QUESTION: 1

Which of the following represents the major route of metabolism for acetaminophen?

Glucuronidation
Sulfation
Cytochrome P-450 oxidation
Direct renal excretion
Plasma breakdown

Answer(s): A

Explanation:

Acetaminophen is metabolized by choices A through D. The major route is glucuronidation catalyzed by UDP-glucuronyltransferase in the liver. Sulfation is the next most common route and is the target mechanism for NAC therapy. Oxidation by cytochrome P-450 results in the formation of N-acetyl-p- benzoquinone imine, which is responsible for the hepatic necrosis caused by acetaminophen overdose. Direct renal excretion represents approximately 5% of the metabolism of acetaminophen. Plasma metabolism of acetaminophen does not generally occur.

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QUESTION: 2

A 15-year-old presents with 6 days of nasal congestion with thin, clear rhinorrhea. She notes mild facial pain but has had no fevers. She feels her symptoms are improving.
What is the most likely cause of her symptoms?

Streptococcus pneumoniae
Viral
Moraxella catarrhalis
Haemophilus influenzae
Staphylococcus aureus

Answer(s): B

Explanation:

This patient shows symptoms of acute sinusitis. The most common etiology of which is viruses.
Indications that an infection is viral as opposed to bacterial included a shorter infection tie (less than 10 days) and no purulent discharge (hers is watery). She does not show any evidence of a complication developing and even notes that her symptoms are improving. If her symptoms were attributed to a bacterium, then the most common cause of acute sinusitis is Streptococcus pneumoniae followed by Haemophilus influenza, then Moraxella catarrhalis. Anaerobic species such as Bacteroides fragilis and Staphylococcus aureus are more commonly found in patients with chronic sinusitis (sinusitis lasting longer than 12 weeks). This is important to realize before indiscriminately providing antibiotics for these patients.

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QUESTION: 3

A 72-year-old woman suffers from a major depressive episode. She has a history of coronary artery disease, atrial fibrillation on anticoagulation therapy, sick sinus syndrome, glaucoma, and chronic obstructive pulmonary disease.
Which of the following medications is most appropriate for the treatment of her depression?

Amitriptyline
Nortriptyline
Doxepin
Fluvoxamine
Escitalopram

Answer(s): E

Explanation:

In older adults, selection of antidepressant medication should be done with various considerations in mind, most notably side effects and risk of drug-drug interactions. The tricyclic antidepressants (TCAs), as discussed on interactions that make them undesirable for the treatment of depression in older adults. A selective serotonin reuptake inhibitor is more favorable than a TCA in this patient. Fluvoxamine has a high risk for drug-drug interactions, whereas escitalopram does not. Fluvoxamine also has high protein binding, and can therefore interact with anticoagulant medications, such a warfarin. Therefore, of the medications listed, escitalopram is the most appropriate in this patient. In older adults, psychotropic medications should be started at a low dose and titrated up slowly to the lowest effective dose.

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QUESTION: 4

Which of these is an example of postrenal acute kidney injury (AKI)?

Benign prostatic hyperplasia
Heart failure
Dehydration
Renal vein thrombosis

Answer(s): A

Explanation:

Benign prostatic hyperplasia (BPH) is an example of postrenal acute kidney injury (AKI). Postrenal AKI, as the name suggests, involves an effect ‘post’ or ‘beyond’ the kidney, to problems that emerge downstream from the kidney. BPH is one such example of that. Other examples include kidney stones, bladder stones and bladder cancer.

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