Pharmacotherapy Principles And Practice 5th Edition By Marie A. Chisholm-Burns, Terry L. Schwinghamm

Pharmacotherapy Principles and Practice 5th Edition Chisholm-Burns Test Bank CHAPTER 1. Introduction 1. What is the name under which a drug is listed by the U.S. Food and Drug Administration (FDA)? a.

Brand b.

Nonproprietary

c.

Official

d.

Trademark 2. Which source contains information specific to nutritional supplements? a.

USP Dictionary of USAN & International Drug Names b.

Natural Medicines Comprehensive Database

c.

United States Pharmacopoeia/National Formulary (USP NF)

d.

Drug Interaction Facts 3. What is the most comprehensive reference available to research a drug interaction? a.

Drug Facts and Comparisons b.

Drug Interaction Facts

c.

Handbook on Injectable Drugs

d.

MartindaleThe Complete Drug Reference 4. The physician has written an order for a drug with which the nurse is unfamiliar. Which section of thePhysicians Desk Reference (PDR) is most helpful to get information about this drug? a.

Manufacturers section b.

Brand and Generic Name section

c.

Product Category section

d.

Product Information section 5. Which online drug reference makes available to health care providers and the public a standard, comprehensive, up to date look up and downloadable resource about medicines? a.

American Drug Index b.

American Hospital Formulary

c.

DailyMed

d.

Physicians Desk Reference (PDR) 6. Which legislation authorizes the FDA to determine the safety of a drug before its marketing? a.

Federal Food, Drug, and Cosmetic Act (1938) b.

Durham Humphrey Amendment (1952)

c.

Controlled Substances Act (1970)

d.

Kefauver Harris Drug Amendment (1962)

7. Meperidine (Demerol) is a narcotic with a high potential for physical and psychological dependency. Under which classification does this drug fall? a.I b.II c.III d.IV 8. What would the FDA do to expedite drug development and approval for an outbreak of smallpox, for which there is no known treatment? a.

List smallpox as a health orphan disease. b.

Omit the preclinical research phase.

c.

Extend the clinical research phase.

d.

Fast track the investigational drug.

9. Which statement is true about over the counter (OTC) drugs? a.

They are not listed in the USP NF. b.

A prescription from a health care provider is needed.

c.

They are sold without a prescription.

d.

They are known only by their brand names.

10. Which is the most authoritative reference for medications that are injected? a.

Physicians Desk Reference b.

Handbook on Injectable Drugs

c.

DailyMed

d.

Handbook of Nonprescription Drugs 11. The nurse is administering Lomotil, a Schedule V drug. Which statement is true about this drugs classification? a.

Abuse potential for this drug is low. b.

Psychological dependency is likely.

c.

There is a high potential for abuse.

d.

This drug is not a controlled substance.

12. The nurse is transcribing new orders written for a patient with a substance abuse history.

Choose the medication ordered that has the greatest risk for abuse. a.

Lomotil b.

Diazepam

c.

Phenobarbital

d.

Lortab 13. The nurse is caring for a patient newly diagnosed with type 1 diabetes mellitus. Which approach(es) to therapeutic methods would be considered in this patients treatment? (Select all that apply.) a.

Therapeutic drugs b.

Concentrated carbohydrate diet

c.

Family centered care

d.

Regular daily exercise and activity

e.

Daily baths

14. An older adult experiencing shortness of breath is brought to the hospital by her daughter.

While obtaining the medication history from the patient and her daughter, the nurse discovers that neither has a list of the patients current medications or prescriptions. All the patient has is a weekly pill dispenser that contains four different pills. The prescriptions are filled through the local pharmacy. Which resource(s) would be appropriate to use in determining the medication names and doses? (Select all that apply.) a.

MartindaleThe Complete Drug Reference b.

Physicians Desk Reference, Section 4

c.

Senior citizens center

d.

Patients home pharmacy 15. The nurse planning patient teaching regarding drug names would include which statement(s)? (Select all that apply.) a.

Most drug companies place their products on the market under generic names. b.

The official name is the name under which the drug is listed by the U.S. Food and Drug Administration (FDA).

c.

Brand names are easier to pronounce, spell, and remember.

d.

The first letter of the generic name is not capitalized.

e.

The chemical name is most meaningful to the patient.

16. When categorizing, the nurse is aware that which drug(s) would be considered Schedule II? (Select all that apply.) a.

Marijuana b.

Percodan

c.

Amphetamines

d.

Fiorinal

e.

Flurazepam Answers 1. C 2. C

3. B 4. B 5. C 6. A 7. B 8. D 9. C 10. B 11. A 12. D 13. A,B,D 14. B,D 15. B,C,D 16.B,C

CHAPTER 2. GERIATRICS 1. The following is an accurate description of the aging population: A. The number of older adults will reach 17 million in 2030 B. The ratio of women to men will no longer exist C. The surviving baby boomers will be more racially diverse than previous elders D. The surviving baby boomers will have less financial resources than previous elders E. The minority elder populations are projected to decrease in 2020 2. Education and health literacy in the older Americans can be described as: A. In 2007, 62% of Hispanic elders had high school degrees B. Nearly 20% of people 75 years and older have low health literacy C. In 2007, 62% of black elders had high school degrees D. Nearly 40% of people 75 years and older have low health literacy E. None of the above 3. Following are common chronic conditions older Americans have: A. Diabetes, hypertension, cancer B. Hypertension, Alzheimer disease, Parkinson disease C. Asthma, stroke, hypothyroidism D. Chronic lower respiratory diseases, Alzheimer disease, stroke E. Cancer, heart disease, Parkinson disease 4. The most important pharmacokinetic change that occurs with aging is: A. Reduced renal function B. Delayed gastric emptying C. Increased conjugation D. Phase II hepatic metabolism E. Deconditioning 5. All of the following are incorporated into the Cockcroft–Gault equation except: A. Age B. Gender C. Serum albumin D. Serum creatinine E. Weight 6. Because of pharmacodynamic changes, older adults have increased sensitivity to: A. Acetaminophen B. Metformin C. Aspirin D. Morphine E. Cyanocobalamin 7. Polypharmacy use in older adults does not result in: A. Increased adherence B. Increased drug–drug interaction C. Increased complex regimen D. Increased hospitalization E. Increased health care cost 8. According to the 2012 Beers criteria, the following drug should be avoided in older adults:

A. Diazepam B. Warfarin C. Aspirin D. Pravastatin E. Mirtazapine 9. The following statement about pain in older adults is true: A. Older adults do not feel as much pain as younger adults.

B. Older adults experience less addiction when using opioids for nerve pain.

C. Pain is not a quality indicator in long-term care facilities because it is not an objective measure.

D. Pain is frequently undertreated and underreported in elders.

E. Elders are more comfortable with opioid use because they are closer to end of life.

10. The predictors of adverse drug reactions include the following except: A. More than four medications B. Longer than 14 days of hospital stay C. More than four active medical problems D. Smoking history E. History of alcohol use 11. Medication nonadherence among older adults is influenced by: A. More than two prescribers B. Four or more medication changes in past 12 months C. History of more than two surgeries D. Having no caregiver help E. More than two chronic conditions for at least 10 years 12. Anticoagulation therapy in older adults: A. has proven benefit in atrial fibrillation B. should be withheld due to bleeding side effects C. should be withheld due to fall risks D. is more beneficial in the very sick E. is less beneficial in the community-dwelling ambulatory patient 13. Geriatric assessment: A. should only be performed by a board-certified geriatrician B. is an interprofessional collaborative process C. routinely includes a formal driving evaluation by occupational therapy D. includes history taking from the patient alone without family for maximum privacy E. is usually done at the hospital during an acute admission 14. Quality indicators: A. monitor costs related to pressure ulcer formation in long-term care facilities B. are used to measure the environmental quality of outpatient geriatric clinics C. do not include subjective complaints such as pain D. focus on physical health issues and do not include mental health issues E. are used by facility administrators and government overseers to identify problem areas 15. The following statement about pharmacotherapy in older adults is false: A. Renal function needs to be monitored for patients on digoxin.

B. Beers criteria indicate inappropriate medications.

C. Benzodiazepines may cause significant adverse effects.

D. Albumin needs to be monitored for patients on phenytoin.

E. Drug monitoring is often unnecessary due to multimorbidity.

Answers 1. C 2. D 3. A 4. A 5. C 6. D 7. A 8. A 9. D 10. D 11. B 12. A 13. B 14. E 15. E

CHAPTER 3. PEDIATRICS 1. AJ is a 14-day-old premature male infant, born at 30-week GA, started on ampicillin and gentamicin for neonatal sepsis. Which pharmacokinetic parameter affects the patient’s dosing frequency of gentamicin?

A. Absorption B. Protein binding C. Metabolism—Phase I reactions D. Metabolism—Phase II reactions E. Elimination half-life 2. Which is an appropriate maintenance fluid requirement for a 4-year-old boy with a weight of 40 pounds?

A. ~1400 mL/day B. ~1600 mL/day C. ~1800 mL/day D. ~2000 mL/day E. ~2200 mL/day 3. MM is a 6-month-old male infant who was born at 34-week GA. You are asked to evaluate his renal function in preparation for starting intravenous antibiotics. Which method for assessment is most appropriate?

A. “Bedside” Schwartz equation B. Cockcroft–Gault equation C. Schwartz (original) equation D. Modification of diet in renal disease (MDRD) equation E. Urine output alone 4. PG, a 1-week-old, 2.5-kg girl born at 30-week GA, is to be started on gentamicin for suspected neonatal sepsis. Which of the following is true regarding PG’s apparent volume of distribution (Vd) in milliliters per kilogram for gentamicin compared with adults and children with normal renal function?

A. Vd will be less than those used in adults and children.

B. Vd will be greater than those used in adults and children.

C. Vd will be less than those used in adults but similar to children.

D. Vd will be greater than those used in adults but less than in children.

E. Vd will be the same as adults and children.

5. NC is a 5-year-old boy who is to start carbamazepine, an antiepileptic medication, for seizure disorder. Which pharmacokinetic parameter affects his daily dose requirement of carbamazepine, by body weight?

A. Absorption B. Distribution C. Metabolism—Phase I reactions D. Metabolism—Phase II reactions E. Elimination 6. Which of the following is not an appropriate treatment of cold symptoms in a 1-year-old child?

A. Adequate oral fluid intake B. Dextromethorphan cough syrup C. Honey (orally)

D. Ibuprofen every 8 hours as needed for fever E. Saline nasal spray as needed 7. KC is a 3-week-old male infant born at 37-week GA with a urinary tract infection (UTI). Which age-dependent factor hinders the use of ceftriaxone for KC’s UTI? A. Gastric pH B. Glomerular filtration rate C. Intrapulmonary circulation D. Serum albumin E. Total body water 8. What is the estimated creatinine clearance for a 2-month-old term male infant whose weight is 4.5 kg, length 23.6 in (60 cm), and serum creatinine 0.5 mg/dL (or 44 µmol/L)?

A. 16 mL/min/1.73 m2 B. 21 mL/min/1.73 m2 C. 39 mL/min/1.73 m2 D. 54 mL/min/1.73 m2 E. 66 mL/min/1.73 m2 9. In the outpatient setting, which of the following is not a feasible factor to consider when assessing for potential illness in an infant?

A. Behavior such as lethargy and irritability B. Body temperature C. Diaper changes (urine output) D. Oral intake E. Mean arterial pressure 10. Which of the following items would be least appropriate to mix to mask the taste of medication for a 10-month-old infant?

A. Applesauce B. Chocolate syrup C. Honey D. Pear puree E. Strawberry gelatin 11. Which patient is at greatest risk for a medication error?

A. A 2-year-old girl (12 kg) who is started on amoxicillin suspension with dose rounded within 10% to meet a measurable volume.

B. A 3-day-old boy (2.8 kg) who is on a low concentration heparin drip to maintain his umbilical arterial catheter.

C. A 7-day-old premature female infant (1.5 kg) who is receiving gentamicin doses using a smart pump for infusion.

D. A 10-year-old girl (55 lb [24.9 kg]) started on an insulin drip for diabetic ketoacidosis.

E. A 12-year-old boy (34 kg) started on started on oxycodone for acute pain after surgery.

12. KT, an 18-month-old girl, swallowed some of her grandfather’s medications from his weekly pillbox. KT’s grandfather states that he is taking medications for blood pressure, sleep, and high cholesterol. He states that “she is a little

sleepy and not behaving like herself right now.” Which is the most appropriate action to manage the accidental ingestion for this child?

A. Administer ipecac syrup immediately and induce emesis until paramedics arrive B. Allow KT to “sleep off” the medication and contact her pediatrician tomorrow C. Direct her family to take KT to the emergency department and contact local/regional poison control center D. Give continuous oral fluids to dilute the medication’s effects E. Monitor the child’s blood pressure at home and go to the emergency department if it is too low 13. Which is false about medication use in pediatric patients?

A. Caregivers should be educated about measurement of liquid medication for each medication.

B. It is appropriate to recommend a tablet formulation for any child of age 5 years and younger.

C. Obtaining a child’s medication history should include prescription, over-the-counter, and complementary medications.

D. Suspendability, stability, uniformity, and palatability are important factors to consider when compounding a liquid formulation.

E. When using intravenous formulations, fluid status and comorbidities like congenital heart disease should be considered.

14. Which statement is false regarding complementary and alternative medicine (CAM) use in the pediatric population?

A. CAM is routinely disclosed in medication histories from parents/caregivers.

B. Common illnesses in which CAM may be used include cancer, asthma, and autism spectrum disorder.

C. Discussion of CAM use should be encouraged with parents/caregivers.

D. Drug interactions are possible with CAM use.

E. There are limited data regarding the use of ginger and echinacea in children.

15. Which statement is false regarding off-label use of medications: A. It includes use of a medication outside the licensed age range.

B. It is not permitted by law in the pediatric population due to lack of data.

C. It is based on limited data about the use in infants and children.

D. It is used in situations where there is no appropriate pediatric-approved alternative.

E. It includes dosing outside of those recommended by the manufacturer’s package insert.

Answers 1. E 2. A 3. C 4. B

5. C 6. B 7. D 8. D 9. E 10. C 11. D 12. C 13. B 14. A 15. B

CHAPTER 4. PALLIATIVE CARE 1. JP is being treated for lung cancer, and received his last chemotherapy infusion 3 weeks ago. He is currently reporting nausea and vomiting since he started taking morphine for his cancer-related pain. Which of the following antiemetics would be the best option to treat his uncontrolled nausea and vomiting?

A. Ondansetron B. Aprepitant C. Lorazepam D. Haloperidol E. Dolasetron 2. A patient diagnosed with advanced COPD is reporting dyspnea associated with thickened pulmonary secretions. The patient has a strong cough reflex and is adequately hydrated. Which of the following is the best option for this patient?

A. Oxygen therapy B. Low-dose oral morphine C. Scopolamine patches D. Nebulized saline E. Lorazepam 3. Delirium often presents gradually, with persistent decline in memory and global functioning.

A. True B. False 4. In a patient diagnosed with advanced heart failure, who is demonstrating excessive fluid overload symptoms, which of the following medication should be reduced or discontinued?

A. Digoxin B. Beta-adrenergic blocker C. Angiotensin-converting enzyme (ACE) inhibitor D. Loop diuretic E. Aspirin 5. Nausea secondary to gastroparesis is most appropriately treated by which of the following agents?

A. Lorazepam B. Haloperidol C. Metoclopramide D. Ondansteron E. Dolasteron 6. Which of the following adjuvant is often used in conjunction with standard opioid therapy for the treatment of severe bone pain?

A. Acetaminophen B. Corticosteroids C. Lorazepam D. Tricyclic antidepressants E. Alprazolam 7. Which of the following best describes the cause of death in patients diagnosed with

Lou Gehrig disease?

A. Opportunistic infections D. Anorexia E. Renal failure 8. A patient is eligible for the hospice Medicare benefit in the United States if they have a terminal diagnosis with of prognosis of less than: A. 1 month if the disease runs its usual course B. 3 months if the disease runs its usual course C. 6 months if the disease runs its usual course D. 12 months if the disease runs its usual course E. None of the above 9. Palliative care is considered appropriate care for which of the following: A. Breast cancer B. Chronic heart failure C. Alzheimer disease D. AIDS E. All of the above 10. Benzodiazepine as monotherapy in patients with delirium is the treatment of choice.

A. True B. False 11. The dose of short-acting opioids for the treatment of breakthrough pain should be equal to: A. 1%–2% of the daily maintenance dose B. 5%–20% of the daily maintenance dose C. 25%–35% of the daily maintenance dose D. Short-acting opioids should never be used in palliative care 12. Low-dose opioids may be effective in treating which of the following: A. Nausea B. Vomiting C. Dyspnea D. Terminal secretions 13. Due to questionable necessity of simvastatin therapy in hospice patients, this medication should be evaluated for discontinuation in end of life care.

A. True B. False 14. Which of the following agent(s) may be given sublingually?

A. Lorazepam B. Haloperidol C. Atropine D. All of the above 15. Methadone may be used to effectively manage which of the following?

A. Neuropathic pain B. Visceral pain C. Bone pain D. All of the above

Answers 1. D 2. D 3. B 4. B 5. C 6. B 7. B 8. C 9. E 10. False 11. B 12. C 13. A 14. D 15. D

CHAPTER 5. HYPERTENSION 1. A 55-year-old white man with seated office blood pressure (BP) readings of 144/92 mm Hg and 136/84 mm Hg is asked to return in 2 weeks for repeat measurements, which are 138/88 mm Hg and 134/82 mm Hg. Which of the following classifies DG’s BP per the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) joint Clinical Practice Guidelines for the Management of Hypertension in the Community?

A. Isolated systolic hypertension B. Stage 1 hypertension C. Prehypertension D. Optimal BP E. Stage 2 hypertension 2. Lupus-like syndrome is a possible side effect of which of the following drug(s)?

A. Clonidine B. Minoxidil C. Doxazosin D. Hydralazine E. Reserpine 3. A 55-year-old black woman has a history of left ventricular hypertrophy with a left ventricular ejection fraction of 55%. She has had hypertension for 10 years and is currently taking chlorthalidone 25 mg daily, metoprolol succinate 50 mg daily, and amlodipine 2.5 mg daily. Her averaged BP is 152/94 mm Hg with a heart rate of 54 beats/min. Her physical exam is unremarkable and basic metabolic panel reveals serum creatinine of 0.8 mg/dL [71 µmol/L] and potassium of 3.9 mEq/L (3.9 mmol/L). She reports allergies to fosinopril and aspirin. Which of the following represents the optimal course of action?

A. Increase amlodipine to 5 mg and have her take it at bedtime B. Increase metoprolol succinate to 100 mg daily C. Add lisinopril 5 mg daily D. Add spironolactone 50 mg daily E. A or B 4. A 34-year-old black man presents to your clinic with a BP of 160/94 mm Hg. Repeat readings over the next 2 weeks average 156/92 mm Hg. The patient has no past medical history with the exception of Crohn disease, which is currently treated with chronic steroid therapy. He is also taking an over-the-counter NSAID for ongoing back pain. Physical examination and laboratory tests are unremarkable.

Appropriate interventions at this time include: A. No intervention because patient most likely has drug-induced hypertension B. Discontinuation of the NSAID C. Reassessment of the dose and need for long-ter 5. A 68-year-old white man has resistant hypertension, prior myocardial infarction, and chronic kidney disease (CKD; serum creatinine 1.8 mg/dL [159 μmol/L], estimated creatinine clearance 40 mL/min [0.67 mL/s]). You are initiating ramipril today. What is the most appropriate timeframe for laboratory follow-up?

A. 1 to 2 days B. 1 to 2 weeks

C. 1 to 2 months D. 3 to 4 months E. 4 to 6 months 6. A 47-year-old Hispanic man has primary hypertension with an average BP of 172/98 mm Hg and heart rate of 70 beats/min. His most recent serum potassium is 4.5 mEq/L (4.5 mmol/L), serum creatinine is 1.1 mg/dL (97 µmol/L) and calculated creatinine clearance is 102 mL/min (1.70 mL/s). Which of the following antihypertensives would be most appropriate at this time?

A. Furosemide B. Atenolol C. Chlorthalidone and lisinopril initiated concurrently D. Amlodipine and lisinopril initiated concurrently E. C or D 7. A 67-year-old Asian man with a recent non-ST segment elevation MI (2 weeks ago) has an average BP of 148/86 mm Hg and a heart rate of 76 beats/min. Which of the following antihypertensive agents is preferred in this setting?

A. Metoprolol tartrate B. Acebutolol C. Hydrochlorothiazide D. Spironolactone E. A or B 8. Which of the following treatments is (are) the most appropriate for a hypertensive emergency?

A. Normalization of BP within hours B. Reduction in mean arterial pressure by 25% to 50% within minutes to hours C. Reduction in mean arterial pressure up to 25% within minutes to hours D. Administration of sublingual nifedipine E. C and D 9. A 65-year-old black man with history of hypertension, prior MI, and benign prostatic hypertrophy, is currently receiving amlodipine 5 mg QAM and metoprolol succinate 50 mg once daily. He has an average 24-hour Ambulatory Blood Pressure of 156/92 mm Hg and HR of 66 beats/min with notable nocturnal hypertension. He complains of nocturia but states that the swelling in his feet improved when his amlodipine dose was reduced. Which of the following presents the most clinically appropriate course of action?

A. Initiate tamsulosin 0.4 mg daily at bedtime B. Increase amlodipine to 10 mg daily and change to bedtime C. Increase metoprolol succinate to 50 mg twice daily D. Initiate chlorthalidone 50 mg daily at bedtime E. Initiate doxazosin 2 mg daily at bedtime 10. A 67-year-old black man has resistant hypertension. Past medical history is also significant for heart failure with left ventricular systolic dysfunction, dyslipidemia, and peripheral vascular disease. Medications currently include lisinopril, carvedilol, and furosemide. Current blood pressure is 146/88 mm Hg and when repeated 148/82 mm Hg. Which of the following additions to his medication regimen would be an inappropriate choice at this time?

A. Amlodipine B. Felodipine C. Hydralazine/Isosorbide Dinitrate D. Minoxidil E. Spironolactone 11. A 32-year-old woman is 20 weeks pregnant and has a history of gestational diabetes. She presents with an average BP of 154/96 mm Hg and a heart rate of 60 beats/min. Her laboratory results are remarkable for proteinuria, elevated serum uric acid, and low potassium. Which of the following presents the most appropriate course of action?

A. Closely monitor her BP and provide supportive care B. Start Losartan 50 mg daily while monitoring BP C. Start methyldopa 250 mg every 6 hours while monitoring BP D. Start labetalol 100 mg every 12 hours while monitoring BP E. Start chlorthalidone 25 mg daily while monitoring BP 12. A 45-year-old black man has a past medical history significant only for hypertension. Despite therapy with lisinopril 40 mg daily, hydrochlorothiazide 12.5 mg daily, and amlodipine 10 mg daily, his home and office BPs over the last 2 weeks remain elevated with an average reading of 154/92 mm Hg. All laboratory results are within normal limits. Which of the following would be a reasonable change to his antihypertensive regimen?

A. Replace hydrochlorothiazide with chlorthalidone 25 mg daily B. Add aliskiren 150 mg daily C. Add spironolactone 50 mg daily D. Add losartan 25 mg daily E. B or D 13. A 29-year-old woman has had stage 1 hypertension for the past 2 years that has been well controlled (BP range of 100–110/60–65 mm Hg) on lisinopril 10 mg once daily. She has successfully implemented lifestyle modifications, losing 14 kg (31 lb) and obtaining a body mass index of 21 kg/m2 . She informs you she is going to start trying to get pregnant. What changes should be instituted with her antihypertensive therapy at this time?

A. Discontinuing lisinopril and monitoring BP closely with lifestyle modifications B. Discontinuing lisinopril and initiating methyldopa C. Continuing lisinopril because her BP is well controlled D. Reducing lisinopril dose to 2.5 mg daily and maintaining lifestyle modifications E. Discontinuing lisinopril and starting HCTZ 14. A 57-year-old white woman has type 2 diabetes, morbid obesity, and hypertension. She is currently taking only lisinopril 20 mg daily and her office blood pressures are consistently at goal < 140/90 mm Hg, but her home readings are significantly higher. Which of the following is a possible explanation for her elevated home readings?

A. Her home BP cuff is too small B. She has white coat hypertension C. Her home BP cuff is too large

D. She checks her blood pressure immediately after exercise E. All of the above 15. A 56-year-old black woman is currently on verapamil ER 360 mg once daily. She has a past medical history of hypertension and atrial fibrillation. Today, her office BP readings are 137/97 mm Hg and 144/96 mm Hg with a heart rate of 60 beats/min.

Which of the following is the most appropriate intervention?

A. Add amlodipine 5 mg daily B. Increase verapamil ER to 360 mg twice daily C. Add chlorthalidone 12.5 mg daily D. Add lisinopril 5 mg daily E. Either C or D ANSWERS 1. C 2. D 3. A 4. E 5. B 6. E 7. A 8. C 9. E 10. D 11. C 12. A 13. A 14. A 15. E

CHAPTER 6. HEART FAILURE 1. Which of the following finding, when reduced, indicates impaired systolic function in a patient with heart failure?

A. BNP B. SCr C. LVEF D. LVH E. Troponin 2. What is the most common etiology of heart failure?

A. Ischemic B. Idiopathic, unknown cause C. Viral cardiomyopathy D. Drug-induced E. Hypertension Use the following to answer questions 3–5: A 58-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years, dyslipidemia, and is status post myocardial infarction 2 years ago.

Physical exam reveals the following: BP 148/96 mmHg, pulse 98 beats/min, Ht: 5’11’’ (180 cm), Wt: 189 lb (86 kg; usual = 178 lb [ (+) JVD, (−) HJR or hepatomegaly (+) S3, (+) S4 ECG: regular rate/rhythm, evidence of old infarct ECHO: EF 33% (0.33) CXR: Crackles bilaterally and cardiomegaly (enlarged heart) Labs: Sodium: 142 mE/L (142 mmol/L) Potassium: 3.7 mEq/L (3.7 mmol/L) Magnesium: 1.8 mEq/L (0.90 mmol/L) BUN: 22 mg/dL (7.9 mmol/L) SCr: 1.3 mg/dL (115 µmol/L) BNP: 322 pg/mL (322 ng/L; 93 pmol/L) Current medications: Aspirin 81 mg daily Diltiazem 180 mg daily Glipizide 10 mg twice daily for diabetes Simvastatin 20 mg nightly at bedtime Acetaminophen 500 mg twice daily 3. Which of the patient’s medications can exacerbate systolic dysfunction heart failure?

A. Glipizide B. Diltiazem C. Acetaminophen D. b and c

E. All of the above 4. Which of the following is TRUE regarding the patient’s current NYHA functional class and stage of heart failure?

A. Class III, Stage B B. Class III, Stage C C. Class II, Stage B D. Class II, Stage C E. Class IV, Stage C 5. Which of the following is the MOST appropriate ACUTE treatment plan for the patient’s heart failure?

A. Add HCTZ 12.5 mg Qday, since creatinine clearance is above 30 mL/min (0.5 mL/s) B. Add HCTZ 25 mg Qday, increase dose of diltiazem to 240 mg Qday C. Add furosemide 20 mg BID and nesiritide infusion since BNP is elevated D. Add furosemide 20 mg BID and lisinopril 10 mg Qday, discontinue diltiazem E. Add furosemide 20 mg BID, and carvedilol 3.125 mg twice daily, discontinue diltiazem 6. What is the medical term for the symptom of “feels short of breath when she lies down at night”?

A. Orthopnea B. Hepatojugular reflux C. Paroxysmal nocturnal dyspnea D. Pulmonary congestion E. Peripheral edema 7. Which of the following is TRUE regarding ACE inhibitors in heart failure?

A. Should be used mainly in severe heart failure, NYHA functional class IV B. Efficacy of ACE inhibitors is a class effect C. May be used in place of hydralazine and isosorbide dinitrate in cases of renal dysfunction D. Can be replaced by angiotensin receptor blockers if the patient has hyperkalemia E. Should be discontinued if creatinine clearance decreases by more than 10% 8. Which of the following is TRUE regarding β-blockers in heart failure?

A. Ideally should be started in setting of congestion to aid in diuresis B. FDA-approved agents include carvedilol and metoprolol succinate C. Metoprolol tartrate is more efficacious than carvedilol for heart failure D. Chronic β-blockade increases ventricular mass E. Metoprolol has more potent blood pressure lowering effects compared to carvedilol 9. A 74-year-old woman presents to clinic for heart failure follow-up. She is classified as NYHA FC II. Her blood pressure is 144/82 mm Hg, and most recent EF is 26% (0.26).

Her current medication regimen includes lisinopril 20 mg Qday, carvedilol 25 mg BID, digoxin 0.125 mg Qday, and furosemide 20 mg BID. Which of the following would be the BEST choice to add at this time?

A. Metolazone B. Hydralazine and isosorbide C. Spironolactone

D. Hydrochlorothiazide E. Valsartan 10. Mineralocorticoid receptor antagonists (or aldosterone receptor antagonists) have been shown to reduce mortality in patients with heart failure. Which of the following is TRUE about MRAs? A. Spironolactone leads more frequently to gynecomastia compared to eplerenone B. Associated with hypokalemia C. Can only be used in NYHA functional class IV D. Used after maximizing ACE inhibitors, β-blockers, and digoxin E. Added to loop diuretic when a patient is resistant to its effects to enhance removal of fluid 11. A 76-year-old man is admitted to the hospital presenting with peripheral and pulmonary edema, decreased urinary output, hypotension, and altered mental status. Pertinent values: PCWP = 32 mm Hg (4.3 kPa), Cardiac index (CI) = 1.8 L/min/m2 . Based on his presentation, what hemodynamic subset is he in?

A. I B. II C. III D. IV E. II and IV 12. Which of the following diuretic combinations is used for the purpose of reducing congestion in the setting of diuretic resistance?

A. Hydrochlorothiazide and spironolactone B. Spironolactone and torsemide C. Furosemide and spironolactone D. Furosemide and metolazone E. Nesiritide and spironolactone 13. A 68-year-old African American woman is admitted to the hospital for new onset acute decompensated heart failure. Her current medications include felodipine 2.5 mg Qday and atorvastatin 20 mg Qday. Hemodynamic readings include a PCWP of 16 (2.1 kPa) and a CI of 1.8 L/min/m2 . Which of the following is the MOST appropriate treatment plan?

A. Fluids, inotropes B. Diuretics, vasodilators C. Fluids, inotropes, vasodilators D. Diuretics, fluids, inotropes E. Diuretics, inotropes, vasodilators 14. Which of the following statements is most appropriate for patient counseling on nonpharmacologic management of heart failure?

A. Supervised exercise is recommended including aerobic activity and weight lifting B. Contact health care provider if weight increases by more than 3 lb (1.4 kg) in a day or 5 lb (2.3 kg) in a week C. Lower dietary sodium intake to no more than 2 grams per day D. Maintain alcohol intake to no more than 2 drinks per day if diagnosed with

alcohol-induced cardiomyopathy E. Weight should be kept at 15% above ideal body weight to maintain adequate nutrition absorption 15. A 68-year-old woman is admitted for decompensated heart failure, hemodynamic subset IV. Her current medication regimen includes enalapril 10 mg BID, digoxin 0.125 mg Qday, carvedilol 12.5 mg BID, furosemide 80 mg BID, and potassium chloride (K-Dur) 40 mEq (40 mmol) BID. Which of the following is TRUE regarding using milrinone therapy in this patient?

A. Milrinone can interact with her β-blocker therapy due to its β-agonist mechanism B. Effects begin to wear off after 72 hours due to tolerance C. Dose needs to be adjusted in renal dysfunction D. Milrinone is not appropriate to use in subset IV E. a and c ANSWER S 1. C 2. A 3. B 4. B 5. D 6. A 7. B 8. B 9. C 10. A 11. D 12. D 13. A 14. B 15. C

CHAPTER 7. ISCHEMIC HEART DISEASE 1. A 50-year-old, nonsmoking woman has no significant past medical history. A physical exam and laboratory tests reveal the following: Height 5’4” (163 cm), weight 184 lb (83.6 kg), blood pressure 134/80 mm Hg, heart rate 70 beats/min, total cholesterol 184 mg/dL (4.76 mmol/L), LDL cholesterol 110 mg/dL (2.84 mmol/L), HDL cholesterol 46 mg/dL (1.19 mmol/L), and triglycerides 140 mg/dL (1.58 mmol/L). Which of the following are risk factors for IHD in this patient?

A. Age, hypertension, dyslipidemia B. Obesity C. Age, dyslipidemia D. Obesity, hypertension E. Hypertension, dyslipidemia 2. Which of the following is characteristic of an atherosclerotic lesion in a patient with chronic stable angina?

A. Thick fibrous cap B. Thrombosis C. Large lipid core D. Plaque rupture E. Platelet aggregation 3. A 47-year-old man has been prescribed sublingual nitroglycerin tablets for acute relief of angina symptoms. When counseling him on the proper use of sublingual nitroglycerin, which of the following statements is correct regarding when to call 9-1-1?

A. Call 9-1-1 if symptoms have not subsided 5 minutes after administration B. Call 9-1-1 if symptoms have not subsided 30 minutes after administration C. Call 9-1-1 prior to taking nitroglycerin D. Take 1 tablet every 5 minutes as needed for a maximum of three doses; call 9-1-1 if symptoms remain 5 minutes after the third dose E. Take one tablet every 8 to 12 hours; call 9-1-1 if dizziness occurs 4. A 65-year-old postmenopausal woman has a history of hypertension, dyslipidemia, and chronic stable angina. Her current medications are atenolol 50 mg PO daily, simvastatin 40 mg PO at bedtime, and SL nitroglycerin as needed. She has allergies/intolerances to aspirin (angioedema) and enalapril (cough). Which of the following should be added to her drug regimen to reduce her risk for cardiovascular events?

A. clopidogrel B. dipyridamole C. niacin D. nifedipine E. ticagrelor 5. A 45-year-old man diagnosed with hypertension, diabetes, and IHD was recently hospitalized for unstable angina. A coronary angiogram performed during hospitalization revealed single vessel disease not amenable to PCI. He is currently taking carvedilol 6.25 mg PO twice daily, lisinopril 10 mg PO daily, and metformin 500 mg PO twice daily. His blood pressure is 126/78 mm Hg and heart rate is 62 beats/min. A fasting lipid profile shows the following: LDL cholesterol 127 mg/dL (3.28 mmol/L), HDL cholesterol 36 mg/dL (0.93 mmol/L), and triglycerides 157 mg/dL (1.77 mmol/L). He is a current smoker. What additional therapy should be considered to treat this patient’s IHD and lower his risk of ischemic events?

A. Add low-intensity statin (eg, pravastatin 20 mg/day).

B. Add moderate-intensity statin (eg, lovastatin 40 mg/day) C. Add high-intensity statin (eg, atorvastatin 80 mg/day) D. Add prasugrel E. Add varenicline 6. A 53-year-old woman with a history of hypertension and dyslipidemia undergoes a thorough cardiac workup for new onset chest tightness and shortness of breath on exertion. A cardiac catheterization shows no significant coronary artery obstruction. She is believed to have microvascular disease. Her blood pressure is 148/90 mm Hg and heart rate is 74 beats/min. Her current medications include benazepril 10 mg PO daily and simvastatin 40 mg PO hs. What is the most appropriate therapy to manage her angina symptoms?

A. Increase benazepril to 20 mg daily B. Add metoprolol C. Add aspirin D. Add doxazosin E. Add hydralazine 7. What is the recommended treatment duration of dual antiplatelet therapy following implantation of a drug eluting stent?

A. 1 week B. 1 month C. 3 months D. 6 months E. At least 12 months 8. A 60-year-old obese woman with hypertension and dyslipidemia is being started on ranolazine for microvascular angina. Her current medications include aspirin 81 mg/day, lisinopril 10 mg daily, metoprolol 50 mg twice daily, and simvastatin 40 mg/day. A fasting lipid profile reveals the following: LDL cholesterol 65 mg/dL (1.68 mmol/L), HDL cholesterol 54 mg/dL (1.40 mmol/L), and triglycerides 108 mg/dL (1.22 mmol/L). What changes, if any, should be made to her statin regimen?

A. Change to a low-intensity statin (eg, pravastatin 20 mg/day) B. Change to a high-intensity statin (eg, rosuvastatin 20 mg/day.

C. Continue simvastatin 40 mg/day D. Reduce the dose of simvastatin to 20 mg/day E. Increase the dose of simvastatin to 80 mg/day 9. A 58-year-old woman with hypertension and coronary artery disease underwent percutaneous coronary intervention with placement of two drug eluting stents one week ago. Genotyping is done and reveals that she has the CYP2C19 poor metabolizer phenotype. Which of the following is the most appropriate antiplatelet therapy for this patient?

A. Clopidogrel plus aspirin B. Clopidogrel plus prasugrel C. Prasugrel plus aspirin D. High dose aspirin E. Dipyridamole plus aspirin 10. A 56-year-old woman was recently diagnosed with ischemic heart disease. Her current medications include conjugated estrogen 0.625 mg/day, fish oil 1 gm twice daily, aspirin 81 mg daily, atenolol 100 mg daily, lisinopril 20 mg daily, and rosuvastatin 20 mg daily. Which of the

following changes to the patient’s regimen are appropriate?

A. Add clopidogrel B. Add vitamin E C. Change rosuvastatin to pravastatin D. Discontinue conjugated estrogen E. Discontinue fish oil 11. A 60-year-old man with a history of hypertension, diabetes, and dyslipidemia is being treated with lisinopril 10 mg PO daily, simvastatin 20 mg PO daily, and metformin XR PO 500 mg daily. His current blood pressure is 150/88 mm Hg and heart rate is 80 beats/min. He presents with complaints of chest pressure and shortness of breath occurring with exertion. He is diagnosed with variant angina. In addition to sublingual nitroglycerin, what is the most appropriate change to his drug therapy?

A. Add amlodipine B. Add isosorbide mononitrate C. Add metoprolol D. Add ranolazine E. Add thiazide diuretic (eg, chlorthalidone) 12. A 55-year-old man with a history of dyslipidemia and ischemic heart disease had a myocardial infarction 3 months ago. His current medications are aspirin 81 mg PO once daily, metoprolol XL 200 mg PO daily, simvastatin 40 mg PO at bedtime, and sublingual nitroglycerin as needed. He continues to experience occasional symptoms of angina with exertion. His blood pressure is 124/70 mm Hg, and his pulse is 60 beats/min. What is the most appropriate pharmacologic intervention?

A. Taper off metoprolol and start verapamil B. Add isosorbide mononitrate C. Taper off metoprolol and start nifedipine D. Add diltiazem E. Switch metoprolol to atenolol 13. A 63-year-old woman with a past medical history of dyslipidemia and chronic stable angina treated with aspirin 81 mg PO once daily, atenolol 100 mg PO once daily, simvastatin 40 mg PO once daily, and sublingual nitroglycerin as needed. Her angina symptoms are currently well controlled. Her blood pressure is 148/90 mm Hg, and her pulse is 70 beats/min. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?

A. ramipril B. isosorbide dinitrate C. ranolazine D. verapamil E. bupropion 14. A 59-year-old man has a history of hypertension, dyslipidemia, ischemic heart disease, and pulmonary hypertension. He is currently taking aspirin 81 mg PO daily, atorvastatin 40 mg PO daily, ramipril 5 mg PO daily, metoprolol XL 100 mg PO daily, and sildenafil 20 mg PO thrice daily. His blood pressure is 102/76 mm Hg and heart rate is 60 beats/min. He continues to experience ischemic symptoms with minimal exertion. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?

A. Add felodipine

B. Add isosorbide mononitrate C. Add ranolazine D. Decrease metoprolol XL to 50 mg daily E. Increase metoprolol XL to 200 mg daily 15. A 68-year-old man with a history of hypertension, dyslipidemia, and chronic obstructive pulmonary disease was recently diagnosed with chronic stable angina. His current medications are chlorthalidone 25 mg PO daily, atorvastatin 40 mg PO at bedtime, salmeterol one inhalation every 12 hours, fluticasone MDI two puffs twice a day, and albuterol MDI one to two puffs every 4 hours prn. His vital signs are a heart rate of 86 beats/min and blood pressure of 150/90 mm Hg. In addition to sublingual nitroglycerin, what is the most appropriate change to his drug therapy?

A. Start propranolol B. Start ranolazine C. Start amlodipine D. Start isosorbide mononitrate E. Start verapamil ANSWERS 1. B 2. A 3. A 4. A 5. C 6. B 7. E 8. D 9. C 10. D 11. A 12. B 13. A 14. C 15. E

CHAPTER 8. ACUTE CORONARY SYNDROMES 1. A 68-year-old man with a history of ischemic heart disease develops severe chest pain (8/10 on a pain scale) with subsequent ECG depression in leads II, III, and aVF. Serum creatinine is 1.0 mg/dL (88 µmol/L) and troponin I is 3.4 ng/mL (3.4 mcg/L; 3400 ng/L). Which of the following differentiates MI from UA in this patient?

A. Location of the coronary artery blockade B. Quality of chest discomfort C. Severity of coronary artery disease D. Elevated plasma troponin concentration E. ECG changes 2. A 76-year-old man with prior history of coronary artery disease, hypertension, hyperlipidemia and stroke is found to have STEMI and receives a DES. Which dual antiplatelet regimen is most appropriate for him to receive at time of discharge?

A. Aspirin 325 mg and clopidogrel 75 mg daily B. Aspirin 325 mg and ticagrelor 90 mg twice daily C. Aspirin 325 mg and prasugrel 10 mg daily D. Aspirin 81 mg and prasugrel 10 mg daily E. Aspirin 81 mg and ticagrelor 90 mg twice daily 3. An 82-year-old man with STEMI was brought by ambulance to a small community hospital during nighttime (offpeak) hours. The nearest hospital with operating catheterization facilities is a 2.5-hour distance away. Which of the following addresses the appropriate reperfusion for this patient?

A. Fibrinolytic therapy B. An early invasive strategy C. A delayed invasive strategy D. An ischemia-guided approach E. A percutaneous strategy 4. A 54-year-old woman with a CrCl of 20 ml/min (0.33 mL/s) is being treated for ACS by utilizing an ischemiaguided strategy. In addition to aspirin 81 mg daily, which of the following medication combinations is most appropriate in this patient?

A. Clopidogrel, UFH, abciximab B Ticagrelor, enoxaparin, eptifibatide C. Prasugrel, fondaparinux D. Ticagrelor, UFH E. Clopidogrel, bivalirudin, tirofiban 5. A 62-kg (137-lb) man with CrCl of 55 mL/min (0.92 mL/s) is found to have a NSTE-ACS. Troponin levels, drawn at three separate intervals, are all negative. Which of the following is the preferred antithrombotic regimen, in addition to ASA and clopidogrel if an ischemia-guided strategy is chosen?

A. UFH infusion and eptifibatide IV infusion 2 mcg/kg/min B. Enoxaparin 60-mg SC twice daily C. Bivalirudin bolus plus infusion

D. Fondaparinux 2.5 mg SC twice daily E. Bivalirudin bolus plus eptifibatide IV infusion 2 mcg/kg/min 6. A 45-year-old patient with STEMI presents to a hospital without the capacity to perform primary PCI. It has been 2 hours since the onset of chest discomfort with BP mcg/L; 10,800 ng/L). In addition to ASA and IV NTG which early therapy option would be best to start within the first 24 hours to treat symptoms, and prevent long term complications?

A. Clopidogrel, enoxaparin, ramipril, reteplase B. Clopidogrel, enoxaparin, tenecteplase C. Reteplase, UFH, metoprolol, enalapril D. Tenecteplase, bivalirudin, metoprolol E. Alteplase, bivalirudin, lisinopril 7. Which of the following is a contraindication to eplerenone in a patient with heart failure following MI? A. EF less than 40% (0.40) B. Persistent angina C. Angioedema to an ACE inhibitor D. Serum potassium of 5.6 mEq/L (5.6 mmol/L) E. Heart rate less than 60 beats/min 8. Which of the following represents the most appropriate antiplatelet regimen in a 55-year-old patient (weight 70 kg [154 lb]) administered tenecteplase 2 hours previously for STEMI? A. 600-mg clopidogrel loading dose, followed by 75 mg daily B. 300-mg clopidogrel loading dose, followed by 75 mg daily C. No clopidogrel load, followed by 75 mg daily D. 60-mg prasugrel loading dose, followed by 5 mg daily E. 60-mg prasugrel loading dose, followed by 10 mg daily 9. Which of the following patients is most likely to receive the most benefit from a GPI? A. A 47-year-old diabetic man with STEMI undergoing primary PCI receiving ticagrelor B A 68-year-old man with NSTE-ACS undergoing PCI receiving bivalirudin and prasugrel C. A 60-year-old woman with negative troponins, receiving clopidogrel D. An 82-year-old man with positive troponins, receiving ticagrelor E. A 53-year-old woman with positive troponins, receiving heparin 10. Which of the following anticoagulants is preferred for PCI in a patient with a history of heparin-induced thrombocytopenia and ACS? A. UFH B. Enoxaparin C. Bivalirudin D. Fondaparinux E. Dalteparin 11. Which of the following is the correct coagulation monitoring goal for a patient with ACS receiving enoxaparin?

A. Activated partial thromboplastin time (aPTT) 2.0 to 3.0 times control B. aPTT 50 to 70 seconds C. Activated clotting time less than 32 seconds

D. Anti-Xa levels greater than 1.5 IU/mL (1.5 kIU/L) E. No coagulation goal recommended 12. Which of the following best describes a patient with ACS who is a candidate for treatment with amlodipine added to β-blocker?

A. Continued chest discomfort despite nitrates and atenolol B. Acute heart failure while receiving metoprolol C. HR of 80 bpm and BP of 150/90 mm Hg while receiving low-dose metoprolol and enalapril D. Stable chronic obstructive pulmonary disease receiving a low-dose atenolol E. Contraindication to metoprolol receiving diltiazem 13. In patients undergoing coronary artery bypass graft (CABG) surgery, which of the following is a preferred antithrombotic strategy in addition to aspirin?

A. UFH, discontinue prasugrel 5 days prior to surgery B. Eptifibatide, discontinue clopidogrel 7 days prior to surgery C. UFH, discontinue ticagrelor 5 days prior to surgery D. Fondaparinux, discontinue clopidogrel 5 days prior to surgery E. Bivalirudin, discontinue prasugrel 24 hours prior to surgery 14. Which anticoagulant regimen would be most appropriate for a 76-year-old woman (weight 64 kg [141 lb]) with NSTE-ACS with an estimated CrCl of 50 ml/min (0.83 mL/s) undergoing PCI? A. UFH 3800 unit bolus, followed by 800 units/hour B. Enoxaparin 140-mg SC twice daily C. Fondaparinux 2.5-mg SC daily D. Bivalirudin 24.5-mg bolus, followed by 35 mg/kg/hour infusion E. No anticoagulant needed 15. Secondary interventions proven to reduce risk after ACS include all the following except: A. Pneumococcal vaccination in age older than 65 years B. Cardiac rehabilitation C. Nonsteroidal anti-inflammatory agents D. Cholesterol management E. Dual antiplatelet therapy ANSWERS 1. D 2. E 3. A 4. D 5. B 6. B 7. D 8. B 9. E 10. C 11. E 12. A 13. C 14. A 15. C

CHAPTER 9. ARRHYTHMIAS 1. Where in the heart is the atrioventricular (AV) node located?

A. High right atrium B. Low right atrium C. Junction of the atria and ventricles D. High right ventricle 2. Which phase of the ventricular action potential is most likely to be altered by a sodium channel blocking drug?

A. Phase 0 B. Phase 1 C. Phase 2 D. Phase 3 3. Which one of the following ECG intervals or durations corresponds most closely to phase 3 on the ventricular action potential?

A. PR interval B. QRS complex C. QT interval D. T wave 4. Which one of the following arrhythmias increases the risk of stroke two- to sevenfold?

A. Atrial fibrillation (AF) B. Paroxysmal supraventricular tachycardia (PSVT) C. Ventricular premature depolarizations (VPDs) Arrhythmias 2 D. Ventricular tachycardia (VT) 5. Which one of the following most accurately describes the mechanism of AF? A. Increased automaticity in the atria, triggering a single atrial reentrant circuit B. Increased automaticity in the atria, triggering multiple simultaneous atrial reentrant circuits C. Increased automaticity in the pulmonary veins, triggering a single atrial reentrant circuit D. Increased automaticity in the pulmonary veins, triggering multiple simultaneous atrial reentrant circuits 6. Which one of the following most accurately describes the mechanism of PSVT? A. A single reentrant circuit in the atrium B. Multiple simultaneous reentrant circuits in the atria C. Reentry involving the AV node D. Reentry occurring in the ventricles 7. Which of the following is the common myocardial pathology associated with hypertension, ischemic heart disease, heart failure, and valve disease that promotes the electrophysiological alterations that result in atrial fibrillation?

A. Fibrosis of the SA node B. Fibrosis of the AV node C. Left atrial hypertrophy D. Left ventricular hypertrophy 8. A 66-year-old man presents to the ED complaining of palpitations, dizziness, lightheadedness, and near-syncope. Past medical history is significant for hypertension for 10 years.

ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline.

Arrhythmias 3

His blood pressure in the ED is 99/63 mm Hg, and his heart rate is 125 beats/min. Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg D. Metoprolol 5 mg IV administered over 2 minutes 9. A 58-year-old woman presents to the ED complaining of dizziness. ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline. She has a past medical history of hypertension and heart failure (left ventricular ejection fraction 30% [0.30]). Her blood pressure in the ED is 105/65 mm Hg, and her heart rate is 145 beats/min. Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg D. Diltiazem 0.25 mg/kg IV bolus followed by 5 mg/hour IV continuous infusion 10. A 58-year-old woman presents to the ED complaining of dizziness and crushing chest pain.

ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline.

She has a past medical history of hypertension and heart failure (left ventricular ejection fraction 25% [0.25]). Her blood pressure in the ED is 85/65 mm Hg, and her heart rate is 160 beats/min.

Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg Arrhythmias 4 D. Diltiazem 0.25 mg/kg IV bolus followed by 5 mg/hour IV continuous infusion 11. A 56-year-old woman has paroxysmal atrial fibrillation and a history of hypertension. A recent exercise–stress test revealed no chest pain or evidence of ischemic changes on ECG, and she has no evidence of heart failure. She is currently receiving the maximum dose of the appropriate drug for ventricular rate control; however, she continues to complain of palpitations and dizziness approximately twice weekly, and these episodes last for approximately 3 to 4 hours. Which one of the following is the most appropriate therapy at this time?

A. Amiodarone B. Catheter ablation C. Procainamide D. No additional drug therapy is indicated 12. A 65-year-old man has a past medical history of hypertension and coronary artery disease, for which he is currently receiving hydrochlorothiazide 25 mg daily, enalapril 10 mg twice daily, and amlodipine 10 mg daily. He presents to his physician complaining of intermittent palpitations and light-headedness. An ambulatory ECG reveals 6 to 10 ventricular premature depolarizations per hour, intermittent couplets, and a heart rate of 82 beats/min. Which one of the following is the most appropriate course of action?

A. Amiodarone 400 mg daily B. Flecainide 150 mg every 12 hours C. Metoprolol 50 mg twice daily D. No treatment should be initiated Arrhythmias 5

13. A 65-year-old man was admitted to the cardiac intensive care unit today with an exacerbation of heart failure due to a hypertensive crisis. Echocardiogram reveals a left ventricular ejection fraction of 35% [0.35]. He also has a past history of hypertension and dyslipidemia. While in the cardiac intensive care unit, the patient complains of palpitations and light-headedness, and his blood pressure is 105/70 mm Hg. ECG reveals ventricular tachycardia at a rate of 125 beats/min, which lasts longer than 30 seconds and does not terminate on its own. Which one of the following is the most appropriate treatment?

A. No treatment is necessary B. Intravenous amiodarone C. Intravenous procainamide D. Immediate direct current cardioversion 14. Which one of the following best describes the role of drug therapy in patients with ventricular fibrillation?

A. Drugs cause termination of ventricular fibrillation and return of spontaneous circulation B. Drugs convert ventricular fibrillation into ventricular tachycardia, which can then be terminated by direct current cardioversion C. Drugs improve the likelihood of success of electrical defibrillation, but alone do not terminate ventricular fibrillation D. Drugs remove the need for cardiopulmonary resuscitation 15. Which one of the following is a risk factor for drug-induced torsades de pointes?

A. Age older than 55 years B. Female sex C. Hypertension Arrhythmias 6 D. Chronic obstructive pulmonary disease Arrhythmias 7 ANSWERS 1. B 2. A 3. D 4. A 5.

D 6. C 7. C 8. D 9. C 10. A 11.

B 12. C 13. B 14. C 15. B

CHAPTER 10. VENOUS THROMBOEMBOLISM 1. A 42-year-old Asian woman just returned from vacation in Ethiopia. She presents to the emergency department (ED) with shortness of breath and is subsequently diagnosed with pulmonary embolism (PE). She weighs 45 kg (100 lb; body mass index [BMI] 19 kg/m2 ).

Medications on admission include: estrogen-containing oral contraceptives, ibuprofen (prn), and ginseng tablets. She smokes one pack of cigarettes per day and drinks alcoholic beverages three to four times per week. Her sister died (age 41) of PE 4 years ago. The factors that most likely predisposed this patient for venous thromboembolism (VTE) include: A. Age, ibuprofen use, smoking B. Female sex, foreign travel, weight C. Asian ancestry, ginseng use, regular alcohol consumption D. Recent immobility, estrogen use, inherited disorder of hypercoagulability 2. The following is a recommended risk assessment model for estimating VTE risk specific to hospitalized medical patients: A. The CAPRINI Risk Prediction Score B. The WELLS Risk Prediction Score C. The PADUA Risk Prediction Score D. The PESCI Risk Prediction Score 3. Which VTE prevention strategy is the most appropriate for a 61-year-old patient who is undergoing a knee replacement surgery tomorrow, weighs 94 kg (207 lb), has an estimated creatinine clearance of 58 mL/min (0.97 mL/s), and has no known contraindications to anticoagulant drugs?

A. Rivaroxaban 15 mg given orally every 12 hours B. Fondaparinux 2.5 mg given SC every 24 hours C. Aspirin 81 mg given orally every 24 hours D. Early ambulation combined with graduated compression stockings (GCS) 4. Which of the following prophylactic strategies is most appropriate for a 62-year-old patient who is admitted to hospital with left-sided paralysis following an acute hemorrhagic stroke?

A. GCS B. Early ambulation C. Inferior vena cava (IVC) filter D. Intermittent pneumatic compression (IPC) 5. Which of the following anticoagulants would be an appropriate option as single therapy for the initial acute-phase treatment of patients diagnosed with acute lower extremity DVT? A. Apixaban B. Dabigatran C. Desirudin D. Warfarin 6. A patient is diagnosed with a left lower extremity deep vein thrombosis (DVT) and is initiated on intravenous unfractionated heparin (UFH) and warfarin therapy concurrently. How long should UFH and warfarin be overlapped?

A. For at least 4 days as long as the aPTT is greater than 50 seconds for 3 days B. For at least 5 days and only after the INR is greater than 2 C. For 7 days or until the INR is greater than 2.5 D. UFH can be discontinued once the aPTT is greater than 75 seconds, regardless of the length

of therapy 7. A patient had hip replacement surgery 2 weeks ago. He now presents with a right lower extremity DVT. He is admitted to the hospital for anticoagulation treatment. Following surgery, he received dalteparin 5000 units SC daily for 10 days. It was noted that his platelet count dropped from 390 × 103 /mm3 (390 × 109 /L) following the surgery to 160 × 103 /mm3 (160 × 109 /L) on the day of discharge. He has no previous history of thromboembolic events. Which of the following treatment options would be the best recommendation in this patient’s case?

A. Warfarin should be started now and continued for 6 months.

B. Unfractionated heparin (UFH) and warfarin should be started now and continued for 3 months.

C. Enoxaparin should be started now and the patient should be evaluated for thrombotic thrombocytopenic purpura.

D. Fondaparinux should be started now and the patient should be evaluated for heparin-induced thrombocytopenia.

8. The following statement is TRUE regarding drug interactions with the novel oral anticoagulants in patients with normal renal function: A. Avoid use of Rivaroxaban with combined strong CYP3A4 inhibitors and P-glycoprotein inhibitors B. Avoid use of Rivaroxaban with combined moderate CYP3A4 inhibitors and P-glycoprotein inhibitors C. Avoid use of Dabigatran with combined strong CYP3A4 inhibitors and P-glycoprotein inhibitors D. Avoid use of Dabigatran with combined moderate CYP3A4 inhibitors and P-glycoprotein inhibitors 9. In patients presenting with acute PE, thrombolytic therapy is recommended if: A. The patient has palpitations and hemoptysis B. Started within 4 hours of when patient first experiences symptoms C. The patient appears to be in shock (eg, systolic blood pressure < 90 mm Hg) D. The patient has elevated D-dimer concentration > 1000 ng/mL (1000 mcg/L) 10. A 47-year-old Caucasian man is being treated with warfarin 5 mg daily for PE diagnosed 6 weeks ago. Today, he presents to clinic for an INR check and is found to have an INR of 11.7.

His CBC is normal, and he has no complaints or signs/symptoms of bleeding. You take the following approach to manage his INR: A. Hold his warfarin until INR < 2 and then resume warfarin at 5 mg daily B. Give vitamin K 2.5 mg PO and hold his warfarin until INR < 2, then resume warfarin at 5 mg daily C. Give Vitamin K 2.5 mg IV and hold his warfarin until INR < 2, then resume warfarin at 5 mg daily D. Give Vitamin K 10 mg IV and admit patient to the hospital until INR < 2, then resume warfarin at 5 mg daily

11. An 82-year-old man was admitted to hospital and recently diagnosed with acute DVT. Treatment has been initiated with intravenous UFH. Twelve hours later, his aPTT is greater than 150 seconds and he is noted to have bright red blood per rectum. Which of the following is the best course of action in the management of this patient?

A. Hold heparin therapy for 60 minutes and then reduce infusion rate by 20% B. Hold heparin therapy and give vitamin K via slow IV infusion C. Hold heparin therapy and give recombinant factor VII D. Hold heparin therapy and give protamine sulfate via slow IV infusion 12. A 29-year-old woman is admitted for acute DVT. She reports that she had a PE last year, 2 weeks following the birth of her daughter. She was treated with enoxaparin and warfarin for 3 months. Her symptoms completely resolved. What is the recommended duration of anticoagulation therapy in this case now?

A. 3 months and then reevaluate risks and benefits B. 6 months and then discontinue C. 12 months and then reduce the dose by 50% for an additional 2 years D. Lifelong 13. Which of the following is the most appropriate treatment for a pregnant patient (first trimester) with a newly diagnosed acute PE? A. Enoxaparin SC 1 mg/kg twice daily B. Fondaparinux SC 2.5 mg daily C. UFH SC 333 units/kg followed by 250 units/kg twice daily D. Warfarin dose adjusted to achieve an INR goal of 2 to 3 14. Which of the following is the most appropriate initial treatment option in a patient with an acute DVT and a documented history of heparin-induced thrombocytopenia (HIT) 7 months ago but no history of prior VTE? A. Clopidogrel B. Dabigatran C. Dalteparin D. Warfarin 15. Which of the following statements accurately describes a potential advantage of the direct oral anticoagulants (apixaban, dabigatran, rivaroxaban) over warfarin in the treatment of VTE? A. More patients are able to tolerate the direct oral anticoagulants than warfarin.

B. Adherence with direct oral anticoagulants is 20%–30% better than adherence to warfarin.

C. When bleeding occurs, direct oral anticoagulants are more easily reversed than warfarin.

D. The onset of anticoagulant activity is more rapid with direct oral anticoagulants when compared to warfarin.

ANSWERS 1. D 2. C 3. B 4. D 5. A 6. B 7. D 8. A 9. C

10. B 11. D 12. A 13. A 14. B 15. D CHAPTER 11. STROKE 1. Which one of the following is true regarding the use of heparin and low–molecular weight heparins (LMWHs) in acute ischemic stroke?

A. Should be used emergently in all patients B. Increase the risk of hemorrhagic conversion C. Should be administered preferentially instead of IV alteplase D. Improve outcomes in most patients if dosed properly E. Should be used in the acute setting if IV alteplase is not an option 2. A 62-year-old Hispanic woman had a stroke 2 years ago. She presents to clinic complaining of several episodes of “not being able to get the words out” over the past 2 days. She has had gastrointestinal upset with ASA in the past and is currently being treated for peripheral arterial disease and arthritis. Which one of the following medications would be the most appropriate for stroke prevention in this patient?

A. Ticlopidine 250 mg twice daily B. Clopidogrel 75 mg daily C. ASA and ER dipyridamole 25/200 mg twice daily D. ASA 50 mg daily E. No treatment is necessary 3. A 64-year-old African American woman with a history of ischemic stroke several months ago was previously prescribed ASA 325 mg daily, but developed an allergy to ASA and stopped taking it 2 weeks ago. Which one of the following is the most appropriate recommendation at this time?

A. Make no change at this time B. Change the ASA dose from 325 mg daily to 50 mg daily C. Discontinue ASA and begin clopidogrel 75 mg daily D. Restart ASA 325 mg every other day E. Discontinue ASA and begin ticlopidine 250 mg twice daily 4. Which one of the following is the most important diagnostic test for ischemic and hemorrhagic stroke?

A. Carotid Doppler studies B. Transthoracic echocardiogram C. Transcranial Doppler D. CT scan of the head E. MRI of the neck 5. A 68-year-old male patient is admitted to the acute stroke unit for IV alteplase approximately 2.5 hours after his symptoms began. His blood pressure is 198/115 mm Hg on admission to the acute stroke unit. Which one of the following is the appropriate treatment at this time?

A. Administer IV alteplase immediately using recommended dosing B. Administer labetalol 10 mg IV and recheck BP in 10 minutes C. Hold IV alteplase and recheck BP in 30 minutes

D. Hold IV alteplase and complete a full neurologic examination E. Hold IV alteplase as patient is not an appropriate candidate for treatment 6. A 64-year-old African American man is diagnosed with ischemic stroke. He was taking ASA 81 mg daily at the time of his ischemic stroke and claims he never missed a dose. Which one of the following recommendations would be most appropriate for prevention of a recurrent stroke?

A. Continue aspirin; however, increase the dose to 325 mg po BID B. Continue his current aspirin regimen C. Discontinue aspirin and start clopidogrel 75 mg po daily D. Discontinue aspirin and start dipyridamole 100 mg po QID E. Discontinue aspirin and start warfarin with an INR goal of 2–3 7. A 54-year-old white woman has diabetes, hypertension and dyslipidemia. She gets little activity during her working hours as an administrative assistant and eats a normal diet. Which one of the following represents her combination of risk factors for stroke?

A. Inactivity, age, race, poor diet B. Hypertension, dyslipidemia C. Hypertension, dyslipidemia, race, gender D. Hypertension, dyslipidemia, diabetes, inactivity E. Hypertension, diabetes, gender 8. Carotid endarterectomy is recommended in which one of the following situations?

A.57-year-old man with symptomatic carotid artery occlusion of 47% B.73-year-old man with recent stroke and symptomatic carotid artery occlusion of 70% C.83-year-old woman with asymptomatic carotid artery occlusion of 65% D.62-year-old woman with asymptomatic carotid artery occlusion of 47% E.78-year-old man with high operative risk and symptomatic carotid artery occlusion of 65% 9. Recombinant factor VIIa has been studied in clinical trials of patients with ICH. Which one of the following is true regarding this agent?

A. Shown to increase mortality at 90 days B. Shown to decrease overall functioning at 90 days C. Increased the incidence of thromboembolic events D. Improved patient survival E. Improved functional outcome 10.Which of the following are risk factors for both ischemic stroke and hemorrhagic stroke?

A. Hypertension, cigarette smoking, male gender B. Cocaine use, arteriovenous malformation C. Trauma, hypertension, cigarette smoking D. Male gender, trauma E. Cocaine use, cigarette smoking, trauma 11.An 84-year-old woman with a history of TIAs and ischemic stroke experiences difficulty speaking that lasts over 2 hours. She presents acutely to the ED 3.5 hours after her symptoms started. She is currently on aspirin 81 mg daily. Which one of the following is a contraindication to alteplase therapy for this patient?

A. Symptoms started greater than 3 hours ago B. History of TIAs C. History of aspirin use D. Age more than 80 years old E. History of previous ischemic stroke

12. Of the following, who would have the highest risk for an ischemic stroke?

A. 35-year-old pregnant woman B. 69-year-old Japanese man C. 72-year-old Caucasian woman D. 52-year-old African American woman E. 80-year-old African American man 13.A patient is brought in to the emergency department with suspected ischemic stroke. His symptoms started approximately 3 hours ago. Which one of the following is true regarding the use of alteplase in this patient?

A. It is too late to administer alteplase as the first hour after symptom onset is past.

B. Alteplase would need to be administered within the next 1.5 hours if the patient is found to be a candidate for treatment.

C. Alteplase must be administered within 6 hours of symptom onset.

D. Alteplase must be administered within 12 hours of symptom onset.

E. Alteplase is only used within the first 90 minutes after symptom onset.

14. A 63-year-old African American woman is being discharged after a stroke. She has a history of hypertension, dyslipidemia and smoking. Which one of the following discharge plans is appropriate?

A. Blood pressure control, statin therapy, referral to smoking cessation program, aspirin B. Blood pressure control, statin therapy C. Statin therapy, referral to smoking cessation program, aspirin D. Referral to a smoking cessation program E. Blood pressure control 15.Vasospasm is a complication of subarachnoid hemorrhage. Which one of the following is the drug of choice to decrease morbidity secondary to vasospasm?

A. Nifedipine B. Aminocaproic acid C. Nimodipine D. Diltiazem E. Labetalol ANSWERS 1. B 2.B 3. C 4. D 5. B 6. C 7. D 8. B 9. C 10.A 11.D 12.E 13.B 14. A 15.C

CHAPTER 12. DYSLIPIDEMIAS 1. A 38-year-old woman presents to your clinic today with new onset chest pain that occurs after walking a few blocks. Her father had a heart attack at age 40. Her diet is low in saturated fats and cholesterol. The patient is otherwise healthy and does not smoke. Her lipid panel today is: total cholesterol 350 mg/dL (9.05 mmol/L), HDL cholesterol 40 mg/dL (1.03 mmol/L), and triglycerides 120 mg/dL (1.36 mmol/L). What is her non-HDL cholesterol and LDL cholesterol?

A. 310 mg/dL (8.02 mmol/L) and 286 mg/dL (7.40 mmol/L) B. 390 mg/dL (10.09 mmol/L) and 334 mg/dL (8.64 mmol/L) C. 310 mg/dL (8.02 mmol/L) and unable to calculate D. 350 mg/dL (9.05 mmol/L) and 286 mg/dL (7.40 mmol/L) E. 310 mg/dL (8.02 mmol/L) and 230 mg/dL (5.95 mmol/L) 2. What is this patient’s primary target for intervention?

A. Triglycerides B. LDL cholesterol C. Non-HDL cholesterol D. HDL cholesterol E. Non-HDL and LDL cholesterol 3. What is your assessment of this patient’s lipid disorder?

A. She has hypercholesterolemia and is likely polygenic B. She has hypercholesterolemia and heterozygous familial hypercholesterolemia C. She has hypertriglyceridemia D. She has a combined dyslipidemia E. She has homozygous familial hypercholesterolemia 4. According to the ACC/AHA guidelines, what intervention would be most appropriate for this patient?

A. Start simvastatin 80 mg daily B. Start prescription omega-3 fatty acid esters 4 g daily C. Start ezetimibe 10 mg daily D. Start a high-intensity statin E. Start gemfibrozil 600 mg twice daily 5. The patient returns to clinic after 4 months for follow-up and post percutaneous coronary intervention of her left anterior descending coronary artery with the following lipid panel: total cholesterol 230 mg/dL (5.95 mmol/L); triglycerides 100 mg/dL (1.13 mmol/L); HDL cholesterol 44 mg/dL (1.14 mmol/L); LDL cholesterol 166 mg/dL (4.29 mmol/L). According to the NLA guidelines, what are the non-HDL cholesterol and LDL cholesterol goals for this patient?

A. Less than 160 mg/dL (4.14 mmol/L) and less than 130 mg/dL (3.36 mmol/L) B. Less than 130 mg/dL (3.36 mmol/L) and less than 100 mg/dL (2.59 mmol/L) C. Less than 100 mg/dL (2.59 mmol/L) and less than 70 mg/dL (1.81 mmol/L) D. At least a 50% reduction in atherogenic cholesterol E. Cholesterol goals are not recommended 6. What would be the next appropriate intervention for this patient?

A. Lomitapide 5 mg daily B. Fenofibrate 160 mg daily C. Ezetimibe 10 mg daily D. Prescription omega-3 fatty acid esters E. Change to atorvastatin 20 mg daily

7. Which type of therapy would be most appropriate for a 58-year-old woman with type 2 DM, evidence of end-organ damage and total cholesterol 210 mg/dL (5.43 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), triglycerides 850 mg/dL (9.61 mmol/L), and non-HDL cholesterol 165 mg/dL (4.27 mmol/L)?

A. Atorvastatin 10 mg daily B. Pravastatin 20 mg daily C. Cholestyramine one scoop twice daily D. Gemfibrozil 600 mg twice daily E. Alcohol and carbohydrate restriction 8. According to the NLA, which risk category does this patient best fit?

A. Very High Risk B. High Risk C. Moderate Risk D. Low Risk E. Need more information to determine 9. Which of the following is not a secondary cause of dyslipidemia?

A. Hypothyroidism B. Hyperthyroidism C. Diabetes D. Renal failure E. Protease inhibitors 10. For which patients would you consider calculating a quantitative risk score?

A. Patients with three major ASCVD risk factors B. Patients with preexisting ASCVD C. Patients with HDL exceeding 50 mg/dL (1.29 mmol/L) D. Patients with two major ASCVD risk factors and not very high-risk or high-risk conditions.

E. Patients with triglycerides exceeding 500 mg/dL (5.65 mmol/L) 11. A patient diagnosed with metabolic syndrome and CHD is taking atorvastatin 20 mg daily.

His non-HDL cholesterol is 118 mg/dL (3.05 mmol/L) and LDL cholesterol is 78 mg/dL (2.02 mmol/L). His primary care physician has tried to increase atorvastatin to 40 mg; however, the patient complains of muscle pain and weakness shortly after the dose is escalated. His triglycerides are currently 198 mg/dL (2.24 mmol/L), HDL cholesterol is 39 mg/dL (1.01 mmol/L), and total cholesterol is 157 mg/dL (4.06 mmol/L). What would be the most appropriate intervention?

A. Continue current therapy and monitor his progress B. Add ezetimibe 10 mg daily C. Add gemfibrozil 600 mg twice daily D. Add niacin ER 500 mg at bedtime E. Switch to pravastatin 20 mg at bedtime 12. Which lipoprotein particle is not considered to be atherogenic A. LDL B. IDL C. VLDL D. Small-dense LDL E. HDL 13. A 56-year-old woman who smokes two packs of cigarettes per day is admitted to the

emergency room with severe left-sided chest pain and numbness down her left arm. She is diagnosed with acute coronary syndrome and undergoes percutaneous coronary intervention of her right coronary artery. Her lipid profile obtained in the emergency room reveals the following: total cholesterol 229 mg/dL (5.92 mmol/L), non-HDL cholesterol 181 mg/dL (4.68 mmol/L), LDL cholesterol 152 mg/dL (3.93 mmol/L), HDL cholesterol 48 mg/dL (1.24 mmol/L), and triglycerides 147 mg/dL (1.66 mmol/L). What would be the most appropriate initial therapy?

A. Mipomersen 200 mg once weekly B. Pravastatin 40 mg daily C. Atorvastatin 80 mg daily D. Rosuvastatin 20 mg daily E. Pitavastatin 4 mg daily 14. Which side effect can be caused by statin therapy?

A. Fatty liver B. New onset diabetes C. Gout D. Flushing E. None of the above 15. Choose the best answer that explains the difference in liver toxicity between IR niacin and sustained-release niacin.

A. Sustained-release preparations result in higher blood levels of nicotinuric acid B. Sustained-release preparations quickly saturate the low-affinity, high capacity metabolic pathway C. Sustained-release preparations have a slow absorption rate allowing more niacin to be metabolized by the amidation pathway D. Sustained-release niacin only causes liver toxicity when used in doses exceeding 4 g E. None of the above ANSWERS 1. A 2. E 3. B 4. D 5. C 6. C 7. D 8. A 9. B 10. D 11. B 12. E 13. E 14. B 15. C

CHAPTER 13. HYPOVOLEMIC SHOCK 1. Which of the following is the key goal of therapy in the first hour of hypovolemic shock?

A. MAP greater than 90 mm Hg B. SBP greater than 90 mm Hg C. SBP greater than 60 mm Hg D. Hematocrit is at least 30% (0.30) using transfusions E. Normalization of urine output and base deficit 2. What should be the first pharmacologic/fluid intervention in an adult patient with an SBP less than 90 mm Hg or MAP less than 60 mm Hg? A. Administer 2 units of Type O PRBCs B. Administer 1000 to 2000 mL of 0.9% NaCl or LR C. Begin dopamine or norepinephrine infusion D. Administer 5% albumin infusion E. Begin stress ulcer prophylaxis and antithrombotic therapy 3. What is the primary reason that hetastarch products are no longer recommended for initial resuscitation in hypovolemic shock?

A. Crystalloids clearly result in lower mortality B. Hetastarch has a higher risk of infections C. Hetastarch is more effective but avoided due to high cost D. Hetastarch is associated with acute kidney injury E. Crystalloids require a smaller administration volume 4. What potential adverse event requires caution if using dextran in hemorrhagic hypovolemic shock?

A. Hemolytic reaction B. Risk of infection from contamination C. Drug-induced pancreatitis D. Inhibition of the coagulation cascade E. Electrolyte abnormalities 5. What are some primary indications for whole blood/PRBC administration in the acute resuscitation phase in adults?

A. All patients should receive 2 units of Type O PRBCs B. Blood losses exceeding 750 mL or ongoing bleeding C. Blood losses exceeding 1500 mL or ongoing bleeding D. Administer in patients with a PA catheter and vasopressors E. Administer in all patients requiring mechanical ventilation 6. When should a norepinephrine infusion be started?

A. Only in patients with hemorrhagic hypovolemic shock B. In all patients with hypovolemic shock C. If patient’s BP responds well to the initial fluid bolus D. In all patients who require Type O PRBCs E. If there is evidence of cerebral or myocardial ischemia 7. What is the reason why norepinephrine is generally recommended as the first choice vasopressor over dopamine or epinephrine in patients with hypovolemic shock?

A. Lower mortality B. Lower costs C. Fewer tachyarrhythmias

D. More inotropic activity E. More powerful BP elevation 8. A patient with a history of severe heart failure is in hypovolemic shock from massive gastrointestinal fluid losses. The patient’s BP is improving with fluids and dopamine 25 mcg/kg/min, but his cardiac index is 1.8 L/min/m2 (0.03 L/s/m 2 ) and PAOP is 18 mm Hg. What should be done to improve cardiac index?

A. Administer 2 L of normal saline over 1 hour B. Start dobutamine infusion C. Administer 5 mL/kg of hetastarch D. Administer 2 units of Type O PRBCs E. Intubate patient and start mechanical ventilation 9. A patient with a history of type 2 diabetes, uncontrolled hypertension, and rheumatoid arthritis is in hypovolemic shock from bleeding after a lawnmower accident. Home medications include metoprolol 100 mg twice daily, hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, metformin 500 mg twice daily, and prednisone 20 mg daily.

Which of the following drug-related issues is most likely to contribute to hypotension over the next few days?

A. Long-acting antihypertensive effects of metoprolol B. Long-acting antihypertensive effects of amlodipine C. Hypovolemia exacerbated by previous hydrochlorothiazide use D. The risk of metformin-associated metabolic acidosis E. Adrenal suppression from using systemic prednisone 10. Which of the following is an important goal of therapy at 24 hours after the onset of hypovolemic shock that may improve mortality?

A. Normalization of blood pressure and heart rate B. Normalization of urine output and base deficit C. Discontinuation of vasopressors and inotropes D. Ensuring the hematocrit is at least 30% (0.30) E. Normalization of body and skin temperature 11. What should be done for a patient who is still hypotensive (MAP 50 mm Hg) after an initial bolus of 2000 mL of LR, 2 units of PRBCs (current hematocrit 32% [0.32]), and norepinephrine at 2 mcg/min?

A. Administer 1000 to 2000 mL of NS or LR B. Increase norepinephrine to 4 mcg/min C. Add dobutamine at 10 mcg/kg/min D. Give 2 more units of PRBCs E. Begin stress ulcer prophylaxis and antithrombotic therapy 12. A patient who presented with hypovolemic shock and confusion from severe vomiting and diarrhea has received a total of four liters of LR over the past 3 hours. Her mental status is back to normal and her current vital signs are BP 95/65 mm Hg, HR 93, RR 14.

What is the most appropriate treatment at this time?

A. Administer 1000 to 2000 mL of IV lactated Ringer B. Begin norepinephrine IV infusion at 2 mcg/min

C. Continue to monitor, no fluids or vasopressors needed D. Administer 5 to 10 mL/kg of Type O negative PRBCs E. Place a pulmonary artery catheter for more intensive monitoring 13. A patient with hemorrhagic hypovolemic shock has responded well to fluid resuscitation and no longer has signs of active bleeding. What is the most appropriate threshold for administering a transfusion of PRBCs at this time?

A. Hemoglobin less than 7 g/dL (70 g/L or 4.34 mmol/L) B. Hemoglobin less than 8.5 g/dL (85 g/L or 5.3 mmol/L) C. Hemoglobin less than 10 g/dL (100 g/L or 6.2 mmol/L) D. Platelets less than 20 × 103 /mm3 (20 x 109 /L) E. If the patient has ongoing organ dysfunction 14. Which statement is true regarding the use of recombinant activated factor VII (rFVIIa) for hemorrhagic hypovolemic shock?

A. Provides clinical benefits if given within 3 hours of the onset of bleeding B. Should not be used because of concerns about cost and thromboembolic events C. Should only be used in patients who require blood transfusions D. Decreases mortality in patients with, or at risk of, significant bleeding E. Should not be used because of increased mortality, especially in older patients 15. Based on a recent clinical trial, which of the following represents the most appropriate use of tranexamic acid as an adjunctive antifibrinolytic agent in hypovolemic shock?

A. All trauma patients regardless of blood loss and timing B. Within 3 hours in all trauma patients with shock C. In all trauma patients who require blood transfusions D. In all trauma patients with significant bleeding E. Within 3 hours in trauma patients with significant bleeding ANSWERS 1. B 2. B 3. D 4. D 5. C 6. E 7. C 8. B 9. E 10. B 11. A 12. C 13. A 14. B 15. E

CHAPTER 14. ASTHMA 1. Which one of the following is a common symptom of chronic asthma?

A. Cyanosis B. Wheezing C. Hypoxemia D. Edema E. Nasal congestion 2. Which one of the following comorbid conditions may worsen asthma control?

A. Obesity B. Hypertension C. Diabetes D. Hyperlipidemia E. Otitis media 3. Which one of the following situations indicates controlled asthma?

A. Using one canister of albuterol each month B. Exercising with SABA use before the activity C. Waking at night only three times a week with a cough D. Visiting the emergency department one time in the past year for asthma E. Missing school once a month because of asthma symptoms 4. An 11-year-old boy with asthma reports using albuterol once or twice in the past month. He is able to play soccer well by using albuterol before games. He denies waking at night, and his last spirometry reading FEV1/FVC was 88% (0.88). What additional asthma treatment is appropriate for this patient?

A. Montelukast B. Salmeterol C. Prednisone D. Ciclesonide E. No additional medication needed 5. Which one of the following educational strategies may help an asthma patient with worsening asthma from cats, strong odors, gastroesophageal reflux disease (GERD), cold air, and upper respiratory infections?

A. Have pets groomed monthly B. Use bleach to clean the bathroom once a week C. Take medication for GERD as needed for symptoms D. Wear a scarf to cover the nose and mouth during cold winter months E. Obtain an influenza vaccine after the age of 65 6. The optimal delivery method of albuterol for a typical 16-year-old asthma patient is: A. Nebulization B. Oral solution C. MDI with a valved-holding chamber and mask D. MDI E. Oral tablet 7. Which one of the following medications requires monitoring of growth in children?

A. Montelukast B. Zileuton C. Theophylline

D. Fluticasone E. Omalizumab 8. During pregnancy, which one of the following medications is preferred as the longterm control medication?

A. Budesonide B. Theophylline C. Montelukast D. Omalizumab E. Zafirlukast 9. Dosing for omalizumab is based on which of the following criteria?

A. Age B. Renal function C. Baseline IgE levels D. Liver function E. Baseline severity of asthma 10. A 25-year-old woman is taking levalbuterol and formoterol for her poorly controlled asthma. Which one of the following therapeutic recommendations is most appropriate for her?

A. Switch formoterol to tiotropium B. Add fluticasone DPI to her regimen C. Switch formoterol alone to budesonide/formoterol MDI D. Add montelukast to her regimen E. Discontinue levalbuterol and continue formoterol 11. Proper use of inhaled corticosteroids includes: A. Priming the inhaler before each use B. Checking to see if the inhaler is empty by shaking the inhaler C. Discontinuing inhaled corticosteroids while oral corticosteroids are being used D. Waiting to use the medication until an acute asthma exacerbation occurs E. Rinsing the mouth after each use 12. Which one of the following medications may worsen asthma control?

A. Carvedilol B. Furosemide C. Losartan D. Varenicline E. Atorvastatin 13. A 15-year-old boy with a diagnosis of moderate, persistent asthma returns to his physician’s office. He has had no exacerbations in the last 2 years, and he has no complaints about his current regimen of fluticasone 220 mcg, 1 puff twice daily, montelukast 10 mg daily, and albuterol as needed. After 3 months of well-controlled asthma, which one of the following therapeutic recommendations is recommended?

A. Discontinue albuterol B. Lower the dose of fluticasone C. Switch fluticasone to salmeterol D. Lower the dose of montelukast E. Switch albuterol to levalbuterol 14. A 21-year-old woman with asthma calls the clinic very short of breath and wondering

if she should initiate prednisone. She has been using her albuterol via nebulization every 2 hours with minimal relief of her wheezing and shortness of breath. Her peak flow is 180 L/min and her personal best is 400 L/min. What therapeutic recommendation is best in this situation?

A. Stop all medications and call 9-1-1 B. Start prednisone at home and continue albuterol nebulization until her peak flow is greater than 70% of her personal best C. Double the dose of her ICS/LABA inhaler D. Discontinue albuterol and start ipratropium nebulization E. Initiate prednisone at home, continue albuterol MDI, and proceed to the emergency department 15. Which one of the following statements is true about treatment of an asthma exacerbation in the hospital?

A. Corticosteroids are administered intravenously for the fastest onset of action B. Oxygen therapy is initiated for all patients C. Albuterol may be administered continuously via nebulization D. Inhaled corticosteroids are discontinued while in the hospital E. Corticosteroid dosing in the hospital is double that of outpatient use ANSWERS 1. B 2. A 3. B 4. E 5. D 6. D 7. D 8. A 9. C 10. C 11. E 12. A 13. B 14. E 15. C

CHAPTER 15. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1. All of the following play a role in the pathophysiology of COPD except: A. Chronic inflammation from repeated exposure to noxious particles and gases B. An imbalance between proteinases and antiproteinases C. Inflammation similar to what is seen in asthma, which is mainly mediated through eosinophils and mast cells D. Oxidative stress E. Impairment of the normal protective and repair mechanisms in the lungs 2. In COPD, where in the lungs is the primary site of obstruction?

A. Large bronchi B. Large bronchioles C. Mucus glands D. Small bronchi and bronchioles E. Trachea 3. A 67-year-old man presents to his primary care physician complaining of productive cough and dyspnea on exertion for the past 6 months; COPD is suspected. Which of the following further supports the diagnosis of COPD? A. A 45 pack–year history of smoking B. FEV1/FVC of 60% (0.60) C. Family history of AAT deficiency D. Fifteen years of employment in a plastics plant with exposure to talc E. All of the above 4. Which of the following is an adverse effect of tiotropium?

A. Hypokalemia B. Dry mouth C. Insomnia D. Irritability E. Seizures 5. A 66-year-old man was admitted to the hospital 4 days ago for an acute COPD exacerbation.

During this hospitalization, he has been treated with albuterol 2.5 mg via nebulizer every 4 hours, ipratropium 0.5 mg via nebulizer every 8 hours, prednisone 30 mg orally once daily, and cefuroxime axetil 500 mg orally twice daily, as well as fluticasone 110 mcg inhaled twice daily and theophylline 200 mg orally twice daily (fluticasone and theophylline were continued from outpatient treatment). Today he complains of restlessness and feeling like his heart is racing, which he attributes to being unable to smoke since being admitted to the hospital. Which of the following is/are alternative causes of these symptoms?

A. Theophylline toxicity secondary to reduced metabolism B. Adverse effect of albuterol C. Adverse effect of fluticasone D. All of the above E. A and B only 6. A 65-year-old woman with emphysema is seen in clinic today for a checkup. Her current COPD pharmacotherapy includes tiotropium 18 mcg once daily, an albuterol MDI as needed and formoterol 12 mcg every 12 hours. She is adherent with medications and uses her inhalers correctly. She reports increasing use of albuterol over the last 3 months and increased breathlessness; she denies any recent changes in sputum. Her postbronchodilator FEV1 today is

42%. Which of the following is the most appropriate change to her current treatment regimen?

A. Add roflumilast 500 mcg orally every 24 hours B. Add methylprednisolone 60 mg intravenously every 6 hours C. Discontinue formoterol and start fluticasone furoate/vilanterol 100 mcg/ 25 mcg, one inhalation daily D. Add fluticasone/salmeterol 500 mcg/50 mcg, one inhalation every 12 hours E. Discontinue tiotropium and formoterol and start umeclidinium/vilanterol 62.5 mcg/25 mcg, one inhalation daily 7. A 75-year-old man with severe COPD currently treated with tiotropium, formoterol/budesonide, and albuterol MDI as needed presents to the clinic complaining of a more frequent cough, increased sputum production, and a change in sputum color. The last time he had symptoms like these was 6 months ago, and at that time he was hospitalized for 3 days.

After being diagnosed with a COPD exacerbation and continuing his current maintenance therapies, which of the following is the most appropriate initial treatment recommendation?

A. Mometasone 220 mcg inhalation every 12 hours B. Doxycycline 100 mg orally every 12 hours C. Ipratropium two inhalations every 6 hours D. Theophylline 300 mg orally every 12 hours E. All of the above are appropriate initial treatment recommendations 8. An 81-year-old woman presents to the emergency department complaining of symptoms consistent with a COPD exacerbation. She tells you that she takes only tiotropium daily at home and that she is supposed to be on one other inhaler but has not had it refilled in the last 6 months.

Which of the following would be the most appropriate medication to add to her regimen in the emergency department?

A. Ipratropium B. Aminophylline C. Roflumilast D. Levalbuterol E. None of the above would be an appropriate recommendation 9. Which of the following interventions might be appropriate for a patient with moderate (GOLD 2) COPD currently using only an albuterol MDI? A. Oxygen therapy for 16 hours per day B. Two weeks of pulmonary rehabilitation C. Surgery (eg, bullectomy) D. Lung transplantation E. All of the above would be considered appropriate interventions 10. A 67-year-old man with chronic cough and sputum production, an FEV1/FVC of 68% (0.68), and an FEV1 65% of predicted can be classified according to the GOLD guidelines as: A. Not having COPD B. GOLD 1: mild C. GOLD 2: moderate D. GOLD 3: severe E. GOLD 4: very severe 11. All of the following are appropriate patient education points for COPD except: A. Smoking cessation counseling B. Role of regular exercise

C. End-of-life issues and resuscitation wishes D. When to quit taking medications as symptoms improve E. Signs and symptoms of an exacerbation 12. Inhaled corticosteroids may improve all of the following parameters in a COPD patient with an FEV1 of 55% except: A. Symptom frequency B. Lung function C. Quality of life D. Exacerbation rates E. Mortality rates 13. A 58-year-old man with COPD was started on inhaled corticosteroids 2 months ago. Which one of the following parameters would be best for evaluating the effectiveness of the inhaled corticosteroid and determining if continued use is needed?

A. Arterial blood gases B. Body mass index C. Symptom improvement D. Chest x-ray E. FEV1 14. A 59-year-old man presents with cough, sputum production, and dyspnea with exertion that began 6 months ago. He is a nonsmoker, but he has worked as a bartender four nights a week for the last 32 years. Lung examination reveals significant wheezing bilaterally. Which one of the following confirms the suspected diagnosis of COPD? A. PaCO2 55 mm Hg (7.3 kPa) on arterial blood gas B. Exposure to secondhand smoke C. Postbronchodilator FEV1/FVC ratio of 60% (0.60) D. FEV1 75% E. Absence of infiltrates on chest x-ray 15. A 72-year-old man with COPD, hypertension, dyslipidemia, coronary artery disease, and osteoarthritis presents to clinic for routine follow-up. He is currently treated with formoterol, albuterol as needed, lisinopril, metoprolol, atorvastatin, aspirin, and acetaminophen. He reports no changes in his respiratory symptoms. His COPD Assessment Test (CAT) score is 9. He did go to an urgent care facility twice in the past 5 months for worsening COPD. He was treated with antibiotics and prednisone on both occasions. His pulmonary function tests (PFTs) today reveal an FEV1 of 54%. Which of the following is the most appropriate medication change to make today?

A. No changes are needed because the patient’s symptoms are stable B. Change formoterol to the combination inhaler budesonide–formoterol C. Add ciclesonide D. Discontinue metoprolol E. Both B and D should be done today ANSWERS 1. C 2. D 3. E 4. B 5. E

6. C 7. B 8. D 9. A 10. C 11. D 12. E 13. C 14. C 15. B CHAPTER 16. CYSTIC FIBROSIS 1. Airway clearance therapy in patients with cystic fibrosis (CF) should be performed by the patient or patient’s caregiver: A. Only when the patient is symptomatic B. At least three times per day during acute exacerbations C. Every Monday, Wednesday, and Friday D. Only under the direct supervision of a respiratory therapist E. With at least two different methods 2. A 5-year-old male CF patient presents with poor nutritional status. Height is 105 cm (25th percentile), and weight is 14.5 kg (< 3rd percentile). He takes Zenpep 10,000 two caps with meals and one cap with snacks, and he has four loose stools per day. Which of the following are appropriate nutritional interventions?

A. Dietary counseling to increase caloric intake B. Increase Zenpep 10,000 to three caps with meals and two caps with snacks C. Admit to hospital for initiation of intravenous parenteral nutrition D. A and B E. A, B, and C 3. Dornase alfa is used in CF for which of the following reasons: A. Chronic Pseudomonas aeruginosa suppression B. Mucolytic activity C. Sputum induction D. A and B E. B and C 4. The following culture and sensitivity results are reported for a 13-year-old CF patient: Current month: P. aeruginosa (sensitive to cefepime, ceftazidime, piperacillin-tazobactam, meropenem, aztreonam, gentamicin, tobramycin, amikacin, ciprofloxacin).

One month ago: S. aureus (sensitive to vancomycin, sulfamethoxazole-trimethoprim, minocycline, linezolid; resistant to cefazolin, clindamycin, erythromycin, nafcillin, gentamicin) and P. aeruginosa (sensitive to cefepime, ceftazidime, piperacillin-tazobactam, meropenem, aztreonam, tobramycin, amikacin; resistant to gentamicin, ciprofloxacin) Six months ago: A. xylosoxidans (sensitive to ceftazidime, sulfamethoxazole-trimethoprim, and piperacillin-tazobactam; resistant to ticarcillin-clavulanate, minocycline, levofloxacin) Based on these results, the most appropriate inpatient antibiotic regimen is: A. Piperacillin-tazobactam, ciprofloxacin, and vancomycin B. Piperacillin-tazobactam, tobramycin, and vancomycin C. Cefepime, tobramycin, and clindamycin

D. Cefepime, tobramycin, and minocycline E. Ceftazidime, gentamicin, and sulfamethoxazole-trimethoprim 5. Patients with a history of anaphylactic reaction to ticarcillin-clavulanate and cefepime can most safely be treated with which antibiotic?

A. Meropenem B. Ertapenem C. Loracarbef D. Aztreonam E. Dicloxacillin 6. An 8-year-old CF patient with F508del and G551D CFTR gene mutations is prescribed ivacaftor for chronic maintenance therapy. Which of the following statements should not be included in medication counseling?

A. Ivacaftor interacts with many medications. Ask your CF doctor or pharmacist before stating any new medications.

B. All other chronic maintenance therapies should be continued after starting ivacaftor.

C. Ivacaftor should be taken on an empty stomach.

D. Blood tests will be ordered periodically to monitor liver function while taking ivacaftor.

E. Adherence to therapy is very important to optimize the effectiveness of ivacaftor.

7. CF patients have altered pharmacokinetic parameters because of: A. Increased fat stores B. Chronic maldigestion leading to increased protein binding C. Hepatic sequestration of antibiotics D. Increased percent lean body mass compared with total body mass E. Tolerance of faster infusion rates 8. The preferred treatment for a patient with newly diagnosed cystic fibrosis–related diabetes (CFRD) without documented fasting hyperglycemia is: A. Insulin glargine 20 units subcutaneously every evening B. Lispro insulin 1 unit per 15 g of carbohydrates with meals and snacks C. Isophane insulin sliding scale for glucose levels greater than 150 mg/dL (8.3 mmol/L) D. Metformin 500 mg orally twice daily E. Glyburide 5 mg orally once daily 9. Current maintenance therapy for CF is designed with the following goal(s) in mind: A. Delay of disease progression B. Normal growth and development C. Disease cure D. Two of the above E. All of the above 10. A 25-year-old CF patient (weight: 48 kg) with a history of P. aeruginosa colonization presents to clinic with complaints of slowly declining lung function over the past 2 years.

FEV1 has declined from 62% predicted to 48% predicted during this time. Current maintenance therapies include albuterol 2.5 mg nebulized twice daily with chest physiotherapy, dornase alfa 2.5 mg nebulized every morning, hypertonic saline 7% 4 mL nebulized every evening, AquADEKs one capsule daily, omeprazole 20 mg daily, and CREON 24,000 three caps with meals and two caps with snacks. What antiinflammatory treatment is most appropriate for this patient?

A. Azithromycin 500 mg three times per week

B. Ibuprofen 20 mg/kg/dose twice daily C. Fluticasone 220 mcg two puffs twice daily D. Prednisone 10 mg daily E. All of the above are reasonable treatment options 11. A 48-year-old female patient (weight: 38 kg) with a history of CF diagnosed at age 5 is admitted through the emergency department for treatment of a pulmonary exacerbation. Her FEV1 is 21% predicted. Additional medical history is significant for CFRD, osteoporosis, pancreatic insufficiency, depression, and pneumothorax. The patient is new to your CF center, and no pharmacokinetic history is available. Which of the following statements is true?

A. The patient is likely to have increased tobramycin clearance due to pancreatic insufficiency B. Serum creatinine does not need to be screened in this patient C. Tobramycin should be dosed every 8 hours in all CF patients D. This patient is at higher risk for delayed tobramycin clearance due to age and cumulative lifetime exposure to aminoglycosides E. Aminoglycosides should be avoided in this patient because pharmacokinetic history is unknown 12. Which of the following scenarios is most likely to cause pancreatic enzyme replacement therapy treatment failure?

A. Opening enzyme capsules and sprinkling beads on applesauce B. Crushing enzyme beads and mixing in with infant formula C. Taking enzyme capsules throughout a meal D. Eating an apple every afternoon without taking enzymes E. Taking ranitidine as needed for heartburn symptoms 13. A 21-year-old CF patient wishes to start chronic suppressive antibiotic therapy due to frequent exacerbations and declining lung function. Culture history is notable for MRSA, P. aeruginosa, and Aspergillus fumigatus. Which of the following is not a favorable option?

A. Aztreonam lysine inhalation 75 mg three times daily, alternating cycles of 28 days on/off B. Tobramycin inhalation powder 112 mg twice daily, alternating cycles of 28 days on/off C. Colistin 150 mg inhalation twice daily, alternating cycles of 28 days on/off D. Minocycline 100 mg by mouth twice daily with alternating inhaled tobramycin solution 300 mg BID in 28-day cycles E. All of the above are routinely accepted regimens and should be selected by patient preference 14. Patients on chronic azithromycin therapy should be monitored for: A. Growth of Mycobacterium abscessus on sputum cultures B. Development of renal toxicity C. Hyperglycemia D. Osteoporosis E. Thrombocytopenia 15. CF patients on IV aminoglycosides for pulmonary exacerbations should be monitored by which of the following methods?

A. Daily tobramycin trough concentrations B. Peak and trough concentrations weekly C. Initial determination of peak and trough concentrations per local CF center protocol, then weekly trough concentrations D. Initial determination of peak and trough concentrations per local CF center protocol, then weekly peak concentrations

E. No concentration monitoring is needed with empiric dosing as long as serum creatinine is within normal limits for age ANSWERS 1. B 2. D 3. B 4. B 5. D 6. C 7. D 8. B 9. D 10. A 11. D 12. B 13. D 14. A 15. C CHAPTER 17. GASTROESOPHAGEAL REFLUX DISEASE 1. Which one of the following GERD symptom is considered complicated and requires further diagnostic evaluation?

A. Heartburn B. Regurgitation C. Chronic cough D. Difficulty swallowing E. Hiatal hernia 2. Extraesophageal syndrome associated with GERD refers to: A. Erosions of the esophagus B. Gastroesophageal reflux symptoms associated with disease processes in organs other than the esophagus C. Inflammation of the esophagus D. Replacement of the squamous epithelial lining in the esophagus with columnar epithelial lining E. Barrett esophagus 3. Which of the following PPI regimens is/are preferred as initial treatment in a 60-year-old patient with erosive esophagitis?

A. Lansoprazole 30 mg once daily × 3 weeks B. Pantoprazole 40 mg twice daily × 24 weeks C. Esomeprazole 20 mg once daily × 8 weeks D. Rabeprazole 20 mg once daily as needed E. Any of the above would be a preferred treatment 4. Which of the following PPIs would offer dosing flexibility relative to meal timing?

A. Dexlansoprazole B. Lansoprazole C. Omeprazole/sodium bicarbonate D. Omeprazole

E. A and C only 5. On-demand therapy would be most appropriate in patients with: A. Atypical symptoms B. Intermittent reflux symptoms C. Barrett esophagus D. Erosive esophagitis E. Strictures 6. Which one of the following medications may worsen the symptoms of GERD by decreasing lower esophageal sphincter pressure?

A. Nifedipine B. Alendronate C. Naproxen D. Quinidine E. Ferrous sulfate 7. What is the best treatment regimen for a 55-year-old patient who complains of difficulty swallowing for the last 3 months?

A. Patient-directed therapy with OTC PPI for 2 months. If no improvement, then refer to physician for further evaluation B. An 8-week course of metoclopramide 10 mg three times daily. If no improvement, then refer to physician for further evaluation C. An 8-week course of standard dose PPI (once daily) plus further diagnostic evaluation by physician for complicated symptoms D. An 8-week course of standard dose PPI (once daily) plus standard dose H2receptor antagonist for breakthrough symptoms E. Lifestyle modifications only 8. The goals of treatment of GERD are to: A. Alleviate symptoms B. Promote healing of mucosal injury C. Prevent complications D. Decrease esophageal pH to less than 2 E. A, B, and C are all correct 9. Which of the following risk factors would not be a justification for using a PPI in a patient on clopidogrel?

A. Prior history of upper GI bleed B. Advanced age C. Dual antiplatelet therapy D. Erosive esophagitis E. Intermittent GERD symptoms 10. Which recommendation would be most appropriate regarding calcium supplementation for prevention of bone fractures in a healthy 24-year-old woman taking omeprazole 20 mg once daily for GERD? A. Elemental calcium 2000 mg daily in divided doses B. No calcium is needed because she does not have risk factors for osteoporosis or fractures C. Elemental calcium 2000 mg daily plus vitamin D 800 units daily D. Calcium citrate 500 mg four times daily

E. Calcium gluconate 1 gram IV every month 11. What is the best treatment option for a patient with GERD symptoms that are refractory to the initial PPI regimen?

A. Change to a different PPI B. Increase the frequency of the current PPI to twice daily C. Change to a high-dose H2-receptor antagonist regimen (eg, rantidine 150 mg four times daily) D. A and B only E. A, B, and C 12. PPIs decrease stomach acid by which of the following mechanisms?

A. Inhibiting gastric H+ /K+ -adenosine triphosphatase in gastric parietal cells B. Inhibiting histamine2 receptors in gastric parietal cells C. Forming a viscous solution that floats on the surface of the gastric contents D. Forming a protective coating over the damaged mucosa E. Increasing GI motility 13. Maintenance therapy is indicated for patients with: A. Continued symptoms after PPI discontinued B. Barrett esophagus C. Erosive esophagitis D. Extraesophageal syndromes associated with GERD E. All of the above 14. Which of the following is not considered a potential risk associated with the use of PPIs? A. Clostridium difficile infections B. Community-acquired pneumonia C. Hyperkalemia D. Bone fractures E. Hypomagnesemia 15. Which of the following surgical options for GERD would be preferred in a morbidly obese patient?

A. Transoral incisionless fundoplication B. Vertical banded gastroplasty C. Application of radiofrequency energy to the lower esophageal sphincter D. Bariatric surgery with Roux-en-Y gastric bypass E. Any of the above options would be acceptable ANSWERS 1. D 2. B 3. C 4. E 5. B 6. A 7. C 8. E 9. E

10. B 11. D 12. A 13. E 14. C 15. D CHAPTER 18. PEPTIC ULCER DISEASE 1. Which of the following is not a common cause of peptic ulcer disease (PUD)?

A. Chronic alcohol ingestion B. Nonsteroidal antiinflammatory drugs (NSAIDs) C. Stress-related mucosal damage D. Helicobacter pylori infection E. All of the above are common causes of PUD 2. Which of the following is a complication of PUD? A. GI bleeding B. Perforation C. Obstruction D. All of the above E. None of the above 3. Which of the following is an indication for stress ulcer prophylaxis (SUP) in critically ill patients according to the 1999 American Society of Health-System Pharmacists (ASHP) published guidelines?

A. Mechanical ventilation for longer than 48 hours B. Patients admitted to telemetry for heart failure C. Platelet count greater than 50,000/mm3 (50 × 109 /L) but less than 150,000/mm3 (150 × 109 /L) D. Thermal injuries to more than 15% of body surface area E. Admission to ICU on enteral feedings 4. Which of the following is an important mechanism of prostaglandin mucosal protection?

A. Stimulation of both mucus and phospholipid production B. Promotion of bicarbonate secretion C. Increased mucosal cell turnover D. All of the above E. None of the above 5. A 65-year-old woman presents with new onset epigastric pain, recent 10-pound (4.5kg) weight loss, and anemia. What diagnostic test should this patient undergo?

A. Urea breath test B. Stool antigen testing for H. pylori C. Esophagogastroduodenoscopy (EGD) D. H. pylori serology testing E. Manometry 6. A prophylactic medication regimen to prevent NSAID-induced ulcers would not be

recommended in: A. A 65-year-old patient on long-term NSAID therapy for osteoarthritis B. A 60-year-old patient on aspirin therapy for cardioprotection C. A 72-year-old patient with history of GI bleeding on NSAID therapy for osteoarthritis D. A 30-year-old patient who takes NSAID for occasional tension headaches E. An 80-year-old patient on high-dose corticosteroids for lupus and history of GI bleeding 7. A preferred first-line option for treating a newly diagnosed patient with H. pylori infection and a penicillin allergy is: A. A triple-drug regimen consisting of a proton pump inhibitor (PPI), clarithromycin and tetracycline B. A triple-drug regimen consisting of a PPI, levofloxacin, and tetracycline C. A quadruple-drug regimen with bismuth subsalicylate, metronidazole, tetracycline, and a PPI D. Dual therapy consisting of a PPI and metronidazole E. None of the above 8. Which one of the following should be considered when evaluating a patient who has failed H. pylori eradication therapy?

A. Patient adherence B. Preexisting antimicrobial resistance C. Potential reinfection D. All of the above E. None of the above 9. Which of the following tests can be used to confirm eradication of H. pylori?

A.Urea breath test B. Stool antigen assay C. EGD with biopsies D.Serologic testing E. Both A and D 10. Which of the following statements is true regarding misoprostol?

A. Misoprostol is a synthetic prostacyclin analog that exogenously replaces prostacyclin stores B. Misoprostol is safe to use in pregnancy C. Misoprostol is indicated for reducing the risk of H. pylori-induced gastric ulcer D. Misoprostol is limited by a high frequency of GI side effects E. Misoprostol is the drug of choice for stress ulcer prophylaxis 11. Which of the following is an independent risk factor for the development of NSAID-induced peptic ulcers?

A. Concomitant use of corticosteroids B. Alcohol consumption C. Concomitant use of selective serotonin receptor inhibitors (SSRIs) D. Smoking E. All of the above 12. Which one of the following statements is true regarding H. pylori antimicrobial resistance?

A. Metronidazole resistance is more prevalent in North America than in Asia B. Clarithromycin resistance occurs in approximately 10% of H. pylori isolates C. Amoxicillin and tetracycline resistance occur in most H. pylori isolates

D. Antimicrobial resistance with H. pylori is not a concern E. None of the above 13. In which of the following situations is confirmation of H. pylori eradication recommended?

A. Patients who have undergone resection for early gastric cancer B. Patients with gastric MALT lymphoma C. Patients with persistent symptoms after H. pylori treatment D. None of the above E. All of the above 14. Which of the following is not a goal of PUD therapy?

A. Resolve symptoms B. Increase acid secretion C. Promote epithelial healing D. Prevent ulcer-related complications E. Prevent ulcer recurrence 15. Refractory peptic ulcers will most likely require which of the following interventions?

A. An increase in the H2RA dose B. An evaluation of serum pepsin to exclude Zollinger-Ellison syndrome C. H. pylori testing if not done previously D. Combination therapy with an H2RA and PPI E. All of the above ANSWERS 1. A 2. D 3. A 4. D 5. C 6. D 7. C 8. D 9. E 10. D 11. C 12. B 13. D 14. B 15. C

CHAPTER 19. INFLAMMATORY BOWEL DISEASE 1. Which mesalamine formulation would be most appropriate for a patient with active ulcerative colitis (UC) who has extensive disease?

A. Intravenous solution B. Delayed-release capsule C. Enema D. Suppository 2. Which medication is delivered via intravenous infusion?

A. Budesonide B. Infliximab C. Balsalazide D. Methotrexate 3. Prior to initiating therapy with azathioprine, patients should be evaluated for activity of which enzyme?

A. Thiopurine methyltransferase B. Azathioprine dehydrogenase C. Dihydrofolate reductase D. Alanine aminotransferase 4. Loperamide should be avoided in patients with active UC due to its ability to induce which one of the following complications?

A. Toxic megacolon B. Intestinal stricture C. Fistula formation D. Pancreatitis 5. Probiotics may be most helpful in patients with IBD who have: A. Pouchitis B. Fistulae C. Proctitis D. Arthritis 6. Which one of the following medications would be contraindicated in a pregnant patient with CD? A. Sulfasalazine B. Budesonide C. Infliximab D. Methotrexate 7. Which one of the following disorders is a possible extraintestinal manifestation of inflammatory bowel disease?

A. Erythema nodosum B. Migraine headaches C. Asthma D. Sinusitis 8. The mechanism of action of vedolizumab can best be characterized as: A. TNF-α inhibition B. Purine antagonism C. Folate antagonism D. Leukocyte adhesion inhibition

9.Budesonide would be most appropriate for use in a patient with Crohn disease when the disease location is confined to the: A. Duodenum B. Jejunum C. Terminal ileum D. Descending colon 10. Patients receiving the enema formulation of mesalamine should be instructed to: A. Use the medication on an as-needed basis only B. Lie on their left side when administering C. Retain the contents for no more than 30 minutes D. Avoid administration at bedtime 11. Certolizumab works by inhibiting the activity of: A. Interleukin-6 B. Leukocyte adhesion molecules C. Tumor necrosis factor alpha D. B lymphocytes 12. Combining infliximab and azathioprine may increase a patient’s risk for developing: A. Lymphoma B. Hepatitis C. Heart failure D. Encephalopathy 13. Which condition is considered a contraindication to infliximab therapy?

A. Diabetes B. Hypothyroidism C. Dyslipidemia D. Advanced heart failure 14. Which therapy could be considered for treatment of severe active CD in a patient failing adalimumab?

A. Balsalazide B. Vedolizumab C. Olsalazine D. Budesonide 15. Which medication is most appropriate for quickly suppressing inflammation in patients with moderately active UC who are failing aminosalicylate therapy?

A. Balsalazide B. Prednisone C. 6-mercaptopurine D. Methotrexate ANSWERS 1. B 2. B 3. A 4. A 5. A 6. D 7. A

8. D 9. C 10. B 11. C 12. A 13. D 14. B 15. B CHAPTER 20. NAUSEA AND VOMITING 1. A 52-year-old man presents with chronic lower back pain that he has managed with ibuprofen 400 mg PO three times daily. He reinjured his back moving boxes and 2 days ago was started on hydrocodone 5 mg/acetaminophen 325 mg every 4 hours as needed for pain. He also has a history of hypertension and asthma for which he takes lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, fluticasone 250 mcg/salmeterol 50 mcg twice daily, and albuterol MDI two puffs as needed for shortness of breath. Today he complains of nausea with one episode of vomiting this morning. What is most likely to be causing his nausea and vomiting?

A. Lisinopril B. Hydrochlorothiazide C. Hydrocodone D. Acetaminophen E. Fluticasone 2. All of the following are true regarding nausea except: A. It is an objective finding B. It is accompanied by tachycardia C. It increases salivation D. It is accompanied by diaphoresis 3. The adverse effects of doxylamine include: A. Salivation, diarrhea, insomnia B. Dry mouth, constipation, drowsiness C. Salivation, constipation, insomnia D. Dry mouth, diarrhea, drowsiness 4. Benzodiazepines are associated with all of the following adverse effects except: A. Respiratory depression B. Sedation C. Dyskinesia D. Amnesia 5. A 57-year-old obese woman is scheduled to undergo lengthy abdominal surgery. She smokes one pack of cigarettes per day, does not drink alcohol, and has a history of motion sickness.

Which set of risk factors predisposes this patient to postoperative nausea and vomiting (PONV)?

A. Female sex, smoking history, and alcohol history B. Body habitus, history of motion sickness, and alcohol history C. Female gender, history of motion sickness, and duration of surgery D. Body habitus, smoking history, and alcohol history E. Female gender, history of motion sickness, and smoking history 6. Nonpharmacologic treatment options for motion sickness include:

A. Increasing exposure to movement to acclimate to it more quickly B. Reading in a moving vehicle to distract from the motion C. Restricting ventilation to prevent olfactory stimulation of motion sickness D. Placing the head between the knees to reduce visual stimulation E. Sitting in the center of a boat to reduce the magnitude of the movement 7. Which of the following statements about aprepitant is true?

A. It is a 5-HT3 antagonist B. It is ineffective for prevention of PONV C. It is renally eliminated D. It prevents acute and delayed CINV when used with standard antiemetics 8. A 58-year-old man is undergoing surgical toe amputation. He does not have patient-specific risk factors for PONV, and his surgery will be short with minimal risks for PONV. He was not given PONV prophylaxis prior to the procedure but experiences nausea and vomiting in the postanesthesia care unit. The nurse asks you for a treatment recommendation. Which of the following options is the best recommendation?

A. Diphenhydramine 25 mg orally B. Ondansetron 8 mg orally C. Scopolamine transdermal patch D. Granisetron 0.1 mg IV E. Dexamethasone 5 mg IV 9. A 62-year-old woman with acute myeloid leukemia is in clinic to receive her first day of cytarabine 100 mg/m2 IV and daunorubicin 45 mg/m2 IV, which is a moderately emetogenic, non-anthracycline/cyclophosphamide regimen. Which of the following prophylactic antiemetic regimens would be preferred for prevention of acute nausea and vomiting in this patient?

A. Palonosetron plus dexamethasone B. Dolasetron plus lorazepam C. Metoclopramide plus dexamethasone D. Granisetron plus aprepitant E. Prochlorperazine plus dexamethasone 10. A 65-year-old woman is being treated for refractory chronic myelogenous leukemia (CML) with hydroxyurea. Which one of the following antiemetic regimens would be the most appropriate to administer prior to the hydroxyurea dose for preventing CINV? A. Granisetron plus dexamethasone plus aprepitant B. Palonosetron plus dexamethasone C. Dexamethasone D. Metoclopramide E. No prophylaxis is required 11. A 69-year-old woman with non–small-cell lung cancer is scheduled to receive her first cycle of cisplatin 100 mg/m2 plus gemcitabine 1000 mg/m2 . Which of the following oral regimens would be most appropriate for preventing acute and delayed nausea and vomiting?

A. Ondansetron, dexamethasone, and aprepitant on days 1–4 B. Ondansetron, dexamethasone, and aprepitant on day 1 C. Ondansetron and dexamethasone on day 1, and aprepitant on days 1–4

D. Ondansetron day 1, dexamethasone days 1–4, and aprepitant day 1 E. Ondansetron day 1, dexamethasone days 1–4, and aprepitant days 1–3 12. A 50-year-old woman had a hysterectomy and now presents with an abdominal abscess. She has a history of diabetes, gastroparesis, hypertension, and dyslipidemia. Her home medications are metformin, glipizide, erythromycin, ramipril, and simvastatin. Which one of the patient’s medications makes droperidol contraindicated for PONV? A. Simvastatin B. Erythromycin C. Metformin D. Ramipril E. Glipizide 13. A 30-year-old woman is going deep-sea fishing this weekend. The last time she went on a similar excursion, she got seasick about an hour after leaving port and shortly after drinking three margaritas and eating several tacos. She asks you to recommend something to help prevent seasickness. What is the best recommendation?

A. Apply a transdermal scopolamine patch 1 hour before the trip B. Take granisetron one mg orally 4 hours before the trip C. Take aprepitant 40 mg orally 3 hours before the trip D. Take meclizine 50 mg orally if nausea or vomiting occurs E. Take methylprednisolone 8 mg orally if nausea or vomiting occurs 14. A 26-year-old woman in her first trimester of pregnancy (week 9) is experiencing severe nausea and vomiting that is interfering with her ability to maintain an acceptable level of nutrition. Which one of the following antiemetic regimens would be the most appropriate?

A. Methylprednisolone 12 mg orally twice daily as needed B. Droperidol 0.625 mg orally every 12 hours as needed C. Doxylamine 10 mg/pyridoxine 10mg, two tablets at bedtime D. Dolasetron 100 mg orally every 8 hours as needed E. Dronabinol 5–15 mg/m2 every 2–4 hours as needed 15. The vestibular system is replete with which types of receptors?

A. Histaminic B. Dopaminergic C. Neurokinin-1 D. Serotonergic E. Adrenergic ANSWERS 1. C 2. A 3. B 4. C 5. C 6. E 7. D 8. D 9. A 10. E

11. E 12. B 13. A 14. C 15. A CHAPTER 21. CONSTIPATION, DIARRHEA, & IRRITABLE BOWEL 1. Which one of the following conditions is associated with constipation?

A. Hypotension B. Diabetes mellitus HypertensionD. Chronic obstructive pulmonary disease E. Hyperuricemia 2. Which one of the following characteristics should prompt a patient to seek medical attention for constipation?

A. Sudden change in bowel habits after age 50 B. Presence of 4 or more bowel movements per week C. Presence of flatulence D. Change in dietary habits E. Age of 7 to 12 years 3. All of the following medications are associated with causing constipation except: A. Ibuprofen B. Clonidine C. Ondansetron D. Ferrous sulfate E. Clindamycin 4. Alarm factors associated with constipation include all of the following except: A. New onset or worsening of constipation B. Family history of colon cancer C. Weight gain D. Anemia E. Blood in the stool 5. Which one of the following oral laxatives is best to relieve constipation during pregnancy?

A. Mineral oil B. Senna C. Bisacodyl D. Docusate sodium E. Castor oil 6. Which one of the following types of diarrhea resolves during a period of fasting?

A. Inflammatory B. Secretory C. Osmotic D. Altered motility E. None of the above 7. The diarrhea associated with lactase deficiency may be reduced or avoided by implementing which one of the following measures?

A. Using lactose tablets with precipitating foods B. Regular ingestion of yogurt C. Substituting acidophilus milk for regular milk D. Avoiding any precipitating foods E. All of the above are correct 8. Which one of the following treatments is preferred as fluid replacement in a 6-year-old child who is experiencing diarrhea without vomiting for the past 12 hours?

A. Gatorade B. Mountain Dew C. Pedialyte D. Mineral water E. Milk 9. All of the conditions listed below may present with chronic diarrhea except: A. Crohn’s disease B. Malabsorption syndromes C. Irritable bowel syndrome D. Hyperthyroidism E. All of the above conditions may present with associated chronic diarrhea 10. In some cases of chronic diarrhea, an effective treatment may include use of which of the following?

A. Soluble fiber B. Insoluble fiber C. Wheat bran D. Cheerios E. b and c only are correct 11. Which one of the following statements regarding irritable bowel syndrome (IBS) is false?

A. There is a significant impact on health-related quality of life B. Work productivity is rarely affected in IBS sufferers C. Costs to society associated with IBS are high D. Abdominal pain and bloating affect quality of life in IBS E. IBS affects twice as many women as men 12. Which one of the following statements about IBS is true?

A. Bloating is identified as one of the most bothersome symptoms in patients with IBS B. Dysregulation of the autonomic nervous system is more common in patients with mild rather than more severe left-sided cramping C. Primary care physicians treat very few IBS patients D. The principal outcome sought in IBS treatment is normalizing the intestine E. Rome II and Rome III diagnostic criteria for IBS are identical 13. Abnormal concentration and/or response to which of the following substances is thought to be an important part of the development of IBS? A. Serotonin B. Acetylcholine C. Substance P D. Secretin

E. Somatostatin 14. Rifaximin use in IBS is best characterized by which of the following statements?

A. It is not appreciably absorbed by the gastrointestinal tract B. It is useful for treating traveler’s diarrhea C. It is associated with few adverse effects D. It treats bacterial proliferation in the gut, which may be responsible for GI symptoms E. It does not lead to bacterial resistance 15. Which one of the following therapies is unlikely to have an effect on gut motility?

A. Cognitive behavioral therapy B. Peppermint oil C. Loperamide D. Amitriptyline E. All of the above can affect gut motility ANSWERS 1. B 2. A 3. E 4. C 5. D 6. C 7. E 8. C 9. E 10. E 11. B 12. A 13. A 14. D 15. E CHAPTER 22. PORTAL HYPERTENSION & CIRRHOSIS 1. The police bring a 54-year-old man to the emergency department after he is found wandering aimlessly on a college campus. He is alert and oriented × 1 (he knows his name) but doesn’t know the season or where he is. His initial physical examination is noncontributory with the exception of moderate jaundice, scleral icterus, and a distended abdomen. A toxicology screen is negative for drugs and alcohol, but his serum ammonia level is elevated. Which of the following initial therapies is most appropriate?

A. Lactulose B. Metronidazole C. Neomycin D. Rifaximin E. Flumazenil 2. A patient with known cirrhosis has complaints of abdominal pain. The medical resident performs a therapeutic paracentesis and removes 6 L of fluid. What is the most appropriate adjunct therapy?

A. Give 50 g of 25% albumin B. Give 10 g of 25% albumin

C. Give 100 g of 5% albumin D. Do not give albumin 3. Fluid obtained from a cirrhotic patient during paracentesis was sent to the laboratory for analysis with the following results: PMN count 340 cells/μL (340 × 106 /L), SAAG 1.3 g/dL (13 g/L), gram stain negative. What is the most appropriate therapy?

A. No drug therapy necessary B. Intensify diuresis C. Initiate narrow-spectrum antibiotics D. Initiate broad-spectrum antibiotics 4. What is the most appropriate drug regimen to decrease the accumulation of peritoneal fluid (ascites) in a patient with low blood pressure and no peripheral edema?

A. Spironolactone B. Furosemide C. 25% albumin D. Midodrine E. A and C only 5. How should an SAAG of 1.3 g/dL (13 g/L) be interpreted?

A. Indicates peritoneal infection as cause of ascites B. Indicates portal hypertension as cause of ascites C. Indicates heart failure as cause of ascites D. Indicates malignancy as cause of ascites 6. Which one of the following statements is correct regarding spontaneous bacterial peritonitis (SBP) as a complication of cirrhosis?

A. Do not prescribe antibiotics if the paracentesis gram stain is negative B. Always use a broad-spectrum antibiotic for suspected SBP because it is usually polymicrobial C. SBP is usually monomicrobial, so a narrow spectrum antibiotic should be used empirically D. Patients with prior SBP should be assessed for long-term antibiotic prophylaxis 7. A patient with long-standing cirrhosis has confirmed SBP. What is the most appropriate antibiotic therapy?

A. Vancomycin 1 g IV every 12 hours B. Ceftriaxone 1 g IV every 24 hours C. Trimethoprim/sulfamethoxazole two double-strength tablets orally every 12 hours D. Nitrofurantoin 100 mg orally every 12 hours 8. Why should patients with SBP receive albumin on Day 1 and Day 3 of treatment?

A. To prevent ascites B. To prevent hepatorenal syndrome (HRS) C. To prevent variceal bleeding D. To prevent hypoalbuminemia 9. A patient with hepatorenal syndrome is transferred from the emergency department.

What is the most appropriate initial therapy?

A. Albumin 1 g/kg IV, midodrine 7.5 mg orally three times daily, octreotide 100 mcg subcutaneously three times daily

B. Albumin 6 to 8 g/kg IV, propranolol 10 mg orally twice daily, octreotide 50mcg/hour IV infusion C. Spironolactone 100 mg orally daily, furosemide 40 mg orally daily D. Propranolol 10 mg orally twice daily, midodrine 7.5 mg orally three times daily, furosemide 20 mg orally twice daily 10. What is the cause of the thrombocytopenia that often occurs in patients with cirrhosis?

A. Decreased hepatic synthesis of platelet-stimulating factors B. Bone marrow failure C. Splenic sequestration of platelets D. A and C only E. A, B, and C 11. What factors other than thrombocytopenia can contribute to increased risk of bleeding in patients with cirrhosis?

A. Increased variceal pressure due to volume overload ing B. Progression of cirrhosis with increased first-pass metabolism of foods rich in vitamin K C. Decreased synthetic function combined with vitamin K malabsorption D. Decreased albumin with increased systemic venous pressure 12. What is the most appropriate initial therapy for a cirrhotic patient who presents with hematemesis?

A. Octreotide IV infusion and IV proton-pump inhibitor B. Octreotide IV infusion and oral propranolol C. Fluoroquinolone IV and oral midodrine D. Third-generation cephalosporin IV and octreotide IV infusion 13. Which one of the following statements is accurate regarding a patient with variceal bleeding?

A. Low-dose propranolol alone is the regimen of choice for secondary prophylaxis; it has been shown to reduce the risk of rebleeding B. If the patient has a history of hypertension, it may be appropriate to use metoprolol succinate to control portal hypertension C. Most patients should be started on propranolol and isosorbide mononitrate to decrease blood pressure and reduce the risk of repeated bleeding D. If endoscopic band ligation stops the bleeding, further pharmacologic therapy is not warranted 14. Which one of the following is correct regarding the progression and etiology of cirrhosis?

A. The most common cause of cirrhosis in the United States is hepatitis B B. Results of the physical examination and laboratory report are often the only way to determine the etiology of cirrhosis C. Cirrhosis is the progressive replacement of viable hepatocytes with fibrosis and scar tissue D. Cirrhosis is easily reversible if it is diagnosed early 15. What is the cause of hyponatremia that often occurs in patients with advanced cirrhosis?

A. Decreased sodium intake due to reduced absorption B. Increased water retention from activation of the renin-angiotensin-aldosterone

system C. Change in sodium and potassium balance because of hyperaldosteronism D. Decreased water excretion because of hepatorenal syndrome ANSWERS 1. A 2. A 3. D 4. A 5. B 6. D 7. B 8. B 9. A 10. D 11. C 12. D 13. A 14. C 15. B CHAPTER 23. PANCREATITIS 1. Which one of the following are common causes of acute pancreatitis?

A. Hypertension, gallstones, diabetes mellitus B. Chronic obstructive pulmonary disease, hypertriglyceridemia, medications C. Ethanol abuse, gallstones, pregnancy D. Hereditary predisposition, obesity, gallstones E. Obesity, hypertension, hypertriglyceridemia 2. Complications of acute pancreatitis may include all of the following except: A. Acute respiratory distress syndrome B. Acute kidney injury C. Abscess formation D. Hypertension E. Pancreatic infection 3. Which of the following are complications of chronic pancreatitis?

A. Ascites B. Glucose intolerance C. Malnutrition D. Both B and C 4. Which of the following tests should be reviewed to work up a patient for pancreatitis?

A. Lipase, amylase, triglycerides B. Amylase, serum calcium, hemoglobin C. Triglycerides, hemoglobin, serum glucose D. Alanine aminotransferase (ALT), lipase, serum magnesium E. Serum calcium, lipase, C-reactive protein 5. Which of the following is not an indicator that the patient may require transfer to an ICU? A. Systolic blood pressure less than80 mm Hg B. Multiple organ dysfunction

C. Temperature greater than 38°C with altered mental status D. Respiratory rate greater than 35 breaths/min E. Food intolerance 6. Initial treatment of acute pancreatitis should include: A. Enzyme supplementation B. Fluid resuscitation C. Empiric antibiotics D. Full oral diet E. Enrollment in alcohol abstinence counseling 7. Which of the following are risk factors for chronic pancreatitis?

A. Obesity and race B. Hypertension, enalapril use C. Ethanol, tobacco, and enalapril use D. Aspirin, ibuprofen, ethanol, and tobacco use 8. Which of the following bacteria are likely to be implicated in infected pancreatic necrosis?

A. Listeria monocytogenes B. Haemophilus influenzae C. Klebsiella pneumoniae D. Streptococcus agalactiae E. Mycobacterium tuberculosis 9. Which statement best describes the pathophysiology of chronic pancreatitis?

A. Pancreatic necrosis secondary to damage to the pancreatic tissue B. Autolysis of the pancreas secondary to early activation of pancreatic enzymes C. An inflammatory process leading to endocrine and exocrine dysfunction secondary to diffuse scaring and fibrosis D. Inflammation of the pancreas secondary to a predominantly neutrophilic inflammatory response 10. Differences between acute pancreatitis and chronic pancreatitis include which of the following?

A. Serum creatinine is elevated in acute but not chronic pancreatitis B. Serum thromboplastin is elevated in acute but not chronic pancreatitis C. Serum creatine kinase (CK) is elevated in acute but not chronic pancreatitis D. Serum amylase is elevated in acute but not chronic pancreatitis E. Serum potassium is elevated in acute but not chronic pancreatitis 11. Which of the following treatments can decrease morbidity and mortality in acute pancreatitis?

A. Famotidine B. Atropine C. Weight loss D. Ethanol cessation E. Pancreatic enzyme supplementation 12. Which of the following interventions has not been shown to decrease pain in chronic pancreatitis?

A. Opioids such as morphine B. Proton pump inhibitors

C. Ethanol cessation D. Avoidance of fatty meals E. Smoking cessation 13. What would be a suitable starting prescription for pancreatic enzyme supplementation in a 23-year-old woman with cystic fibrosis weighing 45 kg who presents with steatorrhea greater than 15 g/day)?

A. Creon 12,000: 2 capsules orally before meals, 1 capsule orally before snacks B. Zenpep 15,000: 3 capsules orally before meals, 1 capsule orally before snacks C. Creon 24,000: 1 capsule orally before meals and snacks D. Pancreaze 21,000: 4 capsules orally before meals and 2 capsules before snacks E. Creon 3000: 8 capsules orally before meals and 4 capsule before snacks 14. Which of the following statements best describes acute pancreatitis?

A. Acute pancreatitis is most commonly caused by an infectious process B. Patients with acute pancreatitis should receive total parenteral nutrition for at least 7 days, even if they are able to tolerate an enteral diet, to allow time for the inflammation to subside C. Acute pancreatitis may lead to pancreatic necrosis within the first 2 weeks of presentation D. Patients presenting with acute pancreatitis should be fluid restricted E. Patients with acute pancreatitis often present with coffee-ground emesis and dark maroon stools 15. Fluid resuscitation should include: A. Albumin 25% 100-mL bolus infusion B. Lactated Ringer’s 2-L bolus infusion C. D5W + 0.9% NaCl infused at 125 mL/hour D. 0.45% NaCl 2-L bolus infusion ANSWERS 1. C 2. D 3. D 4. A 5. E 6. B 7. C 8. C 9. C 10. D 11. D 12. B 13. A 14. C 15. B

CHAPTER 24. VIRAL HEPATITIS 1. A 31-year-old Latino woman presents with complaints of fatigue. She returned from a business trip to Mexico 10 days ago. She visits her primary care physician who orders laboratory tests. The results indicate the ALT level is mildly elevated and hepatitis serologies are anti-HAV IgM(+), anti-HAV IgG (−), HBsAg(−), anti-HBc IgG(−), anti-HBc IgM (−) and anti-HCV (−). Which vaccine should be recommended?

A. Immune globulin (IG) B. Hepatitis A vaccine only C. Hepatitis B vaccine only D. Hepatitis A and Immune globulin E. Hepatitis B and Immune globulin 2. A 43-year-old black woman has HBeAg-negative chronic hepatitis B. Her risk factors include using intravenous drugs at the age of 15. Her past medical history is significant for hypertension, diabetes and severe rheumatoid arthritis. Her renal function is normal, and ALT levels are three times the upper limits of normal. Which one of the following is the best treatment option for her hepatitis B? A. Adefovir dipivoxil B. Sofosbuvir C. Simeprevir D. Pegylated interferon E. Entecavir 3. A 53-year-old black man presents with hepatitis C, genotype 2 disease, and a baseline HCV RNA level of 64,145 IU/mL (64,145 kIU/L). He acquired the infection via a blood transfusion in the 1970s.

He is presently on week 4 of pegylated interferon, ribavirin and simeprevir therapy. He states that he is doing well and has minimal complaints that include minimal fatigue and flulike symptoms the day after he gets his injection. Laboratory test results are within the reference range except for the hemoglobin level 10.3g/dL (103 g/L; 6.39 mmol/L) and ANC 0.4 × 103 /mm3 (0.4 ×109 /L). When these laboratory tests were repeated 2 days later, the hemoglobin was 10.4 g/dL(104 g/L; 6.46 mmol/L) and ANC was 0.4 × 103 /mm3 (0.4 × 109 /L). Which of the following treatment plans should be recommended because of adverse drug effects?

A. Reduce the dose of pegylated interferon and ribavirin by half

B. Add erythropoietin therapy C. Reduce the dose of pegylated interferon by a quarter D. Add granulocyte colony-stimulating factor E. Add granulocyte colony-stimulating factor and erythropoietin therapy 4. A 27-year-old Asian woman is due to give birth to a baby boy in 1 month. Prior to becoming pregnant, she drank alcohol occasionally and did not smoke. She never used IV drugs or had a blood transfusion.

The HBsAg test is negative. Which vaccination regimen should be recommended for her newborn baby?

A. Hepatitis A vaccine at birth B. Hepatitis A and B vaccine at 6 months C. Immune globulin within 24 hours of birth D. Immune globulin and hepatitis B vaccine within 12 hours of birth E. Hepatitis B vaccine only at discharge 5. A 34-year-old man will be starting treatment for hepatitis C. He has genotype 2a disease and a baseline HCV RNA level of 309,021 IU/mL (309,021 kIU/L) with all other baseline laboratory test results normal.

He has no past medical history. His mode of viral transmission was a tattoo done unprofessionally. His doctor wants to initiate hepatitis C therapy. What hepatitis C regimen should be prescribed?

A. Pegylated interferon and ribavirin B. Sofosbuvir and ledipasvir C. Simeprevir and ribavirin D. Sofosbuvir and ribavirin E. Ombitasvir, paritaprevir, ritonavir, and dasabuvir 6. A 37-year-old Asian man presents to the clinic with hepatitis B that is being treated with lamivudine.

Today is week 12 of therapy. What lab-oratory test(s) should be obtained to determine if therapy is effective?

A. ALT B. HBV DNA C. Anti-HBe D. ALT and Anti-HBe E. ALT and HBV DNA 7. A 57-year-old African American man is undergoing HCV treatment with ledipasvir and sofosbuvir. He has genotype 1a disease and had bridging fibrosis on a liver biopsy performed 1 year ago. His baseline HCV RNA level is 1,113,531 IU/mL (1,113,531 kIU/L), and at week 6 the HCV RNA level was 321,521 IU/mL (321,521 kIU/L). What treatment strategy should be recommended now?

A. Discontinue ledipasvir and sofosbuvir now B. Add pegylated interferon and ribavirin and treat up to 24 weeks C. Add simeprevir and treat up to 48 weeks

D. Continue ledipasvir and sofosbuvir and treat up to 24 weeks E. Discontinue ledipasvir/sofosbuvir FDC and initiate sofosbuvir and simeprevir for 24 weeks 8. A 59-year-old white woman presents with complaints of fatigue, pale-colored stools, and itching. She had returned from vacation in Africa one week ago. She had a blood transfusion in 1969 and had one tattoo placed on her left arm that was not done professionally. She denies IV drug use but does drink alcohol excessively (at least a six- pack of beer daily). Her husband died 2 years ago due to liver cancer.

Her primary care physician made the diagnosis of acute viral hepatitis. Which one of the following is the most likely mode of transmission for the patient’s acute viral hepatitis?

A. Excessive alcohol intake B. Unprofessionally performed tattoo C. Recent travel to Africa D. Sexual transmission from her husband E. Blood transfusion in 1969 9. A 42-year-old man has hepatitis C and hypertension that is well controlled with medications.

He admits to having anger management issues and is followed monthly by psychiatry. He contracted the HCV via IV drug use and had a blood transfusion in 2004. He has genotype 3a disease with a baseline HCV RNA level of 631,471 IU/mL (631,471 kIU/L). His weight is 72 kg (158.4 lb) and he is 5’8” (173 cm) tall.

Which one of the following is the best option to treat his hepatitis C? A. Pegylated interferon and ribavirin B. Pegylated interferon and simeprevir and ribavirin C. Ribavirin and sofosbuvir D. Ombitasvir, paritaprevir, ritonavir, and dasabuvir E. Ledipasvir and sofosbuvir 10. A 27-year-old woman presents with chronic hepatitis B infection that has not been treated.

Her 1year-old son has received all the recommended vaccines to date including 2 doses of the hepatitis B vaccine. Today she is in clinic with her son for a follow-up visit and immunizations. Which of the following vaccines should her son receive today?

A. Hepatitis A vaccine B. Hepatitis B vaccine C. Hepatitis A vaccine and hepatitis B vaccine D. Hepatitis A vaccine and immune globulin E. Hepatitis B vaccine and immune globulin 11. A 49-year-old woman presents with hepatitis C, genotype 1a disease, with no known risk factors. Her liver biopsy demonstrates cirrhosis. She has no past medical or surgical history. Which treatment is recommended for her hepatitis C? A. Pegylated interferon, ribavirin, and sofosbuvir

B. Simeprevir, Sofosbuvir, and pegylated interferon C. Ledipasvir, sofosbuvir, and pegylated interferon D. Ribavirin, ombitasvir, paritaprevir, ritonavir and dasabuvir E. Pegylated interferon, ribavirin, and simeprevir 12. A 32-year-old Korean man with HBeAg-positive chronic hepatitis B was treated initially with lamivudine and developed resistance. Lamivudine was discontinued and entecavir 1 mg daily was initiated when the HBV DNA level was greater than 450,000 IU/mL (450,000 kIU/L). His viral count remained undetectable for 1 year with entecavir but then rebounded back to baseline 9 months later. Which treatment option is the best to manage this patient’s hepatitis B? A. Discontinue entecavir and change to pegylated interferon B. Continue entecavir and add pegylated interferon C. Continue entecavir and add adefovir D. Continue entecavir and add tenofovir E. Continue entecavir and add telbivudine 13. A 44-year-old man will be traveling to Africa on a medical mission in 2 weeks. His hepatitis serologies are as follows: anti-HAV IgM (−), anti-HAV IgG (+), anti-HBs (−), HBsAg (+), HBeAg (−), antiHBcIgG (+), anti-HBcIgM (−), and anti-HBe (−). Which one of the following prophylaxis regimens should be recommended prior to his departure to Africa?

A. No vaccine B. Immune globulin C. Immune globulin and VAQTA D. Twinrix E. Engerix-B 14. A 35-year-old woman has hepatitis C genotype 2a disease that was treated with pegylated interferon 180 mcg and ribavirin 400 mg twice daily for 14 weeks 3 years ago. She had discontinued treatment early because she lost insurance coverage. She had a sustained viral response (SVR) at 6 months after treatment, but at 1 year the HCV RNA level was detectable. Today she returns to clinic to be evaluated for retreatment of hepatitis C infection. She weighs 190 pounds (86.4 kg) and is 5’6” (168 cm).

Which treatment option is the best to manage this patient’s hepatitis C? A. Pegylated interferon 180 mcg weekly and ribavirin 400 mg twice daily for 48 weeks B. Pegylated interferon 180 mcg weekly and ribavirin 600 mg twice daily for 24 weeks C. Pegylated interferon 180 mcg weekly, ribavirin 600 mg twice daily, and sofosbuvir 150 mg daily for 12 weeks D. Ribavirin 600 mg twice daily and sofosbuvir 150 mg daily for 12 weeks E. Ribavirin 600 mg twice daily and sofosbuvir 150 mg daily for 24 weeks 15. A 33-year-old white woman developed acute viral hepatitis 5 days ago. Her hepatitis serologies are as follows: anti-HAV IgM(+), anti-HAV IgG (−), anti-HCV (−), HBsAg (−), and anti-HBs (+).

Which one

of the following options is best to treat her acute viral hepatitis?

A. No treatment is needed at this time except for supportive care B. Administer immune globulin C. Administer the hepatitis A vaccine D. Administer the hepatitis A and B vaccine immediately E. Administer the hepatitis A vaccine and immune globulin immediately ANSWERS 1. B 2. E 3. D 4. E 5. D 6. E 7. A 8. C 9. C 10. C 11. D 12. D 13. A 14. D 15. C CHAPTER 25. ACUTE KIDNEY INJURY Questions 1 and 2 refer to the following case. A 71-year-old man is transferred to the ICU with pneumonia and sepsis. His baseline serum creatinine upon admission to the hospital was 0.9 mg/dL (80 µmol/L).

Two days later, his serum creatinine has increased to 2.1 mg/dL (186 µmol/L). His urine output is 1800 mL in the past 24 hours.

1. His acute kidney injury would best be classified as which of the following based on the KDIGO staging system?

A. Stage 1 B. Stage 2 C. Stage 3 D. Loss E. End stage 2. His urine output would be classified as which of the following?

A. Anuria B. Oliguria C. Normal D. Polyuria E. Unable to assess Questions 3 and 4 refer to the following case. A 66-year-old woman (weight 140 pounds [63.5 kg], height 5’4”

[163 cm]) is admitted to the hospital for a GI bleed. She has a history of diabetes mellitus and baseline Scr 1.4 mg/dL (124 µmol/L). Laboratory work today reveals BUN 65 mg/dL (23.2 mmol/L) and SCr 2.8 mg/dL (248 µmol/L).

Chronic medications include metoprolol, atorvastatin, and glyburide.

3. What of the following statements is true regarding assessment of kidney function in this patient?

A. MDRD equation should be used to estimate GFR B. Cockcroft-Gault equation should be used to estimate GFR C. 24-hour urinary data should be used to estimate GFR D. Equations that estimate ClCr with a single SCr are not accurate in this patient E. Her renal function is similar to baseline 4. Based on the patient’s BUN and SCr concentration, which of the following is a likely cause for her AKI? A. Prerenal AKI due to GI bleed B. Intrinsic AKI due to diabetes C. Postrenal AKI due to obstruction D. Intrinsic AKI due to history of CKD E. Prerenal AKI due to a chronic medication Questions 5 to 7 refer to the following case: A 63-year old man (70 kg [154 lb]) is diagnosed with intrinsic acute kidney injury (AKI) secondary to ischemia after cardiac surgery. Three days later, his urine output is 350 mL in the last 24 hours. His estimated CrCl is 20 mL/min (0.33 mL/s). He has signs of volume overload, including 2+ pedal edema, crackles, weight gain, and increased jugular venous pressure.

5. Which of the following would be a reasonable starting dose of furosemide for this patient?

A. 1 g IV B. 500 mg IV C. 200 mg orally D. 80 mg IV E. 5-mg/h IV continuous infusion 6. The patient has a prior history of a sulfonamide allergy. Which of the following statements is true regarding administration of furosemide in this patient?

A. Furosemide should be continued; cross-reactivity with furosemide is low B. Furosemide should be discontinued; cross-reactivity with furosemide is moderate C. Furosemide should be discontinued; cross-reactivity with furosemide is high D. Furosemide should be continued; furosemide does not contain a sulfa moiety E. Furosemide should be discontinued; initiate bumetanide 7. Little increase in his urine output is noted following initial furosemide administration. Which of the following recommendations would be warranted at this time?

A. Increase dose of furosemide B. Switch to bumetanide

C. Switch to spironolactone D. Add hydrochlorothiazide E. Add mannitol 8. Extended-interval aminoglycoside dosing decreases the incidence of nephrotoxicity over conventional multiday dosing regimens by which of the following rationales?

A. Dilation of the afferent arterioles at high doses, which decreases glomerular capillary pressure B. Saturation of proximal tubule update sites, allowing excretion of the remaining aminoglycoside molecules C. Maintaining aminoglycoside trough concentrations consistently less than 2 mcg/mL (2 mg/L) D. Shorter total length of treatment with once-daily dosing compared with multiday dosing E. There is no benefit of once daily dosing of aminoglycosides to decrease AKI 9. Which of the following aminoglycosides is more nephrotoxic in clinical practice?

A. Amikacin B. Gentamicin C. All equally nephrotoxic D. Tobramycin E. Netilmicin 10. The incidence of AKI as a result of amphotericin B is highest with which of the following formulations?

A. Conventional desoxycholate amphotericin B B. Amphotericin B lipid complex (ABLC) C. Liposomal amphotericin B (L-AmB) D. Amphotericin B colloidal dispersion (ABCD) E. All are equally nephrotoxic 11. A 66-year-old woman with AKI (SCr = 4.6 mg/dL [407 µmol/L]) presents with mild pain.

Her physician initiates therapy with naproxen. You recommend which of the following?

A. Discontinue naproxen; initiate therapy with acetaminophen B. Discontinue naproxen; initiate therapy with ibuprofen C. Discontinue naproxen; initiate therapy with sulindac D. Continue naproxen but at a reduced dose E. Continue naproxen; monitor kidney function closely Questions 12 to 14 refer to the following case. A 69-year-old white woman has a past medical history of chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension. Her serum creatinine is stable at 1.4 mg/dL (124 µmol/L), and she is not volume overloaded. She will be receiving IV contrast dye for a cardiac catheterization.

12. All of the following have been found to decrease the risk of contrast-induced AKI except which of the following?

A. Hydration with normal saline B. Reduced volume of contrast

C. Nonionic contrast agent administration D. Administration of oral acetylcysteine E. Hydration with sodium bicarbonate 13. Which of her medications is most likely to contribute to worsening AKI? A. Hydrochlorothiazide B. Atorvastatin C. Enalapril D. Atenolol E. Acetaminophen 14. Following the catheterization, she develops acute kidney injury and is fluid overloaded. She is receiving furosemide 200 mg IV every 6 hours, with an increase in urine output from 600 mL in the last 24 hours to 1300 mL in the last 24 hours. Which of the following would you recommend next to improve urine output?

A. Add spironolactone, 50 mg orally daily B. Switch to bumetanide, 4 mg IV every 6 hours C. Increase the dose of furosemide to 1 g IV every 12 hours D. Add metolazone, 5 mg orally daily E. Add dopamine, 5 mcg/kg/minute IV 15. A 63-year-old man has suffered a GI bleed. His BUN and serum creatinine are elevated at 52 mg/dL (18.6 mmol/L) and 2.4 mg/dL (212µmol/L), respectively. His blood pressure is 105/68 mm Hg, urinary sodium concentration is 10 mEq/L (10 mmol/L), and fractional excretion of sodium is 0.5%.

Which of the following treatments is recommended at this time?

A. loop diuretic, such as furosemide B. bolus of IV fluids, such as normal saline C. ACE Inhibitor, such as enalapril D. thiazide diuretic, such as hydrochlorothiazide E. Dopamine agonist, such as fenoldopam ANSWERS 1. B 2. C 3. D 4. A 5. D 6. A 7. A 8. B 9. C 10. A 11. A 12. D

13. C 14. D 15. B CHAPTER 26. CHRONIC & END-STAGE RENAL DISEASE 1. Which of the following would not hasten the progression of chronic kidney disease (CKD) to end-stage kidney disease (ESKD)?

A. Cigarette smoking B. High blood pressure C. Hyperglycemia D. Low birth weight E. Proteinuria 2. CY is a 42-year-old Asian woman with the following laboratory values: eGFR 48 mL/min/1.73 m2 (0.46 mL/s/m2 ) and urine albumin:creatinine ratio 15 mg/g creatinine (1.7 mg/mmol creatinine). How would you classify her CKD? A. GFR category 2; Albuminuria category A1 B. GFR category 3a; Albuminuria category A1 C. GFR category 3b; Albuminuria category A2 D. GFR category 4; Albuminuria category A2 E. GFR category 5; Albuminuria category A3 3. JF is a 52-year-old Caucasian man with a history of polycystic kidney disease (PCKD) who presents for followup. His laboratory values indicate an eGFR 35 ml/min/1.73 m 2 (0.34 ml/s/m2 ) and urine albumin:creatine ratio of 45 mg/g creatinine (5.1 mg/mmol creatinine). His BP today was 135/86 mm Hg, which is consistent with the BP readings he has been taking at home. He is currently taking no antihypertensives. Which of the following treatments would you recommend to control his blood pressure?

A. Amlodipine 5 mg orally daily B. Hydrochlorothiazide 25 mg orally daily C. Lisinopril 10 mg orally daily D. Metoprolol 25 mg orally twice daily E. No treatment is necessary as his blood pressure is at goal.

2 4. JF is a 38-year-old African American man with hypertension. He was born with one kidney and dropped out of school at age 7. His father is currently receiving hemodialysis. He does not smoke cigarettes, but does drink alcohol occasionally. Which of the following is not a risk factor for CKD? A. African American ethnicity

B. Alcohol consumption C. Born with one kidney D. Family history of kidney disease E. Low education level 5. Which of the following describes the mechanism by which sodium balance is maintained in CKD? A. A functioning nephron excretes sodium at a fixed rate, regardless of the degree of kidney dysfunction.

B. Fluid retention stimulates atrial natriuretic peptide (ANP) to retain sodium to maintain sodium and fluid balance.

C. In CKD, the kidneys are not able to alter sodium reabsorption when the GFR falls below 60 ml/min/1.73 m 2 (1 ml/s/m2 ).

D. Increased sodium excretion creates an osmotic diuresis that results in urine osmolality close to plasma osmolality.

E. Restricting sodium intake is recommended in CKD to decrease overall sodium load and promote water excretion.

6. Which of the following statements is true regarding anemia of CKD? A. Blood loss during hemodialysis exacerbates the anemia.

B. It is caused by a decrease in erythropoietin production.

C. Uremia shortens the lifespan of red blood cells (RBC) which intensifies the anemia.

D. All of the above are true statements.

7. FY is a 58-year-old 90-kg man who is receiving hemodialysis. He receives Epoetin alfa 3000 units IV with each dialysis session. His laboratory parameters reveal: Hgb 9.1 g/dL (91 g/L; 5.65 mmol/L); serum ferritin 56 3 ng/mL (56 µg/L; 126 pmol/L); transferrin saturation (TSAT) 12% (0.12). Which of the following is the most appropriate treatment for him?

A. Change to darbepoetin, 40 mcg weekly with dialysis B. Increase Epoetin alfa to 150 unit/kg subcutaneously three times weekly C. Ferrous sulfate, 300 mg orally three times daily D. Iron sucrose, 100 mg intravenously (IV) weekly for 10 doses E. B and C 8. Parathyroid hormone (PTH) activity does not cause: A. Decreased phosphate excretion from the kidney B. Increased calcium reabsorption from the kidney C. Increased vitamin D activation in the kidney D. Increased calcium resorption from the bones

E. PTH causes all of the above activities 9. MP is a 62-year-old man with a history of CKD (GFR category 4) who presents with a corrected calcium level of 8.6 mg/dL (2.15 mmol/L); serum phosphorus level of 7.2 mg/dL (2.33 mmol/L); and PTH level of 135 pg/mL (135 ng/L; 14.4 pmol/L). Which of the following treatments would you recommend for his hyperphosphatemia?

A. Aluminum hydroxide 600 mg orally three times daily with meals B. Calcium acetate 667 mg orally three times a day with meals C. Calcitriol 0.25 mcg orally daily D. Cinacalcet 30 mg orally daily E. Lanthanum carbonate 600 mg orally twice daily 10. Which of the following is not a consequence of declining renal function?

A. Activation of vitamin D increases to maintain normal bone turnover.

B. Bleeding can result from accumulation of uremic toxins.

C. Parathyroid hormone levels increase to promote phosphorus excretion.

4 D. Potassium excretion increases to maintain normal levels in Stage 3 CKD. E. Protein excretion contributes to further loss of functioning nephrons.

11. Which of the following is not an indication for initiating hemodialysis in a patient with CKD? A. Intractable nausea B. Mental status changes due to volume overload C. Serum creatinine 7.3 mg/dL (645 mol/L) D. Serum potassium 6.2 mEq/L (6.2 mmol/L) E. Weight loss due to anorexia 12. Which of the following statements is true regarding hemodialysis?

A. Arteriovenous grafts (AVG) have a shorter survival time but are able to be used sooner than arteriovenous fistulas (AVF).

B. Arteriovenous fistulas (AVF) have the highest failure rate owing to thrombosis and infection.

C. Convection allows for the passive movement of small molecules across the dialyzer membrane.

D. Lower clearance rates of urea make hemodialysis allow for intermittent treatment three times weekly.

E. Ultrafiltration results in the removal of large molecules, including drugs, from the bloodstream.

13. Which of the following is true regarding potassium balance in CKD? A. Furosemide is ineffective in promoting potassium excretion when the GFR falls below 25 ml/min/1.73 m2 (0.24 ml/s/m2 ).

B. In CKD, aldosterone secretion increases GI excretion of potassium to maintain potassium balance.

C. Medications that increase serum potassium levels with normal kidney function have little effect in CKD. D. Once GFR falls below 40 ml/min/1.73 m2 (0.39 ml/s/m2 ), serum potassium levels increase.

E. Potassium restriction in CKD will lead to a negative potassium balance that can affect cardiac function.

14. Which of the following is not an appropriate treatment for metabolic acidosis in a patient with CKD? A. Calcium carbonate 500 mg orally three times daily.

5 B. Increase dialysate bicarbonate concentration.

C. Sodium bicarbonate 1300 mg orally twice daily.

D. All of the above are appropriate treatments for a patient receiving hemodialysis.

15. Which of the following is true regarding peritoneal dialysis (PD)?

A. Lower dwell times can increase solute removal during peritoneal dialysis exchanges.

B. Peritoneal dialysis causes a more rapid decline in residual renal function.

C. Peritoneal dialysis exchanges are associated with increased blood loss.

D. Peritoneal dialysis results in a lower clearance rate of urea than hemodialysis.

E. The mesothelial cells of the peritoneum act as the dialyzer in peritoneal dialysis.

6 ANSWERS 1. B 2. B 3. C 4. C 5. D 6. D 7. D 8. C 9. B 10. A 11. C 12. A 13. B 14. A 15. D

CHAPTER 27. FLUID & ELECTROLYTES 1. Which of the following may cause an osmolar gap?

A. Ethanol B. Lorazepam C. Mannitol D. A and B only E. All of the above are correct 2. LM is a 67-year-old man admitted with esophageal cancer. Patient parameters are height 185 cm (6'1") and weight 84 kg (185 lb). Determine the patient’s fluid requirements.

A. 1680 mL/day B. 2780 mL/day C. 2840 mL/day D. 2980 mL/day E. 3180 mL/day 3. A 48-year-old man was admitted to the intensive care unit after sustaining head trauma. His sodium concentration increased from 142 mEq/L (142 mmol/L) on admission to 162 mEq/L (162 mmol/L) 2 days after admission. His weight at admission was 71 kg (156 lb). Which of the following amounts most closely approximates the free water deficit in this patient?

A. 2 L B. 4 L C. 7 L D. 10 L E. 12 L 4. A 67-year-old woman (80 kg) with a history of congestive heart failure presents to the clinic with a potassium of 3.1 mEq/L (3.1 mmol/L). Her medications include digoxin 0.125 mg daily, amlodipine 10 mg daily, furosemide 40 mg daily, lisinopril 20 mg daily, and aspirin 81 mg daily. What strategy would your recommend with regard to potassium in this patient?

2 A. Begin potassium liquid 20 mEq/mL (20 mmol/mL) as 30 mL orally three times daily B. Begin potassium chloride tablets 8 mEq (8 mmol) orally daily C. Begin potassium chloride tablets 20 mEq (20 mmol) orally daily D. Admit to the hospital and give IV potassium chloride 40 mEq/L (40 mmol/L) over 1 hour E. No action is necessary 5. A 76-year-old intubated man (90 kg) has been receiving fluid resuscitation with normal saline.

His morning labs are sodium 142 mEq/L (142 mmol/L), potassium 4.1 mEq/L (4.1 mmol/L), chloride 119 mEq/L (119 mmol/L), bicarbonate 17 mEq/L (17 mmol/L), BUN 50 mg/dL (17.9 mmol/L), and creatinine

3.2 mg/dL (283 µmol/L). Blood gases are pH of 7.34 (7.35–7.45), CO2 33 mm Hg (4.4 kPa; 35– 45 mm Hg or 4.7–6.0 kPa), and HCO3 17 mEq/L or mmol/L (22–26 mEq/L or mmol/L)). After 3 L, his BP is 148/66 and heart rate is 69. Urine output has improved significantly over the last shift. The treatment plan is for more fluids. What changes would you recommend regarding fluid replacement in this patient?

A. Change normal saline to albumin B. Change normal saline to hypertonic saline (NaCl 3%) C. Change normal saline to D5W D. Change normal saline to lactated ringer’s E. Maintain current use of normal saline 6. Which of the following best describe the use of hydroxyethyl starch (HES) solutions??

A. Less expensive than crystalloids B. Relatively safe in renal dysfunction C. Considered routine maintenance fluid D. Increased risk of death in clinical trials compared to crystalloids E. Demonstrates oxygen carrying capacity 7. The majority of body fluids can be found in which compartment?

A. Intracellular B. Extracellular C. Transcellular 3 D. Interstitium E. Intravascular 8. A 44-year-old woman is admitted with a working diagnosis of sepsis. Her blood pressure is 95/55 and her serum sodium is 156 mEq/L (156 mmol/L). Which of the following would be the best initial strategy for fluid resuscitation?

A. Albumin B. 0.9% sodium chloride C. 3% normal saline D. 5% dextrose in water E. Hetastarch 9. A 25-year-old woman has been hospitalized secondary to a suspected seizure. She has a calcium of 6.5 mg/dL (1.63 mmol/L) and albumin of 2.0 g/dL (20 g/L). The corrected calcium is calculated to be: A. 7.3 mg/dL (1.83 mmol/L) B. 8.1 mg/dL (2.03 mmol/L) C. 8.8 mg/dL (2.20 mmol/L) D. 9.7 mg/dL (2.43 mmol/L) E. None of the above are correct 10. Which of the following medications is most likely to cause hyponatremia?

A. Olanzapine (Zyprexa)

B. Piperacillin/tazobactam (Zosyn) C. Gentamicin D. Clonidine (Catapres) E. Nebivolol (Bystolic) 11. The long-term use of pantoprazole (Protonix) may be associated with: A. Hypomagnesemia B. Hypokalemia C. Hypocalcemia 4 D. A + B only E. All of the above are correct 12. The appropriate use of hypertonic saline (3%) would include: A. Symptomatic hyponatremia B. Traumatic brain injury C. Use as routine maintenance fluid D. A and B only E. All of the above are correct 13. A 27-year-old woman was admitted with a 3-month history of shortness of breath and polyuria. Physical examination revealed a lethargic female with a blood pressure of 111/72 mm Hg and heart rate of 110 beats/min. Extremities were without edema.

Her laboratory test results reveal sodium 131 mEq/L (131 mmol/L), potassium 4.5 mEq/L (4.5 mmol/L), chloride 95 mEq/L (95 mmol/L), bicarbonate 15 mEq/L (15 mmol/L), albumin 3.5 g/dl (35 g/L), glucose 726 mg/dL (40.3 mmol/L), pH 7.32, PaCO2 28 mm Hg (3.7 kPa), HCO3 14 mEq/L (14 mmol/L).

Calculate the anion gap in this patient?

A. 8 B. 16 C. 21 D. 36 E. None of the above 14. What is the best medication to be given when treating chronic hyponatremia in a patient with cirrhosis?

A. Hypertonic saline solution B. Demeclocycline C. Tolvaptan (Samsca) D. Conivaptan (Vaprisol) E. Urea 15. Which of the following is a treatment for hyperphosphatemia?

5 A. Sodium polystyrene sulfonate (Kayexalate) B. Zoledronic acid (Zometa) C. Furosemide (Lasix)

D. Lanthanum carbonate (Fosrenol) E. Vitamin D 6 ANSWERS 1. E 2. B 3. C 4. C 5. D 6. D 7. A 8. B 9. B 10.A 11. E 12. D 13.C 14. C 15. D

CHAPTER 28. ACID-BASE DISTURBANCES Case for Questions 1–3. A 70-year-old woman with multiple recent admissions for congestive heart failure and medical noncompliance presents to the ED with progressive dyspnea and bilateral leg swelling.

She is in significant respiratory distress with markedly labored respirations. Laboratory data immediately before intubation are as follows: pH 7.24, PaCO2 60 mm Hg (8.0 kPa), HCO3 − 26 mEq/L (26 mmol/L).

1. The clinical scenario and laboratory findings suggest which of the following?

A. Pulmonary edema with acute respiratory acidosis B. Exacerbation of chronic obstructive pulmonary disease with chronic respiratory acidosis C. Excessive diuresis with chronic metabolic alkalosis D. New-onset diabetic ketoacidosis 2. Is the observed compensation appropriate?

A. No, the HCO3 − has increased by 2 mEq/L (2 mmol/L) B. Yes, the HCO3 − has increased by 2 mEq/L (2 mmol/L) C. Yes, the PaCO2 has increased by 20 mm Hg (2.7 kPa) D. No, the PaCO2 has increased by 20 mm Hg (2.7 kPa) 3. This patient had a difficult airway and during efforts to establish an artificial airway the PaCO2 increased by an additional 10 mm Hg (1.3 kPa). What would you expect the pH to be?

A. 7.32 B. 7.24 C. 7.16 D. 7.14 Case for Questions 4–6. A 20-year-old insulin-dependent diabetic is admitted for excessive thirst and polyuria. She has not taken her insulin therapy for “several days” because she could not afford her medications. Her laboratory test results reveal pH 7.26, PaCO2 16 mm Hg (2.1 kPa), HCO3 − 10 mEq/L (10 mmol/L), sodium 136 mEq/L (136 mmol/L), potassium 4.8 mEq/L (4.8 mmol/L), chloride 101 mEq/L (101 mmol/L).

4. What is this patient’s anion gap?

A. 9 2 B. 19 C. 25 D. 30

5. Which of the following acid–base disturbances is consistent with the patient’s arterial blood gas?

A. Normal anion gap metabolic acidosis B. Anion gap metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis 6. What is the likely cause of the patient’s acid–base disorder?

A. Hyperventilation B. Water intoxication C. Diabetic ketoacidosis D. Surreptitious diuretic abuse 7. Which of the following would be expected in a 55-year-old woman with a partial small bowel obstruction who has been NPO (nothing by mouth) with a nasogastric tube in place for the past 5 days?

A. Decreased pH, increased PaCO2, decreased HCO3 − B. Decreased pH, decreased PaCO2, decreased HCO3 − C. Increased pH, increased PaCO2, increased HCO3 − D. Increased pH, decreased PaCO2, decreased HCO3 − 8. A 62-year-old man is sent to the emergency department from a local nursing home after he was noted to be “acting funny” by the staff. Shortly after arrival the patient’s mental status rapidly deteriorated and he was intubated for airway protection. During transfer to the intensive care unit (ICU) the patient is handventilated by the respiratory therapist using an Ambu bag. The following arterial blood gas is obtained on arrival to the ICU: pH 7.53, PaCO2 25 mm Hg (3.3 kPa), and HCO3 − 22 mEq/L (22 mmol/L). Which of the following is the most likely explanation for the observed blood gas values?

A. Narcotic overdose B. Diuretic therapy 3 C. Hypoventilation secondary to an acute stroke D. Iatrogenic hyperventilation Case for Questions 9 and 10. You are seeing an obtunded patient in the emergency room. The patient is a homeless alcoholic who is well known to the emergency room staff. His laboratory data are as follows: pH 7.52, PaCO2 18 mm Hg (2.4 kPa), HCO3 − 14 mEq/L (14 mmol/L), sodium 145 mEq/L (145 mmol/L), and chloride 100 mEq/L (100

mmol/L).

9. Characterize this patient’s acid–base disorder.

A. Respiratory alkalosis, anion gap metabolic acidosis, metabolic alkalosis B. Respiratory alkalosis, metabolic alkalosis C. Anion gap metabolic acidosis, metabolic alkalosis D. Respiratory acidosis, anion gap metabolic acidosis, metabolic alkalosis 10. Which of the following comorbid conditions could account for the observed derangements in his arterial blood gasses and chemistries?

A. Salicylate overdose B. Alcoholic ketoacidosis, persistent vomiting, and aspiration pneumonia with hyperventilation C. Noncompliance with hemodialysis and infectious diarrhea D. Diabetic ketoacidosis and heroin overdose Case for Questions 11–13. A 60-year-old woman has been hospitalized in the intensive care unit for several weeks.

Her hospital course has been complicated by aspiration pneumonia and sepsis requiring prolonged use of antibiotics.

Over the last few days, she has started spiking fevers and has had profuse watery diarrhea. Her laboratory test results reveal pH 7.32, PaCO2 30 mm Hg (4.0 kPa), HCO3 − 15 mEq/L (15 mmol/L), sodium 138 mEq/L (138 mmol/L), potassium 3.5 mEq/L (3.5 mmol/L), chloride 115 mEq/L (115 mmol/L).

11. What is this patient’s anion gap?

A. 8 B. 10 C. 15 D. 17 4 12. Which of the following acid–base disturbances is consistent with the patient’s arterial blood gas?

A. Anion gap metabolic acidosis B. Normal anion gap metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis 13. What is the likely cause of the patient’s acid–base disorder?

A. Lactic acidosis B. Septic shock C. Clostridium difficile–associated diarrhea D. Uremia 14. A 22-year-old man with known schizophrenia was brought to the emergency room by family members for progressive confusion. Earlier he had told a neighbor that the “radio waves” were telling him to poison himself.

Although his arterial blood gas is not available yet, his other laboratory data include sodium 140 mEq/L (140

mmol/L), potassium 3.2 mEq/L (3.2 mmol/L), chloride 103 mEq/L (103 mmol/L), HCO3 − 16 mEq/L (16 mmol/L).

Based on nothing other than these chemistries, which of the following intoxications is improbable?

A. Ethylene glycol B. Methanol C. Salicylates D. Lithium 15. In a patient with metabolic alkalosis, the lungs attempt to compensate by the carbon dioxide level?

A. Hypoventilating, increase B. Hypoventilating, decrease C. Hyperventilating, increase D. Hyperventilating, decrease 5 ANSWERS 1. A 2. B 3. C 4. C 5. B 6. C 7. C 8. D 9. A 10. B 11. A 12. B 13. C 14. D 15. A

to

Chapter 29. Alzheimer Disease 1. Common symptoms of Alzheimer disease (AD) include which of the following: A. Memory loss B. Language difficulties C. Loss of initiative D. Change in mood or personality E. All of the above 2. Which of the following is a risk factor for AD? A. NSAID use B. Male gender C. Diabetes D. Low socioeconomic class E. All of the above 3. Death in patients with AD could be a result of: A. Sepsis B. Heart attack C. The disease itself D. Influenza E. Hyperglycemia 4. Pathologic characteristics of AD include: A. Neurofibrillary tangles B. Neuritic plaques C. Loss of acetylcholine activity D. Both B and C E. A, B, and C 2 5. Which of the following laboratory tests should be ordered for a patient to exclude other causes of dementia?

A. HIV test B. Vitamin B12 level C. Complete blood count (CBC) D. Basic metabolic panel E. All of the above 6. CK is a 75-year-old man who presents to his primary care clinic with his son. The son complains of his father’s memory loss over the last year, stating that he frequently forgets to turn off the car and lock the doors to his home. He is constantly misplacing items such as the car keys, his cell phone, and his wallet. He struggles sometimes to come up with the correct word for identifying simple objects, such as the desk or TV. Which of the following would be the most appropriate diagnosis for CK? A. All-cause dementia B. Probable AD dementia C. Possible AD dementia D. Lewy body dementia E. Vascular dementia 7. CK’s son should be counseled on which of the following to help treat his father?

A. Using a gentle calm approach with CK

B. Empathizing with CK C. Using distraction and redirection with CK D. Providing a safe environment for CK E. All of the above 8. Which of the following medications, and correct initiating dose, would be appropriate to begin in CK? A. Tacrine, 40 mg four times daily B. Donepezil, 5 mg daily C. Rivastigmine, 9.5 mg/24 h applied once daily 3 D. Galantamine, 16 mg daily E. Memantine, 10 mg twice daily 9. RK is a 75-year-old man who presents to his neurologist with symptoms of dementia of the Alzheimer type. The neurologist decides to begin donepezil at 10 mg daily. Which of the following should be of concern to the physician?

A. Tremors B. Creatinine clearance C. Agitation D. Nausea E. Sedation 10. NE is a 70-year-old woman with dementia of the Alzheimer type. She has been treated with galantamine 12 mg twice daily for the last 3 years. She currently presents to the clinic with symptoms of agitation and aggression toward her daughter, her caregiver. The daughter has tried to redirect and give reassurance to NE, but these strategies have failed. Which of the following would be the most appropriate treatment recommendation for NE to begin at bedtime?

A. Olanzapine 10 mg B. Risperidone 0.25 mg C. Ziprasidone 60 mg D. Venlafaxine 75 mg E. Carbamazepine 200 mg 11. Cholinesterase inhibitor therapy should be discontinued or changed in all of the following cases except: A. Poor tolerance to the medication B. Lack of clinical improvement after 3 to 6 months at optimal dosing C. Continued deterioration at the pretreatment rate D. Poor adherence to the medication E. Slowed deterioration following the initiation of treatment 12. Which of the following mechanisms are potential pathways for future therapies for AD? A. Increasing the production of glutamate 4 B. Stimulating the formation of estrogen C. Increasing the aggregation of Aβ into amyloid plaques D. Limiting inflammation caused by Aβ E. Increasing the neurotoxicity caused by glutamate 13. Potential treatments for behavioral symptoms of AD include which of the following: A. Temazepam

B. Eszopiclone C. Buspirone D. Methylphenidate E. Trazodone 14. WH is an 80-year-old man with recent onset of dementia of the Alzheimer type. He has been treated for the last 6 months with galantamine 12 mg daily but is still experiencing moderate deterioration. Treatment options for WH include which of the following: A. Discontinuing the galantamine therapy and starting ginkgo B. Increasing the dose of galantamine C. Continuing the galantamine and adding vitamin E D. Discontinuing the galantamine and starting an NSAID E. Continuing the galantamine at the current dose and adding caprylidene 15. Which of the following genotypes have a poorer response to available treatments for AD? A. CYP2D6 extensive metabolizer B. CYP2D6 intermediate metabolizer C. Apo E-2/2 D. Apo E-3/3 E. Apo E-4/4 5 Answers 1. E 2. C 3. A 4. E 5. E 6. B 7. E 8. B 9. A 10. B 11. E 12. D 13. E 14. B 15. E

Chapter 30. Multiple Sclerosis 1. Which of the following medications is preferred for treatment of acute relapses?

A. Interferon β-1a B. Glatiramer acetate C. Methylprednisolone D. Tizanidine E. Any of the above is acceptable 2. Which of the following may help decrease the severity of flu-like symptoms from βinterferons?

A. Taking ibuprofen about 30 minutes prior to giving the injection B. Using the buttocks as an injection site C. Applying hydrocortisone 1% cream to the injection site about 30 minutes prior to the injection, then wiping it off with an alcohol wipe just prior to performing the injection D. Rotating the injection sites E. All of the above 3. Which of the following medications may be most helpful for MS-associated fatigue?

A. Carisoprodol B. Tizanidine C. Amantadine D. Dicyclomine E. A and C 4. Which of the following toxicities is associated with mitoxantrone therapy?

A. Neuropathy 2 Multiple Sclerosis B. Cardiac C. Renal D. Pulmonary E. None of the above 5. When should treatment to prevent MS relapses begin?

A. As soon as possible after diagnosis B. After the fourth relapse C. When the patient experiences functional impairment D. Any time after age 35 years E. None of the above 6. What is the purpose of symptomatic therapies in MS treatment?

A. Speed the recovery of the patient after an acute relapse B. Decrease the number of relapses C. Prevent permanent neurologic damage D. Minimize the impact of MS on quality of life E. B and D 7. Living in which of the following places would most increase a patient’s chances of developing MS? A. Minnesota B. Kentucky C. Georgia

D. Texas E. All confer equal risk 3 Multiple Sclerosis 8. A patient tells you that she is really afraid of needles and would like the least frequently administered product for self-injection to prevent MS exacerbations. Which of the following will you recommend?

A. Interferon β-1a IM B. Interferon β-1a SQ C. Interferon β-1b SQ D. Glatiramer acetate E. Peginterferon β-1a SQ 9. A patient with aggressive MS decides she would like to become pregnant. Because of her aggressive disease, her treatment team decides to use a disease-modifying therapy during pregnancy. Which medicine is best?

A. Fingolimod B. Interferon β-1a SQ C. Mitoxantrone D. Teriflunomide E. Any of the above 10. If a patient develops a serious adverse effect requiring discontinuation of the diseasemodifying therapy, with which of the following is it necessary to do accelerated elimination procedures?

A. Interferon β-1b SQ B. Fingolimod C. Glatiramer acetate D. Natalizumab 4 Multiple Sclerosis E. Teriflunomide 11. Which of following medications is effective for progressive MS without relapses?

A. Fingolimod B. Interferon β-1a SQ C. Mitoxantrone D. Teriflunomide E. None of the above 12. Treatment of CIS with which of the following is most appropriate?

A. Dimethyl fumarate B. Fingolimod C. Interferon β-1a SQ D. Mitoxantrone E. None of the above 13. Dalfampridine should not be initiated in which of the following patients?

A. Patient with diabetes B. Patient with hypertension

C. Patient with rheumatoid arthritis D. Patient with seizure disorder E. Dalfampridine can be initiated in any of these patients 14. Which of the following is an appropriate treatment goal for a bed-bound patient treated with tizanidine?

A. Patient will ambulate without assistive devices B. Patient will walk 25 feet (~7.5 meters) in 10 seconds 5 Multiple Sclerosis C. Patient will be free of pain related to spasticity D. Patient will not have inappropriate emotional outbursts E. Patient will not have urinary tract infections related to catheterization 15. Which of the following conditions can cause a transient worsening in MS symptoms?

A. Having an influenza immunization B. Taking a sauna C. Taking a water aerobics class D. Taking guitar lessons E. Walking in the snow 6 Multiple Sclerosis Answers 1.

C 2.

E 3.

C 4.

B 5.

A 6.

D 7.

A 8.

E 9.

B 10.

E 11.

E 12.

C 13.

D 14.

C 15.

B Chapter 31. Epilepsy 1. BW is a 28-year-old man recently diagnosed with partial seizures. He works as a certified public accountant, and has begun treatment with lamotrigine. In which of the following activities is he most likely to experience difficulties due to his seizure diagnosis?

A. Performing mathematical calculations B. Keeping his driver license C. Renewing his accountant license D. Applying for graduate school 2. Which of the following neurotransmitters appears to be depleted in some patients with epilepsy?

A. GABA B. Glutamate C. Serotonin D. Acetylcholine 3. A 19-year-old woman is experiencing repeated episodes of uncontrolled twitches and jerks of her right hand. She is alert throughout these episodes. Her neurological examination and laboratory tests are normal. An EEG reveals left temporal spikes consistent with seizures. What type of seizure is she most likely experiencing?

A. Complex partial B. Myoclonic C. Infantile spasms D. Simple partial 4. A 17-year-old woman was just diagnosed with juvenile myoclonic epilepsy (JME). Which of the following antiepileptic drugs should be started?

A. Valproate B. Levetiracetam C. Oxcarbazepine D. Pregabalin 5. In which of the following groups of patients is increased monitoring of AED serum concentrations advisable?

A. Nonpregnant women B. Men starting gabapentin C. Children D. Patients with nonepileptic events 6. Three months ago, lamotrigine was added to the therapeutic regimen of a 45-year-old man taking carbamazepine for partial seizures. The physician decides to taper and discontinue the carbamazepine. He is currently taking lamotrigine 600 mg daily. Which of the following lamotrigine doses will most likely be required after the carbamazepine is discontinued?

A. 400 mg twice daily B. 300 mg three times a day

C. 200 mg twice daily D. 50 mg twice daily 7. A 28-year-old woman is started on oxcarbazepine for partial seizures. Which of the following should she take in addition to the oxcarbazepine?

A. Vitamin C B. Riboflavin C. Vitamin A D. Folic acid 8. A 75-year-old man was recently diagnosed with new onset seizures. Which of the following would be the best drug to initiate in this patient?

A. Lamotrigine B. Phenytoin C. Valproate D. Carbamazepine 9. A 35-year-old woman is being started on lamotrigine for newly diagnosed epilepsy. She is otherwise healthy and is not taking any medications except for acetaminophen for an occasional headache. Which of the following will be most important to monitor as she starts lamotrigine?

A. Vision B. Blood count C. Rash D. Heart rhythm 10. A 25-year-old woman presents a new prescription for levetiracetam in your pharmacy. She explains that she was recently diagnosed with epilepsy. Upon reviewing her medication profile, you find that she is taking a low estrogen birth control product and occasionally takes ibuprofen for headaches. Which of the following options would be best to tell her?

A. Talk to your physician about taking a high estrogen birth control product B. Use alternate forms of birth control C. Talk with your physician about taking a progesterone-only birth control product D. You should not experience problems with your current birth control 11. A 30-year-old patient is treated with oxcarbazepine for partial seizures. She has been seizurefree on this treatment for 1 year. Her most recent EEG, from a year ago, was read as occasional left temporal sharp waves. She would like to stop oxcarbazepine due to being seizure-free for a year. Which of the following treatment options would be best?

A. Discontinue oxcarbazepine immediately B. Taper and discontinue oxcarbazepine over 3 months C. Increase her oxcarbazepine dose D. Continue oxcarbazepine at the current dose 12. A 32-year-old man is taking phenytoin 300 mg daily for seizures. His phenytoin serum concentration is 8 mg/L, and he has experienced a 50% increase in seizures over the last month.

He does not report any increase in dose-related adverse effects. The physician would like to increase the phenytoin dose. Which of the following doses would be the best new dose for this patient?

A. 350 mg B. 600 mg C. 550 mg

D. 330 mg 13. A 72-year-old man has taken carbamazepine for 20 years with excellent control of his seizures. He was recently diagnosed with atrial fibrillation and his physician started amiodarone.

Which of the following would be best to monitor as the amiodarone is started?

A. Increased seizures B. Diplopia C. Renal function D. Hepatic function 14. A 28-year-old woman is taking levetiracetam for seizures. She comes to clinic today and is 3 months pregnant. Which of the following would be of greatest concern over the remainder of her pregnancy?

A. Increased levetiracetam adverse effects B. Birth defects C. Increased seizures D. Premature labor 15. A 46-year-old man is taking tramadol 100 mg every 4 to 6 hours for back pain. Yesterday he experienced a generalized tonic-clonic seizure. He has never had seizures previously, and his neurological exam is completely normal. His pain is affecting his mood, and he feels depressed.

Which of the following would be the best management of this patient?

A. Start an antiepileptic drug B. Make no changes in medications and carefully monitor C. Start bupropion for depression D. Discontinue tramadol Answers 1.

B 2.

A 3.

D 4.

B 5.

C 6.

C 7.

D 8.

A 9.

C 10.

D 11.

D

12.

A 13.

B 14.

C 15.

D

Chapter 31. Epilepsy 1. BW is a 28-year-old man recently diagnosed with partial seizures. He works as a certified public accountant, and has begun treatment with lamotrigine. In which of the following activities is he most likely to experience difficulties due to his seizure diagnosis?

A. Performing mathematical calculations B. Keeping his driver license C. Renewing his accountant license D. Applying for graduate school 2. Which of the following neurotransmitters appears to be depleted in some patients with epilepsy?

A. GABA B. Glutamate C. Serotonin D. Acetylcholine 3. A 19-year-old woman is experiencing repeated episodes of uncontrolled twitches and jerks of her right hand. She is alert throughout these episodes. Her neurological examination and laboratory tests are normal. An EEG reveals left temporal spikes consistent with seizures. What type of seizure is she most likely experiencing?

A. Complex partial B. Myoclonic C. Infantile spasms D. Simple partial 4. A 17-year-old woman was just diagnosed with juvenile myoclonic epilepsy (JME). Which of the following antiepileptic drugs should be started?

A. Valproate B. Levetiracetam C. Oxcarbazepine D. Pregabalin 5. In which of the following groups of patients is increased monitoring of AED serum concentrations advisable?

A. Nonpregnant women B. Men starting gabapentin C. Children D. Patients with nonepileptic events 6. Three months ago, lamotrigine was added to the therapeutic regimen of a 45-year-old man taking carbamazepine for partial seizures. The physician decides to taper and discontinue the

carbamazepine. He is currently taking lamotrigine 600 mg daily. Which of the following lamotrigine doses will most likely be required after the carbamazepine is discontinued?

A. 400 mg twice daily B. 300 mg three times a day C. 200 mg twice daily D. 50 mg twice daily 7. A 28-year-old woman is started on oxcarbazepine for partial seizures. Which of the following should she take in addition to the oxcarbazepine?

A. Vitamin C B. Riboflavin C. Vitamin A D. Folic acid 8. A 75-year-old man was recently diagnosed with new onset seizures. Which of the following would be the best drug to initiate in this patient?

A. Lamotrigine B. Phenytoin C. Valproate D. Carbamazepine 9. A 35-year-old woman is being started on lamotrigine for newly diagnosed epilepsy. She is otherwise healthy and is not taking any medications except for acetaminophen for an occasional headache. Which of the following will be most important to monitor as she starts lamotrigine?

A. Vision B. Blood count C. Rash D. Heart rhythm 10. A 25-year-old woman presents a new prescription for levetiracetam in your pharmacy. She explains that she was recently diagnosed with epilepsy. Upon reviewing her medication profile, you find that she is taking a low estrogen birth control product and occasionally takes ibuprofen for headaches. Which of the following options would be best to tell her?

A. Talk to your physician about taking a high estrogen birth control product B. Use alternate forms of birth control C. Talk with your physician about taking a progesterone-only birth control product D. You should not experience problems with your current birth control 11. A 30-year-old patient is treated with oxcarbazepine for partial seizures. She has been seizurefree on this treatment for 1 year. Her most recent EEG, from a year ago, was read as occasional left temporal sharp waves. She would like to stop oxcarbazepine due to being seizure-free for a year. Which of the following treatment options would be best?

A. Discontinue oxcarbazepine immediately B. Taper and discontinue oxcarbazepine over 3 months C. Increase her oxcarbazepine dose D. Continue oxcarbazepine at the current dose 12. A 32-year-old man is taking phenytoin 300 mg daily for seizures. His phenytoin serum concentration is 8 mg/L, and he has experienced a 50% increase in seizures over the last month.

He does not report any increase in dose-related adverse effects. The physician would like to increase the phenytoin dose. Which of the following doses would be the best new dose for this

patient?

A. 350 mg B. 600 mg C. 550 mg D. 330 mg 13. A 72-year-old man has taken carbamazepine for 20 years with excellent control of his seizures. He was recently diagnosed with atrial fibrillation and his physician started amiodarone.

Which of the following would be best to monitor as the amiodarone is started?

A. Increased seizures B. Diplopia C. Renal function D. Hepatic function 14. A 28-year-old woman is taking levetiracetam for seizures. She comes to clinic today and is 3 months pregnant. Which of the following would be of greatest concern over the remainder of her pregnancy?

A. Increased levetiracetam adverse effects B. Birth defects C. Increased seizures D. Premature labor 15. A 46-year-old man is taking tramadol 100 mg every 4 to 6 hours for back pain. Yesterday he experienced a generalized tonic-clonic seizure. He has never had seizures previously, and his neurological exam is completely normal. His pain is affecting his mood, and he feels depressed.

Which of the following would be the best management of this patient?

A. Start an antiepileptic drug B. Make no changes in medications and carefully monitor C. Start bupropion for depression D. Discontinue tramadol Answers 1.B 2.A 3.D 4.B 5.C 6.C 7.D 8.A 9.C 10.D 11.D 12.A 13.B 14.C 15.D

Chapter 32. Statue Epilepticus 1. A 46-year-old man is brought into the emergency department after having convulsions for approximately 10 minutes. What is the best choice for an initial medication for this patient?

A. propofol B. phenytoin C. diazepam D. phenobarbital E. topiramate 2. A patient is admitted to the emergency department and diagnosed with status epilepticus. He has a blood pressure of 90/65 and a heart rate of 120 beats/min. Which of the following combinations of agents will have the least effects on this patient’s cardiorespiratory system?

A. lorazepam and phenytoin B. midazolam and valproate sodium C. diazepam and fosphenytoin D. midazolam and phenobarbital E. lorazepam and propofol 3. Which of the following is a sign of prolonged generalized convulsive status epilepticus?

A. hypertension B. incontinence C. sweating D. fever E. rhabdomyolysis 4. Which of the following receptor activity changes may occur during status epilepticus?

A. A decrease in GABA receptor activity and an increase in NMDA receptor activity B. An increase GABA receptor activity and an increase in NMDA receptor activity C. A decrease in GABA receptor activity and a decrease in NMDA receptor activity D. An increase in GABA receptor activity and a decrease in NMDA receptor activity E. None of the above 5. All of the following drugs used in the treatment of status epilepticus contain considerable amounts of propylene glycol except?

A. diazepam B. fosphenytoin C. lorazepam D. phenytoin E. Both B and D 6. A patient is receiving an intravenous loading dose of phenytoin 1000 mg as therapy for status epilepticus. Over what minimal time period should this dose be infused?

A. 5 minutes B. 10 minutes C. 15 minutes 3 D. 20 minutes E. 30 minutes 7. A 7-year-old boy is admitted to the emergency department in status epilepticus. The nurses and physicians are unable to obtain IV access in him. Which of the following could be an appropriate initial treatment recommendation?

A. fosphenytoin IM B. diazepam PR C. lorazepam IM D. topiramate IM E. midazolam PR 8. A patient is seen in the emergency department for ongoing seizure activity. He has been seizing for at least 10 minutes. A family member provides a history of hypertension, diabetes, and hyperlipidemia. Which of the following should be performed next?

A. Obtain EEG B. Give diazepam C. Check blood glucose D. Give IV dextrose E. Load with phenytoin 9. Which of the following pairs is a correct sequence for a 75 kg patient in status epilepticus?

A. Lorazepam 2 mg IV push followed by phenytoin 1500 mg IV bolus 4 B. Lorazepam 8 mg IV push followed by phenytoin 1000 mg IV bolus C. Diazepam 15 mg IV push followed by fosphenytoin 1500 mg PE IV bolus D. Diazepam 5 mg IV push followed by valproic acid 1000 mg IV bolus E. Midazolam 4 mg/hour infusion followed by fosphenytoin 1500 mg PE IV bolus 10. A 57-year-old man is being treated for status epilepticus. He has already received one dose of IV lorazepam 5 minutes ago and continues to have convulsions. His breathing is now slow and shallow, and his oxygen saturation is 87% (0.87) on room air. His blood pressure is 109/67, and his heart rate is 93 beats/min. What would be the next appropriate step?

A. Give a second dose of lorazepam B. Switch to intravenous diazepam C. Give a loading dose of fosphenytoin D. Consider obtaining an EEG E. Consider endotracheal intubation 11. When treating status epilepticus in older adults, which of the following is true?

A. Hepatic and renal clearance are usually higher.

B. The infusion rates used are typically faster.

C. They are less prone to the side effects of drugs.

D. They display a decreased protein binding.

E. They are at lower risk for drug and disease state interactions.

5 12. A 24-year-old woman who is 7 months pregnant develops status epilepticus while being seen in clinic. Which of the following is true?

A. Phenytoin is not considered since it is teratogenic.

B. Levetiracetam is the agent of choice for status epilepticus in pregnant females.

C. The fetus is at risk of hypoxia if the status epilepticus is not treated quickly.

D. Lorazepam is administered intravenously at a dose of 0.4 mg/kg.

E. The volume of distribution is considerably lower in pregnant females.

13. A 42-year-old mechanically ventilated woman is being treated for status epileptics in the intensive care unit. She has received two doses of lorazepam and a loading dose of phenytoin. It

has been 45 minutes since the start of therapy with no improvement in her condition. Her tonicclonic movements are diminishing, but she is not arousable. What would be the next appropriate step?

A. Give another dose of IV lorazepam B. Give a dose of IV diazepam C. Bolus with IV valproic acid D. Initiate midazolam infusion E. Give a second phenytoin bolus 14. All of the following agents can be given intravenously in refractory status epilepticus except?

A. isoflurane B. lacosamide 6 C. ketamine D. levetiracetam E. none of the above 15. You are helping to treat a 50 kg patient in refractory status epilepticus who is currently on midazolam infusion at 5 mg/hour. She has been on this dose for the past 12 hours, and the continuous EEG reports ongoing seizure activity. She is receiving therapeutic doses of fosphenytoin. Which of the following would be the next best intervention?

A. Increase the infusion rate by 5 mg/hour B. Give a 5 mg IV bolus of midazolam C. Switch to propofol infusion D. Start levetiracetam therapy E. Give a ketamine bolus 7 Answers 1. C 2. B 3. E 4. A 5. B 6. D 7. B 8. C 9. C 10. E 11. D 12. C 13. D 14. A 15. B

Chapter 33. Parkinson Disease 1. Patients with Parkinson disease (PD) have both motor and nonmotor symptoms. Which of the following statements regarding nonmotor symptoms associated with PD is true?

A. Depression is common in PD and can become worse when starting a COMT inhibitor B. Diarrhea is usually problematic throughout the course of PD in most patients C. Sleep problems are related to drug therapy for PD and can easily be treated by changing medications D. Improving the on time may improve select nonmotor symptoms E. The risk of falls in patients with PD is similar to that of patients without PD 2. BB, a 75-year-old man with PD, comes to the pharmacy to pick up his prescriptions. He is currently taking Sinemet, ropinirole, and rasagiline. His wife tells you that for the last month after starting the ropinirole her husband has been talking to people who are not present. BB does not seem bothered by the hallucinations. Which of the following is appropriate to minimize BB’s hallucinations?

A. Decrease the dose of Sinemet or ropinirole B. Switch rasagiline to a COMT inhibitor C. The hallucination should improve without intervention as he becomes used to the medications changes D. Add low dose quetiapine E. A and D 3. CC has had PD for 10 years. He takes one carbidopa/levodopa 25/100 mg tablet at 8 AM, 2 PM, and 8 PM, and he reports that the 8 AM dose and 2 PM dose wear off 1 to 2 hours early.

Which of the following options would be best to minimize early wearing off symptoms for this patient?

A. Administer levodopa with food and add a dopamine agonist B. Change to carbidopa/levodopa liquid formulation C. Increase each carbidopa/levodopa dose by one tablet D. Decrease the dosage of carbidopa to 10 mg E. Change dose times of carbidopa/levodopa to 8 AM, Noon, 4 PM and possibly 8 PM if needed 4. DD is a newly diagnosed patient with PD. Which of the following statements regarding treatment with MAO-B inhibitors is true?

A. Greatest efficacy has been seen in late-stage PD B. Neuropsychiatric effects such as depression are common and problematic C. Insomnia is more common with selegiline than with rasagiline D. Dyskinesias usually improve when adding a MAO-B inhibitor E. They are proven to be neuroprotective 5. You are managing the drug therapy of a 60-year-old female patient diagnosed with PD 2 years ago who has not been on medications previously. She is a piano teacher and now complains of slowness and worsening tremor in her right hand, making it difficult for her to work. Based on this information, what is your recommendation?

A. Tolcapone B. Pramipexole C. Amantadine D. Selegiline

E. Delay treatment 6. Which of the following associated symptoms of PD will not improve with lowering the dose of PD medications?

A. Psychosis B. Depression C. Orthostatic hypotension D. Sleep disturbances E. Nausea 7. A new patient with Parkinson disease comes to the pharmacy with a prescription for pramipexole 0.25 mg at bedtime. Which of the following is the most common adverse effect of pramipexole?

A. Obsessive behavior B. Livedo reticularis C. Nausea D. Thickening of heart valves 8. A patient comes into your clinic for a “second opinion.” He was told that his PD symptoms were mild and he should delay starting medicine. Which of the following are reasons for delaying levodopa treatment?

A. Nonpharmacologic treatment may improve symptoms B. Dopamine agonists are equally effective to levodopa in controlling motor symptoms C. The later levodopa is started, the later depression symptoms start D. The risk of motor fluctuations is greater in patients starting levodopa versus a dopamine agonist E. Starting with a monoamine oxidase (MAO-B) inhibitor decreases the risk of drug interactions 9. An 82-year-old man is diagnosed with early PD. His symptoms are mild constipation and tremor in his right hand that are affecting his quality of life. Which of the following medications would you suggest starting?

A. Amantadine B. Levodopa C. Tolcapone D. Entacapone E. Pramipexole 10. A 75-year-old man receives a new prescription for Sinemet 10/100 TID, as he was just diagnosed with Parkinson disease. He also takes iron and vitamin C supplements for Restless Legs Syndrome. Which of the following is appropriate?

A. Tell the patient that he should take Sinemet every other day to allow for drug-free days and add rasagiline for neuroprotection B. Call the physician and suggest that the prescription be changed to Sinemet 25/100 C. Tell the patient that he should take both his medicines at the same time to improve compliance D. Advise the patient to space the iron and levodopa dosing by 2 hours E. B and D are true 11. Which treatment symptom pair is the best initial treatment for the nonmotor symptoms of PD?

A. Treat seborrhea with dandruff shampoos B. Treat postural hypotension with prednisone C. Treat constipation with amantadine D. Treat hallucinations with chlorpromazine E. Treat nausea with promethazine 12. A 65-year-old patient with Parkinson disease asks you to explain which surgical procedure could be an option for him. Based on available evidence, which of the following is the best answer at this time?

A. Pallidotomy B. Deep-brain stimulation C. Thalamotomy D. Spheramine transplantation E. None of the above are options 13. KM is a 68-year-old woman with a history of Parkinson disease on Sinemet 25/100 (dosed at 7 AM, 11 AM, 2 PM, 7 PM). The patient reports that she has trouble initiating movements on some days and that she is constantly worried about falling. She tried changing the timing of her medications, but stopped because she became increasingly “off.” She also reports new symptoms of anxiety and apathy. Which of the following is true?

A. Adding a COMT inhibitor would increase on time and possibly help her symptoms 6 6 B. The patient could be suffering from freezing episodes, which may be exacerbated by her anxiety C. Adding a benzodiazepine may help with her anxiety, but may also increase her risk of falls D. B and C E. All of the above 14. MM is a 60-year-old man who has come in for evaluation of the following symptoms: increased sadness, constipation, urinary frequency, slowness, and mild tremor in his right hand. Which of the following statements is true about the onset of PD symptoms and the treatment goals?

A. Sinemet should be started as soon as possible to minimize the demyelization of dopamine neurons B. Constipation is a very common autonomic symptom of PD and may precede the motor symptoms C. Sinemet and surgery can stop the progression of symptoms D. Sadness, constipation, and urinary frequency can be associated symptoms of PD but are not treatable with medications E. Maintaining an active physical activity program has little effect on the progression of symptoms 7 7 15. ML is a 65-year-old Asian man who presents with symptoms of tremor, slowness, and stiffness. His current medications include loxapine, atorvastatin, hydrochlorothiazide, and metoclopramide. Which of the following medications could contribute to his PD symptoms?

A. Loxapine B. Atorvastatin C. Metoclopramide D. A and B E. A and C 8 8 Answers 1. D 2. E 3. E 4. C 5. B 6. B 7. C 8. D 9. B 10. E 11. A 12. B 13. E 14. B 15. E Chapter 34. Pain Management 1. Which of the following would NOT be an appropriate choice for postoperative pain management in a patient dependent on opioids?

A. Epidural analgesia with morphine and bupivacaine B. Patient-controlled analgesia with hydromorphone C. Oral oxycodone 5 mg po every 4 to 6 hours as needed for pain D. Morphine 10 mg IV every 4 to 6 hours as needed for pain 2. Mrs. B is an 85-year-old patient with a diagnosis of severe Alzheimer disease and metastatic breast cancer. Upon admission to the long-term care facility, pain management is listed in her care plan. Which of the following pain assessment tools may be helpful in monitoring the effectiveness of her pain medication?

I. Visual analog scale II. PAINAD III. Physiological indicators A. I only B. III only C. I and II D. II and III E. I, II, and III 3. If tolerance occurs in a patient who is receiving long-term opioid therapy, this means

that: Pain Management 2 2 A. The patient has become addicted and should be referred to a drug treatment program B. The patient has lost control over his or her use of the medication, and treatment should be discontinued C. The patient is having a normal physiological response to the medication and will experience a withdrawal syndrome if the medication is stopped or quickly decreased D. The patient has become tolerant to the drug, and another therapeutic category must be selected E. The dose can be increased as needed to achieve pain relief 4. BA is a 58-year-old man with lung cancer and bone metastases who is currently receiving morphine oral solution 10 mg every 4 hours around the clock. In the last 24 hours, BA has used an additional 20 mg of morphine as rescue doses. He desires to switch to a sustained-release form of morphine, MS Contin. Suggest the most appropriate dose of MS Contin for this patient.

A. MS Contin 60 mg every day B. MS Contin 90 mg every day C. MS Contin 30 mg two times daily D. MS Contin 45 mg two times daily E. MS Contin 80 mg every day 5. Which additional therapy may be appropriate for BA? A. Amphetamine B. NSAID C. Tricyclic antidepressants Pain Management 3 3 D. Antihistamine E. Antiepileptic 6. MA is an oncology patient who is currently receiving morphine oral solution 10 mg every 4 hours. Recommend an appropriate rescue dose for this patient.

A. 0.5 mg to 1 mg PO every 1 to 2 hours B. 3 to 6 mg PO every 1 to 2 hours C. 3 to 6 mg PO every 4 hours D. 0.5 mg to 1 mg PO every 4 hours E. 5 mg to 10 mg PO every 4 hours 7. Mrs. Jones is a 78-year-old woman with a history of diabetes, treated with oral medications. Recently, she has been complaining of pain in her feet that she describes as “numbness and tingling”. What is the most likely pathophysiologic type of pain in this case?

A. Nociceptive B. Inflammatory C. Neuropathic D. Functional

E. Acute 8. A physician requests your advice regarding use of an opiate for chronic, nonmalignant pain. Which of the following is the most appropriate response?

A. Morphine IR (immediate release) is the gold standard B. Opioids should always be avoided in chronic pain situations C. Limited evidence exists for long-term opioid treatment Pain Management 4 4 D. A mixed agonist/antagonist may be preferred E. A short-acting opioid may be preferred 9. LB is a 67-year-old woman with complaints of pain in the knee. She has occasional swelling but no deformity. She describes pain as a 3 on a scale of 1 to 10. Her primary care physician asks you for advice regarding initial pain management for this patient.

What would you select as initial treatment for her pain?

A. Motrin IB (ibuprofen) 200 mg every 6 hours B. Tylenol (acetaminophen) 325 mg every 4 to 6 hours C. Tylenol Extra-Strength (acetaminophen) 500 mg two tablets every 6 hours D. Ecotrin (enteric-coated aspirin) 325 mg every 4 to 6 hours E. Celecoxib 200 mg daily 10. FG is a 65-year-old man with lower back pain. He complains of numbness and electricshock–like pain localized to his lumbar region. Which of the following would be the most appropriate initial treatment for his type of pain?

A. Duloxetine B. Gabapentin C. Amitriptyline D. Lidocaine transdermal E. Pregabalin 11. C.K. is 45-year woman with a new diagnosis of fibromyalgia. Her main complaints are fatigue and difficulty sleeping. Which of the following would you recommend for initial treatment of her condition?

A. Amitriptyline 10 mg HS B. Pregabalin 50 mg TID C. Naproxen 500 mg BID D. Tramadol 50 mg HS E. Oxycodone SR 10 mg BID Pain Management 5 5 12. RS is a 62-year-old investment banker who had been suffering with chronic low back pain for the past 2 months subsequent to a motor vehicle accident. He has been evaluated, and no pathology is noted. He is trying to adhere to a prescribed exercise plan but is limited by pain. His provider ordered morphine 5 to 10 mg orally every 4 hours, which provided good relief but caused itching. The prescriber has asked you to calculate a dose of oxycodone that will provide equivalent pain control. RS says a total daily dose of about 45 mg of oral morphine provides good pain control. What total daily dose of oxycodone would you recommend?

A. 60 mg

B. 45 mg C. 30 mg D. 20 mg E. 15 mg 13. P.S. is a 62-year-old man with tetraplegia due a motor vehicle accident 20 years ago. He complains of intense left flank pain due to hydronephrosis of the left kidney. He rates the pain as 7 or 8 on scale of 1 to 10 and describes it as constant. He is not a surgical candidate for removal of the diseased kidney. Which of the following would be the best recommendation for treatment of P.S.’s visceral pain?

A. Acetaminophen B. Celecoxib C. Hydromorphone D. Gabapentin E. Venlafaxine 14. Which of the following statements regarding the transmission of pain is correct?

Pain Management 6 6 I. C-fibers are responsible for transmission of acute, sharp pain II. Nociceptors may be stimulated by a thermal, mechanical, or chemical stimulus III. Modulation of pain impulses may occur in the dorsal horn, the brain, and the descending (efferent) system.

A. I only B. III only C. I and II D. II and III E. I, II, and III 15. CO is a 64-year-old woman with metastatic breast cancer. Pain has been controlled with the following medications: hydromorphone (Dilaudid) 10 mg IV every 1 hour and levorphanol (Levo-Dromoran) 10 mg PO every 4 hours. As the hospice care pharmacist, you are asked to convert this patient to a morphine infusion. Based on CO’s opioid requirement, recommend an initial infusion rate (mg/hour) of parenteral morphine.

A. 70 mg/hour B. 55 mg/hour C. 25 mg/hour D. 110 mg/hour E. 160 mg/h Pain Management 7 7 Answers 1. A 2. D 3. E 4. C 5. B 6. B 7. C

8. C 9. C 10. D 11. A 12. D 13. C 14. D 15. B

Chapter 35. Headache 1. Which of the following triptans would be appropriate for prevention of menstrual migraines?

A. Sumatriptan B. Almotriptan C. Frovatriptan D. Elmotriptan 2. Why should NSAIDs be avoided for headache in the third trimester of pregnancy?

A. Potential for teratogenicity B. Premature closure of the ductus arteriosus C. Induction of labor D. All of the above 3. Which of the following herbal medications might be effective at decreasing incidence of migraines?

A. Ginkgo biloba B. Ginseng C. Butterbur D. Chromium 4. Which of the following would be associated with an increased prevalence of migraine headache?

A. Low income B. Female sex C. Age > 30 2 D. All of the above 5. Which of the following types of headache is least common?

A. Migraine B. Tension C. Cluster D. Medication overuse headache 6. Which of the following triptans should be recommended for patients who have nausea/vomiting associated with migraine headaches?

A. Zolmitriptan B. Eletriptan

C. Almotriptan D. Naratriptan 7. How many headache days in a 1-month period must occur in order for a patient to be classified as having a chronic tension-type headache (TTH)?

A. 15 B. 4 C. 10 D. 7 8. The pathogenesis of TTH is related to which of the following presumed mechanisms?

A. Muscle contraction B. Hypoxemia C. Hereditary factors D. CNS pain sensitization 3 9. Which of the following is a characteristic of a cluster headache?

A. Chronic daily pain B. More common in men C. Onset after age 50 D. Dull, band-like frontal pain 10. A 20-year-old college sophomore presents to the student health department with the “worst headache of my life.” She provides a history of migraine headache treated with triptans. On physical examination, she is running a fever, her neck is stiffened, and a rash is noted. This type of headache disorder is classified as which of the following?

A. Treatment emergent B. Primary C. Secondary D. Uncomplicated 11. Which of the following is the most appropriate pharmacologic recommendation to treat severe nausea and vomiting in a headache patient?

A. High flow oxygen therapy B. Oral opioid analgesics C. Intramuscular chlorpromazine D. Intravenous dihydroergotamine (DHE) 12. Which of the following prophylactic treatments could potentially lead to the development of the “serotonin syndrome” in a patient prescribed naratriptan for migraine headache?

A. Timolol B. Valproic acid 4 C. Topiramate D. None of the above 13. Serotonin receptor agonists (triptans) are available in all of the following dosage forms except: A. Intranasal spray B. Orally disintegrating tablet C. Rectal suppository D. Subcutaneous injection

14. Which of the following therapeutic interventions would be most appropriate for the acute management of migraine without aura in a 54-year-old woman recently discharged from the coronary care unit (CCU) after an acute myocardial infarction (AMI)?

A. Intranasal sumatriptan B. Oral acetaminophen and hydrocodone C. Oral rizatriptan D. Subcutaneous DHE 15. Which of the following nonpharmacologic therapies is/are appropriate recommendation(s) for prevention of migraine headache?

A. Consistent sleep-wake cycle B. Caffeine avoidance C. Daily physical activity D. All of the above 5 Answers 1. C 2. B 3. C 4. D 5. C 6. A 7. A 8. D 9. B 10. C 11. C 12. D 13. C 14. B 15. D

Chapter 36. Substance-Related 1. According to recent US national estimates, which of the following substances is associated with the highest incidence of new drug initiates among individuals younger than 18 years?

A. Alcohol B. Opioids C. Cannabinoids D. Nicotine E. Stimulants 2. The rewarding effects of acute drug use are partially the result of the activation of which of the following neuronal pathways?

A. The hypothalamic pituitary circuit, resulting in corticotropin-releasing factor (CRF) release B. The tuberoinfundibular dopamine (DA) pathway, resulting in release of endorphins C. The mesocorticolimbic DA pathway, resulting in activation of nucleus accumbens (NA) D. The serotonin projections from the raphe nuclei, activating the hippocampus and amygdala E. The dopamine receptors (D1) in the caudate, resulting in the release of glutamate in the NA Substance-related Disorders 2 3. Which of the following substances is not associated with a DSM-5 intoxication criteria set?

A. Alcohol B. Opioids C. Cannabinoids D. Nicotine E. Stimulant 4. A young college student is brought into the emergency department (ED) after a party at his fraternity house. His fraternity brothers are alarmed because they were not able to arouse him when they found him slumped on the floor in the bathroom. His blood alcohol concentration (BAC) is 580 mg/dL (0.58% or 126 mmol/L). Which of the following best explains his current state?

A. His blood ethanol level is likely to explain his current state, but it would be prudent to check for the presence of other drugs that could potentiate ethanol effects.

B. His blood ethanol level is unlikely to explain his current state. He has probably fallen in the bathroom, so he should be rushed to radiology to check for a cerebral hemorrhage.

C. His blood ethanol level could explain his current state, but only if he has also used an opioid; it would potentiate the CNS and respiratory depressant effects of ethanol.

D. His blood ethanol level could explain his current state, but he should be sent home to “sleep it off” because ethanol self-ingestion is never fatal, and he is not likely to need medical support.

E. An alcohol antagonist should be administered immediately to reverse the BAC effects.

Substance-related Disorders 3 5. Which of the following medications is the most appropriate to treat a patient experiencing alcohol withdrawal who has a positive past medical history of alcohol withdrawal related seizures?

A. Phenytoin B. Diazepam C. Clonidine D. Valproic acid

6. GF is a 36-year-old woman who has a 10-year history of heavy ethanol use combined with daily heroin use over the past year. Additionally, she has used cocaine at least weekly for the last 8 months. After being admitted to the hospital after an automobile accident, her treatment team is worried about drug withdrawal complicating her medical treatment. She is likely to be in the greatest medical danger from: A. Cocaine withdrawal because it is often associated with seizures B. Heroin withdrawal because it is often very uncomfortable and fatal C. Ethanol withdrawal associated with seizures, delirium, and death D. None of the above are dangerous medical situations E. All of the above are dangerous medical situations 7. A 48-year-old man is undergoing acute alcohol withdrawal. What is the most important issue regarding the administration of thiamine during alcohol withdrawal?

Substance-related Disorders 4 A. It should be continued for at least 3 weeks.

B. It should be combined with other vitamins in an IV fluid.

C. It should be given before any glucose-containing fluids.

D. It should be combined with magnesium in an IV fluid.

E. It should be avoided unless encephalopathy is present.

8. Which of the following medications should be AVOIDED in a patient being treated for an alcohol use disorder who you believe is likely to relapse and continue drinking alcohol?

A. Acamprosate B. Disulfiram C. Naltrexone D. All the above E. None of the above Substance-related Disorders 5 9. A 22-year-old woman with a 3-year heroin addiction has decided to undergo detoxification and treatment for her addiction. Assuming you have approval to use buprenorphine in this patient, how should you initiate buprenorphine treatment?

A. Have the patient wait 7 days from the last heroin use, verify that the withdrawal symptoms have decreased to a Clinical Opiate Withdrawal Scale (COWS) score of less than 5, and then initiate treatment at 4 mg given twice daily.

B. Because buprenorphine has low bioavailability that can be further impaired by vomiting associated with heroin withdrawal, wait 12 hours after last heroin use and initiate treatment with 4 mg buprenorphine given IV. C. Initiate rapid withdrawal using naloxone under conscious sedation. Wait until the patient has been free of withdrawal symptoms for 2 weeks and initiate buprenorphine 2 mg twice daily and titrate up to 32 mg/day if necessary.

D. Verify that the patient’s last heroin use occurred at least 12 hours ago and that the COWS score is greater than or equal to 5. Then initiate treatment at 2 to 4 mg every 2 hours up to a maximum of 8 mg over the first 24 hours.

E. Wait until COWS score is greater than 5, and then send patient home with doses of clonidine and loperamide for withdrawal symptoms. Have the patient return in 3 days to begin treatment with 4 mg twice daily of buprenorphine.

Substance-related Disorders 6 10. You are treating a pregnant woman who currently smokes one pack per day of cigarettes, consumes variable levels of alcohol on most days, and periodically injects heroin. Your treatment team has decided to aggressively manage this woman with pharmacotherapy to try to protect the fetus from substance use exposure, particularly illicit opioids. Which of the following medications should be AVOIDED in this patient?

A. Nicotine patch B. Methadone C. Buprenorphine D. Varenicline 11. The coingestion of cannabinoids and which of the following substances could potentially be acutely problematic for a patient with moderate to severe cardiovascular disease?

A. Cigarette smoking B. Amphetamines C. Anticholinergic medication D. All of the above E. None of the above Substance-related Disorders 7 12. Synthetic cannabinoid (eg, Spice or K2) users may present with severe psychiatric manifestations including psychosis and acute onset anxiety. Identify the primary theorized cause of psychiatric symptoms associated with the use synthetic cannabinoids?

A. Route of administration B. High THC potency C. Lack of cannabidiol D. Low THC potency E. Addition of cannabidiol 13. AS is a 47-year-old man with a long history of alcohol dependence and co-occurring major depressive disorder (MDD). He was admitted 2 weeks ago to an inpatient unit for alcohol withdrawal (CIWA-Ar = 18) complicated by seizure activity. His nausea and vomiting, seizures, and hypertension completely abated after a tapering regimen of lorazepam, and he now exhibits a clear sensorium and no agitation. However, AS remains extremely depressed with marked anhedonia. Given AS’s history of recent alcohol withdrawal seizure activity, which antidepressant should be avoided when selecting pharmacotherapy for his cooccurring MDD? A. Venlafaxine B. Fluoxetine C. Sertraline D. Mirtazapine E. Bupropion Substance-related Disorders 8 14. A 28-year-old man who is a known drug user is admitted to the emergency department. He presents with sedation, pinpoint pupils, hypothermia, and respiratory depression. Assuming other medical etiologies have been ruled out, the clinical picture is most consistent with which of the following substance use presentations?

A. Alcohol withdrawal B. Cocaine withdrawal C. Amphetamine withdrawal D. Alcohol intoxication E. Opioid intoxication 15. Which statement concerning varenicline 2 mg/day for smoking cessation is true?

A. It is no more efficacious than placebo.

B. It triples the likelihood of abstinence at 6 months.

C. It triples the likelihood of abstinence at 2 years.

D. It is no longer prescribed in the United States because of toxicity.

E. It is limited in scope to individuals with normal hepatic function.

Substance-related Disorders 9 Answers 1. C 2. C 3. D 4. A 5. B 6. C 7. C 8. B 9. D 10. A 11. D 12. C 13. E 14. E 15. B

Chapter 37. Schizophrenia 1. Which of the following statements is not true?

A. If the patient has lack of response to two adequate antipsychotic trials, a trial of clozapine should be considered.

B. All antipsychotics, other than clozapine, have similar efficacy.

C. It is appropriate to choose an antipsychotic based on which side effects will be most tolerable to the patient.

D. All antipsychotics have equal risk of weight gain and metabolic disturbances.

E. The results of the CATIE trial showed some FGAs may be as well tolerated as SGAs. 2. Which of the following statements regarding the diagnosis of schizophrenia is true?

A. The presence of psychosis is diagnostic for schizophrenia.

B. The presence of disorganization is necessary for diagnosis.

C. Symptoms must be present for at least 1 week.

D. Symptoms must be documented by MRI changes.

E. Social and/or occupational dysfunction must be present.

3. Which of the following side effects of antipsychotic medications would have a delayed occurrence of onset that is usually months to years after initiation of the medication?

A. Sedation B. Dry mouth C. Tardive dyskinesia D. Weight gain E. All of the above 2 4. Which of the following schizophrenia symptoms is most likely to respond to antipsychotic treatment?

A. Hallucinations B. Cognition C. Impaired judgment D. Disorganization E. Negative symptoms 5. Which of the following situations would be the most appropriate for the use of clozapine?

A. A 19-year-old patient first presenting with psychotic symptoms B. A 65-year-old patient with schizophrenia and multiple myeloma C. A 43-year-old patient rehospitalized after nonadherence to olanzapine and risperidone.

D. A 35-year-old patient rehospitalized after failing treatment with haloperidol E. A 33-year-old patient with a lack of response to separate trials of risperidone and aripiprazole 6. Which two antipsychotics are generally associated with the most weight gain in people with schizophrenia?

A. Risperidone and quetiapine B. Aripiprazole and ziprasidone C. Clozapine and olanzapine D. Olanzapine and aripiprazole E. Risperidone and ziprasidone 7. Adolescents treated with antipsychotics compared with adults: A. May be more at risk for EPS 3

B. Experience little to no weight gain C. Should be started with higher doses D. Should be titrated at a faster rate E. All of the above 8. Which of the following antipsychotic medications does not come in a long-acting injectable formulation?

A. Clozapine B. Risperidone C. Olanzapine D. Aripirazole E. Haloperidol 9. Which of the following statements regarding the treatment of schizophrenia is true?

A. Antipsychotic treatment should continue for up to 4 weeks after remission of symptoms.

B. Neuroleptic malignant syndrome only occurs with FGA treatment.

C. Cognitive function is greatly improved by antipsychotic treatments.

D. Most antipsychotics require dose titration upon initiation for maximum efficacy.

E. Treatment for schizophrenia usually results in a return to baseline functioning.

10. When treating schizophrenia in the elderly, which is true?

A. New onset psychosis late in life is most likely late-life schizophrenia.

B. The same side-effect risk is observed in the elderly compared to younger adults.

C. Some antipsychotic medications can worsen cognitive ability.

D. Orthostatic blood pressure changes are not a concern, as most patients are bedridden.

E. No dosage adjustments are needed when prescribing for the elderly.

4 11. In patients taking antipsychotics, routine monitoring for metabolic side effects should be performed, including which of the following laboratory and clinical measures?

A. Lipid panel B. Fasting glucose C. Body weight D. Waist circumference E. All of the above 12. Which of the following is not a side effect related to dopamine antagonism?

A. Prolactin elevation B. Tremor C. Dizziness D. Dystonia E. Akathisia 13. In general, an advantage of second-generation antipsychotics (SGAs) over first-generation antipsychotics (FGAs) is their A. No risk of tardive dyskinesia B. Lower incidence of EPS C. Lower cost D. Fewer interactions with other medications E. Indications for use in the elderly 14. All of the following are true of clozapine except: A. Is indicated after the patient has not responded to two adequate antipsychotic trials.

B. Has no more risk of weight gain than other antipsychotic medications.

5 C. Requires blood monitoring for as long as the patient takes the drug.

D. Is the only antipsychotic with differential efficacy for positive symptoms.

E. Can cause hypersalivation.

15. When considering the differential diagnosis of a patient presenting with new onset psychotic symptoms, which of the following would make a diagnosis of schizophrenia unlikely?

A. A young man with psychosis while being treated with a course of steroids.

B. An elderly person with psychosis in nursing home C. A person with severe depression who believes God is punishing him.

D. A person with a long history of alcohol dependence presents with hallucinations E. All of the above 6 Answers 1. D 2. E 3. C 4. A 5. E 6. C 7. A 8. A 9. D 10. C 11. E 12. C 13. B 14. B 15. E

Chapter 38. Major Depressive Disorders 1. Which of the following SSRIs requires up to a 5-week washout period because of the long half-life of its potent active metabolite?

A. Escitalopram B. Fluvoxamine C. Fluoxetine D. Sertraline 2. Which of the following symptoms is most likely to improve within approximately 1 week of starting treatment?

A. Depressed mood B. Suicidal thoughts C. Anhedonia D. Sleep 3. Of the following combinations of medications, which one would you want to avoid?

A. Fluoxetine-lithium B. Fluoxetine-phenelzine C. Citalopram-valproic acid D. Citalopram-aripiprazole 2 4. A 26-year-old man with a history of depression has been taking sertraline 200 mg/day for 12 weeks with no response. The patient has no other complications. The physician asks for your recommendation. The most reasonable recommendation would be to: A. Increase sertraline B. Add fluoxetine C. Switch to amitriptyline D. Change to venlafaxine E. Decrease sertraline 5. Which of the following is a dangerous combination?

A. MAOI-lorazepam B. MAOI-acetaminophen C. MAOI-meperidine D. MAOI-ziprasidone 6. A 23-year-old married white woman comes to the outpatient psychiatric clinic complaining of decreased sleep, decreased appetite, decreased concentration, depressed mood, thoughts of death, and lack of interest in activities for 6 weeks’ duration. She has no history of psychiatric illness and takes no medications except for Ortho-Tri Cyclen Lo daily. Based upon the patients symptoms, choose the best medication to treat this patient.

A. Nefazodone 100 mg po twice daily 3 B. Paroxetine 20 mg po daily C. St. John’s wort 300 mg po three times daily D. Amitriptyline 25 mg at bedtime 7. A 36-year-old man is admitted to the hospital for a severe methicillin-resistant Staphylococcus aureus diabetic foot infection and is started on linezolid 600 mg IV every 12 hours. His medication profile includes paroxetine 40 mg every morning, trazodone 100 mg at bedtime as needed for sleep, and metformin 1000 mg po twice daily. After 3

days on these medications, the patient becomes agitated, confused, and diaphoretic and develops myoclonic jerks. Which of the following is the most likely diagnosis?

A. Overdose of metformin B. Bacterial meningitis C. Neuroleptic malignant syndrome D. Serotonin syndrome 8. A 46-year-old woman presents to the psychiatric outpatient clinic for follow-up treatment of major depression. She is currently on paroxetine 10 mg at bedtime, which she started taking 2 months ago when admitted to the psychiatric hospital for suicidal ideation.

During the interview, she says that she does not think the medication is working because she is just as depressed as she was before taking the medication and has recently started drinking eight to 10 beers daily to alleviate the depression. Before this episode, she was sober for 4 years. Which of the following treatment strategies would be the appropriate choice for this patient?

4 A. Stop the paroxetine and start nefazodone 100 mg po twice daily B. Increase the dose of paroxetine to 20 mg po at bedtime C. Stop the paroxetine and start duloxetine 20 mg/day D. Continue the paroxetine at the same dose for a longer period of time to evaluate whether she will respond or not 9. Which of the following is a flaw in the monoamine hypothesis of depression?

A. Concentrations of neurotransmitters are reduced in the synaptic cleft B. A switch to a different class of antidepressants does not improve response C. Antidepressant response is associated with a therapeutic level of the medication D. Antidepressant effects on neurotransmitters do not temporally correspond to response.

10. A 26-year-old patient with a first episode of depression has been treated with duloxetine 60 mg twice daily for the past 4 months. The patient would like to discontinue treatment.

The patient should be told that they need at least full months of antidepressant therapy after reaching full remission.

A. 3 B. 6 C. 9 D. 12 5 11. Which of the side effects of trazodone for the treatment of depression is most frequently observed?

A. Hematuria B. Delayed orgasm C. Priapism D. Orthostasis 12. An antidepressant that may be dangerous in overdose is A. Mirtazapine B. Amitriptyline C. Fluoxetine D. Escitalopram

13. A 28-year-old man with a history of depression has been taking sertraline 200 mg daily for 12 weeks with no response. The patient has no other complaints. The physician asks for your recommendation. The most reasonable recommendation would be to: A. Increase sertraline B. Add fluoxetine C. Switch to amitriptyline D. Change to venlafaxine 6 14. AS is an 18-year-old woman hospitalized for the fourth time for major depressive disorder. On this occasion, AS was admitted for suicidal ideation. Her other symptoms include loss of appetite, insomnia, decreased energy, increased agitation, and anhedonia for the past 2 months. Although she did well her first semester of college, AS “partied: a lot and broke up with a new boyfriend. Two months ago, AS refused to go back to college after the winter holidays. She does not have any other medical problems. AS’s mother and grandfather have a history of bipolar illness, and her father has a history of substance abuse. AS’s symptoms meet the criteria for major depressive disorder based upon the fact that she has: A. A history of mania B. A history of substance abuse C. Felt suicidal and had four target symptoms for more than 10 days D. Had a loss of pleasure and four target symptoms for more than 2 weeks.

15. A 38-year-old male is diagnosed with major depressive disorder by his general practitioner. His symptoms include depressed mood, insomnia, decreased appetite, and poor concentration. He denies suicidal ideation. The patient remembers that his mother and brother responded well to venlafaxine in the past, and he would like to try the same medication. Which of the following monitoring parameters would be the most important to follow on this medication?

A. Blood pressure B. White blood cell count 7 C. Electrocardiogram D. Potassium levels 8 Answers 1.

C 2.

D 3.

B 4.

D 5.

C 6.

B

7.

D 8.

B 9.

D 10.

B 11.

D 12.

B 13.

D 14.

D 15.

A 1 Chapter 39. Bipolar Disorder 1. A history of which of the following is the key feature of bipolar disorder with rapid cycling according to the DSM-5?

A. A major depressive episode switching to mania B. Mania switching to a major depressive episode C. More than five manic episodes in 12 months D. More than three mood episodes in 12 months 2. Factors that increase risk of suicide in individuals with bipolar disorder include: A. A high number of depressive episodes B. Late age of onset C. Low educational status D. Negative family history of bipolar disorder 3. Epidemiologic studies show patients with bipolar I disorder spend: A. More time manic than depressed B. More time depressed than manic C. The same amount of time manic and depressed 2 D. More time acutely ill than stable 4. Another psychiatric illness that can include a history of manic episodes is: A. Major depressive disorder B. Panic disorder C. Schizoaffective disorder D. Schizophrenia 5. Which of the following would be the least appropriate initial choice for pharmacologic therapy of a patient with a manic episode?

A. Divalproex

B. Lamotrigine C. Quetiapine D. Risperidone 6. The primary treatment for acute bipolar depression is: A. Antidepressant drugs B. Family and interpersonal therapy C. Electroconvulsive therapy 3 D. Mood-stabilizing drugs 7. Which of the following second-generation antipsychotic drugs is FDA approved for treatment of acute bipolar depression as monotherapy?

A. Lamotrigine B. Lurasidone C. Risperidone D. Ziprasidone 8. The recommended therapeutic serum concentration range for lithium, inclusive of both acute and maintenance therapy in otherwise healthy, nonelderly adults is: A. 0.3 to 0.8 mEq/L (mmol/L) B. 0.6 to 1 mEq/L (mmol/L) C. 0.6 to 1.5 mEq/L (mmol/L) D. 1.1 to 1.5 mEq/L (mmol/L) 9. Divalproex is more likely than other mood-stabilizing drugs to cause which of the following?

A. Increased serum creatinine B. Leukopenia 4 C. Hypothyroidism D. Thrombocytopenia 10. Which mood stabilizer is most associated with a potentially life-threatening rash?

A. Carbamazepine B. Lamotrigine C. Lithium D. Divalproex 11. Which of the following drugs classified as a mood-stabilizing drug is FDA approved for the treatment of bipolar disorder in children and adolescents?

A. Carbamazepine B. Divalproex C. Lamotrigine D. Lithium 12. Which mood-stabilizing drug is associated with neural tube defects?

A. Clonazepam B. Divalproex 5 C. Lithium D. Lamotrigine 13. When adding divalproex to the therapy of a patient already taking lamotrigine, the dosage of lamotrigine should:

A. Stay the same B. Be increased by 50% C. Be decreased by 50% D. Lamotrigine should be discontinued 14. Which category of patients is most likely to experience weight gain due to second-generation antipsychotic therapy?

A. Children and adolescents B. Middle-aged adults C. Older adults (age greater than 65) D. Young adults 15. Which of the following mood-stabilizing drugs induces its own metabolism?

A. Carbamazepine 6 D. Divalproex C. Lamotrigine D. Lithium 7 Answers 1. D 2. A 3. B 4. C 5. B 6. D 7. B 8. C 9. D 10. B 11. D 12. B 13. C 14. A 15. A

Chapter 40. Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder 1. Which of the following statements regarding panic disorder is true?

A. Panic attacks are expected and have an identifiable trigger B. Panic attacks usually peak in intensity in about 1 hour.

C. Agoraphobia is always present.

D. It is more common in men.

E. Panic symptoms are self-limiting in duration.

2. Which of the following substances/medications would not be expected to contribute to panic anxiety?

A. Albuterol B. Olanzapine C. Cannabis D. Phenylephrine E. Caffeine 3. Pregabalin is a preferred treatment for a patient with GAD and a history of which of the following?

A. Comorbid depression B. Alcohol dependence C. Did not tolerate SSRIs D. Renal impairment E. Nonadherence 2 4. The following treatment would be preferred for a 12-year-old with SAD. A. Alprazolam B. Fluoxetine C. Pregabalin D. Cognitive-behavioral therapy (CBT) E. Individual supportive psychotherapy 5. Which of the following statements is true regarding quetiapine in the treatment of anxiety disorders?

A. Is effective for treatment of panic disorder B. Is associated with weight gain, sedation, and fatigue C. Is effective in doses above 300 mg/day D. Superior efficacy to SSRIs E. Similar efficacy to CBT 6. Which of the following medications is not appropriate initial treatment for a 23-year-old woman with GAD and no other comorbidities?

A. Pregabalin B. Quetiapine C. Sertraline D. Venlafaxine E. Fluoxetine 7. Which of the following is true of CBT in the treatment of anxiety?

A. Only effective when delivered face to face 3 B. Is inferior to antidepressants in acute treatment of panic disorder

C. Is associated with more sustainable benefits than antidepressants D. Is not effective for children with anxiety disorders E. Is less expensive than medications 8. A 23-year-old otherwise healthy woman with GAD has no past history of drug or alcohol abuse and no family history of substance abuse. She is started on lorazepam 0.5 mg three times daily. Which of the following side effects will you warn her about? a. Risk of withdrawal symptoms upon discontinuation b. Sedation c. Anterograde amnesia d. Slowed reaction time e. All of the above 9. Which initial antidepressant regimen is likely to be the best tolerated by a patient with panic disorder?

A. Duloxetine 60 mg daily B. Bupropion 300 mg XL daily C. Imipramine 50 mg three times daily D. Paroxetine 10 mg daily E. Buspirone 15 mg three times daily 10. A 22-year-old woman with SAD has significant improvement in anxiety after 14 weeks of treatment with sertraline. How long should she remain on sertraline?

A. Discontinue now 4 B. Additional 3 months C. Additional 6 months D. Additional 1–2 years E. Lifetime therapy 11. A 26-year-old African American man with SAD has been stable on sertraline 100 mg/day for the past year. He reports to the clinic today with complaints of increased anxiety, agitation, and nausea. Upon further examination, you notice he last filled his sertraline Rx (90-day supply) 4 months ago. Medications: Ibuprofen 400 mg as needed for joint pain. He reports taking sertraline most days but ran out 4 days ago. What is most likely going on with AS? A. Serotonin syndrome B. Serotonin withdrawal C. Neuroleptic malignant syndrome D. Relapse of SAD E. Rebound anxiety 12. A 78-year-old black woman has HTN, DJD, osteoporosis, and GAD. Which of the following medications is the best choice for management of her GAD? A. Pregabalin B. Trazodone C. Quetiapine D. Escitalopram E. Mirtazapine 5 13. What is the best initial treatment for a 39-year-old man with comorbid panic disorder and alcohol use disorder?

A. Sertraline B. Quetiapine C. Pregabalin D. Bupropion E. Alprazolam 14. What monitoring parameters should be followed in a 10-year-old initiated on fluoxetine for SAD? A. Suicidal Ideation B. School performance C. Anxiety Symptoms D. Nausea, headache, stomach ache E. All of the above 15. Which of the following GAD patients is most likely to be a CYP 2C19 poor metabolizer and will have an exaggerated response to diazepam 5 mg three times daily with increased sedation and CNS and cognitive side effects?

A. 25-year-old white woman B. 25-year-old black woman C. 45-year-old black man D. 45-year-old Asian man E. 45-year-old white man 6 Answers 1 E 2 B 3 C 4 D 5 B 6 B 7 C 8 E 9 D 10 C 11 B 12 D 13 A 14 E 15 D

Chapter 41. Sleep Disorders 1. AD is a 58-year-old man who presents to your clinic with the complaint that he “just can’t sleep at night.” Upon further questioning, he reports that he typically falls asleep without problem but wakes up multiple times throughout the night. Which of the following sleep disorders could AD possibly have?

A. Insomnia B. Obstructive sleep apnea C. Narcolepsy D. Restless legs syndrome E. All of the above 2. RS is a 28-year-old man with a history of obsessive-compulsive disorder who reports that he kicks his legs during the night, which wakes him up. He reports that he does not really have any symptoms of restless legs syndrome, but the leg kicking frequently awakens him in the middle of the night and causes him to be sleepy during the daytime.

RS has a body mass index of 21 kg/m2 and is normotensive, and his wife says he does not snore or stop breathing during sleep. What would you recommend for RS? A. Temazepam 15 mg at bedtime B. Polysomnography C. Pramipexole 0.5 mg at bedtime D. Multiple sleep latency test E. Gabapentin 300 mg at bedtime 3. Regarding therapies for the treatment of insomnia all of the following are correct except: 2 A. Sedating antidepressants are commonly used to treat insomnia despite few good studies that document efficacy for insomnia.

B. Nonbenzodiazepines (zolpidem, zaleplon, eszopiclone) are generally associated with less rebound insomnia than traditional benzodiazepines.

C. Based on efficacy studies, BZDRAs and ramelteon are the drugs of choice for the treatment of insomnia.

D. Suvorexant is an orexin receptor antagonist used for insomnia that is novel because it is not a controlled substance.

E. All of the above are correct.

4. Which of the following is a consequence of unidentified and untreated sleep disorders?

A. Hypertension B. Motor vehicle accidents C. Excessive daytime sleepiness D. Irritability E. All of the above 5. BB is a 48-year-old man with a history of RLS. Over the past year, his RLS has gotten worse, and he has increased the dose of his pramipexole therapy to 1 mg prior to bedtime. His symptoms started appearing earlier in the day, and he had new symptoms in his arms. What strategy should be implemented to manage his symptom augmentation?

A. Switch to a shorter-acting dopaminergic agent B. Switch to a longer-acting dopaminergic agent

C. Increase the dose of pramipexole 3 D. Check serum ferritin and replete iron if necessary E. Both B and D 6. TQ is a 51-year-old woman who presents to your clinic today with a complaint of difficulty initiating sleep. She goes to bed at 10 PM and awakens at 6 AM but frequently does not fall asleep for 1.5 to 2 hours. This problem has persisted for 9 months. TQ also has a history of alcohol abuse. Based on the available information, which agent would be the best choice to treat TQ’s complaint?

A. Ramelteon B. Temazepam C. Flurazepam D. Eszopiclone E. Amitriptyline 7. BL is a 24-year-old college student with narcolepsy (no cataplexy) who is taking methylphenidate 20 mg/day (he takes this at 8 AM before his first class). Currently, this works well at reducing sleepiness in the morning, but next semester, BL will have morning and late afternoon classes and is worried he will not be able to stay awake for afternoon classes. Which of the following might be the best strategy for the upcoming semester?

A. Methylphenidate 10 mg twice daily (8 AM and 6 PM) B. Methylphenidate 20 mg SR twice daily and 10 mg prn afternoon sleepiness C. Dextroamphetamine 10 mg/day (8 AM) D. Sodium Oxybate 2.25 g at bedtime and 3 hours later E. Selegiline 10 mg/day at 8 AM 4 8. JM is a 38-year-old man traveling to Europe on business. He asks you for a recommendation to treat jet lag upon his arrival. Based on the available evidence, which agent would you recommend?

A. Valerian B. Diphenhydramine C. Mirtazapine D. Melatonin E. Quazepam 9. A patient presents to the clinic and tells you that he is looking for something to help him fall asleep at night. He reports that he frequently goes to bed and cannot fall asleep for 2 or 3 hours, so he lies in bed and watches television. Upon further questioning, he relays the following information about his sleep and medical history: SH: Retired and married with two grown children. No tobacco use. Does not drink alcohol or caffeine. He exercises at the health club in the mornings.

Sleep patterns: Goes to bed on average at 11 PM and awakens with alarm at 6 AM but frequently does not fall asleep until 1 or 2 AM. No awakenings after he is asleep. No reports of limb restlessness. Tired in the daytime and naps for about an hour each afternoon but thinks it is related to inadequate sleep time. What would you recommend to the patient to improve his sleep hygiene?

A. Instruct him not to exercise; it may contribute to his complaint.

B. Instruct him to continue watching television in bed; it will help him fall asleep more easily.

5 C. Recommend he drink alcohol in the evening to take the edge off.

D. Instruct him to avoid daytime naps.

E. Recommend all of the above.

10. GR is a 58-year-old man with obstructive sleep apnea (OSA) and hypertension. He is currently using continuous positive airway pressure (CPAP) therapy (8 cm of water pressure [0.8 kPa]) for his OSA and uses it about 6.5 hours each night. His Epworth Sleepiness Scale score was 19 out of 24 when he first started CPAP, and it has improved, but he is still sleepy (current score, 14 out of 24). He has not gained any weight since starting CPAP therapy. What would be the best recommendation for GR? A. He should start methylphenidate 20 mg SR in the morning for his daytime sleepiness.

B. He should increase his CPAP pressure to 12 cm water pressure (1.2 kPa).

C. He should start dextroamphetamine/amphetamine 30 mg XR in the morning for his daytime sleepiness.

D. He should start modafinil 200 mg in the morning for daytime sleepiness.

E. None of the above.

11. In the treatment of restless legs syndrome, which of the following are disadvantages to the various treatments?

A. Levodopa-carbidopa—application site reactions B. Pramipexole—risk of compulsive behaviors C. Gabapentin enacarbil—high risk of symptom augmentation D. Zaleplon—constipation E. All of the above 6 12. DP is a 46-year-old woman who presents with a complaint of difficulty initiating sleep.

After a careful sleep history, you rule out other potential sleep disorders and want to start her on drug therapy for her insomnia. Which of the following would be the best recommendation?

A. Amitriptyline 10 mg at bedtime B. Flurazepam 15 mg at bedtime C. Zaleplon 5 mg at bedtime D. Doxepin 3 mg at bedtime E. None of the above 13. A patient with restless legs syndrome has been taking ropinirole 1 mg before bedtime to treat her symptoms. She takes her ropinirole at 7 PM, goes to bed at 9 PM, and wants to awaken at 6 AM for work. She explains that ropinirole helps her before going to bed and for the first few hours of sleep, but her symptoms reemerge around 3 AM, causing her to awaken too early. Her serum ferritin is 88 ng/mL (mcg/L; 198 pmol/L). What is happening with this patient’s therapy?

A. Patient is experiencing tolerance to the ropinirole.

B. Patient is experiencing symptom augmentation.

C. The ropinirole has worn off at 3 AM due to relatively short half-life.

D. Patient is experiencing morning symptoms due to iron deficiency.

E. All of the above.

14. DH is a 34-year-old woman with a history of narcolepsy with cataplexy. She takes modafinil (Provigil) 200 mg each morning and 200 mg at noon to help control her sleepiness but does not receive much benefit from it. Her Epworth Sleepiness Scale 7 score was 19 out of 24 today in clinic. She reports that she is most sleepy in the middle of the afternoon. She had not previously been on therapy for cataplexy. Today, she reports that her cataplexy has worsened and that she wishes to try something to help.

What regimen would you recommend to better control DH’s narcolepsy and cataplexy?

A. Switch to methylphenidate 20 mg SR in the morning and at noon and add venlafaxine 75 mg/day.

B. Increase her modafinil to 400 mg in the morning and 200 mg at noon.

C. Keep modafinil dose the same and add venlafaxine 75 mg in the morning.

D. Switch to methylphenidate 10 mg taken in the morning.

E. Switch to dextroamphetamine 5 mg in the morning and fluoxetine 10 mg in the morning.

15. VF is a 74-year-old man who is accompanied today in your clinic by his wife. She reports that for the past few months, VF thrashes around in bed violently during the latter half of the night (one to two times per week). He has flown out of bed on occasion and bruised his arm by hitting the wall. When asked about these episodes, he replies that he is usually dreaming about a struggle before he wakes up. What is the best diagnosis and matching appropriate therapy for VF? A. NREM parasomnia—sleep walking—clonazepam B. NREM parasomnia—night terrors—bupropion C. REM parasomnia—REM behavior disorder—clonazepam D. Periodic limb movements of sleep—ropinirole E. Restless legs syndrome—gabapentin 8 Answers 1.E 2.A 3.D 4.E 5.E 6.A 7.B 8.D 9.D 10.D 11.B 12.C 13.C 14.A 15.C

Chapter 42. Attention-Deficit/Hyperactivity Disorder 1. Which of the following statements about ADHD is true?

A. Prevalence is much higher in girls than boys during grade school.

B. ADHD is a diagnosis confined to children that should not be used in adolescents or adults.

C. Patients with ADHD frequently have other comorbidities such as conduct disorder.

D. Dysfunction of the neurotransmitter serotonin is thought to be crucial in the pathology of ADHD. E. According to the DSM-5 diagnostic criteria for ADHD, symptoms of inattention and/or hyperactivity or impulsivity must be present before 6 years of age.

2. Management strategies for minimizing the side effects of stimulant medication in ADHD patients might include: A. Administering a stimulant dose after meals if decreased appetite is occurring B. Changing to longer-acting stimulant in the case of rebound symptoms C. Changing to clonidine or guanfacine if severe motor tics occur D. Monitoring blood pressure periodically in an adult ADHD patient E. All of the above 3. A 9-year-old girl was diagnosed with ADHD 6 months ago and has not responded to drug therapy. She was prescribed methylphenidate for 3 months and then switched to dextroamphetamine for 3 months. What ADHD medication(s) would be appropriate to switch this girl to now?

A. Mixed salts of amphetamine B. Imipramine C. Atomoxetine D. A or C E. Fluoxetine 4. After a third trial with a stimulant medication, the above 9-year-old girl still has not responded to therapy. Which of the following would be a rational step in therapy?

A. Lisdexamfetamine B. Extended-release guanfacine C. Atomoxetine D. B or C E. A or C 5. Appropriate medication counseling for the parent of a child with ADHD might include: A. Stating that growth delay has been documented with stimulant use, but the evidence is controversial B. Advising administration of a stimulant dose earlier in the day if the child is experiencing insomnia at bedtime C. Stressing that there is no evidence linking treatment of ADHD patients with stimulants to a greater likelihood of substance abuse later in life D. Mentioning that stimulants may be used, albeit cautiously, if the child also has a wellcontrolled seizure disorder.

E. All of the above 6. Extended-acting formulations of methylphenidate have been developed in order to: A. Overcome the problem of a drug with a long duration of effect that frequently leads to adverse effects B. Minimize the prescription costs associated with the use of short-acting and intermediate-

acting methylphenidate formulations C. Avoid the need for administration of a second dose of methylphenidate while children with ADHD are at school D. Minimize the potential for insomnia at bedtime E. Match the proven superior efficacy of nonstimulant medications (atomoxetine, bupropion, clonidine, and guanfacine) in treating symptoms of ADHD 7. A patient is newly diagnosed with ADHD. Upon review of the patient’s medical history, it was noted that the patient has a 3-year history of seizures. Which of the following ADHD medications should be avoided in this patient?

A. Methylphenidate B. Bupropion C. Atomoxetine D. Clonidine E. Paroxetine 8. Clonidine or guanfacine are sometimes used as adjuncts to stimulants in treating patients with ADHD in order to accomplish which of the following: A. Lessen sedation B. Increase blood pressure C. Decrease seizure risk D. Control aggressive or disruptive behavior E. Achieve a quicker onset of therapeutic effect 9. When initiating stimulant therapy, which of the following parameters should be assessed before treatment is initiated and at every follow-up visit: A. ECG, weight, blood pressure, and pulse B. Electroencephalogram, hyperactivity & impulsiveness in classroom, blood pressure and pulse C. Neuroimaging study, stomach ache, weight, and pulse D. Height, weight, blood pressure, and pulse E. Liver function tests, attentiveness to family chores, weight, and blood pressure 10. A 5-year-old boy has received a newly confirmed diagnosis of hyperactive/impulsive ADHD. The preferred initial treatment for this boy would be which of the following: A. Train the parents to establish a reward/consequence system for his behavior B. Short-acting methylphenidate (Methylin) given twice daily C. Extended-acting methylphenidate (Concerta) given once daily D. Guanfacine (Intuniv) given once daily E. Bupropion SR given twice daily 11. Which of the following statements about stimulant use in patients with ADHD is true?

A. Chronic use of stimulants will negatively affect growth and final height of children when they reach adulthood.

B. Stimulant use has been shown to decrease appetite in children.

C. Alcohol and substance abuse is more prevalent in patients who have been treated with stimulants.

D. If a patient fails to respond to one stimulant, there is no need to try a different stimulant because of a high likelihood of nonresponse.

E. Stimulants should never be used in patients with motor tics.

12. A patient has been newly diagnosed with ADHD and comorbid depression. Which of the following is most proven to be beneficial in treating both ADHD and depression?

A. Methylphenidate B. Guanfacine C. Bupropion D. Atomoxetine E. Clonidine 13. A 21-year-old woman with ADHD works as a waitress and has trouble paying for her prescription medication because of a lack of third-party coverage. She takes methylphenidate (Methylin ER) 40 mg (two 20-mg tablets) every morning with breakfast just before going to work, which begins at 8:00 AM. Inattentiveness to her customer requests early in her shift is getting her in trouble. She seems to function much better in the later morning and afternoon. The most cost-effective change to make to this woman’s ADHD medication regimen would be to: A. Switch her to lisdexamfetamine (Vyvanse), 30-mg capsule every morning.

B. Add a 10-mg dose of regular-release short-acting methylphenidate to her present regimen in the morning.

C. Switch her to methylphenidate (Daytrana), 30-mg patch daily for 9 hours.

D. Add atomoxetine (Strattera), 10-mg capsule every morning to her present regimen.

E. Switch her to methylphenidate (Concerta), 36-mg tablet every morning.

14. The potential advantage of using atomoxetine instead of a stimulant for the treatment of ADHD includes which of the following: A. Less risk of hepatotoxicity B. Reduced risk of suicide C. Decreased risk of abuse D. Less cost of treatment E. Avoidance of potential drug–drug interactions 15. A symptom of inattentive ADHD (as opposed to hyperactive or ADHD) may include: A. Being easily distracted from an activity B. Running around the class room when it is not appropriate C. An inability to sit for extended periods D. Answering questions prematurely E. Cramming or shoving in line when waiting for one’s turn Answers 1. C 2. E 3. D 4. D 5. E 6. C 7. B 8. D 9. D 10. A 11. B 12. C 13. B 14. C 15. A

Chapter 43. Diabetes Mellitus 1. A 46-year-old man presents for his annual physical. He states that he has been going to the bathroom more frequently than normal and has lost approximately 20 pounds (9.1 kg) in the past 6 months without trying. His random glucose today is 252 mg/dL (14.0 mmol/L). Which of the following is most appropriate to confirm diagnosis of type 2 diabetes?

A. Obtain a fasting glucose level in the morning.

B. Have patient perform a 2-hour oral glucose tolerance test.

C. Obtain patient’s hemoglobin A1c.

D. Obtain a repeat random glucose level.

E. Nothing; there is enough information available to diagnose patient with type 2 diabetes.

2. A 36-year-old Caucasian woman is concerned about her risks for developing type 2 diabetes because her mother and father have the disease. Currently, she weighs 145 lbs (66 kg; BMI = 22 kg/m2 ) and has no other medical conditions. All of her children weighed less than 8 lbs (3.6 kg) at birth and she is preparing for her second marathon. The most appropriate recommendation for screening is to begin: A. At the age of 45 then every 3 years if normal.

B. At the age of 45 then every year if normal.

C. At the age of 40 then every 3 years if normal.

D. At the age of 40 then every year if normal.

E. As soon as possible then every year if normal.

Questions 3–5 refer to the following case: A 67-year-old Caucasian woman has been recently diagnosed with type 2 diabetes. Her past medical history is significant for hypertension, hyperlipidemia, and hypothyroidism. Her current medications include hydrochlorothiazide, levothyroxine, and simvastatin. At diagnosis, her vitals and labs were as follows: BP 157/94 mm Hg, Wt 157 lbs (71 kg; BMI = 24 kg/m2 ), A1c 8.7% (0.087; 72 mmol/mol Hgb), FPG 174 mg/dL (9.7 mmol/L), LDL 52 mg/dL (1.34 mmol/L), HDL 59 mg/dL (1.53 mmol/L), TG 45 mg/dL (0.51 mmol/L).

3. Which of the following is the most appropriate recommendation for therapy according to the ADA algorithm?

A. Lifestyle changes only B. Metformin only C. Intensive insulin only D. Lifestyle changes and metformin E. Lifestyle changes and intensive insulin Diabetes Mellitus 2 4. What is the patient’s goal blood pressure according to current ADA treatment guidelines?

A. Less than 125/80 B. Less than 130/80 C. Less than 135/85 D. Less than 140/90 E.Less than 150/90 5. What is the most appropriate medication to add to the patient’s regimen to control her hypertension?

A. Amlodipine B. Clonidine C. Lisinopril D. Metoprolol E. Verapamil 6. Which of the following statements regarding nonpharmacologic therapy for treatment of diabetes is true?

A. Individualized meal plans should be developed for people with diabetes based on cultural preferences, comorbidities, and daily schedule as much as possible.

B. Current clinical evidence supports the use of dietary supplements such as chromium in the management of diabetes.

C. Weight loss works best for patients with type 1 diabetes since most are overweight.

D. Long-term goals for physical activity should include at least 30 minutes of aerobic exercise once a week for all patients with diabetes.

E. Influenza vaccinations are recommended for all patients with diabetes every 5 years.

7. A 12-year-old boy is newly diagnosed with type 1 diabetes. His current height is 60 in (152 cm) and he weighs 40 kg (88 lb). What dose of basal insulin should be initiated for him?

A. 12 units insulin glargine B. 6 units insulin lispro C. 4 units insulin detemir D. 3 units insulin aspart E. 2 units insulin glulisine 8. Oral glucose lowering agents that primarily inhibit the breakdown of glucagon-like peptide 1 are classified as: A. Sulfonylureas B. SGLT2 inhibitors C. DPP-4 inhibitors Diabetes Mellitus 3 D. Meglitinides E. Thiazolidinediones 9. A 32-year-old woman is diagnosed with gestational diabetes after being administered an oral glucose tolerance test during her 28th-week of gestation. She has not been able to reduce or control her glucose readings with lifestyle interventions alone and her physician wants to start pharmacotherapy. Which agent below is the preferred medication, considering her glucose readings are significantly elevated?

A. Glyburide B. Insulin glargine C. NPH insulin D. Liraglutide E. Metformin 10. A 59-year-old Asian American woman has a 3-year history of T2DM. She presents with no new complaints today. Her labs and vitals are: A1c 8.1% (0.081; 65 mmol/mol Hgb), FBG 320 mg/dL (17.8 mmol/L), LDL 118 mg/dL (3.05 mmol/L), HDL 32 mg/dL (0.83 mmol/L), TG 325 mg/dL (3.67 mmol/L), SCr 1.9 mg/dL (168 µmol/L), BP 128/78 mm Hg, HR 68 beats/min, Wt 135 lb (61.4 kg), Ht 5’2” (157 cm). Her current medications are: Glimepiride 2 mg once daily

Metformin 1000 mg twice daily Exenatide 10 mcg twice daily Sitagliptin 50 mg daily Alendronate 70 mg/week Simvastatin 20 mg once daily Paroxetine 20 mg once daily Aspirin 81 mg once daily Which of her medications should be discontinued and for what reason?

A. Glimepiride—may increase risk of heart failure B. Metformin—due to renal dysfunction C. Exenatide—may cause weight gain D. Sitagliptin—may increase nausea and vomiting E. None of her medications should be discontinued 11. A 38-year-old man with type 1 diabetes presents requesting help with his insulin management. He needs to update his insulin to carbohydrate ratio in order to accurately dose his bolus insulin at meals. Which rule below should he use to calculate his insulin to carbohydrate ratio given that he administers insulin lispro in his pump?

A. Rule of 450 B. Rule of 500 C. Rule of 1500 D. Rule of 1800 Diabetes Mellitus 4 E. Rule of 2000 12. A 17-year-old female patient with type 1 diabetes currently uses a total of 40 units of insulin aspart daily in her pump. What is the expected reduction in glucose per unit of insulin for her?

A. 12.5 mg/dL (0.7 mmol/L) B. 30 mg/dL (1.7 mmol/L) C. 37.5 mg/dL (2.1 mmol/L) D. 45 mg/dL (2.5 mmol/L) E. 50 mg/dL (2.8 mmol/L) 13. Select the oral medication from the list below that is most likely to result in weight loss for patients with diabetes.

A. Dapagliflozin B. Glyburide C. Liraglutide D. Pioglitazone E. Sitagliptin 14. A 57-year-old man has had type 2 diabetes for approximately 15 years. His physician is initiating insulin therapy today due to his elevated A1c despite oral therapy. Which of the following is the most appropriate option?

A. Initiate insulin glargine 10 units every night at bedtime B. Initiate insulin lispro 10 units every night at bedtime C. Initiate insulin aspart 10 units every morning D. Initiate insulin glulisine 10 units twice daily E. Initiate 70% insulin aspart protamine/30% insulin aspart 10 units every night at bedtime 15. All of the following are true regarding noninsulin injectable therapy for treatment of diabetes,

except: A. Albiglutide is administered once weekly.

B. Exenatide lowers glucose levels by several mechanisms including regulating gastric emptying.

C. Liraglutide and albiglutide are administered without regard to meals.

D. Pramlintide is approved for use in patients with type 1 and 2 diabetes currently using insulin E. Pramlintide is as effective as insulin at lowering A1C levels in patients with type 1 diabetes.

Diabetes Mellitus 5 Answers 1. E 2. A 3. D 4. D 5. C 6. A 7. A 8. C 9. C 10. B 11. B 12. D 13. A 14. A 15. E

Chapter 44. Thyroid Disorders 1. The serum T4 level is not a good test for screening and monitoring for thyroid disease because: A. The assay is difficult to perform and not available in most clinical laboratories B. The results can be affected by alteration in protein binding, making interpretation difficult C. It is too sensitive, with a high percent of false positive results D. Serum T3 is a better test since it is the active hormone E. All of the above 2. The prevalence of hypothyroidism is higher in: A. Women B. Elderly patients C. Patients with other autoimmune endocrine disorders D. Patients treated with amiodarone E. All of the above are correct 3. What is the target TSH range (mIU/L or µIU/mL) for patients being treated for hypothyroidism or hyperthyroidism?

A. Undetectable B. 2.5 to 4.5 C. 1.4 to 2.5 D. 0.5 to 4 E. 4 to 5 4. Which of the following is a reasonable choice in treating a patient with newly diagnosed hypothyroidism?

A. Desiccated thyroid Thyroid Disorders 2 B. liotrix C. levothyroxine D. liothyronine E. All are reasonable choices 5. Levothyroxine products should not be substituted at refill because: A. No marketed products are AB rated by the FDA Orange Book.

B. All state regulations prohibit the substitution of narrow therapeutic index drugs.

C. Small differences in bioavailability may result in loss of disease control.

D. Patients will be nonadherent if it is switched.

E. A and B are correct.

6. Patients with mild or subclinical hypothyroidism should be considered for LT4 therapy if the patient has: A. A family history of thyroid disease B. Elevated LDL cholesterol C. Positive TSHR-AbS antibody D. A history of hypertension E. All of the above 7. What is the starting daily dose of LT4 in an 87 kg (191 lb), 5’4” (163 cm) 32-year old patient, otherwise healthy, with overt hypothyroidism?

A. 25 mcg B. 50 mcg

C. 75 mcg D. 100 mcg E. 150 mcg Thyroid Disorders 3 8. In a patient receiving stable LT4 therapy, laboratory monitoring should be performed every .

A. Month B. 6 to 8 weeks C. 3 months D. Year E. 5 years 9. Which of the following is a consequence of undertreatment with LT4?

A. Hypercholesterolemia B. Cardiovascular disease C. Fatigue D. Infertility E. All of the above 10. Untreated hyperthyroidism in the elderly can result in: A. Mania B. Atrial fibrillation C. Deafness D. Hirsutism E. A and D are true 11. Which of the following drugs may be used to quickly relieve symptoms seen in hyperthyroidism?

A. Radioactive iodine B. Propylthiouracil C. Methimazole Thyroid Disorders 4 D. Lithium E. Propranolol 12. Why is propylthiouracil (PTU) the antithyroid therapy of choice in pregnant patients with Graves disease?

A. It is less hepatotoxic than methimazole (MMI) B. It may be less teratogenic than MMI C. It has less risk of causing fetal hypothyroidism than MMI D. It causes less agranulocytosis in these patients than MMI E. A and C are true 13. In the setting of antithyroid therapy, which of the following statements regarding agranulocytosis is not true?

A. Agranulocytosis occurs in 0.3% of patients.

B. Patients may present with fever and sore throat.

C. Monitoring for agranulocytosis is controversial.

D. Incidence of agranulocytosis is higher in patients treated with propylthiouracil.

E. Agranulocytosis usually occurs within the first 3 months of therapy.

14. Why has use of methimazole increased dramatically in the United States compared to

propylthiouracil (PTU) in the treatment of most patients with Graves disease?

A. It may cause fewer adverse effects such as hepatotoxicity than PTU. B. It has a shorter half-life than PTU. C. It is renally excreted so no adjustment is needed for liver disease.

D. It blocks the conversion of T4 to T3.

E. A and D are true 15. Why should critically ill patients with nonthyroidal illness (“euthyroid sick syndrome”) and a low serum T4 level not be treated with LT4?

Thyroid Disorders 5 A. The alteration in the thyroid axis is an appropriate physiologic response to metabolic stress.

B. Liothyronine (T3) is the preferred treatment C. There is no intravenous form of LT4 to administer in the ICU. D. The low serum T4 improves patient outcomes.

E. A and D are true Thyroid Disorders 6 Answers 1. B 2. A 3. D 4. C 5. C 6. B 7. D 8. D 9. E 10. B 11. E 12. B 13. D 14. A 15. D

Chapter 45. Adrenal Gland Disorders 1. Which of the following is true regarding the hypothalamic-pituitary-adrenal (HPA) axis?

A. Corticotropin-releasing hormone (CRH) is secreted by the hypothalamus to stimulate adrenocorticotropic hormone (ACTH) secretion from the anterior pituitary.

B. The adrenal cortex stimulates the anterior pituitary to secrete cortisol.

C. Cortisol exerts positive feedback on the hypothalamus to increase secretion of CRH. D. The adrenal medulla produces testosterone and estrogen under the control of the pituitary.

E. Aldosterone is produced in the pituitary.

2. Which of the following is the most common etiology of primary adrenal insufficiency?

A. An autoimmune process B. Chronic glucocorticoid administration at supraphysiologic dose C. Infection D. Adrenalectomy E. Megestrol acetate 3. The clinical presentation of primary adrenal insufficiency differs from that of secondary or tertiary adrenal insufficiency in the following way(s): A. Hyperpigmentation is commonly seen in secondary and tertiary adrenal insufficiency.

B. Hyperkalemia is more commonly seen in primary adrenal insufficiency.

C. Decreased aldosterone concentrations is most often seen in primary adrenal insufficiency.

Adrenal gland disorders 2 D. B and C E. A, B, and C 4. A 43-year-old woman comes to the pharmacy asking for help selecting “iron pills.” She states that she has been feeling gradually more “tired and weak over the past couple of years.” Upon further questioning, she also complains of recurring dizziness, nausea, and diarrhea, and a 10pound (4.5 kg) weight loss over the past year. She fills her prescriptions at the pharmacy, and a review of the medication profile reveals that fluticasone/salmeterol DPI 500/50 mcg one inhalation bid, albuterol MDI two puffs every 4 hours as needed, HCTZ 25 mg daily, and pantoprazole 40 mg daily have been prescribed. She also has a history of asthma exacerbations requiring hospitalization and prednisone taper treatment one or two times per year. Which of the following would be the most appropriate step to take?

A. Refer for medical evaluation for possible hypocortisolism.

B. Refer for medical evaluation for possible hypercortisolism.

C. Help her select a B-complex vitamin product to treat fatigue.

D. Help her select an iron-containing supplement to treat fatigue.

E. Refer for medical evaluation of anemia.

5. A 48-year-old man is diagnosed with chronic adrenal insufficiency. Which of the following patient education recommendations should be addressed to avoid an acute adrenal crisis?

A. Always carry identification (eg, medical alert bracelet) listing the diagnosis.

B. Take corticosteroid supplementation as directed and do not abruptly stop treatment.

C. Advise all treating health care professionals that he has a diagnosis of chronic adrenal insufficiency.

Adrenal gland disorders 3 D. Supplemental dosing of glucocorticoid as may be required during an acute illness, including infections, surgery, or even fever.

E. All of the above 6. Which of the following statements regarding the treatment of chronic adrenal insufficiency with glucocorticoid supplementation is false?

A. Give glucocorticoid replacement at a dose equal to approximately 15 to 25 mg/day of hydrocortisone.

B. Give hydrocortisone once daily in the morning to optimize medication adherence.

C. The dose of the glucocorticoid may need to be increased with concomitant administration of a CYP3A4 inducer.

D. The dose of the glucocorticoid may need to be decreased with concomitant administration of a CYP3A4 inhibitor.

E. Patients with secondary or tertiary adrenal insufficiency may need a lower dose of glucocorticoid compared to those with primary adrenal insufficiency.

7. How should the treatment plan for a patient with adrenal insufficiency be monitored?

A. Monitor for resolution of symptoms of adrenal insufficiency.

B. Monitor for resolution of the underlying etiology of adrenal insufficiency such as infection.

C. Monitor for development of signs and symptoms of hypercortisolism.

D. Monitor for development of mineralocorticoid excess such as hypertension, hypokalemia, and fluid retention.

E. All of the above 8. Which of the following glucocorticoids possesses the most mineralocorticoid activity?

Adrenal gland disorders 4 A. Methylprednisolone B. Betamethasone C. Hydrocortisone D. Dexamethasone E. Prednisone 9. What is the first step in the management of a patient presenting with clinical manifestations consistent with an acute adrenal crisis?

A. Perform rapid ACTH stimulation test to confirm adrenal insufficiency.

B. Perform testing to distinguish between primary, secondary, and tertiary adrenal insufficiency.

C. Perform the metyrapone test to confirm the diagnosis of acute adrenal insufficiency.

D. Correct volume depletion and hypoglycemia, and provide glucocorticoid replacement.

E. Any of the above would be a reasonable first step.

10. Which of the following is the most common etiology of Cushing syndrome?

A. Exogenous glucocorticoid administration B. Adrenal adenoma C. Adrenal carcinoma D. Ectopic ACTH syndrome E. ACTH-secreting pituitary tumor 11. Which of the following strategies can be utilized to prevent the development of Cushing syndrome in patients requiring treatment with glucocorticoid therapy?

A. Give the highest effective dose for the longest duration possible.

B. If possible, administer glucocorticoid via routes that minimize systemic exposure.

Adrenal gland disorders 5 C. Avoid concurrent administration of medications that can induce glucocorticoid metabolism.

D. If possible, administer glucocorticoid with CYP3A4 inhibitors.

E. If possible, calculate the total 24-hour dose of the glucocorticoid and administer every other day instead of daily.

12. A complication of all treatments for Cushing syndrome is: A. Risk of hypocortisolism and adrenal insufficiency B. Hepatic impairment C. Renal impairment D. Less than 50% remission rate E. Hyperlipidemia 13. Which of the following drug treatment of Cushing syndrome can cause hyperlipidemia?

A. Ketoconazole B. Mitotane C. Etomidate D. Metyrapone E. All of the above 14. Which of the following treatment options for Cushing syndrome may also be useful in the diagnosis of adrenal insufficiency?

A. Etomidate B. Ketoconazole C. Mitotane D. Metyrapone Adrenal gland disorders 6 E. Octreotide 15. Which of the following statements regarding ketoconazole administration is true?

A. It is a strong CYP450 3A4 inducer.

B. It stimulates adrenal steroidogenesis.

C. It requires gastric acidity for dissolution and absorption.

D. It can increase testosterone synthesis.

E. Its onset of clinical improvement is much slower than mitotane.

Adrenal gland disorders 7 ANSWERS 1. A 2. A 3. D 4. A 5. E 6. B 7. E 8. C 9. D 10. A

11. B 12. A 13. B 14. D 15. C

Chapter 46. Pituitary Gland DisorderS 1. All of the following complications are associated with prolonged exposure of elevated growth hormone (GH) and insulin-like growth factor-I (IGF-I) concentrations in patients with acromegaly except: A. Colon cancer B. Osteoarthritis C. Diabetes mellitus D. Coronary artery disease E. Urinary incontinence 2. A 42 year-old man with acromegaly underwent transsphenoidal pituitary surgery for his microadenoma 6 months ago but continues to require pharmacotherapy with lanreotide Autogel 120 mg every 4 weeks. After 4 months of treatment on lanreotide, the patient exhibits partial response to therapy. What is the most appropriate treatment regimen for the patient at this time?

A. Continue lanreotide, start pegvisomant B. Discontinue lanreotide, start pegvisomant C. Continue lanreotide with radiation therapy D. Discontinue lanreotide, initiate radiation therapy E. Continue lanreotide, increase frequency of injections 3. A 43-year-old man with acromegaly presented with elevated IGF-I and GH concentrations.

After experiencing intolerance to somatostatin analogs, lanreotide Autogel is discontinued and the patient is started on pegvisomant 10 mg daily. Which of the following is the most important parameter to monitor in this patient?

A. Serum creatinine Pituitary gland disorders 2 B. Growth hormone concentration C. Liver function tests D. Presence of gallstones E. Heart rate 4. Which of the following medication(s) will likely require dosage adjustment in a 36-year-old kidney transplant patient recently started on lanreotide for acromegaly?

A. Cyclosporine B. Insulin detemir C. Lisinopril

D. Cyclosporine, insulin detemir E. Cyclosporine, insulin detemir, lisinopril 5. All of the following drug/adverse reaction pair combinations are correct except: A. Bromocriptine: hypertension B. Cabergoline: dizziness C. Pegvisomant: abnormal liver enzymes D. Lanreotide: gallstone E. Recombinant GH therapy: peripheral edema 6. A 43-year-old man with history of hypothyroidism, diabetes, and stunted growth recently diagnosed with peak GH concentration of 3 ng/mL (3 µg/L; 136 pmol/L) after two GH stimulation tests. Which of the following clinical presenting signs or symptoms is (are) suggestive of growth hormone deficiency?

A. Increased sweating B. Increased insulin sensitivity Pituitary gland disorders 3 C. Increased energy and strength D. Decreased muscle mass E. Decreased sensitivity to heat and cold 7. Which one of the following pituitary gland disorder and clinical presentation pair combinations is correct?

A. Acromegaly: infertility B. Acromegaly: oligomenorrhea C. GH deficiency: depression D. Hyperprolactinemia: enlarged hands E. Hyperprolactinemia: hypergonadism 8. Which one of the following is the most appropriate treatment goal for the management of hyperprolactinemia?

A. Remove the pituitary gland since it is malfunctioning B. Reduce prolactin concentrations as much as possible C. Suppress gonadal function in males and females D. Restore normal fertility in males and females E. Treat osteoporosis since it is likely to occur 9. Which of the following is the most appropriate GH replacement dose to initiate in a 62yearold woman with growth hormone deficiency and type 2 diabetes mellitus?

A. 0.6 mg/day B. 0.5 mg/day C. 0.4 mg/day D. 0.3 mg/day Pituitary gland disorders 4 E. 0.2 mg/day 10. Which of the following GH deficient patients may require a higher initial GH replacement dose?

A. 68-year-old man with normal renal function B. 11-year-old girl weight 30 kg C. 24-year-old woman taking oral contraceptives D. 45-year-old obese man with diabetes

E. None of the above 11. All of the following are important to evaluate when a patient presents with elevated prolactin concentration of 30 mcg/mL (30 mcg/L; 1304 pmol/L), except: A. Stress level when taking prolactin measurement B. Use of dopamine antagonist medications C. Use of β-blocker medications D. Presence of chronic renal failure E. Presence of hypothyroidism 12. All of the following pharmacologic classes have been associated with drug-induced hyperprolactinemia except: A. Histamine2 receptor antagonists B. Nucleoside reverse transcriptase inhibitors C. Protease inhibitors D. Progestins E. Estrogens Pituitary gland disorders 5 13. A 28-year-old woman with elevated prolactin concentration of 45 ng/ml (45 mcg/L; 1957 pmol/L) presents without any complaints and normal menstrual cycle. Which one of the following treatment options is the most appropriate first-line therapy for management of the patient’s hyperprolactinemia?

A. Clinical observation B. Bromocriptine C. Cabergoline D. Radiation therapy E. Transsphenoidal microsurgery 14. A 32-year-old woman presents with oligomenorrhea, weight gain, and excess hair growth.

Diagnosis of hyperprolactinemia is confirmed with elevated prolactin concentration of 55 ng/mL (55 mcg/L; 2391 pmol/L). The patient and her husband have been trying to conceive for over a year without success. Which of the following treatment options is the most appropriate first-line therapy?

A. Bromocriptine 0.625 mg at bedtime without birth control B. Cabergoline 0.5 mg once weekly with adequate birth control C. Clinical observation due to desire to conceive D. Radiation therapy due to desire to conceive E. Refer for transsphenoidal microsurgery 15. Which of the following is the preferred treatment for a 40-year-old woman diagnosed with both acromegaly and hyperprolactinemia?

A. Cabergoline B. Bromocriptine Pituitary gland disorders 6 C. Lanreotide D. Pegvisomant E. Radiation therapy Pituitary gland disorders 7 Answers 1. E

2. A 3. C 4. D 5. A 6. D 7. C 8. D 9. E 10. C 11. C 12. B 13. A 14. B 15. A

Chapter 47. Pregnancy and Lactation: Therapeutic Considerations 1. When analyzing information on the safety of a drug exposure during pregnancy, which one of these statements is true?

A. It is estimated that approximately 10% of congenital anomalies are caused by a medication exposure.

B. FDA categories should not be used to assess the safety of medication use during pregnancy.

C. Animal studies are of equal value with human data to inform on teratogenic risk of a drug.

D. Before a medication is put on the market, it is mandatory to have human pregnancy safety data.

E. The fetogenesis period is the most at risk period for structural congenital anomalies following a teratogenic exposure.

2. Which of the following key points is appropriate when considering the use of lamotrigine during breast-feeding?

A. It is contraindicated to use lamotrigine during breast-feeding.

B. Lamotrigine blood concentration of a breast-fed infant can be up to 10% to 50% of simultaneous maternal blood concentration.

C. Several cases of severe rash have been reported in breast-fed infants whose mothers were taking lamotrigine.

D. When mothers who take lamotrigine breast-feed, the drug is usually undetectable in the 2 infants’ serum.

E. There is scarcity of data on lamotrigine during breast-feeding.

3.A 36-year-old woman wishes to become pregnant with her second child. She has been treated for type 2 diabetes for 3 years. She has a well balanced diet with plenty of vegetable and fruits. Based on this information, which of the following is the most appropriate folic acid recommendation for this patient to prevent congenital anomalies?

A. Folic acid 4 mg orally daily starting at 10 weeks’ gestation and throughout pregnancy.

B. Folic acid 0.4 mg with a multivitamin orally daily starting at least 1 month before pregnancy and throughout the first trimester.

C. Folic acid 4 mg with a multivitamin orally daily starting 3 months before pregnancy and

throughout the first trimester.

D. Multivitamin containing 0.4 to 0.8 mg of folic acid orally daily starting 1 month before pregnancy and throughout the first trimester.

E. No folic acid supplement is required since folic acid is provided by her diet.

4.Which one of the following periods is considered the organogenesis (embryogenesis) period?

A. Days 1 to 14 postconception B. Days 1 to 14 after last menses C. Days 14 to 28 postconception D. Days 14 to 77 after last menses E. Days 1 to 56 postconception 3 5. Which of the following medications should never be used in pregnancy?

A. Warfarin B. Naproxen C. Norfloxacin D. Methotrexate E. Methimazole 6. During the first trimester of pregnancy, each of the following screening tests should be performed except: A. Hemoglobin and hematocrit B. Group B Streptococcus vaginal-rectal culture C. HIV D. Urinalysis with Gram stain and culture E. Chlamydia screening 7. Which of the following statements on bacterial vaginosis during pregnancy is true?

A. Bacterial vaginosis is associated with an increased risk of postpartum urinary tract infections.

B. Clindamycin, one vaginal ovule daily for 7 days, is a first-line treatment for bacterial vaginosis during pregnancy.

C. Universal screening for bacterial vaginosis at 16 weeks of pregnancy is recommended.

D. Since bacterial vaginosis is associated with adverse pregnancy outcomes, sexual partners of pregnant women who test positive for bacterial vaginosis should be treated.

4 E. Metronidazole 500 mg orally twice daily for 7 days is one of the best treatments for bacterial vaginosis during pregnancy.

8.A 22-year-old pregnant woman complains of pain following a severe ankle sprain. Ice and acetaminophen 650 mg orally every 6 hours are not relieving her pain. She rates her pain as 7 out of 10 on a visual analogue scale. She is 32 weeks pregnant. Which of the following is the best recommendation for her pain at this point?

A. Acetaminophen 2 g orally every 4 hours regularly B. Acetaminophen 1 g orally every 6 hours as needed C. Codeine 15 to 30 mg orally every 4 hours as needed D. Glucosamine 500 mg orally three times daily for 5 days E. Ibuprofen 400 mg four times daily as needed 9. Which one of the following is a first-line recommendation for the treatment bacterial mastitis in a breast-feeding woman with moderate symptoms?

A. Vancomycin 250 mg orally four times daily for 10 days B. Fluconazole 200 mg orally once daily for 14 days C. Cephalexin 500 mg orally four times daily for 10 to 14 days D. Topical bacitracin ointment twice daily for 14 days E. No antibiotic is usually recommended 10. Which of the following maternal treatments has not been associated with a reduction of adverse pregnancy outcomes?

5 A. Ceftriaxone for gonorrhea B. Metronidazole for trichomoniasis C. Azithromycin for chlamydia D. Penicillin G benzathine for syphilis E. Oral acyclovir starting at 36 weeks gestation for herpes prevention 11. Which of the following regimens is the most appropriate tocolytic at 30 weeks of pregnancy?

A. Dexamethasone 2 mg IM every 24 hours for 48 hours B. Nifedipine 10 mg orally every 20 minutes three times, then 10 mg every 6 hours for 48 hours C. Magnesium sulphate 2 g IV, then 1 g/h for 48 hours D. Amoxicillin 1 g orally once, then 250 mg every 8 hours for 24 hours E. Indomethacin 25 mg orally every 6 hours for 5 days 12.Which of the following statements is true?

A. Antibiotics carry more risks than urinary tract infections during pregnancy.

B. Antihypertensive agents carry more risks of fetal malformations than hypertension.

C. Heparins carry more risks of fetal complications than warfarin.

D. Antiepileptic agents carry more risks of fetal malformation than epilepsy.

E. Propylthiouracil displays more risks of fetal malformations than hyperthyroidism.

13.Which of the following women should not be started on group B streptococcus antibiotic prophylaxis?

6 A. Preterm premature rupture of membranes, 30 weeks, first pregnancy, and GBS status unknown B. Onset of labor, 34 weeks, second pregnancy, GBS status unknown, and negative status at previous delivery C. Onset of labor, 38 weeks, third pregnancy, and second baby had GBS neonatal infection D. Rupture of membranes, 39 weeks, first pregnancy, and negative GBS status at 36 weeks E. Onset of labor, 40 weeks, first pregnancy, and positive urine culture for GBS 14.Chose the correct statement A. Lithium is associated with an increased risk of cardiac malformations when used between the 5th and 10th weeks of pregnancy B. Newer antipsychotics are not well studied and should be avoided during pregnancy C. Valproic acid is the treatment of choice for rapid cycling bipolar disorders during pregnancy D. Lithium has been associated with neonatal hypotonia (floppy infant syndrome) when used during the first trimester of pregnancy E. Lithium pharmacokinetics is changed during pregnancy which leads usually to doses reductions during the second and third trimesters.

15.MM gave birth this morning to a healthy 3.2 kg baby at 39 weeks gestation. She has been

treated for a bipolar disease for several years. Her medication was not changed or adjusted during pregnancy. She would like to breast-feed. What would be the appropriate recommendation?

Medications: Lithium 900 mg orally at bedtime; citalopram 20 mg orally daily in the morning; 7 lorazepam 1 mg orally at bedtime as needed (takes it twice weekly) A. The baby should be admitted to the neonatal intensive care unit for close monitoring B. Lithium should be changed for valproic acid which does not pass extensively into breast milk C. Lithium can be used during breast-feeding in selected reliable women as long as close monitoring of the infant (including thyroid and renal functions, and lithium serum levels) can be ensured.

D. Citalopram can be used during breast-feeding as long as close monitoring of the infant (weight, renal and liver functions) can be ensured E. Lorazepam should be switched to clonazepam which has a long half-life 8 Answers 1. B 2. B 3. C 4. D 5. D 6. B 7. E 8. C 9. C 10. B 11. B 12. D 13. D 14. A 15. C

Chapter 48. Contraception 1. All of the following are the functional phases of the menstrual cycle except: A. Follicular B. Ovulatory C. Implantation D. Menstrual 2. Rapid return of fertility would be least likely to occur upon discontinuation of which of the following contraceptives: A. NuvaRing B. Depo-Provera C. Yasmin D. Ortho Evra 3. COCs work by inhibiting ovulation. The progestin component of COCs works mainly by suppressing which of the following hormones: A. Gonadotropin-releasing hormone (GnRH) B. Luteinizing hormone (LH) C. Follicle-stimulating hormone (FSH) D. Growth hormone (GH) 4. Potential risks associated with the use of oral contraceptives include all of the following except: A. Venous thromboembolism B. Hypertension C. Gallbladder disease D. Breast cancer 2 5. Which of the following is considered to be an absolute contraindication to the use of COCs? A. Smoking 10 cigarettes per day B. History of migraine headache disorder without aura C. Postpartum 2 weeks following delivery D. Uterine fibroids 6. If a woman has breakthrough bleeding or spotting that continues beyond her normal menses, what would be the most appropriate suggestion to decrease this side effect?

A. Increase progestin dose B. Decrease progestin dose C. Increase estrogen dose D. Decrease estrogen dose 7. Which of the following COCs is FDA-approved for the treatment of PMDD? A. Yaz B. Yasmin C. Seasonique D. Loestrin 24 Fe 8. Unlike COCs, which of the following risks has not been associated with progestin-only pills?

A. Hypertension B. Venous thromboembolism C. Headaches D. Acne

9. Which of the following medications may increase metabolism of COCs, decreasing their efficacy?

A. Phenytoin 3 B. Alprazolam C. Prednisone D. Tetracycline 10. Select the agent most likely to have its metabolism increased by a COC. A. Theophylline B. St. John’s wort C. Rifampin D. Lamotrigine 11. The use of oral contraceptives has been linked (either directly or indirectly) to a decrease in the risk for which of the following types of cancer?

A. Endometrial cancer B. Cervical cancer C. Hepatocellular cancer D. Breast cancer 12. Which of the following oral contraceptives is available by prescription only?

A. Plan B One Step B. My Way C. ella D. Next Choice One Dose 13. Which of the following is not an example of an extended-cycle contraceptive?

A. Loestrin 24 Fe B. Seasonique C. Yasmin 4 D. Lybrel 14. The most effective fertility awareness–based contraceptive method is thought to be the: A. Calendar (rhythm) method B. Temperature method C. Cervical mucous method D. Symptothermal method 15. Contraceptives that can prevent both pregnancy and STIs include: A. Diaphragms B. Condoms C. Intrauterine devices D. Both A and B 5 Answers 1. C 2. B 3. B 4. D 5. C

6. C 7. A 8. B 9. A 10. D 11. A 12. C 13. C 14. D 15. B

Chapter 49. Menstruation-Related Disorders 1. The medical management of should result in the relief of pelvic pain, an improved quality of life, and a reduction in related lost school/work days.

A. Amenorrhea B. Anovulatory bleeding C. Dysmenorrhea D. Menorrhagia E. Polycystic ovary syndrome 2. Regardless of the cause of amenorrhea, which of the following lifestyle interventions is most appropriate?

A. Increase the level of exercise B. Increase the intake of dietary calcium and vitamin D C. Decrease the intake of alcohol D. Decrease the level of exercise E. Transition to a gluten-free diet 3. The primary goal of estrogen therapy in amenorrhea is to improve the patient’s bone health. A progestin is added to: A. Augment estrogen’s effects on bone B. Improve overall quality of life C. Prevent endometrial hyperplasia D. Restore fertility E. Counter estrogen’s negative effects on lipids 2 4. A 35-year-old woman presents with complaints of increasingly heavy menses that last approximately 7 days per month. A CBC shows a 2 g/dL (20 g/L; 1.24 mmol/L) drop in hemoglobin over the past 15 months. A Pap smear and endometrial biopsy are performed, and are both negative. Her past medical history is significant for a deep vein thrombosis 3 years ago secondary to her oral contraceptive. Which of the

following is most appropriate first-line therapy for this patient?

A. A combination oral contraceptive with 50 mcg of ethinyl estradiol plus desogestrel B. Mefenamic acid 500 mg by mouth followed by 250 mg by mouth four times daily during menses C. Levonorgestrel IUD releasing 20 mcg of levonorgestrel daily D. Medroxyprogesterone acetate 10 mg by mouth on days 5 through 26 of the menstrual cycle E. Acetaminophen 650 mg by mouth four times daily 5. Which of the following treatments for dysmenorrhea results in the most rapid symptom improvement?

A. Acetaminophen B. Levonorgestrel IUD C. A standard (28-day) combination oral contraceptive D. An extended cycle (91-day) combination oral contraceptive E. NSAIDs 6. Which of the following statements is true regarding the use of NSAIDs and OCs in patients with menorrhagia?

3 A. The reduction in blood loss is inversely proportional to pretreatment blood loss.

B. The increase in blood loss is inversely proportional to pretreatment blood loss.

C. The reduction in blood loss is proportional to pretreatment blood loss.

D. The increase in blood loss is proportional to pretreatment blood loss.

E. None of the above 7. A 32-year-old woman presents with complaints of irregular menses and difficulty becoming pregnant. She has been taking tetracycline for acne 8 years. She is hirsute around the jaw line, her BMI is 32 kg/m2, and her waist circumference is 40 inches (102 cm). A pelvic ultrasound is performed that shows polycystic ovaries. In addressing her infertility related to PCOS, in addition to recommending weight loss, which of the following is most appropriate for this patient?

A. Clomiphene 50 by mouth daily for 5 days starting on day 5 of the menstrual cycle B. Medroxyprogesterone acetate 10 mg by mouth daily for 10 days C. Metformin 850 mg by mouth twice daily D. Pioglitazone 15 mg by mouth daily E. A and D 8. Initially, the recommended treatment for acute bleeding episodes associated with anovulation is: A. Estrogen B. Letrozole 4 C. Levonorgestrel IUD D. Mefenamic acid E. Naproxen

9. Which of the following agents is no longer recommended for the treatment of anovulatory bleeding?

A. Estrogen via combination oral contraceptives B. Letrozole C. Depot medroxyprogesterone acetate D. Metformin E. Pioglitazone 10. Which of the following treatment options is most appropriate to control acute bleeding as well as prevent recurrent bleeding in a 25-year-old anovulatory woman with signs of high androgen levels?

A. An oral contraceptive containing at least 35 mcg of ethinyl estradiol in combination with the progesterone, drospirenone; one tablet taken by mouth three times daily for 1 week followed by one tablet daily for 3 weeks B. An oral contraceptive containing at least 35 mcg of ethinyl estradiol in combination with norethindrone acetate; one tablet taken by mouth daily for 4 weeks C. Medroxyprogesterone acetate 5 mg taken by mouth daily for 1 week followed by 2.5 mg daily for 3 weeks D. Medroxyprogesterone acetate 5 mg taken by mouth daily for 4 weeks E. None of the above 5 11. Which of the following agents is most appropriate for the management of dysmenorrhea when nonpharmacologic options have failed?

A. Depot medroxyprogesterone acetate 150 mg intramuscularly every 12 weeks B. Ibuprofen 800 mg by mouth three times daily during menses C. Levonorgestrel IUD releasing 20 mcg of levonorgestrel daily D. Medroxyprogesterone acetate 5 mg by mouth daily E. Oral contraceptive with 35 mcg of ethinyl estradiol plus norgestimate daily 12. When using an OC for the management of dysmenorrhea in an adolescent, additional benefit(s), dependent on the specific option chosen, may include: A. Reduced endometrial cancer risk B. Pregnancy prevention C. Improved acne D. None of the above E. A, B, and C 13. The treatment goals of include preserving bone density, preventing bone loss, improving quality of life, and restoring menstruation.

A. Amenorrhea B. Dysmenorrhea C. Menorrhagia D. Polycystic ovary syndrome E. None of the above 6 14. Which of the following menorrhagia treatment options have been shown to reduce menstrual blood flow by 75% to 95% and result in up to 80% of treated women experiencing amenorrhea after 12 months?

A. Combination oral contraceptives B. Ibuprofen C. Levonogestrel IUD D. Medroxyprogesterone acetate E. All of the above 15. Which of the following non-hormonal treatment options is well tolerated from a gastrointestinal standpoint and is recommended for patients with vonWillebrand disease as a cause of menorrhagia?

A. Ibuprofen B. Mefenamic acid C. Naproxen D. Tranexamic acid E. None of the above 7 Answers 1.

C 2.

B 3.

C 4.

B 5.

E 6.

C 7.

A 8.

A 9.

E 10.

A 11.

B 12.

E 13.

A 14.

C 15.

D

Chapter 50. Hormone Therapy in Menopause 1. Which of the following statements regarding menopause is true?

A. Menopause is diagnosed after a series of increasing FSH concentrations.

B. The primary symptom of menopause is vulvovaginal atrophy.

C. Women who undergo surgical menopause experience similar vasomotor symptoms as women who undergo natural menopause.

D. The perimenopausal period is characterized by an increase in cycle interval and a decrease in cycle length.

2. A 48-year-old woman wants to know about the overall use of hormones based upon recent data, including WHI and HERS. The most accurate statement would be: A. Estrogen with and without progesterone has been shown to increase heart attacks and breast cancer in postmenopausal women.

B. Estrogen and progesterone increased the risk of invasive breast cancer in postmenopausal women, but estrogen alone did not.

C. Evidence indicates topical and compounded products are safer than oral products because absorption is minimal and cardiovascular risks have not been shown to be significantly increased.

D. Evidence had demonstrated an increase in cardiovascular events in postmenopausal women who started estrogen regardless of time since initiation.

3. A 49-year-old woman who had a hysterectomy 6 months ago is seeking treatment for her vasomotor symptoms. Which of the following recommendations would be most appropriate?

A. Combination estrogen/progestogen for no longer than 2 years HORMONE THERAPY IN MENOPAUSE 2 2 B. Estrogen alone for no longer than 5 years C. Estradiol vaginal cream until symptoms resolve D. Black cohosh for no longer than 2 years 4. A 60-year-old woman has suffered from worsening hot flashes and urinary incontinence over the past year. Her last menstrual period was over 3 years ago. PMH is significant for hyperlipidemia taking simvastatin 40 mg daily. She smokes 1 ppd and has one glass of wine with dinner. Recommend the most appropriate treatment for this patient.

A. CEE 0.3 mg daily + MPA 1.5 mg daily B. Venlafaxine 75 mg daily C. CEE 0.625 mg daily D. Estradiol vaginal cream, apply as directed 5. A 54-year-old postmenopausal woman presents to the clinic complaining of hot flashes. Her PMH is significant for tobacco use and CAD. Her last menstrual period was approximately 14 months ago after having a hysterectomy. She states she suffers from five hot flashes per day and two per night that wake her from sleep. Recommend the most appropriate treatment for the patient’s hot flashes.

A. CEE 0.6 mg daily plus MPA 1.5 mg daily B. CEE 0.3 mg daily C. Clonidine 0.1 mg daily D. Paroxetine 20 mg daily HORMONE THERAPY IN MENOPAUSE 3

3 6. A 57-year-old woman has taken CEE 0.3/MPA 2.5 for the past 2 years for vasomotor symptoms. She has become more and more concerned about the use of estrogens and would like to try an alternative therapy for control of her hot flashes. Based on demonstrated efficacy, which one of the following alternative regimens would be the most appropriate choice for this patient?

A. Dong quai 4.5 g daily B. Wild yam extract 40 mg daily C. Soy isoflavones 80 g daily D. Black cohosh 40 mg daily 7. A 56-year-old woman who presents to you with complaints of vaginal dryness and dyspareunia. She states she has been experiencing these symptoms for over 3 months, and it is starting to affect her marriage. Her past medical history is significant for hypertension and type 2 diabetes mellitus. Her past surgical history is significant for a cholecystectomy and hysterectomy. Her medication regimen includes metoprolol (Lopressor), HCTZ, atorvastatin (Lipitor), metformin (Glucophage), and aspirin. Which of the following medications is most appropriate to recommend for her menopausal symptoms?

A. CEE 0.625 mg B. CEE 0.3 mg + MPA 1.5 mg C. Paroxetine CR 40 mg D. Vaginal estradiol (Vagifem) 8. A 48-year-old newly menopausal woman has been taking a low-dose oral contraceptive pill for about 1 year during perimenopause. She is now considered fully menopausal and is questioning what she can take that has evidence of alleviating her menopausal symptoms. Her HORMONE THERAPY IN MENOPAUSE 4 4 medical history is significant for osteoarthritis and asthma. She has not had a hysterectomy.

Which one of the following is the best treatment recommendation?

A. Continue the oral contraceptive for 1 to 2 years until the menopausal symptoms have most likely resolved B. Evening primrose oil in addition to stress reduction and relaxation techniques C. A serotonin reuptake inhibitor (SSRI) in addition to stress reduction and relaxation techniques D. Estrogen therapy (Premarin 0.3 mg/d) in addition to stress and relaxation techniques 9. A 52-year-old woman presents with complaints of hot flashes and night sweats. She states that they often cause her to change her bed clothes in the middle of the night and are affecting her sleep quality. Her past medical history is significant for osteoporosis and venous thromboembolism. She currently takes alendronate 70 mg weekly and aspirin 81 mg orally every day. She has not had a hysterectomy. Which of the following therapies is most appropriate for this patient?

A. Estradiol vaginal cream, apply as directed B. CEE 0.3 mg + MPA 2.5 mg C. CEE 0.3 mg D. Paroxetine CR 12.5 mg 10. A 60-year-old woman who has been taking HT for 9 years. She was started on this therapy following a hysterectomy for uterine fibroids. Her past medical history is significant for hypertension and osteoarthritis. She currently takes CEE 0.3 mg + MPA 1.5 mg orally every day, hydrochlorothiazide 25 mg orally every day, and acetaminophen 1000 mg orally thrice daily. She

smokes one pack of cigarettes per day and drinks one glass of wine on the weekends. You are HORMONE THERAPY IN MENOPAUSE 5 5 seeing her in clinic today for a follow-up blood pressure check, and she asks you if she still needs to take her HT. She states adherence to her medication regimen and denies adverse effects.

Which of the following is the appropriate response to her concern?

A. Discontinue the oral HT, and start her on a topical product to decrease her risk of CHD and breast cancer.

B. Continue the HT because her risk of CHD and breast cancer are low and she will receive osteoporosis benefits.

C. Discontinue the HT by tapering the regimen over 3 to 6 months since she may no longer need treatment for vasomotor symptoms and does have risk factors for CHD. D. Discontinue the HT, and follow up with her by phone in 2 weeks to assess for a return in vasomotor symptoms.

11. A 55-year-old woman was recently started on HT (CEE 0.3 mg + MPA 2.5 mg) daily for hot flashes that began to disrupt her daily activities. She presents with complaints of weight gain (3.2 kg [7 lb]) and severe bloating approximately 6 weeks after starting therapy. She states that some days “she feels like she is going to pop.” Her past medical history is significant for mild intermittent asthma and hypothyroidism. She currently takes albuterol as needed and levothyroxine 50 mcg orally every day. She states that she is adherent to the medication regimen and denies adverse effects. She does not smoke or drink alcohol.

Which of the following actions is the most appropriate initial step to take with this patient?

A. Discontinue oral HT, and start vaginal estradiol cream B. Switch to a combination transdermal product C. Decrease the dose of CEE to 0.3 mg every other day HORMONE THERAPY IN MENOPAUSE 6 6 D. Switch the patient to a cyclical combined HT regimen 12. A 49-year-old woman who had a hysterectomy 6 months ago is given a prescription for hormone therapy. However, she is concerned about the risk of a clot because she has a friend who had a similar problem with hormones. Which one of the following would most likely minimize this risk?

A. Limit use to no more than 5 years B. Delay treatment for 6 more months C. Use of oral medroxyprogesterone acetate D. Use of a transdermal estrogen product 13. A 51-year-old woman with a PMH significant for hypothyroidism, HTN, and GERD. She has been suffering from severe hot flashes that wake her up every night about three or four times.

She has a past surgical history significant for a knee replacement in 1995 and a hysterectomy in 1998 for uterine fibroids. Medications include Synthroid 0.075 mg daily, HCTZ 25 mg daily, and Protonix 20 mg daily. She used to smoke one pack of cigarettes per day but quit 5 years ago. She does drink socially. The physician starts EG on CEE 0.3 mg daily.

Based upon the patient’s history, she should be educated specifically on which of the following potential adverse effects??

A. Depression and anxiety B. Gallbladder disease and venous thromboembolism

C. Bloating and weight gain D. Osteoporosis and CHD HORMONE THERAPY IN MENOPAUSE 7 7 14. A patient was using HT for hot flashes and vulvovaginal atrophy until 1 year ago when she was diagnosed with stage 2 breast cancer. Six months following completion of her chemotherapy and radiation she complains of recurrent hot flashes. Recommend the most appropriate therapy for the patient’s hot flashes.

A. Restart CEE 0.3 mg + MPA 1.5 mg daily B. Isoflavones 80 mg daily C. A bioidentical preparation D. Gabapentin 300 mg daily 15. A healthy 43-year-old woman who recently had a hysterectomy because of uncontrolled dysfunctional uterine bleeding and has been using an estrogen transdermal patch for 3 months to control severe menopausal symptoms. She does not have a personal or family history of breast cancer or clotting disorders, but there is a history of heart disease in the family. When asked about continuing the estrogen patch in this patient, which one of the following recommendations is best at this time?

A. Can continue treatment, but recommend short term and monitor B. Continue treatment but switch to an oral estrogen C. Continue treatment, but need to add a progestogen 12 to 14 days/month D. Discontinue treatment HORMONE THERAPY IN MENOPAUSE 8 8 Answers 1. D 2. B 3. B 4. A 5. D 6. C 7. D 8. C 9. D 10. C 11. B 12. D 13. C 14. D 15. A

Chapter 51. Erectile Dysfunction 1. Which of the following distinguishes the PDE-5 inhibitor tadalafil from avanafil, vardenafil, and sildenafil?

A. Efficacy B. Safety C. Speed of onset D. Duration of action E. All of the above 2. Which of the following is/are contraindications to the use of PDE-5 inhibitors?

A. History of a myocardial infarction 6 months ago B. Mild, stable angina C. NYHA Class I heart failure D. Nitrate use E. All of the above are contraindications to the use of PDE-5 inhibitors 3. Which of the following statements regarding the management of ED is most accurate?

A. Avanafil has been proven to offer superior efficacy vs sildenafil B. Intracavernosal injections are ideal for younger men in new relationships C. Penile prosthesis insertion is considered when less invasive options have failed D. Intraurethral alprostadil is more effective than intracavernosal alprostadil injections E. PDE inhibitors may worsen hypertension 4. Which of the following medication regimens is most likely to promote ED in a patient with hypertension, gastroesophageal reflux, and dyslipidemia?

A. Losartan, aluminum hydroxide, and fenofibrate B. Lisinopril, calcium carbonate, and niacin C. Diltiazem, lisinopril, and ranitidine D. Amlodipine, calcium carbonate, and fenofibrate E. Metoprolol, spironolactone, and gemfibrozil 2 5. Which of the following statements is correct regarding PDE inhibitor use for ED? A. Tadalafil may be taken with a high-fat meal B. Sildenafil has a significant drug interaction with antiarrhythmic medications C. Vardenafil’s time to onset of effect is within 10 minutes D. All are contraindicated in patients taking oral anticoagulants E. All are considered second-line therapy options in patients with diabetes 6. A 55-year-old man with ED has recently been prescribed 50 mg of sildenafil for organic ED. He returns upset that it did not work and would like to switch to something else. Which of the following could have led to the failed response?

A. He took the sildenafil on an empty stomach.

B. The dose of sildenafil was taken an hour prior to attempting intercourse.

C. After taking the sildenafil, he waited for a response before approaching his partner.

D. He attempted multiple times with this dose before returning to his provider.

7. Which of the following describes how ED should be managed in a patient with CV disease assessed to have high risk according to the Princeton Consensus Conference?

A. Low-dose PDE inhibitor

B. Penile prosthesis C. Low-dose intraurethral alprostadil D. VED E. Patient must be stable and in low to moderate risk to initiate treatment 8. Which formulation of testosterone replacement is associated with wide swings of serum testosterone concentrations?

A. Daily transdermal testosterone gel B. Daily transdermal testosterone patch C. Twice daily buccal testosterone D. Every two week intramuscular (IM) testosterone cypionate 3 9. Which of the following statements are correct regarding VEDs? A. They are an appropriate first line therapy for young men in new relationships B. The constriction band may be left on up to 90 minutes C. They are contraindicated in men taking nitrates D. Adverse effects include painful ejaculation or inability to ejaculate E. They should never be combined with other ED therapies 10. A 68-year-old patient presents to the clinic after initiation of avanafil 200 mg 3 months ago. He continues to be unsuccessful with intercourse despite correct use and appropriate expectations. What would be the best approach to his ED treatment at this time?

A. Increase avanafil dose to 300 mg as needed B. Draw serum testosterone concentrations to assess for hypogonadism C. Switch to sildenafil 25 mg as needed D. Combine avanafil at current dose with an α-blocker E. Initiate spironolactone for treatment of his hypertension 11. A patient in his 40s presents with complaints of some erections, but not sufficient for intercourse with his new sexual partner. When questioned, he states that he recently ended his marriage, takes no chronic medications, and has excellent past physical and mental health. Which of the following interventions would you suggest first?

A. Initiate a PDE-5 inhibitor B. Vacuum erection device C. Counseling and reassurance D. Penile prosthesis E. Intracavernosal injections of alprostadil 12. Which of the following are risk factors for the development of organic ED? A. Psychiatric disorders B. Neurologic disorders (eg, Parkinson disease) C. Diabetes mellitus 4 D. Cardiovascular diseases E. All of the above 13. Which of the following statements regarding intracavernosal injections for ED are correct?

A. Medication should be injected into each cavernosa separately.

B. Dose titration should occur in the prescriber’s office.

C. Dose should be titrated to achieve an erection lasting 4 hours.

D. Patients may use injections daily if desired.

E. A common side effect is a difficulty discriminating blue from green 14. The usual dose of sildenafil should be reduced in which of the following situations?

A. Elderly B. Hepatic impairment C. Renal impairment D. Concomitant use of an α-blocker E. All of the above 15. Which of the following is not a desired characteristic of a therapy for ED? A. Lead to an erection lasting more than 4 hours B. Minimal side effects C. Convenient administration D. Quick onset of action E. Few drug interactions 5 Answers 1. D 2. D 3. C 4. E 5. A 6. C 7. E 8. D 9. D 10. B 11. C 12. E 13. B 14. D 15. A

Chapter 52. Benign Prostatic Hyperplasia 1. A uroselective α-adrenergic antagonist inhibits this α-adrenergic receptor in prostatic smooth muscle?

A. α1A B. α1D C. α1B D. α2A E. α2B 2. Use of a 5α-reductase inhibitor can be expected to reduce the volume of an enlarged prostate gland by this percentage.

A. 10 B. 20 C. 50 D. 75 E. 100 3. Use of an α-adrenergic antagonist or a 5α-reductase inhibitor can be expected to have this clinical effect in patients with symptomatic BPH: A. Decrease peak urinary flow rate B. Increase postvoid residual urine volume C. Increase detrusor relaxation D. Improve bladder emptying E. Increase urinary frequency 4. Which of these agent(s) has/have a low likelihood of causing cardiovascular adverse effects in a patient with BPH who also is receiving antihypertensives for essential hypertension?

1. Alfuzosin 2. Tamsulosin 3. Silodosin A. 1 only B. 2 only C. 3 only D. 1 and 3 only E. 1, 2, and 3 5. Which one of the following statements about tadalafil’s use for LUTS is correct?

A. It should be dosed on demand or when needed.

B. It is indicated for patients with complications of BPH. C. It works by causing relaxation of the detrusor muscle.

D. It produces an increase in peak urinary flow rate.

E. It reduces the AUA symptom score by at least 3 points.

6. The benefits of combination treatment with a 5α-reductase inhibitor and α-adrenergic antagonist for BPH includes all of the following except: A. Increasing urinary flow rate B. Decreasing AUA Symptom Score C. Decreasing prostate gland size D. Increasing need for prostatectomy

E. Decreasing risk of acute urinary retention 7. Which one of the following statements about mirabegron’s use for LUTS is correct?

A. It reduces obstructive voiding symptoms.

B. It reduces irritative voiding symptoms.

C. It shrinks an enlarged prostate.

D. A common adverse effect is erectile dysfunction.

E. It is contraindicated in patients taking nitrates.

8. Which one of the following agents requires a dosage reduction in a patient with an estimated creatinine clearance of 30 to 40 mL/min (0.50 to 0.67 mL/s)?

A. Tamsulosin B. Alfuzosin C. Silodosin D. Dutasteride E. Finasteride 9. The treatment of choice for a patient with recurrent urinary tract infections and acute urinary retention secondary to BPH is: A. α-adrenergic antagonist B. β3-agonist C. combination of α-adrenergic antagonist and 5α reductase inhibitor D. prostatectomy E. mirabegron plus tadalafil 10. Which one of the following statements about functionally uroselective α-adrenergic antagonists is correct?

A. Doxazosin and terazosin are pharmacologically uroselective.

B. Functionally uroselective agents are more likely formulated as controlled release, rather than immediate release.

C. Uroselective agents are more likely to be effective for treating genitourinary tract disorders than disorders of other organ systems.

D. Hypotension is more likely to occur with clinically uroselective agents than with nonclinically uroselective agents.

E. Clinically uroselective agents should not be taken along with a 5α reductase inhibitor.

11. A patient takes doxazosin controlled-release tablets 8 mg orally every day for 1 month.

However, he runs out of medication and does not take it for 3 days. Upon resuming his medication, he should: A. Restart doxazosin controlled-release tablets 8 mg orally every day B. Switch to doxazosin immediate-release tablets, start at 2 mg orally every day and then slowly retitrate up C. Start doxazosin controlled-release tablets 4 mg orally every day and then slowly retitrate up to 8 mg daily over 3 to 4 weeks D. Double the dose of doxazosin controlled-release tablets, start at 16 mg orally every day for 3 days, then decrease to 8 mg orally every day E. Start doxazosin controlled-release tablets 4 mg orally on day 1, then 4 mg orally twice a day on day 2, then 8 mg orally on day 3 and thereafter 12. Which one of the following side effects of finasteride could be treated with a phosphodiesterase inhibitor?

A. Gynecomastia

B. Decreased libido C. Erectile dysfunction D. Retrograde ejaculation E. Hirsutism 13. RR has an AUA Symptom Score of 6. A diagnosis of mild LUTS due to BPH is made.

The treatment of choice is: A. Watchful waiting B. α-Adrenergic antagonist C. 5α-Reductase inhibitor D. Anticholinergic agent E. Minimally invasive surgery 14. RR has an AUA Symptom Score of 25. The clinical presentation is consistent with severe BPH. DRE reveals a 25 g (0.9 oz) prostate. The patient has no BPH-related complications. The treatment of choice is: A. Watchful waiting B. α-Adrenergic antagonist C. 5α-Reductase inhibitor D. α-Adrenergic antagonist +5α-reductase inhibitor E. Transurethral resection of the prostate 15. SS has an AUA Symptom Score of 35 and complains of severe LUTS. DRE reveals a 50 g (1.8 oz) prostate and PSA is 1.9 ng/mL (1.9 mcg/L). The patient has no BPH-related complications. The treatment of choice is: A. Watchful waiting B. α-Adrenergic antagonist C. 5α-Reductase inhibitor D. α-Adrenergic antagonist + 5α-reductase inhibitor E. Transurethral resection of the prostate Answers 1. A 2. B 3. D 4. E 5. E 6. D 7. B 8. C 9. D 10. B 11. C 12. C 13. A 14. B 15. D

Chapter 53. Urinary Incontinence and Pediatric Enuresis 1. Stimulation of muscarinic cholinergic receptors in the bladder muscle may be responsible for: A. Functional incontinence B. Urge incontinence C. Bladder overactivity D. Bladder underactivity E. Both B and C are correct 2. Delayed access to toileting facilities due to severe arthritic pain is a risk factor for: A. Functional incontinence B. Urge incontinence C. Overflow incontinence D. Stress incontinence E. Both A and A are correct 3. Fecal impaction in an elderly patient may be responsible for: A. Functional incontinence B. Urge incontinence C. Bladder overactivity D. Bladder underactivity E. None of the above 4. A 52-year-old postmenopausal, overweight woman complains of small volumes of urine leakage when she coughs, laughs, or practices yoga. She denies urinary frequency or incontinence at night. Her incontinence is most likely caused by: A. Functional incontinence B. Stress incontinence C. Overactive bladder D. Overflow incontinence E. Urge incontinence 5. Which of the following agents has the lowest incidence of dry mouth as a side effect according to its package insert?

A. Trospium IR B. Solifenacin C. Fesoterodine D. Oxybutynin XL E. Oxybutynin TDS 6. Which of the following drugs is most appropriate for managing urge incontinence?

A. Imipramine B. Estrogens C. Phenylpropanolamine D. Oxybutynin E. Bethanechol 7. Which of the following agents is most appropriate for managing atonic bladder?

A. Imipramine B. Estrogens

C. Phenylpropanolamine D. Oxybutynin E. Bethanechol 8. A 50-year-old woman is newly diagnosed with overactive bladder with urge incontinence.

Her current medications include clarithromycin and fluoxetine. Which of the following agents is most likely to provide symptom control with the fewest drug interactions?

A. Bethanechol B. Darifenacin C. Estrogen D. Solifenacin E. Trospium 9. Which one of the following drug-induced incontinence pairs is correct?

A. Terazosin/functional incontinence B. Enalapril/stress incontinence C. Estradiol/overflow incontinence D. Tolterodine/urge incontinence E. Morphine/urge incontinence 10. All of the following are risk factors for stress incontinence except: A. Traumatic childbirth B. Radical prostatectomy C. Surgery for benign prostatic hyperplasia D. Nasal decongestant for cold symptoms E. Menopause 11. In an older male with diagnosed symptomatic benign prostatic hyperplasia, addition of which of the following may lead to acute urinary retention?

A. Pseudoephedrine B. Prazosin C. Bethanechol D. Oxybutynin E. Both A and D are correct 12. Which of the following is the first-line therapy for a motivated child with primary monosymptomatic enuresis?

A. Oxybutynin B. Imipramine C. Desmopressin D. Enuresis alarms E. Flavoxate 13. Which of the following is the best initial choice for preventing bedwetting in a child who plans to go for a sleepover at a friend’s house?

A. Oxybutynin B. Imipramine C. Vasopressin D. Desmopressin E. Flavoxate 14. Which of the following treatments for pediatric enuresis has the lowest relapse rate after an adequate duration of trial?

A. Desmopressin B. Fluid restriction C. Imipramine D. Enuresis alarm therapy E. Awakening from sleep before enuresis episodes 15. Which of the following statements is true regarding pediatric enuresis?

A. A relapse is defined by more than 3 wet nights per week after a period of dryness.

B. Enuresis alarm therapy is not helpful when reinitiated in a child with a relapse of enuresis.

C. If a child fails to remain dry for 2 consecutive nights, he shall be penalized by removing rewards previously gained for agreed-upon behaviors.

D. Initial management with education, motivational and behavioral therapy should be discontinued after 2 weeks of trial.

E. Children should drink no more than 8 oz (240 mL) of fluid 1 hour before to 8 hours after taking oral desmopressin.

Answers 1.

E 2.

A 3.

A 4.

B 5.

E 6.

D 7.

E 8.

E 9.

B 10.

D 11.

E 12.

D 13.

D 14.

D 15.

E

Chapter 54. Allergic and Pseudoallergic Drug Reactions 1. Of all adverse drug reactions reported in hospitals, the percentage of these that are allergic or immunologic is: A. 33% B. 50% to 60% C. 5% to 10% D. 1% to 2% E. > 95% 2. Fifteen minutes after the start of a piperacillin/tazobactam infusion, the patient develops severe itching and difficulty breathing. What type of Gell and Coombs reaction is occurring?

A. Type I B. Type II C. Type III D. Type IVa E. Type IVb 3. A site of drug metabolism that might explain why skin reactions occur with a variety of different drugs is: A. Skin keratinocytes B. The kidney C. Skin epidermocytes D. The liver E. The lungs 4. What type(s) of Gell and Coombs reactions can penicillins cause?

A. Types I and II only B. Types II and III only C. Types I and III only D. Type I only E. Types I, II, III, and IV 5. Pseudoallergic drug reactions differ from allergic reactions in that they: A. Are based on the structure of the drug B. Involve the activation of the patient’s immune system C. Represent common biological functions such as direct histamine release D. Require the drug to be bound to a protein E. Involve T-cell activation 6. Of patients claiming to have penicillin allergies, what percentage will have a negative penicillin skin test?

A. 5% B. 33% C. 50% D. 75% E. 90% 7. Cross-allergenicity between penicillins and cephalosporins: A. Occurs at a low rate, less than 6% B. Is uncommon, less than 0.05%

C. Is common, greater than 90% D. Is variable but most studies estimate around 50% E. Never occurs 8. A patient with an allergy to aztreonam should not receive which of the following cephalosporins?

A. ceftazidime B. cephalexin C. cefotetan D. cefepime E. cefpirome 9. The drug or drug class that is responsible for the most cases of toxic epidermal necrolysis is: A. β-Lactam antibiotics B. Sulfonamide antibiotics C. Insulin D. Thiazide diuretics E. Sulfonylureas 10. The immediate intervention with an anaphylactic reaction in an adult should be: A. Intravenous epinephrine 1 to 4 mcg/min and titrate to response B. Intramuscular epinephrine (1:1000) 0.3 mg then repeat every 5 minutes as needed C. Subcutaneous epinephrine (1:1000) 0.6 mg then repeat every 5 minutes as needed D. Intramuscular epinephrine (1:1000) 0.3 mg then repeat every 15 minutes as needed E. Intramuscular epinephrine (1:10,000) 0.3 mg then repeat every 5 minutes as needed 11. Which of the following statements is false?

A. IgE-mediated reactions can occur with aspirin.

B. A patient who has experienced an allergic or pseudoallergic reaction to aspirin should never receive aspirin for primary or secondary prevention in coronary artery disease.

C. The potential cross-reactivity for IgE-mediated reactions between aspirin and COX-1 inhibiting nonsteroidal anti-inflammatory agents is fairly small.

D. Cross-reactivity between COX-2 inhibitors and aspirin are rare.

E. Chronic idiopathic urticaria is a major risk factor for aspirin-induced pseudoallergic reactions.

12. Which of the following steps should be taken in patients at greater risk for reactions to radiocontrast media?

A. Use diuretics to minimize fluid volume B. Use higher osmolar agents C. Pretreat with prednisone and diphenhydramine D. Use ionic osmolar agents E. Use desensitization process 13. A person taking oxycodone 5 mg/acetaminophen 325 mg, two tablets every 4 hours as needed for pain, starts itching all over within 20 minutes of each dose. Which of the following statements is true?

A. The itching is most likely due to the oxycodone stimulating mast cell release.

B. The itching is most likely due to a Gell and Coombs Type I reaction.

C. The itching is a warning that the patient is allergic to opiates and should not receive them.

D. The itching is most likely due to the underlying cause of the patient’s pain.

E. The itching is an early sign of anaphylaxis and the patient should receive epinephrine immediately.

14. Cross-sensitivity among phenytoin, carbamazepine, and phenobarbital ranges from: A. 0% to 1% B. 5% to 10% C. 20% to 30% D. 40% to 80% E. 90% to 100% 15. Which of the following statements is/are true regarding drug desensitization?

A. Desensitization can be performed safely in an outpatient clinic setting.

B. More patients are harmed by withholding a medication or using a less effective alternative agent than by desensitization.

C. Type I, II, III, and IV reactions can be prevented with drug desensitization.

D. Similar to allergy shots, drug desensitization may take months before the patient is adequately desensitized.

E. All of the above are true.

Answers 1. C 2. A 3. A 4. E 5. C 6. E 7. A 8. A 9. B 10. B 11. B 12. C 13. A 14. D 15. B

Chapter 55. Solid Organ Transplant Questions 1 to 9 are related to the following case: A 38-year-old white man is scheduled to receive a living-unrelated renal transplant this week at your hospital. The donor is the patient’s 35-year-old brother-in-law, who is a 6-out-of-6 HLA mismatch. The patient’s underlying renal failure is presumed to be due to uncontrolled diabetes mellitus and hypertension. He has required hemodialysis for the past 3 months. His past medical history is significant for diabetes mellitus, obesity (95 kg), hypertension, hyperlipidemia, gout, depression, and hypothyroidism. He drinks alcohol socially and has a remote history of tobacco usage. He is a father of three and has been married for the past 12 years.

Current medication list: levothyroxine 125 mcg once daily, allopurinol 100 mg once daily, simvastatin 20 mg once daily, amlodipine 5 mg once daily, metoprolol succinate 100 mg once daily, insulin glargine 24 units at bedtime, insulin aspart (sliding scale), and sertraline 50 mg once daily 1. The patient is blood type-O. During the evaluation of his family members for a potential donor, the team told him that he required a donor with the same blood type. His brother-in-law was also a blood type-O. What type of rejection would the patient be at risk for if he received a renal transplant from a donor who wasn’t a blood type-O donor?

A. Antibody-mediated rejection B. Acute rejection C. Hyperacute rejection D. Chronic rejection E. None of the above 2. The transplant surgeon on your team would prefer to use basiliximab as induction therapy due to its efficacy and superior tolerability. The team is aware that basiliximab is a monoclonal antibody but is unaware of how it exerts its effect on lymphocytes. What is the best description for basiliximab’s mechanism of action?

A. Inhibits IL-2 receptor mediated activation of lymphocytes B. Alters T-cell activation, homing, and cytotoxic activities C. Targets the CD3 receptor found on activated T cells D. Binds to CD52 found on B and T lymphocytes E. Targets the CD20 receptor found on B cells 3. The patient understands the purpose of induction therapy and agrees to treatment. What sideeffect of basiliximab can he expect to experience?

A. Hyperlipidemia B. Hypertension C. Hyperacute rejection D. Infection E. Hypertrophic cardiomyopathy Solid Organ Transplantation 2 4. The team would like to begin the patient on a calcineurin inhibitor on postoperative day 1 after a 24-hour assessment of his renal function. Based on his medical history, which calcineurin inhibitor would be the most appropriate?

A. Belatacept B. Tacrolimus C. Mycophenolate mofetil D. Sirolimus

E. Prednisone 5. During rounds on postoperative day 1, the team decides to restart all of the patient’s pretransplant medications. Additionally, the surgical resident asks if azathioprine would be an appropriate antiproliferative agent for him. You inform the team that azathioprine will have a significant interaction with which of his pretransplant medications?

A. Metoprolol B. Amlodipine C. Simvastatin D. Allopurinol E. Sertraline 6. The patient becomes anxious about the amount of medications he’ll be required to take as an outpatient. He states that he heard of an intermittent intravenous immunosuppressive called belatacept and is curious if he qualifies for its use. What viral serology would have to be assessed in the patient prior to administration of belatacept?

A. Human Immunodeficiency Virus B. Herpes simplex virus C. Influenza virus D. Cytomegalovirus E. Epstein-Barr Virus 7. The team decides against the use of belatacept and begins the patient on tacrolimus, mycophenolate mofetil, and prednisone. Which of his comorbidities is the combination of prednisone and tacrolimus most likely to exasperate?

A. Diabetes mellitus B. Depression C. Hypothyroidism D. Hyperlipidemia E. Gout 8. The team would like to begin antifungal therapy in the patient as a prophylaxis for thrush.

Which of the following medications is not considered to interact with his current immunosuppressive therapy?

A. Fluconazole B. Clotrimazole C. Voriconazole D. Nystatin Solid Organ Transplantation 3 E. Itraconazole 9. In addition to his pretransplant medications, the patient is discharged on tacrolimus, mycophenolate mofetil, prednisone, valganciclovir, atovaquone, and clotrimazole. He returns to your clinic 1-week later with a tacrolimus trough concentration of greater than 20 ng/ml (20 mcg/L or 25 nmol/L). Which medication is most likely responsible for his supertherapeutic tacrolimus level?

A. Tacrolimus B. Prednisone C. Mycophenolate mofetil D. Atovaquone E. Clotrimazole

10. Which of the following immunosuppressive medications is most likely to cause alopecia and new onset diabetes after transplantation?

A. Azathioprine B. Prednisone C. Tacrolimus D. Cyclosporine E. Mycophenolate mofetil 11. What is the conversion to enteric coated mycophenolic acid if a patient is receiving 500 mg of mycophenolate mofetil twice daily?

A. 180 mg twice daily B. 360 mg twice daily C. 540 mg twice daily D. 720 mg twice daily E. 1000 mg twice daily 12. Which of the following medications is contraindicated in liver transplant recipients?

A. Mycophenolate mofetil B. Tacrolimus C. Sirolimus D. Cyclosporine microemulsion E. Azathioprine 13. The following best describes the mechanism of action of which immunosuppressant: a proteasome inhibitor that induces cell-cycle arrest and apoptosis of plasma cells.

A. Bortezomib B. Rituximab C. Alemtuzumab D. Eculizumab E. Intravenous Immunoglobulin 14. Which of the following immunosuppressive medications has a FDA-approved risk evaluation and mitigation strategy in place?

Solid Organ Transplantation 4 A. Enteric coated mycophenolic acid B. Tacrolimus C. Azathioprine D. Prednisone E. Cyclosporine 15. The process that allows organ-specific antigens to be accepted as self is also known as: A. Tolerance B. Allorecognition C. Adaptation D. Major histocompatability complex E. Antibody-mediated rejection Solid Organ Transplantation 5 Answers 1. C 2. A

3. D 4. B 5. D 6. E 7. A 8. D 9. E 10. C 11. B 12. C 13. A 14. A 15. A

Chapter 56. Osteoporosis 1. RW is a 45-year-old African-American woman with an 18 pack–year smoking history who quit 10 years ago and has a BMI of 32 kg/m2 . She is currently on a 1-week prednisone taper for an asthma exacerbation and takes lisinopril 20 mg daily for hypertension. Which characteristic is associated with an increased risk of developing osteoporosis?

A. African American ethnicity B. Presence of hypertension C. Present systemic oral glucocorticoid therapy D. Female sex E. BMI greater than 30 kg/m2 2. You are a pharmacist involved in bone density screening during a health fair in your community. Several patients present to your booth for a peripheral bone density measurement. Based on the following descriptions and recommendations from the National Osteoporosis Foundation, who should be referred to a health care provider for follow-up and evaluation of bone mineral density by central DXA? A. 71-year-old man with low bone mineral density B. 66-year-old woman with low calcium intake and nicotine dependence C. 53-year-old active African-American man receiving chronic glucocorticoid therapy D. 58-year-old woman with a FRAX 10-year probability of hip fracture of 3.2% E. All of these patients meet criteria for screening by central DXA. 3. MM is an 82-year-old frail woman who is recovering from a vertebral compression fracture. At her follow-up appointment today, her primary care provider has asked the team to make interventions to reduce her fall risk. Which factor would decrease her risk of falls?

2 A. Discontinuation of oxybutynin B. Changing amitriptyline to diphenhydramine for sleep C. Use of lorazepam several nights per week D. Initiation of metoprolol E. Tapering of nonsteroidal anti-inflammatory agents 4. RS is a 75-year-old woman with newly diagnosed osteoporosis who is being discharged from the hospital after total hip replacement due to hip fracture. She has never taken any medication for osteoporosis. Her history is significant for GERD, DVT associated with oral contraceptive use 20 years ago, and family history of breast cancer. Which therapy may offer the most benefit in this patient?

A. Denosumab 60 mg subcutaneously every 6 months B. Calcitonin one spray daily in alternating nostrils C. Raloxifene 60 mg orally daily D. Teriparatide 20 mcg subcutaneously daily E. Zoledronic acid 5 mg IV every 12 months 5. PM is a 68-year-old woman with a past medical history of hypertension and osteoarthritis who has been told by her primary care physician that she should start risedronate treatment of osteoporosis (T-score of −2.6 at femoral neck). Her other medications include chlorthalidone 25 mg daily and ibuprofen 600 mg TID. She recently read in a women’s magazine that medications like alendronate and risedronate can cause “jaw problems,” especially in patients who have dental procedures. She is concerned about starting the

medication because she needs to have some dental work done. What factor could increase her risk for osteonecrosis of the jaw (ONJ)?

3 A. Concomitant thiazide diuretic use B. Preexisting dental disease C. Use of oral instead of IV bisphosphonate D. Use of concomitant gastrointestinal toxic drugs E. There are no risk factors that could increase her risk of ONJ 6. TB is a 78-year-old man with a history of vertebral compression fractures, hypertension, osteoarthritis, and depression. Spinal kyphosis is noted on physical examination.

Laboratory results show normal testosterone and vitamin D levels. DXA results include a T-score of −2.2 in the left hip and −2.9 in the lumbar spine. His physician would like to initiate treatment for osteoporosis. Which initial therapy is recommended for this patient?

A. Testosterone 200 mg intramuscularly every 4 weeks B. Alendronate 70 mg orally once weekly 30 minutes before breakfast C. Calcitonin salmon nasal spray one spray daily in alternating nostrils D. Teriparatide 20 mcg subcutaneously daily E. Ibandronate 150 mg by mouth every month 7. Which osteoporosis drug is correctly matched with its contraindication?

A. Zoledronic acid—previous thromboembolism B. Calcitonin—bone pain C. Denosumab—uncorrected hypocalcemia D. Raloxifene—osteosarcoma E. Teriparatide—uncorrected hypocalcemia 4 8. CM is a 62-year-old woman who recently started bisphosphonate therapy for osteoporosis.

Due to a history of dry mouth, the patient is experiencing difficulty swallowing her ibandronate tablets. What the best recommendation for CM? A. Take ibandronate with the first meal of the day.

B. Take ibandronate with a full glass of milk.

C. Crush the ibandronate tablet and mix it with a small amount of pudding or applesauce and take it.

D. Dissolve ibandronate in a full glass of water and drink it.

E. Consider switching to an IV bisphosphonate.

9. SP is a 60-year-old postmenopausal obese woman with a history of DVTs. She has a family history of osteoporosis and breast cancer and inquires about the use of raloxifene, because she heard that it might prevent osteoporosis and protect against breast cancer. Which one of the following is a correct statement?

A. She does not have an indication for raloxifene due to her menopausal status.

B. She has a contraindication due to her history of DVT. C. Her family history of breast cancer precludes use of raloxifene.

D. Raloxifene is not indicated for her age group.

E. Raloxifene is an appropriate agent for MW. 10. CC is a 57-year-old woman with osteoarthritis, GERD, migraines, and hypertension who takes omeprazole daily, lisinopril daily, ibuprofen TID as needed for pain, and sumatriptan as needed for migraines. Which condition or medication may increase her risk of

osteoporosis?

A. Ibuprofen 5 B. Osteoarthritis C. Omeprazole D. Sumatriptan E. Lisinopril 11. AK is a 66-year-old woman who was recently prescribed teriparatide. Which is an important counseling point for this medication?

A. Injection pens should be kept frozen until they are ready to be used.

B. Each injection pen should last 90 days.

C. This medication should be administered once a month.

D. Contact your doctor right away if you have bone pain.

E. This medication can only be used for a maximum of 5 years.

12. A 72-year-old woman with a history of hypertension, gastroesophageal reflux disease, and breast cancer status-post completion of anastrozole therapy 7 years ago presents to a primary care physician for a new patient work-up. Her current medications include lisinopril 5 mg daily and omeprazole 20 mg daily. The physician would like to evaluate the patient for the presence of osteoporosis. Which evaluation or tests would aid in the decision to recommend drug therapy for osteoporosis in this patient?

A. Calcium and vitamin D laboratory tests B. Bone densitometry; thoracic and lumbar spine x-ray C. Evaluation of exercise and exercise tolerance D. Basic metabolic panel and biochemical markers of bone turnover E. Fall risk assessment 13. Which patient is a candidate for screening BMD measurement?

6 A. 55-year-old woman with osteoarthritis B. 48-year-old woman with wrist fracture secondary to motor vehicle crash C. 69-year-old man with 40 pack–year history of smoking, quit 5 years ago D. 68-year-old woman with 2-cm height loss from adulthood E. 25-year-old woman who received a 10-day course of steroids for asthma 14. TD is a 68-year-old man with several risk factors for osteoporosis, including current cigarette smoking, alcohol consumption of three to five drinks per day, low body weight, and physical inactivity. Laboratory test results showed 25-hydroxyvitamin D level of 18 ng/mL (45 nmol/L). What recommendation can be made for TD to decrease his osteoporosis risk?

A. Increase dietary intake of fortified milk, egg yolks, and salt-water fish B. Increase sun exposure + vitamin D3 800 IU daily C. Calcium citrate + D3 200 IU twice daily + multivitamin (vitamin D3 400 IU) daily D. Ergocalciferol 50,000 IU once weekly for 8 weeks; then cholecalciferol 2000 IU daily E. Ergocalciferol 50,000 IU once weekly indefinitely A. Calcitonin 200 IU intranasal daily in alternating nostrils 7 15. PW is a 53-year-old woman with a history of esophageal stricture status-post dilatation due to longstanding GERD and vasomotor symptoms associated with menopause. A recent

DXA scan showed a T-score of −2.5 in the lumbar spine and −2.6 in the left hip. Which therapy is most appropriate for PW? B. Denosumab 60 mg subcutaneously every 6 months C. Raloxifene 60 mg orally once daily D. Risedronate 35 mg orally once weekly E. Ibandronate 150 mg orally once monthly 8 Answers 1.

D 2. E 3. A 4. E 5. B 6. B 7. C 8. E 9. B 10.

C 11. D 12. B 13. D 14. D 15. A Chapter 57. Rheumatoid Arthritis 1. Which of the following treatment goals should be considered in a patient newly diagnosed with systemic JIA? A. Control of hypertension B. Maintain normal growth C. Evaluate for osteoporosis risk D. Protect joint function by limiting activity E. Initiate treatment for uveitis 2. A 42-year-old woman presents to your local community pharmacy with complaints of increasing joint pain. She states that her primary care physician is still trying to determine whether the diagnosis is osteoarthritis (OA) or rheumatoid arthritis (RA). While at the pharmacy to fill a new prescription for celecoxib, she asks you if she should be concerned about rheumatoid arthritis because she knows very little about it. In addition to joint pain and swelling, you describe which one of the following as being associated with rheumatoid arthritis?

A. Asthma B. Colon cancer C. Osteodystrophy D. Renal insufficiency E. Cardiovascular disease 3. Janus kinases may influence the pathogenesis of RA by:

A. Releasing cytokines B. Releasing antibodies C. Presenting antigens to B lymphocytes D. Enhancing cell signaling E. Binding CD28 receptors to antigen-presenting cells 4. Tocilizumab is most appropriate in which one of the following patients?

A. A 36-year-old woman diagnosed today with mild rheumatoid factor-negative RA B. A 51-year-old man with a 2-year history of RF-negative RA and an inadequate response to methotrexate monotherapy and methotrexate/abatacept combination therapy C. A 65-year-old man with a 10-year history of RF-positive RA and a fear of needles/injections D. A 42-year-old woman with a 6-year history of RF-positive RA and an inadequate response to methotrexate/etanercept and methotrexate/rituximab combination therapy E. A 4-year-old boy with juvenile idiopathic arthritis (JIA) and an inadequate response to anakinra 5. TP is a 66-year-old woman with a history of RF-positive RA for 10 years of moderate severity with features of poor prognosis, COPD for 3 years, and heart failure for 2 years. She is a smoker and drinks two glasses of wine weekly. She does not exercise. Her current medications include methotrexate 15 mg once weekly, folic acid 1 mg daily, hydrochlorothiazide 25 mg daily, ibuprofen 800 mg three times daily as needed (used approximately once monthly), and prednisone 7.5 mg daily during acute RA flares. Her BP today is 172/88 mm Hg and CRP is 4.2 mg/L. During a recent visit with the rheumatologist, she reported a gradual increase in morning stiffness, joint pain, and swelling over the last 2 months. The rheumatologist would like to initiate combination disease-modifying antirheumatic drug (DMARD) therapy to help control her symptoms and prevent disease progression. Which one of the following is the most appropriate agent to add to her current regimen?

A. Anakinra 100 mg SC daily B. Rituximab 1000 mg IV at 0 and 2 weeks C. Tocilizumab 8 mg/kg IV every 4 weeks D. Abatacept 750 mg IV at 0, 2, and 4 weeks then every 4 weeks E. Infliximab 3 mg/kg IV at 0, 2, and 6 weeks then every 8 weeks 6. Which one of the following drugs may worsen a patient’s lipid profile?

A. Golimumab B. Hydroxychloroquine C. Tofacitinib D. Infliximab E. Anakinra 7. A 56-year-old man recently diagnosed with RA has a medical history significant for chronic renal insufficiency, hepatitis, and diabetes. Which one of the following DMARDs should be considered at this time?

A. Leflunomide B. Azathioprine C. Methotrexate D. Sulfasalazine E. Hydroxychloroquine 8. A 32-year-old woman with a 2-year history of RA is taking methotrexate 10 mg weekly, leflunomide 20 mg once daily, montelukast 10 mg once daily, and folic acid 1 mg daily. She is

interested in getting pregnant. Which of the following steps is/are necessary prior to conception?

I. Initiate cholestyramine 8 g three times daily for 11 days II. Reduce methotrexate dose to 5 mg once weekly, increase folic acid to 2 mg daily III. Discontinue montelukast A. I only B. III only C. I and II D. II and III E. I, II, and III 9. Factors associated with poor outcomes of RA include which one of the following: A. Late age of disease onset B. Negative rheumatoid factor C. Multiple (> 20) tender and swollen joints D. Absence of extraarticular manifestations E. Normal ESR levels 10. A 46-year-old woman has a longstanding history of rheumatoid factor-positive RA. She weighs 58.2 kg (128 lb) and is 165 cm (5’5”) tall. Her most recent medication profile includes prednisone 10 mg orally once daily, etanercept 50 mg IV once weekly (replaced infliximab 2 years ago), methotrexate 7.5 mg orally once weekly, calcium 600 mg orally twice daily, vitamin D 400 units orally once daily, and nabumetone 1000 mg orally once daily as needed. She reports increased frequency of joint pain, tenderness, and morning stiffness. The decision is made to modify her treatment regimen. Which one of the following is the most appropriate option?

A. Increase etanercept to 50 mg IV once daily B. Discontinue etanercept; begin rituximab 1000 mg IV at 0 and 2 weeks C. Discontinue etanercept, initiate abatacept 750 mg IV on days 1, 15, and every 28 days thereafter D. Initiate tocilizumab 8 mg/kg IV once monthly E. Increase methotrexate to 15 mg orally once weekly 11. Which one of the following counseling points should be discussed with a patient regarding a new prescription for methotrexate for RA? A. New onset cough B. An infusion reaction C. Changes in peripheral vision D. Yellow-orange skin discoloration E. Increased patchy skin pigmentation 12. Which of the following signs is/are suggestive of rheumatoid arthritis?

I. Morning stiffness lasting less than 30 minutes II. Gradual onset of symptoms over years III. Tenderness and swelling in MCPs A. I only B. III only C. I and II D. II and III E. I, II, and III 13. A 5-year-old boy and his mother present to the pediatrician. The child has a 2-month history of intermittent fevers, joint pain, and tenderness in seven joints and a rash that occasionally

develops across his buttocks. The rash is not present when the physician examines him. The child weighs 18.2 kg (40 lb). Which one of the following disorders does the patient likely have?

A. RA B. Systemic JIA C. Polyarticular JIA D. Oligoarticular JIA E. Osteoarthritis 14. For the patient in the previous question, which one of the following regimens offers the most appropriate treatment?

A. Ibuprofen 90 mg orally every 8 hours B. Methotrexate 5 mg orally once weekly C. Etanercept 25 mg IV once weekly D. Prednisone 5 mg orally once daily E. Abatacept 500 mg IV on days 1 and 15 and then every 28 days thereafter 15. A 43-year-old cosmetologist with rheumatoid factor-positive RA was maintained on methotrexate 12.5 mg orally once weekly for approximately 7 years. Her past medical history is significant for dyslipidemia, type 1 diabetes, and anorexia. Signs and symptoms of disease are emerging, and the addition of etanercept is under consideration. Which one of the following tests is necessary to finalize the treatment decision?

A. Oral glucose tolerance test B. Complete blood count C. Liver function tests D. Tuberculin skin test E. Lipid panel Answers 1. B 2. E 3. D 4. D 5. B 6. C 7. E 8. A 9. C 10. B 11. A 12. B 13. B 14. A 15. D

Chapter 58. Osteoarthritis 1. Which one of the following is characteristic of osteoarthritis (OA)?

A. Unilateral joint pain upon waking B. Joint stiffness in the morning lasting 45 minutes C. Elevated C-reactive protein (CRP) level D. Elevated erythrocyte sedimentation rate (ESR) E. All of the above 2. All of the following are considered risk factors for OA except: A. Heavy physical activity B. Age C. Obesity D. Ethnicity E. Joint trauma 3. Which one of the following is the most appropriate treatment approach in a patient at risk for developing OA? A. Promote lifestyle changes targeted at risk factors for OA B. Initiate tramadol 50 mg every 4 to 6 hours as needed C. Initiate ibuprofen 200 mg every 6 hours as needed D. Initiate acetaminophen 325 mg every 4 to 6 hours as needed, and promote lifestyle changes targeted at risk factors for OA E. Initiate ibuprofen 200 mg every 6 hours as needed, and promote lifestyle changes targeted at risk factors for OA 2 4. Therapy with celecoxib, rather than a non-selective NSAID, would be most appropriate for which of the following patients? a. 58-year-old woman with metabolic syndrome and gastroesophageal reflux disease b. 69-year-old man with a history of Helicobacter pylori peptic ulcer disease c. 53-year-old woman with a strong family history of myocardial infarction and previous GI upset with ibuprofen use d. 47-year-old man with a history of GI bleed from previous indomethacin use e. 70-year-old woman with chronic renal insufficiency who takes low-dose aspirin for cardioprotection 5. Treatment with naproxen monotherapy, rather than another non-selective NSAID, would be most appropriate for which of the following patients?

A. 49-year-old woman with metabolic syndrome and history of MI B. 70-year-old man with a history of Helicobacter pylori peptic ulcer disease C. 58-year-old man with a strong family history of myocardial infarction and previous GI bleed with ibuprofen use D. 67-year-old man with a history of GI bleed from previous indomethacin use E. 70-year-old woman with chronic heart failure 6. Which one of the following regimens is considered an adequate trial of acetaminophen before assessing treatment success or failure?

3 A. 325 mg every 6 hours for 1 month

B. 325 mg every 6 hours for 2 months C. 1000 mg every 6 hours for 1 month D. 500 mg every 8 hours for 2 months E. 325 mg every 4 to 6 hours for 1 month 7. Compared with oral NSAIDs, topical NSAIDs are: A. More effective for hip OA B. More effective for knee OA C. Less effective for hand OA D. Associated with fewer systemic toxicities E. All of the above 8. For which of the following patients would concomitant naproxen and a PPI be most appropriate?

A. 49-year-old woman with metabolic syndrome B. 70-year-old man with a history of Helicobacter pylori peptic ulcer disease C. 58-year-old man with a history of myocardial infarction and previous gastric ulcer with ibuprofen use D. 67-year-old man with a history of GI bleed from previous indomethacin use E. 70-year-old woman with chronic heart failure 9. Nonpharmacologic therapies for OA include which of the following?

4 A. Stretching B. Application of heat C. Weight loss D. Occupational therapy E. All of the above 10.Which of the following circumstances warrants consideration to initiating chronic opioid therapy? a. Untreated moderate to severe OA. b. Moderate to severe OA refractory to acetaminophen. c. Moderate to severe OA refractory to acetaminophen and a history of chronic heart failure. d. Mild to moderate OA refractory to acetaminophen. e. All of the above 11.Compared to nonselective NSAIDs, COX-2—selective agents: A. Reduce OA-related pain to a greater extent B. Have a lower risk for cardiovascular adverse events C. Have a lower risk for adverse renal effects D. Have a lower risk of gastrointestinal bleeds E. All of the above 12.Which of the following statements is true regarding the use of glucosamine/chondroitin for OA? 5 A. Treatment benefit is moderate but consistent among all types and severities of OA. B. Because glucosamine/chondroitin is regulated as a dietary supplement,

product standards are consistent and reliable.

C. Glucosamine/chondroitin is generally well tolerated, but treatment benefits are uncertain.

D. Both glucosamine and chondroitin pose a high risk for anaphylaxis in patients with shellfish allergy.

E. Glucosamine-containing products are contraindicated in patients with uncontrolled disease 13.Which of the following is true regarding intraarticular corticosteroid use in a patient achieving a partial response to naproxen 500 mg twice daily for left knee OA? A. Pain relief will occur rapidly and persist for up to 6 months.

B. Intraarticular corticosteroids should not be used concomitantly with naproxen.

C. Intraarticular corticosteroids are useful for polyarticular symptoms due to their systemic mechanism of action.

D. The affected joint can be injected monthly until response.

E. Intraarticular corticosteroids may be more effective if an inflammatory component is present.

6 14.Which one of the following drug regimens is most appropriate for a patient with OA who has with chronic renal insufficiency (creatinine clearance 28 mL/min [0.47 mL/s]) and who has failed acetaminophen monotherapy?

A. Nabumetone 50 mg twice daily B. Celecoxib 100 mg twice daily C. Naproxen 500 mg twice daily D. Tramadol 100 mg three times daily E. Oxycodone 5 mg immediate-release every 4 to 6 hours as needed 15.Patients attempting treatment with topical capsaicin should be counseled on which of the following?

A. Do not allow contact with eyes or mucous membranes B. When applying to knee, wash hands after application C. May take 2 weeks of daily treatment to experience benefit D. May experience burning sensation at application site E. All of the above 7 Answers 1.

A 2.

D 3.

A 4.

D 5.

A

6.

C 7.

D 8.

C 9.

E 10.

C 11.

D 12.

C 13.

E 14.

D 15.

E

Chapter 59. Gout and Hyperuricemia 1. Which one of the following statements concerning febuxostat in the treatment of gout is correct?

A. It is more effective in reducing acute gouty flares than allopurinol titrated to the serum uric acid (SUA) target.

B. It should not be used in patients with a history of allopurinol hypersensitivity syndrome.

C. Liver function tests should be monitored when initiating and titrating therapy.

D. Combination therapy with allopurinol and febuxostat can achieve greater decreases in SUA than either agent alone.

E. Febuxostat should be avoided in patients with mild-to-moderate renal impairment.

2. What would be an appropriate starting dose of allopurinol in a 55-year-old man with gout and chronic kidney disease if his serum creatinine is 2.1 mg/dL (186 μmol/L)? He is 5’7” (170 cm) and weighs 75 kg (165 lb).

A. 50 mg daily B. 100 mg every other day C. 100 mg daily D. 300 mg daily E. Allopurinol is not recommended in patients with chronic kidney disease 3. A 42-year-old woman presents to her family physician 48 hours after the onset of her third acute gout flare this year with complaints of severe pain and swelling of her left knee. She is currently prescribed febuxostat 40 mg once daily (initiated last month) and her serum uric acid today is 9.6 mg/dL (571 μmol/L). Except for gout, her past medical history is unremarkable, and she is adherent to current therapy. What do you recommend to optimize the patient’s pharmacotherapy regimen?

A. Increase febuxostat to 80 mg daily and add colchicine for acute treatment followed by antiinflammatory prophylaxis.

B. Continue febuxostat 40 mg daily and add naproxen for acute treatment followed by antiinflammatory prophylaxis.

C. Continue febuxostat 40 mg daily and add colchicine for acute treatment followed by antiinflammatory prophylaxis.

D. Increase febuxostat to 80 mg daily and add naproxen for acute treatment followed by antiinflammatory prophylaxis.

E. Continue febuxostat 40 mg daily and add probenecid for additional urate lowering once acute attack resolves.

4. Which one of the following statements concerning indomethacin use in acute gout is correct?

A. Studies have determined that indomethacin is the most effective NSAID in acute gout.

B. Indomethacin should be avoided because of its cost relative to other NSAIDs. C. Other NSAIDs may be as effective as indomethacin in acute gout with more favorable safety profiles.

D. Colchicine is more effective than indomethacin in acute gout.

E. Corticosteroids are more effective than indomethacin in acute gout.

5. Which one of the following patients should be considered for initiation of urate-lowering therapy?

A. A patient experiencing his first acute attack with multiple tophi on his knee.

B. A patient experiencing his first acute attack with stage 1 chronic kidney disease.

C. An asymptomatic patient with a serum uric acid (SUA) of 15 mg/dL (892 μmol/L).

D. A patient after resolution of a severe second attack of gout in the past 2 years.

E. A patient with a strong family history of gout who is started on niacin therapy.

6. A 70-year-old patient with chronic gout develops a mild maculopapular rash 1 week after initiating allopurinol therapy, and alternative therapy to lower his SUA is considered. His past medical history is significant for hypertension, obesity, and chronic kidney disease (last estimated creatinine clearance 25 mL/min [0.42 mL/s]). Which one of the following statements is true concerning this case?

A. Probenecid would be an appropriate choice for treatment of chronic gout.

B. Allopurinol desensitization could be attempted in this patient.

C. High-dose febuxostat would be needed to reach SUA goals in this patient.

D. The dose and schedule of pegloticase would be the most convenient option for the patient.

E. None of the above responses are correct.

7. A patient with a history of severe chronic gout, including multiple tophi and uric acid nephropathy, is being considered for pegloticase therapy because other treatments have failed to lower the SUA to goal. His past medical history is significant for hypertension, asthma, and dyslipidemia. He smokes one pack of cigarettes daily and works as a long-haul truck driver.

Which one of the following statements is true concerning this case?

A. Asthma is a contraindication to pegloticase treatment.

B. Pegloticase would not be expected to be effective if other standard treatments have failed.

C. The patient should be screened for G6PD deficiency prior to initiation.

D. If pegloticase is initiated, the patient should be premedicated with fexofenadine 180 mg IV and omeprazole 40 mg po prior to the infusion.

E. Pegloticase should be used in combination with allopurinol to prevent rebound gouty flares.

8. An emergency room physician asks you why a lower dose of colchicine is now recommended for treatment of acute gout flares. What is your response?

A. The lower dosage regimen is associated with fewer gastrointestinal adverse effects.

B. Although the lower dose of colchicine is less effective, it is also safer and thus preferred.

C. Since most patients with gout are taking allopurinol, the chance of a drug interaction is less if the lower dose of colchicine is used.

D. The lower dose of colchicine is associated with less liver toxicity.

E. None of the above responses are correct.

9. A 55-year-old man is newly diagnosed with gout and hyperuricemia. His past medical history is significant for type 2 diabetes, dyslipidemia, and hypertension, all well controlled.

Medications include atorvastatin 40 mg at bedtime, niacin 1000 mg at bedtime, lisinopril 10 mg daily, metformin 500 mg twice daily, and aspirin 81 mg daily. He does not meet criteria for urate-lowering therapy, and the physician wishes to implement other antihyperuricemic measures. What is the best recommendation?

A. Consider changing lisinopril to losartan.

B. Add fenofibrate to current lipid-lowering therapy.

C. Consider changing lisinopril to hydrochlorothiazide.

D. Discontinue aspirin 81 mg daily.

E. Increase niacin to 1500 mg at bedtime.

10. Which one of the following statements is true regarding anti-inflammatory prophylaxis during initiation of urate-lowering therapy?

A. It is not recommended during initiation of allopurinol therapy in patients with renal insufficiency.

B. Colchicine 1.2 mg orally for one dose followed by 0.6 mg 1 hour later is the recommended first-line regimen.

C. Naproxen is less likely to cause renal insufficiency than other NSAIDs for anti-inflammatory prophylaxis.

D. Low-dose NSAID therapy should be combined with acid suppression therapy to prevent GI adverse effects.

E. Low-dose prednisone is the recommended first-line therapy for anti-inflammatory prophylaxis.

11. Which combination regimen is inappropriate for managing severe pain during an acute gouty attack?

A. Colchicine + NSAID B. NSAID + oral corticosteroid C. Colchicine + oral corticosteroid D. Oral corticosteroid + intraarticular corticosteroid E. NSAID + intraarticular corticosteroid 12. Which one of the following nonpharmacologic measures may be helpful in providing pain relief from an acute gouty attack?

A. Application of heat B. Application of ice C. Compression hose applied to the affected area D. Increased oral intake of water E. Brisk massage of the affected area 13. A 35-year-old man presents to an urgent care clinic with signs and symptoms consistent with acute gouty arthritis of his right ankle. Uric acid crystals are found in the aspirated articular fluid from the ankle. He has a history of poorly controlled dyslipidemia and drinks three beers nightly.

He is an avid runner and reports eating fruits, vegetables, and low-fat dairy products. Which of the following sets of characteristics are risk factors for gout in this patient?

A. Male sex and intense physical activity B. Consumption of alcohol and low-fat dairy products C. Dyslipidemia and alcohol consumption D. Age and consumption of low-fat dairy products E. Dyslipidemia and age 14. In which patient population should HLA-B*5801 screening be considered prior to allopurinol initiation?

A. Routine screening is recommended for all patients B. Patients of Korean descent with stage 2 or worse chronic kidney disease C. Patients with a history of Stevens-Johnson syndrome D. Caucasian patients with chronic kidney disease E. All patients of Thai descent 15. A patient with gout has recently been started on allopurinol and is undergoing dose titration.

What laboratory test should be monitored at monthly follow-up visits during this period?

A. Urinalysis B. Serum urate C. Serum creatinine D. Aspartate aminotransferase E. No routine lab monitoring is required

Answers 1. C 2. C 3. D 4. C 5. A 6. B 7. C 8. A 9. A 10. D 11. B 12. B 13. C 14. E 15. B

Chapter 60. Musculoskeletal Disorders 1. Which one of the following is the major inflammatory mediator associated with soft-tissue injury?

A. Prostaglandin (PG) B. Lipoxygenase C. Cyclooxygenase (COX) D. Arachidonic acid E. Thromboxanes 2. A patient presents with a knee injury from a football game. There is no apparent swelling, and the patient prefers an oral analgesic over a topical product. Which of the following is the best choice for systemic analgesia for this patient?

A. Aspirin B. Acetaminophen C. Codeine D. Naproxen E. Tramadol 3. The counterirritant that produces an effect through a cooling sensation is: A. Camphor B. Capsaicin C. Methyl salicylate D. Allyl isothiocyanate E. Methyl nicotinate 2 4. Which of the following topical products should be avoided in patients with an aspirin allergy?

A. Ammonia water B. Camphor C. Menthol D. Methyl salicylate E. Methyl nicotinate 5. Which one of the following instructions should be included in an education plan for a patient using a counterirritant that contains menthol?

A. Burning sensation upon application will subside with regular use.

B. The product has little to no medicinal odor.

C. Must use regularly for 1 to 2 weeks before onset of effect.

D. After application, wrap the affected area tightly with a bandage.

E. Do not use with a heating pad.

6. Which one of the following instructions should be included in a patient education plan for diclofenac patches?

A. Apply immediately prior to bathing or showering.

B. Product may be used in combination with topical capsaicin.

C. If rash or irritation develops, apply moisturizer before patch application.

D. Discard used patches out of reach of children and pets.

E. Use with oral diclofenac for maximum effect.

3 7. A 52-year-old man desires to use a topical product for a few days to treat knee pain from osteoarthritis that worsened after moving his son into a new apartment. He has no known drug

allergies and a past medical history of dyslipidemia. He expresses a desire for a topical product without a medicinal odor. Which one of the following is the best recommendation?

A. Menthol B. Capsaicin C. Diclofenac gel D. Lidocaine gel E. Camphor 8. Heat, instead of ice, is recommended as nonpharmacologic therapy in a patient with which one of the following conditions?

A. Ankle injury sustained this morning with swelling B. Shoulder soreness and swelling from baseball practice 1 week ago C. Knee injury sustained last week with no remaining swelling D. Tendonitis of the wrist from repetitive strain while typing E. Elbow pain from a tennis game yesterday accompanied by swelling 9. The preferred treatment option for a patient with a chronic overuse knee injury accompanied by inflammation is: A. Camphor B. Capsaicin C. Ibuprofen 4 D. Acetaminophen E. Menthol 10. Which one of the following topical medications must be used regularly to have a therapeutic effect?

A. Capsaicin B. Menthol C. Methyl nicotinate D. Methyl salicylate E. Trolamine salicylate 11. Use of alcoholic beverages should be assessed prior to selecting which agent?

A. Acetaminophen B. Capsaicin C. Camphor D. Methyl salicylate E. Menthol 12. Which one of the following statements regarding nonpharmacologic therapy after musculoskeletal injury is appropriate?

A. Cool the area with ice for 15 minutes and repeat every 2 hours.

B. Alternate heat applications with ice when swelling is present.

C. Prolonged rest shortens recovery time.

5 D. Begin wrapping the compression bandage at the area proximal to the injury.

E. Apply ice directly to the skin for maximum cooling.

13. A patient with lower back pain after gardening buys an over-the-counter product containing camphor, menthol, and methyl salicylate. How often should she be advised to apply the product?

A. Once daily in the morning

B. Up to three to five times daily C. Twice daily upon waking and at bedtime D. Once daily at bedtime E. Every 1 to 2 hours as needed for pain 14. The appropriate timeframe to assess effectiveness of pharmacologic therapy for chronic pain treated with topical capsaicin is: A. 3 to 5 days B. 1 week C. 2 weeks D. 1 month E. 3 months 6 15. In which one of the following situations is self-care with a counterirritant a therapeutic option prior to referral to a physician??

A. Symptoms persisting for more than 7 days B. Intact skin in area of injury C. Symptoms resolving, but then recurring D. Symptoms worsening E. Symptoms over a large area 7 Answers 1. A 2. B 3. A 4. D 5. E 6. D 7. C 8. C 9. C 10. A 11. A 12. A 13. B 14. C 15. B

Chapter 61. Glaucoma 1. The preferred treatment option for a 67-year-old man with primary open-angle glaucoma (POAG), no significant past medical history (PMH), and allergy to benzalkonium chloride is: A. Tafluprost B. Latanoprost C. Brinzolamide D. Carbachol E. Levobunolol 2. An appropriate counseling statement for timolol is: A. This medication has no significant systemic effects.

B. This medication may cause mydriasis.

C. Do not use this medication if you are allergic to sulfonamides.

D. This medication may cause an increase in iris pigmentation.

E. This medication may cause bradycardia.

3. All of the following characteristics would increase a patient’s risk of developing primary angle-closure glaucoma except: A. Myopia B. Female gender C. Shallow anterior chamber D. Central corneal thickness of 560 µm E. Asian descent 4. The following drug would be contraindicated in a patient with primary open-angle glaucoma (POAG) and allergy to sulfonamides: A. Travoprost B. Betaxolol C. Brinzolamide D. Pilocarpine 5. The following drug has little clinically significant systemic adverse effects: A. Bimatoprost B. Brimonidine C. Carteolol D. Acetazolamide E. Apraclonidine 6. The following drug may darken pigmentation of the iris: A. Tafluprost B. Carteolol C. Brinzolamide D. Pilocarpine E. Levobunolol 7. The following medications are likely to increase IOP in a patient with primary angle-closure glaucoma (PACG) except: A. Diphenhydramine B. Amitriptyline C. Pseudoephedrine D. Lisinopril E. Topiramate

8. Latanoporst decreases intraocular pressure by which of the following mechanisms?

A. Increases aqueous humor outflow through the trabecular meshwork B. Decreases uveoscleral outflow C. Increase aqueous humor production D. Decreases aqueous humor production E. Increases uveoscleral outflow 9. EW is 60-year-old African American woman. PMH is significant for asthma, HTN, and gastroesophageal reflux disease (GERD). She is diagnosed today with primary open-angle glaucoma (POAG). Her medications include Lisinopril, fluticasone HFA MDI, albuterol HFA MDI and, omeprazole 20 mg by mouth daily. All of the following medications are a reasonable choice for initial of her POAG except: A. Bimatoprost B. Brimonidine C. Betaxolol D. Travoprost E. Latanoprost 10. Aqueous humor that exits the eye via the trabecular meshwork leaves through which structure?

A. Ciliary muscles B. Uveoscleral pathway C. Schlemm canal D. Pupil E. Cornea 11. Betaxolol decreases intraocular pressure by which of the following mechanisms?

A. Increases aqueous humor outflow through the trabecular meshwork B. Decreases uveoscleral outflow C. Increases aqueous humor production D. Decreases aqueous humor production E. Increases uveoscleral outflow 12. OP is a 75-year-old man who presents to the emergency department with complaints of blurred vision and eye pain in his right eye. He also reports nausea. Upon examination, the patient’s right eye has a cloudy cornea and conjunctival hyperemia. The right pupil is semidilated and fixed to light. Gonioscopy reveals closed anterior angle of the right eye. IOP of the right eye is 60 mm Hg (8.0 kPa). The patient is diagnosed with closed-angle glaucoma.

Which of the following statements is false regarding the treatment of acute angle-closure crisis?

A. The patient needs immediate lowering of the IOP to preserve vision in the right eye.

B. Timolol would be an appropriate agent to initially lower the patient’s IOP. C. Pilocarpine therapy should be added once IOP has been lowered to less than 50 mm Hg (6.7 kPa).

D. Laser iridotomy or surgical iridectomy are only needed in cases in which the IOP is refractory to pharmacotherapy.

E. Acetazolamide is carbonic anhydrase inhibitor that can be given orally for patients with closed-angle glaucoma to lower their IOP. 13. Which of the following characteristics would increase a patient’s risk of developing primary

open glaucoma?

A. Hyperopia B. Hispanic descent C. Shallow anterior chamber D. Central corneal thickness of 560 µm E. Asian descent 14. CC is a 72-year-old woman that is diagnosed with primary open-angle glaucoma (POAG).

Ophthalmic evaluation reveals the following: tonometry measured an IOP of 26 mm Hg (3.5 kPa) in the right eye and 27 mm Hg (3.6 kPa) in the left eye. Ophthalmoscopy revealed cupping of the optic discs both eyes, and visual field examination revealed a nerve fiber bundle defect.

Pachymetry reveals a central corneal thickness of 510 µm. Pupils were normal in both eyes and gonioscopy indicated that anterior chamber angles were open bilaterally. The patient has PMH significant for rheumatoid arthritis and allergic rhinitis. Which of the following medications should this patient avoid to prevent a medication induced increase in IOP? A. Diphenhydramine B. Amitriptylline C. Promethazine D. Phenylephrine E. None of the above 15. Brinzolamide decreases intraocular pressure by: A. Increasing aqueous humor outflow through the trabecular meshwork B. Decreasing uveoscleral outflow C. Increasing aqueous humor production D. Decreasing aqueous humor production E. Increasing uveoscleral outflow Answers 1. A 2. E 3. A 4. C 5. A 6. A 7. D 8. E 9. C 10.C 11.D 12.D 13.C 14.E 15.D

Chapter 62. Ophthalmic DisorderS 1. Which of the following ophthalmic emergencies requires an immediate consult with an ophthalmologist?

A. Blood in the eye B. Corneal abrasion C. Acute chemical burn D. Macular edema E. Corneal ulcer 2. Which of the following medications for ocular allergies is a mast cell stabilizer?

A. Pheniramine B. Cromolyn sodium C. Ketorolac D. Loteprednol E. Emedastine 3. Which of the following is an appropriate treatment for corneal abrasion in a 50year-old woman on warfarin therapy?

A. Oral NSAIDs B. Topical antibiotics C. Saline irrigation D. Eye patches E. Contact lenses 4. A 25-year-old man presents with red eye with an abrupt onset, copious purulent discharge and rapid progression. What is the probable diagnosis?

A. Allergic conjunctivitis B. Viral conjunctivitis C. Hyperacute bacterial conjunctivitis D. Bacterial keratitis E. Traumatic injury 5. Antibiotic choice for bacterial conjunctivitis needs to cover which organism?

A. Neisseria B. Staphylococcus C. Haemophilus D. Streptococcus E. Chlamydia 6. Which of the following is NOT a risk factor for bacterial keratitis?

A. Contact lenses B. Diabetes Mellitus C. Oral NSAIDs D. Corneal epithelial edema E. Atopic dermatitis 7. A 23-year-old woman patient presents with photophobia and blurred vision after trying to remove her new contact lenses before swimming. Which of the following antibiotics would be the most initial therapy?

A. Erythromycin 0.5% ointment B. Azithromycin 1% solution C. Polymyxin B with bacitracin ointment

D. Sulfacetamide 10% solution E. Moxifloxacin 0.5% solution 8. Patients with a diagnosis of herpetic conjunctivitis should be treated with a topical steroid. True or false?

A. True B. False 9. What is the appropriate topical recommendation for a 33-year-old man who presents with ocular allergy symptoms and has tried an artificial tear solution and pheniramine/naphazoline?

A. Olopatadine B. Antazoline C. Loteprednol D. Ketorolac E. Emedastine 10. A 44-year-old patient is diagnosed with severe bacterial keratitis and prescribed broad-spectrum antibiotic therapy with gatifloxacin. The next day, she returns with a complaint of worsening inflammation. You advise: A. Change the antibiotic to moxifloxacin.

B. Change the antibiotic to a fortified antibiotic.

C. No change in therapy.

D. Culture the organism.

E. Switch to a topical corticosteroid.

11. The correct dosing of lodoxamide 0.2% in children 2 or older is one to two drops in each eye twice daily. True or False?

A. True B. False 12. β-Carotene supplementation should not be recommended for which group of people?

A. Patients older than 60 years B. Patients younger than 60 years C. Patients with intermediate age-related macular degeneration (AMD) D. Patients who smoke E. Patients at a high risk of AMD 13. In age-related macular degeneration, central vision is preserved. True or false?

A. True B. False 14. Which of the following medications used to treat age-related macular degeneration is dosed seven times per year?

A. Bevacizumab B. Ranibizumab C. Pegaptanib D. Verteporfin E. Aflibercept 15. Which of the following medications is the primary treatment for patients with dry eye?

A. Anti-inflammatory agents

B. Artificial tears C. Cyclosporin emulsion D. Pilocarpine E. Cevimeline Answers 1. C 2. B 3. B 4. C 5. B 6. C 7. E 8. B 9. A 10. C 11. B 12. D 13. B 14. E 15. B

CHAPTER 63. ALLERGIC RHINITIS 1. Pick the symptom that is least characteristic of allergic rhinitis.

A. Nasal itch B. Ocular itch C. Rhinorrhea D. Sneezing E. Wheezing 2. Pick the symptom of allergic rhinitis that is usually the most bothersome.

A. Allergic salute B. Chemosis C. Nasal congestion D. Postnasal drip (posterior rhinitis) E. Tearing eyes 3. Which category of medication is the most effective for the majority of symptoms of allergic rhinitis?

A. Intranasal antihistamine B. Intranasal antimuscarinic C. Intranasal corticosteroid D. Intranasal decongestant E. Intranasal mast cell stabilizer/cromone 2 4. Which approach is best for treatment of rhinitis medicamentosa, along with tapering the intranasal decongestant?

A. Intranasal olopatadine B. Intranasal fluticasone propionate + azelastine C. Intranasal saline irrigation D. Oral corticosteroid burst and taper E. Oral pseudoephedrine for 5 to 7 days 5. Which agent would you recommend for treatment of ocular itch and tearing that is unresponsive to intranasal fluticasone propionate + azelastine?

A. Intranasal cromolyn B. Intraocular ketotifen C. Intranasal mometasone D. Intraocular naphazoline E. Oral pseudoephedrine 6. Which mode of therapy underlies the management of all patients with allergic rhinitis?

A. Education about allergen avoidance B. Education about complications of allergic rhinitis C. Intranasal corticosteroids D. Intranasal saline irrigation E. Sublingual immunotherapy 3 7. Which choice would be your recommendation to a 30-year-old woman who complains of runny nose, sneezing, and ocular tearing and itch, when episodically exposed to her friend's cats, as an OTC agent she could use for preexposure?

A. Intranasal cromolyn B. Intranasal ipratropium C. Intranasal triamcinolone D. Intraocular ketotifen E. Oral pseudoephedrine 8. Which choice would you recommend as an OTC medication for initial therapy of mild, intermittent (probably seasonal) allergic rhinitis in an otherwise healthy 7year-old child?

A. Intranasal cromolyn B. Intranasal oxymetazoline C. Intranasal triamcinolone D. Oral loratadine E. Oral phenylephrine 9. A 24-year-old woman, who is known to be 8 weeks pregnant, has been on oral montelukast, oral loratadine, and intranasal cromolyn for moderately severe, persistent allergic rhinitis. Her symptoms of nasal congestion, rhinorrhea, sneezing, and ocular itching are still poorly controlled, despite good adherence. Pick the most 4 appropriate drug from the choices below to recommend as an additional and/or replacement medication.

A. Intranasal budesonide B. Intranasal ipratropium C. Intranasal naphazoline D. Intranasal olopatadine E. Oral pseudoephedrine 10. Pick the most appropriate recommendation for relief of severe persistent allergic rhinitis symptoms in a patient who complains of bad taste, nasal irritation, and occasional epistaxis while using intranasal triamcinolone.

A. Add intranasal olopatadine B. Add oral fexofenadine C. Add oral pseudoephedrine D. Replace triamcinolone with intranasal ciclesonide as HFA metered-dose pump E. Replace triamcinolone with intranasal fluticasone propionate + azelastine 11. Pick the drug that should generally be used for no more than 3 consecutive days.

A. Intranasal azelastine B. Intranasal cromolyn C. Intranasal ipratropium D. Intranasal oxymetazoline 5 E. Oral pseudoephedrine 12. Pick the therapy, from the choices below, which is best limited only to patients with concurrent allergic rhinitis and asthma.

A. Intranasal beclomethasone as HFA metered-dose ipump B. Intranasal fluticasone propionate + azelastine C. Intraocular ketotifen

D. Oral montelukast E. Subcutaneous omalizumab 13. Pick the most accurate statement about intranasal corticosteroids.

A. Chronic use of intranasal corticosteroids for allergic rhinitis is associated with frequent systemic side effects.

B. Intranasal corticosteroids are effective for both phases of the allergic response in allergic rhinitis.

C. Intranasal corticosteroids should not be used in pregnant women.

D. Mometasone is the only intranasal corticosteroid indicated for children younger than 6 years.

E. Only fluticasone propionate, among the intranasal corticosteroids, is available OTC. 14. Pick the best recommendation for additional chronic therapy of a 68-year-old male patient with symptomatic benign prostatic hyperplasia/hypertrophy (BPH), marginally controlled hypertension, and persistent rhinorrhea due to a mixed 6 vasomotor and allergic rhinitis, unresponsive to appropriate doses of oral fexofenadine and intranasal fluticasone propionate + azelastine.

A. Intranasal budesonide B. Intranasal ipratropium C. Intranasal oxymetazoline D. Oral prednisolone burst and taper E. Oral pseudoephedrine 15. Pick the most accurate statement about nasal saline irrigation therapy for allergic rhinitis.

A. Hypertonic sodium chloride solutions are more effective for allergic rhinitis than “normal” (0.9%) saline when used as a nasal irrigation.

B. Iodized sodium chloride (salt) is best to use for nasal saline irrigations because the iodine exerts additional osmotic effects that reduce nasal congestion.

C. Nasal saline irrigation may provide some benefit to any patient with allergic rhinitis.

D. Nasal saline irrigation therapy is contraindicated in pregnant women because of the potential for excess sodium absorption, which can predispose to polyhydramnios and preeclampsia.

E. Nasal saline irrigation therapy is a poor choice in the elderly due to their increased incidence of rhinorrhea.

7 ANSWERS 1. E 2. C 3. C 4. D 5. B 6. A 7. A

8. D 9. A 10. D 11. D 12. E 13. B 14. B 15. C

Chapter 64. Psoriasis 1. Which of the following is not a comorbidity of psoriasis?

A. Crohn disease B. Hypertension C. Metabolic syndrome D. Diabetes E. All of the above are comorbidities of psoriasis 2. Which of the following histocompatibility complex is genetically linked to psoriasis?

A. HLA-Cw* on Chromosome 06 B. HLA-Cw* on Chromosomes 17 C. HLA-Cw* on Chromosomes X and Y D. Genes involved in peptide signaling are likely associated with psoriasis.

3. Which of the following options is considered nonpharmacological approach to treatment psoriasis?

A. Psychotherapy for reduction of stress B. Medicated moisturizers C. Aveeno moisturizer containing fragrance is recommended D. Use of tight-fitting cloth to help retain moisture on lesions 4. Which of the following drugs may cause new onset of psoriasis?

A. Metoprolol B. Acetylsalicylic acid C. Lithium D. Prednisone E. All of the above 5. All of the following cytokines play a major role in the inflammatory process of psoriasis except: A. Tumor necrosis factor (TNF-α) B. Interleukin 1 β (IL-1 β) C. Interleukin 2 γ (IL-2 γ) D. Interferon β (IFN-β) 6. A 61-year-old man presents with mild plaque psoriasis affecting his elbows and knees.

Which of the following constitute an initial pharmacologic therapy for him: A. Clobetasol spray B. Betamethasone ointment C. Betamethasone cream D. Hydrocortisone lotion 7. A 25-year-old woman in her first trimester presents with moderate plaque psoriasis affecting her face, scalp, trunk, arms, and legs. Which of the following would not be appropriate?

A. Calcipotriol 50 mcg/g ointment B. Betamethasone valerate 0.1% scalp lotion C. Hydrocortisone 1% to lesions on her face D. Anthralin 0.2% cream E. Tazarotene 0.05% gel 8. Effective combination therapies include all of the following except: A. Topical corticosteroid + calcipotriol B. Topical corticosteroid + tazarotene

C. Topical corticosteroid + methotrexate D. Topical corticosteroid + UVB E. Acitretin + PUVA 9. Calcipotriol can be inactivated by: A. UVA B. Anthralin C. Acitretin D. None of the above E. All of the above 10. A 45-year-old man has new-onset moderate to severe plaque psoriasis with a history of liver cirrhosis for the past 5 years. Which of the following systemic agents would be appropriate as initial therapy?

A. Infliximab B. Adalimumab C. Methotrexate D. Cyclosporine 11. Which of the following statements is true about effective combination therapy for psoriasis?

A. Tazarotene can be used with UVB B. Acitretin can be used with calcipotriol C. Cyclosporine can be used with calcipotriol D. None of the above E. All of the above 12. An obese 68-year-old man with severe psoriasis has been receiving treatment with methotrexate. Which of the following would not be an appropriate monitoring parameter during therapy?

A. Annual pulmonary function testing B. Annual auditory function testing C. Liver function tests every 1 to 2 months D. Consider liver biopsy at a cumulative methotrexate dose of 1.5 g E. Complete blood count monthly to bimonthly 13. Appropriate use of cyclosporine includes all of the following except: A. Patients with severe inflammatory flares of psoriasis B. Patients with recalcitrant psoriasis who have failed other therapies C. Waiting for a month before considering a dosage increase, if the response is inadequate D. Using a combination of cyclosporine and PUVA E. Using a combination of cyclosporine and SCAT 14. Which cytokine modulator is a TNF-α inhibitor?

A. Methotrexate B. Etanercept C. Alefacept D. Acitretin 15. Which of the following natural products has been shown effective in managing psoriasis in combination with vitamin B12 cream?

A. Aloe vera B. Avocado oil

C. Relieva D. Bovine cartilage Answers 1. E 2. A 3. A 4. A 5. D 6. B 7. E 8. D 9. A 10. A 11. E 12. B 13. D 14. B 15. B

CHAPTER 65 1.

Manifestations of superficial dermatophytosis of the skin include: A)

scaling.

B)

erythema.

C)

vesicles.

D)

infiltration.

2.

Onychomycosis initially causes the toenail to appear keratin.

A)

black

B)

cracked

C)

opaque

D)

eroded

3.

A yeast-like Candida albicans fungal infection can be differentiated from a tinea fungal infection by the presence of:

A)

circular patches.

B)

satellite lesions.

C)

fungal spores.

D)

raised borders.

4.

Warts develop when

A)

melanocytes

B)

keratinocytes

C)

sebaceous glands

D)

subcutaneous cells

5.

target lesions.

B)

dark erythema.

C)

epidermal edema.

D)

silver-white scale.

Papulosquamous dermatoses, such as psoriasis, are a group of skin disorders characterized by:

A)

scaling papules.

B)

granular scabbing.

C)

raised red borders.

D)

nodular ulcerations.

7.

are invaded by human papillomavirus (HPV).

Allergic and hypersensitivity dermatoses are characterized by:

A)

6.

as the fungus digests the nail

A thermal burn described as involving the entire epidermis and dermis is classified as:

A)

full third-degree.

B)

deep first-degree.

C)

partial second-degree.

D)

full-thickness second-degree.

8.

The main cause of decubitus ulcers (bedsores) is lymph.

A)

external pressure

B)

shearing forces

C)

tissue edema

D)

thrombosis

9.

Dysplastic nevi are precursors of malignant melanoma that are:

A)

larger than other nevi.

B)

oval epidermal nests.

C)

dermal cords of cells.

D)

brown rounded papules.

10.

Which one of the following skin disorders seen in elderly persons is considered a premalignant lesion?

A)

Cherry angiomas

B)

Actinic keratosis

C)

Solar lentigines

D)

Telangiectases

11.

Which of the following disorders of the skin is most likely to respond to treatment with systemic antibiotics?

A)

Acne vulgaris

B)

Urticaria

C)

Atopic dermatitis

D)

Verrucae

12.

that impairs the flow of blood and

Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the patient with psoriasis, a disorder that results from:

A)

increased epidermal cell turnover.

B)

an IgE-mediated immune reaction.

C)

hormonal influences on sebaceous gland activity.

D)

human papillomaviruses (HPV).

13.

A patient has been admitted to the intensive care unit of the hospital after developing toxic epidermal necrolysis (TEN) consequent to the administration of a sulfonamide antibiotic.

What pathophysiologic phenomenon is likely the greatest immediate threat to this patients health?

A)

The development of bacterial cellulitis on compromised skin surfaces

B)

Fluid and electrolyte imbalances resulting from the loss skin integrity

C)

A cascading autoimmune response that may result in shock

D)

The presence of diffuse lesions and skin sloughing on the patients mucous membranesA

14.

mans winter vacation to a tropical destination has been accompanied by repeated sunburns. What process accounts for the damaging effects of the suns radiation?

A)

Initiation of an autoimmune response

B)

Compensatory increases in melanin production

C)

Damage to epidermal cell DNA and free radical production

D)

Hyperkeratinization and the formation of microscopic, subcutaneous lesions

15.

A 44-year-old man has been brought to the emergency department by emergency medical services with severe electrical burns resulting from a workplace accident. The most immediate threat to this patients survival at this time is:

A)

infection.

B)

hemodynamic instability.

C)

acute pain.

D)

decreased protein synthesis and impaired healing.

16.

A 79-year-old patient has been confined to bed after a severe hemorrhagic stroke that has caused hemiplegia. Which of the following measures should his care team prioritize in the prevention of pressure ulcers?

A)

Prophylactic antibiotics

B)

Repositioning the patient on a scheduled basis

C)

Applying protective dressings to vulnerable areas

D)

Parenteral nutrition

17.

Which of the following actions involves the greatest risk of skin shearing?

A)

Inserting a peripheral intravenous catheter

B)

Rolling the patient from a supine to side-lying position

C)

Pulling the patient up in bed

D)

Helping the patient ambulate after surgery

18.

A)

What neoplasm of the skin is associated with the poorest prognosis?

Malignant melanoma

B)

Basal cell carcinoma

C)

Intraepidermal squamous cell carcinoma

D)

Invasive squamous cell carcinoma

19.

The transition of a melanoma from radial growth to vertical growth is associated with:

A)

failure of the integrity of the basement membrane.

B)

involvement of the nonkeratinizing cells.

C)

spontaneous resolution.

D)

an increased risk of metastasis.

20.

A 5-year-old girl has been presented for care by her father due to her recent development of macules on her trunk, extremities, and mucous membranes. The child is mildly febrile but her primary symptom is extreme pruritus. What disorder of the skin should the clinician who is assessing the child first suspect?

A)

Varicella

B)

Lichen planus

C)

Rosacea

D) Answer Key 1.

A 2.

C

3.

B

4.

B

5.

C

6.

A

7.

D

8.

A

9.

A

10.

B

11.

A

12.

A

13.

D

14.

C

15.

B

16.

B

17.

C

Impetigo

18.

A

19.

D

20.

A

CHAPTER 66 1. After the patient has been determined to have anemia, what laboratory parameter should subsequently be evaluated to aid in identifying macrocytic versus microcytic anemia?

A. Hct B. MCV C. Iron D. Folic acid 2. The largest approved dose for a parenteral iron formulation is 750 mg. This is the maximum approved dose for which parenteral iron formulation?

A. Sodium ferric gluconate complex B. Ferric carboxymaltose C. Iron sucrose injection D. Ferumoxytol injection 3. Typically anemia of chronic disease is characterized by which of the following?

A. Normocytic anemia and normal or increased ferritin B. Microcytic anemia and decreased ferritin C. Microcytic anemia and normal or increased ferritin D. Normocytic anemia and decreased ferritin 4. What initial daily dose of folic acid is typically effective in treating anemia secondary to folic acid deficiency?

A. 100 mcg B. 400 mcg C. 1 mg D. 4 mg 5. Which of the following is correct regarding the laboratory evaluation for anemia?

A. The CBC is the first laboratory test that should be conducted B. Iron studies should be evaluated when the MCV is low C. When the MCV is high folic acid and Vitamin B12 levels should be ordered D. All of the above 6. Which of the following statements regarding ESAs is correct?

A. Clinical practice guidelines consider epoetin-α and darbepoetin-α to be therapeutic equivalents.

B. Clinical practice guidelines consider epoetin-α superior to darbepoetin-α because of superior efficacy.

C. Clinical practice guidelines consider darbepoetin-α superior to epoetin-α because of superior efficacy.

D. Clinical practice guidelines consider epoetin-α superior to darbepoetin-α because of superior toxicity profile.

7. Which of the following statements regarding anemia in patients with CKD is incorrect?

A. Anemia from CKD requires larger doses of epoetin than anemia due to cancer B. Anemia from CKD is usually a normocytic, normochromic anemia due to EPO

deficiency C. Early treatment of anemia from CKD has been associated with positive outcomes D. Anemia evaluation and treatment in patients with CKD should be initiated before patients start dialysis 8. To optimize the efficacy of ESA therapy it is necessary to assess which of the following?

A. Serum cyanocobalamin levels B. Serum folate levels C. Serum iron levels D. All of the above 9. Which of the following statements regarding the FDA labeling requirements for ESA therapy is true?

A. The hemoglobin for initiation of therapy should be < 10 g/dL (100 g/L; 6.21 mmol/L) B. Limit ESA therapy to patients receiving chemotherapy or radiation therapy C. ESAs should be limited to patients with chronic kidney disease D. All of the above are true 10. What if any ESA dose modification is recommended if a patient’s Hgb increases by 1 g/dL (10 g/L; 0.62 mmol/L) or to more than 10 g/dL (100 g/L; 6.21 mmol/L)?

A. Recommend the ESA dose be decreased by 25% and recheck Hgb in 4 weeks B. Recommend the ESA dose be decreased by 50% and recheck Hgb in 4 weeks C. Recommend no change in the ESA dosage regimen and recheck Hgb in 4 weeks D. Discontinue the ESA and recheck Hgb in 4 weeks 11. According to the 2011, FDA safety communication to improve the safe use of ESAs in patients with CKD what is the recommended target Hgb for a patient with CKD on hemodialysis?

A. 10 g/dL (100 g/L; 6.21 mmol/L) B. 11 g/dL (110 g/L; 6.83 mmol/L) C. 12 g/dL (120 g/L; 7.45 mmol/L) 4 D. 13 g/dL (130 g/L; 8.07 mmol/L) 12. What adverse event can happen if the hemoglobin level is titrated to normal with an ESA in patients with chemotherapy-induced anemia?

A. Diminished quality of life B. The patient will be at a higher risk for disease progression and stroke C. Thrombocytopenia D. Iron stores will be depleted, and the patient must receive iron supplementation 13. You have determined that RH has iron-deficiency anemia, and you plan to initiate oral iron therapy. Which of the following oral iron regimens are correct for RH? A. 325 mg of ferrous sulfate once daily since it provides 325 mg of elemental iron B. 325 mg of ferrous sulfate three times daily since it provides about 200 mg of elemental iron C. The initial dose of oral iron does not matter since the dose is titrated to effect D. Ferrous sulfate 300 mg twice daily since it provides 600 mg of elemental iron 14. What is the preferred route of cyanocobalamin administration when initiating therapy for a patient with pernicious anemia?

A. Oral B. Intranasal

C. Either intramuscular or subcutaneous injection D. There is no preferred route of administration when initiating treatment. Any of the above administration routes are acceptable.

15. An increase in reticulocytes occurs as a result of which of the following?

A. Iron deficiency anemia B. Folic acid deficiency anemia C. Vitamin B12 deficiency anemia D. Effective treatment of anemia caused by iron, folic acid, and vitamin B12 deficiencies.

Answers 1. B 2. B 3. A 4. C 5. D 6. A 7. A 8. C 9. A 10. D 11. B 12. B 13. B 14. D 15. D

Chapter 67 1. Extrinsic pathway of anticoagulation involves: A. Factor XII B. Factor VII C. Factor IX D. Factor XI 2. Which of the following statements is true?

A. Each unit of factor (F) VIII replacement administered per kilogram of body weight raises the plasma FVIII level 1% (0.01 IU/mL [10 IU/L]).

B. Each unit of FVIII replacement administered per kilogram of body weight raises the plasma FVIII level 2% (0.02 IU/mL [20 IU/L]).

C. Each unit of FIX replacement administered per kilogram of body weight yields a 0.5% rise in plasma (0.005 IU/mL [5 IU/L]) FIX level.

D. Each unit of FIX replacement administered per kilogram of body weight yields a 2% rise in plasma (0.02 IU/mL [20 IU/L]) FIX level.

E. Each unit of FIX replacement administered per kilogram of body weight yields a 3% rise in plasma (0.03 IU/mL [30 IU/L]) FIX level.

3. To increase the FVIII level from 0% to 80% in a 50-kg hemophiliac, units of FVIII should be administered.

A. 500 B. 3000 C. 4000 D. 1600 E. 2000 4. Which of the following is the medication of choice to control mild joint pain associated with joint destruction in patients with hemophilia?

A. Ibuprofen B. Acetaminophen C. Oxycodone D. Naproxen E. Aminocaproic acid 5. Which of the following is the best approach to treating a nonbleeding 60-kg hemophilia patient with 3 BU/mL (3000 BU/L) of factor VIII inhibitor?

A. 7200 mcg of recombinant factor VIIa IV every 2 hours B. 4500 units of aPCC IV twice daily C. Immune tolerance induction, factor VIII replacement per levels D. 6000 porcine units of recombinant porcine factor VIII IV daily E. 6000 units of Advate IV twice daily 6. Which of the following statements is true about desmopressin acetate (DDAVP) therapy in von Willebrand disease (vWD)?

A. Due to its potential to be contaminated with viruses, solvent/detergent viral inactivation process is used.

B. It is less effective in vWD compared with hemophilia patients.

C. It can be administered as a 0.3-mcg/kg oral dose twice daily.

D. Administration of a test dose can predict patient’s response to therapy.

E. The main adverse effect is hypernatremia.

7. A 30-year old patient with type 3vWD is scheduled for an intra-abdominal surgery. Which of the following products should be administered prior to surgery to control the bleeding?

A. DDAVP B. Refacto C. Humate-P D. Tranexamic acid E. Rixubis 8. Which of the following is a typical presenting symptom for patient with thrombotic thrombocytopenic purpura (TTP)?

A. Constipation B. Cough C. Confusion D. Hives E. Throat swelling 9. The vWD type most likely to respond to desmopressin treatment is: A. Type 1 B. Type 2 C. Type 2A D. Type 2B E. Type 3 10. For a 3-year-old boy diagnosed with idiopathic thrombocytopenic purpura (ITP), no bleeding, and platelet count of 25,000/mm3 (25 109 /L), the following is recommended: A. Prednisone, 1 to 1.5 mg/kg/day IV B. Anti-D immunoglobulin, 75 µg/kg one dose C. Laparoscopic splenectomy D. Close monitoring, no treatment E. Platelet transfusion 11. All of the following can cause TTP except: A. Rituximab B. Ticlopidine C. Malignancy D. Bone marrow transplant 12. Which of the following interventions is the most important to decrease mortality due to TTP? A. Plasma exchange B. Methylprednisolone C. Rituximab D. Alphanate E. Fresh-frozen plasma 13. Adult-onset ITP: A. Is sudden B. Affects both sexes equally C. Affects women two to three times more often than men

D. Affects men two to three times more than women E. Is usually self-limiting 14. Which of the following is true regarding use of thrombopoietic growth factors in ITP? A. Romiplostim can be given orally twice a day B. Eltrombopag is FDA approved for use in children older than 1 year of age C. Use of thrombopoietic growth factors is associated with long-term sustained response D. Eltrombopag has a warning on hepatic decompensation in patients with HCV infection being treated with interferon/ribavirin regimens E. Romiplostim can be considered as a first-line therapy in adult patients with platelet counts less than 30,000/mm3 (30 109/L) 15. What is the mainstay of treatment for recessively inherited coagulation disorder (RICD)?

A. Fresh-frozen plasma (FFP) B. Prothrombin complex concentrates (PCCs) C. Cryoprecipitate D. Tranexamic acid E. Platelet transfusions Answers 1. B 2. B 3. E 4. B 5. C 6. D 7. C 8. C 9. A 10. D 11. A 12. A 13. C 14. D 15. A

Chapter 68 1. Which of the following factors can contribute to increased risk for vasoocclusion in sickle cell disease patients?

A. Decreased red blood cell (RBC) deformability B. High RBC fetal hemoglobin (HbF) concentration C. Low RBC adult hemoglobin (HbA) concentration D. Rapid RBC transit through microcirculation E. Decreased RBC viscosity 2. MM is a 9-year-old boy with sickle cell disease (SCD) who has just had a stroke. He is starting to regain some motor function and is progressing well. What is the most effective measure that can be taken to prevent further strokes in MM? A. Hydroxyurea taken daily for life B. IV antibiotics for 10 days to prevent meningitis C. Anticoagulant medications D. Chronic transfusion RBC therapy for life E. Iron chelation therapy 3. Which of the following choices may best help to prevent infectious complications from sickle cell disease?

A. Immunize for S. pneumoniae and take daily oral PenVK until age 6 B. Immunize for H. flu and take oral PenVK at the first sign of a fever C. Immunize for Hepatitis B and give IV antibiotics at the first sign of a fever D. Immunize for influenza and keep the patient adequately hydrated E. Immunize for N.meningitidis and take daily oral amoxicillin until age 6 4. A 30-year old man with sickle cell disease presents to the ER with complaints of lethargy and tiredness increasing over the past 2 weeks. His oxygen saturation level is 86% (0.86) on room air. Hemoglobin is 5.4 g/dL (54 g/L; 3.35 mmol/L). WBC is 5 × 103 /mm3 (5 ×109/L), platelets 100 × 103/mm3(100 × 109/L). Oral temperature is 37.5 C. What one therapeutic intervention will have the best impact on his chief complaint?

A. IV antibiotics B. Packed RBC transfusion C. IV fluids (give two times maintenance) D. Oxygen to keep saturations > 95% (0.95) E. IV morphine 5. A 22-year-old woman with SCD is admitted for acute chest syndrome. She has an oral temperature of 102.2 F (39.0 C), is receiving appropriate fluid, and is receiving oxygen by nasal cannula because her oxygen saturations on room air were 85% (0.85). Her drug profile includes intravenous morphine for pain and oral diphenhydramine for itching. Which one of the following is most appropriate to add to this patient’s regimen at this time?

A. Methylprednisolone IV every 12 hours.

B. Albuterol metered-dose inhaler every 4 hours.

C. Ceftriaxone IV every 12 hours.

D. Vancomycin IV every 12 hours E. Hydroxyurea orally every 24 hours 6. A 2-year-old child with SCD should receive which of the following in addition to the required childhood immunizations?

A. Influenza vaccine B. Meningococcal vaccine C. Papillomavirus vaccine D. PPV 23 vaccine E. Rotavirus vaccine 7. A child who presents with severe anemia due to sequestration crisis should receive IV fluids and: A. Decitabine B. Epoetin C. Hydroxyurea D. Morphine E. RBC transfusion 8. Select the appropriate penicillin prophylaxis regimen for a 4-year-old child with SCD A. 250 mg twice daily until 5 years of age, then discontinue B. 250 mg twice daily and continue through adolescence C. 125 mg twice daily until 5 years of age, then discontinue D. 125 mg twice daily and continue through adolescence E. 125 mg twice daily until 5 years of age, then 250 mg twice daily 9. Which laboratory parameter necessitates temporary discontinuation of hydroxyurea therapy in a 14-year-old boy?

A. Absolute neutrophil count less than 7 103/µL (7 109/L) B. Hemoglobin value less than 5 g/dL (50 g/L or 3.1 mmol/L) C. Mean corpuscular volume less than 72 fL (72/µm3) D. Platelets less than 90 103/µL (90 109/L) E. Reticulocytes less than 80 103/µL (80 109/L) 10. All of the following are complications that can occur because of vasoocclusion except: A. Congestive heart failure B. Leg ulcers C. Priapism D. Renal insufficiency E. Stroke 11. Which of the following therapies is an appropriate treatment for SCD-related priapism?

A. Corticosteroids, such as prednisone B. Antibiotics, such as ceftriaxone C. Vasoconstrictors, such as epinephrine D. IV fluids, such as D51/2NS E. All of the above 12. RS is a 20-year old man with SCD who takes folic acid daily along with ibuprofen and hydrocodone/acetaminophen at least 4 days a week to control his baseline pain. He presents to the ED with right shoulder pain that he rates as 9/10 on a visual analog pain scale. He is to be admitted to the hospital for pain control. What is the most appropriate initial pain medication choice for this patient?

A. Continue his ibuprofen and hydrocodone/acetaminophen on a scheduled basis B. Start ketorolac IV every 6 hours with scheduled oral morphine C. Start acetaminophen IV every 6 hours with scheduled IV meperidine D. Start ketorolac IV every 6 hours with morphine PCA

E. Start ibuprofen IV every 6 hours with fentanyl PCA 13. Select the most appropriate empiric treatment for suspected pneumonia in an adult patient with SCD. A. Cefotaxime + vancomycin B. Ciprofloxacin + erythromycin C. Gentamicin + ampicillin D. Meropenem + penicillin E. Piperacillin/tazobactam + tobramycin 14.TL is a 9-year-old girl with SCD who has been admitted to the hospital for pain control associated with a vasoocclusive crisis. She is currently receiving a morphine PCA with both a continuous basal rate as well as on-demand dosing. Today on hospitalization day 3, she is complaining of severe itching all over, which is distressing to her. Which of the following is the best option for treating her pruritus?

A. Triamcinolone 0.1% applied topically to the affected area every 6 hours.

B. Diphenhydramine cream 1% applied topically to the affected area every 6 hours.

C. Hydroxyzine intramuscularly every 6 hours as needed.

D. Diphenhydramine intravenously every 6 hours.

E. Loratadine orally every 24 hours 15. A 3-year-old girl (Wt 13.5 kg) with SCD presents with a serum ferritin concentration of 2500 ng/mL (2500 mcg/L; 5618 pmol/L) because of frequent RBC transfusions. Which of the following statements concerning deferasirox (Exjade) is the best when deciding the initial intervention for this patient?

A. Deferasirox is not indicated in young children B. Give 250-mg tablet once daily C. Give 250-mg tablet + 125-mg tablet once daily D. Give 500-mg tablet once daily E. Give 500-mg tablet + 125-mg tablet once daily Answers 1.

A 2.

D 3.

A 4.

B 5.

C 6.

D 7.

E 8.

A

9.

B 10.

A 11.

C 12.

D 13.

B 14.

D 15.

B

Chapter 69 1. Findings consistent with an infection include: A. Fever B. Elevated WBC count C. Elevated procalcitonin D. Left shift E. All of the above 2. refers to development of resistance occurring in a patient’s nontargeted flora that can cause secondary infections.

A. Collateral damage B. Nonadherence C. De-escalation D. Pharmacodynamics E. Source control 3. Which one of the following is true regarding the initial empiric selection of antimicrobial agents?

A. Empirical selection of antimicrobial therapy should be related to severity of illness.

B. Given several antimicrobial choices, the antimicrobial most associated with collateral damage is preferred.

C. In most cases, double coverage is synergistic, prevents the emergence of resistance, improves outcomes, and is superior to monotherapy.

D. Antimicrobial cost should be the primary factor when deciding on empiric therapy E. Consideration of previous antimicrobial exposure is not necessary when choosing empiric therapy.

4. All but which one of the following factors is important to consider when selecting an antibiotic dosing regimen?

A. Source-specific location of infection B. Minimum inhibitory concentration (MIC) of the likely pathogens C. Route of administration D. Antimicrobial agent cost E. Metabolism and elimination of the antimicrobial 5. Causes of antimicrobial failure include: A. Inadequate diagnosis B. Development of a new infection with a resistant organism C. Poor source control D. Nonadherence E. All of the above 6. Which statement regarding a Gram stain is not correct?

2 A. Performed to identify if bacteria are present B. If bacteria are present, they will be stained by Gram stain C. Gram stain can determine morphological characteristics of bacteria D. Presence of WBCs indicates inflammation E. Gram stain can evaluate if a specimen is poorly collected or contaminated

describes the relationship between drug exposure and pharmacologic effect of antibacterial activity or human toxicology.

A. Pharmacokinetics B. Concentration-dependent activity C. Pharmacodynamics D. Minimum inhibitory concentration (MIC) E. Drug distribution 8. Which of the following statements is true regarding normal flora?

A. An endogenous infection arises from one’s own normal flora.

B. Normally sterile sites include the cerebrospinal fluid, blood, and urine.

C. The large intestine contains more anaerobes than aerobes.

D. Normal flora of the skin includes streptococcal species.

E. All of the above 9. Which of the following statements regarding a patient history is false?

A. Previous antimicrobial use may predispose a patient to resistant pathogens.

B. The history should focus on making the diagnosis.

C. Recent health care utilization is a determinant in selecting antimicrobial therapy.

D. dConcomitant medications may interact with the selected antimicrobial agent.

E. All of the above are true.

10. Virulence refers to: A. Bacteria that cause disease as well as colonizing flora.

B. The presence of bacteria that are not causing disease.

C. The presence of bacteria that are causing disease.

D. The pathogenicity or disease severity produced by an organism.

E. Antimicrobial therapy targeting bacterial colonization may lead to the emergence of resistant bacteria.

11. A left shift refers to: A. An increase in immature neutrophils or bands.

B. Leukopenia that may occur secondary to certain medications.

C. An elevated WBC count.

D. An elevated CRP. E. The WBC count and differential.

12. Which of the following factors may influence selection of the antimicrobial agent, dose, and monitoring?

A. Concomitant medications 3 B. Renal/hepatic function C. Pregnancy D. Drug allergies E. All of the above 13. Which statement regarding the minimum inhibitory concentration (MIC) is true?

A. MIC is the highest concentration of antimicrobial that inhibits visible bacterial growth.

B. It accurately predicts the in vivo outcome.

C. MIC, along with the breakpoint, determines whether the organism is susceptible, intermediate, or resistant to a specific antimicrobial agent.

7.

D. Breakpoint is the concentration of the antimicrobial that can be achieved in the urine after a standard dose of that agent.

E. If the MIC is below the breakpoint, the organism is considered resistant to that agent.

14. Host factors that should be considered when selecting an antimicrobial regimen include: A. Concomitant medications B. Drug allergies C. Age D. Anatomical location of infection E. All of the above 15. Which one of the following monitoring parameters is not routinely performed?

A. Temperature B. Reculture of specimens C. Renal function D. WBC count with differential E. Follow-up on culture and susceptibility reports 4 Answers 1.E 2.A 3.A 4.D 5.E 6.B 7.C 8.E 9.E 10.D 11.A 12.E 13.C 14.E 15.B

Chapter 70 1. A 73-year-old patient with a documented allergy to sulfa agents (bronchoconstriction) should receive which antimicrobial(s) for listeriosis treatment?

A. Ceftriaxone B. Ampicillin C. Gentamicin D. Vancomycin plus gentamicin 2. Which patient would be assumed to be at the highest risk of meningococcal meningitis?

A. 4-year-old attending daycare B. 34-year-old pregnant woman C. 78-year-old hospital volunteer D. 19-year-old college sophomore 3. Which of the following antibiotic therapy should be used for pneumococcal meningitis in a patient with a severe, Type 1 allergy to penicillins and cephalosporins?

A. Vancomycin 2 B. Aztreonam C. Meropenem D. Sulfamethoxazole-trimethoprim 4. Meningococcal vaccine is recommended in which of the following patients: A. 2-month-old infant B. 67-year-old woman with diabetes C. 5-year-old attending daycare D. 12-year-old attending public school 5. Which of the following antimicrobial agents should be considered in empirical therapy of postneurosurgical meningitis?

A. Ceftriaxone B. Cefepime C. Doxycycline D. Moxifloxacin 6. What is the agent of choice for maintenance therapy in cryptococcal meningitis in a patient with a CD4+ count of 33 cells/mm3 (33 × 106/L)?

A. Lipid formulation of amphotericin B. Posaconazole 3 C. Micafungin D. Fluconazole 7. What is the primary reason for inclusion of vancomycin in empiric treatment of adults with community-acquired bacterial meningitis?

A. Treatment of methicillin-resistant Staphylococcus aureus (MRSA) B. Treatment of drug-resistant Streptococcus pneumoniae C. Treatment of drug-resistant Neisseria meningitidis D. Treatment of methicillin-resistant Staphylococcus epidermidis (MRSE)

8 Which of the following patients is at risk for meningitis secondary to direct inoculation?

A. A 3 year old with otitis media B. A 21 year old with community acquired pneumonia C. A 27 year old with traumatic brain injury D. A 71 year old with age-related hearing loss 9. Antimicrobial therapy should be ideally administered in patients with suspected meningitis: A. Orally in the outpatient setting following blood cultures B. Orally in the outpatient setting following lumbar puncture C. Parenterally in the inpatient setting following lumbar puncture D. Parenterally in the inpatient setting immediately upon admission 10. Initial therapy in the treatment of bacterial meningitis should be: A. Targeted, low-dose therapy aimed at pathogens based on vaccination history B. Targeted, high-dose therapy aimed at pathogens based on recent exposure 4 C. Broad spectrum, low-dose therapy aimed at all common causative pathogens D. Broad spectrum, high-dose therapy aimed at all common causative pathogens 11. The most common pathogen responsible for neonatal meningitis is: A. S. agalactiae B. N. meningitidis C. S. aureus D. HSV Type 2 12. Which of the following patients is most likely to have bacterial meningitis secondary to S. aureus?

A. A 6-year-old with recent MRSA cellulitis B. An 18-year-old man with a positive MRSA nares screen C. A 27-year-old with recent brain injury and craniotomy D. A 68-year-old hospitalized with pneumonia 13. Standard empiric therapy for a college student presenting with signs and symptoms consistent with bacterial meningitis would most appropriately include: A. Ceftriaxone and vancomycin B. Ampicillin and vancomycin C. Linezolid and ampicillin D. Ceftriaxone and ampicillin 14. The appropriate first-line therapy for an adult patient with HSV encephalitis is: A. No active antiviral therapy, supportive care B. Acyclovir 10 mg/kg IV every 8 hours C. Foscarnet 20 mg/kg IV every 8 hours 5 D. Ganciclovir 2.5 mg/kg IV every 12 hours 15. Which of the following is true regarding adjunctive dexamethasone therapy?

A. Should be given following the initiation of antibiotics B. Does not alter vancomycin penetration into the CSF C. Recommended in adults with pneumococcal meningitis D. Recommended in neonatal meningitis 16. Close contacts of adult patients with pneumococcal meningitis should receive antibiotic prophylaxis with one of the following options except:

A. Ciprofloxacin 500 mg orally for one dose B. Amoxicillin 1 g orally for four doses C. Rifampin 600 mg orally for four doses D. No prophylaxis 6 Answers 1.

B 2.

D 3.

A 4.

D 5.

B 6.

D 7.

B 8.

C 9.

C 10.

D 11.

A 12.

C 13.

A 14.

B 15.

B 16.

D

Chapter 71 1. Which of the following statements regarding the epidemiology of community-acquired pneumonia is correct?

A. Mycoplasma pneumoniae is the most prevalent bacterial pathogen.

B. Haemophilus influenzae is a common pathogen in adults who smoke tobacco.

C. Necrotizing CAP which is common in children is caused by CA-MRSA and associated with a high (42%) mortality rate.

D. Mixed infections with bacteria and viruses are an uncommon cause of CAP in adults, incidence less than 5%.

2. AJ is a 52-year-old man admitted to the hospital with suspected aspiration pneumonia.

His home medications are lisinopril 20 mg once daily and omeprazole 20 mg once daily.

What organisms need to be considered as causative agents in AJ? A. Staphylococcus aureus, Escherichia coli, and viridans Streptococci B. Anaerobes, E. coli, and viridans Streptococci C. S. aureus and anaerobes D. Anaerobes and Streptococcus pneumoniae E. Anaerobes, viridians Streptococci, Streptococcus pneumoniae, E. coli, and S. aureus 3. CD is a 66-year-old woman admitted to the hospital for respiratory failure. Upon admission she was intubated. She was improving and on day 9 was starting to be weaned off the ventilator. On day 9 her respiratory symptoms were worsening and full ventilator settings were required. She is diagnosed with ventilator-associated pneumonia. Which of the following organisms are most likely associated with her pneumonia?

A. S. pneumoniae, H. influenzae, MRSA, and MSSA B. H. influenzae, enteric GNB, anaerobes, and MSSA C. Pseudomonas aeruginosa, Acinetobacter spp., and MRSA D. S. pneumoniae, H. influenzae, viridians Streptococci, and MRSA E. P. aeruginosa, Acinetobacter spp., anaerobes, and S. pneumoniae 4. PF is a 50-year-old man who smokes two packs of cigarettes per day. Which of the following host defenses that protect the lung are known to be impaired by the smoke?

A. Mucous and ciliated cells B. Alveolar macrophages C. Immunoglobulin (IgA, IgG, and IgM) D. A and C E. All of the above 2 5. GH is a 58-year-old woman who presents to the emergency room complaining of a productive cough (greenish/yellowish stuff) and chest tightness. She states this feels different from her usual cough. Two weeks earlier, she had developed a cold, which was resolving prior to the onset of the current symptoms. For the last week she babysat her 2year-old grandson who had an ear infection and could not attend his daycare.

PMH: COPD 6 years Allergies: cephalosporins—hives, shortness of breath SH: smoked 2-ppd 10 years, quit 2 years ago, lives with her husband (nonsmoker) Vitals: 100.8°F (38.2°C), HR 80, 118/86 Pulse Ox: 82% (0.82) on room air PE: Lungs: rales, rhonchi, decreased breath sounds over right mid lobe

Chest x-ray: right mid lobe infiltrate Sputum Gram stain: Moderate WBCs, no organisms seen What signs, symptoms, and risk factors does GH have that are associated with communityacquired pneumonia?

A. Cough, shortness of breath, difficulty breathing, rales, rhonchi, decreased breath sounds, chest x-ray findings B. Fever, myalgias, mental status changes, cough, low oxygenation, exposure to grandson, chest x-ray findings, chest tightness C. Chest x-ray findings, cough, fever, shortness of breath, rales, rhonchi, decreased breath sounds, chest tightness D. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness, fever, exposure to grandson E. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness, fever, chest x-ray findings, exposure to grandson 6. Immune responses to pneumonia include the following: A. Alveolar macrophages engulfing organisms attempting to contain the infection B. Cytokine release from macrophages increasing mucous production C. Alveolar macrophages engulfing organisms and presenting the antigens to elicit an adaptive immune response D. A and C E. All of the above 7. GH is a 58-year-old woman who presents to the emergency room complaining of a productive cough (greenish/yellowish stuff) and chest tightness. She states this feels different from her usual cough. Two weeks earlier, she had developed a cold, which was resolving prior to the onset of the current symptoms. For the last week she babysat her 2year-old grandson who had an ear infection and could not attend his daycare.

PMH: COPD 6 years Allergies: cephalosporins—hives, shortness of breath SH: smoked 2-ppd 10 years, quit 2 months ago, lives with her husband (nonsmoker) Vitals: 100.8°F (38.2°C), HR 80, 118/86 Pulse Ox: 82% (0.82) on room air PE: Lungs: rales, rhonchi, decreased breath sounds over right mid lobe 3 Chest x-ray: right mid lobe infiltrate Sputum Gram stain: Moderate WBCs, no organisms seen What factors need to be considered before empirical therapy for CAP can be selected for GH? A. COPD and quit smoking 2 months ago B. Chest x-ray—right mid lobe infiltrate and decreased breath sounds over right mid lobe C. Allergy to cephalosporins D. A and C E. All of the above 8. Which of the following statements regarding resistance is paired to the appropriate organism?

A. The absence of a cell wall results in resistance to β-lactams for Moraxella catarrhalis.

B. β-Lactamase production confers resistance to penicillin for S. pneumoniae C. Methylation of ribosomes confers clarithromycin resistance for S. pneumoniae D. β-Lactamase production within H. influenzae has steadily increased over the past 10 years with rates now over 70% 9. JF is a 60-year-old woman presents to the emergency room complaining of a productive cough (greenish/yellowish stuff) and chest tightness. PMH: HTN 4 years. Vitals: 101.2°F (38.4°C), HR 80, 118/86, respiratory rate 18, pulse oximetry (oxygen saturation) 96% (0.96) on room air. Ht 5’5” (165 cm) Wt 140 lbs (63.6 kg). Allergies: NKDA. Home medication is atenolol 50 mg once daily. Chest x-ray: right mid lobe infiltrate. She is alert and oriented × 3. Her electrocardiogram is normal, renal function is normal (creatinine clearance 75 mL/min [1.25 mL/s]), and WBCs are 11.8 cells/mm3 (11.8 106 /L).

Which of the following would be the most appropriate empirical therapy for JF’s pneumonia?

A. Azithromycin 500 mg PO every 24 hours B. Levofloxacin 750 mg PO every 24 hours C. Ceftriaxone 1 g IV plus azithromycin 500 mg IV every 24 hours D. Cefepime 2 g IV plus doxycycline 100 mg IV q12h 10. DR is a 72-year-old man who presented to the hospital for a hernia repair. PMH is significant for smoking for the last 20 years. He has been intubated for the last 12 days, and attempts to wean DR off of the ventilator failed. The nurses noted increased volume 4 and purulence of secretions from the ventilator. Chest x-ray: left lower lobe infiltrate.

Urinary DFA for Legionella is negative. Ht 5’10” (178 cm) Wt 75 kg and he has NKDA. PMH is negative, and home medications are 1 multivitamin once daily. Creatinine clearance is 70 mL/min (1.17 mL/s), WBCs are 13.5 cells/mm3 (13.5 106 /L), and temperature is 100.4° F (38.0°C).

Which of the following organisms are the most likely pathogens for DR’s pneumonia?

A. MRSA, extended-spectrum β-lactamase–producing Klebsiella pneumoniae, P. aeruginosa, Acinetobacter spp.

B. S. pneumoniae, MSSA, E. coli, K. pneumoniae C. Anaerobes, viridans Streptococci, E. coli, K. pneumoniae D. S. pneumoniae, H. influenzae, M. catarrhalis, M. pneumoniae, C. pneumoniae, and Legionella pneumophila 11. DR underwent bronchoscopy, and the Gram stain of the bronchoalveolar lavage shows moderate gram-positive cocci in clusters, moderate gram-negative bacilli, and many WBCs. Which of the following would be the most appropriate empirical regimen for DR’s pneumonia?

A. Moxifloxacin 400 mg IV or PO every 24 hours plus vancomycin 1500 mg IV every 12 hours plus cefepime 2 g IV every 12 hours B. Nafcillin 2 g IV every 6 hours plus cefepime 2 g IV every 12 hours plus tobramycin 380 mg IV every 24 hours

C. Vancomycin 1500 mg IV every 12 hours plus cefepime 2 g IV every 12 hours plus tobramycin 380 mg IV every 24 hours D. Azithromycin 500 mg IV every 24 hours plus ceftriaxone 1 g IV every 24 hours E. Ertapenem 1 g IV every 24 hours plus ceftriaxone 1 g IV every 24 hours 12. Which of the following factors is/are the most important considerations for determining the duration of therapy for DR? A. Clinical pulmonary infection score B. Time to the start of clinical improvement C. Risks for toxicity associated with the therapy D. A and C E. All of the above 13. Which of the following are appropriate outcome evaluations for pneumonia?

A. Improvement of symptoms within 48 to 72 hours for HAP, HCAP, and VAP B. Resolution of symptoms within 96 to 120 hours for HAP, HCAP, and VAP C. Improvement of symptoms within 48 to 72 hours for CAP D. Resolution of symptoms within 48 to 72 hours for CAP 14. CC is a 24-year-old woman inquiring about the receiving the influenza and pneumococcal vaccines at your pharmacy. She has asthma, has no drug or food allergies, and is 6 months pregnant. Which of the following vaccines can she receive?

A. Fluzone intradermal B. Influenza intranasal C. 13-valent conjugated pneumococcal D. 7-valent conjugated pneumococcal E. None, she has to wait until after the pregnancy to be vaccinated 15. AK is a 12-year-old child who will have to undergo a splenectomy. In order to minimize pneumococcal disease after the splenectomy, AK should receive: A. The polysaccharide vaccine B. The 13-valent conjugated vaccine C. No vaccine because they are not effective in the absence of a spleen and AK should be placed on penicillin prophylaxis to prevent pneumococcal disease Answers 1. B 2. B 3. C 4. A 5. E 6. E 7. D 8. C 9. A 10. A 11. C 12. A 13. C 14. A 15. A

Chapter 72 1. ML is a 14-month-old girl diagnosed with acute otitis media. She presented to the pediatric clinic today with a fever of 102.4°F (39.1°C) and tugging of her right ear for the past 24 hours.

She developed rhinorrhea, nasal congestion, and sneezing approximately 3 days ago, but those symptoms have improved. She attends daycare 3 days a week and has a 4-year-old brother who attends preschool. This is her first episode of acute otitis media. She had a urinary tract infection when she was 10 months old, which was treated with amoxicillin successfully. What risk factor(s) for otitis media is/are present in ML? A. Female sex B. Daycare attendance C. Young sibling D. Antibiotic therapy 4 months ago E. B and C are both risk factors 2. ML has been vaccinated appropriately according to recommended childhood immunization schedules. The most likely bacterial pathogen causing her infection is: A. Streptococcus pneumoniae B. Streptococcus pyogenes C. Moraxella catarrhalis D. Staphylococcus aureus E. Influenza 3. Acute otitis media should be diagnosed in a child with which of the following signs/symptoms?

A. Middle ear effusion only 2 B. Middle ear effusion and mild erythema of the tympanic membrane C. Moderate bulging of the tympanic membrane and otalgia D. Mild erythema of the tympanic membrane, middle ear effusion, and hearing impairment for at least 72 hours E. None of these signs/symptoms are consistent with acute otitis media 4. JJ is a 13-month-old boy with bilateral acute otitis media that is not severe. He was treated for a similar episode 4 months ago with amoxicillin and developed a nonurticarial rash. Which of the following is the most appropriate treatment approach for JJ? A. Amoxicillin-clavulanate B. Azithromycin C. Cefdinir D. Clindamycin E. Observation option 5. Adjunctive therapies for acute otitis media that are effective for reducing symptoms include: A. Analgesics B. Antihistamines C. Decongestants D. Corticosteroids E. All of the above 6. Which patient is most likely to have acute bacterial rhinosinusitis?

A. 6-year-old boy with nasal discharge for 5 days and congestion for 4 days whose symptoms are improving

3 B. 18-year-old woman with persistent rhinorrhea and cough for 5 days and headache for 2 days C. 42-year-old man with nasal congestion and nasal discharge for 5 days that became purulent on day 3 D. 35-year-old woman with nasal congestion and postnasal discharge for 5 days that was initially improving but now has headache, increased discharge, and cough E. 55-year-old man with rhinorrhea and postnasal discharge for 4 weeks 7. Risk factors for acute bacterial rhinosinusitis include all of the following except: A. Viral upper respiratory tract infection B. Asthma C. Cigarette smoke exposure D. Perennial allergic rhinitis E. Intranasal medication use 8. A 39-year-old woman presents to an ambulatory care clinic with a 5-day history of nasal congestion and postnasal discharge. She tried oral phenylephrine for the last 2 days with very little relief of her congestion. Over the last 2 days, she developed right maxillary facial pain, a fever of 100.4°F (38.0°C), and a cough that is most pronounced in the morning. She reports an allergy to penicillin (“abdominal pain and diarrhea”) and she has not been treated with any antibiotics for the past 5 years. What is the most appropriate antibiotic for this patient?

A. Amoxicillin for 7 days B. Moxifloxacin for 5 days C. Azithromycin for 5 days D. Cefdinir for 7 days E. None of the above; she is not a candidate for antibiotics at this time 9. Adherence to prescribed antibiotic therapy can reduce bacterial resistance. Which antibiotic regimen would you consider using in a 10-year-old boy with acute bacterial rhinosinusitis to promote adherence?

A. Levofloxacin 500 mg every day for 5 days.

B. Clarithromycin 500 mg twice a day for 5 days.

C. Amoxicillin 500 mg twice a day for 3 days.

D. Azithromycin 500 mg every day for 3 days.

E. None of these are appropriate options for this patient.

10. Which of the following is not a goal of antibiotic therapy for streptococcal pharyngitis?

A. Minimize spread of infection to close contacts B. Prevention of rheumatic fever C. Prevention of postinfectious glomerulonephritis D. Reduce the duration of symptoms E. None of the above; they are all goals of antibiotic therapy 11. Which patient most likely has streptococcal pharyngitis?

A. A 12-month-old boy with a 1-day history of rhinorrhea, vomiting, and a temperature of 101.3°F (38.5°C) and evidence of pharyngeal erythema upon physical examination B. A 6-year-old girl with a 2-day history of sore throat, fever of 101.5°F (38.6°C), pain upon swallowing, poor oral intake, and tonsillar erythema with exudates C. A 10-year-old girl with a 2-day history of sore throat, pain upon swallowing, postnasal drip, and pharyngeal erythema

5 D. A 21-year-old male college student with a 3-day history of rhinorrhea, 2 days of cough and sore throat, and temperature of 100.1°F (37.8°C) E. A 34-year-old woman with a 2-day history of fatigue, 1-day history of sore throat, and temperature of 99.3°F (37.4°C) 12. A 7-year-old girl is diagnosed with streptococcal pharyngitis. She developed a nonurticarial rash after receiving amoxicillin for sinusitis last year. What antibiotic regimen is most appropriate for this child?

A. Penicillin VK for 10 days B. Azithromycin for 5 days C. Cephalexin for 10 days D. Trimethoprim-sulfamethoxazole for 10 days E. Clindamycin for 5 days 13. A 10-year-old girl presents to her pediatrician’s office with a 2-day history of throat pain, poor appetite, fever of 100.3°F (37.9°C), and fatigue. Her mother reports that “strep throat” has been identified at her school recently. Physical examination reveals pharyngeal and tonsillar erythema without exudates. What is the most appropriate course of action?

A. Perform a rapid streptococcal antigen detection test and treat with antibiotics if the test is positive B. Perform a throat culture and immediately initiate antibiotics because this patient is likely to have streptococcal pharyngitis C. Perform a throat culture; if it is negative, perform a follow-up rapid antigen detection test and treat with antibiotics if this test is positive 6 D. Initiate antibiotics without any diagnostic testing since her symptoms and possible exposure to streptococcal disease are sufficient to make the diagnosis E. Diagnose her with a viral upper respiratory tract infection and send her home without performing any diagnostic testing 14. A 44-year-old man presents to the pharmacy with complaints of nasal congestion, thick nasal discharge, cough, and headache for 4 days. He has a past medical history that is significant for seasonal allergies to grass and ragweed and he has had “sinus infections in the past.” What should you recommend for him?

A. Echinacea, diphenhydramine, and pseudoephedrine B. Acetaminophen, nasal saline spray, and phenylephrine C. Ibuprofen, vitamin C, and dextromethorphan D. Intranasal oxymetazoline for up to 7 days; if he is still symptomatic in a week, he should contact a health care provider E. Refer him to a health care provider for an antibiotic prescription 15. A 2-year-old girl’s mother calls her health care provider’s office for advice. Her daughter has had cold symptoms (rhinorrhea, nonproductive cough, and temperature of 100.2°F [37.9°C]) for the past 2 days. She asks what she can give to her to help her feel better so she can go back to daycare. Which of these is the best therapeutic recommendation?

A. Diphenhydramine and acetaminophen B. Dextromethorphan and guaifenesin C. Echinacea D. Air humidification and nasal saline drops

E. Pseudoephedrine and ibuprofen 7 Answers 1.

E 2. A 3. C 4. C 5. A 6.

D 7. B 8. A 9.

E 10. C 11. B 12. C 13. A 14. B 15. D

Chapter 73 1. A 4-year-old child is brought into the clinic by his mother with complaints of blisters covering his forehead, nose, and cheeks, which have gradually worsened over the last week.

His face is red, and many vesicular lesions are noted. Yellowish crusts are present where blisters have apparently ruptured. The child is diagnosed with impetigo. Which of the following statements regarding the treatment of this child’s impetigo is true?

A. Topical antibiotics, like mupirocin, should be utilized first because of their enhanced efficacy.

B. Macrolide antibiotics, such as erythromycin, are typically preferred first line because of their low rates of staphylococcal and GAS resistance.

C. Because of the potential for severe complications associated even with mild impetigo, IV antibiotic therapy is the most appropriate treatment option.

D. First-generation cephalosporins and penicillinase-stable penicillins are considered firstline treatment for this child since oral therapy is indicated.

2. A 46 year-old man with diabetes presents with a very large and painful nodule on his neck.

The nodule is draining pus from multiple hair follicles. The best management in this case is: A. Daily cleansing with soap and water, as it is most likely acne.

B. Warm moist compresses, as it is most likely folliculitis.

C. Application of a topical antibiotic, as it is most likely erysipelas.

D. Incision and drainage, as it is most likely a carbuncle.

3. SM is a 43 year-old quadriplegic man. His wife brings him into the clinic, stating that he hasn’t been feeling well lately. His appetite has been poor, and he has lost 20 lb (9 kg) in the 2 last month. SM states that he has been feeling fatigued and “a bit dizzy” at times. His temperature at the clinic is 102.2˚F (39.0°C), his blood pressure is 85/46 mm Hg, and physical examination reveals a large, stage 3 pressure sore on his sacrum, with surrounding cellulitis and necrotic debris. Which of the following risk factors for pressure ulcer development is not applicable to SM’s case?

A. Age B. Malnutrition C. Limited mobility D. Loss of sensation 4. Which of the following antibiotics is most appropriate for the treatment of SM’s condition (assume no drug allergies)?

A. Silver sulfadiazine 1% cream applied three times daily to the pressure ulcer B. Amoxicillin/clavulanate C. Vancomycin in combination with piperacillin/tazobactam D. None of the above. SM’s pressure ulcer is not infected, so no antibiotic therapy is required.

5. A 17-year-old high school athlete is seen in the clinic for redness and swelling of his right upper extremity. He is a wrestler at the local high school, and his symptoms began soon after experiencing a severe mat burn to his elbow. His arm is erythematous with poorly defined margins extending from his elbow midway to his wrist. You suspect CA-MRSA after an outbreak was recently reported by the media. Which of the following antibiotics would not be appropriate for this patient?

A. Clindamycin

3 B. Trimethoprim-sulfamethoxazole DS C. Metronidazole D. Doxycycline 6. A 46-year-old man is seen by his primary care physician for redness, mild pain, and swelling of his left lower extremity. He remembers hitting his shin on a bed frame, but denies any injury more severe than a bruise. The area is warm to the touch and has a poorly defined area of erythema extending outward from his shin around to his calf. What would be the most appropriate treatment option at this time?

A. Vancomycin B. Dicloxacillin C. Erythromycin D. Levofloxacin 7. A 64-year-old woman with multiple medical problems is hospitalized after what was presumed to be a case of CA-MRSA cellulitis. After 3 days of a 10-day course of trimethoprim-sulfamethoxazole DS, she is now experiencing fevers, chills, and significant pain in her right leg. The affected area has several blisters and bullae indicative of severe ischemia, with a gangrenous area in the center. The patient is diagnosed with necrotizing fasciitis and undergoes surgical debridement. What would be the most appropriate recommendation for her antimicrobial therapy at this time?

A. Trimethoprim-sulfamethoxazole DS should be continued, as she is only on day 3 and improvement is likely B. Discontinue trimethoprim-sulfamethoxazole DS, and begin oral levofloxacin plus clindamycin 4 C. Discontinue trimethoprim-sulfamethoxazole DS, and begin IV meropenem D. Continue trimethoprim-sulfamethoxazole DS, but add penicillin VK 8. A 44-year-old man with a 37-year history of type 1 diabetes mellitus is diagnosed with a PEDIS grade 2 diabetic foot infection. Despite the infection, he is otherwise systemically well. Which of the following statements regarding his treatment plan is true?

A. PEDIS grade 2 infections are limb-threatening, and in this case, would most appropriately be treated with IV antibiotics.

B. Because of the often inevitable immunopathic, angiopathic, and neuropathic changes associated with hyperglycemia, further preventative measures have no role in this patient.

C. Antibiotic coverage should typically be broad spectrum because of the polymicrobial nature of many diabetic foot infections.

D. Extended treatment duration of 28 days is required for resolution of most PEDIS grade 2 infections.

9. RM is a 65 year-old diabetic man who presents to the clinic with a purulent, foul-smelling, necrotic foot ulcer on his heel with cellulitis encompassing most of his foot and lower left extremity. On examination, the ulcer can be probed to the bone. His white blood cell count is 9.8 103 cell/µL (9.8 109 /L), temperature 100.2˚F (37.9°C), and SCr 0.8 mg/dL (71 µmol/L). He states that he does not feel well. He is admitted to the local hospital. Which of the following antimicrobial regimens is most appropriate for RM?

A. Moxifloxacin 400 mg by mouth every 24 hours B. Linezolid 600 mg IV every 12 hours C. Nafcillin 2 g IV every 4 hours + ceftriaxone 2 g IV every 24 hours 5 D. Linezolid 600 mg by mouth every 12 hours + ertapenem 1 g IV every 24 hours 10. Two days later, deep wound cultures reveal that the pathogen causing RM’s diabetic foot infection is Pseudomonas aeruginosa. What should be done with regard to his antimicrobial therapy?

A. No change is required. Previously selected therapy covers Pseudomonas.

B. Change to tigecycline 100-mg IV load, then 50 mg every 12 hours.

C. Change to piperacillin-tazobactam 3.375 g IV every 6 hours.

D. Change to TMP-SMX DS 2 tablets every 12 hours.

11. RM is diagnosed with osteomyelitis and undergoes surgical debridement of necrotic bone.

However, it is felt that some infected bone and/or tissue may remain. He is now on day 10 of your recommended regimen (5 days postsurgical debridement). Does RM require continuation of his antibiotic? If so, what is an appropriate duration of antibiotic therapy?

A. No. Stop therapy as 10 days is plenty, and we should minimize the risks of medication exposure.

B. Yes. Continue for 4 more days, then stop.

C. Yes. Continue for at least 2 more weeks (and possibly longer).

D. Yes. However, switch to strictly topical therapy for 4 weeks to improve wound healing.

12. A 20-year-old woman comes into the emergency department with complaints of hand pain and noticeable swelling and erythema around her wrist. She reports experiencing a cat bite 6 several days ago while house-sitting for a neighbor. Antimicrobial coverage should be provided for which of the following microorganisms?

A. Staphylococcus aureus B. Viridans streptococci C. Pasteurella multocida D. Escherichia coli 13. PL is a pregnant 23 year-old woman (38-week gestation) who presents to the emergency department 2 hours after sustaining a cat bite to her hand. On examination, a deep puncture wound is revealed, but no signs of infection are present. Which of the following prophylactic antibiotic regimens should be prescribed for this patient?

A. Doxycycline 100 mg by mouth every 12 hours for 5 days B. Amoxicillin/clavulanate 875 mg by mouth every 12 hours for 5 days C. Levofloxacin 500 mg by mouth daily + clindamycin 300 mg by mouth every 6 hours for 5 days D. Trimethoprim-sulfamethoxazole DS one tablet by mouth every 12 hours + clindamycin 300 mg by mouth every 6 hours for 5 days 14. Which of the following statements is true regarding human bite injuries?

A. Antimicrobial coverage for human bites should include Strep and Staph spp., Eikenella corrodens, and anaerobes.

B. Prophylactic antibiotic therapy for human bites is rarely warranted because infectious complications are rare.

7

C. Aggressive irrigation and cleansing of the wound should be avoided to prevent deeper tissue involvement.

D. Clenched-fist injuries are less prone to infection, and unless involvement includes broken bone, follow-up is not necessary.

15. When developing a patient care and monitoring plan for the treatment of SSTI, which of the following considerations is false?

A. Clinical manifestations and severity of infection can help determine the need for oral versus IV antimicrobial therapy.

B. Monitoring for efficacy should be based on resolution of signs, symptoms, and laboratory evidence of infection, if available.

C. Patients should be counseled on the importance of discontinuation of therapy immediately once their signs and symptoms of infection have resolved.

D. Adherence to an antimicrobial regimen is important, and in certain populations (eg, pediatrics), ease of administration and palatability of antibiotic therapy is crucial for ensuring resolution of infection.

8 Answers 1. D 2. D 3. A 4. C 5. C 6. B 7. C 8. C 9. D 10. C 11. C 12. C 13. B 14. A 15. C

Chapter 74 1. Which of the following is least likely to develop IE? A. 24-year-old male who has a history of IVDU B. 63-year-old female with a prosthetic tricuspid valve C. 32-year-old male with blood cultures positive for S. aureus for 4 days D. 41-year-old female recently discharged for a mastectomy 2. Which of the following statements is false regarding IE? A. Coagulase-negative staphylococci are the predominant organism causing PVE. B. Patients with HACEK organisms present acutely.

C. IVDUs are at an increased risk of developing IE caused by less common organisms.

D. A patient is more likely to present as a culture-negative if recently received antimicrobials.

3. Which of the following peripheral manifestations causes painless plaques when it occurs?

A. Janeway lesions B. Osler nodes C. Petechiae 2 D. Splinter hemorrhage 4. Which of the following signs/symptoms would likely be from a patient presenting with Streptococcus mitis IE? A. Fevers of 102 F (38.9 C) and chills B. Patient complaints of not feeling well for the past week C. A weight loss of 15 pounds (6.8 kg) in past month D. Petechiae on the abdominal wall 5. Which of the following is considered a major criteria in the diagnosis of IE? A. A preexisting murmur which has now become significantly worse B. A patient with an endocardial abscess C. A positive blood culture with Klebsiella pneumoniae in two separate blood cultures drawn 12 hours apart D. A patient who has a history of IV drug abuse for the past 5 years 6. Which of the following statements regarding treatment considerations is true?

A. Combination therapy is needed against all gram-positive bacteria.

B. Antimicrobial efficacy is affected by the amount of bacteria within the vegetation.

C. Surgery is only required in patients who have prosthetic valves.

3 D. Newer agents should be used in place of older traditional therapy due to better activity.

7. Which of the following antibiotic regimens would be the most appropriate for a patient with viridans group streptococcal IE (penicillin MIC < 0.0125 mcg/mL [0.0125 mg/L]) in a patient reported allergy to penicillin (rash)?

A. Ampicillin B. Penicillin G C. Cefazolin D. Ceftriaxone 8. Which of the following is the best synergistic combination for treatment of a native-valve enterococcal endocarditis caused by strains susceptible to penicillin, aminoglycosides, and

vancomycin?

A. Ampicillin plus gentamicin B. Ampicillin plus tobramycin C. Ampicillin plus rifampin D. Vancomycin plus rifampin 9. Which of the following is incorrect regarding fungal endocarditis?

A. It is more common in patients that have received a prolonged course of antibiotics.

4 B. Chance of survival is approximately 85%.

C. The most commonly associated pathogens are Candida spp. and Aspergillus spp.

D. High-dose therapy and surgery are required.

10. Which of the following types of IE would not warrant combination therapy?

A. Native valve Pseudomonas spp. IE B. Native valve Enterococcus spp. IE C. Native valve methicillin-resistant S. aureus IE D. Native valve penicillin-intermediate S. bovis IE 11. Which of the following treatments would be the MOST appropriate empiric treatment regimen for a PVE (prosthetic valve endocarditis) with S. aureus?

A. Penicillin G plus gentamicin plus rifampin for 6 weeks B. Nafcillin plus gentamicin for 4 weeks plus surgery C. Vancomycin plus gentamicin for 4 weeks plus rifampin for 2 weeks D. Vancomycin plus rifampin for 6 weeks plus gentamicin for 2 weeks 12. Which of the following treatment regimens would be the most appropriate for a patient with Kingella kingae IE? A. Penicillin G 3 million units every 4 hours for 4 weeks 5 B. Cefazolin 1 g every 8 hours for 6 weeks C. Ceftriaxone 2 g every 24 hours for 4 weeks D. Ciprofloxacin 400 mg every 12 hours for 2 weeks 13. Which of the following patients should be recommended a prophylactic regimen prior to undergoing a major dental procedure involving manipulation of gingival tissue?

A. A 4-year-old patient with repaired congenital heart defect at age 2 B. A patient with a cardiac pacemaker C. A patient who recently received coronary artery stents after a heart attack D. A patient who had streptococcal endocarditis 20 years ago 14. Which of the following would be the most appropriate oral prophylactic antibiotic for a patient who is allergic to penicillin?

A. Amoxicillin B. Ceftriaxone C. Clindamycin D. Vancomycin 15. During follow-up, which of the following should be assessed for eradication of the infection (ie, cure)?

6 A. Antimicrobial serum concentrations B. Complete blood count

C. Use of prophylactic antibiotics for appropriate dental procedures D. Physical exam Answers 1. D 2. B 3. A 4. C 5. B 6. B 7. D 8. A 9. B 10. C 11. D 12. C 13. D 14. C 15. D

Chapter 75 1. SJ is a 42-year-old man who has a yearly purified protein derivative (PPD) skin test performed because he works at a long-term care facility. Forty-eight hours after the PPD test was placed, he had a 12-mm area of induration. This is the first time he has reacted to this test. His chest radiograph is negative. Which one of the following is appropriate in view of SJ’s PPD response?

A. No treatment is necessary and SJ should have another PPD test done in 1 year.

B. Another PPD test should be performed in 1 week to see if this is a booster effect.

C. SJ should be monitored closely, but no treatment is necessary because he is over 35 years of age.

D. SJ should be started on isoniazid 300 mg daily for 6 months.

2. What LTBI treatment regimen should be recommended for patients who have a positive IFNγ test and have been exposed to isoniazid resistant TB? A. Isoniazid and rifapentine for 3 months B. Isoniazid, rifampin, and ethambutol or pyrazinamide for 4 months C. Rifampin for 4 months D. Rifampin for 6 months 3. Treatment for an HIV-positive patient with TB should: A. Be delayed until the patient’s CD4 count is more than 1000 cells/mm3 (109 /L) B. Be at least 6 months C. Consist of higher doses of antituberculosis medications D. Be initiated 6 months after antiretroviral therapy is started 2 4. Rifabutin should be chosen over rifapentine or rifampin when a patient is being treated for TB and is on certain combined antiretroviral therapy (cART) regimens because it: A. Has a better side effect profile in HIV-positive patients B. Is less likely to induce hepatic clearance of the cART drugs C. Has a lower risk of anterior uveitis in HIV-positive patients D. Is easier to obtain serum concentrations of rifabutin 5. A 70-year-old HIV positive Vietamese man was recently infected with M. tuberculosis 3 months ago. He is a current smoker and has a history of IV drug use. His past medical history includes small cell lung cancer, hypertension, and diabetes mellitis and arthritis. Which one of the following is his strongest risk factor for the development of TB disease?

A. Asian race B. Age > 65 years old C. HIV positive status D. Recent infection with M. tuberculosis 6. A 45-year-old man with chronic liver disease secondary to alcoholism is diagnosed with pulmonary tuberculosis. His AST and ALT are 100 IU/L and 56 IU/L (1.67 μkat/L and 0.93 μkat/L), respectively. He continues to drink at least six pack of beer daily. Which one of the following would be the most appropriate options for treatment of his tuberculosis at this time, in addition to more frequent monitoring of liver function tests?

A. Treat the patient with the standard four drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol)

B. Modify the patient’s regimen to exclude any hepatotoxic drugs C. Discuss abstinence during the period of treatment for TB 3 D. Administer a once weekly dosing as this is recommended in patients with elevated liver function tests.

7. A 40-year-old woman currently on treatment for tuberculosis disease comes to the pharmacy and states she shows a positive pregnancy test despite being on oral contraceptives. Which one of the following drugs most likely caused her to become pregnant?

A. Pyrazinamide B. Isoniazid C. Ethambutol D. Rifampin 8. Therapeutic drug monitoring (TDM) may be useful especially when TB patients: A. Are slow to respond to standard treatment B. Have elevated liver function tests C. Are infected with isoniazid resistant strains of TB D. Are receiving three times weekly regimens 9. An 48-year-old malnourished woman patient is started on treatment of latent tuberculosis.

Based on the CDC treatment guidelines, what is the most appropriate recommendation?

A. Vitamin B6 daily B. Vitamin B12 daily C. Vitamin B12 three times a week D. Rifampin instead of isoniazid for LTBI 10. A hospitalized patient’s sputum sample is sent to the laboratory for mycobacterial (AFB) smear and culture. The first AFB smear and IGRA is reported as negative, the culture is still pending. Which of the following would be true?

4 A. The patient does not have tuberculosis disease.

B. The culture is expected to be negative also.

C. The patient can be removed from isolation after the three AFB smears are negative.

D. The patient can be removed from isolation after the first AFB smear is negative.

11. A patient newly diagnosed culture positive pulmonary TB caused by a drug-susceptible organism has completed 2 months of initial phase treatment with isoniazid, rifampin, pyrazinamide, and ethambutol daily. He is responding well to therapy. Which of the following regimens would you recommend for continuation phase of treatment?

A. Isoniazid and pyrazinamide 4 months B. Ethambutol and rifampin 4 months C. Isoniazid and rifampin 6 months D. Isoniazid and rifampin 4 months 12. A 64-year-old man with a history of congestive heart failure is starting treatment for tuberculosis. Which one of the following anti-TB medications requires ECG monitoring if used in this patient?

A. Bedaquiline B. Cycloserine C. Pyrazinamide D. Ethambutol

13. An otherwise healthy 30-year-old woman with active TB has been anti-TB medication for the past 6 weeks (RIPE: rifampin, isoniazid, pyrazinamide, and ethambutol). However, for the past 2 weeks, she has noticed trouble reading phone numbers in the phone book and has had 5 trouble reading the newspaper. On exam, her visual acuity and red/green perception are diminished. Which of the following is the most likely cause of her symptoms?

A. Ethambutol B. Rifampin C. Isoniazid D. TB dissemination to her eyes 14. The best way to ensure TB patients take their medication is to: A. Have someone watch the patient swallow each dose of medication or DOT B. Measure serum drug levels C. Make sure the patient understands the importance of taking the medicine D. Ask patients if they are taking their medications 15. Assuming an HIV-negative patient becomes culture negative after 1 month of treatment, drug regiments that contain isoniazid and rifampin (plus 2 months of pyrazinamide) generally should be continued for a minimum of : A. 4 months B. 6 months C. 9 months D. 12 months 6 Answers 1.

D 2.

C 3.

B 4.

B 5.

C 6.

A 7.

D 8.

A 9.

A 10.

C 11.

D

12.

A 13.

A 14.

A 15.

B

Chapter 76 1. A 2-month-old male child is brought to the hospital 2 days after onset of a very watery diarrhea. His weight is noted to be 12.5 lb (5.7 kg), which is decreased from his previous recorded weight of 15 lb (6.8 kg). His blood pressure is low and his heart rate is increased.

His fontanelle and eye orbits are noted to be deeply sunken and tears are absent. His extremities are cool and mottled and his urine output is less than 1 mL/kg/h. He is noted to be lethargic upon presentation. Which one of the following therapies would be most appropriate for this patient: A. ORT at 50 mL/kg over 2 to 4 hours B. ORT at 100 mL/kg over 2to 4 hours C. D5W at 100 mL/h for 2 hours; then reassess fluid status D. Lactated Ringers at 250 mL/h for at least 6 hours E. Lactated Ringers at 20 mL/kg over 15 to 20 minutes and repeat as necessary 2. A 4-year-old child with a 3-day history of viral gastroenteritis presents to his local medical clinic with signs of severe dehydration secondary to multiple vomiting episodes. Which one of the following antiemetic agents should be considered for the treatment of this child: A. Aprepitant B. Dexamethasone C. Diphenhydramine D. Dolasetron E. Ondansetron 3. Which one of the following is least likely to be associated with shigellosis: A. Bacteremia B. Dysentery C. Fractional Stools D. Tenesmus E. Vomiting 4. Antimicrobial agents are contraindicated in which of the following infections because they may induce the expression and release of toxin, which may predispose a patient to develop hemolytic-uremic syndrome (HUS): A. Cholera B. Cryptosporidiosis C. Enterohemorrhagic E. coli D. Enterotoxigenic E. coli E. Salmonellosis 5. All of the following could be considered for the treatment of a patient with shigellosis except: A. Azithromycin B. Ceftriaxone C. Ciprofloxacin D. Fidaxomicin E. Levofloxacin 6. Two days after disembarking from a cruise ship, a 26-year-old woman presents to her local medical clinic complaining of abdominal cramping and vomiting for the past 36 hours. She states that she noted some watery diarrhea that developed the last day or so of her cruise, but now the stools are of smaller volume, but appear to be bloody. A presumptive diagnosis of shigellosis is made. Which one of the following therapies should be recommended:

2 A. Levofloxacin B. Loperamide C. Metronidazole D. Trimethoprim-Sulfamethoxazole E. No antibiotic therapy is indicated for this infection 7. Rifaximin is approved for the treatment of Traveler diarrhea (TD) caused by which one of the following organisms: A. Campylobacter B. Enterohemorrhagic E. coli C. Enterotoxigenic E. coli D. Salmonella E. Shigella 8. A vaccine is available in the United States for which one of the following infections: A. C. difficile enterocolitis B. Enterohemorrhagic E. coli C. Shigellosis D. Traveler diarrhea E. Typhoid fever 9. A 36-year-old woman presents with a 3-day history of high fevers, headaches, and bloody diarrhea. She also reports fairly significant abdominal pain and states that she thinks she might have appendicitis. She reports eating some chicken that may have been undercooked a few days previously. She also takes a proton-pump inhibitor on a daily basis for gastroesophageal reflux disease. Which one of the following should be recommended for the treatment of this patient: A. Azithromycin B. Levofloxacin C. Metronidazole D. Trimethoprim-Sulfamethoxazole E. No antibiotic therapy is indicated for this infection 10. Which one of the following is the preferred first-line drug for a patient infected with S. typhi: A. Ceftriaxone B. Ciprofloxacin C. Erythromycin D. Metronidazole E. Trimethoprim-Sulfamethoxazole 11. The cornerstone of treatment for a patient with cholera is: A. Azithromycin B. Glucose-based ORT C. Intravenous 0.9% NaCl D. Metronidazole E. Rice-based ORT 12. Which statement is false regarding C. difficile enterocolitis: A. It is caused by a gram-positive, spore-forming anaerobic organism B. A more virulent strain is now associated with many outbreaks C. Toxin production is essential for disease to occur

3 D. More than 90% of cases occur during or following antimicrobial therapy E. Infections only occur in patients who have been recently hospitalized 13. The only FDA-approved agent for the treatment of cryptosporidiosis is: A. Azithromycin B. Fidaxomicin C. Nitazoxanide D. Paromomycin E. Rifaximin 14. A patient who is on a 2-week business trip to Mexico develops an acute onset of profuse, watery diarrhea that does not appear to be bloody. He is not experiencing any abdominal cramping and no fever is present. However, the diarrhea is interfering with his scheduled business meetings. Which one of the following therapeutic options should be recommended: A. Doxycycline alone B. Loperamide + Doxycycline C. Loperamide alone D. Loperamide + Levofloxacin E. Fidaxomicin alone 15. A 66-year-old man, who has been in the ICU for 2 weeks, has recently completed a course of broad-spectrum antibiotics for ventilator-associated pneumonia. He has now developed a severe case of diarrhea that is noted to be profuse, watery, and greenish in color. He has a new-onset high fever, his white blood cell count has increased to 27,000/mm3 (27 × 109 /L), and his serum creatinine has increased to 1.8 mg/dL (159 µmol/L) from a baseline of 1.0 mg/dL (88 µmol/L). According to current clinical practice guidelines, which one of the following therapies should be recommended: A. Metronidazole 500 mg (by mouth) three times daily B. Metronidazole 500 mg (by mouth) three times daily + Loperamide after each loose stool C. Vancomycin 125 mg (by mouth) four times daily D. Vancomycin 125 mg (by mouth) four times daily + Loperamide after each loose stool E. Vancomycin 1 gram (IVPB) every 12 hours 16. All of the following therapeutic options may be recommended for second or later recurrences of C. difficile infection (CDI) or for prevention of recurrent CDI episodes except: A. Fidaxomicin B. Metronidazole C. Rifaximin D. Tapered or pulsed oral vancomycin E. Fecal microbiota transplantation 4 Answers 1. C 2. E 3. C

4. D 5. A 6. C 7. E 8. A 9. B 10. E 11. E 12. C 13. D 14. C 15. B 16. B

Chapter 77 1. Which of the following would be considered a primary intra-abdominal infection?

A. A patient with small bowel obstruction and peritonitis after receiving chemotherapy B. A patient who was knifed in the abdomen with rupture of the intestine C. Peritonitis in a patient undergoing peritoneal dialysis D. A patient who presents with a perforated GI ulcer 2. With the phenomenon of third spacing in initial intra-abdominal infections, effective circulating blood volume increases in response to a decrease in cardiac output.

In primary peritonitis, bacteria enter the abdomen via the bloodstream, lymphatic system by which of the following mechanisms?

A. Via a peritoneal dialysis catheter B. Via perforation of the GI tracts C. Via fallopian tube transfer D. All of the above 3. In patients with secondary peritonitis, bacteria may enter the abdomen via which of the following: A. Through a hemodialysis catheter B. Through the damage done to the GI tract by blunt trauma C. Through the bloodstream when there is damage to the GI tract D. Through a peritoneal dialysis catheter 4. Community-acquired complicated intra-abdominal infections can be treated with the following agent(s) for a high-severity infection: A. Ampicillin-sulbactam B. Ticarcillin-clavulanate C. Amoxicillin-clavulanate D. Piperacillin-tazobactam 5. A patient has been undergoing continuous ambulatory peritoneal dialysis (CAPD) and presents with cloudy dialysate, an intermittent, mild fever, and an elevated WBC. The most important factor(s) to consider when selecting an initial antimicrobial agent is (are): A. The dialysis centers and the patient’s history of infecting organisms and their

sensitivities B. How long the patient has undergone CAPD and the time interval since their last infection C. The extent of the patient’s residual renal function D. The modality of dialysis (CAPD or APD) 6. A 46-year-old immunocompromised man is diagnosed with a perforated peptic ulcer.

What is the first-line treatment for this patient?

A. Clindamycin B. Metronidazole 2 C. Cefepime D. Cefazolin 7. What is the most efficacious treatment for an IAI in a cirrhotic patient who is found to have a primary bacterial peritonitis?

A. Source control with appropriate drainage B. Correct antimicrobial agent C. Fluid therapy D. None of the above 8. An acceptable initial IP empiric antimicrobial therapy for a 35-year-old with spontaneous bacterial peritonitis and a history of rash with cephalexin is: A. Cefazolin plus ceftazidime (LD 500 mg/L, MD 125 mg/L for each) B. Tobramycin (LD 8 mg/L, MD 4 mg/L) C. Vancomycin (LD 1000 mg/L, MD 25 mg/L) D. Imipenem-cilastatin (LD 250 mg/L, MD 50 mg/L) 9. Penetrating abdominal trauma resulting in acute bacterial peritonitis can be treated with oral antimicrobial therapy with the following: A. Levofloxacin plus metronidazole B. Ciprofloxacin C. Levofloxacin plus amoxicillin-clavulanate D. Moxifloxacin 10. The appropriate duration of treatment for most secondary intra-abdominal infections of mild to moderate severity is: A. 24 hours B. 10 days C. 3 days D. 4 to 7 days 11. The main consideration for not adding an aminoglycoside in a patient with an IAI is the following adverse effect?

A. Hepatotoxicity B. Neurotoxicity C. Cardiotoxicity D. Nephrotoxicity 12. In a patient that requires treatment for acute cholangitis who is allergic to penicillin, the most appropriate agent is: A. Aminoglycoside with clindamycin B. Aminoglycoside with ampicillin

C. Aminoglycoside with vancomycin D. Aminoglycoside with metronidazole 13. A 70-year-old is undergoing peritoneal dialysis for chronic renal failure. His urine output is 500 mL/24 hours. He has developed mild abdominal cramping with slight fevers. What is the best empiric regimen for this patient?

A. Vancomycin (loading dose [LD] 1000 mg/L, maintenance dose [MD] 250 mg/L) B. Cefepime [LD 250 mg/L, MD 125 mg/L] C. Ceftazidime [LD 500 mg/L, MD 125 mg/L] plus cefazolin [LD 500 mg/L, MD 250 mg/L] D. Gentamicin [LD 8 mg/L, MD 4 mg/L] plus cefazolin [LD 500 mg/L, MD 125 mg/L] 3 14. Drug XY is being reviewed for addition to your hospital formulary. What is the most important consideration in its indication for IAIs as you review and vote?

A. Its endorsement from national/international guideline expert reviewers B. Its resistance patterns C. Its cost and adverse effect profile D. Its spectrum of microbiological activity 15. One microorganism not covered by tigecycline’s spectrum of activity is: A. E. coli B. Proteus spp.

C. Pseudomonas D. Klebsiella 4 Answers 1. C 2. A 3. B 4. D 5. A 6. D 7. B 8. A 9. A 10. D 11. D 12. C 13. D 14. A 15. C

Chapter 78 1. Plasmodium falciparum can be characterized as: A. Being associated with relapses after initial therapy B. Does not result in thrombocytopenia C. Does not co-exist with other species of plasmodium D. Is the only one that causes cerebral malaria E. Is less severe in pregnancy 2. AR is a 23-year-old US Marine who was evacuated from Liberia after he developed nausea and vomiting, abdominal pain, and high fever and chills. It was reported he had thrombocytopenia and an enlarged spleen. He was admitted to Walter Reed Hospital and treated with IV chloroquine. However, on the third day, he became delirious and his fever spiked at 41oC. This patient is most probably infected with: A. P. vivax malaria B. Yellow fever C. P. falciparum malaria D. Amebiasis E. None of the above 3. Artesunate is a derivative of: A. Pyrimethamine B. Cinchona alkaloid 2 C. Quinine D. Proguanil E. None of the above 4. Complications of falciparum malaria include the following: A. Hypoglycemia and acute renal failure B. Hepatorenal syndrome C. Agranulocytosis D. Peritonitis E. None of the above 5. Amebic liver abscess (ALA): A. Should be treated with diloxanide furoate alone.

B. Should be routinely aspirated.

C. Usually affects the right lobe of the liver.

D. Is associated with eosinophilia.

E. All the above 6. MY is a 46-year-old recent immigrant of Vietnam who has been diagnosed with amebiasis. Abdominal ultrasound indicates he may have an amebic abscess in his liver. The treatment of choice in this patient is: A. Tetracycline 500 mg three times daily for 14 days B. Chloroquine 500 mg three times daily for 21 days C. Diloxanide 500 mg three times daily for 10 days 3 D. Metronidazole 750 mg three times daily for 7 days followed by iodoquinol E. Combination of paromomycin and iodoquinol

7. TR is a 44-year-old native of Cambodia who is diagnosed with malaria which is classified as P. vivax. He is treated with atovaquone/proguanil and remains well for six months. However, soon after this period, his fever and chills recur and he has all the typical symptoms of malaria. Initially, his regimen should have also included the following drug to ensure malaria is completely eradicated.

A. Mefloquine B. Metronidazole C. Primaquine D. Doxycycline E. Iodoquinol 8. Strongyloides stercoralis hyperinfection may occur: A. In patients with hypoglycemia B. In life-threatening peritonitis C. In meningococcal meningitis D. In highly immunosuppressed patients E. All the above 9. A 51-year-old native of Brazil was diagnosed by the Centers for Disease and Prevention (CDC) with chronic T. cruzi. You may expect the following manifestations in this patient: 4 A. Cardiomyopathy B. First-degree heart block C. Arrhythmia D. “Mega” syndrome E. All the above 10.Hookworm infection (Ancylostoma duodenale): A. Is usually spread by fecal-oral route B. Diagnosed by microscopy from sample taken from perineal area C. Causes diarrhea in nonimmune subjects D. Causes bowel obstruction E. Causes injury by lytic destruction of tissue 11.BL is a 5-month-old infant brought by his mother to the clinic because lice infestation. The treatment of choice that you would suggest: A. Lindane B. Permethrin 5% C. Permethrin 1% D. Benzyl alcohol 5% E. Selsun shampoo 5 12.The following drug(s) are contraindicated /or should be used with caution in epileptics and subjects with depression.

A. Mefloquine B. Doxycycline C. Chloroquine D. Ciprofloxacin E. Metronidazole

13.Patients with scabies who do not respond readily to permethrin application, should also receive: A. Malathion B. Albendazole C. Benzyl alcohol D. Application of sulfur E. Ivermectin 14.Nephrotic syndrome is a recognized complication of: A. Giardiasis B. Plasmodium malariae C. Neurocysticercosis D. Chagas disease E. None of the above 6 15.The drug of choice for cysticercosis is: A. Albendazole B. Mebendazole C. Primaquine D. Atovaquone E. Proguanil Answers 1.D 2.C 3.E 4.A 5.C 6.D 7.C 8.D 9.E 10.E 11.C 12.A 13.E 14.B 15.A

Chapter 79 1. The preferred treatment option for an initial UTI episode in a 22-year-old female patient with normal renal function is: A. Trimethoprim-sulfamethoxazole B. Cefuroxime C. Nitrofurantoin D. Amoxicillin E. Ciprofloxacin 2. Which of the following treatments options may be used in patients with uncomplicated cystitis as a single-dose therapy: A. Ciprofloxacin B. Amoxicillin/clavulanate C. Gentamicin D. Fosfomycin E. Methenamine 3. The preferred antibiotic regimen in a male patient with pyelonephritis and concomitant urosepsis due to Pseudomonas aeruginosa is: A. Ertapenem B. Amoxicillin-clavulanic acid C. Fosfomycin D. Piperacillin-tazobactam 2 E. Gentamicin 4. The preferred regimen for patients requiring a single-dose intravenous antibiotic as supplemental therapy for treatment of pyelonephritis due to fluoroquinolone resistant E. coli is: A. Trimethoprim-sulfamethoxazole B. Ceftriaxone C. Ampicillin/sulbactam D. Ceftazidime E. Ciprofloxacin 5. Which of the following fluoroquinolone antibiotics should not be used for UTIs due to its limited urinary excretion?

A. Moxifloxacin B. Ofloxacin C. Levofloxacin D. Ciprofloxacin E. Norfloxacin 6. Decreases in a patient’s glomerular filtration rate can significantly decrease urine concentrations of all of the following antibiotics except: A. Gentamicin B. Levofloxacin 3 C. Minocycline D. Nitrofurantoin E. Trimethoprim-sulfamethoxazole

7. A 29-year-old woman who is 20 weeks pregnant has a routine clean-catch urine growth E. coli at a scheduled visit. The following are treatment options for this patient except: a. Amoxicillin-clavulanate b. Cephalexin c. Ciprofloxacin d. Trimethoprim/sulfamethoxazole e. Nitrofurantoin 8. A 26-year-old man with a fever of 39.8°C and flank pain who had a renal transplant 6 months ago and is still on high doses of immunosuppressive therapy. Blood cultures are no growth at 48 hours, but Klebsiella pneumoniae (> 200 CFU/mL [200 × 103CFU/L] ) is isolated from his clean-catch urine sample. The patient has a recent history of a long hospital and intensive care unit stay. His creatinine clearance is currently estimated to be 50 mL/min (0.83 mL/s), and is hepatic function is normal. Based on his medical history, which of the following is the most appropriate empiric antimicrobial therapy?

A. Cefazolin B. Cefepime C. Ciprofloxacin D. Doripenem E. No treatment is recommended at this time 4 9. The urine identification and susceptibility results from the previous patient return Klebsiella pneumoniae that is sensitive to all of the antibiotics listed in question 8. Which of the following antibiotics is most appropriate for this patient’s complicated UTI as outpatient treatment?

A. Cefazolin B. Cefepime C. Ciprofloxacin D. Doripenem E. No treatment is recommended at this time 10. Methenamine hippurate and methenamine mandelate are effective options for preventing recurrent UTIs due to its mechanism of action of: A. Acidifying the urine B. Conversion to the antimicrobial formaldehyde C. Preventing microbial attachment D. Increasing renal clearance of pathogens E. Recolonization of normal flora 11. The appropriate treatment for an asymptomatic 65-year-old man with an indwelling catheter, moderate renal impairment, and bacteriuria with pan-susceptible Enterobactercloacae is: A. Trimethoprim-sulfamethoxazole B. Ciprofloxacin C. Ampicillin-sulbactam 5 D. Cefepime E. Hold antibiotics and remove the catheter if possible 12. A 60-year-old woman with a urinary catheter develops symptoms of a UTI that include

fever, flank pain, elevated white blood count. The patient cannot have the catheter removed, but he is started on ciprofloxacin. The catheter be replaced: A. Immediately B. When the initial catheter is 1 week old C. When the initial catheter is 2 weeks old D. When the initial catheter is 4 weeks old E. The catheter should not be replaced as this increasing the risk of reinfection 13. For patients requiring continuous prophylaxis due to recurrent lower tract UTIs, the recommended duration for a prophylaxis course is: A. 2 weeks B. 1 month C. 3 months D. 6 months E. 1 year 14. Nitrofurantoin or fosfomycin are currently recommended over ciprofloxacin as first-line empiric agents for treatment of uncomplicated cystitis because these two agents possess: A. Limited scope of activity directed toward common uropathogens 6 B. Increased adherence potential C. Greater activity against E. coli D. Lower probability for resistance emergence in E. coli E. No differences have been shown between fluoroquinolone, nitrofurantoin, and fosfomycin treatment regimens 15. A 5-year-old girl with no significant past medical history presents to the pediatrician due to increased urinary incontinence and general complaints of back pain.

Recommend the most appropriate empiric antibiotic regimen.

A. Doxycycline B. Ertapenem C. Norfloxacin D. Amoxicillin-clavulanic acid E. Tobramycin 7 Answers 1.

C 2.

D 3.

D 4.

B 5.

A 6.

B

7.

C 8.

C 9.

C 10.

B 11.

E 12.

C 13.

D 14.

A 15.

D

Chapter 80 1. Penicillin is the drug of choice in which of the following conditions?

A. Syphilis B. Chlamydia C. Genital warts D. Chancroid 2. Which of the following agents should not be prescribed for MSM or patients with a history of recent foreign travel and a positive diagnosis of Neisseria gonorrhoeae?

A. Doxycycline B. Azithromycin C. Penicillin G D. Ofloxacin 3. Which of the following regimens is considered to be effective treatment for Disseminated Gonococcal Infection?

A. Ofloxacin 400 mg orally three times daily for 14 days B. Benzathine Penicillin 2.4 million units once weekly for 3 weeks C. Azithromycin 1 g as a one time dose D. Ceftriaxone 1 g IM or IV every 24 hours until improvement is noted 4. In which of the following stages of syphilis would fatigue, diffuse rash, fever, and a genital or perineal condyloma be observed?

A. Primary B. Secondary C. Latent Early D. Latent Late 5. If a patient has been diagnosed with primary syphilis, after how many month of treatment should a follow-up quantitative nontreponemal titer be ordered?

A. 1, 2, and 3 B. 3, 6, and 12 C. 6, 12, and 24 D. 9, 18, and 36 6. If a patient has been diagnosed with neurosyphilis and pleocytosis is present, how often should one reexamine the patient’s cerebral spinal fluid?

A. Every 3 months B. Every 4 months C. Every 5 month D. Every 6 months 7. Which dose of metronidazole should be administered for 7 days to treat trichomoniasis?

A. 250 mg orally two times daily B. 500 mg orally two times daily C. 250 mg orally three times daily D. 500 mg orally three times daily 8. Which of the following is considered an alternative choice for the treatment of trichomoniasis?

A. Tinidazole

B. Ceftriaxone C. Azithromycin D. Doxycycline 9. HPV types 6 and 11 are responsible for which of the following conditions?

A. Genital herpes B. Gential warts C. Bacterial vaginosis D. Chanchroid 10. Which of the following agents may be used during pregnancy for the treatment of HPV? A. Podofilox B. Fluorouracil C. Bichloroacetic acid D. Sinecatechins 11. Which of the following factors is used to determine choice of therapy with regard to genital warts?

A. Size of lesion B. Site of lesion C. Morphology of lesion D. All of the above 12. Which of the following is a beneficial outcome of agents used in the treatment of HSV? A. Bacterial shedding B. Healing time C. Muscle growth D. Weight loss 13. When should the initiation of HSV therapy occur for an episodic occurrence?

A. Within the first month B. When a patient becomes symptomatic with fever C. After a biopsy is performed D. Within one day of onset 14.Which is not employed during the suppressive stage of HSV treatment?

A. Cidofovir orally B. Famciclovir orally C. Acyclovir orally D. Valacyclovir orally 15. Which of the following is the preferred parenteral treatment for PID? A. Cephalexin IV four times a day B. Cefaclor by mouth three times a day C. Cefotetan IV twice a day D. Vaccine given in four injections over a period of 9 months Answers 1.

A 2.

D

3.

D 4.

B 5.

C 6.

D 7.

D 8.

A 9.

B 10.

C 11.

D 12.

B 13.

D 14.

A 15.

C

Chapter 81 Case pertaining to questions 1–6: An 82-year-old woman with no known allergies was admitted to the hospital to receive surgical and medical management for suspected osteomyelitis of the tibia. During surgical debridement, a bone biopsy was obtained for culture and histopathology.

The microbiology laboratory reported Staphylococcus aureus, susceptible to vancomycin, linezolid, daptomycin, trimethoprim-sulfamethoxazole but resistant to penicillin, oxacillin, ciprofloxacin, erythromycin, and clindamycin.

1. Select an appropriate intravenous antimicrobial regimen for this patient.

A. Linezolid B. Levofloxacin C. Nafcillin D. Trimethoprim-sulfamethoxazole E. Vancomycin 2. Which laboratory parameter(s) should be monitored weekly in this patient receiving intravenous antibiotic therapy?

A. Liver function tests B. BUN/SCr C. Vancomycin trough D. A and B E. B and C 3. Response to therapy can be evaluated by the following laboratory test(s): A. CPK 2 2 B. CRP C. ESR D. A and B E. B and C 4. Following 3 weeks of intravenous therapy with clinical improvement, the clinician would now like to switch to oral therapy. What do you recommend?

A. Daptomycin B. Linezolid C. Levofloxacin D. Trimethoprim-sulfamethoxazole E. Vancomycin 5. Which laboratory parameter should be monitored weekly with this oral regimen?

A. Amylase/lipase B. BUN/SCr C. CBC D. CPK E. LFT 6. What is the minimum duration of therapy for this patient according to Infectious Diseases Society of America (IDSA) guidelines?

A. 4 weeks B. 6 weeks C. 8 weeks

D. 3 months 3 3 E. 6 months Case pertaining to questions 7–10: An 8-year-old boy with a sulfa allergy presents to the emergency department with worsening signs and symptoms of cellulitis. He is on day 5 of cephalexin therapy. The medical team has ordered laboratory tests and imaging studies for suspected osteomyelitis.

7. Which imaging study(s) would be appropriate for diagnosis in this patient?

A. X-ray B. MRI C. CT scan D. A and B E. All of the above 8. Osteomyelitis can be definitely diagnosed by: A. Isolation of organism(s) from bone biopsy B. Isolation of organism(s) from sinus tract C. Positive imaging test and elevated ESR D. A and B E. B and C 9. The route of infection in this patient is most likely.

A. Acute B. Chronic C. Contiguous with vascular insufficiency D. Contiguous without vascular insufficiency E. Hematogenous 4 4 10. Blood cultures (two sets) obtained in the emergency department were positive for S. aureus. Sensitivity data were as followings: susceptible to clindamycin, levofloxacin, linezolid, trimethoprim-sulfamethoxazole and vancomycin, but resistant to penicillin, oxacillin, and erythromycin. Disk diffusion test (D-test) was reported as negative. The patient was admitted for intravenous therapy and is now being discharged on oral therapy.

Which oral regimen would you recommend for this patient?

A. Clindamycin B. Doxycycline C. Levofloxacin D. Rifampin E. Trimethoprim-sulfamethoxazole and rifampin Case pertaining to questions 11–15: A 57-year-old man (Ht 183 cm [6’]; Wt 103 kg [227 lb]) with noninsulin-dependent diabetes and a nonhealing foot ulcer presents to the clinic with pain, redness, and swelling around the ulcer. An x-ray of the foot shows bone destruction consistent with osteomyelitis. Pertinent laboratory values: BUN 19 mg/dL (6.8 mmol/L); SCr 1.2 mg/dL (106 µmol/L). He has no known allergies.

11. What organism(s) should be empirically covered for this patient?

A. Gram-positives

B. Gram-negatives C. Gram-positives and anaerobes D. Gram-negative and anaerobes E. Gram-positives, gram-negatives, and anaerobes 5 5 12. Select an appropriate empiric antimicrobial regimen for this patient.

A. Aztreonam and vancomycin B. Ceftazidime and vancomycin C. Ciprofloxacin and vancomycin D. Metronidazole and vancomycin E. Piperacillin/tazobactam and vancomycin 13. If the patient begins vancomycin therapy, what dosage regimen would you recommend?

A. 1000-mg IV infusion every 8 hours B. 1000-mg IV infusion every 12 hours C. 1000-mg IV infusion every 24 hours D. 1500-mg IV infusion every 12 hours E. 1500-mg IV infusion every 24 hours 14. If you want to ensure therapeutic vancomycin concentration(s), what monitoring parameter(s) should be performed?

A. Obtain trough after first dose B. Obtain trough at steady-state C. Obtain peak after first dose D. Obtain peak at steady-state E. Obtain both peak and trough at steady-state 6 6 15. The clinician discharged the patient on daptomycin to be administered once daily in the infusion clinic. Which laboratory parameter should be monitored weekly?

A. Amylase/lipase B. BUN/SCr C. CBC D. CPK E. LFT 7 7 Answers 1.

E 2.

E 3.

E 4.

B 5.

C 6.

C 7.

D 8.

A 9.

D 10.

A 11.

E 12.

E 13.

D 14.

B 15.

D

Chapter 82 1. AB is a 75-year-old patient who presents from his nursing home with a urinary tract infection.

He is febrile with a temperature of 39.1oC, a heart rate of 102 beats/min, respiratory rate of 12 breaths/min, and a blood pressure of 135/75 mm Hg. Which of the following does AB meet criteria for?

A. Systemic inflammatory response syndrome (SIRS) B. Bacteremia C. Septic shock D. Disseminated intravascular coagulation (DIC) 2. Select the laboratory test(s) that should be ordered for AB. A. Complete blood count with differential B. Comprehensive metabolic panel C. Urinalysis with culture and gram stain D. All of the above 3. AB’s blood pressure begins to decline. His current blood pressure is 101/50 mm Hg and you wish to administer a fluid challenge. What type of fluid(s) do you recommend?

A. 25% albumin B. Crystalloids C. Hydroxyethyl starch D. 5% dextrose 4. Select the target goal for fluid resuscitation.

A. Central venous pressure 8 to 12 mmHg (1.1–1.6 kPa) B. Mean arterial pressure greater than or equal to 65 mm Hg (8.6 kPa) C. Urine output greater than or equal to 0.5 mL/kg/h D. All of the above 5. AB is diagnosed with a urinary tract infection and is ordered to start antibiotics. What should be ordered and completed prior to initiation of antibiotics (if possible)?

A. Stress ulcer prophylaxis B. DVT prophylaxis C. Microbiologic cultures D. Norepinephrine 6. Despite appropriate fluid resuscitation, AB remains hypotensive and his current blood pressure is 90/45 mm Hg. Which vasopressor agent do you recommend to initiate?

A. Norepinephrine B. Dopamine C. Epinephrine D. Phenylephrine 7. After initiating norepinephrine, AB continues to require increasing dose titrations and his MAP remains < 65 mm Hg (8.6 kPa). What other therapies can you consider adding?

A. Heparin B. Hydrocortisone C. Pantoprazole D. Albumin 8. If utilized, what daily dose of hydrocortisone is recommended?

2 A. 50 mg IV

B. 200 mg IV C. 300 mg IV D. 500 mg IV 9. The nurse approaches you to let you know that AB’s last blood glucose measurements have been high. His last two readings over the past 6 hours are 195 mg/dL (10.8 mmol/L) and 254 mg/dL (14.1 mmol/L). The nurse tells you that when she alerted the physician he told her that septic patients are often hyperglycemic and do not need intervention. What is the most appropriate recommendation?

A. Agree with the physician, no intervention needed B. When blood glucose measurements have been greater than 150 mg/dL (8.3 mmol/L) for 24 hours, initiate therapy with sliding scale insulin C. When two consecutive blood glucose measurements are greater than 180 mg/dL (10.0 mmol/L), initiate therapy with continuous infusion of regular insulin to maintain blood glucose levels between 140 and 180 mg/dL (7.8 and 10.0 mmol/L).

D. When two consecutive blood glucose measurements are greater than 180 mg/dL (10.0 mmol/L), initiate therapy with continuous infusion of regular insulin to maintain blood glucose levels between 80 and 110 mg/dL (4.4 and 6.1 mmol/L).

10. Which of the following is/are potential complications of sepsis?

A. AKI B. ARDS C. DIC D. All of the above 11. What is the threshold for the transfusion of red blood cells in patients with no other compelling indications?

A. Less than 7 gm/dL (70 g/L; 4.34 mmol/L) B. Less than 10 gm/dL (100 g/L; 6.21 mmol/L) C. Less than 12 gm/dL (120 g/L; 7.45 mmol/L) D. Less than 15 gm/dL (150 g/L; 9.31 mmol/L) 12. Select the sepsis complication that would alter the dose of renally eliminated medications.

A. ARDS B. DIC C. AKI D. Thrombocytopenia 13. What other adjunctive therapies should be initiated in mechanically ventilated patients with sepsis who do not have contraindications?

A. Deep vein thrombosis prophylaxis B. Stress ulcer prophylaxis C. Sodium bicarbonate therapy D. A and B 14. AB’s blood pressure has improved over the last 3 days and he is off vasopressors. What other therapy should be weaned at this time?

A. Heparin B. Antimicrobial therapy 3

C. Hydrocortisone D. Pantoprazole 15. Which of the following interventions have been associated with decreased mortality rates in septic patients?

A. Administration of intravenous hydrocortisone 200 mg daily as soon as shock is recognized B. Appropriate antimicrobials administered within the first hour C. Tight glycemic control targeting a blood glucose range of 80 to 110 mg/dL (4.4–6.1 mmol/L) D. A and B 4 Answers 1. A. 2. D. 3. B. 4. D. 5. C. 6. A. 7. B. 8. B. 9. C. 10. D. 11. A. 12. C. 13. D. 14. C. 15. B.

Chapter 83 1. JT is a 25-year-old asthmatic woman who presents with vaginal itching accompanied by curd-like discharge. According to her chart, she was in the clinic 2 weeks ago for uncontrolled asthma for which she was prescribed a course of oral prednisone. She was also, according to her chart, diagnosed with vulvovaginal candidiasis last year. Her reports that her symptoms are similar to those she experienced with that infection. What would you recommend for treating her infection?

A. An over-the-counter topical azole or a single dose of oral fluconazole 150mg B. Long-term suppressive therapy C. Candida cultures 2. Referring to the previous question, although JT may have other risk factors that we cannot yet identify, what known risk factor does she have?

A. Broad-spectrum antibiotic use B. Diabetes C. Sexual activity D. Systemic corticosteroid E. Altered vaginal pH 3. CS, a 42-year-old woman, presents with her fifth episode of vulvovaginal candidiasis in a year. To achieve remission, CS should be treated with: A. Oral itraconazole B. 14 days of boric acid capsules intravaginally C. Two doses of oral fluconazole 150 mg dosed 3 days apart 2 D. One dose of oral fluconazole 150 mg 4. After achieving remission, CS (from previous question) is initiated on long-term suppressive therapy. To improve adherence, the preferred treatment is: A. Miconazole cream B. Oral fluconazole C. Boric acid in gelatin capsules D. Oral itraconazole 5. RG, a 22-year-old pregnant woman, comes to the clinic complaining of vaginal itching.

This is her first pregnancy so she was unsure if this was just a “normal part of pregnancy.”

Since she is 7 months pregnant, she is having difficult seeing past her abdomen so she is seeking help determining the cause of her itching. to eat and cries more than usual. Upon examination, the practitioner notes a non-odorous discharge. Which of the following should be considered as part of her care plan: A. Amphotericin B B. Oral fluconazole C. Miconazole cream x 2 weeks D. Clotrimazole cream x 3 days 6. HA is a 40-year-old HIV-infected patient who returns to your clinic for follow-up after completing a 7-day course of topical clotrimazole for oropharyngeal candidiasis. HA admits that her symptoms have not resolved. In addition to her previous symptoms, she also has developed retrosternal pain and difficulty swallowing. Which of the following should not be considered as part of her care plan?

A. Endoscopy

3 B. Mucosal biopsy and culture C. Oral fluconazole D. Another week of topical clotrimazole 7. GT is a 28-year-old HIV-infected patient who has repeatedly been treated with fluconazole for recurrent oropharyngeal candidiasis. Despite treatment with a 2-week course of fluconazole, GT’s most recent infection did not resolve. Cultures reveal a fluconazole-resistant Candida albicans isolate. The practitioner decides to initiate daily itraconazole therapy. Therapy should be continued for: A. 2-4 weeks B. 3 months C. 10 days D. 6 months 8. While attending morning rounds, you are asked to make recommendations on two patients who have developed oropharyngeal candidiasis. One patient has leukemia and is currently in a neutropenic phase, while the other patient is status-post kidney transplant.

Which patient is at a greater risk of dissemination, therefore, requires more aggressive treatment?

A. Both patients should be treated aggressively.

B. The neutropenic patient should be treated more aggressively.

C. The transplant patient should be treated more aggressively.

D. Neither patient requires any treatment.

9. Which of the following is a recommended nonpharmacologic prevention or treatment for fungal skin infections: 4 A. Wearing tight-fitting clothing and socks B. Avoiding soap on infected area C. Wearing protective footwear in public areas D. Wearing wool clothing 10. True or false. In cases of onychomycosis, mycologic cure is only achieved when the nail looks normal so patients should be advised to continue therapy until the nail returns to its normal appearance.

A. True B. False 11. True or False. When treating tinea corporis, treatment should be stopped immediately upon symptom relief.

A. True B. False 12. True or False. Powders are the treatment of choice for hyperkeratotic lesions.

A. True B. False 13. Which fungal skin infection requires 6 weeks of therapy due to the severity of infection and inflammation?

A. Tinea pedis B. Tinea capitis C. Tinea cruris

14. Which fungal skin infection requires treatment with oral antifungal agents?

A. Tinea pedis 5 B. Tinea cruris C. Tinea capitis D. Tinea corporis 15. TS is a 50-year-old man who presents to your clinic with thick, opaque, and friable toenails. The toenails have begun to separate from the nail bed. TS has a history of hepatic failure. Which is an appropriate treatment option?

A. Nystatin ointment B. Itraconazole 200 mg twice daily for 1 week per month for 2 months C. Terbinafine 250 mg daily for 3 months D. Ciclopirox nail lacquer for 48 weeks 6 Answers 1.

A 2.

D 3.

D 4.

B 5.

C 6.

D 7.

A 8.

B 9. C 10. B 11.

B 12.

B 13. B 14.

C 15.

D

Chapter 84 1. A 44-year-old otherwise healthy patient from Tempe, Arizona, presents with a 4-week history of complaints of fever and malaise. A chest x-ray demonstrates several small nodular lesions in both lungs and mediastinal adenopathy. Based on this patient history, the most likely fungal cause of this pneumonia is: A. Histoplasma capsulatum B. Blastomycosis dermatitidis C. Coccidioidomycosis immitis D. Cryptococcus neoformans E. Aspergillus fumigatus 2. Which dosing approach (formulation ) of posaconazole will achieve the highest serum levels in a majority of patients?

A. Administer the suspension as a single daily dose B. Administer the suspension in multiple daily doses (2–4 times per day) C. Administer the suspension hour prior to or 2 hours after meals D. Administer delayed-released tablets once daily 3. Phototoxic reactions with voriconazole: A. Are not necessarily preventable with sunscreen B. Have been associated with increased risk of squamous cell carcinoma C. Typically resolve after the third day of dosing D. Occur in patients who are developing hepatotoxic reactions to voriconazole E. Are associated with trough serum concentrations greater than 5.5 mcg/mL (5.5 mg/L; 15.7 µmol/L) 4. Nephrotoxicity with amphotericin B: A. Is prevented by using lipid formulations of the drug B. Is prevented by administering saline infusions before and after doses C. Is enhanced when the drug is administered by continuous infusion D. Is enhanced with higher treatment doses and prolonged treatment E. Rarely develops in hydrated patients 5. Which antifungals pharmacokinetic properties are closely linked to pharmacogenetic differences in cytochrome P450 2C19 metabolism?

A. Fluconazole B. Voriconazole C. Itraconazole D. Posaconazole 2 6. A 56-year-old womanis admitted to the surgical intensive care unit with signs of systemic inflammatory response syndrome (SIRS), renal dysfunction, and infection following an emergency exploratory laparotomy. The patient is started on broad-spectrum antibiotics.

What is the most likely fungal pathogen in this setting?

A. Candida species B. Cryptococcus spp.

C. Aspergillus spp.

D. Coccidioidomycosis E. Mucormycosis 7. Candida krusei is considered intrinsically resistant to:

A. Echinocandins B. Fluconazole C. Itraconazole D. Voriconazole E. Posaconazole 8. A patient with acute myelogenous leukemia receiving remission induction chemotherapy develops nodular opacities and pan-sinusitis while receiving voriconazole. Serum galactomannan is negative (index 0.2). The patient’s last voriconazole trough was determined to be 2.2 mcg/mL (2.2 mg/L; 6.3 µmol/L). An examination of the mouth also reveals necrotic ulcers on the hard palate. The most likely infection in this patient is: A. Aspergillosis B. Mucormycosis C. Invasive Candidiasis D. Histoplasmosis E. Cryptococcosis 9. A patient with a prior history of successfully-treated disseminated aspergillosis has been taking voriconazole 300 mg orally twice daily for 6 months and now presents with complaints of hand and shoulder pain that has progressive worsened over the last month.

The patients symptoms are most consistent with: A. Voriconazole-associated peripheral neuropathy B. Voriconazole-associated fluoride toxicity (periostitis) C. Voriconazole-associated myotoxicity (rhabdomyolysis) D. Symptoms are unlikely to be related to voriconazole 3 10. Which of the following interventions in patients with invasive candidiasis have been identified as an independent predictor of improved survival?

A. Receipt of antifungal therapy within 6 hours of a positive culture B. Receipt of antifungal therapy before a positive culture C. Treatment with an echinocandin D. Infection with Candida tropicalis 11. Which of the following non-albicans Candida species is most likely to be resistant to both triazole and echinocandin antifungals?

A. C. parapsilosis B. C. tropicalis C. C. glabrata D. C. krusei 12. Combination antifungal therapy has been definitely proven to reduce mortality for which of the following invasive fungal infections?

A. Histoplasmosis pneumonia B. Invasive candidiasis C. Invasive aspergillosis D. Cryptocococcal meningitis 13. Which of the following strategies would be most appropriate for verifying a patient’s voriconazole exposure by therapeutic drug monitoring?

A. Check peak and trough concentrations on day 1 of therapy B. Check trough concentration on day 1 of therapy

C. Draw samples at steady state 1, 6, and 12hours after a dose to calculate the area under the curve D. Check a trough concentration after 4 to 7 days of therapy 14. Which of the following patient risk variables is associated with increased risk of mold infection?

A. Presence of a central venous catheter B. Prolonged neutropenia (ie,> 3 weeks) C. Broad-spectrum antibiotic therapy D. Residence in the Mississippi River Valley 4 15. A 54 year old afebrile ICU patient with an indwelling Foley (urinary) catheter receiving broad-spectrum antibiotic therapy has positive urine culture for C. albicans. The patient has no other evidence of infection or symptoms. What is the best treatment approach at this time: A. Start an echinocandin as the patient is at high risk for invasive candidiasis B. No treatment is indicated at this time C. Start bladder irrigations with amphotericin B (0.1 mg/L) to clear the colonization D. Start fluconazole 400 mg once daily Answers 1. C 2. D 3. B 4. D 5. B 6. A 7. B 8. B 9. B 10. C 11. C 12. D 13. D 14. B 15. B

Chapter 85 1. Which of the following antimicrobials is not recommended for use in surgical prophylaxis?

A. Ampicillin B. Cefazolin C. Ertapenem D. A and B E. A and C 2. Which of the following should be factored into selection of a surgical prophylaxis agent?

A. Type of surgical procedure B. History of MRSA infections C. Patient’s weight D. Antimicrobial spectrum E. All of the above 3. Which of the following is not true regarding surgical site infection (SSI)?

A. It is the second most common cause of nosocomial infection.

B. It increases patient length of stay and healthcare costs.

C. Up to 20% of extra-abdominal operation patients will develop an SSI. D. All of the above are true.

E. None of the above is true.

4. Choose the appropriately matched surgical procedure with antimicrobial prophylaxis.

A. Colorectal surgery, cefazolin B. Orthopedic surgery, ertapenem C. Hysterectomy, ertapenem D. Cardiothoracic, cefuroxime E. All of the above are correct.

5. Which of the following statements is true?

A. All antimicrobials should be infused 2 hours prior to first incision.

B. Most surgical site infections are caused by E. coli.

C. Surgical prophylaxis should be continued for at least 48 hours.

D. Poor surgical technique is the only reason patients get surgical site infecitons.

E. None of the above are true.

2 6. Which of the following is guideline recommended routes of administration for antimicrobial prophylaxis?

A. Topical B. Intravenous C. Oral D. A and B E. B and C 7. For which of the following patients, is cefazolin an appropriate surgical prophylaxis?

A. LD, a 32-year-old woman with a history of frequent UTIs scheduled for a hysterectomy B. WO, an 87-year-old man with a history of MSSA infection scheduled for kidney stone removal C. FN, a 59-year-old woman with a history of Lyme disease scheduled for a cardiac

bypass surgery D. All of the above E. None of the above 8. Which of the following wound classifications is correctly matched with its description?

A. Clean: controlled opening with minor technique break B. Clean-contaminated: procedures performed emergently C. Contaminated: obvious infection present D. Dirty: major spillage or technique break E. None of the above 9. Which of the following methods is not considered to reduce the risk of postoperative infection?

A. Staphylococcus aureus decolonization B. Supplemental warming C. Intensive glucose control D. 80% (0.80) inspired oxygen E. All of the above reduce the risk of postoperative infection.

10. In which of the following surgical procedures is an infection due to gram-negative bacteria most likely?

A. Vascular B. Neurosurgery C. Appendectomy D. A and C E. B and C 3 11. Which of the following have been used for MSSA/MRSA decolonization prior to surgery?

A. Chlorhexidine body wash B. Intranasal mupirocin ointment C. Cefazolin irrigation D. A and B E. B and C 12. Cefazolin is an appropriate choice for surgical prophylaxis for all of the following situations except: A. Appendectomy B. Colorectal surgery C. Hysterectomy D. A and B E. B and C 13. For which of the following reasons, should prophylactic antimicrobial therapy be continued beyond 24 hours?

A. The patient asks for continuation of therapy for 7 days as a family member has had an SSI recently.

B. The provider believes clinical evidence show that 48 hours of therapy prevents more SSIs. C. Bacteria that cause SSIs are usually not introduced into the wound until 2 to 3 days after surgery.

D. Due to surgical complications, the classification of the wound was changed to contaminated.

E. All are valid reasons for continuing antimicrobial therapy beyond 24 hours.

14. Which of the following organisms is most likely to cause an SSI in contaminated colorectal surgery?

A. Escherichia coli B. Staphylococcus aureus C. Bacteroides fragilis D. Candida albicans E. All of the above 4 15. Which of the following situations meets the CDC criteria for an SSI? A. RJ, a 33-year-old man who underwent an appendectomy 4 months ago, presents with gastroenteritis B. HT, a 67-year-old woman who underwent a hysterectomy 15 days ago, presents with suspected pneumonia C. WA, a 23-year-old man who underwent knee replacement surgery 3 months ago, presents with purulent knee drainage D. KP, an 88-year-old woman who underwent open heart surgery 34 days ago, presents with a suspected endocarditis E. None of the above 5 Answers 1.A 2.E 3.D 4.D 5.E 6.D 7.D 8.B 9.C 10.C 11.D 12.D 13.D 14.E 15.C

Chapter 86 1. What vaccine should a newborn infant receive prior to being discharged from the hospital?

A. Inactivate influenza B. Hepatitis B C. Hepatitis A D. Pertussis E. Diphtheria and tetanus toxiod 2. It is October and a pregnant woman who is 27-week gestation comes to the obstetrician’s office for a routine visit. What vaccines should she receive?

A. Inactivated influenza B. Tetanus, reduced diphtheria, and acellular pertussis C. Hepatitis B D. A and B E. All of the above 3. What vaccine should the 63-year-old grandmother of a newborn infant receive?

A. Tetanus, reduced diphtheria, and acellular pertussis B. Zoster vaccine C. Pneumococcal D. Meningococcal E. No vaccines are necessary 2 4. A 4 year old is seeing his pediatrician for a routine check-up. He received 4 polio vaccinations in the infant series. Should this child receive another polio vaccination at this visit?

A. Yes B. No 5. An 18-year-old sexually active woman is being seen by her health provider before leaving for college. When she was 12 years, she only received meningococcal and Tetanus, reduced diphtheria, and acellular pertussis vaccines. What vaccinations should she receive during this visit?

A. Human papillomavirus vaccine B. Meningococcal C. Tetanus, reduced diphtheria, and acellular pertussis D. A and B E. All of the above 6. A 5-year-old child is being seen by the pediatrician for otitis media; the child is otherwise healthy. Influenza vaccines just arrived in the pediatrician’s office. What recommendation should be made regarding this child receiving influenza vaccine during this visit?

A. Administer live attenuated influenza vaccine B. Administer inactivated influenza vaccine C. Do not vaccinate because the child is sick 3 7. A 4 year old is at the health provider’s office for a routine check-up. The child received a heart transplant 13 months ago and has not had any complications. What vaccines

should the child receive at this visit?

A. Diphtheria, tetanus, acellular pertussis B. Polio C. Measles, mumps, rubella D. A and B E. All of the above 8. A 28-year-old woman works at a health care facility that requires all employees to receive yearly influenza vaccination, but she is afraid of needles. Which influenza formulation should be recommended for this individual to receive?

A. Intranasal B. Intramuscular C. Intradermal 9. Which vaccine is most likely to cause pain at the injection site?

A. Live attenuated influenza B. Measles, mumps, rubella C. Polio D. Tetanus, reduced diphtheria, and acellular pertussis E. Varicella 4 10. A 45-year-old man was just diagnosed with Guillain-Barré syndrome. He received the influenza vaccine 5 months ago. What statement is true regarding the association of Guillain-Barré syndrome and influenza vaccine in this patient?

A. Guillain-Barré syndrome is most likely due to the influenza vaccine B. Guillain-Barré syndrome is not related to the influenza vaccine 11. A group of 50 toddlers at ta daycare center were immunized with the influenza vaccine.

Which statement is true?

A. The toddlers received the influenza vaccine B. The toddlers have immunity to the influenza vaccine strains C. Both A and B 12. A 35 year old has just had his spleen removed following a motor vehicle accident. What vaccines should be administered prior to discharge from the hospital?

A. Measles, mumps, rubella B. 23-valent pneumococcal polysaccharide C. 13-valent pneumococcal conjugate D. Tetanus, reduced diphtheria, and acellular pertussis E. Varicella 13. Administering pneumococcal conjugate vaccine to children has protected older patients from invasive pneumococcal diseases. This is an example of: A. Cocoon immunity B. Herd immunity C. Routine immunization 5 D. Targeted immunization 14. A 40-year-old man develops a fever 12 hours after receiving an inactivated influenza vaccine. The nurse explains to the man that he: A. Is having an expected reaction to the influenza vaccine

B. Got the flu from the influenza vaccine C. Will need an appointment to see a doctor 15. Which vaccine requires regular booster doses?

A. Haemophilus influenzae type B B. Hepatitis B C. Measles D. Tetanus E. Varicella 6 Answers 1.

B 2.

D 3.

A 4.

A 5.

D 6.

A 7.

E 8.

C 9.

D 10.

B 11.

C 12.

C 13.

B 14.

A 15.

D

Chapter 87 1. ML is a 56-year-old man who returns to clinic for a discussion of initiating antiretroviral treatment after being recently diagnosed.

HIV RNA = 125,000 copies/mL (125 106 copies/L) and CD4+ T-cell count = 390 cells/mm3 (390 106 /L) were obtained 2 weeks ago. The baseline HIV genotype shows NNRTI resistance. He is 6’ tall (183 cm) and weighs 176 lbs (80 kg). Today, his laboratory test results reveal a serum creatinine of 1.43 mg/dL (126 µmol/L). He is HLA-B*5701 negative.

His current medications include simvastatin 40 mg daily, hydrochlorothiazide 25 mg daily, omeprazole 20 mg, and sildenafil 50 mg daily 1 hour prior to sexual activity. He states that he prefers a regimen that requires the “least number of pills per day.”

Which regimen would be the best for this antiretroviral-naïve patient?

A. Tenofovir + emtricitabine + efavirenz B. Tenofovir + emtricitabine + rilpivirine C. Tenofovir + emtricitabine + elvitegravir + cobicistat D. Abacavir + lamivudine + dolutegravir E. Tenofovir + emtricitabine + atazanavir 2. Which of the following is/are true regarding cobicistat?

A. Cobicistat is a pharmacokinetic enhancer that is administered with raltegravir.

B. Cobicistat is an integrase inhibitor with potent antiviral activity.

2 C. Cobicistat has a very low potential for drug interactions.

D. Cobicistat is a pharmacokinetic enhancer that is administered with elvitegravir.

E. A and C 3. Which of the following recommended regimens for antiretroviral naïve patients should be avoided if the baseline HIV RNA is greater than or equal to 100,000 copies/mL (100 × 106 copies/L)?

A. Tenofovir + emtricitabine + efavirenz B. Tenofovir + emtricitabine + elvitegravir + cobicistat C. Tenofovir + emtricitabine + atazanavir + ritonavir D. Tenofovir + emtricitabine + rilpivirine E. Tenofovir + emtricitabine + dolutegravir 4. Which of the following is/are commonly associated with the use of atazanavir?

A. Neuropsychiatric events B. Hyperbilirubinemia C. Hyperphosphatemia D. A and B only E. A, B, and C 5. A patient in clinic was recently started on Atripla. Which of the following is an appropriate counseling point review prior to initiation of therapy?

A. Take this medication with a high fat meal to ensure adequate absorption 3 B. Take this medication in the morning 1 hour before breakfast C. Take this medication on an empty stomach at bedtime D. Take this medication twice daily on an empty stomach E. Take this medication at any point throughout the day, whenever you remember 6. Which of the following adverse effects are associated with the use of tenofovir?

A. Decreased bone mineral density B. Renal impairment C. Hyperbilirubinemia D. A and B E. A and C 7. ML is antiretroviral-naïve and will initiate antiretroviral therapy today. His current medications include simvastatin 40 mg daily, digoxin 0.25 mg daily, atenolol 50 mg daily, and intranasal fluticasone 100 mcg daily. Which of the following regimens is MOST likely to result in significant drug interactions with ML’s current medications?

A. Tenofovir + emtricitabine + raltegravir B. Tenofovir + emtricitabine + elvitegravir + cobicistat C. Tenofovir + emtricitabine + dolutegravir D. None of the above. Integrase inhibitors have a relatively low potential for drug interactions E. All of the above. Integrase inhibitors are potent cytochrome P450 3A4 inhibitors.

4 8. A recently diagnosed patient with a history of poorly controlled epilepsy on a stable dose of phenytoin 300 mg twice daily needs to initiate antiretroviral treatment (HIV RNA of 150,000 copies/mL [150 106 copies/L], CD4+ count of 350 cells/mm3 [350 106 /L]).

To avoid drug–drug interactions that will either decrease the efficacy of her antiretrovirals or affect her phenytoin concentrations, which preferred antiretroviral regimen could be considered?

A. Tenofovir + emtricitabine + efavirenz B. Tenofovir + emtricitabine + raltegravir C. Abacavir + lamivudine + darunavir/ritonavir D. Abacavir + lamivudine + nevirapine E. Atazanavir/ritonavir + raltegravir 9. Which of the following situations does not increase the risk of HIV transmission with vaginal intercourse?

A. Active herpes lesions B. High viral load in an HIV-infected partner C. Uncircumcised male partner D. Use of a female condom E. Sporadic condom use only 5

10. Which of the following antiretrovirals is least likely to cause significant drug–drug interactions with concomitant medications that are substrates of CYP450 cytochromes?

A. Raltegravir B. Efavirenz C. Atazanavir D. Maraviroc E. Nevirapine 11. When obtaining HIV resistance testing, which of the following should be considered?

A. Virtual phenotype is the preferred test.

B. Viral load should be greater than 1000 copies/mL (1.0 106 copies/L).

C. CD4+ count should be less than 100 cells/mm3 (100 106 /L).

D. Patients should be currently receiving or have received antiretrovirals within the past 4 weeks.

E. CD4+ count should be greater than 100 cells/mm3 (100 106 /L).

12. A woman who presents 6 weeks’ pregnant and is currently taking emtricitabine, tenofovir, and efavirenz should have which of the following changes made to her antiretroviral regimen: 6 A. Change efavirenz to a boosted PI B. Discontinue all antiretrovirals during pregnancy C. Change to zidovudine only D. Add a boosted PI to the current regimen E. Change the tenofovir to stavudine 13. Which of the following antiretrovirals is the least likely to cause hyperlipidemia?

A. Darunavir B. Efavirenz C. Saquinavir D. Atazanavir E. Indinavir 14. Which of the following regimens contains a combination of antiretrovirals that should be avoided?

A. Lamivudine + abacavir + lopinavir/ritonavir B. Didanosine + stavudine + efavirenz C. Tenofovir + lamivudine + rilpivirine 7 D. Emtricitabine + tenofovir + efavirenz E. Lamivudine + zidovudine + raltegravir 15. Risk factors for HIV infection do not include?

A. Men who have sex with men (MSM) B. Sharing needles C. Breast-feeding by an HIV-positive mother

D. Kissing E. Unprotected heterosexual vaginal intercourse 8 Answers 1.

D 2.

D 3.

D 4.

B 5.

C 6.

D 7.

B 8.

B 9. D 10. A 11. D 12. A 13. D 14. B 15. D

Chapter 88 1. Which of the following most correctly describes the pattern of cell growth in tumors according to the Gompertzian growth model?

A. The growth rate of tumor cells decreases steadily as the tumor grows larger.

B. The growth rate of tumor cells increases steadily as the tumor grows larger.

C. The growth rate of tumor cells is constant.

D. The growth rate of tumor cells follows an exponential growth pattern.

E. None of the above.

2. In the multistep model of carcinogenesis, which of the following stages is reversible and is a target for cancer prevention strategies?

A. Initiation B. Promotion C. Transformation D. Progression E. Conversion 3. Individuals homozygous for UTT1A1*28 are at an increased risk of febrile neutropenia and diarrhea and should be considered for upfront dose reduction when receiving which of the following agents?

A. Ifosfamide B. Cabazitaxel C. Regorafenib D. Irinotecan 2 E. Ramicirumab 4. All of the following agents are vesicants and are likely to produce severe tissue damage if extravasated EXCEPT: A. Doxorubicin B. Fluorouracil C. Vincristine D. Mechlorethamine E. Dactinomycin 5. Patients with NSCLC that is ALK positive as detected by an FDA-approved test would benefit from which of the following agents?

A. Vemurafenib B. Imatinib C. Crizotinib D. Cetuximab E. Ibrutinib 6. Which of the following agents produces laryngeal bronchospasm as an acute neurotoxic effect, which can be exacerbated by cold temperatures or cold food/drinks?

A. Carboplatin B. Cisplatin C. Oxaliplatin D. Paclitaxel E. Docetaxel 3

7. Patients must receive premedication prior to receiving paclitaxel to decrease the likelihood of: A. Cardiotoxicity B. Myelosuppression C. Neurotoxicity D. Renal failure E. Hypersensitivity reactions 8. How can the mechanism of a taxane best be explained?

A. Interference with microtubule assembly B. Interference with microtubule disassembly C. Formation of free radicals D. Inhibitor of thymidylate synthase E. DNA strand breakage 9. A 19-year-old patient is receiving his first cycle of chemotherapy for ALL. He is receiving methotrexate, doxorubicin, cyclophosphamide, leucovorin, mercaptopurine as part of his chemotherapy regimen. Aggressive hydration, steroids, allopurinol, and antiemetics are all prescribed as supportive care medications. Which of these identifies a potential mechanism of a major drug interaction that requires dosage modification?

A. Inhibition of xanthine oxidase B. Inhibition of dihydrofolate reductase C. Formation of free oxygen radicals D. Formation of acrolein E. Inhibition of DNA polymerase 4 10. A newly diagnosed non-small cell lung cancer patient is about to receive combination chemotherapy consisting of carboplatin and paclitaxel. The order for carboplatin is written as follows: Carboplatin AUC 6. The patient has a calculated creatinine clearance (CrCl) of 80 mL/min (1.33 mL/s) and a BSA of 2 m2 . Assuming all laboratory and clinical parameters are acceptable, what dose of carboplatin should this patient receive?

A. 6 mg B. 12 mg C. 160 mg D. 630 mg E. 1260 mg 11. Which of the following is the best treatment of diarrhea that occurs 48 hours after a dose of irinotecan?

A. Atropine 0.4 mg IV after each loose stool.

B. Diphenoxylate/atropine one tablet after each loose stool with a maximum of eight doses per 24 hours.

C. Loperamide 2 mg orally after each loose stool with a maximum of eight doses per 24 hours.

D. Loperamide 2 mg orally every 2 hours, or 4 mg every 4 hours, until the diarrhea has stopped for 12 hours.

E. There is no need to treat diarrhea in this case.

12. Patient will receive cyclophosphamide intravenously today, and then go home. What is

the most important thing to have the patient do during the next 24 hours?

A. Make sure to take loperamide 2 mg orally every 4 hours around the clock 5 B. Make sure to wash all linens at home to prevent infections C. Make sure to drink fluids and void every 4 to 6 hours D. Make sure to avoid eating fresh fruits and vegetables E. Make sure to avoid cold temperatures, foods, and drinks 13. All of the following ancillary orders are necessary when administering cisplatin chemotherapy for a typical patient EXCEPT which of the following?

A. Routine assessment of ejection fraction B. Aggressive hydration C. Aggressive prophylactic antiemetics D. Routine assessment of renal function E. Routine assessment of electrolytes 14. A patient just has been receiving chemotherapy for cancer. Since the last scan, the tumor has decreased in size by about 50%. According the RECIST 1.1 criteria, how can this patient’s response be evaluated?

A. Complete response B. Partial response C. Progressive disease D. Stable disease 15. A patient recently had surgery to remove a diagnosed breast cancer. It had invaded her lymph nodes, but her surgeon is confident he “got it all.” Treatment given to decrease the chance of recurrence, even though there is no trace of cancer left is called .

A. Primary treatment B. Neoadjuvant treatment 6 C. Adjuvant treatment D. Palliative chemotherapy E. Supportive care 7 Answers 1.

A 2.

B 3.

D 4.

B 5.

C 6.

C 7.

E

8.

B 9.

A 10.

D 11.

D 12.

C 13.

A 14.

B 15.

C

Chapter 89 1. The woman at greatest risk for developing breast cancer is: A. African American aged 53 years with no family history of breast cancer B. Canadian Caucasian aged 53 years with grandmother having a history of breast cancer C. Ashkenazi Jew aged 53 years who tested negative for BRCA 1 and 2 mutations D. Hispanic aged 53 years with a history of atypical hyperplasia and a sister with breast cancer E. Asian aged 53 years who had taken oral contraceptives between 20 and 30 years of age 2. KA, a 58-year-old partner in a large accounting firm, had an abnormal lesion measuring approximately 1.2 cm detected by mammography biopsied. Pathological review confirmed a diagnosis in invasive breast cancer. Standard testing for receptors indicated ER positive, PR negative, and HER2 (1+ by IHC). The intrinsic subtype of this patient’s breast cancer is: A. Luminal A B. Luminal B (HER2 negative) C. Luminal B (HER2 positive) D. HER2 enriched E. Basal-like 3. Complete workup of KA (previous question) indicated stage 1 breast cancer. With regards to this patient, the primary treatment modality is: A. Neoadjuvant therapy B. Surgery, sentinel node biopsy, and radiation (if BCS is performed) C. Adjuvant tamoxifen alone D. Trastuzumab monotherapy E. Trastuzumab + chemotherapy 4. If adjuvant therapy is indicated in KA (same patient), appropriate systemic treatment could include: A. Trastuzumab monotherapy (only) for 12 months B. Trastuzumab + lapatinib doublet for 12 months C. Surgical castration or LHRH agonist D. Cyclophosphamide + doxorubicin for four cycles, followed by trastuzumab for 12 months and anastrozole for 5 years E. Anastrozole for 5 years +/− cyclophosphamide/docetaxel for four cycles 5. A 36-year-old woman is diagnosed with stage 2, intrinsic subtype HER2-amplified (by FISH) breast cancer. Rational management of the disease in this patient could include: A. Pertuzumab + trastuzumab + docetaxel as first-line therapy B. Doxorubicin and cyclophosphamide with concurrent trastuzumab as systemic adjuvant therapy for four cycles; followed by trastuzumab alone to complete 1 year C. Lapatanib + trastuzumab as systemic adjuvant therapy D. Docetaxel + carboplatin + concurrent trastuzumab as systemic adjuvant therapy for four cycles; followed by trastuzumab alone to complete 1 year E. Doxorubicin + cyclophosphamide followed by 5 years of tamoxifen 2 2 6. The woman with the best overall prognosis is: A. 31 years old, stage 2, node-positive, triple-negative breast cancer B. 41 years old, inflammatory breast cancer

C. 51 years old, stage 4 (bone only metastasis), ER-positive breast cancer D. 61 years old, stage 2, HER2-positive breast cancer E. 71 years old, stage 2, sentinel node positive, ER- and PR-positive breast cancer 7. Appropriate first-line adjuvant endocrine therapy for postmenopausal women is: A. Fulvestrant B. LHRH agonist + anastrozole C. Oophorectomy D. Megestrol acetate E. Letrozole or tamoxifen 8. Surgical castration is a treatment option for ER-positive metastatic and early breast cancers.

When performed in the adjuvant setting, bilateral oophorectomy is likely to be associated with: A. Complete estrogen deprivation in postmenopausal women B. Inducing endometrial cancer in a small but significant number of premenopausal women C. Decreasing the incidence of contralateral breast cancer in premenopausal women D. Decreasing the incidence of skeletal-related events in postmenopausal women E. Reducing the risk for cardiovascular disease, cognitive impairment, and anxiety symptoms in premenopausal women 9. Estrogen deprivation, the mechanistic mode of all endocrine therapies, can be achieved by: A. Reducing circulating levels of estrogens with tamoxifen B. Blocking estrogen binding to ER with exemestane C. Inducing castrate levels of estrogens with goserelin postmenopausal women D. Downregulating ER with fulvestrant E. Inhibiting total body estrogen synthesis with ovariectomy 10. A 37-year-old woman has a large fungating mass on her left breast. Although infection is part of the differential diagnosis, tissue biopsy confirmed a diagnosis of inflammatory breast cancer.

Additional studies indicated the tumor to be ER negative, PR weakly positive and HER2 negative with no evidence of metastasis. The surgical oncologist felt that breast conserving surgery was possible depending of the response to neoadjuvant therapy. The best tumor response is likely to be achieved with: A. Whole breast irradiation B. Tamoxifen C. LHRH agonist D. Doxorubicin + cyclophosphamide followed by paclitaxel E. Doxorubicin + cyclophosphamide followed by tamoxifen 11. A 43-year-old woman was diagnosed with stage 2, HER2 overexpressing breast cancer 28 months ago. She completed six cycles of adjuvant doxorubicin + cyclophosphamide and 12 months of 3 3 trastuzumab. Follow-up imaging studies indicated two new liver lesions. Results of the liver biopsy indicated recurrent breast cancer. The patient performance status is very good. The most appropriate

strategy at this time is: A. Best supportive care only B. Resume trastuzumab monotherapy C. Doxorubicin + cyclophosphamide + trastuzumab for six cycles D. Lapatinib + pertuzumab E. Trastuzumab + pertuzumab + docetaxel 12. Treatment of elderly patients with breast cancer can, at times, be a difficult. For example, a 74-year-old grandmother is diagnosed with stage 2, luminal A breast cancer. Except for mild hypertension, severe osteoporosis and a surgically repaired hip the woman is otherwise quite active. Following surgical mastectomy, the most appropriate systemic adjuvant therapy is: A. Tamoxifen for at least 5 years B. One of the AIs for at least 5 years C. Fulvestrant for at least 5 years D. LHRH agonist E. Paclitaxel for four cycles 13. Treatment of postmenopausal women with advanced breast cancer can be even more difficult than the above situation. For example, a 67-year-old grandmother is diagnosed with hormone receptor negative, HER2 positive breast cancer. Her medical history is significant for coronary artery disease with a mild decrease in cardiac ejection fraction, hypertension, and type 2 diabetes. Of the following chemotherapy regimens, the best treatment option for this patient is: A. Gemcitabine only till disease progression or intolerable toxicity B. Low-dose doxorubicin only till disease progression or impending cardiotoxicity C. Vinorelbine + trastuzumab till disease progression D. Epirubicin + cyclophosphamide + trastuzumab till disease progression or intolerable toxicity E. Doxorubicin + paclitaxel + trastuzumab till disease progression or intolerable toxicity 14.A 44-year-old premenopausal woman was diagnosed with HER2 amplified metastatic breast cancer 7 months ago. She was being treated with the combination of trastuzumab, pertuzumab, and docetaxel when new metastasis was found in the liver which has resulted in decreased appetite, weight loss, and significant nausea. Her (ECOG) performance status is 2 and is disease related. Second-line therapy for her disease should be: A. Trastuzumab + pertuzumab + an anthracycline B. Trastuzumab + pertuzumab + bevacizumab C. Lapatinib + capecitabine D. Trastuzumab − emtansine E. Trastuzumab − emtansine + paclitaxel 4

4 15. A 48-year-old woman was diagnosed with node-positive luminal A breast cancer in January 2012. Following surgical lumpectomy and radiation, she was treated four cycles of adjuvant doxorubicin and cyclophosphamide followed by four cycles of paclitaxel because of a high recurrence score. After completing the taxane, she was started on tamoxifen with plans of switching to an AI after 2 to 3 years to complete 5 years of the AI. After 2 years of tamoxifen, which she continues to tolerate well except for hot flashes. Switching to an AI at this time may be rational and appropriate. With regards to AI therapy: A. Her menopausal status is not an issue since she is now 50 years of age.

B. Her menopausal status cannot be determined accurately because tamoxifen lowers the circulating estrogen levels.

C. Her menopausal status will be accurately reflected by LH levels soon after menopause.

D. Determination of her menopausal status is critical before AI therapy is initiated.

E. Her menopausal status is certain to be postmenopausal because prior chemotherapy almost absolutely causes chemical castration.

5 5 Answers 1.

D 2.

B 3.

B 4.

E 5.

D 6.

E 7.

E 8.

C 9.

D 10.

D 11.

E 12.

A 13.

C 14.

D 15.

D

Chapter 90 1. All of the following scenarios are consistent with a recommendation to be screened with a low-dose CT scan for lung cancer (according to the recent guidelines)?

A. A 45-year-old man who has smoked a pack a day since the age of 13 years B. A 65-year-old woman with a 40 pack–year smoking history, who quit smoking 10 years ago C. A 50-year-old coal miner whose father and brother died of lung cancer in their 60s D. All of the above fit the screening criteria E. None of the above fit the screening criteria 2. Treatment options for a patient with stage IIIb adenocarcinoma and an ECOG PS score of 3 may include all of the following EXCEPT: A. Palliative radiotherapy B. Surgical resection of a distant metastasis C. Platinum-containing doublet chemotherapy D. Single agent targeted agent E. Treatment of comorbidities to improve performance 3. A well-performing stage IV adenocarcinoma NSCLC patient with a mutation in exon 19 of the EGFR gene should be treated with: A. Cetuximab B. Cisplatin-gemcitabine C. Afatinib D. Bevacizumab E. Radiotherapy 4. Premedications to prevent nausea and vomiting with cisplatin vinorelbine should include: A. A neurokinin inhibitor B. Metoclopramide C. Promethazine D. A benzodiazepine E. Diphenhydramine 5. Which of the following is NOT considered to be an acceptable regimen for advanced stage squamous cell NSCLC? A. Carboplatin/paclitaxel B. Cisplatin/vinorelbine C. Gemcitabine/paclitaxel D. Pemetrexed/cisplatin E. Gemcitabine/docetaxel 6. Which of the following is a reasonable premedication for an EGFR-targeted therapy?

A. Dexamethasone 2 B. Doxycycline C. Fosaprepitant D. Folate and vitamin B12

E. None of the above 7. What is the standard method of evaluating NSCLC response: A. Tumor volume calculation (based on bidimensional measurements) B. RECIST criteria (longitudinal sum of lesions) C. Change in PET scan intensity (metabolic changes in tumor cells) D. Based on biomarker or genetic changes E. Change in Veterans Administration Lung Cancer Study Group stage 8. What are the goals of treatment for a patient with stage IIIb squamous histology lung cancer?

A. Improvement of quality of life B. Alleviation of symptoms C. Prolong life D. All of the above E. Cure disease 9. Which of the following is optimally treated with chemoradiotherapy?

A. Stage IA squamous NSCLC B. Stage IIB large cell NSCLC C. Stage IIIA adenocarcinoma NSCLC D. Limited stage SCLC E. Extensive stage SCLC 10. Which of the following improves survival of limited stage SCLC? A. Maintenance methotrexate B. Prophylactic cranial radiation C. Adjuvant platinum doublet and bevacizumab D. Neoadjuvant (induction) ceritinib E. All of the above 11. Which of the following patients is the best candidate for bevacizumab combined with chemotherapy?

A. Extensive stage SCLC B. Stage IIb adenocarcinoma C. Stage IV large cell NSCLC D. Stage IIIB squamous cell NSCLC E. None of the above 12. What is the prerequisite genetic mutation for ceritinib therapy?

A. BRAF mutations B. EGFR mutations C. KRAS mutations D. ALK translocations or rearrangements E. EGFR amplifications 13. Which patient is the best candidate for adjuvant cisplatin/vinorelbine?

A. 40-year-old white woman with recently resected stage IA adenocarcinoma.

B. 45-year-old African American man with recently resected stage IIB squamous cell carcinoma and negative surgical margins.

3 C. 63-year-old Caucasian woman with a PS of 3 and recently resected stage Ia large cell NSCLC. The patient was found to have a mutation in the KRAS gene in the

resected tumor.

D. 65-year-old Caucasian man with a PS of 2 and recently resected stage IB adenocarcinoma. The patient was found to have an ALK translocation in the resected tumor.

E. 45-year-old African American man with a PS of 1 and recently diagnosed stage IIIB adenocarcinoma with positive surgical margins and no identifiable mutationsin the KRAS, EGFR, or ALK genes.

14. Which subtype of NSCLC is not genotyped for a targetable EGFR or ALK mutation?

A. Neuroendocrine.

B. Large cell.

C. Squamous cell.

D. Adenocarcinoma.

E. Genotyping is not a standard for any of the above.

15. What is the most common toxicity of afatinib?

A. Neutropenia B. Diarrhea C. Hepatotoxicity D. Ocular toxicity E. Electrolyte abnormalities 4 Answers 1.B 2.C 3.C 4.A 5.B 6.A 7.B 8.D 9.D 10.B 11.C 12.D 13.B 14.C 15.B

Chapter 91 1. Which of the following is the main risk factor for the development of colon cancer?

A. Age B. Familial adenomatosis polyposis (FAP) C. Family history D. Gender E. Diabetes 2. Which of the following is a common presenting sign and symptom for colon cancer?

A. Infection B. High white blood cell count C. Change in bowel habits D. Shortness of breath E. Elevated serum creatinine 3. In which stage of colon cancer has adjuvant chemotherapy been proven to have no clinical benefit?

A. Stage I B. Stage II C. Stage III D. Stage IV 4. Stage II colon cancer with which of the following patient or tumor characteristics would likely benefit from treatment with chemotherapy?

A. Younger patients B. EGFR-positive tumors 2 C. Patient presents with bowel perforation D. KRAS mutant positive tumors E. Patient presents with a T3 lesion 5. The preferred treatment option for a patient with stage III colon cancer is: A. Combined chemotherapy and radiation followed by complete surgical resection B. Chemotherapy followed by complete surgical resection C. Complete surgical resection followed by adjuvant chemotherapy D. Curative radiation followed by adjuvant chemotherapy E. Complete surgical resection with no adjuvant therapy 6. A68-year-old man diagnosed with stage IV colon cancer (positive for KRAS mutation) is scheduled to receive chemotherapy consisting of the FOLFOX regimen. Which of the following statements regarding his treatment regimen is correct?

A. The bolus schedule of 5- fluorouracil (FU) is preferred because it is associated with a higher response rates compared with infusional 5-FU. B. EGFR inhibitors, such as cetuximab, should be added to the FOLFOX regimen.

C. FOLFIRI is the preferred regimen for first-line treatment of metastatic disease because it has superior overall survival to FOLFOX. D. The leucovorin is administered after the 5-FU in attempt to “rescue” the patient from 5-FU– associated toxicity.

E. Bevacizumab should be added to the FOLFOX regimen.

7. Which of the following treatment regimens can be used for the treatment of stage III colon cancer?

A. FOLFOX (folinic acid, 5-FU, oxaliplatin) B. FOLFOX + bevacizumab C. FOLFIRI (folinic acid, 5-FU, Irinotecan) D. FOLFIRI + bevacizumab 8. Which of the following statements regarding capecitabine-associated toxicity is correct?

A. Hand–foot syndrome and diarrhea are common toxicities.

B. Skin rashes that develop on capecitabine are associated with increased response rates.

C. Leukopenia occurs most frequently when capecitabine is administered intravenously.

D. Leucovorin is used in combination with capecitabine to prevent toxicities.

E. All of the above are correct.

9. All of the following are goals of treating metastatic colon cancer except: A. Treatment strategies should be designed to improve quality of life.

B. Treatment plans should be designed with the intent to cure the patient.

C. Treatment strategies should be designed to allow for exposure to all active agents.

D. Preventing complications from therapy is an important end point.

E. Treatment has been shown to reduce symptoms and improve survival.

10. A72-year-old woman with relapsed metastatic colon cancer after FOLFIRI therapy presents to the clinic. The decision is made to start salvage irinotecan + cetuximab chemotherapy. Which of the following is true regarding these agents?

A. Patients with mutated KRAS genes have increased response rates to cetuximab.

B. Patients who develop diarrhea have decreased response rates to cetuximab.

C. Irinotecan should not be given because the patient has already failed irinotecan as part of FOLFIRI. D. Cetuximab is more effective with irinotecan than when used as a monotherapy agent.

E. EGFR status by immunohistochemistry will assist in predicting response to therapy.

11. Which of the following pharmacogenetic tests may be useful in predicting toxicity from irinotecan?

A. DPD activity B. CEA levels C. UGT1A1 activity D. EGFR status E. KRAS status 12. For the treatment of colorectal cancer, ziv-aflibercept is FDA approved as: A. A single agent for adjuvant therapy in colorectal cancer B. A single agent therapy in metastatic colorectal cancer C. Combination therapy with FOLFIRI-based chemotherapy D. Combination therapy with bevacizumab-based chemotherapy E. Combination therapy with FOLFOX-based chemotherapy 13. Which of the following drugs requires close monitoring for the development of neuropathy during the course of therapy?

A. Bevacizumab B. Cetuximab C. Oxaliplatin D. Capecitabine

E. Irinotecan 14. The dose of regorafenib would need likely need to be decreased in a patient which of the following conditions: A. Elevated serum creatinine B. Elevated bilirubin C. On a known CYP3A4 inducer D. On concurrent antihypertensive therapy E. Elevated blood glucose 15. The following is the appropriate screening recommendation for a 52-year-old man with an average risk of colon cancer?

A. Fecal occult blood test (FOBT) annually with no further tests needed unless positive B. FOBT and flexible sigmoidoscopy both performed every 5 years C. FOBT annually and colonoscopy performed every 10 years D. FOBT and CEA levels both performed annually with colonoscopy every 5 years E. FOBT and stool DNA testing both with annual computed tomographic colonography Answers 1. A 2. C 3. A 4. C 5. C 6. E 7. A 8. A 9. B 10. D 11. C 12. C 13. C 14. B 15. C

Chapter 92 1. Which of the following is true regarding finasteride and dutasteride in the prevention of prostate cancer?

A. Dutasteride is FDA approved for prostate cancer chemoprevention.

B. Finasteride is FDA approved for prostate cancer chemoprevention.

C. Both finasteride and dutasteride are FDA approved for prostate cancer chemoprevention.

D. Neither agent is FDA approved, but the benefits and risks should be discussed with men with a normal PSA result and undergoing regular screening.

E. Neither agent is FDA approved and should not be used.

2. Which of the following does not increase the risk for prostate cancer?

A. African American ancestry B. Older age C. Benign prostatic hyperplasia D. High-fat diet E. Family history 3. Which of the following is the gold standard method for diagnosing prostate cancer?

A. Transrectal ultrasound (TRUS) B. Digital rectal examination (DRE) C. Prostate tissue biopsy D. Prostate-specific antigen (PSA) E. Bone marrow biopsy 4. Seizures are a rare, but serious adverse effect caused by which of the following medications?

A. Abiraterone 2 B. Enzalutamide C. Docetaxel D. Sipuleucel-T E. Cabazitaxel 5. Which of the following is an effective method to decrease the tumor flare syndrome associated with the first few weeks of LHRH agonist therapy?

A. Start the LHRH agonist with a loading dose to rapidly achieve steady-state levels.

B. Start an antiandrogen before the LHRH agonist and continue for the first 3 to 4 weeks of therapy.

C. Start the LHRH agonist with a 50% dose decrease, slowly titrating to a full dose over 3 to 4 weeks.

D. Alternate LHRH agonists during the first 3 to 4 months of therapy.

E. Maintain testosterone levels above castration levels.

6. A 64-year-old man with newly diagnosed metastatic prostate cancer presents to the clinic.

Which of the following would be considered standard first-line therapy?

A. Docetaxel and prednisone B. Finasteride C. Leuprolide D. Flutamide E. Supportive care alone 7. An advantage of Degarelix over leuprolide is which of the following?

A. Rapid reduction in testosterone and lack of a tumor flare

B. Improved response rates 3 C. Improved overall survival D. Oral dosing regimen E. Less expensive 8. Which of the following describes antiandrogen withdrawal?

A. Discontinuing antiandrogen therapy in a patient with prostate cancer that has progressive disease on an antiandrogen B. Adding an additional antiandrogen in a patient progressing on an LHRH agonist C. A strategy to decrease the tumor flare associated with starting an LHRH agonist D. All of the above E. None of the above 9. A 92-year-old man recently diagnosed with early stage prostate cancer is asymptomatic. His physician recommends observation. Which of the following is a rationale for recommending observation in this patient?

A. Life expectancy of less than 10 years B. Early stage prostate cancer with long expected survival C. Avoids toxicity of unnecessary therapy D. Avoids cost of unnecessary therapy E. All of the above 10. Which of the following methods of androgen deprivation therapy are effective?

A. Goserelin 10.8 mg implant every 12 weeks.

B. Leuprolide 22.5 mg depot every 12 weeks.

C. Orchiectomy.

D. All of these methods are considered equally effective.

4 E. None of these methods are effective.

11. Which of the following is TRUE regarding the treatment of metastatic hormone refractory prostate cancer with the regimen docetaxel 75 mg/m2 every 3 weeks combined with prednisone 5 mg?

A. Docetaxel is primarily renally eliminated, so dose adjustment may be required in patients with renal disease.

B. Docetaxel should only be used in patients who have had progressive disease while being treated with mitoxantrone.

C. The combination of estramustine (280 mg three times a day on days 1 to 5) and docetaxel 60 mg/m2 on day 2, every 3 weeks is more effective and has less toxicity.

D. Androgen deprivation therapy must be discontinued before starting docetaxel.

E. Docetaxel is primarily eliminated hepatically, so patients with hepatic failure may not be eligible for treatment with docetaxel.

12. Which of the following antiandrogens is FDA approved for castration-resistant prostate cancer and can be used prior to chemotherapy or following progression on chemotherapy?

A. Bicalutamide B. Enzalutamide C. Nilutamide

D. Flutamide E. Abiraterone 13. Which of the following most accurately describes adverse events associated with leuprolide?

A. Ototoxicity, mucositis, and alopecia B. Alopecia, peripheral neuropathy, and fluid retention 5 C. Hot flushes, osteoporosis, and gynecomastia D. Headache, confusion, pruritus, and fluid retention E. Nausea, mucositis, and hot flushes 14. Radium-223 improves survival and provides significant palliation of pain in which of the following scenarios?

A. Locally advanced prostate cancer undergoing curative intent radiation therapy followed by adjuvant androgen deprivation B. Local prostate cancer status postradical prostatectomy C. Initial therapy of metastatic prostate cancer prior to androgen deprivation D. Metastatic castration-resistant prostate cancer with significant bone disease and limited softtissue disease 15. Which of the following best describes the role of sipuleucel-T in the treatment of castrationresistant prostate cancer?

A. Provides significant palliation and disease response with no proven survival benefit B. Improves survival in prostate cancer, but only in patients not previously treated with chemotherapy Local prostate cancer status postradical prostatectomy C. Improves survival compared to placebo, with objective disease responses similar to placebo D. Prevents progression of skeletal-related metastases and decreases pain medication requirements 6 Answers 1. D 2. C 3. C 4. B 5. B 6.

C 7. A 8. A 9. E 10. D 11. E 12. B 13. C 14. D 15. C 1 1

Chapter 93 1. All of the following are risk factors for developing skin cancer except: A. Ability to tan easily B. Immunosuppression C. Aging D. History of squamous cell carcinoma E. Family history of melanoma 2. Which of the follow is not a proper strategy to minimizing exposure to UV rays?

A. Avoid sunlight when it is most intense during the day B. Use sunscreen that is at least SPF 30 C. Be cautious of sun exposure when surrounded by sand, snow, and water D. Application of sunscreen twice a day will provide coverage for the entire day at the beach E. The use of hats and tightly woven clothing 3. Which of the following DOES NOT match the drug’s mechanism of action?

A. IL-2 stimulates B and T cells B. Trametinib is a MEK kinase inhibitor C. Dabrafenib is a BRAF kinase inhibitor D. Pembrolizumab inhibits PD-1L of tumor cells E. Ipilimumab enhances T-cell activation and proliferation through CTLA-4 4. A 35-year-old woman diagnosed with stage IIB melanoma underwent surgical excision of the tumor with a 2-cm margin and a complete lymphadenopathy. Which of the following would be an appropriate adjuvant therapy for this patient?

A. IL-2 2 2 B. Pegylated IFN C. IFN D. Dacarbazine E. Ipilimumab 5. A 35-year-old woman is diagnosed with unresectable stage IIIC melanoma, and the decision was made to start her on dabrafenib. Six weeks into her therapy, it was noted on routine checkup that this patient had developed new lesions on her legs, and further evaluation confirmed that it is squamous cell carcinoma. What is the recommendation for the management of this patient’s therapy now?

A. Reduce the dose of dabrafenib B. Switch to IFN C. Continue dabrafenib D. Switch to ipilimumab E. Switch to IL-2 6. Which of the following is NOT a rare but serious adverse event of ipilimumab?

A. Enterocolitis B. Hepatitis C. Dermatitis D. Foot-hand syndrome E. Neuropathy 7. A 31-year-old man diagnosed with melanoma with metastasis to the brain presents to the

clinic. Genetic testing revealed that he is positive for the BRAF V600E mutation. Which of the following agents would be an appropriate therapy for this patient?

3 3 A. Ipilimumab B. Trametinib C. Vemurafenib D. Dabrafenib E. Nivolumab 8. Which of the follow therapies is NOT a preferred systemic therapy for metastatic melanoma?

A. Ipilimumab B. Nivolumab C. Pembrolizumab D. Dabrafenib + trametinib E. Interferon 9. Which of the following is a primary therapy for basal cell carcinoma?

A. Surgery B. Radiation C. Dabrafenib + trametinib D. IL-2 E. INF 10. Which of the following medications is in a REMS program?

A. Ipilimumab.

B. Pembrolizumab C. Dabrafenib D. Vemurafenib.

E. IFN 4 4 11. A patient is about to start IL-2 therapy for her metastatic melanoma in the intensive care unit at a dose of 600,000 IU/kg every 8 hours for 14 doses. Her current medications include hydrochlorothiazide 25 mg once daily for hypertension and metformin 100 mg twice daily for type II diabetes. She is also on montelukast 10 mg/day; budesonide 200 mcg, two puffs twice daily; and albuterol one or two puffs every 4 to 6 hours as needed for asthma. Which of the following orders is appropriate for this patient?

A. Discontinue all medications before starting IL-2 therapy.

B. Discontinue the medications for hypertension before starting IL-2 therapy C. Discontinue the medications for asthma before starting IL-2 therapy D. Discontinue the medication for diabetes before starting IL-2 therapy E. No changes in the medication regimen are required 12. Which of the following is an adjuvant to surgical treatment for metastatic melanoma?

A. IL-2 B. IFN C. Ipilimumab D. Dabrafenab + trametinib E. Pembrolizumab

13. Which of the following is an indication for IFN-α-2b?

A. Unresectable stage III melanoma B. Stage IV melanoma C. Adjuvant therapy after resection for bulky stage II or stage III melanoma D. Adjuvant therapy after resection for stage I melanoma 5 5 E. All of the above 14. A 65-year-old man diagnosed with superficial basal cell carcinoma on his neck presents to the clinic. Which of the following is not the best treatment option for SW? A. Radiation B. 0.5% microsphere-encapsulated fluorouracil C. Imiquimod D. Methyl aminolevulinate E. Surgical excision 15. A 72-year-old woman diagnosed with squamous cell carcinoma in situ presents to the clinic, and she will be initiated with imiquimod. Choose the true statement regarding imiquimod.

A. It is a photosensitizing agent that is activated by exposure to a light source.

B. It is an immune-modulating agent.

C. It is a chemotherapy agent.

D. It is a radiation-sensitizing agent.

E. None of the above 6 6 Answers 1. A 2. D 3. D 4. C 5. C 6. D 7. D 8. E 9. A 10. A 11. B 12. B 13. C 14. A 15. B

Chapter 94 1. What family history would suggest that patient needs to be screened for hereditary risk for ovarian cancer?

A. Having a mother and aunt diagnosed with breast cancer B. Having two cousins diagnosed with ovarian cancer C. Having a mother with breast cancer and sister with ovarian cancer D. Having a grandmother and cousin diagnosed with cervical cancer 2. Which of the following factors may increase risk of developing ovarian cancer?

A. Use of ovulation stimulatory agents B. Use of phytoestrogen nutritional supplements C. Short term use of hormone replacement therapy D. Short-term use of oral contraceptives 3. A 27-year-old woman presents to your clinic with concerns about her risk of ovarian cancer.

She wants to know what will minimize her risk of ovarian cancer. Which of the following would be the best option for a premenopausal woman with no family history of cancer to prevent ovarian cancer?

A. Regular annual pelvic examination B. Routine transvaginal ultrasonography and CA-125 level C. Oral contraceptive use D. Tubal ligation 4. A46-year-old married premenopausal woman who just completed genetic screening that revealed she is a carrier of the BRCA1 gene. She confirms she has two children and has completed her childbearing years. Which of the following would be the best option to reduce her risk of ovarian cancer?

A. Bilateral salpingo-oophorectomy B. Mastectomy C. Hysterectomy D. Long-term use of oral contraceptive 5. A28-year-old woman who has mild episodes of diarrhea associated with her irritable bowel syndrome but otherwise is in good health and feels well. She is only child but has no family history of cancer. She just received her results from her gynecologist that she has CA-125 level of 38 kU/L (lab upper limit of normal is 35 kU/L). Based on this information, what follow-up would you recommend to rule out ovarian cancer?

A. Transvaginal ultrasonography.

B. Pelvic examination.

C. Laboratory studies repeated in 6 months.

D. She does not need any additional follow-up.

6. A 64-year-old woman presents to your pharmacy for the third consecutive month “What else can I take for this indigestion and cramps?” she asks. “Nothing I take seems to be working.”

What is the most appropriate way for you to respond?

A. Recommend she continue taking the antacid and improve her diet.

B. Recommend she switch to proton pump inhibitor for 1 week and if she has no improvement, see her doctor.

C. Determine what other symptoms she may be having and offer a differential for the pain.

D. Suggest she seek medical attention because her abdominal discomfort has been a persistent problem.

E. Tell the patient she probably has ovarian cancer and should see gynecologist immediately.

7. A27-year-old woman that presented with unilateral ovarian mass on her left ovary presents to clinic. She underwent TAH-BSO tumor optimal debulking surgery with negative peritoneal washings. She was diagnosed with stage IA epithelial ovarian cancer. Which of the following would be the best adjuvant treatment for DS to receive after surgery?

A. Observation with routine 3-month follow-up examinations B. External-beam one-shot radiation C. Tamoxifen 20 mg twice daily for 5 years D. Carboplatin AUC = 5 IV every 21 days for six cycles E. Six cycles of paclitaxel 175 mg/m2 IV plus carboplatin AUC = 5 IV every 21 days 8. In a 54-year-old patient with diabetic neuropathy, what chemotherapy regimen would you recommend for first-line treatment of stage IIb epithelial ovarian cancer?

A. Paclitaxel 175 mg/m2 over 3 hours + carboplatin AUC = 5 over 1 hour B. Paclitaxel 135 mg/m2 over 24 hours +cisplatin 75 mg/m2 over 4 hours C. Paclitaxel 80 mg/m2 IV over 1 hour every week + carboplatin AUC = 6 over 1 hour on day 1 only D. Docetaxel 75 mg/m2 over 1 hour + carboplatin AUC = 5 over 1 hour E. Docetaxel 75 mg/m2 over 1 hour + cisplatin 75 mg/m2 over 4 hours 9. Aa 49-year-old woman with newly diagnosed ovarian cancer will receive paclitaxel IV/cisplatin IP on day 1 and paclitaxel IP on day 8 after surgery. What surgical complication may exclude her from receiving IP chemotherapy?

A. Blood clot in her left leg diagnosed 2 weeks postsurgery B. Bowel resection resulting in temporary ostomy C. Hypersensitivity reaction to anesthesia D. Wound infection at incision site 2 days postsurgery 10. A58-year-old woman diagnosed with stage IIc ovarian cancer, underwent TAH-BSO and optimal tumor debulking. She has completed six cycles of taxane–platinum chemotherapy with her local gynecologic oncologist. Her CT scan results are negative and CA-125 was within normal limits after completion of two cycles and has remained normal since that time.

She would like continue with maintenance chemotherapy to improve her chances of long term CR. Which of the following would be best option to recommend in her treatment planning visit?

A. Additional 3 cycles of carboplatin every 21 days B. Additional 3 cycles of paclitaxel every 21 days C. Additional 3 cycles of paclitaxel and carboplatin every 21 days D. Additional 12 cycles of carboplatin every 28 days E. Additional 12 cycles of paclitaxel every 28 days

11. A47-year-old woman with stage IIIb recurrent ovarian cancer presents for follow-up. At her chemotherapy clearance appointment, she learns she has recurrence 7 months after completion of her primary treatment with paclitaxel and carboplatin. Her CBC is within normal limits, her CrCl is 85 mL/min (1.42 mL/s), total bilirubin is 2.5 mg/dL (42.8 µmol/L), and AST is 94 IU/L (1.57 µkat/L). Which of the following would be the best chemotherapy regimen for DR to receive for her next course of treatment?

A. Bevacizumab +cyclophosphamide B. Liposomal doxorubicin C. Gemcitabine + cisplatin D. Docetaxel E. Vinorelbine 12. A71-year-old patient with recurrent platinum-sensitive ovarian cancer that is still experiencing residual neuropathy and struggled with neutropenia with her primary treatment that she completed over 18 months ago. Which of the following would be best combination chemotherapy regimen?

A. Liposomal doxorubicin + carboplatin B. Paclitaxel + carboplatin C. Gemcitabine + carboplatin D. Docetaxel + cisplatin 13. A67-year-old woman with recurrent platinum-resistant ovarian cancer presents to clinic. She is currently receiving topotecan 3 mg/m2 once a week for 3 weeks followed by a week of rest.

However, during the third cycle, she was unable to receive her dose on week 3 because she was neutropenic, requiring the dose to be held. She returns to the clinic today for consideration of cycle 4 of weekly topotecan. Her CT scan from yesterday showed a slight progression of disease. Which of the following would be the best option to proceed with her chemotherapy treatment?

A. Gemcitabine 800 mg/m2 on days 1, 8, and 15 every 21 days B. Docetaxel 75 mg/m2 IV once every 21 days C. Vinorelbine 30 mg/m2 on days 1, 8, and 15 every 28 days D. Letrozole 2.5 mg PO once daily every 28 days 14. A58-year-old woman who just completed her primary treatment for stage IIIa ovarian cancer and returns for her first 3-month follow up examination. Her CT results are negative for disease, and CA-125 is undetectable. She reports she has recovered well from the side effects of chemotherapy, but she is still struggling with hot flashes and insomnia. Which of the following would be the best option for the management of PR’s surgical menopause?

A. Hormone replacement with progesterone alone B. Hormone replacement with both progesterone and estrogen C. Venlafaxine D. Black cohosh 15. Which of the following would be best management options to relieve constipation in an ovarian cancer patient with a newly diagnosed small bowel obstruction?

A. Palliative surgery

B. Stool softeners and hydration C. Enema D. Natural stimulant laxative Answers 1. C 2. A 3. C 4. A 5. D 6. D. 7. A 8. D 9. B 10. E. 11. C 12. A 13. D 14. C 15. A

Chapter 95 1. Which of the following prognostic factors in AML is associated with the highest risk of relapse?

A. Ethnicity B. Body mass index C. Age D. Minimal residual disease 2. Which of the following agents is most frequently used as prophylaxis for the prevention of fungal infections in AML? A. Itraconazole B. Voriconazole C. Fluconazole D. Amphotericin B 3. Which of the two agents are most frequently used for the treatment of induction therapy in AML? A. Vincristine and asparaginase B. Doxorubicin and cyclophosphamide C. Cytarabine and daunorubicin D. Methotrexate and vincristine 4. The single strongest prognostic factor in ALL is: A. Age B. Initial white count C. Presence of central nervous system leukemia (CNS3) D. Early treatment response as assessed by minimal residual disease(MRD) at end of induction 5. The ALL treatment modality that is most associated with later development of secondary acute myeloid leukemia with balanced translocations is: A. Alkylating agents B. High dose methotrexate C. Clofarabine D. Epipodophyllotoxins 6. Which of the following features excludes a diagnosis of B-cell precursor ALL? A. Presence of T-cell receptor gene rearrangements B. Mediastinal mass C. WBC count > 500,000/microliter D. Expression of cytoplasmic CD3 7.Which of the following translocation is seen in Philadelphia chromosome positive (Ph+ pre Bcell ALL) ?

A. t(9;22)(q34;q11) B. t(1;19)(q23;p13) C. t(11;14)(p13;q11.2) D. t(8;22)(q24;q11) 8. Which of the following prognostic factors is most likely associated with the risk of relapse induction therapy for acute lymphocytic leukemia?

2 2

A. CNS disease at diagnosis B. DNA index greater than 1.16 at diagnosis C. Minimal residual disease 1% at the end of induction D. White blood cell count at diagnosis 6 103 /mm3 (6 109 /L) 9. Which of the following is the most frequent late side effect associated with daunorubicin?

A. Constipation B. Renal toxicity C. Cardiotoxicity D. Hyperglycemia 10. Which of the following agents would be considered an appropriate addition to therapy for a 35-year-old man with Ph+ ALL? A. Nelarabine B. Etoposide C. Dasatinib D. Dexamethasone 11. Which of the following is considered a poor prognostic factor in ALL? A. Female gender B. DNA index greater than 1.16 C. Age of 15 years at time of diagnosis D. White blood count of 5 103 /mm3 (5 109 /L) 12. Current standard systemic induction medications for a 15-year-old girl with pre–B-cell ALL, a DNA index of 1, and an initial WBC count of 55 103 /mm3 (55 109 /L) would be: A. Daunorubicin and cytarabine 3 3 B. Daunorubicin, vincristine, asparaginase, and prednisone C. Asparaginase, vincristine, and dexamethasone D. Idarubicin, vincristine, asparaginase, and dexamethasone 13. A 17-year-old boy who is now 4 years off treatment for ALL presents with anemia, thrombocytopenia, and fatigue. On bone marrow biopsy, he is found to have secondary AML. His treatment for ALL included methotrexate, cyclophosphamide, vincristine, daunorubicin, etoposide, dexamethasone, and asparaginase. Which one of the following agents is most likely to have contributed to his secondary AML? A. Dexamethasone B. Daunorubicin C. Asparaginase D. Etoposide

14. The patient is a 13 year-old boy who was treated for T-cell ALL at the age of 3 years. His treatment consisted of standard chemotherapy together with intrathecal therapy and cranial radiation for CNS prophylaxis. Which one of the following late effects is this patient most likely to have because of his CNS radiation?

A. Learning disabilities and a secondary brain tumor B. Learning disabilities and hyperthyroidism C. Learning disabilities and obesity D. Secondary brain tumor and sterility 15. A 25-year-old woman is newly diagnosed with ALL. She will receive prednisone, asparaginase, vincristine, and daunorubicin. Her laboratory values are within normal limits with the exception of a uric acid concentration of 9 mg/dL (535 µmol/L), serum creatinine 4 4 concentration of 2.1 mg/dL (186 µmol/L), and lactate dehydrogenase concentration of 950 U/L (15.8 µkat/L). Which of the following statements best describes the role of rasburicase for AB? A. Prevention of hyperkalemia and requirement of dialysis B. Prevention of tumor lysis syndrome C. Prevention of hyperkalemia and hyperphosphatemia D. Prevention of uric acid nephropathy 5 5 Answers 1.D 2.C 3.C 4.D 5.D 6.A 7.A 8.C 9.C 10.C 11.C 12.B 13.B 14.A 15.B

Chapter 96 1. First-line treatment options for newly diagnosed Ph positive chronic phase CML include: A. Bosutinib, dasatinib, and imatinib B. Bosutinib, imatinib, and ponatinib C. Dasatinib, imatinib, and nilotinib D. Imatinib, ponatinib, and omacetaxine E. Imatinib, ibrutinib, and omacetaxine 2. Bosulif is in the class of drugs known as: A. Antimetabolites B. Immunomodulatory agents C. Monoclonal antibodies D. Proteasome inhibitors E. Tyrosine kinase inhibitors 3. Patient counseling points for dasatinib include: A. Avoiding iron preparations B. Avoiding proton pump inhibitors C. Discussing hand-foot syndrome D. Discussing peripheral neuropathy E. Taking with food 4. JH is a 42-year-old man with chronic phase CML who is being treated with imatinib. He fails to achieve a complete cytogenetic response by 12 months. Which is the most appropriate treatment option?

A. Continue imatinib B. Switch to dasatinib C. Switch to ponatinib D. Switch to omacetaxine E. Switch to ibrutinib 5. CP has chronic phase CML and has not achieved a complete hematologic and cytogenetic response on first-line therapy. Mutational analysis shows the T315I mutations. Which is the most appropriate treatment option?

A. Bosutinib B. Dasatinib C. Ibrutinib D. Nilotinib E. Ponatinib 6. The tyrosine kinase inhibitors used in CML inhibit: A. BCR-ABL B. Bruton pathway C. Nuclear factor kappa B D. Phosphatidylinositol-3 E. Vascular endothelial growth factor 7. Ponatinib has been associated with an increase in: A. Arterial thrombotic events B. Peripheral neuropathy C. Pulmonary hypertension 2

2 D. Seizures E. Secondary malignancies 8. LH is an 82-year-old man who was diagnosed with chronic lymphocytic leukemia through a routine blood examination. Which statement is correct regarding his cancer?

A. Allogeneic stem cell transplantation should be considered for curative potential.

B. Combination therapy with FCR should be initiated because it is easily tolerated.

C. Observation is preferred because delaying therapy does not affect overall survival.

D. Oral chemotherapy such as chlorambucil should be initiated because it has been shown to improve overall survival when started early in the disease course.

E. Rituximab therapy should be given as maintenance therapy to further eradicate the disease.

9. Which regimen is most appropriate for a newly diagnosed 45 year old with symptomatic CLL? A. Alemtuzumab, bendamustine, and rituximab B. Chlorambucil and prednisone C. Fludarabine, cyclophosphamide, and rituximab D. Ofatumumab and ibrutinib E. Thalidomide, dexamethasone, and bortezomib 10. Black-box warnings for idelalisib’s include: A. Arterial thromboembolism and pneumonitis B. Hepatotoxicity and pneumonitis C. Hepatoxicity and progressive multifocal encephalopathy D. Progressive multifocal encephalopathy and gastrointestinal perforation E. Reactivation of hepatitis B and tumor lysis syndrome 11. Which prophylactic antimicrobial is recommended with alemtuzumab therapy?

A. Acyclovir B. Ciprofloxacin C. Metronidazole D. Pipercillan/tazobactam E. Vancomycin 12. Disease characteristics of multiple myeloma include the following: A. Anemia, cardiac complication and renal insufficiency B. Anemia, hypercalcemia and renal insufficiency C. Renal insufficiency, hypocalcemia and cardiac complications D. Renal insufficiency, osteolytic lesions and pulmonary toxicity E. Osteolytic lesions, renal insufficiency and cardiac complications 13. Which multiple myeloma maintenance therapy has been associated with an increase in secondary malignancies following stem cell transplantation?

A. Bortezomib B. Lenalidomide C. Pamidronate

D. Thalidomide 3 3 E. Zolendronic acid 14. Which drugs increase the risk of thrombotic events?

A. Bortezomib, thalidomide, and lenalidomide B. Bortezomib, carfilzomib, and thalidomide C. Bortezomib, melphalan, and prednisone D. Carfilzomib, melphalan, and lenalidomide E. Lenalidomide, thalidomide, and dexamethasone 15. The most appropriate induction regimen for a transplant eligible patient with MM is: A. Bortezomib, lenalidomide, and dexamethasone B. Bortezomib, melphalan, and thalidomide C. Carfilzomib, pomalidomide, and dexamethasone D. Melphalan, prednisone, and thalidomide E. Melphalan, prednisone, and bortezomib 4 4 Answers 1.C 2.E 3.B 4.B 5.E 6.A 7.A 8.C 9.C 10.B 11.A 12.B 13.B 14.E 15.B

Chapter 97 1. Which of the following kinase inhibitors can be used in the treatment of patients with follicular lymphoma that has progressed despite multiple chemotherapy treatments?

A. Regorafenib B.Vandetanib C.Imatinib D.Idelalisib E. Dasatinib 2. Which of the following unique toxicities are associated with the ABVD regimen?

A. Pulmonary fibrosis B. Hemorrhagic cystitis C. Hepatic encephalopathy D. Osteopenia E. All of the above 3. For a patient presenting with lymphadenopathy and a suspected diagnosis of lymphoma, the most appropriate diagnostic test would be: A. Abdominal x-ray B. Fine-needle aspirate C. Surgical lymph node excision D. Bone scan E. Serum protein electrophoresis 4. Which of the following prophylactic medications should be administered before the infusion of single-agent rituximab?

A. Diphenhydramine B. Filgrastim C. Ondansetron D. Allopurinol E. Fosaprepitant 5. Which of the following agents should not be administered intrathecally for a patient with primary CNS lymphoma?

A. Cytarabine B. Vincristine C. Methotrexate D. Hydrocorotisone E. All of these medications can be administered intrathecally 6. Which of the following is not a negative prognostic factor in advanced Hodgkin lymphoma?

A. Platelets < 100,000/µL (100 × 109/L) B. WBCs > 15,000/mm3 (15 × 109/L) C. Stage IV disease D. Male gender E. Albumin < 4 g/dL (40 g/L) 7. Standard chemotherapy for front-line treatment for advanced (stage III/IV) diffuse large B-cell lymphoma is: A. m-BACOD B. PROMACE-CytaBOM C. Rituximab + bendamustine

D. CHOP E. Rituximab + CHOP 8. What is the most common type of lymphoma?

A. Hodgkin lymphoma B. Follicular lymphoma C. Diffuse large B-cell lymphoma D. Mantle-cell lymphoma E. Burkitt lymphoma 9. Which of the following can be used with rituximab as single agent chemotherapy in the treatment of follicular lymphoma?

A. Dacarbazine B. Bendamustine C. Doxorubicin D. Vincristine E. Mechlorethamine 10. A 47-year-old woman with a new diagnosis of bulky, unfavorable stage II HL would most likely be treated with which of the following: A. Extended field radiation B. Brentuximab C. High-dose chemotherapy followed by a stem cell transplant D. Stanford V E. Dose-escalated BEACOPP 11. Reasonable therapeutic options for patients with newly diagnosed stage III/IV follicular NHL include all of the following except: A. Cyclophosphamide, vincristine, prednisone, and rituximab B. Bendamustine and rituximab C. Cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab D. Fludarabine and rituximab E. Ibritumomab-yttrium 90 12. The defining histopathologic cell for Hodgkin lymphoma is: A. Transformed cytotoxic T cell B. Malignant NK cell C. Reed-Sternberg cell D. CD33 + clonal B cell E. Pluripotent stem cell 13. Hodgkin lymphoma is most consistently associated with which of the following?

A. Rhinovirus B. Epstein-Barr virus C. Influenza virus D. Adenovirus E. Cytomegalovirus 14. Which of the following monoclonal antibodies is used in the treatment of Hodgkin lymphoma?

A. Gemtuzumab ozogamicin B. Rituximab C. Brentuximab vedotin

D. ibritumomab-yttrium 90 E. Pertuzumab 15. Which of the following is a chemotherapy regimen utilized in the treatment of relapsed diffuse large B-cell lymphoma?

A. rCHOP B. MOPP C. Stanford V D. ESHAP E. rCEOP 6 6 Answers 1. D 2. A 3. C 4. A 5. B 6. A 7. E 8. C 9. B 10. D 11. E 12. C 13. B 14. C 15. D

Chapter 98 1. Which of the following statements is false regarding mobilization of peripheral blood progenitor cells (PBPCs) for autologous transplant?

A. The combination of chemotherapy with filgrastim enhances PBPC mobilization relative to filgrastim alone B. Apheresis is continued daily until the target number of PBPCs per kilogram of the recipient’s weight is obtained C. For adult recipients, the number of CD34+ cells does not correlate with time to engraftment D. Lower yield of CD34+ cells is associated with administration of stem cell toxic drugs and intensive prior chemotherapy or radiotherapy 2. The donor may experience bone pain with growth factor injections Which of the following statements is true regarding the different graft sources for allogeneic transplant?

A. PBPC grafts contain less T and B cells than bone marrow grafts and therefore a decreased risk of graft-versus-host disease B. A bone marrow graft is associated with quicker neutrophil and platelet engraftment C. Umbilical cord blood transplants are limited by the inability to use donor-lymphocyte infusions in the event of relapse.

D. Adult patients are not eligible for umbilical cord blood transplants E. T-cell-depleted grafts reduce the incidence of GVHD with similar incidence of graft failure and relapse 3. A 45-year-old woman who presents with non-Hodgkin lymphoma in second complete remission. You are explaining the rationale related to myeloablative preparative regimens for autologous hematopoietic stem cell transplantation (HSCT). Which of the following statements is true regarding the use of HSCT for this patient?

A. Myeloablative regimens result in mixed donor chimerism B. The anti-lymphoma effect is mediated by high chemotherapy doses C. The antilymphoma effect is mediated by high chemotherapy doses and a graft-versustumor (GVT) effect D. Low chemotherapy doses are needed to ensure engraftment with subsequent GVT effects E. High chemotherapy doses are needed for successful engraftment 4. When counseling a patient regarding potential toxicities of busulfan and fludarabine when used as a preparative regimen for HSCT, which of the following potential adverse effects should not be discussed?

A. Seizures B. Nausea and vomiting C. Sinusoidal obstructive syndrome (SOS) D. Hepatotoxicity E. All of the above should be discussed 5. Which of the following statements is false regarding the use of total body irradiation containing preparative regimens?

A. TBI is effective against disease in sanctuary sites such as the central nervous system and testes

B. Cataracts are one of the long-term toxicities of TBI C. TBI is a component of both myeloablative and nonmyeloablative preparative regimens D. TBI does not result in active metabolites that may interfere with the activity of donor hematopoietic cells E. All of the above are true statements 6. A 65-year-old man is undergoing a nonmyeloablative HSCT from a HLA-matched sibling donor for acute myeloid leukemia in first complete remission per a clinical trial.

His preparative regimen consists of fludarabine and busulfan. Which of the following statements are true regarding nonmyeloablative transplants?

A. The nonmyeloablative preparative regimen completely eliminates host normal and malignant cells B. Autologous recovery will never occur if the graft is rejected C. After chimerism develops, donor-lymphocyte infusion can be administered safely in patients without GVHD to eradicate malignant cells D. Adverse effects are more likely with nonmyeloablative regimens compared to myeloablative regimens E. Nonmyeloablative regimens are not recommended in older patients 7. Which of the following pharmacokinetic and pharmacodynamic relationships have been observed in HSCT patients?

A. Busulfan area under the curve (AUC) and sinusoidal obstruction syndrome (SOS) in those receiving BU/CY B. Cyclosporine trough concentration and nephrotoxicity C. SOS and the AUC of cyclophosphamide metabolites D. CYP 3A4 interactions with tacrolimus E. All of the above 8. Which of the following are appropriate scenarios for antifungal prophylaxis in the HSCT setting?

A. Fluconazole 400 mg orally daily beginning day +1 after HSCT B. Posaconazole 200 mg orally three times per day in patients with grade II-IV gastrointestinal GVHD receiving total parenteral nutrition C. Itraconazole 200 mg orally twice daily beginning with administration of busulfan and cyclophosphamide preparative regimen prior to HSCT D. Voriconazole 200 mg orally twice daily beginning day +5 after autologous HSCT E. All of the above are acceptable antifungal prophylaxis regimens for given scenarios 9. A 34-year-old man is on day +35 after receiving cyclophosphamide/total body irradiation preparative regimen who complains of new onset diarrhea and rash. Graft-versus-host disease prophylaxis includes tacrolimus 2 mg orally twice daily (concentration: 2 ng/mL), and methotrexate 15 mg/m2 administered on day +1 and 10 mg/m2 on days +3, +6, and +11. A skin biopsy is performed and reveals Grade II-IV GVHD. The recommended treatment is: A. Increase tacrolimus to 3 mg orally twice daily and check trough in 2 to 3 days; add methylprednisolone 2 mg/kg/day B. Methylprednisolone 2 mg/kg/day and discontinue tacrolimus C. Increase tacrolimus to 3 mg orally twice daily and add sirolimus

D. Add mycophenolate 15 mg/kg per dose twice daily E. Add antithymocyte globulin (ATG) 10. Plerixafor is indicated in which of the following scenarios?

A. Allogeneic transplant with a matched sibling donor B. In combination with granulocyte colony stimulating factor in preparation for autologous transplant for acute leukemia C. To mobilize PBPCs for collection and subsequent autologous transplantation for NHL and MM D. Alternative mobilization strategy for patients with an allergy to filgrastim E. None of the above 11. Which of the following statements is false regarding the management of viral infections during allogeneic HSCT? A. Patients undergoing myeloablative HSCT are at highest risk for herpes simplex virus from days 0 to 30 after HSCT B. Preemptive therapy for CMV includes initiating ganciclovir upon detection of CMV through blood assays C. Foscarnet may be used for preemptive therapy of CMV reactivation prior to engraftment D. CMV monitoring should occur through at least day + 30 after HSCT 12. To reduce potential exposure of HSCT recipients to such respiratory viruses, visitors and staff members with respiratory signs and symptoms of a viral illness may not be allowed direct contact with patients.

Which of the following statements is false regarding histocompatibility and hematopoietic stem cell transplantation?

A. Siblings are the best chance for a histocompatible match within a family B. The chance for complete histocompatibility occurring in an individual with only one sibling is 25% C. Histocompatibility is evaluated by studies of cell surface antigens, human leukocyte antigens (HLA) D. 70% of patients with more than one sibling will have an HLA-identical match E. The degree of histocompatibility between donor and recipient is the most important factor associated with the development of acute GVHD 13. What monitoring plan for engraftment would you recommend for a patient undergoing a myeloablative HSCT with a busulfan/cyclophosphamide preparative regimen?

A. CBC with differential weekly beginning on day 0 B. CBC with differential daily beginning on day +7 C. CBC daily beginning at the initiation of the preparative regimen D. CBC with differential daily beginning at the initiation of the preparative regimen E. CBC with differential twice daily beginning at the initiation of the preparative regimen 14. Which of the following may be initiated in steroid-refractory chronic GVHD? A. Rituximab B. Mycophenolate mofetil

C. Extracorporeal photochemotherapy D. Infliximab E. All of the above are choices for steroid-refractory chronic GVHD 15. Long-term survivors of HSCT are at risk for all of the following except A. Osteopenia B. Hypothyroidism C. Infertility D. Infectious complications E. Diabetes 8 Answers 1.

C 2.

C 3.

B 4.

E 5.

E 6.

C 7.

E 8.

A 9.

A 10.

C 11.

D 12.

D 13.

D 14.

E 15.

E

Chapter 99 1. A patient has been prescribed crizotinib 250 mg twice daily for anaplastic lymphoma kinase (ALK)-positive NSCLC. This oral anticancer agent has a moderate/high risk for causing emesis.

This patient does not have any additional risk factors for CINV. Which of the following is the best approach to manage CINV for this patient?

A. NK1 antagonist, 5HT3 antagonist, and dexamethasone on the first 3 days of each cycle B. Prochlorperazine every 4 to 6 hours as needed C. Ondansetron daily before each dose of crizotinib D. Olanzapine and dexamethasone for the first 5 days of each cycle 2. Which of the following ingredients should be part of a mouth rinse recommended for any patient who is at risk for developing mucositis to lessen its severity if it occurs?

A. Chlorhexidine B. Hydrogen peroxide C. Salt water D. Alcohol 3. Which of the following patients is at low risk for developing febrile neutropenia?

A. A 45-year-old woman with depression, anxiety, and stage 2 breast cancer receiving adjuvant therapy with doxorubicin and cyclophosphamide who has temperature of 99.3°F (37.4 °C) B. A 75-year-old man with COPD and stage 4 esophageal cancer treated with cisplatin and fluorouracil who develops oral candidiasis from concurrent radiation and has temperature of 100.6°F (38.1 °C) C. A 65-year-old man with diabetes and blast phase CML treated with nilotinib for the past 4 months who has temperature 99˚F (37.2 °C) D. A 73-year-old man with CHF and stage 4 prostate cancer treated with docetaxel who required pegfilgrastim 24 hours after each dose for the last three cycles 99.9°F (37.7 °C).

4. How should a chemotherapy patient with ANC 1250/mm3 (1.25 × 109 /L) and temperature 100°F (37.8°C) with adequate renal and hepatic function who is determined to be at low risk for infection according to the MAASC assessment tool be treated?

A. Hospitalized for immediate parenteral administration of broad-spectrum antibacterials before culture results are obtained B. Treated as an outpatient with fluoroquinolones and granulocyte colony-stimulating factors C. Hospitalized and treated with granulocyte colony-stimulating factors while culture results are pending D. Treated as an outpatient with alternating acetaminophen and ibuprofen and monitored closely for worsening neutropenia 5. A 54-year-old man with SCLC develops superior vena cava syndrome (SVCS) and has symptoms despite high-dose glucocorticoids. Which of the following is the most reasonable approach to manage his SVCS? A. Refer the patient to immediate surgery B. Administer high-dose glucocorticoids for an additional 3 days C. Start aggressive hydration D. Refer the patient to the anticoagulation clinic 6. A 63-year-old woman is being treated with the MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy for stage IV bladder cancer. This regimen has a risk of

FN that is at least 20%. Which of the following is the best strategy to prevent infection in MT? A. Filgrastim B. Levofloxacin C. Dexamethasone D. Amoxicillin/clavulanic acid 7. A 66-year-old woman with stage IV adenocarcinoma NSCLC is receiving pemetrexed and cisplatin chemotherapy. She is considered low risk for infection by MASCC despite her temperature today of 100°F (37.8°C)and ANC 1200/mm3 (1.2 × 109 /L). Which of the following is the best strategy to prevent infection in this patient?

A. Vigilant hand hygiene B. Pegfilgrastim 6 mg subcutaneously 24 hours postchemotherapy C. Ciprofloxacin 500 mg orally twice daily for 14 days D. SMX-TMP double-strength orally twice daily for 10 days 8. A 72-year-old man with extensive stage SCLC presents to his oncologist today to discuss his treatment plan. Which of the following is the best approach to prevent brain metastases for this patient?

A. Cisplatin and etoposide B. Amifostine C. Prophylactic cranial irradiation D. High-dose glucocorticoids 9. Which of the following patients is least likely to develop hemorrhagic cystitis?

A. A 24-year-old man with Hodgkin lymphoma receiving ICE chemotherapy that includes ifosfamide 5 g/m2 B. A 42-year-old woman with non-Hodgkin lymphoma being treated with cyclophosphamide 750 mg/m2 IV every 12 hours for 4 days (total dose 6 g/m2 ) as part of a transplant regimen.

C. A 34-year-old woman with nephrotic syndrome being treated with cyclophosphamide 200 mg orally once daily D. A 57-year-old woman with stage IIa breast cancer treated with doxorubicin 60 mg/m2 And cyclophosphamide 600 mg/m2 10. Which of the following is an appropriate management strategy for a patient experiencing mucositis from oral capecitabine for stage IV colon cancer?

A. Amifostine B. Ice chips C. Palifermin D. Leucovorin 11. What is the role of olanzapine in CINV? A. It is an alternative to a neurokinin-1–based regimen for highly emetogenic chemotherapy.

B. It is an alternative to a neurokinin-1–based regimen for highly and moderately emetogenic chemotherapy.

C. It is an alternative to a neurokinin-1–based regimen regimen for moderately emetogenic chemotherapy.

D. It is only effective as an as-needed medication for anticipatory nausea and vomiting.

12. A 54-year-old woman presents to the clinic with stage IV rectal cancer for treatment with cycle 2 of fluorouracil continuous IV infusion over 4 days. This regimen has low emetic risk but she reports two episodes of vomiting with cycle 1 relieved by three doses of as needed prochlorperazine. She has a history of motion sickness and has not slept well this last week because of anxiety about her prognosis. Which of the following is the most appropriate CINV regimen for this patient for cycle 2?

A. 5HT3-antagonist and dexamethasone days 1–3 B. Prochlorperazine as needed C. Aprepitant, 5HT3-antagonist, and dexamethasone days 1–3 D. Olanzapine and dronabinol days 1–3 13. A 69-year-old man with extensive stage small cell lung cancer presents with a corrected calcium level of 11.5 mg/dL (2.88 mmol/L) but denies feeling fatigued, confused, or having headaches. Which of the following is the best treatment for the immediate treatment of HJ’s hypercalcemia?

A. Cisplatin 100 mg/m2 IV on day 1 and etoposide 100 mg/m2 IV on days 1, 2, and 3 B. Calcitonin 4 units/kg IM every 4 to 6 hours C. Normal saline 500 mL/hour for 24 to 48 hours D. Zoledronic acid 4 mg IV 14. The main difference between allopurinol and ruboxistat in the management of tumor lysis syndrome (TLS) is: A. Allopurinol is effective for both prevention and treatment of TLS but ruboxistat is only effective for prevention.

B. Ruboxistat is effective for both prevention and treatment of TLS but allopurinol is only effective for prevention.

C. Allopurinol is only effective for prevention of TLS and ruboxistat is only effective for treatment.

D. Ruboxistat is only effective for prevention of TLS and allopurinol is only effective for treatment.

15. Dexrazoxane is an antidote to extravasation caused by: A. Taxanes B. Anthracyclines C. Platinum D. Fluoropyrimidines Answers 1. D 2. C 3. A 4. D 5. A 6. A 7. A 8. C 9. C 10. B

11. A 12. A 13. A 14. B 15. B

Chapter 100 1. Which one of the following is an appropriate indication for PN? A. Severe malnutrition with a functional GI tract B. Intentional weight loss C. Fluid and electrolyte deficits D. Short-bowel syndrome E. Well-nourished patient, NPO × 3 days 2. Which of the following commercially available concentrations of IV lipid emulsions is FDA approved ONLY for infusion in a TNA (ie, should not be directly infused into the patient or via Y-site)?

A. 2% B. 10% C. 15% D. 20% E. 30% 3. What is the maximum recommended osmolarity for a PN admixture that is administered via a peripheral vein (ie, peripheral PN, or PPN)?

A. 300 mOsm/L B. 500 mOsm/L C. 900 mOsm/L D. 1500 mOsm/L E. 2000 mOsm/L 4. Which of the following is an advantage of TNAs (total nutrient admixtures) over 2-in-1 PN formulations?

A. Stability is improved with TNAs. B. Visual inspection is easier with TNAs. C. A 0.22- micronbacterial retention filter may be used with TNAs. D. A greater number of medications are compatible with TNAs. E. Vein irritation is decreased with TNAs. 5. Which of the following actions will INCREASE the likelihood of calcium-phosphate precipitation in PN admixtures?

A. Refrigerating the PN bag B. Use of calcium chloride as the calcium salt C. Separating the addition of calcium and phosphate salts when compounding D. Decreasing the pH of the PN solution E. All of the above 6. Which of the following is a potential advantage of standardized, commercially available (premixed) PN formulations available in the United States?

A. They contain high concentrations of amino acids.

B. There are multiple volumes available.

C. They are suitable for complex patient populations (eg, patients with organ dysfunction).

D. There may be a lower risk of microbial contamination due to fewer manipulations.

E. There are multiple formulations available that contain IVFE. 7. Addition or coinfusion of bicarbonate with PN admixtures is contraindicated because it can lead to: A. Formation of insoluble calcium carbonate

B. Sodium-phosphate precipitation C. Increased PN admixture acidity D. Potassium-phosphate precipitation E. Increased risk of infection 8. Which of the following trace minerals are known contaminants of parenteral products used in the making of PN and may accumulate in patients on long-term PN? A. Chromium and manganese B. Aluminum and selenium C. Iron and chromium D. Zinc and selenium E. Manganese and iron 9. Which of the following medications (when indicated) can be safely added to PN admixtures?

A. Insulin glargine B. Famotidine C. Pantoprazole D. Enoxaparin E. Iron sucrose 10. Which of the following would NOT be in agreement with recommendations from A.S.P.E.N. regarding PN safety?

A. Implementing electronic PN order forms (eg, in a CPOE system) and removing paper/handwritten PN order forms B. Implementing electronic transmission of PN orders from a CPOE system to an automated compounder and removing manual transcription of PN orders C. Developing PN education and annual competency assessment for all health care professionals involved in any aspect of PN therapy D. Removing clinical decision support and dose limit alerts from PN orders in a CPOE system and in an automated compounding device to avoid alert fatigue E. Developing institution-specific PN policies and procedures to address all aspects of the PN use process 11. Which of the following is a potential adverse effect associated with overfeeding?

A. Hyperglycemia B. Hypertriglyceridemia C. Hypercapnia D. Hepatic steatosis E. All of the above 12. Which of the following factors is a potential cause of metabolic bone disease in PNdependent patients?

A. Sodium deficiency B. Manganese accumulation and toxicity C. Aluminum accumulation and toxicity D. Essential fatty acid deficiency E. Hypertriglyceridemia 13. A deficiency of which of the following can lead to lactic acidosis and neurological abnormalities?

A. Dextrose B. Thiamine C. Folic acid D. Essential fatty acids E. Zinc 14. The classic metabolic derangements associated with refeeding syndrome are: A. Hyperphosphatemia and hyperkalemia B. Hyperphosphatemia and hypokalemia C. Hyperphosphatemia and hypermagnesemia D. Hypokalemia and hypermagnesemia E. Hypophosphatemia and hypokalemia 15. Which of the following parameters should be monitored at baseline prior to initiation of PN? A. Serum electrolyte and glucose concentrations B. Nitrogen balance C. Blood cultures D. Serum trace element concentrations E. Serum vitamin concentrations Answers 1. D. 2. E. 3. C. 4. E. 5. B. 6. D. 7. A. 8. A. 9. B. 10. D. 11. E. 12. C. 13. B. 14. E. 15. A.

Chapter 101 1. Which of the following statements is true regarding GI tract structure and function?

A. The process of digestion begins in the stomach.

B. The pyloric sphincter separates the esophagus from the stomach.

C. The liquid form of food produced in the stomach is known as chyme.

D. Most protein, carbohydrate, and fat absorption occurs in the duodenum.

E. The pancreas secretes large amounts of acid important for digestion of food.

2. Which of the following would most appropriately be considered a contraindication to EN? A. Nasopharyngeal tumor B. Inflammatory bowel disease C. Mild to moderate pancreatitis D. Closed head injury E. Diffuse peritonitis 3. Which of the following initial goal regimens would, according to general guidelines, be most appropriate for a 100-kg hospitalized patient with a body mass index of 33 kg/m2?

A. 1200 kcal (5023 kJ) and 100 g of protein B. 1400 kcal (5860 kJ) and 120 g of protein C. 1800 kcal (7534 kJ) and 80 g protein D. 1800 kcal (7534 kJ) and 120 g protein E. 2400 kcal (10,046 kJ) and 100 g protein 4. Which of the following initial goal regimens would, according to general guidelines, be most appropriate for a 60-kg hospitalized patient with a body mass index of 22 kg/m2 A. 1000 kcal (4186 kJ) and 90 g of protein B. 1200 kcal (5023 kJ) and 40 g of protein C. 1800 kcal (7534 kJ) and 90 g of protein D. 2400 kcal (10,046 kJ) and 60 g of protein E. 2,400 kcal (10,046 kJ) and 120 g of protein 5. Which of the following is most accurate regarding specialized nutritional support?

A. There is no good evidence to demonstrate benefit of starting therapy within the first 2 days of intensive care.

B. Malnutrition before illness may be a good indication for starting therapy sooner.

C. Most patients requiring specialized nutritional support should be provided 35 to 40 kcal (147–167 kJ) per kg of body weight per day.

D. It is more difficult to overfeed patients with PN compared with EN. E. A benefit of PN compared with EN is more efficient prevention of bacterial translocation.

6. Which of the following best describes aspiration in patients receiving tube feedings?

A. Risk reduced if tip of tube is proximal to ligament of Treitz B. Often caused by aspiration of nasopharyngeal secretions rather than feedings C. Can be decreased by decreasing angle of head of bed to less than 30 degrees D. Incidence less with NG tubes than with PEG tubes E. Can eliminate by use of postpyloric feedings 7. Which of the following best describes methods of delivery of EN? A. Bolus feedings are appropriate for delivery of duodenal feedings.

B. Intermittent feedings are appropriate for delivery of jejunal feedings.

C. Either bolus or continuous feedings are appropriate for delivery of gastric feedings.

D. An advantage of a PEJ tube compared with a PEG tube is ease of placement.

E. Most PEG tubes are placed by a surgeon during abdominal surgery.

8. Which of the following best describes EN for patients with renal dysfunction?

A. Products used in this population generally have low caloric density.

B. Products used in this population generally have lower amounts of potassium, phosphorus, and magnesium compared with standard EN products.

C. Products designed for patients receiving dialysis are generally relatively low in protein.

D. Formulas enriched with essential amino acids are the most commonly used products in this population.

E. Use of standard EN formulas should be avoided in dialysis patients because of the non–essential amino acid content.

9. Which of the following is true regarding EN in patients with hemodynamic instability?

A. Gastric feedings are strictly contraindicated in patients on any dose of vasopressor.

B. Gastric feedings at low rates may be trialed in patients on low, stable dosages of vasopressors.

C. Jejunal feedings are safer compared to gastric feedings in patients on vasopressors.

D. A polymeric formula would more likely be tolerated compared to an elemental formula in a patient on high-dose vasopressors.

E. EN can be initiated in patients on high dosages of phenylephrine but should be avoided if the patient is receiving vasopressin.

10. EN formulas designed to alleviate hepatic encephalopathy contain which of the following amino acid profiles compared to standard formulas?

A. Fewer BCAA and more AAA B. Fewer AAA and more BCAA C. Fewer BCAA and same amount of AAA D. Fewer AAA and same amount of BCAA E. Fewer BCAA and fewer AAA 11. Which of the following types of feeding tubes is most commonly placed in patients requiring long-term EN? A. Nasogastric B. Orogastric C. Nasojejunal D. PEG E. PEJ 12. Which one of the following statements is true regarding components of EN? A. Soluble fiber is omitted from most formulas due to propensity to cause abdominal discomfort.

B. Standard protein content of EN formulas is about 30% of total calories.

C. Formulas containing simple sugars are lower in osmolality than those containing maltodextrin.

D. MCT oil does not provide EFAs. E. A liquid MVI supplement is generally required for patients on EN due to inadequate content in the EN formula.

13. Which of the following is best practice for EN? A. The best fluid for flushing feeding tubes is diet soda.

B. When administering medications through a feeding tube, 5 mL of water should be used as a flush between medications.

C. Before and after medication administration down a feeding tube, 10 to 30 mL of fruit juice should be used to flush the tube.

D. Antacids should routinely be placed down jejunal tubes to decrease acidity of the lower small intestine.

E. Tube feedings should be stopped for 2 hours before and 2 hours after tube administration of most medications.

14. Which of the following would be most likely to develop in an EN patient experiencing acute renal insufficiency?

A. Hypernatremia B. Hypocalcemia C. Hypomagnesemia D. Hypophosphatemia E. Hyperkalemia 15. Absorption of which of the following medications has most commonly been reported to be compromised in patients receiving EN? A. Itraconazole B. Metoclopramide C. Sorbitol D. Sucralfate E. Phenytoin Answers 1. C 2. E 3. B 4. C 5. B 6. B 7. C 8. B 9. B 10. B 11. D 12. D 13. B 14. E 15. E

Chapter 102 1. Pharmacologic treatment is an option for a patient with a BMI of kg/m2 and hypertension when weight loss goals have not been met following comprehensive lifestyle intervention for 6 months.

A. 22 B. 26 C. 32 D. 24 E. None of the above 2. A female patient with a BMI of 31 kg/m2 comes into the clinic today. She has type 2 diabetes mellitus and smokes. What is the goal of treatment for this patient?

A. Prevent weight gain.

B. Promote weight loss at a rate of 1 to 2 lb (~0.5–0.9 kg) per week.

C. Control related risk factors.

D. Both A and B are correct answers E. Answers A, B, and C are correct 3. Orlistat may cause severe liver damage. Which of the following are symptoms of severe liver damage that should be immediately reported to the patient’s health care provider?

A. Itching B. Yellowing of the eyes or skin C. Dark urine D. All of the above E. None of the above 4. A 56-year-old male patient presents to clinic. He has a past medical history of GERD, sleep apnea, allergic rhinitis, and osteoarthritis. He currently smokes two packs per day and continues to drink two alcoholic beverages on the weekend. Which of the following are obesity-related comorbidities that increase this patient’s risk of death?

A. GERD, allergic rhinitis, and osteoarthritis B. Sleep apnea, current tobacco use, and osteoarthritis C. GERD, sleep apnea, and current alcohol intake D. Current tobacco use, allergic rhinitis, and GERD E. Sleep apnea, allergic rhinitis, and GERD 5. A patient recently diagnosed with obesity (160 lb [73 kg]; BMI, 31 kg/m2 ) 2 weeks ago returns today with her food diary. Upon review, her average daily caloric intake is 2200 kcal/day (9209 kJ/day). What suggestions, if any, do you provide for her today?

A. Restrict daily calories to 600 kcal/day (2511 kJ/day).

B. Restrict daily calories to 1100 kcal/day (4604 kJ/day).

C. Restrict daily calories to 1700 kcal/day (7116 kJ/day).

D. Restrict daily calories to 50% of current diet.

E. Do not restrict caloric intake.

6. The four stages suggested for the treatment of obesity in children and adolescents include all of the following except: A. Intensive Weight Lifting Program

B. Structured Weight Management C. Prevention Plus D. Tertiary Care Intervention E. Comprehensive Multidisciplinary Intervention 7. Bariatric surgery is a viable option for weight loss in the following situation: A. A patient with a BMI of 25 kg/m2 B. A patient with a BMI greater than 30 kg/m2 and hypertension C. A patient with a BMI greater than 35 kg/m2 and GERD D. A patient with a BMI of 38 kg/m2 E. A patient with a BMI greater than 35 kg/m and diabetes mellitus type 2 8. The following are potential considerations for medication management following bariatric surgery except: A. Avoid NSAID use B. Recommend fat-soluble vitamins C. Recommend vaginal suppositories D. Recommend extended-release agents E. Avoid oral bisphosphonates 9. Which of the following is not a recommended reduced-calorie diet?

A. AHA Step-1 diet B. High-protein diet C. Vegas ultra diet D. Low-fat diet E. Mediterranean diet 10. All of the following drugs can cause weight gain except: A. Selective serotonin reuptake inhibitors B. Phenytoin C. Insulin D. Corticosteroids E. Quetiapine 11. Your collaborative physician calls you for a recommendation for his obese, 59-year-old female patient with a history of hypertension and previous myocardial infarction. She has been adhering to a calorie-restricted diet and has increased her physical activity but still has been unable to attain her weight loss targets. The physician asks what pharmacologic choice you would recommend.

A. Orlistat B. Phentermine C. Diethylpropion D. Amphetamine E. Phendimetrazine 12. A patient taking one tablet of phentermine 37.5 mg daily presents to your pharmacy today complaining that she has been unable to sleep at night. The insomnia started about the same time as the phentermine was initiated. She denies heart palpitations but reports being a little irritable and has a dry mouth. She also reports that she takes the medication with her largest meal in the evening. What would your recommend she do?

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A. Take one tablet every other day.

B. Cut the tablet in half and take one-half tablet twice daily.

C. Take one tablet every morning.

D. Take one-half tablet every morning.

E. Take one tablet twice daily.

13. Which of the following educational statements would you not provide to a patient starting orlistat?

A. Increased gas and oily stools may occur while taking orlistat.

B. Take orlistat three times a day with or without food.

C. Take a multivitamin daily 2 hours before or after the dose of orlistat.

D. If the patient is also taking levothyroxine daily, separate the doses by 4 hours.

E. Orlistat may be taken up to 1 hour after a meal.

14. All of the following are common adverse drug reaction associated with naltrexone-bupropion use except: A. Nausea B. Diarrhea C. Headache D. Dizziness E. Insomnia 15. Which of the following pharmacologic agents for weight loss are approved for long-term use?

A. Orlistat B. Lorcaserin C. Phentermine-topiramate D. All of the above E. None of the above Answers 1. C 2. E 3. D 4. B 5. C 6. A 7. E 8. D 9. C 10. B 11. A 12. C 13. B 14. B 15. D