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  • Question 1 - A 65-year-old patient arrives after an acute overdose of digoxin. She is experiencing...

    Incorrect

    • A 65-year-old patient arrives after an acute overdose of digoxin. She is experiencing nausea and is expressing concerns about palpitations.
      What is the indication for administering DigiFab to this patient?

      Your Answer: Heart rate of 40 bpm

      Correct Answer: Ventricular tachycardia

      Explanation:

      Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).

      DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.

      The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:

      Acute digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Potassium level >5 mmol/l
      – Ingestion of >10 mg of digoxin (in adults)
      – Ingestion of >4 mg of digoxin (in children)
      – Digoxin level >12 ng/ml

      Chronic digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Significant gastrointestinal symptoms
      – Symptoms of digoxin toxicity in the presence of renal failure

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      93.5
      Seconds
  • Question 2 - A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given anti-tuberculous...

    Correct

    • A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given anti-tuberculous medication. The mother experiences liver damage, and the newborn experiences seizures and neuropathy.
      Which of the following drugs is the most probable cause of these abnormalities?

      Your Answer: Isoniazid

      Explanation:

      The standard drug regimen for tuberculosis is generally safe to use during pregnancy, with the exception of streptomycin which should be avoided. However, the use of isoniazid during pregnancy has been associated with potential risks such as liver damage in the mother and the possibility of neuropathy and seizures in the newborn.

      Here is a list outlining some commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If taken during the second and third trimesters, these medications can lead to reduced blood flow, kidney failure, and a condition called oligohydramnios.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity, resulting in hearing loss in the baby.

      Aspirin: High doses of aspirin can increase the risk of first trimester abortions, delayed labor, premature closure of the fetal ductus arteriosus, and a condition called fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When taken late in pregnancy, these medications can cause respiratory depression in the baby and lead to a withdrawal syndrome.

      Calcium-channel blockers: If taken during the first trimester, these drugs can cause abnormalities in the fingers and toes. If taken during the second and third trimesters, they may result in fetal growth retardation.

      Carbamazepine: This medication can increase the risk of hemorrhagic disease in the newborn and neural tube defects.

      Chloramphenicol: Use of this drug in newborns can lead to a condition known as grey baby syndrome.

      Corticosteroids: If taken during the first trimester, corticosteroids may increase the risk of orofacial clefts in the baby.

      Danazol: When taken during the first trimester, this medication can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect the development of male sex organs in the baby.

      Haloperidol: If taken during the first trimester, this medication may increase the risk of limb malformations. If taken during the third trimester, it can lead to an increased risk of extrapyramidal symptoms in the newborn.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 3 - A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30...

    Correct

    • A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30 minutes ago. She is currently showing no symptoms and her vital signs are stable. The attending physician recommends administering a dose of activated charcoal.
      Which of the following substances or toxins is activated charcoal NOT effective in decontaminating?

      Your Answer: Lithium

      Explanation:

      Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. It is produced by subjecting carbonaceous matter to high temperatures, a process known as pyrolysis, and then concentrating it with a zinc chloride solution. This creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This porous structure helps prevent the absorption of the harmful toxin by up to 50%.

      The usual dosage of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to give the charcoal within one hour of ingestion, and it may be repeated after one hour if necessary.

      However, there are certain situations where activated charcoal should not be used. If the patient is unconscious or in a coma, there is a risk of aspiration, so the charcoal should not be given. Similarly, if seizures are likely to occur, there is a risk of aspiration and the charcoal should be avoided. Additionally, if there is reduced gastrointestinal motility, there is a risk of obstruction, so activated charcoal should not be used in such cases.

      Activated charcoal is effective in treating overdose with various drugs and toxins, including aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in treating overdose with substances such as iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.

      There are some potential adverse effects associated with activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhaling the charcoal into the lungs), and impaired absorption of oral medications or antidotes.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 4 - A 42-year-old woman with a lengthy history of depression arrives at the Emergency...

    Incorrect

    • A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on her heart medication. She informs you that she took verapamil SR 160 mg tablets approximately 30 minutes ago before being discovered by her husband.

      What is the mechanism of action of verapamil?

      Your Answer: Angiotensin II receptor blockade

      Correct Answer: L-type calcium channel blockade

      Explanation:

      Calcium-channel blocker overdose is a serious matter and should be regarded as potentially life-threatening. Verapamil and diltiazem are the two most dangerous types of calcium channel blockers when taken in excess. They work by attaching to the alpha-1 subunit of L-type calcium channels, which stops calcium from entering the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 5 - A 40-year-old male with schizophrenia is brought to the emergency department by the...

    Incorrect

    • A 40-year-old male with schizophrenia is brought to the emergency department by the CPN after admitting to ingesting approximately 100 aspirin tablets one hour ago. He is now experiencing tinnitus. When would you initially measure salicylate levels in this patient?

      Your Answer: 4 hours post ingestion

      Correct Answer: 2 hours post ingestion

      Explanation:

      If a person shows symptoms after ingesting salicylate, their salicylate levels should be measured 2 hours after ingestion. However, if the person does not show any symptoms, the levels should be measured 4 hours after ingestion. It is important to note that if enteric coated preparations are taken, salicylate levels may continue to increase for up to 12 hours. Therefore, it is necessary to regularly check the levels every 2-3 hours until they start to decrease.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 6 - A 14 year old female is brought to the emergency department by her...

    Incorrect

    • A 14 year old female is brought to the emergency department by her parents approximately 90 minutes after taking an overdose. The patient tells you she was at her friend's house and they got into an argument which ended with her friend telling her she was ending their friendship. The patient grabbed a bottle of pills from the bathroom and swallowed all of them before leaving. She didn't tell her friend she had taken the pills and wanted her to feel guilty but now regrets her actions. The patient tells you she didn't read the name on the bottle and threw the bottle away as she walked home. The patient also tells you she didn't see how many pills were in the bottle but thinks there were 20-30 of them. Several attempts to contact the patient's friend to try and clarify the identity of the pills are unsuccessful. The patient advises you she feels nauseated and has ringing in her ears. You also note the patient is hyperventilating. A blood gas sample is taken and is shown below:

      Parameter Result
      pH 7.49
      pO2 14.3 KPa
      pCO2 3.4 KPa
      HCO3- 25 mmol/L
      BE -1

      Which of the following best describes the acid base disturbance?

      Your Answer: Metabolic acidosis

      Correct Answer: Respiratory alkalosis

      Explanation:

      An elevated pH (normal range 7.34-7.45) suggests alkalosis. A low pCO2 (normal range 4.4-6.0 Kpa) indicates that the respiratory system is causing the alkalosis. The metabolic system, on the other hand, is not contributing to either alkalosis or acidosis as both the bicarbonate and base excess levels are within the normal ranges.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      130.2
      Seconds
  • Question 7 - A 14 year old female is brought to the emergency department by her...

    Incorrect

    • A 14 year old female is brought to the emergency department by her parents approximately 90 minutes after taking an overdose. The patient tells you she was at her friend's house and they got into an argument which ended with her friend telling her she was ending their friendship. The patient grabbed a bottle of pills from the bathroom and swallowed all of them before leaving. She didn't tell her friend she had taken the pills and wanted her to feel guilty but now regrets her actions. The patient tells you she didn't read the name on the bottle and threw the bottle away as she walked home. The patient also tells you she didn't see how many pills were in the bottle but thinks there were 20-30 of them. Several attempts to contact the patient's friend to try and clarify the identity of the pills are unsuccessful. The patient advises you she feels nauseated and has ringing in her ears. You also note the patient is hyperventilating. A blood gas sample is taken and is shown below:

      Parameter Result
      pH 7.49
      pO2 14.3 KPa
      pCO2 3.4 KPa
      HCO3- 25 mmol/L
      BE -1

      What is the likely causative agent?

      Your Answer: Amitriptyline

      Correct Answer: Aspirin

      Explanation:

      Tinnitus is often seen as an early indication of salicylate toxicity, which occurs when there is an excessive use of salicylate. Another common symptom is feeling nauseous and/or vomiting. In the initial stages of a salicylate overdose, individuals may experience respiratory alkalosis, which is caused by the direct stimulation of the respiratory centers in the medulla by salicylate. This leads to hyperventilation and the elimination of carbon dioxide, resulting in alkalosis. As the body metabolizes salicylate, a metabolic acidosis may develop.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      42.6
      Seconds
  • Question 8 - A 40-year-old man is brought to the Emergency Department by his wife after...

    Incorrect

    • A 40-year-old man is brought to the Emergency Department by his wife after taking an excessive amount of one of his prescribed medications. Upon further inquiry, you uncover that he has overdosed on quetiapine. You consult with your supervisor about the case, and she clarifies that the symptoms of this type of poisoning are caused by the blocking of central and peripheral acetylcholine receptors.
      What is one of the clinical effects that arises from the blockade of central acetylcholine receptors?

      Your Answer:

      Correct Answer: Tremor

      Explanation:

      Anticholinergic drugs work by blocking the effects of acetylcholine, a neurotransmitter, in both the central and peripheral nervous systems. These drugs are commonly used in clinical practice and include antihistamines, typical and atypical antipsychotics, anticonvulsants, antidepressants, antispasmodics, antiemetics, antiparkinsonian agents, antimuscarinics, and certain plants. When someone ingests an anticholinergic drug, they may experience a toxidrome, which is characterized by an agitated delirium and various signs of acetylcholine receptor blockade in the central and peripheral systems.

      The central effects of anticholinergic drugs result in an agitated delirium, which is marked by fluctuating mental status, confusion, restlessness, visual hallucinations, picking at objects in the air, mumbling, slurred speech, disruptive behavior, tremor, myoclonus, and in rare cases, coma or seizures. On the other hand, the peripheral effects can vary and may include dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 9 - A 25-year-old man is given a medication for a health condition during the...

    Incorrect

    • A 25-year-old man is given a medication for a health condition during the 2nd trimester of his partner's pregnancy. As a result, the newborn developed kernicterus and early closure of the ductus arteriosus.
      Which of the following medications is the most probable cause of these abnormalities?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      The use of low-dose aspirin during pregnancy is considered safe and can be used to manage recurrent miscarriage, clotting disorders, and pre-eclampsia. On the other hand, high-dose aspirin carries several risks, especially if used in the third trimester. These risks include delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus (a condition that affects the brain due to high levels of bilirubin). Additionally, there is a slight increase in the risk of first-trimester abortion if high-dose aspirin is used early in pregnancy.

      Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:

      Drug: ACE inhibitors (e.g. ramipril)
      Adverse effects: If given in the second and third trimester, ACE inhibitors can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Drug: Aminoglycosides (e.g. gentamicin)
      Adverse effects: Aminoglycosides can cause ototoxicity (damage to the ear) and deafness.

      Drug: Aspirin
      Adverse effects: High doses of aspirin can cause first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) have no significant associated risk.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 10 - A 30-year-old woman with a history of schizophrenia comes in with a side...

    Incorrect

    • A 30-year-old woman with a history of schizophrenia comes in with a side effect caused by the antipsychotic medication she is currently using.

      Which ONE statement about the side effects of antipsychotic drugs is accurate?

      Your Answer:

      Correct Answer: Haloperidol is the most common antipsychotic drug to cause extrapyramidal side effects

      Explanation:

      Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.

      Tardive dyskinesia, which involves rhythmic and involuntary movements of the tongue, face, and jaw, typically develops after long-term treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative drug, and treatment options are generally ineffective.

      Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to occur after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.

      Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.

      Elderly patients with dementia-related psychosis who are treated with haloperidol have an increased risk of mortality. This is believed to be due to a higher likelihood of experiencing cardiovascular events and infections such as pneumonia.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 11 - A young patient has developed a tremor and is experiencing nausea and vomiting...

    Incorrect

    • A young patient has developed a tremor and is experiencing nausea and vomiting as a result of taking a prescribed medication. Additionally, the patient has developed nephrogenic diabetes insipidus.
      Which of the following medications is most likely to be the cause of these symptoms?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      Lithium is a commonly prescribed medication for bipolar disorder, as it helps stabilize mood. The recommended therapeutic range for lithium levels is typically between 0.4 and 0.8 mmol/l, although this range may vary depending on the laboratory. For maintenance therapy and treatment in older individuals, the lower end of the range is usually targeted. Toxic effects of lithium are typically observed when levels exceed 1.5 mmol/l. It is important to monitor lithium levels one week after starting therapy and after any dosage adjustments.

      One potential side effect of lithium is the development of nephrogenic diabetes insipidus, a condition that affects the kidneys’ ability to concentrate urine. However, lithium does not cause diabetes mellitus. Another known side effect is hypothyroidism, which is a decrease in thyroid hormone production, but it does not lead to hyperthyroidism, an overactive thyroid.

      Signs of lithium toxicity include nausea, vomiting, diarrhea, tremors, ataxia (loss of coordination), confusion, increased muscle tone, clonus (repetitive, involuntary muscle contractions), nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is crucial to be aware of these symptoms and seek medical attention if they occur.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 12 - You assess a 42-year-old woman who has a background of schizophrenia. She was...

    Incorrect

    • You assess a 42-year-old woman who has a background of schizophrenia. She was initiated on an atypical antipsychotic drug a few months ago and has since experienced significant weight gain.
      Which SPECIFIC atypical antipsychotic medication is most likely to be accountable for her weight gain?

      Your Answer:

      Correct Answer: Clozapine

      Explanation:

      Clozapine is the atypical antipsychotic that is most likely to result in notable weight gain. Additionally, it is linked to the emergence of impaired glucose metabolism and metabolic syndrome.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 13 - A 30-year-old man has ingested an excessive amount of paracetamol. He consumed the...

    Incorrect

    • A 30-year-old man has ingested an excessive amount of paracetamol. He consumed the overdose 12 hours ago and is unsure of the number of tablets he has taken.
      Which of the following substances can be utilized as an antidote for paracetamol overdose?

      Your Answer:

      Correct Answer: Methionine

      Explanation:

      The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is an extremely effective antidote, but its effectiveness decreases quickly if administered more than a few hours after a significant ingestion. Ingestions that exceed 75 mg/kg are considered to be significant.

      For patients who decline treatment, methionine is a helpful alternative. It is taken orally in a dosage of 2.5 g every 4 hours, with a total dose of 10 g.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 14 - A 32-year-old woman is given a medication for a medical ailment during the...

    Incorrect

    • A 32-year-old woman is given a medication for a medical ailment during the first trimester of her pregnancy. As a result, the newborn experiences nasal hypoplasia, bone stippling, and bilateral optic atrophy.
      Which of the listed drugs is the probable culprit for these abnormalities?

      Your Answer:

      Correct Answer: Warfarin

      Explanation:

      During the first trimester of pregnancy, the use of warfarin can lead to a condition known as fetal warfarin syndrome. This condition is characterized by nasal hypoplasia, bone stippling, bilateral optic atrophy, and intellectual disability in the baby. However, if warfarin is taken during the second or third trimester, it can cause optic atrophy, cataracts, microcephaly, microphthalmia, intellectual disability, and both fetal and maternal hemorrhage.

      There are several other drugs that can have adverse effects during pregnancy. For example, ACE inhibitors like ramipril can cause hypoperfusion, renal failure, and the oligohydramnios sequence if taken during the second and third trimesters. Aminoglycosides such as gentamicin can lead to ototoxicity and deafness in the baby. High doses of aspirin can result in first trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses of aspirin (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines like diazepam, when taken late in pregnancy, can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if taken during the first trimester, can cause phalangeal abnormalities, while their use in the second and third trimesters can lead to fetal growth retardation. Carbamazepine can result in hemorrhagic disease of the newborn and neural tube defects. Chloramphenicol can cause gray baby syndrome. Corticosteroids, if taken during the first trimester, may cause orofacial clefts.

      Danazol, if taken during the first trimester, can cause masculinization of the female fetuses genitals. Finasteride should not be handled by pregnant women as crushed or broken tablets can be absorbed through the skin and affect male sex organ development. Haloperidol, if taken during the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the newborn.

      Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the baby. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations and spontaneous abortion.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 15 - A 3-year-old toddler is brought to the Emergency Department after ingesting a few...

    Incorrect

    • A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his mother's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable. The attending physician recommends giving a dose of activated charcoal. The child weighs 15 kg.
      What is the appropriate dosage of activated charcoal to administer in this case?

      Your Answer:

      Correct Answer: 20 g orally

      Explanation:

      Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.

      The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 16 - You are summoned to the resuscitation room to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation room to aid in the care of a 48-year-old woman who was saved from a residential fire. The patient has superficial partial thickness burns on the palms of her hands, which she sustained while attempting to open scorching door handles during her escape from the fire. The fire department rescued her from a bedroom filled with smoke. The paramedics inform you that the patient appeared lethargic at the scene. A blood gas sample is obtained. Which of the following findings would indicate a potential diagnosis of cyanide poisoning?

      Your Answer:

      Correct Answer: Lactate >10 mmol/L

      Explanation:

      Moderate to severe cyanide poisoning typically leads to a condition called high anion gap metabolic acidosis, characterized by elevated levels of lactate (>10 mmol/L). Cyanide toxicity can occur from inhaling smoke produced by burning materials such as plastics, wools, silk, and other natural and synthetic polymers, which can release hydrogen cyanide (HCN). Symptoms of cyanide poisoning include headaches, nausea, decreased consciousness or loss of consciousness, and seizures. Measuring cyanide levels is not immediately helpful in managing a patient suspected of cyanide toxicity. Cyanide binds to the ferric (Fe3+) ion of cytochrome oxidase, causing a condition known as histotoxic hypoxia and resulting in lactic acidosis. The presence of a high lactate level (>10) and a classic high anion gap metabolic acidosis should raise suspicion of cyanide poisoning in a clinician.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

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  • Question 17 - A 42 year old woman is brought into the emergency department by ambulance...

    Incorrect

    • A 42 year old woman is brought into the emergency department by ambulance after confessing to consuming a significant amount of amitriptyline following a breakup. The patient then experiences a seizure. Which medication is the most suitable for managing the seizure?

      Your Answer:

      Correct Answer: Diazepam

      Explanation:

      When it comes to managing seizures in cases of TCA overdose, benzodiazepines are considered the most effective treatment. Diazepam or lorazepam are commonly administered for this purpose. However, it’s important to note that lamotrigine and carbamazepine are typically used for preventing seizures rather than for immediate seizure control.

      Further Reading:

      Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.

      TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.

      Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.

      Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.

      There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.

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  • Question 18 - A 30-year-old woman with a history of bipolar disorder presents with a side...

    Incorrect

    • A 30-year-old woman with a history of bipolar disorder presents with a side effect from the mood stabilizer medication that she is currently taking.

      Which SINGLE statement regarding the side effects of mood stabilizer drugs is FALSE?

      Your Answer:

      Correct Answer: Dystonia tends to only appear after long-term treatment

      Explanation:

      Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.

      Tardive dyskinesia, which involves involuntary rhythmic movements of the tongue, face, and jaw, typically occurs after prolonged treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative medication, and treatment options are generally ineffective.

      Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to appear after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.

      Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.

      In individuals with renal impairment, there is an increased sensitivity of the brain to antipsychotic drugs, necessitating the use of reduced doses.

      Elderly patients with dementia-related psychosis who are treated with haloperidol face an elevated risk of mortality. This is believed to be due to an increased likelihood of cardiovascular events and infections such as pneumonia.

      Contraindications for the use of antipsychotic drugs include reduced consciousness or coma, central nervous system depression, and the presence of phaeochromocytoma.

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  • Question 19 - A 35-year-old man with a history of bipolar affective disorder presents with symptoms...

    Incorrect

    • A 35-year-old man with a history of bipolar affective disorder presents with symptoms suggestive of lithium toxicity.
      Which of the following symptoms is LEAST likely to be observed?

      Your Answer:

      Correct Answer: SIADH

      Explanation:

      SIADH is a medical condition that is not brought on by lithium toxicity. However, lithium toxicity does have its own distinct set of symptoms. These symptoms include nausea and vomiting, diarrhea, tremors, ataxia, confusion, increased muscle tone, clonus, nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is important to note that SIADH and lithium toxicity are separate conditions with their own unique characteristics.

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  • Question 20 - A 35-year-old woman is given a medication for a medical condition during her...

    Incorrect

    • A 35-year-old woman is given a medication for a medical condition during her pregnancy. As a result, the newborn experiences multiple significant birth defects, such as neural tube, craniofacial, and limb abnormalities.

      Which of the following medications is the most probable culprit for these anomalies?

      Your Answer:

      Correct Answer: Sodium valproate

      Explanation:

      Sodium valproate is considered the most high-risk anti-epileptic drug during pregnancy. A recent review found that up to 40% of children born to women who took sodium valproate while pregnant experienced some form of adverse effect. These effects include a 1.5% risk of neural tube defects and an increased risk of cardiac, craniofacial, and limb defects. Additionally, there is a significant risk of neurodevelopmental problems in childhood.

      Here is a list outlining the commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.

      Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose a significant risk.

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimester, they can lead to fetal growth retardation.

      Carbamazepine: This drug can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can result in gray baby syndrome.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.

      Danazol: If given in the first trimester, this drug can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol: If given in the first trimester, this drug may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Maternal bleeding and thrombocytopenia are potential adverse outcomes.

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  • Question 21 - A 42-year-old male patient with epilepsy complains of feeling down. You observe that...

    Incorrect

    • A 42-year-old male patient with epilepsy complains of feeling down. You observe that he has rough facial features, gum hypertrophy, and noticeable facial acne. Additionally, he exhibits an unsteady gait while walking.
      Which ONE anti-epileptic medication is most likely causing his symptoms?

      Your Answer:

      Correct Answer: Phenytoin

      Explanation:

      Phenytoin is a potent anti-epileptic drug that is no longer recommended as the initial treatment for generalized or partial epilepsy due to its toxic effects. Users often experience common symptoms such as ataxia, nystagmus, diplopia, tremor, and dysarthria. Additionally, other side effects may include depression, decreased cognitive abilities, coarse facial features, acne, gum enlargement, polyneuropathy, and blood disorders.

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  • Question 22 - A 25-year-old woman with a previous diagnosis of depression is admitted to the...

    Incorrect

    • A 25-year-old woman with a previous diagnosis of depression is admitted to the emergency department following an unintentional ingestion of amitriptyline tablets. Which toxidrome is commonly associated with an overdose of amitriptyline?

      Your Answer:

      Correct Answer: Anticholinergic

      Explanation:

      An overdose of Amitriptyline, a tricyclic antidepressant, leads to a toxic effect known as anticholinergic toxidrome. This occurs when the muscarinic acetylcholine receptors are blocked, causing the characteristic signs and symptoms associated with this condition.

      Further Reading:

      Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.

      TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.

      Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.

      Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.

      There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.

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  • Question 23 - A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose...

    Incorrect

    • A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose 45 minutes ago. He is currently showing no symptoms and is stable in terms of blood flow. The attending physician recommends administering a dose of activated charcoal.
      Which of the following substances or toxins is activated charcoal effective in decontaminating?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. It is produced by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then treating it with a zinc chloride solution to increase its concentration. This process creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This allows it to effectively inhibit the absorption of toxins by up to 50%.

      The usual dose of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to administer it within one hour of ingestion, and it may be repeated after one hour if necessary.

      However, there are certain situations where activated charcoal should not be used. These include cases where the patient is unconscious or in a coma, as there is a risk of aspiration. It should also be avoided if seizures are imminent, as there is a risk of aspiration. Additionally, if there is reduced gastrointestinal motility, activated charcoal should not be used to prevent the risk of obstruction.

      Activated charcoal is effective in treating overdose with certain drugs and toxins, such as aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in cases of overdose with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.

      There are potential adverse effects associated with the use of activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhalation of charcoal into the lungs), and impaired absorption of oral medications or antidotes.

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  • Question 24 - You conduct a medication review on a 68-year-old man with a history of...

    Incorrect

    • You conduct a medication review on a 68-year-old man with a history of angina. He is currently prescribed 10 mg bisoprolol once daily and GTN spray as needed. However, he continues to experience symptoms.
      Which ONE medication should be avoided in this patient?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Beta-blockers, like bisoprolol, and verapamil have a strong negative effect on the force of ventricular contraction. When these medications are taken together, they can significantly reduce ventricular contraction and lead to a slow heart rate, known as bradycardia. Additionally, the risk of developing AV block is increased. In certain situations, this combination can result in severe low blood pressure or even a complete absence of heart rhythm, known as asystole. Therefore, it is important to avoid using these medications together to prevent these potentially dangerous effects.

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  • Question 25 - A 35-year-old patient with a history of schizophrenia comes in with side effects...

    Incorrect

    • A 35-year-old patient with a history of schizophrenia comes in with side effects from a medication that he recently began taking for this condition. Upon examination, you observe that he is experiencing severe muscular rigidity, a decreased level of consciousness, and a body temperature of 40ºC.
      Which of the following medications is most likely causing these symptoms?

      Your Answer:

      Correct Answer: Chlorpromazine

      Explanation:

      First-generation antipsychotics, also known as conventional or typical antipsychotics, are potent blockers of dopamine D2 receptors. However, these drugs also have varying effects on other receptors such as serotonin type 2 (5-HT2), alpha1, histaminic, and muscarinic receptors.

      One of the major drawbacks of first-generation antipsychotics is their high incidence of extrapyramidal side effects. These include rigidity, bradykinesia, dystonias, tremor, akathisia, and tardive dyskinesia. Additionally, there is a rare but life-threatening reaction called neuroleptic malignant syndrome (NMS) that can occur with these medications. NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. It typically occurs shortly after starting or increasing the dose of a neuroleptic medication.

      In contrast, second-generation antipsychotics, also known as novel or atypical antipsychotics, have a lower risk of extrapyramidal side effects and NMS compared to their first-generation counterparts. However, they are associated with higher rates of metabolic effects and weight gain.

      It is important to differentiate serotonin syndrome from NMS as they share similar features. Serotonin syndrome is most commonly caused by serotonin-specific reuptake inhibitors.

      Here are some commonly encountered examples of first- and second-generation antipsychotics:

      First-generation:
      – Chlopromazine
      – Haloperidol
      – Fluphenazine
      – Trifluoperazine

      Second-generation:
      – Clozapine
      – Olanzapine
      – Quetiapine
      – Risperidone
      – Aripiprazole

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  • Question 26 - A 25-year-old man has had discoloured teeth since taking a medication in his...

    Incorrect

    • A 25-year-old man has had discoloured teeth since taking a medication in his youth. Upon examination, visible greyish-brown horizontal stripes can be observed across all of his teeth.
      Which SINGLE medication is most likely responsible for this?

      Your Answer:

      Correct Answer: Doxycycline

      Explanation:

      Tetracycline antibiotics, such as tetracycline and doxycycline, have the potential to cause staining on permanent teeth while they are still forming beneath the gum line. This staining occurs when the drug becomes calcified within the tooth during its development. It is important to note that children are vulnerable to tetracycline-related tooth staining until approximately the age of 8. Additionally, pregnant women should avoid taking tetracycline as it can affect the development of teeth in the unborn child.

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  • Question 27 - A 25-year-old male is brought to the emergency department after intentionally ingesting 70...

    Incorrect

    • A 25-year-old male is brought to the emergency department after intentionally ingesting 70 amitriptyline tablets. You administer activated charcoal to the patient. Which other medication, listed as an antidote on the RCEM/NPIS, can be used to treat tricyclic overdose?

      Your Answer:

      Correct Answer: Sodium bicarbonate

      Explanation:

      In the latest guideline published in 2021 by RCEM and NPIS regarding antidote availability for emergency departments, it is emphasized that immediate access to sodium bicarbonate is essential for treating TCA overdose. It is worth noting that previous versions of the guideline included glucagon as a recommended treatment for TCA overdose, but this reference has been omitted in the latest edition.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

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  • Question 28 - A 28-year-old man is brought in by ambulance. He is unconscious and was...

    Incorrect

    • A 28-year-old man is brought in by ambulance. He is unconscious and was discovered next to an empty container of antifreeze by his girlfriend.
      What type of acid-base imbalance would you anticipate in a patient with ethylene glycol poisoning?

      Your Answer:

      Correct Answer: Raised anion gap metabolic acidosis

      Explanation:

      The following list provides a summary of common causes for different acid-base disorders.

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

      Metabolic alkalosis can be caused by vomiting, potassium depletion (often due to diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can occur due to lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction) or ketoacidosis (such as in diabetes, starvation, or alcohol excess). It can also be a result of renal failure or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Metabolic acidosis with a normal anion gap can be caused by conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

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  • Question 29 - A 72-year-old woman with a history of hypertension and kidney disease is prescribed...

    Incorrect

    • A 72-year-old woman with a history of hypertension and kidney disease is prescribed a new diuretic medication. Upon reviewing her blood test results, you observe the presence of hyperkalemia.
      Which of the following diuretics is most likely to be the cause?

      Your Answer:

      Correct Answer: Spironolactone

      Explanation:

      Spironolactone is a medication used to treat conditions such as congestive cardiac failure, hypertension, hepatic cirrhosis with ascites and edema, and Conn’s syndrome. It functions as a competitive aldosterone receptor antagonist, primarily working in the distal convoluted tubule. In this area, it hinders the reabsorption of sodium ions and enhances the reabsorption of potassium ions. Spironolactone is commonly known as a potassium-sparing diuretic.

      The main side effect of spironolactone is hyperkalemia, particularly when renal impairment is present. In severe cases, hyperkalemia can be life-threatening. Additionally, there is a notable occurrence of gastrointestinal disturbances, with nausea and vomiting being the most common. Women may experience menstrual disturbances, while men may develop gynecomastia, both of which are attributed to the antiandrogenic effects of spironolactone.

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  • Question 30 - A 68-year-old man complains of chest pain and difficulty breathing. He was recently...

    Incorrect

    • A 68-year-old man complains of chest pain and difficulty breathing. He was recently prescribed bendroflumethiazide.
      What is the most frequently observed side effect of bendroflumethiazide?

      Your Answer:

      Correct Answer: Impaired glucose tolerance

      Explanation:

      Common side effects of bendroflumethiazide include postural hypotension, electrolyte disturbance (such as hypokalaemia, hyponatraemia, and hypercalcaemia), impaired glucose tolerance, gout, impotence, and fatigue. Rare side effects of bendroflumethiazide include thrombocytopenia, agranulocytosis, photosensitive rash, pancreatitis, and renal failure.

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