicle accident. After the accident she develops intermittent severe lancinating pains down the medial border of her arm, but has no objective sensory or motor physical signs in that limb. Which of the following medications has been shown to be MOST effective as an analgesic for this patient? ``` A. 9-tetra-hydro-cannibinol B. Zonisamide C Gabapentin D. Dexamethasone E. diclofenac gel ```

C Gabapentin This is nerve pain (gabapentin commonly used - yes, it is an anti-seizure drug)

In an attempt to mitigate the current epidemic of opiate/opioid related deaths the CDC published guidelines use of opioids to treat chronic pain syndromes that did not involve cancer, palliative care or end of life care. A gymnast with chronic back primarily secondary to degenerative joint disease and a prior collapsed vertebrae is seen by new is PCP for evaluation for analgesic therapy. Her baseline pain score is 3 with a maximum of 7 for which she takes regular naproxen 225 mg twice daily, this allows her to be generally active, but compromises her enjoyment of life. She has previously been prescribed a trial of gabapentin and venlafaxine without benefit. In this patient which is the most appropriate therapeutic plan if the use of an opioid is deemed necessary to improve her pain control. A. the effectiveness of the analgesic regimen need only be assessed /reviewed based on a single question 0-10 pain scale B. routine testing of her urine for DOA and/or drug adherence is not advised C. routine checking of a prescription drug monitoring program (if available) is unnecessary D. the open ended use of a fixed dose of 75 mg /day of oxycodone as monotherapy or in combination with APAP has a relatively low risk of addiction E. initiate therapy with an immediate release opioid formulation

E. initiate therapy with an immediate release opioid formulation ==> always START with immediate release - to taper ==> then MAINTAIN with extended release for the rest -- the opposite is true

A 52-year-old contractor is taking a relatively high dose of fluoxetine (Prozac™) to treat a severe depression, and it seems to be responding reasonably well. He also takes daily low-dose aspirin, and hydrochlorothiazide plus metoprolol for his moderate but well-controlled hypertension. All of these meds, except his aspirin, are continued up until the day of surgery. He is admitted to the hospital for a few days for an elective total hip replacement. His anesthesia included midazolam, morphine, propofol, and vecuronium. In the PACU, he begins to receive an intravenous opioid delivered by PCA, which is then continued on the floor. That evening, as he becomes more fully awake and in pain, he self administers larger doses of this opioid that permit him to score his pain as 4/10—acceptable to him, without depressing his respiration. Later that evening, he becomes febrile to 103 F and disoriented, and begins to exhibit myoclonic jerking of his muscles, increased muscle tone, and hyperactive reflexes. He exhibits sustained ankle clonus, hyperlacrimation, and hypersalivation, along with tachycardia and hypertension. This syndrome most likely represents: ``` A. Neuroleptic malignant syndrome B. A severe anxiety attack C. Toxic serotonin syndrome D. A post-operative wound infection E. Malignant hyperthermia ```

C. Toxic serotonin syndrome classic picture likely seretonin drug (fluoxetine, or MAO-I) + meperidine

``` The attending confirms the clinical diagnosis of toxic serotonin syndrome. Which of the following opioid was he most likely receiving to provide analgesia post-operatively? A. Hydromorphone (Dilaudid™) B. Codeine C. Meperidine (Demerol™) D. Morphine E. Oxycodone ```

C. Meperidine (Demerol™ == seretonin reuptake inhibitor

This episode of toxic serotonin syndrome was most likely caused by a drug interaction due to which of the following mechanisms of drug interactions that we discussed in class? ``` A. Pharmacodynamic B. Deliberate C. Pharmacokinetic D. Pharmaceutical E. Accidental ```

A. Pharmacodynamic ==> because receptor-level interaction

It’s impossible for any physician to memorize all possible drug interactions between all 5,000 or so drugs currently approved by the FDA. However, since most drug interactions are caused by pharmacodynamic or pharmacokinetic interactions, the thoughtful physician can often anticipate them and avoid them, even if they are not related to the pharmacodynamic actions that most often lead the drugs to be prescribed. Which one of the following potential adverse drug-drug interactions happens (fortunately rarely) because many physicians simply don’t think of it or anticipate it when they prescribe these drug pairs? A. The development of serious rhabdomyolysis when erythromycin or clarithromycin are begun in a patient who is already receiving atorvastatin B. The additive risk of liver toxicity when acetaminophen is given with oxycodone for analgesia C. Increased risk of gastritis when naproxen is given with omeprazole D. The additive lowering of blood pressure when amlodipine is added to lisinopril E. The synergistic cidal activity when penicillin and gentamicin are given together to treat enterococcus

A. The development of serious rhabdomyolysis when erythromycin or clarithromycin are begun in a patient who is already receiving atorvastatin ==> erythromycin = Cyp inhibitor --> increase levels of statin == rhabdo acetaminophen + oxycodone == accepted risk of liver toxicity naproxen + omeprazole == DECREASED risk of gastritis amlodipine + lisinopril == accepted risk of hypotension penicillin + gentamicin == KNOWN (and sought) added benefit

Looking back on the overall process that led to the voluntary withdrawal of VIOXX™ (rofecoxib) from the market by Merck, we can most firmly conclude that: A. The FDA’s process of voluntary reporting of ADR’s by physicians worked very well in providing an early “signal” of a major problem B. Most patients taking Celebrex™ (celecoxib) today, and their doctors, are well informed that this drug causes a higher risk of stroke and heart attack than does treatment with placebo C.The current system of FDA-appointed expert advisory panels to review possible unexpected adverse drug reactions performed well D. Meta-analysis of studies showed as early as 2000 that use of COX-2 inhibitors produced a higher incidence of strokes and heart attacks than did treatment with either placebo or naproxen E. The manufacturer initiated this voluntary action at the earliest possible time

D. Meta-analysis of studies showed as early as 2000 that use of COX-2 inhibitors produced a higher incidence of strokes and heart attacks than did treatment with either placebo or naproxen

When the FDA approves a new generic drug product for sale by a generic drug manufacturer, it requires that the new generic product must: A. Contain the same excipients as the older brand-name drug B. Contain the same active ingredient, in the same dose, as the older brand-name drug C. Have the same color and as the older brand-name drug to make it easier for patients to recognize D. Demonstrate the same degree of clinical efficacy as the brand-name product in head-to-head Phase III clinical trials E. Cost at least 50% less than the older brand-name drug

B. Contain the same active ingredient, in the same dose, as the older brand-name drug excipients = color, taste, etc.

A large national medical device company (Ultrashock Corporation) manufactures implantable pacemaker/defibrillator devices and leads. It has just come out with a “new, improved” version of its older product, which was approved by the FDA 3 years earlier. This new version has two design improvements, according to the manufacturer: the battery is designed to last for 3 years rather than 2 years, and the flexible wire lead is designed to be more resistant to fracture from arm movements. According to current practice within the FDA, what must the company do in order to have this new version of their popular device “cleared” by the FDA? A. The manufacturer must set up a registry to track all patients who receive the new, improved device B. The new device must be clinically tested in at least 100 patients for at least one year to demonstrate its efficacy and safety over time C. The manufacturer must convince the FDA that these changes are simply minor improvements to the older, FDA-approved version of the device D. The manufacturer must submit experimental data showing that when installed in animals (e.g. dog, chimp) the new battery really does last longer than the older battery

C. The manufacturer must convince the FDA that these changes are simply minor improvements to the older, FDA-approved version of the device PMA supplemental process

A 2014 observational study of more than 90,000 Medicare patients who were started on a statin found that 93% received a generic statin, while 7% of the patients were begun on a brand-name statin. While we know that the generic version was less expensive, what was the study’s most surprising finding in terms of clinical outcomes? A. The mean age of the patients was 75.6 years B. There was no statistically significant difference found in the clinical outcomes of interest in the two groups C. The average PDC was 77% for patients in the generic group, and 71% for patients in the brand-name group D. . There was an 8% reduction in adverse clinical outcomes of interest in the brand-name group compared to the generic group E. There was an 8% reduction in clinical outcomes of interest (hospitalization for an acute coronary syndrome or stroke and all-cause mortality) in the generic group compared to the brand-name group

E. There was an 8% reduction in clinical outcomes of interest (hospitalization for an acute coronary syndrome or stroke and all-cause mortality) in the generic group compared to the brand-name group MOST SURPRISING TRUE - mean age of pts was 75.6 years - average PDC (generic) = 77%; average PDC (brand) = 71% --> PDC = proportion of days covered (PDC) - measure of adherence - 8% reduction in clinical outcomes of interest in generic v. brand name, likely d/t adherence d/t lower cost

Ampicillin is an older drug, a “second generation” or “amino” penicillin, introduced into clinical practice in about 1955. Surprisingly, it is still, to this day, one of the “front line” agents for treating suspected or confirmed cases of bacterial meningitis. In a 3-week old infant who develops clinical evidence of bacterial meningitis, with culture and sensitivity pending and no organisms seen on the gram stain, why is ampicillin specifically recommended for empiric treatment of the patient for 24-48 hours until definitive culture and sensitivity data become available? ``` A. To cover Enterococcus B. To cover S. aureus C. To cover Listeria D. To cover Pneumococcus E. To cover E. coli ```

C. To cover Listeria

The spectrum of activity of Penicillin G aqueous, an intravenous drug from the 1940’s, is much more limited than some of the newer antibiotic drugs such as ceftriaxone or meropenem. Despite this fact, it is better than any other drug at crossing the blood-brain barrier, and getting itself transported into the CSF, which is an extremely helpful attribute when treating a patient with acute bacterial meningitis. For a dose of intravenous aqueous penicillin G, the ratio of the AUC in the CSF, compared to the AUC in plasma, goes from 2% (in patients without meningeal inflammation) up to how high in patients with meningitits with significant meningeal inflammation? ``` A. From 2% up to about 60% B. From 2% up to about 20% C. From 2% (non-inflamed) up to about 5% (with inflammation) D. From 2% up to about 80% E. From 2% up to about 40% ```

B. From 2% up to about 20%

64-year-old lawyer has been in good health, with no major medical problems. He wakes up one morning with a sharp pain in his left lower quadrant, which is made worse when he presses in that area with his fingers. At rest, he rates the pain as 3/10, but with pressure, he rates it as 6/10. He has not noted any vomiting or diarrhea, but he has no appetite, and feels very slightly nauseated. His bowel habits have been normal, and he has not noted diarrhea, constipation, or any blood or mucous in his stool. Urination has been normal. He sees his physician, who finds a healthy appearing man sitting up on the exam table in mild distress. VS T 100.4, P 105, BP 120/72 (his usual), RR 14, oxygen saturation 99% on RA. The patient winces when he lies down for his abdominal exam. His abdomen is flat and nondistended. BS are active and normal in sound. There is no tympany. There is 3+ tenderness on palpation in the LLQ, with no masses felt. The rest of abdominal exam is normal. Rectal exam reveals a bit more tenderness on the left side than on the right, but no masses are felt. Urinalysis in office is normal except for 1+ WBC on dipstick (leukoesterase positive). The physician schedules the patient for an outpatient CT scan of the abdomen and pelvis with both oral and IV contrast, scheduled for later in the afternoon. In the meantime, he wishes to begin oral, outpatient empiric treatment for his #1 diagnosis. The best oral drug regimen in this situation, of the choices listed below, would be: ``` A. Ampicillin and sulbactam B. Levofloxacin and metronidazole C. Ciprofloxacin and vancomycin D. Cephalexin and dicloxacillin E. Amoxicillin and gentamicin ```

B. Levofloxacin and metronidazole

In the treatment of neonates and infants with bacterial meningitis, why is cefotaxime recommended for empiric management rather than ceftriaxone, which is usually recommended in older children and adults? A. Cefotaxime is less expensive, and most children have poor health insurance B. Cefotaxime has better coverage of gram negative rods C. Cefotaxime has superior penetration into the CSF D. Cefotaxime is less likely to cause biliary sludge E. Cefotaxime has better coverage of pneumococcus

D. Cefotaxime is less likely to cause biliary sludge cefotaxime & ceftriaxone are both 3rd gen cephalosporins and have very similar profiles elsewise

When we think about the ability of various antibiotics to penetrate from blood (plasma) into the CSF, we are aware that the penicillins as a class are considered to have excellent “penetration”, whereas the aminoglycosides as a class are considered to have very poor “penetration”. Which of the following factors seems to be LEAST important in determining the concentration of the antibiotic in the CSF? You Answered A. Molecular weight of the drug B. Presence of active transport processes from CSF out to plasma C. Presence of active transport processes from plasma into CSF D. The effects of the antibiotic on the rate of production of CSF E. Plasma concentration of the drug

D. The effects of the antibiotic on the rate of production of CSF

``` A 22-year-old football player develops a large painful boil on his right buttock. He has never had a lesion like this before, but several of his football teammates have developed similar lesions on other parts of their bodies. In fact, they have compared “sores” while showering in the locker room after practice. He goes to the student health services, where his lesion is incised and drained, the pus is sent off for gram stain and culture, and he is placed on oral co-trimoxazole. This use of the antibiotic in this situation would be called: A. Prophylactic use B. Therapeutic use C. Conditional use D. Definitive use E. Empiric use ```

E. Empiric use He has an infection, but you don't know what it is yet

In this same case mentioned above, you are reviewing this patient’s chart for quality control at the student health service. The note written by the physician under “assessment and plan” is very brief and sketchy, or (to be blunt) incomplete. Your best guess is that the treating physician likely prescribed this drug (oral co-trimoxazole) for this patient in this setting because he was worried that the pathogen was most likely: A. S. epidermidis sensitive to methicillin B. S. aureus sensitive to methicillin C. Str. Viridans sensitive to methicillin D. S. epidermidis resistant to methicillin E. S. aureus resistant to methicillin

E. S. aureus resistant to methicillin Would be using Bactrim for MRSA

``` At our medical center (DHMC) in 2012, based on culture and sensitivity data obtained from 871 separate (non-urine) cultures obtained on outpatients, about 68% of strains of S. aureus were sensitive to which one of the following antibiotics that we commonly use clinically today in 2017? A. Cefazolin B. Pencillin G C. Vancomycin D. Trimethoprim-sulfamethoxazole E, Methicillin ```

A. Cefazolin and Nafcillin, Ceftriaxone

HMC for the past 10 years or more, antibitoics in the carbapenem class are highly restricted, meaning that no intern can prescribe them for a patient without the prior approval of a physician from the ID service. This has been true over the years for imipenem (initially), then meropenem, and most recently ertapenem. The main reason for this type of tight control over the use of these newer antibiotics is: A. Relatively few strains of GNRs in hospitalized patients are sensitive B. All of the drugs in this class are quite expensive C. Relatively few strains of GPCs in hospitalized patients are sensitive D. There is concern that overuse of these drugs will hasten the development of resistance in both gram-negative and gram-positive bacterial pathogens E. The drugs in this class are quite narrow in spectrum, and thus unlikely to cover the pathogen when the drug is used empirically

D. There is concern that overuse of these drugs will hasten the development of resistance in both gram-negative and gram-positive bacterial pathogens "relatively few strains of GPCs and GNRs are RESISTANT - for now

From required reference: In their 2016 review article about the use of antimicrobial prophylaxis for various types of surgery, The Medical Letter made a number of specific recommendations. Which one of the following was a core principle that was emphasized in their review? A. The drug chosen should be directed against the most likely infecting organisms, and should eradicate virtually every potential pathogen to be effective B. Most experts recommend the use of broad-spectrum drugs such as ceftriaxone, cefepime, or ertapenem for this indication C. The prophylactic antibiotic should be given prior to the procedure, and continued for a total of 24-48 hours after the procedure is completed D. In hospitals where MRSA is a common cause of surgical site infections, vancomycin prophylaxis should be used instead cefazolin E. The infusion of the appropriate antibiotic should be started within 60 minutes before the initial incision, to ensure adequate serum and tissues levels of the drug

E. The infusion of the appropriate antibiotic should be started within 60 minutes before the initial incision, to ensure adequate serum and tissues levels of the drug --> if Vanco - then 60-120 min The drug chosen should be directed against the most likely infecting organisms==> does NOT need to eradicate every pathogen Most experts DO NOTrecommend the use of broad-spectrum drugs such as ceftriaxone, cefepime, or ertapenem ==> rather, 2nd gen cephalosporins will work The prophylactic antibiotic should be given prior to the procedure, and NOT continued for a total of 24-48 hours after the procedure is completed In hospitals where MRSA is a common cause of surgical site infections, cefazolin >> vancomycin

A 55 year old women is seen for routine annual follow up. She is generally very healthy and is currently only taking zolpidem 10 mg PO at night, intermittently for insomnia. She tells you that she is also regularly taking a number of herbal remedies/nutraceuticals/nutritional supplements. Which of the following herbal remedies/nutraceuticals that she is taking would cause you to advise her to reduce the dose of zolpidem if she DISCONTINUES taking these herbal/dietary supplements? ``` A. Cranberry juice B. Horehound C. St. John’s Wort D. Turmuric E. Echinacea ```

C. St. John’s Wort CYP inducer --> taking SJW - she would require a higher dose of zolpidem. If no longer taking SJW - would require a lower dose

A 60 year old Caucasian female had a successful liver transplant 5 months ago. His current immunosuppressive regimen consists of mycophenolate mofetil 1.5 g PO and cyclosporine 375 mg PO, both twice daily. She is admitted with an episode of acute rejection of her liver transplant. On admission his trough cyclosporin whole blood concentration was 95 ng/mL (Therapeutic range 250-350 ng/mL). Consumption of which of the following MOST LIKELY precipitated this therapeutic failure? ``` A. Lagavulin single malt whisky (special reserve) B. Pomegranates C. Cabernet sauvignon (red) wine D. Star fruit E. Moet-Chandon champagne F. Seville oranges ```

C. Cabernet sauvignon (red) wine red wine reduces the drug levels of cyclosporine (acting similar to a Cyp inducer in that sense) Seville oranges, star fruit == Cyp inhibitors == would INCREASE drug levels

A 73 year old male patient has coronary artery disease, hypertension, paroxysmal SVTs, mild asthma. He is being treated with inhaled salmeterol and fluticasone, albuterol prn, verapamil, lisinopril, rosuvastatin, aspirin (low dose) and hydrochlorothiazide. He decides to begin a diet which contains large amounts of citrus fruits, particularly pomela fruit. Which of the following adverse drug effects would you predict is MOST likely to occur if there is no modification of his current therapeutic regimen? ``` A. a-v block B. angioedema C. myalgia and myopathy D. hyperuricemia E. diaphoresis and tinnitus ```

A. a-v block Verapamil was on the list ==> contraindicated in heart block can precipitate sxs of heart block Statins in general interact with grapefruit juice, but not rosuvastatin

Several nutraceutical products are advertised as being able to enhance mens sexual prowess and performance. Which of the following is the MOST COMMON type/class of drugs that were found to be undeclared content in these products, that the FDA removed from the market? ``` A. Selective serotonin reuptake inhibitors B. Androgens C. Phosphodiesterase inhibitors D. Precursors of nitric oxide E. Alpha antagonists ```

C. Phosphodiesterase inhibitors "fuel up plus" == undeclared amounts of sildenafil

Patients in acute shock, from a variety of causes, are most likely to demonstrate an abnormality in which of the following serum chemistry results? ``` A. Creatinine B. Lactate C. Na D. Phosphorous E. K ```

B. Lactate

In patients in cardiogenic shock, which one of the following “pressors” is felt to offer the most effective positive inotropic effect (stimulation of LV contractility), with relatively less propensity to cause excessive vasoconstriction, vasodilatation, tachycardia, or arrhythmias? ``` A. Norepinephrine B. Dobutamine C. Dopamine D. Epinephrine E. Isoproterenol ```

B. Dobutamine best for cardiogenic shock

A 56-yo psychiatry nurse is found by her husband unconscious on the floor next to her bed. On her bedside table are found empty bottles of the following medications, with her name on the prescription labels: acetaminophen, naproxen, atenolol, chlorpromazine, and diazepam. The number of “missing” pills from each bottle is unknown, but they are not recently filled prescriptions. In the ER, the patient is unconscious, with BP 90/60 and P 110. (In her medical record, her usual BP in clinic was 135/92.) She is intubated, then lavaged, and then given activated charcoal. She is then transferred to your ICU team. A few hours later you are called because her BP has slowly dropped down to 76/46, HR 128. She has already received several liters of crystalloid. On your exam now in the ICU, the patient remains unresponsive, and is intubated without need for additional sedation. VS include T 37 C, BP 76/46, HR 128, RR 14 (on vent), oxygen saturation 99% on 35% FIO2. Pupils are 6 mm and barely responsive. Skin is dry, pink, and warm. Urine output over last 2 hours is 30 ml. A Swan-Ganz catheter is placed, and shows CVP 3, PCW 13, CO 7.0, BP 76/46, calculated SVR 606. Which one of her potential overdose medications is most likely responsible for her shock state characterized by coma, dilated pupils, warm and dry skin, tachycardia, very low blood pressure, low calculated SVR, and evidence of poor renal perfusion? ``` A. Naproxen B. Chlorpromazine C. Atenolol D. Diazepam E. Acetaminophen ```

B. Chlorpromazine anti-cholinergic warm, flushed, dry skin with DILATED PUPILS

Initial resuscitation in most patients with shock involves administration of intravenous fluids. Over the years, there has been great debate about whether fluids containing colloids were superior to “regular” crystalloid fluids (normal saline or Lactated Ringers), and a number of different types of colloids have been tried. In their paper published in 2013, Annane et al (from France) reported in JAMA the results of their CRISTAL Randomized Trial. The most important finding of their trials was that among ICU patients presenting with hypovolemic shock: A. The need for mechanical ventilation was significantly less in the colloid group B. The need for treatment with vasopressors was significantly less in the colloid group C. All of the colloids used (gelatins, dextrans, hydroxyethyl starches, or albumin solutions) were more effective than use of crystalloids (isotonic saline or Ringer lactate solution) D. The need for renal replacement therapy was significantly less in the colloid group E. Mortality at 28 days was not significantly different in patients treated with colloids vs crystalloids

E. Mortality at 28 days was not significantly different in patients treated with colloids vs crystalloids

In an analysis of 100 consecutive serious medication errors in our hospital in 2017, which either occurred or nearly occurred (e.g. near misses), it is likely that the main factor leading to such errors would be found to be: A. Patient bad luck B. A single poorly trained individual C. Several small breakdowns in different locations within the overall drug prescribing/ dispensing/administration system D. A breakdown or malfunction in a computer order entry EPIC program E. A single lazy individual

C. Several small breakdowns in different locations within the overall drug prescribing/ dispensing/administration system swiss cheese!

In a classically drawn root cause analysis of a medication error utilizing a “fishbone” diagram, which one of the following arms is not usually included? ``` A. Equipment B. Policies C. Leadership D. People E. Procedures ```

C. Leadership People & Equipment Policies & Procedures

Most of you, during your PGY I year, will spend some time working in an emergency room. On the medical side of your ER, a number of senior patients (over age 65) will come into the ER for evaluation and treatment of what eventually is found to be an adverse drug reaction. In this context, recent work (in the last few years) using a national database has established that the drug most likely to cause such patient visits to the ER, often serious enough to require admission, is: ``` A. Insulin B. Warfarin C. Amoxicillin D. Digoxin E. Oral hypoglycemic drugs ```

B. Warfarin warfarin (33%), insulins (14%), oral antiplatelets (13%), oral hypoglycemic drugs (11%), opioids (

In their 2008 paper about learning from their medication errors, authors from an Australian hospital proposed several steps that hospitals could take to try to reduce the frequency of medication errors in their own hospitals. Which one of the following steps was NOT emphasized by the authors for implementation? A. Staff (doctors and nurses) need further training in how to recognize and deal with error-prone clinical situations B. Doctors and nurse should pay attention to, and try to reduce, communication errors related to drug prescribing and administration C. Improved access to drug information at the point of prescribing would be helpful in reducing medication errors Correct! D. Reducing staffing levels in particularly busy areas could help to prevent medication errors E. All prescribers must acquire basic knowledge about a drug before prescribing a drug that they are not familiar with

D. Reducing staffing levels in particularly busy areas could help to prevent medication errors obviously

In 1962, the Congress passed legislation that now required, for the first time, that all new drug products approved by the FDA had to be proven to be: A. Less expensive than other drugs already approved for the same indication B. Safe (based on clinical studies) C. Better than other drugs already in use for the same indication D. Accurately labels as to contents (including all major excipients such as liquid vehicles) E. Effective (based on clinical trials)

E. Effective (based on clinical trials) new FDA rule that drugs had to show efficacy

The international clinical crisis that stimulated intense congressional discussion that led to this new FDA authority in 1962 was: A. The demonstration that most drugs are able to pass across the placenta from mother to fetus B. The demonstration that maternal ingestion of tetracycline can lead to discolored teeth in infants C. The discovery that use of thalidomide during early pregnancy led to severe teratogenic effects D. The recent proof of lack of effective treatment for hypertension during pregnancy E. The discovery that lack of sufficient folate during early pregnancy led to increased risk of neural tube defects

C. The discovery that use of thalidomide during early pregnancy led to severe teratogenic effects yea - makes no sense. FDA rule in 1962 was that drugs needed to be effective

``` In the 1979 FDA Codes describing drug toxicity during pregnancy, which of the five FDA categories listed below corresponded to this description: “Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the (human) fetus”? C X A D B ```

Class B ==> or that it shows no harm in animal studies

``` When the pregnant mother continues to engage in substance abuse during pregnancy, which of the following substances appears to pose the greatest overall risk to the fetus? A. Alcohol B. Opioids C. Nicotine (smoking) D. Cocaine E. Marijuana F. Methamphetamine ```

A.Alcohol is the worst

In women with pre-existing and successfully treated schizophrenia or bipolar disorder, there is risk of a relapse of the underlying psychiatric illness during pregnancy, which becomes much larger if the antipsychotic drug is stopped in early pregnancy. If the antipsychotic drug is continued during pregnancy, which of the following risks to the fetus appears to be lowest? A. Gestational diabetes B. Fetal malformation C. Neonatal withdrawal syndrome or abnormal muscle movements D. Prematurity E. Low or high birth weight

B. Fetal malformation

A 64 year old male is generally recuperating well at 4 days post op for an anterior resection and anastomosis for colo-rectal cancer. That evening while sitting in his room he develops acute shortness of breath, dizziness and when given 4L of oxygen via a nasal cannula he has an Sp02 of 88% on 4L. An urgent CT angiogram confirms the diagnosis of a major multi segmental pulmonary embolus. Which of the following additional clinical features would make you treat this patient initially with recombinant tissue plasminogen activator (rtPA), knowing that the patient did not have any other contraindications to using this drug? A. respiratory rate of 22/min B. BP 72/48 mm Hg C. severe right sided pleuritic chest pain and a temperature of 38.2oC D. reduced breath sounds in the right mid zone and right lung base E. a fall in the jugular venous pressure (i.e. JVD) on inspiration F. sinus tachycardia 128/min

B. BP 72/48 mm Hg worse ==> b/c due to cardiac compromise, leading to poor cardiac output ==> Kussmaul sign = showing RV compromise d/t cardiac tamponade

A 68 year old Asian women develops transient numbness and weakness of her right arm and hand and slurring of her speech which lasted 20 minutes two hours ago. She had several episodes like this 4 weeks ago and was initially started on clopidogrel 75 mg PO daily because of a prior severe allergic reaction to aspirin. Since on this therapy she had no further episodes, until this one. The cause of her recurrent TIA despite being treated with standard doses of clopidogrel is MOST LIKELY due to which of the following? A. she has the CYP3A5 poor metabolizer genotype B. concurrently taking St. Johns wort C. concurrently taking pantoprazole D. she has the CYP2C19 poor metabolizer genotype E. she has the CYP2D6 ultra-rapid metabolizer genotype F. not being treated with the combination of dipyridamole and clopidogrel initially

D. she has the CYP2C19 poor metabolizer genotype Clopidogrel is a prodrug == needs to be metabolilzed

A 66 year old Caucasian female with hypertension and non-valvular atrial fibrillation is being treated with lisinopril, dofetilide and dabigatran. She has normal renal function for her age and is on no other additional medications. Approximately 5 weeks after starting treatment for her atrial fibrillation she develops an acute onset of severe headache aphasia and complete loss of motor function in her left arm and leg. Her urgent head CT scan shows a large right parietal/internal capsular hemorrhage. In addition to discontinuing the dabigatran which of the following agents/procedures is MOST APPROPRIATE to minimize ongoing intracerebral hemorrhage? ``` A. charcoal hemoperfusion B. the Fab fragment, idarucizumab C. hemodialysis D. fresh frozen plasma concentrate E. factor VII F, fresh platelet transfusion plus fresh frozen plasma concentrate ```

B. the Fab fragment, idarucizumab == antidote for dabigatran

in the US, prednisone is the most commonly prescribed oral glucocorticoid. However, in England, prednisolone is the most widely prescribed oral glucocorticoid drug. What is the main advantage of prednisolone over prednisone? A. Prednisolone causes fewer side effects B. Prednisolone is an active drug, and does not require metabolism to become active C. Prednisolone (at the same dose) is more effective D. Prednisolone has a higher oral bioavailability E. Prednisolone is more potent

B. Prednisolone is an active drug, and does not require metabolism to become active both prednisone & prednisolone are active drugs

A patient in the ICU has no adrenal gland activity, and received daily replacement doses of glucocorticoids (hydrocortisone 20 mg AM + 5 mg PM po) every day. In the ICU, following severe trauma and burns, the intern intended to give maximal stress doses of hydrocortisone (300 mg IV per day in divided doses) to the patient, but the pharmacy was out of this preparation. What would be a comparable dose of methylprednisolone? ``` A. 100 mg IV per day in divided doses B. 80 mg IV per day in divided doses C. 20 mg IV per day in divided doses D. 40 mg IV per day in divided doses E. 60 mg IV per day in divided doses ```

E. 60 mg IV per day in divided doses methylprednisolone is 5x more potent HC: methylprednisolone 5:1 300:60 IV

A young woman in her thirties was receiving treatment for her SLE with daily oral prednisone. Her physicians were working hard to keep her daily dose as low as possible, and to keep her total period of treatment with oral steroids as short as possible. Despite these efforts, she went on to develop aseptic necrosis of both femoral heads. She eventually went on to need bilateral total hip replacements because the condition was so painful. She may have developed this problem, despite these best efforts by her physicians to minimize her exposure, because: A. She had below-normal activity of CYP 2D6 B. She had below-normal activity of CYP 1A2 C. She had above-normal activity of CYP 1A2 D. She had below-normal activity of CYP 3A4 E. She had above-normal activity of CYP 2D6 F. She had above-normal activity of CYP 3A4

D. She had below-normal activity of CYP 3A4 Prednisone is inactivated by Cyp3A4 low Cyp3A4 activity == higher levels of Prednisone

Which of the following is NOT a service that is currently offered by pharmacists for inpatients at DHMC? A. PK support and recommendations for dose adjustments for antibiotics such as vancomycin B. Participating on team walk rounds for many floor and ICU teams C. Double checking the drugs you order against the list of the patient’s previous ADRs and drug allergies D. Writing patient prescriptions on the day of discharge E. Providing advice on special drug formulations, such as which drugs can be ground up for use via NG tubes

D. Writing patient prescriptions on the day of discharge There are some places that do it, but DHMC does not

On the morning of the patient’s discharge, or perhaps the evening before discharge, which member of the healthcare team has likely had the most contact with the patient, knowledge of the various drugs and their indications, and is in the best position to discuss medications planned for discharge with the patient and/or the patient’s family? ``` The intern The attending The primary care nurse The clinical pharmacist The resident The chief resident ```

The intern The one who knows the pt the best

An intern is having a very busy evening, trying to admit four new, acutely ill patients to his or her service, get their admission notes written, and get admission orders written as well. The resident for the team is supervising that intern, one other intern, and also seeing the occasional new inpatient consultation on surgery. In the rush that evening, the intern writes an order for one patient to treat the apparent acute cellulitis with cefazolin, even though the patient can’t give an accurate medical history (he is delirious), and the chart indicates the patient had developed severe hives one year earlier after receiving one dose of Mezlin™. The pharmacist dispenses the antibiotic to the floor, the nurse begins to infuse the intravenous antibiotic, and 5 minutes after starting the infusion, the patient develops hives, wheezing, and mild angioedema involving the tongue and lips. The nurse recognizes this acute reaction, stops the infusion, and pages the intern, who gives a verbal telephone order for the appropriate medications. Fortunately, the patient does well. AS with most medication errors, there were multiple factors that contributed to this event, but the most important factor is arguably: A. The intern was very rushed, and didn’t take enough time to check the patient’s list of past drug allergic reactions before writing medication orders B. The pharmacist should have checked more closely before sending the antibiotic to the floor C. The nurse should have checked more carefully before administering the drug D. The resident should have been consulted before any drugs were ordered by the intern E. The attending should have been consulted before any drugs were ordered by the intern

A. The intern was very rushed, and didn’t take enough time to check the patient’s list of past drug allergic reactions before writing medication orders ere ordered by the intern all goes back to the intern

A 79 year-old Caucasian female has atrial fibrillation, heart failure, COPD, hypertension, diabetes mellitus and is being prescribed 11 drugs for her comorbid conditions. Based on the literature which of following drugs she is taking is MOST LIKELY to cause her to be admitted to hospital because of a serious adverse drug reaction? ``` A. glipizide B. metoprolol C. metformin D. warfarin E. lisinopril ```

D. warfarin most common iatrogenic cause of hospitalization

A 92-year-old man is admitted to the hospital with recently increasing confusion, disorientation. and drowsiness. He has no focal neurological signs and no evidence on laboratory testing of electrolyte, metabolic or endocrine abnormalities to explain his altered mental status. His head CT shows some very mild cerebral atrophy but is otherwise normal. Which of the following drugs that he is currently taking is MOST likely responsible for his current clinical condition? ``` A. tiotropium B. rosuvastatin C. salmeterol + fluticasone (MDI) D. L-thyroxine E. diphenhydramine ```

E. diphenhydramine very common cause of sedation, confusion

When comparing the dosing of fondaparinux to be given to a patient aged 85 compared to a patient aged 30 which of the following is CORRECT? A. the dose of fondaparinux should be lower in the 85 year old patient compared to that in a the 30 year old patient because of reduced renal clearance B. the dose of fondaparinux should be higher in the 85 year old patient compared to that in a the 30 year old patient because of an increased volume of distribution due to its lipophilic nature C. the dose of fondaparinux should be lower in the 85 year old patient compared to that in a the 30 year old patient because of reduced hepatic clearance D. the dose of fondaparinux should be the same for both patients as age does not affect fondaparinux clearance nor affects its anti-Xa activity E. fondaparinux should not be administered to patients over 80 because it was not studied in this patient population F. the dose of fondaparinux should be higher in the 85 year old patient compared to that in a the 30 year old patient because of the increased plasma protein binding

A. the dose of fondaparinux should be lower in the 85 year old patient compared to that in a the 30 year old patient because of reduced renal clearance anti-Xa's are renally cleared ==> assume the CrCl decreases by 10ml/min every 10 decades ==> so in elderly, should expect to decrease the dose d/t decrease in renal clearance

The use of PPIs, such as omeprazole, is widespread and treatment maybe continued long-term. In the elderly such long-term use of PPIs (beyond 8 weeks) is associated with which of the following unanticipated side effects? A. conjugated hyperbilirubinemia with intrahepatic cholestasis B. hyperkalemia C. cardiomyopathy with pulmonary hypertension D. clostridium difficile infection E. IgM mediated glomerulonephritis

D. clostridium difficile infection very common ADR in elderly & in chronic use

Which one of the following general approaches or principles to managing a patient with a deliberate or accidental toxic exposure was found to be LEAST helpful in the management of the patient described with severe clinical toxicity from an organic mercury compound? A. Ordering appropriate, specific laboratory studies when indicated and available B. Hastening elimination of a drug or poison when there is a safe and effective way to do so C. Anticipating further complications from the drug or poison as the case evolves D. Minimizing enteral absorption of a drug or poison after a recent exposure oral exposure E. Generating a possible diagnosis from performing a detailed history and physical exam

D. Minimizing enteral absorption of a drug or poison after a recent exposure oral exposure because can't really get out much == just have to assume that most of it would have been absorbed by then.

Which one of the following sentences best explains the mechanism of action of DMSA in patients with clinical toxicity from high levels (concentrations) of lead measured in whole blood? A. The metal-drug complex is actively secreted into bile, which is its main pathway of excretion and clearance in lead-toxic patients. B. DMSA prevents absorption of ingested lead in the stomach, such as lead dust from old white lead-containing paint. Correct! C. The heavy metal binds covalently to the –SH group of DMSA, while the –COOH group promotes renal excretion D. The --COOH group on the DMSA molecule binds covalently to the lead molecule, thereby reducing the neurotoxicity of lead. E. The --SH group on the DMSA molecule promotes renal excretion of the DMSA-lead complex

C. The heavy metal binds covalently to the –SH group of DMSA, while the –COOH group promotes renal excretion direct quote

In the 1950’s in Minimata, Japan, patients developed a strange neurological disease primarily because: A. The mercury-contaminated waste water from the factory contaminated the town’s water supply B. The elemental mercury dumped into the local bay severely altered the pH of the local sea water, leading to a severe reduction in the number of live fish that were caught, thereby leading to local protein malnutrition of the population C. The mercury-contaminated waste from the factory poisoned the fish in the bay, leading to bizarre behavior by the sick fish, including their attacking fishermen and swimmers Correct! D. The mercury dumped into the bay was eventually organified to monomethyl mercury by plants in the bay, and then passed up the foodchain into larger fish, which were eventually caught and eaten by the local inhabitants

D. The mercury dumped into the bay was eventually organified to monomethyl mercury by plants in the bay, and then passed up the foodchain into larger fish, which were eventually caught and eaten by the local inhabitants example of bottom-up amplification ==> for those who eat a lot of tuna

Other than the Minimata Japan catastrophe in the 1950’s, perhaps the best example of a cluster of patients developing severe and even fatal neurotoxicity from methylmercury ingestion or exposure occurred in Iraq when: A. US forces in Iraq in 1993-1995 used large amounts of ammunition made from spent plutonium, which was contaminated with mercury (another heavy metal), and which leached into the ground water from the spent ammunition B. A severe drought occurred in Iraq in 1971, and the wheat seed that contained a mercury-based fungicide was ground into flour to make bread C. Saddam Hussein used chemical weapons against Iran in the 1980’s war D. Saddam Hussein used chemical weapons against the Iraqi Kurds in the 1980’s E. Saddam Hussein was developing weapons of mass destruction in the early 1990’s

B. A severe drought occurred in Iraq in 1971, and the wheat seed that contained a mercury-based fungicide was ground into flour to make bread

Cases Flashcards

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