Question: 1 of 100 / Overall score: 100%A 70-year-old man presented with increasing dyspnoea. In his history, he had suffered a myocardial infarction two years previously which had been complicated by ventricular arrhythmias. At admission his oxygen saturations were 85% on air and a chest X-ray revealed bilateral patchy infiltration of both lung fields with a cardiothoracic ratio of 20/30 cm. Which of the following drugs that he has been prescribed is most likely to explain these findings?(Please select an option)

Amiodarone Correct

Atorvastatin

Aspirin

Furosemide

Ramipril This patient has desaturation with patchy infiltration on CXR suggesting a diagnosis of amiodarone-induced lung disease. Usually the presentation is insidious and the disorder associated with the cumulative dose. Treatment depends on withdrawing amiodarone and initiation of steroid therapy. Differential diagnosis is any lymphangitis/pnemonitis but High resolution CT can help by demonstration of radio-dense plaques etc.Question: 2 of 100 / Overall score: 100%Imidazoline receptorsTrue / False

are found in the medulla Correct

stimulation leads to increased sympathetic activity Correct

stimulation leads to reduced arterial blood pressure Correct

stimulation leads to increased excretion of sodium and water Correct

have a physiological role in haemorrhagic shock Correct a-also kidneys and adrenal b-stimulation leads to decreased central and peripheral sympathetic activity c-this is the action of the antihypertensive drug moxonidine d-the action of I1 receptors in the kidney e-no physiological role identified nor any natural endogenous ligand has been found. They may somehow be involved in the 'metabolic syndrome' - hyperglycaemia, hyperlipidaemia and insulin resistance. (Drugs and Therapeutics Bulletin 1997;35(5):33-36 and Lancet Jan 17. 1998) Question: 3 of 100 / Overall score: 87%The following are features of poisoning with organo-phosphorous insecticidesTrue / False

the effects may follow eating contaminated fruit Correct the acute symptoms and signs are due to widespread cytotoxic damage in the nervous system Incorrect answer selected incontinence of urine or faeces is an early manifestation Correct

flaccid paralysis of the limbs may occur some weeks after exposure Correct the use of penicillamine reduces structural damage and leads to gradual recovery

Incorrect answer selected causes irreversible inhibition of acetylcholinesterase, Rx with antimuscarinics

Question: 4 of 100 / Overall score: 65%Lead poisoning:(Please select an option)

Causes adrenal suppression

Can only result from lead ingestion Incorrect answer selected

Is associated with a macrocytic anaemia

Causes a peripheral neuropathy due to demyelination This is the correct answer

Commonly presents with diarrhoea Lead can also be absorbed through the skin and by inhalation. Associated with iron deficiency & a microcytic anaemia. Most common GI symptoms are abdominal colic and constipation.

Question: 5 of 100 / Overall score: 64%Recognised causes of methaemoglobinaemia include:True / False

dapsone Correct

isoniazid Correct

lidocaine Incorrect answer selected

isobutyl nitrite Incorrect answer selected

cotrimoxazole Correct b – isoniazid causes peripheral neuropathy, hepatitis and drug-induced lupus. It is metabolised by acetylation and in 'slow acetylators' there is an increased risk of neuropathy but a decreased risk of hepatitis and lupus. c,d,e – Causes of methaemoglobinaemia include hereditary haemoglobinopathies, nitrites / nitrates, analine dyes, phenacetin, sulphonamides, chlorates, lidocaine, heavy metals

Question: 6 of 100 / Overall score: 53%A 25-year-old male homosexual is admitted with dyspnoea and weight loss of 2 months duration. He is diagnosed with Pneumocystis pneumoniae due to AIDS. Which of the following concerning Pneumocystis pneumonia is true?(Please select an option)

May have an extra pulmonary presentation This is the correct answer

It is always associated with X-ray changes Incorrect answer selected

It is caused by a bacterium

Elevated serum antibodies to P. carinii are helpful diagnostically

It is best treated with intravenous pentamidine a-Any HIV associated condition. b-5-15% have normal CXR (always is always false ... but not always!). c-A fungus. d-There is polyclonal B-cell activation in AIDS. e-intravenous cotrimoxazole. (Dr Shu Ho)

Question: 7 of 100 / Overall score: 49%Gabapentin

True / Falseis a potent hepatic enzyme inducer Correct side effects typically include visual field defects with long-term use Incorrect answer selected therapy is best monitored through measuring plasma concentrations Incorrect answer selected is of particular value as monotherapy in absence attacks (petit mal) Incorrect answer selected requires dose adjustment in renal disease Incorrect answer selected

Gabapentin does not induce cytochrome P450 unlike other anticonvulsants such as phenytoin and phenobarbitone. Vigabatrin may cause visual field defects, which may be irreversible. Rarely have visual disturbances been associated with gabapentin. No use in Petit Mal and is used for add-on therapy in partial or generalised seizures.

Question: 8 of 100 / Overall score: 45%The following drugs can safely be given togetherTrue / False

indomethacin and enalapril Incorrect answer selected

adrenaline and amitriptyline Correct

aspirin and phenobarbitone Incorrect answer selected

oral contraceptives and kaolin Incorrect answer selected

ranitidine and warfarin Incorrect answer selected 1st stem: constriction of afferent glomerular arteriole (indomethacin) + dilatation of efferent arteriole (ACE I) leads to decreased GFR.4th stem: no interaction mentioned in BNF.

Question: 9 of 100 / Overall score: 47%Amiodarone:True / False

decreases the sensitivity of the pituitary to T4 and T3 Incorrect answer selected

inhibits TSH release Incorrect answer selected

inhibits thyroid hormone synthesis Correct

reduces peripheral conversion of T4 to T3 Correct

contains iodine Correct No wonder it interferes with thyroid function! Amiodarone can cause hyper or hypothyroidism. Question: 10 of 100 / Overall score: 42%A 40-year-old ex-footballer presents requesting treatment for alcoholism and is prescribed disulfiram.What is the mode of action of disulfiram?(Please select an option)

Decreases severity of alcohol withdrawal Incorrect answer selected

Helps alcoholics to drink safely

Inhibits acetaldehyde dehydrogenase activity This is the correct answer

Inhibits alcohol dehydrogenase activity

Reduces the desire for alcohol Alcohol is mainly metabolised in the liver to acetaldehyde by alcohol dehydrogenase.Acetaldehyde is then oxidised to acetate by acetaldehyde dehydrogenase (AcDH).Disulfiram irreversibly inhibits the oxidation of acetaldehyde by competing with the cofactor nicotinamide adenine dinucleotide (NAD) for binding sites on AcDH.The increased acetaldehyde levels are thought to produce the unpleasant side effects associated with acetaldehyde syndrome such as headaches, nausea, flushing etcetera.

Question: 11 of 100 / Overall score: 38%Isotretinoin is associated withTrue / False

teratogenicity in pregnancy This is the correct answer

dry nasal mucosa This is the correct answer

increased serum triglycerides This is the correct answer

gynaecomastia This is the correct answer

benign intracranial hypertension This is the correct answer a-important teratogenic risk b-dry skin and mucosal surfaces c-and cholesterol d-but may cause hair thinning or hirsutism e-and cataracts, corneal opacities, headaches, drowsiness, thrombocytopenia, anaemia and so many other things it is a natural attractor for exams

Question: 12 of 100 / Overall score: 35%An 18-year-old female presents 12 weeks into an unplanned pregnancy. She had been diagnosed with epilepsy six years ago which was well controlled on sodium valproate and had been taking the combined oral contraceptive pill (OCP) for three years.Which of the following is correct concerning this patient?(Please select an option)

Lamotrigine should be substituted for sodium valproate She should be advised to have a termination of her pregnancy. Incorrect answer selected Sodium valproate interaction with the oral contraceptive increased the risk of pregnancy. The dose of sodium valproate should be increased. There is an increased risk of a neural tube defect in her fetus. This is the correct answer

This patient has become pregnant on valproate.This therapy has controlled her seizures and should not be changed now.However, there is an increased risk of neural tube defects associated with valproate and this could be reduced by folate therapy.Valproate is not an enzyme inducer and unlike other anticonvulsants would not speed up metabolism of the OCP.

It is entirely up to the individual if they wish to pursue the pregnancy or not.

Question: 13 of 100 / Overall score: 32%A 36-year-old female presents with a six month history of having problems sleeping at night. She has been woken on numerous occasions by her legs which are irritable and feel that they are being tugged. She needs to keep moving them. This urge lasts for variable periods and she finds little relief from rubbing the legs. No abnormalities are noted on examination of her legs.Which of the following is the most appropriate treatment for this patient?(Please select an option)

Amitriptyline Incorrect answer selected

Gabapentin

Psychiatric referral

Ropinirole This is the correct answer

Venlafaxine This patient has features of restless legs syndrome (RLS). Typically there is an uncomfortable sensation in the legs and a feeling of needing to move them.The exact aetiology is unknown. Although no specific tests exist for the diagnosis it is based on the International Restless Legs Syndrome Study Group four basic criteria for diagnosing RLS:(1) a desire to move the limbs, often associated with paresthesias or dysesthesias(2) symptoms that are worse or present only during rest and are partially or temporarily relieved by activity(3) motor restlessness, and(4) nocturnal worsening of symptoms.Treatment depends on the severity of the problem and the most appropriate treatment here would be ropinirole, which is the only agent licensed for this purpose.

Question: 14 of 100 / Overall score: 34%The causes of SIADH include:True / False

empyema Incorrect answer selected

subdural haematoma Correct

chlorpropamide Incorrect answer selected

desmethylchlortetracycline Correct

hyperthyroidism Correct c-And carbamazepine, phenothiazines, tricyclics, syntocin. d-Used in the treatment. e-Hypothryroidism. (Dr Mick Bialas)

Question: 15 of 100 / Overall score: 35%The following diuretics are correctly linked with their site of action:True / False

Furosemide and thick ascending limb of the loop of Henle Correct

Bendroflumethiazide and the proximal tubule Incorrect answer selected Mannitol and the descending limb of the loop of Henle Incorrect answer selected Metolazone and the early distal tubule Correct

Spironolactone and the cortical collecting tubule Incorrect answer selected Thiazides of which metolazone and bendroflumethiazide are examples, inhibit sodium reabsorption at the distal convoluted tubule. Loop diuretics inhibit reabsorption from the ascending limb of the loop of Henle. Spironolactone antagonises the effect of aldosterone on the distal convoluted tubule. Mannitol is an osmotic diuretic and works primarily on the proximal convoluted tubule.Question: 16 of 100 / Overall score: 34%Nephrogenic diabetes inspipdus:True / False

has autosomal recessive inheritance Incorrect answer selected

can be associated with sickle cell anaemia Incorrect answer selected

serum vasopressin levels are normal or low Incorrect answer selected

can be caused by hypercalcaemia Correct

responds to treatment with thiazides Incorrect answer selected a-X-linked, c-normal or high. (Dr Mick Bialas)Question: 17 of 100 / Overall score: 32%Which of the following drugs is most likely to cause systemic lupus-like syndrome? (Please select an option)

Baclofen

Isoniazid

Methotrexate

Procainamide This is the correct answer

Sulphasalazine Incorrect answer selected A recessive gene is responsible for the activity of hepatic N-acetyl transferase resulting in slow or fast (intermediate and fast groups get lumped together) acetylation.45% of the United Kingdom population are slow acetylators.

Drugs affected include:   isoniazid hydralazine dapsone procainamide and sulphasalazine.   Slow acetylators have increased risk of isoniazid-induced peripheral neuropathy,

and hydralazine or procainamide-induced systemic lupus erythematosus (SLE).  

Fast acetylators were considered more at risk of isoniazid-induced hepatitis but this is not bourne out by the recent evidence.

Question: 18 of 100 / Overall score: 36%A 65-year-old African man with a known history of hypertension presents with ankle oedema after taking an antihypertensive prescribed by his general practitioner.He is now found to have a blood pressure of 160/100 mmHg.Which of the following would be the preferred drug for this patient?(Please select an option)

Amlodipine

Atenolol

Bendroflumethiazide Correct

Ramipril

Verapamil The patient has ankle oedema which is usually due to vasodilatation by calcium channel blockers.The preferred initial antihypertensive therapy for the elderly African patient will be bendrofluthiazide according to BHS guideline, 2004.Angiotensin-converting enzyme (ACE) inhibitors are preferred for those patients with heart failure or diabetic nephropathy.ß-blockers are preferred for post-myocardial infarction and ischaemic heart disease.Question: 19 of 100 / Overall score: 38%A 40-year-old man presents with unsteadiness of gait and bilateral gynaecomastia. These two features can be explained byTrue / False

Klinefelter's syndrome Correct

long-term therapy with phenytoin Correct

carcinoma of the lung Correct

long term corticosteroid therapy Incorrect answer selected

chronic alcohol abuse Correct Phenytoin may cause both ataxia and gynaecomastia. Other causes would include alcohol and lung cancer (associated with paraneoplastic cerebral atrophy)Question: 20 of 100 / Overall score: 36%A 50-year-old man with hypertension already on furosemide, ramipril and digoxin is found to have poor left ventricular function on echocardiogram.Which antihypertensive should be added?(Please select an option)

Carvedilol This is the correct answer

Diltiazem Incorrect answer selected

Doxazosin

Hydralazine

Nifedipine

This patient has hypertension and reduced ejection fraction (EF) on echo indicating an element of failure.In these circumstances the most appropriate agent with evidence to support its use for reducing morbidity and mortality in failure would be the addition of a beta blocker.Question: 21 of 100 / Overall score: 39%An 18 year-old girl receives radioactive iodine as treatment of thyrotoxicosis. Which of the following is the most likely long-term complication of this treatment?(Please select an option)

hypoparathyroidism

hypothyroidism Correct

increased risk of developing cancer

recurrent laryngeal nerve damage

osteoporosis RAI is safe and that is why it is given across all ages as a definitive treatment of thyroxicosis. The most likely side effect of radioactive iodine is hypothyroidism with approx 80% developing hypothyroidism after therapy. There is no evidence to suggest that RAI is associated with any cancers. However, RAI must not be given to pregnant females particularly after the 12th gestational week as it would be taken up by the developing foetal thyroid causing fetal hypothyroidism and is also considered to be teratogenic. Recurrent laryngeal nerve damage is a potential risk of thyroid surgery, not RAI.Question: 22 of 100 / Overall score: 41%BaclofenTrue / False

derived from GABA Correct

causes rhabdomyolysis Correct

reduces cerebral but not spinal spasticity Correct

cause hallucinations when withdrawn Correct

reduce Ca2+ release from sarcoplasmic reticulum Incorrect answer selected Primary site of action = spinal cord, by depressing monosynaptic and polysynaptic transmission. It can hyperpolarise cells by increasing K+ conductance and inhibit Ca2+ channels in others. Rhabdomyolysis caused by clofibrate, aminocaproic acid, HMGCoA reductase inhibitors and neuroleptics (neuroleptic malignant syndrome).Question: 23 of 100 / Overall score: 43%A 17-year-old woman underwent a renal transplant. She was concerned about the effects of long-term ciclosporin treatment.Which one of the following is a common adverse effect of this drug?(Please select an option)

Alopecia

Bone marrow depression

Hepatotoxicity

Nephrotoxicity Correct

Paraesthesia Ciclosporin causes hypertrichosis rather than alopecia and the most frequent adverse side effect of this drug is nephrotoxicity.Post renal transplant, the two most common causes of declining renal function are graft rejection and ciclosporin toxicity.Hepatototoxicity and  parasthesia are less common side effects of the drug.Question: 24 of 100 / Overall score: 42%A 17-year-old female presents to the emergency department following self-confessed paracetamol poisoning after discovering she is eight weeks pregnant and had a row with her boyfriend.She claims to have taken an approximately 30 paracetamol tablets approximately 58 hours ago. Her history is considered to be reliable. There are no abnormalities to find on examination. Her blood sugar by finger prick testing was 3.1 mmol/l.Which of the following would be the most appropriate treatment for this patient?(Please select an option)

Haemodialysis

Intravenous dextrose infusion Incorrect answer selected

Intravenous N-acetylcysteine This is the correct answer

Oral activated charcoal

Oral vitamin K Irrespective of the pregnancy, this girl should receive n-acetyl cysteine.Paracetamol concentration is unhelpful in delayed presentation of paracetamol overdose. A dose of more than150mg/kg is considered to be toxic and toxicity occurs at a lower concentration if the patient is thought to be in high risk group.Clotting screen international normalised ratio (INR), liver function tests, acid-base balance and plasma glucose should be taken without delay prior to starting treatment with N-acetylcysteine.Serial monitoring of clotting screen is required and N-acetylcysteine should continue until INR returns to normal.Further advice on treatment of complicated cases should be sought from National Poisons Information Service. Other supportive treatment is guided by the patient's condition.Question: 25 of 100 / Overall score: 40%A 58-year-old woman presents with early features of COPD. She is a heavy smoker and asks about drugs that may help her to stop smoking. In particular, she has heard about a new drug that is now available called Champix (varenicline).

Varenicline is an agent used in the treatment of smokers to help them quit. Which of the following best describes its mechanism of action?(Please select an option)

An a2-noradrenergic agonist that suppresses sympathetic activity

Is a nicotine replacement therapy Incorrect answer selected

Is a partial agonist of the alpha4beta2 nicotinic receptor This is the correct answer

A tricyclic antidepressant with mostly noradrenergic properties

Reduces uptake of dopamine, serotonin and norepinephrine There are now many therapies that have been investigated for use in smoking cessation. Newer drugs are becoming available that have been sepecifically developed for smoking cessation. Varenicline is one of them.Nicotine is a simulant and releases dopamine in the brain that leads to addictive effects of smoking. Its effects can be replaced in other ways using nicotine replacement therapy and this reduces the addiction to cigarrette smoking. Bupropion (Zyban) reduces the neuronal uptake of dopamine, serotonin and norepinephrine. Clonidine, a second line agent in smoking cessation because of its side effects, is an a2-noradrenergic agonist that suppresses sympathetic activity. Nortriptyline is a tricyclic antidepressant with mostly noradrenergic properties and is an agent that appears to be effective. Varenicline is a non-nicotine drug that is a partial agonist of the alpha4beta2 nicotinic receptor.Further reading:Int J Clin Pract. 2006 May;60(5):571-6 (Review)JAMA. 2006 Jul 5;296(1):47-55 (trial vs. bupropion and placebo)Royal College of Physicians publication on smoking cessationOther news articles on VareniclineQuestion: 26 of 100 / Overall score: 40%Dopa-decarboxylase inhibitorsTrue / False

enhance the effect of levodopa on the substantia nigra Incorrect answer selected

reduce the extracerebral complications of L-dopa therapy Correct

have anticholinergic activity Correct should not be given in combination with dopamine agonists Incorrect answer selected prevent L-dopa associated dyskinesias Incorrect answer selected

A – Dopa-decarboxylase inhibitors prevent the systemic metabolism of levodopa which leads to higher CNS levels. The effect itself is not enhanced only the concentration of available levodopa. B – these include nausea, vomiting, postural hypotension and cardiac arrhythmias. D – the combination makes dyskinetic movements more likely E - No. Dyskinesias are a CNS effect of levodopa. Question: 27 of 100 / Overall score: 40%The following statements about growth hormone are true:True / False

arginine is a potent inhibitor of growth hormone release Incorrect answer selected hypoglycaemia is a potent growth hormone stimulus Correct

growth hormone has a dual hypothalamic regulation Incorrect answer selected

increased levels can lead to enlargement of the liver Incorrect answer selected

bromocriptine can suppress growth hormone release Correct e-?paradoxically in acromegaly - keyword 'can'. (Dr Mick Bialas)Question: 28 of 100 / Overall score: 39%

A 29-year-old woman is receiving subcutaneous Clexane (low-molecular weight heparin [LMWH]) for the treatment of pulmonary embolism. She is 30 weeks pregnant and develops bruising on her lower arms.The blood pressure in the left lateral position is 125/75 mmHg.What is the most appropriate test for this patient?(Please select an option)

Anti factor Xa levels Incorrect answer selected

APTT

Platelet count This is the correct answer

Serum albumin

Serum potassium This is likely to be heparin-induced thrombocytopaenia (HIT).Long-term LMWH treatment has been associated with low platelet counts and this is the test which is likely to provide you with the most information.Clexane may cause hyperkalaemia, but this is unlikely to cause bruisisng.Albumin levels may increase in pregnancy but serum albumin may be low due to haemodilution.Activated partial thromboplastin time (APTT) is not of use in monitoring LMWH activity, although APTT may be prolonged in high dose Clexane treatment.Factor Xa levels can be used to monitor efficacy of treatment but the suggestion of brusing here points more to HIT for which Xa levels would not be a useful guide.Question: 29 of 100 / Overall score: 41%A 70-year-old female who is receiving amiodarone for paroxysmal atrial fibrillation presents with tiredness and weight loss.Investigations reveal:C-reactive protein 6 mg/L (<10)

Free Thyroxine 38 pmol/L (10-22)TSH <0.05 mU/L (0.4-5)

Which is the most appropriate treatment for this patient?(Please select an option)

Carbimazole Correct

Lithium therapy

Prednisolone

Radioiodine therapy

thyroidectomy The most appropriate initial treatment of this amiodarone induced hyperthyroidism would be carbimazole. Despite stopping the amiodarone, thyrotoxicosis may persist for many months and so additional treatment is often required. Two types of amiodarone induced hyperthyroidism are recognised. The first being a consequence of iodine overload contained within the amiodarone of which the above is a typical example and the second type is due to an acute thyroiditis with thyroid cell destruction and increased parameters of inflammation. The former is best treated with carbimazole, the latter with prednisolone.

Question: 30 of 100 / Overall score: 39%A new drug is being studied to find the most appropriate dose in a dose response study. Small doses of the drug lead to a linear increase in serum drug concentration. At higher doses there is an exponential rise in serum drug concentration. Which of the following best describes the pharmacokinetic properties of this new drug?(Please select an option)

first order kinetics Incorrect answer selected

first pass effect

long plasma half life

saturation kinetics This is the correct answer

zero order kinetics The description of the kinetics of this new drug show that with small doses there is a linear response (first order kinetics) to dosing but this becomes saturated and the serum concentration of the drug rises sharply (zero order kinetics). This response is typical of drugs such as phenytoin (saturates liver metabolism).Question: 31 of 100 / Overall score: 38%A 24-year-old man presents with a headache that has been present for nine months. He has headache almost every day, mainly frontal, sometimes with nausea. Current medication includes paracetamol, brufen and codeine with only transient relief of symptoms. He has a history of depression. Examination was normal.What is the most likely diagnosis?(Please select an option)

analgesic misuse headache This is the correct answer

cluster headache Incorrect answer selected

frontal brain tumour

headache due to depression

migraine This is one of the commonest cause of chronic daily headache (the commonest is chronic tension type headache). It is commonly caused by the chronic use of analgesics such as codeine phosphate and paracetamol). Threatment consists of reducing the amount of analgesics gradually until stopped.Question: 32 of 100 / Overall score: 40%Which of the following is correct concerning oseltamivir?(Please select an option)

It is a direct viral cytotoxic agent

It is administered via an inhaler

It is a haemaglutinase inhibitor

It is effective if administered within 72 hours of symptoms of flu

It is of value in prophylaxis against influenza Correct Oseltamivir (Tamiflu), like its predecessor zanamivir (Relenza) functions as an antiviral through inhibition of the enzyme neuraminidase inhibitor, thus slowing viral replication down rather than directly killing the virus particle.

This slowing down of replication is important in permitting time for the body's own immune system to deal with the virus.Unlike inhaled zanamivir, oseltamivir is administered orally.However, viral replication is rapid and to be effective, the drug must be given as early as possible after the development of symptoms of flu and preferably within 48 hours.There is evidence to support its use as a prophylactic agent against influenza and it is also generally free from serious side effects.Question: 33 of 100 / Overall score: 41%The following drugs are of proven benefit in improving prognosis in chronic heart failure (CHF):True / False

Enalapril in mild heart failure Correct

Digoxin Incorrect answer selected

Nitrates and prazosin combination Correct

Nitrates and hydralazine combination Correct

Xamoterol in mild heart failure Incorrect answer selected Drugs that will improve mortality in CHF include beta blockers, angiotensin-converting enzyme inhibitors (ACEi) and spironolactone.b-Symptoms yes, prognosis no. (NEJM 1997;336(8):575-6).Alternatives to ACEi where contra-indicated include hydralazine and nitrate combinations (V-HEFT study).Question: 34 of 100 / Overall score: 39%A diagnosis of diabetes mellitus is being considered in 32-year-old woman who is 16 weeks pregnant. Her body mass index (BMI) was 22 kg/m2 (18 - 25). A 75g oral glucose tolerance test revealed:Time Plasma glucose concentration0 hr 6.0 mmol/l (3.0-6.0)2hr 12.5 mmol/l (<11.1)

Which of the following is the most appropriate step in the management of this patient?(Please select an option)

Low calorie diet Incorrect answer selected

Glipizide therapy

Metformin therapy

Repeat her oral glucose tolerance test in four weeks

Insulin therapy This is the correct answer The result confirms a diagnosis of gestational diabetes mellitus with the 2hr OGTT result above 11.1 mmol/l. To minimise the fetal consequences of GDM (macrosomia, fetal malformations, still birth, IUGR etc), the patient’s glycaemia should be strictly controlled with insulin. A low calorie diet is inappropriate and neither metformin nor glipizide are licenced for use in pregnancy. There is no point in repeating the OGTT in 4 weeks as control is required NOW.Question: 35 of 100 / Overall score: 41%

An 85-year-old woman presented with bilateral osteoarthritis of the knees. She had no history of previous gastrointestinal disease. Which of the following is the most appropriate initial treatment for her? (Please select an option)

Celecoxib

Naproxen

Dihydrocodeine

Paracetamol Correct

Topical diclofenac. The recommendations of the American College of Rheumatology published in Arthritis and Rheumatism 2000, recommend acetaminophen (paracetamol) together with non-pharmacological interventions (exercise, diet) as first line therapy of mild/moderate OA of hips or knees.Question: 36 of 100 / Overall score: 42%In patients with subclinical folate deficiency, megaloblastic anaemia may be precipitated by the administration ofTrue / False

alcohol Correct

methotrexate Correct

phenytoin Correct

chloroquine Incorrect answer selected

sulphasalazine Correct +co-trimoxazole, pyrimethamine, pregnancy!Question: 37 of 100 / Overall score: 42%Long term corticosteroid therapy may be associated withTrue / False

hypochloraemic alkalosis Incorrect answer selected

positive nitrogen balance Incorrect answer selected

thrombophlebitis Incorrect answer selected

increased gastric acidity Correct

sleeplessness Incorrect answer selected Effects include hyperglycaemia (diabetes), increased catabolism (breakdown protein with increased urea), weight gain (excessive adiposity), salt and water retention (hypertension), increased osteoclast activity (reduced bone mineral density and osteoporosis) and CNS effects (depression, anxiety, poor sleep). It is also associated with an increased incidence of peptic ulceration with increased gastric acid secretion and reduced mucosal protection.Question: 38 of 100 / Overall score: 43%A 55-year-old female has recently commenced leflunomide for sero-negative rheumatoid arthritis. At baseline, prior to commencing the drug, her AST was 33 U/L (1-31) and her ALT was 40 U/L (5-35). She attends for routine blood monitoring. Her FBC is normal but her liver function tests (LFTs) reveal:

AST 58 U/L (1-31)ALT 71 U/L (5-35)

Alkaline Phosphatase 100 U/L (45-105)Bilirubin 12 µmol/L (1-22)

What is the most appropriate management option for this patient?(Please select an option)

Continue leflunomide and monitor LFTs in one month

Continue leflunomide and monitor LFTs in two weeks

Stop leflunomide and commence washout procedure.

Stop the leflunomide and repeat tests in two weeks. Correct

Stop leflunomide and seek urgent rheumatological advice. Leflunomide is associated with serious hepatotoxicity.Increased aminotransferases are commonly seen in association with therapy occurring in 15-20% of cases (less than a two fold rise).However, more serious elevation (greater than three fold) is seen in less than 5%.Generally, most hepatic events occur within the first six months of use. Guidelines suggest that where there is a less than two fold elevation of transaminases, the drug should be stopped and the LFT repeated in two weeks. If the results have returned to normal then the drug can be recommenced.As the active drug has such a long half life (approximately 15 days), in patients with severe elevations of LFTs, wash out treatment may be required to assist in excretion/reduce absorption of the drug.This includes cholestyramine and activated charcoal.Retroperitoneal fibrosis is associated withTrue / False

extensive ureteric obstruction Correct

bile duct obstruction This is the correct answer

Hashimoto's thyroiditis This is the correct answer

Peyronie's disease This is the correct answer

busulphan therapy This is the correct answer Retroperitoneal fibrosis is a rare disorder associated with dense fibrosis, usually of the retroperitoneum, producing oedema and biliary, and ureteric obstruction. It is associated with methysergide therapy, Riedel's thyroiditis and peyronie's disease.Question: 40 of 100 / Overall score: 43%The following drugs cause hypokalaemia:True / False

A Commencement of digoxin for atrial fibrillation Correct

B ACE inhibitors Correct

C Salbutamol for asthma Correct D Vitamin B12 for the treatment of pernicious anaemia Incorrect answer selected E Cimetidine for duodenal ulcer Incorrect answer selected

A Unless it causes vomiting - perhaps that is why 'commencement' is stated to exclude digoxin toxicity.B Angiotensin-converting enzyme (ACE) inhibitors cause hyperkalaemia.C Especially if high doses in nebulisers for acute asthma.D Particularly at the beginning of treatment.

Question: 41 of 100 / Overall score: 44%A 60-year-old male who has been prescribed lisinopril for hypertension presents with an irritating cough. What is the mechanism responsible for ACE-induced cough? (Please select an option)

Angiotensin I accumulation

Asthma

Bradykinin accumulation Correct

Laryngeal irritation

Renin accumulation The enzyme ACE is also responsible for the metabolism of bradykinin in mast cells. The accumulation of this substance is responsible for the cough found in up to 30% of subjects taking ACE-inhibitors. This phenomenon is not seen in subjects taking Angiotensin receptor blockers such as Losartan.

Question: 42 of 100 / Overall score: 43%In patients receiving mono-amine oxidase inhibitors, adverse reactions may occur as a result of ingestion of:True / False

Amitryptiline This is the correct answer

Allopurinol This is the correct answer

Isoprenaline This is the correct answer

Aspirin This is the correct answer

Pethidine This is the correct answer e)-Pethidine and possibly other opiates.See also BNFQuestion: 43 of 100 / Overall score: 45%A 63-year-old man was found collapsed.A department of psychiatry outpatient card was found in his jacket, together with a bottle of procyclidine tablets.He was febrile (38.2°C), conscious but unresponsive to commands. The blood pressure was 160/105 mmHg and there was marked muscle rigidity.What is the most likely diagnosis?(Please select an option)

Acute catatonic schizophrenia

Bacterial meningitis

Cerebral malaria

Neuroleptic malignant syndrome Correct

Procyclidine overdose The symptoms are typical of neuroleptic malignant syndrome (NMS).NMS is characterised by:

fever muscular rigidity altered mental status autonomic dysfunction.

Procyclidine is used to treat the Parkinsonian side-effects of neuroleptics; its presence in the patient's pocket implies that he was taking neuroleptics.Signs of procyclidine overdose include:

agitation confusion sleeplessness lasting up to 24 hours or more. Pupils are dilated and unreactive to light. Visual and auditory hallucinations and tachycardia have also been reported.

Question: 44 of 100 / Overall score: 45%Prostaglandins and leukotrienesTrue / False

leukotrienes are derived from arachidonate via the lipo-oxygenase pathway Correct prostaglandin cyclic endoperoxides are formed from arachidonate via the cyclo-oxygenase pathway Correct prostacyclin is a vasoconstrictor and potentiates platelet aggregation Correct tissue damage from free radicals can occur if there is excessive activation of the cyclo-oxygenase pathway Incorrect answer selected thromboxane A2 is derived from PGI2 (prostacyclin) through the action of thromboxane synthetase Incorrect answer selected

a!-therefore accumulate in aspirin therapy ?cause of bronchoconstriction, c-vasodilates + decreases platelet aggregation, e!

Question: 45 of 100 / Overall score: 46%RetinopathyTrue / False

occurs with peak prevalence of 80% at 20 years after diagnosis of diabetes Correct with maculopathy is commoner in older patients Correct

is seen in nearly all patients with endstage diabetic renal failure Correct

therapy with photocoagulation produces an iatrogenic choroidoretinitis Correct

with cotton wool spots are a result of vascular infarcts Correct

Question: 46 of 100 / Overall score: 46%The following are true in acute renal failure in humansTrue / False

'renal-dose' dopamine (2 - 5 mcg/kg/min) increases renal blood flow Correct loop diuretics decrease the metabolic requirements of the kidney Incorrect answer selected loop diuretics have been shown to accelerate recovery of glomerular filtration Correct the use of 'renal-dose' dopamine may cause ischaemia of the gut Incorrect answer selected changing oliguric renal failure to polyuric renal failure by the use of diuretics has been shown to have a survival benefit Incorrect answer selected

Dopamine and loop diuretics are of unproven value in acute renal failure. Loop diuretics may be of use when room needs to be made for drugs or nutrition but early dialysis would be better in this situation. However, physiologically it is argued that renal dose dopamine improves renal blood flow. J Royal Coll Physicians of London 1997;31(1):10-15. d-Lancet 1990;344:7-8.

Question: 47 of 100 / Overall score: 47%In selective alpha-1 blockadeTrue / False

there is postural hypotension with an increase in heart rate Correct

prostatic symptoms improve with small doses Correct

LDL is reduced with prolonged therapy Incorrect answer selected there is worsening of plasma glucose control in diabetics with prolonged therapy

Correct priapism can occur Correct

a-There is a 'first dose' effect with selective alpha 1 blockers (doxazosin, terazosin etc.) characterised by marked postural hypotension and tachycardia. Agreed these drugs do not cause (or at least are less likely to cause) reflex tachycardia in the long term. Alpha 2 blockade exaggerates the reflex tachycardia by facilitating the release of noradrenaline presynaptically. (Dr Dean Jenkins) c-LDL, triglycerides and total cholesterol d-improves insulin sensitivity (Dr Shu Ho)

Question: 48 of 100 / Overall score: 48%Drugs which reduce renal concentrating ability includeTrue / False

amoxicillin Correct

lithium Correct

tetracycline Incorrect answer selected

salbutamol Correct

amphotericin B Correct Causes of DI include lithium, amphotericin B and demeclocycline - not tetracycline.

Question: 49 of 100 / Overall score: 48%Side effects of streptomycinTrue / False

are enhanced by associated folate deficiency Incorrect answer selected

include irreversible vestibular damage Correct

are liable to occur with chronic liver disease Correct

are not seen if the drug is given orally Incorrect answer selected

are more common in the elderly Correct b+c) Like gentamicin, streptomycin is associated with renal and oto-toxicity. It is excreted renally and liver impairment does not affect its elimination.d) -not absorbed.e) Side effects are more common in elderly subjects due to the reduced volumes of distribution and reduced renal reserve.In the treatment of hypercalcaemiaTrue / False

mithramycin is useful long-term therapy This is the correct answer

calcitonin may be useful acutely This is the correct answer high-dose prednisolone (60mg/day) will reduce serum calcium acutely in primary hyperparathyridism This is the correct answer severe hypocalcaemia may follow removal of a single parathyroid adenoma This is the correct answer peritoneal dialysis is effective This is the correct answer

e - low calcium dialysis fluid can be used

Question: 1 of 100 / Overall score: 100%A 16-year-old female attends casualty 15 hours after ingesting approximately 30g of paracetamol and 2g of dihydrocodeine. On examination, she is drowsy with a Glasgow Coma Scale of 15. Her pulse is 100 beats per minute, blood pressure is 110/66 mmHg and she has pinpoint pupils, with saturations of 96% on air. What is the most appropriate treatment for this patient?(Please select an option)

Activated charcoal by mouth

Gastric lavage

N-Acetylcysteine intravenously Correct

Naloxone intravenously

10% Dextrose infusion This patient has taken a significant overdose of paracetamol, and is presenting late at 15 hours.She is at risk of hepatocellular damage and needs to be commenced on an infusion of IV N-Acetylcysteine immediately. It is continued for 30 hours and sometimes beyond this, depending on results of prothrombin time, liver function tests, urea and electrolytes, and glucose.Activated charcoal is given to patients presenting within one hour of overdose.Flumazenil is reserved for reversal of benzodiazepine induced respiratory depression.Naloxone is used for opiate-induced respiratory depression.

Question: 2 of 100 / Overall score: 50%A 65-year-old lady with a history of recurrent DVT. She has been weaned off her warfarin and started on intravenous heparin prior to cardiac bypass for ischaemic heart disease. She seems to require very high doses of heparin to achieve adequate anticoagulation especially during surgery.Which of the following conditions would explain her thrombophilia and her heparin resistance?(Please select an option)

Activated Protein C resistance

Antithrombin III deficiency This is the correct answer

Lupus anticoagulant Incorrect answer selected

Protein C deficiency

Protein S deficiency  "Cardiac surgery produces a unique activation of coagulation due to the presence of the cardiopulmonary bypass (CPB) circuit. Whilst not yet fully elucidated, the mechanisms of activation of coagulation during CPB may involve activation of fX by the tissue factor-mediated pathway within the pericardial cavity, in addition to direct generation of fXa on the surface of monocytes by Cathepsin G, a substance released from activated monocytes. The inhibition of fXa in these situations involves the AT-dependent mechanism of action of heparin." British Journal of Anaesthesia, 2002, Vol. 88, No. 4 467-469Question: 3 of 100 / Overall score: 47%Drugs which can be given in near normal dosage in severe renal failure include:True / False

Benzylpenicillin Incorrect answer selected

Digitoxin Correct

Doxycycline Incorrect answer selected

Rifampicin Incorrect answer selected

Streptomycin Correct Drugs whose concentrations may accumulate in renal failure include digoxin (digitoxin metabolised by liver), streptomycin, penicillins, statins, furosemide.Doxycycline can worsen renal function.

Question: 4 of 100 / Overall score: 60%A 48-year-old female with rheumatoid arthritis has the following full blood count results:

Haemoglobin 11.4 g/dL (11.5-16.5)Platelets 470 x109/L (150-400 x109)

White Cell Count 9.0 x109/L (4-11 x109)MCV 102 fL (80-96)

Which drug is she likely to be taking?(Please select an option)

Ciclosporin

Hydroxychloroquine

Leflunomide

Methotrexate Correct

Myocrisin Leflunomide is associated rarely with anaemia, thrombocytopaenia and eosinophilia. Ciclosporin may be associated with a mild anaemia. Methotrexate may be associated with haematopoietic suppression, leading to profound, and sometimes sudden leucopenia and thombocytopaenia.Methotrexate may lead to macrocytosis as a result of B12 or folate deficiency. Myocrisin may also rarely lead to blood disorders, pancytopaenia and leucopenia. The elevated platelet count here probably relates to the rheumatoid arthritis itself.

Question: 5 of 100 / Overall score: 64%Hepatic glucuronyl-transferase activity is increased byTrue / False

barbiturates Correct

antihistamines Correct

carbamazepine Correct

steroids Incorrect answer selected

tetracyclines Correct Barbiturates and carbamazeine induce HGT but antihistamines inhibit these enzymes. No effect of steroids or tetracycline.

Question: 6 of 100 / Overall score: 67%The following are recognised causes of acute bronchospasm in asthmatic patientsTrue / False

captopril Correct

paracetamol Correct

atenolol Correct

salmeterol Incorrect answer selected

ibuprofen Correct

B-blockers and aspirin (including non-steroidal anti-inflammatory drugs) can exacerbate or provoke an asthma attack. There may be paradoxical bronchospasm with salmeterol, as with other inhalation therapy.

Question: 7 of 100 / Overall score: 57%A 65-year-old male presents with arthralgia and sleep disturbance following the introduction of simvastatin. He has a history of hypertension and ischaemic heart disease for which he is receiving aspirin, atenolol and eprosartan together with simvastatin 40 mg od which has been introduced in the last one month. Previously, he had been taking atorvastatin but this was changed to simvastatin after he complained of arthralgia. Investigations reveal:Creatine Phosphokinase (CPK) 156 U/L (40-170)

Total Cholesterol 5.1 mmol/L (<5.2)LDL-Cholesterol 3.1 mmol/L (<3.36)

Triglycerides 1.7 mmol/L (0.45-1.69)HDL-Cholesterol 1.2 mmol/L (>1.55)

Which is the most appropriate treatment for his lipid profile?(Please select an option)

Ezetimibe This is the correct answer

Fenofibrate Incorrect answer selected

Nicotinic acid slow release

Omega-3 fatty acids

Rosuvastatin The primary treatment target in this case is a total cholesterol < 4 mmol/l and LDL C < 2 mmol/l. Plasma triglyceride and HDL-C are already at the currently accepted target levels. This patient describes typical statin associated side effects which are generally a class effect and dose related. The most common adverse event with statin therapy is athralgia or myopathy often with normal CPK levels. Myositis and rhabdomyolysis are rare statin associated myopathy side effects and are defined on the basis of CPK levels > 10X normal along with features of muscle pain and myoglobinuria (for rhabdomyolysis). Risk factors predisposing to statin myopathy include advanced age, trauma, thyroid dysfunction and concomitant medication that can raise statin bioavailability including amiodarone, verapamil and many other agents that are metabolised by the Cytochrome P450 enzyme system. Ezetimibe montherapy produces reductions in TC and LDL-C of around 20% and since tolerability issues are likely to occur with another statin, ezetimibe is the best treatment option. Clinical trial data has demonstrated continuing event rate reduction to LDL-C levels below 2 mmol/l and a meta-analysis of lipid lowering trials has demonstrated a 1 mmol/l reduction in LDL-C is associated with a 23% RRR in CHD events irrespective of baseline risk and the method of cholesterol reduction.

Question: 8 of 100 / Overall score: 50%The following drugs have anticholinergic properties

True / Falsetricyclic antidepressants This is the correct answer

phenothiazines This is the correct answer

antihistamines This is the correct answer

sulphonylureas This is the correct answer

barbiturates This is the correct answer c-some drugs of this class e.g. chlorpheniramine and promethazine d-oral hypoglycaemics - stimulate insulin release Other notable anticholinergics - propanthiline and anti-Parkinsonian drugs (amantidine, orphenadrine)

Question: 9 of 100 / Overall score: 44%The following drugs when given in therapeutic dosage may cause cardiac failureTrue / False

phenylbutazone This is the correct answer

carbimazole This is the correct answer

carbenoxalone This is the correct answer

propranolol This is the correct answer

propantheline This is the correct answer a+c by retention of sodium

Question: 10 of 100 / Overall score: 40%Which of the following drugs are recognised causes of pulmonary fibrosisTrue / False

penicillamine This is the correct answer

busulphan This is the correct answer

methotrexate This is the correct answer

prednisolone This is the correct answer

sulphamethoxazole This is the correct answer a - Lung complications have been reported - Goodpasture's syndrome. d - Prednisolone may be used to treat pulmonary fibrosis, especially cryptogenic fibrosing alveolitis. Another commonly implicated drug is amiodarone.

Question: 11 of 100 / Overall score: 42%The anticoagulant effect of warfarin may be increased byTrue / False

carbamazepine Incorrect answer selected

metronidazole Incorrect answer selected

Vitamin K Correct

paracetamol Correct

aspirin Correct

a - carbamazepine is an enzyme inducer and will increase the metabolism of warfarin and lead wot a reduced anticoagulant effect b - metronidazole is an enzyme inhibitor c - vitamin K will reduce the anticoagulant effect (What is the mode of action of warfarin? Warfarin interferes with vitamin K metabolism and prevents the caroboxylation of glutamic residues in factors II, VII, IX and X.) d - unless taken in overdose causing liver damage paracetamol shouldn't interact with warfarin - however note JAMA 1998;279(9):657-62 (thanks to Paul Lee MD paullee123@worldnet.att.net, Cardiology Fellow, Mount Sinae School of Medicine for the reference) e - aspirin competes for protein binding with warfarin Question: 12 of 100 / Overall score: 45%Rapid reduction of elevated blood pressure is effected byTrue / False

sublingual nifedipine Correct

oral diazoxide Correct

intramuscular hydralazine Correct

oral methyldopa Correct

intravenous clonidine Incorrect answer selected e-paradoxically elevation Question: 13 of 100 / Overall score: 49%Which are trueTrue / False

Osmolality is the number of osmoles of solute per kilogram of solvent Correct osmolality can be calculated from 2(sodium + potassium) + glucose + chloride mmol/l Correct in ethanol poisoning, the measured osmolality can exceed calculated osmolality

Correct one osmole of a substance depresses the freezing point by 1.86°C Correct the main determinant of intracellular fluid osmolality is intracellular potassium concentration Correct

Question: 14 of 100 / Overall score: 46%Rapid bolus intravenous adenosine would be expected to terminate the following arrhythmias:True / False

atrial flutter with 2:1 atrioventricular block This is the correct answer

paroxysmal atrial fibrillation Incorrect answer selected

atrioventricular nodal re-entry tachycardia This is the correct answer

orthodromic atrioventricular re-entry tachycardia This is the correct answer

catecholamine-sensitive ventricular tachycardia This is the correct answer a-It would increase the degree of atrioventricular block which will aid the diagnosis but would not usually stop the atrial flutter. b-As in a) it would slow the atrioventricular conduction but not stop the atrial fibrillation. c-Atrioventricular nodal re-entry tachycardia is a re-entry circuit within the atrioventricular node which is terminated by adenosine. d-This is the commonest tachycardia associated with WPW syndrome. The

circuit is from atria to ventricles via the atrioventricular node and back to the atria via the accessory pathway. e-Catecholamine-sensitive ventricular tachycardia occurs in young people with no other obvious structural heart disease. They get ventricular tachycardia on exertion which is sensitive to adenosine (Circulation 74, No. 2, 270-280, 1986). There are always exceptions to the rules! If you haven't heard of a condition then don't answer it.

Question: 15 of 100 / Overall score: 47%The following statements are correctTrue / False

sotalol is at least as selective as atenolol at cardiac rather than bronchial and vascular adrenoceptors Incorrect answer selected ipratropium is at least as effective as salbutamol in patients with airways obstruction in chronic bronchitis Correct oral sustained release theophylline is at least as effective as aminophylline suppositories in preventing early morning wheezing Incorrect answer selected orciprenaline is at least as selective as salbutamol for bronchial smooth muscle rather than heart muscle Correct slow intravenous infusion of corticosteroid is at least as effective as the same dose given by intravenous injection in the management of status asthmaticus Correct

a- Cardioselective (beta 1 > beta 2) betablockers include atenolol, betaxolol, bisoprolol and metoprolol. Sotalol is not cardioselective but does have an additional class III anti-arrhythmic activity. e- infusion needs a preceeding bolus dose to be as effective (apparently)

Question: 16 of 100 / Overall score: 44%A 60-year-old patient with metastatic breast carcinoma for attends the clinic. She complains of pain in the jaw and ulceration within the oral cavity, which has persisted for 4 weeks following a dental extraction. She has had a course of antibiotic therapy for suspected secondary infection of the ulceration. On examination there is ulceration within the oral cavity, which extends as far as the underlying mandible. Which of the following drugs is likely to be responsible for her presentation?

Anastrozole

Diclofenac.

Prednisolone

Tamoxifen Incorrect answer selected

Zoledronic acid This is the correct answer The likely causative agent is the nitrogen containing bisphosphonate Zoledronic acid. The clinical scenario suggests a diagnosis of Bisphosphonate associated osteonecrosis of the jaw. This is a recently recognised adverse effect of bisphosphonate therapy. This is a consequence of potent antiresorptive action of the nitrogen containing bisphosphonates. Most cases have been associated with Zoledronic acid and Pamidronate given Intravenously for metastatic bone disease. The reported incidence in patients with malignancy treated with these drugs is between 1.3-4.0%. Dental disease is a recognised

predisposing factor. The lesions usually heal with minimal surgical debridement, chlorhexideine mouthwashes, antibiotics and analgesia. Question: 17 of 100 / Overall score: 42%Selective neutropenia may be due toTrue / False

treatment with chlorpromazine Correct

treatment with carbimazole This is the correct answer

a familial trait This is the correct answer

miliary tuberculosis This is the correct answer

treatment with phenytoin This is the correct answerQuestion: 18 of 100 / Overall score: 42%Griseofulvin is an effective treatment of infection with:True / False

Candida albicans Incorrect answer selected

Trichophyton rubra Correct

Microsporum canis Incorrect answer selected

Malassezia furfur Incorrect answer selected

Taenia solium Correct a-not sensitive, d (pityriasis versicolor) not sensitive, e=tape worm!

Question: 19 of 100 / Overall score: 44%The following associations are true in patients who drink alcoholTrue / False

cephamandole and facial flushing Correct

verapamil and prolonged intoxication Correct

methotrexate and reduced risk of hepatic dysfunction Correct

moclobemide and hypertensive crisis Incorrect answer selected

chlorpropamide and facial flushing Correct a-the only cephalosporin that does it, c-increased, d-but true for other MAOIs. Drugs and Therapeutics Bulletin 1996;34(5):36-8

Question: 20 of 100 / Overall score: 42%A 39-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication

Serum sodium 128 mmol/L (137-144)Plasma osmolality 272 mosmol/L (275-290)Urine osmolality 380 mosmol/L (350-1000)

Which of the following drugs was prescribed?(Please select an option)

Aspirin

Fluoxetine This is the correct answer

Furosemide Incorrect answer selected

Lithium

Metoprolol This lady has hyponatraemia, hypotonicity (low serum osmolality) and inappropriately concentrated urine) which is consistent with Syndrome of Inappropriate ADH. Of the drugs listed fluoxetine is the most likely cause of SIADH.Question: 21 of 100 / Overall score: 40%Phenothiazine derivativesTrue / False

have an antihistaminic effect This is the correct answer

act as local anaesthetics This is the correct answer

potentiate the effects of morphine This is the correct answer

may cause light hypersensitivity This is the correct answer

may precipitate fits in those prone to epilepsy This is the correct answer d - photosensitive rash and also pigmentation e - lower seizure threshold Question: 23 of 100 / Overall score: 44%The following cause vasoconstriction:True / False

prostacyclin Correct

endothelin Correct

atrial natriuretic peptide Correct

midodrine Incorrect answer selected

angiotensin II Correct a - Used as an intravenous infusion for critically ischaemic limbs. b - A powerful endothelium-derived vasoconstrictor. c- Vasodilator and natriuretic. d - Alpha agonist used in the treatment of postural hypotension. e - Causes vasoconstriction, increased thirst, increased ADH secreteion and increased alsosterone levels. Question: 24 of 100 / Overall score: 43%A 39-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication

Serum sodium 144 mmol/L (137-144)Plasma osmolality 299 mosmol/L (275-290)Urine osmolality 210 mosmol/L (350-1000)

Which of the following drugs was prescribed?(Please select an option)

Aspirin

Fluoxetine Incorrect answer selected

Glibenclamide

Lithium This is the correct answer

Metoprolol

This lady has eunatraemia, hypertonicity (high serum osmolality) and inappropriately dilute urine) which is consistent with Diabetes insipidus. Of the drugs listed Lithium would be the most likely to cause a nephrogenic DI.Further reading: eMedicine - LithiumQuestion: 25 of 100 / Overall score: 43%The following combinations may be hazardousTrue / False

phenytoin and cimetidine Incorrect answer selected

L-Dopa and phenelzine Incorrect answer selected

warfarin and nitrazepam Correct

indomethacin and amiloride Correct

atenolol and verapamil Correct a-cimetidine inhibits metabolism and increases serum levels of phenytoin b-phenelzine is a monoamine oxidase inhibitor and with levodopa may cause hypertensive crisis c-a not uncommon combination on geriatric wards d-increased risk of hyperkalaemia e-risk of AV block e / False

is a naturally occuring purine nucleoside This is the correct answer

stimulates the cardiac atrioventricular node This is the correct answer

is competitively inhibited by theophylline This is the correct answer

is associated with bronchoconstriction This is the correct answer

is a potent vasodilator This is the correct answer Adenosine is a purine nucleoside which blocks the av node. AMP, ADP and ATP are nucleotides. It may produce bronchoconstriction and is therefore avoided in asthma. It also produces vasodilatation with reduced BP.(Dr Jacob Easaw) Question: 27 of 100 / Overall score: 41%Recognised side-effects of long-term therapy with a thiazide diuretic are:True / False

Hypermagnesaemia This is the correct answer

Hypertriglyceridaemia Correct

Hyperuricaemia Correct

Hypoglycaemia This is the correct answer

Metabolic acidosis This is the correct answer Thiazides may increase both cholesterol and triglycerides, and cause metabolic (hypochloraemic) alkalosis.They also cause hypokalaemia, hypercalcaemia, hyperglycaemia and impotence.Question: 28 of 100 / Overall score: 43%A man aged 40 is found to be uraemic. The following facts might give a useful lead to the aetiologyTrue / False

he had haematuria as a child Correct

he works in an iron foundry Correct three of his children had haemolytic disease of the newborn Incorrect answer selected he has taken tablets regularly for fibrositis Correct

he suffers from migraine Correct Haematuria as a child suggests previous nephritis. Tablest for fibrositis suggest NSAID nephropathy which again may apply for migraine although retroperitoneal fibrosis with ureteric constriction is another possibility. Working in an iron foundry should be pretty irrelevant (siderosis not a cause of uraemia) and haemolytic disease of newborn also an irrelevance.Question: 29 of 100 / Overall score: 41%Glycosuria is a recognised finding inTrue / False

acute paracetamol poisoning This is the correct answer

intracranial haemorrhage This is the correct answer

glucose-6-phosphate-dehydrogenase deficiency This is the correct answer

hypothyroidism This is the correct answer

phaechromocytoma This is the correct answerQuestion: 30 of 100 / Overall score: 40%A 45-year-old female with chronic schizophrenia was recently converted to a new anti-psychotic agent. She presented two weeks later with a sore throat and fever.Her full blood count shows:

Haemoglobin 12.5 g/dL (11.5-16.5)White cell count 1.3 x109/L (4-11 x109)

Platelets 135 x109/L (150-400 x109)What drug is she likely to have commenced?(Please select an option)

Clozapine This is the correct answer

Haloperidol

Olanzapine Incorrect answer selected

Quetiapine

Risperidone Unlike the other newer antipsychotic agents, Clozapine is associated with agranulocytosis in approximately 1-2% of patients. The mechanism through which this happens remains unclear.Question: 31 of 100 / Overall score: 41%Atrial Natriuretic PeptideTrue / False

inhibits Na reabsorption in the loop of Henle Incorrect answer selected

levels are low in severe congestive cardiac failure Correct

inhibits renin release. Correct

has a short half life (4-5 mins) Correct

is a vasodilator Correct a - Distal convoluted tubule. b - Levels rise with stretching of the atrial wall. c - It is a vasodilator by preventing angiotensin II mediated vasoconstriction and inhibits renin release. Question: 32 of 100 / Overall score: 40%A 17-year-old female presents after taking an overdose of her grandmothers medication.Investigations revealed a serum potassium of 6 mmol/L (3.5-4.9).Which one of the following drugs is the most likely cause of this abnormality?(Please select an option)

Aspirin

Digoxin Incorrect answer selected

Fluoxetine

Omeprazole

Propranolol This is the correct answer Betablockers, particularly propranolol, in overdose can cause hyperkalaemia by transmembrane shifts. It is useful to think of the opposite - beta-agonists such as salbutamol are far more widely known to cause hypokalaemia.Overdose of digoxin therapy most commonly manifests as rhythm disturbance, and may be exacerbated by hyper- or hypokalaemia. Salicylate overdose causes metabolic acidosis and respiratory alkalosis.Question: 33 of 100 / Overall score: 39%Which of the following is true of radioactive iodine (131I) therapy?(Please select an option)

Causes hypothyroidism in 90% of treated patients within three months Incorrect answer selected Causes a deterioration in ophthalmopathy in patients with Graves' disease This is the correct answer Is associated with a subsequently increased risk of infertility

Is associated with an increased risk of thyroid lymphoma

Is the preferred treatment in amiodarone induced thyrotoxicosis RAI is associated with the induction of hypothyroidism in the majority of subjects by three months (70%) with 10% failing at the first dose at about 18 months.It may precipitate deterioration in ophthalmopathy in patients with Graves.There is no evidence of either increased risk of infertility or lymphoma after RAI with evidence suggesting that it is quite safe.Withdrawing amiodarone is the preferred treatment in amiodarone induced thyrotoxicosis and often the iodine uptake would be low in these patients making 131I therapy unhelpful.Question: 34 of 100 / Overall score: 41%A 73-year-old man presented with a two week history of breathlessness and easy bruising. Investigations show:

Haemoglobin 6.9 g/dL (13.0-18.0)White cell count 0.4 x 109/L (4-11)

Platelet count 9 x 109/L (150-400)Bone marrow aspirate all cellular elements reducedWhich drug is the most likely cause of these abnormalities?(Please select an option)

Acyclovir

Amiloride

Amoxicillin

Paracetamol

Trimethoprim Correct There is a pancytopenia and marrow aspirate shows reduction in production of all cellular elements. Trimethoprim is the drug most likely of these 5 to cause depression of haematopoiesis as this picture would be particularly unusual with paracetamol, amiloride acyclovir and amoxicillin.Question: 35 of 100 / Overall score: 40%In the management of overdoseTrue / False

repeated oral charcoal is of benefit in carbamazepine overdose This is the correct answer N-acetylcysteine decreases mortality in encephalopathy associated with paracetamol overdose Correct theophylline can cause hyperkalaemia This is the correct answer

ethylene glycol causes metabolic acidosis This is the correct answer

cocaine overdose causes metabolic acidosis Incorrect answer selected a-and aspirin, dapsone, paraquat, phenobarbitone, quinine, theophylline (BNF) c-hypokalaemia d-30mins - 12 hours postingestion. ethanol like inebriation, acidosis, calcium oxaluria. 12-36 hours pulmonary oedema, cyanosis, cardiomegaly - death most common in this pahse. 2-3 days renal failure. Rx bicarb, ethanol, haemodialysis. e-and tachycardia, hypertension, dilated pupils, hypertonia, convulsions, coma Question: 36 of 100 / Overall score: 39%Aspirin potentiates the action of the followingTrue / False

warfarin Correct

sulphonamides This is the correct answer

chlorpropamide This is the correct answer

diazepam This is the correct answer

tetracyclines This is the correct answer a-too easy, b-also bound to plasma proteins, c-asprin can cause hypoglycaemia Question: 37 of 100 / Overall score: 38%A 52-year-old woman takes Lithium Carbonate for manic depression and also takes Codeine and Diclofenac prescribed by her GP for osteoarthritis.Which one of the following statements is correct?(Please select an option)

Codeine will reduce the bioavailablity of Lithium

The analgesic effect of Codeine will be reduced by co-administration of Diclofenac The nephrotoxicity of Diclofenac will be increased in this patient Incorrect answer selected Plasma Lithium concentration will be increased by Codeine Plasma Lithium concentrations will be raised by Diclofenac This is the correct answer

Diclofenac decreases renal Lithium clearance and increases Lithium concentrations. Codeine and diclofenac are frequently co-prescribed.Question: 38 of 100 / Overall score: 40%A 19-year-old man with glucose-6-phosphate dehydrogenase deficiency wishes to travel to Africa. Which one of the following should he be advised to avoid?(Please select an option)

primaquine Correct

loperamide

mefloquine

ibuprofen

yellow fever vaccine G6PD deficiency is inherited in an X-linked fashion and predisposes RBCs to haemolysis. Drugs recognised to predispose to acute haemolysis in G6PD deficiency include antimalarials such as Primaquine, sulphonamides, Nitrofurantoin and Nalidixic acid.Question: 39 of 100 / Overall score: 41%Which of the following may affect T cell immunity?True / False

angio-oedema Correct

Wiskott-Aldrich syndrome Correct

measles Incorrect answer selected

DiGeorge syndrome Correct

ataxia telangiectasia Incorrect answer selected Wiskott-Aldrich syndrome is an X linked immunodeficiency disorder characterised by lymphopenia and recurrent bacterial infections. DiGeorge syndrome is thymic aplasia with agammaglobulinaemia.Question: 40 of 100 / Overall score: 40%Which of the following drugs may cause pulmonary fibrosis?True / False

nalidixic acid Incorrect answer selected

vincristine Incorrect answer selected

sulphasalazine Correct

corticosteroids Correct

penicillamine Incorrect answer selected

a - Although other rheumatology drugs do - Gold, Methotrexate b - Bleomycin and Cyclophosphamide do however. d - Corticosteroids are sometimes used to treat pulmonary fibrosis. e - see A Other drugs include amiodarone and nitrofurantoin.Question: 41 of 100 / Overall score: 42%The following drugs may exacerbate asthmaTrue / False

propranolol Correct

captopril Correct

pyrimethamine Correct

cyclophosphamide Correct

aspirin Correct Drugs that are well recognised to exacerbate asttma include Beta-blockers, NSAIDs and Opiates.Question: 42 of 100 / Overall score: 43%A 46-year-old male presents passing 4-5 litres of urine per day, after commencing a new drug.

Serum sodium 142 mmol/l (137-144)Plasma osmolality 295 mosmol/l (275-290)Urine osmolality 280 mosmol/l (350-1000)

What drug was prescribed?(Please select an option)

Carbamazepine

Chlorpropamide

Fluoxetine

Furosemide

Lithium Correct The patient appears to have a drug induced Diabetes Insipidus based upon the high urine output, low urine osmolality and the high plasma osmolality. The most likely cause is Lithium. Chlorpropamide causes a SIADH as does carbamazepine and fluoxetine. Furosemide is another possibility but if it had dried the patient out the plasma sodium would be expected to be higher. It is most likely that the patient has started lithium for a psychiatric disorder. A 46-year-old male would be unlikely to be receiving high doses of furosemide.Question: 43 of 100 / Overall score: 42%You are asked to advise on analgesia for a 44-year-old woman with acute intermittent porphyria who has undergone wisdom teeth extraction.Which of the following drugs is safe for use in her treatment?(Please select an option)

Cephalexin

Cetirizine

Diclofenac Incorrect answer selected

Erythromycin

Ibuprofen This is the correct answer Many drugs may induce acute porphyric crises,thus great care must be taken when prescribing for patients with acute porphyria. Drugs unsafe for use in acute porphyria include barbiturates, tricyclic antidepressants, MAOIs, amphetamines, anabolic steroids, hormone replacement therapy, benzodiazepines, diuretics, captopril, cephalosporins, erythromycin, isoniazid, sulphonamides, sulphonylureas, theophylline, antihistamines, nifedipine, verapamil, amiodarone and simvastatin. Ibuprofen is safe for use in acute intermittent porphyria, but diclofenac should be avoided.Question: 44 of 100 / Overall score: 41%Endothelial derived relaxing factor, EDRF:True / False

antagonises the vasodilatory effect of prostacycline This is the correct answer

is released from macrophages This is the correct answer

causes platelet disaggregation This is the correct answer

causes an increase in cAMP This is the correct answer

may play an important part in septic shock This is the correct answer EDRF is nitric oxide and is released from the endothelium. It is antiatherogenic in action and inhibits platelet aggregation but does not cause disaggregation. It is found in many cell types including macrophages. d-cGMP (Dr Shu Ho) (Dr Jacob Easaw - e) Question: 45 of 100 / Overall score: 42%Nephrotoxicity is described with the following drugsTrue / False

gentamicin Correct

polymixin B Incorrect answer selected

acetazolamide Incorrect answer selected

ampicillin Correct

rifampicin Correct Nephrotoxicity is associated with many antibiotics typically tetracyclines, cephalosporins and gentamicin. It has also been 'described' in association with penicillins (immune origin), azetazolamide (carbonic anhydrase inhibitor) and rifampicin. (More ...)n diabetic amyotrophyTrue / False

serum creatinine kinase is raised This is the correct answer

improvement does not occur without insulin This is the correct answer

pain occurs This is the correct answer

the sural nerve action potential is increased This is the correct answer

steroids enhance recovery This is the correct answer Diabetic amyotrophy causes an assymetrical painful weakness of both quadriceps associated with femoral nerve involvement of unknown aetiology. It typically occurs in elderly males and may be the first presenting feature of diabetes. Typically it is treated with insulin, whose anabolic effects may improve the weakness.Question: 47 of 100 / Overall score: 42%

A 62 year-old female presents with deteriorating arthralgia associated with long-standing Rheumatoid arthritis. She was prescribed Celecoxib in place of naproxen.Which of the following concerning Celecoxib is correct?(Please select an option)

Co-treatment with diuretic can be given more safely than with naproxen

Celecoxib acts by inhibiting a different enzyme than naproxen

Celecoxib has a lower level of anti-platelet activity than naproxen Correct

Anti-inflammatory effects of celecoxib are superior to those of naproxen

Celecoxib is associated with reduced hepatotoxicity compared with naproxen Celecoxib is a COX (Cyclo-oxygenase)-2 inhibitor differing from the other NSAIDs such as Naproxen which affects both COX-1 and COX-2. COX-1 is involved in platelet aggregation and inhibition of this by the NSAIDs produces its beneficial cardiovascular effects. However platelet aggregation is not affected by COX-2. Rofecoxib, Vioxx has been withdrawn due to its increased cardiovascular events compared with Naproxen.Question: 48 of 100 / Overall score: 43%ACE inhibitor therapy causes a reduction in:True / False

Total mortality when given intravenously within 24 hours of a MI Correct

Premature death from all causes 2-3 days after a MI Incorrect answer selected Incidence of MI when given to post-infarct patients with asymptomatic LV dysfunction Correct Mortality in patients with asymptomatic LV dysfunction Correct Renal dysfunction in IDDM patients independently of antihypertensive actions Incorrect answer selected

a-Beta blockers not ACE. c+d - The SOLVD or SAVE studies. e- CAPPPQuestion: 49 of 100 / Overall score: 43%Folic acid metabolism can be affected byTrue / False

tetracycline Correct

pyrimethamine Incorrect answer selected

vitamin B12 Correct

methotrexate Correct

brufen Correct Drugs which inhibit dihydrofolate reductase = methotrexate, pyrimethamine and trimethoprim. Drugs which interfere with absorption/storage of folate = phenytoin, primidone, oral contraceptives. The following adverse effects are associated with listed drugsTrue / False

heart failure and indomethacin This is the correct answer

cutaneous vasculitis and allopurinol This is the correct answer

proteinuria and azathioprine This is the correct answer

myopathy and hydroxychloroquine This is the correct answer

myasthenia gravis and sulphasalazine This is the correct answer a - NSAIDs may precipitate, or complicate treatment of, hypertension and cardiac failure b - allopurinpol should be stopped immediately if a rash occurs c - penicillamine is a cause of nephrotic syndrome d - Hydroxychloroquinine can cause both cardiac and muscular myopathy, it is reversible and improve when the drug is withdrawn. (Current Medical Diagnosis and treatment.2000: p 831 ). (sarmad_salim@hotmail.com)Question: 51 of 100 / Overall score: 42%The following are true regarding thiazide diuretics:True / False

the antihypertensive effect relates only to their natriuretic potency Incorrect answer selected the cause hyperuricaemia by xanthine oxidase induction Incorrect answer selected there is a direct dose response relationship bewteen thiazide treatment and risk of cardiac arrest Correct the antihypertensive effect is reduced by concurrent use of NSAIDs Incorrect answer selected use of bendroflumethiazide in a patient taking lithium leads to increased lithium excretion Incorrect answer selected

This is a very poor question and highlights a lot of the deficiencies of the multiple true-false style MCQ. Anyhow ... a - Thiazide reduce blood pressure by two mechanisms - natriuresis and reduction of peripheral resistance. b - Thiazides interfere with urate excretion. c - This is from the risk of hypokalaemia. This is a concern about the long term use of thiazides. d - NSAIDs may complicate antihypertensive therapy. e - Bendroflumethiazide therapy leads to reduced lithium excretion - levels should be monitored carefully. Question: 52 of 100 / Overall score: 43%A 17-year-old female presents with acute breathlessness. She has had asthma for approximately three years and recently commenced new therapy.Which agent may be responsible for this exacerbation?(Please select an option)

Beclomethasone

Ipratropium bromide

Montelukast

Salmeterol Correct

Theophylline Salmeterol has been reported to produce an acute exacerbation of asthma, possibly through an acute hypersensitivity reaction.Question: 53 of 100 / Overall score: 43%The following drugs need dose adjustment in renal failureTrue / False

carbamazepine Incorrect answer selected

erythromycin Incorrect answer selected

digoxin Correct

acyclovir Incorrect answer selected

vancomycin Correct a - carbamazepine is metabolised in the liver b - in severe renal impairment dose is limited to 1.5 per day because of the risk of ototoxicity c - too easy! d - nephrotoxicity e - too easy!Question: 54 of 100 / Overall score: 43%Amiodarone:True / False

stimulates tissues to convert T4 to T3 Incorrect answer selected

causes pigmentation of the retina Incorrect answer selected

leads to the accumulation of metabolically inactive reverse T3 Correct

increases the anticoagulant effect of warfarin Correct is cleared from the body with a half-life of approximately one week after chronic dosing Incorrect answer selected

Amiodarone inhibits the conversion of T4 to T3 and increases the amount of rT3. Corneal microdeposits may occur. The half-life of amiodarone is several weeks.Question: 55 of 100 / Overall score: 43%Anticoagulation with Warfarin therapyTrue / False

Is required for life in asymptomatic patients with protein C deficiency Incorrect answer selected Produces skin necrosis in patients with activated protein C resistance (Factor V Leiden) Correct Is indicated for carotid artery stenosis Incorrect answer selected Is required for six weeks in spontaneous proximal deep vein thrombosis Incorrect answer selected Treatment is contraindicated in the first trimester of pregnancy Correct

Warfarin treatment is not required in asymptomatic protein C deficiency and subjects with APC resistance, protein S or protein C deficiency appear to be particularly prone to skin necrosis. There is no evidence to establish its use in the treatment of carotid stenosis. Six weeks of therapy is sufficient for the treatment of a distal(below knee) DVT. Warfarin is teratogenic.Question: 56 of 100 / Overall score: 42%Which of the following can be given safely in acute intermittent porphyria?True / False

a. Pethidine This is the correct answer

b. Gentamicin This is the correct answer

c. Alcohol This is the correct answer

d. Aspirin This is the correct answer

e. Chlorpromazine This is the correct answer a.  Opiates safe in the treatment of acute intermittent porphyria.

b.  Penicillins are also safe in such treatment.c.  Barbiturates and the oral contracepive pill are the main ones to remember as being unsafe.d.  Paracetamol is also unsafe in treatment.e.  Lithium, nortriptyline, chlordiazepoxide and oxazepam are also safe.Drugs unsafe in porphyriaQuestion: 57 of 100 / Overall score: 41%A 45-year-old HIV-seropositive man attended the outpatient clinic for the results of a fasting serum lipid test.He had been diagnosed with HIV disease two years previously and was started on highly active antiretroviral therapy. One year after commencing antiretrovirals, his CD4 count had risen from 10 cells/mm3 to 120 cells/mm3 with an undetectable viral load.His current medications consisted of zidovudine, lamivudine lopinavir, aciclovir, fluconazole and co-trimoxazole.

Fasting lipid profile revealed:Serum cholesterol 4.1 mmol/L (<5.2)Serum triglyceride 18.2 mmol/L (0.45-1.69)Which of the following medications is most likely to be responsible for these results?(Please select an option)

Co-trimoxazole

Fluconazole Incorrect answer selected

Lamivudine

Lopinavir This is the correct answer

Zidovudine Lipodystrophy, lipoatrophy and alterations in serum lipid values have been observed in patients with human immunodeficiency virus (HIV) disease taking highly active antiretroviral therapy.Elevated serum lipid levels have been associated with premature coronary artery disease.Hypertriglyceridaemia is also thought to contribute to central fat deposition, and insulin resistance that is also seen in these patients.

Abnormalities of serum lipid levels are likely to be multifactorial in patients with HIV disease, but appear much commoner in patients taking protease inhibitors.Isolated hypertriglyceridaemia can occur in HIV disease in the absence of protease inhibitors, but extremely high serum triglycerides have been documented in some patients treated with these drugs.

If the elevation in lipid levels is modest, measures such as dietary modification and exercise may be tried first. Omega-3 fish oils may also be beneficial in reducing modestly-elevated serum triglycerides.In refractory cases, or where there is extreme isolated hypertriglyceridaemia, a fibrate should be used.In addition, patients with HIV disease may also have elevated serum lipid levels due to familial hyperlipidaemia.

Question: 58 of 100 / Overall score: 42%A 28-year-old, primigravid woman developed a swollen painful left leg at 12 weeks gestation.Doppler ultrasound of her leg venous system showed a left popliteal vein thrombosis.Which one of the following treatments is associated with the greatest risk to the foetus?(Please select an option)

Aspirin

Intravenous unfractionated Heparin

Subcutaneous low molecular weight Heparin

Subcutaneous unfractionated Heparin

Warfarin Correct Oral anticoagulants are teratogenic and should not be given in the first trimester of pregnancy.Oral anticoagulants cross the placenta, and increase the risk of fetal and placental haemorrhage. Aspirin appears to be relatively safe as are heparins.Question: 59 of 100 / Overall score: 42%A 16-year-old man is brought to the emergency department with a GCS (Glasgow coma scale) rating of 3/15.Within 10 minutes he regained consciousness with a GCS of 15/15, is sitting up and talking.What is he likely to have taken?(Please select an option)

Inhaled solvent glue This is the correct answer

Smoked heroin

Smoked marijuana

Snorted cocaine

Taken ecstacy Incorrect answer selected This patient was markedly comatose on arrival but quickly regains consciousness. This suggests a short acting (probably) inhaled anaesthetic-like agent - glue.Marijuana would not be expected to produce this level of coma and the effects of cocaine would last much longer.The inhaled solvents, due to their lipophilicity, are rapidly absorbed through the lungs and then quickly distributed to the brain and other organs. The effects therefore appear within minutes of inhalation.Typical substances that are inhaled include toluene aromatic hydrocarbons and butane.Question: 60 of 100 / Overall score: 42%Contra-indications to the use of metformin include:True / False

Cardiac failure Incorrect answer selected

Alcohol abuse Correct

Peripheral neuropathy Correct

Hepatic dysfunction Correct

Renal failure Correct Metformin therapy may be associated with lactic acidosis as a serious but rare side effect. Contra-indications indicated in the BNF include Cardiac, hepatic and renal failure. Alcohol abuse may also predispose. Unlike phenformin, metformin is only rarely associated with lactic acidosis and many diabetologists ignore these criteria without any ill effect.Question: 62 of 100 / Overall score: 44%Which of the following statements are true concerning treatment with angiotensin-converting enzyme (ACE) inhibitors?True / False

ACE inhibitors can decrease plasma atrial natriuretic peptide levels Incorrect answer selected ACE inhibitors can worsen silent renovascular disease. Correct ACE inhibitor therapy in combination with digoxin and diuretics significantly reduce mortality in patients with chronic heart failure. Correct ACE inhibitors therapy post myocardial infarction attenuates left ventricular enlargement. Incorrect answer selected They can reduce the serum bradykinin concentration Correct

Increased bradykinin concentrations and deteriorating renal function in renal artery stenosis are effects of ACE inhibitor therapy.ACEI are well described to reduce mortality in trials of heart failure with combination therapy, for example ATLAS, and assist with remodelling.Question: 63 of 100 / Overall score: 43%Causes of gynaecomastia include:True / False

Bronchial carcinoma Correct

Griseofulvin This is the correct answer

Hypothyroidism This is the correct answer

Phenothiazines This is the correct answer

Renal failure This is the correct answer Hyperthyroidism, not hypothyroidism, is a cause of gynaecomastia.All the other given options may be causes.Question: 64 of 100 / Overall score: 42%A 58-year-old male presents with painful breast tissue.Six weeks previously he was treated for atrial fibrillation and had a number of drugs commenced.Which one of the following drugs may have caused this problem?(Please select an option)

Aspirin

Digoxin

Flecainide Incorrect answer selected

Spironolactone This is the correct answer

Warfarin

Digoxin may cause gynaecomastia but usually only on prolonged use.Spironolactone is well known to cause gynaecomastia due to its well described anti-androgen effects.Question: 65 of 100 / Overall score: 43%A 24-year-old female who has previously suffered with severe depression presents with secondary amenorrhoea.She is found to have a prolactin of 645mU/L (normal 50-350).Which of the drugs which she takes may cause this?(Please select an option)

Becotide

Omeprazole

Montelukast

Risperidone Correct

Sertraline Antipsychotic medications are known to elevate prolactin levels, due to dopamine antagonist effects.Sertraline is not thought to exert dopamine antagonist effects and thus does not result in hyperprolactinaemia.The other medications on her list have not been associated with hyperprolactinaemia.Question: 66 of 100 / Overall score: 44%Which of the following is a contraindication to immunisation?(Please select an option)

Infantile eczema requiring topical steroids.

Oral poliomyelitis vaccine to a child on oral steroids. Correct

A history of prolonged jaundice.

A child with congenital adrenal hyperplasia on oral cortisone.

A child with cerebral palsy. Common misconceptions regarding immunisations include:

A family history of adverse reaction, or a previous history of pertussis, measles, rubella or mumps infection.

Prematurity or low birth weight. Stable neurological conditions such as cerebral palsy or Down's Syndrome. Asthma, eczema, hayfever or snuffles. Contact with an infectious disease, or treatment with antibiotics or topical

steroids. Pregnant mother or a mother who is breast feeding. Prolonged jaundice. Patients on replacement corticosteroids.

Oral polio vaccine should not be given to immunosuppressed children, their siblings or household contacts. In children with HIV, there is little evidence that they themselves will have problems, but excretion may be prolonged, and this may give rise to an increased risk of infection of HIV positive household contacts.