Five medication lists in one session

Correct answer: A. Alpha-1 adrenergic receptor antagonist

• A. CORRECT. Terazosin, like prazosin and doxazosin, is an ALPHA-1 ADRENERGIC ANTAGONIST. Blocking alpha-1 receptors relaxes vascular smooth muscle, lowering peripheral resistance, and — the reason this patient takes it — relaxes the smooth muscle of the prostate and bladder neck, relieving obstructive urinary symptoms. The dentally relevant adverse effects follow directly from the vasodilatation: FIRST-DOSE and POSTURAL HYPOTENSION with dizziness and syncope, plus drowsiness, nasal congestion and palpitations. Raise the chair slowly and support the patient on standing.
• B. ACE inhibition describes the drugs ending in ‘-pril’, which block conversion of angiotensin I to angiotensin II and characteristically cause a dry cough.
• C. Beta-1 selective antagonism describes metoprolol and atenolol, which lower heart rate and cardiac output. They have no role in prostatic obstruction.
• D. Calcium channel blockade describes amlodipine, nifedipine, diltiazem and verapamil — and among these the dihydropyridines are the ones associated with gingival enlargement.

Note: ⚠️ The recall also asked which finding is NOT associated with terazosin, and keyed BLEEDING. That is right — alpha-1 blockers have no effect on platelets or the coagulation cascade, so no haemostatic modification is required for surgery. The modification they DO require is postural.

Correct answer: D. It inhibits CYP3A4, raising simvastatin levels and risking rhabdomyolysis

• A. There is no clinically significant absorption interaction between fluconazole and terazosin.
• B. Nystatin and fluconazole are not antagonistic; they simply work by related mechanisms on ergosterol and its synthesis.
• C. Fluconazole is active against Candida albicans and is a standard systemic agent for oral candidiasis. The problem here is the interaction, not the spectrum.
• D. CORRECT. The azole antifungals are potent inhibitors of CYP3A4, and simvastatin, lovastatin and atorvastatin are CYP3A4 SUBSTRATES. Inhibiting the enzyme causes statin plasma levels to rise sharply, and the consequence is MYOPATHY progressing to RHABDOMYOLYSIS — muscle pain and weakness, dark urine from myoglobinuria, and acute kidney injury. The safer routes are a TOPICAL antifungal, or liaison with the physician about briefly holding the statin. Note that pravastatin and rosuvastatin are not CYP3A4-dependent and are far less affected.

Note: The same CYP3A4 mechanism makes ERYTHROMYCIN and CLARITHROMYCIN dangerous with these statins — and grapefruit juice does it too. Fluconazole additionally potentiates WARFARIN, raising the INR, and even topical MICONAZOLE gel is absorbed sufficiently to do this. Miconazole is not the safe topical alternative in an anticoagulated patient; nystatin is.

Correct answer: B. Reduced glomerular filtration rate

• A. Gastric acid production DECREASES with age, and gastric emptying slows. These alter the rate of absorption somewhat but rarely the extent, and they are not the governing concern.
• B. CORRECT. Glomerular filtration declines steadily with age — roughly 1% per year after about 40 — so a 90-year-old may have half the renal clearance of a young adult. The trap is that SERUM CREATININE is a poor guide in the elderly: reduced muscle mass keeps it deceptively normal even when clearance is substantially impaired, so an estimated GFR or a Cockcroft-Gault calculation is needed. Renally excreted drugs accumulate, and most of the antibiotics used in dentistry — the penicillins and cephalosporins — are renally cleared. Reduce the dose or lengthen the interval.
• C. Total body water DECREASES with age and body fat proportion increases. That reduces the volume of distribution of water-soluble drugs and INCREASES it for lipid-soluble ones, prolonging their half-life — relevant for benzodiazepines, but not the leading antibiotic consideration.
• D. Hepatic mass and hepatic blood flow both DECREASE with age, so first-pass metabolism FALLS — which raises the bioavailability of drugs with high first-pass extraction rather than lowering it.

Note: The wider geriatric prescribing picture: polypharmacy and interaction risk, reduced serum albumin raising the free fraction of highly protein-bound drugs, and greater CNS sensitivity to sedatives and opioids. Start low and go slow, and review the whole medication list rather than the new prescription alone.

Correct answer: A. Generalised reduced bone density with a thinned inferior cortex and coarse trabeculation

• A. CORRECT. The underlying disease is OSTEOPOROSIS, and the drugs slow its progression without reversing it. Expect the radiographic signs of generalised osteopenia: a THINNED MANDIBULAR INFERIOR CORTEX — a recognised incidental screening sign on panoramic films — with reduced overall density and a sparser, coarser trabecular pattern. What alendronate does NOT do is make the jaws look dense.
• B. Diffusely dense bone with obliterated marrow spaces describes OSTEOPETROSIS, a failure of osteoclastic resorption — the opposite of this patient's disease.
• C. Punched-out radiolucencies without a corticated rim are characteristic of MULTIPLE MYELOMA.
• D. A ground-glass pattern suggests FIBROUS DYSPLASIA, or the generalised granular change of hyperparathyroidism. Neither is expected here.

Note: The two management points that matter more than the radiograph. First, MRONJ risk from the oral bisphosphonate: low for oral therapy under about four years, rising beyond that, and this patient is at six. Second, methotrexate adds impaired healing and immunosuppression — and NSAIDs must be used with caution alongside it, because they reduce methotrexate's renal clearance and can precipitate toxicity, which makes acetaminophen the safer analgesic.

Correct answer: B. Tachycardia

• A. Hypoventilation with hypercapnia IS characteristic, caused by reduced central respiratory drive and respiratory muscle weakness. It is the usual mechanism of death and the reason airway support is a priority.
• B. CORRECT as the exception. Myxedema coma is the extreme end of HYPOthyroidism, so every system is slowed — the patient is BRADYCARDIC, as this one is at 48 bpm, with reduced cardiac output and hypotension. TACHYCARDIA belongs to the opposite emergency, THYROID STORM, alongside hyperthermia, agitation, tremor and atrial fibrillation. Confusing the two crises is exactly what this item tests.
• C. Hypothermia IS characteristic and is often profound, and it classically occurs WITHOUT shivering. A normal temperature in a hypothyroid patient who is also septic should be read as a warning sign rather than reassurance.
• D. Hyponatraemia IS characteristic, resulting from impaired free water excretion. Hypoglycaemia commonly accompanies it.

Note: Precipitants are cold exposure, infection, trauma, and — directly relevant to dentistry — SEDATIVES AND OPIOIDS. An undiagnosed or undertreated hypothyroid patient is exquisitely sensitive to CNS depressants, so sedation must be approached with real caution and elective care deferred until the patient is euthyroid. Treatment is intravenous levothyroxine with intravenous hydrocortisone and supportive care; mortality remains substantial even when treated.