Past Paper
MCQ
PHARMACOLGY MCQ
(Autonomic Pharmacology)
MCQ Questions
1) You are an Emergency Department Registrar. At 2am a patient presents with a
systolic BP of less than 100.
The left ventricular filling pressure of more than
20mmHG and a cardiac output of less than 2.5L/min. In this patient what is your first
line of treatment?
a. normal saline
b. diuretics
c. inotropes
d. vasodilators
e. vasodilators and inotropes
ANSWER - ?
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Cardiac Output (Q) = Heart Rate x Stroke Volume = 5 L/min
Cardiac Output can normally Increase 700% during Exercise
Q is Increased by: Anxiety and excitement (50-100%), Eating (30%),
Exercise, High environmental temperatures, Pregnancy, Adrenaline
Q is Decreased by: Standing from lying, Rapid arrhythmias, Heart disease
NB - Heart receives 15% of the Cardiac Output at Rest
2)
Which
a.
b.
c.
d.
3)
Regarding neurotransmitters in the brain
a. strychnine stimulates glycine receptors – antagonizes glycine receptors
b. atropine antagonises GABA receptors – antagonize muscarinic receptors
c. butyrophenones stimulate dopamine receptors – antagonize DA receptors
d. ondansotron antagonises seretonin receptors
– YES
e. atenolol stimulates noradrenaline receptors
– erm….no





does not cause vasoconstriction
lactate
serotonin
adrenaline
ADH
Summary of Neurotransmitters
Acetylcholine
Noradrenaline
Seretonin
Glycine
Dopamine
2
4) Beta-Blockers
i) Regarding adrenoceptor antagonists, which of the following is ‘selective’?
a. labetolol
b. pindolol
c. propranolol
ANSWER – B
d. phenoxybenzamine
ii)
a.
b.
c.
d.
Beta-blockers
cannot be used with calcium channel blockers
can be used in variant angina
works in angina by vasodilatation
increases myocardial oxygen consumption
iii)
a.
b.
c.
Propanolol
Is a sodium channel blocker
Is lipid soluble
Is excreted unchanged
All options are FALSE
ANSWER – ?B
iv) Regarding the Beta Blocker Propranolol:
Which statement is CORRECT?
a.
b.
c.
d.
has Na+ blocking activity
is beta 1 selective
has intrinsic sympathomimetic activity
is poorly lipid soluble
ANSWER – A
v) Metoprolol
a. Is an Unselective Beta-blocker
b. Is only renally excreted
c. Half life is 3-4 hours
d. Has a very high first pass metabolism
e. IV dose is the same as oral dose
ANSWER – C
vi)
a.
b.
c.
ANSWER – C



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

Regarding the Beta Blocker Propranolol
Is a highly selective B receptor antagonist
Is poorly lipid soluble
Has sodium channel blocking activity
Labetalol – has effects on alpha and beta receptors. T ½ 4.9 hours
Sotalol – also has effects on potassium channels (class III)
Pinodol – Beta 1 Selective
Nadolol – very long acting
Propranolol – Relatively UN-selective Beta Blocker (makes asthma worse)
- Notably the Exception in most cases when it comes to Beta Blockers
- Poorly absorbed orally (unlike most other Beta Blockers)
- t ½ 3-6 hours
- Crosses the Blood Brain Barrier – Seizures in Overdose
NB Phenoxybenzamine - an unselective Beta Blocker
3
5) Beta-Blockers 2
i) The most lipid soluble beta blocker is
a. Propranolol
b. Atenolol
c. Metoprolol
d. Pindolol
e. Sotalol
ANSWER – A
ii)
a.
b.
c.
d.
e.
Propranolol
is a highly selective beta receptor antagonist
is poorly lipid soluble
has sodium channel blocking action
has intrinsic sympathomimetic activity
has an oral bioavailability of > 50 %
ANSWER – C
iii)
a.
b.
c.
d.
e.
Characteristics of the drug propranolol include all of the following EXCEPT
lipid solubility
local anaesthetic action
half life of 3-6 hours
bioavaliability of 30 %
beta sympathetic selectivity
ANSWER – E
6) Inhaled Anticholinergic Drugs
i) The Drug Ipratropium (Atrovent®)
a. can cause significant side effects that can last up to 4 hours
b. has a significant effect on the central nervous system
c. has a marginally less systemic action than atropine
d. equally effective in bronchodilation as a β2 receptor agonist
ANSWER - A
ii)
a.
b.
c.
d.
e.
Regarding ipratropium
It readily enters the CNS
It causes miosis
It is well absorbed orally
It inhibits mast cells
It can cause severe effects which last for 4 hours
iii)
a.
b.
c.
d.
Ipratropium bromide
does not usually cause acute angle glaucoma
does not cause the development of tolerance
inhibits mucociliary clearance
does not work synergistically with salbutamol



ANSWER - E
Ipratropium is an Isopropryl Quaternary Atropine Derivative
Anticholinergic with T ½ of 3 hours and onset over 20 minutes
Generally minimally absorbed and the drug is not metabolised
7) Cholinergic Drugs
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i) Regarding the acetylcholinesterase inhibitors (e.g. physiostigmine, neostigmine)
which of the following is TRUE?
a. These drugs reverse the effects of suxamethonium
b. These drugs cause tachycardia
c. They cause decreased secretions
d. They reverse the effects of tubocurarine
ANSWER – D
ii)
a.
b.
c.
d.
Anticholinesterases
antagonise tuburocarine
antagonise sux
are never used in myasthenia gravis
regenerate Ach
iii)
a.
b.
c.
d.
Anticholinesterases (various stems in past pharmacology exams)
Are not useful in myasthenia gravis
Antagonise sux
Antagonise tubocurarine
Decrease BP
ANSWER – C
iv)
a.
b.
c.
d.
e.
The cholinesterase inhibitor with the shortest duration of action is
physostigmine
edrophonium
neostigmine
parathion
malathion
ANSWER – B
vii)
a.
b.
c.
d.
Praloxidime
regenerates
regenerates
regenerates
regenerates


acetylcholine
acetylcholine receptor
acetylcholinesterase
succinylcholine
ANSWER – A
ANSWER – C
These drugs are used in reversal of anaesthesia and a small dose of
Glycopyrolate or Atropine are often required to counteract the cholinergic
effects of the drug
These drugs have a number of useful applications including the following:
Edrophorium (Tensilon®) Testing (Myasthaenia Gravis)
Bethanachol - Atonic Bladder
Pilocarpine – Glaucoma
‘Stigmine’ treatment of Anticholinergic Syndrome
Reversal of paralysis at the end of operation
Donezepil in Alzheimer's
Length of Action – ‘Phonium (short) – ‘Thion (long).
Pralidoxime reactivates cholinesterase after organophosphate binding / inhibition
5
8) Anticholinergic Drugs 2
i) Benztropine
a.
b.
c.
d.
e.
causes
Miosis
Diarrhoea
Confusion
Bronchorroea
GIT haemorrhage
–
–
–
–
–
mydriasis
constipation
this one
dries up secretions
don’t think so
ANSWER – B
ii)) The major
a.
b.
c.
d.
e.
side effect of benztropine is (NB centrally acting)
miosis
confusion
diarrohea
GIT haemorrhage
Bronchorrhea
iii) Side effects of atropine are all EXCEPT
a. Bronchodilation
b. Increased GI motility
c. Bradycardia with low doses
d. Cutaneous vasodilatation at high doses

ANSWER – B
ANSWER – B
Anticholinergic effects:
- Hot as Hare (hyperthermic)
- Blind as Bat (blurred vision)
- Dry as a Bone (dry mouth and reduced secretions and GIT motility)
(urinary retention)
- Red as a Beet (flushed)
- Mad as a Hatter (agitation, confusion)
9) Drugs and the Eye
i) Regarding the treatments for glaucoma, which INCREASES aqueous outflow?
a. timolol
b. lantanoprost
c. carbechol
d. adrenaline
e. acetazolamide
ANSWER - B
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a.
b.
c.
ii) Match these eye drugs with their mechanism of action
pilocarpine and ciliary contraction
prostaglandins and decreased aqueous production
b-blockers and increased outflow
a.
b.
c.
d.
e.
iii) Regarding the treatment of glaucoma, which DECREASES aqueous outflow?
Timolol
Lantanoprost
Carbechol
Adrenaline
Acetazolamide
a.
b.
c.
d.
iv) Treatment of glaucoma does not include
alpha blocker – alpha stimulation
beta blocker – timolol
carbonic anhydrase inhibitor – acetazolamide
cholino-mimetic agents – pilocarpine
a.
b.
c.
v) Effects of occular medications:
pilocarpine – ciliary muscle contraction
prostaglandin = reduced secretion
timolol = pupil ilatation
a.
b.
c.
d.
a.
b.
c.
d.
e.
ANSWER – A
vi) Regarding the eye, which of the following causes decreased outflow?
timolol
adrenaline
carbechol
prostaglandins
ANSWER – All False
vii) Drugs used to treat glaucoma; which is CORRECT pairing
pilocarpine – ciliary muscle contraction
timolol – ciliary muscle contraction
acetazolamide – increased aqueous production
latanoprost – increased aqueous production
dipivefrine – decreased outflow
ANSWER – A
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They Seem to like this ‘eye’ autonomic question:
Pilocarpine – ciliary muscle contraction (cholinoceptor agonist)
Muscarinic Blocker like Atropine would decrease outflow
Timolol – β-blocker →↓ secretion
Acetazolamide – CA inhib →↓ HCO3 prodn
Latanoprost – prostaglandin →↑ outflow
9) Depolarsiing Muscle Relaxants
i) Concerning the IV drug Suxamethonium, which is TRUE?
a. acts via non-competitive blockade of receptors
b. has no significant CVS side effects
c. is broken down by ‘pseudocholinesterase’ at the Neuromuscular Junction
d. cannot be used for Rapid Sequence Intubation
7
ANSWER – A
ii) Suxamethonium
a. Is a non-depolarising neuromuscular blocking agent
b. Is contraindicated in all eye operations
c. Stimulates cardiac muscarinic receptors and autonomic ganglia
d. Its action is directly terminated by the action of plasma cholinesterase
e. Should not be administered to patients with burns > 24 hours old because of its
hypercalcaemic effect
ANSWER – ?C





Suxemethonium is an acetylcholine dimer
80% or more is metabolized before it reaches target site (NMJ)
Side effects (basically increased everything except HR) - ↑IOP ↑?ICP ↑Saliva
↑Gastric Secretions ↑ BP ↑ Muscle Pains ↑
Trismus and Malignant Hyperthermia
Avoid in Hyperkalaemia and Burns more than 24-48 hours old
11) Toxicology Presentations
i) You are an Emergency Department Registrar. At 2am a patient presents who
ingested a ‘substance’. They are confused and agitated. They have mydriasis and a
temperature of 39 degrees Celsius. This is LEAST likely caused by:
a. adrenaline
b. amphetamines
c. aspirin
d. chlordiazepoxide
ANSWER – D
ii) A young male punter comes in with a high blood pressure, mydriasis and a high
temperature. Which drug has he most likely taken?
a. Atropine
b. Adrenaline
c. Aspirin
d. Naloxone
e. Cocaine
ANSWER – E
iii) A man presents with dilated pupils, confusion, hyperpyrexia.
Which of the following drugs would not account for this
a. atropine OD
– could well be this one
b. morphine
– this one
c. datura
– ???
iv) A healthy young man recieves a normal dose of a drug which induces midriasis
and increased systolic blood pressure . The drug could be:
a. adrenaline
– this one
b. acetylcholine
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v) A young man presents with dilated pupils, confusion and hyperpyrexia. Which
of the following could not account for these effects.
a. Atropine
b. Datura
c. Morphine
– this one
vi) A 51 year old presents to hospital with classic cardiac chest pain. Further
investigation includes and angiogram, which is normal. The cardiologist makes a
diagnosis of "vasospasm". Which is most likely to cause this?
a) Adrenaline
b) Propranolol
c) Prazocin
d) Atropine
ANSWER – A
vii) A patient presents with difficulty walking, agitated, a temperature of 39
degrees and dilated pupils. Which is least likely to produce this effect?
a. atropine OD
– cause all the above
b. amphetamine OD
– cause agitation, staggering
c. aspirin OD
– causes hyperpyrexia, agitation
d. tricyclic OD
– doesn’t cause these – seizures + arrythmias
e. angels trumpet
– aka datura – contains atropine
viii) A young man is injected with an iv drug. He shows a resultant tachycardia,
midriasis, normal blood pressure and reduced sweating. The most likely drug is
a. nicotinic antagonist
– no – would have muscular symptoms
b. muscarinic antagonist – this one – eg atropine
c. cholinomimitic
– would be miosis, decreased HR, increased sweating
d. adrenergic agonist
– would raise BP, and increase sweating
e. adrenergic antagonist – would be bradycardic
ix) An overdose patient has tachycardia, hypertension and urinary retention;
what did they overdose on?
a. Aspirin
b. Amphotericin
c. Tricyclics
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
Chlordiazepoxide is a long acting benzodiazepine
The other drugs could cause a similar clinical picture
Atropine may have an effect when applied directly to the eye
12) Autonomic effects of Psychiatric Medications
i) Regarding Amitryptiline (Tricyclic Antidepressant) which are NOT effects
a. Diarrhoea and Increased Bowel Sounds
b. Sedation
c. Urinary retention
d. Postural hypotension
e. Impotence
ANSWER – A
ii) Regarding SSRI’s
9
a.
b.
c.
d.
e.
haemodialysis is useful in OD
inhibit cytochrome P450
have minimal drug interactions
have anti-muscarinic effects
?protein binding
ANSWER – B
The most dangerous drug in overdose is
a. imipramine
b. moclobenide
c. sertraline
d. trazodone
e. paroxeteine
ANSWER – A
Antidepressant with the highest antimuscarinic effect is
a. amitryptiline
b. imipramine
ANSWER – B


SSRI - highly protein bound
SSRI – unlikely to be ‘dangerous’ in OD (citalopram has significant cardiac
effects including QT prolongation in OD)

Tricyclics (TCAs) may have Anticholinergic effects:
- Hot as Hare (hyperthermic)
- Blind as Bat (blurred vision)
- Dry as a Bone (dry mouth and reduced secretions and GIT motility)
(urinary retention)
- Red as a Beet (flushed)
- Mad as a Hatter (agitation, confusion)
10) Muscle Relaxants
i) Regarding non-depolarising muscle relaxants
a. Pancuronium is eliminated via the kidney
b. Rocuronium is an isoquinolone derivative
c. Rocuronium undergoes Hoffman elimination
d. Vecuronium is eliminated predominantly via the kidney
e. Atracurium is eliminated via plasma pseudocholinesterase
ANSWER – A
ii)
a.
b.
c.
d.
Neuromuscular junction blockers; which is INCORRECT
vecuronium is predominantly kidney excreted
atracurium is inactivated by Hofmann elimination
pancuronium has a longer duration of action than vecuronium
pancuronium and vecuronium have the same structure
ANSWER – A
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iii)
a.
b.
c.
d.
e.
The muscle relaxant commonly associated with tachycardia is low dose
Suxamethonium
Atracurium
Vecuronium
Pancuronium
Tubocurare
ANSWER – D
iv)
a.
b.
c.
d.
Which of the following statements are FALSE regarding vecuronium
it has minimal cardiovascular effects
its duration of action is less than ten minutes
it is predominantly renally excreted
it has a significantly longer duration of action than pancuronium
ANSWER – B
v) Which is true of neuromuscular blockers
a. atracurium causes hypotension in volume depleted patients
b. pancuronium causes histamine release
c. vecuronium is an isoquinolone derivative
d. ‘gallium’ is eliminated by the liver
e. gentamicin increases their efficacy
vi)
a.
b.
c.
d.
ANSWER – E
Which drug decreases the effect of neuromuscular blockade?
Atropine
Tubocurarine
gentamicin
neostigmine
ANSWER – D
vii) Which statement is true regarding recovery from irreversible neuromuscular
blockade?
a. it relies on receptor turnover
– yes
viii) The muscle relaxant with the longest duration of action is
a. atracurium
b. mivacurium
c. pancuronium
d. vecuronium
ANSWER – C
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ix) Vecuronium, all of the following are true except
a.
Has minimal CVS effects
b.
Is predominantly renally excreted – no, liver excretion
c.
Has a significantly longer duration of action than pancuronium – no, panc longer
x) Atracurium
a.
Has a longer duration of action than vecuronium
b.
Is associated with histamine release
c.
Is a steroid derivative
d.
Is eliminated by non renal/liver dependant mechanisms
xi) Regarding pancuronium - which is incorrect?
a.
It is a steroid
b.
It does not release histamine
c.
It is renally excreted
d.
It has a shorter duration of action than vecuronium
ANSWER – B
ANSWER – D
xii) Termination of irreversible neuromuscular block involves
a.
regeneration of receptors
–this one
b.
increase in end plate Ach




Atracurium is usually used in renal failure patients as it undergoes Hoffman
Degradation
Panc and vec are same structure – steroid derivative – no histamine release.
Panc causes tachy
Atrac tubo – isoquinoline derivatives – histamine release as well as sux
21) Prazosin; which is correct
a. it is non-selective
b. reduces afterload and preload
- alpha-1 selective
– alpha-1 cause vasoconstriction
(therefore inhibiting lowers systemic BP)
- 2-3hours
- ??
- don’t think so
c. half life is 18 hours
d. alters lipid levels
e. causes lupus like syndrome
28) Prazosin
a. is non-selective
b. worsens lipid levels
c. causes SLE like syndrome
d. reduces BP by affecting both resistance + capacitance vessels
this one – alpha
29) Prazosin
a. Has a half life of 18 hours
b. Adversely affects lipid profiles
c. Produces a reflex bradycardia
d. Has a first dose hypotensive effect
? this one
e. Can increase CO by decreasing preload and leaving afterload unchanged

Alpha Blockers
12




.
.
.
12)
i) L-dopa; which is correct
a. abrupt stop can increase tremor
b. precursor to dopamine
c. ? 25% reaches the brain
– causes rebound hypertension
– yes, by L amino acid decarboxylase
– 1-3% only
ii) What is true of L-Dopa?
a. 33% reaches the CNS
– 1-3%
b. it is the precursor of dopamine
– true
c. suddenly stopping it will cause tremor – rigidity
d. it’s half life is about 5 hours
– 1 hour
e. 40% less is required if it is given with a peripheral carboxylase inhibitor
– up to 75%
iii) Regarding the treatment of Parkinsons, which is INCORRECT
a. L-dopa is contraindicated in acute psychoses
– true
b. Bromocriptine has less CNS effects than L-dopa
– FALSE more CNS effects
Administration of L-dopa with a dopa decarboxylase inhibitor decreases side effects
iv) In the treatment of parkinsons disease
a) Antimuscarinics are better for the treatment of (?) tremor than
dopamine agonists – less effective
b) Administration of L-dopa with a dopa decarboxylase inhibitor
decreases side effects – true
v) L-Dopa
a. 1-3% reaches the brain – true
b. Precursor to tyrosine – no, both precursor to dopamine
c. abrupt stop can increase tremor – no rigidity
d. rarely needs increase in dose once effective – needs to keep increasing
hence dose holidays




Parkinson’s Drugs
.
.
.
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Which
a.
b.
c.
d.
of the following drugs has a pure beta agonist effect in the circulation?
Adrenaline
Levosimendin
Noradrenaline
Isoprenaline
ANSWER – D
Which adrenergic agent has a pure beta agonist effect in the circulation?
a. Adrenaline
b. Noradrenaline
c. Isoprenaline
d. Levosimendin
ANSWER – C
What is the correct order of catecholamine synthesis?
a. Tryptophan – dopa – dopamine – adrenaline – noradrenaline
b. Tysosine - dopa- dopamine – adrenaline – noradrenaine
c. Tyrosine – dopa – dopamine – noradrenaline – adrenaline
d. Tyrosine – dopamine – dopa – noradrenaline – adrenaline
e. Tyrosine – dopamine – dopa – adrenaline – noradrenaline
Isoprenaline’s effects include all EXCEPT
a. hyperglycaemia
b. increased glycerol
c. bronchodilation
d. increased diastolic pressure
– no
– yes
ANSWER – D
The drug Dobutamine
a. Results in ATP -> AMP – activates adenylyl cyclase ATP -> cAMP
b. Can decrease systemic vascular resistance / afterload –
c. .
d.
ANSWER – C
Salbutamol
Initially causes a drop in PaO2
Cause hyperkalemia
Cause hypercarbia
Alpha receptor activation causes
uterine relaxation
cutaneous vessel dilaation
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15
VIVA
Pharmacology
Notes
Most Common Topics are listed
first
16
List of Topics for the PHARMACOLGY VIVA
(BRACKET DENOTES THE APPROX NUMBER OF OCCURENCES AS OF 2009)
Topics for VIVA – PHARMACOLOGY ACEM

Section 1 Basic Pharmacology
(always one question from this area)
Pharmacokinetics (Half Life, Clearance, Elimination Kinetics, Biotransformation,
First Pass Metabolism) Other Basic Topics, (New agents Agonists and
Antagonists, Receptors, 2nd Messengers, Drug Responsiveness, Potency and
Efficacy, Volume of Distribution, Steady state, Loading Does
(20+)
Age, Pregnancy, Drugs in Children

(7)
Section 2 – Antibiotics and Antivirals
Antibiotics (Beta Lactams Macrolides)
(27)
Acyclovir and Antiretrovirals
(3)

Section 3 – Cardiac Drugs
Anti Anginals, CCF and Beta-Blockers (sotalol)
(11)
Antihypertensives (Emergency, ACE inhibitor)
(6)
Sodium Channel Blockers and LA
(6)
Calcium channel Blockers
(6)
Atropine
(3)
Adenosine
(3)
Frusemide / Diuretics
(3)
Amiodarone
(3)
Digoxin
(2)
Adrenaline (Vasopressors and Resus Drugs)
(5)
17

Section 4 – CNS Drugs
Suxemethonmium ( and DPMR)
(7)
Tri-cyclic Antidepressants, SSRI
(5)
Benzodiazepines
(4)
Phenytoin
(4)
Barbiturates
(4)
Carbamazepine
(3)
Propafol
(3)
Ketamine
(3)
Nitrous Oxide, Halothane and Sevoflurane
(2)
Haloperidol and Antipsychotics
(2)
MOA Inhibitors
(2)
Anti-emetics
(2)
Alcohol and Methanol
(2)
Sodium valproate
(1)

Section 5 – Endocrine Drugs
Glucagon and Insulin
(4)
Steroids
(4)
Oral Hypoglycaemics
(3)

Section 6 – Opioids and Analgesics
Aspirin and NSAIDS and COX
(7)
Opiates and Receptors
(6)
Paracetamol
(2)
Colchicine
(1)
18

Section 7 – Anticoagulants and Thrombolysis
Heparin
(4)
Thrombolysis
(3)
Warfarin
(2)
Clopidogrel
(2)

Section 8 – Respiratory Drugs
Salbutamol
(2)
Cromoglycate
(1)
Benztropine
(1)
Ipratropium
(1)
Methylxanthines
(1)

Section 9 – Immunisation, GI Drugs and Toxicology
PPIs and H2 Antagonists
(3)
Immunisation (Active, Passive, Specific)
(2)
Methods of Decontamination
(1)

Section 10 – New Topics
RCT and other methods of analysis of new drugs
Drugs in Pregnancy
Drugs in the Elderly
Toxicology
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The Pharmacology Template
PHARMACOKINETICS
-
Introduction (Drug, class, prototype drug, history etc)
-
Absorption and Routes of Administration and Bioavailability
-
Distribution
-
Metabolism of Drug
-
Clearance
-
Half Life
-
Dosing
-
Monitoring
PHARMACODYNAMICS
-
Introduction (as above)
-
Mechanism of Action of the Drug
-
Organ Effects (E.g. CV, Resp, GI, CNS)
-
Side Effects
-
Indications (Primary Secondary)
-
Contraindications
-
Toxidromes
-
Major Drug Interactions
-
Other Specific Idiosyncratic Issues with the Drug
Memorise this template and use it as a framework for
answering questions in the Viva. I found it a very useful
way of forming my answers.
At this stage I would recommend
www.4um.com/tutorial/pharmak.htm and page 36-38 of
‘Basic and Clinical Pharmacology’ for rapid reference.
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