Pharmacology Question Set 2

A 65-year-old male is suffering from hypercholesterolemia. There is a family history of cardiac deaths and other cardiovascular diseases. The patient is a smoker. His BMI is more than 25 kg/m2. Total cholesterol is more than 240 mg/dL and LDL is more than 160 mg/dL. He was prescribed a hypolipidemic drug. During treatment, a lab test shows an increase in the serum transaminases in the blood. Also, myopathy is observed in the patient. The drug responsible for the adverse effects mentioned above is?

A 28 year old female presents with a vaginal discharge for the past one week. She maintains a monogamous relationship. Her pregnancy test is positive and a wet mount showed motile Trichomonads. The drug of choice for the patient is:

A 23-year-old male presents with a complaint of swelling of the left knee. He noticed the swelling one day ago while preparing for the college basketball game. Synovial fluid tap shows a WBC cell count of 90000 cell/mm^3. The mechanism of action of the drug which is used in his treatment is?

An experimental drug is ES 62 was being studied. It reduces the growth of Vancomycin resistant Staph aureus. It is a highly lipid soluble. The initial dose which is supposed to be given at the time of initial treatment is dependent on:

A 56-year-old man comes to your office with a 2-month history of dry cough. His past medical history includes a recent myocardial infarction (MI), after which he was placed on several medications. He does not smoke and do not has a history of bronchial asthma. Which of the following medications may be the causative factor for this symptom?

A 70-year-old man notices passage of blood in urine after he has completed a cycle of chemotherapy for non-Hodgkin’s lymphoma. He comes to you with this complaint and states for lower abdominal pain, frequency and urgency. You decide this could be a side effect by one of the chemotherapeutic agents. Which agent it might be-?

A 44-year-old male comes to your chamber complaining that he is experiencing erectile dysfunction for 1 month. He is a patient of hypertension and angina pectoris and under regular treatment. You evaluate the drugs and judge that the erectile dysfunction is due to a medication. Which one of the following may be the culprit?

A 58-year-old African male patient admitted to the neurology department with sudden severe headache and vomiting. He has poorly controlled hypertension, taking several medications for it. CT scan is normal; CSF study shows RBCs. Injectable labetalol is advised. Doctor advices some other medications. Which of the followings may be included?

A 60-year-old hypertensive patient with Ischemic Heart Disease is taking glyceryl trinitrate. The following medications are safeguard for cardiovascular stress during sexual intercourse for this patient, except?

28-year-old pregnant lady comes to the ER with headache, blurring of vision and vomiting. On examination, her BP is 195/150 mm Hg, ankle edema present, urinary proteinuria present. On inquiry, she is primi and it is 23 weeks of gestation. All on a sudden, she develops convulsion. Intravenous magnesium sulphate is introduced immediately and she recovers smoothly. During discharge, which of the following medication will be justified?

A 64-year-old male patient is admitted into the emergency room with an acute myocardial infarction (AMI). His recent ECG shows ventricular tachyarrhythmia. This arrhythmia is life-threatening and must be controlled immediately. Which of the following drugs would be best to quickly control the condition?

A patient comes to the ER with severe hyperkalemia. He is taking amiloride for long duration. Which of the following measures will lead to cardiac arrhythmia?

A 63-year-old lady comes to the ER with a history of chronic heart failure. She is taking several medications for this condition. Which of the following medication cannot be given for long period?

A 27-year-old pregnant woman develops severe hypertension. Doctor prescribes her an injectable antihypertensive along with a beta blocker. Her blood pressure returns to normal, but she develops a side effect that is very similar to systemic lupus erythematosus. How does this medication lower blood pressure?

A 68-year-old man comes to the emergency department complaining having difficulty breathing. Two weeks before he was treated for IHD and ventricular tachycardia. A chest X-ray reveals pulmonary fibrosis. Which antiarrhythmic was he taking?

A 59-year-old man comes to the clinic with angina while exerted. The doctor advised him nitroglycerine in the morning and afternoon. A medical student asks him why a nitrate is given in such a schedule instead of giving in morning-afternoon-night dosing schedule. What’s your judgment?

18-year old girl presents with recurrent episodes of headache. The pain is usually unilateral, pulsatile in character, exacerbated by light and noise, usually lasts for few hours to a full day. Pain sometimes precipitates by eating chocolates. These headaches disturb her daily routine activities. Physical examination was within normal limits. She also has essential tremors. Which drug is suitable in her case for prevention of similar future episodes of headache?

40 year old male presented to you with episodes of sudden severe pain in his right side of face that lasts for only few seconds. Pain is lancinating, gives the sensation of electrical shocks in the affected area. The pain is precipitated by chewing or touching the face. You prescribed him the drug of choice for his condition. Which of the following side effects of this drug the patient should be informed of?

A 13- year old girl presents with a right sided infected ingrown toe nail. On examination, skin on the lateral side of toe is red, warm, swollen and tender to touch. When gentle pressure is applied, the pus oozes out. You sent the pus for the culture and sensitivity. The offending organism came out to be Methicillin resistant staphylococcus aureus. Which of the following drugs is effective against this organism?

A 7-year old boy is having frequent episodes of blanking out or daydreaming. Each episode lasts for less than 10 seconds. During the episode, he is unaware of what is going on around him and does not respond to the calling. After the episode, he continues whatever he was doing before. EEG shows generalized 3-4 Hz spike-and-slow-wave complexes. The mechanism of action of the drug of choice for this condition is:

A 56-year old man came into the emergency room due to sudden onset of severe eye pain and blurring of vision. The patient noted the onset of the symptoms an hour prior to tearing and progressive decrease in vision. Upon referral to the ophthalmology resident on duty, a cloudy cornea and decreased visual acuity was observed during the physical exam. A diagnosis of glaucoma was made. Timolol is used as a drug for open angle closure glaucoma. The mechanism of action is?

A 60-year old patient came in for her regular consultation at your clinic. She is diabetic and hypertensive. She had a previous history of myocardial infarction (2 years ago) and was maintained on anticoagulants. When changing anticoagulants from heparin to warfarin, warfarin therapy is usually overlapped with heparin for the first 1-2 days. The rationale behind the overlapping is?

A 24-year old male presents to the emergency room due to difficulty in breathing and blurring of vision in the left eye. The patient has no comorbidities; however, you noted that he had more than six sexual partners (both men and women) and did not use any form of protection during sexual intercourse. He has no family history of any disease with no maintenance medications. Upon physical examination, the patient has crackles on all lung surfaces and positive eye findings. A suspicion of HIV is noted. The mechanism of action of the drug that can be given for the eye symptoms is?

A 65-year old female presented to the ER due to progressive dyspnea. She is a known hypertensive, but is poorly compliant with medications. On history taking, patient claims to experience orthopnea, paroxysmal nocturnal dyspnea, and easy fatigability. On physical examination, her blood pressure is 80/50 mm Hg. There is prominent neck vein distention. S3 gallop, bibasal crackles and grade-3 bipedal edema were also detected. A 2d echo was done which showed a depressed ejection fraction of 32%. Which of the following drug should not be given to this patient?

A 37-year old female diagnosed with chronic schizophrenia maintained on an antipsychotic medication was brought to the clinic due to a 3-days history of fever. Physical examination showed presence of tonsillar exudates. A CBC was requested which showed markedly decreased WBC count. The medication was immediately discontinued by the patient’s physician. The antipsychotic medication that could have caused this problem is?

You are currently employed as a clinical researcher for a new drug to be used for the treatment of Parkinson’s disease. Currently, you are already done with the proposed mechanism of the new drug. You are in the clinical phase of drug development wherein the drug is studied in patients with the target disease to determine its efficacy. Which of the following phases the new drug will fall?

A 25-year old female came in with a chief complain of cough for more than 3-weeks which was accompanied by night sweats, weight loss, and body malaise. On physical examination, the patient had slightly pale palpebral conjunctivae, multiple bilateral posterior cervical lymphadenopathies, but with no adventitious breath sounds on bilateral lung fields. The rest of the physical examination was routine. The patient was given a regimen that was to be followed for 6 months. On follow-up after 2 months, the patient’s ALT and AST tests were above normal. Which of the following antitubercular drug could have contributed to this lab result?

A 30-year old female came to her OBGyn for consultation for infertility treatment. The patient reports intercourse with her husband at least 3 times per week with increasing frequency during the periods. The lab reports of her husband revealed adequate sperm count. After all workups were complete, her OBGyn prescribed a medication similar to GnRH to be administered in a pulsatile manner. The drug prescribed to the patient is?

A 70-year old male with chronic heart failure came in ED due to difficulty in breathing. The patient is a known hypertensive for 20 years maintained on Amlodipine and Telmisartan. You noted that he is also being given a diuretic that blocks the Na+ channels in the cortical collecting tubule. What drug is being referred to in this case?

A 65-year old male presented with gradually increasing rigidity of arms and legs, and slowness in performing tasks. He has noticed hand tremors which increase at rest and decreases with the movement. On examination, he does not swing his arms while walking and takes shorter strides. An antiviral drug was prescribed that alleviated the patient’s symptoms. Which antiviral drug was most probably prescribed to the patient?

A 24-year-old Mexican woman delivers a girl by normal vaginal delivery, Apgar scores are 8 and 10 at 1 and 5 minutes respectively, newborn vitals are normal. On examination, the attending pediatrician finds an absence of skin in the central area of the scalp, which is circular in shape, 0.5 cm in size. The remaining examination is normal. The mother gives past history of having constant diarrhea for 3 months about 2 years ago, weight loss of 5 kg in 3 months, palpitations, and she always felt her skin to be warmer than others. She visited a community hospital and was prescribed a drug for the same. She did not visit the hospital for any of her routine check-ups and continued taking drugs. Which drug can predispose to the condition of the newborn?

An endocrinologist is working with a pharmaceutical research company on a new drug for diabetes mellitus type II. In their experimental studies, they retrieved a component from Gila monster saliva, which was found to have more than half of similar amino acid sequences as that of glucagon-like peptide-1. During the preclinical animal studies, this was found to be helpful in the diabetic control of the experimental mouse. Now, as the next step towards it, they are trying to inhibit the enzyme responsible for degradation of glucagon-like peptide-1. Which of the following drug has a similar mechanism of action to the new drug which is being investigated in the next step?

A 42-year-old man comes to the emergency department with complaints of palpitation, two episodes of vomiting and difficulty in breathing for the past one hour. He is a software engineer by profession and had consumed 90 ml of scotch at a party 3 hours ago. He has no similar past history; he smokes 10 packs per year and drinks alcohol occasionally. He was recently diagnosed with diabetes two months back and was started on single drug therapy. He also has a history of hypothyroidism for the past two years and is under treatment. He tells you that he is regular with his treatment and check-ups. On examination, his face appears red; BP is 100/60 mm of Hg. EKG shows sinus tachycardia. Which of the following drug is responsible for this patient’s presentation?

A 24-year-old male presents to you for the routine follow-up of his asthma. He is currently on albuterol, corticosteroids and salmeterol, all via inhaled route. The patient is compliant with his medications, but still complains of episodic shortness of breath and wheezing. The peak expiratory flow (PEF) has improved since the last visit, but is still less than the ideal-predicted values, based on age, sex, and height. You have added montelukast in his treatment regimen. What is the mechanism of action of this drug?

A 9-year-old girl presents in the emergency room with severe shortness of breath, cough, and wheezing after playing with her friends in the garden. She has history of bronchial asthma and is looking confused. Physical exam reveals: Respiratory rate = 39 breaths/ minute, Pulse rate = 121 beats/ minute, Blood pressure = 129/67 mmHg and Temperature = 99°F. She has bilateral diffuse wheezes on chest auscultation. Which of the following is the most appropriate drug to rapidly reverse her bronchoconstriction?

A 28-year-old man comes to his GP for a regular checkup. He has recently been diagnosed with asthma and was given short acting β2 agonists to use in case of need. He said he usually uses the medication 1-2 times per week. Which of the following is the most appropriate treatment in this case?

A 56-year-old woman presents to her physician with the complaints of pain in her fingers and wrist for the last 6 months. She says the pain present in both hands and her wrists are also swollen. Furthermore, she describes morning stiffness in her joints lasting about 2 hours which improves with use. She has been taking acetaminophen which provided minimal relief but the swelling has gotten worse. She also feels increasingly tired. Her past medical history reveals she has successfully treated for Helicobacter pylori (H. pylori) related ulcers last year but still takes omeprazole for her mild gastroesophageal reflux. Her past history is otherwise unremarkable. She stopped drinking when her gastric symptoms started and have never smoked. Which of the following analgesic drugs is relatively safe in this patient?

A 45-year-old male presents to his physician with worsening of his joint pain and stiffness. He was diagnosed with rheumatoid arthritis 3 months back and is currently taking celecoxib and methotrexate. He also takes omeprazole for occasional gastric reflux. He has no other medical concerns. His vitals are as follows: pulse is 80/min, respirations are 16/min, and blood pressure is 122/80 mmHg. On examination, his left wrist is swollen, stiff, and warm to touch while his right wrist is red and warm. He has a limitation of movement at the proximal interphalangeal and metacarpophalangeal joints of both hands. The rest of the examination is unremarkable. An x-ray of the hand shows progressive degeneration of several joints. A second-line agent, etanercept, is added to help control the progressing arthritis. Which of the following should be ordered before starting the new medication?

A 69-year-old female comes to the physician’s clinic for an annual flu shot. She was diagnosed with mild rheumatoid arthritis 3 years back and has been taking celecoxib and methotrexate to manage her condition. She also takes a daily folate-containing multivitamin. She has had three elective cesarean sections during her late twenties and had an appendectomy in her teens. Her family history is insignificant. She does not consume alcohol, smoke cigarettes, or take recreational drugs. Her physical examination is unremarkable. Recent labs show: Hemoglobin (Hb%): 14.2 g/dL Mean Corpuscular Volume (MCV): 83 fl Since she is symptom free, she asks the physician if her medications can be discontinued. Which of the following test is most sensitive in monitoring her therapy?

A 59-year-old woman presents to the emergency department at night with intense, sharp pain in her great toe for the last hour. This is her second visit to the emergency this year with the same complaint. Her right great toe is visibly red, moderately tender, and warm to touch. She is visibly distressed and the rest of the examination is unremarkable. An X-ray of the foot reveals no abnormalities. Joint arthrocentesis of the inflamed toe reveals urate crystals. Her labs show: Serum Glucose (random): 170 mg/dL Serum Electrolytes: Sodium: 140 mEq/L Potassium: 4.1 mEq/L Chloride: 100 mEq/L Uric Acid: 7.2 mg/dl Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 9 mg/dl Cholesterol, total: 170 mg/dL HDL-cholesterol: 43 mg/dL LDL-cholesterol: 73 mg/dL Triglycerides: 135 mg/dL Ibuprofen is prescribed for her symptoms. She is decided to be put on a chronic therapy to prevent future attacks of arthritis. Which of the following drugs was most likely started in this patient?

A 53-year-old man presents to the physician with swelling of right knee since the previous night. He also had a sharp pain in the joint last night which was reduced by ibuprofen and an ice-pack. The pain persists but is tolerable. He has never had joint pains before. His medical history reveals Coronary Artery Bypass Graft (CABG) done a year ago for which he takes aspirin, atorvastatin, captopril, and carvedilol. He also takes a vitamin C pill daily. He has a 20-pack-year history of smoking but quit 5 years back. He was a heavy drinker for the past 30 years back but now drinks only a few drinks on the weekends. On examination, the right knee is erythematous, warm and swollen, It is slightly tender to touch. Mild systolic ejection murmur is heard on chest auscultation. Surgical scars are present on this chest and left leg. The remainder of the examination is insignificant. Arthrocentesis is performed and the presence of urate crystals in the joint aspirate confirms the suspicion of gout. Which of his medications most likely precipitated his current symptoms?

A 26-year-old woman presented to the doctor’s office for blood in her urine for 2 days. She has an increased urinary frequency at night for several days and recently noticed a reddish tinge in her urine. She is concerned about her feet appearing to be swollen during this time. She has been feeling increasingly fatigued for the past week as well. Past medical history is relevant for occasional bluish discoloration of her fingers during exposure to cold. She gives no history of joint pains, rashes, or skin changes. She has been otherwise healthy in the past. Vitals are as follows: pulse is 80/min, respirations are 14/min and blood pressure is 140/88 mmHg. On examination, she has mild bilateral swelling of the feet, but all other joints are normal. No other findings are seen. Labs show: Serum Glucose (fasting):88 mg/dL Serum Electrolytes: Sodium: 143 mEq/L Potassium: 3.7 mEq/L Chloride: 102 mEq/L Serum Creatinine: 1.7 mg/dl Blood Urea Nitrogen: 32 mg/dl Cholesterol, total: 180 mg/dL HDL-cholesterol: 43 mg/dL LDL-cholesterol: 75 mg/dL Triglycerides: 135 mg/dL Hemoglobin (Hb%): 12.5 g/dL Mean Corpuscular Volume (MCV): 80 fl Reticulocyte count: 1 % Erythrocyte count: 5.1 million/mm^3 Thyroid Stimulating Hormone: 4.5 μU/mL Urinalysis: Glucose: Negative Protein: +++ Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: +++ A renal biopsy is ordered. Which of the following drugs should be started?

A 25-year-old pregnant woman presents to her obstetrician for an advice on getting epidural anesthesia for an expected vaginal delivery soon. She is in her third trimester and has not received any antenatal care till now. This is her second pregnancy. Her first child was delivered safely at home by an unlicensed midwife. She felt traumatized by her first experience and wishes to receive an epidural for the upcoming delivery. Upon inquiry, she admits that she desires a “fully natural experience” and has taken no supplements or shots during or after her first pregnancy. Her child also did not receive any post delivery injection or vaccination. Her first child is healthy. She has an A (-) negative blood group while her husband has an O (+) positive blood group. Gestational age is calculated to be 28 weeks. Which of the following should be immediately administered to prevent a potentially serious complication at this delivery?

An 78-year-old woman comes to the physician with the complaints of difficulty in swallowing and retrosternal chest pain for the past couple of weeks. The pain radiates to the epigastric region and increases whenever she eats or drinks anything. The pain is not aggravated by exertion and she denies shortness of breath, nausea or vomiting, cough, sore throat, weight loss or melena. She was feeling well two weeks ago and never used to have heartburns before. She has never smoked but consumes alcohol occasionally. Past medical history is significant for hypertension, osteoporosis, stress incontinence, and cataract in left eye for which she underwent surgery 2 years back for intraocular lens implant. She is currently taking Rosuvastatin, Enalapril, Risedronate, and Oxybutynin. Her vitals are pulse: 74 /min, Respirations: 14 /min and blood pressure: 140/86 mmHg. Abdominal examination reveals tenderness over the epigastric region. The remainder of the physical examination is unremarkable. An ECG is performed and shows mild left axis deviation. Which is the best management option for this patient?

A 50-year-old man presents to the Emergency Room with a rapid onset of severe, right periorbital pain, an ipsilateral throbbing headache, and blurring of vision for the last one hour. He was out walking with his friend when he felt short of breath. His friend gave him to take a puff of his rescue inhaler because it often relives his breathlessness. Soon thereafter, the patient’s eye symptoms started. He has no history of any medical condition and was only hospitalized once in his teenage years for an appendectomy. His pulse is 100/min and regular, respirations are 18 /min, temperature is 98F and blood pressure 130/86 mmHg. His right pupil is fixed and dilated. Fundoscopic examination of the right eye is difficult due to “clouding” of the cornea and tonometry reveals an increased Intraocular pressure (IOP). He is in acute distress. Physical examination reveals abnormal findings. His therapy is begun with Ibuprofen, Acetazolamide, Timolol, Pilocarpine, and topical Prednisolone. His symptoms are only mildly reduced. What is the next best step in the management of this patient?

A 60-year-old female presents to you with the complaints of visual difficulties. She says she sees less than what she was able to see a few years back. Objects appear clear but she just can’t see as well as before. She first noticed this when she went to the movies with her grandkids and could not see the whole screen. She has no complaints of redness, itchiness or excessive tearing of the eyes. She takes a daily multivitamin, Captopril for her hypertension and Acetaminophen for the occasional headache. Her blood pressure chart shows her hypertension is well controlled. She is otherwise in good health. Her examination is insignificant. Vitals are blood pressure: 130/80 mmHg, pulse: 80 bpm and regular, respirations: 14/min, and temperature: 98° F. Her labs are within normal limits. Eye examination reveals: Visual acuity: normal, Visual fields: reduced, with enlarged blind spots, Tonometry: mildly increased IOP. A diagnosis of open angle glaucoma is made and the patient is started on Brimonidine. Which best describes the beneficial action of Brimonidine in this patient?

A 45-year-old female presents to the office with the complaint of generalized weakness which has been getting worse over the last few months. She says she just does not have the energy for her daily activities anymore. She gets winded quite easily when she takes her dog for a walk in the evening. She says that her mood is generally ok and she gets together with her friends every weekend. She works as a teacher at a local elementary school and used to have frequent headaches while at work. Her husband is a commercial pilot and is frequently away for extended periods of time. Her only son is a sophomore in college and visits her every other week. She has had issues in the past with her hypertension but her blood pressure is now well-controlled as she is compliant with her medication. She is currently taking Atorvastatin and Lisinopril. Her blood pressure is 130/80 mmHg, pulse is 90 bpm, temperature is 98F and respirations are 16 /min. On examination, she appears slightly pale and lethargic. Her ECG today is normal and recent lab work shows: Serum Creatinine: 1.5 mg/dL Estimated GFR: 37.6 mL/min Hemoglobin (Hb%): 9 g/dL Mean Corpuscular Hemoglobin (MCH): 27 pg Mean Corpuscular Hemoglobin: Concentration(MCHC): 36gm/dl Mean Corpuscular Volume (MCV): 85 fl Reticulocyte count : 0.1 % Erythrocyte count: 2.5 million/mm^3 Serum Iron: 160 μg/dL Serum Ferritin: 150 ng/mL Total Iron Binding Capacity: 105 μg/dL Serum vitamin B12: 254 pg/mL Serum folic acid: 18 ng/mL Thyroid Stimulating Hormone: 3.5 μU/mL Which of the following will most likely help her?

A 38-year-old actress presents to the ER with increasing fatigue, finding it increasingly difficult to talk for the last few hours. Her medical records show she is taking metformin and insulin to control her diabetes. Obtaining a history is difficult, but she tells you that she recently transitioned to acting live on-stage and started taking a pill to “calm my nerves”. Which symptom is the patient most likely to complain of?

The parents of a 14-year-old boy are concerned about insulin use for his recently diagnosed Type 1 Diabetes. Currently he takes regular insulin twice a day and checks his blood glucose three times a day. He appears to have a caught a cold while at school and they were wondering how to modify his treatment.

A 24-year-old bodybuilder presents to you for an annual check-up. He tells you he is on a protein rich diet that only allows for minimal carbohydrate intake. His buddy suggested he try glucagon to help him lose some excess weight before the upcoming competition. Which effect of glucagon is he attempting to exploit?

A 44-year-old male comes to the office for a follow-up visit for diabetes and hypertension. He says that he tries to eat healthily and exercise more but admits that he could do more. He complains of having to urinate frequently but denies burning sensation with micturition. He also complains of a mild cough that began several years back when he was hospitalized for a “heart attack”. Recently his cardiologist told him that his heart is 'quite weak'. Currently, he takes Metformin, Aspirin, Rosuvastatin, Captopril and Furosemide. Examination reveals an irregular pulse of 74/min, respirations of 14/min, blood pressure of 130/80 mmHg, and temperature of 98 °F. His BMI is 32 kg/m2. He has visible jugular pulsations on the neck. Recent lab work shows: Glycated Hemoglobin (Hb A1c): 7.5 % Fasting Blood Glucose: 120 mg/dl Serum Electrolytes: Sodium: 138 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 1.3 mg/dl Blood Urea Nitrogen: 18 mg/dl What is the next best step in the management of this patient?

Parents of a 16-year-old Type 1 diabetic boy visit the clinic for information regarding a new injectable drug, Exenatide, that only needs to be administered once a week. They are quite excited about the prospect of switching their son's medication as he now has to take multiple shots of insulin everyday. They request the doctor to start their son on this medication right away. The boy’s blood glucose levels are quite difficult to control on his current regimen due to poor compliance. His BMI is 19 kg/m2. He has had difficulty putting on weight despite eating quite a bit. Which of the following best describes why is it not possible to start the boy on a weekly dose of Exenatide instead of daily insulin?

A 36-year-old woman comes to the physician with the complaint of a whitish vaginal discharge since the last week. She also complains of itching and discomfort around her genitals. Her symptoms are getting worse. She has been changing her undergarments frequently and changed the brand of detergent she uses to wash her clothes but it did not resolve her problem. Additionally she admits to having painful urination and increased urinary frequency for the past one month which she was told are expected side effects of her medication. She denies fever and malaise. She has two children, both delivered via cesarean section in her late twenties. She is currently taking Atorvastatin, Captopril, Metformin, and Empagliflozin for her hypertension and Type 2 Diabetes. Her medications were changed one month back to improve her glycemic control. A lab report from one month back shows her HbA1c to be 7.5%. She has a mild allergy to peanuts and carries an Epinephrine injection with her at all times. Her blood pressure today is 126/84 mmHg and her fingerstick glucose is 108 mg/dL. Pelvic examination reveals erythema and mild edema of the vulva. A thick, white, clumpy vaginal discharge is seen. The vaginal pH is 4. Microscopic examination of a KOH-treated sample of the discharge demonstrates lysis of normal cellular elements with branching pseudohyphae. What is the next best step in her management?

A 24-year-old accountant is brought to the Emergency Room by her co-workers after they found her unconscious at her cubicle when they returned from lunch. One of them tells you that she has diabetes but does not know anything more about her condition. They are trying to contact her family members for more information. Her vitals show a pulse of 110/min, respirations are 24/min, and temperature of 98 °F with a blood pressure of 90/60 mmHg. She is breathing heavily and gives irrelevant responses to questions. Her skin and mucous membranes appear dry. Examination of the abdomen reveals mild tenderness. Tendon reflexes are slightly delayed. Labs findings include: Finger Stick Glucose: 630 mg/dl Arterial Blood Gas Analysis: pH: 7.1 pO2: 90 mmHg PCO2: 33 mmHg HCO3: 8 mEq/L Serum: Sodium: 135 mEq/L Potassium: 3.1 mEq/L Chloride: 136 mEq/L Blood Urea Nitrogen: 20 mg/dl Serum Creatinine: 1.2 mg/dl Urine examination shows: Glucose: Positive Ketones: Positive Leucocytes: Negative Nitrite: Negative RBC: Negative Casts: Negative She is immediately started on a bolus of IV 0.9% NaCl. Which is the next best step in the management of this patient?

A 30-year-old male presents to the physician with the complaint of heartburn for the past couple of weeks. He feels a burning sensation in his chest, at times reaching his throat, usually worse after eating spicy foods. He often drinks a can of beer in the evening after work. He is overweight and actively trying to lose weight. There is no history of cough, difficulty swallowing, hematemesis, or melena. He does not smoke or drink alcohol. The physician recommends him to eat smaller meals, avoid spicy foods, and refrain from alcohol before bedtime. He comes back again a month later with no change in his heartburn despite having followed all the advice. On examination his blood pressure is 124/82 mmHg, pulse is 72/min and regular, and respirations are 14 /min. Abdominal tenderness is absent. What is the next best step in the management of this patient?

A 25-year-old female presents to the Emergency Room with generalized abdominal pain and vomiting for past one hour. She has had watery diarrhea for several days with no blood or pus in the stools. She is taking an over-the-counter anti-diarrheal medication and drinking Oral Rehydration Solution. Her diarrhea has subsided once she took the medication. She is slightly confused and cannot recall the name of the medication though. Her past medical history shows she was hospitalized 10 years back for an appendectomy and 4 years back for a fractured ulna following a motor vehicle accident. On examination, her pulse is 104 bpm, blood pressure is 120/80 mmHg, respirations are 14 /min with shallow breathing and temperature is 98 °F. Furthermore, her pupils are constricted and her hands feel cold. Her abdomen is soft and mildly tender with a palpable bladder. Rebound tenderness cannot be elicited either. Fingerstick blood glucose is 124 mg/dL. Blood sample is drawn and sent to lab, a urinary catheter is placed, and intravenous fluids started. Abdominal imaging shows no abnormalities. Which of the following is the next best step in the management of this patient?

A 40-year-old woman presents to the clinic with the complaints of ongoing heartburn despite being on treatment for the last few months. She describes a burning sensation in her chest after even the smallest portion of meals. She has stopped eating fatty and spicy foods as they aggravate her heartburn significantly. She has also stopped drinking alcohol but is unable to quit smoking. Her attempts to lose weight have failed. Her current BMI is 26 kg/m2. On her last visit, she was started on Omeprazole and Ranitidine but she still having symptoms. She had previously used oral antacids but had to stop because of intolerable constipation. She has had a mild cough for several years. Her medical history is otherwise unremarkable. On examination she has a pulse of 90/min, blood pressure of 120/67 mmHg, respirations of 14 /min and a temperature of 98 °F. Her teeth are yellow-stained and the physical exam is otherwise unremarkable. What is the next best step in her management?

A 20-year-old college student presents to the doctor’s office for advice on improving his health. He admits to eating junk food mostly although he knows that he should lose some weight. His daily physical activity is limited to walking around the college campus between classes. Except for the occasional headache for which he takes acetaminophen, he has no health concerns and takes no other medications. He denies smoking and illicit drug use but admits to occasional beer binge drinking on weekends. He is sexually active with his current girlfriend and regularly uses condoms. His mother has type 2 diabetes and obesity while his father has hypertension and hypercholesterolemia. His pulse is 74/min, respirations are 16/min, and blood pressure is 130/76 mmHg. His Body Mass Index (BMI) is 29 kg/m2. Examination reveals an overweight young male and is otherwise unremarkable. Routine lab tests show: Serum Glucose (fasting): 100 mg/dL Serum Electrolytes: Sodium: 141 mEq/L Potassium: 4.0 mEq/L Chloride: 100 mEq/L Cholesterol, total: 190 mg/dL HDL-cholesterol: 42 mg/dL LDL-cholesterol: 70 mg/dL Triglycerides: 184 mg/dL Urinalysis: Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: Negative Which of the following lifestyle changes will benefit this patient the most?

A 30-year-old architect comes to the doctor’s office for an annual checkup. He feels healthy and his only concern is an occasional headache after work. He underwent an appendectomy 10 years back and fractured his arm playing football in high school. Except for the occasional cold, the rest of his medical history is unremarkable. His mother has type 2 diabetes while his father and grandfather both have hypertension. He does not drink alcohol, smoke cigarettes, or use drugs. Examination reveals an overweight black male of 1.67 m (5 foot 6 inches) weighing 80 kg (176 lb) with a protuberant belly. Vitals show a regular pulse of 78 bpm, respirations 16/min, and temperature of 36.8 °C (98.2 °F). The examination yields no significant findings. During his last two visits, his blood pressure readings have been 140/86 mmHg and 136/82 mmHg. Today his blood pressure is 136/86 mmHg and his lab tests show: Serum Glucose (fasting): 90 mg/dL Serum Electrolytes: Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 9 mg/dl Urinalysis Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrite: Negative Red Blood Cells (RBC): Negative Casts: Negative. What is the next best step in management of this patient?

A 50-year-old woman is brought to the emergency department by her husband for shivering and fever that started an hour ago. She is sweating profusely and is irritable when asked questions. Her other medications include captopril, metformin, and fluoxetine for her hypertension, diabetes, and depression. Earlier in the day, she took St. John's Wort because she was told by a friend that it helps in depression. She has no history of allergies. On examination pulse rate is 130/min, respirations are 18/min, blood pressure is 176/92 mmHg, temperature is 38.5 °C (101.3 °F). Increased bowel sounds are heard in the abdomen. Hyperreflexia is noted, clonus is elicited, and sensations are decreased in the feet. Mydriasis is seen and she is diaphoretic. She is well-oriented but irritable throughout the examination. Fingerstick glucose is 140 mg/dL. An ECG shows sinus tachycardia but is otherwise normal. What is the likely cause of this patient's condition?

A 65-year-old female comes to the physician’s clinic for her decreasing memory for past few weeks. She vividly describes how she forgot where she put her car keys this morning and did not remember to wish her grandson on his birthday last week. Despite her memory concerns, she is able to remember most of the things and has continued to live independently. She is a widow and maintains an active social circle to keep herself busy. Her concerns arise from reading about Alzheimer’s disease in a magazine which prompted her to be more aware of her memory lapses. There is no history of Alzheimer’s in her family. Her medical history is significant for an acute cardiac event several years back and she has been taking aspirin, carvedilol, and captopril since then. She has never smoked and occasionally drinks wine with dinner. She has already started doing Sudoku puzzles to improve her mental abilities. She heard from a friend that Ginkgo can help improve her brain function and prevent memory loss and asks if she should start taking it. What would be the most appropriate response by the physician to her question?

A 53-year-old man comes to the doctor's office with concerns about his blood pressure. He was recently told that he has high blood pressure at a local health fair. He has not seen a doctor since leaving college because he never felt the need for medical attention. Although he feels perfectly fine, he is concerned because his father had hypertension and died due to a heart attack at the age of 61. He does not smoke but drinks occasionally. His blood pressure today is 150/90 mmHg. His physical examination is insignificant. Labs are ordered and he is asked to monitor his blood pressure at home before his follow-up visit. Two weeks later, his blood pressure is 140/90 mmHg and his home blood pressure ranged from 130/90 mmHg to 155/95 mmHg. An electrocardiogram (EKG) is normal. Lab tests show: Serum Glucose (fasting): 88 mg/dL Serum Electrolytes: Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 10 mg/dl Cholesterol, total: 250 mg/dL HDL-cholesterol: 35 mg/dL LDL-cholesterol: 186 mg/dL Triglycerides:´250 mg/dL Urinalysis: Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: Negative Regular exercise and a “heart healthy diet” are advised. He is started on lisinopril for his hypertension. Which of the following medications should be added in this patient?

A 47-year-old female presents to the emergency department in a frantic state and demands immediate treatment for her "allergic reaction" which started soon after she had lunch, about an hour ago. She had her usual meal of homemade salad and lemonade. She was recently started on niacin because she could not tolerate statins. Her only other medication is captopril for hypertension. She has no respiratory distress and denies having a runny nose, watering from the eyes, and diarrhea. She says that she has a stinging sensation on her face. She has no history of allergies and no family history of allergies as well. Her vitals are as follows: pulse is 90/min, respirations are 16/min, blood pressure is 120/80 mmHg, and oxygen saturation is 98 % on room air. On examination, her face and trunk have a flushed appearance. Reminder of the physical examination is unremarkable. The attending physician reassures her that she is not in any immediate danger and within the next hour her symptoms subside. She is advised to take aspirin 30 minutes before her other medications and sent home. Which of the following is the etiology of her symptoms?

A 40-year-old female visits the office for a routine medical checkup. She admits to being careless about her health but now wants to improve. She is working with a personal trainer at the gym and is following a weight reduction diet plan. Despite a 20 kg (44 lb) weight loss over the last year, she still feels she is fat. She was a frequent binge drinker but now she has reduced her alcohol consumption to a single glass of wine with dinner and the occasional beer on the weekend. She also has a 15 pack-year smoking history, but quit 6 months back after she developed cough and shortness of breath that improved later. She admits to trying various recreational drugs in the past. On her last visit, she was started on rosuvastatin for elevated cholesterol. She is sexually active with her partner and they have two children. She is uncertain of her family history as she was raised in foster care. Her vitals are as follows: pulse is 80/min, respirations are 16/min, and blood pressure is 122/80 mmHg. Physical examination reveals a visibly overweight female with a Body Mass Index (BMI) of 34 kg/m2. The remainder of the examination yields no significant findings. An electrocardiogram (EKG) and chest X-ray are both normal. Lab tests show: Serum Glucose (fasting): 95 mg/dL Serum Electrolytes: Sodium: 140 mEq/L Potassium: 3.8 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 10 mg/dl Cholesterol, total: 180 mg/dL HDL-cholesterol: 42 mg/dL LDL-cholesterol: 70 mg/dL Triglycerides: 365 mg/dL Urinalysis: Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: Negative Which medication would most likely further improve her lipid profile?

A 79-year-old male comes to the physician's office for a regular appointment. He had a myocardial infarction three years back and was started on aspirin, carvedilol, captopril and high dose atorvastatin. He denies any shortness of breath and cough. He exercises regularly and is on a healthy diet good for his heart. His vitals today are pulse: 80/min, respirations: 16/min, and blood pressure: 122/80 mmHg. Physical examination reveals an overweight male with a Body Mass Index (BMI) of 28 kg/m2. His fasting lipid profile shows: Total cholesterol: 200 mg/dL High-Density Lipoprotein (HDL): 35 mg/dL Low-Density Lipoprotein (LDL): 140 mg/dL Triglycerides: 120 mg/dL Which of the following drugs should be added to his regimen?

A 75-year-old male is brought to the physician by his son for a tremor in his hands and arms. He has had the tremor for "many years" but it has worsened in the last year. The tremor is more prominent at rest and nearly disappears on movement. His son says the patient's movements have been slower and the patient reports difficulty initiating voluntary movements. There is no significant past medical history. He often drinks wine but this does not affect his tremors. Examination reveals a “pill-rolling” resting tremor. The tremor is accentuated when the patient is asked to clench the contralateral hand and alleviated by finger-nose testing. The patient is unable to play an imaginary piano with his fingers. Increased tone of arm muscles and resistance to passive movement at the joints is noted. When asked to walk across the room, he has difficulty taking the first step, has a stooped posture and takes short rapid steps. His face is expressionless throughout the examination. Which of the following drugs would be most effective for his condition?

A 32-year-old woman comes to the office for a follow-up visit. She was diagnosed with diabetes a month back but refused to start medications despite thorough counseling. She tried exercising and eating healthy in an attempt to “cure” her diabetes. She managed to lose 4 lbs in a month. Today she complains of increased urinary frequency, the same symptom that lead to her initial suspicion of diabetes. She feels more energized since she started going to the gym regularly. She has never been hospitalized in her life and has no other medical concerns. She is happily married and plans on having kids in the next few years. She is a nonsmoker, denies illicit drug use, and drinks socially. Her vitals show a pulse of 80/min, respirations of 16/min, blood pressure of 120/80 mmHg and temperature of 98.4 °F. Her BMI is 33 kg/m2. Physical exam findings are insignificant. Her fingerstick glucose today is 214 mg/dL. Labs ordered on her last visit show: Glycated Hemoglobin (HbA1c): 7.1 % Blood Glucose (fasting): 130 mg/dL Serum: Serum Electrolytes: Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 9 mg/dl Urinalysis shows: Glucose: Positive Ketones: Negative Leucocytes: Negative Nitrite: Negative Red Blood Cells (RBC): Negative Casts: Negative The physician informs the patient that her diabetes is not well-controlled despite her lifestyle changes. She agrees to start medication but expresses concerns about gaining weight. What is the best treatment option for this patient?

A 28-year-old woman presents to the physician's office concerned about her facial hair. She has noticed a marked growth and darkening of hair on her face and feels embarrassed. Occasionally she reports seeing objects as two but believes that is just because she is fatigued. She has asthma that is well-controlled by medication and was recently diagnosed with epilepsy. She had a seizure 6 months back and was started on phenytoin. Her other medications include albuterol and beclomethasone. She also takes a daily multivitamin and a garlic supplement. She does not smoke, drink or use recreational drugs. She works in the marketing department of a local firm. Her father has asthma. Her pulse is 75/min, respirations are 15 /min and blood pressure is 110/76 mmHg. Examination reveals a healthy female with excessive facial hair growth and enlarged gums. Her Body Mass Index (BMI) is 24 kg/m2. The rest of the examination is unremarkable. Which of her medications is most likely responsible for her symptoms?

A 20-year-old female is brought by her roommate to the physician's office following a seizure two hours back. The roommate describes seeing the patient suddenly "freeze", collapse, and start having jerky movement involving her entire body. The patient can not recall the episode but does remember 'seeing stars' before losing consciousness. She remembers being confused about where she was and having urinated in her clothes when she gained consciousness. A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital. Her past medical history is unremarkable. She denies alcohol and drug use. The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage gated sodium channels and is also used in status epilepticus. When used for the long-term, which of the following complications can develop with this drug?

A 25-year-old female presents to the physician for her first prenatal visit following a positive home pregnancy test. She missed two periods but assumed it to be due to stress at work. While she and her husband were not planning to have a child at this time, they have decided to continue with the pregnancy. Her medical history significant for migraine headaches, seizures, and asthma. She takes multiple medications for her condition. Ultrasound confirms 9 weeks of intrauterine pregnancy. Which of her medications poses the most risk to the fetus?

A 42-year-old homeless male is brought to the emergency department after he was found unconscious in a park. A CT scan of the head is normal and the patient is treated for acute alcohol intoxication and is admitted to the hospital. The next day, he starts yelling at the hospital staff and saying he wants to go home. His pulse is 120/min, respirations are 22/min, and blood pressure is 136/88 mmHg. On examination, he is confused and agitated. He is sweating profusely, particularly on the palms of his hands, and his skin appears pale. The patient is started on the preferred drug for his condition and his symptoms abate. What is the mechanism of action of the drug given to this patient?

A 20-year-old female presents to the emergency department with chest pain for the last 20 minutes. She describes a "squeezing" sensation in the chest and can feel her heart 'racing'. Worried that she might be having a heart attack, she took aspirin before coming to the hospital. Five days back, she had similar symptoms but they resolved within 10 minutes. She is a college student and works part-time at a local bookstore. Her medical and family history is unremarkable. She denies drug and alcohol use. Vital signs show a temperature of 37 °C (98.6 °F), a pulse of 110 /min, respirations are 28/min, and a blood pressure of 136/80 mmHg. On examination, the patient appears fidgety and restless. An echocardiogram (ECG) shows sinus tachycardia but is otherwise normal. Which of the following drugs is most appropriate at this time?

A 25-year-old male is brought to the emergency department by paramedics for a seizure lasting over 30 minutes. His neighbors found him outside his apartment with all four limbs flailing and not responding to his name. His past medical history is not available. He continues to be unresponsive and is slightly cyanotic with irregular breathing. His teeth are clenched tightly. The ER physician orders intravenous glucose and an anti-seizure medication. What is the mechanism of the drug most likely administered to stop his seizure?

A 46-year-old male presents to the doctor’s office for worsening pain in multiple joints for two weeks. The pain is most severe in the proximal parts of his fingers and in his wrists. It has now spread to his elbows and occasionally his knees also hurt. Joints on both sides of the body are involved. He also complains of morning stiffness that improves with activity and reports feeling fatigued during the day. He lost 3 kg (6.6 lb) over the last three months. He was started on ibuprofen 2 months back for his pain and he reports that initially his pain subsided but over the last few weeks it has worsened. Which of the following is the next best therapy to be added in the management of this patient?

A 35-year-old shipyard worker presents to the emergency department with a sharp pain in his left big toe for five hours. He has never had such pain before and says that it started after an evening of heavy drinking with his friends a few days back. He took acetaminophen and ibuprofen for the pain and is now concerned that he might have a fractured toe because the pain is “more or less the same.” There is no history of trauma. He takes no other medications. His mother is diabetic and his father is hypertensive. He admits to regular drinking and the occasional binge on the weekends but has never smoked or used recreational drugs. His pulse is 86/min, respirations are 14/min, and blood pressure is 130/80 mmHg. Examination reveals a muscular, slightly overweight male in obvious distress. The first metatarsophalangeal joint of the left foot is red, severely tender and swollen. No obvious deformity is seen. The rest of the examination is unremarkable. Laboratory tests are ordered. Which of the following drugs would be most appropriate to alleviate this patient's symptoms?

A 28-year-old primigravida presents to her obstetrician at 28 weeks of gestation for a routine appointment. She can feel her baby move and respond to outside sounds. She has no complaints of her own at this visit. She has gained 9 kg (19.8 lb) so far. Currently, she is taking a prenatal multivitamin which contains iron and folic acid. Her blood type is A (-) negative and her husband's is A (+) positive. She has no significant past medical or family history. She stopped drinking alcohol 2 years back and does not smoke or use recreational drugs. Pulse is 90 /min, blood pressure 114/68, and respirations 18/min. Examination shows a gravid uterus, extending 28 cm above the pubic symphysis. Occasional movements are observed in the abdomen. There is no guarding or tenderness. Fetal heart sound can be auscultated. The rest of the examination is normal. What is the role of anti-D (Rhogam) in this case?

A 58-year-old actuary visits the physician clinic with the complaint of an occasional tremor in his left hand. While the tremor disappears when he moves his hand, he finds it increasingly difficult to type and feels his handwriting has gotten much smaller. He finds the tremor is more pronounced when he is stressed out at work. He also complains of a decrease in his sense of smell, mild constipation, difficulty sleeping, and increased urinary frequency - all of which he feels is him "just getting older". Vitals are pulse of 74/min, respirations of 14/min, blood pressure of 130/70 mmHg, and temperature of 98°F. On examination, a resting tremor in the left hand is noted with mild rigidity in the upper limbs and mask like facies. While performing finger-to-nose and rapid alternating movements, he has some difficulty. All his movements are slow. Sensory examination is normal. His gait is normal except for a decreased arm swing. Which of the following drugs acts directly on the receptors responsible for his condition?

A 38-year-old man presents to the doctor's office with a one-year history of resting tremor and clumsiness in his right hand. His symptoms are interfering with his work as a teacher and his colleagues are wondering if he has issues with drinking or drugs. He is increasingly embarrassed and tends to keep his hand in his pocket. He denies drinking in excess and has never taken any recreational drugs. He is losing interest in meeting friends for their weekly rounds of golf and generally feels “down”. He has no other health concerns and takes no medications. His grandfather had a tremor and his father passed away at a young age. Neither his brother nor his sister has a tremor. Vitals are pulse of 70/min, respirations of 15/min, blood pressure of 124/70 mmHg, and temperature of 98.1 °F. Examination reveals decreased facial expression, hypophonia, resting tremor in the right hand, rigidity in the upper limbs, and normal reflexes. No abnormalities of posture are seen and gait is normal except for decreased arm swing on the right. The rest of the examination is unremarkable. Which of the following medications will help both his movement disorder and depressive symptoms?

An 85-year-old male is brought to the physician by his wife for reappearance of his Parkinson’s symptoms for the last few months. He has been treated with various drugs over the last 20 years. The patient’s wife says that his symptoms are worse as he nears the time for his next dose of medication. The patient's movements have been slower and it's difficult to initiate voluntary movements. He was diagnosed with hypertension 10 years ago and has been compliant with his medications. His current medications are levodopa/carbidopa, rasagiline, aspirin, and captopril. Vitals are pulse of 70/min, respirations of 15/min, blood pressure of 130/76 mmHg, and temperature of 98.1°F. Examination reveals the expected “pill-rolling” resting tremor which is alleviated by movement. Increased tone of arm muscles and resistance to passive movement at the joints is noted. When asked to walk across the room, he has difficulty taking the first step and has a stooped posture and takes short, rapid steps. Labs show: Serum Glucose (fasting): 97 mg/dL Serum Electrolytes: Sodium: 141 mEq/L Potassium: 4.0 mEq/L Chloride: 100 mEq/L Cholesterol (total): 190 mg/dL HDL-cholesterol: 42 mg/dL LDL-cholesterol: 70 mg/dL Triglycerides: 184 mg/dL He is started on a drug that increases the efficacy of his current anti-Parkinson medication. Which of the following is most likely added to his current medication?

A 62-year-old man is brought to the physician by his wife for increasing forgetfulness and confusion for the last 6 months. According to his wife, he has always been in good health but now can barely remember important life events. His wife no longer lets him drive because he constantly forgets his way home. This morning he forgot to put on his shoes and was quite confused when his wife pointed it out. He denies having a low mood, sleep problems, and loss of interest. He abstained from alcohol since he graduated from college and has never smoked nor used recreational drugs. He has no significant family or past medical history. His pulse is 74/min, respirations are 16/min, and blood pressure is 130/84 mmHg. Except for a Mini Mental state Examination (MMSE) score of 20/30, the remaining physical examination is unremarkable. Imaging studies including a chest x-ray and CT-brain reveal no findings. An electrocardiogram (ECG) is also normal. Labs show: Serum Glucose (fasting): 88 mg/dL Serum Electrolytes: Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 10 mg/dl Cholesterol (total): 180 mg/dL HDL-cholesterol: 43 mg/dL LDL-cholesterol: 75 mg/dL Triglycerides: 135 mg/dL Hemoglobin (Hb %): 15 g/dL Mean Corpuscular Volume (MCV): 85 fl Reticulocyte count: 1 % Erythrocyte count: 5.1 million/mm3 Thyroid Stimulating Hormone: 3.5 μU/mL Urinalysis: Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: Negative He is started on a drug that increases the efficacy of his current anti-Parkinson medication. Which of the following is most likely added to his current medication?

A 77-year-old man is brought to the clinic by his son for increasing confusion and a mild headache for several months. His headache is easily relieved by acetaminophen but the increasing confusion is what the son is most concerned about. The patient has a history of progressive memory impairment and was diagnosed with Alzheimer’s dementia 2 years back. There is no significant past medical or family history. His pulse is 72/min, respirations are 14/min, and blood pressure is 130/84 mmHg. The neurological examination reveals moderated cognitive impairment and significant short-term memory loss. The rest of the examination is unremarkable. A CT scan of the brain is normal as is his electrocardiogram. His labs are shown below: Serum Glucose (fasting): 90 mg/dL Serum Electrolytes Sodium: 140 mEq/L Potassium: 4.1 mEq/L Chloride: 100 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 9 mg/dl Cholesterol, total: 170 mg/dL HDL-cholesterol: 43 mg/dL LDL-cholesterol: 73 mg/dL Triglycerides: 135 mg/dL Hemoglobin (Hb %): 15.3 g/dL Mean Corpuscular Volume (MCV): 83 fl Reticulocyte count: 0.8% Erythrocyte count: 5.3 million/mm3 Thyroid Stimulating Hormone: 4.3 μU/mL He was previously started on a drug which according to the son is “no longer working.” The patient and his son are counselled that medications can help reduce the severity of symptoms but will not stop or reverse the disease progression. The patient was initially treated with a drug that increases acetylcholine levels in the brain. A second drug is added to help alleviate the patient’s symptoms. Which of the following is the most likely drug added to this patient's regimen?

A 43-year-old man presents to the emergency department with a severe, throbbing, left-sided headache for the last two hours. The pain has progressively increased and is aggravated by movement. He has had similar episodes in the past and would take acetaminophen and “sleep it off”, however, this time the noise from his neighbors kept him from sleeping. He also complains that the light in the room is intolerably bright and he is starting to feel nauseous. Vitals are pulse: 110 bpm, respirations: 15/min, and blood pressure: 136/86 mmHg. Physical examination reveals mild conjunctival injection in the left eye while the Intraocular Pressure (IOP) is normal. The rest of the examination is normal. He is prescribed a medication which relieves his symptoms and he is ready to go home. During discharge, the patient wants more of this medication to prevent episodes in future. The ED physician explains to him that the medication is only effective in terminating acute attacks but not for prevention. The drug that was prescribed to him works via which of the following receptors?

A 60-year-old woman presents to the emergency room with a chest pain that started 20 minutes ago while watching television at home. The pain is substernal and squeezing in nature. She rates it as a 6/10 pain and admits to having similar pain in the past with exertion. Her past medical history is significant for diabetes mellitus controlled by metformin. Physical examination is insignificant. An electrocardiogram (ECG) shows ST-segment depression in the lateral leads. She is started on aspirin, nitroglycerin, metoprolol, unfractionated heparin, and insulin. She is asked not to take metformin while at the hospital. Three sets of cardiac enzymes are negative. Lab results are given below: Serum Glucose: 88 mg/dL Serum Electrolytes: Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 1.2 mg/dl Blood Urea Nitrogen: 22 mg/dl Cholesterol, total: 170 mg/dL HDL-cholesterol: 40 mg/dL LDL-cholesterol: 80 mg/dL Triglycerides: 170 mg/dL Hematocrit: 38 % Hemoglobin: 13 g/dL Leucocyte count: 7500/mm3 Platelet count: 185,000 /mm3 Partial Thromboplastin Time (aPTT): 30 seconds Prothrombin Time (PT): 12 seconds Urinalysis: Glucose: Negative Ketones: Negative Leucocytes: Negative Nitrites: Negative Red Blood Cells (RBC): Negative Casts: Negative An echocardiogram reveals left ventricular wall motion abnormalities. With her pain subsiding, the patient is admitted and the medications continued. A coronary angiography is planned in two days. Besides regular blood glucose testing, which of the following should be closely monitored in this patient?

A 75-year-old male presents to the emergency department with a "racing heart" and lightheadedness for three hours. He has had similar episodes in the past but never lasting this long. He denies chest pain, shortness of breath, headaches, and fever. He had a myocardial infarction 4 years back and currently takes captopril, metoprolol, and atorvastatin. His pulse is irregularly irregular and cardiac auscultation reveals an irregular heart rhythm. Lab reports show: Serum Glucose: 88 mg/dL Sodium: 142 mEq/L Potassium: 3.9 mEq/L Chloride: 101 mEq/L Serum Creatinine: 0.8 mg/dl Blood Urea Nitrogen: 10 mg/dl Cholesterol, total 170 mg/dL HDL-cholesterol: 40 mg/dL LDL-cholesterol: 80 mg/dL Triglycerides: 170 mg/dL Hematocrit: 38 % Hemoglobin: 13 g/dL Leucocyte count: 7500/mm3 Platelet count: 185,000 /mm3 Partial Thromboplastin Time (aPTT): 30 seconds Prothrombin Time (PT): 12 seconds Cardiac enzymes: Negative ECG shows absence of P-waves with irregular RR complex. A few hours later, his symptoms subside and he is discharged with an additional anticoagulation drug. Which of the following mechanisms explains how this new medication will exert its effects?

A 69-year-old man is brought by his son to the emergency department with weakness in his right arm and leg. The man insists that he is fine and blames his son for "creating panic". Four hours back, he was having tea with his wife when he suddenly dropped his teacup. He has difficulty moving his right arm since and cannot walk because his right leg feels stuck. He has a history of hypertension and dyslipidemia for which he currently takes lisinopril and atorvastatin. Furthermore, he is allergic to aspirin and peanuts. A Computerized Tomography (CT) scan shows evidence of an ischemic stroke. Which medication would most likely prevent such attacks in this patient in future?

An 38-year-old woman visits the doctor's office for progressive weakness and pallor for the last few weeks. She also complains of shortness of breath during her yoga class. She denies fever, cough, runny nose, changes in appetite or bowel and bladder habit. Previously, she had no complaints except for an occasional migraine which was relieved by acetaminophen. For the last month, she has been having more frequent attacks of migraines and was started on prophylactic aspirin. Vitals reveal a pulse of 102 bpm, respirations 18/min, and blood pressure 130/84 mmHg. Her blood pressure on previous visits has been 110/76 mmHg, 120/78 mmHg, and 114/80 mmHg. Physical examination is otherwise unremarkable. Stool for occult blood is positive. Besides a low hemoglobin concentration, which other lab finding is expected in this patient?

A 24-year-old woman presents to a physician with a history of cough, cold, nasal congestion, earache, and fever for last five days. She had used some over-the-counter medicines for last three days, but her symptoms have persisted. She also mentions that she frequently suffers from nose congestion, nasal discharge, earache and headache for last one year, especially after she has been moved to a polluted city. Today her pain has decreased, but yellowish discharge is coming out from her right ear. After detailed evaluation, the physician diagnosed her condition as acute otitis media with chronic sinusitis and prescribes her amoxicillin for at least two weeks and other symptomatic treatment. Asking about possibility of pregnancy, she mentions that she uses combination oral contraceptive pills (OCPs) for contraception. The physician suggests that her husband should use condoms for contraception as she requires antibiotic therapy. Which of the following mechanisms best explains the need for additional contraception in the woman?

A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about ten hours ago. She tells the doctor that although they usually use barrier method of contraception, this time they forgot. However, she does not wish to become pregnant. She also mentions that she is a known case of major depression and does not want to take an estrogen containing pill. After necessary counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel. Which of the following is the primary mechanism of action of this drug?

A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about ten hours ago. She tells the doctor that although they usually use barrier method of contraception, this time they forgot. However, she does not wish to become pregnant. She also mentions that she is a known case of major depression and does not want to take an estrogen containing pill. After necessary counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel. Which of the following is the primary mechanism of action of this drug?

A 28-year-old woman presents to a physician with complaints of fever, cough, and cold for the last two days. She does not have any other symptom and she has no significant past medical history. She has recently started using combined oral contraceptive pills (OCPs) for contraception. On physical examination, her temperature is 101ºF, pulse is 98/minute, blood pressure is 122/80 mm Hg, and respiratory rate is 14/minute. Nasal mucosa and pharynx are inflamed, and there is absence of purulent discharge. Auscultation of chest does not reveal any abnormality. Upon asking, she mentions that she has been a heavy smoker for last five years, smoking approximately 15-20 cigarettes per day. Knowing this, the physician suggests she should discontinue use of combined OCPs and choose an alternative contraception method. Which of the following best explains the rationale behind the suggestion made by the physician?

A health-aware parent is asking the pediatrician about immunization for her newborn. The pediatrician explains about basic principles of immunization, types of vaccines, possible adverse effects, and immunization schedule. Regarding how immunization works, the pediatrician explains that there are mainly two types of vaccine. The first type of vaccine provides stronger and more lasting immunity as they induce both cellular and humoral immune responses. The second type of vaccines produce mainly humoral response only, and their overall efficacy is less as compared to the first type. Which of the following vaccines belongs to the first type of vaccines that the pediatrician is talking about?

The parents of a newly adopted Asian child report that he is suffering from diarrhea and bloating. The symptoms are severe mostly after consuming dairy products and ice-cream. Results of his physical examination are normal and also there are no systemic symptoms or weight loss. What is the first line of therapy?

A 20-years old male student at University of Georgia visits your clinic with complains of erythematous eruption, and intense itching sensations on the buttocks. He informs you of a few weeks earlier university trip in rural-southern Georgia, followed by camping and canoeing. Stool tests suggest strongyloides larvae presence. Which treatment option from the following is indicated?

A 35 year old woman is under your supervision and suffers from right upper quadrant pain for over a month. There is no significant weight-loss, changes in bowel habits or nausea. Her medical history is clear and she only takes oral contraceptives and multivitamins. Your examination reveals following information: Serum α-fetoprotein: normal, Palpable liver mass: 2 cm (below the right costal margin), Abdominal CT scan: 2 hypervascular lesions (3-cm and in the right hepatic lobe) present. This result from the abdominal CT scan suggests hepatocellular adenoma in the patient. What is the next most important and appropriate step in this case?

A 36-years old man presents to a physician for medical evaluation. The patient is taking prednisone and azathioprine for the last 6 months after receiving cadaveric (deceased donor) renal transplant. The patient is experiencing symptoms of fever (101.5°F), cough and anorexia for the last 6 to 7 days. His cough is producing thick sputum that contains branched, irregular and gram-positive filaments. A left lower lobe-nodule that is 5 cm with eccentric or central cavitation is visible in the chest x-ray. Which antibiotic would you suggest this patient as first-line therapy/treatment?

Which one of the given medical illnesses demands caspofungin as a first-line therapy option?

A 38-year-old dental assistant presents with increased weakness and fatigue. Laboratory findings showed megaloblastic anemia. Which of the following is most likely responsible for the presence of anemia?

An 18-year-old male was undergoing anesthesia for appendectomy. On administration of a muscle relaxant, a gradual fall in the blood pressure together with increased airway resistance was noticed. The airway resistance improved with the administration of diphenhydramine. The most likely muscle relaxant that was administered is:

A 38-year-old male underwent appendectomy. Postoperatively, after being shifted to the ward, he complains of seeing people and hearing voices. Which of the following anesthetic is most likely responsible for the present clinical scenario?

A 32-year-old female presents with pain in the right lower iliac fossa. Rebound tenderness is positive in this patient. She was diagnosed with appendicitis and was operated under general anesthesia. Postoperative lab findings showed increased levels of transaminases with the absence of increased bilirubin. Which of the following agent is most likely responsible for the elevation of the enzymes?

A 54-year-old male underwent elective cholecystectomy. Surgery was performed under general anesthesia with nitrous oxide. The oxygen saturation gradually decreased to 84% at the end of the surgery, which responded to 100% oxygen. What is the most likely etiology of the decreased saturation?

A 22-year-old male sustained a shoulder dislocation while playing college football. Reduction of the shoulder was performed after administering ketamine. Which of the following will be most likely seen in this patient after administrating ketamine?

A 62-year-old female was scheduled for mechanical ventilation for respiratory failure. She was administered pancuronium as a muscle relaxant before intubation. Which of the following statement is accurate regarding pancuronium?

A 26-year-old female underwent cesarean section for a complicated pregnancy. She complains of severe occipital headache since day two after surgery. Headache is associated with neck pain and stiffness. Which of the following is the most accurate statement regarding the present clinical complaint?

A 54-year-old female was advised hysterectomy due to the presence of premalignant lesions confined to the uterus without any sort of invasion. She has been diagnosed with myasthenia gravis. She was administered nitrous oxide, desflurane, and atracurium as anesthetics. Which of the following is the most accurate statement regarding atracurium?

A 68-year-old male presents to the emergency room with history of head injury. CT scan shows the presence of an epidural hematoma that needs immediate intervention. Which of the following is the anesthetic of choice in this condition?

A 45-year-old male was admitted in the intensive care unit for the treatment of sepsis and he could no longer protect his airway. He was administered a skeletal muscle relaxant and was intubated. He suddenly developed arrhythmias and EKG showed tall T waves. Which of the following is responsible for the clinical scenario?