Week 3 Questions

For which one of the following patients should you be most concerned with regard to the medication being taken? a)A 68 year old man with intermittent atrial fibrillation taking warfarin b)A 74 year old woman taking amitriptyline for depression c)An 82 year old woman with essential hypertension taking hydrochlorothiazide d) A 72 year old man taking insulin for Type 2 diabetes mellitus

A 74 year old woman taking amitriptyline for depression

A 75-year-old woman comes to the office because she has difficulty maintaining sleep. She wakes up a few times each night, often because of back pain; she rates the pain as 6-7 on a 10-point scale. History includes osteoarthritis of the lumbar back and knee, coronary artery disease, stage 3 chronic kidney disease, and depression. Medications include citalopram 20 mg/d, glucosamine sulfate 500 mg four times daily, extended-release metoprolol 50 mg/d, aspirin 81 mg/d, and acetaminophen 1,000 mg every 8 hours. Based on laboratory findings, estimated creatinine clearance is 50 mL/min. Which one of the following is the best next step in management? (A) Add ibuprofen 400 mg at bedtime. (B) Add oxycodone 2.5 mg at bedtime. (C) Add temazepam 7.5 mg at bedtime. (D) Add zolpidem 10 mg at bedtime.

Add oxycodone 2.5 mg at bedtime

Mr. P. is a 74 year old man brought to the emergency department by ambulance following a fall at home. He has a long history of mild hypertension treated with terazosin 2mg daily and BPH. He also takes a multivitamin daily and calcium with vitamin D (OTC). Recently his primary care provider added Flomax for BPH. For the last 3 nights he has also taken lorazepam 2 mg, which he borrowed from a friend, because he has been having some problems sleeping. He is alert and oriented and, other than pain in his left hip, has no complaints. He has no past history of falls, cognitive impairment or mental confusion. Based on the above information, which of the following is the most likely cause for his fall? a) Additive effect of Flomax b) Sleep deprivation secondary to terazosin c) Orthostatic hypotension secondary to lorazepam d) Dizziness related to terazosin

Additive effect of Flomax

Dry mouth may cause which one of the following problems in older adults? a. Difficulty in retention of dentures b. Increased risk of dental decay c. Difficulty in swallowing and taste d. Fissured or inflamed tongue e. All of the above

All of the above

Mrs. W., a 73 year old patient of your practice partner, presents for discharge follow up after a recent hospital admission for an episode of confusion and a fall at home. She only sustained minor soft tissue injuries from the fall and the confusion subsided during the admission. She has a history of hypertension and hyperlipidemia which have been well-controlled by her current medications. She is alert, oriented, and ambulating without difficulty. She has no complaints today except for some difficulty sleeping which began prior to admission and for which she was taking a low dose of temazepam at bedtime. She was discharged with instructions to continue all her pre-admission medications. Which of the following must be included in Mrs. L.'s plan of care to reduce her risk for future episodes of confusion and falls? a) Begin a trial of non-pharmacological sleep hygiene and safety measures b) Check to make sure that she is taking her medications as directed c) Taper off temazepam d) All of the above

All of the above

Which of the following may increase the risk of an adverse drug reaction in an older adult? a)Polypharmacy b)Having several healthcare providers c) Using more than one pharmacy for her prescriptions d) All of the above

All of the above

Which one of the following patients is at greatest risk for a drug-drug interaction? a) A 78 year old man taking atorvastin and amlodipine b) An 67 year old woman taking warfarin and ibuprofen c) An 85 year old woman taking vitamin D and donepezil d) A 70 year old woman taking metformin and low dose aspirin

An 67 year old woman taking warfarin and ibuprofen

Which one of the following patients is at GREATEST RISK for a drug-disease interaction? a) An 88 year old man with Parkinson's disease taking carvedilol b)A 76 year old woman with hypertension taking loratadine c) A 70 year old man with congestive heart failure taking naproxen d) A 75 year old woman with stress incontinence taking oxybutynin

An 88 year old man with Parkinson's disease taking carvedilol

An 83-year-old woman visits your office with complaints of decreased appetite and weight loss. Which of the following is not responsible for reduced calorie intake in older adults? a. Inability to obtain food because of social factors, decreased income, social isolation, and depression b. Illness or medication that can suppress appetite or impair absorption c. An increase in senses such as smell and taste that make food more palatable d. Increased functional problems that can make it difficult to prepare meals e. Improperly fitting dentures

An increase in senses such as smell and taste that make food more palatable

An 82-year-old man is brought to the emergency department because he had sudden loss of consciousness without warning while standing in line at the theater. He regained consciousness within a couple of minutes, but he described a spinning sensation and double vision. History includes hypertension, diabetes, and coronary artery disease. On physical examination, blood pressure is 180/100 mmHg and heart rate is 105 beats per minute. His speech is slurred (dysarthria), and he has a dysconjugate gaze and left-sided ataxia. Serial troponin levels are normal. Urgent noncontrast CT of the head done 2 hours after he lost consciousness was unremarkable. Electrocardiography shows mild sinus tachycardia. Which one of the following medications is indicated in the acute setting? (A) Aspirin (B) Fludrocortisone (C) Labetalol (D) Midodrine (E) Treatment-dose heparin

Aspirin

Mrs. A. is an 85 year old woman who has recently relocated to your town and is in need of a new primary care provider. She has several chronic medical conditions and hands you her long list of medications. Which of the following resources will assist you in managing her medication use safely and appropriately? a) Fulmer's SPICES b) Holstein's Guidelines c) Beers Criteria d) The Lawton Scale

Beers criteria

A 75-year-old man with prostate cancer is scheduled to begin treatment with leuprolide acetate injection every 3 months. To determine his risk of osteoporosis-related fracture, dual-energy x-ray absorptiometry (DEXA) is performed to measure baseline bone mineral density. T-score is −2.2 in the left femoral neck. Weight is 70 kg (154 lb) and height is 172.2 cm (67.8 in). Based on Fracture Risk Assessment (FRAX) calculation, estimated 10-year risk is 4.1% for hip fracture and 10% for any osteoporotic fracture. Which one of the following antiresorptive therapies is most likely to prevent osteoporosis fracture as a complication of androgen deprivation therapy? (A) Estradiol (B) Selective estrogen-receptor modulator, eg, raloxifene (C) Bisphosphonate (D) Nasal salmon calcitonin

Bisphosphonate

The high-risk anatomic sites for oral and oropharyngeal squamous cell carcinomas (SCCs) include all of the following except which one? a. Ventral tongue b. Buccal mucosa c. Floor of mouth d. Soft palate e. Tonsillar fold

Buccal mucosa

A 97-year-old man is brought to the office by his daughter because she is concerned that he may no longer be able to live alone. History includes degenerative joint disease, atrial fibrillation, hypertension, and multi-infarct dementia with significant difficulty with word finding and short-term memory (1of 3 recall). He had gastrointestinal bleeding related to warfarin use. Until 6 months ago, he could transfer independently, rise from a chair without using his arms, and ambulate with a walker. Current medications are aspirin 81 mg/d and acetaminophen 650 mg as needed for pain. Over the past 6 months he has lost approximately 6.8 kg (15 lb) and has had increased difficulty with transfers and ambulation. He states that he has no acute pain. Physical examination confirms weight loss. Blood pressure is 124/70 mmHg and heart rate is 62 beats per minute and regular, with a grade 3/6 systolic ejection murmur that is heard best at the base and does not radiate. There is no dependent edema. He uses his arms to transfer and tolerates weight bearing. He is unable to ambulate a functional distance independently. Which one of the following is most likely to identify a reversible cause for his weight loss? (A) Measurement of serum cholesterol and lymphocyte count (B) CBC and measurement of thyrotropin level (C) Measurement of albumin and prealbumin levels (D) Measurement of transferrin level

CBC and measurement of thyrotropin level

Your 86-year-old nursing home patient can no longer meet her nutritional needs orally and is losing weight. Your first consideration in addressing this situation is to: a. Start enteral feedings via percutaneous endoscopic gastrostomy tube. b. Start parenteral feedings. c. Order a nutrition consult. d. Check the chart for an advance directive. e. Consult with the patient's family regarding aggressive nutrition support

Check the chart for an advance directive

An 81-year-old woman undergoes evaluation for nutritional status 6 days after surgery for a ruptured appendix. She responded well to intravenous fluids and antibiotics, and she has been afebrile for 4 days. She is now on a regular diet, and nurses' notes indicate that she is consuming 50%-75% of her meals. Past medical history is unremarkable. On examination, she is alert and oriented and in no acute distress. Weight is 79.5 kg (175 lb), 5 kg (11 lb) above weight on admission. BMI is 28 kg/m2. Lungs are clear, and jugular venous pressure is <7 cm. There is 3-4+ pretibial and presacral edema that was not present at admission. There is a surgical wound in the right lower quadrant of the abdomen. Laboratory findings are normal for electrolytes, BUN, creatinine, and WBC count. Which one of the following would be most helpful for assessing the adequacy of the patient's nutrient intake? (A) Serum albumin level (B) Serum prealbumin level (C) Daily weighing (D) Resting metabolic rate measured by indirect calorimetry (E) Complete calorie counts for the next 3 days

Complete calorie counts for the next 3 days

A 90-year-old woman is brought to the office because she has had increasing difficulty with urinary and fecal incontinence over the past 3 months. She is accompanied by her daughter, who is her primary caregiver. The daughter reports that the patient has had urinary incontinence for 2 years. It has been managed adequately in the home with prompted voiding, but there is now increased urinary frequency as well as fecal incontinence 2-3 times each week; the latter is particularly bothersome. The daughter believes that she will be unable to care for her mother at home if this situation persists. History includes Alzheimer disease, hypothyroidism, and osteoarthritis. Her medication regimen has had the following changes in the past 6 months: simvastatin was discontinued; donepezil was titrated from a starting dose of 5 mg to 10 mg/d, levothyroxine was increased to 112 mcg/d, and acetaminophen 500 mg twice daily was added. Which one of the following would be the most appropriate strategy to consider? A) Start extended-release oxybutynin 10 mg/d. (B) Start memantine 5 mg/d and titrate upward by 5 mg/wk. (C) Start loperamide 2 mg up to twice daily as needed. (D) Decrease levothyroxine dosage. (E) Decrease donepezil.

Decrease donepezil

An 83-year-old woman comes to the emergency department because for the past 24 hours she has been dizzy and passing black stools. History includes atrial fibrillation, hypertension, and COPD. Medications include dabigatran 150 mg twice daily, lisinopril 10 mg/d, hydrochlorothiazide 12.5 mg/d, albuterolipratropium 1 inhalation four times daily, and a daily multivitamin. She has taken dabigatran for 3 years, and lisinopril and hydrochlorothiazide for 20 years. She lives alone and her family and neighbors check on her daily. She states that 1 week ago she had food poisoning, and since then she has had multiple bouts of vomiting and diarrhea. She has been self-treating her gastrointestinal symptoms with over-the-counter bismuth subsalicylate (Pepto-Bismol®). On examination, blood pressure is 116/72 mmHg seated and 90/50 mmHg standing. Heart rate is 102 beats per minute, and respiratory rate is 18 breaths per minute. Laboratory findings: Hemoglobin 9.5 g/dL Hematocrit 29% Platelets 227/μL BUN 28 mg/dL Serum creatinine 1.8 mg/dL (baseline 1 mg/dL) Estimated creatinine clearance 25 mL/min Which one of the following is the most likely cause of her dizziness, anemia, and relative hypotension? (A) Decreased renal clearance of dabigatran (B) Drug interaction between dabigatran and Pepto-Bismol® (C) Increased absorption of Pepto-Bismol® (D) Adverse effect of Pepto-Bismol®

Decreased renal clearance of dabigatran

A 65-year-old woman comes to the office to establish care. She has no significant past medical history. Current medications are omega-3 fish oil 2,000 IU/d, daily multivitamin, vitamin C 500 mg/d, vitamin E 400 IU/d, and calcium 1,000 mg twice a day. She experienced menopause at age 50. Her mother died at age 90 after hip fracture. The patient engages in aerobic weight-bearing exercise for 30 minutes daily and weight training for 30 minutes 3 times per week. She has never smoked and drinks only an occasional glass of wine. She drinks 2 glasses of skim milk and 1 glass of calcium-fortified fruit juice daily. She limits red meat to twice each week and eats organically raised chicken or fish on other days. Her diet is high in fruits and vegetables. On examination, blood pressure is 120/70 mmHg. The patient has no documented height loss. Results of a CBC, basic comprehensive metabolic panel, and fasting serum lipid panel are normal. Serum calcium level is 9.5 mg/dL, and 25(OH)D level is 25 ng/mL. Results of dual-energy x-ray absorptiometry (DEXA) for baseline bone mineral density are T-score of −2.2 for lumbar spine, −1.5 for total hip, and −1.9 for left femoral neck. According to Fracture Risk Assessment (FRAX) calculation, 10-year probability for major osteoporotic fracture and hip fracture is 14% and 2%, respectively. Which one of the following is the most appropriate intervention? (A) Prescribe oral ibandronate 150 mg, once each month with glass of water 1 hour before breakfast. (B) Prescribe oral raloxifene 60 mg/d. (C) Discontinue calcium supplement. (D) Add supplemental vitamin D3 to 1,000 IU/d.

Discontinue calcium supplement

Patient SL is a 68-year-old male you are seeing for follow-up of uncontrolled hypertension. He is currently prescribed amlodipine 10 mg daily, azilsartan (Edarbi) 40 mg daily, metoprolol tartrate 50 mg bid, and hydrochlorothiazide (HCTZ) 25 mg daily, and his blood pressure is consistently above target. Secondary causes of hypertension have been ruled out. You ask him about missing doses and he tells you that it is difficult to take so many tablets and the brand-name medication is very expensive. Select the best way to improve this patient's adherence. a. Discontinue amlodipine and azilsartan and start amlodipine/valsartan (Exforge) 10/160 mg once daily. b. Discontinue azilsartan and HCTZ and initiate losartan/HCTZ 50/25 mg once daily. c. Discontinue azilsartan and initiate captopril 12.5 mg tid. d. Discontinue metoprolol tartrate and initiate clonidine 0.1 mg/24-hour patch once weekly

Discontinue metoprolol tartrate and initiate clonidine 0.1 mg/24-hour patch once weekly

An 84-year-old man comes to the office for a same-day appointment, because he is concerned that his acutely increasing difficulty voiding over the past 2 days indicates that he has prostate cancer. He visited an urgent care center 1 week ago for allergic rhinitis and sinus congestion, and was prescribed loratadine 10 mg/d, pseudoephedrine 30 mg twice daily, and a nasal corticosteroid 1 spray twice daily in each nostril. On physical examination, the suprapubic area is slightly tender and dull to percussion. Genitalia are normal. The prostate is moderately enlarged, with no tenderness, nodularity, or other abnormality. Ultrasonography of the bladder after an attempted void shows a post-void residual of 275 mL, which is confirmed by in-and-out catheterization. Urinalysis reveals no evidence of infection. Creatinine level (1.1 mg/dL) has not changed from baseline. Which one of the following is the most appropriate next step in management? (A) Discontinue loratadine. (B) Discontinue pseudoephedrine. (C) Start tamsulosin 0.4 mg/d. (D) Start finasteride 5 mg/d. (E) Refer for urodynamic evaluation.

Discontinue pseudoephedrine

The husband of an 82-year-old woman calls the clinic to report changes in her behavior over the last few days. She is confused, becomes agitated when he assists with ADLs, and will not eat because she thinks she is being poisoned. History includes hypertension, depression, osteoarthritis, probable Alzheimer disease (diagnosed 2 years ago), and urinary incontinence. Her score on the Mini-Mental State Examination was 22 of 30 at her last visit 2 months ago. Medications include acetaminophen 325 mg four times daily, donepezil 5 mg/d, extended-release memantine 14 mg/d, hydrochlorothiazide 25 mg/d, lisinopril 10 mg/d, tolterodine 2 mg twice daily, and citalopram 20 mg/d. The donepezil and memantine were begun 2 years ago, tolterodine was increased 1 week ago, and citalopram was increased (from 10 mg) 2 months ago. A visiting nurse obtains laboratory samples later that day. Laboratory findings: BUN 18 mg/dL Serum creatinine 1.1 mg/dL Sodium 138 mEq/L Glucose 81 mg/dL (consistent with prior measurements) Urinalysis shows 0-5 WBCs/high-power field and is negative for bacteria and leukocyte esterase. Which one of the following is most appropriate at this time? (A) Discontinue tolterodine. (B) Increase extended-release memantine to 28 mg/d. (C) Start lorazepam 0.5 mg twice daily. (D) Start risperidone 0.25 mg/d.

Discontinue tolterodine

A 91-year-old man comes to the clinic because he has post-herpetic neuralgia that affects his right upper chest. Wearing a shirt causes him severe discomfort, and he has difficulty sleeping. History includes overactive bladder. His only current medication is oxybutynin 5 mg twice daily. He lives alone and is independent in ADLs. Recent laboratory findings indicate normal renal and hepatic function. He asks for help with the pain but requests a medication with the least amount of adverse effects. Topical lidocaine is prescribed in the form of a patch. He returns 1 week later and reports only moderate improvement in pain. He requests additional help managing the pain. Which one of the following is the most appropriate next step in pharmacologic management? (A) Amitriptyline 10 mg at bedtime (B) Clonazepam 0.5 mg at bedtime (C) Gabapentin 100 mg at bedtime (D) Morphine 7.5 mg twice daily (E) Prednisone 5 mg daily

Gabapentin 100 mg at bedtime

Your patient is hospitalized following a cerebrovascular accident. He is at nutritional risk because he has dysphagia as a result of the stroke. The first step to nutrition intervention is to: a. Get a swallowing assessment so that the level of food texture and fluid viscosity can be determined for his diet order. b. Start enteral feedings via a nasogastric tube. c. Thicken all liquids to honey-like consistency until a complete assessment can be made. d. Start the patient on a liquid nutritional supplement. e. Order a general diet

Get a swallowing assessment so that the level of food texture and fluid viscosity can be determined for his diet order

A 78-year-old man reports gradual onset of anxiety symptoms over the past 10 years. He generally prefers not to take prescription medications, which he considers too strong. He instead uses a variety of over-the-counter medicines and herbal remedies as he needs them. Which one of these herbal supplements is most likely to contribute to his anxiety symptoms? (A) Echinacea (B) Guarana (C) Passionflower (D) Ginkgo biloba (E) Kava

Guarana

A 73-year-old woman is brought to the emergency department because she had a syncopal episode at her nursing home. The patient was sitting and eating lunch when she suddenly slumped over and lost consciousness. The episode lasted 30 seconds, and the patient had a rapid return to baseline. History includes dementia, coronary artery disease, hyperlipidemia, and diabetes mellitus. Current medications are glyburide, hydrochlorothiazide, haloperidol, and simvastatin. On examination, blood pressure is 116/68 mmHg and heart rate is 58 beats per minute. Blood glucose level is 110 mg/dL. Electrolyte levels are normal. Electrocardiography shows mild sinus bradycardia, QTc interval of 540 msec, QRS interval of 60 msec, and PR interval of 150 msec. Which one of the following medications should be discontinued at this time? (A) Hydrochlorothiazide (B) Glyburide (C) Haloperidol (D) Simvastatin

Haloperidol

A 66-year-old woman returns to the office after a 14-day course of celecoxib 200 mg/d for tenderness and effusion in her right knee. She now has dyspnea, increased swelling in the lower extremities, and fatigue. History includes hypertension, type 2 diabetes mellitus, ischemic cardiomyopathy, and chronic kidney disease. At her previous visit 2 weeks ago, blood pressure was 140/84 mmHg and pulse was 70 beats per minute. At today's visit, blood pressure is 188/100 mmHg. BUN is 67 mg/dL (baseline 41 mg/dL), and serum creatinine level is 3.9 mg/dL (baseline 1.9 mg/dL). Urinalysis is normal. Which one of the following is the most likely mechanism by which celecoxib caused acute renal failure? (A) Acute papillary necrosis with renal obstruction (B) Acute tubular necrosis from drug-induced nephrotoxicity (C) Drug reaction causing allergic interstitial nephritis (D) Hemodynamic renal insufficiency

Hemodynamic renal insufficiency

A 75-year-old man undergoes evaluation because he has gradually lost 4.5 kg (10 lb) over the last 4 months. History includes ketosis-prone diabetes. He had an esophageal rupture >1 year ago that required creation of a spit fistula (esophagus to chest wall), because anastomosis of the esophagus to the stomach was not possible. His hospital stay included prolonged immobility. The patient was discharged to a nursing home and has lived there since. Nutrition comprises a bolus of commercially available solution via gastrostomy tube 4 times daily and has not changed since his admission. Since admission to the nursing facility, the patient has made significant improvements in daily function. He can propel himself in a wheelchair and ambulate approximately 100 ft with 1 assistant. The patient was unaware that he had been losing weight. He reports that after each tube feeding, he has an uncomfortable sensation of fullness and fecal urgency, and he passes loose, nonbloody stool. He states that he never misses a feeding, but frequently ends it before completion because of the fecal urgency. He reports no palpitations, night sweats, heat or cold intolerance, anxiety or depression. Physical examination confirms weight loss but is otherwise unremarkable. Laboratory findings show mild anemia and mild renal insufficiency. Hemoglobin A1c level is 7.6%. There is no evidence of blood in stool. Which one of the following is the most likely cause of the patient's weight loss? (A) Inadequate caloric intake (B) Malabsorption (C) Occult malignancy (D) Inadequate control of diabetes

Inadequate caloric intake

A 76-year-old man comes to the office because over the last 2 months he has had decreased appetite and he has felt increasingly lethargic. He states that he has been stumbling frequently and has numbness, tingling, burning, stiffness, and weakness in his hands. He has lost 5.8 kg (12.8 lb). He has had no swelling or signs of inflammation in his hands, and his feet have not bothered him. Approximately 2 weeks ago he began to have episodes of lower abdominal pain and stiffness in his hips, back, and shoulders. His wife notes that his gait is unsteady and that he has nearly fallen at night when going to the bathroom. For the last 2 days, he has had intermittent diffuse abdominal pain that radiates to his back, shoulders, and arms. He has not traveled out of state or to rural areas in several years. History is unremarkable, and he does not take prescription medications, supplements, herbal products, or over-thecounter medications, except acetaminophen occasionally. He has never used illicit drugs, alcohol, or tobacco products. On examination, he appears chronically ill but alert and oriented, and vital signs are normal. His weight is down 2 kg since his appointment 6 months ago. His tongue is enlarged, painful, and red, and there is tenderness on deep palpation in the epigastric region. There is bilateral pronator drift, decreased sensation to light touch in hands and feet, and normal vibration and temperature sensation in the arms but not in the legs and feet. Gait is normal when the patient walks heel-to-toe or on his heels or toes with his eyes open. When he closes his eyes, he loses his balance even while standing still (positive Romberg test). The remainder of the examination is normal. Laboratory findings: Serum globulin 2.1 g/dL Total bilirubin 2.1 mg/dL, with normal direct bilirubin Lactate dehydrogenase 653 U/L Hemoglobin 8.7 g/dL with normal chromic, normocytic indices Red-cell distribution width 28% Reticulocytes 0.80% The WBC count, platelet count, and differential are normal, as are results of electrocardiography and chest radiography. Which one of the following additional studies would be most helpful in securing the correct diagnosis? (A) Bone marrow biopsy and aspirate (B) CT of the chest, abdomen, and pelvis (C) Levels of serum iron, iron-binding capacity, vitamin B12, and methylmalonic acid (D) Blood tests for HIV, Lyme disease, and syphilis (E) Levels of C-reactive protein, antinuclear antibody, and antineutrophil cytoplasmic antibodies

Levels of serum iron, iron-binding capacity, vitamin B12, and methylmalonic acid

A 75-year-old woman comes to the office for routine follow-up. Medications include aspirin 81 mg, glipizide 5 mg, lisinopril 5 mg, and pravastatin 20 mg, each taken daily. She states that she feels well overall, except that in the last several months she has had difficulty sleeping, such that her energy level is affected. She sleeps intermittently about 4 hours each night. There have been no changes in her sleep routine, and she does not drink caffeine after 10 am. She is not depressed or anxious. She asks whether she should try melatonin to help her sleep. Which one of the following is important to know? (A) Melatonin will interact with glipizide. (B) Long-acting melatonin is more effective than the short-acting form. (C) There is insufficient evidence that melatonin improves insomnia compared with placebo. (D) Melatonin will interact with pravastatin

Long-acting melatonin is more effective than the short-acting form

A 77-year-old man undergoes evaluation because he fell in the nursing home. History includes hypertension, atrial fibrillation, and insomnia. On examination, blood pressure is 140/80 mmHg seated and 120/70 mmHg standing. Heart rate is 68 beats per minute and irregularly irregular. He did not sustain any significant injuries in the fall. His medications are reviewed. Which one of his medications is most strongly associated with falls? (A) Amlodipine (B) Vitamin D (C) Warfarin (D) Amiodarone (E) Lorazepam

Lorazepam

Which of the following statements about the use of over-the-counter (OTC) drugs by older adults and the risk of an adverse drug reaction is TRUE? a)Many older adults see OTCs as benign b)The risk of an adverse drug reaction is much greater with prescription drugs than with OTCs c)Most of the OTCs used by older adults are low risk d)The use of OTCs by older adults is much less than that of younger adults

Many older adults see OTCs as benign

A 76-year-old woman with metastatic breast cancer has pain due to bony metastases and is now receiving home hospice services. She has been depressed since coming home. Her pain is treated with opioids, which have helped but have also caused occasional nausea without vomiting. She and her family ask whether there are nonpharmacologic alternatives, such as massage, that would alleviate her symptoms. Which one of the following is true regarding the use of massage to treat pain? (A) There is no evidence that massage alleviates pain in patients with cancer. (B) Only massage provided by licensed professionals has been shown to alleviate pain caused by cancer. (C) Massage provided by a caregiver for 20 minutes, 3-4 times per week, can alleviate cancer pain. (D) Massage can alleviate cancer pain but not depression.

Massage provided by a caregiver for 20 minutes, 3-4 times per week, can alleviate cancer pain

An 82-year-old man comes to the office because his wife is concerned about abnormal behaviors during sleep. History includes Parkinson disease, hypertension, and arthritis. For the past year, he has been mumbling or yelling in his sleep. During the past 3 months, at least 3 times each week, he has also been sitting up and moving his hands and arms, as if he were pushing someone away. Last week, he injured his hand when he knocked over the night lamp. When questioned, he sometimes recalls dreams in which he is playing football or basketball. Polysomnography shows increased motor activity in rapid eye movement (REM) sleep and mild obstructive sleep apnea. Which one of the following is the best initial treatment for this patient? (A) Clonazepam (B) Gabapentin (C) Sertraline (D) Melatonin

Melatonin

An 85-year-old woman comes to the office for follow-up after hospitalization 7 days ago for chest pain and dyspnea. Non-ST elevation myocardial infarction (NSTEMI) was diagnosed, and she received a bare metal stent to the left anterior descending coronary artery. She reports feeling well since discharge, with no chest pain or dyspnea. At baseline, she is cognitively intact and physically active. History includes hypertension and arthritis with episodic flares. Medication before myocardial infarction was amlodipine 5 mg/d. Amlodipine was discontinued, and medications at hospital discharge are metoprolol 25 mg twice daily, lisinopril 5 mg/d, aspirin 81 mg/d, and clopidogrel 75 mg/d. She recalls that the hospital cardiologist mentioned statin therapy, but she does not remember any details, and will not follow-up with him since he does not participate in her insurance plan. Which one of the following is the most appropriate management strategy regarding statins for patients who have had acute myocardial infarction? (A) The benefits of statin therapy are proved, particularly for adults >80 years old. (B) Moderate-potency statins should be prescribed for patients ≥75 years old for secondary prevention. (C) Statins should be uptitrated if baseline level of low-density lipoprotein cholesterol is >130 mg/dL. (D) Initial management requires starting statins concurrently with diet therapy

Moderate-potency statins should be prescribed for patients ≥75 years old for secondary prevention

Which one of the following statements about the use of antibiotic prophylaxis before dental appointments is false? a. There is little evidence to support the benefit of antibiotic prophylaxis for all dental visits by patients at increased risk of infective endocarditis (IE). b. Patients with pins, plates, or screws do not need antibiotic prophylaxis. c. American Heart Association guidelines recommend azithromycin or clindamycin for prophylaxis in penicillin-allergic patients at risk of IE. d. Most prosthetic joint infections are caused by common oral bacteria

Most prosthetic joint infections are caused by common oral bacteria

An 82-year-old woman comes to the office because she has had fatigue, increased pedal edema, and weight gain since she fell on her knees 1 week ago. She went to the emergency department after the fall for knee pain. The fall was clearly accidental and not caused by arrhythmias or syncope. Radiography of the knees showed no fracture, and she was prescribed treatment for her pain. However, documentation from the emergency department visit is unavailable. History includes heart failure, which has been stable for 18 months. Current medications are metoprolol, furosemide, and an ACE inhibitor. On examination, neck veins are distended. There are crackles in both lower lung fields. Which one of the following is most likely the treatment prescribed in the emergency department for the knee pain? (A) Acetaminophen 500 mg every 6 hours (B) Naproxen sodium 220 mg every 12 hours (C) Diclofenac patch to knee twice daily (D) Tramadol 50 mg every 8 hours

Naproxen sodium 220 mg every 12 hours

Which one of the following micronutrient supplements promotes healing of pressure ulcers in older adults? (A) Zinc sulfate (B) Selenium (C) Vitamin C (D) Daily multivitamin that contains zinc, selenium, iron, and vitamins A, C, and E (E) No supplement is necessary

No supplement is necessary

A 70-year-old woman comes to the office for routine follow-up. History includes moderate Alzheimer disease, hypertension, and hypercholesterolemia. Medications include aspirin 81 mg, lisinopril 10 mg, simvastatin 40 mg, and donepezil 10 mg, each taken daily. She is accompanied by her daughter, who asks whether her mother would benefit from herbal or other supplement therapies for Alzheimer disease. Which one of the following supplements is most likely to help slow the progression of Alzheimer disease? (A) Ginkgo biloba (B) Caprylic acid (C) Coenzyme Q 10 (D) Omega-3 fatty acid (E) None

None

Which one of the following reflects the current best evidence regarding vitamin D screening and supplementation among asymptomatic older adults? (A) Older adults should take oral vitamin D3 5,000 IU/d. (B) Levels of 25(OH) vitamin D should be checked in all older adults; patients with levels <30 ng/dL should take oral vitamin D 2 50,000 IU every week until the level is >30 ng/dL. (C) Older adults should consult a health care provider about whether they should have their 25(OH) vitamin D level checked or take vitamin D supplements. (D) There is no proven value to measuring 25(OH) vitamin D level or taking a vitamin D supplement

Older adults should consult a health care provider about whether they should have their 25(OH) vitamin D level checked or take vitamin D supplements

An 87-year-old man is brought to the emergency room because he has a femoral neck fracture. He fell on his way to the bathroom at night. History includes diabetes, hypertension, and gastroesophageal reflux disease. Which one of the following medications may have increased his risk of fracture after the fall? (A) Glargine (B) Omeprazole (C) Nifedipine (D) Cimetidine

Omeprazole

An 85-year-old woman is admitted to the hospital because she has intractable nausea and vomiting. History includes hypothyroidism, Parkinson disease, mild cognitive impairment, and metastatic ovarian cancer. She has peritoneal carcinomatosis, which appears to have worsened on recent imaging, and her oncologist informed her that there are no further treatment options for the cancer. Medications include levothyroxine and amlodipine; she has oxycodone and ondansetron at home but does not take them regularly. Oral intake is poor; she has a bowel movement every other day. On examination, abdomen is distended, with positive bowel sounds and diffuse tenderness to palpation. Abdominal radiography shows no air fluid levels or signs of obstruction or impaction. Intravenous hydration is started. Which one of the following is the best treatment for her nausea? (A) Ondansetron 4 mg every 8 hours around the clock (B) Ondansetron 4 mg every 8 hours as needed for nausea (C) Prochlorperazine 10 mg every 6 hours as needed for nausea (D) Metoclopramide 10 mg every 6 hours as needed for nausea (E) Scopolamine patch, changed every 72 hours

Ondansetron 4 mg every 8 hours around the clock

A 75-year-old man comes to the office for a preadmission physical examination for an assisted-living facility. History includes mild early dementia and hypercholesterolemia. Current medications are donepezil, simvastatin, daily multivitamin, and aspirin 81 mg/d. On examination, blood pressure is 120/75 mmHg and heart rate is 75 beats per minute. There is accentuated kyphosis of the thoracic spine but no pain on palpation. Heart, lung, and abdominal findings are normal. He uses his arms to stand from a seated position, and appears unsteady when asked to turn around while walking. He uses a cane to steady his gait. Level of 25(OH)D level is 30.2 ng/mL. All other laboratory findings, including serum calcium level and estimated glomerular filtration rate, are normal. Bone mineral density is measured by dualenergy x-ray absorptiometry (DEXA). T-score is −1.0 in lumbar spine, −2.0 in left total hip, and −2.7 in left femoral neck. A high-calcium diet, participation in an exercise program, and pharmacologic treatment are recommended. Which one of the following is the most appropriate pharmacologic treatment for this patient? (A) Oral alendronate 70 mg weekly, 30 minutes before breakfast with a glass of water (B) Intravenous zoledronic acid 5 mg yearly (C) Topical testosterone cream 5 g applied daily (D) Subcutaneous denosumab 60 mg every 6 months

Oral alendronate 70 mg weekly, 30 minutes before breakfast with a glass of water

An 85-year-old man comes to the office because he has been having episodes of dizziness. The dizziness is typically elicited by movement, such as by standing up from a seated position. In between these episodes he feels somewhat lightheaded. Further investigation of the timeline suggests that symptoms started shortly after his last visit to the office, when some dosage adjustments were made to his usual medications. History includes hypertension, coronary artery disease, gastroesophageal reflux, urinary incontinence, and COPD. Which one of the following medications is most likely to have been adjusted at his previous visit that could have resulted in the dizziness? (A) Omeprazole (B) Fluticasone inhaler (C) Aspirin (D) Oxybutynin

Oxybutynin

A 74-year-old woman is brought to the office because she has severe bilateral hip pain related to osteoarthritis. History also includes mild dementia, chronic kidney disease (baseline creatinine 2.2 mg/dL), seizure disorder, and heart failure (ejection fraction 25%). Current medications are acetaminophen 650 mg three times daily, furosemide 40 mg/d, carbamazepine 200 mg three times daily, donepezil 10 mg/d, lisinopril 10 mg/d, and metoprolol succinate 100 mg/d. Over the last month, the pain has increased such that she can only ambulate with a walker and now needs help with toileting. She is not a candidate for hip replacement surgery. Which one of the following is the most appropriate pharmacologic treatment for the patient's pain? (A) Carbamazepine titrated to 400 mg three times daily (B) Ibuprofen 400 mg three times daily (C) Immediate-release oral morphine 7.5 mg every 8 hours, held for sedation (D) Oxycodone 2.5 mg every 8 hours, held for sedation (E) Tramadol 50 mg every 6 hours as needed for pain

Oxycodone 2.5 mg every 8 hours, held for sedation

Which of the following is true in regard to iron supplementation for iron-deficiency anemia? (A) Parenteral iron is the first-line treatment for iron deficiency. (B) Poor adherence to oral iron therapy might become an issue during treatment. (C) There is a significant difference among the oral iron preparations in regard to efficacy. (D) Drug-drug interactions are not common with oral iron supplements.

Poor adherence to oral iron therapy might become an issue during treatment

A 79-year-old woman undergoes evaluation because she has lost approximately 10% of her body weight over the last 3 months. History includes Alzheimer disease (diagnosed approximately 6 years ago), hypertension, hyperlipidemia, and osteoarthritis, as well as bowel and bladder incontinence. Medications include senna 2 tablets at bedtime and acetaminophen 650 mg twice daily; blood pressure is well controlled without medication. She has lived in a nursing facility for 12 months. She is primarily wheelchair bound but can transfer with assistance, and she requires assistance with bathing and dressing. Her speech is dysarthric and limited to single words. She is typically pleasant and often observed to be humming or singing. Her food intake has declined significantly despite modifications in the consistency and content of her diet. The patient's family has provided foods that she previously enjoyed, and staff have set up her tray to facilitate her ability to eat. Which one of the following is the most appropriate next step in managing the patient's weight loss? (A) Program of careful hand feeding (B) Referral for placement of gastrostomy tube (C) Addition of oral nutritional supplements (D) Evaluation for occult malignancy

Program of careful hand feeding

An 81-year-old woman is admitted to a nursing home after she was hospitalized for 6 weeks for pneumonia and acute respiratory failure. On admission to the hospital, weight was 82.5 kg (182 lb), and there was no edema in her lower extremities. She required intubation and ventilatory support for 3 days. The hospital course was complicated by acute kidney injury that required dialysis, prolonged ileus, several pressure ulcers, a urinary tract infection, Clostridium difficile-induced colitis, and a mild right-hemisphere stroke. Her condition improved and, at hospital discharge, all catheters, intravenous lines, and antibiotics were discontinued. She was ambulating short distances and tolerating a regular diet. Recent assessments by a dietitian and a speech therapist found no evidence of chewing or swallowing difficulties. She is deconditioned and needs assistance with all ADLs. On examination in the nursing home, temperature is 37° C (98.6° F), blood pressure is 148/90 mmHg, pulse is 78 beats per minute, and respiratory rate is 18 breaths per minute. Weight is 82 kg (181 lb). Pretibial and presacral edema is 3-4+ , and there is an unstageable 5 cm × 4 cm sacral pressure ulcer surrounded by noninflamed, healthy skin. Chest, cardiac, and abdominal findings are unremarkable. Muscle strength testing shows mild weakness of the left upper extremity. Laboratory findings: Hemoglobin 10.5 g/dL WBC count 7.8/μL Creatinine 1.8 mg/dL BUN 12 mg/dL Albumin 2.7 g/dL Which one of the following is most appropriate for optimizing the patient's nutritional status? (A) Start megestrol acetate, 400 mg orally twice each day. (B) Order a complete swallowing assessment. (C) Place a feeding tube and start enteral feedings with a high-protein polymeric (nutritionally complete) formula at a rate sufficient to provide 30 kcal/kg daily. (D) Provide feeding assistance and monitor nutrient intake with complete calorie counts for the next 3 days. (E) Start a high-protein oral nutritional supplement, 240 mL three times daily between meals

Provide feeding assistance and monitor nutrient intake with complete calorie counts for the next 3 days

An 84-year-old woman comes to the clinic to establish care. She recently moved to the area to be closer to her children and grandchildren. History includes coronary artery disease, hypertension, heart failure, dyslipidemia, and osteoarthritis. Medications are lisinopril 20 mg/d, furosemide 40 mg/d, digoxin 0.125 mg/d, aspirin 81 mg/d, atorvastatin 40 mg/d, and acetaminophen 1,000 mg three times daily. She describes feeling short of breath with moderate activity. On examination, blood pressure is 122/78 mmHg, heart rate is 86 beats per minute, and respiratory rate is 16 breaths per minute. Echocardiography from 1 year ago shows left ventricular hypertrophy, ejection fraction of 30%, and normal valve function. There are no signs of fluid overload. Laboratory findings: Low-density lipoprotein (direct assay) 70 mg/dL Sodium 136 mEq/L Potassium 5.2 mEq/L BUN 30 mg/dL Serum creatinine 1.6 mg/dL Which one of the following is the most important next step? (A) Reduce atorvastatin. (B) Reduce lisinopril. (C) Reduce digoxin. (D) Add eplerenone

Reduce digoxin

An 80-year-old woman who fell in her kitchen at home and underwent repair of hip fracture 3 days ago now reports dizziness. The nurse notes excessive daytime drowsiness. History includes hypertension, frequent falls, and post-herpetic neuralgia. Medications before admission have been restarted; they include hydrochlorothiazide 12.5 mg/d, extended-release metoprolol 50 mg/d, amlodipine 10 mg/d, gabapentin 600 mg three times daily, and calcium carbonate tablets 500 mg three times daily. The following medications were started after surgery: subcutaneous enoxaparin 30 mg/d, daily multivitamin, docusate 250 mg twice daily, and senna 8.6 mg twice daily. Oxycodone, 5-15 mg every 4 hours as needed, is on order for pain; she received two 10-mg doses in the last 24 hours. On examination, the patient weighs 45 kg (99 lb). Blood pressure is 144/76 mmHg, with no orthostatic changes. Estimated creatinine clearance, based on laboratory samples drawn today, is 30 mL/min; 2 months ago, estimated clearance was 60 mL/min. Which one of the following is the best next step in management? (A) Discontinue oxycodone. (B) Increase enoxaparin to 30 mg twice daily. (C) Reduce gabapentin to 600 mg twice daily. (D) Start alendronate 70 mg once weekly.

Reduce gabapentin to 600 mg twice daily.

An 88-year-old woman is brought to the office by her daughter, who requests a second opinion on her mother's condition. The patient lives in a nursing facility. History includes moderate to severe dementia, poor physical performance with frailty (poor ambulation, sarcopenia, exhaustion), and metabolic syndrome, with hypertension, increased cholesterol, and increased waist circumference. Medications include 3 antihypertensive agents, metformin, calcium, a statin, an antidepressant, and a stool softener. Bone mineral density tests identify low bone mass at the hip; she has never had a fracture. She had complicated grief and situational depression when her husband died 16 years ago. On examination, she appears pleasant and is cooperative. She has significant difficulty with word finding and following multistep commands. Blood pressure is 110/68 mmHg. BMI is 29 kg/m2 and she has truncal obesity. She is unable to rise from a chair without using her hands but shows fair to good balance. Muscle wasting is evident in her arms and legs. Which one of the following would most benefit the patient? (A) Weight reduction and exercise regimen (B) Review of medications (C) Treatment of low bone mass (D) Physical therapy consult for poor physical performance (E) Initiation of vitamin D supplementation

Review of medications

A 67-year-old woman comes to the office for a routine physical examination. History is unremarkable. She takes a multivitamin daily but no other medications or supplements. Her mother has recovered well from a hip fracture 5 years ago and is otherwise healthy. Her father has hypertension and developed coronary artery disease in his 70s. The patient does not smoke, drink alcohol, or use illicit drugs. She describes her diet as high in carbohydrates and processed food, and low in fresh fruits, vegetables, and milk or other sources of calcium. She is generally sedentary. Which one of the following recommendations regarding vitamin supplements is most appropriate for this patient? (A) She should continue taking the multivitamin. (B) She should discontinue the multivitamin. (C) She should discontinue the multivitamin and begin a well-balanced diet. (D) She should discontinue the multivitamin and start vitamin D 400 IU daily

She should discontinue the multivitamin and begin a well-balanced diet

An 81-year-old man comes to the office for routine follow-up. He resides in an assisted-living facility, which manages his medications, and is independent with most ADLs. History includes COPD, type 2 diabetes, coronary artery disease, hypertension, atrial fibrillation, depression, and recently vascular dementia. Medications include tiotropium 1 capsule inhaled daily, albuterol 2 puffs every 6 hours as needed, metformin 500 mg twice daily, lisinopril 10 mg/d, warfarin 3 mg/d, metoprolol 100 mg twice daily, aspirin 81 mg/d, and citalopram 20 mg/d. On examination, blood pressure is 144/88 mmHg, and heart rate is 77 beats per minute. His Mini-Mental State Examination score is 26 of 30. Laboratory findings: LDL 174 mg/dL HDL 32 mg/dL Triglycerides 190 mg/dL Serum creatinine 1.3 mg/dL Hemoglobin A1c 7.20% Aspartate aminotransferase 44 U/L Alanine aminotransferase 48 U/L Which one of the following is the most appropriate next step in caring for this patient? (A) Increase lisinopril. (B) Start insulin. (C) Start simvastatin. (D) Continue present management

Start simvastatin

Patient ER is a 67-year-old female without any complaints. She is a functional patient living in the community with a history of hypertension. Blood work reveals a low-density lipoprotein (LDL) significantly above goal for the second time this year, despite lifestyle modification. Select the most appropriate therapeutic plan at this time. a. Consider lifestyle modification for 3 more months b. Initiate atorvastatin 80 mg daily c. No medical intervention at this time d. Start simvastatin 10 mg daily

Start simvastatin 10 mg daily

A 75-year-old woman comes to the office for follow-up for resistant hypertension. She has had hypertension for 20 years. During the past 2 years, her blood pressure has ranged from 160/80 mmHg to 180/80 mmHg despite several changes in medication. Current medications include hydrochlorothiazide 25 mg/d, metoprolol succinate 50 mg/d, hydralazine 25 mg three times daily, and lisinopril 40 mg/d. Limited adherence to treatment is suspected, based on pharmacy records and a pattern of missing scheduled visits. She states that she feels well and has no headache, sweating, or palpitations. She stopped smoking 5 years ago. There is no history of diabetes, stroke, or coronary heart disease. On examination, blood pressure is 165/80 mmHg sitting and 155/75 mmHg standing, and heart rate is 80 beats per minute. Cardiac findings are normal. There is an upper abdominal systolic bruit, but aortic impulse is not enlarged. There are no femoral bruits, and pedal pulses are normal. Neurologic findings, including assessment of mental status, are normal. Creatinine level is 1.3 mg/dL, and estimated glomerular filtration rate is 55 mL/min; sodium, potassium, and calcium levels and CBC are normal. Ultrasonography shows 75% stenosis of the right renal artery. Which one of the following is the most appropriate next step in management? (A) Increase hydralazine. (B) Stop hydralazine and start amlodipine. (C) Schedule magnetic resonance angiography. (D) Increase metoprolol succinate.

Stop hydralazine and start amlodipine

Patient GG is an 82-year-old female with complaints of dysuria and polyuria. A urinalysis is positive for a urinary tract infection. She is 55 kg, her serum creatinine is 1.5 mg/dL, and she has no known drug allergies. Which of the following is the most appropriate antibiotic regimen? a. Ciprofloxacin 500 mg bid for 3 days b. Nitrofurantoin 100 mg bid for 7 days c. Sulfamethoxazole/trimethoprim 400/80 mg bid for 3 days d. Sulfamethoxazole/trimethoprim 800/160 mg bid for 3 days

Sulfamethoxazole/trimethoprim 400/80 mg bid for 3 days

An 81-year-old man undergoes evaluation because he vomited overnight and has since had a nonproductive cough, rapid breathing, and fever. History includes severe intellectual disability and schizophrenia; in addition, he has a gastrostomy tube because of severe dysphagia. The patient lives in a nursing home and is dependent for all ADLs. He does not speak. On examination, he appears thin and chronically ill, but he does not appear to be in respiratory distress. Temperature is 38.5° C (101.3° F), heart rate is 85 beats per minute, blood pressure is 115/70 mmHg, and respiratory rate is 24 breaths per minute; O2 saturation is 91% on room air. Cardiac auscultation reveals regular rhythm and rate without murmur. Lung sounds are coarse throughout. Laboratory findings: WBC count 19.2/μL, with 77% neutrophils and 9% bands Hemoglobin 10.1 g/dL Hematocrit 31% Platelets 258,000/μL Sodium 139 mEq/L Potassium 3.9 mEq/L Chloride 100 mEq/L Carbon dioxide 26 mEq/L BUN 29 mg/dL Creatinine 0.44 mg/dL Chest radiography shows diffuse mild interstitial prominence, unchanged from prior examinations. Which one of the following is the most appropriate first-line treatment? (A) Ceftriaxone 1 g IM and azithromycin 500 mg via gastrostomy tube (B) Clindamycin 450 mg three times daily via gastrostomy tube (C) Prednisone 60 mg via gastrostomy tube (D) Supplemental oxygen

Supplemental oxygen

Risk factors for dental decay include all but which one of the following? a. Regular use of anticholinergic medications b. A diet high in carbohydrates c. Overzealous toothbrushing d. The aging of the salivary glands

The aging of the salivary glands

Which one of the following statements about oral-systemic linkages is false? a. Periodontal disease has been shown to increase the risk for poor glycemic control. b. Improving oral hygiene reduces the risk of respiratory disease. c. There is evidence that periodontal disease is a causative factor for atherosclerotic disease. d. Older adults with oral problems have lower Healthy Eating Index scores. e. Poor oral health affects speaking, swallowing, self-image, and socialization

There is evidence that periodontal disease is a causative factor for atherosclerotic disease

A 78-year-old man comes to the office for routine follow-up. History includes hypertension, hypercholesterolemia, and benign prostatic hyperplasia (BPH). Medications include hydrochlorothiazide 25 mg, tamsulosin 0.4 mg, and simvastatin 20 mg, each taken daily. He has heard that saw palmetto may be used for treatment of BPH and asks whether he should try it. Which one of the following statements is true? (A) Saw palmetto would interact with hydrochlorothiazide. (B) Saw palmetto may decrease symptoms of BPH, but its effectiveness will depend on the formulation (capsule, extract, or tea). (C) There is insufficient evidence that saw palmetto will decrease his symptoms of BPH. (D) Saw palmetto would interact with simvastatin.

There is insufficient evidence that saw palmetto will decrease his symptoms of BPH

A 76-year-old man is brought to the emergency department because he has an acute exacerbation of COPD. He has no viral respiratory symptoms, cough, or change in sputum color or production, and there have been no changes in his medications. A review of records indicates that his disease has been stable for the past 2 years, with no exacerbations. The records also indicate that 1 week ago he received a new prescription for eye drops. On further questioning, the patient states that he recently visited an ophthalmologist because he had blurry vision. Glaucoma was diagnosed, and several different topical drops were prescribed. Which one of the following medications is most likely to have exacerbated the COPD? (A) Timolol (B) Brimonidine (C) Pilocarpine (D) Latanoprost

Timolol

A 72-year-old man comes to the office because he has increased difficulty with urination, including straining to void and occasional urinary incontinence. History includes benign prostatic hyperplasia, COPD, type 2 diabetes, peripheral neuropathy, and seasonal allergies. Medications include tamsulosin 0.4 mg at bedtime, gabapentin 600 mg twice daily, metformin 1,000 mg twice daily, loratadine 10 mg/d, fluticasone nasal inhaler 2 sprays in each nostril daily, tiotropium 1 capsule inhaled daily, and albuterol 2 inhalations as needed 4 times daily. The gabapentin dosage was increased 3 weeks ago. On examination, the prostate is not enlarged, and urinary tract infection is excluded. Which one of the following is the most likely cause of his urinary symptoms? (A) Gabapentin (B) Loratadine (C) Tamsulosin (D) Tiotropium

Tiotropium

Mrs. Jones is a 72-year-old female who has been living alone, and has come to your office for a routine physical examination. During the visit you notice that Mrs. Jones has lost 15 pounds since her last visit 6 months ago. You decide to get some laboratory work to investigate the weight loss further. Which of the following is the least useful marker for evaluating nutritional status? a. Serum cholesterol b. Total lymphocyte count c. Serum albumin d. Serial weight measurement e. Serum prealbumin

Total lymphocyte count

A 70-year-old man comes to the office because he has knee pain. He has been walking more since he started a part-time job at a hardware store 2 months ago. He mentions that his mood has been down since his wife died 6 months ago. He has no history of psychiatric illness, and he does not smoke, drink, or use drugs. His children live out of state. Score on the Geriatric Depression Scale is 9. He states that he does not like to take medications but would consider taking "something natural" for his mood. Each of the following therapies may help with depression EXCEPT: (A) Curcumin (B) St. John's wort (C) S-adenosyl methionine (SAMe) (D) Valerian

Valerian

A recently widowed 74-year-old woman comes to your office with depression and fatigue. She has a documented weight loss of 5 lbs since her last visit 3 months ago. She confesses that she has not been preparing meals and eating like she did when her husband was alive. She is not surprised that she has lost weight since her husband died last month. A nutritional assessment confirms that she is still in good nutritional health but is at risk for malnutrition because of depression, eating alone, and social isolation. What is the first nutrition strategy you recommend? a. She should consume a commercial high-calorie supplement once or twice a day to prevent further weight loss. b. Visit a senior nutrition program. c. Move to a retirement home. d. Start cooking again. e. Volunteer at the local food bank.

Visit a senior nutrition program

Which of the following drugs is considered a high risk medication for a patient with a history of seizures? a) bupropion b) celecoxib c) nifedipine d) fluconazole

bupropion

Mrs. L. is a 71 year old woman who has been your patient for several years. You have been treating her for insomnia for about 2 months with non-pharmacological interventions. She tells you that they are "helping a little" but some nights it is just impossible for her to sleep. She asks you if you could give her a "small amount" of medication for her to use on those nights. Which of the following would be an appropriate medication for Mrs. L.? a)flurazepam b) diphenhydramine c) meprobamate d) Eszopiclone

diphenhydramine