Clinical pharma - ahmad salh

A 28-year-old woman presented to hospital with a 12-h history of progressive shortness of breath and leD-sided chest pain. The chest pain was exacerbated by deep inspiraFon and coughing. Her past medical history included a deep vein thrombosis in her right calf 3 years earlier and two miscarriages in the third trimester of pregnancy. She took no regular medicaFons and had no known drug allergies. She worked as a traffic warden, did not smoke, and drank around 10 units of alcohol per week. The paFent appeared dyspnoeic but otherwise well. Her heart rate was 80 bpm and her blood pressure was 124/90 mmHg. Her heart sounds were normal. Her chest was clear, her respiratory rate was 18 and her peripheral oxygen saturaFons (SpO2) were 97% on room air. Results: Bloods: WCC 10.1, Hb 135, Plt 280 CT pulmonary angiogram: there is a leD-sided subsegmental pulmonary embolus. Progress: The paFent was advised that she was likely to have an underlying prothromboFc condiFon, such as anFphospholipid syndrome, based on her history of recurrent venous thromboemboli. Which one of the treatments below is most appropriate for this paFent to be discharged home with?

A 68-year-old woman presented to her general pracFFoner complaining of a 2-week history of ankle swelling. Her past medical history included hypertension, iron deficiency anaemia, anxiety and restless legs syndrome. Her regular medicaFons are listed below. She was a reFred estate agent and lived with her partner. She drank approximately 14 units of alcohol per week and had never smoked. The paFent appeared well. Her heart rate was 60 bpm and her blood pressure was 128/84 mmHg. Her chest was clear and her abdomen was soD and non-tender. There was mild pi]ng oedema around the ankles but no peripheral oedema elsewhere. Results: Bloods: WCC 7.3, Hb 130, Plt 188, Na 138, K 4.0, Creat 60, CRP <1, NT pro-BNP 120 (reference range <300 ng/L) ECG: normal sinus rhythm, no evidence of leD ventricular hypertrophy. The general pracFFoner suspects that the peripheral oedema is an adverse effect related to her current medicaFon. Which two of the medicaFons below commonly cause peripheral oedema?

A 48-year-old man presented to the emergency department complaining of chest pain. The pain was located over the centre of his chest and radiated to his leD arm and up to his jaw. The pain was crushing in nature and the paFent rated it as 10/10 in severity. There was associated nausea but no vomiFng. The paFent’s past medical history included hypertension and type-2 diabetes mellitus. His regular medicaFons were mehormin 1 g BD and ramipril 5 mg OD; he had no known drug allergies. The paFent received a single dose of aspirin 300 mg PO and two sprays of GTN from the paramedics. The paFent appeared uncomfortable and diaphoreFc but systems examinaFon was unremarkable. His observaFons were as follows: temperature 37.0°C, HR 90 bpm, BP 150/90 mmHg, RR 18, and SpO2 99% on room air. Results: ECG: normal sinus rhythm; no ischaemic changes QuesFon Which two of the following drugs should be prescribed next?

A 76-year-old man with a history of atrial fibrillaFon and ischaemic heart disease presents to the emergency department complaining of fever, painful muscles and malaise. Rhabdomyolosis is suspected. He is currently taking pravastaFn 40 mg od, digoxin 125 μg od, warfarin 3 mg od, fluconazole 100 mg od and omeprazole 20 mg od. Select the TWO prescripFons that are most likely to be contribuFng to his presentaFon.

A 19-year-old woman presented to hospital complaining of shortness of breath and cough. She had been feeling unwell with increasing difficulty in breathing over the preceding 6 h. She had been otherwise well recently, aside from a wrist injury that she sustained 24 h ago playing badminton. She had managed this with ice packs and simple analgesia. Her past medical history was significant for asthma. She had no known drug allergies and her only medicaFon was a salbutamol inhaler that was used ‘as needed’. The paFent was studying philosophy at university, did not smoke, and drank approximately 14 units of alcohol per week. On examinaFon, the paFent was visibly dyspnoeic. There was a widespread polyphonic expiratory wheeze heard throughout her chest. Her respiratory rate was 20 breaths per minute and her peripheral oxygen saturaFons (SpO2) were 100% on room air. Results: Chest X-ray: clear lung fields, no signs of consolidaFon or collapse. Which medicaFons below should be iniFally prescribed for the paFent in the emergency department EXCEPT??

A 20-year-old woman presented to hospital complaining of shortness of breath and cough. She had been feeling unwell with increasing difficulty in breathing over the preceding 6 h. She had been otherwise well recently, aside from a wrist injury that she sustained 24 h ago playing badminton. She had managed this with ice packs and simple analgesia. Her past medical history was significant for asthma. She had no known drug allergies and her only medicaFon was a salbutamol inhaler that was used ‘as needed’. The paFent was studying philosophy at university, did not smoke, and drank approximately 14 units of alcohol per week. On examinaFon, the paFent was visibly dyspnoeic. There was a widespread polyphonic expiratory wheeze heard throughout her chest. Her respiratory rate was 20 breaths per minute and her peripheral oxygen saturaFons (SpO2) were 100% on room air. Results: Chest X-ray: clear lung fields, no signs of consolidaFon or collapse. Which one medicaFon is most likely to have precipitated the onset of the paFent’s symptoms?

. A 75-year-old man has a fever of 104°F. He develops a cough that produces blood-Fnged sputum with gram-posiFve cocci in clusters. A chest x-ray shows increased density in the right upper lobe. Which of the following penicillin is likely to fail to treat this infecFon adequately?

7. A 68-year-old man with atrial fi brillaFon and ischaemic heart disease has been admited to hospital with symptomaFc anaemia and easy bruising. He had been taking an anFbioFc for a dental infecFon over the preceding week. He has complained of rapid palpitaFons and his treatment was changed by his GP. On admission his INR is 12 and his ECG shows atrial fi brillaFon with a ventricular rate of 37. His current regular medicines are listed. Select the ONE prescripFon that is most likely to have interacted with his warfarin to cause a raised INR

A 68-year-old man with atrial fi brillaFon and ischaemic heart disease has been admited to hospital with symptomaFc anaemia and easy bruising. He had been taking an anFbioFc for a dental infecFon over the preceding week. He has complained of rapid palpitaFons and his treatment was changed by his GP. On admission his INR is 12 and his ECG shows atrial fi brillaFon with a ventricular rate of 37. His current regular medicines are listed. Select the THREE prescripFons that are most likely to be contribuFng to his slow pulse.

. A 26-year-old woman presented to hospital with fevers and vomiFng. She reported a 4-day history of dysuria and urinary frequency and had developed right-sided abdominal pain over the preceding 24 h. She had no significant past medical history and took no regular medicaFons. She worked as an art teacher, did not drink alcohol and had never smoked. She reported that she had recently started a new relaFonship and had several episodes of unprotected sexual intercourse over the past fortnight. The paFent had a temperature of 39.0°C. Her heart rate was 110 bpm and her blood pressure was 110/78 mmHg. Her abdomen was soD throughout but tender over the right flank. Results: Urine dip: no blood, 2+ leucocytes, no protein, posiFve for nitrites, β-HCG negaFve Preliminary urine culture result: Gram negaFve bacilli present. The paFent was treated for presumed pyelonephriFs with intravenous gentamicin. Due to a prescribing error, she received two doses of gentamicin within an hour. An incident report form completed. Which four adverse effects are most likely to occur as a result of gentamicin toxicity?

A 6-year-old boy was brought to his general pracFFoner by his parents aDer developing a fever and a sore throat. He had been feeling unwell for 2 days. His younger sister had experienced similar symptoms earlier. The paFent had no past medical history, had no known drug allergies and did not take any regular medicaFons. He lived with his parents and two siblings and atended the local school. On examinaFon, the paFent appeared clinically well. His temperature was 37.8°C. His throat appeared erythematous but the tonsils were not enlarged. Systems examinaFon was otherwise unremarkable. The paFent’s parents asked whether there were any ‘over-the-counter’ medicines that they could purchase to relieve his symptoms of sore throat and fever. Which one of the medicaFons below should the parents be advised to avoid, where possible, in children under the age of 12 years?

A 44-year-old woman atends her GP with occasional heartburn, water brash and a biter taste in her mouth. She has no weight loss, no problems swallowing and has a good appeFte. Which one of the following opFons is most appropriate?

. A 74-year-old man is admited with leD hemiparesis, leD limb numbness and leD-sided visual disturbance. He awoke with the symptoms six hours ago. He tells you that he experienced a mild and transient weakness of his leD limbs a few days ago but this resolved fully within minutes and he sought no medical help at that Fme. Past medical history: chronic obstrucFve pulmonary disease and asthma. Drug history: salbutamol inhaler two puff s as required. Smoking history: 50 pack-year history of smoking. On examinaFon Temperature 36.4°C, HR 66/min and regular, BP 160/86 mmHg. Grade 3 power of the leD limbs, diminished sensaFon over the leD limbs and a leD homonymous hemianopia on confrontaFon tesFng. Respiratory examinaFon reveals faint expiratory wheeze. InvesFgaFons CT of the brain shows an area of recent cerebral infarcFon in the territory of the right middle cerebral artery. ECG shows sinus rhythm. Select the TWO most appropriate management opFons for iniFaFon during his inpaFent stay

As part of a mulFdrug atack on a paFent’s infecFon with Mycobacterium tuberculosis, a physician plans to use an aminoglycoside anFbioFc. Which of the following is most acFve against the tubercle bacillus and seems to be associated with the fewest problems with resistance or typical aminoglycoside-induced adverse effects?

A 35-year-old man presented to hospital complaining of shortness of breath and a cough. The paFent described worsening dyspnoea over the course of 3–4 weeks, with a nonproducFve cough and intermitent fevers. The paFent’s past medical history included HIV infecFon. He had no known drug allergies and was taking no regular medicaFons, although he had been advised to take anF-retroviral therapy for several years. He worked as a bartender, smoked 5– 10 cigaretes daily and drank 15–20 units of alcohol per week. The paFent appeared clinically well. He had coarse crackles over the right base and leD midzone. His respiratory rate was 22 and his SpO2 was 95% on room air, falling to 88% when mobilising. A chest X-ray showed bilateral perihilar consolidaFon and fine, reFcular intersFFal changes. Sputum cultures: posiFve for PneumocysFs jirovecii pneumonia. The paFent has been diagnosed with PneumocysFs jirovecii pneumonia. He weighs 70 kg. Prescribe an appropriate course of oral anFbioFcs to treat this paFent using the chart below.

. A paFent suffering status asthmaFcus presents in the emergency department. Blood gases reveal severe respiratory acidosis and hypoxia. Even large parenteral doses of a selecFve β2 agonist fail to dilate the airways adequately; rather, they cause dangerous degrees of tachycardia. Which of the following pharmacologic intervenFons or approaches is most likely to control the acute symptoms and restore the bronchodilator efficacy of the adrenergic drug?

A 35-year-old woman complains of itching in the vulval area. Hangingdrop examinaFon of the urine reveals trichomonads. Which of the following is the preferred treatment for the trichomoniasis?

A 45-year-old man postmyocardial infarcFon (MI) is being treated with several drugs, including intravenous unfracFonated heparin. Stool guaiac on admission was negaFve, but is now four, and he has had an episode of hematemesis. Which of the following would be the best drug to administer to counteract the effects of excessive heparin remaining in the circulaFon?

. A 65 year old paFent has a severe bacterial infecFon that normally would respond to an oral penicillin or a cephalosporin. However, his chart documents anaphylactoid reacFons to both drugs. Which of the following would be the best choice for treaFng the infecFon and poses the least risk of cross-reacFvity and an allergic response?

A 27-year-old man was brought to hospital with a painful leD leg. He had noFced increasing pain and swelling over his leD thigh for several days. He had been feeling feverish and became lightheaded when he atempted to stand up. He had no significant past medical history and took no regular medicaFons. The paFent was a current intravenous drug user and injected heroin several Fmes daily, with his leD groin being his favoured injecFon site. He did not drink alcohol and did not use other recreaFonal drugs. He had no fixed abode and usually sleeps in a hostel.On examinaFon, the paFent was febrile (temperature 39.0°C) and appeared generally unwell. His heart sounds were dual with no murmurs, his heart rate was 100 bpm and his blood pressure was 100/70 mmHg. The leD thigh appeared erythematous and swollen and the skin was hot to touch. There was a yellow-green exudate oozing from a sinus tract in his leD groin. Bloods: WCC 18.7, Hb 139, Plt 298, Na 142, K 4.2, Creat 72 (eGFR 90), CRP 281 Ultrasound Doppler of leD leg: no evidence of a deep vein thrombosis Swab from leD groin: Gram posiFve cocci – resistant to penicillins, sensiFve to vancomycin Blood cultures: no bacterial growth. The paFent was iniFally prescribed intravenous flucloxacillin, however, once the microbiology results were available, intravenous vancomycin was prescribed instead. Which of the following opFons is the most appropriate way to monitor the serum concentraFons of vancomycin?

20. A 75 yearold paFents with hepaFc coma, or portal-systemic encephalopathy, decreasing the producFon and absorpFon of ammonia from the gastrointesFnal (GI) tract will be beneficial. Which of the following is the anFbioFc of choice in this situaFon and this purpose?

A 35-year-old man was being treated in hospital for a community-acquired pneumonia. He was receiving intravenous anFbioFcs and was likely to be in hospital for more than 24 h. The paFent had no past medical history, took no regular medicaFons and had no known drug allergies. The paFent drank approximately 1 L of vodka daily plus 2–4 cans of strong lager (approximately 50 units of alcohol per day). ADer 6 h in hospital, he became tremulous and sweaty and his nurse reported concerns that he is withdrawing from alcohol. Bloods: WCC 14.2, Hb 140, Plt 220, Na 138, K 4.2, Creat 70, CRP 80, Bili 14, ALT 35, ALP 52, INR 1.1. Using the ‘as needed’ drug chart below, prescribe one medicaFon to treat his symptoms of alcohol withdrawal. On the ‘regular medicaFons’ drug chart, prescribe one medicaFon to help prevent the paFent from developing Wernicke’s encephalopathy.

Which of the following anFbioFc has greater acFvity against Streptococcus pneumoniae than ciprofloxacin and is used for respiratory and urinary tract infecFon?

A 39-year-old woman was brought to hospital aDer developing shortness of breath. She reported that she had recently started taking a course of flucloxacillin 500 mg PO QDS for an infected cut on her finger. She took the second dose of the anFbioFc and developed shortness of breath and chest Fghtness approximately 20 min later. She had no past medical history, took no regular medicaFons and had no known allergies. She worked as a university lecturer, drank 20 units of alcohol per week and was an ex-smoker. Which of the following, the most important drug to administer at this point?

A 38-year-old woman presented to hospital complaining of right leg swelling and pain. She noFced the swelling develop approximately 24 h earlier and the right calf had since become increasingly tender. She was now struggling to weight-bear on her right leg. She denied any shortness of breath, cough or chest pain. She was 32-weeks pregnant and, unFl this point, the pregnancy has been uncomplicated. This was her third pregnancy and there were no significant complicaFons associated with the previous two pregnancies. She had no past medical history and took no regular medicaFons. She lived with her partner and children and did not work. On examinaFon, the right calf was erythematous and hot to touch. The diameter of the right calf was 10 cm greater than the diameter of the leD calf. The pedal pulses were palpable bilaterally and sensaFon was intact throughout. Systemic examinaFon was otherwise unremarkable. Results: Bloods: WCC 7.2, Hb 112, MCV 83, Plt 289, Na 140, K 4.0, Creat 36 A Doppler ultrasound scan idenFfied a right lower limb deep vein thrombosis extending into the popliteal vein. This paFent has a confirmed deep vein thrombosis in her right leg. You have been advised by the haematology team to commence treatment with

55 year old hospitalized paFent requires an anFbioFc that is most effecFve against P. aeruginosa. Which of the following is the quinolone of choice?

A 68-year-old man presents with a longstanding history of erecFle dysfuncFon (ED). He has a history of ischaemic heart disease, and takes atenolol and isosorbide mononitrate, amongst other medicaFons for secondary prevenFon. He has recently remarried and wishes to engage in sexual intercourse with his new partner. He asks whether he can have a prescripFon for Viagra® (sildenafil), which belongs to a class of drugs that:

A 62 year old woman was admited to the hospital two days ago for complicated acute pyelonephriFs. She was iniFally started on piperacillin-tazobactam. On day 2 of hospital stay, urinary cultures are posiFve for ampicillin resistant enterococci. The paFent is started on Vancomycin . While receiving her first dose of vancomycin, she develops flushing, redness and itching over her upper body. On physical examinaFon, her temperature is 101F, HR 120/min and blood pressure is 120/70 mm hg. There is erythema on her chest. An intravenous cannula is in place on her leD arm. There is no erythema or tenderness at the cannula site. Which of the following is the most appropriate next step in management?

. A 27-year-old woman presented to hospital with a 24-h history of headache and fever. The headache was global, had come on gradually and was now severe. The paFent had been feeling unwell since the past day and described episodes of feeling cold and shivery. She complained that light caused discomfort to her eyes and she was thus holding a scarf over her face. The paFent had vomited several Fmes. She had no past medical history, did not take any regular medicaFons and had no known drug allergies. The paFent was febrile at 38.6°C. Her heart rate was 110 bpm and her blood pressure was 106/60 mmHg. She was photophobic and Kernig’s sign was posiFve. Using the once-only side of the drug chart below, please prescribe the first medicaFon that should be administered to the paFent.

A 74-year-old man was admited to hospital complaining of diarrhoea. He reported passing watery green-brown stool, up to 20 Fmes in the preceding 24 h. He had not experienced any episodes of vomiFng or abdominal pain. His past medical history included chronic obstrucFve pulmonary disease, with several infecFve exacerbaFons over the past 2 months, all of which were treated with courses of prednisolone and anFbioFcs. His regular medicaFons included carbocisteine 375 mg BD, a salbutamol inhaler and a budesonide/formoterol combinaFon inhaler. He was a reFred psychologist, was an ex-smoker with a 40-pack year history, and did not drink alcohol regularly. The paFent was febrile (temperature 38.0°C), tachycardic (HR 100) and hypotensive (BP 96/68 mmHg). His abdomen was soD but distended and his bowel sounds were high pitched. Results: Bloods: WCC 28.4, Hb 130, Plt 409, Na 133, K 3.2, Creat 98, CRP 88 Stool culture: Clostridium difficile bacteria idenFfied Abdominal X-ray: prominent dilated loops of bowel. Which one of the below therapies would be most appropriate for this paFent?

. A 70-year-old woman was brought to hospital aDer slipping on a wet floor and hurFng her right knee. She denied any chest pain, palpitaFons, headache, shortness of breath or generalized weakness prior to the fall. Her past medical history included atrial fibrillaFon and glaucoma. She had no known allergies and her regular medicaFons were: 3 mg warfarin OD, bisoprolol 2.5 mg OD, and latanoprost eye drops – 2 drops in her right eye OD. She was a reFred musician, lived alone and was fully independent. She did not drink alcohol and had never smoked. On examinaFon, the paFent appeared well and was fully orientated to Fme, place and person. Her heart rate was 60 bpm and irregularly irregular, her blood pressure was 120/80 mmHg (there was no postural drop) and her heart sounds were dual with no audible murmurs. Her chest was clear. Her abdomen was soD and non-tender. There was a small haematoma overlying her right knee joint but movement was fully preserved. Results: Bloods: WCC 8.5, Hb 119, Plt 158, Na 140, K 4.0, Creat 50, CRP 13, INR 8.2.Which one of the following opFons is most appropriate in this case?

A 24-year-old man presented to the emergency room aDer developing palpitaFons. He reported that he had atended a party the night before where he had consumed 12–14 pints of beer. When he awoke the following morning, he was aware of palpitaFons but had not experienced chest pain or shortness of breath. He had no significant past medical history and did not take any medicaFons. He worked in digital markeFng as a social media influencer, smoked approximately 10 cigaretes per week and drank approximately 25 units of alcohol per week. He denied any recreaFonal drug use. The paFent appeared clinically well. His heart rate was 170 and his blood pressure was 140/80 mmHg. Results: Bloods: WCC 5.1, Hb 162, Plt 320, Na 138, K 4.0, Creat 76, Mg 0.90, CRP <1. ECG shows a narrow complex tachycardia consistent with supraventricular tachycardia (SVT). Based on the above informaFon, prescribe the most appropriate treatment for this paFent.

. A paFent has been receiving otherwise “proper” doses of a drug for 5 days straight. Dosing was done correctly, starFng with usual maintenance doses; no loading dose strategy was used. Then, and rather precipitously, they develop signs and symptoms of widespread thromboFc events; platelet counts decline significantly concomitant with the thrombosis. The paFent dies within 24 h of the onset of signs and symptoms. Which is the most likely cause?

. A 50-year-old man has an infecFon with Legionella. Assuming no contraindicaFons, which of the following is the drug of choice?

. A 55 year old man takes digoxin 125 μg for atrial fi brillaFon but his ventricular rate is not controlled. His measured digoxin level is 1.4 nmol/L (target range 0.5–2 nmol/L). Which of the following possibiliFes may explain why digoxin has not controlled his ventricular rate?

A 68 year old man presents to your office with complaints of producFve cough and low grade fever for past two days. He denies any sick contacts. On physical examinaFon, his temperature is 100F, breath sounds are reduced in leD lower lobe. A chest x-ray reveals leD lower lobe infiltrate. Laboratory invesFgaFons reveal WBC count of 12,000/μl with 80% neutrophils. Sputum gram stain and cultures are sent for. Blood cultures have been obtained and are pending. He received a Flu vaccine about one month ago but never received a pneumococcal vaccine. The next important step in managing this paFent:

A 4 year old boy had fever and mother used paracetamol. Which of the following best describes this drug effect?

A mother calls to report that her 6-year-old child appears to have swallowed a large amount of an over-the-counter sleep aid about 5 h ago. The product contained only one acFve drug, and knowing your drugs you suspect the poisoning is due to diphenhydramine. Assuming your reasoned guess about the cause of poisoning was correct, which of the following signs or symptoms would you expect to find, upon physical exam, to confirm your hunch?

A 75 yearold paFents with hepaFc coma or portal-systemic encephalopathy decreasing the producFon and absorpFon of ammonia from the gastrointesFnal (GI) tract will be beneficial. What anFbioFc would be most useful in this situaFon?

A 75-year-old man was admited to hospital with community-acquired pneumonia. Whilst he was in hospital, he was transferred to an elderly care ward, where his regular medicaFons were reviewed – several drugs were stopped but he also commenced new drugs. Six days into his hospital admission, the paFent developed jaundice and abdominal pain. His blood showed abnormal liver funcFon (see below). An abdominal ultrasound scan was unremarkable and you are asked to review his medicaFons to establish whether he could have a druginduced liver injury. Bloods: Bili 49, ALT 60, ALP 210, Albumin 30, GGT 196, INR 1.2 Which one of the drugs below are most likely responsible for the paFent’s potenFal hepatotoxicity?

A paFent undergoing cancer chemotherapy gets ondansetron for prophylaxis of drug-induced nausea and vomiFng. Which of the following best describes this drug’s main mechanism of acFon in this se]ng?

1. A 78-year-old man was brought to hospital by his family aDer developing symptoms of nausea and vomiFng. He had been vomiFng intermitently for the preceding 24 h and was unable to tolerate oral fluids. He also reported several episodes of diarrhoea, passing watery greenbrown stools on each occasion. The paFent had been feeling well unFl the onset of the vomiFng and had experienced no recent illnesses. Of note, he had not received any courses of anFbioFcs recently. His granddaughter had experienced similar symptoms of diarrhoea and vomiFng 3–4 days earlier. The paFent appeared generally well although his mucus membranes were dry. His blood pressure was 100/70 mHg and his heart rate was 102 beats per minute. His abdomen was soD and non-tender throughout with normal bowel sounds. Bloods: WCC 14.2 (neutrophils 11.3, lymphocytes 2.5), Hb 123, MCV 85, Plt 350, Na 134, K 3.6, Creat 120 (baseline 80), CRP 46, Blood glucose 5.4. Which medicaFons should be prescribed to treat the paFent’s nausea and vomiFng?