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King Saud University                                                             11/11/1423H

College of Pharmacy                                                                          Dr. Lina Ashour

Dept. of Clinical Pharmacy                                                                Total: 20 pts.

PHCL 441

Final Exam

Name:                                                                                       ID#                        

 

I.Cases:

Case #1:

J.F., a 76 y.o. male with a long history of chronic stable angina controlled with isosorbide dinitrate

40 mg TID ( 7:00 am,12 noon, 5:00 pm ) and propranolol 80 mg BID ( 7:00 am, 5:00 pm ), stopped his propranolol abruptly 24 hours ago. He is transported to the hospital ER for the treatment of angina unresponsive to 5 NTG tablets. This unresponsive angina is caused by:

 

a.        Side effects of isosorbide dinitrate

b.       Abrupt withdrawal of propranolol

c.        Side effects of propranolol

d.       Tolerance to isosorbide dinitrate

e.        Tolerance to propranolol

 

 

 

 

 

 

Case #2:

D.B., a 75 y.o. obese ( 92kg, 6ft. tall ) male, is admitted to the hospital with right calf swelling, discoloration and pain of one day’s duration. He denies trauma to the calf, but reveals that several days before the onset of the symptoms he was a passenger in a car for a long trip, during which he sat in a fixed position for many hours. He does not complain of SOB, cough, or chest pain. His past medical history includes coronary artery disease, myocardial infarction (MI) at ages 55 and 65, and hypercholesterolemia. His medications are diltiazem CD 240mg PO QD, isosorbide dinitrate 30 mg PO TID, atenolol 50mg PO QD, and lovastatin 20 mg PO PM.

 

                                Initial lab. Values include:

                                Hct          36.5%                     ( 42%-52%)

                                PT           10.8 sec                ( INR 1.0 )

                                aPTT      23.6 sec                ( 24-36 )

                                Plt.          255,000/mm3        ( 150,000-300,000 )

 

Questions:

 

1.        What signs and symptoms demonstrated by D.B. are consistent with DVT?

  1. Right calf swelling
  2. Right calf pain and discoloration
  3. Chest pain
  4. Both a and b only
  5. All of the above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.        What risk factors does D.B. exhibit which are associated with DVT?

 

1.        Obesity

2.        Prolonged sitting in a car

3.        Myocardial infarction

4.        Coronary artery disease

5.        Being a male

a.    1&2 only

b.       2, 4, and 5

c.        2, 3, and 5

d.       1, 3, and 4

e.        1, 2,3,and 4

 

3.        What are the factors that you base your DVT diagnosis on?

  1. The signs and symptoms of DVT
  2. The presence of risk factors associated with DVT
  3. Doppler ultrasonography or duplex scanning
  4. Both b and c only
  5. All of the above together are correct

 

4.        A loading dose of heparin is required in the acute treatment of DVT or PE in order to:

 

1.        Minimize heparin-induced thrombocytopenia

2.        Achieve a therapeutic level of heparin rapidly

3.        Overcome the relative resistance to anticoagulation during active thromboembolism

4.        Reach a therapeutic INR of 2-3  rapidly

5.        Prevent recurrences of thromboembolism

 

a.        1, 3, and 5

b.       2, 3, and 4

c.        2 & 3 only

d.       1, 4, and 5

e.        1, 2, 3, 4, and5

 

5.  Which of the following is NOT a major monitoring parameter for heparin therapy?

a.        aPTT

b.       Hematocrit and platelet count

c.        PT

d.       Signs of bleeding

e.        Signs & symptoms of thrombus extension and PE

 

6.  For how long should heparin be continued in the management of D.B.?

a.        2 to 3 days

b.       4 to 5 days

c.        7 to 10 days

d.       10 to 14 days

e.        2 to 3 weeks

 

 

7.  When should warafarin be initiated?

a.        On the first day of hospitalization

b.       On the third day of hospitalization

c.        On the fifth day of hospitalization

d.       On the seventh day of hospitalization

e.        On the tenth day of hospitalization

          

 

   

 

  Case #3:

B.N., a 56 y.o. male, has just undergone cardiac catheterization which showed 2-vessel CAD. He refuses to take nitrate because they cause severe headaches. His physician begins anti-anginal therapy with nifedipine 10 mg p.o. TID.

 

Questions:

 

1.        Why is nifedipine monotherapy not appropriate in this case?

a.        It can cause a myocardial depressant effect

b.       It has a high profile of drug -drug interaction

c.        It can cause reflex tachycardia which may worsen the angina above

d.       All of the above are correct

e.        None of the above is correct

 

2.        How can the physician modify the nifedipine therapy?

a.        By switching to a beta blocker

b.       By adding a beta blocker to nifedipine

c.        By switching to verapamil or diltiazem

d.       By adding verapamil or diltiazem to nifedipine

e.        Any one of the above may be correct   

 

 

 

 

 

MCQ:     CHOOSE ONE BEST ANSWER ONLY

 

1.        Important pathophysiologic factors that impair blood flow in angina include:

  1. Atherosclerotic plaques
  2. Increased coronary vasomotor tone
  3. Platelet aggregation and thrombi formation
  4. Both a and c only
  5. Any one or more of the above

 

2.        Drug therapy regimens for angina patients must be individualized and include

a. Nitrates

  1. Beta blockers
  2. Calcium channel blockers
  3. Aspirin
  4. Any one or more of the above alone or in various combinations

 

3.         Choose the INCORRECT statement regarding variant angina:

  1. It causes an elevation in the HR-BP product with pain.
  2. It can occur with or without atherosclerosis.
  3. Chest pain generally occurs in younger patients at rest.
  4. It shows an ST-segment elevation on the ECG.
  5. Smoking and alcohol are important contributing factors.

 

 

 

 

 

 

 

 

 

 

 

4.        Beta blockers are likely to worsen :

1.        Variant angina

2.        Chronic stable angina

3.        Silent myocardial ischemia

4.        Unstable angina

5.        Myocardial infarction

 

a.        1, 3, and 5

b.       1 only

c.        2&4 only

d.       3&5 only

e.        3, 4, and5                                

 

5. Which of the following is the least specific to AMI and is rarely used in its diagnosis?

a.        AST

b.       CK-MB

c.        LDH-1

d.       Troponin-1

e.        All of the above are specific for AMI diagnosis

 

6. Choose the INCORRECT statement regarding the heparin use in DVT prevention:

a.        A fixed low-dose of 5000 U SQ every 12 hours is effective in DVT prevention.

b.       Low dose heparin is effective in the prevention of DVT in hip surgery patients.

c.        aPTT monitoring is unnecessary with low- dose preventive heparin therapy.

d.       The first dose is administered several hours preoperatively, and dosing should continue until

the patient is fully ambulatory.

      e.    Enoxaparin is a low molecular weight heparin that is approved for the prvention of DVT in hip

             replacement surgery.

               

7. Which of the following conditions may require chronic therapy with warfarin?

a.        Recurrent thromboembolism

b.       Antithrombin III deficiency

c.        Protein C or protein S deficiency

d.       Malignancy

e.        All of the above

 

8. Which of the following adverse effects is NOT associated with heparin therapy?

a.        Skin necrosis

b.       Hemorrhage

c.        Osteoporosis

d.       Thrombocytopenia

e.        Hyperkalemia

 

9. Which of the following indicates successful reperfusion by thrombolytics?

a.        The sudden relief of chest pain

b.       Resolution of  ST segment elevation on the ECG

c.        The onset of reperfusion bradycardia 

d.       Both a and b are correct

e.        All of the above are correct

 

 

 

 

10. Choose the INCORRECT statement regarding Type I heparin-induced thrombocytopenia:

a.        It is an immune- mediated reaction.

b.       It is reversible.

c.        Patients remain asymptomatic with this adverse reaction.

d.       Heparin therapy should be continued even with this reaction.

e.        Platelet count remains above 100,000/mm3 .

 

11. All of the following are factors that can influence the risk of bleeding during heparinization,

      EXCEPT:

a.        Duration of therapy.

b.       Advanced age.

c.        Serious comorbid illness.

d.       Concomitant aspirin therapy.

e.        The intensity of anticoagulation with heparin.

 

12. Choose the INCORRECT statement regarding the rapid reversal of warfarin therapy in the major,

      life-threatening bleeding:

a.        Withholding warfarin therapy.

b.       Fresh frozen plasma should be given.

c.        Large doses of vitamin K should be given.

d.       Small doses of vitamin K should be sufficient.

e.        Clotting factor concentrates could be given.

 

13. Choose the CORRECT statement about the medical conditions that can influence anticoagulation

      status:

a.        Diarrhea can cause decreases in PT due to increased intestinal absorption of vitamin K.

b.       Febrile illness causes increased hypoprothrombinemic response due to enhanced catabolism

of clotting factors.

c.        CHF can cause a decrease in PT by increasing the warfarin metabolism.

d.       Liver disease can cause a decrease in PT by increasing the warfarin metabolism.

e.        None of the above is correct.

 

14. Once a stable warfarin dose has been reached, patient assessment and PT monitoring should

 be done every:

       a.   4 to 6 hours

       b.   24 hours

       c.   4 to 6 days

       d.   4 to 6 weeks

       e.   4 to 6 months

 

15. Which of the following induces the warfarin metabolism :

a.        Rifampin

b.       Chloramphenicol

c.        Allopurinol

d.       Erythromycin

e.        Ciprofoxacin

 

 

 

III. TRUE or FALSE:

 

T             F              1. Protamine has been utilized to neutralize warfarin activity in case of an overdose.

 

T             F              2. Lung scanning and lung angiogram are used to confirm the diagnosis of pulmonary

                                 embolism.

 

T             F              3. aPTT should be evaluated 2 hours after the loading dose of heparin and again 2 hours

                                 after any future changes in infusion rate; and once dosing is stable, aPTT should be

                                    evaluated once a week.

 

T             F              4. Warfarin does NOT cross the placental barrier and therefore is preferred over heparin in 

                                 pregnancy. 

                                

T             F              5. In patients with DVT or PE, low intensity warfarin therapy should be aimed at

                                 prolonging the PT to an INR of 2.5 to 3.5.

 

T             F              6. It is preferred to use streptokinase over tPA for AMI patients over the age of 75 years.

 

T             F              7. The average warfarin dose to reach an INR of 2.0 to 3.0 is 40 to 50 mg in the general

                                 population.

 

T             F              8. DVT preceded PE in 80% or more of patients.

                                 

T             F              9. After changing the warfarin dose, it takes several hours for warfarin to reach a new

                                steady state due to the short elimination half-lives of both warfarin and vitamin K-      

                                dependent clotting factors.

 

T             F              10. The reduction in mortality due to thrombolytics reached statistical significance only if 

                                   given within 24 hours from the onset of chest pain. 

                                             

T             F              11. The definitive diagnosis of coronary heart disease can be made only by myocardial

                                       imaging.

 

T             F              12. Nitrates produce vasodilation by inhibiting cGMP and stimulating thromboxane

                                   synthetase.

 

T             F              13. Tolerance to nitrate therapy can be minimized by maintaining a nitrate- free interval of

                                   about 4 to 6 hours or using the maximum therapeutic dose of nitrate.

 

T             F              14. Ticlopidine is preferred over clopidogrel as an alternative to aspirin due to its greater

                                   antiplatelet effect and fewer adverse effects.

 

T             F              15. Aspirin reduces the incidence of MI and death from cardiac causes by 50% to 70%

                                      in patients with unstable angina.

 

 

 

 

 

 

 

 

                                                                                                                GOOD LUCK……

 

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