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  • Question 1 - A 28-year-old female with no significant medical history is started on carbamazepine for...

    Incorrect

    • A 28-year-old female with no significant medical history is started on carbamazepine for focal impaired awareness seizures. She drinks alcohol moderately. After three months, she experiences a series of seizures and her carbamazepine levels are found to be subtherapeutic. Despite being fully compliant, a pill-count reveals this. What is the probable cause?

      Your Answer: Alcohol binge

      Correct Answer: Auto-induction of liver enzymes

      Explanation:

      Carbamazepine induces the P450 enzyme system, leading to increased metabolism of carbamazepine through auto-induction.

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.

      On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 2 - A 52-year-old woman had a anterior myocardial infarction (MI) three weeks ago and...

    Correct

    • A 52-year-old woman had a anterior myocardial infarction (MI) three weeks ago and has been prescribed various drugs by the cardiology team.
      Which of the following medications is most likely to decrease this patient’s mortality post-MI?

      Your Answer: Bisoprolol

      Explanation:

      Common Medications for Cardiovascular Conditions

      Bisoprolol is a beta-blocker that specifically targets the heart, reducing strain by decreasing pre-load and after-load. It has been found to be effective in reducing mortality after a heart attack, especially in patients with heart failure.

      Amiodarone is an anti-arrhythmic drug that can be used to prevent irregular heartbeats. However, it does not improve mortality rates in post-heart attack patients.

      Isosorbide mononitrate is a medication that helps lower blood pressure and can alleviate chest pain in stable angina. It does not improve mortality rates and should be used with caution when taken with sildenafil.

      Nicorandil works by dilating the coronary arteries, reducing chest pain in stable angina. While it does not improve prognostic outcomes, it can improve symptoms.

      Patients who have experienced a myocardial infarction (MI) should be started on a combination of medications to improve their outcomes. The following medications are recommended for post-MI patients:

      1. Statin: This medication helps to lower cholesterol levels and reduce the risk of future cardiovascular events.

      2. ACE inhibitor: This medication helps to lower blood pressure and reduce the risk of heart failure.

      3. Beta blocker: This medication helps to reduce the workload on the heart and improve its function.

      4. Aspirin: This medication helps to prevent blood clots and reduce the risk of future cardiovascular events.

      Other medications may be used to relieve symptoms, such as ISMN and nicorandil, but they do not offer any mortality benefit. It is important for post-MI patients to take their medications as prescribed and to follow up with their healthcare provider regularly to monitor their progress.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      11.6
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  • Question 3 - Methimazole (MMI) has a modest therapeutic advantage over carbimazole in the treatment of...

    Incorrect

    • Methimazole (MMI) has a modest therapeutic advantage over carbimazole in the treatment of thyrotoxicosis.
      Which of the following properties causes this?
      Select the SINGLE property from the list below.

      Your Answer: Not excreted in breast milk

      Correct Answer: Inhibits T4 to T3 conversion

      Explanation:

      Comparison of PTU and Carbimazole in the Treatment of Hyperthyroidism

      PTU and carbimazole are two commonly used medications in the treatment of hyperthyroidism. While both drugs are effective in reducing thyroid hormone levels, there are some differences in their mechanisms of action and adverse effects.

      One advantage of PTU over carbimazole is its ability to inhibit the conversion of T4 to the more active form T3. This is due to its inhibition of the enzyme 5′-deiodinase. However, both drugs inhibit the organification of iodine at the thyroid gland by inhibiting the enzyme thyroperoxidase.

      While both drugs are present in breast milk, the amount is likely too small to affect the infant. However, high doses may impact neonatal thyroid function, so monitoring is necessary.

      Carbimazole is considered to be at least 10 times as potent as PTU. Additionally, the two drugs have different chemical structures and therefore have slightly different adverse effects profiles. Common side effects include rash, hair loss, and skin pigmentation, while rare but serious side effects include aplastic anaemia, agranulocytosis, and fulminant liver failure.

      Patients taking either medication should be aware of the signs of liver disease and seek medical attention if they experience symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus. Regular liver function monitoring is also recommended.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      18.2
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  • Question 4 - A 68 year old male presents to the emergency department with a 2...

    Correct

    • A 68 year old male presents to the emergency department with a 2 day history of worsening flank pain. He has felt hot, feverish and been unable to keep fluids down. Examination reveals a blood pressure of 110/70 mmHg, tachycardia 120 beats per minute and left flank pain to palpation. Urine dipstick is positive for leucocytes +++ and nitrites +++. A diagnosis of pyelonephritis is made and intravenous gentamicin is prescribed.
      What is the most common complication associated with gentamicin?

      Your Answer: Nephrotoxicity

      Explanation:

      Nephrotoxicity is a known side effect of aminoglycosides.

      Gentamicin, an aminoglycoside antibiotic, is highly effective against gram negative bacteria and is often used to treat severe infections, particularly those affecting the urinary tract and abdomen. However, one of the common complications associated with gentamicin use is nephrotoxicity, which occurs due to the narrow therapeutic window required to achieve a therapeutic dose. Exceeding this index can lead to kidney damage. Ototoxicity is another potential complication that is often tested in final exams.

      Gentamicin is a type of antibiotic belonging to the aminoglycoside class. It is not easily soluble in lipids, which is why it is administered either parentally or topically. Gentamicin is commonly used to treat infective endocarditis and otitis externa. However, it is important to note that gentamicin can cause adverse effects such as ototoxicity and nephrotoxicity. Ototoxicity is caused by damage to the auditory or vestibular nerve, which can be irreversible. Nephrotoxicity occurs when gentamicin accumulates in the body, particularly in patients with renal failure, leading to acute tubular necrosis. The risk of toxicity is increased when gentamicin is used in conjunction with furosemide. Therefore, lower doses and more frequent monitoring are required.

      It is important to note that gentamicin is contraindicated in patients with myasthenia gravis. Due to the potential for toxicity, it is crucial to monitor plasma concentrations of gentamicin. Both peak levels (measured one hour after administration) and trough levels (measured just before the next dose) are monitored. If the trough level is high, the interval between doses should be increased. If the peak level is high, the dose should be decreased. By carefully monitoring gentamicin levels, healthcare providers can ensure that patients receive the appropriate dose without experiencing adverse effects.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      52.7
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  • Question 5 - A 56-year-old man with a history of hypertension presents for follow-up. He is...

    Incorrect

    • A 56-year-old man with a history of hypertension presents for follow-up. He is currently on lisinopril 10 mg once daily, simvastatin 40 mg once daily, and aspirin 75mg once daily. His blood pressure is well managed at 126/78 mmHg. However, he informs the healthcare provider that he is scheduled for a tooth extraction next week. What guidance should be provided regarding his aspirin regimen?

      Your Answer: Stop 72 hours before, restart 24 hours after procedure

      Correct Answer: Take aspirin as normal

      Explanation:

      According to the BNF section on ‘Prescribing in dental practice’, patients who are taking anti-platelets should not discontinue their medication and should continue taking it as prescribed.

      The Mechanism and Guidelines for Aspirin Use in Cardiovascular Disease

      Aspirin is a medication that works by blocking the action of cyclooxygenase-1 and 2, which are responsible for the synthesis of prostaglandin, prostacyclin, and thromboxane. By inhibiting the formation of thromboxane A2 in platelets, aspirin reduces their ability to aggregate, making it a widely used medication in cardiovascular disease. However, recent trials have cast doubt on the use of aspirin in primary prevention of cardiovascular disease, leading to changes in guidelines. Aspirin is now recommended as a first-line treatment for patients with ischaemic heart disease, but it should not be used in children under 16 due to the risk of Reye’s syndrome. The medication can also potentiate the effects of oral hypoglycaemics, warfarin, and steroids.

      The Medicines and Healthcare products Regulatory Agency (MHRA) issued a drug safety update in January 2010, reminding prescribers that aspirin is not licensed for primary prevention. NICE now recommends clopidogrel as a first-line treatment following an ischaemic stroke and for peripheral arterial disease. However, the situation is more complex for TIAs, with recent Royal College of Physician (RCP) guidelines supporting the use of clopidogrel, while older NICE guidelines still recommend aspirin + dipyridamole – a position the RCP state is ‘illogical’. Despite these changes, aspirin remains an important medication in the treatment of cardiovascular disease, and its use should be carefully considered based on individual patient needs and risk factors.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      24.8
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  • Question 6 - Which of the following antihypertensive agents controls blood pressure by blocking the peripheral...

    Correct

    • Which of the following antihypertensive agents controls blood pressure by blocking the peripheral α1 -adrenoceptor?

      Your Answer: Doxazosin

      Explanation:

      Mechanisms of Action of Antihypertensive Drugs

      Doxazosin is an a1-adrenergic receptor blocker that relaxes vascular smooth muscle tone, leading to decreased peripheral vascular resistance and blood pressure.

      Losartan is a selective angiotensin II receptor type 1 antagonist that reduces the end-organ response to angiotensin II, resulting in decreased total peripheral resistance and cardiac venous return.

      Minoxidil is a potassium channel opener that causes vasodilatation mainly in arterial resistance vessels, with significant hypertrichosis as a side effect.

      Methyldopa inhibits dopa decarboxylase, leading to reduced dopaminergic and adrenergic neurotransmission and a modest decrease in blood pressure. It also activates presynaptic central nervous system a2-adrenergic receptors, inhibiting sympathetic nervous system output.

      Clonidine activates presynaptic a2-receptors in the brain stem, decreasing peripheral vascular resistance and blood pressure by inhibiting the release of noradrenaline.

      Overall, these antihypertensive drugs work through different mechanisms to lower blood pressure and reduce the risk of cardiovascular disease.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      23
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  • Question 7 - A 30-year-old man with a known history of peanut allergy arrives at the...

    Incorrect

    • A 30-year-old man with a known history of peanut allergy arrives at the Emergency Department with facial swelling. Upon examination, his blood pressure is 85/60 mmHg, pulse is 120 bpm, and he has a bilateral expiratory wheeze. Which type of adrenaline should be administered?

      Your Answer: 0.5ml 1:10,000 IM

      Correct Answer: 0.5ml 1:1,000 IM

      Explanation:

      Please find below the recommended doses of adrenaline for Adult Life Support (ALS) in different scenarios:

      – Anaphylaxis: 0.5mg or 0.5ml of 1:1,000 adrenaline should be administered intramuscularly.
      – Cardiac arrest: For intravenous administration, 1mg or 10ml of 1:10,000 adrenaline or 1ml of 1:1000 adrenaline is recommended.

      Understanding Adrenaline and Its Indications

      Adrenaline is a type of sympathomimetic amine that has both alpha and beta adrenergic stimulating properties. It is commonly used in emergency situations such as anaphylaxis and cardiac arrest. For anaphylaxis, the recommended adult life support adrenaline dose is 0.5ml 1:1,000 IM, while for cardiac arrest, it is 10ml 1:10,000 IV or 1ml of 1:1000 IV.

      Adrenaline is responsible for the fight or flight response and is released by the adrenal glands. It acts on α 1 and 2, β 1 and 2 receptors, and causes vasoconstriction in the skin and kidneys, resulting in a narrow pulse pressure. It also increases cardiac output and total peripheral resistance, while causing vasodilation in skeletal muscle vessels.

      When adrenaline acts on α adrenergic receptors, it inhibits insulin secretion by the pancreas and stimulates glycogenolysis in the liver and muscle. On the other hand, when it acts on β adrenergic receptors, it stimulates glucagon secretion in the pancreas, stimulates ACTH, and stimulates lipolysis by adipose tissue.

      In case of accidental injection, the management involves local infiltration of phentolamine. Understanding the indications and actions of adrenaline is crucial in emergency situations, and proper administration can help save lives.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      26.8
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  • Question 8 - An 80-year-old man comes in for a routine check-up with his General Practitioner....

    Incorrect

    • An 80-year-old man comes in for a routine check-up with his General Practitioner. He has a medical history of atrial fibrillation, type II diabetes, depression, and chronic alcohol abuse. His current medications include warfarin 3 mg once daily, ramipril 2.5 mg once daily, bisoprolol 2 mg once daily, erythromycin 500 mg four times daily (day five of a 7-day course for cellulitis on the leg), and sertraline 50 mg once daily (started four weeks ago). He is allergic to penicillin. His blood work shows an INR of 6.5 (target 2.0-3.0). What is the most likely reason for his elevated INR?

      Your Answer: Erythromycin is a P450 inducer

      Correct Answer: Erythromycin is a P450 inhibiter

      Explanation:

      The patient is taking erythromycin for cellulitis, which inhibits the cytochrome P450 enzymes responsible for breaking down drugs like warfarin and statins. As a result, the effects of warfarin are potentiated, leading to a higher than expected INR. Bisoprolol is unlikely to have contributed to the change in INR as it does not affect the P450 system. Chronic alcohol abuse can induce P450 enzymes, but this would cause a lower INR. Erythromycin is an inhibitor, not an inducer, of P450 enzymes. Sertraline, though recently started, is also an enzyme inhibitor and cannot explain the high INR.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 9 - A 28-year-old woman with established epilepsy has recently had her medication changed at...

    Correct

    • A 28-year-old woman with established epilepsy has recently had her medication changed at her epilepsy clinic. She now reports abdominal pain, weight loss and feeling anxious all the time.
      Which of the following medications is likely to have been started?

      Your Answer: Levetiracetam (Keppra®)

      Explanation:

      Common Side Effects of Anticonvulsants: A Comparison of Five Medications

      Anticonvulsants are commonly used to treat seizures and other neurological conditions. However, they often come with side effects that can impact a patient’s quality of life. Here, we compare the common side effects of five anticonvulsant medications: levetiracetam, carbamazepine, lamotrigine, phenytoin, and sodium valproate.

      Levetiracetam (Keppra®) is known for causing gastrointestinal symptoms such as abdominal pain, diarrhea, dyspepsia, nausea, and vomiting. It can also lead to anorexia and anxiety.

      Carbamazepine is rarely associated with abdominal pain and anorexia, but it can cause other gastrointestinal symptoms such as nausea, vomiting, constipation, or diarrhea. It is not known to cause anxiety.

      Lamotrigine (Lamictal®) can cause gastrointestinal symptoms such as nausea, vomiting, and diarrhea, but it is not known to cause abdominal pain, weight loss, or anxiety.

      Phenytoin is commonly associated with anorexia, constipation, nausea, and vomiting. It is not known to cause abdominal pain or anxiety, but it can lead to serious blood disorders such as aplastic anemia and megaloblastic anemia.

      Sodium valproate (Epilim®) is commonly associated with diarrhea, dyspepsia, nausea, and weight gain. It can also cause aggression and behavioral changes, ataxia and tremors, and transient hair loss.

      It is important to note that these are not the only side effects associated with these medications. Patients should always consult with their healthcare provider about the potential risks and benefits of any medication.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 10 - You are having a consultation with a 49-year-old man for his initial diabetes...

    Incorrect

    • You are having a consultation with a 49-year-old man for his initial diabetes review. Following 3 months of metformin treatment, his HbA1c has shown improvement. Unfortunately, he hasn't been able to make any lifestyle modifications. You are content with the management of his type 2 diabetes mellitus. However, the patient reports experiencing significant gastrointestinal (GI) adverse effects due to metformin.

      What would be your approach to managing this patient?

      Your Answer: Keep him on metformin

      Correct Answer: Switch to a modified-release formulation of metformin

      Explanation:

      If the patient experiences GI side-effects with metformin, it is recommended to try a modified-release formulation before considering switching to a second-line agent. Modified-release formulations are known to cause fewer GI side-effects compared to other formulations. It is advisable to continue with metformin as it is effective for the patient rather than trying another medication that may not work as well.

      Continuing with the same formulation of metformin is not a suitable solution as the patient is experiencing significant GI side-effects. Modified-release formulations can help manage diabetes while reducing these side-effects.

      Discontinuing all antidiabetic medications is not recommended as the patient has not made any lifestyle changes and requires medical support to manage their diabetes.

      While second-line agents like sulfonylureas may be effective in managing diabetes and reducing GI side-effects, they may not be as effective as metformin and may cause their own set of side-effects. These medications should be considered only when combination therapy is required.

      GLP-1 receptor antagonists are effective antidiabetic medications, but they are expensive and inconvenient as they require injection. Therefore, other medications should be tried before considering these.

      Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.

      While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.

      There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.

      When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      34.8
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