Pharmacology

Questions

DIRECTIONS (Questions 1-63): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

1. A child is brought to the emergency department for evaluation of his disoriented state. This began shortly after he ate some berries in the garden. He is noted to be very warm, flushed, and to have dilated pupils. The most appropriate action includes administration of

(A) atropine

(B) aspirin

(D) physostigmine

(E) phenylephrine

2. Fluoxetine is used for the treatment of

(A) influenza

(B) major depressive disorder

(D) Parkinson disease

(E) Hodgkin disease

3. A 52-kg patient undergoes anesthesia for removal of a bronchial carcinoma. His anesthesia consists of propofol, isoflurane, and N₂O/O₂, in addition to 50 mg of rocuronium after intubation. At the end of the procedure 3 h later, only one weak twitch is palpable on train-of-four stimulation, and the patient remains apneic. The most likely explanation for apnea in this patient is

(A) rocuronium overdose

(B) delayed pulmonary elimination of nitrous oxide after lung surgery

(D) hypoxic pulmonary vasoconstriction

(E) respiratory depression from residual effects of propofol

4. Dobutamine

(A) is primarily an α-adrenoceptor agonist

(B) has primarily β₁-adrenoceptor effects

(D) is associated with severe increases in heart rate

(E) is a naturally occurring catecholamine

5. A patient is scheduled for an elective cardioversion. A single intravenous injection of a short-acting agent is planned. Which one of the following agents is most likely to cause vomiting after the procedure when used in this patient?

(A) Ketamine

(B) Thiopental

(D) Methohexital

(E) Propofol

6. Esmolol is inactivated by

(A) monoamine oxidase

(B) catechol O-methyltransferase

(D) plasma pseudocholinesterase

(E) acetylcholinesterase

7. An 18-year-old patient with a history of asthma is brought to the operating room for emergent laparoscopic appendectomy for perforated appendix. Shortly after induction of general endotracheal anesthesia, the patient experiences severe bronchospasm. Which one of the following drugs, administered as monotherapy with a pressurized metered-dose inhaler via a spacer chamber through the ventilator circuit, is most likely to result in bronchodilation in the acute setting?

(A) Ipratropium bromide

(B) Albuterol

(D) Terbutaline

(E) Salmeterol

8. A 55-year-old woman scheduled to undergo carotid endarterectomy has been smoking heavily for over 40 years and wishes to quit. Which one of the following medications is best at alleviating the symptoms of nicotine withdrawal?

(A) Buspirone

(B) Alprazolam

(D) Zolpidem

(E) Citalopram

9. Botulinum toxin interferes with neuromuscular transmission by

(A) preventing synthesis of acetylcholine

(B) preventing breakdown of acetylcholine

(D) preventing release of acetylcholine

(E) blocking receptors for acetylcholine

10. A 62-year-old male with a history of diabetes mellitus, hypertension, and coronary artery disease is admitted to the hospital for unstable angina. He was recently diagnosed with heparin-induced thrombocytopenia type II and is now scheduled to undergo off-pump coronary artery bypass grafting for severe three-vessel coronary artery disease. A suitable agent for intraoperative anticoagulation would be

(A) heparin

(B) warfarin

(D) fondaparinux

(E) clopidogrel

DIRECTIONS: Use the following scenario to answer Questions 11-12: A 61-year-old male with a past medical history of diverticulosis is admitted to the intensive care unit after undergoing an emergent laparotomy with sigmoid colectomy and creation of Hartman’s pouch for perforated diverticulitis. According to the surgeon, there was frank contamination of the peritoneal cavity. Despite broad-spectrum antibiotic coverage, the patient develops symptoms consistent with septic shock on the first postoperative day.

11. Despite aggressive fluid resuscitation and blood pressure support with norepinephrine, the patient remains hypotensive. A 2-D echocardiogram is obtained that shows no wall motion abnormalities, a hyperdynamic left ventricle, and a calculated cardiac index of 4.8 L/min/m². Which one of the following agents would be most useful in addition to the norepinephrine for the treatment of this patient’s hypotension?

(A) Milrinone

(B) Ephedrine

(D) Dobutamine

(E) Vasopressin

12. On the second postoperative day, the patient continues to require high-dose vasopressor support with two medications despite adequate fluid resuscitation. Low dose hydrocortisone therapy is started. Which one of the following statements is true?

(A) In patients with septic shock, addition of low dose glucocorticoids may enhance the vascular reactivity to vasoactive substances.

(B) Glucocorticoids in the setting of septic shock will enhance the bactericidal effect of broad-spectrum antibiotics.

(D) The major action of hydrocortisone in this setting is sodium retention with subsequent improvement of volume status.

(E) Administration of glucocorticoids will most likely cause leukopenia in this patient.

13. A 51-year-old female with an anxiety disorder is admitted for elective surgery. Because the patient is extremely nervous, lorazepam is given IV in repeat, subhypnotic doses to manage her anxiety. Which one of the following statements is most accurate?

(A) The patient’s motor function is likely to be more impaired than her cognitive function.

(B) Lorazepam is more rapid in onset as compared to midazolam.

(D) To achieve anxiolysis, highly sedating doses of the drug have to be administered.

(E) Administration of lorazepam will cause retrograde amnesia.

14. Milrinone

(A) is a catecholamine used for treatment of congestive heart failure

(B) is an antiarrhythmic drug

(D) inhibits Na⁺,K⁺-ATPase

(E) has a longer elimination half-life than inamrinone

15. A patient who is taking lithium for treatment of bipolar disorder is scheduled to have general anesthesia. The lithium

(A) need not be considered in the anesthetic regimen

(B) may affect both depolarizing and nondepolarizing muscle relaxants

(D) should be stopped 2 weeks before surgery

(E) may increase anesthetic requirements

16. A drug that is associated with pulmonary toxicity is

(A) doxorubicin

(B) bleomycin

(D) methotrexate

(E) l-asparaginase

17. A 48-year-old woman takes a tricyclic antidepressant for depression. This patient

(A) may have an increased number of arrhythmias

(B) should have halothane and pancuronium as drugs of choice

(D) may become hypotensive with ketamine

(E) may have short emergence with thiopental

18. A 66-year-old male with a history of diabetes mellitus, hypertension, and coronary artery disease is to undergo urgent surgery for an expanding 6.4 cm infrarenal abdominal aortic aneurysm. He had a myocardial infarction twelve months ago at which time he underwent percutaneous coronary angioplasty with placement of drug-eluting stents to the left anterior descending and right coronary arteries. Current medications include clopidogrel and aspirin that were started after the stent placement. With respect to the combination of these two drugs and the intraoperative risk of bleeding, it is true that

(A) both drugs exert their antiplatelet effect through the same mechanism

(B) clopidogrel does not add significantly to the risk of bleeding posed by aspirin

(D) both drugs can be antagonized

(E) clopidogrel should be discontinued 5-10 days prior to surgery in elective cases were surgical hemostasis is needed

19. Gabapentin

(A) is approved for the monotherapy of partial seizures

(B) is a benzodiazepine

(D) is useful for the treatment of migraine, chronic pain, and bipolar disorder

(E) increases the plasma concentrations of carbamazepine and phenobarbital when used concomitantly

20. A heroin addict injects six bags of heroin per day. After being involved in a motorcycle accident resulting in a fracture of the tibia, he is brought to the emergency department. Which one of the following analgesics is most likely to be effective and least likely to precipitate an acute withdrawal syndrome or cause significant toxicity?

(A) Meperidine

(B) Nalbuphine

(D) Butorphanol

(E) Fentanyl

21. Which one of the following is a β-adrenoceptor antagonist?

(A) Isoproterenol

(B) Dobutamine

(D) Albuterol

(E) Ritodrine

22. A 76-year-old male is undergoing CABG for severe three vessel coronary artery disease under cardiopulmonary bypass (CPB) with full anticoagulation with heparin. After uncomplicated weaning from CPB, the surgeon requests reversal of the anticoagulant with protamine. Shortly after administration of a ratio of 1 mg intravenous protamine to 1 mg heparin, the patient develops sudden onset of hemodynamic instability. Which one of the following statements regarding protamine is most accurate?

(A) Anaphylactic reactions occur in about 10% of diabetic patients on protamine-containing insulin (NPH insulin) who are administered intravenous protamine.

(B) Anaphylactic protamine reaction in the general population consisting of pulmonary hypertension, right ventricular dysfunction, and systemic hypotension is rare.

(D) Protamine is equally effective in reversing the anticoagulant activity of low molecular weight heparin as compared to unfractionated heparin.

(E) Protamine can be used as a specific antidote for fondaparinux.

23. Dantrolene

(A) has a half-life of about 36 h

(B) reduces concentrations of intracellular calcium

(D) in the setting of malignant hyperthermia is dosed at 1 mg/kg initial bolus

(E) causes nephrotoxicity

24. A 76-year-old patient with a history of NYHA stage IV heart failure is admitted to the intensive care unit for the treatment of acute, decompensated heart failure. The patient is hypotensive, tachycardic, and in respiratory distress with increased work of breathing as well as hypoxemia documented on ABG. Which one of the following is the most appropriate therapeutic agent?

(A) Losartan

(B) Fenoldopam

(D) Nicardipine

(E) Nesiritide

25. Nifedipine

(A) may cause tachycardia as a compensatory effect

(B) exerts its therapeutic effect by slowing AV-node conduction

(D) is a coronary vasoconstrictor

(E) has positive inotropic effects

26. Doxorubicin may produce a cardiomyopathy that

(A) is present only during therapy

(B) is independent of the dose administered

(D) can be evaluated with echocardiography

27. A homeless person buys an inexpensive quart of denatured alcohol (90% ethanol, 10% methanol) at a hardware store. He mixes a pint of denatured alcohol with a half-gallon of orange juice and drinks the mixture over a period of an hour. A short while later, he is found unconscious and brought to the emergency department of a nearby hospital. All of the following statements about this patient are true EXCEPT

(A) he is likely to have been drunk prior to drinking the denatured alcohol because he did not recognize the abnormal taste of the methanol present in it

(B) he is likely to have a severe metabolic acidosis due to the effects of a metabolite of one of the alcohols he ingested

(D) his decreased level of consciousness is likely due to the direct effects of one of the alcohols he ingested

(E) he is likely to benefit from hemodialysis

28. Tachyphylaxis

(A) can occur with administration of phenylephrine

(B) describes the rapidly decreasing effectiveness of certain drugs with repeat administration

(D) is also known as “ceiling effect”

(E) can occur due to induction of enzyme systems

29. A mechanism that accurately describes the effect of a drug used to produce deliberate hypotension is

(A) sodium nitroprusside only dilates resistance vessels

(B) nicardipine causes coronary and peripheral vasodilatation

(D) nitroglycerin primarily dilates resistance vessels

(E) esmolol will attain a decrease in blood pressure faster than a decrease in heart rate

30. A patient with a history of type 1 diabetes mellitus, coronary artery disease, and COPD is to receive β-blocker therapy as part of an antihypertensive regimen. The most suitable agent for this indication is

(A) propranolol

(B) labetalol

(D) carvedilol

(E) pindolol

31. Which one of the following agents used as an adjunct in the therapy of chronic pain can cause rebound hypertension after abrupt cessation of therapy?

(A) Topiramate

(B) Clonidine

(D) Carbamazepine

(E) Gabapentin

32. Mannitol

(A) is effective at decreasing ICP in the absence of blood-brain barrier integrity

(B) is useful in the treatment of dialysis disequilibrium syndrome

(D) is almost completely reabsorbed from the renal tubule

(E) is effective at providing perioperative renal protection during high-risk urologic procedures

33. Based on the neurotransmitter aberrations that are thought to be responsible for the symptoms of Parkinson disease, which one of the following drug types would be therapeutic in a patient with Parkinson disease?

(A) Monoamine oxidase inhibitor

(B) Phenothiazine

(D) Serotonin antagonist

(E) Serotonin reuptake inhibitor

34. The withdrawal syndrome in a person physically dependent on which one of the following drugs can be fatal?

(A) Amphetamine

(B) Phencyclidine

(D) Heroin

(E) Eszopiclone

35. Fenoldopam

(A) activates α- and β-adrenoceptors

(B) causes a dose related decrease in renal blood flow and glomerular filtration rate

(D) is a selective dopamine D₁ receptor agonist used to treat severe hypertension

(E) causes a dose-dependent increase in heart rate and cardiac contractility

36. Which one of the following agents may be administered via the intravenous route to treat postpartum hemorrhage?

(A) Oxytocin

(B) Prostaglandin F_2α

(D) Progesterone

(E) Prostaglandin E₂

37. A 34-year-old woman has a history of prolonged paralysis after a short, elective operation, and she was subsequently shown to be homozygous for the atypical form of the butyrylcholinesterase gene. Her 4-year-old son now needs anesthesia for bilateral myringotomy and ear tube placement. What is the probability that her son will have a prolonged response to succinylcholine?

(A) 25%

(B) 50%

(D) Cannot be calculated without more information

38. A 22-year-old female college student is scheduled for placement of a tunneled IV catheter for total parenteral nutrition. She has a history of anorexia nervosa and is severely malnourished. It would be reasonable to avoid which one of the following medications in the perioperative period?

(A) Cefazolin

(B) Droperidol

(D) Vancomycin

(E) Sevoflurane

39. Each of the following characteristics applied to an anesthesiologist might be suggestive, but not diagnostic, of self-administration of intravenous opioids EXCEPT

(A) wearing a long sleeve t-shirt underneath a scrub top

(B) chronically showing up late for work

(D) requesting more frequent breaks than other colleagues

(E) avoiding changing into scrubs in the locker room

40. A 44-year-old woman with a significant history of prior postoperative nausea and vomiting is given aprepitant preoperatively before a diagnostic laparoscopy as part of a multidrug antiemetic regimen. Aprepitant interacts most strongly with which endogenous ligand?

(A) β-endorphin

(B) Dynorphin A

(D) Proopiomelanocortin

(E) Leu-enkephalin

41. A person whose ancestors came from which one of the following geographical areas is most likely to need the lowest daily dose of warfarin to maintain a therapeutic value for INR?

(A) Sub-Saharan Africa

(B) China

(D) Southern Europe

(E) Arabian peninsula

DIRECTIONS: Use the following table to answer Question 42:

42. The intravenous administration of sodium bicarbonate will increase the excretion rate of which one of the following drugs to the greatest degree?

(A) Diazepam

(B) Isopropanol

(D) Pancuronium

(E) Phenobarbital

43. An anesthesiologist is deployed in the desert of a Middle Eastern country. An artillery shell explodes in the midst of his base, and an alarm is sounded because a nerve gas has been detected. He is not wearing protective gear and should therefore immediately inject himself with

(A) diazepam and atropine

(B) physostigmine and diazepam

(D) pralidoxime and atropine

(E) pralidoxime and diazepam

44. The benzodiazepine that is most appropriate as a bedtime sedative due to its pharmacokinetic properties is

(A) oxazepam

(B) nordazepam

(D) flurazepam

(E) quazepam

45. Stereospecific binding of an agonist to the μ-opioid receptor produces all of the following effects EXCEPT

(A) euphoria

(B) cough suppression

(D) constipation

(E) analgesia

46. Cyclooxygenase (COX) is associated with participating in numerous physiological functions. Which one of the following effects is primarily ascribable to COX-2 as opposed to COX-1?

(A) Platelet adhesiveness

(B) Inflammation

(D) Pain perception

(E) Protection of GI mucosa against acid damage

47. Metoprolol exerts its therapeutic effect via

(A) β₁-adrenoceptor agonism

(B) β₁-adrenoceptor antagonism

(D) α₂-adrenoceptor antagonism

(E) α₁-adrenoceptor antagonism

48. Both diazepam and buspirone

(A) lower seizure threshold

(B) cause sleepiness

(D) display cross-tolerance with ethanol

(E) decrease anxiety

49. A patient has been recently diagnosed with bipolar disorder. He is also on dialysis due to renal failure resulting from untreated ureteral reflux. His psychiatrist wishes to begin chronic therapy with a medication to prevent further manic episodes. Which one of the following is the BEST choice in this patient?

(A) Lithium carbonate

(B) Citalopram

(D) Phenelzine

(E) Bupropion

50. Which one of the following opioids is ineffective as an analgesic in a significant fraction of the population due to a genetic polymorphism?

(A) Codeine

(B) Hydromorphone

(D) Methadone

(E) Oxycodone

51. Soon after a patient is started on haloperidol he begins complaining of feeling stiff and having difficulty in performing rapid, fine motor movements like typing at his computer keyboard. Which one of the following medications will MOST likely help these new-onset symptoms?

(A) Fluoxetine

(B) Diazepam

(D) Benztropine

(E) Lithium

52. Which one of the following characteristics of a substance make it less likely to be abused by humans?

(A) Tolerance develops to some of its effects.

(B) It potentiates dopamine neural activity.

(D) It has a rapid onset.

(E) It has a long duration.

53. A 47-year-old man with long-standing type I diabetes mellitus has severe peripheral vascular disease and peripheral neuropathy. His feet are chronically cold and blue and are extremely painful. In commencing therapy for his painful feet, the least appropriate medication to try first is

(A) oxcarbazepine

(B) oxycodone

(D) amitriptyline

(E) carbamazepine

DIRECTIONS (Questions 54-59): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Agonists decrease the heart rate by inhibiting adenyl cyclase.

(B) Agonists cause vasoconstriction in arterioles by activating phospholipase C and increasing the intracellular concentration of calcium.

(D) Agonists increase ganglionic transmission by activating phospholipase C and increasing the concentration of inositol triphosphate.

(E) Agonists cause vasodilation by inhibiting guanylyl cyclase.

(F) Agonists cause vasodilation by increasing endothelial nitric oxide synthase.

(G) Agonists relax bronchial smooth muscle by activating adenyl cyclase.

(H) Agonists inhibit transmission in sympathetic neurons by inhibiting adenyl cyclase.

For each autonomic receptor, select the corresponding mechanism of action:

54. Muscarinic M₁

55. Muscarinic M₂

56. Muscarinic M₃

57. Adrenergic α_1A

58. Adrenergic α_2A

59. Adrenergic β₂

DIRECTIONS (Questions 60-63): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Increases numbers of adipocytes and increases uptake of fatty acids by adipocytes

(B) Blocks voltage-dependent calcium channels decreasing intracellular calcium in pancreatic β cells

(D) Increases the activity of AMP-dependent protein kinase (AMPK) increasing fatty acid oxidation in hepatocytes

(E) Inhibits Na⁺-K⁺-ATPase thereby increasing intracellular potassium in adipocytes

(F) Inhibits phosphodiesterase (PDE) thereby increasing insulin release from pancreatic β cells

(G) Agonist at the GLP-1 (glucagon-like peptide) receptor

(H) Causes closure of K_ATP channels in pancreatic β cells increasing insulin release

For each medication used to treat diabetes mellitus, select the corresponding mechanism of action:

60. Exenatide

61. Rosiglitazone

62. Metformin

63. Repaglinide