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HHSC Department of Pharmacy

Integrated Therapeutics-It Mid-Exam-II for 3 deg Year B.Pharm
Students

1. A 27 years old female patient was diagnosed with hypertension with a BP of 145/105mm Hg (stage
II). The patient is not pregnant and no near future plan to become pregnant and have no other
comorbid condition, which of the following drag regimen would be preferable for this patient.

A. Hydrochlorthiazide 25 mg PO QD
B. Enalapril 5 mg PO QD
C. Enalapril 5 mg PO QD Hydrochlorthiazide 25 mg PO QD
D. Hydrochlorthiazide 25 mg PO QD + Nifidepine 30 mg QD

2. Which of the following is preferred as an add-on therapy to control BP for a patient who is status
postmyocardial infarction with a BP of 146/88 mm Hg (144/86 mm Hg when repeated) while treated
with Beta blocker and ACEI?

A. Hydrochlorthiazed
B. B. Valsartan
C. C. Amilodipin
D. D. Prazosin

3. Mrs. Aster is a 33-year-old female just returned from vacation after long air travel. She presents to
the emergency department (ED) with shortness of breath and is subsequently diagnosed with
pulmonary embolism (PE). She weighs 110 kg and her BMI is 40kg / (m ^ 2) Medications on admission
include: estrogen-containing oral contraceptives, ibuprofen PRN. She smokes one pack of
cigarettes/day and drinks alcoholic beverages three to four times per week. Most predisposing risk
factors to PE in this patient;

A. Being female, Obesity and smoking

B. Obesity, immobility, estrogen-containing oral contraceptives and smoking
C. Regular alcohol consumption and obesity
D. Recent immobility, Age and ibuprofen use

4. Mr. Kebede is diagnosed with a left lower extremity deep vein thrombosis (DVT) an initiated on
enoxaparin and warfarin therapy. How long therapy with enoxapari warfarin should be overlapped
for?

A. at least 2 days as long as the INR > 2

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B. at least 5 days and until the DR > 2

C. at least 9 days and until the LNR > 2
D. Enoxaparin therapy can be discontinued regardless INR value

5. We have a 50-year-old man with asymptomatic hyperuricemia, and we are about to start therapy
for newly diagnosed essential hypertension (BP 146/90 mm Hg, based on repeated measurements
with the patient supine and at rest). Which of the following antihypertensive drugs is most likely to
increase his serum uric acid levels further, and possibly precipitate gout attack?

A. Captopril
B. Losartan
C. Hydrochlorothiazide
D. Verapamil

6. A 52-year old woman with a history of type 2 DM comes to the physician because of facial swelling
around her lips & eye (Angeoedema). On her last visit 3 wks ago she was diagnosed with HTN &
appropriate pharmacotherapy was initiated. Which of the following agents could account for the
adverse drug reaction in this pt?

A. Clonidine
B. Lisinopril
C. Nifedipine
D. Atenolol

7. A 68-year-old man has recently been diagnosed with HTN & started on monotherapy designed to
reduce peripheral resistance & prevent Na & water retention. Since commencing treatment he has
developed a persistent cough. Which of the following drugs would have the same benefits but would
not cause the cough?

A. Losartan
B. Propranolol
C. Enalapril
D. Nifedipine

8. JF is a slim 60 year old female (54", 110 lbs) who is diagnosed with stage 1 hypertension. Her BP
averages 135/85. She has no other comorbid conditions, and is otherwise in excellent health. What
initial therapy would be most appropriate for JF?

A. Diltiazem
B. Furosemide
C. Hydrochlorothiazide
D. Lifestyle improvements

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9. HK a 51 year old woman who has been on notihypertensive drug thepy for the past 3 mond, Doring
her must rett her besting blood ghose level wind the 112 mg/dl. (above normal) Which spent in an
hypermis drug regimer wind het likely to have caused her glow intolerance?

A. Diltiazen
B. Hydrochlorothiazide
C. Lisinopril
D. Losartan

10. KP is a 64-year-old African American woman with a history of ischemic stroke sevent months ago.
She was previously prescribed ASA 325 mg daily but developed an allergy to ASA and stopped taking it
2 weeks ago. Which one of the following is the most appropriate recommendation at this time?

A. Make no change at this time

B. Change the ASA dose from 325 mg daily to 81 mg daily
C. Discontinue ASA and begin clopidogrel 75 mg daily
D. Restart ASA 325 mg every other day

11. Which one of the following is the recommended initial drug therapy for chronic, stable exertional
angina once PRN use of nitroglycerin is no longer adequate?

A. Beta blockers such as Atenolol 50 mg qd

B. Dihydropyridine CCBs such as Nifedipine 60 mg tid
C. Anticoagulants such as Warfarin 5 mg qd
D. Non Dihydropyridine CCBs such as Diltiazem SR 240 mg qd

12. Which of the following is true regarding ACE inhibitors in HF?

A. Are cornerstone of treatment for HF so that should be used in all stages of HF

B. Should be added once patient is symptomatic
C. Are less efficacious than angiotensin receptor blockers (ARBs)
D. Should be substituted by ARBs when patient suffer from angioedema

13. Which of the following treatments is most appropriate for a hypertensive emergency?

A. Normalization of BP within hours

B. Reduction in mean arterial pressure by 25% to 50% within minutes to hours
C. Reduction in mean arterial pressure up to 25% within minutes to hours
D. Administration of sublingual nifedipine

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14. According to the American Heart Association, what is the target BP for a patient ventricular
dysfunction (heart failure)?

A. Less than 140/90 mm Hg

B. Less than 130/85 mm Hg
C. Less than 130/80 mm
D. Less than 120/80 mm

15. Which of the following is preferred as initial antihypertensive therapy for a 64-year-old woman
who is diagnosed with hypertension and has a history of ischemic stroke (6 month ago), with a BP of
166/108 mm Hg (164/106 mm Hg when repeated)?

A. Thiazide diuretic with an ACE inhibitor

B. Thiazide diuretic with a non-selective B-blocker
C. A thiazide-type diuretic alone
D. ACE inhibitor alone

16. Mrs. Tigist is a 74-year-old female presenting to clinic for HF follow-up. She is classifi NYHA FC III.
Her BP is 144/82, and most recent EF is 26%. Her current medic regimen includes lisinopril 20 mg daily,
digoxin 0.125 mg daily, and furosemide 20 mg a day. Which of the following would be the best choice
to add at this time?

A. Hydrochlorothiazide
B. Hydralazine and isosorbide
C. Spironolactone
D. Metoprolol

17. A patient with exertional angina has chest pain after walking three blocks. Isos dinitrate (ISDN) 10
mg q6h (6 A.M., 12 noon, 6 P.M., and 12 midnight) is started. days after starting ISDN, the patient can
walk four blocks without chest pain. One later, the patient can walk only two blocks without chest
pain. Which of the followings most appropriate action?

A. Decrease the ISDN dose to 5 mg tid.

B. Increase the ISDN dose to 20 mg q6h.
C. Change to nitroglycerine ointment applied for a 24-h period.
D. Decrease the ISDN dosing interval to 6 A.M., 12 noon, and 6 P.M

18. Which of the following therapies reduce the risk of mortality, heart failure, reinfarct stroke
following MI from either STE or NSTE ACS, patients should receive induced treatment with

A. Aspirin
B. B-blocker

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C. ACE inhibitor
D. All

19. The most common cause of an acute coronary syndrome (ACS) is:

A. Gradual narrowing of a coronary artery, decreasing coronary artery blood flow

B. Increased myocardial oxygen demand
C. Atherosclerotic plaque rupture with superimposed clot
D. Coronary artery spasm

20. Which of the following correctly characterizes the clinical presentation of STE MI?

A. Chest pain is an infrequent Boding in patent with an ML

B. All patients with MI have chest pain
C. Chest pain is the sole diagnostic determinant of ML
D. Chest pain may occur together with diaphoresis, nausea or vomiting and shortness of breath

21. Which of the following best describes a patient with NSTE ezgan (303 who is a candidate for
treatment with diltiazem(Calcium ch

A. Heart failure while receiving metoprolol

B. Continued chest discomfort despite nitrates and ancil
C. Heart rate of 55 bpm while receiving anmolal
D. Stable chronic obstructive pulmonary disease

22. Key findings on ECG indicating myocardial damage

A. ST-segment elevation
B. ST-segment depression
C. T-wave invention
D. All of the beve

23. Mr. Kebede is a 55-year- old man with seated office blood pressure (3 mm Hg and 138/72 mm Hg.
He is asked to return in 2 weeks for gen are 138/68 and 134/71 mm Hg. Which of the following
classifies Mabel's P

A. Isolated systolic hypertension

B. Stage 1 hypertension
C. Polyamin
D. Optimal BP

24. Effective lifestyle modifications to lower BP

A. Weight reduction to maintain normal body weight

B. Dietary sodium restriction
C. Moderation of alcohol consumption
D. All of the above are effective in lowering 32

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OTHER QUESTIONS

6.Mrs. Alimaz is a 40-year-old woman with stage 1 hypertension for the past 2 years that has been
well controlled (BP range of 100-110/60-65 mm Hg for more than 1 year) on lisinopril, 5 mg once daily.
She has successfully implemented lifestyle modifications, losing 14 kg (30 lb) and obtaining a body
mass index of 21 kg/m2. She informs you she is going to start trying to get pregnant. What changes
should be instituted with her antihypertensive therapy at this time?

A. Discontinuing lisinopril and monitoring BP closely with lifestyle modifications

B. Discontinuing lisinopril and initiating methyldopa
C. Continuing lisinopril because her BP is well controlled
D. Reducing lisinopril dose to 2.5 mg daily and maintaining lifestyle modifications

7. A 67-year-old man with a recent myocardial infarction has an average BP of 148/86 mm Hg and a
pulse of 76 bpm. Which of the following antihypertensive agents is preferred in this setting?

E. Metoprolol tartrate
F. Hydrochlorothiazide
G. Spironolactone
H. All of the above

8. Which of the following are potential causes of resistant hypertension?

A. Obesity
B. Cyclosporine
C. Volume overload
D. All of the above

9. Which of the following treatments is most appropriate for a hypertensive emergency?

A. Normalization of BP within hours

B. Reduction in mean arterial pressure by 25% to 50% within minutes to hours
C. Reduction in mean arterial pressure up to 25% within minutes to hours
D. Administration of sublingual nifedipine

10. According to the American Heart Association, what is the target BP for a patient with left
ventricular dysfunction (heart failure)?

A. Less than 140/90 mm Hg

B. Less than 130/85 mm Hg
C. Less than 130/80 mm Hg
D. Less than 120/80 mm Hg

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11. Which of the following is preferred as add-on therapy for a patient who is status post-MI (1 month
ago) with a BP of 146/88 mm Hg (144/86 mm Hg when repeated) while treated with metoprolol XL
200 mg daily?

A. Hydrochlorthiazed
B. Valsartan
C. Amlodipine
D. Lisinopril

12. Which of the following is preferred as initial antihypertensive therapy for a 63-year-old woman
who is diagnosed with hypertension and has a history of ischemic stroke (6 months ago), with a BP of
166/108 mm Hg (164/106 mm Hg when repeated)?

A. A thiazide-type diuretic with an ACE inhibitor

B. A thiazide-type diuretic with a non-selective B-blocker
C. A thiazide-type diuretic alone
D. An ACE inhibitor alone

13. In order to minimize the risk of hypokalemia from diuretics, the most appropriate strategy would
include

A. Limiting the dose of hydrochlorothiazide to 12.5 to 25 mg.

B. Using loop diuretics.
C. Using potassium-sparing diuretics as the primary therapy.
D. Having all patients switch their dietary salt to potassium chloride salt substitutes

14. When patients with renal insufficiency develop severe cough from ACE inhibitors, what would be
the best alternative to provide renal protection?

A. Propranolol
B. Hydrochlorothiazide
C. Losartan
D. Clonidine

15. Which agent causes so much fluid retention and tachycardia that it should be used along with a
diuretic and a beta blocker?

A. Diltiazem
B. Minoxidil
C. Captopril
D. Losarta

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16. Which of the following agents would not be preferred for a hypertensive patient with heart failure
associated with left ventricular systolic dysfunction?

A. Carvedilol
B. Metoprolol Succinate SA
C. Lisinopril
D. Diltiazem

17. Cough is an adverse effect associated with which of the following medications?

A. Enalapril
B. Valsartan
C. Carvedilol
D. Spironolactone

18. Which of the following are risk factors for spironolactone-induced hyperkalemia?

A. Concomitant digoxin therapy

B. Increased peripheral edema
C. Concomitant furosemide therapy
D. Concomitant lisinopril therapy

Questions 19-23 pertain to the following case:

Mr. Dejene is a 58-year-old male who presents to the clinic today with complaints of increasing
shortness of breath (SOB) while dressing and carrying groceries and a 4.55 kg (10 lb) weight gain. A
few months prior, Mr. Dejene noticed episodes of waking in the middle of the night with SOB,
difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history
of osteoarthritis * 10 deg years, hypertension x 4 years, diabetes mellitus x 5 years, dylipidemia, and is
status postmyocardial infarction 2 years ago.

Physical exam reveals the following:

BP 148/96, pulse 98. Ht: 5 ^ prime 11^ prime prime (180 cm), Wt: 86 kg (189 lb; usual = 81 kg [178 lb)),
body mass index (BMI): 26.4 Kg / m * 2 (+) Jugular venous distention (JVD), (-) hepatojugular reflex (HJR)
or hepatomegaly,

► (+) S3, (+) 84

► ECG: regular rate/rhythm, evidence of old infarct

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► ECHO: Ejection fraction (EF) 33%

► CXR: Crackles bilaterally and cardiomegaly (enlarged heart)

► Labs:

Sodium: 142mEq / L (142mmol / L)

Potassium: 3.7mEq / L (3.7mmol / L)

Magnesium: 1.8mEq / L (0.9 mmol/L)

► SCr: 1.3mg / d * L (115mu*mol / L)

► Blood urea nitrogen (BUN): 22mg / d * L (7.8mmol / L)

Current medications:

 Aspirin 81 mg daily,
 Diltiazem 180 mg daily,
 Glipizide 10 mg twice daily for diabetes,
 Simvastatin 20 mg nightly at bedtime, and
 Ibuprofen 400 mg four twice daily

19. Which of the following finding(s) specifically indicate(s) presence of left ventricular systolic
dysfunction?

A. (+) S4
B. Cardiomegaly
C. Ejection fraction 33%
D. Hypertension

20. What is the most likely cause(s) of Dejene's heart failure (HF)?

A. Ischemic
B. Idiopathic, unknown cause
C. Viral cardiomyopathy
D. All of the above

21. Which of Mr. Dejene's medications can exacerbate HF?

A. Glipizide
B. Diltiazem
C. Ibuprofen
D. B and C

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22. Which of the following is true regarding Mr. Dejene's current New York Heart Association (NYHA)
functional class (FC) and American College of Cardiology/ American Heart Association (ACC/AHA) stage
of HF?

A. Class III, Stage B

B. Class III, Stage C
C. Class II, Stage B
D. Class II, Stage C

23. W/h of the following is the most appropriate acute treatment plan for Mr. Dejene's HF?

A. Add HCTZ 12.5 mg as daily, since renal function is above 30mL / m * in

B. Add HCTZ 25 mg as daily, increase dose of diltiazem to 240 mg Qday
C. Add furosemide 20 mg twice a day and lisinopril 20 mg as daily
D. Add furosemide 20 mg twice a day and discontinue diltiazem

24. Which of the following is true regarding ACE inhibitors in HF?

A. Are cornerstone of treatment for HF so that should be used in all stages of HF

B. Should be added once patient is symptomatic
C. Are less efficacious than angiotensin receptor blockers (ARBs)
D. Should be substituted by ARBs when patient suffer from angioedema

25. Mrs. Tigist is a 74-year-old female presenting to clinic for HF follow-up. She is classified as NYHA FC
III. Her BP is 144/82, and most recent EF is 26%. Her current medication regimen includes lisinopril 20
mg daily, digoxin 0.125 mg daily, and furosemide 20 mg twice a day. Which of the following would be
the best choice to add at this time?

A. Hydrochlorothiazide
B. Hydralazine and isosorbide
C. Spironolactone
D. Metoprolol

26. Mr. Yoseph is a 76-year-old male admitted to the hospital presenting with peripheral and
pulmonary edema, decreased urinary output, hypotension, and altered mental status. Pertinent
values: pulmonary capillary wedge pressure (PCWP) * 22 , cardiac index (CI) 1.9.

Based on his presentation, what hemodynamic subset is he in?

A. I
B. II
C. III
D. IV

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27. Which of the following is a strategy used to overcome diuretic resistance in HF?

A. Decrease dosing frequency

B. Use of a combination of two loop diuretics
C. Utilizing a continuous infusion of a loop diuretic
D. Decrease overall dose

28. Which of the following is true regarding B-blockers in HF?

A. Used only in NYHA FC II due to potential for worsening HF symptoms

B. Atenolol, carvedilol, and metoprolol are shown to be equally efficacious in decreasing mortality
in HF
C. Chronic B-blockade decreases ventricular mass and improve ventricular shape
D. Starting dose for metoprolol succinate 50 mg as daily, titrated up to 200 mg as daily

29. Which one of the following is the recommended initial drug therapy for chronic, stable exertional
angina once PRN use of nitroglycerin is no longer adequate?

A. Beta blockers such as Atenolol 50 mg qd

B. Dihydropyridine CCBs such as Nifedipine 60 mg tid
C. Anticoagulants such as Warfarin 5 mg qd
D. Non Dihydropyridine CCBs such as Diltiazem SR 240 mg qd

30. A patient with exertional angina has chest pain after walking three blocks. Isosorbide dinitrate
(ISDN) 10 mg q6h (6 A.M., 12 noon, 6 P.M., and 12 midnight) is started. Three days after starting ISDN,
the patient can walk four blocks without chest pain. One month later, the patient can walk only two
blocks without chest pain. Which of the followings is the most appropriate action?

A. Decrease the ISDN dose to 5 mg tid.

B. Increase the ISDN dose to 20 mg q6h.
C. Change to nitroglycerine ointment applied for a 24-h period.
D. Decrease the ISDN dosing interval to 6 A.M., 12 noon, and 6 P.M

31. Aspirin should be given to all pts with angina unless contraindications exist because aspirin has
been shown to reduce the risk of MI and coronary heart disease death.

A. The statement is true, and the reason is true.

B. The statement is true, but the reason is false.
C. The statement is false, but the reason is true.
D. The statement is false and the reason is false

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32. Which of the following is an adverse effect of immediate-release nifedipine that limits its use for
Ischemic Heart Diseases such as chronic stable angina?

A. Reflex Tachycardia
B. Bradycardia
C. Hypertension
D. Hypotension

33. Which one of the following should not be used in the treatment of variant (Prinzmetal's angina)?

A. Isosorbide mononitrate
B. Metoprolol
C. Diltiazem
D. Verapamil

34. Which of the following best describes a patient with NSTE acute coronary syndrome (ACS) who is a
candidate for treatment with diltiazem?

A. Heart failure while receiving metoprolol

B. Continued chest discomfort despite nitrates and atenolol
C. Heart rate of 55 bpm while receiving atenolol
D. All

35. Which of the following therapies reduce the risk of mortality, heart failure, reinfarction, or stroke
following MI from either STE or NSTE ACS, patients should receive indefinite treatment with

A. Aspirin
B. B-blocker
C. ACE inhibitor
D. All

36. The most common cause of an acute coronary syndrome (ACS) is:

A. Gradual narrowing of a coronary artery, decreasing coronary artery blood flow

B. Increased myocardial oxygen demand
C. Atherosclerotic plaque rupture with superimposed clot
D. Coronary artery spasm

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37. Mrs. Almaz is a 33-year-old female just returned from vacation from Southeast Asia after Long-haul
air travel. She presents to the emergency department (ED) with shortness of breath and is
subsequently diagnosed with pulmonary embolism (PE). She weighs 110 kg (242 lb; body mass index
(BMI) 40). Medications on admission include: estrogen-containing oral contraceptives, ibuprofen PRN.
She smokes one pack of cigarettes per day and drinks alcoholic beverages three to four times per
week. The factors that predispose this patient for venous thromboembolism (VTE) include:

A. Sex, weight, smoking

B. Weight, recent immobility, estrogen use and smoking
C. Regular alcohol consumption, weight
D. Recent immobility, age, ibuprofen use

38. A 58-year-old female is hospitalized with severe congestive heart failure exacerbation. Which risk
category would best describe this patient's risk of VT E^ prime

A. Low
B. Moderate
C. High
D. None of the above

39. Mr. Kebede is diagnosed with a left lower extremity deep vein thrombosis (DVT) and is initiated on
enoxaparin and warfarin therapy. How long should enoxaparin and warfarin be overlapped?

A. For at least 4 days as long as the International Normalized Ratio (INR) is greater than 2
B. For at least 5 days and until the INR is greater than 2
C. For at least 7 days and until the INR is greater than 2
D. Enoxaparin therapy can be discontinued once INR is greater than 2, regardless of the length of
therapy

40. Kibrom is 6 weeks after a knee replacement surgery. He now presents with a right lower extremity
DVT. He is admitted for anticoagulation treatment with heparin and warfarin. He has no previous
history or thromboembolic events. Which of the following treatment options would be the best
recommendation in Kibrom's case?

A. Warfarin should be started on the first day with unfractionated heparin (UFH) therapy and
continued for 3 months
B. Warfarin should be started 5 days after UFH therapy and continued for 3 months
C. Warfarin should be started on the first day with UFH therapy and continued indefinitely
D. Warfarin should be started 5 days after UFH therapy and continued indefinitely

41. Aster is a 60-year-old female admitted to hospital and recently diagnosed with acute DVT.
Treatment has been initiated with UFH. Twelve hours later her aPTT is greater than 200 seconds and

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she is noted to have bright red blood per rectum. Which of the following is true regarding the
management of this patient?

A. Hold heparin therapy and treat the source of bleeding

B. Hold heparin therapy and give vitamin K via slow IV infusion
C. Hold heparin therapy and give recombinant factor VII
D. Hold heparin therapy, give protamine sulfate via slow IV infusion, and treat the source of
bleeding

42. Which of the following is the recommended initial treatment option in a patient with an acute DVT
and with heparin-induced thrombocytopenia (HIT)?

A. LMWH
B. Warfarin
C. Fondaparinux
D. None of the above

43. Which of the following is the acceptable treatment option for a pregnant patient (first trimester)
with a newly diagnosed acute PE?

A. Warfarin
B. UFH
C. Enoxaparin
D. B and C

44. Which anticoagulant is preferred for the initial/Acute treatment of patients with a diagnosis of
VTE?

A. Aspirin
B. LMW Heparin
C. Warfarin
D. None of the above

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