A 20-year-old female presents to student health at her university for excessive daytime sleepiness. She states that her sleepiness has caused her to fall asleep in all of her classes for the last semester, and that her grades are suffering as a result. She states that she normally gets 7 hours of sleep per night, and notes that when she falls asleep during the day, she immediately starts having dreams. She denies any cataplexy. A polysomnogram and a multiple sleep latency test rule out obstructive sleep apnea and confirm her diagnosis. She is started on a daytime medication that acts both by direct neurotransmitter release and reuptake inhibition. What other condition can this medication be used to treat?
Q102
A 21-year-old female is brought by her brother to the emergency department after having a generalized tonic-clonic seizure one hour ago. She is slightly confused and has no recollection of her seizure. Her brother relayed that the patient has a history of severe anxiety for which she takes medication. For the past several days, he noticed that his sister exhibited body tremors, appeared to be agitated with quick mood changes, and, at times, was delirious. He states his sister recently ran out of her medications while visiting from out of town. Which of the following would best treat the patient's condition?
Q103
A 55-year-old woman seeks evaluation of difficult and incomplete voiding and spontaneous urine leakage that occurs continuously during the day and night. The symptoms are not associated with physical exertion. She denies any urethral or vaginal discharge. She is menopausal and does not take hormone replacement therapy. At 33 years of age, she had a right salpingectomy as treatment for an ectopic pregnancy. She has a 2-year history of a major depressive disorder and takes amitriptyline (100 mg before the bedtime). She was also diagnosed 5 years ago with arterial hypertension, which is controlled with enalapril (20 mg daily) and metoprolol (50 mg daily). The weight is 71 kg (156.5 lb) and the height is 155 cm (5 ft). The vital signs are as follows: blood pressure 135/80 mm Hg, heart rate 67/min, respiratory rate 13/min, and temperature 36.4℃ (97.5℉). The physical examination is significant for a palpable urinary bladder. The neurologic examination is within normal limits. The gynecologic examination shows grade 1 uterine prolapse. Which of the following is the most probable cause of the patient’s symptoms?
Q104
A 58-year-old woman comes to the physician because of an itchy rash on her leg 3 days after she returned from a camping trip with her grandchildren. Examination shows a linear, erythematous, maculopapular rash on the left lower extremity. Treatment with a drug is begun that is also effective for motion sickness. One hour later, she reports dry mouth. This adverse effect is most likely mediated through which of the following?
Q105
A 55-year-old man presents with burning and shooting in his feet and lower legs, which becomes more severe at night. In the past 6 months, the pain has become much worse and disturbs his sleep. He has a history of type 2 diabetes mellitus and essential hypertension. Which of the following best represent the etiology of this patient’s condition?
Q106
A 19-year-old girl comes to the physician for evaluation after a minor motor vehicle collision. While driving down a residential street, a young boy ran out in front of her, chasing after a ball. She applied the brakes of her vehicle and avoided hitting the boy, but then she suddenly experienced generalized weakness that rendered her unable to operate the vehicle and collided at low speed with a parked car. One minute later, she recovered her strength. She was uninjured. She has had several similar episodes of transient generalized weakness over the past month, once during an argument with her mother and another time while watching her favorite comedy movie. She has also had excessive daytime sleepiness for 18 months despite 9 hours of sleep nightly and 2 daily naps. She has fallen asleep in class several times. She often sees intensely bright colors as she is falling asleep. During this time, she is often unable to move; this inability to move is very distressing to her. Which of the following is the most appropriate nighttime pharmacotherapy for this patient?
Q107
A 53-year-old woman is brought to the emergency department by her husband because of difficulty walking, slurred speech, and progressive drowsiness. The husband reports that his wife has appeared depressed over the past few days. She has a history of insomnia and social anxiety disorder. She appears lethargic. Her temperature is 36.2°C (97.1°F), pulse is 88/min, respirations are 12/min, and blood pressure is 110/80 mm Hg. Neurologic examination shows normal pupils. There is diffuse hypotonia and decreased deep tendon reflexes. Administration of a drug that acts as a competitive antagonist at which of the following receptors is most likely to reverse this patient's symptoms?
Q108
A 70-year-old female presents to you for an office visit with complaints of forgetfulness. The patient states that over the last several years, the patient has stopped cooking for herself even though she lives alone. Recently, she also forgot how to drive back home from the grocery store and has difficulty paying her bills. The patient says she has been healthy over her whole life and does not take any medications. Her vitals are normal and her physical exam does not reveal any focal neurological deficits. Her mini-mental status exam is scored 19/30 and her MRI reveals diffuse cortical atrophy. What is the best initial treatment for this patient's condition?
Q109
A 46-year-old man presents after he accidentally got splashed with a liquid insecticide that was stored in a bucket in the storeroom one hour ago. He says that he can’t stop coughing and is having problems breathing. He also says he has a pain in his thighs which is unbearable, and his vision is blurry. His temperature is 36.7°C (98.1°F), the pulse is 130/min, the blood pressure is 144/92 mm Hg, and the respiratory rate is 20/min. On physical examination, the patient shows mild generalized pallor, moderate respiratory distress, excessive salivation, and diaphoresis. Cough is non-productive. Pupils are constricted (pinpoint). The cardiopulmonary exam reveals bilateral crepitus. The patient is administered atropine and pralidoxime, which help improve his symptoms. Which of the following is most likely to improve in this patient with the administration of atropine?
Q110
A 19-year-old woman is brought to the emergency room by her mother. She found her daughter pale, cold to the touch, and collapsed next to her bed earlier this morning. The patient has no previous medical or psychiatric history, but the mother does report that her daughter has not had her periods for the last 3 months. In the emergency department, the patient is alert and oriented. Her vitals include: blood pressure 80/60 mm Hg supine, heart rate 55/min. On physical examination, the patient appears pale and emaciated. A urine pregnancy test is negative. She is suspected of having an eating disorder. Which of the following treatment options would be contraindicated in this patient?
Cholinergic/Adrenergic drugs US Medical PG Practice Questions and MCQs
Question 101: A 20-year-old female presents to student health at her university for excessive daytime sleepiness. She states that her sleepiness has caused her to fall asleep in all of her classes for the last semester, and that her grades are suffering as a result. She states that she normally gets 7 hours of sleep per night, and notes that when she falls asleep during the day, she immediately starts having dreams. She denies any cataplexy. A polysomnogram and a multiple sleep latency test rule out obstructive sleep apnea and confirm her diagnosis. She is started on a daytime medication that acts both by direct neurotransmitter release and reuptake inhibition. What other condition can this medication be used to treat?
A. Obsessive-compulsive disorder
B. Bulimia
C. Attention-deficit hyperactivity disorder (Correct Answer)
D. Tourette syndrome
E. Alcohol withdrawal
Explanation: ***Attention-deficit hyperactivity disorder***
- The patient's presentation is consistent with **narcolepsy type 2 (without cataplexy)**, given the excessive daytime sleepiness, short latency to REM sleep (immediate dreaming), and exclusion of sleep apnea. The medication described, acting via **direct neurotransmitter release and reuptake inhibition**, is characteristic of a stimulant like **methylphenidate** or an amphetamine-based drug.
- These stimulants are commonly used as first-line treatment for **attention-deficit hyperactivity disorder (ADHD)** due to their effects on dopamine and norepinephrine in the brain, improving focus and reducing impulsivity.
*Obsessive-compulsive disorder*
- **Obsessive-compulsive disorder (OCD)** is typically treated with selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy.
- Stimulants are not indicated for OCD and may even worsen anxiety symptoms in some individuals.
*Bulimia*
- **Bulimia nervosa** is often managed with a combination of psychotherapy (e.g., cognitive behavioral therapy) and antidepressants like fluoxetine.
- Stimulants are not a primary treatment for bulimia and could potentially exacerbate some symptoms or risks due to their appetite-suppressing effects.
*Tourette syndrome*
- **Tourette syndrome** involves motor and vocal tics and is often treated with alpha-2 adrenergic agonists (e.g., guanfacine, clonidine) or dopamine receptor blocking agents.
- Stimulants generally are not used for Tourette syndrome as they can sometimes worsen tics.
*Alcohol withdrawal*
- **Alcohol withdrawal** is a medical emergency managed with benzodiazepines to prevent seizures and delirium tremens.
- Stimulants are contraindicated in alcohol withdrawal as they can increase seizure risk and cardiac complications.
Question 102: A 21-year-old female is brought by her brother to the emergency department after having a generalized tonic-clonic seizure one hour ago. She is slightly confused and has no recollection of her seizure. Her brother relayed that the patient has a history of severe anxiety for which she takes medication. For the past several days, he noticed that his sister exhibited body tremors, appeared to be agitated with quick mood changes, and, at times, was delirious. He states his sister recently ran out of her medications while visiting from out of town. Which of the following would best treat the patient's condition?
A. Varenicline
B. Naloxone
C. Methadone
D. Diazepam (Correct Answer)
E. Flumazenil
Explanation: ***Diazepam***
- The patient's presentation suggests **benzodiazepine withdrawal**, characterized by anxiety, tremors, agitation, mood swings, delirium, and seizures. **Diazepam**, a long-acting benzodiazepine, is the most appropriate treatment to reverse these withdrawal symptoms.
- Benzodiazepines work by enhancing the effect of **GABA** (gamma-aminobutyric acid), an inhibitory neurotransmitter, and withdrawal leads to a state of neuronal hyperexcitability.
*Varenicline*
- **Varenicline** is a medication used for **smoking cessation**.
- It acts as a partial agonist at nicotinic acetylcholine receptors and is not indicated for benzodiazepine withdrawal.
*Naloxone*
- **Naloxone** is an **opioid antagonist** used to reverse opioid overdose.
- It has no role in the management of benzodiazepine withdrawal.
*Methadone*
- **Methadone** is a long-acting opioid agonist primarily used for **opioid dependence treatment** and chronic pain management.
- It is not indicated for treating benzodiazepine withdrawal symptoms.
*Flumazenil*
- **Flumazenil** is a **benzodiazepine receptor antagonist** (competitive antagonist at the benzodiazepine binding site on the GABA-A receptor) used to reverse benzodiazepine overdose.
- Administering **flumazenil** in a patient with benzodiazepine dependence can precipitate or worsen withdrawal symptoms, including seizures, and is therefore contraindicated.
Question 103: A 55-year-old woman seeks evaluation of difficult and incomplete voiding and spontaneous urine leakage that occurs continuously during the day and night. The symptoms are not associated with physical exertion. She denies any urethral or vaginal discharge. She is menopausal and does not take hormone replacement therapy. At 33 years of age, she had a right salpingectomy as treatment for an ectopic pregnancy. She has a 2-year history of a major depressive disorder and takes amitriptyline (100 mg before the bedtime). She was also diagnosed 5 years ago with arterial hypertension, which is controlled with enalapril (20 mg daily) and metoprolol (50 mg daily). The weight is 71 kg (156.5 lb) and the height is 155 cm (5 ft). The vital signs are as follows: blood pressure 135/80 mm Hg, heart rate 67/min, respiratory rate 13/min, and temperature 36.4℃ (97.5℉). The physical examination is significant for a palpable urinary bladder. The neurologic examination is within normal limits. The gynecologic examination shows grade 1 uterine prolapse. Which of the following is the most probable cause of the patient’s symptoms?
A. Blockage of M-cholinoreceptors (Correct Answer)
B. Blockage of β-adrenoreceptors
C. Activation of α1-adrenoceptors
D. Urethral hypermobility
E. Urethral strictures
Explanation: ***Blockage of M-cholinoreceptors***
- The patient is taking **amitriptyline**, a tricyclic antidepressant with significant **anticholinergic** properties, which can block M-cholinoreceptors in the bladder, leading to impaired detrusor contraction and difficulty voiding.
- This blockage results in **urinary retention** with overflow incontinence, as evidenced by the palpable bladder and continuous urine leakage not associated with exertion.
*Blockage of β-adrenoreceptors*
- **Metoprolol** is a beta-blocker that primarily affects the heart and blood vessels; it does not directly impair bladder emptying or cause urinary retention by blocking β-adrenoreceptors in the bladder.
- While β3-adrenoreceptors in the bladder can relax the detrusor, their blockage is not a common cause of severe voiding dysfunction and continuous leakage.
*Activation of α1-adrenoceptors*
- **α1-adrenoceptors** in the bladder neck and urethra cause smooth muscle contraction, contributing to urinary retention if overactive. However, none of the patient's medications are known to significantly activate these receptors in a way that would cause such severe and continuous leakage.
- Activation of α1-adrenoceptors is more typically associated with conditions like benign prostatic hyperplasia in men, not directly with the described presentation in a woman.
*Urethral hypermobility*
- **Urethral hypermobility** is a common cause of **stress incontinence**, which involves urine leakage with physical exertion, coughing, or sneezing, and not continuous leakage day and night as described here.
- The patient explicitly denies symptoms associated with physical exertion, making stress incontinence due to urethral hypermobility less likely.
*Urethral strictures*
- **Urethral strictures** cause **obstructive voiding symptoms** and can lead to overflow incontinence; however, they are less common in women and typically present with a history of trauma, infection, or instrumentation, which is not mentioned.
- Given the patient's medication history, drug-induced anticholinergic effects are a more probable cause for the complex voiding dysfunction.
Question 104: A 58-year-old woman comes to the physician because of an itchy rash on her leg 3 days after she returned from a camping trip with her grandchildren. Examination shows a linear, erythematous, maculopapular rash on the left lower extremity. Treatment with a drug is begun that is also effective for motion sickness. One hour later, she reports dry mouth. This adverse effect is most likely mediated through which of the following?
A. Antagonism at acetylcholine receptors (Correct Answer)
B. Agonism at β-adrenergic receptors
C. Antagonism at histamine receptors
D. Antagonism at α-adrenergic receptors
E. Antagonism at serotonin receptors
Explanation: ***Antagonism at acetylcholine receptors***
- The patient likely has **poison ivy** or a similar allergic contact dermatitis, treated with a first-generation **antihistamine** (e.g., diphenhydramine) due to its known efficacy for itching and motion sickness.
- Classic side effects of first-generation antihistamines like **dry mouth** (xerostomia) are primarily due to their **anticholinergic activity**, blocking muscarinic acetylcholine receptors.
*Agonism at β-adrenergic receptors*
- **Beta-adrenergic agonism** would typically cause effects such as **tachycardia**, bronchodilation, and tremor, and is not associated with dry mouth.
- Drugs acting as β-agonists are not typically used for allergic rashes or motion sickness.
*Antagonism at histamine receptors*
- While the drug is an **antihistamine**, blocking histamine H1 receptors primarily alleviates **itching, allergy symptoms, and nausea/motion sickness**.
- While antihistamines can cause dry mouth, this specific effect is primarily attributable to their **off-target anticholinergic action**, not direct histamine receptor antagonism.
*Antagonism at α-adrenergic receptors*
- **Alpha-adrenergic antagonism** (e.g., doxazosin) typically causes **vasodilation**, orthostatic hypotension, and pupillary constriction, and is not a common mechanism for dry mouth.
- This mechanism is not relevant to the treatment of an itchy rash or motion sickness.
*Antagonism at serotonin receptors*
- **Serotonin receptor antagonism** can be involved in treating conditions like nausea (e.g., ondansetron) or migraines, but is not the primary mechanism responsible for dry mouth in this context.
- While some drugs have serotonergic activity, this effect is not the direct cause of dry mouth described.
Question 105: A 55-year-old man presents with burning and shooting in his feet and lower legs, which becomes more severe at night. In the past 6 months, the pain has become much worse and disturbs his sleep. He has a history of type 2 diabetes mellitus and essential hypertension. Which of the following best represent the etiology of this patient’s condition?
A. Autonomic neuropathy
B. Distal symmetric sensorimotor polyneuropathy (Correct Answer)
C. Isolated peripheral nerve neuropathy
D. Isolated cranial nerve neuropathy
E. Radiculopathy
Explanation: ***Distal symmetric sensorimotor polyneuropathy***
- This condition is the most common form of **diabetic neuropathy**, characterized by **burning, shooting pain** predominantly in the feet and lower legs, **worsening at night**.
- The patient's history of **type 2 diabetes mellitus** is a strong risk factor, and the symmetric distribution of symptoms indicates a polyneuropathy, affecting both sensory and motor nerves distally.
*Autonomic neuropathy*
- This involves damage to the **autonomic nervous system**, leading to symptoms like **orthostatic hypotension**, gastroparesis, or bladder dysfunction.
- While common in diabetes, it does not typically present with the described **burning and shooting pain** in the extremities.
*Isolated peripheral nerve neuropathy*
- This diagnosis implies damage to a **single peripheral nerve**, often due to compression or trauma, resulting in focal symptoms.
- The patient's symptoms are **bilateral and symmetric**, affecting multiple nerves, rather than an isolated nerve.
*Isolated cranial nerve neuropathy*
- This involves damage to one or more of the **cranial nerves**, leading to symptoms such as vision changes, facial weakness, or difficulty swallowing.
- The described symptoms of **pain in the feet and lower legs** do not align with cranial nerve involvement.
*Radiculopathy*
- **Radiculopathy** refers to nerve root compression, often causing pain, numbness, or weakness in a **dermatomal or myotomal distribution**.
- The patient's diffuse, symmetric symptoms in the feet and lower legs are more consistent with a polyneuropathy than a specific nerve root compression.
Question 106: A 19-year-old girl comes to the physician for evaluation after a minor motor vehicle collision. While driving down a residential street, a young boy ran out in front of her, chasing after a ball. She applied the brakes of her vehicle and avoided hitting the boy, but then she suddenly experienced generalized weakness that rendered her unable to operate the vehicle and collided at low speed with a parked car. One minute later, she recovered her strength. She was uninjured. She has had several similar episodes of transient generalized weakness over the past month, once during an argument with her mother and another time while watching her favorite comedy movie. She has also had excessive daytime sleepiness for 18 months despite 9 hours of sleep nightly and 2 daily naps. She has fallen asleep in class several times. She often sees intensely bright colors as she is falling asleep. During this time, she is often unable to move; this inability to move is very distressing to her. Which of the following is the most appropriate nighttime pharmacotherapy for this patient?
A. Sodium oxybate (Correct Answer)
B. Duloxetine
C. Amphetamine
D. Guanfacine
E. Fluoxetine
Explanation: ***Sodium oxybate***
- This patient's symptoms (excessive daytime sleepiness, **cataplexy** triggered by strong emotions, **hypnagogic hallucinations**, and **sleep paralysis**) are classic for **narcolepsy**. Sodium oxybate (gamma-hydroxybutyrate) is effective for treating both cataplexy and excessive daytime sleepiness in narcolepsy by improving **nighttime sleep quality**.
- It is taken at night, typically in two doses, to help consolidate sleep and reduce the frequency and severity of narcolepsy symptoms during the day and can alleviate cataplexy.
*Duloxetine*
- **Duloxetine** is a **serotonin-norepinephrine reuptake inhibitor (SNRI)** primarily used to treat depression, anxiety, and neuropathic pain. While SNRIs can be used off-label to help manage cataplexy by elevating monoamine levels, they are generally not considered first-line for significant sleepiness in narcolepsy.
- It would not address the primary issue of **excessive daytime sleepiness** in narcolepsy as effectively as stimulants or sodium oxybate would, and its main effect would be on improving cataplexy, not consolidating nighttime sleep.
*Amphetamine*
- **Amphetamines** are central nervous system stimulants primarily used to treat **excessive daytime sleepiness** in narcolepsy. However, they do not directly address cataplexy, hypnagogic hallucinations, or sleep paralysis, and are taken during the day.
- The question asks for appropriate **nighttime pharmacotherapy**, and amphetamines would worsen nocturnal sleep and are not suitable for nighttime administration in narcolepsy.
*Guanfacine*
- **Guanfacine** is an alpha-2 adrenergic agonist primarily used to treat **attention deficit hyperactivity disorder (ADHD)** and hypertension.
- It is not indicated for the treatment of narcolepsy or its associated symptoms like cataplexy, excessive daytime sleepiness, or sleep-related phenomena.
*Fluoxetine*
- **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)** commonly used for depression, anxiety, and obsessive-compulsive disorder. While SSRIs, like SNRIs, can be used to treat **cataplexy** by increasing serotonin levels, they are not typically prescribed as a primary nighttime treatment for narcolepsy's broad spectrum of symptoms.
- It is generally taken in the morning to avoid potential sleep disturbances and would not address the poor nighttime sleep or daytime sleepiness as effectively as sodium oxybate, thereby failing to meet the criteria for comprehensive nighttime pharmacotherapy.
Question 107: A 53-year-old woman is brought to the emergency department by her husband because of difficulty walking, slurred speech, and progressive drowsiness. The husband reports that his wife has appeared depressed over the past few days. She has a history of insomnia and social anxiety disorder. She appears lethargic. Her temperature is 36.2°C (97.1°F), pulse is 88/min, respirations are 12/min, and blood pressure is 110/80 mm Hg. Neurologic examination shows normal pupils. There is diffuse hypotonia and decreased deep tendon reflexes. Administration of a drug that acts as a competitive antagonist at which of the following receptors is most likely to reverse this patient's symptoms?
A. D2 dopamine receptor
B. Muscarinic acetylcholine receptor
C. 5-hydroxytryptamine2 receptor
D. GABAA receptor (Correct Answer)
E. Ryanodine receptor
Explanation: ***GABAA receptor***
- The patient's symptoms of **sedation**, **slurred speech**, **ataxia** (difficulty walking), **diffuse hypotonia**, and **decreased deep tendon reflexes** are classic signs of **benzodiazepine overdose**.
- **Benzodiazepines** act as **positive allosteric modulators** at the GABA-A receptor, enhancing the effects of GABA and increasing chloride influx, leading to neuronal hyperpolarization and central nervous system depression. A **competitive antagonist** like **flumazenil** can reverse these effects.
*D2 dopamine receptor*
- Antagonism of **D2 dopamine receptors** is associated with **antipsychotic medications** and can lead to **extrapyramidal symptoms** or neuroleptic malignant syndrome, which do not match the patient's presentation.
- While dopamine receptors are involved in mood, their acute antagonism would not explain the rapid-onset, severe CNS depression described.
*Muscarinic acetylcholine receptor*
- **Muscarinic antagonists** (e.g., atropine, scopolamine) cause anticholinergic effects like **dry mouth**, **mydriasis**, **tachycardia**, and **delirium**, which are not observed in this patient.
- Reversal of these receptors would only be indicated in cases of anticholinergic toxicity, not the present signs of CNS depression.
*5-hydroxytryptamine2 receptor*
- **5-HT2 receptor antagonists** are used in some antipsychotics or for migraine prophylaxis, and their primary effects are not central nervous system depression of this nature.
- Overactivation or inhibition of these receptors does not typically manifest with the specific constellation of symptoms seen here (hypotonia, decreased reflexes, prominent sedation).
*Ryanodine receptor*
- **Ryanodine receptors** are primarily involved in **calcium release from the sarcoplasmic reticulum** in muscle cells, playing a role in muscle contraction.
- Drugs acting on these receptors (e.g., dantrolene for malignant hyperthermia) affect muscle tone and contractility, but not the broad CNS depression symptoms presented in this case.
Question 108: A 70-year-old female presents to you for an office visit with complaints of forgetfulness. The patient states that over the last several years, the patient has stopped cooking for herself even though she lives alone. Recently, she also forgot how to drive back home from the grocery store and has difficulty paying her bills. The patient says she has been healthy over her whole life and does not take any medications. Her vitals are normal and her physical exam does not reveal any focal neurological deficits. Her mini-mental status exam is scored 19/30 and her MRI reveals diffuse cortical atrophy. What is the best initial treatment for this patient's condition?
A. Rivastigmine (Correct Answer)
B. Memantine
C. Bromocriptine
D. Pramipexole
E. Ropinirole
Explanation: ***Rivastigmine***
- This patient presents with symptoms and signs consistent with **Alzheimer's disease**, including gradual onset of **cognitive decline** impacting daily activities and diffuse cortical atrophy on MRI.
- **Rivastigmine** is an **acetylcholinesterase inhibitor** indicated for mild-to-moderate Alzheimer's disease, which works by increasing acetylcholine levels in the brain.
*Memantine*
- **Memantine** is an **NMDA receptor antagonist** typically used for **moderate-to-severe Alzheimer's disease**, often in combination with acetylcholinesterase inhibitors.
- While it can be beneficial, it is generally not considered the *initial* treatment for mild-to-moderate cases where acetylcholinesterase inhibitors are preferred.
*Bromocriptine*
- **Bromocriptine** is a **dopamine agonist** primarily used in the treatment of **Parkinson's disease** or hyperprolactinemia.
- It is not indicated for the management of Alzheimer's disease and would not address the underlying cholinergic deficit.
*Pramipexole*
- **Pramipexole** is a **dopamine agonist** used to treat **Parkinson's disease** and restless legs syndrome.
- It does not have a role in the treatment of Alzheimer's disease or other forms of dementia.
*Ropinirole*
- **Ropinirole** is another **dopamine agonist** primarily used for **Parkinson's disease** and restless legs syndrome.
- It is not an appropriate treatment for the cognitive decline seen in Alzheimer's disease.
Question 109: A 46-year-old man presents after he accidentally got splashed with a liquid insecticide that was stored in a bucket in the storeroom one hour ago. He says that he can’t stop coughing and is having problems breathing. He also says he has a pain in his thighs which is unbearable, and his vision is blurry. His temperature is 36.7°C (98.1°F), the pulse is 130/min, the blood pressure is 144/92 mm Hg, and the respiratory rate is 20/min. On physical examination, the patient shows mild generalized pallor, moderate respiratory distress, excessive salivation, and diaphoresis. Cough is non-productive. Pupils are constricted (pinpoint). The cardiopulmonary exam reveals bilateral crepitus. The patient is administered atropine and pralidoxime, which help improve his symptoms. Which of the following is most likely to improve in this patient with the administration of atropine?
A. Muscle cramps
B. Hypertension
C. Tachycardia
D. Bronchospasm (Correct Answer)
E. Pallor
Explanation: ***Bronchospasm***
- The patient exhibits symptoms of **cholinergic crisis** due to organophosphate poisoning, including respiratory distress and excessive salivation. **Atropine** is a muscarinic antagonist that blocks the effects of acetylcholine at muscarinic receptors, thereby relieving **bronchospasm** and reducing secretions.
- Relief of bronchospasm will improve breathing difficulties, a prominent symptom in this patient.
*Muscle cramps*
- **Organophosphate poisoning** can cause **nicotinic effects** like muscle fasciculations and cramps due to excessive acetylcholine at the neuromuscular junction.
- **Atropine primarily targets muscarinic receptors** and has little to no effect on nicotinic receptors, so it would not significantly improve muscle cramps.
*Hypertension*
- **Organophosphate poisoning** typically causes **bradycardia and hypotension** in severe cases, although transient hypertension can occur due to sympathetic activation.
- While atropine can increase heart rate, its direct effect on blood pressure in this context is complex and primarily aimed at reversing muscarinic effects rather than directly treating hypertension.
*Tachycardia*
- The patient presents with **tachycardia (pulse 130/min)**, which is an expected finding in symptomatic organophosphate poisoning, often compensatory to hypotension or due to central nervous system effects.
- **Atropine** itself is a heart rate-elevating drug that blocks parasympathetic stimulation, so it would likely exacerbate or have no corrective effect on existing tachycardia.
*Pallor*
- Pallor can be a non-specific symptom, possibly related to poor circulation or anemia.
- **Atropine** directly addresses muscarinic effects of organophosphate poisoning (e.g., bronchorrhea, bradycardia) and would not be expected to directly improve **pallor**.
Question 110: A 19-year-old woman is brought to the emergency room by her mother. She found her daughter pale, cold to the touch, and collapsed next to her bed earlier this morning. The patient has no previous medical or psychiatric history, but the mother does report that her daughter has not had her periods for the last 3 months. In the emergency department, the patient is alert and oriented. Her vitals include: blood pressure 80/60 mm Hg supine, heart rate 55/min. On physical examination, the patient appears pale and emaciated. A urine pregnancy test is negative. She is suspected of having an eating disorder. Which of the following treatment options would be contraindicated in this patient?
A. Olanzapine
B. Bupropion (Correct Answer)
C. Cognitive-behavioral therapy
D. Selective serotonin reuptake inhibitors
E. High caloric food
Explanation: ***Bupropion***
- **Bupropion** is contraindicated in patients with **anorexia nervosa** or **bulimia nervosa** due to the increased risk of **seizures**.
- Patients with eating disorders often have electrolyte imbalances and metabolic derangements, which further lower the seizure threshold.
*Olanzapine*
- **Olanzapine**, an atypical antipsychotic, can be used in patients with anorexia nervosa to help with **weight gain** and reduce rigid thinking patterns.
- It is particularly useful when significant **anxiety** or **psychotic features** are present, which can exacerbate the eating disorder.
*Cognitive-behavioral therapy*
- **Cognitive-behavioral therapy (CBT)** is a cornerstone of treatment for eating disorders, including anorexia nervosa.
- It helps patients identify and change distorted thoughts and behaviors related to food, weight, and body image.
*Selective serotonin reuptake inhibitors*
- **SSRIs** may be used in anorexia nervosa, primarily after **weight restoration**, to address co-occurring **depression** or **anxiety disorders**.
- They are generally not effective for acute weight gain but can prevent relapse and treat underlying mood disturbances.
*High caloric food*
- Providing **high-caloric food** and nutritional rehabilitation is essential in managing anorexia nervosa to reverse the state of **malnutrition**.
- This must be done carefully to avoid **refeeding syndrome**, a potentially fatal shift in fluid and electrolytes that can occur with rapid refeeding.
