Polypharmacy management — MCQs

10 questions

A 75 year-old gentleman presents to his general practitioner. He is currently being treated for hypertension and is on a multi-drug regimen. His current blood pressure is 180/100. The physician would like to begin treatment with minoxidil or hydralazine. Which of the following side effects is associated with administration of these drugs?

A pharmaceutical company conducts a randomized clinical trial to demonstrate that their new anticoagulant drug, Aclotsaban, prevents more thrombotic events following total knee arthroplasty than the current standard of care. A significant number of patients are lost to follow-up, and many fail to complete treatment according to the study arm to which they were assigned. Despite these protocol deviations, the results for the patients who completed the course of Aclotsaban are encouraging. Which of the following analytical approaches is most appropriate for the primary analysis to establish the efficacy of Aclotsaban?

A 62-year-old man comes to his primary care physician with a 3-month history of insomnia and severe work anxiety. He says that he is unable to retire because he has no financial resources; however, the stress level at his work has been causing him to have worsening performance and he is afraid of being fired. He thinks that he would be able to resume work normally if he was able to decrease his level of anxiety. His physician prescribes him a trial 1-month regimen of benzodiazepine therapy and schedules a follow-up appointment to see whether this treatment has been effective. Three weeks later, the patient's wife calls and says "My husband was fired from work and it's your fault for prescribing that medication! I know he must have been taking too much of that drug. Don't you know that he had a horrible problem with drug abuse in his 30s?" Which of the following is the most appropriate first action for the physician to take?

A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?

A 35-year-old woman is presenting for a general wellness checkup. She is generally healthy and has no complaints. The patient does not smoke, drinks 1 alcoholic drink per day, and exercises 1 day per week. She recently had silicone breast implants placed 1 month ago. Her family history is notable for a heart attack in her mother and father at the age of 71 and 55 respectively. Her father had colon cancer at the age of 70. Her temperature is 99.0°F (37.2°C), blood pressure is 121/81 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate initial step in management?

A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A 72-year-old man presents to his primary care provider at an outpatient clinic for ongoing management of his chronic hypertension. His past medical history is significant for diabetes and osteoarthritis though neither are currently being treated with medication. At this visit, his blood pressure is found to be 154/113 mmHg so he is started on lisinopril. After leaving the physician's office, he visits his local pharmacy and fills the prescription for lisinopril before going home. If this patient is insured by medicare with a prescription drug benefit provided by a private company through medicare, which of the following components of medicare are being used during this visit?

A 53-year-old woman with type 2 diabetes mellitus is admitted for evaluation of recurrent episodes of nausea, tremors, and excessive sweating. She works as a nurse and reports self-measured blood glucose levels below 50 mg/dL on several occasions. Her family history is positive for borderline personality disorder. The only medication listed in her history is metformin. Which of the following is the most appropriate next step in management?

A 32-year-old man with a history of major depressive disorder is brought to the emergency department by his wife because of a sudden onset of restlessness and disorientation that developed 3 hours ago. The patient’s wife says that he suddenly started sweating, having tremors, and mumbling to himself. Yesterday, the patient visited his psychiatrist with worsening depression who added phenelzine to his current treatment regimen. No other significant past medical history. His temperature is 39.7°C (103.5°F), blood pressure is 145/90 mm Hg, and pulse is 115/min. On physical examination, the skin is flushed. Mucous membranes are dry, and pupils are dilated. There is pronounced clonus in the extremities bilaterally. Babinski sign is present bilaterally. All the patient’s medications are discontinued, and intravenous fluids are started. Which of the following drugs most likely interacted with phenelzine to cause this patient’s condition?

Q10

A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?

Polypharmacy management US Medical PG Practice Questions and MCQs

Question 1: A 75 year-old gentleman presents to his general practitioner. He is currently being treated for hypertension and is on a multi-drug regimen. His current blood pressure is 180/100. The physician would like to begin treatment with minoxidil or hydralazine. Which of the following side effects is associated with administration of these drugs?

A. Persistent cough
B. Cyanosis in extremities
C. Fetal renal toxicity
D. Systemic volume loss
E. Reflex tachycardia (Correct Answer)

Explanation: ***Reflex tachycardia*** - Both **minoxidil** and **hydralazine** are direct arterial vasodilators, causing a significant drop in **peripheral vascular resistance**. - This vasodilation triggers a **baroreflex response**, leading to an increase in heart rate and **cardiac contractility** to maintain cardiac output, resulting in reflex tachycardia. *Persistent cough* - **Persistent cough** is a common side effect associated with **ACE inhibitors**, such as lisinopril or enalapril, due to the accumulation of **bradykinin**. - This side effect is not typically seen with **minoxidil** or **hydralazine**, which act directly on vascular smooth muscle to cause vasodilation. *Cyanosis in extremities* - **Cyanosis** (bluish discoloration of the skin and mucous membranes) usually indicates **hypoxemia** or poor peripheral perfusion. - While sometimes associated with severe cardiogenic shock or specific drug toxicities like methemoglobinemia (not related to minoxidil or hydralazine), it is not a direct or typical side effect of these vasodilators. *Fetal renal toxicity* - **Fetal renal toxicity**, including **fetal renal dysfunction** and **oligohydramnios**, is a well-known risk associated with **ACE inhibitors** and **ARBs** during pregnancy. - Neither **minoxidil** nor **hydralazine** are primarily linked to this specific fetal adverse effect, though hydralazine can be used in pregnancy for severe hypertension. *Systemic volume loss* - **Systemic volume loss** is usually caused by conditions like **dehydration**, excessive diuresis, or hemorrhage. - While vasodilators can reduce blood pressure, they do not directly cause **systemic volume depletion**; rather, the reflex response to vasodilation can include fluid retention to counteract the blood pressure drop.

Question 2: A pharmaceutical company conducts a randomized clinical trial to demonstrate that their new anticoagulant drug, Aclotsaban, prevents more thrombotic events following total knee arthroplasty than the current standard of care. A significant number of patients are lost to follow-up, and many fail to complete treatment according to the study arm to which they were assigned. Despite these protocol deviations, the results for the patients who completed the course of Aclotsaban are encouraging. Which of the following analytical approaches is most appropriate for the primary analysis to establish the efficacy of Aclotsaban?

A. Intention-to-treat analysis (Correct Answer)
B. Sub-group analysis
C. Per-protocol analysis
D. As-treated analysis
E. Non-inferiority analysis

Explanation: ***Intention-to-treat analysis*** - **Intention-to-treat (ITT) analysis** is the gold standard for the **primary analysis in superiority trials** and includes all patients in the groups to which they were originally randomized, regardless of protocol deviations, loss to follow-up, or treatment discontinuation. - ITT preserves **randomization balance**, prevents bias from selective dropout (patients may drop out due to adverse effects or lack of efficacy), and provides a **conservative, realistic estimate** of treatment effect in actual clinical practice. - For **regulatory approval and establishing efficacy**, ITT is the most appropriate primary analysis method even when dropout rates are high, as it maintains the integrity of the randomized comparison. *Per-protocol analysis* - **Per-protocol analysis** includes only patients who completed the study exactly as planned without protocol deviations. - While the encouraging results in completers are noted, per-protocol analysis can **introduce significant bias** by excluding patients who dropped out due to adverse events or lack of efficacy, potentially **overestimating treatment benefit**. - Per-protocol is typically used as a **secondary/supportive analysis**, not the primary method for establishing superiority. *As-treated analysis* - **As-treated analysis** categorizes patients according to the treatment they actually received rather than their randomized assignment. - This violates the principle of randomization and can introduce **confounding bias**, as actual treatment received may be influenced by prognostic factors. *Sub-group analysis* - **Sub-group analysis** evaluates treatment effects within specific patient subsets. - This is **hypothesis-generating** rather than confirmatory and increases the risk of false-positive findings (multiple comparisons problem) unless pre-specified in the protocol. *Non-inferiority analysis* - **Non-inferiority analysis** tests whether a new treatment is not worse than control by more than a pre-specified margin. - The goal here is to demonstrate **superiority** (better than standard care), not non-inferiority, making this approach inappropriate.

Question 3: A 62-year-old man comes to his primary care physician with a 3-month history of insomnia and severe work anxiety. He says that he is unable to retire because he has no financial resources; however, the stress level at his work has been causing him to have worsening performance and he is afraid of being fired. He thinks that he would be able to resume work normally if he was able to decrease his level of anxiety. His physician prescribes him a trial 1-month regimen of benzodiazepine therapy and schedules a follow-up appointment to see whether this treatment has been effective. Three weeks later, the patient's wife calls and says "My husband was fired from work and it's your fault for prescribing that medication! I know he must have been taking too much of that drug. Don't you know that he had a horrible problem with drug abuse in his 30s?" Which of the following is the most appropriate first action for the physician to take?

A. Discharge the patient for inappropriate use of medication
B. Contact the physician's medical practice insurance company regarding a potential claim
C. Refer the patient to a substance abuse program
D. Contact the patient directly to discuss the situation (Correct Answer)
E. Inform the patient's wife that patient information cannot be disclosed to her due to HIPAA

Explanation: ***Contact the patient directly to discuss the situation*** - The physician's immediate priority is to address the patient's well-being and medication use directly with the patient, as the patient-doctor relationship is paramount and confidential. - This allows the physician to gather information directly from the patient, assess the current situation, and plan appropriate next steps, which may include medication adjustment, referral, or relapse prevention depending on the patient's account. *Discharge the patient for inappropriate use of medication* - Discharging the patient based solely on a third-party report, especially without direct communication with the patient, would be premature and could be interpreted as **patient abandonment**. - This action does not prioritize the patient's immediate medical and psychological needs and could worsen their situation by removing them from care. *Contact the physician's medical practice insurance company regarding a potential claim* - While potential legal implications exist, contacting the insurance company is not the **first and most appropriate medical action** to take. - The immediate priority is the patient's health and safety, and managing potential legal risks can be addressed after ensuring the patient's well-being. *Refer the patient to a substance abuse program* - Although the patient's history and the wife's concerns suggest a potential for substance abuse, a direct referral without first assessing the patient and confirming misuse would be premature. - The physician needs to **personally evaluate the patient** to determine the appropriate course of action, which might include such a referral, but it shouldn't be the very first step based on indirect information. *Inform the patient's wife that patient information cannot be disclosed to her due to HIPAA* - While the physician can listen to the wife's concerns (HIPAA does not prohibit receiving information from third parties), the physician **cannot discuss the patient's care or confirm treatment details** without the patient's authorization. - However, simply informing the wife about confidentiality restrictions without taking action to contact and assess the patient is not the most appropriate first step—the priority is patient care, not just explaining privacy rules.

Question 4: A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?

A. Normal aging
B. Lewy body dementia
C. Vascular dementia (Correct Answer)
D. Pseudodementia (depression-related cognitive impairment)
E. Alzheimer's dementia

Explanation: ***Vascular dementia*** - This diagnosis is strongly supported by the patient's **stepwise decline** in cognitive function following a "series of falls" (likely small strokes or transient ischemic attacks) and his extensive history of **vascular risk factors** including hypertension, diabetes, and previous myocardial infarction. - The acute worsening of confusion over 24 hours, coupled with pre-existing impaired executive function (inability to cook or pay bills), is characteristic of **vascular dementia's fluctuating course** and presentation often linked to new cerebrovascular events. *Incorrect: Normal aging* - **Normal aging** involves a very gradual and mild decline in cognitive functions, primarily affecting processing speed and memory recall, without significant impairment in daily activities. - This patient's rapid, stepwise decline and inability to perform instrumental activities of daily living (IADLs) such as cooking and managing finances go beyond what is considered normal cognitive changes with aging. *Incorrect: Lewy body dementia* - **Lewy body dementia** is characterized by prominent **fluctuations in attention and alertness**, recurrent visual hallucinations, and spontaneous parkinsonism, none of which are explicitly mentioned as primary features in this patient's presentation. - While fluctuations in confusion are present, the history of a clear stepwise decline post-falls and significant vascular risk factors points away from Lewy body dementia as the most likely primary cause. *Incorrect: Pseudodementia (depression-related cognitive impairment)* - **Pseudodementia** refers to cognitive impairment that occurs in the context of **major depression**, where patients may exhibit poor concentration, memory difficulties, and psychomotor slowing that mimics dementia. - While this patient is on fluoxetine for depression, the **stepwise decline** after clear vascular events (falls), multiple vascular risk factors, and impaired executive function point to a true neurodegenerative process rather than depression-induced cognitive changes, which typically improve with treatment of the underlying mood disorder. *Incorrect: Alzheimer's dementia* - **Alzheimer's dementia** typically presents with a **gradual and progressive decline** in memory, particularly episodic memory, followed by other cognitive domains over several years. - The patient's history of a clear **stepwise decline** in function after acute events (falls) and the strong presence of **vascular risk factors** make vascular dementia a more fitting diagnosis than Alzheimer's, which is not typically associated with such a sudden, step-like progression.

Question 5: A 35-year-old woman is presenting for a general wellness checkup. She is generally healthy and has no complaints. The patient does not smoke, drinks 1 alcoholic drink per day, and exercises 1 day per week. She recently had silicone breast implants placed 1 month ago. Her family history is notable for a heart attack in her mother and father at the age of 71 and 55 respectively. Her father had colon cancer at the age of 70. Her temperature is 99.0°F (37.2°C), blood pressure is 121/81 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate initial step in management?

A. Alcohol cessation
B. Colonoscopy at age 60
C. Mammography at age 50
D. Colonoscopy at age 40 (Correct Answer)
E. Mammography now

Explanation: ***Colonoscopy at age 40*** - This patient has a **first-degree relative (father) diagnosed with colorectal cancer at age 70**, which increases her risk compared to the average population. - Current **USPSTF and ACS guidelines** recommend that individuals with a first-degree relative diagnosed with colorectal cancer at **age 60 or older** should begin screening at **age 40** (or 10 years before the age of diagnosis in the relative, whichever is earlier). - Since her father was diagnosed at age 70, she should start screening at age 40 (which is 10 years earlier and also the recommended age for those with family history). - At age 35, she does **not yet need** colonoscopy, but should plan for screening in 5 years. *Colonoscopy now* - This is **too early** based on current guidelines. - Immediate colonoscopy at age 35 is not indicated in an asymptomatic patient whose father was diagnosed at age 70. - Screening at age 40 provides adequate time for early detection while avoiding unnecessary early intervention. *Colonoscopy at age 60* - This is **too late** and ignores the increased risk from family history. - Delaying screening until age 60 would miss the recommended earlier screening window for patients with first-degree relatives with CRC. *Alcohol cessation* - The patient drinks **1 alcoholic drink per day**, which is within recommended limits for women. - While reducing alcohol consumption has general health benefits, this is not the most urgent preventive measure given her family history of colon cancer. *Mammography now* - Screening mammography typically begins at **age 40-50** for average-risk women. - At age 35 with no specific high-risk factors (no BRCA mutation, no strong early-onset breast cancer family history), mammography is not indicated now. *Mammography at age 50* - While this may be appropriate for breast cancer screening depending on guidelines followed, it is **not the priority** given her significant family history of colorectal cancer requiring earlier intervention.

Question 6: A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Prescribe oxycodone
B. Short-term rehabilitation
C. Home hospice care (Correct Answer)
D. Inpatient palliative care
E. Evaluation for alternative methods of feeding

Explanation: ***Home hospice care*** - This patient exhibits advanced **dementia** with significant decline in function, frequent aspiration events, and substantial **weight loss**, indicating a prognosis of less than six months. **Hospice care** focuses on comfort and dignity during the end-of-life stage. - The daughter's recollection of the patient's wishes to avoid life-sustaining measures, combined with the current medical complexity and poor prognosis, supports the transition to **hospice services** to manage symptoms and provide support to both the patient and family. *Prescribe oxycodone* - There is no mention of pain in the patient’s presentation; therefore, prescribing an **opioid** like oxycodone is not indicated and could cause adverse effects such as **sedation** and **constipation**, which would further complicate her care. - While patients with advanced dementia may experience pain, it must be assessed and confirmed before prescribing **analgesics**. *Short-term rehabilitation* - Given the patient's advanced dementia, severe functional decline, recurrent aspiration pneumonia, and malnourishment, **short-term rehabilitation** to improve functional status is unlikely to be effective. - The patient's underlying condition is progressive and irreversible, making restoration of independent function an unrealistic goal. *Inpatient palliative care* - While **palliative care** focuses on symptom management and quality of life, **inpatient palliative care** is typically reserved for patients with severe symptoms requiring constant medical attention that cannot be managed at home. - In this case, the patient's symptoms, while serious, appear amenable to management in a home setting with the comprehensive support offered by **hospice**. *Evaluation for alternative methods of feeding* - In advanced dementia, **percutaneous endoscopic gastrostomy (PEG) tube feeding** does not improve survival, reduce aspiration risk, or enhance quality of life. - Given the patient's advanced stage of disease and the recalled wishes to avoid life-sustaining measures, initiating **artificial feeding** would be contrary to comfort-focused care.

Question 7: A 72-year-old man presents to his primary care provider at an outpatient clinic for ongoing management of his chronic hypertension. His past medical history is significant for diabetes and osteoarthritis though neither are currently being treated with medication. At this visit, his blood pressure is found to be 154/113 mmHg so he is started on lisinopril. After leaving the physician's office, he visits his local pharmacy and fills the prescription for lisinopril before going home. If this patient is insured by medicare with a prescription drug benefit provided by a private company through medicare, which of the following components of medicare are being used during this visit?

A. Part A alone
B. Parts A and B
C. Parts B and D (Correct Answer)
D. Parts A, B, C and D
E. Part B alone

Explanation: ***Parts B and D*** - The visit to the **primary care provider** at an outpatient clinic for hypertension management is covered under **Medicare Part B** (medical insurance), which includes doctor's services and outpatient care. - The prescription for lisinopril, filled at a local pharmacy with a prescription drug benefit provided by a private company through Medicare, signifies the use of **Medicare Part D** for prescription drug coverage. *Part A alone* - **Medicare Part A** covers hospital insurance, including inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. - This scenario describes an **outpatient visit** and a **prescription fill**, neither of which falls under Part A coverage. *Parts A and B* - While Part B is correctly identified as covering the outpatient visit, **Part A** is not applicable as the patient was neither hospitalized nor receiving skilled nursing or hospice care. - The scenario also involves a **prescription drug benefit**, which is covered by Part D, not Part A or B. *Parts A, B, C and D* - This option would imply coverage for inpatient care (A), outpatient care (B), a managed care plan (C), and prescription drugs (D). - Although Part B and Part D are relevant, there is no mention of an inpatient stay (Part A) or an enrollment in a Medicare Advantage Plan (Part C) that would consolidate these benefits. *Part B alone* - **Medicare Part B** covers the outpatient visit to the primary care provider. However, it **does not cover prescription drugs** obtained from a pharmacy. - The patient filled a prescription, which specifically falls under **Medicare Part D**.

Question 8: A 53-year-old woman with type 2 diabetes mellitus is admitted for evaluation of recurrent episodes of nausea, tremors, and excessive sweating. She works as a nurse and reports self-measured blood glucose levels below 50 mg/dL on several occasions. Her family history is positive for borderline personality disorder. The only medication listed in her history is metformin. Which of the following is the most appropriate next step in management?

A. Measure serum C-peptide concentration
B. Ask the patient if she is taking any medications other than metformin (Correct Answer)
C. Search the patient's belongings for insulin
D. Measure glycated hemoglobin concentration
E. Report the patient to her employer

Explanation: ***Ask the patient if she is taking any medications other than metformin*** - The patient's presentation with recurrent **hypoglycemic symptoms** (nausea, tremors, sweating) and documented low blood glucose, while only being prescribed metformin (which does not cause hypoglycemia), strongly suggests **exogenous insulin or sulfonylurea use**. - A direct question about other medications is a crucial initial step to ascertain the cause of her hypoglycemia and to rule out **factitious hypoglycemia**, especially given her profession as a nurse and a family history that might suggest psychological vulnerabilities, although not a direct diagnosis for the patient. *Measure serum C-peptide concentration* - While **low C-peptide** in the presence of hypoglycemia would suggest exogenous insulin administration, and high C-peptide might point to an insulinoma, this test should be done *after* ruling out common causes like the undisclosed use of other medications. - This is a more invasive and less direct initial step compared to simply asking the patient about medication use, especially when a readily reversible cause (undisclosed medication) is possible. *Search the patient's belongings for insulin* - Searching a patient's belongings without their consent is a serious ethical breach and a violation of privacy. - This action should only be considered as a last resort in extreme circumstances and with appropriate legal and ethical oversight, not as an initial diagnostic step. *Measure glycated hemoglobin concentration* - **Glycated hemoglobin (HbA1c)** reflects average blood glucose levels over the past 2-3 months and is used to monitor long-term glycemic control in diabetic patients. - While useful for diabetes management, it will not directly identify the acute cause of recurrent hypoglycemic episodes or distinguish between endogenous and exogenous insulin sources. *Report the patient to her employer* - Reporting the patient to her employer prematurely, without a definitive diagnosis or understanding the full context of her condition, is unethical and unprofessional. - The immediate priority is to diagnose and manage the patient's medical condition, ensuring her safety and well-being, before considering professional implications.

Question 9: A 32-year-old man with a history of major depressive disorder is brought to the emergency department by his wife because of a sudden onset of restlessness and disorientation that developed 3 hours ago. The patient’s wife says that he suddenly started sweating, having tremors, and mumbling to himself. Yesterday, the patient visited his psychiatrist with worsening depression who added phenelzine to his current treatment regimen. No other significant past medical history. His temperature is 39.7°C (103.5°F), blood pressure is 145/90 mm Hg, and pulse is 115/min. On physical examination, the skin is flushed. Mucous membranes are dry, and pupils are dilated. There is pronounced clonus in the extremities bilaterally. Babinski sign is present bilaterally. All the patient’s medications are discontinued, and intravenous fluids are started. Which of the following drugs most likely interacted with phenelzine to cause this patient’s condition?

A. Sertraline (Correct Answer)
B. Olanzapine
C. Mirtazapine
D. Bupropion
E. Lithium

Explanation: ***Sertraline*** - The patient exhibits classic symptoms of **serotonin syndrome**, including **mental status changes (disorientation, mumbling), autonomic hyperactivity (sweating, fever, flushed skin, tachycardia, hypertension, dry mucous membranes, dilated pupils)**, and **neuromuscular abnormalities (tremors, clonus, Babinski sign)**. - **Sertraline** is an **SSRI** (selective serotonin reuptake inhibitor). The concurrent use of an **SSRI** with **phenelzine**, a **MAOI** (monoamine oxidase inhibitor), can lead to a dangerous overabundance of serotonin in the central nervous system, predictably causing **serotonin syndrome**. - This is a **classic, high-risk drug interaction** that is absolutely contraindicated. *Olanzapine* - **Olanzapine** is an **atypical antipsychotic** primarily used to treat schizophrenia and bipolar disorder, and it does not significantly impact serotonin levels in a way that would precipitate serotonin syndrome when combined with a MAOI. - Its main mechanisms involve antagonism at **dopamine D2 and serotonin 5-HT2A receptors**, and it generally does not elevate serotonin to toxic levels. *Mirtazapine* - **Mirtazapine** is an **alpha-2 adrenergic antagonist** and specific **serotonin receptor antagonist** (5-HT2 and 5-HT3). While it can theoretically interact with MAOIs, it enhances serotonergic transmission indirectly through increased norepinephrine release rather than directly blocking serotonin reuptake. - The risk of serotonin syndrome with mirtazapine + MAOI is **significantly lower than with SSRIs + MAOI**, though caution is still warranted. It would not be the **most likely** cause in this scenario. *Bupropion* - **Bupropion** is a **norepinephrine-dopamine reuptake inhibitor (NDRI)**; it does not significantly affect serotonin levels. - Therefore, it would not interact with **phenelzine** to cause serotonin syndrome. *Lithium* - **Lithium** is a **mood stabilizer** primarily used for bipolar disorder. It has no direct serotonergic mechanism that would interact with a **MAOI** to cause serotonin syndrome. - Its therapeutic effects are thought to be mediated through various intracellular signaling pathways.

Question 10: A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?

A. Colorectal screening (Correct Answer)
B. Blood glucose and/or HbA1c screening
C. Blood pressure at least once every 3 years
D. Yearly Pap smear
E. Bone mineral density screening

Explanation: ***Colorectal screening*** - **Colorectal cancer screening** is generally recommended to start at age **45 years** for individuals at average risk. - This patient is 46 years old, making immediate colorectal screening appropriate based on current guidelines. *Blood glucose and/or HbA1c screening* - **Blood glucose or HbA1c screening** for diabetes is recommended starting at age **35 for all adults** or earlier if there are risk factors such as obesity or a family history of diabetes. - While this patient is 46, this screening should have already been initiated, and it is not the *most* uniquely recommended screening for this specific age that might have been overlooked. *Blood pressure at least once every 3 years* - **Blood pressure screening** should be performed **at least annually** for adults aged 40 and older, or more frequently if there are risk factors. - Screening only every 3 years is insufficient for a 46-year-old patient. *Yearly Pap smear* - **Pap smear frequency** has changed; for women aged 30-65 with normal results, screening is recommended every **3 years** with cytology alone, or every 5 years with high-risk HPV testing alone or co-testing. - A yearly Pap smear is no longer typical practice for a woman with normal prior results and no specific risk factors. *Bone mineral density screening* - **Bone mineral density (BMD) screening** for osteoporosis is typically recommended for women starting at age **65 years** or earlier if they have significant risk factors. - This patient is 46 years old and has no mentioned risk factors, so BMD screening is not routinely indicated at this age.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free