PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

INTRODUCTION, ANATOMY AND PHYSIOLOGY, LABORATORY AND DIAGNOSTICS TESTS OF

NEUROLOGIC DISORDERS

It is used most often as an evaluation for markers of central nervous system (CNS) infections, such as
meningitis and encephalitis, but it is also useful in diagnosing subarachnoid hemorrhage or multiple
sclerosis.
 CT Scan
 Lumbar puncture
 MRI
 EEG

A 23 year old female presents complaining of hearing changes and balance issues. Which cranial nerve is
most likely involved with her problems?
 CN V
 CN IX
 CN XI
 CN VIII

Condition in which the eye makes repetitive uncontrolled movements.

 Clonus
 Babinski (+)
 Nystagmus
 Fasciculation

It is used primarily in the diagnosis of seizures and evaluation of patients with altered mental status.
 Lumbar puncture
 EEG
 PET scan
 CT Scan

Past and recently discontinued medications and any medications used previously, including reasons for
discontinuation, may or may not be included in the history taking.
 True
 False

Gag reflex is obtained by touching the back of the pharynx with the tongue depressor and watching the
elevation of the palate. This tests both the sensory and motor components of _______.
 None of the above
 CN V & VII
 CN II & III
 CN IX & X

Consists of comparing bone conduction (placing the tuning fork on the mastoid process) versus air
conduction (placing the tuning fork in front of the pinna).
 Weber Test
 Romberg test
 Rinne Test
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Babinski test

The patient is asked to identify odors (eg, soap, coffee, cloves) presented to each nostril while the other
nostril is occluded. Alcohol, ammonia, and other irritants are used only to test the nociceptive receptors
of _______ when malingering is suspected.
 CN I
 CN V
 CN IV
 CN III

Offers the advantages of better anatomic detail and has no radiation risk; however, it takes longer to
perform, and is more expensive.
 MRI
 PET Scan
 SPECT Scan
 CT Scan

A patient presents with concerns about his vision. He states that he is experiencing double vision. Upon
evaluation you conclude that he has lateral rectus palsy. Which cranial nerve is most likely lesioned in
this young man?
 CN IV
 CN III
 CN VI
 CN II

The limbal junction of the cornea is lightly touched with a strand of cotton. The patient is asked if they
feel the touch as well as the examiner observing the reflex blink.
 None of the above
 CN V & VII
 CN II & III
 CN VII & IX

A neurologist conduct a history taking on an adult patient with recent numbness and tingling in her left
arm. Which of the following should be asked?
 When was your last menstrual period?
 Were there any anomalies when you were born?
 Does anything worsen your symptoms?
 Do you have shortness of breath that causes the symptom to occur?

A general physical examination is important because it can reveal evidence of systemic disease that may
secondarily affect the nervous system.
 True
 False

Match the Neurologic Complaints and Its Main Domain.

Prompts Submitted Answers
memory loss mental status
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

myalgia motor function

high-pitched ringing cranial nerves
Paresthesia sensation
loss of the sense of smell cranial nerves

Match the Cranial Nerves and Its Function.

Prompts Submitted Answers
Mixed nerve which enables swallowing, CN IX
salivation, taste sensation and general oral cavity
sensations.
Motor nerve which enables phonation and CN XI
movements of the head and shoulders
Motor nerve which enables eye movement, CN III
constriction of the pupil and lens
accommodation.
Mixed nerve which supplies sensation to the CN V
facial skin.
Sensory nerve responsible for hearing, balance CN VIII
and motion.

A middle aged man expresses to you that he is concerned that he cannot taste anything on the anterior
portion of his tongue. What nerve innervates this portion of the tongue?
 CN VIII
 CN IX
 CN X
 CN VII

Ptosis (drooping) occurs with myasthenia gravis, which is a dysfunction of CN _____.

 None of the above
 II
 VII
 IV

Responsible for most reflexes as well as respiratory and cardiovascular rhythms.

 Cerebellum
 Cerebrum
 Brainstem
 None of the above

Neurologic examination is performed to localize a lesion in the CNS or PNS whereas neurologic history is
performed to define the clinical problem.
 True
 False

Bell's palsy is a disorder of movement, muscle tone or posture that is caused by damage that occurs to
the immature, developing brain, most often before birth.
 True
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 False

Bell's Palsy is an affliction of one of the cranial nerves. Typically, a person with Bell's Palsy has a difficult
time tasting food. Based on that bit of information, which cranial nerve is affected?
 CN VII
 CN V
 CN VI
 CN X

The following tests are performed to a patient: tandem walking, walking on tiptoe, Romberg testing.
Which of the following was assessed?
 Cranial nerves
 Gait
 Reflexes
 Mental status

ALZHEIMER’S DISEASE

YS, an 82 year old female, has Parkinson's disease, heart failure (mild), urinary incontinence and early
onset Alzheimer disease. She becomes agitated in the evening. Her maintenance medications are the
following:
Levodopa-carbidopa CR 200/50 mg po bid
Risperidone 0.25 mg po bid
Bumetanide 1 mg po daily
Donepezil 10 mg po daily
Amitriptyline 25mg po qhs
Ramipril 2.5 mg po qam
Calcium citrate 500 mg (elemental) po tid
Identify any drug therapy problem/s and provide appropriate recommendation/intervention/s. Use
SOAP/SBAR format.
Your Answer (5 points)
 (ESSAY)

All of the following are early signs of Alzheimer disease, except:

 trouble handling money and paying bills
 increased sleeping
 loss of spontaneity and sense of initiative
 mood and personality changes

One of the symptoms of Alzheimer disease is consistent inability to produce words for things that they
want to talk about. This refers to:
 agnoxia
 apraxia
 none of the above
 circumlocution
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Difficulty with the motor planning to perform tasks or movements when asked, provided that the
request or command is understood and he/she is willing to perform the task.
 apraxia
 anomia
 aphasia
 agnosia

Matching type. Identify the following AD symptoms if cognitive, non-cognitive or functional.

Prompts Submitted Answers
Debbie can't recognize objects, persons, sounds, cognitive
shapes, or smells.
Erwin is experiencing some hallucinations and non-cognitive
delusions.
Anthony can't dress himself. functional
Mr. Celestino's repetitive mannerisms and non-cognitive
activities.
Angelica uses many words where fewer would cognitive
do.

All of the following are laboratory tests performed in AD, except:

 Rule out electrolyte and glucose abnormalities and renal and hepatic dysfunction with a
comprehensive metabolic panel
 Rule out anemia and infection with complete blood cell count
 Rule out hypothyroidism and hyperthyroidism with thyroid function tests
 None of the above

The primary goal of treatment in Alzheimer Disease

 F. All of the above
 E. B and C
 A. symptomatically treat cognitive difficulties
 B. preserve patient function as long as possible
 C. treating the psychiatric and behavioral sequelae
 D. A and B
Feedback
secondary goal-treating the psychiatric and behavioral sequelae

First drug to be examined as cholinesterase inhibitor but severely limit its usefulness due to significant
side effects, including hepatotoxicity.
 Galantamine
 Tacrine
 Rivastigmine
 Donepezil

Memantine antagonizes NMDA receptors. Which of the following excitatory neurotransmitter in the
brain implicated in long-term potentiation, a neuronal mechanism important for learning and memory?
 Acetylcholine
 Glutamate
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Dopamine
 Serotonin

The mainstay of therapy for patients with Alzheimer disease is the use of centrally acting cholinesterase
inhibitors to attempt to compensate for the depletion of acetylcholine in the cerebral cortex and
hippocampus.
 True
 False

A partial N-methyl-D-aspartate (NMDA) antagonist is approved for treatment of moderate and severe
AD. Titrate to recommended maintenance dose as tolerated.
 True
 False

NSAIDs, prednisone, and Vitamin E supplementation are not recommended for general use in the
treatment or prevention of AD at the present time.
 True
 False

Benzodiazepines impair cognition, worsen breathing disorders, and may increase the risk of falls in AD
patients. Their routine use is not advised, except on an "as needed basis" for infrequent episodes of
agitation.
 True
 False

Why are brain MRI and CT performed in patients with suspected Alzheimer's disease?
 To detect other causes of dementia (eg, stroke, tumor, small-vessel disease)
 To detect brain calcifications associated with Alzheimer's disease
 To measure brain size
 To detect brain sclerotic lesions associated with Alzheimer's disease

Which genotypes are associated with the highest risk of developing Alzheimer's disease?
 PARK7 gene
 Apolipoprotein E (APOE) alleles
 CFTR gene
 BRCA1 gene

An 76-year-old woman was diagnosed with Alzheimer's Disease 5 years ago. Her symptoms first became
apparent to her family about 1 year before the diagnosis was made. Her MMSE score is 14, she is unable
to perform most activities of daily living, and she does not recognize her caregivers on some days.
Which of the following drugs/drug combinations has NOT been shown to be effective therapy for this
patient’s stage of AD?
 Memantine
 Donepezil + Rivastigmine
 Donepezil + Memantine
 Donepezil
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

A 82-year-old woman was diagnosed with AD 2 months ago. Her MMSE score at the time of diagnosis
was 22. At that time, donepezil was started at a dose of 5 mg nightly at bedtime. Would it be considered
appropriate to add memantine to her drug regimen at this time?
 Yes, she is unlikely to respond to donepezil
 Yes, she has moderate AD
 No, she has mild AD
 No, memantine should never be added to cholinesterase inhibitor therapy

PRELIMINARY EXAMINATION - NEURO AND PSYCH DISORDERS

It is used primarily in the diagnosis of seizures and evaluation of patients with altered mental status.
 Lumbar puncture
 CT Scan
 PET scan
 EEG

Offers the advantages of better anatomic detail and has no radiation risk; however, it takes longer to
perform, and is more expensive.
 SPECT Scan
 PET Scan
 MRI
 CT Scan

It is used most often as an evaluation for markers of central nervous system (CNS) infections, such as
meningitis and encephalitis, but it is also useful in diagnosing subarachnoid hemorrhage or multiple
sclerosis.
 CT Scan
 MRI
 Lumbar puncture
 EEG

A neurologist conduct a history taking on an adult patient with recent numbness and tingling in her left
arm. Which of the following should be asked?
 Were there any anomalies when you were born?
 When was your last menstrual period?
 Does anything worsen your symptoms?
 Do you have shortness of breath that causes the symptom to occur?

The following tests are performed to a patient: tandem walking, walking on tiptoe, Romberg testing.
Which of the following was assessed?
 Cranial nerves
 Gait
 Reflexes
 Mental status

Match the Neurologic Complaints and Its Main Domain.

PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

facial agnosia mental status

muscle weakening motor function
difficulty swallowing cranial nerves
numbness of extremities sensation
drooping of the eyelid cranial nerves

CASE 1.
A patient suffered fractures in his frontal bone as well as several facial bones making up the orbit of his
left eye. After trauma care and a bone reconstruction, the patient exhibited external strabismus (eye
rotates laterally), he could not focus on objects with his left eye and his left pupil did not respond to
changes in light intensity. A study of the activity of the extrinsic muscles of his left eye found only the
superior oblique and the lateral rectus muscles were still functional. Further investigation found that the
left superior orbital fissure was compressing one of the cranial nerve associated with the eye.
What cranial nerve is damaged?
 CN VII
 CN V
 CN III
 CN II

CASE 2.
A patient was diagnosed with Stage IV breast cancer 15 months ago and underwent chemotherapy for
several months before a bilateral mastectomy was performed. She then completed six weeks of
radiation therapy to the chest wall. Recently, she has been experiencing the inability to manipulate the
tongue during chewing and swallowing, as well as difficulty in speech. Further investigation indicated
that the left side of her tongue appeared to be paralyzed when asked to protrude her tongue past her
lips. An MRI was performed and revealed a lesion present at the base of the skull that was affecting this
particular cranial nerve.
What cranial nerve is damaged?
 CN V
 CN IX
 CN X
 CN XII

CASE 3.
A patient was diagnosed with DM Type2 several years ago and despite her doctor’s advice she really
does not watch what she eats and she rarely gets any exercise. As a result, it is very difficult to keep her
blood glucose levels at an acceptable level. Recently, the patient has been suffering from severe
gastrointestinal discomfort, including acid reflux and abdominal pain. After a visit with her doctor, she is
told that her symptoms are possibly related to prolonged high blood glucose levels that have damaged a
cranial nerve. He discusses treatment options with her, but warns her that her symptoms will likely be
something that she has to deal with for the rest of her life, just like her diabetes. He also emphasizes the
importance of a healthy diet and refers her to a nutritional counselor.
What cranial nerve is damage?
 CN V
 CN X
 CN VII
 CN IX
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

CASE 4.
A 74-year-old patient has been undergoing radiation treatment for low-risk prostate cancer. He is being
seen by his primary care physician for what appears to be the flu. He has a fever and he is complaining
of a headache and painful joints. Additionally, he is complaining of intense pain and a burning sensation
around the area of his forehead. He is treated for the flu and given a shot of prednisone. He is asked to
follow up in one week. Upon his second visit, he is no longer suffering from flu-like symptoms, but he is
now exhibiting a rash on the area of his forehead. He continues to experience pain and a burning
sensation in this area. It is determined that he has had an occurrence of herpes zoster that is affecting a
cranial nerve. He is prescribed pain medications and is given some instructions on how to ease the pain.
A month later, the patient returns. The rash has cleared, but he still experiences some mild pain in the
affected area. Fortunately the pain bates over the next few weeks.
What cranial nerve is damaged?
 CN V
 CN VII
 CN III
 CN X

CASE 5.
A patient suffer from ‘whiplash injury’. As the days passed, she began to suffer neuromuscular
symptoms. She exhibited a profound tilting of the head to the right side of her body. Other tests by an
orthopedic physician indicated partial paralysis of the right sternocleidomastoid muscle. Subsequent x-
rays revealed two displaced cervical vertebrae that were placing pressure on the rootlets of one of her
cranial nerves. After surgery to realign the vertebrae and physical therapy, the symptoms partially
disappeared within weeks and were almost entirely reversed within a few weeks.
What cranial nerve is damaged?
 CN IX
 CN XII
 CN X
 CN XI

CASE 6.
An epidemic of diphtheria has emerged in an isolated region amongst a population of children who
received school waivers that allowed them to attend school without the normal immunizations. Several
of the children’s illnesses have progressed beyond the common respiratory symptoms of the disease
and the Diphtheria toxin has begun to infiltrate other tissues. In particular, the myocardium of the heart
and the peripheral nervous system are exhibiting inflammation (neuritis). In one case, a cranial nerve
has become particularly inflamed and only partially functional. The child presents with a loss of the
sense of taste, a poor oxygen saturation in the blood of 70% of normal and alternating hypo- and hyper-
tension.
What cranial nerve is damaged?
 CN X
 CN IX
 CN VII
 CN V
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Neurologic history is performed to localize a lesion in the CNS or PNS whereas neurologic examination is
performed to define the clinical problem.
 True
 False

Brain stem is a bundle of nerve tissue that is responsible for reflexes as well as respiratory and
cardiovascular ryhthms.
 True
 False

Condition in which the eye makes repetitive uncontrolled movements.

 Clonus
 Nystagmus
 Babinski (+)
 Fasciculation

A patient presents with concerns about his vision. He states that he is experiencing double vision. Upon
evaluation you conclude that he has lateral rectus palsy. Which cranial nerve is most likely lesioned in
this young man?
 CN II
 CN IV
 CN VI
 CN III

A middle aged man expresses to you that he is concerned that he cannot taste anything on the anterior
portion of his tongue. CN VII innervates this portion of the tongue.
 True
 False

Benzodiazepines impair cognition, worsen breathing disorders, and may increase the risk of falls in AD
patients. Their routine use is not advised, except on an "as needed basis" for infrequent episodes of
agitation.
 True
 False

NSAIDs, prednisone, and Vitamin E supplementation are not recommended for general use in the
treatment or prevention of AD at the present time.
 True
 False

Memantine antagonizes NMDA receptors. Which of the following excitatory neurotransmitter in the
brain implicated in long-term potentiation, a neuronal mechanism important for learning and memory?
 Dopamine
 Serotonin
 Acetylcholine
 Glutamate
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

First drug to be examined as cholinesterase inhibitor but severely limit its usefulness due to significant
side effects, including hepatotoxicity.
 Donepezil
 Tacrine
 Galantamine
 Rivastigmine

Difficulties in speaking, listening, reading, and writing, but does not affect intelligence.
 anomia
 aphasia
 agnosia
 apraxia

A 82-year-old woman was diagnosed with AD 2 months ago. Her MMSE score at the time of diagnosis
was 22. At that time, donepezil was started at a dose of 5 mg nightly at bedtime. Would it be considered
appropriate to add memantine to her drug regimen at this time?
 No, memantine should never be added to cholinesterase inhibitor therapy
 Yes, she has moderate AD
 Yes, she is unlikely to respond to donepezil
 No, she has mild AD

Which genotypes are associated with the highest risk of developing Alzheimer's disease?
 BRCA1 gene
 CFTR gene
 PARK7 gene
 Apolipoprotein E (APOE) alleles

Why are brain MRI and CT performed in patients with suspected Alzheimer's disease?
 To detect brain calcifications associated with Alzheimer's disease
 To measure brain size
 To detect brain sclerotic lesions associated with Alzheimer's disease
 To detect other causes of dementia (eg, stroke, tumor, small-vessel disease)

All of the following are early signs of Alzheimer disease, except:

 trouble handling money and paying bills
 mood and personality changes
 loss of spontaneity and sense of initiative
 increased sleeping

All of the following are laboratory tests performed in AD, except:

 Rule out hypothyroidism and hyperthyroidism with thyroid function tests
 Rule out anemia and infection with complete blood cell count
 Rule out electrolyte and glucose abnormalities and renal and hepatic dysfunction with a
comprehensive metabolic panel
 None of the above
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Mr. Simeon, a 72-year-old retired scientist, has been having problems with his short-term memory,
which his family ignored as the result of aging. They've noted changes in his behavior over time, as well
as difficulty performing basic tasks and increased confusion. This caused his wife and children to see
their doctor, who confirmed a diagnosis of Alzheimer's disease-related dementia. Mr. Simeon had a
minor stroke at the age of 45 and has since been on Aspirin 80mg 1 tab once daily. He is otherwise in
good health, and although advised to stop smoking has not done so. After a few months, Mr. Simeon's
cognitive function worsens and he is prescribed Galantamine 4mg two times a day for 4 weeks,
increasing to 8mg two times a day for at least 4 weeks. Treatment is stopped after one week, due to side
effects.
(12/15)
Questions:
 Mr. Simeon's wife asks, "How did she get Alzheimer? We don't know anyone else who has it."
How would you explain AD to the family in layman's term? (4 points)
 What class of drug is Galantamine? What advice would you give when handling out this
prescription? (4 points)
 Galantamine, however, was discontinued due to side effects. What other treatments options are
available? (4 points)
 What is the role of antipsychotic drugs in the management of non-cognitive symptoms? (3
points)
Your Answer (15 points)
 (ESSAY)

Alzheimer Disease presents with a sudden onset of mental status change with acute loss of executive
function.
 True
 False

Amyloid is evil and the cause of Alzheimer Disease.

 True
 False

Ms. Murillo, a 37-year-old woman, came to the clinic to have her long-term neurologic problems
evaluated. She had noticed some substantial changes in neurologic functions for many years, specifically
heat intolerance, which resulted in a stumbling gait and a tendency to fall. Over the course of several
years, her visual acuity seemed to change. She was working very hard and under a lot of stress two
months ago. Her neurologic state deteriorated after she became ill with the flu. She couldn't grasp
anything in her hands, had substantial tremors, and was extremely tired at the time. She suffered a few
serious falls as well. She had experienced arthralgia on the right and and subsequently on the left side of
her body. Then, the patient abruptly developed a right hemisensory deficit after several days of work.
The MRI scan was performed at that time and revealed a multifocal white matter disease - areas of
increased T2 signal in both cerebral hemispheres. A spinal tap was also performed, which revealed
oligoclonal bands in the CSF. Visual evoked response testing was abnormal with slowed conduction in
optic nerves. The patient is currently suffering with multiple problems associated to her disease. She has
impaired urinary bladder function, which necessitates multiple voids in the mornings and nocturia times,
and she remains weak and numb on her right side. She developed incontinence and now requires the
use of a pad during the day. The patient also shows a tendency for aspirating both liquids and solids.
Question
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 a. Create a list of all symptoms in this patient's history that might lead you to consider Multiple
Sclerosis. (5 points)
 b. What medical complication/s can arise from this neurologic problem? How will you manage
this medical complication/s? (5 points)
Your Answer (10 points)
 (ESSAY)

All of the following are side effects of interferon therapy, except:

 depression
 fever
 phlebitis
 chills
 facial flushing

Interferon-βla (Rebif) differs from Interferon-βla (Avonex) in what way?

 Rebif is given once per week
 Rebif is given as an intramuscular injection
 Rebif causes tissue necrosis
 Rebif is given subcutaneously
 Rebif is given three times per month

Electric shock-like sensations that start in back and radiate to legs.

 Lhermitte's symptoms
 Paresthesia
 Uhthoff's symptoms
 Hypesthesia

SM is a 49-year-old female with MS who presents to the clinic with complaints of fatigue. The physician
decides to prescribe a medication for the symptomatic treatment of fatigue. Which of the following
agents would be appropriate?
 Pregabalin
 Tizanidine
 Amantadine
 Gabapentin

It is used to detect increase level of mononuclear cell count and intrathecal IgG.
 CT Scan
 MRI
 CSF Exam
 Evoked Potentials

It is the preferred agent for the treatment of trigeminal neuralgia and it is used in the same doses that
are used for the treatment of seizure disorders.
 Tizanidine
 Carbamazepine
 Clonazepam
 Diazepam
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

When counseling a patient about interferon therapy for MS, you should communicate to the patient
which important aspect regarding efficacy?
 He or she must freeze the medication.
 He or she will start to notice a change in symptoms immediately.
 The medication works best if a double dose is given.
 It may take up to 1 or 2 years to see a change on the MRI.

Glatiramer acetate (Copaxone) is thought to act by which of the following mechanisms of action?
 Inhibition of the proliferation of reactive T cells
 Decrease matrix metalloproteinases
 Blockage of the binding of major histocompatibility (MHC) class II products to myelin basic
protein (MBP)
 Decreased number of adhesion molecules

In Multiple Sclerosis, the body's own system target the body cells which causes the glial cells to undergo
atrophy and proliferation leading to scar tissue formation in the brain.
 True
 False

Longer duration of IV Methylprednisolone therapy are associated with acne and fungal infections, mood
alteration and rarely, gastrointestinal hemorrhage.
 True
 False

NSAIDS or Acetaminophen taken before and at regular intervals for 24 hours after administration may
alleviate the flu-like symptoms of Interferons.
 True
 False

Sedation, dizziness and dry mouth are the most commonly reported adverse effects of Tizanidine, but
hypotension also can occur, as well as a rare but severe hepatotoxicity.
 True
 False

EPILEPSY

Used as adjunctive therapy in the treatment of partial seizures in adults and children as young as 4 years
of age.
 Levetiracetam
 Lamotrigine
 Oxcarbazepine
 None of the above

Epilepsy is a neurological disorder in which nerve cell activity in the brain becomes disrupted, causing
seizures or periods of unusual behavior, sensations and sometimes loss of consciousness.
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 True
 False

First-line therapy for patients with newly diagnosed partial seizures and for patients with primary
generalized convulsive seizures.
 Carbamazepine
 Topiramate
 Valproic acid
 Levetiracetam

Match the AED and its adverse effect.

Prompts Submitted Answers
Carbamazepine Spina bifida
Gabapentin Aggresive behavior
Phenobarbital Steven-Johnson syndrome
Valproic acid Alopecia
Vigabatrin Reduce visual acuity

First-line AED for partial seizures as an adjunct and/or monotherapy. It is also approved for the
treatment pf tonic-clonic seizures in primary generalized epilepsy.
 Phenobarbital
 Phenytoin
 Topiramate
 Valproic acid

All of the following are factors favoring successful withdrawal of anti-epileptic drugs, except:
 Normal EEG
 Complete seizure control within 1 year of onset
 An onset of seizures after age 2 but before age 25
 Seizure-free period of 2-4 years

Drugs used in the modulation of voltage-gated ion channel, except:

 Tegretol
 Valium
 Lamictal
 Dilantin

Single seizure event does not constitute epilepsy. If it keep coming back, with atleast 2 unprovoked
seizures with or without convulsion, that’s epilepsy.
 True
 False

A seizure that lasts more than 10 minutes or 3 seizures without a normal period in between indicates a
convulsive status epilepticus, which requires emergency treatment.
 True
 False
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Drug of first choice for atonic seizures and for juvenile myoclonic epilepsy.
 Levetiracetam
 Lamotrigine
 Topiramate
 Valproic acid

Effective for patients with chronic pain and with partial seizures who have failed initial treatment.
 None of the above
 Gabapentin
 Topiramate
 Lamotrigine

When a person is awake and aware during a seizure, it’s called focal onset impaired awareness seizure.
 True
 False

Absence seizures are more common in children and they can be so brief that they sometimes are not
detected for months.
 True
 False

Drug of choice for neonatal seizures.

 Carbamazepine
 Valproic acid
 Phenytoin
 None of the above

The most serious side effect reported is hepatotoxity

 Valproic acid
 Phenytoin
 Phenobarbital
 Carbamazepine

Some of the newer agents are believed to cause fewer neurobehavioral or cognitive effects. Which of
the following may cause substantial cognitive impairment, particularly when used at high doses or
during rapid dose escalation?
 Topiramate
 Gabapentin
 Lamotrigine
 None of the above

HEADACHE DISORDERS

Preventive migraine therapies are administered on a daily basis to reduce the frequency, severity, and
duration of attacks and improve responsiveness to symptomatic migraine therapies.
 True
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 False

Migraine-specific therapy that is most effective at relieving pain and associated symptoms.
 Analgesics
 Triptans
 NSAIDS
 Corticosteroids

Frequent use can lead to the development of dependency and rebound headache.
 Serotonin antagonists
 Opiate analgesics
 Ergot derivatives
 Serotonin agonists

Sumatriptan is available for the following administration, except:

 oral
 none of the above
 intranasal
 subcutaneous

Stroke, epilepsy, major depression, sleep apnea, and anxiety disorder show decreased comorbidity with
migraine.
 True
 False

Which of the following drugs should not be used within 24 hours of each other?
 Triptans and Opiate analgesics
 Triptans and NSAIDS
 Triptans and Ergot derivatives
 Triptans and Beta blockers

The standard acute treatment of cluster headache

 Analgesics
 Ergot derivatives
 Triptans
 None of the above
Feedback
Oxygen

Fever, weight loss and accelerated hypertension are examples of headache red flags that warrant urgent
further evaluation.
 True
 False

Mean frequency of attacks is 3 days per month.

 Acute tension-type headache
 Episodic tension-type headache
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Chronic tension-type headache

 None of the above

Pharmacologic treatment of acute headache should be started early to abort the intensification of pain
and to improve symptomatic response to therapy.
 True
 False

Which analgesic preparation is the best option when nausea and vomiting are severe?
 Injection
 Suppository
 Oral
 Nasal spray

The primary short-term goal of migraine treatment is to achieve rapid pain relief that allows the patient
to resume normal activities while the long-term goal of therapy is to prevent headache recurrence and
diminution of headache severity.
 True
 False

Cluster headache duration of pain

 30mins to 7 days
 None of the above
 4hrs to 72hrs
 2secs to 10mins

No side effects have been reported with the use of oxygen, but caution should be used for those who
smoke or who have history of ischemic heart disease.
 True
 False

Not effective in patients with tension-type headache who do not have depression.
 SSRI
 TCA
 SNRI
 None of the above

Medication overuse headache, also called rebound headaches are caused by regular, long term-use of
medication to treat headaches, such as migraines.
 True
 False

Positive symptoms of aura do not include:

 spots
 partial loss of vision
 flickering lights
 wavy lines
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

β-Blockers should be used with caution in patients with the following, except:
 none of the above
 depression
 diabetes mellitus
 congestive heart failure
 asthma

Verapamil is the preferred calcium channel blocker for the prevention of tension-type headaches.
 True
 False

The triptans are contraindicated in patients with the following, except:

 transient ischemic attack
 asthma
 none of the above
 angina pectoris
 uncontrolled hypertension

MIDTERMS

All of the following are factors favoring successful withdrawal of anti-epileptic drugs, except:
 An onset of seizures after age 2 but before age 25
 Seizure-free period of 2-4 years
 Complete seizure control within 1 year of onset
 Normal EEG

Some of the newer agents are believed to cause fewer neurobehavioral or cognitive effects. Which of
the following may cause substantial cognitive impairment, particularly when used at high doses or
during rapid dose escalation?
 Topiramate
 None of the above
 Lamotrigine
 Gabapentin

Drug of first choice for atonic seizures and for juvenile myoclonic epilepsy.
 Lamotrigine
 Levetiracetam
 Valproic acid
 Topiramate

First-line therapy for patients with newly diagnosed partial seizures and for patients with primary
generalized convulsive seizures.
 Topiramate
 Valproic acid
 Carbamazepine
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Levetiracetam

Effective for patients with chronic pain and with partial seizures who have failed initial treatment.
 Topiramate
 Lamotrigine
 Gabapentin
 None of the above

Drugs used in the modulation of voltage-gated ion channel, except:

 Tegretol
 Lamictal
 Dilantin
 Valium

Used as adjunctive therapy in the treatment of partial seizures in adults and children as young as 4 years
of age.
 Oxcarbazepine
 Lamotrigine
 None of the above
 Levetiracetam

Drug of choice for neonatal seizures.

 Phenytoin
 Carbamazepine
 None of the above
 Valproic acid

First-line AED for partial seizures as an adjunct and/or monotherapy. It is also approved for the
treatment of tonic-clonic seizures in primary generalized epilepsy.
 Valproic acid
 Topiramate
 Phenytoin
 Phenobarbital

The most serious side effect reported is liver damage.

 Valproic acid
 Phenytoin
 Carbamazepine
 Phenobarbital

β-Blockers should be used with caution in patients with the following, except:
 asthma
 congestive heart failure
 none of the above
 diabetes mellitus
 depression
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

The triptans are contraindicated in patients with the following, except:

 transient ischemic attack
 asthma
 uncontrolled hypertension
 angina pectoris
 none of the above

Sumatriptan is available for the following administration, except:

 oral
 none of the above
 intranasal
 subcutaneous

Which of the following drugs should not be used within 24 hours of each other?
 Triptans and Beta blockers
 Triptans and Opiate analgesics
 Triptans and NSAIDS
 Triptans and Ergot derivatives

Positive symptoms of aura do not include:

 spots
 flickering lights
 partial loss of vision
 wavy lines

Migraine-specific therapy that is most effective at relieving pain and associated symptoms.
 Triptans
 Analgesics
 Corticosteroids
 NSAIDS

Which analgesic preparation is the best option when nausea and vomiting are severe?
 Injection
 Nasal spray
 Oral
 Suppository

Frequent use can lead to the development of dependency and rebound headache.
 Serotonin antagonists
 Opiate analgesics
 Serotonin agonists
 Ergot derivatives

The standard acute treatment of cluster headache

 None of the above
 Ergot derivatives
 Triptans
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Analgesics
Feedback
Oxygen

Not effective in patients with tension-type headache who do not have depression.
 SNRI
 TCA
 None of the above
 SSRI

IDP with presence of at least two of the following: resting tremor, rigidity, or bradykinesia.
 clinically confirmed
 clinically probable
 clinically possible
 clinically definite

For patients who are older, cognitively impaired, or experiencing moderately severe functional
impairment, which of the following is more preferred?
 Rasagiline
 Entacapone
 Levodopa + Carbidopa
 Benztropine

May cause livedo reticularis, a reversible condition characterized by diffuse mottling of the skin affecting
the upper or lower extremities and often accompanied by lower-extremity edema.
 Amantadine
 Trihexyphenidyl
 Pramipexole
 Levodopa

Use of anticholinergic agents is limited due to the development of intolerable side effects, necessitating
dosage reduction or drug discontinuation. All of the following are common adverse effects of
anticholinergic medications, except:
 blurred vision
 diarrhea
 urinary retention
 confusion

It is a second-generation, irreversible, selective MAO-B inhibitor administered at 0.5 or 1 mg once daily.

 Selegiline
 Amantadine
 Bromocriptine
 Rasagiline

The non-ergot dopamine agonists are safer than the ergot-derived agonists and are useful as
monotherapy in mild-moderate IPD, and also as adjuncts to L-dopa therapy in patients with motor
fluctuations. Which of the following is an example of ergot-derived agonist?
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 none of the above

 pramipexole
 bromocriptine
 ropinirole

Medication-induced parkinsonism can mimic IPD, so it is important to establish if such medications have
been used. All of the following medications can mimic IDP, except:
 Chlorpromazine
 None of the above
 Metoclopramide
 Prochlorperazine

Which of the following is incorrectly paired?

 dysarthria-difficulty arising from a seated position
 dysphagia-difficulty with swallowing
 hypomimia-reduced facial animation
 hypophonia-reduced voice volume

Dopamine agonist or a drug formulation that provides sustained drug levels overnight is best given at
night to ____.
 reduce stomach upset
 reduce toxicity
 improve absorption
 reduce nocturnal off episodes

It is not associated with hepatotoxicity and considered as one of the first adjunctive agent needed for
managing motor fluctuations.
 Entacapone
 Rasagiline
 Selegiline
 Tolcapone

Which of the following is/are considered as adverse effect/s of opioids?

 two of the choices
 all of the choices
 constricted pupils
 constipation
 hypoventilation

Which of the following is an excitatory neurotransmitter involved in pain transmission?

 None of the above
 ϒ-aminobutyric acid (GABA)
 Β-endorphin
 Glutamate

All of the following are synthetic opioids, except:

 Methadone
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 Tramadol
 Fentanyl
 Codeine

Attention must be given to mental/emotional factors that alter the pain threshold. Which of the
following mental/emotional factors can lower the pain threshold?
 rest
 sympathy
 fear
 understanding

Wong-Baker facial grimace scale is a pain scale that healthcare providers use to help measure and better
define a person's pain. Which of the following best describe Wong-Baker facial grimace scale?
 it has 12 lines, each of which has a descriptor—such as faint, strong, intense, and very intense—
placed in the middle of it.
 six faces depict different expressions, ranging from happy to extremely upset —each is
assigned a numerical rating between 0 (smiling) and 10 (crying).
 consists of 78 words that describe pain in which a person rates their own pain by marking the
words that most closely match up to their feelings.
 uses colors that are usually positioned in a line with corresponding numbers or words that
describe your pain.

Match the subtypes of chronic pain and its example.

Prompts Submitted Answers
pain that persists beyond the normal healing time complex regional pain syndrome
pain related to a chronic disease pain secondary to osteoarthritis
pain without an identifiable organic cause fibromyalgia
pain associated with cancer tumor invasion

Match the type of pain and its description.

Prompts Submitted Answers
somatic pain arising from skin, bone, joint, muscle, or connective tissue and most often
presents as throbbing and well localized
visceral pain can manifest as pain feeling as if it is coming from other structures/internal
organs or as a well-localized phenomenon.
neuropathic pain associated with injury to a nerve or the central nervous system
functional pain real, perceived pain that has no demonstrable anatomic lesion or pathological
abnormalities

Compared to traditional as-needed opioid dosing, PCA yields better pain control, improved patient
satisfaction, and relatively few differences in side effects.
 True
 False

Pain is always subjective and is best diagnosed based on patient description and history.
 True
 False
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

At normal therapeutic concentrations, opioid analgesics do not affect other sensory modalities, such as
sensitivity to touch, sight, or hearing; however, as the dosage increases, so do the undesirable side
effects.
 True
 False

1. ES is a 32-year-old accountant who has a history of recent-onset complex-partial seizures (four during
the past 6 days) that are believed to be secondary to a closed head injury suffered in a motor vehicle
accident 3 months ago. He has no known drug allergies. What is the most reasonable initial medication
can you suggest to the patient? Explain the mechanism of action and its possible side effects. (5 points)
2. BE is a 6-year-old girl who was diagnosed of typical childhood absence seizures. She is recently
reported as having multiple staring spells during the day in class. She is allergic to penicillin. What would
be the most appropriate initial therapy for this patient? Explain the mechanism of action and its possible
side effects. (5 points)
Your Answer (10 points)
 (ESSAY)

1. Asking questions in an open-ended way designed to provide more detailed and emotional responses
can lead to a more complete and accurate picture of how disabling migraines may be for individual
patients, allowing better assessment of disease severity and potentially changing therapy and
management plans. Give 5 examples of an open-ended questions that you can ask to a patient with
migraine. (5 points)
2. A young male patient complains of recurrent, severe headache behind one eye, associated with
severe tearing and runny nose. The attacks are frequent and last about 30-60 minutes several times per
day. He had these headaches for a month last year but never sought care. What type of headache is this
and how do you cure it? Include both pharmacological and non-pharmacological treatment. (5 points)

Your Answer(10 points)

 (ESSAY)

PAIN MANAGEMENT QUIZ

Question 1
Match the following characteristics of pain and their corresponding open-ended question. Choose the
best answer.
Prompts Submitted Answers
Palliative factors What makes the pain better?
Provocative factors What makes the pain worse?
Quality Describe the pain.
Onset and duration When did the pain begin and how long has it been since the pain began?
Intensity How does this pain compare with other pain you have experienced?

Question 2
If the pain is moderate, always consider around-the-clock regimens. May use NSAIDS around the clock
with an opioid as needed when the risk does not outweigh the benefits.
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

 True
 False

Question 3
Be cautious when combining opiate analgesics with alcohol or other CNS stimulant because this
combination is potentially harmful and possibly lethal.
 True
 False
Feedback
CNS depressant

Question 4
Rest, mood elevation, sympathy, and understanding can lower the pain threshold.
 True
 False

Question 5
The Wong-Baker facial grimace scale is used to interpret expressed pain when the patient cannot
communicate his/her pain intensity.
 True
 False

Question 6
Analgesia should be initiated with the most effective analgesic agent having the fewest side effects.
 True
 False

Question 7
Typically, an NSAID should be continued for a minimum of 1 month prior to evaluating the need to
switch agents.
 True
 False

Question 8
Oral Ketorolac can be given as 10mg every 6 hours (max dose: 40mg/day) for a maximum of 7 days.
 True
 False
Feedback
maximum of 5 days including parenteral doses

Question 9
The choice of opiate should be based on patient acceptance, analgesic effectiveness, pharmacokinetic,
pharmacodynamic, and side-effect profiles.
 True
 False

Question 10
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Among the morphine-like agonists, Morphine is the naturally occurring opioid analgesic.
 True
 False
Feedback
Morphine and codeine

Question 11
Patients in severe pain may receive very high doses of opioids with no unwanted side effects, but as the
pain subsides, patients may not tolerate even very low doses.
 True
 False

Question 12
In patients who have oral access, the oral route is preferred. In some scenarios, such as acute severe
pain or when the patient is unable to take oral medications, alternative routes of therapy (e.g.,
intravenous) may be preferred.
 True
 False

Question 13
Compared to traditional as-needed opioid dosing, patient-controlled analgesia yields better pain control,
improved patient satisfaction, and relatively few differences in side effects.
 True
 False

Question 14
Patient-controlled analgesia requires careful monitoring and is best used by experienced practitioners.
 True
 False

Question 15
Naloxone is used most often to reverse the toxic effects of agonist- and agonist–antagonist-derived
opioids such as respiratory depression, constipation and pinpoint pupils.
 True
 False

Question 16
Adjuvant analgesics are pharmacologic agents with individual characteristics that make them useful in
the management of pain but that typically are not classified as analgesics.
 True
 False

ASSESSMENT: INTRO, ASSESSMENT OF PSYCHIATRIC DISORDERS , ATTENTION DEFICIT HYPERACTIVITY

DISORDER

Matching type. Choose the best answer.

PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Prompts Submitted Answers

Insight patient awareness that he or she has a mental illness and the impact of that
illness on his or her life.
Judgment ability to make decisions appropriate to the situation and can be impaired in
a variety of mental illnesses.
Abstraction ability to interpret information such as a proverb ("People in glass houses
shouldn't throw stones") or identify similarities or differences between
words (e.g, apple and orange)
Memory ability to recall past experiences and is classified as sensory stores (which
lasts seconds)
Sensorium refers to the alertness of the patient, and if he or she is not fully alert, the
amount of stimulation needed to awaken the patient.
Illusion visual misperceptions involving a misinterpretation of a real sensory
stimulus.
Obsession unwanted thoughts or ideas that intrude into a person's thinking.
Compulsion actions performed in response to the obsessions or to control anxiety
associated with the obsession.
Hallucination false sensory impressions or perceptions that occur in the absence of an
external stimulus.
Delusion fixed, false beliefs that are not based in reality or consistent with the
patient's religion or culture.

The MSE provides a subjective evaluation used in diagnosis, assessment of the course of the illness, and
response to treatment.
 True
 False

The appearance of the patient throughout the psychiatric interview should be noted except dress,
grooming and hygiene, use of cosmetics, and facial expressions to avoid bias.
 True
 False

Affect describes the patient's current emotional tone, as expressed through facial expression, body
posture, and tone of voice. On the other hand, mood describes feelings, which are subjectively reported
by the patient. Change in facial expression and the presence of tears, flushing, sweating, or tremors
should be noted.
 True
 False

Although there are no tests to definitively indicate that a patient has a specific mental illness, laboratory
tests are important to clarify the etiology of presenting symptoms. General laboratory screening is not
useful for ruling out medical causes of psychiatric illnesses and medication monitoring.
 True
 False
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Family history should include a medication history of the immediate relatives because a family
member's response to a given medication might predict an individual patient's response to that same
medication.
 True
 False

Perseveration is overproductive, rapid speech during which the patient jumps rapidly from one idea to
the next.
 True
 False

Match the type of psychological testing and its description.

Prompts Submitted Answers
the most common psychometric test devised to assess Minnesota Multiphasic Personality
personality traits and psychopathology. This data can Inventory
be used to draw conclusions about the test taker’s
psychopathy or to interpret psychological
characteristics compared to the norm.
an intelligence test first published in 1955 and Wechsler Adult Intelligence Scale
designed to measure intelligence in adults and older
adolescents. It consisted of six verbal and five
performance subtests.
a projective method of psychological testing in which The Rorschach Test
a person is asked to describe what he or she sees in
10 inkblots, of which some are black or gray and
others have patches of colour.
is an individually administered pencil and paper test Bender Visual Motor Gestalt Test
used to make a diagnosis of brain injury. There are
nine geometric figures drawn in black which are
presented to the examinee one at a time; then, the
examinee is asked to copy the figure on a blank sheet
of paper.

What structural brain change is the most well-established marker for ADHD?
 Enlarged ventricles and diminished basal ganglia
 Underdevelopment of the locus coeruleus
 Overgrown lateral lobe of the amygdala
 Cortical thinning and delay in cortical thickness

A 4-year-old child exhibits severe hyperactivity at preschool and is asked to leave preschool due to
aggression, impulsivity, and not following directions. Which of the following statements describes an
additional diagnostic criterion needed for a diagnosis of ADHD?
 Learning disability needs to be ruled out.
 The symptom duration would need to be 6 weeks.
 These impairing symptoms are also present at home.
 The patient must be at least 6 years old.
PHARMACOTHERAPY 8 (NEUROLOGIC & PSYCH DISORDERS) 0900-1200 Sat

Which ADHD medication is most likely associated with excessive daytime sedation requiring counseling
regarding possible sleepiness during the school day?
 Clonidine
 Atomoxetine
 Lisdexamfetamine
 Bupropion

Which of the following is an appropriate starting dose of Atomoxetine for a 10-year-old (100 lb [45 kg])
child with ADHD?
 20 mg twice daily
 25 mg in the morning
 30 mg at bedtime
 10 mg twice daily

Which of the following statements most accurately describes the clinical presentation of adult ADHD?
 Disorganization increases in frequency and severity over the adult life span.
 Hyperactivity and impulsivity are the most prominent symptoms.
 Distractibility and difficulty with sustained mental effort are most common.
 Adults frequently report racing thoughts, mood swings, and insomnia.

Match the following childhood disorders and its manifestation.

Prompts Submitted Answers
repeated bed wetting Enuresis
mimic noises and words Tourette's disorder
uncontrollable use of obscene language Tourette's disorder
Disorganization and problems prioritizing ADHD
Trouble sitting still and doing quiet tasks ADHD