Imperial PPQs Flashcards

Question

# October 2023 What is the 'block and replace' regime for Graves' disease?

Answer 1

Carbimazole 40mg is started and thyroxine is added when the patient is euthyroid.

Answer 2

15mg PO OD (up to 40mg PO OD)

Answer 3

NICE states 'Propylthiouracil is usually not used first-line, due to a small risk of **severe liver injury**, except in certain circumstances such as pre-pregnancy or the first trimester of pregnancy, or for specialist treatment of thyrotoxic crisis. It may be used second line if carbimazole is not tolerated.'

Answer 4

Levodopa 250mg PO twice daily ## Footnote Selegiline (E) is an oral monoamine oxidase-B inhibitor, and typically provides less improvement in motor symptoms and daily functioning. Given that these motor problems seem to be most debilitating for the patient, this is not the most appropriate therapy at this stage, though may be offered later. Ropinirole (D) is an oral dopamine agonist and also a possible first-line therapy. However, like selegiline it typically provides less improvement in motor symptoms than levodopa. Amantadine (A) is a second line drug used if dyskinesia is not sufficiently improved following a first line therapy. Entacapone (B) is also a second line drug used as an adjunct to levodopa if motor symptoms persist.

Answer 5

Sumatriptan 100mg PO once only

Answer 6

Switch Microgynon to Cerazette 75 micrograms PO daily

Answer 7

Prednisolone 50mg PO OD

Answer 8

Alginate therapy (e.g. Gaviscon) following every feed. For children 1-23 months (body weight 4.5kg and above): 2 sachets as required - to be mixed with feeds (or water, for breastfed infants). Max. 12 per day.

Answer 9

5 or more times per day More frequently during periods of physical activity and during intercurrent illness

Answer 10

Oxybutynin hydrochloride (Or tolterodeine)

Answer 11

Gliclazide can cause **hypoglycaemia** so she must eat regular meals.

Answer 12

Naloxone hydrochloride 400 micrograms intravenous once only Naloxone 400 micrograms intravenous once

Answer 13

**Lithium** Other names: lithium carbonate, Camcolit, Priadel (tablets)

Answer 14

Fasting plasma glucose level of 5.6 mmol/L or above; or Two-hour plasma glucose level of 7.8 mmol/L or above.

Answer 15

Women with gestational diabetes who have a fasting plasma glucose below 7 mmol/litre at diagnosis, should first attempt a change in **diet and exercise alone** in order to reduce blood glucose. If blood glucose targets are **not met within 1 to 2 weeks, metformin hydrochloride** may be prescribed. Insulin may be prescribed if metformin is contraindicated or not acceptable and may also be added to treatment if metformin is not effective alone. The starting dose for **Metformin is 500mg once daily** for one week, which can be tapered up according to response to treatment.

Answer 16

Dizziness secondary to dehydration

Answer 17

Atorvastatin 20mg PO once a day (at night)

Answer 18

150micrograms

Answer 19

Glucagon 1mg IM STAT ## Footnote This is the most appropriate option given the circumstances of concern over swallow (reduced GCS) and lack of IV access. Glucagon can be given immediately here through IM administration and avoids any delay in treatment caused by attempting to site a cannula. A cannula should be sited ASAP (as the patient will require IV glucose) but not at the expense of treating the hypoglycaemia.

Answer 20

Ipratropium bromide 500 micrograms nebulised

Answer 21

WIth food (to maximise absorption) At the same time each day.

Answer 22

Drugs that should normally not be stopped before surgery include antiepileptics, antiparkinsonian drugs, antipsychotics, anxiolytics, bronchodilators, cardiovascular drugs (but see potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, and angiotensin-ll receptor antagonists), glaucoma drugs, immunosuppressants, drugs of dependence, and thyroid or antithyroid drugs.

Answer 23

If the patient will miss more than one meal or there is significant risk of the patient developing AKI ## Footnote A variable rate intravenous insulin infusion should be started if the metformin hydrochloride dose is more than once a day. Otherwise, insulin should only be started if blood-glucose concentration is >12mmol/litre on two consecutive occasions. Metformin should not be recommenced until the patient is eating and drinking again, and normal renal function has been assured.

Answer 24

Any progesterone only pill

Answer 25

Drowsiness ## Footnote Correct answer - Drowsiness. Clonazepam is a benzodiazepine. One of the most common side effects of benzodiazepines is drowsiness. It is worth noting that clonazepam is the second line medication used in myoclonic seizures.

Answer 26

NICE CKS recommends **hydrogen peroxide 1% cream** for 'people who are not systemically unwell or at a high risk of complications'. However if this is unsuitable a topical antibiotic may be appropriate, fusidic acid 2% apply three times a day for 5 days, or Mupirocin 2% apply three times a day for 5 days if fusidic acid resistance is suspected or confirmed.

Answer 27

ORAL fluid challenge

Answer 28

Gentamicin should be given at 5-7mg/kg and the dose rounded to the nearest 20mg. The maximum dose will vary depending on local guidelines but should not exceed 500mg (in some trusts the maximum dose is 480mg so check your local guidelines). In obese patients the calculation should be based on ideal body weight rather than actual body weight. Doses need to be reduced in cases of impaired renal function and patients weighing <40kg.

Answer 29

In patients without varices (as in this case), NICE states "offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy". PPIs should not be started until after the endoscopy in suspected non-variceal bleeds. The IV PPI used most often is omeprazole, but esomeprazole is an alternative listed in the BNF. IV pantoprazole is not typically used in this instance (although it can be used for Gl ulceration).

Answer 30

In suspected variceal bleeds, patients should be treated immediately with terlipressin and prophylactic antibiotics prior to endoscopy

Answer 31

Body mass index

Answer 32

Risk of bladder cancer

Answer 33

Elevated BMI (risk of further weight gain)

Answer 34

LAMA e.g. tiotropium

Answer 35

**Benzodiazepine** Both chlordiazepoxide and diazepam are licenced for the use of alcohol-related withdrawal symptoms in the UK. ## Footnote This is because long-acting benzodiazepines with active metabolites (such as chlordiazepoxide and diazepam) have a lower chance of recurrent withdrawal or seizures due to missed doses than shorting acting benzodiazepines. A notable exception is in patients with severe liver impairment, where a shorter acting benzodiazepine such a lorazepam may be preferred - this should only be prescribed by a specialist team.

Answer 36

severe liver impairment ## Footnote Both chlordiazepoxide and diazepam are licenced for the use of alcohol-related withdrawal symptoms in the UK. This is because long-acting benzodiazepines with active metabolites (such as chlordiazepoxide and diazepam) have a lower chance of recurrent withdrawal or seizures due to missed doses than shorting acting benzodiazepines. A notable exception is in patients with severe liver impairment, where a shorter acting benzodiazepine such a lorazepam may be preferred - this should only be prescribed by a specialist team.

Answer 37

PR It is common to give NSAIDs PR for patients with renal colic given that they often feel nauseated and may vomit.

Answer 38

Phenoxymethylpenicillin

Answer 39

moderately potent topical corticosteroid, such as clobetasone butyrate 0.05%.

Answer 40

A correction factor (CF) is an estimate of how much 1 unit of rapid acting insulin will lower someone's blood glucose. It can be calculated by dividing 100 by the total daily dose (TDD) of insulin. ## Footnote For this patient the usual TDD is therefore: 18 (18 units of Insulin Glargine once daily) + 21 (7 units of Novorapid three times daily) = 39. This patient's CF is therefore 100/39 = ~2.5. So for every 1 unit of rapid acting insulin, this patient's blood glucose will fall by approximately 2.5 mmol/L. This patient therefore requires approximately 4 units of Novorapid to bring their blood glucose back in to normal range.

Answer 41

The most appropriate first step would therefore be to prescribe an antipyretic, such as paracetamol. The dose of paracetamol for a child 4-5 years old is 240mg every 4-6 hours up to a maximum of 4 doses per day.

Answer 42

Treatment is with an antiviral ointment (either aciclovir or ganciclovir). Steroid eyedrops (such as dexamethasone) may be used cautiously by specialists in cases of necrotising stromal keratitis but should otherwise be avoided due to the risk of transforming a simple dendritic ulcer into an extensive amoeboid ulcer involving all layers of the cornea or aggravating secondary infections.

Answer 43

Cotrimoxazole ## Footnote https://bnf.nice.org.uk/treatment-summary/pneumocystis-pneumonia.html

Answer 44

Worsening SOB for weeks, non-productive cough, fever, night sweats No improvement with oral antibiotics History of HIV May have oral thrush too

Answer 45

The next appropriate step would therefore be the addition of a topical NSAID (which are particularly useful for hand and knee OA). If topical NSAIDs were not effective, they should be stopped and oral NSAIDs or weak opioids could then be tried.

Answer 46

If symptoms have not resolved within 3 days despite regular use of paracetamol and ibuprofen, it would be reasonable to prescribe antibiotics. Amoxicillin is first choice.

Answer 47

After sun exposure (e.g. being on holiday)? Asymptomatic with no pruritis Hyperpigmented and hypopigmented macular lesions and patches, with fine overlying scale

Answer 48

If an extensive area is involved, prescribe an antifungal shampoo such as: Ketoconazole 2% shampoo If only small areas are involved, consider prescribing an antifungal cream as an alternative: Imidazole creams (such as clotrimazole [preferred in pregnancy], econazole, or ketoconazole) can be applied twice a day for up to 2–3 weeks.

Answer 49

Oral steroids should be given to people presenting within 72 hours of the onset of symptoms.

Answer 50

**Apixaban**, dabigatran, edoxaban and **rivaroxaban** ## Footnote However, both dabigatran and edoxaban require the patient to have been given 5 days of parental anticoagulation (such as with a subcutaneous LMWH) prior to initiation.

Answer 51

subcutaneous LMWH (such as dalteparin, tinzaparin or enoxaparin

Answer 52

Aggressive intravenous fluid therapy. The total fluid input for patients with symptomatic or severe hypercalcaemia should be 4-6L over 24 hours. Bisphosphonates may be used only when the patient has been adequately hydrated.

Answer 53

This patient is receiving a high-dose of corticosteroid and is likely to continue doing so for a prolonged period (at least 3 months). She is therefore at high-risk of developing osteoporosis and prophylaxis should be prescribed alongside her prednisolone. **Alendronate** (alendronic acid) is first line in this case

Answer 54

blood glucose of >33.3 mmol/L, a serum osmolality of >320 mmol/kg and volume depletion in the absence of significant ketoacidosis (pH> 7.3, HCO3 > 15 mol/L, ketones negative).

Answer 55

Patients will routinely require 3-6 litres of fluid within 12 hours to correct their fluid deficit ## Footnote In this situation giving 1L sodium chloride 0.9% over 1 hour would be appropriate in the first instance.

Answer 56

The blood glucose should not be reduced by more than 5 mmol/hour. Insulin should only be started once the glucose has stabilised following adequate rehydration.

Answer 57

a leukotrine receptor antagonist (LTRA e.g. montelukast).

Answer 58

Amiodarone 300mg IV over 20 minutes

Answer 59

Treatment is usually with oral doxycycline for 21 days, except in cases where the central nervous system is involved where IV ceftriaxone can be used as an alternative.

Answer 60

Magnesium sulfate IV 2g over 10 minutes

Answer 61

If the fasting blood glucose is over 7.0 mol/L, then insulin should be offered immediately.

Answer 62

Bacterial vaginosis Treatment is with either topical or oral metronidazole.

Answer 63

The first priority in an acute presentation of adrenal insufficiency should be to ensure the patient is adequately hydrated and this patient has already been appropriate prescribed IV 0.9% sodium chloride for fluid resuscitation. Following this he should be treated with a corticosteroid - typically hydrocortisone 100 - 200mg either IM or IV.

Answer 64

Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) are recommended as options for the management of mild to moderate AD. Memantine monotherapy is recommended only for those who are intolerant to acetylcholinesterase inhibitors or who have severe AD ## Footnote Lorazepam, risperidone and olanzapine may be used to manage the psychological and behavioural symptoms of dementia in specific cases but should only be prescribed by a specialist.

Answer 65

trial giving magnesium sulfate 2g IV. ## Footnote However, the most important point is to consider the need for intubation early and to escalate to the senior medical team and intensive care team so that this can be facilitated without a delay if required.

Answer 66

The most important abnormality to correct in this case is the **phosphate**. This is best done via an IV infusion.

Answer 67

chronic CO2 retention and compensated hypercapnic respiratory failure (type 2 respiratory failure)

Answer 68

Their inspired oxygen (Fi02) therefore needs to be carefully increased to address their hypoxaemia as a priority. The most appropriate way to do this is via a Venturi mask which consistently delivers an FiOz of 28% whilst reducing the risk of inducing respiratory acidosis. ## Footnote The patient's SpO2 and clinical condition should then be monitored closely and the Fiz increased further (to a 35% Venturi mask) should the target of 88-92% not be achieved. Once target saturations have been reached, an arterial blood gas should be performed to ensure that the higher FiOz has not caused a respiratory acidosis. If it has, the FiOz should not be turned down, as it is required to prevent hypoxaemia. Rather, other steps need to be considered to treat the respiratory acidosis (optimising medical management or NIV)

Answer 69

Spirometry ## Footnote NICE CKS advises to monitor asthma control at each review in adults, young people and children aged 5 and overusing either spirometry or peak flow variability testing (twice daily peak flow monitoring). Therefore the correct answer is spirometry as a single peak flow measurement would not be sufficient. The other components of an asthma review can be found within the NICE guidance linked below and form an integral component of the management of asthma.

Answer 70

NICE CKS recommends a hormonal levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment (e.g. Mirena). If this is declined or unsuitable, tranexamic acid or a non-steroidal antiinflammatory drug (NSAID) is recommended.

Answer 71

There is a high clinical suspicion of Epiglottitis in an unvaccinated child with stridor, drooling and respiratory compromise.

Answer 72

NICE guidelines state that antibiotic therapy for Epiglottitis is Cefotaxime or Ceftriaxone as first line. If there is a history of immediate hypersensitivity to penicillins or cephalosporins, Chloramphenicol is a suitable second line option. ## Footnote Cefotaxime dose is 50mg/kg every 8-12 hours Ceftriaxone dosage is 50-80 mg/kg once daily, doses at the higher end of the recommended range used in severe cases; maximum 4 g per day. Oral options would not be suitable in this child due to the acuity and airway obstruction.

Answer 73

Review choice of antibiotic when results are available. Change the antibiotic according to susceptibility results if bacteria are resistant - use narrow-spectrum antibiotics if possible and seek specialist advice if unsure. Send urine for culture once treatment is completed to ensure clearance of infection. ## Footnote Correct answer - Repeat urine culture only once treatment complete even if symptoms resolve to ensure clearance of infection.

Answer 74

Offer a nonsteroidal anti-inflammatory drug (NSAID), unless contraindicated. Options include **ibuprofen, naproxen, mefenamic acid, flurbiprofen, or tiaprofenic acid**. Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient. If the woman does not wish to conceive, consider prescribing a 3-6 month trial of a hormonal contraceptive as an alternative first-line treatment. ## Footnote If the response to individual treatments is insufficient, a combination of an NSAID (or paracetamol) and hormonal contraception may be considered. Consider recommending the following non-drug measures (in addition to drug treatments) to help reduce pain: Local application of heat (for example, a hot water bottle or heat patch). * Transcutaneous electrical nerve stimulation (TENS) — set to a high frequency. * Provide patient information on dysmenorrhoea. * If symptoms are severe and do not responded to initial treatment within 3-6 months, or if there is doubt about the diagnosis, refer to a gynaecologist.

Answer 75

A common side effect of the MMR vaccine is a fever or rash, which typically occurs a week after the vaccination. ## Footnote Parotid swelling occurs in around 1% children, but usually around the 3rd week. Febrile seizures can occur rarely following the first dose of the MMR vaccine, but usually around days 6-11 after the vaccine. Idiopathic thrombocytopenic purpura (ITP) is a rare side effect, which usually occurs within 6 weeks of the first dose. Adverse effects are much more common after the first dose of the MMR vaccine, rather than the second.

Answer 76

24mg ## Footnote Oral morphine is prescribed at 1/10. This total dose is then divided up depending on whether the immediate-release (4-hourly dosing) into or moderate-release preparation (12-hourly dosing) is prescribed. Additional doses for breakthrough pain should also be prescribed to sue as required.

Answer 77

Hydrocortisone 1% cream/ointment ## Footnote Prescribe generous amounts of emollients, and advise frequent and liberal use. Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1% for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.

Answer 78

Lithium excretion is significantly reduced by ACE inhibitors. Check if patient has a NEW diagnosis of HTN, indicating that ramipril was recently started.

Answer 79

Give LMWH e.g. enoxaparin ## Footnote Women with previous VTE (except those with a single previous VTE related to major surgery and no other risk factors) should be offered thromboprophylaxis with LMWH throughout the antenatal period. Women with previous VTE should be offered pre-pregnancy counselling and a prospective management plan for thromboprophylaxis in pregnancy made. Those who become pregnant before receiving such counselling should be referred at the earliest opportunity in pregnancy to a clinician with expertise in thrombosis in pregnancy.

Answer 80

Mebendazole 100 mg oral once only

Answer 81

Clarithromycin 62.5 mg oral twice a day Erythromycin 125 mg oral four times a day

Answer 82

urgent transfer to hospital, B2 agonists and early steroids.

Answer 83

This woman's acute history and raised ESR is supportive of a diagnosis of polymyalgia rheumatica. The first line treatment of polymyalgia rheumatica is with **prednisolone 15mg PO OD.** Patients should be reviewed after one week to assess the clinical response and, if improving, the dose can be reduced slowly after 3 to 4 weeks.

Answer 84

Codeine should be avoided in breastfeeding as it carries a risk of breathing difficulties in the infant./

Answer 85

Ulipristal Acetate (EllaOne) should be considered as the first-line hormonal emergency contraception for a woman who has had unprotected intercourse in the last 120 hours. Levonorgestrel is effective if taken within 72 hours of unprotected intercourse and may also be used between 72-96 hours [unlicensed use], however its efficacy decreases with time.

Answer 86

Lithium levels are normally measured one week after starting treatment, one week after every dose change, and weekly until the levels are stable. Once levels are stable, levels are usually measured every 3 months. Lithium levels should be checked 12 hours post dose. TFTs, U&Es, calcium and weight need to be measured every 6 months.

Answer 87

30 minutes

Answer 88

The maximum allowable dose of Lidocaine based on weight is 4.5 mg/kg.

Answer 89

Cetirizine hydrochloride Loratadine

Answer 90

Phenytoin is likely to have reduced the efficacy of her oral contraceptive pill. ## Footnote Liver enzyme inducing medication can reduce the efficacy of combined oral contraception pills (COCP). Medications which induce liver enzymes include: rifampicin, rifabutin, griseofulvin, carbamazepine, phenytoin, and St John's Wort, amongst others. Women who take any of these medications should be on an alternative form of contraception. It should be noted that levothyroxine does reduce the efficacy of the COCP, but the COCP can increase need for thyroid hormones. NICE CKS recommends if taken together, to monitor thyroid function and adjust the dose of levothyroxine accordingly.

Answer 91

The iris of the treated eye may change colour ## Footnote As the patient has moderate primary open angle glaucoma treatment is necessary to prevent further progression of the condition and preserve vision as much as possible. First line treatments are either prostaglandin analogues (such as Latanoprost) or beta-blockers (such as Timolol). Before initiating treatment, patients should be warned of a possible change in eye colour as an increase in the brown pigment in the iris can occur, which may be permanent; particular care is required in those with mixed coloured irides and those receiving treatment to one eye only. Changes in eyelashes and vellus hair can also occur, and patients should also be advised to avoid repeated contact of the eye drop solution with skin as this can lead to hair growth or skin pigmentation. Treatment is not always necessary - in mild primary open angle glaucoma patients can be regularly monitored by an optometrist and referred for treatment when deemed necessary. Lifetime monitoring is required once treatment is commenced.

Answer 92

Orlistat 120 mg oral once a day

Answer 93

This question is about monitoring of antipsychotic drugs. According to the BNF: "It is advisable to monitor prolactin concentration at the start of therapy, at 6 months, and then yearly." Other monitoring tests required include Weight, BMI, blood pressure, U&E, LFTs, glucose, HbA1C, FBC, TFTs, lipids & ECG. A baseline Chest X Ray, Creatinine Kinase, Echocardiogram, or vitamin D are not required for monitoring antipsychotic drugs.

Answer 94

Clinical review should be carried out after a 3 month trial to achieve maximum effect from HRT. HRT does not require blood monitoring as the aim of treatment is the alleviation of symptoms.

Answer 95

## Footnote NOTE: terbinafine should not be given to children

Answer 96

Statins should be **avoided in pregnancy** (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.

Imperial PPQs Flashcards

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