Medicines 37

Question 1

What is spina bifida and how is it prevented?

Answer 1

Spina bifida is a neural tube defect where the spine and spinal cord fail to develop properly during early pregnancy, leading to a gap in the spinal column. This can cause nerve damage and physical disabilities ranging from mild to severe.

Prevention
The primary way to reduce the risk of spina bifida is by ensuring adequate folic acid (vitamin B9) intake before and during early pregnancy:

✅ Folic acid supplementation:

400 micrograms daily for women planning pregnancy and during the first 12 weeks of pregnancy (including obesity and endometriosis).

5 mg daily for high-risk women (e.g., previous neural tube defect pregnancy, diabetes, or taking antiepileptic drugs or have sickle-cell disease.).

Question 2

What does the acronym MDRD?

Answer 2

MDRD stands for “Modification of Diet in Renal Disease.”

It refers to the MDRD equation, which is used to estimate the glomerular filtration rate (eGFR) and assess kidney function. This formula takes into account serum creatinine, age, gender, and race to estimate kidney function in patients with chronic kidney disease (CKD).

Question 3

What are the side effects of glucocorticoids and mineral corticoids?

Answer 3

🔹 Mineralocorticoid Side Effects:

⬆ Hypertension

💧 Sodium & Water Retention

⬇ Potassium & Calcium Loss

📌 Most marked with: Fludrocortisone
📌 Significant with: Hydrocortisone, corticotropin, tetracosactide
📌 Negligible with: Betamethasone, dexamethasone
📌 Slight with: Methylprednisolone, prednisolone, triamcinolone

🔹 Glucocorticoid Side Effects:

🍬 Diabetes

🦴 Osteoporosis & Fractures (hip, vertebrae)

⚠ Avascular necrosis of femoral head

💪 Muscle wasting (proximal myopathy)

⚡ Psychiatric reactions

🩸 Weak link to peptic ulceration & perforation

Question 4

What is considered as the first line treatment for nocturnal enuresis?

Answer 4

Enuresis alarms are generally considered a first-line treatment for bedwetting

❌ Do not use an enuresis alarm if:

🚫 The child/parents do not want to use one.

💧 Bedwetting is less than 1–2 times per week.

😓 Parents struggle emotionally with the burden of bedwetting.

😠 Parents express anger, negativity, or blame toward the child.

👶 The child is under 7 years old and cannot use an alarm.

Question 5

What are the symptoms of Thrush?

Answer 5

✅ White, cottage cheese-like vaginal discharge (usually odorless)
✅ Itching & irritation around the vulva and vagina
✅ Soreness & stinging during sex or when urinating

🔹 Common triggers: Antibiotics, pregnancy, diabetes, weak immune system

Question 6

How do combined oral contraceptives (COCs) affect migraines?

Answer 6

COCs can:

⛔ Trigger or worsen migraines — especially during the pill-free interval when oestrogen levels drop.

⚠️ Increase the risk of stroke in people who have migraine with aura (especially if over 35 or a smoker).

Question 7

out of ropinorole and levodopa cause more impulse control disorders

Answer 7

Impulse control disorders (compulsive gambling, hypersexuality, binge eating, or obsessive shopping) can develop in a person with Parkinson’s disease who is on any dopaminergic therapy at any stage in the disease. Levodopa is also associated with impulse control disorders, however the answer reference given states: ‘Conversely, excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with dopamine-receptor agonists than with levodopa.’ Thus ropinirole is the best answer.

Question 8

What schedule is midazolam?

Answer 8

🔐 Schedule 3 (CD No Reg Required) —
Midazolam ✅ - NO CD cupboard

Temazepam ✅ - CD cupboard

Both require CD prescription requirements & safe custody.

📦 Schedule 4 Part I (CD Anab) — Minimal control
Diazepam

Lorazepam

Clonazepam

Nitrazepam

Oxazepam

No safe custody, no register entry, and CD Rx writing requirements do not apply (but still POMs).

Question 9

What causes oral herpes?

Answer 9

Oral herpes is known as herpes labialis.

Question 10

Which antihistamines are contraindicated with glaucoma?

Answer 10

First-generation (sedating) antihistamines are generally contraindicated or used with caution in patients with narrow-angle (angle-closure) glaucoma because they have anticholinergic effects that can increase intraocular pressure (IOP).

🚫 Examples (first-generation antihistamines):
Chlorphenamine

Promethazine

Diphenhydramine

Hydroxyzine

Cyclizine

Question 11

What is the treatment for addisons disease? (NICE)

Answer 11

💊 1. Glucocorticoid Replacement
✅ Hydrocortisone

Adults: 15–25 mg daily in divided doses.

Example: 10 mg on waking, 5 mg at noon, 5 mg early evening.

Alternatively: 15 mg AM, 10 mg PM (less preferred).

Children: 8–10 mg/m²/day (3–4 divided doses).

Dosing should match circadian rhythm (or wake/sleep cycle in shift workers).

Alternative: Prednisolone (if specialist prescribes it).

🧂 Mineralocorticoid Replacement
✅ Drug: Fludrocortisone

Adults: 50–200 micrograms daily.

Children: Higher requirement + may need salt supplements.

May need dose increase in hot climates due to salt loss via sweat.

⚙️ Androgen Replacement (Specialist only)
✅ Optional: DHEA (unlicensed)

Prescribed only if persistent fatigue or symptoms despite optimal therapy.

Managed by endocrinology.

Question 12

Which medication class stimulates insulin secretion by pancreatic beta cells

Answer 12

Sulphonylureas

Question 13

Which GLP-1 receptor agonists are licensed for weight loss?

Answer 13

Liraglutide (brand name Saxenda)

Semaglutide (brand name Wegovy)

Also Tirzapetide but is GIP aswell as GLP-1

Question 14

What are the recommended antibiotics for Hospital Acquired Pneumonia, both non severe and severe

Answer 14

💊 First-Line Oral Antibiotic (Non-Severe, Low Resistance Risk):
Co-amoxiclav
📌 500/125 mg TDS for 5 days, then review.

💊 Oral Alternatives (Penicillin Allergy or Co-amoxiclav Unsuitable):
(Based on microbiological advice + resistance data)

Doxycycline
📌 200 mg stat, then 100 mg OD for 4 days

Cefalexin ⚠️ (Caution in penicillin allergy)
📌 500 mg BD–TDS (up to 1–1.5 g TDS–QDS)

Co-trimoxazole ⚠️ (Off-label)
📌 960 mg BD

Levofloxacin ⚠️ (Off-label, only if IV switch)
📌 500 mg OD or BD

🔔 MHRA 2024 Warning:
Fluoroquinolones (e.g. levofloxacin) carry risks of long-term disabling side effects → use only if other options inappropriate.

💉 First-Line IV Antibiotics (Severe or High Resistance Risk):
Piperacillin with tazobactam
📌 4.5 g TDS–QDS

Ceftazidime
📌 2 g TDS

Ceftriaxone
📌 2 g OD

Cefuroxime
📌 750 mg TDS–QDS, up to 1.5 g QDS

Meropenem
📌 0.5–1 g TDS

Ceftazidime + Avibactam
📌 2/0.5 g TDS

Levofloxacin ⚠️ (Only if others unsuitable)
📌 500 mg OD or BD (higher dose if severe)

Question 15

How long is a trimester during pregnancy ?

Answer 15

12-14 weeks

Question 16

Which antibiotic is preferred for C diff reoccurrence (within 12 weeks)

Answer 16

Fidaxomicin PO
Rationale:

Recurrent CDI (within 12 weeks of a previous episode)
According to NICE and local guidelines, fidaxomicin is preferred over vancomycin for recurrent CDI as it has a lower recurrence rate due to its narrower spectrum and preservation of gut microbiota.

Question 17

Which antibiotics are contraindicated in myasthenia gravis

Answer 17

❌ Antibiotics Contraindicated or Caution in Myasthenia Gravis (Risk of Neuromuscular Blockade)
Avoid or use with caution due to potential worsening of muscle weakness or respiratory failure:

1. Aminoglycosides

Examples: Gentamicin, Amikacin, Tobramycin

Notes: High risk — may cause severe neuromuscular blockade; avoid unless essential.

2. Fluoroquinolones

Examples: Ciprofloxacin, Levofloxacin, Moxifloxacin

Notes: MHRA warning – can exacerbate myasthenia gravis; avoid if possible.

3. Macrolides

Examples: Erythromycin, Clarithromycin, Azithromycin

Notes: Can worsen symptoms — use with caution.

4. Tetracyclines

Examples: Doxycycline, Tetracycline

Notes: May impair neuromuscular transmission — use with caution.

5. Polymyxins

Examples: Colistin, Polymyxin B

Notes: High risk of neuromuscular blockade.

6. Penicillamine (not an antibiotic but relevant)

Notes: Known to induce or worsen myasthenia gravis — avoid.

Question 18

What is key to remember about amphotericin B

Answer 18

Anaphylaxis can occur with any intravenous amphotericin B product and a test dose is advisable before the first infusion in a new course; the patient should be carefully observed for at least 30 minutes after the test dose.

Question 19

which antifungals are contraindicated in heart failure due to a risk of worsening symptoms

Answer 19

Itraconazole has negative inotropic effects, which means it reduces the strength of heart muscle contractions.

This can exacerbate congestive heart failure (CHF), particularly at higher doses (e.g. 200 mg twice daily).

MHRA warning: Avoid itraconazole in patients with ventricular dysfunction or history of heart failure, unless the benefit outweighs the risk.

Question 20

What would the blood tests show for hyperthyroidism and hypothyroidism

Answer 20

Hyperthyroidism
TSH: Low

Free T4: High

Free T3: High

Hypothyroidism
TSH: High (Primary) or Low (Secondary)

Free T4: Low

Free T3: Low or Normal

Question 21

What are the typical symptoms of cystitis?

Answer 21

🔥😣 Pain, burning, or stinging when peeing

🚽⏰ Needing to pee more often and urgently than usual

🌫️💧 Pee that’s dark, cloudy, or strong-smelling

🤕⬇️ Pain low down in the tummy (lower abdominal pain)

Question 22

What is the treatment for day time sleepiness in Parkinsons Disease?

Answer 22

💊 Adjust Parkinson’s medication under specialist guidance

🚫 Rule out reversible causes (e.g., other drugs, physical conditions)

🌞😴 If persistent, consider MODAFANIL for excessive daytime sleepiness

🔄 Review modafinil treatment at least every 12 months

🚗 Patients should not drive, must inform the DVLA, and consider occupational risks

Question 23

Where is pain associated with the following conditions?
Appendicitis
Diverticulitis
Gastric ulcer
Irritable bowel syndrome
Renal colic

Answer 23

🩻 Appendicitis – Central abdominal pain that moves to the right lower quadrant (RLQ)

📉 Diverticulitis & IBS – Pain typically in the left lower quadrant (LLQ)

💥 Renal colic – Severe pain in the loin/flank, may radiate to groin

🔥 Peptic ulcer – Epigastric pain, may worsen on an empty stomach and improve with food

Question 24

When should HRT be stopped?

Answer 24

✅ A: Stop HRT if any of the following occur:

🔴 Cardiovascular / Respiratory

Sudden severe chest pain (even if not radiating)

Sudden breathlessness or coughing blood

Unexplained calf pain/swelling (DVT risk)

🟡 Gastrointestinal

Severe abdominal pain

🧠 Neurological

Unusual, severe or worsening headache

Sudden vision/hearing disturbances

Dysphasia, fainting, collapse

First seizure or stroke-like symptoms (e.g., one-sided weakness)

🧪 Liver

Signs of hepatitis, jaundice, or liver enlargement

🩺 Blood Pressure

Sustained BP >160/95 mmHg

🦵 Post-surgical or trauma

Prolonged immobility after surgery or leg injury

🚫 New contraindications

Discovery of a risk factor that contraindicates HRT

Question 25

What is Misoprostol, and what are its main actions and uses?

Answer 25

🧪 Class: Synthetic prostaglandin E1 analogue 🌟 Pharmacological Actions: 🔹 Gastrointestinal effects Antisecretory: Reduces gastric acid secretion Mucosal protection: Increases mucus and bicarbonate production → promotes healing of gastric and duodenal ulcers Often used for NSAID-induced ulcer prevention in at-risk patients 🔹 Uterotonic effects Acts as a potent uterine stimulant Stimulates uterine contractions and cervical softening (ripening) 💊 Clinical Uses: GI Protection Prevention and treatment of NSAID-induced ulcers Obstetric/Gynaecological Uses (under specialist supervision) Medical abortion (following mifepristone) Induction of labour (off-label in the UK) Management of postpartum haemorrhage (PPH) Missed or incomplete miscarriage