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Central Nervous System Pharmacology- Part 3
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1. A 26-year-old woman has been on antidepressant therapy for several Today she complains of missing her period and having galactor- rhea, and your careful assessment suggests that she has developed some dyskinesias (mild tremors, for example) not unlike those you would typically associate with a phenothiazine or butyrophenone (eg, haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug most l ikely to have caused these findings?
2. A patient has been taking an oral monoamine oxidase inhibitor (MAOI), but that fact i s unknown to the health team who i s now taking care of her, for unrelated medical conditions, in the The patient receives a drug that leads to a fatal response characterized by profound fever, delirium, psychotic behavior, and status epilepticus. It was found to have occurred because of an interaction with the MAOI. Which, most l ikely, was this second drug or the drug class to which i t belongs?
3. A young woman i s taken to the emergency department by some of her It seems they were out on “bar night” and someone s l ipped something into her alcoholic beverage, the fi rst and only one she consumed that night. She i s now extraordinarily drowsy and has l i ttle recall of what happened between the time she s ipped her drink and now. Someone overheard another bar patron talking about “roofies.” You suspect her drink was spiked with Rohypnol, the lesser-known generic name of which i s flunitrazepam. A positive response (ie, symptom improvement) to what drug that you give would confirm your suspicion?
4. In deciding on pharmacotherapy for many patients you’ve diagnosed with depression, you’ve usually considered starting with an SSRI or, in some cases, a tri Today you assess a patient and suspect endogenous depression. While discussing treatment options they refer to a drug by name and ask you about i t; they’ve seen many advertisements for i t in magazines and on TV. The drug (generic name) i s bupropion. In what main way does bupropion differ from either or both the SSRIs or tri cyclics?
- Higher incidence of CNS depression, drowsiness
- Higher incidence of weight gain
- Less drug-induced sexual dysfunction
- Much more common and severe falls of resting blood pressure and orthostatic hypotension More severe and more frequent peripheral anticholinergic (atropine-like) s ide effects
- Stronger inhibition of monoamine oxidase
5. A 33-year-old woman patient treated with haloperidol i s seen in the emergency department (ED). Her husband describes complaints of rapidly worsening fever, muscle stiffness, and Her level of consciousness i s diminishing. Her temperature i s 104°F, and her blood creatine kinase (CK) level i s elevated. What i s the most l ikely explanation for these findings?
- Allergic response to her medication
- Neuroleptic malignant syndrome (NMS)
- Tardive dyskinesia
6. Nearly all the drugs used as primary therapy, or as adjuncts, for the treatment of Parkinson disease or drug-induced parkinsonism exert their desired effects directly in the brain’s striatum. Which one exerts i ts main effects in the gut, not in the brain?
7. You have a patient with severe postoperative pain who i s not getting adequate analgesia from usually effective doses of The physician orders an immediate switch to pentazocine (at usually effective analgesic doses). What i s the most l ikely outcome of stopping the morphine and immediately starting the pentazocine?
- Abrupt, added respiratory depression
- Acute development of physical dependence
- Worsening of pain
8. The chosen pharmacologic approach to managing a patient with mild and recently diagnosed parkinsonism will be to enhance specifically the activity of endogenous brain dopamine by inhibiting i ts metabolic What drug works primarily by that mechanism?
9. Chlorpromazine has been prescribed for a patient with schizophrenia, and the patient has been taking the drug, at usually effective doses, for about 6 Today he comes to the hospital with other medical conditions that require surgery and the administration of other drugs, and we decide it is unwise to stop the chlorpromazine and run the ri sk of psychotic behavior while we perform other interventions. What other s igns/symptoms that the patient may also have or acquire as the result of surgery and drug therapy are most l ikely to be affected beneficially by the continued use of chlorpromazine?
- Epilepsy and the ri sk of seizures
- Nausea and vomiting
- Urinary retention caused by abdominal surgery
- Xerostomia (dry mouth) caused by antimuscarinic drugs used to prevent intra-operative bradycardia
`10. There are, rightfully, concerns about cocaine abuse, and too many deaths have occurred from smoking “crack” cocaine or injecting or nasally inhaling the What statement best describes the main mechanism by which cocaine exerts i ts deleterious effects in the central nervous system or in the periphery?
- Directly activates, as an agonist, both α- and β1-adrenergic receptors
- Enhances neuronally mediated adrenergic receptor activation by inhibiting neuronal norepinephrine reuptake
- Inhibits catecholamine inactivation by inhibiting MAO and catechol-O-methyltransferase
- Produces bradycardia and vasodilation, leading to hypotension and acute heart failure, by blocking neuronal NE release.
- Stimulates autonomic nerve conduction effectively, leading to increased neuronal norepinephrine release
11. One approach to managing hyperprolactinemia i s to administer a drug that has relative selectivity, as an agonist, for central (as an agonist) dopamine D2 What drug works in that manner?
12. We perform a meta-analysis on the ability of various antipsychotic drugs to cause constipation, urinary retention, blurred vis ion, and dry mouth—all of which reflect s ignificant blockade of muscarinic receptors in the peripheral nervous What drug most l ikely caused these unwanted effects?
13. It i s obvious that morphine should always be administered “with care.” However, one of i ts expected effects that occur only while the drug i s being given makes i t particularly dangerous to administer to certain patients unless “special measures” can be taken to prevent this adverse Which comorbidity weighs against using morphine, unless you fi rst take precautions to prevent adverse consequences from occurring?
- Acute pulmonary edema
- Closed-head injury
- History of epilepsy
- Recent/evolving myocardial infarction
14. A 66-year-old woman has terminal cancer, and i s in She i s receiving round-the-clock opioids, at rather high doses, but sti l l reports what she describes as s ignificant burning, shooting pain. The physician believes i t i s neuropathic. Increasing the dose of opioids may be helpful, but that option i s ruled-out at this time because doing so i s l ikely to suppress ventilation excessively. In addition, the patient does not want the excessive grogginess that i s apt to occur with more opioid on board. Although the patient i s not at all hypertensive, the physician prescribes as an analgesic adjunct that i s far more widely used as an antihypertensive drug. What i s the most l ikely adjunctive drug she prescribed?
15. A patient i s on long-term methadone therapy as part of a holistic plan to curb their opioid addiction and What phrase best describes a characteristic of this drug?
- Causes pentazocine-like activation of κ receptors and blockade of μ receptors
- Has greater oral bioavailability than morphine, especially when oral administration i s started
- Remarkably devoid of such typical opioid analgesic s ide effects as constipation and respiratory depression
- Useful for maintenance therapy in opioid- (eg, heroin-) dependent individuals, but lacks cl inically useful analgesic effects
- When abruptly stopped after long-term administration, causes a withdrawal syndrome that i s more intense, but briefer, than that associated with morphine or heroin withdrawal
16. A mom gets a note from her 10-year-old daughter’s teacher that the child recently started experiencing numerous albeit brief episodes of “just staring into space” throughout the school The mother realizes she’s noticed the same in her girl at home. After a trip to the pediatrician, and referral to a neurologist, a diagnosis of absence epilepsy i s made. What drug i s generally considered the preferred starting drug for this type of epilepsy in an otherwise healthy child?
17. A 43-year-old woman becomes hypertensive and suffers a fatal acute coronary syndrome shortly after starting therapy on a Autopsy shows l i ttle in the way of coronary atherosclerosis, but ECG changes noted just before her death revealed s ignificant myocardial i schemia in the myocardium served by the left anterior descending and ci rcumflex coronary arteries. The cause of death i s thought to involve coronary vasospasm. What drug most l ikely precipitated this event?
- Bromocriptine for Parkinson disease
- Ergotamine given to abort a migraine attack
- Morphine for post-trauma analgesia
- Phenoxybenzamine used for carcinoid syndrome
- Phenytoin to manage generalized tonic-clonic seizures
18. Promethazine, a phenothiazine derivative with substantial anti-emetic, antitussive, and H1-histamine receptor blocking activity, has a cl inical profile quite s imilar to Recently the FDA mandated a “black box warning” for this widely used drug. The FDA now warns against use of the drug, in all doses and forms, for children aged 2 years or younger. Fatalities have occurred in these young patients, even in response to dosages that previously were considered therapeutic and safe. What i s the most l ikely cause of death from promethazine in these patients?
- Complete (third degree) heart block followed by asystole
- Hypertensive cris i s , intracranial hemorrhage
- Parkinsonian-like dyskinesias, including tardive dyskinesias
- Severe and refractory diarrhea leading to fluid and electrolyte loss
- Ventilatory depression, apnea, excessive CNS depression