MSN 611 FINAL

A 65-year-old woman visits her primary care provider for her annual checkup. The nurse measures her blood pressure, which is 152/89 mmHg. She has no history of high blood pressure, diabetes, or dyslipidemia. The provider decides to start the patient on amlodipine besylate, 5 mg once daily. How should the patient be counseled about the mechanism of action of this medication?

"Amlodipine will widen blood vessels by blocking calcium from going into the cells and make it easier for blood to flow through and reduce blood pressure."

When starting a patient on warfarin, approximately how long does it take for anticoagulation to increase the INR?

48 to 72 hours

A 78-year-old woman reports that memory loss over the last few years is progressing to the point that she is having difficulty conducting daily activities. She has trouble remembering why she left her house to run errands and has found it increasingly difficult to manage her finances. The Mini-Mental State Examination (MMSE) score is 23/30. Physical examination is unremarkable, and routine blood test results are within normal limits. Given the likely diagnosis, what is the mechanism of the most appropriate pharmacotherapy for this patient?

Acetylcholinesterase inhibitor

A 58-year-old man is brought to the emergency department with confusion and slow breathing. His wife found him on the floor and was unable to arouse him. His wife says he has been unable to get any relief lately and thinks he may be using more medication than prescribed. He has had terminal colon cancer for two years and was about to enter palliative care. He is currently taking transdermal fentanyl patches, opioids, and an oxygen tank. His blood pressure is 100/60 mm Hg, and his respiratory rate is 8 breaths/min. He has pinpoint pupils and is difficult to arouse. What is the mechanism of the drug that should be administered first?

Antagonizes opioid effects by competing for the µ opiate receptor sites

A 25-year-old woman presents with depression resistant to multiple classes of antidepressants. A nonselective monoamine oxidase inhibitor (MAOI) is prescribed. Which of the following should be included in patient counseling regarding the prevention of one of the most serious adverse effects of this drug?

Avoid tyramine-containing foods

A 17-year-old male comes into the emergency department complaining of shortness of breath. He came directly from his first practice on the high school soccer team. He reports that he had similar symptoms when he was younger, but has since outgrown them. His blood pressure is currently 130/82 mmHg, heart rate is 98 bpm, oxygen saturation is 87% on room air, and respiratory rate is 27 breaths/min. A chest radiograph shows no abnormalities, and the electrocardiogram (ECG) is normal. After giving him 100% oxygen therapy, he is given an inhaled medication. What type of receptor does the most likely medication affect?

Beta 2

A 60-year old man is brought to the emergency department after an episode of syncope. The patient was watching television when he felt light-headed and lost consciousness. He regained consciousness after a minute spontaneously. The patient's past medical history is significant for hypertension, diabetes, and peripheral neuropathy. His medications include metformin, hydrochlorothiazide, and amitriptyline. ECG in the emergency department shows a QT interval of 480 ms. What is the mechanism of action of the drug responsible for this patient's symptoms and ECG findings?

Blocking the reuptake of both serotonin and norepinephrine neurotransmitters

A 5-year-old boy presents with a worsening cough and thick yellow-green nasal discharge for the past two weeks. He has no chronic medical conditions and is not taking any medication. His immunizations are up to date. Vital signs show a temperature of 39.2 C (102.6 F), blood pressure of 120/80 mmHg, pulse of 92/min, and respiratory rate of 20/min. On examination, nasal turbinates are swollen and erythematous, and there is a thick purulent discharge from the nares. Lungs are clear on auscultation. Amoxicillin-clavulanate is prescribed for acute bacterial sinusitis. What is the role of the clavulanate component in amoxicillin-clavulanate?

Clavulanate inhibits beta-lactamase produced by bacteria to prevent the inactivation of amoxicillin

A 50-year-old woman presents to the clinic with new-onset bowel symptoms. She is straining to have a bowel motion and describes her stools as hard and pellet-like. She had a hip-fracture repair 2-weeks ago and is on oral morphine for pain control. She is a ten pack-year smoker and consumes alcohol occasionally. She is afebrile, and her vitals are stable. The abdominal exam is unremarkable. Of the following, what is the mechanism of action of the medication that could have avoided this patient's problem?

Decreases the surface tension of the stool-water interface and facilitates stool passage

A 67-year-old man presents to the emergency department with bradycardia with a heart rate of 44 beats per minute and blood pressure of 100/60 mmHg. Which of the following medication should be held to ensure his heart rate rises?

Diltiazem

A 45-year-old man presents for follow-up after a diagnosis of diabetes mellitus type 2 and initiation of metformin three months ago. He says he would like to discontinue the metformin because of its adverse effects. He feels embarrassed at work because of metformin-associated diarrhea, and he has been feeling nauseous on most days. The patient confirms that he followed the metformin titration regimen provided by the clinician and is currently taking metformin IR 1000 mg twice daily with meals. What is the most appropriate next step in treatment?

Discontinue metformin IR and start metformin extended-release

A 65-year-old woman presents to a clinic for a preoperative visit before total hip arthroplasty. The clinician discusses medications to prevent deep vein thrombosis postoperatively and potential reversal agents in the setting of bleeding. The medication which the clinician plans on using may be reversed by protamin sulfate. What is the mechanism of action of this medication?

Enhances the action of antithrombin III

A 65-year-old male patient presents to the clinic for a follow-up visit after starting a new medication for chronic insomnia. He reports that his sleep has improved, but he has been experiencing concerning side effects. His wife has noticed him sleepwalking, eating during the night, and attempting to drive his car at night. The patient has no recollection of these events and is concerned. His blood pressure is 130/80 mmHg, pulse 82/min, respirations 18/min, and temperature 98.0 F (36.7 C). Physical examination is unremarkable. What is the mechanism of action of the medication responsible for the patient's side effects?

GABA-A receptor agonist

A 50-year-old male presents to the clinic complaining of numbness in the hands and feet. He also complains of an increased urinary frequency. On presentation, he is afebrile, has a pulse rate of 76 bpm, a blood pressure of 130/80 mmHg, and a respiratory rate of 14 breaths/min. The detailed physical examination does not reveal any significant findings. He has a hemoglobin of 13 g/dl, a total leukocyte count of 4800/mm^3, and a platelet count of 280,000/mm^3. His blood sugar levels are 288 mg/dl, 2 hours postprandial. He was diagnosed with hypertension two years ago, and his medical record shows he is compliant with medications. He is planning to be put on oral hypoglycemic treatment with metformin. He is also prescribed atorvastatin for vascular disease prevention, which acts by which of the following mechanisms?

HMG-CoA reductase inhibition

A 53-year-old man presents to the office for a routine checkup appointment for his heart-failure. He was diagnosed with heart failure 4 years ago after experiencing progressive dyspnea and bilateral lower extremity edema. The patient's most recent echo was done 6 months ago, showing an ejection fraction of 40%, stable from last year. He currently takes spironolactone, lisinopril, and carvedilol for the management of his heart failure. He is switched from lisinopril to sacubitril/valsartan. Which of the following best describes the mechanism of action of this combination drug?

Inhibition of BNP breakdown through neprilysin inhibiting action; angiotensin receptor blockade;

Adalimumab is being considered for a 39-year-old woman with a long-standing history of chronic plaque psoriasis who recently immigrated from Pakistan. What baseline investigation must be performed before initiating therapy?

Mantoux tuberculin skin test

A 78-year-old man presents to the emergency department after being found to have ingested several packets of acetaminophen at home. His son brings the empty packets with the patient, and it is calculated that he ingested 12 grams of acetaminophen approximately 3 hours ago. The patient is currently stable. What is the most appropriate treatment for this patient's overdose?

N-acetylcysteine

A 21 yr old male patient has been prescribed an anesthetic medication prior to a surgical procedure that resulted in the patient having visual distortions and feeling as is he is floating and detached from reality. After the patient begins regaining consciousness, he complains of nausea, vomiting and appears confused. The mechanism of action of the anesthetic that was prescribed relates to which of the following receptors?

NMDA

A 55-year-old male patient with a history of type 2 diabetes mellitus and hyperlipidemia presents to the emergency room for evaluation of substernal chest pain that he states began 1 hour ago after playing outside with his son. The patient reports that this pain has been transient for the past 3 months, but is usually provoked whenever he goes outside to do yard work. He states that this pain is typically relieved once he goes inside to take a break. A medication is given to the patient and he reports a rapid relief of his pain. Which medication was given?

Nitroglycerin

A 65-year-old man starts treatment with linezolid for methicillin-resistant Staphylococcus aureus (MRSA) infection. Two days later, he complains of fever, sweating, confusion, and agitation. His blood pressure is 150/91 mmHg, and his heart rate is 110/minute. A physical exam reveals diaphoresis, shivering, and hyperreflexia. The patient has a history of allergic rhinitis, hypercholesterolemia, depression, and peptic ulcer disease. His usual medications include lovastatin, astemizole, phenelzine, and famotidine. Which of the following most likely caused a drug interaction with linezolid?

Phenelzine

A 71-year-old man presents to the clinic for his monthly check-up. His vital signs show blood pressure of 133/92 mmHg, a temperature of 98.7 F, and a pulse of 104/minute. The patient has a history of atrial fibrillation. The physical exam is unremarkable. He is currently prescribed several medications, including warfarin. The patient's international normalized ratio (INR) has changed from his last visit from 2.3 to currently 6.2. Which of the following is the next best step in managing this patient?

Phytonadione

A 22-year-old patient with type 1 diabetes mellitus receives 12 units of regular insulin and 26 units of NPH insulin subcutaneously daily. Which of the following is an appropriate instruction for this patient regarding her new prescription?

Roll the NPH insulin bottle between the palms of the hands before drawing it up

A 70-year-old man presents to the clinic for routine follow-up. He has heart failure with reduced ejection fraction (HFrEF) and is in New York Heart Association (NYHA) class 3. His current medications include carvedilol, lisinopril, and spironolactone. His most recent echocardiogram shows an ejection fraction of 30%. The patient wants to continue with his current lifestyle for as long as possible. Which of the following is most likely to reduce his risk of mortality?

Substituting sacubitril-valsartan for lisinopril

A 17-year-old female presents for a follow-up on major depressive disorder therapy with venlafaxine. The mother and patient state that the patient's symptoms have improved. She has been performing better at school, enjoying activities with her friends, and going to the gym every day. However, the patient has trouble falling asleep. The mother states that she gives her daughter a cough medication, dextromethorphan, to make her drowsy and help her fall asleep. The mother and patient ask if they should be concerned about the use of dextromethorphan. What is the best response to their question?

There is an increased risk of serotonin syndrome if dextromethorphan is used with venlafaxine.

A 34-year old female has been troubled by migraine headaches that typically occur 5 to 6 times monthly. Treatment of the headaches when they occur is moderately successful. She asks whether there is anything she can do to reduce the frequency with which these headaches occur. She also has been troubled by long-standing mood issues, with episodes that are weeks long where she feels sad. What therapy might be recommended that can both reduce the frequency of her migraine attacks and may also be useful in improving her mood?

Venlafaxine

A client visits a provider with complaints of vaginal discharge and itching. After evaluation of the vagina and the discharge, bacterial vaginosis is diagnosed, and metronidazole is added for 7 days. What is the most important instruction to be given to this client?

abstain from alcohol

A mother brings her son, who has asthma. She would like to know if she can give her child acetaminophen. She has heard reports that it may worsen asthma. What is the current consensus on acetaminophen and asthma?

acetaminophen does not worsen asthma

A 45-year-old man is brought to the hospital by his sister with a history of seeing a man following him for the last nine months. He says that only he can see this man. She also says that he lost his job four months ago because of poor performance. Since then, the patient has been living in his room and does not go outside because he thinks that someone might kill him. On examination, the patient's vitals are normal. The clinician prescribes a medication that is known for extrapyramidal symptoms. This patient is at increased risk of developing which of the following in the next 24 hours?

acute dystonia

A 50-year-old female patient presents to the clinic due to constipation for the past two weeks. She describes her stool as hard, bullet-like. The patient had no recent medical history. The patient does not smoke but drinks alcohol socially. Her blood pressure is 110/70 mmHg, her pulse rate is 70 beats per minute, and her temperature is 37.5 C (99.5 F). Physical examination is within normal. What is the first treatment plan for her constipation?

add fiber to her diet and increase water intake

A 60-year-old man falls to the ground abruptly while walking. Chest compressions are immediately performed, and he was placed on a Lucas device en route to the emergency department. Upon reaching the emergency department, the cardiac monitor was attached, which showed a heart rate of 44 beats per minute and unrecordable blood pressure. His pulses are still not palpable. What is the first drug this patient should receive?

adrenaline

A 65-year-old woman presents to the healthcare provider for an evaluation. The patient had been placed on digoxin for atrial fibrillation. Which of the following drugs, if given, can significantly increase the levels of digoxin in the patient's serum?

amiodorone

A 65-year-old man presents with confusion and anuria. His past medical history is significant for hypertension, hyperlipidemia, insomnia, and diabetes mellitus with peripheral neuropathy. The patient is awake and oriented to person only. His blood pressure is 110/80 mmHg, pulse 90/min, respiratory rate is 18/min, and oxygen saturation 98% on room air. Physical examination is normal except for suprapubic fullness. On catheterization, 800 mL of urine is drained. Which of the following drugs is most likely the cause of this patient's presentation?

amitriptyline

A 17-year-old male patient comes to the clinic. He has been experiencing a headache, facial pain, runny nose, and nasal congestion. His blood pressure is 110/70 mmHg, heart rate is 100 beats/min, and temperature is 37.5 C (99.5 F). A culture has been taken, which shows a Gram-negative coccobacillus rod. Which of the following drug treatments is first-line for this patient's condition?

amoxicillin

A group of clinical researchers is investigating the management of osteoarthritis in patients with underlying psychiatric disorders. Patients recruited for the study are analyzed based on their medication regimen. 25% of patients in the study take a medication that binds to opioid receptors. What is a primary indication for the use of the drug mentioned above?

analgesia

A 65-year-old man visits his primary care provider for a routine checkup. On examination, his blood pressure is 159/88 mmHg. This is confirmed on repeat ambulatory blood pressure monitoring at home over the following seven days. A once-daily amlodipine regime is prescribed. When counseling the patient about this medication, which of the following statements best describes possible ankle edema?

ankle edema occurs in approximately 10% of patients taking amlodipine 10mg once daily

A 35-year-old woman comes to the office for pain and burning during urination for the past few days. She denies fever, abdominal or flank pain, bloody urine, or passing any stones while urinating. She has a medical history of gastroesophageal reflux disease, diabetes mellitus type 2, and hyperlipidemia. She takes over-the-counter antacids, pantoprazole, metformin, and atorvastatin. She is para 2 with both normal vaginal delivery and her last menstrual period was three weeks ago. She uses oral contraceptive pills for contraception. Her temperature is 37.2 C, her pulse is 70 beats/min, her respiratory rate is 12 breaths/min, and her blood pressure is 130/80 mmHg. On examination, she denies suprapubic pain or costovertebral angle tenderness. Urinalysis reveals white blood cells of 20-25/hpf and red blood cells of 5-10/hpf with no casts. Urinary nitrites and leukocyte esterase are positive, and glucose and ketone are absent. White blood cell count is 7800/mm3. Serum creatinine is 1.1 mg/dL and blood urea nitrogen is 17 mg/dL. Urine culture grows Escherichia coli. The patient is started on a drug that inhibits an enzyme required in bacterial DNA replication. The patient is counseled about adherence and the adverse effect of this drug. About which of her other medications should she be counseled?

antacid

A 65-year-old man presents to the emergency department with chest pain and diaphoresis for the past one and a half-hour that developed while he was doing work in his garage. Over the past few months, he has had two similar episodes occurring after physical exertion, each lasting for 10 to 15 minutes. The patient has a past medical history of diabetes mellitus, hypertension, and gastroesophageal reflux disease, for which he takes famotidine, amlodipine, and metformin. Vital signs show blood pressure of 138/92 mmHg, pulse 110/min, and temperature 98.6 F (37 C). On physical examination, the patient is in acute distress and marked diaphoresis is noted. He is given a chewable drug as part of standard protocol. What role does this drug play in the management of the patient's acute condition?

antiplatelet coagulation

A 56-year-old man comes to the emergency department after consuming several tablets. He complains of nausea, vomiting, and ringing in both ears. He has vomited several times before coming to the department. He has a diagnosed case of bipolar disorder for which he has been using lithium for the last two years. He also takes aspirin as a prophylactic treatment for myocardial infarction. Furthermore, he takes levothyroxine for his hypothyroidism. A few weeks ago, he started on paracetamol and diazepam for back muscle spasm. What is the most likely overdose of the medication causing his symptoms?

aspirin

A researcher is working on a new medication that has shown efficacy in acute asthma exacerbations. It reverses bronchoconstriction by inhibiting cholinergic receptors and can be administered intranasally. This drug is similar in its effects to which of the following?

atropine

A 22-year-old female suffers from seasonal allergies as well as mild persistent asthma. She is currently on fluticasone/salmeterol and salbutamol. The physician prescribes a new asthmatic prophylaxis asthmatic medication to control both her comorbidities. Which of the following best describes the mechanism of action for this medication?

blocks the action of leukotriene D4

A 48-year-old man with a 20-pack-year smoking history presents with three weeks of insomnia, anhedonia, and decreased concentration after losing his father to lung cancer. He worries that he will die of cancer and be unable to provide for his family. He often feels "down" and spends most of his day in bed. He has lost 5 lbs (2.2 kg) over the past two weeks due to poor appetite. He denies suicidal ideation and would like to quit smoking. What is the best pharmacotherapy for this patient?

bupropion

An otherwise healthy 12-year-old boy is brought to the clinic by his mother with fever's chief complaint for three days. His mother notes he has had a dry cough, congestion, and fevers as high as 103 F at home. Starting two days ago, he began complaining about pain in his right ear. The patient's immunizations are up to date, and no one else is currently sick at home. Vital signs include blood pressure 112/76 mmHg, pulse 107/min, respiratory rate 18/min, temperature 39 C (102.2 F), SaO2 of 99% on room air. On examination, an erythematous and moderately bulging right tympanic membrane with a fluid level is observed behind the membrane. Visual inspection of the left ear reveals a normal-appearing tympanic membrane. The remainder of the child's exam is unremarkable. What is the mechanism of action of the medication that would be prescribed to him?

cell wall synthesis inhibitor

A 45-year-old woman is brought to the emergency department by her partner for symptoms related to alcohol withdrawal. Her pulse is 115/min, and her blood pressure is 145/90 mmHg. The patient is given a medication that acts on GABA-A receptor chloride ion channels. Which of the following is one of this medication's most serious adverse effects?

central nervous system depression

A 26-year-old woman is brought to the emergency department with an acute severe headache. Her partner reports that it started 6 hours ago and that she vomited several times at home. The patient is holding her hands over her eyes and reports severe unilateral retroorbital throbbing pain. She has no significant past medical history and takes no regular medications. Her vital signs are within normal limits. There is no gross neurological deficit on examination of the cranial nerves and limbs. Given the most likely diagnosis, what is the mechanism of action of the best drug for the acute treatment of this patient's condition?

cerebral vasoconstriction

A 60-year old man is brought to the emergency department after an episode of syncope. The patient was watching television when he felt lightheaded and lost consciousness. He does not remember any abnormal body movements associated with the episode and he regained consciousness after a minute. However, the patient is still feeling lightheaded. The physical examination of the patient shows a pulse rate of 45/min and a blood pressure of 100/60 mmHg. Emergency department ECG reveals sinus bradycardia. The patient is given oxygen support and is started on an IV medication that will block which of the following receptors to improve this patient's heart rate?

cholinergic receptors

An 8-month-old boy presents with a new onset of fever, urinary hesitancy, and frequency for three days. This is his second episode of similar complaints in the same month. He has a history of recurrent urinary tract infections since his birth. He has a 4-year-old sibling who is healthy. He has normal growth and development and achieved his milestones on time. The urine culture of catheterized specimens grew >100,000 colony-forming units of Escherichia coli. The renal ultrasound shows mild hydronephrosis of the left kidney, and the voiding cystourethrogram shows moderate dilatation of the left ureter and pelvis. The patient is managed with nitrofurantoin and paracetamol. The patient is discharged on a prophylactic antibiotic for his condition. Which of the following antimicrobial agents is contraindicated in this patient?

ciprofloxacin

Emergency medical services are called to a house party where a 21-year-old man has been unresponsive. On initial assessment, he is snoring with a respiratory rate of 6 breaths/min and a Glasgow Coma Scale score (GCS) of E2V2M4. His pupils are constricted and nonreactive to light. He is given an intramuscular (IM) injection, and his GCS improves to E3V4M6 within a few minutes. What is the mechanism of action of the drug given via IM injection?

competitive antagonist

A 42-year-old male presents to the clinic with a 6-month history of severe, throbbing headaches. These headaches are generally unilateral and are worsened by light and sound. He states that these headaches occur biweekly and occasionally interrupt his workday. He has not noticed any significant improvement with ibuprofen, naproxen, or acetaminophen. His blood pressure is 139/80 mmHg, pulse 82/min, respirations 14/min, and temperature 98.0 F (36.7 C). No abnormalities are noted on physical examination. Which of the following effects is caused by the most appropriate treatment option for this patient?

constriction of cerebral blood vessels

A 39-year-old woman with multiple sclerosis presents to a healthcare provider with a complaint of muscle spasms. The provider decides to administer a benzodiazepine to manage the condition. Which of the following benzodiazepines will most likely be used to manage her condition?

diazepam

A 65-year-old man presents with his son to the clinician with complaints of orthopnea, dyspnea on climbing a few steps, vomiting, diarrhea, and visual changes. The patient also complains of urinary incontinence and cannot recall his daily prescribed medications. Physical examination shows a raised jugular venous pressure, expiratory wheezing, and a significant S3 heart sound. An EKG is performed that shows decreased QT interval, prolongation of the PR interval, and T wave inversion/flattening. Increased levels of which of the following drugs is the likely cause for the patient's findings?

digoxin

A 60-year-old woman presents with joint pain and swelling in her hands. She says the pain is typically worst in the mornings when she wakes up and improves during the day. She has no past medical history and takes no medications. On examination, she has warm, tender swelling of the metacarpophalangeal joints bilaterally. She is prescribed a drug that is neither a non-steroidal anti-inflammatory or corticosteroid. What is the class of the drug that has most likely been prescribed?

disease-modifying anti-rheumatic

A 23-year-old female was recently prescribed fluconazole and "other antibiotics she forgets" after getting a local infection in Mississippi. After receiving treatment for histoplasmosis, she begins to feel better but now complains of vaginal itching and discharge. She denies any other symptoms except she had some loose stool after eating some "old food" yesterday. What is the explanation for this patient's new presenting symptoms?

disruption of normal vaginal flora

A 65-year-old man presents to the clinic due to constipation for the past 2 weeks. He describes his stool as hard, bullet-like. The patient had a past medical history of hypertension and diabetes mellitus for the past 4 years, and he takes his medication as prescribed. His medication includes lisinopril, metformin. The patient has a 10 pack-year smoking history and drinks alcohol socially. His blood pressure is 140/80 mmHg, pulse rate 70/minute, and the temperature is 37.5 C. Physical examination is unremarkable. A medication that allows the passage of water and fat into the stool mass is prescribed to the patient. Which of the following best identifies this medication?

docusate

A 23-year-old man recently started taking a new medication for the long-standing history of hallucinations, poor eye contact, flat affect, and poor work performance. After six days of using this medication, this patient presents to the emergency department with acute neck stiffness. On exam, his head is rotated to the left and flexed in a fixed position. The medication used by this patient mainly works by blocking which of the following receptor?

dopamine receptor

A 12-month old presents to his pediatrician for a well-child visit. The exam is mostly normal, except the pediatrician notes significantly discolored teeth. The mother insists that she only allows her child to drink milk and water. Upon further questioning, the mother reveals she was on medication for acne before she knew she was pregnant. What medication was she most likely given?

doxycycline

A 17-year-old patient presents to the clinic after experiencing significant dysphagia and retrosternal heartburn. He was recently prescribed medication to treat a genital chlamydial infection. Which of the following medications could have caused this patient's presenting symptoms while treating the genital chlamydial infection?

doxycycline

An 82-year-old man presents to the clinic for follow-up. He has been recently found to have worsening renal function and blood pressure. He currently takes amlodipine 10 mg daily, spironolactone 100 mg daily, and furosemide 40 mg. His other medical history includes stage IV chronic kidney disease, mild dementia, a 30-pack-year smoking history, and symptomatic sinus bradycardia. Around 1 month ago, he was admitted to the hospital with sudden onset chest tightness and dyspnea on exertion. A heart catheterization showed very mild non-obstructive coronary artery disease with moderately elevated systemic vascular resistance. He was discharged from the hospital on his same home medications. Current vital signs show blood pressure 158/92 mmHg and heart rate 52/min. Treatment with hydralazine is being considered. Which of the following adverse effects is least likely to occur during the first few weeks of initiating this medication?

drug induced lupus

A 55-year-old woman with a past medical history of type 1 diabetes mellitus presents with nausea and vomiting for the past three days. She also reports feeling dizzy when she gets up quickly from a seated position. Her blood pressure is 125/85 mmHg, and his heart rate is 102 per minute. The provider writes the patient a prescription for metoclopramide. Which of the following is the most appropriate side effect to focus on during patient education about this drug?

dystonia

A 16-year-old presents for staring spells that occur several times a day. Each episode lasts only a few seconds and occurs at random times of the day. The patient continues regular activity after the event and is not confused. The patient is otherwise healthy with no recent trauma or infections. The patient is not on any medications. EEG reveals a 3-Hz spike and waveform. Which of the following is the first-line treatment for this patient?

ethosuximide

A 48-year-old male presents for a pre-employment checkup. Currently, he is not experiencing any symptoms. His past medical history includes type 2 diabetes mellitus, hypertension, and hypercholesterolemia. Medications include metformin, hydrochlorothiazide, multivitamin supplements, and atorvastatin. He practices healthy lifestyle habits and consumes a lot of vegetables. He has a 10-pack-year smoking history. His heart rate is 82 bpm, respirations are 16/min, blood pressure is 120/74 mmHg, and the temperature is 98.7 F (37.0 C). Cardiovascular examination shows normal heart sounds heard on auscultation without murmurs. A chest x-ray reveals a hyperdense shadow on the left infraclavicular region. CBC, liver function tests, and serum electrolytes are within normal limits. He is started on the recommended treatment regimen and discharged. After a week of treatment, he complains of reddish-orange discoloration of his saliva. Which of the following is the likely mechanism of the reddish-orange discoloration of his saliva?

excretion route of a drug

A 65-year-old man presents to the office for a follow-up. He had a stent placed in his right coronary artery two years ago for unstable angina. He reports that he exercises regularly and is compliant with a heart-healthy diet. His current medications include atorvastatin 80 mg daily for dyslipidemia. The lipid profile shows total cholesterol is 195 mg/dL, HDL is 33 mg/dL, LDL is 110 mg/dL, and triglycerides are 120 mg/dL. Which of the following has been shown to improve cardiovascular outcomes when added to statins for secondary prevention?

ezetimibe

A 65-year-old man presents to the office with increased frequency, urgency, nocturia, and hesitancy in micturition for the past week. He also complains of pain in ejaculation. He has no flank pain, dysuria, hematuria, or fever. He is in a monogamous relationship and uses condoms regularly. His temperature is 98.6 F (37 C), pulse rate is 77 beats/ minute, respiration is 14 breaths/minute, and blood pressure is 130/80 mmHg. There is no costovertebral angle tenderness or suprapubic tenderness, and external genitalia examination is normal. Digital rectal examination shows normal sphincter tone and reflexes with slightly enlarged and tender prostate. Urinalysis shows many WBCs with no RBCs or casts. Urine culture grows E. coli. Serum prostate-specific antigen is 8ng/mL (reference range of less than 3.5 ng/mL). Which of the following drug class can be used to treat the patient's condition?

fluroquinolone

A 54-year-old woman presents to the clinic complaining of fatigue for 3 months. The patient also has occasional abdominal pain and nausea for the past several months. The patient's past medical history includes diabetes managed with diet and exercise, hypertension treated with lisinopril, rheumatoid arthritis treated with methotrexate. Vital signs are within normal limits. Physical examination shows a pale obese woman. Lab work has been ordered. Which of the following is the most likely cause of this patient's symptoms?

folic acid deficiency

A 50-year-old male with a history of congestive heart failure with reduced ejection fraction, coronary artery disease, hypertension, dyslipidemia, CKD stage III presented to the physician's clinic with complaints of decreased hearing in both ears for last 4 weeks. Patient denies any history of ear infection, trauma to the ear or head, ear fullness, nausea, headache or tinnitus. The patient also mentions that 2 months ago the patient was admitted with septic shock secondary to UTI and was treated with broad-spectrum antibiotics including gentamicin and cefepime. Current home medications are aspirin 81 mg/day, metoprolol 50 mg twice a day, atorvastatin 40 mg/day, lisinopril 10 mg/day, furosemide 40 mg twice a day. Patient report no change in heart failure medications since last 6 months. Which of the following is the most likely cause of hearing impairment?

gentamicin and furosemide

A 30-year-old woman presents to the emergency department for dizziness and ataxia that occurred recently. Her current medications include vitamin D, metformin, and carbamazepine. It is discovered that the patient recently started a weight loss diet based on natural ingredients. Which of the following ingredient in her diet that could cause her current symptoms?

grapefruit juice

A 41-year-old woman is involved in a serious skiing accident, requiring surgery for a fractured femur. Postoperatively she develops methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Infusion of a synthetic oxazolidinone antimicrobial drug is initiated. Which of the following is one of the most common adverse effects of this drug?

headache

A 55-year-old man presented to the emergency department complaining of difficulty breathing after little exertion. Upon further questioning, he states the dyspnea is worst on lying down and improves in sitting position. The patient also has a significant past medical history of diabetes mellitus, hypertension, and hyperlipidemia. He further adds that last month he was admitted for acute myocardial infarction. The physician suspects the diagnosis of congestive heart failure and starts furosemide. Which of the following symptoms is most likely to be observed after administering furosemide?

high urine output

A 72-year-old male with a past medical history of hypothyroidism and hyperlipidemia presents with acute onset weakness to his right upper and lower extremities and slurring of his speech. His symptoms all began about 2.5 hours ago. He takes no blood thinners and had no inciting trauma or events. His vitals show a blood pressure of 170/100 mmHg with a heart rate of 86 bpm and a respiratory rate of 15 breaths per minute. His physical examination shows significant slurring of speech and 3/5 strength in the upper and lower extremities on the right. He is sent for computed tomography (CT) scan for concern of an ischemic stroke, which reveals no active bleeding. His point of care glucose shows 30 mg/dL, his platelet count is 200,000 per microliter and an INR of 1.1. Which of the following excludes him from consideration of alteplase at this time?

his abnormal glucose testing excludes him

A 50-year-old man presents to the clinic with epigastric pain that began four months ago. He has a history of obesity, drinks three beers per night and has a 30-pack-year smoking history, and currently smokes one pack per day. His vital signs are a blood pressure of 120/70 mmHg, a heart rate of 75/min, and a temperature of 37.0 C (98.6 F). The physical exam is not contributory. Inhibition of which of the following mediators will most likely resolve the patient's chief complaint?

histamine

A 55-year-old African American woman with a history of hypertension and heart failure with reduced ejection presents to her cardiologist's office for follow up. She is already taking lisinopril, carvedilol, aspirin, high-dose spironolactone, and isosorbide dinitrate-hydralazine. Which of the following complications is most likely to occur in this patient?

hyperkalemia

A 10-year-old African American girl with a history of moderate persistent asthma is brought into the clinic for continued shortness of breath and wheezing. She is currently being treated with a low-dose steroid and a short-acting beta-agonist. The child's family reports their daughter's symptoms are worse at night or when she is exposed to cold air. The family listed no known drug allergies but did indicate a dairy allergy. After further evaluation of the patient's severe chronic asthma symptoms, she is prescribed a low dose of an inhaled corticosteroid and long-acting beta-2 agonist combination. Before leaving the clinic, she is administered one dose of fluticasone propionate/salmeterol 100/50 mcg inhalation powder. Shortly after administration, she develops chest tightness and requires oxygen therapy and albuterol. Which of the following best explains the girl's sudden worsening of symptoms?

hypersensitivity to fluticasone/salmeterol inhalation powder formulation

A 40-year-old man was brought to the emergency department due to a severe headache for the past hour. His symptoms started 2 hours after having dinner with his family. On further questioning, his wife revealed that they had pizza and red wine for dinner. On physical exam, he appears anxious and tremulous. Medical history includes atypical depression being treated with phenelzine. He does not smoke or use illicit drugs. Which of the following Is the most likely finding?

hypertension

Which of the following is an adverse effect of administering the drug of choice in anaphylactic shock?

hypertension

A 16-year-old female presents to the emergency department after intentionally ingesting 30 metoprolol succinate 100-milligram pills. This was done in a suicide attempt approximately 1 hour prior to arrival. She told her parents after the ingestion, and they brought her to the emergency department. The patient currently has no complaints. Which metabolic derangement could occur with this type of ingestion?

hypoglycemia

A 16-year-old girl is brought to the emergency department due to a decreased level of consciousness and abdominal pain. Her mother says that she has vomited twice before coming to the hospital. She has no known medical history, and this is the first time to have these symptoms. Her family history is significant for diabetes in her mother and 2 uncles. Her glucose level is 574 mg/dL, creatinine 0.8 mg/dL, potassium 3.7 mEq/L, sodium is 137 mEq/L, and her white blood count is 12700/microL. Her urine dipstick shows glucose 4+ and ketones 3+. She is given normal saline. She is also given an infusion of the next appropriate medication. Which of the following side effects is most likely to occur with this infusion?

hypokalemia

A 37-year-old man with chronic persistent asthma is currently prescribed salbutamol, fluticasone, and salmeterol. Which of the following changes in potassium levels is most likely to be seen?

hypokalemia due to an intracellular shift

A 73-year-old male presents with worsening symptoms of Parkinson disease. He was diagnosed five years ago and was started on ropinirole. Over the past month, he has been having more difficulty walking. He states he feels sluggish and has noticed his "pill-rolling" tremor has gotten progressively worse. His provider recommends that he be started on a combination extended-release capsule containing both levodopa and carbidopa. The addition of carbidopa has what effect on this patient's treatment regimen?

increased central nervous system uptake of levodopa

A 65-year-old man visits a provider for a follow-up visit. The client has persistently uncontrolled hyperglycemia despite multiple oral medications. The provider plans to start the client on insulin. Which of the following actions is caused by this hormone?

induces cellular intake of glucose

A 60-year old man comes to the emergency department with severe sub-sternal chest pain that radiates to his left arm, neck, and jaw and is associated with nausea and diaphoresis. The pain started 2 hours ago and is progressively getting worse. Emergency department ECG reveals ST elevation in the anterior chest wall leads. The patient is transferred to the coronary intervention unit under the supportive protocol, where he undergoes percutaneous intervention and stent placement. Along with aspirin, the patient is started on another antiplatelet agent to prevent premature stent thrombosis. What is the mechanism of action of the second agent?

inhibit ADP receptors on the platelets

A 67-year-old man comes to the emergency department due to an acute episode of confusion, dizziness, and diaphoresis for the past three hours. A detailed history reveals that the patient took a sex-enhancing drug that he ordered from the internet. He took the drug four hours ago and started to feel dizzy soon after. His past medical history is significant for hypertension, ischemic heart disease, and diabetes mellitus. He claims to be very compliant with his medication and never misses a dose. Vital signs show a blood pressure of 80/40 mmHg, pulse of 105 bpm, respiratory rate of 18 breaths/min, and a temperature of 37 C (98.6 F). Examination of the abdomen reveals a soft, non-tender abdomen with no masses on deep palpation. Cardiopulmonary examination shows no pertinent findings as well. Emergency treatment with intravenous normal saline is started, and the patient stabilizes. What is the likely mechanism of action of the drug?

inhibition of phosphodiesterase 5

A 66-year-old man with a history of follicular non-Hodgkins lymphoma is being treated with anthracycline therapy, interferon adjuvant therapy, and supportive pain medications. Over the course of his treatment, this patient develops suicidal ideation. Which of the following medications is most likely responsible for this patient's symptoms?

interferon-alpha 2b

A 65-year-old woman diagnosed with chronic stable angina presents for a refill of nitroglycerine. Her past medical history is significant for hypertension. Nitroglycerin should be prescribed in what manner for this patient?

intermittent use of nitroglycerin with nitrate free intervals

A 65-year-old man presents to the clinic due to weak penile erections for the past six months. He states that he has had trouble attaining and maintaining an erection. He adds that he does not get nocturnal erections as well. The patient denies any trauma or injury to his penis. His past medical history is significant for hypertension, diabetes mellitus, and obesity. He denies smoking, alcohol use, and illicit drug use. Vital signs are blood pressure of 132/88 mmHg, pulse of 85/min, and respiratory rate of 16/min. Examination findings are not suggestive of any ailment. A phosphodiesterase five inhibitor is prescribed for this patient's presenting complaint. Two weeks later, he presents to the emergency department with disorientation and extreme hypotension. Coadministration of which of the following medicines is most likely responsible for this presentation?

isosorbide dinitrate

A 41-year-old G5P4004 at 38 weeks, 0 days pregnant presents for late prenatal testing. She is found to have IgM-positive antibodies for HSV-2. The patient desires to deliver vaginally. Which of the following statements is correct regarding the treatment of choice for this patient's condition?

it is generally safe in pregnancy

A 54-year-old female with no significant past medical history presents with a 6-month history of recurring "cold sores on my mouth." On exam, there are several vesicular lesions on her lips. A 5% concentration of the antiviral ointment is administered. Regarding this antiviral ointment, it is important to teach the patient which one of the following?

lesions may occur again at a later date despite treatment

A patient is rushed to the emergency department with an apparent drug overdose. His presentation includes tachycardia, palpitations, and chest pain. An IV beta-blocker is ordered to stabilize cardiac activity. Which of the following drugs is the most likely culprit for this overdose?

levothryoxine

A patient has developed swelling in his neck, constipation, weight gain, and hair loss. His family members have noticed him crying often, and he admits to turning off the air conditioner despite the hot climate. Two years ago, he was treated with radioactive iodine for similar symptoms. Which of the following is the most appropriate drug for treating this patient's condition?

levothyroxine, T4

A 56-year-old female with a history of coronary artery disease (CAD), asthma, and Chronic Obstructive Pulmonary Disease (COPD) presents with chief complaints of lower extremity swelling and shortness of breath. She denies any abdominal pain, nausea, vomiting, or dysuria. Her symptoms have progressed for the last three months. She complains of the inability to lie down and uses four pillows at night. She drinks alcohol occasionally and smokes one pack per day. Past medical history is significant for hypertension controlled with diet and exercise. In the emergency department, vitals revealed blood pressure of 102/63 mmHg, heart rate of 71 per minute, respirations of 19 per minute, temperature 98.9 F, and oxygen saturation of 94% on 2 L. Cardiac auscultation is significant for pansystolic murmur in left fifth intercostal space half-inch lateral to the midclavicular line. Jugular venous distention along with bilateral lower extremity pitting edema is noted. Which of the following medications has been proven to have a mortality benefit for the disease process causing this patient's symptoms?

lisinopril

A healthcare provider reviews home medications for a 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidemia. He was admitted to the cardiac unit for unstable angina. Among his medications, he is on an HMG-CoA reductase inhibitor. Which of the following would need to be monitored regularly in this patient?

liver function tests

A 55-year-old man presents with two days of progressive shortness of breath and cough productive of copious yellow sputum without fever or chills. The patient's medical history is significant for hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). He currently smokes one pack of cigarettes daily. He states that his COPD has generally been well-controlled with tiotropium. Other medications include lisinopril, amlodipine, metformin, and rosuvastatin. His blood pressure is 152/100 mmHg, pulse 100 beats per minute, respiratory rate 22 breaths per minute, pulse oximetry 95% on room air, and temperature 97.2 F (36.2 C). He can answer questions fully and speak in complete sentences. Lung auscultation demonstrates bilateral rhonchi, a chest radiograph is unremarkable, and the forced expiratory volume (FEV1) is 65% of predicted. The clinician considers prescribing azithromycin. What is the most appropriate evaluation before prescribing azithromycin for this patient?

local antibiogram

A 25-year-old male patient presents to the clinic complaining of a runny nose, constant sneezing, and watery eyes for the past week. Yellowish to white discharge from the patient's nasal mucosa is noted upon examination. What is the next step in management for this individual?

loratadine

A 16-year-old male presents with a fever and sore throat. On physical examination, there are multiple swollen lymph nodes in his neck, and hepatosplenomegaly is noted. A monospot test is positive. The patient is advised to stop contact sports for a year, and treatment with amoxicillin is initiated. Which of the following is the patient at high risk of developing due to his current medication?

maculopapular rash

A 65-year-old man recently underwent a difficult colon resection and is in the ICU with signs of heart failure. His urine output had dropped to less than 10 ml/hour, and he has developed significant edema and ascites. His ejection fraction is about 40%, but his renal function seems intact. Which of the following may be of the most benefit to him?

mannitol

A 67-year-old patient is admitted to the hospital for a hypertensive emergency. His blood pressure on admission is 210/80 mmHg, with pulse 95/min. He is given an intravenous smooth muscle dilating medication to decrease his blood pressure promptly. Repeat vital signs show an increased heart rate of 130/min. He begins to feel new-onset palpitations without chest pain. What is the most likely cause of the patient's new symptoms?

medication side effect

A patient with type 2 diabetes mellitus presents complaining of nausea, vomiting, abdominal bloating, tachypnea, and feeling weak. Palpation reveals a tender and enlarged liver and elevated liver enzymes. His serum bicarbonate is low, and his lactate level reads high at 4.5 mmol/L. Which anti-glycemic drug is the most likely culprit?

metformin

A 35-year-old female patient diagnosed with rheumatoid arthritis visits a rheumatology clinic. Her provider is considering prescribing a disease-modifying antirheumatic drug. Her past medication history reveals an allergic reaction to sulfa containing antibiotics. She is not planning to be pregnant. She prefers an oral drug than an injection. Which of the following drugs is most likely suitable for her?

methotrexate

A 59-year-old male is admitted to the coronary care unit for the management of decompensated heart failure. He is currently afebrile, has a pulse rate of 98 bpm, a blood pressure of 80/50 mmHg, and a respiratory rate of 25 breaths/min. The chest auscultation reveals basal crepitations, and bilateral pedal edema is also present. For hemodynamic stability, dobutamine is planned to be administered. Which of the following pharmacological agents usually help best in countering the direct cardiac effects of dobutamine?

metoprolol

A 16-year-old female is being treated for insulin dependent diabetes mellitus and develops a perineal abscess. It is foul smelling and you suspect an anaerobic infection. Which of the following antibiotics has anaerobic activity?

metronidazole

A 5-year-old boy is brought to the clinic by his parents because of a worsening cough and thick yellow-green nasal discharge for the past 2 weeks. The patient has no chronic medical conditions, and he is not taking any medication. His immunization is up to date. Vital signs show temperature 39.2 C, blood pressure 120/80 mmHg, pulse 92/min, and respiratory rate 20/min. On examination, nasal turbinates are swollen and erythematous, and there is a thick purulent discharge from the nares; lungs are clear on auscultation. Amoxicillin-clavulanate is prescribed, which results in the complete resolution of symptoms in two days. Which of the following is the most likely organism responsible for this patient's initial presentation?

moraxella catarrhalis

A 66-year-old man is brought to the hospital with clasped knife rigidity and resting tremors. After a physical examination, the clinician prescribes a drug that is known for treating drug-induced extrapyramidal symptoms. A week later, the patient is brought to the emergency department with complaints of confusion, delirium, and urinary retention. Which of the following best identifies the primary mechanism of action of this medication?

muscarinic receptor antagonist

A 25-year-old woman presents with severe acute asthma exacerbation. She inadequately responds to a combination of nebulized albuterol, inhaled ipratropium, prednisone, and oxygen. The clinical team decides to administer intravenous magnesium sulfate. While placing the order, the clinician receives an alert for potential overdose with this medication. Which of the following symptoms is most likely to occur with magnesium overdose?

muscle weakness

A 17-year-old male with a heart rate of 110 beats per minute and blood pressure of 100/60 mmHg requires emergency surgery after he was diagnosed with appendicitis. The clinician uses an agent for induction during his appendectomy. The agent is often used in patients with asthma. Which of the following side effects of this particular agent may require prophylactic treatment?

nausea and vomiting

A 32-year-old woman with schizophrenia is currently treated with haloperidol. The patient was brought to the emergency department by her mother with symptoms of confusion, diaphoresis, agitation, muscular rigidity, and tachycardia with elevated white blood count and creatine phosphokinase. Which of the following conditions is the patient most likely experiencing?

neuroleptic malignant syndrome

A 17-year-old male with a history of asthma presents to the urgent care with an asthma exacerbation due to having an upper respiratory infection. His daily medications are a short-acting beta-agonist, loratadine, and a corticosteroid inhaler to control his asthma and allergies. He reports that he is using his albuterol (short-acting beta agonist) daily. On physical examination, he has diffuse bilateral wheezing bilaterally, and he is not using accessory muscles. The provider adds an oral medication to control his asthma symptoms and allergies. What is one of the most serious adverse effects of the medication?

neuropsychiatric events

What is the advantage of loperamide over atropine/diphenoxylate?

no opiate effects at normal doses

A 25-year-old man is found to have constant stomach pain after taking over-the-counter medications to relieve joint pain. Which of the following medicines is most likely to help treat the patient?

omperazole

Which of the following medications is known to decrease both basal and stimulated gastric acid secretion?

omperazole

A 68-year-old man is undergoing treatment in an inpatient palliative care setting. Since yesterday, he has been complaining of nausea and vomiting related to chemotherapy treatment. Which of the following medications is most likely to be effective for the patient's symptoms?

ondansetron

A 65-year-old man underwent surgery for basal cell carcinoma of the helical rim of the ear. Margins were clear on frozen sections. Due to the size of the defect, an advancement flap was performed. What signs or symptoms are associated with the Black Box Warning of the antibiotic that would be most appropriate for the patient to receive postoperatively?

pain in the achilles tendon

A 50-year-old male is admitted to the intensive care unit following myocardial infarction. His current vitals include a temperature of 98.6 F (37 C), a pulse rate of 98 bpm, a blood pressure of 80/55 mmHg, and a respiratory rate of 20 breaths/min. The chest auscultation does not demonstrate any abnormal findings. In line with the initial emergency management for the ischemic event, dobutamine is to be administered to counter the cardiogenic shock. Which of the following would accurately explain the main role of dobutamine in achieving hemodynamic stability in this patient?

predominant beta-1 receptor activity

A 25-year-old woman presents to the clinician with complaints of frequent burning micturition and suprapubic discomfort from the past two days. The patient is sexually active and has no significant past medical history. Urinalysis reveals the presence of leukocyte esterase and a high level of nitrites. The clinician prescribes her a combination antibiotic that inhibits two steps in the bacterial biosynthesis of tetrahydrofolate. Which of the following is a contraindication to the use of this medication?

pregnancy

A 44-year-old female with a past medical history significant for hypertension is brought to the emergency department by ambulance for altered mental status and diaphoresis. The patient had a right knee arthroscopy under general anesthesia five days ago, which was complicated by postoperative nausea and vomiting. Family members state that she was treated with multiple medications to stop her vomiting. She was discharged the same day of surgery and had been making an uneventful recovery at home. She takes hydrochlorothiazide for hypertension, which is well controlled. She has been taking acetaminophen for pain at home as prescribed by her surgeon. Vital signs are taken and show a blood pressure of 150/90 mmHg, pulse 110/min, respiratory rate 18/min, temperature 101.4 F, and SpO2 97% on room air. A physical exam is significant for tachycardia, diaphoresis, muscle rigidity, and mild confusion (able to state her name, location, but not date). Labs are drawn and show a leukocytosis, elevated CPK, and mild transaminitis. The patient is diagnosed with neuroleptic malignant syndrome (NMS) is admitted to the wards for further monitoring and treatment. What is the likely etiology of NMS in this patient?

promethazine

A 65-year-old female patient is undergoing cardiac surgery. In the operating room, the patient has been successfully anticoagulated during cardiopulmonary bypass. The drug that has been used directly binds to antithrombin 3, leading to a conformation change that inhibits thrombus formation. After cardiopulmonary bypass is discontinued, the anticoagulation needs to be reversed. What medication is appropriate for this purpose?

protamine sulfate

A 25-year-old sexually active female comes to the clinician with complaints of frequent urination, burning micturition, and mild supra-pubic pain for two days. She gives no history of fever, nausea, flank pain, or vomiting. After an appropriate workup, the clinician prescribes her a medication taken up by bacterial intracellular nitroreductases to produce the active form of the drug to treat her condition. Which of the following is a well-known severe adverse effect of the drug most likely given in this case?

pulmonary toxicity

A 25-year-old male comes to the outpatient department for regular follow-up. His medical conditions include gastroesophageal reflux disease and Tourette syndrome, for which he takes famotidine and clonidine. He complains about a recent worsening of his tics that has been causing him emotional distress. The practitioner decides to stop his current medication and try a new drug to treat the patient's tics. Which of the following should concern the practitioner when discontinuing his current medication?

rebound hypertensive crisis

An adult female visits a clinic for right jaw pain. Evaluation reveals that she has trigeminal neuralgia. The provider plan to start her on carbamazepine. Further inquiry reveals the use of combined oral contraceptive pills. What significant medication interaction should the provider consider while giving these two drugs together?

reduced contraceptive protection

A 50-year-old man presents to the clinician with complaints of cough with a copious amount of yellow sputum production for the past two years. He also feels fatigued most of the time and complains of dyspnea. The patient has no history of fever. He has a significant history of cigarette smoking for the past 30 years. The physical examination is significant for peripheral cyanosis and diffuse wheezes throughout both lung fields. The clinician prescribes him a medication that acts on muscarinic receptors to cause which of the following effects for the symptomatic relief?

reduces cholinergic effects on bronchial smooth muscle causing bronchodilation

A 32-year-old primigravida at 34 weeks gestation presents with severe headache, blurring of vision, vomiting, and epigastric pain from the past 6 hours. She has no past medical history. Vital signs show oxygen saturation of 98% on room air, respiratory rate of 20 per minute, heart rate of 80 beats per minute, blood pressure of 170/110 mmHg, and temperature of 36.7 C (98 F). She is started on an IV medication for the acute control of her severe hypertension. By which of the following mechanisms will this drug reduce the patient's blood pressure?

relaxation of arteriolar smooth muscles

A 40-year-old male presents to the clinic with complaints of dry, hacking, and nonproductive cough for one week. He denies any fever, chest pain, or shortness of breath. The patient states that the cough has been progressing and does not have any postural or diurnal variation. Because of this severe cough, he has not been sleeping well. He experiences abdominal pain due to severe coughing. He has tried several over-the-counter cough medications with minimal improvement in his symptoms. His medical history is significant for type 2 diabetes mellitus and hypertension. He is on metformin, lisinopril, baby aspirin, and some over-the-counter vitamins. On examination, the heart rate is 82 bpm, respiratory rate of 16/min, and blood pressure is 130/80 mmHg. Lung auscultation is clear. S1 and S2 are well heard without any murmurs on cardiac auscultation. The patient does not have any history of sinus infection. Which of the following is the appropriate next step in managing this patient?

replace lisinopril with lostartan

A 52-year-old woman comes to the emergency department due to a day of worsening pain and swelling in her left leg. The patient has a history of breast cancer treated surgery and is currently undergoing adjuvant radiotherapy and chemotherapy. She was admitted two weeks ago for lower extremity deep vein thrombosis and was discharged on warfarin. The patient is taking warfarin daily, but due to her frequent hospital visits for chemotherapy and radiotherapy sessions, her diet schedule is variable. She has also missed her clinic appointments for INR monitoring. On examination, her latest INR is 1.1. Venous Doppler ultrasound shows Deep vein thrombosis in the left popliteal vein extending to the femoral vein. What is the next best step in the management of this patient?

replace warfarin with rivaroxban

A 20-year-old woman G2P1 at 32 weeks gestation presents to the emergency department with a severe headache. Her vital signs reveal a blood pressure of 201/98 mmHg. Urine dipstick shows 3+ protein. After the initial evaluation, preparations are made for an emergency cesarean section. Meanwhile, she is started on a continuous intravenous infusion of magnesium sulfate for the prevention of seizures. What is a severe, yet preventable, complication of continuous intravenous magnesium sulfate therapy?

respiratory depression

A 39-year-old woman presents to a healthcare provider with the complaint of muscle spasms. On examination, she has a blood pressure of 126/89 mmHg, a pulse of 89/min, a respiratory rate of 22/min, and she is afebrile. The provider decides to prescribe a benzodiazepine to manage the condition. This medication is contraindicated in patients with which of the following conditions?

respiratory depression

A 55-year-old man presents with a 1-month history of insomnia and fatigue. He states that he has been unable to complete work tasks and no longer enjoys his hobbies or going out with friends. He also reports a decreased appetite and bouts of crying. The patient has a past medical history of seizures, hypothyroidism, diabetes mellitus, and asthma. His blood pressure is 110/75 mm Hg, and his heart rate is 75 bpm. The clinician prescribes venlafaxine. Which of the following conditions requires caution when using venlafaxine in this patient?

seizures

A 40-year-old male with a history of bipolar 1 disorder is admitted to a psychiatric in-patient facility after an episode of aggression and is currently prescribed aripiprazole. While on the in-patient psychiatric unit, he continues to be agitated with the in-patient staff and other patients on the unit. The psychiatrist prescribes him lithium to augment treatment for agitation. Lithium by acting on which of the neurotransmitters will be helpful for the patient's agitation?

serotonin

A 33-year-old patient presents to the emergency department with a two-day history of nausea and vomiting. The initial workup includes a urine pregnancy test, which is negative. The patient reports a medical history of depression and anxiety, for which she takes sertraline, as well as chronic pain, for which she takes tramadol. The patient is started on intravenous ondansetron. Which of the following may occur?

serotonin syndrome

A 74-year-old man with a past medical history of atrial fibrillation, dyslipidemia, diabetes mellitus, gout, and sick sinus syndrome is admitted to the telemetry unit after a syncopal event. His vitals upon presentation are blood pressure of 100/70 mmHg and heart rate of 75 beats per minute. Diltiazem therapy is being considered. Which of the following is the strongest contraindication for diltiazem therapy in this patient?

sick sinus syndrome

A 65-year-old woman presents to the clinic with signs and symptoms of depression. She states she has been feeling hopeless and depressed for the past six months since her mother's death and the loss of her job. She has a past medical history of chronic sinusitis, for which she has been taking antihistamines for the past two months. Her current vital signs are as follows; blood pressure 126/80 mmHg, heart rate 70/min, respiratory rate 18/min, and temperature 98.6 F. What is the next best step for this patient?

start on sertraline

A 35-year-old Asian woman with a history of substance abuse stabilized on methadone and clonazepam for many years is recently started on carbamazepine by a healthcare provider. The patient reports that she has been having fatigue, fever, teary eyes, sweating, blisters in the mouth, and joint pain. What is the most likely cause of her symptoms?

steven johnson syndrome

A 43-year-old female presents to the dermatologist with fever, rash, burning pain, and ulcers in the mouth, around the lips, and genital regions. The patient is being treated for recurrent generalized tonic-clonic seizures. Which of the following side effects should the patient have been warned of by the provider?

stevens-johnson syndrome

A 65-year-old male patient with hypertension, heart failure with preserved ejection fraction, diabetes mellitus, chronic kidney disease, and cirrhosis presents to the clinic for follow-up. His last visit was three months ago. During the last visit, amlodipine (10 mg daily) was prescribed due to elevated blood pressure in the clinic. His other medications include aspirin, lisinopril, atorvastatin, furosemide, insulin, and multivitamins. The patient noticed a blurring of vision while changing position for the last month. He also had a fall last week but did not have any major injuries. His symptoms are concerning for orthostatic hypotension. What would be the best next intervention?

stop amlodipine

A 45-year-old female patient presents to the clinic complaining of a runny nose with white mucus discharge, itchiness, and watery eyes. The patient reports that she has been taking diphenhydramine for the past week, which is helping but makes her very sleepy at work. What is the next step in management?

stop diphenhydramine and start loratadine 10mg once daily

A 21-year-old man is admitted to the intensive care unit (ICU) after a motor vehicle collision in which he was the restrained driver. He has a past medical history of type 1 diabetes, is well-controlled with insulin, has no surgical history, and does not drink alcohol or use recreational drugs. His physical exam reveals an average build, abrasions on his face, and ecchymosis on his chest and abdomen in the shape of his seat belt. CT scan reveals a left orbital blowout fracture. He is in a coma and does not respond to stimuli. Famotidine is started to reduce the possibility of developing which of the following?

stress induced ulcer

A 42 year-old-male patient is brought to the emergency department after having been thrown off his motorbike after which his lower extremities were crushed by a passing semi-truck. His vital signs are stable although the patient is unconscious and has significant crush injuries to his bilateral lower extremities below the knees. It is decided to intubate the patient to protect his airway. Which drug is contraindicated in this scenario?

succinylcholine

A 42-year-old male comes into the emergency department after being struck as a pedestrian by a truck at 30 mph. When he arrived at the hospital, his Glasgow Coma Scale was 6, and he had significant facial trauma. Additionally, he had a positive FAST exam, and emergent surgery was indicated. Before being transferred to the operating room, the emergency department physician attempted rapid sequence intubation with rocuronium as the paralytic agent. Unfortunately, due to the extensive facial trauma, intubation was unsuccessful. What pharmacological agent should be used in this scenario due to the difficulties in intubation?

sugammadex

A 25-year-old woman with a history of generalized seizure disorder got married recently. She had juvenile myoclonic seizures during her teenage which evolved into her present generalized convulsive seizures. She states she wants to start a family with her husband. She is currently taking sodium valproate 1 g twice a day to control her seizures. She has not had a seizure for the past 1 year. She does not use tobacco or alcohol. Her sister recently gave birth to a baby with anencephaly. She heard that valproate may have a similar risk and is concerned about what she should do to prevent it. In addition to advising her about healthy lifestyles and vitamin supplements, what should be the advice about her antiseizure medication?

switch valproate to lamtroigine

A 68-year-old man with end-stage chronic obstructive pulmonary disease (COPD) is undergoing palliative therapy for worsening dyspnea and productive cough. The patient had a 20 pack-year smoking history and quit smoking 12 months ago. The patient is currently using a handheld nebulizer treatment with albuterol. The patient then reports a rapid heart rate, increased mental alertness, and insomnia. Activation of which of the following systems is primarily responsible for the patient's symptoms?

sympathetic nervous system

Which of the following is the most likely consequence of the rapid administration of high-dose intravenous epinephrine?

tachycardia

A patient develops endometrial carcinoma. Which one of the following drugs has the patient most likely been taking?

tamoxifen

A 25-year-old female marathon runner presents to the urgent care for urinary urgency and polyuria. She states that her symptoms started three days ago and have persisted despite trying to stay hydrated and drinking a lot of cranberry juice. Her past medical history is significant for Achilles tendinopathy, which she attributed to a running injury last year. The physical examination is unremarkable and vital signs are within normal limits. Urinalysis demonstrates pyuria and positive leukocyte esterase. The decision to start a fluoroquinolone is discussed with the patient, and she agrees to treatment. Which of the following side effects is of significant concern in this patient?

tendonitis

A 27-year-old male with a past medical history of tuberculosis presents to the outpatient clinic with complaints of diarrhea and crampy abdominal pain. The patient was diagnosed with tuberculosis 16 weeks ago and is currently on treatment with isoniazid and rifampicin. Complete blood count shows an elevated WBC count. Blood testing shows that liver function tests are normal. Which of the following is the best next step in the management of this patient?

testing for clostridium difficle

A patient has been taking ethynyl estradiol and is to begin taking phenytoin for a seizure disorder. What change, if any, should be anticipated in this patient's ethynyl estradiol dosage?

the dosage will be increased

A 25-year-old female patient comes to you for urinary discomfort and frequency. Urine culture shows that her infection is susceptible to sulfamethoxazole/trimethoprim. What is the benefit of using these drugs together?

the drugs inhibit sequential steps of the folate synthesis pathway

A 68-year-old man diagnosed with Parkinson's disease six years ago was initially treated with ropinirole. Still, his symptoms have worsened over the past few months, and he comes in seeking additional treatment options. He is started on an immediate-release combination pill of carbidopa/levodopa. What is a common problem related to dosing with this combination of medications?

the effectiveness of the medications fluctuated during the day

A patient has been diagnosed with metabolic acidosis. His medication record shows that he is currently taking diclofenac, atenolol, albuterol, and topiramate. Which of these medications is most likely responsible for the patient's condition?

topiramate

A 55-year-old man presents with difficulty passing urine and suprapubic discomfort for the past 2 days. His symptoms are progressively worsening. The patient's past medical history is significant for depression, and he was recently started on a new medication due to refractory symptoms. The physical examination reveals tachycardia, a dry mouth, and suprapubic fullness. What is the class of medication that is responsible for this patient's presenting symptoms?

tricyclic antidepressants

A 65-year-old female comes to the clinician with pain behind her left heel for a day. The pain is aggravated by dorsiflexion of the feet. She denies stiffness, weakness, numbness, tingling, or redness of her feet and toes. She has diabetes managed with Insulin and osteoarthritis of the knee managed with painkillers. She was recently treated for an episode of urinary tract infection. She eats a balanced diet and walks for 30 minutes every day. Her vital signs are normal. On examination, there is no warmth, redness, or swelling on her feet, but there is tenderness 3 centimeters above the posterior calcaneus on the left side. Bilateral motor strength, reflexes, and sensation are normal. Which of the following is the most likely cause of the condition?

use of prescription medication

The test results for a patient are back and are showing elevations in AST and ALT, suggesting hepatotoxicity. Upon reviewing his medication record, you find that he was recently prescribed fluoxetine, omeprazole, valproic acid, and metformin. Which of the following medications is most likely to have caused the elevation in AST and ALT?

valproic acid

A 45-year-old woman develops pruritis, erythematous rash on the face and neck, and hypotension during initial intravenous antimicrobial treatment. Which of the following most likely caused this patients presentation?

vancomycin

A 55-year-old man presents with septicemia after recovering from a motorcycle accident in the hospital. The clinician suspects that the septicemia is caused by methicillin-resistant Staphylococcus aureus (MRSA). Which of the following would provide the best antibiotic coverage for this patient?

vancomycin

A 17-year-old male with an abscess of the leg secondary to methcillin-resistant Staphylococcus aureus. H was started on intravenous vancomycin. Several minutes into the infusion, the patient developed a pruritic rash on his face and neck. His blood pressure decreases from 120/80 mmHg to 90/60 mmHg. The patient has most likely developed which of the following?

vancomycin flushing syndrome

A 45-year-old man is brought in by emergency medical services while seizing. Seizure resolves with two doses of 2 mg of lorazepam in the emergency department. The patient is in a post-ictal state. His blood pressure is 140/90 mmHg, the pulse is 85/min, the temperature is 99 F, and the respiratory rate is 14/min. Labs showed a serum sodium level of 91 mEq/L, potassium of 4.1 mEq/L, and chloride of 106 mEq/L. The decision is made to intubate the patient using etomidate and succinylcholine. Propofol drip is started for sedation. Twenty minutes later, the healthcare provider notices that the patient's blood pressure is now 98/65 mmHg. What caused the drop the blood pressure?

vasodilation

A 60-year-old patient is admitted with pain and stiffness in the right calf described as 7/10, crampy, and non-radiating. History is significant for epilepsy treated with phenobarbital. Vital signs are blood pressure 130/85mmHg, temperature 98.7 F (37 C), heart rate 70 bpm, and respiratory rate 18 breaths/min. Physical examination findings include calf pain with dorsiflexion of the right foot, swelling, erythema, and tenderness of the right calf. Doppler ultrasound shows a clot in the right calf. During the patient's hospital stay, INR is consistently 1.0. Which drug is impacted by phenobarbital's hepatic enzyme induction and would have to be increased or decreased to maintain a therapeutic level?

warfarin, increased