PSA

Question 1

What is a well known side effect of ticagrelor in treating patients with ACS?

Answer 1

Dyspnoea

Question 2

What is the NICE guidance on constipation? (i.e 1st line to 3rd etc)

Answer 2

1. Bulk forming laxative (Isphagula husk)
2. Osmotic Laxative (Macrogol / lactulose) - if stools hard
3. Stimulant (Senna/bisacodyl) - if stools soft but failing to pass NB contraindicated in bowel obstruction.

Question 3

DVT 1st line ____
DVT in pregnancy 1st line ____

Answer 3

Apixaban
Rivaroxaban

LMWH

Question 4

Cardiac Arrest - 4Hs and 4Ts

Answer 4

Hypoxia
Hypo/hyperthermia
Hypo/hyperkalaemia
Hypovolaemia

Tension Pneumothorax
Tamponade
Toxins
Thrombosis

Question 5

Methotrexate monitoring requirements

Answer 5

In view of reports of blood dyscrasias (i.e anaemia, leukopenia, and thrombocytopenia. - including fatalities) and liver cirrhosis with low-dose methotrexate patients should:

**FBC
U+E’s
LFTs **

• every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
• be advised to report all symptoms and signs suggestive of infection, especially sore throat

Question 6

Regular monitoring of _ is required in cyclosporin therapy

Answer 6

Kidney function - U+E’s

Question 7

A threshold of ____ g/L is used when using a restrictive transfusion threshold. Higher thresholds (usually _____ g/L) are used in acute coronary syndrome and restrictive transfusion is not used in cases of major haemorrhage.

Answer 7

70g/L

80g/L

1 unit of crossmatched blood should be used in patients who are below the threshold and not actively bleeding

2 units of crossmatched blood can be used if patient is actively bleeding

2 units of O- blood should be transfused only in an emergency where there is no time to crossmatch.

Question 8

Adrenaline doses in:

Anaphylaxis _______

Asystole/PEA _____ (to be repeated every 3-5mins if necessary)

Answer 8

500ug IM (1 in 1000)

1mg IV (1 in 10000)

Question 9

A systolic BP of ____ mmHg and above is defined as severe hypertension.

Patients with severe hypertension should be referred for same-day specialist review if they have signs of end organ damage:

• on fundoscopy (such as papilloedema or retinal haemorrhage) indicating accelerated hypertension
• if they have signs of end-organ damage (such as confusion, heart failure or AKI)
• or if they have suspected phaeochromocytoma (such as postural hypotension, palpitations or abdominal pain). In this case, there is postural hypotension on examination and therefore a secondary care review is indicated.

Answer 9

180

Question 10

Omeprazole can cause _____. Therefore it is important to monitor _____ levels before and after starting therapy, particularly in this case when the patient has an underlying arrhythmia and is taking digoxin. Hypomagnesaemia can lead to an increased risk of arrhythmia and digoxin toxicity.

Answer 10

Hypomagnesamia

The BNF states that:

Measurement of serum-magnesium concentrations should be considered before and during prolonged treatment with a proton pump inhibitor, especially when used with other drugs that cause hypomagnesaemia or with digoxin.

Although it is important to monitor other electrolytes in this patient due to the use of ramipril (potential renal impairment) and a loop diuretic (possible hypokalemia, hypochloremia and hypocalcaemia), these are not directly affected by omeprazole.

Question 11

Omeprazole can cause _____. Therefore it is important to monitor _____ levels before and after starting therapy, particularly in this case when the patient has an underlying arrhythmia and is taking digoxin. Hypomagnesaemia can lead to an increased risk of arrhythmia and digoxin toxicity.

Answer 11

Hypomagnesamia

The BNF states that:

Measurement of serum-magnesium concentrations should be considered before and during prolonged treatment with a proton pump inhibitor, especially when used with other drugs that cause hypomagnesaemia or with digoxin.

Although it is important to monitor other electrolytes in this patient due to the use of ramipril (potential renal impairment) and a loop diuretic (possible hypokalemia, hypochloremia and hypocalcaemia), these are not directly affected by omeprazole.

Question 12

____ need to be regularly monitored in patients who are prescribed amiodarone due to a key side effect of _____.

Answer 12

TFTs

thyrotoxicosis

Question 13

Adults

Moderate acute asthma:

Severe acute asthma (Any one of the following):

Life-threatening acute asthma (Any one of the following in a patient with severe asthma):

Near-fatal acute asthma:

Answer 13

Moderate acute asthma:

Increasing symptoms;
Peak flow > 50-75% best or predicted;
No features of acute severe asthma.

Severe acute asthma:

Any one of the following:

Peak flow 33-50% best or predicted;
Respiratory rate ≥ 25/min;
Heart rate ≥ 110/min;
Inability to complete sentences in one breath.

Life-threatening acute asthma:

Any one of the following in a patient with severe asthma:

Peak flow < 33% best or predicted;
Arterial oxygen saturation (SpO2) < 92%;
Partial arterial pressure of oxygen (PaO2) < 8 kPa;
Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa);
Silent chest;
Cyanosis;
Poor respiratory effort;
Arrhythmia;
Exhaustion;
Altered conscious level;
Hypotension.

Near-fatal acute asthma:

Raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures.

Question 14

Routine serum-lithium monitoring should be performed ____ after initiation and after each dose change until concentrations are stable, then every ____ for the first year, and ____ thereafter.

Answer 14

weekly

3 months

every 6 months

Question 15

Patients and carers should be advised to seek immediate medical advice if _____ develops whilst taking clozapine.

This is due to the potentially fatal risk of _____ , ____ , and ____.

Answer 15

constipation

intestinal obstruction, faecal impaction and paralytic ileus

Question 16

____ can cause peripheral vasoconstriction and so worsen ischaemia in peripheral vascular disease (PVD),

Answer 16

Beta-blockers

Question 17

The most likely diagnosis is cellulitis secondary to a recent break in the skin.

The BNF recommends _______ 0.5–1 g QDS for 5–7 days as the first-line antibiotic for cellulitis.

The BNF recommends the following alternatives in the context of penicillin allergy:

Clarithromycin 500 mg twice daily for 5–7 days (if not pregnant)
Erythromycin 500mg PO QDS for 5-7 days (if pregnant)

Secondary care referral for intravenous antibiotics would be indicated if there were signs of ________.

Answer 17

Flucloxacillin - first line

Clarithromycin 500 mg twice daily for 5–7 days (if* not pregnant*)

Erythromycin 500mg PO QDS for 5-7 days (if pregnant)

• Systemic infection
• Severe cellulitis affecting large areas of skin,
• Multiple co-morbidities
• Immunocompromise
• Infection near the eyes or nose
• If the patient is unable to tolerate oral antibiotics.

Question 18

____ is the treatment of choice for severe salicylate (aspirin) poisoning, for example, when the salicylate concentration exceeds ____ mg/L, or in the presence of severe metabolic acidosis.

Answer 18

Haemodialysis

700

Question 19

Gentamicin and botulinum toxin are both _____ blockers. Therefore, due to their synergic effect gentamicin should not be administered during the treatment of overactive bladder with botulinum toxin.

Answer 19

neuromuscular

Question 20

Metoclopramide can thus cause extrapyramidal side effects including _____.

The patient in this scenario is most likely having an _____ crisis secondary to metoclopramide.

Acute dystonic reactions are more common in ____ and ____ who take metoclopramide

Answer 20

Dopamine antagonism

acute dystonic reactions

oculogyric

children and young adults (age <30)

Question 21

The BNF recommends _____ over cyanocobalamin for replacement therapy in B12 deficiency, as it is retained in the body longer.

Dosing regimes of hydroxocobalamin vary depending on the presence of _____ symptoms, such as _____ or _____ .

Answer 21

hydroxocobalamin

neurological

decreased vibratory sense or loss of proprioception

Question 22

Hypertension

Young (<55) and/or Fat _____

Old (>55) and/or black ____

Answer 22

ACEi (i.e Ramipril 2.5mg)

Ca2+ channel blocker (i.e Amlodipine 5mg)

Question 23

First-line management for BPH with bothersome symptoms includes an _____ which works through smooth muscle relaxation in the ______ and ______ .

Options referenced in the BNF include:

____ hydrochloride - 400 micrograms once daily.
_____ (immediate-release) - 1 mg daily (dose may be doubled at intervals of 1–2 weeks according to response - maximum 10 mg per day)
Alfuzosin hydrochloride - 2.5 mg 3 times a day (maximum 10 mg per day)
Terazosin - 1 mg daily (dose may be doubled at intervals of 1–2 weeks according to response - maximum 10 mg per day)

Answer 23

alpha blocker

prostate and bladder neck.

Tamsulosin
Doxazosin

Women - OAB
Oxybutynin and tolteridine - antimuscurinics

Oxybutynin is more efficient but has a poor safety profile in older patients - falls/dry mouth/mental health. Tolteridine is safer in this regard.

Question 24

What is the most appropriate option to monitor for the beneficial effects of furosemide in HF patients?

Answer 24

Weight changes

Question 25

The BNF recommends that for patients who continue to be breathless or have exacerbations, physicians should consider treatment with a long-acting beta2 agonist (LABA) and an inhaled corticosteroid (ICS). Inhaled corticosteroids should be reviewed annually and continued if effective.

Appropriate prescriptions could therefore include any licenced combination of _____ - there are several options:

Answer 25

ICS + LABA

Formoterol with beclometasone (fostair)

Formoterol with budesonide

Salmeterol with fluticasone

Question 26

Several common medications may contribute to tinnitus.

Examples include _____

Answer 26

ACE inhibitors such as ramipril.

Other examples include
* aspirin
* quinine (malaria)
* diuretics such as furosemide.

Question 27

Delirium Tremens is characterised by agitation, confusion, paranoia, and visual and auditory hallucinations.

The BNF recommends that _____ should be used as first-line management.

_____ [unlicensed] can be given as 2nd line therapy.

Answer 27

oral lorazepam

Haloperidol

Question 28

_____ is an SGLT2 inhibitor. It prevents glucose reabsorption in the renal proximal convoluted tubule, which increases urinary glucose excretion. A rare or very rare side effect of this medication is ______ .

Answer 28

Dapagliflozin

Fournier’s gangrene.

Fournier gangrene is a type of necrotizing fasciitis affecting the external genitalia and/or perineum. It commonly occurs in older men, but it can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised.

Question 29

Diclofenac is now contraindicated in any patient with a history of _____, as it has been shown to increase the risk of ______.

Answer 29

ischaemic heart disease

developing major cardiovascular events.

Question 30

Scabies is characterised by ____ pruritus and is associated with overcrowded living conditions such as care homes and prisons.

The lesions have a characteristic appearance of _____ (wavy white-grey thread-like lines with a small black dot at the end) and symmetrical red papules.

Scabies is treated by applying ____ 5% cream to the whole body (including the face and scalp in the young, elderly and immunocompromised), which is then washed off after 8-12 hours. This treatment should then be repeated one week after the initial application.

Answer 30

nocturnal

linear burrows

Permethrin (a class of medications called scabicides and pediculicides. It works by killing lice and mites)

Question 31

Blood monitoring requirements for Lithium?

Answer 31

Every 6 months (routine) :

U+Es (Nephrogenic Diabetes Insipidus)

Calcium (Hyperparathyroidism)

Thyroid Dysfunction (Hypothryroidism)

Cardiac function (i.e ECG)

Weight

Question 32

A small rise in creatinine < _____ is to be expected in initiation of ACEi.

Answer 32

20%

Question 33

An increase in statin dose is required if after ____ months there is not a >_____ % reduction in Non-HDL Cholesterol (i.e LDL cholesterol)

Answer 33

3 months

40%

Question 34

Acute Dystonic Reaction 1st line therapy - ______.

Answer 34

Procyclidine (anti-cholinergic)

Question 35

Acute Dystonic Reaction 1st line therapy - ______.

Answer 35

Procyclidine (anti-cholinergic)

Question 36

HRT that provides cyclical and continuous options?

Answer 36

Estradiol and Norethisterone