2014 Clinical Pharmacist Assessment

A 64-year-old man presents to the emergency department 90 minutes after acute-onset altered mental status, slurred speech, and right-sided weakness. His medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation. The patient’s family states that he was taking lisinopril, metformin, and warfarin as an outpatient. Physical examination reveals a blood pressure of 170/95 mm Hg and heart rate of 89 beats/minute. Ongoing aphasia and right-sided weakness are confirmed, and his NIH (National Institutes of Health) stroke scale score is 24. An emergency non-contrast head computed tomography is performed within 1 hour of presentation, and the results are consistent with an acute ischemic stroke. Results of urgent laboratory tests show an international normalized ratio (INR) of 1.4.

Which is the most appropriate therapy for this patient at this time?

A 57-year-old man with a history of end-stage renal disease and epilepsy is currently taking phenytoin 300 mg daily for seizure control. His most recent total phenytoin level was 12.4 mg/L (49.1 µmoI/L), and his albumin level is 2.7 g/dL (27 g/L).

On the basis of this patient's current serum phenytoin concentration, which adjustment should be made to his regimen?

A 66-year-old female is admitted to the ICU, is intubated and sedated on a propofol infusion at 60 mcg/kg/min. She is being treated empirically for health care–associated pneumonia. Her current medications include: morphine, vancomycin, propofol, amiodarone, donepezil, citalopram, amlodipine, lisinopril, pantoprazole, piperacillin/tazobactam, hydrochlorothiazide, memantine, and insulin glargine. Her RASS (Richmond Agitation Sedation Scale) score is between +1 and +3 today (restless to very agitated), though the nurse states morphine calms her on the ventilator.


Which of the following would improve her comfort on the ventilator?

A patient was started on a selegiline patch 3 days ago for major depression. The family states that it is not working. Which of the following is the MOST appropriate action to take at this time?

A 55-year-old male presents with uncontrolled hypertension and is currently receiving hydrochlorothiazide 25 mg daily. His medical history is significant for gastroesophageal reflux disease and he was recently diagnosed with gout.

Which antihypertensive agent may be added and could reduce his uric acid level?

A 17-year-old woman is 27 weeks pregnant with her first child. She is just now seeking medical care. the patient does not remember whether she has ever had a tetanus vaccination but does remember getting some "shots" at a primary care checkup about 3–4 years ago. No medical records are available.

Regarding the patient's tetanus status, which is the most appropriate action to take now?

A patient presents to the emergency department with a dermatologic reaction after initiating a new medication that has caused a full-thickness necrosis of the skin, with the epidermis separating from the dermis. He is given a diagnosis of Stevens-Johnson syndrome and is transported to the burn unit.

Which is the primary therapy for Stevens-Johnson syndrome?

A 76-year-old woman arrives in the emergency department after being found unconcious. Her medical history includes the following: hypertension, systolic heart failure, and atrial fibrillation. Home medications include warfarin, lisinopril, and carvedilol. Her laboratory values on admission include hemoglobin 12 g/dL, hematocrit 36%, platelet count 96,000/mm3, and international normalized ratio (INR) 2.1. On arrival, her blood pressure is 200/120 mm Hg. An urgent head computed tomography reveals an acute intracerebral hemorrhage (ICH).

Which treatment is most appropriate for initial management of this patient’s ICH?

A 57-year-old white man with a medical history significant for hypertension (HTN) is brought to the emergency department (ED) by ambulance experiencing 4 hours of substernal chest pressure at rest. The patient states that during the past 2 weeks, he noticed fleeting twinges of chest pressure after exertion, but these episodes were relieved by rest. This morning, while walking his dog, he developed heavy chest pressure. Once home, he rested and took an antacid without relief of chest discomfort. He called 9-1-1. His current medications include metoprolol XL 50 mg orally daily for his HTN. His vital signs include blood pressure 120/80 mm Hg and heart rate 55 beats/minute. His fecal occult blood test is negative. He has no signs of acute heart failure. Electrocardiography performed 5 minutes after presentation to the ED reveals normal sinus rhythm with 3 mm of ST-segment elevation in the inferior leads. Pertinent laboratory values include serum creatinine 1 mg/dL, troponin I 5.2 ng/mL (normal, less than 0.5 ng/mL), and creatine kinase, myocardial bound 8.5 ng/mL (normal, less than 3 ng/mL). The hospital does not have a cardiac catheterization laboratory, and the nearest transferring facility is 2.5 hours away.

Which option is a current American College of Cardiology/American Heart Association (ACC/AHA) quality performance measure for ST-elevation myocardial infarction (STEMI) that should be assessed in the management of this patient?

A 22-year-old white woman who complains of feeling tired, mentally sluggish, and has gained 10 pounds over the past few months. Physical exam reveals delayed deep tendon reflexes, and a firm, enlarged thyroid gland. Laboratory values at this clinic visit are as follows: FT4, 0.6 ng/dL; TSH 20 mIU/L; +thyroid antibodies: The patient's weight is 70 kg. She is diagnosed with having Hashimoto’s thyroiditis.

Which one of the following would be the preferred therapy for this patient?

When completing an inservice about alcohol withdrawal treatment for new medical residents, you provide information about the best benzodiazepine to use depending on the patient characteristics.

For the patient with a significant history of seizures during alcohol withdrawal and delirium tremens, which medication would be the best treatment option to initiate if the patient is in alcohol detoxification and needs treatment for withdrawal seizures?

A 66-year-old white man presents to the clinic with a 1- to 2-year history of chronic obstructive pulmonary disease (COPD). He has a 35-year history of smoking and is experiencing increased shortness of breath and difficulty exercising. His COPD Assessment Test (CAT) score today is 9, and his most recent forced expiratory volume in 1 second (FEV1) is 45%. He had 1 exacerbation 9 months ago. His medication regimen consists of inhaled ipratropium 2 puffs every 6 hours as needed.

Which of the following is the most appropriate drug therapy regimen for this patient?

A 39 year old female with infertility is suffering from depression and has failed attempts at counseling. Which antidepressant is associated with malformations when used during pregnancy?

You are rounding on a 28-year-old man with a history of hypertension and type 1 diabetes mellitus who was admitted through the emergency department to your unit for the treatment of angioedema. He has no known previous allergies of any kind. He reports no contact with new foods or substances. His only current medications are insulin glargine 30 units subcutaneously at bedtime, Insulin aspart [rDNA origin] injection (NovoLog) 10 units subcutaneously with each meal, and lisinopril 10 mg daily. All therapies have been stable for 3 years. The attending physician knows that angiotensin-converting enzyme inhibitors (ACEIs) are often associated with angioedema and wants to know your opinion on whether ACEIs could be the cause.

Which of the following is the most appropriate response?

Patients taking protease inhibitors should avoid drinking grapefruit juice because it:

An 87-year-old woman who is a nursing home resident, was recently admitted to the hospital for treatment of community-acquired pneumonia. She has a history of type 2 diabetes mellitus (DM), hypertension (HTN), and stage 5 chronic kidney disease (on hemodialysis). While having her blood pressure checked, the patient suddenly becomes dizzy and loses consciousness. The monitor shows that the patient is in asystole. Cardiopulmonary resuscitation (CPR) is immediately initiated and will be continued for as long as this arrhythmia persists.

Which would be the most appropriate treatment to initiate in this patient at this time?

A prospective trial was conducted to compare the effects of using compression-only cardiopulmonary resuscitation (CPR) with standard CPR on survival rates in patients experiencing out-of-hospital cardiac arrest. A total of 1276 patients were randomized to undergo either compression-only CPR or standard CPR (15 compressions alternating with 2 ventilations). The 30-day survival rates were 8.7% in the patients receiving compression-only CPR and 7% in the group receiving standard CPR (absolute difference, 1.7 percentage points; 95% confidence interval [CI] –1.2 to 4.6).

Which statement is most appropriate with respect to the results of this trial?

Which medication form would be the BEST option for a drug that is prone to first-pass metabolism?

A 33-year old man who weighs 105kg and is 6’0” tall presents with diffuse abdominal pain for several days which is increasing in intensity. He had to return early from a week-long “camping trip with the guys” where he reported drinking 12-24 beers daily. His present vital signs include BP 159/89, T 38.1, HR 93, RR 22. Laboratory analysis include SCr 1.8mg/dl, WBC 14,000/L, Amylase 400 IU/L, Lipase 250 IU/L, Blood glucose 220 mg/dl.

What therapeutic intervention is best?

A 71-year-old Caucasian woman visited her physician and adjusted several of her medications. Three days later she presents with a headache, nausea and confusion. She has type 2 diabetes, dyslipidemia, hypertension and depression. She is taking metoprolol 25 mg twice daily, chlorthalidone 25 mg daily, chlorpropamide 500 mg daily, simvastatin 40 mg daily, and sertraline 50 mg daily. Laboratory tests were performed and the patient was diagnosed to have syndrome of inappropriate antidiuretic hormone (SIADH).

Which one of the following treatment regimens is most likely to be associated with this patient’s syndrome of inappropriate antidiuretic hormone (SIADH)?

A 61-year-old man is admitted to the intensive care unit. His medical history is significant for type 2 diabetes mellitus, heart failure, coronary artery disease, and chronic obstructive pulmonary disease. The patient presents in the emergency department (ED) with a blood pressure of 68/40 mm Hg, heart rate 118 beats/minute, temperature 38.3ºC, and white blood cell count 14.6 x 103 cells/mm3. Blood, urine, and sputum cultures are obtained in the ED. Fluid resuscitation is initiated without an adequate response. The patient is emergently intubated and subsequently transferred to the medical intensive care unit for suspected septic shock requiring vasopressor support.

Which option would be the optimal choice in selecting a first-line vasoactive agent for this patient?

A 10-year-old girl with ALL (acute lymphoblastic leukemia) received cytarabine 3 days ago as her chemotherapy regimen. She presents to the hematology/oncology clinic with a fever and an absolute neutrophil count (ANC) of 79 cells/mm3.

Which is the most appropriate empiric antimicrobial therapy for this patient?

Researchers are evaluating the potential beneficial effects of an investigational therapy for the treatment of Crohn’s disease. Investigators are asking study participants to record their bowel movements into a personal diary, listing the number and consistency of bowel movements and any associated pain throughout the day. Researchers will categorize each patient’s bowel movements into one of the following categories: 1-5 bowel movements per day; 6-10 bowel movements per day, greater or equal to 11 bowel movements per day.

Which of the following data types most appropriately represents the categories of bowel movements?

In a recently published clinical trial comparing rivaroxaban versus placebo in patients with recent acute coronary syndrome (ACS), the authors reported that the risk of myocardial infarction (MI) in the rivaroxaban group was 3.76% (384 MI’s out of 10,225 patients) in the rivaroxaban-treated patients and 4.47% (229 MI’s out of 5,125 patients) in the placebo-treated patients. What is the number of patients with recent ACS that would need to be treated (NNT) to reduce the risk of one MI?

To increase the power of a study, the researchers should:

A patient presents with a prescription for Xalatan. Xalatan is probably used to treat with of the following disease states?

Leucovorin should be given as rescue therapy to patients receiving __________, but will increase both the toxicity and the chemotherapeutic activity of ___________.

A 55-year-old man has a single visible tophus of the first metatarsophalangeal joint. He has a 7-year history of chronic gout, and he has had two or three attacks during the past year requiring medical attention. His uric acid concentration is 8.5 mg/dL. His medical history is significant for stage 2 chronic kidney disease. The patient started taking allopurinol 1 year ago and currently takes 100 mg orally daily.

In addition to acute anti-inflammatory treatment, which is best for managing this patient’s current situation?

A 60-year-old woman was admitted 5 days ago for treatment of a lower extremity thromboembolism. A heparin drip was initiated on admission and has remained therapeutic for the past 3 days. Today, the patient has acute shortness of breath, and her oxygenation saturation has dropped to 89%. A spiral computed tomography reveals the presence of a pulmonary embolism. Laboratory results are as follows: sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 105 mEq/L, CO2 27 mEq/L, blood urea nitrogen 45 mg/dL, serum creatinine 2.3 mg/dL, white blood cell count 7.2 x 103 cells/mm3, hemoglobin 9.2 g/dL, hematocrit 28%, and platelet count 62,000/mm3 (on admittance, 248,000/mm3).

Which constitutes the best initial management of this patient?

A patient presents to the pharmacy with prescriptions for Biaxin, Amoxil, and Nexium. The patient is probably being treated for which of the following infections?

A 87-year-old man (5'9", 190 lb) with a medical history significant for type 2 diabetes mellitus (DM) and hypertension (HTN), presents to the emergency department (ED) with substernal chest pressure and 2-mm ST-segment depression in leads V2–V4. His vital signs include blood pressure (BP) 168/92 mm Hg and heart rate (HR) 100 beats/minute. His current medications include metformin 500 mg orally twice daily and lisinopril 10 mg orally daily. Pertinent laboratory results include SCr 1.8 mg/dL, hemoglobin 12.8 g/dL, hematocrit 38%, and troponin I (TnI) 4.7 ng/mL (normal, less than 0.5 ng/mL).

Which medication regimen would be best to initiate for this patient upon admission to the hospital, regardless of whether he will be going for percutaneous coronary intervention (PCI)?

A 47-year-old male is admitted to the general medicine floor of your hospital with a 3-day history of a productive cough with greenish yellow sputum and shortness of breath. He has a white blood cell count of 13 K/mm3 (baseline 5), serum creatinine of 1.2 mg/dL (baseline 1–1.3 mg/dL), and Tmax of 38.3ºC, and his admission chest X-ray shows a left lower lobe pneumonia. He has no known drug allergies but a medical history significant for a living related kidney transplant 10 years ago for end-stage renal disease caused by polycystic kidney disease. In his history from a transplant clinic note 5 months ago, you see that he has had no recent treated rejections; is maintained on tacrolimus 1 mg orally twice daily with goal serum troughs between 2 and 4 ng/mL and prednisone 5 mg daily; and is seen yearly by the transplant nephrologists but that he has no other history of hospital or emergency department contact. The medical resident calls you for help with antibiotic initiation.

Which of the following is the best choice for empiric antibiotic therapy?

A 42-year-old man, has a 10 year history of depression that has received adequate trials of citalopram, sertraline, mirtazapine, venlafaxine and bupropion without signficant relief of the depression. He is currently treated with fluoxetine 40 mg daily. He comes in to your pharmacy to pick up an antibiotic prescription for his 8-year-old son. During your discussion with the patient concerning his son's medication, the depressed male, he mentions that he recently started hearing his dead father’s voice which is occurring throughout the day and has been occurring frequently for the past 2 weeks. He has felt so depressed that he believes life might be better if he "just wasn’t around anymore." He also states “I might have to get rid of my son so that the evilness of the world does not harm him.” You strongly encourage the patient to immediately call the clinician who is treating his depression and discuss the new symptom and his current concerns.

Which of the following would be the best choice to treat this patient’s symptoms?

A patient has an estimated creatinine clearance of 24ml/min. Wihich of the following medications does NOT require a dosage reduction?

A 66-year-old man presents to the hospital with end-stage chronic obstructive pulmonary disease (COPD) characterized as chronic bronchitis and chronic respiratory failure.

Which has been conclusively shown to increase survival in this type of patient?

A 60-kg patient is to receive a constant IV infusion of dobutamine at a rate of 5 mcg/kg/min. The available solution has a concentration of 0.5mg/ml. For what rate should the infusion pump be set?

Your Pharmacy and Therapeutics (P&T) Committee is performing a drug class review of the α1-adrenergic antagonists approved for benign prostatic hypertrophy (BPH) for a single-drug formulary selection. A recommendation is made to establish terazosin as a preferred agent.

Which of the following best represents your thoughts on the P&T's recommendation?

A 76-year-old man, has a history of paroxysmal atrial fibrillation, which is currently rate controlled; hypertension; rosacea; stage 4 chronic kidney disease; and benign prostatic hypertrophy. His medications include aspirin 81 mg/day, diltiazem extended release 240 mg/day, and doxycycline 40 mg/day.

Which represents the optimal anticoagulation strategy for this patient?

Researchers conducted a 12-week, randomized, placebo-controlled trial of a new blood pressure–lowering medication at two different doses. The primary end point of the trial was the change in systolic blood pressure from baseline between the three groups.

Which statistical test would be most appropriate for comparing this end point between the three groups?

A pharmacist is conducting a medication use evaluation of dexmedetomidine in the surgical intensive care unit for quality improvement purposes.

Which of the following is a true statement regarding the use of protected health information for quality improvement purposes according to HIPAA (Health Insurance Portability and Accountability Act of 1996)?

Poor metabolizers of CYP2D6 are most likely to receive therapeutic benefit from which of the following opioids?

A 65-year-old woman with a history of long-standing diabetes is brought to your hospital with left-sided paralysis and sudden, temporary loss of consciousness. Her baseline serum creatinine is 1.8 mg/dL. She is scheduled to receive an intravenous contrast agent for a CT (computed tomography) scan to rule out a possible stroke.

Which medication would be best to give this patient to decrease her likelihood of developing acute renal failure?

A 37-year-old woman is admitted to the trauma intensive care unit for a fracture-dislocation of the thoracic spine secondary to a motor vehicle collision. She is immediately taken to the operating room for stabilization of her spine. She has no significant medical history and no known drug allergies.

Which option is most appropriate for perioperative antibiotic administration in this patient?

Which of the following atypical antipsychotics requires rigorous monitoring of WBC and ANC?

Information on IV medication compatibility can be found in which of the following references?
I. Facts and Comparisons
II. Physician’s Desk Reference
III. Trissel’s Handbook on Injectable Drugs

A 35-year-old female presents to an asthma clinic appointment. She is currently on an albuterol metered dose inhaler (MDI) 2 puffs every 4 hours as needed and a medium dose of inhaled fluticasone by a MDI. She tells you that she has had to use albuterol about four or five times a week for shortness of breath for the past 2–3 weeks. She also tells you that this usually relieves the shortness of breath, making her able to continue with her daily activities. Her peak expiratory flow (PEF) record shows that her “baseline” has been established at 350 L/minute, and the recordings listed (morning) are generally about 75% of baseline. When she reassesses her PEF after the albuterol dose, it is about 97% of her baseline.

Given this scenario, which would be the best therapeutic option at this time?

A 33-year-old first-trimester pregnant female (5’7’’, 60 kg) is referred to your high-risk obstetrics clinic for an acute deep venous thrombosis (DVT). This is her first thromboembolic event; she has no family history of thrombotic events.

Which would be the most appropriate therapy to initiate?

A 19-year old female patient, returns to your clinic for Type 1 diabetes management. The family has limited health care and no prescription coverage at this time. The patient denies any episodes of hypoglycemia. At the last visit, you prescribed NPH 18 units and Humulin R 8 units before breakfast and NPH 8 units and Humulin R 6 units before evening meal. Her SMBG readings are as follows for the past few days:
Breakfast 95 97 101 89
Noon 201 172 210 198
Dinner 79 98 82 85
Bedtime 128 108 122 120
Which one of the following would be the best insulin adjustment at this time for this patient.?

Which of the following is/are TRUE of tricyclic antidepressants:
I. They may exhibit anticholinergic side effects.
II. They are very dangerous and often fatal in overdosage.
III. They have a significant drug-food interaction with aged cheese.

A placebo-controlled clinical trial is conducted comparing an investigational anti-platelet agent for preventing stroke. The hemoglobin levels are monitored for adverse effect of the investigational agent. The mean hemoglobin value for the investigational agent-treated group is found to be 13.7 gm/dL with a standard deviation of 1.9 gm/dL. Based on these values, and assuming a normal distribution of the groups’ hemoglobin values, which of the following minimum (below the mean) and maximum values (above the mean) would most completely incorporate over 99% of all the values of the investigational-agent study sample?