Clinical Pharmacy Practice Exam Questions

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Clinical Pharmacy practice Exam questions.

Consist of three (3) segments:

This segment consists of 15 items. Answer each question.

Question 1
Which diuretic would cause increased excretion of sodium, potassium, magnesium, and calcium and would promote the reabsorption of uric acid?

1. Bumetanide
2. Hydrochlorothiazide (HCTZ)
3. Spironolactone
4. Triamterene

Answer: 1. Bumetanide

Rationale: The correct answer is bumetanide. HCTZ decreases the excretion of calcium. Spironolactone and triamterene are potassium sparing.

Question 2
Which antimicrobial has nearly equivalent oral and parenteral bioavailability?

1. Ampicillin
2. Cefuroxime
3. Linezolid
4. Vancomycin

Answer: 3. Linezolid

Rationale: Linezolid has a documented oral bioavailability of nearly 100%.

Question 3

Which drug would require a dosing adjustment for a documented creatinine clearance of less than 30 mL/minute?

1. Ceftriaxone
2. Metronidazole
3. Pantoprazole
4. Ranitidine

Answer: 4. Ranitidine

Rationale: Dosage adjustments are only necessary for ranitidine with a creatinine clearance of 35 mL/minute. The rest do not need adjustments.

Question 4
Which agent is the best treatment option for a patient taking warfarin with an international normalized ratio of 11.0 and no signs of bleeding?

1. Cyanocobalamin
2. Phytonadione
3. Protamine
4. Tocopherol

Answer: 2. Phytonadione

Rationale: The correct answer is phytonadione (vitamin K). Warfarin acts as an anticoagulant through inhibition of the vitamin K–dependent clotting factions II, VII, IX, and X. Administration of phytonadione is indicated in warfarin overdose. Protamine is used to reverse heparin overdose. Tocopherol is a form of vitamin E and has no role in reversing warfarin overdose. Cyanocobalamin is vitamin B12 and is commonly used to treat pernicious anemia.

Question 5
Which drug class is considered the pharmacologic first-line treatment of choice for posttraumatic stress disorder (PTSD)?

1. Anticonvulsants
2. Atypical antipsychotics
3. Benzodiazepines
4. Selective serotonin reuptake Inhibitors (SSRIs)

Answer: 4. SSRIs

Rationale: SSRIs are recognized by several resources as the first-line treatments (together with psychotherapy).

Question 6
A 5-year-old boy is given a diagnosis of mild croup. Which medication would be most appropriate to recommend?

1. Oral dexamethasone
2. Nebulized albuterol
3. Nebulized racemic epinephrine
4. Nebulized 3% saline

Answer: 1. Oral dexamethasone

Rationale: The correct answer is 1, oral dexamethasone (it is used to decrease pharyngeal inflammation). Racemic epinephrine is first line but, in severe episodes, not mild. Albuterol is beta-specific and will not help with edema in the upper airway. This is also true for 3% saline, which is used in bronchiolitis.

Question 7
An elderly nursing home resident develops diarrhea that is caused by Clostridium difficile. Which agent is contraindicated?

1. Cholestyramine
2. Diphenoxylate/atropine
3. Kaolin-pectin
4. Psyllium

Answer: 2. Diphenoxylate/atropine

Rationale: The correct answer is diphenoxylate/atropine. With toxin-mediated diarrhea, use of agents to slow motility would be contraindicated. In addition, this agent should be avoided in elderly patients, if possible, because of the increased risk of anticholinergic adverse effects in this population. Kaolin-pectin, cholestyramine, and psyllium are all acceptable options for symptom control for this type of diarrhea.

Question 8
A new osteoporosis drug is being tested to prevent fractures. If 25 of 100 patients in the control group experience a fracture compared with 5 of 100 patients in the treatment group, what is the number needed to treat (NNT)for the new drug?

1. 0.2
2. 0.8
3. 5
4. 20

Answer: 3. 5 patients

Rationale: The correct answer is 5. The NNT is calculated as 1/absolute risk reduction (ARR). In this case, the ARR is 0.2 (difference in event rates between drug and placebo = 0.25 − 0.05). The relative risk (RR) is 0.2 (event rate drug/event rate placebo = 0.05/0.25), and the OR (odds ratio) is 0.2 (odds of event on drug/odds of event on placebo = [5/25]/[95/75]).

Question 9
Which sedative is most likely to cause transient adrenal insufficiency when used for rapid sequence intubation?

1. Etomidate
2. Ketamine
3. Midazolam
4. Propofol

Answer: 1. Etomidate

Rationale: The correct answer is etomidate. The other agents have no known effect on adrenal function or cortisol production.

Question 10
A 70-year-old man with stage IV renal cell carcinoma is beginning sorafenib therapy. In consultation with the patient, which adverse effect should you discuss the potential development of?

1. Hypertension
2. Neutropenia
3. Peripheral neuropathy
4. Renal failure

Answer: 1. Hypertension

Rationale: Hypertension may develop within the first few weeks of therapy or slowly over the continuance of therapy. The exact etiology of hypertension is unclear, but it may be the result of pressor stimulation responses, increasing extracellular volume, and/or decreasing vascular compliance. Although trials continue to investigate the etiology of hypertension, effective management is critical to minimizing the long-term sequelae of treatment-induced hypertension.

Question 11
Which condition may result in a decrease in total phenytoin concentration in patients who routinely take phenytoin?

1. Addition of isoniazid therapy
2. Chronic alcohol abuse
3. Stage II chronic kidney disease (CKD)
4. Metabolic alkalosis secondary to diuretic therapy

Answer: 2. Chronic alcohol abuse

Rationale: Choice 2 is correct because a decrease in liver function from chronic alcohol abuse will result in a decrease in albumin production, thus decreasing the total phenytoin protein bound concentration, resulting in an increase in phenytoin-free fraction.

Choice 1 is incorrect because the addition of isoniazid will decrease the metabolism of phenytoin, potentially increasing the total phenytoin concentration. Choices 3 and 4 are incorrect because neither affects phenytoin binding to albumin.

Question 12
A propofol infusion provides the following amount of nutrition per volume:

1. 10 kcal/mL
2. 9 kcal/mL
3. 4 kcal/mL
4. 1.1 kcal/mL

Answer: 4. 1.1 kcal/mL

Rationale: An intravenous anaesthetic agent, propofol, provides 1.1 kcal of nutrition per milliliter to the patient, which is identical to a 10% intravenous lipid emulsion.

Question 13
Which regimen is the MOST appropriate first-line therapy for the management of postherpetic neuralgia?

1. Venlafaxine 25 mg orally 3 times/day
2. Nortriptyline 25 mg orally at bedtime
3. Diclofenac 1.3% topical patch applied twice daily
4. Lidocaine 5% topical patch applied for 12 hours/day

Answer: 4. Lidocaine 5% topical patch applied for 12 hours/day

Rationale: The correct answer is lidocaine 5% patch applied for 12 hours/day. Lidocaine 5% patches are U.S. Food and Drug Administration (FDA) approved for postherpetic neuralgia, and they provide analgesia within hours after application. Venlafaxine and nortriptyline must be administered for at least 1–2 weeks before a therapeutic response is seen and therefore may not be considered first-line therapy. Diclofenac and other nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically effective for the management of neuropathic pain.

Question 14
Which cytochrome P450 (CYP) isoenzyme is MOST likely responsible for the drug-drug interaction between clopidogrel and proton pump inhibitors?

1. CYP1A2
2. CYP2C9
3. CYP2C19
4. CYP3A4

Answer: 3. CYP2C19

Rationale: Competitive inhibition of CYP2C19 by proton pump inhibitors decreases the availability of the active metabolite of clopidogrel and thereby decreases its effect on platelet function.

Question 15
This agent allows lower maintenance doses or complete discontinuation of calcineurin inhibitors.

1. Alemtuzumab
2. Azathioprine
3. Sirolimus
4. Tacrolimus

Answer: 3. Sirolimus

Rationale: The correct answer is sirolimus. Sirolimus is a mammalian target of rapamycin inhibitor that is used in conjunction with or to replace calcineurin inhibitors in calcineurin inhibitor–“sparing” protocols. Tacrolimus is a calcineurin inhibitor. Alemtuzumab is a humanized monoclonal antibody that has been approved for use in chronic lymphocytic leukemia and that has been used off-label for kidney transplant induction therapy. Azathioprine is a purine antimetabolite that is used in conjunction with calcineurin inhibitors.

Clinical Case:
A 66-year-old man presents to clinic for his routine visit. He has had increasing fatigue during the past month that interferes with his daily activities. He has knee pain when he plays golf, for which he self-medicates with over-the-counter naproxen. He is adherent to all of his prescribed therapy, including dietary restrictions.

Medical History:
Hypertension
Diabetes mellitus
Chronic kidney disease (CKD) secondary to hypertension
Gout
Gastroesophageal reflux disease (GERD)
Benign prostatic hyperplasia (BPH)
Osteoarthritis

Current Medications:
Glipizide 10 mg/day x 6 years
Insulin glargine 15 units at bedtime x 3 months
Enalapril 40 mg/day x 6 years
Allopurinol 100 mg/day x 6 years
Doxazosin 4 mg at bedtime x 2 years
Ranitidine 75 mg/day x 5 years
Calcium carbonate 500 mg 3 times/day with meals x 6 months
Naproxen 250 mg twice daily x 2 weeks

Recent Laboratory Values:
Sodium 136 mEq/L (136 mmol/L)
Potassium 4.7 mEq/L (4.7 mmol/L)
Chloride 101 mEq/L (101 mmol/L)
HCO3 23 mEq/L (23 mmol/L)
Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L)
Serum creatinine (SCr) 3.2 mg/dL (282 micromoles/L)
Estimated glomerular filtration rate (Modification of Diet in Renal Disease [MDRD]) 20 mL/minute/1.73m2
Glucose, random 156 mg/dL (8.7 mmol/L)
Hemoglobin A1c 7.8%
Phosphate 6.0 mg/dL (1.9 mmol/L)
Calcium 10.5 mg/dL (2.63 mmol/L)
Albumin 2.8 g/dL (28 g/L)
White blood cell count 4500/microliter (4.5 x 109/L)
Hemoglobin 9.9 g/dL (99 g/L)
Hematocrit 29.6% (0.296)
Platelet count 175,000/microliter (175 x 109/L)
Ferritin 120 ng/mL (270 pmol/L)
Transferrin saturation 23%

Clinical Case Questions 1–5.

Question 1 – 100 points

The patient has which complication of CKD?

1. Anemia
2. Hyperkalemia
3. Metabolic acidosis
4. Uremic platelet dysfunction
Answer: 1. Anemia

Rationale: According to the Kidney Disease Quality Outcomes Initiative (KDOQI) guidelines, anemia is defined as a hemoglobin value of less than 13.5 g/dL in males. Potassium and serum bicarbonate values are all within the normal range for their assays. Uremic platelet dysfunction cannot be determined by the patient’s laboratory results.

Question 2

This patient is best described as having which stage of CKD?

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Answer: 4. Stage 4

Rationale: The patient’s estimated glomerular filtration rate (eGFR) is 20 mL/minute, which categorizes him as having stage 4 CKD (GFR 15–29 mL/minute).

Question 3

A fasting lipid panel is to be obtained. What is this patient’s low-density lipoprotein (cholesterol) (LDL) goal?

1. Less than 100 mg/dL (2.59 mmol/L)
2. Less than 130 mg/dL (3.36 mmol/L)
3. Less than 160 mg/dL (4.13 mmol/L)
4. Less than 190 mg/dL (4.91 mmol/L)
Answer: 1. Less than 100 mg/dL (2.59 mmol/L)

Rationale: CKD is considered a coronary artery disease risk equivalent. In addition, this patient has type 2 diabetes mellitus, which is considered a coronary heart disease (CHD) risk equivalent. For this reason, the LDL goal for this patient should be that of the highest risk group. Based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, the LDL goal for the highest risk group is less than 100, with an alternate goal of less than 70.

Question 4

Which is the most appropriate adjustment to make in his phosphate binder therapy?

1. Discontinue calcium carbonate.
2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
3. Continue calcium carbonate at the current dose and add aluminum hydroxide 600 mg 3 times/day.
4. Continue calcium carbonate at the current dose and add sevelamer carbonate 800 mg 3 times/day.

Answer: 2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
Rationale: Because the patient has a serum phosphate value that is above the normal range, he requires phosphate binder therapy. He has an elevated calcium level, as evidenced by his laboratory values (10.5 mg/dL), which, if corrected for a low serum albumin using the correction equation (Ca, adj = SCa + 0.8 (4-albumin), would be estimated as 11.46 mg/dL. Hypercalcemia can cause acute kidney injury through vasoconstriction of the afferent arterioles in the kidney. Calcium-based binders are not recommended in hypercalcemia, so discontinuing the calcium-based binder is warranted in this patient. Aluminum should be avoided as long-term phosphate binder therapy. Sevelamer is the best option in this patient.

Question 5
By what mechanism could the patient’s choice of naproxen be adversely affecting his renal function?

1. Direct toxic effect on the renal tubules
2. Constriction of the afferent arteriole
3. Dilation of the efferent arteriole
4. Decreased tubular reabsorption of sodium

Answer: 2. Constriction of the afferent arteriole

Rationale: NSAIDs such as naproxen can cause many different types of injury to the kidney. The most likely short-term problem with taking an NSAID for this patient is functional acute kidney injury, resulting from a decreased production of vasodilatory prostaglandins, which act on the afferent arterioles of the kidney. In patients who rely on afferent arteriole vasodilation to maintain their GFR, this causes a drop in GFR. Choice 1 is incorrect because there is no direct toxic effect on the renal tubules. Choice 4 is incorrect because the inhibition of PGE2 syntheses can lead to increased sodium reabsorption, causing peripheral edema, which is the most common renal effect of NSAIDs. Edema and sodium retention are usually mild, resulting in weight gain of 1–2 kg.

Segment
3…
This segment will consist of 15 items in five predetermined categories. Point values for each item are indicated below. Please circle your answer for each item.

Cardiovascular Disorders

Item 1

The U.S. Preventive Services Task Force (USPSTF) recommends aspirin for the primary prevention of cardiovascular disease in a 62-year-old man when his 10-year CHD risk is equal to or greater than what level:

1. 3%
2. 5%
3. 7%
4. 9%

Answer: 4. 9%

Rationale: The USPSTF created a recommendation statement on the use of “Aspirin for the Prevention of Cardiovascular Disease.” In this statement, the USPSTF balances the risk of CHD with the risk of bleeding in patients using aspirin for the primary prevention of CHD. The cut point for benefit in the male age group of 60–69 is having a 10-year CHD risk of 9% or more.

Item 2
Which medication is considered the first-line agent for the treatment of leg pain secondary to intermittent claudication?

1. Aspirin
2. Cilostazol
3. Clopidogrel
4. Pentoxifylline

Answer: 2. Cilostazol

Rationale: The treatment of choice for patients experiencing leg pain caused by intermittent claudication is cilostazol. Pentoxifylline has been shown to be comparable to placebo; therefore, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have designated it a second-tier therapy. Although aspirin and clopidogrel are used for peripheral arterial disease to reduce cardiovascular mortality, these agents have not shown a reduction in ischemic leg pain.

Item 3

A hemodynamically stable patient with systolic heart failure is initiated on amiodarone for an irregularly irregular rhythm. The patient currently receives lisinopril 20 mg orally once daily, metoprolol succinate 25 mg orally once daily, furosemide 40 mg orally once daily, and digoxin 0.25 mg orally once daily. Physical examination reveals no lower extremity edema or pulmonary crackles. What medication adjustment should occur immediately?

1. Change furosemide 40 mg orally to 20 mg intravenously daily.
2. Increase lisinopril to 40 mg orally once daily.
3. Decrease digoxin to 0.125 mg orally once daily.
4. Switch metoprolol succinate 25 mg once daily to metoprolol tartrate 12.5 mg orally twice daily.

Answer: 3. Decrease digoxin to 0.125 mg orally once daily.

Rationale: Amiodarone reduces the clearance of digoxin by inhibiting P-glycoprotein. This drug interaction is predictable and clinically significant, requiring a proactive 50% reduction in digoxin. An increase in furosemide is not necessary in a patient without edema or crackles. This patient is currently receiving the target dose of lisinopril, and an increase beyond the target dose is not needed. An equipotent dose change from metoprolol succinate to tartrate is unnecessary in a hemodynamically stable patient with systolic heart failure.

Endocrinology

Item 1

A 68-year-old woman with hypertension, chronic heart failure, and stage 3 CKD has just received a diagnosis of type 2 diabetes mellitus. Laboratory values include hemoglobin A1c 8.8%, serum creatinine (SCr) 1.6 mg/dL, potassium 4.0 mEq/L, aspartate aminotransferase 18 IU/L, and alanine aminotransferase 20 IU/L. Which of the following is the most appropriate initial therapy?

1. Glipizide
2. Metformin
3. Pioglitazone
4. Sitagliptin

Answer: 1. Glipizide

Rationale: Glipizide is the only tier 1 American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) therapy listed, and it is not contraindicated in this patient. The agent will likely provide the hemoglobin A1c reduction needed. Although metformin is also a tier 1 therapy, it is contraindicated because of the patient’s elevated SCr. Sitagliptin is not recommended as a first-line therapy because of the lack of compelling efficacy data. Pioglitazone is not a tier 1 therapy, and it has a relative contraindication in patients with heart failure.

Item 2

A 65-year-old woman with hypothyroidism treated with levothyroxine 0.75 mg/day has been euthyroid for the past 4 years. Since her last clinic visit 6 months ago, she has been given diagnoses of hyperlipidemia, osteoporosis, and nonvalvular atrial fibrillation, and she has been initiated on the following medications:

Alendronate 70 mg once weekly
Calcium carbonate 1200 mg/vitamin D 800 IU supplement daily
Simvastatin 20 mg/day
Warfarin 2.5 mg/day

Her thyroid-stimulating hormone (TSH) level today is 6.9 mIU/L. Which medication most likely contributed to the loss of a euthyroid state?

1. Alendronate
2. Calcium carbonate/vitamin D supplement
3. Simvastatin
4. Warfarin

Answer: 2. Calcium carbonate/vitamin D supplement

Rationale: Calcium carbonate decreases the absorption of levothyroxine, thereby decreasing T3/T4 levels, which results in an increased TSH. There is no interaction between levothyroxine and alendronate or simvastatin. Warfarin does not affect levothyroxine levels; however, a change in thyroid status can affect the metabolism of vitamin K–dependent clotting factors and precipitate a need for altered warfarin dosing.

Item 3

A 72-year-old woman presents with lower back pain. She has a history of vertebral-crush fractures caused by osteoporosis (T-score of −3.0 at spine). She has severe gastroesophageal reflux disease (GERD). Which is the most appropriate initial treatment?

1. Alendronate
2. Calcitonin
3. Teriparatide
4. Zoledronic acid

Answer: 4. Zoledronic acid

Rationale: The correct answer is zoledronic acid for this patient because of the type of fracture and the presence of GERD. Bisphosphonates such as an alendronate would be the initial choice; however, because this patient has severe GERD, only an intravenous bisphosphonate would be an option. Teriparatide would be a second-line choice or first line if the T-score were −3.5. Calcitonin is a fourth-line choice in this patient. Although pain relief is believed to be a benefit with calcitonin, current practice is to manage pain and fracture risk separately.

Emergency Medicine

Item 1

In which clinical situation would a shock be recommended during resuscitation efforts when there is no pulse?

1. Asystole
2. Atrial fibrillation
3. First-degree heart block
4. Ventricular fibrillation

Answer: 4. Ventricular fibrillation

Rationale: The Advanced Cardiac Life Support (ACLS) Cardiac Arrest algorithm within the cardiopulmonary resuscitation and emergency cardiovascular care guidelines by the AHA has two major branches: rhythms that are amenable to shock and those that are not. Ventricular fibrillation and ventricular tachycardia can be shocked; it is recommended that asystole and pulseless electrical activity not be shocked. Both atrial fibrillation and first-degree heart block would be considered pulseless electrical activity in the above question because the victim has no pulse.

Question 2

A patient presents to the emergency department with sedation, miosis, and decreased bowel sounds. Respiratory rate is 6 breaths/minute; temperature is 98.2°F (37.2°C). Which medication would likely cause this collection of symptoms?

1. Benztropine
2. Oxycodone
3. Fluoxetine
4. Methylphenidate

Answer: 2. Oxycodone

Rationale: Toxidromes are a collection of signs and symptoms. All of the above are consistent with an opioid toxidrome. Anticholinergics (benztropine) would produce mydriasis, not miosis; fluoxetine is relatively safe, but it can cause serotonin syndrome, which would result in increased reflexes and temperature. Methylphenidate would cause agitation, mydriasis, and hyperthermia.

Question 3

Assuming a potentially toxic ingestion for each of the substances listed, in which situation would activated charcoal be expected to have the greatest benefit to decrease the chances of toxicity?

1. Lithium ingestion 45 minutes ago
2. Kerosene ingestion 5 minutes ago
3. Acetaminophen 90 minutes ago
4. Digoxin 52 minutes ago

Answer: 4 . Digoxin 52 minutes ago

Rationale: Activated charcoal is most beneficial when used within 60 minutes of the ingestion. There are situations within this window when activated charcoal is not indicated, including drugs that do not bind well to activated charcoal (lithium) or when there is a risk of aspiration (kerosene, a hydrocarbon)

Psychiatry/CNS Disorders

Item 1

A patient presents to the emergency department experiencing drug withdrawal. Which drug poses the greatest risk of death because of withdrawal?

1. Cocaine
2. Amphetamines
3. Morphine
4. Ethanol

Answer: 4. Ethanol

Rationale: Central nervous system stimulants do not result in medically serious signs. Although morphine produces significant withdrawal signs and symptoms, rarely does withdrawal result in death. With ethanol, death may result from exhaustion or unknown causes if patients enter delirium tremens (5% of withdrawal population).

Item 2

A 25-year-old woman is experiencing her first major depressive episode. She was initiated on sertraline a few months ago and titrated up to 100 mg/day to achieve better control of symptoms. What is the optimal duration of antidepressant therapy in this patient?

1. 3 months after the acute phase of her illness subsides
2. 6 months after the acute phase of her illness subsides
3. 1 year after the acute phase of her illness subsides
4. 1 year from the onset of the depressive episode

Answer: 2. 6 months after the acute phase of her illness subsides

Rationale: When treating the first depressive episode, antidepressants must be given for an additional 4–9 months after the acute episode has resolved.

Item 3

A 66-year-old man with a long-standing history of Parkinson disease (diagnosed 12 years ago) presents to the clinic for assessment. His current medications include carbidopa/levodopa 25–100 mg every 4 hours, pramipexole 1.5 mg 3 times/day, entacapone 200 mg every 4 hours, and benztropine 2 mg/day.

He experiences uncontrollable involuntary movements of his legs and arms that usually occur around the time for his next medication dose. Which drug on his current profile is most likely causing this symptom?

1. Benztropine
2. Entacapone
3. Levodopa
4. Pramipexole

Answer: 3. Levodopa

Rationale: The correct answer is levodopa. A substantial number of patients develop levodopa-induced complications within several years of starting this drug. These include motor fluctuations (the wearing-off phenomenon), involuntary movements known as dyskinesia, abnormal postures of the extremities and trunk known as dystonia, and a variety of complex fluctuations in motor function. This phenomenon may be explained by the observation that dopamine nerve terminals are able to store and release dopamine early in the course of disease, but when disease is more advanced and there is increasing degeneration of dopamine terminals, the concentration of dopamine in the basal ganglia is much more dependent on plasma levodopa levels. Ways to treat this include decreasing the levodopa dose, using a dopamine agonist, replacing sustained-release levodopa with regular levodopa in dyskinesias occurring in the late afternoon, or using levodopa dosing more frequently.

Infectious Diseases

Item 1

What is the most appropriate empiric treatment regimen for a patient with community-acquired pneumonia who needs admission to the general medical ward of a hospital?

1. Doxycycline and azithromycin
2. Ceftriaxone and azithromycin
3. Moxifloxacin and ceftriaxone
4. Vancomycin and ceftriaxone

Answer: 2. Ceftriaxone and azithromycin

Rationale: The correct answer is ceftriaxone and azithromycin. The doxycycline and azithromycin combination does not have adequate coverage for S. pneumoniae. Moxifloxacin could be used alone and does not need to be added to ceftriaxone in this patient. Vancomycin would only be used in health care–associated infections with risk of methicillin-resistant Staphylococcus aureus.

Item 2

A 44-year-old man is initiated on fluconazole for fungemia. His blood cultures are currently growing Candida spp. If identified by culture, which of species of Candida would warrant a change in antifungal therapy?

1. Candida parapsilosis
2. Candida tropicalis
3. Candida glabrata
4. Candida albicans

Answer: 3. Candida glabrata

Rationale: Fluconazole covers all Candida spp. except Candida glabrata and Candida krusei.

Item 3

A 30-year-old man with a history of poorly controlled schizophrenia secondary to poor adherence to his antipsychotic medications has newly diagnosed human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection.

His initial laboratory values are:
HIV viral load – 625,000 copies/mL
CD4 count – 75 cells/microliter (SI 0.075 x 109/L)
HBV viral load – 500 copies/mL
SCr and liver enzymes are within normal limits.
The HIV genotype reveals no significant mutations.

Which regimen would be the best recommendation for initial therapy in this patient?

1. Efavirenz/tenofovir/emtricitabine 1 tablet by mouth once daily
2. Tenofovir/emtricitabine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once daily, and atazanavir 300 mg by mouth once daily
3. Abacavir/lamivudine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once daily, and atazanavir 300 mg by mouth once daily
4. Tenofovir/emtricitabine 1 tablet by mouth once daily and lopinavir/ritonavir 400-mg/100-mg tablet 2 tablets by mouth twice daily

Answer: 2. Tenofovir/emtricitabine (Truvada) 1 tablet by mouth once daily, ritonavir (Norvir) 100 mg by mouth once daily, and atazanavir (Reyataz) 300 mg by mouth once daily

Rationale: According to U.S. Department of Health and Human Services (DHHS) guidelines, first-line highly active antiretroviral therapy (HAART) regimens should include a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs), with tenofovir/emtricitabine (Truvada) as the preferred NRTIs. Moreover, Truvada is recommended as part of the HAART regimen in patients with hepatitis B coinfection. In addition to the NRTI backbone of Truvada, the initial regimen should include efavirenz, ritonavir-boosted atazanavir, or raltegravir. Efavirenz would not be the best option given its potential to exacerbate psychotic symptoms in patients with a history of psychiatric illness.Clinical Pharmacy practice Exam questions.

Consist of three (3) segments:

This segment consists of 15 items. Answer each question.

Question 1
Which diuretic would cause increased excretion of sodium, potassium, magnesium, and calcium and would promote the reabsorption of uric acid?

1. Bumetanide
2. Hydrochlorothiazide (HCTZ)
3. Spironolactone
4. Triamterene

Answer: 1. Bumetanide

Rationale: The correct answer is bumetanide. HCTZ decreases the excretion of calcium. Spironolactone and triamterene are potassium sparing.

Question 2
Which antimicrobial has nearly equivalent oral and parenteral bioavailability?

1. Ampicillin
2. Cefuroxime
3. Linezolid
4. Vancomycin

Answer: 3. Linezolid

Rationale: Linezolid has a documented oral bioavailability of nearly 100%.

Question 3

Which drug would require a dosing adjustment for a documented creatinine clearance of less than 30 mL/minute?

1. Ceftriaxone
2. Metronidazole
3. Pantoprazole
4. Ranitidine

Answer: 4. Ranitidine

Rationale: Dosage adjustments are only necessary for ranitidine with a creatinine clearance of 35 mL/minute. The rest do not need adjustments.

Question 4
Which agent is the best treatment option for a patient taking warfarin with an international normalized ratio of 11.0 and no signs of bleeding?

1. Cyanocobalamin
2. Phytonadione
3. Protamine
4. Tocopherol

Answer: 2. Phytonadione

Rationale: The correct answer is phytonadione (vitamin K). Warfarin acts as an anticoagulant through inhibition of the vitamin K–dependent clotting factions II, VII, IX, and X. Administration of phytonadione is indicated in warfarin overdose. Protamine is used to reverse heparin overdose. Tocopherol is a form of vitamin E and has no role in reversing warfarin overdose. Cyanocobalamin is vitamin B12 and is commonly used to treat pernicious anemia.

Question 5
Which drug class is considered the pharmacologic first-line treatment of choice for posttraumatic stress disorder (PTSD)?

1. Anticonvulsants
2. Atypical antipsychotics
3. Benzodiazepines
4. Selective serotonin reuptake Inhibitors (SSRIs)

Answer: 4. SSRIs

Rationale: SSRIs are recognized by several resources as the first-line treatments (together with psychotherapy).

Question 6
A 5-year-old boy is given a diagnosis of mild croup. Which medication would be most appropriate to recommend?

1. Oral dexamethasone
2. Nebulized albuterol
3. Nebulized racemic epinephrine
4. Nebulized 3% saline

Answer: 1. Oral dexamethasone

Rationale: The correct answer is 1, oral dexamethasone (it is used to decrease pharyngeal inflammation). Racemic epinephrine is first line but, in severe episodes, not mild. Albuterol is beta-specific and will not help with edema in the upper airway. This is also true for 3% saline, which is used in bronchiolitis.

Question 7
An elderly nursing home resident develops diarrhea that is caused by Clostridium difficile. Which agent is contraindicated?

1. Cholestyramine
2. Diphenoxylate/atropine
3. Kaolin-pectin
4. Psyllium

Answer: 2. Diphenoxylate/atropine

Rationale: The correct answer is diphenoxylate/atropine. With toxin-mediated diarrhea, use of agents to slow motility would be contraindicated. In addition, this agent should be avoided in elderly patients, if possible, because of the increased risk of anticholinergic adverse effects in this population. Kaolin-pectin, cholestyramine, and psyllium are all acceptable options for symptom control for this type of diarrhea.

Question 8
A new osteoporosis drug is being tested to prevent fractures. If 25 of 100 patients in the control group experience a fracture compared with 5 of 100 patients in the treatment group, what is the number needed to treat (NNT)for the new drug?

1. 0.2
2. 0.8
3. 5
4. 20

Answer: 3. 5 patients

Rationale: The correct answer is 5. The NNT is calculated as 1/absolute risk reduction (ARR). In this case, the ARR is 0.2 (difference in event rates between drug and placebo = 0.25 − 0.05). The relative risk (RR) is 0.2 (event rate drug/event rate placebo = 0.05/0.25), and the OR (odds ratio) is 0.2 (odds of event on drug/odds of event on placebo = [5/25]/[95/75]).

Question 9
Which sedative is most likely to cause transient adrenal insufficiency when used for rapid sequence intubation?

1. Etomidate
2. Ketamine
3. Midazolam
4. Propofol

Answer: 1. Etomidate

Rationale: The correct answer is etomidate. The other agents have no known effect on adrenal function or cortisol production.

Question 10
A 70-year-old man with stage IV renal cell carcinoma is beginning sorafenib therapy. In consultation with the patient, which adverse effect should you discuss the potential development of?

1. Hypertension
2. Neutropenia
3. Peripheral neuropathy
4. Renal failure

Answer: 1. Hypertension

Rationale: Hypertension may develop within the first few weeks of therapy or slowly over the continuance of therapy. The exact etiology of hypertension is unclear, but it may be the result of pressor stimulation responses, increasing extracellular volume, and/or decreasing vascular compliance. Although trials continue to investigate the etiology of hypertension, effective management is critical to minimizing the long-term sequelae of treatment-induced hypertension.

Question 11
Which condition may result in a decrease in total phenytoin concentration in patients who routinely take phenytoin?

1. Addition of isoniazid therapy
2. Chronic alcohol abuse
3. Stage II chronic kidney disease (CKD)
4. Metabolic alkalosis secondary to diuretic therapy

Answer: 2. Chronic alcohol abuse

Rationale: Choice 2 is correct because a decrease in liver function from chronic alcohol abuse will result in a decrease in albumin production, thus decreasing the total phenytoin protein bound concentration, resulting in an increase in phenytoin-free fraction.

Choice 1 is incorrect because the addition of isoniazid will decrease the metabolism of phenytoin, potentially increasing the total phenytoin concentration. Choices 3 and 4 are incorrect because neither affects phenytoin binding to albumin.

Question 12
A propofol infusion provides the following amount of nutrition per volume:

1. 10 kcal/mL
2. 9 kcal/mL
3. 4 kcal/mL
4. 1.1 kcal/mL

Answer: 4. 1.1 kcal/mL

Rationale: An intravenous anaesthetic agent, propofol, provides 1.1 kcal of nutrition per milliliter to the patient, which is identical to a 10% intravenous lipid emulsion.

Question 13
Which regimen is the MOST appropriate first-line therapy for the management of postherpetic neuralgia?

1. Venlafaxine 25 mg orally 3 times/day
2. Nortriptyline 25 mg orally at bedtime
3. Diclofenac 1.3% topical patch applied twice daily
4. Lidocaine 5% topical patch applied for 12 hours/day

Answer: 4. Lidocaine 5% topical patch applied for 12 hours/day

Rationale: The correct answer is lidocaine 5% patch applied for 12 hours/day. Lidocaine 5% patches are U.S. Food and Drug Administration (FDA) approved for postherpetic neuralgia, and they provide analgesia within hours after application. Venlafaxine and nortriptyline must be administered for at least 1–2 weeks before a therapeutic response is seen and therefore may not be considered first-line therapy. Diclofenac and other nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically effective for the management of neuropathic pain.

Question 14
Which cytochrome P450 (CYP) isoenzyme is MOST likely responsible for the drug-drug interaction between clopidogrel and proton pump inhibitors?

1. CYP1A2
2. CYP2C9
3. CYP2C19
4. CYP3A4

Answer: 3. CYP2C19

Rationale: Competitive inhibition of CYP2C19 by proton pump inhibitors decreases the availability of the active metabolite of clopidogrel and thereby decreases its effect on platelet function.

Question 15
This agent allows lower maintenance doses or complete discontinuation of calcineurin inhibitors.

1. Alemtuzumab
2. Azathioprine
3. Sirolimus
4. Tacrolimus

Answer: 3. Sirolimus

Rationale: The correct answer is sirolimus. Sirolimus is a mammalian target of rapamycin inhibitor that is used in conjunction with or to replace calcineurin inhibitors in calcineurin inhibitor–“sparing” protocols. Tacrolimus is a calcineurin inhibitor. Alemtuzumab is a humanized monoclonal antibody that has been approved for use in chronic lymphocytic leukemia and that has been used off-label for kidney transplant induction therapy. Azathioprine is a purine antimetabolite that is used in conjunction with calcineurin inhibitors.

Clinical Case:
A 66-year-old man presents to clinic for his routine visit. He has had increasing fatigue during the past month that interferes with his daily activities. He has knee pain when he plays golf, for which he self-medicates with over-the-counter naproxen. He is adherent to all of his prescribed therapy, including dietary restrictions.

Medical History:
Hypertension
Diabetes mellitus
Chronic kidney disease (CKD) secondary to hypertension
Gout
Gastroesophageal reflux disease (GERD)
Benign prostatic hyperplasia (BPH)
Osteoarthritis

Current Medications:
Glipizide 10 mg/day x 6 years
Insulin glargine 15 units at bedtime x 3 months
Enalapril 40 mg/day x 6 years
Allopurinol 100 mg/day x 6 years
Doxazosin 4 mg at bedtime x 2 years
Ranitidine 75 mg/day x 5 years
Calcium carbonate 500 mg 3 times/day with meals x 6 months
Naproxen 250 mg twice daily x 2 weeks

Recent Laboratory Values:
Sodium 136 mEq/L (136 mmol/L)
Potassium 4.7 mEq/L (4.7 mmol/L)
Chloride 101 mEq/L (101 mmol/L)
HCO3 23 mEq/L (23 mmol/L)
Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L)
Serum creatinine (SCr) 3.2 mg/dL (282 micromoles/L)
Estimated glomerular filtration rate (Modification of Diet in Renal Disease [MDRD]) 20 mL/minute/1.73m2
Glucose, random 156 mg/dL (8.7 mmol/L)
Hemoglobin A1c 7.8%
Phosphate 6.0 mg/dL (1.9 mmol/L)
Calcium 10.5 mg/dL (2.63 mmol/L)
Albumin 2.8 g/dL (28 g/L)
White blood cell count 4500/microliter (4.5 x 109/L)
Hemoglobin 9.9 g/dL (99 g/L)
Hematocrit 29.6% (0.296)
Platelet count 175,000/microliter (175 x 109/L)
Ferritin 120 ng/mL (270 pmol/L)
Transferrin saturation 23%

Clinical Case Questions 1–5.

Question 1 – 100 points

The patient has which complication of CKD?

1. Anemia
2. Hyperkalemia
3. Metabolic acidosis
4. Uremic platelet dysfunction
Answer: 1. Anemia

Rationale: According to the Kidney Disease Quality Outcomes Initiative (KDOQI) guidelines, anemia is defined as a hemoglobin value of less than 13.5 g/dL in males. Potassium and serum bicarbonate values are all within the normal range for their assays. Uremic platelet dysfunction cannot be determined by the patient’s laboratory results.

Question 2

This patient is best described as having which stage of CKD?

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Answer: 4. Stage 4

Rationale: The patient’s estimated glomerular filtration rate (eGFR) is 20 mL/minute, which categorizes him as having stage 4 CKD (GFR 15–29 mL/minute).

Question 3

A fasting lipid panel is to be obtained. What is this patient’s low-density lipoprotein (cholesterol) (LDL) goal?

1. Less than 100 mg/dL (2.59 mmol/L)
2. Less than 130 mg/dL (3.36 mmol/L)
3. Less than 160 mg/dL (4.13 mmol/L)
4. Less than 190 mg/dL (4.91 mmol/L)
Answer: 1. Less than 100 mg/dL (2.59 mmol/L)

Rationale: CKD is considered a coronary artery disease risk equivalent. In addition, this patient has type 2 diabetes mellitus, which is considered a coronary heart disease (CHD) risk equivalent. For this reason, the LDL goal for this patient should be that of the highest risk group. Based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, the LDL goal for the highest risk group is less than 100, with an alternate goal of less than 70.

Question 4

Which is the most appropriate adjustment to make in his phosphate binder therapy?

1. Discontinue calcium carbonate.
2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
3. Continue calcium carbonate at the current dose and add aluminum hydroxide 600 mg 3 times/day.
4. Continue calcium carbonate at the current dose and add sevelamer carbonate 800 mg 3 times/day.

Answer: 2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
Rationale: Because the patient has a serum phosphate value that is above the normal range, he requires phosphate binder therapy. He has an elevated calcium level, as evidenced by his laboratory values (10.5 mg/dL), which, if corrected for a low serum albumin using the correction equation (Ca, adj = SCa + 0.8 (4-albumin), would be estimated as 11.46 mg/dL. Hypercalcemia can cause acute kidney injury through vasoconstriction of the afferent arterioles in the kidney. Calcium-based binders are not recommended in hypercalcemia, so discontinuing the calcium-based binder is warranted in this patient. Aluminum should be avoided as long-term phosphate binder therapy. Sevelamer is the best option in this patient.

Question 5
By what mechanism could the patient’s choice of naproxen be adversely affecting his renal function?

1. Direct toxic effect on the renal tubules
2. Constriction of the afferent arteriole
3. Dilation of the efferent arteriole
4. Decreased tubular reabsorption of sodium

Answer: 2. Constriction of the afferent arteriole

Rationale: NSAIDs such as naproxen can cause many different types of injury to the kidney. The most likely short-term problem with taking an NSAID for this patient is functional acute kidney injury, resulting from a decreased production of vasodilatory prostaglandins, which act on the afferent arterioles of the kidney. In patients who rely on afferent arteriole vasodilation to maintain their GFR, this causes a drop in GFR. Choice 1 is incorrect because there is no direct toxic effect on the renal tubules. Choice 4 is incorrect because the inhibition of PGE2 syntheses can lead to increased sodium reabsorption, causing peripheral edema, which is the most common renal effect of NSAIDs. Edema and sodium retention are usually mild, resulting in weight gain of 1–2 kg.

Segment
3…
This segment will consist of 15 items in five predetermined categories. Point values for each item are indicated below. Please circle your answer for each item.

Cardiovascular Disorders

Item 1

The U.S. Preventive Services Task Force (USPSTF) recommends aspirin for the primary prevention of cardiovascular disease in a 62-year-old man when his 10-year CHD risk is equal to or greater than what level:

1. 3%
2. 5%
3. 7%
4. 9%

Answer: 4. 9%

Rationale: The USPSTF created a recommendation statement on the use of “Aspirin for the Prevention of Cardiovascular Disease.” In this statement, the USPSTF balances the risk of CHD with the risk of bleeding in patients using aspirin for the primary prevention of CHD. The cut point for benefit in the male age group of 60–69 is having a 10-year CHD risk of 9% or more.

Item 2
Which medication is considered the first-line agent for the treatment of leg pain secondary to intermittent claudication?

1. Aspirin
2. Cilostazol
3. Clopidogrel
4. Pentoxifylline

Answer: 2. Cilostazol

Rationale: The treatment of choice for patients experiencing leg pain caused by intermittent claudication is cilostazol. Pentoxifylline has been shown to be comparable to placebo; therefore, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have designated it a second-tier therapy. Although aspirin and clopidogrel are used for peripheral arterial disease to reduce cardiovascular mortality, these agents have not shown a reduction in ischemic leg pain.

Item 3

A hemodynamically stable patient with systolic heart failure is initiated on amiodarone for an irregularly irregular rhythm. The patient currently receives lisinopril 20 mg orally once daily, metoprolol succinate 25 mg orally once daily, furosemide 40 mg orally once daily, and digoxin 0.25 mg orally once daily. Physical examination reveals no lower extremity edema or pulmonary crackles. What medication adjustment should occur immediately?

1. Change furosemide 40 mg orally to 20 mg intravenously daily.
2. Increase lisinopril to 40 mg orally once daily.
3. Decrease digoxin to 0.125 mg orally once daily.
4. Switch metoprolol succinate 25 mg once daily to metoprolol tartrate 12.5 mg orally twice daily.

Answer: 3. Decrease digoxin to 0.125 mg orally once daily.

Rationale: Amiodarone reduces the clearance of digoxin by inhibiting P-glycoprotein. This drug interaction is predictable and clinically significant, requiring a proactive 50% reduction in digoxin. An increase in furosemide is not necessary in a patient without edema or crackles. This patient is currently receiving the target dose of lisinopril, and an increase beyond the target dose is not needed. An equipotent dose change from metoprolol succinate to tartrate is unnecessary in a hemodynamically stable patient with systolic heart failure.

Endocrinology

Item 1

A 68-year-old woman with hypertension, chronic heart failure, and stage 3 CKD has just received a diagnosis of type 2 diabetes mellitus. Laboratory values include hemoglobin A1c 8.8%, serum creatinine (SCr) 1.6 mg/dL, potassium 4.0 mEq/L, aspartate aminotransferase 18 IU/L, and alanine aminotransferase 20 IU/L. Which of the following is the most appropriate initial therapy?

1. Glipizide
2. Metformin
3. Pioglitazone
4. Sitagliptin

Answer: 1. Glipizide

Rationale: Glipizide is the only tier 1 American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) therapy listed, and it is not contraindicated in this patient. The agent will likely provide the hemoglobin A1c reduction needed. Although metformin is also a tier 1 therapy, it is contraindicated because of the patient’s elevated SCr. Sitagliptin is not recommended as a first-line therapy because of the lack of compelling efficacy data. Pioglitazone is not a tier 1 therapy, and it has a relative contraindication in patients with heart failure.

Item 2

A 65-year-old woman with hypothyroidism treated with levothyroxine 0.75 mg/day has been euthyroid for the past 4 years. Since her last clinic visit 6 months ago, she has been given diagnoses of hyperlipidemia, osteoporosis, and nonvalvular atrial fibrillation, and she has been initiated on the following medications:

Alendronate 70 mg once weekly
Calcium carbonate 1200 mg/vitamin D 800 IU supplement daily
Simvastatin 20 mg/day
Warfarin 2.5 mg/day

Her thyroid-stimulating hormone (TSH) level today is 6.9 mIU/L. Which medication most likely contributed to the loss of a euthyroid state?

1. Alendronate
2. Calcium carbonate/vitamin D supplement
3. Simvastatin
4. Warfarin

Answer: 2. Calcium carbonate/vitamin D supplement

Rationale: Calcium carbonate decreases the absorption of levothyroxine, thereby decreasing T3/T4 levels, which results in an increased TSH. There is no interaction between levothyroxine and alendronate or simvastatin. Warfarin does not affect levothyroxine levels; however, a change in thyroid status can affect the metabolism of vitamin K–dependent clotting factors and precipitate a need for altered warfarin dosing.

Item 3

A 72-year-old woman presents with lower back pain. She has a history of vertebral-crush fractures caused by osteoporosis (T-score of −3.0 at spine). She has severe gastroesophageal reflux disease (GERD). Which is the most appropriate initial treatment?

1. Alendronate
2. Calcitonin
3. Teriparatide
4. Zoledronic acid

Answer: 4. Zoledronic acid

Rationale: The correct answer is zoledronic acid for this patient because of the type of fracture and the presence of GERD. Bisphosphonates such as an alendronate would be the initial choice; however, because this patient has severe GERD, only an intravenous bisphosphonate would be an option. Teriparatide would be a second-line choice or first line if the T-score were −3.5. Calcitonin is a fourth-line choice in this patient. Although pain relief is believed to be a benefit with calcitonin, current practice is to manage pain and fracture risk separately.

Emergency Medicine

Item 1

In which clinical situation would a shock be recommended during resuscitation efforts when there is no pulse?

1. Asystole
2. Atrial fibrillation
3. First-degree heart block
4. Ventricular fibrillation

Answer: 4. Ventricular fibrillation

Rationale: The Advanced Cardiac Life Support (ACLS) Cardiac Arrest algorithm within the cardiopulmonary resuscitation and emergency cardiovascular care guidelines by the AHA has two major branches: rhythms that are amenable to shock and those that are not. Ventricular fibrillation and ventricular tachycardia can be shocked; it is recommended that asystole and pulseless electrical activity not be shocked. Both atrial fibrillation and first-degree heart block would be considered pulseless electrical activity in the above question because the victim has no pulse.

Question 2

A patient presents to the emergency department with sedation, miosis, and decreased bowel sounds. Respiratory rate is 6 breaths/minute; temperature is 98.2°F (37.2°C). Which medication would likely cause this collection of symptoms?

1. Benztropine
2. Oxycodone
3. Fluoxetine
4. Methylphenidate

Answer: 2. Oxycodone

Rationale: Toxidromes are a collection of signs and symptoms. All of the above are consistent with an opioid toxidrome. Anticholinergics (benztropine) would produce mydriasis, not miosis; fluoxetine is relatively safe, but it can cause serotonin syndrome, which would result in increased reflexes and temperature. Methylphenidate would cause agitation, mydriasis, and hyperthermia.

Question 3

Assuming a potentially toxic ingestion for each of the substances listed, in which situation would activated charcoal be expected to have the greatest benefit to decrease the chances of toxicity?

1. Lithium ingestion 45 minutes ago
2. Kerosene ingestion 5 minutes ago
3. Acetaminophen 90 minutes ago
4. Digoxin 52 minutes ago

Answer: 4 . Digoxin 52 minutes ago

Rationale: Activated charcoal is most beneficial when used within 60 minutes of the ingestion. There are situations within this window when activated charcoal is not indicated, including drugs that do not bind well to activated charcoal (lithium) or when there is a risk of aspiration (kerosene, a hydrocarbon)

Psychiatry/CNS Disorders

Item 1

A patient presents to the emergency department experiencing drug withdrawal. Which drug poses the greatest risk of death because of withdrawal?

1. Cocaine
2. Amphetamines
3. Morphine
4. Ethanol

Answer: 4. Ethanol

Rationale: Central nervous system stimulants do not result in medically serious signs. Although morphine produces significant withdrawal signs and symptoms, rarely does withdrawal result in death. With ethanol, death may result from exhaustion or unknown causes if patients enter delirium tremens (5% of withdrawal population).

Item 2

A 25-year-old woman is experiencing her first major depressive episode. She was initiated on sertraline a few months ago and titrated up to 100 mg/day to achieve better control of symptoms. What is the optimal duration of antidepressant therapy in this patient?

1. 3 months after the acute phase of her illness subsides
2. 6 months after the acute phase of her illness subsides
3. 1 year after the acute phase of her illness subsides
4. 1 year from the onset of the depressive episode

Answer: 2. 6 months after the acute phase of her illness subsides

Rationale: When treating the first depressive episode, antidepressants must be given for an additional 4–9 months after the acute episode has resolved.

Item 3

A 66-year-old man with a long-standing history of Parkinson disease (diagnosed 12 years ago) presents to the clinic for assessment. His current medications include carbidopa/levodopa 25–100 mg every 4 hours, pramipexole 1.5 mg 3 times/day, entacapone 200 mg every 4 hours, and benztropine 2 mg/day.

He experiences uncontrollable involuntary movements of his legs and arms that usually occur around the time for his next medication dose. Which drug on his current profile is most likely causing this symptom?

1. Benztropine
2. Entacapone
3. Levodopa
4. Pramipexole

Answer: 3. Levodopa

Rationale: The correct answer is levodopa. A substantial number of patients develop levodopa-induced complications within several years of starting this drug. These include motor fluctuations (the wearing-off phenomenon), involuntary movements known as dyskinesia, abnormal postures of the extremities and trunk known as dystonia, and a variety of complex fluctuations in motor function. This phenomenon may be explained by the observation that dopamine nerve terminals are able to store and release dopamine early in the course of disease, but when disease is more advanced and there is increasing degeneration of dopamine terminals, the concentration of dopamine in the basal ganglia is much more dependent on plasma levodopa levels. Ways to treat this include decreasing the levodopa dose, using a dopamine agonist, replacing sustained-release levodopa with regular levodopa in dyskinesias occurring in the late afternoon, or using levodopa dosing more frequently.

Infectious Diseases

Item 1

What is the most appropriate empiric treatment regimen for a patient with community-acquired pneumonia who needs admission to the general medical ward of a hospital?

1. Doxycycline and azithromycin
2. Ceftriaxone and azithromycin
3. Moxifloxacin and ceftriaxone
4. Vancomycin and ceftriaxone

Answer: 2. Ceftriaxone and azithromycin

Rationale: The correct answer is ceftriaxone and azithromycin. The doxycycline and azithromycin combination does not have adequate coverage for S. pneumoniae. Moxifloxacin could be used alone and does not need to be added to ceftriaxone in this patient. Vancomycin would only be used in health care–associated infections with risk of methicillin-resistant Staphylococcus aureus.

Item 2

A 44-year-old man is initiated on fluconazole for fungemia. His blood cultures are currently growing Candida spp. If identified by culture, which of species of Candida would warrant a change in antifungal therapy?

1. Candida parapsilosis
2. Candida tropicalis
3. Candida glabrata
4. Candida albicans

Answer: 3. Candida glabrata

Rationale: Fluconazole covers all Candida spp. except Candida glabrata and Candida krusei.

Item 3

A 30-year-old man with a history of poorly controlled schizophrenia secondary to poor adherence to his antipsychotic medications has newly diagnosed human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection.

His initial laboratory values are:
HIV viral load – 625,000 copies/mL
CD4 count – 75 cells/microliter (SI 0.075 x 109/L)
HBV viral load – 500 copies/mL
SCr and liver enzymes are within normal limits.
The HIV genotype reveals no significant mutations.

Which regimen would be the best recommendation for initial therapy in this patient?

1. Efavirenz/tenofovir/emtricitabine 1 tablet by mouth once daily
2. Tenofovir/emtricitabine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once daily, and atazanavir 300 mg by mouth once daily
3. Abacavir/lamivudine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once daily, and atazanavir 300 mg by mouth once daily
4. Tenofovir/emtricitabine 1 tablet by mouth once daily and lopinavir/ritonavir 400-mg/100-mg tablet 2 tablets by mouth twice daily

Answer: 2. Tenofovir/emtricitabine (Truvada) 1 tablet by mouth once daily, ritonavir (Norvir) 100 mg by mouth once daily, and atazanavir (Reyataz) 300 mg by mouth once daily

Rationale: According to U.S. Department of Health and Human Services (DHHS) guidelines, first-line highly active antiretroviral therapy (HAART) regimens should include a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs), with tenofovir/emtricitabine (Truvada) as the preferred NRTIs. Moreover, Truvada is recommended as part of the HAART regimen in patients with hepatitis B coinfection. In addition to the NRTI backbone of Truvada, the initial regimen should include efavirenz, ritonavir-boosted atazanavir, or raltegravir. Efavirenz would not be the best option given its potential to exacerbate psychotic symptoms in patients with a history of psychiatric illness.

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