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Aug 09, 2014
Quiz I MCQ Nov 2014

1) A family physician, in rush, handed a prescription reading: Rx: rosuvastatin 20 mg 1 tablet every
day for a diabetic patient with normal lipid profile and did not explain to the patient the
prescription is what for.
Which of the following ethical norms was not deliberated in the previous behavior?
a. Veracity
b. Fidelity
c. Autonomy
d. Beneficence
e. Nonmaleficence

2) W.E. is a 65-year-old type-2 diabetic male living in North Carolina and is visiting his brother in
British Columbia. Today, he presented at the pharmacy prescription drop-off area and asked for
the pharmacist. The pharmacist inquired from W.E. about his query. W.E. told the pharmacist
that the Canadian physician whom he saw today cosigned his U.S. prescriptions for irbesartan
300 mg OD and for metformin 500 mg BID and did not, in fact, perform a physical examination,
but the nurse handed him the prescriptions after a wait time of over 4 hours as the clinic was
extremely busy. If the pharmacist agrees to fill the prescription, which of the following ethical
principles would be violated the MOST?
a. Nonmaleficence
b. Beneficence
c. Autonomy
d. Confidentiality
e. Veracity

3) All of the following statements are true regarding Addisons disease EXCEPT:
a. Primary disease is most likely caused by autoimmune idiopathic atrophy, whereas secondary
hypocortisolism is most commonly caused by abrupt discontinuation of chronic corticosteroid
therapy
b. It is a disease characterized by the hypofunction of the adrenal medulla and the cessation of its
endocrine secretion
c. Hallmarks of the disease are fatigue, hypotension, and hyperpigmentation
d. Onset of severe symptoms may be precipitated by an acute infection
e. Diagnostic findings include high plasma ACTH with low plasma cortisol

4) All of the following are suitable counseling tips for a patient with primary adrenal insufficiency on
corticosteroid therapy EXCEPT:
a. Corticosteroid dose could be doubled in case of an infection
b. Side effects such as weight gain, risk of peptic ulcer, risk of hyperglycemia, and risk of bone
thinning are unlikely
c. Morning doses of hydrocortisone should be preferably avoided
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d. In case of acute vomiting and diarrhea immediate self-administration of 100 mg parenteral
hydrocortisone is advisable
e. An ample amount of table salt is recommended, especially during exercise and in summer

5) S.H. is a 77-year-old type-2 diabetic male patient who has just had his 2
nd
abnormal ECG
showing atrial fibrillation. His most updated medication profile includes: levothyroxine 50 mcg,
furosemide 20 mg, atorvastatin 20 mg, metoprolol 25 mg BID, perindopril 4 mg, amlodipine 5
mg, metformin 500 mg TID, gliclazide MR 60 mg. S.H. has just filled his 1
st
warfarin trial
prescription at your pharmacy. All of the following are risk factors for S.H. for a probable
cerebrovascular accident EXCEPT:
a. His age
b. Blood pressure > 140/90 mmHg
c. A1c% > 8.5% at diagnosis
d. TSH < 0.2 mIU/L
e. EF < 35%

6) Which of the following type-2 diabetic patients will need more frequent blood sugar monitoring
the LEAST?
a. A patient taking aspirin, metoprolol, hydrochlorothiazide, and atorvastatin
b. An asthmatic patient on inhaled fluticasone
c. A patient with history of getting very low blood sugars
d. A patient having a cold
e. A patient with a foot ulcer

7) Which of the following adverse events is (are) associated with insulin injections:
I. Lipoatrophy
II. Lipohypertrophy
III. Hypoglycemia
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

8) All of the following are side effects of lithium EXCEPT:
a. Hand tremors
b. Acne
c. Polyuria and polydipsia
d. Leucocytosis
e. Manic attacks

9) Blood sugar levels should be monitored the LEAST in patients on which of the following
medications?
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a. Pravastatin
b. Metoprolol
c. Metolazone
d. Quetiapine
e. Moxifloxacin

10) Of the following medications, the LEAST likely drug which might cause a change in creatinine
clearance is:
a. Telmisartan
b. Indomethacin
c. Metformin
d. Tobramycin
e. Cisplatin

11) L.V. is 45-year-old male patient (BMI 18.2) who presented at the pharmacy today and
complained to his pharmacist of symptoms of frequent urination, of being always thirsty in spite
of drinking a lot of water, and of blurred vision. The pharmacist inquired more about L.V.s
symptoms and the patient mentioned that he also suffers occasionally of tingling in the legs.
When the pharmacist asked L.V. about his lifestyle, the patient answered that he is on a healthy
diet and that he exercises regularly, but has been lately under much stress in his job as a project
management in a multinational engineering company. He also reported that lately he feels tired
more quickly and that he lost about 12 lbs. L.V. medical history is free of any disease conditions
and he does not take any prescription medications but just uses some non-prescription pain
killers for his infrequent migraine attacks. The pharmacist on duty asked L.V. if he agrees to
perform a random glucose measurement. The patient agreed to the pharmacist suggestion and
the results of his one-time random glucose was 19 mmol/L. What is the MOST appropriate
advice the pharmacist should provide to L.V.?
a. You most probably developed occupational diabetes but needs to confirm it with further blood
work.
b. You need to do some more bloodwork and lifestyle modifications.
c. You need to do some more bloodwork and you will probably be on an antidiabetic medication.
d. You need to do some more bloodwork and you will probably start on insulin in addition to an oral
antidiabetic medication.
e. Stress and over-the-counter medications are most probably causing your symptoms.

12) According to the Canadian Diabetes Association 2013 recommendations, the use of insulin is
appropriate in all of the following type-2 diabetes scenarios EXCEPT:
a. A 72-year-old male patient with an A1c > 7.5% on triple oral therapy
b. A 47-year-old female with new-onset diabetes and an A1c 8.5%.
c. A 62-year-old female patient with dilated cardiomyopathy.
d. A 37-year-old female patient planning her 3
rd
pregnancy.
e. A 55-year-old male patient with uncontrolled hypertension and dyslipidemia.

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13) The use of thiazolidinediones is not an appropriate antidiabetic medication in all of the following
patients conditions EXCEPT:
a. A type-1 diabetes male patient
b. A type-2 diabetes male patient with hypertriglyceridemia
c. A type-2 diabetic patient with moderate left ventricular systolic dysfunction
d. A type 2 diabetes male patient with alcoholic liver disease
e. A type-2 diabetes postmenopausal female with a recent history of nontraumatic bone fracture

14) A type-2 diabetic male patient (71 year-old; 200 Lbs.; GFR = 57 mL/min) with PAD was
requested for diagnostic imaging following a recurrence of an acute flank pain and the patient
was administered IV iohexol (Omnipaque, iodine 46%) 2mL/Kg. The patient profile reveals the
following medications which were filled at the hospital pharmacy after his last discharge 10 days
due to stress-induced hyperglycemia by a UTI and failure to achieve target A1c:
Novolin ge Toronto (8-10 units before each meal),
Novolin NPH (20 units AM and 30 units PM)
Ramipril (5 mg daily),
Aspirin (81 mg daily),
Cotrimoxazole DS (800/160 mg BID)
A week ago, the patients family physician added combination sitagliptin/metformin (JANUMET
50/850 mg BID) to the patients care plan which was filled at his regular community pharmacy.
The patient is taking also multivitamin supplements which he got over-the-counter from his
community pharmacy. Which of his current medications should have been taken care of before
the imaging procedure?
a. Acute care discharge antibacterial
b. Parenteral antidiabetic medications
c. Oral antidiabetic medications
d. Antihypertensive medication
e. Prophylactic medication

15) The problematic medication(s) chosen in the previous question should have been stopped for
the following reason:
a. Risk of lactic acidosis
b. Risk of diabetic ketoacidosis
c. Risk of reducing renal perfusion
d. Risk of increasing serum creatinine
e. Nephrolithiasis

16) The fact that the medication was not stopped prior to initiating the imaging procedure is likely
due to:
a. The best possible medication history performed by the hospital pharmacist provided an
incomplete list of the patients medications.
b. Improper medication reconciliation process at admission level.
c. Patient did not comply with the new medication orders.
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d. Lack of communication between the patient and the physician.
e. Lack of communication between the patient and the community pharmacist.

17) Appropriate measures to solve and follow-up on the current situation include all of the following
EXCEPT:
a. Stop the potentially hazardous agent immediately and properly hydrate the patient.
b. Monitor serum creatinine.
c. Monitor blood pH.
d. Monitor fasting blood glucose.
e. Monitor serum sodium.

18) Which of the following disease conditions could be classified as autoimmune diseases the
LEAST?
a. Lupus
b. Type-2 Diabetes Mellitus
c. Graves disease
d. Rheumatoid arthritis
e. Multiple sclerosis

19) Side effects for long-term use of oral corticosteroids are most likely to include all of the following
manifestations EXCEPT:
a. Stimulation of the HPA axis
b. Leucocytosis
c. Osteoporosis
d. Psychosis
e. Dysglycemia

20) G.H. has type 2 diabetes mellitus and CKD. She has been prescribed metformin 1000 mg BID
plus gliclazide modified release 60 mg BID (DIAMICRON MR). G.H.s BMI is 39 lbs/in
2
and
she enjoys fried food and sweets, especially chocolate.
Which of the following lab tests should be monitored over time to evaluate the appropriateness of
G.H.'s glycemic treatment?
I. HbA1c
II. Albumin-to-creatinine ratio
III. eGFR
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

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21) At this current office visit, G.H.s HbA1c is 9.7%, despite being prescribed a biguanide and
gliclazide. Which interventions can be considered the MOST appropriate for this patient,
assuming the patient has been adherent to her medication regimen?
a. Refer the patient to a diabetic educator
b. Increase the dose of metformin to its maximum
c. Switch to immediate release gliclazide 160 mg BID
d. Add-on a DPP-IV inhibitor 5 mg/day
e. Add-on insulin NPH HS

22) G.H.s therapeutic plan was managed according to the most appropriate regimen, and 6 months
later, her HbA1c declined to 8.1%. What is the BEST recommendation to manage G.H.s
diabetes now?
a. Continue on current regimen with no further medications added and re-assess in 3 months
b. Add-on acarbose
c. Omit metformin and initiate meal-time rapid-acting insulin on top of current therapy
d. Omit oral therapy except metformin and switch to glargine HS plus pre-meal glulisine TID
e. Initiate prandial regular insulin on top of current regimen

23) Should G.H. be switched to insulin instead of oral therapy, which of the following regimens is the
MOST appropriate in her case taken into consideration that she is initially not willing to learn or
perform self-injections and will depend on her 55-year-old husband?
I. NPH HS and regular insulin before meals 3 times daily
II. Glargine HS and regular insulin before meals 3 times daily
III. Pre-mixed insulin 30/70
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

24) Assuming that G.H. was started on the most appropriate insulin regimen, but her prandial
glucose levels were still slightly high and her family physician was looking for the pharmacist
advice regarding the optimal addition to her background insulin which will only cause modest
changes to her currently controlled HbA1c and will minimally interact with her other medications.
What would be the MOST appropriate recommendation in this case?
a. No medication added
b. Acarbose
c. Saxaglitpin
d. Pioglitazone
e. Repaglinide

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25) A few months later and using insulin pens, G.H. was compliant to and stabilized on 8 units lispro
(Humalog) before day meals and 20 units NPH (HUMULIN N) at bed time. Her average
readings during self-monitoring her blood sugar levels for the last 2 weeks are:
BSL mmol/L 8:00 15:00 20:00
Fasting 11.2
Postprandial 9.9 8.7 7.3

Lately, G.H. gained 3-4 lbs. and her most recent A1c after her current therapeutic regimen is 6.5%.
Her blood sugar level could MOST likely be controlled by which of the following therapeutic
interventions?
a. Increasing the dose of bed time insulin
b. Increasing the dose of bedtime metformin
c. Adding repaglinide at morning time
d. Decreasing the dose of basal insulin
e. Decreasing the dose of bolus insulin

26) In case of a diabetic coma which has been confirmed to be due to hyperglycemia, which type of
insulin should be promptly given to the affected patient?
I. Bolus insulin
II. Crystalline zinc insulin
III. Isophane insulin
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

27) Which of the following is NOT a sign typically associated with hypoglycemia?
a. Numbness in the tongue
b. Shakiness
c. Fast heartbeat
d. Frequent urination
e. Clamminess

28) F.A. is a 71-year-old male with type-2 diabetes and a Charcot foot, a history of foot ulceration
and a previously amputated hallux. F.A. smokes half a pack to one pack of cigarette per day and
reported earlier this year to his family doctor that lately he cannot make it to this post box, one
block across the street because of a throbbing pain in his legs, especially the right one. Lately,
his blood sugar levels were not adequately controlled and he has presented to his family
physician with a newly identified plantar ulcer on his left foot. Upon point of care hemoglobin A1c
testing, F.A.s current A1c was found to be 9.4% with a 30-day self-monitoring of fasting blood
glucose average of 10 mmol/L. F.A. was referred to a podiatrist who noted that the foot is red,
swollen and hot with purulent discharge from the ulcer and marked erythema in the surrounding
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tissues. Debridement of the wound was performed, and a tissue sample was taken by scraping
the debrided base with a sterile scalpel for culture. Because F.A. was intolerant to
amoxicillin/clavulanate, his podiatrist prescribed levofloxacin 500 mg daily and metronidazole as
empiric therapy until the culture results are received. Four days later, the podiatrist office called
the patient and advised him to continue on the antibiotic for another 10 days because the wound
was infected.
F.A.s Current Medication List:
Levofloxacin 500 mg PO daily
Metronidazole 500 mg PO BID
Metformin 1500 mg PO BID
Gliclazide 60 mg MR PO BID
Insulin glargine 18 units SC QHS
Ramipril 10 mg PO daily
Pentoxifylline 400 mg SR PO TID
Atorvastatin 40 mg PO daily
Clopidogrel 75 mg PO daily
Duloxetine 60 mg PO BID
A few days later, F.A. calls the pharmacy reporting that his blood readings are much higher since
starting the antibiotic. When asked about his readings, F.A. reports that his waking blood sugar
readings have ranged from 11-12 mmol/L over the previous 5 days. JM is considering stopping his
antibiotic because he is worried it is making his diabetes worse.
What is the MOST appropriate advice that should be given to F.A.?
a. Stop levofloxacin as it might cause blood sugar abnormalities
b. Continue on levofloxacin but switch metronidazole to clindamycin
c. Switch to amoxicillin/clavulanate plus metronidazole
d. Continue on current regiment until finished
e. Increase the dose of your insulin by 2 units every 3 days until target FPG reached while on your
current antibiotic regimen until finished

29) Which of the following is a patients risk factor contributing the LEAST to the development of
diabetic foot ulcer in F.A.s case?
a. Old age
b. High blood sugar
c. Peripheral neuropathic disease
d. Peripheral arterial disease
e. Smoking 10-20 cigarettes per day

30) Which of the following could be considered the LEAST important goal of therapy for F.A.s ulcer?
a. Control any localized pain
b. Limit and cure infection
c. Promote healing process
d. Hasten ambulation
e. Prevent recurrence
we need strict glycemic control cause of diabetic
foot ulcer and also surgery haati so option e.
age is answer
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31) In F.A.s case, glycosylated hemoglobin (A1c) could be BEST used in clinical practice as a
surrogate marker to predict all of the following EXCEPT:
a. Diabetic microvascular complications
b. Diabetic macrovascular complications
c. Diagnosis of diabetes
d. Long-term glycemic control
e. Therapeutic efficacy of glucose lowering medications

32) Considering a case like F.A. with multiple admissions to hospitals for diabetic foot, which of the
following specialties is LEAST recommended to F.A.?
a. Social worker
b. Chiropractor
c. Podiatrist
d. Dietitian
e. Occupational therapist

33) L.M. is a 48-year-old type-2 male diabetic patient who has just been admitted to the emergency
department with fever, chest pain, and cough. A CXR revealed unilobar infiltrates and ACS was
excluded by cardiac troponins. L.M. history shows an attempt of smoking cessation, BPH, a wrist
fracture, and a generalized rash when he was administered cephalexin for a soft tissue infection
secondary to his wrist fracture. The triage note of the patient recorded by the admitting resident
reports the use of the following: tamsulosin, metformin, glyburide, ramipril, and atorvastatin
along with a final diagnosis of CAP to be treated using a home-based therapy.
Which of the following is the MOST convenient antibiotic or antibiotic combo that is supposedly
on the triage note of L.M.?
a. Cefuroxime axetil 500 mg BID for 7 days and azithromycin 500 mg OD for 3 days
b. Azithromycin 500 mg po STAT and 250 mg days 2-5
c. Doxycyline 100 mg BID for day 1 then OD days 2-7
d. Moxifloxacin 400 mg for 5 days
e. Clarithromycin 1000 mg po once daily and amoxicillin 1000 mg BID for 10 days

34) M.G. is a diabetic patient who is planning to fast Ramadan. He has been well stabilized on
metformin (500 mg TID) and repaglinide (1 mg BID). What is the LEAST appropriate advice a
pharmacist could give to M.G. during Ramadan fasting:
a. Avoid exercise as it might not be safe during the fasting period
b. Avoid frequent blood glucose monitoring as it can lead to hypoglycemic shocks
c. Divide the metformin dose equally between Iftar and Suhur and omit repaglinide doses
d. Modify the timing of metformin doses while maintaining your repaglinide regimen
e. Consider an add-on saxagliptin PO once daily before Iftar time

35) M.G. was switched to 45 units of NPH insulin (Humulin-N) daily (30 units AM and 15 units PM)
instead of his oral secretagogue while maintaining a once daily dose of 750 mg modified-release
metformin. What will be the pharmacist MOST appropriate advice in this case?
most not least
answer,
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a. Avoid strenuous exercise while fasting time and continue on your current therapy
b. Use bolus insulin at the pre-dawn time and NPH insulin at the pre-sunset time
c. Use basal insulin at the pre-dawn time but rapid-acting insulin at the pre-sunset time
d. Switch insulin to an oral hypoglycemic sulfonylurea
e. Switch to immediate-release metformin formulations

36) A.C. is a 57-year-old African-American man with a history of hypertension (3 years) and
dyslipidemia (2 years), and BPH (1 year). Medications include a beta blocker, diuretic, statin,
tamsulosin, and low-dose aspirin. On physical exam, no other abnormalities were detected. A.C.
has no prior history of chronic kidney disease.
Which of the following is NOT required for A.C.s medical evaluation for kidney disease?
I. ACR
II. e-GFR
III. 24-hour urine collection for protein
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

37) A.C.s labs from this office visit also revealed an eGFR of 59 mL/min/1.73 m
2
and an albumin-to-
creatinine ratio (ACR) of 5 mg/mmol. ACs self-monitoring of blood pressure shows an average
of 135/84 mm Hg. Which action(s) should be pursued?
I. Prescribe an ACE inhibitor or an angiotensin receptor blocker
II. Refer to a nephrologist
III. Re-assess e-GFR and ACR in 3 months
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

38) Two months later, A.C. was admitted with chest pain. His electrocardiogram showed abnormal
ST-segment changes in the anterior leads. He was diagnosed with non-ST elevation myocardial
infarction, and he has just undergone coronary angioplasty and stenting. A.C.s vital signs reveal
a blood pressure of 168/89 mm Hg, despite being prescribed the maximum dose of the beta
blocker and diuretic. A.C. also has an e-GFR of 54 mL/min/1.73 m
2
(down from 59 mL/min/1.73
m
2
3 months ago) and an ACR of 12 mg/mmol (up from 5 mg/mmol 3 months ago). All other
pertinent labs are within normal limits.
Which possible adjustments should be FIRST considered for A.C.s antihypertensive treatment?
a. Discontinue diuretic and add ACE inhibitor or ARB
b. Switch the beta blocker to ACE inhibitor or ARB
c. Add a calcium channel blocker and ACE inhibitor or ARB
iftar
suhur
answer
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d. Add an ACE inhibitor or ARB
e. Add clopidogrel and ACE inhibitor or ARB

39) All of the following could be considered advantages of insulin pens EXCEPT:
a. It is easier to distinguish insulin type by pen color
b. It provides a handier means of mixing different insulin types
c. It offers convenience and are less bulkier to carry
d. It enables higher dosing accuracy
e. It contributes to minimizing dosing errors

40) Which of the following is NOT a correct counseling given by a pharmacist to a type-2 diabetic
patient on insulin regarding insulin pens and dosers?
a. Whichever type of insulin pen you use, you will need to attach a new pen needle onto the pen
with each injection and remove it after every use
b. Reusable insulin pens need to be primed with every single use, whereas disposable pens
require a first-time single priming
c. An insulin pen may be kept in the pocket or purse at room temperature while in use; however, it
should not get warm or be exposed to direct sunlight
d. Insulin pens minimize waste of expired insulin if low doses of insulin are used
e. Insulin dosers have clear, readable dials and easy-to grip shapes that are designed for people
with vision problems and poor hand control

41) Which of the following is NOT true regarding pre-filled syringes of pre-mixed insulins?
a. When mixing short-acting insulin with intermediate-acting insulin, draw isophane insulin at last
b. Disinfect the rubber closure and pierce at 45 with the needles bevel edge facing upwards
c. While the needle is still in the vial, adjust the insulin solution/suspension to the desired volume
d. Recap needle and place vertically in a clean, unused zip-lock bag
e. Do not place a refrigerate label if insulin syringes are to be used within 4 weeks

42) Which of the following might be related the LEAST to strict glycemic control in type-2 diabetes?
a. Increasing the risk of hypoglycemia
b. Decreasing the risk of ischemic attacks
c. Avoiding vascular eye complications
d. Minimizing the manifestation of chronic kidney disease
e. Postponing overactive bladder

43) A pharmacy is organizing a Diabetes Awareness Day. Which of the following would be of
LEAST interest to the event attendees?
a. Advertising the event with special emphasis on population 40-70 years old
b. Performing an onsite A1c measurement
c. Inviting dietitians, family physicians, nurse educators and endocrinologists
d. Organizing a seminar and distributing a brochure about updated clinical guidelines for the
management of diabetes
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e. Presenting a data show about societal burdens of overweight and obesity, life style modifications
and diet programs

44) Which of the following therapy-related factors is LEAST likely to decrease patient compliance to
treatment?
a. Increasing number of medications taken
b. Increasing number of dosing times
c. Long duration of treatment period
d. Medication side effect
e. Social stigmatization

45) Which of the following is LEAST recommended to treat hypoglycemia in a type-2 diabetic patient
on acarbose (GLUCOBAY)?
a. Milk
b. Glucose gel
c. Canned apple juice
d. Glucagon
e. Honey

46) Which of the following is the LEAST likely side effect with acarbose (GLUCOBAY)?
a. Dyspepsia
b. Flatulence
c. Abdominal bloating
d. Diarrhea
e. Hypoglycemia

47) Which of the following combination of factors would promote effective self-management in type-2
diabetes the most?
a. Understand, assess, assist, advise, and follow-up
b. Introduce, gather information, plan, implement, and follow-up
c. Evaluate, educate, collaborate, demonstrate, and follow-up
d. Assess, educate, collaborate, set targets, and follow-up
e. Assess, educate, demonstrate, arrange, and follow-up

48) The first step in creating a patient action plan in type-2 diabetes is:
a. Establishing an A1c%goal
b. Reviewing all current medications
c. Setting goal date for hammering A1c% target
d. Facilitating patients self-identified goal
e. Recoding failed attempts to target A1c%

49) A 47-year-old type-2 diabetic male patient on metformin/sitaglitpin and glicalzide has just
performed some lab works and the results were as follows: A1c% 9.0, FPG 10.2, LDL-C 2.5
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mmol/L, ACR 2.5 mg/mmol, e-GFR 100 mL/min/1.73 m
2
, and no glycosuria. What is the best
recommendation for vascular protection of this patient in light of the CDA 2013 guidelines?
a. Aspirin 81 mg
b. Aspirin 81 mg and atorvastatin 40 mg
c. Aspirin 81 mg and metoprolol 100 mg
d. Aspirin 81 mg, atorvastatin 40 mg, and ramipril 10 mg
e. Rosuvastatin 20 mg and telmisartan 40 mg

50) The 24-hours creatinine excretion in a healthy human adult will significantly correlate with all of
the following factors EXCEPT:
a. Kidney size
b. Age and hydration status
c. Glomerular filtration rate
d. Proximal tubular secretion
e. Tubular reabsorption

51) Serum creatinine level in a healthy human adult is LEAST likely to show fluctuations with respect
to which of the following factors:
a. Gender
b. Muscle mass
c. Diet
d. Obesity
e. Liver metabolism

52) The MOST reliable marker used for the diagnosis and prognosis of chronic kidney disease is:
a. Albumin-to-creatinine ratio (ACR)
b. Serum creatinine (SCr)
c. Urinary creatinine (UCr)
d. Cystatin C
e. Glomerular filtration rate (GFR)

53) Several lines of clinical evidence suggest that ramipril has all of the following effects EXCEPT:
a. Cardioprotective effect
b. Antiproteinuric effect
c. Rhythm control effect
d. Renoprotective effect
e. Antioxidant effect

54) The marker which will correlate with a diagnosis of acute renal failure the MOST is:
a. Creatinine clearance (CrCl)
b. Serum creatinine (SCr)
c. Urinary creatinine (UCr)
d. Cystatin C
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e. Glomerular filtration rate (e-GFR)

55) Which of the following disease conditions would MOST LIKELY cause a decrease in SCr?
a. Dehydration
b. Chronic kidney disease
c. Acute renal failure
d. Myasthenia gravis
e. Rhabdomyolysis

56) Which of the following disease conditions or surgical procedures would LEAST LIKELY cause an
increase in SCr?
a. Unilateral nephrectomy
b. Cachexia
c. Systolic heart failure
d. Nephrolithiasis
e. Pyelonephritis

57) Sh.G. is a 62-year-old African-American with a history of myocardial infarction 1 year ago,
hypertension (3 years ago), and dyslipidemia (2 years ago). Medications include a beta blocker,
diuretic, statin, and low-dose aspirin. On physical exam, no other abnormalities were detected.
One year ago, Sh.G. was admitted with chest pain. His electrocardiogram showed abnormal ST-
segment changes in the anterior leads. He was diagnosed with non-ST elevation myocardial
infarction, and he had undergone coronary angioplasty and stenting. Sh.G. has no prior history
of CKD.
Which of the following is sufficiently required for Sh.G.s medical evaluation of kidney disease?
I. Serum creatinine
II. Estimated glomerular filtration rate
III. 24-hour urine collection for protein
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

58) At this current family physician visit, Sh.G.s vital signs reveal a blood pressure of 172/94 mm
Hg. Sh.G. also has an eGFR of 52 mL/min/1.73 m
2
(down from 59 mL/min/1.73 m
2
3 months
ago) and an ACR of 12 mg/mmol (up from 5 mg/mmol 3 months ago). All other pertinent labs are
within normal limits.
Which possible adjustments should be FIRST considered for SH.G.s care plan?
a. Increase the dose of the beta blocker and the diuretic
b. Discontinue diuretic and add ACE inhibitor or ARB
c. Switch the beta blocker to ACE inhibitor or ARB
d. Add an ACE inhibitor or an ARB
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e
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e. Discontinue aspirin and add an ACE inhibitor or an ARB

59) Two weeks after implementing the clinically indicated adjustment in Sh.G.s care plan, his eGFR
has decreased further by 20%. How should you proceed with his antihypertensive treatment?
I. Start a calcium channel blocker instead of the most recently added medication
II. Start an ARB instead of the most recently added medication
III. Continue on the most recently added therapy and monitor
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II and III

60) M.H. is a chronic kidney disease patient on ramipril (ALTACE) 10 mg/day. His latest serum
potassium level was 5.7 mmol/L with no apparent signs of cardiac arrhythmia, paresis, or muscle
weakness on physical examination. M.H.s history is noticeable for an acute coronary syndrome
and a bypass surgery 5 years ago. What is the BEST action to be taken by his physician?
a. Continue ACE inhibitor and reduce bananas, leafy greens, and meat.
b. Perform an ECG, switch to ARB and reduce potassium input by controlling diet.
c. Stop ACE inhibitor and implement dietary potassium restriction.
d. Continue on ACE inhibitor, administer insulin with glucose, and monitor.
e. Administer oral calcium polystyrene sulfonate resin.