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Central Nervous System Pharmacology- Part 4
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1.A 55-year-old undergoes She receives several drugs for pre-anesthesia care, intubation, and intraoperative skeletal muscle paralysis; and a mixture of inhaled and parenteral agents to provide balanced anesthesia. Toward the end of the procedure she develops a rapidly progressing fever, hypertension, hyperkalemia, tachycardia, muscle rigidity, and metabolic acidosis. Which drug combination i s most l ikely to have elicited this reaction?
- Fentanyl and midazolam
- Midazolam and morphine
- Nitrous oxide and etomidate
- Propofol and midazolam
- Succinylcholine and i soflurane
2. A 30-year-old woman with partial seizures i s treated with What i s the specific mechanism of action of this GABA-related anticonvulsant?
- Blocked neuronal reuptake of released GABA
- Directly activated postsynaptic GABA receptors
- Increased neuronal GABA release
- Inhibited catabolism of released GABA
- Stimulated neuronal GABA synthesis by acting as a metabolic precursor
3. A 24-year-old woman has a history of epilepsy that i s being treated with She i s healthy otherwise. She becomes pregnant. What would you do throughout the remainder of her pregnancy, in addition to providing otherwise proper perinatal care?
- Add valproic acid
- Discontinue all anticonvulsant medication
- Increase daily dietary i ron intake
- Prescribe daily folic acid supplements
- Switch from the phenytoin to phenobarbital
4. A patient i s transported to the emergency department by ambulance after repeated episodes of The cause was attributed to severe drug-induced orthostatic hypotension due to α-adrenergic blockade from one of the drug’s main s ide effects. What drug was the most l ikely cause of this problem?
5. Clozapine, as an example of the “atypical antipsychotics,” seldom i s used as fi rst-l ine (initial) therapy of Compared with the older “traditional” antipsychotics, i t i s associated with a much higher ri sk of a serious adverse response. What i s that greater ri sk?
- Extrapyramidal s ide effects (parkinsonism)
- Hypotension, severe
- Ventilatory depression or arrest
6. You’re at the end of the fi rst week of your M3 ob-gyn You are about to go into the delivery room to see your fi rst childbirth. You’ve reviewed her chart and see that she was taking, for the duration of pregnancy, a drug that i s not absolutely contraindicated in pregnancy (ie, not category X). You note that about 1 month before she was prescribed daily oral vi tamin K supplements. The baby i s born and promptly gets an injection of vi tamin K. Knowing what you do about vi tamin K, you correctly reason that these measures were taken to reduce the ri sks of excessive or abnormal bleeding, caused by drug-induced impairments of hepatic vi tamin K-dependent clotting factors, in the newborn. What drug did the mother most l ikely receive during pregnancy, assuming that i t was not in pregnancy category X?
7. When carbidopa i s administered along with levodopa for Parkinson disease, we increase the bioavailability of levodopa by inhibiting the formation of dopamine in the gut. However, the carbidopa-induced inhibition of dopa decarboxylase favors the peripheral metabolism of levodopa to another metabolite that competes with levodopa for transport across the blood-brain This i s catalyzed by catechol-O– methyltransferase (COMT). If your goal i s to inhibit COMT, and so increase the central bio-availability and effects of levodopa, what drug would you choose?
8. A patient has a long history of excessive alcohol He was arrested several times for drunk driving and was referred to a physician for therapy. The physician prescribed a drug to stifle further alcohol ingestion, to be used along with other interventions. The doctor properly instructed the patient not to consume any alcohol, not to use alcohol-containing mouthwashes, nor even apply alcohol-based toiletries, because alcohol may cause a disturbing, i f not dangerous, interaction with his medication. The patient ignored the advice and decided to have a beer. Within minutes he develops flushing, a throbbing headache, nausea, and vomiting. Which drug was he most l ikely taking to curb his alcohol use?
9. A patient with endogenous depression i s started on a drug that selectively inhibits neuronal serotonin (5-HT) reuptake and has minimal effect on the reuptake of norepinephrine or What drug best fi ts this description?
10. A 29-year-old man uses an oral benzodiazepine and alcohol to satisfy his addiction to CNS During the past week, he has been incarcerated and i s not able to obtain the drugs. He i s brought to the medical ward because of the onset of severe anxiety, increased sensitivity to l ight, dizziness, and generalized tremors due to drug withdrawal. On physical examination, he i s hyperreflexic. Which drug would be the best choice to diminish his withdrawal symptoms?
- Chloral hydrate
11. A 50-year-old man has been consuming large amounts of ethanol on an almost daily basis for many One day, unable to find any ethanol, he ingests a large amount of methanol (wood alcohol) that he had bought for his camp lantern. What drug would administer to best treat underlying biochemical consequences of the methanol poisoning?
12. Many news reports have told of a large number of deaths of opioid abusers who purchased and self-administered i l l i ci t drugs that contained lethal amounts of One patient who received this fentanyl-laced drug presents in your emergency department, barely alive. What drug would you administer fi rst, with the best hope that i t can promptly reverse the lethal effects of the fentanyl?
13. A 10-year-old boy has nocturnal His parents take him to a cl inic that specializes in management of this condition. The physician writes an order for a low dose of imipramine. After a couple of weeks on the drug, the episodes of bed-wetting decrease dramatically. What i s the most l ikely mechanism by which the imipramine provided benefit?
- Alleviates depression s igns and symptoms by increasing neuronal catecholamine reuptake
- Blocks muscarinic receptors in the bladder musculature
- Causes sedation such that the boy s leeps through the night without voiding
- Reduces renal blood flow, glomerular fi l tration, and urine output
- Releases antidiuretic hormone (ADH)
14. A patient i s transported to your emergency department because of a A review of his history reveals that he has been treated by different physicians for different medical conditions, and there has been no dialog between them in terms of what they’ve prescribed. One physician prescribed a drug for short-term management of depression. Another prescribed the very same drug, marketed under a different trade name, to help the patient quit smoking cigarettes. What drug was most l ikely prescribed by both doctors, and was the most l ikely cause of the seizures?
- Li thium
15. About 1 year ago you diagnosed schizophrenia s igns and symptoms in a 23-year-old otherwise healthy As a result of intensive psychotherapy, careful ti tration of chlorpromazine dosages, and remarkably good compliance on the patient’s part, he i s well enough to return to work. Several months later, at a scheduled vis i t, you observe numerous s igns and symptoms of drug-induced parkinsonism, and the patient reports rather distressing symptoms of akathisias (inner restlessness, ji tteriness, etc). However, typical manifestations of schizophrenia seem to be well controlled. Which approach i s most l ikely to alleviate the motor and subjective parkinsonian responses, and pose the lowest ri sk of causing schizophrenia s igns and symptoms to reappear?
- Add a catechol -O-methyltransferase inhibitor (eg, tolcapone)
- Add a centrally acting cholinesterase inhibitor (eg, donepezil or tacrine)
- Add benztropine
- Add levodopa or levodopa plus carbidopa
- Switch from chlorpromazine to haloperidol
16. A patient with Parkinson disease starts therapy with a drug that acts in the CNS as an agonist for dopamine It has no direct effects on dopamine synthesis, neuronal reuptake, or metabolic inactivation. What drug fi ts this description the best?
17. A patient develops profound fever, skeletal muscle rigidity, and autonomic and systemic electrolyte imbalances as part of a severe adverse response to a psychoactive The working diagnosis i s neuroleptic malignant syndrome. In addition to administering dantrolene in an attempt to restore some semblance of normal skeletal muscle function, what other drug i s most l ikely to be given to help provide additional symptom relief?
18. A patient diagnosed with depression had been taking amitriptyline for several During a vis i t to his physician he reported difficulty s leeping, so the MD prescribed trazodone, to be taken once daily, at bedtime. The dosages of both the amitriptyline and the trazodone were clearly within the therapeutic range. Several weeks later the patient died. The attorney hired by the deceased man’s patient, as part of a wrongful death suit, contacted several “expert witnesses” who stated that the amitriptylinetrazodone combination caused a lethal serotonin syndrome. Based only on the information presented here, what i s your most reasonable conclusion?
- An interaction between trazodone and an SSRI, each at proper dosages, i s unlikely to cause the serotonin syndrome.
- The trazodone-SSRI combination i s absolutely contraindicated, and should never have been prescribed.
- Trazodone would be appropriate only i f the patient were taking a monoamine oxidase (MAO) inhibitor or for depression.
- Sumatriptan should have been prescribed to prevent the development of the serotonin syndrome.
- Trazodone should never be prescribed to help patients go to s leep, whether or not they are depressed or are taking antidepressants.