A 59-year-old healthy woman presents to her primary care physician’s office six weeks after undergoing an elective breast augmentation procedure in the Dominican Republic. She was told by her surgeon to establish post-operative care once back in the United States. Today she is bothered by nausea and early satiety. Her past medical history is significant only for GERD for which she takes ranitidine. Since the surgery, she has also taken an unknown opioid pain medication that was given to her by the surgeon. She reports that she has been taking approximately ten pills a day. On examination she is afebrile with normal vital signs and her surgical incisions are healing well. Her abdomen is distended and tympanitic. The patient refuses to stop her pain medicine and laxatives are not effective; what medication could be prescribed to ameliorate her gastrointestinal symptoms?
Q512
A 68-year-old man comes to the emergency department 12 hours after the appearance of tender, purple discolorations on his thighs and lower abdomen. He began taking a medication 4 days ago after failed cardioversion for atrial fibrillation, but he cannot remember the name. Physical examination shows a tender bluish-black discoloration on the anterior abdominal wall. A photograph of the right thigh is shown. Which of the following is the most likely explanation for this patient's skin findings?
Q513
A 35-year-old female presents to her primary care physician complaining of right upper quadrant pain over the last 6 months. Pain is worst after eating and feels like intermittent squeezing. She also admits to lighter colored stools and a feeling of itchiness on her skin. Physical exam demonstrates a positive Murphy's sign. The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?
Q514
A 59-year-old male with a 1-year history of bilateral knee arthritis presents with epigastric pain that intensifies with meals. He has been self-medicating with aspirin, taking up to 2,000 mg per day for the past six months. Which of the following medications, if taken instead of aspirin, could have minimized his risk of experiencing this epigastric pain?
Q515
A 62-year-old man presents to his primary care provider complaining of leg pain with exertion for the past 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse in his right calf than in his left, and it goes away when he stops walking. He has also noticed that his symptoms are progressing and that this pain is occurring sooner than before. His medical history is remarkable for type 2 diabetes mellitus and 30-pack-year smoking history. His ankle-brachial index (ABI) is found to be 0.80. Which of the following can be used as initial therapy for this patient's condition?
Q516
A 26-year-old G1P0 woman is brought to the emergency room by her spouse for persistently erratic behavior. Her spouse reports that she has been sleeping > 1 hour a night, and it sometimes seems like she’s talking to herself. She has maxed out their credit cards on baby clothes. The patient’s spouse reports this has been going on for over a month. Since first seeing a physician, she has been prescribed multiple first and second generation antipsychotics, but the patient’s spouse reports that her behavior has failed to improve. Upon examination, the patient is speaking rapidly and occasionally gets up to pace the room. She reports she is doing “amazing,” and that she is “so excited for the baby to get here because I’m going to be the best mom.” She denies illicit drug use, audiovisual hallucinations, or suicidal ideation. The attending psychiatrist prescribes a class of medication the patient has not yet tried to treat the patient’s psychiatric condition. In terms of this new medication, which of the following is the patient’s newborn most likely at increased risk for?
Q517
A 27-year-old man presents to the emergency department for bizarre behavior. The patient had boarded up his house and had been refusing to leave for several weeks. The police were called when a foul odor emanated from his property prompting his neighbors to contact the authorities. Upon questioning, the patient states that he has been pursued by elves for his entire life. He states that he was tired of living in fear, so he decided to lock himself in his house. The patient is poorly kempt and has very poor dentition. The patient has a past medical history of schizophrenia which was previously well controlled with olanzapine. The patient is restarted on olanzapine and monitored over the next several days. Which of the following needs to be monitored long term in this patient?
Q518
A 53-year-old man is brought to the emergency department because of wheezing and shortness of breath that began 1 hour after he took a new medication. Earlier in the day he was diagnosed with stable angina pectoris and prescribed a drug that irreversibly inhibits cyclooxygenase-1 and 2. He has chronic rhinosinusitis and asthma treated with inhaled β-adrenergic agonists and corticosteroids. His respirations are 26/min. Examination shows multiple small, erythematous nasal mucosal lesions. After the patient is stabilized, therapy for primary prevention of coronary artery disease should be switched to a drug with which of the following mechanisms of action?
Q519
A 37-year-old man presents with back pain which began 3 days ago when he was lifting heavy boxes. The pain radiates from the right hip to the back of the thigh. The pain is exacerbated when he bends at the waist. He rates the severity of the pain as 6 out of 10. The patient has asthma and mitral insufficiency due to untreated rheumatic fever in childhood. He has a smoking history of 40 pack-years. His family history is remarkable for rheumatoid arthritis, diabetes, and hypertension. Vital signs are within normal limits. On physical examination, the pain is elicited when the patient is asked to raise his leg without extending his knee. The patient has difficulty walking on his heels. Peripheral pulses are equal and brisk bilaterally. No hair loss, temperature changes, or evidence of peripheral vascular disease is observed. Which of the following is considered the best management option for this patient?
Q520
A 17-year-old white male is brought to the emergency department after being struck by a car. He complains of pain in his right leg and left wrist, and slowly recounts how he was hit by a car while being chased by a lion. In between sentences of the story, he repeatedly complains of dry mouth and severe hunger and requests something to eat and drink. His mother arrives and is very concerned about this behavior, noting that he has been withdrawn lately and doing very poorly in school the past several months. Notable findings on physical exam include conjunctival injection bilaterally and a pulse of 107. What drug is this patient most likely currently abusing?
Autonomic/CV Drugs US Medical PG Practice Questions and MCQs
Question 511: A 59-year-old healthy woman presents to her primary care physician’s office six weeks after undergoing an elective breast augmentation procedure in the Dominican Republic. She was told by her surgeon to establish post-operative care once back in the United States. Today she is bothered by nausea and early satiety. Her past medical history is significant only for GERD for which she takes ranitidine. Since the surgery, she has also taken an unknown opioid pain medication that was given to her by the surgeon. She reports that she has been taking approximately ten pills a day. On examination she is afebrile with normal vital signs and her surgical incisions are healing well. Her abdomen is distended and tympanitic. The patient refuses to stop her pain medicine and laxatives are not effective; what medication could be prescribed to ameliorate her gastrointestinal symptoms?
A. Naloxegol (Correct Answer)
B. Senna
C. Pantoprazole
D. Metoclopramide
E. Naproxen
Explanation: ***Naloxegol***
- This patient is experiencing **opioid-induced constipation (OIC)** due to chronic opioid use, evidenced by nausea, early satiety, abdominal distension, and ineffective laxatives. **Naloxegol** is a peripherally acting mu-opioid receptor antagonist (PAMORA) that blocks opioid effects in the gastrointestinal tract without reversing central analgesia.
- It helps ameliorate OIC symptoms by reducing the constipating effects of opioids while the patient continues to take their pain medication, which is crucial given her refusal to stop.
*Senna*
- **Senna** is a stimulant laxative that works by irritating the bowel mucosa to promote peristalsis.
- While useful for some forms of constipation, it is often ineffective in severe OIC because the primary problem is opioid-mediated reduction in gut motility, not simply a lack of stimulation, and the patient reports laxatives have already been ineffective.
*Pantoprazole*
- **Pantoprazole** is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions like GERD.
- While the patient has a history of GERD, her current symptoms of nausea, early satiety, and abdominal distension are primarily related to opioid use and not acid reflux, making pantoprazole an inappropriate treatment for her current GI complaints.
*Metoclopramide*
- **Metoclopramide** is a dopamine antagonist that acts as a prokinetic agent, increasing gastrointestinal motility.
- Although it can help with nausea and gastric emptying, it primarily addresses the upper GI tract and may not be sufficient for the severe, generalized reduction in motility seen in OIC, and its central dopamine blocking effects can lead to side effects like tardive dyskinesia with chronic use.
*Naproxen*
- **Naproxen** is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
- It has no role in treating gastrointestinal motility disorders or opioid-induced constipation; in fact, chronic NSAID use can cause GI side effects like gastritis and ulcers.
Question 512: A 68-year-old man comes to the emergency department 12 hours after the appearance of tender, purple discolorations on his thighs and lower abdomen. He began taking a medication 4 days ago after failed cardioversion for atrial fibrillation, but he cannot remember the name. Physical examination shows a tender bluish-black discoloration on the anterior abdominal wall. A photograph of the right thigh is shown. Which of the following is the most likely explanation for this patient's skin findings?
A. Antibodies against platelet factor 4
B. Increased levels of protein S
C. Decreased synthesis of antithrombin III
D. Reduced levels of protein C (Correct Answer)
E. Deficiency of vitamin K
Explanation: **Reduced levels of protein C**
- The patient's presentation of **tender, purple discolorations** (skin necrosis) on the thighs and lower abdomen, developing a few days after starting a new medication for atrial fibrillation, is highly suspicious for **coumarin-induced skin necrosis**.
- This adverse event occurs most commonly with **warfarin (a coumarin derivative)**, especially in patients with a **pre-existing protein C deficiency** or when therapy is initiated without adequate bridging, leading to an initial procoagulant state due to the faster reduction of protein C compared to procoagulant factors.
*Antibodies against platelet factor 4*
- This condition describes **heparin-induced thrombocytopenia (HIT)**, where antibodies against platelet factor 4 (PF4) complexed with heparin lead to platelet activation, aggregation, and thrombosis.
- HIT presents with **thrombocytopenia** (which is not mentioned as present here) and thrombotic events, but typically not with the distinct skin necrosis pattern seen with warfarin.
*Increased levels of protein S*
- **Increased levels of protein S** would generally lead to a more effective anticoagulant state rather than a procoagulant state.
- **Protein S** acts as a cofactor for protein C, enhancing its anticoagulant activity. Its elevation would not explain the observed skin necrosis.
*Decreased synthesis of antithrombin III*
- **Antithrombin III deficiency** is a congenital or acquired thrombophilia that can lead to an increased risk of venous and arterial thrombosis.
- While it increases the risk of thrombosis, it does not specifically explain the unique presentation of **warfarin-induced skin necrosis** through its specific mechanism.
*Deficiency of vitamin K*
- **Vitamin K deficiency** leads to impaired synthesis of vitamin K-dependent clotting factors (II, VII, IX, X) and anticoagulant proteins (Protein C and S), often resulting in **bleeding diathesis**, not thrombotic skin necrosis.
- While warfarin works by inhibiting vitamin K epoxide reductase, a severe general deficiency of vitamin K would present differently.
Question 513: A 35-year-old female presents to her primary care physician complaining of right upper quadrant pain over the last 6 months. Pain is worst after eating and feels like intermittent squeezing. She also admits to lighter colored stools and a feeling of itchiness on her skin. Physical exam demonstrates a positive Murphy's sign. The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?
A. Rickets and osteomalacia
B. Hemolytic anemia
C. Night blindness
D. Increased prothrombin time and easy bleeding
E. Scurvy (Correct Answer)
Explanation: ***Scurvy***
- This condition is likely **cholestasis** due to common bile duct obstruction, given the RUQ pain after eating, light-colored stools, itchiness, and **positive Murphy's sign**.
- Cholestasis impairs the absorption of **fat-soluble vitamins** (A, D, E, K), but not **water-soluble vitamins** like vitamin C, which prevents scurvy.
*Rickets and osteomalacia*
- These conditions are caused by **vitamin D deficiency**, which is a **fat-soluble vitamin**.
- Impaired fat absorption in cholestasis would significantly impact vitamin D levels, leading to increased risk of rickets in children and osteomalacia in adults.
*Hemolytic anemia*
- This can be caused by **vitamin E deficiency**, a **fat-soluble vitamin**.
- Cholestasis impairs vitamin E absorption, which can lead to increased red blood cell fragility and hemolytic anemia.
*Night blindness*
- This is a classic symptom of **vitamin A deficiency**, which is a **fat-soluble vitamin**.
- Impaired fat absorption in cholestasis would reduce vitamin A uptake, contributing to night blindness.
*Increased prothrombin time and easy bleeding*
- These symptoms are indicative of **vitamin K deficiency**, a **fat-soluble vitamin**.
- Vitamin K is essential for the synthesis of clotting factors, and its absorption is severely hindered in cholestasis, leading to coagulopathies.
Question 514: A 59-year-old male with a 1-year history of bilateral knee arthritis presents with epigastric pain that intensifies with meals. He has been self-medicating with aspirin, taking up to 2,000 mg per day for the past six months. Which of the following medications, if taken instead of aspirin, could have minimized his risk of experiencing this epigastric pain?
A. Naproxen
B. Celecoxib (Correct Answer)
C. Indomethacin
D. Ibuprofen
E. Ketorolac
Explanation: ***Celecoxib***
- **Celecoxib** is a selective **COX-2 inhibitor**, which preferentially inhibits the COX-2 enzyme responsible for inflammation and pain, while largely sparing COX-1.
- Sparing **COX-1** reduces the inhibition of **prostaglandins** that protect the gastric mucosa, thereby lowering the risk of GI side effects like epigastric pain and ulcers compared to non-selective NSAIDs.
*Naproxen*
- **Naproxen** is a **non-selective NSAID** that inhibits both COX-1 and COX-2 enzymes.
- Inhibition of **COX-1** interferes with the production of protective prostaglandins in the stomach, increasing the risk of gastrointestinal adverse effects such as epigastric pain, ulcers, and bleeding, similar to aspirin.
*Indomethacin*
- **Indomethacin** is a potent **non-selective NSAID** with significant inhibition of both COX-1 and COX-2.
- Its strong **COX-1 inhibition** makes it particularly prone to causing gastrointestinal side effects including severe epigastric pain, nausea, and dyspepsia.
*Ibuprofen*
- **Ibuprofen** is a **non-selective NSAID** commonly used for pain and inflammation that inhibits both COX-1 and COX-2 enzymes.
- Although generally better tolerated than indomethacin or high-dose aspirin, it still carries a dose-dependent risk of **GI adverse effects** due to COX-1 inhibition.
*Ketorolac*
- **Ketorolac** is a potent **non-selective NSAID** primarily used for short-term management of acute moderate to severe pain.
- It has a high risk of **gastrointestinal complications**, including gastric ulcers and bleeding, making it unsuitable for long-term use and not a safer alternative to aspirin in terms of GI risk.
Question 515: A 62-year-old man presents to his primary care provider complaining of leg pain with exertion for the past 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse in his right calf than in his left, and it goes away when he stops walking. He has also noticed that his symptoms are progressing and that this pain is occurring sooner than before. His medical history is remarkable for type 2 diabetes mellitus and 30-pack-year smoking history. His ankle-brachial index (ABI) is found to be 0.80. Which of the following can be used as initial therapy for this patient's condition?
A. Endovascular revascularization
B. Arthroscopic resection
C. Duloxetine
D. Heparin
E. Cilostazol (Correct Answer)
Explanation: ***Cilostazol***
- This patient presents with symptoms highly suggestive of **peripheral artery disease (PAD)**, characterized by **intermittent claudication** (leg pain with exertion relieved by rest) and a **low ankle-brachial index (ABI)** of 0.80.
- **Cilostazol** is a phosphodiesterase inhibitor specifically approved for the symptomatic relief of **intermittent claudication** in patients with PAD, improving walking distance and quality of life.
*Endovascular revascularization*
- **Endovascular revascularization** (e.g., angioplasty, stenting) is typically reserved for patients with more severe symptoms, such as **rest pain**, **non-healing ulcers**, or **gangrene**, or for those who have failed appropriate medical therapy.
- Initial management of **intermittent claudication** usually begins with lifestyle modifications and pharmacotherapy, given the less severe presentation and the current guidelines.
*Arthroscopic resection*
- **Arthroscopic resection** is a surgical procedure primarily used for joint-related problems, such as removing damaged cartilage or bone spurs from a joint.
- It is not indicated for the treatment of **peripheral artery disease** or **intermittent claudication**, which is a vascular condition.
*Duloxetine*
- **Duloxetine** is a serotonin-norepinephrine reuptake inhibitor (SNRI) primarily used for the treatment of **neuropathic pain**, depression, and generalized anxiety disorder.
- While the patient has diabetes (a risk factor for neuropathy), the symptom of **intermittent claudication associated with exertion** and a low ABI points away from neuropathic pain as the primary cause.
*Heparin*
- **Heparin** is an anticoagulant used to prevent blood clot formation, typically in acute settings like **deep vein thrombosis (DVT)**, **pulmonary embolism (PE)**, or acute limb ischemia.
- It is not indicated for the long-term management of stable **peripheral artery disease** with intermittent claudication, as it does not address the underlying atherosclerotic process.
Question 516: A 26-year-old G1P0 woman is brought to the emergency room by her spouse for persistently erratic behavior. Her spouse reports that she has been sleeping > 1 hour a night, and it sometimes seems like she’s talking to herself. She has maxed out their credit cards on baby clothes. The patient’s spouse reports this has been going on for over a month. Since first seeing a physician, she has been prescribed multiple first and second generation antipsychotics, but the patient’s spouse reports that her behavior has failed to improve. Upon examination, the patient is speaking rapidly and occasionally gets up to pace the room. She reports she is doing “amazing,” and that she is “so excited for the baby to get here because I’m going to be the best mom.” She denies illicit drug use, audiovisual hallucinations, or suicidal ideation. The attending psychiatrist prescribes a class of medication the patient has not yet tried to treat the patient’s psychiatric condition. In terms of this new medication, which of the following is the patient’s newborn most likely at increased risk for?
A. Ototoxicity
B. Attention deficit hyperactivity disorder
C. Right ventricular atrialization (Correct Answer)
D. Renal defects
E. Caudal regression syndrome
Explanation: ***Right ventricular atrialization***
- The patient's presentation of persistent **erratic behavior**, **reduced sleep**, rapid speech, and increased spending, enduring for over a month, is highly suggestive of a **manic episode** in the context of **bipolar I disorder**. Since antipsychotics have been ineffective, the next step is often **lithium**.
- **Lithium** exposure during the first trimester of pregnancy is associated with an increased risk of **Ebstein's anomaly**, a congenital heart defect characterized by **right ventricular atrialization** (displacement of the tricuspid valve leaflets into the right ventricle), leading to tricuspid regurgitation and right heart failure.
*Ototoxicity*
- **Ototoxicity** in newborns is typically associated with exposure to medications such as **aminoglycoside antibiotics** (e.g., gentamicin) or certain diuretics (e.g., furosemide) during pregnancy.
- Lithium is not known to cause ototoxicity as a primary birth defect.
*Attention deficit hyperactivity disorder*
- While various prenatal exposures can influence neurodevelopment, there is currently **no strong evidence** linking in-utero lithium exposure specifically to an increased risk of **ADHD** in offspring.
- ADHD is a complex neurodevelopmental disorder with multifactorial origins, including genetic and environmental factors.
*Renal defects*
- While lithium is primarily excreted by the kidneys and can cause **renal dysfunction** in adults (e.g., nephrogenic diabetes insipidus), it is not a prominent teratogen known to cause specific **structural renal defects** in newborns when exposed during pregnancy.
- Renal anomalies are more commonly associated with other medications or genetic syndromes.
*Caudal regression syndrome*
- **Caudal regression syndrome** is a severe congenital anomaly affecting the development of the lower spine and limbs. It is strongly associated with **poorly controlled maternal diabetes**.
- There is no established link between in-utero lithium exposure and caudal regression syndrome.
Question 517: A 27-year-old man presents to the emergency department for bizarre behavior. The patient had boarded up his house and had been refusing to leave for several weeks. The police were called when a foul odor emanated from his property prompting his neighbors to contact the authorities. Upon questioning, the patient states that he has been pursued by elves for his entire life. He states that he was tired of living in fear, so he decided to lock himself in his house. The patient is poorly kempt and has very poor dentition. The patient has a past medical history of schizophrenia which was previously well controlled with olanzapine. The patient is restarted on olanzapine and monitored over the next several days. Which of the following needs to be monitored long term in this patient?
A. CBC
B. HbA1c levels (Correct Answer)
C. ECG
D. Monitoring for acute dystonia
E. Renal function studies
Explanation: ***HbA1c levels***
- **Olanzapine** is associated with significant metabolic side effects, including **weight gain**, **dyslipidemia**, and **new-onset diabetes mellitus**, necessitating long-term monitoring of **glucose metabolism**
- **HbA1c** provides an average of blood glucose levels over the past 2-3 months, making it an excellent indicator for assessing the risk and progression of **diabetes** in patients on olanzapine.
*CBC*
- While some antipsychotics can cause hematological side effects like **agranulocytosis** (e.g., **clozapine**), **olanzapine** is not typically associated with severe bone marrow suppression requiring routine, long-term CBC monitoring.
- CBC monitoring would be more relevant in the short-term if there were specific concerns for infection or adverse drug reactions.
*ECG*
- Some atypical antipsychotics can prolong the **QTc interval**, which would warrant ECG monitoring, but this adverse effect is less commonly associated with **olanzapine** compared to other antipsychotics like **ziprasidone** or **haloperidol**.
- While a baseline ECG might be considered, long-term routine ECG monitoring is not typically indicated without specific cardiac risk factors or symptoms.
*Monitoring for acute dystonia*
- **Acute dystonia** is an extrapyramidal symptom that typically occurs early in treatment with antipsychotics, especially first-generation agents or at the initiation of therapy with second-generation agents like **olanzapine**.
- While important to monitor acutely, it is not a long-term monitoring requirement once the patient is stable on the medication.
*Renal function studies*
- **Olanzapine** is primarily metabolized by the liver, and **renal excretion** plays a minor role in its elimination.
- Therefore, long-term monitoring of renal function is not routinely recommended for patients on olanzapine unless there are pre-existing kidney conditions or other nephrotoxic medications.
Question 518: A 53-year-old man is brought to the emergency department because of wheezing and shortness of breath that began 1 hour after he took a new medication. Earlier in the day he was diagnosed with stable angina pectoris and prescribed a drug that irreversibly inhibits cyclooxygenase-1 and 2. He has chronic rhinosinusitis and asthma treated with inhaled β-adrenergic agonists and corticosteroids. His respirations are 26/min. Examination shows multiple small, erythematous nasal mucosal lesions. After the patient is stabilized, therapy for primary prevention of coronary artery disease should be switched to a drug with which of the following mechanisms of action?
A. Direct inhibition of Factor Xa
B. Sequestration of Ca2+ ions
C. Potentiation of antithrombin III
D. Blockage of P2Y12 component of ADP receptors (Correct Answer)
E. Inhibition of vitamin K epoxide reductase
Explanation: ***Blockage of P2Y12 component of ADP receptors***
- The patient experienced an asthma exacerbation suspected to be due to **aspirin-exacerbated respiratory disease (AERD)**, which is triggered by **aspirin** (a non-selective COX inhibitor).
- Given the need for antiplatelet therapy for CAD, a **P2Y12 receptor antagonist** such as **clopidogrel** is a suitable alternative to aspirin in patients with AERD, as it does not interact with the cyclooxygenase pathway.
*Direct inhibition of Factor Xa*
- This mechanism of action describes drugs like **rivaroxaban** or **apixaban**, which are primarily used as anticoagulants for conditions like atrial fibrillation or venous thromboembolism.
- While they prevent clot formation, they are not typically used for primary prevention of **coronary artery disease (CAD)** in lieu of antiplatelet agents like aspirin or P2Y12 inhibitors.
*Sequestration of Ca2+ ions*
- This refers to **calcium channel blockers (CCBs)**, which are used to treat hypertension, angina, and certain arrhythmias.
- While CCBs can be used to manage angina symptoms, they do not provide the necessary **antiplatelet effect** for primary prevention of cardiovascular events in CAD.
*Potentiation of antithrombin III*
- This is the mechanism of action for **heparins** (e.g., unfractionated heparin, low molecular weight heparin) and related drugs like fondaparinux.
- **Heparins are anticoagulants** used for acute thrombosis or prophylaxis in specific situations, but they are not used for chronic **primary prevention of CAD** in stable patients.
*Inhibition of vitamin K epoxide reductase*
- This describes the mechanism of **warfarin**, a vitamin K antagonist used as an anticoagulant for conditions like atrial fibrillation, prosthetic heart valves, or venous thromboembolism.
- Warfarin is an anticoagulant, not an antiplatelet agent, and is not indicated for **primary prevention of CAD** in this context.
Question 519: A 37-year-old man presents with back pain which began 3 days ago when he was lifting heavy boxes. The pain radiates from the right hip to the back of the thigh. The pain is exacerbated when he bends at the waist. He rates the severity of the pain as 6 out of 10. The patient has asthma and mitral insufficiency due to untreated rheumatic fever in childhood. He has a smoking history of 40 pack-years. His family history is remarkable for rheumatoid arthritis, diabetes, and hypertension. Vital signs are within normal limits. On physical examination, the pain is elicited when the patient is asked to raise his leg without extending his knee. The patient has difficulty walking on his heels. Peripheral pulses are equal and brisk bilaterally. No hair loss, temperature changes, or evidence of peripheral vascular disease is observed. Which of the following is considered the best management option for this patient?
A. Referral for surgery
B. Prescription of opioids
C. Over-the-counter NSAIDs (Correct Answer)
D. Observation
E. Stenting
Explanation: ***Over-the-counter NSAIDs***
- The patient's symptoms are highly suggestive of **acute sciatica caused by disc herniation**, given the radiating back pain, exacerbation with bending, and a positive straight leg raise test.
- **Over-the-counter NSAIDs** (such as ibuprofen or naproxen) are the recommended first-line treatment for acute low back pain and radiculopathy due to their anti-inflammatory and analgesic effects.
- **Important consideration**: While this patient has asthma and mitral insufficiency, NSAIDs remain the most appropriate option among those listed. However, **selective COX-2 inhibitors or acetaminophen** might be considered as safer alternatives given his comorbidities. NSAIDs should be used at the lowest effective dose for the shortest duration, with monitoring for bronchospasm or fluid retention.
*Referral for surgery*
- **Surgical intervention** is typically reserved for cases where conservative management fails after 6-12 weeks, or if there are signs of progressive neurological deficits, severe weakness, or **cauda equina syndrome**.
- The patient's presentation does not indicate an urgent need for surgery, as his symptoms are acute (3 days) and there are no severe neurological deficits described.
*Prescription of opioids*
- **Opioids** are not recommended as a first-line treatment for acute low back pain, especially in the absence of severe, intractable pain.
- Long-term use of opioids carries risks of **addiction**, **tolerance**, and **adverse effects**, and evidence suggests limited efficacy over NSAIDs for acute low back pain.
*Observation*
- While many cases of acute low back pain resolve spontaneously, **observation alone** without any pain management is inappropriate for a patient experiencing pain rated 6/10 and functional impairment (difficulty walking on heels).
- Providing symptomatic relief and encouraging continued activity are important aspects of initial management to prevent chronicity and improve function.
*Stenting*
- **Stenting** is a procedure primarily used to open narrowed arteries to treat conditions like **coronary artery disease** or **peripheral arterial disease**.
- This patient's symptoms are musculoskeletal and neuropathic in origin, with no signs or symptoms of vascular compromise (normal peripheral pulses, no claudication, no evidence of peripheral vascular disease) that would warrant stenting.
Question 520: A 17-year-old white male is brought to the emergency department after being struck by a car. He complains of pain in his right leg and left wrist, and slowly recounts how he was hit by a car while being chased by a lion. In between sentences of the story, he repeatedly complains of dry mouth and severe hunger and requests something to eat and drink. His mother arrives and is very concerned about this behavior, noting that he has been withdrawn lately and doing very poorly in school the past several months. Notable findings on physical exam include conjunctival injection bilaterally and a pulse of 107. What drug is this patient most likely currently abusing?
A. Cocaine
B. Heroin
C. Marijuana (Correct Answer)
D. Benzodiazepines
E. Phencyclidine (PCP)
Explanation: ***Marijuana***
- The patient's **conjunctival injection**, **dry mouth**, and **increased appetite** (the "munchies") are classic signs of marijuana intoxication. His distorted perception of reality (being chased by a lion) and altered mental status are also consistent with marijuana use.
- The history of being withdrawn and poor school performance over several months suggests chronic use and potential cannabis use disorder.
*Cocaine*
- Cocaine intoxication typically presents with **psychomotor agitation**, **tachycardia**, **mydriasis (dilated pupils)**, and potentially paranoia, but not typically increased appetite or conjunctival injection.
- The patient's presentation of a prolonged, elaborate delusional story is less characteristic for cocaine, which tends to produce more acute and often paranoid psychosis.
*Heroin*
- Heroin (opioid) intoxication primarily causes **CNS depression**, **respiratory depression**, **miosis (pinpoint pupils)**, and euphoria, none of which are prominent in this patient's presentation.
- While he has an elevated pulse, the other distinct symptoms of dry mouth, hunger, and conjunctival injection point away from opioid use.
*Benzodiazepines*
- Benzodiazepine intoxication causes **CNS depression**, **sedation**, **ataxia**, and slurred speech, but typically does not cause conjunctival injection, dry mouth, or increased appetite.
- The patient's agitated storytelling and specific physical signs are not consistent with benzodiazepine overdose.
*Phencyclidine (PCP)*
- PCP intoxication is associated with severe behavioral changes including **aggressiveness**, **nystagmus**, **hallucinations**, **dissociative states**, and often a high pain tolerance, which might fit some aspects of the story and trauma.
- However, characteristic signs like **nystagmus** (horizontal or vertical), **hypertension**, and a more profound **dissociative amnesia** or violence are usually more pronounced than what is described.
