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  • Question 1 - ACE inhibitors can cause cough as a side effect. Which of the following...

    Correct

    • ACE inhibitors can cause cough as a side effect. Which of the following statements is true about the cause of this cough? Please select one option.

      Your Answer: They affect the breakdown of bradykinin within the lungs

      Explanation:

      The Effects of ACE Inhibitors on the Lungs

      ACE inhibitors are a class of medications commonly used to treat hypertension and heart failure. While they are generally well-tolerated, they can have some effects on the lungs. Here are some key points to keep in mind:

      – ACE inhibitors can increase the concentration of bradykinin within the lungs, which can lead to a persistent dry cough in some patients.
      – Unlike beta blockers, ACE inhibitors do not cause bronchospasm. In fact, they may be a good choice for patients with asthma or other respiratory conditions.
      – Dysgeusia, or a metallic taste in the mouth, is a possible side effect of ACE inhibitors. This is more common with captopril than with other drugs in this class.
      – ACE inhibitors do not increase bronchial mucus secretion.
      – While ACE inhibitors do cause vasodilation, which can lower blood pressure, they are not associated with pulmonary congestion.

      Overall, ACE inhibitors are generally safe and effective medications for treating hypertension and heart failure. However, patients should be aware of these potential effects on the lungs and discuss any concerns with their healthcare provider.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 2 - A 30-year-old woman presents with a productive cough, weight loss, and night sweats,...

    Correct

    • A 30-year-old woman presents with a productive cough, weight loss, and night sweats, four months after returning from India. She is diagnosed with pulmonary tuberculosis and started on appropriate antibiotics. However, six weeks into her treatment, she experiences numbness and tingling in her distal extremities, a known side effect of isoniazid. What medication should have been prescribed alongside her antibiotic regimen to minimize this side effect?

      Your Answer: Pyridoxine

      Explanation:

      To treat active tuberculosis, isoniazid is often prescribed alongside other antibiotics such as rifampicin, ethambutol, or pyrazinamide. However, it is important to note that isoniazid alone does not protect against peripheral neuropathy, a potential side effect of tuberculosis treatment.

      Rifampicin is an antibiotic that can increase the rate of B6 excretion, which may lead to a deficiency in some individuals.

      Ethambutol is another antibiotic used to treat tuberculosis, but it can cause a loss of visual acuity and color blindness.

      Prednisolone is typically only prescribed for meningeal or pericardial tuberculosis and can cause side effects such as mood changes, weight gain, and immunosuppression.

      Pyrazinamide is another antibiotic used to treat tuberculosis, but it can cause liver toxicity.

      Side-Effects and Mechanism of Action of Tuberculosis Drugs

      Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

      Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

      In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 3 - A 65-year-old man presents to the emergency department with severe chest pain that...

    Correct

    • A 65-year-old man presents to the emergency department with severe chest pain that started an hour ago and is radiating to his left arm. He has a history of type two diabetes and has smoked 50 packs of cigarettes in his lifetime. An ECG shows ST-elevation in leads V2-4, indicating a STEMI. As the healthcare provider, you decide to initiate treatment and give the patient 300mg of aspirin orally. What is the mechanism of action of this medication?

      Your Answer: Non-reversible COX 1 and 2 inhibitor

      Explanation:

      Aspirin irreversibly inhibits both COX 1 and COX 2, preventing the conversion of arachidonic acid into prostaglandin, prostacyclin, and thromboxane. Thromboxane A2 is responsible for platelet aggregation and vasoconstriction. In cases of acute coronary syndrome, high doses of aspirin are administered to prevent the enlargement of the coronary thrombus.

      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
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  • Question 4 - A 65-year-old woman comes to her doctor complaining of dysuria and increased urinary...

    Correct

    • A 65-year-old woman comes to her doctor complaining of dysuria and increased urinary frequency. She is in good health otherwise and does not show any signs of sepsis. During a urine dip test at the doctor's office, blood, leukocytes, protein, and nitrites are detected. The patient has a medical history of asthma, which she manages with salbutamol and beclomethasone inhalers, hypertension, which she treats with amlodipine 10mg daily and ramipril 5mg daily, and stage 3 chronic kidney disease. Which antibiotic should be avoided when treating this patient's urinary tract infection?

      Your Answer: Nitrofurantoin

      Explanation:

      When prescribing antibiotics for patients with chronic kidney disease (CKD), it is important to consider the patient’s level of renal function. Nitrofurantoin, an antibiotic commonly used to treat urinary tract infections, should be avoided in patients with CKD stage 3 or higher due to the risk of treatment failure and potential side effects caused by drug accumulation. Nitrofurantoin requires adequate glomerular filtration to be effective, and an eGFR of less than 40-60ml/min means the drug is unlikely to work. Additionally, nitrofurantoin can cause side effects such as peripheral neuropathy, hepatotoxicity, and pulmonary reactions and fibrosis, particularly in patients with impaired renal function. Amoxicillin and co-amoxiclav are safer options for patients with CKD, although dose reduction may be necessary in severe cases. Ciprofloxacin also requires dose reduction in CKD to avoid crystalluria. Patients taking nitrofurantoin should be aware that the drug may cause urine discoloration, and it is generally safe to use during pregnancy except at full term.

      Prescribing for Patients with Renal Failure

      When it comes to prescribing medication for patients with renal failure, it is important to be aware of which drugs to avoid and which ones require dose adjustment. Antibiotics such as tetracycline and nitrofurantoin should be avoided, as well as NSAIDs, lithium, and metformin. These drugs can potentially harm the kidneys or accumulate in the body, leading to toxicity.

      On the other hand, some drugs can be used with dose adjustment. Antibiotics like penicillins, cephalosporins, vancomycin, gentamicin, and streptomycin, as well as medications like digoxin, atenolol, methotrexate, sulphonylureas, furosemide, and opioids, may require a lower dose in patients with chronic kidney disease. It is important to monitor these patients closely and adjust the dose as needed.

      Finally, there are some drugs that are relatively safe to use in patients with renal failure. Antibiotics like erythromycin and rifampicin, as well as medications like diazepam and warfarin, can sometimes be used at normal doses depending on the degree of chronic kidney disease. However, it is still important to monitor these patients closely and adjust the dose if necessary.

      In summary, prescribing medication for patients with renal failure requires careful consideration of the potential risks and benefits of each drug. By avoiding certain drugs, adjusting doses of others, and monitoring patients closely, healthcare providers can help ensure the safety and effectiveness of treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 5 - A 32-year-old woman with epilepsy complains of acne and bleeding gums. Which medication...

    Correct

    • A 32-year-old woman with epilepsy complains of acne and bleeding gums. Which medication is most likely responsible for these symptoms?

      Your Answer: Phenytoin

      Explanation:

      Side Effects of Common Anticonvulsants

      Anticonvulsants are medications used to treat seizures and epilepsy. However, they commonly have side effects that patients should be aware of. Here are some of the common or more serious side effects reported for some of the most commonly prescribed anticonvulsants:

      Phenytoin: This medication can cause paraesthesia, gingival hypertrophy, tiredness, acne, hirsutism, coarsening of facial appearance, peripheral neuropathy, Steven-Johnson syndrome, and blood dyscrasias (such as aplastic anaemia and megaloblastic anaemia).

      Sodium valproate (Epilim®): Side effects of this medication may include weight gain, thrombocytopenia, transient hair loss, aggression and behavioural changes, ataxia and tremors.

      Carbamazepine: Dry mouth, fatigue, hyponatraemia, blood dyscrasia (such as aplastic anaemia), thrombocytopenia, haemolytic anaemia, eosinophilia, dermatitis, gynaecomastia, male infertility, hepatitis, and restlessness are all possible side effects of this medication.

      Lamotrigine (Lamictal®): Skin rash and hypersensitivity, blurred vision, dizziness, sleep disturbance, and joint pains are some of the side effects that may occur with this medication.

      Levetiracetam (Keppra®): Weight change and anorexia, abdominal pains, nausea, diarrhoea, and anxiety are all possible side effects of this medication.

      It’s important to note that gingival hypertrophy and tenderness are common effects of phenytoin, but not the other medications listed. Patients taking phenytoin should be encouraged to maintain good oral hygiene. Overall, patients should be aware of the potential side effects of their anticonvulsant medication and discuss any concerns with their healthcare provider.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 6 - A 56-year-old man with hypertension presents to the clinic with a complaint of...

    Correct

    • A 56-year-old man with hypertension presents to the clinic with a complaint of ankle swelling that has developed over the past two months. Which medication is the most probable cause of this symptom?

      Your Answer: Amlodipine

      Explanation:

      Calcium channel blockers may cause adverse effects such as headaches, flushing, and swelling in the ankles.

      Understanding Calcium Channel Blockers

      Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.

      Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.

      On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.

      In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 7 - A 25-year-old student is brought to the clinic by his companions as he...

    Correct

    • A 25-year-old student is brought to the clinic by his companions as he appears confused. They mention that he has been experiencing headaches for the past few weeks. During the examination, he has a low-grade fever and his mucosa is unusually pink. What is the probable diagnosis?

      Your Answer: Carbon monoxide poisoning

      Explanation:

      Typical symptoms of carbon monoxide poisoning include confusion and pink mucosae, with a low-grade fever being present in only a small number of cases.

      Understanding Carbon Monoxide Poisoning

      Carbon monoxide poisoning occurs when carbon monoxide, a toxic gas, is inhaled and binds to haemoglobin and myoglobin in the body, resulting in tissue hypoxia. This leads to a left-shift of the oxygen dissociation curve, causing a decrease in oxygen saturation of haemoglobin. In the UK, there are approximately 50 deaths per year from accidental carbon monoxide poisoning.

      Symptoms of carbon monoxide toxicity include headache, nausea and vomiting, vertigo, confusion, and subjective weakness. Severe toxicity can result in pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and even death.

      To diagnose carbon monoxide poisoning, pulse oximetry may not be reliable due to similarities between oxyhaemoglobin and carboxyhaemoglobin. Therefore, a venous or arterial blood gas should be taken to measure carboxyhaemoglobin levels. Non-smokers typically have levels below 3%, while smokers have levels below 10%. Symptomatic patients have levels between 10-30%, and severe toxicity is indicated by levels above 30%. An ECG may also be useful to check for cardiac ischaemia.

      In the emergency department, patients with suspected carbon monoxide poisoning should receive 100% high-flow oxygen via a non-rebreather mask. This decreases the half-life of carboxyhemoglobin and should be administered as soon as possible, with treatment continuing for a minimum of six hours. Target oxygen saturations are 100%, and treatment is generally continued until all symptoms have resolved. For more severe cases, hyperbaric oxygen therapy may be considered, as it has been shown to have better long-term outcomes than standard oxygen therapy. Indications for hyperbaric oxygen therapy include loss of consciousness, neurological signs other than headache, myocardial ischaemia or arrhythmia, and pregnancy.

      Overall, understanding the pathophysiology, symptoms, and management of carbon monoxide poisoning is crucial in preventing and treating this potentially deadly condition.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 8 - A 32-year-old man who drinks 6 cans of soda a day would like...

    Incorrect

    • A 32-year-old man who drinks 6 cans of soda a day would like to stop his habit. He is considering taking varenicline (Champix®) to help him quit smoking and wants to learn about its potential side effects.
      What is the most common side effect associated with orlistat?

      Your Answer: Galactorrhoea

      Correct Answer: Abnormal dreams

      Explanation:

      Understanding the Side Effects of Varenicline

      Varenicline is a medication commonly used to help people quit smoking. However, like any medication, it can have side effects. One of the most common side effects is abnormal dreams and sleep disorders. While eye pain, lacrimation, and visual disturbances can occur, increased intraocular pressure is not a known side effect. Menorrhagia and vaginal discharge may occur, but amenorrhoea and galactorrhoea are not associated with varenicline. It’s important to note that nicotine withdrawal symptoms can occur as early as 4 hours after the last cigarette and peak around 48 hours after quitting. These symptoms can include headache, anxiety, tobacco cravings, appetite changes, nausea, paraesthesiae, sleep disturbance, sweating, and low mood.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 9 - A 82-year-old man and his daughter visit you for a medication review. The...

    Correct

    • A 82-year-old man and his daughter visit you for a medication review. The patient has been experiencing memory loss and was diagnosed with Alzheimer's dementia at a memory clinic three months ago. He also has a medical history of osteoporosis, ischaemic heart disease, and atrial fibrillation. Considering his dementia, which medication should you contemplate discontinuing?

      Your Answer: Amitriptyline

      Explanation:

      Dementia has several causes, most of which are irreversible and progressive. Although medications can slow down the progression, healthcare providers must ensure that their patients are not taking drugs that could exacerbate the condition. The STOPP-START Criteria (Gallagher et al., 2008) provides guidelines for withdrawing medications that may be harmful to the elderly. For instance, tricyclic antidepressants should not be prescribed to patients with dementia as they can worsen cognitive impairment.

      Understanding Dementia: Features and Management

      Dementia is a condition that affects a significant number of people in the UK, with Alzheimer’s disease being the most common cause followed by vascular and Lewy body dementia. However, diagnosing dementia can be challenging and often delayed. To aid in the assessment of dementia, NICE recommends the use of cognitive screening tools such as the 10-point cognitive screener (10-CS) and the 6-Item cognitive impairment test (6CIT) in non-specialist settings. On the other hand, assessment tools such as the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG), and the mini-mental state examination (MMSE) are not recommended for non-specialist settings.

      In primary care, blood screening is usually conducted to exclude reversible causes of dementia such as hypothyroidism. NICE recommends several tests including FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12, and folate levels. Patients are often referred to old-age psychiatrists working in memory clinics for further management. In secondary care, neuroimaging is performed to exclude other reversible conditions and provide information on the aetiology of dementia to guide prognosis and management. The 2011 NICE guidelines state that structural imaging is essential in the investigation of dementia.

      In summary, dementia is a complex condition that requires careful assessment and management. The use of appropriate screening tools and tests can aid in the diagnosis and management of dementia, while neuroimaging can provide valuable information on the underlying causes of the condition.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 10 - You are contemplating prescribing mefloquine as a prophylaxis for malaria for a 26-year-old...

    Incorrect

    • You are contemplating prescribing mefloquine as a prophylaxis for malaria for a 26-year-old female. What is the most crucial contraindication to keep in mind?

      Your Answer: G6PD deficiency

      Correct Answer: A history of anxiety or depression

      Explanation:

      Strengthened Warnings on the Neuropsychiatric Side-Effects of Mefloquine

      Mefloquine, also known as Lariam, is a medication used for the prevention and treatment of certain types of malaria. However, there has been a long-standing concern about its potential neuropsychiatric side-effects. A recent review has led to strengthened warnings about the risks associated with mefloquine.

      Patients taking mefloquine may experience side-effects such as nightmares or anxiety, which could be a warning sign of a more serious neuropsychiatric event. There have been reports of suicide and deliberate self-harm in patients taking mefloquine. Adverse reactions may also continue for several months due to the long half-life of the medication.

      It is important to note that mefloquine should not be used in patients with a history of anxiety, depression, schizophrenia, or other psychiatric disorders. If patients experience any neuropsychiatric side-effects while taking mefloquine, they should stop taking the medication and seek medical advice. These strengthened warnings aim to ensure that patients are fully informed about the potential risks associated with mefloquine.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 11 - A 61-year-old man with a history of type 2 diabetes mellitus and benign...

    Incorrect

    • A 61-year-old man with a history of type 2 diabetes mellitus and benign prostatic hypertrophy experiences urinary retention and an acute kidney injury. Which medication should be discontinued?

      Your Answer: Atenolol

      Correct Answer: Metformin

      Explanation:

      Due to the risk of lactic acidosis, metformin should be discontinued as the patient has developed an acute kidney injury. Additionally, in the future, it may be necessary to discontinue paroxetine as SSRIs can exacerbate urinary retention.

      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
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  • Question 12 - A 65-year-old woman is admitted to hospital with community-acquired pneumonia. She has developed...

    Correct

    • A 65-year-old woman is admitted to hospital with community-acquired pneumonia. She has developed acute kidney injury. Her blood results show the following:
      Test Result Reference range
      Potassium (K) (mmol/l) 6.0 3.5-5.3
      Creatine (Cr) (μmol/l) 220
      Male: 80-110
      Female: 70-100
      Which of the following of her medications should be stopped immediately?

      Your Answer: Ramipril

      Explanation:

      Medication and Renal Impairment: Considerations and Dose Adjustments

      When prescribing medication for patients with renal impairment, it is important to consider the potential for inducing or worsening kidney damage. Here are some considerations and dose adjustments for commonly prescribed medications:

      Ramipril: This ACE inhibitor has the potential to cause hypotension, which can lead to impaired kidney function. In patients with stable renal impairment, a maximum daily dose of 5 mg can be considered. The initial dose should not exceed 1.25 mg daily if eGFR is <30 ml/min per 1.73 m2. Bisoprolol: This medication is not associated with inducing or worsening kidney damage. However, the dose should be reduced if eGFR is lower than 20 ml/min per 1.73 m2 (maximum 10 mg daily). Paracetamol: At therapeutic doses, paracetamol is not associated with kidney damage. However, in overdose, it can cause renal damage. The minimum interval between doses should be six hours if eGFR is <30 ml/min per 1.73 m2. Fluticasone with salmeterol: Neither component of this inhaler is associated with kidney damage and does not require dose adjustment in patients with renal disease. Simvastatin: Statins should be used with caution in patients with renal impairment, as the likelihood of muscle toxicity increases with higher doses. Doses >10 mg daily should be used with caution if eGFR is lower than 30 ml/min per 1.73 m2.

      In summary, medication dosing and selection should be carefully considered in patients with renal impairment to avoid potential kidney damage and ensure optimal therapeutic outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 13 - A patient in her late 60s is hospitalized with digoxin toxicity. Which of...

    Incorrect

    • A patient in her late 60s is hospitalized with digoxin toxicity. Which of her medications is the most probable cause of this condition?

      Your Answer: Doxycycline

      Correct Answer: Diltiazem

      Explanation:

      The use of diltiazem can lead to the development of digoxin toxicity.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 14 - What is the most accurate statement regarding the use of radioactive iodine (131I)...

    Incorrect

    • What is the most accurate statement regarding the use of radioactive iodine (131I) for treating thyrotoxicosis?

      Your Answer: There is hypoparathyroidism secondary to beta-emissions and ablation of the parathyroid gland occurs in 30% of cases.

      Correct Answer: It is not associated with an increased incidence of late leukaemia.

      Explanation:

      Radioactive Iodine (131I) Treatment for Hyperthyroidism: Uses and Potential Complications

      Radioactive iodine (131I) is a commonly used treatment for hyperthyroidism, particularly in cases of toxic nodular hyperthyroidism and Graves’ disease. It works by inducing DNA damage in the thyroid gland, leading to the death of thyroid cells. This treatment is typically administered orally as a capsule or solution, and a standard dosage of 10 mCi is often used. However, the dosage may be increased if necessary, especially in cases of multinodular goitre.

      While 131I treatment is generally safe and effective, there are potential complications to be aware of. For example, it should not be administered to pregnant women, as it can cross the placenta and affect the thyroid gland of the fetus. Women should avoid becoming pregnant for at least six months after treatment, and men should not father children for at least four months after treatment. Additionally, there is a risk of hypoparathyroidism, which occurs in about 30% of cases and typically has a latency period of more than a decade.

      It is important to note that 131I treatment is not recommended for patients with active Graves’ ophthalmopathy, as it may cause progression of the condition. However, early treatment with levothyroxine may help reduce this risk. On the other hand, rapid regression of exophthalmos is expected in almost all cases within the first three months of treatment.

      Overall, 131I treatment is a safe and effective option for many patients with hyperthyroidism. However, it is important to discuss potential risks and benefits with a healthcare provider before undergoing this treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 15 - 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
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  • Question 16 - As a foundation doctor on the neonatal ward, you are updating a prescription...

    Correct

    • As a foundation doctor on the neonatal ward, you are updating a prescription chart for a premature baby born at twenty-six weeks. While reviewing the chart, you come across sildenafil. Can you explain the purpose of sildenafil in neonatal care?

      Your Answer: Treating pulmonary hypertension

      Explanation:

      Sildenafil, also known as Viagra, is typically used to treat erectile dysfunction in adults. However, it can also be used to treat pulmonary hypertension in neonates. The appropriate method for calming a distressed neonate depends on the underlying cause, which is often related to respiratory distress or pain. Gaviscon and ranitidine are sometimes used to treat gastro-oesophageal reflux, although this is not an approved use. Caffeine is sometimes used to help wean a neonate off a ventilator.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 17 - A 7-month-old child has sensorineural deafness and a ventricular septal defect. Her mother...

    Correct

    • A 7-month-old child has sensorineural deafness and a ventricular septal defect. Her mother gives a history of medication for acne, which was stopped when she realised she was pregnant.
      Which of the following drugs is most likely to cause these defects?

      Your Answer: Isotretinoin

      Explanation:

      Acne Medications: Risks and Benefits

      Acne is a common skin condition that affects many people, and there are several medications available to treat it. However, each medication has its own risks and benefits that should be carefully considered before use. Here are some important things to know about the most commonly used acne medications:

      Isotretinoin: This medication is highly effective against acne, but it is also highly teratogenic, meaning it can cause birth defects if taken by women during pregnancy or even a short time before conception. Women who take isotretinoin must use effective contraception before, during, and after treatment, and must be monitored closely for pregnancy. Each prescription is limited to a 30-day supply and must be dispensed within 7 days of the prescription date.

      Cyproterone acetate: This medication is an antiandrogen and progestogen used to treat androgen-related conditions such as acne. Its most serious side effect is direct hepatic toxicity, but it is not known to be teratogenic.

      Oxytetracycline and minocycline: These broad-spectrum tetracycline antibiotics are commonly used to treat acne, but they should be avoided during pregnancy due to potential effects on skeletal development. Minocycline has a broader spectrum than oxytetracycline, but both can cause gastrointestinal and photosensitive allergic reactions.

      Clindamycin: This antibiotic can also be used to treat acne, but it can cause diarrhea and rare but serious side effects such as Stevens-Johnson syndrome and toxic epidermal necrolysis. However, it is safe for use during pregnancy.

      In conclusion, while acne medications can be effective in treating the condition, it is important to carefully consider the risks and benefits of each medication before use, especially for women who are pregnant or may become pregnant.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 18 - 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
      7
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  • Question 19 - You are conducting a medication review on an 80-year-old man who is taking...

    Correct

    • You are conducting a medication review on an 80-year-old man who is taking aspirin, verapamil, allopurinol, and co-codamol. Which medication should be avoided if prescribed concurrently with the current medications?

      Your Answer: Atenolol

      Explanation:

      The combination of beta-blockers and verapamil has the potential to cause severe bradycardia and asystole.

      Beta-blockers are a class of drugs that are primarily used to manage cardiovascular disorders. They have a wide range of indications, including angina, post-myocardial infarction, heart failure, arrhythmias, hypertension, thyrotoxicosis, migraine prophylaxis, and anxiety. Beta-blockers were previously avoided in heart failure, but recent evidence suggests that certain beta-blockers can improve both symptoms and mortality. They have also replaced digoxin as the rate-control drug of choice in atrial fibrillation. However, their role in reducing stroke and myocardial infarction has diminished in recent years due to a lack of evidence. Examples of beta-blockers include atenolol and propranolol, which was one of the first beta-blockers to be developed and is lipid soluble, allowing it to cross the blood-brain barrier.

      Like all drugs, beta-blockers have side-effects, including bronchospasm, cold peripheries, fatigue, sleep disturbances (including nightmares), and erectile dysfunction. They are contraindicated in uncontrolled heart failure, asthma, sick sinus syndrome, and concurrent use with verapamil, which may precipitate severe bradycardia.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 20 - A senior citizen asks you about St John's wort.
    Which of the following statements...

    Correct

    • A senior citizen asks you about St John's wort.
      Which of the following statements about its action is true?

      Your Answer: It can be at least as effective as placebo in depression

      Explanation:

      St John’s Wort: A Natural Remedy for Depression with Limitations

      St John’s wort is a herbal supplement that has been studied for its potential to treat depression. While some studies have shown it to be as effective as standard antidepressants and superior to placebo, its place in the treatment of depression is still uncertain due to limitations in the available evidence base. St John’s wort works by inhibiting the reuptake of certain neurotransmitters, but it can also upregulate liver enzymes and cause liver damage with high-level, long-term use. Despite its potential benefits, it should be avoided in women on contraceptive pills and can interact with other medications such as digoxin and warfarin. While it is widely prescribed in the UK, it is not available on prescription and should be used with caution.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 21 - A 42-year-old woman is admitted to hospital with left-sided weakness. She takes warfarin...

    Incorrect

    • A 42-year-old woman is admitted to hospital with left-sided weakness. She takes warfarin for deep vein thrombosis and her international normalised ratio (INR) is usually in the therapeutic range of 2–3. Her INR is measured on admission to hospital and is 1.1. She has recently started a new medication.
      Which of the following medications is this patient most likely to have recently started?

      Your Answer: Erythromycin

      Correct Answer: Carbamazepine

      Explanation:

      Cytochrome P450 Enzyme Inducers and Inhibitors and their Effects on Warfarin Metabolism

      Warfarin is a commonly used anticoagulant medication that requires careful monitoring of the international normalized ratio (INR) to ensure therapeutic efficacy and prevent bleeding complications. However, certain medications can affect the metabolism of warfarin by inducing or inhibiting cytochrome P450 enzymes in the liver.

      One example of a cytochrome P450 enzyme inducer is carbamazepine, which can increase warfarin metabolism and reduce its effectiveness. This can result in a decreased INR and potentially increase the risk of blood clots. On the other hand, cytochrome P450 enzyme inhibitors such as cimetidine, erythromycin, ketoconazole, and sulfamethoxazole can reduce warfarin metabolism and increase its potency, leading to an increased INR and higher risk of bleeding complications.

      To remember these medications, a helpful mnemonic is PC BRAS for enzyme inducers and SICKFACES.COM for enzyme inhibitors. Patients starting these medications should be closely monitored for changes in their INR and warfarin dosages may need to be adjusted accordingly.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 22 - A 58-year-old man presents to his doctor with concerns about his chest. He...

    Correct

    • A 58-year-old man presents to his doctor with concerns about his chest. He feels embarrassed and believes that he is developing breast tissue. Upon examination, bilateral gynaecomastia is the only abnormal finding. The patient has a medical history of hypertension, high cholesterol, type 2 diabetes, and benign prostatic hyperplasia. Which medication is the most probable cause of this condition?

      Your Answer: Finasteride

      Explanation:

      Gynaecomastia in males can have various underlying causes, some of which may be serious, such as endocrine disorders, liver failure, kidney failure, or malignancy. Additionally, medication-related causes should be considered, as in the case of this patient who was taking finasteride, which is known to cause gynaecomastia. Finasteride functions by inhibiting 5-alpha-reductase, which reduces dihydrotestosterone production and shrinks the prostate. However, it can also lead to side effects such as sexual dysfunction and gynaecomastia.

      Understanding Finasteride: Its Uses and Side Effects

      Finasteride is a medication that works by inhibiting the activity of 5 alpha-reductase, an enzyme responsible for converting testosterone into dihydrotestosterone. This drug is commonly used to treat benign prostatic hyperplasia and male-pattern baldness.

      However, like any medication, finasteride has its own set of adverse effects. Some of the most common side effects include impotence, decreased libido, ejaculation disorders, gynaecomastia, and breast tenderness. It is important to note that finasteride can also cause decreased levels of serum prostate-specific antigen.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 23 - A 65-year-old woman with atrial fibrillation and hypertension is prescribed amiodarone.
    Which of the...

    Incorrect

    • A 65-year-old woman with atrial fibrillation and hypertension is prescribed amiodarone.
      Which of the following blood tests is crucial for monitoring amiodarone use?

      Your Answer: TFTs (monthly)

      Correct Answer: LFTs, TFTs (6-monthly)

      Explanation:

      Drug Monitoring in Primary Care

      Drug monitoring is an essential aspect of patient care, particularly for medications with potential side effects. In primary care, drug monitoring is becoming increasingly common, especially for patients managed through shared-care with specialty care.

      Amiodarone is a medication that requires ongoing monitoring for potential side effects, including pulmonary toxicity, thyroid dysfunction, abnormal liver function, and corneal microdeposits. Monitoring includes checking LFTs and TFTs every six months, a chest radiograph and ECG every 12 months, and an annual ophthalmological examination.

      Azathioprine requires monitoring of FBC and LFTs every three months, while lithium requires monitoring of U&Es, TFTs, and lithium plasma levels every six months. Methotrexate requires monitoring of FBC, U&Es, and LFTs every two to three months.

      In conclusion, drug monitoring is crucial in primary care to ensure patient safety and prevent potential adverse effects. Regular monitoring of blood tests can help detect any changes in a patient’s health and allow for timely intervention.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 24 - A 42-year-old G3P0+2 woman comes for a routine antenatal check at 14 weeks...

    Correct

    • A 42-year-old G3P0+2 woman comes for a routine antenatal check at 14 weeks gestation to her general practitioner. She has a medical history of treatment-resistant schizophrenia, epilepsy, hypertension, antiphospholipid syndrome, and dyslipidemia. Her current medications include lamotrigine, labetalol, atorvastatin, low molecular weight heparin, and clozapine. Additionally, she has started taking nitrofurantoin for a urinary tract infection. What medication should be avoided in this patient?

      Your Answer: Atorvastatin

      Explanation:

      Statin therapy is not recommended during pregnancy

      The correct statement is that all statins, including atorvastatin, are not recommended during pregnancy due to potential risks to the developing fetus. While there is no conclusive evidence of teratogenicity, there have been reports of adverse outcomes such as intrauterine growth restriction and fetal demise in women taking statins during the first trimester. Lipophilic statins like atorvastatin can cross the placenta and reach similar concentrations in both the mother and fetus.

      Clozapine is not a contraindication during pregnancy, as it is an atypical antipsychotic used to treat schizophrenia that is unresponsive to other medications. While caution is advised when using clozapine during pregnancy, it is not considered a contraindication.

      Lamotrigine is also not contraindicated during pregnancy, as it is generally considered safe for use in pregnant women. Unlike many other antiepileptic drugs, lamotrigine has not been associated with an increased risk of congenital malformations.

      Low-molecular-weight-heparin is also not contraindicated during pregnancy, and is often prescribed for women with antiphospholipid syndrome to prevent blood clots. This medication does not cross the placenta and is considered safe for use during pregnancy.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 25 - A 58-year-old man was prescribed medication for shooting pains on the side of...

    Correct

    • A 58-year-old man was prescribed medication for shooting pains on the side of his face. He has been taking the medication without any issues for a few weeks but suddenly complains of a sore throat and bruising.
      Which of the following medications is the most probable cause of these symptoms?

      Your Answer: Carbamazepine

      Explanation:

      Understanding Antiepileptic Drug Side Effects: A Case Study on Trigeminal Neuralgia

      Trigeminal neuralgia is a condition that can be treated with antiepileptic drugs, such as carbamazepine. However, these drugs can also have side effects, including blood disorders. In this case study, we explore the potential side effects of various antiepileptic drugs and how to manage them.

      Carbamazepine is a valid choice for treating trigeminal neuralgia, but it is commonly associated with blood disorders. Patients should be aware of the signs of these disorders and seek medical attention if symptoms develop. Leukopenia that is severe, progressive, or associated with clinical symptoms requires withdrawal.

      Lamotrigine, levetiracetam, phenytoin, and sodium valproate can also cause blood disorders, but they are not used in the treatment of trigeminal neuralgia. It is important to remember that carbamazepine is the first-line agent for this condition, and specialist advice should be sought if it is contraindicated, ineffective, or not tolerated.

      In addition to blood disorders, antiepileptic drugs can have a range of side effects, including parasthesia, weight gain, and skin rash. Patients should be informed of these potential side effects and monitored for any symptoms. By understanding the side effects of antiepileptic drugs, healthcare professionals can provide better care for patients with trigeminal neuralgia.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 26 - A 68-year-old female is hospitalized due to a pulmonary embolism. She has a...

    Correct

    • A 68-year-old female is hospitalized due to a pulmonary embolism. She has a medical history of hypertension, type 2 diabetes mellitus, epilepsy, and schizophrenia. The patient is taking ramipril, olanzapine, metformin, gliclazide, and sodium valproate. The junior doctors are hesitant to start her on warfarin due to a potential interaction that could affect the dosage. Which medication is causing this interaction?

      Your Answer: Sodium valproate

      Explanation:

      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 27 - A 29-year-old man presents to the emergency department after intentionally overdosing on paracetamol....

    Correct

    • A 29-year-old man presents to the emergency department after intentionally overdosing on paracetamol. He reports taking 28 tablets, each containing 500 milligrams of paracetamol, in an attempt to end his life. However, he now expresses regret and desires full medical treatment.

      As the healthcare provider, you determine that a paracetamol level is necessary to guide treatment with acetylcysteine. What is the earliest time frame after ingestion of the tablets that a paracetamol level can be utilized for treatment guidance?

      Your Answer: 4 hours after ingestion

      Explanation:

      A plasma paracetamol level taken within four hours of ingestion cannot be accurately interpreted. This is because the drug is still being absorbed from the gastrointestinal tract during this time, which can result in an underestimation of the total ingestion of paracetamol. To obtain an accurate reading, it is important to wait until at least four hours have passed before taking a blood sample and plotting it on the treatment nomogram.

      For patients who present within one hour of ingestion, activated charcoal may be administered to reduce absorption of the drug. However, a paracetamol level taken at this stage may not provide much useful information.

      In cases where the ingestion time is unknown or the overdose was taken over a period of more than an hour, acetylcysteine treatment may be initiated regardless of the paracetamol level.

      Paracetamol overdose management guidelines were reviewed by the Commission on Human Medicines in 2012. The new guidelines removed the ‘high-risk’ treatment line on the normogram, meaning that all patients are treated the same regardless of their risk factors for hepatotoxicity. However, for situations outside of the normal parameters, it is recommended to consult the National Poisons Information Service/TOXBASE. Patients who present within an hour of overdose may benefit from activated charcoal to reduce drug absorption. Acetylcysteine should be given if the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity. Acetylcysteine is now infused over 1 hour to reduce adverse effects. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate. The King’s College Hospital criteria for liver transplantation in paracetamol liver failure include arterial pH < 7.3, prothrombin time > 100 seconds, creatinine > 300 µmol/l, and grade III or IV encephalopathy.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 28 - A 47-year-old man is hospitalized for pneumonia and has a medical history of...

    Correct

    • A 47-year-old man is hospitalized for pneumonia and has a medical history of Addison's disease, taking hydrocortisone (20 mg in the mornings and 10mg in the afternoon). What is the best course of action regarding his steroid dosage?

      Your Answer: Double hydrocortisone to 40mg mornings and 20mg afternoon

      Explanation:

      Understanding Corticosteroids and Their Side-Effects

      Corticosteroids are commonly prescribed therapies used to replace or augment the natural activity of endogenous steroids. They can be administered systemically or locally, depending on the condition being treated. However, the usage of corticosteroids is limited due to their numerous side-effects, which are more common with prolonged and systemic therapy.

      Glucocorticoid side-effects include impaired glucose regulation, increased appetite and weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome, moon face, buffalo hump, striae, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis, insomnia, mania, depression, psychosis, peptic ulceration, acute pancreatitis, glaucoma, cataracts, suppression of growth in children, intracranial hypertension, and neutrophilia.

      On the other hand, mineralocorticoid side-effects include fluid retention and hypertension. It is important to note that patients on long-term steroids should have their doses doubled during intercurrent illness. Longer-term systemic corticosteroids suppress the natural production of endogenous steroids, so they should not be withdrawn abruptly as this may precipitate an Addisonian crisis. The British National Formulary suggests gradual withdrawal of systemic corticosteroids if patients have received more than 40mg prednisolone daily for more than one week, received more than three weeks of treatment, or recently received repeated courses.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 29 - A 50-year-old male with a history of bipolar disorder is experiencing an acute...

    Correct

    • A 50-year-old male with a history of bipolar disorder is experiencing an acute state of confusion. Which of the following medications is most likely to cause lithium toxicity in this patient?

      Your Answer: Bendroflumethiazide

      Explanation:

      Thiazides can cause lithium toxicity, while sodium bicarbonate and aminophylline can lower plasma levels of lithium.

      Understanding Lithium Toxicity

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. However, it has a narrow therapeutic range of 0.4-1.0 mmol/L and a long plasma half-life, making it crucial to monitor its levels in the blood. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain medications such as diuretics, ACE inhibitors, NSAIDs, and metronidazole.

      Symptoms of lithium toxicity include a coarse tremor, hyperreflexia, acute confusion, polyuria, seizures, and even coma. It is important to manage toxicity promptly, as mild to moderate cases may respond to volume resuscitation with normal saline. However, severe cases may require hemodialysis to remove excess lithium from the body. Some healthcare providers may also use sodium bicarbonate to increase the alkalinity of the urine and promote lithium excretion, although evidence supporting its effectiveness is limited.

      In summary, understanding lithium toxicity is crucial for healthcare providers and individuals taking lithium. Monitoring lithium levels in the blood and promptly managing toxicity can prevent serious complications and ensure the safe use of this medication.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 30 - Which one of the following investigations is essential prior to initiating anti-tuberculosis treatment...

    Correct

    • Which one of the following investigations is essential prior to initiating anti-tuberculosis treatment in elderly patients?

      Your Answer: Liver functions tests

      Explanation:

      The management of tuberculosis has been outlined in guidelines by the British Thoracic Society. It is recommended that liver function tests are conducted in all cases and monitored during treatment. Prior to starting ethambutol, it is important to check visual acuity and renal function.

      Side-Effects and Mechanism of Action of Tuberculosis Drugs

      Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

      Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

      In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 31 - A 65-year-old man visits his GP for a medication review. He has been...

    Incorrect

    • A 65-year-old man visits his GP for a medication review. He has been diagnosed with stable congestive heart failure. As you review his repeat prescriptions, you consider his new diagnosis. The patient has type 2 diabetes mellitus, osteoarthritis, and erectile dysfunction. What is the most crucial medication to avoid in patients with chronic heart failure among his current medications?

      Your Answer: Sildenafil

      Correct Answer: Diclofenac

      Explanation:

      Patients with heart failure should exercise caution when using NSAIDs as they have the potential to worsen the condition by causing fluid retention, particularly diclofenac.

      Medications to Avoid in Patients with Heart Failure

      Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.

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      • Pharmacology/Therapeutics
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  • Question 32 - A 42-year-old man experiences a sudden onset of migraine and is administered a...

    Correct

    • A 42-year-old man experiences a sudden onset of migraine and is administered a subcutaneous injection of sumatriptan, resulting in the alleviation of his symptoms.
      What is the mechanism of action of the drug?

      Your Answer: Causing vasoconstriction of cranial arteries

      Explanation:

      Understanding the Mechanisms of Sumatriptan: A Migraine and Cluster Headache Treatment

      Sumatriptan is a medication commonly used to treat migraine and cluster headaches. It works by activating specific serotonin receptors (5-HT1D and 5-HT1B) found on cranial and basilar arteries, causing vasoconstriction of these blood vessels. This medication can be administered orally, by subcutaneous injection, or intranasally.

      It is important to note that sumatriptan has no effect on adrenergic receptors or acetylcholinesterase receptors. It is also not a cyclooxygenase (COX) inhibitor or an opioid receptor agonist or antagonist.

      In addition to its effects on blood vessels, sumatriptan has been shown to decrease the activity of the trigeminal nerve, which is responsible for its effectiveness in treating cluster headaches.

      Overall, understanding the mechanisms of sumatriptan can help healthcare professionals and patients better understand how this medication works to alleviate the symptoms of migraine and cluster headaches.

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      • Pharmacology/Therapeutics
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  • Question 33 - A 50-year-old man is recommended bupropion to aid in smoking cessation. What is...

    Correct

    • A 50-year-old man is recommended bupropion to aid in smoking cessation. What is the mechanism of action of bupropion?

      Your Answer: Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

      Explanation:

      NICE guidance recommends offering nicotine replacement therapy (NRT), varenicline, or bupropion to patients for smoking cessation, with no preference for one medication over another. NRT should be offered in combination for those with high nicotine dependence or inadequate response to single forms. Varenicline should be started a week before the target stop date and monitored for adverse effects, including nausea and suicidal behavior. Bupropion should also be started before the target stop date and is contraindicated in epilepsy, pregnancy, and breastfeeding. Pregnant women should be tested for smoking and referred to NHS Stop Smoking Services, with first-line interventions being cognitive behavior therapy, motivational interviewing, or structured self-help and support. NRT may be used if other measures fail, but varenicline and bupropion are contraindicated.

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      • Pharmacology/Therapeutics
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  • Question 34 - A 42-year-old woman with epilepsy complains of hair loss and tremors. Her husband...

    Incorrect

    • A 42-year-old woman with epilepsy complains of hair loss and tremors. Her husband reports that she has become more irritable since starting her medication.
      Which medication is the most likely culprit?

      Your Answer: Phenytoin

      Correct Answer: Sodium valproate (Epilim®)

      Explanation:

      Common Side Effects of Anticonvulsants and Analysis of Symptoms Associated with Different Medications

      Anticonvulsants are commonly used to treat seizures, but they can also have side effects. One of the most common side effects of sodium valproate is hair loss, along with aggression and tremors. Levetiracetam is commonly associated with aggression and tremors, but rarely with alopecia. Carbamazepine is rarely associated with aggression or alopecia, and lamotrigine is commonly associated with aggression and tremors but not hair loss. Phenytoin is commonly associated with tremors but not the other symptoms mentioned. This analysis can help identify which medication may be causing certain symptoms. Other common side effects of anticonvulsants include fatigue, skin rashes, and gastrointestinal issues. It is important to consult with a healthcare provider about any concerns regarding medication side effects.

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      • Pharmacology/Therapeutics
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  • Question 35 - A 30-year-old farmer with a history of depression arrives at the emergency department...

    Correct

    • A 30-year-old farmer with a history of depression arrives at the emergency department complaining of blurred vision, runny nose, watery eyes, diarrhoea, and vomiting. The patient admits to ingesting a pesticide in an attempt to commit suicide. What other clinical manifestations should be anticipated in this individual?

      Your Answer: Bradycardia

      Explanation:

      This individual is displaying symptoms consistent with organophosphate poisoning, which is a type of pesticide. Organophosphate pesticides work by inhibiting acetylcholinesterase, which affects the nervous system. This causes an accumulation of acetylcholine at nerve synapses and neuromuscular junctions, resulting in excessive stimulation of muscarinic and nicotinic receptors. As a result, bradycardia is a common symptom. The recommended treatment for organophosphate poisoning is atropine, which should be administered every 10-20 minutes until secretions dry up and the heart rate increases to 80-90 beats per minute.

      The options of dilated pupils, dry mouth, and hallucinations are incorrect. Organophosphate poisoning typically causes miosis (constricted pupils) due to overstimulation of the parasympathetic system, excessive secretions including salivation, bronchial secretions, diarrhea, and vomiting. While confusion, agitation, and coma may occur in severe cases, hallucinations are not a common symptom.

      Understanding Organophosphate Insecticide Poisoning

      Organophosphate insecticide poisoning is a condition that occurs when there is an accumulation of acetylcholine in the body, leading to the inhibition of acetylcholinesterase. This, in turn, causes an upregulation of nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic organophosphorus compound that has similar effects. The symptoms of organophosphate poisoning can be remembered using the mnemonic SLUD, which stands for salivation, lacrimation, urination, and defecation/diarrhea. Other symptoms include hypotension, bradycardia, small pupils, and muscle fasciculation.

      The management of organophosphate poisoning involves the use of atropine, which helps to counteract the effects of acetylcholine. However, the role of pralidoxime in the treatment of this condition is still unclear. Meta-analyses conducted to date have failed to show any clear benefit of pralidoxime in the management of organophosphate poisoning.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 36 - An older woman with advanced breast cancer has been discharged from the hospital...

    Correct

    • An older woman with advanced breast cancer has been discharged from the hospital for palliative care at home. She was prescribed oral morphine at a dose of 10mg four times a day to manage her pain from bony metastases. This dosage was effective in controlling her pain.

      However, the patient's condition has worsened, and she is now experiencing difficulty swallowing, making it impossible to take the medication orally. The GP has recommended converting the morphine to a subcutaneous injection, which will be administered by the district nurses.

      What is the appropriate subcutaneous morphine dose for this patient?

      Your Answer: 5mg four times daily

      Explanation:

      To convert from oral to subcutaneous morphine, divide the oral dose by two. In this case, the recommended subcutaneous morphine dose is 5mg four times daily, which is equivalent to 10mg of oral morphine four times daily. As the patient’s pain is currently well controlled, there is no need to adjust the analgesia dose.

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

      Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 37 - A 72-year-old male presents with weight loss and heat intolerance. He is taking...

    Correct

    • A 72-year-old male presents with weight loss and heat intolerance. He is taking multiple medications for atrial fibrillation, ischaemic heart disease and rheumatoid arthritis. Thyroid function tests are requested and the results are shown in the table below:
      Thyroid stimulating hormone (TSH) 0.2 mU/L
      Free T4 35 pmol/L
      What is the most likely cause of these findings?

      Your Answer: Amiodarone

      Explanation:

      Amiodarone and Thyroid Dysfunction

      Amiodarone is a medication used to treat heart rhythm disorders. However, around 1 in 6 patients taking amiodarone develop thyroid dysfunction. This can manifest as either amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT).

      The pathophysiology of AIH is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect. This is an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide. Despite this, amiodarone may be continued if desirable.

      On the other hand, AIT may be divided into two types: type 1 and type 2. Type 1 is caused by excess iodine-induced thyroid hormone synthesis, while type 2 is caused by amiodarone-related destructive thyroiditis. In patients with AIT, amiodarone should be stopped if possible.

      It is important for healthcare professionals to monitor patients taking amiodarone for any signs of thyroid dysfunction and adjust treatment accordingly.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 38 - You are reviewing an elderly patient's blood results:

    K+ 6.2 mmol/l

    Which medication is the...

    Correct

    • You are reviewing an elderly patient's blood results:

      K+ 6.2 mmol/l

      Which medication is the most probable cause of this outcome?

      Your Answer: Spironolactone

      Explanation:

      Understanding Hyperkalaemia: Causes and Symptoms

      Hyperkalaemia is a condition characterized by high levels of potassium in the blood. The regulation of plasma potassium levels is influenced by various factors such as aldosterone, insulin levels, and acid-base balance. When metabolic acidosis occurs, hyperkalaemia may develop as hydrogen and potassium ions compete for exchange with sodium ions across cell membranes and in the distal tubule. ECG changes that may be observed in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.

      There are several causes of hyperkalaemia, including acute kidney injury, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Certain drugs such as potassium-sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin can also cause hyperkalaemia. It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. On the other hand, beta-agonists like Salbutamol are sometimes used as emergency treatment.

      Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes. It is essential to monitor potassium levels in the blood to prevent complications associated with hyperkalaemia. If left untreated, hyperkalaemia can lead to serious health problems such as cardiac arrhythmias and even death.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 39 - A 28-year-old female with no significant medical history is started on carbamazepine for...

    Correct

    • 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: 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 40 - A 70-year-old man arrives at the emergency department complaining of feeling generally unwell...

    Incorrect

    • A 70-year-old man arrives at the emergency department complaining of feeling generally unwell and lethargic for the past 2 weeks. He reports a yellow-green tinge to his vision as his only other symptom. The patient has a medical history of atrial fibrillation, depression, and a myocardial infarction 3 years ago. He takes multiple medications that come in a blister pack, but he is unsure of their names. Upon blood testing, his Digoxin concentration is 3 mcg/l (<1 mcg/l). What medication could have caused this clinical presentation?

      Your Answer: Simvastatin

      Correct Answer: Bendroflumethiazide

      Explanation:

      Thiazides like bendroflumethiazide can cause digoxin toxicity by causing hypokalaemia, which allows digoxin to have more of an effect on Na+/K+ ATPase. Symptoms of digoxin toxicity are vague but may include gastrointestinal upset, weakness, fatigue, and xanthopsia. Citalopram, isosorbide mononitrate, and ramipril do not appear to have any significant effect on digoxin toxicity.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 41 - A 38-year-old man presents to the emergency department with chest pain that started...

    Incorrect

    • A 38-year-old man presents to the emergency department with chest pain that started 2 hours ago. He describes the pain as radiating to his left arm and jaw. He has no significant past medical history; he drinks alcohol occasionally and admits to sometimes using illegal drugs.

      On examination, he appears sweaty and agitated. His limbs are mildly hypertonic and hyper-reflexive, and his pupils are dilated. His blood pressure is 175/82 mmHg. An ECG shows some QRS widening and QT prolongation, as well as ST depression and T wave inversion in several leads.

      What should be given as part of the acute management?

      Your Answer: Naloxone

      Correct Answer: Diazepam

      Explanation:

      In the case of a suspected myocardial infarction (MI) caused by cocaine use, the recommended first-line treatment is intravenous benzodiazepines, such as diazepam, to alleviate coronary artery vasospasm. Nitrates can also be administered to relieve chest pain. Atorvastatin, which is used to lower cholesterol levels and prevent future MIs, is not appropriate for immediate treatment. While beta-blockers like bisoprolol are typically used to manage MIs, their use in cocaine-related MIs is controversial due to the potential to worsen coronary vasospasm. Naloxone, which reverses opioid overdose symptoms like respiratory depression and constricted pupils, is not indicated in this case as the patient is intoxicated with cocaine, not opioids.

      Understanding Cocaine Toxicity

      Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.

      Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.

      Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.

      In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 42 - Which of the following is the least commonly associated with cocaine toxicity? ...

    Correct

    • Which of the following is the least commonly associated with cocaine toxicity?

      Your Answer: Metabolic alkalosis

      Explanation:

      Understanding Cocaine Toxicity

      Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.

      Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.

      Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.

      In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 43 - A 52-year-old man on several medications develops bruising. Blood tests reveal thrombocytopenia.
    Which medication...

    Correct

    • A 52-year-old man on several medications develops bruising. Blood tests reveal thrombocytopenia.
      Which medication is the most probable cause of this?

      Your Answer: Ibuprofen

      Explanation:

      Medications and their potential to cause thrombocytopenia

      Thrombocytopenia is a condition where there is a low platelet count in the blood, which can lead to bleeding and bruising. Some medications have been known to cause immune-mediated, drug-induced thrombocytopenia. Ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), is one such medication. It interacts with platelet membrane glycoprotein, resulting in the formation of drug-glycoprotein complexes that can trigger the production of antibodies. The mechanism behind this is not entirely clear. Paracetamol and bisoprolol have a low likelihood of causing thrombocytopenia, making them safer alternatives. Simvastatin also has a low risk of causing thrombocytopenia. Warfarin, on the other hand, has a potential side effect of bleeding but is not directly linked to causing thrombocytopenia. It is important to be aware of the potential risks associated with medications and to consult with a healthcare professional before taking any new medication.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 44 - A 35-year-old woman is recommended varenicline to aid in her smoking cessation. What...

    Correct

    • A 35-year-old woman is recommended varenicline to aid in her smoking cessation. What is the mechanism of action of varenicline?

      Your Answer: Nicotinic receptor partial agonist

      Explanation:

      NICE guidance recommends offering nicotine replacement therapy (NRT), varenicline, or bupropion to patients for smoking cessation, with no preference for one medication over another. NRT should be offered in combination for those with high nicotine dependence or inadequate response to single forms. Varenicline should be started a week before the target stop date and monitored for adverse effects, including nausea and suicidal behavior. Bupropion should also be started before the target stop date and is contraindicated in epilepsy, pregnancy, and breastfeeding. Pregnant women should be tested for smoking and referred to NHS Stop Smoking Services, with first-line interventions being cognitive behavior therapy, motivational interviewing, or structured self-help and support. NRT may be used if other measures fail, but varenicline and bupropion are contraindicated.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 45 - Which one of the following statements regarding metformin is not true? ...

    Correct

    • Which one of the following statements regarding metformin is not true?

      Your Answer: Increases endogenous insulin secretion

      Explanation:

      Sulphonylureas possess the characteristic of enhancing the secretion of insulin produced naturally within the body.

      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
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  • Question 46 - A 45-year-old woman has been using diphenhydramine (Benadryl) for allergy relief. She reports...

    Incorrect

    • A 45-year-old woman has been using diphenhydramine (Benadryl) for allergy relief. She reports using it frequently and her doctor suspects she may be experiencing symptoms of the anticholinergic syndrome (ACS).
      Which of the following statements accurately describes the anticholinergic syndrome?

      Your Answer: Bradycardia is common

      Correct Answer: Hot, dry skin occurs

      Explanation:

      Understanding Anticholinergic Syndrome: Symptoms and Treatment

      Anticholinergic syndrome is a condition that occurs when there is an inhibition of cholinergic neurotransmission at muscarinic receptor sites. It can be caused by the ingestion of various medications, intentional overdose, inadvertent ingestion, medical non-compliance, or geriatric polypharmacy. The syndrome produces central nervous system effects, peripheral nervous system effects, or both, resulting in a range of symptoms.

      Symptoms of anticholinergic syndrome include flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status, fever, sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, and myoclonic jerking. Hot, dry skin and constricted pupils are also common manifestations.

      Treatment for anticholinergic syndrome involves stabilizing the patient in A&E and removing the toxin from the gastrointestinal tract. This can be done with a single dose of activated charcoal by mouth or nasogastric tube. Gastric lavage, followed by activated charcoal administration, is acceptable for patients presenting with altered mental state and within 1 hour of ingestion.

      Physostigmine salicylate is the classic antidote for anticholinergic toxicity. While most patients can be safely treated without it, it is recommended when tachydysrhythmia is present. However, physostigmine is contraindicated in patients with cardiac conduction disturbances on ECG.

      In conclusion, understanding the symptoms and treatment of anticholinergic syndrome is crucial for healthcare professionals to provide appropriate care for patients who may present with this condition.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 47 - Prolonged use of which drug can result in tachyphylaxis, which is an acute...

    Correct

    • Prolonged use of which drug can result in tachyphylaxis, which is an acute and sudden decrease in response to a drug after its administration, leading to a rapid and short-term onset of drug tolerance?

      Your Answer: Xylometazoline (eg Sudafed® nasal spray)

      Explanation:

      Common Drugs and Tachyphylaxis: Understanding the Risk

      Nasal decongestants, such as xylometazoline, are often used to relieve nasal congestion. However, prolonged use can lead to rebound congestion, known as rhinitis medicamentosa. Amiodarone, an antiarrhythmic drug, has a long half-life and potential for drug interactions even after treatment has stopped. Metronidazole, an antimicrobial drug, can be absorbed systemically and may interact with other medications. Naproxen, a non-steroidal anti-inflammatory drug, has no evidence of tachyphylaxis. Phenoxymethylpenicillin, an antibiotic, is not associated with tachyphylaxis. Understanding the risk of tachyphylaxis with common drugs is important for safe and effective use.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 48 - A 38-year-old woman with rheumatoid arthritis visits her doctor every three months for...

    Correct

    • A 38-year-old woman with rheumatoid arthritis visits her doctor every three months for blood tests. Which of the following blood tests is necessary for monitoring the use of methotrexate?

      Your Answer: FBC, U&Es, LFTs

      Explanation:

      Importance of Drug Monitoring in Primary Care

      Patients on methotrexate require regular monitoring of their blood tests to prevent severe side effects. The three essential blood tests that need monitoring are FBC, U&Es, and LFTs. Methotrexate can cause blood dyscrasias, liver cirrhosis, and kidney failure, making it crucial to monitor these tests every 2-3 months once therapy has stabilized. Patients should report any symptoms of infection, bruising, mouth ulcers, abdominal discomfort, dark urine, and shortness of breath. They should also avoid self-medication with over-the-counter aspirin or ibuprofen.

      Thyroid function is not affected by methotrexate, and regular monitoring is not necessary unless there is another medical condition that justifies it. However, patients on methotrexate should report any signs of blood disorders such as ecchymosis and telangiectasia.

      Drug monitoring is becoming increasingly common in primary care, especially for patients under shared care with secondary/specialty care. Some examples of drug monitoring in primary care include amiodarone, azathioprine, lithium, and methotrexate. Each drug requires specific blood tests, and the frequency of monitoring varies. For instance, patients on methotrexate require FBC, U&Es, and LFTs every 2-3 months.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 49 - A 56-year-old woman with a lengthy history of rheumatoid arthritis presents to the...

    Correct

    • A 56-year-old woman with a lengthy history of rheumatoid arthritis presents to the clinic with a chief complaint of dyspnea. During the examination, her oxygen saturation is found to be 92% on room air, and spirometry reveals a restrictive pattern accompanied by a decreased transfer factor. Which medication is the most probable cause of her symptoms?

      Your Answer: Methotrexate

      Explanation:

      The use of methotrexate as well as other anti-rheumatoid drugs like sulfasalazine and gold may lead to the development of lung fibrosis in patients. This patient is currently experiencing pulmonary fibrosis which could be attributed to the use of methotrexate.

      Drugs that can lead to lung fibrosis

      Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 50 - You are reviewing some blood results and notice that a 32-year-old man admitted...

    Incorrect

    • You are reviewing some blood results and notice that a 32-year-old man admitted earlier has hyperkalaemia. You go back and review the drugs he is taking to see if any of them could be contributing to the newly diagnosed hyperkalaemia.
      Which of the following would contribute to the patient’s hyperkalaemia?

      Your Answer: β-agonists

      Correct Answer: Digoxin

      Explanation:

      Drugs and their Effects on Serum Potassium Levels

      Serum potassium levels can be affected by various drugs. Digoxin toxicity, especially in patients with renal impairment, can cause hyperkalaemia. Theophylline can lead to hypokalaemia, which can be potentiated by concomitant treatment with corticosteroids and diuretics. Loop and thiazide diuretics can also cause hypokalaemia due to increased sodium reabsorption at the expense of potassium and hydrogen ions. β-agonists such as bronchodilators can cause hypokalaemia, while β-blockade can lead to hyponatraemia and hyperkalaemia. Lithium use is not associated with changes in serum potassium levels. It is important to monitor serum potassium concentrations when using these drugs to prevent adverse effects.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 51 - A 28-year-old woman with established epilepsy has recently had her medication changed at...

    Incorrect

    • 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: Lamotrigine (Lamictal®)

      Correct 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 52 - A 64-year-old man with a history of type 2 diabetes mellitus and ischaemic...

    Incorrect

    • A 64-year-old man with a history of type 2 diabetes mellitus and ischaemic heart disease visits his GP complaining of erectile dysfunction. What medication would make prescribing sildenafil contraindicated?

      Your Answer: Gliclazide

      Correct Answer: Isosorbide mononitrate

      Explanation:

      Sildenafil, a PDE 5 inhibitor, should not be taken with nitrates or nicorandil as it can enhance the vasodilating effects of these medications.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      28
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  • Question 53 - You assess a 79-year-old woman who is on digoxin for atrial fibrillation. What...

    Incorrect

    • You assess a 79-year-old woman who is on digoxin for atrial fibrillation. What factor is most likely to increase her risk of developing digoxin toxicity?

      Your Answer: Concurrent clarithromycin use

      Correct Answer: Hypokalaemia

      Explanation:

      Patients with hypokalaemia are more likely to experience digoxin toxicity.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 54 - A 25-year-old man presents to his General Practitioner with a 3-month history of...

    Incorrect

    • A 25-year-old man presents to his General Practitioner with a 3-month history of diarrhoea and intermittent abdominal pain. He has also noticed blood mixed with his stools over the past week. He is referred to secondary care where he has a colonoscopy and is diagnosed with Crohn’s disease.
      Which of the following medications would be used to induce remission in this patient with a first presentation of Crohn’s disease?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Azathioprine

      Correct Answer: Prednisolone

      Explanation:

      Treatment Options for Crohn’s Disease

      Crohn’s disease is a chronic inflammatory bowel disease that can cause a range of symptoms, including abdominal pain, diarrhea, and weight loss. There are several treatment options available for patients with Crohn’s disease, depending on the severity of their symptoms and the stage of their disease.

      Prednisolone is a commonly used corticosteroid for patients with a first presentation of Crohn’s disease or a single inflammatory exacerbation within a 12-month period. Azathioprine may be added to glucocorticoid treatment to induce remission if there are more than two exacerbations in a 12-month period or difficulty in tapering the glucocorticoid dose. Infliximab is recommended for adults with severe active Crohn’s disease who have not responded to or are intolerant to conventional therapy.

      Mesalazine, an aminosalicylate, may be used for a first presentation of Crohn’s disease if glucocorticoids are contraindicated or not tolerated. It may also be used in addition to oral steroid treatment. Methotrexate should not be used as a monotherapy to induce remission. Instead, corticosteroids are the first-line treatment for inducing remission in patients with a first presentation of Crohn’s disease. If an adjuvant treatment is required, azathioprine or mercaptopurine can be taken with the corticosteroid. If these medications cannot be tolerated, methotrexate may be added instead.

      In summary, the treatment options for Crohn’s disease vary depending on the severity of the disease and the patient’s response to previous treatments. It is important for patients to work closely with their healthcare provider to determine the best course of treatment for their individual needs.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 55 - A 68-year-old man comes to the Emergency Department with severe inflammation of his...

    Incorrect

    • A 68-year-old man comes to the Emergency Department with severe inflammation of his first metatarsophalangeal joint. He reports swelling and tenderness of the joint and a sample of fluid is sent for microscopy. He has a medical history of hypertension and duodenal ulcers.
      What is the most suitable initial medication to prescribe?
      Choose ONE option from the list provided.

      Your Answer: Diclofenac

      Correct Answer: Colchicine

      Explanation:

      Managing Gout: Treatment Options and Contraindications

      Gout is a type of arthritis caused by the deposition of urate crystals in the synovial fluid. Chronic hyperuricemia is the primary cause of this condition. The acute management of gout involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine as first-line treatment. However, the maximum dose of NSAIDs should be prescribed until 1-2 days after the symptoms have settled, and gastroprotection may also be necessary. Colchicine has a slower onset of action and may cause diarrhea as a side effect. Oral steroids or intra-articular steroid injections may be considered if NSAIDs and colchicine are contraindicated. Allopurinol is not recommended during the acute phase but is useful for preventing recurrent attacks of gout. Diclofenac and indomethacin are contraindicated in patients with duodenal ulcers, and colchicine is a suitable alternative for the treatment of gout. Diazepam, a benzodiazepine, is not useful in the treatment of gout as it does not have anti-inflammatory or analgesic properties.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      21.1
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  • Question 56 - Amiodarone is known to cause which side effect? Choose ONE option from the...

    Correct

    • Amiodarone is known to cause which side effect? Choose ONE option from the list provided.

      Your Answer: Hyperthyroidism

      Explanation:

      Understanding the Side Effects of Amiodarone: A Comprehensive Overview

      Amiodarone is a medication commonly used to treat cardiac arrhythmias. However, it is important to be aware of its potential side effects. Here is a breakdown of some of the most important things to know:

      Hyperthyroidism: Amiodarone can cause both hypo and hyperthyroidism. Patients taking this medication should have their thyroid function checked regularly.

      COPD: While amiodarone is not known to cause COPD, it can lead to pulmonary toxicity, including pneumonitis and fibrosis. Patients should have yearly chest x-rays.

      Drug-induced diabetes mellitus: There is no known association between amiodarone and the development of diabetes mellitus.

      Drug-induced pemphigus: Long-term use of amiodarone can cause phototoxicity and skin discoloration. Patients should protect their skin from light during treatment. However, it is not known to cause drug-induced pemphigus.

      Renal calculi: There is no known association between amiodarone and the development of kidney disease, including renal calculi.

      Other important side effects of amiodarone include hepatotoxicity, bradycardia, phototoxicity, and development of corneal deposits. If you are taking amiodarone, it is important to be aware of these potential side effects and to discuss any concerns with your healthcare provider.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      10.7
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  • Question 57 - A 55-year-old man has an HbA1c of 54 mmol/mol after 3 months of...

    Incorrect

    • A 55-year-old man has an HbA1c of 54 mmol/mol after 3 months of lifestyle changes, following a previous reading of HbA1c of 52 mmol/mol. You suggest that he should begin taking metformin standard release in addition to lifestyle interventions. He has normal renal function and no other medical issues. You inform him of the possibility of gastrointestinal discomfort.

      What is the typical duration before considering increasing the dosage to alleviate these symptoms for this patient?

      Your Answer: 28 days

      Correct Answer: 7 days

      Explanation:

      It is recommended to increase the dose of metformin gradually, with a minimum of one week between each increase.

      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
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  • Question 58 - A 70-year-old hypertensive man with asthma, heart failure and peptic ulcer disease reports...

    Correct

    • A 70-year-old hypertensive man with asthma, heart failure and peptic ulcer disease reports experiencing yellowish-green halos for the past week. He has also been feeling nauseous and has lost his appetite. Despite his conditions being well controlled, physical examination reveals no abnormalities. Which of the following medications that he is taking could potentially be responsible for his current symptoms?

      Your Answer: Digoxin

      Explanation:

      Common Side Effects and Risks of Medications

      Digoxin Toxicity: Symptoms and Risk Factors
      Digoxin toxicity can cause vague symptoms such as anorexia, nausea, confusion, and fatigue, as well as dysrhythmias. Risk factors for toxicity include imbalances in potassium, magnesium, and calcium levels.

      Salbutamol: Common Side Effects and Hypokalaemia
      Salbutamol may cause fine tremors, anxiety, headaches, and muscle cramps. Prolonged use or high doses can lead to hypokalaemia, which is especially concerning in patients with renal failure.

      Enalapril: Common Side Effects and Serious Risks
      Enalapril therapy may cause raised serum creatinine, dizziness, hypotension, syncope, and dry cough. The most serious risk is angio-oedema, which can obstruct airways.

      Ranitidine: Common Side Effects
      H2-receptor antagonists like ranitidine may cause diarrhea, dizziness, and headaches.

      Aspirin: Contraindications
      Aspirin should be avoided in patients with a history of hypersensitivity to NSAIDs or gastritis/peptic ulcer disease due to the increased risk of gastrointestinal bleeding.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 59 - Sue, 75, has chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus....

    Correct

    • Sue, 75, has chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus. She has been experiencing diarrhoea and vomiting for the past 3 days and her family have brought her to the emergency department as they are worried. History, examination and blood tests reveal Sue to be dehydrated and to have developed an acute kidney injury with an estimated glomerular filtration rate (eGFR) of 29 ml/min/1.73m². As per NICE guidelines, which medication should be discontinued?

      Your Answer: Metformin

      Explanation:

      If the creatinine level is above 130 micromol/l (or eGFR is below 45 ml/min), NICE recommends that the dosage of metformin be reviewed, and if the creatinine level is above 150 micromol/l (or eGFR is below 30 ml/min), metformin should be discontinued. It is important to note that metformin is the drug that should be stopped in this situation, according to NICE guidelines for the treatment of diabetes mellitus.

      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
      31.2
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  • Question 60 - A 38-year-old man visits his General Practitioner complaining of a sore throat. He...

    Correct

    • A 38-year-old man visits his General Practitioner complaining of a sore throat. He has a Centor score of 4 due to the presence of a fever, cervical lymphadenopathy, absence of cough, and white exudate on his tonsils. He is allergic to penicillin and takes simvastatin as his only medication. What is the most suitable antibiotic to prescribe for his sore throat?

      Your Answer: Doxycycline

      Explanation:

      A patient with a Centor score of 4 likely has acute group A streptococcal tonsillitis and requires antibiotics. However, the patient is allergic to penicillins and takes simvastatin, which is metabolized by the cytochrome P450 enzymes. Phenoxymethylpenicillin, the usual first-line treatment, cannot be used due to the allergy. Macrolides such as clarithromycin and erythromycin should also be avoided as they inhibit the cytochrome P450 enzymes and can increase the risk of statin-induced myopathy. Co-amoxiclav is not an option either. Therefore, doxycycline is the best choice as it is not a penicillin and does not affect the cytochrome P450 enzymes, allowing for concurrent use with simvastatin.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 61 - A 56-year-old woman is prescribed amlodipine by her doctor for stage 2 hypertension....

    Incorrect

    • A 56-year-old woman is prescribed amlodipine by her doctor for stage 2 hypertension. She is worried about the possible side-effects as she is already taking three other medications.

      What is a common side-effect of amlodipine?

      Your Answer: Tinnitus

      Correct Answer: Headache

      Explanation:

      Headache is a frequent side-effect of calcium-channel blockers like amlodipine. Bradycardia, cough, and hyperhidrosis are not side-effects of calcium-channel blockers, but rather of beta-blockers, ACE inhibitors, and calcium-channel blockers, respectively.

      Understanding Calcium Channel Blockers

      Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.

      Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.

      On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.

      In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 62 - Which of the following is a contraindication to using a triptan for treating...

    Incorrect

    • Which of the following is a contraindication to using a triptan for treating migraines in elderly patients?

      Your Answer: Concurrent pizotifen use

      Correct Answer: A history of ischaemic heart disease

      Explanation:

      Triptan use is contraindicated in individuals with cardiovascular disease.

      Triptans for Migraine Treatment

      Triptans are medications that act as agonists for 5-HT1B and 5-HT1D receptors and are commonly used in the acute treatment of migraines. They are often prescribed in combination with NSAIDs or paracetamol and are typically taken as soon as possible after the onset of a headache, rather than at the onset of an aura. Triptans are available in various forms, including oral tablets, orodispersible tablets, nasal sprays, and subcutaneous injections.

      While triptans are generally well-tolerated, some patients may experience triptan sensations, such as tingling, heat, tightness in the throat and chest, heaviness, or pressure. It is important to note that triptans are contraindicated in patients with a history of or significant risk factors for ischaemic heart disease or cerebrovascular disease.

      In summary, triptans are a commonly used medication for the acute treatment of migraines. They should be taken as soon as possible after the onset of a headache and are available in various forms. However, patients should be aware of potential adverse effects and contraindications before taking triptans.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 63 - An 80-year-old man comes in for a routine check-up with his General Practitioner....

    Correct

    • 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 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
      51.5
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  • Question 64 - A 50-year-old-man comes to the emergency department with a 10-hour history of colicky...

    Correct

    • A 50-year-old-man comes to the emergency department with a 10-hour history of colicky abdominal pain, abdominal distension, constipation and an inability to pass flatus. He reports feeling nauseous but has not vomited.
      What should not be done in the management of this patient?

      Your Answer: IV metoclopramide

      Explanation:

      Metoclopramide should be avoided in cases of bowel obstruction due to its prokinetic properties that can worsen the condition and even lead to perforation. Moclobemide, an antidepressant, may cause gastrointestinal upset but is not contraindicated in suspected bowel obstruction. Conservative management for bowel obstruction includes NG tube insertion, catheterization, and IV fluid resuscitation. Ondansetron, an antiemetic, can be useful in managing nausea. Opioid-based analgesia, such as pethidine and diamorphine, is effective in relieving obstruction-related pain despite its potential to reduce bowel motility. Intravenous fluids, such as Hartmann’s solution, are crucial in countering hypovolemia caused by fluid hypersecretion into the obstructed bowel lumen.

      Metoclopramide is a medication that is commonly used to manage nausea. It works by blocking D2 receptors in the chemoreceptor trigger zone, which helps to alleviate feelings of sickness. In addition to its antiemetic properties, metoclopramide also has other uses, such as treating gastro-oesophageal reflux disease and gastroparesis caused by diabetic neuropathy. It is often combined with analgesics to treat migraines, which can cause gastroparesis and slow the absorption of pain medication.

      However, metoclopramide can have some adverse effects, such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. These side effects are particularly problematic in children and young adults. It is important to note that metoclopramide should not be used in cases of bowel obstruction, but it may be helpful in cases of paralytic ileus.

      Although metoclopramide primarily works as a D2 receptor antagonist, its mechanism of action is quite complex. It also acts as a mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist. The antiemetic effects of metoclopramide are due to its D2 receptor antagonist activity in the chemoreceptor trigger zone, while its gastroprokinetic effects are mediated by both D2 receptor antagonist and 5-HT4 receptor agonist activity. At higher doses, the 5-HT3 receptor antagonist activity also comes into play.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 65 - An 72-year-old man arrives at the emergency department complaining of palpitations, dizziness, and...

    Correct

    • An 72-year-old man arrives at the emergency department complaining of palpitations, dizziness, and shortness of breath. He has a medical history of COPD and is currently being treated for pneumonia with antibiotics. Upon examination, his heart rate is 170/min, respiratory rate is 22/min, blood pressure is 140/92 mmHg, and temperature is 36.3 ºC. An electrocardiogram reveals a polymorphic ventricular tachycardia with oscillatory changes in amplitude of the QRS complexes around the isoelectric line. Which medication is most likely responsible for his symptoms?

      Your Answer: Azithromycin

      Explanation:

      Azithromycin is the macrolide antibiotic that can cause torsades de pointes, which is evident in this patient presenting with dizziness, shortness of breath, palpitations, and polymorphic ventricular tachycardia with oscillatory changes. Macrolides can lead to a long QT interval, which can be fatal if not treated promptly with intravenous magnesium to stabilize the cardiac myocytes. Amoxicillin, doxycycline, and flucloxacillin are other antibiotics used to treat pneumonia but have not been associated with long QT intervals and torsades de pointes. However, they can cause other side effects such as diarrhea, nausea, vomiting, skin reactions, and thrombocytopenia.

      Torsades de Pointes: A Life-Threatening Condition

      Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.

      The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 66 - A 55-year-old woman has recently undergone a partial abdominal hysterectomy and unilateral salpingo-oophorectomy,...

    Incorrect

    • A 55-year-old woman has recently undergone a partial abdominal hysterectomy and unilateral salpingo-oophorectomy, and is discussing hormone replacement therapy.
      Which of the following pieces of advice may she be offered?

      Your Answer: Oestrogen therapy, if started immediately, will prevent osteoporotic fractures in old age

      Correct Answer: The benefits of oestrogen therapy are maintained only so long as treatment is continued for the next 5-10 years at least

      Explanation:

      Oestrogen therapy must be continued for at least 5-10 years to maintain its benefits, including a decreased risk of fragility fractures. Starting oestrogen therapy immediately can prevent osteoporotic fractures in old age. Bisphosphonates are the first-line treatment for bone-sparing. HRT should not be prescribed solely for preventing osteoporosis, but a combination of oestrogen and progesterone should be used in women with a uterus. Patients who have a salpingo-oophorectomy should be monitored for hormone-related conditions. SSRIs, SNRIs, and clonidine should not be the first-line treatment for vasomotor symptoms alone. Vaginal oestrogen can be offered to women with urogenital atrophy, even if they are on systemic HRT.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 67 - You are having a consultation with a 49-year-old man for his initial diabetes...

    Correct

    • 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: 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
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  • Question 68 - Concurrent use of which one of the following would decrease the effectiveness of...

    Correct

    • Concurrent use of which one of the following would decrease the effectiveness of the combined oral contraceptive pill for a 25-year-old woman?

      Your Answer: Carbamazepine

      Explanation:

      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 69 - An 80-year-old man is admitted to the orthogeriatric ward following a femoral fracture...

    Correct

    • An 80-year-old man is admitted to the orthogeriatric ward following a femoral fracture from a fall. He has a medical history of diabetes mellitus type 2, benign prostate hyperplasia, and severe hay fever. After a few days, the patient reports experiencing suprapubic discomfort and difficulty urinating. Which medication is the most probable cause of his symptoms?

      Your Answer: Codeine

      Explanation:

      Urinary retention is a common side effect of opioid analgesia, including the use of codeine. Other medications that can cause this issue include tricyclic antidepressants, anticholinergics, and NSAIDs. Doxazosin, an alpha-blocker, is often prescribed to improve symptoms of benign prostatic hyperplasia and reduce resistance to bladder outflow. Duloxetine, an SSRI used to treat diabetic neuropathy, does not typically cause urinary retention. Finasteride, a 5-alpha reductase inhibitor, is a second-line treatment for benign prostatic hyperplasia when alpha-blockers are not effective, as it reduces prostatic bulk.

      Drugs that can cause urinary retention

      Urinary retention is a condition where a person is unable to empty their bladder completely. This can be caused by various factors, including certain medications. Some drugs that may lead to urinary retention include tricyclic antidepressants like amitriptyline, anticholinergics such as antipsychotics and antihistamines, opioids, NSAIDs, and disopyramide. These drugs can affect the muscles that control the bladder, making it difficult to urinate.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 70 - A 47-year-old male presents to the emergency department with a productive cough and...

    Correct

    • A 47-year-old male presents to the emergency department with a productive cough and fever. He has a medical history of systemic lupus erythematosus, gout, dyspepsia, and had a renal transplant 3 years ago. His current medications include azathioprine, allopurinol, and omeprazole. He drinks 25 units of alcohol a week and has done so for the past decade.

      His vital signs are as follows:
      Respiratory rate of 34 /min
      Pulse of 123 bpm
      Temperature of 39.4ºC
      Blood pressure of 84/56 mmHg
      Oxygen saturation of 94% on room air

      Blood results show:
      Hb 90 g/L Male: (135-180)
      Platelets 85 * 109/L (150 - 400)
      WBC 1.3 * 109/L (4.0 - 11.0)
      Neuts 0.7 * 109/L (2.0 - 7.0)

      What drug interaction is likely responsible for this patient's presentation?

      Your Answer: Azathioprine and allopurinol use

      Explanation:

      The use of allopurinol in combination with azathioprine can increase the risk of myelosuppression and neutropenic sepsis. This is because azathioprine is metabolized to its active form, 6-mercaptopurine, which is then metabolized by xanthine oxidase. Allopurinol inhibits xanthine oxidase, leading to an accumulation of 6-mercaptopurine and an increased risk of myelosuppression. Chronic alcohol use and omeprazole use do not significantly increase the risk of myelosuppression when used with azathioprine or allopurinol.

      Allopurinol is a medication used to prevent gout by inhibiting xanthine oxidase. Traditionally, it was believed that urate-lowering therapy (ULT) should not be started until two weeks after an acute attack to avoid further attacks. However, the evidence supporting this is weak, and the British Society of Rheumatology (BSR) now recommends delaying ULT until inflammation has settled to make long-term drug decisions while the patient is not in pain. The initial dose of allopurinol is 100 mg once daily, with the dose titrated every few weeks to aim for a serum uric acid level of less than 300 µmol/l. Colchicine cover should be considered when starting allopurinol, and NSAIDs can be used if colchicine cannot be tolerated. ULT is recommended for patients with two or more attacks in 12 months, tophi, renal disease, uric acid renal stones, prophylaxis if on cytotoxics or diuretics, and Lesch-Nyhan syndrome.

      The most significant adverse effects of allopurinol are dermatological, and patients should stop taking the medication immediately if they develop a rash. Severe cutaneous adverse reaction (SCAR), drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome are potential risks. Certain ethnic groups, such as the Chinese, Korean, and Thai people, are at an increased risk of these dermatological reactions. Patients at high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele. Allopurinol can interact with other medications, such as azathioprine, cyclophosphamide, and theophylline. Azathioprine is metabolized to the active compound 6-mercaptopurine, which is oxidized to 6-thiouric acid by xanthine oxidase. Allopurinol can lead to high levels of 6-mercaptopurine, so a much-reduced dose must be used if the combination cannot be avoided. Allopurinol also reduces renal clearance of cyclophosphamide, which may cause marrow toxicity. Additionally, allopurinol causes an increase in plasma concentration of theophylline by inhibiting its breakdown.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 71 - A 70-year-old man is experiencing excessive breast tissue growth and is worried about...

    Correct

    • A 70-year-old man is experiencing excessive breast tissue growth and is worried about it. He has a medical history of dyspepsia, hypertension, and left ventricular systolic dysfunction, and has recently undergone treatment for prostate cancer. Which medication from his prescription list is the most likely cause of his symptoms?

      Your Answer: Goserelin

      Explanation:

      The use of GnRH agonists (such as goserelin) for treating prostate cancer can lead to the development of gynaecomastia. This medication can also cause loss of libido and erectile dysfunction due to its mode of action. Bisoprolol does not have any known association with gynaecomastia. While metoclopramide can cause nipple discharge and hyperprolactinaemia, it is not linked to gynaecomastia. On the other hand, cimetidine (not omeprazole) is known to cause gynaecomastia.

      Understanding Gynaecomastia: Causes and Drug Triggers

      Gynaecomastia is a medical condition that occurs when males develop an abnormal amount of breast tissue. This condition is usually caused by an increased ratio of oestrogen to androgen. It is important to differentiate the causes of galactorrhoea, which is due to the actions of prolactin on breast tissue, from those of gynaecomastia.

      There are several causes of gynaecomastia, including physiological changes that occur during puberty, syndromes with androgen deficiency such as Kallman’s and Klinefelter’s, testicular failure, liver disease, testicular cancer, ectopic tumour secretion, hyperthyroidism, and haemodialysis. Additionally, certain drugs can trigger gynaecomastia, with spironolactone being the most common drug cause. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids.

      It is important to note that while drug-induced gynaecomastia is rare, there are still some drugs that can trigger this condition. Some of the very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa. Understanding the causes and drug triggers of gynaecomastia can help individuals seek appropriate medical attention and treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 72 - 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
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  • Question 73 - A 56-year-old man with a history of hypertension presents for follow-up. He is...

    Correct

    • 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: 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
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  • Question 74 - A 25-year-old man comes to you with concerns about feeling unwell along with...

    Correct

    • A 25-year-old man comes to you with concerns about feeling unwell along with his roommate for the past few weeks. What is the most prevalent symptom of carbon monoxide poisoning?

      Your Answer: Headache

      Explanation:

      The most common symptom of carbon monoxide poisoning is a headache. Severe toxicity can be identified by cherry red skin, which is typically observed after death.

      Understanding Carbon Monoxide Poisoning

      Carbon monoxide poisoning occurs when carbon monoxide, a toxic gas, is inhaled and binds to haemoglobin and myoglobin in the body, resulting in tissue hypoxia. This leads to a left-shift of the oxygen dissociation curve, causing a decrease in oxygen saturation of haemoglobin. In the UK, there are approximately 50 deaths per year from accidental carbon monoxide poisoning.

      Symptoms of carbon monoxide toxicity include headache, nausea and vomiting, vertigo, confusion, and subjective weakness. Severe toxicity can result in pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and even death.

      To diagnose carbon monoxide poisoning, pulse oximetry may not be reliable due to similarities between oxyhaemoglobin and carboxyhaemoglobin. Therefore, a venous or arterial blood gas should be taken to measure carboxyhaemoglobin levels. Non-smokers typically have levels below 3%, while smokers have levels below 10%. Symptomatic patients have levels between 10-30%, and severe toxicity is indicated by levels above 30%. An ECG may also be useful to check for cardiac ischaemia.

      In the emergency department, patients with suspected carbon monoxide poisoning should receive 100% high-flow oxygen via a non-rebreather mask. This decreases the half-life of carboxyhemoglobin and should be administered as soon as possible, with treatment continuing for a minimum of six hours. Target oxygen saturations are 100%, and treatment is generally continued until all symptoms have resolved. For more severe cases, hyperbaric oxygen therapy may be considered, as it has been shown to have better long-term outcomes than standard oxygen therapy. Indications for hyperbaric oxygen therapy include loss of consciousness, neurological signs other than headache, myocardial ischaemia or arrhythmia, and pregnancy.

      Overall, understanding the pathophysiology, symptoms, and management of carbon monoxide poisoning is crucial in preventing and treating this potentially deadly condition.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 75 - What statement regarding the pharmacology of trimethoprim is correct? Choose only one option...

    Correct

    • What statement regarding the pharmacology of trimethoprim is correct? Choose only one option from the list.

      Your Answer: It can be combined with sulfamethoxazole for synergistic reasons

      Explanation:

      Understanding Trimethoprim: Uses, Synergy, and Potential Side Effects

      Trimethoprim is an antimicrobial drug that is commonly used to treat urinary tract infections and prevent Pneumocystis jirovecii pneumonia. It works by inhibiting the reduction of dihydrofolic acid to tetrahydrofolic acid, which is essential for bacterial DNA synthesis. While it is often combined with sulfamethoxazole for synergistic reasons, serum level monitoring is not required for dosage guidance. However, caution should be exercised in individuals with a predisposition to folate deficiency, as trimethoprim can lower folic acid levels and lead to megaloblastic anemia. While hepatic toxicity has not been reported, it is important to be aware of potential side effects when using this medication.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 76 - A 21-year-old female inpatient on the surgical ward developed sudden uncontrollable eye movements,...

    Incorrect

    • A 21-year-old female inpatient on the surgical ward developed sudden uncontrollable eye movements, with prolonged involuntary upward deviation of the eyes.
      Which of the following drugs is most likely to be responsible?

      Your Answer: Carbamazepine

      Correct Answer: Metoclopramide

      Explanation:

      Understanding the Causes of Dystonic Reactions: A Comparison of Common Drugs

      Metoclopramide, carbamazepine, cyclopentolate, lidocaine, and procyclidine are all drugs that can cause various side effects, including disturbances in eye movement. However, when it comes to dystonic reactions, metoclopramide and procyclidine are the most likely culprits. Metoclopramide, commonly used for nausea and vomiting, can induce acute dystonic reactions involving facial and skeletal muscle spasms and oculogyric crises. On the other hand, procyclidine, an anti-muscarinic drug, is useful in the immediate treatment of a drug-induced oculogyric crisis. Understanding the differences between these drugs and their potential side effects is crucial in providing appropriate treatment for patients experiencing dystonic reactions.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 77 - A 68-year-old woman with chronic osteoarthritis to multiple joints has been managed on...

    Incorrect

    • A 68-year-old woman with chronic osteoarthritis to multiple joints has been managed on morphine modified-release for several months. She currently takes 30 mg morphine modified-release twice daily. She has also been using Oramorph 10 mg four times daily for the past week because the twice-daily, 30-mg morphine modified-release has not been helping. You decide to increase the total dose of modified-release morphine.
      Which of the following is the most appropriate dose of morphine modified-release?
      Select the SINGLE most appropriate dose from the list below. Select ONE option only.

      Your Answer: Morphine modified-release 40 mg twice daily

      Correct Answer: Morphine modified-release 50 mg twice daily

      Explanation:

      Understanding Opioid Conversion and Dosage Adjustments

      When managing pain in patients with advanced and progressive disease, strong opioids such as morphine are often used. However, as the patient’s condition changes, adjustments to the dosage and type of opioid may be necessary.

      For example, if a patient is using a total of 100 mg of morphine in 24 hours and requires increased use of Oramorph PRN, it may be appropriate to increase the total daily dose of morphine modified-release. To calculate the new dose, simply add the total amount of morphine used in 24 hours and divide by 2, which gives a twice-daily dose for morphine modified-release.

      It is important to note that transdermal patch formulations should not be routinely offered to patients for whom oral opioids are suitable. If a patient requires additional pain relief, other options such as adding a fentanyl patch may be considered.

      When converting between different opioids, it is important to consult the BNF or local guidance for equi-analgesic potencies. For example, 10 mg of oral morphine is equivalent to 100 mg of codeine phosphate or dihydrocodeine, 1.3 mg of hydromorphone, 5 mg of oxycodone, 25 mg of tapentadol, or 67 mg of tramadol.

      Dosage adjustments should always be undertaken with specialist advice, especially when converting to or from methadone. Transdermal opioids also require careful consideration, with buprenorphine and fentanyl patches available in various strengths and corresponding oral morphine equivalents.

      In summary, understanding opioid conversion and dosage adjustments is crucial for effective pain management in patients with advanced and progressive disease.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 78 - A senior citizen who is taking digoxin asks you about the toxic effects...

    Correct

    • A senior citizen who is taking digoxin asks you about the toxic effects of digoxin therapy, having read about it on the internet.
      Which of the following is associated with digoxin toxicity?

      Your Answer: Premature ventricular beats

      Explanation:

      Understanding Digoxin Toxicity: Symptoms and Risk Factors

      Digoxin toxicity can occur suddenly in cases of overdose or gradually during long-term treatment. It is a common issue among elderly patients and is often associated with risk factors such as hypokalemia, hypomagnesemia, and hypercalcemia. The most common and earliest dysrhythmia in digoxin toxicity is the finding of premature ventricular beats on an ECG, along with sinus bradycardia. Other ECG changes may include depressed conduction, bigeminal and trigeminal rhythms, ventricular bigeminy, and bidirectional ventricular tachycardia. Hair loss is not associated with digoxin toxicity, but gum/gingival hypertrophy can be caused by other drugs. Loss of appetite, vomiting, anorexia, and fatigue are common symptoms reported by patients. It is important to understand the symptoms and risk factors associated with digoxin toxicity to ensure proper treatment and management.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 79 - A 61-year-old man with a known history of type 2 diabetes mellitus, atrial...

    Correct

    • A 61-year-old man with a known history of type 2 diabetes mellitus, atrial fibrillation and epilepsy presents with a complaint of feeling generally unwell. He reports a blue tinge to his vision. Which medication is most likely responsible for this symptom?

      Your Answer: Sildenafil

      Explanation:

      Drug-induced visual alterations
      Viagra, also known as ‘the blue pill’, can cause blue-tinted vision. Digoxin, on the other hand, may result in yellow-green vision.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 80 - A 25-year-old man presents to the emergency department with symptoms of nausea and...

    Correct

    • A 25-year-old man presents to the emergency department with symptoms of nausea and vomiting. An F1 administers metoclopramide, but 20 minutes later the patient reports feeling as though his eyes are stuck in an abnormal position and he cannot move them. What is the likely cause of this man's symptoms?

      Your Answer: Acute dystonia

      Explanation:

      The administration of metoclopramide can result in extrapyramidal side effects, with acute dystonia being the earliest and most common. This can lead to oculogyric crises, particularly in young individuals. Long-term side effects may include akathisia, parkinsonism, and tardive dyskinesia. The patient’s history does not suggest an allergic reaction, as there were no symptoms such as facial or lip swelling, breathing or circulatory issues, or the presence of a rash.

      Metoclopramide is a medication that is commonly used to manage nausea. It works by blocking D2 receptors in the chemoreceptor trigger zone, which helps to alleviate feelings of sickness. In addition to its antiemetic properties, metoclopramide also has other uses, such as treating gastro-oesophageal reflux disease and gastroparesis caused by diabetic neuropathy. It is often combined with analgesics to treat migraines, which can cause gastroparesis and slow the absorption of pain medication.

      However, metoclopramide can have some adverse effects, such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. These side effects are particularly problematic in children and young adults. It is important to note that metoclopramide should not be used in cases of bowel obstruction, but it may be helpful in cases of paralytic ileus.

      Although metoclopramide primarily works as a D2 receptor antagonist, its mechanism of action is quite complex. It also acts as a mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist. The antiemetic effects of metoclopramide are due to its D2 receptor antagonist activity in the chemoreceptor trigger zone, while its gastroprokinetic effects are mediated by both D2 receptor antagonist and 5-HT4 receptor agonist activity. At higher doses, the 5-HT3 receptor antagonist activity also comes into play.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 81 - A patient who cannot tolerate aspirin is prescribed clopidogrel for secondary prevention of...

    Incorrect

    • A patient who cannot tolerate aspirin is prescribed clopidogrel for secondary prevention of ischaemic heart disease. What medication, if taken concurrently, may reduce the effectiveness of clopidogrel?

      Your Answer: Long-term tetracycline use (e.g. For acne rosacea)

      Correct Answer: Omeprazole

      Explanation:

      Clopidogrel: An Antiplatelet Agent for Cardiovascular Disease

      Clopidogrel is a medication used to manage cardiovascular disease by preventing platelets from sticking together and forming clots. It is commonly used in patients with acute coronary syndrome and is now also recommended as a first-line treatment for patients following an ischaemic stroke or with peripheral arterial disease. Clopidogrel belongs to a class of drugs called thienopyridines, which work in a similar way. Other examples of thienopyridines include prasugrel, ticagrelor, and ticlopidine.

      Clopidogrel works by blocking the P2Y12 adenosine diphosphate (ADP) receptor, which prevents platelets from becoming activated. However, concurrent use of proton pump inhibitors (PPIs) may make clopidogrel less effective. The Medicines and Healthcare products Regulatory Agency (MHRA) issued a warning in July 2009 about this interaction, and although evidence is inconsistent, omeprazole and esomeprazole are still cause for concern. Other PPIs, such as lansoprazole, are considered safe to use with clopidogrel. It is important to consult with a healthcare provider before taking any medications to ensure safe and effective treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 82 - A 70-year-old man in the cardiology ward is experiencing muscle cramps, palpitations, and...

    Correct

    • A 70-year-old man in the cardiology ward is experiencing muscle cramps, palpitations, and constipation. Upon conducting blood tests, the following results were obtained: Sodium 140 mmol/L, Potassium 3.1mmol/L, Calcium 2.2mmol/L, Phosphate 1.1mmol/L, and Magnesium 0.7mmol/L. Which medication is the most probable cause of this disturbance?

      Your Answer: Bumetanide

      Explanation:

      Hypokalaemia is a possible adverse effect of loop diuretics, such as bumetanide. Other potential side effects of bumetanide include hypocalcaemia, metabolic alkalosis, ototoxicity, and gout. Digoxin toxicity may lead to hyperkalaemia, but not hypokalaemia. Ace inhibitors like enalapril are more likely to cause hyperkalaemia than hypokalaemia, and may also result in dry cough, hypotension, and angioedema. Propranolol, a non-selective beta blocker, is not typically associated with hypokalaemia, but may cause bronchospasm, hypertriglyceridemia, and hypoglycaemia.

      Loop Diuretics: Mechanism of Action and Indications

      Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. This reduces the absorption of NaCl and increases the excretion of water and electrolytes, making them effective in treating conditions such as heart failure and resistant hypertension. Loop diuretics act on NKCC2, which is more prevalent in the kidneys.

      As loop diuretics work on the apical membrane, they must first be filtered into the tubules by the glomerulus before they can have an effect. This means that patients with poor renal function may require higher doses to achieve a sufficient concentration within the tubules.

      Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also effective in treating resistant hypertension, particularly in patients with renal impairment.

      However, loop diuretics can have adverse effects, including hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment (from dehydration and direct toxic effect), hyperglycemia (less common than with thiazides), and gout.

      In summary, loop diuretics are effective medications for treating heart failure and resistant hypertension, but their use should be carefully monitored due to potential adverse effects. Patients with poor renal function may require higher doses to achieve therapeutic effects.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 83 - A 55-year-old man with a history of coronary artery disease is interested in...

    Correct

    • A 55-year-old man with a history of coronary artery disease is interested in using sildenafil to treat his erectile dysfunction. Is there any medication that could potentially prohibit its use?

      Your Answer: Nicorandil

      Explanation:

      Nitrates and nicorandil are contraindicated with PDE 5 inhibitors such as sildenafil due to the nitrate component in nicorandil and its additional function as a potassium channel activator.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 84 - Which one of the following statements regarding metformin is true? ...

    Incorrect

    • Which one of the following statements regarding metformin is true?

      Your Answer: May cause a metabolic alkalosis

      Correct Answer: Should be stopped in a patient admitted with a myocardial infarction

      Explanation:

      After a heart attack, Metformin usage should be discontinued as it can increase the risk of lactic acidosis. However, it can be reintroduced at a later time. To manage diabetes, an insulin/dextrose infusion such as the DIGAMI regimen can be used.

      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
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  • Question 85 - Which of the following statements about saxagliptin is true? ...

    Correct

    • Which of the following statements about saxagliptin is true?

      Your Answer: It is a DPP-4 inhibitor

      Explanation:

      Saxagliptin: A DPP-4 Inhibitor for Type 2 Diabetes Treatment

      Saxagliptin is an oral hypoglycaemic drug that belongs to the dipeptidyl peptidase-4 (DPP-4) inhibitor class. Its mechanism of action involves slowing down the breakdown of incretin hormones, which stimulates insulin production and reduces gluconeogenesis in the liver. Compared to sitagliptin, saxagliptin has a shorter half-life. It is safe to use in patients with mild to moderate renal impairment, but should be avoided in severe cases. Saxagliptin is recommended as first-line therapy for type 2 diabetes in combination with other drugs or as initial monotherapy if metformin is contraindicated or not tolerated. However, its use during pregnancy and breastfeeding should be avoided due to potential toxicity. Regular monitoring of renal function is necessary before and during saxagliptin treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 86 - A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking...

    Incorrect

    • A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking a detailed medical history and conducting a thorough physical examination, the GP orders an outpatient chest CT scan. The results reveal lung fibrosis as the likely cause of the patient's symptoms. The patient has a medical history of gout and rheumatoid arthritis. Which medication prescribed to the patient is most likely responsible for causing lung fibrosis?

      Your Answer: Nefopam

      Correct Answer: Sulfasalazine

      Explanation:

      Drugs that can lead to lung fibrosis

      Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 87 - A 28-year-old woman who is 16 weeks' pregnant complains of frequent urination. Urinalysis...

    Correct

    • A 28-year-old woman who is 16 weeks' pregnant complains of frequent urination. Urinalysis confirms the presence of nitrites and leukocytes.
      What is the most appropriate antibiotic to prescribe?

      Your Answer: Nitrofurantoin

      Explanation:

      Management of Urinary Tract Infections in Pregnancy: Antibiotic Options and Guidelines

      Urinary tract infections (UTIs) are common during pregnancy and require prompt treatment to prevent complications. The current UK antimicrobial guidelines recommend nitrofurantoin as the first-line treatment for UTIs in pregnancy, with amoxicillin as an alternative if the microorganism is susceptible to it. Trimethoprim should be avoided due to its teratogenicity risk, while ciprofloxacin is only used for specific cases. Vancomycin is reserved for severe cases of Clostridium difficile infection. Symptomatic relief with paracetamol can also be offered. Urine cultures should be sent before starting empirical antibiotic treatment and as a test of cure after treatment completion. Follow-up is necessary to check treatment response and culture results. This article provides a comprehensive overview of the antibiotic options and guidelines for managing UTIs in pregnancy.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 88 - A 50-year-old man with a history of ischaemic heart disease complains of myalgia....

    Correct

    • A 50-year-old man with a history of ischaemic heart disease complains of myalgia. He has been taking aspirin, simvastatin, and atenolol for a long time. A creatine kinase test is performed due to his statin use, and the results show:
      Creatine kinase 1,420 u/l (< 190 u/l)

      The patient's symptoms appeared after starting a new medication. Which of the following is the most probable cause of the elevated creatine kinase levels?

      Your Answer: Clarithromycin

      Explanation:

      The interaction between statins and erythromycin/clarithromycin is significant and frequent, and in this case, the patient has experienced statin-induced myopathy due to clarithromycin.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 89 - Methimazole (MMI) has a modest therapeutic advantage over carbimazole in the treatment of...

    Correct

    • 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: 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
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  • Question 90 - A 55-year-old woman has been prescribed simvastatin for primary prevention of cardiovascular disease...

    Correct

    • A 55-year-old woman has been prescribed simvastatin for primary prevention of cardiovascular disease (CVD).
      Which of the following should be the NEXT step?

      Your Answer: Check LFTs and lipid profiles at 3 months

      Explanation:

      Monitoring Statin Therapy: Recommended Blood Tests and Timing

      Statin therapy is a common treatment for patients with high cholesterol levels, both for primary and secondary prevention of cardiovascular disease. However, regular monitoring is necessary to ensure the treatment is effective and safe. Here are some recommended blood tests and their timing for monitoring statin therapy:

      Recommended Blood Tests and Timing for Monitoring Statin Therapy

      Check LFTs and lipid profiles at 3 months

      Within three months of starting high-intensity statin treatment, it is recommended to measure total cholesterol, HDL-cholesterol, and non-HDL cholesterol. The aim is to achieve a >40% reduction in non-HDL-cholesterol. LFTs should also be checked at this time and again at 12 months, unless clinically indicated.

      Check LFTs and lipid profiles at 12 months

      Both LFTs and the lipid profile should be checked at 12 months, but it is important to assess whether a suitable cholesterol level reduction has been achieved earlier in the process. This allows for discussion of adherence to medication, diet, and lifestyle measures, and consideration of increasing the dose.

      Check LFTs at 1 week

      Checking LFTs within a week of starting treatment is not necessary, as any liver abnormalities would be unlikely to develop so soon without the patient experiencing symptoms of acute liver disease.

      Check the lipid profiles at 1 month

      It takes approximately 6-8 weeks for a stable result in lipid reduction to be seen after starting a statin, so checking the lipid profile at 1 month is not appropriate.

      Check TFTs at 3 months

      There is no need to check thyroid function tests during statin therapy for monitoring purposes. However, patients with other conditions that justify TFTs should have them done as clinically appropriate.

      Regular monitoring of statin therapy through blood tests is crucial for ensuring the treatment is effective and safe for patients with high cholesterol levels.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 91 - ß-blockers (ß-adrenergic agents) are used in the treatment of angina due to their...

    Correct

    • ß-blockers (ß-adrenergic agents) are used in the treatment of angina due to their specific properties. Which property from the list below is utilized for this purpose?

      Your Answer: Decrease the heart rate and myocardial contractility

      Explanation:

      The Effects of Beta Blockers on the Heart and Vasculature

      Beta blockers are medications that inhibit the actions of adrenaline and noradrenaline on the heart and vasculature. By blocking beta-1 receptors, they decrease heart rate and myocardial contractility, resulting in a reduction in cardiac workload and oxygen demand. This negative chronotropic and inotropic effect also helps control heart rate and decreases cardiac contractility.

      While beta-2 receptors can cause vascular muscle dilation, the effect is overshadowed by the more dominant vasoconstricting alpha-1 receptors. Therefore, beta blockers may cause some vascular constriction, but the greatest effect remains in the heart.

      Beta blockers also have anti-arrhythmic effects by depressing sinus node function and atrioventricular node conduction. They can decrease left atrium diameter and volume, alleviating high pressure in the left atrium. However, a 2017 study found that beta-blocker use is associated with impaired left atrium function in hypertension.

      Overall, beta blockers have been shown to decrease mortality rates, reduce hospitalizations and the risk of sudden death, improve left ventricular function and exercise tolerance, and reduce heart failure functional class.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 92 - A characteristic clinical finding of opioid overdose is: ...

    Correct

    • A characteristic clinical finding of opioid overdose is:

      Your Answer: Bradycardia

      Explanation:

      Understanding the Symptoms of Opioid Overdose: The Opioid Overdose Triad

      Opioid overdose is a serious and potentially life-threatening condition that can result from the misuse or abuse of opioids. It is important to recognize the symptoms of opioid overdose in order to provide prompt and effective treatment. The opioid overdose triad is a set of three hallmark symptoms that are commonly seen in opioid overdose: decreased level of consciousness, pinpoint pupils, and respiratory depression.

      Bradycardia, or a slow heart rate, is a common side effect of opioid overdose. However, hypothermia is not typically seen in opioid overdose and is more commonly associated with barbiturate overdose. Tachypnoea, or rapid respiration, is not a symptom of opioid overdose; instead, respiratory depression, or slow and shallow breathing, is a key feature. Prolonged hypoxia from respiratory depression can lead to permanent damage to the central nervous system or even death, even if treatment with naloxone is given. It is important to note that alcohol can also cause respiratory depression and increase the risk of overdose when taken with opioids.

      Sweating and lacrimation, or excessive sweating and tearing, are frequently seen in early opioid withdrawal but are not symptoms of overdose. Pupillary constriction, or pinpoint pupils, is a hallmark feature of opioid overdose, while pupillary dilatation is not.

      Recognizing the symptoms of opioid overdose, including the opioid overdose triad, is crucial for prompt and effective treatment. If you suspect someone is experiencing an opioid overdose, call for emergency medical assistance immediately.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 93 - A 32-year-old woman is diagnosed with breast cancer. After undergoing a wide local...

    Incorrect

    • A 32-year-old woman is diagnosed with breast cancer. After undergoing a wide local excision, it is discovered that the tumour is oestrogen-receptor positive. To lower the risk of recurrence, she is prescribed tamoxifen as adjuvant treatment. What is the most probable adverse effect she may encounter?

      Your Answer: Deep vein thrombosis

      Correct Answer: Hot flushes

      Explanation:

      Hot flushes are a common side effect of tamoxifen, a medication used to treat oestrogen-receptor positive breast cancer by selectively blocking oestrogen receptors. Other side effects are similar to those experienced during menopause due to the systemic blockade of oestrogen receptors. Tamoxifen does not cause deep vein thrombosis (DVT) in itself, but patients taking it are at a higher risk of developing DVT during periods of immobility. Patients with a personal or family history of unprovoked thromboembolism should not start tamoxifen treatment. Tamoxifen increases the risk of developing endometrial cancer over time, but the risk is still lower than that of experiencing hot flushes. Hair thinning, rather than hair loss, is a possible side effect of tamoxifen. Tamoxifen may also cause headaches, including migraines, but this occurs less frequently than hot flushes.

      Tamoxifen: A SERM for Breast Cancer Management

      Tamoxifen is a medication that belongs to the class of Selective oEstrogen Receptor Modulators (SERMs). It works by acting as an antagonist to the oestrogen receptor while also partially agonizing it. This medication is commonly used in the management of breast cancer that is positive for oestrogen receptors. However, tamoxifen can cause some adverse effects such as menstrual disturbances like vaginal bleeding and amenorrhoea, hot flushes, venous thromboembolism, and endometrial cancer. Climacteric side-effects are also common, with 3% of patients stopping tamoxifen due to this reason. Typically, tamoxifen is used for five years after the removal of the tumour. For those who are at risk of endometrial cancer, raloxifene is a better option as it is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer.

      Overall, tamoxifen is a useful medication for the management of breast cancer that is positive for oestrogen receptors. However, it is important to be aware of the potential adverse effects that it can cause. Patients who experience any of these side-effects should consult their healthcare provider. Additionally, for those who are at risk of endometrial cancer, raloxifene may be a better option to consider.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 94 - A 26-year-old woman with bipolar disorder presents to the GP clinic for a...

    Incorrect

    • A 26-year-old woman with bipolar disorder presents to the GP clinic for a medication review as she plans to conceive. She is currently prescribed lithium as a mood stabilizer. What potential fetal abnormality should be considered with this medication?

      Your Answer: Craniofacial abnormalities

      Correct Answer: Ebstein's anomaly

      Explanation:

      Cardiac foetal abnormalities, specifically Ebstein’s anomaly, can be caused by lithium. Chloramphenicol is linked to ‘Grey baby’ syndrome, while ACE inhibitors, alcohol, carbamazepine, valproate, and warfarin are associated with craniofacial abnormalities. Carbamazepine and valproate are also linked to neural tube defects.

      Harmful Drugs and Medical Conditions for Developing Fetuses

      During pregnancy, certain drugs and medical conditions can harm the developing fetus. These harmful substances and conditions are known as teratogens. Some of the teratogens that can cause harm to a developing fetus include ACE inhibitors, alcohol, aminoglycosides, carbamazepine, chloramphenicol, cocaine, diethylstilbesterol, lithium, maternal diabetes mellitus, smoking, tetracyclines, thalidomide, and warfarin.

      ACE inhibitors can cause renal dysgenesis and craniofacial abnormalities in the fetus. Alcohol consumption during pregnancy can lead to craniofacial abnormalities. Aminoglycosides can cause ototoxicity, while carbamazepine can cause neural tube defects and craniofacial abnormalities. Chloramphenicol can cause grey baby syndrome, and cocaine can lead to intrauterine growth retardation and preterm labor.

      Diethylstilbesterol can cause vaginal clear cell adenocarcinoma, while lithium can cause Ebstein’s anomaly (atrialized right ventricle). Maternal diabetes mellitus can cause macrosomia, neural tube defects, polyhydramnios, preterm labor, and caudal regression syndrome. Smoking during pregnancy can lead to preterm labor and intrauterine growth retardation. Tetracyclines can cause discolored teeth, while thalidomide can cause limb reduction defects. Finally, warfarin can cause craniofacial abnormalities in the fetus.

      It is important for pregnant women to avoid exposure to these harmful substances and conditions to ensure the healthy development of their fetus.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 95 - Which of the following relating to St John's Wort is not true? ...

    Correct

    • Which of the following relating to St John's Wort is not true?

      Your Answer: Causes inhibition of the P450 system

      Explanation:

      The P450 system is known to be induced by St John’s Wort.

      St John’s Wort: An Alternative Treatment for Mild-Moderate Depression

      St John’s Wort has been found to be as effective as tricyclic antidepressants in treating mild-moderate depression. Its mechanism of action is thought to be similar to SSRIs, although it has also been shown to inhibit noradrenaline uptake. However, the National Institute for Health and Care Excellence (NICE) advises against its use due to uncertainty about appropriate doses, variation in the nature of preparations, and potential serious interactions with other drugs.

      In clinical trials, the adverse effects of St John’s Wort were similar to those of a placebo. However, it can cause serotonin syndrome and is an inducer of the P450 system, which can lead to decreased levels of drugs such as warfarin and ciclosporin. Additionally, the effectiveness of the combined oral contraceptive pill may be reduced.

      Overall, St John’s Wort may be a viable alternative treatment for those with mild-moderate depression. However, caution should be exercised due to potential interactions with other medications and the lack of standardization in dosing and preparation. It is important to consult with a healthcare professional before starting any new treatment.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 96 - A 70-year-old male has been admitted to the cardiology ward following his presentation...

    Correct

    • A 70-year-old male has been admitted to the cardiology ward following his presentation to the emergency department with palpitations and dyspnoea. After further investigations, he was diagnosed with atrial fibrillation and prescribed digoxin for rate control. What is the recommended frequency for routine drug monitoring in this case?

      Your Answer: No routine monitoring required

      Explanation:

      Digoxin levels do not require regular monitoring, unless there is suspicion of toxicity. As this patient is commencing digoxin and has no signs of toxicity, routine monitoring is unnecessary. It is not necessary to measure digoxin levels every month until they have stabilized, nor is it appropriate to monitor the drug every 2 weeks for the first 3 months. Routine monitoring is also not required annually throughout the course of treatment.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 97 - A 50-year-old woman presents to the Emergency department with sudden onset palpitations and...

    Correct

    • A 50-year-old woman presents to the Emergency department with sudden onset palpitations and breathlessness after breakfast. The ECG shows atrial fibrillation. The physician advises her that she has an elevated risk of stroke and recommends starting anticoagulant medication. What scoring system is used to assess stroke risk in patients with atrial fibrillation?

      Your Answer: CHA2DS2-VASc

      Explanation:

      The CHA2DS2-VASc score is utilized for assessing the necessity of anticoagulation in patients with atrial fibrillation. The HAS-BLED score estimates the likelihood of major bleeding in patients receiving anticoagulation for atrial fibrillation. The DRAGON score predicts the 3-month outcome in patients with ischemic stroke who are treated with tissue plasminogen activator (tPA). The ABCD2 score is employed to determine the risk of stroke in patients who have experienced a suspected TIA.

      Common Scoring Systems in Medicine

      In medicine, there are various scoring systems used to assess and determine the severity of different conditions. These scoring systems help healthcare professionals make informed decisions about treatment options and patient care. Some of the most commonly used scoring systems include the CHA2DS2-VASc for anticoagulation in atrial fibrillation, the ABCD2 for risk stratifying patients who have had a suspected TIA, and the NYHA for assessing heart failure severity.

      Other scoring systems include the DAS28 for measuring disease activity in rheumatoid arthritis, the Child-Pugh classification for assessing the severity of liver cirrhosis, and the Wells score for estimating the risk of deep vein thrombosis. The MMSE is used to assess cognitive impairment, while the HAD and PHQ-9 are used to assess the severity of anxiety and depression symptoms. The GAD-7 is a screening tool for generalized anxiety disorder, and the Edinburgh Postnatal Depression Score is used to screen for postnatal depression.

      Other scoring systems include the SCOFF questionnaire for detecting eating disorders, the AUDIT and CAGE for alcohol screening, and the FAST for identifying the symptoms of a stroke. The CURB-65 is used to assess the prognosis of a patient with pneumonia, while the Epworth Sleepiness Scale is used in the assessment of suspected obstructive sleep apnea. The IPSS and Gleason score are used to indicate prognosis in prostate cancer, while the APGAR assesses the health of a newborn immediately after birth. The Bishop score is used to help assess whether induction of labor will be required, and the Waterlow score assesses the risk of a patient developing a pressure sore. Finally, the FRAX is a risk assessment tool developed by WHO which calculates a patient’s 10-year risk of developing an osteoporosis-related fracture.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 98 - A 30-year-old woman has been diagnosed with Graves disease and has been prescribed...

    Correct

    • A 30-year-old woman has been diagnosed with Graves disease and has been prescribed carbimazole. What is the most severe side effect of carbimazole?

      Your Answer: Reversible agranulocytosis

      Explanation:

      Carbimazole: Side Effects and Mechanism of Action

      Carbimazole is a medication used to treat hyperthyroidism by inhibiting the production of thyroid hormones. However, it can also cause several side effects that patients should be aware of.

      The most serious side effect is bone marrow suppression, which can lead to neutropenia and agranulocytosis. Patients should report any symptoms of infection immediately, as routine monitoring of white cell count is not useful. Cholestatic jaundice and drug-induced hepatitis are also possible side effects, but usually reversible upon discontinuation of the drug. Hypoprothrombinaemia, a rare side effect, can increase the risk of bleeding in patients on anticoagulant therapy.

      Carbimazole works by inhibiting the enzyme thyroperoxidase, which is responsible for the synthesis of thyroid hormones. However, its onset of clinical effects is slow because it takes time to deplete the large store of pre-formed thyroid hormones in the thyroid gland.

      In addition to its anti-thyroid effect, carbimazole also has a modest immunosuppressive activity, reduces the serum level of thyroid-stimulating hormone antibody, and can cause a reduction in clotting factor prothrombin. However, these effects are not thought to contribute significantly to its efficacy.

      Overall, patients taking carbimazole should be aware of its potential side effects and report any symptoms to their healthcare provider promptly.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 99 - A 28-year-old man who has been on antiepileptic medication for several years presents...

    Correct

    • A 28-year-old man who has been on antiepileptic medication for several years presents with complaints of fatigue, weakness, bone pain, tingling and numbness in his lower limbs and swelling of his gums. Upon investigation, the following results were obtained:
      Investigation Result Normal value
      Haemoglobin 90 g/l 120-155 g/l
      Mean corpuscular volume 110 fl/red cell 80-96 fl/red cell
      White cell count 6.8 × 109/l 4.5-11 x 109/l
      Platelets 180 × 109/l 150-450 x 109/l
      Alkaline phosphatase 600 IU/l 44-147 IU/l
      Parathyroid hormone 12.2 pmol/ml 10-55 pg/ml
      Which of the following antiepileptic medications is most likely responsible for these symptoms?

      Your Answer: Phenytoin

      Explanation:

      Common Side Effects of Antiepileptic Drugs

      Antiepileptic drugs are commonly used to treat seizures and epilepsy. However, they can also cause various side effects. Here are some of the common side effects of the most commonly used antiepileptic drugs:

      Phenytoin: This drug can cause fatigue, bony tenderness, paraesthesiae, and gingival hypertrophy. Patients should maintain good oral hygiene to minimize this problem. Megaloblastic anemia is a rare but possible side effect.

      Phenobarbital: This drug can cause fatigue, bony tenderness, and paraesthesiae. However, it is not associated with gingival hypertrophy. Megaloblastic anemia is a common side effect, which can be treated with folic acid.

      Primidone: This drug is metabolized to phenobarbital, so its side effects are similar to those of phenobarbital. Drowsiness, visual disturbances, headache, and dizziness are the most common ones. Plasma concentrations of the derived phenobarbital should be monitored for optimum response dosing.

      Sodium valproate: This drug can cause nausea, drowsiness, dizziness, vomiting, and general weakness. Rare but serious side effects include thrombocytopenia, hepatotoxicity, and pancreatitis. Treatment should be withdrawn immediately if there are signs of hepatic dysfunction or pancreatitis.

      Carbamazepine: This drug is associated with blood dyscrasias. Rarely, there are major effects of aplastic anemia and agranulocytosis, but more commonly, they are minor changes limited to decreased white cell count and thrombocytopenia. Regular monitoring of blood counts and hepatic and renal function is recommended. It also carries an increased risk of hyponatremia and syndrome of inappropriate antidiuretic hormone secretion.

      Common Side Effects of Antiepileptic Drugs

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 100 - A 45-year-old woman presents with symptoms of reflux oesophagitis. You decide to initiate...

    Correct

    • A 45-year-old woman presents with symptoms of reflux oesophagitis. You decide to initiate treatment with lansoprazole, as she has already made lifestyle modifications but has not experienced complete relief from her reflux symptoms.
      What is the mechanism of action of lansoprazole?

      Your Answer: It inhibits the H+/K+ ATP ‘proton pump’

      Explanation:

      Proton pump inhibitors (PPIs) are a type of medication that reduces the production of gastric acid by irreversibly blocking the hydrogen/potassium adenosine triphosphatase enzyme system, also known as the gastric proton pump. This is achieved by inhibiting the H+/K+ ATPase proton pump, not the H+/Na+ or H+/Ca2+ ATP proton pumps. PPIs, such as lansoprazole and omeprazole, are more effective than H2 receptor antagonists like ranitidine and are commonly used to treat peptic ulcer disease, gastro-oesophageal reflux disease (GORD), and as part of the triple therapy regimen for the eradication of Helicobacter pylori. Antihistamines, on the other hand, act on histamine receptors such as the H1 and H2 receptors, which are found in smooth muscle, vascular endothelial cells, and the central nervous system.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 101 - A 65-year-old male is prescribed simvastatin for hyperlipidaemia. What is the most probable...

    Incorrect

    • A 65-year-old male is prescribed simvastatin for hyperlipidaemia. What is the most probable interaction with his medication?

      Your Answer:

      Correct Answer: Grapefruit juice

      Explanation:

      The enzyme CYP3A4, which belongs to the cytochrome P450 family, is strongly inhibited by grapefruit juice.

      Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

      Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

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      • Pharmacology/Therapeutics
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  • Question 102 - A 65-year-old man is scheduled for an elective knee replacement and presents to...

    Incorrect

    • A 65-year-old man is scheduled for an elective knee replacement and presents to the orthopaedic surgery ward. He has osteoarthritis and hypertension and is currently being treated for an episode of giant cell arteritis that occurred four months ago with 20 mg prednisolone daily. This will be his first surgery and he is feeling anxious about the anaesthetic. What is the most crucial medication to prescribe before the operation?

      Your Answer:

      Correct Answer: Hydrocortisone

      Explanation:

      Patients who are on chronic glucocorticoid therapy, such as prednisolone for the treatment of conditions like giant cell arteritis, may require hydrocortisone supplementation before undergoing surgery. This is because long-term use of glucocorticoids can suppress the hypothalamic-pituitary-adrenal axis, which can lead to inadequate adrenal gland response during times of stress, such as surgery. The amount of hydrocortisone required depends on the type of surgery being performed, with minor procedures under local anesthesia not requiring supplementation. For moderate to major surgeries, 50mg to 100mg of hydrocortisone should be given before induction, followed by additional doses every 8 hours for 24 hours. Diazepam should not be routinely given to control anxiety, and there is no indication that this patient requires additional medications for her hypertension preoperatively. Instead, the patient may benefit from speaking with someone who can provide reassurance about the procedure.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

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      • Pharmacology/Therapeutics
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  • Question 103 - Concurrent use of which one of the following would decrease the effectiveness of...

    Incorrect

    • Concurrent use of which one of the following would decrease the effectiveness of the combined oral contraceptive pill in individuals under the age of 18?

      Your Answer:

      Correct Answer: St John's Wort

      Explanation:

      The effectiveness of the combined oral contraceptive pill may be reduced by St John’s Wort, which is an enzyme inducer that speeds up the metabolism of the pill in the liver’s P450 enzyme system.

      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.

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      • Pharmacology/Therapeutics
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  • Question 104 - A patient in their early 50s with type 2 diabetes mellitus and chronic...

    Incorrect

    • A patient in their early 50s with type 2 diabetes mellitus and chronic heart failure (NYHA class II) presents for a check-up. Their diabetes is currently managed through diet, but their HbA1c has increased to 64 mmol/mol (8.0%). Which of the following medications should be avoided due to contraindication?

      Your Answer:

      Correct Answer: Pioglitazone

      Explanation:

      Medications to Avoid in Patients with Heart Failure

      Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.

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      • Pharmacology/Therapeutics
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  • Question 105 - A 35-year-old man presents with a 5-month history of cough, fever, and unexplained...

    Incorrect

    • A 35-year-old man presents with a 5-month history of cough, fever, and unexplained weight loss. Acid-fast bacilli are detected in his sputum culture. He is prescribed a drug regimen consisting of isoniazid and rifampicin for 6 months, along with ethambutol and pyrazinamide for the first 2 months. Additionally, he is advised to take pyridoxine to prevent which complication?

      Your Answer:

      Correct Answer: Peripheral neuropathy

      Explanation:

      Prescribing pyridoxine can help lower the risk of peripheral neuropathy associated with isoniazid.

      Side-Effects and Mechanism of Action of Tuberculosis Drugs

      Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

      Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

      In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

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      • Pharmacology/Therapeutics
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  • Question 106 - A 50-year-old homeless female IVDU presents to the ER with a respiratory rate...

    Incorrect

    • A 50-year-old homeless female IVDU presents to the ER with a respiratory rate of 8/min and drowsiness. Her blood pressure is 85/60 mmHg and her heart rate is 120 bpm. The doctor observes pinpoint pupils and needle track marks on both arms during the physical examination. After receiving emergency treatment, she responds well and is recommended to stay as an inpatient for detoxification. What medication is suitable for her detoxification?

      Your Answer:

      Correct Answer: Methadone

      Explanation:

      The recommended first-line treatment for opioid detoxification is methadone or buprenorphine. A patient with pinpoint pupils, hypotension, tachycardia, drowsiness, and low respiratory rate is likely to have overdosed on opioids. Methadone, a man-made opioid, is used to reduce withdrawal symptoms in those dependent on stronger opioids like heroin. NICE guidelines suggest outpatient detoxification as the routine option, unless the patient has not benefited from it in the past, has physical or mental health needs, social issues, or requires polydrug detoxification. Flumazenil and naloxone are not used in opioid detoxification, but in benzodiazepine poisoning and emergency management of opioid overdose, respectively. Pralidoxime is used in organophosphate poisoning, not in opioid overdoses.

      Understanding Opioid Misuse and Management

      Opioid misuse is a serious problem that can lead to various complications and health risks. Opioids are substances that bind to opioid receptors, including both natural and synthetic opioids. Signs of opioid misuse include rhinorrhoea, needle track marks, pinpoint pupils, drowsiness, watering eyes, and yawning. Complications of opioid misuse can range from viral and bacterial infections to venous thromboembolism and overdose, which can lead to respiratory depression and death.

      In case of an opioid overdose, emergency management involves administering IV or IM naloxone, which has a rapid onset and relatively short duration of action. Harm reduction interventions such as needle exchange and testing for HIV, hepatitis B & C can also be helpful.

      Patients with opioid dependence are usually managed by specialist drug dependence clinics or GPs with a specialist interest. Treatment options may include maintenance therapy or detoxification, with methadone or buprenorphine recommended as the first-line treatment by NICE. Compliance is monitored using urinalysis, and detoxification can last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community. Understanding opioid misuse and management is crucial in addressing this growing public health concern.

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      • Pharmacology/Therapeutics
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  • Question 107 - The action of warfarin is characterized by which of the following statements? ...

    Incorrect

    • The action of warfarin is characterized by which of the following statements?

      Your Answer:

      Correct Answer: It interacts with miconazole to increase anticoagulant effect

      Explanation:

      Warfarin, a medication used to prevent blood clots, can interact with other drugs and have various effects on the body. For example, certain antimicrobial agents can increase the risk of bleeding in patients taking warfarin, including azole antifungals, macrolides, quinolones, co-trimoxazole, penicillins, and cephalosporins. Miconazole, in particular, can greatly enhance the anticoagulant effect of warfarin. Warfarin works by blocking the action of vitamin K epoxide reductase, which reactivates vitamin K1. This decreases the clotting ability of certain factors in the blood. However, warfarin can also have negative effects, such as warfarin necrosis, a rare but serious complication that can lead to skin necrosis and limb gangrene. When taking warfarin, it is important to consider drug interactions, such as displacement from protein-binding sites or enzyme inhibition or induction.

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