MRCP2 Flashcards

Question

Features of canabinoid overdose?

Answer 1

CNS: agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma. Cardiac: tachycardia, hypertension, chest pain, palpitations, ECG changes. Renal: acute kidney injury. Muscular: hypertonia, myoclonus, muscle jerking and myalgia. Other: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia

Answer 2

headache: 90% of cases nausea and vomiting: 50% vertigo: 50% confusion: 30% subjective weakness: 20% severe toxicity: 'pink' skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death

Answer 3

< 3% non-smokers

Answer 4

10 - 30% symptomatic: headache, vomiting > 30% severe toxicity

Answer 5

100% high-flow oxygen via a non-rebreather mask from a physiological perspective, this decreases the half-life of carboxyhemoglobin (COHb)

Answer 6

NRG-1 is a synthetic cathinone drug derivative of phenylpropanone which is a naturally occurring psychotrope in khat (Catha edulis).

Answer 7

increasing synaptic concentrations of noradrenaline, dopamine and serotonin sensation of euphoria, detachment and wellbeing as well as upregulation of the sympathetic system.

Answer 8

Hyponatraemia Serotonin syndrome

Answer 9

Infusion of 3% saline solution at a maximum rate of 1ml/kg/hour

Answer 10

Liberated serotonin and causes agitation, confusion, muscle hyperactivity with fasciculations, hypertonia and clonus. Creatine kinase and white cell counts are often raised and body temperature may be extremely high.

Answer 11

Decreases clonal proliferation of T cells by reducing IL-2 release

Answer 12

nephrotoxicity hepatotoxicity fluid retention hypertension hyperkalaemia hypertrichosis gingival hyperplasia tremor impaired glucose tolerance hyperlipidaemia increased susceptibility to severe infection

Answer 13

Ciclosporin

Answer 14

cocaine blocks the uptake of dopamine, noradrenaline and serotonin

Answer 15

coronary artery spasm → myocardial ischaemia/infarction both tachycardia and bradycardia may occur hypertension QRS widening and QT prolongation aortic dissection

Answer 16

seizures mydriasis hypertonia hyperreflexia

Answer 17

agitation psychosis hallucinations

Answer 18

ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding hyperthermia metabolic acidosis rhabdomyolysis

Answer 19

benzodiazepines are generally first-line for most cocaine-related problems

Answer 20

'classical' features: brick-red skin, smell of bitter almonds acute: hypoxia, hypotension, headache, confusion chronic: ataxia, peripheral neuropathy, dermatitis

Answer 21

supportive measures: 100% oxygen definitive: hydroxocobalamin (intravenously) + combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously) dicobalt edetate

Answer 22

decreases conduction through the atrioventricular node slows the ventricular rate in atrial fibrillation and flutter increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase stimulates vagus nerve

Answer 23

Toxicty can occur even if within therapeutic range BNF advises that the likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.

Answer 24

generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia) gynaecomastia

Answer 25

classically: hypokalaemia increasing age renal failure myocardial ischaemia hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis hypoalbuminaemia hypothermia hypothyroidism

Answer 26

digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects

Answer 27

Digibind correct arrhythmias monitor potassium

Answer 28

Parkinson's disease prolactinoma/galactorrhoea cyclical breast disease acromegaly

Answer 29

nausea/vomiting postural hypotension hallucinations daytime somnolence

Answer 30

Skin, liver, kidneys, lungs and heart.

Answer 31

morbilliform skin rash exfoliative dermatitis, high fever, and inflammation of one or more organs

Answer 32

Can develop any of: raised and low white count, eosinophilia , thrombocytopaenia, anaemia, atypical lymphocytes develop kidney disease which is usually mild (interstitial nephritis is common, renal failure is rare), myocarditis, pericarditis, liver enlargement, hepatitis and rarely hepatic necrosis with liver failure lung disease (pneumonitis, pleuritis, pneumonia), neurological involvement which may lead to meningitis and encephalitis, gastrointestinal symptoms severe cases, acute colitis and pancreatitis can occur, and endocrine abnormalities may include thyroiditis and diabetes.

Answer 33

Hospitalisation Reaction suspected to be drug related Acute skin rash Fever about 38ºC Enlarged lymph nodes at two sites Involvement of at least one internal organ Blood count abnormalities such as low platelets, raised eosinophils or abnormal lymphocyte count.

Answer 34

thiazides, furosemide (less common) steroids tacrolimus, ciclosporin interferon-alpha nicotinic acid antipsychotics Beta-blockers cause a slight impairment of glucose tolerance

Answer 35

tricyclic antidepressants e.g. amitriptyline anticholinergics e.g. antipsychotics, antihistamines opioids NSAIDs disopyramide

Answer 36

Alpha-1: Decongestants (e.g. phenylephrine/oxymetazoline) Alpha-2: Glaucoma (e.g. topical brimonidine)

Answer 37

Benign prostatic hyperplasia (e.g. tamsulosin) Hypertension (e.g. doxazosin)

Answer 38

Inotropes (e.g. dobutamine)

Answer 39

Non-selective & selective beta-blockers (e.g. atenolol, bisoprolol

Answer 40

Bronchodilators (e.g. salbutamol)

Answer 41

Non-selective beta-blockers (e.g. propranolol, labetalol)

Answer 42

Parkinson's disease (e.g. ropinirole) Prolactinoma

Answer 43

Schizophrenia (antipsychotics e.g. haloperidol) Anti-emetics (e.g. metoclopramide/domperidone)

Answer 44

Benzodiazepines Baclofen

Answer 45

Flumazenil

Answer 46

Glaucoma (e.g. pilocarpine)

Answer 47

Atropine (e.g. for bradycardia) Bronchodilator (e.g. ipratropium bromide, tiotropium) Urge incontinence (e.g. oxybutynin)

Answer 48

Nicotine Varenicline (used for smoking cessation) Depolarising muscle relaxant (e.g. suxamethonium)

Answer 49

Non-depolarising muscle relaxants (e.g. atracurium)

Answer 50

Triptans (for acute migraine, e.g. zolmitriptan)

Answer 51

Anti-emetics (e.g. ondansetron)

Answer 52

amiodarone cytotoxic agents: busulphan, bleomycin anti-rheumatoid drugs: methotrexate, sulfasalazine nitrofurantoin ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide)

Answer 53

Ecstasy (MDMA, 3,4-Methylenedioxymethamphetamine

Answer 54

neurological: agitation, anxiety, confusion, ataxia cardiovascular: tachycardia, hypertension hyponatraemia hyperthermia rhabdomyolysis

Answer 55

Dantrolene -may be used for hyperthermia if simple measures fail

Answer 56

Stage 1: symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness Stage 2: metabolic acidosis with high anion gap and high osmolar gap. Also tachycardia, hypertension Stage 3: acute kidney injury

Answer 57

fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol competing with ethylene glycol for the enzyme alcohol dehydrogenaseimits the formation of toxic metabolites Haemofiltration

Answer 58

class 1c antiarrhythmic QRS widening

Answer 59

atrial fibrillation SVT associated with accessory pathway e.g. Wolf-Parkinson-White syndrome

Answer 60

post myocardial infarction structural heart disease: e.g. heart failure sinus node dysfunction; second-degree or greater AV block atrial flutter

Answer 61

negatively inotropic bradycardia proarrhythmic oral paraesthesia visual disturbances

Answer 62

MYASTHENIA GRAVIS

Answer 63

garlic-like odour hypersalivation nausea, vomiting and diarrhoea, abdominal pain oral burns, gastrointestinal bleeding shortness of breath muscle spasms renal tubular acidosis cardiomyopathy jaundice intestinal haemorrhage seizure coma

Answer 64

hardened patches of skin hyperpigmentation of the skin anorexia, weight loss weakness muscle aches chills polyneuritis, peripheral neuropathy ataxia

Answer 65

oedema- subcutaneous and pulmonary Mee's lines (transverse white lines across fingernails) jaundice hypotension exfoliative dermatitis haemolysis ventricular arrhythmia

Answer 66

Activates antithrombin III. Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa

Answer 67

Activates antithrombin III. Forms a complex that inhibits factor Xa

Answer 68

antibodies form against complexes of platelet factor 4 (PF4) and heparin PF4-heparin complexes on the platelet surface and induce platelet activation by cross-linking FcγIIA receptors

Answer 69

5-10 days post treatment

Answer 70

direct thrombin inhibitor e.g. argatroban danaparoid

Answer 71

Metabolic acidosis Erosion of gastric mucosa → GI bleeding Shock Hepatotoxicity and coagulopathy

Answer 72

40mg/kg elemental iron and are asymptomatic can be observed at home. > 40mg/kg elemental iron or who are symptomatic need medical assessment with serum iron levels measured 2-4 hours post-ingestion and abdominal x-ray. decontamination procedure of choice and is performed on all patients presenting within 4 hours who have ingested > 60mg/kg elemental iron or have undissolved tablets on abdominal x-ray. (whole bowel irrigation)

Answer 73

Patients with serum iron level > 90umol/l, Patients with serum iron level 60-90umol/l, who are symptomatic or have persistent iron on abdominal x-ray despite whole bowel irrigation Any patient with shock, coma or metabolic acidosis

Answer 74

20% Lipid emulsion

Answer 75

excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle

Answer 76

chromosome 19 encoding the ryanodine receptor Autosomal dominant

Answer 77

halothane suxamethonium other drugs: antipsychotics (neuroleptic malignant syndrome)

Answer 78

dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

Answer 79

fomepizole (competitive inhibitor of alcohol dehydrogenase) or ethanol haemodialysis cofactor therapy with folinic acid to reduce ophthalmological complications

Answer 80

alcohol (intoxication, nausea etc) and also specific visual problems, including blindness

Answer 81

acute treatment of variceal haemorrhage acromegaly carcinoid syndrome prevent complications following pancreatic surgery VIPomas refractory diarrhoea

Answer 82

Gallstones

Answer 83

Longterm somatostatin analogue

Answer 84

acetylcholinesterase leading to upregulation of nicotinic and muscarinic cholinergic neurotransmission.

Answer 85

Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia also: small pupils, muscle fasciculation

Answer 86

atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Answer 87

activated charcoal if ingested < 1 hour ago N-acetylcysteine (NAC) liver transplantation

Answer 88

urinary alkalinization with IV bicarbonate haemodialysis

Answer 89

Flumazenil The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.

Answer 90

IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity

Answer 91

haemodialysis may be needed in severe toxicity

Answer 92

if bradycardic then atropine in resistant cases glucagon may be used

Answer 93

fomepizole or ethanol haemodialysis

Answer 94

Dimercaprol, calcium edetate

Answer 95

Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

Answer 96

antiepileptics: phenytoin, carbamazepine barbiturates: phenobarbitone rifampicin St John's Wort chronic alcohol intake griseofulvin smoking (affects CYP1A2, reason why smokers require more aminophylline)

Answer 97

antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine,omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin

Answer 98

- 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity - staggered overdose - patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol - patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal

Answer 99

Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy

Answer 100

alcohol, cocaine, amphetamines ciprofloxacin, levofloxacin aminophylline, theophylline bupropion methylphenidate (used in ADHD) mefenamic acid

Answer 101

antibiotics: tetracycline, nitrofurantoin NSAIDs lithium metformin

Answer 102

most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin digoxin, atenolol methotrexate sulphonylureas furosemide opioids

Answer 103

tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies ACE inhibitors, angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents

Answer 104

VERY TOXIC ventricular tachyarrhythmias or fibrillation Hypoglycaemia Looks similar to salicylate poisoning leaves permanent neural damage, if the patient survives.

Answer 105

inhibit topoisomerase II (DNA gyrase) and topoisomerase IV

Answer 106

lower seizure threshold in patients with epilepsy tendon damage (including rupture) - the risk is increased in patients also taking steroids cartilage damage has been demonstrated in animal models and for this reason quinolones are generally avoided (but not necessarily contraindicated) in children lengthens QT interval

Answer 107

Quinolones should generally be avoided in women who are pregnant or breastfeeding avoid in G6PD

Answer 108

hyperventilation (centrally stimulates respiration) tinnitus lethargy sweating, pyrexia* nausea/vomiting hyperglycaemia and hypoglycaemia seizures coma

Answer 109

serum concentration > 700mg/L metabolic acidosis resistant to treatment acute renal failure pulmonary oedema seizures coma

Answer 110

monoamine oxidase inhibitors SSRIs St John's Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome tramadol may also interact with SSRIs ecstasy amphetamines

Answer 111

neuromuscular excitation hyperreflexia myoclonus rigidity autonomic nervous system excitation hyperthermia sweating altered mental state confusion

Answer 112

Cause SSRI --> serotonin Cause Antipsycotic --> neuroleptic Fast onset --> serotonin Slow onset --> neuroleptic Hyperreflexia --> serotonin Weak reflexes --> Neuroleptic dilated pupils --> serotonin Normal pupils --> neuroleptic lead pip reptic --> neurleptic

Answer 113

cyproheptadine and chlorpromazine

Answer 114

Dantrolene

Answer 115

decreases clonal proliferation of T cells by reducing IL-2 release binds to FKBP forming a complex which inhibits calcineurin, a phosphotase that activates various transcription factors in T cells this contrasts with ciclosporin, which binds to cyclophilin rather than FKBP Very similar to ciclosporin

Answer 116

painful polyneuropathy mood change alopecia

Answer 117

flu-like symptoms and diarrhoea are common cardiotoxicity more common when anthracyclines have also been used an echo is usually performed before starting treatment

Answer 118

hepatitis, orange secretions flu-like symptoms

Answer 119

Peripheral neuroapthy hepatitis, agranulocytosis liver enzyme inhibitor

Answer 120

pyridoxine (Vitamin B6)

Answer 121

hyperuricaemia causing gout arthralgia, myalgia hepatitis

Answer 122

optic neuritis: check visual acuity before and during treatment

Answer 123

Prophylaxis Elective hip LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days or LMWH for 28 days combined with anti-embolism stockings until discharge or Rivaroxaban

Answer 124

Aspirin (75 or 150 mg) for 14 days or LMWH for 14 days combined with anti-embolism stockings until discharge or Rivaroxaban

Answer 125

Colour flow doppler

Answer 126

(5-HT2 receptor antagonist)

Answer 127

Adder bites are rare, but when they occur may be extremely painful; the mainstay of treatment is analgesia and supportive therapy. Discuss the use of antivenin with NPIS and do not apply a tourniquet

Answer 128

when INR <1.3, and ALT less than twice upper limit

Answer 129

RAISED GLUCOSE direct corrosion on the gastrointestinal tract may be seen within six hours neutrophil leucocytosis and significant haemolysis of samples due to the high plasma iron burden. APTT tends to be prolonged in iron toxicity compared to the prolongation of prothrombin time in a paracetamol poisoning. Severe iron toxicity presents with liver failure, gastrointestinal caustic damage and coagulopathy with raised APTT. Early hyperglycaemia and extensively haemolysed samples may also indicate significant iron burden

Answer 130

clozapine and olanzapine

Answer 131

Bivalirudin

Answer 132

Inhaled Nitrous oxide

Answer 133

Ciprofloxain strong enzyme inhibitor

Answer 134

Grievous Bodily Harm' is a colourless, odourless, bitter-tasting substance that acts as a CNS depressant Date rape drug Rapid recovery

Answer 135

Serotonin release assay

Answer 136

Broad complex

Answer 137

Serum heavy metals

Answer 138

Broad complex

Answer 139

fompeziole

Answer 140

Beta blockers

Answer 141

euphoria + coma --> GHB Dissociative symptoms --> Methotaxime Acute cerebellar syndrome --> methoxetamine intoxication.

Answer 142

Increased appetite Gastrointestinal dysfunction Mood swings Anxiety Acne Oedema Libido change Scrotal pain Erectile dysfunction Menstrual irregularities

Answer 143

Hirsutism Voice pitch changes Male pattern baldness Skin striae or keloid scarring Chest pain Clitoral hypertrophy Short stature due to premature fusion of growth plates

Answer 144

serotonin syndrome

Answer 145

Intrathecal baclofen withdrawal syndrome is associated with severe spasticity, rhabdomyolysis, acute renal failure and multisystem organ failure

Answer 146

Severe cases Or if they are pregnant

Answer 147

NSAID Thiazides Angiotensin-converting enzyme (ACE) inhibitors

Answer 148

painful polyneuropathy, mood change and alopecia. Treatment is chelation therapy with oral Prussian Blue

Answer 149

Elevated testoestoner: low FSH and low LH

Answer 150

Nitrofurantoin is best avoided in patients with CKD stage 3 or higher due to the significant risk of treatment failure and occurrence of side effects due to drug accumulation

Answer 151

Mechanical If > 12 hours then dalteparin

Answer 152

Urine dithionate testing

Answer 153

Avoid in first 3 months

Answer 154

Cathinone toxicity

Answer 155

failure is defined as two or more fractures on treatment, or one fracture with a reduction in bone density (as in this patient).

Answer 156

Presence of DVT

Answer 157

can be considered for some patient's after five years treatment. patients less than 75 years old with a femoral neck T-score greater than -2.5 and who are defined as low risk by WHO Fracture Risk Assessment Tool (FRAX) must repeat DEXA in 2 years though

Answer 158

elastic, fragile skin joint hypermobility: recurrent joint dislocation easy bruising aortic regurgitation, mitral valve prolapse and aortic dissection subarachnoid haemorrhage angioid retinal streaks

Answer 159

Salivary gland biopsy is the most definitive way of confirming the diagnosis of primary Sjogren’s syndrome - sections will show a typical lymphocytic infiltrate

Answer 160

1. Paracetamol + opical NSAIDs are only appropriate for osteoarthritis of the hands and knees. Second line treatment includes oral NSAIDs, codeine, capsaicin cream and intra-articular corticosteroids.

Answer 161

mcardle syndrome

Answer 162

Periglide Carbergoline