X2 Flashcards

Question

Answer 1

The correct answer is B, add furosemide 40mg daily while continuing spironolactone. In ascites due to cirrhosis, spironolactone is typically started first due to its aldosterone-antagonising effect, but if insufficient, furosemide is added to promote fluid loss and maintain electrolyte balance. A spironolactone to furosemide ratio of 100:40 is commonly used to balance potassium levels and minimise adverse effects. Monotherapy with furosemide is avoided due to the risk of hypokalaemia and worsening renal function. Increasing spironolactone further without furosemide is unlikely to achieve sufficient diuresis at this stage

Answer 2

The correct answer is C, aching and weakness in the legs. Statins, including atorvastatin, are associated with muscle-related side effects, ranging from myopathy to rhabdomyolysis. Patients should be counselled to report unexplained muscle pain, tenderness or weakness, particularly if accompanied by fever or malaise. Early recognition and stopping the statin are key to preventing progression to more severe toxicity. Other listed symptoms are either unrelated or not serious enough to stop therapy.

Answer 3

The correct answer is C, provide a delayed prescription with safety-netting advice. This patient has symptoms of a self-limiting viral upper respiratory tract infection. According to NICE and PHE antimicrobial prescribing guidelines, immediate antibiotics are not usually indicated unless red flags are present (e.g. very unwell, immunocompromised, or signs of bacterial infection). A delayed prescription is appropriate when symptoms are not severe but the patient is concerned, as it allows for antibiotics to be started if symptoms worsen or do not improve within 3-5 days, while promoting antibiotic stewardship. Safety-netting advice is essential.

Answer 4

The correct answer is D, advise nasal saline drops and reassure the mother. Most cough and cold remedies are not licensed for use in children under 6 years, and especially not in infants under 3 months. Products such as simple linctus or lemon and honey syrup are not licensed for this age group. Menthol-based vapour rubs can cause respiratory distress in very young infants and are generally licensed in those aged 2 years and over. Ibuprofen is not licensed under 3 months of age, and in the absence of fever or pain, there is no clinical indication. Nasal saline drops, which are licensed from birth, are the safest and most appropriate choice, alongside reassurance, as symptoms are likely to be viral and self-limiting.

Answer 5

The correct answer is B, budesonide/formoterol as required (AIR therapy). The updated asthma treatment algorithm now recommends starting with Anti- Inflammatory Reliever (AIR) therapy for newly diagnosed or mild asthma, using low- dose ICS/formoterol as both the reliever and anti-inflammatory. This simplifies treatment and addresses inflammation early. Symbicort Turbohaler 200/6 is the only UK-licensed product for AIR use. Options A and C reflect older stepwise approaches, while options D and E represent higher intensity MART regimens more appropriate for moderate or poorly controlled asthma, not mild cases.

Answer 6

The correct answer is E, signs of high blood sugar such as excessive thirst and urination. Olanzapine is associated with a high risk of metabolic side effects, including hyperglycaemia, weight gain, and diabetes mellitus. Patients should be counselled to monitor for signs such as increased thirst, frequent urination, fatigue, or unexplained weight loss, and to seek prompt medical advice if these occur. While other side effects such as sedation or restlessness (e.g. akathisia) may occur, metabolic complications are often silent until severe, making early counselling critical.

Answer 7

The correct answer is C, Take the tablets on an empty stomach, ideally with orange juice. Iron absorption is maximised when taken on an empty stomach and enhanced by vitamin C, which is found in orange juice. Tea and milk can reduce absorption due to their calcium and tannin content. Although gastrointestinal discomfort is common, the best approach is not to reduce the dose unless necessary, but rather to manage timing and co-administration. It can be taken after food to reduce gastro-intestinal side-effects if necessary

Answer 8

The correct answer is A, Report all adverse reactions, regardless of severity, for newly licensed medicines. For newly licensed medicines—identified by a black triangle on their SmPC—the MHRA encourages healthcare professionals and patients to report all suspected adverse drug reactions (ADRs), regardless of severity or whether they are already listed in the SmPC. This comprehensive reporting helps the MHRA to gather additional safety data during the post-marketing surveillance period. Mild reactions, such as injection site irritation and transient headaches, though not clinically serious, contribute to a complete safety profile and are therefore important to report. Options B through E restrict reporting based on severity, timing, or clinical consequence, which does not align with the MHRA's recommendation that all ADRs should be reported for new medicines.

Answer 9

The correct answer is C, Coarse tremor. Coarse tremor is a classic neurological sign of lithium toxicity, typically accompanied by symptoms such as confusion, ataxia, slurred speech, and sometimes seizures or coma at higher levels. The risk of lithium toxicity increases significantly when interacting medicines such as thiazide diuretics (e.g. bendroflumethiazide) or ACE inhibitors are introduced, as they reduce renal clearance of lithium.

Answer 10

The correct answer is C, Paroxetine withdrawal reaction. Paroxetine is associated with significant withdrawal symptoms due to its short half- life and high serotonin reuptake inhibition. Stopping paroxetine suddenly can lead to symptoms such as dizziness, electric shock sensations ("brain zaps"), irritability, mood changes, and flu-like symptoms. These symptoms are not due to serotonin syndrome (which occurs during use or overdose), nor do they suggest new bipolar disorder or hyponatraemia. Gradual tapering under medical supervision is essential to prevent withdrawal reactions.

Answer 11

The correct answer is C, 8mL. Recommended dose = 20mg/kg × 20kg = 400mg per dose Amoxicillin suspension strength = 250mg in 5mL → 50mg/mL Volume required per dose = 400mg ÷ 50mg/mL = 8mL This is the correct amount to administer three times daily for 5 days.

Answer 12

The correct answer is D, 2 years. Under the Human Medicines Regulations 2012, any signed order for the supply of a POM medicine (such as co-codamol 15/500) for use in a professional setting (e.g. podiatrist clinics) must be retained for at least 2 years from the date of supply. This is to ensure a traceable record is available for inspection and audit purposes. The signed order must include the professional’s details and the exact quantity supplied.

Answer 13

The correct answer is C, Lactulose oral solution. In pregnancy, bulk-forming laxatives are considered first-line, but if ineffective, osmotic laxatives such as lactulose are considered safe and effective. Stimulant laxatives like senna or bisacodyl are generally reserved for short-term use and may cause uterine contractions in high doses. Docusate can be considered, but lactulose has a longer track record of safe use in pregnancy.

Answer 14

The correct answer is D, Flunitrazepam 1mg tablets. Under the Misuse of Drugs (Safe Custody) Regulations 1973, Schedule 2 controlled drugs, except for quinalbarbitone (secobarbital) and certain Schedule 3 controlled drugs must be stored in a locked CD cabinet in community pharmacies. Although Schedule 3 drugs are generally exempt from safe custody requirements, there are exceptions. The following Schedule 3 drugs do require safe custody: * Buprenorphine * Diethylpropion * Flunitrazepam * Temazepam

Answer 15

The correct answer is D, do not dispense and contact the prescriber before supplying any dose. According to national guidelines (e.g. Drug misuse and dependence: UK guidelines on clinical management), if a patient misses three or more consecutive days of methadone treatment, there is a significant risk of loss of tolerance and potential overdose upon resumption of the usual dose. In such cases, pharmacists must not supply methadone without first consulting the prescriber, who will assess the need for dose reduction or re-titration. Pharmacists have a legal and professional responsibility to withhold supply and contact the prescriber immediately if a patient has missed three or more consecutive doses of methadone or buprenorphine.

Answer 16

The correct answer is E, Wash monthly in warm soapy water, allow to air-dry without rinsing or wiping. Spacer devices should be cleaned about once a month using warm soapy water, but importantly, should not be rinsed or wiped dry. Rinsing or drying the inside of the spacer can lead to static build-up, which reduces the amount of medication delivered to the lungs. Instead, they should be left to air dry naturally in a vertical position, which helps preserve the effectiveness of the device.

Answer 17

The correct answer is C, Filgrastim. Filgrastim is a recombinant granulocyte-colony stimulating factor (G-CSF) used to reduce the duration and severity of neutropenia in patients undergoing chemotherapy. It works by stimulating the bone marrow to increase neutrophil production. Methotrexate is an immunosuppressant and cytotoxic drug used in various malignancies and autoimmune conditions, but it is not appropriate for treating neutropenia. Epoetin alfa and darbepoetin alfa stimulate red blood cell production, not white cells. Rituximab targets B-cells in lymphomas and autoimmune diseases, but it does not increase neutrophil counts.

Answer 18

The correct answer is E, Benzydamine hydrochloride oral rinse. Benzydamine is a locally acting analgesic and anti-inflammatory that provides symptomatic relief for painful mouth ulcers. Corticosteroid lozenges are already being used, and systemic corticosteroids like prednisolone are not typically first-line unless ulcers are severe and persistent. Antibacterial (amoxicillin) and antifungal (fluconazole, nystatin) treatments are not appropriate unless there is clear evidence of secondary infection. Benzydamine rinse can be used as an adjunct for pain relief during ulcer flare-ups

Answer 19

The correct answer is B, Vitamin B12. Vitamin B12 deficiency can lead to a range of symptoms including recurrent aphthous mouth ulcers, fatigue, and neurological symptoms such as paresthesia (pins and needles). This deficiency is common in older adults and individuals with dietary restrictions or malabsorption issues. Other vitamin deficiencies can cause mucosal changes or fatigue, but B12 is the most closely linked to both the oral and neurological symptoms Mr P is experiencing.

Answer 20

The correct answer is C, Metformin. Metformin should be temporarily withheld during episodes of acute illness such as vomiting or diarrhoea due to the risk of lactic acidosis, especially when dehydration or impaired renal function is possible. According to national sick day guidance, medicines such as ACE inhibitors, ARBs, diuretics, NSAIDs, and metformin should be stopped temporarily until the patient recovers and is able to eat and drink normally. In contrast, atorvastatin, amlodipine, and lansoprazole do not pose an immediate risk in this scenario and do not need to be withheld.

Answer 21

Ispaghula husk is a bulk-forming laxative and is generally not appropriate for managing constipation in palliative care or in patients with reduced mobility, advanced disease, or opioid-induced constipation, particularly when there is inadequate fluid intake or risk of bowel obstruction. It can worsen symptoms such as bloating and abdominal discomfort. In contrast: * Lactulose (an osmotic laxative) and senna (a stimulant laxative) are commonly used for opioid-induced constipation. * Docusate sodium has both stool-softening and mild stimulant properties. * Naloxegol, a peripherally acting µ-opioid receptor antagonist, may be considered for opioid-induced constipation when conventional laxatives are inadequate. Therefore, ispaghula husk is least appropriate in this clinical scena

Answer 22

The correct answer is C, Short-acting beta-2 agonist (SABA). According to NICE guidelines and GOLD recommendations, the first-line treatment for acute symptom relief in patients with COPD, especially during a presentation without signs of infection or exacerbation, is a short-acting bronchodilator, such as salbutamol. * Oral corticosteroids are reserved for acute exacerbations with worsening symptoms and signs of inflammation. * LAMA and LABA inhalers are used for maintenance therapy, not acute relief. * Theophylline is rarely used due to its narrow therapeutic index and is not recommended as initial therapy. Therefore, a SABA is the most appropriate choice for initial management in this case.

Answer 23

The correct answer is E, 150/90 mmHg. According to NICE NG136 guidelines, the clinic blood pressure target for adults aged 80 years and over is below 150/90 mmHg. A lower target (e.g. 140/90 mmHg) applies to younger adults under the age of 80. This patient’s blood pressure of 142/88 mmHg meets the target, but his symptoms of postural hypotension may indicate overtreatment or the need to review timing of administration and standing BP. Therefore, 150/90 mmHg remains the most appropriate clinical target for his age group.

Answer 24

The correct answer is B, Felodipine modified-release. Felodipine is a modified-release calcium-channel blocker designed to release the drug slowly over time. Crushing modified-release tablets can destroy the formulation, resulting in dose dumping, an increased risk of adverse effects, and toxicity. It must not be crushed for NG tube administration. The NEWT guidelines should be consulted to determine appropriate NG tube administration advice. Paracetamol, chlorphenamine, betahistine, and acetazolamide can generally be crushed or dispersed unless stated otherwise in the product’s SPC.

Answer 25

The correct answer is E, Isophane insulin. NICE guidance recommends that insulin therapy should be initiated immediately in women diagnosed with gestational diabetes who have a fasting plasma glucose level above 7.0 mmol/L at the time of diagnosis. Insulin can be started with or without metformin, but it remains the primary treatment of choice in this context due to the increased risk of complications with higher fasting glucose levels. Metformin may be used if fasting plasma glucose is below 7.0 mmol/L and dietary measures fail. Gliclazide, pioglitazone, and exenatide are not recommended during pregnancy due to safety concerns.

Answer 26

The correct answer is A, When two different eye preparations must be used at the same time, leave an interval of at least 5 minutes between each eye drop When administering multiple topical ophthalmic preparations, patients should be advised to leave at least a 5-minute gap between each different eye drop to prevent one from diluting or washing out the other. This helps ensure optimal absorption and therapeutic effect.

Answer 27

The correct answer is C, lercanidipine hydrochloride. According to NICE NG136 on hypertension management, patients of Black African or African–Caribbean family origin without type 2 diabetes should be offered a calcium- channel blocker (CCB) as first-line therapy. ACE inhibitors, such as ramipril, are less effective in this population due to lower renin activity. Lercanidipine, a dihydropyridine CCB, is an appropriate choice.

Answer 28

The correct answer is A, Anusol Plus HC ointment. Anusol Plus HC contains hydrocortisone and lidocaine and is available as a pharmacy (P) medicine without the need for a prescription. This makes it the most suitable OTC option for a patient seeking similar symptomatic relief to Anugesic-HC, which also contains a corticosteroid and local anaesthetic. The other listed products (Xyloproct, Ultraproct, Uniroid-HC, and Scheriproct) are all prescription-only medicines (POMs) and cannot legally be supplied without a prescription.

Answer 29

The correct answer is E, omeprazole interacts with clopidogrel to reduce the antiplatelet effect of clopidogrel. This interaction is clinically significant and well-documented. Omeprazole inhibits CYP2C19, the enzyme responsible for converting clopidogrel (a prodrug) into its active form. This can lead to reduced antiplatelet activity and increased cardiovascular risk, particularly in patients using clopidogrel for secondary prevention after events like stroke or myocardial infarction.

Answer 30

The correct answer is A, at least 6 hours after an oral dose has been administered. Plasma digoxin levels should be measured at least 6 hours post-dose to allow for proper tissue distribution, avoiding falsely elevated readings. Measuring levels too early can misrepresent the true steady-state concentration. This is particularly important due to digoxin’s narrow therapeutic index. In patients with heart failure who remain symptomatic despite standard treatment and are in sinus rhythm, digoxin may be used as a third-line option to improve symptoms and reduce hospital admissions.

Answer 31

The correct answer is D, advise Mr L that he is experiencing a side effect of isosorbide mononitrate; it is safe to continue taking it, but he may wish to see his GP if the headaches persist. Throbbing headache is a common and well-recognised adverse effect of nitrate therapy, including isosorbide mononitrate. It usually occurs early in treatment and often subsides with continued use as tolerance develops. Patients should be reassured that it is a known effect, and advised not to stop the medication abruptly without medical review, especially since it is being used for angina prophylaxis. If the headaches remain troublesome, the GP may consider a dose adjustment or switch to a different anti-anginal agent.

Answer 32

The correct answer is B, Sell one spray at a cost price plus retail mark-up, and make no records. Nitrolingual® Spray (glyceryl trinitrate) is classified as a Pharmacy (P) medicine. This means it can be sold without a prescription under the supervision of a pharmacist, provided the pharmacist is satisfied that it is for a genuine clinical need and the supply is safe and appropriate. Since this patient has been prescribed the medicine previously and confirms continued need, it is lawful and appropriate to sell it as a P medicine. There is no legal requirement to make a record of this sale in the prescription-only medicine (POM) register as it is not a POM. Emergency supply provisions are not applicable here because the product is not prescription-only.

Answer 33

The correct answer is B, Contemplation. In the Cycle of Change (used to understand stages of behavioural change), the contemplation stage refers to when a person recognises there is a problem and begins to consider taking action. This stage typically involves ambivalence—acknowledging the negative consequences of the behaviour while also feeling uncertain or not yet committed to change. In this scenario, the patient has become aware of the seriousness of his heroin use following an overdose and is seeking advice, which demonstrates readiness to reflect and possibly act, but he has not yet started treatment. This aligns with contemplation. * Pre-contemplation would apply if he had no recognition of a problem. * Action would apply if he had already started therapy or made concrete steps toward quitting. * Lapse and relapse refer to returning to previous behaviours after an attempt to stop.

Answer 34

The correct answer is A, Hypoglycaemia. Phenytoin overdose presents with dose-related neurological symptoms, especially as plasma levels rise. Common signs of toxicity include: * Nystagmus (involuntary eye movements) * Ataxia (loss of coordination) * Confusion * Diplopia (double vision) These are consistent with the drug’s central nervous system depressant effects. Hypoglycaemia is not associated with phenytoin toxicity and is therefore not a typical feature. On the contrary, phenytoin can inhibit insulin release and may occasionally cause hyperglycaemia, not low blood sugar

Answer 35

The correct answer is D, £1000. According to the DVLA guidelines, people with medical conditions such as epilepsy must notify the DVLA if the condition may affect their ability to drive safely. Failing to do so is a criminal offence and can lead to a fine of up to £1000. Additionally, if an individual withholds this information and is subsequently involved in an accident, prosecution may follow. This regulation exists to ensure public and personal safety on the road.

Answer 36

The correct answer is C, 12 months. According to DVLA medical standards, a person with epilepsy may apply for a Group 1 driving licence (cars and motorcycles) only if they have been seizure-free for at least 12 months, regardless of whether they are on antiepileptic medication. This rule helps ensure public safety and allows the DVLA to assess the likelihood of seizure recurrence. If Miss R has been seizure-free for less than 12 months, her application would be declined, and she must wait until she meets the minimum threshold before reapplying.

Answer 37

The correct answer is E, Alendronic acid. In patients recovering from an acute coronary syndrome (ACS) such as a myocardial infarction, the standard discharge medications typically include: * Dual antiplatelet therapy (DAPT): Aspirin plus a P2Y12 inhibitor (e.g., clopidogrel) for at least 12 months to reduce the risk of further thrombotic events. * Beta-blocker (e.g., bisoprolol): To reduce cardiac workload and prevent arrhythmias. * ACE inhibitor (e.g., ramipril): To improve long-term cardiac outcomes, especially in patients with reduced left ventricular function. * High-intensity statin (e.g., atorvastatin): To manage cholesterol and reduce cardiovascular risk. Alendronic acid, a bisphosphonate used to treat or prevent osteoporosis, would not typically be prescribed in the absence of a bone health concern or corticosteroid use. It is unrelated to the management of ACS and therefore is the least appropriate medication on this discharge list.

Answer 38

Flucloxacillin is a penicillin-based antibiotic that is poorly absorbed if taken with food, as food significantly reduces its bioavailability. To ensure therapeutic efficacy, it is advised that flucloxacillin be taken on an empty stomach.

Answer 39

The correct answer is D, Low molecular weight heparin (LMWH). According to RCOG guidelines, low molecular weight heparin (LMWH) is the preferred thromboprophylactic agent during pregnancy and the postpartum period for women who are hospitalised and at risk of venous thromboembolism (VTE). * LMWH does not cross the placenta and has a well-established safety profile in pregnancy. * Warfarin is contraindicated in pregnancy due to its teratogenicity, particularly during the first trimester. * Edoxaban and other DOACs (direct oral anticoagulants) are also not recommended in pregnancy due to limited safety data. * Aspirin and clopidogrel are antiplatelet agents, not suitable or recommended for standard VTE prophylaxis in pregnancy.

Answer 40

The correct answer is E, Reduced risk of dementia. Combined hormonal contraceptives (CHCs) have multiple recognised non- contraceptive benefits, including: * Reduced risk of endometrial and ovarian cancer * Improved control of menstrual-related symptoms such as dysmenorrhoea and menorrhagia * Improvement in acne in some women due to suppression of androgens * Cycle regulation and reduction of premenstrual syndrome symptoms However, reduced risk of dementia is not an evidence-based benefit of CHC use. In fact, some studies have raised concerns over the long-term cognitive effects of hormonal therapies, though data remains inconclusive.

Answer 41

The correct answer is B, Sudden disturbance of vision. Key clinical warning signs that warrant discontinuation include: * Sudden disturbances of vision, hearing, or other perceptual disorders * First-time or worsening migraine or unusually severe headaches * Signs suggestive of thrombosis: leg pain/swelling, stabbing chest pain, shortness of breath * Liver dysfunction: jaundice, severe upper abdominal pain, or liver enlargement * Surgical risk: Planned major surgery or immobilisation * Significant rise in blood pressure * Exacerbation of pre-existing conditions that worsen during hormonal use

Answer 42

The correct answer is D, Fluticasone nasal spray. For patients presenting with nasal congestion alongside sneezing and watery eyes, intranasal corticosteroids such as fluticasone are considered the most effective treatment option. They address both inflammatory symptoms and congestion, which antihistamines alone may not fully relieve. Given the patient is a student with upcoming exams, sedating antihistamines like chlorphenamine and promethazine are unsuitable due to their potential to impair cognitive function. Loratadine and cetirizine are non-sedating antihistamines but are generally less effective at relieving nasal congestion compared to intranasal steroids. Therefore, fluticasone nasal spray provides optimal symptom relief without sedation, making it the most appropriate recommendation in this case

Answer 43

The correct answer is A, Bonjela Cool Mint®. Bonjela Cool Mint® contains salicylate, a derivative of aspirin, which is not suitable for children under 16 years due to the risk of Reye’s syndrome, a rare but serious condition. It is specifically contraindicated in infants and young children, making it the least appropriate option in this scenario. Other products such as Calgel®, Anbesol®, and Teetha® are licensed for use in teething infants and contain local anaesthetics or herbal ingredients to provide temporary relief from teething pain. Ashton and Parsons Infant Powder® is also considered suitable for infants and is commonly used during teething episodes, though its evidence base is limited. For infants under 6 months, it is crucial to only recommend products that are specifically licensed for use in that age group, and Bonjela Cool Mint® does not meet that criterion

Answer 44

The correct answer is E, Refer her to the GP for further investigation and prompt treatment. Pregnant women with suspected urinary tract infection (UTI), including symptoms such as dysuria, urgency, and frequency, must be referred to their GP without delay for further investigation and appropriate antibiotic treatment. Untreated UTIs in pregnancy can progress to pyelonephritis or cause complications such as preterm labour or low birth weight. While products such as paracetamol can relieve pain, and urinary alkalinisers (e.g. sodium citrate or potassium citrate) are often used for symptom relief in non- pregnant patients, these do not treat the underlying infection and are not routinely recommended in pregnancy. Furthermore, cranberry products and urine alkalinisers are not recommended by NICE CKS for UTI management in pregnancy. Prompt referral ensures appropriate diagnosis and antibiotic therapy, aligned with national guidance for safe care in pregnancy.

Answer 45

The correct answer is D, Provide advice in relation to ‘sleep hygiene’. For adults with short-term insomnia and no underlying medical condition, the first-line approach should always focus on non-pharmacological interventions, particularly good sleep hygiene practices. These include maintaining a consistent bedtime routine, avoiding caffeine and electronic screens before bed, and ensuring the sleep environment is quiet and comfortable. Promethazine, an OTC sedating antihistamine, may sometimes be used for short- term sleep disturbances but should not be the first-line option due to risk of side effects and tolerance. Melatonin is a prescription-only medicine in the UK and is generally reserved for older adults or specific sleep disorders under medical supervision. Acrivastine is a non-sedating antihistamine and is not effective for sleep. Referral for drug misuse is inappropriate here as there is no indication of substance misuse in the scenario. Providing tailored lifestyle advice remains the most appropriate and safest approach for this patient at this stage.

Answer 46

The correct answer is D, 72 hours. Under the Human Medicines Regulations 2012, when a pharmacist makes an emergency supply at the request of a prescriber, the prescriber must provide a written prescription within 72 hours of the supply. This applies even if the prescriber is not the patient’s usual doctor, as long as they are able to provide the appropriate prescription within the required legal timeframe. In this case, a salbutamol inhaler is not a Controlled Drug and can be supplied in an emergency without a prescription, provided all conditions are met — including the prescriber undertaking to provide a prescription within 72 hours. The pharmacist must record the supply in the Prescription-Only Medicine (POM) register at the time of supply.

Answer 47

Colchicine is a recommended option for treating acute gout, particularly in elderly patients or those with comorbidities such as cardiovascular disease, hypertension, or benign prostatic hyperplasia, where NSAIDs may be contraindicated or poorly tolerated. It should be used with caution in renal impairment, and the maximum dose is 1.5mg per course, typically 500 micrograms two to four times a day until symptom relief or maximum dose is reached. * Ketorolac, while a potent NSAID, is not recommended for the treatment of acute gout. It is generally used only for short-term moderate to severe pain in hospital settings (e.g. postoperative pain) and should not be used for more than 2 days due to its high risk of gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients. * Diclofenac is an NSAID that can be used in acute gout but is less suitable in older adults with cardiovascular disease. * Allopurinol and febuxostat are urate-lowering therapies used for long-term prevention of gout, not for acute flares.

Answer 48

The correct answer is C, 3 sprays. The standard guidance for GTN spray in angina is to use one or two sprays under the tongue at the onset of chest pain. If the pain does not resolve after 5 minutes, a second dose can be used. If the pain persists 5 minutes after the second dose, a third and final spray may be used. If there is no improvement after three sprays within 15 minutes, the patient should call 999 for an ambulance immediately.

Answer 49

Cyclophosphamide. Cyclophosphamide is a well-known cause of haemorrhagic cystitis due to its metabolite acrolein, which is excreted in urine and irritates the bladder mucosa. Methotrexate and doxorubicin are associated with other toxicities but not specifically haemorrhagic cystitis. Cisplatin is nephrotoxic but not associated with this particular condition.

Answer 50

The correct answer is A, Mesna. Mesna (mercaptoethane sulfonate) is routinely co-administered with cyclophosphamide or ifosfamide to neutralise acrolein in the bladder and prevent urotoxicity. It binds to acrolein, rendering it inactive, and thereby protects the urothelium.

Answer 51

Acrolein is the toxic metabolite of cyclophosphamide and ifosfamide that causes direct irritation and inflammation of the bladder lining, leading to haemorrhagic cystitis. Preventive strategies are essential in patients receiving high-dose cyclophosphamide.

Answer 52

The correct answer is D, 12 weeks. According to the NHS childhood immunisation schedule, the 6-in-1 vaccine is administered at 8, 12, and 16 weeks of age. The second dose is due 4 weeks after the first, making 12 weeks the correct interval for the next administration. Giving the vaccine too early may reduce the effectiveness and not align with the established immunisation schedule.

Answer 53

The correct answer is B, lay him on his back and raise his legs. This patient is breathing and has a pulse, which means CPR is not appropriate. The best first aid response for a person who has fainted but is breathing is to lay them on their back and elevate the legs. This position helps restore blood flow to the brain and can aid in recovery from fainting (syncope). Administering sugar-based products (such as honey) is only appropriate for conscious hypoglycaemic patients. Massaging or rubbing parts of the body is not a recommended or evidence-based emergency intervention for fainting.

Answer 54

The correct answer is E, Levomepromazine. Levomepromazine is commonly used in palliative care as a broad-spectrum anti- emetic and is effective in patients where other agents, such as haloperidol, have failed. It is particularly beneficial when nausea and vomiting are multifactorial or when centrally acting causes are suspected. It also has sedative properties, which can be helpful in the palliative context.

Answer 55

The correct answer is D, Ondansetron. Ondansetron is a 5HT3 receptor antagonist with minimal renal clearance, making it appropriate for patients with significant renal impairment. It is effective for controlling nausea and vomiting and does not pose the same risks of extrapyramidal side effects or QT prolongation at standard doses when compared to some other agents.

Answer 56

The correct answer is B, Domperidone. Domperidone is considered safer in Parkinson’s disease as it does not cross the blood-brain barrier, reducing the risk of worsening extrapyramidal symptoms. Alternatives like metoclopramide or haloperidol are dopamine antagonists that may worsen motor symptoms and should be avoided

Answer 57

The correct answer is A, swollen ankle. Amlodipine is a calcium channel blocker associated with peripheral oedema, especially swollen ankles. This occurs due to vasodilation of arterioles without corresponding venodilation, leading to capillary fluid leakage.

Answer 58

The correct answer is B, rhabdomyolysis. This patient is on simvastatin 40mg and amlodipine — a known interaction that increases the risk of statin-induced myopathy and rhabdomyolysis. The simvastatin dose should not exceed 20mg when used with amlodipine.

Answer 59

The correct answer is E, erectile dysfunction. Thiazide diuretics like bendroflumethiazide are known to cause erectile dysfunction as a side effect due to decreased vascular perfusion and potential psychological impacts.

Answer 60

The correct answer is A, sumatriptan. Sumatriptan, a serotonin (5HT1) receptor agonist used for acute migraine, may cause drowsiness. Patients should be cautioned that if affected, they should avoid driving or operating machinery.

Answer 61

Alendronic acid must be taken with a full glass of water, on an empty stomach, while sitting or standing upright. Patients should remain upright for at least 30 minutes post-dose to minimise the risk of oesophageal irritation and ulceration.

Answer 62

Doxycycline absorption is impaired by divalent and trivalent cations found in indigestion remedies and supplements (e.g., calcium, iron, zinc). Patients should avoid these for at least 2 hours before or after taking doxycycline to prevent reduced effectiveness.

Answer 63

The correct answer is C, furosemide. Furosemide is a loop diuretic recommended to manage fluid overload in patients with heart failure. It is effective for symptom relief in those experiencing oedema or breathlessness and is suitable in patients with normal renal and liver function.

Answer 64

Carvedilol is one of the three beta-blockers (alongside bisoprolol and nebivolol) licensed for the treatment of chronic heart failure. It is often initiated at 3.125mg twice daily and titrated upwards depending on clinical response and tolerability.

Answer 65

This combination is recommended for patients with heart failure who cannot tolerate ACE inhibitors or ARBs, due to side effects such as a persistent dry cough. It is especially beneficial in patients with hypertension and systolic dysfunction.

Answer 66

The correct answer is A, paracetamol. Paracetamol overdose is associated with hepatotoxicity due to accumulation of the toxic metabolite NAPQI. Clinical signs include right upper quadrant pain, hypoglycaemia, and encephalopathy in severe cases. Early treatment with acetylcysteine is critical to prevent liver failure.

Answer 67

The correct answer is F, morphine. Codeine is a prodrug that is metabolised in the liver via CYP2D6 to its active form, morphine. Approximately 10–15% of the administered dose is converted into morphine, meaning 240mg of codeine yields roughly 30mg of morphine in an average metaboliser.

Answer 68

The correct answer is H, aspirin. Aspirin is contraindicated in children under 16 years due to the risk of Reye’s syndrome, a rare but serious condition that causes swelling in the liver and brain. Safer alternatives such as paracetamol or ibuprofen should be used in this age group instead.

Answer 69

Tiotropium is a long-acting muscarinic antagonist (LAMA) used in the management of chronic obstructive pulmonary disease (COPD) to reduce exacerbations and improve breathlessness. It is often added when inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combinations such as Seretide® are insufficient on their own

Answer 70

Ipratropium is a short-acting muscarinic antagonist (SAMA) with a typical duration of action of 4–6 hours. A bitter or metallic taste is a commonly reported side effect associated with ipratropium when administered via MDI.

Answer 71

The correct answer is H, prednisolone. Prednisolone is often included in COPD rescue packs for managing acute exacerbations. The dosing regimen described (six tablets immediately followed by six daily) aligns with a 5-day course of 30mg daily, which is the standard short-term treatment for COPD exacerbations to reduce inflammation and improve symptoms.

Answer 72

The correct answer is H, ramipril. According to NICE hypertension guidelines, for adults under the age of 55 with no Black African or Caribbean heritage, a renin–angiotensin system (RAS) inhibitor such as an ACE inhibitor (e.g., ramipril) is first-line. In this case, the patient is a 49- year-old Caucasian woman, so ramipril is appropriate. Amlodipine would be preferred in those over 55 or of Black African/Caribbean origin

Answer 73

The correct answer is B, clopidogrel. Clopidogrel is an antiplatelet agent used for the prevention of arterial thrombosis, particularly in the context of acute coronary syndromes and stroke prevention. It is not suitable for the treatment of venous thromboembolism (VTE) such as deep vein thrombosis. The appropriate agents for DVT include low molecular weight heparins (e.g., enoxaparin, dalteparin, tinzaparin), unfractionated heparin, and direct oral anticoagulants (e.g., apixaban, rivaroxaban, dabigatran).

Answer 74

The correct answer is E, hyperkalaemia. Spironolactone is a potassium-sparing diuretic that inhibits aldosterone, reducing sodium reabsorption and potassium excretion. It is contraindicated in patients with hyperkalaemia or at risk of developing hyperkalaemia due to the increased danger of life-threatening arrhythmias. Routine monitoring of serum potassium is essential, especially at higher doses or in patients with impaired renal function.

Answer 75

The correct answer is F, recommend the doctor to stop the drug immediately. Severe bruising and haematuria are signs of serious bleeding, which may be due to warfarin toxicity and an elevated INR. In such cases, immediate cessation of warfarin is required, along with urgent medical evaluation and possible administration of vitamin K or reversal agents. While INR testing is essential, the presence of active bleeding warrants immediate interruption of anticoagulation therapy as a safety-first response.

Answer 76

The correct answer is H, Tolbutamide. In patients with moderate renal impairment (eGFR 30–60 mL/min), glibenclamide should be avoided due to its long half-life and increased risk of prolonged hypoglycaemia. Tolbutamide is a short-acting sulphonylurea and is generally safer in patients with CKD as it is less renally cleared. It is important to individualise treatment based on renal function and hypoglycaemia risk.

Answer 77

The correct answer is D, Epoetin alfa. Anaemia in patients with end-stage chronic kidney disease is frequently caused by a deficiency in erythropoietin production. This patient’s iron levels are adequate, and she is not bleeding, making epoetin alfa, a synthetic erythropoiesis-stimulating agent (ESA), the most appropriate treatment. Epoetin alfa helps stimulate red blood cell production in the bone marrow.

Answer 78

Hydoxycobalamin - pernicious anaemia leads to vitamin b12 deficiency due to impaired absorption. Hydoxycobalamin, given intramuscularly, is the treatment choice for b12 deficiency in the UK. Cyanocobalamin is used orally in dietary deficiencies but pernicious anaemia requires parenteral administration

Answer 79

The correct answer is G, Coeliac dietary advice. This patient likely has coeliac disease, as suggested by positive tTG antibodies and symptoms of malabsorption. The first step in management is referral for a confirmatory biopsy; however, initial dietary counselling and patient education are essential. Patients should not start a gluten-free diet until biopsy is performed, but discussing the importance of a gluten-containing diet and what coeliac disease involves is vital.

Answer 80

This patient is showing signs of a mild to moderate flare-up of ulcerative colitis, with blood and mucus in the stool. Mesalazine, a 5-aminosalicylic acid (5-ASA) compound, is the first-line treatment for inducing and maintaining remission in mild- to-moderate UC. Anti-motility agents like loperamide are contraindicated in active UC due to the risk of toxic megacolon. Laxatives and acid suppressants are not relevant in this scenario.

Answer 81

In pregnant women with hyperthyroidism, propylthiouracil is preferred during the first trimester due to the teratogenic risk associated with carbimazole. After the first trimester, patients may be switched back due to the risk of hepatotoxicity with propylthioruacil

Answer 82

The correct answer is H, Hydrocortisone. This patient is likely experiencing an Addisonian crisis, a life-threatening emergency due to acute adrenal insufficiency. Immediate administration of IV hydrocortisone and fluid resuscitation is critical. Prednisolone is not appropriate in this emergency setting due to its slower onset and oral route. Levothyroxine, sitagliptin, and antithyroid agents are not appropriate for adrenal insufficiency.

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