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Various - mainly clin pharm > Treating common conditions > Flashcards

Treating common conditions Flashcards

1
Q

First line acute treatment of migraine?

A

Oral triptans (if >17) - 5-HT1 agonist and NSAIDS/paracetamol

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2
Q

Migraine prophylaxis?

A

either topiramate (5-HT antagonist) or propranolol ‘according to the person’s preference, comorbidities and risk of adverse events. Propranolol should be used in preference to topiramate in women of child bearing age

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3
Q

If migraine prophylaxis fails?

A

‘a course of up to 10 sessions of acupuncture over 5-8 weeks’ or gabapentin

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4
Q

for women with predictable menstrual migraine treatment NICE recommend:

A

either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day)

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5
Q

Management of paracetamol overdose

A

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

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6
Q

Management of salicylate overdose

A

urinary alkalinization is now rarely used - it is contraindicated in cerebral and pulmonary oedema with most units now proceeding straight to haemodialysis in cases of severe poisoning
haemodialysis

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7
Q

Benzodiazepine overdose management

A

Flumazenil

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8
Q

Management of warfarin overdose

A

Vitamin K, prothrombin complex

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9
Q

Management of heparin overdose

A

Protamine sulphate

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10
Q

Management of b-blocker overdose

A

if bradycardic then atropine

in resistant cases glucagon may be used

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11
Q

Management of ethylene glycol overdose

A

Management has changed in recent times
ethanol has been used for many years
works by competing with ethylene glycol for the enzyme alcohol dehydrogenase
this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid)

fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line
haemodialysis also has a role in refractory cases

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12
Q

Management of methanol overdose

A

fomepizole or ethanol

haemodialysis

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13
Q

Management of organophosphorus insecticide overdose

A

atropine

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

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14
Q

Cyanide antidote(s)

A

Hydroxocobalamin;

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

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15
Q

Opiate overdose antidote

A

Naloxone

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16
Q

Benzodiazepines

A

Flumazenil

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17
Q

Management of lithium overdose

A

mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

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18
Q

When do you use a broad-spectrum cephalosporin or quinolone?

A

acute pyelonephritis

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19
Q

Statins drug monitoring

A

LFTs at baseline, 3 months and 12 months

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20
Q

ACE inhibitor monitoring

A

U&E

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21
Q

Amiodarone monitoring

A

TFT, LFT

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22
Q

Methotrexate monitoring

A

FBC, LFT, U&E

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23
Q

Azathioprine monitoring

A

FBC, LFT

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24
Q

Lithium monitoring

A

Lithium level, TFT, U&E

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25
Q

Sodium valproate monitoring

A

LFT

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26
Q

Glitazone monitoring

A

LFT

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27
Q

CIs to sildenafil (PDE V inhibitor)

A

patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction
non-arteritic anterior ischaemic optic neuropathy

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28
Q

Side effects of sildenafil

A 
visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
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29
Q

P450 inhibitors

A 
antibiotics: ciprofloxacin, erythromycin
isoniazid
cimetidine, omeprazole
amiodarone
allopurinol
imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin
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30
Q

SEs of levodopa

A

dyskinesia (involuntary writhing movements), ‘on-off’ effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness

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31
Q

What are antimuscarinics used for?

A

now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease

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32
Q

How does amantadine work?

A

probably increases dopamine release and inhibits its uptake at dopaminergic synapses

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33
Q

3 common uses of propranolol

A 
migraine prophylaxis (women of childbearing age)
prophylaxis of variceal haemorrhage
essential tremor
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34
Q

2 uses of sertraline

A

generalised anxiety disorder

depression (post-myocardial infaction)

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35
Q

Name 2 drug causes of psychosis

A

levodopa

corticosteroids

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36
Q

5 drug causes of confusion?

A 
digoxin
amantadine
amantadine
phenytoin
metoclopramide
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37
Q

Which b-blocker is lipid soluble therefore crosses the blood-brain barrier?

A

Propranolol

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38
Q

B-blocker side effects? (4)

A

bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares

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39
Q

CIs to b-blocker use?

A

uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia

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40
Q

Drug which causes tendon damage?

A

Cipro

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41
Q

Drugs which cause fluid retention?

A 
pioglitazone
corticosteroids
ciclosporin
hydralazine
minoxidil
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42
Q

Drugs which cause akathisia (severe restlessness)?

A

Anti-psychotics

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43
Q

Unwasted effects of levodopa?

A

dyskinesia, ‘on-off’ effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness

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44
Q

4 SEs of amantadine

A

ataxia, slurred speech, confusion, dizziness and livedo reticularis

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45
Q

3 adverse effects of bisphosphonates

A

oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft (alendronate)

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46
Q

Which drugs not to give with statins?

A

clarithromycin

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47
Q

When can’t you give metformin?

A

After a recent MI - may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration

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48
Q

Metformin - SEs

A

gastrointestinal upsets are common
reduced vitamin B12 absorption
lactic acidosis with severe liver disease or renal failure

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49
Q

Important contraindication to metformin?

A

chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)

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50
Q

When should you not give sildenafil, sumatriptan or hydralazine?

A

After a recent MI

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51
Q

Metformin and contrast?

A

CI’d with iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter

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52
Q

2 drugs contraindicated in IHD?

A

sumatriptan

hydralazine

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53
Q

Adverse effects of triptans?

A

‘triptan sensations’ - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure

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54
Q

When are thiazolidinediones CId?

A

fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin

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55
Q

Common SEs of thiazides?

A 
dehydration & postural hypotension
hyponatraemia, hypokalaemia, hypercalcaemia
gout
impaired glucose tolerance
impotence
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56
Q

Rare adverse effects of thiazides?

A

thrombocytopaenia
agranulocytosis
photosensitivity rash
pancreatitis

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57
Q

Which cardiac type drugs should you not give together as they can cause bradycardia?

A

B-blockers and verapamil

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58
Q

Which drugs has minimal glucocorticoid activity, very high mineralocorticoid activity?

A

Fludrocortisone

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59
Q

Which drugs have very high glucocorticoid activity, minimal mineralocorticoid activity?

A

Dexamethasone, Betmethasone

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60
Q

Which drug has predominant glucocorticoid activity, low mineralocorticoid activity?

A

Prednisolone

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61
Q

Glucocorticoid activity, high mineralocorticoid activity?

A

Hydrocortisone

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62
Q

Mineralocorticoid SEs? (2)

A

fluid retention

hypertension

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63
Q

the BNF suggests gradual withdrawal of systemic corticosteroids if patients have:

A

received more than 40mg prednisolone daily for more than one week, received more than 3 weeks treatment or recently received repeated courses

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64
Q

endocrine SEs of glucocorticoids?

A

impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia

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65
Q

Muskuloskeletal SEs of glucocorticoids?

A

musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head

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66
Q

immunosuppression SEs of glucocorticoids?

A

Increased susceptibility to severe infection, reactivation of tuberculosis

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67
Q

psychiatric SEs of glucocorticoids?

A

insomnia, mania, depression, psychosis

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68
Q

gastrointestinal SEs of glucocorticoids?

A

peptic ulceration, acute pancreatitis

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69
Q

ophthalmic SEs of glucocorticoids?

A

glaucoma, cataracts

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70
Q

other SEs of glucocorticoids?

A

suppression of growth in children
intracranial hypertension
Cushing’s syndrome

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71
Q

Which electrolyte is increased by thiazide diuretics?

A

Calcium

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72
Q

Endocrine SE of thiazides?

A

Impaired glucose tolerance

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73
Q

CIs to sildenafil use

A

patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction
non-arteritic anterior ischaemic optic neuropathy

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74
Q

sildenafil SEs

A 
visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
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75
Q

What is digoxin’s mechanism of action?

A

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

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76
Q

Features of digoxin toxicity?

A

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

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77
Q

Precipitating factors for digoxin toxicity?

A 
classically: hypokalaemia*
increasing age
renal failure
myocardial ischaemia
hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis
hypoalbuminaemia
hypothermia
hypothyroidism
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78
Q

Drugs which can precipitate digoxin toxicity?

A

amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics

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79
Q

Rx for digoxin toxicity?

A

Digibind
correct arrhythmias
monitor potassium

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80
Q

3 drugs causes of myositis?

A

statins
nicotinic acid
fenofibrate

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81
Q

Drug which causes angioedema?

A

ACE inhibitors eg. enalapril

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82
Q

4 main SEs of ACEis?

A

cough
angioedema: may occur up to a year after starting treatment
hyperkalaemia
first-dose hypotension (esp in patients taking diuretics)

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83
Q

Monitoring with ACEis?

A

urea and electrolytes should be checked before treatment is initiated and after increasing the dose
a rise in the creatinine and potassium may be expected after starting ACE inhibitors. Acceptable changes are an increase in serum creatinine, up to 30%* from baseline and an increase in potassium up to 5.5 mmol/l*.

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84
Q

Cautions and contraindications with ACEis?

A

pregnancy and breastfeeding - avoid
renovascular disease - significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis
aortic stenosis - may result in hypotension
patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) - significantly increases the risk of hypotension
hereditary of idiopathic angioedema

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85
Q

Verapamil SEs

A

Heart failure, constipation, hypotension, bradycardia, flushing

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86
Q

Diltiazem indications

A

Angina, hypertension

Less negatively inotropic than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers

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87
Q

Drug cause of non-arteritic anterior ischaemic neuropathy?

A

sildenafil

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88
Q

Nifedipine/amlodipine SEs

A

Flushing, headache, ankle swelling

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89
Q

Drugs for Raynauds’?

A

Dihydropiridines eg amlodipine

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90
Q

SEs of diltiazem

A

Hypotension, bradycardia (less than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers), heart failure, ankle swelling

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91
Q

4 drugs causes of gout?

A

thiazides
loop diuretics
pyrazinamide
nicotinic acid

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92
Q

Can corticosteroids cause:
hirsutism?
renal failure?
pancreatitis?

A

1) yes
2) no
3) yes

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93
Q

Which drug causes gynaecomastia?

A

spironolactone

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94
Q

Common adverse effects of sulphonylureas?

A 
hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide)
weight gain
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95
Q

Rarer adverse effects with sulphonylureas?

A 
syndrome of inappropriate ADH secretion
bone marrow suppression
liver damage (cholestatic)
photosensitivity
peripheral neuropathy
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96
Q

What are the NICE recommendations for metformin in CKD?

A

That the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)

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97
Q

Which drug causes orange tears and urine?

A

rifampicin

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98
Q

3 drug causes of hypothyroidism?

A

amiodarone
lithium
carbimazole

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99
Q

3 SEs of statins

A

Myopathy (esp lipophilic ones): includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase.
Liver impairment
?Stroke - there is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke (not in primary prevention)

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100
Q

What do the 2008 NICE guidelines recommend re. liver function and statins?

A

checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range

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101
Q

When do the Royal College of Physicians recommend avoiding statins?

A

In patients with a history of intracerebral haemorrhage

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102
Q

Who should receive a statin?

A

all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease) & NICE recommend anyone with a 10-year cardiovascular risk >= 20%
Now diabetic patients > 40-years-old who have no obvious cardiovascular risk (e.g. Non-smoker, not obese, normotensive etc) and have a cardiovascular risk < 20%/10 years do not need to be given a statin.

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103
Q

What are the JBS’ guidelines for lipid lowering?

A 
Total cholesterol (mmol/l)	    LDL cholesterol
Joint British Societies	< 4.0	                    < 2.0
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104
Q

What is exenatide?

A

glucagon-like peptide-1 mimetic

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105
Q

How does valproate work?

A

increases GABA activity

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106
Q

Valproate GI SEs?

A

gastrointestinal: nausea, increased appetite and weight gain

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107
Q

Valproate ‘itis’ SEs?

A

hepatitis

pancreatitis

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108
Q

Valproate neuro SEs?

A

ataxia

tremor

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109
Q

Valproate haem SE?

A

thromobcytopaenia

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110
Q

Valproate random SEs?

A

teratogenic

alopecia: regrowth may be curly

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111
Q

Valproate U&E SE?

A

hyponatraemia

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112
Q

What is sitagliptin? Mech of action? Weight gain?

A

Dipeptidyl peptidase-4 inhibitor - also doesn’t cause weight gain.

Whilst it is well known that insulin resistance and insufficient B-cell compensation occur other effects are also seen in type 2 diabetes mellitus (T2DM). In normal physiology an oral glucose load results in a greater release of insulin than if the same load is given intravenously - this known as the incretin effect. This effect is largely mediated by GLP-1 and is known to be decreased in T2DM.

Increasing GLP-1 levels, either by the administration of an analogue (GLP-1 mimetics, e.g. exenatide) or inhibiting its breakdown (dipeptidyl peptidase-4, DPP-4 inhibitors - the gliptins), is therefore the target of two recent classes of drug.

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113
Q

Which drug can cause osteonecrosis of the jaw?

A

bisphosphonates

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114
Q

7 drugs precipitating digoxin toxicity?

A

amiodarone, quinidine, verapamil, diltiazem, spironolactone, thiazides, loop diuretics

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115
Q

4 drugs causes of constipation

A

verapamil
tricyclic antidepressants
opioids
antipsychotics

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116
Q

Drugs causing thrombocytopenia (also quinidine)?

A

heparin
sodium valproate
thiazides

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117
Q

Which drug is metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis?

A

azathioprine

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118
Q

eg of an a2 receptor agonist?

A

brimonidine

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119
Q

Which drugs causes blue discolouration of vision?

A

sildenafil

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120
Q

Common drug cause of gout?

A

thiazides

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121
Q

4 drugs which cause pancreatitis?

A

corticosteroids
sodium valproate
thiazides
valproic acid

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122
Q

2 drugs causing myalgia?

A

statins

fenofibrate

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123
Q

U&E abnormality with ACEis?

A

hyperkalaemia

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124
Q

Somatostatin analogue?

A

Octreotide

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125
Q

3 drugs which cause pulmonary fibrosis?

A

amiodarone
methotrexate
bromocriptine

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126
Q

What is amiodarone? When indicated?

A

A class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias

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127
Q

Adverse effects of amiodarone use (exc. bradycardia, thyroid dysfunction

  • eyes
  • lungs
  • liver
  • nerves/muscles
  • skin
  • heart
A 
corneal deposits
pulmonary fibrosis/pneumonitis
liver fibrosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity, 'slate-grey' appearance
bradycardia
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128
Q

The use of amiodarone is limited by a number of factors, e.g.:

A

long half-life (20-100 days)
should ideally be given into central veins (causes thrombophlebitis)
has proarrhythmic effects due to lengthening of the QT interval
interacts with drugs commonly used concurrently e.g. Decreases metabolism of warfarin

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129
Q

Adverse effects of loop diuretics (U&Es)

A 
hypotension
hyponatraemia
hypokalaemia
hypochloraemic alkalosis
hypocalcaemia
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130
Q

Non-U&E adverse effects of loop diuretics?

A

ototoxicity
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout

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131
Q

2 ‘A’ drugs which lengthen the GT interval

A

amiodarone

adenosine

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132
Q

Drugs causing hyperkalaemia (exc. ACEs/ARBs, spiro)

A

heparin
amiloride
ciclosporin

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133
Q

Common SEs of sulphonylureas?

A

hypos and weight gain

(less often:
syndrome of inappropriate ADH secretion
bone marrow suppression
liver damage (cholestatic)
photosensitivity
peripheral neuropathy)
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134
Q

2 drugs which can cause Steven-Johnson syndrome? ( flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Can progress to TEN)

A

lamotrigine

carbamazepine

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135
Q

3 drugs causes of anorexia?

A

levodopa
digoxin
interferon-alpha

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136
Q

Adenosine SEs?

A

chest pain
bronchospasm
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

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137
Q

Drug for urinary incontinence?

A

oxybutynin

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138
Q

5 drugs causing a dry mouth?

A 
isotretinoin
tricyclic antidepressants
levodopa
antipsychotics
chlorpheniramine
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139
Q

What are ondansetron & granisetron?

A

5HT3 agonists

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140
Q

5 indications for spiro?

A

ascites: patients with cirrhosis develop a secondary hyperaldosteronism
heart failure (NYHA III + IV, patients already taking ACE inhibitor)
nephrotic syndrome
Conn’s syndrome

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141
Q

3 idiosyncratic/unexpected SEs of thiazides?

A

gout, pre-diabetes, impotence

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142
Q

How does amiloride work?

A

Blocks the epithelial sodium channel in the distal convoluted tubule

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143
Q

AEDs causing dizziness?

A

phenytoin

carbamazepine

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144
Q

AEDs causing tremor?

A

lithium
sodium valproate
valproic acid

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145
Q

Carbamazepine MOA?

A

sodium channel blocker, decreasing the sodium influx into neurons which in turn decreases excitability

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146
Q

Carbamazepine SEs?

A 
P450 enzyme inducer
dizziness and ataxia
drowsiness
headache
visual disturbances (especially diplopia)
Steven-Johnson syndrome
leucopenia and agranulocytosis
syndrome of inappropriate ADH secretion
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147
Q

Valproate SEs?

A 
gastrointestinal: nausea
increased appetite and weight gain
alopecia: regrowth may be curly
ataxia
tremor
hepatitis
pancreatitis
thromobcytopaenia
teratogenic
hyponatraemia
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148
Q

3 drugs assoc’d with TB reactivation?

A

corticosteroids
infliximab
etanercept

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149
Q

Common SE of sulphasalazine?

A

Oligospermia

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150
Q

Which is the anti- CD52 mab? When used?

A

Alemtuzumab
Treatment of B-cell chronic lymphocytic leukemia (B-CLL) in patients who have been treated with alkylating agents and who have failed fludarabine therapy

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151
Q

Sildenafil CI’d when?

A

patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction
non-arteritic anterior ischaemic optic neuropathy

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152
Q

Most severe valproate SEs?

A 
ataxia
hepatitis
pancreatitis
thromobcytopaenia
teratogenic
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153
Q

Effect of loop diuretics on Ca levels?

A

Lower them

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154
Q

Treatment for Wernicke’s encephalopathy (Vitamin B1 deficiency leading to worsening confusion, ataxia and nystagmus)?

A

Sedative (reducing dose of chlordiazepoxide; a benzodiazepine)
• Anti-epileptic medication if seizures occur
• Vitamin B1 (to prevent Wernicke’s encephalopathy)

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155
Q

Common causes of acute confusion in the elderly

A
  1. Infection
  2. Heart disease
  3. Metabolic disturbance (hypoxia, electrolyte disturbance, hypoglycaemia)
  4. Brain disease (stroke)
  5. Drugs (night sedation, alcohol withdrawal)
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156
Q

What does the abbreviated mental test score include?

A

Five questions about person, time and place

  1. What is your age?
  2. What is your date of birth? (day and month sufficient)
  3. What is the time to the nearest hour?
  4. What is the year?
  5. What is the name of the hospital or number of the residence where the patient is situated?

Three questions about factual knowledge

  1. Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
  2. In what year did World War 1 begin?
  3. Name the present monarch/dictator/prime minister/president

Two questions about calculation/memory

  1. Count backwards from 20 down to 1
  2. Give the patient an address, and ask him or her to repeat it at the end of the test
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157
Q

What is Donepezil?

A

a cholinesterase inhibitor in the CNS to augment cholinergic transmission

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158
Q

Donepezil SEs/problems?

A

Many patients do not respond to the drug; some get worse
• GI disturbances are common (20%)
• It is reltively expensive

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159
Q

Which anti-depressants are first line in patients and why?

A 
SSRIs 
lower risk of withdrawal
low risk of suicide
low risk in overdose
now mostly generic drugs
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160
Q

When are MAOIs used?

A

MAOI reserved for resistant cases and usually only prescribed by psychiatrists

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161
Q

Problem with TCAs?

A

anticholinergic adverse effects cause withdrawal

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162
Q

Adverse effects of neuroleptics (eg. haloperidol, chlorpromazine)?

A 
Anticholinergic effects (dry mouth etc)
• Postural hypotension (alpha blockade)
• Parkinsonism (dopamine antagonism)
• Sedation
• Cholestasis leading to jaundice
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163
Q

With chronic use of neuroleptics, patients develop?

A

a spectrum of extrapyramidal disorders (involuntary movements including athetosis, chorea)

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164
Q

Problems with benzos for sleep?

A

TOLERANCE
DEPENDENCE
WITHDRAWAL REACTIONS

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165
Q

Uses of benzos?

A 
Hypnotics
Pre-operative medication 
• Acutely confused patient 
• Acute anxiety
• Acute epilepsy
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166
Q

Treatment of a PE?

A

Heparin and warfarin. If severe: thrombolysis too.

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167
Q

Treatment with statins should be discontinued when?

A

if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

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168
Q

3 SEs of statins?

A

myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase.
liver impairment: the 2008 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
there is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke.

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169
Q

b-blocker side effect on hands?

A

cold

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170
Q

5 drugs to avoid in renal failure

A

antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin

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171
Q

Drugs likely to accumulate in chronic kidney disease - need dose adjustment

A 
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
digoxin, atenolol
methotrexate
sulphonylureas
furosemide
opioids
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172
Q

How does azathioprine work? and what need to measure before starting?

A

Azathioprine is metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

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173
Q

3 SEs of azathioprine

A

bone marrow depression
nausea/vomiting
pancreatitis

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174
Q

Myocardial infarction: secondary prevention

A 
All patients should be offered the following drugs:
ACE inhibitor
beta-blocker
aspirin
statin

Clopidogrel
since clopidogrel came off patent it is now much more widely used post-MI
STEMI: the European Society of Cardiology recommend dual antiplatelets for 12 months. In the UK this means aspirin + clopidogrel

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175
Q

What is nicorandil?

A

a potassium channel activator which has a vasodilatory effect on the coronary arteries.

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176
Q

Side-effects of nicorandil include

A

headache, flushing

and anal ulceration.

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177
Q

Side effect of thiazides (hyper…)

A

calcaemia

glycaemia (impaired glucose tolerance)

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178
Q

To convert from oral morphine to diamorphine …?

A

the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 = 40mg)

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179
Q

Drug causes of gynaecomastia

A 
spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
gonadorelin analogues e.g. Goserelin, buserelin
oestrogens, anabolic steroids
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180
Q

Way to remember phenytoin SEs?

A

Phenytoin is associated with a large number of adverse effects. These may be divided into acute, chronic, idiosyncratic and teratogenic

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181
Q

Acute SEs of phenytoin:

A

initially: dizziness, diplopia, nystagmus, slurred speech, ataxia
later: confusion, seizures

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182
Q

Chronic SEs of phenytoin

A

common:
gingival hyperplasia (secondary to increased expression of PDGF),
hirsutism, coarsening of facial features,
drowsiness
megaloblastic anaemia (secondary to altered folate metabolism)
peripheral neuropathy
enhanced vitamin D metabolism causing osteomalacia
lymphadenopathy
dyskinesia

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183
Q

Idiosyncratic SEs of phenytoin

A 
fever
rashes, including severe reactions such as toxic epidermal necrolysis
hepatitis
Dupuytren's contracture*
aplastic anaemia
drug-induced lupus
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184
Q

Teratogenic effects of phenytoin

A

associated with cleft palate and congenital heart disease

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185
Q

Drug causes of raised prolactin/galactorrhea?

A

metoclopramide, domperidone
phenothiazines
haloperidol

very rare: SSRIs, opioids

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186
Q

Sulphonylurea SEs? (4)

A
  • Syndrome of inappropriate ADH secretion
  • Hypoglycaemic episodes
  • Increased appetite and weight gain
  • Liver dysfunction (cholestatic)
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187
Q

Glitazone (thiazolidinedione) side effects ?

A

• Weight gain
• Fluid retention
• Liver dysfunction
• Fractures

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188
Q

Metformin SEs?

A
  • Gastrointestinal side-effects

* Lactic acidosis

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189
Q

things that potentiate warfarin?

A

liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
cranberry juice
drugs which displace warfarin from plasma albumin, e.g. NSAIDs
inhibit platelet function: NSAIDs

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190
Q

SEs of warfarin?

A

haemorrhage
teratogenic, although can be used in breast-feeding mothers
skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin. Thrombosis may occur in venules leading to skin necrosis
purple toes

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191
Q

2 drugs which enhance and reduce effect of adenosine respectively?

A

dipyridamole enhances effect

aminophylline reduces effect

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192
Q

Dangerous SE of carbimazole?

A

Agranulocytosis - monitor by FBC

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193
Q

The mechanism by which carbimazole decreases the formation of thyroxine by the thyroid gland is not fully understood. Possible actions include:

A

inhibiting the iodination of tyrosyl residues in thyroglobulin
competitively inhibit the thyroperoxidase-catalysed oxidation reactions

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194
Q

add which drug for pneumonia secondary to flu?

A

fluclox (staph suspected)

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195
Q

Which drug for an atypical pneumonia?

A

Clarithromycin

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196
Q

Precipitating factors for digoxin toxicity?

A 
classically: hypokalaemia*
increasing age
renal failure
myocardial ischaemia
hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis
hypoalbuminaemia
hypothermia
hypothyroidism
drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics
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197
Q

Mx of digoxin toxicity?

A

Digibind
correct arrhythmias
monitor potassium

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198
Q

Features of opioid misuse?

A 
rhinorrhoea
needle track marks
pinpoint pupils
drowsiness
watering eyes
yawning
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199
Q

Migraine prophylaxis

A

topiramate or propanolol

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200
Q

CIs to thrombolysis

A 
active internal bleeding
recent head injury, haemorrhage, trauma or surgery
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months ago
aortic dissection
pregnancy
severe hypertension
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201
Q

EPO SEs

A

accelerated hypertension (potentially leading to encephalopathy and seizures)
bone aches
flu-like symptoms
skin rashes, urticaria
pure red cell aplasia* (due to antibodies against erythropoietin)
raised PCV increases risk of thrombosis (e.g. Fistula)
iron deficiency 2nd to increased erythropoiesis

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202
Q

Who should have osteoporosis prophylaxis when on steroids?

A

Assessment for treatment - patients taking the equivalent of prednisolone 7.5 mg or more each day for 3 months, and one of the following
are over the age of 65 years
have a history of a fragility fracture
have a T-score less than - 1.5 SD

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203
Q

Random SE of bisphosphonates?

A

osteonecrosis of the jaw

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204
Q

Problem with ISMN in angina?

A

tolerance

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205
Q

Amiodarone is associated with a wide variety of adverse effects, including:

A

thyroid dysfunction: both hypothyroidism and hyperthyroidism
corneal deposits: present in most patients, rarely interfere with vision, usually reversible on withdrawal of drug
pulmonary fibrosis/pneumonitis
liver cirrhosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity
‘slate-grey’ appearance
prolonged QT interval
thrombophlebitis and injection site reactions
bradycardia

206
Q

Which Abx most likely to lower the seizure threshold?

A

Quinolones

207
Q

How do quinolones work?

A

inhibit topoisomeras II (DNA gyrase) and topoisomerase IV

208
Q

joint type SEs of quinolones?

A

tendon damage (including rupture) - the risk is increased in patients also taking steroids

209
Q

TB drug most likely to cause optic neuritis (blurred vision)

A

ethambutol

210
Q

monitoring for azathioprine?

A

FBC, LFT

211
Q

What is viagra contraindicated by?

A

nitrates and nicorandil (has a nitrate component)

212
Q

Which drugs are in the continuation phase for TB treatment (3rd to 7th month)?

A

Rifampicin & isoniazid

213
Q

4 main SEs of b-blockers?

A

bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares

214
Q

4 CIs to b-blocker us?

A

uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use

215
Q

Rx for b-blocker OD?

A

atropine then glucagon if this doesn’t work

216
Q

About montelukast?

A

have both anti-inflammatory and bronchodilatory properties
should be used when patients are poorly controlled on high-dose inhaled corticosteroids and a long-acting b2-agonist
particularly useful in aspirin-induced asthma
associated with the development of Churg-Strauss syndrome

217
Q

Patients with aortic stenosis are at risk of profound hypotension with …?

A

ACE inhibitors.

218
Q

Gingival hyperplasia causes: (4)

A

PACC: phenytoin, AML (leuk), ciclosporin, calcium channel blockers (esp nifedipine)

219
Q

Eye problems caused by amiodarone

A

corneal opacities and optic neuritis

220
Q

Tuberculin skin tests are an example of … hypersensitivity reactions.

A

type IV (delayed)

These are largely mediated by interferon-γ secreted by Th1 cells which in turn stimulates macrophage activity.

221
Q

Amiodarone - MOA:

A

blocks potassium channels (class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. )

222
Q

Contraindications to triptan use?

A

patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease

223
Q

SEs of viagra?

A 
visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
224
Q

5-HT3 antagonists are?

A

antiemetics used mainly in the management of chemotherapy related nausea.

Examples:
ondansetron
granisetron

225
Q

Paracetamol overdose - high risk if?

A

chronic alcohol, HIV, anorexia or P450 inducers

226
Q

Abx that cause pancytopaenia?

A

antibiotics: trimethoprim, chloramphenicol

227
Q

anti-rheumatoid drugs that cause pancytopaenia?

A

gold, penicillamine

228
Q

anti-epileptic drugs that cause pancytopaenia?

A

carbamazepine

229
Q

random drugs that cause pancytopaenia?

A

carbimazole* (also agranulocytosis)

tolbutamide

230
Q

ciclosporin common SE?

A

nephrotoxicity

231
Q

2 drugs which reduce plasma concentrations of lithium, one which increases it?

A

Both sodium bicarbonate and aminophylline may reduce plasma concentrations of lithium; thiazides increase it

232
Q

antimuscarinics used in urinary incontinence

A

tolterodene, oxybutynin and solifenacin

233
Q

Examples of muscarinic antagonists used in different conditions (than urinary incontinence) include

A

ipratropium (chronic obstructive pulmonary disease) and procyclidine (Parkinson’s disease).

234
Q

Haemochromatosis - features?

A

is not associated with polycythaemia. Blood tests typically reveal a raised ferritin and iron, associated with a transferrin saturation of greater than 60% and a low total iron binding capacity

235
Q

characteristics of platelet disorders

A

epistaxis and menorrhagia are common whilst haemoarthroses and muscle haematomas are rare

236
Q

The combination of a petechial skin rash combined with a slightly elevated APTT and reduced factor VIII activity make … the most likely diagnosis

Disseminated intravascular coagulation
Idiopathic thrombocytopenic purpura
Von Willebrand's disease
Haemophilia A
Haemophilia B
A

Von Willebrand’s disease

237
Q

Management of von Willebrand disease?

A

tranexamic acid for mild bleeding
desmopressin (DDAVP): raises levels of vWF by inducing release of vWF from Weibel-Palade bodies in endothelial cells
factor VIII concentrate

238
Q

Prophylaxis of tumour lysis syndrome?

A

rasburicase prophylactically

239
Q

features of tumour lysis syndrome

A 
hyperkalaemia
hyperphosphataemia
hypocalcaemia
hyperuricaemia
acute renal failure
240
Q

alternative name for Factor V Leiden?

A

activated protein C resistance

241
Q

Thrombophilia: causes (4 inherited, 2 acquired)

A

Inherited
activated protein C resistance (factor V Leiden)
antithrombin III deficiency
protein C & S deficiency

Acquired
antiphospholipid syndrome
the Pill

242
Q

What is the most common and important viral infection in solid organ transplant recipients?

A

Cytomegalovirus

Ganciclovir is the treatment of choice in such patients.

243
Q

Features of renal cell carcinoma:

A

classical triad: haematuria, loin pain, abdominal mass
pyrexia of unknown origin
left varicocele (due to occlusion of left testicular vein)
endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
25% have metastases at presentation

244
Q

Features of Chlamydia

A

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria

245
Q

Features of minimal change disease

A

nephrotic syndrome
normotension - hypertension is rare
highly selective proteinuria*
renal biopsy: electron microscopy shows fusion of podocytes

246
Q

Management of minimal change disease?

A

majority of cases (80%) are steroid responsive

cyclophosphamide is the next step for steroid resistant cases

247
Q

infections in renal transplant patients?

A

Over 50% of renal transplant patients have a significant infection within the first 12 months of having a renal transplant.

At the time of transplant the CMV-serological status of the donor and recipient are noted. The highest risk is seen in CMV-seronegative recipients who receive a kidney from a CMV-seropositive donor. These patients are usually given antiviral prophylaxis.

Cytomegalovirus tend to be seen after four weeks as before this time the immune system has not been fully affected by the immunosuppressants.

248
Q

Features of coeliac

A

Chronic or intermittent diarrhoea
Failure to thrive or faltering growth (in children)
Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
Prolonged fatigue (‘tired all the time’)
Recurrent abdominal pain, cramping or distension
Sudden or unexpected weight loss
Unexplained iron-deficiency anaemia

249
Q

Conditions associated with coeliac

A

Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes

250
Q

Genetic associations with Coeliac?

HLA-DR1
HLA-DQ2
HLA-B6
HLA-DP2

A

HLA-DQ2

It is strongly associated with HLA-DQ2 (95% of patients) and HLA-B8 (80%) as well as HLA-DR3 and HLA-DR7

251
Q

Auer rods are in what disease (typically)?

A

AML

252
Q
  1. Acute lymphoblastic leukemia:

A. Often has a relatively good prognosis
B. Never occurs in children
C. Is classified according to morphologic appearance
D. Is only diagnosed when 20% or more of the nucleated cells are lymphoblasts
E. Is an indolent disease

A

AA. Often has a relatively good prognosis

253
Q
  1. Which of the following is a GOOD prognostic indicator in acute lymphoblastic leukemia?
A. Age less than 1
B. A WBC >10,000
C. B-lineage immunophenotype
D. Normal cytogenetics
E. Age >10
A

C. B-lineage immunophenotype

254
Q

fatigue, splenomegaly, and massive leukocytosis with neutrophilia points towards…

A

CML

255
Q

What is CD31

A

an endothelial cell marker - positive in angiosarcoma

256
Q

How does Sitagliptin work?

A

Dipeptidyl peptidase-4 inhibitor

DPP-4 inhibitors work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin.

Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed. These hormones are released throughout the day and levels are increased at meal times.

257
Q

Clinical features of PBC?

vs PSC

A 
PBC:
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly

late: may progress to liver failure

PSC: Inflammation and scarring of the bile ducts can lead to liver damage and cirrhosis - a condition where normal liver tissue is replaced by scar tissue (fibrosis). In many cases the symptoms develop gradually over weeks or months. At the beginning of the disease, many people have no symptoms at all. The most common early symptoms include feeling more tired than usual, feeling generally unwell, itchy skin, weight loss and having some discomfort in the right upper tummy (abdomen). Jaundice can develop when the condition worsens.
Various complications can occur in some people with PSC:

Deficiencies of some vitamins, usually vitamins A, D, E and K
infective cholangitis.
Cholangiocarcinoma

258
Q

Medical treatment of PSC?

A

ursodeoxycholic acid

259
Q

Associations of PSC? Most commonly?

A

IBD - most commonly U/C. 4/5 of patients have one or other

260
Q

Complications of PBC?

A

malabsorption: osteomalacia, coagulopathy
sicca syndrome in 70% of cases
portal hypertension
hepatocellular cancer (20-fold increased risk)

261
Q

5 SEs of ursodeoxycholic acid

A

weight gain loose stools
thinning hair
nausea (feeling sick) and vomiting

262
Q

meds for PBC

A

UDCA and colestyramine (for itching), steroids if associated with AI hepatitis

263
Q

Hep C and chronic infection - common?

A 
chronic infection (80-85%) - only 15-20% of patients will clear the virus after an acute infection and hence the majority will develop chronic hepatitis C
cirrhosis (20-30% of those with chronic disease)
264
Q

a 35-year-old woman is found to have a blood pressure of 180/110 mmHg. She complains of feeling tired and weak. Routine bloods show hypokalaemia

stereotypical Hx for?

A

primary hyperaldosteronism

265
Q

Stereotypical Hx for Addison’s?

A

a 40-year-old woman presents with lethargy, weakness and weight loss. On examination her blood pressure is 80/50 mmHg and there is hyperpigmentation of the skin

266
Q

Causes of primary hyperaldosteronism?

A

Primary hyperaldosteronism was previously thought to be most commonly caused by an adrenal adenoma, termed Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. Differentiating between the two is important as this determines treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism

267
Q

Management of hyperaldosteronism?

A

adrenal adenoma: surgery
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

Differentiating between the two is important as this determines treatment.

268
Q

hypokalaemia
high blood pressure
high serum aldosterone
low serum renin

is suggestive of?

A

primary hyperaldosteronism

269
Q

the ‘3 10%s’ of phaeochromocytoma

A

bilateral in 10%
malignant in 10%
extra-adrenal in 10% (most common site = organ of Zuckerkandl, adjacent to the bifurcation of the aorta)

270
Q

Test for phaeo?

A

24 hr urinary collection of metanephrines (sensitivity 97%*)

this has replaced a 24 hr urinary collection of catecholamines (sensitivity 86%)

271
Q

Mx of phaeo?

A

Surgery is the definitive management. The patient must first however be stabilized with medical management:
alpha-blocker (e.g. phenoxybenzamine), given before a
beta-blocker (e.g. propranolol)

272
Q

TSH is raised, T4 is low, anti-TPO is positive suggests?

A

Hashimoto’s thyroiditis

273
Q

3 associations of coeliac?

A 
dermatitis herpetiformis (a vesicular, pruritic skin eruption) Type 1 diabetes mellitus 
Autoimmune hepatitis
274
Q

coeliac disease associated with which complication

chronic pancreatitis
hyposplenism
renal stones

A

hyposplenism

275
Q

Granulomas in Crohn’s or UC?

A

Crohn’s

276
Q

how do sulphonylureas work?

A

increase panc. insulin secretion

277
Q

Investigation of PSC?

A

Investigation
ERCP is the standard diagnostic tool, showing multiple biliary strictures giving a ‘beaded’ appearance
ANCA may be positive
there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as ‘onion skin’

278
Q

What is AMA suggestive of?

A

PBC

279
Q

Cancer associated with Hashimotos?

A

Thyroid lymphoma

280
Q

Fistula more in Crohn’s or UC?

A

Crohn’s

281
Q

Haemochromatosis assocated with?

Pancreatic cancer
DM
Pulmonary fibrosis

A

DM

Presenting features
early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
‘bronze’ skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)

282
Q

A 60-year-old woman with a history of polycythaemia rubra vera presents with abdominal pain and distension. She is found to have ascites and hepatomegaly on examination - suggests?

A

Budd-Chiari syndrome

283
Q

3 conditions with a goitre?

A

subacute thyroiditis
Hashimoto’s thyroiditis
Riedel’s thyroiditis

284
Q

Mx of lithium toxicity

A

mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

285
Q

Mx of amitriptiline overdose

A

IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
dialysis is ineffective in removing tricyclics

286
Q

Mx of beta-blocker overdose?

A

if bradycardic then atropine

in resistant cases glucagon may be used

287
Q

Lesch-Nyhan and psych symptoms?

A

Self harm common

288
Q

Who is most at isk of self harm?

A

schizophrenia.

Though 2/3 have depression, and >90% of those who present with self harm have at least one psych disorder.
Also assoc’d with substance misuse and anxiety disorders.

Also personality disorder (eg. borderline/emotionally unstable, histrionic).

289
Q

Which meds reduce self-harm risk?

A

lithium in bipolar
clozapine in treatment-resistant schizophrenia

Controversy around SSRIs - can increase motivation before improving mood/changing mindset (hopelessness, worthlessness, helplessness, pessimism)

290
Q

Why do people self-harm? (6)

A 
to communicate distress/seek help
escape a situation
escape unbearable anguish
change behaviour of others
 to die
to escape tension
291
Q

how many paractamol ODs per year in the UK

When did the limited amount legislation come in?

A

70,000

1998 - has reduced paracetamol ODs by 20%

292
Q

How much paracetamol can cause severe liver damage

A

10-15g (20-30 tablets)

5g in those at high risk

293
Q

How does paractemaol damage the liver

A

NAPQI (metabolite). This depletes glutathione (antioxidant)

Activated charcoal if presents within 2 hours
NAC (glutathione precursor) to mitigate effects

294
Q

Cut-off for NAC treatment if >8 hours post-overdose

A

150mg/kg

295
Q

How much does self-arm increase suicide risk by?

A

50-100 times

296
Q

Questions to ask for risk assessment after an episode of self-harm

A

Circumstances - when, where, what, how, why, who was around? affairs in order? notes, drunk/sober, disclose it? how did they access care?
had they planned it?
how feeling now?

Obtain a collateral history (family, GP), look at notes.

Use of scales not recommended but be aware of actuarial risk factors

People are poor at predicting their future behaviour - 20% only decide to 5 mins before the event.

297
Q

Wha comes after a risk assessment?

A

Risk management plan

eg. referral to secondary services
Counselling or psychological therapy
drug/alcohol support services
Citizen's advice bureau 
Homeless charities/council
Third sector and voluntary organisations
Encourage problem-solving
298
Q

How coroners classify deaths

A

Suicide
Open
Misadventure
Narrative verdict

Important for life insurance

299
Q

Kubler-Ross grief cycle

A 
stability
immobilisation (low)
denial
anger (high)
bargaining
depression (low)
testing
acceptance
300
Q

Durkheim’s classifications of suicide

A

Egoistic - not belonging to society, detachment from community
Altruistic - for society eg. soldiers
Anomic - moral confusion and lack of direction
Fatalistic

301
Q

complications of acute post-streptococcal glomerulonephritis?

A

hypertension, renal failure and electrolyte imbalances

302
Q

Kawasaki’s disease Mx?

A

gamma globulin

303
Q

Mx of chronic inflammatory demyelinating polyneuropathy (CIDP)?

A

corticosteroids, plasmapheresis and intravenous immunoglobulin

304
Q

Drug treatment of ANCA vasculitides?

A

Both cyclophosphamide and rituximab are used as induction agents in very active or severe disease.

Cyclophosphamide is a chemotherapy drug that is converted in the liver to its active form, phosphoramide mustard, which causes DNA crosslinking and hence apoptosis of rapidly dividing cells, including lymphocytes. Rituximab is a monoclonal antibody directed against CD20, and causes profound B cell depletion but has no direct effect on T cells or granulocytes.

Azathioprine and mycophenolate mofetil are usually used as maintenance agents or for their steroid sparing effect. In a patient with mild disease they can be used to induce remission but take three to four weeks to have their maximal effect, and hence are not appropriate in severe or very active disease.

Ciclosporin is a calcineurin inhibitor widely used in transplantation to block IL-2 production and hence block proliferation signals to T cells. It is not widely used in the treatment of ANCA vasculitis.

305
Q

Sign and management in sigmoid volvulus?

A

The abdominal x ray shows the classic ‘coffee bean’ sign.

The treatment of uncomplicated sigmoid volvulus is endoscopy and decompression to relieve large bowel obstruction and prevent ischaemia.

In the absence of peritonitis decompression of the sigmoid colon with rigid or flexible endoscopy is crucial before ischaemia ensues.

This patient has colicky abdominal pain rather than continuous pain and has no localised abdominal tenderness. This indicates obstructed but not ischaemic or perforated bowel (that is, the patient does not have peritonitis) and therefore, laparotomy is not immediately indicated.

306
Q

3 things patients with small bowel obstruction need?

A

Patients with bowel obstruction need

Intravenous fluid to replace fluid and electrolyte loss into the lumen of obstructed bowel
A nasogastric tube to decompress the small bowel and prevent vomiting and
A urinary catheter to guide fluid resuscitation

307
Q

What happens in Kawasaki disease?

A

desquamation of the fingers and toes begins in the periungual region, may involve the palms and soles, and usually is observed one to two weeks after the onset of fever.

308
Q

causative agent and symptoms in scarlet fever?

A

the skin rash is associated with streptococcal Group A infection and the skin begins to peel usually around the sixth day of the rash.

309
Q

papular urticaria

A

The histopathologic pattern in papular urticaria consists of

Mild sub-epidermal oedema
Extravasation of erythrocytes
Interstitial eosinophils
Exocytosis of lymphocytes.
The reaction is thought to be caused by a haematogenously disseminated antigen deposited by an arthropod bite in a patient who is sensitive.
310
Q

Drugs causing gynaecomastia?

A

Digitalis/ digoxin, spironolactone, cyproterone acetate, cimetidine, oestrogens, cannabis, testosterone, anabolic steroids.

311
Q

What is normal pressure hydrocephalus is characterised by?

A

dementia, urinary incontinence, gait apraxia; usually in the elderly. CSF pressure is normal but brain scans show enlarged ventricles.

312
Q

A 65-year-old vegan presents with a history of falls and loss of sensation in his feet. On examination he has a distal sensory loss, absent knee jerks and extensor plantar responses.

Stereotypical Hx of?

A

B12 deficiency

Subacute combined degeneration of the cord due to vitamin B12 deficiency is the most likely cause. Another recognised feature is loss of sphincter control. Treatment with vitamin B12 reverses the peripheral nerve damage but has little effect on the CNS.

313
Q

A 63-year-old man was admitted to hospital with eight hours’ duration of severe chest pain.
He had a history of hypertension and hypercholesterolaemia but no previous history of ischaemic heart disease. His electrocardiogram showed inferior ST segment elevation myocardial infarction (STEMI) and he was thrombolysed in the cardiac care unit. He made a good recovery but three days later became acutely breathless.
On examination he had a respiratory rate of 36 per minute and a pulse of 128 beats per minute and regular. His blood pressure was 80/45 mmHg and oxygen saturations were 85% on room air. Auscultation revealed a gallop rhythm and a harsh systolic murmur at the apex. Chest examination revealed widespread crackles and wheezes.

What is the most likely explanation for these findings?

A

papillary muscle rupture

This patient presents with features of acute left ventricular failure and has a chest x ray which shows pulmonary oedema as reflected by Kerley B lines and interstitial oedema.

The examination findings indicate a harsh systolic murmur at the apex which, in association with acute pulmonary oedema, would be most in keeping with a papillary muscle rupture in association with myocardial infarction.

The posteromedial papillary muscle is twice as likely to rupture as is the anterolateral papillary muscle. This is because it is frequently supplied by only one coronary artery (usually the right) system.

314
Q

A 60-year-old woman presents one day after having had a cholecystectomy, with mild breathlessness and temperature of 37.5°C. On auscultaion breath sounds were reduced in both lung bases.

A

This woman has developed a slight fever and breathlessness occurring one day after a procedure which suggests atelectasis.

315
Q

How does a pneumothorax affect BP?

A

Hypotension is produced in a tension pneumothorax by compression of the venous component of the mediastinum, reducing the return of blood to the heart and producing the sign of a raised JVP.

316
Q

Treatment of a tension pneumothorax

A

A needle thoracostomy involves inserting a large bore cannula into the second intercostal space in the mid clavicular line, which should produce a reassuring ‘hiss’ along with a rapid improvement in the patient’s condition.

317
Q

How does erythromycin work?

A

interferes with bacterial protein synthesis, inhibiting replication.

318
Q

How does aminophylline work?

Which drugs to avoid combining with it?

A

It is a methylxanthine derivative drug used in the treatment of bronchial asthma. It works by inhibiting phosphodiesterase and thus dampening inflammatory response via modulation of the cytokine cascade. It also has an antagonistic effect at adenosine receptors and it is this pharmacological action which can cause toxicity.

Erythromycin is considered the most culpable macrolide in terms of its interaction with aminophylline, although some drugs which are not commonly available in the United Kingdom, such as troleandromycin, seem to inhibit the enzyme system more acutely.

319
Q

Risk of salbutamol + macrolide?

A

a theoretical risk of increase in QT interval prolongation BT normally only seen when the salbutamol is administered intravenously or when multiple nebulised doses have delivered an excess of the drug.

320
Q

What is omalizumab?

A

a subcutaneously delivered monoclonal antibody which binds to IgE and is used in patients with severe asthma with proven IgE mediated sensitivity. It is reserved usually for use only in restricted centres. It causes few drug interactions but it may precipitate an anaphylactic reaction in susceptible individuals at administration.

321
Q

SEs/ toxicity due to aminophylline?

A 
Flushing
Agitation
Nausea & Vomiting
Tachycardia & Arrhythmia including supraventricular tachycardias, Torsades de pointes and
Seizures.
322
Q

Normocytic, normochromic anaemia may be caused by:

A

Acute blood loss
Haemolytic anaemia
Chronic disorders, and
Leucoerythroblastic anaemias

323
Q

recent studies suggest that … are the beta-blockers associated with reduced morbidity and mortality in congestive cardiac failure

A

carvedilol (COPERNICUS), bisoprolol (CIBIS) and metoprolol (MERIT-HF)

324
Q

Causes of glomerular proteinuria include:

A

Primary glomerular disease
Glomerulonephritis
Anti-GBM disease (Goodpasture’s syndrome)
Immune complex deposition
Inherited conditions such as Alport’s syndrome

Secondary glomerular disease
Diabetes, or other systemic diseases.

325
Q

9 causes of erythema nodosum?

A 
A	Behcet's disease
B	Drug induced (e.g. OCP, penicillins)
C	Inflammatory bowel disease
D	Lymphoma
E	Mycoplasma pneumonia
F	Rheumatoid arthritis
G	Sarcoidosis
H	Streptococcal infection
I	Tuberculosis
326
Q

risks and CIs of pioglitazone

A

weight gain
liver impairment
fluid retention (co CI’d in CCF)
bladder cancer risk

327
Q

verapamil causes …
whereas amlodipine causes …

(both cause flushing and heart failure)

A

constipation,

ankle swelling

328
Q

Epilepsy: first-line medications

partial vs absence siezure Mx?

A

Carbamazepine - partial seizures

Sodium valproate or ethosuximide - absence seizures

329
Q

Stages of HTN?

A

Stage 1 hypertension Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Stage 2 hypertension Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Severe hypertension Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

330
Q

HTN: stratifying for treatment:

A

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
offer drug treatment regardless of age

331
Q

Which vaccines use live attenuated viruses/bacteria?

A 
Measles
Mumps
Polio (Sabin; Salk is inactivated)
Rubella
Yellow fever, and
BCG
Tetanus toxoid is used in this vaccine.
332
Q

which of these diseases cause rigors?

Acute cholecystitis 
Acute pancreatitis
Acute pyelonephritis  
Hodgkin's disease  
Ureteric calculi
A

Rigors are due to bacteraemia/viraemia and are associated with pyogenic infections.

Hodgkin’s disease is associated with night sweats but not rigors.

Uncomplicated ureteric calculi are associated with the typical renal colic pain without rigors.

333
Q

presentation of S. typhi (typhoid fever)

A

The incubation period is 7-14 days during which some patients may have a transient diarrhoea. As bacteraemia develops patients have

Chills
Diaphoresis
Cough
Headache
Myalgia
Delirium
Fever.
Constipation develops early due to ileocaecal obstruction by swollen Payer patches.
Patients may develop rose spots which are salmon-coloured, blanching 1-4 cm maculopapular rash. They appear on the trunk and may resolve in two to five days.
334
Q

Test for C. diff colitis?

Commonest Abx to cause it?

A

Stool cytotoxin tests are used to detect C. difficile infection which may remain positive even after the infection ceases.

cephalosporins, amoxicillin and clindamycin.

335
Q

Presentation and predisposing factors for E. histolytica

A

cyst may cause amoebic colitis or amoebic liver abscess.
In colitis the symptoms are of a gradual onset and typically involve abdominal pain, diarrhoea, blood stools and weight loss.

Immunosuppressive agents, such as corticosteroids, are a predisposing factor, as are pregnancy, poor nutrition and young children.

336
Q

What is Entamoeba histolytica?

A

A pseudopod-forming non-flagellated protozoa responsible for amoebiasis.

337
Q

If endocarditis is a possibility then what blood cultures should be taken?

A

at least 3 sets of cultures, from different sites, are required.

338
Q

What type of resistance is important in E. coli?

Abx of choice?

A 
Some Escherichia coli isolates produce an ESBL that inactivates second and third generation cephalosporins.
The class of drugs that will most reliably treat these infections are the carbapenems e.g. imipenem, meropenem
339
Q

SE of fluoroquinolones?

A

achilles tendonitis

lowers seizure threshold

340
Q

chloroquine SE?

A

retinopathy

341
Q

Which Abx is Legionella sensitive to?

A

macrolides and ciprofloxacin.

342
Q

Abx for MRSA

A

vanc & teic

343
Q

Long-term a patient who has had a heart attack will need …?

A

aspirin, clopidogrel, a statin, a beta-blocker, and an ACE-inhibitor.

344
Q

Common SEs of phenytoin

A

Gingival hypertrophy and tenderness as well as coarse facial features and hirsutism may occur.
ataxia, peripheral neuropathy, megaloblastic anaemia, thrombocytopaenia

345
Q

phenytoin OD can cause? (eye symptoms)

A

blurred vision and nystagmus.

346
Q

which chemo drugs are alkyalting agents? (6)

A 
Cyclophosphamide
Chlorambucil
Melphalan
Nitrosoureas (-mustine)
Procarbazine, and
Cisplatin.
347
Q

Stereotypical Hx of Bartter syndrome?

A

A 2-month-old girl has failure to thrive, polyuria and medullary nephrocalcinosis affecting both kidneys, with alkalosis on ABG.
U&E reveals: hypokalaemia, hyponatraemia, and hypochloridaemia.

Infantile type includes: fever, dehydration
growth retardation, and nephrocalcinosis.

348
Q

5 contraindications to the COCP?

A 
Cancer of the breast and genitalia
Liver disease
History of or current thromboembolism
Cardiac abnormalities
Congenital hyperlipidaemia
Undiagnosed abnormal uterine bleeding.
349
Q

5 causes of gum hypertrophy (3 are drugs)

A 
Ciclosporin
Nifedipine
Phenytoin, 
chronic renal failure, 
leukaemia.
350
Q

post-renal transplant HTN?

A

Post-transplant hypertension may be due to ciclosporin toxicity or steroid therapy.
Renal artery stenosis may occur in the donor kidney.
Hypertension may be a manifestation of chronic rejection. Chronic graft rejection takes months to years and patients develop a slow decline in glomerular filtration rate, interstitial nephritis or glomerulonephritis.

351
Q

How does acute kidney transplant rejection present?

A

can occur at any time and manifests as graft swelling, fever, abdominal pain and oliguria.

352
Q

prophylaxis for spontaneous bacterial peritonitis

A

ciprofloxacin

353
Q

Side effect of octreotide on the liver?

A

gall stones

354
Q

Liver SE of chlorpromazine

A

acute cholestasis

355
Q

which gene does aflatoxin affect?

A

p53

356
Q

Low glucose and high protein are seen when?

A

bacterial eg. E. coli and meningococcal meningitis

In cryptococcal meningitis the glucose is usually reduced but there is usually a predominance of lymphocytes.
With late tuberculous meningitis, lymphocytes usually predominate except in early disease where there may be 80% polymorphs.
Not seen in echo virus meningitis but they are seen in one quarter of cases of mumps and herpes virus meningitis.

357
Q

rehydration of a child in hypovolaemic shock

A

20 ml/kg of N. saline

358
Q

Correction over … hours is needed in hypernatraemic dehydration (Na >155 mmol/L) to minimise the risk of cerebral oedema.

A

48

359
Q

Typo of insulin in DKA?

A

fixed rate initially

vs variable rate in HONK/high glucose without urine ketones

360
Q

Describe the different Hepatitis viruses?

A

Hepatitis A is a picornavirus that is transmitted faeco-orally. It has a positive single-stranded genome.

There is a 90% vertical transmission rate in hepatitis B which belongs to the Hepadnaviridae and has an unusual partially double-stranded circular genome.

Hep C is a single stranded RNA flavivirus with a 3% vertical transmission rate. It can be transmitted via blood/blood products. It is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis

Hepatitis D is an incomplete virus which has a small RNA genome and can only occur in patients already infected with HBV.

361
Q

Factors increasing the risk of an ectopic pregnancy

A

Previous tubal surgery
Endometriosis
Damage
Pelvic inflammatory disease.

362
Q

What is jersey finger?

A

a traumatic avulsion of the flexor digitorum profundus from its insertion into the distal phalanx.The patient has pain and is unable to actively flex at the DIPJ. A fragment of bone can be avulsed from the distal phalanx during the injury. The photograph demonstrates this. The injury is caused by forced hyperextension of the DIPJ with simultaneous activation of the FDP, classically seen when attempting to grab a jersey during rubgy.

363
Q

early treatment for Goodpastures?

A

plasma exchange

Then steroids and cyclophosphamide longer- term

364
Q

antibodies causing Goodpastures?

A

antibodies to type IV collagen

365
Q

Prerequisite of plasma exchange?

A

large bore venous access to allow rapid removal and return of blood, such as an arterio-venous fistula or central venous access.

366
Q

Complications of plasma exchange?

A

low calcium, thought to be transient secondary to the citrate anticoagulant used (which binds calcium), and deranged clotting from removal of clotting factors.

367
Q

6 other diseases in which plasma exchange is used?

A 
TTP
ANCA vasculitis
MG
Guillain-Barre syndrome
Cryoglobulinaemia and
Hyperviscosity syndromes.
368
Q

How do fibrates work?

A

The mechanism of action is not fully known, but is likely to involve the following:

  1. Increased lipoprotein lipase (LPL) action which causes:
    Lipolysis of VLDL particles and chylomicrons
    Removal of triglycerides from the blood, and
    Storage of triglycerides in adipose, striated muscle and body cells.
  2. Increased PPAR- alpha activity:
    Reduced triglyceride production by the liver
    Increases oxidation of fatty acids
    Likely to have anti-inflammatory and anti-atherogenic effects.
369
Q

Instructions for taking bisphosphonates

A

Only once a week
Take the tablet first thing in the morning, at least 30 minutes before other medications or food
Take with a glass of water - not juice, tea or coffee
After taking the tablet, remain upright for at least 30 minutes to allow the tablet to pass safely into the stomach.

370
Q

SEs of bisphosphonates?

A

Gastrointestinal disturbance is common but usually mild
Alendronate can cause oesophagitis which can be severe
Risedronate is better tolerated
Some can cause bone pain.
Risk of osteonecrosis of the jaw and of AF (matrix metalloproteinase?)

371
Q

Patients who have oesophagitis should do what?

A

should stop their treatment and should be considered either for an intravenous or intramuscular bisphosphonate, or for another agent.

372
Q

which diuretics to treat hypercalcaemia?

A

Loops
Furosemide is a loop diuretic which promotes calcium excretion. It is used in the management of severe hypercalcaemia, usually with IV fluid replacement to prevent dehydration, known to further elevate calcium levels.

373
Q

Prognosis of Goodpasture’s disease?

A

One year mortality has dropped from >90% to 10-20%. In survivors, 60% will reach end stage renal failure and require long term renal replacement therapy.
Any patient presenting already anuric has a lower chance of renal recovery than one who is oliguric.

374
Q

… is a monoclonal antibody used in the treatment of autoimmune diseases such as multiple sclerosis and ANCA-associated vasculitis. It can also be used as an induction agent in solid organ transplantation.

A

Alemtuzumab, or Campath,

375
Q

Cell recovery following alemtuzumab - timeline?

A

B cells are the first subset to recover, beginning to return by three to six months, and reaching levels within the normal range by six to 24 months.

CD8 T cell recovery follows shortly after, beginning at six to nine months and reaching the normal range by nine to 24 months.

CD4 T cell recovery is much slower, for reasons which are not fully understood. CD4 counts can remain suppressed for many years following a single treatment, although many patients show recovery of cells to low levels by 12 months.

376
Q

(non-core) features of nephrotic syndrome?

A

Little or no haematuria
Caused by glomerular pathology
Hyperlipidaemia can be marked and leads to increased cardiovascular risk
Reduced immunoglobulins can predispose to infection
Loss of certain proteins can predispose to thrombosis - renal vein thrombosis is a recognised complication
Creatinine can be normal or elevated.

377
Q

nephrotic syndrome causes?

A

Glomerulonephritis, such as minimal change disease, membraneous glomerulonephritis, etc
Focal segmental glomerulosclerosis
Diabetic nephropathy
Amyloid (AL form)
Connective tissue disease such as systemic lupus erythematosus.

378
Q

which anti-depressants dangerous with local anaesthesia?

A

MAOIs- there is a real risk of precipitating a catecholamine crisis. Extent of symptoms varies from patient to patient depending on dose of both MAOI and type of topical anaesthesia used. Dental surgeries often ask patients taking MAOIs to disclose this so that local anaesthetics not containing adrenaline derivatives can be used.

379
Q

Management of hyperkalaemia?

(Hx: An elderly man comes in, dehydrated, has been on the floor at home. The ECG is done first, and you note peaked T waves and you think the QRS complex may be slightly broad.)

A

This patient should initially receive calcium gluconate (10 ml of 10%) to protect the myocardium, and this can be repeated if worrying ECG features persist.

A venous blood gas would be a quick way of getting a potassium level, and this should be confirmed with a laboratory sample. It is important to repeat after treatment to ensure the potassium level is decreasing. Refractory hyperkalaemia (>6.5 mmol/L) is an indication for urgent renal replacement therapy, and certainly needs discussion with a nephrologist. Salbutamol is an effective treatment at quickly lowering potassium levels, and is useful if IV access is proving difficult, and thus an insulin/dextrose infusion cannot be started quickly. Large doses (10-20 mg) are needed to provide a sufficient effect.

Calcium resonium is used to bind potassium in the gut, and helps to reduce total body potassium. However, it takes a number of hours to have its effect and thus would not be a priority in the acute management of hyperkalaemia.

380
Q

What is status epilepticus? Treatment?

A

Status epilepticus is a medical emergency, where two or more seizures follow each other without regaining consciousness or when one seizure lasts for 30 minutes or longer.

There is a risk of cardiorespiratory failure and death if grand mal seizures are involved.

381
Q

Causes of status epilepticus?

A

In known epileptics several factors such as abrupt withdrawal of treatment, alcohol abuse or poor compliance may precipitate status epilepticus.

However more than half of cases occur in people with no history of epilepsy. Of these many are due to eclampsia in pregnant women.

382
Q

The classic triad of symptoms in aortic stenosis are:

A

Angina
Exertional syncope, and
Exertional shortness of breath.

383
Q

Investigation and staging of Aortic stenosis?

A

The diagnosis may be confirmed with Echo demonstrating a gradient across the aortic valve.

Gradients above 50 mmHg suggest moderate severity stenosis.

Valve replacement is prognostically beneficial in severe stenosis.

Ventricular arrhythmias may cause sudden death.

384
Q

Factors associated with a poor prognosis in upper GI bleeding?

A

Shock, continued or rebleeding, chronic liver disease and old age are all associated with a poor prognosis.

385
Q

urea and calcium in AKI?

A

AKI often causes a marked elevation in urea compared to creatinine and hypocalcaemia would be unusual. However, hypocalcaemia is common in CKD4-5.

386
Q

MAOIs and dental surgery?

A

Monoamine oxidase inhibitors have many drug and dietary interactions; dentists should be warned of their use to avoid catecholamine crises when using adrenaline in local anaesthesia.

387
Q

In cryptococcal meningitis what does CSF contain?

A

the glucose is usually reduced but there is usually a predominance of lymphocytes.

388
Q

histology of coeliac disease?

A

subtotal or total villous atrophy, with crypt hyperplasia.

http://www.nature.com/nri/journal/v2/n9/fig_tab/nri885_F1.html

389
Q

Effects of potassium and magnesium on T waves?

A

A high potassium level causes tall peaked T waves with disappearance of the ST segment. A low potassium causes flattened T waves with the appearance of a U wave. High and low magnesium levels produce the same patterns as potassium.

390
Q

Effects of pericarditis on T wave?

A

ST segment elevation may be caused by acute myocardial infarction (MI) or Prinzmetal’s angina or pericarditis.

To differentiate the two, acute MI has upwardly convex ST segments and is present in only a few leads with reciprocal changes in others, and in pericarditis the ST segments are upwardly concave and are usually present in all leads.

391
Q

2 infections causing jaundice, purpura and hepatosplenomegaly in neonates?

A

congenitally acquired cytomegalovirus (CMV) and toxoplasmosis infection

392
Q

Jaundice in beta thalassaemia?

A

The jaundice usually starts at the age of about 3 months because haemoglobin F is still the predominant haemoglobin in neonates.

393
Q

What does the sciatic nerve supply?

A

It supplies the hamstrings and all the muscles of the lower leg and foot via the tibial and common peroneal nerve, additionally it also is responsible for the sensation of the lateral side of the leg below the knee.

394
Q

Clinical features of sciatic nerve lesions

A

Foot drop
Loss of power below the knee and loss of knee flexion
Loss of ankle jerk and plantar response (not knee jerk), and
Loss of sensation below the knee on the lateral side.

395
Q

Mechanisms of different anti emetics?

Which are good for chemo patients?

A

Prochlorperazine and droperidol are both dopamine antagonists.
Cyclizine is an anticholinergic drug.
Granisetron is a 5HT3 receptor antagonist, is of the same class of drug as ondansetron.
Both granisetron and dexamethasone are useful antiemetics in the management of nausea and vomiting secondary to cytotoxic chemotherapy.

396
Q

When are larger doses of methadone required?

A

in those taking anticonvulsants, rifampicin, erythromycin, grapefruit juice and antiretroviral medications.

397
Q

How do drugs that inhibit CYP3A4 enzyme system affect cardiac rhythm?

A

increase the risk of ventricular arrhythmias due to prolongation of QTc interval.
eg. erythromycin and cisapride, cimetidine, isoniazid

398
Q

4 epilepsy drugs that are enzyme inducers

A

carbamazepine, phenytoin, primidone and phenobarbitone

399
Q

Gentamicin and the kidneys?

A

Gentamicin is nephrotoxic, causing acute tubular necrosis. It is also associated with ototoxicity.

400
Q

Drugs causing retroperitoneal fibrosis and so ureteric obstruction?

A

Methysergide, rosiglitazone

401
Q

When do giant ‘A’ waves occur?

A

when there is a poorly compliant right ventricle (or tricuspid stenosis) increasing the impedence against which the right atrium has to eject blood.

402
Q

In constrictive pericarditis the JVP is …?

A

high with an abrupt fall in systole (x descent) and may rise with inspiration (Kussmaul’s sign).

403
Q

when is coarctation of the aorta seen?

A

Usually it is associated with a bicuspid aortic valve and hypoplastic aortic arch.

It is seen in:
Turner's syndrome
Cerebral "berry" aneurysms
Neurofibromatosis I
Williams syndrome (congenital hypercalcaemia)
Sturge-Weber.
404
Q

What does coarctation of the aorta involve

A

Often presents in childhood with heart failure
The condition involves collateral flow around the scapulae, through the subclavian vessels and upper intercostal arteries.

405
Q

associations of carpal tunnel syndrome?

A

myxoedema, rheumatoid arthritis, diabetes, acromegaly and pregnancy.

406
Q

triggers of transient synovities

A

minor trauma, post-vaccination or drugs and infections, such as:

Gastrointestinal
Urinary tract, or
Respiratory tract.

407
Q

Tumour markers for:
ovarian cancer
hepatocellular carcinoma
bowel cancer

A

CA125
AFP
CEA

408
Q

hypoxic ischaemic encephalopathy is associated with

A

Irritability
Fits
Cardiovascular instability
Haematuria (due to ATN)

409
Q

Rheumatic fever - skin sign?

A

Erythema marginatum

410
Q

Erythema nodosum - cancer causes?

It is also associated with thrombophlebitis migricans.

A

commonly associated with lymphomas, leukaemias, and renal cell carcinoma. Not associated with carcinoma of the head of the pancreas.

411
Q

Pyoderma gangrenosum is commonly associated with

A

inflammatory bowel diseases (Crohn’s and ulcerative colitis). It may also be seen in rheumatoid arthritis.

Less common associations include chronic active hepatitis, myelodysplasia and solid tumours.

412
Q

Atropine, phenothiazines and imipramine all have what common effect

A

anticholinergic - so reduce secretions, gut motility etc

413
Q

most important drug for a diabetic with microalbuminuria

A

ACEis§

414
Q

KCH criteria for liver transplantation

A

arterial pH 3.0 mmol/L after fluid rehydration, or if all three of the following occur in a 24 hour period:
PT >100 seconds
Creatinine >300 µmol/L
Grade III/IV encephalopathy.

415
Q

blood markers of anti-streptococcal GN

A

Decrease of serum complement is recognised. Also anti-streptococcal exoenzymes, such as anti-streptolysin (ASO), etc.

416
Q

resp complications of post-strep GN:

A

Dyspnoea is recognised; fluid overload and hyponatraemia.

417
Q

histology of post-strep GN

A

Diffuse endocapillary proliferative glomerulonephritis is typical; focal glomerular lesions would suggest an alternative diagnosis.

418
Q

how do fluoroquinolones eg. cipro work?

A

affects function of DNA gyrase

419
Q

How to investigate a palpable thyroid nodule?

A

A palpable thyroid nodule should be investigated with fine needle aspiration (FNA) which should be carried out under the auspices of a thyroid clinic.

If the nodule is palpable, neither a thyroid ultrasound nor an uptake scan is indicated prior to FNA.

420
Q

features of meningitis septicaemia

A

Neisseria meningitidis is the causative agent and the features are divided into meningitic and septic. Meningitic features include:

Vomiting
Neck stiffness
Photophobia
Kernig sign
Brudzinski sign
Focal neurology
Opisthotonus.
Septic features include:
Systemically unwell
Pyrexia
Anorexia
Reduced tone.
Purpura result from increased capillary permeability.
421
Q

Maculopapular rash and white oral lesions describes …?

A

Measles - the white oral lesions are Koplik spots - a pathognomic feature of the infection.

422
Q

Exenatide has the following metabolic effects

A

Stimulates insulin release
Inhibits glucose production by the liver
Slows gastric emptying
Suppresses appetite.

423
Q

drug causes of Long QT?

A

amiodarone
sotalol
Type 1a antiarrhythmic drugs.

Medications that more commonly cause Torsades
Bepridil
Disopyramide
Procainamide
Quinidine
Sotalol
Medications that less frequently cause Torsades
Amiodarone
Chlorpromazine & haloperidol & droperidol
Cisapride
Clarithromycin
Domperidone
Erythromycin
Lidoflazine
Mesoridazine
Methadone
Sparfloxacin
Thioridazine
424
Q

Metabolic causes of long QT?

A

Hypocalcaemia

Hypokalaemia

425
Q

differential of ESR >100

increase in plasma proteins or RBC aggregation

A
426
Q

Causes of Massive Splenomegaly: >20cm

A
427
Q

inf. causes of splenomegaly

A
428
Q

Cuases of a neutrophilia (differential)

A

Bacterial infection - Left shift, Toxic granulation, Vacuolation
Stress: trauma, surgery, burns, haemorrhage
Steroids
Inflammation: MI, PAN
Myeloproliferative disorders: e.g. CML

429
Q

eosinophilia differential?

A
430
Q

lymphocytosis causes

A
431
Q

drugs causing neutropenia

A

chemo, cytotoxics, carbimazole, sulphonamides

432
Q

tear drop cells suggest?

A

BM infiltration

433
Q

what is prgressive multifocal leukoencephalopathy?

A

in HIV/AIDS
Demyelinating inflammation of brain white matter
caused by JC virus.

434
Q

Meningitis in HIV?

A

cryptococcal

435
Q

Rx for cryptococcal meningitis

A

Amphotericin B + flucytosine for 2wks then fluconazole for for 6mo / until CD4 >200

436
Q

Rx for Hep C, indications?

A
437
Q

drugs causing liver cirrhosis

A

Methotrexate, amiodarone, isoniazid

438
Q

Symptoms of botulism?

A

Afebrile
Descending symmetric flaccid paralysis
No sensory signs
Autonomic: dry mouth, fixed dilated pupils

439
Q

Listeria presentation

A

Watery diarrhoea, cramps, flu-like
Pneumonia
Meningoencephalitis
Miscarriage

440
Q

Entameoba histolytica presentation

A

Dysentery, wind, tenesmus Wt. loss if chronic
Liver abscess
- RUQ pain, swinging fever, sweats
- Mass in R lobe Flask-shaped ulcer on histo

441
Q

Entameoba Rx?

A

Metro

442
Q

Yersinia presentation

A

Abdo pain, fever, diarrhoea
Mesenteric adenitis
Reactive arthritis, pharyngitis, pericarditis
Erythema Nodosum

443
Q

Yersinia treatment

A

ciprofloxacin

444
Q

Enteric fever organisms (cause abdo pain and fever)

A

Typhoidal salmonella, Yersinia enterocolitica, Brucella

445
Q

Secondary syphilis presentation

A

6wks -6mo wks after chancre

446
Q

Diagnosing syphilis

A

Cardiolipin antibody

447
Q

Cause of cat-scratch disease?

A

Bartonella henselae

Treat w/ azithromyin

448
Q

Time course of lyme disease?

A 
Early localised:
- Erythema migrans (target lesions)
Early disseminated:
- Malaise, LN, migratory arthritis, hepatitis
Late persistent :
- Arthritis, focal neuro (Bell’s palsy), heart block,
myocarditis
- Lymphocytoma: blue/red ear lobe
449
Q

presentation of Weil’s disease (leptospirosis)

A

High fever, headache, myalgia / myositis Cough, chest pain ± haemoptysis
± hepatitis ̄c jaundice
± meningitis

450
Q

NSAID nephrotoxicity

A

histologically due to interstitial nephritis and may be accompanied by an eosinophilia, rash and non-specific symptoms such as lethargy and fatigue.

451
Q

Addisons: biochem abnormalities?

A

Addison’s disease is a cause of hyperkalaemia as hypocortisolism reduces renal potassium excretion due to reduced activation of the sodium/potassium pump in the distal convoluted tubule.

The biochemical picture is therefore one of:

Hyponatraemia
Elevated urea
Hypoglycaemia, and
Hyperkalaemia.
Hyperkalaemia initially causes membrane excitability due to partial membrane depolarisation then, as levels of serum potassium increase, it may cause muscle weakness, arrhythmias, and eventually cardiac arrest.

As the hyperkalaemia progresses, the ECG changes deteriorate: peaked T waves, decreased P waves and QRS widening.

452
Q

IBD complications

A 
colon cancer
fistulae and fissures
abscess formation
stricture formation, and
toxic dilatation of the colon with the risk of perforation.
453
Q

Azathioprine SEs

A

Hepatotoxicity
Myelosuppression such as neutropenia and thrombocytopenia (not iron deficiency anaemia)
Azoospermia (like sulfasalazine) in males
Alopecia
Nausea and vomiting
Hepatitis, and
Increased susceptibility to infection.
There is also an increased risk of cancer associated with its long term use - lymphoma and skin cancer.

454
Q

BZD withdrawal symptoms include

A

rebound anxiety, insomnia and depression which can last for weeks or months.

455
Q

A reduced neutrophil count may be feature of:

A

Sepsis
Pernicious anaemia, and
Systemic lupus erythematosus.
It is frequently due to drug therapy such as carbimazole or cytotoxics.

456
Q

Lesch-Nyhan syndrome is due to …?
pathology
presentation

A

Lesch-Nyhan syndrome is due to deficiency of HPRT (hypoxanthine-guanine phosphoribosyl transferase), which is associated with purine overproduction, hyperuricaemia and gout. There is also a neurological syndrome characterised by choreoathetosis, spasticity, mental deficiency and behavioural disturbance (particularly self-mutilation). It is an X linked recessive disorder.

457
Q

Causes of erythema nodosum

A

Acute sarcoidosis
Streptococcal infection
Rheumatic fever
Primary tuberculosis
Drugs, for example, sulfonamides, penicillin, oral contraceptive pill, codeine, salicylates, barbiturates
Others - pregnancy, ulcerative colitis (UC), Crohn’s disease, malignancy, Behcet’s syndrome.
Co-trimoxazole is the combination of trimethoprim and the sulfonamide, sulfamethoxazole.

458
Q

Trigeminal neuralgia Mx

A

Carbamazepine 100-400mg, 8 hourly

459
Q

Drugs likely to cause TB reactivation

A

corticosteroids
infliximab
etanercept

460
Q

drugs causing tachycardia

A

isosorbide mononitrate
minoxidil
hydralazine

461
Q

sildenafil adverse effects?

A

nasal congestion
blue vision & non-arteritic anterior ischaemic neuropathy
flushing
GI upset
headaches
don’t give with nitrates, or with other PDE inhibitors

462
Q

valproate adverse effects

A 
gastrointestinal: nausea
appetite increased + weight gain
alopecia: regrowth may be curly
ataxia &tremor
hepatitis & pancreatitis
thrombocytopaenia
teratogenic
hyponatraemia
463
Q

drugs causing ataxia

A

sodium valproate
phenytoin
carbamazepine
amantadine

464
Q

SEs of carbamazepine

A

P450 enzyme inducer
dizziness and ataxia
drowsiness, headache
visual disturbances (especially diplopia)
Steven-Johnson syndrome
leucopenia and agranulocytosis
syndrome of inappropriate ADH secretion (-> hyponatraemia

465
Q

how does carbamazepine work?

A

Na channel blocker

466
Q

Thiazides MoA?

A

inhibits sodium absorption at the beginning of the distal convoluted tubule

467
Q

drugs causing agranulocytosis

A 
carbimazole
azathioprine
phenytoin
carbamazepine
methotrexate
thiazides
chloramphenicol
antipsychotics
ganciclovir
interferon-alpha
468
Q

nephrotoxic drugs

A 
ciclosporin
aminoglycosides eg. gentamycin
amphotericin B
foscarnet
vancomycin
loop diuretics
NSAIDs
469
Q

Nicotinic acid is used … ?

A

in the treatment of patients with hyperlipidaemia, although its use is limited by side-effects. As well as lowering cholesterol and triglyceride concentrations it also raises HDL levels

470
Q

Adverse effects of nicotinic acid

A

flushing
impaired glucose tolerance
myositis

471
Q

The use of amiodarone is limited by a number of factors: (4)

A

long half-life (20-100 days)
should ideally be given into central veins (causes thrombophlebitis)
has proarrhythmic effects due to lengthening of the QT interval
interacts with drugs commonly used concurrently e.g. decreases metabolism of warfarin
numerous long-term adverse effects

472
Q

Monitoring of patients taking amiodarone (before, during)

A

TFT, LFT, U&E, CXR prior to treatment

TFT, LFT every 6 months

473
Q

Adverse effects of amiodarone use

A 
thyroid dysfunction
corneal deposits
pulmonary fibrosis/pneumonitis
liver fibrosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity
'slate-grey' appearance
thrombophlebitis and injection site reactions
bradycardia
474
Q

Criteria for GCA Dx (need 3/5)

A

Age over 50
New onset of new type of localised headache
ESR >50 mm/hr by the Westergreen method
Temporal artery tenderness to palpation or decreased pulsation
Arterial biopsy showing granulomatous inflammation or mononuclear cell infiltration usually with multinucleated giant cells.

475
Q

2 drug causes of psychosis?

A

levodopa, corticosteroids

476
Q

durgs that precipitate digoxin toxicity

A 
spironolactone
anti-psychotics?
Ace inhibitors
quinidine
thiazides
loop diuretics
Ca channel blockers
ciclosporin
beta blockers
477
Q

MoA of bisphosphate analogues

A

pyrophosphate analogues, inhibit osteoclast activity

478
Q

drug causes of siADH

A 
carbamazepine
valproate
chlorpropramide, 
selective serotonin reuptake inhibitor (SSRIs) and TCAs
lithium, MDMA/ecstasy, 
tramadol, haloperidol, 
vincristine, desmopressin
479
Q

drugs causing hepatotoxicity

A 
pioglitazone
amiodarone
sulfonylureas
ciclosporin
sodium valproate
methotrexate
phenytoin
rifampicin
pyrazinamide
statins
valproic acid
halothane
480
Q

sulphasalazine SEs

A

rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia

Mesalazine: side-effects seen in patients taking sulphasalazine are avoided
mesalazine is still associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis

481
Q

Drugs which increase fracture risk

A

pioglitazone
heparin
bisphosphonates

482
Q

Test before starting on azathioprine?

A

TPMT (as it is a prodrug of thipurine)

483
Q

drugs causing confusion

A

digoxin
amantadine
phenytoin
metoclopramide

484
Q

causes of microcytic anaemia

A 
iron-deficiency anaemia
thalassaemia*
congenital sideroblastic anaemia
anaemia of chronic disease (more commonly a normocytic, normochromic picture)
lead poisoning
485
Q

Treatment for Behcet’s disease?

A

Steroids or colchicine

486
Q

Triad in Behcet’s disease?

A

oral ulcers
genital ulcers
iritis

Other associations: venous + arterial thrombosis, pericarditis, episcleritis, polyarteritis, abdo pain/diarrhoea

487
Q

Resp causes of clubbing:

A

Normal: Suppurative diseases – CF, empyema, bronchiectasis, non-small cell carcinoma, CFA – cryptogenic fibrosing alveoli tis
Rare: Lung abcess, mesothelioma, empyema, asbestosis

488
Q

Acute treatment of gout

A

Colchicine, strong NSAIDs e.g. indomethacin or steroids.

Allopurinol only later.

489
Q

Renal osteodystrophy produces:

A 
reduced 1 hydroxylation of vitamin D, which leads to:
Reduced absorption of calcium
Increased phosphate concentrations
Hyperparathyroidism, and
Osteomalacia.
490
Q

ECG in atrial flutter:

A

No P waves, fast but regular rhythm. The inferior leads may suggest the “saw-toothed” P wave pattern typical of atrial flutter.

491
Q

Drugs useful in hypertension in pregnancy include:

A

Hydralazine
Methyldopa
Nifedipine, and
Labetalol.

492
Q

Drugs to be avoided in pregnancy include:

A

Diuretics
ACE inhibitors - AT and antagonists
Reserpine, and
Sodium nitroprusside.

493
Q

Causes of pseudo-obstruction:

A 
Hypothyroidism
Hypokalaemia
Diabetes
Uraemia, and
Hypocalcaemia, etc.
494
Q

Coeliac treatment

A

Dapsone

Gluten free diet.

495
Q

About WPW syndrome:

A

Amiodarone increases the refractory period in the accessory path

Although orthodromic tachycardia is the commonest it frequently has phasic aberrant conduction making it broad.

Verapamil is NOT the treatment of choice for an associated SVT. Verapamil may exacerbate the rhythm disturbance associated with WPW and atrial fibrillation (AF) may result in ventricular fibrillation (VF).

496
Q

Congenital varicella syndrome is characterised by

A 
Cerebral cortical and cerebellar hypoplasia
Microcephaly
Convulsions
Limb hypoplasia
Rudimentary digits.
497
Q

Rubella effects on babies:

A

cataracts, cardiac abnormalities, thrombocytopenia and cerebral calcification

The fetus is most vulnerable in the first 16 weeks of pregnancy. Cataracts are associated with infections in weeks 8-9, deafness at 5-7 weeks and cardiac lesions from 5-10 weeks. Diagnosis is based on rising antibody titres in blood taken 10 days apart and the presence of IGM antibodies at 4-5 weeks from incubation period.

498
Q

Neonatal infection with listeria - effects?

A

usually multi-organ and granulomata may be found on the skin and the pharynx.

Treatment is with ampicillin and gentamicin.

499
Q

Neonatal infection with listeria - treatment?

A

ampicillin and gentamicin

500
Q

Causes of enlarged/sunken fontanelles

A

In the above question both subdural effusions and tuberculous meningitis result in raised ICP.
Dehydration often presents with a sunken fontanelle.
An enlarged posterior fontanelle is often found in babies born with congenital hypothyroidism.
Delayed closure of the fontanelle may be seen in cases of hypercalcaemia.

501
Q

Diagnosing beta-thalassaemia

A

The diagnosis of beta thalassaemia is usually suggested by
The presence of an isolated, mild microcytic anaemia
Target cells on the peripheral blood smear and
A normal red blood cell count.

An elevation of Hb A2 (2 alpha-globin chains complexed with 2 delta-globin chains) demonstrated by electrophoresis confirms the diagnosis of beta thalassaemia. The Hb A2 level in these patients usually is approximately 4-6%.

In rare cases of concurrent severe iron deficiency the increased Hb A2 level may not be observed although it becomes evident with iron repletion.

502
Q

when would you close an ASD?

A

in any patient where the defect has persisted beyond 6 months of age.

503
Q

When and where are Koplik’s spots found?

A

opposite the premolars two days prior to the development of the rash in measles

504
Q

Clinical features of vitamin A deficiency include

A

night blindness, dry skin, dry conjunctiva and cornea (xerophthalmia), Bitot’s spots (white plaques of keratinised epithelial cells. Deficiency is common in young children from developing countries.

505
Q

Urgent treatment for vit A deficiency

A

is with oral retinal palmitate 50,000 units on two successive days.

506
Q

A 2-month-old child presents with snuffliness and difficulty in feeding. He has a crusty nose and low-grade fever.
His respiratory rate is 40/min and moderate recession. On auscultation he has scattered crackles and wheezes.
What is the most likely diagnosis?

A

The history is suggestive of a viral bronchiolitis. There are clinical signs of both upper and lower respiratory disease.

Babies are often obligate nasal breathers in the first few months of life.

Normal saline nose drops may assist feeds by thinning nasal secretions.

507
Q

Electrolyte abnormalities common in pyloric stenosis

A

often showing hyponatraemia, hypokalaemia and a profound hypochloraemic metabolic alkalosis. As the alkalosis worsens, the increasing bicarbonate may combine with calcium ions and so reduce ionised serum calcium. Rarely, tetany may result.

508
Q

An 18-month-old boy presents with a three days of fever which rises to a maximum of 39.2°C. This then resolves as a maculopapular rash appears.

Most likely cause?

A

Roseola infantum
The 18-month-old has the classical description of roseola, caused by human herpes virus 6. A similar picture is caused by HHV7, though it has a peak presentation between 3-4 years.

509
Q

A 2-year-old girl presents with a two day history of temperature of 38.2°C and pinpoint spots over the shins which are blanching.

Most likely cause?

A

Enterovirus
In the 2-year-old, although fever with petechiae may be due to meningococcal disease, they are usually caused by viruses, with Enterovirus being most common. The blanching lesions would argue against meningococcus here.

510
Q

Intussusception tends to occur in regions in which a peristaltic segment abuts on to an aperistaltic segment. These include?

A

Enlarged Peyer’s patches
Meckel’s diverticula
Tumours and
Haematomas complicating Henoch-Schonlein purpura.

511
Q

What is Gaucher’s disease?

A

It is an inherited autosomal recessive disorder of lipid metabolism. It is due to a beta-glucosidase deficiency.

This causes an accumulation of glycolipids (especially glucosylceramide) principally in the phagocytic cells of the body but also (less commonly) in the cells of the central nervous system.

Clinical features include

Hepatosplenomegaly (splenomegaly can be massive which can cause a pancytopenia)
Neurological dysfunction
Bone erosions particularly of the long bones and fractures
Pingueculae - orange wedge-shaped deposits in the subconjunctiva and a yellow/brown discolouration of the skin particularly those areas exposed to sunlight.

Gaucher cells (look like wrinkled paper) are characteristically seen in reticuloendothelial cells.

Bone erosions may occur near areas of excessive bone growth and lead to fractures. However, the commonest bone condition in adults with Gaucher’s is avascular necrosis.

Various - mainly clin pharm (5 decks)

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