A 27-year-old nursing assistant with a history of major depression and bulimia is brought to the emergency department after a suicide attempt.  She claims to have ingested several diuretic pills 18 hours ago.  The patient complains of frequent, large-volume urinations that started shortly after she ingested the pills.  She has also been very thirsty but she denies nausea, vomiting, or diarrhea.  Her temperature is 36.7 C (98 F), blood pressure is 96/60 mm Hg, pulse is 110/min, and respirations are 14/min.  Physical examination shows dry oral mucosa and reduced skin turgor.  Laboratory results are as follows:

Which of the following medications did this patient most likely ingest?

A 65-year-old man comes to the office for follow-up monitoring of type 2 diabetes mellitus.  He was diagnosed with diabetes 7 years ago and follows a strict diet to control his blood sugar level.  The patient takes no medications.  Blood pressure is 139/88 mm Hg and pulse is 70/min.  Physical examination shows decreased lower-extremity sensation with a 10-g monofilament.  His most recent hemoglobin A1c is 7.4% (normal, <5.6%).  Serum creatinine is 1.0 mg/dL and serum potassium is 3.8 mEq/L.  Further laboratory evaluation reveals increased urinary albumin excretion, but a conventional urinalysis is within normal limits.  In addition to starting antihyperglycemic treatment, which of the following is the best pharmacotherapy for this patient?

An unresponsive 62-year-old man is brought to the emergency department after sustaining multiple injuries in a major motor vehicle accident.  He is obtunded but responds to painful stimuli.  His blood pressure is 160/90 mm Hg, pulse is 72/min, and respirations are 10/min.  A few hours after initial treatment and stabilization, he develops severe tachypnea and decreased oxygenation.  His chest x-ray shows evidence of pulmonary edema.  He is rapidly intubated and given oxygen but acutely worsens and dies a few hours later, despite aggressive measures.  Which of the following drugs could have caused this patient’s condition?

A 72-year-old woman presents with difficulty hearing.  She was admitted 1 week ago for dyspnea, orthopnea, and bilateral leg swelling which has been slowly improving with treatment.  Her family members report that for the past 2 days, she has been turning her TV volume higher and they have to speak loudly for her to hear.  Her hearing was normal prior to the hospitalization.  Her medical problems include hypertension, heart failure, and chronic kidney disease.  Examination shows moderate bilateral sensorineural hearing loss.  Which of the following medications most likely contributed to this patient’s hearing impairment?

A 63-year-old man comes to the emergency department due to muscle weakness with severe cramping in the lower extremities.  The cramps are severe enough to disrupt his sleep.  The patient also exercises daily but has had to suspend his exercise regimen in the last 3 days due to the symptoms.  Past medical history is notable for hypertension, for which he was started on chlorthalidone and amlodipine 4 weeks ago.  Blood pressure in the emergency department is 140/86 mm Hg and pulse is 90/min.  The heart has a regular rate and rhythm, and he has palpable pedal pulses with no peripheral edema.  Which of the following is the most likely cause of this patient’s muscular symptoms?

A 36-year-old man comes to the emergency department due to severe, acute knee pain that awoke him from sleep.  He has a history of end-stage renal disease for which he underwent a renal transplant 8 weeks ago.  The patient takes an immunosuppressive regimen that includes cyclosporine and low-dose prednisone.  He visited his nephrologist last week and serum creatinine levels were normal with no proteinuria.  Temperature is 37.5 C (99.5 F), blood pressure is 136/78 mm Hg, and pulse is 88/min.  Examination shows redness, warmth, and a small effusion in the left knee.  Passive range of motion at the knee causes severe pain.  Microscopic examination of joint fluid from the knee shows numerous neutrophils as well as both intra- and extracellular crystals as shown in the exhibit.  Which of the following mechanisms is most likely responsible for this patient’s acute symptoms?

An 80-year-old woman presents to the office for evaluation of progressively worsening urinary incontinence.  The patient reports that she is leaking urine “all of the time” and is using the bathroom multiple times at night.  She loses urine immediately after she has the urge to void and often cannot make it to the bathroom.  The patient was recently diagnosed with mild cognitive impairment but maintains independence with the assistance of her husband.  She has no other medical problems.  Vital signs are normal.  Pelvic examination shows vaginal atrophy but is otherwise normal.  There is no leaking of urine with cough or Valsalva maneuver.  Postvoid residual volume and urinalysis are normal.  A medication with which of the following pharmacodynamic effects would be most helpful in treating this patient’s urinary incontinence?

A 54-year-old man is hospitalized after a planned abdominal surgery.  One of his physicians administers a new drug whose mechanism of action you do not know.  Shortly after administration of the drug the patient develops flushing, diaphoresis and nausea.  His blood pressure is 100/70 mmHg and heart rate is 55/min.  His pupils are constricted but reactive to light.  This medication is most likely given for which of the following conditions?

A 52-year-old woman comes to the office due to episodic incontinence for the last several months.  She states that these episodes occur almost every day and are very embarrassing.  They begin as an urge to urinate, and most of the time she cannot make it to the bathroom before urinating on herself.  Physical examination, including pelvic examination, is unremarkable.  A urinalysis is within normal limits.  Urodynamic evaluation is significant for detrusor instability.  Initial non-pharmacologic measures are unsuccessful and pharmacologic therapy is considered.  The appropriate treatment for this patient’s condition includes an agent with which of the following effects?

A 56-year-old woman comes to clinic for follow-up of heart failure with reduced ejection fraction.  Over the last 3 months, the patient has been hospitalized twice due to acute decompensation of heart failure that required treatment with intravenous furosemide.  Since her most recent discharge, she has been taking high doses of oral furosemide, but she continues to have progressive lower extremity edema and weight gain.  Serum creatinine is 1.2 mg/dL and serum potassium is 4.1 mEq/L.  The patient is started on metolazone.  The addition of metolazone is likely to assist in treating this patient because of which of the following effects of furosemide?

A 56-year-old man with type 2 diabetes mellitus, hypertension, and chronic kidney disease is found to have a persistently elevated serum potassium level.  He takes lisinopril.  Blood pressure is 130/90 mm Hg.  Physical examination shows no abnormalities.  The patient is prescribed patiromer therapy.  Which of the following best describes the mechanism of action of this medication?

A 62-year-old man comes to the office due to decreased libido and failure to achieve satisfactory erections.  The patient has coronary artery disease and heart failure with reduced ejection fraction and was prescribed spironolactone therapy several months ago.  Other medications include aspirin, lisinopril, furosemide, and metoprolol.  Blood pressure is 110/70 mm Hg and pulse is 70/min.  Oxygen saturation is 95% on room air.  Examination shows a left ventricular S3 and trace pitting ankle edema.  Breast examination demonstrates bilateral enlargement with mild tenderness.  Which of the following is the most likely cause of this patient’s current symptoms?

A 68-year-old man comes to the emergency department due to a 1-week history of increasing leg and abdominal swelling.  The patient has a history of pulmonary hypertension and cor pulmonale from advanced chronic obstructive pulmonary disease.  Other medical conditions include hypertension and gout.  Physical examination shows scattered rhonchi, prolonged expiratory phase of expiration, mild ascites, and extensive edema of the abdominal wall and lower extremities.  The patient is hospitalized and intravenous loop diuretic therapy is begun.  Two days later, acetazolamide is added to his treatment regimen.  Which of the following most likely prompted the additional therapy in this patient?

A 59-year-old man who is being treated for hypercholesterolemia, diabetes, and hypertension comes to the physician for a scheduled follow-up visit three weeks after starting a new medication.  He has no new complaints.  Blood work drawn yesterday shows an interim increase in potassium from 4.8 mEq/L to 5.2 mEq/L and a creatinine elevation from 1.2 mg/dL to 1.6 mg/dL.  Administration of which of the following drugs is most likely responsible for the change in this patient’s renal function?

A 54-year-old man comes to the office due to new-onset muscle cramps.  The patient has a history of hypertension and was started on hydrochlorothiazide 4 weeks ago.  Blood pressure is 138/86 mm Hg and pulse is 78/min.  Examination shows no abnormalities.  Based on his most recent laboratory results, triamterene is added to the current therapy.  Which of the following best describes the mechanism of action of this medication?

A 55-year-old woman with stage IV chronic kidney disease due to type 2 diabetes mellitus comes to the office for a follow-up visit.  Blood pressure is 140/90 mm Hg and pulse is 78/min.  BMI is 31 kg/m².  Laboratory results are as follows:

The patient’s serum phosphorus has been persistently elevated despite strict dietary phosphate restriction.  Treatment with sevelamer is initiated.  This medication reduces the serum phosphorus level by which of the following mechanisms?

A 57-year-old man comes to the emergency department due to the abrupt onset of severe right eye pain and ipsilateral headache.  The patient also has severe nausea and describes seeing halos around objects.  After initial treatment with the appropriate medication, the pain severity decreases.  Urine output also slightly increases, and the urine pH becomes more alkaline.  The medication used to treat this patient’s eye condition predominantly acts on which of the following nephron segments?

A 74-year-old woman comes to the emergency department due to left hip pain and inability to walk after a fall.  She is being treated by her primary care provider for various medical conditions including hypertension, congestive heart failure, chronic atrial fibrillation, type 2 diabetes mellitus, trigeminal neuralgia, depression, and gastroesophageal reflux disease.  On examination, the left leg is shorter than the right and externally rotated.  She is not able to move the left hip.  An imaging study confirms acute femoral neck fracture.  Her bone density, measured by quantitative x-ray densitometry, is consistent with osteoporosis.  Which of the following drugs, had it been used as part of the medical regimen, would have had a beneficial effect on calcium homeostasis and reduced this patient’s fracture risk?

A 57-year-old man comes to the office for a follow-up appointment.  He has a history of systolic heart failure, which has been managed with appropriate medical therapy.  The patient experiences significant functional impairment at baseline and is able to walk only short distances.  His most recent echocardiogram revealed a left ventricular ejection fraction of 30% (normal ≥55%).  The physician decides to add spironolactone to the treatment regimen.  The addition of this medication is most likely to cause a decrease in which of the following?

A 55-year-old woman is treated with ramipril for primary (essential) hypertension.  Her blood pressure decreases to normal value over several weeks of treatment.  The patient seems to be compliant with her medication and experiences no significant side effects.  She has no other medical issues and takes no other medications.  She does not use tobacco, alcohol, or illicit drugs.  Physical examination shows no abnormalities.  Which of the following is the most likely combination of changes in response to this patient’s treatment (AT = angiotensin)?

A 36-year-old woman with end-stage renal disease secondary to type 1 diabetes mellitus comes to the office for routine examination.  The patient’s medical history includes hypertension, diabetic retinopathy, and neuropathy.  Hemodialysis was started 2 months ago along with an erythropoiesis-stimulating agent.  She takes daily long- and short-acting insulin, lisinopril, and calcitriol.  Her hemoglobin has increased from 7.4 g/dL to 10.2 g/dL over the past 2 months.  Which of the following complications is most likely to be seen with the agent used to treat this patient’s anemia?

A 30-year-old man presents to your office with fatigue, muscle weakness and occasional headaches.  His blood pressure is 180/110 mmHg and his heart rate is 80/min.  Laboratory evaluation reveals low serum potassium, severely depressed plasma renin activity, and a CT scan demonstrates a right-sided adrenal mass.  After treatment for several weeks, the patient’s symptoms resolve, his blood pressure is decreased to 130/70 mmHg and his heart rate is 75/min.  Which of the following drugs was most likely used in this patient?

A 46-year-old man comes to the emergency department with flank pain and hematuria.  The pain is similar to several previous episodes of kidney stones.  Abdominal imaging reveals a radiopaque calculus in the right ureter.  The patient is admitted to the hospital and given intravenous hydration and analgesics.  He subsequently passes the stone with rapid relief of his symptoms.  Chemical analysis reveals that the stone is composed primarily of calcium oxalate.  Which of the following medications is most likely to prevent recurrent stone formation in this patient?