IV

A P P E N D I X

Examination 2

DIRECTIONS: Each numbered item or incomplete statement
in this section is followed by answers or by completions of the
statement. Select the ONE lettered answer or completion that is
BEST in each case.
1. A patient is admitted to the emergency department with
signs and symptoms that could be due to either a muscarinic
stimulant or an opioid. Which of the following is a common
effect of both muscarinic stimulant drugs and opioids?
(A) Decreased peristalsis
(B) Decreased secretion by salivary glands
(C) Hypertension
(D) Inhibition of thermoregulatory sweat glands
(E) Miosis
2. Which statement about nitric oxide is most correct?
(A) Nitric oxide is synthesized in vascular endothelium
and the brain
(B) Nitric oxide is released from storage vesicles by
acetylcholine
(C) Nitric oxide synthase is stimulated by nitroprusside
(D) Nitric oxide synthase is inhibited by histamine
(E) Nitric oxide causes pulmonary vasoconstriction
3. A 35-year-old patient is brought to the emergency depart-
ment in a drug-induced coma. Blood samples taken over the
next several hours show a declining drug concentration, as
shown in the graph below. Which of the following drugs is
the most likely cause of this patient’s coma?
Log plasma concentration
4. In a laboratory study of a new agent, the activity of a
membrane-bound enzyme was found to be decreased by the
drug. Analysis of this enzyme molecule revealed that it is
a part of a membrane transporter. Which of the following
receptors combine enzyme activity with a transport function?
(A) Acetylcholine nicotinic receptors
(B) G protein-coupled receptors
(C) Insulin receptors
(D) Sodium pump
(E) Vitamin D receptors
5. A patient with a myocardial infarction, heart failure, and an
arrhythmia is to receive lidocaine by constant IV infusion.
The target plasma concentration is 3 mg/L. The pharmaco-
kinetic parameters for lidocaine in the general population are
Vd 70 L, CL 35 L/h, and t1/2 1.4 h. An infusion is begun. The
plasma concentration of lidocaine is measured 2.8 h later and
reported to be 2.4 mg/L. This indicates that the final steady
state plasma concentration in this patient will be
(A) 1.5 mg/L
(B) 2.4 mg/L
(C) 3.2 mg/L
(D) 4.6 mg/L
(E) 6.9 mg/L
6. A new drug for the prophylaxis of asthma is under develop-
ment in a pharmaceutical company. Before human trials can
begin, FDA regulations require that
(A) All acute and chronic animal toxicity data be submitted
to the FDA
(B) The drug be shown to be free of carcinogenic effects
(C) The drug be shown to be safe in animals with the target

disease
(D) The drug be studied in 3 mammalian species
(E) The effect of the drug on reproduction be studied in at
least 2 animal species
7. A family with 3 young children is using their old stove and
city gas to heat their apartment during a harsh winter. They
taped all the windows to let no heat escape. The next day, the
Time family is found unconscious. Which of the following might
have caused this?
(A) Carbon monoxide
(B) Hydrocarbons
(A) Aspirin (C) Ozone
(B) Diazepam (D) Nitrogen dioxide
(C) Ethanol (E) Sulfur dioxide
(D) Phenytoin

551

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 552    APPENDIX IV
8. A patient admitted to the emergency department is vomiting
blood. Her supine blood pressure is 100/60 mm Hg; sitting
up, her BP is 50/0. Which of the following most accurately
describes the probable autonomic response to the bleeding?
(A) Slow heart rate, dilated pupils, damp skin
(B) Rapid heart rate, dilated pupils, damp skin
(C) Slow heart rate, dry skin, increased bowel sounds
(D) Rapid heart rate, dry skin, constricted pupils, increased
bowel sounds
(E) Rapid heart rate, constricted pupils, warm skin
9. A 65-year-old man has chronic open-angle glaucoma. The
drug that is most likely to have therapeutic value for this
condition is
(A) Ephedrine
(B) Isoproterenol
(C) Latanoprost
(D) Mannitol
(E) Propranolol
10. A new drug was administered to a group of normal volunteers
in a phase 1 clinical trial. Intravenous bolus doses produced
the changes in blood pressure and heart rate shown in the
graph below.
Drug administered
Systolic blood pressure
Heart rate
Diastolic blood pressure
0 1 2 (B) Edrophonium
Time (min)
The most probable receptor affinities of this new drug are
(A) α1, α2, and β1
(B) α1 and α2 only
(C) β1 and β2 only
(D) Muscarinic M3 only
(E) Nicotinic NN only
11. Persons who regularly ingest three or more alcoholic drinks
daily can develop severe hepatotoxicity after doses of acet-
aminophen that are not toxic to individuals with normal
liver function. This increased sensitivity to acetaminophen’s
toxicity is due to which of the following mechanisms?
(A) Decreased availability of acetaldehyde dehydrogenase
(B) Decreased hepatocellular stores of NADPH
(C) Increased extraction of acetaminophen by the cirrhotic
liver
(D) Increased activity of cytochrome P450 mixed function
oxidase isozymes
(E) Increased liver blood flow
Trevor_App-IV_p551-566.indd 552
12. An example of a phase I drug-metabolizing reaction is
(A) Acetylation
(B) Glucuronidation
(C) Hydroxylation
(D) Methylation
(E) Sulfation
Questions 13 and 14. A 52-year-old plumber comes to the office
with a complaint of periodic onset of chest pain, described as a
sensation of heavy pressure over the sternum that comes on when
he exercises and disappears within 15 min when he stops. After
a full physical examination and further evaluation, you make the
diagnosis of angina of effort.
13. In considering medical therapy for this patient, which of the
following best describes the beneficial action of propranolol
in this condition?
(A) Dilation of coronary arterioles reduces resistance and
increases coronary flow through ischemic tissue
(B) Dilation of peripheral veins increases cardiac work
(C) Block of β receptors results in decreased end systolic
cardiac size
(D) Block of β receptors results in decreased cardiac work
(E) Decreased venous return reduces end diastolic cardiac size
14. A drug that is useful in angina but causes constipation, edema,
and increased cardiac size is
(A) Atenolol
(B) Hydralazine
(C) Isosorbide dinitrate
(D) Nitroglycerin
(E) Verapamil
15. A 15-year-old girl is admitted complaining of palpitations
and shortness of breath. An ECG reveals sinus tachycardia
with a heart rate of 160 bpm. A drug suitable for producing
a brief (5- to 15-min) increase in vagal effects on the heart is
(A) Adenosine
(C) Ergotamine
(D) Pralidoxime
(E) Pyridostigmine
16. A patient with a 30-yr history of type 1 diabetes comes to you
with a complaint of bloating and sour belching after meals.
On several occasions, vomiting has occurred after a meal.
Evaluation reveals delayed emptying of the stomach, and you
diagnose diabetic gastroparesis. Which drug would be most
useful in this patient?
(A) Famotidine
(B) Metoclopramide
(C) Misoprostol
(D) Omeprazole
(E) Ondansetron
17. An important difference between nonselective α-receptor
antagonists and α1-selective antagonists is that α1-selective
antagonists
(A) Are more likely to cause hypoglycemia
(B) Are less likely to precipitate bronchoconstriction in
patients with asthma
(C) Have greater efficacy in relaxing smooth muscle in the
urinary tract
(D) Produce less reflex tachycardia
(E) Reduce mean arterial blood pressure to a greater extent
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 Examination 2    553

18. A 70-year-old woman with mild to moderate hypertension 22. Metoprolol and minoxidil have which of the following effects
fell 2 years ago during a spell of dizziness and broke her hip. in common?
During the last 18 mo, her blood pressure has increased. Now (A) Decreased cardiac force
she is to be treated for a blood pressure of 160/95 mm Hg. (B) Decreased cardiac output
When treating hypertension chronically, orthostatic hypoten- (C) Decreased mean arterial blood pressure
sion is greatest with (D) Increased systemic vascular resistance
(A) ACE inhibitors (E) Tachycardia
(B) Arteriolar dilators
(C) Centrally acting α2 agonists 23. A 54-year-old farmer is brought to the emergency depart-
(D) Peripherally acting α1 antagonists ment in a coma. Blood assay reveals severe hypercalcemia.
(E) Beta blockers Which of the following is the most appropriate immediate
therapy for this man?
19. A 52-year-old woman is admitted to the emergency depart- (A) Aldosterone antagonist plus saline infusion
ment with a history of drug treatment for several conditions. (B) Loop diuretic plus saline infusion
Her serum electrolytes are found to be as follows (normal (C) NSAID plus saline infusion
values in parentheses): (D) Strong opioid plus saline infusion
(E) Thiazide diuretic plus saline infusion
Na+ 140 mEq/L (135–145) K+ 6.5 mEq/L (3.5–5.0)
24. A 55-year-old executive has hypertension and cardiac hyper-
Cl− 100 mEq/L (98–107) pH 7.3 (7.31–7.41) trophy. He is being treated with diuretics. The mechanism of
This patient has probably been taking action of chlorthalidone is best described as
(A) Acetazolamide (A) Interference with H+/HCO3− exchange
(B) Atenolol (B) Blockade of a Na+/Cl− cotransporter
(C) Digoxin (C) Blockade of a Na+/K+/2Cl− transporter
(D) Furosemide (D) Blockade of carbonic anhydrase
(E) Spironolactone (E) Alteration of expression of his DNA

20. A 40-year-old woman was being treated for chronic moder-
ate hypertension. When she went on vacation and forgot her
pills, her blood pressure rose markedly and she was admitted
to the emergency service with blurred vision, severe head-
ache, and retinal hemorrhages. Her blood pressure was found
to be 200/120 mm Hg. A drug that is most likely to be fol-
lowed by severe rebound hypertension if stopped suddenly is
(A) Atenolol
(B) Clonidine
(C) Labetalol
(D) Losartan
(E) Prazosin
21. Ventricular muscle from a cardiac biopsy was prepared for
transmembrane potential recording in an isolated muscle
chamber. Action potentials were recorded before and after
application of drug X.
0 mV Time
Drug X
25. A 56-year-old woman has arthritis of the knees that limits
her activity and post-herpetic neuralgia on her torso after an
episode of herpes zoster. Which of the following drugs is used
topically to control arthritic pain and post-herpetic neuralgia?
(A) Aliskiren
(B) Bosentan
(C) Capsaicin
(D) Losartan
(E) Nesiritide
26. In your pursuit of a Nobel Prize, you have been studying sev-
eral intracellular enzymes. You recall that cyclooxygenase-1
and -2 are responsible for the
(A) Conversion of GTP to cyclic GMP (cGMP)
(B) Conversion of ATP to cyclic AMP (cAMP)
(C) Metabolic degradation of cAMP
(D) Synthesis of leukotrienes from arachidonate
(E) Synthesis of prostaglandins from arachidonate
Questions 27 and 28. A 16-year-old student has had asthma
for 8 years. The number of episodes of severe bronchospasm has
increased recently, and you have been asked to review the thera-
peutic plan.

Control 27. Which of the following agents is most likely to be of imme-

diate therapeutic value in relieving an acute bronchospastic
attack?
–100 mV (A) Albuterol
(B) Atenolol
(C) Formoterol
Identify drug X from the following list. (D) Metoprolol
(A) Adenosine (E) Theophylline
(B) Amiodarone
(C) Ibutilide
(D) Quinidine
(E) Verapamil

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 554    APPENDIX IV

28. A long-acting β2-selective agonist that is used as an inhaled 35. Which antimalarial drug can cause a dose-dependent toxic
prophylactic therapy for moderate or severe asthma is state that includes blurred vision, dizziness, flushed and
(A) Ipratropium sweaty skin, nausea, diarrhea, and tinnitus?
(B) Montelukast (A) Artesunate
(C) Salmeterol (B) Atovaquone-proguanil
(D) Theophylline (C) Mefloquine
(E) Zafirlukast (D) Quinidine
(E) Primaquine
29. Lidocaine is commonly used as a local anesthetic. If a patient
mistakenly receives a toxic dose of lidocaine intravenously, 36. JP is a 47-year-old woman with type 2 diabetes. She is tak-
the patient is likely to exhibit ing metformin, glipizide, and pioglitazone. In spite of her
(A) Cardiovascular stimulation medications, the HbA1c is 8%. You propose to add a new
(B) Excessive salivation, mydriasis, and diarrhea medication that acts in the kidney to lower her HbA1c to less
(C) Hyperthermia and hypertension than 6.5%. Which of the following oral antidiabetic drugs
(D) No effects immediately but then delayed, massive should you add?
hepatocellular damage (A) Acarbose
(E) Seizures and coma (B) Canagliflozin
(C) Exenatide
30. Early in an anesthesia procedure, which includes the use of (D) Repaglinide
succinylcholine and halothane, a surgical patient develops (E) Sitagliptin
severe muscle rigidity, hypertension, and hyperthermia.
Management of this patient will almost certainly include the 37. A young patient with end-stage kidney disease receives a
administration of transplant from a living related donor who is HLA-identical
(A) Baclofen and red blood cell ABO matched. To prevent rejection, the
(B) Dantrolene transplant recipient is treated with cyclosporine. Two years
(C) Fentanyl after initiating cyclosporine therapy, the patient developed
(D) Naloxone evidence of cyclosporine-induced nephrotoxicity and hyper-
(E) Tubocurarine tension. He was switched to an immunosuppressant that
lacks renal toxicity and produces its immunosuppressant
31. A 34-year-old woman in her second trimester of pregnancy effect by inhibiting the de novo pathway of guanosine phos-
presented with a tender, red, swollen calf that was diagnosed phate synthesis. The new immunosuppressant is which of the
as a deep vein thrombosis (DVT) and was treated success- following drugs?
fully. However, because of the high risk of recurrence of the (A) Azathioprine
DVT, she was treated with an anticoagulant for the remain- (B) Etanercept
der of her pregnancy. The drug used most likely was which (C) Mycophenolate mofetil
of the following? (D) Sulfasalazine
(A) Aspirin (E) Prednisone
(B) Clopidogrel
(C) Enoxaparin 38. The mechanism of high-level isoniazid (INH) resistance of
(D) Bivalirudin M tuberculosis is
(E) Warfarin (A) Changed pathway of mycolic acid synthesis
(B) Decreased intracellular accumulation of isoniazid
32. Which of the following is an inhibitor of fungal cell membrane (C) Formation of drug-inactivating N-methyltransferase
synthesis and is effective intravenously in the management of (D) Mutation in the inhA gene
disseminated infections due to Aspergillus or Candida species? (E) Reduced expression of the katG gene
(A) Amphotericin B
(B) Caspofungin 39. A 2-year-old girl was brought to the emergency department
(C) Flucytosine because of vomiting, bloody diarrhea, and hypotension. An
(D) Nystatin abdominal x-ray film showed multiple radiopaque pills, and a
(E) Voriconazole relative at the child’s home reported the discovery of an open
bottle of iron pills behind a large piece of furniture. In addi-
33. Which of the following statements about acyclovir is accurate? tion to supportive care, treatment of the child is most likely
(A) A pro-drug converted to valacyclovir by hepatic enzymes to include which of the following actions?
(B) Active versus cytomegalovirus (A) Intravenous administration of acetylcysteine
(C) Bioactivated by viral thymidine kinase (B) Intravenous administration of deferoxamine
(D) Highly active against papilloma virus (HPV) (C) Intravenous administration of pralidoxime
(E) Toxic to bone marrow (D) Oral administration of activated charcoal
34. A 5-year-old boy was diagnosed as having an intestinal infec- (E) Oral administration of edetate (EDTA)
tion with Enterobius vermicularis (pinworm). He should be
treated with
(A) Ivermectin
(B) Mebendazole
(C) Mefloquine
(D) Praziquantel
(E) Quinine

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 Examination 2    555

40. A 55-year-old patient with a 30 pack-year history of smoking 44. An individual who ingested an antifreeze solution containing
and chronic obstructive pulmonary disease (COPD) reports ethylene glycol was brought to a hospital emergency
frequent episodes of bronchospasm. She has been using an department. In an attempt to prevent severe acidosis and
over-the-counter bronchodilator inhaler but complains of renal damage, the patient was given fomepizole. Fomepizole
palpitations and chest pain when she uses the inhaler. Which is useful in ethylene glycol poisoning because it inhibits
of the following would relieve her bronchospasm without which of the following?
causing cardiac stimulation? (A) Alcohol dehydrogenase
(A) Albuterol (B) Aldehyde dehydrogenase
(B) Metaproterenol (C) Enzymes in the microsomal ethanol-oxidizing
(C) Metoprolol system (MEOS)
(D) Tiotropium (D) Enzymes that require thiamin as a cofactor
(E) Verapamil (E) Glutathione transferase
41. A 57-year-old contractor with hypertension has been treated 45. A young patient has a seizure disorder with recurrent con-
by 2 different physicians. He now comes to the emergency tractions starting in muscles of the right hand that spread
department with a severe reaction. Questioning reveals that through the arm and the right side of the face. The attacks
he has been taking captopril and spironolactone. This com- last for only a minute or two with no loss of consciousness.
bination is usually ill-advised because of the risk of Which of the following drugs is least likely to be useful in the
(A) Bone loss and osteoporosis treatment of this patient?
(B) Calcium-containing kidney stones (A) Carbamazepine
(C) Hyperkalemia (B) Ethosuximide
(D) Metabolic acidosis (C) Lamotrigine
(E) Postural hypotension (D) Phenobarbital
(E) Phenytoin
42. The research division of a pharmaceutical corporation has
characterized the receptor-blocking actions of 5 new drugs, 46. A young woman suffering from myoclonic seizures was
each of which may have potential therapeutic value. The receiving effective single-drug therapy. Because she was plan-
relative intensities of their blocking actions are shown in the ning a pregnancy, her physician switched her to an alternative
following table. Because each of these drugs is lipophilic and medication with much less potential for teratogenicity. The
can cross the blood-brain barrier, they are expected to have original antiseizure drug prescribed for this patient was most
CNS effects. likely to have been
(A) Baclofen
Based on the data shown in the table below, which drug (B) Diazepam
is most likely to exacerbate the symptoms of Parkinson’s (C) Ethosuximide
disease? (D) Olanzapine
(E) Valproic acid
Blocking Action on CNS Receptors
47. The mechanism of local anesthetic action of cocaine is
Adrenergic Cholinergic Dopaminergic GABAergic (A) Activation of G protein-linked membrane receptors
Drug (Beta) (M) (D2) (GABAA) (B) Block of the reuptake of norepinephrine at sympathetic
nerve endings
A ++ +++ +++ None
(C) Competitive pharmacologic antagonism of nicotinic
B None None None ++++ receptors
(D) Inhibition of blood and tissue enzymes that hydrolyze
C None ++++ + None acetylcholine
(E) Use-dependent blockade of voltage-gated sodium
D + None +++ + channels
E None + + + 48. A patient is brought to the emergency department suffer-
ing from an overdose of an illicit drug. She is agitated, has
Key: Number of + signs denotes intensity of blocking actions. disordered thought processes, suffers from paranoia, and
(A) Drug A “hears voices.” Her physical symptoms include tachycardia,
(B) Drug B hyperreflexia, and hyperthermia. The drug most likely to be
(C) Drug C responsible for her condition is
(D) Drug D (A) Gamma-hydroxybutyrate (GHB)
(E) Drug E (B) Hashish
(C) Heroin
43. Which statement is most accurate? (D) Marijuana
(A) Alprazolam is effective in obsessive-compulsive disorders (E) Methamphetamine
(B) Clonazepam is a useful antiseizure drug
(C) Diazepam is a drug of choice for bipolar affective disorder
(D) Ramelteon is used in status epilepticus
(E) Symptoms of alcohol withdrawal may be alleviated by
buspirone

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 556    APPENDIX IV
49. Regarding drugs that relax skeletal muscle, which one of the
following statements is accurate?
(A) Baclofen blocks the release of calcium from skeletal
muscle fibers.
(B) Dantrolene is an activator of specific GABA receptors in
the spinal cord.
(C) Halothane decreases the action of skeletal muscle
relaxants.
(D) Muscle relaxation caused by succinylcholine is not
reversed by acetylcholinesterase inhibitors.
(E) Tubocurarine prevents histamine release via a stabilizing
action on mast cells.
50. Although fentanyl or one of its congeners is usually adminis-
tered in the early stages of a general anesthesia procedure, it
is likely that the patient will receive an injection of morphine
during the last phase. The rationale for switching to mor-
phine is that the drug has
(A) A longer duration of action
(B) Greater analgesic efficacy
(C) More of a “ceiling effect” and less tendency to cause
respiratory failure
(D) Mu (μ) opioid receptor agonist activity, whereas fen-
tanyl is a selective kappa (κ) receptor agonist
(E) The advantage of being more completely reversed by
naloxone
51. Intellectual disability, microcephaly, and underdevelopment of
the midface region in an infant is associated with chronic heavy
maternal use during pregnancy of which of the following?
(A) Cocaine
(B) Diazepam
(C) Ethanol
(D) Heroin
(E) Methylenedioxymethamphetamine (MDMA)
52. After ingestion of a meal that included sardines, cheese, and
red wine, a patient taking phenelzine experienced an increase
in blood pressure to 187/133 mm Hg. He was taken to the
emergency department. The most likely explanation for this
untoward effect is that phenelzine
(A) Acts to release tyramine from these foods
(B) Inhibits storage of catecholamines in vesicles
(C) Inhibits the metabolism of catecholamines
(D) Is an activator of tyrosine hydroxylase
(E) Promotes the release of norepinephrine from sympa-
thetic nerve endings
53. Which one of the following is characteristic of succinylcholine?
(A) Actions in phase I block are reversed by neostigmine
(B) Is an antagonist at muscarinic receptors
(C) Blocks the release of histamine
(D) May cause hyperkalemia
(E) Is primarily metabolized by acetylcholinesterase
Trevor_App-IV_p551-566.indd 556
54. A 48-year-old surgical patient was anesthetized with an intra-
venous bolus dose of propofol, then maintained on isoflurane
with vecuronium as the skeletal muscle relaxant. At the end
of the surgical procedure, she was given pyridostigmine and
glycopyrrolate. The rationale for use of glycopyrrolate was to
(A) Antagonize the skeletal muscle relaxation caused by
vecuronium
(B) Counter emetic effects of the inhaled anesthetic
(C) Counter the potential cardiac effects of the acetylcholin-
esterase inhibitor
(D) Prevent muscle fasciculations
(E) Provide postoperative analgesia
55. A woman taking haloperidol developed a spectrum of adverse
effects that included the amenorrhea-galactorrhea syndrome
and extrapyramidal dysfunction. Another, newer, antipsy-
chotic drug was prescribed which however caused weight gain
and hyperglycemia due to a diabetogenic action. The drug
prescribed was
(A) Bupropion
(B) Chlorpromazine
(C) Fluoxetine
(D) Lithium
(E) Olanzapine
56. Naloxone will not antagonize or reverse
(A) Analgesic effects of morphine in a cancer patient
(B) Drug actions resulting from activation of μ-opioid
receptors
(C) Opioid-analgesic overdose in a patient on methadone
maintenance
(D) Pupillary constriction caused by levorphanol
(E) Respiratory depression caused by overdose of nefazodone
57. Several drugs used in patients with advanced Parkinson’s dis-
ease allow patients to lower their dose of l-dopa/carbidopa,
and thus reduce the incidence of l-dopa-induced dyskinesias.
These drugs also decrease the amount of “off ” time for the
patient. Which drug is used in this way but does not, if used
alone, ameliorate the symptoms of early Parkinson’s disease or
enhance CNS dopaminergic activity?
(A) Amantadine
(B) Bromocriptine
(C) Entacapone
(D) Pramipexole
(E) Selegiline
58. Ramelteon, a drug prescribed for insomnia, is thought to act
in the CNS via
(A) Activation of benzodiazepine receptors
(B) Activation of melatonin receptors
(C) Block of the GABA transporter
(D) Inhibition of GABA metabolism
(E) Stimulation of glutamate receptors
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Questions 59 and 60. A young man comes to a community clinic
with a urogenital infection that, based on the Gram stain, appears
to be due to Neisseria gonorrhoeae. Questioning suggests that the
patient acquired the infection while vacationing abroad. The
physician is concerned about drug resistance of the gonococcus.
59. Which drug is least likely to be effective in the treatment of
gonorrhea in this patient?
(A) Amoxicillin
(B) Azithromycin
(C) Cefixime
(D) Ceftriaxone
(E) Ciprofloxacin
60. The physician is also concerned about the possibility of a
nongonococcal urethritis in this patient. Several antibiotics in
the list below are active in nongonococcal urethritis. However,
these infections, including those caused by C trachomatis, can
usually be eradicated by the administration of a single dose of
(A) Azithromycin
(B) Doxycycline
(C) Erythromycin
(D) Levofloxacin
(E) Trimethoprim-sulfamethoxazole
61. The antibacterial action of aminoglycosides is due to their ability to
(A) Activate autolytic enzymes
(B) Bind to the 30S ribosomal subunit and block initiation
of bacterial protein synthesis
(C) Inhibit bacterial topoisomerases II and IV
(D) Inhibit the synthesis of precursors of the linear peptido-
glycan chains of the bacterial cell wall
(E) Interfere with the synthesis of tetrahydrofolate
62. A 26-year-old woman with chronic bronchitis lives in a
region of the country where winter conditions are harsh. Her
physician recommends prophylactic use of oral doxycycline,
to be taken once daily, during the winter season. Which state-
ment about the characteristics and use of doxycycline in this
patient is accurate?
(A) Absorption from the gastrointestinal tract is enhanced
by yogurt.
(B) Elimination of doxycycline is predominantly via cyto-
chrome P450-mediated hepatic metabolism.
(C) Formation of drug-metabolizing enzymes is a primary
mechanism of resistance to tetracyclines.
(D) The patient should discontinue the tetracycline if she
becomes pregnant.
(E) The tetracyclines have no value in prophylaxis against
infections in patients with chronic bronchitis.
63. AT, a 23-year-old woman with severe asthma, has been taking
oral prednisone to reduce her asthma attacks. She is encour-
aged when you tell her about budesonide, an inhaled steroid.
The topical administration and short half-life of budesonide
greatly reduce the risk of systemic side effects compared with
oral prednisone. The long-term daily oral administration of
therapeutic doses of prednisone results in which of the fol-
lowing adverse effects?
(A) Anemia
(B) Decreased bone density
(C) Elevated serum calcium concentration
(D) Hyperplasia of cells in the zona fasciculata and zona
reticularis of the adrenal cortex
(E) Increased male-pattern hair growth in women
Trevor_App-IV_p551-566.indd 557
Examination 2    557
64. A 67-year-old man with osteoporosis is being treated with
once-weekly alendronate. This medication has the potential
to cause which of the following unusual adverse effects?
(A) A bluish hue to skin color
(B) Esophageal irritation
(C) Impairment of blue-green color vision
(D) Priapism
(E) Tendinitis
65. Which of the following drugs is approved for primary pro-
phylaxis in AIDS patients with low CD4 counts against
infections due to Mycobacterium avium-intracellulare?
(A) Amoxicillin
(B) Ceftriaxone
(C) Clarithromycin
(D) Doxycycline
(E) Nafcillin
66. A 30-year-old male patient who is HIV positive has a CD4 T
lymphocyte count of 450 cells/μL (normal, 600–1500 cells/μL)
and a viral RNA load of 11,000 copies/mL. His treatment
involves a 3-drug antiviral regimen (HAART) consisting of
zidovudine, didanosine, and efavirenz. Efavirenz limits HIV
infection by
(A) Binding to the active site of HIV reverse transcriptase
(B) Blocking the binding of HIV virions to the CD4 recep-
tor on T cells
(C) Inhibiting the HIV enzyme that cleaves sialic acid resi-
dues from the surface of HIV virions
(D) Inhibiting the HIV protease
(E) Serving as an allosteric inhibitor of HIV reverse
transcriptase
Questions 67 and 68. A 73-year-old patient has chronic pul-
monary dysfunction requiring daily hospital visits for respiratory
therapy. She has now been admitted to the hospital with pneu-
monia, and it is not clear whether the infection is community or
hospital acquired.
67. If she has a community-acquired pneumonia, coverage must
be provided for pneumococci and atypical pathogens. In such
a case, the most appropriate drug treatment in this patient is
(A) Ampicillin plus gentamycin
(B) Ceftriaxone plus erythromycin
(C) Penicillin G plus gentamicin
(D) Ticarcillin-clavulanic acid
(E) Trimethoprim-sulfamethoxazole
68. If she has a hospital-acquired pneumonia, coverage must be
provided for Gram-negative bacteria (especially Pseudomonas
aeruginosa) and for Staphylococcus aureus, many of which can
be multiple drug-resistant organisms. In such a case, empiric
treatment is likely to involve
(A) Amoxicillin-clavulanic acid
(B) Cefazolin plus metronidazole
(C) Doxycycline
(D) Imipenem
(E) Vancomycin plus piperacillin/tazobactam
7/13/18 6:00 PM
 558    APPENDIX IV

69. Resistance to acyclovir is most commonly due to mutations
in a viral gene that encodes a protein that
(A) Converts viral single-stranded RNA into double-
stranded DNA
(B) Phosphorylates acyclovir
(C) Synthesizes glutathione
(D) Transports acyclovir into the cell
(E) Transports acyclovir out of the cell
70. A male patient with AIDS has a CD4 T lymphocyte count of
50 cells/μL (normal, 600–1500 cells/μL). He is being main-
tained on a multidrug regimen consisting of acyclovir, clar-
ithromycin, dronabinol, fluconazole, lamivudine, indinavir,
trimethoprim, sulfamethoxazole, and zidovudine. The drug
that provides prophylaxis against cryptococcal infections of
the meninges is
(A) Acyclovir
(B) Clarithromycin
(C) Fluconazole
(D) Lamivudine
(E) Trimethoprim-sulfamethoxazole
Questions 71 and 72. A patient with diffuse non-Hodgkin’s
lymphoma is treated with a combination drug regimen that
includes bleomycin, cyclophosphamide, vincristine, doxorubicin,
and prednisone.
71. The patient’s cumulative dose of bleomycin will be carefully
monitored because high cumulative doses are associated with
which of the following?
(A) Cardiotoxicity
(B) Hemorrhagic cystitis
(C) Hypoglycemia
(D) Peripheral neuropathy
(E) Pulmonary fibrosis
72. Dexrazoxane is thought to protect against the distinctive
toxicity of which drug in this patient’s regimen?
(A) Bleomycin
(B) Cyclophosphamide
(C) Doxorubicin
(D) Prednisone
(E) Vincristine
73. After delivery of a healthy infant, a young woman begins to
bleed heavily because her uterus has failed to contract. Which
drug should be administered to this woman to reduce the
bleeding?
(A) Prednisone
(B) Desmopressin
(C) Leuprolide
(D) Oxytocin
(E) Prolactin
74. A 52-year-old woman needs hormone replacement therapy.
In addition to estrogen you add a progestin to the regimen.
Progestin in hormone replacement therapy provides which of
the following effects?
(A) Prevents thromboembolic events
(B) Provides better control of problematic hot flushes
(C) Reduces the risk of endometrial cancer
(D) Restores regular vaginal bleeding
(E) Slows bone loss
75. You are on the hospital pharmacy committee and revising the
formulary. Relative to loratadine, diphenhydramine is more
likely to
(A) Be used for treatment of asthma
(B) Be used for treatment of gastroesophageal reflux disease
(C) Cause cardiac arrhythmias in overdose
(D) Have efficacy in the prevention of motion sickness
(E) Increase the serum concentration of warfarin
76. Chronic heart failure is commonly treated with a combina-
tion of drugs that improve symptoms and may provide long-
term survival benefits. Three drugs or drug groups that have
been shown in clinical trials to provide survival benefits in
patients with chronic heart failure are
(A) ACE inhibitors, carvedilol, and spironolactone
(B) Alpha1-selective antagonists, digoxin, and hydro­chloro­-
thiazide
(C) Digoxin, β-agonists, and nitroglycerin
(D) Dobutamine, propranolol, and furosemide
(E) Verapamil, isosorbide dinitrate, and furosemide
77. A 34-year-old woman presented with nervousness, increased
perspiration, tachycardia, hand tremors, insomnia, and thin-
ning of the skin. Hyperthyroidism was confirmed. Which of
the following is a drug that inhibits the synthesis of thyroid
hormone by preventing coupling of iodotyrosine molecules?
(A) Dexamethasone
(B) Levothyroxine
(C) Lithium
(D) Methimazole
(E) Propranolol
78. Long-term use of meperidine for analgesia is avoided because
the accumulation of a metabolite, normeperidine, is associ-
ated with risk of
(A) Constipation
(B) Dependence
(C) Neutropenia
(D) Renal impairment
(E) Seizures
79. A 60-year-old man with a history of a mild myocardial
infarction has the following lipid panel. Serum HDL choles-
terol; 33 mg/dL; serum triglyceride (TG) level: 160 mg/dL.
Total serum cholesterol: 150 mg/dL. (Optimal values for
a man > 20 years; HDL > 40 mg/dL; TG < 100 mg/dL; LDL
< 100 mg/dL; total cholesterol < 200 mg/dL.) Which of the
following drugs is likely to result in the correction of this
patient’s dyslipidemia?
(A) Cholestyramine
(B) Ezetimibe
(C) Gemfibrozil
(D) Lovastatin
(E) Pioglitazone
80. JT underwent successful cardiac surgery. At the end of the
procedure protamine was administered. Protamine can be
used to partially reverse the anticoagulant effect of which of
the following?
(A) Abciximab
(B) Clopidogrel
(C) Dabigatran
(D) Unfractionated heparin
(E) Warfarin

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 Examination 2    559

81. In a patient with familial combined hyperlipidemia that is 87. A 29-year-old accountant has recurrent episodes of tachycar-
associated with increased VLDL and LDL, which of the fol- dia with ECG characteristics of torsades de pointes. Which of
lowing drugs is most likely to increase plasma triglycerides the following drugs is most likely to reduce these episodes?
while also decreasing plasma LDL? (A) Adenosine
(A) Cholestyramine (B) Amiodarone
(B) Ezetimibe (C) Dofetilide
(C) Gemfibrozil (D) Procainamide
(D) Niacin (E) Sotalol
(E) Lovastatin
88. Which one of the following pairs of drug and indication is
82. A 31-year-old premenopausal woman has been using a accurate?
combined oral contraceptive for 10 years. As a result of this (A) Amphetamine: Alzheimer’s dementia
contraceptive use, she has a reduced risk of which of the (B) Bupropion: acute anxiety
following? (C) Fluoxetine: insomnia
(A) Deep vein thrombosis (D) Pramipexole: Parkinson’s disease
(B) Episodes of migraine headache (E) Ramelteon: attention deficit disorder
(C) Ischemic stroke
(D) Ovarian cancer 89. You are rotating in the emergency department. Your attend-
(E) Pituitary adenoma ing asks you which of the following toxic compounds is cor-
rectly paired with an antidote that is used in the treatment of
83. A 54-year-old woman was treated with anticoagulants for a poisoned patient?
deep vein thrombosis. Four days after starting the medica- (A) Acetaminophen: antidote is vitamin K
tion, she noticed pain and redness with black skin under her (B) Beta-blocker: antidote is dobutamine
breasts. The physician diagnosed dermal vascular necrosis (C) Ethanol: antidote is methanol
resulting from protein C deficiency. Her condition was (D) Cyanide: antidote is hydroxocobalamin
caused by which one of the following drugs? (E) Tricyclic antidepressants: antidote is neostigmine
(A) Aspirin
(B) Dabigatran 90. While taking a shower, AJ found a small lump in her breast.
(C) Clopidogrel She was diagnosed with breast cancer and was started on
(D) Heparin neoadjuvant chemotherapy. Concomitantly she was given
(E) Warfarin mercaptoethanesulfonate (MESNA) to decrease the risk of
hematuria. Which of the following drugs was in her chemo-
84. A 45-year-old woman suffers from abdominal pain and therapy regimen?
bloody diarrhea that has been diagnosed as Crohn’s disease. (A) Cyclophosphamide
Which of the following is a first-line drug for treatment of (B) Azathioprine
Crohn’s disease that acts locally in the gastrointestinal tract to (C) Fluorouracil
provide an anti-inflammatory effect? (D) Methotrexate
(A) Aluminum hydroxide (E) Vinblastine
(B) Metoclopramide
(C) Misoprostol 91. A 64-year-old recipient of a kidney transplant was being
(D) Mesalamine treated with immunosuppressants. After several episodes of
(E) Ranitidine gout, the decision was made to treat his gout with the xan-
thine oxidase inhibitor allopurinol. The dose of which of the
85. A 24-year-old man with a history of partial seizures has been following of his immunosuppressant drugs should be reduced
treated with standard anticonvulsants for several years. He to avoid excessive bone marrow suppression due to a drug-
is currently taking valproic acid, which is not fully effective, drug interaction?
and his neurologist prescribes another drug approved for (A) Azathioprine
adjunctive use in partial seizures. Unfortunately, the patient (B) Cyclosporine
develops a toxic epidermal necrolysis. The second drug pre- (C) Hydroxychloroquine
scribed was (D) Methotrexate
(A) Diazepam (E) Tacrolimus
(B) Ethosuximide
(C) Felbamate
(D) Lamotrigine
(E) Phenobarbital
86. Drugs classified as selective serotonin reuptake inhibitors
have minimal clinical efficacy in the treatment of patients
who suffer from
(A) Bulimia
(B) Diminished sexual function and interest
(C) Obsessive-compulsive disorder (OCD)
(D) Panic attacks
(E) Premenstrual dysphoric disorder (PMDD)

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 560    APPENDIX IV

92. A 57-year-old man presented with signs and symptoms of   97. Which of the following drugs is most likely to cause hypo-
acute gout that included intense pain of 1 day duration in glycemia when used as monotherapy in the treatment of a
the first metatarsophalangeal joint of his right big toe; the patient with type 2 diabetes?
joint was swollen, tender, and red. Examination of synovial (A) Acarbose
fluid removed from the joint revealed negatively birefringent (B) Canagliflozin
needle-shaped crystals of uric acid. The patient had a serum (C) Glipizide
uric acid concentration of 10 mg/dL (normal 3.0–7.4 mg/dL). (D) Metformin
This was the patient’s first episode of gout. He did not have (E) Miglitol
any other medical illnesses and was not taking any medications. (F) Rosiglitazone
Which of the following is the most appropriate drug for
immediate treatment of this acute attack of gout?   98. JW is a 78-year-old man diagnosed with deep vein
(A) Febuxostat thrombosis. The patient has a history of heparin-induced
(B) Indomethacin thrombocytopenia. Which of the following is the most
(C) Methotrexate appropriate drug for parenteral administration in this
(D) Morphine patient?
(E) Probenecid (A) Argatroban
(B) Eptifibatide
93. A 23-year-old pregnant woman is referred by her obstetrician (C) Clopidogrel
for evaluation of anemia. Lab tests reveal macrocytic anemia, (D) Unfractionated heparin
an increased serum concentration of transferrin, and a nor- (E) Warfarin
mal serum concentration of vitamin B12. What deficiency is
Questions 99 and 100. A drug (Drug 1) was given as an IV bolus
the most likely cause of her anemia and what effect does this
deficiency have on her child? to a subject while blood pressure and heart rate were recorded as
(A) Cobalamin; cardiac abnormality shown on the left side of the graph below. After recovery from the
(B) Erythropoietin; congenital neutropenia effects of Drug 1, a long-acting dose of Drug 2 was given. After
(C) Folic acid; neural tube defect the recorder was turned back on, Drug 1 was repeated with the
(D) Intrinsic factor; kidney damage results shown on the right side of the graph.
(E) Iron; limb deformity
94. A 42-year-old woman developed a syndrome of polyuria,
Blood pressure (mm Hg),

thirst, and hypernatremia after surgical removal of part of Drug 1 Drug 2 Drug 1
heart rate (per min)

her pituitary gland. These signs and symptoms will be treated

120
with which of the following?
(A) Bromocriptine Heart
(B) Desmopressin 80 rate
(C) Octreotide
(D) Prednisone
(E) Somatropin
95. AP is a 46-year-old woman who experienced progressive
weight loss, tachycardia (110 bpm), nervousness, anxiety, and   99. Identify Drug 1 from the following list.
a slight tremor. She has been on propranolol for the last three (A) Albuterol
months and her symptoms are not under control. Which of (B) Angiotensin II
the following should be next step in the treatment of this (C) Bradykinin
patient? (D) Epinephrine
(A) Leuprolide (E) Hexamethonium
(B) Levothyroxine (T4) (F) Isoproterenol
(C) Liothyronine (T3) (G) Norepinephrine
(D) Radioactive iodine (131I) (H) Phenylephrine
(I) Prazosin
96. A 54-year-old woman was found to have node-positive breast (J) Reserpine
cancer. Following her surgery, she was treated with a drug
that prevents the conversion of testosterone to estradiol. The 100. Identify Drug 2 from the following list.
drug used for her treatment most likely was which of the (A) Albuterol
following? (B) Angiotensin II
(A) Anastrozole (C) Endothelin
(B) Ethinylestradiol (D) Epinephrine
(C) Finasteride (E) Ipratropium
(D) Spironolactone (F) Losartan
(E) Tamoxifen (G) Norepinephrine
(H) Phentolamine
(I) Phenylephrine
(J) Ranolazine

Trevor_App-IV_p551-566.indd 560 7/13/18 6:00 PM


ANSWER KEY FOR EXAMINATION 2*
1. E (7, 31) Neither opioids nor muscarinic agonists decrease
salivation, decrease sweating, or raise blood pressure. Opi-
oids decrease peristalsis; muscarinics increase it. Both drug
groups can cause miosis.
2. A (19) Nitric oxide (NO) is not stored; it is synthesized on
demand in response to acetylcholine, histamine, and other
drugs in several tissues, including brain and endothelium.
NO is released from the nitroprusside molecule.
3. B (1) The graph shows first-order elimination of the drug
in question (note ordinate is a log scale). Aspirin, ethanol,
and phenytoin are eliminated mainly by zero-order kinetics.
Diazepam is the only drug in the list that is eliminated by
first-order kinetics.
4. D (2) A membrane-bound ATPase enzyme is part of the
Na+/K+ sodium pump.
5. C (3) During the continuous IV infusion of a drug cleared
by first-order kinetics, the plasma concentration approaches
steady state according to the algorithm: 50% at 1 half-life,
75% at 2, etc. Since the sample was taken at two half-lives,
the steady state concentration will be in the range of four-
thirds the measured concentration (2.4/0.75) or 3.2 mg/L.
6. E (1) Before clinical trials can be carried out with a new
drug, reproductive toxicity data must be provided for at
least 2 species. Chronic toxicity studies in animals are often
carried out while clinical trials are underway.
7. A (56) Carbon monoxide is a byproduct of combustion
and can accumulate when a stove is used in a closed room,
particularly when used longer than overnight.
8. B (6) Questions that involve the baroreceptor reflex are
common; Figure 6–4 is very high yield. The major responses
to hypotension are sympathetic discharge (choice B) and
activation of the renin-angiotensin-aldosterone system. The
damp skin associated with sympathetic discharge is due to
activation of sweat glands.
9. C (10, 18) Mannitol is sometimes used to rapidly reduce
intraocular pressure in acute angle-closure glaucoma. Of the
drugs listed, only latanoprost is used in chronic glaucoma.
10. C (9) The graph shows a marked decrease in diastolic blood
pressure and marked increase in heart rate, with only a
small, transient increase in systolic blood pressure. These
effects are characteristic of isoproterenol and similar β1, β2
agonists. A muscarinic agonist would decrease both systolic
and diastolic blood pressure.
11. D (4, 23, 36) Chronic alcohol use induces hepatic cyto-
chrome P450 mixed oxidase isozymes. Elevated P450
activity converts more acetaminophen into a toxic interme-
diate, which requires inactivation by glutathione (GSH).
This alcohol-induced increase in P450 increases the risk of
reaching a level of toxic acetaminophen metabolite that can
overwhelm the liver’s detoxification capacity and result in
severe hepatotoxicity.
12. C (4) Acetylation, glucuronidation, methylation, and sulfa-
tion are phase II conjugation reactions.
13. D (12) Although β blockers may cause long-term changes in
vascular resistance, the primary action in angina is decreased car-
diac rate and contractility with resulting decreased cardiac work.
*Numbers in parentheses are chapters in which more information about answers
is found.
Trevor_App-IV_p551-566.indd 561
Examination 2    561
14. E (12) Verapamil and diltiazem are useful for prophylaxis of
both effort and vasospastic angina. Calcium blockers reduce
cardiac work and oxygen demand. They also cause constipa-
tion and sometimes peripheral edema that is not associated
with heart failure.
15. B (7) Symptomatic paroxysmal sinus tachycardia often
occurs in young patients and can sometimes be converted
to normal sinus rhythm with increased vagal discharge.
Brief amplification (5–15 min) of the vagal effects on the
heart can be accomplished with a short-acting cholinesterase
inhibitor such as edrophonium. Pyridostigmine (E) would
have a much longer action (4–6 hr). Adenosine is often used
in paroxysmal atrio-ventricular tachycardia; it has a duration
of 10–15 seconds and acts on adenosine receptors.
16. B (59) Metoclopramide, a dopamine D2 receptor antago-
nist, is a prokinetic drug that can be used to increase gastric
emptying and intestinal motility in patients with diabetes-
associated gastric paresis. Famotidine is a histamine H2
receptor antagonist used for acid-peptic disease. Misoprostol
is a prostaglandin E1 analog used for acid-peptic disease
and for medical abortions. Omeprazole is a proton pump
inhibitor used for acid-peptic disease, and ondansetron is a
serotonin 5-HT3 receptor antagonist used as an antiemetic.
Metoclopramide is the only prokinetic drug in the list.
17. D (10) Reflex tachycardia is a major disadvantage of nonse-
lective α blockers in the treatment of hypertension because
the tachycardia is exaggerated by the α2 blockade of nonse-
lective agents. The α1-selective blockers are much less likely
to exaggerate this baroreflex response.
18. D (11) ACE inhibitors, arteriolar dilators, and β blockers
do not ordinarily cause orthostatic hypotension; venodila-
tors do. Peripheral α1 antagonists block sympathetic effects
on both arterioles and veins and thus may cause orthostatic
hypotension, especially with the first few doses.
19. E (15) This patient is hyperkalemic and slightly acidotic.
These changes are typical of a K+-sparing diuretic such as
spironolactone or eplerenone.
20. B (11) Of the drugs listed, only clonidine, an α2 agonist,
is associated with severe rebound hypertension if stopped
suddenly. It is speculated that this effect is due to down-
regulation of α2 receptors.
21. C (14) The action potential is prolonged without significant
slowing of the upstroke, so the drug effect is mainly on
potassium channels (group 3 action, eg, ibutilide) and not
on both sodium and potassium channels (group 1A action,
eg, quinidine).
22. C (10, 11) Minoxidil reduces blood pressure by direct
vasodilation. Metoprolol has indirect effects on vascular
tone but (at least initially) reduces pressure by reducing car-
diac output. Later, it probably reduces renin secretion and
angiotensin II. Minoxidil evokes reflex sympathetic dis-
charge and increases cardiac force, output, and rate, whereas
metoprolol blocks β adrenoceptors and reduces force,
output, and rate.
23. B (15, 42) Loop diuretics decrease calcium absorption from
the urine into blood and can reduce serum calcium, whereas
thiazide diuretics decrease calcium excretion from the blood
into the urine. None of the other options listed here affects
serum calcium. Saline infusion is needed to prevent hemo-
concentration caused by a strong diuresis. Opioids are indi-
cated for acute management of severe pain due to kidney
stones and would be contraindicated in coma.
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 562    APPENDIX IV
24. B (15) Chlorthalidone is a thiazide-like diuretic and acts
on the Na+/Cl– transporter in the distal convoluted tubule.
Furosemide acts on the ascending limb of the loop of
Henle and inhibits the major transporter in this segment, a
Na+/K+/2Cl− transporter.
25. C (17) Substance P is the endogenous peptide closely associ-
ated with peripheral pain transmission, and capsaicin (the
“hot” component from hot peppers) is an antagonist.
26. E (18) The cyclooxygenase enzymes are responsible for
cyclizing arachidonate to prostaglandin precursors.
27. A (20) Albuterol, metaproterenol, and terbutaline are rapid-
onset, selective β2 agonists used as first-line therapy for acute
asthma.
28. C (20) Salmeterol and formoterol are slow-onset, long-
acting, selective β2 agonists usually used by inhalation with
corticosteroids in asthma prophylaxis. Indacaterol and
vilanterol are similar but approved only for COPD.
29. E (26) In overdose, intravenous lidocaine causes typical local
anesthetic toxicity including central nervous system stimula-
tion with possible seizures. Cardiovascular depression may
occur, but it is usually minor.
30. B (25, 27) Malignant hyperthermia is a rare disorder char-
acterized by massive calcium release within skeletal muscle
triggered by use of succinylcholine in anesthesia protocols.
Dantrolene is given to block calcium release.
31. C (34) Deep vein thromboses are less responsive to the
antiplatelet agents (aspirin, clopidogrel). Warfarin is tera-
togenic and is contraindicated in pregnancy. Bivalirudin
is a thrombin inhibitor that can be used parenterally only.
Enoxaparin, a low-molecular-weight (LMW) heparin, is the
drug of choice to treat and prevent deep vein thromboses
and is safe to use during pregnancy.
32. E (48) Amphotericin B and caspofungin are active against
many systemic fungal infections, but they interfere with fun-
gal cell wall functions. Voriconazole, an azole antifungal like
fluconazole, itraconazole, and posaconazole, interferes with
cell membrane synthesis by inhibiting ergosterol synthesis.
33. C (49) Acyclovir is a guanosine analog activated by viral thy-
midine kinases of HSV and VZV to form acyclovir triphos-
phate, a competitive substrate for DNA polymerase; it results
in chain termination when incorporated into viral DNA.
34. B (53) Mebendazole is the primary drug for treatment of
pinworm, roundworm, and whipworm infections. The drug
is contraindicated in pregnancy. Mebendazole and thiaben-
dazole (a more toxic azole) are inhibitors of microtubule
synthesis in nematodes.
35. D (52) These dose-related symptoms are characteristic
adverse effects of the alkaloids (eg, quinine, quinidine)
derived from the bark of the cinchona tree and are termed
cinchonism.
36. B (41) Canagliflozin is a SGLT2 inhibitor that increases
glucose excretion by the kidney. Acarbose inhibits polysac-
charide breakdown. Exenatide is a GLP analogue. Repa-
glinide is an insulin secretagogue and sitagliptin is a DPP-IV
inhibitor.
37. C (55) Mycophenolate mofetil is an immunosuppressant
whose active metabolite inhibits de novo production of gua-
nosine nucleotides. Lymphocytes are particularly sensitive to
the antimetabolite effect of mycophenolate mofetil because
they lack the alternative salvage pathway for guanosine syn-
thesis that is present in most cells.
Trevor_App-IV_p551-566.indd 562
38. E (47) Mutations in the katG gene result in the underpro-
duction of mycobacterial catalase-peroxidase, an enzyme
that bioactivates INH, facilitating its interaction with its
target ketoacyl carrier protein synthetase. The result is high-
level resistance to INH. Mutations in the inhA gene result
in low-level resistance with cross-resistance to pyrazinamide.
39. B (57, 58) Deferoxamine, a chelator with high selectivity
and affinity for iron, is used intravenously for acute iron
poisoning. Activated charcoal does not bind iron. Acetyl-
cysteine is used for acetaminophen poisoning. Pralidoxime
is used for organophosphate poisoning. Intravenous EDTA
is used for lead poisoning; oral EDTA does not significantly
reduce iron absorption after an oral iron overdose.
40. D (9, 20) Albuterol and metaproterenol are β2-selective
bronchodilators used in asthma and may cause undesirable
cardiac stimulation in COPD patients. Metoprolol is a
β blocker and would precipitate bronchospasm. Verapamil
blocks calcium channels but has little useful effect in
bronchospasm. Tiotropium is a long-acting muscarinic
antagonist administered by inhalation and has a useful
bronchodilator effect in COPD with little systemic effect.
41. C (11, 15) Spironolactone inhibits potassium excretion
in the kidney by blocking aldosterone. Captopril reduces
angiotensin II levels and secondarily reduces aldosterone.
The combination may increase serum potassium to danger-
ous levels.
42. D (21, 28) Antagonism at dopamine D2 receptors in the CNS
is equated with parkinsonian symptoms (Drugs A and D).
However, in the case of Drug A, this action would be offset
by its ability to block muscarinic receptors. M blockers, eg,
benztropine, improve tremor and rigidity in parkinsonism
but have little effect on bradykinesia.
43. B (22, 29) Clonazepam, a benzodiazepine, is effective in the
management of absence seizures and is also used in the treatment
of bipolar disorder. Alprazolam is useful in anxiety; clomipramine
and SSRIs are useful in obsessive-compulsive disorder.
44. A (23) Fomepizole, an antidote for ethylene glycol and
methanol poisoning, inhibits alcohol dehydrogenase, which
converts ethylene glycol and methanol to toxic metabolites.
45. B (24) Simple partial seizures can have the characteristics of
the “jacksonian march.” Many drugs are used in its manage-
ment including those listed, with the exception of ethosuxi-
mide, which is useful in absence seizures but not effective
in partial seizures or generalized tonic-clonic seizure states.
46. E (24) Myoclonic seizure syndromes are usually treated
with valproic acid. Neural tube defects (spina bifida) are
associated with the use of valproic acid during pregnancy.
Lamotrigine is approved for adjunctive use but is often
used as a sole agent, and several backup drugs are available
including topiramate and zonisamide.
47. E (26) Local anesthetics block voltage-dependent sodium
channels in excitable tissues including nerves and muscle,
decreasing action-potential conduction. Rapidly firing fibers
are more sensitive than slowly firing nerve fibers. Cocaine
has this action and also blocks the reuptake of norepineph-
rine at sympathetic neuroeffector junctions with effects on
both the heart and the CNS.
48. E (32) The signs and symptoms are those of high-dose
abuse of dextroamphetamine or methamphetamine. There
is no specific antidote, and supportive measures are directed
toward protection against cardiac arrhythmias and seizures
and control of body temperature.
7/13/18 6:00 PM

49. D (27) Baclofen activates GABAB receptors, dantrolene
blocks the release of calcium from skeletal muscle sarcoplas-
mic reticulum, halothane enhances skeletal muscle relaxants,
and tubocurarine causes histamine release. Acetylcholines-
terase inhibitors do not reverse skeletal muscle relaxation
caused by succinylcholine.
50. A (31) Fentanyl is much shorter acting than morphine. Both
drugs are μ-receptor activators, equally effective in terms of
analgesic activity and reversible by naloxone. Both drugs
cause respiratory depression at high doses.
51. C (23) Intellectual disability, microcephaly, and facial dys-
morphia are characteristics of fetal alcohol syndrome, caused
by excessive use of ethanol during pregnancy.
52. C (9, 30, 61) Phenelzine, a rarely used antidepressant, is
a potent MAO-B inhibitor and increases the amount of
catecholamine transmitter stored in sympathetic nerve
endings. When an indirectly acting sympathomimetic such
as tyramine (found in some foods) avoids first-pass metabo-
lism (due to MAO inhibition) and reaches the nerve endings,
it can release large amounts of norepinephrine and cause a
hypertensive crisis.
53. D (27) In phase I block, the action of succinylcholine is
not reversed by acetylcholinesterase inhibitors. The drug is
metabolized by pseudocholinesterases. It may cause hista-
mine release, and it can cause hyperkalemia.
54. C (7, 8, 27) The acetylcholinesterase inhibitor pyridostig-
mine can reverse skeletal muscle relaxation (caused by
vecuronium) but may also cause bradycardia, a muscarinic
effect. The later effect can be prevented by use of glycopyr-
rolate, which has muscarinic receptor blocking action.
55. E (29) Significant weight gain and hyperglycemia due to
a diabetogenic action occur with several atypical antipsy-
chotics, especially clozapine (not listed) and olanzapine.
Neurologic dysfunctions are less common with the atypical
agents.
56. E (30, 31) Naloxone is an opioid μ-receptor antagonist and
will oppose the actions of opioids at this class of receptors
including analgesia, miosis, and symptoms of opioid over-
dose including respiratory depression. However, respiratory
depression due to nefazodone, a 5-HT2A antagonist, is not
exerted via the μ-opioid receptor.
57. C (28) Entacapone is a catechol-O-methyltransferase inhibi-
tor that enhances the action of levodopa by preventing its
metabolism in the blood and peripheral tissues. It does not
cross the blood-brain barrier and if used alone will not ame-
liorate symptoms of Parkinson’s disease.
58. B (22) The hypnotic action of ramelteon is thought to be
due to its activation of melatonin receptors in the suprachi-
asmatic nuclei of the CNS.
59. A (43, 46) The drugs of choice for treatment of gonorrhea
currently are the cephalosporins ceftriaxone and cefixime.
Azithromycin and spectinomycin are alternatives. Resistance
to amoxicillin is common.
60. A (44) The only drug likely to be effective in nongonococ-
cal urethritis in a single dose is azithromycin, which has an
elimination half-life of several days. Other drugs used in
nongonococcal urethritis include clindamycin, ofloxacin,
and the tetracyclines.
61. B (45) The aminoglycoside antibiotics are bactericidal
inhibitors of protein synthesis. Recall that their actions con-
tinue well beyond their short half-lives because they exert a
postantibiotic action.
Trevor_App-IV_p551-566.indd 563
Examination 2    563
62. D (44) Tetracycline use during pregnancy is discouraged
since fetal exposure to these antibiotics may ultimately lead
to irregularities in bone growth and dentition. In addition,
gastrointestinal effects and the potential for hepatic dysfunc-
tion are increased in the pregnant patient.
63. B (39) Long-term use of prednisone has several side effects
such as growth inhibition, diabetes, muscle wasting, and
osteoporosis. Regarding the other options: Excess steroid
use results in baldness. Corticosteroids (such as prednisone)
can be used to treat some hemolytic anemias. Choice D is
incorrect because it describes congenital adrenal hyperplasia,
a condition in which the adrenal gland fails to make the
hormones cortisol and aldosterone. Treatment would be to
provide these hormones to restore physiological levels.
64. B (42) The bisphosphonates can cause esophageal irritation,
which is managed by drinking fluids and staying upright
for 30 minutes after taking the drug. Blue skin is an adverse
effect of amiodarone. Color vision can be affected by anti-
TB treatment. Priapism can be caused by sildenafil in com-
bination with nitrates, and tendinitis is an adverse effect of
fluoroquinolones.
65. C (44, 47) Azithromycin (not listed) or clarithromycin
with or without rifabutin is recommended for primary pro-
phylaxis against Mycobacterium avium complex (MAC) in
patients with AIDS.
66. E (49) Efavirenz is used in highly active antiretroviral
therapy (HAART) regimens against HIV. The drug is a non-
nucleoside allosteric inhibitor of HIV reverse transcriptase
(NNRTI) and does not bind to the active site of the enzyme.
67. B (43, 44, 46) In a community-acquired pneumonia, the
wider spectrum cephalosporin ceftriaxone would cover typi-
cal organisms, and erythromycin would be active against the
atypical organisms.
68. E (43, 44, 46) Single antimicrobial drug therapy would be
inadequate coverage in a hospital-acquired pneumonia that
could include possible infection due to multidrug-resistant
staphylococci as well as Gram-negative bacilli such as Pseudomo-
nas aeruginosa. Vancomycin should cover Gram-positive organ-
isms, and piperacillin plus the penicillinase inhibitor would be
active against most strains of likely Gram-negative pathogens.
69. B (49) Many resistant strains of HSV commonly lack
thymidine kinase, the enzyme involved in the viral-specific
activation of acyclovir by phosphorylation.
70. C (48) Fluconazole is the only antifungal drug listed. It is
the drug of choice for treatment and secondary prophylaxis
against cryptococcal meningitis.
71. E (54) Bleomycin is one of the 4 drugs for which myelosup-
pression is not dose-limiting. The 3 others are cisplatin for
nephrotoxicity, doxorubicin for cardiotoxicity, and vincris-
tine for peripheral neuropathy.
72. C (54) The cardiotoxicity of doxorubicin (one of the 4 drugs
with unique dose-limiting toxicity; see Question 71) can be
mitigated by dexrazoxane.
73. D (37) The posterior pituitary hormone oxytocin contracts
uterine smooth muscle. It is used to augment labor and, in
this case, to treat postpartum uterine atony.
74. C (40) Progestins act on the endometrium, where estrogen
agonists can induce proliferation and increase the risk of
endometrial cancer. Progestins have been shown to reduce
this risk. Progestin toxicity includes increased blood pressure
and a decrease in HDL. Long-term use of progestins can
lead to a reduction in bone density.
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 564    APPENDIX IV
75. D (16) Diphenhydramine is a first-generation anti-H1 blocker
with significant anti-motion sickness and sedative actions.
Loratadine is a second-generation antihistamine with neither
of these effects. Neither drug is effective in asthma or GERD,
and neither blocks drug-metabolizing enzymes.
76. A (13) While therapeutic strategies in chronic heart failure
include use of several different drug classes including diuret-
ics and positive inotropic agents, 3 drugs or drug groups
have been shown to provide survival benefits: ACE inhibi-
tors, certain β blockers including carvedilol, and the aldoste-
rone antagonists spironolactone and eplerenone.
77. D (38) Methimazole and propylthiouracil (PTU) are small
sulfur-containing thioamides that inhibit thyroid hormone
synthesis by blocking peroxidase catalyzed reactions, iodin-
ation of thyroglobulin, and coupling of DIT and MIT (see
Figure 38–1). Dexamethasone is an orally active cortico-
steroid, lithium is a mood stabilizer, and propranolol is a
β-blocker capable of inhibiting the peripheral conversion
of T4 to T3.
78. E (31) Meperidine is a strong opioid agonist with analgesic
efficacy equivalent to that of morphine. The drug has a musca-
rinic blocking action and does not cause miosis or contraction
of biliary smooth muscle. With long-term use, its metabolite
normeperidine accumulates and may cause seizures.
79. C (35) The patient has elevated triglycerides. Fibrates
are the main triglyceride-lowering drugs, acting through
PPAR-alpha activation. Fibrates also increase HDL. Cho-
lestyramine, ezetimibe, and lovastatin mainly lower LDL
cholesterol, whereas pioglitazone is an antidiabetic drug that
increases insulin sensitivity through PPAR-γ activation.
80. D (34) Heparin is negatively charged and will be effectively
complexed with the positively charged protamine. There is
no antidote for options A and B. If the effect of warfarin is
too great, vitamin K1 supplements or parenteral phytonadi-
one (vitamin K1) can be added in addition to dose reduc-
tion. For urgent reversal of anticoagulation by any drug,
fresh frozen plasma may be used.
81. A (35) Resins increase triglycerides (TGs), particularly
in patients who are genetically predisposed to high TGs.
Ezetimibe has no effect on TGs, but fibrates and niacin both
lower TGs and lovastatin mostly lowers LDL cholesterol.
82. D (40) Combination hormonal contraceptives have clinical
uses and beneficial effects in treatment of acne, hirsutism,
and dysmenorrhea. In addition, with long-term use, they
have been shown to reduce the risk of ovarian and endome-
trial cancer.
83. E (34) Warfarin interferes with gamma carboxylation of
clotting factors IX, X, VII, and II, and the anticlotting fac-
tors protein C and protein S. Dabigatran, an oral thrombin
inhibitor, carries the risk of bleeding and not thrombosis.
Aspirin can cause gastrointestinal ulcers and bleeding.
Heparin is the only drug on this list that can also cause
thrombosis, but in the case of heparin, it is mediated not
through protein C but rather through an immunologic reac-
tion against heparin-platelet complexes.
84. D (59) Mesalamine is a form of 5-aminosalicylic acid
(5-ASA) used as first-line treatment for inflammatory
bowel disease. Aluminum hydroxide is an antacid used for
symptomatic relief of heartburn. Metoclopramide is a pro-
kinetic agent. Misoprostol (a prostaglandin) and ranitidine
(H2 receptor blocker) are used for acid-peptic disease.
Trevor_App-IV_p551-566.indd 564
85. D (24) A number of antiseizure drugs cause serious tox-
icities, including hepatotoxicity with both valproic acid and
felbamate. In the case of lamotrigine, which has been com-
monly used in myoclonic seizures, toxic epidermal necroly-
sis (Stevens-Johnson syndrome) has occurred.
86. B (30) The selective serotonin reuptake inhibitor (SSRI) class
of antidepressants has been shown to have therapeutic value
in a wide range of psychiatric dysfunctions ranging from
bulimia to obsessive compulsive disorder. One of the adverse
effects of SSRIs is diminished sexual function and interest.
87. B (14) Adenosine is favored for the prompt conversion of
atrioventricular nodal rhythms to normal sinus rhythm.
Group 1a drugs such as quinidine and procainamide are
associated with increased risk of torsades. Amiodarone,
a broad-spectrum antiarrhythmic, has the best record of
reducing this risk.
88. D (28) Pramipexole is a non-ergot dopamine agonist with
high affinity for the D3 receptor. It is used as monotherapy
in mild parkinsonism and together with levodopa in more
advanced disease. Mental disturbances such as confusion,
delusions, and impulsivity are more common with prami-
pexole than with levodopa.
89. D (33, 58) In cyanide poisoning, the vitamin B12 analog
hydroxocobalamin reacts with cyanide to form cyanocobala-
min, another form of B12 that is stored in the liver.
90. A (54) Cyclophosphamide is converted into acrolein, which
damages the kidney. Mesna can bind to and detoxify
acrolein. Note that the dose-limiting toxicity of cyclophos-
phamide is bone marrow suppression.
91. A (54, 55) Allopurinol interferes with the metabolism of aza-
thioprine, increasing plasma levels of 6-mercaptopurine, which
may result in potentially fatal blood dyscrasias. Concomitant
use requires the dose of azathioprine to be reduced by 75%.
92. B (36) Treatment of gout falls into 2 categories: (1) to
treat the acute attack, in which the goal is to reduce pain
and inflammation, and (2) to prevent attacks by reducing
the uric acid pool through inhibition of uric acid buildup
(allopurinol and febuxostat) or by enhanced elimination
(probenecid). Indomethacin is an NSAID that can reduce
pain and inflammation. Morphine will reduce the pain but
not the inflammation, and methotrexate is more effective for
immuno-inflammatory disorders.
93. C (33) Deficiencies of folic acid or vitamin B12 are the most
common causes of megaloblastic anemia. If a patient with this
type of anemia has a normal serum vitamin B12 concentra-
tion, folate deficiency is the most likely cause of the anemia.
Deficiency of folic acid during early pregnancy is associated
with increased risk of a neural tube defect in the newborn. In
the US, cereals and grains are supplemented with folic acid
in an effort to decrease the incidence of folic acid deficiency.
94. B (37) This woman’s central diabetes insipidus is due to
insufficient posterior pituitary production of vasopressin.
Desmopressin, a selective vasopressin V2 receptor agonist,
can be administered orally, nasally, or parenterally to treat
central diabetes insipidus. Bromocriptine is a dopamine D2
receptor agonist used to inhibit prolactin release; octreotide
is a somatostatin receptor agonist, used to stop bleeding and
treat acromegaly and several other hormone-secreting tumors;
prednisone is a corticosteroid used as an immunosuppressant;
somatropin, the recombinant form of human GH, is used for
GH deficiency in children and adults and in the treatment of
children with genetic diseases associated with short stature.
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95. D (37, 38) RAI is effective for radiation-induced destruc-
tion of thyroid parenchyma. T3 and T4 are thyroid
preparations used in hypothyroidism; leuprolide is a
gonadotropin-releasing hormone (GnRH) analog. In men
and women, steady (non-pulsatile) dosing with these GnRH
agonists inhibits gonadotropin release by downregulating
GnRH receptors in the pituitary cells that normally release
gonadotropins.
96. A (40, 54) Anastrozole prevents conversion of testosterone
to estradiol. Ethinyl estradiol is an orally available form of
estradiol. Finasteride is a 5-α-reductase inhibitor. Spirono-
lactone is an androgen receptor antagonist (used mainly as
a K-sparing diuretic), and tamoxifen is a selective estrogen
receptor modulator.
97. C (41) Glipizide is the only agent in this list that can stimu-
late insulin secretion, potentially leading to hypoglycemia.
Canagliflozin is an SGLT2 inhibitor reducing renal glucose
reabsorption. Acarbose and miglitol inhibit polysaccharide
breakdown. Metformin acts in the liver. Rosiglitazone is a
PPAR-γ activator.
Trevor_App-IV_p551-566.indd 565
Examination 2    565
98. A (34) Deep vein thromboses tend to be fibrin-rich and
platelet-poor, making them less responsive to the antiplatelet
agents (eptifibatide, clopidogrel). Unfractionated heparin
carries the risk of triggering more heparin-induced throm-
bocytopenia. Warfarin will take several days to achieve a
therapeutic effect. Argatroban (direct thrombin inhibitor) is
the drug of choice for fast anticoagulation in patients with
heparin-induced thrombocytopenia.
99. G (9, 10) See answers to questions 95 and 96 in Examina-
tion 1 (Appendix II). Drug 1 evokes a strong pressor effect
and a bradycardia that is probably a reflex compensatory
response. Thus, both norepinephrine and phenylephrine are
possible answers. However, the action of Drug 2 unmasks a
tachycardia (a β adrenoceptor effect) produced by Drug 1,
so this agonist must be norepinephrine; phenylephrine does
not have β agonist action.
100. H (10) See answers to the preceding question and to ques-
tions 95 and 96 in Examination 1. Drug 2 is an α blocker
without β-blocking action.
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