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Chapter 3. MAJOR ORGAN SYSTEMS PHARMACOLOGY

«DRUGS USED TO TREAT CONGESTIVE EART FAILURE (CHF)»

19. Two patients with multiple cardiovascular diseases are being treated long-term with digoxin, furosemide, triamterene, atorvastatin, and nitroglycerine.

One patient reports occasional nausea, vomiting, and anorexia, and a Cyellow-greenish tint” to white objects and bright lights. These signs and symptoms are most characteristic of toxicity due to which drug?

Another patient, treated with the same regimen, reports non-specific muscle aches and pains. Serum electrolyte profiles are normal. Muscle trauma has been ruled-out. Which drug is the most likely cause of the symptoms?

20. A 76-year-old woman with an 8-year history of CHF that has been well controlled with digoxin and furosemide develops recurrence of dyspnea on exertion. On physical examination, she has sinus tachycardia, rales at the base of both lungs, and 4 + pitting edema of the lower extremities. Which drug could be added to her therapeutic regimen?

«ANTI-ARRHYTHMIC DRUGS»

21. Following a myocardial infarct, a 40-year-old male patient is being treated with a drug that affords prophylaxis against cardiac arrhythmias. He complains of dizziness and feelings of nausea but has not vomited. Sometimes he sees “double”, and bright lights bother him. EGG reveals prolongation of the QRS complex and increased QT interval. Which drug is most likely to be responsible for these effects?

22. A patient with hyperthyroidism develops a cardiac arrhythmia. What is the optimal treatment of the patient?

23. Following a myocardial infarction, a patient in the emergency room of a hospital develops ventricular tachycardia. What is the best drug to manage this situation?

24. A 36-year-old man is seen in the ED with tachycardia, a respiratory rate of 26 breaths per minute (BPM), and ECG evidence of an arrhythmia.
An intravenous bolus dose of an antiarrhythmic agent is administered, and within 30 s, he has a respiratory rate of 45 BPM and complains of a burning sensation in his chest. Which drug is most likely to have caused the adverse effect?

«ANTIANGINAL DRUGS»

25. A 45-year-old man asks his physician for a prescription for sildenafil to improve his sexual performance. Because of risks from a serious drug interaction, this drug should not be prescribed, and the patient should be urged not to try to obtain it from other sources, if he is also taking which drug?

26. A 60-year-old man is brought to A&E with central crushing chest pain. He has been in pain for several hours and it was not relieved by nitroglycerin. The man was feeling nauseous and was very anxious. His blood pressure was 140/75. An ECG revealed ST segment elevation, pathological Q waves and inversion of the T wave in leads II, III and aVF. A diagnosis of acute inferior myocardial infarction (MI) was made.

(a) What drugs should be administered immediately to this patient?

(b) What contraindications should you consider?

(c) What drugs would you prescribe for this patient to take long-term when he returns home?

«ANTIHYPERTENSIVE DRUGS»

27. A 54-year-old male patient with hypertension has been treated with a thiazide and clonidine for several years, with repeated BP measurements close to 140/90 and no significant side effects, except a decreased sexual interest. In your office, he complains of palpitations, and now his pulse is 100/min with BP of 165/118 both sitting and standing. He has not gained weight but admits to mild anxiety over his marital relationship. What is the most likely cause of his current problem?

28. Which one of the following is the most appropriate drug to use for the patient described in parentheses?

A. Captopril (60-year-old woman with diabetic nephropathy)

B. Nitroprusside (50-year-old man with BP of 140/95)

C. Losartan (29-year-old pregnant woman)

D. Propranolol (40-year-old patient with peripheral vascular disease)

E. Reserpine (37-year-old patient with pheochromocytoma)

29. A 90-year-old male patient with HTN is being treated with furosemide, lisinopril, and spironolactone. Because of a fainting spell, he is brought to the ER, where his BP supine is 105/60, falling to 65/42 when he is asked to sit up. What is the most reasonable case?

30. A 52-year-old woman with essential hypertension, hypercholesterolemia, and chronic-stable angina develops constipation. It is attributed to one of her medications. Which was the most likely cause?

31. A 50-year-old man with a 2-year history of essential hypertension well controlled on hydrochlorothiazide is found on a recent physical examination to have a blood pressure of 160/105 mmHg. The hydrochlorothiazide is substituted with another agent. Two weeks later, he returns for follow-up complaining of a loss of taste. Which drug is most likely to have caused the adverse effect?

32. Your patient has severe (Stage 4) hypertension that is being controlled with a combination of hydralazine, furosemide, and carvedilol. He also has had bouts of atrial fibrillation that are being managed long term with quinidine and warfarin for prophylaxis of thromboembolism. The patient presents with fever, chills, arthralgia, and a purplish discoloration on the face. The diagnosis is a drug-induced lupus-like syndrome. Which drug in the regimen noted above is most likely to have accounted for this finding?

33. A patient with a history of hypertension, heart failure, and peripheral vascular disease has been on oral therapy with drugs suitable for each for about 3 months. He runs out of the medication and plans to have the prescriptions refilled in a week. Within a day or two after stopping his medications he experiences an episode of severe tachycardia accompanied by tachyarrhythmias, and an abrupt rise of blood pressure to 240/140 mmHg – well above pretreatment levels. He complains of chest pain, anxiety, and a pounding headache. Soon thereafter he suffers a hemorrhagic stroke. Abruptly stopping which drug is most likely to account for these responses?

34. Listed below are short descriptions of various patients, all of whom have recently diagnosed Stage II essential hypertension and a stated comorbidity or other pertinent finding. You are to start oral therapy for the hypertension. Your goal is to select the antihypertensive drug with a profile that makes it the best choice – or, in other stated instances, the poorest or worst choice – for the patient described.

a) Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker

b) b-adrenergic blocker

c) Nifedipine

d) Thiazide diuretic

e) Verapamil or diltiazem

A. Best choice for a 50-year-old man with well-controlled type 2 diabetes and normal renal function (and no microalbuminuria).

B. Most likely to trigger a gout attack or worsen asymptomatic hyperuricemia.

C. Best choice for a patient who is tachycardic and has chronic open-angle glaucoma.

D. Best choice for a patient who has a history of vasospastic (variant, or Prinzmetal’s) angina pectoris.

E. Worst choice for a patient with vasospastic angina because it may worsen the condition.

F. Worst choice for a pregnant woman.

G. Most likely to exacerbate tachycardia in a patient who is already taking sublingual nitroglycerin for chronic-stable (exercise-induced) angina pectoris.

H. Most likely to exacerbate asthma by facilitating or causing bronchoconstriction.

I. May cause breathing difficulty for an asthmatic by thickening airway mucus secretions and so obstructing the airways with viscous mucus.

J. Poorest choice for a patient with poorly controlled insulin-dependent diabetes mellitus because it will mask a symptom of severe hypoglycemia and delay recovery from a hypoglycemic episode.

35. A patient has stage III essential hypertension but normal ventricular function. After evaluating the responses to several other antihypertensive drugs, alone and in combination, the physician places the patient on oral hydralazine. Which of the following adjunct(s) is/are likely to be needed to manage the expected and unwanted cardiovascular side effects of the hydralazine?

a) Captopril plus nifedipine

b) Digoxin plus spironolactone

c) Digoxin plus vitamin K

d) Hydrochlorothiazide and a b-blocker

e) Nitroglycerin

f) Triamterene plus amiloride

36. A routine blood pressure measurement at a GP surgery revealed that the patient, a 50-year-old man, had a blood pressure of 180/110. Several repeated visits confirmed these pressures. No cause was found for the hypertension although the patient smoked 20 cigarettes a day and was slightly obese.

(a) At this time, the patient felt perfectly well and asked why he should be worried about his blood pressure. What will you tell him?

(b) What general advice will you give?

(c) What antihypertensive drug might you consider for initial therapy?

(d) After 3 months his blood pressure is still not controlled. What factors might be contributing to this failure of treatment and what should you do next?

«DIURETIC DRUGS»

37. A new diuretic is being studied in human volunteers. Compared with placebo, the new drug increases urine volume, decreases urinary Ca2+, increases body pH, and decreases serum K+. If this new drug has a similar mechanism of action to an established diuretic, to which group it probably belong to?

38. An 83-year-old man has been effectively treated with hydrochlorothiazide to control his elevated blood pressure. He has had a recent onset of weakness. Blood chemistry analysis reveals a K+ of 2,5 mEq/L. Another drug is added, and 1 month later his serum K+ is 4,0 mEq/L. Which drug is most likely to have caused the changes?

39. A 76-year-old man with a combined history of bronchogenic carcinoma and CHF is maintained on a diuretic to control pulmonary and peripheral edema. Recent measurement of blood electrolytes reveals an elevated serum Ca2+. Which drug is most likely to have caused the changes?

40. A 66-year-old woman with CHF and hearing loss is given a diuretic as part of a regimen that includes digoxin and an ACE inhibitor. In the course of treatment, she develops an AV conduction defect and is found to be hypomagnesemic. She also reports what she describes as some hearing loss, which is reversed when the drug is stopped. Which drug is most likely to have caused the changes?

«DRUGS USED TO TREAT GASTROINTESTINAL DISORDERS»

41. A patient with multiple medical problems is taking several drugs, including theophylline, warfarin, quinidine, and phenytoin. Despite the likelihood of interactions, dosages of each are adjusted carefully so their serum concentrations and effects are acceptable. However, the patient suffers some GI distress and purchases and begins consuming an over-the-counter “heartburn” remedy. He presents with excessive or toxic effects from all his other medications. He almost certainly took which H2-blocker?

42. A patient with renal failure is undergoing periodic hemodialysis while awaiting a transplant. Between dialysis sessions we want to reduce the body’s phosphate load by reducing dietary phosphate absorption and removing some phosphate already in the blood. Which antacid would we administer orally?

43. We have two patients. One requires suppression of emesis caused by an anticancer drug that causes a high incidence and severity of vomiting (highly emetogenic drug). Another patient has severe diabetic gastroparesis and gastroesophageal reflux, which requires relief. Which drug would be suitable for both indications (assuming no specific contraindications)?

44. A patient presents with severe abdominal pain and a “burning” sensation. Endoscopy reveals several benign ulcers in the antral mucosa of the stomach. When therapy is started, which will provide the fastest – albeit probably the briefest – relief of the discomfort with just a single dose?

45. A patient has multiple gastric ulcers but has done nothing about them. Shortly after consuming a large meal and large amounts of alcohol, he experiences significant GI distress. He takes an over-the-counter heartburn remedy. Within a minute or two he develops what he will later describe as a “bad bloated feeling”. Several of the ulcers have begun to bleed and he experiences searing pain. The patient becomes profoundly hypotensive from upper GI blood loss and is transported to the hospital. Endoscopy confirms multiple bleeds; the endoscopist remarks that it appears as if the lesions had been literally stretched apart, causing additional tissue damage that led to the hemorrhage. Which drug the patient most likely took?

«DRUGS USED TO TREAT RESPIRATORY DISORDERS»

46. A 16-year-old boy with breathing difficulty is seen in the emergency department. He is diagnosed with asthma and given urgent care. The next day he visits his primary physician, who starts him on therapy with albuterol, to be inhaled “as needed” (for acute symptom control – rescue therapy). After several weeks the patient says he needs to use the inhaler several times a day, nearly every day, because “breathing just gets real hard; I can’t get much air in.” The physician’s assessment is that symptom severity and frequency are getting progressively and quickly worse. Which initial therapeutic modification for outpatient management would be most reasonable, with the greatest likelihood of controlling the asthma?

47. A young boy is diagnosed with asthma. His primary symptom is frequent cough, not bronchospasm or wheezing. Other asthma medications are started, but until their effects develop fully we wish to suppress the cough without running a risk of suppressing ventilatory drive or causing sedation or other unwanted effects. Which antitussive drug would best meet these needs?

48. A patient suffering status asthmaticus presents in the emergency department. Blood gases reveal severe respiratory acidosis and hypoxia. Even large parenteral doses of a b2-agonist fail to dilate the airways adequately; rather, they cause dangerous degrees of tachycardia. Which drug should be done, pharmacologically, to manage the pulmonary problems and restore the efficacy of the adrenergic drug?

«DRUGS AFFECTING BLOOD»

49. A 45-year-old man postmyocardial infarction (MI) for 1 week is being treated with intravenous heparin. Stool guaiac on admission was negative, but is now 4+, and he has had an episode of hematemesis. We stop the heparin. Which drug should be administered to counteract the effects of excessive heparin remaining in the circulation?

50. A 64-year-old woman has had several episodes of transient ischemic attacks (TIAs). Aspirin would be a preferred treatment, but she has a history of severe “aspirin sensitivity” manifest as intense bronchoconstriction. What would be a suitable alternative to the aspirin?

51. A patient on long-term warfarin therapy arrives at the clinic for her weekly prothrombin time measurement. Her INR (international normalized ratio) is dangerously prolonged, and the physical exam reveals petechial hemorrhages. She’s had episodes of long-lasting epistaxis over the last 2 days. Aside from stopping the warfarin (and admitting the patient for follow-up), which drug should be administered?

52. A patient with hypertension and heart failure has been treated for 2 years with carvedilol and lisinopril. He has just had hip replacement surgery, and because he is not ambulating, is on unfractionated heparin, postoperatively, for prophylaxis of deep venous thrombosis. The ACE inhibitor and b-blocker are being given too, and oral antacids and ranitidine
(H2-antagonist) have been added for prophylaxis of acute stress ulcers. Five days postop he experiences sudden onset dyspnea and electrocardiographic and other indications of an acute MI. The patient’s platelet counts are dangerously low. What is most likely underlying problem?

53. A 22-year-old varsity hockey player visits you because he has excessive bruising after a game 2 days before. His knee had been bothering him, so he took 2 aspirin tablets before the game. Other than getting checked 10 times during the game, he denies any excessive or unusual trauma. As you ponder the etiology you order several blood tests. Which test or finding do you expect to be abnormal?

54. A patient presents with malaise, and skin and mucous membranes appear pale. Among the key findings from blood work are hypochromic, microcytic red cells and reduced red cell count; reduced hematocrit; reduced reticulocyte count; and reduced total hemoglobin content. Assuming the most likely diagnosis is correct, the proper approach would be to administer which supplemental?


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