Download 1 - ISpatula

QUESTION 1:
CORRECT (You correctly answered B)
A 79-year-old man with a past medical history of hypertension and dyslipidemia presents to clinic
complaining of dizziness and palpitations that have been occurring for the past 2– 3 days. An ECG
reveals that he is in atrial fibrillation (HR = 120 bpm). Which of the following drug regimens would be
most appropriate for stroke prevention in this patient?
A. Aspirin 325 mg po daily
B. Warfarin (titrated to an INR of 2– 3)
C. Low-dose warfarin (titrated to an INR 1.2– 1.5) and aspirin 325 mg po daily
D. This patient does not need antithrombotic therapy and should be cardioverted immediately.
QUESTION 2: :
CORRECT (You correctly answered A)
Raloxifene increases the risk for which of the following?
A. Venous thromboembolism
B. Breast cancer
C. Colon cancer
D. Inflammatory bowel disease
E. None of the above choices is correct
QUESTION 3:
CORRECT (You correctly answered C)
You are asked to see a patient who suffered a cardiac arrest and was successfully resuscitated at the
local airport by an automated external defibrillator. He is transported to your hospital and admitted to
the CCU. His cardiac enzymes are markedly elevated and demonstrate that he had an MI. Which of
the following would be the most appropriate chronic treatment strategy for this patient?
A. Implantable cardioverter-defibrillator
B. Empiric oral amiodarone
C. Revascularization (if possible) and then chronic oral metoprolol
D. Electrophysiologic testing to see if the patient has sustained ventricular tachycardia or
fibrillation
QUESTION 4:
CORRECT (You correctly answered B)
Which of the signs or symptoms listed below are the least consistent with the diagnosis of DVT?
A. The examiner feels a palpable cord in the patient's right leg.
B. The patient's right and left ankles are very swollen.
C. The patient complains of pain in the right leg when flexing the right foot.
D. The patient's left leg appears red and feels hot.
QUESTION 5:
CORRECT (You correctly answered C)
Which of the following is not consistent with the clinical profile of drug-induced torsade de pointes?
A. Females are at higher risk.
B. It usually occurs within several days of initiating the offending agent.
C. It is always dose related (i.e., large doses = higher risk).
D. It often occurs in association with underlying heart disease and electrolyte abnormalities.
QUESTION 6:
CORRECT (You correctly answered D)
A 55-year-old female with a history of atrial fibrillation is admitted for pharmacologic cardioversion. In
the CCU, she is given 2 mg of intravenous ibutilide, which terminates the atrial fibrillation. However,
shortly thereafter, she suffers several long episodes of polymorphic ventricular tachycardia with a
prolonged QT interval during sinus rhythm. Which of the following would be the most appropriate
treatment for this arrhythmia?
A. Intravenous epinephrine 1 mg
B. Intravenous amiodarone 300 mg
C. Intravenous lidocaine 100 mg
D. Intravenous magnesium 2 g
QUESTION 7:
CORRECT (You correctly answered B)
A patient is initiating dalteparin subcutaneously and warfarin sodium orally for the treatment of DVT
on an outpatient basis. Which of the following laboratory monitoring plans is the most appropriate to
determine response and toxicity to this drug treatment regimen?
A. Measure platelet count, aPTT, and INR daily
B. Measure INR in 2 days and platelet count in 7 days
C. Measure INR in 12 hours, aPTT in 4 days, and hemoglobin in 30 days
D. Measure clotting time, serum creatinine, and liver function tests every 3 days
QUESTION 8:
CORRECT (You correctly answered A)
The class Ic antiarrhythmics, such as flecainide, slow conduction velocity through sodium-dependent
tissue the most at normal heart rates. The reason for this is that flecainide does which of the
following?
A. It has "slow on-off" kinetics for the sodium channel.
B. It has "fast on-off" kinetics for the sodium channel.
C. It has rate-dependent effects in blocking the sodium channel.
D. It blocks the sodium channel primarily in the inactivated state.
QUESTION 9:
CORRECT (You correctly answered A)
A 32-year-old obese woman comes to the pharmacy to pick up her prescription for
norgestimate/ethinyl estradiol (Ortho-Cyclen). A pack of cigarettes falls out of her purse. This is a
concern because:
A. Smoking increases the risk of venous thromboembolism.
B. Smoking inhibits the metabolism of oral contraceptives.
C. Smoking increases the risk of ovarian cancer.
D. Oral contraceptives increase the risk for smoking-related gastrointestinal ulcers.
QUESTION 10:
CORRECT (You correctly answered A)
Which of the following individuals would be the most appropriate candidate for outpatient VTE
treatment?
A. A 64-year-old male who uses insulin to control his diabetes
B. A 44-year-old female with a recent history of IV drug abuse
C. A 92-year-old male who does not have a telephone and no social support
D. A 53-year-old female who complains of leg pain, swelling, and shortness of breath
Related Topics:
- venous thromboembolism
QUESTION 11:
CORRECT (You correctly answered C)
Ms. Smith is a 67-year-old female who has had recurrent DVT and has been taking warfarin for the
past 3 years. Her last six INR values have been within her goal range. Today, the patient's INR is 1.2.
Which of the following would be the most likely explanation?
A. Ms. Smith inadvertently took an extra dose of warfarin last night.
B. Ms. Smith drank tomato and carrot juice for breakfast this morning.
C. Ms. Smith ate spinach and basil pesto fettuccini for dinner last night.
D. Ms. Smith finished a 10-day course of sulfamethoxazole/trimethoprim (SMZ/TMP) for a urinary
tract infection yesterday.
QUESTION 12:
CORRECT (You correctly answered C)
You are asked to see a patient with new-onset atrial fibrillation, a rapid ventricular response (heart
rate = 179 bpm) and thyrotoxicosis. Currently, his only symptoms are weakness and palpitations.
Which of the following do you suggest as initial therapy?
A. Intravenous digoxin to control his ventricular rate
B. Intravenous ibutilide to restore sinus rhythm
C. Intravenous esmolol to control his ventricular rate
D. Intravenous amiodarone to control his ventricular rate
QUESTION 13:
CORRECT (You correctly answered D)
Which of the following patients would be at greatest risk for developing a DVT in the next month?
A. A 23-year-old male admitted to the ICU in diabetic ketoacidosis with mental status changes
B. A 59-year-old male with three vessel coronary artery disease who smokes two packs of
cigarettes per day
C. A 46-year-old female undergoing an abdominal hysterectomy due to irregular menses
D. A 78-year-old obese female with severe osteoarthritis for the past 15 years who will have an
elective knee replacement tomorrow
QUESTION 14:
CORRECT (You correctly answered C)
You see a patient in clinic with paroxysmal atrial fibrillation receiving the following medications:
digoxin 0.25 mg po daily (last digoxin level 1.1 ng/mL), warfarin 6 mg po daily (INR 2– 3 for the past
4 weeks). Now the physician would like to attempt to restore and maintain sinus rhythm with oral
amiodarone. Which of the following recommendations should you make regarding the management of
this patient?
1. To avoid the drug interactions, try quinidine instead of amiodarone.
2. Decrease the warfarin dose to 4 mg po daily.
3. Decrease the digoxin dose to 0.125 mg po daily.
4. Discontinue the warfarin the day after sinus rhythm is restored.
A. 3 only
B. 1 and 4 only
C. 2 and 3 only
D. 3 and 4 only
QUESTION 15:
CORRECT (You correctly answered C)
Mr. Jones develops an objectively confirmed deep vein thrombosis (DVT) while receiving
unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis for the past 7 days. The
patient's platelet count has dropped by 50% and is less than 100,000; therefore, heparin-induced
thrombocytopenia is strongly suspected. Mr. Jones is 5 foot 11 inches tall and weighs 100 kg. Which
of the following strategies would be the most appropriate in the initial management for Mr. Jones?
A. Stop heparin and start warfarin 5mg orally every day
B. Stop heparin and start enoxaparin 100 mg SC q 12 h
C. Stop heparin and start argatroban 200 mcg/min via intravenous infusion
D. Stop heparin therapy and wait for results of laboratory tests to confirm diagnosis before
making a treatment decision
QUESTION 16:
CORRECT (You correctly answered C)
Low-dose unfractionated heparin (5,000 units SC q 12 h) would be an appropriate choice to prevent
VTE for which of following patients?
A. A 77-year-old male receiving a hip fracture repair following an automobile accident
B. A 42-year-old female undergoing an abdominal hysterectomy for ovarian cancer
C. A 51-year-old male with benign prostatic hyperplasia and undergoing an abdominal
prostatectomy
D. A 28-year-old female with a history of recurrent DVT undergoing bowel resection surgery for
severe Crohn's disease
QUESTION 17:
CORRECT (You correctly answered C)
In addition to starting warfarin sodium therapy, which of the following would be the most
appropriate initial acute treatment regimen for a 57-year-old, 120-kg male who has a proximal DVT
and no other comorbid conditions?
A. Dalteparin 5,000 units IV bolus followed by 1,000 units SC q 24 h
B. Enoxaparin 30 mg SC q 12 h
C. Fondaparinux 10 mg SC q 24 h
D. Unfractionated heparin 5,000 unit IV bolus followed by 1,000 units/h given by continuous IV
infusion
QUESTION 18:
CORRECT (You correctly answered B)
Which of the following electrophysiologic properties does propafenone possess?
A. Vaughan-Williams class III only
B. Vaughan-Williams class Ib only
C. Vaughan-Williams class Ic and II
D. Vaughan-Williams class Ia and IV
QUESTION 19:
CORRECT (You correctly answered D)
The probability of developing a deep vein thrombosis following knee replacement surgery, in the
absence of pharmacologic or mechanical prevention methods, is:
A. Less than 1%
B. Up to 4%
C. Approxiamtely 10%
D. Greater than 40%
QUESTION 20:
CORRECT (You correctly answered C)
A 19-year-old female with a history of WPW syndrome is seen in the ER. She has no other medical
problems or known heart disease. Her current ECG shows a wide QRS tachycardia (irregular) (heart
rate = 178 bpm). Her BP is stable and she does not feel syncopal. Which of the following agents would
be the most appropriate to administer to this patient at this time?
A. Intravenous adenosine
B. Intravenous verapamil
C. Intravenous procainamide
D. Intravenous lidocaine
QUESTION 21:
CORRECT (You correctly answered A)
Which of the following drugs would be most appropriate to restore sinus rhythm in a patient with AV
nodal reentry or orthodromic AV reentry?
A. Adenosine
B. Procainamide
C. Lidocaine
D. Digoxin
QUESTION 22:
CORRECT (You correctly answered D)
You are following a patient who is receiving chronic oral amiodarone. Which of the following
parameters should be monitored in this patient?
1. Chest x-ray
2. Thyroid function tests
3. Liver function tests
4. Ophthalmologic exams
A. 1 and 2 only
B. 2 and 3 only
C. 1, 2 and 3 only
D. 1, 2, 3 and 4
QUESTION 23:
CORRECT (You correctly answered A)
The Cardiac Arrhythmia Suppression Trial (CAST) was one of the most important studies ever
completed. Which of the following did not result from the CAST?
A. We learned that complex PVCs should not be treated with class III antiarrhythmics, such as
sotalol.
B. We learned that complex PVCs should not be treated with class Ic antiarrhythmics, such as
flecainide or moricizine.
C. Drug companies stopped their efforts to find new class Ic antiarrhythmics.
D. Suppression of complex PVCs after a myocardial infarction with class Ic antiarrhythmics may
lead to an increase in mortality.
QUESTION 24:
CORRECT (You correctly answered B)
A 54-year old male (5'9", 175 lb) presents to the ER complaining of worsening palpitations, shortness
of breath, and fatigue. He has a history of MI (5 months ago), HF (LVEF = 25%), paroxysmal AF, and
pulmonary fibrosis secondary to amiodarone (occurred 1 year ago). His current medications include
aspirin, enalapril, furosemide, carvedilol, atorvastatin, digoxin, and warfarin. His vitals are BP 115/70
mmHg, HR 72 bpm. Pertinent labs include SCr 1.3 mg/dL, digoxin 0.6 ng/mL, and INR 2.6. His ECG
reveals: AF, HR 70 bpm, QT interval 400 msec. He undergoes successful electrical cardioversion and is
now in sinus rhythm. The plan is to start chronic antiarrhythmic therapy to maintain him in sinus
rhythm. Which of the following antiarrhythmic drugs would be most appropriate to maintain him in
sinus rhythm?
A. Amiodarone
B. Dofetilide
C. Flecainide
D. Sotalol
QUESTION 25:
CORRECT (You correctly answered A)
Based on the results of the AFFIRM, RACE, STAF, PIAF, and HOT-CAFE trials, which of the following
statements regarding the initial management of a patient with atrial fibrillation is correct?
A. It would be reasonable to initially use a "rate-control" strategy with digoxin, nondihydropyridine calcium blockers, and/or beta blockers.
B. It would be reasonable to initially use a "rhythm-control" strategy with low-dose amiodarone in
order to maintain sinus rhythm.
C. It would be reasonable to initially use a "rhythm-control" strategy with sotalol in order to
maintain sinus rhythm.
D. It would be reasonable to initially use a "rate-control" strategy with low-dose amiodarone.
Related Topics:
- arrhythmias
- atrial fibrillation
- venous thromboembolism
QUESTION 26:
CORRECT (You correctly answered C)
Graduated compression stockings for VTE prophylaxis are:
A. A relatively expensive strategy
B. Poorly tolerated by the majority of patients
C. An acceptable strategy for the patients at high risk for bleeding
D. Inappropriate when used in combination with anticoagulant drugs
QUESTION 27:
CORRECT (You correctly answered A)
A 71-year-old female taking warfarin for the past 2 months for a DVT following a hip replacement
surgery comes to clinic today. The patient's INR is 6.4. Her vital signs are stable; she has no
complaints; she is fully ambulatory; and there is no evidence of bleeding. Which of following
interventions would be the most appropriate management strategy at this point in time?
A. Omit the next 2 doses of warfarin and remeasure INR in 3 days.
B. Administer vitamin K 5 mg orally; omit next dose of warfarin; and remeasure INR in 7 days.
C. Administer clotting factor concentrates; omit next dose of warfarin; and remeasure INR in 24
hours
D. Administer vitamin K 10 mg IV push (over 2 minutes); remeasure INR in 2 hours; and repeat if
INR remains >3.0.
QUESTION 28:
CORRECT (You correctly answered B)
A 65-year-old man has a history of MI (6 months ago; current EF = 25%) and recurrent sustained
ventricular tachycardia. During his electrophysiologic study, he experienced inducible sustained
ventricular tachycardia (rate = 240 bpm) that caused him to pass out. Which of the following will
probably be the treatment of choice for this patient's arrhythmia?
A. Radiofrequency ablation of the Kent bundle
B. Implantable cardioverter-defibrillator
C. Chronic sotalol therapy
D. No therapy at present—close follow up only
Self-Assessment Quiz
Your Results:
The correct answer for each question is indicated by a
1
.
Mr. Jones develops an objectively confirmed deep vein thrombosis (DVT) while
receiving unfractionated heparin (UFH) for venous thromboembolism (VTE)
INCORRECT prophylaxis for the past 7 days. The patient’s platelet count has dropped by
50% and is less than 100,000; therefore, heparin-induced thrombocytopenia is
strongly suspected. Mr. Jones is 5 foot 11 inches tall and weighs 100 kg.
Which of the following strategies would be the most appropriate in the initial
management for Mr. Jones?
A)Stop heparin and start warfarin 5mg orally every day
B)Stop heparin and start enoxaparin 100 mg SC q 12 h
C)Stop heparin and start argatroban 200 mcg/min via intravenous
infusion
D)Stop heparin therapy and wait for results of laboratory tests to
confirm diagnosis before making a treatment decision
2
INCORRECT
Which of the following patients would be at greatest risk for developing a DVT in
the next month?
A)A 23-year-old male admitted to the ICU in diabetic ketoacidosis with
mental status changes
B)A 59-year-old male with three vessel coronary artery disease who
smokes two packs of cigarettes per day
C)A 46-year-old female undergoing an abdominal hysterectomy due to
irregular menses
D)A 78-year-old obese female with severe osteoarthritis for the past
15 years who will have an elective knee replacement tomorrow
3
INCORRECT
Which of the signs or symptoms listed below are the least consistent with the
diagnosis of DVT?
A)The examiner feels a palpable cord in the patient’s right leg.
B)The patient’s right and left ankles are very swollen.
C)The patient complains of pain in the right leg when flexing the right
foot.
D)The patient’s left leg appears red and feels hot.
4
INCORRECT
The probability of developing a deep vein thrombosis following knee replacement
surgery, in the absence of pharmacologic or mechanical prevention methods, is:
A)Less than 1%
B)Up to 4%
C)Approxiamtely 10%
D)Greater than 40%
5
INCORRECT Graduated compression stockings for VTE prophylaxis are:
A)A relatively expensive strategy
B)Poorly tolerated by the majority of patients
C)An acceptable strategy for the patients at high risk for bleeding
D)Inappropriate when used in combination with anticoagulant drugs
6
CORRECT
Which of the following statements regarding warfarin sodium is true?
A)Warfarin slows the production of protein C in the liver.
B)Warfarin should never be used in combination with other
anticoagulant drugs.
C)Although it has a long half-life, warfarin produces its anticoagulation
effect rapidly.
D)Warfarin is effective for the long-term treatment of VTE but is not
useful for VTE prophylaxis.
7
INCORRECT
Low-dose unfractionated heparin (5,000 units SC q 12 h) would be an
appropriate choice to prevent VTE for which of following patients?
A)A 77-year-old male receiving a hip fracture repair following an
automobile accident
B)A 42-year-old female undergoing an abdominal hysterectomy for
ovarian cancer
C)A 51-year-old male with benign prostatic hyperplasia and
undergoing an abdominal prostatectomy
D)A 28-year-old female with a history of recurrent DVT undergoing
bowel resection surgery for severe Crohn’s disease
8
INCORRECT
Which of the following statements regarding the low-molecular-weight heparins
(LMWHs) is true?
A)LMWHs are direct inhibitors of thrombin formation.
B)LMWHs are identical to unfractionated heparin but are more potent.
C)LMWHs are poorly absorbed following subcutaneous administration.
D)LMWHs are a heterogenous mixture of molecules of varying weights
and lengths.
9
INCORRECT
Which of the following statements regarding unfractionated heparin (UFH) is
true?
A)UFH molecules with fewer than 18 saccharide units possess no
anticoagulant activity.
B)UFH should be given in significantly lower doses to patients with
liver disease.
C)UFH is rapidly and completely absorbed when administered
subcutaneously in doses of 5,000 units or less.
D)Even when weight-based dosing protocols are use, UFH produces an
unpredictable degree of anticoagulation.
10
CORRECT
Which of the following individuals would be the most appropriate candidate for
outpatient VTE treatment?
A)A 64-year-old male who uses insulin to control his diabetes
B)A 44-year-old female with a recent history of IV drug abuse
C)A 92-year-old male who does not have a telephone and no social
support
D)A 53-year-old female who complains of leg pain, swelling, and
shortness of breath
11
In addition to starting warfarin sodium therapy, which of the following would be
INCORRECT the most appropriate initial acute treatment regimen for a 57-year-old, 120-kg
male who has a proximal DVT and no other comorbid conditions?
A)Dalteparin 5,000 units IV bolus followed by 1,000 units SC q 24 h
B)Enoxaparin 30 mg SC q 12 h
C)Fondaparinux 10 mg SC q 24 h
D)Unfractionated heparin 5,000 unit IV bolus followed by 1,000
units/h given by continuous IV infusion
12
CORRECT
A 71-year-old female taking warfarin for the past 2 months for a DVT following a
hip replacement surgery comes to clinic today. The patient’s INR is 6.4. Her vital
signs are stable; she has no complaints; she is fully ambulatory; and there is no
evidence of bleeding. Which of following interventions would be the most
appropriate management strategy at this point in time?
A)Omit the next 2 doses of warfarin and remeasure INR in 3 days.
B)Administer vitamin K 5 mg orally; omit next dose of warfarin; and
remeasure INR in 7 days.
C)Administer clotting factor concentrates; omit next dose of warfarin;
and remeasure INR in 24 hours
D)Administer vitamin K 10 mg IV push (over 2 minutes); remeasure
INR in 2 hours; and repeat if INR remains >3.0.
13
CORRECT
Which of the following individuals would be at the greatest risk for a major bleed
if given warfarin therapy?
A)An 81-year-old woman with frequent tonic-clonic seizures who had
neurosurgery last week
B)A 54-year-old man with well-controlled high blood pressure who
enjoys playing golf on weekends
C)A 74-year-old woman with poorly controlled diabetes mellitus type 2
who drinks one glass of wine with dinner
D)A 42-year-old man with coronary artery disease who takes aspirin
81 mg daily and who participates in a daily exercise program at the
gym
14
A 76-year-old male has been stable on warfarin 5 mg daily for the past 6
months for the treatment of recurrent DVTs. The patient has been prescribed
amiodarone to control a symptomatic dysrhythmia. The patient will be given a
INCORRECT loading dose in the hospital today and then discharged home on amiodarone
200 mg daily.
Which of the following would be the most appropriate dose of warfarin for this
patient now?
A)0.5 mg
B)2.5 mg
C)5 mg
D)10 mg
15
Ms. Smith is a 67-year-old female who has had recurrent DVT and has been
taking warfarin for the past 3 years. Her last six INR values have been within
INCORRECT
her goal range. Today, the patient’s INR is 1.2.
Which of the following would be the most likely explanation?
A)Ms. Smith inadvertently took an extra dose of warfarin last night.
B)Ms. Smith drank tomato and carrot juice for breakfast this morning.
C)Ms. Smith ate spinach and basil pesto fettuccini for dinner last
night.
D)Ms. Smith finished a 10-day course of
sulfamethoxazole/trimethoprim (SMZ/TMP) for a urinary tract
infection yesterday.
16
A patient is initiating dalteparin subcutaneously and warfarin sodium orally for
the treatment of DVT on an outpatient basis. Which of the following laboratory
INCORRECT
monitoring plans is the most appropriate to determine response and toxicity to
this drug treatment regimen?
A)Measure platelet count, aPTT, and INR daily
B)Measure INR in 2 days and platelet count in 7 days
C)Measure INR in 12 hours, aPTT in 4 days, and hemoglobin in 30
days
D)Measure clotting time, serum creatinine, and liver function tests
every 3 days