QUESTION: 29

A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMSE). During the administration of the MMSE, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship.

Which of the following accurately describes this patient's condition?

There is no genetic basis for development of this disease.
It is usually abrupt in onset.
There is no correlation between age and prevalence of this disease.
Environmental exposure is a proven risk factor for development of this disease.
It is one of the most common terminal illnesses in developed nations.

Answer(s): E

Explanation:

This patient's symptoms are most consistent with Alzheimer disease. Alzheimer disease is a prominent condition in developed nations, ranking as the third most common terminal illness behind heart disease and cancer. It is the most common form of dementia, with over 4 million Americans having the condition in the United States alone. There is a direct correlation between advanced age and increasing prevalence of Alzheimer disease. While there is an early-onset form of familial Alzheimer disease that may appear as early as the third decade of life, this accounts for only a small percentage of total Alzheimer cases. There does appear to be a genetic component to the development of Alzheimer disease, as it has been demonstrated that first-degree relatives of Alzheimer patients possess an increased risk for development of the condition. Genes on chromosomes 1, 14, and 21 have been implicated in this association. While age and family history are important risk factors, there is no evidence proving that environmental factors lead to an increased chance for development of the disease. Progression of Alzheimer dementia is typically insidious, spanning as many as several years. Anticholinergic agents and any other medication with anticholinergic effects are contraindicated in the setting of Alzheimer dementia. Their use may lead to worsening of cognition and may contribute to decreased efficacy of medications used in the treatment of Alzheimer dementia. Tricyclic antidepressants such as amitriptyline should be avoided for this reason. Risperidone, olanzapine, and quetiapine are atypical antipsychotic medications which are useful in the treatment of emotional withdrawal and delusions which may arise in Alzheimer patients. Trazodone, carbamazepine, and divalproex are moodstabilizing medications which are useful in patients who display marked agitation. While trazodone does display some anticholinergic side effects, they are far less pronounced than those seen with amitriptyline.

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QUESTION: 30

A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMSE). During the administration of the MMSE, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship.

Use of which of the following medications would be the most likely to lead to worsening of symptoms in this patient?

risperidone
amitriptyline
olanzapine
quetiapine
trazodone

Answer(s): B

Explanation:

This patient's symptoms are most consistent with Alzheimer disease. Alzheimer disease is a prominent condition in developed nations, ranking as the third most common terminal illness behind heart disease and cancer. It is the most common form of dementia, with over 4 million Americans having the condition in the United States alone. There is a direct correlation between advanced age and increasing prevalence of Alzheimer disease. While there is an early-onset form of familial Alzheimer disease that may appear as early as the third decade of life, this accounts for only a small percentage of total Alzheimer cases. There does appear to be a genetic component to the development of Alzheimer disease, as it has been demonstrated that first-degree relatives of Alzheimer patients possess an increased risk for development of the condition. Genes on chromosomes 1, 14, and 21 have been implicated in this association. While age and family history are important risk factors, there is no evidence proving that environmental factors lead to an increased chance for development of the disease. Progression of Alzheimer dementia is typically insidious, spanning as many as several years.

Anticholinergic agents and any other medication with anticholinergic effects are contraindicated in the setting of Alzheimer dementia. Their use may lead to worsening of cognition and may contribute to decreased efficacy of medications used in the treatment of Alzheimer dementia. Tricyclic antidepressants such as amitriptyline should be avoided for this reason. Risperidone, olanzapine, and quetiapine are atypical antipsychotic medications which are useful in the treatment of emotional withdrawal and delusions which may arise in Alzheimer patients. Trazodone, carbamazepine, and divalproex are moodstabilizing medications which are useful in patients who display marked agitation. While trazodone does display some anticholinergic side effects, they are far less pronounced than those seen with amitriptyline.

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QUESTION: 31

A 28-year-old woman presents to your clinic complaining of feeling "on edge." Upon further questioning, you discover that she has also noticed problems with irritability, insomnia, fatigue, and restlessness. She also has a history of worrying about things that seem to not bother those around her. She states these symptoms have been present for years but have recently become worse. When you try to gather more information, she interrupts to say that she cannot stay much longer because she is afraid that she will lose her new job as a machinist.
Which of the following medications would be most appropriate in this patient?

diazepam
amitriptyline
doxepin
oxazepam
buspirone

Answer(s): E

Explanation:

This patient's symptoms are consistent with an anxiety disorder. Given her occupation, an anxiolytic medication with no sedative properties would be most preferable. Buspirone is a nonsedating anxiolytic agent that is a partial agonist at 5-HT1A receptors. Unlike benzodiazepines, such as diazepam and oxazepam (Serax), it has no hypnotic, anticonvulsant, or muscle relaxant properties. Amitriptyline and doxepin have also been used to treat anxiety, especially when associated with depression; however, these drugs are also sedating.

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QUESTION: 32

A 54-year-old male with uncontrolled type II diabetes and well-controlled hypertension presents with complaints of erectile dysfunction. The patient requests Viagra (sildenafil), as his friends have used it with success. However, he is concerned as he was told by someone that Viagra can be fatal if used with some blood pressure medications. You would advise the patient that the use of which of the following is contraindicated in patients taking sildenafil?

isosorbide mononitrate
metoprolol
verapamil
captopril
clonidine

Answer(s): A

Explanation:

Sildenafil is a phosphodiesterase inhibitor effective in the treatment of erectile dysfunction the mechanism of action of which is related to an increase in intracellular cyclic guanosine monophosphate (GMP). Nitrates increase cyclic GMP via the activation of guanylyl cyclase. When the two drugs interact, there can be a dramatic fall in blood pressure related to extreme vasodilation. The other selections can reduce blood pressure; however, since their mechanisms of action are not associated with the intracellular concentration of cyclic GMP, there is no synergistic interaction with sildenafil

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