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By: U. Felipe, M.B. B.CH. B.A.O., Ph.D.
Deputy Director, Vanderbilt University School of Medicine
What is the most to have signifcant elevation of liver function tests on likely explanation for these fndings? Which of the follow- (A) Patient also drank four beers in addition to using ing medications should be maintained at current the scopolamine patch doses in this patient? An adequate including prednisone and neostigmine is seen by a anesthesia history could not be obtained from the new physician treatment plantar fasciitis buy detrol 4 mg without a prescription. The procedure is 15 A 79-year-old man undergoes a hip replacement pro- estimated to take approximately 10 min to complete medicine 48 12 cheap 4mg detrol otc. Principles of Neuropharmacology 37 16 An 8-month-old girl is brought to the emergency 20 A 62-year-old retired small business owner has had department by her parents because she has been slowly increasing intraocular pressure bilaterally medicine 81 cheap detrol 2mg fast delivery. While coma, which also happens to cross the blood–brain talking with the parents, you discover that they some- barrier better than other drugs in its class. He is currently on an intrave- lowing a-adrenergic agonists would be expected to nous epinephrine drip to maintain his blood pressure have the strongest potency at the a-receptor? He is very sensitive to the medication 22 A 37-year-old woman with a history of asthma is side effects and is reluctant to take medications for brought to the emergency department suffering from an this reason. Her room air pulse oximetry is 86% and her involve the use of which of the following agents to lips are blue. She becomes unre- (A) Alfuzosin sponsive a few minutes later then becomes pulseless (B) Doxazosin and apneic. One member of the group still had some plant parts in his pocket, which you use to iden- 23 A 37-year-old woman with hyperthyroidism and tify deadly nightshade that contains compounds asthma has frequent asthma attacks, requiring inhala- metabolized to atropine. Her most recent (A) Bronchospasm blood tests reveal elevated T3 and T4 levels twice the (B) Lacrimation normal values. In (E) Phenylephrine contrast to normal individuals, the patients with Parkinson’s disease have an abundance of which of the 25 A 32-year-old man presents to his primary care physi- following neurons and associated neurotransmitters? After being on the medication for 6 months, 26 A 49-year-old man who smokes three packs of ciga- a renal ultrasound is obtained that reveals bilateral rettes per day for the last 20 years (60 pack years) is hydronephrosis and elevation of his serum creatinine currently taking an oral nicotine agent to stop smok- to 2. The patient and family are made aware of such side effects as nausea, vomiting, diarrhea, and muscle cramps. He has not had any (C) Purine metabolism impairment issues in the last few years and does not need supple- (D) Transaminase enzyme elevation mental oxygen. Which of the following agents may be benefcial to delay the need for ventilator support in (E) Uremia this patient? Which of the fol- (D) Prednisolone lowing is a metabolite specifc to the breakdown of (E) Riluzole epinephrine? Which of the (C) Homovanillic acid following patients would have the most limited (D) Metanephrine response to their symptoms if given a prescription for diazepam? During his interview, it is discovered that he is (C) A 42-year-old man with seizure disorder taking several outdated drugs for his medical condi- (D) A 45-year-old woman with seizure disorder tion. One of his medical conditions is hypertension, (E) A 52-year-old man with spinal cord pain from an for which he takes a drug that prevents neurotrans- accident mitter uptake into vesicles. This prevents neurons from being able to concentrate and store certain neu- 39 A 40-year-old man with chronic anxiety and alcohol rotransmitters such as norepinephrine. Which (B) Methyldopa of the following is the best agent to help this patient (C) Reserpine get to sleep? Which of the following agents may be benefcial in 40 An 83-year-old woman with Parkinson’s disease is slowing the progression of this disease? Which of the fol- (E) Stimulation of norepinephrine release lowing agents may be benefcial in assisting her with improved ambulation? At the end of her work- parents say that he is allergic to bee stings, and the day, she says her eyes feel “heavy” and “droopy,” patient is having great diffculty breathing. His symptoms improve Pyridostigmine is prescribed to treat her myasthenia as molecules of epinephrine bind to b2-receptors in gravis. Physical examination of the heart, lungs, (E) Reside in the cytoplasm, not the cell surface and abdomen are within normal limits. Which of the following would be the best treatment option for his 42 In review of the benzodiazepine class, which of the generalized anxiety disorder? Physical examination of 43 A 38-year-old man with chronic anxiety and agitation the heart, lungs, and abdomen are within normal is currently being treated with a long-acting benzodi- limits. Which of the follow- (B) Lorazepam ing is the most likely abnormality to be noted on this (C) Temazepam study?
There are many (C) Lorazepam is a benzodiazepine that blocks sei- drugs used to control or limit seizure activity treatment xerosis buy 2mg detrol otc. Its Carbamazepine is a drug that may cause blurred vi- most common side effect is sedation and does not sion and diplopia with use symptoms depression cheap detrol online master card. Its most common side effect is metabolism medicine 2016 order detrol now, so dosage adjustments early in therapy sedation and does not usually cause visual distur- may be necessary. Which of (A) Impermeability to the blood–brain barrier the following would be expected following steady state (B) Long duration of action intravenous dosing of agent X, a b2-receptor agonist? Which of the follow- 3 A 58-year-old woman who is obese presents to the ing agents prevents the development of preterm labor? What is the effect of have tumors less than 3 cm in size and are confned to the ibuprofen on her anticoagulation regimen? Which of the following patients would be most likely to suffer an adverse event related to this medication? It is anticipated that the procedure (C) A 45-year-old man with hyperparathyroid adenoma will take approximately 16 h. Which of the following agents will have limited cedure, the ophthalmologist dilates his pupils with effcacy in the management of this patient? Which of the fol- (A) Labetalol lowing describes an effect of the sympathetic nervous (B) Methyldopa system? The started on a trial of terazosin, after which his symp- pain stops, so he disregards the episode entirely until toms improve dramatically. Which of the following the next day when he experiences a “funny feeling in describes terazosin’s drug class? The intended effect of sotalol in- 2 (C) Anticholinergic volves modifying which phase of the cardiac myocyte (D) b -Adrenergic agonist action potential? Later, he developed ventricular tachycardia and is treated with 19 A 35-year-old man presents to the emergency depart- an antiarrhythmic. After a week of antiarrhythmic ment complaining of a cough and runny nose of treatment, he began having diffculty breathing. His surgery goes smoothly, but the next day he develops chest palpita- 20 A 54-year-old woman with severe essential hyperten- tions. Metoprolol is started to keep his supraventricu- sion refractory to treatment switched to a new antihy- lar tachycardia from interfering with ventricular pertensive drug 1 month ago. She has passed calcium oxalate stones in determined that she is experiencing Prinzmetal an- the past and likely has another stone. She is given a her for the stone, which of the following diuretics prescription for nifedipine to relax her vascular could be started to prevent future calcium oxalate smooth musculature. Which (B) Dry cough of the following is a calcium channel blocker that (C) Erectile dysfunction works primarily on vascular smooth muscle? Which of the 27 A 57-year-old man with hypertension presents to his following physiologic effects of nitric oxide will be primary care physician for a follow-up checkup. Which of the following param- (E) Spontaneous minute ventilation increases eters is most likely to change because of his metopro- lol therapy? Which of the following patients will (D) Creatinine clearance require the largest doses of inhalational anesthetic (E) White blood cell count agents? She recovers well initially but soon (B) Patient 2: blood pressure of 150/80 mm Hg, pulse 5 develops left heart failure. Her physician prescribes 100 beats/minute multiple medications to treat different aspects of heart (C) Patient 3: blood pressure of 120/80 mm Hg, pulse 5 failure, including isosorbide dinitrate. Which of the following sources of you expect to be elevated in this patient’s blood as a intracellular calcium plays the most minor role in direct result of alteplase? Cardiovascular Pharmacology 85 (A) Exchange with sodium (A) Bicarbonate (B) Intracellular transport via voltage-sensitivechannels (B) Chloride (C) Intracellular vacuolar release of calcium (C) Glucose (D) Mitochondria release of calcium (D) Potassium (E) Sarcoplasmic reticulum release of calcium (E) Sodium 30 A 72-year-old man is having an electrocardiogram 34 A 62-year-old man with congestive heart failure and performed by his primary care physician to further hypertension on digoxin takes an extra few pills evaluate intermittent chest pain. Regarding the phase 0 because he is angry about his daughter being pregnant of the cardiac action potential, which of the following out of wedlock. If elec- (A) Calcium channels open resulting in outward trocardiogram is performed, which of the following current would be most likely? She complains of a 4-week history of diarrhea, prove to have additional beneft in the treatment of sweats, and muscle weakness.
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Spironolactone treatment innovations detrol 1mg overnight delivery, a competitive inhibitor of aldosterone (see Chapter 15) medicine to induce labor order detrol online now, also competes with dihydrotestosterone for the androgen receptors in target tissues medicine zalim lotion buy on line detrol. It is used in dosages of 50–200 mg/d in the treatment of hirsutism in women and appears to be as effective as finasteride, flutamide, or cyproterone in this condition. For example, various androgens, including testosterone and testosterone enanthate, in a dosage of 400 mg per month, produced azoospermia in less than half the men treated. Testosterone in combination with danazol was well tolerated but no more effective than testosterone alone. However, preliminary studies indicate that the intramuscular administration of 100 mg of testosterone enanthate weekly together with 500 mg of levonorgestrel daily orally can produce azoospermia in 94% of men. Retinoic acid is important in the maturation of sperm and the testis contains a unique isoform of the alcohol dehydrogenase enzyme that converts retinol to retinoic acid but no nontoxic inhibitor of this enzyme has been found to date. Cyproterone acetate, a very potent progestin and antiandrogen, also produces oligospermia; however, it does not cause reliable contraception. This compound destroys elements of the seminiferous epithelium but does not significantly alter the endocrine function of the testis. In Chinese studies, large numbers of men were treated with 20 mg/d of gossypol or gossypol acetic acid for 2 months, followed by a maintenance dosage of 60 mg/wk. Preliminary data indicate that recovery (return of normal sperm count) following discontinuance of gossypol administration is more apt to occur in men whose counts do not fall to extremely low levels and when administration is not continued for more than 2 years. Because of low efficacy and significant toxicity, gossypol has been abandoned as a candidate male contraceptive. Bechlioulis A et al: Endothelial function, but not carotid intima-media thickness, is affected early in menopause and is associated with severity of hot flushes. Böttner M, Thelen P, Jarry H: Estrogen receptor beta: Tissue distribution and the still largely enigmatic physiological function. Kalantaridou S et al: Premature ovarian failure, endothelial dysfunction, and estrogen-progesterone replacement. Paulmurugan R et al: In vitro and in vivo molecular imaging of estrogen receptor α and β homo- and heterodimerization: exploration of new modes of receptor regulation. She should also be advised to get adequate exercise and increase her calcium and vitamin D intake as treatment for her osteoporosis. Her family history is significant for obesity, diabetes, high blood pressure, and coronary artery disease in both parents and several siblings. Laboratory tests reveal a random blood sugar of 261 mg/dL; this is confirmed with a fasting plasma glucose of 192 mg/dL. A fasting lipid panel reveals total cholesterol 264 mg/dL, triglycerides 255 mg/dL, high-density lipoproteins 43 mg/dL, and low-density lipoproteins 170 mg/dL. Diabetes mellitus is defined as an elevated blood glucose associated with absent or inadequate pancreatic insulin secretion, with or without concurrent impairment of insulin action. The disease states underlying the diagnosis of diabetes mellitus are now classified into four categories: type 1, type 2, other, and gestational diabetes mellitus. Type 1 Diabetes Mellitus The hallmark of type 1 diabetes is selective beta cell (B cell) destruction and severe or absolute insulin deficiency. Although most patients are younger than 30 years of age at the time of diagnosis, the onset can occur at any age. Type 1 diabetes is found in all ethnic groups, but the highest incidence is in people from northern Europe and from Sardinia. Susceptibility appears to involve a multifactorial genetic linkage, but only 10–15% of patients have a positive family history. These antibodies facilitate the diagnosis of type 1a diabetes and can also be used to screen family members at risk for developing the disease. Pharmacologic insulin is administered by injection into the subcutaneous tissue using a manual injection device or an insulin pump that continuously infuses insulin under the skin. Interruption of the insulin replacement therapy can be life-threatening and can result in diabetic ketoacidosis or death. Diabetic ketoacidosis is caused by insufficient or absent insulin and results from excess release of fatty acids and subsequent formation of toxic levels of ketoacids. Some patients with type 1 diabetes have a more indolent autoimmune process and initially retain enough beta cell function to avoid ketosis.
Ribavirin can be administered as an aerosol using a It is contraindicated in pregnant women and in the male small-particle aerosol generator medicine 802 order genuine detrol. Women of childbearing by this route symptoms nausea headache fatigue order detrol 1mg without prescription, the drug has only minimal systemic ab- potential and male partners of these women must use sorption medicine 5513 discount detrol 1mg free shipping, with drug concentrations in respiratory tract two effective forms of contraception during ribavirin secretions approximately 100 times as high as those treatment and for 6 months post therapy. Oral absorption is rapid, and first-pass women should not directly care for patients receiving metabolism is extensive; ribavirin’s oral bioavailability ribavirin. Similarly, persons with Ribavirin is reversibly phosphorylated by all nucle- coronary disease should not use ribavirin, because ated cells. In vitro, ribavirin inhibits the phos- Clinical Uses phorylation reactions that are required for activation of Ribavirin aerosol (Virazole) is indicated in the treat- zidovudine and stavudine. Lamivudine Treatment is most effective if begun within 3 days of the Lamivudine is a synthetic cytidine analogue used in the onset of symptoms. Its acti- Although ribavirin monotherapy is ineffective vation requires phosphorylation by cellular enzymes. Pulmonary function may decline if aerosol rib- Absorption, Metabolism, and Excretion avirin is used in adults with chronic obstructive lung dis- ease or asthma. Deterioration of pulmonary and cardio- Lamivudine is rapidly absorbed from the gastrointesti- vascular function has also been seen in severely ill nal tract and has an oral bioavailability of approxi- infants given this preparation. Health care changed by the kidney and has an elimination half-life workers exposed to aerosol ribavirin during its adminis- of 5 to 7 hours. Resistance appears in up to one- monthly intramuscular injection prior to and during third of patients after 1 year of treatment. It contains Serious adverse reactions caused by palivizumab are 95% human and 5% murine antibody sequences and rare. Although no anaphylactoid reactions have been re- Palivizumab is composed of the human framework re- ported to date, the possibility of this reaction exists be- gion of the IgG-1 -chain joined to the antigen-binding cause palivizumab is a protein. Caitlyn Doe is a 24-year-old woman in her third pected to produce a significantly higher concentra- month of pregnancy. She has had severe pain, tion of active metabolite in cells infected with its swelling, and redness in both eyes for several days target virus? Doe’s physician diagnosed herpes sim- (B) Foscarnet plex keratoconjunctivitis; the infection has spread (C) Oseltamivir deep into the surrounding tissues. Which of the following drugs should not be given in (A) Cidofovir combination with zidovudine because of an in- (B) Docosanol creased risk of myelosuppression? Mitchell Jones, a 35-year-old man, began treatment (D) Famciclovir for hepatitis C with interferon- -2b and ribavirin (E) Zanamivir (Rebetron) 4 weeks ago. Acyclovir is in pregnancy category B: animal (A) Inhibition of a viral enzyme that aids the studies have shown no evidence of harm to the fe- spread of virus through respiratory mucus and is re- tus, but no large, controlled studies of human out- quired for the release of progeny virus comes have been performed. Docosanol is used for cold sores (C) Stimulation of the tyrosine kinase activity of and is not indicated for ophthalmic use. Interferons and ribavirin are both likely to cause for cellular enzymes required for viral replication anemia; the combination of these two agents in- (E) Inhibition of the viral protease required for creases this possibility. Interferons do not stimulate protein processing prior to assembly of progeny lymphocyte proliferation. The conversion of penciclovir to its active form particles through neuraminic acid–rich respiratory requires initial monophosphorylation by viral secretions and is required for the release of progeny thymidine kinases, then conversion to its active virions. Thus, the mechanism of action of nucleoside analogue antivi- concentration of penciclovir triphosphate is particu- ral drugs. Case Study Picking Up More Than Knowledge in College im Smith had severe herpes labialis while he was for 7 days. Smith went to the emergency health service prescribed penciclovir cream to department complaining of wheezing and an itchy decrease the severity and duration of his many cold rash over much of his body. Smith developed an allergy to and moved to a new city following the breakup of a topical penciclovir when he was treated with this long-term relationship. He to penciclovir allowed him to develop an visited his physician because painful eruptions anaphylactoid reaction following the conversion of developed on his chest the previous day. His doctor oral famciclovir to penciclovir by hepatic first-pass diagnosed acute herpes zoster (shingles) and metabolism. Fusion of cytes and macrophages; these cells are present in all the viral and cellular membranes follows as the virus tissues and can live for many months. In this system, drugs of infections that under normal conditions are not life working by different mechanisms produce a sequential threatening.