A 21-year-old man presents for a pre-employment medical check-up. He has a history of persistent asthma and regularly uses inhaled fluticasone for prophylaxis. For the last week, he has been experiencing increasing symptoms, such as night time cough and wheezing on exertion. Because his albuterol metered-dose inhaler ran out, he has been taking oral albuterol 3 times a day for the last 3 days, which has improved his symptoms. The physician performs a complete physical examination and orders laboratory tests. Which of the following findings is most likely to be present on his physical examination or laboratory studies?
Q112
A 76-year-old male presents to his primary care physician because he is concerned about changes in urination. Over the last few months, he has noticed increased urinary frequency as well as difficulty with initiating and stopping urination. He denies having pain with urination. Physical exam reveals a uniformly enlarged and non-tender prostate. Lab tests showed that the prostate specific antigen (PSA) was within normal limits. The patient did not tolerate an alpha blocker due to episodes of syncope so another medication is prescribed that affects testosterone metabolism. Which of the following disorders can also be treated with the medication most likely prescribed in this case?
Q113
A 40-year-old male presents to the clinic. The patient has begun taking large doses of vitamin E in order to slow down the aging process and increase his sexual output. He has placed himself on this regimen following reading a website that encouraged this, without consulting a healthcare professional. He is interested in knowing if it is alright to continue his supplementation. Which of the following side-effects should he be concerned about should he continue his regimen?
Q114
A 23-year-old man is brought to the emergency department by the police for impaired cognition and agitation after being struck in the head at a local nightclub. The patient refuses to respond to questions and continues to be markedly agitated. An alcoholic smell is noted. His temperature is 36.9°C (98.4°F), pulse is 104/min, respirations are 24/min, and blood pressure is 148/95 mm Hg. He is confused and oriented only to person. Neurological examination shows miosis and nystagmus but is quickly aborted after the patient tries to attack several members of the care team. CT scan of the head shows no abnormalities. Ingestion of which of the following substances most likely explains this patient's symptoms?
Q115
A previously healthy 5-year-old girl is brought to the emergency department because of difficulty breathing and vomiting that began 1 hour after she took an amoxicillin tablet. She appears anxious. Her pulse is 140/min, respirations are 40/min, and blood pressure is 72/39 mmHg. She has several well-circumscribed, raised, erythematous plaques scattered diffusely over her trunk and extremities. Pulmonary examination shows diffuse, bilateral wheezing. Which of the following is the most appropriate initial pharmacotherapy?
Q116
A 32-year-old man is brought to the emergency department because he was found stumbling in the street heedless of oncoming traffic. On arrival, he is found to be sluggish and has slow and sometimes incoherent speech. He is also drowsy and falls asleep several times during questioning. Chart review shows that he has previously been admitted after getting a severe cut during a bar fight. Otherwise, he is known to be intermittently homeless and has poorly managed diabetes. Serum testing reveals the presence of a substance that increases the duration of opening for an important channel. Which of the following symptoms may be seen if the most likely substance in this patient is abruptly discontinued?
Q117
A 33-year-old man comes to the physician because of a 2-month history of burning epigastric pain, dry cough, and occasional regurgitation. The pain is aggravated by eating and lying down. Physical examination shows a soft, non-tender abdomen. Upper endoscopy shows hyperemia in the distal third of the esophagus. Which of the following drugs is most likely to directly inhibit the common pathway of gastric acid secretion?
Q118
A 59-year-old man is brought to the emergency department one hour after developing shortness of breath and “squeezing” chest pain that began while he was mowing the lawn. He has asthma, hypertension, and erectile dysfunction. Current medications include salmeterol, amlodipine, lisinopril, and vardenafil. His pulse is 110/min and blood pressure is 122/70 mm Hg. Physical examination shows diaphoresis. An ECG shows sinus tachycardia. Sublingual nitroglycerin is administered. Five minutes later, his pulse is 137/min and his blood pressure is 78/40 mm Hg. Which of the following is the most likely mechanism of this patient's hypotension?
Q119
A 40-year-old homeless man is brought to the emergency department after police found him in the park lying on the ground with a minor cut at the back of his head. He is confused with slurred speech and fails a breathalyzer test. Pupils are normal in size and reactive to light. A bolus of intravenous dextrose, thiamine, and naloxone is given in the emergency department. The cut on the head is sutured. Blood and urine are drawn for toxicology screening. The blood-alcohol level comes out to be 200 mg/dL. Liver function test showed an AST of 320 U/L, ALT of 150 U/L, gamma-glutamyl transferase of 100 U/L, and total and direct bilirubin level are within normal limits. Which additional physical examination finding is most likely to be present in this patient?
Q120
A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?
Autonomic/CV Drugs US Medical PG Practice Questions and MCQs
Question 111: A 21-year-old man presents for a pre-employment medical check-up. He has a history of persistent asthma and regularly uses inhaled fluticasone for prophylaxis. For the last week, he has been experiencing increasing symptoms, such as night time cough and wheezing on exertion. Because his albuterol metered-dose inhaler ran out, he has been taking oral albuterol 3 times a day for the last 3 days, which has improved his symptoms. The physician performs a complete physical examination and orders laboratory tests. Which of the following findings is most likely to be present on his physical examination or laboratory studies?
A. Serum magnesium is 2.4 mEq/L (1.2 mmol/L)
B. Upbeat nystagmus
C. Myoclonus
D. Pulse rate is 116/min (Correct Answer)
E. Serum potassium is 5.5 mEq/L (5.5 mmol/L)
Explanation: ***Pulse rate is 116/min***
- Oral **albuterol** is a **beta-2 adrenergic agonist** that can cause systemic side effects, including **tachycardia** and palpitations, especially when taken in higher or more frequent doses.
- The patient's increased albuterol use as an oral formulation, rather than a metered-dose inhaler, leads to higher systemic absorption and a greater likelihood of adverse effects like a **fast heart rate**.
*Serum magnesium is 2.4 mEq/L (1.2 mmol/L)*
- This value is within the normal range for serum magnesium, and albuterol use is not typically associated with changes in magnesium levels.
- While magnesium can be used in acute severe asthma, it is not an expected side effect of albuterol to significantly alter serum magnesium.
*Upbeat nystagmus*
- **Upbeat nystagmus** is a neurological sign often associated with **brainstem lesions** or certain drug toxicities (e.g., lithium, carbamazepine, alcohol) but is not a typical side effect of albuterol.
- Albuterol's primary effects are on the **sympathetic nervous system** and smooth muscle in the airways, not directly on vestibular or brainstem function to cause nystagmus.
*Myoclonus*
- **Myoclonus** (brief, involuntary twitching of a muscle or group of muscles) is not a common side effect of albuterol.
- While high doses of **beta-agonists** can cause tremors, myoclonus specifically suggests a different neurological pathology or drug toxicity.
*Serum potassium is 5.5 mEq/L (5.5 mmol/L)*
- This value indicates **hyperkalemia**, while **beta-2 agonists** like albuterol are known to cause a shift of potassium *into* cells, leading to **hypokalemia**, not hyperkalemia.
- Therefore, a finding of hyperkalemia would be inconsistent with albuterol use and instead might suggest kidney dysfunction or other underlying conditions.
Question 112: A 76-year-old male presents to his primary care physician because he is concerned about changes in urination. Over the last few months, he has noticed increased urinary frequency as well as difficulty with initiating and stopping urination. He denies having pain with urination. Physical exam reveals a uniformly enlarged and non-tender prostate. Lab tests showed that the prostate specific antigen (PSA) was within normal limits. The patient did not tolerate an alpha blocker due to episodes of syncope so another medication is prescribed that affects testosterone metabolism. Which of the following disorders can also be treated with the medication most likely prescribed in this case?
A. Prostate adenocarcinoma
B. Male pattern baldness (Correct Answer)
C. Hypogonadism
D. Erectile dysfunction
E. Polycystic ovarian syndrome (PCOS)
Explanation: ***Male pattern baldness***
- The patient's symptoms (urinary frequency, difficulty initiating/stopping urination, uniformly enlarged prostate, normal PSA) are consistent with **benign prostatic hyperplasia (BPH)**. Since he couldn't tolerate alpha-blockers, a **5-alpha reductase inhibitor** like **finasteride** or **dutasteride** would likely be prescribed, which works by blocking the conversion of testosterone to dihydrotestosterone (DHT).
- **Male pattern baldness (androgenetic alopecia)** is also caused by DHT and can be treated with 5-alpha reductase inhibitors such as finasteride.
*Prostate adenocarcinoma*
- While 5-alpha reductase inhibitors can reduce the risk of prostate cancer, they are **not a primary treatment** for established prostate adenocarcinoma.
- Prostate adenocarcinoma is typically managed with surgery, radiation, or more aggressive hormonal therapies if advanced.
*Hypogonadism*
- Hypogonadism is characterized by **low testosterone levels**; 5-alpha reductase inhibitors actually decrease the conversion of testosterone to DHT, which could potentially worsen symptoms associated with low testosterone if used inappropriately.
- The primary treatment for hypogonadism is **testosterone replacement therapy**.
*Erectile dysfunction*
- Erectile dysfunction is often treated with **phosphodiesterase-5 inhibitors (PDE5i)** like sildenafil or tadalafil, which improve blood flow to the penis.
- While BPH can sometimes contribute to ED, 5-alpha reductase inhibitors are **not a first-line treatment** for primary ED and can even have ED as a side effect.
*Polycystic ovarian syndrome (PCOS)*
- PCOS is a hormonal disorder affecting women, characterized by **elevated androgen levels** and ovarian cysts.
- While anti-androgens can be used in PCOS to manage symptoms like hirsutism, **5-alpha reductase inhibitors are not a standard treatment** for the overall syndrome and this medication is prescribed for a male patient.
Question 113: A 40-year-old male presents to the clinic. The patient has begun taking large doses of vitamin E in order to slow down the aging process and increase his sexual output. He has placed himself on this regimen following reading a website that encouraged this, without consulting a healthcare professional. He is interested in knowing if it is alright to continue his supplementation. Which of the following side-effects should he be concerned about should he continue his regimen?
A. Retinopathy
B. Hemorrhage (Correct Answer)
C. Peripheral neuropathy
D. Deep venous thrombosis
E. Night blindness
Explanation: ***Hemorrhage***
- High doses of **vitamin E** can inhibit **vitamin K-dependent coagulation factors**, leading to an increased risk of bleeding or **hemorrhage**.
- This effect is particularly pronounced when vitamin E is taken in conjunction with **anticoagulant medications** like warfarin.
*Retinopathy*
- **Retinopathy** is not a common side effect associated with high-dose vitamin E supplementation.
- It is more typically linked to conditions like **diabetes** or **hypertension**.
*Peripheral neuropathy*
- **Peripheral neuropathy** is primarily associated with deficiencies in other vitamins, such as **vitamin B12** or **B6 toxicity**, not with vitamin E supplementation.
- Excessive vitamin E intake does not directly cause nerve damage in the periphery.
*Deep venous thrombosis*
- **Deep venous thrombosis (DVT)** is a condition involving blood clot formation, and vitamin E supplementation is generally **not associated with an increased risk of DVT**.
- In fact, vitamin E's anticoagulant properties might theoretically reduce clot formation, though this is not a primary clinical indication for its use.
*Night blindness*
- **Night blindness** is a classic symptom of **vitamin A deficiency**, which is unrelated to vitamin E intake.
- Vitamin E overdose does not cause vision impairment such as night blindness.
Question 114: A 23-year-old man is brought to the emergency department by the police for impaired cognition and agitation after being struck in the head at a local nightclub. The patient refuses to respond to questions and continues to be markedly agitated. An alcoholic smell is noted. His temperature is 36.9°C (98.4°F), pulse is 104/min, respirations are 24/min, and blood pressure is 148/95 mm Hg. He is confused and oriented only to person. Neurological examination shows miosis and nystagmus but is quickly aborted after the patient tries to attack several members of the care team. CT scan of the head shows no abnormalities. Ingestion of which of the following substances most likely explains this patient's symptoms?
A. Lysergic acid diethylamide
B. Phencyclidine (Correct Answer)
C. Alcohol
D. Heroin
E. Methamphetamine
Explanation: ***Phencyclidine***
- **Phencyclidine (PCP)** intoxication is characterized by a combination of severe **agitation**, **aggression**, impaired cognition, nystagmus (vertical or horizontal), and miotic pupils, which precisely matches the patient's presentation.
- The patient's violent behavior and refusal to cooperate with examination despite an initial head injury also align with the dissociative and stimulant effects of PCP.
*Lysergic acid diethylamide*
- **LSD** typically causes hallucinations, altered perceptions, and dilated pupils (**mydriasis**), rather than the miotic pupils and marked aggression seen in this patient.
- While agitation can occur with LSD, the extreme violence and neurological signs like nystagmus point away from it as the primary cause.
*Alcohol*
- While alcohol can cause impaired cognition and agitation, the presence of **miosis** and **nystagmus** in this agitated state, especially given the degree of disorientation and aggression, is more characteristic of other substances.
- The "alcoholic smell" could be a red herring or co-ingestion, but the overall clinical picture is not solely attributable to acute alcohol intoxication.
*Heroin*
- **Heroin (opioid)** overdose typically causes **sedation**, respiratory depression, and pinpoint pupils (**miosis**), which is contrary to the agitation, aggression, and elevated vital signs described.
- The patient's high blood pressure and pulse are inconsistent with opioid effects.
*Methamphetamine*
- **Methamphetamine** intoxication leads to agitation, paranoia, and elevated vital signs (tachycardia, hypertension), but typically causes **mydriasis (dilated pupils)**, not miosis.
- Although agitation and aggression are significant features, the pupillary findings help differentiate it from PCP.
Question 115: A previously healthy 5-year-old girl is brought to the emergency department because of difficulty breathing and vomiting that began 1 hour after she took an amoxicillin tablet. She appears anxious. Her pulse is 140/min, respirations are 40/min, and blood pressure is 72/39 mmHg. She has several well-circumscribed, raised, erythematous plaques scattered diffusely over her trunk and extremities. Pulmonary examination shows diffuse, bilateral wheezing. Which of the following is the most appropriate initial pharmacotherapy?
A. Norepinephrine
B. Dobutamine
C. Methylprednisolone
D. Epinephrine (Correct Answer)
E. Diphenhydramine
Explanation: ***Epinephrine***
- This patient presents with **anaphylaxis** due to amoxicillin, characterized by rapidly developing **respiratory distress** (wheezing, tachypnea), **circulatory compromise** (hypotension, tachycardia), and **cutaneous manifestations** (urticaria).
- **Epinephrine** is the first-line treatment for anaphylaxis because it stabilizes mast cells, causes **vasoconstriction** to improve blood pressure, and promotes **bronchodilation** to alleviate respiratory symptoms.
*Norepinephrine*
- **Norepinephrine** is a potent **vasopressor** primarily used for septic shock or conditions requiring significant vasoconstriction.
- It lacks the bronchodilatory effects and mast cell-stabilizing properties that are crucial in managing the respiratory and systemic inflammatory components of anaphylaxis.
*Dobutamine*
- **Dobutamine** is a **beta-1 adrenergic agonist** primarily used to increase cardiac contractility and heart rate in cases of cardiogenic shock or heart failure.
- It would not address the systemic vasodilation, bronchospasm, or immune-mediated aspects of anaphylaxis effectively.
*Methylprednisolone*
- **Methylprednisolone** is a **corticosteroid** that acts to reduce inflammation and prevent biphasic anaphylactic reactions.
- While important in the overall management of anaphylaxis, it has a delayed onset of action and is not the appropriate initial therapy for acute life-threatening symptoms; **epinephrine** is critical for immediate stabilization.
*Diphenhydramine*
- **Diphenhydramine** is an **antihistamine** that blocks histamine H1 receptors, helping to reduce symptoms such as urticaria and pruritus.
- It does not address the life-threatening aspects of anaphylaxis, such as hypotension and bronchospasm, and should be used as an adjunct rather than initial monotherapy.
Question 116: A 32-year-old man is brought to the emergency department because he was found stumbling in the street heedless of oncoming traffic. On arrival, he is found to be sluggish and has slow and sometimes incoherent speech. He is also drowsy and falls asleep several times during questioning. Chart review shows that he has previously been admitted after getting a severe cut during a bar fight. Otherwise, he is known to be intermittently homeless and has poorly managed diabetes. Serum testing reveals the presence of a substance that increases the duration of opening for an important channel. Which of the following symptoms may be seen if the most likely substance in this patient is abruptly discontinued?
A. Tremors
B. Insomnia
C. Delayed delirium
D. Piloerection
E. Seizures (Correct Answer)
Explanation: ***Seizures***
- This patient presents with symptoms of **central nervous system (CNS) depression** (sluggish, incoherent speech, drowsiness) and a history suggestive of **substance abuse** (homelessness, bar fight).
- The key clue is that the substance **increases the duration of opening** of the GABA-A receptor channel, which specifically describes **barbiturates** (benzodiazepines increase the **frequency** of opening, not duration).
- Abrupt discontinuation of barbiturates can lead to life-threatening **withdrawal seizures** due to CNS hyperexcitability when GABAergic inhibition is suddenly removed [1].
- This is the most critical and potentially fatal complication of barbiturate withdrawal.
*Tremors*
- While **tremors** can occur during withdrawal from CNS depressants, they are a less severe symptom compared to seizures.
- Tremors are common in withdrawal syndromes but do not represent the most life-threatening risk in acute barbiturate withdrawal.
*Insomnia*
- **Insomnia** is a common symptom of withdrawal from CNS depressants due to rebound CNS hyperactivity [1].
- However, compared to seizures, insomnia is not life-threatening and is a less critical feature of barbiturate withdrawal.
*Delayed delirium*
- **Delirium** can occur during severe withdrawal, particularly **delirium tremens** in alcohol withdrawal.
- While delirium may develop, the most immediate and severe risk for barbiturate withdrawal is seizures, which can occur within hours to days of cessation.
*Piloerection*
- **Piloerection** (goosebumps) is a classic symptom of **opioid withdrawal**, resulting from sympathetic nervous system activation.
- This symptom is **not** characteristic of withdrawal from barbiturates or other GABAergic substances, making it an incorrect choice.
Question 117: A 33-year-old man comes to the physician because of a 2-month history of burning epigastric pain, dry cough, and occasional regurgitation. The pain is aggravated by eating and lying down. Physical examination shows a soft, non-tender abdomen. Upper endoscopy shows hyperemia in the distal third of the esophagus. Which of the following drugs is most likely to directly inhibit the common pathway of gastric acid secretion?
A. Pirenzepine
B. Ranitidine
C. Lansoprazole (Correct Answer)
D. Aluminum hydroxide
E. Octreotide
Explanation: ***Lansoprazole***
- **Lansoprazole** is a **proton pump inhibitor (PPI)** that irreversibly blocks the **H+/K+-ATPase (proton pump)** in gastric parietal cells, the final common pathway for gastric acid secretion.
- By inhibiting this pump, PPIs effectively reduce acid production, providing significant relief for symptoms like **burning epigastric pain** and **regurgitation** as seen in **gastroesophageal reflux disease (GERD)**.
*Pirenzepine*
- **Pirenzepine** is a **muscarinic M1 receptor antagonist** that selectively inhibits gastric acid secretion stimulated by acetylcholine.
- While it reduces acid, it does not directly target the final common pathway (the proton pump) and is less potent than PPIs.
*Ranitidine*
- **Ranitidine** is an **H2 receptor antagonist** that blocks histamine-mediated acid secretion from parietal cells.
- Although it reduces acid production, it does not inhibit the proton pump directly, which is the common pathway for all acid secretagogues.
*Aluminum hydroxide*
- **Aluminum hydroxide** is an **antacid** that neutralizes existing stomach acid by acting as a buffer.
- It does not inhibit acid secretion but rather works on the acid that has already been secreted.
*Octreotide*
- **Octreotide** is a **somatostatin analog** that inhibits various gastrointestinal hormones, including gastrin, thereby indirectly reducing acid secretion.
- It is primarily used for conditions like **variceal bleeding** or **neuroendocrine tumors** like **gastrinomas**, not for routine GERD treatment.
Question 118: A 59-year-old man is brought to the emergency department one hour after developing shortness of breath and “squeezing” chest pain that began while he was mowing the lawn. He has asthma, hypertension, and erectile dysfunction. Current medications include salmeterol, amlodipine, lisinopril, and vardenafil. His pulse is 110/min and blood pressure is 122/70 mm Hg. Physical examination shows diaphoresis. An ECG shows sinus tachycardia. Sublingual nitroglycerin is administered. Five minutes later, his pulse is 137/min and his blood pressure is 78/40 mm Hg. Which of the following is the most likely mechanism of this patient's hypotension?
A. Bradykinin accumulation
B. Cyclic GMP elevation (Correct Answer)
C. Decreased nitric oxide production
D. Calcium channel antagonism
E. Alpha-1 receptor antagonism
Explanation: ***Cyclic GMP elevation***
- The patient's severe hypotension after nitroglycerin administration is likely due to an interaction with **vardenafil**, a **phosphodiesterase-5 (PDE5) inhibitor**.
- Both nitroglycerin and vardenafil increase levels of **cyclic guanosine monophosphate (cGMP)**, leading to excessive systemic vasodilation and profound hypotension.
*Bradykinin accumulation*
- This is a well-known side effect of **ACE inhibitors (e.g., lisinopril)**, manifesting primarily as a dry cough or angioedema.
- While the patient is on lisinopril, bradykinin accumulation does not immediately cause severe hypotension following nitroglycerin administration in this manner.
*Decreased nitric oxide production*
- Nitric oxide (NO) is a **vasodilator**; decreased production would typically lead to vasoconstriction and *increased* blood pressure, not hypotension.
- Nitroglycerin, in fact, works by **increasing NO production** or release to induce vasodilation.
*Calcium channel antagonism*
- **Amlodipine** is a calcium channel blocker, which can cause vasodilation and lower blood pressure.
- However, the sudden and severe drop in blood pressure observed *after* nitroglycerin is not primarily due to an additive effect of amlodipine in the way PDE5 inhibitors interact.
*Alpha-1 receptor antagonism*
- Alpha-1 receptor antagonists (e.g., prazosin, doxazosin) cause **vasodilation** by blocking norepinephrine's action on blood vessels.
- While they can cause orthostatic hypotension, the patient is not on such a medication, and this mechanism does not explain the acute, severe drop seen after nitroglycerin.
Question 119: A 40-year-old homeless man is brought to the emergency department after police found him in the park lying on the ground with a minor cut at the back of his head. He is confused with slurred speech and fails a breathalyzer test. Pupils are normal in size and reactive to light. A bolus of intravenous dextrose, thiamine, and naloxone is given in the emergency department. The cut on the head is sutured. Blood and urine are drawn for toxicology screening. The blood-alcohol level comes out to be 200 mg/dL. Liver function test showed an AST of 320 U/L, ALT of 150 U/L, gamma-glutamyl transferase of 100 U/L, and total and direct bilirubin level are within normal limits. Which additional physical examination finding is most likely to be present in this patient?
A. Pin point pupil
B. Vertical nystagmus
C. Ataxic gait (Correct Answer)
D. Increased appetite
E. High blood pressure
Explanation: ***Ataxic gait***
- Chronic alcohol abuse, suggested by elevated AST, ALT, and GGT levels, leads to **cerebellar degeneration** which manifests as an **ataxic gait**.
- **Alcohol intoxication** itself can cause disequilibrium and staggering, contributing to an ataxic presentation.
*Pin point pupil*
- **Pinpoint pupils** are typically associated with **opioid intoxication** or pontine hemorrhage, neither of which is indicated here.
- The patient's pupils are specifically noted as **normal in size and reactive to light**, ruling out this finding.
*Vertical nystagmus*
- **Vertical nystagmus** is often a sign of **brainstem dysfunction** or certain drug toxicities (e.g., phencyclidine, phenytoin), rather than typical alcohol intoxication or chronic alcoholic effects.
- While nystagmus can occur with alcohol, it's more commonly horizontal; vertical nystagmus would suggest a different or additional pathology.
*Increased appetite*
- **Increased appetite** is not a characteristic symptom of acute alcohol intoxication or chronic alcoholism.
- Chronic alcoholics often experience **malnutrition** and **decreased appetite** due to the metabolic effects of alcohol and associated organ damage.
*High blood pressure*
- While chronic alcoholism can lead to **hypertension** over time, acute alcohol intoxication typically causes **vasodilation and hypotension**.
- This patient's presentation with acute intoxication would more likely involve a lower, rather than higher, blood pressure.
Question 120: A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?
A. Counsel patient and continue same opioid dose
B. Increase dosage of morphine (Correct Answer)
C. Change morphine to a non-opioid analgesic
D. Initiate palliative radiotherapy
E. Initiate cognitive behavioral therapy
Explanation: ***Increase dosage of morphine***
- The patient is experiencing severe, **uncontrolled pain** (8-9/10), indicating her current morphine dose is inadequate. In palliative care, the goal is to provide maximum comfort, and **opioid dose escalation** is appropriate to achieve this.
- While respiratory depression is a concern with opioids, in patients with chronic pain who are already on opioids, **tolerance to respiratory depressant effects** develops more quickly than tolerance to analgesic effects. Careful titration and monitoring can safely increase pain relief.
*Counsel patient and continue same opioid dose*
- The patient's pain is severe and unmanaged, so simply counseling her without addressing the **inadequate analgesia** would be inappropriate and unethical.
- Continuing the same dose would perpetuate her suffering, as the current regimen is clearly **insufficient for pain control**.
*Change morphine to a non-opioid analgesic*
- For severe cancer pain (8-9/10), **non-opioid analgesics** alone are typically ineffective.
- Switching to a non-opioid would likely lead to even poorer pain control and increased suffering, as opioids are the **cornerstone of severe cancer pain management**.
*Initiate palliative radiotherapy*
- While **radiotherapy** can be effective for localized pain caused by bone metastases, its onset of action is not immediate, and the primary issue here is urgent, **uncontrolled systemic pain**.
- It is not an appropriate initial step for immediate pain relief in a patient already in hospice with widespread metastatic disease and severe current pain.
*Initiate cognitive behavioral therapy*
- **Cognitive behavioral therapy (CBT)** can be a useful adjunct in chronic pain management to help with coping strategies and psychological distress.
- However, it does not directly address the severe, acute physical pain the patient is experiencing and is not a substitute for **pharmacological pain control** in this context.
