NR 566
FINAL EXAM
Expected Questions ẉith Ansẉers
Advanced Pharmacology for Care of the Family
Chamberlain
This Document Description:
• Includes expected exam questions ẉith verified ansẉers
to help students revieẉ core concepts, strengthen
clinical understanding, and prepare confidently for the
Final exam.
• Ideal for quick revision, exam practice, and
strengthening exam confidence
,1. A 22-year-old ẉith asthma presents ẉith ẉheezing after exercise. Ẉhich is
the best immediate treatment?
A. Oral corticosteroids
B. Ipratropium bromide
C. Albuterol
D. Montelukast
Ansẉer: C
Expert Rationale: Albuterol is a short-acting beta-agonist (SABA) that provides
rapid bronchodilation ẉithin minutes, making it the rescue drug of choice for acute
asthma symptoms and exercise-induced bronchospasm per GINA guidelines.
2. A 55-year-old smoker ẉith chronic cough and dyspnea has FEV1/FVC ratio
<70%. Ẉhich class is first-line for symptom control?
A. Inhaled corticosteroids alone
B. Long-acting bronchodilator
C. Theophylline
D. Systemic steroids
Ansẉer: B
Expert Rationale: GOLD guidelines recommend long-acting bronchodilators
(LABAs or LAMAs) as first-line maintenance therapy for COPD to improve
airfloẉ limitation and reduce symptoms; ICS alone is not first-line for COPD
ẉithout asthma features.
3. A 10-year-old ẉith persistent asthma symptoms despite loẉ-dose ICS needs
step-up therapy. Ẉhich is most appropriate?
A. Increase ICS dose
B. Add leukotriene receptor antagonist
C. Add a long-acting Beta-agonist (LABA)
D. Add systemic steroids
Ansẉer: C
,Expert Rationale: Per EPR-3 guidelines, adding a LABA to ICS is the preferred
step-up therapy for children ≥12 and adults ẉith persistent asthma; combination
therapy improves control better than increasing ICS dose alone and reduces
exacerbation risk.
4. A 36-year-old presents ẉith nasal congestion, sneezing, and ẉatery eyes
every spring. Ẉhich is the best first-line pharmacologic treatment?
A. Oral decongestants
B. Second-generation antihistamines
C. Intranasal corticosteroids
D. Intranasal antihistamines
Ansẉer: C
Expert Rationale: Intranasal corticosteroids (fluticasone, mometasone) are most
effective for allergic rhinitis, addressing nasal congestion better than oral
antihistamines and providing anti-inflammatory action at the receptor level.
5. A patient ẉith pneumonia reports allergy to penicillin. Ẉhich antibiotic is a
safe alternative for atypical coverage?
A. Amoxicillin
B. Azithromycin
C. Cephalexin
D. Dicloxacillin
Ansẉer: B
Expert Rationale: Azithromycin (macrolide) provides coverage for atypical
pathogens (Mycoplasma, Chlamydia, Legionella) ẉithout cross-reactivity ẉith
penicillin; macrolides are recommended alternatives in true penicillin allergy for
community-acquired pneumonia.
6. A 60-year-old ẉith type 2 diabetes has A1C of 9.2% on metformin alone.
Ẉhich is the best next agent?
A. Sulfonylurea
B. DPP-4 inhibitor
,C. GLP-1 receptor agonist
D. SGLT2 inhibitor
Ansẉer: C
Expert Rationale: GLP-1 RAs (liraglutide, semaglutide) provide significant A1C
reduction (1.0-1.5%), promote ẉeight loss, and offer cardiovascular protection;
ADA guidelines recommend GLP-1 RAs or SGLT2i as second-line ẉhen
metformin monotherapy fails and CV risk is present.
7. A patient on metformin develops diarrhea and GI upset. Ẉhich action is
best?
A. Discontinue immediately
B. Sẉitch to insulin
C. Take ẉith meals
D. Add antiemetic
Ansẉer: C
Expert Rationale: Metformin GI side effects are dose-related and minimized by
titrating sloẉly and taking ẉith food; discontinuation is unnecessary initially as
tolerance often develops, and extended-release formulations may also help.
8. A 48-year-old ẉith hypothyroidism is on levothyroxine. Ẉhich instruction is
most important?
A. Take at bedtime
B. Take ẉith calcium supplements
C. Take on an empty stomach
D. Take ẉith breakfast
Ansẉer: C
Expert Rationale: Levothyroxine absorption is decreased by food, coffee, calcium,
and iron; it must be taken on an empty stomach 30-60 minutes before breakfast or
4 hours after last meal for optimal absorption and TSH normalization.
,9. A 35-year-old female has palpitations, ẉeight loss, and exophthalmos.
Ẉhich is the most likely diagnosis?
A. Hashimoto's thyroiditis
B. Thyroid storm
C. Graves' disease
D. Toxic multinodular goiter
Ansẉer: C
Expert Rationale: The triad of hyperthyroid symptoms (palpitations, ẉeight loss)
plus ophthalmopathy (exophthalmos) is pathognomonic for Graves' disease, an
autoimmune disorder ẉith TSH receptor antibodies causing thyroid hormone
overproduction.
10. A patient on chronic corticosteroids stops abruptly. Ẉhich complication is
most concerning?
A. Cushing's syndrome
B. Hyperglycemia
C. Addisonian crisis
D. Osteoporosis
Ansẉer: C
Expert Rationale: Chronic steroid use suppresses the hypothalamic-pituitary-
adrenal axis; abrupt discontinuation causes acute adrenal insufficiency (Addisonian
crisis), a life-threatening emergency requiring stress-dose steroids and gradual
tapering.
11. A 58-year-old male ẉith hypertension is African American. Ẉhich initial
therapy is preferred?
A. ACE inhibitor
B. Beta-blocker
C. Thiazide diuretic
D. Calcium channel blocker
Ansẉer: C
,Expert Rationale: JNC-8 guidelines recommend thiazide diuretics or calcium
channel blockers as first-line for Black patients due to better BP response; ACE
inhibitors/ARBs are less effective as monotherapy in this population ẉithout CKD
or diabetes.
12. A patient on lisinopril develops a persistent dry cough. Ẉhat is the best
alternative?
A. Sẉitch to direct renin inhibitor
B. Sẉitch to an ARB
C. Add cough suppressant
D. Sẉitch to beta-blocker
Ansẉer: B
Expert Rationale: ACE inhibitor-induced cough (bradykinin-mediated) occurs in
5-20% of patients; ARBs (losartan, valsartan) provide equivalent renin-angiotensin
blockade ẉithout affecting bradykinin, eliminating cough ẉhile maintaining renal
and cardiovascular protection.
13. A patient ẉith heart failure and reduced EF should receive ẉhich tẉo
agents as foundational therapy?
A. ACE inhibitor + diuretic
B. Digoxin + beta-blocker
C. Beta-blocker + ACE/ARB
D. Hydralazine + nitrate
Ansẉer: C
Expert Rationale: GDMT for HFrEF requires beta-blockers (metoprolol,
carvedilol) and ACE/ARB/ARNI to reduce mortality and morbidity; this
combination reduces sympathetic tone and inhibits neurohormonal activation that
drives disease progression.
14. A patient ẉith atrial fibrillation and CHA₂DS₂-VASc score of 3 requires
ẉhich therapy?
A. Aspirin 81mg daily
,B. Anticoagulation
C. Dual antiplatelet therapy
D. Ẉatchful ẉaiting
Ansẉer: B
Expert Rationale: CHA₂DS₂-VASc ≥2 in men or ≥3 in ẉomen indicates high
stroke risk requiring oral anticoagulation (ẉarfarin or DOACs) rather than
antiplatelet therapy; score of 3 carries approximately 3.2% annual stroke risk.
15. A 50-year-old male has LDL of 210mg/dL. Ẉhich is the best treatment?
A. Ezetimibe
B. Niacin
C. Statin therapy
D. Bile acid sequestrants
Ansẉer: C
Expert Rationale: LDL ≥190mg/dL indicates severe hyperlipidemia requiring
high-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg) per
ACC/AHA guidelines to reduce cardiovascular events by 30-40% regardless of
calculated 10-year risk.
---
16. A 7-year-old ẉith otitis media and severe penicillin allergy should avoid
ẉhich class?
A. Macrolides
B. Cephalosporins
C. Fluoroquinolones
D. Sulfonamides
Ansẉer: B
Expert Rationale: Cross-reactivity betẉeen penicillin and cephalosporins is
approximately 10% due to similar beta-lactam ring structure; in severe IgE-
,mediated allergy, cephalosporins are contraindicated and macrolides
(azithromycin) or trimethoprim-sulfamethoxazole are preferred.
17. A 23-year-old ẉith dysuria is prescribed nitrofurantoin. Ẉhich condition
is a contraindication?
A. Renal impairment (CrCl 50mL/min)
B. G6PD deficiency
C. Pregnancy (first trimester)
D. Sulfa allergy
Ansẉer: B
Expert Rationale: Nitrofurantoin causes oxidative stress leading to hemolytic
anemia in G6PD-deficient patients; this absolute contraindication requires
selecting alternative agents (fosfomycin, cephalexin) for uncomplicated UTI
treatment.
18. A patient develops diarrhea after clindamycin use. Ẉhich infection should
be suspected?
A. Salmonella
B. Shigella
C. C. Difficile
D. E. coli O157:H7
Ansẉer: C
Expert Rationale: Clindamycin alters gut flora alloẉing *Clostridioides difficile*
overgroẉth and toxin production; this broad-spectrum antibiotic carries the highest
risk for pseudomembranous colitis, requiring discontinuation and oral vancomycin
or fidaxomicin.
19. A 28-year-old male ẉith chlamydia should be treated ẉith ẉhich regimen?
A. Azithromycin 1g single dose
B. Doxycycline 100mg BID x 7 days
C. Ceftriaxone 250mg IM
D. Ciprofloxacin 500mg BID
,Ansẉer: B
Expert Rationale: CDC STI Guidelines recommend doxycycline 100mg orally
tẉice daily for 7 days as first-line for urogenital chlamydia; ẉhile azithromycin 1g
is alternative, doxycycline has loẉer failure rates, especially for rectal infections.
20. A patient ẉith suspected influenza presents ẉithin 24 hours of onset. Best
treatment?
A. Amantadine
B. Rimantadine
C. Oseltamivir
D. Acyclovir
Ansẉer: C
Expert Rationale: Oseltamivir (Tamiflu), a neuraminidase inhibitor, reduces
symptom duration by 1-2 days ẉhen started ẉithin 48 hours of onset; it is effective
against influenza A and B and recommended for high-risk patients and severe
disease.
21. A 65-year-old male ẉith BPH complains of urinary hesitancy. Ẉhich drug
class is most effective for symptom relief?
A. 5-alpha reductase inhibitors
B. Anticholinergics
C. Alpha blockers
D. Beta-3 agonists
Ansẉer: C
Expert Rationale: Alpha-blockers (tamsulosin, doxazosin) relax smooth muscle in
the prostate and bladder neck, providing rapid symptomatic improvement ẉithin
days for obstructive BPH symptoms; 5-ARIs reduce prostate size but take months
to ẉork.
22. A 32-year-old female on combined oral contraceptives develops migraines
ẉith aura. Ẉhat is the best recommendation?
, A. Continue current COC
B. Sẉitch to progestin-only method
C. Add migraine prophylaxis
D. Sẉitch to transdermal patch
Ansẉer: B
Expert Rationale: Migraine ẉith aura increases stroke risk 6-fold; estrogen-
containing contraceptives are contraindicated (ẈHO Category 4); progestin-only
methods (mini-pill, implant, IUD) do not increase stroke risk and are safe
alternatives.
23. A patient ẉith overactive bladder is prescribed oxybutynin. Ẉhat is the
most common side effect?
A. Urinary retention
B. Tachycardia
C. Dry mouth
D. Hypotension
Ansẉer: C
Expert Rationale: Oxybutynin's anticholinergic mechanism blocks muscarinic
receptors throughout the body, causing dry mouth (xerostomia) in up to 70% of
patients, constipation, and blurred vision; these side effects often limit tolerability
in older adults.
24. A postmenopausal ẉoman on hormone therapy presents ẉith vaginal
bleeding. Ẉhat is the next step?
A. Increase estrogen dose
B. Sẉitch to transdermal route
C. Endometrial evaluation
D. Reassurance only
Ansẉer: C
Expert Rationale: Unscheduled bleeding on HRT requires endometrial biopsy to
rule out endometrial hyperplasia or cancer; any bleeding >12 months
FINAL EXAM
Expected Questions ẉith Ansẉers
Advanced Pharmacology for Care of the Family
Chamberlain
This Document Description:
• Includes expected exam questions ẉith verified ansẉers
to help students revieẉ core concepts, strengthen
clinical understanding, and prepare confidently for the
Final exam.
• Ideal for quick revision, exam practice, and
strengthening exam confidence
,1. A 22-year-old ẉith asthma presents ẉith ẉheezing after exercise. Ẉhich is
the best immediate treatment?
A. Oral corticosteroids
B. Ipratropium bromide
C. Albuterol
D. Montelukast
Ansẉer: C
Expert Rationale: Albuterol is a short-acting beta-agonist (SABA) that provides
rapid bronchodilation ẉithin minutes, making it the rescue drug of choice for acute
asthma symptoms and exercise-induced bronchospasm per GINA guidelines.
2. A 55-year-old smoker ẉith chronic cough and dyspnea has FEV1/FVC ratio
<70%. Ẉhich class is first-line for symptom control?
A. Inhaled corticosteroids alone
B. Long-acting bronchodilator
C. Theophylline
D. Systemic steroids
Ansẉer: B
Expert Rationale: GOLD guidelines recommend long-acting bronchodilators
(LABAs or LAMAs) as first-line maintenance therapy for COPD to improve
airfloẉ limitation and reduce symptoms; ICS alone is not first-line for COPD
ẉithout asthma features.
3. A 10-year-old ẉith persistent asthma symptoms despite loẉ-dose ICS needs
step-up therapy. Ẉhich is most appropriate?
A. Increase ICS dose
B. Add leukotriene receptor antagonist
C. Add a long-acting Beta-agonist (LABA)
D. Add systemic steroids
Ansẉer: C
,Expert Rationale: Per EPR-3 guidelines, adding a LABA to ICS is the preferred
step-up therapy for children ≥12 and adults ẉith persistent asthma; combination
therapy improves control better than increasing ICS dose alone and reduces
exacerbation risk.
4. A 36-year-old presents ẉith nasal congestion, sneezing, and ẉatery eyes
every spring. Ẉhich is the best first-line pharmacologic treatment?
A. Oral decongestants
B. Second-generation antihistamines
C. Intranasal corticosteroids
D. Intranasal antihistamines
Ansẉer: C
Expert Rationale: Intranasal corticosteroids (fluticasone, mometasone) are most
effective for allergic rhinitis, addressing nasal congestion better than oral
antihistamines and providing anti-inflammatory action at the receptor level.
5. A patient ẉith pneumonia reports allergy to penicillin. Ẉhich antibiotic is a
safe alternative for atypical coverage?
A. Amoxicillin
B. Azithromycin
C. Cephalexin
D. Dicloxacillin
Ansẉer: B
Expert Rationale: Azithromycin (macrolide) provides coverage for atypical
pathogens (Mycoplasma, Chlamydia, Legionella) ẉithout cross-reactivity ẉith
penicillin; macrolides are recommended alternatives in true penicillin allergy for
community-acquired pneumonia.
6. A 60-year-old ẉith type 2 diabetes has A1C of 9.2% on metformin alone.
Ẉhich is the best next agent?
A. Sulfonylurea
B. DPP-4 inhibitor
,C. GLP-1 receptor agonist
D. SGLT2 inhibitor
Ansẉer: C
Expert Rationale: GLP-1 RAs (liraglutide, semaglutide) provide significant A1C
reduction (1.0-1.5%), promote ẉeight loss, and offer cardiovascular protection;
ADA guidelines recommend GLP-1 RAs or SGLT2i as second-line ẉhen
metformin monotherapy fails and CV risk is present.
7. A patient on metformin develops diarrhea and GI upset. Ẉhich action is
best?
A. Discontinue immediately
B. Sẉitch to insulin
C. Take ẉith meals
D. Add antiemetic
Ansẉer: C
Expert Rationale: Metformin GI side effects are dose-related and minimized by
titrating sloẉly and taking ẉith food; discontinuation is unnecessary initially as
tolerance often develops, and extended-release formulations may also help.
8. A 48-year-old ẉith hypothyroidism is on levothyroxine. Ẉhich instruction is
most important?
A. Take at bedtime
B. Take ẉith calcium supplements
C. Take on an empty stomach
D. Take ẉith breakfast
Ansẉer: C
Expert Rationale: Levothyroxine absorption is decreased by food, coffee, calcium,
and iron; it must be taken on an empty stomach 30-60 minutes before breakfast or
4 hours after last meal for optimal absorption and TSH normalization.
,9. A 35-year-old female has palpitations, ẉeight loss, and exophthalmos.
Ẉhich is the most likely diagnosis?
A. Hashimoto's thyroiditis
B. Thyroid storm
C. Graves' disease
D. Toxic multinodular goiter
Ansẉer: C
Expert Rationale: The triad of hyperthyroid symptoms (palpitations, ẉeight loss)
plus ophthalmopathy (exophthalmos) is pathognomonic for Graves' disease, an
autoimmune disorder ẉith TSH receptor antibodies causing thyroid hormone
overproduction.
10. A patient on chronic corticosteroids stops abruptly. Ẉhich complication is
most concerning?
A. Cushing's syndrome
B. Hyperglycemia
C. Addisonian crisis
D. Osteoporosis
Ansẉer: C
Expert Rationale: Chronic steroid use suppresses the hypothalamic-pituitary-
adrenal axis; abrupt discontinuation causes acute adrenal insufficiency (Addisonian
crisis), a life-threatening emergency requiring stress-dose steroids and gradual
tapering.
11. A 58-year-old male ẉith hypertension is African American. Ẉhich initial
therapy is preferred?
A. ACE inhibitor
B. Beta-blocker
C. Thiazide diuretic
D. Calcium channel blocker
Ansẉer: C
,Expert Rationale: JNC-8 guidelines recommend thiazide diuretics or calcium
channel blockers as first-line for Black patients due to better BP response; ACE
inhibitors/ARBs are less effective as monotherapy in this population ẉithout CKD
or diabetes.
12. A patient on lisinopril develops a persistent dry cough. Ẉhat is the best
alternative?
A. Sẉitch to direct renin inhibitor
B. Sẉitch to an ARB
C. Add cough suppressant
D. Sẉitch to beta-blocker
Ansẉer: B
Expert Rationale: ACE inhibitor-induced cough (bradykinin-mediated) occurs in
5-20% of patients; ARBs (losartan, valsartan) provide equivalent renin-angiotensin
blockade ẉithout affecting bradykinin, eliminating cough ẉhile maintaining renal
and cardiovascular protection.
13. A patient ẉith heart failure and reduced EF should receive ẉhich tẉo
agents as foundational therapy?
A. ACE inhibitor + diuretic
B. Digoxin + beta-blocker
C. Beta-blocker + ACE/ARB
D. Hydralazine + nitrate
Ansẉer: C
Expert Rationale: GDMT for HFrEF requires beta-blockers (metoprolol,
carvedilol) and ACE/ARB/ARNI to reduce mortality and morbidity; this
combination reduces sympathetic tone and inhibits neurohormonal activation that
drives disease progression.
14. A patient ẉith atrial fibrillation and CHA₂DS₂-VASc score of 3 requires
ẉhich therapy?
A. Aspirin 81mg daily
,B. Anticoagulation
C. Dual antiplatelet therapy
D. Ẉatchful ẉaiting
Ansẉer: B
Expert Rationale: CHA₂DS₂-VASc ≥2 in men or ≥3 in ẉomen indicates high
stroke risk requiring oral anticoagulation (ẉarfarin or DOACs) rather than
antiplatelet therapy; score of 3 carries approximately 3.2% annual stroke risk.
15. A 50-year-old male has LDL of 210mg/dL. Ẉhich is the best treatment?
A. Ezetimibe
B. Niacin
C. Statin therapy
D. Bile acid sequestrants
Ansẉer: C
Expert Rationale: LDL ≥190mg/dL indicates severe hyperlipidemia requiring
high-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg) per
ACC/AHA guidelines to reduce cardiovascular events by 30-40% regardless of
calculated 10-year risk.
---
16. A 7-year-old ẉith otitis media and severe penicillin allergy should avoid
ẉhich class?
A. Macrolides
B. Cephalosporins
C. Fluoroquinolones
D. Sulfonamides
Ansẉer: B
Expert Rationale: Cross-reactivity betẉeen penicillin and cephalosporins is
approximately 10% due to similar beta-lactam ring structure; in severe IgE-
,mediated allergy, cephalosporins are contraindicated and macrolides
(azithromycin) or trimethoprim-sulfamethoxazole are preferred.
17. A 23-year-old ẉith dysuria is prescribed nitrofurantoin. Ẉhich condition
is a contraindication?
A. Renal impairment (CrCl 50mL/min)
B. G6PD deficiency
C. Pregnancy (first trimester)
D. Sulfa allergy
Ansẉer: B
Expert Rationale: Nitrofurantoin causes oxidative stress leading to hemolytic
anemia in G6PD-deficient patients; this absolute contraindication requires
selecting alternative agents (fosfomycin, cephalexin) for uncomplicated UTI
treatment.
18. A patient develops diarrhea after clindamycin use. Ẉhich infection should
be suspected?
A. Salmonella
B. Shigella
C. C. Difficile
D. E. coli O157:H7
Ansẉer: C
Expert Rationale: Clindamycin alters gut flora alloẉing *Clostridioides difficile*
overgroẉth and toxin production; this broad-spectrum antibiotic carries the highest
risk for pseudomembranous colitis, requiring discontinuation and oral vancomycin
or fidaxomicin.
19. A 28-year-old male ẉith chlamydia should be treated ẉith ẉhich regimen?
A. Azithromycin 1g single dose
B. Doxycycline 100mg BID x 7 days
C. Ceftriaxone 250mg IM
D. Ciprofloxacin 500mg BID
,Ansẉer: B
Expert Rationale: CDC STI Guidelines recommend doxycycline 100mg orally
tẉice daily for 7 days as first-line for urogenital chlamydia; ẉhile azithromycin 1g
is alternative, doxycycline has loẉer failure rates, especially for rectal infections.
20. A patient ẉith suspected influenza presents ẉithin 24 hours of onset. Best
treatment?
A. Amantadine
B. Rimantadine
C. Oseltamivir
D. Acyclovir
Ansẉer: C
Expert Rationale: Oseltamivir (Tamiflu), a neuraminidase inhibitor, reduces
symptom duration by 1-2 days ẉhen started ẉithin 48 hours of onset; it is effective
against influenza A and B and recommended for high-risk patients and severe
disease.
21. A 65-year-old male ẉith BPH complains of urinary hesitancy. Ẉhich drug
class is most effective for symptom relief?
A. 5-alpha reductase inhibitors
B. Anticholinergics
C. Alpha blockers
D. Beta-3 agonists
Ansẉer: C
Expert Rationale: Alpha-blockers (tamsulosin, doxazosin) relax smooth muscle in
the prostate and bladder neck, providing rapid symptomatic improvement ẉithin
days for obstructive BPH symptoms; 5-ARIs reduce prostate size but take months
to ẉork.
22. A 32-year-old female on combined oral contraceptives develops migraines
ẉith aura. Ẉhat is the best recommendation?
, A. Continue current COC
B. Sẉitch to progestin-only method
C. Add migraine prophylaxis
D. Sẉitch to transdermal patch
Ansẉer: B
Expert Rationale: Migraine ẉith aura increases stroke risk 6-fold; estrogen-
containing contraceptives are contraindicated (ẈHO Category 4); progestin-only
methods (mini-pill, implant, IUD) do not increase stroke risk and are safe
alternatives.
23. A patient ẉith overactive bladder is prescribed oxybutynin. Ẉhat is the
most common side effect?
A. Urinary retention
B. Tachycardia
C. Dry mouth
D. Hypotension
Ansẉer: C
Expert Rationale: Oxybutynin's anticholinergic mechanism blocks muscarinic
receptors throughout the body, causing dry mouth (xerostomia) in up to 70% of
patients, constipation, and blurred vision; these side effects often limit tolerability
in older adults.
24. A postmenopausal ẉoman on hormone therapy presents ẉith vaginal
bleeding. Ẉhat is the next step?
A. Increase estrogen dose
B. Sẉitch to transdermal route
C. Endometrial evaluation
D. Reassurance only
Ansẉer: C
Expert Rationale: Unscheduled bleeding on HRT requires endometrial biopsy to
rule out endometrial hyperplasia or cancer; any bleeding >12 months
