Научная электронная библиотека
Монографии, изданные в издательстве Российской Академии Естествознания
Chapter 4. CENTRAL NERVOUS SYSTEM PHARMACOLOGY
«ANESTHETICS»
55. A 55-year-old woman undergoes surgery. She receives several drugs for preanesthesia care, intubation, and intraoperative skeletal muscle paralysis; and a mixture of inhaled anesthetics to complete the balanced anesthesia. Toward the end of the procedure she develops hyperthermia, hypertension, hyperkalemia, tachycardia, muscle rigidity, and metabolic acidosis. What drug is most likely to have participated in this reaction? What should be administered specifically in an attempt to correct the abnormal skeletal muscle activity that is mainly responsible for all the other secondary signs and symptoms?
56. A 48-year-old woman has had difficulty swallowing for 6 months. She requires premedication (sedation, not conscious) for an endoscopic examination. What drug should be administered?
57. A patient on the trauma-burn unit receives a drug to ease dressing changes. They experience good, prompt analgesia, but despite the absence of pain sensation their heart rate and blood pressure rise much as if the sympathetic nervous system were activated by painful responses. As the effects of the drug develop their skeletal muscle tone progressively increases. They appear awake at times because their eyes periodically open. As drug effects wear off they hallucinate and behave in a very agitated fashion. Which anesthetic was given?
a) Fentanyl
b) Ketamine
c) Midazolam
d) Succinylcholine
e) Thiopental
58. A 29-year-old man requires suturing for a deep laceration in his palm. He is allergic to benzocaine. Which other local anesthetic could be used, posing the lowest risk of another allergic response?
«SEDATIVE-HYPNOTICS»
59. A 29-year-old man uses secobarbital to satisfy his addiction to barbiturates. During the past week, he is imprisoned and is not able to obtain the drug. He is brought to the prison medical ward because of the onset of severe anxiety, increased sensitivity to light, dizziness, and generalized tremors. On physical examination, he is hyperreflexic. What agent should he be given to diminish his withdrawal symptoms?
60. A 72-year-old woman with a history of anxiety that is treated with diazepam decides to triple her daily dose because of increasing fearfulness about “environmental noises”. Two days after her attempt at self-prescribing, she is found extremely lethargic and nonresponsive. On examination, she is found to be stuporous and have diminished reaction to pain and decreased reflexes. Respirations are 8/min and shallow. What drug should we give specifically to reverse these signs and symptoms?
61. An 85-year-old man is given diazepam to help him sleep at night. A few weeks later his son finds him in a state of self-neglect. He is taken to hospital where he is found to be drowsy and confused.
(a) Why was diazepam a bad choice of drug for this elderly patient?
(b) How should he be treated in hospital?
(c) What would be a more suitable hypnotic for this patient?
«ANTICONVULSANT DRUGS.
ANTIPARKINSONIAN DRUGS.»
62. A 14-year-old girl is brought to the ED by her mother, who has observed that her daughter has abruptly experienced an impartment of consciousness associated with clonic jerking of the eyelids and starting into space lasting approximately 30 s. What drug should be administered?
63. A patient who has been treated for Parkinson’s disease for about a year presents with purplish, mottled changes to her skin. What drug is the most likely cause?
64. A young boy who has been treated for epilepsy for a year is referred to an oral surgeon for evaluation and probable treatment of massive overgrowth of his gingival tissues. Some teeth are almost completely covered with hyperplasic tissue. What drug is associated with this finding?
65. A major problem that must be faced when administering anticonvulsants with many other medications (including other antiepileptic drugs) involves drug interactions due to altered metabolism. Which of the following drugs is likely to cause excessive or toxic effects from certain other drugs by inhibiting their metabolism?
a) Carbamazepine
b) Ethosuximide
c) Phenobarbital
d) Phenytoin
e) Valproic acid
«ANTIPSYCHOTICS. ANTIDEPRESSANTS.»
66. A 33-year-old woman patient treated with haloperidol for a history of schizophrenia is seen in the emergency department (ED) because of complaints of fever, stiffness, and tremor. Her temperature is 104°F, and her serum creatine kinase (CK) level is elevated. What has occurred?
67. A 19-year-old woman whose roommate is being treated for depression decides that she is also depressed and surreptitiously takes her roommate’s pills “as directed on the bottle” for several days. One night, she makes herself a snack of chicken liver pate and bleu cheese, accompanied by a glass of red wine. She soon develops headache, nausea, and palpitations. She goes to the ED, where her blood pressure is found to be 200/110 mmHg. What antidepressant did she take?
68. A 36-year-old unemployed dishwasher with no history of seizures presents with difficulty thinking coherently and claims he is an astronaut. Following treatment, he suddenly has a grand mal seizure. What neuroleptic agent was the most likely cause?
69. A 41-year-old woman is seen in the psychiatric clinic for a follow-up appointment. She has been taking an antidepressant for 3 weeks with some improvement in mood. However, she complains of drowsiness, palpitations, dry mouth, and feeling faint on standing. What antidepressant is she most likely taking?
70. A 31-year-old woman is treated with an antipsychotic agent because of a recent history of spontaneously removing her clothing in public places and claiming she hears voices telling her to do so. Her blood pressure is normally 130/70 mmHg. Since being treated with a drug, she has had several bouts of syncope. Orthostatic hypotension was noted on physical examination. What drug most likely caused this?
71. A patient has a history of cardiac arrhythmias due to a prolonged QT-interval (“long QT syndrome”). Which CNS drug should be avoided in this patient because it can cause further QT-prolongation, with an associated and high risk of serious ventricular arrhythmias including torsade de pointes?
72. A woman develops akathisia, a Parkinson-like syndrome, galactorrhea, and amenorrhea, during drug therapy. These responses reflect which receptors and which drug she was given?
73. A patient exhibiting multiple facial tics, aggressive outbursts of behavior, and spontaneous repetitive foul language. What is the reason of such manifestations? This syndrome is managed appropriately with which of the following drugs?
74. After a few weeks on a drug, useful to treat affective disorders, a patient reports profound thirst and the production of copious volumes of clear (dilute) urine each day. This is a fairly common, and unique, side effect of which drug?
75. A 26-year-old woman with reactive depression complains of missing her period and having milk discharge from her breasts (galactorrhea). Pregnancy tests are negative. Which drug is most likely to have caused these findings?
«NARCOTIC ANALGESICS»
76. A patient with severe, acute trauma pain requires analgesia. The physician orders morphine. Which of the following coexisting conditions would pose the greatest risk from morphine’s use in this case?
a) Acute pulmonary oedema
b) Closed head injury
c) Compound fractures of both femurs
d) Hypertension
e) Opioid abuse, recent history of
f) Recent myocardial infarction
77. A person who was physically dependent on and an abuser of heroin is now maintained on methadone. He succumbs to temptation and buys an opioid on the street. He takes it and rapidly goes into withdrawal. Which of the following drugs did he take?
a) Meperidine
b) Heroin
c) Pentazocine
d) Codeine
e) Propoxyphene
78. You have a patient with severe postoperative pain who is not getting adequate analgesia from usually effective doses of morphine. The physician orders an immediate switch to a high dose of pentazocine. What is the most likely outcome?
79. A 20-year-old man is found unconscious in a park. He is brought to A&E. There are no signs of injury and his blood sugar is normal. A used syringe was found by him and there are needle tracks on his arms. He has small pupils and slow, shallow respiration.
(a) What is the most likely diagnosis?
(b) What treatment should be given immediately?
(c) The patient recovers consciousness but an hour later becomes unconscious again. What has happened?
«CNS – STIMULANTS»
80. A 12-year-old boy has been treated with methylphenidate for the last three years. His younger sister finds the bottle of pills and consumes enough to cause significant toxicity. What findings would
you expect?
81. A 10 year-old boy displays hyperactivity and is unable to focus on his schoolwork because of an inability to focus on the activity. Which drug might prove effective for relieving the boy’s main symptoms?
«ALCOHOLS»
82. A 30-year-old alcohol abuser decides to abstain from alcohol. Liver function tests are, fortunately, normal. Shortly after abstaining he becomes agitated, anxious, has visual hallucinations, is generally totally disorientated, and suffers bouts of insomnia. What agent would be indicated for managing these signs and symptoms?
83. Although a patient was instructed not to use alcohol because of a medication he is taking, he ignored advice and decided to have a cocktail. Within minutes he develops flushing, a throbbing headache, nausea, and vomiting. What medication was he taking?
84. A 60-year-old man was brought to A&E unconscious and smelling of alcohol. Examination did not reveal any head injury and blood glucose was in the normal range. The next morning he was awake and admitted to drinking a bottle of whisky daily in addition to cider and other drinks.
(a) What would be the main risk in withdrawing alcohol from this patient? How would you alleviate this risk?
(b) What vitamin deficiency might this patient have?
(c) What drugs can be helpful in maintaining abstinence in patients dependent on alcohol?