Mid-term exam of pharmacotherapy 4

Mid-term exam

Pharmacotherapy 4
‫ خالد األكحلي‬/‫الدكتور‬

‫ فريق قلم صيدلي‬/‫إعداد‬

Theoretical part.
Q1: choose only one answer for each question.
1) The first-line inotropic agent for hypovolemic shock is:
a) Dobutamine.
b) Dopamine.
c) Norepinephrine.
d) Epinephrine.
e) Phenylephrine.
2) Which of the following is not an etiology factor of myocardial
infarction?
a) Smoking.
b) Diabetes Mellitus.
c) Hypertension.
d) Hyperlipidemia.
e) Tachycardia.
3) During the diagnosis of prinzmetal angina which ECG change is shown?
a) ST elevation.
b) ST depression.
c) T wave inversion.
d) T wave peaked.
4) Which of the following is the most sensitive marker for heart muscle
damage?
a) Creatine phosphokinase.
b) Lactate dehydrogenase.
c) Troponins.
d) Alkaline phosphatase.
e) Aspartate aminotransferase.
5) In NSTEMI which of the following is shown in the ECG?
a) No ECG changes.
b) T wave inversion.
c) ST depression.
d) ST elevation.
e) All of the above.
6) Venous thromboembolism includes:
a) DVT.
 b) Pulmonary embolism.
c) Heart failure.
d) A and C.
e) A and B.
7) Which of the following results from orthopedic surgery?
a) Hypercoagulability.
b) Vascular injury.
c) Venous stasis.
d) Drug-induced coagulability.
e) Malignancy.
8) Which of the following drugs cause DVT?
a) Heparin.
b) Warfarin.
c) Fondaparinux.
d) Enoxaparin.
e) Estrogen.
9) All of the following are symptoms of DVT EXCEPT:
a) Unilateral leg swelling.
b) Warmth.
c) Pain.
d) Erythema.
e) Hemoptysis.
10) All of the following are symptoms of PE EXCEPT:
a) Palpitations.
b) Cough.
c) Diaphoresis
d) Tachycardia.
e) Warmth.
11) All of the following are symptoms of post-thrombotic syndrome
EXCEPT:
a) Tachycardia.
b) Pain.
c) Tenderness.
d) Skin discoloration.
e) Ulceration.
12) A lab test of thrombocytopenia is:
 a) Presence and high level of factor VII
b) Low platelet count.
c) Low level of factor VIII
d) Presence and high level of factor VIII
13) Which drug requires measuring INR used for treating
thromboembolism?
a) Heparin.
b) Alteplase.
c) Warfarin.
d) Enoxaparin.
e) Fondaparinux.
14) Routine coagulation testing is not required for which drug?
a) Bivalirudin.
b) Lepirudin.
c) Desirudin
d) Fondaparinux.
e) Argatroban.
15) What is the most predominant artery that is most commonly blocked
by a clot?
a) Arteries of the lower extremities.
b) Arteries of the upper extremities.
c) Carotid artery.
d) Coronary artery.
16) TIAs are focal ischemic neurologic deficit lasting …
a) More than 24 hours.
b) Exact 24 hours.
c) Less than 30 minutes.
d) More than 30 minutes.
17) All of the following are non-modifiable risk factors for stroke
EXCEPT one:
a) Male gender.
b) Increased age.
c) Family history.
d) Hypertension.
18) All of the following are modifiable risk factors of a stroke EXCEPT
one non-modifiable:
 a) Dyslipidemia.
b) Diabetes mellitus.
c) Cigarette smoking.
d) Low birth weight.
19) 20% of embolic strokes arise from:
a) Hung.
b) Liver.
c) Heart.
d) Kidney.
20) All of the following are types of hemorrhagic stroke EXCEPT:
a) Gastric hemorrhage.
b) Subarachnoid hemorrhage.
c) Intracerebral hemorrhage.
d) Subdural hematoma.
e) A and D.
21) Much of the early mortality of hemorrhagic stroke is due to:
a) Increased blood pressure.
b) Increased intracranial pressure.
c) Increased intestinal hemorrhage.
d) Decreased intracranial pressure.
22) A drug used in stroke within 3 hours of onset.
a) Aspirin.
b) Clopidogrel.
c) Alteplase.
d) Heparin.
23) The Joint National Committee and AHA/ASA guidelines recommend
…. For reduction of blood pressure in a patient with stroke or TIA after
the acute period.
a) ACEIs and beta-blockers.
b) ACEIs and diuretics.
c) ACEIs and CCBs.
d) CCBs and beta-blockers.
24) Calcium channel blocker …. Is recommended to reduce the incidence
and severity of neurologic deficits resulting from the delayed ischemia:
a) Nicardipine.
b) Verapamil.
 c) Amlodipine
d) Nimodipine.
e) Diltiazem.
25) Patients with hypovolemic shock may present with the following
EXCEPT:
a) Thirst.
b) Weakness.
c) Lightheadedness.
d) Dizziness.
e) Vomiting.
26) Blood pressure in hypovolemic shock is characterized by:
a) SBP < 110 mmHg
b) SBP < 90 mmHg
c) SBP < 60 mmHg
d) SBP < 20 mmHg
e) All of the above
27) Aggravation of bleeding is experienced in which one of the following
fluid replacements?
a) Albumin 5%
b) Albumin 25%
c) Dextran.
d) 0.9% normal saline.
28) Which of the following can cause ischemia, chest pain, and myocardial
infarction in patients with coronary artery disease?
a) Norepinephrine.
b) Dopamine.
c) Epinephrine.
d) Phenylephrine.
e) Dobutamine.
29) Which one of the following drugs increases the SA node automaticity?
a) Digoxin
b) Calcium blocker
c) Beta-blocker
d) Epinephrine
e) Phenytoin
30) Which of the following drugs caused torsade de pointe?
 a) Quinidine.
b) Phenytoin.
c) Epinephrine.
d) Norepinephrine.
31) Which of the following should be used for atrial fibrillation?
a) Digoxin.
b) Hydralazine.
c) Epinephrine.
d) nitrate.
32) Which one of the following is considered not dangerous arrhythmia?
a) Atrial flutter.
b) Atrial fibrillation.
c) Paroxysmal supraventricular tachycardia.
d) Ventricular fibrillation.
e) All of the above.
33) The best drug for the treatment of bradyarrhythmia is:
a) IV Hyoscine.
b) IV Digoxin.
c) IV Beta-blockers.
d) IV verapamil.
e) IV atropine.
34) Which of the following agent used to treat the patient who came to the
Hospital complained of ventricular arrhythmia?
a) Amiodarone
b) losartan
c) Hydralazine.
d) Bumetanide.
e) Captopril
35) A non-pacemaker action potential is generated in which phase of
cardiac actions potential.
a) Phase 4.
b) Phase 3
c) Phase 2
d) Phase 1
e) Phase 0
36) All of the following are class one antiarrhythmic agents EXCEPT
 a) Flecainide
b) Propafenone
c) Moricizine
d) Quinidine
e) Diltiazem
37) All of the following are class three antiarrhythmic agents EXCEPT....
a) Amiodarone
b) Bretylium
c) Propranolol.
d) Sotalol
e) Ibutilide
38) Which one of the following drugs develops antibodies and is used for
thrombocytopenia?
a) Bivalirudin.
b) Leprudin.
c) Desrudin.
d) Argatroban.
39) Which of the following is a thrombolytic?
a) clopidogrel
b) Glycoprotein IIb/IIIa
c) Aspirin
d) Alteplase
40) Which of the following is the drug of choice to treat myocardial
infarction?
a) Hydrocortisone.
b) Morphine Sulphate.
c) Prazosin.
d) Metformin.
e) Acarbose

Practical part.

Section I

Case 1
“…”
1) The initial treatment for the above case is:
a) Nitroglycerine.
b) Hydralazine.
c) Morphine.
d) Verapamil.
2) What is the most appropriate treatment for his dyslipidemia:
a) Statin
b) Niacin
c) Fibrate derivatives
d) Bile acid
3) The clot of the above case is:
a) Fibrin rich.
b) Platelet-rich.
c) Factor VII rich.
d) Factor IX rich.
4) What is the non-modifiable risk factor in this patient?
a) Hypertension.
b) Diabetes mellitus.
c) Gender.
d) Dyslipidemia.
5) The suitable reperfusion drug for the above case is:
a) Alteplase.
b) Reteplase.
c) Aspirin.
d) Streptokinase.
e) All of the above.
6) The coronary artery of the above patient is blocked…
a) Totally.
b) Partially.
7) The best long-term treatment for the above patient is:
a) Aspirin, beta-blockers, ACE inhibitors, and statin.
b) Aspirin, ACE inhibitors, and statin.
c) Warfarin, beta-blockers, ACE inhibitors, and statin.
d) Aspirin, nitrates, ACE inhibitors, and statin.
 e) Nitrate, ACE inhibitors, and statin.
8) Can this patient take low molecular weight heparin?
a) Yes.
b) No.
9) This patient is diabetic, what drug is most suitable for him?
a) Beta-blockers.
b) Calcium channel blockers.
10) The above patient has hypertension, what should you, as a clinical
pharmacist, recommend for him?
a) Take more sodium.
b) Drink plenty of water.
c) Do nothing.
d) Sodium restriction.
Section II

Case 1
“...”
Analyze the case and justify your answer

Risk factors: male gender, age > 45 years, and smoker.

Symptoms: severe chest pain, shortness of breath, and sweating.
Signs: ST elevation on the ECG and high level of troponins.
Diagnosis: STEMI

Initial treatment: the initial treatment includes NTG, aspirin and/or

clopidogrel, morphine. Let’s assume that this patient had been given NTG by
the paramedic but he must have not responded to it because he has MI. since he
has been given 300 mg aspirin, now he should be given 2-5 morphine slowly IV
to relieve his severe chest pain. An intravenous dose of 5000 units of heparin
and alteplase 15 mg IV bolus followed by 0.75 mg/kg infusion over 30 minutes,
followed by 0.5 mg/kg infusion over 60 minutes, and then 1000 units of heparin
administered by IV infusion for at least 24 hours.
Long-term treatment:
 • 75 mg of aspirin once daily.
• Ramipril 2.5 mg twice daily started within 3-10 days after the MI and
titrated to a maintenance dose of 2.5-5 mg twice daily.
• Simvastatin 20-40 mg once daily taken at night
• However, he is hypotensive (100/60), his blood pressure should be
corrected and then an initial dose of 2.5 mg bisoprolol titrated over time up
to a maximum of 20 mg.
Monitoring and counseling:
He should be aware of the side effects of his long-term medication in order to
act properly in case he got any adverse effects. He should be told to check his
cholesterol after 6-12 weeks from starting his simvastatin. And he should be
aware of the myopathy that is associated with statin agents and should be told to
report any muscle pain, tenderness or weakness. About aspirin, he should be
educated how and when to take it, once in the morning after breakfast. About his
bisoprolol, he should be told to report any intolerance and not to discontinue it
abruptly.

Section III

Case 1
A 64-year-old male patient, Mr. TS, is to be prescribed aspirin therapy
following an acute myocardial infarction.

Question
What questions should you ask Mr. TS before starting treatment with
aspirin?
Answer

Mr. TS should be asked if he has had aspirin before and, if so, whether he
tolerated it. Caution is necessary for elderly patients, in those with uncontrolled
hypertension, and in patients taking other drugs that increase the risk of
bleeding. Caution is also required in those with a previous history of peptic
ulceration, and some manufacturers advise

avoidance in such circumstances; active peptic ulceration is a definite

contraindication. Other contraindications include severe hepatic impairment,
severe renal failure, hemophilia, and other bleeding disorders. Aspirin may
induce bronchospasm or angioedema in susceptible individuals, for example, in
asthmatics, and caution should be exercised in these circumstances.
case 2
Mrs. BC, a 56-year-old woman on warfarin therapy for atrial fibrillation with
mitral stenosis, appears to become resistant to warfarin after previously good
control on 5 mg daily. Her INR does not rise above 1.4 even when her warfarin
dose is increased to 20 mg daily.
Question

What can be done to find the cause of the resistance?

Answer
Mrs. BC should be asked about any new medications which might have been
introduced recently, including over-the-counter and herbal preparations. Some
proprietary medicines may contain vitamin K, which could cause resistance by
pharmacodynamic mechanisms. Other medicines, including the herbal medicine
St John’s wort, might induce warfarin metabolism and result in resistance as a
result of a pharmacokinetic

interaction (see Table 23.4). One other cause of apparent resistance to warfarin
is poor adherence, and this should, therefore, be considered. Supervised
administration of the dose and/or measurement of plasma warfarin
concentrations may be of value if this is suspected
case 3
Mr. DS was admitted to the hospital for an emergency laparotomy for a
perforated gut. He has a history of paroxysmal AF for which he has recently
been started on amiodarone 200 mg once daily. Following the laparotomy, Mr.
DS has new-onset AF that the medical team would like to treat
pharmacologically. His only other current medication is thromboprophylaxis
with enoxaparin 20 mg once daily.

Questions
1. What treatment plan would you initially suggest for Mr. DS?
2. What longer-term monitoring would be appropriate for Mr. DS if he was
to remain taking amiodarone?

Answers
1. If Mr. DS has any electrolyte abnormalities, these should be corrected. If he
remains in AF he should be prescribed amiodarone by i.v. infusion, because
acutely amiodarone can be effective in cardioversion. The reduced dose of
enoxaparin is because Mr. DS is a post-surgical patient and at high risk of
bleeding. Mr. DS cardioverts back to sinus rhythm following a bolus dose of
300 mg amiodarone. The plan is to maintain him on amiodarone for a short
period, for example, a week (600 mg daily) to try to keep him in sinus rhythm,
to stop if he is maintained back in sinus rhythm during this period
2. If Mr. DS was to continue amiodarone therapy longer-term, then the
following monitoring would be appropriate:

Chest X-ray: pulmonary Baseline and if symptoms present.

Thyroid function test Baseline and every 3–6 months.
Liver function tests Baseline and every 3–6 months.
Eye examination Baseline and every 12 months.

ECG Baseline and as required.

Clinical evaluation Baseline and every 3 months.