Special Pops: Final Exam Review

Multiple Choice

Where does fertilization take place?

• Uterus

• Fallopian tube

• Ovary

• Blastocyte

• Trophoblast

Multiple Choice

Which subunit is specific to hCG?

• Alpha

• Beta

Multiple Choice

Which subunit is identical to other pituitary hormones such as LH, FSH, and TSH?

• Alpha

• Beta

Open Ended

hCG is responsible for what?

Poll

A 36-year-old female wishes to become pregnant with her second child. Her first child was born with spina bifida. Which of the following is the most appropriate folic acid (folate) recommendation for this patient?

• Folic acid 4 mg orally daily starting at ten weeks’ gestation

• Folic acid 0.4 mg with a multivitamin orally daily starting at least 1 month before pregnancy.

• Folic acid 4 mg with a multivitamin orally daily starting 3 months before pregnancy.

• Multivitamin containing 0.4 to 0.8 mg of folic acid orally daily starting 3 month before pregnancy.

• No folic acid supplement is required.

Multiple Choice

Which one of the following periods is considered the all-or-nothing period?

• Days 1 to 14 postconception

• Days 1 to 14 after last menses

• Days 14 to 28 postconception

• Days 1 to 56 after last menses

• Days 1 to 56 postconception

Multiple Choice

Which of the following medications should never be used in pregnancy?

• Warfarin (Coumadin)

• Naproxen (Aleve)

• Norfloxacin (Noroxin)

• Methotrexate (Rheumatrex)

• Methimazole (Tapazole)

Poll

If left untreated, an UTI can lead to which of the following issues?

• AKI

• CKD

• Pyelonephritis

• Kernicterus

Poll

A 22-year-old pregnant female complains of pain following a severe ankle sprain. Ice and acetaminophen 650 mg orally Q6H are not relieving her pain. She rates her pain as 7 out of 10 on a visual analogue scale. She is 32 weeks pregnant. Which of the following is the best recommendation for her pain at this point?

• APAP 2g PO Q4H regularly

• APAP 1g PO Q6H PRN

• Codeine 15 to 30 mg PO Q4H PRN

• Glucosamine 500 mg PO TID for 5 days

• Ibuprofen 400 mg PO QID PRN

Multiple Choice

Which of the following regimens is the most appropriate tocolytic at 30 weeks of pregnancy?

Tocolytics are drugs that are used to delay your delivery for a short time (up to 48 hours) if you begin labor too early in your pregnancy.

• Dexamethasone 2 mg IM every 24 hours for 48 hours

• Nifedipine 30 mg orally, then 10 mg every 6 hours for 48 hours

• Magnesium sulphate 2 g IV, then 1 g/h for 48 hours

• Amoxicillin 1 g orally once, then 250 mg every 8 hours for 24 hours

• Indomethacin 25 mg orally every 6 hours for 5 days

Multiple Choice

Which of the following statements is TRUE?

• Hypoglycemic agents convey more risks of fetal malformations than diabetes.

• Antihypertensive agents carry more risks of fetal malformations than hypertension.

• Heparins carry more risk of fetal complications than warfarin.

• Antiepileptic agents carry more risk of fetal malformation than epilepsy.

• Antithyroid agents display more risk of fetal malformations than hyperthyroidism.

Poll

MH, 20 weeks pregnant, is seen at the clinic and complains of heartburn. She has tried antacids with very little relief. All tests and evaluations are normal. Which treatment should be recommended? Why?

• Omeprazole 20 mg orally daily

• Pantoprazole 40 mg orally daily

• Sucralfate 1 g orally four times daily

• Famotidine 10 mg orally twice daily

• Metoclopramide 10 mg orally four times daily

Multiple Choice

Which hormone is responsible for causing the final maturation of the follicle, ovulation, and the corpus luteum?

• Estrogen

• FSH

• LH

• Progesterone

Multiple Choice

Select the most true answer in regards to FSH.

• Secreted by the hypothalamus

• The most dominant hormone in the luteal phase

• Secretion is suppressed by estrogen

• A + C

• All of the above

Multiple Choice

All of the following are false in regards to hCG except:

• Produced by trophoblasts

• Responsible for maintaining the synthesis of estrogen until placenta is able to

• Detected in maternal circulation and urine ~ 11 hours postconception

• All of the above are true

Multiple Select

Which of the following statements is/are true?

Select all that apply

• Prolactin stimulates production and secretion of milk by nipple stimulation

• Milk production regulated by infant demand

• Metoclopramide (Reglan), dopamine agonist that increases PRL secretion when lactation is decreased or inadequate milk production

• Breastfeeding decreases postpartum blood loss

Poll

Which of the following is/are the best preconception education options for patients wanting to conceive in the next 9 to 12 months?

Select all that apply

• Drink no more than 6 cups of coffee each day

• Eat a balanced diet

• Avoid smoking

• Avoid alcohol and illicit drugs

• All of the above

Multiple Choice

Which of the following answer choices does not affect drug diffusing across the placenta?

• Fetal Gender

• Molecular Weight

• Protein Binding

• Lipophilicity

• Ionization

Poll

Which of the following medications should be avoided during the 3rd trimester of pregnancy?

Select all that apply

• Enalapril

• APAP

• Ibuprofen

• Ciprofloxacin

• Levothyroxine

Multiple Choice

Which of the following is the best gestational diabetes treatment option for the pregnant patient?

• Metformin

• Insulin

• DPP-4 inhibitors

• GLP-1 agonists

• SGLT-2 inhibitors

Multiple Choice

If a pregestational pt presents to the office with an HbA1C of > 12%, what sort of risk is present?

• NTDs

• Same risk as giving teratogens

• Hypoglycemia

• ASA use

Multiple Choice

When dealing with Early Abnormal Glucose Metabolism, fasting blood sugar levels should be ≥ ____ mg/dL (and/or) an A1c ≥ ___ %.

• 110 mg/dL -and- 5.9%

• 110 mg/dL -or- 5.9%

• 130 mg/dL -and- 8%

• 130 mg/dL -or- 8%

Multiple Choice

T/F: If a pt has gestational diabetes, they should be tested for pre-DM or overt DM 4-12 weeks postpartum and then every 3 years after.

• True

• False

Multiple Choice

Which of the following is true about hypertension in pregnancy?

• Defined as BP >140/90 w/ proteinuria

• Labetalol gained favor due to decreased SE profile

• Causes decreased TBW

• Nifedipine IR used for HTN and also can inhibit labor

Multiple Select

What can be treatment options for UTIs in pregnant patients?

• Sulfamethoxazole/Trimethoprim

• Nitrofurantoin

• Ciprofloxacin

• Amoxicillin

Multiple Choice

T/F: Avoidance of short-acting drugs is better than long-acting formulations because there will not be enough drug to cross the placenta.

• True

• False

Multiple Choice

Which of the following would be in breast milk but not formula?

• Proteins

• Fats

• Carbs

• Growth/immune factors and cytokines

• Vitamins

Open Ended

What's the difference between prolactin and oxytocin?

Multiple Select

High levels of which of the following hormones will stop the production of milk?

Select all that apply

• Oxytocin

• Prolactin

• FSH

• Estrogen

• Progesterone

Multiple Select

Which of the following options are benefits of breastfeeding in regards to the baby?

Select all that apply

• Decreased incidence and severity of infectious processes (otitis media, UTI, RTI)

• Possible decreased risk of obesity, IBD, and celiac disease

• Decreased risks of SIDS

• None of the above

Poll

Which of the following is true in regards to increasing the mother's milk production?

• Drinking a beer a day does not affect the milk production

• Metoclopramide can be used for months at a time

• Fenugreek may cause mother's milk to smell like maple syrup

• Milk production regulated by infant demand

Multiple Select

Which of the following options are benefits of breastfeeding in regards to the mother?

Select all that apply

• Decreased postpartum blood loss

• More rapid uterine involution

• Earlier return to pre-pregnancy weight

• Decreased risk of breast and ovarian cancer

• Decreased risk of osteoporosis

Multiple Choice

A person's internal sense of self and how they fit into the world, from the perspective of gender is known as which of the following?

• Gender Identity

• Sex

• Orientation

• Non-binary

Multiple Choice

The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, or speech and mannerisms. Gender identity and gender expression may differ; for example a woman (transgender or non-transgender) may have an androgynous appearance, or a man (transgender or non-transgender) may have a feminine form of self-expression.

• Gender Identity

• Gender Expression

• Sexual Orientation

• Non-binary

Multiple Choice

A person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person. Genderqueer is another term used by some with this range of identities.

• Gender Identity

• Gender Expression

• Sexual Orientation

• Gender Nonconforming

Multiple Select

Terms to describe gender nonconforming or nonbinary persons, based on the directionality of their gender identity. A trans-masculine person has a masculine spectrum gender identity, with the sex of female listed on their original birth certificate. A trans-feminine person has a feminine spectrum gender identity, the sex of male listed on their original birth certificate. In portions of these Guidelines, in the interest of brevity and clarity, transgender men/women are inclusive of gender non-conforming or nonbinary persons on the respective spectra.

Select all that apply

• Gender Identity

• Trans-masculine

• Sexual Orientation

• Gender Nonconforming

• Trans-feminine

Multiple Select

These terms generally refer to those who may wear the clothing of a gender that differs from the sex which they were assigned at birth for entertainment, self-expression, or sexual pleasure. Some crossdressers and people who dress in drag may exhibit an overlap with components of a transgender identity. The term transvestite is no longer used in the English language and is considered pejorative.

• Crossdresser

• Drag Queen

• Drag King

• Transsexual

• Nonbinary

Multiple Choice

Describes sexual attraction only, and is not directly related to gender identity. The sexual orientation of transgender people should be defined by the individual. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.

• Gender Identity

• Gender Expression

• Sexual Orientation

• Gender Nonconforming

Terminology and definitions | Gender Affirming Health Program

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Multiple Select

Which of the following choices is/are recognized as valid pathways to the initiation of gender affirming hormone therapy?

Select all that apply

• "referral letter" from a mental health professional

• "informed consent"

• Prescription from their PCP

• Nothing is needed to initiate therapy

Multiple Choice

"Which of the following choices is/are recognized as valid pathways to the initiation of gender affirming hormone therapy"

Following this question, what organization is responsible for this recognition?

• NASPA

• WPATH Standards of Care

• United Nations

• OSPA

Multiple Select

Which of the following healthcare providers may prescribe gender affirming hormones?

Select all that apply

• PCPs

• Endocrinologists

• PAs

• Nurse Practitioners

• Obstetricians-gynecologists

Multiple Select

Gender affirming hormone therapy medications may be used to treat which of the following other disease states?

Select all that apply

• Menopause

• Contraception

• Hirsutism

• Male pattern baldness + prostatism

• Abnormal uterine bleeding

Initiating hormone therapy | Gender Affirming Health Program

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Open Ended

What kind of changes may we see associated w/ feminizing hormonal therapy?

Multiple Choice

Which of the following is considered the primary class of estrogen used for feminizing therapy? It is a "bioidentical" hormone in that it is chemically identical to that from the human ovary.

• 17-alpha estradiol

• 17-beta estradiol

• Estradiol

• Progestin

• None of these

Multiple Select

17-Beta Estradiol is most commonly delivered to transgender women via which of the following?

Select all that apply

• Transdermal patch

• Oral + Sublingual tablets

• Injection of conjugated esters

• Anally

• Vaginally

Multiple Choice

Which of the following medications are not recommended for the use with feminizing therapy?

• Premarin

• Estradiol Valerate

• 17-beta Estradiol

• All of these may be used

Open Ended

Why shouldn't Premarin be used for feminizing therapy?

Multiple Choice

T/F: In the setting of gender affirmation, there is no need for cycle or bleeding regulation, and thus the use of ethinyl estradiol and its inherent risks are not warranted

• True

• False

Multiple Choice

Which of the following is not a side effect associated with estrogens?

• Migraines

• Mood swings

• Hot flashes

• Weigh loss

Multiple Choice

Androgen blockers allow for which of the following?

• more side effects associated with feminizing therapy

• Lower estradiol dosing

• ↑ associated risks when affecting the pituitary gonadotropin suppression

• All of the above are correct

Poll

Which of the following is the most commonly used androgen blocker in the US?

• Spironolactone

• Finasteride

• Pioglitazone

• Dutasteride

Multiple Select

Which of the following medications would be good choices for those unable to tolerate, or with contraindications to the use of spironolactone?

Select all that apply

• Finasteride

• Pioglitazone

• Dutasteride

• Furosemide

Multiple Choice

Which of the following may serve as surrogate markers to indicate adequate sex hormone levels for maintaining bone density in such patients?

• Titration of dosing to get clinical effects

• monitor hormone levels

• Insure suppressed gonadotropin levels

• All of the above

Multiple Choice

Well-designed studies have been established in the role of progestogens in feminizing hormone regimens

• True

• False

Multiple Choice

Which of the following may be reported with the use of progestogens?

• Anecdotal improvement of breast and/or areolar development

• Mood

• Libido

• All of the above

Multiple Choice

For transgender care, the target range when monitoring total testosterone levels should be which of the following?

• > 72 ng/dl

• < 55 ng/dl

• < 65 ng/dl

• > 100 ng/dl

Overview of feminizing hormone therapy | Gender Affirming Health Program

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Open Ended

Why are oral methyltestosterone and other synthetics not recommended for the use in transgender men?

Poll

Which of the following may be some benefits of subcutaneous administration vs. IM administration of testosterone?

Select all that apply

• Smaller -less painful needle

• Avoid scarring + fibrosis

• Can only be used IM not SubQ

• More complications but better satisfaction of the patient

VOID​

Open Ended

How should testosterone levels be titrated in transgender men?

Overview of masculinizing hormone therapy | Gender Affirming Health Program

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Poll

Which of the following is/are drugs that can increase the risk of falls in the elderly?

• Anticholinergic drugs

• Benzodiazepines

• Antihistamines

• Opioids

• Diuretics

Open Ended

List any potentially inappropriate medications (PIMs) Mrs. Mildred is taking...

Open Ended

Recommend a more appropriate alternative for each PIM...

Open Ended

Describe any adherence-related recommendations you would make...

Open Ended

Do you consider metoprolol appropriate for this patient? Why or why not?

Multiple Choice

Which of the following statements is true in regards to physiological changes in the elderly population?

• Increase in visual acuity

• Baroreceptor activity increases, causing HTN

• Hypertrophy of the thyroid gland develops

• Myocardial sensitivity to B-adrenergic stimulation decreases

Multiple Choice

Results of age-related changes in total body composition include which of the following?

• Increased plasma concentrations of digoxin

• Decreased half-life of diazepam

• Increased volume of distribution of water-soluble drugs

• A+B

• All of the above

Open Ended

Why is Mr. Norris' treatment of choice for insomnia inappropriate?

Open Ended

What would be more appropriate treatment options for his insomnia?

Open Ended

What other changes may be made to his medication regimen?

Open Ended

What vaccinations s be recommended at this time?

Multiple Choice

Select the best answer choice in regards to Amitriptyline (Elavil)

• Is the antidepressant of choice for elderly patients

• Has strong anticholinergic and sedative properties

• Has weak anticholinergic properties

• Has weak sedation properties

Multiple Choice

Long acting benzodiazepines...

• Have a short half-life in elderly patients

• Produce minimal sedation in elderly patients

• Increase the risk of falls and fractures in the elderly

• Preferred over short-acting if a benzo is needed

Fill in the Blanks

Fill in the Blanks

Open Ended

Which medications may cause problems with constipation?

Fill in the Blanks

Fill in the Blanks

Open Ended

What would you recommend to treat his constipation?

Open Ended

What is wrong with his use of Ambien (zolpidem) to treat his insomnia?

Multiple Choice

What may happen with the long term use of NSAIDs?

• May produce GI bleeding

• May cause renal failure

• May increase BP

• All of the above

Multiple Choice

According to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which of the following drugs are considered inappropriate for use in older adults?

• Propoxyphene

• Diphenhydramine

• Sertraline (Zoloft)

• A + B

• All of the above

Multiple Choice

An 80-year old female who is a new referral to your medication management clinic.  She complains of loss of large volumes of urine, a sense of urinary urgency and increased nighttime frequency.  During your interview, she admits that she doesn’t sleep very well at night, but says she gets plenty of sleep in the afternoon.  PMH is positive for osteoarthritis, urinary incontinence, HTN, & diabetes mellitus.

 

Which of the following drugs is the MOST APPROPRIATE initial treatment for this patient’s incontinence?

• Oxybutynin immediate release (Ditropan®) 5mg po TID

• Oxybutynin extended release (Ditropan XL®) 5 mg po BID

• Tolterodine immediate release (Detrol®) 2 mg po BID

• Tolterodine extended release (Detrol LA®) 2 mg po QD

• Other

Multiple Choice

**Assuming vaccination was given prior to guideline changes**

Which of the following patients would be an appropriate candidate for revaccination with PPSV?

• 67 y/o pt who received first dose at age 62

• 77 y/o pt who received first dose at age 65

• 63 y/o pt who received first dose at age 60

• 78 y/o pt who received first dose at age 70

• Nobody qualifies and should be given PCV

Multiple Choice

Ryan is a 64 y/o man with an active case of herpes zoster.  He has never had herpes zoster in the past and does not recall ever having the chickenpox. (Common for older patients – 80 y/o)

Should Ryan receive the Shingles vaccine today?

• Yes

• No

Open Ended

How long should Ryan wait after his active herpes infection before receiving the zoster vaccine?

Multiple Choice

An 84-year old male who presents to your medication management clinic for assistance in selecting a Medicare drug plan. During your interview, he also admits that he’s not as “regular” as he used to be & that his eating habits are not very good since his wife’s death almost a year ago.  PMH is positive for HTN, open-angle glaucoma, & depression. Medications include: Enalapril 10 mg po daily, Diphenhydramine 50 mg qhs prn insomnia, Amitriptyline 100 mg q morning, and Bisacodyl 5mg 4 to 5 days per week.

Which of the medications may be exacerbating this patient’s constipation?

• Diphen-hydramine

• Amitriptyline

• Clonidine

• A + B

• All of the above

Multiple Choice

In regards to the previous question, which of the following options would be appropriate nonpharmacologic strategies for his constipation?

• Adding more fiber-rich foods to his diet

• Recognition that he may no longer need a daily bowel movement

• Decreasing water intake

• A + B

• All of the above

Multiple Choice

In regards to the previous question, Which of the following pharmacologic recommendations is MOST APPROPRIATE for treatment of his constipation?

• Increase bisacodyl 5mg from 4-5 days per week to bisacodyl 5mg daily.

• Continue bisacodyl 5mg 4-5 days per week & add docusate calcium 240 mg daily.

• Discontinue bisacodyl 5mg & start Metamucil® wafers with 8 ounces of fluid daily until a bowel movement is produced. 

• Discontinue bisacodyl 5mg & start castor oil 60 ml orally every day.

• None of the above

Multiple Choice

An 80-year old female who is a new referral to your medication management clinic.  She complains of loss of large volumes of urine, a sense of urinary urgency and increased nighttime frequency.  During your interview, she admits that she doesn’t sleep very well at night, but says she gets plenty of sleep in the afternoon.  PMH is positive for osteoarthritis, urinary incontinence, HTN, & diabetes mellitus.  As requested, she brought all of her medications for evaluation. Which of the following non-pharmacological recommendations may improve her sleep disturbances?

• Avoiding daytime naps

• Watching television in bed until she falls asleep

• Avoiding fluids after supper

• A + B

• A + C

Multiple Choice

Which of the following age-related changes is true of older adults?

• Increased myocardial sensitivity to B-adrenergic stimulation

• Decreased duration of action for fat soluble drugs

• Increased hepatic blood flow

• Decreased baroreceptor activity

Multiple Choice

______ is a risk factor for adverse drug events in the elderly

• Age ≤ 85 years old

• Use of any antihypertensive medications

• Use of anticholinergic drugs

• Increased body weight/BMI > 22 kg/m²

Multiple Choice

Ways to improve adherence in older adults include:

• Urging use of single pharmacy

• Providing only verbal instructions for medications

• Prescribing medications that are similar in appearance

• Keeping D/C medications for later use

Multiple Choice

According to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which medications listed below is considered potentially inappropriate for use in older adults?

• Diphenhydramine 25 mg po PRN QHS

• Atenolol 50 mg po QD

• Aspirin 81 mg po QD

• Docusate Sodium 100 mg po QD

Multiple Choice

Which of the following recommendations should be made concerning his current medication regimen?

• Refer him to a physician for his own Talacen prescription of the same strength and directions

• Increase cyclobenzaprine (Flexeril) to 10 mg PRN

• Take HCTZ in the morning instead of evening

• Discontinue daily use of docusate sodium

Multiple Choice

Which of the following medications would be the most appropriate choice for pharmacological treatment of his urinary incontinence?

• Duloxetine (Cymbalta)

• Oxybutynin IR (Ditropan)

• Tolterodine IR (Detrol)

• Tamsulosin (Flomax)

Multiple Choice

How can the pt from the previous case help improve his sleep?

• Treating his depression due to his wife's death

• Taking afternoon naps

• Staying in bed as long as possible to increase the likelihood that he will get sleepy

• Increase Benadryl dose to 50 mg QHS

Multiple Choice

In regards to the previous case, if use of a prescription medication is needed to treat the sleep disorder, the most appropriate initial recommendation is:

• Eszopiclone (Lunesta®) 2mg immediately before bedtime x 1 month

• Flurazepam (Dalmane®) 30 mg before bedtime x 1 month

• Ramelteon (Rozerem®) 8mg within 30 minutes of going to bed x 7 to 10 days

• Zolpidem (Ambien®) 10 mg immediately before bedtime x 7 to 10 days

Multiple Choice

In regards to the previous case, what should be said about H1N1 and vaccination?

• He is at high risk of contracting the disease

• His risk for complications is minimal if he does get the vaccine

• He does not need to get the vaccine at all

• He should get the vaccine when it is first available to him

Multiple Choice

Which of the medications listed is highly likely to exacerbate her constipation?

• Verapamil

• Omeprazole

• Lisinopril

• Ibuprofen

• All of the above

Multiple Choice

Which of the following recommendations is most appropriate to treat the pt's constipation?

• Take Dulcolax once daily

• Discontinue Dulcolax

• Discontinue regular use of Dulcolax, start regular bulk laxative +/- stool softener

• Discontinue Dulcolax, begin Amitiza (lubiprostone) BID

• None of the above

Multiple Choice

What would be the most appropriate initial treatment of her urinary incontinence?

• Cymbalta (duloxetine) 40 mg BID

• Detrol XL (Tolterodine) 2 mg QD

• Ditropan (oxybutynin) 5 mg TID

• Ditropan XL (oxybutynin ER) 5 mg BID

• None of the above

Multiple Choice

Which of the following additional therapeutic changes is appropriate for her overall medication regimen?

• Add citalopram (Celexa®) 20 mg daily to current antidepressant regimen.

• Decrease Valium to 5mg daily.

• Discontinue Darvocet-N 100. Start trial of acetaminophen 500 mg twice daily.

• Discontinue ibuprofen 400 mg q 6 hours.  Start piroxicam (Feldene®) 20 mg daily.

• All of the above

Multiple Select

Constipation is most often treated with which of the following products?

Select all that apply

• Docusate Sodium

• Miralax

• Senna

• Mineral Oil

• All of the above may be used

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