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  • Question 1 - A 62-year-old software developer with lung cancer is currently taking MST 30mg bd...

    Incorrect

    • A 62-year-old software developer with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?

      Your Answer: 5 mg

      Correct Answer: 10 mg

      Explanation:

      The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.

    • This question is part of the following fields:

      • Pharmacology
      13.3
      Seconds
  • Question 2 - A 20-year-old male presents to the emergency department about 4 hours after ingesting...

    Correct

    • A 20-year-old male presents to the emergency department about 4 hours after ingesting 20g of paracetamol. N-acetyl cysteine was started immediately. What is the mechanism of action of N-acetyl cysteine?

      Your Answer: Replenishes glutathione

      Explanation:

      N-acetylcysteine depletes glutathione reserves by providing cysteine, which is an essential precursor in glutathione production.

      Glutathione within the liver can normally detoxify these minuscule quantities of NAPQI and prevent tissue damage.
      N-acetylcysteine (NAC) is the mainstay of therapy for acetaminophen toxicity.

      Paracetamol overdose:
      The liver normally conjugates paracetamol with glucuronic acid/sulphate. During an overdose, the conjugation system becomes saturated leading to oxidation by cytochrome P450 (predominately CYP2E1) mixed-function oxidases. This produces a toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI).

      Normally glutathione acts as a defence mechanism by conjugating with the toxin forming the non-toxic mercapturic acid. If glutathione stores run-out, the toxin forms covalent bonds with cell proteins, denaturing them and leading to cell death.

      Other uses: In COPD, cystic fibrosis, and other lung conditions, nebulized NAC has mucolytic, anti-inflammatory, and antioxidant properties.

    • This question is part of the following fields:

      • Pharmacology
      6.1
      Seconds
  • Question 3 - A 35-year-old man was brought to the ER with acute confusion. He's a...

    Correct

    • A 35-year-old man was brought to the ER with acute confusion. He's a known case of bipolar disorder under treatment with mood stabilizers. Blood investigations revealed lithium toxicity. A decision is made to start the patient on sodium bicarbonate. What is the rationale behind the use of sodium bicarbonate in this patient?

      Your Answer: Increases urine alkalinity

      Explanation:

      The rationale behind the use of sodium bicarbonate is that it increases the alkalinity of the urine promoting lithium excretion. The preferred treatment in severe cases would be haemodialysis.

      Lithium is a mood-stabilizing drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Lithium toxicity generally occurs following concentrations > 1.5 mmol/L.

      Toxicity may be precipitated by dehydration, renal failure, diuretics (especially Bendroflumethiazide), ACE inhibitors, NSAIDs and metronidazole.

      Features of toxicity
      Coarse tremor (a fine tremor is seen in therapeutic levels)
      Hyperreflexia
      Acute confusion
      Seizure
      Coma

      Management
      Mild-moderate toxicity may respond to volume resuscitation with normal saline
      Haemodialysis may be needed in severe toxicity
      Sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion.

    • This question is part of the following fields:

      • Pharmacology
      9.8
      Seconds
  • Question 4 - A 25-year-old male presented to accident and emergency 4 days ago, following an...

    Correct

    • A 25-year-old male presented to accident and emergency 4 days ago, following an intentional paracetamol overdose. He had taken 20x 500mg tablets, all at once. He denies any alcohol intake. Blood investigations 4 hours after ingestion showed: Paracetamol: 14 mg/l INR: 1 Liver enzymes: No abnormality detected Bilirubin: Mild elevation He was seen by the mental health team and discharged. The blood investigations were repeated: Bilirubin: Within normal limits Urea: 21 mmol/L, Creatinine: 300 µmol/L, What is the likely cause of these results?

      Your Answer: Delayed paracetamol nephrotoxicity

      Explanation:

      The most likely cause for these results is delayed paracetamol nephrotoxicity.

      The blood investigations of this patient are highly suggestive of acute kidney injury.
      Paracetamol overdose is well known to cause hepatotoxicity, but not for its delayed nephrotoxicity, especially in significant overdose. Appropriate monitoring of a patient’s blood tests is important.

      Management:
      NAC (N-Acetyl cysteine) has a clear role in preventing acetaminophen-induced liver necrosis. Although NAC has not been proven to be harmful to the kidney, its role in patients without hepatoxicity and only isolated renal dysfunction is uncertain.

      Other options:
      -There are no features in the history that are suggestive of dehydration and pre-renal AKI presenting in this manner in a 25-year-old would be very unusual.
      – Minimal change nephropathy typically presents with a nephrotic picture of kidney injury.
      – Berger’s more commonly presents with isolated haematuria.

    • This question is part of the following fields:

      • Pharmacology
      17.5
      Seconds
  • Question 5 - A 76-year-old man has been admitted with a respiratory tract infection. On examination,...

    Correct

    • A 76-year-old man has been admitted with a respiratory tract infection. On examination, he was found to be confused and dyspnoeic with O2 saturation of 88%. He has a 60 pack-year smoking history. An arterial blood gas analysis reveals CO2 retention. He has been deemed unfit for admission into the intensive care unit. The physician elects to begin a doxapram infusion. Among the following statements which best fits with the characteristics of doxapram?

      Your Answer: Epilepsy is a contraindication for doxapram use

      Explanation:

      The statement that fits the characteristics of doxapram is, epilepsy is a contraindication for doxapram use. Concurrent use with theophylline may increase agitation not relaxation.

      Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.

      Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
      The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.

      Drug interactions:
      Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.

    • This question is part of the following fields:

      • Pharmacology
      40617.5
      Seconds
  • Question 6 - A 22-year-old university student is admitted after taking drugs at a night club....

    Correct

    • A 22-year-old university student is admitted after taking drugs at a night club. Which of the following features suggest she had taken ecstasy (MDMA)?

      Your Answer: A pyrexia of 40°C

      Explanation:

      MDMA commonly known as ecstasy or molly, is a psychoactive drug primarily used as a recreational drug. The desired effects include altered sensations, increased energy, empathy, and pleasure. Features of MDMA abuse include hyponatraemia, tachycardia, hyperventilation, and hyperthermia.

    • This question is part of the following fields:

      • Pharmacology
      896.5
      Seconds
  • Question 7 - A 70-year-old male presents with chest pain. His past medical history includes hypertension...

    Correct

    • A 70-year-old male presents with chest pain. His past medical history includes hypertension and angina. He continues to smoke about 20 cigarettes per day despite being advised about lifestyle modifications. Blood investigations obtained in the emergency department show: Na+: 133 mmol/L, K+: 3.3 mmol/L, Urea: 4.5 mmol/L, Creatinine: 90 μmol/L, Which among the following is the most likely explanation for the abnormalities seen in the above investigations?

      Your Answer: Bendroflumethiazide therapy

      Explanation:

      The blood investigations in this patient reveal hyponatremia as well as hypokalaemia. Among the options provided, Bendroflumethiazide therapy can cause the above presentation with the electrolyte disturbances.
      Note:
      – Spironolactone is a potassium-sparing diuretic that is associated with hyperkalaemia.
      – Enalapril therapy can cause side effects of dizziness, hypotension, cough, and rarely a rash.
      – Felodipine therapy can cause side effects of dizziness, headache, cough, and palpitations.

    • This question is part of the following fields:

      • Pharmacology
      17
      Seconds
  • Question 8 - A 30-year-old female presented with upper abdominal pain. She was diagnosed with an...

    Correct

    • A 30-year-old female presented with upper abdominal pain. She was diagnosed with an unknown coagulopathy and has a previous history of stroke. She has been on warfarin therapy for the past 4 months. Her international normalised ratio (INR) was stabilised between 2.5 and 3.0. Noticing abnormal coagulation results, her surgeon has requested a medical consult. Her blood investigations revealed: White cell count: 13 × 109/L, Haemoglobin (Hb): 11 g/dL, Activated partial thromboplastin time (APTT): Normal Platelets: 140 × 109/L, INR: 6.0 Pancreatic enzymes and liver function tests were normal. Other investigations: An ultrasound of the abdomen was normal. An upper GI endoscopy revealed mild gastritis. What is the most appropriate step to be taken regarding warfarin therapy?

      Your Answer: Stop warfarin and observe

      Explanation:

      The most appropriate treatment in this patient would be to stop warfarin therapy and keep the patient under observation.

      The drugs that lead to enhanced potency of warfarin include: disulfiram, trimethoprim-sulphamethoxazole, metronidazole, phenylbutazone, aspirin, heparin, and clofibrate.
      Liver disease, thrombocytopenia, hyperthyroidism also increase the oral anticoagulant potency.
      If the patient has minor bleeding and the international normalized ratio (INR) is >6.0, warfarin should be stopped; the INR should be rechecked daily and in addition to the stoppage of warfarin, vitamin K 2.5 mg oral or 0.5 mg intravenously should also be administered.
      In a patient with INR of 2.0 or 3.0, it takes two or three times longer for that individual’s blood to clot than someone who is not taking any anticoagulants. Most patients on warfarin have an INR goal of 2 to 3.

      If there is major bleeding then prothrombin complex concentrates 50 u/kg or fresh-frozen plasma 15 ml/kg may be considered.

    • This question is part of the following fields:

      • Pharmacology
      67.2
      Seconds
  • Question 9 - A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg...

    Incorrect

    • A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg at night for Addison’s disease. The endocrinology consultant would like her to take prednisolone instead. What dose of prednisolone should be started?

      Your Answer: 5 mg

      Correct Answer: 7 mg

      Explanation:

      1mg Prednisolone = 4mg hydrocortisone, so the actual equivalent daily dose is 7mg.

    • This question is part of the following fields:

      • Pharmacology
      43.8
      Seconds
  • Question 10 - A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure...

    Incorrect

    • A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure is being started on digoxin. What is the mechanism of action of digoxin?

      Your Answer: inhibits the Na+/K+ ATPase pump

      Correct Answer:

      Explanation:

      Digoxin acts by inhibiting the Na+/K+ ATPase pump.
      Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.

      Mechanism of action:
      It decreases the conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and atrial flutter.
      It increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. It also stimulates the vagus nerve.

      Digoxin toxicity:
      Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. The likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.
      Clinical feature of digoxin toxicity include a general feeling of unwell, lethargy, nausea & vomiting, anorexia, confusion, xanthopsia, arrhythmias (e.g. AV block, bradycardia), and gynaecomastia

      Precipitating factors:
      Hypokalaemia
      Increasing age
      Renal failure
      Myocardial ischemia
      Hypomagnesaemia, hypercalcemia, hypernatremia, acidosis
      Hypoalbuminemia
      Hypothermia
      Hypothyroidism
      Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in the distal convoluted tubule, therefore, reduce excretion), ciclosporin. Also, drugs that cause hypokalaemia e.g. thiazides and loop diuretics.

      Management of digoxin toxicity:
      Digibind
      Correct arrhythmias
      Monitor and maintain potassium levels within the normal limits.

    • This question is part of the following fields:

      • Pharmacology
      6.6
      Seconds
  • Question 11 - Treatment of an acute attack of gout with allopurinol may result in which...

    Correct

    • Treatment of an acute attack of gout with allopurinol may result in which of the following?

      Your Answer: Exacerbation and prolongation of the attack

      Explanation:

      Initiation of allopurinol treatment during an attack can exacerbate and prolong the episode. Thus treatment should be delayed until the attack resolves.

    • This question is part of the following fields:

      • Pharmacology
      7.4
      Seconds
  • Question 12 - A 35-year-old male was brought to you in a confused state. Although not...

    Incorrect

    • A 35-year-old male was brought to you in a confused state. Although not your patient, you can make out that the man has a history of schizophrenia, and has recently had his medications altered. Clinically, you find evidence of a lower respiratory tract infection, and blood investigations indicate a neutropenic picture. What is the most likely drug causing the neutropenia?

      Your Answer: Olanzapine

      Correct Answer: Clozapine

      Explanation:

      Clozapine can cause neutropenia or agranulocytosis.

      Clozapine is an atypical antipsychotic used in the treatment of schizophrenia, and in patients who are intolerant to, or unresponsive to other antipsychotics.

      It is a weak D2-receptor and D1-receptor blocking activity, with noradrenolytic, anticholinergic, and antihistaminic properties.

      Many antipsychotic drugs can occasionally cause bone marrow depression, but agranulocytosis is particularly associated with clozapine.

      Other side effects include:
      Hypotension, tachycardia
      Fever, sedation, seizures (with high doses)
      Appetite increase
      Constipation
      Heartburn
      Weight gain
      Extrapyramidal symptoms
      Agranulocytosis
      Neuroleptic malignant syndrome

    • This question is part of the following fields:

      • Pharmacology
      11.8
      Seconds
  • Question 13 - A 24-year-old student is brought to A&E having ingested at least 20 tablets...

    Correct

    • A 24-year-old student is brought to A&E having ingested at least 20 tablets of paracetamol 8 hours earlier. She weighs 61kg. What should her immediate management consist of?

      Your Answer: Intravenous N-acetylcysteine

      Explanation:

      Activated charcoal is useful if given within one hour of the paracetamol overdose. Liver function tests, INR and prothrombin time will be normal, as liver damage may not manifest until 24 hours or more after ingestion.

      The antidote of choice is intravenous N-acetylcysteine, which provides complete protection against toxicity if given within 10 hours of the overdose.

    • This question is part of the following fields:

      • Pharmacology
      9
      Seconds
  • Question 14 - The mechanism of action of low molecular weight heparin, has the greatest effect...

    Incorrect

    • The mechanism of action of low molecular weight heparin, has the greatest effect on which of the following components of the coagulation cascade?

      Your Answer: Thrombin

      Correct Answer: Factor Xa

      Explanation:

      Mechanism of action of low molecular weight heparin (LMWH):
      It inhibits coagulation by activating antithrombin III. Antithrombin III binds to and inhibits factor Xa. In doing so it prevents activation of the final common path; Xa inactivation means that prothrombin is not activated to thrombin, thereby not converting fibrinogen into fibrin for the formation of a clot.

      LMHW is a small fragment of a larger mucopolysaccharide, heparin. Heparin works similarly, by binding antithrombin III and activating it. Heparin also has a binding site for thrombin, so thrombin can interact with antithrombin III and heparin, thus inhibiting coagulation.
      Heparin has a faster onset of anticoagulant action as it will inhibit not only Xa but also thrombin, while LMWH acts only on Xa inhibition.

      Compared to heparin, LMWHs have a longer half-life, so dosing is more predictable and can be less frequent, most commonly once per day.

      Dosage and uses:
      LMWH is administered via subcutaneous injection. This has long-term implications on the choice of anticoagulant for prophylaxis, for example, in orthopaedic patients recovering from joint replacement surgery, or in the treatment of DVT/PE.

      Adverse effects:
      The main risk of LMWH will be bleeding. The specific antidote for heparin-induced bleeding is protamine sulphate.
      Less commonly it can cause:
      Heparin-induced thrombocytopenia (HIT)
      Osteoporosis and spontaneous fractures
      Hypoaldosteronism
      Hypersensitivity reactions

    • This question is part of the following fields:

      • Pharmacology
      14.8
      Seconds
  • Question 15 - A 42-year-old female with type 1 diabetes who has undergone a renal transplant...

    Correct

    • A 42-year-old female with type 1 diabetes who has undergone a renal transplant is being reviewed. She is taking azathioprine and tacrolimus for immunosuppression. Which among the following is correct regarding the given immunosuppressive agents?

      Your Answer: Tacrolimus is a calcineurin inhibitor

      Explanation:

      Tacrolimus is a calcineurin inhibitor used as an immunosuppressive agent used for prophylaxis of organ rejection post-transplant.

      Pharmacology: Calcineurin inhibition leads to reduced T-lymphocyte signal transduction and IL-2 expression. It has a half-life of 12 hours (average).

      Other off-label indications for the use of tacrolimus include Crohn disease, graft-versus-host disease (GVHD), myasthenia gravis, rheumatoid arthritis.

      Adverse effects of tacrolimus includes:
      Cardiovascular: Angina pectoris, cardiac arrhythmias, hypertension
      Central nervous system: Abnormal dreams, headaches, insomnia, tremors.
      Dermatologic: Acne vulgaris, alopecia, pruritis, rash
      Endocrine and metabolic: Decreased serum bicarbonate, decreased serum iron, new-onset diabetes mellitus after transplant (NODAT), electrolyte disturbances.
      Gastrointestinal: Abdominal pain, nausea, vomiting, diarrhoea
      Genitourinary: Urinary tract infection
      Hepatic: Abnormal hepatic function tests
      Neuromuscular and skeletal: Arthralgia, muscle cramps
      Ophthalmic: Blurred vision, visual disturbance
      Otic: Otalgia, otitis media, tinnitus
      Renal: Acute renal failure

      Other options:
      Sirolimus (a macrolide) is an mTOR inhibitor that blocks the response to IL-2 and has a half-life of 12–15 hours.
      Azathioprine inhibits purine synthesis, an essential step in the proliferation of white cells and has a half-life of around 5 hours.

    • This question is part of the following fields:

      • Pharmacology
      6.1
      Seconds
  • Question 16 - A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She...

    Incorrect

    • A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She has been unable to keep fluids down for 4 days and has been treated with metoclopramide. She develops a dystonic reaction. What is the most appropriate treatment for the woman?

      Your Answer: Domperidone

      Correct Answer: Benztropine

      Explanation:

      Acute dystonic reactions (extrapyramidal symptoms) such as spasmodic torticollis, trismus, and oculogyric crises can occur following the administration of metoclopramide or stemetil and thus, neither is recommended for the treatment of nausea in young women.

      Such reactions respond well to treatment with benztropine or procyclidine.
      – Benztropine: It is an anticholinergic medication with significant CNS penetration.
      A single dose of benztropine 1 to 2 mg IV followed by 1 to 2 mg p.o twice a day for up to 7 days to prevent a recurrence. Subsequently, both the offending agent and those from the same group should be avoided.
      – Alternatively, diphenhydramine can be used intravenously (up to a dose of 50mg) or intramuscularly followed by p.o therapy every 6 hours for 1 to 2 to prevent a recurrence.
      – Second-line therapy with IV benzodiazepines is reserved for those patients who do not respond to anticholinergics.

    • This question is part of the following fields:

      • Pharmacology
      15.5
      Seconds
  • Question 17 - A 50-year-old farmer, under treatment for depression, presents to the emergency department following...

    Correct

    • A 50-year-old farmer, under treatment for depression, presents to the emergency department following an intentional overdose of an unidentified substance. On examination, he was found to be bradycardic, hypotensive, hyper-salivating, and disoriented. On ocular examination, his pupils were found to be miotic. What is the most likely substance he ingested?

      Your Answer: An organophosphate insecticide

      Explanation:

      The farmer has most likely ingested an organophosphate insecticide.
      Organophosphorus compounds are used widely as:
      • Insecticides – Malathion, parathion, diazinon, dichlorvos
      • Nerve gases – Soman, sarin, tabun, VX
      • Ophthalmic agents – Echothiophate
      • Antihelmintics – Trichlorfon
      • Herbicides – merphos
      • Industrial chemical (plasticizer) – Tricresyl phosphate
      Signs and symptoms of Organophosphorus Poisoning (OPP) can be classified as:
      • Muscarinic effects:
      o Cardiovascular – Bradycardia, hypotension
      o Respiratory – Rhinorrhoea, bronchorrhea, bronchospasm, cough, severe respiratory distress
      o Gastrointestinal – Hypersalivation, nausea and vomiting, abdominal pain, diarrhoea, faecal incontinence
      o Genitourinary – Incontinence
      o Ocular – Blurred vision, miosis
      o Glands – Increased lacrimation, diaphoresis
      • Nicotinic effects:
      o Muscle fasciculation, weakness, cramping, diaphragmatic failure, and autonomic side effects include: hypertension, tachycardia, and mydriasis.
      • Central nervous system (CNS) effects:
      o Anxiety, emotional lability, restlessness, confusion, ataxia, tremors, seizures, coma, apnoea
      Mainstay Treatment:
      • Decontamination
      • Securing Airway, Breathing and Circulation
      • Atropine
      • Pralidoxime
      • Benzodiazepines

    • This question is part of the following fields:

      • Pharmacology
      118.3
      Seconds
  • Question 18 - A 30-year-old woman is admitted for drainage of an abscess in her left...

    Incorrect

    • A 30-year-old woman is admitted for drainage of an abscess in her left forearm. She has revealed that she was regular heroin user and has stopped for the past few days. Clinical signs are pointing towards opioid withdrawal. What is the next step in managing this patient?

      Your Answer: Ask her how much heroin she uses per day and give her a dose of methadone syrup equivalent to this

      Correct Answer: Give her 10 mg of methadone syrup and wait 60 min to determine its effect

      Explanation:

      The next step in managing this patient is to give 10 mg and continue administering in 10 mg increments each hour until symptoms are under control.

      Methadone alleviates opioid withdrawal symptoms and reduces cravings. Methadone is useful for detoxification from longer-acting opioids such as morphine or methadone itself.
      Methadone should be used with caution if the patient has:
      Respiratory deficiency
      Acute alcohol dependence
      Head injury
      Treatment with monoamine oxidase inhibitors (MAOIs)
      Ulcerating colitis or Crohn’s disease
      Severe hepatic impairment
      The dose must be reviewed on a daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects. The greater the dose of opioids used by the patient, the greater the dose of methadone required to control withdrawal symptoms.

      To avoid the risk of overdose in the first days of treatment The recommended dosing of methadone is 30mg in two doses of 15mg morning and evening.

      It is important to note that a methadone dose equivalent to what the patient reports they are taking should never be given.
      It is rare to need more than 40 mg per 24 hours: beware of overdosing which can lead to respiratory arrest.

    • This question is part of the following fields:

      • Pharmacology
      26.5
      Seconds
  • Question 19 - A 53-year-old female teacher asks about hormone replacement therapy (HRT). What is the...

    Incorrect

    • A 53-year-old female teacher asks about hormone replacement therapy (HRT). What is the most compelling indication for starting HRT?

      Your Answer: Prevention of osteoporosis

      Correct Answer: Control of vasomotor symptoms such as flushing

      Explanation:

      Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with a progestogen (in women with a uterus), to help alleviate menopausal symptoms. The main indication is the control of vasomotor symptoms. The other indications, such as reversal of vaginal atrophy and prevention of osteoporosis, should be treated with other agents as first-line therapies.

    • This question is part of the following fields:

      • Pharmacology
      9.1
      Seconds
  • Question 20 - A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary...

    Correct

    • A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary modifications and weight reduction. He needs to be started on an oral hypoglycaemic agent. Which among the following statements regarding oral hypoglycaemic agents is true?

      Your Answer: Acarbose inhibits α-glucosidase

      Explanation:

      Different Oral Hypoglycaemic Agents (OHAs) and their respective mechanism(s) of action include:
      • Sulfonylureas (such as, glipizide, gliclazide, glimepiride) – bind to ATP sensitive Potassium channels (K – ATP channels) in the ? cells of the islets of the pancreas. Inhibition of these channels lead to an altered resting membrane potential in these cells causing an influx of calcium which increases insulin secretion.
      • Meglitinides (like Repaglinide) through a different receptor, they similarly regulate K – ATP channels thereby causing an increase in insulin secretion.
      • Biguanides (e.g., Metformin) increase the hepatic AMP-activated protein kinase activity leading to reduced gluconeogenesis and lipogenesis and increased insulin-mediated uptake of glucose in muscles. (it doesn’t increase insulin secretion)
      • Thiazolidinediones (rosiglitazone, pioglitazone) bind to PPAR-? and increase peripheral uptake of glucose and decrease hepatic glucose production.
      • α-Glucosidase inhibitors (such as acarbose, miglitol, voglibose) competitively inhibit α-glucosidase enzymes in the intestine that digest the dietary starch thus, inhibiting the polysaccharide reabsorption as well as metabolism of sucrose to glucose and fructose.
      • DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin) prolong the action of glucagon-like peptide. This leads to inhibition of glucagon release, increase in insulin secretion and a decrease in gastric emptying leading to a decrease in blood glucose levels.
      • SGLT2 inhibitors (dapagliflozin and canagliflozin) inhibit glucose reabsorption in the proximal tubules of the renal glomeruli leading to glycosuria which in-turn reduces blood glucose levels.
      Note: Side effects of pioglitazone are weight gain, pedal oedema, bone loss and precipitation of congestive cardiac failure.

    • This question is part of the following fields:

      • Pharmacology
      481.1
      Seconds
  • Question 21 - A 30-year-old female was brought to the ER in a confused state. The...

    Incorrect

    • A 30-year-old female was brought to the ER in a confused state. The patient works in a photograph development laboratory. On admission, she was hypoxic and hypotensive. A provisional diagnosis of cyanide poisoning was made. What is the definitive treatment?

      Your Answer: Penicillamine

      Correct Answer: Hydroxocobalamin

      Explanation:

      Cyanide poisoning:
      Aetiology:
      Smoke inhalation, suicidal ingestion, and industrial exposure (specific industrial processes involving cyanide include metal cleaning, reclaiming, or hardening; fumigation; electroplating; and photo processing) are the most frequent sources of cyanide poisoning. Treatment with sodium nitroprusside or long-term consumption of cyanide-containing foods is a possible source.
      Cyanide exposure most often occurs via inhalation or ingestion, but liquid cyanide can be absorbed through the skin or eyes. Once absorbed, cyanide enters the blood stream and is distributed rapidly to all organs and tissues in the body. 

      Pathophysiology:
      Inside cells, cyanide attaches itself to ubiquitous metalloenzymes, rendering them inactive. Its principal toxicity results from inactivation of cytochrome oxidase (at cytochrome a3), thus uncoupling mitochondrial oxidative phosphorylation and inhibiting cellular respiration, even in the presence of adequate oxygen stores.

      Presentation:
      • ‘Classical’ features: brick-red skin, smell of bitter almonds
      • Acute: hypoxia, hypotension, headache, confusion
      • Chronic: ataxia, peripheral neuropathy, dermatitis

      Management:
      • Supportive measures: 100% oxygen, ventilatory assistance in the form of intubation if required.
      • Definitive: Hydroxocobalamin (iv) is considered the drug of choice and is approved by the FDA for treating known or suspected cyanide poisoning.
      • Coadministration of sodium thiosulfate (through a separate line or sequentially) has been suggested to have a synergistic effect on detoxification.
      Mechanism of action of hydroxocobalamin:
      • Hydroxocobalamin combines with cyanide to form cyanocobalamin (vitamin B-12), which is renally cleared.
      • Alternatively, cyanocobalamin may dissociate from cyanide at a slow enough rate to allow for cyanide detoxification by the mitochondrial enzyme rhodanese.

    • This question is part of the following fields:

      • Pharmacology
      16.6
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  • Question 22 - In the event of an overdose, haemodialysis is ineffective as a treatment modality...

    Correct

    • In the event of an overdose, haemodialysis is ineffective as a treatment modality for which of the following drugs?

      Your Answer: Tricyclics

      Explanation:

      Tricyclic compounds can’t be cleared by haemodialysis.

      Drugs that can be cleared with haemodialysis include: (BLAST)
      – Barbiturate
      – Lithium
      – Alcohol (inc methanol, ethylene glycol)
      – Salicylates
      – Theophyllines (charcoal hemoperfusion is preferable)

      Drugs which cannot be cleared with haemodialysis include:
      – Tricyclics
      – Benzodiazepines
      – Dextropropoxyphene (Co-proxamol)
      – Digoxin
      – Beta-blockers

    • This question is part of the following fields:

      • Pharmacology
      22.7
      Seconds
  • Question 23 - A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required)...

    Correct

    • A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?

      Your Answer: It is a long-acting anticholinergic agent

      Explanation:

      Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
      It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
      The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
      Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
      Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation.

    • This question is part of the following fields:

      • Pharmacology
      14.8
      Seconds
  • Question 24 - Which of the following is the most common clinical feature of carbon monoxide...

    Correct

    • Which of the following is the most common clinical feature of carbon monoxide poisoning?

      Your Answer: Headache

      Explanation:

      Carbon monoxide (CO) poisoning:
      It is considered as the great imitator of other diseases as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.

      Clinical features of carbon monoxide toxicity:
      Headache: 90% of cases (most common clinical feature)
      Nausea and vomiting: 50%
      Vertigo: 50%
      Confusion: 30%
      Subjective weakness: 20%
      Severe toxicity: ‘pink’ skin and mucosa, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death
      Cherry red skin is a sign of severe toxicity and is usually a post-mortem finding.
      Management
      • 100% oxygen
      • Hyperbaric oxygen therapy (HBOT)

      The use of Hyperbaric oxygen therapy (HBOT) for treatment mild to moderate CO poisoning is not routine.
      The selection criteria for HBOT in cases of CO poisoning include:
      • COHb levels > 20-25%
      • COHb levels > 20% in pregnant patient
      • Loss of consciousness
      • Severe metabolic acidosis (pH <7.1)
      • Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)

    • This question is part of the following fields:

      • Pharmacology
      7.6
      Seconds
  • Question 25 - A 73-year-old female is being reviewed in the osteoporosis clinic. She had a...

    Incorrect

    • A 73-year-old female is being reviewed in the osteoporosis clinic. She had a fracture of her left hip 5 years ago and was started on alendronate. Following the development of persistent musculoskeletal pain, alendronate was replaced with risedronate, which was also stopped for similar reasons. Strontium ranelate was therefore started but was also stopped due to the development of deep vein thrombosis in the right leg. Her current T-score is -4.1. A decision is made to start a trial of denosumab. What is the mechanism of action of denosumab?

      Your Answer: Monoclonal antibody against osteoprotegerin

      Correct Answer: Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

      Explanation:

      The principal mechanism by which strontium inhibits osteoclast activity is by enhancing the secretion of osteoprotegerin (OPG) and by reducing the expression of the receptor activator of nuclear factor κB ligand (RANKL) in osteoblasts.

      Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures.

      Management:
      Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
      Alendronate is the first-line treatment. Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate.
      Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates.
      Other medications that are useful in the treatment of osteoporosis are denosumab, teriparatide, raloxifene, etc.

    • This question is part of the following fields:

      • Pharmacology
      17.9
      Seconds
  • Question 26 - Around 30 patients have been admitted to the hospital following a suspected chemical...

    Correct

    • Around 30 patients have been admitted to the hospital following a suspected chemical attack in the city. The patients are extremely unwell, with symptoms of excessive salivation, lacrimation, diarrhoea, and emesis. Sarin gas was suspected as the most likely agent used in the attack. What is the mechanism of action of this chemical agent?

      Your Answer: Inhibition of acetylcholinesterase

      Explanation:

      Sarin acts by inhibiting acetylcholinesterase.

      Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase
      Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase. This results in high levels of acetylcholine (ACh).

      The effects of excessive ACh can be remembered by the mnemonic DUMBELLS:
      Diarrhoea
      Urination
      Miosis/muscle weakness
      Bronchorrhea/Bradycardia
      Emesis
      Lacrimation
      Salivation/sweating

      Organophosphate insecticide poisoning:
      One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase
      Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
      Salivation
      Lacrimation
      Urination
      Defecation/diarrhoea
      cardiovascular: hypotension, bradycardia
      miosis, muscle fasciculation.

      Organophosphate poisoning is treated with the anti-muscarinic atropine.

    • This question is part of the following fields:

      • Pharmacology
      13.1
      Seconds
  • Question 27 - Which among the following antihypertensives is centrally acting? ...

    Correct

    • Which among the following antihypertensives is centrally acting?

      Your Answer: Moxonidine

      Explanation:

      Moxonidine and alpha-methyl dopa are centrally acting antihypertensives and modify blood pressure through modifying sympathetic activity.

      Other options:
      Verapamil is a calcium antagonist.
      Minoxidil and hydralazine are both vasodilators.
      Phenoxybenzamine is an alpha-blocker.

      Adverse effects:
      Dry mouth and somnolence were the most frequently reported adverse events, followed by headache, dizziness, nausea and allergic skin reactions.

    • This question is part of the following fields:

      • Pharmacology
      6.2
      Seconds
  • Question 28 - A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and...

    Incorrect

    • A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and breathing difficulty. He also complains of a continuous ringing sensation in both his ears for the past couple of days. He admits to consuming a lot of over the counter painkillers for the past few days. Which of the following drugs is the most likely cause of these symptoms?

      Your Answer: Co-proxamol

      Correct Answer: Aspirin

      Explanation:

      The presence of tinnitus, fever and hyperventilation are clues for aspirin (salicylate) toxicity.
      Clinical Presentation of salicylate toxicity can include:
      • Pulmonary manifestations include: Hyperventilation, hyperpnea, severe dyspnoea due to noncardiogenic pulmonary oedema, fever and dyspnoea due to aspiration pneumonitis
      • Auditory symptoms caused by the ototoxicity of salicylate poisoning include: Hard of hearing and deafness, and tinnitus (commonly encountered when serum salicylate concentrations exceed 30 mg/dL).
      • Cardiovascular manifestations include: Tachycardia, hypotension, dysrhythmias – E.g., ventricular tachycardia, ventricular fibrillation, multiple premature ventricular contractions, asystole – with severe intoxication, Electrocardiogram (ECG) abnormalities – E.g., U waves, flattened T waves, QT prolongation may reflect hypokalaemia.
      • Neurologic manifestations include: CNS depression, with manifestations ranging from somnolence and lethargy to seizures and coma, tremors, blurring of vision, seizures, cerebral oedema – With severe intoxication, encephalopathy
      • GI manifestations include: Nausea and vomiting, which are very common with acute toxicity, epigastric pain, GI haemorrhage – More common with chronic intoxication, intestinal perforation, pancreatitis, hepatitis – Generally in chronic toxicity; rare in acute toxicity, Oesophageal strictures – Reported as a very rare delayed complication
      • Genitourinary manifestations include: Acute kidney injury (NSAID induced Nephropathy) is an uncommon complication of salicylate toxicity, renal failure may be secondary to multisystem organ failure.
      • Hematologic effects may include prolongation of the prothrombin and bleeding times and decreased platelet adhesiveness. Disseminated intravascular coagulation (DIC) may be noted with multisystem organ failure in association with chronic salicylate toxicity.
      • Electrolyte imbalances like: Dehydration, hypocalcaemia, acidaemia, Syndrome of inappropriate antidiuretic hormone secretion (SIADH), hypokalaemia
      Management of these patients should be done in the following manner:
      • Secure Airway, Breathing, and Circulation
      • Supportive therapy
      • GI decontamination
      • Urinary excretion and alkalization
      • Haemodialysis

    • This question is part of the following fields:

      • Pharmacology
      21.5
      Seconds
  • Question 29 - An 81-year-old male presented to the emergency department following a fall at home....

    Correct

    • An 81-year-old male presented to the emergency department following a fall at home. He was diagnosed with osteoporosis about five years ago. He presently complains of significant low back pain. A lumbar spine X-ray was suggestive of a fractured lumbar vertebra. A subsequent MRI scan of the lumbosacral spine revealed a new L3 burst fracture with no evidence of cord compression. A neurosurgical consult was sought and conservative management was planned accordingly in the form of pain control, physiotherapy, and mobilization (as allowed by the pain). He also has been diagnosed with chronic renal disease (stage IV) with a creatinine clearance of 21ml/min, he was started on a Buprenorphine patch. Which of the following opioids would be safest to use for his breakthrough pain?

      Your Answer: Oxycodone

      Explanation:

      Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure.
      Active metabolites of morphine accumulate in renal failure which means that long-term use is contraindicated in patients with moderate/severe renal failure.
      These toxic metabolites can accumulate causing toxicity and risk overdose.
      Oxycodone is mainly metabolised in the liver and thus safer to use in patients with moderate to end-stage renal failure with dose reductions.
      Adverse effects:
      Constipation is the most common overall side effect. Others include: asthenia, dizziness, dry mouth, headache, nausea, pruritus, etc.

      Medications in renal failure:
      Drugs to be avoided in patients with renal failure
      Antibiotics: tetracycline, nitrofurantoin
      NSAIDs
      Lithium
      Metformin
      Drugs that require dose adjustment:
      Most antibiotics including penicillin, cephalosporins, vancomycin, gentamicin, streptomycin
      Digoxin, atenolol
      Methotrexate
      Sulphonylureas
      Furosemide
      Opioids
      Relatively safe drugs:
      Antibiotics: erythromycin, rifampicin
      Diazepam
      Warfarin

    • This question is part of the following fields:

      • Pharmacology
      33.6
      Seconds
  • Question 30 - A 50-year-old male presents to the ER allegedly claiming that he consumed a...

    Incorrect

    • A 50-year-old male presents to the ER allegedly claiming that he consumed a bottle of antifreeze. Which of the following symptoms is least likely to be associated with this kind of poisoning?

      Your Answer: Hypertension

      Correct Answer: Loss of vision

      Explanation:

      Loss of vision after consumption of antifreeze is a characteristic presentation of methanol poisoning.

      Pathophysiology of methanol toxicity:
      When ingested, methanol is absorbed rapidly via the gastrointestinal tract in less than 10 minutes. Methanol is not protein-bound and is absorbed directly into the total body water compartment.
      Metabolism occurs mainly in the liver through serial oxidation via alcohol dehydrogenase and aldehyde dehydrogenase but begins with alcohol dehydrogenase present in the gastric mucosa.
      Alcohol dehydrogenase oxidizes methanol to formaldehyde, and aldehyde dehydrogenase subsequently oxidizes formaldehyde to formic acid.
      Formic acid is the primary toxic metabolite that accounts for the associated anion gap metabolic acidosis and end-organ damage.

      Clinical presentation:
      Patients who present within the first 12 to 24 hours following ingestion may appear normal, and this is described as the latent period.
      Nausea, vomiting, and abdominal pain subsequently ensue, followed by CNS depression and hyperventilation due to metabolic acidosis.
      Ocular symptoms associated with retinal toxicity are often evident in the form of blurry vision, decreased visual acuity, photophobia, and “halo vision.”

      Treatment:
      Treatment options for methanol toxicity include supportive care, fomepizole (Antizole, 4-Methylpyrazole or 4MP), ethanol, dialysis, and folate.

    • This question is part of the following fields:

      • Pharmacology
      11.6
      Seconds
  • Question 31 - A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring...

    Incorrect

    • A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring treated with rifampicin, isoniazid, and pyrazinamide. He is commenced on streptomycin. Which among the following is the most likely neurological side-effect of streptomycin?

      Your Answer: Optic nerve

      Correct Answer: Vestibular damage

      Explanation:

      Vestibular damage is a neurological side effect of streptomycin.

      Streptomycin is an aminoglycoside bactericidal antibiotic. It is used in the treatment of tularaemia and resistant mycobacterial infections.
      The most common neurological side-effect is vestibular damage leading to vertigo and vomiting.
      Cochlear damage is less frequent and results in deafness.
      Other side-effects include rashes, angioneurotic oedema, and nephrotoxicity.

    • This question is part of the following fields:

      • Pharmacology
      18.7
      Seconds
  • Question 32 - A 40-year-old man is admitted to the Emergency Department in a confused state....

    Correct

    • A 40-year-old man is admitted to the Emergency Department in a confused state. He tells you that he consumed two bottles of antifreeze. On examination, his pulse is 120 bpm and blood pressure is 140/90 mmHg. An arterial blood gas analysis shows uncompensated metabolic acidosis. He is transferred to the high dependency unit and ethanol is given via a nasogastric tube. How does ethanol help this patient?

      Your Answer: Competes with ethylene glycol for alcohol dehydrogenase

      Explanation:

      Ethanol competes with ethylene glycol for alcohol dehydrogenase and thus, helps manage a patient with ethylene glycol toxicity.

      Ethylene glycol is a type of alcohol used as a coolant or antifreeze
      Features of toxicity are divided into 3 stages:
      Stage 1: (30 min to 12 hours after exposure) Symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness (CNS depression)
      Stage 2: (12 – 48 hours after exposure) Metabolic acidosis with a high anion gap and high osmolar gap. Also tachycardia, hypertension
      Stage 3: (24 – 72 hours after exposure) Acute renal failure

      Management has changed in recent times:
      Fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol.
      Ethanol has been used for many years works by competing with ethylene glycol for the enzyme alcohol dehydrogenase this limits the formation of toxic metabolites (e.g. glycolaldehyde and glycolic acid) which are responsible for the hemodynamic/metabolic features of poisoning.
      Haemodialysis has a role in refractory cases.

    • This question is part of the following fields:

      • Pharmacology
      15.1
      Seconds
  • Question 33 - An 18-year-old young lady is brought to the ER by her mother. She...

    Correct

    • An 18-year-old young lady is brought to the ER by her mother. She was found, lying on the floor having consumed an unidentified quantity of her mother's prescription pills with alcohol. The patient's mother is a known hypertensive under treatment. On examination, the patient was found to be lethargic, hypotensive with a BP of 70/50 mmHg, and bradycardic with a pulse rate of 38 bpm. A finger prick glucose is 3.2 mmol/L. Which TWO among the following are the most appropriate steps for the initial management of this patient?

      Your Answer: Glucagon and isoprenaline

      Explanation:

      The most appropriate steps of initial management include iv glucagon and iv isoprenaline.

      The most likely diagnosis in the above scenario (decreased conscious level, profound hypertension, and bradycardia) is β-blocker toxicity/overdose.
      Bronchospasm rarely occurs in an overdose of β-blockers, except where there is a history of asthma.

      Immediate management is to give iv glucagons (50–150μg/kg) followed by infusion to treat hypotension and isoprenaline or atropine to treat bradycardia.
      Where patients fail to respond to these measures, temporary pacing may be required.
      If the patient is seen within the first 4 hours of the overdose, gastric lavage may be of value.

    • This question is part of the following fields:

      • Pharmacology
      48.2
      Seconds
  • Question 34 - Which one of the following features is least recognised in long-term lithium use?...

    Incorrect

    • Which one of the following features is least recognised in long-term lithium use?

      Your Answer: Diarrhoea

      Correct Answer: Alopecia

      Explanation:

      All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium.

      Common lithium side effects may include:
      – dizziness, drowsiness;
      – tremors in your hands;
      – trouble walking;
      – dry mouth, increased thirst or urination;
      – nausea, vomiting, loss of appetite, stomach pain;
      – cold feeling or discoloration in your fingers or toes;
      – rash; or.
      – blurred vision.

    • This question is part of the following fields:

      • Pharmacology
      11.4
      Seconds
  • Question 35 - A 34-year-old man was brought to the ER following a road-traffic-accident. An X-ray...

    Correct

    • A 34-year-old man was brought to the ER following a road-traffic-accident. An X-ray of his left thigh revealed a fractured shaft of the left femur. He has a known history of opioid abuse. You are called to the ward to assess him after he becomes unwell. Which of the following clinical features are NOT compatible with a diagnosis of opioid withdrawal?

      Your Answer: Hypothermia

      Explanation:

      Among the options provided, hypothermia is not a symptom of opioid withdrawal.

      Symptoms of opioid withdrawal include dysphoric mood, yawning, insomnia, muscle aches, lacrimation/rhinorrhoea, papillary dilatation, piloerection, fever, sweating, nausea/vomiting, diarrhoea.
      If the patient is having an opioid withdrawal reaction, then give 10 mg of methadone syrup and wait about 60 min to determine its effect.

      COWS (Clinical Opioid Withdrawal Scale) assessment for opioid withdrawal is commonly used to determine the severity of opioid withdrawal.

    • This question is part of the following fields:

      • Pharmacology
      18.9
      Seconds
  • Question 36 - A 28-year-old female admitted for a course of chemotherapy, has been taking high...

    Correct

    • A 28-year-old female admitted for a course of chemotherapy, has been taking high dose steroids for a few days. The nurses report that she is very agitated and talks about trying to open the window of her room and jump out from the fourth floor. You review her notes and see that she admits to drinking a few glasses of wine per week and has smoked cannabis on a few occasions. On examination her BP is 145/88 mmHg, her pulse is 80 bpm. Blood investigations reveal: Haemoglobin: 12.1 g/dL (11.5-16.5) WBC count: 16.2 x 103/dL (4-11) Platelets: 200 x 109/L (150-400) C-reactive protein: 9 nmol/l (<10) Sodium: 140 mmol/l (135-146) Potassium: 3.9 mmol/l (3.5-5) Creatinine: 92 μmol/l (79-118) Which of the following is the most likely diagnosis?

      Your Answer: Corticosteroid-related psychosis

      Explanation:

      Agitation, hypomania and suicidal intent within a few days after initiating corticosteroid therapy is highly suggestive of a diagnosis of corticosteroid-induced psychosis.

      In some patients corticosteroid related psychosis has been diagnosed up to 12 weeks or more after commencing therapy.

      Euphoria and hypomania are considered to be the most common psychiatric symptoms reported during short courses of steroids.
      During long-term treatment, depressive symptoms were the most common.
      Higher steroid doses appear to carry an increased risk for such adverse effects; however, there is no significant relationship between dose and time to onset, duration, and severity of symptoms.

      Management: Reduction or cessation of corticosteroids is the mainstay of treatment for steroid psychosis. For those patients who cannot tolerate this reduction/cessation of steroids, mood stabilizers may be of some benefit.

    • This question is part of the following fields:

      • Pharmacology
      149.2
      Seconds
  • Question 37 - A 56-year-old male presents to the emergency department with confusion and agitation for...

    Correct

    • A 56-year-old male presents to the emergency department with confusion and agitation for the past four hours. He is a known alcoholic who has abstained from drinking for the past three days. On examination, he is sweating, agitated and disorientated. His temperature is 37.7°C, pulse 112 bpm regular and blood pressure is 150/76 mmHg. Blood investigations performed in the emergency department reveal: FBC: Normal U&E: Normal Plasma glucose: 4.6 mmol/l (3.6-6) Which of the following medications would be the most appropriate treatment for this man?

      Your Answer: Oral lorazepam

      Explanation:

      The most probable diagnosis for this patient is delirium tremens due to alcohol withdrawal, which should be treated as a medical emergency. 
      Delirium tremens is a hyperadrenergic state and is often associated with tachycardia, hyperthermia, hypertension, tachypnoea, tremor, and mydriasis.
      Treatment:
      – The most common and validated treatment for alcohol withdrawal is benzodiazepine: first-line treatment includes oral lorazepam.
      – If the symptoms persist, or the medication is refused, parenteral lorazepam, haloperidol or olanzapine should be given.
      – Central-acting, alpha-2 agonists such as clonidine and dexmedetomidine should not be used alone for the treatment of alcohol withdrawal.
      – It is also recommended to avoid using alcohol, antipsychotics, anticonvulsants, beta-adrenergic receptor blockers, and baclofen for the treatment of alcohol withdrawal as there are not enough studies to support the safety of these.

    • This question is part of the following fields:

      • Pharmacology
      33.9
      Seconds
  • Question 38 - A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on...

    Correct

    • A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on the CHOP regimen (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone). Her pre-chemotherapy blood investigations show: Hb: 11.8 g/dL, Platelets: 423 x 109/L, WBC: 11.2 x 109/L, Na+: 143 mmol/L, K+: 3.9 mmol/L, Urea: 6.2 mmol/L, Creatinine: 78 μmol/L, Uric acid: 0.45 mmol/L, Ciprofloxacin is prescribed in addition to the CHOP regimen to reduce the risk of neutropenic sepsis. Which of the following drugs should be added to lower the risk of other complications?

      Your Answer: Allopurinol

      Explanation:

      Tumour lysis syndrome (TLS) occurs most notably in patients with haematological malignancies including, Non-Hodgkin’s Lymphoma (NHL) and Acute Lymphocytic Leukaemia (ALL).
      Risk factors for TLS include:
      • Large tumour burden
      • Sensitivity of the tumour to chemotherapy
      • Rapid tumour growth rate
      TLS is characterized by:
      • Hyperuricemia
      • Hyperkalaemia
      • Hyperphosphatemia
      • Hypocalcaemia
      Treatment of TLS:
      • Allopurinol: It is a xanthine oxidase inhibitor, it reduces the conversion of nucleic acid by-products to uric acid. Thus, it prevents urate nephropathy and subsequent oliguric renal failure. Note: dose reduction is essential in renal failure or if given along with mercaptopurine or azathioprine.
      Alternatives to Allopurinol: Febuxostat; Rasburicase are useful in patients with hyperuricemia.
      • Hydration
      • Diuresis: Should be considered in well hydrated patients with insufficient urine output. Furosemide to be considered in normo-volemic patients with hyperkalaemia. Urine alkalization can be considered for promoting alkaline diuresis.
      • Treatment of electrolyte imbalances including hyperkalaemia, hyperphosphatemia, and hypocalcaemia.
      • Dialysis can be considered in refractory cases.

    • This question is part of the following fields:

      • Pharmacology
      136.2
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  • Question 39 - A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints...

    Correct

    • A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints of excessive weight gain. She is consuming oral contraceptive pills. Which among the following is the best alternative to valproate for treating long-term epilepsy?

      Your Answer: Lamotrigine

      Explanation:

      Among the given anti-epileptics the best drug that can be given in this patient is lamotrigine.
      Topiramate, carbamazepine, phenytoin, and phenobarbital are all hepatic enzyme inducers and are associated with decreased effectiveness of the oral contraceptive (OCP) due to acceleration of the metabolism of oestrogens and progestogens.
      If she is planning on pregnancy then registry studies suggest that lamotrigine would also be the best choice.
      Other hepatic enzyme inducers include rifampicin, spironolactone, griseofulvin, etc.

    • This question is part of the following fields:

      • Pharmacology
      13.3
      Seconds
  • Question 40 - A 45-year-old male is brought to the emergency department after being found collapsed,...

    Correct

    • A 45-year-old male is brought to the emergency department after being found collapsed, outside a nightclub. The ER team found an empty bottle of amyl nitrate in his pocket. The patient is hypoxic with an O2 saturation of 84% and is confused. Which of the following is the best treatment for this patient?

      Your Answer: Methylene blue

      Explanation:

      The best treatment for the patient in question would be methylene blue.
      The most probable diagnosis in this patient is methemoglobinemia due to the ingestion of amyl nitrate.

      Amyl nitrate promotes the formation of methaemoglobin, which avidly conserves oxygen and leads to decreased tissue oxygen saturations.

      Treatment of choice includes methylene blue and vitamin C.

      Adverse effects:
      Benign side effects include green or blue discoloration of urine and patients should be forewarned.
      Significant side effects are based on methylene blue, itself, being an oxidizing agent and an inhibitor of monoamine oxidase A (MAO-A).
      As an oxidizing agent, methylene blue can actually precipitate methemoglobinemia or haemolysis in high doses or when ineffectively reduced.
      Methylene blue administration in a patient taking a serotonergic agents may predispose to serotonin syndrome.

      Note: Although methylene blue administration is controversial in the setting of G6PD-deficiency due to reduced levels of NADPH, it is not contraindicated and should be administered cautiously and judiciously.

    • This question is part of the following fields:

      • Pharmacology
      10.7
      Seconds
  • Question 41 - An 80-year-old woman with advanced COPD has been admitted to the medicine ward...

    Correct

    • An 80-year-old woman with advanced COPD has been admitted to the medicine ward in an unconscious state. She appears to have an acute lower respiratory tract infection. After consulting with an anaesthesiologist it was concluded that she was not a candidate for intensive care unit admission and thus, a decision was made to start the patient on doxapram therapy. Which of the following best fits the characteristics of doxapram?

      Your Answer: It is contraindicated in hyperthyroidism

      Explanation:

      The two statements that fit the characteristics of doxapram are, epilepsy is a contraindication for doxapram use and concurrent use with theophylline may increase agitation.

      Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.

      Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
      The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.

      Drug interactions:
      Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.

    • This question is part of the following fields:

      • Pharmacology
      11.1
      Seconds
  • Question 42 - A 55-year-old male presents with complaints suggestive of erectile dysfunction. He also provides...

    Correct

    • A 55-year-old male presents with complaints suggestive of erectile dysfunction. He also provides a history of ischaemic heart disease for which he is under treatment. The GP decides to start him on sildenafil citrate. Which of the following medications may contraindicate the use of sildenafil in this patient?

      Your Answer: Nicorandil

      Explanation:

      The use of nitrates and nicorandil concomitantly with sildenafil citrate is contraindicated.

      Sildenafil (Viagra) is a phosphodiesterase type V inhibitor used in the treatment of impotence.

      Contraindications
      – Patients taking nitrates and related drugs such as nicorandil
      – Hypotension
      – Recent stroke or myocardial infarction (NICE recommend waiting 6 months)

      Side-effects:
      Visual disturbances e.g. cyanopsia, non-arthritic anterior ischaemic Neuropathy
      Nasal congestion
      Flushing
      Gastrointestinal side-effects
      Headache

    • This question is part of the following fields:

      • Pharmacology
      17.1
      Seconds
  • Question 43 - A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and...

    Correct

    • A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and is not using any birth control other than barrier method. Which among the following antihypertensives is contraindicated in this patient?

      Your Answer: Lisinopril

      Explanation:

      Among the following hypertensives, lisinopril (an ACE inhibitor) is contraindicated in patients who are planning for pregnancy.

      Per the NICE guidelines, when treating the woman in question, she should be treated as if she were pregnant given the absence of effective contraception.
      ACE inhibitors such as lisinopril are known teratogens and most be avoided.

      Drugs contraindicated in pregnancy:
      Antibiotics
      Tetracyclines
      Aminoglycosides
      Sulphonamides and trimethoprim
      Quinolones

      Other drugs:
      ACE inhibitors, angiotensin II receptor antagonists
      Statins
      Warfarin
      Sulfonylureas
      Retinoids (including topical)
      Cytotoxic agents
      The majority of antiepileptics including valproate, carbamazepine, and phenytoin are known to be potentially harmful.

    • This question is part of the following fields:

      • Pharmacology
      122.6
      Seconds
  • Question 44 - A 45-year-old woman has been diagnosed with T1N1M1 malignancy in the left breast,...

    Correct

    • A 45-year-old woman has been diagnosed with T1N1M1 malignancy in the left breast, with metastases detectable in the lower thoracic vertebrae and the left lung. Before the initiation of treatment of this patient with trastuzumab, which is the most important investigation to perform?

      Your Answer: Echo

      Explanation:

      Before the initiation of trastuzumab, an echocardiography is a must to rule out any pre-existing cardiac abnormalities as trastuzumab is cardiotoxic.

      Trastuzumab (Herceptin) is a monoclonal antibody directed against the HER2/neu receptor. It is used mainly in metastatic breast cancer although some patients with early disease are now also given trastuzumab.

      Adverse effects include:
      Flu-like symptoms and diarrhoea are common.
      Cardiotoxicity:
      – Risk increases when anthracyclines are used concomitantly.
      – Trastuzumab-induced cardiac dysfunctions are regarded as less severe and largely reversible because primary cardiomyocyte do not show ultrastructure changes unlike those associated with anthracycline-induced cardiotoxicity.
      – Primary myocyte injury does not occur in patients who were treated with trastuzumab.

    • This question is part of the following fields:

      • Pharmacology
      12.8
      Seconds
  • Question 45 - A 50-year-old man is admitted with nausea and excessive drowsiness after taking an...

    Incorrect

    • A 50-year-old man is admitted with nausea and excessive drowsiness after taking an antihistamine tablet with grapefruit juice. Which of the following liver enzyme systems is affected by grapefruit juice causing the given side effect?

      Your Answer:

      Correct Answer: Cytochrome p450 3A4

      Explanation:

      The cytochrome p450 3A4 enzyme system in the liver is affected by grapefruit juice.

      Patients taking antihistamines should be advised to avoid drinking grapefruit juice. This is because constituents of grapefruit juice such as naringin and bergamottin inhibit CYP3A4 in the liver, particularly at high doses, leading to decreased drug elimination via hepatic metabolism and can increase potential drug toxicities.

      Inhibition of this enzyme system leads to reduced metabolism of antihistamines leading to an increased incidence of side effects like excessive drowsiness and nausea as in this patient.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 46 - Among the following which is the beneficial effect of nitro-glycerine? ...

    Incorrect

    • Among the following which is the beneficial effect of nitro-glycerine?

      Your Answer:

      Correct Answer: Dilation of systemic veins

      Explanation:

      Dilation of systemic veins is a beneficial effect of nitro-glycerine.

      Administration of nitro-glycerine results in the dilation of systemic veins and decrease of myocardial wall tension and oxygen demand. Dilatation of systemic veins can cause reduced systemic vascular resistance leading to reduced cardiac workload thus reducing anginal symptoms secondary to demand ischemia.

      This is accompanied by vasodilation of large and medium-sized coronary arteries with increased coronary blood flow to the sub endocardium.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 47 - A 33-year-old electrical technician presents following an overdose. Anticholinergic syndrome is suspected. Which...

    Incorrect

    • A 33-year-old electrical technician presents following an overdose. Anticholinergic syndrome is suspected. Which of the following is true?

      Your Answer:

      Correct Answer: Mydriasis occurs

      Explanation:

      Anticholinergic syndrome occurs following overdose with drugs that have prominent anticholinergic activity including tricyclic antidepressants, antihistamines and atropine. Features include dry, warm, flushed skin, urinary retention, tachycardia, mydriasis (dilated pupils) and agitation.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 48 - What is the rationale concerning the use of sodium cromoglycate in the prophylaxis...

    Incorrect

    • What is the rationale concerning the use of sodium cromoglycate in the prophylaxis of bronchial asthma?

      Your Answer:

      Correct Answer: Inhibition of mast-cell degranulation

      Explanation:

      Sodium cromoglycate principally acts by inhibiting the degranulation of mast cells triggered by the interaction of antigen and IgE.
      The inhibitory effect on mast cells appears to be cell-type specific since cromoglycate has little inhibitory effect on mediator release from human basophils.
      Thus, it inhibits the release of histamine, leukotrienes, and slow-reacting substance of anaphylaxis from mast cells by inhibiting degranulation following exposure to reactive antigens.

      Adverse effects include cough, flushing, palpitation, chest pain, nasal congestion, nausea, fatigue, migraine, etc.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 49 - A 82-year-old woman admitted following a fractured neck of femur has been discharged....

    Incorrect

    • A 82-year-old woman admitted following a fractured neck of femur has been discharged. On review, she is making good progress but consideration is given to secondary prevention of further fractures. What is the most appropriate step in the prevention of further fractures?

      Your Answer:

      Correct Answer: Start oral bisphosphonate

      Explanation:

      In such a clinical scenario, NICE guidelines support initiating treatment with bisphosphonates without waiting for a DEXA scan.

      Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures.

      Management:
      Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
      Alendronate is the first-line treatment. Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate.
      Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates.
      Other medications that are useful in the treatment of osteoporosis are denosumab, teriparatide, raloxifene, etc.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 50 - Which of the following enzymes are involved in Phase I drug metabolism? ...

    Incorrect

    • Which of the following enzymes are involved in Phase I drug metabolism?

      Your Answer:

      Correct Answer: Alcohol dehydrogenase

      Explanation:

      Drug metabolism can be broadly classified into:
      Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.

      Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 51 - Which of the given adverse effects should be anticipated following the administration of...

    Incorrect

    • Which of the given adverse effects should be anticipated following the administration of an anticholinesterase?

      Your Answer:

      Correct Answer: Bradycardia and miosis

      Explanation:

      Bradycardia and miosis should be anticipated following the administration of anticholinesterases.

      Anticholinesterase agents include the following medications:
      – Pyridostigmine, neostigmine, and edrophonium which play a significant role in the diagnosis and the management of myasthenia gravis.
      – Rivastigmine, galantamine and donepezil are cholinesterase inhibitors found to be significantly useful in the management of Alzheimer’s disease.

      Mechanism of action and pharmacological effects:
      Inhibition of cholinesterase increases the level and the duration of action of acetylcholine within the synaptic cleft.

      Thus, cholinergic effects such as a reduction in heart rate (bradycardia), miosis (pupillary constriction), increased secretions, increased gastrointestinal motility and reduction in BP may occur with anticholinesterases.

      Toxins such as organophosphates and carbamates also are primarily anticholinergic and cause the following typical SLUDGE symptoms:
      – Salivation
      – Lacrimation
      – Urination
      – Diaphoresis
      – Gastrointestinal upset
      – Emesis

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 52 - A 20-year-old male presented to the clinic with a long term history of...

    Incorrect

    • A 20-year-old male presented to the clinic with a long term history of pins and needles sensation in both hands. He also has prognathism. He also gives a history of recent onset right upper quadrant pain after being started on a new medication for his condition. Which of the following medications acting on his endocrine system can be responsible for this adverse effect?

      Your Answer:

      Correct Answer: Octreotide

      Explanation:

      The patient (known case of acromegaly) seems to have developed cholelithiasis (presenting with right upper quadrant pain) probably due to octreotide.

      It is a long-acting analogue of somatostatin which is released from D cells of the pancreas and inhibits the release of growth hormone, glucagon, and insulin.

      Uses
      – Acute treatment of variceal haemorrhage
      – Acromegaly
      – Carcinoid syndrome
      – Prevent complications following pancreatic surgery
      – VIPomas
      – Refractory diarrhoea

      Adverse effects
      Gallstones (secondary to biliary stasis)

      Other options:
      – Bromocriptine – a dopamine agonist with side effects arising from its stimulation of the brain vomiting centre.
      – Desmopressin – predominantly used in patients with diabetes insipidus by increasing the presence of aquaporin channels in the distal collecting duct to increase water reabsorption from the kidneys. The main side effects include headache and facial flushing due to hypertension.
      – Metformin – mainly reduces hepatic gluconeogenesis in patients with type 2 diabetes, common side effects include diarrhoea, vomiting, and lactic acidosis
      – Levothyroxine – synthetic thyroxine used in patients with hypothyroidism, common side effects result from incorrect dosing and mimic the symptoms of hyperthyroidism.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 53 - A 30-year-old male with a history of premature cardiovascular disease in the family...

    Incorrect

    • A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations. His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l. You elect to commence him on atorvastatin 20 mg PO daily. Which of the following best describes the mechanism of action of the statins?

      Your Answer:

      Correct Answer: They inhibit HMG CoA reductase

      Explanation:

      Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.
      Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions.
      This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 54 - A 27-year-old male is admitted after drinking engine coolant in an apparent suicide...

    Incorrect

    • A 27-year-old male is admitted after drinking engine coolant in an apparent suicide attempt. Lab investigations reveal: pH 7.1 (7.36-7.44) pO2 15.3 kPa (11.3-12.6) pCO2 3.2 kPa (4.7-6.0) Standard bicarbonate 2.2 mmol/L (20-28) Serum calcium 1.82 mmol/L (2.2-2.6) After replacing calcium, which of the following is the most urgent treatment for this man?

      Your Answer:

      Correct Answer: 8.4% bicarbonate infusion

      Explanation:

      Carbon monoxide has high affinity for haemoglobin and myoglobin resulting in a left-shift of the oxygen dissociation curve and tissue hypoxia. There are approximately 50 deaths per year from accidental carbon monoxide poisoning in the UK. In these circumstances, antidotal therapy to block alcohol dehydrogenase with ethanol or 4-MP alone is insufficient to treat the poisoning. Data suggest that a severe lactic acidosis needs initial correction and in this patient the most appropriate treatment would be IV fluids with bicarbonate to correct the metabolic acidosis. Haemodialysis may be required thereafter.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 55 - A 75-year-old man has presented to the clinic with a complaint of disturbed...

    Incorrect

    • A 75-year-old man has presented to the clinic with a complaint of disturbed sleep. The physician has prescribed temazepam. Which of the following best describes the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Enhances the effect of gamma-aminobutyric acid

      Explanation:

      Temazepam is an orally available benzodiazepine used in the therapy of insomnia.
      The soporific activity of the benzodiazepines is mediated by their ability to enhance gamma-aminobutyric acid (GABA) mediated inhibition of synaptic transmission through binding to the GABA-A receptor.
      The recommended initial dose for insomnia is 7.5 mg before bedtime, increasing as needed to a maximum dose of 30 mg.

      The most common side effects of temazepam are dose-related and include daytime drowsiness, lethargy, ataxia, dysarthria, and dizziness.
      Tolerance develops to these side effects, but tolerance may also develop to the effects on insomnia.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 56 - Which of the following is correct regarding lead poisoning? ...

    Incorrect

    • Which of the following is correct regarding lead poisoning?

      Your Answer:

      Correct Answer: Causes a peripheral neuropathy due to demyelination

      Explanation:

      Lead can be absorbed through the skin and by inhalation. It is associated with iron deficiency and a microcytic anaemia. The most common gastrointestinal symptoms are abdominal colic and constipation.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 57 - What is the mechanism of action of carbimazole? ...

    Incorrect

    • What is the mechanism of action of carbimazole?

      Your Answer:

      Correct Answer: Inhibition of the iodination of tyrosine

      Explanation:

      Carbimazole is used to treat hyperthyroidism. Carbimazole is a pro-drug as after absorption it is converted to the active form, methimazole. Methimazole prevents thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4 (thyroxine).

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 58 - A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic....

    Incorrect

    • A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic. Which among the following is true regarding memantine, a drug which has been approved for the management of dementia in the UK?

      Your Answer:

      Correct Answer: It is an NMDA-receptor agonist

      Explanation:

      Memantine is an antagonist of the NMDA (N-Methyl-D-Aspartate)-receptor subtype of glutamate receptor. It is used to slow the neurotoxicity thought to be involved in Alzheimer’s disease and other neurodegenerative diseases.

      Drug interactions:
      When given concomitantly with other NMDA-receptor antagonists (e.g., ketamine, amantadine) increase the risk of psychosis.
      Dopamine agonists, L-dopa, and anticholinergics enhance effects of memantine.
      Antispasmodics (e.g., baclofen)  enhance effects, as memantine has some antispasmodic effects.
      Drugs excreted by cationic transporters in the kidney (e.g. quinine, cimetidine, ranitidine) reduce excretion.

      Common adverse effects include dizziness, headache, confusion, diarrhoea, and constipation.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 59 - A 23-year-old female known with schizophrenia is being reviewed in the emergency department....

    Incorrect

    • A 23-year-old female known with schizophrenia is being reviewed in the emergency department. Her mother claims that she has been 'staring' for the past few hours but has now developed abnormal head movements and has gone 'cross-eyed'. On examination, the patient's neck is extended and positioned to the right. Her eyes are deviated upwards and are slightly converged. Given the likely diagnosis, what is the most appropriate treatment?

      Your Answer:

      Correct Answer: Procyclidine

      Explanation:

      The most probable diagnosis in this patient is an oculogyric crisis, that is most appropriately managed with procyclidine or benztropine (antimuscarinic).

      An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions.

      Features include:
      Restlessness, agitation
      Involuntary upward deviation of the eyes

      Causes:
      Phenothiazines
      Haloperidol
      Metoclopramide
      Postencephalitic Parkinson’s disease

      Management:
      Intravenous antimuscarinic agents like benztropine or procyclidine, alternatively diphenhydramine or ethopropazine maybe used.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 60 - A 26-year-old student has been brought to the emergency department in a confused...

    Incorrect

    • A 26-year-old student has been brought to the emergency department in a confused state. His friends report that he has been complaining of headaches for the past few weeks. He has a low-grade fever and on examination is noted to have abnormally pink mucosa. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Carbon monoxide poisoning

      Explanation:

      Confusion and pink mucosae are typical features of CO poisoning.
      The patient often presents, most commonly with headaches, and other symptoms like malaise, nausea, and dizziness.

      Carbon monoxide (CO) poisoning, considered as the great imitator of other diseases as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.

      Features of carbon monoxide toxicity
      – Headache: 90% of cases
      – Nausea and vomiting: 50%
      – Vertigo: 50%
      – Confusion: 30%
      – Subjective weakness: 20%
      – Severe toxicity: ‘pink’ skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death

      Treatment:
      Use of Hyperbaric oxygen therapy (HBOT) for treating mild to moderate CO poisoning is not routine.
      The selection criteria for HBOT in cases of CO poisoning include:
      • COHb levels > 20-25%
      • COHb levels > 20% in pregnant patient
      • Loss of consciousness
      • Severe metabolic acidosis (pH <7.1)
      • Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 61 - A 50-year-old male was under treatment for bipolar disease. He was brought to...

    Incorrect

    • A 50-year-old male was under treatment for bipolar disease. He was brought to the emergency department as he had become increasingly confused over the past two days. He had vomiting and diarrhoea. He was also consuming and passing a lot of water. On examination, he was disoriented. He had vertical nystagmus and was ataxic. What two investigations are likely to lead to the correct diagnosis?

      Your Answer:

      Correct Answer: Desmopressin test and serum lithium level

      Explanation:

      Desmopressin test (done to differentiate nephrogenic diabetes insipidus from central diabetes insipidus), and serum lithium levels can together confirm a diagnosis of lithium-induced nephrogenic diabetes insipidus.

      Bipolar disease is most often managed with mood stabilizers like lithium. This patient develops gastrointestinal symptoms followed by an acute confusional state associated with polyuria and polydipsia. These symptoms are suggestive of diabetes insipidus.

      In a case where these symptoms occur in a bipolar patient under treatment, lithium-induced nephrogenic diabetes insipidus should be considered as the most probable cause.

      Lithium intoxication can present with symptoms of nausea, vomiting, mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, especially vertical nystagmus and stupor or coma. Diffuse myoclonic twitching and nephrogenic diabetes insipidus can also occur. Such a clinical syndrome occurs above the serum level of lithium of 1.5–2.0 mEq/L.

      Management:
      – Correcting electrolyte abnormalities in patients with acute disease is critical and often life-saving.
      – Treatment should be initiated with parenteral fluids to replete hypovolemia (normal saline at 200-250 mL/h), followed by administration of hypotonic fluid (0.5% normal saline).
      – On the restoration of the volume status of the patient forced diuresis should be initiated by the administration of parenteral furosemide or bumetanide accompanied by continued intravenous hypotonic fluid administration to maintain volume status.
      – Polyuria is managed with hydrochlorothiazide combined with amiloride, acetazolamide.

    • This question is part of the following fields:

      • Pharmacology
      0
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  • Question 62 - A 18-year-old female is brought to the emergency department by her boyfriend. He...

    Incorrect

    • A 18-year-old female is brought to the emergency department by her boyfriend. He is concerned that she may have taken an overdose of her mom's morphine sulphate pills after being depressed about her mother, who is dying of carcinoma of the breast. Which of the following may point towards his suspicion?

      Your Answer:

      Correct Answer: Sweating

      Explanation:

      Excessive sweating points towards a morphine overdose.

      Morphine is considered the classic opioid analgesic with which other painkillers are compared. Like other medications in this class, morphine has an affinity for delta, kappa, and mu-opioid receptors.
      Most commonly used in pain management, morphine provides major relief to patients afflicted with pain.

      Among the more common adverse effects of morphine use is constipation. Other side effects include nausea, vomiting, drowsiness, and confusion. Psychological and physical dependence may occur.

      Other side effects include bronchospasm, angioedema, urinary retention, ureteric or biliary spasm, dry mouth, sweating, rash, facial flushing, vertigo, tachycardia, bradycardia, palpitations, orthostatic hypotension, hypothermia, restlessness, mood change, hallucinations, seizures (adults and children) and miosis, headache and allergic reactions (including anaphylaxis) and decreased libido or potency.

      Raised intracranial pressure occurs in some patients. Muscle rigidity may occur with high doses. Elevated liver enzymes may occur due to biliary sphincter constriction. Large doses can lead to respiratory depression, circulatory failure, and coma.

      Treatment of opioid overdose:
      Initial treatment of overdose begins with supportive care.
      Naloxone is a pure competitive antagonist of opiate receptors and has no agonistic activity. The drug is relatively safe and can be administered intravenous, intramuscular, subcutaneous or via the endotracheal tube.
      Alternatively, nalmefene and naltrexone maybe considered.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 63 - What is the mechanism of action of sumatriptan? ...

    Incorrect

    • What is the mechanism of action of sumatriptan?

      Your Answer:

      Correct Answer: 5-HT1 agonist

      Explanation:

      Triptans are specific 5-HT1 agonists used in the acute treatment of migraine. They are generally used as first-line therapy in combination with an NSAID or paracetamol.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 64 - A 60-year-old male is under treatment with azathioprine after a renal transplant. During...

    Incorrect

    • A 60-year-old male is under treatment with azathioprine after a renal transplant. During his review, he complains of pain and swelling over his left great toe. Investigations reveal hyperuricemia. Suspecting gout, he was started on allopurinol. Subsequently, he develops aplastic anaemia. Which of the following is the most appropriate reason for his bone marrow failure?

      Your Answer:

      Correct Answer: Mercaptopurine toxicity

      Explanation:

      The cause for bone marrow suppression in this patient is most probably mercaptopurine toxicity.
      Azathioprine is metabolized to 6-mercaptopurine (6-MP), which itself is metabolized by xanthine oxidase.
      Xanthine oxidase inhibition by allopurinol leads to the accumulation of 6-MP which then precipitates bone marrow failure.
      This may be potentially fatal if unrecognized.
      Clinical presentation:
      Toxicity symptoms include gastrointestinal symptoms, bradycardia, hepatotoxicity, myelosuppression.

    • This question is part of the following fields:

      • Pharmacology
      0
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  • Question 65 - A 25-year-old female presents to the emergency department with severe breathlessness and tinnitus....

    Incorrect

    • A 25-year-old female presents to the emergency department with severe breathlessness and tinnitus. She is under treatment for asthma and depression with albuterol and amitriptyline respectively. On examination, she seems agitated with a BP of 100/44, a pulse rate of 112 bpm, a respiratory rate of 30 cycles/min, and a temperature of 37.8'C. An arterial blood gas performed reveals: pH: 7.48 (7.36 – 7.44) pO2: 11.2 kPa (11.3 – 12.6 kPa) pCO2: 1.9 kPa (4.7 – 6.0 kPa) Bicarbonate: 13 mmol/l (20 – 28 mmol/L) What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Salicylate poisoning

      Explanation:

      The blood gas analysis provided above is suggestive of a mixed respiratory alkalosis and metabolic acidosis characteristic of salicylate overdose.

      Pathophysiology:
      The direct stimulation of the cerebral medulla causes hyperventilation and respiratory alkalosis.
      As it is metabolized, it causes an uncoupling of oxidative phosphorylation in the mitochondria.
      Lactate levels then increase due to the increase in anaerobic metabolism. This, along with a slight contribution from the salicylate metabolites result in metabolic acidosis.

      Tinnitus is characteristic and salicylate ototoxicity may produce deafness. Other neurological sequelae include encephalopathy and agitation, seizures and CNS depression and coma. Cardiovascular complications include tachycardia, hypotension, and dysrhythmias (VT, VF, and asystole).

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 66 - A 70-year-old man presents with nocturia, hesitancy and terminal dribbling of urine. Prostate...

    Incorrect

    • A 70-year-old man presents with nocturia, hesitancy and terminal dribbling of urine. Prostate examination reveals a moderately enlarged prostate with no irregular features and a well-defined median sulcus. Blood investigations show a PSA level of 1.3 ng/mL. Among the options provided below what is the most appropriate management for this patient?

      Your Answer:

      Correct Answer: Alpha-1 antagonist

      Explanation:

      Benign Prostatic Enlargement or Hyperplasia (BPE/BPH) is the most probable diagnosis of the patient in question. It is a histological diagnosis characterized by proliferation of the cellular elements of the prostate.
      The initial treatment modality of choice is selective alpha 1 antagonists (such as Prazosin, Alfuzosin and Indoramin, and long acting agents like, Terazosin, Doxazosin, etc.) as they provide immediate relief from the bothersome lower urinary tract symptoms (LUTS).
      Other treatment modalities include:
      • Non-selective alpha blockers: no longer used due to severe adverse effects and the availability of selective alpha 1 blockers.
      • 5 alpha reductase inhibitors: Finasteride and Dutasteride, they target the underlying disease process and reduce the overall prostate volume. Thus, reduce the urinary retention and the lower urinary tract symptoms. (They do not provide immediate relief from LUTS and thus are not preferred as first line drugs over alpha 1 antagonists)
      • PDE-5 Inhibitors: The long-acting tadalafil has proven to be useful.
      • Surgical Treatment modalities: TURP, Prostatectomy, etc.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 67 - A 20-year-old female has been admitted with an acute infection. She gives a...

    Incorrect

    • A 20-year-old female has been admitted with an acute infection. She gives a history suggestive of hypersensitivity to amoxicillin. After consultation with the allergy specialist, she has now been diagnosed with an IgE mediated penicillin allergy. Which of the following drugs should be avoided in this patient?

      Your Answer:

      Correct Answer: Cefalexin

      Explanation:

      Cefalexin should be avoided in this patient.
      This patient is known to have a severe penicillin allergy. None of the above antibiotics are penicillin based. However, 0.5 – 6.5% of patients who are proven to have an IgE mediated penicillin allergy will also be allergic to cephalosporins, including cefalexin.

      Penicillin, cephalosporins, and carbapenems are all members of the beta-lactam group of antibiotics and share a common beta-lactam ring. There is, therefore, a small risk of allergy cross-over between all these antibiotics. The rates of allergy cross-over are lower with second and third-generation cephalosporins than first-generation cephalosporins such as cefalexin.

      It is important to question the patient carefully to ascertain what symptoms they had on exposure to penicillin. Symptoms such as an urticarial rash or itching make it more likely that they have an IgE mediated allergy.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 68 - A 25-year-old student consumed a bottle of vodka at a party, the next...

    Incorrect

    • A 25-year-old student consumed a bottle of vodka at a party, the next day he finds that he feels excessively thirsty and is passing more urine than usual. Which of the following mechanisms best explains the polyuria due to excessive alcohol consumption?

      Your Answer:

      Correct Answer: Ethanol inhibits ADH secretion

      Explanation:

      Ethanol reduces the calcium-dependent secretion of anti-diuretic hormone (ADH) by blocking channels in the neurohypophyseal nerve terminal.
      Thus, ethanol’s inhibitory effect helps to explain the increased diuresis experienced during intoxicated states as well as increased free water loss; without appropriate ADH secretion, more water is excreted by the kidneys.

      Nausea associated with hangovers is mainly due to vagal stimulation to the vomiting centre.
      Following a particularly severe episode of alcohol excess, people may experience tremors due to increased glutamate production by neurons to compensate for the previous inhibition by ethanol.

      Management of alcoholism:
      Nutritional support:
      – Alcoholic patients should receive oral thiamine if their ‘diet may be deficient’.
      Pharmacological management:
      – Benzodiazepines for acute withdrawal
      – Disulfiram promotes abstinence – alcohol intake causes a severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis.
      – Acamprosate reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo-controlled trials.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 69 - A 25-year-old woman presented to the ED with carbon monoxide poisoning. High-flow oxygen...

    Incorrect

    • A 25-year-old woman presented to the ED with carbon monoxide poisoning. High-flow oxygen was administered immediately. She had a GCS of 15 and her vitals were stable. Which one of the following is not an indication for hyperbaric oxygen therapy in this scenario?

      Your Answer:

      Correct Answer: A carboxyhaemoglobin concentration of 16%

      Explanation:

      Carbon monoxide (CO) poisoning, considered as the great imitator of other diseases, as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.

      Use of Hyperbaric oxygen therapy (HBOT) for treatment of mild to moderate CO poisoning is not routine.
      The selection criteria for HBOT in cases of CO poisoning include:
      • COHb levels > 20-25%
      • COHb levels > 20% in pregnant patient
      • Loss of consciousness
      • Severe metabolic acidosis (pH <7.1)
      • Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)
      Principle of HBOT:
      Exposing patients to 100 percent oxygen under supra-atmospheric conditions results in a decrease in the half-life (t1/2) of COHb, from , 90 min in atmospheric air to , 30 minutes. The amount of oxygen dissolved in the blood also rises from , 0.3 to 6 mL/dL, increasing the delivery of non-haemoglobin-bound oxygen to the tissues.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 70 - A patient who has mild benign prostatic hyperplasia has been advised to take...

    Incorrect

    • A patient who has mild benign prostatic hyperplasia has been advised to take finasteride. The mechanism of action of this drug involves inhibition of the production of which of the following androgens?

      Your Answer:

      Correct Answer: Dihydrotestosterone

      Explanation:

      Finasteride inhibits the formation of dihydrotestosterone.
      Finasteride is a 5α-reductase inhibitor and thus, inhibits the conversion of testosterone to dihydrotestosterone (DHT).

      DHT is much more active than testosterone and binds more avidly to cytoplasmic receptors. DHT stimulates prostate growth and may be responsible for benign prostatic hyperplasia in the elderly.

      Thus, finasteride can cause a reduction in prostatic volume and help in managing a patient with benign prostatic hyperplasia.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 71 - A 50-year-old hypertensive male on phenytoin and clobazam for partial seizures is also...

    Incorrect

    • A 50-year-old hypertensive male on phenytoin and clobazam for partial seizures is also taking lisinopril, cimetidine, sucralfate, and allopurinol. The last few drugs were added recently. He now presents with ataxia, slurred speech, and blurred vision. Which recently added drug is most likely to be the cause of his latest symptoms?

      Your Answer:

      Correct Answer: Cimetidine

      Explanation:

      The symptoms of ataxia, slurred speech and blurred vision are all suggestive of phenytoin toxicity. Cimetidine increases the efficacy of phenytoin by reducing its hepatic metabolism.

      Phenytoin has a narrow therapeutic index (10-20 mg/L) and its levels are monitored by measuring the total phenytoin concentration.
      Cimetidine is an H2 receptor antagonist used in the treatment of peptic ulcers. It acts by decreasing gastric acid secretion.
      Cimetidine also has an inhibitory effect on several isoforms of the cytochrome enzyme system including the CYP450 enzymatic pathway. Phenytoin is metabolized by the same cytochrome P450 enzyme system in the liver.
      Thus, the simultaneous administration of both these medications leads to an inhibition of phenytoin metabolism and thus increases its circulating levels leading to phenytoin toxicity.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 72 - A 50-year-old man with a history of hyperlipidaemia, currently under treatment with simvastatin...

    Incorrect

    • A 50-year-old man with a history of hyperlipidaemia, currently under treatment with simvastatin 10mg was found to have persistently high cholesterol levels. Previous attempts to increase the dose of simvastatin have resulted in myalgia. Given this history, which one of the following lipid-regulating drugs should definitely be avoided?

      Your Answer:

      Correct Answer: Bezafibrate

      Explanation:

      Both fibrates and nicotinic acid have been associated with myositis, especially when combined with a statin. However, the Committee on Safety of Medicines has produced guidance which specifically warns about the concomitant prescription of fibrates with statins concerning muscle toxicity.

      Bezafibrate: It is a fibric acid derivative (fibrate) that has been used as a class of agents known to decrease triglyceride levels while substantially increasing HDL-C levels.
      Pharmacological effects:
      – Increases VLDL catabolism by increasing lipoprotein and hepatic triglyceride lipase.
      – Decreases triglyceride synthesis by inhibiting acetyl-CoA reductase.
      – Decreases cholesterol synthesis by inhibiting HMG-CoA reductase.

      Side effects:
      – Hypersensitivity
      – Primary biliary cirrhosis
      – Pre-existing gallbladder disease
      – Concurrent use with HMG-CoA inhibitors (statins) can produce myopathy
      – Hepatic/renal impairment in a patient warrants dose adjustment as this drug is primarily excreted via the renal mechanism.

      Contraindications: Concurrent use of MAO inhibitors, hypersensitivity, pre-existing cholestasis, and pregnancy.

      Use: It can be used to treat Barth syndrome (characterized by dilated cardiomyopathy, neutropenia (presenting with recurrent infections), skeletal myopathy and short stature)

    • This question is part of the following fields:

      • Pharmacology
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  • Question 73 - A 47-year-old woman diagnosed with oestrogen receptor positive breast cancer three months back...

    Incorrect

    • A 47-year-old woman diagnosed with oestrogen receptor positive breast cancer three months back was started on treatment with tamoxifen. Which of the following is most likely a complaint of this patient during her review today?

      Your Answer:

      Correct Answer: Hot flushes

      Explanation:

      The most likely complaint of this patient would be hot flushes.

      Alopecia and cataracts are listed in the BNF as possible side-effects. They are however not as prevalent as hot flushes, which are very common in pre-menopausal women.

      Tamoxifen is a Selective Oestrogen Receptor Modulator (SERM) which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer

      Adverse effects:
      Menstrual disturbance: vaginal bleeding, amenorrhoea
      Hot flushes – 3% of patients stop taking tamoxifen due to climacteric side-effects.
      Venous thromboembolism.
      Endometrial cancer
      Tamoxifen is typically used for 5 years following the removal of the tumour.

      Raloxifene is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer.

      Although antagonistic with respects to breast tissue tamoxifen may serve as an agonist at other sites. Therefore the risk of endometrial cancer is increased cancer.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 74 - A 30-year-old agitated male was brought to the emergency department by his friend....

    Incorrect

    • A 30-year-old agitated male was brought to the emergency department by his friend. Though there is little previous history, the friend believes that he has been suffering from depression for several years, and his medications have been changed by his general practitioner quite recently. On examination the patient is agitated and confused, his pupils are dilated. He also has tremors, excessive sweating, and grinding of teeth. His heart rate is 118 beats/min, which is regular, and is febrile with a temperature of 38.5°C. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Serotonin syndrome

      Explanation:

      The most probable diagnosis in this patient is serotonin syndrome.

      The serotonin syndrome is a cluster of symptoms and signs (range from barely perceptible tremor to life-threatening hyperthermia and shock).
      It may occur when SSRIs such as citalopram, escitalopram, fluoxetine, fluoxetine, paroxetine, and sertraline that impair the reuptake of serotonin from the synaptic cleft into the presynaptic neuron are taken in combination with monoamine oxidase inhibitors or tricyclic antidepressants. It has also been reported following an overdose of selective serotonin reuptake inhibitors (SSRIs) alone.

      Treatment:
      Most cases of serotonin syndrome are mild and will resolve with removal of the offending drug alone.
      After stopping all serotonergic drugs, management is largely supportive and aimed at preventing complications.
      Patients frequently require sedation, which is best facilitated with benzodiazepines.
      Antipsychotics should be avoided because of their anticholinergic properties, which may inhibit sweating and heat dissipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 75 - A 27-year-old female diagnosed with rheumatoid arthritis has failed to respond to methotrexate...

    Incorrect

    • A 27-year-old female diagnosed with rheumatoid arthritis has failed to respond to methotrexate and sulfasalazine. Her GP decides to start her on etanercept injections. Which one among the following is an adverse effect associated with the use of etanercept?

      Your Answer:

      Correct Answer: Reactivation of tuberculosis

      Explanation:

      Among the give options, reactivation of tuberculosis may occur in a patient under treatment with etanercept.
      Etanercept is a biological TNF inhibit commonly used to control ankylosing spondylitis, juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis.
      Etanercept is a soluble receptor that binds both TNF-alpha and TNF-beta to inhibit the inflammatory response in joints and skin that is characteristic of these autoimmune disorders.
      The most common adverse effects include infections (viral, bacterial, and fungal – mostly upper respiratory tract infections) and injection site reaction (erythema, itching, pain, swelling, bleeding, bruising).
      Rarely it can also cause, reactivation of hepatitis B and TB, pneumocystis pneumonia, congestive cardiac failure, Steven-Johnson syndrome, toxic epidermal necrolysis, etc.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 76 - A 39-year-old accountant with long-standing gastro-oesophageal reflux disease is reviewed in clinic. He...

    Incorrect

    • A 39-year-old accountant with long-standing gastro-oesophageal reflux disease is reviewed in clinic. He has recently switched from ranitidine to omeprazole. What is the main benefit of omeprazole compared to ranitidine?

      Your Answer:

      Correct Answer: Irreversible blockade of H+/K+ ATPase

      Explanation:

      Proton pump inhibitors can reduce gastric acid secretion by up to 99%. Acid production resumes following the normal renewal of gastric parietal cells.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 77 - A 48-year-old male with a history of bipolar disorder presents with acute confusion....

    Incorrect

    • A 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed: Lithium level: 4.2 mmol/L, Na+: 136 mmol/L, K+: 4.6 mmol/L, Urea: 8.1 mmol/L, Creatinine: 99 µmol/L, Bicarbonate: 18 mmol/L, What is the most appropriate management for the patient?

      Your Answer:

      Correct Answer: Arrange haemodialysis

      Explanation:

      The presentation of the patient is typical of chronic lithium toxicity (due to the presence of mainly neurological manifestations). Additional to the blood investigations mentioned, urine analysis, electrolyte levels, and renal function should also be performed. A low urine Anion gap and a low urine specific gravity are highly suggestive of lithium toxicity.
      ECG obtained in this patient is likely to show: nonspecific, diffuse ST segment depression with T wave inversion.
      Acute lithium toxicity presents with more GI manifestations while, the clinical features of chronic lithium toxicity are mainly neurological and can include:
      Coarse tremors (fine tremors are seen in therapeutic levels), hyperreflexia, acute confusion, seizures, and coma.
      The management of lithium toxicity is as follows:
      Immediate GI decontamination with gastric lavage (in case of acute intoxication)
      Saline Administrations: the goal of saline administration is to restore GFR, normalize urine output and enhance lithium clearance.
      Haemodialysis remains the mainstay treatment for lithium toxicity as lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.
      The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP Workgroup) recommendations for dialysis (extracorporeal treatment) in lithium toxicity include:
      • Impaired kidney function and lithium levels > 4.0 mEq/L
      • Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
      • Levels are > 5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hours
      As post-dialysis rebound elevations in lithium levels have been documented, continuous veno-venous hemofiltration (CVVH) has been advocated.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 78 - Which of the following statements is false regarding the bioavailability of a drug?...

    Incorrect

    • Which of the following statements is false regarding the bioavailability of a drug?

      Your Answer:

      Correct Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination

      Explanation:

      Renal elimination of a drug has no role in altering the bioavailability of a drug.
      The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
      Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.

      Other options are true:
      By definition, the bioavailability of a drug given intravenously is 100%.
      Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
      Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 79 - A 22-year-old female comes to you for counselling regarding the initiation of combined...

    Incorrect

    • A 22-year-old female comes to you for counselling regarding the initiation of combined oral contraceptive pill. Which of the following statements is correct?

      Your Answer:

      Correct Answer: She will still be protected against pregnancy if she takes amoxicillin for a lower respiratory tract infection while on the combined pill

      Explanation:

      The true statement among the given options is that she will still be protected against pregnancy if she takes amoxicillin for a lower respiratory tract infection while on the combined pill.

      Other than enzyme-inducing antibiotics such as rifampicin, antibiotics do not reduce the efficacy of the combined oral contraceptive pill.

      It was previously advised that barrier methods of contraception should be used if taking an antibiotic while using the contraceptive pill, due to concerns that antibiotics might reduce the absorption of the pill. This is now known to be untrue. However, if the absorptive ability of the gut is compromised for another reason, such as severe diarrhoea or vomiting, or bowel disease, this may affect the efficacy of the pill.

      The exception to the antibiotic rule is that hepatic enzyme-inducing antibiotics such as rifampicin and rifaximin do reduce the efficacy of the pill. Other enzyme-inducing drugs, such as phenytoin, phenobarbital, carbamazepine or St John’s Wort can also reduce the effectiveness of the pill.

      Other options:
      The combined pill is often prescribed for women with heavy periods as it can make them lighter and less painful.
      There is no evidence that women on the combined pill put on any significant weight, although they may experience bloating at certain times in the course.
      Women on the pill require monitoring of their blood pressure.
      There are multiple different types of combined pills.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 80 - A 50-year-old male was brought to the ER after the accidental consumption of...

    Incorrect

    • A 50-year-old male was brought to the ER after the accidental consumption of 300 ml of diethylene glycol. Blood investigations were suggestive of metabolic acidosis and renal failure. What is the appropriate management in this patient?

      Your Answer:

      Correct Answer: Haemodialysis and oral ethanol

      Explanation:

      Among the given options the most appropriate management in this patient would be ethanol and haemodialysis.

      Ethanol competes with ethylene glycol for alcohol dehydrogenase and thus, helps manage a patient with ethylene glycol toxicity.

      Ethylene glycol is a type of alcohol used as a coolant or antifreeze
      Features of toxicity are divided into 3 stages:
      Stage 1: (30 min to 12 hours after exposure) Symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness (CNS depression)
      Stage 2: (12 – 48 hours after exposure) Metabolic acidosis with a high anion gap and high osmolar gap. Also tachycardia, hypertension
      Stage 3: (24 – 72 hours after exposure) Acute renal failure

      Management has changed in recent times:
      Fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol.
      Ethanol has been used for many years works by competing with ethylene glycol for the enzyme alcohol dehydrogenase this limits the formation of toxic metabolites (e.g. glycolaldehyde and glycolic acid) which are responsible for the hemodynamic/metabolic features of poisoning.
      Haemodialysis has a role in refractory cases.

    • This question is part of the following fields:

      • Pharmacology
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