Deck 12: Pharmacology

Question 1

A 29-year-old woman comes to the office with a 2-month history of right lower quadrant pain and intermittent diarrhea.  Vital signs are normal.  The examination is unremarkable except for right lower quadrant tenderness.  After confirmatory testing, the patient is given a delayed ileal-release medication that works by binding to a cytosolic receptor, translocating to the nucleus, and inhibiting nuclear factor-kappa-B (NF-κB).  The patient is most likely being treated with which of the following medications?

A)Azathioprine
B)Budesonide
C)Infliximab
D)Methotrexate
E)Mycophenolate

Answer 1

B

This patient has chronic right lower abdominal pain with tenderness and intermittent diarrhea, symptoms that raise suspicion for Crohn disease with ongoing active inflammation.  Patients with mild Crohn disease (eg, limited area of inflammation, no evidence of systemic involvement) are often treated with a targeted-release glucocorticoid such as budesonide to reduce inflammation and induce disease remission.
Glucocorticoids, like many other lipid-derived hormones (eg, progesterone, estrogen), bind to a cytosolic receptor rather than a cell surface receptor.  The glucocorticoid-receptor complex can then translocate into the nucleus, bind to the relevant DNA regions, and cause a tissue-specific alteration in transcription.  In immune cells, the effects of glucocorticoids include inhibition of proinflammatory transcription factors such as nuclear factor-kappa-B (NF-κB), which results in reduced expression of cytokines and inflammatory mediators (eg, TNF-alpha) along with decreased immune cell survival and propagation.
Oral budesonide (often given in a delayed-release preparation that targets the ileum) is especially useful in Crohn disease because it has high topical potency and less systemic adverse effects than other glucocorticoids (eg, prednisone) due to high first-pass metabolism.
(Choices A and E)  Azathioprine and mycophenolate can be used to reduce inflammation in patients with moderate-severe Crohn disease by inhibition of de novo purine synthesis, which immune cells (eg, B and T cells) are especially dependent on during proliferation.  Both agents inhibit key enzymes in the purine synthesis pathway (which occurs in the cytosol) rather than inhibiting transcription factors.
(Choice C)  Although infliximab can be used to induce remission in patients with moderate-severe Crohn disease, it is a monoclonal antibody that reduces inflammation by binding to and inhibiting the proinflammatory effects of tumor necrosis factor-alpha (TNF-alpha), a cytokine that is primarily found extracellularly.
(Choice D)  Methotrexate and its breakdown products are folic acid analogues that can reduce inflammation by competitively inhibiting multiple folate-dependent enzymes rather than inhibiting transcription factors.
Educational objective:
Budesonide, like other glucocorticoids, reduces inflammation by binding to a cytosolic receptor, translocating into the nucleus, and inhibiting proinflammatory transcription factors such as nuclear factor-kappa-B (NF-κB).  It is especially useful in reducing transmural bowel inflammation in patients with Crohn disease because it has high topical potency and limited systemic adverse effects due to high first-pass metabolism.

Question 2

A 54-year-old man is transferred to the hospital from his cardiologist's office due to atrial fibrillation with rapid ventricular response.  His symptoms began 24 hours earlier with palpitations, lightheadedness, and chest tightness.  The patient has had similar episodes several times during the last year.  Past history is notable for mitral valve repair 3 years ago for severe symptomatic mitral regurgitation.  The patient undergoes direct current cardioversion due to worsening hemodynamic instability, with resolution of the arrhythmia and all associated symptoms.  He is considered for long-term amiodarone therapy to prevent future arrhythmic episodes.  Which of the following should be tested before initiating this medication?

A)24-hour urinary cortisol
B)24-hour urinary metanephrines
C)Oral glucose tolerance test
D)Serum prolactin
E)Serum testosterone
F)Serum TSH

Answer 2

F

Amiodarone is a class III anti-arrhythmic agent used to suppress life-threatening rhythm disturbances.  Because it is 40% iodine by weight, amIODarone can cause a number of alterations in thyroid function.  It can cause hypothyroidism due to decreased production of thyroid hormone.  Individuals with pre-existing autoimmune thyroid disease are at greatest risk and so should be screened for subclinical hypothyroidism with a serum TSH assay prior to initiating amiodarone therapy.  Amiodarone can also cause hyperthyroidism due to increased thyroid hormone synthesis or destructive thyroiditis with release of preformed thyroid hormone.
(Choices A and B)  Amiodarone is not associated with altered function of the adrenal cortex or medulla.
(Choice C)  The oral glucose tolerance test is used to screen for diabetes mellitus, primarily in pregnant women.  Amiodarone is not associated with significant alterations in insulin sensitivity or blood glucose levels.
(Choice D)  Release of prolactin is primarily regulated by inhibitory effects of dopamine from the hypothalamus.  Release is stimulated to a small degree by thyrotropin-releasing hormone and therefore may be mildly affected by amiodarone.  However, these effects would not be clinically significant.
(Choice E)  Amiodarone can cause erectile dysfunction, which may be related to its alpha and beta adrenoreceptor blocking effect.  Amiodarone does not significantly alter serum testosterone levels.
Educational objective:
Amiodarone is 40% iodine by weight.  It can cause hypothyroidism due to decreased production of thyroid hormone.  Amiodarone can also cause hyperthyroidism due to increased thyroid hormone synthesis or destructive thyroiditis with release of preformed thyroid hormone.
__________
References:
Effects of amiodarone therapy on thyroid function.
(http://www.ncbi.nlm.nih.gov/pubmed/19935743)

Question 3

A 42-year-old woman is hospitalized due to fever and chills after a hemodialysis session.  The patient has a history of end-stage kidney disease due to IgA nephropathy and recently began intermittent dialysis through a tunneled catheter.  Medical history includes depression, for which she takes citalopram.  Temperature is 38.4 C (101.1 F), blood pressure is 130/80 mm Hg, and pulse is 94/min.  There is no erythema or tenderness at the catheter site, and the remainder of the physical examination shows no abnormalities.  Blood cultures are obtained, and empiric vancomycin and ceftazidime are initiated.  While receiving the intravenous vancomycin infusion, the patient reports a burning, itching sensation.  Vital signs are unchanged, but repeat examination shows an erythematous rash involving the face and neck.  She reports no history of drug allergy but has never received these antibiotics.  Which of the following is the most likely underlying cause of this patient's current condition?

A)Bacterial product release
B)Cross-reacting antibodies
C)Direct mast cell activation
D)Drug-specific antibodies
E)Serotonergic drug interaction

Answer 3

C

This patient was given vancomycin and shortly thereafter developed burning, itching, and an erythematous rash on the face and neck, raising strong suspicion for red man syndrome (RMS).  RMS is a nonallergic reaction that occurs when vancomycin is infused too rapidly; rapid vancomycin infusion can directly activate mast cells, leading to the release of potent vasoactive mediators (eg, histamine).
Manifestations of RMS include flushing, pruritus, and an erythematous rash, which is usually seen on the upper torso, neck, and face.  Myalgias and hypotension can occasionally occur.  Discontinuation of the vancomycin and administration of diphenhydramine are usually curative.  Because RMS is not IgE mediated, it is not a true allergic reaction, so vancomycin infusion can be resumed at a slower rate once symptoms resolve.
(Choice A)  Patients with spirochetal illness (eg, syphilis, Lyme disease) can develop the Jarisch-Herxheimer reaction after the initiation of antimicrobial therapy.  It is caused by massive release of bacterial products into the circulation due to widespread bacterial lysis.  However, most cases arise several hours (not minutes) after antimicrobial therapy and are marked by high fever and worsened constitutional symptoms (eg, headache, myalgia).
(Choices B and D)  Antibody-mediated drug reactions generally require previous exposure (sensitization) to the medication.  This patient who has never received vancomycin is unlikely to have an antibody-mediated reaction; furthermore, such reactions are rare with vancomycin and are usually marked by urticaria, pruritus, hypotension, and angioedema.
(Choice E)  Serotonergic drug interactions are most common with drugs that affect the serotonin system such as selective serotonin reuptake inhibitors, tricyclic antidepressants, and certain antiemetics (eg, ondansetron).  However, most cases are marked by alterations in autonomic function (eg, hypertension, tachycardia, hyperthermia), and rash is unusual.
Educational objective:
Red man syndrome (RMS) is the most common adverse reaction to vancomycin.  It occurs due to rapid vancomycin infusion, which leads to the direct activation of mast cells and the subsequent release of vasoactive mediators.  Patients develop flushing, pruritus, and an erythematous rash on the upper torso, face, and neck within minutes of initiation.  Because RMS is not a true allergic reaction (not IgE mediated), vancomycin can be restarted at a slower rate of infusion once symptoms resolve.

Question 4

A 62-year-old woman is admitted to the hospital for a living-donor kidney transplant.  She has a history of end-stage kidney disease due to diabetic nephropathy and has been undergoing hemodialysis for the last 2 years.  The transplant surgery is performed without complication, and the patient demonstrates good urine output afterward.  To help prevent rejection, she is given a medication that inhibits the conversion of inosine monophosphate to guanosine monophosphate primarily in lymphocytes, causing reduced proliferation of activated lymphocytes.  Which of the following medications is most likely being used in this patient?

A)Azathioprine
B)Mycophenolate
C)Prednisone
D)Sirolimus
E)Tacrolimus

Question 5

A 22-year-old woman comes to the emergency department after development of a diffuse pruritic rash following a meal at a buffet restaurant an hour ago.  She also felt light-headed and nearly fainted.  The patient has no prior medical conditions and takes no medications.  Temperature is 37 C (98.6 F), blood pressure is 96/52 mm Hg, pulse is 126/min, and respirations are 16/min.  Physical examination shows mild lip swelling; the tongue appears normal.  Heart auscultation demonstrates regular tachycardia without extraneous sounds.  Lung sounds are clear with normal work of breathing.  Skin examination shows confluent urticaria on the neck, shoulders, and abdomen.  Intravenous fluids are begun, and intramuscular epinephrine is administered immediately.  In addition to its effect on airway and circulation, this medication is most likely to improve this patient's condition through which of the following mechanisms?

A)Blockade of tissue histamine receptors
B)Decreased IgE Fc receptors on mast cells
C)Decreased leukotriene synthesis in leukocytes
D)Decreased mediator release from mast cells
E)Decreased number of circulating eosinophils

Question 6

A 32-year-old man comes to the clinic for follow-up due to Crohn disease.  The patient was initially diagnosed 3 years ago and achieved disease remission following a course of high-dose glucocorticoids.  He remained in remission until 2 months ago, when he experienced an acute flare of diarrhea and abdominal pain that required a brief hospitalization and another course of high-dose glucocorticoids.  The patient completed a prescribed glucocorticoid taper earlier this week and says that his symptoms have returned to "about normal."  Azathioprine maintenance therapy is started to help prevent future flares.  Which of the following most accurately describes the expected effects of this new medication on immune function?

Question 7

A 50-year-old woman comes to the office due to cough, shortness of breath, fatigue, and weight loss.  The patient does not use tobacco or alcohol.  Blood pressure is 110/70 mm Hg, pulse is 88/min and regular, and oxygen saturation on room air is 96%.  Lung examination reveals scattered crackles.  Serum calcium levels are elevated.  Imaging studies reveal mediastinal fullness and diffuse, bilateral, ground-glass lung opacities.  Biopsy of the lung lesions shows granulomas with multinucleated giant cells; no microorganisms or particulates are present.  Appropriate pharmacotherapy is initiated.  At follow-up a few days later, the symptoms have improved but blood glucose is elevated.  Which of the following additional changes is most likely present in this patient due to her treatment?

A)Decreased production of IL-10
B)Impaired migration of neutrophils to inflammatory sites
C)Increased apoptosis of neutrophils
D)Increased expression of IL-1
E)Increased formation of 1,25-dihydroxyvitamin D
F)Increased production of prostaglandins

Question 8

A 60-year-old man comes to the office for a routine follow-up visit.  He feels well overall except for an intermittent, mild, generalized headache.  The patient has no known medical problems and takes no medications.  He does not smoke, follows a generally healthy diet, and exercises daily.  On examination, his blood pressure is 150/85 mm Hg, and he is started on lisinopril.  At a follow-up visit, the patient's blood pressure is 128/78 mm Hg.  He also has a dry cough that began a few weeks after starting lisinopril.  This drug is stopped and losartan is now prescribed.  The patient seems to be compliant with his medication; the cough resolves and he experiences no significant side effects.  When compared with no treatment at all, this patient's current therapy is most likely to result in which of the following changes?

Question 9

A 12-year-old girl is being evaluated for recurrent episodes of self-limited colicky abdominal pain and nausea lasting several days.  She was also recently hospitalized for an episode of difficulty breathing.  The patient has no significant past medical history, but her mother has a history of attacks of severe abdominal pain and diarrhea.  Physical examination is unremarkable.  Laboratory evaluation reveals decreased serum complement C4 and C1 esterase inhibitor levels.  Which of the following drugs is contraindicated in this patient?

A)Captopril
B)Furosemide
C)Methotrexate
D)Metoprolol
E)Penicillin

Question 10

An 8-year-old girl is brought to the office by her mother due to chronic pruritus affecting her arms.  The mother states that the patient is always scratching herself.  She scratches through the night, affecting her ability to sleep.  Her sister has similar, but less severe, symptoms.  The patient also has intermittent asthma.  The rash is shown in the exhibit. 

First-line therapy for this patient's condition works by which of the following mechanisms of action?

A)Blockade of leukotriene receptors in inflamed tissue
B)Increasing the number of resident dendritic cells
C)Induction of keratinocyte apoptosis
D)Inhibition of phospholipase A₂ activity in cell membranes
E)Reduction of serum IgE levels

Question 11

A 60-year-old man who was recently diagnosed with hypertension comes to the office for follow-up.  He was treated with lisinopril but stopped a week ago due to a dry, nagging cough.  Past medical history is notable for type 2 diabetes mellitus with moderately increased albuminuria but normal creatinine clearance.  His other medications include metformin and rosuvastatin.  The patient does not smoke or drink alcohol.  His blood pressure is 150/92 mm Hg.  BMI is 31 kg/m².  Physical examination, including the heart and lungs, is unremarkable.  Which of the following is the best treatment for this patient's hypertension?

A)Diltiazem
B)Hydralazine
C)Metoprolol
D)Ramipril
E)Valsartan

Question 12

A 71-year-old woman comes to the office for follow-up.  She has a history of systolic heart failure and was hospitalized 2 weeks ago for an exacerbation, which was treated with intravenous diuretics.  Since discharge the patient has been taking oral diuretics and says her shortness of breath has improved, but she is now experiencing muscle weakness and cramping.  Blood pressure is 128/72 mm Hg and pulse is 80/min.  Physical examination shows mildly decreased muscle strength in the lower extremities.  Laboratory evaluation reveals a serum potassium level of 2.2 mEq/L.  The patient receives potassium supplements, which improve the weakness.  Another diuretic is added to her medical regimen to help prevent this adverse effect in the future.  This additional medication predominantly acts on which of the following nephron segments?

A)A
B)B
C)C
D)D
E)E
F)F

Question 13

A 62-year-old woman undergoes hip replacement surgery.  The patient has a history of advanced hip osteoarthritis that limits her daily activities.  She has no other medical conditions and no known drug allergies.  After appropriate preoperative evaluation, total hip arthroplasty is performed under general anesthesia.  The intraoperative course is uncomplicated, and after recovery from anesthesia, patient-controlled intravenous morphine is started for pain control.  Several minutes later, the patient reports generalized itching.  Physical examination reveals hypotension, tachycardia, and mild bilateral wheezing but no rashes.  Which of the following drug effects is most likely responsible for this patient's current condition?

A)Decreased myocardial contractility
B)Decreased sympathetic output
C)Direct mast cell degranulation
D)Formation of drug-IgE complexes
E)Increased 5-lipoxygenase activity

Question 14

A 75-year-old man comes to the urgent care center with acute onset of a pruritic rash after eating strawberries.  The patient has no associated swelling in or around the mouth, no wheezing, and no difficulty breathing.  Past medical history is notable for coronary artery disease, for which he takes atorvastatin, lisinopril, aspirin, and metoprolol.  He also has a history of allergy to dog and cat dander.  The patient does not use alcohol or tobacco.  His family reports that he lives alone and his functional status has been declining.  He walks with a cane, has poor vision, and is frequently forgetful.  The patient also has occasional dizziness when standing up and a history of frequent falls.  Which of the following would be the most appropriate medication to treat this patient's acute symptoms?

A)Chlorpheniramine
B)Diphenhydramine
C)Hydroxyzine
D)Loratadine
E)Promethazine

Question 15

A 44-year-old man comes to the office for a routine check-up.  Past medical history is significant for hypercholesterolemia, which he has controlled through diet.  His father died of a myocardial infarction at age 56, and his mother, who is still living, has a history of stroke.  On physical examination, the patient's blood pressure is 160/100 mm Hg and heart rate is 70/min.  He is started on enalapril.  During the first 7 days of therapy, the patient's glomerular filtration rate (GFR) adjusts as shown in the graph below. Which of the following structures was most likely affected by a downstream effect of enalapril and is therefore responsible for this patient's renal response?

A)Afferent arterioles
B)Distal tubules
C)Efferent arterioles
D)Proximal tubules
E)Vasa recta

Question 16

A 79-year-old man is brought to the hospital due to confusion for the past 2 days.  The patient has had nausea, decreased appetite, and poor oral intake for several weeks.  He has also mentioned that everything around him has "a yellow tint."  He has no abdominal pain.  Medical history includes long-standing heart failure with reduced ejection fraction and atrial fibrillation.  Medications include metoprolol, digoxin, lisinopril, and apixaban.  The patient is afebrile.  Blood pressure is 130/80 mm Hg and pulse is 58/min.  The abdomen is soft and nontender; there is no rigidity or rebound and no masses are present.  Age-related changes in which of the following factors most likely accounts for this patient's symptoms?

A)Intestinal absorption
B)Liver enzyme activity
C)Muscle mass
D)Plasma protein binding
E)Renal clearance

Question 17

A 69-year-old man comes to the office due to a 6-month history of chest tightness when he walks uphill or climbs stairs.  The discomfort radiates to his throat and lasts 5-10 minutes before slowly subsiding.  Medical history is significant for hyperlipidemia and type 2 diabetes mellitus.  His father had coronary artery bypass surgery at age 60 and his mother suffered a stroke.  Vital signs are normal.  Cardiac examination reveals no murmurs or additional heart sounds.  The patient is prescribed a medication that is metabolized to S-nitrosothiols in the vascular smooth muscle cells, and he reports rapid and significant symptom relief.  Which of the following components of the cardiovascular system is most susceptible to the medication prescribed to this patient?

A)Cardiac muscle
B)Large arteries
C)Large veins
D)Precapillary sphincters
E)Small arteries and arterioles

Question 18

A 67-year-old man with nonischemic cardiomyopathy comes to the office for follow-up.  He recently was hospitalized for acute decompensated heart failure.  The patient's symptoms have improved with multidrug treatment, but he has persistent shortness of breath on mild exertion.  He has a history of hypertension and hypercholesterolemia.  Blood pressure is 115/70 mm Hg and pulse is 66/min.  There is a third heart sound on heart auscultation and mild lower extremity pitting edema.  A recent echocardiogram showed a left ventricular ejection fraction of 30%.  Which of the following diuretics would most likely improve survival if added to this patient's current regimen?

A)Acetazolamide
B)Furosemide
C)Hydrochlorothiazide
D)Mannitol
E)Spironolactone
F)Triamterene

Question 19

A 57-year-old male with suspected bacterial pneumonia is admitted to the hospital and given ceftriaxone and azithromycin for treatment.  Soon after the first dose of ceftriaxone, he complains of difficulty breathing, abdominal cramps, and lightheadedness.  His current blood pressure is 70/50 mmHg, while his heart rate is 120/min.  Physical examination reveals a diffuse maculopapular rash.  Which of the following drugs should be administered next to this patient?

A)Corticosteroids
B)Epinephrine
C)Norepinephrine
D)Dobutamine
E)Diphenhydramine

Question 20

A 56-year-old man comes to the hospital due to 24 hours of burning substernal chest pain.  The most intense pain occurred approximately 6 hours ago, and it has started to subside.  The patient has a history of diabetes mellitus.  ECG shows sinus rhythm with ST-segment elevation in leads V3 to V5.  In the cardiac catheterization laboratory, he is found to have total occlusion of the left anterior descending artery.  Successful intervention is performed to restore blood flow in the artery.  The next day, the patient's echocardiogram shows a normal-sized left ventricle with no evidence of hypertrophy; there is apical and anterior akinesia with a reduced left ventricular ejection fraction of 38%.  Which of the following is the most likely long-term effect of ACE inhibitor therapy in this patient?

A)Attenuation of left ventricular chamber dilation
B)Enhanced collagen deposition in the apical myocardium
C)Enhanced collagen deposition in the peri-infarct myocardium
D)Enhanced left ventricular hypertrophy in basal segments
E)Increase in left ventricular stroke work

Question 21

A 56-year-old man comes to the emergency department due to palpitations and lightheadedness over the last 2 hours.  He has a history of hypertension but no other cardiac conditions and never before had similar symptoms.  The patient drinks 1 to 2 alcoholic beverages daily but does not smoke cigarettes or use illicit drugs.  Blood pressure is 132/76 mm Hg and pulse is 116/min and irregular.  Cardiopulmonary examination is normal, except for tachycardia.  Resting ECG shows atrial fibrillation.  The patient undergoes transesophageal echocardiography, which reveals normal cardiac anatomy and no intracardiac thrombi.  Electrical cardioversion is performed.  After the intervention, sinus rhythm is restored, and amiodarone therapy is begun to maintain normal sinus rhythm.  Which of the following cardiac electrophysiologic changes are most likely to occur in this patient due to the medication?

Question 22

A new antiarrhythmic medication (drug A) is tested in a series of experiments that measure the flow of ions responsible for producing an action potential in cardiac muscle cells.  Ion flow is measured before and after the drug is administered, and the results are shown in the chart below (each colored line represents a different type of ion). Drug A has an antiarrhythmic effect most similar to which of the following drugs?

A)Adenosine
B)Digoxin
C)Dofetilide
D)Esmolol
E)Flecainide
F)Lidocaine
G)Quinidine
H)Verapamil

Question 23

A 47-year-old man comes to the office for follow-up of his elevated blood pressure.  The patient's medical history is significant for stable angina pectoris, for which he takes sublingual nitroglycerin as needed.  He has no orthopnea, paroxysmal nocturnal dyspnea, or lower extremity swelling.  His blood pressure is 154/107 mm Hg and pulse is 86/min.  Physical examination shows no abnormalities.  The patient is started on a low dose of atenolol.  Which of the following cellular changes will most likely occur as a direct effect of this medication?

Question 24

A 45-year-old man comes to the clinic due to recurrent palpitations accompanied by chest discomfort and shortness of breath.  A year ago, he was diagnosed with paroxysmal atrial fibrillation treated with rate control using a beta blocker.  Past medical history is also significant for hypertension and obesity.  Echocardiogram shows left atrial enlargement, normal left ventricular ejection fraction, and no significant valvular disease.  24-hour Holter monitoring reveals bursts of atrial fibrillation associated with the patient's symptoms.  He is initiated on dofetilide to maintain normal sinus rhythm.  This medication exerts its main effect on which portion of the action potential curve?

A)A
B)B
C)C
D)D
E)E

Question 25

A 24-year-old man comes to the emergency department due to the sudden onset of palpitations.  The patient says it feels like "my heart is racing."  He had an episode similar to this a year ago that resolved spontaneously.  Blood pressure is 126/74 mm Hg and pulse is 164/min.  Rapid intravenous administration of a medication to this patient results in instantaneous resolution of the arrhythmia but is accompanied by short-lived flushing, burning in the chest, and shortness of breath.  Which of the following medications was used to treat this patient's condition?

A)Adenosine
B)Amiodarone
C)Digoxin
D)Ibutilide
E)Lidocaine
F)Verapamil

Question 26

A 65-year-old man is brought to the emergency department due to central chest pain for the past 2 hours.  The patient describes the pain as "very severe" and "going back all the way to my spine."  He has never had similar pain.  Medical history is significant for hypertension; the patient has been nonadherent with prescribed medical therapy and follow-up visits.  He has a 20-pack-year smoking history.  Blood pressure is 195/101 mm Hg, and pulse is 93/min and regular.  Chest examination reveals clear lungs.  ECG shows sinus rhythm and voltage criteria for left ventricular hypertrophy.  Portable chest x-ray reveals a widened mediastinum.  The patient is immediately treated with intravenous esmolol.  Which of the following is the most likely purpose of this patient's current therapy?

A)Decreasing left ventricular contraction velocity
B)Decreasing myocardial oxygen demand
C)Decreasing peripheral vascular resistance
D)Increasing left ventricular filling pressure
E)Increasing left ventricular stroke volume

Question 27

A 44-year-old man reports exertional shortness of breath and palpitations.  On examination, he has a systolic murmur at the left sternal border and cardiac apex, which gets louder when he stands up.  He is diagnosed with obstructive hypertrophic cardiomyopathy and paroxysmal atrial fibrillation, and is started on a medication.  Changes in the action potential of ventricular muscle cells before and after administration of medication are shown in the image below Black curve = Before administration of medication
Red curve = After administration of medicationThe patient is most likely being treated with which of the following medications?

A)Adenosine
B)Digoxin
C)Diltiazem
D)Disopyramide
E)Flecainide
F)Lidocaine
G)Propranolol

Question 28

A 40-year-old female with a history of depression and hypertension is brought to the ER after being found obtunded in her apartment.  She is hypotensive and bradycardic on physical examination.  Intravenous glucagon is administered, and her condition improves.  Which of the following intracellular changes is most likely responsible for the improvement in her condition?

A)Increased synaptic release of glutamate
B)Decreased cAMP in vascular smooth muscle
C)Decreased DAG in vascular smooth muscle
D)Increased cAMP in cardiac myocytes
E)Increased IP₃ in cardiac myocytes

Question 29

A 62-year-old man comes to the office for follow-up of hypertension.  He was diagnosed with hypertension 10 years ago and has been treated with a number of different medications.  However, the patient has had to discontinue several medications due to side effects such as dizziness, palpitations, and headaches.  Currently he takes ramipril and chlorthalidone and is tolerating them well.  Blood pressure is 160/92 mm Hg and was 158/89 mm Hg at his most recent prior visit.  ECG shows sinus bradycardia (55/min) with PR interval prolongation (280 msec).  Which of the following medications would be most effective for lowering this patient's blood pressure without worsening his ECG abnormalities?

A)Diltiazem
B)Metoprolol
C)Nifedipine
D)Sotalol
E)Verapamil

Question 30

A 45-year-old man who was recently started on medication for paroxysmal atrial fibrillation undergoes stress ECG testing.  The patient exercises on a treadmill for 9 minutes and reaches 98% of age-predicted maximal heart rate without chest pain or ST-segment changes.  His pre-test resting QRS complex duration is 95 msec (normal: 80-120 msec) and corrected QT (QTc) interval duration is 410 msec (normal <440 msec).  ECG findings recorded at his maximally achieved heart rate show a QRS complex duration of 125 msec and QTc interval duration of 400 msec.  Based on the patient's test results, which of the following medications is most likely being used to treat his atrial fibrillation?

A)Atenolol
B)Digoxin
C)Dofetilide
D)Flecainide
E)Verapamil

Question 31

An investigator studies the effects of 2 different medications on the heart rate of patients with persistent atrial fibrillation.  After participants receive therapeutic doses of medication for several days, their heart rates are measured for 24 hours at rest and during 10 minutes of moderate exercise.  The results are compared against placebo and shown in the graphs below.  Which of the following medications is most likely represented by the red line (drug 1)?

A)Amlodipine
B)Atenolol
C)Digoxin
D)Lisinopril

Question 32

A 60-year-old man comes to the emergency department with dizziness and palpitations.  He woke up this morning with an intermittent pounding sensation in his chest.  The patient has occasionally experienced a similar sensation in the past and did not think it was serious.  Later, while mowing the lawn, he became lightheaded and had to sit down to avoid passing out.  After receiving the appropriate workup, the patient is diagnosed with a cardiac arrhythmia and started on a medication known to prolong the QT interval.  However, the drug is associated with a lower incidence of torsade de pointes than other QT-prolonging agents.  Which of the following medications was most likely used in this patient?

A)Adenosine
B)Amiodarone
C)Digoxin
D)Esmolol
E)Lidocaine
F)Procainamide
G)Verapamil

Question 33

A 37-year-old man with no significant medical history comes to the office due to intermittent palpitations.  He has a healthy lifestyle, exercises daily, and does not use tobacco, alcohol, or illicit drugs.  ECG shows atrial fibrillation with rapid ventricular response.  Echocardiogram reveals normal heart function with no significant valvular disease.  The patient is started on an antiarrhythmic medication that is known to be effective against both atrial and ventricular arrhythmias.  On ECG, this medication causes QRS prolongation with only minimal increase in QT interval duration.  Which of the following regions of the action potential curve is most affected by this drug?

A)A
B)B
C)C
D)D
E)E

Question 34

A 47-year-old man with known coronary artery disease comes to the emergency department with chest tightness, sweating, and palpitations.  His symptoms began abruptly 2 hours ago while he was at work.  Six months ago, the patient underwent percutaneous angioplasty of the right coronary artery.  Past medical history also includes anxiety and panic attacks.  Blood pressure is 180/90 mm Hg and pulse is 110/min with a regular rhythm.  An esmolol infusion produces rapid symptom relief and heart rate slowing.  Which of the following portions of the ECG will be affected most significantly by the medication?

A)A
B)B
C)C
D)D
E)E

Question 35

A 65-year-old man comes to the emergency department due to substernal chest discomfort and intermittent palpitations that began this morning.  The patient has a history of coronary artery disease and stable angina that is managed medically.  He takes high-dose metoprolol, atorvastatin, and low-dose aspirin.  The patient reports that he has been traveling for the past week and ran out of his medications 2 days ago.  Temperature is 37 C (98.6 F), blood pressure is 148/82 mm Hg, and pulse is 112/min.  ECG reveals sinus tachycardia with a 1-mm ST segment depression in the lateral leads.  Which of the following is most likely responsible for this patient's presentation?

A)Increased levels of circulating catecholamines
B)Predominant activation of alpha-adrenergic receptors
C)Reduced activity of cyclic AMP-mediated messaging
D)Reduced cellular sensitivity to circulating catecholamines
E)Upregulation of beta-adrenergic receptors

Question 36

A 55-year-old man comes to the emergency department due to an hour of intense substernal chest burning accompanied by sweating.  He has a history of obesity and diet-controlled type 2 diabetes mellitus.  On initial evaluation, blood pressure is 110/70 mm Hg and pulse is 60/min and regular.  Oxygen saturation is 98% on room air.  The patient is comfortable lying flat and no heart murmurs are heard.  Lungs are clear on auscultation.  Immediate ECG shows normal sinus rhythm with a 2-mm ST-segment elevation in leads II, III, and aVF.  Aspirin and morphine are administered.  As the patient is about to be transported to the catheterization lab for urgent percutaneous coronary intervention, he develops dizziness and the telemetry monitor shows sinus bradycardia at 40/min.  The patient appears pale and diaphoretic and peripheral pulses are faint.  Blood pressure is 70/40 mm Hg.  Which of the following is the best immediate step for managing this patient's condition?

A)Adenosine
B)Alteplase
C)Amiodarone
D)Atropine
E)Naloxone
F)Physostigmine

Question 37

A 50-year-old man has recurrent episodes of paroxysmal atrial fibrillation accompanied by uncomfortable palpitations and chest pressure.  Echocardiogram reveals normal biventricular function and no significant valvular disease.  Coronary angiography reveals no obstructive coronary artery disease.  The patient is started on medication to reduce his symptoms.  Two weeks later, he is seen in the emergency department for lightheadedness, weakness, and presyncope.  ECG reveals sinus bradycardia at a rate of 53/min with QTc prolongation (508 msec).  Telemetry monitoring reveals a short episode of self-resolved torsades de pointes.  Which of the following medications was most likely used to treat this patient's palpitations?

A)Diltiazem
B)Metoprolol
C)Mexiletine
D)Ranolazine
E)Sotalol

Question 38

A 49-year-old woman is brought to the emergency department with squeezing chest pain and profuse sweating for the last 2 hours.  Medical history includes diet-controlled type 2 diabetes mellitus.  ECG reveals ST-segment elevation in leads I, aVL, and V1-V4.  The patient is immediately taken to the cardiac catheterization laboratory, where she is found to have complete occlusion of the left anterior descending coronary artery.  The blockage is opened with percutaneous coronary intervention with stenting, but afterward she experiences recurrent and sustained episodes of ventricular arrhythmia.  She is treated with an antiarrhythmic agent that preferentially binds to rapidly depolarizing and ischemic ventricular myocardial fibers and has minimal effect on normal ventricular myocardium.  Which of the following agents was most likely used in this patient?

A)Adenosine
B)Digoxin
C)Diltiazem
D)Ibutilide
E)Lidocaine
F)Metoprolol
G)Procainamide

Question 39

A new drug has been developed to treat cardiac arrhythmias.  The drug has high affinity for activated and inactivated sodium channels but relatively little affinity for resting sodium channels.  An experiment is devised to maintain sodium channels in the inactivated state for a prolonged period, during which they are exposed to the new drug.  After allowing the sodium channels to return to the resting state, the speed of the drug's dissociation from the sodium channels is recorded and shown below.  The dissociation curve for quinidine is given for comparison. The pharmacologic action of the new drug is most similar to which of the following drugs?

A)Disopyramide
B)Flecainide
C)Lidocaine
D)Propranolol
E)Sotalol
F)Verapamil

Question 40

A 34-year-old man diagnosed with advanced non-Hodgkin lymphoma undergoes doxorubicin-containing chemotherapy with good clinical response.  Several weeks after the last chemotherapy cycle, the patient comes to the office with progressive exertional dyspnea.  He has difficulty sleeping flat at night and needs to use multiple pillows to fall asleep.  The patient is a lifetime nonsmoker and has no family history of heart disease.  Blood pressure is 124/72 mm Hg, pulse is 86/min, and respirations are 16/min.  Oxygen saturation on room air is 96%.  Which of the following is most likely responsible for this patient's current symptoms?

A)Dilated cardiomyopathy
B)Focal myocardial scarring
C)Hypertrophic cardiomyopathy
D)Pericardial thickening and fibrosis
E)Restrictive cardiomyopathy
F)Right ventricular pressure overload

Question 41

A 54-year-old man with nonischemic cardiomyopathy comes to the office for a follow-up visit.  He has been hospitalized frequently for acute decompensated heart failure, and currently has dyspnea on mild exertion.  The patient also has a history of hypertension and takes multiple medications.  Blood pressure is 116/70 mm Hg, and pulse is 72/min and regular.  Physical examination shows elevated jugular venous pressure, bibasilar lung crackles, and lower extremity edema.  Serum creatinine is 1.0 mg/dL and serum potassium is 4.2 mEq/L.  Three weeks after starting digoxin therapy, the patient reports symptomatic improvement.  Which of the following is the initial cellular event triggering this response to the new medication?

A)Decreased sodium efflux from myocardial cells
B)Increased intracellular calcium concentration
C)Increased intracellular cyclic AMP concentration
D)Increased potassium influx into myocardial cells
E)Troponin sensitization to calcium

Question 42

A 64-year-old man comes to the office due to exertional chest pain over the last 6 months.  He is a lifelong 1 pack per day cigarette smoker and has a history of type 2 diabetes mellitus and peripheral artery disease.  The patient undergoes treadmill exercise stress testing and develops substernal chest pain on moderate exertion accompanied by ECG changes that resolve immediately upon rest.  He refuses invasive cardiac testing.  The patient is started on low-dose aspirin therapy for secondary prevention of cardiovascular disease but experiences shortness of breath and wheezing with the medication.  Which of the following is the best alternate therapy for this patient?

A)Apixaban
B)Cilostazol
C)Clopidogrel
D)Enoxaparin
E)Eptifibatide
F)Naproxen
G)Warfarin

Question 43

A 62-year-old man who underwent mitral valve replacement 1 month ago is being evaluated in the emergency department for low-grade fevers.  He has some malaise and dyspnea.  Multiple sets of blood cultures are drawn and, within hours, all bottles grow gram-positive cocci in clusters that are catalase-positive and coagulase-negative.  The decision is made to begin empiric antibiotic therapy.  Initial empiric treatment should include which of the following antibiotics?

A)Ceftriaxone
B)Ciprofloxacin
C)Clindamycin
D)Nafcillin
E)Penicillin G
F)Vancomycin

Question 44

A 68-year-old man comes to the office due to several weeks of progressive exertional dyspnea and lower extremity edema.  Medical history is significant for non-Hodgkin lymphoma, which is in remission after chemotherapy 8 years ago.  Blood pressure is 126/76 mm Hg and pulse is 88/min.  Physical examination reveals bibasilar lung crackles and 1+ bilateral lower extremity edema.  Echocardiography shows biventricular dilation and a left ventricular ejection fraction of 35%.  Stress myocardial perfusion scan is negative for inducible ischemia.  After initial stabilization, long-term use of which of the following medications will most likely improve survival in this patient?

A)Amiodarone
B)Amlodipine
C)Carvedilol
D)Digoxin
E)Diltiazem
F)Flecainide
G)Furosemide

Question 45

A 57-year-old man is seen in the office after an episode of acute pancreatitis.  Hospital evaluation found no evidence of gallstones.  The patient does not consume alcohol, but he does have a history of severe hypertriglyceridemia.  He was treated with a fibrate medication in the past but could not tolerate it due to liver toxicity.  He has no history of diabetes mellitus or hypertension.  On examination, the patient has no abdominal tenderness.  Laboratory studies show normal hepatic and pancreatic enzyme levels, but the patient again has a severely elevated triglyceride level.  The physician prescribes the appropriate medications and explains that the patient is likely to experience skin flushing and warmth after taking the pills.  Which of the following is the primary agent mediating these side effects?

A)Histamine
B)Platelet-activating factor
C)Prostaglandin
D)Serotonin
E)Substance P

Question 46

A 63-year-old man comes to the office for a follow-up visit.  Two months ago, he was hospitalized for chest pain and was found to have a blockage in the left anterior descending artery.  He had percutaneous coronary intervention with placement of a drug-eluting stent, and was discharged on appropriate medical therapy.  His other medical problems include hypertension, type 2 diabetes mellitus, and degenerative joint disease.  The patient has been taking all his medications as prescribed.  He has no chest pain but does have diffuse muscle aches and cramps, especially after exercise.  Physical examination is unremarkable.  Laboratory testing reveals elevated serum creatine kinase.  The medication most likely responsible for this patient's current findings also causes which of the following effects?

A)Decreased gastric mucosal prostaglandin synthesis
B)Elevated plasma bradykinin level
C)Impaired potassium entry into cells
D)Increased hepatocyte LDL receptor recycling
E)Increased renal calcium reabsorption
F)Inhibition of hepatic gluconeogenesis

Question 47

A 77-year-old man comes to the office after he was found to have high blood pressure during a health fair.  The patient denies any medical problems and feels proud that he has not needed to see a doctor for many years.  His blood pressure is 170/70 mm Hg and pulse is 74/min.  Other physical examination findings are normal.  The patient is started on a medication to treat his hypertension.  During his follow-up visit 3 weeks later, he reports bilateral leg swelling.  He has no chest pain, shortness of breath, or abdominal symptoms.  His blood pressure is 135/65 mm Hg and pulse is 80/min.  Cardiopulmonary examination is normal, but there is bilateral, symmetrical, 2+ pitting lower extremity edema.  Laboratory studies show serum creatinine of 0.8 mg/dL, and urinalysis is negative for proteinuria.  Which of the following was most likely prescribed to treat this patient's hypertension?

A)Amlodipine
B)Eplerenone
C)Hydrochlorothiazide
D)Ramipril
E)Torsemide
F)Valsartan

Question 48

A 72-year-old man is brought to the hospital due to severe substernal chest pain and shortness of breath for the last several hours.  The pain started suddenly when he was outside working in the garden.  Medical history includes diet-controlled diabetes mellitus and hypertension.  Physical examination reveals bilateral crackles and a third heart sound.  ECG shows ST elevation in multiple leads.  The patient is diagnosed with an acute myocardial infarction complicated by acute severe heart failure.  He is started on dobutamine infusion and prepared for coronary catheterization.  Which of the following is most likely to be increased due to the medication used in this patient?

A)Cardiac diastolic filling time
B)Myocardial oxygen consumption
C)Peripheral vascular resistance
D)Pulmonary capillary wedge pressure
E)Right ventricular end diastolic pressure

Question 49

In an experiment investigating vasoconstriction of the arterial wall, two samples of isolated porcine arterial vessels are studied.  Vascular tone is measured in the control vessel during infusion of increasing doses of norepinephrine.  The other vessel is pretreated with experimental drug A prior to infusion of norepinephrine.  A graph of the study results is depicted below. Drug A is most similar to which of the following agents?

A)Atropine
B)Labetalol
C)Phenoxybenzamine
D)Phentolamine
E)Propranolol

Question 50

A 56-year-old Caucasian female presents to your office with chronic cough.  She says that the cough is dry and affects quality of her life significantly.  She denies chest pain, hemoptysis and shortness of breath.  Her past medical history is significant for long-standing hypertension, diabetes and myocardial infarction experienced two months ago.  She does not smoke or consume alcohol.  Her blood pressure is 130/70 mmHg and heart rate is 70/min.  Which of the following is the best next step in the management of this patient?

A)Careful review of family history
B)Careful review of past allergic episodes
C)Careful review of current medications
D)Careful review of diet and physical activity
E)Chest x-ray

Question 51

A 53-year-old man comes to the physician for a follow-up visit after an acute myocardial infarction.  His medications include metoprolol and low-dose aspirin.  He used to smoke 2 packs of cigarettes daily but quit after his myocardial infarction.  The patient's father has hypertension and his mother has type 2 diabetes mellitus.  He currently weighs 100 kg (220 lb) and is 178 cm (70 in) tall.  Examination shows an obese male with no other abnormalities.  His total serum cholesterol level is 155 mg/dL, with an HDL level of 27 mg/dL and a triglyceride level of 92 mg/dL.  Which of the following lipid-lowering agents would be most effective for preventing future cardiovascular events in this patient?

A)Absorption inhibitor
B)Cationic exchange resin
C)Enzyme inhibitor
D)Essential fatty acids
E)Pharmacologic vitamin
F)Transcription factor ligand

Question 52

A 58-year-old man comes to the office due to progressive fatigue, dyspnea on exertion, and orthopnea.  Medical history is significant for hypertension, hyperlipidemia, and a myocardial infarction 2 years ago.  The patient says he has not taken his medications in several months because he was "feeling well."  Blood pressure is 160/95 mm Hg and pulse is 94/min and regular.  Physical examination shows bilateral lung crackles and lower extremity edema.  The point of maximal impulse is displaced toward the axilla, and an S3 is heard.  Serum creatinine is 0.9 mg/dL and serum potassium is 4.2 mEq/L.  After this patient's condition has stabilized, long-term use of which of the following medications will most likely reduce mortality?

A)Amlodipine
B)Digoxin
C)Diltiazem
D)Furosemide
E)Hydrochlorothiazide
F)Lisinopril
G)Triamterene

Question 53

A 52-year-old woman with a history of locally advanced breast cancer comes to the office for follow-up.  The patient is undergoing trastuzumab-based chemotherapy but has not received radiation therapy.  She has no symptoms except mild fatigue.  Blood pressure is 120/72 mm Hg and pulse is 85/min and regular.  The patient is afebrile.  Transthoracic echocardiography reveals a left ventricular ejection fraction of 40% with no evidence of valvular disease.  Cardiac assessment prior to chemotherapy initiation was normal.  Which of the following pathologic findings is most likely to be present in this patient's heart?

A)Abnormal protein accumulation in the extracellular space
B)Focal ischemic cardiomyocyte necrosis
C)Myocardial tumor cell infiltration
D)Patchy cardiomyocyte necrosis with diffuse myocardial fibrosis
E)Reduced cardiomyocyte contractility with no fibrosis

Question 54

Physiologists conduct a series of experiments on hypophysectomized animals to investigate the effects of cortisol on vascular reactivity.  Their initial tests show that administration of cortisol alone does not elicit a vascular response.  Next, the researchers measure vascular reactivity to an infusion of norepinephrine both with and without pretreatment with cortisol.  The results of their experiments are shown in the graph below. Which of the following pharmacologic principles best describes the effect of cortisol in this experiment?

A)Additive effect
B)Alteration in metabolism
C)Permissiveness
D)Synergistic effect
E)Tachyphylaxis

Question 55

A 65-year-old man comes to the physician after missing a follow-up appointment for congestive heart failure.  He missed his appointment due to an upset stomach that will not go away.  A detailed history reveals disturbed color perception, anorexia, nausea, vomiting, and diarrhea that have worsened over the past 2 weeks.  His congestive heart failure has thus far been controlled effectively with multiple medications.  If the cause of this patient's current symptoms is not corrected, which of the following complications is most likely to develop?

A)Angioedema
B)Arrhythmia
C)Bronchoconstriction
D)Hypotension
E)Pulmonary edema

Question 56

A 76-year-old woman is brought to the emergency department by her son due to lethargy and confusion over the past 2 days.  The patient has persistent atrial fibrillation and congestive heart failure and is on multiple medications.  Recently, she has had nausea and decreased appetite.  Today, she had 3 episodes of vomiting.  The patient also reports vision difficulties.  Temperature is 36.7 C (98 F) and blood pressure is 133/80 mm Hg.  Laboratory results are as follows: ECG shows junctional escape rhythm at a rate of 48/min with occasional ventricular premature beats.  Increased blood level of which of the following medications is most likely responsible for her symptoms?

A)Amiodarone
B)Aspirin
C)Digoxin
D)Diltiazem
E)Furosemide
F)Metoprolol
G)Spironolactone
H)Valsartan

Question 57

A 48-year-old man comes to the office for a follow-up visit.  He was diagnosed with hypercholesterolemia 6 months ago and has been strictly following dietary and lifestyle modifications as advised.  The patient has no other medical problems.  He does not use tobacco, alcohol, or illicit drugs.  His father has diabetes mellitus and coronary artery disease.  The patient's blood pressure is 126/70 mm Hg and BMI is 33.1 kg/m².  Physical examination is normal.  Laboratory studies show a current LDL level of 190 mg/dL.  Which of the following should be obtained before starting statin therapy in this patient?

A)Apolipoprotein-B level
B)Complete blood count
C)Lipoprotein lipase activity assay
D)Liver transaminase levels
E)Serum cortisol level
F)Serum creatinine

Question 58

A 45-year-old man comes to the hospital with acute onset of severe chest pain and diaphoresis.  The patient describes the pain as "squeezing," different from any discomfort he has ever had.  He has a past medical history of hypertension, and his father underwent coronary artery bypass grafting at age 50.  The patient is diagnosed with acute ST-elevation myocardial infarction and undergoes an urgent coronary intervention with stent placement into the right coronary artery.  He is also started on high-intensity atorvastatin therapy, along with antiplatelet therapy and appropriate medications to control blood pressure.  Four weeks later, the patient's total cholesterol level is 140 mg/dL, down from 200 mg/dL before discharge.  Which of the following has most likely increased as the result of the therapy?

A)ApoB-100 concentration
B)Biliary excretion of cholesterol
C)LDL receptor density
D)Plasma free fatty acids
E)VLDL concentration

Question 59

A 36-year-old man comes to the office after he was found to have an abnormal lipid panel during employee wellness testing at his company.  He has no prior medical problems and takes no medications.  The patient is a software technician and has a sedentary lifestyle.  He eats mostly fast foods, rarely exercises, and drinks 2-3 cans of beer daily.  His BMI is 31 kg/m².  Physical examination is unremarkable.  Results of laboratory studies performed in the office are as follows: Lifestyle modification with a balanced diet, regular exercise, and reduced alcohol intake is advised.  He is also started on fenofibrate therapy.  This medication is most likely to help the patient by which of the following mechanisms?

A)Blocking intestinal cholesterol absorption
B)Decreasing hepatic cholesterol synthesis
C)Increasing fecal loss of cholesterol derivatives
D)Inhibiting LDL receptor degradation
E)Reducing hepatic VLDL production

Question 60

A 60-year-old man comes to the office for follow-up due to persistent atrial fibrillation.  He reports occasional palpitations and poor exercise tolerance.  For the past year, the patient's atrial fibrillation has been managed with a rate-control strategy using metoprolol.  Three months ago, his metoprolol dosage was increased for improved rate control, but today in the office, he reports that he was unable to tolerate the new dosage due to dizziness.  Blood pressure is 110/70 mm Hg and pulse is 105/min and irregular.  Examination shows no abnormalities.  Echocardiography reveals left atrial enlargement, an ejection fraction of 59%, and no significant valvular disease.  The patient is advised to remain on his previously tolerated metoprolol dose, and digoxin is added to the medication regimen.  Four weeks later, he reports symptom improvement.  Resting pulse is 84/min and irregular.  Which of the following best explains digoxin's effect on heart rate in this patient?

A)Decreased atrial refractoriness
B)Decreased cardiomyocyte action potential duration
C)Decreased Purkinje fiber automaticity
D)Increased parasympathetic tone
E)Increased ventricular contractility

Question 61

A 55-year-old man comes to the emergency department with recurrent episodes of retrosternal chest pain.  The episodes occur during physical activity, usually when he climbs stairs or walks uphill.  The patient has no known medical problems and does not use tobacco, alcohol, or illicit drugs.  He is given a sublingual tablet and reports rapid relief of the pain.  This drug most likely improved this patient's symptoms by causing which of the following hemodynamic changes?

A)Decrease in arteriolar resistance
B)Decrease in heart rate
C)Decrease in left ventricular end-diastolic volume
D)Increase in coronary blood flow
E)Increase in coronary perfusion pressure

Question 62

A 54-year-old man comes to the office due to new-onset muscle cramps.  The patient has a history of hypertension and was started on hydrochlorothiazide 4 weeks ago.  Blood pressure is 138/86 mm Hg and pulse is 78/min.  Examination shows no abnormalities.  Based on his most recent laboratory results, triamterene is added to the current therapy.  Which of the following best describes the mechanism of action of this medication?

A)Blocking renal tubular epithelial sodium channels
B)Decreased aldosterone production
C)Increased intestinal absorption of potassium
D)Inhibiting aldosterone receptor activity in renal collecting duct
E)Inhibiting Na+/K+ ATPase activity in skeletal muscle

Question 63

A 23-year-old man comes to the office due to chest discomfort that usually occurs during exercise, such as jogging or climbing stairs.  The symptoms go away 5 to 10 minutes after he stops.  The patient has not had syncope but mentions some shortness of breath that accompanies the chest pain.  Family history includes an uncle who died suddenly at age 35.  Blood pressure is 122/70 mm Hg and pulse is 70/min and regular.  The apical impulse is strong and sustained.  While supine, the patient has a soft crescendo-decrescendo systolic murmur at the apex and left sternal border; it becomes quite pronounced when he stands.  Which of the following medications should be avoided while treating this patient's condition?

A)Amiodarone
B)Disopyramide
C)Isosorbide dinitrate
D)Metoprolol
E)Verapamil

Question 64

A 72-year-old man is brought to the emergency department with waxing and waning chest pressure over the past several hours.  The patient says he occasionally gets a similar sensation that lasts 5-10 minutes when he walks briskly up the stairs.  Medical history is significant for hypertension and hyperlipidemia; he has been nonadherent with prescribed medical therapy and follow-up visits.  The patient has a 25-pack-year smoking history.  Blood pressure is 211/105 mm Hg, and pulse is 88/min and regular.  Chest examination reveals no heart murmurs, and the lungs are clear.  ECG shows sinus rhythm and nonspecific ST-segment changes.  A medication is administered intravenously and produces the following hemodynamic effects compared to baseline: Which of the following medications was most likely used in this patient?

A)Hydralazine
B)Labetalol
C)Metoprolol
D)Nitroprusside
E)Phentolamine

Question 65

A 66-year-old man comes to the emergency department due to several episodes of lightheadedness and a recent fall.  The symptoms are especially pronounced in the morning when he gets up from bed.  The patient takes medications for hypertension, stable angina pectoris, gout, and benign prostate hyperplasia.  He also has osteoarthritis of the right knee and takes occasional nonsteroidal anti-inflammatory drugs.  His blood pressure is 120/80 mm Hg and pulse is 70/min in the supine position, and 90/60 mm Hg and 87/min on standing, respectively.  Cardiopulmonary examination is normal.  Blockade of which of the following receptors is most likely contributing to this patient's current condition?

A)α1-adrenergic
B)α2-adrenergic
C)β1-adrenergic
D)β2-adrenergic
E)D1-dopaminergic

Question 66

A 64-year-old man with a long-standing history of hypertension is brought to the emergency department with a dry cough and shortness of breath.  The patient has been unable to sleep in the flat position for the past 2 days.  Blood pressure is 192/102 mm Hg and pulse is 92/min and regular.  Physical examination reveals an S4 and bibasilar crackles.  He is started on intravenous nitroglycerin infusion and soon after reports significant symptomatic relief.  Which of the following physiologic changes are most likely to occur following administration of this medication?

Question 67

A 50-year-old man is brought to the ER with severe dizziness and confusion.  He states that he had an episode of chest pain and took several tablets of nitroglycerin.  His current medications include a daily aspirin for heart attack prevention, an occasional acetaminophen for headaches and occasionally tadalafil for erectile dysfunction.  His blood pressure is 50/20 mmHg and his heart rate is 120 beats/min.  Which of the following cellular changes is most likely responsible for this patient's symptoms?

A)Receptor downregulation
B)G_s protein phosphorylation
C)Cyclic GMP accumulation
D)Tyrosine kinase overactivity
E)Enhanced phospholipid metabolism
F)Tolerance development

Question 68

A 42-year-old man comes to the emergency department due to an episode of syncope.  He was standing in his kitchen this morning when he felt palpitations for about 3 seconds; the next thing he remembers is waking up on the floor.  The patient has had intermittent palpitations for the last few weeks, sometimes with associated lightheadedness.  He has no significant medical history other than chronic lower back pain that began following a fall from a ladder 3 years ago.  The patient fractured several lumbar vertebrae in that fall and required a surgical lumbar fusion.  His back pain was uncontrolled with conservative measures, and he has been treated with escalating doses of methadone for the past year.  He does not smoke or drink alcohol.  The patient has a remote history of intravenous heroin abuse but has not used it for 20 years.  He has no family history of early-onset heart disease, blood clots, or sudden death.  Blood pressure is 120/70 mm Hg when supine and 125/75 mm Hg when standing.  Physical examination is unremarkable.  Which of the following ECG findings is most likely in this patient?

A)Atrioventricular block
B)Deep Q waves
C)QT interval prolongation
D)Sinus pauses
E)Ventricular preexcitation

Question 69

A 43-year-old man comes to the emergency department due to a 3-day history of persistent headaches.  The patient has a history of hypertension and has had poor medical follow-up.  Blood pressure is 224/115 mm Hg and pulse is 67/min.  He appears mildly confused during the physical examination, but no focal neurologic deficits are noted.  Funduscopic examination shows bilateral papilledema.  Serum creatinine is 1.4 mg/dL.  An intravenous medication is initiated that causes arteriolar dilation while also improving renal perfusion and increasing natriuresis.  Which of the following agents is most likely being used in this patient?

A)Esmolol
B)Fenoldopam
C)Hydralazine
D)Nitroglycerin
E)Phenylephrine

Question 70

An 82-year-old man is brought to the emergency department after a syncopal episode.  He has had no chest pain or dyspnea but he has constipation of recent onset.  He was hospitalized 2 weeks ago for atrial fibrillation with rapid ventricular response and was discharged home with oral medications after appropriate management.  Medical history is also significant for hypertension and severe chronic obstructive pulmonary disease requiring home supplemental oxygen.  Blood pressure is 105/60 mm Hg and pulse is 50/min.  Examination reveals bilaterally decreased breath sounds, no wheezing, and normal heart sounds.  ECG shows new-onset second-degree atrioventricular block.  Which of the following drugs is the most likely cause of his current condition?

A)Amlodipine
B)Diltiazem
C)Hydrochlorothiazide
D)Lidocaine
E)Propranolol
F)Terazosin
G)Valsartan

Question 71

A 60-year-old Caucasian male is diagnosed with exertional angina.  His treatment regimen includes metoprolol, isosorbide dinitrate and aspirin.  He takes isosorbide dinitrate early in the morning and again in the afternoon, but he does not take an evening dose.  Such a pattern of drug administration is intended to decrease which of the following?

A)Pharmacokinetic drug interaction
B)Pharmacodynamic drug antagonism
C)Effect potentiation
D)Tolerance development
E)Withdrawal symptoms
F)Drug noncompliance

Question 72

A 25-year-old man comes to the office due to shortness of breath.  He states that even moderate exertion forces him to stop to catch his breath.  The patient has no family history of sudden cardiac death.  He does not use tobacco or illicit drugs.  On examination, the patient has a faint systolic murmur at the left sternal border in the supine position that increases to 3/6 in intensity with Valsalva maneuver.  Echocardiography shows interventricular septal hypertrophy and increased left ventricular mass.  The patient is started on high-dose beta blocker therapy.  On follow-up 2 weeks later, he reports significant improvement in his shortness of breath.  Physical examination reveals no murmurs supine or with Valsalva.  Which of the following best accounts for improvement of this patient's symptoms?

A)Dilation of epicardial coronary arteries
B)Increase in left ventricular outflow tract flow velocity
C)Reduction in left ventricular contractility
D)Reduction in left ventricular mass
E)Reduction in left ventricular preload

Question 73

A 56-year-old woman comes to clinic for follow-up of heart failure with reduced ejection fraction.  Over the last 3 months, the patient has been hospitalized twice due to acute decompensation of heart failure that required treatment with intravenous furosemide.  Since her most recent discharge, she has been taking high doses of oral furosemide, but she continues to have progressive lower extremity edema and weight gain.  Serum creatinine is 1.2 mg/dL and serum potassium is 4.1 mEq/L.  The patient is started on metolazone.  The addition of metolazone is likely to assist in treating this patient because of which of the following effects of furosemide?

A)Increased calcium delivery to the distal tubules
B)Increased sodium delivery to the distal tubules
C)Increased tubular reabsorption of bicarbonate
D)Increased tubular reabsorption of uric acid
E)Reduced tubular reabsorption of glucose
F)Reduced tubular reabsorption of potassium

Question 74

A 60-year-old man comes to the hospital with chest pain.  He has had intermittent, squeezing substernal pain over the last 3 days that is now sustained.  The patient has no associated palpitations, lightheadedness, or shortness of breath.  Medical history is notable for moderate chronic obstructive pulmonary disease with a recent admission for an exacerbation.  Blood pressure is 145/90 mm Hg and pulse is 93/min.  Oxygen saturation by pulse oximetry is 98% on room air.  Physical examination shows no heart murmurs, and lungs are clear to auscultation.  ECG shows sinus rhythm with 2-mm anterior ST segment elevation.  Cardiac troponin I levels are elevated.  Which of the following is the most appropriate treatment for this patient?

A)Ibutilide
B)Metoprolol
C)Nadolol
D)Propranolol
E)Sotalol

Question 75

A 60-year-old man with known coronary artery disease comes to the office due to exertional chest tightness for the last 6 months.  The symptoms occur when he walks more than 3 blocks, especially in cold weather.  The patient underwent coronary artery bypass graft surgery 3 years ago for progressive angina.  Past medical history also includes asthma, benign prostate hyperplasia, and peripheral artery disease.  The physician discusses adding isosorbide dinitrate to his current therapy but the patient is concerned about adverse effects.  Which of the following is most likely to occur in this patient with the add-on therapy?

A)Atrioventricular conduction delay
B)Cold extremities
C)Constipation
D)Joint pains
E)Nocturnal wheezing
F)Throbbing headaches
G)Urinary retention

Question 76

A 64-year-old man comes to the office for follow-up of hypertension.  At the last 2 visits, his blood pressure was persistently elevated.  The patient has been treated with lisinopril for the past 5 years, but his other blood pressure medications have been changed several times due to various adverse effects.  Medical history is significant for type 2 diabetes mellitus, coronary artery disease with stable angina, and moderately increased albuminuria.  Blood pressure is 145/87 mm Hg and pulse is 70/min.  BMI is 31 kg/m².  Physical examination shows trace bilateral lower extremity edema.  ECG is unremarkable.  Serum laboratory results are as follows: Review of the patient's medical records shows similar serum laboratory results 6 months ago.  Which of the following medications should be avoided in this patient?

A)Amlodipine
B)Bumetanide
C)Diltiazem
D)Eplerenone
E)Furosemide
F)Metoprolol

Question 77

A 17-year-old girl is brought to the emergency department after an episode of syncope.  The patient was sitting on the couch watching television when she suddenly passed out.  She had no symptoms prior to the event and regained consciousness spontaneously after approximately 2 minutes.  Her family noticed a brief twitching while the patient was unconscious, but she had no tongue biting or bowel or bladder incontinence.  The patient is taking an antimicrobial agent for a recent infection but has no other chronic medical conditions.  Her uncle died suddenly 2 years ago.  A detailed evaluation reveals a decrease-in-function mutation in the KCNH2 gene, which codes for a voltage-gated potassium channel that is active during the repolarization phase of cardiomyocyte action potential.  The patient's medication was causing further impairment of the ion channel function, leading to the incident of syncope.  This patient was most likely taking which of the following medications?

A)Acyclovir
B)Amoxicillin
C)Cephalexin
D)Doxycycline
E)Erythromycin
F)Terbinafine

Question 78

A 53-year-old man comes to the emergency department with shortness of breath and chest tightness.  The patient was playing in a poker tournament when his symptoms first began.  He has a history of hypertension and is not compliant with his medications.  His last medical follow-up was a year ago.  Blood pressure is 195/115 mm Hg and pulse is 90/min and regular.  Lung examination reveals bibasilar crackles.  Nitroglycerin infusion is started and results in significant symptomatic improvement.  Repeat blood pressure is 165/90 mm Hg.  Which of the following intracellular events is most likely responsible for the beneficial effects of this patient's treatment?

A)Actin phosphorylation
B)Calcium release from sarcoplasmic reticulum
C)Enhanced cyclic mononucleotide degradation
D)Inositol triphosphate accumulation
E)Myosin dephosphorylation
F)Tyrosine kinase activation

Question 79

A 76-year-old man is brought to the emergency department with severe midsternal chest pain and diaphoresis.  Past medical history is significant for hypertension, type 2 diabetes mellitus, and asymptomatic right carotid artery stenosis.  His blood pressure is 120/70 mm Hg and pulse is 75/min.  Lungs are clear on auscultation.  ECG shows ST segment elevations greater than 1 mm in leads II, III, and aVF.  The patient receives aspirin immediately upon arrival followed by alteplase and a low-dose beta blocker.  A single dose of intravenous morphine is given for pain control.  Several hours later, the patient is found to be comatose with asymmetric pupils and an irregular breathing pattern.  What is the most likely cause of this patient's current condition?

A)Carotid artery thrombosis
B)Dissection of the ascending aorta
C)Interventricular septum perforation
D)Intracerebral hemorrhage
E)Myocardial reperfusion injury
F)Opioid overdose
G)Pulmonary embolism

Question 80

A 45-year-old man is brought to a rural emergency department due to severe chest pain, sweating, and nausea.  The symptoms began suddenly an hour ago.  He has no significant medical history.  His father died at age 50 after experiencing sudden-onset chest pain.  The patient smokes a pack of cigarettes daily.  He does not take any medications and has no known drug allergies.  Examination shows normal heart sounds and breath sounds.  ECG shows sinus tachycardia with ST segment elevation in leads II, III, and aVF.  Medical management for the patient's acute condition is initiated.  After initial treatment, the chest pain decreases in intensity and a reperfusion complex ventricular arrhythmia emerges.  The arrhythmia is asymptomatic and resolves spontaneously.  Which of the following drugs is most likely responsible for rapid reperfusion in this patient?

A)Alteplase
B)Apixaban
C)Argatroban
D)Aspirin
E)Heparin
F)Prasugrel
G)Rosuvastatin