2012 Answers - ACCP

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1

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201
2

ACCP Clinical Pharmacy Challenge

Local Competition

Exam Key


The following examination will consist of three (3) segments:


Trivia/Lightning

Participants will have the opportunity to answer up to 15 true
-
false or multiple
-
choice questions.
Each item answered correctly will be worth 75 points. The subject content for
questions in this
segment will be selected from

the following categories:



Pharm
acology
(including, but not limited to, mechanism of action,
adverse

effect
profiles, drug interactions, dosing, approved indications, and monitoring parameters)



Pharmacokinetics/Pharmacodynamics

and/or
Pharmacogenomics



Clinical Pharmacy History



Biostatist
ics



Health Outcomes

Clinical Case

Participants will be presented with a clinical case vignette (
50
0 words or less) and a series of five
one
-
best
-
answer questions based on the information in the case text and/or supporting laboratory,
physical examination, and/or medical history information contained therein. Point values for each
question in this categ
ory will be assigned on the basis of difficulty (one 100
-
point item, two 200
-
point items, and
two

300
-
point items).


Jeopardy Style

Participants will have an opportunity to answer questions of varying point values

(100, 200, or
300 points) in five predeter
mined categories and may answer as many as possible within the
allotted time. All items in this segment will be multiple choice.

Items in the segment will be
selected from five (5) of the following categories:

Anticoagulation



Asthma/COPD



Biostatistics

Cardiovascular Disorders

Clinical Trial Design


Critical Care

Dermatology



Drug Information


Emergency Medicine

Endocrinology



Geriatrics



GI/Liver/Nutrition

Hematology/Oncology


Immunology/Transplantation

Infectious Diseases

Nephrology



Pain and
Palliative Care

Pediatrics

Psychiatry/CNS Disorders

Vaccinations



Women’s Healt
h

CNS = central nervous system; COPD = chronic obstructive pulmonary disease; GI =
gastrointestinal.

Follow the instructions given by your local faculty member or proctor for
each segment of the examination.



Do NOT open the examination booklet until instructed to do so.


Page
2

of
22



201
2

ACCP Clinical Pharmacy Challenge

Local Competition Examination




Trivia/Lightning Section

This section consists of 15 items. Each corr
ect answer is worth 75 points.
Please circle your
answer for each question.


Question 1


Which diuretic would cause increased excretion of sodium, potassium, magnesium, and calcium
and
would
promote the reabsorption of uric acid?


1.

Bumetanide

2.

Hydrochlorothiazide

(HCTZ)

3.

Spironolactone

4.

Triamterene



Answer:

1.

Bumetanide


Rationale: T
he correct answer is bumetanide.

HCTZ decreases the excretion of calcium.

Spironolactone and triamterene are potassium sparing.


Citation: Drugs for hypertension.

Treat
G
uidel Med Lett 2009;7:1

10.


Question 2


Which antimicrobial has
nearly

equivalent ora
l and parenteral bioavailability?


1.

Ampicillin

2.

Cefuroxime

3.

Linezolid

4.

Vancomycin


Answer: 3. Linezolid


Rationale:

Linezolid has a documented oral bioavailability of
nearly

100%.


Citation:

Linezolid
[p
rescribing
i
nformation
]
.
New York:
Pharmacia and Upjohn
,
2012.



Question 3



Which drug would require a dosing adjustment for a documented creatinine clearance
of less than
30

m
L
/min
ute
?


1.

Ceftriaxone

2.

Metronidazole

3.

Pantoprazole

Team/Individual ID

______________________

Total Score ________


For Administrative

Use Only


Page
3

of
22

4.

Ranitidine


Answer: 4. Ranitidine


Rationale: Dosage adjustments are only necessary f
or ranitidine with a creatinine clearance of 35

mL/min
ute
.

The rest do not need adjustments.


Citation:
Ranitidine
[p
rescribing
i
nformation
]
.
Princeton, NJ:
Sandoz, 2011.



Question 4

Which agent is the best treatment option
for a

patient
taking

warfarin with an
international
normalized ratio
of
11.0 and

no signs of bleeding?


1.

Cyanocobalamin

2.

Phytonadione

3.

Protamine

4.

Tocopherol


Answer:

2. Phytonadione


Rationale:

The correct answer is phytonadione (
v
itamin K). Warfarin acts as an anticoagulant
thro
ugh inhibition of the
v
itamin K

dependent clotting factions II, VII, IX
,

and X.

Administration
of
p
hytonadione is indicated in warfarin overdose.

Protamine is used to reverse heparin overdose.

Tocopherol is a form of
v
itamin E and has no role in reversing
warfarin overdose.
Cyanocobalamin is
v
itamin B
12
and is commonly used to treat pernicious anemia.


Citation
s
:

Holbrook A, Shulman S, Witt DM, et al
.

Evidence
-
b
ased
m
anagement of

a
nticoagulant
t
herapy:
a
ntithrombotic: American College of Chest Physicians
Evidence
-
Based Clinical Practice
Guidelines (9th Edition).

Chest
2012;141
:
e152S

e184S
.


Phytonadione
[p
rescribing
i
nformation
]
.
Lake Forest, IL:
Hospira, 2004.



Question 5


Which drug class is considered the pharmacologic first
-
line treatment of choice for
p
osttraumatic
s
tress
d
isorder (PTSD)?


1.

Anticonvulsants

2.

Atypical
a
ntipsychotics

3.

Benzodiazepines

4.

Selective
s
erotonin
r
euptake
I
nhibitors

(SSRIs)


Answer:

4. SSRIs


Rationale:

SSRIs are recognized by several resources as the first
-
line treatments (
together

with
psychotherapy)
.


Citation:
Jeffreys M. Clinician’s Guide to Medications for PTSD; Department of Veterans
Affairs. Available at

http://www.ptsd.va.gov/professional/pages/
clinicians
-
guide
-
to
-
medications
-
for
-
ptsd.asp
. Accessed
February
24
, 20
12.




Page
4

of
22

Question 6

A 5
-
year
-
old
boy

is
given a
diagnos
is of

mild croup.

Which medication would be most
appropriate to recommend?


1.

Oral d
examethasone

2.

Nebulized albuterol

3.

Nebulized racemic
epinephrine

4.

Nebulized 3% saline


Answer: 1.
Oral d
exameth
as
one


Rationale:

The correct answer is 1, oral dexamethasone (it is used to decrease pharyngeal
inflammation).

Racemic epinephrine is first line but
,

in severe episodes, not mild.

Albuterol is
beta
-
specific and w
ill not

help with edema in the upper airway.

This is

also

true for 3% saline,
which is used in bronchiolitis.


Citation:

Bjornson C, Johnson DW.

Croup.

Lancet 2008;371:329

39.



Question 7


An elderly nursing home resident develops diarrhea that is caused by
Clostridium difficile
. Which
agent is
contraindicated
?



1.

Cholestyramine

2.

Diphenoxylate/atropine

3.

Kaolin
-
pectin

4.

Psyllium


Answer:

2. Diphenoxylate/atropine


Rationale:

The correct answer is
diphenoxylate/atropine.

With toxin
-
mediated diarrhea, use of
agents to slow motility would be contraindicated.
In a
ddition, this agent should be avoided in
elderly patients
,

if possible
,

because of

the
increased risk of anticholinergic
adverse
effects in t
his
population.
Kaolin
-
pectin, cholestyramine, and psyllium are all acceptable options for symptom
control for this type of diarrhea.


Citation:

Oral Lomotil, Drug
-
Disease Contraindications
.

Available
at
http://www.medscape.com/druginfo/dosage?drugid=6876&
drugname=Lomotil+Oral&monotype
=default. A
c
cessed
March 28
,
201
2
.



Question 8


A new osteoporosis drug is being tested to prevent fractures. If 25 of 100 patients in the control
group experience a fracture compared
with

5 of 100 patients in the treatment group, what is the
number needed to treat (NNT)for the new drug?


1.

0.2

2.

0.8

3.

5

4.

20



Page
5

of
22

Answer:

3. 5 patients


Rationale:

The correct answer is 5. The NNT is calculated as 1/
absolute risk reduction (
ARR
)
. In
this case, the ARR
is 0.2 (difference in event rates between drug and placebo = 0.25


0.05). The
relative risk (
RR
)

is 0.2 (event rate drug/event rate placebo = 0.05/0.25)
,

and the OR
(odds ratio)
is 0.2 (odds of event on drug/odds of event on placebo = [5/25]/[95/75]).


Ci
tation:

Riegelman RK, Hirsch RP. Studying a Study and Testing a Test
: How to Read the
Health Science Literature
, 3rd ed.
Philadelphia: Lippincott
-
Raven, 1996:
33, 35, 52.



Question 9


Which sedative is most likely to cause transient adrenal insufficiency
when used for rapid
sequence intubation?


1.

Etomidate

2.

Ketamine

3.

Midazolam

4.

Propofol


Answer:

1. Etomidate


Rationale:

The correct answer is etomidate.

The other agents have
no

known effect on adrenal
function or cortisol production.


Citation:
Etomidate
[
prescribing information
]
.

Bedford, OH:
Bedford Laboratories, 2004.



Question 10


A 70
-
year
-
old ma
n

with
s
tage IV
r
enal
c
ell
c
arcinoma is beginning sorafenib therapy.

In

consultation with the patient,
which adverse effect
should
you
discuss the potential
development
of?



1.

Hypertension

2.

Neutropen
ia

3.

Peripheral
n
europathy

4.

Renal
f
ailu
r
e


Answer:

1.

Hypertension


Rationale:

Hypertension may develop within the first few weeks of therapy or slowly over the
continuance of therapy. The exact etiology of hypertension

is unclear, but it may be the result of
pressor stimulation responses, increasing extracellular volume, and/or decreasing vascular
compliance. Although trials continue to investigate the etiology of hypertension, effective
management is critical to minimi
zing

the

long
-
term sequelae of treatment
-
induced hypertension.


Citation: Shenhong W, Chen JJ, Kudelka A
,

et al.

Incidence and risk of hypertension with
sorafenib in patients with cancer: a systematic review and meta
-
analysis
.

Lancet Oncol
2008;9:117

23.



Question 11



Page
6

of
22

Which condition may result in a
decrease

in total phenytoin concentration in patients who
routinely take phenytoin?


1.

Addition of isoniazid therapy

2.

Chronic alcohol abuse

3.

Stage
II

c
hronic kidney disease

(CKD)

4.

Metabolic alkalosis secondary to
diuretic therapy


Answer: 2. Chronic alcohol abuse


Rationale:
Choice
2 is correct because

a decrease in

liver function

from chronic alcohol abuse

will
result in a
decrease
in
albumin production
,

thus decreasing
the
total phenytoin

protein bound

concentrat
ion
,

resulting in an

increas
e

in
phenytoin
-
free fraction
.


Choice
1
i
s
i
ncorrect because
the
addition of isoniazid

will decrease the metabolism of phenytoin,
potentially increasing the total phenytoin concentration
.

Choices
3 and 4 are
in
correct because
neither affects phenytoin binding to albumin.


Citation:

Johannessen SI, Johannessen Landmark C. Antiepileptic Drug Interactions


Principles
and Clinical Implications.
Curr Neuropharmacol 2010;8:254

67.



Question 12


A propofol infusion provides the foll
owing amount of nutrition per volume:


1.

10 kcal/mL

2.

9 kcal/mL

3.

4 kcal/mL

4.

1.1 kcal/mL


Answer:

4.
1.1 kcal/mL


Rationale:

An intravenous anaesthetic agent, propofol
,

provides 1.1 kcal

of
nutrition

per milliliter

to the patient
,

which is identical to a 10%
intravenous

lipid emulsion.


Citation:

Gottschlich
MM, ed
.
T
he A.S.P.E.N. Nutrition Support Core Curriculum:

A Case
-
Based
Approach
-
The Adult Patient
, 2nd ed
.
Silver Spring, MD: A.S.P.E.N., 2007:
63

4
.




Question 13


Which regimen is the MOST appropriate
first
-
line therapy for the management of postherpetic
neuralgia?


1.

Venlafaxine 25

mg orally
3

times
/
day

2.

Nortriptyline 25

mg orally at bedtime

3.

Diclofenac 1.3% topical patch applied twice daily

4.

Lidocaine 5% topical patch applied for 12 hours
/
day


Answer:
4.
L
idocaine 5% topical patch applied for 12 hours
/
day


Rationale:

T
he correct answer is lidocaine 5% patch applied for 12 hours
/
day. Lidocaine 5%
patches are
U.S. Food and Drug Administration (
FDA
)

approved for postherpetic neuralgia
,

and

Page
7

of
22

they
provide analges
ia within hours after application. Venlafaxine and nortriptyline must be
administered for at least 1

2 weeks before a therapeutic response is seen and therefore may not be
considered first
-
line therapy. Diclofenac and other
nonsteroidal anti
-
inflammatory d
rugs
(
NSAIDs
)

are not typically effective for the management of neuropathic pain.


Citation:

Dworkin RH
,

O

Connor AB. Pharmacologic management of neuropathic pain:
evidence
-
based recommendations. Pain 2007;132:237

51
.



Question 14


Which
cytochrome P450 (
CYP
)

isoenzyme is MOST likely responsible for the drug
-
drug
interaction between clopidogrel and proton pump inhibitors?


1.

CYP1A2

2.

CYP2C9

3.

CYP2C19

4.

CYP3A4


Answer:

3.

CYP2C19


Rationale: Competitive inhibition of CYP2C19 by
p
roton pump inhibitors decreases the
availability of the active metabolite of clopidogrel and thereby decreases its effect o
n

platelet
function.


Citation:

Riche DM, Call RJ.
PPIs and Plavix:
s
o,
w
hat
t
o
d
o
n
ow? Pharmacoth
er
a
p
y
2010;30:477e

478e
.

A
vailable at
http://www.pharmacotherapy.org/av
p/Pharm3012_Riche_AVP.pdf
.

Accessed
February
13
, 20
12
.



Question 15

This agent allows lower maintenance doses or complete discontinuation of calcineurin inhibitors.


1.

Alemtuzum
a
b

2.

Azathioprine

3.

S
irolimus

4.

Tacrolimus


Answer:

3. Sirolimus


Rationale:

The correct answer is
s
irolimus.

Sirolimus is a mammalian target of rapamycin
inhibitor
that

is used in conju
n
ction
with
or to replace calcineurin inhibitors in calcineurin
inhibitor


sparing


protocols.

Tacrolimus is a calcineurin inhibitor.

Alemtuzumab is a humanized
monoclonal antibody that has been approved for use in chronic lymphocytic leukemia and
that
has been used off
-
label for kidney transplant induction therapy.

Azathioprine is a purine
antimetabolite
that is
used in conju
n
ction with

calcineurin inhibitors.


Citation: Krensky AM,

Vincenti F, Bennett WM.

Immunosuppressants,
t
olerogens, and
i
mmunostimulants.

In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilman

s The
Pharmacological Basis

of Therapeutics
. New York: McGraw
-
Hill, 2006
:
chap 52.





Team/Individual ID

_____________________________


Trivia Segment Score ________


For Administrative Use Only


Page
8

of
22











































You have reached the end of the
Trivia/Lightning Segment of the exam.


Do NOT proceed to the next segment of
the exam until

instructed to do so.


Page
9

of
22

Clinical Case Segment

This segment consists of a case vignette and
five

items based on the vignette information.



Case Vignette
:

A 66
-
year
-
old man

presents to clinic for his routine visit. He
has

had

increasing fatigue
during

the
past month that interferes with his daily activities.

He has knee pain when he play
s

golf
,

for
which

he
self
-
medicates with over
-
the
-
counter naproxen.

He is
adherent

to

all of his prescribed
therapy, including dietary res
trictions.


Medical History
:

Hypertension

Di
abetes mellitus

C
hronic kidney disease

(CKD)

secondary to hypertension

G
out

Gastroesophageal
r
eflux
d
isease (GERD)

B
enign prostatic
hyperplasia

(BPH)

Osteoarthritis


Current Medications
:

Glipizide 10 mg
/
day

x 6 years

Insulin glargine 15 u
nits at bedtime
x 3 month
s

Enalapril 40 mg
/
day

x 6 years

Allopurinol 100 mg
/
day

x 6 years

Doxazosin 4 mg
at bedtime

x 2 year
s

Ranitidine 75 mg
/
day

x 5 years

Calcium carbonate 500 mg
3

times
/
day with meals

x 6 month
s

Naproxen

250

mg twice daily

x
2

weeks


Recent
L
ab
oratory Value
s:

Sodium

136 mEq/L (136 mmol/L)

Potassium

4.7 mEq/L (4.7 mmol/L)

C
hloride

101 mEq/L (101 mmol/L)

H
CO
3

23 mEq/L (23 mmol/L)

Blood urea nitrogen (
BUN
)

44 mg/dL

(15.7 mmol/L
)

Serum creatinine (
SCr
)

3.2
mg/dL (282 micromol
es
/L)

Estimated glomerular filtration rate

(
Modification of Diet in Renal Disease [
MDRD
]
) 20
mL/min
ute
/1.73m
2

Glucose, random

156 mg/dL (8.7 mmol/L)

H
emoglobin A
1c

7.8%

Phosphate 6.0 mg/dL (1.9 mmol/L)

Calcium 10.5 mg/dL (2.63 mmol/L)

Al
bumin 2.8 g/dL (28 g/L)

W
hite blood cell count

4500/micro
liter

(4.5 x 10
9
/L)

H
emoglobin

9.9 g/dL (99 g/L)

Hematocrit
29.6% (0.296)

Platelet

count

175,000/micro
liter

(175 x 10
9
/L
)

Ferritin 120 ng/mL (270 pmol/L)

Transferrin saturation 23%


Proceed to the
following page to answer Clinical Case Questions 1

5.




Page
10

of
22

Question 1



100 points


The patient has which complication of
CKD
?


1.

Anemia

2.

Hyperkalemia

3.

Metabolic acidosis

4.

Uremic platelet dysfunction

Answer:

1. Anemia


Rationale:

According to the
Kidney Disease
Quality Outcomes Initiative (
KDOQI
)

guidelines,
anemia is defined as a hemoglobin
value
of
less than 13.5 g/dL in males
.

Potassium and serum
bicarbonate
value
s are all within the normal range for their assays.

Uremic platelet dysfunction
cannot be determin
ed by the patient’s laboratory results.


Citation:

KDOQI Anemia Guidelines 2007
. Available at

http://www.kidney.org/professionals/KDOQI/guidelines_anemia/guide2.htm#cpr11
.

A
ccessed
March 28
, 20
1
2
.



Question 2


200 points


This patient is best described
as having which stage of CKD?


1.

Stage 1

2.

Stage 2

3.

Stage 3

4.

Stage 4


Answer: 4. Stage 4


Rationale:

The patient’s estimated
glomerular filtration rate (e
GFR
)

is 20

mL/min
ute,

which
categorizes him as
having
s
tage 4 CKD (GFR

15

29 m
L
/min
ute
)
.


Citation:

KDOQI
Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation,
Classification, and Stratification
. Part 4
.

Definition and Classification of Stages of Chronic
Kidney Disease. Available at
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_cla
ss_g2.htm
.

Accessed
February
13
, 20
12.


Question 3


200 points


A fasting lipid panel is to be obtained.

What is this
patient

s
low
-
density lipoprotein (cholesterol)
(
LDL
)

goal?


1.

Less than 100 mg/dL (2.59 mmol/L)

2.

Less than 130 mg/dL (3.36 mmol/L)

3.

Less
than 160 mg/dL (4.13 mmol/L)

4.

Less than 190 mg/dL (4.91 mmol/L)


Page
11

of
22

Answer: 1.

Less than 100

mg/dL (2.59 mmol/L)


Rationale:

CKD is considered

a
coronary artery disease
risk equivalent.
In a
ddition, this patient
has type 2 diabetes

mellitus
, which is considered

a
coronary heart disease (
CHD
)

risk equivalent.
For this reason, the LDL goal for this patient should be that of the highest risk group.

Based on
the
National Cholesterol Education Program Adult Treatment Panel III (
NCEP ATP III
)

guidelines, the LDL goal for the highest risk group is
less than

100
,

with an alternate goal of
less
than

70
.


Citations:

American Heart Association Councils on Kidney in Cardiovascular Disease, High
Blood Pressure Research, Clinical Cardiology, and Epidem
iology and Prevention. Kidney disease
as a risk factor for development of cardiovascular disease. Circulation 2003;108:2154

69.


The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. ATP 3 Final
Report
.

A
vailable at
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf
.

A
ccessed
March
28
,
201
2
.


NCEP Report: Implications of Recent Clinical Trials for the National Cholesterol Education
Program Adult Treatment Panel III Guidelines
.

Circulatio
n 2004;110:227

39
.

A
vailable at

http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.pdf
.

A
ccessed
March

2
8
, 20
1
2
.


Reference for conversion for

LDL to SI units:

Katz A,

Ferraro M, Sluss PM.

Laboratory
r
eference
v
alues.

N Engl J Med 2004;351
:
1548

6
3
.



Question 4



300 points


Which is the most appropriate adjustment to make in his phosphate binder therapy?


1.

Discontinue calcium carbonate
.

2.

Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg
3

times
/
day
.

3.

Continue calcium carbonate at the current dose and add aluminum hydroxide 600 mg
3

times
/
day
.

4.

Continue calcium carbonate at the current dose and add sevelamer carbonate 800 mg
3

times
/
day
.


Answer:

2.

Discontinue calcium carbonate and initiate sevelamer ca
rbonate 1600 mg
3

times
/
da
y.

Rationale:

Because
the patient ha
s

a serum phosphate
value

that is above the normal range, he
require
s

phosphate binder therapy
.

He has an elevated calcium

level
,

as evidenced by his
lab
oratory value
s (10.5 mg/dL), which
,

if corrected for a low serum albumin using the correction
equation (Ca, adj = SCa + 0.8 (4
-
albumin)
,

would be estimated
as

11.46 mg/dL.

Hypercalcemia
can cause acute kidney injury through vasoconstriction of the af
ferent arterioles in the kidney.
Calcium
-
based binders are not recommended in hypercalcemia
,

so discontinuing the calcium
-
based binder is warranted in this patient.

Aluminum should be avoided as long
-
term phosphate
binder therapy.

Sevelamer is the best option in this patient.


Citations: KDIGO CK
D
-
MBD Guidelines, 2009
. Available at

http://www.kdigo.org/guidelines/mbd/guide4.html#chap41
.

A
ccessed
March

2
8
, 20
1
2
.



Page
12

of
22

Abeulo JG
.

Normotensive ischemic acute renal failure
.

N Engl J Med 2007;357:797

805
.

KDIGO CKD
-
MBD Guidelines, 2009
. Available at

http://www.kdigo.org/guidelines/mbd/guide4.html#chap41
.

A
ccessed
March
2
8
, 20
1
2
.




Question 5


300 points

By what mechanism could the patient’s
choice of
naproxen

be
adversely affecting

his
r
enal
function?


1.

Direct toxic effect on the renal tubules

2.

Constriction of the afferent arteriole

3.

Dilation of the efferent arteriole

4.

Decreased tubular reabsorption of sodium


Answer:

2. Constriction of the afferent arteriole


Rationale
:

NSAIDs such as naproxen can cause
many

different types of injury to the kidney.

The
most likely short
-
term problem with taking an NSAID for this patient is functional acute kidney
injury, result
ing

from a decreased production of vasodilatory prostaglandins
,

which act on the
afferent arterioles

of the kidney.

In patients who rely on afferent arteriole vasodilation to maintain
their GFR, this causes a drop in GFR.

Choice 1 is incorrect
because

there is no direct toxic effect
on the rena
l

tubules. Choice 4 is incorrect
because

the inhibition of PG
E2
syntheses

can lead to
increase
d

sodium reabsorption, causing peripheral edema, which is the most common renal effect
of NSAID
s
.

Edema and sodium retention are usually mild, resulting in weigh
t
gain of 1

2 kg
.


Citation:
Abeulo JG
.

Normotensive ischemic
acute renal failure
.

N

Engl J Med 2007;357:797

805.









Team/Individual ID

_____________________________



Case S
egment Score ________


For Administrative Use Only

You have reached the end of the
Clinical Case Segment.



Do NOT proceed to the next segment of
the exam until instructed to do so.


Page
13

of
22



Jeopardy Segment

This segment will consist of 15 items in
five

predetermined categories. Point values for each item
are indicated below. Please circle your answer for each item.



Cardiovascular
Disorders



Item 1
(
100 point
s
)



The U.S. Preventive Services Task Force
(USPSTF)
recommends aspirin for the primary
prevention of cardiovascular disease in a 62
-
year
-
old man when his 10
-
year CHD risk is equal to
or greater than what level:


1.

3%

2.

5%

3.

7%

4.

9%


Answer: 4. 9%


Rationale: The USPSTF created a recommendation statement on the use of

Aspirin for the
Prevention of Cardiovascular Disease.


In this statement, the USPSTF balances the risk of CHD
with the risk of bleeding in patients using aspirin for
the

primary prevention of CHD. The cut
point for benefit in the male age group of 60

69 is having a 10
-
year CHD risk of 9% or more.


Citation:

U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular
disease: U.S. Preventive Services
Task Force recommendation statement.

Ann Intern Med
2009;150:396

404
.



Item 2
(
200

point
s
)


Which medication is considered the first
-
line agent for the treatment of leg pain secondary to
intermittent claudication?


1.

Aspirin

2.

Cilostazol

3.

Clopidogrel

4.

Pentoxify
lline


Answer: 2. Cilostazol


Rationale: The treatment of choice for patients experiencing leg pain caused by intermittent
claudication is cilostazol. Pentoxifylline has been shown to be comparable to placebo; therefore,
the
American College of Cardiology/
American Heart Association

(
ACC/AHA
)

guidelines have
designated it a second
-
tier therapy. Although aspirin and clopidogrel are used for peripheral
arterial disease to reduce cardiovascular mortality, these agents have not shown a reduction in
ischemic leg pain.


Citation: Hirsch AT, Haskal Z
J, Hertzer NR, et al. ACC/AHA guidelines for the management of
patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal

Page
14

of
22

aortic): executive summary: a collaborative report from the American Association for Vascular
Surger
y/Society for Vascular Surgery, Society for Cardiovascular Angiography and
Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology,
and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop
Guidel
ines for the Management of Patients With Peripheral Arterial Disease).

2011 ACCF/AHA
Focused Update of the Guideline for the Management of Patients
w
ith Peripheral Artery Disease
(Updating the 2005 Guideline)
.

J Am Coll Cardiol 2011;58:2020

45.


Item 3
(
300 point
s
)


A hemodynamically stable patient with systolic heart failure is initiated on amiodarone for an
irregularly irregular rhythm. The patient currently receives lisinopril 20 mg orally once daily,
metoprolol succinate 25 mg orally once daily, furos
emide 40 mg orally once daily, and digoxin
0.25 mg orally once daily. Physical examination reveals no lower extremity edema or pulmonary
crackles. What medication adjustment should occur immediately?


1.

Change furosemide 40 mg orally to 20 mg intravenously d
aily
.

2.

Increase lisinopril to 40 mg orally once daily
.

3.

Decrease digoxin to 0.125 mg orally once daily
.

4.

Switch metoprolol succinate 25 mg once daily to metoprolol tartrate

12.5 mg orally twice
daily
.


Answer: 3. Decrease digoxin to 0.125 mg orally
once
daily
.


Rationale: Amiodarone reduces the clearance of digoxin by inhibiting P
-
glycoprotein. This drug
interaction is predictable and clinically significant, requiring a proactive 50% reduction in
digoxin. An increase in furosemide is not necessary in a patient

without edema or crackles. Th
is

patient is currently receiving the target dose of lisinopril, and an increase beyond the target dose
is not needed. An equipotent dose change from metoprolol succinate to tartrate is
unnecessary

in
a hemodynamically stable patient with systolic heart failure.


Citation: Nademanee K, Kannan R, Hendrickson J, Ookhtens M, Kay I, Singh BN.
Amiodarone
-
digoxin interaction: clinical significance, time course of development, potential pharmacokinetic
mec
hanisms and therapeutic implications. J Am Coll Cardiol 1984;4:111

6.





















Page
15

of
22

Endocrinology



Item 1 (100 points)



A 68
-
year
-
old
woman

with hypertension, chronic heart failure, and stage 3 CKD
has just received
a

diagnos
is of

type 2 diabetes

mellitus
.

Lab
oratory value
s include
hemoglobin
A
1c

8.8%,
serum
creatinine
(S
Cr
)

1.6 mg/dL,
potassium
4.0 mEq/L,
aspartate aminotransferase
18 IU/L,
and
alanine aminotransferase
20 IU/L.

Which of the following is the most appropriate initial therapy?


1.

G
lipizide

2.

Metformin

3.

Pioglitazone

4.

Sitagliptin


Answer: 1. Glipizide


Rationale:

Glipizide is the only tier
1

American Diabetes Association (ADA)
/European
Association for the Study of Diabetes (
EASD
)

therapy listed
,

and
it
is
not contraindicated
in

this
patient.

The agent will likely provide the
hemoglobin
A
1c

reduction needed.

Although metformin
is also a tier 1 therapy, it is contraindicated
because of

the patient’s elevated
SCr
.

Sitagliptin is
not recommended as a first
-
line therapy
because of

the lack of compelling efficacy data.

Pioglitazone is not a tier 1 therapy
,

and
it
has a relative contraindication in patients with heart
failure.


Citation:
Nathan D, et al.
ADA EASD Consensus Statement. Diabetes Care
2009;
32:193

203
.


Item 2 (200 points
)



A 65
-
year
-
old woman with
hypothyroidism

treated with levothyroxine 0.75

mg
/
day has been
euthyroid for the past 4 years. Since her last clinic visit 6

months ago
,

she
h
as

been

given
diagnos
e
s of

hyperlipidemia, osteoporosis
,

and nonvalvular atrial fibrillation
,

and
she has been
initiat
ed on the following medications:



Alendronate
70 mg once weekly


Calcium
c
arbonate

1200

mg
/
v
itamin D

8
00 IU

supplement daily


Simvastatin 20

mg
/
day


Warfarin 2.5 mg
/
day



Her

thyroid
-
stimulatin
g hormone

(TSH)

level
today is 6.9

mIU/L
.

Which medication most likely
contributed to the loss of a euthyroid state?


1.

Alendronate

2.

Calcium

c
arbonate/
v
itamin D supplement

3.

Simvastatin

4.

Warfarin


Answer:

2.

Calcium
c
arbonate/
v
itamin D supplement


Rationale: Calcium
c
arbonate decreases the absorption of levothyroxine
,

thereby decreasing
T3/T4 levels
,

which results in an increased TSH.

There is no interaction between levothyroxine
and
a
lendronate or
s
imvastatin.

Warfarin does not affect levothyroxine

levels; however
,

a change

Page
16

of
22

in thyroid status can
affe
ct the metabolism of vitamin K

dependent clotting factors and
precipitate a need for altered warfarin dosing.


Citation:
Synthroid® (
Levothyroxine
)
[
prescribing information
]
.
North Chicago, IL:
Abbot
t

La
b
oratorie
s
,

2011.




Item 3 (300 points)



A 72
-
year
-
old woman presents with lower back pain.

She has a history of vertebral
-
crush
fractures
caused by

osteoporosis (
T
-
score of

3.0 at spine).

She has severe
gastroesophageal
reflux disease (
GERD
)
.

Which is
the most appropriate initial treatment?


1.

Alendronate

2.

Calcitonin

3.

Teriparatide

4.

Zoledronic acid


Answer:

4. Zoledronic acid


Rationale:

The correct answer is zoledronic acid for this patient
because of the

type of fracture
and the presence of GERD
.

Bisphosphonates such as an alendronate would be the initial choice;
however
,

because

this patient has severe GERD,
only
an
intravenous

bisphosphonate would be an
option.

Teriparatide would be a second
-
line choice or first line if
the
T
-
score were

3.5.

Calcitonin is a fourth
-
line choice in this patient.

Although

pain relief is
believed

to be a benefit
with calcitonin, current practice is to manage pain and fracture risk separately.


Citation: Gaudio A, Morabito N.

Pharmacological management of severe pos
tmenopausal
osteoporosis. Drugs Aging 2005;22:405

17.

























Page
17

of
22





Emergency Medicine


Item 1 (100 points)


In which clinical situation would a shock be recommended during resuscitation efforts when there
is no pulse?


1. Asystole

2. Atrial
fibrillation

3. First
-
degree heart block

4. Ventricular fibrillation


Answer: 4. Ventricular fibrillation


Rationale: The
Advanced Cardiac Life Support (
ACLS
)

Cardiac Arrest algorithm within the
cardiopulmonary resuscitation and emergency cardiovascular ca
re guidelines by the A
HA

has
two major branches
:

rhythms that are amenable to shock and those that are not. Ventricular
fibrillation and ventricular tachycardia can be shocked; it is recommended that asystole and
pulseless electrical activity not be shocked. Both atrial fibrillation and first
-
degree hea
rt block
would be considered pulseless electrical activity in the above question because the victim has no
pulse.


Citation: Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life
support: 2010 American Heart Association guidelines
for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010;122:S729

S767.



Question 2 (200 points)


A patient presents to the emergency department with sedation, miosis, and decreased bowel
sounds. Respiratory rate is 6 breaths
/minute; temperature is 98.2°F (37.2°C). Which medication
would likely cause this collection of symptoms?


1. Benztropine

2. Oxycodone

3. Fluoxetine

4. Methylphenidate


Answer: 2. Oxycodone


Rationale: Toxidromes are a collection of signs and symptoms. All

of the above are consistent
with an opioid toxidrome. Anticholinergics (benztropine) would produce mydriasis, not miosis;
fluoxetine is relatively safe, but it can cause serotonin syndrome, which would result in increased
reflexes and temperature. Methylp
henidate would cause agitation, mydriasis, and hyperthermia.


Holstege CP, Dobmeier SG, Bechtel LK. Critical care toxicology. Emerg Med Clin North Am
2008;25:715

39.




Page
18

of
22




Question 3 (300 points)


Assuming a potentially toxic ingestion for each of the subs
tances listed, in which situation would
activated charcoal be expected to have the greatest benefit to decrease the chances of toxicity?


1.

Lithium ingestion 45 minutes ago

2.

Kerosene ingestion 5 minutes ago

3.

Acetaminophen 90 minutes ago

4.

Digoxin 52 minutes ago


Answer:
4
. Digoxin 52 minutes ago


Rationale: Activated charcoal is most beneficial when used within 60 minutes of the ingestion.
There are situations within this window when activated charcoal is not indicated, including drugs
that do not bind well to ac
tivated charcoal (lithium) or when there is a risk of aspiration
(kerosene, a hydrocarbon).


Citation: American Academy of Clinical Toxicology and European Association of Poison Centers
and Clinical Toxicologists. Position paper: single
-
dose activated char
coal. Clin Toxicol
2005;43:61

87.
































Page
19

of
22







Psychiatry/CNS Disorders



Item 1
(
100
p
oin
ts
)



A patient presents to the emergency department experiencing drug withdrawal. Which drug poses
the greatest risk of death because of
withdrawal?


1.

Cocaine

2.

Amphetamines

3.

Morphine

4.

Ethanol


Answer: 4. Ethanol


Rationale: C
entral nervous system
stimulants do not result in medically serious signs. Although
morphine produces significant withdrawal signs and symptoms, rarely does withdrawal result in
death. With ethanol,
death may result from exhaustion or unknown causes
if patients enter
delirium t
remens (5% of withdrawal population).


Citations:

Doering PL. Chapter 74. Substance
-
Related Disorders: Overview and Depressants,
Stimulants, and Hallucinogens. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG,
Yee GC, eds.
Pharmacotherapy: A Pathop
hysiologic Approach
. 8th ed. New York: McGraw
-
Hill; 2011. http://0
-
www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?aID=7987346. Accessed
March 29, 2012.


Doering PL, Li RM. Chapter 75. Substance
-
Related Disorders: Alcohol, Nicotine, and Caffe
ine.
In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds.
Pharmacotherapy: A
Pathophysiologic Approach
. 8th ed. New York: McGraw
-
Hill; 2011. http://0
-
www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?aID=7987625. Accessed
Marc
h 29, 2012



Item 2

(
200 poin
ts
)



A 25
-
year
-
old woman is experiencing her first major depressive episode. She was
initiat
ed on
sertraline a few months ago and titrated up to 100 mg
/
day to achieve better control of symptoms.
What is the optimal duration of

antidepressant therapy in this patient?


1.

3 months after the acute phase of her illness subsides

2.

6 months after the acute phase of her illness subsides

3.

1 year after the acute phase of her illness subsides

4.

1 year from the onset of the depressive episode


An
swer: 2. 6 months after the acute phase of her illness subsides



Page
20

of
22

Rationale: When treating the first depressive episode, antidepressants must be given for an
additional 4

9 months after the acute episode has resolved.


Citations: Jackson CW, Cates ME,
Feldman JM. Major depressive disorder. In: Chisholm MA,
Schwinghammer TL, Wells BG, eds. Pharmacotherapy Principles and Practice, 2nd ed. New
York: McGraw
-
Hill, 2010:664.


American Psychiatric Association Practice Guidelines. Treatment of Patients with Maj
or
Depressive Disorder, 3rd ed. 2010. Available at
http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_7.aspx
. Accessed Ma
rch

28
,
201
2
.



Item 3

(
300 point
s
)



A 66
-
year
-
old man with a long
-
standing history of Parkinson disease (diagnosed 12 years ago)
presents to the clinic for
assessment
. His current medications include carbidopa/levodopa 25

100
mg every 4 hours, pramipexole 1.5 mg
3

times
/
day, entacapone 200 m
g every 4 hours, and
benztropine 2 mg
/
day.


He experiences uncontrollable involuntary movements of his legs and arms that usually occur
around the time for his next medication dose. Which drug on his current profile is most likely
causing this symptom?


1.

Be
nztropine

2.

Entacapone

3.

Levodopa

4.

Pramipexole


Answer: 3. Levodopa


Rationale: The correct answer is levodopa. A substantial number of patients develop levodopa
-
induced complications within several years of starting this drug. These include motor fluctuations
(the wearing
-
off phenomenon), involuntary movements known as dyskinesia, abnormal postures
of the extremities and trunk known as dystonia, and a variety of complex fluctuations in motor
function. This phenomenon may be explained by the observation that dop
amine nerve terminals
are able to store and release dopamine early in the course of disease, but when disease is more
advanced and there is increasing degeneration of dopamine terminals, the concentration of
dopamine in the basal ganglia is much more depen
dent on plasma levodopa levels. Ways to treat
this include decreasing the levodopa dose, using a dopamine agonist, replacing
sustained
-
release

levodopa with regular levodopa in dyskinesias occurring in the late afternoon, or using levodopa
dosing more freq
uently.


Citation: Chen JJ, Nelson MV, Swope DM. Parkinson’s disease.
In:
DiPiro JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM, eds.
Pharmacotherapy: A Pathophysiologic Approach,
7e:
http://0
-
www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?aID=3204031
.
Accessed
March

28
, 201
2
.








Page
21

of
22





Infectious Diseases



Item 1
(
100 poin
ts
)



What is the most appropriate empiric treatment regimen for a patient with community
-
acquired
pneumonia who needs admission to the general medical ward of a hospital?


1.

Doxycycline and azithromycin

2.

Ceftriaxone and azithromycin

3.

Moxifloxacin and ceftriaxone

4.

Vancomycin and ceftriaxone


Answer: 2. Ceftriaxone and azithromycin


Rationale: The correct ans
wer is ceftriaxone and azithromycin. The doxycycline and
azithromycin combination does not have adequate coverage for
S. pneumoniae
. Moxifloxacin
could be used alone and does not need to be added to ceftriaxone in this patient. Vancomycin
would only be use
d in health care

associated infections with risk of methicillin
-
resistant
Staphylococcus aureus
.


Citation:
Mandell LA, Wunderlink RG, Anzueto A, et al. Infectious Diseases Society of
America/American

Thoracic Society consensus guidelines on the management

of c
ommunity
-
acquired pneumonia in adults
.

Clin Infect Dis 2007;44:S27

S72.




Item 2 (200 points)


A 44
-
year
-
old ma
n

is initiated on fluconazole for fungemia. His blood cultures are currently
growing
Candida

sp
p
. If identified by culture, which of species of
Candida

would warrant a
change in antifungal therapy?


1.

Candida parapsilosis

2.

Candida tropicalis

3.

Candida glabrata

4.

Candida albicans


Answer:

3.
Candida glabrata


Rationale:

Fluconazole covers all
Candida

sp
p.

except
Candida glabrata

and
Candida krusei
.


Citation
s
: Pappas PG
,

et al. Clinical
p
ractice
g
uidelines for the
m
anagement of
c
andidiasis: 2009
u
pdate by the Infectious Diseases Society of America. C
lin
I
nfect
D
is

2009;48:503

35.


Gilbert DN
,

e
t al. The Sanford Guide to Antimicrobial Therapy.

Sperryville, VA: Antimicrobial
Therapy, 2007
:109.




Page
22

of
22




Item 3

(
300 point
s
)



A 30
-
year
-
old man with a history of poorly controlled schizophrenia secondary to poor adherence
to his antipsychotic medications
has

newly diagnosed
human immunodeficiency virus (
HIV
)

and
hepatitis B
virus (HBV)
coinfection.


His initial laboratory values are:

HIV viral load


625,000 copies/mL

CD
4

count


75 cells/microliter (
SI
0.075 x 10
9
/L)

HBV viral load


500 copies/mL

S
C
r

and liver enzymes are within normal limits.

The HIV genotype reveals no significant mutations.


Which regimen would be the best recommendation for initial therapy in this patient?


1.

Efavirenz/tenofovir/emtricitabine 1 tablet by mouth once daily

2.

Tenofovir/e
mtricitabine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once
daily, and atazanavir 300 mg by mouth once daily

3.

Abacavir/lamivudine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once
daily, and atazanavir 300 mg by mouth once daily

4.

Ten
ofovir/emtricitabine 1 tablet by mouth once daily and lopinavir/ritonavir 400
-
mg/100
-
mg tablet 2 tablets by mouth twice daily


Answer: 2. Tenofovir/emtricitabine (Truvada) 1 tablet by mouth once daily, ritonavir (Norvir)
100 mg by mouth once daily, and ata
zanavir (Reyataz) 300 mg by mouth once daily


Rationale: According to
U.S. Department of Health and Human Services (
DHHS
)

guidelines,
first
-
line
highly active antiretroviral therapy

(
HAART
)

regimens should include a backbone of
two nucleoside reverse trans
criptase inhibitors (NRTIs)
,

with tenofovir/emtricitabine (Truvada) as
the preferred NRTIs. Moreover, Truvada is recommended as part of the HAART regimen in
patients with hepatitis B coinfection. In addition to the NRTI backbone of Truvada, the initial
reg
imen should include efavirenz, ritonavir
-
boosted atazanavir, or raltegravir. Efavirenz would
not be the best option given its potential to exacerbate psychotic symptoms in patients with a
history of psychiatric illness.


Citation: Panel on Antiretroviral G
uidelines for Adults and Adolescents. Guidelines for the Use
of Antiretroviral Agents in HIV
-
1
-
Infected Adults and Adolescents. U.S. Department of Health
and Human Services, January 10, 2011; 1

166. Available at
http://www.aidsinfo.nih.gov/ContentFiles/Adu
ltandAdolescentGL.pdf
. Accessed
March

28
, 201
2
.








Team/Individual ID

______________________



Jeopardy Segment

Score ________


For Administrative Use Only