Lead poisoning:
(Please select 1 option)
Causes adrenal suppression
Incorrect answer selected
Can only result from lead ingestion
Is associated with a macrocytic anaemia
Causes a peripheral neuropathy due to demyelination
This is the correct answer
Commonly presents with diarrhoea
Lead can also be absorbed through the skin and by inhalation. Associated with iron deficiency & a
microcytic anaemia. Most common GI symptoms are abdominal colic and constipation
A 17-year-old female presents to the emergency department following self-confessed paracetamol
poisoning after discovering she is eight weeks pregnant and had a row with her boyfriend.
She claims to have taken an approximately 30 paracetamol tablets approximately 58 hours ago.
Her history is considered to be reliable. There are no abnormalities to find on examination. Her
blood sugar by finger prick testing was 3.1 mmol/l.
Which of the following would be the most appropriate treatment for this patient?
(Please select 1 option)
Haemodialysis
Intravenous dextrose infusion
Intravenous N-acetylcysteine
Correct
Oral activated charcoal
Oral vitamin K
Irrespective of the pregnancy, this girl should receive n-acetyl cysteine.
Paracetamol concentration is unhelpful in delayed presentation of paracetamol overdose. A dose of
more than150mg/kg is considered to be toxic and toxicity occurs at a lower concentration if the
patient is thought to be in high risk group.
Clotting screen international normalised ratio (INR), liver function tests, acid-base balance and
plasma glucose should be taken without delay prior to starting treatment with N-acetylcysteine.
Serial monitoring of clotting screen is required and N-acetylcysteine should continue until INR
returns to normal.
Further advice on treatment of complicated cases should be sought from National Poisons
Information Service. Other supportive treatment is guided by the patient's condition.
A 60-year-old male who has been prescribed lisinopril for hypertension presents with an irritating
cough. What is the mechanism responsible for ACE-induced cough?
(Please select 1 option)
Angiotensin I accumulation
Asthma
Bradykinin accumulation
Correct
Laryngeal irritation
Renin accumulation
The enzyme ACE is also responsible for the metabolism of bradykinin in mast cells. The accumulation
of this substance is responsible for the cough found in up to 30% of subjects taking ACE-inhibitors.
This phenomenon is not seen in subjects taking Angiotensin receptor blockers such as Losartan.
A 30-year-old man is admitted three hours after taking an overdose of amitriptyline and
diazepam.
On examination he was drowsy with a Glasgow coma scale of 8, he had a pulse of 140 beats per
minute, a blood pressure of 114/88 mmHg and dilated pupils. His oxygen saturation was 90% on
room air.
What is the most appropriate initial action for this patient?
(Please select 1 option)
Activated charcoal
CT head scan
ECG
This is the correct answer
IV atenolol
IV flumazenil
Incorrect answer selected
Daft question really. The most appropriate initial action would be to get the investigations done as
quickly as possible - arterial blood gases and ECG, as the latter may show QRS widening and merit
treatment.
Then, the next step would be gastric decontamination with lavage and activated charcoal.
Treatment with bicarbonate is also advocated as this patient displays features of severe TCA
overdose.
He does not need a CT scan as the symptoms are typical of tricyclic overdose.
Flumazenil is not appropriate for this patient as the symptoms are mostly of TCA overdose nor is IV
atenolol appropriate for the arrhythmias - bretylium, phenytoin or lidocaine
A 58-year-old male presents with painful breast tissue.
Six weeks previously he was treated for atrial fibrillation and had a number of drugs commenced.
Which one of the following drugs may have caused this problem?
(Please select 1 option)
Aspirin
Digoxin
Incorrect answer selected
Flecainide
Spironolactone
This is the correct answer
Warfarin
Digoxin may cause gynaecomastia but usually only on prolonged use.
Spironolactone is well known to cause gynaecomastia due to its well described anti-androgen
effects.
A 24-year-old female who has previously suffered with severe depression presents with secondary
amenorrhoea.
She is found to have a prolactin of 645mU/L (normal 50-350).
Which of the drugs which she takes may cause this?
(Please select 1 option)
Becotide
Omeprazole
Montelukast
Risperidone
Sertraline
This is the correct answer
Incorrect answer selected
Antipsychotic medications are known to elevate prolactin levels, due to dopamine antagonist
effects.
Sertraline is not thought to exert dopamine antagonist effects and thus does not result in
hyperprolactinaemia.
The other medications on her list have not been associated with hyperprolactinaemia.
A middle-aged lady presents with cervical and inguinal lymphadenopathy. She is also experiencing
pins and needles in a glove and stocking distribution, and has gum hypertrophy. She has a
previous history of epilepsy and is on regular medication.
Which of the following drugs is most likely to cause her symptoms?
(Please select 1 option)
Carbamazepine
Phenobarbitone
Phenytoin
Correct
Sodium valproate
Vigabatrin
Recognised side effects of phenytoin include
 drowsiness
 ataxia
 confusion
 blurred vision
 dizziness
 nystagmus
 permanent cerebellar ataxia
 peripheral neuropathy
 rashes
 gum hypertrophy
 thickening of the facial features
 lymphadenopathy
 chorea
 sleep disturbance.
Remarkable side effects of other anti-epileptic drugs are:
 drowsiness
 blurred vision
 dizziness
 leukopaenia
 SIADH and rash (carbamazepine)
 liver toxicity (sodium valproate)
 severe rash (lamotrigine)
 retinal damage (vigabatrin)
 aplastic anaemia (felbamate).
A 42-year-old man presents with gingival hypertrophy. Which of his cardiac medications is likely to
be responsible?
(Please select 1 option)
Amlodipine
Correct
Atenolol
Digoxin
GTN
Simvastatin
Calcium channel blockers and drugs like phenytoin and cyclosporin are associated with gingival
hypertrophy.
A 60-year-old male with diet controlled type 2 diabetes mellitus is commenced on
metformin due to deteriorating glycaemic control.
Which of the following is true regarding metformin?
(Please select 1 option)
It does not require any functioning pancreatic islet cells for its action
Incorrect answer selected
It is contra-indicated in patients suffering a myocardial infarction (MI)
correct answer
This is the
It is safe in patients with renal impairment
It may cause metabolic alkalosis
It often causes hypoglycaemia
Metformin is a biguanide which acts to improve insulin sensitivity through mechanisms that involve
hepatic gluconeogenesis and improved muscle glucose utilisation.
Thus, some insulin must be produced for it to have an effect.
It is associated with hypoglycaemia although this side effect is unusual.
It is contra-indicated in subjects with renal failure, hepatic failure and heart failure due to the
association with lactic acidosis.
The BNF states that there should be a six week "cooling off" period post-MI before the
commencement or recommencement of metformin.
A 60-year-old retired nurse with idiopathic Parkinson’s disease presented with motor
oscillations and on-off periods. She had received Co-Beneldopa for 5 years. Selegiline
was added to her treatment.
Which one of the following enzymes does Selegiline act on to cause this adjuvant
action?
(Please select 1 option)
catechol-0-methyltransferase
dopa decarboxylase
dopamine hydroxylase
monoamine oxidase
Correct
tyrosine hydroxylase
Selegiline is a MAO-B inhibitor
Which of the following pharmacological agents acts through the opening of potassium channels?
(Please select 1 option)
Amiloride
Glibenclamide
Lidocaine
Nicorandil
Correct
Phenytoin
Nicorandil is a potent potassium channel activator. It relaxes vascular smooth muscle through
membrane hyperpolarization via increased transmembrane potassium conductance and, like
nitrates, through an increase in intracellular cyclic GMP. Glibenclamide blocks potassium channels.
Amiloride inhibits the action of aldosterone on the distal convoluted tubule producing potassium
reabsorption.
Which of the following is a metabolic effect of exenatide?
(Please select 1 option)
Accelerates gastric emptying
Improves insulin sensitivity
Incorrect answer selected
Inhibits insulin release
Promotes gluconeogenesis by the liver
Suppresses appetite
This is the correct answer
Exenetide mimics the effect of the gut hormone GLP-1 (glucagon-like peptide 1) and has favourable
effects on the metabolism of individuals with diabetes mellitus.
Exenetide suppresses appetite, inhibits glucose production in the liver, slows gastric emptying and
stimulates insulin release.
It does not increase insulin sensitivity which is achieved by drugs such as metformin and the
glitazones.
In summary exenatide has the following metabolic effects:
 Stimulates insulin release
 Inhibits glucose production by the liver
 Slows gastric emptying
 Suppresses appetite.
Diabetes Care 27:2628-2635, 2004
A 60-year-old female suffers from bipolar affective disorder and is being treated with Lithium. She
also has a long history of hypertension for which she is on treatment. During a recent clinic visit
her blood pressure was noted to be 170/94 mmHg and a new antihypertensive agent was added.
A week later she presents with features of Lithium toxicity including tremor, nausea and
weakness.
The addition of which one of the following drugs was likely to have precipitated the Lithium
toxicity?
(Please select 1 option)
Doxazosin
Hydrallazine
Lisinopril
Correct
Minoxidil
Moxonidine
The precipitation of Lithium toxicity by diuretics is well appreciated. Yet ACE inhibitors and
Angiotensin Antagonists are also capable of precipitating Lithium toxicity through reduced Lithium
clearance. Other drugs that may precipitate Lithium toxicity include NSAIDs, tetracycline, phenytoin
and ciclosporin.
A 68-year-old lady presented to her general practitioner with a history of generalised tiredness.
She had recently been commenced on a water tablet to ease her swollen feet. She was also
diagnosed with glaucoma for which she used topical eye drops.
Investigations:
Serum sodium
138 mmol/L (137-144)
Serum potassium
Haemolysed sample
Serum urea
4.3 mmol/L (2.5-7.5)
Serum creatinine
88 µmol/L (60-110)
Serum corrected calcium
2.68 mmol/L (2.2-2.6)
Which diuretic was this lady most probably taking?
(Please select 1 option)
acetazolamide
amiloride
bendroflumethiazide
Correct
furosemide
indapamide
Thiazide diuretics are associated with increased calcium concentrations as well as raised urate
A 62-year-old male presented to the urologists with symptoms of urinary hesitancy and dribbling.
They diagnose benign prostatic hyperplasia and he is commenced on finasteride.
Through which of the following mechanisms does finasteride function?
(Please select 1 option)
5-alpha-reductase inhibitor
Alpha receptor antagonist
LHRH analogue
Correct
LHRH antagonist
Testosterone receptor antagonist
Finasteride is a 5-alpha-reductase inhibitor preventing the conversion of testosterone to the active
dihydrotestosterone (DHT).
Consequently this agent opposes testosterone, so gynaecomastia and reduced libido are common
side effects.
It is also taken orally (under the brand name Propecia) for the treatment of male pattern hair loss!
A 17-year-old boy is admitted with a severe paracetamol overdose following an argument with his
girlfriend. He is treated with intravenous N-acetylcysteine. Paracetamol is normally metabolised
to harmless compounds except in overdose. Which of the following compounds is the toxic
metabolite that accumulates during paracetamol overdose and is reduced by treatment with Nacetylcysteine?
(Please select 1 option)
Glucuronide
Homocysteine
Methionine
N-acetyl-p-benzoquinoneimine
Correct
N-hydroxyacetaminophen
Paracetamol is predominantly metabolised to glucuronide and sulphate conjugates, which are
excreted in the urine. Hepatotoxicity is related to the conversion of a small proportion of the
ingested dose to N-acetyl-p-benzoquinoneimine. In therapeutic doses N-acetyl-pbenzoquinoneimine is detoxified by conjugation with glutathione in the liver, but once the protective
intracellular glutathione stores are depleted hepatic and renal damage may ensue. NAC and
Methionine replenishes glutathione stores in the liver and may also act through its Sulphhydryl (-SH)
group as a direct reducing agent.
Further Reading: Wikipedia - paracetamol OD
75-year-old patient being treated for heart failure presents with hyperkalaemia, the potassium
being 6.9mmol/L (Normal 3.5-5.0). He was recently commenced on Amiloride. The interaction of
Amiloride with which of his drugs listed below is likely to have caused the hyperkalaemia?
(Please select 1 option)
Bisoprolol
Digoxin
Metolazone
Perindopril
Correct
Warfarin
The co-administration of a potassium-sparing diuretic and an ACE inhibitor, in this case Perindopril,
may result in profound hyperkalaemia, as has occurred in this patient. Thus patients on both these
drugs should have their potassium monitored closely. Metolazone may result in profound
hypokalaemia
Which one of the following is a recognised treatment option in poisoning?
(Please select 1 option)
Ethanol for isopropyl alcohol poisoning
Glucagon for cocaine poisoning
Methylene blue for cyanide poisoning
N-acetylcysteine in paraquat poisoning
Pralidoxime in sarin (nerve gas) poisoning
Correct
Sarin is an organophosphorus. Pralidoxime reactivates acetyl cholinesterase enzyme. It should be
used in the first few hours.
Ethanol reduces the formation of toxic metabolites produced after ingestion of methanol and
ethylene glycol, but not isopropyl alcohol.
Glucagon is used in symptomatic beta-blocker overdose.
N-acetylcysteine is used in paracetamol overdose.
Methylene blue is the antidote for serious methaemoglobinaemia.
A 55-year-old male who is being treated with Lithium for a bipolar disorder has a long history of
hypertension for which he is receiving escalating doses of medication. On his most recent visit to
clinic his blood pressure was noted to be 166/102 mmHg and new antihypertensive was added to
his current antihypertensive therapy. Five days later he presents with features of Lithium toxicity
including tremor, nausea and weakness.
The addition of which of the following drugs was likely to have precipitated the Lithium toxicity?
(Please select 1 option)
Doxazosin
Hydrallazine
Irbesartan
Minoxidil
Correct
Moxonidine
The precipitation of Lithium toxicity by diuretics is well appreciated. Yet ACE inhibitors and
Angiotensin Antagonists are also capable of precipitating Lithium toxicity through reduced Lithium
clearance. Other drugs that may precipitate Lithium toxicity include NSAIDs, tetracycline, phenytoin
and ciclosporin
A 44-year-old man presents with new onset bilateral gynaecomastia. He has been
diagnosed with Zollinger-Ellison syndrome in the last year. He underwent normal
puberty at age 14. Which of the following drugs would be most likely to cause
gynaecomastia?
(Please select 1 option)
Cimetidine
Correct
Famotidine
Lanzoprazole
Rabeprazole sodium
Ranitidine
The answer to this question is cimetidine which is an H2 receptor antagonist. Blockade of
androgen-responsive receptors in the target organ appears to be the most likely mechanism
involved. Reasearch has shown that the other drugs listed above which may also be used as part
of the treatment of Zollinger-Ellison syndrome have a much lower almost insignificant risk in the
development of gynaecomastia.
Other drugs that can casue gynaecomastia include - spironolactone, digoxin, methyldopa,
gonadotrophins and cyproterone acetate.
Zollinger-Ellison sydrome
The association of peptic ulcer with a gastrin-secreting pancreatic adenoma - 50-60% are malignant. It occurs in
approx 0.1% of patients with duodenal ulcer disease and is to be suspected in those with multiple peptic ulcers that
are resistant to drugs.
In a study, healthy volunteers are given 50 mls of 50% dextrose solution by one of two routes.
Route A is intravenous and Route B is via a nasogastric tube. Every 15 minutes the plasma insulin
level and glucose is measured and plotted on a graph. Which of the following statements would
best describe the likely results comparing Route A to Route B in this experiment?
(Please select 1 option)
Insulin higher, glucose higher in Route A
Insulin higher, glucose higher in Route B
Insulin higher, glucose lower in Route A
Insulin higher, glucose lower in Route B
This is the correct answer
Insulin and glucose the same in Route A and Route B
Incorrect answer selected
Glucose given via the gut elicits a greater insulin response as compared to the same quantity given
intravenously even though the plasma glucose peak is higher when it is given IV. This phenomenon is
called the 'incretin effect'.
The incretin effect denominates the phenomenon that oral glucose elicits a higher insulin response
than does intravenous glucose. The two hormones responsible for the incretin effect, glucosedependent insulinotropic hormone (GIP) and glucagon-like peptide-1 (GLP-1), are secreted after oral
glucose loads and augment insulin secretion in response to hyperglycemia. Gastric Inhibitory
Polypeptide and Glucagon-Like Peptide-1 in the Pathogenesis of Type 2 Diabetes. Diabetes 53:S190S196, 2004
The investigation of the incretin effect is not usually performed using the same quantity of glucose
as in this question. An 'isoglycaemic study' is often used where an infusion of glucose is designed to
copy exactly the blood glucose profile generated in an individual or animal by a certain enteral
glucose load.
Exenatide (synthetic exendin-4) is a new agent for the treatment of Type 2 Diabetes. Exendin-4
occurs naturally in the saliva venom of the North American lizard called the Gila Monster. It mimics
the action of the gut hormone GLP-1 (Glucagon-like peptide 1)
In which of the following would the first drug be associated with increased pharmacological action
of the second drug?
(Please select 1 option)
Erythromycin : theophylline
This is the correct answer
Phenytoin : ethinyloestradiol
Ranitidine : cortiocosteroid
Rifampicin : warfarin
Valproate : phenobarbitone
Incorrect answer selected
Erythromycin would inhibit the metabolism of theophylline.
Ranitidine unlike cimetidine is not an enzyme inhibitor.
Phenytoin would speed up metabolism of ethinyl-oestradiol making the pill less effective.
Rifampicin is a well recognised enzyme inducer.
A 24-year-old female presents with a two week history of polyuria and polydipsia together with
frequent nocturia.
Investigations show
Serum Sodium
144 mmol/L (137-144)
Serum Potassium
3.3 mmol/L (3.5-4.9)
Serum Calcium
2.6 mmol/L (2.2-2.6)
Plasma glucose
6.8 mmol/L (3.0-6.0)
Serum Osmolality
310 mOsmol/L (275-295)
What is the diagnosis?
(Please select 1 option)
Diabetes Insipidus
Diabetes Mellitus
Drug abuse
This is the correct answer
Primary hyperparathyroidism
Primary polydipsia
Incorrect answer selected
This patient has polyuria and polydipsia of relative recent onset and has an elevated plasma
osmolality with a high calcium and glucose concentration. These features would be unlikely in DI and
are more in keeping with thiazide diuretic abuse - high calcium, glucose and hypokalaemia.
Similarly, the serum osmolality would be low in association with primary polydipsia. There may be
plenty of variations purely by alteration of the biochemistry of this question in the exam
Which term best describes the affinity of a drug for its receptor?
(Please select 1 option)
Efficacy
Intrinsic activity
Potency
Selectivity
This is the correct answer
Incorrect answer selected
Therapeutic effect
Affinity is the measure of the net molecular attraction between a drug (or neurotransmitter or
hormone) and its receptor. The receptor's affinity for binding a drug determines the concentration
of drug required to form a significant number of drug-receptor complexes. Affinity and intrinsic
activity are determinants of potency. Efficacy contributes both to potency and to the maximum
effect of the agonist. Efficacy is a measure of the efficiency of the drug–receptor complex in
initiating the signal transduction process.
A 30-year-old patient with learning difficulties is admitted as a medical emergency.
The patient complains of headache, anorexia and vomiting.
On examination she is febrile with a temperature of 38°C, pulse 110 bpm and is clinically
jaundiced.
Investigations reveal:
Bilirubin
60 µmol/L
(1-22)
Albumin
28 g/L
(37-49)
AST
400 IU/L
(5-40)
Alkaline Phosphatase
400 IU/L
(45-105)
Prothrombin time
35 seconds
(<14)
She was commenced on a new medication within the last three months.
Which do you suspect maybe contributing to the presentation?
(Please select 1 option)
Cabergoline
Carbamazepine
Lamotrigine
Metformin
Sodium valproate
Correct
Sodium valproate can occasionally have an idiosyncratic response leading to severe or even fatal
hepatic toxicity.
This is more common if the patient has a metabolic or degenerative disorder, organic brain disease
or severe seizures associated with mental retardation. Usually this reaction occurs within the first
three months of therapy.
Carbamazepine can be associated with jaundice occasionally, however the history of mental
retardation and short history of drug use point to sodium valproate as the cause.
Lamotrigine can disrupt liver function tests (LFTs).
Metformin and cabergoline do not affect liver function however caution is advised when using
these drugs in patients with hepatic disease.
A 22-year-old male is admitted after drinking engine coolant in an apparent suicide attempt after
finding his wife in bed with the postman. Investigations reveal:
pH
7.1 (7.36-7.44)
pO2
15.3 kPa (11.3-12.6)
pCO2
3.2 kPa (4.7-6.0)
Standard Bicarbonate
2.2 mmol/L (20-28)
Serum Calcium
1.82 mmol/L (2.2-2.6)
After replacing calcium, which of the following is the most urgent treatment for this man?
(Please select 1 option)
Alcohol infusion
8.4% bicarbonate infusion
Femopizole infusion
Correct
Gastric lavage
Haemodialysis
Engine coolant contains ethylene glycol. Ingestion of as little as 30-60ml is capable of causing death.
Traditional management of poisoning includes the use of ethanol, with or without hemodialysis.
Activated charcoal is not indicated, and gastric lavage may be beneficial only in the first hour after
ingestion. However, fomepizole, has recently been approved for use and is a competitive inhibitor of
alcohol dehydrogenase. However, it is very expensive and the evidence supporting its use over
alcohol is lacking. Also, this patient already has a severe metabolic acidosis. In this circumstance,
antidotal therapy to block alcohol dehydrogenase with ethanol or 4-MP alone is insufficient to treat
the poisoning. Data suggest that a severe lactic acidosis needs initial correction and in this patient
the most appropriate treatment would be IV fluids with bicarbonate to correct the metabolic
acidosis. Then haemodialysis is probably required.
A 55-year-old woman who has a history of atrial fibrillation and is receiving warfarin and digoxin,
informs you that she has been feeling down of late and has been self medicating with St John's
Wort that she obtained from a health shop. Which of the following interactions may be expected
between St John's Wort and her current medication?
(Please select 1 option)
INR is likely to be increased
INR is likely to be reduced
Correct
INR is likely to be unaffected
There is an increased risk of digoxin toxicity
Digoxin concentrations are unlikely to be affected
St John's Wort is now commonly taken for depressive symptoms, yet it is a liver enzyme inducer and
therefore has interactions with medications typically reducing the efficacy. In this regard, St John's
Wort may reduce the efficacy of Warfarin, requiring increased dose to maintain the INR and it may
also reduce the efficacy of Digoxin
Which of the following drugs interacts with cranberry juice?
(Please select 1 option)
Amiodarone
Digoxin
Propranolol
Simvastatin
Warfarin
Correct
This is a pathetic question but apparently this theme has been asked in the exam. I suspect that the
authors of this paper were the culprits in composing this question. The answer is warfarin.
Which of the following antiemetics functions through inhibition of neurokinin (NK)1 receptor?
(Please select 1 option)
Aprepitant
Correct
Domperidone
Hyoscine
Granisteron
Ondansetron
Aprepitant is a neurokinin receptor blocker used in the prevention of chemotherapy induced nausea.
Ondansetron and granisetron are 5HT3 antagonists. Hyoscine is an anticholinergic/antihistaminergic.
Domperidone is an antidopaminergic agent.
A 53-year-old male is receiving treatment with imatinib for chronic myeloid leukaemia. Which of
the following is imatinib?
(Please select 1 option)
Inhibits p53
Inhibits HER
Inhibits guanylate cyclase
Inhibits MAP kinase
Inhibits tyrosine kinase
Correct
Imatinib is an inhibitor of tyrosine kinase and is used in the treatment of conditions such as CML and
GIST tumours. It inhibits TK on abl proto-oncogene, c-kit and the PDGF-R. In CML, the Philadelphia
chromosome leads to a fusion protein of abl with bcr (breakpoint cluster region), termed bcr-abl. As
this is now a continuously active tyrosine kinase, imatinib is used to decrease bcr-abl activity.
A 53-year-old female with surgically treated acromegaly is receiving treatment with Octreotide
therapy due to persistently elevated growth hormone concentrations following surgery. What is
the mechanism of action of Octreotide?
(Please select 1 option)
Inhibition growth hormone receptor
Inhibition of dopamine D2 receptor
Inhibition of IGF-1 receptor
Inhibition of GHRH receptor
Stimulation of the somatostatin receptor
Correct
Octreotide is a somatostatin analogue and directly inhibits growth hormone secretion through
interaction with sms receptors. It is also used in the treatment of neuroendocrine tumours such as
carcinoid tumours again through interaction with somatostatin receptors
A 59-year-old male presents with a three day history of marked muscle aches and weakness. He
has ischaemic heart disease for which he takes a number of drugs including simvastatin and has
been taking these drugs for a number of years without any problem. On this occasion his CPK
confirms a diagnosis of rhabdomyolysis with a level of 4200 iu/l (<200). Which of the following
health supplements is he most likely to have taken that would have contributed to the statininduced rhabdomyolysis?
(Please select 1 option)
Cranberry juice
Cod liver oil capsules
Ginseng
Grapefruit juice
Correct
Vitamin C
Grapefruit juice is well recognised to inhibit statin metabolism thereby potentiating the myotoxicity.
In particular, grapefruit juice should be avoided with simvastatin and lovastatin and it also inhibits
metabolism of CCB and theophylline
A 16-year-old female is admitted after taking an overdose of her mother's propranolol tablets
approximately 2 hours ago. On examination she is drowsy and has a pulse of 40 beats per minute
with a blood pressure of 80/40 mmHg. She is treated with activated charcoal, IV fluids and IV
atropine but her bradycardia and hypotension fail to respond. Which of the following would be
the most appropriate next stage in her management?
(Please select 1 option)
IV adenaline
IV amiodarone
IV glucagon
Correct
IV Phenytoin
Insertion of temporary pacemaker
In those in whom initial atropine is unsuccessful, IV Glucagon is a recommended treatment for betablocker overdose with some evidence indicating improvement in bradycardia and blood pressure.
A farmer, on treatment for depression is admitted acutely 1 hour following an intentional
overdose of an unidentified substance. On examination he is bradycardic, hypotensive,
disorientated, hypersalivating, and has small pupils. He has most likely ingested :
(Please select 1 option)
Paracetamol
A tricyclic anti-depressant
Paraquat
An organophosphate insectacide
Correct
Cyanide
Hypersalivation and miosis are the specific clues to acetycholine overactivity. Occupational access to
organophosphate insectacides. Pupils tend to be dilated with TCA OD. Paracetamol, cyanide, and
paraquat shouldn't affect pupils
An elderly asthmatic lady on treatment with high dose prednisolone, complains of a 4 week
history of right hip pain. She comments that recently she seems to be developing more facial hair
and adds that she has also been diagnosed with high blood pressure and diabetes. On examination
she is noted to be unable to weight bear on the right side. What is the most likely cause of her hip
pain?
(Please select 1 option)
Avascular necrosis of femoral head
Correct
Dislocation of the hip joint
Fracture neck of femur
Gout
Osteoarthritis of the hip joint
This question simply tests the knowledge of side-effects of corticosteroids (a favourite theme in
MRCP 1). The patient has features of hypercortisolism. Obviously, avascular necrosis of femoral head
is the cause of her right hip pain.
Which of the following statements regarding Antabuse (disulfiram) are correct?
(Please select 1 option)
Antabuse acts by promoting the metabolism of acetaldehyde
Can be used in patients with a history of psychosis in order to limit alcohol excess
Can be used to assist abstinence from alcohol in patients with heart disease.
Patients using alcohol based perfumes may develop serious reactions
Correct
Requires regular dose titration once initiated
Antabuse inhibits the breakdown of acetaldehyde, which is a major metabolite of alcohol.
It is the accumulation of acetaldehyde which causes the flushing, sweating, palpitations, nausea,
and vomiting seen in patients taking Antabuse who imbibe alcohol.
These reactions may also occur with alcohol based products, for example, perfume.
Antabuse is contraindicated in cirrhosis and heart disease, and psychosis is a relative
contraindication for its use.
A 30-year-old man presents to the Emergency Department with a history of drug overdose.
He is known to be repeatedly admitted with similar episodes of self-harm. On this occasion he is
drowsy and has prominent hypersalivation.
Which of the following agents, found on his person, is the likely cause?
(Please select 1 option)
Chlormethiazole
This is the correct answer
Cocaine
Dosulepin
L-dopa
Solvent cannister
Incorrect answer selected
Hypersalivation is seen with:
 parasympathomimetic agents
 insecticides
 arsenic
 strychnine
 chlormethiazole
 clozapine
and others.
Solvent abuse may cause an acneiform rash around the buccal cavity.
Cocaine abuse leads to hypertension and nasal septum perforation.
The other agents are anticholinergic and would cause dry mouth in overdose
A 45-year-old obese male with a two year history of type 2 diabetes has recently commenced
metformin at a dose of 500 mg twice daily. However, he re-attends clinic and reports numerous
gastrointestinal side effects including bloating and flatulence. He is keen to stop metformin and
commence an alternative agent.
Which of the following drugs is the most appropriate choice?
(Please select 1 option)
Acarbose
Exenatide
Insulin
Pioglitazone
Correct
Repaglinide
An obese type 2 diabetic patient is almost certain to be insulin resistant.
Current guidelines suggest that first line therapy in obese, insulin resistant patients should be an
insulin sensitising agent (Bailey C et al. Br J Diabetes Vas Dis 2006; 6: 147-148). Metformin is the drug
of choice in this patient therefore.
However, in patients intolerant of metformin, the thiazolidinediones rosiglitazone and pioglitazone
are licensed for monotherapy for insulin resistant patients.
Previously, sulphonylureas, such as gliclazide, would have been advocated in these circumstances,
but current opinion favours rosiglitazone and pioglitazone in such a patient.
The recent joint ADA / EASD guidelines for treatment in Type 2 diabetics suggests the glitazones are
a useful choice where hypoglycaemia is to be avoided. Glitazones increase the risk of congestive
heart failure. There is currently controversy over rosiglitazone since some data suggest it is
associated with an increased risk of ischaemic heart disease.
A 23-year-old footballer was prescribed Ibuprofen by his GP for a sprained ankle. Several hours
later he felt very unwell and was passing dark urine. The peripheral blood film shows many
schistocytes. The lab results show:
Haemoglobin
<9 g/dL (13.0-18.0)
WBC
7 x109/L (4-11 x109) with normal differentials
Platelets
450 x109/L (150-400 x109)
Reticulocyte count
5% (0.5-2.4)
Bilirubin
40 mol/L (1-22)
What is the most likely cause for his presentation?
(Please select 1 option)
Allergic reaction
Autoimmune haemolytic anaemia
Incorrect answer selected
Glucose-6-phosphate dehydrogenase deficiency
This is the correct answer
Paroxysmal nocturnal haemoglobinuria
Pyruvate kinase deficiency
This is a case of intravascular haemolysis with haemoglobinuria. The patient has the history of taking
Ibuprofen which is an oxidant and causes hemolysis in patients with G-6-PD deficiency. Oxidative
stressors can be infectious agents, drugs, chemicals and certain legumes. In G-6-PD deficient
patients, oxidative stress exposes interior sulfhydryl groups that are oxidized and cannot be reduced,
leading to irreversible denaturation of the hemoglobin with Heinz body formation. Schistocytes are
red blood cell fragments that result from membrane damage. They are sometimes referred to as
"bite cells".
A 38-year-old male is admitted with an hour history of chest pain, confusion and agitation after
taking a recreational drug.
On examination, he is confused, has a temperature of 38.3°C and a blood pressure of 188/102
mmHg.
Which of the following drugs is most likely to be responsible for his presentation?
(Please select 1 option)
Cocaine
Correct
Ecstasy (MDMA)
Gamma hydroxybutyrate (GHB)
LSD
Opiates
In this scenario, the young male presents with confusion and agitation following drug abuse.
The most likely agent is cocaine.
Through central effects, cocaine induces sweating, pyrexia and also adrenergic mediated
hypertension.
It may also be responsible for coronary and cerebral artery spasm causing infarction.
A 72-year-old man presents with painful lumps in his feet and is diagnosed with gout.
Following initial treatment with non-steroidal anti-inflammatory agents he is started on
allopurinol.
How does this work?
(Please select 1 option)
Increases urinary uric acid excretion
Inhibits cyclooxygenase II
Inhibits macrophage tubular formation
Inhibits nitric oxide synthase
Inhibits xanthine oxidase
Correct
Allopurinol inhibits xanthine oxidase, the enzyme involved in the conversion of purines into uric acid.
A 45-year-old female is admitted with fatigue, nausea and weight loss.
She is known to have abused alcohol for many years and has previously developed delirium
tremens. She stopped drinking alcohol two days ago.
On examination, she is thin, alert and orientated. She is slightly icteric, with features of chronic
liver disease but there is no flapping tremor.
Pulse is 88 bpm regular, blood pressure is 106/74 mmHg and temperature is 37°C.
She is treated with IV thiamine.
Which of the following agents would be recommended for the prevention of acute alcohol
withdrawal?
(Please select 1 option)
IM haloperidol
IV diazepam
Oral diazepam
This is the correct answer
Oral quetiapine
No preventative treatment required.
Incorrect answer selected
This patient with features of alcoholic chronic liver disease would be regarded at high risk of
developing acute alcohol withdrawal, particularly in view of her past history of delirium tremens.
Benzodiazepines are appropriate agents in preventing acute alcohol withdrawal and oral agents
such as lorazepam and diazepam are recommended.
A 45-year-old woman has, approximately four hours ago, taken an unknown quantity of
amitriptyline tablets that were being prescribed for her depression She is feeling drowsy, agitated
and has a dry mouth.
An ECG shows wide QRS complexes with arrhythmias. Blood gas analysis revealed:
pH
7.2 (7.36-7.44)
PaO2
10 KPa (11.3-12.6)
PaCO2
4 KPa (4.7-6.0)
What is the most appropriate treatment?
(Please select 1 option)
Activated charcoal
Gastric lavage
Haemodialysis
Intravenous insulin
Intravenous sodium bicarbonate
Correct
There is no specific treatment for tricyclic antidepressant poisoning.
500 ml of 1.26% sodium bicarbonate should be used to treat arrhythmias, hypotension and
significant ECG abnormalities to a pH of 7.50 - 7.55 in tricyclic antidepressant overdose even in the
absence of acidosis.
Which if the following is the mechanism of action of warfarin?
(Please select 1 option)
Activation of gamma-glutamyl carboxylase
Chelation of calcium
Inhibition of activated factor X
Inhibition of vitamin K epoxide reductase
This is the correct answer
Inhibition of vitamin K-dependent carboxylase
Incorrect answer selected
The Vitamin K epoxide is in turn recycled back to Vitamin K and Vitamin K hydroquinone by another
enzyme, the vitamin K epoxide reductase (VKOR). Warfarin inhibits epoxide reductase (specifically
the VKORC1 subunit), thereby diminishing available vitamin K and Vitamin K hydroquinone in the
tissues, which inhibits the carboxylation activity of the glutamyl carboxylase. When this occurs, the
coagulation factors are no longer carboxylated at certain glutamic acid residues, and are incapable of
binding to the endothelial surface of blood vessels, and are thus biologically inactive. (Wikipedia warfarin)
A 45-year-old man with Type 2 Diabetes is being treated with Exenatide. Which of the following
would be a recognised adverse effect of his treatment?
(Please select 1 option)
Hyperglycaemia
Hypertension
Peripheral oedema
Renal impairment
Weight loss
Incorrect answer selected
This is the correct answer
Exenatide (synthetic exendin-4) is a new agent for the treatment of Type 2 Diabetes. Exendin-4
occurs naturally in the saliva venom of the North American lizard called the Gila Monster. It mimics
the action of the gut hormone GLP-1 (Glucagon-like peptide 1). It causes hypoglycaemia (which is its
therapeutic effect) especially when used in combination with oral antidiabetic drugs, weight loss,
nausea and other gastrointestinal side effects
A 70-year-old man presents with an episode of syncope. On subsequent investigation he is found
to have marked postural hypotension. He has been taking felodipine for hypertension for a
number of years and he also takes aspirin. On further questioning he appears to have taken up a
new healthier lifestyle on his seventieth birthday. Which of the following health supplements is he
most likely to have taken that would have contributed to the calcium-channel blocker induced
hypotension?
(Please select 1 option)
Cranberry juice
Cod liver oil capsules
Ginseng
Grapefruit juice
Correct
Vitamin C
Grapefruit juice interacts with drugs. The basis for this interaction has been diligently explored and
appears to relate to both flavanoid and nonflavanoid components of grapefruit juice interfering with
enterocyte CYP3A4 activity. Of the calcium channel blockers felodipine in particular is affected. Am J
Hypertens (2006) 19: 768-73
Which of the following antiemetics functions through antagonism of the 5-hydroxytryptamine 3A
receptor?
(Please select 1 option)
Aprepitant
Domperidone
Hyoscine
Metoclopramide
Ondansetron
Correct
Ondansetron is a serotonin 5-HT3 receptor antagonist used mainly to treat nausea and vomiting
following chemotherapy. Its effects are thought to be on both peripheral and central nerves. One
part is to reduce the activity of the vagus nerve, which is a nerve that activates the vomiting center
in the medulla oblongata, the other is a blockage of serotonin receptors in the chemoreceptor
trigger zone. It does not have much effect on vomiting due to motion sickness. This drug does not
have any effect on dopamine receptors or muscarinic receptors.
Which of the following antiemetics functions as a cholinergic muscarinic antagonist?
(Please select 1 option)
Aprepitant
Domperidone
Hyoscine
Correct
Metoclopramide
Ondansetron
Scopolamine is named after the genus Scopolia. The name "hyoscine" is from the scientific name for
henbane, Hyoscyamus niger. It acts as a competitive antagonist at muscarinic acetylcholine
receptors; it is thus classified as an anticholinergic or as an anti-muscarinic drug
A 63-year-old female presents with dry mouth of 3 months duration. She is taking medication for
hypertension, stress incontinence and reflux oesophagitis. Which of the following may be
responsible for her dry mouth?
(Please select 1 option)
Oxybutinin
Correct
Doxazosin
Hydrallazine
Cimetdine
Bendroflumethiazide
Oxybutinin is an effective treatment for detrussor instability and is a parasympathetic muscarinic
antagonist. Consequently dry mouth is a problem in up to 70% of cases. Bendroflumethiazide, the
thiazide diuretic, at a dose of 2.5 mg per day is not associated with dry mouth. Cimetdine is a H2
antagonist and is not associated with dry mouth
A 63-year-old patient with bipolar disorder and Type 2 diabetes trips over a step and sustains an
injury to her left hand. She is unable to dorsiflex her left hand, and an orthopaedic registrar
diagnosis a ruptured extensor tendon.
She is receiving treatment for an infected diabetic foot ulcer.
Which of the following therapies may be implicated in this injury?
(Please select 1 option)
Aripiprazole
Exenatide
Fusidic acid
Levofloxacin
Correct
Naproxen
The quinolones have recently been associated with tendon rupture. Rupture has been reported in
the Achilles, shoulder and hand.
This may occur due to disruption of the extracellular matrix and depletion of collagen which is
observed in animal models.
Aripiprazole is a second generation antipsychotic, and exenatide is a glucagon like-peptide 1
analogue used in the management of Type 2 diabetes. Neither of these products has been
associated with tendon rupture.
A 40-year-old ex-footballer presents requesting treatment for alcoholism and is prescribed
disulfiram.
What is the mode of action of disulfiram?
(Please select 1 option)
Decreases severity of alcohol withdrawal
Helps alcoholics to drink safely
Inhibits acetaldehyde dehydrogenase activity
Correct
Inhibits alcohol dehydrogenase activity
Reduces the desire for alcohol
Alcohol is mainly metabolised in the liver to acetaldehyde by alcohol dehydrogenase.
Acetaldehyde is then oxidised to acetate by acetaldehyde dehydrogenase (AcDH).
Disulfiram irreversibly inhibits the oxidation of acetaldehyde by competing with the cofactor
nicotinamide adenine dinucleotide (NAD) for binding sites on AcDH.
The increased acetaldehyde levels are thought to produce the unpleasant side effects associated
with acetaldehyde syndrome such as headaches, nausea, flushing, etc.
With respect to symptoms of withdrawal related to chronic alcohol use, which of the following
statements is correct?
(Please select 1 option)
Benzodiazepines are ineffective in the treatment of seizuressecondary to alcohol
withdrawal, due to cross tolerance withethanol a Type A gamma amino-aminobutyric acid
receptor
Carbamazepine is as effective as benzodiazepines in the acute treatment of the symptoms
of alcohol withdrawal This is the correct answer
Phenytoin is an effective treatment for seizures related to alcohol withdrawal
Withdrawal reflects enhanced neurotransmission in type A gamma-aminobutyric acid
pathways Incorrect answer selected
Withdrawal reflects reduced neurotransmission in N-methyl-D-aspartate pathways
Carbamazepine at a starting dose of 800 mg per 24 hours has been shown to be as effective as
oxazepam in the treatment of acute alcohol withdrawal.
Phenytoin is not effective in the treatment of alcohol withdrawal-related seizures.
Alcohol withdrawal reflects the damping of neurotransmission through type A gamma-amino-butyric
pathways, and enhanced neurotransmission through N-methyl-D-aspartate pathways.
For a review see NEJM348:18;1788-90.
A 33-year-old woman with a history of alcoholism and self-neglect, presents with an
episode of blood streaked vomiting. This is attributed to minor Mallory-Weiss tear. She
is admitted to hospital and given an intravenous infusion of 5% dextrose. Her serum
potassium concentration is noted the following day to have fallen to 1.9 mmol/L (3.54.9) on admission. What is the likely mechanism for the fall in potassium concentration?
(Please select 1 option)
Cortisol release in response to stress increasing renal potassium loss
Decompensated liver failure causing aldosterone secretion
Intracellular re-uptake in response to re-feeding with glucose
Correct
Metabolic acidosis increasing renal potassium excretion
Potassium levels falling following gastric loss in vomiting
This neglected person is being fed with dextrose, which will cause an elevation of circulating insulin
to maintain glycaemic control. This will consequently drive potassium intracellularly so reducing
extracellular potassium concentration.
A 32-year-old woman treated with hydrocortisone 10 mg in the morning and 10 mg in the evening
for Addison's disease, presents to the clinic with poor compliance.
She feels that the hydrocortisone upsets her stomach and wants to switch to enteric coated
prednisolone.
What would be the appropriate corresponding daily dose of prednisolone?
(Please select 1 option)
4mg daily
5mg daily
Correct
7mg daily
10mg daily
15mg daily
The approximate equivalent glucocorticoid action of prednisolone to hydrocortisone is 4:1.
Hence the equivalent dose for 20 mg of hydrocortisone is roughly 5 mg per day of prednisolone.
For other glucocorticoid dose conversions try this online glucocorticoid dose calculator
A 45-year-old female presents with a six month history of exertional dyspnoea and is diagnosed
with pulmonary fibrosis (PF).
Over the last one year she has received a variety of medications.
Which of the following drugs could be responsible?
(Please select 1 option)
Dexamethasone
Ibuprofen
Nalidixic acid
Penicillamine
Sulphasalazine
Correct
Sulphasalazine as well as other rheumatology drugs such as gold and methotrexate can cause
pulmonary fibrosis.
Bleomycin and cyclophosphamide rather than vincristine may be responsible.
Corticosteroids are sometimes given as a trial in pulmonary fibrosis.
Nalidixic acid is associated with seizures and visual disturbances. However nitrofurantoin is well
recognised to cause PF.
Other drugs include amiodarone and nitrofurantoin.
A 63-year-old man was found collapsed.
A department of psychiatry outpatient card was found in his jacket, together with a bottle of
procyclidine tablets.
He was febrile (38.2°C), conscious but unresponsive to commands. The blood pressure was
160/105 mmHg and there was marked muscle rigidity.
What is the most likely diagnosis?
(Please select 1 option)
Acute catatonic schizophrenia
Bacterial meningitis
Cerebral malaria
Neuroleptic malignant syndrome
Correct
Procyclidine overdose
The symptoms are typical of neuroleptic malignant syndrome (NMS).
NMS is characterised by:
 Fever
 Muscular rigidity
 Altered mental status
 Autonomic dysfunction.
Procyclidine is used to treat the Parkinsonian side-effects of neuroleptics; its presence in the
patient's pocket implies that he was taking neuroleptics.
Signs of procyclidine overdose include:
 Agitation
 Confusion
 Sleeplessness lasting up to 24 hours or more
 Pupils are dilated and unreactive to light.
Visual and auditory hallucinations and tachycardia have also been reported
A 90-year-old man with chronic leukaemia presents with gout which his general
practitioner treats with Allopurinol. How does Allopurinol prevent the accumulation of
uric acid?
(Please select 1 option)
By competing for its transporter to the kidney
By enhancing its solubility
By inhibiting purine synthesis
Correct
By inhibiting pyrimidine synthesis
By inhibiting the inflammatory response it causes
Allopurinol is a xanthine oxidase inhibitor and is converted by this enzyme to alloxanthine in this
form it inhibits the conversion of hypoxanthine to xanthine, and the conversion of xanthine to uric
acid. Therefore inhibiting the formation of uric acid.
Which of the following cytotoxic agents acts by inhibiting purine synthesis?
(Please select 1 option)
Bleomycin
Cisplatin
Doxorubicin
Methotrexate
Correct
Vincristine
Methotrexate inhibits purine synthesis. J. Biol. Chem., Vol. 262, Issue 28, 13520-13526, Oct,
1987. The other drugs have different mechanisms of action.
Useful therapy for improving fertility in Polycystic ovarian syndrome include
(Please select 1 option)
Cyproterone acetate
Ethinyl oestradiol
Metformin
Correct
Glibenclamide
Spironolactone
Metformin has been shown to increase the rate of conception in PCOs through improved insulin
sensitivity. Ethinyloestradiol and cyproterone acetate combine to form Dianette the oral
contraceptive. Spironolactone is used for hirsuitism but is teratogenic. Glibenclamide is not used in
PCOs.
Oral therapy with which of the following may cause galactorrhoea?
(Please select 1 option)
Bromocriptine
Cabergoline
Spironolactone
Cimetidine
Incorrect answer selected
Domperidone
This is the correct answer
Domperidone is a dopamine antagonist producing large rises in prolactin concentrations.
Spironolactone has no effect on prolactin and Cimetidine produces hyperprolactinaemia only when
given IV. Both bromocriptine and cabergoline are dopamine agonists and reduce prolactin.
A 29-year-old man is starting a chemotherapy regime that includes cisplatin. Which of the
following is the mechanism of action of cisplatin?
(Please select 1 option)
Causes crosslinking in DNA
Correct
Degrades preformed DNA
Inhibits purine synthesis
Reduces the formation of microtubules
Stabilises DNA-topoisomerase II complex
"Cisplatin acts by crosslinking DNA in several different ways, making it impossible for rapidly dividing
cells to duplicate their DNA for mitosis." Wikipedia: cisplatin
Interferon alpha immunotherapy is used as treatment of which for the following conditions?
(Please select 1 option)
Acute lymphoblastic leukaemia
Acute myeloid leukaemia
Burkitt's lymphoma
Hairy cell leukaemia
Correct
Myelodysplastic syndrome
"Interferon-alpha is an immune system hormone which is very helpful to a relatively small number of
patients, and somewhat helpful to most patients. Most commonly, the drug helps stabilize the
disease or produce a slow, minor improvement. The typical dosing schedule injects 3 million units of
Interferon-alpha (not pegylated versions) three times a week, although the original protocol began
with six months of daily injections." Wikipedia: Hiary Cell Leukaemia
A 45-year-old male takes Lithium for a bipolar affective disorder. Which of the following drugs
would be contra-indicated in conjunction with Lithium?
(Please select 1 option)
Atenolol
Bendroflumethiazide
Codeine Phosphate
Correct
Flucloxacillin
Thyroxine
Caution should be exercised when taking Lithium and diuretics as the latter may reduce renal
clearance of lithium and increase serum lithium concentrations. NSAIDs also increase Lithium
concentrations. Metronidazole, ACEis and Calcium channel blockers also increase serum Lithium
concentrations
A 26-year-old woman was being treated in the outpatient clinic for autoimmune hypothyroidism.
She was taking 150µg of thyroxine and 200 mg of amiodarone.
Investigations reveal:
Plasma prolactin
654 mU/L
(<360)
Plasma free T4
24 pmol/L
(10-22)
Plasma free T3
5.2 pmol/L
(5-10)
Plasma thyroid-stimulating hormone
68 mU/L
(0.4-5)
What is the most likely explanation for her high TSH levels?
(Please select 1 option)
Amiodarone effect
Hyperprolactinaemia
Poor compliance with medications
Correct
Thyroid hormone resistance
TSH producing pituitary adenoma
This young woman has a slightly elevated thyroxine (T4) and an elevated thyroid-stimulating
hormone (TSH).
The most probable explanation is poor compliance. This also explains the slightly high prolactin
concentration too; a consequence of reduced dopaminergic tone on the lactotrophs.
The typical scenario is that the patients take their medication in the days before the clinic.
This is a classic MRCP question and is highly discriminating. Consider this one carefully and try
to understand fully why this is not an effect of amiodarone.
A 29-year-old man who is a keen amateur photographer with his own development studio
presented to the Emergency department with confusion. His partner said he had been under a
great deal of stress recently and she found him foolishly drinking a developer solution with a
poison symbol on it. He is hypoxic and hypotensive. The local poisons unit suggests a diagnosis of
cyanide poisoning. Which of the following would be the most appropriate treatment?
(Please select 1 option)
Desferrioxamine
Dicobalt EDTA
Correct
Gastric lavage with Fuller's earth
Haemodialysis
Penicillamine
Potassium ferricyanide is used chiefly for blueprints, in photography, for staining wood, in calico
printing, and in electroplating.
Kelocyanor (dicobalt EDTA), given by intravenous injection, has been proven to be of use when
administered to seriously ill victims of confirmed cyanide poisoning. It is itself toxic, however, and
can kill if used wrongly. HSE knows of several cases of inappropriate use resulting in hospital
treatment. Its administration is beyond the scope of first aid and a recommendation has been made
in the past that a 'Kelocyanor kit' should be kept by users of cyanide and transported to hospital with
the patient. Unfortunately we are aware of cases where this has misled doctors to treat patients for
cyanide poisoning when this diagnosis was not correct. UK guidelines for the first aid of cyanide
poisoning
A 24-year-old male presents after developing a bluish discolouration of the body, lips and nails. He
denies any relevant past medical history. Examination reveals a central cyanosis and a grey
complexion.
Investigation revealed:
Haemoglobin
17.0 g/dL (13.0-18.0)
PaO2
13.0 kPa (11.3-12.6)
SaO2 (using an oximeter)
85% (>95)
What is the most likely diagnosis?
(Please select 1 option)
Argyria
Cyanotic congenital heart disease
Haemochromatosis
Methaemoglobinaemia
Correct
Methylene blue poisoning
This patient is otherwise well and has no specific features of congenital heart disease (clubbing etc).
He appears desaturated with sats of 85% yet good pO2. This is a typical description of
methaemoglobinaemia which is the accumulation of reversibly oxidised methaemoglobin causing
reduced oxygen affinity of the Hb molecule with consequent cyanosis. It can occur due to an
inherited condition or as a consequence of drugs such as nitrites.
Argyria is colloidal silver toxicity. more ...
A 48-year-old lady with Addison's disease presented in a small peripheral clinic. She says that she
has run out of her hydrocortisone and she usually takes 20 mg in the morning and 10 mg in the
evening. No hydrocortisone is available at the clinic but you do have prednisolone which you
would like to prescribe instead until a prescription of hydrocortisone can be dispensed. What is
the equivalent daily dose of prednisolone?
(Please select 1 option)
2.5 mg
5 mg
7.5 mg
Correct
10 mg
20 mg
1 mg is equivalent to 4 mg hydrocortisone so this lady should be given 7.5 mg. If 2.5 mg tablets were
not available (to go with a 5 mg tablet to make 7.5 mg tablet) then 10 mg would be fine. It is better
to overdose rather than under-dose especially where there is stress or illness.
A patient is suspected of having taken a substance with anticholinesterase effects. Which of the
following combinations of signs, if present, would be the most likely to confirm this effect?
(Please select 1 option)
Bradycardia and miosis
Correct
Bradycardia and mydriasis
Bradycardia and urinary retention
Tachycardia and diarrhoea
Tachycardia and lacrimation
An Acetylcholinesterase inhibitor or Anti-cholinesterase is a chemical that inhibits the cholinesterase
enzyme from breaking down acetylcholine (ACh), so increasing both the level and duration of action
of the neurotransmitter acetylcholine. ACh can stimulate postganglionic receptors to produce effects
such as salivation, lacrimation, defecation, micturition, sweating, miosis, bradycardia, and
bronchospasm. Muscarine produces these effects, and hence they are referred to as muscarinic
effects, and the postganglionic receptors are called muscarine receptors. (eMedicine)
SLUD (Salivation, Lacrimation, Urination, Defecation [and emesis]) is a syndrome of pathological
effects indicative of massive discharge of the parasympathetic nervous system. Unlikely to occur
naturally, SLUD is usually encountered only in cases of drug overdose or exposure to nerve gases.
Nerve gases irreversibly inhibit the enzyme acetylcholinesterase; this results in a chronically high
level of acetylcholine at cholinergic synapses throughout the body, thus chronically stimulating
acetylcholine receptors throughout the body. (Wikipedia)
A 68-year-old lady with mitral valve disease and atrial fibrillation is taking warfarin.
Lately her international normalised (INR) has fallen and the dose of warfarin has had to
be increased.
Which of the following new treatments may account for this change?
(Please select 1 option)
Allopurinol
Amiodarone
Clarithromycin
Sertraline
St John's wort
Correct
The metabolism of warfarin has been increased since it is becoming less effective.
St John's wort is an enzyme inducer.
The other drugs are enzyme inhibitors.
A 40-year-old lady presents with a swollen right calf. She has a history of mental health
problems and is on a number of medications. Which of the following treatments
increases the risk of thromboembolism?
(Please select 1 option)
Antipsychotics
This is the correct answer
Benzodiazepines
Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Tricyclic antidepressants
Incorrect answer selected
The oral contraceptive and antipsychotics are possible causes of thromboembolism.
A 70-year-old woman is on multiple medications for various conditions and she is found to have a
macrocytic anaemia with a low serum B12. Which of the following medications is a possible cause
of the B12 deficiency?
(Please select 1 option)
Amiodarone
Ezetimibe
Metformin
This is the correct answer
Nicotinic acid
Sodium valproate
Incorrect answer selected
Metformin can lead to reduced B12 absorption but this is not usually a clinical problem.
"The clinician must be aware of the possibility of metformin-associated B12 deficiency in users who
suffer cognitive impairment, peripheral neuropathy, subacute combined degeneration of the cord or
anaemia." Age Ageing. 2006 Mar;35(2):200-1
The drug of choice for the treatment of Chlamydia trachomatis infection during pregnancy is:
(Please select 1 option)
Metronidazole
Cephazolin
Amoxicillin
Correct
Tetracycline
Clindamycin
Chlamydia infection in the non-pregnant state is usually treated with a tetracycline, or with
erythromycin. More recently, however, amoxicillin has been found to be as effective as the latter.
During pregnancy, tetracycline therapy is contraindicated because of its incorporation into fetal
bones and teeth.
Thus, of the options listed, amoxicillin is the drug of choice
A 55-year-old man on treatment for hypertension, epilepsy and gasto-oesophageal reflux disease
presented with an urticarial skin eruption. A drug reaction is suspected since he has recently
started a new drug. Which of the following medications is most likely to be responsible?
(Please select 1 option)
Aspirin
Correct
Atorvastatin
Omeprazole
Paracetamol
Sodium valproate
"Urticaria is one of the most common dermatologic problems seen by primary care physicians and
often a source of frustration for patient and physician alike. Pinpointing the cause may be
challenging--or impossible--because of the many and varied triggers.
"Patients with aspirin sensitivity can present with either mucosal reactions (the aspirin triad of nasal
polyposis, sinusitis, and asthma) or cutaneous reactions (urticaria or anaphylaxis)."
Postgrad Med 2001;109(2):107-23
A 65-year-old man has locally advanced pancreatic cancer and has been paying privately for
treatment with Erlotinib (Tarceva) for the past 9 months. It has worked effectively for that period
but a recent CT scan showed further growth in the tumour.
Which of the following mechanisms best explains this resistance to treatment with Erlotinib?
(Please select 1 option)
Development of antibodies to Erlotinib
Lack of autophosphorylation at binding site
Malabsorption
Mutated IGF-1 receptor
Correct
Reduced expression of EGFR
Erlotinib specifically targets the epidermal growth factor receptor tyrosine kinase (which is required
for the conformational change) and binds in a reversible fashion to the adenosine triphosphate
binding site. For the signal to be transmitted, two members of the EGFR family need to come
together to form a homodimer. These then use the molecule of ATP to autophosphorylate each
other, which causes a conformational change in their intracellular structure, exposing a further
binding site for binding proteins that cause a signal cascade to the nucleus. By inhibiting the ATP,
autophosphorylation is not possible and the signal is stopped.
A key issue with EGFR-directed treatments is that after a period of 8-12 months, the cancer cells
become resistant to the treatment, most commonly by recruiting a mutated IGF-1 receptor to act as
one of the EGFR partners in the homodimer, so forming a heterodimer. This allows the signal to be
transmitted even in the presence of an EGFR inhibitor. Some IGR-1R inhibitors are in various stages
of development (based either around tyrphostins such as AG1024 or AG538 or pyrrolo[2,3-d]pyrimidine derivatives such as NVP-AEW541.
You look up a drug in the BNF and note the following against it:
What does this signify?
(Please select 1 option)
Drug is not available on the NHS
Prescription only drug
Incorrect answer selected
Over the counter therapy
Report any potential adverse event
This is the correct answer
Report only potentially serious adverse events
The Committee on the Safety of Medicines assigns the inverted black triangle to those relatively new
drugs/vaccines or blood products to notify prescriber's that the drug is under surveillance and that
all suspected adverse reactions associated with the drug should be reported, typically with a yellow
card
This symbol appears next to a drug that you have looked up in the BNF:
What does this signify?
(Please select 1 option)
Not available for prescription on the NHS
Correct
Not recommended for NHS use
Only available for specialist use and not for the wider NHS use
Over the counter only therapy
Specialist licence required for prescription on the NHS
This symbol signifies that the drug is not available for NHS prescription but may be available as a
private script.
What does this symbol signify?
(Please select 1 option)
Prescribing can be optional and medication can be obtained over the counter
Medication only available as prescription by licenced practitioner
Intense monitoring required for any adverse events
Pharmacist prescribable drug
Controlled drug
Correct
Prescription Only Medicine - POM and can be prescribed only by licensed medical or dental
practitioners
symbol appears next to a drug in the BNF.
What does this signify?
(Please select 1 option)
A drug less suitable for prescribing
Correct
A drug that requires closer surveillance for possible side effects
Controlled drug
Over the counter medication
Prescription only therapy
This symbol indicates those preparations that are considered by the Joint Formulary Committee to
be less suitable for prescribing. Although such preparations may not be considered first choice
agents their use may be justifiable under certain circumstances.
A type 2 diabetic patient being treated with gliclazide, presents with sweating and dizziness. He is
on treatment for hypertension, atrial fibrillation, joint pain and indigestion. Blood glucose was 1.9
mmol/L (3.0-6.0). Which of the following drugs is responsible?
(Please select 1 option)
Aspirin
Atenolol
Digoxin
Fluconazole
Correct
Ranitidine
Gliclazide is highly bound to plasma proteins, about 94%. Its free plasma level increases on
displacement by aspirin given for joint pains. As a result of drug interaction, hypoglycemia may be
potentiated when a sulfonylurea is used concurrently with agents such as: long-acting sulfonamides,
tuberculostatics, phenylbutazone, clofibrate, MAO inhibitors, coumarin derivatives, salicylates,
probenecid, propranolol, cimetidine, disopyramide and angiotensin converting enzyme inhibitors.
Plasma protein binding of fluconazole is low and its excreted by kidney. Gliclazide is a sulphonylurea
drug with an intermediate half-life of around 11 hours. It is extensively metabolised within the liver
by CYP2C9. Renal clearance accounts for only 4% of total drug clearance. As fluconazole is a potent
inhibitor of CYP2C8 and CYP2C9, it may also interact with the sulphonylureas (eg. glimepiride and
gliclazide). Thus the best answer in this scenario would be likely to be Fluconazole.
A 45-year-old female with chronic schizophrenia was recently converted to a new anti-psychotic
agent. She presented two weeks later with a sore throat and fever.
Her full blood count shows:
Haemoglobin
12.5 g/dL (11.5-16.5)
White cell count
1.3 x109/L (4-11 x109)
Platelets
135 x109/L (150-400 x109)
What drug is she likely to have commenced?
(Please select 1 option)
Clozapine
Correct
Haloperidol
Olanzapine
Quetiapine
Risperidone
Unlike the other newer antipsychotic agents, clozapine is associated with agranulocytosis in
approximately 1-2% of patients.
The mechanism through which this happens remains unclear
A 59-year-old male type 2 diabetic is attending the foot clinic regularly. He has a neuropathic ulcer
complicated by osteomyelitis a deep wound swab has grown Staphylococcus aureus and E coli. He
also takes warfarin for atrial fibirillation.
Which of the following antibiotics will reduce the anticoagulant effect of Warfarin?
(Please select 1 option)
Ciprofloxacin
Co-trimoxazole
Erythromycin
Metronidazole
Rifampicin
Correct
The anticoagulant effect of warfarin can be affected by drugs, which induce or inhibit the action of
enzymes involved in the metabolism of warfarin. Rifampicin is known to induce the action of such
enzymes therefore increasing the metabolism of warfarin so reducing its anticoagulant effect.
Erythromycin and ciprofloxacin inhibit the effect of these enzymes therefore enhancing the
anticoagulant effect of warfarin.
Metronidazole and Co-trimoxazole inhibit the clearance of the active S isomer of warfarin
therefore enhancing its anticoagulant effect.
A 30-year-old male presented with a paranoid psychosis accompanied by visual hallucinations
which resolved over the next three days.
Which one of the following is the most likely diagnosis?
(Please select 1 option)
Alcohol withdrawal.
Correct
Diazepam dependence.
Fluoxetine overdose.
Heroin withdrawal.
Smoking cannabis.
The paranoid psychosis with visual hallucinations is highly suggestive of delirium tremens - alcohol
withdrawal
Folic acid metabolism can be affected by
(Please select 1 option)
tetracycline
pyrimethamine
Correct
vitamin B12
penicillin
brufen
Drugs which inhibit dihydrofolate reductase = methotrexate, pyrimethamine and trimethoprim.
Drugs which interfere with absorption/storage of folate = phenytoin, primidone, oral
contraceptives
Galactorrhea + hyperPL => DA antagonist [maxolon, domperidone]
A 30 year-old female presents with a one year history of galactorrhoea. She has been receiving
treatment for hay fever, depression, obesity and dyspepsia. Her investigations reveal:
Full Blood Count
Normal
Urea and electrolytes
Normal
Prolactin
820 mU/L (<360)
Free thyroxine (T4)
18.3 pmol/L (10-22)
TSH concentration
2.1 mU/L (0.4-5)
Which one of the following drugs is most likely to explain these findings?
(Please select 1 option)
Astemizole
Metoclopramide
Correct
Paroxetine
Ranitidine
Sibutramine
Although the SSRIs are also rarely associated with hyperprolactinaemia, the answer has to be
Metoclopramide which is a dopamine antagonist that is typically associated with
hyperprolactinaemia.
A firm 2-3 cm mass is palpable in the upper outer quadrant of the right breast of a 52year-old woman.
There are no palpable axillary lymph nodes.
A lumpectomy with axillary node dissection is performed and the breast lesion is found
to have positive immunohistochemical staining for HER2/neu (c-erb B2).
Staining for oestrogen and progesterone receptors is negative.
Which of the following additional treatment options is most appropriate, based upon
these findings?
(Please select 1 option)
Radical mastectomy
St John's wort
Tamoxifen
Trastuzumab
Correct
Vancomycin
This is an infiltrating ductal carcinoma.
The lack of oestrogen receptor staining suggests a poor response to hormonal therapy with
tamoxifen.
The positive C-erb B2 (HER2/neu) staining suggests that trastuzumab (Herceptin) may be
effective.
A 52-year-old woman who complains of exertional breathlessness presents to the clinic as she is
desperate to stop smoking.
She has had a number of unsuccessful attempts to stop smoking over the years and has tried
nicotine patches.
Which of the following would be an appropriate choice to assist in her attempts at smoking
cessation?
(Please select 1 option)
Acupuncture
Hypnotism
Nicotine gum
Nortriptyline
Varenicline
Correct
Varenicline (Champix) is an oral anti-smoking agent with dual action, reducing the craving for
cigarettes and also making the smoking of cigarettes less pleasurable. ASH, Action on Smoking and
Health have released guidance on its use. It appears to be effective and safe with the main side
effect being nausea.
Varenicline appears to be more effective in clinical trials than either bupropion or placebo and is
prescribed for 12 weeks in the first instance with further 12 week course if craving still persists
A 48-year-old lady with a history of epilepsy and ischaemic heart disease presented with the
following Full Blood Count.
Haemoglobin
7.4 g/dL
(11.5 - 16.5)
Mean cell volume
125 fL
(80 - 96)
White cell count
2.5 x 10 9/L
(4 - 11)
Platelet count
130 x 10 9/L
(150 - 400)
Which of the following medications is the most likely cause?
(Please select 1 option)
Carbamazepine
Clopidogrel
Furosemide
Phenytoin
Correct
Spironolactone
There is a macrocytic anaemia with low platelets and WCC typical of a nutritional deficiency.
Phenytoin can lead to folate deficiency and is therefore the most likely cause
With regard to poisoning / overdose:
(Please select 1 option)
Phenobarbitone causes a metabolic acidosis
Ethylene glycol causes a metabolic alkalosis and renal failure
Aspirin causes acidosis due to hypoventilation
Methanol causes a metabolic acidosis with an increased anion gap
Correct
Chlormethiazole causes hyperthermia and hypertension
Aspirin causes hyperventilation which may result in a respiratory alkalosis; massive overdose may
cause a metabolic acidosis.
Phenobarbitone and chlormethiazole both suppress the central nervous system causing
hypoventilation, hypotension and hypothermia.
Ethylene glycol causes a metabolic acidosis.
Methanol is metabolised to formaldehyde and formic acid
An 18-year-old Asian female is noted to have gingival hypertrophy by her dentist.
Which of the following is most likely to be responsible for her presentation?
(Please select 1 option)
Carbamazepine
Scurvy
Lead poisoning
Phenytoin
Correct
Sodium valproate
The inclusion of 'Asian' descent in this question is intended as a distractor.
Gum hypertrophy may be seen in conditions such as acute myeloid leukaemias and with drugs such
as phenytoin.
Scurvy (vitamin C deficiency) is associated with bleeding gums.
Lead toxicity is associated with pigmentation of the gingiva.
Carbamazepine is not associated with gingival hyperplasia but recognised side effects include ataxia,
drowsiness and blood dyscrasias.
Which of the following reactions is involved in the metabolism of paracetamol under
normal conditions?
(Please select 1 option)
Acetylation
Conjugation to glucuronic acid
Correct
Conjugation to glutathione
Cytochrome p450 dependent oxidation
Hydrolysis
Paracetamol is conjugated to glucuronic acid and sulphate under normal conditions.
In overdose these processes become saturated and the drug is then conjugated with glutathione.
If the glutathione supply is depleted then a toxic metabolite is formed
Which of the following doses of prednisolone is equivalent in its glucocorticoid potency
to 20mg of hydrocortisone?
(Please select 1 option)
2 mg
5 mg
Correct
10 mg
15 mg
20 mg
It is important to know the relative potencies of the glucocorticoids.
Dexamethasone for instance is roughly 30 times more potent than hydrocortisone
In which of the following have randomised controlled trials shown that long-term
oxygen therapy
(LTOT) reduces mortality?
(Please select 1 option)
Asthma
Cor pulmonale due to chronic airflow obstruction
Correct
Cryptogenic fibrosing alveolitis
Cystic fibrosis
Pulmonary sarcoidosis
Adequate data for LTOT prolonging survival exists only for chronic obstructive pulmonary disease
(COPD) although in practice it is assumed to apply in other chronic hypoxaemic lung conditions.
A 35-year-old woman with known seafood allergy presented after developing an itchy rash at a
restaurant. She had widespread urticaria which spared her neck and face.
On examination, her blood pressure is 130/70 mmHg, pulse 95 bpm, respiratory rate 24/min and
O2 saturation 99% on air.
Intravenous hydrocortisone and intramuscular antihistamine have been given.
What is the next most appropriate step in the management of this patient?
(Please select 1 option)
Inhaled adrenaline
Intramuscular adrenaline
Incorrect answer selected
Intravenous adrenaline
Observe
This is the correct answer
Subcutaneous adrenaline
Where there is a history of a typical allergic reaction as here current United Kingdom resuscitation
guidelines suggest adrenaline if there is:

stridor
 wheeze
 respiratory distress or
 clinical evidence of shock.
A literature review in the BMJ includes a copy of the algorithm and a discussion of the evidence for
adrenaline. BMJ 2003;327:1332-1335
An overweight, 60-year-old female with an eight year history of Type 2 diabetes mellitus presents
with deteriorating glycaemic control. She takes gliclazide 160 mg twice daily. Investigations reveal:
Sodium and potassium
Normal
Serum urea
10 mmol/L (2.5-7.5)
Serum creatinine
160 µmol/L (60-110)
Serum alanine transaminase
31 U/L (5-35)
Serum aspartate transferase
30 U/L (1-31)
HbA1C
9.0% (3.8-6.4)
Which of the following would be the most appropriate additional therapy for improved glycaemic
control?
(Please select 1 option)
Acarbose
Guar gum
Metformin
Repaglinide
Incorrect answer selected
Rosiglitazone
This is the correct answer
This woman with diabetes has poor glycaemic control with renal impairment.
With creatinine concentrations above 150 µmol/L, metformin is not recommended due to the small
risk of lactic acidosis.
Therefore, the most appropriate treatment as recommended by NICE would be rosiglitazone as liver
function tests are normal and there is no suggestion of heart failure.
Acarbose is poorly tolerated and is now rarely prescribed.
Guar gum has little place in the treatment of diabetes.
Repaglinide the non-sulphonylurea insulin secretagogue would have little benefit in conjunction with
a traditional SU such as gliclazide.
The following are causes of drug induced hepatitis except:
(Please select 1 option)
Amiodarone
Ethambutol
Correct
Isoniazid
Methyldopa
Pyrazinamide
Side effects of ethambutol are largely confined to visual disturbances in form of loss of acuity, colour
blindness and restriction of visual fields. It does not cause hepatitis and is renally excreted. Isoniazid,
amiodarone, pyrazinamide and methlydopa are a cause of drug induced hepatitis.
A 48-year-old man is admitted with nausea and excessive drowsiness after taking an antihistamine
tablet. He has previously used the antihistamine but on this occasion he has recently been
drinking large amounts of grapefruit juice for his health.
Grapefruit juice is suspected of causing a drug interaction in this man. Which of the following liver
enzyme systems is affected by grapefruit juice?
(Please select 1 option)
Cytochrome p450 3A4
Correct
Glycine decarboxylase
Glucuronidation
Glutathione S-transferase
Sulfation
Bergamottin is a constituent of grapefruit juice and is metabolised by the Cytochrome p450 3A4
pathway.
A youth worker, aged 40, presents to the Emergency Department with vomiting. On
detailed questioning, he states that he has taken about 36 paracetamol tablets two
hours previously. He is vomiting profusely with a blood pressure of 90/60 mmHg.
Which of the following measures would be the most appropriate immediate step in the
management of this patient?
(Please select 1 option)
Coagulation screen
IV fluids
Correct
IV N-acetyl cysteine
Oral methionone
Paracetamol levels
The most pressing issue in this patient is resuscitation as he is vomiting and is hypotensive.
It is unusual to see such hypotension in paracetamol overdose but is feasible in a massive
overdose and usually associated with lactic acidosis.
It is too early to carry out paracetamol levels as these should be carried out at four hours.
Although he states that he has taken 18 g of paracetamol this may NOT be the case and he may
not require N-acetyl cysteine. You can wait. In fact the benefit of N-acetyl cysteine is maximum as
long as it is given within eight hours of ingestion. Its benefit extends up to 24 hours.
An elevated international normalised ratio (INR) gives an indication of hepatocellular damage and
again this will not be seen at presentation of paracetamol overdose.
Further reading:
Emergency treatment of paracetamol poisoning. British National Formulary. BNF 56.
Daly FFS, Fountain JS, Murray L, Graudins A, Buckley NA. Guidelines for the management of
paracetamol poisoning in Australia and New Zealand - explanation and elaboration; consensus
statement from clinical toxicologists consulting to the Australasian poisons information centres.
MJA 2008; 188 (5): 296-302
The antibiotic combination quinupristin and dalfopristin are:
(Please select 1 option)
Administered orally.
Effective against multi-resistant Staph. aureus
Correct
Effective against resistant mycobacterium TB.
Indicated in subjects with chronic renal impairment.
Particularly effective in the treatment of pseudomonas infection in cystic fibrosis.
Quinupristin and dalfopristin are a synergistic combination of a streptogramin A and B respectively.
They are effective against gram positive aerobes and are particularly useful against resistant Strep.
pneumoniae and Staph. aureus.
They can be administered only via a central line
A 17-year-old female presents with three headaches over a six month period.
She describes the headaches as severe, right-sided and lasting for twelve hours and
associated with nausea and photophobia.
Each is preceded by spots before her eyes.
What is the most appropriate initial treatment for this patient?
(Please select 1 option)
Diclofenac at the onset of the next attack
Ergotamine suppository at the onset of the next attack
Paracetamol plus metoclopramide at the onset of the next attack
Correct
Prophylaxis with propranolol
Sumatriptan at the onset of the next attack
First line treatment of acute migraine consists of simple analgesic (either soluble paracetamol or
aspirin) and an antiemetic (usually domperidone or metoclopramide).
Second line treatment includes the use of non-steroidal anti-inflammatory drugs such as
diclofenac.
If the above measures fail to alleviate the attacks, then triptan therapy (for example, sumatriptan)
is indicated.
It is important for patients to take the treatment as early as possible.
Long-term prophylaxis with drugs (for example, propranolol) is only indicated if the attacks are
frequent (more than two a month).
A 42-year-old man presented with confusion following a seizure.
He has a history of epilepsy and is also known to the community psychiatry team.
Examination reveals that he has a temperature of 37°C, BP 138/84 mmHG, coarse
tremor and a pulse of 90 bpm.
Which of the following is the most likely underlying diagnosis?
(Please select 1 option)
Benzodiazepine overdose
Carbamazepine toxicity
Lithium toxicity
Correct
Neuroleptic malignant syndrome
Tricyclic overdose
The tremor, seizure and confusion should raise the possibility of lithium toxicity which is the
condition that best fits this clinical picture.
A 57-year-old man attends the outpatient clinic. He has been a Type 2 diabetic for 7
years having been diagnosed following after an acute myocardial infarction at 50 years
of age.
His diabetes was deteriorating with blood glucose readings of 9-12 at home despite
following a diet and taking regular exercise.
Another practitioner commenced him on Rosiglitazone. His current treatment is
Metformin 850 tds, Rosiglitazone 4 mg, Aspirin 75 mg/day, Carvedilol 12.5 mg bd,
Ramipril 10 mg od, Furosemide 80 mg daily, Simvastatin 40 mg/day.
On examination he is overweight with a BMI of 29, his BP is 128/74 mmHg with pulse
rate of 63 min-1. He has no heart murmurs and there is some pitting oedema in the lower
limbs. Auscultation reveals a clear chest with no evidence of pulmonary oedema. He is
obese with no organomegaly.
His ECG shows sinus rhythm with poor r wave progression.
His Hba1c checked in the clinic is 8.5% (3.8-6.4).
What is the most appropriate way to treat his glycaemic control?
(Please select 1 option)
Add Gliclazide 80mg bd
Increase Rosiglitazone to 8mg daily
Stop metformin and use Avandamet (combination of Metformin and Rosiglitazone)
Substitute Rosiglitazone with Glilazide 80mg bd
Correct
Substitute Rosiglitazone with Pioglitazone 15mg daily
This patient is likely to be insulin resistant; however there is evidence of heart failure and
fluid overload, so use of thiazolinediones (Rosiglitazone or Pioglitazone) are absolutely
contraindicated. These drugs promote fluid retention by means of an action on the collecting
ducts of the kidney so promoting sodium and water retention.
The only appropriate action therefore is to stop Rosiglitazone, substituting this with the insulin
secretagogue gliclazide which will hopefully improve his glycaemic control.
A 52-year-old accountant presents with a five hour history of confusion and agitation.
He is known to have an alcohol problem but has avoided all alcohol for the last three
days.
On examination, he is sweating, is agitated and disorientated.
His temperature is 37.5°C, pulse 110 bpm regular and blood pressure is 152/74 mmHg.
He claims to see things on the walls.
His investigations reveal:
FBC
Normal
U+Es
Normal
Plasma glucose
4.6 mmol/l (3.6-6)
Which of the following agents would be the most appropriate treatment for this man?
(Please select 1 option)
IV Haloperidol
IV Lorazepam
This is the correct answer
IV Phenytoin
IV Phenobarbital
Oral diazepam
Incorrect answer selected
This is a typical history of delirium tremens (DTs).
Patients with chronic alcohol dependency typically develop withdrawal symptoms two to three days
following abstinence from alcohol.
Features of:
- clouding of consciousness
- visual hallucinations
- diaphoresis
- pyrexia and
- hypertension
are typical and it is important to maintain adequate hydration.
Parenteral benzodiazepines are the treatment of choice for delirium tremens and include
diazepam, lorazepam, chlordiazepoxide and midazolam.
Which one of the following concerning insulin is correct?
(Please select 1 option)
Acts via a similar mechanism to steroid receptors
Can be detected in the lymph
Correct
Causes an increased glucose-protein transport on the endoplasmic reticulum
Interacts with the nuclear membrane
Is synthesised in the alpha cells of Islets of Langerhans
Insulin acts via cell surface receptors.
Insulin binding to its receptor results in receptor autophosphorylation on tyrosine residues and the
tyrosine phosphorylation of insulin receptor substrates (IRS-1, IRS-2 and IRS-3) by the insulin
receptor tyrosine kinase.
Insulin is synthesised in the beta cells of the Islets of Langerhans not the alpha cells
A 58-year-old woman presents with early features of COPD. She is a heavy smoker and
asks about drugs that may help her to stop smoking. In particular, she has heard about
a new drug that is now available called Champix (varenicline).
Varenicline is an agent used in the treatment of smokers to help them quit.
Which of the following best describes its mechanism of action?
(Please select 1 option)
A tricyclic antidepressant with mostly noradrenergic properties
An a2-noradrenergic agonist that suppresses sympathetic activity
Is a nicotine replacement therapy
Is a partial agonist of the alpha4beta2 nicotinic receptor
Correct
Reduces uptake of dopamine, serotonin and norepinephrine
There are now many therapies that have been investigated for use in smoking cessation. Newer
drugs are becoming available that have been sepecifically developed for smoking cessation.
Varenicline is one of them.
Nicotine is a simulant and releases dopamine in the brain that leads to addictive effects of
smoking. Its effects can be replaced in other ways using nicotine replacement therapy and this
reduces the addiction to cigarette smoking.
Bupropion (Zyban) reduces the neuronal uptake of dopamine, serotonin and norepinephrine.
Clonidine, a second line agent in smoking cessation because of its side effects, is an a2noradrenergic agonist that suppresses sympathetic activity.
Nortriptyline is a tricyclic antidepressant with mostly noradrenergic properties and is an agent
that appears to be effective.
Varenicline is a non-nicotine drug that is a partial agonist of the alpha4beta2 nicotinic receptor.
Further reading:
Int J Clin Pract. 2006 May;60(5):571-6 (Review)
JAMA. 2006 Jul 5;296(1):47-55 (trial vs. bupropion and placebo)
Royal College of Physicians publication on smoking cessation
Other news articles on Varenicline
In considering the management of convulsions select the correct statement from the list below.
(Please select 1 option)
Hypoglycaemia should always be considered.
Correct
If the fit lasts longer than five minutes, then PR diazepam should be given.
Paraldehyde is best given intramuscularly.
Phenobarbitone is a useful therapy in school age children.
When associated with fever, antibiotics should always be given to cover the possibility of
meningitis.
Status epilepticus is defined as continuous convulsion lasting longer than 30 minutes, or the
occurrence of serial convulsions between which there is no return of consciousness. It may be
generalised (tonic clonic, absent) or partial (simple, complex, or with secondary generalisation).
Generalised tonic clonic seizures predominate. There are 3 major sub-types:
 Prolonged febrile seizures.
 Idiopathic status epilepticus (no underlying central nervous system [CNS] lesion or insult).
 Symptomatic (long-standing neurological disorder or metabolic abnormality).
The most common cause in a child less than 3 years is a prolonged febrile seizure. Sleep deprivation
and drug withdrawal can also precipitate it.
The relationship between neurological outcome and duration of status epilepticus is unknown in
children and adults. In the animal model, 60 minutes of constant seizure activity is associated with
pathological changes, even when metabolic homeostasis is maintained.
Cell death thus results in increased metabolic demands from continually discharging neurones.
Vulnerable areas include the hippocampus, the mid to low cerebellum, middle cortical areas, and
thalamus.
Approximately 20 minutes of status epilepticus produces regional oxygen sufficiency deficiency
promoting cell damage and necrosis. This is, therefore, used as the threshold in children.
Initial management begins with ABC. Hypoglycaemia should be excluded (if present 5ml/kg of 10%
dextrose is given by IV infusion), and blood obtained for full blood count, electrolytes including
calcium and magnesium, glucose, creatinine, anticonvulsant levels. Blood and urine may be obtained
for toxicology. Arterial blood gases should be done, and consideration given to lumbar puncture.
First line anticonvulsant therapy would be Lorazepam/Diazepam given IV if possible. If seizures
persist then phenytoin may be given as a loading dose followed by an infusion. Phenobarbitone may
be used as first line in infants. Paraldehyde can be given as a dilute solution intravenously, or
administered rectally or IM. The latter two routes can produce tissue damage and sloughing, so
these should be reserved for exceptional circumstances.
To which of the following drug classes do the oral hypoglycaemic agents, rosiglitazone
and pioglitazone belong?
(Please select 1 option)
A peroxisome proliferator activating receptor (PPAR)-alpha agonist
A peroxisome proliferator activating receptor (PPAR)-gamma agonist
Correct
A sulphonylurea
A biguanide
An alpha-glucosidase inhibitor
Rosi- and pio- glitazone belong to a new class of oral hypoglycaemic agents - PPAR gamma
agonists.
Through activation of this receptor they modulate adipocyte function and improve insulin
sensitivity
An adolescent boy presents with unexplained neurological illness.
Which one of the following would suggest substance abuse?
(Please select 1 option)
A history of attention deficit disorder.
A history of family conflict.
A history of low self-esteem.
A history of social isolation.
Deposits around the mouth.
Correct
An increasing number of adolescents are experimenting with alcohol, drugs and solvents, usually
soon after entering secondary school. Unfortunately, this includes a rising number of young girls
smoking.
Factors associated with drug use include low self-esteem, social isolation, depression, family
conflicts and other conduct disorders.
Presentations suggestive of substance abuse include altered behaviour, sniffer's rash, injection
sites, chronic upper respiratory tract infection, irregular pulse, glue stains on the skin or clothes,
and acute intoxication - ataxia, coma, respiratory depression and cardiac arrhythmia.
The only specific thing indicating substance abuse in this case is, therefore, the deposits
presumably of glue around the mouth.
Sniffer's rash consists of inflammation and ulceration around the mouth and nose