Past Paper Questions Flashcards
A middle-aged patient with type 2 diabetes mellitus comes for review. He also has chronic heart failure secondary to dilated cardiomyopathy (NYHA class II). His diabetes is currently diet-controlled but his HbA1c has risen to 64 mmol/mol (8.0%). Which one of the following medications is contraindicated?
Metformin Pioglitazone Glipizide Exenatide Acarbose
Pioglitazone
The correct answer is Pioglitazone because it is contraindicated in patients with heart failure. Pioglitazone is a thiazolidinedione, which works by increasing insulin sensitivity in peripheral tissues and decreasing hepatic gluconeogenesis. However, it can cause fluid retention and exacerbate heart failure, making it unsuitable for patients with pre-existing heart failure.
An elderly man is admitted to the acute medical unit with dyspnoea. He is known to have ischaemic heart disease and chronic heart failure (NYHA class III). He develops atrial fibrillation with a fast ventricular response during his admission. Which one of the following drugs is contraindicated?
Amiodarone Digoxin Bisoprolol Flecainide Warfarin
Flecainide
The correct answer is Flecainide. Flecainide is a class IC antiarrhythmic that works by slowing the conduction of electrical impulses in the heart. However, it should not be used in patients with structural heart disease, such as ischaemic heart disease and chronic heart failure, due to an increased risk of arrhythmia and mortality. This has been established by studies like the Cardiac Arrhythmia Suppression Trial (CAST) which found an increased risk of death or nonfatal cardiac arrest in post-myocardial infarction patients treated with class IC antiarrhythmics.
A 26-year-old woman with a history of hypothyroidism and antiphospholipid syndrome becomes pregnant. Which one of the following is contraindicated in pregnancy?
Aspirin Low-molecular weight heparin Warfarin Levothyroxine Unfractionated heparin
Warfarin is contraindicated in pregnancy. Most women are switched to low-molecular weight heparin for the duration of the pregnancy.
A 43-year-old woman is referred to psychiatry following repeated episodes of hypomaniac behaviour interspersed with periods of depression. Her past medical history includes psoriasis and a deep vein thrombosis 11 years ago. Which one of the following medications is most likely to worsen her psoriasis?
Sodium valproate Quetiapine Lithium Valproaic acid Fluoxetine
lithium
You review a 60-year-old patient who is known to have chronic obstructive pulmonary disease and epilepsy. Her seizure control has recently worsened. Which one of the following drugs is most likely to worsen seizure control?
Tiotropium (inhaled) Sertraline Clarithromycin Carbocisteine Aminophylline
The correct answer is Aminophylline. Aminophylline, a bronchodilator often used in the management of chronic obstructive pulmonary disease (COPD), has been associated with lowering the seizure threshold and thus can lead to increased seizure activity. This occurs due to its mechanism of action as a nonselective adenosine receptor antagonist and phosphodiesterase inhibitor, causing an increase in intracellular cyclic AMP and subsequent neuronal excitation.
A 39-year-old woman who has recently been diagnosed with hypertension becomes pregnant. Which one of the following medications is contraindicated in pregnancy?
Hydralazine Nifedipine Methyldopa Labetalol Lisinopril
Lisinopril
ACE inhibitors such as lisinopril are known teratogens and most be avoided in pregnant women.
A 72-year-old man who has chronic heart failure secondary to ischaemic heart disease presents with knee pain. A recent x-ray has shown osteoarthritis. Which one of the following medications should be avoided if possible?
Oral ibuprofen Oral paracetamol Oral codeine Oral tramadol Topical diclofenac
Oral NSAIDs such as ibuprofen should be avoided in heart failure as they may cause fluid retention.
You are reviewing a middle-aged man with asthma. Which one of the following drugs is contraindicated?
Lidocaine (intravenous) Adenosine Ramipril Verapamil Doxazosin
Adenosine!!!!
Which one of the following antibiotics should be avoided in patients with epilepsy?
Clindamycin Clarithromycin Levofloxacin Nitrofurantoin Trimethoprim
The correct answer is Levofloxacin. Levofloxacin is a fluoroquinolone antibiotic that has been associated with an increased risk of seizures in patients with epilepsy. This is thought to be due to its inhibitory effect on the gamma-aminobutyric acid (GABA) receptor, which plays a crucial role in the regulation of neuronal excitability. In patients with epilepsy, where there is already a tendency for hyperexcitability, this inhibition can potentially trigger seizures. Therefore, according to UK guidelines, it should be avoided in these patients.
A 21-year-old man presents to the Emergency Department following a deliberate paracetamol overdose four hours ago. He is unsure how many tablets he took but thinks ‘it was about 20’. A blood sample is immediately taken - the results are shown below:
Give activated charcoal + intravenous acetylcysteine Give intravenous acetylcysteine No treatment needed Gastric lavage + intravenous acetylcysteine Repeat the paracetamol level in 4 hours
No treatment needed
As this man took the overdose 4 hours ago we can check his paracetamol levels straight away. Looking at the paracetamol treatment graph he is clearly under the normal treatment line so no treatment is needed.
A 37-year-old woman with a history of type 2 diabetes mellitus and obesity presents after a late period. The urinary hCG test is positive. Her current medication is as follows:
Orlistat 120mg tds
Simvastatin 40mg on
Aspirin 75mg od
Metformin 1g bd
Paracetamol 1g qds
Aqueous cream prn
Which one of her medications must be stopped straight away?
Simvastatin 40mg on
A 68-year-old woman is admitted to the Acute Medical Unit with dyspnoea.
Select the TWO prescriptions that are most likely to interact with each other.
A. Bisoprolol 5mg od B. Aspirin 75mg od C. Ramipril 10mg od D. Indapamide 2.5mg od E. Verapamil 80mg tds
Correct answer: A E
Beta-blockers and verapamil should never be prescribed together due to the risk of life-threatening bradycardias.
A 72-year-old woman is admitted to the Emergency Department with lethargy, nausea and confusion. Her family report that she has not been eating or drinking much for the past few days. Her background includes atrial fibrillation for which she is treated with digoxin and warfarin. The admitting doctor is concerned about the possiblilty of digoxin toxicity and requests a digoxin level.
Select the two other tests that are most relevant when assessing whether this patient has digoxin toxicity.
A. ECG B. Full blood count C. Visual acuity test with a Snellen chart D. Liver function tests E. Urea and electrolytes
ECG and U&Es due to hypokalaemia
The digoxin level can only be properly interpreted in the context of the serum potassium as toxicity may occur at low-normal concentrations if hypokalaemia is present.
A 59-year-old woman who has recently had a mastectomy for breast cancer is started on tamoxifen by your consultant. She asks you to discuss tamoxifen therapy with the patient.
Select the two most appropriate pieces of information to convey to the patient from the list below:
A. Tamoxifen increases the risk of blood clots. She should seek medical attention if calf pain occurs B. Tamoxifen therapy is normally used for 2 years following mastectomy C. Hot flushes are common in patients who take tamoxifen D. There is a small increased risk of uterine fibroids in patients taking tamoxifen E. Patients should book an urgent appointment with their doctor if they develop a sore throat
You answered: A C
Tamoxifen increases the risk of blood clots. She should seek medical attention if calf pain occurs
There is a small increased risk of uterine fibroids in patients taking tamoxifen
A 65-year-old is being treated with intravenous gentamicin for a severe staphylococcal infection. He was started on three times a day treatment yesterday and has had 3 doses so far. Peak and trough levels are taken:
Gentamicin serum concentration
Peak 8mg/litre (5-10mg/litre)
Trough 3mg/litre (<2mg/litre)
He weighs 80kg and is currently receiving a dose of gentamicin 80mg IV tds. What is the most appropriate action?
- Switch to gentamicin 80mg bd
- Reduce gentamicin to 40mg tds
- Switch to gentamicin 80mg morning, 60mg lunchtime and 40mg evening
- Reduce gentamicin to 60mg tds
- Skip the next dose of gentamicin then repeat levels
The interval between the doses should be increased if the trough levels are raised
You are rewriting a prescription chart, a copy of which is given below:
Which one of the above drugs is prescribed incorrectly?
The dose of insulin glargine (Lantus) should be prescribed as ‘22 UNITS’ not ‘22U’. This is a cardinal sin in terms of insulin prescribing and is frequently cited in critical incident reports. ‘22U’ may be misread by nursing staff as 220 units - as a result there have been a number of incidents where patients receive 10 times the required dose.
You have been bleeped whilst on-call to prescribe fluids a 79-year-old man who is nil-by-mouth following a stroke. He weighs around 80kg. His fluid chart is as follows:
A nurse has attached a copy of his latest U&Es:
Na+ 140 mmol/l
K+ 4.2 mmol/l
Urea 5.4 mmol/l
Creatinine 98 µmol/l
What is the most appropriate fluid to prescribe?
5% glucose should be avoided in patients who have had a stroke due to the increased risk of cerebral oedema. Prescribing a further bag of 0.9% normal saline with maintenance potassium is therefore the most appropriate course of action.
