Clinical pharmacology questions Flashcards
(178 cards)
1
Q
21 yr old student High fever Headache Rash Treatment?
A
Meningitis
IM benzylpenicillin in community
Ceftriaxone in hospital
2
Q
21yr old student
high fever
headache
rash
prophylaxis for flatmate?
A
ciprofloxacin or rifampicin
3
Q
24yr old nurse has a witnessed grand map tonic clonic seizure at work. Treatment? chlordiazepoxide diazepam flumazenil lorazepam phenobarbitone
A
Lorazepam
- benzo
- slightly more effective than diazepam
- lower lipid solubility so lasts longer in vascular compartment
- GABA receptor
- immediate acting
- decreases chances of recurrent seizures
4
Q
24yr old nurse has a witnessed grand map tonic clonic seizure at work.
There is no clear cause of her fit. What is the most appropriate course of action
carbamazepine
diazepam
lamotrigine
no treatment
sodium valproate
A
no treatment as this is the first seizure
but investigate
5
Q
24yr old nurse has a witnessed grand map tonic clonic seizure at work. This is her 2nd seizure. There is no clear cause carbamazepine diazepam lamotrigine no treatment sodium valproate
A
carbamazepine
sodium valproate is often a first line treatment but not in women of child bearing age as teratogenic (neural tube defects, hypospadias)
risk of NTDs with carbamazepine is 1% rather than 1.5% with sodium valproate
6
Q
23 yr old - headache, n &v, photo and phono-phobia. preceded by by flashing lights in periphery of her vision. which of the following is the most appropriate? codeine phosphate ibuprofen paracetamol and metoclopramide morphine high flow oxygen
A
paracetamol and metoclopramide
7
Q
47 woman - PKD headache. neck rigidity third nerve palsy. head CT normal. LP Which will refute a SAH? visual inspection for xanthachromia 3 tube test measurement of oxyhaemaglobin assessment of WCC to RBC count measurement of bilirubin
A
measurement of bilirubin
(RBC lyse -> haemoglobin -> oxyhaem -> bilirubin)
LP 12hrs after headache
visual inspection for xanthachromia - yellow or not
3 tube test - count RBCs in each bottle. if traumatic tap - no. of RBCs should go down - not a good test
measurement of oxyhaemaglobin - can be formed in vivo or in vitro
assessment of WCC to RBC count : normal = 1000:1
measurement of bilirubin - only formed in vivo therefore the correct answer
8
Q
SAH Which artery is most likely? basilar ant communicating posterior cerebral post communicating post cerebral artery
A
post communicating
basilar -
bifurcation of the internal carotid
posterior cerebral
post communicating - common sites of berry aneurysms, commonly affect oculomotor nerve - correct answer
post cerebral artery - rare but may affect trochlear
9
Q
42 yr old man collpases with a sudden headache. CT scan shows spidery blood (white)
What drug can delay ischaemic deficit following SAH?
amlodipine
aspirin
nimodipine
magnesium sulphate
statins
A
nimodipine
amlodipine aspirin - cause of SAH nimodipine - Correct - Ca2+ channel blocker - as trial done on nimodipine magnesium sulphate - not indicated statins -
10
Q
75yr left facial droop, left side weakness, arm and leg, power 3/5. CT scan shows early changes of MCA infarction. WHich drug should be given? alteplase abciximab aspirin dipyridamole heparin
A
aspirin
alteplase - cant establish time of onset - has to be within 4.5 hrs for this Rx
abciximab - MAB against IIb/IIIa - used in ACS
aspirin - correct answer
dipyridamole - only for individuals in a 2nd stroke
heparin - not used as risk of haemorrhagic transformation
11
Q
TIA - which treatment alteplase abciximab aspirin dipyridamole heparin
A
aspirin or clopidogrel used in TIA
12
Q
24 yr old cyclist. 2 day hx of tingling in his feet. 24 hrs it has got worse and can no longer move his legs. receding URTI. preferred Rx? acyclovir azathioprine broad spectrum antibiotics IvIG IV steroids
A
IvIG - correct for GBS as autoantibodies (or plasma exchange)
13
Q
42 yr old - confused. behaving strangely for last 36 hrs. most approp management? broad spectrum antibiotics observation CT and LP CT with contrast MRI head
A
CT and LP- correct answer to rule out meningitis
Differentials - encephalitis & meningitis
14
Q
Tx encephalitis aciclovir amoxicillin benzypenicillin ceftriaxone
A
aciclovir
encephalitis is almost always viral
15
Q
43. right lower motor neuron 7th palsy. Rx aciclovir amoxicillin aspirin prednisolone tramcinalone
A
prednisolone for Bell’s palsy
16
Q
56 woman, bradykinesia, resting tremor, festinant gait. which drug could cause this aspirin cyclizine ramipril rispiridone sertraline
A
rispiridone - correct - antipsychotic (anti dopaminergic)
17
Q
34 woman. mild confusion, unsteady gait and dysconjugate gaze. which of the following drugs is the most appropriate to treat her?
aciclovir chlordiazepoxide ceftriaxone multivitamins thiamine
A
thiamine
to avoid korsakoffs
? wernickes encephalopathy
18
Q
34 yr old - double vision & feeling of fatigue. O/E complex opthalmoplegia and fatiguable proximal weakness in all muscle groups. otherwise well. Rx? azathioprine IvIG plasma exchange prednisolone pyridostigmine
A
azathioprine - a regular Rx for myasthenia gravis not for acute Rx
pyridostigmine - correct - increase ACh as is ACEI
if bulbar involvement - risk of respiratory failure
then Rx would be IvIG
19
Q
58 memory impairment. MSE = alert and attentive with average vocab. Remembers 1 /5 objects after 2 mins and has marked difficulty with reasoning and abstraction delirium dementia korsakoffs major depression organic amnestic syndrome
A
Dementia
delirium - pnt semi-conscious
korsakoffs - STM deficit but intact reasoning
major depression - not attentive normally
organic amnestic syndrome - normal reasoning and abstraction, forget who they are
20
Q
24 - morning headache, worse on coughing or bending down. odd sound in ears. Bilateral papilloedema. MRI - empty sella. Rx aspirin acetazolamide LP optic nerve fenestration surgical shunting
A
idiopathic intracranial hypertension
LP
measure opening and closing pressure
scan first to check for SOL as would cone if there was a structural abnormality
21
Q
73 yr old - shuffling gait and tremor. Parkinsons. First line treatment apomorphine amantadine L-Dopa and carbidopa combination carbergoline procyclidine
A
L-Dopa and carbidopa
apomorphine - last line Rx
amantadine - anti-flu, does have small dopaminergic agonist
L-Dopa and carbidopa combination - correct - no evidence that it hastens the progression of the disease (or ropinirole - DA agonist)
carbergoline - no longer used as retroperitoneal fibrosis in small no of pnts
procyclidine - used to be used for tremor but not any more
22
Q
79 loses vision in left eye. fluctuatung vision in that eye in last week. generally unwell for 4 wks. sore ear and weak shoulders. vision in left eye is reduced to hand movements. RAPD & pale swollen optic disc. ESR 112, WCC 11.6. RX?
A
GCA - giant cell arteritis
steroids
23
Q
1 day hx of painful r eye. pain severe and vomited twice. R eye has acuity of hand movement only. L eye 6/12. R eye severely injected with a cloudy eye. pupil is fixed and semi-dilated. Diagnosis retinal detachment acute iritis optic neuritis acute closed angle glaucoma cataract
A
acute closed angle glaucoma
24
Q
66 progressive loss of vision. has SLE and on immunosuppressive therapy for last 15 yrs Diagnosis retinal detachment acute iritis optic neuritis acute closed angle glaucoma cataract
A
steroid induced cataract
25
25 post partum. headache, altered mental state and mild weakness of LHS involving leg and arm. CT - infarction with subsequent venous phase MRI confirms a filling defect in the transverse venous sinus. small area of haemorrhage assoc with infarct. Rx
heparin
clopidogrel
warfarin
heparin
treat clot despite haemorrhage
then use warfarin
26
elderly man, fatigue, fine wrinkled skin, hairless in the armpits and pubic area and hypotensive. thyroxine 8, thyroid stimulating hormone low
```
alteplase
beta interferon
corticosteroids
natalizumab
no rx required
```
hypopituitarism
corticosteroids hastens recovery
27
```
54 yr old female with a history of gout secondary to rx for her RA develops a swollen, tender right knee. O/E she has an antalgic gait with reduced ROM. What is the most appropriate initial management?
ANA
CT
knee aspirate MCS
serum urate
start ibuprofen
```
knee aspirate MCS - correct (as must rule out septic joint)
28
```
Septic joint Rx
benpen
fluclox
fluclox & sodium fusidate
clarithromycin
clindamycin
```
fluclox + sodium fusidate
clindamycin if penicillin allergic
Prosthetic joints are most often infected with staph epidermidis -Treat with vancomycin & beta lactam & rifampicin
29
```
Newborn in heart block. Blood test from mother : FBC anaemia, RF +, ANA +, dsDNA -, CCP -
What is the mothers diagnosis?
RA
stills
systemic sclerosis
SLE
sjogren's
```
sjogrens
30
Newborn in heart block. Blood test from mother : FBC anaemia, RF +, ANA +, dsDNA -, CCP -
Which antibody is responsible for causing the neonatal heart block
anti-jo
anti-ro
anti-la
RF
anti-nucleolar
anti-Ro
anti-Ro +ve in pnts with sjogrens - can cross placenta and enter fetus and block SA node
neonates need support until antibodies have cleared
```
anti-jo - dermatomyositis (heliotrope rash) & polymyositis
anti-ro - correct
anti-la - in sjogrens
RF - sjogrens
anti-nucleolar
```
31
```
27 yr old recurrent episodes of acute abdo pain - presents with acute airway obstruction. intubation difficult due to laryngeal oedema. known to have hereditary angiooedema. pathology?
Wiskott-Aldrich syndrome
c1q deficiency
c1 esterase inhibitor deficiency
C3/c4 deficiency
kallikrenin deficiency
```
c1 esterase inhibitor deficiency
Wiskott-Aldrich syndrome - thrombocytopenia, immune deficiency and eczema
c1q deficiency - proposed hypothesis for cause of SLE - uncontrolled immune response to challenges
c1 esterase inhibitor deficiency - correct - prevents build up of kallikrenin which causes airway obstruction
C3/c4 deficiency - fatal probably (can reduce during flares of SLE)
kallikrenin deficiency
32
27 yr old recurrent episodes of acute abdo pain - presents with acute airway obstruction. intubation difficult due to laryngeal oedema. known to have hereditary angiooedema.what is the most appropriate Rx
IM adrenalin (1ml of 1:1000) (or 10ml 1:10000 IV)
IV hydrocortisone
chlorpeniamine
fresh frozen plasma
IV dopamine
FFP - as enzyme in FFP
33
```
8 yr old to A&E with chest pain. Her mother reports that over the past 2 wks she has been quite unwell with fevers and rashes. She is afebrile, fissuring of lips and peeling of soles of her feet. 2cm swelling in neck. painful joints. ECG - myocardial ischaemia. Diagnosis?
Stills disease
Takayasu's arteritis
Kawasaki disease
polyarteritis nodosa
acute lymphoblastic leukaemia
```
KAWASAKI
Stills disease - juvenile RA
Takayasu's arteritis - large cell arteritis
Kawasaki disease - strawberry red tongue, fissuring of the lips, cervical lyphadenopathys - correct
polyarteritis nodosa - in teens earliest, kawaaki in an adult
acute lymphoblastic leukaemia
34
```
8 yr old to A&E with chest pain. Her mother reports that over the past 2 wks she has been quite unwell with fevers and rashes. She is afebrile, fissuring of lips and peeling of soles of her feet. 2cm swelling in neck. painful joints. ECG - myocardial ischaemia. Rx?
prednisolone
IvIG
haemodialysis
adrenaline
FFP
```
Kawasaki disease
| Rx IvIG, plasmaphoresis
35
```
34 yr old female, on rx for pulmonary TB. malar rash and 2 wk hx of myalgia, malaise and arthralgia. GP wants to investigate for suspected drug induced lupus. most specifc test?
anti nuclear antibody
anti dsDNA antibody
anti histone antibody
anti smith antibody
anti Ro antibody
```
anti histone antibody - correct - as most specific for drug induced
36
```
34 yr old female, on rx for pulmonary TB. malar rash and 2 wk hx of myalgia, malaise and arthralgia. GP wants to investigate for suspected drug induced lupus. Which drug?
rifampicin
ethambutol
isoniazid
pyrazinamide
pyridoxine
```
isoniazid
```
rifampicin = p450 inducer
ethambutol = colour blindness
```
37
```
27 yr old male. Rx for chlamydia infection. presents conjunctivitis and unusual rash on feet. wrist and ankle pain for last 5 days. diagnosis?
reactive arthritis
ank spond
behcets disease
psoriatic arthritis
enteropathic arthritis
```
reactive arthritis
keratoderma blemorrhagica is the rash
38
```
45 yr old previous hx of pulmonary TB is started on treatment of her RA develops cough with haemoptysis, assoc with fevers and night sweats. Agent?
abciximab
infliximab
rituximab
ciclosporin
tacrolimus
```
infliximab - TNF alpha receptor blocker
| role in Rx of RA
39
```
54 yr old man. taking long term immunosuppressan for IBD. He also takes spironolactone, furosemide, perindopril. started on allopurinol following a flare of gout. FBC yesterday reveals a pancytopenia and on exam he has gingivitis and evidence of bruising. Causative agent?
azathioprine
cyclophosphamide
infliximab
etanercept
methotrexate
```
azathioprine
40
```
31 yr old female - SLE. Diagnostic value of ANA
sensitive and specific
sensitive but not specific
specific but not sensitive
high positive predictive value
low positive predictive value
```
sensitive but not specific
anti-sm is most specific for SLE
anti-scl70 most specific for systemic sclerosis
anti-TopoI - limited sclerosis
41
```
Azathioprine. MOA?
anti CD20 antibody
dihydrofolate reductase inhibitor methotrexate
purine analogue
pyrimidine analogue
alkylating agent
```
purine analogue
anti CD20 antibody - Rituximab assoc with severe immunosuppression
dihydrofolate reductase inhibitor - methotrexate - megaloblastic anaemia
purine analogue - correct - myelosuppression
pyrimidine analogue - flourouracil
alkylating agent - cyclophosphamide - cancer risk increases
42
genetic polymorphisms in which enzymes can predispose pnts taking azathioprine to increased risk of severe myelosuppresssion?
```
p450 dependent mixed function oxidase
catalase
glutathione synthase
thiopurine-S-methyltransferase
thiol oxidase
```
thiopurine-S-methyltransferase
43
```
45 yr old woman with severe SLE required a renal transplant. She was started on immunosuppressive therapy. which drug "reduces purine synthesis via reversible inhibition of inosine monophosphate dehydrogenase"?
azathioprine
cyclophosphamide
mycophenolate mofetil
ciclosporin
tacrolimus
```
azathioprine - purine analogue and stops DNA forming (myelosuppression, potentiated by allopurinol)
cyclophosphamide - alkylating agent (cross-link DNA stopping replication) (haemorrhagic cystitis)
mycophenolate mofetil - correct
ciclosporin - calcineurin inhibitor so inhibit T cells (hypertensive, hirsuitism, hyperglycaemia, gingivitis)
tacrolimus - calcineurin inhibitor so inhibit T cells (SE: hyperglycaemic)
44
```
severe RA. started on a new med. 4 months later - hypertensive. Exam reveals gingivitis.
ciclosporin
cyclophosphamide
hydroxychloroquine
mycophenolate mofetil
methotrexate
```
ciclosporin - correct - hirsuit, coarse tremor, hypertension (also for phenytoin)
cyclophosphamide
hydroxychloroquine - aplastic anaemia - idiosyncratic reaction
mycophenolate mofetil
methotrexate
45
```
23 male - 3 month hx of progressive lower back pain, worse in the morning , attends optician with this red eye
diagnosis
scleritis
epscleritis
ant uveitis
lens dislocation
keratitis
```
ant uveitis - correct (assoc with HLA-B27 spondyloarthritides)
46
```
which agent reduces disease progression in ank spond
NSAIDS
azathioprine
methotrexate
infliximab
cyclophosphamide
```
infliximab
47
54 yr old male presents to A&E with 3 days of dark urine assoc with joint pains and ankle swelling . On exam - hypertensive (180/90) and he has evidence of recent epistaxis. Pattern of glomerular injury?
focal global glomerulonephritis
focal segmental glomerulonephritis
focal segmental glomerulonephritis with crescent formation
diffuse global glomerulonephritis with crescent formation
diffuse global glomerulonephritis
diffuse global glomerulonephritis with crescent formation - correct
crescents increase risk of rapidly progresssive glomerulonephritis
48
```
patient with severe rheumatoid arthritis is started on a drug. 4 months later she is hypertensive. exam reveals severe gingivitis. which is the likely causative agent?
methotrexate
ciclosporin
hydroxychloroquine
mycophenolate mofetil
```
methotrexate - dihydrofolate reductase inhibitor (enzyme involved in purine synthesis)
ciclosporin - correct
hydroxychloroquine
mycophenolate mofetil
49
```
34 yr old presents with a migratory arthritis, progressed to the left knee and now involves the right wrist. he reports a urethral discharge. on exam he has a single mouth ulcer and arthralgia. HLA-B27 is negative. what is the most likely diagnosis?
Behçet's disease
Crohn's disease
reactive arthritis (Reiters)
gonorrhoea
rheumatoid arthritis
```
Gonorrhoea - mouth ulcers, intracellular diplococcus, urethral discharge, pharyngitis, migratory arthralgia
Behçet's disease (mouth ulcers,genital ulcers and uveitis)
Crohn's disease (crampy abdo pain, mucus in stool, change in bowel habit, night pain, weight loss, anorexia, fevers)
reactive arthritis (Reiters) - is HLA-B27 positive
gonorrhoea (intracellular diplococcus)- correct
rheumatoid arthritis -
50
man from syria, 35yrs old. 3yr fluctuating malaise feveres, weight loss, odynophagia, persistent arthralgia of knees, wrists and ankles. 8 episodes of bloody diarrhoea over last 2 days. biopsies - non-specific colitis. pain during sex. intermittent dysuria. 2 ulcers in oropharynx and one genital ulcer. Painful nodules on shins and evidence of thrombophlebitis. Abdomen was tender but not peritonitic and PR exam unremarkable. Ocular exam - uveitis and optic atrophy. Initial investigations showed he was pyrexial with a tachycardia and a CRP 150 and Hb 96 . Management?
arrange CT colonoscopy
arrange colonoscopy
start oral prednisolone and review in 1 wk
perform inpatient work up including AXR
start azathioprine
perform inpatient work up including AXR - correct as anaemia, high inflammatory markers and pyrexial therefore admit
```
Truelove & witts criteria for admitting patients with colitis
is the person passing 6 stools per day
is temp >37.5
is pulse >90
is Hb 30
-- ADMIT
```
51
```
man from syria, 35yrs old. 3yr fluctuating malaise feveres, weight loss, odynophagia, persistent arthralgia of knees, wrists and ankles. 8 episodes of bloody diarrhoea over last 2 days. biopsies - non-specific colitis. pain during sex. intermittent dysuria. 2 ulcers in oropharynx and one genital ulcer. Painful nodules on shins and evidence of thrombophlebitis. Abdomen was tender but not peritonitic and PR exam unremarkable. Ocular exam - uveitis and optic atrophy. Initial investigations showed he was pyrexial with a tachycardia and a CRP 150 and Hb 96 .
RF -ve
ANA -ve
dsDNA -ve
plts 500
WCC 15
pathergy test +ve
radiology of joints - nothing abnormal detected
colonoscopy - pending
```
```
UC
Crohns
Sjogrens
Reiters
Behcets
SLE
```
Behcets - correct - pathergy test , if from syria/Turkey think behcets
52
```
25 yr old 6 month hx of wrosening fatigue, night sweats arthralgia and recurrent fevers. she is hypertensive, and 2 months hx of raynauds (bilateral). blood tests reveal anaemia assoc with raised ESR and hyperaldosteronism. absent pulses in left arm. most likely cause of her symptoms?
polyarteritis nodosa
giant cell arteritis
kawasaki disease
takayasus arteritis
microscopic polyangitis
```
takayasus arteritis - correct - as absent pulses , hyperaldosteronism due to renal artery stenosis, large artery vasculitis cause hypertension due to kidney disturbance.
53
54 year old male with chest pain and SOB. He is on warfarin with a target INR of 2.5 for a DVT 2 months ago. He has fatigue and is itchy. FBC: Hb 18.6 Plts normal. WCC 5.
a. Essential thrombocythaenia
b. Gaistocks syndrome
c. multiple myeloma
d. myelofibrosis
e. polycythaemia rubra vera
e. polycythaemia rubra vera.
erythrocyte monoclonal expansion -> myelofibrosis
can be premalignant (essential throbocythaenia is also premalignant) -> AML
If plts were near 1000 - essential thrombocythaenia more likely
Gaistocks syndrome = thrombovythaenia & hypertension
Multiple myeloma = bone pain, raised ESR, monoclonal bands in urine
myelofibrosis- giant splenomegaly, tear drop cells, dry bone marrow tap
54
```
Hb low, WCC normal, Plts normal.
Reticulocytes low
MCV mildly low
RDR normal
K+ high, urea and creat high
Ca low
DAT -ve
low serum iron
TIBC low
Transferrin high
```
What is the diagnosis
Anaemia of chronic disease secondary to CKD
Urea and creatinine high indicating renal failure. MCV is only milady low so picture is more one of a normocytic anaemia than microcytic. (if iron deficient would expect TIBC to be high). Low reticulocytes is also a clue. This is due to the lack of erythropoietin synthesis.
DAT -ve indicates no autoimmune haemolysis
Ca is low due to lack of action of 1alpha hydroxylase in making activated calcidiol
If urea had been elevated and not creatinine - this would be more indicative of a bleed / haemolysis
If creatinine high alone - ?renal failure ? afro caribbean
55
```
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. What is the cellular abnormality?
p53 mutation
RAS mutation
Mutated mismatch repair tumour
chromosomal translocation
DNA crosslinking
```
chromosomal translocation - this is the t(9,22) philadelphia chromosome translocation that is present in CML
p53 mutations inherited in Li Fraumeni
RAS mutation - part of chain for colorectal cancer
Mutated mismatch repair tumour - Lynch syndrome (also causes HNPCC, ovarian and endometrial cancers)
DNA crosslinking = mech pf action of cyclophosphamide
56
```
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. What is the chromosomal translocation?
t(14,18)
t(9,22)
t(15,17)
t(11,22)
t(8,14)
```
t(9,22) - this is the philadelphia chromosome in CML
t(14,18) = follicular lymphoma- bcl-2
t(15,17) = APML (retinoid acid suppressor -> give retinoic acid - vit a)
t(11,22) = Ewings sarcoma - bone cancer children - noon skin appearance
t(8,14) - burkitts lymphoma - EBV - c-myc
EBV is also assoc with nasopharyngeal and liver cancers
57
```
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. Pnt given red cell and plt transfusion and imatinib. MOA of imatinib?
monoclonal antibody vs bcr-abl fusion
toxin vs bcr-abl fusion protein
nucleoside analogue
tyrosine kinase inhibitor
alkylating agent
```
tyrosine kinase inhibitor
58
```
60 year old male on an anti platelet following an acute MI. He has a macrocytic anaemia & unconjugated hyperbilirubinaemia & schistocytes. Neurologically he has fluctuating mood, odd behaviour. He has a high urea and creatinine.
Giant cell arteritis
Haemolytic uraemic syndrome
Idiopathic thrombocytopaenic purport
Thrombotic thrombocytopaenic purpura
frontal lobe dementia
```
Thrombotic thrombocytopaenic purpura
If has recently eaten a dodgy burger it may have contained campylobacter jejuni (gram -, spiral rod) -> can trigger HUS. Also caused dark urine and schistocytes.
TTP - often triggered by drugs.
Both are MAHA
ITP is platelet type bleeding - petechiae, eccymosis. plts
59
```
45 year old male on warfarin for metallic heart valve. Has an upper GI bleed. Tachycardic, tachyopnoeic & postural drop in BP. Haematemesis. Optimal management to reverse the anticoagulation?
cryopecipitate
frozen fresh plasma
prothrombin complex concentrate
stop warfarin and restart when INR
```
Prothrombin complex concentrate
Vit K would completely reverse anticoag and pnt would require LMWH after because of valve
FFP - would take too long
cyroprecipitate - used in DIC patients (as they use up fibrinogen and this is packed with fibrinogen)
60
45 yr old male on warfarin for a metallic heart valve and is going to undergo surgery. What anticoagulation during surgery?
LMWH
unfractionated heparin
stop warfarin and restart after surgery
reverse anticoag with Vit K
administer prothrombin complex concentrate
Unfractionated heparin & monitor APTT (intrinsic pathway)
Use as has short half life and can give IV
61
15 year old male in ITU for meningococcal sepsis. Diagnosed with Waterhouse-Friederichson syndrome following adrenal failure. Clotting screen results consistent with cause of adrenal failure?
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products low
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products normal
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products high
- PT high, APTT high, plts normal, bleeding time high
- PT high, APTT normal, plts normal, bleeding time high
Waterhouse–Friderichsen syndrome is defined as adrenal gland failure due to bleeding into the adrenal glands, caused by severe bacterial infection.
PT high, APTT high, plts low, bleeding time high, fibrin degradation products high
as has DIC and fibrin is being used to degradation products are high
62
Causes of DIC?
```
sepsis
pre-eclampsia
HELLP (high liver enzymes, low platelets)
amniotic fluid embolus (causes PE too)
malignancy
trauma
leukaemia
transfusion reactions
fat embolus (also cause PE)
```
63
22 year old female. abdo pain 8/10. opened bowels. pretechial rash on buttocks. bloods Hb 12, WCC high, plts normal, CRP high, LFTs normal
```
aspirin overdose
henoch-schonlein purpura
immune thrombocytopaenic purpura
leukaemia
osler-weber rendu syndrome
```
henoch-schonlein purpura
the abdo pain is due to mesenteric ichaemia
the purpura is due to a problem of the vessel wall rather than plt number (Immune thrombocytopaenic purpura ) or function (aspirin overdose).
64
```
34 year old male. Penicillamine for wilsons disease. A&E - facial swelling and dross bipedal oedema. Urine dip +++ protein but -ve for blood, nitrites and leucocytes. 2 days later develops renal vein thrombosis. Def of which protein led to this?
antithrombin III
factor II
plasminogen
protein C
protein S
```
antithrombin III protein lost in nephrotic syndrome
65
which is a complication of warfarin
clots
skin necrosis
dementia
skin necrosis
- lose protein C first (is one of the vit K clotting factors) and is prothrombotic
-> gangrene of toes
therefore start warfarin with heparin cover
warfarin requires loading as has zero order kinetics like amiodarone and digoxin and ehtanol
66
```
20 yr old male 3 DVTs. Clotting reveals decreased APTT which didn't correct upon rx with activated protein C. Diagnosis?
antithrombin III deficiency
factor V leiden
protein C deficiency
protein S deficiency
prothrombin mutant
```
factor V leiden
most common clotting abnormality
also protein C works on factor V therefore is factor V a mutant no matter how much protein C patient is still susceptible to clots
67
32 female. Lethargy. Itchy bullous rash on extensor surfaces. Blood film - howell jolly bodies.
atrophic gastritis and pernicious anaemia
coeliacs
crohns
steven-johnson disease
hashimotos thyroiditis
coeliacs
the rash is dermatitis herpatiformis
also coeliacs is a cause of hyposplenism and this explains the howell jolly bodies.
SJS - assoc with erythema multiform involving mucosal membranes.
atrophic gsatritis and coeliacs are assoc with increased risk of GALT lymphoma
68
40 female cough 6 months. weight loss and decreased exercise. <1 yr smoking hx. on Xray - 1 well circumscribed lesion
```
adenocarcinoma
aspergilloma
large cell carcinoma
small
squamous
```
adenocarcinoma
- no smoking hx required
aspergilloma - expect more systemic features e.g. fever
small - normally metastasised on presentation
squamous - assoc highly with smoking
bronchoalveolar carcinoma is a subtype of adenocarcinoma and is the most common in non-smoking females
69
drug causes of immune mediated haemolysis
```
cephalosporins
dapsone
levodopa
levofloxacin
methyldopa
nitrofurantoin
NSAIDs
```
70
```
Half life of naloxone
5mins
15mins
60mins
180mins
360mins
```
60mins
give 400-1200mcg IV for opioid overdose
clinical effects in 1-2mins and lasts 45mins
naloxone doesn't work as well after buprenorphine overdose
71
Benzo overdose?
flumazenil should always be used
may be associated with ataxia and dysarthria
dicobalt edetate is an effective antidote
effect NMDA receptor
not exacerbated by alcohol
may be assoc with ataxia and dysarthria `(and decreased gcs )
usually managed with supportive care. if severe then flumazenil used - only on expert advice
72
```
what is a prognostic marker of paracetamol overdose?
AST
ALP
bilirubin
PT
paracetamol level
```
Prothrombin time
other prognostic markers:
73
```
Which is the molecule responsible for paracetamol toxicity:
N-acetylcystein
Glutathione
N-acetyl-benzoquinoneimine
methionine
P-aminophenol
```
N-acetyl-benzoquinoneimine
it uses up all glutathione & damages liver
N-acetylcysteine use to treat paracetamol overdoses as replenishes glutathione
concern when >75mg/kg paractamol level
74
presentation of paracetamol overdose
RUQ pain, n/v
bleeding, jaundice, hypoglycaemia & encephalopathy reflect significant hepatic failure
takes 48-72 hrs for hepatic necrosis
75
Treatment paracetamol overdose
24 hrs treat if INR >1.3 and/or ALT x2
if prognostic markers deteriorate -> transplant list
76
Prognostic markers paracetamol overdose
PT time >20s indicates significant hepatic damage, >180s (90% mortality)
Creatinine >300mmol/l (70% mortality)
lactate over 3.5 despite fluid resuscitation
signs of encephalopathy
77
38 yr old woman on warfarin for previous PE and DVT. Presents with haematemesis
```
BP87/53 PR124
INR 9
Treatment of most immediate benefit?
stop warfarin
FFP 1 unit
cryoprecipitate 2 units
Vit K
Prothrombin complex concentrate
```
Prothrombin complex concentrate
50 units/kg upto 3000 units
contains factors II, VII, IX, X (vit k dependent)
(stopping warfarin will only have effect after 20-60hrs (its half-life))
Vit K is effective but takes longer to work & causes resistance to warfarin
FFP used if Prothrombin complex conc not available
Cryoprecipitate contains VIII, XIII, vWF and fibrinogen - used in haemophilia, vWD, DIC & post-massive transfusion
78
16 yr old, SOB
ABP 7.49 PaO2 15.5 PaCO2 2.4 HCO3 12
```
imipramine
aspirin
paracetamol
citalopram
amphetamine
```
aspirin
```
CLinical features:
tinnitus
hyperventilation
diurphoresis
vomiting
coma
death
```
resp alkalosis and metabolic acidosis
79
```
salicylate overdose is assoc with which of the following
tinnitus
yellow vision
constricted pupils
metallic taste
brisk reflexes
```
tinnitus
yellow vision = digoxin overdose
constricted pupils = opiates
brisk reflexes = TCAs, SSRIs
80
Management of salicylate overdose
750 - consider haemodialysis
81
```
which of the following is inconsistent with MDMA (ecstasy) overdose?
diaphoresis
hypertension
miosis
hyperthermia
rhabdomyolysis
```
Miosis - as have dilated pupils
Ecstasy -> picture of catecholamine surge
hyperpyrexia, diaphoresis, hypertension, tachycardiac, mydriasis, cerebral oedema, seizures
82
```
Ecstasy OD is most likely to cause which electrolyte abnormality?
hypernatraemia
hyponatraemia
hypokalaemia
hypercalcaemia
hypocalcaemia
```
hyponatraemia due to polydipsia
| Rhabdo may cause an initial rise in calcium then a fall
83
complications of ecstasy overdose
```
hyponatraemia
dehydration & ARF
DIC
acute hepatitis
MI & CVA
```
84
Management of ecstasy overdose
cooling, anti-pyretics, potentially IV dantrolene
benzos for seizures
careful fluid management
85
40yr old homeless man. OD. Temp 36.5, P120, BP 105/70 RR28
pupils 5mm fixed
dry mucous membranes
palpable bladder
```
found with an empty packet of amytryptiline
Rx?
activated charcoal
IV bicarbonate
IV sodium dantrolene
IV intralipid
IV fomepizole
```
IV bicarbonate
Management
if less 1hr - activated charcoal
if not IV bicarbonate
if fails consider intralipis
```
CLinically:
sinus tachycardia, hypotension
resp depression
hallucinations
seizures
anti-cholinergic - dry mucous membrane, urinary retension, pupil dilatation, ileus
```
Investigations
ECG - prolonged QRS/QT -> arrythmias
Metabolic acidosis
Rhabdo
86
```
which arrhythmia does amitryptyline not cause?
Mobitz type I
2:1
VT
sinus bradycardia
1st degree heart block
```
2:1 block
87
Digoxin toxicity electolyte abnormalities
hypokalaemia
hypomagnaesia
hypercalcaemia
hyperkalaemia
88
Digoxin toxicity clinical signs
fatigue n/v confusion
blurred vision /yellow vision
arrhythmia - bradycardias most common
89
Beta blocker overdose
glucagon
90
Ethylene glycol
fomepizole
91
carbon monoxide
oxygen (hyperbaric)
92
iron
desferoxamine
93
lead
sodium calcium edetate
94
organophosphates
atropine / pralidoxime
95
Na valproate
L-carnitine
96
cyanide
dicobalt edetate
97
arsenic
dimercaprol
98
Drugs causing Stephen Johnson Syndrome
```
Sulphonamides (incl. sulphasalazine)
Co-trimoxazole (used to treat pneumocystis pneumonia)
Penicillins
Phenytoin
and others..
```
SJS = erythema multiforme + mucosal involvement
99
Erythema nodosum causes
Penicillins
Oestrogen
Sulphonamides
Phenytoin
```
M
UC/Crohns
SLE/sarcoid
Oestrogens
Drugs (as above)
O
N
```
100
```
Commonest cause of pneumonia in patients getting pneumonia after influenza?
Strep pneumo
Haem influenzae
Staph aureus
Moraxella catarrhalis
Klebsiella
```
Staph aureus
(it is also more common in patients with hospital acquired pneumonia)
Strep pneumo - commonest cause of CAP and of pneumonia in COPD pmts
H.Influenzae - another common cause of CAP and HAP
Moraxella - assoc with COPD - rare cause of pneumonia in these patients
101
Which antibiotics would you give to treat a pnt with severe community acquired pneumonia.
iv co-amoxiclav and clarithromycin
oral amoxicillin and erythromycin
oral ciprofloxacin
IV antibiotics should be used for severe CAP & changed to oral once there has been an improvement for 24 hrs
Ciprofloxcin is not a treatment fr CAP due to resistance
Levofloxacin is an alternative Rx
102
5 days after IV antibiotics for community acquired pneumonia - patient begins to deteriorate. SOB and R sided chest pain & more oxygen required to maintain SpO2 92%
What would you do?
Pleural aspiration
Nothing
Chest drain
Suspect empyema
Do a pleural aspiration to discover whether it is a simple or complicated parapneumonic effusion or an empyema.
Send pleural fluid for microscopy, cytology, protein, lactate dehydrogenase, glucose and pH.
Pleural tap under USS guidance
If empyema - insert chest drain
if pH
103
67 yr old with bronchiectasis. 3 wk hx of worsening breathlessness, cough and sputum. Had oral Abx but symptoms fail to improve. Sputum culture reveals pseudomonas aeruginosa.
Admitted for Rx.
What describes the mechanism of action of the antibiotic of choice?
```
disruption of cell membrane
inhibition of cell wall synth
inhibition of folate synth
inhibition of nucleic acid synth
inhibition of protein synth
```
abx = ceftazidime
MOA - inhibition of cell wall synth as is a beta lactam antibiotic
104
Causes of metabolic acidosis with raised anion gap
```
MUDPILES
Methanol
Uraemia
DKA
Propylene glycol
Isoniazid
Lactic acidosis
Ethylene Glycol
Salicylates
```
105
causes of a metabolic acidosis + normal anion gap
Addisons
GI
Renal
106
```
50yr old woman. HbA1c 9 despite Rx with metformin and gliclazide. All are acceptable ways of improving control of diabetes except:
adding acarbose
adding pioglitazone
adding exenatide
sitagliptin
insulin
```
acarbose -- as only slows carbohydrate absorption and digestion. No effect on glucose production, or insulin resistance or levels of insulin
Pioglitazone decreases insulin resistance. It is a thiazolidine
```
Exenatide = GLP1 analogue (liraglutide)
Sitagliptin = DPP4 inhibitor
```
107
45 yr old man - fatigue, polydipsia. BM 22.3 mmol/l. OE/ BMI 36kg/m2 PR 84 & BP 144/84. Na 140. K 3.9, Urea 5.2. Creatinine 101 & glucose 22.1
Initial drug therapy
Metformin
108
35 yr old. T1DM. 2x daily novomix. Consistently high glucose levels before lunch. WHich is the most appropriate change?
a. add 8u of novorapid insulin before lunch
b. convert to a continuous subcut insulin infusion
c. decrease morning dose of insulin to 14u
d. increase eve dose of novomix to 24u
e. increase morning dose novomix to 28u
increase morning dose novomix to 28u - correct (gets rid of spike before lunch)
109
53 yr old. random BM 9.5. GP repeats fasting value on 2 occasions - 6.4 and 6.7 and HBA1c 7.5%. which of the following is the most appropriate course of therapy?
encourage him to persue diet and exercise
initiate gliclazide
initiate metformin
do nothing
exercise and diet
110
```
35 woman. T1DM. abdominal pain. Missed insulin for 2 days. BM 37. ketones 4+ glucose 4+. tolerating fluids. Na 121mmol/l. Cause of low sodium?
hyperglycaemia
hypothyroidism
renal failure
SIADH
volume depletion
```
hyperglycaemia
pseudohyponatraemia - hyperglycaemia, hyperlipidaemia, high plasma protein due to dilution
will self correct when treat DKA
other causes of hyponatraemia
volume deplete - renal losses, GI losses, skin (burns)
euvolaemic - SIADH (elevated urine osmolality) & hypothyroidism, psychogenic or polydipsia (if urine osmolality decreased)
overloaded - heart, renal, liver failure and nephrotic syndrome
111
71. T2DM. lethargy polyuria. Hyperosmolar hyperglycaemia state (HHS) considered. Which of the following would be least considered.
ph >7.3
bicarb <15
serum osmolality 310
serum osmolality - must be above 320/300 to be significant
112
45 polydipsia. glucose and calcium normal. Water deprivation test performed.
starting plasma osmolality high
final urine osmolality low
urine osmolality post-DDAVP (desmopressin) higher
a. SIADH
b. psychogenic polydipsia
c. cranial diabetes insipidus
cranial diabetes insipidus
113
75 yr old. drowsy and confused after hip replacement. abnormal thyroid function.
sick euthyroid syndrome (NTI - non-thyroid illness)
114
64 yr old. thyrotoxicosis due to graves. resting tremor Rx.
propranolol
115
75 woman. GCS 13/15. T 33.5. HR 40. BP 90/60. Free T4 undetectable. Na 128 and CK 600. She is rewarmed and started on levothyroxine IV> IV 0.9& saline
What is the cause of her symptoms
myxoedema crisis
(decompensated hypothyroidism)
treatment = IV hydrocortisone and IV levothyroxine
116
```
Test for acromegaly
insulin clamp test
oral glucose tolerance test
pituitary MRI
serum growth hormone levels
serum insulin levels
```
oral glucose tolerance test
| IGF1 levels useful in monitoring acromegaly
117
```
Patient with increased finger and shoe size. moderately sized pituitary tumour on MRI. What is the most appropriate first line therapy?
Bromocriptine
External beam radiotherapy
Ocreotide
Ramiprile & 6 monthly surveillance
trans-sphenoidal surgery
```
trans-sphenoidal surgery
118
```
35 yr old man. BP 240/120mmHg & LVH. Na 138. K 2.8 Urea 5. Creat 84 Glucose 5.4. Renin undetectable. Probable cause 2ndry hypertension is:
addisons
conns
cushings
phaechromocytoma
renal artery stenosis
```
Conns
Cushings would expect higher K
Phaeo = expect higher K and other symptoms
Renal artery stenosis is unlikely
119
45 female. lethargy. Na 129 K5.1 Urea 5.3 Creat 99. Total T3 66 (high)
```
Ix to reveal diagnosis?
serum glucose
TSH
free T4
Overnight dexamethasone suppression test
Short synacthen test
```
short synacthen test - for addisons
thyroid and corticosteroid binding globulin (CBG) have an inverse relationship. As thyroid levels come up, CBG goes down, leaving more cortisol free. Cortisol is also released from CBG as body temperature rises, and body temperature correlates positively with thyroid levels. So raising thyroid can naturally raise cortisol levels.
overnight dexamethasone suppression test is for cushiness
120
```
55. Thirst. urinary freq and abdo pain. serum ca 3.2 alb 40 vit D 40 phosphate 0.8 ESR 12
bone scan
USS parathyroid glands
USS kidneys
Urinary Bence Jones protein
Serum protein electrophoresis
```
USS parathyroid glands - correct (primary hyperparathyroidism)
USS kidneys- not useful
Urinary Bence Jones protein (for myeloma but would have raised ESR)
Serum protein electrophoresis (for myeloma but would have raised ESR)
121
```
MEN type 1. Features
adrenal nodules
hyperparathyroidism
hyperthyroidism
hypothyroidism
phaeochromocytoma
```
hypoerparathyroidism
MEN type 1
Pancreas
Pituitary
Parathyroid
MEN type 2
phaeo
pancreas
medullary thyroid
122
```
Pnt. Eyes don't open to any stimulus. Abnromal sounds that were difficult to comprehend. Abnromally drew arm towards body when pricked with a neurotic. GCS?
5
6
7
9
11
```
6
Eyes: not opening, open to pain, open to voice, open spontaneously
Speech: none, difficult to comprehend, inappropriate, confused, normal
Movement: none, extension, flexion, withdraws from pain, localises to pain, responds to commands
If GCS <8 needs to be intubated
123
24 yr old - sharp chest pain and dyspnoea. 6 wk hx pruritus. worse following a hot shower. CXR normal and betaHCG normal. Polycythaemic Hb19.6. A first PE is suspected. What is the most approp Rx?
fondaparinux for 3 months
treatment dose LMWH & warfarin until INR 2.5 then warfarin alone for at least 6 months
treatment dose LMWH & warfarin until INR 3.5 then warfarin alone for at least 6 months
treatment dose LMWH & warfarin until INR 2.5 then warfarin alone for at least 3 months
Treatment dose LMWH & warfarin until INR 2.5 then lifelong warfarin plus IVC filter
treatment dose LMWH & warfarin until INR 3.5 then warfarin alone for at least 6 months
pnt doesn't have reversible risk factor (DVT, pregnant, etc.)
but this (polycythaemia) is a lifelong / chronic risk factor
INR 3.5 if recurrent PEs e.g. PE on warfarin
INR 3.5 if metallic heart valve
Rx for polycythaemia = venesection
124
67 hx of AF, brittle asthma and peripheral vascular disease. 3hr hx palpitations. ECG narrow complex tachy. rate of 240 and 2:1 AV-block. Primary survey reveals: BP 140/80, sats 98%. What is the most appropriate next step?
```
adenosine
digoxin
verapamil
DC cardioversion
IV amiodarone
```
give adenosine 6mg IV - cant give because brittle asthma (AV node blocker)
give loading dose digoxin
give verapamil - class IV ca channel blocker, non-dihydropyridine - correct (option for an SVT as increase resistance of AV node)
synchronise DC cardioversion (only haemodynamically compromised: HR >200, flash pulmonary oedema, urinary output none, gcs low etc.)
IV amiodarone 300mg - for structurally abnormal hearts, class III anti-dyrhythmic - blocks potassium channels (prolongs refractory period), Risk of long QT interval -> torsades de pointes (polymorphic VT)
125
```
58 publican. haematemesis. collapse. GCS8/15. RR35 Sats 94%. BP 85/50 PR 135. IV fluid resuscitation is commenced following an NG tube. Intervention until definitive treatment?
ocreotide
terlipressin
propranolol
terlipressin
atenolol
noradrenaline
```
terlipressin is correct - ADH analogue. potent vasoconstrictor - so will increase BP. affects splanchnic circulation- reduces flow to area. Promotes clotting - release of factor 8.
Desmopressin - promotes clotting (haemophilia B - promotes release of factor 8)
ocreotide - bleeding PUD. somatostatin analogue.
terlipressin
propranolol -> vasodilatation (secondary prevention of variceal haemorrhages)
atenolol - cardioselective beta blocker
noradrenaline
126
variceal bleeding.
upon arrival to A&E what is the single best management option to reduce/stop the haemorrhage
```
OGD plus sclerotherapy
OGD plus band ligation
tranexamic acid
terlipressin
dobutamine
```
OGD plus band ligation = correct
tranexamic acid - prevents fibrinogen being activated. useful in haemorrhage. promotes clotting. previously used for menorrhagia
127
28. IDDM. GCS reduced to 12/15 over 48 hrs. patches of depigmented skin. postural drop in BP. ECG shows sine wave (what tented T waves turn into ) - next stage is VF
```
IV hydrocortisone and fludrocortisone
synchronised DC cardioversion
10 units of actrapid and 50ml 50% dextrose
10ml 10% calcium gluconate iV
contact ITU registrar
```
10ml 10% calcium gluconate iV
Addisonian crisis - postural drop as fluid vol low as not much mineralocorticoids, hx of autoimmune disease, vitiligo,
d. Stabilises an unstable myocardium
b would also be sensible as pnt is heading towards VF
Addisons - hyperkalaemia, metabolic acidosis. normal anion gap
128
```
Anti dsDNA has which type of staining pattern:
homogenous
nucleolar
peripheral
speckled
```
homogonous - dsDNA and anti-histone
Speckled = anti-Ro and anti-La
129
```
69 presents with oesophagitis - which is least likely to be contributory?
alendronic acid
amlodipine
isosorbide mononitrate
sando-K
domperidone
```
domperidone as prokinetic so supports movement
alendronic acid - bisphosphonate - given 7am & sit upright after taking and eat something - chemical injury to oesophagus
amlodipine - ca channel blocker - relax oesophageal sphincter so higher risk
isosorbide mononitrate - relaxes smooth muscle -> more reflux
sando-K - potassium salts for hypokalaemia
130
```
45 yr old presents with difficulty swallowing and regurgitation of non-digested food. Barium swallow shows achalasia (inability of relaxation of the LOS, loss of peristalsis in lower oesophagus) See air-fluid level (visible on normal CXR behind aorta). which is not a treatment option for the primary disorder?
botulinum toxin
endoscopic dilatation
nitrates
omeprazole
surgical myotomy
```
omeprazole
botulinum toxin - relax sphincter
endoscopic dilatation - to relieve pressure
nitrates - relax LOS but transient treatment
omeprazole - tick (only helpful for complications)
surgical myotomy - surgical option
131
```
64 yr old with RA takes naproxen. Epigastric discomfort, OGD - mild gastritis. Treatment initiated to protect peptic ulcer. Now getting diarrhoea. Stool microbiology is sent - it is -ve. Which drug is most likely to have been started?
gaviscon
lansoprazole
misoprostol
ranitidine
sucralfate
```
misoprostol
gaviscon
lansoprazole (increased risk of c diff)
misoprostol - prostaglandin analog - stimulates regrowth of gastric mucosa - avoid in women who are pregnant (premature miscarriage), diarrhoea- tick
ranitidine - h2 antag
sucralfate - contains aluminium -> constipation
132
36 yr old man - 2l fresh haematemesis. O/E palmar erythema, multiple spider naevi. tachycardic and postural drop in BP. Receives IV fluids and at endoscopy is found to have oesophageal varices which are banded. Which is the most appropriate initial treatment for secondary prevention of variceal bleeding?
metoprolol
propranolol
rifampicin
terlipressin
TIPS (transjugular intrahepatic portosystemic shunt)
propranolol
metoprolol (cardioselective) - beta 1 only
propranolol - tick - beta blocker beta 1 and 2 - vasoconstriction
rifampicin - antibiotic used in encephalopathy
terlipressin - vasopressor (used in acute setting), can worsen cardiovascular disease
TIPS (transjugular intrahepatic portosystemic shunt) - option later down the line, increase risk of encephalopathy as shunt blood that would be detoxified in the liver, into systemic circulation
133
60 yr old - dyspepsia
endoscopy - no ulcers but H.pylori +
Management
lifestyle advice + low dose PPI when needed
PPI, amoxicillin & clarithromycin for 1 wk. Repeat H pylori in 6-8 wks to test for cure
PPI, bismuth, metronidazole and tetracycline for 1 wk
PPI, amoxicillin and clarithromycin for 1 wk. no need to retest
PPI, amoxicillin, clarithromycin for 1 wk. Continue PPI for further 3 wks
PPI, amoxicillin and clarithromycin for 1 wk. no need to retest - correct as no ulcers
if ulcers - triple therapy then longer with PPI
if under 55 and no alarm symptoms - A
dont retest unless persistent symptoms
134
```
42 yr old DMT1 develops severe gastroparesis (delayed gastric emptying). which one most appropriate 1st line antiemetic?
cyclizine
domperidone
hyoscine
levomepromazine
ondansetron
```
cyclizine - histamine antag (can decomponsate AF, drowsy)
domperidone or metoclopramide - dopamine antag, prokinetic
hyoscine - competitive antag of AChR (motion sickness especially, patch behind ear)
levomepromazine - histamine antagonist
ondansetron - 5HT3 receptor antag (chemotherapy, good pre-op)
equal efficacy
delayed gastric empyting is the problem
domperidone is correct - prokinetic and acts on chemo trigger zone
135
```
27 yr old - Crohn's disease + 1 wk hx of diarrhoea and abdo pain. 2 inflammatory exacerbations over 12 months. steroids and diarrhoea improves. initial treatment option to maintain remission after resolution of an acute flare?
azathioprine
mesalazine
infliximab
budenosine
methotrexate
```
azathioprine - maintenance of crohns but takes weeks to work
mesalazine - mild exacerbations, maintenance of UC
infliximab - rescue therapy for crohns or UC if not getting better with steroids (in UC cyclosporin is another option)
budenosine - steroid poorly absorbed - good for settling milder flares
methotrexate - 2nd or 3rd line treatment
136
```
28 yr old Crohn's disease with peri anal abscess. 3 month course of metronidazole. most likely SE
bone marrow suppression
oligozoospermia
pancreatitis
peripheral neuropathy
stevens- Johnson syndrome
```
metronidazole - good for anaerobes and protozoa infections. interferes with nucleic acid synth
GI side effects
peripheral neuropathy (only a SE when taken for months) - common and irreversible
good efficacy
137
```
small bowel crohns and they are reviewed in clinic. mild fatigue but no exertional dyspnoea, chest pain or pre-syncope. blood tests show hb of 6.3, fe 4 and TIBC 90. what is the most appropriate treatment?
blood transfusion
dietary advice
iv iron supplementation
oral ferrous gluconate
oral ferrous sulphate
```
blood transfusion (rapid ongoing blood loss, anaemia with severe SOB, angina pain, syncope, collapse - are indications)
dietary advice
iv iron supplementation - correct (iron mainly absorbed in small intestine, flares may be exacerbated with oral treatment)
oral ferrous gluconate (no advantage over oral ferrous sulphate)
oral ferrous sulphate
138
55 yr old with paraesthesia in fingers and toes. Routine bloods shows megaloblastic anaemia and on subsequent testing vit b12 and folate def. what is the most appropriate means of vit supplementation?
folate daily and vit b12 intramuscularly simultaneously
folate daily and vit b 12 intramuscularly once neuro signs resolved
vit b 12 intramusc 3/wk, folate when neuro signs resolve
vit b12 IM monthly, then folate once neuro signs resolve
vit b12 iv 3/wk, then folate once neuro signs resolve
neuro symptoms more likely caused by b12 def so should treat first
IM is correct route - give until symptoms resolve
so C is correct
if folate first u may see improvement in blood results but you might mask progressive neurological deficit.
folate stimulates consumption of b12 -> subacute demyelination of the cord -> paralysis
139
```
52 yr old caucasian . 4 month diarrhoea and weight loss joint aches and pains in knees. wife noted he is increasingly depressed and withdrawn over the last few wks. wide -based gait
hb low
alb low
CRP
eosinophils normal
amylase normal
```
```
duodenal biopsy shows villous atrophy - infiltration of macrophages with lamina propria staining + for PAS
Rx?
gluten free diet
ceftriaxone and doxycyline
ivermectin
mesalazine
metronidazole
```
whipples disease - small bowel malabsorption
- joint problems
- cerebellar ataxia
```
gluten free diet - coeliac
ceftriaxone and doxycyline
ivermectin - strongyloides helminth treatment (small bowel malabsorption) may be latent for many years. eosinophils are always raised
mesalazine
metronidazole
```
correct answer ceftriaxone and doxycycline
140
```
coeliac disease
not a recognised complication?
anaemia
dermatomyositis
hyposplenism
intestinal T cell lymphoma
osteoporosis
```
anaemia
dermatomyositis - correct
hyposplenism - well recognised - mech not clear
intestinal T cell lymphoma -
osteoporosis - common (osteomalacia, calcium and vit d deficient)
141
19 yr old abdo pain and vomiting
on long term steroids which neglected to take
appears lethargic and has diffuse abdo tenderness
BP 80/45 HR 110 sats 96%
dizzy on standing and postural drop in BP
what is the first line management option?
blood results: VBG - ph acidotic, BE -3, lactate 2.5 glucose 3.5, na 128, k 5.8 cl 100 hco3 21
cefuroxime
fludrocortisone
hydrocortisone
insulin/dextrose
oramorph
```
cefuroxime
fludrocortisone - mineralocorticoid
hydrocortisone -correct - gluco and mineralocorticoid (and fluid rescusitate)
insulin/dextrose - in DKA
oramorph
```
addisonian crisis
aldosterone -> salt and water retention (she is lacking it so postural drop)
DKA and addisonian crisis both present with severe abdo pain and vomiting
142
73 yr old with AF and severe abdo pain. O/E diffuse abdo tenderness no guarding or rebound and abdo soft. AXR - normal. Blood tests unremarkable except WCC 15.2. VBG - acidotic, lactate 8, hco3 24 na 130 k 3.5
```
most appropriate test?
amylase
CT angiogram
D-dimer
endoscopy
US abdomen
```
```
amylase - not specific
CT angiogram - correct - problem could be arterial or venous or splanchnic vasoconstriction. will help diagnosis
D-dimer
endoscopy
US abdomen
```
could be bowel ischaemia secondary to AF
severe abdo pain in over 75 is ruptured AAA or ischaemic bowel until proven otherwise
143
```
73 yr old painful constipation. dietary changes dont help. taking codeine for chronic back pain and doesnt want to change her analgesic. colonoscopy normal.
bisacodyl and senna
glycerine suppository
lactulose and movicol
movicol and senna
phosphate enema
```
bisacodyl and senna - stimulant laxative
glycerine suppository - osmotic (2nd or 3rd line)
lactulose and movicol - osmotic
movicol and senna - combination of stimulant and osmotic - correct
phosphate enema - osmotic
144
```
26 yr old with CF - recurrent abdo pain and diarrhoea. appropriate treatment
codeine
colestyramine
creon
loperamide
octreotide
```
codeine - constipating effect but wont treat underlying problem. also can cause sphincter of oddi to spasm
colestyramine - binds to bile acids
creon - correct - pancreatic replacement therapy (lipases, proteases and amylases)
loperamide - antidiarrhoea
octreotide - somatostatin analog - used to treat severe watery diarrhoea and sudden redding of the face caused by carcinoid tumours
pnts with CF can often become pancreatic insufficient
inability to break down lipids
145
```
34 HIV & IBD - abdo pain. amylase 1700 IU/L
which is least likely to be responsible
azathioprine
didanosine
infliximab
prednisolone
sulphasalazine
```
```
azathioprine
didanosine (DDI) - ARV
infliximab - correct (anti-TNF)
prednisolone
sulphasalazine
```
Drug causes of pancreatitis - azathioprine, ARVs, prednisolone, sulphasalazine, didanosine, bendroflumethiazine, furosemide, pentamidine, sodium valproate
146
causes of pancreatitis
```
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
M umps
Autoimmune
Scorpion stings
Hyperlipidaemia, hypercalcaemia
ERCP
Drugs - azathioprine, ARVs, sulphasalazine
```
147
```
50 yr old abdo distension. 20 units ETOH / day. palmar erythema, parotid swelling and spider naevi. no encephalopathy Na 118
ascitic drain
diuretics
fluid restriction
IV saline
salt restriction
```
IV saline is correct
ascites assoc with portal hypertension (-> splanchnic dilatation) -> activates RAS system -> aldosterone release (salt and water retention)
spironolactone can be useful
148
35 yr old - confusion. paracetamol overdose. GCS 13/15. dorwsy and agitated. acute liver failure. which is least prognostic of morbidity in ALF?
```
ALT >300
creatinine >300
grade III-IV encephalopathy
INR - >6.5 (PT >100s)
pH
```
ALT
| INR is most important
149
young pregnant mother is undergoing antenatal screening. Hep B infection shows following results
```
HBV surface antigen -ve
HBV sufarce antibody - positive
HBeAg negative
HBe AB +
HBV core antibody IgG positive
```
```
acute HBV infection
chronic HBV infection
chronic HBV with precore mutation
resolved HBV infection
vaccinated against HBV
```
correct answer = resolved HBV infection
vaccine only contains surface antigen therefore pnt must have been exposed as has produced HBe antibody and core antibody. e antigen tells you how infective you are. E antigen + - very infective. E antibody + = low risk of transmission
chronic HBV with precore mutation - HBeAg negative but HBe AB + and HBV surface antigen +
Hep A and C
IgM - acute
IgG - previous infection
150
56 yr old with jaundice. increasingly fatigued and excoriation marks over skin. skin pigmented. US abdo shows no biliary duct dilatation. which test is most likely to reveal the underlying diagnosis
```
AMA
c-ANCA
p-ANCA
ANA
SMA
```
correct answer = AMA
primary biliary cirrhosis - IgM, AMA
primary sclerosing cholangitis - p-ANCA +
autoimmune hep - type 1 - high IgG, ANA and SMA
type 2 - anti - LKM1
type III - seronegative
c-ANCA - wegeners granulomatosis - not relevant here
151
Rx if not sure if UTI or pneumonia
Co-amoxiclav
| covers Gram + and Gram -
152
Pneumonia treatment
Amoxicillin
Co-amoxiclav (if moderate)
Clarithromycin if penicillin allergic or suspect atypical pneumonia
Co-amoxiclav + clarithromycin if severe
153
Aspirations pneumonia Rx
Co-amoxiclav
154
If severe CAP and penicillin allergic Rx
Teicoplanin
155
Cellulitis Rx
Most likely to be staph aureus
so flucloxacillin
If severe cellulitis give flucloxacillin and benpen
covers staph aureus and strep
If allergic to penicillin clindamycin
156
Rx necrotising fasciitis
```
Surgical debridement
benpen + ciprofloxacin + clindamycin
benpen - covers group A strep
clostridium perfringens - ciprofloxacin
clindamycin is synergistic with benpen - inhibits protein synthesis so inhibits toxin production
```
157
Rx MRSA
Teicoplanin or vancomycin
158
Animal bites
Co-amoxiclav
159
Septic arthritis Rx
staph aureus
1st line - flucloxacillin + sodium fusidate
penicillin allergy - clindamycin
160
Osteomyelitis Rx
staph aureus
1st line - flucloxacillin + sodium fusidate
penicillin allergy - clindamycin
161
Endocarditis
first line: amoxicillin and gentamicin
if strep viridans: benpen and gentamicin
if staph aureus: flucloxacillin
Prosthetic heart valve (worry about staph epidermidis) - teicoplanin + gentamicin + rifampicin
teicoplanin is key drug
rifampicin - good anti-staph activity
penicillin allergy - teicoplanin + gentamicin
162
Gastroenteritis
generally don't treat
ciprofloxacin
```
campylobacter - helical org and doesnt respond to ciprofloxacin due to resistance
so treat with clarithromycin
PC = abdo pain worse than diarrhoea
undercooked chicken
3-4 days after eating
```
163
C difficile Rx
metronidazole
vancomycin (oral) - so less toxicity as low bioavailability
fidaxomicin
164
Travelers diarrhoea Rx?
Africa & Middle East - ciprofloxacin (e.coli or salmonella)
Asia - azithromycin
Giardia - protozoal infection - subacute and goes on longer - small bowel parasite - bloating, floating stools, belching, rotten egg smell - stool sample (70% +)
- metronidazole or tinidazole (over 98% effective)
- no alcohol
- No eosinophilia
165
Surgical infections
Cefuroxime and metronidazole
penicillin allergic - ciprofloxacin + metronidazole
166
Cholecystitis and diverticulitis Rx
cholecystitis & diverticulitis
1st line - co-amoxiclav
penicillin allergy - cipro &
severe: cefuroxime?
167
UTIs Rx
uncomplicated UTI
trimethoprim - 1st line - v effective. 2 tablets 3 days. not in 1st / 2nd trimester
nitrofurantoin - 2nd line - v effective but higher pill burden QDS for 5 days. need reasonable renal function. Risk of pulmonary fibrosis
amoxicillin - resistance is 50%
ciprofloxacin - v effective and good penetration into urine. good for ascending infections
cefadroxil - first line if pregnant
168
Pyelonephritis
ciprofloxacin (PO)
cefuroxime (IV)
if septic shock add gentamicin
169
prostatitis
ciprofloxacin
170
Meningitis
Benpen in community
Ceftriaxone 2-4g IV
if encephalitis possible - add in aciclovir
if pneumococcus likely- add dexamethasone
if listeria - add ampicillin
Penicillin allergy - chloramphenicol (excellent penetration)
171
Neutropenic sepsis
1st line: piperacillin - taxobactam + gentamicin
SE chemotherapy - disruption to gut epithelial barrier. so from pnts own flora
if not getting better in 48 hrs think
?resistance -> switch tazobactam to meropenem
? staphylococcus -> add teicoplanin for staph aureus
?fungal infection -> add in anti-fungal
172
Characteristic SE Amoxicillin
• Rash with infectious mononucleosis
173
Characteristic SE co-amoxiclav
cholestasis
174
Characteristic SE flucloxacillin
cholestasis
175
Characteristic SE erythromycin
GI upset
| prolonged QT interval
176
Characteristic SE ciprofloxacin
lowers seizure threshold
| tendonitis
177
characteristic SE trimethroprim
* Rashes, including photosensitivity
* Pruritus
* Suppression of haematopoiesis
178
With which drug can allopurinol not be prescribed?
Azathioprine
Allopurinol is a xanthine oxidase inhibitor. It prevents the breakdown of purines that produce uric acid. Azathioprine is metabolised into mercaptopurine and therefore its breakdown is slowed down when it is co-prescribed with allopurinol.
