Pharmacology Qbank

Question 1

A 62 year-old male complains of axial back pain worsening over the past 2 years without inciting event or trauma. He has no red flag symptoms. He denies radiation of his pain. He has tried acetaminophen, ibuprofen, and physical therapy without relief. Advanced imaging confirms the diagnosis of lumbar facet arthropathy, and the patient elects to proceed with diagnostic lumbar medial branch blocks with the hope of proceeding to radiofrequency ablation for longer-lasting pain relief. You elect to inject bupivacaine along the medial branches, and the patient is instructed to fill out a pain diary in which he records his visual analog pain scores every hour for the 10 hours following the procedure. If the bupivacaine is effective, for how long do you anticipate his pain scores will be reduced following the procedure?

Answer 1

4-8 hours

Question 2

An otherwise healthy 56 year-old female presents to your outpatient clinic after referral from her primary care physician. The patient reports a 4-month history of episodic sharp, severe, lightning-like pain in her left jaw that has become more frequent recently. She describes 10-second episodes of pain along her jawline on the left side, occasionally brought on by brushing her teeth or chewing food. She otherwise denies all symptoms. Her dentition is pristine. She has no pain over her temporomandibular joints bilaterally. You prescribe the first-line medication for her condition; what is the mechanism of action of this drug?

Answer 2

Sodium channel inhibition

Question 3

Which of the following is the correct mechanism of action of pregabalin?

Answer 3

L-type calcium channel antagonist

Question 4

NSAIDs (nonsteroidal anti-inflammatory drugs) reduce pain by reducing the production of which of the following compounds?

Answer 4

Prostaglandins

Question 5

Which of the following medications serves as a GABA-B receptor agonist?

Answer 5

Baclofen

Question 6

Which of the following enzymes produces prostaglandins which protect the stomach lining?

Answer 6

COX-1

Question 7

A 47 year-old female presents for refractory migraines. She has tried over the counter acetaminophen, ibuprofen, antiepileptics, propranolol, amitriptyline, and triptans with no relief. Her neurologist has also recommended lifestyle modifications including daily exercise, appropriate sleep hygiene, and limited alcohol and caffeine. Despite these measures, she has 20 migraine days per month, with each migraine lasting 5-6 hours. You recommend botulinum toxin for her migraines. A typical botulinum toxin protocol consists of the following:

Answer 7

155 units divided into 31 sites

Question 8

One main difference between dantrolene and the other antispasticity agents is:

Answer 8

Its peripheral mechanism of action

Question 9

Prednisone functions by directly inhibiting the production of which of the following compounds?

Answer 9

Corticosteroids, such as prednisone, function by inhibiting the enzyme phospholipase A2 (PLA-2), which normally produces arachidonic acid.

Question 10

Which of the following medications stimulates the bowel wall to induce peristalsis?

Answer 10

Senna

Question 11

A patient with no past medical history other than chronic right knee pain presents for a second opinion regarding management of his right knee pain and instability. He states that he went to an orthopedic surgeon who had no recommendations for him other than knee replacement given the severity of his osteoarthritis on plain films. The patient wants to avoid surgery at all costs. He has no findings of ligamentous instability on exam, and you agree that his pain is likely related to his arthritis. In the past, he has tried and had inadequate relief with acetaminophen, lidocaine patches, heat/ice, hinged knee brace, and footwear corrections. You suggest trialing nonsteroidal anti-inflammatories, but he reports that he is concerned about the risk of peptic ulcers. You suggest meloxicam which acts via the following mechanism:

Answer 11

COX-2 inhibition

Question 12

Which of the following is the correct mechanism of action for gabapentin?

Answer 12

Gabapentin functions as an L-type calcium channel antagonist in the central nervous system (CNS).

Question 13

Which of the following medications is FDA-approved to treat neuropathic pain due to trigeminal neuralgia?

Answer 13

Carbamazepine is the only FDA-approved to treat trigeminal neuralgia. Oxcarbazepine can also be effective.

Question 14

Which of the following conditions would prompt you
to use a lower dose of baclofen than is typical?

Answer 14

Chronic kidney disease

Question 15

All of the following medications are most likely to increase a patient’s liver enzymes except which of the following?

Answer 15

Dantrolene and tizanidine can increase liver enzymes
Acetaminophen toxicity can cause elevated liver enzymes.
Baclofen is renally cleared

Question 16

Which of the following medications is FDA-approved to treat diabetic peripheral neuropathic pain?

Answer 16

Gabapentin

Question 17

A 55 year-old male presents with complaints of low sexual arousal, erectile dysfunction, and low testosterone on a recent blood draw. Which of the following medications is he most likely taking?

Answer 17

Morphine

Question 18

Tizanidine’s mechanism of action includes which of the following?

Answer 18

Alpha-2 agonist

Question 19

A 52 year-old male who was previously active and healthy begins to notice muscle twitching and difficulty swallowing salivary secretions over the course of 2 months. He then begins to notice some weakness in his right arm and left leg. Electrodiagnostic studies reveal probable amyotrophic lateral sclerosis. He is started on riluzole by his neurologist. At his initial consultation with you, he asks you about the mechanism of riluzole. You respond with:

Answer 19

Riluzole blocks glutamate action in the central nervous system

Question 20

Diazepam’s mechanism of action is best described as which of the following?

Answer 20

GABA-A agonist

Question 21

A 24 year-old male suffers a traumatic subarachnoid hemorrhage and multiple orthopedic fractures after he was an unhelmeted bicyclist in a bicycle vs. car accident. His blood alcohol content upon presentation to the emergency department is 0.23. A craniectomy is required, and he is initially placed on a ventilator and later requires a G-tube. During his hospitalization, the PM&R consult team is not consulted. After a few weeks in the intensive care unit, he is discharged to an acute rehab facility. Upon admission to the rehab unit, you note that he is somnolent, oriented to person and place but not time, and he exhibits a Modified Ashworth Scale of 2-3 in several muscle groups in his left upper and lower extremities. Which medicine should be started for his spasticity?

Answer 21

The patient is noted to have spasticity as well as somnolence upon admission to the rehab facility. Dantrolene is likely the best choice here, as dantrolene acts peripherally on the ryanodine receptor in the sarcoplasmic reticulum of muscle cells.

Question 22

Approximately how long is the expected duration of action for botulinum toxin injections?

Answer 22

3 months

Question 23

A 49 year-old female with history of untreated depression, poorly controlled diabetes, and insomnia presents for evaluation of burning in bilateral feet up to the ankles. She states it began about 1 year ago with a sensation of “bee-stings” on her toes, and since that time it has gradually ascended to the level of her ankles. Electrodiagnostic studies reveal a length-dependent peripheral neuropathy. The patient asks for medication for her symptoms. Chart review reveals allergies to multiple medications, including gabapentin and duloxetine. You decide to trial amitriptyline, and warn the patient of possible side effects including all of the following except:

Answer 23

Excessive salivation
Tricyclic antidepressants -> has anticholinergic side effects including dry mouth (not excessive salivation), urinary retention, and constipation are all possible side effects.

Question 24

Which of the following medications enhances endogenous dopamine release in the brain?

Answer 24

Amantadine

Question 25

Mirabegron promotes urine storage in the bladder by stimulating which of the following receptors?

Answer 25

Mirabegron is a Beta-3 receptor agonist, which is theoretically very selective for the bladder wall, and promotes urine storage.

Question 26

As a new PM&R resident, you are rounding with your attending, an upper-level resident, and a medical student. You stop outside of a patient’s room who complains of significant numbness and tingling in a stocking-glove fashion. Chart review reveals significant peripheral neuropathy findings on EMG, believed to be a result of uncontrolled diabetes. The patient has tried and had side effects with typical oral medications for neuropathic pain including gabapentin, pregabalin, duloxetine, and amitriptyline. The patient is interested in trialing a medicine his friend recommended, topical capsaicin, but wants to know more about its mechanism of action; your attending asks you to explain the mechanism of action to the patient. You respond with:

Answer 26

Capsaicin depletes substance P, thereby decreasing pain transmission

Question 27

A 50 year-old overweight male presents to your clinic in severe pain that extends from his right buttock down his posterior thigh and calf, into his heel and plantar aspect of his right foot. He tells you that his pain began immediately after lifting a heavy box while helping his daughter move into her apartment. Prior to the patient’s consult with you, his primary care physician ordered scheduled ibuprofen, gabapentin, and 6 weeks of physical therapy, none of which have reduced his symptoms. You order an MRI of the lumbar spine without contrast, which shows impingement of the traversing right S1 nerve due to an L5-S1 disc herniation. The patient elects to proceed with a transforaminal epidural steroid injection with fluoroscopic guidance; which steroid is preferred for this injection?

Answer 27

For transforaminal epidural steroid injections, a non-particulate steroid is favored over particulate steroids. Non-particulate steroids are smaller in size than particulate steroids. The larger particles in particulate steroids are thought to pose a higher risk of causing a spinal cord infarct if accidentally injected into the vertebral artery, which is in the proximity of the target location of transforaminal epidural steroid injections. Of the choices listed, only dexamethasone is a non-particulate steroid, and therefore the correct answer. Remember: dEXamethasone “EXes” out the particulates!

Question 28

A 32 year-old male with a C5 ASIA A spinal cord injury sustained 1 month ago presents to the acute rehabilitation hospital and reports no bowel movement for 4 days. He has a foley catheter in place and is wearing adult diapers; he reports incontinence of bowels since his injury. Review of his medication list at the outside hospital shows that he is on oxycodone-acetaminophen scheduled and as needed for pain, and his only bowel medication is polyethylene glycol daily. You decide to order senna along with digital rectal stimulation around 7 pm, following afternoon therapies and dinner. When should the senna be scheduled?

Answer 28

Senna is typically given approximately 8 hours prior to desired bowel movement to stimulate movement of stool to the rectal vault prior to bisacodyl and digital rectal stimulation, hence the correct answer is late morning to noon (approximately 8 hours before desired bowel movement at 7 pm, in this case).

Question 29

You are considering methods by which you may stimulate motor recovery in a patient who sustained an acute ischemic right middle cerebral artery (MCA) stroke 2 weeks ago, resulting in left hemiparesis. Which of the following medications would be most appropriate for this task?

Answer 29

Fluoxetine has been demonstrated to enhance motor recovery in patients with acute ischemic stroke, per the FLAME trial from 2011. Chollet, François, et al. “Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial.” The Lancet Neurology 10.2 (2011): 123-130.

Question 30

Which of the following is the most likely side effect of taking nortriptyline?

Answer 30

TCAs such as amitriptyline and nortriptyline inhibit the reuptake of serotonin and norepinephrine. They also have anticholinergic side effects, including dry mouth, constipation, and urinary retention. Furthermore, sedation is a commonly reported side effect, and some patients use TCAs to improve their sleep.

Question 31

Which of the following medications would be most appropriate to increase arousal and attention in a patient with a history of traumatic brain injury and post-traumatic epilepsy?

Answer 31

Methylphenidate
-Of the medications listed, methylphenidate has the best evidence for not lowering the seizure threshold (i.e. not increasing seizure risk) when used as a neurostimulant.

Question 32

Which of the following medications functions as an osmotic laxative?

Answer 32

Docusate is a stool softener. Senna is a stimulant that stimulates the bowel wall to induce peristalsis. Polyethylene glycol and lactulose are osmotic laxatives. Bisacodyl is a rectal wall irritant that stimulates the rectal wall, causing expulsion of the stool bolus.

Question 33

Which of the following medications is NOT United States Food and Drug Administration-approved (FDA-approved) to treat spasticity?

Answer 33

Cyclobenzaprine
-The US FDA has approved baclofen, tizanidine, dantrolene, diazepam, and botulinum toxins for the treatment of spasticity.

Question 34

Which of the following receptors, when stimulated, increases presynaptic chloride influx into the neuron?

Answer 34

The GABA-A receptor causes presynaptic chloride influx into the axon. The GABA-B1 receptor inhibits presynaptic calcium influx into the neuron. GABA-B2 increases postsynaptic potassium conductance out of the neuron. All of these effects serve to reduce synaptic transmission of action potentials. Tizanidine binds to alpha-2 receptors to stimulate them, which inhibits the spinal reflex arc.

Question 35

Which of the following medications functions as an N-methyl-D-aspartate receptor (NMDA receptor) antagonist?

Answer 35

Methadone

Question 36

Which of the following medications is the best option if your goal is pain control without the risk of the patient developing a gastric ulcer?

Answer 36

Acetaminophen

Question 37

Which of the following medications has been shown to improve survival by a few months in patients with amyotrophic lateral sclerosis (ALS)?

Answer 37

Riluzole

Question 38

Your patient with C5 ASIA B spinal cord injury presents with urinary incontinence. You elect to trial oxybutynin. Common side effects from oxybutynin include constipation and dry mouth secondary to which class of neurotransmitter activity?

Answer 38

Common side effects of medications (oxybutynin, tolterodine) which calm down detrusor muscle activity include anticholinergic side effects such as dry mouth and constipation.

Question 39

A 43 year-old male with C8 ASIA C spinal cord injury presents for functional rehabilitation. He has been struggling with spasticity and neuropathic pain interfering with his performance of activities of daily living. He has been learning bladder self-catheterization. His pain medication has caused him to have infrequent bowel movements, which cause him discomfort. You elect to start polyethylene glycol, counseling the patient that this medication operates by which of the following mechanisms?

Answer 39

Functioning as an osmotic laxative