Case 1.1.
A 22-year-old woman is brought into the emergency department via ambulance because
of a suicide attempt. Soon after a “night on the town,” she called her boyfriend saying
that she took a handful of sleeping pills. On examination, she appears lethargic, but
groans and moves all her extremities to painful stimuli. Her blood pressure is 110/70 mm
Hg, heart rate is 80 bpm, and oxygen saturation is 99 percent. Her pupils are of normal
size and reactive to light. Her deep tendon reflexes are normal bilaterally. In the field, she
was given an intravenous bolus of dextrose and an ampule of naloxone without response.
Her boyfriend, with whom she had an argument, brings in the bottle of sleeping
medication, which reads “lorazepam.”
What is the danger of an overdose with this class of medication?
What is the cellular mechanism of action of this class of medication?
What pharmacologic agent can be used to treat this patient, and what is its
Lorazepam belongs to the class of drugs known as benzodiazepines, which are commonly
prescribed for anxiety and sleep disorders. Overdose with benzodiazepines, including
lorazepam, can lead to respiratory depression, coma, and death.
The mechanism of action of benzodiazepines involves enhancing the activity of the
neurotransmitter GABA in the brain. GABA is an inhibitory neurotransmitter that
reduces neuronal activity and helps to produce a calming effect. Between alpha and
gamma subunit Benzodiazepines bind to specific sites between alpha and gamma on
GABA receptors, increasing the affinity of GABA for its receptors and thus increasing
the inhibitory effects of GABA.
In this patient, the pharmacologic agent that may be used to treat her is flumazenil, which
is a benzodiazepine receptor antagonist. Flumazenil competes with benzodiazepines for
binding to GABA receptors, effectively reversing the sedative and respiratory depressant
effects of benzodiazepine overdose. Flumazenil can be administered intravenously, and
its onset of action is rapid, with a half-life of about one hour.
It is important to note that flumazenil should only be used in patients with a known or
suspected benzodiazepine overdose. It is contraindicated in patients who have taken
benzodiazepines for seizure control, as flumazenil can precipitate seizures in these
patients. Additionally, flumazenil may have a short duration of action, and the patient
may require additional doses or continuous infusion to maintain its effect. Close
monitoring of vital signs and respiratory function is essential during and after flumazenil
administration.
1.2. An 18-year-old male is having difficulty sleeping because of the death of his
grandfather. He is given a benzodiazepine that does which of the following?
A. Binds to serotonin 5-HT 1receptors
B. Binds to GABA A receptors
C. Is an antagonist at α-adrenoceptors
D. Is an antagonist at dopamine D 2receptors
The benzodiazepine given to the 18-year-old male is most likely binding to GABA A
receptors.
The antidepressant action of imipramine is thought to be caused by the blockade of
prejunctional neuronal norepinephrine and serotonin uptake transporters in the CNS. This
results in an increase in the levels of these neurotransmitters in the synaptic cleft, leading
to improved mood and decreased symptoms of depression. The other options listed are
not related to the mechanism of action of imipramine.
1.3. The antidepressant action of imipramine is thought to be caused by which of the
following?
A. Blockade of prejunctional α2-adrenoceptors
B. Blockade of prejunctional neuronal norepinephrine and serotonin uptake transporters
in the CNS
C. Increased numbers of α-adrenoceptors
D. Inhibition of monoamine oxidase
ption A is incorrect because the blockade of prejunctional α2-adrenoceptors can lead to
an increase in the release of norepinephrine, which is the opposite of what is desired in
the treatment of depression.
Option C is also incorrect because an increase in the number of α-adrenoceptors is not
thought to be a mechanism of action of imipramine.
Option D is incorrect because inhibition of monoamine oxidase is the mechanism of
action for another class of antidepressants called monoamine oxidase inhibitors (MAOIs).
Imipramine belongs to the class of tricyclic antidepressants (TCAs) which have a
different mechanism of action.
Case 2.1.
A 43-year-old woman is brought into the emergency room by her concerned husband,
who reports that he witnessed his wife having convulsions. According to the husband, the
patient suffers from severe alcoholism, but she stopped drinking 2 days ago. She has no
history of seizures and she does not take any medications. On physical examination, the
patient appears agitated, diaphoretic, and confused. She is tachycardic, hypertensive, has
bilateral hand tremors, and has a fever of 100.7°F. You immediately start intravenous
administration of a medication that will treat the patient for alcohol withdrawal symptoms
and you admit her to the hospital for further monitoring and treatment of her condition.
Which drug do you have preferred? Diazepam, clorazipate, chlorazipoxide( used in
patient who sent have seizure )
What is the mechanism of action of this drug? GABA A agonist
What abnormalities commonly occur with this drug administration? Anterograde
amnesisa, seizure, drowsiness, paradoxical inhibition causes anxiety, euphoria.
2.2 A 30-year-old man is being treated with isoniazid chemoprophylaxis for an exposure
to TB. Which of the following antidepressant agents inhibits hepatic microsomal
enzymes to cause clinically significant drug-drug interactions?
A. Fluoxetine
B. Imipramine
C. Phenelzine
D. Trazodone
The antidepressant agent that inhibits hepatic microsomal enzymes and causes clinically
significant drug-drug interactions is fluoxetine.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that inhibits the activity of
the cytochrome P450 isozyme CYP2D6, which is responsible for the metabolism of
many drugs, including isoniazid. Inhibition of CYP2D6 can lead to increased serum
concentrations of isoniazid, potentially causing toxicity. Therefore, when prescribing
isoniazid to patients taking fluoxetine, the dose of isoniazid should be adjusted
accordingly.
Imipramine, phenelzine, and trazodone are not known to inhibit hepatic microsomal
enzymes to a clinically significant degree, and they are less likely to interact with
isoniazid in this way. However, it is always important to consider potential drug
interactions and to monitor patients closely when they are taking multiple medications.
2.3 Inhibitors of serotonin (5-HT) uptake such as paroxetine interact significantly with
which of the following drugs?
a. Chlorpromazine
b. Tranylcypromine
c. Halothane
d. Benztropine
e. Digoxin
The correct answer is b. Tranylcypromine.
Paroxetine is a selective serotonin reuptake inhibitor (SSRI) that inhibits the reuptake of
serotonin, a neurotransmitter that regulates mood, appetite, and other physiological
processes. Tranylcypromine is a monoamine oxidase inhibitor (MAOI) that blocks the
breakdown of serotonin, norepinephrine, and dopamine. Combining an SSRI like
paroxetine with an MAOI like tranylcypromine can lead to a potentially life-threatening
condition called serotonin syndrome, which is characterized by symptoms such as
agitation, confusion, fever, tremors, and muscle rigidity.
Chlorpromazine is an antipsychotic medication that does not directly interact with
serotonin uptake inhibitors. Halothane is a general anesthetic that may interact with some
medications, but it does not have a known interaction with paroxetine. Benztropine is an
anticholinergic medication used to treat Parkinson's disease and may have some drug
interactions, but it does not interact significantly with paroxetine. Digoxin is a cardiac
glycoside used to treat heart failure and arrhythmias and does not interact with serotonin
uptake inhibitors.
Case 3.1
A 46-year-old man is brought to the emergency room after being involved in a serious
motor vehicle collision. The trauma team determines that the patient has an isolated head
injury and that he will need intubation. As the anesthesiologist on call, you are asked to
help with the rapid sequence induction of anesthesia and intubation. As you prepare to
intubate the patient, you ask the trauma nurse to administer a medication that indirectly
potentiates GABA receptor activity and is commonly used for anesthesia induction.
Which drug do you have preferred?
What is the mechanism of action of this drug?
What abnormalities commonly occur with this drug administration?
The drug of choice for anesthesia induction in this scenario is propofol.
The mechanism of action of propofol involves potentiation of GABA receptor activity.
GABA (gamma-aminobutyric acid) is an inhibitory neurotransmitter that binds to GABA
receptors in the brain and nervous system, resulting in the inhibition of neuronal activity.
Propofol enhances the activity of GABA at these receptors, leading to sedation,
anesthesia, and suppression of consciousness.
Common abnormalities that can occur with propofol administration include hypotension,
respiratory depression, apnea, and reduced cardiac output. These effects are dosedependent, and careful monitoring is required to avoid overdosing or underdosing.
Propofol can also cause pain on injection, which can be minimized by pretreating with
lidocaine or administering the drug slowly. Additionally, propofol can lower the seizure
threshold, so caution should be taken when administering to patients with a history of
seizures.
3.2 An 18-year-old man is brought into the emergency department with a seizure that has
lasted 15 minutes without resolution. After administering oxygen, which pharmacologic
agent is most appropriate to arrest the seizure?
A. Lidocaine
B. Lorazepam
C. Chlordiazepoxide
D. Triazolam
The most appropriate pharmacologic agent to arrest a seizure in this scenario is
lorazepam (B).
Lorazepam is a benzodiazepine that enhances the activity of GABA, an inhibitory
neurotransmitter in the brain. It is a first-line agent for the treatment of seizures and status
epilepticus, as it has a rapid onset of action and a long duration of action. The
recommended initial dose of lorazepam for the treatment of seizures is 0.1 mg/kg IV,
with a maximum dose of 4 mg.
3.3. A 40-year-old male with repetitive obsessive behavior that prevents him from
carrying out simple tasks is treated with fluoxetine. How is fluoxetine classified?
a. As an MAO inhibitor (MAOI)
b. As a tricyclic nonselective amine reuptake inhibitor
c. As a heterocyclic nonselective amine reuptake inhibitor
d. As a selective serotonin reuptake inhibitor
e. As an α2-adrenergic receptor inhibitor
f. As a muscarinic receptor inhibitor
Fluoxetine is classified as a selective serotonin reuptake inhibitor (SSRI) (D).
SSRIs, such as fluoxetine, are a class of antidepressant drugs that inhibit the reuptake of
serotonin, a neurotransmitter that is involved in the regulation of mood, appetite, and
other physiological processes. By increasing the levels of serotonin in the brain, SSRIs
can help alleviate symptoms of depression, anxiety, and other psychiatric disorders
Case 4.1.
A 48-year-old male patient presents to your primary care clinic, complaining of insomnia.
The patient states that he has not been able to sleep since switching to the night shift at
his job. His past medical history is notable for substance abuse and you are wary of
prescribing medications that have addictive properties. In addition to advising the patient
on good sleep hygiene practices, you also prescribe a short-acting sleep aid that acts by
potentiating GABA at the same location on the GABAA receptors that benzodiazepines
bind, but is not associated with significant dependence if used for a short period of time.
Which drug do you have preferred?
What is the mechanism of action of this drug?
What abnormalities commonly occur with this drug administration?
The preferred drug for this patient's insomnia is a non-benzodiazepine hypnotic such as
zolpidem or zaleplon.
The mechanism of action of these drugs is similar to benzodiazepines in that they
potentiate the activity of GABA at the GABAA receptor, leading to sedative and
hypnotic effects. However, unlike benzodiazepines, non-benzodiazepine hypnotics have a
more selective action on the GABAA receptor, which reduces the potential for
dependence and addiction.
Common abnormalities that can occur with the administration of non-benzodiazepine
hypnotics include dizziness, headache, gastrointestinal disturbances, and next-day
somnolence or impaired driving. These effects are generally mild and transient, and the
risk of dependence and withdrawal is low when the medication is used for a short period
of time as prescribed.
4.2 A 22-year-old man presents to his primary care physician with progressively
worsening hallucinations and delusions. His friends describe him as less interested in
certain activities and less talkative than he used to be. The physician prescribes clozapine
for schizophrenia. Which of the following symptoms will be helped most by clozapine?
(A) Attention deficit
(B) Delusions ( 2nd gen antipsychotic)
(C) Flat affect
(D) Lack of motivation
(E) Poverty of speech
4.3. A 53-year-old woman with schizophrenia managed for years with chlorpromazine
complains of a dry mouth, constipation, blurred vision, and feeling tired. Low-potency
typical antipsychotics such as chlorpromazine are known to interfere with many
neurotransmitter receptors aside from their target. Which of the following type of
receptors is spared from antagonism by chlorpromazine?
(A) a-Adrenergic receptors
(B) b-Adrenergic receptors
(C) Dopamine receptors
(D) Histamine receptors
(E) Muscarinic cholinergic receptors
5.1. A 44-year-old man with schizophrenia is being treated with a low-potency typical
antipsychotic. He complains that his medication’s side effects are more than he can
handle and wants to try another medication. If he was to switch from a low-potency to a
high potency antipsychotic drug, which of the following side effects would likely
diminish?
(A) Anticholinergic effects
(B) Parkinsonism
(C) Perioral tremor
(D) Tardive dyskinesia
(E) Torticollis
5.2 A 35-year-old man complains of seeing giant spiders in the hospital room. He is
tremulous and agitated, is hypertensive, and admits to heavy alcohol use at home. Which
of the following actions of the benzodiazepines is the main rationale for their use to
manage this patient?
A. Vasodilation
B. Hypnosis
C. Cross-tolerance with alcohol
D. Elevation of mood
The main rationale for using benzodiazepines to manage this patient is their ability to
produce hypnosis (B) and sedation, which can help alleviate the patient's agitation and
anxiety, as well as prevent further hallucinations or delirium.
Benzodiazepines are a class of drugs that act as positive allosteric modulators of the
GABAA receptor, which enhances the activity of the inhibitory neurotransmitter GABA,
leading to a reduction in neuronal excitability and sedative effects. In this patient,
benzodiazepines can help control his symptoms of alcohol withdrawal, which is a
potentially life-threatening condition characterized by tremors, hallucinations, agitation,
and autonomic instability.
5.3. A 26-year-old female with reactive depression complains of missing her period and
having milk discharge from her breasts. She has no signs of pregnancy, including a
negative pregnancy test. Which of the following might have caused these findings?
a. Clomipramine
b. Amoxapine
c. Fluoxetine
d. Mirtazapine
e. Tranylcypromine
The medication that might have caused these findings is prolactin-elevating
antidepressants such as amoxapine or clomipramine. TCA
Amoxapine and clomipramine are tricyclic antidepressants that have a higher affinity for
the serotonin transporter than the norepinephrine transporter, which can cause an increase
in prolactin secretion through 5-HT2C receptor blockade. Prolactin is a hormone that
stimulates milk production in the mammary glands and can cause amenorrhea and
galactorrhea, which are the symptoms reported by the patient.
Case 6.1.
A 50-year-old salesman was admitted to the hospital with acute appendicitis. He has no
significant medical history, takes no medications, does not smoke cigarettes, and has an
alcoholic beverage “once in a while with the boys.” He underwent an uncomplicated
appendectomy. On the second hospital day, you find him to be quite agitated and sweaty.
His temperature, heart rate, and blood pressure are elevated. A short time later he has a
grand mal seizure. You suspect that he is having withdrawal symptoms from chronic
alcohol abuse and give IV lorazepam for immediate control of the seizures and plan to
start him on oral chlordiazepoxide when he is more stable.
What are the acute pharmacologic effects of ethanol?
What are the chronic pharmacologic effects of ethanol?
How is alcohol metabolized? What is the pharmacologic basis for using benzodiazepines
to manage alcohol withdrawal? Acute pharmacologic effects of ethanol:
Acute pharmacologic effects of ethanol:
CNS depression (including sedation, impaired judgment , creased anxiety, decreased
inhibitions)
Vasodilation (flushing)
Increased heart rate
Increased gastric acid secretion (difficulty walking, blurred vision, slurred speech,
impaired memory, slow reaction)
Diuresis
Chronic pharmacologic effects of ethanol:
CNS toxicity (including neuronal cell death and decreased brain volume)
Liver disease (including cirrhosis and hepatitis)
Pancreatitis
Increased risk of certain cancers (such as liver and breast cancer)
Nutritional deficiencies (especially thiamine deficiency leading to Wernicke-Korsakoff
syndrome)
Alcohol is primarily metabolized in the liver by alcohol dehydrogenase (ADH) to
acetaldehyde, which is then further metabolized to acetate by aldehyde dehydrogenase
(ALDH). Acetate is then converted to carbon dioxide and water, which are excreted.
Benzodiazepines are used to manage alcohol withdrawal due to their ability to enhance
the activity of the inhibitory neurotransmitter GABA in the brain. Chronic alcohol use
leads to downregulation of GABA receptors, and abrupt cessation of alcohol can lead to a
state of hyperexcitability, which can cause seizures, tremors, and other withdrawal
symptoms. Benzodiazepines can help to reduce the risk of seizures and other
complications by increasing GABA activity and dampening CNS excitability.
Chlordiazepoxide is a long-acting benzodiazepine that is commonly used in the treatment
of alcohol withdrawal due to its slow onset of action and prolonged duration of effect.
6.2. A 19-year-old female whose roommate is being treated for depression decides that
she is also depressed and secretly takes her roommate’s pills “as directed on the bottle”
for several days. One night, she makes herself a snack of chicken liver paté and bleu
cheese, accompanied by a glass of red wine. She soon develops headache, nausea, and
palpitations. She goes to the ED, where her blood pressure is found to be 200/110 mmHg.
What antidepressant did she take?
a. Sertraline
b. Phenelzine
c. Nortriptyline
d. Trazodone
e. Fluoxetine
The answer is b. (Hardman, p 444.) This patient ate tyramine-rich cheese reaction ( i.v
phentolamine) alpha blocker , alpha 1 in vas smooth ms and alpha 2 in brain and
periphery.
foods while taking an MAOI and went into hypertensive crisis. Tyramine
causes release of stored catecholamines from presynaptic terminals, which
can cause hypertension, headache, tachycardia, cardiac arrhythmias, nausea,
and stroke. In patients who do not take MAOIs, tyramine is inactivated
in the gut by MAO, and patients taking MAOIs must be warned about the
dangers of eating tyramine-rich foods.
6.3 A 55-year-old woman with insomnia took medication every night to help her sleep.
After several weeks, she began exhibiting psychotic-like symptoms, including delusions.
Which of the following medications was she most likely prescribed?
A. Buspirone.
B. Flumazenil.
C. Ramelteon.
D. Temazepam.
E. Zaleplon.
The most likely medication that the woman was prescribed is Temazepam, a
benzodiazepine commonly used as a sleep aid. Long-term use of benzodiazepines for
insomnia can lead to the development of tolerance, dependence, and withdrawal
symptoms upon discontinuation. Psychotic-like symptoms, including delusions, are rare
but possible side effects of benzodiazepine use
Case 7.1.
An 8-year-old girl is brought in by her mother for evaluation of allergies. Each year in the
spring the child develops a runny nose; itchy, watery eyes; and sneezing. She has been
treated in the past with diphenhydramine, but the child’s teacher says that she is very
drowsy during school. She has no other medical problems and is on no chronic
medications. Her examination is unremarkable today. You diagnose her with seasonal
allergic rhinitis and prescribe fexofenadine.
What is the mechanism of action of antihistamine medications?
What are the common side effects of antihistamine medications?
What is the pharmacologic basis of switching to fexofenadine?
Antihistamines are medications that block the effects of histamine, a chemical released by mast cells and
basophils in response to allergens. Histamine is responsible for causing the symptoms of allergic reactions,
such as itching, swelling, and increased mucus production. By blocking histamine receptors, antihistamines
can reduce or prevent these symptoms.
Common side effects of antihistamines include drowsiness, dizziness, dry mouth, and constipation. Firstgeneration antihistamines, such as diphenhydramine, are more likely to cause sedation and other central
nervous system effects, while second-generation antihistamines, such as fexofenadine, are less likely to
cause these side effects.
Fexofenadine is a second-generation antihistamine that is less likely to cause drowsiness and other central
nervous system effects compared to diphenhydramine. This is because fexofenadine does not easily cross
the blood-brain barrier, which separates the circulating blood from the brain extracellular fluid. This means
that fexofenadine can block histamine receptors in the body without affecting the central nervous system to
a significant extent, making it a good choice for patients who need to remain alert and functional during the
day.
7.2. A 41-year-old female is seen in the psychiatric clinic for a follow-up appointment.
She has been taking an antidepressant for three weeks with some improvement in mood.
However, she complains of drowsiness, palpitations, dry mouth, and feeling faint on
standing. Which antidepressant is she taking?
a. Amitriptyline
b. Trazodone
c. Fluoxetine
d. Venlafaxine
e. Bupropion
The symptoms described are consistent with anticholinergic side effects, which are
commonly associated with tricyclic antidepressants such as amitriptyline. Therefore, the
answer is a. Amitriptyline.
Explanation:
Amitriptyline is a tricyclic antidepressant that blocks the reuptake of serotonin and
norepinephrine. It also has anticholinergic properties, which can cause side effects such
as dry mouth, constipation, blurred vision, urinary retention, drowsiness, and orthostatic
hypotension. These side effects are due to the blockade of muscarinic receptors by the
medication
7.3. A 31-year-old female has been treated with fluoxetine for two months with no
improvement in her depression. You decide to switch antidepressant therapy to
phenelzine and instruct her to wait one week after stopping fluoxetine to start taking the
new pills. She begins therapy immediately with phenyline without discontinuing
fluoxetine. Two days later, she is brought to the ED with unstable vital signs, muscle
rigidity, myoclonus, and hyperthermia. What caused these findings?
a. Increased serotonin (5-HT) in synapses
b. Increased norepinephrine in synapses
c. Increased acetylcholine in synapses
d. Increased dopamine in synapses
a. Increased serotonin (5-HT) in synapses
This is a case of serotonin syndrome, a potentially life-threatening condition that can
occur when two or more medications that affect serotonin levels are taken together.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that increases the level of
serotonin in the synapse, and phenelzine is a monoamine oxidase inhibitor (MAOI) that
can inhibit the breakdown of serotonin. The combination of these medications can lead to
a dangerous increase in serotonin levels, causing symptoms such as muscle rigidity,
myoclonus, hyperthermia, and unstable vital signs.
Case 8.1.
A 35-year-old woman comes to her physician complaining o not being able to sleep or
the past week. She is prescribed zolpidem to be taken at bedtime.
a. What type o drug is zolpidem and what is its mechanism o action?
b. What side effects should this woman be warned of ?
After discontinuation of zolpidem, the beneficial effects on sleep reportedly persist
or up to 1 week, but mild rebound insomnia on the first night also has occurred.
c. What considerations should her physician be aware of when treating insomnia
in this patient?
a. Zolpidem is a hypnotic medication that belongs to the class of drugs known as nonbenzodiazepine gamma-aminobutyric acid (GABA) agonists. Its mechanism of action is
to bind selectively to the GABA-A receptor subtype, which enhances the inhibitory
effects of GABA, leading to the sedative, hypnotic, and anxiolytic effects.
b. Common side effects of zolpidem include drowsiness, dizziness, confusion,
unsteadiness, and daytime sleepiness. It can also cause amnesia, sleepwalking, and other
complex sleep behaviors. Zolpidem has a potential risk of dependency and withdrawal
symptoms such as rebound insomnia, tremors, sweating, and seizures.
c. The physician should consider non-pharmacological interventions such as sleep
hygiene education, cognitive-behavioral therapy, and relaxation techniques before
prescribing hypnotic medications. If medication is necessary, the physician should
prescribe the lowest effective dose for the shortest duration possible, monitor the patient's
response, and avoid prescribing it for more than 2-4 weeks to reduce the risk of
dependency and withdrawal symptoms. Additionally, the physician should instruct the
patient to take the medication only at bedtime and avoid activities that require mental
alertness, such as driving or operating machinery, until she knows how the medication
affects her. The physician should also monitor for signs of rebound insomnia and
withdrawal symptoms upon discontinuation of the medication.
8.2. A 35-year-old man who is an immigrant has been taking prazepam for anxiety for 10
years. This drug is not available in the United States, so he goes to see a physician about
a drug that would be a good replacement. What might happen to this patient if he was
unable to replace his prazepam and abruptly quit taking it?
(A) Adrenal insufficiency
(B) Convulsions and hallucinations
(C) Fever and muscle rigidity
(D) Myocardial infarction
(E) Respiratory depression
8.3. A 26-year-old man complains of tremors, tachycardia, and diaphoresis when
speaking in public. He has started a new job that requires him to give frequent
presentations to large audiences and is worried he would not be able to work effectively.
His physician prescribes propranolol. How will propranolol help with this patient’s
anxiety?
(A) CNS sedation
(B) CNS stimulation
(C) Patients with anxiety usually have comorbid heart disease
(D) Propranolol is not used to treat anxiety
(E) Symptomatic relief
Propranolol works by blocking the action of the sympathetic nervous system, which is
responsible for the body's "fight or flight" response to stress. By blocking this response,
propranolol can reduce the physical symptoms of anxiety, allowing the patient to perform
better during public speaking or other anxiety-provoking situations. The medication does
not cause CNS sedation or stimulation, and it is commonly used to treat anxiety
disorders, particularly social anxiety disorder.
9.1. A 56-year-old man came to the clinic with complaints of tremor, bradykinesia, and
“a feeling of persistent restlessness” after beginning a new antipsychotic regimen 2
months ago. The patient has a history of schizophrenia and depression. He is afraid he
may have Parkinson’s syndrome. The doctor recommended cessation of the new regimen
and assures the patient the symptoms will clear after a few weeks or months after
withdrawal. What antipsychotic was the most likely to have caused the patient’s
symptoms?
(A) Aripiprazole
(B) Clozapine
(C) Haloperidol( Typical 1st generation antipsychotic and very potent so there is risk of
EPS)
(D) Olanzapine
(E) Ziprasidone
9.2.Which of the following represents an adaptive response to the long-term use of
agonists?
A. Increased synthesis of receptors.
B. Decreased degradation of receptors.
C. Decreased density of postsynaptic receptors.
D. Increased density of postsynaptic receptors.
E. None of the above.
9.3. A 42-year-old woman was prescribed an SSRI and has been taking her medication
diligently for more than a year. During the winter, she developed a cough that kept her up
at night. She decided to get some cough medicine to help her sleep, but she woke up in
the middle of the night with tremors, chills, and diarrhea. It is likely that she was
exhibiting:
A. A tyramine reaction.
B. Neuroleptic malignant syndrome.
C. Serotonin syndrome.
D. REM sleep deprivation.
E. The flu.
Serotonin syndrome. The combination of an SSRI and cough medicine can increase
serotonin levels in the brain, leading to symptoms such as tremors, chills, and diarrhea.
This is known as serotonin syndrome and can be a potentially life-threatening condition if
not treated promptly. It is important for patients to inform their healthcare provider of all
medications and supplements they are taking to prevent drug interactions. For eg.
Dextromethorpham it activates opioid rcpt on cough centre in brain and supress cough
reflex also they block serotonin reuptake.
Case 10.1
A 23-year-old male college student is brought to the ER because he cannot be aroused.
The patient has a history o depression and he has been acting depressed over his classes
lately. The patient has a prescription or lorazepam or anxiety and insomnia. In the ER he
is given antidote intravenously.
a. What type o drug is this antidote and what is its role in treating a benzodiazepine
overdose?
The antidote for benzodiazepine overdose is flumazenil, which is a competitive
antagonist at the benzodiazepine receptor site on the GABA-A receptor. Flumazenil is
used to reverse the sedative effects of benzodiazepines and to treat benzodiazepine
overdose by blocking their actions on the GABA-A receptor, which is the main
mechanism by which benzodiazepines produce their sedative effects.
10.2. A 62-year-old man presents with cogwheel rigidity, resting tremor, and
bradykinesia. He is diagnosed with Parkinson’s disease. His medications include a
monoamine oxidase (MAO) inhibitor and a catechol-O-methyltransferase (COMT)
inhibitor. The intent of inhibiting these enzymes is to increase synaptic dopamine,
although many amine neurotransmitters are substrates for both of these enzymes. Which
of the following is a substrate for MAO only?
(A) Acetylcholine
(B) Epinephrine
(C) g-Aminobutyric acid
(D) Norepinephrine
(E) Serotonin
MAO and COMT are both
used in the metabolism of dopamine, epinephrine, and
norepinephrine. Serotonin, also known as 5-hydroxytryptamine, is a monoamine but is
not a catecholamine. It is, therefore, not a substrate for COMT.
Oxidation by MAO is the first step in serotonin
metabolism. The next step is carried out by aldehyde
dehydrogenase and produces 5-hydroxyindoleacetic
acid (5-HIAA), which is excreted by the kidneys.
(A) Acetylcholine is a substrate for neither MAO nor
COMT. It is broken down by acetylcholinesterase
found in the synaptic cleft. (B) Epinephrine is a substrate of both MAO and COMT. Each
neurotransmitter undergoes metabolism by each enzyme; whether
first by MAO or first by COMT, it does not matter.
(C) g-Aminobutyric acid (GABA) is neither a substrate for MAO or COMT. GABA is
broken down by
GABA transaminase. This enzyme is the target of a
medication called vigabatrin used to treat infantile
spasms. (D) Norepinephrine is a substrate of both
MAO and COMT. Each neurotransmitter undergoes
metabolism by each enzyme; whether first by MAO or
first by COMT, it does not matter
10.3 Ramelteon, recently approved for the treatment of insomnia, has a mechanism of
action very different from zaleplon, which is also used to treat insomnia. Ramelteon has
its effects by interacting with which receptors in the hypothalamus?
A. Melatonin receptors. ( On melatonin 1 nd 2 for sleep induction, not btter than z
compounds)
B. GABAA receptors.
C. 5-HT receptors.
D. Glutamate receptors.
E. Muscarinic receptors.
Case 11.1
A 66-year-old man is brought to the ER with extreme anxiety, agitation, irritation, and
confusion. It is learned that, because o early dementia, he recently did not renew his
prescription or alprazolam, which he had been taking or the past 3 years or anxiety.
a. What is the likely cause o this patient’s change in mental status?
b. What are the options or treating this patient?
a. The likely cause of this patient's change in mental status is benzodiazepine withdrawal,
as he did not renew his prescription for alprazolam, which he had been taking for the past
3 years for anxiety. Maybe dependence or abuse .
b..One option would be to reinstitute the alprazolam and once it has its calming effects,
begin a slow tapering of the dose. Another option would be to begin a benzodiazepine
with a longer t1/2 such as flurazepam and once it has its calming effects, discontinue its
use and let the long half-life taper the effects and avoid withdrawal. Each of these options
would depend on the ability of the patient or a caregiver to administer the drug.
11.2. A 49-year-old man with long-standing schizophrenia is hospitalized for a symptom
exacerbation. His primary care physician places him on a second-generation
antipsychotic agent. Characteristics of this agent include which of the following?
(A) Considered to be typical antipsychotic agents
(B) Have fewer extrapyramidal symptoms than first generation agents
(C) Low risk of development of diabetes mellitus
(D) Low risk of development of hypercholesterolemia
(E) Low risk of development of weight gain
The second-generation
antipsychotic drugs (also referred to as “atypical”
antipsychotics) have fewer extrapyramidal symptoms
(EPS) than the first-generation agents but are associated with a higher risk of metabolic
side effects, such
as diabetes, hypercholesterolemia, and weight gain.
The second-generation drugs appear to owe their
unique activity to blockade of both serotonin and
dopamine (and, perhaps, other) receptors. (A) The
second-generation antipsychotic agents are referred to
as the atypical antipsychotic agents. (C) These agents
have a high rate of development of diabetes mellitus.
(D) These agents can cause hypercholesterolemia.
(E) These agents can cause significant weight gain.
11.3. A 53-year-old man with long-standing schizophrenia has failed therapy with both
first- and second-generation antipsychotic agents. He still has significant problems with
mood, delusions, and hallucinations. He is placed on clozapine. Which of the following
effects must the treating physician be aware of?
(A) Agranulocytosis
(B) Cholelithiasis
(C) Pancreatitis
(D) Pituitary adenoma
(E) Polycythemia
Clozapine can
produce bone marrow suppression, seizures, and cardiovascular side effects. The risk of
severe agranulocytosis necessitates frequent monitoring of white blood cell counts.
12.1. A 53-year-old man with schizophrenia presents to his primary care physician for
follow-up. He has been treated with multiple different antipsychotic agents during his
lifetime. Which of the following antipsychotic agents has the highest affinity for the D2
receptors?
(A) Clozapine( high affinity for D1, D4, 5-HT2, muscarinic, and
adrenergic receptors, but it is also a weak dopamine D2-receptor antagonis)
(B) Olanzapine (more 5HT2A)
(C) Quetiapine
(D) Risperidone (blocks 5HT2A more than D2)
(E) Tramadol (opioid blocks reuptake of serotonin nd NE)
12.2. A 21-year-old man complains of depressed mood, lack of pleasure in activities he
previously enjoyed, and lack of energy. This has been going on for 2.5 years now. His
physician prescribes fluoxetine. Which of the following side effects is most likely to
occur in this patient?
(A) Abdominal pain
(B) Peptic ulcers
(C) Impotence
(D) Loss of taste
(E) Pancreatitis
This patient’s presentation suggests major depressive disorder. Fluoxetine can be used to
treat depression. It is a selective serotonin reuptake inhibitor (SSRI) that improves mood
by prolonging the actions of serotonin in the brain. It maytake weeks of SSRI use before
a patient notices improvements in symptoms,although side effects may appear more
rapidly. SSRIs frequently
cause sexual side effects, including impotence (erectile dysfunction), decreased libido,
and ejaculatory dysfunction in males.
12.3. After norepinephrine is released, it binds to receptors on the target organs. Then, it
must be removed from the synaptic space. Which of the following mechanisms describes
correct removal of norepinephrine from the synaptic space?
(A) ATPase pump is stimulated by cocaine
(B) ATPase pump is stimulated by imipramine
(C) Diffusion from the general circulation back into the synaptic space
(D) Metabolism to O-methylated derivatives in the synaptic space
(E) Pump system pumps norepinephrine out of the neuron
Case 13.1
A caretaker drives an 82-year-old patient to his physical therapy session in the morning.
When therapy is complete, the patient walks out the door, and you find him still sitting on
the bench waiting for a ride home when you are leaving. When you ask him where he
lives, he tells you that he “gets all turned around and can't remember.” Which of the
following drugs is commonly prescribed to treat this condition?
A. Donepezil.
B. Fluoxetine.
C. Selegiline.
D. Alprazolam.
E. Haloperidol.
13.2 A 38-year-old woman with alcohol use disorder in remission for 2 years is
requesting medication for treatment of anxiety. Which of the following drugs would be
the least appropriate choice to target anxiety symptoms in this patient?
A. A benzodiazepine such as lorazepam.
B. A serotonin selective reuptake inhibitor such as sertraline.
C. A nonbenzodiazepine anxiolytic such as buspirone.
D. A serotonin/norepinephrine reuptake inhibitor such as venlafaxine.
A benzodiazepine such as lorazepam (Option A) would be the least appropriate choice to
target anxiety symptoms in a patient with a history of alcohol use disorder in remission.
Benzodiazepines have a high potential for abuse and dependence, and individuals with a
history of substance use disorders may be at increased risk for developing a
benzodiazepine use disorder. Moreover, benzodiazepines can interact with alcohol and
may increase the risk of relapse.
The other options listed are all appropriate choices for treating anxiety symptoms in
patients with alcohol use disorder in remission. Serotonin selective reuptake inhibitors
such as sertraline (Option B), nonbenzodiazepine anxiolytics such as buspirone (Option
C), and serotonin/norepinephrine reuptake inhibitors such as venlafaxine (Option D) are
all effective and generally safe options for treating anxiety symptoms in this population.
However, the choice of medication may depend on the individual patient's clinical profile
and preferences, as well as the presence of any comorbid conditions.
13.3. Stimulation of inhibitory neurons causes which of the following effects at the
postsynaptic membrane?
(A) Binding of GABA at the postsynaptic membrane
(B) Depolarization
(C) Stimulation of epinephrine
(D) Transient decrease in permeability of chloride
(E) Transient decrease in permeability of potassium
GABA is an inhibitory neurotransmitter that is synthesized and released by inhibitory
neurons in the central nervous system. When GABA binds to receptors on the
postsynaptic membrane, it causes an increase in the permeability of chloride ions, leading
to hyperpolarization of the membrane potential and a decrease in the likelihood of an
action potential being generated.
Case 14.1.
A 66-year-old man comes in to your office for evaluation of a tremor. He has noticed a
progressively worsening tremor in his hands for the past 6 months. The tremor is worse
when he is resting and improves a little when he reaches for an object or is using his
hands. He has also noticed that it is harder to “get started” when he stands up to walk. He
takes several small, “shuffling” steps before he can reach his full stride. He has no
significant medical history and takes only an aspirin a day. On examination you note that
his face is fairly expressionless; he has a pill-rolling-type tremor of his hands at rest and
has cogwheel rigidity of his arms. You diagnose him with idiopathic X disease and
prescribe a combination of some drugs.
What is the most common cause of the symptoms of idiopathic X disease?
Which drugs combination has been administered?
What is the mechanism of action of administered drugs?
Why is these drugs usually given in combination?
Based on the symptoms described in the scenario, the most likely diagnosis is idiopathic
Parkinson's disease.
The drugs commonly prescribed for Parkinson's disease include levodopa and carbidopa
in combination. Levodopa is a precursor to dopamine, a neurotransmitter that is depleted
in Parkinson's disease. Carbidopa is a medication that inhibits the breakdown of levodopa
in the bloodstream, allowing more of it to reach the brain where it can be converted into
dopamine.
The mechanism of action of levodopa is to increase the availability of dopamine in the
brain, thereby improving motor function and reducing tremors. Carbidopa is a dopa
analog which blocks peripheral metabolism of dopa decarboxulase and increase dopamin
level and also it islipid insoluble and sent cross BBB and is used in combination with
levodopa to increase the amount of levodopa that reaches the brain and reduce side
effects such as nausea and vomiting.
Levodopa is metabolised by dopa decarboxulase and it is available in our whole body so
90% of levodopa is metabolised and very less reaches our brain so in order to increase the
drug amount that reaches our brain we give carpidopa which blocks dopa decarboxylase
nd increase percentage amount .
14.2. A 44-year-old woman with social anxiety disorder is found to have an ovarian mass
lesion. She is scheduled for exploratory laparoscopy. Her current medications include
paroxetine. Important considerations for the treating anesthesiologist include screening
for which of the following conditions?
(A) Dizziness
(B) Insomnia
(C) Neuroleptic malignant syndrome
(D) Nervousness
(E) Slowing of the heart rate
Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening
condition that can occur in patients who are taking certain medications, including
paroxetine. NMS is characterized by fever, muscle rigidity, and altered mental status,
among other symptoms, and can be triggered by anesthesia or surgery.
Therefore, the anesthesiologist must screen for NMS in patients who are taking
paroxetine or other medications that increase the risk of NMS. Additionally, the
anesthesiologist must be prepared to manage any potential complications of anesthesia in
patients with social anxiety disorder. The other options listed are not as relevant to this
scenario. Caused due to severe D2nrcpt blocakadeg...give Dantrolenfor hyperthermia
blocks RyR rcpt or D2 agonist .
14.3. A 49-year-old man with manic depression has been maintained on lithium for longterm therapy. However, because of worsening of symptoms, he is placed on
ziprasidone(Atypical antipsychotic with M block) The patient must be warned about
which of the following adverse effects?
(A) Asthenia
(B) Erectile dysfunction
(C) Hypertension
(D) Slowing of heart rate
(E) Visual changes (improved color vision)
Case 15.1
A 47-year-old woman is recovering from a hysterectomy. Her physician prescribes an
opioid analgesic as needed for postoperative pain ( Tramadol pethidine, meperidine).
Opioids can cause many effects in addition to analgesia including constipation,
respiratory depression, euphoria, miosis, and drowsiness. With prolonged use, tolerance
(constipation, convulsion, meiosis) develops to most of these effects. Which of the
following effects persists in spite of tolerance leading to a decrease in the other effects?
(A) Analgesia
(B) Constipation
(C) Drowsiness
(D) Euphoria
(E) Nausea and vomiting
15.2. A 53-year-old man is requesting meperidine or his chronic back pain. His physician
is reluctant to use meperidine or the treatment of chronic pain because of
a. metabolite toxicity.Meperidine is metabolized to a toxic metabolite called
normeperidine, which can accumulate in the body with prolonged use and cause seizures
and other neurological complications.
b. poor oral absorption.
c. increased addiction potential.
d. patient noncompliance.
e. likelihood that meperidine will be diverted or sale on the street.
15.3. A 62-year-old woman with symptoms of feeling blue, sad, and without feelings
presents to her primary care physician for treatment. She has a prior medical history of
narrow-angle glaucoma. Which of the following treatments should be avoided in this
patient?
(A) Amitriptyline(Blocks M rcpt , TCA)
(B) Bupropion
(C) Fluvoxamine
(D) Mirtazapine
(E) Sertraline
Case 16.1.
A 63-year-old man presents to your clinic complaining of the gradual onset of stiffness in
his extremities. He also tells you that he has recently noticed a tremor in his right arm. As
you are interviewing the patient, you notice that he has a blank expression on his face.
Physical examination is significant for cogwheel rigidity in all extremities, a pill-rolling
tremor, and a shuffling gait. While ordering further tests, you decide to start the patient
on a medication that will act to increase the levels of neurotransmitter in his brain.
Which drug has been administered? Levodopa carbidopa
What is the mechanism of action of administered drug? Pro drug of dopamin so increase
dopamin in brain and carbidopa is analog of dopa
What is the toxicity of administered drug? It can cause hypotension D1, nasea vomiting
D2, psychosis D2 in limbic system, D2 in straiatum cause levodopa induced dyskinesia
(amantadin,levateracitam)
16.2. A 25-year-old woman is being treated for a laceration to the forearm. Local
anesthesia is used prior to suturing. An allergic reaction is most likely to occur with
which of the following local anesthetics?
A. Bupivacaine
B. Lidocaine
C. Mepivacaine
D. Procaine
16.3. A 32-year-old known drug abuser ran out of drugs and had no way to purchase
more to support his habit. As a consequence, he began exhibiting symptoms of
withdrawal. Which of the following drugs results in a life-threatening withdrawal?
A. Cocaine.
B. Pentobarbital.
C. Heroin.
D. LSD.
E. Methamphetamine.
Case 17.1
An 18-year-old man is brought into the emergency department after being found on the
street unresponsive. He is lethargic and does not answer questions. He has been given 1
ampule of Dextrose intravenously without result. On examination, his heart rate is 60
beats per minute, and respiratory rate is 8 per minute and shallow. His pupils are pinpoint
and not reactive. There are multiple intravenous track marks on his arms bilaterally. The
emergency physician concludes that the patient has had a drug overdose.
What is the most likely diagnosis? Opioid overdosing
What is the most appropriate medication for this condition? Nalaxone ( pure antagonist)
short half life , se increase cathacholamin ,htn,aarhthmia,pulm edema.
17.2 The withdrawal symptoms following barbiturate cessation are similar to the
withdrawal symptoms from:
A. Heroin.
B. Alcohol.
C. Phenothiazines.
D. Morphine.
E. All of above
17.3. A 43-year-old man with severe hepatic cirrhosis requires a sedative or insomnia.
Which of the following sedatives would be the best choice or this patient?
a. Phenobarbital
b. Diazepam
c. Lorazepam ( lorazipam and oxazepam undergo extrahepatic conjugation and do not
form active metabolites)
d. Secobarbital barbuturate extensively metabolised in liver
e. Flurazepam ( diaze and flurqzi metabolised by liver and active metabolites
accymulate)
Case 18.1.
A 74-year-old woman presents to your clinic for management of her Parkinson’s disease.
Her daughter, who accompanies her, reports that her mother is experiencing significant
side effects from her anti-parkinsonism medications. She reports that she has observed
her mother move her arms and legs uncontrollably. You determine that the side effects
are likely due to the first-line medication used to treat her condition, and you decide to try
to reduce her requirement for that medication by prescribing another medication that
works to decrease the breakdown of dopamine.
Which drug has been administered? Comt and MAO B blocker
What is the mechanism of action of administered drug? Both block central and peripheral
( antacapon , opicapon) both tolcapone ...metabolism of dopamine
What is the toxicity of administered drug? Dopaminergic side effect like nausea
vomiting, hypotension,
18.2 A 73-year-old man with Alzheimer’s disease is being treated with donepezil.
Because his cognition is deteriorating, Memantine is added. Memantine is a
noncompetitive antagonist o the
a. dopamine D2 receptor.
b. NMDA-type glutamate receptor.
c. β adrenergic receptor.
d. α adrenergic receptor.
e. 5-H 2 serotonergic receptor
18.3. A 64-year-old woman had a mole on her back that required dermatological removal
using a local anesthetic. These drugs exert their therapeutic effects primarily by:
A. Stimulating activity–dependent Na+ channels.
B. Blocking activity–dependent Na+ channels.
C. Stimulating activity–independent Na+ channels.
D. Blocking activity–independent Na+ channels.
E. Blocking activity–dependent K+ channels.
Case 19.1.
A 30-year-old woman presents to the office for treatment of an ingrown toenail. For the
past 3 weeks she has had progressively worsening redness, swelling, and pain from the
area around the right great toenail. On examination you find that the distal, medial corner
of the right great toenail is ingrowing. The skin on the medial border of the nail is red and
tender. There is a visible purulent drainage as well. You place her on a 1-week course of
oral cephalexin and have her return to the office. On follow-up, the redness is markedly
improved, and there is no further drainage. You surgically correct the ingrown toenail
after achieving local anesthesia with 2 percent lidocaine injected to infiltrate the digital
nerves.
What is the mechanism of action of lidocaine as an anesthetic agent?
Why does the treatment of infection increase the effectiveness of the local anesthetic?
Lidocaine is a local anesthetic that works by blocking voltage-gated sodium channels in
nerve fibers. When lidocaine is administered, it diffuses through the surrounding tissue
and into the nerve fibers. Once inside the nerve fibers, lidocaine blocks sodium channels
and prevents the conduction of nerve impulses, resulting in numbness and loss of
sensation in the area where the drug was injected.
The treatment of infection can increase the effectiveness of the local anesthetic because
infection causes inflammation in the area. Inflammation causes the release of protons,
which can decrease the pH of the tissue and decrease the effectiveness of local
anesthetics. By treating the infection with antibiotics, the inflammation and release of
protons are reduced, which can improve the efficacy of the local anesthetic. Additionally,
the use of antibiotics can help prevent the spread of infection, reducing the risk of
complications from the surgical procedure
19.2. A 42-year-old man with chronic pain is brought to the emergency room because of
over-sedation and respiratory depression while using fentanyl patches. He is given
intravenous naloxone. He is not given oral naloxone because naloxone
a. is not absorbed rom the GI tract.
b. undergoes first-pass metabolism in the liver.
c. is metabolized to an inactive metabolite in the GI lining.
d. is excreted unchanged in the urine.
e. is destroyed by stomach acid.
19.3. A 68-year-old woman with a long history of sadness, gloom, and weight loss
presents to her primary care physician for treatment. She is treated with a selective
serotonin reuptake inhibitor. Which of the following statements is true?
(A) Maximum benefit may require 1 year
(B) Most patients require three antidepressants
(C) Twenty percent of patients with adequate doses for 8 weeks respond to therapy
(D) Two weeks of therapy are required for mood improvement
Case 20.1.
An 18-year-old male with past medical history of epilepsy since childhood presents via
ambulance to the ER for status epilepticus. He has finally been stabilized by repeated
doses of IV lorazepam. His mother states he had an unremarkable birth history, no prior
head trauma, and negative head MRI in the past. He is noncompliant with his
antiepileptic—phenytoin. His last seizure was 3 months ago, and usually is controlled if
he takes his medication regularly. In the ER, patient is confused, is combative, but
otherwise has a normal neurological and cardiovascular examination. There is also no
evidence of any trauma. His initial labs including a blood count, comprehensive
metabolic panel, and urine drug screen are negative. His phenytoin level is undetectable.
You give him an IV loading dose of fosphenytoin and reorder his home oral dose.
What is the mechanism of action of phenytoin? Na blocker, used in gtcs,ps, neuroathic
pain , arrthmia class 1b
What are the major adverse effects of phenytoin? Hyperplasia of gums, hirsutism,
teratogenic cleft lip and palate, nystagmus, ataxia, lymph adenopathy. Hemmoragic
disease of new born, neutropenia, fetal hydantoin syndrome
20.2. A 75-year-o d woman with Parkinson’s disease is being treated with the
combination of levodopa/carbidopa. Entacapone is added. This patient is treated with this
combination of drugs to increase the amount of which of the following substance to reach
the CNS?
a. Carbidopa
b. Levodopa
c. Entacapone
d. Acety cho ine
e. Dopamine
20.3. A 54-year-old man with multiple medical problems and anxiety is placed on
diazepam. He has been taking the medication for 6 months. He is concerned that he is
having changes in his memory as a result of being on this medication. Which of the
following memory effects are likely?
(A) Anterograde amnesia
(B) Long-term memory loss
(C) Loss of ability to taste
(D) Loss of prior negative memories
(E) Short-term memory loss
Case 21.1
A 17-year-old girl with a history of grand mal seizures presents to your neurology clinic
for a follow-up visit. She reports that she has had one seizure, which lasted 4 minutes,
since her appointment 1 month ago. She is currently only on a single medication for
seizure control, which acts by blocking sodium channels on the neuronal cell membrane.
Upon further questioning, you discover that the patient is sexually active. You strongly
encourage the patient to practice birth control as her anti-epileptic medication is
associated with severe birth defects, including growth retardation and congenital cardiac
and palate malformations.(phenytoin)
What is the most appropriate medication for this condition? Lamotrigine (Na+ , ca block,
decrease glutamate)
What are the complications linked with this drug administration? Ataxia. Diplopia. SJS,
nausea, vomiting anxiety, depression and irritability), rare steven johns syndrome and
blood disorder (leukopenia and thrombocytopenia)
22.2. A 62-year-old woman with a history of mental decline, impaired physical activity,
and significant mood impairment is seen by her primary care physician. Treatment with a
tricyclic antidepressant has begun. Which of the following statements regarding this
therapeutic option is true?
(A) Mental alertness is unlikely to change
(B) Mood elevation is likely
(C) Morbid preoccupation will unlikely change
(D) Physical dependence will occur
(E) Psychological dependence will occur
22.3 A woman who just landed her first job in a big marketing firm started to deliver a
major presentation in the boardroom. Suddenly her hands began to sweat, and she felt her
heart beat so fast that she began to feel lightheaded. Prescribing which of the following
medications would be the best choice to alleviate this patient's symptoms before she gives
her presentations?
A. A benzodiazepine.
B. A β-adrenergic receptor blocker.
C. A monoamine oxidase A inhibitor.
D. A serotonin selective reuptake inhibitor.
E. A serotonin/norepinephrine reuptake inhibitor.
Case 23.1.
A middle-aged man is transported to the emergency department unconscious and
accompanied by a nurse from the medical floor. The nurse states that the patient was in
line in front of her in the hospital cafeteria when he suddenly fell to the floor. He then
had a “generalized tonic-clonic seizure.” She called for assistance and accompanied him
to the emergency department. No other historical information is available. On physical
examination, the patient is confused and unresponsive to commands. He is breathing
adequately and has oxygen in place via nasal prongs. His vital signs are as follows:
temperature, 38°C; blood pressure, 170/90 mm Hg; heart rate, 105 bpm; respiratory rate,
18/min. Oxygen saturation is 99% on 2 L of oxygen. Neurologic examination is notable
for reactive pupils of 3 mm, intact gag reflex, decreased movement of the left side of the
body, and Babinski reflexes bilaterally. Examination is otherwise unremarkable.
Describe what is meant by a generalized tonic-clonic seizure.
Tonic phase (less than 1 min) involves abrupt loss of consciousness, muscle rigidity, and
respiration
arrest; clonic phase (2–3 min) involves jerking of body muscles, with lip or tongue biting,
and fecal and urinary incontinence; formerly called grand mal
What are some of the underlying causes of seizure disorders? : Recurrent seizures are in
many cases idiopathic, particularly in children. Seizures may also be due to brain injury
from trauma, stroke, mass lesion, or infection. Finally, one must consider metabolic
causes such as hypoglycemia, electrolyte abnormalities, and alcohol withdrawal. The
cause of this patient's seizure is unknown because of the lack of an available history
Which cause might you be most concerned about in this patient?: However, because he
has focal neurologic findings, with decreased movement on his left side, one must
suspect an underlying brain lesion in the right cerebral hemisphere
What is the likely pathophysiology of the seizure in this patient?: idiopathic
What is the most appropriate medication for this condition? Valproic acid,
carbamazepine, and phenytoin are the drugs of
choice for generalized tonic-clonic (grand mal) seizures.
23.2. A 43-year-old woman with a history of fibromyalgia(condition in which whole
body pains ) and depression presents to her primary care physician for treatment. She
complains of feeling sad and worthless in addition to multiple somatic complaints. Which
of the following treatments would be best for this patient?
(A) Duloxetine. Milnacipram also
(B) Fluoxetine
(C) Mirtazapine
(D) Sertraline
(E) Watchful waiting Duloxetine. Duloxetine is a serotonin/norepinephrine reuptake
inhibitor that can be
used for depression accompanied by neuropathic
pain. Selective serotonin reuptake inhibitors (fluoxetine and sertraline), monoamine
oxidase inhibitors
(phenelzine), and atypical antidepressants (mirtazapine) have little activity against
neuropathic pain.
(B) Fluoxetine will treat depression but not neuropathic pain. (C) Mirtazapine will treat
depression but
not neuropathic pain. (D) Sertraline will only treat
the depression in this patient. (E) This patient needs
treatment so watchful waiting is not appropriate
23.3. A 66-year-old woman with Alzheimer’s disease is being treated with the
choinesterase inhibitor donepezil. The patient’s famiy earns that donepezi is reflated to
pesticides. When the family expresses concern they are to do that donepezil may decrease
the rate of cognition decline by increasing the concentration of which substance in the
brain?
a. Acetylcholine
b. Serotonin
c. Dopamine
d. Epinephrine
e. Glutamate
The cholinesterase inhibitor donepezil is a medication commonly used in the treatment of
Alzheimer's disease. It works by inhibiting the enzyme acetylcholinesterase, which
breaks down the neurotransmitter acetylcholine in the brain. This increases the
concentration of acetylcholine in the brain, which is thought to improve cognitive
function in Alzheimer's disease.
Therefore, the correct answer is (a) Acetylcholine. Donepezil and other cholinesterase
inhibitors are not related to pesticides, but they are similar in structure to certain
chemicals used as insecticides. However, the therapeutic effects of donepezil in
Alzheimer's disease are due to its ability to increase the concentration of acetylcholine in
the brain, rather than any pesticidal properties.
Case 24.1.
A 32-year-old epileptic patient presents to the emergency department, complaining of a
severe rash. On physical examination, you note large, warm, red lesions in various stages
of blistering all over the patient’s body. There are also evidence of lesions on his mucous
membranes, including his mouth and lips and conjunctiva. You immediately call for a
dermatology consult and begin supportive treatment with intravenous fluids and pain
control. The dermatologist confirms your suspected diagnosis of toxic epidermal
necrolysis and on further discussion, you discover that the patient had recently started a
new anti-epileptic medication, stopped the medication for a while, and then restarted the
medication over the last few days. You believe that the patient’s dermatological
emergency is due to this anti-epileptic drug and you admit him to the hospital. Caused by
Carbamaxepin or Lamotrigine
What is the most appropriate medication for this condition? The most appropriate
treatment for toxic epidermal necrolysis (TEN) is the immediate discontinuation of the
suspected causative drug and supportive care. In addition to pain control and intravenous
fluids, the patient should be managed in a burn unit or intensive care unit with frequent
monitoring of vital signs, electrolyte levels, and fluid status. Wound care is also an
essential aspect of management, and patients with large areas of skin loss may require
surgical intervention, including skin grafting. ( Cyclosporine and Etanercept) cancenurin
blocker
What are the complications linked with this drug administration?Complications
associated with TEN include sepsis, multi-organ failure, and death. Patients with TEN are
also at increased risk of developing long-term complications, such as scarring, vision
loss, and pulmonary fibrosis. Patients who survive TEN require close follow-up and
ongoing management to prevent these complications and optimize their long-term
outcomes. ( Hirsutism, nephrotoxic, hyperplasia of gums, hyperuricemia ,
hyperlipidemia, hepatotoxicity)
24.2. A 65-year-old man with Parkinson’s disease is treated with pramipexole. This drug
acts as an agonist at striatal
a. 5-H serotonergic receptors.
b. D1 dopaminergic receptors.
c. norepinephrine adrenergic receptors.
d. D2 dopaminergic receptors.(somnolence, compulsive gambling and sexual activity,
fatigue, used in on off phenomenon)
e. opiate μ receptors.
24.3. A 42-year-old woman with feelings of sadness, despair, and tearfulness presents to
her primary care physician for management. She has no prior medical or surgical history.
Therapy with bupropion has begun. The treating physician must be aware of which of the
following contraindications?
(A) Anorexia. ( Increase release and block reuptake of NE and Dopamine)
(B) Depression
(C) Seasonal affective disorder
(D) Seasonal affective disorder with mania
(E) Transient ischemic attacks
Case 25.1.
A 26-year-old woman is referred to your neurology clinic for treatment of her seizure
disorder. She suffered her first generalized tonic-clonic seizure 2 months ago and has
been experiencing seizures about once a week since. Her past medical history is
significant for bipolar disorder for which she takes lithium to treat. Upon further
questioning, you learn that she started lithium about 2 months ago, but prior to that, she
had been taking a different medication to treat her bipolar disorder. You begin to wonder
if her prior medication had not only been treating her bipolar disorder, but also had been
suppressing her seizures as well.
What is the most appropriate medication for this condition? Valproate ca blocker, na
blocker, increase GABA
What are the complications linked with this drug administration?Vomiting,nausea,
alopecia, liver toxicity cause hyperammonemia, pancreatitis, rash, obesity, tremor,
teratogenic(neural tube defect)
25.2. An 18-year-old woman presents to clinic because of difficulty with school. She
recently started college and is living on her own for the first time. She is constantly
preoccupied with wondering if the door is locked. She checks the lock at least 20 times
before she is able to leave her apartment. This often makes her late for class. She had
been on selective serotonin reuptake inhibitors in the past, but they are ineffective. What
is the most appropriate treatment for this patient?
(A) Amitriptyline
(B) Clomipramine blocks maximum serotonin reuptake, TCA)
(C) Lithium
(D) Quetiapine
(E) Venlafaxine
B: Clomipramine. This patient has
obsessive-compulsive disorder. Clomipramine is a
tricyclic antidepressant that is also used in the treatment of obsessive-compulsive
disorder. It is used as a
second-line treatment when selective serotonin reuptake inhibitors fail.
25.3. Most drugs used for the treatment of Alzheimer disease are directed toward
increasing the amount of which neurotransmitter in the brain?
A. Norepinephrine.
B. Dopamine.
C. Serotonin.
D. Glutamate.
E. Acetylcholine.
Case 26.1.
An 11-year-old boy is brought to your pediatric neurology clinic because his mother is
concerned about his behavior. The mother tells you that she has noticed that the patient
simply stops in his tracks and enters a staring, trance-like state for 15 to 30 seconds.
During these episodes, he is unresponsive and unaware of his surroundings. After these
episodes, the patient returns to normal and has no memory of the event and no lingering
effects. You decide to workup the patient thoroughly for absence seizures, but, in the
meantime, you reassure the mother that there is a very effective medication, which acts
by reducing calcium current across neuronal cell membranes, that can help manage and
treat this patient’s symptoms.
What is the most appropriate medication for this condition?
What are the complications linked with this drug administration?
26.2.A 72-year-old man with Parkinson disease is being treated with L-DOPA/carbidopa.
The beneficial effect of carbidopa may be attributed to which of the following actions?
A. Its conversion to L-DOPA.
B. Its conversion to dopamine.
C. Its inability to cross the blood-brain barrier.
D. Inhibition of COMT.
E. Inhibition of MAO.
26.3. A 19-year-old college student has overdosed on phenobarbital. After standard
supportive care, the physician in the ER should do which o the following to hasten the
elimination o phenobarbital?
a. Acidi y the urine
b. Acidi y the blood
c. Alkalinize the blood
d. Alkalinize the urine
e. Use a drug to stimulate hepatic CYP 2C19
Case 27.1.
A 42-year-old woman presents to your clinic, complaining of migraine headaches. She
describes her headache episodes as being located to right side of her head with a
throbbing quality. She also notes that she is exquisitely sensitive to light and sound when
she experiences one of these headaches and that she will sometimes see flashing lights
right before the headache begins. She has tried using sumatriptan without relief and is
wondering if you can prescribe another medication to treat her migraines. You decide to
prescribe a medication for her that is used in the treatment of both migraines and seizure
disorders, but you warn her that she may experience difficulties with attention and
memory while on this medication.
What is the most appropriate medication for this condition? Topiraamate ( na blocker, k
opener, CA blocker,
What are the complications linked with this drug administration?Metabolic acidosis,
nephrolithiasis,hypohydrosis, weight gain, secondary angle closer glaucoma
27.2 A 29-year-old woman is being treated with valproic acid or simple partial seizures.
She is at risk or developing a rise in her plasma
a. calcium.
b. hepatic transaminases.
c. blood urea nitrogen (BUN).
d. potassium.
e. glucose.
27.3. A 32-year-old woman is taking ramelteon or chronic insomnia. Ramelteon binds to
a. melatonin receptors M1and M2
b. muscarinic receptors M3
c. nicotinic receptors. d. α1-adrenergic receptors.
e. D2 dopaminergic receptors.
Case 28.1.
A 23-year-old man with a history of complex partial seizures presents to your neurology
clinic for a follow-up visit. He reports that his seizures have been occurring more
frequently over the last 4 weeks. This increase in seizure frequency occurred after
phenytoin was discontinued from his regimen because he was unable to tolerate the drug.
He currently is taking only a high dose of carbamazepine for seizure control. You decide
to add another anti-epileptic agent, which acts by inhibiting the reuptake of GABA in the
synaptic cleft. When he asks you what side effects he can expect from the new
medication, you tell him that it may give him some nausea, diarrhea, and drowsiness, but
that he will likely not experience any of the serious side effects he suffered while taking
phenytoin.
What is the most appropriate medication for this condition?Tiagabine is an antiepileptic
drug that works by inhibiting the reuptake of GABA in the synaptic cleft, thereby
increasing the availability of GABA in the brain. GABA is an inhibitory neurotransmitter
that helps to regulate the excitability of neurons in the brain, and its availability is
decreased in patients with epilepsy. Blocks GABA transaminase
What are the complications linked with this drug administration? Nausea, Dizziness,
Fatigue, Tremor, Headache, Insomnia, Abdominal pain, Constipation, Blurred vision,
Nervousness or anxiety
28.2.A 43-year-old woman is prescribed a benzodiazepine or anxiety. The choice o which
benzodiazepine to prescribe should be based on
a. volume o distribution.
b. plasma half -life.
c. protein binding.
d. the indications approved by the FDA.
e. creatinine clearance.
28.3.A 47-year-old woman is recovering from a hysterectomy. Her physician prescribes
an opioid analgesic as needed for postoperative pain. Opioids can cause many effects in
addition to analgesia including constipation, respiratory depression, euphoria, miosis, and
drowsiness. With prolonged use, tolerance develops to most of these effects. Which of
the following effects persists in spite of tolerance leading to a decrease in the other
effects?
(A) Analgesia
(B) Constipation
(C) Drowsiness
(D) Euphoria
(E) Nausea and vomiting
Case 29.1.
A 47-year-old woman presents to neurology clinic, complaining of several neurological
symptoms. The patient reports episodes of inexplicable fear and sadness as well as a
concurrent feeling of an altered sense of smell and a sense of spatial distortion. She
denies any loss of consciousness during these episodes. After a full neurological
examination and workup, you diagnose the patient with simple partial seizures and you
prescribe a medication to treat her simple partial seizures. When the patient asks you how
the drug works, you explain that the exact mechanism of action of the medication is
unknown; however, it likely interrupts nerve conduction across the synapse by binding to
synaptic vesicle proteins.
What is the most appropriate medication for this condition? Levetiracetam is an AED that
is believed to work by binding to the synaptic vesicle protein SV2A, which reduces the
release of neurotransmitters such as glutamate, thereby decreasing excitatory activity in
the brain. The exact mechanism of action of levetiracetam is not fully understood, but it
is known to be effective in treating partial seizures.
What are the complications linked with this drug administration? Drowsiness or fatigue,
Dizziness,, Headache, Irritability or mood changes, Incoordination or clumsiness,
Nausea, or vomiting, Loss of appetite, Weakness, Insomnia, Behavioral changes or
agitation, Depression or suicidal thoughts, Skin rash or hives, Severe dizziness or fainting
Difficulty breathing.
29.2. Which types of neurons originate primarily in the substantia nigra and
hypothalamus?
A. Noradrenergic.
B. Serotoninergic.
C. Dopaminergic.
D. GABAergic.
E. Histaminergic.
29.3 A 53-year-old man with 15 years o alcohol abuse has developed weakness in his
legs and the onset of heart failure. The primary treatment is
a. digoxin.
b. metoprolol.
c. creatine.
d. abstinence from alcohol.
e. thiamine.
Case 30.1.
A 42-year-old woman presents to your clinic complaining of diffuse body aches for the
last 6 months. After a full history and physical examination including assessment of the
18 tender points, you begin to suspect that the patient may be suffering from
fibromyalgia. In addition to ordering some routine blood work to rule out inflammatory
arthritis, myositis, and metabolic abnormalities, you decide to start the patient on a
medication that may improve her symptoms by binding to voltage-gated calcium ion
channels in the CNS, thereby decreasing glutamate and norepinephrine release.
What is the most appropriate medication for this condition? Pregabalin( GABA analogue)
is an anticonvulsant medication that is also approved for the treatment of fibromyalgia. It
is believed to work by binding to voltage-gated calcium ion channels in the CNS, thereby
decreasing glutamate and norepinephrine release. This mechanism of action is thought to
reduce pain and other symptoms associated with fibromyalgia.
What are the complications linked with this drug administration? Dizziness, Drowsiness,
Fatigue, Dry mouth, Edema (swelling of the arms, hands, feet, ankles, or lower legs),
Blurred vision, Weight gain, Difficulty concentrating or memory problems, Tremors or
shaking, Headache, Nausea or vomiting, Constipation or diarrhea
Back pain or joint pain
30.2. A 22-year-old man presents to his primary care physician with progressively
worsening hallucinations and delusions. His friends describe him as less interested in
certain activities and less talkative than he used to be. The physician prescribes clozapine
for schizophrenia. Which of the following symptoms will be helped most by clozapine?
(A) Attention deficit
(B) Delusions
(C) Flat affect
(D) Lack of motivation
(E) Poverty of speech
Clozapine is a second-generation antipsychotic medication that works by blocking
dopamine and serotonin receptors in the brain. It is often prescribed for patients with
schizophrenia who have not responded well to other antipsychotic medications or who
have experienced significant side effects from those medications. While clozapine may
also improve other symptoms of schizophrenia, such as negative symptoms like lack of
motivation and flat affect, it is particularly effective in treating positive symptoms like
delusions and hallucinations.
30.3. A 53-year-old woman with schizophrenia managed for years with chlorpromazine
complains of a dry mouth, constipation, blurred vision, and feeling tired. Low-potency
typical antipsychotics such as chlorpromazine are known to interfere with many
neurotransmitter receptors aside from their target. Which of the following type of
receptors is spared from antagonism by chlorpromazine?
(A) a-Adrenergic receptors
(B) b-Adrenergic receptors
(C) Dopamine receptors
(D) Histamine receptors
(E) Muscarinic cholinergic receptors
Case 31.1
An 86-year-old man is brought to your geriatrics clinic by his daughter. He was
diagnosed with Alzheimer disease 1 year ago and has been treated with donepezil since.
His daughter reports that her father’s dementia has continued to worsen. He often forgets
who she is and has been found wandering the streets twice in the last 2 weeks. You tell
the daughter that her father will likely need full-time care at this point. In the meantime,
you also prescribe another medication that acts as an N-methyl-D-aspartate (NMDA)
receptor antagonist in the hopes of providing some symptomatic improvement in his
dementia. Memantamine
What are the complications linked with this drug administration?ommon side effects of
memantine can include headache, confusion, dizziness, constipation, and diarrhea. Less
common side effects may include hallucinations, agitation, and urinary tract infections. In
rare cases, memantine can also cause seizures or changes in heart rhythm. It is important
to talk to a healthcare provider if you experience any side effects while taking
memantine.
31.2. A 44-year-old man with schizophrenia is being treated with a low-potency typical
antipsychotic. He complains that his medication’s side effects are more than he can
handle and wants to try another medication. If he was to switch from a low-potency to a
high potency antipsychotic drug, which of the following side effects would likely
diminish?
(A) Anticholinergic effects
(B) Parkinsonism
(C) Perioral tremor
(D) Tardive dyskinesia
(E) Torticollis
31.3. A 35-year-old man who is an immigrant has been taking prazepam for anxiety for
10 years. This drug is not available in the United States, so he goes to see a physician
about a drug that would be a good replacement. What might happen to this patient if he
was unable to replace his prazepam and abruptly quit taking it?
(A) Adrenal insufficiency
(B) Convulsions and hallucinations
(C) Fever and muscle rigidity
(D) Myocardial infarction
(E) Respiratory depression
Case 32.1
A 24-year-old male presents to the emergency department complaining of severe pelvic
pain. He reports that he has been suffering from insomnia recently, so he took one of his
brother’s prescription pills to help him sleep earlier in the evening. Unfortunately, he
states that he has been experiencing a painful, unremitting erection for the past 5 hours.
As you rapidly initiate treatment for his symptoms, you explain that his condition is
likely a side effect of the medication he took for sleep, which can also be used as an
atypical antidepressant.
What is the most appropriate medication for this condition?
he medication the patient took for sleep and that can also be used as an atypical
antidepressant is likely trazodone.5HT2 blocker . The prolonged, painful erection that
the patient is experiencing is a medical emergency known as priapism. The most
appropriate medication for this condition is phenylephrine, which is an alpha-1
adrenergic agonist that causes smooth muscle contraction in the penis, thereby reducing
blood flow and helping to relieve the erection. If phenylephrine is not effective, more
invasive treatments such as aspiration or injection of vasoconstrictive agents may be
necessary. It is important to note that priapism is a rare but serious side effect of
trazodone, and patients should be advised to seek medical attention immediately if they
experience prolonged erections.
What are the complications linked with this drug administration? common side effects of
trazodone include dizziness, drowsiness, headache, dry mouth, blurred vision,
constipation, and gastrointestinal distress. Other less common side effects may include
priapism (prolonged, painful erection), orthostatic hypotension (drop in blood pressure
upon standing), and cardiac arrhythmias. It is important to discuss any potential side
effects with your healthcare provider before starting this medication.
32.2. A 42-year-old woman was prescribed an SSRI and has been taking her medication
diligently for more than a year. During the winter, she developed a cough that kept her up
at night. She decided to get some cough medicine to help her sleep, but she woke up in
the middle of the night with tremors, chills, and diarrhea. It is likely that she was
exhibiting:
A. A tyramine reaction.
B. Neuroleptic malignant syndrome.
C. Serotonin syndrome.
D. REM sleep deprivation.
E. The flu.
32.3. A 62-year-old man presents with cogwheel rigidity, resting tremor, and
bradykinesia. He is diagnosed with Parkinson’s disease. His medications include a
monoamine oxidase (MAO) inhibitor and a catechol-O-methyltransferase (COMT)
inhibitor. The intent of inhibiting these enzymes is to increase synaptic dopamine,
although many amine neurotransmitters are substrates for both of these enzymes. Which
of the following is a substrate for MAO only?
(A) Acetylcholine
(B) Epinephrine
(C) g-Aminobutyric acid
(D) Norepinephrine
(E) Serotonin
Case 33.1
A 36-year-old woman is seen in your psychiatry clinic for a follow-up appointment. She
was recently discharged from a psychiatric hospital, where she was admitted for auditory
hallucinations. The admitting physician did not believe her to be suffering from
schizophrenia, but instead diagnosed her as having atypical depression with psychotic
features. She was started on a new medication to help control her illness. In your office,
she asks you about the possible side effects of her new medication. You tell the patient
that it is important to avoid certain foods, such as cheese, red wine, and smoked sausage,
since ingestion of these foods in conjunction with her new medication could lead to a
hypertensive crisis.
What is the most appropriate medication for this condition?
The medication being described is likely an MAOI (monoamine oxidase inhibitor), which
is used to treat atypical depression with psychotic features. The warning about avoiding
certain foods is due to the potential interaction between MAOIs and tyramine, a
compound found in aged or fermented foods. The combination of an MAOI and
tyramine-containing foods can lead to a hypertensive crisis. Therefore, the most
appropriate medication for this condition is likely an MAOI, such as phenelzine
What are the complications linked with this drug administration? Drowsiness, Dizziness
Dry mouth, Constipation, Blurred vision, Urinary retention, Weight gain, Sexual
dysfunction, Orthostatic hypotension, Hypertensive crisis (when taken with foods or
medications containing tyramine)
33.2. A 21-year-old man complains of depressed mood, lack of pleasure in activities he
previously enjoyed, and lack of energy. This has been going on for 2.5 years now. His
physician prescribes fluoxetine. Which of the following side effects is most likely to
occur in this patient?
(A) Abdominal pain
(B) Peptic ulcers
(C) Impotence
(D) Loss of taste
(E) Pancreatitis
33.3. After norepinephrine is released, it binds to receptors on the target organs. Then, it
must be removed from the synaptic space. Which of the following mechanisms describes
correct removal of norepinephrine from the synaptic space?
(A) ATPase pump is stimulated by cocaine
(B) ATPase pump is stimulated by imipramine
(C) Diffusion from the general circulation back into the synaptic space
(D) Metabolism to O-methylated derivatives in the synaptic space
(E) Pump system pumps norepinephrine out of the neuron
Case 34.1
A 21-year-old college student presents to your office complaining of fatigue. He also
notes that he no longer enjoys spending time with friends and family and that his grades
have suffered this past semester. He denies explicit suicidal ideation, although he does
admit that he has recently thought about whether life is worth living. Worried about his
performance in school, he has attempted to reduce anxiety by taking up smoking. After
telling the patient that his symptoms may be signs of depression, you also voice concern
over his smoking habits. You both agree to try a drug that may be effective in reducing
his psychiatric symptoms as well as making it easier for him to discontinue his smoking
habit.
What is the most appropriate medication for this condition?
bupropion, which is an antidepressant that has been shown to be effective in reducing
symptoms of depression as well as aiding in smoking cessation. Bupropion acts on
norepinephrine and dopamine neurotransmitter systems, which may explain its
effectiveness in treating both depression and smoking addiction.
What are the complications linked with this drug administration? Dry mouth, Headache
Insomnia, Nausea and vomiting, Constipation, Agitation or anxiety, Tremors, Sweating
Changes in appetite or weight, Blurred vision, Dizziness or lightheadedness, In rare
cases, bupropion can also cause serious side effects such as seizures, high blood pressure,
and suicidal thoughts or behaviors.
34.2. Stimulation of inhibitory neurons causes which of the following effects at the
postsynaptic membrane?
(A) Binding of GABA at the postsynaptic membrane
(B) Depolarization
(C) Stimulation of epinephrine
(D) Transient decrease in permeability of chloride
(E) Transient decrease in permeability of potassium
34.3. A 68-year-old woman with a long history of sadness, gloom, and weight loss
presents to her primary care physician for treatment. She is treated with a selective
serotonin reuptake inhibitor. Which of the following statements is true?
(A) Maximum benefit may require 1 year
(B) Most patients require three antidepressants
(C) Twenty percent of patients with adequate doses for 8 weeks respond to therapy
(D) Two weeks of therapy are required for mood improvement
Case 35.1
A 44-year-old man presents to your office complaining of lower back pain. The patient
works in construction, and he reports that the pain began suddenly after he tried to lift a
heavy sandbag at work 5 weeks ago. Since then, he has been managing his symptoms
with NSAIDs and acetaminophen. Unfortunately, he has continued to have painful,
debilitating back spasms. After discussing several options, you both agree that opioids are
a poor choice and instead decide that physical therapy in addition to an anti-spasmodic
agent may provide the most symptomatic benefit.
What is the most appropriate medication for this condition? ? One commonly used
skeletal muscle relaxant is cyclobenzaprine, which is FDA-approved for the short-term
treatment (2-3 weeks) of muscle spasms associated with acute painful musculoskeletal
conditions. Cyclobenzaprine is thought to work by reducing muscle spasms through its
action on the central nervous system. Cyclobenzaprine is a centrally acting muscle
relaxant that is used to alleviate musculoskeletal pain and spasms. It is believed to work
by decreasing motor neuron activity, thereby reducing muscle tone and spasms.
Specifically, it acts as a selective antagonist at the presynaptic α2-adrenergic receptors in
the central nervous system, which leads to an increase in the release of norepinephrine.
This increase in norepinephrine results in a reduction in muscle tone and spasticity.
What are the complications linked with this drug administration?Common side effects of
cyclobenzaprine include drowsiness, dizziness, dry mouth, and blurred vision. It is
important to note that cyclobenzaprine should be used with caution in patients who have
glaucoma, urinary retention, or who are taking certain medications such as MAO
inhibitors.
35.2. A 54-year-old man with multiple medical problems and anxiety is placed on
diazepam. He has been taking the medication for 6 months. He is concerned that he is
having changes in his memory as a result of being on this medication. Which of the
following memory effects are likely?
(A) Anterograde amnesia
(B) Long-term memory loss
(C) Loss of ability to taste
(D) Loss of prior negative memories
(E) Short-term memory loss
35.3. A 62-year-old woman with a history of mental decline, impaired physical activity,
and significant mood impairment is seen by her primary care physician. Treatment with a
tricyclic antidepressant has begun. Which of the following statements regarding this
therapeutic option is true?
(A) Mental alertness is unlikely to change
(B) Mood elevation is likely
(C) Morbid preoccupation will unlikely change
(D) Physical dependence will occur
(E) Psychological dependence will occur
Case 36.1
A 35-year-old business professional is seen in your clinic to discuss treatment for his
generalized anxiety disorder. He is currently taking benzodiazepines as needed to serve
as his anxiolytic. He is concerned about the addictive nature of his current therapy and he
is also upset that he cannot use his current medication with social alcohol intake. He
would like to change his medication regimen. You prescribe an agent that fits the needs
of the patient, but you inform him that it may take 1 to 3 weeks to show efficacy against
his generalized anxiety.
What is the most appropriate medication for this condition? he most appropriate
medication for generalized anxiety disorder that may take 1 to 3 weeks to show efficacy
is a selective serotonin reuptake inhibitor (SSRI) such as escitalopram, fluoxetine, or
sertraline. These medications are effective in reducing symptoms of anxiety and have less
potential for abuse and addiction than benzodiazepines. Additionally, they do not have
the same contraindication with alcohol consumption.
What are the complications linked with this drug administration? Nausea and vomiting,
Diarrhea or constipation, Headache,, Insomnia or drowsiness, Sexual dysfunction (e.g.
decreased libido, difficulty achieving orgasm), Weight gain, Sweating or flushing, Dry
mouth, Tremors
36.2. A 43-year-old woman with a history of fibromyalgia and depression presents to her
primary care physician for treatment. She complains of feeling sad and worthless in
addition to multiple somatic complaints. Which of the following treatments would be best
for this patient?
(A) Duloxetine
(B) Fluoxetine
(C) Mirtazapine
(D) Sertraline
(E) Watchful waiting
36.3. A 62-year-old woman with symptoms of feeling blue, sad, and without feelings
presents to her primary care physician for treatment. She has a prior medical history of
narrow-angle glaucoma. Which of the following treatments should be avoided in this
patient?
(A) Amitriptyline
(B) Bupropion
(C) Fluvoxamine
(D) Mirtazapine
(E) Sertraline
Case 37.1.
A 24-year-old motorcyclist had an accident a week ago that resulted in an open wound on
his knee that became infected. When he decided to seek medical help, the physician told
him that he could not use lidocaine as a local anesthetic prior to suturing the wound
because:
A. The wound was too old.
B. Lidocaine is a strong acid.
C. Lidocaine would be destroyed by plasma esterases.
D. Lidocaine would be in a charged form in the infected area and would not readily
penetrate the cell membrane.
E. Could easily gain entry to the brain
nfections lead to an acidic environment that favors the ionized form of local anesthetics
like lidocaine. The ionized form does not penetrate cell membranes easily and thus is less
effective in blocking nerve impulses.
37.2. A 43-year-old man with postsurgical pain is placed on an intravenous patient
controlled analgesia pump with morphine as the analgesic. This form of analgesic
administration is prefferred to oral administration because morphine
a. is not absorbed orally.
b. administered orally is rapidly eliminated in the urine.
c. administered orally does not penetrate the brain.
d. administered orally causes more severe constipation.
e. administered parenterally bypasses first-pass metabolism.
37.3 Which of the following agents is often combined with local anesthetics to
prevent its systemic distribution from the site of injection?
A. Acetylcholine
B. Dopamine
C. Epinephrine
D. γ-Aminobutyric acid (GABA)
Case 38.1.
A 65-year-old woman presents to your clinic, complaining of severe lower back pain that
developed after she tried to pick up a heavy box in her attic. Physical examination is
suggestive of a herniated disc in the lumbar spine and imaging studies confirm your
findings. You begin the patient on a high-dose non-steroidal anti-inflammatory regimen
and you suggest that she start physical therapy. After 3 days, the patient calls your office,
saying that the pain is unbearable and not controlled on the non-steroidal antiinflammatory medications. She is very reluctant to try an opiate medication for her pain,
so you decide to instead prescribe a medication that acts as a very weak opioid agonist
and also has been shown to inhibit the reuptake of norepinephrine and serotonin at the
synaptic junction.
What is the most appropriate medication for this condition? The most appropriate
medication for this patient would be tramadol, which is a weak opioid agonist
What is the mechanism of action of this drug? inhibits the reuptake of norepinephrine and
serotonin at the synaptic junction.
What are the complications linked with this drug administration? Nausea and vomiting
Dizziness and drowsiness, Headache, Constipation, Dry mouth, Sweating, Itching,
Decreased appetite, Seizures (especially at higher doses), Serotonin syndrome (in
combination with other serotonergic medications), Respiratory depression (especially in
patients with respiratory compromise)
38.2. A 42-year-old woman with feelings of sadness, despair, and tearfulness presents to
her primary care physician for management. She has no prior medical or surgical history.
Therapy with bupropion has begun. The treating physician must be aware of which of the
following contraindications?
(A) Anorexia
(B) Depression
(C) Seasonal affective disorder
(D) Seasonal affective disorder with mania
(E) Transient ischemic attacks
38.3. An 18-year-old woman presents to clinic because of difficulty with school. She
recently started college and is living on her own for the first time. She is constantly
preoccupied with wondering if the door is locked. She checks the lock at least 20 times
before she is able to leave her apartment. This often makes her late for class. She had
been on selective serotonin reuptake inhibitors in the past, but they are ineffective. What
is the most appropriate treatment for this patient?
(A) Amitriptyline
(B) Clomipramine
(C) Lithium
(D) Quetiapine
(E) Venlafaxine
Case 39.1.
A 30-year-old woman presents to your office for the evaluation of fatigue. For the past 2
months she has felt run down. She says that she doesn’t feel like participating in activities
that she previously enjoyed, such as her weekly softball games. She has not been sleeping
well and has not had much of an appetite. On questioning, she admits to feeling “down in
the dumps” most of the time and has found herself crying frequently. She has never gone
through anything like this before. She denies any thoughts of wanting to hurt herself or
anyone else. She denies any symptoms now or previously of mania. She also denies any
visual/auditory hallucinations, paranoia, delusions, or other psychotic symptoms. Other
than becoming tearful during her interview, her physical examination is normal. Her
blood tests, including a complete blood count and thyroid function, are normal. A serum
pregnancy test is negative. You diagnose her as having a major depression and, along
with referring her for counseling, start her on fluoxetine.
What is the mechanism of action of fluoxetine?luoxetine is a selective serotonin reuptake
inhibitor (SSRI), which works by increasing the amount of serotonin available in the
brain. Serotonin is a neurotransmitter involved in regulating mood, anxiety, and other
physiological functions, and the increase in its availability is thought to improve
symptoms of depression. Fluoxetine selectively inhibits the reuptake of serotonin from
the synaptic cleft, leading to an increase in its concentration and prolonging its action at
the receptor sites.
What are the common side effects of fluoxetine?Some common side effects of fluoxetine
include nausea, diarrhea, headache, insomnia, drowsiness, anxiety, nervousness,
agitation, and decreased sexual desire or ability. In some cases, fluoxetine can also cause
weight loss or weight gain, depending on the individual. Rare but potentially serious side
effects of fluoxetine include serotonin syndrome, which can cause symptoms such as
confusion, rapid heart rate, high blood pressure, fever, and seizures, as well as suicidal
thoughts or behavior. It is important to monitor for any new or worsening symptoms
while taking fluoxetine and to contact a healthcare provider if any concerning side effects
occur.
39.2 A 26-year-old man complains of tremors, tachycardia, and diaphoresis when
speaking in public. He has started a new job that requires him to give frequent
presentations to large audiences and is worried he would not be able to work effectively.
His physician prescribes propranolol. How will propranolol help with this patient’s
anxiety?
(A) CNS sedation
(B) CNS stimulation
(C) Patients with anxiety usually have comorbid heart disease
(D) Propranolol is not used to treat anxiety
(E) Symptomatic relief
39.3 A 56-year-old man came to the clinic with complaints of tremor, bradykinesia, and
“a feeling of persistent restlessness” after beginning a new antipsychotic regimen 2
months ago. The patient has a history of schizophrenia and depression. He is afraid he
may have Parkinson’s syndrome. The doctor recommended cessation of the new regimen
and assures the patient the symptoms will clear after a few weeks or months after
withdrawal. What antipsychotic was the most likely to have caused the patient’s
symptoms?
(A) Aripiprazole
(B) Clozapine
(C) Haloperidol
(D) Olanzapine
(E) Ziprasidone
Case 40.1
A 31-year-old man presents to the emergency room after having been involved in a bar
brawl at a local establishment. He has sustained a deep cut to his left forearm. After
thoroughly cleaning the wound and confirming that there is no residual debris in the
wound, you explain to the patient that he will need stitches. He asks whether he will feel
any pain during the procedure, and you reassure him that you will administer a
medication to the area of the wound that will dull his sensation to pain by blocking
neuronal sodium channels.
What is the most appropriate medication for this condition? The most appropriate
medication for blocking neuronal sodium channels and providing local anesthesia for
wound closure is a local anesthetic such as lidocaine, bupivacaine, or procaine. These
medications work by inhibiting the influx of sodium ions into neurons, which prevents
the generation and conduction of nerve impulses responsible for transmitting pain signals
to the brain. In this case, lidocaine is commonly used for local anesthesia in minor
surgical procedures.
What are the complications linked with this drug administrationTemporary burning,
stinging, or itching at the site of injection, Numbness or tingling
40.2. A 20-year-old man is given codeine to relieve the pain of a sprained ankle. After
two days the man returns to his doctor saying that the codeine is not effective. A likely
cause is due to
a. poor absorption.
b. rapid urinary excretion.
c. poor metabolism.
d. high protein binding.
e. poor brain penetration.
40.3. Termination of the action of local anesthetics:
A. Depends on the type of local anesthetic, i.e., ester or amide.
B. Involves hydrolysis by plasma cholinesterases.
C. Involves plasma-protein binding.
D. Involves primarily vascular redistribution.
E. Is enhanced in the presence of vasoconstrictors such as epinephrine.
he termination of action of local anesthetics depends on the type of local anesthetic used,
i.e., ester or amide. Ester-type local anesthetics are hydrolyzed by plasma cholinesterases,
whereas amide-type local anesthetics are metabolized in the liver. Plasma-protein binding
and vascular redistribution do play a role in the duration of action of local anesthetics, but
they are not the primary mechanisms of termination. Vasoconstrictors such as
epinephrine can be added to local anesthetics to prolong their duration of action, but they
do not enhance the termination of action.