Passmedicine MRCP Part I

Table of contents :
Cardiology.pdf (p.1-765)......Page 1
Clinical haematologyoncology.pdf (p.766-1225)......Page 766
Clinical pharmacology and toxicology.pdf (p.1226-1665)......Page 1226
Clinical sciences.pdf (p.1666-2495)......Page 1666
Dermatology.pdf (p.2496-2781)......Page 2496
Endocrinology.pdf (p.2782-3185)......Page 2782
Gastroenterology.pdf (p.3186-3679)......Page 3186
Infectious diseases and STIs.pdf (p.3680-4241)......Page 3680
Nephrology.pdf (p.4242-4551)......Page 4242
Neurology.pdf (p.4552-5225)......Page 4552
Ophthalmology.pdf (p.5226-5345)......Page 5226
Psychiatry.pdf (p.5346-5521)......Page 5346
Respiratory medicine.pdf (p.5522-5863)......Page 5522
Rheumatology.pdf (p.5864-6249)......Page 5864

Citation preview

Question 1 of 382 A 70-year-old man with an existing diagnosis of 5.0 em abdominal aortic aneurysm and atrial fibrillation presents with acute onset abdominal pain radiating to his back. He is still actively bleeding and his observations show the following: Blood pressure 90/40 mmHg Heart rat e 140 beats per minute The decision is made to proceed with emergency surgery with in the next thirty minutes Whi ch of the following is the most appro priate management of warfarin therapy?

Give 5 mg vitam in K intravenously Stop warfarin and commence treatment dose enoxaparin only

Begin dual therapy with warfarin and enoxaparin until INR is in range

Dr

Give four-factor proth rombin complex concentrat e 25-50 units/ kg

As se m

Continue warfarin but bridge with enoxaparin immediately after surgery

Give 5 mg vitam in K intravenously Stop warfarin and commence treatment dose enoxaparin only Continue warfarin but bridge with enoxaparin immediately after surgery

I

Give four-factor prothrombin complex concentrate 25 -50 units/ kg Begin dual therapy with warfarin and enoxaparin until INR is in range

Patients on warfarin undergoing emergency surgery - give four-factor prothrombin complex concentrate Important for me

Less ' mpc rtC~nt

British Journal of Haemat ology Guidelines in patients on warfarin having emergency surgery: If surgery can wait for 6-8 hours - give 5 mg vitamin K IV If surgery can't wait - 25-50 units/kg four-factor prothrombin complex

As se m

The guidance is to stop warfarin before elective or emergency surgery, so options 3 and 5 are incorrect

Dr

Because this is emergency surgery, reversal of anti-coagu lation is necessary so option 2 is incorrect

A 71-year-old man who had rheumatic fever as a child is admitted t o the cardiology ward

with suspected infective endocarditis. This is confirmed by blood cultures and

echocardiography. Which one of the following is most likely to be represent a need for

su rgical intervention?

A septic embolism in the right kidney Persistent pyrexia after 48 hou rs of antibiotics Lengthening o f the PR int erval on ECG

se As Dr

Streptococcus viridans isolat ed on blood cultu res

m

Pre-existing left ventricular impairment

I

A septic e mbolisT in the right kidney Persistent pyrexia after 48 hou rs of antibiotics Lengthening of the PR interval on ECG Pre-existing left ventricular impa irment

Streptococcus viridans

isolated on b lood cu ltures

Infective e ndoca rditis - indications for su rge ry: • seve re valvular inco mpete nce • a o rtic ab scess (often indicated by a lengthe ning PR interva l) • infections resista nt to antib iotics/ fu ng al infections • ca rdiac fa ilure refracto ry to sta ndard medica l treatment • recurrent embo li a fter antibiotic the ra py Less 'mpcrtant

As se m

Important for me

Dr

Lengthening o f the PR interval is like ly to represent a n aortic root abscess which will require su rgical intervention.

A 65 -year-old patient with chronic kidney disease is found to have a deficiency of antithrom bin III after he p resented to emergency department with left leg pain and swelling . A doppler-ultraso und scan of the leg confirms deep venous thrombosis (DVT). The patient is started on dabigatran. What is the mecha nism o f action of dabigatran?

Activates anti -thrombin III P2Y12 inhibitor

Direct factor X activator

Dr

Direct th rombin inhib itor

As se m

Glycoprotein lib/Ilia inhibitor

P2Y12 inhibitor Glycoprotein lib/lila inhibitor Direct throm bin inhibitor Direct factor X activator

Dabigatran is a direct thrombin inhibitor Important for me

Less ' m ::~c rtant

MOA

Heparin

activates anti-thrombin III

Clopidogrel

P2Y12 inhibitor

Abciximab

glycoprotein lib/lila inhibitor

Dabigatran

direct thrombin inhibitor

Rivaroxaban

direct fact or X inhibito r

Dr

Drug name

As se m

Below is a table of the drugs and their mechanisms of actions (MOA):

Which one o f the following is a cause of a soft second heart sound?

Ao rtic stenosis Ao rtic regurgitation

m

Mitral stenos is

Pu lmonary hypertension

Dr

As

se

Mitral regurgitation

I

Aortic stenosis

CD

Aortic regurgitation

6D CD

Mitral stenosis Mitral regurgit ation

«ED

Pulmonary hypertension

«ED

Second heart sound (S2) • loud: hypertension • soft: AS • fixed split: ASD • reversed sp lit: LBBB

As se m

S2 is soft in severe aortic stenosis

Less imocrtont

Dr

Important for me

A 62-year-old man is reviewed two hou rs after a successfu l elective DC cardioversion for atrial fibrillation. Six weeks ago he p resented in fast atrial f ibrillation. A d ecision was made at the time t o wa rfa rinise him for six w eeks after which he was to be cardioverted. During this time he had a normal t ransthoracic echocardiog ram. He has no past medical history o f note other than treatment for a basal cell carcinoma. What is the most app ropriate plan regarding anticoagulation?

Can stop immediately Continue warfarinisation for 1 week then review following

Continue warfarinisation for 4 weeks then review

Dr

Lifelong aspirin

As se m

Lifelong warfarin

-

Can stop immediately

~

Continue warfarinisation for 1 week then review following Lifel ong warfarin

se As Dr

Continue warfarinisation for 4 weeks then review

m

Lifelong aspirin

Which one o f the following cl inical feat u res wou ld b e least consist ent w it h a diagnosis of

severe pre-eclampsia?

Head ache Epigastric pain Ref lexes difficu lt to elicit

se As Dr

Papilloed ema

m

Low platelet count

Headache Epigastric pain Reflexes difficult to elicit Low platelet count

se

m

Papilloedema

Dr

As

Severe pre-eclampsia is associated with hyperreflexia and clonus. A low platelet cou nt may indicate the patient is developing HELLP syndrom e

Which one of the following is least associated with aortic regurgitation?

Rheumatic f ever William's syndrome Syphilis

se As Dr

Post-rheumatic disease

m

Bicuspid aortic valve

Rheumatic fever

f!D

~li a m's syndrome

CD

Syphi lis

GD

Bicuspid aortic valve

QD

CD se As Dr

Wi ll ia m's syndrome is associated with suprava lvular aortic stenosis.

m

Post-rheumatic disease

A 67 -year-old wo man presents t o the cardiology clinic for urgent review. She is known to have mitral stenosis, but feels like her exercise tolerance has deteriorat ed rapidly over the past few months. She is short of breath on minimal exercise and suffers from haemoptysis Current medication includes bisopro lol lOmg, isosorbide dinitrat e 60mg, and furosemide 40m g daily. Her blood pressure is 105/ 88 mmHg, pulse is 62 (slow atrial fibrillation). There are crackles at both lung bases on auscultation of the chest. Which of the following is the most appro priate next st ep?

Surgical valve replacement Percuta neous mitra l valvotomy

Ram ipril

Dr

Increased furosemide dose

As se m

Digoxin

Percuta neous mitral valvoto my Digox\Ln _ _ Increased furosem ide d ose Ram ipril

Percutaneous mitral com missu roto my is the inte rvention of cho ice fo r severe mitra l stenosis Important for me

l ess 'mocrtont

At this point, with a na rrow pulse pressure, resista nt ca rdiac fa il ure, a nd a narrow, low pulse pressu re, it seems app ropriate to move to percutaneous va lvotomy. Co ntra -i ndications to va lvotomy include a mitra l va lve area > 1.5 cm 2, presence of leh a trial th rom bus on ECHO, greate r than mild mitra l regurgitatio n, severe va lve ca lcification, seve re concom itant aortic valve disease, seve re comb ined mixed tricuspid va lve disease, and concomitant coro na ry a rte ry d isea se requ iring bypass su rgery. In the event symptoms are not resolved by va lvoto my, fo rma l surg ical valve rep la cement is indicated.

Dr

As se m

Surgica l va lve re p lace ment is on ly indicated where valvotomy is contra indicated o r is unsu ccessful. There is ve ry limited opportu nity to increase med ical the rapy in th is populatio n, with systolic blood p ressu re o nly just above 100, and a heart rate of 62 beats oer minute.

A 71-yea r-old man who is known to have atrial fibrillation co mes fo r review. He had a tra nsie nt ischaem ic attack two weeks ago and takes bendroflumethiazide fo r hype rtens ion but is otherwise well. His latest b lood p ressure is 124/ 76 mmHg . You are discussing management o ptions to try and reduce his future risk o f having a stroke. What is his CHA2DS2-VASc sco re?

1

2

5

Dr

4

As se m

3

CD

2

GD

3

fD

r4

CiD

5

GD se

m

1

Dr

age of 75 years) and two point s ('52') fo r the recent TIA.

As

One point for hypertension, one point for being over the age of 65 years (but und er the

A 28-yea r-o ld ma n with hypertrophic o bstructive ca rd iomyo pathy is investigated for pa lpitatio ns. A 24 hour ECG revea ls runs o f no n-susta ined ve ntricu la r tachycardia. What is the most a pp ropriate ma nagement?

AV node ablation Accessory pathway a blation Am iodaro ne

se As Dr

Sotalo l

m

Im p la nta ble ca rdioverter defibrillator

AV node a blation Accessj ry pathway a blatio n Am iodarone

~plantable cardioverter defibrillator

-

Sota lo l

As

Dr

Most ca rd io log ists wou ld now proceed to inserting a n imp lantab le cardioverte r d efibri llato r to lower the risk of sud den cardia c d eath

se

m

"""

Which o f the fo llowing is not true rega rd ing B-type natriuretic peptide?

Secreted ma inly by the ventricles Acts as a d iu retic Acts as a vasoconstricto r

Dr

Reduces sympathetic tone

As

se

m

Leve ls rise in leh ventricula r fa ilu re

Secreted ma inly by the ventricles Acts as a d iu retic Acts as a vasoconstrictor Leve ls rise in leh ventricula r fa ilu re Reduces sympathetic to ne

• vasodilator • diuretic and natriuretic • suppresses both sympathetic tone an d the renin-angiotensin-aldoste rone

Important for me

Less impcrtont

Dr

system

As se m

BN P - actions:

What is the role of troponi n in cardiac muscle?

Component of the thick filaments Acts as a linin g of the T tubules Anchors thick filament to Z-discs

se As Dr

Anchors thick and thin filaments together

m

Component of the thin filaments

What is t he role of tropo nin in cardia c muscle?

CD

Acts as a lining of the T tubules

f!D

Anchors thick filament to Z-discs

. (D

Component of the thin filaments

ED

Anchors thick and thin filaments together

fD As se

m

I

Component of the thick filaments

Dr

The other compo nents of thin filaments are actin and tropomyosin. Thick filaments are primarily composed of myosi n.

An 11-year-old boy who is known to have Down's syndrom e is reviewed in the cardiology clinic. Over the past year his pa rents report that he is more tired and breathless when he plays with his peers and siblings. On exam ination he appea rs cyanosed at rest. His p ulse is 90/min with no rad io-femoral d elay. There is a systolic mu rm ur and a loud second heart sound. A right ventricular heave is noted and the JVP is elevated. What is the most likely diagnosis?

Eisenmenger's synd rome Fulm ina nt patent ductus arteriosus

Tetralogy of Fa llot with pu lmonary atresia

Dr

Ebstei n's a nomaly

As se m

Fulm ina nt tra nsposition o f the great arteries

Eisenmenger's syndrome

I

Fulminant pat ent ductus arteriosus Fulr inant tra nsp osition of t he great arteries Ebstein's anomaly

se

m

Tetralogy of Fallot w ith pulmonary at resia

Dr

shunt is likely t o have reversed resulting in Eisen menger's syndrome.

As

This boy is likely to have b een born with a at rioventricular sept al d efect. Over t ime t he

A 45-yea r-o ld fe mal e is d ue to unde rg o a denta l extractio n fo r re lief o f ne uralg ic pain. Additio na lly, she is having a hyste recto my in 4 weeks fo r a fibro id ute rus with me no rrhagia. She me nti ons to you that s he has previously been d iagnosed with a heart murmur and wa nts to know if this will affect her o pe ration. In regard to her va lvula r heart disease and associated risk, what is the most a ppro priate thing to advise he r?

She should have a ntibiotic p rophylaxis a t the time o f hysterectomy o nly She should have a ntibiotic p rophylaxis for both proced u res She is not at risk o f infective endoca rd itis so shou ld not wo rry

As se m

She is at theo retical risk o f infective e ndoca rditis b ut antibiotic pro phylaxis is no longer a dvised routine ly fo r e ither procedure

Dr

She should b e offe red chlo rhexidine mouthwash as pro phylaxis when undergoing the denta l extraction

She should have a ntibiotic p rophylaxis a t the time of hysterectomy only

(D

She should have antibiotic p rophylaxis for both p rocedures

CD f!D

She is not at risk of infective endocarditis so should not worry e is at theoretical risk of infective end ocarditis b ut antib iotic prophylaxis is no ger advised rout inely for e ither procedure

GD

She should b e offered chlorhexidine mouthwash as prophylaxis when undergo ing the denta l extraction

CD

Antibiotic pro hylaxis to prevent infective e ndoca rditis is not routi nely reco mmend ed in the UK fo r d ental and othe r p roced ures Important for me

l ess ' m ::~c rtont

The answe r to th is question is based on NICE Gu idance (CG64 - Ma rch 2008).

Dr

recom mended.

As se m

Acco rding to th is guidance, as neither procedure requ ires prophylaxis (either antibiotics or mouthwash) the only app ropriate answer he re is 4 : that the patient is at theoretical risk o f infective endoca rditis but that antibiotic prophylaxis is no longer routine ly

Which one o f the followin g conditions is most associated with a b isferiens pulse?

Cardiac ta mponade Severe leh ventricu la r failure Aortic stenosis

se As Dr

Mixed aortic valve disease

m

Patent ductus arteriosus

Which one of the followin g conditions is most associated with a bisferiens pulse?

Card iac ta mponade Severe leh ventricular failure Aortic stenosis Patent d uctus a rteriosus

As se

m

Mixed aortic valve disease

Important for me

l ess ' m ::~c rtont

Dr

Bisfe riens p ulse - mixed aortic valve d isease

A 54-yea r-old man with angina has a p ercutaneous coro na ry intervention with in serti on of a drug-eluting stent. What is the s ing le most important risk facto r for stent thro mbosis?

Age of patie nt Premature withdrawal of a nti platelet the ra py Faili ng to adhe re to ca rd iac rehab ilitation p rog ram

se As Dr

Histo ry of diabetes mellitus

m

Duration o f proced u re

Age of patient Premature withdrawal of a nti platelet t herapy Faili ng to adhere to card iac reha bilitation p rogram Duratio n o f procedure History of d iabetes mellitus

PC!: stent throm bosis - with drawal of a ntiplate lets b igg est risk factor

m

As se

Diabetes mell it us is a risk factor for restenosis rather than stent throm bos is

Less im:>crtc.nt

Dr

Important for me

A 52-yea r-old man is seen in the hypertension clinic. He was d iagnosed a rou nd three months ago and sta rted on ram ipril. This has b een titrated up to lOmg o d but his b lood p ressure remains around 156/92 mmHg. What is the most ap po priate next step in management?

Add bendroflumethiazide Add bisop rolol Switch ramipril to perindopril

se As Dr

Add losa rta n

m

Add am lodipine

Add bendroflumethiazide

D.

Add bisoprolol

CD

• •

Switch ra mipril to perindopril

I

fD

Add amlodipine Add los arta n

Calcium channe l blockers are now preferred to thiazides in the treatment of hypertension Important for me

Less imocrtant

Dr

hypertension.

As se m

The 2011 NICE guidelines reflect ed the chang ing evidence base supporting the use o f calcium channel blockers in preference to thiazide-type diuretics in the management of

Which one of the followi ng is not a risk factor for the development of pre -eclampsia?

Body mass index of 38 kg/m"2 Smoking A woman carrying twins

se As Dr

Diabetes mellitus

m

Nulliparity

CD

Body mass index of 38 kg/m"2

ED

A womar carrying twins

CD

Nulliparity

CD

Diabetes mellitus

CD As

se

m

Smoking

Dr

There is some evidence to suggest that pre-eclampsia is actually less common in smokers

A 34-year-old man is investigated following an unexplai ned collapse whilst at work. A resting ECG shows convex ST elevation in Vl-V3 with a partial right bundle bra nch block pattern. What is the most likely diagnosis?

Catecholam inergic polymorphic ventricular tachycardia Hypertrophic obstructive cardiomyopathy Arrhythmogenic right ventricular ca rdiomyopathy

se As Dr

Normal variant

m

Brugada syndrom e

Catecholaminergic polymorphic ventricular tachycardia

Hypertrophic obstructive cardiomyopathy Arrhythmogen ic right ventricular cardiomyopathy

se As Dr

Normal variant

m

Brugada syndrome

An 83-year-old male p resents with ischaemic sou nding che st pain th at has persisted for the past one hour. A 12-lea d ECG is p erformed and s hows deep T wave inversio n in leads Vl and V2. Which is the mo st like ly imp lica ted corona ry arte ry?

Left circumflex artery Left mai n stem artery

As se

Distal left a nterior d escending artery

Dr

Right corona ry artery

m

Proxima l left anterior descending artery

Left circumf lex artery Left main stem artery Proximal left anterior descending artery Right co ronary artery Dista l left ant erio r descen ding artery

Ischaem ic changes in leads Vl-V4 - left anterior descending Important for me

Less imocrtc.nt

As se m

Wellens' syndrome is an ECG manifestation of critical proximal left anterio r descending (LAD) coronary artery stenosis in patients with unstable angina. It is characterized by

Dr

sym metrical, often deep (> 2 mm), T wave inversions in the anterior precordial leads.

A 62-yea r-old female with no past medical history is adm itted to hospita l with a left-sided he mipa resis. Exa mination reveals that she is in atrial fibrillation. CT scan of her brain shows a cerebral infarction. What is the most appropriate anticoagulation strategy for this patient?

Life-long warfa rin, sta rted immed iately Aspirin started immediately switching to life-long warfarin after 2 weeks Life-long aspirin, started immed iately

se As Dr

6 months of warfarin, started im mediately

m

Life-long aspirin started after 2 weeks

Life-long warfa rin, sta rted immediately

fiD

Aspirin started immediately switching to life-long warfarin after 2 weeks

GD

m

Life-long aspirin started after 2 weeks

C)

se

As Dr

6 months of warfarin, started immediately

m

Life-long aspirin, started immediately

m

A 55-year-old man presents w ith a 2-hour hist ory palpitations. He has no other history of note and is generally fit and well. An ECG confirms fast atrial fibrillation with a rate of 140/ min. He has a fear of sedation an d requests pharmacologica l cardioversion. Which one of the following agents is most likely to cardiovert him int o sinus rhythm?

Atenolol Procainamide Flecainide

se As Dr

Digoxin

m

Disopyramide

CD

Atenolol Procain amide

GD

Flecainide

CD CD

Digoxin

fD As

se

m

Disopyramide

Important for me

Less imocrtont

Dr

Atrial fibrillation - ca rdioversion: amiodarone + flecainide

You are asked to urgently review a 61-year-old fema le on the ca rdiology wa rd due to difficu lty in breathing. On examination she has a raised JVP with bilateral fine crackles to the mid zones. Blood pressure is 94/60 mmHg and the pulse is 140-150 and irregular. ECG confirms atrial fibrillation. What is the most appropriate management?

IV amiodarone IV digoxin Urgent synchronised DC cardioversion

se As Dr

IV flecainide

m

Oral digoxin

IV amiodarone IV digoxin Urgent synchronised DC cardioversion Ora l digoxin

se

m

IV flecainide

Dr

cardioversion

As

Heart fa ilure is one of the adverse signs indicating the need for urgent synchronised DC

A 72-year-o ld man p resents to the Emergency Department with a broad complex tachycardia. Which o f the following features wou ld make it more likely that this was due to a supraventricular tachycardia rath er tha n a ventricu lar tachycardia?

History of ischaem ic heart d isease Left axis deviation Capture beats

se As Dr

QRS comp lex greater than 160 ms

m

Absence o f QRS concord ance in chest leads

I

flD

Left axis deviation

GD

Capture beats

fiD

Absence of QRS concordance in chest leads

CD

QRS complex greater than 160 ms

flD As

se

m

I

Histo{ o f ischaem ic heart d isease

Dr

Positive QRS concordance in the chest leads is associated with ventricu la r tachycardia

A 60-yea r-o ld ma le has a past med ical history of hypertension, type II diabetes a nd ischaem ic heart disease. He has recently been started o n a new me d icatio n. His GP notices that his HbAlc has increased sig nifica ntly over the same period. Which me d icatio n is most li kely to have adversely a ffected his g lycaemic control?

Alendronic acid Am iodarone Allopurinol

se As Dr

Calcium carbonate and vitamin D3

m

Bendroflumethiazid e

Alendronic acid Amiodarone AlloRurino l Bend rof l u methiazide Calcium carbonate and vita min D3

Bendroflumethiazides can wo rsen glucose tolerance Important for me

Less · m oc rtC~nt

The correct answer is bend roflumet hiazide. Thiazides can worsen g lycaemic control and increase urate levels w hich can worsen gout . The other drugs are not known t o have an

https:/ / b nf.nice .o rg. u k/ d rug/ bend rofl u meth iazid e. html#s ideE ffect s

Dr

BN F:

As se m

effect on glycaem ic control.

A 65-year-old female with a known history of heart failure presents for an annual checkup. She is found t o have a blood pressure of 170/ 100 mmHg. Her current medications are furosemide and aspirin. What is the most appropriate medication to add?

Bendroflumethiazide Spironolactone Bisoprolol

se As Dr

Enalapril

m

Vera pamil

Bendroflumethiazide

CD

Spironolactone

•

. GD

Verapamil

f!D

Enalapril

fD

As se

Both enalapril and bisoprolol have been shown to improve prognosis in patients with heart failure. Enalapril however would also be better at treating the hypertension. NICE

Dr

guidelines recommend the introduction of an ACE inhibitor prior to a bet a-blocker in patients with chronic heart failure

m

Bisoprolol

Each one of the fo llowing is associat ed w ith left axis deviation on ECG, except:

Left ant erior hemiblock Ostium primum ASD Left posterior hemiblock

As Dr

Left bundle branch block

se

m

Obesity

Left ant erior hemiblock Ostium primum ASD

-

~ posterior hemiblock

~

Obesity

As

se

m

Left bundle branch block

Important for me

Less impcrtont

Dr

Right axis deviation - left posterior hemiblock

A 55-year-old man with a history o f ischaemic heart disease presents t o the Emergency Department w ith palpitations for the past 10 days. Examination of his pulse reveals a rate o f 130 bpm which is irregularly irregular. He has had one previou s episode of atrial fibrillation 3 months ago which was t erminated by elective cardioversion following warfarinisation. What term best descri bes his arrhythmia?

Paroxysmal atrial fibrillation Atrial flutter

Secondary atrial fibrillatio n

Dr

Persistent atrial fibrillation

As se m

Permanent atrial fibrillation

II. 55-yea r-o ld man with a histo ry o f ischaemic hea rt disease presents to the Eme rgency

De partment with pa lpitations fo r the past 10 d ays. Exa mination of his p ulse reveals a rate Jf 130 bp m which is irregularly irregu la r. He has had one previous ep isode of atria l fibrillation 3 months ago which was te rminated by e lective ca rdiove rsion fo llowing Na rfarin isation. What term best d escri bes his a rrhythmia?

-

Paroxysma l atrial fibrill ation

~

Atrial flutter

As se

Secondary atrial fibrillation

Dr

~sistent atrial fibrillation

m

Permanent a trial fibrillation

A 64-year-old man with a history of type 2 diabetes mellitus is admitted with chest pain

to the Emergency Department. An ECG shows ST elevation in the anterior leads and he is

thrombolysed and transferred to the Coronary Ca re Unit (CCU). His usual medication

includes simvastatin, gliclazide and met formin. How should his diabetes be managed

whilst in CCU?

Stop metformin. Continue gliclazide at a higher d ose Stop metformin & gliclazide. Start subcutaneous insulin (basal- bolus regime)

As se

Stop metformin & gliclazide. Start intravenous insu lin infusion

m

Continue metformin & gliclazi de at same d ose

Dr

Stop metformin & gliclazide. Start subcutaneous in su lin (biphasic insulin regime)

Stop metformin. Continue gliclazide at a higher dose Stop metformin & gliclazide. St art subcutaneous insulin (basal-b olus regime)

-

Continue metformin & gliclazide at same dose

"""'

Stop metformin & gliclazide. Start intravenol!ls insu lin infusion Stop metformin & gliclazide. St art subcutaneous insulin (biphasic insulin regime) CD

The benefits o f tight glycaemic control following a myocardial infarction were init ially established by the DIGAMI study. These findings were not repeated in the later DIGAMI 2 study. However modern clinical practice is still that type 2 diabetics are converted to intravenous insulin in the immediat e period following a myocardial infarction.

As se m

NICE in 2011 recommended the following: 'Manage hyperglycaemia in patients admitted

Dr

to hospital for an acute coronary syndrome (ACS) by keeping blood glucose levels below 11.0 mmol/litre while avoiding hypoglycaemia. In the first instance, consider a doseadjusted insulin infusion with regular monitoring of blood glucose levels.'

Each one of the following may cause leh bu ndle branch block, except:

Cardiomyopathy Atrial septa l defect (ostium secund um) Hypertension

As Dr

Ischaemic heart disease

se

m

Idiopathic fibrosis

CD

Cardiomyopathy Atrial septal defect (ostium secundum)

6D

HypertensL jo_n_ _

GD

Idiopathic fibrosis

6D m

•

Dr

As

se

Ischaem ic hea rt disease

A 55-yea r-old female p rese nts to the e mergency depa rtment with an e ight-ho ur history o f heart palpitations. She has a hea rt rate of 200 b eats pe r minute and an ECG shows

regular QRS com plexes o f 0.08 seconds . She ha s not had a ny chest pa in or episode s o f syncope and has no signs o f heart fa ilu re. Her bloo d pressu re is 130/90 mmHg a nd her oxyg en saturations a re 97% on a ir. What should you d o first?

Carotid s in us ma ssage Adenosine 6mg

As se

Atro pi ne O.S mg

Dr

Am ioda ro ne 300mg

m

Adenosine 12mg

I

-

Carotid sinus massage

CD

Adenosine 6mg

CD

r :f enosine 12mg

m m

Amiodarone 300mg Atropine O.S mg

This fema le has a regu la r narrow complex tachycardia with no adverse featu res. The first step in this instance wou ld, the refore, be to try va gal manoeuvres, for example, a carotid sinus massage. If this is unsuccessful, IV adenos ine should b e given (6mg at first, followed by 12mg if no response, and then by a furthe r 12mg if a ga in no response). If this is unsu ccessfu l cons ider atrial flutter as the d iagnosis a nd treat as appropriate.

Dr

Atropine is used in the management of bradyca rdia .

As se m

Amiodarone can be used for rhythm control if the patients' narrow complex tachycardia is due to atrial fibrillation or atrial flutter. It co uld a lso be used in the ma nagement of b road com plex tachycardia.

An 89-year-old man attends your clinic, comp laining of bright spots in his vision that come and go. He has a past medical hist ory o f asthma, triple vessel coronary artery disease opting for medical management of his anginal sympt oms, and has just completed a course of itraconazole for a fungal infection. His heart rate is 60bpm and blood pressure 120/70mmHg. Which of his regular medications is most likely resp onsible for his sympt oms?

Am lodipine Beza fibrat e Ivabradine

Dr

Ventolin

As se m

Ranolazine

I

Ivab rad ine

ED

Ranolazine

GD CD

Ventolin

Ivabrad ine is ind icated fo r the sympto matic re lief of angina in patients with a heart rate > 70, as an a lternative to first line the rap ies. It is a lso ind icated fo r the treatm ent of chronic heart fail ure (NYHA II-IV) in addition to standa rd the rapy, in patients with a heart rate of > 75.

The mode o f action o f ivabradi ne is by inhibition of If channels (known as funny channe ls), I = current, f =funny. These funny channels are so called because of their unusual features compared to other ion channe ls. They a re mixed sodium and potass ium channe ls found in spontaneously active reg ions o f the heart such as the s inoatrial node and are triggered by hyperpola risation. Activated funny channe ls a llow an influx o f positive ions, triggering d e polarisation and are therefo re responsible for the spontaneous activity o f cardiac

As se m

myo cytes.

Dr

By inhibiting If channels ivabrad ine de lays d epola risation in the sinoatria l nod e and the refore selectively s lows heart rate .

A 71-yea r-o ld woman is a dmitted with acute dysp noea to the Emergency Departme nt. Oxygen satu rations a re 94% on 28% supp le me ntary oxyge n and her resp iratory rate is 30/min. A rap id B-type natriu retic p eptide (BNP) assay is rep orted as fo llows: BNP

62 pg/ml

What is the b est interpretation o f this resu lt?

No co nclus io n ca n b e drawn fro m this result Pulmonary em bolis m is the most like ly cause of her symptoms If a further BNP level is above 50 pg/ml after o ne hour then this is diag nostic of hea rt failu re

Dr

Heart fa ilure is highly likely to be the ca use of he r dyspnoea

As se m

Heart fa ilure is u nlike ly to be the cause of her dyspnoea

I

No concl usion can be drawn from this resu lt

-

Pulmonary embolism is the most likely cause of her symptoms

~

If a further BNP level is above SO pg/ml after one hour then this is diagnostic of

As

Heart failure is highly likely to be the cause of her dyspnoea

se

m

Heart failure is unlikely to be the cause of her dyspnoea

Dr

I

heart failure

A 72-year-old man with a history of chronic heart failure secondary to ischaemic cardiomyopathy is reviewed. He was discharged two weeks ago from hospital following a myocardial infarction. An echocardiogram done during his admission showed a left ventricular ejection fraction of 40% but did not demonstrate any valvular problems. Despite his current treatment with furosemide, ramipril, carvedi lol, aspirin and simvastatin he remai ns short of breath on minimal exertion such as walking 30 metres. On examination his chest is clear and there is minimal peripheral oedema. What is the most appropriat e next step in management?

Stop aspirin Refer fo r cardiac resynch ronisation therapy Switch carved ilol to bisoprolol

Dr

Add an aldosterone antagonist

As se m

Add angiotensi n-2 receptor blocker

Stop asp irin Refer for card iac resynchro nisati on therapy Switch ca rved ilol to b iso prolol

I

Add angiotensin-2 receptor b locker Add an aldosterone antagonist

Dr

As se m

The updated 2010 NICE gu id elines now su ggest that in additio n to a ld osterone antag onists both angiotensi n-2 receptor blockers a nd hydralazine in combinatio n with a nitrate are suitable second -li ne treatments for heart failure. However, g iven that he has had a recent myo ca rdial infa rction the best choice is a n a ld osterone antag on ist - please see the NIC E guide li nes for mo re d eta ils.

A 76-year-old woman is admitted with palpitations. During the cardiovascular examination you notice irregular can non 'a' waves. Wh ich one of the following wou ld account for this finding?

Atrio-ventricular nodal re-entry tachycardia Atrial fibrillation with tricuspid stenosis Ventricular tachyca rdia with 1:1 ventricular-atrial conduction

As Dr

Tricuspid regu rgitation

se

m

Complete heart block

A 76-yea r-old wo man is admitted with palpitations. During the ca rdiovascular exa mi nation you notice irregular cannon 'a' waves. Wh ich one of the following would account fo r this finding?

Atrial fibrillation with tricuspid stenosis Ventricular tachycardia with 1:1 ventricular-atrial conduction

Tricuspid regurgitation

As se

m

Complete hea rt block

Dr

I

Atrio-ventricular nodal re-entry tachycardia

A 63-yea r-old female is brou ght to the Emergency De partment due to a decreased level of consciousness. An urgent CT head is performed as she takes warfa rin for atrial fibrillation an d shows an intracranial haemorrhage. What is the most appropriate management?

Protamine sulphate IV vitamin Kalone IV vitamin K + prothrombin com plex concentrate

Dr

IV vitamin K + fresh froze n plasma

As se

m

Fresh frozen plasma alone

Protamine sulphate IV vit amin K alone IV vitamin K + prothrombin complex co ncentrate Fresh frozen plasma alone IV vitamin K + fresh frozen plasma

Major bl eeding - stop warfarin, give intravenous vitamin K Smg, prothrombin complex co ncentrate Important for me

l ess im:>crtc.nt

availability

Dr

should be used in such an urgent situation. The use of PCC is currently limited by

As se m

As fresh frozen plasma takes time to defrost prothrom bin complex concentrate (PCC)

A 66-yea r-old ma n with no past med ical history of note p resents with central chest pain to the Emergency Department. An ECG shows ST e levation in the anterior leads. He is given aspirin and ticagrelor before going fo r a percutaneous coronary intervention. What is the mecha nism of action of ticagrelor?

Inhibits ATP bind ing to its p latelet receptor Glycoprotein lib/lila inhibitor Phosphodiesterase V inhibitor

Dr

Inhibits ADP b ind ing to its platelet receptor

As se

m

Non-selective phosphodiesterase inhib itor

Inhibits ATP binding to its platelet receptor

Phosphodiest erase V inhibit or Non-selective phosphodiesterase inhibitor Inhibits ADP binding to its platelet receptor

t o platelet receptors Important for me

As se

m

Ticagrelor has a similar mechanism of action to clopidogrel - inhibit s ADP binding Less impc rtc.nt

Dr

I

Glycoprotein lib/lila inhibitor

Which of the follow ing cond it ions is least associat ed with coa rct ation of t he aorta?

Neurofibromatosis Bicusp id aortic valve Prad er-Willi syndrome

Dr

Berry aneurysms

As

se

m

Tu rner's syndrome

Which of the following cond it ions is least associated with coa rct ation of the aorta?

fD

Neurofibromatosis

CD

Bicuspid aortic valve

CD m

Tu rner's syndrome

se

. (!D As

Berry aneurysms

Dr

I

ED.

Prader-Willi syndrome

A 74-year-old man is admitt ed with chest pain associated with ECG changes. A troponi n T t aken 12 hours after admission indicates an acute myocardial infarction. Which one of the following is most likely to predict a poor prognosis?

Hist ory of diabetes mellitus Loss of heart rate variability Left ventricu lar ej ection fraction of 40%

As Dr

Male sex

se

m

Diast olic blood pressure of 110 mmHg

History o f diabetes mellitus

-

Loss o f heart rate variability

~

I

Left ventricular ejection fraction of 40%

-

As

~

Dr

Male sex

se

m

Diastolic b lood pressure of 110 mmH g

Which one of the following is least recognised as an adverse effect of taking bendroflumethiazide?

Hypokalaemia Pseudogout Hypercalcaemia

Dr

Impaired glucose to lerance

As

se

m

Impotence

Hypokalaemia Pseudogout

-

Hypercalcaer r l

~

Impotence Impa ired glucose tolerance

Dr

Bendroflumethiazide predisposes to gout, rather than pseudogout

As

se

m

~

A 65 -yea r-o ld wo man comp lain s o f chest pa in on exertio n such as when wa lki ng up the stairs o r do ing ho usewo rk. She d escribes the pain as a constricting discomfo rt in front o f the chest. The pain typ ically radiates to the left shou ld e r and disa ppea rs on resting . She su ffe rs from severe osteoarthritis of the left knee, which limits he r mo bility. She also suffe rs fro m b rittle asthma a nd high blood pressu re. Her last cho leste ro l check wa s 4 years ago and this was no rma l. She is a no n-s moker. On exam inatio n, she ap pea rs well a nd pa in-free. Hea rt sou nd s we re normal with no murmur. Resting ECG is normal. What is the next step in the investigation of th is lady's symptoms?

Check her cholesterol leve l to d etermine the investig atio n of choice Exe rcise (stress) echoca rd io gram Contrast-enhanced coronary CT angiog raphy

Dr

Invasive coronary a ngiog raphy

As se m

Adenosine stress-CM R

I

Contrast-enhan ced coronary CT ang iog ra phy Adenosine stress-CM R Invasive coronary a ngiog ra phy

Contrast-en hanced CT corona ry angiog ra m is the first line investigation fo r stab le c hest pain of suspected coro nary arte ry d isease aetio logy Important for me

Less : m ::~c rtant

This lady c hest pa in cha racteristics are consistent with typical angina. The first- line investigation reco mmended by NICE is contrast-enhanced CT co ro na ry angiogram cCTA. The new NICE gu ideline no longe r reco mmends using pre-test likeli hood o f the CAD to d etermine the ap propriate first -line investigation. This lady may not b e suitable fo r exercise (stress) echocard iogra m as she suffers fro m seve re osteoa rthritis o f the knee. Stress echocard iogra m with d o buta mine may be a ppropriate but is less sensitive than cCTA (and is not an option fo r this q uestion). Adenosine stress-CM R is ve ry sensitive in d etecting CAD but the use o f a denosine in

As se m

someone with asthma is contra indicated due to the risk o f bro nchospasm. Immediate invasive co ronary ang iogra phy is typica lly not the first-line investig atio n method due to the cost and possible complications. The use of invasive angiography without a 'g atekeeper' non- invasive test is not recommended by NICE but is still recommended by ESC and AHA in patients with very high p re-test likelihood of CAD. Othe r than her age

Dr

a nd hypertension, she does not have other ca rdiovascu la r risk facto rs e .g. smoking, dia betes, etc.

A 71-year-old man with a history o f ischaemic heart disease is brought to the Emergency Department following a 'collapse'. He now feels back to normal. The ECG shows sinus rhythm, 94/min with leh bundle branch block. Given the ECG findings, w hich one of the following is most likely to be found on auscultatio n o f the heart?

Fixed split 52 Lou d 51 Th ird heart sound (53)

Dr

Reversed split 52

As se

m

Widely split 52

CD

Fixed sp lit 52

CD

Lou d Sl Th ird heart sou nd (S3)

GD

W idely split 52

CD

Reversed sp lit 52

CXD

Second heart sound (52) • loud: hypertension • soft: AS

Important for me

Less · m oc rtC~nt

Dr

• reversed sp lit: LBBB

As se m

• fixed split: ASD

You are an SHO working at district general hospit al in Cornwall. A 56-year-old man p resents to the emergency department w ith crush ing central chest pain that started 30 minutes ago. His ECG demonstrates ST elevation in the anterior leads and he is treated for an ST -elevation myocard ial infarction (STEM!). So fa r he has been given aspirin, clopidogrel, low -molecu lar weight heparin (LMWH) and his chest pain has signif icantly improved with sublingual GTN and IV morp hine + metoclopramide. There is no cath- lab on site and and the nearest percutaneous coronary intervention (PC!) centre in Truro is approximately 2 '12 hours away. Which of the following is the most appropriate cou rse of action?

Transfer to PC! centre Give b ivalirudin Start infusion o f unfractionated heparin and transfer to PC! centre

Dr

Give ticagrelor

As se m

Give alteplase

I

Give alteplase Give ticagrelor

In management of STEM! if primary PC! cannot be delivered w ithin 120 minutes then th rombolysis should be given Important for me

Less imocrtant

In the management of STEM! fibrinolysis w ith a drug such as alteplase should be offered if primary PC! cannot be delivered within 120 minutes o f the time when fibrinolysis could have b een given. This problem is most often encountered when a patient initially presents to a district general hos pital that lacks a PC! centre. Am bulances are generally direct ed to PC! centres in cases of chest pain and this has reduced the frequency with which this occurs. If a repeat ECG at 90 minutes does not show resolution of ST elevation the patient w ill require transfer t o a PC! centre regardless. 1- This is inappropriate. The transfer time is over 120 minut es from w hen fibrinolysis cou ld b e given. This would therefore b e an unaccept able delay.

Dr

address the main issue which is the need for PCI/ fibrinolysis.

As se m

2- This is a direct thrombin inhibit or. It has a role in STEM! management but wou ld not

3- Though sometimes used in STEM! again, fibrinolysis or PC! are needed. Additionally,

You a re called to the co ronary care un it. A patient who has been a dmitted following a myocardial infa rction has deve loped a b road complex tachyca rdia . You suspect a diagn osis of polymo rph ic ventricu la r tachyca rd ia . Which one of the following facto rs is most li kely to have precipitated this?

Hypoglycaem ia Bisoprolo l Hypomagnesaem ia

se As Dr

Hyperkalaem ia

m

Dehydration

Yo u are ca lled to the corona ry ca re u nit. A patient who has been a dmitted following a myo ca rdial infarctio n ha s develop ed a b road co mplex ta chyca rdia . You suspect a diagnosis of polymo rphic ve ntricula r tachycardia . Which one of the following factors is most li ke ly to have precipitated this?

I

Hypoglycaem ia

CD

Bisoprolo l

CD CD

Hypomagnesaemia

CD

Dehydration

8D

Hyperka laemia

Hypokalemia is the most importa nt cause of ventricu lar tachycardia (VT) clinica lly,

Dr

com mon a cause as hypomag nesaem ia.

As se m

fo llowed by hypomagnesae mia. Severe hype rkalaem ia may cause VT in certain circumsta nces, fo r exa mple in patients with structu ra l hea rt disease, but it is not as

A 62-year-old man comes for review. In the past month he has had two ep isodes of 'passing out'. The first occurred whilst going upsta irs. The second occurred last week whilst he was getting out of a swimming pool. There were no warning signs prior to these episodes. He was told by people who witnessed the episode last week that he was on ly 'out' for a rou nd 15 seconds. He reports feeling 'groggy' for only a few seconds after the episode. On exam ination pulse is 90 I minute, b lood pressure 110/ 86 mmHg, his lungs are clear and there is a systolic murmu r which radiates to the carotid area. Which one of the following investigations shou ld be a rranged first?

24 hour ECG mon itor Echoca rdiogram Exercise tolerance test

Dr

Carotid d oppler

As se m

CT hea d

24 hou r ECG mo nitor

GD

Echoca rdiogram

ED

• •

Exercise tolera nce test CT hea d

GD

Carotid d opp ler

As se m

The systo lic murmur may be a po inte r to aortic stenosis (AS). Synco pe is a late sig n and typica lly occurs o n exertion in patients with AS. It is the refo re impo rta nt to exclud e this conditio n as a p riority.

stenosis.

Dr

An exercise tolerance test wou ld be contraindicated in a patie nt with susp ected aortic

A 56-year-old man w it h a past histo ry of ischaemic heart disease is admitt ed w ith cent ral chest pain radiat ing to his left arm associated w it h nausea. On arrival in t he Coronary Ca re Unit he is not ed to be in complete heart block. Which coronary artery is likely t o be affect ed?

Circumflex Right coronary Obtuse marginal

Dr

Po sterior d escending

As se

m

Left ant erior descending

m

Circumflex

6D

Right coronary

m

Obtuse ma rgina l

CD

Left anterior descending

m se As Dr

The right coronary artery supplies the atrioventricular node in 90% of patients

m

Posterior d escending

A 60-year-old man who is investigated for exertional chest pain is diagnosed as having angina pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?

Atenolol Aspirin Isosorbide mononitrate

As Dr

Nicorandil

se

m

Ram ipril

Atenolol Asp irin Isosorbide mononitrate Ram ipril Nico randil

Dr

As se

m

Strong evidence exists supporting the use of aspirin in stable angina. The benefit of ACE inhibitors and beta-blockers are significant in patients who've had a myoca rdial infarction but modest in those with stable angina. Please see the CKS li nk for a review of the most recent trials.

An 84-year-old female has become progressively more short of breath over the past 2 months. She is finding it difficu lt t o breath e when lying down and so ha s been sleeping upright in her cha ir for the past two weeks. She also has a cough productive o f frothy sputum and swollen legs. What is the most likely description of her pulse?

Pulsus alt ernans Collapsing Jerky

Dr

Pulsus bisf eriens

As se m

Slow rising

I

Pulsus alternans

CD

Collapsing

CD . CD

Jerky Slow rising

f!D

Pulsus bisferiens

«ED

Pulsus a lternans - seen in left ventricular failure Important for me

Less im:>c rtc.nt

Pulsus a lternans is when the upstroke of the pu lse alte rnatives between strong and weak. It indicates systolic dysfunction and is seen in patients with heart failure. A collapsing pu lse has a forcefu l rapid upstroke AND descent.

A bisferiens pu lse occurs when there a re two sharp upstrokes du ring systole.

Dr

A slow-rising pu lse has a slow upstroke.

As se m

A jerky pu lse is characterised by a rapid forcefu l upstroke.

Which one of the following features is not part of the modified Duke criteria used in the diagnosis of infective endocarditis?

Prolonged PR inte rval Positive serology for Coxiella burnetii Fever > 38°C

As Dr

Positive microbiology from embolic fragments

se

m

Roth spots

I

Prolonged PR inte rval Positive serology for

Coxiella burnetii

Fever > 38°C

Roth spo ts Positive microbiology from embolic fragment s

se

m

A prolonged PR interval is part of the diagnostic criteria o f rheumatic fever. The modified

Dr

o f Cardiology. Det ails ca n b e found in the link b elow

As

Duke criteria have now b een adopted in th e latest guidelines from the European Society

Which part of the jug ular venous wavefo rm is associated with the fall in atria l pressu re during ventricu lar systole?

y descent vwave x descent

As Dr

a wave

se

m

cwave

vwave

CD

x descent

CID

c wave

CD

a wave

. (D se

m

fD

Important for me

As

JVP: x descent = fall in atrial pressu re during ventricu lar systole

l ess i m ::~c rtc.nt

Dr

I

y descent

A 37 -year-old who is 38 weeks p regn ancy is an inpatient on the obstetric ward for the management of pre-eclam psia. Blood pressure is 172/114 mmHg and urine dipstick shows proteinuria +++. A d ecision has been made to start magnesium sulphate thera py as she is deemed at risk of eclampsia. Of the following options, which are the most important pa rameters to monitor whilst the patient is receiving magnesium?

Blood sugar + pu lse rate Reflexes + respiratory rate Blood sugar + respiratory rate

Dr

Gla sgow coma sca le + pulse rate

As se m

Reflexes + pu lse rat e

Blood sugar + p ulse rate Ref lexes + resp irat ory rate Bloo d sugar + resp irat ory rate Reflexes + pu lse rate

-

Glasgow coma sca le + pulse rate

m

. .wr

As

Less · m::~c rtant

Dr

Important for me

se

M ag nesium su lphate - monito r reflexes + res piratory rate

A 17-yea r-o ld gi rl is brought into resus in cardiac arrest. On adm ission she is in asystole a nd attem pts to resuscitate are u nsuccessful. She collapsed whilst competing in a l ,SOOm race at college. The only past medical of note was asthma for which she occasio nally used a sa lbutamo l inhaler. There is no relevant fa mily history. What is the most li ke ly unde rlying cause o f d eath?

Long QT synd rome Hypertrophic obstructive cardiomyopathy Catecho lam inergic p olymorphic ventricula r tachycardia

Dr

Arrhythmogen ic right ve ntricula r dysp lasia

As se m

Brug ada syndro me

Long QT syndrome Hypertrophic obstructive cardiomyopathy Catecholaminergic polymorphic ventricular t achycardia Brugada syndrome Arrhythmogenic right ventricular dysplasia

HOCM is the most common cause of su dden cardiac death in the young Important for me

Less impcrtont

Hypertrophic obstructive cardiomyopathy (HOCM) is a more common cause of su dden cardiac death than arrhythmogenic right ventricular dysplasia (ARVD). Catecholaminergic p olymorphic ventricular t achycardia (CPVT) is a form of inherited cardiac disease which is also associated with sud den ca rdiac death. It is inherited in an autosom al dominant fashion and has a prevalence of around 1:10,000.

As se m

Brugada syndrome is a fo rm of inherited cardiovascular disease which again may present with sudden cardiac death. It is inherited in an aut osomal dominant fashion and has an

Dr

estimated prevalence of 1:5,000-10,000. Brugada syndro me is more common in Asians.

Which one o f t he followin g ECG findings is least associated wit h digoxin use?

Bradycardia Down -sloping ST d epression Flattened T waves

Dr

AV block

As

se

m

Prolonged QT interval

Bradycardia Down -s loping ST depression Flattened T waves

m

~longed QT interval Dr

As

se

AV block

A 49-year-old female is admitted t o the Emergency Department with shortness of breath. On examination the pulse is 114 bpm with blood pressure 106/ 66 mmHg, t emperature 37.7°( and respiratory rate 30/ min. Exam ination of the ca rdiorespirato ry system is unremarkable with a p eak expiratory flow rat e of 400 1/min. Arterial blood gases on air reveal: pH

7.41

pC02

4 .0 kPa

p0 2

7.2 kPa

Follow ing the initiation of oxygen therapy, what is the next most important st ep in management ?

IV aminophylline IV hydrocortisone Low molecular weight heparin

Dr

IV co -trimoxazole

As se m

IV fluids

I

IV aminophylline

m

IV hydrocortisone

GD

Low molecular weight heparin

CD

IV fluids

GD

m

IV co-trimoxazole

Patients with a su spected pulmonary embolism should be initially mana ged with low-molecular weight hepari n Important for me

Less imocrtc.nt

Low-grade pyrexia is common in pulmonary embolism.

Dr

signs points towards a diagnosis o f pulmonary embolism.

As se m

Type 1 respirat ory fai lure in a tachycard ic, t achypnoeic fema le with an absence of chest

Which one o f t he followin g non-invasive met hod s provid es t he most accurat e assessment o f whet her a patient has coronary artery disease?

Contrast enhanced ca rdiac CT Cardiac MRI wit h gadolinium Exercise ECG

As Dr

Transoesophageal echocardiog raphy

se

m

Card iac SPECT wit h reversibility studies

fD

Cardi ac MRI with gadolinium

GD

Exercise ECG

G'D

Cardiac SPECT w it h revers ibility stud ies

fD

m

As

Transoesophageal echocardiography

se

m

Contrast enhanced cardiac CT

Dr

I

A 30-year-old fema le patient tells you that she is planning to become pregnant over the next year. You note from her reco rds that she has a history of ventricular septal defect. Which one of the followin g would represent a contraindication t o her becoming pregnant ?

Aortic regurgitation Having a peri membranou s rather than a muscular defect A previous episode of infective endocarditis

Dr

A history of previous surgical repair

As se

m

Pulmonary hypertension

Aortic regurgitation Having a peri membranous rather than a muscular defect A previous episode of infective endocarditis Pulmonary hyperten sion A history o f previous su rgica l repair

Less ' m ::~c rtant

Dr

Important for me

As

se

m

Women with pulmonary hypertension should avoid becoming pregnant due t o very high mortality levels

The most commo n cause of restrictive cardiomyopathy in the UK is:

Diabetes mellitus Systemic lupus erythematous Haemochromatosis

Dr

Amylo idosis

As

se

m

Tuberculosis

Diabetes mellitus Systemic lupus erythematous Haemochromatosis Tuberculosis Amyloidosis

Important for me

Less 'mpcrtant

Dr

syndrome, sarcoidosis, scleroderma

As se

m

Restrictive cardiomyopathy: amyloid (most common), haemochromatosis, Leffler's

You receive t he blood results of a 76 -year-o ld man who t akes wa rfarin following a pulm onary embolism two months ago. He recently complet ed a cou rse of ant ibiotics. JNR

8.4

On reviewi ng t he patient he is well with no bleed ing or b ru ising. What is t he m ost appropriat e action?

Stop warfa rin + restart when INR < 5.0 + give low-molecu lar weight hepa rin unti l warfa rin rest arted Ora l vitam in K Smg + stop warfarin + rep eat I NR aher 24 hours Stop warfa rin + restart when INR < 3.0

Dr

Fresh f rozen plasma + restart warfarin when INR < 5.0

As se m

Stop warfa rin + restart when INR < 5.0

Stop warfarin + resta rt when INR < 5.0 + give low-molecu lar weight heparin until

I

CD

wa rfarin rest arted Oral vitam in K Smg .,. sto p warfarin .,. rep eat I NR aher 24 hours Stop warfarin + resta rt when INR < 3.0

-

Stop warfa rin + resta rt when INR < 5.0

~

Fresh frozen plasma + restart warfarin when INR < 5.0

INR > 8.0 (no b leed ing)- st op warfarin, g ive oral vitamin K 1-Smg, repeat dose of vitamin K if INR high aher 24 hours, rest art when INR < 5.0 l ess 'moc rtont

Dr

The BNF recommends a dose of between 1 to 5mg o f vitamin K in this situation.

As se m

Important for me

A 54-year-o ld man is admitted following a myocardia l infarction associated with ST elevation. He is treated with thro mbolysis and does not undergo ang iop lasty. What advice s hould he be given regarding driving?

Can continue driving but must info rm DVLA Cannot drive until an ang iogram has been performed and reviewed by a cardiolog ist Cannot drive for 1 week

Dr

Cannot drive for 12 weeks

As se

m

Cannot drive for 4 weeks

Can continue driving but must inform DVLA Cannot drive until an angiogram has been performed and reviewed by a ca rdiologist Cannot drive for 1 week Cannot drive for 4 weeks

Important for me

Less :mpcrtant

Dr

DVLA advice post Ml - cannot drive for 4 weeks

As se

m

Ca not drive for 12 weeks

A 45-yea r-o ld man p resents with chest pain an d breathlessness on exertion. On exam ination, he is bradycardic with a rate of 31 bp m. You notice irregu lar canon 'a ' waves in the JVP. What unde rlying diagnosis is associated with this JVP wavefo rm patte rn?

Complete hea rt block Ventricu la r tachyca rdia Atrio-ventricular nodal re-entry ta chyca rd ia

Dr

Atrial flutte r

As se m

Tricusp id stenosis

I

Comp lete heart block Ventricular tachycardia Atrio-ventricular nodal re -entry ta chycardia

I

-

........

Tricusp id stenosis Atrial flutter

Irregular cannon 'a' waves points towards complete heart block Less im:>crtc.nt

As se m

Important for me

the underlying rhythm.

Dr

Once the JVP waveform pattern is identified as canon 'a' waves, irregularity can identify

You are a CTl in Acut e Medicine covering the hospital at night. You are call ed t o the surgical ward to see a 35-year-old patient w ho is reporting palpitations. She is known to have Wolff- Parkinson-White syndrome. Her ECG shows fast atrial fibrillation. On examination, there is no evidence of haemodynamic instability. What is the most appropriat e pharmacolog ical management option for th is patient?

Adenosine Verapamil Met oprolol

Dr

Flecainide

As se m

Digoxin

Adenosi e

flD

Verapamil

flD

Metoprolol

fD . CD

Digoxin

I

CD

Flecainide

In patients with accessory pathways, such as those with Wolff-Parkinson-White synd rome, AV noda l blocking drugs should be avo ided in atrial fibrillation. This is because blocking the AV node may enhance the rate of conduction through the accessory pathway, causing atrial fibrillation to degenerate into ventricular fibrillation (VF). Verapa mil exerts the most reliable and long-lasting effect on AV node refracto riness and therefore is the most contra-indicated in this scenario. Adenosine has a similar effect and has also been associated with precipitating VF in pre-excited atrial fibrillation.

As se m

Beta-blockers and di goxin also inhibit AV node conduction.

Dr

Flecainide is a sodium channel blocker (ClassIc anti-arrhythmic) which will reduce the excitability of the atrial and ventricular myocardium without AV nodal blockade.

A 65 -yea r-o ld ma n is a d mitted with pa lp itations. The ECG shows a ventricula r rate of 150/ min with a n unde rlying atria l rate of 300/ min. A diagnos is of atrial flutte r is sus pected . What is the treatme nt o f cho ice to pe rmanently resto re sinus rhythm?

Radio frequency ablatio n of the accesso ry pathway Radiofrequency ablatio n of the AV node Radio frequency ablatio n of the tricus pid valve isthmus

Dr

Permanent pace maker

As

se

m

Life lo ng a mio da ro ne

Radiofrequency ablation of the accessory pathway

CD

Radiofrequency ablation of the AV node

GD

Radiofrequency ablation of th e tricuspid valve isthmus

CD CD As

CD

Dr

Permanent pacemaker

se

m

Lifelong amiodarone

A 57 -year-old man comes t o the emergency department w ith severe, central, crushing chest pain. By the time he arrives on the medical admissions unit he is pain-free. He had a myocardial infa rction (MI) two years ago; additionally he has type 2 diabet es mellitus, hypertension and hypercholesterolaemia. His brother died of a MI at a similar age. His repeat prescriptions include aspirin, metformin, ramipril, amlodipine and atorvastatin.

On examination he looks pale and sweaty. On auscultation he has vesicu lar breathing and norma I heart sounds. He is overweight. His oxygen saturations are 98% on air; respiratory rate 14 breaths p er minut e; blood pressure 150/88 mmHg, heart rate 90 beats per minute. His blood sugar (BM) is 22.5. There are no ischaemic changes on his ECG; however a 12 hou r troponin is elevat ed. The admitting doct or has already given aspirin, clopi dogrel and fondaparinux. What is the next step in the management of th is patient?

IV GTN infusion

Additional dose metformin

Dr

Primary PC! within 4 hours

As se m

15L oxygen via non -rebreathe mask

I

IV GTN infusion

(D

lSL oxygen via non- rebreathe mask

m

Primary PC! within 4 hours

fD

Additional dose metformi n

CD

GD

Angiography with in 96 hours

As se m

This man is having a NSTEMI. His myriad risk facto rs him catego rise him as high risk, and therefore he should have definitive angiography+/- stenting within 96 hou rs. He is mainta ining his oxygen saturations, is pain free and has no ST elevation, making the other options incorrect. Metformin is act ua lly best avoided in acute tissue ischaemia due to its association with lactic acidosis.

Dr

See http://nice.o rg.u k/guidance/cg94 for current NICE gu idelines on management of NSTEM I.

A 70 yea r-old ma n presents with a history of chest pa in on exerti on. He is known to have hypertension, currently treated with a mlodipine, and he is also on s imvastatin fo r primary prevention. The chest pain is dull in nature a nd is relieved within a few minutes of rest. His symptoms have been relieved by the use o f his wife's GTN. Which additional medication wou ld be indicated here?

Doxazosin Verapamil lsoso rbide mononitrate

Dr

lvab rad ine

As se m

Atenolol

Doxazosin Verapa mil Isosorbide mononitrate Atenolol Ivab rad ine

A beta- bloc ke r or a calcium channel blocker is used first-line to prevent angina attacks Important for me

l ess im:>crtc.nt

As se m

This ma n presents with classic features o f a ngina. He is already taking a calcium channel blocker for hyperte nsion, so the next most appro priate trea tment would b e a beta blocker. Verapamil wo uld be an alternative if he was n"t ta king a ny other medications.

and ivabradine a re used in the man agement o f angina, but not at this stage.

Dr

Doxazosin is a n alpha blocker used in refracto ry hyperte nsion. Isosorbid e mono nitrate

A 74-year-old man with symptomatic aortic stenosis is reviewed in the cardio logy clin ic. He is otherwise fit and well and keen for int ervention if possible. What type of intervention is he most likely to be offered?

Annua l echocardiography, intervention when valve gradient > 75 mmHg Aortic bypass graft Bioprosthetic aortic valve replacement

As Dr

Mechanical aortic valve replacement

se

m

Balloon valvu loplasty

-

An nual echocardio graphy, intervent ion when valve gradient > 75 mmHg Aortic bypass graft Bioprosthetic aortic valve replacement Balloon valvu loplasty Mechanica l aortic valve replacement

younger patients Important for me

As se m

Prosthetic heart valves - mechanical valves last longer and tend to be given t o l ess i m ::~c rtc.nt

Dr

I

~

A 31-year-old woman of Malaysian origin presents wit h head ache, malaise and j oint pains. For t he past few months she has also experienced pain in t he calves aher wa lking any sign ificant distance. On examination her pu lse is 78/min and blood pressure in t he leh arm is noted t o be 154/98 mmHg. Due to t his raised reading it is measured in t he right arm and fou nd t o be 132/ 80 mmHg. An early diastolic murmur is noted in aortic area and a b ruit is present in t he carot id s. Exam ination of the respirato ry system is unremarkable. What is the most likely diagnosis?

Coarctation o f t he aorta Supravalvular aortic stenosis Ta kayasu's arteritis

Dr

Polyarteritis nodosa

As se m

Buerger's disease

Coa rctation o f the aorta Sup rava lvul ar a o rtic stenosis Ta kayasu's arteritis Buerger's d isease

se

m

Polyarte ritis no dosa

Dr

o f patients with Takayasu's arteritis.

As

The ea rly d iasto lic mu rmu r is caused by aortic regu rg itatio n, which is seen in a ro u nd 20%

Which of the following factors is most strongly associated w ith risk of sud den death in the first six months aher myocardial infarction?

Ventricular ectopics Cigarette smoking 3-vessel coronary disease at angiography

As Dr

High LDL (low density lipoprotein) cholest erol

se

m

Low leh ventricular ejection fraction

Ventricular ectopics Cigarette smoking

-

3-vessel coronary d isease at ang iography

~

p ow left ventricular ejection fraction High LDL (low d ensity lipoprotein) cholestero l

The most important factor predicting outcomes post-STEM! is the presence of new

Dr

As se

m

systolic heart fai lu re. It suggests that a large amount of myoca rdial damage. Those with systolic heart fai lu re post Ml can be up to lOx mo re li kely to d ie than those that do not have an MI.

A 62-year-o ld man is referred from the Emergency Department with a pu lse o f 40 beats/m in. Which one o f the following factors carries the least risk of asysto le when risk stratifyin g the patient?

Ventricu la r pause o f 5 seconds Recent asystole Complete heart block with a narrow complex QRS

Dr

Complete heart block with a b road complex QRS

As

se

m

Mobitz type II AV block

Ventricular pause o f 5 seconds Recent asystole

r

Complete hea rt block with a narrow co mplex QRS Mobitz type II AV block Complete heart block with a b road complex QRS

Dr

pacmg

As se

m

Complete heart block with a narrow complex QRS complex carries the least risk o f asystole as the atrioventricular junctional pacemaker may provide an haemodynam ically acceptable and stable heart rate. The other four factors are ind icatio ns for transvenous

A 55-yea r-old man is ad mitted with centra l chest pa in. His ECG shows ST d ep ression in the inferior lead s and the chest pa in req uires intrave nous morphine to settle. Past medica l histo ry includ es a throm bo lysed myocardial infa rction 2 yea rs ago, asthma a nd type 2 diab etes mellit us. Treatment with aspirin, clop id ogre l and unfra ctionated heparin is com menced. Wh ich one of the fo llowing facto rs shou ld determine if an intravenous glycoprotein Db/lila rece ptor antagonist is to be given?

High GRACE (Globa l Reg istry of Acute Ca rd iac Eve nts) risk sco re + whethe r a percutaneous coro nary inte rventio n is to be performed Degree of ST d e press ion High GRACE (Globa l Reg istry of Acute Card iac Eve nts) risk sco re

Dr

The presence o f recurrent card ia c chest pa in

As se m

Presence of a left ventricu Ia r thrombus

I

High GRACE (Global Registry of Acute Cardiac Events) risk score + w hether a percutaneous coronary intervention is to be performed

High GRACE (Global Registry of Acute Cardiac Events) risk score

m

Presence of a left ventricu lar thrombus

As

se

The presence of recurrent ca rdiac chest pa in

Dr

I

Degree of ST depression

A 50-year-old man is admitted to Resus with a suspected anterior myocardial infarction. An ECG on arrival confirms t he diagnosis and t hrombolysis is prepared. The patient is

stable and his pain is well controlled with intravenous morp hine. Clinical examination

shows a b lood p ressure of 140/ 84 mmH g, pu lse 90 bpm and oxygen sat urati ons on room

air o f 97%. What is the most appropriat e management with rega rds t o oxygen therapy?

2-4 1/min via nasal cannu lae No oxygen therapy 15 1/min via reservoir mask

Dr

35% via Venturi mask

As se m

28% via Venturi mask

CD

2-4 1/min via nasal cannulae

I

CD.

No oxygen therapy

•m

15 1/min via reservoir mask 28% via Venturi mask

m

35% via Venturi mask

se

m

~

Dr

the use o f oxygen in emergency situations.

As

Please see the note below and p rovid ed link - there are now specific guidelines relating to

Which one of the fo llowin g statements is not correct regarding hypertension in p reg nancy?

An increa se above booking rea dings of > 30 mmHg systo lic o r > 15 mmHg diastolic sugg ests hyperte nsion Pre-ecla mpsia occurs in aroun d 5% of pregna ncies Urine d ipstick showing p rotein + is consistent with gestatio nal hypertensio n

As se

Dr

With g estatio na l hypertensio n the blood pressure rises in the second half of p regna ncy

m

A rise in blood pressure before 20 weeks sug gests p re-existing hypertension

-

An increase above booking rea dings o f > 30 mmHg systo lic o r > 15 mmHg

~

d iasto lic suggests hypertension

I

Pre-eclampsia occu rs in a roun d 5% of p regnancies Urine dipstick showing prote in + is consistent with gestational hypertension A rise in b lood pressu re befo re 20 weeks suggests p re-existing hypertensio n With gestational hype rtension th e blood pressu re rises in the second hal f of

Dr

Proteinu ria suggests pre-ecla mps ia

As

se

m

pregnan

A 19-yea r-old ma n co llapses a nd d ies whilst playing rug by at un iversity. At post-mortem a symmetrical ventricu la r septa l hypertrophy is noted. Analysis of the ca rd iac tissue is most likely to demonstrate a d efect in which o ne o f the following?

Tropomyosin Myosin light-chain kinase Calmodulin

As Dr

Beta - myosin heavy cha in protein

se

m

Troponin C

A 19-year-old man collapses and dies w hilst playing rugby at university. At post-mortem asymmetrica l ventricular septal hypertrophy is noted. Analysis of the cardiac tissue is most likely t o demonstrate a defect in which one o f the following?

Tropomyosin Myosin light-chain kinase Calmodulin

,---, Tr ponin C

Dr

As se m

Beta- myosin heavy cha in protein

A 67 -year-old man with a history of hypertension presents to the emergency department with a 24hr history of dyspnoea an d palpitations. He also complains of mild chest discomfort. On examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure 95 I 70 mmHg and a respiratory rat e of 20 breaths/ min. He denies any regular medication and insists he has never experienced anything like this before. An ECG shows absent P waves with QRS com plexes irregularly irregular intervals. What is the most appropriate management?

Clopidogrel Direct cu rrent cardioversion Bisoprolol

Dr

Digoxin

As se m

IV adenosine

Clopidogrel Direct current cardioversion Bisoprolol IV adenosine Digoxin

New onset AF is considered for electrical card ioversion if it presents w ithin 48 hours of presentation Important for me

Less impcrtant

This is an individual presenting a clinical picture of new-on set atrial fibrillation. A blood pressure of 95/70 mmH g in a patient with a history o f high blood pressure, who is currently not taking any blood pressure medication is quite concerning. It suggests that he is hemodynamically unstable. The most appropriate treatment for new-onset atrial fibrillati on (AF) within 48hrs is DC cardioversion if unstable or either DC card ioversion or pharmacological card ioversion. Bet a-blockers ca n be used fo r rate contro l. Clopidogrel is

As se m

not a treatment of AF. Bisoprolol would be a suitable alternative if the patient was more for narrow complex supraventricular tachyarrhythmias

Dr

stable. Digoxin is ideal for patients with AF and heart fa ilure. IV adenosine is a treatment

A 17 -yea r-old ma le is ta ken to the Emergency Department due to a lco hol intoxication. On examination he is noted to be tachycardic with a rate of 140b pm. An ECG shows atria l fibrillation. The following morning he is noted to be in sinus rhythm. What is the most a ppropriate management?

Sotalol and a spirin Sotalol and wa rfarin Refer fo r accessory pathway ab lation

Dr

Discha rge

As se

m

Amio darone and as pirin

A 17-year-old male is taken to t he Emergency Department due to alcohol int oxication. On examination he is not ed to be t achycardic with a rate of 140b pm. An ECG shows atrial fibrillation. The following mornin g he is noted to be in sinus rhythm. What is the most appropriat e management?

Sotalo l and aspirin Sotalo l and warfarin Refer for accessory pathway ablation Amiodarone and aspirin

As se m

Discharge

have been termed 'holiday heart syndrome'. No specific t reatment is required

Dr

Supraventricular arrhythmias secondary to acute alcohol intake are well characterised and

You review a 51 -year-old hypertensive patient who you started on 2.5mg of ramipril one month ago. He is complaining of a tickly cough since starting the medication which is keeping him awake at night. However, is blood pressure is now within normal limits. What should you advise him?

The cough is unlikely t o b e caused by the ramipril, continue the medication and review in a month The cou gh should settle within the next mont h, continue the medication and review in a month Stop the ramipril and prescribe a different ACE-inhibito r

Dr

Stop the ramipril and prescribe candesartan

As se m

Stop the ramipril and prescribe Smg amlodipine

The cough is unlikely t o be caused by the ra mipril, continue the medication and review in a month The cough should settle within the next month, continue the medication and review in a month Stop the ramipri l and prescribe a different ACE -inhibito r Stop the ram ipri l and prescribe 5mg amlodipine Stop the ram ipril and prescribe candesartan

For a patient under 55 who is intolerant to an ACE -i the next st ep wou ld be to offer an angiotensin 2 receptor blocker (ARB) Important for me

l ess 'mocrtont

As se m

ACE inhibitors are commonly associated with a dry, persistent cough. A cough is unlikely to settle without stopping the ACE-inhibitor and prescribing a different class of drug. For an angiotensin 2 receptor blocker (ARB), eg candesartan.

Dr

a patient under 55 who is intolerant to an ACE- inhibito r the next step would be to offer

What is the usual target IN R for a patient with a mechanical mitral valve?

2.0 2.5

3.0

As Dr

4 .0

se

m

3.5

What is the usual target INR for a patient with a mechanical mitral valve?

no

m

2.5

CID

3.0

CD

3.5

C'D

I

4.0

Mechanical valves- target INR:

As se m

• aortic: 3.0 • mi tral: 3.5 _fss

· m::~crtant

Dr

Important for me

Which part of the jug ula r venous wavefo rm is associated with the opening o f the tricuspid va lve?

x descent vwave a wave

Dr

y descent

As

se

m

cwave

flD

vwave

GD

a wave

GD

c wave

(ID

y desce nt

CD m

x descent

As

Less impcrtont

Dr

Important for me

se

JVP: y descent = o pening of tricuspid valve

A patient who is intolerant of as pirin is started on d opid ogrel for the second ary p revention of ischaemic heart disease. Concu rrent use of which one o f the following drugs may make clopidogrel less effective?

Warfarin Omeprazole Codeine

As Dr

Selective serotonin reuptake inhibitors

se

m

Long -term tetracycl ine use (e.g. For acne rosacea)

CD

Warfarin

GD

Omeprazole

a

Codeine

GD

Select ive serotonin reuptake inhib itors

CfD Dr

As

se

m

Long -term tetracycline use (e.g. For acne rosacea)

Each one of the following p hysiolog ical changes occu r during exercise, except:

Increased myocardial contractib ility 50% increase in stroke vo lume Up to 3-fo ld increase in heart rate

As Dr

Venous constriction

se

m

Rise in diasto lic blood pressu re

Each one of the following physiolog ical changes occu r during exercise, except:

Increased myocardial contractibility

-

50% increase in stroke vo lume

~

Up to 3-fold increase in heart rate Rise in diastolic blood pressure

Dr

As

se

m

Venous constriction

A 59-year-old patient was found to have a moderate hyperca lcae mia i n a routine blood sample order by his general practitioner. He is only t aking a non -prescribed prophylactic dose of vitamin D for the last six mont hs, which he had bought o ver the counter. On examination he is bright and alert, wel l perfused with moist mucous membranes. There is no neurological symptoms and electrocardiogram shows a normal sinus rhythm. Hypercalcaemia is a relatively frequent cl inical pro blem and although clinical signs and sympt oms of all hypercalcaemia tend to be similar, there are several clin ical features that may help to distinguish them according to aetiology. Which of the follow ing medical conditions is less likely to produce hypercalcem ia?

Multiple myeloma Primary hyperparathyroidism Sarcoidosis

Dr

Familial hypom agnesemia with hypercalciuria and nephrocalcinosis

As se m

Hodgkin's lymphoma

A 59-yea r-old patient was found to have a moderate hypercalcae mia in a routine b lood sample ord er by his g eneral p ractitioner. He is only taking a non -prescribed p rophylactic d ose of vitamin D fo r the last s ix months, which he had bought o ver the counter. On exam ination he is bright and alert, well perfused with moist mucous membra nes. There is no neuro logical symptoms a nd electrocardiog ram shows a normal sinus rhythm . Hypercalcaemia is a relatively frequent clinical p rob lem and a lthough clinica l signs and sympto ms of a ll hypercalcaem ia tend to be sim ila r, there a re several clinical featu res that may help to distinguish them accord ing to aetiology. Which o f the following med ica l conditions is less likely to produce hypercalcem ia?

Multip le myeloma p

mary hyperparathyro idis m Sa rcoid osis

As se m

Fa mi lial hypomag nesem ia with hypercalciuria and nephrocalcinosis

Dr

I

Hod g ki n's lymphoma

A 57 -yea r-old patient with acute pulmona ry oed ema is ad mitted to th e ITU d epa rtme nt. She has no past medical histo ry of note. A Swan-Ga nz catheter is inserted to enable measu rement of the pulmonary capilla ry wed ge p ressure. Whi ch chambe r of the hea rt d oes th is pressure generally equate to?

The d ifference between the leh atrium a nd right ve ntricle Leh ventricle Leh atrium

Dr

Right atrium

As se

m

Right ventricle

The difference between the leh atrium and right ventricle Leh ventricle Leh atrium Right ventricl e

Dr

As

se

m

Right atrium

A 51-year-old man presents four weeks after being discharged from hospital. He had been admitted with chest pain and th rombolysed for a myocardial infa rct ion. This morning he developed marked tongue and facial swelling. Which one of the following

drugs is most likely to be res ponsible?

Atorvastatin Isosorbide mononitrate Atenolol

Dr

Ra mipril

As se

m

Aspirin

I

m

Atorvastatin

f!D

IsosorbJ e mononitrate

m

Ateno lo l

GD

Ram ipril

CD Dr

ACE inhi bito rs a re the most common cause o f drug -i nduced a ng ioedema.

As

se

m

Aspirin

Which one o f the following is least associa ted with Wolff-Parkinson White synd rome?

Mitral valve pro la pse Ebstein's ano maly Thyrotoxicosis

As Dr

Hypertrophic ca rdiomyopathy

se

m

Coa rctation o f the ao rta

Mitral valve prolapse Ebstein's ano maly Thyrotoxicosis Coarctation of the aorta

Dr

As

se

m

Hypertrophic cardiomyopathy

A 71-yea r-old man who had a bioprosthetic aortic valve replacement three years ago is reviewed. What antithrom botic therapy is he likely to be taking?

Noth ing Aspirin Warfarin: INR 2.0-3.0

Dr

Warfarin: INR 3.0-4.0

As

se

m

Aspirin + clopidogrel

fiB

Nothing

~irin

&D

fiD

Warfarin: INR 2.0-3.0

•

( lspirin + clopidogrel

(ID

Warfarin: INR 3.0-4.0

Prosthetic heart valves - antithrombotic therapy: • bioprosthetic: aspirin

Less imocrtant

Dr

Important for me

As se m

• mechanical: warfarin + aspirin

Which one of the followin g treatment s is not app ropriate in the management of WolffParki nson White?

Verapamil Sot alol Amioda rone

Dr

Radio frequency ablation of the accessory pathway

As

se

m

Flecainide

I

Verapa mil Sotalol Amiodarone Flecainide

se

m

Radiofrequency ablation of the accessory pathway

Dr

As

Verapamil and digoxin should be avoided in patients with Wolff-Parkinson White as they may precipitate VT or VF

A 76-year-old man is reviewed. He was recently admitted aher being found to be in atrial fibrillation. Th is was his second episode of atrial fibrillation. He also takes ram ipril for hypertension but has no other history of note. During admission he was warfarinised and discharged with planned follow-up in the cardiology cl inic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?

Stop wa rfa rin Continue warfa rin for 1 month Stop wa rfa rin + start aspirin

Dr

Continue warfa rin for 6 months

As se m

Continue lifelong warfarin

Stop warfa rin Continue warfa rin for 1 month Stop warfa rin + start aspirin Contin ue lifelong warfarin

se

m

Continue warfarin for 6 months

Dr

As

Warfarin should be continued indefinitely as this is his second episode of atrial fibrillation and he has risk factors for stroke (age, hypertension)

A 47 -yea r-old man is ad mitted to hos pita l fo ll owing an acute co ronary syndro me. He has a history peptic ulcer d isease and his ca rdiologist d ecid es to use clo pidogrel. What is the mechanis m of action of clop id ogrel?

Non -selective p hospho diesterase inhib itor Phospho diesterase V inh ibito r Inhibits ATP bindi ng to its p latelet recepto r

As Dr

Glycop rotein lib/lila inhib ito r

se

m

Inhibits ADP binding to its platelet recepto r

A 47 -yea r-old ma n is admitted to hospital following an acute co ronary syndrome. He has a history peptic ulcer disease and his cardiologist decides to use clopidogrel. What is the mechanis m of action o f clopidogrel?

Non -selective p hosphodiesterase inhibitor Phosphodiesterase V inhibito r Inhibits ATP binding to its platelet recepto r

-

Inhibits ADP b inding to its platelet receptor

~

Glycoprotein lib/lila inhib itor

l ess 'mocrtont

Dr

Important for me

As se m

Clopidogrel inhibits ADP binding to platelet receptors

What is the main reason fo r checking the urea and e lectrolytes p rior to commencing a patient on am io da rone?

To detect hyponatra em ia To detect impaired renal function To detect a metabolic acidosis

Dr

To detect hypokalaemia

As

se

m

To detect hyperkalaemia

What is the main reason for checking the urea and e lectrolytes p rior to commencing a patient on am io da rone?

To detect hyponatraemia To detect im paired rena l function To detect a metabolic acidosis

All antia rrhythmic drugs have the potential to cause arrhythmias. Coexistent hypoka laem ia significantly increases this ris k.

As se m

To detect hypoka laemia

Dr

I

To detect hyperkalaemia

A 44-year-old gentleman presents to the emergency department with chest pain. As the acting cardiology reg istra r, you are asked to see him immediately as he ECG shows ST segment elevatio n in multiple lead s. When you a rrive, he is sitting in bed lean ing forward to rest his arms on his knees. His past medica l history in cludes hypertension, type 1 diabetes me ll itus (diagnosed aged 11) and his father died from a myocardial infarction age 60. In addition to this, he tells you he has been we ll recently apart from a slight 'sore th roat' 2 weeks ago that cleared up with no problems. He first noticed the chest pain 4 hours ago while still in bed th is morning and he describes it as left s ided chest pain with no radiation. He has taken l g pa raceta mo l with minima l improvement. Given the likely diagnosis, which of the following is the most spe cific ECG find ing in this condition?

Reciprocal ST de pression Shortened PR interval 'Tombstoning' ST elevation in all precordial leads

Dr

PR depress ion

As se m

Peaked T waves

Reciprocal ST depression Shortened PR interva l 'Tombstoning' ST elevation in all precordial lead s

I

Peaked T waves PR depress ion

The most li kely diagn osis in the case is acute pericarditis. Though he d oes have some risk factors for ischaemic hea rt disease, there are points in the history which lead you towards a diagnosis of pericarditis: the history of vira l illness, wid espread ST e levatio n and posture o f the patient (sitting forwa rd suggesting th is is comforta ble/gives some pa in re lief) a re typical.

Dr

As se m

All of the above ECG features may be seen in pericarditis. However, the only s pecific finding is PR depression and therefo re this is the most app ropriate a nswer. In addition to this, ST e levation in perica rditis would classically be described as 'saddl e -sha ped .'

A 72-year-old man is st arted on amlodipine 5mg od for hypertension. He has no other past medical history of not e and routine bloods (incl uding fasting glucose) and ECG were normal. What should his target blood pressure be once on treatment?

< 130/80 mmHg < 140/80 mmHg < 140/85 mmHg

Dr

< 150/90 mmHg

As se m

< 140/90 mmHg

CD

< 140/80 mmHg

. CID

< 140/85 mmHg

CD

< 140/90 mmHg

CiD

As

se

m

< 150/90 mmHg

Blood pressure target ( < 80 years, clinic reading) - 140/90 mmHg trrpor.art "or me

_ess

-~oc1:! "l t

Dr

I

< 130/80 mmH g

A 76-year-old gentleman is admitt ed through the Emergency Department with worsening shortness of breath and ankle swelling on a background of left ventricular failure secondary to ischaemic heart disease. He has bibasal crepitations on auscultation and a raised JVP of 4 em with periphera l pitting oedema to his knees. He is commenced on IV fu rosemide. What is the mechanism of action of fu rosemide?

Inhibition of the Na +CI - transporter in the distal convolut ed tubule Aldosterone antagonist Inhibition of the Na +/K+/2CI- co-transporter in the thick ascending limb of the loop of Henle

Dr

Inhibition of sodium channels in the collecting tu bules

As se m

Inhibition of the Na +/K+/ 2CI- co-transporter in the proximal tubule

Inhibition of the Na+CI- transporter in the dist al convolut ed tubule

fl3

Aldosterone antagonist

fD GD

Inhibition of the Na+/K+/2CI- co-transporter in the thick ascending ~mb of the loop of Henle Inhibition of th e Na +/K+/2CI- co-transporter in the proximal tubule

8

In ibition of sodium channels in the collecting tu bul es

8

Furosemide- inhibits the Na-K-CI cotrans porter in the thick ascending limb of the loop of Henle Important for me

Less impcrtant

Loop diuretics (furosemide, bumet anide) act by inhibiting the Na+/K+/ 2CI- cotransporter in the thick ascending limb of the loop of Henle. This causes loss of wat er along with

sodium chloride, potass ium, calcium, and hydrogen ions.

Explanation fo r other options:

• 5. Describes mechanism of amiloride and triamterene

Dr

• 2. Spironolact one and eplerenone are examples of aldost erone antagonists • 4. This answer is incorrect

As se m

• 1. Describes mechanism of thiazide diuretics

Which one of the following diuretics works by inhibiting a transmembrane cotra nsporter protein?

Indapamide Eplerenone Furosemide

As Dr

Mannitol

se

m

Am iloride

Indapamide

fD

Eplerenone

GD

Furosemide

CD

Amiloride

GD

Mannitol

CD

Important for me

l ess ' m ::~c rtc.nt

Dr

loop of Henle

As se

m

Furosemide- inhibits the Na-K-CI cotrans porter in the th ick ascending limb of the

A 62-yea r-old man is reviewed . His blood p ressure is poorly controlled at 152/ 90 mmH g d es pite treatment with ram ip rillOmg o d, bendro flumethiazide 2.5mg o d an d am lo dipi ne lOm g od.In addition to the antihypertensives he a lso takes asp irin and simvastatin. His most recent b lood tests show the fo llowing: Na•

139 mmol/ 1

K•

4.2 mmol/1

Urea

5. 5 mmolfl

Creatinine

98 IJffiOI/1

What is the most ap propriate change to his med ication?

Add frusemide Increase ramipri l to 20mg od Add sp iro nolactone

Dr

Add atenolol

As se m

Add candesarta n

Add frusemide Increase amipril to 20mg od Add spironolactone Add candesartan Add atenolol

Poorly contro lled hypertension, already t aking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ < 4.5mmol/l - add spironolactone l ess ' m ::~c rtont

As se m

Important for me

less than 4.5 mmol/1 spironolactone 25mg od should be started.

Dr

This patient has reached step 4 in the NICE hypertension guidelines. As their potassium is

Which of the following statements concerning the third heart sound is correct?

Caused by systo lic filling of the ventricle May be heard in constrictive pericarditis Associated with atrial septal defects

As Dr

Caused by atrial contraction against a stiff ventricle

se

m

Is characteristically soft in aortic stenosis

Which o f the following statements concern ing the third heart sound is correct ?

I

Caused by syst olic filling of the ventricle

fD

May be heard in constrictive p ericarditis

ED

Associated w it h atrial septal defect s

fD

Is charact eristically soft in aortic st en osis

CD

fD

Caused by atrial contraction ag ainst a stiff ventricle

Third heart soun d - constrictive perica rditis Less ' m ::~c rtant

As se m

Important for me

Dr

A t hird heart sound is often heard in left ventricular failure and constrictive pericardit is

A 68-year-old gentleman is brou ght into resus in yo ur local emergency depa rtment after a syncopa l episode. He is alert but clea rly d istressed. The monitor above the bed showed a heart rate of 190bp m with a blood pressu re of 85/SOmmHg. His oxygen saturations are 98% in high flow oxygen (lSL per mi nute via non -rebreathe mask). You a re awa iti ng a full 12 lead ECG to be performed but the tra ce on cardiac monitor a ppears to show a regular broad complex tachycard ia. A formal ECG subsequently confirms that the arrhythmia is a ventricular tachyca rdia (VT) with a QRS complex duration of lSOms. With regard to the JVP waveform, which of these featu res wou ld you expect to see?

Giant v waves Cannon a waves Prominent x d escent

Dr

Large a waves

As se m

Slow y descent

A

Gia nt v waves

(D

Cannon a waves

caD

Prom ine nt x descent

fD

ydescent

CD ([D

Large a waves

The correct answer is B: cannon a waves. Cannon a waves resu lt from atria l contraction a gainst a closed tricusp id valve a nd the refo re ca n be seen in VT when a trial a nd ve ntricu la r contraction is not co-o rd inated. They ca n a lso be seen in co mplete/3 rd d egree hea rt block a nd atrial flutte r fo r the same rea son.

Dr

pulmona ry hypertension.

As se m

Gia nt V waves are a features of tricuspid regurgitation; p rom ine nt x d escent is a feature of constrictive pericarditis; s low y descent is a featu re of ca rd iac tamponad e a nd tricuspid stenosis; a nd large a waves can be fou nd in tricusp id stenosis, right heart fa ilure and

A 53-year-old man presents as he is worried about palp itat ions. These are described as fast and irregular and typica lly occur twice a d ay. They seem to be more common after drinking alco hol. There is no history of chest pain or syncope. Examination of his cardiovascu lar symptoms is normal with a pu lse of 72/min and a b lood pressu re of 116/78 mmHg. Blood t ests an d a 12-lead ECG are unremarkable. What is the most appropriate next step in manag ement?

Reassure and repeat 12-lead ECG in 3 months time Request a troponin I Arrange an echocardiog ra m

Dr

Arrange an external loop recorder

As se m

Arrange a Holter monitor

Reassure and repeat 12-lead ECG in 3 months tim e Request a troponin I Arra nge an echocardiogram Arrange a Holter monitor

-

Arrange an external loop recorder

"""'

Palpitations should first be investigated with a Holter monitor after initial bloods/ ECG Important for me

l ess ' m ::~c rtont

These episodes are characteristic of an arrhythmia, possibly atrial fibrillation. First-lin e investigations are normal and it is appropriate t o investigate further to exclude an arrhythmia. Holter monitoring should be arranged to try and capture such an episode. Given the episodes occur daily it is reasonable to do this over a 24 hour period initially.

heart failure to warrant an echoc.ardiogram.

As se m

A troponin is not indicated given the absence of chest pain and there is no suggestion of

and the patient continues t o have symptoms.

Dr

An extern al loop recorder should only be considered if the Holter monitoring is normal

A 73 yea r-old male has progressive exertional dyspnoea due to progressive systolic heart fa ilure with a left ve ntricu la r ejection fraction of 30%. What investigation is most usefu l in p redicting sym ptomatic res ponse to ca rdiac resynchro nisation therapy?

Cardiac MRI Transo esophageal Echo Coro na ry angiogram

As Dr

Nu clear perfusion sca n

se

m

ECG

Cardiac MRI

fD

Transoesophageal Echo

«ED fD

Coronary angiogram ECG

tD

Nuclear perfusion scan

fD

The key diagnostic tests used to identify patients likely to benefit from ca rdiac resynchronization t herapy is the t ranst horacic echocardiogram and ECG. Those with left ventricular ejection fractions of 10%

Dr

All patients

As se m

Those who have a pre d icted 6 month mo rtality < 10%

Patients < 75 years of age Patients who have a histo ry of hype rtens ion, ischae mic hea rt disease o r diabetes fliD mell itus Those who have a pred icted 12 month mortality > 10%

se

m

Those who have a pred icted 6 month mortality < 10%

Dr

As

All patients

A patient is given asp irin 300 mg after deve loping an acute co ronary syndrome . What is the mecha nism o f action of aspirin to achieve an antiplatelet effect?

Inhibits the p rod uction of thromboxa ne A2 Inhibits ADP binding to its platelet receptor Inhibits the p rod uction of prostag la ndin H2

As Dr

Inhibits the p rod uction of prostacyclin (PGI2)

se

m

Glycop rotein lib/lila receptor antago nist

Inhibits the production of thromboxane A2 Inhibits ADP binding to its platelet receptor Inhibits the production of prostaglandin H2

m m

As Dr

Inhibits the production of p rostacyclin {PGI2)

se

m

Glycoprotein Ilb/llla receptor antagonist

A 45-year-old woman suffered from sudden onset central crushing chest pain. Her electrocardiogram showed ST-segment elevation. Troponin is slightly ra ised. She was rus hed for an emergency invasive angiogram but th is revealed slight wall irregularities with no luminal obstruction. Subsequently, cardiovascular MR (CMR) showed an apical ballooning of the myocardium resembling an octopus pot. She did not have any significant past medical history. There is a fam ily history of premature corona ry artery disease. Her partner recently passed away of prostate cancer. What is the most likely cause of the ST-segment elevation?

Coronary artery disease Takotsubo card iomyopathy Left ventricular aneurysm

Dr

Hypertrophic cardiomyopathy

As se m

Myocardial infarction

CD

Coronary artery disease

I

Ta kotsubo cardiomyopathy

fD

Left vent ricular aneurysm

GD

Myocardial infarction

CD

Hypertrophic cardio myopathy

m

Ta kotsubo card iomyopathy is a different ial fo r ST -elevation in someone with no o bstructive co rona ry artery disease Important for me

Less impcrtont

The different ial diagnosis for ST -elevation: • myoca rdial infarct ion • perica rdit is/myocarditis • normal variant - 'high take-off' • Ta kotsubo ca rdiomyopathy

• Subarachno id haemorrhage

Dr

• Prinzmet al angina

As se m

• Left ventricu lar aneurysm

An 85-year-old man is admitted on the medical take with a 4 day history of a productive cough, followed by 2 days of shortness of breath, fever and confusion. He has an obvious shadow over the lower zone of h is left lung on chest x-ray which was not t here on a routine x-ray one month earlier. He has a past medical history of asthma, ischaemic heart disease and gallstones. Which of the following is most strongly associated w ith a poor p rognosis?

CURB -65 score of 3 Past medical history of asthma

Saturations of 92% on 8 litres of oxygen via non -rebreathe mask

Dr

Patient meets criteria for sepsis

As se m

Ex-smoker

-

CURB-65 score of 3

~

Pa st medica l histo ry of a sthma Ex-smoker Patie nt meets criteria fo r sepsis Satu rations o f 92% o n 8 litres of oxyg en via non -rebreathe mask

The CURB-65 score can be used for assessing the prognosis of a patient with community acqu ired pnuemonia Important for me

Less impc rtc.nt

This patie nt has com munity-a cq uired pneumon ia. Th e CURB-65 score is used to assess prog nosis a nd risk o f mo rtal ity in patients with com munity-acq uired pneumonia . The full sco re can be found in the backgrou nd notes. A hig her score is linked to a hig he r risk o f in-hos pital morta lity.

NICE pathways - assessment of com munity-acquire d pneumonia

As se m

Having asthma, be ing a n ex-smo ke r, be ing septic o r having a sign ificant o xygen req u irement are like ly a ll associated with worse prognos is b ut d o not have the stre ngth of evide nce be hi nd them to compa re to the CURB-65 sco re.

Dr

https:// pathways.n ice.o rg .u k/. ../assessment-of -commun ity-acq uired -pneu mo nia .pd

A 76-year-old female is admitted after being found on the floor at her home. On

examination she has a core temperature of 30°C. Her serum electrolytes are with in normal

range. Which one of the ECG f indin gs is most like ly to b e seen?

Long QT interval

·u· waves Short PR interval

Dr

Flattened T waves

As

se

m

Second degree heart b lock

I I

Long QT interval

CD

'U ' waves

CD

m

Second degree heart block

CD

Flattened T waves

. CD

Dr

As

se

m

Shot PR interval

Eight months after having a prosthetic heart va lve a patient develops infective endocard itis. What is the most likely causative organism?

Streptococcus viridans Staphylococcus aureus Staphylococcus epidermidis

As Dr

One of the HACEK group

se

m

Coxiella burnetii

I

Streptococcus viridans Staphylococcus aureus Staphylococcus epidermidis Coxiella burnetii One of the HACEK group

Most common cause of endocarditis:

• Staphylococcus aureus • Staphylococcus epidermidis if < 2 months post valve surgery Important for me

l ess im:>crtc.nt

As se m

Coagulase-negat ive staphylococci such as Staphylococcus epidermidis are t he most spectrum of organisms causing endocarditis returns to normal.

Dr

commo n causat ive organisms in t he first 2 months following su rgery. Ah er t his t ime t he

A 67-year-old man is admitted with palpitations. During examination of his JVP he is noted t o have regular ca nnon waves. Which one of the following arrhythmias is most likely t o be responsible for this finding?

Atrio-ventricular nodal re-entry ta chycardia Atrial fibrillation Atrial flutt er

As Dr

Ventricu lar fibrillation

se

m

Complete heart block

I

Atrio-ventricular nodal re-entry ta chyca rdia

-

Atrial fibrillation

. .wl'

Atrial flutter Complete heart block Ventricular fibrillation

Dr

As

se

m

Atrio-ventricular nodal re-entry tachycardia and ventricular tachycardia with 1:1 ventricular-atrial conduction may produce regular cannon waves. Complete heart block causes irregular cannon waves

Which one of the following drugs is best avoided in patients with hypertrophic obstructive cardiomyopathy?

Am iodarone Verapamil Ramipril

As Dr

Atenolol

se

m

Amoxicillin

Which one of the following drugs is best avoided in patients with hypertrophic obstructive cardiomyopathy?

Am iodarone

CD

Verapamil

CD

ED

p .mipril

m

Amoxicillin

CD

Atenolol

ACE- inhibitors should be avoided in patients with HOCM Less imocrtont

As se m

Important for me

as it may precipit ate VT or VF

Dr

Vera pamil should however be avoided in patients with coexistent Wolff- Parkinson White

A 14-year-old boy is admitted with palpitations and is noted to have a long QT i nterval. His on ly past medical history is deafness. What is the likely diagnosis?

Leriche's syndrome Wolff-Pa rkinson White syndrome Jerveii-Lange-Nielsen syndrom e

As Dr

Osler-Weber-Rendu syndrome

se

m

Romano-Ward syndrome

I

Leriche's syndrome

CD

Wolff-Parkinson White syndrome

m

Jerveii-Lange-Nielsen syndrome

CD

Romano-Wa rd syndrome

fD CD

Osler-Weber-Rendu syndrome

Inherited long QT syndrome, sensorineural deafness - Jervell and Lange-Nielsen syndrome Less imocrtc.nt

As se m

Important for me

QT interval

Dr

Jerveii-Lange-Nielsen syndrom e is associated with profound deafness and a prolonged

A 74-year-old woman is reviewed. She recently had ambulatory blood pressure monitoring that showed an average reading of 142/ 90 mmHg. There is no significant past medical hist ory of not e other than hypothyroidism. Her 10-year ca rdiovascular risk score is 23%. What is the most appropriate management?

Start amlodipine Start bendroflumethiazide No treatment requ ired - monitor blood pressure every year

Dr

Repeat ambulatory blood pressure monitoring

As se

m

Start ram ipril

I

Start amlodipine Start bend roflumethiazide No t reatment requ ired - mon itor b lood p ressure

every yea r

Start ramipril

-

Repeat am bulato ry blood pressure monitoring

"""

New ly diagnosed patient w ith hypertension (> 55 years) - ad d a calcium channel b locker Less · m ::~c rtant

As se m

Important for me

years. Treat ment w it h a calcium channel b locker shou ld the refore be st arted.

Dr

The average reading is above t he treatment threshold for patient s b elow the age of 80

A patient who was commenced on a simvastatin six months ago presents with general ised muscles aches. Wh ich one of the following is not a risk factor for statininduced myopathy?

Female gender Large fa ll in LDL-cholesterol Low body mass index

As Dr

Hist ory of diabetes mellitus

se

m

Advanced age

m:t

Large fall in LDL-cholest erol

CD

Low body mass index

m:t CD

Advanced age

As

se

m

History of diabetes mellitus

Dr

I

Female gend er

Each one of the following is associated w ith atrial myxoma, except:

Clubbing Mid-diastolic murmur Pyrexia

As Dr

Atrial fibrillation

se

m

'J' wave on ECG

Clubbing Mid-diastolic mu rmur Pyrexia

'J' wave on ECG

Dr

A 'J' wave is seen in hypothermia

As

se

m

Atrial f ibrillation

Which one o f t he following elect rolyt e dist u rbances is most associat ed with t he d evelop ment of a prolonged QT interval on ECG?

Hyponatraemia Hypocalcaemia Hyperkalaemia

As Dr

Hypophos phataemia

se

m

Hypercalcaem ia

CD

Hypocalcaemia

GD

Hyperka laemia

CD

Hypercalcaem ia

. (D

Hypophos phataemia

m

Hypoca lcem ia is associated with QT interva l pro longation; Hyperca lcemia is associated with QT interval shortening Less · m ::~c rtant

As se m

Important for me

Dr

I

Hyponatrae mia

Which of the following is least associated with mitra l valve p rolapse?

Osteogenesis imperfecta Pseudoxanthoma elasticum Turner's syndrome

Dr

Acromegaly

As

se

m

Marfan's syndrome

Osteogenesis imperfecta Pseudoxanthoma elasticu m Turner's syndrome

-

Marfan's syndrome

~

Acromegaly

se

m

Whil st so me patients with acromegaly have mitral va lve p rolapse (MVP) it is not a

Dr

populat ion is around 5- 10%

As

common associat ion. It shou ld be remembered that the p reva lence of MVP in a standard

Which one o f the fo llowi ng cli nical sig ns wou ld best indicate severe calcified aortic stenosis?

Lou dness of murmur Lou d second hea rt sound Radiation to the carotids

As Dr

Displaced apex beat

se

m

Hypertensi on

Which one of the fo llowin g cl inical signs wou ld best indicate seve re ca lci fied aortic stenosis?

Lou d ness of murmu r

«ED

Lou d second hea rt sound

«ED tiD

r :diation to the carotids

fD

Hypertension

CD

Displaced apex beat

As se m

I

Dr

The apex beat is not norma lly displaced in aortic stenosis. Displacement would ind icate left ventricula r dilatation and hence seve re disease

A 62-year-old female with a history of mitral regurgitation attends her dentist, who intends to perform dental polishing. She is known to be penicillin allergic. What prophylaxis aga inst infective endocarditis should be given?

Oral doxycycline Oral erythromycin No antibiotic prophylaxis needed

As Dr

Oral clindamycin

se

m

Oral ofloxacin

Oral doxycycline Oral erythromycin

-

No antibiotic prophylaxis needed

~

Oral o floxacin Oral clindamycin

Antibiotic prohylaxis t o prevent infective endocarditis is not routinely reco mm ended in the UK fo r dental and other procedures l ess impcrtc.nt

endocarditis prophylaxis

Dr

The 2008 NICE guidelines have fundamentally changed th e approach to infective

As se m

Important for me

A 63 -year-old female on long-term wa rfarin for atrial fibrillation attends the anticoagulation clinic. Despite having a stable INR for the past 4 yea rs on the same dose o f warfarin her INR is measured at 5.4. Which one o f the following is most likely to be responsible?

StJohn's Wort Smoking Carrot juice

Dr

Camomile t ea

As se

m

Cra nberry j uice

tiD

StJohn's Wort Smo king

m

Carrot juice

CD CD

Camomile tea

CD

Dr

As

StJohn's Wort is an inducer of the P450 enzyme system so would cause the INR to decrease, rather than increase.

se

m

Cranbe rry juice

A 60-year-old man presents with increasing shortness-of- breath on exertion. During the examination a third heart sound is hea rd. Examination of the respiratory system is unremarkable. Which one of the following is most consistent with this findi ng?

Dilated cardiomyopathy Hypertrophic obstructive cardiomyopathy Atrial fibrillation

As Dr

Norma l variant

se

m

Mitral stenosis

r ;ated cardiomyopathy Hypertrophic obstructive cardiomyopathy Atrial fibrillation Mitral stenosis

As

se

m

Normal variant

Dr

A third heart sound is only considered a normal variant in patients < 30 years of age.

A 64 -yea r-old man who is known to have ischaemic heart disease is due to sta rt a chemothe ra py regime which includes doxorub icin. His ca rdiolog ist wants to accu rate ly assess his leh ve ntricula r functio n as he is concerned the d oxo rubicin may d amag e his myo ca rdium. Which one of the fo llowing is the most accurate method to determine his leh ventricula r function?

Cardiac co mputed tomog ra phy Echo ca rdiog raphy Exercise ECG

Dr

Coro na ry ang io grap hy

As se m

MUGA scan

Cardiac computed tomogra phy Echocardiography Exr cise ECG

m se As

Coronary angiography

I Dr

MUGA scan

A 62-year-old man is examined in the ca rdiology clinic. During cardiac auscultation it is noted that the pulmonary comp onent of the second heart sound occurs before the aortic. Which one o f the following is associated with this finding?

Pulmonary stenosis Left bundle branch block Right bundle bra nch block

As Dr

Deep inspiration

se

m

Atrial septal defect

I

Pulmonary stenosis

tD

Left bundle b ra nch b lock

GD

Right bundle b ra nch b lock

mt

Atrial septal defect

mt

Deep inspiration

CfD

Second heart sound (52) • loud: hypertension • soft: AS • fixed split: ASD • reversed sp lit: LBBB l ess :mocrtont

As se m

Important for me

cause fixed sp litting o f 52

Dr

Left bundle b ranch b lock causes a reversed sp lit second heart sound. Atrial septal defect s

A 72-yea rs-old lady attends to her genera l practitio ne r with a history of d iabetes mell itus, hyperlipidaemia, hypertension, hypertensive cardiomyopathy, atrial fibrillation and polymyalgia rheumatica. She ha d a non-displaced hum e ral shah fracture 3 years ago treated non -operatively. She is currently taking ato rvastatin, warfarin, furose mide, bendro flumeth iazi de and a low d ose of prednisolone. Which o f the following drugs can increase the osseous matter and decrease the further risk of fracture by decreas ing the amount of calcium excreted by the kidneys?

Atorvastatin Warfarin Fu rosem ide

Dr

Prednisolo ne

As se m

Bendroflumethiazide

Atorvastatin

CD

Warfarin

•

Furosem ide

flD

Bend rofl u methiazide

GD CD

Prednisolone

Th iazide diuretics can cause hyponatraemia, metabolic alkalosis, hypokalaemia and hypocalciuria Important for me

Less impcrtont

Thiazid e diuretics can cause hyponatraemia, met abolic alka losis, hypokalaemia and hypocalciuria. They can conserve calcium by d ecreasing its excretion by kidneys, whereas

As se m

loo p diuret ics (such as fu rosemide) and cause increase calcium excretion and decrease serum calcium levels. Prednisolone as any other st eroid can shift t he calciu m from t he bone to t he kidneys to be excret ed, possibly causing st eroid-induced ost eop orosis.

Dr

Atorvastat in and warfari n d o not interfere w ith calcium homeostasis significantly.

A 67 -year-old diabetic g ent leman who recently und erwent aortic valve replacement p resent ed w ith a fev er, raised inflammat ory markers and d eranged renal function. Which one of the following organisms contribute to the highest rat e o f mortality in patient s with his condit ion?

Enterococci Streptococci Staphyloco cci

Dr

HACEK Organisms

As se

m

Pseudomonas

Streptococci

f!D

Staphylococci

(D

Pseudomonas

m f!D

HACEK Organisms

Stap hylococci is the lea ding organism cont ributing to mortality in infective endocarditis Important for me

Less ' m ::~c rtant

Staph au reu s followed by coagulase-negative staphylococci are two of the most common organisms caus ing infective endocardit is. Enterococci - Belongs to the bowel organisms group and contributes to only 15% o f mortality. Streptococci - Only contribute to around 5% of mortality. Pseudomonas - Rare cause of endocarditis, occu rs when infected water enters t he

As se m

b loodstream.

IJSP.rs.

Dr

HACEK Organisms - Lives on dental gums and are more common in intravenous drug

A 65-year-old man is admitted to the Emergency Department with chest pain, nausea and feeling lethargic. He has a history of type 1 diabetes mellitus and is known to have chronic kidney disease stage 4 secondary to diabetic nephropathy. An ECG taken on admission shows widespread ST elevation. Bloods tests show the following: Na•

140 mmol/ 1

K•

5.8 mmolfl

Urea

26 mmol/ 1

Creatinine

305 ~mol/1

His rena l fu nction one mo nth ago was as follows: Na•

142 mmol/ 1

K•

4.9 mmolfl

Urea

7.9 mmolfl

Creatinine

199 ~mol/1

Pericardiecto my

Dr

Ora l colchicine

As se m

An echoca rdiogram s hows a small effus ion. What is the most appropriate next step in management?

Oral colchicine

f!D

Pericardiectomy

fD

Pericardiocentesis

CD

Intravenous corticosteroids

GD

Haemodialysis

ED se

m

I

Dr

As

This patient has uraemic pericarditis. Haemodialysis is urgently required to correct the uraemia which in turn will improve the symptoms of pericarditis.

A 24-year-old fema le develops transient slurred speech following a flight from Australia

to the United Kingdom. Both aCT head and ECG are normal. Which one of the following

tests is most likely to reveal the underlying cause?

Transoesophageal echo MRI brain Carotid USS Doppler

As Dr

Transthoracic echo

se

m

Cerebral angiogram

I

Transoesophageal echo

ED.

MRI brain

CD

Carotid USS Doppler

flD

Cerebral angiogram

CD

Transthoracic echo

fD

Parad oxical embo lus - PFO most com mon cause - do TOE Important for me

l ess ' m ::~c rtont

As se m

Transesop hageal echocardiograp hy provid es su perior views o f the atrial septum and ovale

Dr

therefore is p referred to t ransthoracic echocardiograp hy for det ecting pat ent foramen

Where is B-type natriuretic peptide mainly secreted from?

Atrial myocardium Juxtaglomerular cells Zona glomerulosa

Dr

Hypothalamus

As

se

m

Ventricu lar myocardium

GD

Atrial myocardium Juxt aglomerular cells

CD

Zona glomerulosa

fD 6D

Ventricular myocardium

fD

B-type natriuretic peptide is mainly secret ed by the ventricu lar myocardium

Less imocrtc.nt

Dr

Important for me

As

se

m

Hypothalamus

A 72-yea r-old female is ad mitted fo r an elective abdomina l ao rtic a neurysm repair. She has a past med ical history of long-standing asthma and an undiagnosed periphe ral neu ro pathy. On day 4 post-op, she d eve lops a net-like rash over her torso with fevers, mya lgias and d iscolouration o f her toes. Blood tests reveal: Hb

128 g/ 1

Plat elet s

240 * 109/ 1

WBC

12.2

8

109/ 1

Eosinophils 2.3 * 109/ 1 Na•

138 mmol/ 1

K•

4 .1 mmol/1

Urea

8 .8 mmol/1

Creatinine

176 J,Jmol/ l

What is the most li kely diagnosis?

Churg-Strauss

Dr

Cholesterol em boli

As se m

DRESS syndro me

DRESS syndrome Cholesterol em boli Chu rg-Strauss Chronic eosinophilic syndrome Arterial thromboembolism

The answer is cholestero l emboli which presents aher a precipitating event such as angiography or abdominal aortic aneurysm repa ir. Clinical features include livedo reticu laris, eosinophilia, pu rpu ra, and rena l failu re.

Dr

As se m

Chu rg-Strauss wou ld be associated with late-onset asthma, chronic eosinophilic syndrome is a diagnosis of exclusion and is a more long-term event, and arterial thromboembolis m would not be associated with eosinophilia. DRESS syndrome wou ld be associated with a drug precipitant which is not mentioned in the question.

Which one of the following statements regarding warfarin is correct?

Warfarin can be used when breast-feeding Hypothyroidism may develop in a small minority of patients Ao rtic prosthetic valves gene rally require a higher INR tha n mitral valves

As Dr

All patients with an IN R of greater than 6.0 should be given vitamin K

se

m

The ta rget INR following a pulmonary embolism is 3.5

Warfarin can be used when breast-feet ng Hypothyroidism may develop in a small minority of patients Aortic prosthetic valves generally require a higher INR than mitral valves

se

m

The target INR following a pulmonary embolism is 3.5

As

All patients with an INR of greater than 6.0 should be given vitamin K

Dr

I

A patient with known heart fa ilure has slight limitation of physical act ivity. She is comfortable at rest but ordinary activit ies such as walking to t he loca l shops resu lts in fatigue, palpitations or dysp noea. What New York Heart Association class best d escribes the severity of their disease?

NYHA Ciass 0 NYHA Class I NYHA Class II

Dr

NYHA Class IV

As se

m

NYHA Class III

m

NYHA Class I

G'D

NYHA Class II

ED

NYHACiass ill

CD

NYHA Class IV

m

Dr

As

se

m

NYHACiass 0

A 65 -year-old man is found to have an eject ion systolic murmur and narrow pu lse pressure on examination. He has experienced no chest pain, b reathlessness or syncope. An echo confirms aortic st enosis and shows an aortic valve gradient o f 36 mmHg. How should this patient be managed?

Routine aortic valve replacement Urgent aortic valve replacement Anticoagu lation

Dr

Regular cardiology outpatient review

As se

m

Aortic valvulop lasty

I

Routine aortic valve rep lacement

GD

Urgent aortic valve replacement

m.

Ant icoagul ation

CD

Aortic valvuloplasty

CD CD

Regu lar cardiology outpatient review

Aortic st enosis management: AVR if sympto matic, otherwise cut-off is gradient o f 40 mmHg Important for me

Less imocrtant

As se m

No action shou ld b e taken at present as he is cu rrent ly asymptomatic. If t he aortic valve su rg ery is sometimes co nsidered in select ed asymptomatic patient s

Dr

gradient > 40 mmHg or t here is evid ence o f significant left ventricular dysfunct ion t hen

You get b leeped in the middl e of you r nig ht sh ift to tal k to a wo rried father who's daug hter has been adm itted with cyanosis. He tells you that they were aware she has had a murmu r s ince b irth, but it ha s on ly been the last few days in which she has had sympto ms. You believe that th is is a ca se of Eisen menge r's synd rome. What is the medical definitio n of Ei senmenger's synd ro me?

The reve rsa l of a right-to-left shunt An au dible ventricu lar septa l d efect Presence of a ventricu lar septa l defect a longside an atrial se ptal d efect

As se m

The reve rsa l of a left-to- right shunt

hypertrophy, ventricu la r septa l defect

Dr

All four o f the following: overrid ing aorta, pulmonary stenosis, right ventricu la r

The reversa l of a right -to-left shunt

(tn

au dible ventricular septal d efect

I

Presence of a ventricular septa l defect alongside an atria l septa l defect The reve rsal o f a left-to-right shunt All four of the following: overriding aorta, pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect

Ei senmenger's syndrome - the reversa l of a left-to -right shunt Less impcrtont

As se m

Important for me

Dr

Eisenmenger's synd ro me is the reversal of left-to-right shunt associated with ventricular septal defects, atrial septa l defect and a patent ductus a rteriosus.

Your review a 41-year-old woman. Four months ago she develop ed a deep vein thrombosis and was warfari nised with a target INR of 2.5. She has presented with a swollen, tender leh calf and a Doppler sca n confirms a fu rther deep vein thrombosis. Her IN R has been above 2.0 for the past three months. You organise some investigations to exclude an underlying prothrombotic condition. What should happen regarding her anticoagulation?

Switch to treatment dose low-molecular weig ht hepa rin Continue on wa rfa rin, continue with IN R ta rget of 2.5 Add aspirin 75 mg od

Dr

Continue on wa rfa rin, increase INR ta rget to 3.5

As se m

Continue on wa rfa rin, increase INR ta rget to 3.0

Add aspirin 75 mg od

-

Continue on wa rfarin, increase I NR target to 3.0 Continue on warfarin, increase INR target to 3.5

se

m

~

As

I

Continue on wa rfarin, continue with INR target of 2.5

Dr

I

Switch to treatment dose low -molecular weight heparin

A 34-yea r-old woman is a dmitted to the Emerge ncy Department fo llowin g a colla pse. An ECG shows a polymorphic ventricula r ta chycardia . Which one of the fo llowing is not associated with an in creased ris k o f d evelo ping torsade de p ointes?

Tricyclic a ntidepressants Subarachnoid haemorrhage Hype rcalcaem ia

As Dr

Hypothe rmia

se

m

Roman o -Wa rd syndrome

Tricyclic a ntidepressants Su barachno id haemorrhage Hypercalcaemia Romano-Ward syndrome Hypothermia

Hypoca lcemia is associated with QT interva l prolongation; Hyperca lcemia is associated with QT interval shortening Less 'mpcrtant

As se m

Important for me

may p red isp ose to the deve lop ment of torsad e d e pointes

Dr

Hypoca lcaem ia, not hypercalcaemia, causes p ro longation of the QT interval and hence

Which one o f the following featu res is not part o f the modified Duke criteria used in the diagn osis of infective endocarditis?

Fever > 38°C Positive molecular assays for specific gene targets Indwelling central line

As Dr

Janeway lesions

se

m

Intravenous drug use

Fever> 38°C Positive molecular assays for sp ecific gene targets Indwelling cent ral line Intravenous drug use

-

Janeway lesions

Dr

European Society of Cardiology. Details can be found in the link below

As

The modified Duke criteria have now been adopted in the latest guidelines from the

se

m

. .wJ

A 71-yea r-old woman is reviewed in the fa ll s clinic. Her blood pressure is 146/ 94 mmHg. This is confirmed o n a second rea ding . In line with recent NICE gu ida nce, what is the most a ppropriate next-step?

Ask he r to come back in 6 months fo r a b lood pressure check Arra nge 3 blood pressure checks with the pra ct ice nurse over the next 2 wee ks with med ica l review following Arra nge ambulatory blood p ressu re monito ring

Dr

Sta rt treatm e nt with a calcium cha nnel b lo cker

As se

m

Rea ssu re her th is is acceptable for he r age

Ask her to come back in 6 months for a b lood pressure check Arrange 3 blood pressu re checks with t he practice nurse over the next 2 weeks

I

wit h medical review following Arrange ambulatory blood pressure monit oring Reassure her t his is acceptable for her age Start t reatment w ith a ca lcium channel blocker

Hypertension - NICE now recommend ambulatory blood pressure monitoring to aid diagnosis Important for me

l ess ' m ::~c rtont

The 2011 NICE guidelines recognise that in t he past t here was overtreat ment o f 'w hite coat' hypertension. The use o f ambulatory blood p ressure monito ring (ABPM) aims t o reduce t his. There is also good evidence that ABPM is a better p redictor o f cardiovascular

As se m

risk t han cl inic b lood p ressure readings. See the followin g st udy for more details:

Dr

Verdecchia P. Prognostic value of ambulatory blood pressure: current evidence and clinical implications. Hypertension 2000; 35: 844-851

A 75-year-old woman is brought to the Emergency Department by her fa mily. She has been getting more short-of -breath over the last 6 w eeks and says her energy levels are low. An ECG on arrival shows atrial fibrillation at a rate of 114 I min. Blood pressure is

128/80 mmHg and a chest x-ray is unremarkable. What is the appropriate drug to control the heart rate?

Felodipine Am iodarone Digoxin

Dr

Bisoprolol

As se m

Flecainide

Felodipine

CD

Am iodarone

. (D

GD

Digoxin Flecainide

m

Bisoprolol

GD

Atrial fibrillation: rate control - beta blockers preferable to digoxin Important for me

l ess ' m ::~c rtont

This question reiterates an important p oint which frequently comes up in exams - digoxin is no longer first-line for rat e control in atrial fibrillation. Her shortness-of -breath is likely

Please see the NICE guidelines fo r further information.

Dr

supported by a normal chest x- ray.

As se m

t o be rat e related and does not necessarily mean that she is in heart failure. This is

A 36-year-old man has present ed to the emergency department with pa lpitations. His heart rate was 138 beats per minut e and an ECG showed a likely su praventricular t achycardia. The registrar asks you t o draw up 6mg of adenosine. Which of t he follow ing drugs may reduce t he action of adenosi ne?

Dipyridamole Bupivacaine Aminop hylline

Dr

Montelukast

As se m

Amiodarone

GD

Dipyridamole

CD

Bupivaca ine

I

fD

Aminophylline Am iodarone

CD

Montelukast

CD

Aminophylline reduces the effect of adenosine Important for me

Less imocrtc.nt

The answer is aminophylline. dipyridamole classically enhances t he act ion. This is

Am iodarone and mont elukast are dist ractors, that have no notable effect.

Dr

enhance t he action of ad enosine.

As se m

commo nly remembered w ith t he mnemonic DEAR. Bupivicaine (and other -caines) all also

You are ca lled to review a 78-year-old man on the surgica l wa rds. He is three days postop following a colectomy. He was recently diagnosed with colon cancer (Duke's C) and has a history of po lymyalgia rheumatica. Current medications include co-codamol 30/ 500, p rednisolone and prophylactic dose low-molecular weight heparin. Five minutes ago he started to co mpla in of severe central chest pa in. An ECG performed by the nurses shows ST elevation in the anterior leads. Aspirin a nd oxygen have been g iven by the Foundatio n 1 doctor. What is the most a ppropriate treatment?

IV dia morphine + increase low-molecular wei ght heparin to treatment dose + d ouble his p redn isolone d ose IV diamorphine + arra nge echoca rdiogram urgently to exclude pericard ia I ta mponade IV dia morphine + call the fam ily in to discu ss withdrawa l o f treatment

Dr

IV dia morphine + thro mbolysis

As se m

IV diamorphine + arra nge percutaneous coronary intervention

-

IV di amorphine + increase low-molecular weight heparin t o t reatment dose +

~

double his p rednisolone d ose IV di amorphine + arra nge echocardiogram urgently t o exclude p ericard ia! tamponade IV di amorphine + call t he fam ily in to discuss wit hdrawal o f treatm ent IV diamorphine + arrange percutaneous coronary intervention

-

IV di amorphine + t hro mbolysis

As se

m

~

recent operation and associat ed risk of bleeding .

Dr

Primary percutaneous coronary intervent ion is the most appropriate treatment given his

A 60-year-old man is admitted with severe central chest pain to the res us department. The admission ECG shows ST elevation in leads V1 -V4 with reciprocal changes in the inferior leads. Which one of the following is most likely to account for these findings?

75% occlusion of the leh ant erior descending artery 75% occlusion of the leh circumflex artery 75% occlusion of the right coronary artery

As Dr

100% occlusion of the leh anterior descending artery

se

m

100% occlusion of the leh circumflex artery

75% occlusion of the leh anterior d escending artery 75% occlusion of the leh circu mflex a rtery 75% occlusion of the right coronary artery 100% occlusion o f the leh circumflex artery

I ery se

m

100% occlusion of the leh anterior d escending

Dr

descend ing artery.

As

Widespread ST elevation in this territory implies a comp lete occlusion of the left anterio r

A 58-year-old man is admitted to the cardiology wa rd aher presenting with fever, malaise and a new murmur. An echocardiogram has s hown a vegetatio n on the aortic valve. Blood cultu res a re reported as follows: Streptococcus sanguinis isolated

What is the most appropriate follow-up given the b lood cu lture resu lts?

Colonoscopy HN test Dental review

Dr

Complement levels

As se m

High resolution CT o f the chest

Colonoscopy HIV test Dental review High resolution CT of the chest

-

........

Complement levels

Patients with very poor dental hygiene - Viridans streptococci e.g . Streptococcus

sanguinis Important for me

l ess :mpcrtont

Streptococcus sanguinis is one o f the viridans g roup streptococci, or a-hemo lytic streptococci, which are common causes of infective endocarditis. They are commensal in the mouth and invasive infection is associated with denta l disease. The American Heart

As se m

Association recommend:

should be eradicated.·

Dr

'A thorough dental evaluation should be obtained and all active sources of oral infection

A 79-year-old woman is reviewed. She has taken bendroflumethiazide 2.5mg od for the past 10 years for hypertension. Her current blood pressure is 150/94 mmHg. Clinical examination is otherwise unremarkable. An echocardiogram from two months ag o is reported as follows: Ejection fraction 48%, moderate left ventr icular hypertrophy. Minimal MR noted

What is the most appropriate next step in management?

Increase bendroflumethiazide to Smg od Stop ben droflumeth iazi de + start frusemide 40mg od Add ram iprii 1.2Smg od

Dr

Add amlodipine Smg od

As se m

Stop ben droflumeth iazi de + start ramipril1.25mg od

Increase bendroflumethiazide to Smg od Stop ben droflumethiazide + start frusemide 40mg od Add ram iprill.25mg od

-

Stop ben droflumethiazide + start ramiprill.25mg od

" "'

Add amlodipine Smg od

The echocardiogram shows a degree of left ventricular impairment. It is important an AC E inhibitor is started in such patients. This will help t o both control her blood pressure and also slow the deterioration in her cardiac function. Even though bendroflumethiazide is no longer the recommend thiazide of choice, and thiazides now co me 'third' in the A + C + D guidelines, NICE do not recommend stopping

impairment.

Dr

A beta- blocker should also be added in the near future given the left ventricu lar

As se m

treatment in patients who are alrea dy taking the drug.

Each one of the fo llowing may cause secondary hypertension, except:

Patent ductus a rteriosus Cush ing 's syndrome Liddle's syndrome

As Dr

Combined ora l contraceptive pill

se

m

11-beta hyd roxylase deficiency

Ea ch one of the following may cause seconda ry hypertensio n, except:

Patent ductus arteriosus Cushing 's syndrome Liddle's syndrome

-

P .-beta hyd rJ ylase deficiency

~

Dr

As

se

m

Com bined oral co ntraceptive pill

A 54-year-old man is admitted to the Emergency Department (ED) aher col lapsing shortly aher complaining of palpit ations. On arrival in the ED he is found to be in ventricular tachycardia and is successfully cardioverted. Later investigations show that he has an underlying long QT syndrome. A implantable cardioverter-defibrillato r (lCD) is inserted. He works as a heavy goods vehicle (HGV) driver. What is the most appropriate advice with regards to driving HGV vehicles?

Permanent bar Cannot drive for 12 months Cannot drive for 6 months

Dr

Can drive stra ightaway

As se m

Cannot drive for 4 weeks

Permanent bar Cannot drive for 12 months Cannot drive for 6 months Cannot drive for 4 weeks

ltrpor:a.r! "or me

_ess r-oc-tart

Dr

lCD means loss of HGV licence. regardless of the circumstances

As

se

m

Can drive straightaway

A 44-year-old man is seen in the cardiology clinic. Fo r the past 6 months he has been experiencing e pisodes of pa lpitations associated with pre-syncopal symptoms. An ECG taken in clin ic shows T wave invers ion in leads Vl-3 associated with a notch at the end of the QRS complex. He is known to have a fam ily history of sudden ca rdiac death. What is the most li kely diag nosis?

Arrhythmogen ic right ventricular cardiomyopathy Catecho lam inerg ic polymorphic ventricul ar tachycardia Hypertrophic obstructive cardiomyopathy

Dr

Brugada syn drome

As se m

Long QT synd rome

I

Arrhythmogenic right ventricular qardiomyopathy Catecholaminergic polymorphic ventricular tachycardia Hypertrophic obstructive cardiomyopathy long QT syndrome

Dr

The notch at the end of the QRS complex is referred to as an epsilon wave.

As

se

m

Brugada syndrome

A 34-year-old woman attends a routine antenatal cl inic at 16 weeks gestation. She has no sign ificant past medica l history but suffe rs with occasional frontal headaches. She is noted to have a blood pressure of 148/ 76mmHg. Urina lysis reveals; pH

6 .5

Protein

+1

Nitrates

0

Leuc

0

Blood

0

What is the most likely diagnosis?

Gestational hype rtension Pre-eclampsia

Chronic hypertension

Dr

Nephrotic syndrome

As se m

HELLP

Gestationa l hype rtension P ,e -eclampsia HELLP

I

Nephrotic syndrome Chronic hypertension

I

The answer here is chronic hypertension. At 16 weeks gestation, this lady is too early into her pregnancy to have developed any of the p regnancy re lated causes of hypertension. The sma ll a mount of protein in her uri ne may also indicate re latively long stand ing hyperte nsion. Inte rmittent frontal headaches are a co mmo n occurre nce and are not a sign of pre-ecla mpsia in this case. Pre-eclampsia and gestational hypertension would only occu r ah er 20 weeks gestation. Pre-eclampsia with sign ificant p roteinuria, g estational hypertens io n without.

https:/ /www.nice.o rg.uk/ g u idance/cg 107/ chapter/guida nee

Dr

For further info rmation on hypertension in p regnancy:

As se m

Neph rotic synd rome would be associated with a la rg e r deg ree of p roteinuria.

A 62-year-old m an is ad mitted to hospital following a myocardial infarction. Four days after admission he develops a further episode of central crush ing chest pain. Which is t he best ca rdia c marker to investigate his chest pa in?

LDH Troponin I Troponin T

As Dr

AST

se

m

CK- MB

m

LDH

I

Troponin I

(D

Troponin T

GD

CK-MB

GD

•

se

m

AST

As

By day four the CK-M B levels should have returned to normal from the initial myocardial

Dr

infarction. If the CK-MB levels are elevated it would indicat e a further coronary event

A 76-yea r-old woman is admitted to the resus depa rtment after collaps ing whilst s hop pi ng. The pa ramedics report she is hypotensive and tachycardia. Initial observations include a heart rate o f 160 bpm and a b lood pressure of 98 I 60 mmHg . A 12 lead ECG s hows a broa d complex tachyca rdia. Which one of the following features on the ECG wou ld suggest a ventricular tachycardia rather tha n a su praventricular tachyca rdia with aberrant conduction?

QRS < 160 ms A corrected QT interva l o f 420ms Atrioventricular dissociation

Dr

Heart rate o f 160 bpm

As se m

Marked right axis deviation

QRS < 160 ms A co rrected QT interval o f 420ms Atrioventricular dissociation

m

Marked right axis deviation

Dr

As

se

Heart rat e o f 160 bpm

A 26-year-old female is admitted to hospital with palpitations. ECG shows a shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead n. What is the definitive management of this condition?

Accessory pathway ablation Lifelong aspiri n AV node ablation

As Dr

Permanent pacemaker

se

m

Lifelong amiodarone

I

m:t

Accessory pathway ablation

'

fD

Lifelong aspirin

Lifelong amiodarone

m m

Permanent pacemaker

CD se

m

AV node ablation

Dr

the definitive treatment

As

This patient has Wolff-Pa rkinson White syndrome, with accessory pathway ablation being

A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the following features would most guide the timing of surgery?

Sym ptomatology of patient Aortic valve gradient of 36 mmHg Pul se pressure

As Dr

Left ventricu lar ej ection fract ion

se

m

Lou dness of murmur

GD CD

Aortic valve gradient o f 36 mmHg

m m

Pulse pressure Loudness o f murmur

GD

Left ventricular ejection fraction

Irrportar1 "or me

_ess ·rrxrtc.rt

Dr

40mmHg

As

se

Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of

m

I

Sym ptomatology of patient

A 42-year-old man has his blood pressure measured as part of a routine medical exam. His blood pressure is recorded as 155/ 95 mmH g. This is unexpected as it has been normal fo r the past 5 annual medica l exams. Which one of the following factors may accou nt for this finding?

Elevation of the measured arm above heart level The measured arm being supported during the reading The patient lying on an examination couch during the readin g

Dr

An undersized blood pressure cuff

As se m

The patient ta lking during the reading

r

Elevation of the measured arm above heart level

r.e measured arm being supported during the reading The patient lying on an examination couch during the readin g The patient ta lking during the reading

As

Less · m ::~c rtant

Dr

Important for me

se

An undersized blood pressure cuff may lead to an overestimation of blood pressure

m

An undersized blood pressure cuff

A 52-year-old man with a history o f hypertension is found to have a 10-year

ca rdiovascular disease risk of 28%. A decision is mad e to start atorvastatin 20m g on. Liver

f unction tests are p erformed p rior to initialisi ng t reatment:

Bilirubin

10 IJmol/1 (3 - 17 umol/1)

ALP

96 u/1 (30 - 150 u/1)

ALT

30 u/1 (10- 45 u/1)

Gamma-GT

28 u/1 (10 - 40 u/1)

Three mont hs lat er t he LFTs are rep eated: Bilirubin

12 IJmol/1 (3 - 17 umol/1)

ALP

107 u/1(30- 150 u/1)

ALT

104 u/1( 10- 45 u/1)

Gamma-GT

76 u/1 (10 - 40 u/1)

What is the most app ropriate course o f action?

Cont inue treatment and rep eat LFTs in 1 mont h

Dr

Reduce d ose t o atorvastatin 10mg on and repeat LFTs in 1 month

As se m

Check creat ine kinase

I

Continue treatment and repeat LFTs in 1

~onth

Check creatine kinase Reduce dose to atorvastatin 10mg on and repeat LFTs in 1 month Stop treatment and consider alternative lipid lowering drug

se

m

Stop treatment and refer to gastroenterology

Dr

As

Treatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

A 72-yea r-old ma n who is known to have chronic kid ney disease sta ge 4 is admitted to the Em ergen cy Depa rtment. Since yesterday he has felt short-of-b reath on exertion and has b een co ughing up bloo d. On examination he tachyca rdic at 110/min with a norma l chest exam ination. What is the most suitable initial im agi ng investigation to exclude a pulmona ry e mbolism?

Ventilati on -perfusion sca n Com puted tomograph ic pu lmo na ry a ngiography Pulmonary ang iography

Dr

Echocardiogram

As se m

MRI thorax

I

Ventilation-perfusion scan Computed tomographic pulmonary angiography

~ulmonary angiography MRI thorax Echocardiogram

Pulmonary embolism and renal impairment- V/Q scan is the investigation of choice Important for me

l ess im:>crtc.nt

As se m

Computed tomograph ic pulmonary angiography (CTPA) is now used first-line to investigate the possiblity of pulmonary embolism. Patients with renal impairment however

Dr

should be offered Ventilation-perfusion (V/Q) scans as the contrast media used during CTPAs is nephrotoxic.

A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why he collapsed but is now fully alert. He is complaining of abdominal pain but his bowel habits are unchanged. He has a past medical history of p rostatism and hypertension. He tells you he doesn't take any medication. On examinat ion he has a Glasgow coma sca le score of 15, a blood pressure o f 98/46 mmHg and a heart rate o f 98beats per minute.

Hb

115 g/ 1

Platelets

32 1 * 109/ 1

WBC

6 .6 * 109/ 1

His radiology results are reported as follows: Chest

PA film, lung fields clear, widened mediastinum

Abdomen

normal bowel gas pattern

CT aortic angiogram

Dr

Urgent echocardiogram

As se m

Which of t he following is t he next most appropriate step in t his man's management?

Urgent echoca rdiog ram CT aortic ang iogram Start IV labetalol Bronchoscopy with pleu ra l b iopsy Pericardiocentesis

Dr

aortic root in a backwards tear, it wou ld not identify mo re distal aortic pathology.

As se

m

In a man with low blood pressure and vague abdomina l pain, always be mind fu l of the possibility of dissection o r aneurysmal rupture. CT imaging with a rterial contrast is the gold stan dard for d iag nosis. Whilst an echoca rdiogram mig ht identify disruption of the

A 60-year-old man is admitted w ith palpitations to the Emergency Department. An ECG

on admission shows a broad complex t achycardia at a rate of 150 bp m. His blood

p ressure is 124/82 mmHg and t here is no evidence of heart fa ilure. Which one of t he

following is it least appropriate to give?

Procainamide Lidoca ine Synch ron ised DC shock

Dr

Vera pamil

As se

m

Adenosine

Proc.ainamide

-

Lidocaine

"""'

Synchronised DC shock Adenosine

-

Verapa mil

~

Ventricular tachycardia - verapamil is contraindicated Important for me

Less · m ::~c rtant

Dr

As se m

Verapa mil should never be given to a patient with a broad complex tachycard ia as it may precipitate ventricular fibrillati on in patients with ventricular tachycard ia. Adenosine is sometimes given in this situation as a 'trial' if there is a strong suspicion the underlying rhythm is a supraventricular tachycardia with aberrant co nduction

Which of the following conditions is not associated with the development of aortic regurgitation?

Rheumatic fever Ankylosing spondylitis Marfan's syndrome

As Dr

Dilated cardiomyopathy

se

m

Syphilis

Rheumatic feve r Ankylosing s po ndylitis

-

Ma rfan's syndrome

~

Syphi lis

se

m

Dilated cardiomyopathy

Dr

aortic reg u rgitation

As

Dilated cardiomyo pathy is associated with the deve lop ment o f mitral regu rgitation, not

Which one o f the followin g cardiac conditions is most associated with a lou der murmur

fo llowing t he Valsa lva manoeuvre?

Mitral stenosis Aortic st enosis Vent ricu lar septal d efect

As Dr

Aortic regurgitation

se

m

Hypertrophic obstructive cardiomyopathy

Mitral stenosis Aortic stenosis Ventricu la r septa l d efect

se

m

Hypertrophic o bstructive cardio myo pathy

Dr

As

Aortic reg urgitation

A 65 -year-old man admitted to the Acute Medical Unit is not ed to have cannon 'a' waves of his j ugular venous pressure during cardiovascu lar examination. Which one of the following wou ld not cause this finding?

Tricuspid stenosis Complete heart block Ventricu lar tachycardia

As Dr

Nodal rhythm

se

m

Single chamber ventricular pacing

ClD

Complete heart block

«ED

Ventricu lar tachycard ia

flD

Single chamber ventricular pacing

GD

Nodal rhythm

tiD se

m

Tricuspid stenosis

As

I I

Dr

Whilst t ricuspid stenosis may cause large 'a' waves it does not cause cannon 'a' waves

A 72-year-old man is admitted to the Emergency Department with chest pain. On initial assessment he is not ed to be pale, have a heart rate of 40/ min and a b lood pressure of 90/ 60 mmH g. Which one of the coronary arteries is most likely t o b e affected?

Po sterior d escending Left ant erior descending Right co ronary

Dr

Left circumf lex

As

se

m

Anterior interventricular

Posterior descending Left anterior descending Right coronary Anterior intervent ricular Left circumflex

Complete heart block following a MI? - right coronary artery lesi on Important for me

Less impcrtont

This patient has d eveloped complete heart block secondary to a right co ronary artery (RCA) infarction. The atrioventricular nod e is supp lied by the post erior interventricu lar

As se m

artery, which in the majority of patients is a branch of t he right coronary artery. In t he artery.

Dr

remaind er of patients the p ost erior interventricu lar artery is supplied by the left circumf lex

Which one o f the followin g is least likely t o cause dilated ca rdiomyopathy?

Wilson's disease Haemochromatosis Coxsackie B

Dr

Alcohol

As

se

m

Hypertension

I

Wilson's disease

CiD

Haemoch romatosis

flD

Coxsackie B

GD

Hypertension

fD

m

Alcohol

Dr

As

se

m

Haemoch romatosis is more commonly associated with restrictive ca rd iomyopathy but a dilated pattern may a lso be seen. There is a known association between Wilson's d isease and cardiomyopathy but this is extremely ra re and not oh en clin ically significa nt

Yo u a re the STl wo rking on card iology. The nurses have a sked yo u to review a 56-yea rold ma n complaining o f dyspnoea which is li miti ng his mobil ity.

He presented th ree days ago with an infe rior STEM!. He was loa ded with 300mg asp irin and 180mg ticagrelor before b ei ng taken to the cath -lab whe re he unde rwent prima ry PC! with a drug eluting stent for a sub-total occl us ion of the right co rona ry artery. He wa s su bsequently comm e nced on a spirin l OOmg od, tica gre lor 90mg bd, ato rvastati n 80mg o d, bisoprolo l Smg od a nd p erind opril Smg od. His echo demonstrated only mildly reduced LV systol ic function (LVEF 50%). His vital s ign s are stable with a blood p ressure 125/70mmHg, heart rate 64b pm, oxygen saturations 98% on room air and te mperature 36.5°C. Examination reveals du al heart sounds with no murmurs and his chest is clear on auscultatio n with no wheeze. JVP is +2cm and there is no peripheral oed ema. His calves a re soft and non tende r. A Chest XRay shows mild atelecta sis a t the bases. His bloods a re unre markable. His ecg shows normal sinus rhythm with inferior q wave s.

With res pect to his dys pnoea, what would be the next best step in his management?

Cease bisopro lo l

Cease ticagrelor and continue asp irin o nly

Dr

Order an urg ent repeat echo

As se m

Substitute ti cagre lor for clo pidogrel

I

Su bstitute ticagrelor for clopidog rel Order an urgent repeat echo Cease ticagre lor and continue aspi rin on ly

-

Start antibiotics for a nosocomial pneu monia

"""'

Dyspnoea is a common side effect of ticag re lor and is estimated to occur in up to 15% of patients started on this medication. It is hypothesised that the sensation of dyspnoea in ticagrelor-treated patients is triggered by adenosine, because ticagrelor inhibits its clea ra nce (by inhibiting the enzyme adenosine deam inase), thereby increasing its concentration in the circulation. It is important to be aware of this s ide effect in order to avoid unnecessary treatment and/ or investigation, as it is easily remed ied by switching the patient to clopidog rel.

Dr

As se m

With res pect to the other options, in this scenario there are no cl inica l featu res to suggest into lerance to a beta-b locker or heart failu re. There a re also no clin ical signs to suggest a hospital acquired pneumonia with basal atelectasis a not uncommon finding in previously ambient patients who are hospitalised. It is important to be aware of the possibility of acute mitra l regurgitation or a ventra l sepal defect post STEM! as these requ ire urgent diag nostic echo and surg ica l repa ir; however, given the fact that this patient is otherwise clinically well apart from subjective dyspnoea, has no murmurs on exam ination or signs of heart failu re, this option is an unlikely cause of his dyspnoea. Whilst ticagrelo r is associated with dyspnoea and cessation of th is medication will most likely result in •. . " . · · to continue on single agent anti -platelet

A 70-year-old woman is brought to the Emergency Department by her relatives. For the past two hours she has experienced palpitations and 'tightness' in her chest. An ECG

t aken on arrival shows baseline atrial act ivity of around 300/ min with a ventricular rate of 150/min. What is the most likely diagnosis?

Atrioventricu lar nodal re-entry t achycardia (AVNRT) Atrial flutt er Atrioventricu lar re-entry tachycardia (AVRT)

Dr

Atrial fibrillation

As se

m

Junctional tachycardia

Atrioventricular nodal re-entry tachycardia (AVNRT) Atrial flutt er

-

.....,

Atrioventricular re-entry tachycard ia (AVRT) Junctional tachyca rdia

As

se

m

Atrial fibrillation

Important for me

Less imocrtc.nt

Dr

Tachycardia with a rate of 150/min ?atrial flutter

A 45 -yea r-old man presents w ith fever. On examinatio n he is noted to have a pan -syst o lic m urmur and sp linter haemo rrha ges. He is genera lly unwell w ith a b lood pressu re of 100/60 m mHg and a t em perature o f 38.8°C. What is t he most suita ble antibiotic therapy

until blood cu lt ure results are known?

IV amoxicillin + gentam icin IV benzylpenicill in + g entam icin IV vancomycin + gentam icin

Dr

IV ceftriaxone + benzylpenicill in

As se

m

IV vancomycin + benzylpenicillin

I

ED.

IV benzylpenicillin + gentamicin

GD

N vancomycin + gentamicin

CID.

N vancomycin + benzylpenicillin

crD se

As Dr

N ceftriaxone + benzylpenicillin

m

IV amoxicillin + gentamicin

CD

A 54-year-old man is admitted to the Emergency Department with a 15 minute history of

crushing centra l chest pain. Which one of the following rises first following a myocardial infarctio n?

AST Troponin I CK

As Dr

Myoglobin

se

m

CK- MB

D

AST

GD

Troponin I

m

CK CK-MB

GD

Myoglobin

ED

Myoglobin rises first following a myocardial infarction

As se

m

Less : m ::~c rtant

Dr

Important for me

A 39-year-old ma le is d iagnosed with pulmonary arterial hyperte nsion. He was started on sildenafil four months ago after testi ng negative during vasodi lator testing but has ha d a poor respo nse to treatment with continued s hortness of b reath on exertion and peripheral oedema.

What add itiona l medications should be co nsidered to delay disease progression and ease

sympto ms?

Diltiazem Isoso rbide mononitrate Ambrisenta n

Dr

Furosemide

As se m

Nifedipine

-

.....,.,

Diltiazem

.....,.,

Isosorbide mononitrate

I

Am b rise ntan Nifed ipine

~

Furosemide

Pulmonary a rte rial hypertensi on patie nts with negative response to vasodilator testi ng s houl d be treated with p rosta cyclin analo gues, e ndotheli n recepto r antag o nists or phosphod iesterase inhib ito rs. Often com b inati on the rapy is required Important for me

Less imocrtc.nt

The correct answer here is to combine si ldenafil a phosphodiesterase inhibitor with an alternative med ication used for treating patients who do not respond to acute vasod ilato r testing. These patients a re candidates fo r treatment with prostacyclin analogues such as iloprost or epoprostenol, endothel in receptor antagonists such as bosentan or ambrisentan and phosphodieste rase inhibitors such as sildenafil. Studies suggest that the

Dr

As se m

use of these medications can improve symptoms, d e lay disease p rog ression and improve survival. As such the correct answer is to ad d in ambrisentan an endothel in recepto r antagonist. As the popularity o f combination therapy increases this is often being do ne at or soon after initiation of treatment.

A 79-year-old man is a d mitted with congestive cardiac fail ure. Bloods on admission show: BNP

3 54 pgfml

Which one o f the followin g wou ld result from elevated BNP levels?

Decreased sodium d iu resis Vasoconstriction of the coronary arteries Inhibition of the renin -angiotensin -a ldosterone system

Dr

Increased sympathetic tone

As se m

Vasoconstriction of the pu lmo na ry vessels

Decreased sodium d iuresis Vasocor striction of the coronary arteries Inhibition of the renin-ang iotens in-aldosterone !ystem

-

Vasoconstriction of the pu lmo na ry vessels

~

Increased sym pathetic tone

BN P - actions: • vasodilator • diuretic and natriu retic • suppresses both sympathetic tone an d the renin-angiotensin-aldoste rone

Less impcrtant

Dr

Important for me

As se m

system

A 36-year-old wo man presents for a routine antenatal review. She is now 15 weeks pregnant. Her blood pressure in cl inic is 154/ 94 mmHg. Th is is confirmed with ambulatory blood pressure monitori ng. On reviewing the not es it app ears her blood pressure four weeks ago was 146/ 88 mmHg. A urine dipstick shows is normal. There is no significant past medical hist ory of note. What is the most likely diagnosis?

Pre-ecl ampsia Pregnancy-i nduced hypertension Whit e-coat hypertension

Dr

Pre-existing hypertension

As se m

Normal physi ologi cal change

Pre -eclampsia Pregnancy-i nduced hype rtension White-coat hypertension No rma l physiologi cal change Pre-existing hypertension

This lady has pre-existin g hypertens io n. Preg nancy-related b lo od pressure p roblems (su ch a s p regnancy-induced hypertension or pre-ecla mpsia) do not occur before 20 weeks. The ra ised a mbulatory b lood p ressure readi ngs exclude a diagnosis of white-coat hyperte nsion.

Dr

As se m

No te the use of the term 'pre-existi ng hypertension' rather than essential hyperte nsion. Ra ised blo od pressure in a 36-year-o ld female is not that com mon and raises the possibility o f seconda ry hype rtens ion.

A 43-yea r-old man who is known to have Wolff-Parkinson White syndrome presents to the Emergency Department with palpitations. He has no other signi ficant history of note. The pa lp itations started around 4 hours ago and a re not associated with chest pa in or shortness of b reath. On examination blood p ressure is 124/80 mm Hg and the chest is clea r on auscu ltation. An ECG show atrial fibrillation at a rate of 154 bpm. Of the followin g options, what is the most appropriate management?

Adenosine Fleca inide Verapamil

Dr

Sota lo l

As se m

Digoxin

Adenosine

CD

Flecainide

ED

Verapamil

CD

Digoxin

. (D

Sot alol

GD

Adenosine should be avoided as blocking the AV node ca n paradoxically increase

Another option to consider in this situation wou ld be DC ca rdioversion

Dr

avoided in patients with Wo lff- Parkinson Whit e as they may precipitat e VT or VF.

As se m

ventricular rat e resulting in fall in ca rdiac output. Verapamil and digoxin should also be

A 72-year-old woman who takes bendroflumet hiazide for hypertension is admitted to t he Em ergency Department. Admission blood s show t he followi ng: Na•

131 mmol/ 1

K•

2.2 mmol/1

Urea

3 . 1 mmol/1

Creatinine

56 IJffiOI/1

Glucose

4 .3 mmol/1

Which one o f t he followin g ECG features is most likely to be seen?

Short PR interval Short QT interval Flattened P waves

Dr

U waves

As se m

J waves

Short PR interval

GD

Short QT interval

•

Flattened P waves

«ED

J waves

m

U waves

CD

Hypokalaemia - U waves on ECG l ess im:>crtc.nt

As se m

Important for me

White syndrome.

Dr

J waves are seen in hypothermia whilst delta waves are associated with Wolff Parkinson

A 56-year-old gentleman is brou ght in by paramedics. The patient faint ed this morning and has not regained consciousness. No inj uries reported from his faint. On examination his heart rate is 37 beats/ minute, respirat ory rate is 16 breaths/ minute, blood pressure is 105/70 mmHg. You order an ECG: The ECG shows prolonged PR interval. What would be the initial management?

IV atropine IV adenosine External pacing

Dr

Oral atropine

As se m

IM adrenaline

I

GD

IV atro p ine

m

IV ad eno sine

. (D

External pacing

~M a d re nal ine

CD

•

Oral a tropine

~mptomatic

b radyca rdi a is treated with atropine Important for me

Less imocrtant

This patient is suffering fro m b radyca rdia with adverse features (syncope) like ly due to his first d egree hea rt block (p rolong ed PR interval). Adverse fea tu res of b radyca rdia are shock, myocardia l ischemia, heart failure a nd synco pe. The initia l treatment is IV atro pine. IV ad enosine is not used in bradyca rdia, it is used in supraventricu la r tachycardias.

IM a d rena line is indicated fo r anap hylaxis

Dr

Ora l a tro pine is o nly indicated for GI disorders caused by smooth muscle spasms.

As se m

Externa l pacing is o nly used if there is no improvement afte r s ix d oses of atro pine.

A 71-year-old man is reviewed in the coronary care unit. He was admitted w it h an ant erior ST-elevation myocardial infarction and received thrombolysis with alt ep la se. Ninety minut es follow ing t his an ECG shows a 30 -40% resolut ion in t he ST elevation. What is t he most app ropriate mana gement?

Percuta neous coro nary intervention Repeat ECG in 4 hou rs, if still not a 50% resolution in ST elevation t hen proceed to percutaneous coronary int ervent ion Repeat thrombo lysis w ith alteplase

As se m

Start a nitrat e infusion

relief

Dr

Inform his relat ives that further intervention is fut ile and ensure adequate pain

Percutaneous coronary intervention

6D

Repeat ECG in 4 ~ou rs, if still not a 50% resolution in ST elevation then proceed to percutaneous coronary intervention

m m

Repeat thrombolysis with alteplase

m

Start a nitrate infusion

As Dr

relief

se

Inform his relatives that further intervention is futile and ensure adequate pain

What is the mechanism of action of nico randil?

Fast-sodium channel antagonist Nitric oxide reductase inhibitor Acts on the If ion cu rrent in the sinoatrial node

As Dr

Glutathione S-transferase inhibitor

se

m

Potassium-channel act ivator

Fast-sodium channel antagonist Nitric oxide reductase inhibitor f

ion current in the sinoatrial node

-

....., m

Acts on the I

Glutathione S-transferase inhibitor

Dr

As

se

Potassium-channel activator

Which one of the following may reduce the effects of adenosine?

Dipyridamole Diltiazem Clopidogrel

se As Dr

Aminophylline

m

Amiodarone

QD

Dipyridamole Diltiazem

m

Clopidogrel

. CD

Amiodarone

CD

I

ED

Aminophylline

Adenosine

As se

m

• dipyridamole enhances effect

lmportart "or me

_ess :rr oc"'ta""tt

Dr

• aminophylline reduces effect

A middle -aged woman is admitted to the Emergency Department with pleu ritic chest pain ten days after having a hysterectomy. There is a clinical suspicion of pulmonary embolism. What is the most commo n chest x-ray finding in patients with pul monary embolism?

Right heart enlargement Normal Pleural effusion

Dr

Dilatation of the pulmonary vessels proximal to the em bolism

As

se

m

Linea r atelectasis

CD

Rig ht heart enlargement

I

6D

Normal

• •

Pleural effusion

~near atelectasis

(fD

Dilatation o f the pulmonary vessels proximal to the embolism

Pulmonary embolism - normal CXR

m

l ess im:>crtc.nt

As se

Important for me

Dr

The vast majority of patients w ith a pu lmonary embolism have a normal chest x-ray.

A 60-yea r-old man is investigated for progressive shortness of breath. On examination a loud P2 is noted associated with a left parasterna l heave. An ECG shows evidence of rig ht ventricular strain and a diagnosis of pulmonary hypertension is suspected. Wh ich one of the following is the sing le most im portant test to confirm the dia gnosis?

Echoca rdiography High resolution CT thorax Cardiac catheterisation

Dr

Ventilation perfusion scanning

As se

m

Pu lmonary angiography

Echoca rdiography High resolution CT thorax Cardiac catheterisation Pulmonary angiography

Dr

As se

m

Whilst echocard iog ra phy may strong ly po int towa rds a d iagnosis of pu lmona ry hypertension a ll patients need to have right heart pressu res measu red . Card iac catheterisation is therefore the single most im portant investigation. Please see the British Thoracic Society gu id elines for mo re d etails.

A 42-year-old man of Afro-Caribbean origin is diagnosed as having hypertension. Secondary causes of hypertension have been excluded. What is the most appropriate initial drug therapy?

Losartan Bisoprolol Indapamide

As Dr

Amlod ipine

se

m

Ram ipril

Losartan

CD

Bisoprolol

fD

Indapamide

m

Amlodipine

GD se

As

ACE inhibitors have reduced efficacy in black patients and are therefore not used

m

GD

first-line Important for me

l ess ' m ::~c rtont

Dr

I

Ram ipril

A 76-year-old man with a history of ischaemic heart disease and hypertension present s fo r review. He ha d a myocardial infarction 20 years ago but has had no problems since. His current medication is clopidogrel, atorvastatin, ramipril and bisoprolol. He has recently been feeling light-headed an ECG shows atrial fibrillation. What antithrombotic medication should he now be ta king?

Continue clopidogrel monotherapy Swit ch to aspirin + clopidogrel

Swit ch to long-term low molecul ar weight hepari n

Dr

Swit ch to an oral anticoagulant

As se m

Swit ch to an oral anticoagulant + clop idogrel

Continue clopidogrel monotherapy Switch to aspirin + clopidogrel

I

Switch to an oral anticoagu lant + clopidogrel Switch to an oral anticoagulant Switch to long-term low molecular weight hepari n

Patients with stable CVD w ho have AF are generally managed on an anticoagulant and the anti platelets stopped Important for me

Less ·mpcrtant

As se m

This patient is at risk o f st roke given his CHADS-VASC score (cardiovascu lar disease,

hypertension, age etc). He, t herefore, requires treatment. As his cardiovascu lar disease is

Dr

stable, he shou ld stop his ant iplatelet and switch to oral anticoagu lant monotherapy.

Where is the site of action of furosemide?

Proximal collecting duct Ascending loo p of Henle Descending loop of Henle

se As Dr

Macula densa

m

Distal collecting duct

Proximal collecting duct

CD

Ascending loop of Henle

fD

Descending loop of Henle

flD

m m

Distal co llecting duct Macula densa

se

m

~

As

Furosemide- inhibits the Na-K-CI cotrans porter in the thick ascending limb of the Important for me

Less impcrtont

Dr

loop of Henle

A 68-year-old ma n presents with a 4-day history of palp itations and increased breathlessness on exertion. An ECG shows atria l fib rillation with a rate of 118 beats per minute. His past medical history in cludes brittle asthma, hypertensio n and congestive ca rdiac failu re and his recent echocard iogram showed a left ventricula r ejection fraction of 32%. What is the most appropriate med ication to control the heart rate in this man?

Vera pa mil Sotalo l

Am iodarone

Dr

Digoxin

As se m

Diltiazem

CD

Verapamil

CiD

Sotalo l Diltiazem

fliD

Digoxin

ED

Amiodarone

GD

Rate-lim iting CCBs should be avoided in patients with AF with heart fai lure with reduced EF (H FrEF) due to their negative inotropic effects Important for me

Less impcrtont

Rate-l imiting calcium channe l blockers (diltiazem and verapamil) should be avoided in patients with atrial fibrillation (AF) with heart failure with reduced ej ection fract ion (HFrEF) due to their negative inotropic effects. Digoxin monotherapy is no longer considered first-line for rate control but may be preferred in patients w ith heart fa ilure and a sedentary lifestyle.

As se m

Sot alol and amiodarone are used t o maint ain sinus rhythm in AF. Standard beta-blockers (not including sotalol) are commonly used for rate control in AF asthma.

Dr

but they are not among the options and should be avoided in this patient with brittle

A 50-year-old man presents t o the emergency departm ent w ith heart palpitations. He is not experiencin g chest pain. He has a long history of alcohol abuse. On examination there is no signs of shock, heart fa ilure or syncope. He app ears malnourished. An ECG shows an irregular tachycardia of 165 beats per minute with a QRS duration of 155ms. Laboratory results reveal a pot assium of 2.1 mmoljl. What should be the next step in management?

Administration of l mg of intravenous adrenaline and 300mg of intravenous amiodarone Defibrillation

Administration of 2g of magnesium

Dr

Defibrillation and 300mg of intravenous amiodarone

As se m

Defibrillation and 1mg of intravenous adrenaline

-

Administration of lmg of intravenous adrenaline and 300mg of intravenous am ioda rone

"""'

Defibrillation

~efibrillati on and lmg of intravenous adrena line Defibrillation and 300mg of intravenous amiodarone Admin istration of 2g of mag nesium

Dr

As se m

The irregular tachycardia with a broad QRS complex is suggestive of either polymorphic ventricular tachycardia (VT), pre -excited atrial fibrillation, or atrial fibrillation with bundle branch block. The long history of alcohol abuse and the severe hypokalaemia make polymorphic ventricular tachycardia (Torsade de Pointes) the most likely diag nosis in this case. As per the Resuscitation Cou ncil tachyca rdia guidelines, as the patient has no adverse featu res, they should receive 2g of mag nesium.

A 34-yea r-old ma n is noted to have a pa n-systo lic murmur associated with la rge V waves in the JVP and pulsatile hepatomegaly. Wh ich one of the following types of congen ital heart disease is most associated with tricuspid regu rgitation?

Atrial septal d efect Ebstei n's ano maly Coarctation o f the aorta

Dr

Ventricu la r septa l d efect

As

se

m

Patent ductus arteriosus

fD

Ebstein's anomaly

CD

fD

Patent ductus arteriosus

m

se As

Ventricular septal defect

m

Coarctation o f the aorta

Dr

I

Atrial septal d efect

&D

A 45-year-old female develops pleuritic chest pain following a hysterectomy 10 days ago. Low -molecu lar weight heparin is given initially and CTPA confirms a pulmonary embolism. There is no previous history of venous thromboembolism. How long should the patient be warfarinised for?

Not suita ble for anticoagulation At least 4 weeks At least 3 months

Dr

12 months

As

se

m

At least 6 months

I

Not suita ble for anticoagu lation

m

At least 4 weeks

m

At least 3 months

CD

At least 6 months

m

m

12 months

'Provoked' pulmonary embol isms are typically treated for 3 months l ess im:>crtc.nt

As se m

Important for me

Dr

As this patient has a temporary risk factor for a throm boem bolic event the recommended period of anticoagu lation is 3 months.

How long shou ld a patient stop driving for following an e lective ca rdiac a ngioplasty?

No restriction 1 week 2 weeks

se As Dr

8 weeks

m

4 weeks

GD

1 week

CD

2 weeks

fD

4weeks

6D

8weeks

m Irrportar t "or me

_ess ·rroc"1! '1t

Dr

DVLA advice following angioplasty • cannot drive for 1 week

As

se

m

No restriction

Where is the most co mmon site for primary cardiac tumours to occur i n adults?

Left atrium Right ventricle Right atrium

Dr

Left ventricle

As

se

m

Left atrial appendage

ED

Left atrium

m

Right ventricle Right atrium

fD

Left atrial appendage

GD. D

Left ventricle

Atrial myxoma - com monest site = left atrium

m

Less ' m ::~c rte;nt

As se

Important for me

Dr

The most com mon site of atrial myxomas is at the fossa ovalis border in the left atrium

Which one o f the fo llowin g statements rega rd ing statin -ind uced myo pathy is incorrect?

Rhabdomyolysis may cause re na l failu re Patients with an e levated creatine kinase often have no symptoms Female sex is a ris k fa ctor

Dr

Pravastatin is more likely to cause myopathy than simvasta tin

As

se

m

Creatine ki nase d oes not need to be routinely checked prio r to co mmenci ng a stat in

Rhabdomyo lysis may cause rena l failure Patients with an e levated creatine kinase often have no symptoms

-

Female sex is a ris k fa ctor

-

Creatine kinase does not need to be routine ly checked prior to commenci ng a statin

~

se

m

Pravastatin is more likely to cause myo pathy than simvastatin

Dr

hydroph ilic stat ins (rosuvastatin, pravastatin, fluvastatin)

As

Myopathy is more common in lipoph ilic stat ins (s imvastatin, ato rvastatin) than re lative ly

A 38-yea r-old lady p resents to the emergency depa rtment with increased shortness of b reath for the last 5 days. On full history taking, yo u find she has a lso recently had some ep isod es of chest pa in o n exertion. She is no rmally fit and we ll but d oes report g enera lised aching and a high temperature a p proximately 2 weeks ago. On exam ination you find that she is haemodynam ica lly stable with a blood pressure on 100/ 65mmHg in the right a rm and a heart rate of 95 bpm. The ra dial p ulse on the right s id e is absent. Heart sounds a re normal and the apex b eat is non d isp laced . He r oxygen saturations a re 95% on a ir and he r respirato ry rate at rest is 20 b reaths pe r minute. Given the history and exa minatio n find ings g iven, what is the most likely d iagnos is? What is the most likely diagnosis?

Type B a ortic dissecti on Acute myocarditis

Periphe ral arterial embolus

Dr

Ta kayasu' s arteritis

As se m

Com mu nity acquired p neumonia

tiD

Acute myocarditis

fD

Com mu nity acquired p neumonia

I

CD

Takayasu's arteritis

fD

Periphe ral arteria l embolus

The correct answe r he re is D: Takayasu 's a rteritis. The key to this q uestion is that a ll but this a nswe r will give some features of histo ry/exam inatio n mentio ned but th is is the o nly a nswe r that explains a ll po ints. Aortic d issection cou ld have simila r symptoms and if invo lving the subclavia n could give an absent radial pulse, however a d escend ing d issectio n (type B) would not normally do this. Commu nity acquire d p neumonia would explain the shortness of breath and perhaps chest pa in seconda ry to pleurisy, but wo uld not exp la in othe r fin dings. Acute myoca rd itis would exp la in shortness o f breath a nd chest pa in but not a bsent radial pulse. Whereas a periphera l arte ria l emb olus wo uld explain the abse nt ra dia l pulse but not the othe r findings.

Othe r causes of a n absent radia l pu lse in clude: aortic dissection with su bclavian

As se m

Ta kayasu's arte ritis is the refo re the on ly app ro priate a nswe r as it expla in s a ll findings.

Dr

involvement and perip hera l a rteria l e mbo lus (as me ntioned above), trauma and iatroge nic

Where is the site of action of bendroflumethiazide?

Proximal convoluted tubu les Ascending loop of Henle

m

Descending loop of Henle

As Dr

Distal part of the distal convoluted tubu les

se

Proximal part of the distal convoluted tubules

Proximal convoluted tu bules Ascending loop of Henl e

Proximal part of the distal convoluted tubules

se

m

Distal part of the distal convoluted tubules

As

Bendroflumethiazide- inhibits sodium reabsorption by blocking the Na- -CIsymporter at the beginning of the distal convoluted tubule trrportar t "or me

_e,ss -,.. :>c'tant

Dr

I

Descending loop of Henle

A 52-year-old woman with a history of breast cancer is admitt ed w ith acute dyspnoea. Her respiratory rat e on admi ssion is 42 I min and her oxygen saturations are 87% on room air. A pulmonary embolism is suspected and she is transferred to the high dependency unit after being treat ed with oxygen and enoxapari n. Which one of the following would be strongest indication fo r thrombolysis?

Extensive deep venous thrombosis Hypot ension

As se

ECG showing right ventricu lar strain

Dr

Hypoxaemia despite high flow oxygen

m

Patient choice following info rm ed consent

Hypotension Patient choice following informed consent Hypoxaemia despite high flow oxygen

Massive PE T hypotension - thrombolyse

As

se

m

ECG showing right ventricular strain

Dr

I

Extensive deep venous thrombosis

A 75-year-old woman was admitted t o the Acute Medica l Unit with pneumonia. Her only past medical hist ory of note is transient ischaemic attack 2 months previously. On initial assessment, ECG revealed atrial fibrillation with a ventricu lar rat e o f 103. She was treat ed with intravenous fluids and antibioti cs. She improved significantly. Two further ECGs overnight revealed normal sinus rhythm. The following day, she was deemed medically fit for discharge. What is the si ngle most appropriate mana gement option regarding her episode of atrial fibrillation?

No follow-up required Repeat ECG in two weeks

24-hour t ape and consider oral anticoagulation

Dr

Aspirin

As se m

Oral anticoagulation

-

No follow-up required

I

~

Repeat ECG in two weeks Oral anticoagulation

~

Aspirin 24-hour ta pe and consider oral anticoagulation

A single episode of paroxysmal atrial fibrillation, even if provoked, should still prompt consideration of anticoagulation Important for me

Less imocrtont

This patient has a CHADSVASC score of three therefore initiating anticoagulation would be appropriate. Despite being provoked by pneumonia, this patient is at high risk of having further episodes of atrial fibrillation. Aspirin is no longer recommended. A 24-hour t ape is useful in patients with sym ptomatic palpit ations, or those who have experienced a thrombo-embolic event without known AF.In this example we have already 'found' atrial fibrillation, and we should initiate treatment. While some studies have linked paroxysmal AF 'burden' on cardiac monitoring to stroke risk, this is not cu rrently in guidelines. We know from the CHADSVASC score that on average, the risk is likely to be high

As se m

(approximately 3.2% per yea r) regardless of burden. A 24-hour tape may be useful when considering an ablation, or assessing the response to rhythm control medication.

Dr

Repeating the ECG in two weeks is not an unreasonable suggestion, but should not preclude initiation of anticoagulation.

Each one of the following is an indication for an implantable ca rdiac defibrillato r, except:

Previous myocardial infarction with non -sustained VT on 24 hr monitoring Wolff-Parkinson White syndrome Hypertrophic obstructive cardiomyopathy

Dr

Long QT syndrome

As

se

m

Previous cardiac arrest due to VF

Previous myocardial infarction with non-sustained VT on 24 hr monitoring

I

Wolff-Parkinson White syndrome Hypertrophic obstructive cardiomyopathy

-

m

Previous cardiac arrest due to VF

Dr

Long QT syndrome

As

se

~

A 52-year-old female with a known history o f systemic sclerosis presents for annual review t o the rheumatology clinic. Which one o f the following symptoms is most charact eristic in patients who have developed pulmonary arterial hypertension?

Exertional dyspnoea Paroxysmal nocturnal dyspnoea

m

Cough

Orthopnoea

Dr

As

se

Early morning dyspnoea

I

Exertional dyspnoea

-

Paroxysma l nocturnal dyspnoea Cough

me

_ess rr xrtart

Dr

ltrporta r~ ~or

As se

Acute vasodilator testing should be used in patients with pulmonary artery hypertension to determine which patient show a significant fall in pulmonary arterial pressure following vasodilators and help guide treatment

m

Early morning dyspnoea

A 28-year-old wo man presents with palpitations. Her heart rate is 160/min an d irregular. Her blood pressu re is 123/ 65 mm Hg, and her oxygen saturation is 97% on breathi ng room air. Her chest is clear on auscultation. Her ECG shows irregular broad complex monomorphic tachyca rdia w ith a stable axis. She has no previous medical history an d has never b een t o a hospital before. What is the most appropriate treatment ?

Diltiazem Bisoprolol

Adenosine

Dr

Magnesium

As se m

Amiodarone

Diltiazem

CD

Bisoprolol

GD

Amiodarone

ED

Magnesium

. flD

Adenosine

GD

The correct answer is am iodarone. This a haemodynamically stable patient with irregular broad complex tachycardia. As the broad-complex tachycardia is irregular it is most likely atrial fibrillation with left bundle branch block or an alternative aberrant conduction pathway such as Wolff-Parkinson-White syndrome. Diltiazem, bisoprolol and adenosine are all contraindicated as they could enhance the aberrant pathway leading to ventricular fibrillation. Magnesium would be appropriate fo r to rsades de pointes but is unlikely as the rhythm is monomorphic.

As se m

Source:

Dr

Pitcher, David, and Jerry Nolan. 'Peri-arrest Arrhythm ias.' Peri-arrest Arrhythm ias. N.p., 2015. Web. 09 Feb. 2017

A 72-yea r-old man is investigated fo r exertional chest pain and has a positive exercise tolerance test. He d eclines an a ng iogram and is discharged on a com bination of aspirin 75m g o d, simvastatin 40mg on, atenolol SOmg o d and a GTN s pray prn. Exa mination reveals a pulse of 72 bp m and a blood p ressure of 130/ 80 mmHg. On review he is still regula rly using his GTN spray. What is the most a pp ropriate next step in management?

Add nifedipine MR 30mg o d Add isosorb ide mononitrate 30mg bd

As se

Add ve rapam il 80mg td s

Dr

Add nicora ndil l Omg bd

m

Increase ateno lol to l OOmg od

Add nifedipine MR 30mg od Add isosorbide monl nitrate 30mg bd Increase atenolol to l OOm g od Add nicorandil lOmg bd Add verapamil 80mg tds

When treating angina, if there is a poor response to the first-l ine drug (e.g. a betablocker), the dose should be titrated up before adding another drug l ess 'mpcrtont

As se m

Important for me

starting dose of isosorbide mononitrate is l Omg bd.

Dr

The BNF recommends an atenolol dose of l OOm g daily in 1 or 2 doses for angina. The

Which of the fo llowing is a cause of a loud second heart sound?

Aortic regu rg ita tion Ventricu la r septa l d efect

m

System ic hyperte nsion

Mitral stenosis

Dr

As

se

Aortic ste nosis

CD

Ventricular septal defect

m

Systemic hypertension

CD

Aortic stenosis

GD

Mitral stenosis

fD

Second heart sound (52) • loud: hypertension • soft: AS

As se m

• fixed split: ASD • reversed split: LBBB Important for me

_ess ;rrocrtant

Dr

I

Aortic regu rgitation

A 54-yea r-old man with atypical chest pain is referred to cardiology. An exercise ECG s hows non -specific ST and T wave changes. Fo llowing th is an coronary ang iogram is performed which demonstrates no evidence of atherosclerosis. A d iagnosis of Prinzmeta l's ang ina is suspected. What is the most appropriate first-line treatment?

Nicorand il Atenolol Felod ipine

se As Dr

Isoso rbide mononitrate

m

Fluoxetine

Nicorandil Atenolol Felodipine

F~oxetine Isosorbide mononitrate

Prinzmeta l angina -treatment = dihydropyridine ca lcium channel blocker

m

As se

See the SIGN guidelines for more det ails.

l ess :mocrtont

Dr

Important for me

Which one o f the following types o f hyperlipidaemia are eruptive xa nthoma most

com monly associated w ith?

Familial hypertriglyceridaemia Familial hypercholesterolaemia Familial co mbined hyperlipidaemia

se As Dr

Hyperlipidaemia secondary to nephrotic syndrome

m

Remna nt hyperlipi daemia

CD

Familial hypercholesterolaemia

GD CD m

Familial combined hyperlipidaemia

CID se

Remnant hyperlipidaemia

As

I

Familial hypertriglyceridaemia

Hyperlipidaemia secondary to nephrotic syndrome

Dr

I

CD

A 64-year-old man with a history of ischae mic heart disease and poor left ventricular function presents with a b road complex tachycardia of 140 bpm. On examination b lood p ressure is 110/74 mmH g. Fusion and capture beats are seen on the 12 lead ECG. What is the first line drug management?

Sotalol Am iodarone Adenosine

Dr

Lidoca ine

As

se

m

Flecainide

fD

Sotalol

I

Amiodarone

flD

Adenosine

fl!D

~cainide

fD

m

Lidocaine

The history of ischaem ic heart disease combined w ith t he presence of fusion and capture also be used in VT, amiodarone wou ld be preferred given his history of poor left

As se m

beats strongly suggests a diagnosis of ventricular tachyca rdia (VT). Whilst lidocaine can ventricular function. In the 2010 joint European Resuscitation Council and Resuscitation

Dr

Council (UK) guidelines amioda rone is also considered first- line in a peri-arrest situation

You are considering prescribing an antibiotic to a 28 -year-old man who t ells you he has Long QT syndrome. Wh ich antibiotic is it most important to avo id?

Doxycycline Trimethoprim Erythromycin

se As Dr

Co -amoxiclav

m

Rifampicin

I

Doxycycline

fD

Trimethoprim

m

Erythromycin

GD

m

[ co-amoxiclav

m Dr

Erythromycin can cause a prolonged QT interval

As

se

m

Rifampicin

A 15-year-old boy collapses and dies whilst playing football at school. He had no past med ical history of note. Post-mo rtem exam ination revea ls asymmetric concentric en largement of the myocardial septum. Given the like ly diag nosis, what is the chance his s ister will also have the same u nderlying d isord er?

0% 25%

m

50%

66%

Dr

As

se

100%

CD

0% 25%

f1D

so%

fZD

100%

fD

•

6%

Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support HOCM Important for me

Less :mpcrtant

The underlying diagnosis is hypertrophic obstruct ive cardiomyopat hy w hich is an

As se m

I

Dr

autosomal dominant disorder. His sister therefore has a 50% chance of being affected.

Which one of the following is not an indication for insertion of a temporary pacemaker?

Complete heart block following an inferior MI - blood pressure normal Complete heart block following an anterior MI - blood pressure norm al

m

Trifascicular block prior to surg ery

Symptomatic bradycardi a not responding to drug treatment

Dr

As

se

Mobitz type II heart block following an anterior MI - blood pressure normal

I

Complete heart block fo llowing an inferio r MI - blood pressure normal Complete heart block following an anterior MI- blood pressure normal Trifascicular block prior to surgery Mobitz type II heart block follow ing an anterior MI - blood pressure normal Symptomatic bradycardia not responding to drug treatment

Complete heart block following an inferior MI is NOT an indication for pacing, unlike with an anterior MI Less impcrtont

As se m

Important for me

the patient is asymptomatic and haemodynamically stable

Dr

Post-inferior MI complete heart block is co mmon and can be managed conservatively if

A 21-yea r-old man colla pses whilst p laying football with his friends at the weekend . By the time he is bro ught into the emergency department he is p ronounced d ea d fo llowing ca rdiac a rrest despite ad equate life support be ing g iven. His fa mily cannot understand how this has hap pened sayi ng that he has a lways been fit and healthy and was a keen sportsman, they do however note that two other fa mily members have died young in similar circu mstances. Which of the following methods of inheritance is correct fo r this cond ition?

Autosomal d om inant Autosomal recessive

Mito chon dria l

Dr

X-li nked d omina nt

As se m

X-li nked recessive

I

CD.

Autosomal dominant

-

Autosomal recessive

I

m

X-linked recessive X-lin ked dominant

CD

Mitochondrial

fD

Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support HOCM Important for me

l ess i m ::~c rtc.nt

Given the circumstances in which this person has died and the fam ily history, one can infer that hypertroph ic cardiomyopathy may be a cause. In hypertrophic cardiomyopathy, the myocardium becomes thickened which can lead to functional impairment of cardiac muscle and sudden death, especially in young athletes. It can ohen run in fam ilies and fam ilial hypertrophic cardiomyopathy is inherited in an

Dr

encodes for a sarcomere protein.

As se m

autosomal dominant pattern and is attributed to a mutation in one of the genes that

A 58-year-old man with no past medical history of note is admitted to hospit al with crushing central chest pain. ECG on arrival shows ant erior ST elevation and he is subsequently thrombolysed with a good resolution of symptoms and ECG changes. Four weeks following the event, which comb ination of drugs should he be t aking?

ACE inhibitor+ beta-blocker + st atin + aspirin Spironolactone + beta -blocker + statin + aspirin ACE inhibitor+ beta-blocker + st atin + aspirin + clopidogrel

se As Dr

Beta-blocker + st atin + aspirin + clopidogrel

m

ACE inhibitor + statin + aspirin + clopidogrel

ACE inhibitor + beta-bl ocker + statin + aspirin !Spironolactone + beta -blocker + statin + aspirin ACE inhibitor + beta-blocker

+

st atin + aspirin + clopidogrel

-

ACE inhibitor+ statin + aspirin + clopidogrel

"""'

Beta- blocker + statin + aspirin + clopidogrel

NICE made the following reco mmendatio n in 2013 relating to people who have had a

STEM! and medica l management w ith or without reperfusion treatment with a fibrinolytic

As se m

agent for up to 12 months

Dr

• offer clopidogrel as a treatment option for at least 1 month and consider continuing

A 62-yea r-old patient presents to the Emergency Depa rtment with a 25 minute history of crush ing centra l chest pain. ECG shows ST elevation in leads I and aVL. Which co ronary territory is likely to be affected?

Late ral Posterior Anteroseptal

se As Dr

Inferior

m

Anterolatera l

GD

Late ral Po sterio r

m

Anteroseptal

CD

Anterolateral

GD

CD As Dr

These ECG changes a re most consistent with a latera l myo ca rdia l infa rction. An anterolate ra l infa rction is more likely to have chang es in the chest lea ds.

se

m

Inferior

A 62-year-old female with a known history of a si gmoid adenocarcinoma is adm itted to hospital with s hortness of b reath and pyrexia . On examination a murmur is heard and an echo revea ls a vegetation on the aortic valve. Which one of the fo llowing organ is ms is most characteristically associated with causing infective endocard itis in patients with colorecta l cancer?

Escherichia coli Enterococcus faecalis

As se

Streptococcus bovis

Dr

Campylobacter

m

Salmonella

fD

Escherichia coli Enterococcus faecalis

CD

m m

Salmanella Campylobacter

I

G13

Irrportart "or me

_ess ·rroc'1.:.'1t

Dr

Streptococcus bovis endocarditis is associated with colorectal cancer

As

se

m

Streptococcus bovis

Which one of the following is an example of a centrally acting antihypertensive?

Minoxidil Hydralazine Sodium nitroprusside

se As Dr

Diazoxide

m

Moxonidine

Minoxidil Hydralazine

-

Sodium nitroprusside

-

........

Dr

Diazoxide

As

se

m

Moxonidine

A 68-yea r-old wo ma n is admitted to hos pita l with com plete hea rt b lo ck. After initia lly being treated with a temporary pacing wire she goes o n to have a pe rma nent pace make r fitted. How soo n a fter the procedu re ca n she drive a ga in?

Immed iately 24 ho urs

m

3 d ays

4 we eks

Dr

As

se

1 we ek

GD

Immediate ly 24 hours

. (D

3 days

• se

m

CI!D As

4 weeks

J

Dr

p :eek

fD

Which one of the following stat ement s regarding the management of pregnant women with severe pre-eclampsia an d eclampsia is incorrect?

Intravenous fluids should be given to prevent rena l failure Magnesium sulphate treatment should continue for 24 hours post-partum Problems are only seen aher 20 weeks gestation

se As Dr

Magnesium sulphate is given to both prevent and treat seizures

m

Reflexes should be monitored during magnesium sulphate infusion

I

-

Intravenous fluids should be given to prevent renal failure

~

Magnesium su lphate t reatment should cont inue for 24 hou rs post-partum Problems are only seen aher 20 weeks gest ation Reflexes should be monitored during magnesium sulphate infusion Magnesium su lphate is given to both p revent and treat seizures

Severe pre-eclam psia - restrict f luids Less ' m::~c rtant

As se m

Important for me

severe pre-eclampsia

Dr

Pulmonary and cerebral oedema are important causes of morb idity and mortality in

A 56-yea r-old man is a d mitted to the Emergency Depa rtment with head aches, chest pa in a nd confusion. His initial o bservations show a blood pressu re of 250/ 140 mmHg, pu lse 90/min and tem perature of 36.4°. On exa minatio n the blood pressu re is confirmed and is eq ual in both arms. Blurri ng of the o ptic d iscs is noted o n exa mination. He has no significant med ical history an d takes no regular medications. What is the most su ita ble initial manage ment?

Oral ramipril Intravenous phe ntolam ine Venesection

Dr

Intravenous hydralazine

As se m

Intrave nous nitroprussi de

Oral ram ipril Intravenous phentolam ine Venesection Intravenous nitroprusside

se

m

Intravenous hydralazine

Dr

for the use of intravenous agents rather than slower acting o ral prepa rations.

As

This patient has ma lig nant hypertension. The presence o f papilloed ema is an indi cation

A 75-yea r-old ma n is a d mitted fo llowing a fter feeling faint. An ECG taken in the d epartment shows a ventricular tachyarrhythmia. His blood p ressure is stable and it is decided to give IV am io darone, with a loadi ng dose being given.

What is the reason for the loading dose being given?

Autoinductio n o f the P450 syste m by am ioda ro ne High ventricular rate leading to rapid dilutio n

Am ioda ro ne exhibiti ng zero -o rd er kineti cs

As se Dr

Reduce the risk of extravasation injury

m

Long half-life o f am iodarone

Autoinduction of the P450 system by amiodarone High ventricular rate leading to rapid dilution Long half -life of amiodarone Reduce the risk of extravasation injury Amiodarone exhibiting zero -order kinetics

Amiodarone has a very long half- life of 20-100 days - loading doses are therefore Less impcrtant

Dr

Important for me

As se m

ohen needed

A 71-year-old woman presents with palpitations and 'lightheadedness'. An ECG shows that she is in atria l fibri llation with a rate of 130 I min. Her blood pressure is no rmal and exam ination of her cardiorespiratory system is otherwise unremarka ble. Her past medical history includes well contro lled asthma (salbutamol & beclomethasone) and dep ression (cita lopram). Her symptoms have been present fo r around three days. What is the most appropriate med icatio n to use for rate control?

Diltiazem Sota lo l Digoxin

Dr

Amiodarone

As se m

Atenolol

ED

Diltiazem Sotalol

m

Digoxin

QD

GD

[ :enolol

CD

Amiodarone

As se

Consideration should also be given to antithromboti c therapy.

Dr

therefore recommend a rate-limiting calcium channel blocker.

m

Her history of asthma is a co ntraindication to the prescription of a beta-blocker. NICE

11'1/hich one o f t he following wou ld not be considered a normal variant on t he ECG o f an

3thlet ic 28 -year-o ld man?

W enckebach phenomenon Sinus bradycardia Junctional rhythm

As Dr

Left bu ndle b ranch b lo ck

se

m

First d egree heart bl ock

Wenckebach pheno menon Sinus bradycardia

-

Junctional rhythm

. .wJ

First degree heart block

m

se

As Dr

~L-eft__b_u_nd_l_e_b_ra_n_c_h_b_lo_c_k--------------~~

. .wJ

Which one o f the followi ng is least associated wit h p rolongation of the PR interva l?

Digoxin to xicity Hypocalcaemia Lyme disease

se As Dr

Ischaemic heart disease

m

Rheumatic fever

I

Digoxin toxicity

tD

Hypocalcaemia

CD

Lyme disease

GD

•

Rhel matic fever

GD se

m

Isc haem ic heart d isease

Dr

with a pro long ed PR interval

As

Hypocalca em ia is associated with a p ro longed QT interva l. Hypokalaemia is associated

Which of the following physiological effects wou ld be expected following administratio n of atropine?

Bradycardia + mydriasis Tachycardia + miosis Bradyca rdia + salivation

Dr

Tachycardia + mydriasis

As

se

m

Bradyca rdia + miosis

CD

Tachycardia + miosis

GD

Bradyca rdia + salivation

•

Bradycardia + miosis

CD

e:D As

se

m

Tachycardia + mydriasis

Dr

I

Bradycardia + mydriasis

A 44-year-old fema le is investigated for suspect ed idiopathic pulmonary hypertension. Which one of the following is the best method fo r deciding upon management strategy?

Genetic testing Acute vasodilator t estin g Trial of endothelin receptor antagonists

se As Dr

Trial of calcium channel blockers

m

Serial echocardiography

m

Genetic t esting Acute vasodilator t esting

fD

Trial of endothelin receptor antagonists

«D

Serial echocardiography

CD

Trial of calcium channel blockers

m

arterial p ressure follow ing vasodilators and help guid e t reatment Important for me

As se

hypertension to d etermine w hich patient show a si gnificant fa ll in pu lmona ry

m

Acute vasodilator t estin g should be used in patients with p ulmonary artery

l ess im:>crtc.nt

Dr

I

The neprilysin inhibitor, sacubitril, in com bination w ith the angiote nsin II receptor blocker, va lsartan, has been shown to reduce mortality, reduce hospitalisations and improve sympto ms in comparison to enalapril in the treatment of heart failure w ith reduced ej ection fraction. What is its mechanism of action in heart fa ilure?

Improves myocardial contraction Prevent s the degradation of natriuretic p eptides such as BNP and AN P Reduces heart rat e

se As Dr

Inhibition of vasopressin release therefore promoting diuresis

m

Multiple inhibition o f renin, angiotensinogen and aldost erone

Improves myocardial contraction

I

Prevents the d egrad ation of natriuretic peptid es such as BNP and AN P Reduces heart rat e

-

Multiple inhibition o f renin, angiotensinogen and aldost erone

~

Inhibit ion of vasop ressin release th erefore promoting diuresis

The correct answer is prevent s the degrad ation of nat riuretic peptides such as BNP and ANP. The nat riuretic peptide system regulat es the detrimental effects of the upregulation of the renin -a ngiotensinogen-a ldost erone syst em (RAAS) which occurs in heart failure. Sodium and wat er retention and vasoconstriction caused by activation o f t he RAAS, sympathetic nervous system and t he action of vasopressin, lead t o increased ventricu lar preload and afterload an d elevated wall stress which in tu rn lead t o p roduction of BNP. BNP acts to p romote natriuresis and vasodilation. At rial st retch leads to t he production o f ANP which has similar biolog ical properties to BNP. Two strat egies have been employed to t ry an d

As se m

improve out comes in heart failure via modulat ion of t his pat hway. The first is t he administration of exogenous natriu retic peptides. Nesiritide, a recombinant human BNP,

initially showed p romising beneficial effects on haemodynamics and nat riuresis in patients

Dr

wit h HF. However, in a large-scale randomised controlled trial, it failed to improve

An 84-year-old female with a backg round of osteoporosis is g iven an infus ion of pa midronate. A week later she p resents to her GP compla ining of paraesthesia. On examination she has hyperreflexia and carpopeda l spasm. Given the electrolyte abnormality she is likely to have developed, what ECG abnorma lity is most associated with th is?

Atrioventricular node block Delta waves Tented T waves

Dr

Atrial flutter

As se m

Long QT

Delta waves

CD

Tented T waves

CD

fD

Long QT

m

Atrial flutter ~

Long QT is associated with hypocalcaemia. Bisphosphonate infusions can lead to hypocalcaemia although it is more common when using large r doses in malignancy induced hypercalcae mia as oppose to the smaller dose used in osteoporosis.

A QT interval of greater than 0.44 seconds is associated with the development of ventricular arrhythm ia, syncope and sudden cardiac death.

• hypotherm ia

Dr

• electrolyte abnorma lities: hypokale mia and hypocalcemia • drugs: tricyclic antidepressants, antihistam ines, erythromycin, clarithromycin, am iodarone, haloperidol • congenital long QT syn dromes: more than 10 d ifferent types recog nised • myoca rdial infa rction/s ign ificant active myocard ia l ische mia • cerebrovascu lar accid ent (subarachnoid haemo rrhage)

As se m

Long QT causes:

A 60-yea r-o ld man is ad mitted following a n acute coronary syndro me. He receives aspirin, clo pi dogre l, nitrates and morphin e. His 6 -mo nth risk score is hig h and pe rcutaneous coro nary interventio n is planned. He is th ere fo re g ive n intrave no us tirofiban. What is the mecha nis m of action o f this drug?

Inhibits the p rod uction o f thromboxa ne A2 Activates a ntithromb in III Coro na ry vasodilator

se As Dr

Reversible d irect thro mbin inhibito r

m

Glycop rotein lib/lila receptor antag on ist

m

Activates antithrombin III

CD

Coronary vasodilator

CD

GD

Reversible di rect thrombin inhibito r

As

se

m

Glycoprotein lib/lila receptor antago nist

Dr

I

Inhibits the p roduction of thromboxane A2

CD

What is the main mechanism o f action of simvastatin?

Bile acid seq uestrant Decreases hepatic HDL synthesis Inhib its lipoprotein lipase

se As Dr

Agonists of PPAR-a lpha

m

Decreases intrinsic cholestero l synt hesis

Bile acid sequestrant Decreases hepatic HDL synthesis Inhibits lipoprotein lipase Decreases intrinsic cholesterol synthesis

Less impcrtont

Dr

Important for me

As

se

Statins inhibit HMG-CoA reductase, t he rate-limiting enzyme in hepatic cholesterol synthesis

m

Agonists of PPAR-alpha

Which one of the followin g is the strongest risk factor for developing infective endocarditis?

Previous episode o f infective endocardit is Intravenous drug use Previous rheumatic fever

se As Dr

Recent denta l surgery

m

Permanent central venous access line

I I

Previous episode o f in fective endocarditis

CD

Intravenous drug use

GD CD

Previous rheumatic fever

m m

Permanent central venous access line

m

Recent d ental surgery

As

se

Infective endocarditis - strongest risk factor is previous episode of infective trrportart '"or me

_ess rr.oo1.Jnt

Dr

endoca rd itis

An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting regular attacks of angina despite taking atenolol l OOmg od. Examination of his cardiovascular system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg. What is the most appropriate next step in management?

Add verapamil 80mg tds Add nicorandillOmg bd Add diltiazem 60mg tds

Dr

Add isosorbide mononitrate 30mg bd

As

se

m

Add nifedipine MR 30mg od

I

Add ve rapamil 80mg td s

CD

Add nicorandil lOmg bd

GD

Add d iltiazem 60m g tds

m.

Add nifedipine MR 30mg od

CD

Add isosorb ide mononitrate 30mg bd

. ED

If angina is not contro ll ed with a beta -blocker, a ca lcium cha nnel blocke r should be a dded Important for me

l ess im:>crtc.nt

The sta rti ng dose of isosorbide mononitrate is l Omg bd.

Dr

bra dyca rdia .

As se m

NICE gui delines recom mend ad d ing a calciu m channe l blocke r for angina which is not a deq uately controlled with beta- blocker monotherapy. Verapa mil is contraindicated whilst ta king a beta-b locke r and diltiazem should be used with caution d ue to the risk of

Which one o f the fo llowing is least associated with myoca rditis?

Chagas' disea se Lyme disease Le ishma nias is

Dr

Toxop lasmos is

As

se

m

Coxsackie virus

CD

Chagas' disease

. CD

Leishmaniasis

CD

Coxsackie virus

m se

As Dr

Toxoplasmosis

m

Lyme disease

tD

A 41-yea r-old man is ad mitted with left-sided pleu ritic chest pain. He has a dry cough and reports that the pain is relieved by sitting fo rward. For the past three days he has been experiencing flu-li ke symptoms. Given the likely diag nosis, what is the most li kely finding on ECG?

Large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III Atrial fibrillation Widesprea d ST elevation

se As Dr

Hyperacute T waves

m

ST segment depression in the anterior leads

Large S wave in lead I, a large Q wave in lead lli and an inverted T wave in lead III G:) Atrial fibrillation

-

Widespread ST elevation

~

se As Dr

Hyperacute T waves

m

ST segment depression in the anterior leads

A 30-yea r-old woman presents to the Emergency Department with a one-d ay history o f central chest pain. The pa in is d escribed as severe, non-radiating and eases on expiration. Cl inical examination of her card iorespirato ry syste m is un rema rkable othe r than a heart rate of 96 I min. An ECG shows widespread ST elevatio n in the anterior, inferior and latera l leads. Bloods show the fo llowing : Full blood count

Normal

Urea and electrolystes

Normal

Troponin I

0.8 ng/ml ( < 0.2 ng/ml)

What is the most likely diagnosis?

Pulmonary embolism Acute co rona ry syndrome Hypertrophic obstructive cardiomyopathy

Dr

Arrhythmogen ic right ventricular cardiomyopathy

As se m

Acute pericard itis

I

Pt_::>nary embolism

-

Acute co rona ry syndrome

"'lo:oWl'

Hypertrophic obstructive cardiomyopathy Acute pericarditis

~

As

se

m

Arrhythmogenic right ventricular cardiomyopathy

Dr

A modest rise in troponin is seen in around one-third of patients with acut e pericarditis.

A 58-yea r-old man presents with breathlessness and chest discomfort. He has d iet controlled dia betes, hypertens ion and hyperlipidaemia. He has a weak rapid, regular pulse of 160 bp m, blood pressure is 80/SOmmHg, he is cold p eripherally and crepitations are heard bibasally on auscultation of the chest. An ECG shows a regular broad complex tachycardia. What is the b est initia l management of this arrhythmia?

Adenosine Amiodarone

Vaga l man oeuvres

Dr

Electrical cardioversion

As se m

Diltiazem

l

Adenosine

-

Am iodarone

~

Diltiazem Electrica l cardiove rs ion

""""

Vaga l man oeuvres

This patient presents with a reg ular broad com plex tachyca rdia with a p alpa ble pulse and the adve rse feature of shock (systo lic blood p ressure = 40%.

Any form of defibrillator is a bar to a Group 2 entitlement.

Dr

failure if it does not lead to distracting or incapacitating sympto ms.

As se m

For Group 1 entitlements, the DVLA does not need to be informed of symptomati c heart

A 75-year-old fema le p resents d ia p horetic and distressed with new onset sternal chest pa in radiating th rough to the back. She has a past history of hypertension on lercanidi pine. On examination her blood pressu re is 190/70 mmHg and there is an ea rly diasto lic murmur heard best at the leh sternal e dge. Her ECG is unremarkab le. What is the next best cou rse of action?

Aspirin/clo pidogre i/IV heparin Cardiac catheterisation CT chest with contrast

Dr

Th rombolysis

As se m

Urgent echocardiog ram

Cardiac catheterisation CT chest with contrast Urgent echocard iogram Thrombolysis

This is a classi c exa mple of an aortic dissection ca usin g aortic regurgitation. The best investigation is going to be a CT chest with IV contrast because the IV contrast will be able to best demo nstrate the size and extent o f the false lumen. The chest X-ray may show a widened mediastinum, but unfortu nately it is not a sensitive o r specific investigation as 20% of patients present with normal chest X-ray and there a re ma ny causes of a widened mediastinum. However, the chest X- ray is a useful first line investigation for this cond ition because of how rea dily availa ble it is, and useful for ruling out many other cond itions. Looking for a sepa ration of the intimal calcification from the outer aortic soh tissue border by 10 mm is an indication of the presence of a dissection. The CT chest with contrast will provid e the most a mount o f information by far, and can demonstrate the extent of the d issection.

The next step is for surgery aher the initia l CT chest with contrast is co mp lete.

Dr

As se m

An echo is a reasonable investigatio n, but will not d emonstrate the extent of the vessel lesion, for which a CT of the chest will demonstrate the lesion much better.

Which one o f the followin g state ments rega rd ing a rrhythmog enic rig ht ventricu lar ca rdiomyo pathy is co rrect?

Inherited in an autosoma l recessive pattern It is now the most common cause of sudden cardiac death in th e UK All patients shou ld have an implantable ca rd iove rter defibrillator fitted

As

cardiomyopathy with d eafness

Dr

Naxos disease is the association o f a rrhythmog enic right ventricu la r

se

m

It is cha racterised by fibrofatty infiltrati on o f the rig ht ventricu la r myocardium

Inherited in an autosomal recessive pattern It is now the most common cause of sudden cardiac death in the UK All patients should have an im plantable cardioverter defibrillator fitted It is characterised by fibrofatty infiltration of the rig ht ventricular myocardium

-

Naxos disease is the association of arrhythmogenic right ventricular cardiomyopathy with deafness

se

m

~

Dr

As

Drug the rapy is used in patients with well tolerated or non life-threatening ventricular arrhythmias.

An e lde rly man with aortic ste nosis is assessed . Which one of the following wou ld make the ejection systo lic murmur qu iete r?

Left ventricu lar systolic dysfunction Thyrotoxicos is Mixed a ortic valve disease

se As Dr

Anaem ia

m

Expiratio n

I

Left ventricular systolic dysfunction Thyrotoxicosis Mixed aortic valve disease Expiration

se

m

Anaemia

Dr

As

Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic valve and hence a qu ieter mu rmur.

A 29-yea r-old woman is investigated fo r increasing dysp noea a nd feeli ng gene rally weak a nd letharg ic. Over the past few months, she has had five episodes of syncope, some of which occu rred fo ll owing exercise. There is no prior medica l history of note a lthough her gra nd mothe r died aged 44 yea rs aher su ffering increasin g s hortness-of-breath and syncop e. On examination her oxygen satu rations a re 98% on room air and the pulse is 78 I min. The second heart sound is loud b ut no murmu rs a re hea rd. Auscu ltation of the c hest is u nremarkab le . What is the most likely diagnosis?

Pulmonary a rte rial hypertensi on Fam ilial pulmona ry stenosis Hypertrophic obstructive cardiomyopathy

Dr

Arrhythmogenic right ve ntricula r dys plasia

As se m

Catecho laminerg ic p olymorphic ventricul ar tachycardia

Pulmonary arterial hypertension

-

Familial pulmonary stenosis

~

Hypertrophic obstructive cardiomyopathy

Dr

Arrhythmogenic right ventricular dysplasia

As

se

m

Catecholaminergic polymorphic ventricular tachycardia

A 51-year-old female presents to the Emergency Department following an episode of transient right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial fibrillation. If the patient remains in chronic atrial fibrillation what is the most suitable form of anticoagulation?

Aspirin Warfa rin, ta rget INR 2-3 No anticoagulation

Dr

Warfa rin, ta rget INR 2-3 for six months then aspirin

As

se

m

Warfa rin, ta rget INR 3-4

I

Asp irin

-

Warfarin, target INR 2-3

~

No anticoagulation

Warfa rin, ta rget INR 3-4 se

m

Warfa rin, ta rget INR 2-3 for six months then aspirin

Dr

As

The CHA2DS2-VASc for this patient is 3 - 2 for the transient ischaemic attack and 1 for being female. She should therefore be offered anticoagulation with warfa rin.

Each one of the following is associated w ith right axis deviation on ECG, except:

Right ventricular hypertrophy Pulmonary embolism Wolf- Parkinson -Wh ite syndrome w ith right -si ded accessory pathway

Dr

Left posterior hemiblock

As

se

m

Chronic lung disease

Right ventricu lar hypertrophy Pulmonary embolism Wolf-Parkinson -White syndrome w ith right-sided accessory pa way Chronic lung disease Left posterior hemiblock

Left axis deviation - Wolff- Parkinson-White syndrom e (right-sided accessory pathway) Less · m ::~c rtant

As se m

Important for me

Wolff- Parkinson-White syndrome is associated with a short PR interval and a wide QRS position of the accessory pathway

Dr

complex with a slurred upstroke, termed a delta wave. Axis deviation depends on the

I I

Staphylococcus aureus

. GD

infection

CD

Culture negative endocarditis

Streptococcus viridans

CD

infection

m m

Low complement levels Prosthetic valve endocarditis

rtrportar t "or me

_e-ss -r; :lc'ient

Dr

Infective endocarditis - streptococcal infection carries a good prognosis

As

se

m

~

A 72-yea r-old man is prescribed a dipyrida mo le in ad d ition to aspi rin fo ll owing an ischaemic stro ke. What is the mechanism of actio n of d ipyridamole?

Phospho diesterase inhibitor Glycoprotein lib/lila inhibito r Inhibits ADP b ind ing to its platelet receptor

Dr

Irreversibly acetylating cyclooxygenase

As

se

m

Agonist o f thromboxane synthase

I

Phosphod iesterase inh ibito r Glycoprotein lib/lila inhibitor Inhibits ADP bind ing to its platelet receptor Agonist of thromboxane synthase Irreversibly acetylating cyclooxygenase

Dipyridamo le is a non-spec ific phosphod iesterase inhibitor and decreases cell ular uptake of adenos ine l ess im:>crtc.nt

As se m

Important for me

Dr

Dipyridamole is genera lly described as a non-specific phosphodiesterase (PDE) inhibitor but it is known to be particularly active against PDES (l ike si ldenafil) a nd PDE6.

A 65-year-old man with no significant past medical history is admitted to the Emergency Department. His ECG is consistent with an anterior myocardial infarction. Unfortunat ely he

develops cardiac arrest shortly aher arriving in the department. What is the most common

cause of death in patients following a myocardial infarction?

Pulmonary embolism Cardiogenic shock Papillary muscle rupture

Complete heart block

Dr

As

se

m

Ventricu lar fibrillation

CD

Papillary muscle rupture

«ED

Ventricular fibrillation

CD

Complete heart block

As

se

m

Cardiogenic shock

Dr

I

m

Pulmonary embolism

m

A 62-year-old man who had a mechanical mitral valve replacement fou r years ago is reviewed. What long t erm antithrombotic therapy is he likely to be taki ng?

Noth ing Direct acting oral anticoagulants

m

Aspirin

Warfarin

Dr

As

se

Aspirin + clopidogrel for the first 12 months

I

Nothing

CD

Direct acting oral anticoagulants

m

• •

Aspirin Aspirin + clopidogrel for the first 12 months

I

(D

Warfarin

Prost hetic heart valves - antithrombotic t herapy: • b ioprost heti c: asp irin • mechanical: warfarin + as pirin Important for me

Less imocrtont

given in addition if t here is an additio nal indicat ion, e.g. ischaem ic heart di sease.

As se m

Following t he 2017 Euro pea n Society of Cardi ology guid elines, aspirin is on ly normally

Dr

Direct acting ora l ant icoagu lants are not used in patients with a mechanical heart va lve.

A 70-year-old woman is prescribed bumet anide for congestive ca rdiac fa ilure. Where is the site of action of bumetanide?

Descending loop of Henle Macula densa Ascending loop of Henle

Dr

Proximal collecting duct

As

se

m

Distal collecting duct

CD

Descending loop of Henle

•

Macula densa

I

Ascen ding loop of Henle

ED

Dist al collecting duct

CfD

Proximal collecting duct

C!D

Furosemide- inhibits the Na-K-CI cotrans porter in the th ick ascending limb of the

Bumetanide, like furosemide, is a loop diuretic.

l ess ' m ::~c rtont

Dr

Important for me

As se m

loop of Henle

Which one o f t he followin g clotting fact ors is not affected by wa rfarin?

Factor II Factor VII Factor XII

Dr

Factor X

As

se

m

Factor IX

Factor II

f.D

Fal or VII

(D

Factor XII

GD

Factor IX

m

Factor X

CD.

Warfarin - clotting factors affected mnemon ic - 1972 (10, 9, 7, 2)

m

As se

Fa ctor XII is not affected by warfarin

Less imocrtont

Dr

Important for me

Which one of the following featu res wou ld indicate ca rdia c tamponade rather than constrictive pericarditis?

Ra ised JVP Muffled heart sounds No Ydescent on JVP

se As Dr

Tachycardia

m

Hypotension

f.D

Raised JVP

ED

No Y descent on JVP

fD.

Hypotension

tiD.

Tachycardia

m As

se

m

Muffled heart sounds

Dr

In cardiac tamponade there is characteristically no Y desce nt o n the JVP. The o ther fou r features are seen in both ca rdiac tamponade and constrictive perica rd itis

In patients with atria l fibrillation (AF), which one o f the following facto rs wou ld make a rate co ntro l strategy, rather than rhythm contro l, mo re su itable?

Congestive heart fa ilure AF secondary to a corrected precipitant Sym ptomatic

se As Dr

First presentation

m

Age> 65 yea rs

Congestive heart fa ilure

-

AF secondary to a corrected precipitant

~

m

Symptomatic

First presentation

Dr

As

se

Age > 65 years

Which one of the followin g patients shou ld not automatically b e p rescribed a statin in the absence of any contra indication?

A 51-yea r-old ma n who had a myocardial infarction 4 years ago and is now a symptomati c A 57 -yea r-old fema le sm oker with a 10-year card iovascular ris k of 23% A 53-yea r-old ma n with intermittent claudication

Dr

As

A 57 -yea r-old ma n with well controlled diabetes mell itus type 2 with a 10-year ca rdiovascular risk of 8%

se

m

A 62-year-old ma n who had a transient ischaemic a ttack 10 mo nths ago

-

A 51-year-old man who had a myocardial infarction 4 years ago and is now asymptomati c A 57-year-old female smoker with a 10-year cardiovascular risk of 23% A 53-year-old man wi th intermittent claudication

As

cardiovascular risk of 8%

Dr

A 57 -year-old man with well controlled diabetes mellitus type 2 with a 10-year

se

m

A 62-year-old man who had a transient ischaemic attack 10 months ago

Which one of the following drugs is most likely to cause a prolonged QT interval?

Metocloprami de Verapamil

m

Ceftriaxone

Digoxin

Dr

As

se

Sot alol

GD

Metoclopramide Verapamil

CD

Ceftriaxone

• CD

Digoxin

CD As

se

m

Sotalol

Important for me

l ess im:>crtc.nt

Dr

Sotalol is known to cause long QT syndrome

A 35-year-old female has paroxysmal atrial fibrillation and was successfully treated with DC cardioversion 1 w eek ago. She is now resultantly on warfarin. A subsequent post cardioversion echocardiogram shows no structural abnormalities. How long should the warfarin b e continued?

3 mont hs Stop immediately

As se

6 mont hs

Dr

Indefinitely

m

4 weeks

3 months

«D

Stop immediately

(D

4 weeks

CD

Indefinite ly

GD

6 months

tiD

It is recom mend ed warfarin be co nti nued for at least 4 weeks afte r successful ca rdiove rsion. If there is structura l abnormalities o r the atria l fibri llatio n is like ly to reoccur the n long term anti-coagulation is recommended.

https:/fwww .res u s.org.u k/EasySiteWeb/Gatewayl in k.aspx? a lid =808

Dr

Resus Co uncil UK peri-arrest a rrhythmia (page 7) :

As se m

BMJ best pract ice: http://bestpractice.bmj.com/ bestpractice/ monogra ph/ 3/treatmenVste p-by-step.html

A 61-yea r-old man with p eriphera l a rterial d isease is prescribed simvastatin. What is the most app ro priate blood test monito ring?

LFTs + creatinine ki nase at baseli ne, 1-3 months a nd at interva ls o f 6 months for 1 year LFTs at baseline and every 3 months for first yea r Routine blood tests not reco mmended

se As Dr

LFTs at baseline, 3 months a nd 12 months

m

LFTs at baseline and annua lly

LFTs + creatinine kinase at baseline, 1-3 months and at interva ls of 6 months for 1 year

QD

LFTs at baseline and every 3 months for first year Routine blood tests not recommended LFTs at baseline and annua lly

As

se

m

LFTs at baseline, 3 mo nths and 12 months

Dr

A fasting li pid profile may a lso be checked du ring monitoring to assess response to treatment.

Symptom-limited trea dmill exercise testing is often d o ne befo re discha rge after a STEM!. Which o f the fo llowing pa ramete rs at exercise testing most strongly indicates a good p rog nosis with medical treatme nt?

Absence o f ST d epressio n Percent (%) predicted maximal heart rate achieved Absence o f ve ntricular arrhythm ia

se As Dr

Above ave rage exe rcise capacity

m

Absence o f chest pa in

Absence o f ST d epressio n Percent (%) predicted maximal heart rate achieved

-

........

Absence o f ve ntricular arrhythmia

I

Absence o f chest pa in Above average exercise capacity

Essentially, the q uestion asks: 'Which o f the fo ll owing is the best predictor o f mo rta lity post-STEM!?'

Dr

pa rticu la rly in e ld e rly persons.

As se m

Above ave rage exercise ca pacity pe rformed befo re di scharge is associated with a g ood p rog nosis a fte r a STEM!. Exercise capacity has been re peatedly shown in studies of exercise testing to be the strongest p red ictor o f morta lity and ca rdiovascular events,

A 72-yea r-old male is adm itted to the Emergency Room fol lowing a collapse at church. ECG reveals dissociation between the P and QRS complexes with a rate of 40 I minute. Which one of the following clinical findings may also be found?

Loud Sl Narrow pulse pressure Giant v waveforms in the JVP

se As Dr

Soft 52

m

Variable intensity of Sl

m

Loud Sl

flD

Giant v waveforms in the JVP

fD

Variable intensity of 51

CD

Complete heart block causes a variable intensity of Sl

As

se

m

Soft 52

Dr

I

Narrow pulse pressure

Which o f the following signs is not associat ed w ith the development of Ei senmenger's syndrome in a patient with a ventricu lar sept al defect?

Worsening of syst olic murmur Ra ised JVP

m

Lou d second heart sound

La rge 'a' waves in j ugular venous waveform

Dr

As

se

Cyanosis

Worsening of systolic murmur Ra isef JVP Loud second heart sound

-

Cyanosis

"""'

syndrome develops

Dr

pulmonary hypertension. The orig inal murmur may disa ppea r once Eisenmenger's

As

se

Eisenmenger's syndrome is characterised by the reversal of the left- right shu nt due to

m

Large 'a' waves in jugular venous waveform

A 51-year-old male represents with chest pain, eight een days after he was diagnosed with a non-ST elevation myocardial infarction. It is severe, central chest pain with radiations to the left shoulder and worse w ith deep inspiration. The pain woke him from sleep at 03:00 and has improved slightly after getting up out of bed. Fi ndings on examination include reduced air entry to both bases coup led with fine basal crepitations. Observations show: Heart rat e

lOSbpm

Blood pressure

130/ 78mmHg

Respirat ory rate

22bpm

Temperature

37 .8 celsius

Oxygen saturations

97%

An initial ECG shows diffuse saddle-shaped ST elevation. An echocardiogram shows a small rim of fluid outside the pericardium. What is the most likely diagnosis?

Second myocardial infarction Pulmonary embolism

Unstable angina

Dr

Cost ochondritis

As se m

Dressier's syndrom e

Second myoca rdial infarct ion

m

Pulmonary embolism

CD

Dressier's syndrome

CID

m m

Costochondritis Unstable angina ~

The correct answer is Dressier's syndrome given the recent history of Ml, d escript ion of changes and pericardia! effusion.

As se m

pain (pleuritic, leh shou lder radiation, worse lying dow n), low-grade t emperature, ECG

Dr

It is treated w ith NSA!Ds preferably or a prolonged cou rse of colchicin e or st eroids.

What does troponin T bind to?

Tropomyosin Actin in thin myo filaments Prot ein kinase C inhibit ors

se As Dr

T -tubu le membrane wa ll

m

Calcium ions

I

Tropomyosin Actin in thin myofilament s Protein kinase C inhibitors

~cium ions

As

se

m

T -tubule membrane wa ll

and regulates muscle contraction by regulating the binding of myosin.

Dr

Tropomyosin is a protein which regulates actin. It associates with actin in muscle fibres

A 67 -year-o ld female is p rescri bed s imvastatin for hyperlipidaemia. Which one of the following is most like ly to interact with her med icatio n?

Orange juice Apple juice

m

Grapefruit juice

Carrot juice

Dr

As

se

Cra nberry juice

m m

Orange juice Apple juice Gra pefru it juice

ED

Cranberry juice

eD

•

Grapefruit j uice is a potent inhibitor of the cytochrome P450 enzyme CYP3A4

Dr

As

se

m

Carrot juice

A 23-year-old woman presents to the Emergency Department with a friend from work. Around 30 minutes ago she developed a 'fluttering' in her chest. She reports feeling 'a bit faint' but den ies any chest pain o r s hortness of b reath. An ECG shows a regular tachycardia of 166 bpm with a QRS duration of O.lls. Blood pressure is 102/ 68 mmHg and oxygen saturations are 99% on roo m air. What is the most appropriate management?

Intravenous magnesium sulphate Direct current cardioversion

Carotid s inus massage

As se Dr

Intravenous adenosine 6mg

m

Intravenous adenosine 3mg

Intravenous magnesium sulphate

-

Dire1 curre nt cardioversion

~

Intravenous adenosine 3mg Intravenous adenosine 6mg Carotid sinus massage

Dr

As

se

m

The first-line management of supraventricular tachycard ia a re vagal manoeuvres such as ca rotid sinus massage. On ly if these fa il shou ld adenosin e be given. There are no indications fo r direct current cardiove rsion as per the ALS guide lines.

A 66-year-old male w ith a 75 pack year history of smoking is admitted with a 2 hour history of central crushing chest pain radiating to his j aw. ECG revealed ST depress ion in II, III, aVF. 6 hour troponin I was 450ng/ L. Grace score revealed 6 month mortality risk of 9%. The patient was started on Tirofiban w hilst waiting for angiography. What is the mechanism of action of Tirofiban?

ADP receptor antagonist Fa ctor Xa inhibitor

Direct thrombin inhibitor

Dr

Cox inhibitor

As se m

Gpllb/llla inhibitor

Fa ctor Xa inhibitor Gpllb/llla inhibit or Cox inhibitor Direct th rombin inhibitor

This 66-year-o ld male has presented with a non ST elevated myoca rdial infarction. Detailed management of NSTEMI's vary fro m trust to trust, but often involve performing a 6 month mortality score (GRACE) to guide treatment. If your score is greater th an intermediate risk (>3%) a glycoprot ein inhibitor is started prior to angiography within 96 hours. Grace score: Lowest

Intermediate Low (1.5-3.0%)

(3-6%)

High (6-9%)

Highest(>9%)

Aspirin

Aspirin +

12 months

Clopidogrel for 12 months &

Glycoprotein inhibitor &

Glycoprotein inhibitor &

Glycoprotein inhibitor &

angiography within 96

angiography within 96

angiography within 96

hours

hours

hours

perfusion/stress imaaina

Dr

outpatient

As se m

( 3.0 nmolfl)

What is the most appropriate management?

Ora l folic acid + blood transfusion Ora l folic acid + start Intramuscular vitam in Bl 2 when folic acid levels are normal Intra muscula r vita min Bl2 + start oral folic acid when vitamin Bl2 levels a re normal

Dr

Ora l p redn isolone

As s

em

Blood transfusio n

Oral folic acid + blood transfusion Oral fo lic acid + sta rt Intramuscu lar vitamin Bl2 when folic acid levels are no rmalfiB Intramuscular vitamin Bl 2 + start ora l folic acid when vitamin Bl 2 levels are normal Blood transfusion Oral prednisolone

Dr

As se

m

It is important in a patient who is also deficient in both vitamin Bl2 and folic acid to treat the Bl2 deficiency first to avoid preci pitating subacute combined degeneration of the cord

A 56-year-old man is investigated for lethargy. A full blood count shows the following: Hb

8.6 g/dl

Platelets

42

WBC

36.4

s

109/1 8

109/1

***Blood film shows 30% myeloid blasts with Auer rods - please liase with haematologist** 8

Given th e likely diagnosis, w hich one of the following is associated with a good prognosis?

Translocation between chromosome 9 and 14 Translocation between chromosome 15 and 17 25% blast following first course of chemotherapy

Dr

Deletion of chromosome 7

As se m

Deletion of chromosome 5

Translocation between chromosome 9 and 14 Translocation between chromosome 15 and 17 25% bias following f irst course of chemoth erapy Deletion of chromosome 5 Delet ion of chromosome 7

Acute myeloid leukaemia- good prognos is: t(15;17) l ess ' m ::~c rtont

leukaemia, which is know n to carry a good prognos is.

Dr

A t ranslocation b etween chromosome 15 and 17 is seen in acut e promyelocytic.

As se m

Important for me

A 74-year-old woman with a past history of chronic lymphocytic leukaemia presents with lethargy. The following blood results are obtained: Hb

7.9 g/ dl

Pit

158 * 109/ 1

wee

24 .0

Blood film :

normochromic, normocytic anaemia

8

10911

What complication has most likely occurred?

Paroxysmal nocturnal haemoglobinuria Microangiopathic haemolytic anaemia

Cold autoimmune haemolytic anaemia

Dr

Warm autoimmune haemolytic anaemia

As se m

Sideroblastic anaemia

-

Paroxysmal nocturnal haemoglobinuria

~

Microangiopathic haemolytic anaemia Sideroblastic anaemia Warm autoimmune haemolytic anaemia

se

m

Cold autoimmune haemolytic anaemia

Dr

lymphocytic leukaemia

As

Warm autoimmune haemolytic anaemia occurs in around 10-15% of patients with chronic

A patient with a history o f recurrent th romboembolic events develops a deep vein thrombosis despite full anticoagu lation with heparin. Wh ich one of the following causes o f thrombophilia is associat ed with resistance t o heparin?

Protein S deficiency Antithrombin III deficiency Protein C deficiency

Dr

Activated protein C resistance

As

se

m

Lupus anticoagulant

Prot ein S deficiency Antithrombin III deficiency

I

Prot ein C deficiency Lupus anticoagulant

m

Activat ed protein C resistance

Ill deficiency may therefore by resistant t o heparin treatment

Dr

As

se

Heparin works by binding to antithrombin III, enhancing its anticoagu lant effect by inhibiting the formation of thrombin and other clotting fact ors. Patient s with antithrombin

A 28-year-old gentleman was diagnosed with Hodgkin's lymphoma after presenting to his GP with painless lymphadenopathy. Following a staging pos itron emission tomography (P ET) scan, nodes invo lving both sides of the d iaphragm were found. Which stage of the Ann-Arbor classification does his presentation fall under?

Stage I Stage II Stage III

As se Dr

Stage V

m

Stage IV

Stage I

m

Stage II

CD

~gelll

GD

Stage N

CD

Stage V

m

Stage Ill of the Ann-Arbor clinical staging of lymphomas involve lymph nodes on both sides of the diaphragm Important for me

Less · m ::~c rtant

The Ann -Arbor classification is used for Hodgkin's lym phoma and is split into 4 stages according to the spread of the disease. Stage I - involves a single regional lymph node

Stage V - Not part of the Ann-Arbor classification

Dr

Stage N - distant spread involving one or more extra lymphatic organs

As se m

Stage II - involves two or more lymph nodes on one side o f the diaphragm

Which of the following is a good prognostic factor in chronic lymphocytic leukaemia?

Female sex Lymphocyte doubling time < 12 months CD38 expression positive

Dr

Raised LDH

As

se

m

Age > 70 years

Female sex Lymphocyte doubling time < 12 months CD38 expression positive

I

m

Age> 70 years

Dr

As

se

Raised LDH

A 10-year-old boy is referred to you following his 7th course of antibiotics for lower respirat ory tract infection in t he last 6 yea rs. He has difficult to co ntrol eczema for which he is currently on a to pical steroid cream . His bloods are as follows

Hb

139 g/1

Plat elets

65

WBC

12.3

8

109/1 8

109/1

In which of t he following genes may you expect to see an abnormality?

WASP

PKDl

RET

Dr

HFEl

As se m

CFTR

WASP

CD

P~D l

•

CFTR

GD

HFEl

m m

RET

As se m

The combination of frequent infections, eczema and thrombocytopenia are characteristic of the Wiskott-Aidrich syndrome, which is caused by an abnormality in the WASP gene.

Dr

The PKDl gene is associated with polycystic ki dney disease, CFTR with cystic fibrosis, HFEl with haemochromatosis and RET an oncogene associated with multiple endocri ne neoplasia and also Hirschsprung's disease.

Which electrolyte disturbance is cisplatin most associated with?

Hypocalcaemia Hyponatraemia Hypomagnesaemia

Dr

Hypercalcaemia

As

se

m

Hypokalaem ia

Hypocalcaemia

CfD

Hyponatraemia

. (D

CD

Hypokalaemia

tiD

Hypercalcaemia

tiD se

m

Hypomagnesaemia

As

Cis platin is associated with hypomagnesaemia

Less · m ::~c rtant

Dr

Important for me

A 29-year-old wo man who has a hist ory of recurrent pulmonary emboli is identified as having factor V Leiden. How does this particular inherited thrombophilia increase her risk of venous throm boembolic events?

Decreased levels of facto r V Increased levels of factor V Activated fact or V is inactivated much more slowly by activated prot ein C

Dr

Decreased antithrombi n III levels

As

se

m

Activated fact or V is inactivated much more quickly by activated protein C

Decreased levels of facto r V

-

Activated factor Vis inactivated much more slowly by activated prot ein C

~

Activated facto r V is inactivated much more quickly by activated protein C

m

Decreased antithrombin III levels

Important for me

As

slowly by activated p rotein C than normal

se

In patient s with factor V Lei den, activated facto r V is inactivated 10 times more

Less 'mpcrtant

Dr

I

Increased levels of factor V

Which one o f the following trans locations is associated with acute p ro mye locytic leukaemia?

t(15;17) t(9;17) t(9;22)

Dr

t(17;22)

As

se

m

t(15;22)

CD

t(9;17)

m

t(9;22)

f!D

t(15;22)

. (D

t(17;22)

CD

Important for me

Less · m ::~c rtant

Dr

Acute promyelocytic leukaemia - t(15;17)

As

se

m

t(15;17)

A 39-yea r-old woman presents with a strange collection of sym ptoms over the past six months. She has been seen by mu ltiple specialists, none of whom have been a ble to find a cause for her sym ptoms. Her symptoms include wo rsening headaches, memory loss, low mood, lethargy, a bdom inal pain causing paroxysms of intermittent genera lised pain, nausea, an unusual taste in her mouth and pa raesthesia in her extre mities. She is irrita ble during you r consultation and at times tea rful complaining that no one is ta ki ng her seriously and confid ing that her Genera l Practitioner had referred her fo r counselling. Routine b lood tests show: Hb

101g/ L

WBC

5.6 10*9/ l

Plat elet s

350 10*9/ l

MCV

77fl

Na

136mmol/l

K

4.3mmoi/L

Urea

18.2mmol/l

Creat inine

408umol/l

What is the likely cause of he r sym ptoms?

Pick's disease Hepatic encephalopathy Lead po ison ing

Dr

Vira l e ncephalitis

As s

em

Early-onset Alzheimer's

Pick's disease Hepatic e ncephalopathy

-

Lead po iso ni ng

~

Early-onset Alzheimer's r Viral e ncepha litis

Lead po isoni ng is o ften occupatio nal and com prises g astro intestina l an d neu ro psychiatric symptoms and anae mia due to interruption to the hae m b iosynthetic pathway. Important for me

Less imocrtont

It is impo rtant to keep lead poisoning in mind as a differentia l, particularly in someone for whom routine investigations are not providing an answer and who clea rly has abnormal pathology (demonstrated by her kidney fa ilure and microcytic anaemia).

As se m

It can cause a varied and often non-specific array of symptoms. Some more 'classical' features include an unusual taste in the mouth and paraesthesia of the extremities.

Dr

Questions may more obviously point to the route of exposu re through industrial exposure or contact with lead-based products such as paint or contam inated water.

A 79-yea r-old fema le with a histo ry of CO PD a nd metastatic lung cancer is a dm itted with increasing s hortness of b reath. Following d iscussion with fam ily it is decided to withdraw a ctive treatment, inclu ding fluid s a nd a ntibiotics, as the adm issio n li kely represents a terminal event. Two d ays after ad mission she b ecomes ag ita ted a nd restless. What is the mo st app ropriate mana gement?

Subcuta neous midazo lam Intramuscula r ha lo pe rido l

Re commence fluids and antibiotics

Dr

Ora l haloperidol

As se m

Ora l lormetazepam

I

Subcutaneous midazolam

CD

Intra muscula r haloperidol

mt CD

Oral lormetazepam

GD m se

CD

As

Recommence fluids and antibiotics

Dr

I

Oral haloperidol

A 64-year-o ld female is b ro ught to t he Emerg ency Department by her fam ily, w ho are concerned about her increasing confusion over the past 2 days. On exami nati on she is found to be pyrexial at 38°C. Blood t ests reveal:

Hb

9.6 g/ dl

Platelet s

65

wee

11.1

Urea

23 .1 mmol/ 1

Creatinine

366 ~mol/1

8

109/ 1 8

109/ 1

What is the most likely d iag nosis?

Wegener's g ranu lom atosis Thro mbotic thro mbo cyto penic purpura

Ra pidly progressive g lomerulo nephritis

Dr

Idiopat hic t hro mbocyto penic pu rpu ra

As se m

Haemo lyt ic uraem ic syndrome

CD

Wegener's granulomatosis

I

Thrombotic thro mbocytopenic purpura

CD

Haemolytic uraemic syndrome

m

•m

Idiopathic thrombocytopenic purpu ra Rapi dly progressive glomerulonephritis

HUS or TTP? Neuro signs point towards TTP Less impcrtont

As se m

Important for me

point towards a diagnosis of thrombotic thrombocyt openic purpu ra

Dr

The combination of neurological features, renal failure, pyrexia and thrombocytopaenia

A 21-yea r-old man attends the emergency depa rtment after noticing blood in his urine. He has been feeli ng fatigued and generally unwell fo r the last two days and has been finding himself getting out o f b reath easily. His housemates had commented yesterday that he was 't urn ing yellow', but he had assumed they were teasing him for being unwell and had igno red them . He is normally fit and well and is not on any regular medications. He has however recently started taking primaqu ine in preparation for a volunteering trip to Tanzan ia next week. On exam ination, he is clea rly jaundiced and tachypnoeic. His urine sample is a dark b rown and is pos itive for b lood and b il irubin. He is afebrile and normotensive, though is requ iring some supplemental oxygen. You a re awa iting the rest of his test resu lts but have received the following from the lab so fa r: Hb

115 g/ 1

MCV

90 fL

Haematocrit

0.3 L/L

Platelets

250 * 109/1

WBC

10.2

Reticulocyte count

2. 1%

Peripheral blood film

Presence of schistocytes, spherocytes and bite cells noted

8

109/J

What is the most li kely reason for this p resentation?

Sickle cell crisis Post-in fectious haemolytic anaemia G6PD deficiency

As s Dr

Pyruvate kinase deficiency

em

Hereditary spherocytosis

I

Sickle cell crisis

m

Post-infectious haemolytic anaemia

CD

G6PD deficiency

GD

Hereditary spherocytosis

f!D

m

Pyruvate kinase deficiency

Ma la ria prophylaxis (e .g. primaquine) can trigger haemolytic anaemia in those with G6PD deficie ncy Important for me

l ess :mpcrtont

This man is presenting with signs and sympto ms of a haemolytic anaemia, the most like ly cause of which is G6PD deficiency. A number o f foods and med ications can trigger haemo lysis in individ uals with G6PD deficiency, an important class o f which are qu inine based anti- malaria l medications. The tempora l li nk between starting mala ria prophylaxis and developing signs of haemolys is makes this the most like ly cause. While a sickle cell crisis can trigger haemolysis, there is nothin g to suggest this patient has sickle cell disease, and no sickle cells are p resent on the blood film. Post-infectious haemolysis can occur with atypical pneumonias such as Mycoplasma (cold -agglutinin disease) and infections th at induce hypersp lenism such as mononucleos is. There is nothing to suggest an infectious cause in this scena rio, however. Congenital haemog lobin defects such as s pherocytosis can a lso cause haemolysis. Whi le there are spherocytes on this man's b lood film, these are present to different degrees in haemo lytic anaem ias o f any cause and as such a re not s pecific.

Dr

physio log ical stress.

As s

em

Pyruvate kinase deficiency is the next most common inhe rited metabolic disorder after G6PD deficiency. Haemolysis in these patients tends to be triggered in times o f s ignificant

Which of the following is deficient in patients with hereditary angioedema?

Cl -I NH C3

m

Heat shock protein type 1

As Dr

Histamine degradation protein (HDP)

se

C6

Cl-INH

f.D

C3

GD

I

m

Heat shock protein type 1 C6

m As

se

m

Histamine degradation protein (HOP)

ltrpor:a.r! "or me

_ess r-oc-tart

Dr

Hereditary angioedema- Cl-INH deficiency

A 67 -year-old man with lung cancer is cu rrently t aking MST 30mg bd for pain relief. What dose of oral morphine solution shou ld he b e prescribed for breakthrough pain?

5 mg

10 mg 15 mg

Dr

30 mg

As

se

m

20 mg

5 mg

fD

10 mg

CD

15 mg

GD

20 mg

fD

30 mg

(D

Breakthrough dose = 1/6th of daily morphine dose l ess im:>crtc.nt

As se m

Important for me

Dr

The tota l daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg

A 18-year-old man who is known to have hereditary spherocytosis is admitted to hospital with lethargy. Admission bloods show the following: Hb

4. 7 g/ dl

Retics

0 .3%

What is the most likely explanation for these findings?

Haemolytic crisis Recent ciprofloxacin therapy

Ang iodysplastic bowel lesions

Dr

Sequestrati on crises

As se m

Parvovirus infection

CD

Haemolytic crisis

CD

Recent ciprofloxacin therapy

I

Parvovirus infection

6D

Sequestrati on crises

(tD

m Dr

This man has had an aplastic crisis secondary to parvovirus infection.

As

se

m

Ang iodysplastic bowel lesions

A 40-year-old female has been diagnosed with haemolytic uraemic syndrome aher an episode o f severe diarrhoea. She has a haemoglobin o f 84 mg/dl. Which of the fo llowing blood results is most likely to be found?

Low haptoglobin Low bilirubin El evated magnesium

Dr

Increased Hb F

As

se

m

Low urea

flD

Low haptoglobin

CD

Low bilirubin

fi!D

Elevated magnesium

CD

Low urea

GD

Increased Hb F

Low haptoglobin levels are foun d in haemolytic anaemias Important for me

l ess 'mocrtont

The pat ient has an intravascular haemolytic anaemia secondary to haemolytic u raemic syndrome. Haptoglob in levels are reduced in intravascular haemolysis b ecause t hey bind t o free haemogl ob in released from lysed erythrocytes. The complexes are t hen removed from the p las ma by t he hepat ic ret iculo -endo thelial cells. Hapto globin levels d ecrease if the rat e o f haemolysis is great er t han t he rate of haptoglob in pro duction. Bilirubin levels are likely t o be elevat ed b ecause of increased metabolism o f haem.

As se m

Magnesium may b e low because o f diarrhoea or unaffected. Urea wou ld be increased due not in acqu ired haemolytic anaemias.

Dr

t o acut e kidney inj u ry. HbF is found in patients w ith in herited haemoglob inopat hies and

A 54-yea r-old man is investigated for a chronic cough. A chest x-ray arra nged by his GP shows a suspicious lesion in the right lung. He has no past history of note and is a lifelong non -smoker. An urgent bronchoscopy is arra nged which is normal. What is the most likely diagnosis?

Lung sa rco ma Squamous cell lung cancer Lung adenocarcinoma

As se Dr

Lung carcinoid

m

Small cell lung cancer

CD

Lung sarcoma

I

Squamous cell lung cancer

C!D

Lung ad enocarcinoma

e:D

Small cell lung cancer

CD

Lung carcinoid

G'D

Lung adenocarcinoma • most common type in non-smokers • peripheral lesion Less :mpcrtant

As se m

Important for me

a p eripherally locat ed lesion.

Dr

The clues are the absence of a smoking history and normal bronchoscopy, which suggests

Which one of the following is the most common cause o f recurrent first trimester spontaneous miscarriage?

Factor V Lei den gene mutation Polycystic ovarian syndrome Hyperprolactinaemia

Dr

Anti phospholipid syndrome

As

se

m

Antithrombin III deficiency

-

Factor V Lei den gene mutation

"""

Polycystic ovarian syndrome Hyperprolactinaemia Antithrombin III deficiency

-

Antiphospholipid syndrome

~

se

m

Anti phospholipid antibodies (aPL) are present in 15% of women with recurrent

Dr

history is less than 2%

As

miscarriage, but in compa rison, the prevalence of aPL in women w ith a low risk obstetric

A 54-yea r-old lady presents with shortness of b reath, distended neck veins, and a swollen and red face. She ha d She undergoes a CT scan of her chest demonstrating obstruction of the superior vena cava (SVC). What is the most li kely cause?

Fibrosing mediastinitis Th rombosis Syphi litic th oracic aortic aneurysm

Dr

Metastatic ma lignancy

As

se

m

Primary mal ignancy

I

Fibrosing mediastinitis

CD

Th ro mbosis

. CD

Syphilitic thora cic a ortic aneu rysm

CD

Primary malignancy

ED

Metastatic mal ignancy

ED

The correct a nswer is a p rimary maligna ncy. Intratho racic malignancy is resp onsible fo r up to 60-85% of SVC o bstruction cases. Most co mmon is non-sma ll cell lung cancer, small cell lung cancer and non-Hodg kin lymp homa. Together these malignancies re present 95% of SVC syndromes caused by ma lignan cy. This can b e the presenti ng featu re o f a undiagnosed tumour. Throm bosis can occur fo llowing pace ma ker wire insertion and

'Sup erio r Vena Cava Synd ro me .' BMJ Best Practice. 20 July 2016.

Dr

Source:

As se m

centra l line placement. Syphilitic thoracic aortic aneu rysm and fibros ing mediastinitis used to be common causes p rio r to widespread a ntib io tic use.

Which one of the followin g stat ement s regarding t he aetiology o f venous thro mboem bol ism (VTE) is correct?

Third g eneration co mbined oral contraceptive pill s are safer t han second g eneration ones VTE d evelops in around 5% of patient s with Goodpasture's syndrome Female g ender is a risk fact or recurrent VTE The second trimester of p reg nancy is associated with a greater risk t han t he

se As Dr

Ta moxifen t herapy increases t he risk of VTE

m

puerpenum

VTE d evelo ps in a round 5% o f patie nts with Good pastu re 's syndro me Female gend er is a risk facto r recu rrent VTE

Tamoxifen therapy increases the risk of VTE

As

se

m

The second trimester o f p reg nancy is associated with a g reater risk than the puerp enum

Dr

I

Third generation combined o ra l contraceptive pill s a re safe r than second generation ones

Which one o f the following may be associated with an increased risk o f venous thromboembolism?

Fluoxetine Selegiline Diazepa m

Dr

Olanzapine

As

se

m

Am itriptyline

Fluoxetine

GD

Selegiline

flD

Diazepa m

fD

•

GD

Dr

Olanzapine

As

se

m

Am1 ll npty · r1ne

What is the most commo n inherited bleeding disorder?

Haemophilia A Activated protein C resistance Haemophilia B

Dr

von Willebrand's disease

As

se

m

Antithrombin III deficiency

(fD

Activated protein C resistance

(D

m

Antithrombin III deficiency

CD se

I

As

von Willebrand's disease

m

Haemophilia B

CD

Dr

I

Haemophilia A

A 32-year-old male presents to you r clin ic for review. He has a history of hereditary spherocytosis and recently und erwent splenectomy. Since t he operation he's noticed a major improvement in his energy levels. If a blood film was taken from the patient, what new histological finding wou ld be observed which wou ld have been absent p rior to splenectomy?

Schistocytes Bite cel ls

Howell-Jolly bodies

Dr

Spherocytes

As se m

Heinz bodies

Schisto cytes

m

Bite cells

CD

Heinz bodies

CD

Sphe~ocytes

. (D

f.D

Howell-Jolly bodies

Howell-Jolly bodies are present in hereditary spherocytosis post-splenectomy Important for me

Less · m::~c rtC~nt

Howell -Jolly bodies are rem nants of the red blood cell (RBC) nucleus which are normally removed by t he spleen. Post -splenectomy these Howell-Jolly b od ies persist and can be o bserved on histo lo gy. Spherocytes would also b e present. However, they wou ld have been obse rved on histology p rior to sp lenect omy.

As se m

Schistocytes are sheared RBCs seen in micro angiopat hic haemolytic anaemia.

(G 6PD) d eficiency.

Dr

Heinz b odies and bite cells are ch aracteristic of glucose- 6-phosp hat e d ehydrogen ase

A 68-yea r-o ld ma n who takes warfa rin fo r atrial fibrillatio n is taken to the emerge ncy d e partment ah er be in g invo lved in a road tra ffic accid ent. His GCS is red uced a nd a CT head shows an intracrania l haemo rrhage . Bloods o n admission show the following: Hb

13 .2 g/1

Plat elet s

222 * 109/1

W BC

11.2

INR

3 .1

8

109/ 1

In ad ditio n to vita mi n K, which o ne of the fo llowing blood p rod ucts should be g iven?

Cryo pre cipitate Plate let tra nsfus io n Prothromb in co mplex co ncentrate

Dr

Fresh frozen plasma (FFP)

As se m

Packed red cells

-

Cryoprecipitate

~

Plate let transfus ion Prothrom b in complex concentrate Packed red cells

m

Fresh frozen plasma (FFP)

Important for me

As Less imocrtc.nt

Dr

anticoagu lation in patients with severe bleeding or a head injury

se

Prothrombin complex concentrate is used for the emergency reversal of

A 64-yea r-old man is reviewed in the haemato logy clinic. Which one of the following features wou ld suggest th at a diagnos is mo noclo nal gammopathy of undeterm ined significance is more likely than myeloma?

Bone pain IgG pa raprote in band = 18g/l Creatinine = 160 IJmol/1

Dr

Lytic lesions on x-ray

As

se

m

Raised beta-2 microg lobulin

Bone pain IgG paraprote in band = 18g/l Creatinine = 160 ).J mol/1 Ra ised beta-2 micrf globulin

m

Lytic lesions on x-ray

se

Paraproteinaemia is seen in both myeloma and monoclonal gammopathy of

Dr

other features indicat e myeloma

As

undet ermined significance (MGUS) - at this level a diagnosis of MGUS is more likely. The

A 51-year-old female is referred to t he haematology clin ic with a haemoglobin of 19.2 g/dl. She is a non-smoker. Her oxygen saturations on roo m air are 98% and she is noted to have mass in the leh upper quadrant. What is t he most useful test to establish whet her she has po lycythaemia vera?

Bone marrow aspiration Blood film Red cell mass

Dr

JAK2 mutation screen

As se

m

Transferrin saturation

Bone marrow aspiration Blood film Red cell mass Transferrin saturation JAK2 mutation screen

Polycythaemia rubra vera - JAK2 mutation Less :mpcrtant

As se m

Important for me

for patients w ith suspected JAK2-negat ive po lycythaemia vera

Dr

The discovery of t he JAK2 mutation has made red cell mass a second- line investigation

A 60-year-old woman develops a d eep vein thrombosis (DVT) 10 days after having a hip replacement despite taking prophyla ctic dose low-molecular weight heparin (LMWH). She has no significant past medical history of note other than osteoarthritis. After being diagnosed she is started on t reatment dose LMWH. What is t he most appropriate anticoagulation strategy?

Continue on t reatment dose LMWH for 6 weeks Continue on t reatment dose LMWH for 3 months

Switch to warfa rin for 6 months

Dr

Switch to warfa rin for 3 months

As se m

Continue on t reatment dose LMWH for 6 months

Continue on t reatment dose LMWH for 6 weeks Continue on t reatment dose LMWH fo r 3 months Continue on t reatment dose LMWH for 6 months Switch to warfa rin for 3 months

-

Switch to warfarin for 6 months

~

Venous thro moboem bolism - length of warfarin t reatment • p rovoked (e.g. recent su rgery): 3 months • unp ro voked: 6 months l ess :mpcrtant

As se m

Important for me

anticoagulated for 3 months.

Dr

The recent su rgery is an obvious 'provoking' factor for the DVT. She should therefore be

A 4 -yea r-o ld child with a d efo rming mandibula r neck swe lling . Biopsy of the lesio n reveals a 'sta rry sky' a ppea ra nce und e r microscopy. Infection with which virus is an essential ste p in the pathogenesis of this di sea se?

HTLV-1

EBV HPV

As se Dr

HSV-2

m

HIV

HTLV-1

C!D

EBV

f%D

HPV

a

HIV

CD

HSV-2

a

EBV infection is imp licated in the pathogenesis of Burkitt's lymphoma Important for me

l ess 'mocrtont

EBV is id entif iable in nearly all cases of Burkitt's lymphoma. HTLV- 1 is associated with adu lt T cel l lymphoma HPV is associated with cervical an d anal cancers HIV inf ect ion is important in the pathogenesis of immuno deficiency-associated Burkitt's

HSV-2 causes genital herpes

Dr

in HIV negative children.

As se m

lymphoma. However, in the endemic variant clearly d escribed here the disease may occur

A 46-yea r-old woman presents to her GP with a 2-month history o f increasin g tiredness and fatigue. She has also noticed that she ha s been getting more short o f breath recently. Her past medica l history includes two urina ry tract infections in the past yea r and lower back pa in fo r which she takes paracetamol. She does not take any othe r med ications. On examination, she is pa le. The GP orders some basel ine blood tests:

Hb

101 g/ 1

(115-165 g/ L)

MCV

88 .1 fl

(80- 100 fl)

Platelet s

129 * 109/1

(140-400 * 109/1)

ESR

114 mm/h

(3-9 mm/h)

WBC

3.2 * 109/ 1

{4.0- 11.0 * 109/1)

Na•

137 mmol/ 1

(1 35- 14Smmol/l)

K•

4 .9 mmol/1

(3. 5-Smmol/ 1)

Urea

10 mmol/ 1

(2.5-6 .7mmol/ l)

Creatinine

108 ~mol/1

( 45-90J,Jmol/ l)

eGFR

SO ml/min/1. 73m2

( >90 ml/min/1. 73m2)

Ca 2 +

2.9 mmoi/L

(2.1 2-2.6Smmoi/L)

What is the next most appropriate investigation?

Renal ultrasound scan Cervical lymph node b iopsy PTH levels

Dr

Seru m e lectrophoresis

As s

em

CT KUB

Renal ultrasound scan

f.D

Cervica l lymph node biopsy

f.D

GD

PTH levels

m.

CT KUB

I

CD

Serum electrophoresis

'CRAB' features of multiple myeloma = hyperCalcaemia, Renal fa ilure, Anaemia (and thrombocytopenia) and Bone fractures/ lytic lesions Important for me

Less imocrtant

The combination of the hist ory, examination findings an d blood test results point towards a diagnosis of multiple myeloma. This patient is demonstrating evidence of all four f eatures of multiple myeloma: • C - hypercalcaemia • R- rena l insu fficiency (suggested by the U&Es and com plicated by the recurrent UTis - patients are susceptible t o infections as the production of antibodies by normal plasma ce lls is impaired) • A -this patient is short of breath due t o her anaemia (and the FBC shows evidence of pancytopenia - typically due to plasma cells infiltrating the bone marrow) • B - bone pain (albeit subtle in the form of a vague hist ory of lower back pain)

The immunoglobulin produced by dysplastic plasma cells shows up as a monoclonal band on serum electrophoresis. Renal ultrasound scan will not aid diagnosis of multiple myeloma. Cervical lym ph node biopsy may be helpful in lymphoma but not myeloma (a bone marrow biopsy would be more helpful in multiple myeloma). PTH levels can help identify the cause of hypercalcaemia but this patient has enough

em

f eatures suggestive of multiple myeloma t o j ustify investigating fo r myeloma first.

As s

CT scan of the kidneys, ureters and bladder is unlikely to be helpful in identifying multip le

Dr

myeloma (although whole-body CT scanning is often used to detect osteolytic lesions).

A 54-yea r-old ma n who has developed d isseminated intravascula r coagulation secondary to sepsis is reviewed . Twenty minutes ago he started to bleed per rectum. Blood products includi ng pa cked red cel ls and fres h frozen plasma have been orde red. What is the single most important facto r in determining whether cryoprecipitate should be given?

A low fibrinogen level A high prothrom bin time A high activated partial thrombo pla stin time

As se Dr

A low haemog lobin

m

A low platelet count

A low fibrinogen level A high prothrombin time A high activated partial thromboplastin time

As

se

A low fibrinogen level is the major criteria determining the use of cryoprecipit ate in

m

A low platelet count

Important for me

Less ·mpcrtant

Dr

bleeding

A 4-yea r-old boy is admitted after developing a haem arthrosis in his right knee whilst playing in the garden. The following blood results are obtained: Plat elets

PT

11 sees

APTT

76 sees

Factor VIlle activity

Normal

What is the most likely diagnosis?

Antithrombin III deficiency Von Willebrand's disease

Haemophilia B

Dr

Haemophilia A

As se m

Anti phospholipid syndrome

CD

Antithrombin III deficiency

6D

Von Willebrand's disease

m

ntiphospholipid syndrome

tiD

Haemophilia B

CD m

I

Haemophilia A

As

antiphospholipid syndrome. A normal factor VIlle activity point s to a diagnosis of

se

A grossly elevated APIT may be caused by heparin therapy, haemophilia or

Dr

haemophilia B (lack of factor IX). Antiphospholipid syndrome is a proth rombotic condition

A 17-year-old man is reviewed in the haemato-oncology multi-d isciplinary meeting with a diagnosis of Acute lymphoblastic leukaemia, (ALL). The results of bone marrow testing, immunophenotyping, and chromosomal analysis are reviewed. Which of the following features is associated with a poor prognosis?

Hypodiploidy Translocation t(12:21)

Trisomy 4

Dr

Translocation t(1:19)

As se m

Precursor B ALL

I

Hypodiplo idy

fD

Translocation t(12:21)

fiD

Precursor B ALL

f!D.

Translocation t(1:19)

CD CD

Trisorr y 4

Hypodiplo idy is seen as a n unfavou ra ble feature in ALL, with th e opp osite, hyper diplo idy associated with a g ood prog nostic o utco me. Trisomy 4, 10 a nd 17 is associated with a g ood p ro gnostic outcome in ALL.

As se m

The t(12;21) tra nslocation associated with a fusion pro te in fo rmerly known as TE L-AM Ll is associated with a g ood prog nostic o utco me in ALL, The t(1:19) tra nslocation is associated with low leve ls o f resistance to chemothe ra py inte rve ntion in ALL, and thus a good p rog nostic outcome. The t(9:22) o r Phila de lp hia translocatio n, is associated with a poor p rog nos1s.

lymphocytes.

Dr

Precursor B-ALL is more res ponsive to chemothera py than that invo lving mo re mature B

A patient presents as she has a stro ng fam ily history of cancer. Which one of the following cancers is least li kely to be inherited?

Colorectal cancer Breast cancer Gastric cancer

Dr

Ovarian cancer

As

se

m

Endometria l cancer

Colorecta l cancer

fD

Breast cancer

fD

Gastric cancer

ED.

Endometrial cancer

fD fiD

Ovarian cancer

Between 5 and 10% of all breast cancers are thou ght to be hereditary. Mutation in the BRCAl and BRCA2 g enes also increase t he risk of ovarian cancer. For colorect al cancer

As se m

around 5% o f cases are caused by heredit ary non -polyposis colorecta l ca rcinoma (HNPCC) and 1% are due to fam ilial adenomatous polyposis. Women who have HNPCC endometrial cancers occur in women with this risk factor.

Dr

also have a markedly increased risk for develop ing endometrial cancer - around 5% of

A 59-year-old female patient presents with headache, lethargy, and a purpuric rash on her shin s.

Hb

89 g/1

Platelets

68

WBC

2.6 * 109/ 1

Protein Electrophoresis

paraprotein 2g/L

lmmunoprotein Electrophoresis

monoclonal lgM

C4

low limit of normal

Rheumatoid Factor

elevated

s

109/1

What is the most likely diagnosis?

Hepatitis C infection Rheumat oid arthritis

Monoclonal gammopathy of unclear significance

Dr

Waldenstrom's macroglobulinaemia

As se m

Sj ogren syndrome

Hepatitis C infection Rheumatoid arth ritis Sjo ~ren synd rome Waldenstrom's macroglobulinaemia

Monoclonal gam mopathy of unclea r significance

As se m

Waldenstrom macrog lobulinaemia is a lymphoplasmacytic lymphoma (lymphoplasmacytic infiltration in the bone ma rrow or lymphatic tissue) associated with an IgM monoclonal p rotein in the serum. It is essentially a bone marrow-based d isease. Patients may develop constitutional symptoms, pancytopen ia (especially anaem ia and th rombocytopen ia),

Dr

o rganomega ly, neuropathy, and symptoms associated with immunoglobu li n depos ition o r hyperviscosity.

A 22-year-old fema le present s to the emergency department with angioedema on 5 occasions i n a six month period. No obvious trigger was identified and she does not improve significantly w hen given IM adrenaline. Her symptoms are caused by a deficiency of which substance?

Bradykinin

Cl est erase inhibitor

As se

Neutrophil elastase

Dr

Kallikrien

m

Eosinophil peroxidase

A 22-year-old fema le presents to the emergency department with angioedema on 5 occasions in a six month period. No obvious trigger was identified and she does not improve significantly when given IM adrenaline. Her sym ptoms are caused by a deficiency o f which substance?

Bradykinin

«ED

Cl esterase inhibitor

fD

Eosinophil peroxidase

m

Kallikrien

CD

Neutrophil elastase

•

Heredit ary angioedema is caused by deficiency o f Cl esterase inhibitor

As se m

Heredit ary angioedema is caused by a deficiency o f Cl esterase inhibitor.

l ess im:>crtc.nt

Dr

Important for me

A 52-yea r-old wo man presents with a pa inless, en la rged lymph node in her neck. She has no other sympto ms. Cytogenetic stu dies revea l a translocation which confirms a dia g nos is o f fo ll icular lymp homa. Which translocatio n was obse rved in the patient's cytogenetic stud ies?

t(9;22) t(8;14)

t(15;17)

Dr

t(14;18)

As se m

t(ll;l4)

t(9;22)

f!D

t(8;14)

CD

t(11;14)

tiD

t (14;18)

CD

t(15;17)

f!D

Follicular lymphoma is characterised by a t(l4:18) t ranslocation Important for me

Less ·mpcrtant

Follicular lymphoma is driven by a translocation involving Ig heavy chain on ch romosome 14 and BCL2 on chromosome 18. t(9;22) is associated with ch ron ic myeloid leukaemia

t(15;17) is associated with acute promyelocytic leukaemia

Dr

t(11;14) is associated with mantle cell lymphoma

As se m

t(8;14) is associated with Burkitt lymphoma

A 67 -year-o ld with chronic kidney disease stage 4 and metastatic prostate cancer presents as his pain is not contro lled with co-codamol. Which one of the following opio ids is it most appropriate to use given his impa ired rena l function?

Buprenorphine Morphine Hydromorphone

se As Dr

Trama dol

m

Diamorphine

Buprenorphine

C!D

Morphine

fiB

CD

Hydromorphone

«D

Trama dol

crD. se

m

Diamorphine

Dr

kidney disease.

As

Alfentanil, buprenorphine and fenta nyl are the preferred opioids in patient s with chronic

Which one of the following haematological malignancies is most commonly associated with the t(ll; l 4) translocation?

Acute promyelocytic leukaemia Burkitt's lymphoma Acute lymphoblastic leukaemia

Dr

Chronic myeloid leukaemia

As

se

m

Mantle cell lymphoma

Acute promyelocytic leukaemia

-

Burkitt's lymphoma

~

Acute lymphoblastic leukaemia

-

~

Dr

Chronic myeloid leukaemia

As

se

m

Mantle cell lymphoma

A 17-year-old man is investigat ed fo r recu rrent infectio ns and easy bruising. In the past year he has had four episodes of pneumonia. Other tha n the bruising he is noted to have severe eczema on his trunk and arms. A full blood count is ordered and reported as follows: Hb

14 .1 g/dl

Pit

82

WBC

5.9 * 109/ 1

Neuts

4.4 * 109/ 1

8

109/1

Further bloods show low immunoglobulin M levels. What is the most likely diagnosis?

Bruton's congenital agammaglobulinaemia Wiskott-Aidrich syndrome

DiGeorge syndrome

Dr

Chediak-H igashi syndrome

As se m

Ataxic telangiectasia

I

Bruton's congenital aga mmag lobulinaem ia

Wiskott-Aidrich syndrome Ataxic telangiectasia

Chediak-Higash i syndrome

Important for me

l ess :mocrtc.nt

Dr

Wiskott-Aidrich syndrome • recu rrent bacterial infections (e.g. Chest) • eczema • t hro mbocytopaenia

As se m

DiGeorge synd rome

A 72-year-old man is referred to haematology with a ra ised haemoglobin. A diagnosis of polycythaemia vera is suspected. Wh ich other abnormality of the blood wou ld be most cons istent with this diagnosis?

Ra ised alkaline phosphatase Hypokalaemia Thrombocytopaenia

Dr

Neutrophilia

As

se

m

Ra ised ferritin level

ED

Ra ised alkaline phosphatase

CD

Hypokalaemia

GD

Ra ised ferritin level

QD

Neutrophilia

6D

As Dr

I

se

m

Thrombocytopaen ia

Which one o f the following causes of primary immunodeficiency is due to a defect in both B-cell and T-cell function?

Common va riable immunodeficiency Chronic granulomat ous disease Wiskott-Aidrich syndrome

Dr

Di George syndrome

As

se

m

Chediak-H igashi syndrome

fD

Common variable immunodeficiency

m

Chronic granulomatous disease

I

Wiskott-Aidrich syndrome

&3

Chediak-Higashi syndrome

• GD

Di George syndrome

Combined B-and T-cell disorders: SOD WAS ataxic (SOD, Wiskott-Aidrich syndrome, ataxic te langiectasia) Important for me

l ess imocrtc.nt

As se m

Wiskott-Aidrich syndrome causes primary immunodeficiency due to a combined B- and T -cell dysfunction. It is inherited in aX-linked recessive fashion and is thou ght to be chest), eczema and thrombocytopenia

Dr

caused by mutation in the WASP gene. Features include recurrent bacterial infections (e.g.

A 54-year-old woman presents to the Emergency Department wit h a five day history of back pain. Her past medical history includes b reast cancer and osteoarthritis. The back pa in is located in the lower thoracic region and is made wo rse by cough ing and sneezing. There has been no change in bowel habit or urinary symptoms. On examination there is diffuse tenderness in t he lower thoraci c reg ion. Peri-a nal sensation is normal and lower limb reflexes are brisk. Which one of the following is the most ap propriate management plan?

Organise outpatient MRI Oral pa raceta mol + urgent MRI

Oral dexamethasone + urgent MRI

Dr

Oral dexamethasone + urgent tho racic/ lumbar spine x- ray

As se m

Oral pa raceta mol + urgent t horacic/lumbar spine x- ray

Organise outpatient MRI Oral pa raceta mol + urgent MRI

-

Ora l pa raceta mol + urgent tho racic/ lumbar spine x-ray

I

""" """

Ora l d examethasone + urgent tho racic/ lumbar sp ine x-ray Oral dexamethasone

+

urgent MRI

This woman has spinal co rd co mpression until proven otherwise and should have urgent assessment.

Dr

As se m

Recent NICE guidelines suggest contacting the local metastatic spina l cord compression coordinator in th is s ituation. This should hopefully prevent delays in treatment by ensuring the patient is admitted to the most appropriate p lace

A 31-year-old woman who is 25-weeks pregnant is brought t o the Emergency Department by her husband. Over the past two days she has become increasingly confused. Her t emperature is 37.8°C and blood pressure is 104/62 mmHg. Blood t ests show:

Hb

8.3 g/dl

Platelets

88

WBC

15.1

Blood film

Fragmented red blood cells

Sodium

139 mmol/ 1

Potassium

5.2 mmol/1

Urea

19.4 mmol/ 1

Creatinine

296 J,Jmol/ 1

8

109/1 8

109/1

What is the most appropriate treatment?

Rituximab Intravenous immunoglobulin

Pla sma exchange

Dr

Ceftriaxone + vancomycin

As se m

Methyl prednisolone

1- :tuximab Intravenous immunog lobulin Methyl predn iso lone Ceftriaxone + vancomycin Plasma exchange

TIP- plasma exchange is fi rst-line l ess im:>crtc.nt

As se m

important for me

preg nancy

Dr

This patient has thrombotic thrombocytopenic pu rpu ra, a co nditio n associated with

Which one of the following wou ld most suggest a leukaemoid reaction rather than chronic myeloid leukaemia?

Ra ised packed cell volume Right shih of neutrophils A low leucocyte alkaline phosphatase score

Dr

Positive osmotic fragility test

As

se

m

Dohle bodies in the white cells

Ra ised packed cell volu me Right sh ih of neutrophils A low leucocyte alkaljne phos phatase score

-

Dohle bodies in the white cells

Dr

Positive osmotic fragility test

As

se

m

~

A 77 -yea r-old lady is adm itted by the e me rgency d epartment comp la ining of d ifficu lty coping at hom e. She is unable to mobilise ind e pendently and has a poo r appetite due to difficu lty swallowing. She ha s a d iagnos is o f oesophageal cancer b ut is not thou ght to be a candidate for chemotherapy. Her GP recently started her on nitrofura nto in for a urina ry tract infection. On examinatio n she is a thin, frail lady who is a lert and o rie nted . There is no neuro log ica l d eficit in the upper lim bs. She has weakness o f hip flexion and knee extension in both legs, b ut marked ly more so on the right. You are ab le to e licit some loss o f p inprick se nsation on the a nterio r thigh. Her reflexes a re bris k with an upgo ing planta r on the right. Her bl ood results are as fol lows: Hb

101 g/ 1

Plat elet s

440 * 109/1

WBC

8.4 * 109/ 1

MCV

99 fL

Na•

136 mmol/ 1

K•

4 .8 mmol/1

Urea

3 .7 mmol/1

Creatinine

52 IJmol/1

What is the next most app ropriate step in th is patie nt's manageme nt?

Transfer to hos pi ce Refer fo r physiotherapy MRI imaging of th e sp inal cord

As s Dr

Stop nitrofuranto in

em

Check B12 a nd folate levels

I

Transfer to hos pi ce

CD

Refer for physiotherapy

m

MRI imaging of the spinal cord

ED.

Check B12 and folate levels

fD

Stop nitro furantoin

GD

As se m

A patient with new lower lim b neurology and a h istory of cancer should raise the suspicion o f metastatic spinal cord compression, which is best d emonstrated on MRI.

less urgent p roblems than cord com pression.

Dr

Although nitrofurantoin and B12 d eficiency could cause a peripheral neuropathy, both are

A 67-year-old man present s f eeling 'generally unwell' and co mplaining of pain in his back and legs. His wife also reports that he has been slight ly confused for the past two weeks. Basi c blood tests are ordered:

Hb

12.1 g/dl

Platelets

411 * 109/1

WBC

7.6 * 109/ 1

Na•

143 mmol/ 1

K•

5.3 mmol/1

Urea

15.7 mmol/ 1

Creatinine

208 ~mol/1

Bilirubin

20 j.Jmol/1

ALP

110 u/1

ALT

55 u/1

yGT

67 u/1

Albumin

31 gfl

Total protein

84 g/1

Calcium

3.10 mmol/ 1

Phosphate

0 . 79 mmol/ 1

What is the most likely underlying diagnosis?

Multiple myeloma Renal ca ncer with bony met astases Sarcoidosis

Dr

Prostate ca ncer with bony met astases

As s

em

Primary hyperparathyroidism

I

Multiple myeloma Renal cancer with bony metastases Sarcoidosis Prima

-

hyperparathyroidism

~

Prostate cancer with bony metastases

Hypercalcaemia, renal failure, high tot al pro tei n = myeloma Important for me

Less imocrtant

One of t he stand out resu lts is t he high calcium level. This immediately narrows t he different ial diagnosis considerably. Remember the two most common causes of

As se m

hypercalcaemia are malignancy and primary hyperparathyroidism. Neither of these alone untreated myeloma.

Dr

wou ld however explain t he renal failure and high total protein, bot h common features of

A 38-year-old Pakistani female was admitted with shortness of breath and a syncopa l episode. She describes a 2 week history of lethargy, ma laise and dizziness. The patient had recently started anti-tubercu lous therapy. History revealed she was not a vegetarian . Hb

8.Sg/dl

MCV

72fl

wee

11

Platelets

225 * 1QA9/ I

TSAT

33%

Ferritin

600ng/ml

Haemoglobin electrophoresis

normal

8

1QA9/ I

Which stain should be applied to a blood fi lm?

Giemsa Gram

Ind ia ink

Dr

Peri's

As se m

Ziehl Neelsen

6D

Giemsa

CD

Gram Ziehl Neelsen

6D

Peri's

CID

India ink

6D

This 38 year o ld Pa kistani female has p rese nted with sym ptomatic anae mia. Blood tests reveal a microcytic anaem ia, th e causes of which can be broadly categorised into : 1, iron d eficiency, 2, thalassaemia trait 3, sid ero blasti c a na emia. Inte rpreting the iro n studies shows a no rmal transfe rrin satu ration a nd normal fe rritin, ru ling out iro n d eficiency anaem ia . Normal haemoglobin electrophoresis rules out tha lassaem ia, there fore the li kely ca use is side ro blastic anaem ia. This is a lso hinte d at by the recent co mmencement of Ison iazid (anti tu berculous the rapy) a cause of side ro blastic a naemia.

Dr

nu cleus o f e rythro blasts.

As se m

Side ro blastic a nae mia when sta ined with Peri's sta in shows ring s id e ro b la sts. The disease is characterised by ineffective erythro po iesis leadin g to poor in co rpo ration o f iron into the

A 34-year-old man who is known to have glucose-6-phosphate dehydroge nase deficiency presents w ith symptoms of a urinary tract infection. He is prescribed an antibiotic. A few days later he becomes unwell and is noticed by his partner t o be pale and j aundiced . What drug is mostly likely to have been prescribed?

Co -amoxiclav Trimethoprim Ciprofloxacin

Dr

Erythromyci n

As se

m

Cefalexin

CD

Trimethoprim

aD

Ciprofloxacin

ED

Cefalexin

CD

Erythromycin

fD

trimet hoprim Important for me

As

se

m

The sulfamethoxazole in co-trimoxazole causes haemolysis in G6PD, not the Less imocrtant

Dr

I

Co -amoxiclav

A 72-year-old man with longstanding Wa ldenstrom's macroglobulinemia presents t o rheumat ology cl inic with joint pains and generalised weakness. Which of the follow ing would be most indicative of Type I cryog lobulinaemia?

Livedo reticularis Raynaud's phenomenon Arthralgia

As se Dr

Low C4 levels

m

Membranop roliferative glomerulonephritis

I

Livedo reticularis

GD

Raynaud's phenomenon

CD

m

Arthralgia Membranoproliferative glomerulonephritis

G'D

Low C4 levels

fD

Raynaud's - Type I cryoglobulinaemia Important for me

Less imocrtont

Cryoglobulinaemia can be caused by paraprotein bands such as those in Waldenstrom's macroglobulinemia and multiple myeloma. Meltzer's triad of arthralgia, weakness and

As se m

palpable purpura are commo n to all types of cryoglobul inaemia - as are membranoproliferative glomerulonephritis and low C4 levels.

Dr

Raynaud's occurs most co mmonly in type 1 cryoglobulinaemia and its presence can be helpful in ascertaining the underlying cause.

A 60-yea r-o ld woman is inve stigated for painful fingers a nd toe s in cold weather. She has p reviously been d iagnosed with Raynau d's phe nomenon b ut she is now experiencing s ignifica nt p urp lish d iscolou ration of her peripheries a nd no se a s well as g enerally feeling tired and lethargic. Blood te sts shows the following: Hb

99 g/1

Platelets

156 * 109/1

WBC

5.9 * 109/1

Blood film

Spherocytes seen

What is the next best inve stigation?

Com pleme nt levels Osmotic fragility test

Direct antiglobu li n test

Dr

Flow c.ytometry of blood

As se m

Anti-nuclea r antibody

se

m Dr

anemia.

As

This lady is likely to have co ld agglutinin disease, a form of autoimmune hemolytic

A 48 year old nurse presents with a short history of epistaxis and bleeding gums. You request urgent bloods, the results of which are shown in the table below: Haemoglobin

86 g/L

White cells

2.3 x lOA9/ L

Platelets

18 x 1QA9/ L

Clotting

deranged

Blood film

bilobed large mononuclear cells

What is the most likely diagnosis?

Von Willebrand's disease Acute lymphoblastic leukaemia

Surreptitious warfari n overdose

Dr

Acute myeloid leukaemia

As se m

Lym phoma

-

Von Willebrand's disease

~

Acute lymphoblastic leukaemia Lymphoma

~ute myeloid leukaemia Surreptitious warfari n overdose

This is a picture of bone marrow fa ilure secondary to acute myeloid leukaemia. In acute leukaemia a malignant expansion abnormal white cells accumulate in the bone marrow, replacing normal haemopoietic cells. Acute expansion of the myeloid stem line (acute myeloid leukaemia) is more common over the age of 45, in comparison with acute lymphoblastic leukaemia which is mostly seen in ch ildren. Lym phoma does not tend to present in th is way, but more so with rubbery enlargement

As se m

of lymph nodes.

but it is ra re that there are abnormalities on blood results.

Dr

Von Wi llebrand's disease may present with epistaxis and bleeding gums in severe cases,

A 38-yea r-old female patient presents to the e mergency de pa rtment with seve re a bd om inal pain, nausea an d vo miting. She also re ports red uced sensation in the bilateral lowe r limb extre mities. She a pp ears highly agitated and labile in mood . Her partne r re ports that this has ha ppened about 6 times befo re and va rious suspected diagnoses we re made for these past ep isodes but no d efinite diagnosis was eve r made. She repo rts that he r mothe r a lso gets such e pisodes. These past suspected d ia gnoses include acute a ppend icitis, rena l ca lculi, acute intestina l o bstruction. They we re all fo und to b e negative. What is the likely diagnosis to account fo r this cl inical presentation?

Acute intermittent porp hyria Porphyria cutanea ta rda

Multip le scle ros is

Dr

Neurotic disorder

As se m

Lead po isoni ng

I

f.ZD

Acut e intermittent porphyria

fD

Porphyria cutanea t arda

G'D

Lead poisoning Neurotic disorder

CD

Multiple sclerosis

CD

Acute intermittent porphyria typica lly presents with abdominal, neurological and psychiatric sympto ms Important for me

Less :mpcrtant

Acut e intermittent porphyria (AlP) typica lly presents with abdominal, neurologica l and psychiatric sympt oms. Porphyria cutanea t arda presents w ith photosensitive bullae. Lead poisoning is possible t o account for this presentation but it doesn't account for the family history. Al P is more likely g iven the family history.

Multiple sclerosis doesn't usually present with gastroint esti nal symptoms.

Dr

considering a psychiatric diagnosis.

As se m

Neuro tic disorder may be possible but physical causes need t o b e ruled out b efo re

A 34-year-old man who is known to have type 1 von Willebrand 's disease asks for advice. He is due to have a tooth extracted at the dentist next week. Which one of the following is the most appropriate management to reduce the risk of b leed ing?

Mefanam ic aci d Vitamin K Desmopressin

Dr

Factor VII concentrate

As

se

m

Factor Vlll concentrate

mt

Mefanamic aci d

f.D

Vitamin K Desmopressin

CD

Factor Vlll concentrate

fD

Factor VII concentrate

CiD

Dr

As

Blood products such as facto r VIII concentrate should be avoided when possible to minimise the risk of transfusion acquired vira l ill nesses.

se

m

I

An 80-year-old man is reviewed in the haematology cl inic. He has been referred due to weight loss, lethargy and a significantly elevated IgM level. Recent bloods show the following: Hb

13.8 g/dl

Platelet s

127 * 109/1

IgM

2150 mg/dl (range 50-330 mg/ dl )

ESR

45 mm/hr

Given the likely diagnosis, w hich one of the follow ing complications is he most likely to develop?

Renal fa ilure Chronic lymphocytic leukaemia Anaemia

Dr

Hyperca lcemia

As se m

Hyperviscosity syndrome

Renal fa ilure Chronic lymphocytic leukaemia Anaemia Hyperviscosity syndrome Hypercalcemia

IgM paraproteinaemia - ?Waldenstrom's macrog lobulinaemia Less imocrtont

As se m

Important for me

Th is patient has Wa ldenstrom's macroglobu linaemia. Hyperviscosity syndrome is p resent

Dr

in around 10 -15% of patients. Other common complicatio ns include hepatosplenomega ly.

A 38-year-old woman presents with a 2-month history of symptoms of fatigue, pa llor and palpitations. She also compla ins of b reathlessness at rest as well as during exertion. She has an established diag nosis of systemic lupus erythematosus (SLE). On abdominal exam ination you notice the spleen is s lightly enla rged. Blood tests reveal: Hb

90 g/1 {115- 160 g/1)

MCV

90 fl (82-100 fl)

D-dimer

150 ng/ml ( crtc.nt

Dr

Important for me

As

Desmopressiin - induces release of von Willebrand's facto r from endothelial cells

se

m

Acts as substit ute carrier molecule for factor VIII

What is the main mechanism by which vitam in B12 is absorbed?

Passive abso rption in the terminal ileum Active absorption in the middle to terminal part of jejunum Active absorption by the parietal cells of the stomach

Dr

Passive abso rption in the proximal ileum

As

se

m

Active absorption in the termina l ileum

Passive absorption in the terminal ileum Active absorption in the middle to terminal part of jejunum Active absorption by the parietal cells of the stomach Active absorption in the terminal ileum Passive absorption in the proximal ileum

Vitamin 812 is actively absorbed in the terminal ileum Less imocrtant

As se m

Important for me

factor.

Dr

A small amount of vitamin 812 is passively absorbed without being bound to intrinsic

A 72-year-old man is admitted with a deep vein th rombosis. He is normally fit and well but has recently lost weight. Blood tests reveal the following: IgG

889 mg/dl ( range 600- 1300 mg/dl)

IgM

1674 mg/dl (range 50-330 mg/dl)

IgA

131 mg/dl ( range 60-300 mg/dl)

What is the most likely diagnosis?

Monoclonal gammopathy of undetermined significance Acute promyelocytic leukaemia

Multiple myeloma

Dr

Anti phospholipid syndrome

As se m

Waldenstrom's macroglobulinaemia

Monoclonal gammopathy of undet ermined significance Acut e promyelocytic leukaemia Waldenstrom's macroglobulinaemia Anti phospholipid syndrome Multi ple myeloma

IgM paraprot einaemia - ?Waldenstrom's macroglobulinaemia Important for me

Less :mpcrtant

Waldenstrom's macroglobulinaemia is more likely than monoclonal gammopathy of hyperviscosity).

As se m

undet ermined significance given the weight loss and deep vein thrombosis (evidence of

Dr

IgG and IgA and the most common type of immunoglobulins produced in myeloma.

You are asked to review a 60-yea r-old Greek man with known glucose-6-phosphate dehydrogenase (G6PD) deficiency who was adm itted with mala ria and a chest infection. He has developed jaundice an d haemolytic anaemia after starting some medications this morning. Which of these medications are most likely to have precipitated his crisis?

Clarith romycin Amoxicil li n

Salbutamol

Dr

Primaquine

As se m

Artesunate

CD

Clarithromycin

(l1

I

oxicillin

CD

Artesunate

m

Primaquine

GD.

Salbut amol

m

~

Malaria prophylaxis (e.g. primaquine) can trigger haemolytic anaemia in t hose w ith G6PD deficiency Important for me

Less imocrtant

Primaquine is a wel l known cause of haemolysis in G6PD d eficiency and is used in the

Source: BNF

Dr

Penicillins and macrolides are safe antibiotics to use in G6PD d eficiency.

As se m

treatment of malaria. Artesunat e is generally considered safe to use in G6PD d eficiency.

A 54-year-old man is investigated for recurrent episodes of abdominal pain associated with weakness of his arms and legs. Wh ich one of the following urine t ests wou ld best indicate lead toxicity?

Haemoglobinuria Coproporphyrin Porphobilinogen

Dr

Ham's test

As

se

m

Uroporphyrin

CD

Haemoglobinuria

ED

Porphobilinogen

fD

Uroporphyrin

tiD.

Ham's test

f!D

Dr

As

se

m

Coproporphyrin

A 74-yea r-old ma le is seen on the acute medical ward with a histo ry of persistent frontal headaches associated with blurred vision fo r the past week. On fu rther questio ning, the patient reports a history of wo rsening fatigue and shortness of breath ove r the preceding 2 months. The results of preliminary investig ations a re as fo llows: Hb

98 g/1

Plat elet s

100 * 109/ 1

WBC

6 * 109/ 1

Erythrocyte Sedimentation Rate

SOmm/hr

On exam ination you note that the patient has enla rged cervical lymph nodes and pa lpa ble sple nomeg a ly. Which o f the fo llowing conditions is most likely to b e the cause of the patient's symptoms?

Hod g kin's lymphoma Multip le myeloma Acute myeloid leuka e mia Waldenstrom's macroglo bulinaemia

Submit answer

Dr

As s

em

Acute lympho blastic leukaemia

Hodgkin's lymphoma Multiple myeloma Acute myelo id leukaemia Wald enstrom 's macroglo bulinaemia

-

Acute lymphoblastic leukaemia

~

Patients with Wa ld enstrom's macroglobu linaem ia ohen present with issues secondary to hyperviscosity Important for me

Less imoc rtc.nt

Wald enstrom 's macroglobulinaemia is a form of lymphoplasmacytoid lymphoma (LPL), cha racterised by a monoclonallgM pa raproteinaemia. This pa raproteinaemia leads to systemic symptoms of hyperviscosity such as headaches, visual disturbances and in rarer cases, strokes and ischaemic orga n d a mage. Many patients ohen present with issues secondary to th is hyperviscosity, as well as the more genera lised systemic symptoms and signs common to many haematolo gical diseases. 1) Hodgkin's lymphoma, although likely to cause cervica l lympha denopathy and splenomega ly, is not usually associated with thrombocyto paenia or issues secondary to hyperviscosity 2) Multiple myeloma ohen ca uses bony pa in in areas o f lesions and isn't ohen associated with lymphadenopathy or organomeg aly

em

3) AML doesn't usual ly cause lympha denopathy o r splenomegaly.

Dr

splenomega ly, would not usually be associated with symptoms o f hyperviscosity

As s

5) ALL is less common in adults, and although capable of ca using lym phadenopathy and

A 54-yea r-old man is diagnosed as having acute mye loid leukaemia. What is the single most imp ortant test in d etermin ing his prognosis?

Gene-expression p rofil ing White cell count at dia gnosis Immu nophenotyping

Dr

Cyto geneti cs

As

se

m

Lactate d ehydrog e nase

I

Gene-expression p rof iling

CD

White cell cou nt at diagnosis

CD

ED

Immunophenotyping

CD

Lactate dehydrogenase

C!D m

I

cytogenetics are t he single most important prognosti c factor.

Dr

All of the above may be important but chromosomal abnormalities detected by

se

Cytogenetics

As

I

What is the most useful marker of p rognosis in myeloma?

Calcium level Urine Bence-Jones protein levels Alkaline phosphatase

Dr

B2-microg lobulin

As

se

m

ESR

GD

Urine Bence-Jones protein levels

G'D . CD

ESR

CD

B2-microg lobulin

As

se

m

Alkaline phosphatase

Dr

I

Calcium level

ED

Which one of the following is associated with a high leucocyte alka line phosphatase score?

Myelofibrosis Pernicious anae mia Infectious mononucleosis

Dr

Chronic myeloid leukaemia

As

se

m

Paroxysmal nocturnal haemog lobinuria

CID

M yelofib rosis

m

Pernicious anaemia

(fD

Paroxysmal nocturnal haemoglobinuria

f!D

Chronic myeloid leukaemia

As

se

m

Infectious mononucleosis

QD

Dr

I

A 45-year-old woman attends the acute medical unit with her second DVT this year. Her background is notable fo r COPD, hypertension and chronic kidney disease stage 4 secondary to membra nous glomerulonephritis. In chronic kidney disease, w hich of the following contributes most to the increased risk of

VTE?

Immobility Loss o f protein C Loss o f antithrombin III

Dr

Lupus anticoagu lant

As se m

Concurrent cancer

m

Immobility

I

Loss of protein C

ED

Loss of antithrombin III

ED.

Concu rrent cancer

CD

Lu pus anticoagulant

. (D

CKD is the most common cause of antith rombin III deficiency Important for me

l ess ' m::~c rtant

Antithrombin III is an im portant regulatory molecu le that reduces the activity of the intrinsic pathway of the clotting cascade. Loss of antithrombin III, thus, increases coagulability. Whilst there are hered itary causes of antithrombin III, it is a particularly small protein and is easily lost through the nephron in CKD.

Dr

As se m

CKD does also increase the risk of concu rrent cancers, but not as significantly as the protein loss. Lu pus anticoagulant is indeed highly prothrom botic and is associated with antiphospholipid syndrome.

A 28-yea r-old man is investigated for cervical lymphadenopathy. A biopsy shows nodular sclerosing Hod gkin's lymphoma. Which one o f the following factors is associated with a poor prognosis?

History of Epstein Ba rr virus infection Mediastinal invo lvement Female sex

se As Dr

Lym phocytes 20% of tota l white blood cells

m

Night sweats

History of Epstein Barr virus infection Mediastinal involvement Female sex

-

Night sweats

~

Dr

Night sweats are a ' B' sym ptom and imply a poor prognosis

As

se

m

Lymphocytes 20% of tota l wh ite blood cells

A 72-year-old man with metastatic small cell lung cancer is admitt ed to the loca l hospice fo r sympt om cont rol. His main problem at t he moment is intractable hiccups. What is the most app ropriat e mana gement?

Chlorpromazine Co deine phos phat e Diazepa m

Dr

Phenytoin

As

se

m

Methadone

Chlorpromazine

GD

Codeine phosphat e

f!D

Diazepam

f!D

• •

Methadone Phenytoin

Hiccups in palliative ca re - chlorpromazine o r haloperidol

m

As se

Haloperidol may also be used

Less ·mpc rte;nt

Dr

Important for me

A 64-yea r-old wo man with meta static b reast ca nce r is brought in by her husband. Over the past two d ays she has develo ped increasing ly severe back pain. Her hus ba nd reports that he r leg s are weak and she is havin g difficulty walking . On e xam ination she has reduced power in both leg s a nd increased tone asso ciated with brisk knee a nd a nkl e reflexe s. There is some sensory loss in the lower limbs a nd feet but p eria na l se nsation is normal. What is the most like ly d iagnos is?

Spina l cord com pression at TlO Cauda eq uina syndrome

Pa ra neoplastic pe rip hera l neuropathy

Dr

Hype rcalcaemia

As se m

Guillain Barre syndrome

Spinal cord compression at TlO Cauda equina syndrom e Guillain Barre syndrome Hypercalcaemia

-

As

se

m

Para neoplastic peripheral neuropathy

Dr

The upper motor neuron signs point t owards a diagnosis of spinal cord co mpression above ll, rather than cauda equina syndrome.

A 30-year-old man is investigated for enlarged, painless cervica l lymph nodes. A biopsy is t aken and a diagnosis o f Hodgkin's lymphoma is made. Which one o f the following types o f Hodgkin's lymphoma carries the best prognosis?

Lym phocyte predominant Mixed cellularity Nodular sclerosing

Dr

Lym phocyte depleted

As

se

m

Hairy cell

Lymphocyte predominant Mixed cellularity Nodular sclerosing Hairy cell

As

Important for me

Less · m ::~c rtant

Dr

Hodgkin's lymphoma - best prognosis = lymphocyte predominant

se

m

Lymphocyte depleted

Which one of t he followin g malignancies may be associat ed w ith HTLV-1?

Adu lt T-cell leukaemia Colorectal cancer Burkitt's lymphoma

Dr

Breast cancer

As

se

m

Medullary t hyroid cancer

GD

Adult T-cell leukaemia

CD

Colorectal cancer

CD

Burkitt's lymphoma

CD

Breast cancer

D

Dr

As

se

m

M eaullary t hyroid cancer

Each one of the following is associated with hyposplenism, except:

Sickle -cell a naem ia Liver cirrhosis System ic lupus e rythem atous

Dr

Sp lenectomy

As

se

m

Co e liac d isease

I

Sickle-cell anaemia

GD

Live r cirrhosis

CiD

Systemic lupus erythematous

GD

~eli a c disease

m

se

As Dr

Splenectomy

f!D

m

A 65-yea r-o ld man comes fo r review. He has a history o f s mall cell lung ca nce r and ischaemic heart disease. His cancer was d iag nosed five months ago and he has recently com pleted a cou rse of c hemothe ra py. From a ca rdiac po int o f view he had a myocardia l infa rctio n two years ago following which he had p rimary a ng io plasty with stent placement. He has had no ang ina s ince. Fo r the past week he has b ecome increasingly s hort-of-b reath. This is wo rse at n ight and is associated with an occasional no n -pro ductive cough. He has a lso noticed that his wed d ing ring feels tight. Clinica l exam ination is o f his chest is unremarka ble. He does howeve r have diste nded neck ve ins and pe riorbita l oed e ma. What is the most likely diag nosis?

Heart fa ilure secondary to chemothe rapy Tu mou r lysis syndrome

Hypercalcaemia

Dr

Sup erior ve na cava obstruct io n

As se m

Nep hrotic synd rome seconda ry to chemotherapy

Heart failure secondary to chemothera py ( lmour lysis synd rome Nep hrotic syndrome secondary to chemothera py

-

Superior vena cava obstruction

Dr

Hypercalcaemia

As

se

m

~

A 22-year-old man with sickle cell anaemia presents with pallor, lethargy and a hea dache. Blood results are as follows: Hb

4 .6 g/dl

Reticulocytes

3%

Infection with a parvovirus is suspected. What is the like ly d iagnosis?

Th rombotic cris is Sequestration crisis

Aplastic crisis

Dr

Haemolytic crisis

As se m

Transformation to myelodysplasia

Thrombotic crisis Sequestration crisis r : ransformation to myelo dysplas ia Haemo lyti c crisis

se

m

~astic crisis Dr

As

The su dd en fa ll in haemoglobi n witho ut an approp riate reticu lo cytosis (3% is just above the no rmal range) is typical of an aplastic crisis, usually seconda ry to parvovirus infectio n

Which one o f the followin g featu res is charact eristic of acute intermittent po rphyria?

Photosensitivity Increased urinary po rp hobilinogen between acute attacks Hypernatraem ia d uring a ttacks

Dr

Increased faeca l p rotoporphyrin excretion

As

se

m

Autosomal recessive inheritance

fD

..

Photosensitivity

r

Increased urinary porphobi linogen between acute attacks

CD

Hypernatraemia du ring a ttacks

f!D se

As

Increased faeca l p rotoporphyrin excretion

m

recessive inherita nce

Dr

IAutosom~l

fD

In idiopathic throm bocytopenic pu rp ura what a re the autoantibod ies most common ly directed at?

Platelet activating factor Glycoprotein lib/lila complex ATP receptor

se As Dr

ADP receptor

m

Anti-thrombin Ill receptor

I I

Platelet activating factor

GD

Glycoprotein lib/lila complex

CD CD

ATP receptor

m

se

As

ADP receptor

m

mreceptor Dr

Anti-thrombin

A 23-year-old woman presents with lethargy. The following blood results are obtained:

Hb

10.4 g/dl

Pit

278 * 109/1

wee

6 .3 * 109/ 1

MeV

68 fl

Blood film

Microcytic hypochromic RBes, marked anisocyt osis and basophilic stippling noted

HbA2

3.9%

What is the most likely diagnosis?

Lead poisoning Sickle cell anaemia

Siderob lastic anaemia

Dr

Heredit ary spherocytosis

As se m

Beta-thalassaemia tra it

Lead poison ing

I

Sickle cell anaem ia Beta-thalassaemia tra it Hered ita ry spherocytos is Sid erob lastic anaem ia

Disproportionate microcytic anaemia -think beta-tha lassaem ia trait Important for me

l ess 'moc rtc.nt

As se m

A microcytic anaemia in a female shou ld raise the possibility of e ither gastrointestinal b lood loss or menorrhag ia . However, there is no history to suggest this and the microcytosis is disproportionately low fo r the haemoglobin level. This comb ined with a raised HbA2 po ints to a d iagnosis of beta-tha lassaem ia trait.

levels.

Dr

Baso philic stippling is also seen in lead poison ing but wou ld not expla in the raised HbA2

A 17-year-old man is invest igated after he bled excessively following a toot h extraction. The following results are obtained: Pit

173 * 109/ 1

PT

12.9 sees

APTT

84

sees

Which clotting factor is he most likely to be deficient in?

Factor VI Factor VII

Factor X

Dr

Factor IX

As se m

Factor VIII

fD

Factor VII

m

Factor VIII

fZD.

Factor IX

CD

Fac or X

CD

haemophilia.

Dr

This man is most likely to have haemophilia A, which accounts for 90% of cases o f

As

se

m

I

Factor VI

Which one of the following is least likely to cause a warm autoimmune haemolytic anaemia?

Mycoplasma infection Methyldopa Chronic lymphocytic leukaemia

Dr

Systemic lupus erythematous

As

se

m

Lymphoma

Mycoplasma infection Methyldopa

~ronic lyT phocytic leukaemia Lym phoma

Dr

anaemia

As

se

Mycoplasma infectio n causes a cold autoimmune haemolytic anaemia. System ic lupus erythematous can rare ly be associated with a mixed-type auto imm une haemo lytic

m

System ic lupus erythematous

A 62-year-o ld woman who is known to have metastatic breast cancer presents with increasing s hortness of b reath. She is cu rrently receiving a chemotherapy reg ime. On exam ination she has a third heart sound and the apex beat is d isplaced to the 6th intercosta l space, a nte rior axillary line. Which one of the fo llowing chemotherapeutic agents is most like ly to be responsible?

•

P ,clitaxel Docetaxel

CD

Bleomycin

(D

As se m

I

Doxorubicin

m

Dr

Dactinomycin

fD

~~clitaxel

CD

Docetaxel

m

Bleomycin

GD

m

Dactinomycin

fD

Important for me

Less imocrtc.nt

Dr

Doxorubici n may cause ca rdiomyopathy

As

se

m

Doxorubicin

A 52-year-old is found t o have chronic myeloid leukaemia following investigation for splenomegaly. Which one of the following best descri bes the function of the BCR-ABL fusion prot ein?

Epidermal growth factor recept or Phospholipase C CD52 co-receptor

Dr

Fibroblast growth factor receptor

As

se

m

Tyrosine kinase

Ep idermal growt h factor recept or Phospholipase C CD52 co-receptor Tyrosine kinase

m

Fibroblast growth factor receptor

As

Less imocrtont

Dr

Important for me

se

Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor

A 49-yea r-old female is adm itted to hospital d ue to shortness of b reath a nd pleuritic chest pain. She also com pla ins of a marked decrease in app etite for the past 4 months . An a d mission chest x-ray shows a right-s ided pleu ral effusion. An underlying malignan cy is suspected a nd a series of tumour markers are requested: u/ml ( < 40)

CA 19-9

55

CA 125

654 u/ml ( < 30)

CA 15-3

9 u/ml ( 450. 10 9/1).

em

The w hite cell different ial in th is case d emonst rat es granulocytes at different stages of

Dr

myeloid leukaemia. The platelet count may also be raised in these patients.

As s

maturation (immature band forms an d mat ure neutrop hils) which is suggestive of chronic

Which one of the following is least recogni sed as a treatment modality in idiopathic thrombocytopenic purpura?

Plasma exchange Splenect omy IV immunoglobulin

Dr

Ora l prednisolone

As

se

m

Cyclophosphamide

CED

Splenectomy

. (!'D

CD

Cyclophosphamide

f.D

Oral prednisolone

se

m

IV immunoglobulin

As

Plasma exchange

Dr

CD

Which one o f the following is least associated with thymomas?

Syndrome inappropriate ADH Myasthenia gravis Red cell aplasia

Dr

Motor neurone disease

As

se

m

Dermatomyos itis

Syndrome inapprop riate AD H

Red cell aplasia

As

Motor neurone disease

se

m

Dermatomyositis

Dr

I I

Myasthenia gravis

A 30 yea r-old ma n presents with recurrent abdo minal pain. This is not associated with food, hea rtburn, indig estion or dysphagia. He has had no weig ht loss. His b lood tests have b een no rmal a nd he has b een given a diagnos is of irritable bowe l syndrome. Desp ite lifestyle modifications a nd laxatives, he has still had recurre nt pa in. He then presents with swe lling of his lips a nd tongue. This is not itchy and he is systemica lly well, but does have a stridor. What would be the most successful ma nag e ment out of the fo ll owing optio ns?

Supportive ca re Adrena li ne

Chlorphena mine

Dr

Fresh frozen plasma

As se m

Prednisolone

Suppo rtive ca re

GD

Ad renali ne

6D

Prednisolone

fD

~sh frozen plasma

ED

Chlorphena mine

tiD

Dr

As se m

This patient has a history and acute p resentation in keepi ng with he red itary ang ioedema. This is ca used by a deficiency o f Cl-esterase inhibitor. It is normally treated with Cl-INH concentrate, however when th is is unavailable, fre sh frozen p lasma is the next best treatment. The lack of itch ing in this case a nd the fact that he is systemica lly well point away from anap hylaxis a s a cause. Heredita ry angioed ema rarely responds to treatment with adrenaline or a ntihistamines. In a rea l life situati on this patient would probably be treated a s a naphylaxis, but the q uestion a sks what the most successful treatme nt would be, and in this case it would be FFP.

Which one of the following causes of primary immunodeficiency is due to a defect in both B-cell and T-cell function?

Di George syndrome Chronic granu lomatous disease Bruton 's congenital aga mmag lobulinaem ia

As Dr

Ataxic telangiectasia

se

m

Leukocyte adhesion deficiency

Which one o f the following causes of primary immunodeficiency is due t o a defect in both B-cell and T-cell function?

-

Di George syndrome

~

Chronic granulomat ous disease Bruton's congenital agammaglobulinaemia

-

Leukocyte adhesion deficiency

"""'

Combined B-and T-cell disorders: SOD WAS ataxic (SOD, Wiskott-Aidrich Important for me

Less :mpcrtant

Dr

syndrome, at axic te langiectasia)

As se m

Ataxic telangiect asia

A 34-yea r-old intravenous d rug user is admitted with a pu rpuric rash a ffecting her legs. Blood tests revea l the fo llowing: Hb

11.4g/dl

Platelets

489 * 109/ 1

wee

12.3

Hev PeR

positive

HBsAg

negative

Rheumatoid factor

positive

e3/ e4

reduced

8

10911

What is the most likely diagnosis?

Polyarte ritis nodosa Henoch-Schon le in pu rpu ra

System ic lupus erythematous

Dr

Cryog lobu linaem ia

As se m

Wegener's granulomatosis

Polyarteritis nod osa Henoch -Schonle in purpura Wegener's g ranu lomatosis Cryog lobu linaem ia

As

se

m

Syste ic lupus erythematous

Dr

He patitis C infectio n is associated with type II (mixed) cryoglobu li na em ia, suggested by the pu rpu ric rash, positive rheu mato id facto r and re duced compl ement levels

Burkitt's lymphoma is associated with wh ich one o f the following genetic changes:

Cyclin 01-IG H gene translocation TEL-JAK2 gene translocation Bel -2 gene translocation

Dr

BCR-Ab ll gene translocation

As

se

m

C-myc gene translocation

Cyclin Dl-IG H gene translocation TEL-JAK2 gene translocation

-

........

Bel-2 gene tra nslocation

......,

C-myc gene translocation

........ m

BCR-Abll gene translocatio n

l ess ' m::~c rtant

Dr

Important for me

As

se

Burkitt's lympho ma - c- myc gene translocation

Chronic lymphocytic leukaemia is mostly due to a:

Polyclonal proliferation of B-celllymphocytes Monoclonal proliferation of B-celllymphocytes Monoclonal pro liferation of large granular lymphocytes

Dr

Polyclonal proliferation ofT -cell lymphocytes

As

se

m

Monoclonal proliferation ofT -cell lymphocytes

Polyclonal proliferation of B-celllymphocytes Monoclonal proliferation of B-cell lymphocytes Mof oclonal proliferation of large granular lymphocytes Monoclonal proliferation ofT -cell lymphocytes

se

m

Polyclonal proliferation ofT -cell lymphocytes

l ess im:>crtc.nt

Dr

Important for me

As

CLL is caused by a monoclonal proliferation of B-cell lymphocytes

A 25-yea r-old woman with prima ry antiphospholipid syndrome is reviewed. She has just had a booking ultrasou nd at 11 weeks gestation which confirms a viable pregnancy. This is her first pregnancy and she is otherwise fit and well. Which one of the following is the reco mmend treatment?

Aspirin + prednisolone Low-molecular weight heparin Prednisolo ne+ low-molecular weight hepa rin

As se Dr

Aspirin

m

Aspirin + low-molecular weight heparin

Asp irin + prednisolone Low -molecu lar weight heparin

I

Prednisolone+ low-molecular weight heparin Asp irin + low-molecular weight heparin Asp irin

Anti phospholipid syndrome in pregnancy: aspirin + LMWH Important for me

Less · m oc rtC~nt

As se m

The ultrasound at 11 weeks gest ation would show a fetal heart if the pregnancy was heparin.

Dr

viable. This patient should therefore be taking both aspirin and low-molecular weight

A 15-yea r-old g irl is referred to haematology. She sta rted having periods three years ago which have a lways been heavy and prolonged. Unfortunately the menorrhagia has responded poorly to trials o f tranexa mic acid and the combined ora l contraceptive pill. Blood tests show the following: Hb

10.3 g/dl

Pit

239 * 109/ 1

WBC

6 .5 * 109/ 1

PT

12.9 sees

APTT

37

sees

What is the most likely diagnosis?

Haemoph ilia B Disseminated intravascu la r coagulation

Von Willebrand's d isease

Dr

Id iopathic thrombocytopenic pu rpu ra

As se m

Haemoph ilia A

-

Haemop hilia B

~

Disseminated intravascular coagulation Haemophilia A

I

Idiopathic thrombocyto penic pu rpura Von Wi llebrand's disease

The mild anaemia is consistent with the long history of menorrha gia.

Dr

As

se

m

Von Willebrand's disease is the most likely diagnos is as it is the most common inheritied bleeding disorder. The mildy elevated APTI is consistent with this diagnosis.

An 80-yea r-old man has spent his whole workin g life as a loft insu lator and is concerned that he may have been exposed to asbestos. He has been informed o f the risk of mesothelioma but wants to know if there are any other conditions for which he is at higher risk than the genera l popu lation. Which of the fo llowing is a lso proven to have a causal li nk with asbestos exposure?

Bronch iectasis Type D d iab etes

Ischaem ic heart disease

Dr

Basal cell carcinoma of the skin

As se m

Bronch ial carcinoma

-

Bronchiectasis

~

Type ll d ia betes Bronchial carcinoma Basal cell carcinoma of the skin Ischaemic heart disease

Exposure to as bestos is a risk facto r for bro nchia l ca rcinoma a s we ll as mesotheliom a Important for me

Less imocrtant

Answer 3 is correct. Asbestos is well known to increase the risk o f mesothel ioma, but also increases the risk of bronchial carcinoma, la ryngeal cancer and ovarian cancer. The re is also some limited evidence that asbestos may increase the ris k of cancer of the stomach, p harynx an d bowel. Exposure to asbestos also increases the risk o f some benign diseases, including pleu ral plaques, diffuse pleu ral thicken ing, a sbestos re lated ben ign p leura l effusions an d asbestosis. BMJ Clinical Review: http://www.bmj.com/ content/339/bmj.b3209.fu ll

As s Dr

https:/ /www.ca ncer.gov/about -cancer/causesp reve ntion/ris k/substances/ asbestos/ asbestos-fact-sheet#q3

em

National Cancer Institute:

A 29-yea r-old man p resented to the hospita l a fte r he had two episodes of bright red urine in the morn ing. He is very worried and tells the attend ing doctor that he has never had such an ep isode b efo re. He has just sta rted working at an engineering firm and is plann ing to get married in a few months. He reports feeling tired fo r the past few months but thoug ht this was due to his job which req uired him to trave l to construction s ites every d ay. He has no sign ificant fam ily history. He had an a ppendectomy when he was a child but other than that he has neve r been ad mitted to the hospital. A blood test reveals a hemoglobin concentration of 11.5 g/ dl and a reticulocyte o f 14% of red b lood cell s. Which of the find ings is the most like ly to be reported upon flow cytometry o f a blood sample from this patient?

C3 negative cells CDSS negative cell s

CDSS a nd CD59 neg ative cel ls

Dr

CS to C9 negative cells

As se m

CD59 negative cells

C3 negative cells CDSS negative cell s CD59 negative cell s CS t o C9 negative cells CDSS and CD59 negative cells

This patient p resent ed with t he signs and symptoms cons istent with a diagnosis of paroxysmal nocturnal hemoglob inuria (PN H). This condition is an acqu ired and ch ron ic fo rm o f int rinsic hemolytic anemia. Pat ients can present w ith hemat u ria, or even simply sympt oms of anemia. Venous throm bosis is also a common occurrence. The classic t riad is hemolytic anemia, pancytopenia, and venous thrombosis. Flow cyt ometry is the gold standard lab oratory investigations and shows CDSS and CD59 negative red an d blood cells. 1: A def iciency o f C3 is a complement d eficiency disorder. Since C3 p lays an important role in the act ivation of both the classica l and alternative complement pathways, a C3 d eficiency confers a higher risk of acquiring recurrent bacterial infections. 2: It is true that t his w ill be p resent in t his pat ient's cells. However, PNH patient s will also have a deficiency of CD59. 3: It is true that t his w ill be p resent in t his pat ients' cells. However, PNH patient s will also have a deficiency of CDSS. 4: Th is would indicate terminal com plement def iciency. This con dition involves a d ef iciency of t he com plements forming the membrane att ack membrane. CS to C9 d eficiency confers a high risk of infection w ith Neisseria organisms. 5: The gold st andard in t he diagnosis of PNH is f low cytometry, and patient s usually have

As s

Ecu lizu mab is a humanized monoclona l antibody which has b een approved for the

em

a d eficien cy of both CDSS and CD59 on their red as well as their white b lood cell s.

Dr

treatment of PNH. It works mainly via the inhib ition of the t erminal complement cascade.

A 49-year-old wo man is referred to t he haematology clinic with easy bruising and recurrent epistaxis. She is otherwise well. Blood tests reveal t he follow ing:

Hb

12.9 gfdl

Platelets

19

wee

6 .6 * 10911

8

109/ 1

The patient refuses consent for a b one marrow examination. What is t he most appropriat e init ial management?

Plat elet t ransf usion Oral prednisolone

Splenect omy

Dr

A BVD chemotherapy

As se m

No t reatment

I

Plat elet t ransf usion

fD

Oral prednisolone

eD CD

No t reatment

• •

A BVD chemotherapy G

lenect omy

ITP- give oral prednisolone Important for me

Less imocrtant

As se m

The likely diagnosis in this patient is idiopathic t hrombocyto penic purpura. The first line d emonstrat e increased megakaryo cytes

Dr

treatment in such pati ents is high -dose prednisolone. Bone marrow examination wou ld

A 52-year-old female patient presents t o the oncology clinic with an 8-months history o f poor appetite and weight loss. She also com plains of a right upper quadrant discomfort which has been present for the last 3 months. An ultrasound scan reveals multiple lesions in the liver suggestive o f liver metast asis. A tumour marker profile reveals a raised level of CA 15-3. What is the most likely primary tumour?

Colorectal carcinoma Small cell lung carcinoma

endometrial carcinoma

Dr

Ovarian carcinoma

As se m

Breast carcinoma

I

Colorectal carcinoma

. CD

Small cell lung carcinoma

m

Breast carcinoma

GD

Ovarian ca rcinoma

GD

fD

endometrial carcino ma

CA 15-3 is a t umour marker in breast cancers Important for me

l ess im:>c rtc.nt

CA 15-3 is a tumou r marker in brea st cancers.

CA 125 is a tumou r marker in ovarian cancers and also endometrial cancers.

Dr

Carci noembryonic antigen (CEA) is a t umour marker in colorect al cancers.

As se m

Bombesin is a tumou r marker in small cell lung cancers.

Which of the following is most associated with thymomas?

Myelodysplasia Thrombocytopenia Acute myeloid leukaemia

Dr

Red cell aplasia

As

se

m

Acute lymphoblastic leukaemia

Myelodysplasia Thrombocytopenia

m

Acute myeloid leukaemia

Red cell aplasia

Dr

As

se

Acute lymphoblastic leukaemia

A 72-yea r-o ld man with metastatic colon cancer is reviewed . He cu rrently takes co codamol 30/ 500 2 tablets qd s fo r pain re lief. Unfortunate ly this is not contro ll ing his pai n. What is the most appropriate change to his med icatio n?

Switch to MST lSmg bd + paracetamol l g q ds Switch to MST 35mg bd + paracetamol l g q ds Add tramad oi SO-lOOmg 1-2 q ds

Dr

Switch to MST lSmg bd

As

se

m

Switch to MST 2Sm g bd

Switch to MST 15mg bd + paracetamol l g q ds Switch to MST 3Smg bd + paracetamo l l g q ds Add tramad oi SO-lOOmg 1-2 q ds Switch to MST 2Smg bd Switch to MST l Smg bd

His tota l cod e ine dose is 30 • 2 • 4 = 240 mg/day. Converting this to o ra l morphine = 24

Dr

to patients on la rge d oses of morph ine

As se

m

mg/day.lt is the refore rea sona ble to start MST l Smg bd as his pain is not currently contro ll ed. Pa racetamol should be continued as it has been shown to give benefits even

A 54-year-old woman is reviewed in oncology clinic follow ing d eb ulking su rgery fo r primary perito neal cancer. She is known t o have two liver metastases. She underwent surgery one month ago and has co me in for review prior t o adjuvant chemotherapy. During her chemotherapy treatment, which t umour marker wou ld be most appropriate to monitor disease prog ression?

CA 15-3 CA 19-9

As se

S-100

Dr

Human chorionic g onadotropin (hCG)

m

CA 125

CA 15-3 CA 19-9

-

CA 125

~

Human chorionic g onadotropin (hCG)

S-100

Ovarian cancer - CA 125 Important for me

l ess 'mpcrtont

CA 125 is the tumou r marker most associat ed w ith pri mary peritonea l cancer as well as o varian ca ncer and can b e used to monit or response to chemotherapy, alongside regular CT scans. It can also b e raised in various ot her ca ncers. The ot her t umou r markers are more approp riate for o ther cancers.

As se m

Source:

Interpret Them.' BMJ (2009): 852-58.

Dr

St urg eon, C. M., L. C. Lai, and M. J. Duffy. 'Serum Tumour Markers: How to Order and

A 35-year-old woman presents with menorrhagia and a persistent sore throat. A full blood count shows the following: Hb

6.8 g/dl

Platelets W BC

Neutrophils

0.8 * 109/ 1

Which one of the following medications is most like ly to account for this finding?

Trimethoprim Rifampicin

Clomifene

Dr

Montelukast

As se m

Olanzapine

CD

Trimethoprim Rifampicin

CD

Olanzapine

fD.

Montelukast

CD C!D

Important for me

l ess 'mpcrtont

Dr

Trimet hoprim may cause pantcytopaenia

As

se

m

Clomifene

A 32-year-old man p resents to the emergency department with abdomina l pa in, numbness and ting ling in bilate ral lower limbs and feeling generally tearful. There is a history of recurrent abdomina l pa in and neu ro logical symptoms in the past, however a diagnosis was never foun d. He is otherwise fit and well. On exam ination, there is reduced sensation up to the knees in a stocking distribution in the lower limbs. The re is no other neu ro logy of note. There is no rash found . You suspect a type of porphyria . What is the most likely find ing to support the diagnosis o f this type of porphyria?

Ra ised urine lead level Ra ised urinary porphob ilinogen

Ra ised urinary protoporp hyrin

Dr

Ra ised urinary uroporphyrinogen decarboxylase

As se m

Ra ised urinary uroporphyrinogen

Ra ised urine lead level Raised urinary porphobilinogen Raised urinary uroporphyrinogen

-

Raised urinary uroporphyrinogen decarboxylase

"""'

Raised urinary protoporphyrin

"""'

In acute intermittent porphyria, urinary porphobilinogen is typica lly raised Important for me

Less imocrtont

The presentation of abdominal pain, neurological and psychiatric symptoms raises the suspicion o f acute intermittent porphyria. In acute interm ittent porphyria (AlP), urinary porphobilinogen is typical ly ra ised. Lead level is not usually raised in porphyria.

Uroporphyrinogen decarboxylase is not usually measured.

As se m

Uroporphyrinogen is usually raised in porphyria cutanea ta rda. The lack of skin lesions makes acute intermittent porphyria more likely.

likely.

Dr

Urinary protoporphyrin may be slightly raised in AlP but raised porphobilinogen is more

A patient is invest igated for leukocytosis. Cyt ogenet ic analysis shows t he presence of t he following t ranslocat ion: t(9;22)(q34;qll). Which haematolog ica l malignancy is most st rong ly associated with this t ranslocation?

Chronic myeloid leukaemia Acute promyelocytic leukaemia Acute lymphoblastic leukaemia

Dr

Mant le cell lymphoma

As

se

m

Burkitt's lymphoma

Chronic myeloid leukaemia Acut e promyelocytic leukaemia Acute lymphoblastic leukaemia Burkitt's lymphoma Mantle cell lymphoma

CML - Philadelphia chromosome - t(9:22) Important for me

Less impcrtont

As se m

The Philadelphia tra nslocation is seen in around 95% of patient s with chronic myeloid translocation.

Dr

leukaemia. Arou nd 25% of adult acute lymphoblastic leukaemia cases also have this

A 25-year-o ld woman wit h primary anti phospholipid syndrome is reviewed. She has j ust had a booking ultrasound at 11 weeks gest ation which confirms a viable pregnancy. This is her first pregnancy and she is otherwise fit and wel l. Which one of the following is the recommend treatment?

Aspirin + prednisolone Low-molecular weight heparin Prednisolone + low-molecular weight heparin Aspirin + low-molecular weight heparin

Dr

Submit answer

As se m

Aspirin

Aspirin + prednisolone ~ ~

Low-molecular weight heparin

I

Prednisolone + low-molecular weight heparin Aspirin + low-molecular weight hT arin Aspirin

Anti phospholipid synd rome in pregnancy: aspiri n + LMWH Impo rtant fo r me

l ess important

The ultrasound at 11 weeks gestation wou ld show a fetal heart if the pregnancy was viable. This patient should therefore be taking both aspirin and low-molecu lar weight heparin.

[ .. I

a'

tt Discuss (2)

Improve ]

Antiphospholipid syndrome: pregnancy Antiphospholipid syndrome is an acquired d isorder characterised by a predisposition to both venous and arterial th romboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE) In pregnancy the following complications may occur: • recurren t miscarriage

• IUGR • pre-eclampsia • placental abruption • pre-term delivery • venous thromboembolism

Management • low-dose aspirin should be commenced once the pregnancy is confirmed on urine testing

As s

• these interventions increase the live birth rate seven-fold

Dr

discontinued at 34 weeks gestation

em

• low molecular weight heparin once a fetal heart is seen on ultrasound. This is usua lly

A 58-year-old man presents w ith polyuria and polydipsia. His body mass index is 32 kg/m 2 A random blood glucose is 11.5 mmol/1confi rming the diagnosis of diabetes mellitus. You decide t o st art him on metformin. What is the mechanism of action of metformin?

Closure ATP-sensitive K-channels PPARy (gamma) agonist

Activation o f the AM P-activated protein kinase (AMPK)

Dr

SGLT2 Inhibit ors

As se m

Dipeptidyl peptidase -4 (DPP-4)

-

Closure ATP-sensit ive K-channels

~

PPARy (gamma) agonist Dipeptidyl peptidase-4 (DPP-4) SGLT2 Inhibitors Activation of the AM P-activated protein kinase (AMPK)

Metformin acts by activation o f the AM P-activated protein kinase (AM PK) Important for me

Less 'mpcrtont

Metf ormin acts by activation of the AMP-activated protein kinase (AM PK). AMPK is a major cellular regulator o f lipid and glucose metabolism. Pharmacological activation of AMPK p romotes glucose uptake, fatty acid oxidation, an d insulin sensitivity. It also inhibits gluconeogenesis. Sulphonylureas (e.g. gliclazide) act by closing ATP-sensit ive K-channels in pancreatic beta cells. This causes increased insulin secretion. Thiazolidinediones (e.g. pioglitazone) are PPARy (gamma) agonists which cause increased insulin sensit ivity. Sitaglipt in is a dipeptidyl peptidase -4 (DPP-4) inhibitor. This enzyme breaks down the incretins GLP-1 and GJP. By preventing GLP-1 and GJP inactivat ion, increased insulin is

Dr

kidneys, resu lt ing in decreased reabsorption o f glucose.

As s

Glif lozin drugs (e.g. dapagliflozin) are a class of medications that inhibit SGLT2 in the

em

secret ed by t he pancreas.

You are an F2 workin g in general practi ce. You are seeing a 64-yea r-old fema le who has type ll diabetes. Her HbAlc rema ins high despite a trial of diet and lifestyle changes. You plan to sta rt her on the most commonly prescribed first-line medication for type II diabetes. Wh ich side effect should you warn her is the most likely?

Headache Diarrhoea Hypoglycaem ia

As se Dr

Urinary tract infections

m

Constipation

Headache

CD

Diarrhoea

(D

Hypoglycaemia

m

Constipation

CD

Urinary tract infections

•

Gastro intestinal side-effects such as dia rrhoea and b loating are a com mon sid e effect with metfo rmin Important for me

Less · m ::~c rtant

The correct a nswer is nu mber 2. NICE that standard re lease metfo rmin should be the initial drug of choice for patients with type II d iabetes. Gastro intestinal side effects such as diarrhoea, flatulence and b loating are a very commo n side effect of metformin. It shou ld be started at a low dose a nd g radually increased to reduce the risk. Gl side effects a re usually less with modified release metformin tha n sta ndard re lease.

Dr

As se m

A headache can be a side effect of metformin but is less common than Gl side effects. Hypoglycaem ia can occur with use o f other diabetic medica tions, including su lphonylureas and insulin, but does not occur with metformin. Urinary tract in fections and thrush are more common with SGLT2 inhibitors which increase the excretion of glucose in urine . Swelling of the feet and ankles can occu r with th iazolidinediones.

A 30-year-old female has been admitted to the medical take with an acute infection. She had a case of anaphylaxis w hich was thought to be due to amoxicillin at age 20. She has since been seen by the allergy specialist and is now known to have an IgE mediated penicillin allergy. Wh ich of the following antibiotics would you be most wary of using in this patient?

Gentamicin Ciprofloxacin

Metronidazole

Dr

Cefa lexin

As se m

Trimethoprim

A small proportion (0.5 - 6.5%) of patients with an lg E medicated penicillin allergy will also be allergic to cep halosporins Important for me

Less imocrtont

This patient is known t o have a severe penici llin allergy. None of the above antibiotics are penicillin based. However, the BNF stat es that 0.5- 6.5% of patients who are proven to have an lgE mediat ed penicillin allergy will also be allergic t o cepha losporins, including cefa lexin. You wou ld, therefore, be most wary of giving cehriaxone t o this patient. Penicillins, cephalosporins, and carbapenems are all members of the bet a-lactam group of antibiotics and share a common beta- lact am ring. There is, therefore, a small risk of allergy cross-over between all these antibiotics. The rat es of allergy cross-over are lower with second and third generation cephalosporins than first generati on cephalosporins such as cefa lexin. Reported penicillin allergy is very common, with up to 10% of patients claiming t o be allergic t o penicillin. However, less than 10% of these people have a true lgE mediated allergy to penici llin. It is important to question the patient carefully to ascertain what sympto ms they had on exposure t o penicillin. Symptoms such as an urticarial rash or

BNF:

Dr

https://bnf.nice.org.uk/drug-class/penicillins-2.htm l#allergyAndCrossSensitivity

As s

em

it ch ing make it more likely that they have an lgE mediated allergy.

A 43-yea r-old woman is a bout to start trea tment with trastuzu mab fo r metastati c brea st ca ncer. What is the most important investigation to perform prior to initiating treatment?

Pu lmonary function tests Echo Liver function tests

Dr

Glucose tolerance test

As

se

m

Chest x-ray

I

Pu lmonary function tests

«D

Echo

CD

Liver function tests

GD

~estx-rr

«D CD

Important for me

Less impcrtant

Dr

Trastuzuma b (Hercepti n) - ca rdiac toxicity is common

As

se

m

Glucose tolerance test

A 35-yea r-o ld man presents to the emergency d epartment aher a night out, having taken an unknown substance. He is known to have a history of depression. On exam ination his Glasgow coma scale (GCS) is 13/15, pup ils are d ilated and d ive rgent. He is tachyca rdic with a heart rate of 110/min, his b lood p ressu re is 124/70mmHg. His ECG shows sinus rhythm, with a lengthened QTc du ration of 480msec. He is dry to the touch. Which substance is he most li kely to have in gested?

Cocaine Sertraline

MDMA

Dr

Amitriptyline

As se m

Diazepa m

I

Cocaine

J

fD

Sertra line

GD

Diazepa m

m

Amitriptyline

GD

MDMA

. GD

The correct answer here is Amitriptyline - a tricyclic a nti de pressant (TCA) ove rdose. Whilst the main effect of TCAs is to increase seroto nin an d noradre na line in th e brain by slowing re-u pta ke, they a lso blo ck hista mine, choli ne rgic and alpha 1 recepto rs . Therefo re in overdose the a nti-choline rgic effects give dilated pupils, dry skin, confusio n, urinary retention and tachycardia. Dive rge nt p upils are a com mon find ing in tricyclic ove rd ose. TCAs a re a lso cardioto xic by ina ctivating sodium chan nels in the hea rt lea di ng to, a s seen here, a potential p rolongatio n of the QTc interval and a widened QRS complex. This can potentia lly lead to ventricular arrhythmias. Other effects o f TCAs not included here in clude seizu res a nd a meta bolic acid osis. In overdose sertrali ne may present with serotonin syndrome. The Glasgow coma scale may be re duced and pu pils dilated, b ut skin would not be dry. A classic fea ture of seroto nin syndrome is hyperreflexia, often with muscle rig idity a nd tremor, which is not d escribed he re. Ad ditionally QTc prolong ation is un likely with selective seroto nin reuptake inh ibitors (citalop ram is an exception). Cocaine produces sym pathetic effects - ag itation, restlessness, increased hea rt rate and blood pressu re . In seve re toxicity hyperthermia a nd rhabd omyo lys is may o ccur. It would not cause a reduced GCS o r a lte red QRS duration on ECG. MDMA (ecstasy) excess presents similarly to cocaine, with increa sed psychomotor a g itation, palpitations a nd hyperthe rmia . Add itiona lly teeth grinding (bruxism) is noted frequently.

Dr

As s

em

Diazepa m ingestion cou ld cause a re d uced GCS d ue to its sed ative effect s. However it wou ld not g enerally affect pupil size, hea rt rate or ECG. It is associated with respiratory d e pression.

Which one o f the followi ng is least associated wit h cocaine t oxicity?

Metabolic alkalosis Hyperthermia Psychosis

Dr

Seizures

As

se

m

Rhabdomyolysis

Metabolic alka losis Hyperthermia

-

~chosis

Dr

Seizures

As

se

m

Rhabdomyolysis

Which of t he follow ing conditions may not be treated by d opamine receptor agonist s?

Parki nson's disease Prola ctinoma Nausea

Dr

Acromegaly

As

se

m

Cyclical breast disease

Parkinson's disease Prolactinoma

-

Nausea

~

Dr

Acromegaly

As

se

m

Cyclical breast a isease

The INR of a patient who has recently started treatment fo r tubercu losis drops from 2.6 t o 1.3. Which one of the followi ng medications is most likely t o be responsible?

Rifampici n Streptomycin Ethambut ol

Dr

Pyrazinamide

As

se

m

Isoniazid

CD

Rifa mpicin Streptomycin

CD

Ethambutol

fD flD

Isoniazid

fD

Pyrazinamide

Rifa mpicin is a P450 enzyme induct or Less ' m ::~c rtant

wa rfarin, t herefore decreasing the INR.

Dr

Rifampicin is a P450 enzyme inducer and w ill t herefore increase the metabolism of

As se m

Important for me

A 31-year-old man is diagnosed with pulmonary tuberculosis. He is commenced on rifa mpicin, isoniazid, pyrazinamide and ethambutol. Two months after commencing treatment routine liver fu nction tests show the following: Bilirubin

29 IJmol/1

ALP

179 u/1

ALT

163 u/1

yGT

219 u/l

Albumin

39 g/1

Which one of the following factors is most likely to increase his risk of isoniazid toxicity?

Concurrent use of lanzoprazole Male gender

Chronic kidney disease stage 3

Dr

Amount of aldehyde dehydrogenase

As se m

Acetylator status

I

tiD

Concu rrent use o f la nzoprazole

•

Ma le gender Acetylator status

GD

Amount of aldehyde d ehydrogenase

tiD

Chronic kidney disease sta ge 3

GD

It was previo usly thou ght that 'fast acetylators' were mo re at risk of isoniazid than othe r patients. Recent research now suggests howeve r that slow acetylators a re actually more li kely to su ffe r hepatotoxicity.

he patotoxicity.

Dr

His concu rre nt use of rifampicin and pyrazinam ide is a lso a risk facto r ison iazid

As se m

Men, unusua lly, are actua lly less likely to d eve lo p isoniazid hepatotoxicity.

Which one of the following drugs is most likely to cause impaired glucose tolerance?

Sulfasalazine Azathioprine Leflunomide

Dr

Tacroli mus

As

se

m

Methotrexate

Which one o f t he followin g drugs is most likely to cause impaired glucose t olerance?

Azathioprine

CD

Lef lunomide

CD

Methotrexate

GD

Tacrolimus

ED As se

m

G'D

Tacrolimus is a cause of impaired glucose tolerance Important for me

Less impcrtant

Dr

I

Sulfasa lazine

Which one of t he following drugs may be cleared by haemodialysis?

Beta-blockers Tricyclics Aspirin

Dr

Digoxin

As

se

m

Benzodiazepines

. CD

Beta-blockers

. GD

Tricyclics

~irin

crD GD (f.D

Dr

Digoxin

As

se

m

Benzodiazepines

Which of the following drugs is most likely t o cause impaired g lucose to lerance?

Bromocriptine Interferon-alpha Strontium

Dr

M o ntelukast

As

se

m

Imipramine

Bromocriptine

ED

Interferon-a lpha

CD . (D

Strontium

j

GD

Montelukast

GD As

Important for me

Less imocrtant

Dr

Glycaemic control in diabet es may be worsened by interferon-a lpha

se

m

Imipramine

A 23-yea r-old man is taken to the Emergency Department by his friends after a night out. He was found acting erratically outside a nightclu b as they were wa itin g for a taxi. His friend reports that they snorted a white powder two hou rs earl ier. This is described as 'MCAT', a 'legal hig h' they obtained from the internet. When managing this patient, which drug group is it most s imilar to?

Ketamine Amphetamine

LSD

Dr

Benzodiazepine

As se m

Opio id

(D

Amphetamine

€D

Opioid

CD CD se

As

LSD

m

Benzodiazepine

Dr

I

Ketam ine

CD

A 69-year-old male patient presents to the GP surgery with a 6-month history of persistent dry cough and shortness o f breath on exertion. His past medical history include Parkinson 's disease, epilepsy, hypertension, type 2 diabetes mellitus. His current medicatio ns include amlod ipine, sodium valproate, bromocriptine, bisoprolol and metformin. Which is most likely cause of his presenting symptoms?

Sodium valproat e Bromocriptine

Metf ormin

Dr

Bisoprolol

As se m

Am lodipine

Sodium valproate

f!D

Bromocriptine

CD

AmlodipiL

CD

Bisoprolol

f.D

Metformin

CD

Ergot-derived dopamine receptor agonists may cause pulmonary fibrosis Important for me

Less · m ::~c rtant

This patient has symptoms of pulmonary fibrosis. Ergot-derived dopamine receptor

As se m

agonists such as bromocriptine may cause pulmonary fi bros is.

Dr

Sodium valproate, amlodipine, bisoprolol and metformin do not usually cause pulmonary fibrosis.

A 58-yea r-old female presents with flush ing, dia rrhoea and hypotension. A s mall bowe l MRI demonstrates a mass in the ileu m. A diagnosis of carcino id syndrome is mad e. You r consu ltant initiates treatment with octreotide. What is the mechanism of action of octreotid e?

Somatostatin antagonist Glucagon -l ike peptide-1 receptor ag on ists

Anti-serotonergic

Dr

Glucagon -l ike peptide-1 receptor antagonist

As se m

Somatostatin an alogue

-

Somatostatin antagonist

~

Glucagon -l ike peptid e -1 recepto r agonists Somatostatin analogue Glucagon -l ike peptid e -1 recepto r antagonist Anti-serotonergic

Octreotide is a so matostatin ana logue Important for me

Less imoc rtc.nt

Octreotide is a somatostatin ana logue. It is a potent inhibitor of gastrointestinal secretions hence why its a first li ne treatment for ca rcinoid syndrome. It is also a potent inhibitor o f g rowth hormone, glucagon, a nd insulin.

As se m

Cyproheptad in e is an anti- histam ine drug which has anti-serotone rgic p roperties. It can also be used in ca rcinoid syndrome.

insu li n secretagogues.

Dr

Glucagon- like peptide-1 recepto r agon ists a re used to treat diabetes mell itus. They are

A 24-yea r-old lady presents with abdomi nal pa in. She states that she is at 24 weeks g esta tion of p regnancy. She has no other past medica l histo ry. On examination she has rhythm ic contractions o f he r a bdomen which are occu rri ng four times per min ute . A speculum exam ination shows a dilated cervix. Which drug could have precipitated this p resentation?

Nimodipine Coca ine

Indo metha cin

Dr

Mag nesium sulphate

As se m

Terb utaline

CD

Nimodipine

I

Coca in e

CD

Terbutaline

CD. . (D

r :agnesium sulphate

fD

Indomethacin

Coca ine can induce p reterm labour Important for me

Less impcrtant

Cocaine is a sympathomimeti c drug. Its use during pregnancy can result in pre-term labour ( < 37 weeks gestation), congenital anomalies, and intrauteri ne growth ret ardation (IUGR). Cocaine can initiate uterine contractions, and is therefore t he most likely agent to

As se m

predispose to pre -te rm labour.

down and reduce the amplitude of contractions.

Dr

All t he other options are tocolytics wh ich may be used during p re-term labour to slow

Which one of the following statements regarding metformin is true?

Should be stopped in a patient adm itted with a myoca rdial infarction Hypoglycaem ia is a recogn ised adve rse effect May cause a metabolic alka losis

Dr

Increases vitam in B12 absorption

As

se

m

May agg ravate necrobiosis lipo idica d iabeticorum

Should be stopped in a patient admitted with a myocardial infarctio n Hypoglycaemia is a recogn ised adve rse effect May cause a metabolic alkalos is May agg ravate necrob ios is lipoidica d ia beticorum Increases vitamin 812 absorption

Dr

the use o f a insu lin/dextrose in fusion (e.g. the DIGAMI reg ime)

As

se

m

Metformin shou ld be stopped following a myoca rd ia l infarction d ue to th e risk of la ctic acidosis . It may be intro duced at a late r date . Dia betic contro l may be achieved through

A 27 -yea r-old man had p resented to accident and emergency 4 days ago fo llowing an intentional pa raceta mol overdose. He ha d taken fifteen SOO mg ta blets, a ll at once. He d en ies any alcoho l inta ke. Bloods 4 hou rs after ingestion showed

Paracetamol

14 mg/ 1

INR

1

Liver enzymes

No abnormality detected

Bilirubin

Mild elevation

He was seen by the menta l health team a nd discharged. You g ave him the advice to attend his GP to have his bloods repeated to see if the hyperb ilirubinaemia had settled. Tod ay he has presented to the hosp ital fro m his GP with 'abnorma l blood results.' Bilirubin

No abnormality detected

Urea

21 mmol/ 1

Creatinine

300 ~mol/1

What is the likely cause of these results?

Pre-re na l AKI secon da ry to dehydration Spurious blood result Delayed paraceta mol nephrotoxicity

Dr

Berger's disease

As s

em

Minimal cha nge ne phropathy

I I

GD

Pre -rena l AKI secon dary to dehydration

•

Spurio us blood result

GD

Delayed paraceta mol nephrotoxicity Minimal cha nge nephropathy

m.

Berger's d isease

•

This gentlema n's blood results d emonstrate an acute kid ney inj ury. The re is nothing in the history to sugg est that the patie nt is d ehyd rated and this would b e very unusual in an o therwise we ll 27-yea r-old man. Minima l cha ng e nephro pathy typica lly presents with a nep hrotic pictu re of kidney inju ry, whilst Be rge r's more co mmonly presents with isolated hae matu ria. Whilst paracetamol ove rdose is well known to cause hepatotoxicity, d elayed nep hrotoxicity is an important e ntity to be aware of, especia lly in significant overd ose. Ap propriate mo nitoring of a patie nt's b lood tests is important, as p er the gu id ance o f

Dr

The following refere nce provides mo re d eta ils and a ca se study https://www.ncbi.nlm.nih.gov/pu bmed/18338302

As se m

TOXBASE.

A 56-year-old man with a history of epilepsy, atrial fibrillation and ischaemic heart disease is noted to have a rash on his fo rearms and face in the ca rdiology clin ic. Which one of the following drugs is most likely to be responsible?

Verapamil Carbamazepine Am iodarone

Dr

Clopidogrel

As

se

m

Digoxin

CD

Verapa mil

fD

Amiodarone

GD

m

Clopidogrel

CD

As

se

m

Digoxin

Dr

I

Carbamazepine

A 55-yea r-old d iabetic man p resents to clin ic concerned about erectile dysfunction. What is the mechanism of action of s ildenafil?

Phospho diesterase type V inhibitor Nitric oxide syntheta se in hibitor Nitric oxide donor

Dr

Phospho diesterase type IV inhibitor

As

se

m

Non -selective p hospho diesterase inhibitor

Phosphodiesterase type V inhibitor Nitric oxide synthetase inhibito r I'!Jitric oxide donor Non -selective phosphodiesterase inhibitor Phosphodiesterase type IV inhibitor

Sildenafil is a phosphodiesterase type V inhibitor

As se

l ess :mocrtont

Dr

Important for me

m

Sildenafil - phosphodiest erase type V inhibito r

A 43-year-old man from South Africa is reviewed in cl inic. He has recently started treatment for tuberculos is but is com plaining of a deterioration in his vision. Which one of the following drugs is most likely to cause decreased visual acuity?

Rifa mpicin Streptomycin Isoniazid

Dr

Pyrazinamide

As

se

m

Ethambut ol

A 43-yea r-old man from South Africa is reviewed in cl inic. He has recently started treatment for tuberculos is but is complaining o f a d ete rioration in his vision. Which one o f the following drugs is most likely to cause d ecreased visua l a cuity?

m

Rifampicin R

I

CD

reptomycin

CD

Ison iazid

fD

Et ham butol

CD

Pyrazinam ide

Optic neu ritis is common in patients taking etha mbuto l l ess 'moc rtc.nt

As se m

Important for me

Dr

Isoniazid may also cause optic neuritis but it is not as co mmon a cause as e thambutol.

A 21-yea r-old stu dent is b rou ght to the Emergency Department by his friends d ue to him being confused. They repo rt he has been com plaining of headaches fo r the past few weeks. He has a low-grade pyrexia and on exam ination is noted to have abnormally pink mucosa. What is the most likely diagnos is?

Carbon monoxid e poisoni ng Men ingitis Pa racetamol overd ose

As se Dr

Methaemoglob in ae mia

m

Subarachno id haemo rrhage

I

Carbon monoxide po isoning Mening itis

P

racetamol ove rd ose Subarachno id hae mo rrhag e

se

m

Methaemoglobin aemia

Dr

g ra de pyrexia is seen in a minority o f cases.

As

Confusion and pink muco sae are typical featu res of carbon mon oxide poisoning. A low-

In the Vaughan Wil liams classification of antiarrhythmics disopyram ide is an example of a:

Class Ia agent Class Ib agent Class Ic agent

Dr

Class IV agent

As

se

m

Class II agent

I

CD

Class Ib agent

fD

~ass Ic agent

. fiD

Class II a gent

(D

Dr

Class IV ag ent

As

se

m

Class !a agent

CD

A 45 -year-old man is started on ciclosporin following a renal transplant. Which one of the following adverse effects is most likely t o occur?

Depression Increased risk of ischaemic heart disease Pulmonary fibrosis

Dr

Nephrotoxicity

As

se

m

Optic neuritis

Depression Increased risk of ischaem ic heart disease Pulmonary f ibrosis

-

Optic neuritis

"""'

Important for me

Less 'mpcrtant

Dr

Ciclosporin may cause nephrotoxicity

As

se

m

Nephrotoxicity

A 27 -yea r-o ld wo man with a histo ry o f depre ss io n p resents to th e Emerg ency Department. She re ports taking 50 para cetamo l tablets yesterday. Bloods a re taken on a d mission. Which one o f the following wou ld most strong ly indi cate the need fo r a live r transplant?

Blood g lucose 2.2 mmol/1 Al T 2364 iu/ 1 I NR 4.1

As se Dr

Arte rial pH 7.27

m

Creatinine 230 !Jmol/1

Blood glu cose 2.2 mmol/1

-

ALT 2364 iu/1

"""

INR 4.1

~

Cre tinine 230 !Jmol/1

As

Hosp ital criteria fo r liver t ransp lantation.

Dr

The arterial pH is t he single most important factor according to the King's College

se

m

Arterial pH 7.27

Which one o f the followin g is not an i ndicat ion for haemodialysis in salicylate overdose?

Acute renal failure Seizures Serum concentration = 400 mg/1

Dr

Metabolic acidos is resist ant to treatment

As

se

m

Pulmonary oede ma

I

Acute renal failure

tiD

Seizures

GD

Serum concentration = 400 mg/1

6D

Pu lmonary oedema

CD fD Dr

A serum concentrat ion of greater t han 700mg/ l is an indicat ion for haemodialysis

As

se

m

Met abolic acidosis resist ant to t reatment

Which of the following drugs is least likely to be affected by a patients acetylator status?

Hydralazine Isoniazid Rifa mpicin

Dr

Sulphonamides

As

se

m

Procainamide

Hydralazine

CD

Isoniazid

CfD

.,

Procainamide

f!D Dr

Sulphonamides

As

se

m

Rifa mpicin

f!D

A 65-yea r-old ma n with a history o f isch aemic heart disease is admitted with ch est pain. The 12-hour troponin T is neg ative. During admissi on his medications were altered to reduce the risk of card iovascular disease and to treat previo us ly u nd iagno sed type 2 diabetes mellitus. Shortly after discha rge he p resents to his GP complaini ng of diarrho ea. Which one o f the followin g medicati ons is most likely to be responsible?

Glicla zide Clopido grel

Atorvastatin

Dr

Metformin

As se m

Rosiglitazone

Gliclazide

CD

Clopidog rel

ED

Rosiglitazone

m GD.

Metformin

ED

Atorvastatin

Gastrointestinal side-effects such as dia rrhoea and b loating are a common side effect with metformin Important for me

l ess : m ::~c rtont

contra indicated following recent e pisodes of tissue hypoxia.

Dr

If this patient had a raised troponin T then metformin may not be su itable as it is

As se m

Gastrointestinal p roblems a re a common side-effect of many medications but are frequently seen in patients taking metform in

A 75-year-old woman present s to the emergency department w ith a fall. She ca nnot reca ll the exact events of the fall but does report a 2-month history of recurrent nausea and headache. Her past medical history includes type 2 diabetes mellitus, hypertensio n and ischaemic heart disease. Physical examination is unremarkable except an unsteady gait although no ataxia evident. Her blood t ests are as follows: Hb

124 g/ dl

Na•

125 mmoi/ L

K•

4.8 mmoi/L

Creatinine

59 IJmoi/L

Urea

5. 2 mmoi/L

Serum osmolality

265 mOsm/kg (reference range 275-295 mOsm/kg)

Which medication may be the cause for this clinica l picture?

Metf ormin Aspirin

Am lodipine

Dr

Bisoprolol

As se m

Chlorpropamide

CfD

Metformin

m

Aspirin

GD

Chlorpropamide

CD

Bisoprolol

CD

Amlodipine

Sulphonylureas may cause syndrom e of inappropriate ADH Important for me

l ess · m ::~c rtont

Hyponatraemia in the cont ext o f euvolaemia and low serum osmolality suggests syndrome of inap propriat e ADH (SIADH). Sulphonylu reas (particularly long-acting ones such as chlorpropamide) are well -established causes of the syndrome of inappropriate ADHl

As se m

Metformin, as pirin, b isoprolol and am lodipine d o not usually cause SIADH.

1. Sola D, Rossi L, Schianca GPC, et al. Sulfonylureas and their use in clinical practice.

Dr

Archives of Medica l Science: AMS. 2015;11(4):840-848. d oi:10.5114/ aoms.2015.53304.

Which one o f the following side-effects is least recognised in patient s taking ciclos porin?

Hypokalaemia Hyperplasia o f the gum Hypertension

Dr

Excessive hair growth

As

se

m

Tremor

I

f.D

Hypokalaemia

Hypertension

m m

Trem or

fD

Excessive hair growth

CD

Hyperplasia o f t he gum

I

Ciclosporin side-effects: everything is increased - fluid, BP, K+, hair, gums, glucose

m

As se

Hyperkalaemia rather t han hypokalaemia is seen wit h ciclospo rin use

Less impcrtont

Dr

Important for me

A 57 -year-old man with a history of ischaemic heart disease is keen t o try sildenafil for erectile dysfunction. Which one o f the followi ng medications may contraindicat e its use?

Nebivolol Losartan Nicorandil

se As Dr

Ram ipril

m

Nifedipine

Nebivolol

m.

Losartan

•

Nicorandil

CD

Nif edipine

GD CD

Ram ipril

PDE 5 inhibitors (e.g. sildenafil) - contraindicated by nitrates and nicorandil

m

l ess ' m ::~crtc.nt

Dr

Nicorandil has a nitrate component as well as being a potassium channe l activator

As se

Important for me

A 25-yea r-old fema le who works in a photograph d evelopment laboratory is taken to the Em ergency Department due to confusion. On admission she is hypoxic and hypotensive. Cyan ide poison ing is suspected following discussion with the loca l poisons unit. What is the definitive treatment?

f!D

Haemod ia lysis

~droxocobalamin Pen ici lla mine

CD

Ferrous su lphate

CD

Desferioxam ine

As se m

(iD

Dr

. (D

GD

Hydroxocobalamin

CD CD

Ferrous su lphate

CD

Desferioxamine

As

se

m

Penici llamine

. (D

Dr

I

Haemodialysis

A 44-year-old fema le with a hist ory of alcohol excess and cirrhosis presents t o the emergen cy department with pa lpitat ions. You receive a call fro m the laboratory who t elephone throug h her electrolyte results: Sodium

133 mmol/ 1

Potassium

3 .8 mmol/1

Calcium

2.02 mmol/ 1

Phosphate

0 .82 mmol/ 1

Magnesium

0 .22 mmol/ 1

Aside from her alco hol excess, w hich of her medications is most likely to contribute to her hypomagnasaemia?

Carvedilol Furosemid e

Spironolactone

Dr

Thiamine

As se m

Omeprazole

•

Carvedilol Furosemide

CD

Omeprazole

. GD

•

Thiamine

f!D

Spironolactone

Both loop and thiazide diuretics inhi bit the reso rptio n o f magnesium in the kidney. Potass ium-sparing diuretics such as spironolactone are not associated with hypomagnesaemia.

Thiamine and carvedilol have no effect on ma gnesium haemostas is.

Dr

associated with hypoma gnesaemia.

As se m

Prote in pump inhibitors such as o meprazole a re associated with low magnesium levels when taken in conjunction with loop or thiazi de d iuretics b ut are not independ ently

A patient is started on the monoclona l antibody trastuzumab. What is the most likely indication?

Crohn's d isease Chronic lymphocytic leukaem ia Renal cancer

Dr

Breast cancer

As

se

m

Colorecta l cancer

Crohn's disease

IChro~ic

-

........

lym phocytic leukaemia

Renal cancer Colorectal cancer

se

m

Brea st cancer

As

Trastuzuma b (Hercepti n) - monoclona l antibo dy that a cts o n the HER2/neu recepto r l ess imocrtc.nt

Dr

Important for me

An 85-year-old gentleman with a background of osteoporosis and chronic kidney disease was admitted following a fall at home. He was experiencing significant lower back pa in. A lumbar spine x-ray was showing s igns of a fractured lumbar vertebra . A subsequent MRI lumbar/sacral scan showed a new L3 bu rst fractu re with no evidence of cord co mp ression. A neurosu rgical opinion was obtained who advised conservative management in the fo rm of pain control, physiotherapy a nd mob ilisatio n as pa in allows. Given his background of chronic renal impa irment with a creatinine clearance of 21ml/min, he was started on a Buprenorphine patch. Which of the following opioids wou ld be safest to use for his b reakthrou gh pain?

Peth id ine Diamorphine

Ibuprofen

Dr

Oxycodone

As se m

Mo rp hine

I

Pethidine

GD

Diamorphine

flD.

Mo rp hine

«D

Oxycodo ne

C!D

•

Ibu profen

Oxycodone is a safe r opioid to use in patients with moderate to end -sta ge renal failure Important for me

l ess imocrtc.nt

Active metabol ites of morphine accumulate in rena l failure which means that long-te rm use is contra indicated in patients with moderate/severe rena l failure. These toxic

Dr

As se m

metabolites can accumulate causing toxicity and risk overdose. Oxycodone is mainly metabolised in the liver a nd thus safer to use in patients with moderate to end-stage renal failure with dose reductions.

A 67 -year-o ld woman is noted to have cornea l opacities durin g a routine opticia ns appointment. These a re not affecting her vision. Which one o f the following drugs is most li kely to be th e cause?

Am iodarone Sodium valproate Methotrexate

Dr

Digoxin

As

se

m

Frusemide

GD

Amiodarone

CD

Sodium valproate

CD

Methotrexate

fD

Digoxin

CD

Dr

Am iodarone therapy can result in both corneal opacities and optic neuritis

As

se

m

[ :use mide

Which one o f the following drugs is most likely to result in a photosensitive rash?

Gentamicin Erythromycin Penici llin

Dr

Amoxicillin

As

se

m

Tetracycline

Gentamicin

m

Eryth romycin

CD

GD

Tetracycline

GD Dr

Amoxicillin

As

se

m

Penici llin

CD

A 56-year-old man from Pakistan presents to his GP with numbness and tin gling in his feet for 1 week. He tells you he has recently started some new medications. Looki ng at his medical history you discover he has recently been diagnosed with tuberculosis and hypertension. Which of the follow ing medications are most likely to be causing the pro blem?

Rifa mpicin Am lodipine

Pyrazinamide

Dr

Isoniazid

As se m

Ramipril

I

Rifa mpicin

fD

Amlod ipi ne

CD

Ram ipril

CD

Isoniazid

GD

Pyrazinamide

CD

Most common side effects

Rifa mpicin

Orange bodily flu ids, rash, hepatotoxicity, drug interactions

Isoniazid

Peripheral neu ropathy, psychosis, hepatotoxicity

Pyrazinam ide

Arthralgia, gout, hepatotoxicity, nausea

Ethambutol

Optic neuritis, rash

Dr

Drug

As se m

Peripheral neu ropathy is a commonly recognised side effect of isoniazid. Although pa raesthesia is listed under the side effects for amlodipine in the BNF, it is uncommon. In this case isoniazid is the most likely answer.

A 73-yea r-old man is prescribed cetuximab after being diagnosed with metastatic colorectal cancer. What target is this monoclonal antibody d irected a ga inst?

Vascular endothelial growth facto r receptor Ang iopoietin-2 recepto rs CD20 protein complex

Dr

Fibroblast growth fa ctor receptor

As

se

m

Epiderma l growth factor receptor

Vascular endothelial growth facto r recepto r Ang iopoietin -2 recepto rs CD20 protein complex Ep idermal growth factor receptor

-

Fibro b last growth factor receptor

Less impcrtant

Dr

Important for me

As

Cetuximab - monoclonal antibody aga inst the epide rmal growth facto r recepto r

se

m

~

A 26-yea r-o ld woman with a histo ry o f schizo phre nia is reviewed in the Eme rgency Department. Her ca re r rep orts that s he has been 'sta ring' fo r the past few hou rs but has now deve lo ped a b normal head movements a nd has g one 'cross -eyed '. On exam ination the patients neck is exte nd ed and positioned to the rig ht. He r eyes a re deviate d upwards a nd a re slightly co nve rged. Given the li kely diag nosis, what is the most ap pro priate treatment?

Procyclid ine Do pamine

Diazepa m

Dr

Haloperido l

As se m

Selegiline

.,

Procyclidine DopaT ine

CD

Selegiline

fD

....___

CfD

Diazepa m

CfD Dr

Benztropine and diphenhydramine are alternative options.

As

se

m

Haloperidol

Which one of the following types of reaction takes place in phase n metabolism of a drug?

Conjugation Hydrolysis Reduction

se As Dr

Dealkylation

m

Deamination

Conjugation

GD

Hydrolysis

fiD

Reduction

f!D

CD

Dealkylation

m

Important for me

Less ' m ::~c rtant

Dr

Drug metabolism • phase 1: oxidation, reduction, hydrolysis • phase II: conjugation

As se m

Deamination

A 48-year-old female is adm itted with cellulitis of her right lower lim bs. A swab culture grows MRSA sensitive to vancomycin, teicoplanin and linezolid. You decide to treat her with teicoplanin. What is the mechanism of action of teicoplanin?

Inhibits bacterial protein synthesis Inhibits bacterial DNA synthesis

Inhibits bacterial RNA synthesis

Dr

Inhibits bacterial folic aci d formation

As se m

Inhibits bacterial cell wall formation

Teicoplan in is similar to vancomycin (e.g. a glycopeptide antibiotic), but has a significantly longer duration of action, allowing once daily administration after the loading dose Important for me

l ess 'mocrtont

Teicoplanin is similar to vancomycin (e.g. a glycopeptide antibiotic), but has a significantly longer duration of action, allowing once daily administration after the loading dose. It inhibits bacterial cell wa ll formation. Antibiotics that inhibits bacterial protein synthesis include macrolides, aminoglycosides, and tetracyclines. Antibiotics that inhibits bacterial DNA synthesis include the quinolones (e.g. ciprofloxacin).

trimoxazole.

Dr

Antibiotics that inhibits bacterial folic acid formation include trimethoprim and co-

As s

em

Antibiotics that inhibits bacterial RNA synthesis include rifampicin.

A 62-year-old woman with a history o f recurrent deep vein thrombosis secondary to antiphospholipid syndrome presents for review. She has taken wa rfa rin for the past 7 years, with a target I NR of 2.0 - 3.0. Her control is normally very good but her last read ing was 1.2. Which one of the fo llowing wou ld explain her current INR?

Starting fluoxetine for depression The fo rmatio n of lupus anticoagulant autoantibod ies Giving up smoking

Dr

A course of ciprofloxacin for a urinary tract in fection

As

se

m

Recent rifam picin as she was a contact of a patient w ith meningococcal meningitis

Starting fluoxetine for depression The fo rmatio n of lupus anticoagulant autoantibodies Giving up smoking Recent rifam picin as she was a cont act of a patient with meningococcal meningitis

Important for me

Less imocrtont

Dr

Rifa mpicin is a P450 enzyme induct or

As

se

m

A course of ciprofloxacin for a urinary tract in fection

Which one o f the fo llowing adre noceptors causes inhib ition of p re -synaptic neu ro trans mitter re lease in response to sympathetic stimulation?

Alpha -1 Alpha -2 Beta-1

Dr

Beta -3

As

se

m

Beta -2

fD

Alpha-2

CD

Beta-1

('fD

Beta-2

('fD

tiD

Dr

Beta-3

As

se

m

Alpha-1

Which of the following drugs is considered most likely to precipitate an att ack of acute intermittent porphyria?

Morphine Aspirin Atenolol

se As Dr

Oral contraceptive pill

m

Metfo rmin

. (D

Morphine Asp irin

6D

Atenolol

GD CD

eD

Dr

Oral contraceptive pill

As

se

m

Metformin

Which of the followi ng drugs is considered least likely to precipitate an attack of acute intermittent porphyria?

Diazepa m Penicillin Thio pentone

Dr

Alcohol

As

se

m

Sulphonamides

f.D

Diazepa m

tiD.

p .nici llin

fD

Sulphona mides

tiD As

CD

Dr

Alcohol

se

m

Th iopentone

A 54-year-old woman is admitted to the Medical Admiss ions Unit following a collapse. Bloods taken on admission show the following: Magnesium

0 .40 mmol/ 1

Which one o f the following factors is most likely to be responsible for this resu lt ?

Excessive resuscit ation with intravenous saline Frusemide therapy

Hypothermia

Dr

Rhabdomyolysis

As se m

Digoxin the rapy

I

Excessive resuscitation with intravenous saline Frusemide therapy Digoxin therapy

Dr

Hypothermia

As

se

m

Rhabdomyolysis

A 13-year-old boy has attended the acut e medica l unit with severe lethargy and j aundice. He has recently taken a medication that his mother feels may have been the cause. She noted her brother once had a similar reaction to a tattoo. You suspect he may have glucose -6-phosphat e dehydrogenase (G6PD) deficiency. Which o f the follow ing drugs wou ld most likely provoke a haemolytic crisis in G6PD deficiency?

Trimethoprim Ibupro fen

Sodium valproate

Dr

Chloroquine

As se m

Ciprofloxacin

CD

Ibupro fen Ciprofloxacin

ED

Chloroquine

CD

CD

Sodium valproate

Ciprofloxacin is contra indicated in G6PD deficiency Important for me

Less · m ::~c rtant

The answer is ciprofloxacin. G6PD deficiency is a (usually) X-l inked recessive condition that predisposes patients t o haemolytic crises following oxidative stress. This most com monly manifest s in the form of certain medications, but some foods (broa d beans) and even henna t attoos ca n prompt a crisis. Variation occurs in known triggers amongst subjects. However, some triggers have a higher likelihood than others - and as such are contraindicat ed absolutely. Quinolones (ciprofloxaci n, norfloxacin & moxifloxacin) have a very high theoretical risk o f haemolysis. Other drugs with a high risk include primaquine, sulfonam ides, methylene blue, dapsone & doxorubicin. Chloroquine has a small risk of haemolysis. Trimethoprim, ibuprofen and

http://www.cych.org .tw/pharm/ MI MS%20Summary%20Table-G6PD.pdf

Dr

This table pro vides a good summary:

As se m

sodium valproat e have no th eoretical risk.

A 46-year-old woman who has recently been diagnosed as having non- Hodgkin's lymphoma is about to start CHOP chemotherapy (cyclophosphamide, hydroxydaunorubicin, vincristine and prednisolone). Her blood s are as follows: Hb

11.8 gfdl

Platelets

423 * 109/1

WBC

11.2 ~ 109/1

Na•

143 mmol/ 1

K•

3.9 mmol/1

Urea

6 .2 mmol/1

Creatinine

78 IJffiOI/1

Uric acid

0.45 mmol/ 1

Ciprofloxacin is also prescribed to reduce the risk of neutropenic sepsis. Which other drug should be added to lower the risk of complications?

Tranexamic acid Allopurinol Ferrous sulphate

As s Dr

Furosemide

em

Aspirin

CD

Tranexamic acid

GD

Ferrous sulphate

fD

Aspi rin

fD

Furosemide

m se

Patients receiving CHOP for non-Hodgkin's lymphoma are at particular risk of tumour

m

I I

Allopurinol

Dr

As

lysis syndrome and associated gout secondary t o hyperuricaemia. Allopurinol is therefo re normally co-prescribed to redu ce this risk.

A 62-year-old male was admitted with a 9 day history o f a cough, productive of green sputum associated with shortness of breath. He describes no weig ht loss, but fever and sweats. He is orientated in time a nd place and states he develops anaphylaxis to pen icil li ns. On exam ination he had coarse inspiratory crackles in the right base, percuss ion was resonant and no added wheeze. Observatio ns: Respiratory rate 25 breaths per minute, satu ration 86% on room a ir, b lood p ressure 110/ 90mmHg, heart rate 94 beats per minute. Hb

12.2 g/dl

wee

19 .2 gfdl

Platelets

344 g/ dl

Na +

139 mmol/ 1

K+

4 .3 mmol/1

urea

9 .9 mmolfl

Creatinine

144 mmol/ 1

CRP

27 mg/1

Chest X- ray showed right lower zone radio -opacity with a ir bronchograms. He was started on an antibiotic as per British thoracic society (BTS) gu idelines. What is the mechanism o f action of that antibiotic?

Reversible inhib ition of 50s ribosome subunit Inhibits DNA gyrase Irreversible inhibition of 30s ribosome sub unit

Dr

Dihydropteroate reductase inhibitor

As s

em

Dihydrofo late reductase inhibitor

Reversible inhibition of 50s ribosome su unit Inhibits DNA gyrase Irreversible inhibition of 30s ribosome sub unit Dihydrofolate reductase inhibitor Dihydropteroate reductase inhibitor

This patient is likely suffering from a pneumonia with a CURB65 score of 1. As per BTS guidance the patient should be started on either Amoxicill in or Clarithromycin. The latter

As se m

should be considered in light of his allergies.

Dr

Clarithromycin is a macrolide antibiotic with good gram positive cover and that of atypica l organisms. It's mechanism of action is via reversible inhibition of 50s ribosome subunit.

A woman who is 24-weeks p regnant presents with a p rod uctive cough. On exam ination crackles can be hea rd in the left base and a decision is mad e to give an antibiotic. Which one of the following is least su itable to p rescribe?

Ciprofloxacin Erythromycin Co-amoxiclav

Dr

Cefaclor

As

se

m

Cefalexin

Ciprofloxacin

CD

Erythromycin

f!D.

Co -amoxiclav

CD

~falexin

CD CD

Cefaclor

The BNF advises avoiding quinolones in pregn ancy due to arthropathy in animal studies. There have been some reports of an increased risk of necrotizing enterocolitis following

As se m

the use of co -amoxiclav in pregnancy. The evidence is however inconclusive and the BNF and the UK t eratology information service.

Dr

states that co-amoxiclav is 'not known to be harmful'. A link is provided both to the BNF

A 34 yea r-old man presents to the Eme rgency Department a fte r being rescued fro m a house fire. On examination he is s ho rt of breath, drowsy and confused, and com pla ins of feeling dizzy with a wo rsen ing headache. He has no evidence of facia l bu rns and no strid o r. His o bservations show: b lood pressure 110/ 82 mm Hg, heart rate 102b pm, o xygen saturations o f 100% on air with a res pirato ry rate o f 35/ min. He appears markedly flushed but is afebrile. His ve nous blood gas results a re shown below. pH

7.28

pC02

3.5 k Pa

p02

15.9 kPa

Na +

139 mmoi/ L

K+

4 .5 mmoi/L

Bicarbonat e

11 mmoi/L

Chloride

113 mmoi/ L

Lactat e

13.6 mmoi/L

In view of the likely diag nosis, what is the most app ropriate inte rve ntion?

Intubate and ve ntilate Intrave nous hydroxo cobalamin 15 litres o f high-flow oxygen via face mask

Dr

Intrave nous so diu m nitro p russide

As s

em

Intrave nous dexa methasone

Intubate and ve ntilate Intravenous hydroxocobala1 in

15 litres o f high-flow oxygen via face mask Intrave nous dexa methasone Intravenous sod iu m nitrop russide

This ma n ha s deve lop ed a cute cya nid e toxicity second ary to b urning plastics in th e house fire. Cya nide ions inhibit mitochondrial cytochrome oxidase, preve nting aero bic respiration. This ma nifests in norma l o xygen saturati ons, a high p02 a nd flus hing (o r 'brick re d' skin) brou ght o n by the excess oxyge nation of ve nous b lood . In the q uestion above it is impo rta nt to note that the blood g as sa mple g iven is ve nous rath er than arteria l. His blood g as a lso demonstrates a increased anio n g a p, co ns istent with his high la ctate (generated by a naerobic resp iration due to the inab ility to use ava ila ble oxygen). The recommend ed treatment fo r mod erate cya nid e toxi city in the UK is one of three o ptio ns: sod ium thiosulfate, hydroxocobalam in or d icobalt edetate. Although a ny one o f these may be used, the on ly optio n given is that of hydroxocoba lam in and this is therefore the co rrect answe r. Hydroxocoba la min a dd itio na lly has the b est s ide -effect p rofile and s peed of onset co mpa red with other treatme nts fo r cyanide poisoning .

tt Discuss (7)

Improve

J

Dr

I •• I ••

As s

em

Intu bation wou ld be a ppro priate treatme nt in the co ntext of a irway burns but this patie nt has no evidence o f these, a lthough close monito ring wou ld be advised . High-flow oxygen is the treatment fo r carb o n monoxid e po iso ning - a sensib le d ifferential. but this man's ve ry hig h lactate and hig h ve nous p02 fit b etter with cya nid e toxi city. Intrave nous d exameth asone wou ld be another treatment fo r a irway oed e ma once a e ndotracheal tube had been p la ced . Intrave nous sodium nitro prussid e is a treatment fo r hig h blood p ressure that can cause cyan id e po ison ing, and would the refo re be inap prop riate.

Each of the fo llowing are true regarding tricycl ic overdose, except

Anticho linergic features are prominent early on Metabolic acidosis is a common complication ECG changes include prolongation of the QT interval

Dr

QRS duration > 160ms is associated w ith ventricu lar arrhythmias

As

se

m

Dialys is is indicated in severe t oxicity

Each o f the fo llowing are true regarding tricycl ic overdose, except:

-

Anticho linergic features are prominent early on

~

Metabolic acidosis is a common complication ECG changes include prolongation of the QT interval

I

As Dr

QRS duration > 160ms is associated with ventricular arrhythmias

se

m

Dialysis is indicated in severe toxicity

What is the mechanism of action of ciclosporin?

Monoclonal antibody against IL-2 recepto r Interferes with purine synthesis IL-1 receptor decoy

Dr

Mercaptopurine antagonist

As

se

m

Decreases IL-2 release by inhibiting calcineurin

Monoclonal antibody against IL-2 receptor Interferes with purine synthesis IL-1 receptor decoy Decreases IL-2 release by inhibiting calcineu rin

Important for me

As

Ciclospori n + tacrolimus: inhibit calcineurin thus decreasing IL-2

se

m

Mercaptopurine antag onist

Less :mpcrtant

Dr

I

A 24-yea r-old woman is admitted to hospita l after presenting with a paracetamol ove rdose. She reported taking 30 pa raceta mol tab lets around 10 hou rs ago. Treatment with acetylcysteine was commenced stra ig ht away following adm ission. She has g rade II encephalopathy on exa mination. Around 24 hou rs after adm ission her bloods are repeated. Which one of the following findin gs is associated with the worst p rognosis?

Arterial pH of 7.37 Bilirubin of 152 IJmo l/1

ALT of 2,687 u/ 1

Dr

Prothrom bin time of 35 seconds

As se m

Creatinine o f 323 1Jmol/l

-

Arterial pH of 7.37

""'

Bilirubin of 152 1Jmol/l Creatinine of 323 j.Jmol/1 Prothrom b in t ime of 35 seconds

se

m

ALT of 2,687 u/1

Dr

a liver transp lant.

As

A creatinine as high as 323 j.Jmol/1 is marker of poor p rognosis and one o f the criteria for

A 65-yea r-old man with a history of type 2 diab etes me llitus an d ischaem ic heart d isease p resents with e rectile dysfunction. It is decided to try si ld enafil therapy. Which one of the fo llowing existing medications may b e continued without making any a djustments?

GTN s pray Nico randil Nateglinide

Dr

Isosorbide mononitrate

As

se

m

Doxazos in

GTN spray Nicora dil Nateglinide Doxazosin

The BNF recommends avoiding alpha-blockers fo r 4 hours after sildenafil

Dr

As

se

m

Isoso rbide mononitrate

A 14-year-old boy is brou ght to the Emergency Department. Whilst in school he inject ed his friends EpiPen into the palm of his left hand. Shortly afterwards the left middle finger became cold and pale. The capillary refill time was around 5-6 seconds. What is the most appropriat e management?

Inhalation of Nitrox (mixture of nitrogen + oxygen) Intravenous nitrate infusion Local infiltration of hist amine

Dr

Local infiltration of phentolamine

As se

m

Intravenous prostacyclin infusion

Inhalation of Nitrox (m ixt u re o f nitrogen + oxygen) Intravenou s nitrate infusion

I

local inf iltration of hist amine

Intravenou s prostacyclin infusion

~al infiltration of phentolamine Adrena line induced ischaem ia - phent o lam ine Less imocrtont

As se m

Important for me

Phentolamine, a short acting alpha blocker, may be used in this situation. It is normally

Dr

used mainly to contro l blood p ressure duri ng surgical resection of p haeochromocytoma

A 42-yea r-old ma le patient p resents to the urgent ca re centre with a 4 -hour history of rapidly evolving rash. He re ports the rash started on the abdomen a nd has not s prea d to his back and the chest. Th e rash is itchy and angry-loo king . He d enies any facial a nd o ra l swe lling . He re po rts that he was o nly sta rted on a course o f antibiotics by his GP fo r a chest infection and took the first d ose an hour b efo re the onset of the rash. On examination, th ere is an extensive erythematous rash with wheals on th e abdomen, back a nd chest. Which antibiotic has he most li ke ly been sta rted on?

Vancomycin Cla rith romycin

Doxycycline

Dr

Trimetho prim

As se m

Penicillin

Vancomycin

GD

Clarithromycin

f!D

Penicillin

GD

Trimethoprim

CD

Doxycycline

CD

Penicillin is a common cause of urtica ria Important for me

l ess :mocrtont

Penicillin is the most common antibiotic that ca n cause urtica ria. The other antibiotics can all cause an allergic rea ction manifesting in urticaria but not as common as penicillin. Given the history of chest infection, penicillin is most likely the antibiotic that was given. Vancomycin is not usually given for community-acquired pneu monia

As se m

Trimethoprim is usually used for urina ry tract infections.

Dr

Doxycycline can cause urticaria but it does so not as co mmonly as penicillin. The questio n is asking which antibiotic is most likely.

What is the mechanism of action of rifampicin?

Inhibits DNA synthesis Interferes with cell wall fo rmatio n Inhibits RNA synthesis

Dr

Inhibits protein synthesis

As

se

m

Causes misrea ding of mRNA

Inhibits DNA synthesis Interferes w ith cell wall formation Inhibits RNA synt hesis Causes misrea ding of mRNA

m

Inhibits p rotein synthesis

l ess : m ::~c rtont

Dr

Important for me

As

se

Rifa mpicin - inhib its RNA synthesis

A 55-year-old female is admitted following an overdose of amitriptyline. On examination she has dilated pupils and is tachyca rdic at 145 bp m, w it h a blood pressure of 102/ 56 mmHg. ECG revea ls a b road comp lex tachyca rdia. Her GCS is 9/15 (M 5, V2, E2). What is the most appropriat e management?

IV amiodarone IV bicarbonate IV magnesium

Dr

Glucagon

As se

m

DC cardi oversion

IV am iodarone

f!D

IV bica rbonate

eD

IV magnesiu m

GD

DC cardiovers ion

fD CD

Gl ucagon

Tricyclic overdose -g ive IV b icarb onate Important for me

l ess 'mocrtont

Dr

be effective, even in patients who are not aci dotic

As se m

Arrhythmias following tricyclic overdose are d ifficult to treat as many commonly used anti -a rrhythmics are contraindicated. The use of sodium bicarbonate has been shown to

A 48-year-old woman with longstanding rheumatoid arthrit is is started on hydroxychloroquine. She has been on met hotrexate monotherapy fo r 1 year and continues to have frequent flares. She undergoes 12 weekly FBC, U&E & LFTs. In the long-term, which additional monitoring is required?

Blood pressure Urinalysis

Anti-histone antibodies

Dr

Thera peutic levels

As se m

Eye assessment

Urinalysis

I

Eye assessment Therapeutic levels Anti-histone antibodies

Hydroxychloroquine can cause retinopathy Important for me

Less imocrtont

Patients on longt erm hydroxychloroquine require annual eye assessments as there is a risk of retinopathy. Other important drug causes of retinopathy include ethambut ol, vigabatrin and amiodarone. Blood pressure measurement is important in ciclosp orin therapy. Urinalysis is required for gold and penicillamine (for protein due to the risk of membranous glomerulonephritis) and cyclophosphamide (for blood due t o the risk of haemorrhagic cystitis and bla dder cancer). No drug requires routine monitoring of anti -histone antibodies (althou gh penicillamine inhibitors ci closporin and t acrolimus.

As se m

can cause drug-in duced lupus) and therapeuti c levels are required for the ca lcineurin

Dr

NICE provide an excellent summary here: https://cks.nice.org.uk/dmards#!management

Which one o f the fo llowi ng statements regard ing drug metab olism is incorrect?

Reduction is an exa mple of a p hase I reaction The maj ority of both phase I and phase II reactions take place in the liver Asp irin undergoes extens ive first -pass metabolism

As

se

m

Products of phase I rea ct io ns a re typica lly more lipid soluble

Dr

Products of phase II rea ctions are typica lly ina ctive and excreted in urine o r b ile

Reduction is an exa mple of a phase I reaction

fi!D

The majority of both phase I and phase II reactions take place in the live r

f!D

Asp irin undergoes extensive first-pass metabolism

fiD

r

GD

Products of phase II reactions are typically inactive a nd excreted in urine o r b ile

GD

Dr

Usually both phase I and II reactions decrease lipid solubility

As

se

m

Products of phase I reactions are typica lly mo re lipid soluble

A 19-year-old stu dent is admitt ed after being found friends confused and sweating in her room. She is unab le to give a history. On examination temperature is 38.1 °C, pulse 108/min, BP 130/ 70 mmHg and resp iratory rate 30/ min. Heart sounds are normal but she has b ibasal fine inspiratory crackles on her chest. ABGs on air: pH

7.28

pC02

2.8 k Pa

p02

14.2 kPa

What is the most likely diagnosis?

Paracetamol overdose Acute pancreatitis

Asp irin overdose

Dr

Legionella p neumonia

As se m

Mycoplasma septicaem ia

Paracetamol overd ose Acute pa ncreatitis Mycoplasma septicaemia I

Legionellj p neu monia Asp irin overdose

Dr

As

se

m

The mixed resp irato ry al kalosis and meta bolic a cidosis in a sweaty, confused patient point towa rds sa licylate overd ose. The deve lopment of pulmona ry oed ema su ggests severe poison ing and is an ind ication fo r haemod ialysis

A 19-yea r-old ma n presents to the Emergency Depa rtment 5 hours ingestin g 20g o f pa raceta mo l. N-a cetyl cystein e is starte d stra ight away. What is the mechanism of action o f N-acetyl cyste ine?

Replen ishes glutathione Inhibits P450 mixed function oxidases Replen ishes glucu ro nic acid

Dr

Neutra lises me rcaptu ric acid

As

se

m

Promotes formation o f N-acetyi- B-benzoquinone im ine

(D

Replenishes glutathione

fD

Inhibits P450 mixed functio n oxidases

GD

Promotes formation o f N-acetyi-B-benzoquinone imine

«D m

Replenishes glucuronic acid

fD Dr

As

se

Neutralises mercapturic acid

Dobutamine is an example of:

Alpha-1 agonist Alpha-2 agonist Beta-1 antagonist

Dr

Beta-1 agon ist

As

se

m

Beta-2 antagonist

fiD

Alpha-2 agonist

. GD

Beta-1 antagonist

GD

Beta-2l antagonist

CD As

CJD

Dr

Beta-1 agon ist

se

m

Alpha-1 agonist

A 29-year-old man comes t o the gastroente rology clinic for review for his Crohn's disease. He has a 2-year hist ory of an anal fistula which has been treat ed with a metronidazole, azathioprine and set on placements, but none of which has been effect ive. Following discussion with the consultant, you plan to start the patient on infliximab. What is the mechanism of action of this medication?

Anti-CD 20 antibody Anti-CD 52 antibody

Anti-CD 4 antibody

Dr

EGFR inhibitor

As se m

Anti -TNF monoclonal antibody

I

Anti-CD 20 antibody

GD

Anti-CD 52 antibody

m GD

Anti -TNF monoclonal antibody

• •

EGFR inhibitor nti-CD 4 antibody

Infliximab is an anti-TNF monoclonal antibody used in the treatment of Crohn 's disease Important for me

Less · m ::~c rtant

Infliximab is an anti-TNF monoclonal antibody used in the treatment of Crohn's disease. An example of anti-CD 20 antibody is rituximab.

An example of anti-CD4 antibody is cedelizuma b.

Dr

An example of EGFR inhibitor is cetuximab.

As se m

An example of anti-CD 52 antibody is alemtuzumab.

A 65 -year-old female is admitted to the Emergency Department following an overdose of a long -acting propranolol preparation. On admission she is bradycardic with a pulse of 36/min and BP 90/50. The bradycardia fails to respond to atropine. What is the most appropriate management?

Temporary cardiac pacing Haemodialysis Glucagon

Dr

Salbut amol in fusion

As se

m

Noradrenaline infusion

Tem porary cardiac pacin g Haemodialysis Glucagon

-

Noradrenaline infusion

~

Salbut amol in fusion

Beta- blocker overdose management: atropine + glucagon l ess im:>crtc.nt

Glu cagon has a positive inotropic action on the heart and d ecreases renal vascular resista nce. It is t herefore useful in patients with bet a-blocker card iot oxicity

As se m

Important for me

Dr

Cardiac pacing should be reserved for patients unresponsive t o pharmacol ogical therapy

A confused 45 -year-old man is admitted to the Emergency Department. He tells staff he has drunk two bottles of antifreeze. On exam ination his pu lse is 120 bpm and blood pressure is 140/ 90 mmHg. Arterial blood g ases show an uncompensated metabol ic acidosis . He is transferred to the high dependency unit and ethanol is given via a nasogastric tube. What is the mechan ism of action of ethanol in this patient?

Binds to glyco lic acid Inhibits aldehyde dehydrogenase

Binds to glycoa ldehyde

Dr

Competes with ethylene glycol for alcohol dehyd rogenase

As se m

Inhibits alcohol dehyd rogenase

11nds

to glyco lic acid

-

Inhibits aldehyde d ehydrogenase Inhibits alcohol de hyd rogenase

~

Binds to glycoa ld ehyde

As

se

m

Competes with ethylene g lyco l for alcohol dehyd rogenase

Dr

I

"""

A 45-year-old female is admitted to the burns unit fo llowing being invo lved in a house fire. She is hypoxic, hypotensive and has flus hed red skin. You suspect cyanide toxicity and treat her with intravenous hydroxocobalam in. What is the mecha nism of cyanide toxicity?

Inhibits the mitochondria l enzyme cytochrome c oxidase Carboxyhemoglobinemia

Competitive inh ibitio n of the enzyme alcohol dehydrogenase

Dr

Depletion of glutathione stores

As se m

Methemoglobin emia

Inhibits the mitochondrial enzyme cytochrome c oxidase Carb oxyhemoglobine mia Methemog o bin emia Depletio n of glutathione stores Competitive inhibition o f the enzyme alcohol d ehydrogenase

Cyanide inh ibits the enzyme cytochrome c oxidase, resulting in cessation of the mitochondrial e lectron transfer chain Important for me

Less ' m::~c rtont

Fires invo lving the b urning o f plastics can resu lt in cya nid e toxicity. Cyanide inhib its the enzyme cytochrome c oxidase, resulting in cessation of the the mitochondrial electron transfer chain . This causes histotoxic hypoxia because the cells of an o rganism are unable to create ATP. Carb oxyhemoglobine mia is a featu re of carbo n monoxide p oisoning . Exposure to smal l concentrations o f CO hind e r the ability of Hb to d elive r oxyg en to the bo dy, because ca rboxyhemoglobi n fo rms more read ily than oxyhaemoglob in. Methe moglo bin emia is a fo rm o f haemoglobin that conta ins the ferric [Fe3 +] fo rm o f iron. The a ffinity for oxygen of the ferric iro n is impaired resulting in tissue hypoxia. It can occur to genetic o r a cquired fo rms (e .g. the use of drugs such as amyl nitrite) . Dep letion of glutathio ne stores occurs in paracetamo l toxicity.

Dr

As s

em

Fomep izole is a competitive in hibito r o f th e enzyme a lcoho l d ehydroge nase and can b e used to treat methano l and ethyle ne glyco l toxicity.

A 45 -year-old man presents t o the Emergency Department stating he has drunk a bottle o f antifreeze. Which one o f the following features are least associated w ith this kind of poisoning?

Metabolic acidos is with high anion gap Acute ren al failure Hypertension

Dr

Loss of vision

As

se

m

Confusion

A 45-year-old man presents to the Emergency Department stating he has drunk a bottle o f antifreeze. Which one o f the following features are least associated w ith this kind of poisoning?

Metabolic acidosis with high anion gap Acute renal failure Hypertension Confusion

I

Loss of vision is seen in methanol rather than ethylene glycol poisoning

Dr

Loss of vision

As se m

I

Which one of the following stat ement s regarding amiodarone-induced thyrotoxicosis (AIT) is correct?

AIT type 2 should be treated with corticosteroi ds Am iodarone should be conti nued in the majority of patient s Carbimazole is contraindicated in AIT type 1

Dr

AIT type 1 is due t o a amiodarone-related destructive thyroiditis

As

se

m

Goitre is usually present in AIT type 2

AIT type 2 should be treated with co rticosteroi ds

C!D

Am iodarone should be conti nued in the majority o f patients

GD

~rbimazole is contra indicated in AIT type 1

CD CD

fD

Dr

AIT type 1 is due to a a mio da ro ne-related d estructive thyro iditis

As

se

m

Goitre is usually present in AIT type 2

A 66-year-old woman with a history of chronic kidney disease stage disease 4 metastatic b reast cancer is admitted with a swollen rig ht calf. Investigations confirm a deep vein thrombosis and she is started on treatment dose d a ltepa rin. As she has a significant d egree of rena l impairment it is decided to monitor her response to daltepa rin. What is the most appropriate blood test to p erform?

Anti-Factor Xa levels Antithrombin III levels

Activated Pa rtial Throm boplastin Time (APTT)

Dr

Protrombin time (PT)

As se m

Anti-Factor Villa levels

Anti-Factor Xa levels Antithrombin III level s

r:~ti-Factor Villa levels

Dr

Activated Partial Thromboplastin Ti me (APTT)

As

se

m

Protrombin time (PT)

Thrombocytopenia is associated w ith each of the following drugs except:

Abciximab Quinine Warfa rin

Dr

Sodium valproat e

As

se

m

Penici llin

Quinine

CD

Warfarin

GD

Penicillin

CD

Sodium valproate

As

se

m

CD

Dr

I

Abciximab

f.D

A 55-yea r-old female p resents to the Emergency Department with a de liberate overdose of amitriptyli ne. Para med ics re port that a box of thirty 50mg ta blets was found e mpty by her bed. On exa mination, she appears a little letha rgic however there is no focal neu ro logical a bno rmality. Observations show heart rate 110/ min, b lood p ressure 105/75mmHg. An ECG shows a sinus tachycardia with a QRS duration of 135ms and a corrected QT interval of 390ms. What is the most app ropriate initial management of this patient?

Intravenous isotonic sa line Intravenous glucagon

Intravenous magnesium su lphate

Dr

Intravenous sod ium bica rbonate

As se m

Intravenous lipid emu lsion

Intravenous isotonic sa line Intravenous g lucagon Intravenous lipid emulsion Intravenous sodium bica rbonate Intravenous magnesium sulphate

Intravenous sodium bica rbonate is the sta nda rd initial therapy for patients who develop ca rdiotoxicity (usually a QRS > lOOms o r a ventricular arrhythm ia) as a resu lt of tricycl ic antidep ressant (TCA) overdose. Intravenous magnesium su lphate can be used as a second-line agent in refractory arrhythmias.

Intravenous isotonic sa line is ind icated in a hypotens ive patient.

Dr

Intravenous glucagon is used in beta b locker overd ose.

As se m

Intravenous lipid emu lsion is an emerg ing thera py for overdose o f li pophil ic com pounds. It may have a role in overdoses of verapam il, beta b lockers, and some TCAs. However it is not an app ropriate first line age nt.

Which one of the fo llowin g is an a bsolute contra indication to combined o ra l contraceptive pill use?

Contro lled hypertension Histo ry of cholestasis Wome n more tha n 35 years o ld and smoking more than 15 cigarettes/day

Dr

Mig raine without aura

As

se

m

BMI of 38 kg/ m " 2

Contro lled hyperte ns ion

-

(D

Histo ry of cholestas is

GJ

BMI of 38 kg/ m " 2

f!D

Migraine without aura

CD

Dr

As

se

m

Women more than 35 years o ld and smoking more than 15 ciga rettes/day

Which one of the following drugs cannot be cleared by haemodialysis?

Asp irin Tricydics Lithium

Dr

Am inophylline

As

se

m

Barbitu rates

CD

Asp irin

CD

Lithi um

. (D

Barb:tu rates

. (D se

m

Tricyclics

GD

As

Am inophylline

Dr

I I

A 45-year-old man presents with pain and swelli ng of his leh big toe. He has recently started treatment for active tuberculosis. Which one of the following medications is likely to be responsi ble?

Streptomycin Rifa mpicin Ethambutol

se As Dr

Pyrazinam ide

m

Isoniazid

Streptomycin

CD

Rifa mpicin

CD

Etham butol

fi!D

Isoniazid

fiD

I

m

GD se

Pyrazinamide

Dr

As

There are case reports of ethambutol-induced gout but it is not listed as a side-effect in the BNF

Which one o f the following drugs causes shortening of the QT interval?

Digoxin Sotalol Am iodarone

Dr

Chloroquine

As

se

m

Tricyclic antidepressants

Digoxin Sot alol Amiodarone Tricyclic antidepressants

prolongation

As

Dr

Digoxin causes shortening o f the QT int erval whilst the other fou r drugs cause QT

se

m

Chloroquine

A 79-year-old ma le patient p resents to the GP surgery with a 1-month history of constipation. He reports that a month ago, he used to open his bowels once a day every morning, but fo r the last month, he was only able to open bowels once every 3 days at best and each time the bowel was opened, the stool is very d ry and lumpy and he has to strain a lot on the toi let. He is very distressed by this. You notice that he was started on a med ication one month ago and you suspect that this might have contributed to his constipation. Which is the most like ly medication he was started on?

Bisoprolol Vera pa mil

Aspirin

Dr

Warfarin

As se m

Metfo rmi n

I

Bisoprolol

«D

Verapamil

ED

Metformin

tED

m m

Warfarin Aspirin

Verapamil commonly causes constipation Important for me

Less im:>crtc.nt

Verapamil, a calcium channel blocker, is a common cause of constipation. Even though many medications can cause constipation, verapamil is the most like ly medication

Metformin, warfarin and aspirin do not usually cause constipation.

Dr

Bisoprolol can cause constipation but not as commonly as verapamil.

As se m

amongst the options given.

A 54-yea r-old ma n with a history of hypertension comes for review. He currently takes lis inopril 10mg od, simvastatin 40mg on a nd aspirin 75mg od. His blood p ressure is well contro ll ed at 124/76 mmHg but he also mentions that he is due to have a tooth extraction next week. What advice shou ld be g iven with regards to his aspi rin use?

Take aspirin as norma l but take tranexam ic 1g tds acid 24 hours before and a fter p rocedure Stop 72 hours before, restart 24 hours after p rocedure

Stop 48 hours before, restart 24 hou rs after p rocedure

Dr

Ta ke aspirin as norma l

As se m

Stop 24 hours before, restart 12 hou rs after p rocedure

Take aspirin as norma l but take tra nexam ic l g td s acid 24 hou rs before a nd a fte r p roced u re

m

Stop 72 hours before, restart 24 hou rs after p rocedu re Stop 24 hours before, restart 12 hou rs after p rocedu re Take aspirin as norma l

se

m

Stop 48 hours before, restart 24 hou rs after p rocedu re

Dr

As

In the BNF section 'Prescribing in dental p ractice ' it advises that patients in this s ituation s hould co ntinue taking anti-p late lets a s normal

In the Vaugha n Williams class ification of antiarrhythmics lidocaine is an example of a:

Class Ia agent Class Ib agent Class Ic agent

Dr

Class IV agent

As

se

m

Class II agent

(D

~ss Ibagent

CD

Class Ic agent

f!D.

Class II agent

CD

Class IV agent

. (D

Dr

As

se

m

Class Ia agent

A 52-year-old homeless man is admitted with suspected ethylene glycol toxicity. Following admission to the High Dependency Unit it is decided to give fomepizole. What is the mechanism of action of fomepizole?

Competitive inhibitor of aldehyde dehydrogenase Binds to glycoaldehyde Binds to glycolic acid

Dr

Competitive inhibitor of alcohol dehyd rogena se

As

se

m

Promotes renal excretion of ethylene glycol

Competitive inhibitor of aldehyde dehydrogenase Binds to glycoaldehyde Binds to glycolic acid

se As Dr

Competitive inhibitor of alcohol dehydrogenase

m

Promotes renal excretion of ethylene glycol

A 40-year-old woman who is known t o be HIV positive is reviewed in the respiratory clinic. She has recently started treatment for tuberculosis and is complaining of a loss of sensation in her hands Which one of the follow ing drugs is most likely to be responsible?

Indinavir Pyrazinamide Zidovudine

Dr

Isoniazid

As

se

m

Streptomycin

CD

Indinavir

Zidovudine

CD

Streptomycin

CD GD

Isoniazid causes peripheral neu ropathy Important for me

As

se

m

Isoniazid

Less :mpcrtant

Dr

I

CD

Pyrazinam ide

A 34-year-old man wit h a history of d epression is admitted to the Emerg ency Department. He stat es he has taken an o verdose of both diazepam and dosulepin. On examination blood pressu re is 116/78 an d t he pulse is 140 bpm. His respiratory rate is 8 per minute and the o xygen saturations are 97% on room air. What is the most appropriat e next course o f action?

Give flumazen il Inse rt a haemodialysis line

Start N-a cetylcysteine infusion

Dr

Give naloxone

As se m

Obtain an ECG

Give flumazen il Inse rt a haemodia lysis line Obtain an ECG Give naloxone Start N-acetylcyste ine infusion

As se m

As this patient has a marked tachyca rdia the first step wou ld be to obtain an ECG. If changes such as QRS widening are seen then intravenous bicarbonate should be g iven

Dr

Some users have argued that a n 'ABC app roach shou ld be taken, with flumazeni l g iven to reverse the respiratory dep ression. The potential risk of doing this would be inducing a seizure given the coexistent tricycl ic overdose

A 37-yea r-o ld wo man with a history of type 2 dia betes mellitus a nd obes ity p resents after a late pe riod. The urina ry hCG test is positive . Her cu rrent med ication is as follows: Orlistat l 20mg tds Simvastatin 40mg on Aspirin 7Smg od Metformin l g bd Paracetamol l g qds Aqueous cream prn

Which one o f her med icatio ns must b e stopp ed stra ig ht away?

Pa raceta mol Asp irin

Metformin

Dr

Orl istat

As se m

Simvastatin

I

Paracetamol

m

Aspirin

CD

Simvastatin

ED

Orlistat

fD

Metformin

f!D

Simvastatin is contraindicated in pregnancy and must be stopped immediately. Metformin is sometimes used in pregnancy although many diabetic women are converted t o insulin for the duration of the pregnancy to try and maximise control and minimise

As se m

compl ications.

according t o the BNF and the benefits are very likely outweighed by risks.

Dr

Whilst orlistat is not a known teratogen it shou ld be used with 'caution' in pregnancy

A 65-year-old man is rushed to the emergency depa rtment by his daughter. He complains of crush ing, central chest pa in. An immediate ECG trace o f his heart shows widespread ST e levation in the anterolatera l chest leads. He is started on aspirin, p rasug rel, morphine, metoclop ramide and nitrates and is taken to the percutaneous coronary intervention (PCI) lab. The ca rdiologist attending suggests starting him on a bciximab for the p revention of further ische mic events. What is the mechanism of action of the drug suggested by the card iolog ist?

Direct factor X inhibitor Direct th rombin inhibitor

Glycoprotein lib/lila inhib itor

Dr

Activates anti -thrombin III

As se m

P2Y12 inhibitor

I I

Direct factor X inhibitor

fD

Direct t hrom bin inhib itor

CD

P2Yl+ nhibitor

CD

Activates anti -thrombin III

m GD

Glycoprotein lib/lila inhib itor

Abciximab is a glycoprotein lib/lila receptor antagon ist

MOA

Heparin

activates anti-thrombin III

Prasugrel

P2Y12 ADP in hibito r

Abciximab

glycoprotein lib/lila inhi bito r

Dabigatran

direct th rombin inhibitor

Rivaroxaban

direct factor X inhibitor

As se m

Drug name

Less imocrtant

Dr

Important for me

A 45-year-old man with a history of epilepsy and psychiatric problems is admitted to the Emergency Department w ith confusion following a se izu re earlier in the day. On examination he is not ed to have a coarse tremo r, blood pressure is 134/86 mmHg, pulse is 84/min and the temp erature is 36.7°C. What is the most likely diagnosis?

Carbamazepine overdose Lith ium t oxicity Benzod iazepine toxicity

As se Dr

Neuroleptic malignant syndrome

m

Tricyclic overdose

I

Carbamazepine overdose

CfD

Lithi um toxicity

CiD

Benzodiazep ine toxicity

CfD

Tricyclic overdose

GD

Neuroleptic malignant syndrome

GD

Less :mpcrtant

As se

Important for me

m

Lithium: fine t remor in chronic treatment, coarse t remor in acute t oxicity

Dr

A t ricyclic overd ose may present w ith seizu res but it d oes not typica l cause a t remor

A 74-year-old male presents to the surgical assessment unit. He has come in w ith lower abdominal pain and has been unable to pass urine for the past 12 hours. On examination he ha s a palpable bladder and is tender in the suprapubic region. On PR examination his prostate is smooth and not enlarged. He has a background of high blood pressure, depression, neuropathic pain and diabet es. What is the most likely cause for this presentation?

Gabapentin Am lodipine

BPH

Dr

Am itriptyline

As se m

Metformin

Gabapentin

CID

Amlod ipine

CD

etformin

CD

Am it riptyline

flD fD

BPH

Amitriptyline can cause urinary retention Important for me

l ess ' m::~c rtant

The other medications do not cause urinary retention.

As se m

This gentleman is in urinary retention. Amitriptyline can cause urinary retention through its anticholinergic activity.

Dr

The patient has a small prostate on PR examination so is unlikely to be suffering from BPH

A 56-yea r-old fema le with a history of dep ression is broug ht in to the Eme rgency Depa rtment by a concerned neig hbou r. Besid e the patient a re em pty blister packets of co-coda mo l 30/ 500, indicating that she may have taken up to 50 tab lets. She is confused with a GCS of 14/15 and is una ble to say when she took the tab lets. What is the most a ppropriate initial manage ment?

Sta rt N-acetyl cysteine imm ed iately Immed iate referral for hae mod ialysis

Observe

Dr

Sta rt N-acetyl cysteine 4 hours a fter prese ntation if leve ls a re elevated

As se m

Give na loxone

Start N-acetyl cysteine imm ediately Immed iate referral for hae mod ialys is Give na loxo ne Sta rt N-acetyl cysteine 4 hours a fter presentation if levels a re elevated Observe

She may have consumed 25g o f paracetamol whi ch is a life-threatening overdose. N-

As se m

acetyl cysteine needs to b e commenced immediate ly.

Dr

There is no mention in the question of respiratory dep ression o r hypoxia to justify the use of naloxone

A 45-year-old female with a history of bipolar disorder presents with an acute co nfusional state. Which one of the following drugs is most likely to precipitate lithium toxicity?

Sodium valproate Atenolol Am inophylline

Dr

Bendroflumethiazide

As

se

m

Sodium bicarbonate

CD

Sodium valproate

CD

Atenolol

IAminop~ylline

CD

Bend rofl umethiazide

CD

lithium. Sodium valproate is not listed in the BNF as interacting with lithium

Dr

Both sodium bicarbonate and aminophylline may reduce plasma concentrations of

se

m

Sodium bicarbonate

As

I

f!D

A 20-year-old man is admitted to the Emergency Department with chest pain. He confid es that he has snorted 'a large amount' of coca ine in the previous hours. Which one of t he fo llowing features is his cocaine use most likely to cause?

Hypokalaemia Hyperthermia Decreased d eep t end on ref lexes

Dr

Metab olic alkalosis

As

se

m

Hypot ension

m

Hyperthermia

CD

fD

Hypot ension

. (D

Metabolic alkalosis

CD

As

se

m

Decreased d eep t end on ref lexes

Dr

I I

Hypokalaemia

Which of the following antibiotics act by inhibiting prot ein synthesis?

Cephalosporins Gentamicin Rifampicin

Dr

Flucloxacill in

As

se

m

Trimethoprim

Gentamicin

eD

Rifa mpicin

«D

Trimethoprim

f!D

Flucloxacillin

CD

Am inoglycosi des inhibit protein synthesis by acting on the 30S ribosomal unit Important for me

As

se

m

GD

Less im:>crtc.nt

Dr

I I

Cephalosporins

You are working in oncolo gy. A 50-year-old patient with an ad enocarcinoma of t he lung (T3 N3 M 1a) comes to clinic. He is an ex-smoker of 20 pack years. He has previously been treated w ith docet axel and cisplatin which have unfortu nately failed. He was subsequently t ested for an EGFR g ene mutation wh ich was found to be negative. His p erformance status is 0. He as ks you about a 'new ag ent' he has read about called nivolumab. How d oes this drug work?

EGFR inhibit or VEGF inhib itor ALK-1 inhibitor

Dr

CTLA -4 inhibitor

As se m

PD-1 inhibito r

EGFR inhibit or

GD

VEG F inhib itor

6D

ALK-1 inhib itor

CD

PD-1 inhibitor

ED

CTLA-4 inhibitor

CD

Immunotherapy is an area which is rapidly advancing in oncology and haemat ology and it is important cli nicians are awa re o f t hese advancements. One area o f immunot herapy t hat has developed in recent years is the emergence of checkpoint inhibito rs. Nivolumab is a PD -1 (programmed cell d eat h) inhibitor. PD - 1 receptors are fou nd on t he su rface o f T cells. When a T cell is alerted t o a cancer cell t he cance r cell ca n express t he PD-L1 p ro t ein. This is a ligand w hich bin ds to t he T ce ll recepto r and d eact ivates it. It is therefore a mechanism cancer cells use to evad e t he immune syst em and disa ble T cells. The PD -1 inhibit ors are antibod ies wh ich b lock t his receptor, leavi ng t he T cell s t o remain active and alert other immune cell s for example macro phages t o the cancer ce lls. EGFR is the epid ermal growth factor receptor. An examp le o f an inhibitor used in lung cancer would be erlotinib (Tarceva). VEGF inhib itors are vascular end ot helial growth fact or i nhibitors. An example is bevacizumab which is used in colorect al cancer. ALK-1 i nhibitors are drugs t hat act on anaplast ic lymphoma kin ase (a tyrosin e kinase). Crizotinib is an ALK- 1 inhibitor wh ich is und ergoing fu rther t rials in NSCLC. CTLA-4 (cytotoxic T -lymphocyte associat ed prot ein 4) is anot her immune checkpoint which dow n-regulat es T cell responses. Blocking this with inhibit ors such as ipilimumab again activat es t he immune syst em against cancer.

em

Nivolumab i n combinat ion wit h ipilimumab has show n encou raging results in pat ients

As s

wit h st age 4 met astatic melanoma and lymphoma. It is currently und ergoing t rials into

Dr

many o t her so lid malignancies such as lung, oesop hagea l and head and neck cancer.

A 60-year-old lady with atrial fibrillation and type 2 diabetes att ends for DC Cardioversion. She has continued her usual medications and 2mg of intravenous diazepam are given for sedation. Her usual medications are aspiri n, ramipril, bisoprolol and metformin. Following DC ca rdioversion she is found t o be in sinus bradycardia with a heart rate of 29. Which reversal agent is most likely t o correct her bradycardia?

Intramuscular flumazenil Intramuscular glucagon

Intravenou s amiodarone

Dr

Intravenou s gluca gon

As se m

Intravenou s flumazenil

Intramuscula r flumazenil Intra muscula r g lucagon Intrave nous flumazenil

~ravenous g lucagon Intrave nous amioda rone

Beta-blocker - atrop ine, glucagon in resistant cases Important for me

l ess 'mocrtont

This lady's b radycardia is most likely to be caused by beta bl ockad e from he r b isopro lol. The recommend ed re ve rsal agent fo r b iso pro lol is intravenous gluca gon. Atro pi ne is li ke ly to be ap prop riate based o n Advanced Life Support treatment pathways to treat the bradyca rdia. The most likely reversa l a gent, however, wou ld be intravenous gluca gon. Intra muscula r glucagon may be used to treat hypoglycaem ia, however is not appropriate fo r reversa l o f beta -blockad e. Flumazenil is not the co rrect a nswer, fo r althou gh this wo uld reverse any remaining sedatio n, it would not reverse the beta-blockade and b radyca rdia.

Dr

Sou rce: BN F

As s

em

Amioda rone is not a re versal agent a nd thus not the correct answe r.

A patient presents to the Emergency Department follow ing the development of an urticarial ski n rash following the introduction of a new drug. Which one of the following is most likely t o be respo nsible?

Omeprazole Sodium valproate Aspirin

Dr

Simvastatin

As

se

m

Paracetamol

m

Omeprazole Sodium valproate

CD

Asp irin

ED

Paracetamol

CD

Simvastatin

fD

Asp irin is a co mmon cause of urticaria l ess :mocrtont

As se m

Important for me

asp1n n

Dr

Although all medications ca n potentially cause urtica ria it is commonly seen secondary to

A 62-year-old man is attends the emergency department in fast atrial fibrillation. He is successfully card ioverted aher the fa ilure of beta-blocker therapy. Upon discharge he is placed on flecainide by the card iologist. Which of the following best describes flecainide's mechanism of action?

Blocking cat echolamine stim ulation of beta one adrenergic receptors in the heart Blocking the Navl.S sodium channels in the heart Blocking the batrachotoxin activated sodium channels of the heart

Dr

Blocking the rectifier potassium current

As se m

Blocking the potassium, sodium and calcium channels o f the heart

I

Blocking catecho la mine stimulatio n of beta one adrenergic receptors in the heart

0

Blocking the Navl.S sodium channels in the hea rt Blocking the batrachotoxin activated sodium channels of the heart Blocki ng the potassiu m, sodium and calcium channels of the heart Blocking the rectifier potassium current

Flecainide works by blocking the Navl.S sodium channel in the heart wh ich slowing the upstroke of the ca rdiac action potential. Bisoprolol works blocki ng the stimulation of beta one adrenergic receptors fou nd ma inly in the heart muscle which ultimately leads to decreased adrenergic tone and stimulation of the heart muscle. Procainamide works in a similar way to flecainide but instead indu ces a rapid blocking of the batrachotoxin activated sodium channels rapidly. Dronedarone's mechanism of action is unclear but it is believed to be involved in both the inhibition of outward potassium channels as well as the reduction of sodium into the cells. It is also thoug ht to have an effect on the calcium channels.

Dr

As se m

Ibutilide works primarily by pro longing the repolarization in atrial an d ventricular myoca rdium. This effect is caused by blocking !Kr, the rapid component of the cardiac delayed rectifier potassium current.

A 35-year-old man with a known hist ory of peanut allergy is admitted to the Emergency Department with a swollen face. On examination blood pressure is 85/ 60 mmHg, pulse 120 bpm and there is a bilatera l expirat ory wheeze. What is the most appropriate form of adrenaline to give?

10m I 1:10,000 N

O.S mll:l,OOO IM O.S mll:lO,OOO IM

As se Dr

Nebulised adrenaline

m

Smll:l,OOOIM

10m I 1:10,000 IV

. (D

0.5ml 1:1.000 IM

GD

0.5ml~:10,000 IM

CiD

5ml1:1,000 IM

CD

Neb ulised ad renaline

m

Recom mend Adult Life Support (ALS) adrenaline d oses

Important for me

l ess imocrtc.nt

Dr

• ca rdiac arrest: 10m I 1:10,000 IV or 1m I of 1:1000 IV

As se m

• anaphylaxis: O.Sml 1:1,000 IM

A 45-yea r-old patient presented with significa nt malnutrition a nd wa s initiated on naso ga stric feeding . Refeed ing blo od tests noted a s ignifica nt hypoma gnesem ia. What ECG cha nges a re most li kely to b e present?

QT shortening QT prolong atio n T-wave inversion

As se Dr

Peaked t-waves

m

Bra dyca rd ia

QT shorte ning

C!D

QT prolongation

CD

T-wave inversion

CD

Bra dyca rd ia

. CD

Pea ked t-waves

fD

The ECG change most typically associated with hypomagnesaem ia is QT pro long atio n. QT shorte ning is mo re typica lly seen with hyperca lcaem ia, cong e nita l QT syndrome and digoxin. T-wave inve rsion is more typica lly seen with coro na ry ischaem ia o r leh ve ntricu la r hypertro phy.

Dr

hypomag nesemia d oes not typically cause a bradyca rdia.

As se m

Peaked t-waves a re more typically seen with hype rcalcaem ia.

Which one of the following drugs demonstrates saturat ion p harmacokinet ics?

Enalapril Bendrofluazide Atenolol

Dr

Paracetamol

As

se

m

Phenytoin

CD

Enalapril

• •

Bendrofluazide Ateno lol

~enytoin

ED.

flD

Important for me

l ess ' m ::~c rtc.nt

Dr

Exhibits zero-order kinetics - phenytoin

As

se

m

Paracetamol

Which one o f t he followin g drugs does not characterist ically und ergo ext ensive first- pass metabolism?

Propranolol Glyceryl tri nitrate Diazepam

Dr

Verapamil

As

se

m

Aspirin

Proprano lol

CD

Glyceryl tri nitrate

GD

.,

Aspirin

tD

f!D

Dr

Verapamil

As

se

m

Diazepa m

A 45 -year-old man is referred to the acut e medica l unit. He had presented earlier in the day to the GP complaining o f ongoing fatigue and polydipsia. A BM (finger-prick glucose) taken in the surgery was 22.3 mmol/1. On examination he is an obese man (BMI 36kg/m 2) with a pulse of 84 bpm and blood pressure of 144/84 mmHg. Blood t ests reveal the following: Na•

14 0 mmol/1

K•

3.9 mmol/1

Bicarbonate

23 mmol/ 1

Urea

5.2 mmolfl

Creatinine

101 molfl

Glucose

2 1.2 mmol/ 1

You encourage him to lose weight and discuss basic dietary advice. What is the most appropriate initial management?

Gliclazide Pioglitazone Exenatide

Dr

Commence insulin therapy

As se m

Metformin

Gliclazide Pioglitazo ne Exenatide Metformin

-

Commence insulin therapy

Dr

Whilst there is a role for exenatide in o bese patient s it is not used first -line.

As

se

m

~

Ta msu losin is a:

Alpha-lb agonist Alpha-la agonist Non-selective a lpha antagonist

Dr

Alpha-lb antagonist

As

se

m

Alpha-la antagonist

Alpha-lb agon ist Alpha-la agonist

Alpha-lb antagonist

As

se

m

Alpha-la antagonist

Dr

I

Non-selective alpha antagonist

Low molecular weight heparin has the greatest inhibitory effect on which one of the following proteins involved in the coagu lation cascade?

Factor !Xa Factor XIa Factor Xa

Dr

Factor XI!a

As

se

m

Thrombin

Factor Xla

m m

Factor Xa

GD

Thrombin

GD

Factor Xlla

m

Dr

As

se

m

Factor !Xa

A 70-yea r-old patient attends the GP with a 10-day history of increasing shortness of breath and ankle swell ing . He has a past medica l history of hypertension, type II diabetes, ischaemic heart disease and systolic heart failu re. He was started on a new medication 10 d ays ago. Which of the below drugs is most likely to have caused his new symptoms?

Bendroflumethiazide Piogl itazone Paracetamol

As se Dr

Rivaroxaban

m

Dapagliflozin

I

Bendroflumethiazide

GD

Pioglitazone

GD

Paracetamol

m

Dapagliflozin

f!D

Rivaroxaban

m

Glitazones can cause fluid retention and decompensation of heart failure Important for me

Less impcrtont

The correct answer is piog litazone. Glitazones are a class of ant i-hypoglycaemics wh ich can cause ret ention o f f luid resu lting in d ecompensat ion of pre-existing heart failure. Other medications which can cause worsen ing of heart fa ilure includ e NSA!Ds, non dihydropyridine ca lcium chan nel b lockers, non -cardia -selective beta blockers, some arrhythmic agents and alpha blockers used for urolog ical p ro blems. BNF:

American College of Cardiology:

As se m

https:/ / bnf.nice.org.u k/ drug/ piog Iitazone.htm I

drugs-can -cause -or-worsen-hf

Dr

http:/ /www.acc.org/latest -in-cardiology/ articles/2017/02/03/09/44/co mmon ly-used -

What is the most a pp ropriate dose of a drena li ne to give during a cardiac a rrest?

1ml1:100,000 IV 10m I 1:1,000 IV 0.5ml1:1,000 IM

Dr

10m I 1:10,000 IV

As

se

m

1ml1:10,000 IV

1ml1:100,000 IV

CD

10m I 1:1,000 IV

CD

0.5ml1:1,000 IM

m.

1ml1:10,000 IV

ED

10m I 1:10,000 IV

CD

Recom mend Adult Life Support (ALS) adrenaline doses • anaphylaxis: O.Sml 1:1,000 IM • cardiac arrest: 10m I 1:10,000 IV or 1m I of 1:1000 IV important for me

l ess im:>crtc.nt

10m I of the 1:10,000 p reparation contains 1mg of ad renaline.

As se m

From the BNF:

mg (1 0 mL) by intravenous injection repeated every 3 -5 minutes if necessary

Dr

Adrenaline (epinephrine) 1 i n 10 000 (100 micrograms/mL) is recommended in a dose of 1

A 43-year-old male patient comes to t he GP surgery for a review of his recent glucose t olerance t est. His past medical h istory inclu des ep ilepsy, renal transp lant, hypertension and ischaemic heart disease. The results are as follows. Fasting blood glucose

6 .8 mmoljl

2 hour post-oral load blood glucose

10.9 mmoljl

Which medicati on is most likely causing t hese results?

Am lodipine Tacrolimus

Verapamil

Dr

Lamot rigine

As se m

Levetiracetam

I

Am lod ipine

CD

Tacroli mus

fD

m. m.

Levetiracetam Lamotrigine

CD

Verapamil

Tacrolimus is a cause of impaired glucose tolerance Important for me

Less impcrtant

This patient 's glucose tolera nce test shows impaired glucose tolerance. Tacro limus is a

As se m

cause of impaired glucose tolerance.

glucose tolera nce.

Dr

Am lodipine, levetiracetam, lamotrigine and verapam il do not commonly cause impaired

A 62-yea r-old female patient p resents to the GP surgery complaining of a rash on her face and her chest. She reports that she first noticed the rash whilst she went on holiday to Spain in July and she only got back 2 days ago. She has a past med ical history of hypertension, ischaemic stroke, type 2 dia betes and epilepsy. On exam ination, there is a ma culopapu lar erythematous rash on her forehead, both cheeks and anterior chest. You notice that she was recently started on a medication. What is the most likely med icatio n that may have caused this rash?

Clopidog re l Am lodipi ne

Metform in

Dr

Bendroflumethiazid e

As se m

Fu rosem ide

Clopidog rel

GD

j .mlodipine

GD

Fu rosem ide

CD

I

ED

Bend roflu methiazid e

. (D

Metfo rmin

Th iazides may cause photosensitivity Important for me

Less impcrtant

Dr

Sodium valp roate, am lod ipine, furose mide and metfo rmin d o not usually cause photosens itivity.

As se m

Given the d istribution o f the rash a nd the histo ry, it is like ly that this is a photosensitive rash. Thiazides may cause photosensitivity.

What is the most a p pro priate time to take b lood samples fo r thera peutic mon ito ring of lithium leve ls?

At any time Immed iate ly befo re next dose 4 hou rs after la st d ose

Dr

12 hou rs a fte r last dose

As

se

m

6 hou rs after last d ose

m

At any time

QD

Immed iate ly before next dose

CD

6 hours after last dose

GD

12 hours after last dose

6D

Dr

As

se

m

4 hours after last dose

A 59-yea r-old ma n with a history o f type 2 dia betes mellitus an d benig n p rostatic hypertrophy develops urinary retention associated with acute renal fai lure. Which one of the following drugs shou ld be disco nti nued?

Gliclazide Paroxetine Atenolol

Dr

Finasteride

As

se

m

Metformin

Gliclazide

CD

Paroxetine

CD

m

Atenolol Metformin

ED.

Finasteride

tiD se

m

As the patient ha s develop ed acute rena l failure metformin should be stopped due to the

Dr

can co ntribut e to urinary retention.

As

risk of lactic acidosis. In the long term paroxetine may also need to be stop ped as SSRi s

A 58-year-old man who is taking lithium for bipolar disorder presents fo r review. During routine examination he found t o be hypertensive with a blood pressure of 166/82 mmHg. This is confirmed with two separate readings. Urine dipstick is negative and renal function is normal. What is the most appropriate medication to start?

Amlodipine Ramipril Losartan

se As Dr

Doxazos in

m

Bendroflumethiazide

Amlodipine

GD

Ram ipril

CD

Losartan

CD

Bendroflumethiazide

CD

Doxazos in

CD

As se m

Diuretics, ACE-inhibitors and ang iotensin II recepto r antagonists may cause lithium toxicity. The BNF advises that neu rotoxicity may be increased when lithium is given with diltiazem or verapam il but there is no significant interaction with amlodipine. Alphablockers are not listed as interacting with lith ium but they would not be first-line treatment for hypertension.

Dr

The NICE hypertension gu idelines suggest amlodipine wouldn't be a bad first choice, even if we ignore his lithium treatment.

Which one of the following immunosuppressant drugs inhibits ca lcineurin in T cel ls?

Mycophenolate mofetil Basiliximab Azathioprine

Dr

Methotrexate

As

se

m

Ciclosporin

Mycophenolate mofetil Basiliximab Azathioprine Ciclosporin Methotrexate

Ciclosporin

+

tacrolimus: inhibit calcineurin thus decreasing IL-2 Important for me

l ess ' m::~c rtant

Dr

As se m

Mycophenolate mofetil inhibits inosine mono phosphate dehydrogenase. Azathioprine is metabolised to the active compound mercapto purine, a purine analogue that inhibits DNA synthesis. Methotrexate is an antimetabolite which inhibits dihydrofo late reductase

A 36-yea r-old male wei ghing 70 kg presents to the Emergency De partment fo llowing an o verdose of pa racetamol in an attempt to en d his life. The patient reports to have taken a total of 15 grams of pa raceta mol over the course of the last 5 hou rs . He currently feels nauseous, but d enies vom iting o r abdominal pain. What is the most app ropriate next step in manag ing this patient?

Check se rum pa raceta mo l levels a nd act as per result Give IV N-acetylcyste ine imm ediately

O bserve patient and d ischarge if remains asymptomatic

Dr

Give IV sodium b icarbonate immediately

As se m

Give IV fom ep izole im med iately

I

Check serum pa raceta mo l levels and act as per result Give N N-acetylcysteine immediately Give N fom epizole im mediately

~Give N sod ium bicarbo nate immediately Observe patient and d ischarge if remains asymptomatic

Patients who take a staggered pa raceta mol overdose shou ld receive treatment with acetylcysteine Important for me

Less imocrtont

Patients who present following staggered ingestion of a potentially toxic dose of pa racetamo l (> 75mg/kg) should be commenced on N acetylcysteine irrespective of serum pa racetamo l co ncentrations. A staggered overdose is defined as 'ingestion of a potentially toxic dose of pa racetamo l over more than one hour'. This patient has ta ken > lSOmg/kg over a period of 5 hours and therefore should be commenced on treatment.

em

Fomepizole is used to the treatment of ethylene g lycol (a ntifreeze) poisoning. N sod ium bicarbonate can be g iven in the treatment of sa licylate and tricyclic antidepressant overdose.

Dr

the development of symptoms.

As s

Given that the patient has ingested a toxic dose, treatment shou ld not be delayed until

A 62-year-old female with chronic renal failure (GFR = 35 mljmin) is diagn osed as having pulmonary tuberculosis. What cha nges need to be made to her anti-tuberculosis reg ime given her renal impairment?

Reduction in isoniazid dose Reduction in rifampicin dose Reduction in pyrazinamide dose

Dr

No changes

As

se

m

Reduction in ethambutol dose

Reduction in rifampicin dose Reduction in pyrazinamide dose

No changes

As

se

m

Reduction in ethambutol dose

Dr

I

Reduction in isoniazid dose

A 57 -year-old male patient presents to the GP surgery complaining of having very vivid dreams. He repo rts a 6-week histo ry of having frequent nightmares w ith extremely disturbing and vivid ima gery. He is quite distressed by this. You review his medication and found t hat he was started on a new medication 6 weeks ago. Which medication was he likely to have been started on?

Nitrat e Bisoprolol

Nicorandil

Dr

Vera pamil

As se m

Am lod ipine

Nitrate

GD

Bisoprolol

fD . (D

Amlodipine Verapamil

GD

Nicorandil

ED

Beta- blockers can cause sleep disturbance Important for me

Less impcrtant

Beta-blockers can cause sleep disturbance. Side effects of nitrates: hypotension, tachycardia and headache

Side effects of nico randil: headache, flushing and anal ulceration

Dr

Verapamil can also cause constipation

As se m

Side effects of calcium channel b lockers: headache, flushing, ankle oedema

Immunoglobulin therapy may be indicated in each of the following except:

Dermatomyositis Guillain-Barre syndrome Kawasaki disease

Dr

Thrombotic thrombocytopenic purpura

As

se

m

Idiopathic thrombocytopenic purpura

-

Dermatomyositis

~

Guillain-Ba rre syndrome Kawasaki disease Id io pathic thro t bocytopenic pu rpu ra

As

stero ids and immunosu ppressants. Plasma exchange is a lso commonly used

Dr

The management o f management thrombotic throm bocyto pen ic pu rpu ra involves

se

m

Thro mbotic thro mbocytopenic p urpurJ

Which of the follow ing drugs is most likely t o be affected by a patients acetylator status?

Ethanol Hydralazine Aspirin

Dr

Verapamil

As

se

m

Phenytoin

CfD

Ethanol

~dralazine

CD (!D

Phenytoin

ED

Verapa mil

CD

Important for me

l ess ' m::~c rtant

Dr

Is affected by acetylator status - hydralazine

As

se

m

Asp irin

A 43-year-old man presents with known acute intermittent porphyria is brought to the Emergency Department by the police due to an acute psychosis. What is the most suitable drug for sedation?

Chloral hydrate Diazepam Phenobarbitone

Dr

Primidone

As

se

m

Chlorpromazine

m se

Dr

As

Chlorpromazine is considered safe to use in patients with acute interm ittent po rphyria. The other d rugs are classified as unsafe

A 25-year-old stu dent p resents to t he GP surgery w it h a 3 -day history o f blocked and runny nose, head ache and sore throat. He has no other sympt oms and has been g enerally f it an d well. He asks you for a medication t o help relieve t he blocked nose. You p rescribe him a phenylephrine hydroch loride nasal spray. What is the mechanism o f action of this medication?

Beta-1 adrenoreceptor antagonist Alpha-1 adrenoreceptor agonist

Alpha-1 adrenoreceptor antagonist

Dr

Beta-2 ad reno receptor agonist

As se m

Alpha-2 adrenoreceptor antagonist

Beta-1 ad renoreceptor antagonist Alpha-1 adrenoreceptor agonist Alpha-2 ar renorecepto r antagonist Beta-2 ad renoreceptor agonist Alpha-1 adrenorecepto r antagonist

Phe nyle phrine is an alpha-1 agonist Important for me

Less · m ::~c rtant

Phe nylephrine is an alpha-1 adrenorece pto r ago nist. It ca uses constrict ion of the blood vessels to ach ieve the decongesta nt effect . It is also used as a vasopressor. An exa mple of beta-1 antagonists is bisoprolol.

An exa mple of alpha-1 anta gonists is doxazosin.

Dr

An exa mple of beta-2 agonists is salbutamol.

As se m

An exa mple of beta-2 antagonists is phentolamine.

Which o f the fo llowing is true regarding the pathophysiology of pa raceta mo l overdose?

Paracetamol is norma lly exclusive ly meta bo lised by the P450 syste m Paracetamol ove rdose leads to a n excess ive build up o f me rca ptu ric a cid Conjugation o f paracetamo l becomes saturated in ove rd ose

Dr

N-acetyl cyste ine acts by antag onising glutathio ne

As

se

m

Glutathio ne levels increase fo llowing pa racetamol o ve rdose leading to hepatocellular death

Paracetamol is normally exclusively metabolised by the P450 system

Conjugation of paracetamol becomes saturated in overdose

N-acetyl cysteine acts by antagonising glutathione

As

se

m

Glutathione levels increase following paracetamol overdose lea ding to hepatocellular death

Dr

I

Paracetamol overdose leads to an excessive build up o f me rcaptu ric acid

A 19-yea r-old female is broug ht to the Emergency De partment by her friend s fo llowing a ni ght out. Her friends state she has taken an un known drug whilst out clubbing. Which one of the following features would most point towa rds the use of ecstasy?

Tem perature of 39.5°C Respirato ry dep ression Hypernatraemia

Dr

Urina ry incontinence

As

se

m

Mios is

Respiratory dep ression

CD GD

M iosis

GD m

Hypernat ra emia

m se

Urinary incontinence

As

I

CD

Dr

I

Tem perature o f 39.5°(

A 34-year-old female with a hist ory of anti-phospholipid syndrome is reviewed in clinic. She is on long-term warfarin and her INR has been stable at 3.0 for over 2 years. Mea surement from one week ago and t oday shows values of 1.5 and 1.3 resp ectively. Which one o f the following medicati ons is most likely to b e res ponsible?

Ciprofloxacin Fluconazole Sodium valproate

As se Dr

Cimetidine

m

Carbamazepine

Ciprofloxacin

GD

Fluconazole

CD f!D

.,

Sodium valproate

CD

Carbamazepine is a P450 enzyme inductor Important for me

As

se

m

Cimetidine

Less : m ::~c rtant

Dr

I

Carbamazepine

What is the most appropriate tim e to ta ke b lood samples for the rapeutic mon itoring of p henytoin leve ls?

At any time 12 hours a fter last dose 6 hours after la st dose

Dr

Immed iately befo re next dose

As

se

m

4 hours after last dose

-

At any time

~

12 hours after last dose 6 hou rs after last dose

Dr

Immediate ly before next dose

As

se

m

4 hou rs after last dose

A 67 -year-old man with a history of atrial fibrillation and ischaemic heart disease presents with symptoms consistent with a chest infection. His current medication incl udes amiodarone, warfarin and simvastatin. Which one of the following antibiotics is it most important to avoid if possible?

Trimethoprim Co-amoxiclav Cefaclor

As se Dr

Erythromycin

m

Levofloxaci n

. (D

Trimethoprim

m m

Co-amoxiclav

~faclor

flD

Erythromycin

GD

Levofloxacin reacts to a lesser extent with both amiodarone and warfarin.

Dr

Eryth romycin may pot entially interact with amioda rone, warfarin and simvastatin.

As

se

m

Levofloxaci n

A 27 -year-old female patient presents to the Emergency Department with 3 episodes of t on ic-clonic seizure in quick succession. Her past medical history includes epilepsy and recent episode of pyelonep hritis. She is not t aking any medication for her epil epsy because she has been seizu re-f ree for many years unt il t his episode. Which medication she started may have caused the recurrence of seizu res?

Erythromyci n Amoxicillin Metronidazole

Dr

Ciprofloxacin

As se m

Flucloxacillin

I

. (D

Erythromyci n AJ oxicillin

CD

Metronidazole

f.D

Flucloxacill in

m

Cipro floxacin

CD

Ciprofloxacin lowers the seizure threshold important for me

l ess im:>crtc.nt

Ciprofloxacin lowers the seizure th reshold. It is likely that it was st arted to treat pyelonephritis. Erythromycin can prolong QT interval.

Flucloxacillin can cause cholestasis.

Dr

Metronidazole can interact with alcohol.

As se m

Amoxicillin does not lower seizu re threshold.

Which of the following is least likely to be a precipitating factor in digoxin toxicity?

Hypernatraemia Hypocalcaem ia Hypokalaemia

Dr

Hypomagnesaemia

As

se

m

Hypothermia

I

Hypernatraemia

6D

Hypocalcaemia

CD

Hypokalaemia

QD

~pothermi a

GD CD Dr

Hyper-, not hypocalcaemia may be a precipitating fact or in digoxin toxicity

As

se

m

Hypomagnesaemia

A 49-yea r-old male patient presents to the GP surgery for a routine review. You notice that he has a ras h on his face. He said he first noticed the rash during a bicycle trip in the south of France. Since he came back from the bicycle trip, the rash has faded slightly. He has a past med ical history of ca rdiac arrhythmia. On examination, there is a ma culopapular erythematous ras h on his forehead and both cheeks. The rest of the exami nation is unremarkable. What is the most likely med ication that may have caused the rash?

Am iodarone Am lodipi ne

Flecainide

Dr

Nicorandil

As se m

Bisoprolol

Amiodarone

GD

Amlodipine

fD

Bisoprolol

. (D

Nicorandil

fl':D

Flecainide

CfD

Amiodarone is a cause of phot osensitivity Important for me

Less : m ::~c rtant

most likely medication to have caused this rash.

Dr

Am lodipine, bisoprolol, nico randil, flecainide do not usually cause photosensitivity.

As se m

This patient is having a photosensitive rash. Given all the medications, amiodarone is the

A 45 -year-old female is admitted with a seizure w hich does not respond to Sm g lorazep am. She is then given an IV loading dose of phenytoin. This is followed by a maintenance dose of once daily oral phenytoin. She lat er develops ataxia and nysta gmus and you are concerned over phenytoin toxicity. What is the most likely cause of phenytoin toxicity in this patient?

First -order elimination Zero -order elimination

Long half life

Dr

Decreased volume of distribution

As se m

Renal dysfunction

First -order elimination

~o-order elimination

-

Renal dysfunction

~

Decreased volume of distribution Long half life

Drugs which exhibit zero-order ki netics include phenytoin, alcohol and salicylates Important for me

l ess :mpcrtant

In cl inical pharmacology, first order kinetics are co nsidered as a linear process, because the rat e of elimination is proportional to the drug concentration. Th is means that the higher the drug concentration, the higher it s elimination rate. In other words, the elimination processes are not saturat ed an d can adapt to the needs of the b ody, to reduce accumulation of the drug. 95% of the drugs in use at therapeutic concentrations are eliminated by first order elimination kinetics. Zero order elimination describes drugs in which the clearance rate depends on an easily saturat ed enzyme syst em. As soon as the system is saturated, the rate of clearance plateaus, and does not vary no matter how much drug is present. This result s in a constant rate of elimination predisposing to high levels of the drug and toxicity. Drugs which exhibit zero-order kinetics include phenytoi n, alcohol and salicylates. The half life of phenytoin has an average of 14 hours. Drugs with long half lives are more likely t o accumulat e and often need therapeutic drug monito ring. The half life is essential t o decide on the appropriate dosing interval. Phenytoin is metabolised by the liver and excret ed in bile as an inactive met abolite. Phenytoin is minimally renal excreted, and dose modification is not required for renal dysfunction, even if severe.

em

This patient is on a once daily dose of phenytoin, therefore the long half life of this agent

Dr

most likely t o be the zero order pharmacokinetics resulting in t oxicity.

As s

is unlikely to be be playing a dominant role in the mechanism of toxicity. It is therefore

A 35-year-old female diabetic is started on erythromycin for gastroparesis. What is the mecha nism of action?

Promotes gastric emptying Inhibits bacterial overgrowth Acts on central chemoreceptor trigger zone

Dr

Stimulates cholecystokinin release

As

se

m

Relaxation of pylo ric sphincter

I

Pro motes gastric emptying Inhibits bacterial overgrowth Acts on central chemoreceptor trigger zone Relaxation of pyloric sphincter

Dr

Erythromycin is used in gastroparesis as it has prokinetic properties

As

se

m

Stimulates cholecystokinin release

Each o f the following drugs are known to inhibit cytoch rome P450, except:

Ketoconazole Cipro floxacin Erythromyci n

Dr

Am iodarone

As

se

m

Clopidogrel

Ketoconazole

«ED

Ciprofloxacin

tiD

Eryth romycin

«ED

~pidogrel

m

se

As Dr

Am iodarone

eD G'D

A 70-year-old man who takes warfarin for atrial fibrillation is found to have an INR o f 6.2. Which of the follow ing drugs is he most likely t o have recently taken?

Ciprofloxacin Flucloxacillin StJohn's Wort

Dr

Aspirin

As

se

m

Carbamazepine

Ciprofloxacin

ED

Flucloxacillin

CD

StJohn's Wort

. f!D

Carbamazepine

GD

fD

Aspirin

Ciprofloxacin is a P450 enzyme inhibitor l ess ' m ::~c rtont

As se m

Important for me

INR.

Dr

Ciprofloxacin is a known inhibitor of the P450 syst em and hence may cause an increase in

A 54-year-old man with hypertension is reviewed in cl inic. He complains that over the past two months he has developed ankle swelling. Which one o f the following drugs is most likely to be responsible?

Perindopril Am lodipine Doxazosin

Dr

Losartan

As

se

m

Moxonidine

Perindopril

fD

Amlodipine

CD

• •m

Doxazosin Moxonidine

Less imocrtant

Dr

Important for me

As

Calcium channe l blockers - side-effects: headache, flushing, ankle oedema

se

m

Losarta n

What is the main mechanism o f action of ond ansetro n?

Do pamine recepto r ago nist 5-HT2 recepto r antagonist Do pamine receptor a nta gonist

Dr

5-HT3 recepto r antagonist

As

se

m

5-HT2 rece pto r ag o nist

Dopamine recepto r agonist 5-HT2 rece pto r antagonist Dopamine receptor antagonist

Dr

5-HT3 rece ptor antagonist

As

se

m

5-HT2 recepto r agon ist

Which one o f t he followin g is an estab lished indicatio n for th e use of Bot ulinum toxin?

Strabismus Hirschsprung's disease Blepharospasm

Dr

Upper limb rigidity in Parkin son's disease

As

se

m

Bell's pa lsy

Strabismus Hirschsprun g's disease Blepharospasm

As Dr

Upper limb rigidity in Parkinson's disease

se

m

Bell's galsy

A 22-year-old man co nsults you as he and his housemate have been feeling generally unwell for the past few weeks. Which one of the following is the most common feature of carbon monoxide poisoning?

Hyperpyrexia Nausea Cherry red skin

Dr

Headache

As

se

m

Confusion

As se

Cherry red skin is a sign of severe toxicity and is usually seen post -mortem

l ess imocrtc.nt

Dr

Important for me

m

Carbon monoxide poison ing - most common feature = headache

A 49-yea r-old homeless man is adm itted to the ITU ahe r drinking a large quantity of metha nol. Treatment with fomepizole is started. What is the mechanism of action of fomepizole?

Chelates methanol Competitive inh ibition o f alcohol dehydrogenase Converts methano l to ethanol

Dr

Formaldehyde dehydrogenase in hibitor

As

se

m

Competitive inh ibition o f al dehyde d ehydrogenase

Chelates methanol ! competitive inhibi tion of alcohol dehydrogenase Converts methanol to ethanol Competitive inhibitio n of aldehyde dehydrogenase Formaldehyde dehydrogenase inhibito r

As se

Important for me

l ess ' m ::~c rtont

Dr

inhibitor of alcohol dehydrogenase

m

Fomepizole - used in ethylene glycol and methanol poisoning - competitive

Which one o f the following drugs is not known t o induce the cytochrome p450 enzyme system?

Rifa mpicin Isoniazid Phenobarbitone

Dr

Carbamazepine

As

se

m

Griseofulvin

I

Rifampicin

GD

Isoniazid

ED

m.

Phenobarbitone Griseofulvirn

f.D

Carbamazepine

CD

As se

Isoniazid is an inhibitor of the P450 system

Less impcrtant

Dr

Important for me

m

Isoniazid in hibits the P450 syst em

You are asked to review a 79-year-old man who reports new onset yellow tinting of his vision. He reports he is on numerous medications but cannot remember their names. His past medical history is significant for heart failure, benign prostatic hyperplasia and COPD. Which of the following medications is most likely responsible for this side effect?

Furosemide Ram ipril Digoxin

Dr

Salbut amol

As se

m

Sildenafil

Ra ipril

m m

Digoxin

GD

Sildenafil

f!D

Furosemide

CD

Salbutamol

Digoxin may cause yellow-green vision Important for me

l ess 'mocrtont

Dr

Sildenafil can cause blue -tinted vision or cyanopsia.

As se m

Due to its narrow therapeutic range, digoxin has a high risk of causing toxicity in patients. A characteristic feature of toxicity is xanthopsia or yellow-tinted vision.

Which one o f the following ECG changes is most consist ent w ith a tricyclic o verdose?

QRS widening Bradycardia Shortening o f QT inte rval

As Dr

ST elevation

se

m

First d egree heart block

QRS widening

-

Bradycardia

~

-

Shortening o f QT interval First degree heart block

Dr

As

se

m

~

A 41-year-old woman is admitted following a deliberate overdose of ethylene glycol. She is confused and unable to give any fu rther history. On exami nation the pulse is 96 I min, blood pressure is 142/ 84 mmHg and temperature 37.1°C. Blood t ests show: Na•

139 mmol/ 1

K•

4.0 mmolfl

Chloride

104 mmol/ 1

Bicarbonat e

26 mmol/ 1

Urea

4.0 mmol/1

Creatinine

88 iJffiOI/1

What is the most appropriate management of this patient?

Ethanol Fomepizole Haemodialysis

Dr

Dantrolene

As se m

Haemofiltration

Ethanol p omepizole Haemodialysis Haemofiltration

Ethylene glycol toxicity management - fome pizole. Also ethanol I haemodialysis Important for me

l ess ' m::~c rtant

developed

Dr

no indication for haemodialysis at this st age, as a met abolic acidosis has not yet

As se m

Fomepizole is now used first -line rather than ethanol in ethylene glycol toxicity. There is

A 44-year-old man asks fo r advice. He is due to go on a long bus j ourney but suffers from debilitating moti on sickness. Which one of the followi ng medications is most likely t o prevent motion sickness?

Cycl izine Chlorpromazine Metoclopramide

Dr

Domperidone

As

se

m

Prochlorperazine

CJD

Chlorpromazine

CfD

Metoc& ramide

fl!D

Prochlorperazine

mt

fD

Motion sickness - hyoscine > cycl izine > promethazine Important for me

As

se

m

Domperidone

Less : m ::~c rtant

Dr

I

Cyclizine

A woma n who is a bout to commence trastuzumab treatment for breast ca ncer has an echoca rdiogram. Which class of chemotherapeutic age nt would predispose her to d eve loping card iac dysfunction?

Vinca alkaloids Platinum-based co mpound s Anthracyclines

Dr

Topoisomerase I inhibitors

As

se

m

Taxa nes

Dr

m

se

As

A 54-year-old woman is treated with rituximab for non- Hodgkin's lym phoma. What is the t arget of rituximab?

CD20 CD 52 Epidermal growth factor receptor

Dr

Vascular endothelial growth factor receptor

As

se

m

CD22

I

CD20

CD

CD 52

CD

GD

Epidermal growth factor receptor

I

m m

CD22

ltrpor::a.r: "or me

_ess rr:>e1.ar:t

Dr

Rituximab - monoclonal antibody against CD20

As

se

m

Vascular endothelial growth factor receptor

A 26-year-old fema le is commenced on carbamazepine for complex partial seizures. She has no previous medical history of note and consumes a moderate amount of alcohol. Three months lat er she is admitted due t o series of seizures and carbamazepine levels are noted to be subtherapeutic. A pill-count reveals the patient is fu lly compliant. What is the most likely explanation?

Auto-inhibition of liver enzymes Prescription of omeprazole

Alcoho l binge

Dr

Auto-induction of liver enzymes

As se m

Prescription of fluoxetine

Auto-inhibition of liver enzymes

-

Prescription of omeprazole

~

Prescription of fluoxetine Auto -induction of liver enzymes Alcohol binge

Carbamazepi ne is a P450 enzyme induct or l ess ' m::~c rtant

As se m

Important for me

carbamazepine itself- auto-induction

Dr

Carbamazepine is an inducer of the P450 system. This in turn increases the metabolism of

A 24-year-old woman presents following a sudden, acut e onset of pain at the back of the ankle whilst jogging, during which she heard a cracking sound. Which one ofthe following medications may have contributed t o th is injury?

Metronidazole Nitrofurantoin Fluconazole

Dr

Terbinafine

As

se

m

Ciprofloxacin

Metronidazole

f.D

Nitrofura ntoin

GD

Fluconazole

CD

Ciprofloxacin

GD

Terb inafine

GD

Cipro floxacin may lea d to tendino pathy Important for me

Less imocrtc.nt

Dr

o ccur

As se m

This patient has classical signs o f Achilles tendon ruptu re. Tend o n d a mage is a we ll d ocum ented co mplication of qu inolone thera py. It appea rs to be an idio syncratic reaction, with the actual media n duration of treatment bei ng 8 days before problems

A 14-year-old girl is t aken t o the Emergency Department, aher being found lyi ng on her bed next to an empty bott le of pills prescribed for her mothe r. On examination she is agitat ed, has a clenched j aw and her eyes are deviated upward s. Which drug is she most likely t o have consu med?

Phenytoin Metoclopramide Amitriptyline

Dr

Nifedipine

As

se

m

Carbamazepine

A 14-yea r-old gi rl is taken to the Eme rgency Department, aher being found lyi ng on her bed next to an empty bottle of p ills p rescribed fo r her mother. On exam ination she is ag itated, has a clenched jaw and her eyes a re d eviated upwa rds. Which drug is she most li kely to have consumed ?

fD

Phenytoin

ED.

r :toclopram ide

Carbamazepi ne

fD

Nifed ip ine

CD As se m

I

fD

Amitriptyline

Dr

This is a classic d escription o f an ocu lo gyric crisis, a fo rm of extra pyra mida l disorder

A 46-year-old fema le with a backgrou nd of alcoho l excess has rout in e bloods checked by her GP. The magnesium result comes back as follows:

Magnesium

0.43 mmol/ 1

(Normal ra nge 0.7-1.0 mmol/1) What side effect of ora l magnesium replacement is likely to be the limiting factor w hen increasing the oral dosage?

Tachya rrhyt hm ias Vom iting

Flushing

Dr

Diarrhoea

As se m

Pruritus

Tachya rrhythm ias

CD

Vom iting

f!D

-

Pruritus Diarrhoea

(D

CD

Flus hing

Dr

As

se

m

Diarrhoea is the correct answer. Magnesium salts ca n be given as laxatives. Other uses for ma gnesium include polymorphic ventricular tachycardia (torsade de pointes), acute asthma an d prevention/treatment of seizures in pre-eclampsia.

A 62-yea r-o ld man presents fou r weeks a fte r initiating metfo rmin fo r typ e 2 diabetes me ll itus. His bo dy mass index is 27.5 kg/ m " 2. Despite slowly titrating the d ose up to SOOmg td s he has exp erienced sig nificant diarrhoea. He has tried red uci ng the d ose back d own to SOOmg bd but his symptoms pers isted. What is the most a ppro priate action?

Switch to p io glitazone 15mg o d Switch to g liclazide 40 mg od Sta rt modi fied relea se metformin SOOm g od with even ing mea l

se As Dr

Arra nge colon oscopy

m

Add loperamide a s requ ired

Swit ch to p ioglitazone lSmg od

I

Swit ch to gliclazide 40mg od Start modified release metformin SOOmg od w ith evening meal Add loperamide as required Arrange colonoscopy

Metformin shou ld be titrated slowly, leave at least 1 week before increasing dose Important for me

l ess 'mocrtont

As se m

If a patient is intolerant to standard metformin then modif ied -release preparations should patients intolera nt of st andard-release met formin.

Dr

be t ried. There is some evidence that t hese produce fewer gastroint estinal side-effect s in

A 43-year-old male presents to the Emergency Department after being foun d at home drowsy and unresponsive. His only regular medication is citalopram. The following arterial blood gas is obtained on arrival. pH

7.20 kPa

pC02

3.4 kPa

p02

13.0 kPa

Anion gap

24 mmol/ 1

Lactate

2.1 mmol/1

Glucose

5.6 mmolfl

(normal range anion gap: 12-16 mmol/1) Both ethanol and paracet amol levels are normal. Which of the following is the most appro priate treatment?

Flumazenil Naloxone

N -acetylcystei ne

Dr

Insulin infusion

As se m

Ethanol

Flumazenil

eD

Naloxone

G'D

Ethanol

ED

fD

Insulin infusion

(fD

N -acetylcystei ne

The causative agent here is ethylene glycol (antifreeze) . A background of depression and a raised anion gap that cannot be explained by lactic or ketoacid osis are clues towards intentional overdose of a toxin causing acidosis. By eliminating the other options, the only viable answer is ethanol. The blood gas shows metabolic acidosis with respirato ry compensation. Flumazenil would be used in benzodiazepine overdose, naloxone in opiat e overdose and n-acetylcysteine in pa racet amol overdose. Opiates and benzodiazepines are more likely to cause resp iratory acidosis through respiratory depression. In view o f t he normal glucose level this exclud es diabetic ketoacid os is and thus insulin infusion is not appropriate. Given the normal serum pa racet amollevels, n-acetylcyst eine is not indicated. N-acetylcysteine act s by p rotectin g hepatocytes from a toxic metabolite produced when the liver b reaks d own paracetamol. Paracetamol overdose wou ld also cause a high anion gap metabolic acidosis usually due t o an associated elevation in lact ate. The anion gap can be used to identify the cause of a metabolic acidosis. The ca lculation is as follows: (Na+ + K+) - (CI- + HC03-) Ra ised anion gap causes include: • lact ic aci dos is • ketoacidosis • renal fa ilure (high urate) • t oxins such as methanol, ethylene glycol. salicylates

The treatment for ethylene glycol poisoning includes oral or parenteral ethanol which competes w it h ethylene glycol p reventing toxic metabolit e formation. Methan ol poisoning would p resent in a similar fashion alth ough this is often associat ed with visual disturbance and occasionally b lindness. Fomepizole can also be used to treat ethylene

em

glycol poisoning.

Dr

often given based on cl inical suspicion.

As s

In most centres t here is a delay in obtaining ethylene glycol levels and t hus treatment is

A 44-yea r-old wo man with oestrogen receptor positive b reast cancer co mes fo r review, three months after starting ta moxifen. Which o ne o f the fo llowing a dve rse effects is most like ly to occu r in this patient?

Myalg ia Cata racts Alop ecia

se As Dr

Cervica I cancer

m

Hot flushes

Myalg ia

•

Cata racts

fD

Alopecia

flD

Hot flushes

CD

Cervical cancer

f!D

.

Tamoxifen may cause hot flushes l ess ' m ::~c rtont

As se m

Important for me

Dr

Alopecia and catara cts a re listed in the BNF as possible s id e -effects. They a re however no t a s p revalent as hot flu shes, which are very com mon in pre-menopa usal women

An elderly man is admitted t o the acut e medical unit w ith dyspnoea. He is know n to have ischaemic heart disease and chro nic heart failure (NYHA class III). He develops atrial fibrillation with a fast ventricular resp onse during his admiss ion. Which one of the following drugs is contra indicated?

Am iodarone Digoxin Bisoprolol

As se Dr

Warfarin

m

Flecainide

Am iodarone

CD

Digoxin

CD

Bisoprolol

(fD

.,

Flecainide

m As Dr

Flecainide is contraindicated in patient s w ith structural heart disease.

se

m

Warfa rin

A 52-year-old lady is admitted f rom the emergency department to t he int ensive care unit with sept ic shock second ary t o pyelonep hrit is. Despit e 4000ml o f IV 0.9% saline in the emergen cy d epartment she remained hypot ensive and was co mm enced on noradrenaline and a fixed d ose vasop ressin infusion. Unfortun ately, despite escalating doses of noradrenaline, her mean arterial pressure (MAP) remains SOmmHg (ta rget > =65 mmH g). She has a rising serum lact ate and she has produ ced only 25m I urine since admission 2h ago. Follow ing consult ation with your consu ltant you elect to start an adrenaline infusion in ad dition to t he vasopressin and noradrenaline. Which of the fo llowing biochemica l abnormalit ies can be expect ed on commencing an IV adrenaline infusion?

Hyperkalaemia Hypoglycaemia Hypernatraemia

Dr

Hypercalcaemia

As se m

Increase in lactate productio n

Hyperka lae t : _ Hypoglycaem ia Hypernatraemia

~rease in lactate production

-

Hypercalcaem ia

"""'

Adrena li ne induces hyperglycem ia, hyperlactatemia and hypokalaemia. Because insu lin secretion is suppressed by a lpha adrene rgic stimulation, p lasma concentration of insulin

As se m

rema ins low. Hyperglycem ia is induced by an increase in g lucose production caused by an increase in hepatic g lycogenolysis and an increase in g luconeogenes is. There is also a ma rked increase in oxygen consumption. In skeleta l muscle, epinephrine increases

decreases muscu lar proteolysis.

Dr

glycolysis and g lycogenolysis, inducing an upsurge in lactate. Muscular lactate serves as a substrate for hepatic neog lucogenesis (Cori cycle). Epinephrine a lso increases li polysis and

A 17 year-old male presents to the Emergency department after being fou nd collapsed at home. He has no past medica l history. He is afebrile. On exam ination he appears unwell. His Glasgow Coma Score (GCS) is 9 (eyes 2, voice 2, motor 5), and he has poor pupillary responses bilaterally. Fundoscopy revea ls macular oedema. His arteria l b lood gas on a ir is s hown: pH

7.21

pC02

4 .7 k Pa

p0 2

15.6 kPa

Na+

143 mmoi/ L

K+

4 .7 mmoi/L

HC03-

12 mmoi/L

Cl-

108 mmoi/ L

Glucose

12.4 mmoi/L

What is the likely diagnosis?

Diabetic ketoacidosis Ethylene glycol overdose Addisonian crisis

As s Dr

Vira l meningitis

em

Methanol toxicity

Diabetic ketoacid osis

6D

~hylene g lycol overaose I

fD

I

Addisonian crisis

CD

Methanol toxicity

CD CD

Viral menin gitis

This patient has features o f a raised anion-gap metabolic acid osis. The most important differentia ls g iven a re methanol toxicity o r ethylene glycol po ison ing, which cause a very s imilar b iochemical and clinica l p icture. Howeve r, the find ing of eye signs (macular oed e ma and poor pupilla ry responses) in the context of a drowsy patient with ra ised anion gap meta bo lic acidosis is strongly suggestive that methanol is the cu lp rit. In exams, cases invo lving methanol toxicity often invo lve patients not meeting your gaze or asking for the lights to be switched on, as well as the more traditiona l visua l acuity resu lts .

Dr

As se m

The patient"s blood gl ucose is not high enough to consid e r diabetic ketoacidosis. An Addisonian crisis would not typically generate a high a nion gap. Vira l mening itis is unli kely to cause collapse and impaired GCS, and wou ld not explain his aci dosis.

A 49-year-old man with a history of bipolar disorder, COPD and hypertension is started on a new anti-hypertensive medication. Two weeks later he is admitted to hospita l with lithium toxicity. Which med ication is most likely to have precipitated this?

Ramipril Am inophylline Atenolol

se As Dr

Doxazosin

m

Am lodipine

Ramipril

6D

Aminophylline

flD. CD

Atenolol

f!D

Doxazosin

. (D

Dr

As

se

m

Am lodipine

A 67 -yea r-old man has a fu ll blood count 8 days after being adm itted with a severe community-acquired pneumonia. He had been treated with intravenous antibiotics and subcutaneous low-mo lecular weight heparin as he had a history of deep vein thromobosis. The resu lts are as follows: Hb

13.0 g/1

Platelets

21 ~ 109/1

WBC

12.1 ~ 109/1

What is the most likely cause of the abnormalities in the blood test?

Antibodies against complexes of p latelet factor 4 (PF4) and heparin Antibodies against platelet -activating factor

Antibodies fo rm against factor VII

Dr

Antibodies against hepa rin act as agonists of the GP!lb/llla receptor

As se m

Antibodies fo rm against complexes of GPlb-IX-V and von Willebrand factor

-

Antibodies against comp lexes of p latelet factor 4 \(F4) and heparin

~

Antibod ies against p latelet-activating factor Antibod ies form against complexes of GPlb-IX-V and von Willebrand factor

"""'

Antibodies against heparin act as agonists of the GPIIb/llla receptor

~

m

Antibod ies form against factor VII

As

p latelet factor 4 (PF4) and heparin

se

Heparin-induced thrombocytopaenia - ant ibod ies form against co mplexes o f

l ess :mocrtant

Dr

Important for me

A 20-year-old stu dent drinks around 500 ml o f vodka at a party. The next morning he feels thirsty and finds he is passing more urine than normal. Which one of the follow ing best explains why people who drink excessive amounts alcohol develop polyuria?

Etha nol inhibits ADH secretion Etha nol induces vasoconstriction of the renal arteries Etha nol increases aquaporin proteins in the proximal convoluted tubule

Dr

Supratentorial reflex to cleanse the body of toxins

As

se

m

Osmotic diuresis induced by ethanol

Ethanol inhibits ADH secretion Etha nol induces vasoconstriction of th e renal arteries Ethanol incrj ases aquaporin proteins in the p roximal convoluted tubule

-

Osmotic diuresis induced by ethanol

~

Supratentorial reflex to cleanse the body of toxins

Ethanol reduces t he calcium-dependent secretion of anti-diuretic hormone (ADH) by blocking channels in the neurohypophyseal nerve terminal.

As se m

Nausea associated with hangovers is mainly due to vagal stimulation to the vomiting centre. Following a particular severe episode of alcohol excess people may experience for the previous inhibition by ethanol.

Dr

tremors. These are due to increased glutamat e p roduction by neurones to compensate

Which one o f the following s ide -effects is most associated with ciclosporin use?

Hepatotoxicity Bone marrow toxicity Red cell aplasia

Dr

Tinnitus

As

se

m

Haemorrhag ic cystitis

ED

Bone marrow toxicity

(D

Red cell aplasia

GD

Haemorrhag ic cystitis

CD

Tinnitus

GD

Ciclosporin may cause nephrotoxicity Important for me

As

se

m

Hepatotoxicity

l ess imocrtc.nt

Dr

I

The hos pital you wo rk at is o n red a le rt after a susp ected che mical attack in the city. Twenty five patients have been ad mitted to the hospita l. The patients are extremely unwe ll. Their sym ptoms inclu de salivation, lacrimatio n, diarrhoea, and emesis. Yo u are instructed by p ublic health that the most likely ag ent used was sarin g as. What is the mechanism o f actio n of sa rin g as?

Inhibition o f acetylcholineste rase Anti-cho li nerg ic

Seroto nerg ic

Dr

Sed ative -hypnotic

As se m

Sym pathomimetic

I

Inhibition of acetylcholinesterase

GD

Anti-cholinergic

GD GD

Sedative-hypnotic

m

Serotonergic

f.D

Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase Important for me

Less important

Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcho linesterase. This results in high levels of acetylcholi ne (ACh).

As s Dr

Organophosphate poisoning is treated with the anti-muscarinic atropine.

em

The effects of excessive ACh can be remembered by the mnemonic DUM BELLS: • Diarrhoea • Urination • Miosis/muscle weakness • Bronchorrhea/ Bradycardia • Emesis • Lacri mation • Salivation/ sweating

Which one o f the following is least recognised as a side-effect of sildenafil?

Blue disco lou ration o f vision Abnormal liver function test s Flushing

Dr

Non-arteritic ant erior ischaemic optic neuropathy

As

se

m

Nasal congestion

GD

Abnormal liver function tests

CD CD

Flushing

GD

Non-arteritic anterior ischaemic optic neuropathy

As

se

m

Nasal congestion

Dr

I

Blue disco lou ration o f vision

Which one of the following is not a recognised indication for the use of octreotide?

Acute variceal haemorrhage Acromegaly V! Poma

Dr

Hepatic encephalopathy

As

se

m

Carcinoid syndrome

GD

Acute variceal haemorrhage

. (D

Acromegaly

I~PomJ

flD f.D se As

I

ED.

Dr

I

Hepatic encephalopathy

m

Carci noid syndrome

A 23-yea r o ld g entle man presents to the emergency d epartment having ingested a pproximate ly 120 ml o f household b leach two hou rs a go. He has a background o f d e pression and p revious su icid a l id eatio n. Cu rrently he is re porting pa in on swa llowing sa liva s ince the in gestio n. Card iovascular, respirato ry and a bd om inal exam inatio n we re unre ma rka ble. The re is no e vide nce o f su rg ica l emphysema o r strido r. A chest x-ray is reported as no rmal. What is the most ap pro priate cou rse o f action?

Tria l of oral fluid, observe fo r 6 hou rs and discha rge if his sym ptoms d o not worse n Ni l by mouth, intravenous proton p ump inhibitor, o esophago -ga stroduodenoscopy in 5 days

Ni l by mouth, oesophago -g astrodu odenoscopy in 5 d ays

Dr

Ni l by mouth, intravenous proton p ump inhibitor, urgent oesophago g astroduodenoscopy

As se m

Inse rt a wid e-bore naso gastric tube and apply s uctio n

worsen Nil by mouth, intravenous proton pump inhibito r, oesophagogastroduodenoscopy in 5 days

-

......,

Insert a wid e-bore nasogastric tube and apply suction

I

Nil by mouth, intravenous proton p ump inhibito r, urgent oesophago-

g astrod uodenoscopy Ni l by mouth, oesophago-gastroduodenoscopy in 5 d ays

Early e ndosco py and risk stratification is im porta nt in patie nts with symptomatic caustic ingestion Important for me

Less ' m ::~c rtant

Caustic in gestion is a re latively common p resentation, with a re lative paucity of evidence to support its management. The co rrect answer here is early endoscopy, ideally within 12 hours (sometimes 24 hou rs dependent on local guida nce). It would seem te mpting to wa it until after the initial insult has passed until performing an endoscopy: however, most

Dr

As se m

guidelines advocate avo iding endoscopy between days 5 a nd 15 post ingestion when oesophag ea l stre ngth is at its lowest (based on experime ntal data fro m animal models). Both o ptio ns advocating delayed end oscopy a re therefore incorrect. Nasogastric tube insertion invo lves potentia l re-exposu re o f the upper GI tract to th e substance and is therefo re not advisable. A tria l of o ral fluid and observation may be app ropriate in asymptomatic patie nts however this patient has odynophagia and shou ld be investigated.

A 43-year-old gentleman present s to t he emergency department wit h central crushing chest pain. ECG shows anterior T wave inversion. He admits t o insu fflating t hree lines of cocaine around one hou r p rior to presentation. He is a heavy smoker but has no past medical hist ory. In ad dit ion to t he standard acut e coronary syndrome management, which f urthe r t reat ment should this pat ient be o ffered?

IV b eta-b locker IV alp ha-blocker

IV dext rose

Dr

IV haloperidol

As se m

IV b enzodiazepine

I

IV beta-b locker

tiD

IV alpha-blocker

CD

IV benzodiazepine

ED

IV ha loperidol

CD

IV dextrose

CD

Patients with MI secondary to coca ine use s hould be g ive n IV be nzodiazepi nes as pa rt of acute (ACS) treatment Important for me

Less ' m ::~c rtant

Dr

As se m

Consensus agreement from bodies such as the America n Heart Association recommend early IV benzodiazepine therapy in addition to ACS treatment in patients with cocainerelated MI. The benzodiazepi nes a re thought to temper the system ic effects of cocaine. Beta - blocker therapy is suggested to be avoided as unopposed alpha-activation in cocaine intoxication can worsen coronary spasm.

Which one o f the following adverse effects is most likely t o be seen in patients taking ciclosporin?

Hypertension Hypokalaemia Alop ecia

Dr

Atrophy of the gums

As

se

m

Dehydration

I

Hypertension

CD

Hypokalaemia

tiD

Alopecia

«!D

~ehydrati on

• GD se

m

Atro phy of the gums

l ess imocrtc.nt

Dr

Important for me

As

Ciclosporin side-effects: everything is increased - fluid, BP, K•, hair, gums, glucose

Which one of the following stat ement s is true regarding monoclonal antibodies?

They are produced by the polymerase cha in reaction Infliximab is useful in chronic lymphocytic leukaemia A hybridoma is a combination of human spleen ce lls and mouse B-cells

se

m

The constant region of the antibody is human in origin

Dr

percutaneous coronary interventions

As

Alemtuzumab is used in the prevention of ischaemic events in patients undergoing

They are produced by the polymerase cha in reaction Infliximab is useful in chronic lymphocytic leukaemia A hybridoma is a combination of human spleen cells and mouse B-cells

se

m

The constant region of the antib dy is human in origin

Dr

undergoing percutaneous coronary interventions

As

Alemtuzumab is used in the prevention of ischaemic events in patients

A 46-year-old man with a history o f hyperlipi daemia is reviewed in clinic. He is currently t aking simvastatin l Omg on but his cho lesterol level remains high. Previou s attempts to increase the dose of simvastatin have resulted in myalgia. Given the histo ry of myalgia, which lipid-regulating drug shou ld b e avoided?

Nicotinic acid Beza fibrate Colestyramine

As se Dr

Ezetimibe

m

Omega-3 fatty acid

fD

Nicotinic acid

CD

r :afibrate

GD

Colestyramine

CD

Omega-3 fatty acid

fD

Ezetimibe

Dr

As se

m

Tough question as both fibrates and nicotinic acid have been associated with myos itis, especially when combined with a statin. However, the Com mittee on Safety of Medicines has p roduced guidance which specifically warns about the concomitant prescription of fibrates with statins in relation to muscle toxicity

A patient known to have bipolar disorder presents to the Emergency Department with confusion. Wh ich one of the following drugs is most likely to precipitat e lithium toxicity?

Frusemide Sodium valproate Digoxin

Dr

Bendroflumethiazide

As

se

m

Sodium bicarbonate

fD

Frusemide Sodium valproate

CD

Digoxin

. (D

Sodium bicarbonate

•

ED As

se

m

Bend roflumethiazide

Dr

The BNF states that 'loo p diuretics are safer than thiazides' in the interactions sect ion.

A 62-year-old is started on allopu rinol prophylaxis following h is second episode of gout in the past 12 months. What is the mechan ism of action o f a llopurino l?

Promotes excretion of uric acid Causes the d epolymerisation of intracell ula r microtub ules Uric acid chelator

Dr

Xanthine oxidase activator

As

se

m

Inhibits xanthine oxidase

Pro motes excretio n of uric acid

CD

Causes th e depolymerisation of intracell ula r microtubu les

CD

Uric acid chelator

m GD

Inhibits xanthine oxidase

CD

Xa nthine oxidase activato r

Allopurinol inhibits xanthine oxidase l ess ' m ::~c rtont

As se m

Important for me

Dr

Xa nthine oxida se is responsible for the oxidation of 6-mercaptopurin e to 6 -thiouric a cid

You are counsell ing a 20-year-old female who is planning to start taking the combined oral contraceptive pill. Which of the following statements is correct?

She will still be protected against pregnancy if she takes amoxicillin for a lower respirato ry tract infection while on the combined pill She should not take the com bined pill if she has heavy periods

Dr

There is only one type and brand of co mbined pill

As

se

She will not require any monitoring once she has started taking the co mbined pill

m

She is like ly to put on 2-3 kilograms of weight per yea r while using the combined pill

I

She will stil l be protected against pregnancy if she takes amoxici ll in for a lower respiratory tract infection while on the combined pill

-

She shou ld not take the combined p ill if she has heavy periods

..wr

She is like ly to put on 2-3 kilograms o f weight per yea r while using the combined pill She will not require any monitoring once she has started taking the combined p ill There is on ly one type and brand o f combined pill

There is no evidence that antibiotics other than enzyme inducing antibiotics such as rifa mpicin reduce the effica cy of the comb ined o ra l contraceptive pill Important for me

l ess : m ::~c rtont

It was previously a dvised that barrier methods of contraception should be used if taking an antibiotic while using the contraceptive p ill, due to concerns that antib iotics might reduce the absorption of the p ill. This is now known to be untrue. Howeve r, if the absorptive ab ility of the gut is comprom ised for another reason, such as severe diarrhoea or vomiting, or bowel disease, this may a ffect the efficacy of the p ill. The exception to the antibiotic rule is that hepatic enzyme- indu cing anti biotics such as rifa mpicin and rifaximin do reduce the efficacy of the p ill. Other enzyme-inducing drug s, such as p henytoin, phenobarb ital, carbamazep ine o r StJohn's Wort can also reduce the effectiveness of the pill. The other statements are not true. The comb ined p ill is often p rescri bed for women with heavy p eriods as it can make them lighter and less pa infu l. There is no evidence that women on the comb ined pil l put on any significant weight, a lthoug h they may experience b loating at certain times in the course. Women on the p ill require monito ring of their b lood pressure. The re are multiple d ifferent types of comb ined p ill.

BNF: https:// b nf.nice.org. u k/treatm ent-summa ryI contra ce pt ives- interactions. htm I

As s

em

NICE - the gui de to the comb ined contraceptive p ill: pill.as px

Dr

https:/jwww.nhs.u k/co nd iti ons/contraception-guide/pages/ combined -co ntraceptive-

What is the mechanism of actio n of flecai nide?

Calcium channel blockers Potass ium channe l blocker Sodium channel blocker

Dr

ADP receptor antagonist

As

se

m

Potassium channe l activator

CD

Calcium channel blockers

GD

Potassiu m channe l blocker

GD

p odium channel blocker

f.D se

m

As Dr

~p recepto r antagonist

m

Potassium channe l act ivator

A 29-yea r-old male with testicular cancer is receiving cisplatin-based che mothe rapy. He has b een give n d examethasone, metoclopramide an d apre pitant prior to receiving chemotherapy. He is now ag itated, very anxious and co mpla ining of ab norma l eye movements. What is the best immediate treatment?

Aspirin IV b enztrop ine Hydrocortisone and p ro methazine

As se Dr

Lorazepam

m

Cease cisplatin

Aspirin IV b enztropine

-

Hydrocortisone and promethazine

~

Cease cisplatin Lorazepam

An oculogyric crises, which is w hat the patient is experiencing, is a dystonic reaction to

As se

metoclopram ide and haloperidol) cha racterized by a prolonged involuntary upward

m

drugs, in particular neuro leptics and dopaminergic medications (classically

is benztropine.

Dr

deviation (bilat eral elevation o f the visual gaze) of the eyes. The standard remedy for this

A 78-year-old woman with a history of recurrent ventricular tachycardia has routine blood tests 3 months after starting amioda rone therapy:

TSH

14.5 mu/ 1

Free T4

8 . 2 pmol/1

How should her thyroid dysfunction be managed?

Continue amiodarone and add folic acid Stop amiodarone and start thyroxine

Continue amiodarone and add thyroxin e

Dr

Stop amiodarone and repeat bloods in 4 weeks

As se m

Stop amiodarone and add carbimazole and thyroxine

-

Continue a miodarone and add fo lic acid

~

Stop am ioda ro ne and sta rt thyroxine Stop am ioda ro ne and ad d carbimazo le a nd thyroxin e

I

Stop am ioda rone and repeat bloods in 4 weeks Continue a miodarone and add thyroxine

Dr

As

se

m

Patients who d evelop hypothyroidism whilst ta kin g amioda rone can continue to take the drug if this is desirable. Give n that this patient has a histo ry o f ve ntricular tachycardia it would be unwise to withdraw am iodarone abruptly

A 39-year-old woman who has recently been diagnosed with hypertension comes for review. She is sexually active but does not cu rrently use any form of contraception other than barrier methods. Which one o f the following medications should be avoided?

Hydralazine Nifedipine Methyldopa

Dr

Lisinopril

As

se

m

Labetalol

I I

Hydralazine

fl'D

Nifedi pine

GD

Methyldopa

GD

Labeta lol

. (D

Lisinop ril

ED

When prescribing this woman shou ld be treated as if she were p regnant g iven the absence o f effective contraception. AC E inhibito rs such as lisinopril a re known te ratogens and most be avoided.

As se m

NICE a re ve ry clear on this point:'Offer antihypertensive drug treatment to women of child-

Dr

bearing potential in line with the recommendations on Management of pregnancy with chronic hypertension·

A 37 -year-old man with a history o f alcohol excess is admitted with alcohol-withdrawal seizures to the acute medical unit. Admission bloods show the following: Na•

137 mmol/ 1

K•

3.0 mmol/1

urea

2.0 mmolfl

Creatinine

78 IJmol/1

Calcium

2.03 mmol/ 1

What other blood abnormality is he also most likely to have?

Hypomagnesaemia Elevated ammonia levels

Raised bilirubin

Dr

Partially compensated met abolic alkal osis

As se m

Hypophos phataemia

Hypomagnesaemia Elevated ammonia levels Hypophos phataemia

-

Partially com pensated met abolic alka losis

Dr

Ra ised bilirubin

As

se

m

"""'

Which of the following relat ing to St John's Wo rt is false?

Adverse effect s in trials is similar to pla cebo May cause serotonin syndrome Mechanism of action is similar t o selective serotonin reuptake inhibito rs

se As Dr

Has been shown to be effective in treating mild -moderate d epression

m

Causes inhibition o f t he P450 system

Adverse effects in trials is s imilar to p la cebo

-

May cause seroton in syndrome

~

Mechanism of actio n is similar to selective seroton in reuptake inhibitors Causes inh ibition of the P450 system

StJohn's Wort is a known inducer o f the P450 system

Dr

As

se

m

Has bi en shown to be effective in treating mild-moderate d e pression

A 71-year-old man who has atrial fibrillation and heart failure is started on digoxin. What is the mechanism of action of digoxin?

Blocks Ca2+ release fro m the sarcoplasmic reticu lum Blocks Na• entry into myocytes Agonist of the myocyte sodium-calcium exchanger

Dr

Inhibits the Na./K• ATPase pump

As

se

m

K• channel blocker

Blocks Ca2+ release from the sarcoplasmic reticu lum +

Blocks Na

-

entry into myocytes

~

Agonist of the myocyte sodium -calcium exchanger channel blocker +

/K

+

ATPase pump

Digoxin - inhibits the Na+/K+ ATPase pump Important for me

As

se

m

Inhibits the Na

+

Less impcrtont

Dr

I

K

Which of the following may reduce the action of aminophylline in patients?

Ciprofloxacin Acute ethanol consumption Omeprazole

Dr

Erythromycin

As

se

m

Smoking

Ciprofloxacin Acute ethanol consumption Omeprazole Smoking Erythromycin

Smoking is a P450 enzyme inductor

Smoking is known to in duce CYP1A2 isoenzyme, reducing the effectiveness of aminophylline

As se m

Less 'mpcrtant

Dr

Important for me

A 49-year-old homeless gentlemen is brou ght to the emergency department with a reduced glasgow coma scale o f 14/15. His pupils are equal but poorly rea ctive t o light and he is complaining of poor eyesight. An ABG is performed. pH

7.21

p0 2

12.3 kPa

pC02

4 .7 k Pa

HC0 3-

14 mmol/1

Na+

140 mmol/ 1

K+

3 .6 mmol/1

Cl-

102 mmol/ 1

Lactate

2.3 mmol/1

Which subst ance is he most likely to have ingested?

Alcohol Methanol

Ethylene glycol

As s

em

Am itriptyline

Dr

Jrer

Aspirin

I

Asp irin

f!D

Alcohol

CD

ED

Methanol

•

Am itriptyline

QD

Ethylene g lycol

This is a com mo n MRCP q uestio n. The inclusion o f a n ABG with a meta bo lic a cidosis invites the read er to calculate the anion g a p. In this case {[Na +) + [K +)} - {[HC03-) + [CI -)} = 27.6 mmol/1 A ra ised anio n ga p metabo lic acidosis - a ll of the possible answe rs he re may p rod uce this p ictu re . As this man is homeless and we a re given no fu rthe r info rmation the most li ke ly causes fo r his p resentatio n a re a lcohol, metha no l a nd ethylene g lycol (a nti- freeze). The answe r he re is indicated by the reduced vision and poorly reactive pupils - a com mon comp lication of methanol poisoning . A meta bo lite o f methanol, fo rmic a cid, accu mulates in the o ptic nerve causing visua l d isturbance a nd eventua lly bli ndness. Alcoho l a nd ethylene g lycol wo uld not p rod uce these visual changes.

As s

~

I •• I •

D ic:r • •sc: f?:)

I

Tm

nrow::~o

J

Dr

orer

em

Aspirin ove rdose mig ht a lso be associated with a respiratory alkalosis - not seen he re . Desp ite the li mited info rmation this p resentatio n d oes not su gg est tricyclic ove rdose you would expect dilated pupils a nd a history of d epression.

What is the most commo n adverse effect experienced by women taking the progestogen only pill?

Irregular vag ina l bleeding Acne Mood swings

Dr

Weight gain

As

se

m

Reduced libido

Irregular vaginal bleeding Acne Mood swings

Dr

Weight gain

As

se

m

Reduced libido

A 16-yea r-o ld gi rl is a dmitted to the Emergency Department late on a Friday night. She is comp laining of palpitations and feeling 'unwell'. Her friend s state that she has had a bad reaction to the alcohol they've been drinking and deny the use o f any illicit substances. On exam ination she is agitated and cl utching her chest. Her pu pils are myd riatic and the pulse rate is 108/ mi n, blood p ressure 130/ 90 mmHg. She says that she is going to be sick. Which of the following substances may account fo r this presentation?

Cannabis Coca ine

Ketam in e

Dr

Hero in

As se m

LSD

CD

Cocaine

CD

LSD

GD

~oin

(D

se

m.

As

Ketamine

Dr

I

m

Cannabis

Which one of the following drugs is most likely to cause impaired glucose tolerance?

Beza fibrat e Simvastatin Nicotinic acid

Dr

Gem fibrozil

As

se

m

Cholestyramine

Simvastatin

fl!D

Nicotinic acid

CD

Cholestyramine

GD

Gemfibrozil

f!D

Important for me

As

Glycaemic control in diabetes may be worsened by nicotinic acid

se

m

f1D

l ess 'mocrtont

Dr

I

Bezafibrate

What is the most a p pro priate time to take b lood samples fo r the rapeutic mon itoring o f ciclosporin leve ls?

6 hours after last dose Immed iately before next dose At any time

Dr

4 hours after last dose

As

se

m

12 hou rs a fte r last dose

GD

Immediately befo re next dose

e:D fD

6D

4 hours after last dose

se

m

12 hours a fter last dose

As

At any time

fD

Dr

I

6 hours after last dose

Which one of the followin g adrenocepto rs cause vasoconstriction and relaxation of GI muscle in response to sympathetic stimulation?

Alpha-1 Alpha-2 Beta-1

Dr

Beta-3

As

se

m

Beta-2

CD

Alpha-2

fD CD

Beta-2

«ED

Beta-3

f.D

se

m

Beta-t

As

I

Alpha-1

Dr

I

A 65-year-old man presents to the Emergency Department with lethargy and leg swell ing. Initia l bloods show the followi ng: Na+

138 mmol/ 1

K+

5.6 mmolfl

Urea

19.3 mmol/ 1

Creatinine

299 ~mol/1

His renal fu nction six months ago was normal. Which one of his regular medications is it most important to stop straight away?

Ibuprofen Warfa rin

Atenolol

Dr

Diazepa m

As se m

Paracetamol

. GD

Ibuprofen

m

Paracetamol

CD

Diazepa m

CD

Atenolol

m se

m

Warfarin

in patients w ith acute kidney injury or chronic kidney disease.

Dr

As

NSA!Ds such as ibuprofen can significantly wo rse n rena l impairment and must be avo ided

Doxazos in is a:

Alpha-1 antagon ist Alpha-1 agonist Non-selective a lpha antagonist

Dr

Alpha-2 antagon ist

As

se

m

Alpha-2 agonist

I

Alpha-1 antagon ist

-

Alpha-1 agonist

I

~

Non -selective a lpha antagonist

'"""'

Alphl -2 agonist

Alpha-2 antagon ist

se

m

'"""'

and ben ign prostatic hypertrophy

Dr

As

Doxazosin is an alpha-1 adrenoceptor antagonist used in the treatment of hypertension

A 58-year-old male patient present s to the ophthalmology w ith deteriorating vision. He reports a 6-months hist ory of gradually worsening blurred vision. His past medica l hist ory includes a history of ventricu lar t achycardia, angina, hypertension, hypercholesterolaemia, type 2 diabetes mellitus and recent malaria. Slit-lamp examination reveals bilat eral diffuse corneal opacity. What is the most likely medication to have caused this clinical pictu re?

Ethambut ol Aspirin Bisoprolol

Dr

chloroquine

As se m

Am iodarone

GD

Ethambutol

-

spirin

CD

Bisoprolol

I

Amiodarone

.,

chlo roqu ine

ED

Amiodarone can cause cornea l opacities Important for me

Less · m ::~c rtant

Am iodarone is t he only medication from t he opt ions to be known to cause corneal opacification.

Chloroqu ine can cause retinopathy but corneal opacif ication is unusual.

Dr

Ethambut ol can cause optic neuritis but cornea l opacificat ion is unusual.

As se m

Aspirin and b isoprolol are not known to cause cornea l opacification.

Which one o f t he followin g features is least associated wit h ecst asy poisoning?

Rhabdomyolysis Hyperthermia Ataxia

Dr

Hypernatraemia

As

se

m

Hypertension

GD

Rhabdomyolysis

. CD

Hyperthermia

CD.

Ataxia

CD

Hypef e nsion

CD m

Hypernatraemia

se

Ecstasy is thought to stimu late the prod uction of anti-diuretic hormone. Users of ecstasy

Dr

As

a lso commonly drink to much water in the (mistaken) belief that this will protect them from the adve rse effects.

Of the following, which one is the most usefu l prognostic ma rker in pa raceta mol ove rdose?

ALT

Prothrom bin time Paracetamolleve ls at presentation

Dr

Paracetamolleve ls at 24 hours

As

se

m

Paracetamolleve ls at 12 hou rs

ALT

Prothrom b in time Paraceta molleve ls at presentation Paracetamolleve ls at 12 hou rs

m

Paracetamolleve ls at 24 hou rs

Dr

As

se

An e leva ted prothro mbin time s ig nifies live r fa ilure in pa racetamol ove rd ose and is a ma rke r o f p oo r p ro g nosis. Howeve r, arte rial pH, creatinin e a nd encephalo pathy a re also ma rke rs of a need fo r live r transp la ntatio n

What is the mechanism of action of hepa rin?

Activates antith rombin ni Vitamin Kantagon ist Activates tissue plasminogen activator

Dr

Inhibits protein C

As

se

m

Inhibits antithrombin III

GD

Activates antithrombin ni Vita min Kantagon ist

CD

Activates tissue plasminogen activato r

m 6D CD

Dr

Inhibits protein C

As

se

m

Inhibits antithrombin III

A 44-yea r-old Bangladeshi man with a history of mitral stenosis and atrial fibrillation is diagnosed with tuberculosis. He is commenced on anti-tuberculosis therapy. Th ree weeks after starting treatment his INR has increased to 5.6. Which one of the following medications is most likely to be responsible for this increase?

Pyrazi namide Iso niazid Rifa mpicin

Dr

Streptomycin

As

se

m

Ethambutol

CiD

Pyrazinamide

I

Isoniazid

C!D

Rifa mpicin

ED

Etha mbutol

m

Streptomycin

fD

Isoniazid inhibits the P450 syste m Important for me

Less imoc rtc.nt

Dr

As se m

It is impo rtant when answering questions relating to liver enzymes to be su re whether the question is asking about inductio n or inhibition. Drugs causing indu ction are ohen well known and candidates may rush to give these as the answer. A raised INR is a result of inhibited liver enzymes

What is the mechanism of action of tacrolimus?

Mercaptopurine ant agonist Interferes with purine synthesis Inhibits inosine monophosphate dehydrogenase

Dr

Decreases IL-2 release by inhibiting calcineu rin

As

se

m

Monoclonal antibody against IL-2 receptor

Mercaptopurine antagonist Interferes with pu rine synthesis Inhibits inosine monophosphate dehydrogenase

m se As

Decreases IL-2 release by inhibiting calcineurin

Dr

I

Monoclonal antibody aga inst IL-2 receptor

A 54-yea r-old obese man presents with lethargy and polyu ria . A fasting blood suga r is requested: Fasting glucose

8.4 mmoljl

He is g iven dietary advice and a decision is made to start metformin. What is the most appropriate p rescription?

Metformin SOOmg od with food for 5 d ays then metfo rmin SOOmg bd for 5 days then metformin SOOmg tds for 20 days then review Metformin SOOmg td s with food

Metformin SOOmg td s taken at least 1 hour before meals

Dr

Metformin lg tds with food

As se m

Metformin SOOmg od with food for 14 days then metformin SOOmg bd for 14 days then review

fiD

Metformin SOOmg od with food for 5 d ays then metformin SOOmg bd for 5 days then metformin SOOmg td s for 20 days t hen review

(D

Metformin SOOmg td s with food etformin SOOmg od with food for 14 days then metf.ormin SOOmg bd for 14

GD

ys then review Metformin 1g td s with food

D

Metformin SOOmg td s taken at least 1 hour befo re meals

8

Metformin shou ld be titrated slowly, leave at least 1 week before increasing dose Less ' m ::~c rtant

As se m

Important for me

The BNF advises leaving at least 1 week before increasing the d ose.

Dr

Gastrointest inal side-effects are more likely t o occur if metformin is not slowly tit rat ed up.

A 43-year-old man with a history of bipolar disorder is admitt ed with acute conf usion. Whilst b eing t ransferred to hospita l he ha d generalised seizu re wh ich terminated spontaneously after aroun d 30 seconds. On arrival in the Emergency Department his GCS is 14/ 15 and he is noted t o have a coarse t remor. A diagnosis of lithium toxicity is suspected. Intravenous access is obt ained, bloods are ta ken and a saline infusion is started. Blood results reveal the following: Lithium level

4 .2 mmol/1

Na•

136 mmol/ 1

K•

4 .6 mmolfl

Urea

8 . 1 mmol/1

Creatinine

99 iJmoljl

Bicarbonate

18 mmol/ 1

What is the most app ropriate management?

Arra nge haemodialysis Int ravenous magnesium

Arra nge plasma exchang e

Dr

Int ravenous hypertonic sal ine

As se m

Int ravenous bicarb onate

.,

Intravenous magnesium

m

Intravenous bicarbonate

flD f.D

Arrange plasma exchange

f.D

m

Intravenous hypertonic saline

As

se

I

Arra nge hae modialysis

Dr

The high lithium level and reduced GCS are an indication for haemodialysis in this patient.

A 62-yea r-old man is com me nced o n finaste ride fo r symptoms of bladd e r outflow o bstruction. Which one of the fo llowing adve rse effects is most associated with this treatment?

Alo pecia Gynaecomastia Prosta te ca nce r

Dr

Po stural hypotensio n

As

se

m

Increased levels of serum prostate s pecific antigen

m

Alopecia Gynaecomastia

.,

Prostate cancer

CD GD

Postural hypotensio

6D

Dr

As

se

m

Increased levels o f serum prostate specific antige n

You are working in oncology. You are reviewing a 55-year-old woman in cli nic with St age !Vb metastatic melanoma. Her disease has sprea d to her liver, lungs and her bra in. Her BRAF st atus is negative. She has been treated with a co mbination of nivo lumab and ipilimumab for the last four month s with a good response. Her recent re-staging CT scan showed no new sites of disease and a good reduction in tumour size. However in the last four weeks she has felt particu larly low in mood and complains that she ohen feels fatigued and lacking energy. She has also complained of a vague int ermittent abdominal discomfort. What would be your first investigation?

Thyroid function test s Screen the patient for depression

CT of the abdomen and pelvis

Dr

Synacthen t est

As se m

MRI of the brai n

Thyroid f unction test s Screen the patient for depression

-

MRI of th e bra in

. .wr

Synacthen test CT of the abdomen and pelvis

Nivoluma b (PD -1 inhibitor) and ipi limumab (CTLA-4 inhibito r) are checkpoint inhibitors which are used in the treatment of metastatic melanoma. Effects on t he endocrine system are being increasingly reported w ith prolonged therapy (hypophysitis and hypot hyro idi sm) and therefore it is important to assess patients caref ully who present with symptoms o f hypothyroidism whilst on these drugs. Answer 2 is not unreasonable but an organic cause fo r her sympto ms must be ruled out first. The vague abdominal discomfort may be constipation related to the hypot hyroidism although many other causes in so meone with metastatic malignancy cou ld be associated. Even so, answer 5 should not be the first investigation. Even though the cancer is responding to treatment

As se m

the patient has new symptoms which should warrant investigation. Answer 3 is wrong; an this scenario.

Dr

MRI is not indicated here. Answer 4 is to test for Addison 's disease which is incorrect in

A 25-year-old woman is diagnosed with a uri nary tract infection. She has a past history of epilepsy and is cu rrently taking sodium valproate. Which one of the fo llowing antibiotics should be avoided if possible

Co-amoxiclav Nitrofurantoin Cefixime

Dr

Ciprofloxacin

As

se

m

Trimethoprim

Co-amoxiclav

m

Nitrofurantoin

CD

ll fixime

CD

Trimethoprim

fiD

Ciprofloxacin

GD

Ciprofloxacin lowers the seizure threshold Important for me

l ess imocrtc.nt

As se m

Whilst many antibiotics can lower the seizure thres hold, this effect is seen particularly with a history of epilepsy, or conditions that predispose to seizures'

Dr

quinolones. The BNF advises that quinolones 'shoul d be used with caution in patients with

A 21-year-old woman presents to t he emergency department w ith confusion, agitation and sweating. Her friends report she has taken an unknown quantity of ecstasy (3,4Methylenedioxymethamphetamine, MDMA) app roximately two hours ago. She is taking sertra line for depression, but has no o t her past medical history. She has no known drug allergies. Neurologica l examinat ion reveals globally increased muscle tone, hyperreflexia and clo nus. Her tym panic membrane temperatu re is 41.2° C. Which management strategy wou ld be most app ropriate?

Cyproheptadine Pi peraci llin/Tazo bactam

Dimercapro l

Dr

Alteplase

As se m

Lipid emulsion therapy

I I

CiD

Cyproheptadine Pi peraci llin/Tazo bactam

CD

Lipid emulsion therapy

fD CD

Alteplase

fiD

Dimercap rol

SSRls + MDM A = higher risk o f serotonin syndrome Important for me

Less impcrtont

This is serotonin syndrome. The com bination of two or more sero tonergic medications greatly increases the risk: in th is case an selective serot on in uptake inhibitor (sertraline) and MDMA. Cyproheptadine is an Hl and nonspeci fic SHT antagonist, recommend ed for treatment of severe serotonin syndro me. Piperacillin/tazobact am is a b road sp ectrum

As se m

beta -lactam antibiotic, often used to t reat sepsis. Lipid emulsion the rapy is used in local anaest hetic toxicity and may also be cons id ered in t ricycl ic overdose. Alteplase is the metal poisoning.

Dr

thro mbolytic ag ent most commonly used in acut e st roke. Dimercaprol is used in heavy

A 23-year-old man is admitted to the emergency department aher being found by his friends 'collapsed' in the bathroom at a house party. On admission he is initially incoherent and combative but settles following diazepam. Thirty minut es aher admission he remains tachycardic with a pulse of 108/ min, blood pressure 144/ 90 mmHg and temperature 37.3°C. You are asked to review him again as he is com plaining of severe abdominal pain. He also reports passing some blood in his stool (which was looser tha n normal) when he went to the toilet 5 minutes ago. What is the single most likely cause of his abdominal pain?

Bleeding duodenal ulcer Haemorrhagic pancreatitis Ischaemic colitis

Dr

Ruptured aortic abdominal aorta

As se m

Disseminat ed intravascular coagu lation

Bleeding duodena l ulcer Hae f1orrhag ic pancreatitis

lschaemic colitis Dissem inated intravascula r coagu lation

se

m

Ruptured aortic abdo mina l aorta

Dr

As

Ischaemic colitis is a recognised p henomenon fo llowing cocaine ingestion a nd should be considered if patients develop abd om inal pa in or rectal bleeding.

A 59-year-old man with a known history of type 2 diabet es mellitus, atrial fibrillation and epilepsy presents as he is feeling generally unwell. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?

Phenytoin Metformin Sildenafil

Dr

Digoxin

As

se

m

Pioglitazone

Phenytoin

f.D

Metf ormin

• fZD

Sildenafil

CD

Pioglitazone

GD

Digoxin

Visual changes secondary t o drugs

Important for me

Less impcrtont

Dr

• yellow-green vision: digoxin

As se m

• blue vision: Viagra ('the blue pill')

A 62-yea r-old male with a history of type 2 diabetes mellitus is investig ated for lethargy. Blood tests are as follows: Na•

139 mmol/ 1

K•

4 .2 mmolfl

Bicarbonat e

15 mmol/ 1

Chloride

105 mmol/ 1

urea

15.2 mmol/ 1

Creatinine

267 J,Jmol/ 1

Glucose

9 .2 mmolfl

Which one o f the followin g is most likely to be contributing to the low bica rbonate value?

Vom iting due to gastropares is Renal tubular acidosis

Rosig litazone

Dr

Metfo rmin

As se m

Addison's disease

Vom iting due to g astro pa resis Renal t ubular acid osis Addison's disease Metformin Rosig litazone

Althou gh ra re, lactic acidosis is an important sid e-effect of metfo rmin Important for me

l ess ' m::~c rtant

The rai sed a nio n ga p is aga inst a diagnosis o f renal tub ula r acidosis.

Dr

it is important to exclude lactic acidosis seconda ry to metfo rmin.

As se m

Whil st the d ecreased bica rbonate va lue may be wo rsened by de te rio rating renal functio n,

Which one of the following is a mixed alpha and beta adrenoceptor antagonist?

Doxazosin Phenoxybenzamine Yohimbine

Dr

Carvedilol

As

se

m

Propranolol

CD

Doxazosin

CD

Yohimbine

GD

Propranojl ol

CD

Carvedilol

CD

Dr

As

se

m

Phenoxybenzamine

A 18-yea r-old ma le is admitted aher deliberately ingesti ng 40 gra ms o f pa racetamo l. Twenty-four hours ah e r adm ission he is reassessed with a view to live r transplantation. Of the following, which one wou ld most strongly indicate the need for a live r tra nsp lant?

CRP 306

Arterial p H 7.25 Creatinine 267 IJmol/1

Dr

INR 5.7

As

se

m

Grade IV encephalopathy

•

CRP 306

ED

Arterial pH 7.25 Creatinine 267 llmol/1

'

CD fD

INR 5.7

tiD se

m

Grade IV encephalopathy

Dr

and I NR must all be grossly abnormal otherwise

As

The arterial pH is the single most important factor. The creatinine, encephalopathy grade

Which one of the following pairs of features wou ld be expected to occur fo llowing administratio n of an anticholinesterase (acetylcholinesterase inhibitor)?

Bradycardia and miosis Bradycardia and urinary retention Tachycardia and diarrhoea

Dr

Tachycardia and lacri mation

As

se

m

Bradycardia and mydriasis

Bradyca rdia and miosis

ED

Bra dyca rd ia and urina ry retention

CfD

Tachycl dia and d ia rrhoea

GD

Bra dyca rd ia and mydriasis

QD

Tachycardia and lacri mation

f!D

Organophosphate insecticide p oisoning - bradycardia

As se m

A clin ical exa mple of an anticholi nesterase is organophosphate compounds

l ess :mocrtc.nt

Dr

Important for me

A 71-year-old man is prescribed digoxin fo r new onset atrial fibrillation. His doctor explains that the full effect will not be seen for one week. Which one of the following is responsible fo r this delayed effect?

Clearance Volume of distribution Absorption

Dr

Half- life

As

se

m

First pass metabolism

m

Clearance

ED

Volume o f distribution

First pass metabolism

GD

Half-life

ED. se

I

(D

Abrorption

m

I

Dr

levels are seen

As

The half-l ife of digoxin is arou nd 36-48 hours. This results in a delay before steady plasma

In which one of the following conditions is intravenous immunoglobuli n therapy most Iikely to be beneficia I?

Graves' ophthalmopathy Kawasaki disease Inclusion body myositis

Dr

Rheumatoid arthritis

As

se

m

Multiple sclerosis

In which one of the fo llowing conditions is intravenous immunoglobu lin therapy most

Ii kely to be beneficia I?

Graves' ophthalmopathy Kawasaki disease Inclusion body myositis

As Dr

Rheumat oid arthritis

se

m

Multiple sclerosis

A 27 -yea r-old female patient p resents to the e mergency de partment with a 4-d ay history of a rash. She reports having taken an overdose of a a medication 1 day p rior to the rash d evelop ing but she refuses to say what she took. She has no past medical history of note but has a history of recu rrent d epress ion and p revious overdose. No fam ily history of note. On p resentation, her observations are: heart rate 56 beats per minute, blood p ressure of 127/72 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 100% on air. On examination, you note a g eneralised non- bla nching petechial rash. Blood resu lts are as follows. Na•

134 mmoi/L

K•

4 .8 mmolfl

Hb

130 g/ L

Platelet

75 x 109/L

Which is the most likely medication she took?

Ibu profen Pa racetamol

Simvastatin

Dr

Sertra line

As se m

Amlodipi ne

GD

Ib uprofen

-

. (D

Paracf amol

• •

Am lod ipine

ED

Sertraline Simvastatin

NSA!Ds a re a cause o f th rom bocytopenia Important for me

Less : m ::~c rtant

thrombo cytopaen ia .

Dr

Paracetamol, am lod ipine, sertraline and simvastatin do not usually cause

As se m

This patient has evidence of thrombocytopaen ia, like ly secondary to NSA!Ds.

Which one o f the fo llowin g enzymes is invo lved in p hase I drug meta bolism?

UD P-glucuro nosyl transferases Pyruvate ca rb oxylase Succinic d e hyd rog enase

Dr

Alcoho l d ehydroge nase

As

se

m

N-acetyl transferases

UDP-glucuronosyl transferases

«D

Pyruvate ca rboxylase

GD CD

Succinic dehydrogenase

GD se

ED

As

I

Dr

I

Alcoho l dehydroge nase

m

N-acetyl transferases

A 29-year-old wo man is admitted to the Emergency Department with ca rb on monoxide poisoning. High-flow oxygen is applied on arrival. Which one of the following is not an indication for hyperbaric oxygen therapy?

A carboxyhaemoglobin concentration o f 16% Arrhythmia Extrapyramidal features

Dr

Pregnancy

As

se

m

Loss of consciousness w hen initially fou nd by paramedics

A carboxyhaemoglobin concentration of 16%

-

Arrhythm ia

"""'

Extra pf amidal features Loss of consciousness when initially found by paramedics

Heavy smokers may have a carboxyhaemoglobin concentration of 10-15%

Dr

As

se

m

Pregnancy

Which one o f t he followin g is no t a recogn ised side-effects o f dopamine recept or agonists?

Postural hypotension Daytime somnolence Galactorrhoea

Dr

Hallucinations

As

se

m

Nausea

Postural hypotension

GD

Daytime somnolence

..

Galactorrhoea

«!D

«!D

Hallucinations

«!D

Dr

As

se

m

Nausea

A 54-year-old female is being investigated for a macrocytic anaemia. Bloods test reveal a low vitamin B12 level. Which one o f the following medications may be co ntributing to this?

Bendroflumethiazide Digoxin Am iodarone

Dr

Metf ormin

As

se

m

Sodium valproat e

fD

o r oxin

CD CD

Sodium valproate

6D

Metformin

se

m

Amiodarone

As

Bendroflumethiazide

Dr

CiD

A 30-yea r-old ma le is admitted to the medica l take with fever, rigo rs, confusion and vom iting. He is found to have a low neutrophil count and is started on treatment for neutropen ic seps is. He had recently b een started on a new anti-epileptic med icatio n. Which o f these medications is most likely to be the cause?

Topiramate Lacosam ide Carbamazepi ne

Dr

Levetira cetam

As se

m

Phe nytoin

Topiramate

. (D

Lacosam ide

m

Carbamazepine

ED

Phenytoin

. fiB

fD

Levetiracetam

Carbamazepine can cause ag ranulocytosis Important for me

Less :mpcrtant

Dr

BNF https://bnf.nice.org.uk/drug/carba mazep ine.html

As se m

The correct answer is carbamazepine. Valproate is a lso associated with agranulocytosis. The othe r anti-epileptics a re not classically known to cause agranulocytos is.

Which one of the followin g statements regarding metformin is false?

Does not cause hypoglycaem ia Increases insu lin sensitivity Decreases hepatic gluconeogenesis

Dr

Reduces GI abso rption o f carbohydrates

As

se

m

Increases end ogenous insu lin secretion

Does not cause hypo glycaemia

~reases insulin sensitivity

I

Decreases he patic gl uconeogenesis Increases endogenous insulin secretion

-

Reduces GI a bso rption of carbohyd rates

Dr

Su lphonylureas have the p roperty of increasing endogenous insu lin secretion

As

se

m

~

A 34-yea r-o ld ma n with a histo ry o f bipo la r disorde r is ad mitted with acute co nfus io n. Lithi um levels confirm the clinica l diag nosis of lithium toxicity. A d ecision is mad e to give sod iu m bica rbonate . What is the mechan ism of action o f sodium b icarbonate in th is sit uation?

Reduce gastro intestinal tract absorption Myoca rdia l stabil iser Neutra lises lith ium ions

Dr

Increases urine alkalinity

As

se

m

Centra l nervous system me mbrane sta ba liser

Reduce gastrointestinal tract absorption Myocardial stabiliser Neutra lises lith ium ions

-

........

Central nervo us system membrane stabaliser

se

m

Increases urine alkalinity

Dr

As

Increasing the alka linity of the urine promotes lith ium excretion. The preferred treatment in severe cases wou ld be haemodialysis

A 54-year-old man who had a renal transplant two years ago is reviewed in cl inic. He is currently taking a combination of ciclosporin and mycophenolat e as immunosuppressive therapy. Two weeks ago he was discharged on oral fluconazole after inpatient treatment for a fungal pneumonia. His creatinine level has increased from 114 !Jmol/1before hospital admission t o 187 IJmol/1t oday. What is the most likely factor contributing to this rise?

Amphotericin -B induced membranous glomerulonephritis Ciclosporin nephrotoxicity

Fluconazole nephrotoxicity

Dr

Mycophenolate nephrotoxicity

As se m

5-fluorocytosine induced minimal cha nge glomerulonephritis

Amphotericin-B induced membranous glomerulonephritis Ciclosporin nephrotoxicity 5-fluorocytosine induced minimal change glomerulonephritis

-

Mycophenolate nephrotoxicity

. ..wl'

Fluconazole nephrotoxicity

Ciclosporin may cause nephrotoxicity l ess ' m ::~c rtc.nt

As se m

Important for me

nephrotoxicity.

Dr

Fluconazole inhibits the met abolism of ciclosporin which increases the risk of ciclosporin

Which one o f the following stat ement s regarding heparin -induced thrombocytopaenia (HIT) is correct?

A fall in the plat elet count of greater than 15% is diagnostic HIT is a pro thrombotic condition Tranexamic acid is the treatment of choice

se

m

HIT usually develops with 2-3 days of starting treatment

Dr

heparin

As

HIT is more common with low -molecular w eight heparin than w ith unfractionated

A fa ll in the platelet count of greater than 15% is diagnostic HIT is a prothrombotic condition Tra11examic acid is the treatment of choice

m

HIT usually develops with 2-3 days of starting treatment

As Dr

unfractionated heparin

se

HIT is more common with low-molecular weight heparin than with

What is t he mechanism of action of macrolides?

Causes misreading of mRNA Interferes with cell wall fo rmation Inhibits DNA synthesis

Dr

Inhibits protein synthesis

As

se

m

Inhibits RNA synthesis

As se m

What is the mechanism of action of ma crolides?

Macrolides - inhibits p rotein synthesis by acting on the 50S subun it of ribosomes

Less imocrtant

Dr

Important for me

A 21-yea r-old patient with long-term pins and needles in both hands and a p rotruded lowe r jaw d evelops rig ht upper q uad rant pa in after being started on a new medication for his condition, which medications acting on his endocrine system is responsible for this adverse effect?

Octreotide Bromocriptine Desmopressin

Dr

Levothyroxine

As se

m

Metfo rmin

I

Octreotide Bromocriptine Desmopressin

-

Metformin

~

Biliary stasis and subsequently ga llsto nes is a common adverse effect of octerotide Important for me

Less imocrtant

Octreotid e is a somatostatin ana logue, which is known to inhibit hepatic bile secretion and gallbladde r emptying leading to biliary stasis and subseq uently an increased risk of developing gallstones. Bromocriptin e - a do pam ine ago nist with side effects arising from its stimu lation o f the brain vomiting centre Desmopress in - predom inantly used in patients with dia betes insipid us by increasing the presence of aq uaporin channels in the dista l collecting duct to increase water reabso rption from the kidneys. Ma in sid e e ffects incl ude headache and facia l flushing d ue to hypertension. Metformi n - ma in ly reduces hepatic gluconeogenesis in patients with type 2 diabetes, commo n side effects include d iarrhoea, vomiting and lactic acidosis

Dr

As s

em

Levothyroxine - synthetic thyroxine used in patients with hypothyro id ism, com mon side e ffects resu lt from incorrect dosing and mi mic the sym ptoms o f hyperthyro idism.

A 45-year-o ld woman presents to you with ongoing constipation. This started about 3 weeks ago after she was started on a new medication by her cardiologist. She is clearly not happy and blames him for it. She has a past medical history of hypertension, atrial fibrillation and psoriasis. Which one of the following drug may be responsible for her presentation?

Warfarin Bisoprolol Omeprazole Verapamil

Dr

Submit answer

As se m

Clindamycin

CB

Warfarin Bisoprolol

CD

Omeprazole

GD

I

CD

Verapam il

CB

Clindamycin

Verapamil can cause const ipation Impo rta nt fo r me

Drug

Adverse effect

Beta-blockers

Cold peripheries, sleep disturbances, bronchospasm

Less important

(contraindicated in asthmatics) Calcium channel

Ankle oedema, constipation, dyspepsia (relax lower

blockers

oesophageal sphincter)

Clindamycin

C.diff, joint pain, heart burn

Warfarin

severe bleeding, red or brown urine, black or bloody stools, stomach pain diarrhoea, fever, cold symptoms and headache

Omeprazole

[ .. I a•

tit Discuss

Im prove

J

Next question )

Calcium channel blockers Calcium channel blockers are primarily used in the management of cardiovascu lar d isease. Voltage-gated calcium channels are present in myocardial cells, cells of t he conduction system and t hose of the vascular smooth muscle. The various types of calcium channel blockers have varying effects on these three areas and it is therefore important to differentiate their uses and actions.

Examples

Indications & notes

Side-effects and cautions

Verapamil

Angina, hypertension, arrhythmias

.,,,.,,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,.

Heart failure,

constipation, Hig hly negatively inotropic

hypotension,

Should not be given with beta -blockers

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