1. How will you prescribe lipase, protease, and amylase components? 2. What is the medication of choice for hypertensive crisis with
... [Show More] pheochromocytoma? Patients with cys- tic fibrosis are often prescribed enzyme replace- ment for pancreat- ic secretions each replacement drug has amylase, li- pase and protease components, how- ever the drug is pre- scribed in units of lipase Surgical resection of the tumor is the first treatment of choice either my open laparotomy or laparoscopy either surgical option re- quires prior treat- ment of nonspecific irreversible adren- ergic adraonore- ceptor blocker phe- noxybenzamine or a shorter acting alpha antagonists, prazosin, terazosin, and doxazosin. Mainly use phenoz- ibenamine in prac- tice. Doing so pro- motes the surgery to proceed while minimizing the like- lihood of severe in- traoperative hyper- 3. What is the onset of action, peak of action, and dura- tion of action of each insulin preparation? 4. Identify the symptoms of hypoglycemia, hyper- glycemia, and ketoacidosis. tension which is likely when the tu- mor is manipulat- ed. (Intermediate Act- ing) NPH Onset-60-90 min after administra- tion, Peak 48 hrs Duration 10-18 hrs. (Short Acting) Reg- ular Onset 30-60 min Peak 2-4 hrs Duration 6-10 hrs (Long Acting) As- part, Lispro, Gluli- sine Onset less than 15 min Peak 1-2 hrs Duration 3-6 hrs (Long Acting) Glargine, Detemir Onset 1-2 hrs Peak NO PEAK Duration 24 hrs Hypoglycemia- dizziness, confusion, diaphoresis, tachycardia Hyperglycemia- 5. When changing from NPH to glargine insulin, how will you adjust the patient's dose? polyphagia, polydipsia, polyuria, blurred vision, and fatigue Ketoacidosis- hall- mark symptoms include acetone breath like nail pol- ish remover or fruity breath. Also ab- dominal pain, nau- sea, vomiting and sob. The initial dose of glargine is reduced by 20% to prevent hypoglycemia. 6. How does metformin work? Decreases hyper- glycemia by de- creasing hepatic glucose produc- tion called he- patic gluconeoge- nesis. The aver- age person with type 2 diabetes has three times the rate of gluco- neogenesis, met- formin treatment reduces this by over 1/3rd. The molecular mecha- nism of metformin isn't completely un- derstood. In addi- tion to suppress- 7. What diagnostic testing is required before and throughout therapy with metformin? ing hepatic glu- cose production, metformin increas- es insulin sen- sitivity, enhances peripheral glucose uptake by induc- ing the phosphoril- ization of glu4 en- hancer factor, de- creases insulin in- duced suppression of fatty acid oxida- tion, and decreas- es absorption of glucose from the GI tract. Also of note** Metformin helps re- duce LDL choles- terol and triglyc- eride levels and is not associated with weight gain, in some people it helps promote weight loss** Metformin is not metabolized, it is cleared from the body by tubular se- cretion and is se- creted unchanged in the urine. Met- formin is unde- tectable in blood plasma within 24 hrs of a single oral dose the average elimination half-life in plasma is 6.2 hrs as it is se- creted in the urine you should check a serum crt to assess renal function. 8. What is the action of gliptin? The mechanism of DDP-4 inhibitors is to increase in- cretin levels in- cretin are GLP1 and GIP which in- hibit glucagon re- lease in which in turn increases insulin secretion, decreases gastric emptying, and de- creases blood glu- cose levels 9. How do GLP agonists work? They bind direct- ly to a recep- tor in the pan- creatic beta cell. These agents work in the same path- way as the DPP-4 inhibitors as men- tioned above but are generally con- sidered more po- tent. 10. When should exenatide be administered? 60 minutes prior to the morning and evening meal 11. How will you assess for granulocytopenia? Signs of a Cold or flu including fever and sore throat 12. What are the adverse effects of propylthiouracil? Agranulocytosis, thrombocytopenia, and fulminant liver failure as stated above, pt's on PTU when they develop fever or sore throat, it would be important to check a CBC preferably with a smear and a diff. 13. What are the adverse effects of levothyroxine? Tachycardia and angina in the elder- ly 14. A patient develops a toxic goiter. What is the recom- mended treatment? 15. What are the adverse effects of PTU and methima- zole? Methimazole for one month then ra- dioactive iodine (p. 641) PTU- Fatal agran- ulocytopenia look for fever and sore throat and TEMPO- RARY ALOPECIA 16. What is the action of biphosphonates? Bone undergoes constant turnover and is kept in balance by os- teoblasts creating bone and os- teoclasts destroy- ing bone. Bispho- sphonates inhibit the digestion of bone by encour- aging osteoclasts to undergo apop- tosis or cell death there by slowing bone loss. Oral bis- phosphonates can cause upset stom- ach and inflamma- tion as well as erosion. Erosions of the esophagus which is the main problem of oral and containing prepara- tions. This can be prevented by sitting upright for 30-60 minutes after tak- ing the medication. If the patient does develop some type of gastric distress, give them oral 30ml of Maalox 3 hrs af- ter taking it. IV bis- phosphonates can give fever and flu like symptoms af- ter the first infusion which is thought to occur because of their potential to activate human T cells 17. Prosobee Which infant formula is linked to impairment of thy- roxine absorption? 18. What are the drug interactions when prescribing poglitazone? 19. What is the drug of choice to treat neurogenic dia- betes insipidus? 20. What is the dosage schedule for alpha-glucosidase inhibitors? Metabolized by the CYP 2C8 which induces just like oral contraceptives. Oral contraceptives will be less effec- tive, which leads to more unin- tended pregnan- cies. Council pa- tients to change to a more reliable method of birth control that is not metabolized by the liver such as depro- pravera, long act- ing reversible con- traceptives such as the IED or im- plantable contra- ceptives such as nexplanon Clorapropramide Take within the first bite of each meal 21. Describe the pharmacodynamics of meglitinides. Citagliptan works to compatibly in- hibit the enzyme dipeptidyl, dipep- tide, or called DDP 4 as mentioned be- fore, this enzyme 22. Type 1 diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90 percent of Type 1 diabetics have: breaks down the in- cretins GLP1 and GIP gastrointesti- nal hormone re- leased in response to a meal. By preventing GLP1 and GIP inactiva- tion, they are able to increase secre- tion of insulin and suppress the re- lease of glucagon by the alpha cells of the pancreas, this process ulti- mately drives cal- cium into the cell, this drives blood glucose levels to- wards normal as the blood glucose level approaches normal, the amount of insulin release in glucagon sup- pression diminish- es thus tending to prevent an over- shoot of subse- quent blood sug- ar hypoglycemia which is seen in some other oral hy- poglycemia agents. A. Autoantibodies to two tyrosine phosphatases A. Autoantibodies to two tyrosine phosphatases B. Mutation of the hepatic transcription factor on chromosome 12 C. A defective glucokinase molecule due to a defec- tive gene on chromosome 7p D. Mutation of the insulin promoter factor 23. Type 2 diabetes is a complex disorder involving: A. Absence of insulin production by the beta cells B. A suboptimal response of insulin-sensitive tissues in the liver C. Increased levels of glucagon-like peptide in the post-prandial period D. Too much fat uptake in the intestine 24. Diagnostic criteria for diabetes include: A. Fasting blood glucose greater than 140 mg/dl on two occasions B. Post-prandial blood glucose greater than 140 mg/dl C. Fasting blood glucose 100 to 125 mg/dl on two occasions D. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl 25. Routine screening of asymptomatic adults for dia- betes is appropriate for A. Individuals who are older than 45 and have a BMI less than 25 kg/m2 B. Native Americans, African Americans, and Hispan- ics C. Persons with HDL cholesterol greater than 100 mg/dl D. Persons with pre-diabetes confirmed on at least two occasions B. A suboptimal response of in- sulin-sensitive tis- sues in the liver D. Symptoms of di- abetes plus a ca- sual blood glucose greater than 200 mg/dl B. Native Amer- icans, African Americans, and Hispanics 26. Screening criteria for children who meet the following criteria should begin at age 10 and occur every 3 years thereafter: A. BMI above the 85th percentile for age and sex B. Family history of diabetes in first- or second-de- gree relative C. Hypertension based on criteria for children D. Any of the above 27. Insulin is used to treat both types of diabetes. It acts by: A. Increasing beta cell response to low blood glucose levels B. Stimulating hepatic glucose production C. Increasing peripheral glucose uptake by skeletal muscle and fat D. Improving the circulation of free fatty acids 28. Adam has Type 1 diabetes and plays tennis for his university. He exhibits a Knowledge deficit about his insulin and his diagnosis. He should be taught that: A. He should increase his CHO intake during times of exercise B. Each brand of insulin is equal in bioavailability, so buy the least expensive C. Alcohol produces hypoglycemia and can help con- trol his diabetes when taken in small amounts D. If he does not want to learn to give himself in- jections, he may substitute an oral hypoglycemic to control his diabetes 29. Insulin preparations are divided into categories based on onset, duration, and intensity of action fol- lowing subcutaneous inject. Which of the following insulin preparations has the shortest onset and du- ration of action? D. Any of the above C. Increasing pe- ripheral glucose uptake by skeletal muscle and fat A. He should in- crease his CHO in- take during times of exercise B. Insulin glulisine A. Insulin lispro B. Insulin glulisine C. Insulin glargine D. Insulin detemir 30. The drug of choice for Type 2 diabetics is metformin. A. Decreases Metformin: A. Decreases glycogenolysis by the liver B. Increases the release of insulin from beta cells C. Increases intestinal uptake of glucose D. Prevents weight gain associated with hyper- glycemia 31. Before prescribing metformin, the provider should: A. Draw a serum creatinine level to assess renal func- tion B. Try the patient on insulin C. Prescribe a thyroid preparation if the patient needs to lose weight D. All of the above 32. Sulfonylureas may be added to a treatment regimen for Type 2 diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 ther- apy because they: A. Increase endogenous insulin secretion B. Have a significant risk for hypoglycemia C. Address the insulin resistance found in Type 2 diabetics D. Improve insulin binding to receptors 33. Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advan- tages of these drugs include: glycogenolysis by the liver A. Draw a serum creatinine level to assess renal func- tion B. Have a signifi- cant risk for hypo- glycemia C. Low risk for hy- poglycemia A. Better reduction in glucose levels than other class- es B. Less weight gain than sulfonylureas C. Low risk for hypoglycemia D. Can be given twice daily 34. Control targets for patients with diabetes include: A. HbA1C between 7 and 8 B. Fasting blood glucose levels between 100 and 120 mg/dl C. Blood pressure less than 130/80 mm Hg D. LDL lipids less than 130 mg/dl 35. Establishing glycemic targets is the first step in treat- ment of both types of diabetes. For Type 1 diabetes: A. Tight control/intensive therapy can be given to adults who are willing to test their blood glucose at least twice daily B. Tight control is acceptable for older adults if they are without complications C. Plasma glucose levels are the same for children as adults D. Conventional therapy has a fasting plasma glu- cose target between 120 and 150 mg/dl 36. Treatment with insulin for Type 1 diabetics: A. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight B. Divides the total doses into three injections based on meal size C. Uses a total daily dose of insulin glargine given once daily with no other insulin required D. Is based on the level of blood glucose 37. When the total daily insulin dose is split and given twice daily, which of the following rules may be fol- lowed? C. Blood pressure less than 130/80 mm Hg D. Conventional therapy has a fast- ing plasma glucose target between 120 and 150 mg/dl A. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight A. Give two-thirds of the total dose in the morning and one-third in the A. Give two-thirds of the total dose in the morning and evening. one-third in the evening. B. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning and two-thirds in the evening. C. Give 50% of an insulin glargine dose in the morn- ing and 50% in the evening. D. Give long-acting insulin in the morning and short-acting insulin at bedtime. 38. Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer long-term complications of diabetes. Patients who should have such a target include: A. Those with long-standing diabetes B. Older adults C. Those with no significant cardiovascular disease D. Young children who are early in their disease 39. Prevention of conversion from pre-diabetes to dia- betes in young children must take highest priority and should focus on: A. Aggressive dietary manipulation to prevent obesi- ty B. Fostering LDL levels less than 100 mg/dl and total cholesterol less than 170 mg/dl to prevent cardiovas- cular disease C. Maintaining a blood pressure that is less than 80% based on weight and height to prevent hypertension D. All of the above 40. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (de- pending upon type of diabetes) are: A. Metformin and insulin C. Those with no significant cardio- vascular disease B. Fostering LDL levels less than 100 mg/dl and total cho- lesterol less than 170 mg/dl to pre- vent cardiovascular disease A. Metformin and insulin B. Sulfonylureas and insulin glargine C. Split-mixed dose insulin and GPL-1 agonists D. Biguanides and insulin lispro 41. Unlike most Type 2 diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is: A. Weight loss in previously overweight persons B. Involuntary loss of 10% of body weight in less than 6 months C. Decline in lean body mass over a 12-month period D. Increase in central versus peripheral body adipos- ity 42. The drugs recommended for older adults with Type 2 diabetes include: A. Second generation sulfonylureas B. Metformin C. Pioglitazone D. Third generation sulfonylureas 43. Ethnic groups differ in their risk for and presentation of diabetes. Hispanics: A. Have a high incidence of obesity, elevated triglyc- erides, and hypertension B. Do best with drugs that foster weight loss, such as metformin C. Both A and B D. Neither A nor B 44. The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of dying from cardiovascular disease. Treatments and targets that do not appear to decrease risk for micro- and macro-vascular complications include: B. Involuntary loss of 10% of body weight in less than 6 months D. Third generation sulfonylureas C. Both A and B A. Glycemic targets between 7% and 7.5% A. Glycemic targets between 7% and 7.5% B. Use of insulin in Type 2 diabetics C. Control of hypertension and hyperlipidemia D. Stopping smoking 45. All diabetic patients with known cardiovascular dis- ease should be treated with: A. Beta blockers to prevent MIs B. ACE inhibitors and aspirin to reduce risk of cardio- vascular events C. Sulfonylureas to decrease cardiovascular mortali- ty D. Pioglitazone to decrease atherosclerotic plaque buildup 46. All diabetic patients with hyperlipidemia should be treated with: A. HMG-CoA reductase inhibitors B. Fibric acid derivatives C. Nicotinic acid D. Colestipol 47. All diabetic patients with hyperlipidemia should be treated with: A. HMG-CoA reductase inhibitors B. Fibric acid derivatives C. Nicotinic acid D. Colestipol 48. Protein restriction helps slow the progression of al- buminuria, GFR decline, and ESRD is some patients with diabetes. It is useful for patients who: A. Cannot tolerate ACE inhibitors or ARBs B. Have uncontrolled hypertension C. Have HbA1C levels above 7% B. ACE inhibitors and aspirin to re- duce risk of cardio- vascular events A. HMG-CoA re- ductase inhibitors C. Nicotinic acid D. Show progres- sion of diabet- ic nephropathy de- spite optimal glu- cose and blood pressure control D. Show progression of diabetic nephropathy despite optimal glucose and blood pressure control 49. Diabetic autonomic neuropathy (DAN) is the earliest and most common complication of diabetes. Symp- toms associated with DAN include: A. Resting tachycardia, exercise intolerance, and or- thostatic hypotension B. Gastroparesis, cold intolerance, and moist skin C. Hyperglycemia, erectile dysfunction, and deficien- cy of free fatty acids D. Pain, loss of sensation, and muscle weakness 50. Drugs used to treat diabetic peripheral neuropathy include: A. Metoclopramide B. Cholinergic agonists C. Cardioselective beta blockers D. Gabapentin 51. The American Diabetic Association has recommend- ed which of the following tests for ongoing manage- ment of diabetes? A. Fasting blood glucose B. HbA1C C. Thyroid function tests D. Electrocardiograms 52. When methimazole is started for hyperthyroidism it may take to see total reversal of hyperthyroid symptoms. A. 2 to 4 weeks B. 1 to 2 months C. 3 to 4 months D. 6 to 12 months A. Resting tachy- cardia, exercise in- tolerance, and or- thostatic hypoten- sion D. Gabapentin B. HbA1C D. 6 to 12 months 53. In addition to methimazole, a symptomatic patient with hyperthyroidism may need a prescription for: A. A calcium channel blocker B. A beta blocker C. Liothyronine D. An alpha blocker 54. After starting a patient with Grave's disease on an antithyroid agent such as methimazole, patient mon- itoring includes TSH and free T4 every: A. 1 to 2 weeks B. 3 to 4 weeks C. 2 to 3 months D. 6 to 9 months 55. A woman who is pregnant and has hyperthyroidism is best managed by a specialty team who will most likely treat her with: A. Methimazole B. Propylthiouracil (PTU) C. Radioactive iodine D. Nothing, treatment is best delayed until after her pregnancy ends 56. Goals of treatment when treating hypothyroidism with thyroid replacement include: A. Normal TSH and free T4 levels B. Resolution of fatigue C. Weight loss to baseline D. All of the above 57. When starting a patient on levothyroxine for hypothy- roidism the patient will need follow-up measurement of thyroid function in: A. 2 weeks B. A beta blocker B. 3 to 4 weeks B. Propylthiouracil (PTU) D. All of the above B. 4 weeks B. 4 weeks C. 2 months D. 6 months 58. Once a patient who is being treated for hypothy- roidism returns to euthyroid with normal TSH levels, he or she should be monitored with TSH and free T4 levels every: A. 2 weeks B. 4 weeks C. 2 months D. 6 months 59. Treatment of a patient with hypothyroidism and car- diovascular disease consists of: A. Levothyroxine B. Liothyronine C. Liotrix D. Methimazole 60. Infants with congenital hypothyroidism are treated with: A. Levothyroxine B. Liothyronine C. Liotrix D. Methimazole 61. When starting a patient with hypothyroidism on thy- roid replacement hormones patient education would include: A. They should feel symptomatic improvement in 1 to 2 weeks B. Drug adverse effects such as lethargy and dry skin may occur C. It may take 4 to 8 weeks to get to euthyroid symp- tomatically and by lab testing D. 6 months A. Levothyroxine A. Levothyroxine C. It may take 4 to 8 weeks to get to euthyroid symp- tomatically and by lab testing D. Due to its short half-life, levothyroxine doses should not be missed 62. Both men and women experience bone loss with ag- ing. The bones most likely to demonstrate significant loss are: A. Cortical bone B. Femoral neck C. Cervical vertebrae D. Pelvic bones 63. Bisphosphonates treat or prevent osteoporosis by: A. Inhibiting osteoclastic activity B. Fostering bone resorption C. Enhancing calcium uptake in bone D. Strengthening the osteoclastic proton pump 64. Prophylactic use of bisphosphonates is recommend- ed for patients with early osteopenia related to long-term use of which of the following drugs? A. Selective estrogen receptor modulators B. Aspirin C. Glucocorticoids D. Calcium supplements 65. Patients with cystic fibrosis are often prescribed en- zyme replacement for pancreatic secretions. Each replacement drug has lipase, protease, and amylase components, but the drug is prescribed in units of: A. Lipase B. Protease C. Amylase D. Pancreatin 66. Brands of pancreatic enzyme replacement drugs are: B. Femoral neck A. Inhibiting osteo- clastic activity C. Glucocorticoids A. Lipase A. Bioequivalent B. About the same in cost per unit of lipase across brands C. Able to be interchanged between generic and brand-name products to reduce cost D. None of the above 67. When given subcutaneously, NPH insulin begins to take effect (onset of action): A. 15 to 30 minutes after administration B. 60 to 90 minutes after administration C. 3 to 4 hours after administration D. 6 to 8 hours after administration 68. Hypoglycemia can result from the action of either in- sulin or an oral hypoglycemic. Signs and symptoms of hypoglycemia include: A. "Fruity" breath odor and rapid respiration B. Diarrhea, abdominal pain, weight loss, and hyper- tension C. Dizziness, confusion, diaphoresis, and tachycardia D. Easy bruising, palpitations, cardiac dysrhythmias, and coma 69. Nonselective beta blockers and alcohol create seri- ous drug interactions with insulin because they: A. Increase blood glucose levels B. Produce unexplained diaphoresis C. Interfere with the ability of the body to metabolize glucose D. Mask the signs and symptoms of altered glucose levels 70. Lipro is an insulin analogue produced by recombi- nant DNA technology. Which of the following state- ments about this form of insulin is NOT true? B. About the same in cost per unit of li- pase across brands B. 60 to 90 minutes after administration C. Dizziness, con- fusion, diaphoresis, and tachycardia D. Mask the signs and symptoms of altered glucose lev- els B. Duration of ac- tion is increased when the dose is in- creased. A. Optimal time of preprandial injection is 15 minutes. B. Duration of action is increased when the dose is increased. C. It is compatible with NPH insulin. D. It has no pronounced peak. 71. The decision may be made to switch from BID NPH insulin to insulin glargine to improve glycemia con- trol throughout the day. If this is done: A. The initial dose of glargine is reduced by 20% to avoid hypoglycemia B. The initial dose of glargine is 2 to 10 Units per day C. Patients who have been on high doses of NPH will need tests for insulin antibodies D. Obese patients may require more than 100 Units per day 72. When blood glucose levels are difficult to control in Type 2 diabetes some form of insulin may be added to the treatment regimen to control blood glucose and limit complications risks. Which of the following statements are accurate based on research? A. Premixed insulin analogues are better at lowering HbA1C and have less risk for hypoglycemia. B. Premixed insulin analogues and the newer pre- mixed insulins are associated with more weight gain than the oral antidiabetic agents. C. Newer premixed insulins are better at lowering HbA1C and post-prandial glucose levels than are long-acting insulins. D. Patients who are not controlled on oral agents and have post-prandial hyperglycemia can have NPH insulin added at bedtime. 73. Metformin is a primary choice of drug to treat hyper- glycemia in Type 2 diabetes because it: A. The initial dose of glargine is re- duced by 20% to avoid hypo- glycemia C. Newer premixed insulins are better at lowering HbA1C and post-prandial glucose levels than are long-acting in- sulins. B. Decreases glycogenolysis by the liver A. Substitutes for insulin usually secreted by the pan- creas B. Decreases glycogenolysis by the liver C. Increases the release of insulin from beta cells D. Decreases peripheral glucose utilization 74. Prior to prescribing metformin, the provider should: A. Draw a serum creatinine to assess renal function A. Draw a serum creatinine to as- sess renal function B. Try the patient on insulin C. Tell the patient to increase iodine intake D. Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions 75. The action of "gliptins" is different from other antidi- abetic agents because they: A. Have a low risk for hypoglycemia B. Are not associated with weight gain C. Close ATP-dependent potassium channels in the beta cell D. Act on the incretin system to indirectly increase insulin production Act on the incretin system to indirect- ly increase insulin production 76. Sitagliptin has been approved for: C. Both A and B A. Monotherapy in once daily doses B. Combination therapy with metformin C. Both A and B D. Neither A nor B 77. GLP-1 agonists: A. Directly bind to a receptor in the pancreatic beta A. Directly bind to a receptor in the pan- creatic beta cell cell B. Have been approved for monotherapy C. Speed gastric emptying to decrease appetite D. Can be given orally once daily 78. D. All of the above Avoid concurrent administration of exenatide with which of the following drugs? A. Digoxin B. Warfarin C. Lovastatin D. All of the above 79. Administration of exenatide is by subcutaneous in- jection: A. 30 minutes prior to the morning meal B. 60 minutes prior to the morning and evening meal C. 15 minutes after the evening meal D. 60 minutes before each meal daily 80. Potentially fatal granulocytopenia has been associat- ed with treatment of hyperthyroidism with propylth- iouracil. Patients should be taught to report: A. Tinnitus and decreased salivation B. Fever and sore throat C. Hypocalcemia and osteoporosis D. Laryngeal edema and difficulty swallowing 81. Elderly patients who are started on levothyroxine for thyroid replacement should be monitored for: A. Excessive sedation B. Tachycardia and angina C. Weight gain D. Cold intolerance B. 60 minutes prior to the morning and evening meal B. Fever and sore throat B. Tachycardia and angina [Show Less]