Written

Question 1

What is the mechanism of action of capitorpril

Answer 1

Inhibits angiotensins converting enzymes whihc prevents angiotensin I from becoming angeotensin II

Question 2

How would captopril influence her cardiac condition

Answer 2

Decrease Both After & preload which improve cardiac performance and increase COP

Decrease secondary hyperaldosternism which decrease edema

Question 3

What would be the effect of captopril on her blood pressure?

Answer 3

a- Mixed VD arterial > Venous

b. Art. VD which decrease TPR which decrease after load

c. Weak vein, VD. Decreases VR and Decreases EDV and decrease pre-load

Question 4

What are the side effects of captopril?

Answer 4

Dry cough
First dose hypotension
Bilateral renal stenosis
Hyperkalemia

Question 5

Although the patient was doing better on captopril, it was noticed that her heart rate is constantly above 100 bpm and this was viewed as a load on her heart.

In general, what drugs can possibly control the heart rate in a heart failure patient and their effects on heart rate?

Answer 5

Digoxin: -ve chronotropic, decrease AV conduction

Ivabradine: inhibits the cardiac pace maker funny current

Bisoprolol: beta blockade. Decrease HR, Decrease work of hear and O2 consumption. Decrease excitability

Question 6

Which of the following could change the decision of using Ivabradine to control heart rate in patient with heart failure? Explain your answer on the basis of its mechanism of action

a) The heart rate is above 120
b) The patient has AF
c) The patient is diabetic
d) The patient is asthmatic

Answer 6

b) The patient has AF

Ivabradine acts by selective specific inhibition of funny currents in SA node requiring sinus rhythm which isn’t the case in AF.

Question 7

What is the mechanism of action of this combination? (Sacubitril/valsartan)

Answer 7

Sacubitril inhibit the enzyme neprilysin which is responsible for degradation of natriuretic peptides causing their accumulation resulting in VD, Natriuresis and Diuresis, lowering BP and reducing aldosterone levels

Question 8

What are the possible benefits of this medicine (Empagliflozin) to the patient?

Answer 8

Reduce the risk of CV death and worsening of HF by blocking SGLT2 protein in the nephron reducing the amount of reabsorbed glucose and sodium in to the blood. This inhibition results in natriuresis and net decrease in preload and afterload.

Question 9

What is the mechanism of action of spironolactone? What are the side effects?

Answer 9

It is a direct antagonist of aldosterone receptor, thereby preventing salt retention and myocardial hypertrophy & remodeling

SE: gynecomastia, hyperkalemia, menstrual irregularities, decrease digitalis action

Question 10

A patient with HFrEF is currently on sacubutril/valsartan, ivabradine, empagliflozin and Spironolactone Pt developed Atrial Fibrillation. The patient was still not well controlled with of the above medications and it was decided to add an inotropic agent. Which of the following is suitable?

a. Digoxin
b. Amrinone
c. Adrenaline
d. Levosimendan

Which drugs are we likely to remove when the selected drug is added and why?

Answer 10

a. Digoxin

Spironolactone should be stopped because it causes hyperkalemia and decreases digitalis activity

Ivabradine, because the patient has no sinus rythm

Question 11

The mechanism of action of the chosen drug in the previous question (levosimendan)

Answer 11

Levosimendan is calcium sensitizers, increase the sensitivity of troponin C fibers to ionic calcium, improving my cordial contractility.

Question 12

Which of the aforementioned anti-hypertensive drugs could be useful if the patient has osteoporosis?

Answer 12

Hydrochlorothiazide produce hypercalcemia by increasing calcium reabsorption from the luminal membrane of tubular cells into the interstitium in exchange of sodium and reducing urine calcium levels

Question 13

The physician ask for serum level of potassium, what will you expect to find?

Answer 13

Hyperkalemia produced by lisinopril and spironolactone might be balanced by hypokalemia of thiazide diuretic

Question 14

Why would the use of NSAIDs in this patient be considered inappropriate?

Answer 14

As NSAIDs inhibit production of vasodilator prostaglandin that mediate partially the anit-hypertensive effects of ACE inhibitors and hydrochlorothiazide

Question 15

If the patient is intolerant to Lisinopril due to dry irritant cough, Indicate the alternative anti-hypertensive that devoid from this side effect

Answer 15

Lisinopril is an ACE inhibitor—> decrease the degradation of circulating bradykinin causing dry irritant cough

Any ARBS does not produce this effect because they have no effect on ACE

Question 16

A 65 year old man with a 2 month history of progressive headache presented to the emergency department with nausea, vomiting, visual disturbance, and confusion for 1 day, his blood pressure was noted as 195/123 mm Hg, MRI of the brain was performed in the emergency department and demonstrated hypertensive encephalopathy.

Mention the other agents that can be prescribed to this patient and mention their mechanism of action

Answer 16

Nitroglycerin: nitro dilator release NO
Nifedipine: CCB
Na Nitroprusside: it is a nitro dilator

Question 17

A 10 year old boy is brought to the emergency department after being stung by a bee. He had been well until he was stung on his right forearm, while playing in the yard. He initially complained of localized pain and swelling. Fifteen minutes later, he began to complain of shortness of breath. His parents brought him immediately to the local emergency department

Explain why epinephrine is the first line treatment in this case?

Answer 17

Bronchodilation (B2)
+ve iontropic & +chronotropic (B1)
inhibition activation of mast cells which decrease histamine and leukotriene release

Question 18

Respiratory symptoms of the boy were not improved after IM epinephrine what will you do next?

Answer 18

Repeated IM adrenaline after 5 minutes

Question 19

What are the advantages of the IM route of epinephrine over IV administration?

Answer 19

It is safer than IV route
It does not require IV access
IM route easier to learn

Question 20

Diphenhydramine IV, Ranitidine IV, Methylprednisolone IV, were given to the boy. Mention mechanism of action of each drug

Answer 20

Methylprednisolone is down regulation of the late phase inflammatory response

Diphenhydramine IV, Ranitidine IV: anti histamines

Question 21

Mention 4 drugs that my cause anaphylaxis

Answer 21

Penicillin
ACE inhibitors
NSAIDS
NMBs

Question 22

What is the role of the vasopressor drug mentioned (norepinephrine) in treatment of cardiogenic shock?

Answer 22

a1 adrenergic agonist–> VC –> increase in both systolic and diastolic blood pressure–> increase coronary blood flow –> indirectly improving cardiac function

Question 23

Mention TWO other vasopressors that can be used in the treatment of cardiogenic shock

Answer 23

epinephrine
vasopressin

Question 24

What is the role of dopamine in the treatment of cardiogenic shock?

Answer 24

increase CO and increase BP

Question 25

What is the role of dobutamine in the treatment of cardiogenic shock?

Answer 25

It is selective B1 stimulant. Its +ve inotropic with minimal increase in HR

Question 26

What is advantage of dobutamine over dopamine?

Answer 26

Dobutamine is more ionotropic than chronotropic, so increase CO with less tachycardia, palpitation

Question 27

Mention 4 Inotropes that can be used in the treatment of cardiogenic shock

Answer 27

Dopamine Dobutamine Milrinone Levosimendan

Question 28

Triptans are not used in the prophylaxis of migraine (ONE reason)

Answer 28

They produce VC of the abnormally dilated cerebral bl vs in acute attack

Question 29

Triptans are not combine with ergot alkaloids (One reason)

Answer 29

They will produce severe VC of the blood vessels

Question 30

If this patient has angina pectoris, and you wish to prescribe a prophylaxis, name one medication you recommend?

Answer 30

Propranolol

Question 31

A 23 year old man with a history of migraine for which he is receiving dihydroergotamine. His headache is now occurring more frequently which interferes with his life In which phase do you think, the drug named dihydroergotamine works in migraine headache?

Answer 31

Acute attack of migraine

Question 32

The patient developed depression after a major accident from her son, which class antidepressant could be effective for both conditions and which would not? Why?

Answer 32

SSRIS are not effective in migraine prophylaxis, TCA are effective in migraine prophylaxis independent of their antidepressant action.

Question 33

Give reason: Why folic acid should not be used alone in treatment of pernicious anemia?

Answer 33

If folic acid used alone in pernicious anemia, it will correct blood picture but worsen neurological manifestations

Question 34

What is the preauction this female should do before receiving the medication? Why?

Answer 34

It is recommended to do sensitivity test, as there is a possibility of hypersensitivity reaction with iron injection.

Question 35

If this female got pregnant, what is the medication that she should receive in the first trimester? Why?

Answer 35

She should receive folic acid daily in the first trimester, for fear of developing congenital anomaly in her baby.

Question 36

Mention the side effects and contraindications of ergot

Answer 36

SE: cold extremities, hypertension, anginal pain and abortion in pregnant females Contraindications: PVD, HTN, IHD and pregnancy

Question 37

What are the drugs that could be prescribed to reduce frequency of migraine attacks?

Answer 37

Beta blockers, CCBs, antidepressant and anticonvulsants

Question 38

A 35 year old female presents with severe unilateral headache. She was diagnosed to have migraine. The doctor prescribes zolmitriptan for her to control the acute attack. What is the role of zolmitriptan in the acute attack?

Answer 38

VC of the abnormally dilated cerebral blood vessels

Question 39

What are the advantages and the disadvantages of using triptan family in treatment of migraine?

Answer 39

Advantages: stimulate serotonin receptor in cerebral bl Disadvantages: neck pain, chest pain, dizziness and abortion in pregnant females