2012 Local Competition Exam Key Final

8/9/2019 2012 Local Competition Exam Key Final

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2012 ACCP Clinical Pharmacy Challenge

Local Competition Exam Key

The following examination will consist of three (3 segments!

Tri"ia#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 thissement will be selected from the followin cateories!

• Pharmacology "includin# but not limited to# mechanism of action# adverse effect

profiles# dru interactions# dosin# approved indications# and monitorin parameters$

• Pharmacokinetics/Pharmacodynamics and/or Pharmacogenomics

• Clinical Pharmacy History

Biostatistics

Health Outcomes

Clinical Case

Participants will be presented with a clinical case vinette "5%% words or less$ and a series of five

one-best-answer questions based on the information in the case te&t and'or supportin laboratory#

physical e&amination# and'or medical history information contained therein. Point values for each

question in this cateory will be assined on the basis of difficulty "one 1%%-point item# two (%%-

point items# and two )%%-point items$.

$eopar%y &tyle

Participants will have an opportunity to answer questions of varyin point values "1%%# (%%# or

)%% points$ in five predetermined cateories and may answer as many as possible within the

allotted time. *ll items in this sement will be multiple choice. +tems in the sement will beselected from five "5$ of the followin cateories!

Anticoagulation Asthma/COPD Biostatistics

Cardiovascular Disorders Clinical Trial Design Critical Care

Dermatology Drug Information Emergency edicine

Endocrinology !eriatrics !I/"iver/#utrition

Hematology/Oncology Immunology/Trans$lantation Infectious Diseases

#e$hrology Pain and Palliative Care Pediatrics

Psychiatry/C#% Disorders &accinations 'omen(s Health

, / central nervous system0 ,P2 / chronic obstructive pulmonary disease0 3+ /

astrointestinal.

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.

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2012 ACCP Clinical Pharmacy Challenge

Local Competition Examination

Tri"ia#Lightning &ection

This section consists of 15 items. Each correct answer is worth 75 points. Please circle your

answer for each question.

Question 1

4hich diuretic would cause increased e&cretion of sodium# potassium# manesium# and calcium

and would promote the reabsorption of uric acid

1. 6umetanide

(. ydrochlorothia8ide ",T9$

). pironolactone:. Triamterene *nswer! 1. 6umetanide

;ationale! The correct answer is bumetanide. ,T9 decreases the e&cretion of calcium.

pironolactone and triamterene are potassium sparin.

,itation! 2rus for hypertension. Treat 3uidel 07!1?1%.

Question 2

4hich antimicrobial has nearly equivalent oral and parenteral bioavailability

1. *mpicillin(. ,efuro&ime

). =ine8olid

:. @ancomycin

*nswer! ). =ine8olid

;ationale! =ine8olid has a documented oral bioavailability of nearly 1%%A.

,itation! =ine8olid Bprescribin informationC. ew Dor! Pharmacia and Fpjohn# (%1(.

Question 3

4hich dru would require a dosin adjustment for a documented creatinine clearance of less than

)% m='minute

1. ,eftria&one

(.


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:. ;anitidine

*nswer! :. ;anitidine

;ationale! 2osae adjustments are only necessary for ranitidine with a creatinine clearance of )5

m='minute. The rest do not need adjustments.

,itation! ;anitidine Bprescribin informationC. Princeton# G! ando8# (%11.

Question 4

4hich aent is the best treatment option for a patient tain warfarin with an international

normali8ed ratio of 11.% and no sins of bleedin

1. ,yanocobalamin(. Phytonadione

). Protamine

:. Tocopherol

*nswer! (. Phytonadione

;ationale! The correct answer is phytonadione "vitamin H$. 4arfarin acts as an anticoaulant

throuh inhibition of the vitamin H?dependent clottin factions ++# @++# +I# and I. *dministration

of phytonadione is indicated in warfarin overdose. Protamine is used to reverse heparin overdose.

Tocopherol is a form of vitamin E and has no role in reversin warfarin overdose.

,yanocobalamin is vitamin 61( and is commonly used to treat pernicious anemia.

,itations! olbroo *# hulman # 4itt 2


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Question 6* 5-year-old boy is iven a dianosis of mild croup. 4hich medication would be most

appropriate to recommend

1. ral de&amethasone

(. ebuli8ed albuterol

). ebuli8ed racemic epinephrine

:. ebuli8ed )A saline

*nswer! 1. ral de&amethasone

;ationale! The correct answer is 1# oral de&amethasone "it is used to decrease pharyneal

inflammation$. ;acemic epinephrine is first line but# in severe episodes# not mild. *lbuterol is

beta-specific and will not help with edema in the upper airway. This is also true for )A saline#

which is used in bronchiolitis.

,itation! 6jornson ,# Gohnson 24. ,roup. =ancet (%%J0)71!)(>?)>.

Question 7

*n elderly nursin home resident develops diarrhea that is caused by Clostridium difficile. 4hichaent is contrain%icate%

1. ,holestyramine

(. 2ipheno&ylate'atropine

). Haolin-pectin

:. Psyllium

*nswer! (. 2ipheno&ylate'atropine

;ationale! The correct answer is dipheno&ylate'atropine. 4ith to&in-mediated diarrhea# use of

aents to slow motility would be contraindicated. +n addition# this aent should be avoided inelderly patients# if possible# because of the increased ris of anticholineric adverse effects in this

population. Haolin-pectin# cholestyramine# and psyllium are all acceptable options for symptomcontrol for this type of diarrhea.

,itation! ral =omotil# 2ru-2isease ,ontraindications. *vailable at

http!''www.medscape.com'druinfo'dosae

druid/MJ7MNdruname/=omotilOralNmonotype/default. *ccessed


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*nswer! ). 5 patients

;ationale! The correct answer is 5. The T is calculated as 1'absolute ris reduction "*;;$. +n

this case# the *;; is %.( "difference in event rates between dru and placebo / %.(5 %.%5$. The

relative ris ";;$ is %.( "event rate dru'event rate placebo / %.%5'%.(5$# and the ; "odds ratio$

is %.( "odds of event on dru'odds of event on placebo / B5'(5C'B>5'75C$.

,itation! ;ieelman ;H# irsch ;P. tudyin a tudy and Testin a Test! ow to ;ead the ealth

cience =iterature# )rd ed. Philadelphia! =ippincott-;aven# 1>>M!))# )5# 5(.

Question 9

4hich sedative is most liely to cause transient adrenal insufficiency when used for rapid

sequence intubation

1. Etomidate

(. Hetamine

).


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4hich condition may result in a %ecrease in total phenytoin concentration in patients whoroutinely tae phenytoin

1. *ddition of isonia8id therapy

(. ,hronic alcohol abuse

). tae ++ chronic idney disease ",H2$

:.


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they provide analesia within hours after application. @enlafa&ine and nortriptyline must beadministered for at least 1?( wees before a therapeutic response is seen and therefore may not

be considered first-line therapy. 2iclofenac and other nonsteroidal anti-inflammatory drus

"*+2s$ are not typically effective for the manaement of neuropathic pain.

,itation! 2worin ;# L,onnor *6. Pharmacoloic manaement of neuropathic pain!

evidence-based recommendations. Pain (%%701)(!()7?51.

Question 14

4hich cytochrome P:5% ",DP$ isoen8yme is ). ,DP(,1>

:. ,DP)*:

*nswer! ). ,DP(,1>

;ationale! ,ompetitive inhibition of ,DP(,1> by proton pump inhibitors decreases theavailability of the active metabolite of clopidorel and thereby decreases its effect on platelet

function.

,itation! ;iche 2


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Clinical Case &egment

#ou have reached the end of theTrivia/$ightning "egment of the exam.

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

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This sement consists of a case vinette and five items based on the vinette information.

Case 'ignette!

* MM-year-old man presents to clinic for his routine visit. e has had increasin fatiue durin the

past month that interferes with his daily activities. e has nee pain when he plays olf# for

which he self-medicates with over-the-counter napro&en. e is adherent to all of his prescribed

therapy# includin dietary restrictions.

e%ical )istory!

ypertension

2iabetes mellitus

,hronic idney disease ",H2$ secondary to hypertension

3out

3astroesophaeal reflu& disease "3E;2$6enin prostatic hyperplasia "6P$

steoarthritis

C*rrent e%ications!

3lipi8ide 1% m'day & M years

+nsulin larine 15 units at bedtime & ) monthsEnalapril :% m'day & M years

*llopurinol 1%% m'day & M years

2o&a8osin : m at bedtime & ( years

;anitidine 75 m'day & 5 years

,alcium carbonate 5%% m ) times'day with meals & M months

apro&en (5% m twice daily & ( wees

+ecent La,oratory 'al*es!

odium 1)M mEq'= "1)M mmol'=$

Potassium :.7 mEq'= ":.7 mmol'=$

,hloride 1%1 mEq'= "1%1 mmol'=$

,) () mEq'= "() mmol'=$6lood urea nitroen "6F$ :: m'd= "15.7 mmol'=$

erum creatinine ",r$ ).( m'd= "(J( micromoles'=$

Estimated lomerular filtration rate ".> 'd= ">> '=$

ematocrit (>.MA "%.(>M$

Platelet count 175#%%%'microliter "175 & 1%>'=$

Kerritin 1(% n'm= "(7% pmol'=$

Transferrin saturation ()A

Procee% to the following page to answer Clinical Case -*estions 1./

-*estion 1 . 100 points

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The patient has which complication of ,H2

1. *nemia

(. yperalemia

). % m'd= ":.>1 mmol'=$

*nswer! 1. =ess than 1%% m'd= "(.5> mmol'=$

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;ationale! ,H2 is considered a coronary artery disease ris equivalent. +n addition# this patienthas type ( diabetes mellitus# which is considered a coronary heart disease ",2$ ris equivalent.

Kor this reason# the =2= oal for this patient should be that of the hihest ris roup. 6ased on

the ational ,holesterol Education Proram *dult Treatment Panel +++ ",EP *TP +++$

uidelines# the =2= oal for the hihest ris roup is less than 1%%# with an alternate oal of less

than 7%.

,itations! *merican eart *ssociation ,ouncils on Hidney in ,ardiovascular 2isease# ih

6lood Pressure ;esearch# ,linical ,ardioloy# and Epidemioloy and Prevention. Hidney diseaseas a ris factor for development of cardiovascular disease. ,irculation (%%)01%J!(15:?M>.

The Third ;eport of the E&pert Panel on 2etection# Evaluation# and Treatment of ih 6lood

,holesterol in *dults. *TP ) Kinal ;eport. *vailable at

http!''www.nhlbi.nih.ov'uidelines'cholesterol'atp)full.pdf. *ccessed . *vailable at

http!''www.nhlbi.nih.ov'uidelines'cholesterol'atp)upd%:.pdf. *ccessed


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-*estion / . 300 points

6y what mechanism could the patientLs choice of napro&en be adversely affectin his renal

function

1. 2irect to&ic effect on the renal tubules

(. ,onstriction of the afferent arteriole

). 2ilation of the efferent arteriole

:. 2ecreased tubular reabsorption of sodium

*nswer! (. ,onstriction of the afferent arteriole

;ationale! *+2s such as napro&en can cause many different types of injury to the idney. The

most liely short-term problem with tain an *+2 for this patient is functional acute idney

injury# resultin from a decreased production of vasodilatory prostalandins# which act on the

afferent arterioles of the idney. +n patients who rely on afferent arteriole vasodilation to maintain

their 3K;# this causes a drop in 3K;. ,hoice 1 is incorrect because there is no direct to&ic effect

on the renal tubules. ,hoice : is incorrect because the inhibition of P3E( syntheses can lead toincreased sodium reabsorption# causin peripheral edema# which is the most common renal effect

of *+2s. Edema and sodium retention are usually mild# resultin in weiht ain of 1?( .

,itation! *beulo G3. ormotensive ischemic acute renal failure. Enl G 7? J%5.

$eopar%y &egment

This sement will consist of 15 items in five predetermined cateories. Point values for each item

are indicated below. Please circle your answer for each item.

#ou have reached the end of the%linical %ase "egment.

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

Team/ndividual D !!!!!!!!!!!!!!!!!!!!!!!!!!!!! %ase "egment "core !!!!!!!!

For Administrative Use Only

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Car%io"asc*lar isor%ers

Item 1 (100 points)

The F.. Preventive ervices Tas Korce "FPTK$ recommends aspirin for the primary

prevention of cardiovascular disease in a M(-year-old man when his 1%-year ,2 ris is equal to

or reater than what level!

1. )A

(. 5A

). 7A

:. >A

*nswer! :. >A

;ationale! The FPTK created a recommendation statement on the use of R*spirin for the

Prevention of ,ardiovascular 2isease.S +n this statement# the FPTK balances the ris of ,2with the ris of bleedin in patients usin aspirin for the primary prevention of ,2. The cut

point for benefit in the male ae roup of M%?M> is havin a 1%-year ,2 ris of >A or more.

,itation! F.. Preventive ervices Tas Korce. *spirin for the prevention of cardiovascular

disease! F.. Preventive ervices Tas Korce recommendation statement. *nn +ntern 015%!)>M?:%:.

Item 2 (200 points)

4hich medication is considered the first-line aent for the treatment of le pain secondary to

intermittent claudication

1. *spirin

(. ,ilosta8ol). ,lopidorel

:. Pento&ifylline

*nswer! (. ,ilosta8ol

;ationale! The treatment of choice for patients e&periencin le pain caused by intermittent

claudication is cilosta8ol. Pento&ifylline has been shown to be comparable to placebo0 therefore#

the *merican ,ollee of ,ardioloy'*merican eart *ssociation "*,,'**$ uidelines have

desinated it a second-tier therapy. *lthouh aspirin and clopidorel are used for peripheral

arterial disease to reduce cardiovascular mortality# these aents have not shown a reduction in

ischemic le pain.

,itation! irsch *T# asal 9G# ert8er ;# et al. *,,'** uidelines for the manaement of

patients with peripheral arterial disease "lower e&tremity# renal# mesenteric# and abdominal

aortic$! e&ecutive summary! a collaborative report from the *merican *ssociation for @ascular

urery'ociety for @ascular urery# ociety for ,ardiovascular *nioraphy and +nterventions#

ociety for @ascular


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the 3uideline for the


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* MJ-year-old woman with hypertension# chronic heart failure# and stae ) ,H2 has just receiveda dianosis of type ( diabetes mellitus. =aboratory values include hemolobin *1c J.JA# serum

creatinine ",r$ 1.M m'd=# potassium :.% mEq'=# aspartate aminotransferase 1J +F'=# and

alanine aminotransferase (% +F'=. 4hich of the followin is the most appropriate initial therapy

1. 3lipi8ide

(. 0)(!1>)?(%).

Item 2 (200 points)

* M5-year-old woman with hypothyroidism treated with levothyro&ine %.75 m'day has been

euthyroid for the past : years. ince her last clinic visit M months ao# she has been iven

dianoses of hyperlipidemia# osteoporosis# and nonvalvular atrial fibrillation# and she has been

initiated on the followin medications!

*lendronate 7% m once weely

,alcium carbonate 1(%% m'vitamin 2 J%% +F supplement daily

imvastatin (% m'day

4arfarin (.5 m'day

er thyroid-stimulatin hormone "T$ level today is M.> m+F'=. 4hich medication most liely

contributed to the loss of a euthyroid state

1. *lendronate

(. ,alcium carbonate'vitamin 2 supplement

). imvastatin

:. 4arfarin

*nswer! (. ,alcium carbonate'vitamin 2 supplement

;ationale! ,alcium carbonate decreases the absorption of levothyro&ine# thereby decreasinT)'T: levels# which results in an increased T. There is no interaction between levothyro&ine

and alendronate or simvastatin. 4arfarin does not affect levothyro&ine levels0 however# a chane

in thyroid status can affect the metabolism of vitamin H?dependent clottin factors and

precipitate a need for altered warfarin dosin.

,itation! ynthroidV "=evothyro&ine$ Bprescribin informationC. orth ,hicao# +=! *bbott

=aboratories# (%11.

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Item 3 (300 points)

* 7(-year-old woman presents with lower bac pain. he has a history of vertebral-crush

fractures caused by osteoporosis "T-score of ).% at spine$. he has severe astroesophaeal

reflu& disease "3E;2$. 4hich is the most appropriate initial treatment

1. *lendronate

(. ,alcitonin). Teriparatide

:. 9oledronic acid

*nswer! :. 9oledronic acid

;ationale! The correct answer is 8oledronic acid for this patient because of the type of fractureand the presence of 3E;2. 6isphosphonates such as an alendronate would be the initial choice0

however# because this patient has severe 3E;2# only an intravenous bisphosphonate would be an

option. Teriparatide would be a second-line choice or first line if the T-score were ).5.

,alcitonin is a fourth-line choice in this patient. *lthouh pain relief is believed to be a benefitwith calcitonin# current practice is to manae pain and fracture ris separately.

,itation! 3audio *#


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+n which clinical situation would a shoc be recommended durin resuscitation efforts when there

is no pulse

1. *systole

(. *trial fibrillation

). Kirst-deree heart bloc

:. @entricular fibrillation

*nswer! :. @entricular fibrillation

;ationale! The *dvanced ,ardiac =ife upport "*,=$ ,ardiac *rrest alorithm within the

cardiopulmonary resuscitation and emerency cardiovascular care uidelines by the ** has two

major branches! rhythms that are amenable to shoc and those that are not. @entricular fibrillation

and ventricular tachycardia can be shoced0 it is recommended that asystole and pulselesselectrical activity not be shoced. 6oth atrial fibrillation and first-deree heart bloc would be

considered pulseless electrical activity in the above question because the victim has no pulse.

,itation! eumar ;4# tto ,4# =in ?7M7.

Question 2 (200 points)

* patient presents to the emerency department with sedation# miosis# and decreased bowel

sounds. ;espiratory rate is M breaths'minute0 temperature is >J.(WK ")7.(W,$. 4hich medication

would liely cause this collection of symptoms

1. 6en8tropine

(. &ycodone

). Kluo&etine

:.


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1. =ithium inestion :5 minutes ao(. Herosene inestion 5 minutes ao

). *cetaminophen >% minutes ao

:. 2io&in 5( minutes ao

*nswer! :. 2io&in 5( minutes ao

;ationale! *ctivated charcoal is most beneficial when used within M% minutes of the inestion.

There are situations within this window when activated charcoal is not indicated# includin drusthat do not bind well to activated charcoal "lithium$ or when there is a ris of aspiration

"erosene# a hydrocarbon$.

,itation! *merican *cademy of ,linical To&icoloy and European *ssociation of Poison ,enters

and ,linical To&icoloists. Position paper! sinle-dose activated charcoal. ,lin To&icol

(%%50:)!M1?J7.

Psychiatry#C& isor%ers

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Item 1 (100 points)

* patient presents to the emerency department e&periencin dru withdrawal. 4hich dru poses

the reatest ris of death because of withdrawal

1. ,ocaine

(. *mphetamines

).


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http!''www.psychiatryonline.com'prac3uide'prac3uide,hapTocQ7.asp&. *ccessed


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4hat is the most appropriate empiric treatment reimen for a patient with community-acquired pneumonia who needs admission to the eneral medical ward of a hospital

1. 2o&ycycline and a8ithromycin

(. ,eftria&one and a8ithromycin

).


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is initial laboratory values are!+@ viral load ? M(5#%%% copies'm=

,2: count ? 75 cells'microliter "%I %.%75 & 1%>'=$

6@ viral load ? 5%% copies'm=

,r and liver en8ymes are within normal limits.

The +@ enotype reveals no sinificant mutations.

4hich reimen would be the best recommendation for initial therapy in this patient

1. Efaviren8'tenofovir'emtricitabine 1 tablet by mouth once daily

(. Tenofovir'emtricitabine 1 tablet by mouth once daily# ritonavir 1%% m by mouth once

daily# and ata8anavir )%% m by mouth once daily

). *bacavir'lamivudine 1 tablet by mouth once daily# ritonavir 1%% m by mouth once daily#

and ata8anavir )%% m by mouth once daily

:. Tenofovir'emtricitabine 1 tablet by mouth once daily and lopinavir'ritonavir :%%-m'1%%-m tablet ( tablets by mouth twice daily

*nswer! (. Tenofovir'emtricitabine "Truvada$ 1 tablet by mouth once daily# ritonavir "orvir$ 1%%

m by mouth once daily# and ata8anavir ";eyata8$ )%% m by mouth once daily

;ationale! *ccordin to F.. 2epartment of ealth and uman ervices "2$ uidelines#first-line hihly active antiretroviral therapy "**;T$ reimens should include a bacbone of

two nucleoside reverse transcriptase inhibitors ";T+s$# with tenofovir'emtricitabine "Truvada$ as

the preferred ;T+s.

2012 Local Competition Exam Key Final

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