A 43-year-old woman walks into the clinic for an annual check-up appointment with her family physician. When asked about any changes in her life, she states that she lost her job about 6 months ago. Since then, she has lived with her boyfriend who is also unemployed. She frequently uses laxatives and takes some over the counter medications to help her sleep. Her blood pressure is 129/87 mm Hg, respirations are 12/min, pulse is 58/min, and temperature is 36.7°C (98.1°F). Her physical exam is mostly benign. Her pupils appear mildly constricted and she appears drowsy and subdued. The physician suspects that the physical findings in this patient are caused by a substance she is likely abusing. Which of the following is the substance?
Q832
A 55-year-old woman comes to the physician because of involuntary rhythmic shaking of both hands for several months. More recently, she also noticed involuntary head nodding movements. The shaking seems to improve after having one or two glasses of wine. Her father had similar symptoms starting at the age of 60. Neurologic examination shows a symmetric hand tremor that worsens with voluntary movement of the respective extremity. The most appropriate pharmacotherapy for this patient's symptoms is also recommended for the treatment of which of the following conditions?
Q833
The drug cilostazol is known for its ability to relax vascular smooth muscle and therefore cause vasodilation through its inhibition of phosphodiesterase 3. Given this mechanism of action, what other effect would be expected?
Q834
A 68-year-old man presents to his primary care physician with a 4-week history of back pain. He says that the pain does not appear to be associated with activity and is somewhat relieved by taking an NSAID. Furthermore, he says that he has had increasing difficulty trying to urinate. His past medical history is significant for kidney stones and a 30-pack-year smoking history. Radiographs reveal osteoblastic lesions in the spine. Which of the following drugs would most likely be effective in treating this patient's disease?
Q835
A 63-year-old man comes to the physician because of generalized fatigue and malaise for 2 months. He has been unable to engage in his daily activities. Three months ago, he was treated for a urinary tract infection with trimethoprim-sulfamethoxazole. He has hypertension, asthma, and chronic lower back pain. Current medications include hydrochlorothiazide, an albuterol inhaler, naproxen, and an aspirin-caffeine combination. Vital signs are within normal limits. Examination shows conjunctival pallor. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.1 g/dL
Leukocyte count 8,900/mm3
Erythrocyte sedimentation rate 13 mm/h
Serum
Na+ 136 mEq/L
K+ 4.8 mEq/L
Cl- 102 mEq/L
Urea nitrogen 41 mg/dL
Glucose 70 mg/dL
Creatinine 2.4 mg/dL
Calcium 9.8 mg/dL
Urine
Protein 1+
Blood 1+
RBCs none
WBCs 8–9/hpf
Bacteria none
Urine cultures are negative. Ultrasound shows shrunken kidneys with irregular contours and papillary calcifications. Which of the following is the most likely underlying mechanism of this patient's renal failure?
Q836
A 54-year-old male presents to clinic complaining that he is not sleeping well because he has to get up from bed to urinate multiple times throughout the night. He says that he strains to void, has terminal dribbling, and has urinary urgency. Past medical history is significant for orthostatic hypotension. On digital rectal exam, you note symmetric firm enlargement of the prostate. Free Prostate-Specific-Antigen (PSA) level is 4.6 ng/mL. Before you finish your physical exam, the patient asks if there is anything you can do for his male-pattern baldness. What is the mechanism of action of the drug that would pharmacologically treat this patient’s urinary issues and his male-pattern baldness?
Q837
An otherwise healthy 23-year-old man comes to the physician because of a 3-day history of mild persistent bleeding from the site of a tooth extraction. He has no prior history of medical procedures or surgeries and no history of easy bruising. He appears well. Vital signs are within normal limits. Laboratory studies show:
Hemoglobin 12.4 g/dL
Platelets 200,000/mm3
Serum
Prothrombin time 25 seconds
Partial thromboplastin time (activated) 35 seconds
Deficiency of which of the following coagulation factors is the most likely cause of this patient’s condition?
Q838
You are currently employed as a clinical researcher working on clinical trials of a new drug to be used for the treatment of Parkinson's disease. Currently, you have already determined the safe clinical dose of the drug in a healthy patient. You are in the phase of drug development where the drug is studied in patients with the target disease to determine its efficacy. Which of the following phases is this new drug currently in?
Q839
A 70 year-old man comes to the emergency department for sudden loss of vision in the right eye over the last 24 hours. He has noticed progressive bilateral loss of central vision over the last year. He has had difficulty reading his newspaper and watching his television. He has smoked 1 pack daily for 50 years. Ophthalmologic examination shows visual acuity of 20/60 in the left eye and 20/200 in the right eye. The pupils are equal and reactive to light. Tonometry reveals an intraocular pressure of 18 mm Hg in the right eye and 20 mm Hg in the left eye. Anterior segment exam is unremarkable. Slit-lamp examination shows subretinal fluid and small hemorrhage with grayish-green discoloration in the macular area in the right eye, and multiple drusen in the left eye with retinal pigment epithelial changes. Which of the following is the most appropriate initial treatment for the patient's illness?
Q840
A 45-year-old man is brought into the clinic by his wife. She reports that her husband has been feeling down since he lost a big project at work 2 months ago. The patient says he feels unmotivated to work or do things around the house. He also says he is not eating or sleeping as usual and spends most of his day pacing about his room. He feels guilty for losing such a project this late in his career and feels overwhelming fear about the future of his company and his family’s well-being. During the interview, he appears to be in mild distress and is wringing his hands. The patient is prescribed citalopram and buspirone. Which of the following side effects is most commonly seen with buspirone?
Autonomic/CV Drugs US Medical PG Practice Questions and MCQs
Question 831: A 43-year-old woman walks into the clinic for an annual check-up appointment with her family physician. When asked about any changes in her life, she states that she lost her job about 6 months ago. Since then, she has lived with her boyfriend who is also unemployed. She frequently uses laxatives and takes some over the counter medications to help her sleep. Her blood pressure is 129/87 mm Hg, respirations are 12/min, pulse is 58/min, and temperature is 36.7°C (98.1°F). Her physical exam is mostly benign. Her pupils appear mildly constricted and she appears drowsy and subdued. The physician suspects that the physical findings in this patient are caused by a substance she is likely abusing. Which of the following is the substance?
A. Cocaine
B. Alprazolam
C. Codeine (Correct Answer)
D. Clonazepam
E. Ketamine
Explanation: ***Codeine***
- **Miosis** (constricted pupils), **drowsiness**, **bradycardia** (pulse 58/min), and **reduced respiratory rate** (12/min) represent the classic **opioid toxidrome**.
- The patient's use of **laxatives** suggests chronic opioid use to manage opioid-induced constipation, a common side effect.
- Codeine is available in many over-the-counter preparations and is commonly abused.
*Cocaine*
- Cocaine is a **sympathomimetic stimulant** that causes **mydriasis** (pupil dilation), tachycardia, hypertension, and increased alertness or agitation.
- The patient's presentation of miosis, bradycardia, and sedation is completely opposite to cocaine intoxication.
*Alprazolam*
- While alprazolam (a benzodiazepine) can cause drowsiness and sedation, it does **not typically cause miosis**.
- Benzodiazepines may cause respiratory depression at high doses but are not associated with the pronounced **miosis** and **bradycardia** seen in this patient.
- The opioid toxidrome is more specific to this clinical presentation.
*Clonazepam*
- Clonazepam, another benzodiazepine, shares similar effects with alprazolam, causing **sedation** and potential respiratory depression at high doses.
- However, like other benzodiazepines, it does **not cause miosis** or bradycardia, which are hallmark features of opioid intoxication.
*Ketamine*
- Ketamine causes a **dissociative state** with **nystagmus**, and typically produces **hypertension and tachycardia** (not bradycardia).
- It does not cause the **miosis**, bradycardia, or classic sedated presentation characteristic of opioid intoxication.
Question 832: A 55-year-old woman comes to the physician because of involuntary rhythmic shaking of both hands for several months. More recently, she also noticed involuntary head nodding movements. The shaking seems to improve after having one or two glasses of wine. Her father had similar symptoms starting at the age of 60. Neurologic examination shows a symmetric hand tremor that worsens with voluntary movement of the respective extremity. The most appropriate pharmacotherapy for this patient's symptoms is also recommended for the treatment of which of the following conditions?
A. Malignant hyperthermia
B. Restless legs syndrome
C. Hyperthyroidism (Correct Answer)
D. Sleepwalking
E. Motion sickness
Explanation: ***Hyperthyroidism***
- The patient presents with **essential tremor**, characterized by **bilateral symmetric hand tremor** that worsens with action, head nodding, and improvement with alcohol. The first-line treatment for essential tremor is **propranolol**, a non-selective beta-blocker.
- Propranolol is also the primary symptomatic treatment for the adrenergic symptoms of **hyperthyroidism**, such as **tachycardia**, tremor, and anxiety, by blocking beta-adrenergic receptors.
*Malignant hyperthermia*
- This is a life-threatening, rare pharmacogenetic disorder triggered by certain anesthetic agents, leading to **skeletal muscle rigidity**, hyperthermia, and metabolic acidosis.
- The primary treatment is **dantrolene**, a muscle relaxant, not propranolol.
*Restless legs syndrome*
- Characterized by an irresistible urge to move the legs, often accompanied by unpleasant sensations, typically worse at rest and in the evening.
- First-line treatments include **dopamine agonists** (e.g., pramipexole, ropinirole) or gabapentin, not propranolol.
*Sleepwalking*
- A type of parasomnia characterized by complex behaviors while partially aroused from NREM sleep, with no memory of the event upon awakening.
- While sometimes managed with low-dose benzodiazepines or antidepressants, propranolol is not a standard treatment.
*Motion sickness*
- Caused by a mismatch between visual and vestibular sensory input, leading to nausea, vomiting, and dizziness.
- Treated with anticholinergic agents like **scopolamine**, or antihistamines such as dimenhydrinate, primarily targeting the vestibular system and central nervous system.
Question 833: The drug cilostazol is known for its ability to relax vascular smooth muscle and therefore cause vasodilation through its inhibition of phosphodiesterase 3. Given this mechanism of action, what other effect would be expected?
A. Antiarrhythmic action
B. Negative chronotropy
C. Angioedema
D. Increased left ventricular end-diastolic volume
E. Positive inotropy (Correct Answer)
Explanation: ***Positive inotropy***
- **Cilostazol** inhibits **phosphodiesterase 3 (PDE3)**, leading to an increase in **cAMP** levels within cardiac myocytes.
- Increased **cAMP** in the heart results in enhanced calcium influx and release, which strengthens myocardial contraction, leading to **positive inotropy**.
*Antiarrhythmic action*
- While some drugs affecting **cAMP** can have antiarrhythmic effects, **PDE3 inhibitors** like cilostazol can sometimes **increase heart rate** and potentially cause or worsen arrhythmias due to increased conduction and excitability.
- Their primary mechanism of action for cardiac effects is **inotropy**, not rhythm stabilization.
*Negative chronotropy*
- **Negative chronotropy** refers to a decrease in heart rate, which is typically seen with drugs that reduce **cAMP** or directly inhibit the **sinoatrial node**.
- As a **PDE3 inhibitor**, cilostazol leads to increased **cAMP**, which usually causes a modest increase in heart rate (**positive chronotropy**), not a decrease.
*Angioedema*
- **Angioedema** is a side effect often associated with **ACE inhibitors** or certain allergic reactions, mediated by bradykinin or histamine release.
- It is not a known or expected effect of **cilostazol** based on its mechanism of **PDE3 inhibition** and cAMP modulation.
*Increased left ventricular end-diastolic volume*
- **Cilostazol** causes **vasodilation**, which **reduces peripheral vascular resistance** and thus **afterload**.
- This reduction in afterload, combined with its **positive inotropic** effects, tends to improve cardiac output and can actually lead to a **decrease** in **left ventricular end-diastolic volume** due to more efficient ejection, rather than an increase.
Question 834: A 68-year-old man presents to his primary care physician with a 4-week history of back pain. He says that the pain does not appear to be associated with activity and is somewhat relieved by taking an NSAID. Furthermore, he says that he has had increasing difficulty trying to urinate. His past medical history is significant for kidney stones and a 30-pack-year smoking history. Radiographs reveal osteoblastic lesions in the spine. Which of the following drugs would most likely be effective in treating this patient's disease?
A. Imatinib
B. Tamsulosin
C. Pulsatile leuprolide
D. Rituximab
E. Continuous leuprolide (Correct Answer)
Explanation: ***Continuous leuprolide***
- The patient's presentation with **back pain**, urinary difficulties (**dysuria**), and **osteoblastic lesions** in an elderly male with a history of smoking is highly suggestive of **metastatic prostate cancer**.
- **Continuous leuprolide** (a GnRH agonist) causes an initial surge in testosterone followed by downregulation of GnRH receptors leading to chemical castration, which is an effective treatment for hormone-sensitive prostate cancer.
*Imatinib*
- **Imatinib** is a **tyrosine kinase inhibitor** primarily used to treat **chronic myeloid leukemia (CML)** and gastrointestinal stromal tumors (GIST).
- It works by inhibiting the BCR-ABL tyrosine kinase in CML and KIT/PDGFRA in GIST, neither of which is relevant to prostate cancer.
*Tamsulosin*
- **Tamsulosin** is an **alpha-1 adrenergic antagonist** used to improve urinary flow in patients with **benign prostatic hyperplasia (BPH)**.
- While the patient has urinary difficulties, the presence of bone metastases (osteoblastic lesions) and back pain points towards malignancy, making BPH treatment alone insufficient.
*Pulsatile leuprolide*
- **Pulsatile leuprolide** administration (a GnRH agonist) mimics the natural pulsatile release of GnRH and is used to **stimulate gonadotropin release** for treating infertility.
- This would increase testosterone levels, which would be detrimental in the treatment of androgen-sensitive prostate cancer.
*Rituximab*
- **Rituximab** is a **monoclonal antibody** targeting the **CD20 antigen** found on B-lymphocytes.
- It is primarily used in the treatment of **non-Hodgkin lymphoma**, chronic lymphocytic leukemia, and certain autoimmune diseases, not prostate cancer.
Question 835: A 63-year-old man comes to the physician because of generalized fatigue and malaise for 2 months. He has been unable to engage in his daily activities. Three months ago, he was treated for a urinary tract infection with trimethoprim-sulfamethoxazole. He has hypertension, asthma, and chronic lower back pain. Current medications include hydrochlorothiazide, an albuterol inhaler, naproxen, and an aspirin-caffeine combination. Vital signs are within normal limits. Examination shows conjunctival pallor. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.1 g/dL
Leukocyte count 8,900/mm3
Erythrocyte sedimentation rate 13 mm/h
Serum
Na+ 136 mEq/L
K+ 4.8 mEq/L
Cl- 102 mEq/L
Urea nitrogen 41 mg/dL
Glucose 70 mg/dL
Creatinine 2.4 mg/dL
Calcium 9.8 mg/dL
Urine
Protein 1+
Blood 1+
RBCs none
WBCs 8–9/hpf
Bacteria none
Urine cultures are negative. Ultrasound shows shrunken kidneys with irregular contours and papillary calcifications. Which of the following is the most likely underlying mechanism of this patient's renal failure?
A. Inhibition of prostaglandin synthesis (Correct Answer)
B. Precipitation of drugs within the renal tubules
C. Hypersensitivity reaction
D. MUC1 gene mutation
E. Excess amount of light chain production
Explanation: ***Inhibition of prostaglandin synthesis***
- This patient's chronic use of **naproxen** (an NSAID) and **aspirin-caffeine combination** is the most probable cause of his **chronic kidney disease** (analgesic nephropathy). NSAIDs inhibit **cyclooxygenase (COX) enzymes**, blocking **prostaglandin synthesis** (including PGE2 and PGI2), which are crucial for maintaining **afferent arteriolar dilation** and renal blood flow, especially in patients with comorbidities like hypertension.
- The imaging findings of **shrunken kidneys with irregular contours and papillary calcifications** are classic for **analgesic nephropathy** from prolonged NSAID use. The elevated **creatinine** (2.4 mg/dL) and **urea nitrogen** (41 mg/dL), along with fatigue and malaise, indicate significant chronic renal impairment.
*Precipitation of drugs within the renal tubules*
- While drug precipitation can cause acute kidney injury (e.g., from certain antibiotics, acyclovir, or methotrexate), it typically leads to **acute tubular necrosis** or **obstructive nephropathy** with crystalluria.
- The presentation here suggests **chronic, insidious kidney damage** over months to years. The specific drugs used by this patient are not primary causes of tubular precipitation leading to this chronic presentation with papillary calcifications.
*Hypersensitivity reaction*
- A **hypersensitivity reaction** (acute interstitial nephritis) typically presents as **acute kidney injury** with features like fever, rash, eosinophilia, and eosinophiluria.
- While trimethoprim-sulfamethoxazole can cause acute interstitial nephritis, the patient was treated **3 months ago** and the symptoms are chronic (2 months duration). The urinalysis does not show characteristic findings like **eosinophiluria** or WBC casts, and the chronic imaging findings point to a different etiology.
*MUC1 gene mutation*
- A **MUC1 gene mutation** is associated with **autosomal dominant tubulointerstitial kidney disease (ADTKD)**, formerly called medullary cystic kidney disease type 1, an inherited disorder leading to progressive chronic kidney disease.
- While this can present with shrunken kidneys, the **papillary calcifications** are characteristic of **analgesic nephropathy**, not ADTKD. Additionally, there is no family history or age of onset typical for a genetic disorder (usually presents earlier in life).
*Excess amount of light chain production*
- **Excess light chain production** is seen in **multiple myeloma**, which can lead to **cast nephropathy** (myeloma kidney), causing renal failure.
- While myeloma can cause fatigue and anemia, other classic features are absent: **normal calcium** (9.8 mg/dL, not hypercalcemic), **normal ESR** (13 mm/h, typically markedly elevated in myeloma), and no evidence of monoclonal protein. The **papillary calcifications** are not typical for myeloma kidney.
Question 836: A 54-year-old male presents to clinic complaining that he is not sleeping well because he has to get up from bed to urinate multiple times throughout the night. He says that he strains to void, has terminal dribbling, and has urinary urgency. Past medical history is significant for orthostatic hypotension. On digital rectal exam, you note symmetric firm enlargement of the prostate. Free Prostate-Specific-Antigen (PSA) level is 4.6 ng/mL. Before you finish your physical exam, the patient asks if there is anything you can do for his male-pattern baldness. What is the mechanism of action of the drug that would pharmacologically treat this patient’s urinary issues and his male-pattern baldness?
A. Squalene epoxidase inhibition
B. 5-alpha reductase inhibition (Correct Answer)
C. 17,20-desmolase inhibition
D. Phosphodiesterase-5 inhibition
E. Alpha-1 blockade
Explanation: ***5-alpha reductase inhibition***
- The patient's symptoms (nocturia, straining, terminal dribbling, urgency, and prostatic enlargement) are consistent with **benign prostatic hyperplasia (BPH)**.
- **5-alpha reductase inhibitors** (e.g., finasteride, dutasteride) block the conversion of **testosterone to dihydrotestosterone (DHT)**, which is responsible for both prostatic growth and male-pattern baldness.
- These drugs are **FDA-approved for both BPH and androgenic alopecia (male-pattern baldness)**, making them ideal for this patient.
- Importantly, they do not worsen orthostatic hypotension, unlike alpha-1 blockers, making them especially suitable given this patient's history.
*Squalene epoxidase inhibition*
- This mechanism of action is associated with **terbinafine**, an antifungal drug used to treat conditions like onychomycosis.
- It has no role in treating BPH or male-pattern baldness.
*17,20-desmolase inhibition*
- **Abiraterone**, a drug used in metastatic prostate cancer, inhibits **17,20-desmolase (CYP17)**, thereby preventing the synthesis of androgens.
- While it affects androgen-dependent prostate conditions, it is reserved for advanced prostate cancer, not BPH, and is not used for male-pattern baldness.
*Phosphodiesterase-5 inhibition*
- **PDE5 inhibitors** (e.g., tadalafil) are FDA-approved for **erectile dysfunction and BPH** by increasing cGMP, which relaxes smooth muscle.
- While effective for BPH urinary symptoms, they do not address male-pattern baldness.
*Alpha-1 blockade*
- **Alpha-1 blockers** (e.g., tamsulosin, terazosin) relax the smooth muscle in the prostate and bladder neck, improving urinary flow in BPH.
- While effective for urinary symptoms of BPH, they have no impact on male-pattern baldness.
- Additionally, they can **worsen orthostatic hypotension**, which is a concern in this patient with a history of orthostatic hypotension.
Question 837: An otherwise healthy 23-year-old man comes to the physician because of a 3-day history of mild persistent bleeding from the site of a tooth extraction. He has no prior history of medical procedures or surgeries and no history of easy bruising. He appears well. Vital signs are within normal limits. Laboratory studies show:
Hemoglobin 12.4 g/dL
Platelets 200,000/mm3
Serum
Prothrombin time 25 seconds
Partial thromboplastin time (activated) 35 seconds
Deficiency of which of the following coagulation factors is the most likely cause of this patient’s condition?
A. Factor II
B. Factor XIII
C. Factor X
D. Factor VII (Correct Answer)
E. Factor V
Explanation: ***Factor VII***
- An **isolated prolonged PT** with a normal aPTT, platelets, and hemoglobin points to a defect in the **extrinsic pathway** of coagulation.
- **Factor VII** is the sole coagulation factor exclusively in the extrinsic pathway, making its deficiency the most likely cause.
*Factor II*
- **Factor II (prothrombin)** is a common pathway factor, so its deficiency would prolong both PT and aPTT.
- The patient's aPTT is normal, ruling out a significant deficiency of Factor II.
*Factor XIII*
- **Factor XIII** is responsible for stabilizing the fibrin clot but does not affect PT or aPTT.
- A deficiency would present with delayed bleeding or poor wound healing, not a prolonged PT.
*Factor X*
- **Factor X** is a common pathway factor, and its deficiency would prolong both PT and aPTT.
- The normal aPTT in this patient makes Factor X deficiency unlikely.
*Factor V*
- **Factor V** is a common pathway factor, and its deficiency would result in prolongation of both PT and aPTT.
- The normal aPTT makes a Factor V deficiency improbable.
Question 838: You are currently employed as a clinical researcher working on clinical trials of a new drug to be used for the treatment of Parkinson's disease. Currently, you have already determined the safe clinical dose of the drug in a healthy patient. You are in the phase of drug development where the drug is studied in patients with the target disease to determine its efficacy. Which of the following phases is this new drug currently in?
A. Phase 4
B. Phase 1
C. Phase 2 (Correct Answer)
D. Phase 0
E. Phase 3
Explanation: ***Phase 2***
- **Phase 2 trials** involve studying the drug in patients with the target disease to assess its **efficacy** and further evaluate safety, typically involving a few hundred patients.
- The question describes a stage after safe dosing in healthy patients (Phase 1) and before large-scale efficacy confirmation (Phase 3), focusing on efficacy in the target population.
*Phase 4*
- **Phase 4 trials** occur **after a drug has been approved** and marketed, monitoring long-term effects, optimal use, and rare side effects in a diverse patient population.
- This phase is conducted post-market approval, whereas the question describes a drug still in development prior to approval.
*Phase 1*
- **Phase 1 trials** primarily focus on determining the **safety and dosage** of a new drug in a **small group of healthy volunteers** (or sometimes patients with advanced disease if the drug is highly toxic).
- The question states that the safe clinical dose in a healthy patient has already been determined, indicating that Phase 1 has been completed.
*Phase 0*
- **Phase 0 trials** are exploratory, very early-stage studies designed to confirm that the drug reaches the target and acts as intended, typically involving a very small number of doses and participants.
- These trials are conducted much earlier in the development process, preceding the determination of safe clinical doses and large-scale efficacy studies.
*Phase 3*
- **Phase 3 trials** are large-scale studies involving hundreds to thousands of patients to confirm **efficacy**, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug to be used safely.
- While Phase 3 does assess efficacy, it follows Phase 2 and is typically conducted on a much larger scale before submitting for regulatory approval.
Question 839: A 70 year-old man comes to the emergency department for sudden loss of vision in the right eye over the last 24 hours. He has noticed progressive bilateral loss of central vision over the last year. He has had difficulty reading his newspaper and watching his television. He has smoked 1 pack daily for 50 years. Ophthalmologic examination shows visual acuity of 20/60 in the left eye and 20/200 in the right eye. The pupils are equal and reactive to light. Tonometry reveals an intraocular pressure of 18 mm Hg in the right eye and 20 mm Hg in the left eye. Anterior segment exam is unremarkable. Slit-lamp examination shows subretinal fluid and small hemorrhage with grayish-green discoloration in the macular area in the right eye, and multiple drusen in the left eye with retinal pigment epithelial changes. Which of the following is the most appropriate initial treatment for the patient's illness?
A. Macular translocation surgery
B. Etanercept
C. Ranibizumab (Correct Answer)
D. Thermal laser photocoagulation
E. Photodynamic therapy
Explanation: ***Ranibizumab***
- The presence of **subretinal fluid**, hemorrhage, and grayish-green discoloration in the macula of the right eye, along with sudden vision loss, is highly suggestive of **wet age-related macular degeneration (AMD)**.
- **Ranibizumab**, an anti-VEGF agent, is the **first-line treatment** for wet AMD, as it inhibits abnormal blood vessel growth and leakage.
*Macular translocation surgery*
- This is an **invasive surgical procedure** considered for select cases of wet AMD, but it is not the initial or preferred treatment due to its complexity and potential complications.
- It involves repositioning the macula to a healthier RPE, typically reserved for cases unresponsive to less invasive therapies.
*Etanercept*
- **Etanercept** is a TNF-alpha inhibitor used primarily for inflammatory conditions like **rheumatoid arthritis** and **psoriasis**.
- It has no role in the treatment of wet AMD, which is a degenerative condition involving angiogenesis.
*Thermal laser photocoagulation*
- While historically used for some types of macular disease, **thermal laser photocoagulation** destroys retinal tissue and can cause **scotomas**.
- It is generally **contraindicated for subfoveal lesions** and has largely been replaced by anti-VEGF therapy for wet AMD due to poorer visual outcomes.
*Photodynamic therapy*
- **Photodynamic therapy (PDT)** with verteporfin was previously used for some forms of wet AMD, particularly those with **predominantly classic choroidal neovascularization**.
- However, **anti-VEGF injections** like ranibizumab are now considered superior with better visual outcomes and are the preferred initial treatment.
Question 840: A 45-year-old man is brought into the clinic by his wife. She reports that her husband has been feeling down since he lost a big project at work 2 months ago. The patient says he feels unmotivated to work or do things around the house. He also says he is not eating or sleeping as usual and spends most of his day pacing about his room. He feels guilty for losing such a project this late in his career and feels overwhelming fear about the future of his company and his family’s well-being. During the interview, he appears to be in mild distress and is wringing his hands. The patient is prescribed citalopram and buspirone. Which of the following side effects is most commonly seen with buspirone?
A. Lightheadedness (Correct Answer)
B. Sleepwalking
C. Respiratory depression
D. Dry mouth
E. Anterograde amnesia
Explanation: ***Lightheadedness***
- **Lightheadedness** and dizziness are among the most frequently reported side effects of **buspirone**, particularly at the initiation of treatment or with dose adjustments.
- This is thought to be related to its modulation of **serotonin receptors** and its impact on the central nervous system.
*Sleepwalking*
- **Sleepwalking** is not a common side effect associated with buspirone; it is more frequently linked with sedatives like **zolpidem**.
- Buspirone is generally considered to have a different mechanism of action and side effect profile than drugs that induce sleepwalking.
*Respiratory depression*
- **Respiratory depression** is a serious side effect most commonly associated with **benzodiazepines** or **opioids**, especially when taken in overdose or combined with other central nervous system depressants.
- Buspirone is known for its **lack of sedative and respiratory depressant effects**, which is a key advantage over benzodiazepines.
*Dry mouth*
- While **dry mouth** can occur with various medications, it is not a primary or most common side effect specifically associated with **buspirone**.
- It's more often seen with drugs that have **anticholinergic properties**, such as tricyclic antidepressants.
*Anterograde amnesia*
- **Anterograde amnesia** is a well-known side effect of **benzodiazepines**, where a person cannot form new memories after taking the drug.
- Buspirone does not typically cause this type of memory impairment, which contributes to its safer profile compared to benzodiazepines.
