A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of generalized reddening of her skin and itching for the past 2 weeks. Her symptoms occur every evening before bedtime and last for about 30 minutes. Three months ago, atorvastatin was stopped after she experienced progressively worsening neck and back pain. Statin therapy was reinitiated at lower doses 3 weeks ago but had to be stopped again after her musculoskeletal symptoms recurred. Her menses occur irregularly at 2–3 month intervals and last for 3–4 days. She has smoked one pack of cigarettes daily for the past 30 years. Her current medications include lisinopril and niacin. Her brother died of colonic adenocarcinoma, and her father died of small cell lung cancer. She is 169 cm (5 ft 6 in) tall and weighs 83 kg (183 lb); BMI is 29 kg/m2. Her vital signs are within normal limits. Physical examination shows no abnormalities. Serum lipid studies show:
Total cholesterol 247 mg/dL
HDL-cholesterol 39 mg/dL
LDL-cholesterol 172 mg/dL
Triglycerides 152 mg/dL
Which of the following is the most appropriate next step in management?
Q972
Several hours after vaginal delivery, a male newborn delivered at full-term develops tachycardia and tachypnea. His blood pressure is within normal limits. Pulse oximetry on room air shows an oxygen saturation of 79% in the right hand and 61% in the left foot. Physical examination shows bluish discoloration of the face and trunk, supraclavicular and intercostal retractions, and a machine-like murmur over the precordium. Bedside echocardiography shows pulmonary and systemic circulation are in parallel rather than in series. What is the most appropriate pharmacotherapy for this patient?
Q973
A 70-year-old Caucasian male visits your office regularly for treatment of New York Heart association class IV congestive heart failure. Which of the following medications would you add to this man's drug regimen in order to improve his overall survival?
Q974
A 16-year-old girl is brought to the emergency department by her friends who say that she took a whole bottle of her mom’s medication. They do not know which medication it was she ingested. The patient is slipping in and out of consciousness and is unable to offer any history. Her temperature is 39.6°C (103.2°F), the heart rate is 135/min, the blood pressure is 178/98 mm Hg, and the respiratory rate is 16/min. On physical examination, there is significant muscle rigidity without tremor or clonus. Which of the following is the best course of treatment for this patient?
Q975
A 51-year-old woman comes to the physician because of a 1-day history of right flank pain and bloody urine. Over the past 2 weeks, she has also developed progressive lower extremity swelling and a 3-kg (7-lb) weight gain. She has a history of chronic hepatitis B infection, which was diagnosed 10 years ago. She frequently flies from California to New York for business. She appears fatigued. Her pulse is 98/min, respirations are 18/min, and blood pressure is 135/75 mm Hg. Examination shows periorbital edema, a distended abdomen, and 2+ edema of the lower extremities. The lungs are clear to auscultation. A CT scan of the abdomen shows a nodular liver with ascites, a large right kidney with abundant collateral vessels, and a filling defect in the right renal vein. Urinalysis shows 4+ protein, positive glucose, and fatty casts. Which of the following is the most likely underlying cause of this patient's renal vein findings?
Q976
A 69-year-old man is brought by his son to the emergency department with weakness in his right arm and leg. The man insists that he is fine and blames his son for "creating panic". Four hours ago the patient was having tea with his wife when he suddenly dropped his teacup. He has had difficulty moving his right arm since then and cannot walk because his right leg feels stuck. He has a history of hypertension and dyslipidemia, for which he currently takes lisinopril and atorvastatin, respectively. He is allergic to aspirin and peanuts. A computerized tomography (CT) scan shows evidence of an ischemic stroke. Which medication would most likely prevent such attacks in this patient in the future?
Q977
A 27-year-old female presents to general medical clinic for a routine checkup. She has a genetic disease marked by a mutation in a chloride transporter. She has a history of chronic bronchitis. She has a brother with a similar history of infections as well as infertility. Which of the following is most likely true regarding a potential vitamin deficiency complication secondary to this patient's chronic illness?
Autonomic/CV Drugs US Medical PG Practice Questions and MCQs
Question 971: A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of generalized reddening of her skin and itching for the past 2 weeks. Her symptoms occur every evening before bedtime and last for about 30 minutes. Three months ago, atorvastatin was stopped after she experienced progressively worsening neck and back pain. Statin therapy was reinitiated at lower doses 3 weeks ago but had to be stopped again after her musculoskeletal symptoms recurred. Her menses occur irregularly at 2–3 month intervals and last for 3–4 days. She has smoked one pack of cigarettes daily for the past 30 years. Her current medications include lisinopril and niacin. Her brother died of colonic adenocarcinoma, and her father died of small cell lung cancer. She is 169 cm (5 ft 6 in) tall and weighs 83 kg (183 lb); BMI is 29 kg/m2. Her vital signs are within normal limits. Physical examination shows no abnormalities. Serum lipid studies show:
Total cholesterol 247 mg/dL
HDL-cholesterol 39 mg/dL
LDL-cholesterol 172 mg/dL
Triglycerides 152 mg/dL
Which of the following is the most appropriate next step in management?
A. Switch lisinopril to hydrochlorothiazide
B. Measure urine hydroxyindoleacetic acid levels
C. Measure urine metanephrine levels
D. Administer ibuprofen
E. Switch niacin to fenofibrate (Correct Answer)
Explanation: ***Switch niacin to fenofibrate***
- The patient is experiencing **niacin-induced flushing** (generalized reddening and itching every evening before bedtime), which is a common side effect of nicotinic acid due to prostaglandin-mediated vasodilation.
- Given her **statin intolerance** (tried twice with recurrent myalgias) and problematic side effects from niacin, switching to an alternative lipid-lowering agent is reasonable for long-term management.
- **Fenofibrate** (a fibrate) primarily lowers triglycerides and can modestly reduce LDL while raising HDL, providing an alternative lipid-lowering approach without the flushing side effects of niacin.
- While her triglycerides are only borderline elevated (152 mg/dL), fenofibrate can still contribute to overall lipid management in this statin-intolerant patient.
*Administer ibuprofen*
- **Ibuprofen or aspirin pre-treatment** (taken 30 minutes before niacin) is actually the **first-line strategy** to prevent niacin-induced flushing by inhibiting prostaglandin synthesis.
- This approach allows continuation of niacin therapy while managing the side effect, which is clinically valuable given her statin intolerance.
- However, in the context of this question, switching to an alternative agent (fenofibrate) may be considered more definitive management rather than ongoing symptomatic prophylaxis, especially if the patient desires to avoid the flushing entirely.
*Switch lisinopril to hydrochlorothiazide*
- There is no indication that **lisinopril** (an ACE inhibitor) is causing problems or is inappropriate for her hypertension.
- Her vital signs are within normal limits, and switching antihypertensive therapy is not indicated when the presenting issue is clearly related to her lipid-lowering medication.
*Measure urine hydroxyindoleacetic acid levels*
- Measuring **urine 5-HIAA** is used to diagnose **carcinoid syndrome**, which can cause episodic flushing.
- However, the temporal relationship between niacin initiation (3 weeks ago) and symptom onset (2 weeks ago), plus the predictable evening timing before bedtime, makes niacin-induced flushing the obvious diagnosis.
*Measure urine metanephrine levels*
- This test diagnoses **pheochromocytoma**, which causes episodic hypertension and flushing.
- The patient has normal vital signs and a clear medication-related cause for her symptoms, making pheochromocytoma investigation unnecessary.
Question 972: Several hours after vaginal delivery, a male newborn delivered at full-term develops tachycardia and tachypnea. His blood pressure is within normal limits. Pulse oximetry on room air shows an oxygen saturation of 79% in the right hand and 61% in the left foot. Physical examination shows bluish discoloration of the face and trunk, supraclavicular and intercostal retractions, and a machine-like murmur over the precordium. Bedside echocardiography shows pulmonary and systemic circulation are in parallel rather than in series. What is the most appropriate pharmacotherapy for this patient?
A. Dopamine
B. Sildenafil
C. Indomethacin
D. Metoprolol
E. Alprostadil (Correct Answer)
Explanation: ***Alprostadil***
- The patient's presentation with **tachycardia, tachypnea, differential cyanosis** (79% in right hand, 61% in left foot), a **machine-like murmur**, and **parallel circulation** on echocardiography is diagnostic of **transposition of the great arteries (TGA)**.
- In TGA, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, creating two parallel circuits. Survival depends on **mixing of oxygenated and deoxygenated blood** through the **foramen ovale, ventricular septal defect (if present), and/or patent ductus arteriosus**.
- **Alprostadil (prostaglandin E1)** is the **first-line pharmacotherapy** for maintaining patency of the **ductus arteriosus**, which is essential for adequate mixing and systemic oxygenation until definitive surgical correction (arterial switch operation) can be performed.
*Dopamine*
- **Dopamine** is a **vasopressor** used to improve cardiac contractility and blood pressure in cases of **hypotension** or **shock**.
- This patient's blood pressure is within normal limits, and his primary issue is inadequate oxygenation due to parallel circulation, not hypoperfusion.
*Sildenafil*
- **Sildenafil** is a **pulmonary vasodilator** used to treat **pulmonary hypertension**.
- While it can improve pulmonary blood flow, the fundamental problem in TGA is the **parallel circulation anatomy**, not pulmonary vascular resistance. Improving pulmonary blood flow alone will not correct the mixing defect.
*Indomethacin*
- **Indomethacin** is a non-steroidal anti-inflammatory drug (NSAID) that **inhibits prostaglandin synthesis**, leading to **closure of the patent ductus arteriosus (PDA)**.
- This would be **contraindicated and potentially fatal** in TGA, as maintaining a *patent* ductus arteriosus is critical for survival by allowing mixing of blood between the systemic and pulmonary circulations.
*Metoprolol*
- **Metoprolol** is a **beta-blocker** used to treat conditions like **tachycardia**, hypertension, and certain arrhythmias.
- The infant's tachycardia is a **compensatory response to hypoxia**; blocking it with metoprolol would reduce cardiac output and worsen tissue oxygenation without addressing the underlying anatomic defect.
Question 973: A 70-year-old Caucasian male visits your office regularly for treatment of New York Heart association class IV congestive heart failure. Which of the following medications would you add to this man's drug regimen in order to improve his overall survival?
A. Spironolactone (Correct Answer)
B. Furosemide
C. Amiloride
D. Acetazolamide
E. Hydrochlorothiazide
Explanation: ***Spironolactone***
- **Spironolactone** is an **aldosterone antagonist** that has been shown to reduce mortality and morbidity in patients with **NYHA Class III and IV heart failure**.
- It works by blocking the harmful effects of **aldosterone** on the heart, such as **fibrosis** and remodeling, improving cardiac function and survival.
*Furosemide*
- **Furosemide** is a **loop diuretic** primarily used to relieve **symptoms of congestion** (edema, dyspnea) in heart failure by promoting fluid excretion.
- While it improves symptoms, **furosemide** alone does not significantly improve long-term survival in patients with heart failure.
*Amiloride*
- **Amiloride** is a **potassium-sparing diuretic** that works by blocking sodium channels in the collecting duct, leading to modest diuresis.
- It is often used to prevent **hypokalemia** caused by other diuretics but does not have the same proven mortality benefit in heart failure as spironolactone.
*Acetazolamide*
- **Acetazolamide** is a **carbonic anhydrase inhibitor** primarily used for glaucoma, metabolic alkalosis, and altitude sickness.
- It has a weaker diuretic effect and is not a commonly used or recommended medication for improving long-term survival in patients with heart failure.
*Hydrochlorothiazide*
- **Hydrochlorothiazide** is a **thiazide diuretic** primarily used for hypertension and mild to moderate edema.
- While it can help manage fluid retention, it does not offer the same mortality benefit in advanced heart failure as aldosterone antagonists like spironolactone.
Question 974: A 16-year-old girl is brought to the emergency department by her friends who say that she took a whole bottle of her mom’s medication. They do not know which medication it was she ingested. The patient is slipping in and out of consciousness and is unable to offer any history. Her temperature is 39.6°C (103.2°F), the heart rate is 135/min, the blood pressure is 178/98 mm Hg, and the respiratory rate is 16/min. On physical examination, there is significant muscle rigidity without tremor or clonus. Which of the following is the best course of treatment for this patient?
A. Cyproheptadine
B. Dantrolene (Correct Answer)
C. Flumazenil
D. Fenoldopam
E. Naloxone
Explanation: ***Dantrolene***
- The patient's presentation with **hyperthermia**, **tachycardia**, **hypertension**, and **severe muscle rigidity without tremor or clonus** is highly suggestive of **neuroleptic malignant syndrome (NMS)** or **malignant hyperthermia**.
- **Dantrolene** is a direct-acting **skeletal muscle relaxant** that reduces calcium release from the sarcoplasmic reticulum, effectively treating the muscle rigidity and hyperthermia in these conditions.
*Cyproheptadine*
- **Cyproheptadine** is an **antihistamine with serotonin antagonist properties** used to treat **serotonin syndrome**, which typically presents with **clonus** and **hyperreflexia**, not the rigidity seen here.
- While both NMS and serotonin syndrome involve hyperthermia, the distinct absence of clonus and presence of severe rigidity points away from serotonin syndrome.
*Flumazenil*
- **Flumazenil** is a **benzodiazepine receptor antagonist** used to reverse **benzodiazepine overdose**.
- Benzodiazepine overdose typically causes **CNS depression** (hypotension, bradycardia, respiratory depression), which is opposite to the patient's hyperdynamic state.
*Fenoldopam*
- **Fenoldopam** is a **D1 dopamine receptor agonist** used intravenously to treat **severe hypertension** and **hypertensive emergencies**.
- Although the patient has hypertension, fenoldopam would not address the underlying pathology of hyperthermia and muscle rigidity, which are the primary life-threatening issues.
*Naloxone*
- **Naloxone** is a **mu-opioid receptor antagonist** used to reverse **opioid overdose**.
- Opioid overdose typically causes **respiratory depression**, **miosis**, and **CNS depression**, which are not consistent with this patient's presentation.
Question 975: A 51-year-old woman comes to the physician because of a 1-day history of right flank pain and bloody urine. Over the past 2 weeks, she has also developed progressive lower extremity swelling and a 3-kg (7-lb) weight gain. She has a history of chronic hepatitis B infection, which was diagnosed 10 years ago. She frequently flies from California to New York for business. She appears fatigued. Her pulse is 98/min, respirations are 18/min, and blood pressure is 135/75 mm Hg. Examination shows periorbital edema, a distended abdomen, and 2+ edema of the lower extremities. The lungs are clear to auscultation. A CT scan of the abdomen shows a nodular liver with ascites, a large right kidney with abundant collateral vessels, and a filling defect in the right renal vein. Urinalysis shows 4+ protein, positive glucose, and fatty casts. Which of the following is the most likely underlying cause of this patient's renal vein findings?
A. Loss of antithrombin III (Correct Answer)
B. Paraneoplastic erythropoietin production
C. Antiphospholipid antibodies
D. Acquired factor VIII deficiency
E. Impaired estrogen degradation
Explanation: ***Loss of antithrombin III***
- The patient presents with **nephrotic syndrome** (periorbital edema, lower extremity swelling, proteinuria, fatty casts), which leads to the urinary loss of anticoagulant proteins, most notably **antithrombin III**.
- **Antithrombin III deficiency** significantly increases the risk of renal vein thrombosis, especially in the setting of membranous nephropathy often associated with chronic hepatitis B.
*Paraneoplastic erythropoietin production*
- While some tumors can produce erythropoietin, leading to **polycythemia**, this patient's symptoms (renal vein thrombosis, nephrotic syndrome) are not primarily indicative of erythropoietin overproduction.
- Polycythemia could predispose to thrombosis, but it's not the direct mechanism for renal vein thrombosis in the context of nephrotic syndrome.
*Antiphospholipid antibodies*
- **Antiphospholipid syndrome** can cause thrombotic events, including renal vein thrombosis.
- However, the strong evidence of **nephrotic syndrome** with attendant loss of antithrombin III is a more direct and common cause for renal vein thrombosis in this clinical scenario.
*Acquired factor VIII deficiency*
- An acquired factor VIII deficiency would typically lead to **bleeding diathesis**, not thrombotic events.
- The patient's symptoms are consistent with hypercoagulability.
*Impaired estrogen degradation*
- Impaired estrogen degradation, often seen in **liver cirrhosis** (which this patient's nodular liver and ascites suggest), can lead to feminization symptoms (e.g., gynecomastia, spider angiomas in men), but does not directly cause renal vein thrombosis.
- While liver disease can affect coagulation factors, the primary driver for thrombosis here is the nephrotic syndrome.
Question 976: A 69-year-old man is brought by his son to the emergency department with weakness in his right arm and leg. The man insists that he is fine and blames his son for "creating panic". Four hours ago the patient was having tea with his wife when he suddenly dropped his teacup. He has had difficulty moving his right arm since then and cannot walk because his right leg feels stuck. He has a history of hypertension and dyslipidemia, for which he currently takes lisinopril and atorvastatin, respectively. He is allergic to aspirin and peanuts. A computerized tomography (CT) scan shows evidence of an ischemic stroke. Which medication would most likely prevent such attacks in this patient in the future?
A. Celecoxib
B. Abciximab
C. Urokinase
D. Clopidogrel (Correct Answer)
E. Alteplase
Explanation: ***Clopidogrel***
- This patient has suffered an **ischemic stroke** and has a **contraindication to aspirin** due to allergy. **Clopidogrel**, an **alternative antiplatelet agent**, is the most appropriate long-term secondary prevention medication to reduce the risk of future thrombotic events.
- As a **P2Y12 inhibitor**, clopidogrel prevents platelet aggregation, thereby reducing the likelihood of clot formation in patients at high risk for cardiovascular events.
*Celecoxib*
- **Celecoxib** is a **COX-2 selective NSAID** primarily used for pain and inflammation. It has no role in the prevention of ischemic stroke.
- While NSAIDs can have antiplatelet effects through COX-1 inhibition, **COX-2 selective inhibitors like celecoxib generally have a prothrombotic effect** and are not indicated for stroke prevention.
*Abciximab*
- **Abciximab** is a **glycoprotein IIb/IIIa inhibitor** that potently prevents platelet aggregation. It is typically used in acute settings, such as during percutaneous coronary intervention (PCI), and not for long-term stroke prevention.
- Its potent antiplatelet effect and **risk of bleeding** make it unsuitable for chronic outpatient management.
*Urokinase*
- **Urokinase** is a **thrombolytic agent** used to dissolve existing blood clots in acute conditions like pulmonary embolism or acute myocardial infarction. It is not indicated for the prevention of future ischemic strokes.
- Thrombolytics carry a **significant risk of hemorrhage** and are solely for acute clot lysis, not chronic prevention.
*Alteplase*
- **Alteplase** is a **tissue plasminogen activator (tPA)**, a thrombolytic used in the **acute treatment of ischemic stroke** within a specific time window to dissolve clots and restore blood flow.
- It is an **acute rescue therapy** and is not used for long-term secondary prevention of stroke due to its high bleeding risk and short duration of action.
Question 977: A 27-year-old female presents to general medical clinic for a routine checkup. She has a genetic disease marked by a mutation in a chloride transporter. She has a history of chronic bronchitis. She has a brother with a similar history of infections as well as infertility. Which of the following is most likely true regarding a potential vitamin deficiency complication secondary to this patient's chronic illness?
A. It may result in connective tissue defects
B. It may result in corneal vascularization
C. It may result in the triad of confusion, ophthalmoplegia, and ataxia
D. It may manifest itself as a prolonged PT (Correct Answer)
E. It may be exacerbated by excessive ingestion of raw eggs
Explanation: ***It may manifest itself as a prolonged PT***
- The patient's presentation with a **chloride transporter mutation**, chronic bronchitis, and a brother with similar infections and infertility is highly suggestive of **cystic fibrosis (CF)**.
- CF leads to **pancreatic insufficiency** and **malabsorption of fat-soluble vitamins (A, D, E, K)**. A deficiency in **vitamin K** can result in impaired synthesis of **clotting factors**, leading to a **prolonged prothrombin time (PT)**.
*It may result in connective tissue defects*
- This symptom is characteristic of **vitamin C deficiency (scurvy)**, which manifests as impaired **collagen synthesis** and fragile connective tissues.
- While CF patients can have various deficiencies, connective tissue defects are not a primary consequence of the fat-soluble vitamin deficiencies associated with CF.
*It may result in corneal vascularization*
- **Corneal vascularization** is typically associated with **riboflavin (vitamin B2) deficiency** or chronic ocular inflammation.
- This is not a common complication of the fat-soluble vitamin malabsorption seen in cystic fibrosis.
*It may result in the triad of confusion, ophthalmoplegia, and ataxia*
- This triad describes **Wernicke-Korsakoff syndrome**, which is caused by a **thiamine (vitamin B1) deficiency**.
- This deficiency is common in alcoholism or severe malnutrition but is not a direct complication of the fat-soluble vitamin malabsorption in cystic fibrosis.
*It may be exacerbated by excessive ingestion of raw eggs*
- Excessive ingestion of raw eggs can lead to **biotin (vitamin B7) deficiency** due to **avidin** binding to biotin, preventing its absorption.
- While CF patients can have various nutritional issues, this specific interaction is unrelated to the fat-soluble vitamin deficiencies caused by their pancreatic insufficiency.
