GRAT-Part 1. Q1-4 Instructions.

1. A 43-year-old farmer presents to the ER after an attempted suicide. His friend saw him ingest a whole bottle
of an unknown compound. The patient has excessive salivation, lacrimation, and diarrhea. His speech is
garbled, he is diaphoretic, and muscle fasciculations are present in the upper and lower extremities. Vital signs
are significant for bradycardia and hypotension. Which of the following is the most appropriate
pharmacotherapy for this patient? – organophosphate poisoning

A. Muscarine(receptor)
B. Atropine + pralidoxime (muscarinic inhibitor + nicotinic inhibitor)
C. Mecamylamine- nicotinic antagonist
D. Physostigmine – acetylcholinesterase inhibitor
E. Bethanechol – muscarinic agonist

Prompt questions.
1. In this case, which type of autonomic receptors are stimulated?
Muscarinic, and nicotinic
2. Based on his presentation, which type of chemical is the toxic agent?
Organophosphate poisoning
3. What is a correct answer? Explain why?
4. How about incorrect answers?

2. The graph below depicts the changes in heart rate and blood pressure caused by the administration of drug
S before and after phenoxybenzamine, mecamylamine & propranolol. Which of the following is most likely
drug S?

A. Isoproterenol
B. Albuterol
C. Epinephrine
D. Norepinephrine
E. Phenylephrine

Prompts
1. How to analyze ANS
graphs?
2. What are the effects of
drug S?
3. What is the effect of drug
S in the presence of phenoxybenzamine?
No effect
4. In this case which answer choices have α adrenergic action?
C, D, E
5. What is the effect of albuterol?
bronchodilation, reflexive increase in tachycardia
6. What is the correct answer?

3. Cardiovascular effects of a low dose of an unknown drug, given

by intravenous infusion are presented in the attached graph. The
arrows indicate when the infusion was started and stopped. The blood pressure recordings show systolic
(green), diastolic (pink), and mean arterial pressure (orange). Peripheral resistance is expressed on an arbitrary
scale, ranging from 0 to 4 units. Which of the following is most likely the unknown drug?

A. Dopamine
B. Isoproterenol
C. Epinephrine
D. Norepinephrine

Prompt questions.
1. Illustrate the reflex bradycardia caused by baroreflex pathway using whiteboard app?
2. What are the cardiovascular effects of a low dose infusion of norepinephrine?
3. What is the correct answer?

4. A 31-year-old man is brought to the emergency department 30 minutes after being stung by several wasps.
He is confused and has difficulty breathing. His temperature is 38°C (100.4°F), pulse is 122/min, respirations
are 34/min, and blood pressure is 80/40 mm Hg. Physical examination shows dry skin and decreased capillary
refill. There are multiple erythematous, inflamed marks on the back and 1+ pitting edema of the ankles. In
addition to the administration of 0.9% saline, the most appropriate next step in management is the
administration of which of the following?

A. Atropine
B. Edrophonium
C. Epinephrine
D. Mecamylamine
E. Methacholine (asthma diagnose)

Prompts
1. Based on his clinical presentation, what is most likely diagnosis? How to treat this condition? - anaphylaxis
2. What is the correct answer? Explain why?
beta2 agonist, allows for vasodilation and brochodilation
3. What about incorrect answers?
 GRAT-Part 2. Q5-8 Instructions.

5. A 10-year-old boy is brought to the physician because of persistent cough, especially on exertion. The
mother says that her son has also been having problems with shortness of breath and wheezing at night. After
further evaluation, the physician prescribes albuterol. Which of the following is the most likely mechanism of
action of this drug?

A. Activation of Gi protein
B. Activation of Gq protein
C. Activation of Gs protein
D. Inhibition of Gs protein
E. Inhibition of Gi protein
F. Inhibition of Gq protein

Prompts.
1. Which type of receptors are activated by albuterol?
B2
2. What is the signal transduction mechanism for beta agonists?
GPCRs  incr. adenylyl cyclase  incr cAMP
3. What is the correct answer?

6. The attached graph depicts the changes in cardiac contractile force, arterial pressure, and heart rate caused
by the administration of epinephrine before and after drug X. Which of the following is most likely drug X?

A. Propranolol – beta1
antagonist
B. Phenylephrine
C. Phentolamine
D. Isoproterenol
E. Atropine

Prompts.
1. What are the effects of drug
X? - beta blocker
2. Give some examples that
acts like drug X?
-olol,
3. What is the correct answer? Why

7. The cardiovascular effects of phenylephrine (X) and drug Y, given by intravenous bolus to a subject with
intact autonomic baroreflex function, are presented in the attached graph. The arrow indicates when the
infusion was started. The recordings show systolic and diastolic blood pressure, and heart rate. Which of the
following drugs is most likely drug Y?
A. Phentolamine
B. Prazosin
C. Propranolol
D. Acetylcholine
E. Mecamylamine

Prompts.
1. Explain the effects of drug X
(phenylephrine) on BP and HR?
reflex brady
2. Which type of receptors are
stimulated by phenylephrine?
A1
3. Interpret the cardiovascular effects
of X+Y?
correcting reflex brady
What is the correct answer?

8. Several new drugs with autonomic actions are being studied in phase 1 clinical trials. Autonomic drug X and
Y were given in moderate doses as intravenous boluses to normal volunteers. The systolic and diastolic blood
pressures changed as shown in the images below. Which of the following drugs most resemble drug X? – beta-
2 agonist

A. Benztropine – M1 antagonist
B. Acetylcholine –
muscarinic/nicotinic agonist
C. Epinephrine
D. Isoproterenol
E. Norepinephrine
F. Carvedilol – a,b antagonist

Prompts
1. What are the cardiovascular
effects of acetylcholine?
2. What is the correct answer?
Explain why?