CGP
- Cardiovascular
- Endocrine
- Geriatrics
- Gastrointestinal disorder
- Infectious disease
- Men’s and women’s health
- Neurology
- Oncology
- Ophthalmic and otics
- Pain management
- Psychiatric
- Renal disease / fluids & electrolytes
- Respiratory
- Skin conditions
- Pharmacokinetics-Pharmacodynamics
- Biostatistics and pharmacoeconomics
- Pharmacy policy, procedure and regulations
The questions in this section are intended to test your knowledge and skills on Geriatric Pharmacy including biostatistics for practicing pharmacist and pharmacist preparing for CGP (Board Certified Geriatric Pharmacist).
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CGP | Psychiatric
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Question 1 |
LJ is a 77 year old female, who was brought by paramedics to ER from an assisted living facility with altered mental status, sluggishness, ataxia, confusion, agitation and severely low blood pressure. LJ is 5 feet 5 inches tall, wt. 75kg and NKDA. Her past medical history includes hypertension, GERD, asthma, osteoarthritis, depression, anxiety and bipolar disorder. Urinalysis is negative, chest x-ray show no evidence of active cardiopulmonary disease. Brain CT show no abnormality except for age related cortical atrophy. Pertinent labs includes sodium 138 mmol/L, potassium 4.5 mmol/L, carbon dioxide 30 mmol/L, creatinine 2.8 mg/dl, lithium level 4.3 mmol/L, lipase 668 units/L, albumin 3.1 g/dL, calcium 10 mg/dL, glucose 93mg/dL, BUN 36mg/dL. LJ’s home medications includes acetaminophen, lorazepam, albuterol inhalation, methocarbamol, furosemide, lamotrigine, lisinopril, lithium, gabapentin, primidone, lovastatin, pantoprazole, paroxetine.
What is the most likely cause of her altered mental status?
Pancreatitis | |
Serotonin syndrome | |
Neuroleptic malignant syndrome | |
Lithium toxicity |
Question 1 Explanation:
Answer D. This patient exhibits the signs of symptoms of lithium intoxication, as evidenced by cardiovascular effects of: bradycardia and hypotension, neurological effects of: altered mental status, confusion, sluggishness and ataxia, electrolyte disturbances of: hypoglycemia, elevated scr, elevated potassium, and elevated serum lithium levels (>2 mmol/L is considered toxic). Altered mental status is a main side effect of lithium poisoning, though patients can present as asymptomatic at acute levels of toxicity. The toxic lithium level rules out the other answer choices for this question. In addition, the patient does not present as afebrile and does not have a clear history of taking psychiatric medications (which is diagnostic criteria for serotonin syndrome and neuroleptic malignant syndrome).
Reference:
Balkhi SE, Mégarbane B. Lithium Toxicity: Clinical Presentations and Management. The Science and Practice of Lithium Therapy. 2016:277-292. doi:10.1007/978-3-319-45923-3_17.
Management of lithium toxicity. Inpharma Weekly. 1997;&NA;(1073):20. doi:10.2165/00128413-199710730-00040.
Reference:
Balkhi SE, Mégarbane B. Lithium Toxicity: Clinical Presentations and Management. The Science and Practice of Lithium Therapy. 2016:277-292. doi:10.1007/978-3-319-45923-3_17.
Management of lithium toxicity. Inpharma Weekly. 1997;&NA;(1073):20. doi:10.2165/00128413-199710730-00040.
Question 2 |
LJ is a 77 year old female, who was brought by paramedics to ER from an assisted living facility with altered mental status, sluggishness, ataxia, confusion, agitation and severely low blood pressure. LJ is 5 feet 5 inches tall, wt. 75kg and NKDA. Her past medical history includes hypertension, GERD, asthma, osteoarthritis, depression, anxiety and bipolar disorder. Urinalysis is negative, chest x-ray show no evidence of active cardiopulmonary disease. Brain CT show no abnormality except for age related cortical atrophy. Pertinent labs includes sodium 138 mmol/L, potassium 4.5 mmol/L, carbon dioxide 30 mmol/L, creatinine 2.8 mg/dl, lithium level 4.3 mmol/L, lipase 668 units/L, albumin 3.1 g/dL, calcium 10 mg/dL, glucose 93mg/dL, BUN 36mg/dL. LJ’s home medications includes acetaminophen, lorazepam, albuterol inhalation, methocarbamol, furosemide, lamotrigine, lisinopril, lithium, gabapentin, primidone, lovastatin, pantoprazole, paroxetine.
What is the most appropriate treatment for her severely low blood pressure?
NS 1000ml bolus | |
Norepinephrine drip | |
Midodrine 5mg orally X1 | |
Albumin 25gm X1 |
Question 2 Explanation:
Answer A. Patients presenting with lithium toxicity are often dehydrated allowing the lithium to concentrate in the blood. Normal saline will rehydrate the patient and in addition to restoring blood pressure help to dilute the lithium in the blood. It is recommended that at least 1-2 L’s be given as a bolus dose. Norepinephrine is frequently utilized for patients with severe hypotension but can only be used after a patient has received adequate fluids. Because the patient is likely dehydrated administering norepinephrine may cause harm to the patients periphery. While mildodrine can be used in severe cases, it is most often reserved for patients who are experiencing orthostatic hypotension and is recommend to start at a dose of 10 mg three times daily. Albumin is not recommended because this patient is dehydrated.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 3 |
LJ is a 77 year old female, who was brought by paramedics to ER from an assisted living facility with altered mental status, sluggishness, ataxia, confusion, agitation and severely low blood pressure. LJ is 5 feet 5 inches tall, wt. 75kg and NKDA. Her past medical history includes hypertension, GERD, asthma, osteoarthritis, depression, anxiety and bipolar disorder. Urinalysis is negative, chest x-ray show no evidence of active cardiopulmonary disease. Brain CT show no abnormality except for age related cortical atrophy. Pertinent labs includes sodium 138 mmol/L, potassium 4.5 mmol/L, carbon dioxide 30 mmol/L, creatinine 2.8 mg/dl, lithium level 4.3 mmol/L, lipase 668 units/L, albumin 3.1 g/dL, calcium 10 mg/dL, glucose 93mg/dL, BUN 36mg/dL. LJ’s home medications includes acetaminophen, lorazepam, albuterol inhalation, methocarbamol, furosemide, lamotrigine, lisinopril, lithium, gabapentin, primidone, lovastatin, pantoprazole, paroxetine.
Which of the following medication can cause lithium toxicity?
Lisinopril | |
Pantoprazole | |
Paroxetine | |
Lisinopril and pantoprazole |
Question 3 Explanation:
Answer A. Medications that have the potential to be nephrotoxic, such as lisinopril can induce lithium toxicity. Pantoprazole is not nephrotoxic, so can be used safely with lithium. While paroxetine should in caution with lithium (serotonin syndrome), it is not nephrotoxic and is therefore not the best answer choice.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 4 |
Which of the following conditions can increase the risk of lithium toxicity?
Advanced age | |
Dehydration due to diuretics | |
Reduced renal function | |
All of the above. |
Question 4 Explanation:
Answer D. Patients with advanced age are at a higher risk of lithium toxicity, as geriatric populations most often experience a reduction in renal function (decreased GFR and volume of distribution), which can lead to decreased excretion of lithium, resulting in toxicity. Patients who are dehydrated due to diuretics are also at an increased risk of toxicity, as these drugs have the potential to be nephrotoxic and can greatly affect essential electrolyte (i.e. sodium) levels.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 5 |
LJ is a 77 year old female, who was brought by paramedics to ER from an assisted living facility with altered mental status, sluggishness, ataxia, confusion, agitation and severely low blood pressure. LJ is 5 feet 5 inches tall, wt. 75kg and NKDA. Her past medical history includes hypertension, GERD, asthma, osteoarthritis, depression, anxiety and bipolar disorder. Urinalysis is negative, chest x-ray show no evidence of active cardiopulmonary disease. Brain CT show no abnormality except for age related cortical atrophy. Pertinent labs includes sodium 138 mmol/L, potassium 4.5 mmol/L, carbon dioxide 30 mmol/L, creatinine 2.8 mg/dl, lithium level 4.3 mmol/L, lipase 668 units/L, albumin 3.1 g/dL, calcium 10 mg/dL, glucose 93mg/dL, BUN 36mg/dL. LJ’s home medications includes acetaminophen, lorazepam, albuterol inhalation, methocarbamol, furosemide, lamotrigine, lisinopril, lithium, gabapentin, primidone, lovastatin, pantoprazole, paroxetine.
Now that we know LJ is in with lithium toxicity what should be monitored besides the lithium levels?
Thyroid function | |
Serum sodium | |
Electrocardiogram | |
All of the above |
Question 5 Explanation:
Answer D. The patients thyroid function (TST) levels should be monitored, due to the fact that lithium toxicity can cause both hypothyroidism and hyperthyroidism. Serum sodium should also be monitored every 6-12 hours in the first 24-48 hours. Finally, the ECG should be monitored, as lithium toxicity can cause QT prolongation, arrhythmias, t-wave abnormalities, and bradycardia.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 6 |
What is the most appropriate treatment for her lithium toxicity besides ABC’s (airway, breathing, circulation) and supportive care?
Hydration and Oral activation charcoal | |
Hydration and polyethylene glycol | |
Hydration and hemodialysis | |
Hydration and sodium polystyrene sulfonate |
Question 6 Explanation:
Answer C. All patients with lithium levels >4 should receive hemodialysis. A combination of water solubility, a low molecular weight, small volume of distribution, and insignificant protein binding allow lithium to be readily eliminated by dialysis. Whole bowel irrigation with polyethylene glycol can be used to treat toxicity, but this procedure is only effective in acute cases or when patients have ingested sustained release formulations of the drug. Activated charcoal does not bind to lithium and will fail to influence its absorption. Kayexalate (sodium polystyrene sulfonate) is not recommended due to its potential to induce hypokalemia in an already dehydrated patient.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 7 |
LJ is a 77 year old female, who was brought by paramedics to ER from an assisted living facility with altered mental status, sluggishness, ataxia, confusion, agitation and severely low blood pressure. LJ is 5 feet 5 inches tall, wt. 75kg and NKDA. Her past medical history includes hypertension, GERD, asthma, osteoarthritis, depression, anxiety and bipolar disorder. Urinalysis is negative, chest x-ray show no evidence of active cardiopulmonary disease. Brain CT show no abnormality except for age related cortical atrophy. Pertinent labs includes sodium 138 mmol/L, potassium 4.5 mmol/L, carbon dioxide 30 mmol/L, creatinine 2.8 mg/dl, lithium level 4.3 mmol/L, lipase 668 units/L, albumin 3.1 g/dL, calcium 10 mg/dL, glucose 93mg/dL, BUN 36mg/dL. LJ’s home medications includes acetaminophen, lorazepam, albuterol inhalation, methocarbamol, furosemide, lamotrigine, lisinopril, lithium, gabapentin, primidone, lovastatin, pantoprazole, paroxetine.
What are the early symptoms of chronic lithium toxicity?
What are the early symptoms of chronic lithium toxicity?
Nausea, vomiting, diarrhea | |
Tremors, slurred speech | |
Diaphoresis, Hyper-salivation | |
All of the above |
Question 7 Explanation:
Tremors, slurred speech and other neurological manifestations are signs of chronic toxicity. Nausea, vomiting, and diarrhea are all acute symptoms. Lithium toxicity is often caused by dehydration, so diaphoresis and hyper-salivation are not correct.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 8 |
What are the early symptoms of chronic lithium toxicity?
Nausea, vomiting, diarrhea | |
Tremors, slurred speech | |
Diaphoresis, Hyper-salivation | |
All of the above |
Question 8 Explanation:
Answer B. Tremors, slurred speech and other neurological manifestations are signs of chronic toxicity. Nausea, vomiting, and diarrhea are all acute symptoms. Lithium toxicity is often caused by dehydration, so diaphoresis and hyper-salivation are not correct.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Reference:
Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. International Journal of Bipolar Disorders. 2015;3(1). doi:10.1186/s40345-015-0040-2.
Question 9 |
All of the following are counseling points for patient on lithium except:
Drink enough fluid to keep your urine clear or pale yellow. | |
Maintain a low sodium diet at all times. | |
Avoid taking medications in the class “NSAIDs” | |
All of the above |
Question 9 Explanation:
Answer B. Patients should stay well hydrated and avoid nephrotoxic medications (such as NSAIDS), but should not be counseled to avoid sodium at all times. Complete avoidance of sodium could potentially lead to hyponatremia.
Reference:
Balkhi SE, Mégarbane B. Lithium Toxicity: Clinical Presentations and Management. The Science and Practice of Lithium Therapy. 2016:277-292. doi:10.1007/978-3-319-45923-3_17.
Reference:
Balkhi SE, Mégarbane B. Lithium Toxicity: Clinical Presentations and Management. The Science and Practice of Lithium Therapy. 2016:277-292. doi:10.1007/978-3-319-45923-3_17.
Question 10 |
JP is a 70yr old male who was found lying on the floor with several empty liquor bottles by his friend. After being brought to the ER his serum alcohol level was found to be 475 mg/dl. Toxicology report negative except for high alcohol level. 2 hours after admission in the ER he was intubated and then transferred to ICU . His liver enzymes and renal function are normal. PT/INR within normal limit. No past medical history. Upon transfer medications includes Propofol, MVI daily, Lorazepam prn and Piperacillin/Tazobactam.
What vitamin should the patient receive to avoid Wernicke- Korsakoff syndrome?
Thiamine | |
Cyanocobalamin | |
Magnesium | |
Folic Acid |
Question 10 Explanation:
Answer A. Thiamine should be administered to prevent Wernicke’s encephalopathy.
Reference:
Management of moderate and severe alcohol withdrawal syndromes. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016.
Question 11 |
JP is a 40yr old male who was found lying on the floor with several empty liquor bottles by his friend. After being brought to the ER his serum alcohol level was found to be 475 mg/dl. Toxicology report negative except for high alcohol level. 2 hours after admission in the ER he was intubated and then transferred to ICU . His liver enzymes and renal function are normal. PT/INR within normal limit. No past medical history. Upon transfer medications includes Propofol, MVI daily, Lorazepam prn and Piperacillin/Tazobactam.
What is the treatment of choice for his acute alcohol withdrawal?
Haloperidol | |
Lorazepam | |
Ziprasidone | |
Alprazolam |
Question 11 Explanation:
Answer B. Benzodiazepines are the most studied drugs for alcohol withdrawal treatment. Long-acting agents such as Diazepam and Chlordiazepoxide may be used. Antipsychotics are not recommended to treat alcohol withdrawal. Haloperidol is an antipsychotic, an inappropriate choice.
Reference:
1) Kosten T, O’Connor P. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786- 95. A good general review of the management of the most common syndromes.
2) Management of moderate and severe alcohol withdrawal syndromes. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016
2) Management of moderate and severe alcohol withdrawal syndromes. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016
Question 12 |
JP is a 40yr old male who was found lying on the floor with several empty liquor bottles by his friend. After being brought to the ER his serum alcohol level was found to be 475 mg/dl. Toxicology report negative except for high alcohol level. 2 hours after admission in the ER he was intubated and then transferred to ICU . His liver enzymes and renal function are normal. PT/INR within normal limit. No past medical history. Upon transfer medications includes Propofol, MVI daily, Lorazepam prn and Piperacillin/Tazobactam.
Which of the following would be appropriate chronic treatment of choice for his alcohol withdrawal?
Acamprosate | |
Metronidazole | |
Diazepam | |
Duloxetine |
Question 12 Explanation:
Answer A. Acamprosate is indicated for ethanol dependence, but only in patients who have become abstinent. Diazepam is not indicated for ethanol dependence but for acute alcohol withdrawal. Metronidazole may interfere with the metabolism of ethanol, resulting in disulfiram-like effects, not indicated for alcohol withdrawal. Patients should try to avoid ethanol ingestion to avoid the risk of undesirable side effects while on Metronidazole. Duloxetine is not indicated to treat alcohol withdrawal.
Reference:
1) Doering P, Boothby L. Substance-related disorders: overview and depressants, stimulants, and halluci¬nogens. In: DiPiro J, Talbert R, Yee G, et al., eds. Pharmacotherapy. A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008.
2) Gold Standard, Inc. Acamprosate (Indications/Dosage). https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=2097&sec=monindi&t=0. Accessed May 24, 2016.
2) Gold Standard, Inc. Acamprosate (Indications/Dosage). https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=2097&sec=monindi&t=0. Accessed May 24, 2016.
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