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"answer": false,
"explanation": "This describes a pneumothorax, which does not fit with the clinical presentation as it would typically cause sudden onset shortness of breath with pleuritic chest pain.",
"id": "10028330",
"label": "e",
"name": "Absence of lung markings at the right apex",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be seen in a lung malignancy (some of which can also cause hypercalcaemia). This would be less common in a younger patient with no mention of smoking history and unlikely to cause erythema nodosum.",
"id": "10028328",
"label": "c",
"name": "Unilateral spiculated mass",
"picture": null,
"votes": 73
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This describes chest X-ray changes that may be seen in acute heart failure. Whilst this also may present with shortness of breath and a dry cough, it would be less likely to occur in a younger patient with no other past medical history, or cause erythema nodosum or hypercalcaemia.",
"id": "10028329",
"label": "d",
"name": "Cardiomegaly and pleural effusions",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This question describes a case of sarcoidosis, a granulomatous disease which can affect multiple systems. It commonly affects women aged 20-40 and can present with progressive dyspnoea and a dry cough. The tender nodules mentioned describe erythema nodusum. Hypercalcaemia can also be seen in sarcoidosis, which is thought to be due to increased active vitamin D production. Bilateral hilar lymphadenopathy is a classic chest X-ray finding of sarcoidosis.",
"id": "10028326",
"label": "a",
"name": "Bilateral hilar lymphadenopathy",
"picture": null,
"votes": 3243
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sarcoidosis typically causes an upper zone pulmonary fibrosis rather than lower zone.",
"id": "10028327",
"label": "b",
"name": "Lower zone pulmonary fibrosis",
"picture": null,
"votes": 80
}
],
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"__typename": "QuestionComment",
"comment": "why not tb",
"createdAt": 1731172765,
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"comment": "Hypercalcaemia + erythema nodosum + dry, non-productive cough = sarcoid. Also typical in women of this age ",
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"name": "Bilateral hilar lymphadenopathy",
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"learningPoint": "Bilateral hilar lymphadenopathy is a characteristic chest X-ray finding in sarcoidosis, often associated with hypercalcaemia and respiratory symptoms.",
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"question": "A 35-year-old female has bilateral raised, tender nodules on her shins. She also complains of shortness of breath and a dry cough for the last 6 months.\n\nShe has no past medical history. A routine blood test shows hypercalcaemia.\n\nGiven the likely diagnosis, what is most likely to be seen on chest X-ray?",
"sbaAnswer": [
"a"
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"totalVotes": 3424,
"typeId": 1,
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173,467,222 | false | 21 | null | 6,495,236 | null | false | [] | null | 18,064 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As a β-2 agonist, salbutamol can cause tachycardia if given in high doses and is commonly seen in patients receiving back-to-back nebulisers.",
"id": "10028331",
"label": "a",
"name": "Tachycardia",
"picture": null,
"votes": 2504
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient may well be tachypnoeic due to respiratory distress, but this is not a side effect of salbutamol treatment.",
"id": "10028332",
"label": "b",
"name": "Tachypnoea",
"picture": null,
"votes": 100
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol tends to cause hyperglycaemia rather than hypoglycaemia at high doses due to increased glycolysis.",
"id": "10028335",
"label": "e",
"name": "Hypoglycaemia",
"picture": null,
"votes": 255
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "At very high doses, salbutamol can cause lactic acidosis. This is thought to be due to increased glycolysis and lipolysis from β-2 activation.",
"id": "10028333",
"label": "c",
"name": "Low lactate",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol toxicity tends to cause hypokalaemia rather than hyperkalaemia due to increased sodium/potassium pump activity.",
"id": "10028334",
"label": "d",
"name": "Hyperkalaemia",
"picture": null,
"votes": 504
}
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"learningPoint": "Salbutamol, a β-2 agonist, can induce tachycardia as a side effect because it stimulates β-2 receptors in the lungs to cause bronchodilation, but it can also indirectly activate β-1 receptors in the heart, leading to an increased heart rate.",
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"question": "A 21-year-old female with a past medical history of asthma has worsening shortness of breath and chest tightness after cold-water swimming.\n\nShe is found to have a diffuse wheeze on examination and is given back-to-back salbutamol nebulisers as initial treatment.\n\nWhat is the most likely complication of this treatment?",
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"a"
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173,467,223 | false | 22 | null | 6,495,236 | null | false | [] | null | 18,066 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This can cause sudden onset flashers and floaters, but would not cause complete visual loss unless it progressed to retinal detachment.",
"id": "10028345",
"label": "e",
"name": "Posterior vitreous detachment",
"picture": null,
"votes": 886
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this could cause an absent red reflex, it would be unlikely to present with sudden onset visual loss but rather progressive blurring of vision over time.",
"id": "10028342",
"label": "b",
"name": "Right sided cataract",
"picture": null,
"votes": 343
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is more commonly seen in children and would be characteristically causes leukocoria (white reflex instead of red) instead of an absent red reflex.",
"id": "10028343",
"label": "c",
"name": "Retinoblastoma",
"picture": null,
"votes": 68
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "In a patient with poorly controlled diabetes and sudden, painless visual loss, vitreous haemorrhage is a key differential. The classic sign on examination is an absent red reflex on the affected side.",
"id": "10028341",
"label": "a",
"name": "Vitreous haemorrhage",
"picture": null,
"votes": 2115
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst his can cause visual difficulties if untreated, it would be painful and likely take a longer time to develop. Corneal scarring may cause a reduced or absent red reflex.",
"id": "10028344",
"label": "d",
"name": "Corneal ulcer",
"picture": null,
"votes": 11
}
],
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"name": "Sudden painless visual loss",
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"name": "Ophthalmology",
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"learningPoint": "Vitreous haemorrhage often presents with sudden, painless vision loss and an absent red reflex, particularly in poorly controlled diabetic patients.",
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"question": "A 57-year-old diabetic patient has sudden loss of vision in their right eye\n\nThey deny any pain or a history of trauma to the eye.\n\nThey are poorly compliant with their diabetic medication and have not attended their scheduled eye checks.\n\nAt the start of ophthalmic examination, they are noted to have an absent red reflex on the right-hand side.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
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173,467,224 | false | 23 | null | 6,495,236 | null | false | [] | null | 18,067 | {
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{
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"answer": false,
"explanation": "This would be used in the treatment of bacterial conjunctivitis, which would also cause a red eye but would present with green/yellow discharge and a foreign body sensation rather than an irregular pupil and photophobia.",
"id": "10028347",
"label": "b",
"name": "Topical chloramphenicol",
"picture": null,
"votes": 324
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This scenario describes a case of anterior uveitis, an inflammation of the middle layer of the eye. The mainstay of treatment is typically steroids combined with drugs like atropine/cyclopentalone to prevent adhesions between the iris and the lens (posterior synechiae). The back pain mentioned may suggest this patient has anterior uveitis related to ankylosing spondylitis.",
"id": "10028346",
"label": "a",
"name": "Topical steroids",
"picture": null,
"votes": 2669
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this may help improve pain, it would not adequately address the underlying inflammation in the eye. The history of back pain responsive to NSAIDs suggests an underlying ankolysing spondylitis.",
"id": "10028350",
"label": "e",
"name": "NSAIDs",
"picture": null,
"votes": 161
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is typically used in the treatment of a stye or chalazion and would be unlikely to help resolve the inflammation in a case of anterior uveitis.",
"id": "10028348",
"label": "c",
"name": "Hot compress",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the surgical management of acute angle closure glaucoma. Whilst this can present with a painful red eye, it is less likely to affect this patient age group and more commonly causes a fixed mid-dilated pupil than an irregular one. Blurry vision and nausea are also common features of acute angle closure glaucoma.",
"id": "10028349",
"label": "d",
"name": "Laser peripheral iridotomy",
"picture": null,
"votes": 246
}
],
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"name": "Uveitis",
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"learningPoint": "Anterior uveitis often presents with eye pain, photophobia, and irregular pupil, and is commonly treated with topical steroids.",
"likes": 3,
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"question": "A 21-year-old male has a red and painful left eye. He describes difficulty looking at bright lights and increased tearing of the eye.\n\nOn examination, his left pupil is irregular in shape.\n\nHe has no past medical history but takes ibuprofen regularly for early morning back pain.\n\nGiven the likely diagnosis, which treatment is most likely to be commenced?",
"sbaAnswer": [
"a"
],
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173,467,225 | false | 24 | null | 6,495,236 | null | false | [] | null | 18,068 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prolactinomas can cause erectile dysfunction, however, vascular causes are more common (especially in a patient with risk factors such as obesity). There is an absence of other symptoms such loss of libido, headaches, or visual changes.",
"id": "10028355",
"label": "e",
"name": "Serum prolactin levels",
"picture": null,
"votes": 231
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely to be helpful in establishing a cause for erectile dysfunction. There is also no mention of symptoms suggestive of anaemia.",
"id": "10028352",
"label": "b",
"name": "Full blood count",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this is a recommended investigation for patients with erectile dysfunction, the presence of secondary sexual hair and muscle mass points away from it. Additionally, given the history of obesity, diabetes is a more likely cause for erectile dysfunction in this patient.",
"id": "10028353",
"label": "c",
"name": "Testosterone levels",
"picture": null,
"votes": 1824
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Gradual onset erectile dysfunction in a middle-aged male with risk factors present should raise suspicion of diabetes mellitus. Vascular causes are the most common organic cause of erectile dysfunction.",
"id": "10028351",
"label": "a",
"name": "HbA1c",
"picture": null,
"votes": 1159
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although prostatic issues can cause erectile dysfunction, this is less common than diabetes as a cause. Additionally, there are no mention of other symptoms associated with prostate cancer (e.g. lower urinary tract symptoms). PSA testing should not routinely be offered to asymptomatic patients.",
"id": "10028354",
"label": "d",
"name": "Prostate specific antigen (PSA)",
"picture": null,
"votes": 144
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "poorly written question it says most helpful in establishing the underlying cause. a raised hba1c doesnt rule out other causes of ED",
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"replies": [
{
"__typename": "QuestionComment",
"comment": "Nope. In that age group, vascular risk factors are the most common cause. The question doesnt ask for the investigation that rules out, it asks you which one is most likely to establish the underlying cause",
"createdAt": 1709542390,
"dislikes": 14,
"id": "43693",
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{
"__typename": "QuestionComment",
"comment": "Am i right in thinking poorly controlled diabetes cause peripheral hair loss? ",
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"displayName": "Jargon Defibrillator",
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"__typename": "QuestionComment",
"comment": "i dont understand, the question doesnt mention secondary sexual hair and muscle mass. it says theyre both appropriate?",
"createdAt": 1717432548,
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"question": "A 53-year-old man has erectile dysfunction. He states it occurred gradually and has worsened over time.\n\nHe denies any symptoms of anxiety or depression and states he has no loss of libido. On examination, he has appropriate body hair and muscle mass.\n\nHe has a past medical history of obesity.\n\nWhich blood test would be most helpful in establishing the underlying diagnosis?",
"sbaAnswer": [
"a"
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} | MarksheetMark |
173,467,226 | false | 25 | null | 6,495,236 | null | false | [] | null | 18,069 | {
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"choices": [
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This potassium-sparing diuretic is commonly associated with gynaecomastia. It is thought to have anti-androgenic effects by preventing testosterone binding to androgen receptors in breast tissue and causing increased clearance of testosterone.",
"id": "10028356",
"label": "a",
"name": "Spironolactone",
"picture": null,
"votes": 3073
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "ACE inhibitors are not associated with gynaecomastia.",
"id": "10028357",
"label": "b",
"name": "Ramipril",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is typically prescribed as an alternative in patients who experience spironolactone-induced gynaecomastia. The patient would be unlikely to be taking the two drugs simultaneously.",
"id": "10028358",
"label": "c",
"name": "Amiloride",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst 5 alpha-reductase inhibitors can cause gynaecomastia, the patient has no history of BPH mentioned and would therefore be unlikely to be taking this medication.",
"id": "10028360",
"label": "e",
"name": "Finasteride",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Statins are not typically associated with gynaecomastia.",
"id": "10028359",
"label": "d",
"name": "Atorvastatin",
"picture": null,
"votes": 30
}
],
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"question": "A 67-year-old male has noticed tenderness and swelling of his breast tissue in recent months\n\nHe has a past medical history of drug resistant hypertension and raised cholesterol.\n\nWhich of the following medications is the most likely cause of his symptoms?",
"sbaAnswer": [
"a"
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173,467,227 | false | 26 | null | 6,495,236 | null | false | [] | null | 18,070 | {
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"answer": false,
"explanation": "As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. Pioglitazone has been linked to worsened outcomes in patients with heart disease and therefore should not be used in this circumstance.",
"id": "10028362",
"label": "b",
"name": "Pioglitazone",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. A DPP-4 inhibitor would have otherwise been an appropriate agent to commence for second-line treatment.",
"id": "10028365",
"label": "e",
"name": "Sitagliptin",
"picture": null,
"votes": 125
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Given this patient has a history of ischaemic heart disease, they should be offered a SGLT-2 inhibitor in conjunction with metformin given the proven cardiovascular benefits of this class of medication.",
"id": "10028361",
"label": "a",
"name": "Dapagliflozin",
"picture": null,
"votes": 2992
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. A sulfonylurea would have otherwise been an appropriate agent to commence for second-line treatment.",
"id": "10028363",
"label": "c",
"name": "Gliclazide",
"picture": null,
"votes": 244
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be considered if second line therapy (combination of two anti-diabetic medication) fails, however, it would not be routinely offered after just metformin was trialled.",
"id": "10028364",
"label": "d",
"name": "Insulin",
"picture": null,
"votes": 27
}
],
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"name": "Type 2 Diabetes Mellitus",
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"question": "A 67-year-old male has a routine HbA1c check as part of his diabetes management. He was started on metformin 12 months ago.\n\nHe has a past medical history of ischaemic heart disease.\n\n* HbA1c: 67mmol/mol (patient target 48mmol/mol)\n\nGiven this result, which additional medication should he be offered in conjunction with metformin?",
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173,467,228 | false | 27 | null | 6,495,236 | null | false | [] | null | 18,071 | {
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"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The results in this case would show an elevated calcium, phosphate and PTH. Tertiary hyperparathyroidism often results from secondary hyperparathyroidism, as the parathyroid glands are chronically hyper-stimulated.",
"id": "10028368",
"label": "c",
"name": "Tertiary hyperparathyroidism",
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"votes": 419
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"answer": true,
"explanation": "The history is describing symptoms suggestive of hypercalcaemia. In most people with Primary Hyperparathyroidism, both calcium and parathyroid are higher than normal. Occasionally, a patient may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should be low when calcium is elevated, a normal or minimally elevated PTH is considered abnormal and usually indicates Primary hyperparathyroidim as if the normal feedback loop was maintained, the PTH should be suppressed.",
"id": "10028366",
"label": "a",
"name": "Primary hyperparathyroidism",
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"votes": 2521
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Osteomalacia is a defect of bone mineralisation secondary to vitamin D deficiency. A low calcium and low phosphate would be seen in osteomalacia, and it would be unlikely to present with renal stones.",
"id": "10028370",
"label": "e",
"name": "Osteomalacia",
"picture": null,
"votes": 80
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The results in this case would show hypocalcaemia and a raised phosphate and an (appropriately) raised PTH. This is usually due to decreased production of active vitamin D (e.g. in CKD).",
"id": "10028367",
"label": "b",
"name": "Secondary hyperparathyroidism",
"picture": null,
"votes": 389
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be rare to see in this patient age group and would not present with any of the symptoms of hypercalcaemia listed above. Additionally, the bone profile is typically normal in osteoporosis.",
"id": "10028369",
"label": "d",
"name": "Osteoporosis",
"picture": null,
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}
],
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{
"__typename": "QuestionComment",
"comment": "why is she getting flank pain?",
"createdAt": 1709463322,
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"__typename": "QuestionComment",
"comment": "I was wondering this too, made me think maybe underlying kidney disease -> CKD -> Tertiary hyperparathyroidism. Maybe it was just a red herring to try and push you towards tertiary rather than primary?",
"createdAt": 1709471187,
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"__typename": "QuestionComment",
"comment": "Trying to get at renal stone given high calcium ",
"createdAt": 1709541505,
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"__typename": "QuestionComment",
"comment": "Hypercalcaemia =\nBones = bone pain\nStones = renal stones\nGroans = discomofrt\nMoans = psychiatric moans (confusion)",
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"__typename": "QuestionComment",
"comment": "Answer is incorrect. It should be ectopic hyperparathyrodism due to renal cell carcinoma (1 year of flank pain and haematuria).",
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"replies": [
{
"__typename": "QuestionComment",
"comment": "Sounds like haematuria and flank pain are new, it’s the symptoms of hypercalacaemia that she’s had for a year ",
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"learningPoint": "Primary hyperparathyroidism is a condition where one or more parathyroid glands produce excess parathyroid hormone (PTH), leading to elevated calcium levels in the blood (hypercalcemia), low phosphate levels, and associated symptoms such as fatigue, kidney stones, and bone pain.",
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"question": "A 23-year-old female has flank pain and haematuria. She mentions she has been experiencing fatigue, bony pain and generalised abdominal pain for the last year.\n\n\nHer blood results show:\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Calcium|3.2 mmol/L|2.2 - 2.6|\n|Phosphate|0.55 mmol/L|0.8 - 1.5|\n|Parathyroid Hormone|62 pmol/L|1.6 - 8.5|\n\n\nWhat is the most likely underlying diagnosis?",
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"a"
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173,467,229 | false | 28 | null | 6,495,236 | null | false | [] | null | 18,072 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate management as the history of an irregular, fixed and non-tender lump in a young male is highly suspicious for testicular cancer and they should therefore be referred as part of a two week wait pathway.",
"id": "10028374",
"label": "d",
"name": "Reassure the patient and advise them to return in 3 months if the mass has not resolved",
"picture": null,
"votes": 32
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be inappropriate management as the patient’s history is more concerning for testicular cancer. They also have no symptoms suggesting epididymo-orchitis (e.g. dysuria, urethral discharge or fever).",
"id": "10028375",
"label": "e",
"name": "Refer to the local sexual health clinic for probable epididymo-orchitis",
"picture": null,
"votes": 53
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Biopsy is rarely done in the case of suspected testicular cancer as it can increase risk of spread by seeding.",
"id": "10028373",
"label": "c",
"name": "Arrange biopsy of the mass",
"picture": null,
"votes": 118
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This scenario is concerning for testicular cancer as there is a fixed, irregular and non-tender swelling. The most appropriate management is therefore a two-week wait referral to Urology and potentially taking blood tests for tumour markers (e.g. AFP, hCG and LDH).",
"id": "10028371",
"label": "a",
"name": "Two week wait referral",
"picture": null,
"votes": 3182
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this might be arranged if the patient is found to have testicular cancer, it would be inappropriate to carry out before a diagnosis of cancer was confirmed.",
"id": "10028372",
"label": "b",
"name": "Arrange CT CAP",
"picture": null,
"votes": 21
}
],
"comments": [],
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"demo": null,
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"id": "3842",
"name": "Testicular Cancer",
"status": null,
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"__typename": "Topic",
"id": "143",
"name": "Urology",
"typeId": 7
},
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"learningPoint": "A fixed, irregular, non-tender testicular mass in a young male warrants a two-week wait referral for suspected testicular cancer.",
"likes": 1,
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"question": "A 23-year-old male has a lump on his right testis.\n\nOn examination, there is a 3mm fixed and irregular mass on the anterior aspect of the right testis. It is non-tender.\n\nHe has no other past medical history.\n\nWhat is the most appropriate initial management?",
"sbaAnswer": [
"a"
],
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} | MarksheetMark |
173,467,230 | false | 29 | null | 6,495,236 | null | false | [] | null | 18,073 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are again rarer than calcium oxalate stones and are usually seen in patients with excessive dietary protein intake or gout.",
"id": "10028379",
"label": "d",
"name": "Uric acid",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a much rarer composition of a renal stone than calcium oxalate and is usually associated with conditions such as renal tubular acidosis.",
"id": "10028378",
"label": "c",
"name": "Calcium phosphate",
"picture": null,
"votes": 391
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are a rare cause of renal stones and usually seen in patients with a rare heritable condition called cystinuria. It can cause recurrent renal stones in affected patients.",
"id": "10028380",
"label": "e",
"name": "Cystine",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are typically seen following Proteus mirabalis infection and may cause staghorn calculi. There is no mention of preceding dysuria or increased urinary frequency to suggest preceding UTI.",
"id": "10028377",
"label": "b",
"name": "Ammonium magnesium phosphate",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the most common type of renal stone. It is much more common than calcium phosphate stone formation. Hyercalciuria has many possible causes; including hypercalcaemia or poor fluid intake. Increased dietary oxalate intake (e.g. chocolate and nuts) or having conditions such as IBD also represent risk factors for formation of calcium oxalate stones.",
"id": "10028376",
"label": "a",
"name": "Calcium oxalate",
"picture": null,
"votes": 2777
}
],
"comments": [],
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"__typename": "Concept",
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},
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"id": "3988",
"name": "Renal Stones",
"status": null,
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"id": "143",
"name": "Urology",
"typeId": 7
},
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"difficulty": 1,
"dislikes": 2,
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"highlights": [],
"id": "18073",
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"learningPoint": "Calcium oxalate stones are the most prevalent type of renal calculi, often associated with hypercalciuria.",
"likes": 0,
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"question": "A 57-year-old male has pain which radiates from his flank towards his groin and has also noticed a dark red tinge to his urine in recent days.\n\nOn examination, he has extreme tenderness in the renal angle and is constantly fidgeting.\n\nA CT KUB confirms the presence of a 6mm renal calculus on the left side.\n\nWhat is the most likely mineral composition of this stone?",
"sbaAnswer": [
"a"
],
"totalVotes": 3413,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,231 | false | 30 | null | 6,495,236 | null | false | [] | null | 18,074 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are not contraindicated in AKI.",
"id": "10028385",
"label": "e",
"name": "Hypromellose eye drops",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This medication is not contraindicated in AKI.",
"id": "10028384",
"label": "d",
"name": "Paracetamol",
"picture": null,
"votes": 22
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These should be stopped if the AKI is due to rhabdomyolysis or if the patient complains of unexplained or persistent muscle pain. In this case, however, atorvastatin can be continued.",
"id": "10028383",
"label": "c",
"name": "Atorvastatin",
"picture": null,
"votes": 76
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "ACE inhibitors should be held in AKI due to the risk of hyperkalaemia. They can also alter kidney perfusion and the ability to maintain GFR.",
"id": "10028381",
"label": "a",
"name": "Ramipril",
"picture": null,
"votes": 3236
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst other NSAIDs may be held in AKI, low dose aspirin is usually continued.",
"id": "10028382",
"label": "b",
"name": "Low-dose aspirin",
"picture": null,
"votes": 57
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
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"id": "3752",
"name": "Acute Kidney Injury",
"status": null,
"topic": {
"__typename": "Topic",
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"name": "Nephrology",
"typeId": 7
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"learningPoint": "In acute kidney injury, ACE inhibitors like ramipril should be temporarily discontinued to prevent worsening renal function and hyperkalaemia.",
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"question": "A 77-year-old male complains of fatigue and low mood following the death of his wife.\n\n\nHe appears very dehydrated on examination.\n\n\nHis renal profile is shown below:\n\n\nCurrently:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|142 mmol/L|135 - 145|\n|Potassium|4.8 mmol/L|3.5 - 5.3|\n|Urea|11.2 mmol/L|2.5 - 7.8|\n|Creatinine|180 µmol/L|60 - 120|\n\n\n 2 months ago:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|4.5 mmol/L|3.5 - 5.3|\n|Urea|5.7 mmol/L|2.5 - 7.8|\n|Creatinine|92 µmol/L|60 - 120|\n\nWhich of his regular medications should be temporarily stopped in light of these results?",
"sbaAnswer": [
"a"
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173,467,232 | false | 31 | null | 6,495,236 | null | false | [] | null | 18,075 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would typically present with fevers, weight loss, flank pain and haematuria rather than the triad of fever, rash and eosinophilia classically seen in AIN.",
"id": "10028390",
"label": "e",
"name": "Renal cell carcinoma",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has presented with the classic triad of AIN; fever, rash and eosinophilia in a setting of decreased renal function. Beta-lactam antibiotics can commonly trigger AIN.",
"id": "10028386",
"label": "a",
"name": "Acute interstitial nephritis",
"picture": null,
"votes": 2942
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is caused by nephrotoxic or ischaemic damage to the renal tubules and typically presents with hypotension and oliguria. Additionally, you would not expect to see the systemic symptoms or presence of eosinophilia.",
"id": "10028387",
"label": "b",
"name": "Acute tubular necrosis",
"picture": null,
"votes": 336
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst a red, hot and swollen joint should raise suspicion for septic arthritis, it is rarely polyarticular and the pain is described as mild with preserved range of motion. Additionally, it would not explain the eosinophilia and presence of a rash.",
"id": "10028388",
"label": "c",
"name": "Septic arthritis",
"picture": null,
"votes": 102
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may present with oedema and be seen in other signs of poor diabetic control (e.g. persistent hyperglycaemia, presence of neuropathy). Additionally, it would not explain the rash, joint pain or eosinophilia. AIN is a far more likely diagnosis in this case despite the past medical history of diabetes.",
"id": "10028389",
"label": "d",
"name": "Diabetic nephropathy",
"picture": null,
"votes": 13
}
],
"comments": [],
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"__typename": "Concept",
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"id": "6058",
"name": "Acute interstitial nephritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "142",
"name": "Nephrology",
"typeId": 7
},
"topicId": 142,
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"difficulty": 1,
"dislikes": 0,
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"highlights": [],
"id": "18075",
"isLikedByMe": 0,
"learningPoint": "Acute interstitial nephritis often presents with fever, rash, eosinophilia, and renal impairment, commonly triggered by beta-lactam antibiotics.",
"likes": 4,
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"question": "A 67-year-old female with a history of diabetes has a widespread maculopapular rash, fever and polyarticular joint pain.\n\nOn examination, her joints are swollen and mildly tender, with range of motion preserved.\n\nHer blood tests show an elevated eosinophil count and raised creatinine, compared to previous results\n\nShe has recently completed a course of co-amoxiclav for an upper UTI.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,467,233 | false | 32 | null | 6,495,236 | null | false | [] | null | 18,076 | {
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"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the answer if the patient drank 2 x 750ml bottles of 40% vodka over the weekend.",
"id": "10028395",
"label": "e",
"name": "207 units",
"picture": null,
"votes": 173
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Alcohol units can be calculated by:\n\n1) Volume of alcohol (ml) x percentage alcohol by volume (ABV)\n2) Divide by 1000\n\n(500ml x 7.0)/1000 = 3.5 units per can\n6 x cans a day = 21 units per day\n21 x 7 days a week = 147 units per week\n\n(750ml x 40)/1000 = 30 units per vodka bottle\n\n147 units from cider + 30 units from vodka = 177 units per week.",
"id": "10028391",
"label": "a",
"name": "177 units",
"picture": null,
"votes": 2109
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the amount if the patient drank 1 x 500ml can of cider per day",
"id": "10028394",
"label": "d",
"name": "54.5 units",
"picture": null,
"votes": 595
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect by a factor of 10.",
"id": "10028392",
"label": "b",
"name": "17.7 units",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This does not include the bottle of vodka.",
"id": "10028393",
"label": "c",
"name": "147 units",
"picture": null,
"votes": 392
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Rookie numbers.",
"createdAt": 1719144893,
"dislikes": 0,
"id": "53601",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
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{
"__typename": "QuestionComment",
"comment": "Ohhh you're hard",
"createdAt": 1719265682,
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"id": "6059",
"name": "Alcohol units",
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"__typename": "Topic",
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"learningPoint": "To calculate alcohol units, use the formula:\nAlcohol units = (Volume of drink in ml) × (ABV in %)/ 100",
"likes": 5,
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"question": "A 47-year-old man would like to cut down on his drinking\n\nHe says he usually drinks 6 x 500ml cans of 7.0% cider daily, plus a 750ml bottle of 40% vodka over the weekend.\n\nHow many units does he consume a week?",
"sbaAnswer": [
"a"
],
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"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,234 | false | 33 | null | 6,495,236 | null | false | [] | null | 18,077 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A blood pressure difference of greater than 20mmHg should raise suspicion of an aortic dissection.",
"id": "10028398",
"label": "c",
"name": "Equivalent blood pressure in both arms",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is more suggestive of heart failure than aortic dissection.",
"id": "10028400",
"label": "e",
"name": "Bilateral pitting oedema",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The most likely diagnosis given the nature of the pain and the presence of a connective tissue disorder is an acute aortic dissection. Neurological symptoms occur because of occlusion of carotid, vertebral, or spinal arteries.",
"id": "10028396",
"label": "a",
"name": "Focal neurological deficits",
"picture": null,
"votes": 756
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An early diastolic murmur may be noted due to aortic regurgitation in a dissection, rather than an end systolic one.",
"id": "10028399",
"label": "d",
"name": "New-onset end-systolic murmur",
"picture": null,
"votes": 1077
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An early diastolic murmur may be noted due to aortic regurgitation in a dissection, rather than a holosystolic one.",
"id": "10028397",
"label": "b",
"name": "New-onset holosystolic murmur",
"picture": null,
"votes": 1442
}
],
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"name": "Aortic Dissection",
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"typeId": 7
},
"topicId": 134,
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"learningPoint": "Focal neurological deficits in the context of acute aortic dissection can occur when the dissection compromises blood flow to the brain or spinal cord, leading to symptoms such as weakness, sensory changes, or paralysis, which indicate potential involvement of the arterial branches supplying these areas.",
"likes": 13,
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"question": "A 45 year old man with a history of Ehler’s Danlos syndrome comes to the emergency department with severe tearing chest pain.\n\nGiven the likely diagnosis, which of the following may be noted on examination?",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,467,235 | false | 34 | null | 6,495,236 | null | false | [] | null | 18,078 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Persistent ST elevation with fatigue is suggestive of an left ventricle aneurysm post-myocardial infarction.",
"id": "10028401",
"label": "a",
"name": "Left Ventricular Aneurysm",
"picture": null,
"votes": 1796
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a form of acute pericarditis post myocardial infarction. This is less likely as the patient only reports fatigue and no chest pain and the ECG does not show global ST elevation or PR depression.",
"id": "10028403",
"label": "c",
"name": "Dressler's Syndrome",
"picture": null,
"votes": 1158
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely as the patient is asymptomatic. Silent myocardial infarctions, whereby no pain is felt do occur, but these are more common in females and diabetics. Persistent territorial ST elevation is more characteristic of a left ventricular aneurysm.",
"id": "10028402",
"label": "b",
"name": "Repeat myocardial infarction",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient has no symptoms suggestive of pulmonary oedema such as breathlessness or peripheral oedema.",
"id": "10028404",
"label": "d",
"name": "Pulmonary Oedema",
"picture": null,
"votes": 68
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be more acute than Dressler's in timeframe. This is less likely as the patient only reports fatigue and no chest pain and the ECG does not show global ST elevation or PR depression.",
"id": "10028405",
"label": "e",
"name": "Pericarditis",
"picture": null,
"votes": 107
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "such a vague bloody question \n",
"createdAt": 1717501964,
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"id": "51896",
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"questionId": 18078,
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"__typename": "QuestionComment",
"comment": "Clearly need more time on the wards!",
"createdAt": 1719144998,
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"question": "A 68 year old man is reviewed by his GP six weeks after he developed an anterior myocardial infarction. The GP performs an ECG which demonstrates ST elevation in the anterior leads. The patient reports fatigue but denies other symptoms.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
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173,467,236 | false | 35 | null | 6,495,236 | null | false | [] | null | 18,079 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "BNP is not specific to myocardial ischaemia and is more commonly used to diagnose heart failure.",
"id": "10028409",
"label": "d",
"name": "Elevated BNP",
"picture": null,
"votes": 57
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Troponins remain elevated for days following a myocardial infarction and so are less useful to assess re-infarct.",
"id": "10028407",
"label": "b",
"name": "Elevated Troponin I",
"picture": null,
"votes": 443
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. As CK-MB levels normalise 48 to 72 hours after myocardial ischemia (vs. troponins, which can persist for days), it is the best marker to assess whether re-infarct has occurred.",
"id": "10028406",
"label": "a",
"name": "Elevated creatine kinase MB (CK-MB)",
"picture": null,
"votes": 1925
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Myoglobin levels rise within the first few hours following a myocardial infarction, making them useful early indicators of ischaemia. They are less specific to re-assess for re-infarct.",
"id": "10028410",
"label": "e",
"name": "Elevated myoglobin",
"picture": null,
"votes": 201
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Troponins remain elevated for days following a myocardial infarction and so are less useful to assess re-infarct.",
"id": "10028408",
"label": "c",
"name": "Elevated Troponin T",
"picture": null,
"votes": 770
}
],
"comments": [],
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"typeId": 7
},
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"dislikes": 4,
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"highlights": [],
"id": "18079",
"isLikedByMe": 0,
"learningPoint": "Elevated creatine kinase MB (CK-MB) levels suggest a recurrent myocardial infarction and typically return to normal within 48 to 72 hours after ischemia.",
"likes": 8,
"multiAnswer": null,
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"question": "A 72 year old man presents with crushing central chest pain at rest, four days following a lateral myocardial infarction.\n\nWhich of the following findings is most suggestive of a repeat infarction?",
"sbaAnswer": [
"a"
],
"totalVotes": 3396,
"typeId": 1,
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173,467,237 | false | 36 | null | 6,495,236 | null | false | [] | null | 18,080 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Transoesophageal echocardiography is vital in the diagnosis of infective endocarditis to visualise vegetations on the valves in the heart. Multiple blood cultures are also essential.",
"id": "10028411",
"label": "a",
"name": "Transoesophageal echocardiogram",
"picture": null,
"votes": 1997
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A routine CT- CAP is not indicated in the diagnosis of infective endocarditis.",
"id": "10028414",
"label": "d",
"name": "CT chest, abdomen and pelvis",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Transthoracic echocardigrams are less specific and less sensitive than transoesophageal echocardigrams for the diagnosis of infective endocarditis.",
"id": "10028412",
"label": "b",
"name": "Transthoracic echocardiogram",
"picture": null,
"votes": 1317
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be useful in patients with prosthetic heart valves but is not first line.",
"id": "10028413",
"label": "c",
"name": "SPECT-CT",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "CT Aortogram is generally used to assess for aneurysms or dissections within the aorta.",
"id": "10028415",
"label": "e",
"name": "CT Aortogram",
"picture": null,
"votes": 23
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The British Infection Association outline transthoracic as first-line, with transoesophageal being reserved for negative transthoracic cases. https://www.britishinfection.org/application/files/2714/1640/8773/Endocarditis_final_BSAC_2012.pdf",
"createdAt": 1738602768,
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"__typename": "User",
"accessLevel": "subscriber",
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"id": "18080",
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"learningPoint": "Transoesophageal echocardiography is crucial for diagnosing infective endocarditis by visualising vegetations on cardiac valves.",
"likes": 12,
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"question": "A 34 year old man comes to the emergency department due to fevers and rigors. He is of no fixed abode at present and uses intravenous drugs. On fundoscopic examination, roth spots are noted.\n\nWhich of the following is most likely to aid diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3392,
"typeId": 1,
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173,467,238 | false | 37 | null | 6,495,236 | null | false | [] | null | 18,081 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Primary hyperaldosteronism would cause hypokalaemia which could precipitate digoxin toxicity, however the patient would be expected to be hypertensive. This is also not a common diagnosis.",
"id": "10028417",
"label": "b",
"name": "Conn's syndrome",
"picture": null,
"votes": 488
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario describes digoxin toxicity which is known to be precipitated by hypokalaemia. Normally digoxin binds to the ATPase pump at the same site as potassium, therefore hypokalaemia precipitates digoxin toxicity as there is less competition to bind to the ATPase pump and digoxin exerts more of an inhibitory effect. Diarrhoea and vomiting due to a gastroenteritis are likely to account for this clinical picture.",
"id": "10028416",
"label": "a",
"name": "Gastroenteritis",
"picture": null,
"votes": 1066
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Rhabdomyolysis may be associated with severe hyperkalaemia, rather than hypokalaemia.",
"id": "10028420",
"label": "e",
"name": "Rhadbomyolysis",
"picture": null,
"votes": 668
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Potassium concentration is typically normal in SIADH.",
"id": "10028419",
"label": "d",
"name": "Syndrome of inappropriate ADH",
"picture": null,
"votes": 623
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril may cause hyperkalaemia which would protect against developing digoxin toxicity.",
"id": "10028418",
"label": "c",
"name": "Ramipril",
"picture": null,
"votes": 532
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Did they mean to give us the potassium?",
"createdAt": 1709636107,
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"id": "43818",
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"__typename": "QuestionComment",
"comment": "i think they expect us to know that gastroenteritis (vomiting and diarrhoea) would lead to hypokalaemia and then that would lead to digoxin toxicity",
"createdAt": 1710597661,
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"__typename": "QuestionComment",
"comment": "Where is the information on diarrhoea and vomitng and hypokalaemia??? Am I just blind?? I don't see nothing?",
"createdAt": 1731860254,
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"comment": "we're all blind",
"createdAt": 1733068546,
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"__typename": "QuestionComment",
"comment": "Is the only clue here the yellow-green tinge?? no mention of D/V or hypokalaemia in the stem or have i gone mad",
"createdAt": 1735754345,
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"comment": "yellow tinge= digoxin toxicity. Digoxin toxicity is precipitated by hypokalaemia. All options EXCEPT gastroenteritis cause HYPERkalaemia, so wouldn't precipitate digoxin toxicity. Gastroenteritis causes hypokalaemia due to vomiting and diarrhoea ",
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"comment": "apart from conn's )",
"createdAt": 1737999549,
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"dislikes": 34,
"explanation": null,
"highlights": [],
"id": "18081",
"isLikedByMe": 0,
"learningPoint": "Gastroenteritis can increase the risk of digoxin toxicity because it can lead to dehydration, electrolyte imbalances (such as low potassium or magnesium levels), and reduced kidney function, all of which can enhance the effects of digoxin and increase the likelihood of toxic side effects.",
"likes": 26,
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"question": "A 69 year old man is brought to the emergency department acutely confused and unable to recall the events of the last few days. He describes a green-yellow tinge to his vision. His current medications include bisoprolol, ramipril and digoxin. His blood pressure has been measured on repeat GP appointments at ~110/60mmHg.\n\nWhich of the following is the most likely to explain the patient’s presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3377,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,239 | false | 38 | null | 6,495,236 | null | false | [] | null | 18,082 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be advice given for a self limiting flare of ankylosing spondylitis but is not appropriate given the severe pain and red flags of cauda equina syndrome in this case.",
"id": "10028425",
"label": "e",
"name": "Discharge and advise to continue on prescribed NSAIDs",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is likely to form the initial management of cases of spinal trauma.",
"id": "10028422",
"label": "b",
"name": "Immobilisation and stabilisation surgery",
"picture": null,
"votes": 151
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario describes cauda equina syndrome, for which ankylosing spondylitis is a risk factor. This is a neurosurgical emergency which requires surgical decompression.",
"id": "10028421",
"label": "a",
"name": "Surgical decompression and laminectomy",
"picture": null,
"votes": 3138
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the preferred treatment for cases of spinal abscess.",
"id": "10028423",
"label": "c",
"name": "Antibiotics and surgical evacuation",
"picture": null,
"votes": 30
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These represent treatment options for spinal metastases/metastatic spinal cord compression.",
"id": "10028424",
"label": "d",
"name": "Vertebrectomy and radiotherapy",
"picture": null,
"votes": 38
}
],
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"id": "6060",
"name": "Cauda Equina Syndrome",
"status": null,
"topic": {
"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
},
"topicId": 141,
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"difficulty": 1,
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"highlights": [],
"id": "18082",
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"learningPoint": "Cauda equina syndrome, often associated with ankylosing spondylitis, necessitates urgent surgical decompression to prevent permanent neurological damage.",
"likes": 2,
"multiAnswer": null,
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"question": "A 28 year old gentleman has been hospitalised due to a painful flare of ankylosing spondylitis and, on examination, has urinated in the bed.\nOn PR examination, there is loss of perianal sensation.\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3372,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,240 | false | 39 | null | 6,495,236 | null | false | [] | null | 18,083 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These represent initial treatment options for cluster headaches.",
"id": "10028429",
"label": "d",
"name": "Prescribe 100% oxygen and subcutaneous sumatriptan",
"picture": null,
"votes": 51
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be an option in flares of rheumatoid arthritis but this vignette does not describe any joint pain, making this less likely.",
"id": "10028430",
"label": "e",
"name": "IV Methylprednisolone",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario describes medication overuse headache, for which the treatment is to cease analgesics. Opiods should be tapered as opposed to stopped due to risk of withdrawal.",
"id": "10028426",
"label": "a",
"name": "Gradually taper tramadol",
"picture": null,
"votes": 2870
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The scenario does not describe a migraine and this treatment is unlikely to help with medication overuse.",
"id": "10028428",
"label": "c",
"name": "Prescribe oral triptans + NSAID",
"picture": null,
"votes": 138
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is likely to precipitate opioid withdrawal.",
"id": "10028427",
"label": "b",
"name": "Immediately cease all analgesics",
"picture": null,
"votes": 276
}
],
"comments": [],
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"__typename": "Concept",
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"id": "6061",
"name": "Medication overuse headache",
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"typeId": 7
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"topicId": 141,
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"learningPoint": "The treatment for medication overuse headache is to cease analgesics, with opioids being tapered gradually rather than stopped abruptly to reduce the risk of withdrawal symptoms.",
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"question": "A 60 year old woman complains of daily headaches. She has no associated scalp tenderness, photophobia, phonophobia, nasal discharge or eye watering.\n\nHer past medical history includes rheumatoid arthritis for which she has recently been started on daily tramadol.\n\nWhich of the following is the most appropriate management plan?",
"sbaAnswer": [
"a"
],
"totalVotes": 3379,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,241 | false | 40 | null | 6,495,236 | null | false | [] | null | 18,084 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario describes normal pressure hydrocephalus for which the treatment is to insert a ventriculoperitoneal shunt to relieve the hydrocephalus, which tends to reverse the symptoms. NPH patients present with polyuria, confusion, rapidly progressive dementia with gait abnormalities.",
"id": "10028431",
"label": "a",
"name": "Ventriculoperitoneal shunt",
"picture": null,
"votes": 2528
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These represent treatment options for Parkinsonism which would present with bradykinesia, shuffling gait and rigidity.",
"id": "10028434",
"label": "d",
"name": "L- Dopa & medication review",
"picture": null,
"votes": 380
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be indicated in cases of metastatic brain cancer but is not appropriate here as NPH is more likely due to absence of headaches and focal neurology.",
"id": "10028435",
"label": "e",
"name": "Palliative care",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an option in various mental health diagnoses and may be used to treat symptoms of depression and anxiety that often arise in patients with dementia.",
"id": "10028433",
"label": "c",
"name": "Cognitive behavioural therapy",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an option in Alzheimer's dementia, which is not the case here.",
"id": "10028432",
"label": "b",
"name": "Donepezil",
"picture": null,
"votes": 388
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "wet,wobbly,weird",
"createdAt": 1709067272,
"dislikes": 0,
"id": "43049",
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"displayName": "CT Kawasaki",
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{
"__typename": "QuestionComment",
"comment": "Isn't the wet referring to urinary incontinence the stem sounds like polyuria ",
"createdAt": 1715025337,
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"id": "48663",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 18084,
"replies": [
{
"__typename": "QuestionComment",
"comment": "In the explanation, it does say \"polyuria\", but the triad is classically: gait ataxia, urinary or faecal incontinence, and dementia.",
"createdAt": 1737024726,
"dislikes": 0,
"id": "60711",
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"displayName": "Amnesia Contusion",
"id": 79228
}
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"displayName": "Edema Dominant",
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"id": "4550",
"name": "Normal pressure hydrocephalus",
"status": null,
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"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
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"topicId": 141,
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"learningPoint": "Normal pressure hydrocephalus presents with confusion, gait abnormalities, and polyuria, often improving with ventriculoperitoneal shunt placement.",
"likes": 3,
"multiAnswer": null,
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"question": "A 72 year old man has been increasingly confused for the last few months. He has become increasingly forgetful and has had several falls. He describes feeling more thirsty and urinating more frequently over the same timeframe.\n\nWhich of the following is the best management option, given the likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3373,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,242 | false | 41 | null | 6,495,236 | null | false | [] | null | 18,085 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is non-epileptic attack disorder. A ketogenic diet may be advised in certain forms of epilepsy, after initiation of anti-epileptic drugs.",
"id": "10028438",
"label": "c",
"name": "Advise a ketogenic diet",
"picture": null,
"votes": 154
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is non-epileptic seizure disorder, which is not treated with anti-epileptic drugs. Valproate may be initiated if further evidence of epilepsy comes to light, but would likely be avoided in a woman of childbearing age.",
"id": "10028439",
"label": "d",
"name": "Initiate on valproate",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This description is typical for non-epileptic seizures whereby patients remain alert, the onset is gradual, and an emotional response may follow. The non-epileptiform EEG supports this diagnosis. Non-epileptic seizures may be related to underlying anxiety or stresses and psychotherapy is the preferred treatment.",
"id": "10028436",
"label": "a",
"name": "Refer for psychotherapy",
"picture": null,
"votes": 2011
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is non-epileptic seizure disorder, which is not treated with anti-epileptic drugs. Lamotrigine may be initiated if further evidence of epilepsy comes to light, as it is preferred to valproate (as it is less teratogenic) in a woman of childbearing age.",
"id": "10028440",
"label": "e",
"name": "Initiate on lamotrigine",
"picture": null,
"votes": 814
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate given CBT and psychotherapies are the preferred treatment for non-epileptic attack disorder. It is important to note that these episodes can have a significant impact on patients' lives.",
"id": "10028437",
"label": "b",
"name": "Reassurance with no further action",
"picture": null,
"votes": 375
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I dont think theres enough to confirm non epileptic. neurologist told me normal EEG can still be epilepsy",
"createdAt": 1738650416,
"dislikes": 0,
"id": "62281",
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"accessLevel": "subscriber",
"displayName": "Henza",
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"demo": null,
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"id": "6062",
"name": "Seizures and Blackouts",
"status": null,
"topic": {
"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
},
"topicId": 141,
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"dislikes": 13,
"explanation": null,
"highlights": [],
"id": "18085",
"isLikedByMe": 0,
"learningPoint": "Non-epileptic seizures are characterised by preserved awareness and emotional responses, often requiring psychotherapy rather than pharmacological treatment.",
"likes": 3,
"multiAnswer": null,
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"question": "A 35 year old woman is referred to a 'first fit' clinic by her GP.\n\nShe describes multiple episodes of gradual onset limb shaking and jerking, during which she is responsive and after which she cries. Her mother has epilepsy.\n\nAn EEG is performed which does not show any epileptiform activity.\n\nWhat is the most appropriate course of action?",
"sbaAnswer": [
"a"
],
"totalVotes": 3369,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,243 | false | 42 | null | 6,495,236 | null | false | [] | null | 18,086 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are treatment options for cases of colorectal cancer, however colonoscopy has not demonstrated a malignancy in this patient.",
"id": "10028444",
"label": "d",
"name": "Initiate on chemotherapy and radiotherapy",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This description is suspicious for familial adenomatous polyposis which confers an extremely high chance of developing colorectal cancer and is normally prophylactically treated with a panproctocolectomy at a young age.",
"id": "10028441",
"label": "a",
"name": "Prophylactic panproctocolectomy",
"picture": null,
"votes": 3053
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may reduce the chances of developing malignancy but given that the polyps in FAP are dispersed through the entire bowel, there is still a high chance of developing colorectal cancer.",
"id": "10028445",
"label": "e",
"name": "Prophylactic right hemicolectomy",
"picture": null,
"votes": 126
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest a palliative approach is required here.",
"id": "10028443",
"label": "c",
"name": "Palliative care",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not ideal given the near certainty the patient will develop colorectal cancer.",
"id": "10028442",
"label": "b",
"name": "Watch and wait approach",
"picture": null,
"votes": 136
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"typeId": 7
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"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6063",
"name": "Colorectal cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "315",
"name": "Surgery",
"typeId": 5
},
"topicId": 315,
"totalCards": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "18086",
"isLikedByMe": 0,
"learningPoint": "Familial adenomatous polyposis (FAP) is a hereditary condition marked by the formation of numerous polyps in the colon and rectum, which have a high cancer risk if untreated, and prophylactic panproctocolectomy is a preventive surgery that removes the entire colon, rectum, and anus to greatly reduce this risk.",
"likes": 0,
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"question": "A 21 year old man presents to the GP with rectal bleeding and fatigue. He reports his dad having bowel cancer for which he had a colostomy bag from early adolescence. Colonoscopy reveals hundreds of polyps throughout his bowel.\n\nWhich of the following is likely to form definitive management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3369,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,244 | false | 43 | null | 6,495,236 | null | false | [] | null | 18,087 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not the investigation of choice for acute mesenteric ischaemia. It is useful in cases of suspected bowel obstruction.",
"id": "10028447",
"label": "b",
"name": "Abdominal X Ray",
"picture": null,
"votes": 290
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is generally indicated in cases of rectal surgery to visualise whether an anastomosis is intact.",
"id": "10028449",
"label": "d",
"name": "Gastrograffin enema",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "CT angiography is required here to visualise the blood supply to the bowel, there is currently no indication for a full CT-CAP.",
"id": "10028450",
"label": "e",
"name": "CT Chest, abdomen and pelvis",
"picture": null,
"votes": 509
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest a colonoscopy would prove beneficial here with no PR bleeding, unexplained changes in bowel habit or malignancy.",
"id": "10028448",
"label": "c",
"name": "Colonoscopy",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This description is suspicious for acute mesenteric ischaemia with severe pain out of keeping with examination findings and a raised lactate (suggestive of ischaemia) on a background of atrial fibrillation. CT angiography is the preferred imaging modality to assess the blood supply to the bowel.",
"id": "10028446",
"label": "a",
"name": "CT Angiography",
"picture": null,
"votes": 2451
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Guarding and rigidity tends to point towards a peritonitic picture. Mesenteric ischaemia would usually find a soft, mildly tender abdomen on examination. ",
"createdAt": 1736855740,
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"id": "6064",
"name": "Acute mesenteric ischaemia",
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"__typename": "Topic",
"id": "315",
"name": "Surgery",
"typeId": 5
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"id": "18087",
"isLikedByMe": 0,
"learningPoint": "Acute mesenteric ischaemia presents with severe abdominal pain, often in patients with atrial fibrillation, and is diagnosed using CT angiography.",
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"question": "A 75 year old man comes to the emergency department with excruciating abdominal pain following a meal. An ECG shows an irregularly irregular rhythm with no P waves visible.\n\nExamination demonstrates guarding and rigidity and on VBG his lactate level is raised.\n\nWhich of the following investigations is diagnostic of the underlying condition?",
"sbaAnswer": [
"a"
],
"totalVotes": 3360,
"typeId": 1,
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} | MarksheetMark |
173,467,245 | false | 44 | null | 6,495,236 | null | false | [] | null | 18,088 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Some complications of gallstones may be treated conservatively in the initial instance with a cholecystectomy perfomed a few weeks later, but this patient is asymptomatic and there is no evidence of cholecystitis/cholangitis.",
"id": "10028455",
"label": "e",
"name": "Intravenous fluids and antibiotics",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest an emergency in this presentation.",
"id": "10028454",
"label": "d",
"name": "Urgent laparotomy",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This describes asymptomatic gallstones which are common and require no treatment unless symptoms develop.",
"id": "10028451",
"label": "a",
"name": "Reassurance with safety netting",
"picture": null,
"votes": 2271
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not indicated in the absence of symptoms, it is indicated if the patient develops symptoms or complications of gallstones.",
"id": "10028452",
"label": "b",
"name": "Elective laparascopic cholecystectomy",
"picture": null,
"votes": 813
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is indicated to clear stones in the bile duct in cases of obstructive jaundice with indications including pancreatic ductal disease.",
"id": "10028453",
"label": "c",
"name": "Endoscopic Retrograde Cholangio-Pancreatography",
"picture": null,
"votes": 216
}
],
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"name": "Gallstone disease",
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"question": "A 45 year old woman is undergoing pre-assessment for bariatric surgery. Imaging reveals gallstones in the gallbladder. She denies any symptoms of indigestion, nausea or vomiting.\n\nWhich of the following treatment options is most appropriate?",
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"a"
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} | MarksheetMark |
173,467,246 | false | 45 | null | 6,495,236 | null | false | [] | null | 18,089 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest pathology in the colon at present.",
"id": "10028460",
"label": "e",
"name": "Colonoscopy",
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},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be considered if gynaecological pathology is suspected on abdominal ultrasound as it is more invasive.",
"id": "10028459",
"label": "d",
"name": "Transvaginal ultrasound",
"picture": null,
"votes": 211
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This describes likely appendicits but an ultrasound scan is often used in females in the first instance to exclude ovarian and gynaecological pathology.",
"id": "10028456",
"label": "a",
"name": "Abdominal ultrasound",
"picture": null,
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},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the preferred diagnostic imaging modality in appendicitis but ovarian and gynaecological pathology can be quickly considered with an ultrasound.",
"id": "10028457",
"label": "b",
"name": "CT Abdomen",
"picture": null,
"votes": 364
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A pregnancy test has been performed already and is negative.",
"id": "10028458",
"label": "c",
"name": "Repeat pregnancy test",
"picture": null,
"votes": 19
}
],
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"id": "18089",
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"learningPoint": "In young women with right iliac fossa pain, abdominal ultrasound is crucial to exclude gynaecological conditions before diagnosing appendicitis.",
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"question": "A 20 year old woman comes to the emergency department with right iliac fossa pain, which started in the umbilicus. She is nauseated and has vomited. She has not eaten since yesterday.\n\nUrinary beta-HCG is negative.\n\nWhat is the most appropriate initial investigation?",
"sbaAnswer": [
"a"
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} | MarksheetMark |
173,467,247 | false | 46 | null | 6,495,236 | null | false | [] | null | 18,090 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be appropriate if the effusion is exudative and felt to be secondary to a possible malignancy, but is not warranted at present.",
"id": "10028464",
"label": "d",
"name": "CT Chest, abdomen and pelvis",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The examination findings and chest x ray do not suggest acute pulmonary oedema and therefore furosemide is not warranted at present.",
"id": "10028465",
"label": "e",
"name": "Intravenous furosemide",
"picture": null,
"votes": 453
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may prove helpful in providing symptomatic relief, but the mainstay of treatment in cases of pleural effusion is establishing and treating the underlying cause.",
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"label": "c",
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"votes": 21
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This woman has a pleural effusion and the aetiology needs to be uncovered through aspiration and pleural fluid analysis of protein content, LDH, cell count, pH, glucose and microbiology testing to ascertain whether it is a transudative or exudative cause.",
"id": "10028461",
"label": "a",
"name": "Pleural aspiration",
"picture": null,
"votes": 2684
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the treatment of choice in cases of tension pneumothorax, which the examination and chest x-ray do not support.",
"id": "10028462",
"label": "b",
"name": "Emergency needle decompression",
"picture": null,
"votes": 164
}
],
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{
"__typename": "QuestionComment",
"comment": "On pleural asiprate order G-CLAP\n\nGlucose\nCytology\nLDH (for lights criteria)\nAcid (pH)\nProtein (for lights criteria)",
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"caption": "https://commons.wikimedia.org/wiki/Category:Pleural_effusion#/media/File:Pleural_effusion-Metastatic_breast_carcinoma_Case_166_(5477628658).jpg",
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"question": "A 50 year old woman presents to the emergency department short of breath. Examination reveals dullness to percussion on the right side.\n\nA chest X ray is performed and shows:\n\n[lightgallery]\n\nWhat is the most appropriate course of management?",
"sbaAnswer": [
"a"
],
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} | MarksheetMark |
173,467,248 | false | 47 | null | 6,495,236 | null | false | [] | null | 18,091 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely to prove helpful in cases of pulmonary embolism whereby the priority is treating the clot.",
"id": "10028468",
"label": "c",
"name": "Chest physiotherapy",
"picture": null,
"votes": 167
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate given her history and symptoms.",
"id": "10028470",
"label": "e",
"name": "Discharge with reassurance",
"picture": null,
"votes": 509
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the treatment of choice in cases of tension pneumothorax, which the examination and chest x ray do not support.",
"id": "10028467",
"label": "b",
"name": "Emergency needle decompression",
"picture": null,
"votes": 194
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This woman likely has a pulmonary embolism with pro-thrombotic risk factors of SLE, pregnancy and immobilisation. Her chest x-ray is normal which is common in pulmonary embolism. She requires a CTPA or V/Q scan, but should be anticoagulated until this can be done.",
"id": "10028466",
"label": "a",
"name": "Start on treatment dose low molecular weight heparin",
"picture": null,
"votes": 2370
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest an infective pathology at present with the chest x-ray appearing normal.",
"id": "10028469",
"label": "d",
"name": "Start on co-amoxiclav and clarithromyxin",
"picture": null,
"votes": 98
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Didn't impact my answer but please, just say she's pregnant. Recent history of hyperemesis doesn't imply she's pregnant now. Unnecessarily confusing ",
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{
"__typename": "QuestionComment",
"comment": "the 'gravidarum' means during pregnancy, if it said hyperemesis alone that would be different",
"createdAt": 1709736991,
"dislikes": 3,
"id": "44016",
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"likes": 2,
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"displayName": "Monoclonal Yeast",
"id": 49743
}
}
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"displayName": "Ale",
"id": 20565
}
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"__typename": "QuestionComment",
"comment": "anyone else think the trachea is devsiated?",
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{
"__typename": "QuestionComment",
"comment": "it's central, maybe you are looking at the right bronchus but this is normal",
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"__typename": "QuestionComment",
"comment": "why did they do a CXR if shes pregnant? the distractors really got me...",
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"displayName": "Maya",
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"learningPoint": "Patients with systemic lupus erythematosus are at increased risk of pulmonary embolism, especially during pregnancy and periods of immobilisation.",
"likes": 8,
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{
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"caption": "https://commons.wikimedia.org/wiki/File:Chest_Xray_PA_3-8-2010.png",
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"index": 0,
"name": "normal cxr.png",
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"question": "A 26 year old woman presents to the emergency department short of breath since yesterday. She is tachycardic on examination. She has systemic lupus erythematosus and has recently been struggling with hyperemesis gravidarum, causing her to take time off work in the last week.\n\nHer chest x-ray is shown below. Further imaging investigations are not available until tomorrow.\n\n[lightgallery]\n\nWhat is the most appropriate management?",
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"a"
],
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173,467,249 | false | 48 | null | 6,495,236 | null | false | [] | null | 18,092 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Codeine is not first line analgesia for osteoarthritis and this option does not address lifestyle measures.",
"id": "10028473",
"label": "c",
"name": "Offer co-codamol",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is nothing to suggest a diagnosis of gout at present warranting allopurinol.",
"id": "10028474",
"label": "d",
"name": "Offer allopurinol",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This man's history and imaging suggest osteoarthritis which is initially treated by lifestyle measures including exercise, weight loss and analgesics including paracetamol and NSAIDs. Topical NSAIDs are first line for knee osteoarthritis.",
"id": "10028471",
"label": "a",
"name": "Lifestyle advice and offer topical ibuprofen",
"picture": null,
"votes": 3126
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be a treatment option later down the line.",
"id": "10028472",
"label": "b",
"name": "Refer for steroid joint injections",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate given the patient likely has osteoarthritis which is chronic and not an emergency, as a last resort ,elective surgery may be required in severe osteoarthritis.",
"id": "10028475",
"label": "e",
"name": "Admit to hospital for emergency surgery",
"picture": null,
"votes": 36
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "This looks like bone on bone would a referral to ortho not be best ",
"createdAt": 1734781349,
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"__typename": "QuestionComment",
"comment": "75yrs obese and 20 a day, topicals are never going to reach the joint space, lifestyle is very much established, showing the man some sympathy and offering an actual solution seems best practice imho",
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"learningPoint": "Osteoarthritis management includes lifestyle modifications, weight loss, and topical NSAIDs as first-line treatment for knee pain and stiffness.",
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"__typename": "Picture",
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"question": "A 75 year old man comes to the GP complaining of knee pain, stiffness and swelling. He is obese and smokes 20 cigarettes a day.\n\nA knee x ray is performed and is shown below:\n\n[lightgallery]\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
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173,467,250 | false | 49 | null | 6,495,236 | null | false | [] | null | 19,550 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035734",
"label": "c",
"name": "Dexamethasone, STAT dose",
"picture": null,
"votes": 2338
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035735",
"label": "d",
"name": "150 micrograms IM adrenaline",
"picture": null,
"votes": 1207
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035736",
"label": "e",
"name": "Amoxicillin",
"picture": null,
"votes": 53
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.",
"id": "10035732",
"label": "a",
"name": "Rigid bronchoscopy",
"picture": null,
"votes": 8839
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035733",
"label": "b",
"name": "Nebulised salbutamol",
"picture": null,
"votes": 722
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Would CXR be indicated at all?",
"createdAt": 1718704129,
"dislikes": 0,
"id": "53165",
"isLikedByMe": 0,
"likes": 1,
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"comment": "If it's already suspected that the kiddy has eaten the forbidden plastic chocolate brick then you are already there with the grabber to remove it with a bronchoscopy. A CXR would only confirm the diagnosis but exposure them to extra radiation and you would still need to go in with the scope. Hope this helps / makes sense :D ",
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"explanation": "# Summary\n\nForeign Body Ingestion (FBI) refers to the swallowing of objects that are not intended to be ingested. Clinical manifestations vary from being asymptomatic to significant morbidity, including esophageal obstruction or perforation, depending on the type and location of the foreign body. Most instances can be managed conservatively, but high-risk objects may necessitate invasive interventions such as endoscopy or open surgery. High-risk objects include batteries, large objects, absorbent materials, magnets swallowed with metal objects, lead-based objects, and objects containing toxins.\n\n# Definition\n\nForeign Body Ingestion is a common pediatric complaint and involves the swallowing of objects not intended for ingestion. While most foreign bodies pass harmlessly through the gastrointestinal tract, some can cause significant complications.\n\n# Epidemiology\n\nForeign Body Ingestion is a prevalent issue among children, particularly those between the ages of six months to three years. This high incidence is attributed to their oral exploratory behavior. Most ingested objects pass spontaneously without causing complications, but a subset may pose a significant health risk.\n\n# Aetiology\n\nObjects often ingested include coins, toys, jewelry, batteries, and food items. The list of potentially ingestible items is virtually limitless but varies based on cultural, environmental, and individual factors. High-risk objects include batteries, large objects that may become trapped at the pylorus, absorbent materials that may cause obstruction, magnets swallowed with metal objects, lead-based objects, and objects containing toxins.\n\n# Signs and Symptoms\n\nThe clinical presentation can range from asymptomatic to significant morbidity. Symptoms include, but are not limited to:\n\n- Drooling\n- Difficulty swallowing or painful swallowing\n- Refusal to eat\n- Chest, throat, or abdominal pain\n- Vomiting\n- Blood in the stool\n\nThe onset and type of symptoms can be influenced by the size, shape, location, and nature of the foreign body.\n\n# Differential Diagnosis\n\nConsider the following conditions in a patient presenting with symptoms suggestive of foreign body ingestion:\n\n- Gastroenteritis: Characterized by nausea, vomiting, diarrhea, abdominal pain.\n- Esophagitis or Gastritis: These could present with similar symptoms of painful swallowing, refusal to eat, and abdominal pain.\n- Appendicitis: Presents with abdominal pain, loss of appetite, nausea, and vomiting.\n- Esophageal stricture or tumor: Can present with difficulty swallowing, chest pain, weight loss, and regurgitation of food or fluids.\n\n# Investigations\n\nInvestigations are unnecessary in an asymptomatic child with a low-risk ingestion. In symptomatic patients or those who have ingested high-risk objects, investigations may include:\n\n- Plain radiography: Most commonly used and can detect radio-opaque objects.\n- Computed Tomography (CT): Offers better sensitivity and specificity for detecting radiolucent foreign bodies.\n- Direct visualization with endoscopy: Useful when there is a high index of suspicion, even if radiological studies are negative.\n\n# Management\n\nThe majority of foreign bodies that are swallowed can be managed conservatively, including observation and symptomatic treatment. High-risk objects such as batteries, sharp objects, or large objects may require endoscopic or surgical removal. Clinicians should provide clear discharge instructions regarding potential complications and when to seek immediate medical attention.\n\n# References\n\n[BMJ Best Practice: Foreign Body Ingestion](https://bestpractice.bmj.com/topics/en-gb/1050)",
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"question": "A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.\n\nWhat is the most appropriate management?",
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"comment": "Ondensatron can be given IV or IM in this circumstance? ",
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"comment": "yeah BNF says slow IV or IM so idk why theyre saying IM is wrong?",
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"comment": "if there's a cannula in situ, it's better to do IV route over IM",
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"comment": "why is domperidone wrong?",
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"comment": "don't give domperidone in someone with parkinsons ",
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"comment": "This is wrong domperidone is gold standard for GI side effects in Parkinson's but that's when nausea and vomiting is associated with opiates, so you would give ondansetron for this patient as the treatment is for post-op nausea and vomiting ",
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"comment": "Re. Cyclizine —> in practice it works better for patients who have nausea from ear related problems eg motion sickness, vestibular neuritis etc…\nOndansetron is typically a good choice for treatment or prophylaxis of post-surgical nausea :) ",
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"comment": "also: cyclizine = CI: heart failure",
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"comment": "Why not haloperidol as the QT interval is not prolonged in this patient? Unless there are other contraindications",
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"comment": "Parkinson's would be a CI as it's a dopamine receptor antagonist",
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"explanation": "Assess cause:\n\n- Infection\n- Hypovolaemia\n- Pain\n- Paralytic ileus\n- Drugs\n\nManagement:\n\n- Non-pharmacological\n\n - Minimise patient movement\n - Analagesia\n - IV fluids if dehydrated\n\n- Pharmacological\n - 5HT3 receptor antagonist e.g. Ondansetron - first line. Risk of QT prolongation and constipation\n - Histamine (H1) receptor antagonist e.g. Cyclizine. Avoid in severe heart failure\n - Dopamine (D2) receptor antagonist e.g. Prochlorperazine. Risk of extrapyramidal side effects (dystonic reactions)\n\nOther anti-emetics such as corticosteroids or Metoclopramide reserved for specific cases of post-operative nausea and vomiting.\n\n# External links \n\n- [NHS Greater Glasgow & Clyde: Adult Therapeutics Handbook: Management of Postoperative Nausea and Vomiting](https://handbook.ggcmedicines.org.uk/guidelines/pain-post-operative-nausea-and-vomiting-and-palliative-care-symptoms/management-of-postoperative-nausea-and-vomiting-ponv/)\n- [Up To Date: Postoperative Nausea and Vomiting](https://www.uptodate.com/contents/postoperative-nausea-and-vomiting)\n- [Norfolk and Norwich University Hospitals: Clinical Guideline for the management of post-operative nausea and vomiting in adults and children](http://www.nnuh.nhs.uk/publication/download/management-of-post-operative-nausea-and-vomiting-in-adults-and-children-clinical-guideline-v1-1/)\n",
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"explanation": "# Drug choice feedback\n\nThis patient requires an anti-emetic. Ondansetron is the most appropriate. Cyclizine is contra-indicated in light of her severe heart failure, whilst prochlorperazine is contra-indicated due to her mild Parkinson's disease, as it can result in extra-pyramidal side effects. Metoclopramide is contra-indicated as it is a pro-kinetic in the context of thias patient's gastrectomy\n\n# Dose/Route/Frequency/Duration feedback\n\nThe dose of IV ondansetron in post-operative nausea and vomiting is 4mg. Whilst it can be given IM, this patient already has a cannula in situ, hence the IV route is preferred.",
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"question": "Case Presentation: A 73-year-old woman admitted to the general ward for observation after a gastrectomy 12 hours ago complains of nausea and has vomited three times. She has been given adequate analgesia.\n\n\n## PH\n\nStomach cancer, severe heart failure, Type 2 Diabetes Mellitus, Obesity, Hyperlipidaemia, Mild Parkinson's Disease\n\n## DH\n\nRamipril 5mg OD PO, Bisoprolol 2.5mg PO, Spironolactone 50mg PO OD, Metformin 1g BD PO, Empaglifozin 10mg PO OD, Atorvastatin 40mg PO OD (NKDA)\n\n## On examination\n\nAppears unwell, not oriented to time and place. Peripheries warm, CRT 2s. Cannula in situ.\n\nTemperature 36.6°C, HR 97, RR 23, BP 113/80, O2 96% RA, GCS 14, Weight 95kg\n\n## Investigations\n\nFBC: Hb 144, WCC 7.3, Plts 324\n\nU&Es: Na<sup>+</sup> 136, K<sup>+</sup> 4.2, Cl<sup>-</sup> 105, Ur 6.8, Cr 98, eGFR 51mL/min/1.73m<sup>2</sup>\n\nECG: Normal sinus rhythm, QTc 430ms (<460ms)\n\n# Prescribing Request\n\nWrite a prescription for one medication that is most appropriate for treating her post-operative nausea and vomiting.",
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"comment": "They should accept sertraline, citalopram etc",
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"comment": "Fluoxetine is preferred in children",
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"comment": "Where in the BNF does it talk about a child receiving fluoxetine ",
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"comment": "In the BNFc if you search depression, it is under drug treatment ",
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"comment": "As a general rule of thumb, if you don't know what the treatment is, first check whatever Tx summary is available in the BNF. It may not always be helpful but in this case, searching depression in the BNFc it tells you fluoxetine is the 1st line recommended pharmacological Tx for depression in children",
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"explanation": "# Summary\n\nDepression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.\n\n# Definition\n\nDepression is a mental health disorder characterised by:\n\n- **ICD-11 Criteria:**\n - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.\n\n- **DSM-V Criteria:**\n - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.\n - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. \n\nThis consists of the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure\n\n**Severity:**\n\n- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.\n- Moderate: Symptoms or functional impairment between \"mild\" and \"severe.\"\n- Severe: The number of symptoms, intensity, and impairment are all greatly increased.\n\n\n# Epidemiology\n\nDepression is a highly prevalent mental health disorder. It represents the third most common reason for consulting a general practitioner in the UK. Depression demonstrates a higher prevalence in females.\n\n# Aetiology\n\nThe aetiology of depression involves a complex interplay of genetic and environmental factors. History of previous mental health issues, physical illnesses, and social challenges like divorce, poverty, and unemployment can all contribute to its development.\n\n# Clinical Features\n\nDepression is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the presence of 5 out of the following 9 symptoms, occurring nearly every day for at least 2 weeks:\n\n1. **Depressed mood or irritability** for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful).\n2. **Anhedonia:** Decreased interest or pleasure in most activities, most of the day.\n3. Significant **weight change** (5%) or change in appetite.\n4. **Sleep alterations:** Insomnia or hypersomnia.\n5. **Activity changes:** Psychomotor agitation or retardation.\n6. **Fatigue** or loss of energy.\n7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.\n8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.\n9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.\n\n### Additional Features (Severe Depression)\n- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.\n- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).\n\n# Differential Diagnosis\n\nThe main differentials and their key signs and symptoms include:\n\n- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.\n- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.\n- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.\n- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.\n- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.\n\n\nVarious organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:\n\n- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.\n- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).\n- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).\n- Chronic conditions such as diabetes and obstructive sleep apnea.\n- Long-standing infections, such as mononucleosis.\n- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.\n\n\n# Investigations\n\n- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).\n- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).\n- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).\n\n# Management\n\nDepression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.\n\r\n**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**\n\n- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). \r\n- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) \r\n- 3rd line = Consider antidepressants \r\n\r\n**Mild depression unresponsive to treatment and moderate-to-severe depression:**\n\n- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)\r\n- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts \r\n\r\n**Severe depression and poor oral intake/psychosis/stupor:**\n\n- 1st line = ECT \n- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.\r\n\n**Recurrent depression:** \n\n- Treated with antidepressant + lithium \r\n\n\nMedical management of depression - additional notes:\n\n- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.\n- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.\n- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)",
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"explanation": "# Drug choice feedback\n\nAs this adolescent is suffering from severe major depressive disorder, and it has not been effectively controlled with cognitive behavioural therapy, pharmacological management may be initiated in conjunction. Fluoxetine should be prescribed, as this is the only antidepressant for which trials show that the risks are outweighed by the benefits. It has a long half-life which makes it useful in younger group of patients whose adherence to medication may be sub-optimal.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe initial dose is 10mg once-daily orally, which can be administered as a single or divided dose.",
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"question": "Case Presentation: A 11-year-old boy has been low in mood and energy. He has been unable to function well at school and socially. He reports being tearful and anxious, although has no thoughts of self-harm. There has been increased stress due to recent changes in his home situation. A trial of talking therapy has been initiated which although effective, has not resulted in the patient returning to his baseline.\n\n\n## PH\n\nNone\n\n## DH\n\nNone (NKDA)\n\n## On examination\n\nNo cyanosis. Normal consciousness but mildly distressed and agitated. \n\nTemperature 36.3°C, HR 80, RR 16, BP 110/68, O<sub>2</sub> 98% RA, GCS 15, Weight 42kg\n\n## Investigations\n\nNone\n\n# Prescribing Request\n\nWrite a prescription for one additional drug that is most appropriate for treating his condition.",
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"comment": "BNF states that IV lorazepam can also be used in status",
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"comment": "but he doesnt have any IV access",
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"comment": "here it said the concentration of midazolam was 5 mg / ml. I said the answer was therefore 1 ml of solution (because there are 5 mg of midazolam in that). But it was wrong? Would you get this wrong in the real exam? Because in real life you would give 1 ml of solution???",
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"comment": "It's only wrong if the exam is asking you for the dose in mg and not the volume to be administered, which was the case for this Qu (the answer units were in mg). As a general rule of thumb, the prescriber states the dose in mg, as the person giving the medication would then need to decide how it's administered",
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"comment": "prescribed 5 mg midaz and oromucosal and it wasn't accepted bc they only take that combination with \"buccal\" ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Drug choice feedback\n\nThis child is most probably suffering from febrile seizures secondary to the ongoing viral infection, and given his past and family history of febrile seizures. Importantly, other major causes of paediatric seizures such as meningococcal disease or hypoglycaemia are excluded based on the examination findings and his blood glucose being normal respectively. As he is still seizing after five minutes, emergency treatment with either diazepam or midazolam should be initiated.\n\n# Dose/Route/Frequency/Duration feedback\n\nDiazepam should be given PR while midazolam should be given buccally. The optimal doses are as above.",
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"question": "Case Presentation: A 3-year-old boy attends the Emergency Department with his mother with a high fever and cough. No changes in urinary habit and no travel history noted. While waiting to be seen, he suddenly begins seizing.\n\n\n\n\n## PH\n\n\nFebrile seizures\n\n\n## DH\n\n\nNone (NKDA)\n\n\n## FHx\n\n\nFather had febrile seizures as a child\n\n\n## On examination\n\n\nThe child is having generalised, tonic-clonic seizure. He was not noted to be irritable, drowsy beforehand. No neck stiffness, no rash seen, fontanelle not bulging.\nNo cannula has been inserted.\n\n\nTemperature 38.9°C, HR 120, RR 25, BP 96/68, O<sub>2</sub> 98% RA, GCS 15 (before seizure began), Weight 15kg\n\n\n## Investigations\n\n\nBM: 5.5 mmol/L (normal range 3.5-5.5 mmol/L).\n\n\nAll other investigation results are pending.\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate for treating his condition should it still persist after five minutes.",
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"comment": "why not magnesium sulfate",
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"comment": "mag sulph is for seizure prophylaxis if i recall correctly, but you'd want to address the hypertension first",
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"comment": "I second this - I gave her magnesium sulphate bc she had hyperreflexia which is a sign of severe pre-eclampsia and you can give mgso4 in severe pre-eclampsia! if anyone knows the answer pls comment ",
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"comment": "the qu asked for what will help her hypertension tho",
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"comment": "why isnt oral labetalol hydrochloride accepted? treatment summary says oral or iv for bp>160/110",
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"comment": "under bnf hypertensive emergencies it recommends prescribing labetalol 50mg, why is this wrong?",
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"explanation": "# Summary\n\nPre-eclampsia is a placental condition that often affects pregnant women from around 20 weeks of gestation, characterised by hypertension and proteinuria. Other symptoms include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia. The exact aetiology is not entirely understood, but it may be due to dysfunctional trophoblast invasion of the spiral arterioles. Key investigations include blood pressure and urine protein measurements. Management strategies include anti-hypertensive treatment, with labetalol as the first-line agent. Magnesium sulphate is used to prevent and treat eclamptic seizures, but the ultimate curative treatment is delivery of the placenta.\n\n# Epidemiology\n\n\n\nPre-eclampsia affects a significant percentage of pregnancies worldwide, although the exact number varies significantly between different populations and healthcare settings. Risk factors include nulliparity, a previous history or family history of pre-eclampsia, increasing maternal age, pre-existing diseases such as hypertension, diabetes, renal disease, autoimmune disease, obesity, and multiple pregnancies.\n\n\n# Aetiology\n\n\n\nThe exact aetiology of pre-eclampsia remains unclear. However, it's believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.\n\n\n# Signs and Symptoms\n\n\nPre-eclampsia is characterised by:\n\n- Hypertension\n- Proteinuria\n- Peripheral oedema\n- Severe headache\n- Drowsiness\n- Visual disturbances\n- Epigastric pain\n- Nausea/vomiting\n- Hyperreflexia\n\n# Maternal complications\n\n- Eclampsia (seizures due to cerebrovascular vasospasm)\n- Organ failure\n- Disseminated intravascular coagulation (DIC)\n- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))\n\n# Foetal complications\n\n- Intrauterine growth restriction\n- Pre-term delivery\n- Placental abruption\n- Neonatal hypoxia\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for pre-eclampsia includes other conditions that can present with hypertensive disorders in pregnancy, such as chronic hypertension, gestational hypertension, and HELLP syndrome. Key signs and symptoms for these conditions include persistent high blood pressure, proteinuria, and various combinations of haemolysis, elevated liver enzymes, and low platelet levels.\n\n# Investigations\n\n\nKey investigations for pre-eclampsia include:\n\n- Blood pressure measurement: To confirm hypertension.\n- Urinalysis: To confirm proteinuria.\n- Blood tests: To assess kidney function, liver function, and clotting status.\n\n# Management\n\nAspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with one high risk factor or two (or more) moderate risk factors. \n\nManagement of pre-eclampsia primarily involves anti-hypertensive treatment, with labetalol being the recommended first-line agent. Other agents that can be used include Nifedipine, Methyldopa and hydralazine. \n\nMagnesium sulphate can be administered for the prevention and treatment of eclamptic seizures. \n\nThe only definitive curative treatment is the delivery of the placenta. It is also crucial to monitor the mother and foetus closely for complications.\n",
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"explanation": "# Drug choice feedback\n\nThis woman is likely suffering from pre-eclampsia. As her systolic blood pressure is above 150mmHg, pharmacological management is indicated. The first line agent for controlling this is with labetalol. Other options include nifedipine or methyldopa. As she does not have any major complications (haemodynamically unstable, coagulation abnormalities or HELLP syndrome), she can be managed conservatively for now i.e. without delivery of the foetus.\n\n# Dose/Route/Frequency/Duration feedback\n\nThere is no fixed dose stated for labetalol as it is given as a continuous infusion, hence a rate instead is recommended which is titrated every 30 minutes according to clinical improvement. Although labetalol can be taken orally, the patient is having nausea and a cannula has been inserted, making the intravenous route preferred.",
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"question": "Case Presentation: A 41-year-old woman, G1P0, who is 32 weeks pregnant is brought to the Emergency Department by her partner with severe headache, blurry vision, severe abdominal pain, nausea and sudden swelling of hands.\n\n\n## PH\n\nType 2 Diabetes Mellitus, Obesity\n\n## DH\n\nMetformin 1g PO OD, Aspirin 75mg PO OD (started from 12th week of gestation) (NKDA)\n\n## On examination\n\nAlert but in pain. Hyperreflexia noted. Mild tenderness in right upper quadrant of abdomen. Generalised oedema noted. No clonus. Cannula in situ.\n\nTemperature 36.2°C, HR 67, RR 13, BP 162/98, O<sub>2</sub> 98% RA, GCS 14, Weight 98kg\n\n## Investigations\n\nProteinuria 2+ on dipstick, no blood noted\n\nFBC, U&E, LFT and Clotting: Normal, HEELP syndrome negative.\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating her blood pressure. ",
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173,467,475 | false | 5 | null | 6,495,239 | null | false | [] | null | 10,054 | {
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"comment": "This child is 8 and can probably take tablets, but when is it generally preferred to give medications as an oral suspension to children? ",
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"comment": "I've been told by some FYs generally when they're 11-12 you can expect them to be able to swallow + comply",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis patient has otitis media, this can be inferred due to the otalgia, otorrhoea and findings on examination. The first line treatment for otitis media in children is amoxicillin. If the patient has a penicillin allergy then you should prescribe clarithromycin.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's ear infection:\n\n- Amoxicillin 500mg PO TDS 5-7 days",
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"question": "Case Presentation: A 8-year-old boy is brought to the GP by his mother due to otalgia. This is affecting his right ear, his hearing on this side is 'muffled' according to his mother. \n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## On examination\n\nTemperature 37.2°C, HR 98, RR 22, BP 111/68, O<sub>2</sub> 99% RA, GCS 15, Weight 25kg\n\nThere is a yellow, purulent discharge from his right ear.\n\nOtoscopy: injection of blood vessels on the tympanic membrane and diffuse erythema of the mid ear. There is a small perforation in the roof of the tympanic membrane.\n\nNo neurological abnormalities detected. No signs of mastoiditis.\n\n## Investigations\n\nNil\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his otitis media.",
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173,467,476 | false | 6 | null | 6,495,239 | null | false | [] | null | 10,058 | {
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"__typename": "QuestionComment",
"comment": "The answers on this mock have been incredibly confusing and inconsistent. How do we know the duration is 4 weeks???",
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"comment": "if in the bnf it has said maximum 4 sachets, how do you know what frequency to put down ? ",
"createdAt": 1735912031,
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"comment": "and for duration - does it matter if you write down 1 month or 4 weeks",
"createdAt": 1735912071,
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"comment": "Why not \"to be reviewed\" \n",
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"comment": "13.8g is an adult dose for a 4 year old. Paediatric sachets not an option on drop down list",
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"explanation": "# Summary\n \n\nConstipation in children is defined as a condition where the child defaecates less than three times per week or experiences significant difficulty in passing stool. The typical signs and symptoms include hard, pellet-like stool that is difficult to pass, and in some cases, overflow diarrhoea. It's primarily diagnosed through patient history and abdominal examination. Management includes a Movicol disimpaction regimen followed by maintenance Movicol, a high-fibre diet, and fostering good toileting habits. \n \n\n# Definition\n \n\nConstipation in children is a clinical condition where the child defecates fewer than three times per week or experiences significant difficulty in passing stool. Chronic constipation in this population is often characterised by hard, pellet-like stool that is difficult to pass.\n \n\n# Epidemiology\n \n\nConstipation in children is a common occurrence, affecting 30% of children aged 4-11 years, however, the peak incidence is around age 2-3 when the child undergoes toilet training. It is likely under-reported as symptoms such as overflow diarrhoea may not be recognised as constipation by parents. \n \n\n# Aetiology\n \n\nThe most common cause of chronic constipation in children is dietary factors, with other contributing factors including:\n \n\n- Fever\n- A low-fibre diet and poor fluid intake \n- Family history of constipation \n- Avoidance of using the toilet\n- Pain upon passing stool, e.g., secondary to an anal fissure or very hard stool\n- Unrecognised sensation of needing to pass stool\n- Sedentary behaviour or impaired mobility \n\nThere is often a trigger for constipation:\n\n- Dietary changes \n- Toilet training \n- Social changes (starting nursery, moving house, fears, family changes)\n- Medications \n- Anal fissure \n \n\n# Signs and symptoms\n \n\nIn children, chronic constipation often presents as:\n \n\n - Hard, pellet-like stool that is difficult to pass\n - Possible overflow diarrhoea due to fluid moving past the hard stool in the rectum\n - Less than 3 stools passed per week \n - The child may have pain and straining during defaecation\n\nFor idiopathic constipation, the following red flags must be ruled out:\n\n- Delayed passage of meconium \n- Onset of constipation within first few weeks of life \n- Failure to thrive (faltering weight gain and growth)\n- \"Ribbon stools\"\n- Neurologic problems in lower limbs \n- Anal abnormalities \n\n\n# Differential diagnosis\n \n\n - **Hirschsprung's disease**: Presents with a delay in passing meconium (>48 hours), a distended abdomen, forceful evacuation of meconium after digital rectal examination, and a history of chronic constipation with poor response to Movicol disimpaction regimens and poor weight gain.\n - **Irritable Bowel Syndrome (IBS)**: May cause chronic constipation and is associated with abdominal pain, bloating, and altered bowel habits. Pain is typically relieved by defecation.\n - **Hypothyroidism**: Can lead to constipation, along with other symptoms such as weight gain, fatigue, cold intolerance, and slow growth in children.\n - **Celiac Disease**: While more commonly associated with diarrhoea, it can sometimes cause constipation. Other symptoms include failure to thrive, abdominal pain, and bloating.\n - **Lead poisoning**: Constipation is one of the symptoms along with learning difficulties, irritability, loss of developmental skills in children, and possibly anaemia.\n - **Anal fissure**: Pain during and after bowel movements can lead to constipation due to the child's fear of experiencing pain again.\n - **Functional constipation**: Characterised by normal anorectal and colonic physiology but the passage of hard stools, infrequent stools, or painful defecation.\n - **Neurological disorders** like Spina Bifida and Cerebral Palsy: These conditions may impact the nerves that control bowel function, leading to constipation.\n \n\n# Investigations\n \n\n- Chronic constipation is generally diagnosed from history and examination\n - Abdominal examination may reveal impacted faeces (hard, depressible masses) \n - Examination to exclude neurologic impairment in lower limbs or abnormal appearance of the anus which may indicate a diagnosis other than idiopathic constipation \n \nIf a specific diagnosis is queried or if the constipation is not responding to treatment, referral for further investigations by a specialist paediatrician is indicated. These include:\n\n- A rectal suction biopsy for Hirschsprung's disease.\n \n\n# Management\n \n\n- The initial treatment of chronic constipation is with a Movicol (polyethylene glycol 3350) disimpaction regimen.\n - If the child does not have faecal impaction, the child can be started on maintenance therapy first. \n - If the child does not respond to Movicol, a stimulant laxative can be added after 2 weeks. \n- This is followed by maintenance Movicol \n- Lifestyle management:\n - Encourage a high-fibre diet with sufficient fluid intake \n - Provide advice about encouraging good toileting habits (i.e. regular toilet times) \n - Regular physical activity \n- In the case of Hirschsprung's disease, definitive management is through the surgical removal of the section of the aganglionic colon. The healthy bowel is then pulled through.\n\n \n# Complications\n\nConstipation in children may lead to:\n\n - Anal fissures\n - Haemorrhoids \n - Rectal prolapse\n - Faecal impaction and overflow soiling \n - Psychological distress to the child \n \n \n# Prognosis \n\nEarlier detection and management of constipation in children is associated with an improved prognosis. For approximately 1/3 of children, the constipation becomes chronic. Following treatment, 60% of children become free from constipation by 1 year and 80% of children have no symptoms by age 16. \n\nComorbidities such as psychological disorders and psychosocial issues are associated with a generally poorer prognosis. \n \n\n# NICE Guidelines \n \n\n[NICE Guidelines on Constipation in Children](https://www.nice.org.uk/guidance/cg99)\n \n# References\n\n[NHS Constipation in children](https://www.nhs.uk/conditions/baby/health/constipation-in-children/) \n\n[Patient info Constipation in children](https://patient.info/digestive-health/constipation/constipation-in-children)",
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"explanation": "## Drug choice feedback\nThis child is suffering from constipation. There are no signs of faecal impaction and so a regular maintenance laxative should be prescribed.\n\nOsmotic (stool softening) laxatives are the first-line drug prescribed in children with constipation. The macrogol 'Movicol' (Polyethylene glycol 3350 plus electrolytes) or Lactulose are recommended as first-line treatment.\n\nStimulant laxatives such as Senna and sodium picosulphate should be used as second-line and so would not be appropriate in this instance.\n\n## Dose/Route/Frequency/Duration feedback\nMovicol is prescribed in sachets. The maintenance dose for a 4-year-old is 1 sachet daily.\n\nLactulose is a liquid prescribed in mL, the dose for a 4-year-old is 2.5-5mL twice daily.",
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"question": "Case Presentation: A 4-year-old boy is brought to the GP by his mother with abdominal pain and infrequent bowel movements. He has been passing 1-2 hard stools per week. His mother reports that he experiences pain when passing stools. He has a good diet and good fluid intake. He has reached all of his developmental milestones. \n\n\n## PH\nNone\n\n## DH\nNone\n\nNKDA\n\n## On examination\nThe patient looks well.\n\nOn palpation of the abdomen, there is generalised tenderness with no guarding and no palpable faecal mass.\n\nHeight: 100cm\n\nWeight: 16kg\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his condition.",
"sbaAnswer": null,
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"typeId": 4,
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173,467,477 | false | 7 | null | 6,495,239 | null | false | [] | null | 10,100 | {
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"__typename": "QuestionComment",
"comment": "on the bnf it says montelukast is for prophylaxis of asthma, not mentioned in treatment summaries ",
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"comment": "the guidelines have changed so if not controlled by moderate MART it says tiotropium?\n",
"createdAt": 1737241969,
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"comment": "this is what BNF says: If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA, consider the following options:\n\nIncreasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or\nA trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or",
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"comment": "https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/managing \n\nThis link provides a photo of the new NICE/ BTS/ SIGN guidelines. If not controlled on moderate MART, you can start a LTRA or LAMA as you mentioned",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis patient's asthma isn't controlled. She is already taking moderate-dose MART. The next step in her treatment would be trial of LAMA or a leukotriene receptor antagonist, in accordance with NICE guidelines. However, because the patient is keen to avoid additional inhalers, montelukast would be the most appropriate option.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe options available to treat this patients uncontrolled asthma are as follows:\n\n- Montelukast 10mg PO OD",
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"question": "Case Presentation: A 23-year-old woman attends her GP to shortness of breath and wheeze. She experiences this intermittently, her symptoms are most likely to occur at night and after exercising. Her FeNO level is re-checked and it is not raised. She is keen to avoid using any more inhalers.\n\n\nShe has good inhaler technique and is taking her prescribed medications as recommended.\n\n## PMH\nAsthma\n\n## DH\nModerate-dose MART.\n\nNKDA.\n\n## On examination\n\nTemperature 36.6°C, HR 68, RR 16, BP 115/78, O<sub>2</sub> 98% RA, GCS 15, Weight 55kg\n\nA polyphonic wheeze is heard on auscultation of her chest, no other abnormalities found.\n\n## Investigations\n\nFEV1/FVC ratio: 56%. FeNO level and blood eosinophils are normal.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat her asthma based on NICE guidelines.",
"sbaAnswer": null,
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173,467,478 | false | 8 | null | 6,495,239 | null | false | [] | null | 18,095 | {
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{
"__typename": "QuestionComment",
"comment": "Do NICE count anyone above age 65 to receive the 'elderly dose'? ",
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"comment": "i want to know this too\n",
"createdAt": 1737242078,
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"comment": "According to NICE, a person is considered elderly if they are 65 or older. This definition applies to people in residential care homes as well.",
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"__typename": "QuestionComment",
"comment": "How do we know the duration for this Rx?",
"createdAt": 1737483298,
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"__typename": "QuestionComment",
"comment": "You have a look at medicinal forms of the drug on BNF and they're available in packets of 28 pills (ie. 4 weeks)",
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"explanation": "# Drug choice feedback\n\nThis is a patient presenting with symptoms and signs of hypothyroidism (dry skin, cold intolerance, alopecia), and the blood tests confirm the likely cause is Hashimoto's thyroiditis (commonest cause of hypothyroidism in the UK). As such, she should be commenced on thyroxine replacement therapy with levothyroxine.\n\n# Dose/Route/Frequency/Duration feedback\n\nNICE recommend considering starting levothyroxine at a dosage of 25–50 *micrograms* per day with titration for adults aged 65 years and over, and adults with a history of cardiovascular disease. It should be taken in the morning on an empty stomach and before any other medication has been taken. The dose can be uptitrated every 4 weeks by 25-50mcg. The patient should be reviewed and have TSH levels every 3 months after initiation of levothyroxine therapy and adjust the dose according to symptoms and TFT results.",
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"question": "Case Presentation: A 67-year-old lady attends her GP for a follow up appointment after her recent blood tests. She had previously presented with feeling cold all the time despite the weather being warm, drier skin than usual and she has also noticed small amounts of hair loss. Her blood test results are below.\n\n\n\n\n## PH\n\n\nVitiligo\n\n\n## DH\n\n\nNKDA\n\n\n## On examination\n\n\nNo cyanosis. Alert and orientated. Two patches of hair loss noted on the scalp.\n\n\nTemperature 37.0°C, HR 60, RR 14, BP 130/73, O<sub>2</sub> saturation 96% RA, GCS 15, Weight 94kg\n\n\n## Investigations\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|10 mU/L|0.3 - 4.2|\n|Free T4|8 pmol/L|9 - 25|\n|Free T3|0.8 pmol/L|3.1 - 6.8|\n\nAnti-TPO (thyroid peroxidase) assay: positive\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate for managing this patient's condition.\n\n",
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173,467,479 | false | 9 | null | 6,495,239 | null | false | [] | null | 6,779 | {
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"__typename": "QuestionComment",
"comment": "Ive also learned that Ibuprofen should not really be used in Asthmatics. Is that a thing? ",
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"__typename": "QuestionComment",
"comment": "Yeah, theoretically at least! NSAIDs are Contraindicated",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. Paracetamol 1g 6-hrly is the maximum recommended dose of paracetamol. Hence, it should not be co-prescribed with another medication which contains paracetamol in it (co-codamol).\n2. NSAIDs may lead to the worsening of renal function and hence, should be stopped during an AKI. Similarly, codeine (co-codamol) should be avoided in AKI due to the risk of adverse effects with reduced excretion.",
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"question": "Case presentation: A 45-year-old woman on the gynaecology ward is recovering from an elective total abdominal hysterectomy. PH Mild COPD, Polymyalgia rheumatica, Uterine fibroids, Familial hypercholestrolaemia. DH. Her current regular medications are listed (below).\n\n\n\n\n **Investigation**\n\n||||\n|---------------------------|:-------:|--------------------|\n|Urea|8.5 mmol/L|2.5 - 7.8|\n|Creatinine|145 µmol/L|60 - 120|\n\n\n\nQuestion 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)\nQuestion 2: Select the TWO prescription that are most appropriate to withhold until her renal function recovers.",
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173,467,480 | false | 10 | null | 6,495,239 | null | false | [] | null | 6,782 | {
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"id": "33816",
"label": "f",
"name": "Fluticasone;400micrograms;inhaled (INH);12-hourly",
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"id": "33813",
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"id": "33817",
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"id": "33812",
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"picture": null,
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"id": "33814",
"label": "d",
"name": "Ramipril;10mg;oral (PO); Daily",
"picture": null,
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"id": "33815",
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"comment": "The explanation doesn't give the answer for question 1. What's the third medication causing prolonged QTc???",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. Typical (haloperidol), atypical (risperidone) antipsychotics and mirtazepine are known to increase the QTc interval.\n2. Haloperidol, given to schizophrenic patients has a maximum dose of 20mg daily. The dose prescribed for this patient is likely to represent a transcription error of daily to 12-hrly.",
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"question": "Case presentation: A 52-year-old man was brought into the Emergency Department by the police under Section 136 following an episode of auditory hallucination. PH Schizophrenia, Severe depression, Hypertension, Ulcerative Colitis. DH His current regular medications are listed (below).\n\n\n**Investigation**\nECG shows a prolonged QTc interval 460ms (normal≤ 430ms)\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his prolonged QTc interval (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,467,481 | false | 11 | null | 6,495,239 | null | false | [] | null | 6,787 | {
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"comment": "Prednisolone can lead to fluid retention for sure, but I don't know regarding angioedema.\n",
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"comment": "why wouldnt amlodipine be correct - is it becuase it only causes peripheral oedema and not angioedema \n",
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"comment": "well duh",
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"comment": "if in a question, theres a few cuases of oedema - how woudl you narrow it down ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. ACEi (perindopril arginine) and tetracycline (oxytetracycline) commonly cause angioedema with the former more common in the Afro-Carribean population. Calcium channel blockers (amlodipine) also cause angioedema but are not common.\n2. Bisoprolol fumarate, given for the treatment of hypertension is given at 5-10mg daily with a maximum dose of 20mg daily. Hence, the correct prescription for 20mg should be daily instead of 12-hrly.",
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"question": "Case presentation: A 70-year-old Afro-Carribean gentleman presents to the GP for his annual flu vaccine. PH Infective exacerbation of COPD, for which he has been receiving treatment for the past 5 days, Hypertension. DH His current regular medicines are listed (below).\n\n\n**On Examination** Red swellings beneath the surface of his eyelid consistent with angioedema.\n\nQuestion 1: Select the ONE prescription that is most likely to be contributing to the angioedema (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,467,482 | false | 12 | null | 6,495,239 | null | false | [] | null | 6,793 | {
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"id": "33895",
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"name": "Enalapril maleate;20mg;Oral (PO);Daily",
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"id": "33896",
"label": "c",
"name": "Enoxaparin sodium;40mg;Subcutaneous (SC);Daily",
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"id": "33894",
"label": "a",
"name": "Metformin hydrochloride;500mg;Oral (PO);8-hourly",
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"id": "33898",
"label": "e",
"name": "Codeine phosphate;60 mg;Oral (PO);6-hourly",
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"id": "33899",
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"name": "Morphine sulfate immediate release (oramorph);10mg;Oral (PO);8-hourly",
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"__typename": "QuestionComment",
"comment": "is metformin not correct also, as it accumulates when renal function decreases as in AKI?",
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"comment": "only if creatinine is above 150 fella",
"createdAt": 1643397841,
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"comment": "also ACEi are more important to stop as they directly impact renal function",
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"comment": "What about holding codeine during an AKI?\n",
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"comment": "how does the patient have an AKI if his Cr has only increased by 10umol? - needs to be at least 25umol in 48hrs or 50% increase in 7 days?",
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"explanation": "# Summary\n\nAcute urinary retention is a medical emergency typified by a sudden inability to pass urine, frequently observed in older males who have undergone recent surgery. Key indicators include pain and discomfort, distension of the bladder, and a lack of urine flow despite the urge to urinate. The condition may be precipitated by factors such as neurological disorders, obstructions, infections, certain medications, or post-operative complications. Investigations comprise a bladder scan, digital rectal exam, urinalysis, and evaluation of post-void residual. Management typically involves immediate catheterisation to relieve the distension, followed by treatment of the underlying cause.\n\n# Definition \n\nAcute urinary retention is a medical emergency marked by the onset of the inability to pass urine over a certain period of time, usually hours to days. \n\n# Aetiology\n\nAcute urinary retention can be triggered by several factors and situations, often in older male patients who have recently undergone anaesthesia for surgery. Any irregularities of the urethral tract such as benign prostatic hyperplasia (BPH) or stricture can elevate the risk of this condition.\n\nProminent causes of urinary retention can be classified according:\n\n- Luminal causes (stone, blood clot, tumour, UTI)\n- Mural causes (stricture, neuromuscular dysfunction)\n- Extra-mural (abdominal/pelvic mass/tumours, retroperitoneal fibrosis)\n- Neurological pathologies (cauda equina, MS)\n- Obstructive pathologies\n- Infectious diseases including UTIs\n- Medications \n\t- Anticholinergic types of medications inhibit parasympathetic activity on the detrusor muscle and its inhibitory effects on the bladder sphincters by blocking the action of acetylcholine, thereby preventing it from binding to receptor sites.\n- Post-operative complications\n- Constipation, especially in the elderly\n\n\nDrugs with alpha-agonist properties obstruct bladder contraction and promote sphincter contraction.\n\nAlcohol is another potential precipitant of acute urinary retention.\n\n# Signs and Symptoms\n\n- Inability to pass urine\n- Lower abdominal discomfort\n- Pain or distress\n- Suprapubic tenderness\n- Suprapubic mass (due to an enlarged bladder)\n- Delirium (hypoactive or hyperactive)\n\n# Investigations\n\nStandard investigations for acute urinary retention include:\n\n- Bladder scan/USS renal tract\n- Digital Rectal Exam\n- Urinalysis and urine MCS\n- Evaluation of post-void residual\n- Bloods tests: FBC, renal profile (renal function is often preserved due to the acuity, unlike in chronic urinary retention), CRP\n- Consider non-contrast CT KUB if stones suspected\n\nThe specific investigations required will be dependent on the accompanying symptoms.\n\n# Management\n\nThe immediate goal in managing acute urinary retention is to relieve the patient's discomfort by decompressing the bladder. This is typically accomplished with **catheterisation**, which can be indwelling or intermittent, depending on the patient's overall health status and the underlying cause of retention. \n\nPost-catheterisation, it is essential to address the underlying cause of retention. The management strategy will therefore depend on the aetiology:\n\n- For obstructive causes such as benign prostatic hyperplasia (BPH), medical management with alpha-blockers (e.g. tamsulosin - Note: Prescribe with caution in the elderly as can exacerbate postural hypotension) or 5-alpha reductase inhibitors (e.g. finasteride) may be employed initially. If medical management fails, surgical intervention like transurethral resection of the prostate (TURP) or prostatectomy may be considered.\n\n- Neurogenic causes require further specialist evaluation, and treatment options can range from medication to surgical interventions, including sacral neuromodulation or creation of urinary diversions, depending on the severity and cause of the neurogenic dysfunction. If there is acute urinary retention/faecal incontinence, saddle paraesthesiae and bilateral leg weakness, this is a neurosurgicalogical emergency necessitating an urgent MRI whole spine to rule out cauda equina syndrome.\n\n- Infections should be managed with appropriate antibiotics, and any identified drug-induced urinary retention should be addressed by discontinuing the offending medication, if possible, and providing symptomatic relief.\n- Bowel care - following PR exam and depending on patient factors such as age, diet and current medications, a laxative may be added or if these have proven to already be ineffective, an enema may be required.\n\n\n# NICE Guidelines\n\n[Click here for the NICE BNF Treatment Summary](https://bnf.nice.org.uk/treatment-summary/urinary-retention.html)",
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"explanation": "1. Codeine phosphate and morphine sulfate are examples of opioids and urinary retention is a common or very common side effect of all opioids. Imipramine sulfate is an example of tricyclic antidepressant. Urinary disorder is a side effect of imipramine and BNF has cautioned against the use of imipramine in patients with known urinary retention\n2. Enalapril maleate is an example of angiotensin-converting enzyme inhibitor (ACE-i). ACE-I should be stopped whenever an AKI arises because it is nephrotoxic and might lead to further renal injury. ACE-I inhibits efferent renal arteriolar vasoconstriction, thus lowering the glomerular filtration pressure.",
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"question": "Case presentation: A 80-year old woman is on a surgical ward recuperating from her total hip replacement that took place three days ago. She complains that she has been having difficulty fully emptying her bladder. The stream is weak and only a small of urine is passed during the day PH: Hypertension, Type 2 Diabetes Mellitus, Depression, Constipation DH: Her current regular prescriptions are listed below\n\n\n\n\n **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Slight tenderness on palpation of hypogastric region\n\n\n **Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\nNegative urine dipstick\nBladder scan reveals a post-void residual volume of 500ml\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|130 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|9.5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|270x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|88 fL|80 - 96|\n|Neutrophils|6.5x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|2.8x10<sup>9</sup>/L|1.5 - 4.0|\n|Sodium|141 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|130 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of the urinary retention?\nQuestion 2: Select the ONE prescription that is most appropriate to withhold until her renal function improves?",
"sbaAnswer": null,
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173,467,483 | false | 13 | null | 6,495,239 | null | false | [] | null | 6,796 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33921",
"label": "g",
"name": "Senna;15 mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"id": "33918",
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"name": "Pioglitazone;45 mg;Oral (PO);Daily",
"picture": null,
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"explanation": null,
"id": "33917",
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"id": "33915",
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"picture": null,
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"id": "33920",
"label": "f",
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"comment": "mirtazapine only causes drowsiness at lower doses ",
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"comment": "Why only at low doses and not higher ones?",
"createdAt": 1737483698,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2729",
"name": "Drugs causing weight gain & drowsiness",
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"typeId": 5
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"dislikes": 2,
"explanation": "1. Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist that is used to treat depression. It works by increasing central noradrenergic and serotonergic neurotransmission. Weight gain is a common or very common side effect of mirtazapine. Gliclazide is a sulfonylurea that works by increasing insulin secretion. Gliclazide is also known to cause weight gain. Pioglitazone is a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist that works by reducing peripheral insulin resistance. Weight gain is a common or very common side effect of pioglitazone.\n2. Drowsiness is a common or very common side effect of mirtazapine. Drowsiness is also listed as an uncommon side effect of omeprazole in BNF.",
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"question": "Case presentation: A 56-year old woman visits her GP for medication review. She reports that she has been putting on weight despite following a healthy diet and exercising regularly. She also complains of feeling drowsy PH: Type 2 Diabetes Mellitus, Depression, GORD, Osteoporosis, Constipation DH: Her current regular prescriptions are listed below\n\n\n**On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender.\n\n**Investigation**:\n\n- Weight 71kg (66kg 6 months ago)\n- BMI: 27\n- HbA1c: 53 mmol/mol\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to the weight gain (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that is most likely be contributing to the drowsiness (mark it with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
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} | MarksheetMark |
173,467,484 | false | 14 | null | 6,495,239 | null | false | [] | null | 10,106 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50233",
"label": "c",
"name": "Spironolactone;100mg;PO;OD",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50232",
"label": "b",
"name": "Furosemide;40mg;PO;OD",
"picture": null,
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},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50237",
"label": "g",
"name": "Methylphenidate hydrochloride;20 mg;PO;TDS",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50231",
"label": "a",
"name": "Ramipril;20mg;PO;OD",
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"answer": false,
"explanation": null,
"id": "50234",
"label": "d",
"name": "Atorvastatin;80mg;PO;OD",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50235",
"label": "e",
"name": "Bisoprolol;7.5 mg;PO;OD",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50238",
"label": "h",
"name": "Paracetamol;500mg;PO;BD",
"picture": null,
"votes": 0
},
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"answer": false,
"explanation": null,
"id": "50236",
"label": "f",
"name": "Metformin;500mg;PO;BD",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50239",
"label": "i",
"name": "Sertraline;50mg;PO;OD",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "where does it say in the BNF that methylphenidate causes cold peripheries?",
"createdAt": 1706006067,
"dislikes": 1,
"id": "39634",
"isLikedByMe": 0,
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"replies": [
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"comment": "its under side effects as 'peripheral coldness' annoyingly",
"createdAt": 1706378505,
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"comment": "methylphenidate 'coldness' is literally under rare S/E",
"createdAt": 1706787282,
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"id": "40444",
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"displayName": "RNA Retrograde",
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"comment": "doesnt ramipril cause raynauds though\n",
"createdAt": 1735830801,
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"comment": "Who on earth is giving this woman methylphenidate ",
"createdAt": 1736881925,
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"id": "60596",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"id": "3635",
"name": "Taking bisoprolol and methylphenidate together increase the risk of cold peripheries and a dosing error in furosemide",
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"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
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"explanation": "1. Both bisoprolol and methylphenidate can cause patient's to experience cold peripheries. Bisoprolol commonly causes cold peripheries as they reduce the amount of blood that is delivered to the fingers and toes.\n2. The maximum dose of ramipril that a patient can take is 10mg PO OD therefore this prescription contains a mistake.",
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"question": "Case presentation: A 78-year-old female is admitted to the cardiology ward. During her stay she has been complaining of cold peripheries.\n\n\n**PH** Congestive cardiac failure, type 2 diabetes mellitus, hypertension, oseteoarthritis hypercholesterolaemia, COPD, ADHD, depression\n\n**DH** Her current medications are listed (below). Weight 110kg.\n\n**On Examination**\n\nHR 88/min, BP 114/89mm Hg, RR 24, O2 sats 92% RA. HS I + II with no added heart sounds. Bilateral basal crepitations heard on auscultation of the lungs.\n\n**Investigation**\n\nCXR shows bilateral pleural effusions\n\nQuestion 1: Select the TWO prescriptions that are most likely to be the cause of her cold peripheries (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
"userPoint": null
} | MarksheetMark |
173,467,485 | false | 15 | null | 6,495,239 | null | false | [] | null | 10,108 | {
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"id": "50257",
"label": "i",
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"id": "50251",
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"id": "50253",
"label": "e",
"name": "Ramipril;10mg;PO;OD",
"picture": null,
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"id": "50252",
"label": "d",
"name": "Clopidogrel;75mg;PO;OD",
"picture": null,
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"id": "50254",
"label": "f",
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"id": "50250",
"label": "b",
"name": "Atorvastatin;80mg;PO;OD",
"picture": null,
"votes": 0
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],
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"__typename": "QuestionComment",
"comment": "I swear PPI causes loose stools\n",
"createdAt": 1706612459,
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"comment": "Isn't constipation a common side-effect for ibuprofen as well?\n",
"createdAt": 1709564035,
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"displayName": "NICU Gastro",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"id": "3637",
"name": "Omeprazole, atorvastatin and ramipril all commonly cause constipation and a dosing error in tamsulosin.",
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"topic": {
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"id": "129",
"name": "Elderly medicine",
"typeId": 5
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"explanation": "1. PPIs, ACE inhibitors, beta blockers and statins commonly cause constipation. Whilst other medications that this patient is on such as clopidogrel, tamsulosin and ibuprofen can cause constipation, these aren't listed as common/very common side effects unlike the omeprazole, ramipril, bisoprolol and atorvastatin.\n\n2. The normal dose for tamsulosin when treating benign prostatic hyperplasia is 400 micrograms. This patient is receiving 400 milligrams of tamsulosin which is much higher than the maximum dose he should be receiving.",
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"question": "Case presentation: A 72-year-old gentleman attends his GP complaining of constipation\n\n\n**PH** Benign prostatic hyperplasia, osteoarthritis, hypertension, prior myocardial infarction, hypercholesterolaemia, allergic rhinitis, gastro-oesophageal reflux disease,\n\n**DH** His current medicines are listed (below). Weight 81kg.\n\nQuestion 1: Select the FOUR prescriptions that are most likely to be contribute to his constipation (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,467,486 | false | 16 | null | 6,495,239 | null | false | [] | null | 10,111 | {
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"id": "50278",
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"__typename": "QuestionComment",
"comment": "\"Some studies suggest a small increased risk of cardiovascular malformations with the use of fluoxetine, and congenital malformations (particularly cardiovascular) with the use of paroxetine, however other studies do not support an association\" \"The available data regarding malformation risk for all SSRIs are conflicting and confounded, and a causal association between the use of SSRIs in pregnancy, and spontaneous miscarriage, preterm delivery, low birth weight, and adverse effects on infant neurodevelopment remains unconfirmed.\" literally does not say anywhere to stop fluoxetine on the BNF",
"createdAt": 1705163220,
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"comment": "What antidepressants can be used in pregnancy?",
"createdAt": 1737652991,
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"comment": "sertraline and citalopram ",
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"comment": "this is dumb",
"createdAt": 1738166181,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"name": "Lithium and isotretinoin are teratogenic medications and a dosing error in paracetamol",
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"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
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"explanation": "1. Lithium and isotretinoin are teratogenic. Lithium is linked with an increased risk of Ebstein's anomaly occurring. Isotretinoin is linked with an increased risk of cardiovascular and ear malformations. Gliclazide should be stopped due to the increased risk of neonatal hypoglycaemia. The BNF advises that antihistamines should be avoided during pregnancy. NB: newer research now suggests that SSRIs including fluoxetine can be safely taken during pregnancy, however the pros and cons should be considered, and it should be given at the lowest effective dose.\n\n2. The dose of paracetamol should be 1g PO QDS in this patient, 1mg is an incorrect dose.",
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"question": "Case presentation: A 28-year-old woman is attends her GP complaining of nausea in the morning. \n\n\n**PH** Bipolar disorder, asthma, type 2 diabetes mellitus, acne, allergic rhinitis\n\n**DH** Her regular medicines are listed (below). Weight 108kg.\n\n**Investigation**\n\nUrinary beta hCG ++\n\nQuestion 1: Select the FOUR prescriptions that she will need to stop taking given her urinary beta hCG test results (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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"typeId": 3,
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173,467,487 | false | 17 | null | 6,495,239 | null | false | [] | null | 6,805 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin",
"id": "33973",
"label": "d",
"name": "Continue VRII for another 12 hours and discontinue if BMs are stable",
"picture": null,
"votes": 1030
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "When transitioning from a VRII to normal subcutaneous insulin, the infusion should be left running for 30-60 minutes afterwards to ensure stable BMs",
"id": "33972",
"label": "c",
"name": "Administer insulin lispro with next meal and discontinue VRII",
"picture": null,
"votes": 1516
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As the patient is able to eat and drink, she should restart her usual subcutaneous fast-acting insulin with her next meal with the VRII running for 30-60 minutes afterwards to ensure stable BMs",
"id": "33970",
"label": "a",
"name": "Administer insulin lispro with next meal and continue VRII for 1 hour afterwards",
"picture": null,
"votes": 3038
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient’s long-acting insulin should only be returned to normal levels at the time of discharge and not whilst still on a VRII",
"id": "33974",
"label": "e",
"name": "Increase insulin glargine to 22 units SC ON and administer insulin lispro with next meal",
"picture": null,
"votes": 473
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin",
"id": "33971",
"label": "b",
"name": "Administer insulin lispro with tomorrow's evening meal and continue VRII for 1 hour afterwards",
"picture": null,
"votes": 693
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "should say how long ago her surgery was/ how long she should be NBM - extensive bowel resection may need to be NBM for up to 48 hrs ",
"createdAt": 1646930924,
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"comment": "where is the guidance on this in the BNF?\n",
"createdAt": 1706612592,
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"comment": "nvm found it under \"Diabetes, surgery and medical illness\"\n",
"createdAt": 1706612840,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"name": "Restarting normal SC insulin following a VRII",
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"id": "13",
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"typeId": 5
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"question": "Case Presentation: A 50 year old woman is a surgical inpatient recovering from an elective anterior resection of sigmoid adenocarcinoma. **PH** type 1 diabetes. **DH** insulin lispro (Humalog) 10 units SC TDS with meals, insulin glargine (Lantus) 22 units SC ON.\n\n\n**O/E**\n\nAlert and oriented. Vital observations stable, surgical site dressing clean with limited strikethrough. Loop ileostomy in RIF, stoma bag collecting yellow liquid stool.\n\nShe is currently on insulin glargine (Lantus) 17 units SC ON and has been receiving a variable rate insulin infusion (VRII) for 12 hours since 7pm yesterday. Her pain and nausea are well controlled, and she recently started eating and drinking. She is now due dinner.\n\nQuestion: Select the most appropriate management with regard to her insulin at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 6750,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,488 | false | 18 | null | 6,495,239 | null | false | [] | null | 6,806 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is in net negative fluid balance and acutely hypotensive. Slow fluid replacement is not an appropriate response to this situation",
"id": "33976",
"label": "b",
"name": "1L 0.9% normal saline over 4 hours",
"picture": null,
"votes": 598
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient is in net negative fluid balance and acutely hypotensive, which may be being exacerbated by beta-blockers and a blunted sympathetic response. A fluid challenge should be initiated and the blood pressure response carefully monitored",
"id": "33975",
"label": "a",
"name": "500ml 0.9% normal saline over 15 minutes",
"picture": null,
"votes": 6018
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although it is increasingly becoming more popular as a maintenance fluid, dextro-saline has limited use as a plasma expander due to its high dextrose concentration and tendency to redistribute",
"id": "33978",
"label": "d",
"name": "500ml 0.45% saline/4% dextrose over 15 minutes",
"picture": null,
"votes": 86
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "5% dextrose is generally not used as a plasma expander as it redistributes quickly across all fluid compartments",
"id": "33977",
"label": "c",
"name": "1L 5% dextrose over 1 hour",
"picture": null,
"votes": 81
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A balanced crystalloid is a good option for fluid resuscitation. It should be administered far more rapidly than over 1 hour for its effects to be maximised",
"id": "33979",
"label": "e",
"name": "1L Hartmann’s solution over 1 hour",
"picture": null,
"votes": 173
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Easy\nMurtaza said we could have got it, so no arguing",
"createdAt": 1704582253,
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"comment": "The above was approved and authorised in the Nomani Residence",
"createdAt": 1704582276,
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"comment": "Is Hartmann's preferred for resuscitation post-op? ",
"createdAt": 1736014426,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2739",
"name": "Negative net fluid balance post-operatively",
"status": null,
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"typeId": 5
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"question": "Case Presentation: A 36 year old man is recovering on the high dependency unit following emergency repair of a proximal aortic dissection. **PH** Marfan syndrome. **DH** atenolol hydrochloride 50mg PO OD, co-codamol 8/500mg PO QDS.\n\n\n**O/E**\n\nDrowsy but maintaining own airway. HR 64, RR 21, BP 95/56, O2 97% 2L NC, Temperature 37.4°C. Peripheries cool, CRT 4s. HS I + II + 0. Midline sternotomy dressing intact, 3x Jackson Pratt drains collecting serosanguinous fluid. Oral mucous membranes appear dry, skin turgor normal.\n\nFluids prescribed: 1L 5% dextrose with 40mmol K over 10h, 1L 0.9% normal saline over 10h, 250ml 5% dextrose with 20mmol K over 4h\n\nUrine output over last 24h = 1.3L\n\nSurgical drain output over last 24h = 1.5L\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 6956,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,489 | false | 19 | null | 6,495,239 | null | false | [] | null | 6,813 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative treatment for ADHD, but is unlicensed for that indication and is less preferred than first line options",
"id": "34012",
"label": "c",
"name": "Dexamfetamine sulfate 2.5mg PO TDS",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative treatment for ADHD if there is inadequate response to first line treatments",
"id": "34011",
"label": "b",
"name": "Atomoxetine 15mg PO OD",
"picture": null,
"votes": 57
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Risperidone may be used to manage behavioural problems associated with ADHD but would not be initiated as a first line treatment",
"id": "34014",
"label": "e",
"name": "Risperidone 250 micrograms PO OD",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is recommended first line to treat ADHD. Lisdexamfetamine mesilate is an alternative first line treatment",
"id": "34010",
"label": "a",
"name": "Methylphenidate hydrochloride 5mg PO OD",
"picture": null,
"votes": 6513
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Fluoxetine is licensed for the treatment of depression in young children. It has no role in treating ADHD alone",
"id": "34013",
"label": "d",
"name": "Fluoxetine 10mg PO OD",
"picture": null,
"votes": 25
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "As this patient is a child - and methylphenidate hydrochloride causes growth retardation in children - would it still be recommended to give?",
"createdAt": 1673605976,
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"createdAt": 1674906973,
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"__typename": "QuestionComment",
"comment": "If in doubt, check the BNFc and that's what it says here! \n",
"createdAt": 1709034682,
"dislikes": 0,
"id": "42981",
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"id": 15514
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2746",
"name": "ADHD in children",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
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"question": "Case Presentation: A 7 year old boy attends a specialist paediatric assessment after being referred via his family GP. He has been reported to have significant difficulty concentrating in school and at home, often disrupting entire class lessons and refusing to sit still for longer than 5 minutes. His mother is now worried about allowing him to play outdoors as he tends towards climbing high objects like trees and fences, and has fallen from them on a number of occasions. His teachers feel that he does exhibit some difficulty in understanding instructions when spoken to, and sometimes makes inappropriate comments in reply to them.\n\n\n**Investigations**\n\nHe has not had any significant developmental delay and has received all his scheduled childhood vaccinations. Baseline ECG normal sinus rhythm. Weight and height on 70th centile for his age and gender. He weighs 30kg.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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"totalVotes": 6675,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,490 | false | 20 | null | 6,495,239 | null | false | [] | null | 6,815 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "SSRIs may be switched where there has been an inadequate response to previously tried SSRIs after up-titration",
"id": "34023",
"label": "d",
"name": "Switch his prescription to citalopram 20mg PO OD",
"picture": null,
"votes": 516
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Switching to a non-SSRI antidepressant may be done in the primary care setting by experienced clinicians, but it is recommended to attempt to elicit a beneficial response with at least two SSRIs beforehand",
"id": "34024",
"label": "e",
"name": "Switch his prescription to mirtazapine 15mg PO OD",
"picture": null,
"votes": 379
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose",
"id": "34022",
"label": "c",
"name": "Maintain his current fluoxetine dose and review after 2 weeks",
"picture": null,
"votes": 1711
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose. The highest dose of fluoxetine that can be prescribed is 60mg",
"id": "34020",
"label": "a",
"name": "Increase the dose of fluoxetine to 40mg PO OD and review after 1 week",
"picture": null,
"votes": 4396
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Combination therapy with SSRIs is not routinely recommended due to the increased risk of developing serotonin syndrome",
"id": "34021",
"label": "b",
"name": "Add sertraline 50mg PO OD to his current prescription",
"picture": null,
"votes": 79
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "SSRIs can take 6 weeks to have an effect so why would we be uptitrating after 4 weeks?",
"createdAt": 1675255816,
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"comment": "The BNF says: Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment. Treatment should be continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. In cases of partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond).\n\nSo i guess it depends on how you interpret the question as to whether you think it was a partial response or not. Hope this helps!\n",
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"comment": "If there is limited or no improvement with antidepressant medication alone, options include:\nAugmenting with group exercise.\nSwitching to a psychological intervention.\nSee the section on Initial management for more information on choices of psychological intervention.\nIncreasing the antidepressant dose or switching the antidepressant to a drug in the same class or different class.\n\ncan do either?",
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"comment": "I thought the SSRI was causing thoughts of suicide which is why I stopped it",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 27 year old man attends a follow-up appointment with his GP. He initially presented one month ago with markedly low mood, loss of interest in his usual activities and feeling tired all the time. His GP diagnosed him with major depressive disorder and prescribed fluoxetine 20mg PO OD.\n\n\n**O/E**\n\nWhen asked about any improvement in his symptoms, the patient reports only a very slight lift to his mood that ‘may as well be the same as before’. He still experiences difficulty sleeping and only leaves the house to work his part-time job as a landscaper, but is finding that increasingly challenging. He says he has infrequent suicidal thoughts, and while he is adamant that he would never act on them in reality, he feels that he really ‘can’t go on like this for much longer’.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,467,491 | false | 21 | null | 6,495,239 | null | false | [] | null | 6,818 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin hydrochloride may have some beneficial effects on fertility in patients with polycystic ovarian syndrome, but there is nothing in the stem to suggest that the patient has PCOS",
"id": "34039",
"label": "e",
"name": "Metformin hydrochloride 500mg PO OD",
"picture": null,
"votes": 208
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a selective oestrogen receptor modulator that stimulates ovulation. It should not be prescribed without a full assessment by a fertility specialist, and is not likely to be indicated as the patient is having regular bleeds which indicates she is ovulating",
"id": "34036",
"label": "b",
"name": "Clomifene citrate 50mg PO OD",
"picture": null,
"votes": 1060
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While megaloblastic anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic",
"id": "34038",
"label": "d",
"name": "Hydroxocobalamin 1mg IM monthly",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "All women who are attempting to conceive and low risk should be taking folic acid to reduce the risk of neural tube defects. Women at high risk (e.g. previous tube defects, family history, diabetics, on epilepsy medication, high BMI) should be on high dose folic acid (5mg OD). As this woman has diabetes she would be considered high-risk and hence 5mg is the correct answer.",
"id": "34035",
"label": "a",
"name": "Folic acid 5mg PO OD",
"picture": null,
"votes": 5389
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While iron deficiency anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic",
"id": "34037",
"label": "c",
"name": "Ferrous sulfate 200mg PO TDS",
"picture": null,
"votes": 233
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Normal MCV is 80-100 ",
"createdAt": 1642708687,
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"comment": "they're not being given folic acid because they're deficient, it's just a good thing to take before pregnancy and up to 3 months to avoid neural tube defects",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"typeId": 5
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"question": "Case Presentation: A 34 year old woman presents to GP with her male partner to solicit advice in conceiving a child. They have been having regular unprotected penetrative sex at least twice a week for four months. She has had one previous pregnancy and termination at the age of 18, and bleeds regularly with a 28 day cycle. She has a background of T2DM which is diet-controlled. She wonders if the GP can prescribe anything that she should be taking while trying to conceive.\n\n\n**Investigations**\n\nFBC: Hb 115, WCC 5.2, Plts 240 x 10^9, MCV 91\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,467,492 | false | 22 | null | 6,495,239 | null | false | [] | null | 10,065 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "It may be appropriate to give a patient with a paracetamol overdose a resuscitation fluid bolus where they vital signs are deranged, however, the patient in this case is currently stable.",
"id": "50090",
"label": "e",
"name": "500mL NaCl 0.9% in 10 minutes",
"picture": null,
"votes": 167
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has taken a paracetamol overdose and presented to A&E in under 1 hour, Activated charcoal should therefore be considered as the initial management of this patient.",
"id": "50086",
"label": "a",
"name": "Activated Charcoal 50g PO (Oral)",
"picture": null,
"votes": 4257
},
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"__typename": "QuestionChoice",
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"explanation": "Diazepam is used in patients who have taken an overdose of stimulant drugs or antipsychotics.",
"id": "50089",
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"name": "Diazepam 10mg PO (Oral)",
"picture": null,
"votes": 4
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haemodialysis is the treatment in severe salicylate poisoning. It would not be appropriate here.",
"id": "50087",
"label": "b",
"name": "Haemodialysis",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Acetylcysteine is used in the treatment of paracetamol poisoning. However, it is used; when a plasma paracetamol concentration is within the treatment threshold, where patients present later than 8 hours and have taken over 150mg/kg of paracetamol or where patients are visibly jaundiced.",
"id": "50088",
"label": "c",
"name": "Acetylcysteine IV",
"picture": null,
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}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "bnf poisoning treatment summary - Although the benefit of gastric decontamination is uncertain, charcoal, activated should be considered if the patient presents within 1 hour of ingesting paracetamol in excess of 150 mg/kg.",
"createdAt": 1705336426,
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"comment": "He has ingested 120 mg/kg, therefore he does not reach that threshold",
"createdAt": 1706275808,
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"explanation": "#### Mechanism of Action\n\nParacetamol increases the pain threshold by inhibiting cyclooxygenase 1 and 2 (COX-1 and COX-2) which are involved in prostaglandin (PG) synthesis. Prostaglandins are responsible for nociception, so if prostaglandin is not synthesised, less nociception will occur. Paracetamol reduces fever by directly acting on heat-regulating centres in the brain, leading to peripheral vasodilation and sweating.\n\n#### Indications\n\n- Pain\n- Pyrexia\n\n#### Side Effects\n\n- Hypotension\n- Hypersensitivity reaction\n- Thrombocytopenia\n- Fulminant hepatic failure (in overdose)\n\n#### Cautions/Contra-indications\n\nGive 1g every four hours, up to a maximum of 4g in a day. Patients under 50kg are at increased risk of toxicity, so the dose must be lowered based on body weight.",
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"question": "Case Presentation: A 29-year-old man is brought to A&E after taking an overdose of paracetamol 20 minutes ago. He has ingested 18 tablets (9g) of paracetamol. **PH** Depression **DH** Citalopram 40mg Oral once daily, NKDA\n\n\n**On examination**\nThe patient looks well, not visibly jaundiced.\n\nBP 116/86, HR90, RR 16, Temperature 36.5°C\n\nWeight 75kg\n\n**Investigations**\n\nBlood to be taken 4hr after ingestion\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,493 | false | 23 | null | 6,495,239 | null | false | [] | null | 10,114 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50303",
"label": "e",
"name": "Add 10 units Humulin I Insulin to take once in the morning",
"picture": null,
"votes": 7
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50302",
"label": "d",
"name": "Add pioglitazone 30mg PO OD",
"picture": null,
"votes": 251
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin. She should be encouraged to keep taking metformin and keep any dietary/lifestyle changes she has employed and the HbA1c should be rechecked in 3 months.",
"id": "50299",
"label": "a",
"name": "Make no changes to her medications",
"picture": null,
"votes": 2561
},
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"__typename": "QuestionChoice",
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"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50301",
"label": "c",
"name": "Add sitagliptin 100mg PO OD",
"picture": null,
"votes": 891
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50300",
"label": "b",
"name": "Add gliclazide 40mg PO OD",
"picture": null,
"votes": 1349
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "when would you consider adding gliclazide here?",
"createdAt": 1703419810,
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"__typename": "QuestionComment",
"comment": "if HbA1c >58??",
"createdAt": 1703951918,
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"__typename": "QuestionComment",
"comment": "i thought the target is 48 mmol/mol with metformin alone, it's only 53 with hypo-causing meds?",
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"__typename": "QuestionComment",
"comment": "same",
"createdAt": 1705108674,
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"comment": "the target is 48, but the threshold for considering adding another drug is 58. So her 53 is suboptimal target, but it is not necessary to add another drug. My guess is she would be given further dietary advice and exercise",
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"comment": "I agree with biopsy cystic! Though the target is 48, the threshold for adding another drug is 58!",
"createdAt": 1735824057,
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"comment": "'If HbA1c levels are poorly controlled despite treatment with a single drug and rise to 58 mmol/mol (7.5%) or higher, drug treatment should be intensified, alongside reinforcement of advice regarding diet, lifestyle, and adherence to drug treatment.\n\nWhen two or more antidiabetic drugs are prescribed, a target HbA1c level of 53 mmol/mol (7.0%) is recommended for patients in which it is appropriate.''",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 73 year old woman attends her GP for a diabetes review. \n\n\n**PH** Type 2 diabetes mellitus, hypercholesterolaemia\n\n**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD. NKDA\n\n**Investigations**\n\nHbA1c 3 months ago: 62 mmol/mol (< 42 mmol/mol)\n\nHbA1c today: 53 mmol/mol (< 42 mmol/mol)\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient isn't having an acute asthma exacerbation nor is he at the point in the asthma treatment ladder in which oral corticosteroids would be considered (this would only be initiated by a specialist).",
"id": "50327",
"label": "d",
"name": "Add oral prednisolone 5mg PO OD",
"picture": null,
"votes": 94
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient isn't having an acute asthma exacerbation therefore this option is inappropriate.",
"id": "50328",
"label": "e",
"name": "Admit to hospital",
"picture": null,
"votes": 78
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Moderate-dose MART may be considered for patients whose asthma remains uncontrolled on low-dose MART. However, a stepwise approach is essential in asthma management, and since this patient has not yet trialed low-dose MART, moderate-dose MART would be premature at this stage.",
"id": "50324",
"label": "a",
"name": "Moderate dose daily maintenance and reliever therapy (MART)",
"picture": null,
"votes": 1141
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Montelukast, a leukotriene receptor antagonist, is not typically considered as a first-line step in asthma management. It may be added as adjunct therapy if symptoms remain uncontrolled on moderate-dose MART. However, since the patient has not yet trialed low-dose or moderate-dose MART, montelukast is not indicated at this stage. ",
"id": "50325",
"label": "b",
"name": "Add montelukast 10 mg PO OD",
"picture": null,
"votes": 757
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient's symptoms of nighttime wheezing and exercise limitation, coupled with an FEV1/FVC ratio of 53%, indicate suboptimal asthma control despite adherence to his current as-needed low-dose ICS/formoterol regimen. The most appropriate next step is to initiate low-dose daily maintenance and reliever therapy (MART), which involves using a low-dose ICS/formoterol combination both as a daily maintenance inhaler and as needed for symptom relief. ",
"id": "50326",
"label": "c",
"name": "Low dose daily maintenance and reliever therapy (MART)",
"picture": null,
"votes": 2997
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "So essentially we're switching from AIR therapy to MART (PRN to regular)?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Moving up the treatment ladder of asthma when a SABA and ICS are not working",
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"question": "Case Presentation: A 26 year old man attends his GP for a review of his asthma. He is still feeling wheezy at night and struggling to exercise. His inhaler technique is good and he is taking his medications as recommended.\n\n**PMH** Asthma\n\n**DH** Low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as required\n\n**On examination**\n\nFEV1/FVC ratio: 53%\n\nQuestion: Select the most appropriate management at this stage.\n",
"sbaAnswer": [
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173,467,495 | false | 25 | null | 6,495,239 | null | false | [] | null | 6,835 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Rather than excessive salivation, sertraline more commonly causes dry mouth",
"id": "34123",
"label": "d",
"name": "Sertraline can lead to excessive salivation",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients should discuss with their doctors before stopping the medication because an abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Besides that, sertraline has not been shown to cause addiction problems",
"id": "34122",
"label": "c",
"name": "He should discontinue his medication once he feels better as sertraline is linked to addiction",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is linked to low sex drive and erectile dysfunction",
"id": "34124",
"label": "e",
"name": "Sertraline can lead to increased sex drive",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. An increase in serotonin levels has been shown to bring about an improvement in symptoms",
"id": "34121",
"label": "b",
"name": "Sertraline works by increasing dopamine levels in the brain",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. It is important to highlight to the patients about the gradual development of full antidepressant effect of SSRI. Patients should be advised to not stop the medication early on even though they might not have felt an improvement because SSRI usually needs to be taken for up to 6 weeks before the benefit is felt",
"id": "34120",
"label": "a",
"name": "He should continue taking the medication even if he does not feel any improvements in the first 6 weeks",
"picture": null,
"votes": 6357
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"typeId": 5
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"question": "Case presentation: A 25-year-old man attends his GP with a 3-month history of low mood and energy. He reports that he no can no longer derive joy from gardening which he used to enjoy. He denies having any suicidal ideation. \r\n\nPhysical examination: HS 1+11 + 0, vesicular breathing with no added lung sounds, abdomen SNT, normal neurological exam\nQuestionnaire: Patient Health Questionnaire (PHQ-9) score is 10/27.\nHe has previously tried computerised cognitive behavioural therapy but found it to be less effective. The patient is advised to commence treatment with sertraline 50mg PO daily and attend another appointment in two weeks’ time to review the medication.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"totalVotes": 6577,
"typeId": 1,
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173,467,496 | false | 26 | null | 6,495,239 | null | false | [] | null | 6,836 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Agitation and sweating are not normal side effects of citalopram. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of serotonin syndrome",
"id": "34129",
"label": "e",
"name": "It is normal to experience agitation and sweating during the course of treatment",
"picture": null,
"votes": 78
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms",
"id": "34128",
"label": "d",
"name": "Citalopram can lead to addiction",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Citalopram is generally safe to be used during breastfeeding. Citalopram usually only passes into breast milk in small quantities and has only been associated with adverse effects in very few breastfed babies. Moreover, grey baby syndrome is more commonly linked with antibiotic chloramphenicol",
"id": "34127",
"label": "c",
"name": "She should not breastfeed if she is taking citalopram because citalopram passes into breast milk in large quantities and can lead to grey baby syndrome",
"picture": null,
"votes": 250
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "If a patient has been feeling better for 6 months or more, he/she might be suggested to come off citalopram. However, patients should be reminded to discuss with their doctors before stopping the medication because abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Dose of citalopram should be tapered and reduced gradually over 4 weeks",
"id": "34125",
"label": "a",
"name": "She should not abruptly discontinue her medication when she is feeling better",
"picture": null,
"votes": 6297
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms",
"id": "34126",
"label": "b",
"name": "Citalopram is a tricyclic antidepressant that works by increasing levels of adrenaline in the brain",
"picture": null,
"votes": 6
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"typeId": 5
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"explanation": "She should not abruptly discontinue her medication when she is feeling better",
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"question": "A 30-year-old woman presents to her GP with a 3-week history of depression, hopelessness, fatigue, poor appetite, and difficulty sleeping. She recently gave birth to her first child a month ago. She denies hallucinations or thoughts of harming her baby. Her Edinburgh Postnatal Depression Scale score is 8/30.\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam\nPMH, DH: NIL\nThe patient is advised to commence treatment with citalopram 20mg PO once daily along with cognitive behavioural therapy and attend another appointment in two weeks’ time to review the medication.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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173,467,497 | false | 27 | null | 6,495,239 | null | false | [] | null | 6,842 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Angioedema is a rare side effect of tamoxifen",
"id": "34158",
"label": "d",
"name": "Angioedema is a common side effect of tamoxifen",
"picture": null,
"votes": 40
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cataract is a common side effect while corneal changes are rarely caused by Tamoxifen",
"id": "34159",
"label": "e",
"name": "Tamoxifen more commonly causes corneal changes than cataract",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tamoxifen is associated with increased endometrial changes that can subsequently lead to hyperplasia, polyps and cancer",
"id": "34157",
"label": "c",
"name": "Tamoxifen reduces the risk of endometrial hyperplasia and polyps",
"picture": null,
"votes": 87
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tamoxifen increases risk of thromboembolism. Hence, patients should seek medical attention straightaway if they suddenly experience breathlessness, chest pain and other signs that are suggestive of pulmonary embolus",
"id": "34155",
"label": "a",
"name": "She should immediately seek medical help if she experiences sudden onset breathlessness and chest pain",
"picture": null,
"votes": 7132
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tamoxifen is contraindicated during pregnancy due to its teratogenicity. Patients should use effective contraception during treatment and for 2 months after cessation of treatment",
"id": "34156",
"label": "b",
"name": "She could attempt to get pregnant during the course of treatment",
"picture": null,
"votes": 69
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2774",
"name": "Tamoxifen",
"status": null,
"topic": {
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"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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"question": "Case presentation: A 35-year-old woman attends the breast clinic to discuss about hormonal therapy for her oestrogen-receptor positive breast cancer. \r\n\nPMH: Breast cancer, Hypertension\nDH: Amlodipine 5mg OD\nSH: Lives alone, smoker (10 pack-year history)\nShe is advised to commence treatment with Tamoxifen 20mg PO daily.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"totalVotes": 7386,
"typeId": 1,
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173,467,498 | false | 28 | null | 6,495,239 | null | false | [] | null | 6,847 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is important to remind the patients not to consume any alcohol during the course of treatment and for 48 hours after the completion of therapy. Metronidazole can interact with alcohol to produce a disulfiram-like reaction that brings about side effects such as hot flushes, palpitation and headache",
"id": "34180",
"label": "a",
"name": "She should not drink alcohol during the course of treatment",
"picture": null,
"votes": 6528
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metronidazole is an antibiotic that is highly effective against anaerobic bacteria and protozoa",
"id": "34181",
"label": "b",
"name": "Metronidazole is an antifungal medication",
"picture": null,
"votes": 171
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients should continue the full course of treatment even if they have felt better to in order to prevent the development of antibiotic resistance in the future",
"id": "34182",
"label": "c",
"name": "She should stop taking the medication once the discharge has gone to reduce the risk of side effects",
"picture": null,
"votes": 199
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metronidazole is associated with decrease in appetite",
"id": "34183",
"label": "d",
"name": "Metronidazole can lead to increased appetite and weight gain",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dark urine is a rare side effect of metronidazole",
"id": "34184",
"label": "e",
"name": "Dark urine is a common side effect of metronidazole",
"picture": null,
"votes": 493
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "no mention of alcohol in BNF section...",
"createdAt": 1675176140,
"dislikes": 1,
"id": "17493",
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{
"__typename": "QuestionComment",
"comment": "The interaction does appear under the interaction tab of the BNF ",
"createdAt": 1705068062,
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"id": "38568",
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"__typename": "QuestionComment",
"comment": "from personal experience do NOT try to do this omfg",
"createdAt": 1738166981,
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "3426",
"name": "Metronidazole and anaerobic cells",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
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"question": "Case presentation: A 25-year-old woman attends her GP appointment with a one-week history of vaginal discharge. She describes the discharge as thin and white and has a fishy odour. A swab is performed and clue cells are seen under the microscope. \r\n\nThe patient is advised to commence treatment with metronidazole 400mg PO twice daily for 7 seven days.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 7422,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,499 | false | 29 | null | 6,495,239 | null | false | [] | null | 6,849 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Usage of isotretinoin during pregnancy is linked to an increased risk of serious congenital abnormalities. Hence, patients who are sexually active are required to use effective contraception during the course of treatment and for four weeks after discontinuation of medication",
"id": "34190",
"label": "a",
"name": "She should not get pregnant during treatment and for at least 1 month after cessation of treatment",
"picture": null,
"votes": 7312
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isotretinoin is not associated with excessive sweat. On the other hand, it can cause the skin to become dry and sensitive to sunlight",
"id": "34194",
"label": "e",
"name": "Excessive sweat is a common side effect of isotretinoin",
"picture": null,
"votes": 9
},
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"explanation": "# Summary\n\nAcne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.\n\n\n# Definition\n\n- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. \n- Vulgaris translates as \"common\", which is true as this condition affects over 80% of adolescents.\n\n# Epidemiology\n\n* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.\n* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.\n* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.\n* Acne affects both males and females, but the prevalence and severity may vary between genders.\n* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.\n\n# Risk Factors\n\nSeveral factors contribute to the development and exacerbation of acne, including:\n\n* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)\n* Increased sebum (oil) production\n* Blockage of hair follicles and sebaceous glands by keratin and sebum\n* Bacterial colonization (Propionibacterium acnes)\n* Family history of acne\n* Certain medications (e.g. corticosteroids, hormonal treatments)\n\n# Pathophysiology\n\n- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.\n- In acne, the corneocytes are excessively cohesive. They do not detach successfully.\n- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.\n- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. \n- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.\n- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. \n- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules. \n- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore referred to as blackheads.\n- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. \n- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. \n- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. \n- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. \n- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. \n\n[lightgallery]\n\n# Classification\n\n- Non-inflammatory: blackheads and whiteheads.\n- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)\n- Mild acne: predominantly non-inflammatory lesions. \n- Moderate acne: predominantly inflammatory papules and pustules. \n- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. \n\n# Clinical Features\n\n- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.\n- The face is most often affected. The neck, chest and back may also be affected.\n- Psychological dysfunction due to changes physical appearance\n- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. \n\t- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.\n\t- Hypertrophic: raised scars.\n\t- Keloid: raised scars that extend beyond the initial boundaries of the injury. \n- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. \n- Post inflammatory erythema: associated with inflammatory acne.\n- Acne fulminans: an uncommon but severe, serious acne presentation. \n\t- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) \n\t- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.\n- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. \n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n- Acne is a clinical diagnosis and investigations are not usually needed. \n- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)\n- Investigations will be required prior to commencing isotretinoin if indicated.\n- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)\n\n# Treatment\n\nManagement of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. \n\n- Each treatment combination is given as a 12 week course. \n- Combination therapies help reduce antimicrobial resistance. \n- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.\n- **Mild-moderate acne** is treated with any 2 of the following in combination:\n\t- Topical benzoyl peroxide.\n\t- Topical antibiotics (clindamycin)\n\t- Topical retinoids (tretinoin/adapalene)\n- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:\n\t- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.\n\t- Topical retinoids + topical antibiotics (clindamycin)\n\t- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.) \n\t- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) \n\t- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. \n\t- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women\n\nNB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.\n\t\n- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:\n\t- Acne fulminans.\n\t- Mild-moderate acne not responding to two 12 week courses of treatment as above.\n\t- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.\n\t- Psychological distress/mental health disorder contributed to by acne.\n\t- Acne with persistent pigmentary changes.\n\t- Acne with scarring.\n- Other available agents:\n\t- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. \n\t- Spironolactone: anti-androgenic - not often used. Not for male patients. \n\t- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. \n\t\t* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension \n\t\t* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment\n\t\t* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.\n\t\n\t\n# Complications\n\n- Post-inflammatory erythema\n- Post-inflammatory hyper- and hypo- pigmentation\n- Psycho/social/sexual dysfunction \n- Scars (atrophic, hypertrophic, keloid)\n\t- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:\n\t\t- Darker skin/Chinese/Hispanic origin \n\t\t- Less than 30 years of age\n\t\t- Previous keloid scarring \n\t- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time. \n\n# NICE Guidelines\n\n[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)",
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"question": "Case presentation: A 32-year-old woman attends the dermatology clinic for her acne vulgaris medication review. She complains that her acne problem has not improved despite taking the medication prescribed diligently. \r\n\nPhysical examination: Widespread nodules and cysts over the face as well as the presence of multiple ice pick scars.\nDH: Topical adapalene once daily; Tetracycline 500mg PO twice daily\nThe patient is advised to commence treatment with Isotretinoin 25mg PO OD under the supervision of her dermatologist.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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"explanation": "A penicillin allergy has no cross-sensitivity with penicillin based medications, it does however have cross-sensitivity with other non steroidal anti-inflammatories and aspirin.",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"comment": "thats what I thought too and its similar to a question on the official mock where it counts it as 5 mmil\n",
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"comment": "if youre talking about the PSA mock thats because it says mmol/L, here it just says mmol",
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"comment": "the coorrect answer is 40 mmol the question in the mock that you guys reference used 'mmol/L' as the units as opposed to mmol which is what is used here",
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"comment": "oh that makes sense thank you\n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1st hour = 10mmol KCl\nNext 2 hours = 20mmol KCl\nNext 2 hours = (2/8 x 40mmol KCl) = 10mmol KCl\n\nTotal dose of potassium in 5 hours\n= 10 + 20 + 10 mmol KCl\n= 40mmol KCl",
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"question": "A 55-year-old gentleman is admitted to Surgical Assessment Unit with likely acute pancreatitis. Following surgical review, he has been kept NBM and IV fluid has been prescribed. Weight 80kg.\n\n\nHis IV fluid regimen has been prescribed as below:\n\n* IV 0.9% Normal Saline 500mL 10mmol KCl over 1 hour\n* IV 0.9% Normal Saline 1L 20mmol KCl over 2 hours\n* IV 0.18% Normal Saline 4% Dextrose 1L 40mmol KCl over 8 hours\n\nWhat dose (mmol) of potassium will have been administered IV in the first 5 hours?",
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"comment": "Is not 140mg since she received 70mg in 12 hours so in 24hrs she will have received 140mg? ",
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"comment": "it would be 0.5 milligrams times 70kg (500micrograms/kg) which is 35 in 12 hours, then times by 2 to get 70mg in the day :) hope that helps!",
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"comment": "45 mcg in the first 6h, nothing for the next 12h followed by a repeat 45mcg in the last 6h of the day",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose of diazepam = 500micrograms/kg\nWeight = 70kg\nEach dose of diazepam\n= 500micrograms/kg x 70kg\n= 35 000 micrograms = 35mg\nTotal dose in 24 hours\n= 35mg x 2 = 70mg",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Total mass (g) of magnesium sulphate required = 28g\n\n10% 10mL ampoule\n= 10g in 100mL\n= 1g in 10mL ampoule\n\nTotal 10% 10mL ampoule required for 28g of magnesium sulphate\n= 28 10% 10mL ampoules",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "500micrograms = 0.5mg\n\n0.5mg needed\n\n5mg in every 1ml\n\n0.5 / 5 = 0.1\n\n0.1mL of haloperidol solution should be delivered.",
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"comment": "i forgot to multiply my answer by 5 oops",
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"comment": "where does it say how many mg does the pt need in a day?\n",
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"comment": "you have to search for the dose of amoxicillin for community acquired pneumonia in the bnf",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "The patient requires a daily dose of 1.5g (1500mg) of amoxicillin (500mg to be taken 3 times a day).\n\nThey have been discharged with 250mg tablets. 1500/250 = 6 tablets needed per day.\n\nThe duration of treatment is 5 days. 5 x 6 = 30. 30 total tablets are therefore needed.",
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"question": " \n\nCase Presentation:\n\nA 64-year-old gentleman attends his GP complaining of a productive cough and shortness of breath. His regular medicines are listed (below). Weight kg.\n\n**PH** Osteoarthritis, Depression\n\n**DH** Ibuprofen 200mg PO QDS, Omeprazole 20mg PO OD, Sertraline 50mg PO OD\n\n**On examination**\nBP 134/74mmHg, HR 78, RR 16, patient is alert\n\nRespiratory exam: Crepitations heard in the left middle zone on auscultation\n\nThe GP decides that this is a community acquired pneumonia and prescribes the patient 250mg amoxicillin capsules to take at home.\n\nHow many amoxicillin tablets should the patient be discharged with for a duration of 5 days?",
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173,467,506 | false | 36 | null | 6,495,239 | null | false | [] | null | 10,146 | {
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "This question asks for the maximum dose possible therefore the answer would be (95 x 7) which is 665mg.",
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"question": " \n\nCase Presentation: A 52-year-old patient has been admitted to the general surgical ward due to an episode of acute diverticulitis. They are prescribed antibiotics for this infection, one of which is a STAT dose of gentamicin. Gentamicin can be given IV 5-7mg/kg once daily at a maximum of 7mg/kg. He weighs 95kg.\n\nWhat is the maximum dose of gentamicin that this gentleman should receive in one day.",
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"comment": "i thought you would also add 5% dehyrdration lol ",
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"comment": "maintenance not replacement",
"createdAt": 1736944971,
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"comment": "sometimes I can't whether you want the absolute fluid volume or a real volume in terms of bags",
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"comment": "In the actual PSA they will make it clear as to what they're asking for, because you're right, I don't think will be prescribing 1580 mL, at the very least not for maintenance fluids",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "The first 10kg of weight replaces fluid at a rate of 100 ml/kg/day.\n\nThe second 10kg of weight replaces fluid at a rate of 50 ml/kg/day.\n\nThen any extra kg in weight above 20kg total weight is replaced at a rate of 20 ml/kg/day.\n\nThis patient weighs 24kg. Therefore he will need 1000ml for his first 10kg of weight, 500ml for his next 10kg of weight and another 80ml for the last 4kg.",
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"question": " \n\nCase Presentation:\n\nA 6 year old boy is admitted to the paediatric ward with abdominal pain and nausea. Weight 24kg.\n\n**On examination**\nBP 102/64mmHg, HR 101, RR 22, patient is alert.\n\nMucus membranes appear moist.\n\nSkin turgor is normal.\n\nCapillary refill time is > 2 seconds.\n\nDue to the boy's nausea he is unable to tolerate oral fluids. It is decided that IV maintenance fluids should be prescribed to ensure adequate hydration is maintained.\n\nWhat **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily maintenance fluids?",
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"comment": "okay but like the bnf says 15-20mg/kg, so if the question was really asking for the minimum volume, wont we be using the 15mg/kg values instead?",
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"comment": "I understand what you are saying, but you are being told in this question that they are being given the 20mg/kg dose so you should use those values\n",
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"explanation": "Dose = 50 kg x 20 mg = 1000mg\nSince maximum concentration is 5 mg/mL, minimum volume is 1000/5 = 200 mL",
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"explanation": "LMWH (Dalteparin sodium) is common or very commonly associated with immune-mediated, drug induced thrombocytopenia. Heparin, which is negatively charged binds to platelet factor 4 (PF4), a positively charged molecule that is released into the circulation upon the activation of platelets. This heparin-PF4 complex acts as a immunogen, which leads to antibody production and the activation and aggregation of platelets. The clearance of the activated platelets can then lead to thrombocytopenia",
"id": "34215",
"label": "a",
"name": "Dalteparin sodium 2500 units SC OD",
"picture": null,
"votes": 5881
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide does not commonly cause thrombocytopenia",
"id": "34218",
"label": "d",
"name": "Furosemide 40mg PO OD",
"picture": null,
"votes": 107
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin does not commonly cause thrombocytopenia",
"id": "34216",
"label": "b",
"name": "Metformin 1g BD PO",
"picture": null,
"votes": 24
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i selected dalteparin and it changed my answer to gliclazide so i got it wrong...",
"createdAt": 1705861537,
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"id": 46270
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 45-year-old man is recovering on the gastroenterology unit following an elective pan proctocolectomy for his UC five days ago. PMH Type 2 diabetes mellitus, Resistant hypertension, Migraine. DH His current regular medicines are listed (below).\n\n\nInvestigation\nPlatelet 100 x 109/L (150-400)\n\n\nQuestion: Select the prescription that is most likely to contribute to his thrombocytopenia.",
"sbaAnswer": [
"a"
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"totalVotes": 6538,
"typeId": 1,
"userPoint": null
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173,467,510 | false | 40 | null | 6,495,239 | null | false | [] | null | 6,863 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline can cause visual impairment such as blurry vision but is generally less associated with xanthopsia",
"id": "34264",
"label": "e",
"name": "Sertraline 50 mg PO OD",
"picture": null,
"votes": 162
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Blurred vision is a rare or very rare side effect of captopril",
"id": "34263",
"label": "d",
"name": "Captopril 25 mg PO BD",
"picture": null,
"votes": 207
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to cause xanthopsia",
"id": "34261",
"label": "b",
"name": "Metformin 500 mg PO TDS",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is not known to cause xanthopsia",
"id": "34262",
"label": "c",
"name": "Gliclazide 40mg PO OD",
"picture": null,
"votes": 92
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Visual disorders are common or very common side effects of digoxin. Digoxin toxicity should be suspected in a case of xanthopsia (yellow vision). Toxicity is increased by electrolyte disturbances such as hypercalcaemia, hypokalaemia and hypomagnesaemia. Serum electrolytes and renal function tests should be arranged besides plasma-digoxin concentration assay",
"id": "34260",
"label": "a",
"name": "Digoxin 250 micrograms PO OD",
"picture": null,
"votes": 5812
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where can we find signs of digoxin toxicity on BNF?\n",
"createdAt": 1705855242,
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"comment": "its under side effects\n",
"createdAt": 1732367983,
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"id": 1823
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case presentation: A 45-year-old man presents to GP with a visual problem. He is concerned that his vision has a yellow tinge. \r\n\nPMH: Diabetes Mellitus, Hypertension, Depression, Atrial fibrillation\nDH: His current regular prescriptions are listed\nObservations: Temperature 36.5, Respiratory rate 14, Blood pressure 128/85, Heart rate 76, Oxygen saturation 100% (on air)\nOn Examination: 6/6 visual acuity\n\nQuestion: Select the prescription that is most likely to be contributing his yellow-tinted vision?",
"sbaAnswer": [
"a"
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173,467,511 | false | 41 | null | 6,495,239 | null | false | [] | null | 6,871 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.",
"id": "34303",
"label": "d",
"name": "Rivaroxaban 20 mg PO OD",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to interact with digoxin",
"id": "34302",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to interact with digoxin",
"id": "34304",
"label": "e",
"name": "Lisinopril 2.5mg PO OD",
"picture": null,
"votes": 237
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Chlortalidone is a thiazide-like diuretic that can be used to treat oedema secondary to heart failure. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. Chlortalidone is predicted to increase the risk of digoxin toxicity when given with digoxin. (Severity of interaction: Severe; Evidence for interaction: Study). Chlortalidone can lead to hypokalaemia that increases risk of digoxin toxicity. Digoxin normally competes with potassium to bind to cellular Na+/K+-ATPase pumps. Hence, when potassium levels are low, digoxin can more easily bind to the pumps",
"id": "34300",
"label": "a",
"name": "Chlortalidone 50 mg PO OD",
"picture": null,
"votes": 5296
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.",
"id": "34301",
"label": "b",
"name": "Carvedilol 3.125 mg PO BD",
"picture": null,
"votes": 769
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "from the BNF: Both Carvedilol and Digoxin can increase the risk of bradycardia.",
"createdAt": 1675198390,
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"comment": "Carvedilol increases the risk of bradys as seen here.\nChlortalidone directly interacts to cause digoxin toxicity to cause the ECG changes we are seeing \n\nSo debatably both cause the clinical picture but I think the digoxin toxicity with ECG changes is the major feature in this question",
"createdAt": 1678031826,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2803",
"name": "Digoxin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
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"explanation": "Chlortalidone 50 mg PO OD",
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"question": "A 67-year-old woman presents to the accident and emergency department with nausea, vomiting and confusion. Two days ago her GP started digoxin 125 micrograms PO once daily for her atrial fibrillation.\n **PMH:** Type 2 Diabetes Mellitus, Atrial fibrillation, Heart failure\n**Observations:** Temperature 36.5°C , blood pressure 125/80 mmHg, heart rate 54 bpm, respiratory rate 18; oxygen saturation 100% (on air).\n \n **On examination:** Irregular S1, S2 with presence of S3; chest is clear with no added lung sounds; abdomen soft and non tender\n\n **ECG:** Downsloping ST depression with a ‘hockeystick’ pattern, flattened T wave, shortened QT interval\nSelect the prescription that is most likely to have interacted with digoxin to cause the clinical picture described above?",
"sbaAnswer": [
"a"
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"totalVotes": 6364,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,512 | false | 42 | null | 6,495,239 | null | false | [] | null | 6,872 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Haemorrhage is a common or very common side effect of warfarin. In a situation where there is minor bleeding and an INR of more than 8, NICE recommends to stop warfarin and give 0.5–1 mg phytomenadione by slow intravenous injection, or 5 mg by mouth",
"id": "34305",
"label": "a",
"name": "Stop warfarin and give phytomenadione 1mg slow IV injection",
"picture": null,
"votes": 4810
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phytomenadione needs to be given if there is bleeding and INR is 8 or more",
"id": "34307",
"label": "c",
"name": "Omit two doses of warfarin and restart thereafter",
"picture": null,
"votes": 163
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urgent intravenous treatment with phytomenadione (vitamin K1), and/or dried prothrombin complex concentrate (factors II, VII, IX, and X), or fresh frozen plasma 15mL/kg is only required if there is heavy bleeding",
"id": "34309",
"label": "e",
"name": "Stop warfarin and commence urgent intravenous treatment with phytomenadione and prothrombin complex concentrate",
"picture": null,
"votes": 1567
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Warfarin needs to be stopped. Phytomenadione also needs to be given if there is bleeding and INR is 8 or more",
"id": "34308",
"label": "d",
"name": "Continue with current dose",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phytomenadione needs to be given if there is bleeding and INR is 8 or more",
"id": "34306",
"label": "b",
"name": "Reduce the dose of warfarin to 5 mg PO OD",
"picture": null,
"votes": 30
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Given the patient has a NOF wouldn't you'd be thinking that there could be more significant internal bleeding... and so you'd go for Fit K and prothrombin complex concentrate... if not why not?",
"createdAt": 1646994264,
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"__typename": "QuestionComment",
"comment": "Yeah I agree, i thought it was a bit strange to just give vit K when he has to go to theatre?",
"createdAt": 1674614099,
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"displayName": "DNA Tachycardia",
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"comment": "We have to only go by what the question says: 'Minor bleeding from a cut on his right hand (and no other bleeding sites)' ",
"createdAt": 1675346338,
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"__typename": "QuestionComment",
"comment": "A tip for anyone doing PSA is to search \"phytomenadione\", and it essentially gives you the treatment for various bleeding severities and INR. Good luck!",
"createdAt": 1706558168,
"dislikes": 0,
"id": "40202",
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"comment": "this person is going to theatre so why would you not give it all",
"createdAt": 1706635849,
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"__typename": "QuestionComment",
"comment": "agree with the theatre people",
"createdAt": 1737648753,
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"__typename": "Concept",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case presentation: A 60-year-old man is brought to the accident and emergency department. He had a fall this morning after accidentally walking into a glass door. Besides his prescribed medication, he has been taking some herbal supplements lately. \r\n\nPMH: Atrial fibrillation\nDH: Warfarin Sodium 10 mg PO once daily, Bisoprolol 10 mg PO once daily\nObservations: Temperature 36.5°C , blood pressure 125/80 mmHg, heart rate 80 bpm, respiratory rate 18; oxygen saturation 100% (on air)\nOn examination: Minor bleeding from a cut on his right hand (and no other bleeding sites), cannot weight bear, pain on external rotation of left leg\nInvestigations: Pelvic x-ray: Left Intracapsular neck of femur fracture ; INR: 8.2\n\nQuestion: Select the most appropriate option for the management of this adverse drug event.",
"sbaAnswer": [
"a"
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"totalVotes": 6585,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,513 | false | 43 | null | 6,495,239 | null | false | [] | null | 10,076 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is a sulphonylurea used to treat type 2 diabetes. It is not known to cause hyperkalaemia.",
"id": "50143",
"label": "c",
"name": "Gliclazide 80mg OD",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has hyperkalaemia. Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i), a known adverse effect of ACE-is is hyperkalaemia.",
"id": "50141",
"label": "a",
"name": "Ramipril 5mg",
"picture": null,
"votes": 4671
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is a biguanide used to treat type 2 diabetes. It is not known to cause hyperkalaemia.",
"id": "50142",
"label": "b",
"name": "Metformin 500mg BD",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is an antibiotic used to treat infections such as pneumonia. It is not known to cause hyperkalaemia.",
"id": "50144",
"label": "d",
"name": "Co-amoxiclav 250/125mg TDS",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Omeprazole is a proton pump inhibitor used to treat gastro-oesophageal reflux disease (GORD). It is known to cause electrolyte imbalances such as hypokalaemia, hyponatraemia, hypocalcaemia and hypomagnesia due to increased renal losses. This patient has hyperkalaemia so this is unlikely to have been caused by omeprazole.",
"id": "50145",
"label": "e",
"name": "Omeprazole 40mg BD",
"picture": null,
"votes": 40
}
],
"comments": [],
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"__typename": "Concept",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 56-year-old gentleman is admitted to the acute medical unit with pneumonia. Weight 90kg. His Medications are listed (below). \n\n\n\n\n **PMH**\n\n\n * Hypertension\n * GORD\n * Type II diabetes mellitus\n\n\n **On examination**\n\n\n * Chest: coarse crackles in left mid to lower zones.\n * HS S1 S2 + no added sounds\n * Abdo SNT\n * Temperature 38.1, BP 110/84, HR 96\n\n\n **Investigation**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|136mmol/L|135 - 145|\n|Potassium|5.5 mmol/L|3.5 - 5.3|\n|Urea|5 mmol/L|2.5 - 7.8|\n|Creatinine|96 µmol/L|60 - 120|\n\n\nQuestion: Which medication is most likely to have contributed to his electrolyte abnormality?",
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"a"
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173,467,514 | false | 44 | null | 6,495,239 | null | false | [] | null | 10,130 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol does not commonly interact with combined oral contraception",
"id": "50380",
"label": "b",
"name": "Salbutamol 200micrograms INH QDS",
"picture": null,
"votes": 6
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Budesonide does not commonly interact with combined oral contraception",
"id": "50381",
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"picture": null,
"votes": 13
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"id": "50382",
"label": "d",
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"picture": null,
"votes": 27
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"__typename": "QuestionChoice",
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"explanation": "Hydromol does not commonly interact with combined oral contraception",
"id": "50383",
"label": "e",
"name": "Hydromol cream one application to affected area BD",
"picture": null,
"votes": 5
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"__typename": "QuestionChoice",
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"explanation": "Carbamazepine is a PY450 enzyme inducer, this is the enzyme responsible for the metabolism of the combined oral contraceptive pills. Increased activity of said enzyme results in the combined oral contraceptive pill being metabolised quicker and therefore having a lower efficacy. Other PY450 inducers include phenytoin, phenobarbital, felbamate, topiramate, oxcarbazepine and primidone.",
"id": "50379",
"label": "a",
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"picture": null,
"votes": 4633
}
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Taking the combined oral contraceptive pill and carbamazepine reduces the efficacy of the combined oral contraceptive pill",
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"question": "Case Presentation: A 18-year-old woman attends her GP asking for the combined oral contraceptive pill. Her regular medicines are listed (below).\n\n\n**PH** Asthma, Epilepsy, Eczema, Allergic rhinitis\n\n**DH** Salbutamol 200micrograms INH QDS, Budesonide 400 micrograms INH BD, Carbamazepine 200mg PO BD, Cetirizine 10mg PO OD, Hydromol cream one application to affected area BD\n\nQuestion: Select the prescription that is most likely to reduce the efficacy of the combined oral contraceptive pill.",
"sbaAnswer": [
"a"
],
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"typeId": 1,
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173,467,515 | false | 45 | null | 6,495,239 | null | false | [] | null | 18,104 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Statins uncommonly cause hepatitis but are not known to cause jaundice.",
"id": "10028510",
"label": "d",
"name": "Atorvastatin 40mg PO OD",
"picture": null,
"votes": 708
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The BNF states metformin can cause hepatitis however the frequency is not known and it is not known to produce a cholestatic picture.",
"id": "10028508",
"label": "b",
"name": "Metformin 1mg OD PO",
"picture": null,
"votes": 91
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Cholestatic jaundice is a recognised side effect of penicillins and can occur either during or shortly after treatment.",
"id": "10028507",
"label": "a",
"name": "Flucloxacillin 1g IV 6-hourly",
"picture": null,
"votes": 2776
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Aspirin does not cause jaundice",
"id": "10028511",
"label": "e",
"name": "Aspirin 75mg PO OD",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine does not cause jaundice.",
"id": "10028509",
"label": "c",
"name": "Amlodipine 5mg PO OD",
"picture": null,
"votes": 33
}
],
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"name": "Flucloxacillin",
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"question": "Case Presentation: A 67-year-old lady is admitted to the acute medical ward for treatment of ongoing cellulitis which did not respond to oral antibiotics. On day 2 of her admission she develops jaundice.\n\n\n\n\n **PH** Hypertension, IHD, Type 2 diabetes\n\n\n **DH** Her current regular medicines are listed (below).\n\n\n **On examination** Yellow sclera\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Alanine Aminotransferase (ALT)|100 IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|30 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|190 IU/L|25 - 115|\n|Bilirubin|69 µmol/L|< 17|\n\nQuestion: Select the prescription that is most likely to be contributing to the jaundice.",
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173,467,516 | false | 46 | null | 6,495,239 | null | false | [] | null | 18,105 | {
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"__typename": "QuestionChoice",
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"explanation": "Vomiting is an uncommon side effect of oral iron supplements, and so is not as common as dark stools.",
"id": "10028514",
"label": "c",
"name": "Vomiting",
"picture": null,
"votes": 557
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "'Bronze' skin is a feature of hereditary haemachromatosis, which is a genetic iron storage disease in which the body absorbs excessive amounts of iron from the diet. It is not a side effect of iron supplementation.",
"id": "10028516",
"label": "e",
"name": "'Bronzing' skin",
"picture": null,
"votes": 46
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Darker (though not black, nor tarry) are a very common side effect of iron replacement therapy and patients should be warned of this in advance as it can be a later source of anxiety and non-compliance.",
"id": "10028512",
"label": "a",
"name": "Dark stools",
"picture": null,
"votes": 3042
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Reduced libido is not a known side effect of ferrous fumarate.",
"id": "10028515",
"label": "d",
"name": "Reduced libido",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sleeping problems are not a side effect of ferrous fumarate.",
"id": "10028513",
"label": "b",
"name": "Sleeping problems",
"picture": null,
"votes": 3
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "I didn't believe that dark stool was an \"adverse\" affect, but more a known side-affect ",
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"comment": "this side effect isnt in the bnf under ferrous fumarate ",
"createdAt": 1735917132,
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"__typename": "QuestionComment",
"comment": "look under patient and carer advice - \"may discolour stools\"",
"createdAt": 1736170191,
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"comment": "That doesn't give you an idea of how common it is though",
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"question": "Case Presentation: A 27-year-old woman presents to the GP complaining of feeling tired all the time. She suffers heavy periods, and subsequent blood tests reveal a microcytic anaemia. She is commenced on ferrous fumarate 210mg OD.\n\n\nQuestion: Select the adverse affect most likely to be caused by this treatment.\n\n**PH** Menorrhagia",
"sbaAnswer": [
"a"
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173,467,517 | false | 47 | null | 6,495,239 | null | false | [] | null | 6,875 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Warfarin has no effect on platelets and thus they have no role in monitoring either the dosing or adverse effects of warfarin",
"id": "34322",
"label": "c",
"name": "Platelet count",
"picture": null,
"votes": 93
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The prothrombin time has no role in monitoring either the dosing or adverse effects of warfarin",
"id": "34323",
"label": "d",
"name": "Prothrombin time",
"picture": null,
"votes": 3102
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dyspepsia is not a known adverse effect associated with warfarin",
"id": "34321",
"label": "b",
"name": "Patient reports new dyspepsia",
"picture": null,
"votes": 91
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "When starting anticoagulation treatment it is important for patients to report any new bruising or bleeding as they may be receiving too high a dose",
"id": "34320",
"label": "a",
"name": "Patient reports easy bruising",
"picture": null,
"votes": 3047
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vitamin K assays are not routinely done in patients taking warfarin as levels will almost certainly be lower and as such this is of negligible clinical usefulness",
"id": "34324",
"label": "e",
"name": "Vitamin K levels",
"picture": null,
"votes": 114
}
],
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{
"__typename": "QuestionComment",
"comment": "WTF\n",
"createdAt": 1704301282,
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"id": "37592",
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"likes": 30,
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"__typename": "QuestionComment",
"comment": "Surely not",
"createdAt": 1706800609,
"dislikes": 0,
"id": "40474",
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"likes": 6,
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"displayName": "Embolism Cystic",
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"__typename": "QuestionComment",
"comment": "lol its PROthrombin time not TT rip my sanity",
"createdAt": 1738088601,
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"id": "61792",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2807",
"name": "Warfarin side effects",
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"typeId": 5
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"question": "Case Presentation: A 37 year old woman is referred to the anticoagulation clinic following a hospital admission for a pulmonary embolus. **PMH** systemic lupus erythematosus, antiphospholipid syndrome. **DH** hydroxychloroquine sulfate 300mg PO OD. NKDA **SH** ex-smoker (5 pack years).\n\n\nHer consultant decides that it is appropriate to pursue lifelong anticoagulation with warfarin sodium at a starting dose of 5mg PO OD.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment in the first few months.",
"sbaAnswer": [
"a"
],
"totalVotes": 6447,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,518 | false | 48 | null | 6,495,239 | null | false | [] | null | 6,876 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done",
"id": "34327",
"label": "c",
"name": "Full blood count",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amiodarone is metabolised and excreted by the liver. Renal function would be useful as a baseline but not with respect to starting this drug",
"id": "34326",
"label": "b",
"name": "Creatinine clearance",
"picture": null,
"votes": 141
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than sodium",
"id": "34328",
"label": "d",
"name": "Serum sodium",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug",
"id": "34329",
"label": "e",
"name": "Troponin",
"picture": null,
"votes": 22
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A potentially severe side effect of amiodarone use is pulmonary fibrosis. Existing lung damage should be ruled out prior to starting this drug",
"id": "34325",
"label": "a",
"name": "Chest X-ray",
"picture": null,
"votes": 6102
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where does it say this in the BNF?",
"createdAt": 1706805111,
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"comment": "Search \"Amiodarone Hydrochloride\" -> Find monitoring requirements on the drug monograph -> Under monitoring of patient parameters C&P'd:\n\nMonitoring of patient parameters For amiodarone hydrochloride\nLiver function tests required before treatment and then every 6 months.\nSerum potassium concentration should be measured before treatment.\nChest x-ray required before treatment.\n\nHope that helps!",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2808",
"name": "Amiodarone side effects",
"status": null,
"topic": {
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"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
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"question": "Case Presentation: A 62 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG holter monitor. **PMH** myocardial infarction with 100% LAD occlusion, hypertension. **DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 5mg PO OD. NKDA\n\n\n**Investigations**\n\n24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds\n\nThe cardiology consultant recommends starting amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an ICD.\n\nQuestion: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.",
"sbaAnswer": [
"a"
],
"totalVotes": 6417,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,519 | false | 49 | null | 6,495,239 | null | false | [] | null | 6,877 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is advised to avoid using co-trimoxazole in patients with severe hepatic impairment but monitoring liver function is not routinely done",
"id": "34334",
"label": "e",
"name": "Liver function tests",
"picture": null,
"votes": 187
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Monitoring of blood co-trimoxazole concentrations may be useful for planning dose adjustments but aberrant levels do not necessarily correspond with development of adverse effects",
"id": "34331",
"label": "b",
"name": "Co-trimoxazole levels",
"picture": null,
"votes": 361
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hypoglycaemia is a very rare side effect of treatment with co-trimoxazole but it is not routine to monitor blood glucose whilst on this drug",
"id": "34332",
"label": "c",
"name": "Blood glucose monitoring",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-trimoxazole has anti-folate activity and monitoring haematics could be considered if taken for an extended period of time or in combination with another anti-folate drug such as methotrexate. However the planned treatment course here is only for 7 days and is unlikely to result in a significant effect",
"id": "34333",
"label": "d",
"name": "Haematinics (ferritin, B12, folate)",
"picture": null,
"votes": 698
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Co-trimoxazole is known to cause hyperkalaemia in patients who are at risk of or have pre-existing renal impairment",
"id": "34330",
"label": "a",
"name": "Urea and electrolytes",
"picture": null,
"votes": 5160
}
],
"comments": [],
"concept": {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"name": "Trimethoprim side effects",
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"typeId": 5
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"question": "Case Presentation: A 67 year old man is admitted to the medical ward for treatment of a diabetic foot ulcer. **PMH** type 2 diabetes, hypertension, diabetic nephropathy. **DH** metformin hydrochloride MR tablets 2g PO OD, insulin glargine (Lantus) 9 units SC BD, doxazosin 4mg PO OD. Allergic to penicillin – urticarial rash. Allergic to gentamicin – anaphylaxis.\n\n\n**Investigations**\n\nFBC: Hb 130, WCC 17.3, Plts 235 x 10^9, MCV 87\n\nU&Es: Na 145, K 4.8, Cl 96, Ur 3.1, Cr 197, eGFR 48mL/min/1.73m^2\n\nLFTs: AST 16, ALT 23, ALP 54\n\nCRP 155\n\nUlcer swab MCS: mixed growth. Primary species Staphylococcus aureus and Staphylococcus epidermidis, isolated Elizabethkingia meningoseptica\n\nBased on the sensitivities and advice from microbiology, the patient’s consultant decides to start co-trimoxazole 960mg IV BD for 7 days.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 6431,
"typeId": 1,
"userPoint": null
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173,467,520 | false | 50 | null | 6,495,239 | null | false | [] | null | 6,884 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that tamsulosin be avoided in patients with severe liver dysfunction but routine monitoring of liver function is not necessary",
"id": "34368",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 189
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary prior to starting this drug",
"id": "34366",
"label": "b",
"name": "Arterial doppler ultrasound",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that tamsulosin be avoided in patients with severe renal dysfunction but routine monitoring of renal function is not necessary",
"id": "34369",
"label": "e",
"name": "Urea and electrolytes",
"picture": null,
"votes": 387
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"__typename": "QuestionChoice",
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"explanation": "As an alpha-blocker, tamsulosin may exacerbate orthostatic hypotension, particularly in the elderly",
"id": "34365",
"label": "a",
"name": "Blood pressure",
"picture": null,
"votes": 6091
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tamsulosin blocks alpha adrenergic receptors rather than beta adrenergic receptors and has very limited activity on the heart",
"id": "34367",
"label": "c",
"name": "ECG",
"picture": null,
"votes": 246
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Tamsuolsin side effects",
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"question": "Case Presentation: A 70 year old man is seen in the outpatient urology clinic for consideration of starting tamsulosin hydrochloride 400 micrograms PO OD to treat benign prostatic hypertrophy. **PMH** temporal arteritis, depression. **DH** venlafaxine modified release 150mg PO OD\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of tamsulosin.",
"sbaAnswer": [
"a"
],
"totalVotes": 6922,
"typeId": 1,
"userPoint": null
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173,467,521 | false | 51 | null | 6,495,239 | null | false | [] | null | 6,885 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic",
"id": "34372",
"label": "c",
"name": "No routine monitoring is required",
"picture": null,
"votes": 118
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that the dose of terbinafine should be reduced in patients with renal impairment, but routine monitoring of renal function is not necessary",
"id": "34374",
"label": "e",
"name": "Serum creatinine",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a necessary monitoring requirement for this drug",
"id": "34371",
"label": "b",
"name": "Fasting lipid profile",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic",
"id": "34370",
"label": "a",
"name": "Liver function tests",
"picture": null,
"votes": 6031
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a necessary monitoring requirement for this drug",
"id": "34373",
"label": "d",
"name": "Platelet count",
"picture": null,
"votes": 13
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2618",
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},
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"demo": null,
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"id": "2817",
"name": "Terbinafine side effects",
"status": null,
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"id": "74",
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"typeId": 5
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"question": "Case Presentation: An 88 year old woman attends a follow-up appointment for review at her GP. One month ago she was seen in the outpatient dermatology clinic for a surgical excision of a basal cell carcinoma. She was incidentally diagnosed at the time with multiple-nail onychomycosis on her left foot and started on terbinafine 250mg PO OD.\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
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"totalVotes": 6197,
"typeId": 1,
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173,467,522 | false | 52 | null | 6,495,239 | null | false | [] | null | 6,892 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is reporting regular bleeds with her last one occurring 5 days ago. There still is a minuscule chance she may be pregnant and one may choose to perform a urine pregnancy test before administering ulipristal acetate, but this is not strictly necessary",
"id": "34409",
"label": "e",
"name": "Urine pregnancy test",
"picture": null,
"votes": 829
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "There are generally no monitoring requirements prior to administering ulipristal acetate as emergency contraception",
"id": "34405",
"label": "a",
"name": "No routine monitoring is required",
"picture": null,
"votes": 2904
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hyper/hypotension is not a known adverse effect of this drug",
"id": "34406",
"label": "b",
"name": "Blood pressure",
"picture": null,
"votes": 187
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to measure height and weight prior to administering ulipristal acetate",
"id": "34408",
"label": "d",
"name": "Height and weight",
"picture": null,
"votes": 194
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ulipristal acetate is metabolised by the liver and as such liver function tests are recommended when it is being used long-term to treat fibroids. This is not necessary if it is taken as a single dose for emergency contraception",
"id": "34407",
"label": "c",
"name": "Liver function tests",
"picture": null,
"votes": 2175
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "BNF:\nPerform liver function tests before treatment initiation—do not initiate if serum transaminases exceed 2 times the upper limit of normal. During the first 2 treatment courses, monitor liver function monthly; for further treatment courses, perform liver function tests once before each new treatment course and when clinically indicated. At the end of each treatment course, perform liver function tests after 2-4 weeks. Discontinue treatment if serum transaminases exceed 3 times the upper limit of normal and closely monitor patient.\n\nPeriodically monitor the endometrium following repeated intermittent treatment.",
"createdAt": 1646856067,
"dislikes": 16,
"id": "8324",
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{
"__typename": "QuestionComment",
"comment": "if you read above that it says \"When used for uterine fibroids\" ",
"createdAt": 1646937391,
"dislikes": 0,
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"displayName": "DNA Hypertension",
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"__typename": "QuestionComment",
"comment": "whatever you say im still doing the pregnancy test irl",
"createdAt": 1737648864,
"dislikes": 0,
"id": "61348",
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"typeId": 2
},
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"demo": null,
"entitlement": null,
"id": "2824",
"name": "Ulipristal acetate side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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"highlights": [],
"id": "6892",
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"question": "Case Presentation: A 27 year old woman attends the walk-in GUM clinic requesting emergency contraception. She had forgotten to take her combined contraceptive pill for two days in a row at the start of the week and had unprotected sex in the same period.\n\n\nHer LMP was 5 days ago and she has a regular cycle of 28 days. She has never been pregnant before.\n\nAfter counselling, it is agreed that she should take ulipristal acetate 30mg PO as a one-off dose for emergency contraception.\n\nQuestion: Select the most appropriate monitoring option required before administering ulipristal acetate.",
"sbaAnswer": [
"a"
],
"totalVotes": 6289,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,523 | false | 53 | null | 6,495,239 | null | false | [] | null | 6,893 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While deep-vein thromboses are a well-known adverse effect of taking oestrogen-containing contraception, it is not necessary to rule out an existing DVT prior to starting contraception",
"id": "34412",
"label": "c",
"name": "Venous doppler ultrasound",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Hypertension is a common adverse effect of the combined oral contraceptive pill and it is recommended that blood pressure should be checked before and while taking the COCP",
"id": "34410",
"label": "a",
"name": "Blood pressure",
"picture": null,
"votes": 4810
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A D-dimer is a specific blood test that is useful in helping to guide clinical diagnosis of a DVT. It is not necessary to perform one prior to starting contraception",
"id": "34413",
"label": "d",
"name": "D-dimer",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to perform an ECG prior to starting contraception",
"id": "34411",
"label": "b",
"name": "ECG",
"picture": null,
"votes": 60
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to monitor the blood pressure and weight prior to starting and while taking the COCP",
"id": "34414",
"label": "e",
"name": "No routine monitoring is required",
"picture": null,
"votes": 1317
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "there are no monitoring requirements for blood pressure. Where is that?\n",
"createdAt": 1675291943,
"dislikes": 0,
"id": "17586",
"isLikedByMe": 0,
"likes": 1,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "you do have to measure BP once per year",
"createdAt": 1737648908,
"dislikes": 0,
"id": "61349",
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"displayName": "Fungal Tyrosine",
"id": 22953
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"__typename": "QuestionComment",
"comment": "its before starting not necessarily monitored",
"createdAt": 1703278067,
"dislikes": 0,
"id": "36709",
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"likes": 2,
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"displayName": "Serotonin Dorsal",
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"__typename": "QuestionComment",
"comment": "Is this on the BNF somewhere? I can't find it",
"createdAt": 1706016615,
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"displayName": "Just Another Med Student",
"id": 46240
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"__typename": "QuestionComment",
"comment": "found in oral contraceptives treatment summary, not the drug page",
"createdAt": 1737751957,
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"explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"question": "A 15 year old girl attends her GP to ask for the combined oral contraceptive pill. During the consultation, her GP is satisfied that there are no safeguarding concerns regarding her partner and that she meets the Fraser guidelines. She is prescribed ethinylestradiol with desogestrel 1 tablet daily for 21 days and a 7-day pill free break.\n\n\nQuestion: Select the most appropriate monitoring option required before starting her contraception.",
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"explanation": "Although this would be part of a panel of investigations if the patient were to suffer adverse bleeding, it would not be a part of routine monitoring.",
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"explanation": "200mg oral morphine sulphate is equivalent to 60mg diamorphine SC. 100mg SC diamorphine will be uptitrating her pain control, which is not necessary when it is currently well controlled",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation:\n\n\nA 80-year-old man was admitted into the Care of the Elderly Ward a week ago for chest infection. His condition has worsened over the last few days and he is not for cardiopulmonary resuscitation. PMH Osteoarthritis, GORD, HTN, Heart failure, pancreatic cancer. DH Morphine sulphate M/R (MST Continus ® ) 75mg PO 12-hrly, Morphine sulphate 10mg/5mL (Oramorph ®) 5mL PO as required, Omeprazole 20mg OD PO, Bisoprolol 10mg PO OD, Ramipril 2.5mg PO OD. He has taken 5 doses of immediate release morphine in the last 24 hour.\nA decision is made by the palliative care team to stop all inappropriate medication and convert his analgesic regimen to a continuous subcutaneous infusion via a syringe driver.\n\nQuestion:\nSelect the most appropriate decision option with regard to his pain management based on these data.",
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"explanation": "This patient has poorly controlled hyperglycaemia (HbA1c 60) despite being started on metformin 500mg TDS. The maximum tolerated dose of metformin is 2g a day. His metformin can be up titrated to the maximum before starting on dual therapy",
"id": "34480",
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"explanation": "His metformin can be up titrated to the maximum before starting on dual therapy",
"id": "34483",
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"explanation": "His metformin can be up titrated to the maximum before starting on dual therapy. If the patient fails to respond to dual oral hypoglycaemic agents, triple therapy can then be considered",
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"name": "Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD",
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"explanation": "Patients with T2DM are often trialled on different combination of oral hypoglycaemic agent prior to initiation of insulin. In this case, uptitrating his metformin should be considered prior to changing his medication to insulin",
"id": "34482",
"label": "c",
"name": "Switch to biphasic insulin detemir 20 units SC",
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"explanation": "The maximum tolerated dose of metformin is 2g a day",
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"comment": "from my understanding, \nMetformin immediate release:\n- Can titrate up metformin e.g. from 500mg BD -> TDS but only if HbA1c below 58 mmol\n- Max dose is 2g daily \n- If not tolerated, try moderate release first\n- If HbA1c rises to 58 (7.5%) on metformin: (should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%))\n\nwe should go straight for another drug as it is >58...??\n",
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"comment": "It doesnt say his metformin dose in the beginning\n",
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"comment": "i want to give him empagliflozin >.<",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation:\n\n\nA 52-year-old man presents to his GP for review of his blood glucose. He was started on metformin 3 months ago when his HbA1c was found to be 52 and 56mmol/mol when tested on two separate occasions. PMH Type 2 diabetes mellitus, Hypertension, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 500mg TDS PO.\n **On Examination**\nBP 125/85 mmHg\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Non-fasting Glucose|13.1 mmol/L|< 6.1|\n|HbA1c (Glycated Haemoglobin)|60 mmol/mol or %|20 - 42 or 4-6%|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|85 µmol/L|60 - 120|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data.",
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"explanation": "Venous thromboembolism is not a recognised side effect of atorvastatin. Therefore, there is no need to stop this drug.",
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"label": "e",
"name": "Stop atorvastatin",
"picture": null,
"votes": 84
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of amlodipine. Therefore, there is no need to stop this drug.",
"id": "50431",
"label": "c",
"name": "Stop amlodipine",
"picture": null,
"votes": 206
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of paracetamol. Therefore there is no need to stop this drug.",
"id": "50432",
"label": "d",
"name": "Stop paracetamol",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has presented with a DVT. Patients who are taking tamoxifen are at an increased risk of developing blood clots. This is because the liver produced more clotting factors in response to processing more oestrogen. This patient should have her hormone replacement therapy switched over to a patch or gel.",
"id": "50429",
"label": "a",
"name": "Stop tamoxifen",
"picture": null,
"votes": 4233
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of ramipril. Therefore, there is no need to stop this drug.",
"id": "50430",
"label": "b",
"name": "Stop ramipril",
"picture": null,
"votes": 52
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "why cant this be cellulitis - in which case the pt would be started on flucloxacillin - in BNF interactions paracetamol and flucloxacillin are listed as severe interactions",
"createdAt": 1737242902,
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"comment": "The interaction listed in the BNF is high anion gap metabolic acidosis (anecdotal evidence quality), which is unlikely present as a DVT and more like DKA or aspirin OD",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 54-year-old woman attends her GP complaining of a sore leg.\n\n\n**PMH**\nHypertension, hypercholesterolaemia\n**DH**\nRamipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD, tamoxifen 20mg PO OD, paracetamol 1g PO QDS\n**Examination**\nThe right calf appears red, swollen and painful to touch. When compared to the other leg it is around 3cm bigger. Their observations are normal.\n\nQuestion: Select the most appropriate decision option based on this data.",
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173,467,528 | false | 58 | null | 6,495,239 | null | false | [] | null | 10,141 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Monitoring at such an extended interval is unsafe given the acute risk of infection associated with agranulocytosis. The priority is immediate cessation and haematology referral.",
"id": "50437",
"label": "d",
"name": "Reduce clozapine dose to 75mg PO BD and repeat bloods in one month",
"picture": null,
"votes": 72
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Increasing the dose would exacerbate the risk of agranulocytosis, as clozapine is directly linked to this haematological side effect.",
"id": "50436",
"label": "c",
"name": "Increase clozapine dose to 125mg PO BD",
"picture": null,
"votes": 6
},
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"__typename": "QuestionChoice",
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"explanation": "Continuing clozapine in the presence of agranulocytosis is contraindicated. This approach puts the patient at significant risk of sepsis or other severe complications.",
"id": "50438",
"label": "e",
"name": "Continue treatment and repeat bloods in one week",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Reducing the dose does not prevent further neutropenia or adequately address the agranulocytosis risk. This approach delays appropriate action and increases the risk of complications.",
"id": "50435",
"label": "b",
"name": "Reduce clozapine dose to 75mg PO BD and repeat bloods in one week",
"picture": null,
"votes": 847
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clozapine is associated with a risk of agranulocytosis, a severe reduction in neutrophils. This patient has neutropenia (neutrophils <1.5x10⁹/L) and agranulocytosis (neutrophils <0.5x10⁹/L), making the continuation of clozapine unsafe. Immediate discontinuation is necessary to prevent life-threatening infections and further haematological decline.",
"id": "50434",
"label": "a",
"name": "Stop clozapine immediately",
"picture": null,
"votes": 3598
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where can you find this in the BNF?",
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"comment": "im wondering the same thing",
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"comment": "control f \"agranulocytosis\" in the clozapine monograph. under cautions",
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"question": "Case Presentation: A 31-year-old female attends psychiatric outpatients for a review of her bloods.\n\n\n\n\n **PMH**\nSchizophrenia\n **DH**\nClozapine 100mg PO BD\n **Investigations**\n\n\n\n||||\n|--------------|:-------:|---------------|\n|White Cell Count|1.6x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|234x10<sup>9</sup>/L|150 - 400|\n|Neutrophils|0.6x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|1.2x10<sup>9</sup>/L|1.5 - 4.0|\n|Monocytes|0.5x10<sup>9</sup>/L|0.2 - 1.0|\n|Eosinophils|0.2x10<sup>9</sup>/L|0 - 0.4|\n|Basophils|0.08x10<sup>9</sup>/L|0 - 0.1|\n|Sodium|136 mmol/L|135 - 145|\n|Potassium|4.1 mmol/L|3.5 - 5.3|\n|Urea|3.3 mmol/L|2.5 - 7.8|\n|Creatinine|61 µmol/L|60 - 120|\n\n\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
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173,467,529 | false | 59 | null | 6,495,239 | null | false | [] | null | 10,142 | {
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"__typename": "QuestionChoice",
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"explanation": "The first step of asthma management is a SABA (salbutamol) and an inhaled corticosteroid, rather than a preventer inhaler alone.",
"id": "50440",
"label": "b",
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"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "This is a combination inhaler which is first line management in patients >12 years old, and may be considered as part of a MART regimen if this patient's symptoms remain uncontrolled.",
"id": "50443",
"label": "e",
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"explanation": "This would be inappropriate as he is not suffering an acute exacerbation and should be managed with inhaled corticosteroids.",
"id": "50442",
"label": "d",
"name": "Prescribe oral prednisolone",
"picture": null,
"votes": 20
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the first step in management of asthma in children over 5 years of age. Salbutamol monotherapy is no longer recommended. Indications for escalating treatment if symptoms remain uncontrolled include: using an inhaled short-acting beta2 agonist three times a week or more, having symptoms of asthma three times a week or more, or waking at night due to asthma symptoms at least once a week.",
"id": "50439",
"label": "a",
"name": "Prescribe salbutamol and a regular low dose inhaled corticosteroid ",
"picture": null,
"votes": 4045
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "are the new MART guidelines only for over 12yos?",
"createdAt": 1737649213,
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"comment": "arghhhh what is going on ",
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"comment": "Was surprised I chose a \"1%\" answer. \nIt seems as if the boy has not yet been prescribed an inhaler, as he is using his brothers. So of course prescribe salbutamol, however not sure why we giving ICS already.\nBNFc states- \"A paediatric low-dose of ICS should be started as maintenance therapy in children who present with any one of the following features: using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.\"\nNone of these features were apparent in this tiny stem, so didn't think he needs it?\nIf evident in the BNF, could someone show it here?",
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"question": "Case Presentation: A 9-year-old boy attends an asthma clinic with his mother following a new diagnosis. She explains that he is still feeling short of breath despite using his brother's blue inhaler. \n\n\n**PMH**\nAsthma\n\n**DH**\nNone\n\nQuestion: Select the most appropriate decision option based on this data",
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173,467,530 | false | 60 | null | 6,495,239 | null | false | [] | null | 10,143 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50448",
"label": "e",
"name": "Increase this patients levothyroxine to 125 micrograms PO OD",
"picture": null,
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},
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"__typename": "QuestionChoice",
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"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50445",
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"id": "50444",
"label": "a",
"name": "Make no changes to her medication",
"picture": null,
"votes": 1451
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50446",
"label": "c",
"name": "Decrease this patients levothyroxine to 50 micrograms PO OD",
"picture": null,
"votes": 2153
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50447",
"label": "d",
"name": "Decrease this patients levothyroxine to 25 micrograms PO OD",
"picture": null,
"votes": 75
}
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"__typename": "QuestionComment",
"comment": "Should you not continue levothyroxine replacement until TSH also normalises? or does this take a longer period of time?",
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"comment": "Could someone explain how we deduce that the patient isnt taking her levothyroxine? ",
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"comment": "It's that her T3 and T4 are normal with a raised TSH. TSH should also be within normal range if she were taking her levothyroxine as instructed",
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"comment": "There's a section on subclinical hypothyroidism if you type in the hypothyroidism treatment summary -> management of primary hypothyroidism",
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"comment": "I do think it should specify if you are to do the stat dose or continuing 2ndary prevention ",
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"explanation": "# Summary\r\n\r\nAcute coronary syndrome (ACS) refers to a set of symptoms and signs that occur due to reduced blood flow to the heart at rest. It encompasses 3 distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). In the case of infarction, this is a medical emergency requiring urgent treatment. ACS is most commonly caused by the rupture of atherosclerotic plaques in coronary arteries leading to further narrowing, and potentially complete occlusion, of these critical blood vessels. Diagnosis involves clinical evaluation, ECGs, and troponin levels. Treatment strategies differ for STEMI and NSTEMI/unstable angina but include oxygen therapy if hypoxic, antiplatelet medication, glyceryl trinitrates, morphine, and percutaneous coronary intervention (PCI). Post-MI management includes aspirin, dual antiplatelet therapy, beta-blockers, ACE inhibitors, high-dose statins, and cardiac rehabilitation. There are many complications to be aware of post-ACS and these include arrhythmias, heart failure, and cardiac tamponade, and others.\r\n\r\n# Definition \r\n\r\nAcute coronary syndrome is a set of symptoms and signs that occur due to decreased blood flow to the heart at rest. It broadly refers to three distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). \r\n\r\n# Epidemiology \r\n\r\nIn the UK, there are over 80,000 hospital admissions due to ACS every year. Coronary artery disease remains the largest cause of death in the UK. \r\n\r\n# Pathophysiology\r\n\r\nCoronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. In stable angina, when the demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. Conversely, in ACS, the symptoms occur at rest. This is because there is sudden plaque rupture and clot formation in the narrowed coronary arteries. If there is partial occlusion of the coronary artery this leads to ischaemia and chest pain at rest (unstable angina). If the coronary artery becomes more occluded or fully occluded this leads to significant hypoperfusion of the myocardium and ultimately leads to infarction (death) of the myocardial tissue (NSTEMI or STEMI). \r\n\r\n# Risk Factors\r\n\r\nCoronary artery disease and the development of plaques can be attributed to non-modifiable and modifiable risk factors. Modifiable risk factors must be addressed in the management of IHD. \r\n\r\n* Non-modifiable:\r\n * Age\r\n * Male sex\r\n * Family history\r\n * Ethnicity (particularly South Asians)\r\n* Modifiable:\r\n * Smoking\r\n * Hypertension\r\n * Hyperlipidaemia\r\n * Hypercholesterolaemia\r\n * Obesity\r\n * Diabetes\r\n * Stress\r\n * High fat diets\r\n * Physical inactivity\r\n\r\n# Classification \r\n\r\nAcute coronary syndrome can be split up into three distinct diagnoses: \r\n\r\n1. **Unstable angina**: caused by partial occlusion of a coronary artery. Troponin negative chest pain with normal/abnormal ECG signs. \r\n2. **Non-ST Elevation Myocardial Infarction**: caused by severe but incomplete occlusion of a coronary artery. Troponin positive chest pain without ST elevation. \r\n3. **ST-Elevation Myocardial Infarction**: caused by complete occlusion of a coronary artery. Troponin positive chest pain with ST elevation on ECG. \r\n\r\n*Myocardial Ischaemia vs. Myocardial Infarction and the Release of Troponin*\r\n\r\nIt is important at this stage to distinguish between angina (stable angina is on exertion and unstable angina is at rest) and myocardial infarction. Angina refers to myocardial ischaemia that causes chest pain but does not lead to the death of myocardial tissue and does not lead to a troponin rise. In myocardial infarction, the hypoperfusion of the myocardium is so profound that it leads to the death of myocardial tissue. It is when there is myocardial tissue death that troponin is released into the bloodstream and a troponin rise is found on blood tests.\r\n\r\n*Type 2 Myocardial Infarction* \r\n\r\nIt is also important to mention that some patient may have myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm). These are usually termed type 2 myocardial infarctions and may not require the conventional treatment outlined below. \r\n\r\n# Symptoms and Signs\r\n\r\n* Chest pain - the classical presentation can be considered in terms of the SOCRATES mnemonic:\r\n * Site - Central/left sided\r\n * Onset - Sudden\r\n * Character - Crushing ('like someone is sitting on your chest')\r\n * Radiation - Left arm, neck and jaw\r\n * Associated symptoms - Nausea, sweating, clamminess, shortness of breath, sometimes vomiting or syncope\r\n * Timing - Constant\r\n * Exacerbating/relieving factors - Worsened by exercise/exertion and may be improved by GTN\r\n * Severity - Often extremely severe\r\n* Atypical presentations may include:\r\n * Epigastric pain\r\n * No pain (more common in elderly and **patients with diabetes**):\r\n * Acute breathlessness\r\n * Palpitations\r\n * Acute confusion\r\n * Diabetic hyperglycaemic crises\r\n * Syncope\r\n\r\n# Differential Diagnoses\r\n\r\nIt is important to remember that there are non-MI causes of chest pain and these should be considered when making a diagnosis:\r\n\r\n* Cardiac\r\n * Myocarditis\r\n * Pericarditis\r\n * Cardiomyopathy\r\n * Valvular disease\r\n * Cardiac trauma\r\n* Pulmonary\r\n * PE\r\n * Pneumonia\r\n * Pneumothorax\r\n* Vascular\r\n * Aortic dissection\r\n* GI\r\n * Oesophageal spasm\r\n * Oesophagitis\r\n * Peptic ulcer\r\n * Pancreatitis\r\n * Cholecystitis\r\n* MSK\r\n * Rib fracture\r\n * Costochondritis\r\n * Muscle injury\r\n * Herpes zoster\r\n\r\n# Diagnosis of ACS \r\n\r\nDiagnosis depends on a combination of clinical, ECG and biochemical findings which helps distinguish between the various types of ACS.\r\n\r\n* Unstable angina - cardiac chest pain at rest + abnormal/normal ECG + **normal troponin**.\r\n* NSTEMI - cardiac chest pain at rest + abnormal/normal ECG (but not ST-elevation) + **raised troponin**\r\n* STEMI - cardiac chest pain at rest + **persistent ST-elevation/new LBBB** (note that there is no need for a troponin in this case).\r\n\r\n## Diagnosis of STEMI\r\n\r\n* ST segment elevation **>2mm** in adjacent chest leads\r\n* ST segment elevation **>1mm** in adjacent limb leads\r\n* New left bundle branch block (LBBB) with chest pain or suspicion of MI\r\n\r\n## Diagnosis of NSTEMI\r\n\r\nDiagnosis of NSTEMI requires two of the following:\r\n\r\n* Cardiac chest pain\r\n* Newly abnormal ECG which does not demonstrate ST-elevation e.g. ST depression, T wave inversion or non-specific changes. \r\n* Raised troponin (with no other reasonable explanation)\r\n\r\n# Investigations\r\n\r\n## Bedside \r\n\r\n* ECG \r\n\t* Looking for ST-elevation, LBBB or other ST abnormalities\r\n\t* This is the most important investigation and should not be delayed for other investigations (e.g. bloods) because this will define immediate management.\r\n\t* If an ECG shows STEMI then troponin is essentially irrelevant and the patient requires immediate treatment.\r\n\r\n## Bloods \r\n\r\n* Troponin: performed **at least 3 hours** after pain starts. It will also need to be repeated (usually 6 hours after the first level) in order to demonstrate a dynamic troponin rise. \r\n* Renal function: good renal function is required for coronary angiogram +/- PCI due to the use of contrast. \r\n* HbA1c and lipid profile: looking for modifiable risk factors for coronary artery disease. \r\n* FBC and CRP - rule out infectious causes of chest pain\r\n* D-dimer - may be used in _appropriate_ patients to rule out PE. *Be very careful about who you do a D-dimer on!*\r\n\r\n## Imaging \r\n\r\n* CXR: should be completed in all those presenting with a chest symptoms. It will help to rule out other causes of chest pain (e.g. pneumothorax) and look for complications of a large MI (e.g. pulmonary oedema in acute heart failure). \r\n\r\n# ECG Interpretation - Cardiac Territories and Affected Vessels\r\n\r\nThe importance of a 12-lead ECG is that it allows one to view electrical activity of the heart from different \"views\". In MI (particularly STEMI) this allows you to understand which territory (and therefore which vessel) is being affected.\r\n\r\n| Location of ST elevation | Area of myocardium | Coronary artery |\r\n| -------------------------- | ------------------ | -------------------- |\r\n| II, III, aVF | Inferior | RCA |\r\n| V1-2 | Septal | Proximal LAD |\r\n| V3-4 | Anterior | LAD |\r\n| V5-6 | Apex | Distal LAD/ LCx/ RCA |\r\n| I, aVL | Lateral | Lcx |\r\n| V7-V9 (ST depression V1-3) | Posterolateral | RCA/ LCx |\r\n\r\n\r\nRCA: right coronary artery, LAD: left anterior descending, LCx: Left circumflex\r\n\r\n[lightgallery]\r\n\r\n[lightgallery2]\r\n\r\n[lightgallery3]\r\n\r\n[lightgallery4]\r\n\r\n\r\nNSTEMIs may also show T wave abnormalities (such as ST depression and T wave inversions) in vascular territories as above. However, changes can also often not include all the specific leads of that territory in an NSTEMI.\r\n\r\n# Troponin Interpretation\r\n\r\nTroponin is a myocardial protein that is released into the bloodstream when cardiac myocytes are damaged. Serum levels typically rise **3 hours** after myocardial infarction begins.\r\n\r\nDifferent hospitals have differing guidelines (and assays) for interpretations of results. In general there are three groups of troponin levels:\r\n\r\n* Low - definitely no myocardial cell death. The patient is not having an MI although they may be experiencing unstable angina.\r\n* Mildly raised - This is an equivocal result and may be due to other non-MI related factors (see below). These patients usually need a <u>6-12 hour repeat test</u>.\r\n * If repeat troponin is raised on the repeat they are having an MI.\r\n * If repeat troponin is stable or falling then they are unlikely to be having an MI.\r\n* Definitely raised with sequential dynamic troponin rises - MI confirmed (be aware of the possibility of a Type 2 MI)\r\n\r\n## Non-ACS causes of a raised troponin\r\n\r\nAlthough troponin is often used diagnose myocardial infarction, there are in fact many causes of a raised troponin:\r\n\r\n* Myocardial infarction\r\n* Pericarditis\r\n* Myocarditis\r\n* Arrythmias\r\n* Defibrillation\r\n* Acute heart failure\r\n* Pulmonary embolus\r\n* Type A aortic dissection\r\n* Chronic kidney disease\r\n* Prolonged strenuous exercise\r\n* Sepsis\r\n\r\nIt is therefore critical to have good clinical grounds to test a troponin in order to avoid unnecessary treatments and investigations.\r\n\r\n# Management\r\n\r\nAcute management depends on the type of acute coronary syndrome. It is broadly split into the management of STEMI and the management of NSTEMI/unstable angina. \r\n\r\n# Management of STEMI\r\n\r\n[lightgallery5]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg**\r\n - Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg)\r\n - For those going on to have PCI, NICE guidance suggests adding prasugrel (if not on anti-coagulation) or clopidogrel (if on anti-coagulation)\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Primary percutaneous coronary intervention (PPCI) for those who:\r\n - Present **within 12 hours of onset of pain** AND\r\n - Are **<2 hours** since <u>first medical contact</u>\r\n\r\nRemember that (particularly in STEMI) _time is heart_ therefore urgent treatment, escalation, and delivery of PPCI is critical to good outcomes.\r\n\r\n# Management of NSTEMI/Unstable Angina\r\n\r\n[lightgallery6]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg** and fondaparinux\r\n * Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given **prasugrel or ticagrelor** unless they have a high risk of bleeding where **PO clopidogrel 300mg** is more appropriate.\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Start antithrombin therapy such as **treatment dose low molecular weight heparin** or **fondaparinux** if they are for an immediate angiogram\r\n6. Patients with <u>high 6 month risk of mortality</u> should be offered an angiogram within 96 hours of symptom onset.\r\n\r\nNote that management of unstable angina is similar to that of NSTEMI with aspirin for all patients and fondaparinux and early angiography for those at high risk.\r\n\r\n# Post-MI management\r\n\r\n[lightgallery7]\r\n\r\n* ALL patients post-MI patients should be started on the following 5 drugs:\r\n 1. **Aspirin 75mg OM** + second anti-platelet (**clopidogrel 75mg OD** or **ticagrelor 90mg OD**)\r\n 2. **Beta blocker (normally bisoprolol)**\r\n 3. **ACE-inhibitor (normally ramipril)**\r\n 4. **High dose statin (e.g. Atorvastatin 80mg ON)**\r\n* All patients should have an **ECHO** performed to assess systolic function and any evidence of heart failure should be treated.\r\n* All patients should be referred to **cardiac rehabilitation**.\r\n* Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia. \r\n\r\n# Complications\r\n\r\n* Ventricular arrhythmia\r\n* Recurrent ischaemia/infarction/angina\r\n* Acute mitral regurgitation\r\n* Congestive heart failure\r\n* 2nd, 3rd degree heart block\r\n* Cardiogenic shock\r\n* Cardiac tamponade\r\n* Ventricular septal defects\r\n* Left ventricular thrombus/aneurysm\r\n* Left/right ventricular free wall rupture\r\n* Dressler's Syndrome\r\n* Acute pericarditis\r\n\r\n## Ventricular Arrhythmias\r\n\r\n* Ventricular arrhythmias can occur as a consequence of MI, during cardiac catheterisation, or after reperfusion.\r\n* Most post-MI ventricular arrhythmias are short lived and self-resolve.\r\n* However if sustained VT or VF occurs they should be treated as per the Advanced Life Support protocols.\r\n\r\n## Recurrent Ischaemia/Infarction/Angina\r\n\r\n* Occasionally inserted stents can thrombose requiring reintervention.\r\n* New infarcts can occur in different vascular territories - this is less likely in the age of PCI where all territory are imaged during the procedure.\r\n* Angina and chest pain can continue for some time after an MI and is more common in NSTEMI patients.\r\n\r\n## Congestive Heart Failure\r\n\r\n* Heart failure can occur as a consequence of impairment heart muscle function secondary to ischaemia.\r\n* It should be treated as any other acute heart failure.\r\n* Ventricular function may improve over months as the heart muscle recovers.\r\n\r\n## Heart Block\r\n\r\n* Various levels of heart block are common - particularly following **inferior** infarcts (because the right coronary artery supplies the SAN).\r\n* These may be treated with:\r\n * Simple observation (as many will revert back to sinus rhythm)\r\n * Transcutaneous/venous pacing (if symptomatic)\r\n * Permanent pacing (if failing to resolve)\r\n\r\n## Left Ventricular Thrombus/Aneurysm\r\n\r\n* Aneurysm can occur following an anterior MI where the myocardium can be susceptible to wall stress leading to an aneurysm.\r\n* It may be silent, cause arrhythmias or embolic events.\r\n* It is definitely diagnosed on ECHO but ECG may show persisting ST elevation.\r\n* Thrombus can form either within an above described aneurysm or around hypokinetic regions of the myocardium.\r\n* Thrombi can embolise causing complications such as stroke, acute limb ischaemia and mesenteric ischaemia.\r\n\r\n## Left/Right Ventricular Free Wall Rupture\r\n\r\n* Necrosis of the free walls of either ventricle can lead to rupture allowing blood into the pericardial space.\r\n* This leads to a rapid tamponade and normally leads to cardiac arrest/death within seconds.\r\n* Treatment includes pericardiocentesis and surgery but prognosis is extremely poor.\r\n\r\n## Acute Mitral Regurgitation\r\n\r\n* This can occur because of papillary muscle rupture and carries a poor prognosis. Occurs commonly due to infero-osterior MI. \r\n* This presents with:\r\n * Pansystolic murmur heard best at the apex\r\n * Severe and sudden heart failure\r\n* It is diagnosed on echocardiogram and may require surgical correction.\r\n\r\n## Ventricular Septal Defect\r\n\r\n* Interventricular septal rupture is a short-term complications of myocardial infarction.\r\n* Rupture caused by an anterior infarct is generally apical and simple.\r\n* Rupture caused by an inferior infarct is generally basal and more complex.\r\n* Without reperfusion, septal rupture typically occurs within the first week after the infarction.\r\n* Features of septal rupture include:\r\n * Shortness of breath\r\n * Chest pain\r\n * Heart failure\r\n * Hypotension\r\n * Harsh, loud pan-systolic murmur along the left sternal border.\r\n * Palpable parasternal thrill.\r\n* Diagnosis is with echocardiogram.\r\n* Patients are managed with emergency cardiac surgery.\r\n\r\n## Dressler's syndrome\r\n\r\n* Dressler's syndrome or post-infarction pericarditis typically presents with persistent fever and pleuritic chest pain **2-3 weeks** or up to a few months after an MI.\r\n* Note that patients can get pericarditis immediately following MI which is NOT considered Dressler's syndrome.\r\n* Symptoms usually resolve after several days.\r\n* Occasionally it can also present with features of pericardial effusion and has become relatively uncommon since the introduction of PCI.\r\n* Management: **high dose aspirin**\r\n\r\n# Prognosis \r\n\r\nDue to the development of PPCI and post-MI care (cardiac rehabilitation) the mortality rates following myocardial infarction continue to decline. Those patients who go on to develop heart failure after myocardial infarction have a significantly worse prognosis than those who do not. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines for Unstable Angina and NSTEMI](https://www.nice.org.uk/guidance/cg94)\r\n\n[NICE Guidelines for STEMI](https://www.nice.org.uk/guidance/cg167)\r\n\r\n# References\r\n\r\n[Patient UK Information on Acute Coronary Syndrome](<https://patient.info/doctor/acute-coronary-syndrome-pro>)",
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"question": "Case Presentation: A 58-year-old gentleman is brought to the Emergency Department with sudden-onset 1-hour history of chest pain radiating to his left shoulder, accompanied by shortness of breath, nausea and diaphoresis.\n\n\n\n\n## PH\n\n\nHyperlipidaemia, Type 2 Diabetes Mellitus\n\n\n## DH\n\n\nAtorvastatin 40mg PO ON, Metformin 1g PO BD (reports allergy to aspirin)\n\n\n## On examination\n\n\nAppears distressed, very sweaty. Seated up in bed. Percussion resonant throughout. HS I + II + 0, chest clear. Calves soft and non-tender. No cyanosis.\n\n\nTemperature 36.6°C, HR 98, RR 28, BP 140/88, O2 98% RA, GCS 15, Weight 89kg\n\n\n## Investigations\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|144 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|223x10<sup>9</sup>/L|150 - 400|\n|Sodium|137 mmol/L|135 - 145|\n|Potassium|4.6 mmol/L|3.5 - 5.3|\n|Chloride|100 mmol/L|95 - 106|\n|Urea|8.1 mmol/L|2.5 - 7.8|\n|Creatinine|97 µmol/L|60 - 120|\n|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|\n|Troponin T|30 ng/L|<14|\n|Non-fasting Glucose|12 mmol/L|< 6.1|\n\nCXR: normal\n\n\nECG: ST-elevation in leads II, III and aVL with reciprocal changes\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate to reduce the chance of recurrent atherothrombotic events.",
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"comment": "why not GTN to treat \"episodes of pain\"",
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"comment": "He’s already on it ",
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"comment": "Can anyone tell if I wouldn't score anything for this question if my medication choice was \"verapamil hydrochloride 40 mg tablets\" ?",
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"comment": "in the PSA you'll probably get 4/5 marks for that because it is technically correct, but you're giving two tablets instead of one, so it's less ideal than giving 80mg tablets",
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"explanation": "# Summary\r\n\r\nStable angina, characterised by chest pain triggered by myocardial ischemia, is most commonly caused by coronary artery disease. Typical anginal chest pain is described as an exertional chest discomfort that may radiate to the jaw/neck/arm and that is alleviated by rest (<5 minutes) or with GTN spray. Diagnosis involves investigations such as ECG, blood tests, and CT coronary angiogram. Management includes conservative measures to optimise cardiovascular risk factors, medical treatment with anti-anginal medications, and revascularisation options like coronary artery bypass graft or percutaneous coronary intervention in cases not controlled by medical therapy.\r\n\r\n# Definition \r\n\r\nTypical anginal chest pain is defined by the following 3 features:\r\n\r\n1. Constriction/heavy discomfort to chest that may radiate to the jaw/neck/arm.\r\n2. Brought on by exertion.\r\n3. Alleviated by rest (<5 minutes) or GTN spray. \r\n\r\n3/3 features = typical angina pain \r\n\r\n2/3 features = atypical angina pain\r\n\r\n0-1/3 features = non-anginal pain \r\n\r\n# Epidemiology \r\n\r\nA 2020 Health Survey for England estimated prevalence in all UK adults as 3%, increasing to a prevalence of 10–12% in women aged 65–84 years and 12–14% in similarly aged men. \r\n\r\n# Pathophysiology\r\n\r\nStable angina occurs as a result of a mismatch of myocardial oxygen supply and demand. Most commonly, stable angina is due to coronary artery disease. Coronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. When demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. \r\n\r\nOther rarer causes of stable angina include anaemia, aortic stenosis, or hypertrophic cardiomyopathy.\r\n \r\n# Classification \r\n \r\nStable angina pain can be considered by its limitations on day-to-day activity:\r\n\r\n* Class I: no angina with normal physical activity. Strenuous activity may cause symptoms. \r\n* Class II: angina pain causes slight limitation on normal physical activity. \r\n* Class III: angina causes marked limitation on normal physical activity. \r\n* Class IV: angina occurs with any physical activity and may occur at rest (see unstable angina). \r\n\r\n# Symptoms and Signs\r\n\r\n* Central, constricting chest pain that radiates to neck/jaw/arm. \r\n* Exertional chest pain that is relieved on rest/GTN. \r\n* Associated symptoms: nausea, vomiting, clamminess or sweating. \r\n\r\nStable angina may have no clinical signs on examination at rest.\r\n\r\n# Differential Diagnoses \r\n\r\n* **Acute Coronary Syndrome (ACS)** \r\n\t* **Similarities**: cardiac-sounding chest pain as a presenting complaint for both. Similar patient profile with significant risk factors for coronary artery disease. \r\n\t* **Differences**: stable angina only occurs on exertion and is alleviated by rest. ACS chest pain occurs at rest. \r\n\r\n* **Gastro-oesophageal reflux disease (GORD)** \r\n\t* **Similarities**: both may present with central chest discomfort/pain. \r\n\t* **Differences**: discomfort in stable angina commonly described as a squeezing or pressure-like pain brought on by exertion. GORD-related chest discomfort often described as a burning sensation that is triggered by certain foods, alcohol, or lying down. \r\n\r\n* **Costochondritis** \r\n\t* **Similarities**: both present with chest pain. \r\n\t* **Differences**: costochondritis refers to inflammation of the cartilage connecting ribs to the sternum. The pain is described as sharp and can be reproduced by pressing on the chest wall. \r\n\r\n* **Pleuritic Chest Pain e.g. Pulmonary Embolism, Pneumonia** \r\n\t* **Similarities**: both present with chest pain or discomfort. \r\n\t* **Differences**: pleuritic chest pain is often described as sharp and worse on inspiration. Pleuritic chest pain will also be accompanied by clinical features relating to the underlying cause e.g. productive cough, fevers, risk factors for VTE, or a hot swollen calf. \r\n\r\nOther differential diagnoses include anxiety, aortic dissection (radiates to the back), and other causes of musculoskeletal chest pain. \r\n\r\n# Investigations\r\n\r\nOnce atypical/typical anginal pain is suspected: \r\n\r\n**Routine investigations in primary care**: \r\n\r\n* ECG - to assess for ischaemic changes or previous MI. \r\n* Bloods - FBC and TFTs (to exclude anaemia and hyperthyroidism respectively which can exacerbate angina symptoms).\r\n* Consider cardivascular risk factors: hypertension, hypercholesterolaemia, diabetes mellitus, smoking. \r\n\r\n**1st line investigations**\r\n\r\n* CT coronary angiogram (CT CA)- indicated if typical/atypical angina pain or if ECG shows ischaemic changes in chest pain with <2 angina features.\r\n\r\n**2nd line investigations** \r\n\r\nIf CTCA is inconclusive the patient may undergo functional imaging: \r\n\r\n* Stress echocardiogram \r\n* Myocardial perfusion SPECT \r\n* Cardiac MRI\r\n\r\n**3rd line investigations**\r\n\r\nInvasive coronary angiography can be performed if there are inconclusive results from non-invasive testing.\r\n\r\n# Management\r\n\r\n## Conservative management\r\n\r\nConservative management involves the optimisation of cardiovascular risk factors to reduce the atherosclerotic process. \r\n\r\n* Smoking cessation\r\n* Glycaemic control\r\n* Hypertension\r\n* Hyperlipidaemia\r\n* Weight loss\r\n* Alcohol intake \r\n\r\n## Medical management \r\n\r\n* Secondary prevention: aspirin 75mg OD and statin 80mg ON. \r\n* GTN spray for symptom relief: inform patient of side-effects (headache, flushing, dizziness) and to repeat dose if pain not stopped after 5 minutes. \r\n\r\n*Emergency help should be sought if pain not subsided after 2 doses of GTN as this may indicate acute coronary syndrome.* \r\n\r\n**Anti-anginal medications**\r\n\r\n**1st line** = beta-blocker (bisoprolol) OR calcium channel blocker (verapamil or diltiazem). *Do not combine due to risk of heart block*. \n\nIf taking a beta-blocker and symptoms are uncontrolled, switch to, or add, a long-acting dihydropyridine calcium-channel blocker (CCB), such as amlodipine, modified-release nifedipine. If taking a non-dyhydropyridine calcium channel blocker already, switch to a beta blocker.\r\n\r\nIf neither can be tolerated, consider a long-acting nitrate (ISMN), ivabradine, nicorandil or ranolazine. \r\n\r\n**2nd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker (amlodipine or nifedipine)\r\n\r\n**3rd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker AND long-acting nitrate.\r\n\r\nA 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. At this stage, revascularisation with PCI or CABG must be considered. \r\n\r\n## Revascularisation\r\n\r\nRevascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with: \r\n\r\n* Symptoms which are not controlled by optimal medical management.\r\n* Complex 3 vessel disease and/or significant left main stem on CTCA. \r\n\r\n# NICE Guidelines\n\r\n[NICE Guidance on Cardiac-Sounding Chest Pain](<https://www.nice.org.uk/guidance/cg95/chapter/Recommendations>) \r\n\n[NICE Guidance on Stable Angina](<https://www.nice.org.uk/guidance/cg126/chapter/Guidance>) \r\n\r\n# References\r\n\r\n[Patient UK Information on Stable Angina](<https://patient.info/doctor/stable-angina-2>) ",
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"question": "Case Presentation: A 62-year-old gentleman has been admitted to the ward after being seen in the Emergency Department for episodes of chest pain on exertion which resolve when at rest.\n\n\n## PH\n\nHypertension, Type 2 Diabetes Mellitus, Asthma\n\n## DH\n\nRamipril 5mg PO OD, Metformin 500mg BD PO, Salbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD. He was prescribed Glyceryl Trinitrate 400micrograms/dose aerosol sublingual spray, 1 spray PRN in the Emergency Department (Allergy to Clarithromycin)\n\n## On examination\n\nAppears well, oriented to time and place. HS I + II + 0, chest clear.\n\nTemperature 36.2°C, HR 76, RR 14, BP 135/88, O<sub>2</sub> 99% RA, GCS 15, Weight 89kg\n\n## Investigations\n\nCXR: Normal, no cardiomegaly\n\nECG: Normal sinus rhythm, no Q-waves or inverted T-waves\n\n# Prescribing Request\n\nWrite a prescription for one additional drug that is most appropriate for treating his episodes of chest pain.",
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"comment": "Given the patient has difficulty sleeping, wouldn't you consider Mirtazapine as a first line choice?",
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"comment": "Sertraline is the safest because of the history of post-MI (has the most evidence base) for this past medical history. ",
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"comment": "This man has had a recent MI and Sertraline is known to prolong QTc. Given no ECG information has been given, wouldn't the safest drug be Fluoxetine (which does not prolong QTc)?",
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"comment": "why is citalopram not right? Its also an SSRI so i dont get why its wrong\n",
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"explanation": "# Summary\n\nDepression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.\n\n# Definition\n\nDepression is a mental health disorder characterised by:\n\n- **ICD-11 Criteria:**\n - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.\n\n- **DSM-V Criteria:**\n - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.\n - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. \n\nThis consists of the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure\n\n**Severity:**\n\n- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.\n- Moderate: Symptoms or functional impairment between \"mild\" and \"severe.\"\n- Severe: The number of symptoms, intensity, and impairment are all greatly increased.\n\n\n# Epidemiology\n\nDepression is a highly prevalent mental health disorder. 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Significant **weight change** (5%) or change in appetite.\n4. **Sleep alterations:** Insomnia or hypersomnia.\n5. **Activity changes:** Psychomotor agitation or retardation.\n6. **Fatigue** or loss of energy.\n7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.\n8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.\n9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.\n\n### Additional Features (Severe Depression)\n- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.\n- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).\n\n# Differential Diagnosis\n\nThe main differentials and their key signs and symptoms include:\n\n- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.\n- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.\n- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.\n- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.\n- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.\n\n\nVarious organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:\n\n- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.\n- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).\n- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).\n- Chronic conditions such as diabetes and obstructive sleep apnea.\n- Long-standing infections, such as mononucleosis.\n- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.\n\n\n# Investigations\n\n- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).\n- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).\n- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).\n\n# Management\n\nDepression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.\n\r\n**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**\n\n- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). \r\n- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) \r\n- 3rd line = Consider antidepressants \r\n\r\n**Mild depression unresponsive to treatment and moderate-to-severe depression:**\n\n- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)\r\n- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts \r\n\r\n**Severe depression and poor oral intake/psychosis/stupor:**\n\n- 1st line = ECT \n- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.\r\n\n**Recurrent depression:** \n\n- Treated with antidepressant + lithium \r\n\n\nMedical management of depression - additional notes:\n\n- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.\n- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.\n- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)",
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"explanation": "# Drug choice feedback\n\nThis gentleman is suffering from moderate to severe major depressive disorder. Apart from recommending cognitive behavioural therapy, the first line pharmacological therapy is a selective serotonin reuptake inhibitor (SSRI). Given his recent myocardial infarct, sertraline is the optimal choice in light of its safety being studied in this group of patients and a lower propensity of interactions with other medications. All other SSRIs should be considered only if the patient is intolerant to sertraline or no significant clinical effect is seen.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe initial dose is 50mg orally once-daily. This needs to be reviewed regularly.",
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"question": "Case Presentation: A 52-year-old gentleman sees his GP for low mood and energy with anhedonia. He has trouble sleeping and has low self-confidence. He does not report major problems with eating nor any suicidal thoughts.\n\n\n## PH\n\nHyperlipidaemia, Type 2 Diabetes Mellitus, Myocardial Infarct (3 months ago)\n\n## DH\n\nAtorvastatin 80mg PO OD, Enalapril maleate 10mg PO OD, Bisoprolol 2.5mg PO OD, Metformin 1g PO BD (NKDA)\n\n## On examination\n\nAppears low in mood, speech volume reduced. Slow spontaneous movement and reactivity noted.\n\nTemperature 36.2°C, HR 76, RR 14, BP 135/88, O<sub>2</sub> 99% RA, GCS 15, Weight 89kg\n\n## Investigations\n\nECG: Normal sinus rhythm\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating his condition.",
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"explanation": "# Summary\n\n\nChronic hypertension and gestational hypertension are common conditions that may affect pregnant women. They are defined by consistently high blood pressure readings over a certain threshold. Typical signs and symptoms include elevated blood pressure readings, with gestational hypertension specifically presenting after 20 weeks of gestation with no proteinuria. Differential diagnosis may include preeclampsia and chronic kidney disease. Investigations primarily focus on blood pressure monitoring and urinalysis. Management strategies include the use of safe anti-hypertensive medications, such as labetalol, methyldopa, and nifedipine, and regular monitoring.\n\n\n# Definition\n\n\nChronic hypertension refers to high blood pressure that predates pregnancy or is diagnosed before 20 weeks of gestation. Gestational hypertension, on the other hand, is the onset of high blood pressure after 20 weeks gestation without the presence of proteinuria.\n\n\n# Epidemiology\n\n\nBoth chronic and gestational hypertension are common conditions amongst pregnant women. It is crucial to manage these conditions effectively to prevent complications such as preeclampsia and low birth weight.\n\n\n# Aetiology\n\n\nThe causes of chronic and gestational hypertension are multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.\n\n\n# Signs and Symptoms\n\n\nThey are primarily asymptomatic but are detected through elevated blood pressure readings. Gestational hypertension specifically presents after 20 weeks of gestation with no proteinuria.\n\n\n# Differential Diagnosis\n\n\n- Preeclampsia: Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation.\n- Chronic Kidney Disease: Typically presents with proteinuria, haematuria, and a rise in serum creatinine.\n\n# Investigations\n\nInvestigations primarily focus on blood pressure monitoring and urinalysis. Regular monitoring and testing are recommended to track the course of the condition and evaluate the effectiveness of treatments.\n\n# Management\n\nManagement strategies for chronic and gestational hypertension in pregnancy include:\n\n- Discontinuation of some anti-hypertensive medications (particularly ACE inhibitors or ARBs) and switching to pregnancy-safe alternatives such as labetalol.\n- Regular blood pressure monitoring.\n- For gestational hypertension above 140/90 mmHg, offer pharmacological treatment; first line management is oral labetalol.\n- If labetalol is not tolerated, alternatives include methyldopa and nifedipine.\n- Regular urinalysis is recommended for all women.\n\n# NICE Guidelines\n\n[NICE - Hypertension in\npregnancy: diagnosis and\nmanagement](https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365)\n\n",
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"question": "Case Presentation: A 62-year-old white gentleman returns to his GP to receive the results of his ambulatory blood pressure monitoring. It is determined to be 158/97mmHg. His estimated 10-year risk of cardiovascular disease is 7%.\n\n\n\n\n## PH\n\n\nAllergic rhinitis, Migraine\n\n\n## DH\n\n\nFexofenadine hydrochloride 120mg PO OD PRN, Propranolol 80mg PO BD (NKDA)\n\n\n## On examination\n\n\nAlert and oriented. Neurological examination normal. Fundoscopy normal.\n\n\nTemperature 36.0°C, HR 72, RR 14, BP 161/94, O<sub>2</sub> 100% RA, GCS 15, Weight 82kg\n\n\n## Investigations\n\n\nUrine dipstick negative\n\n\nBM: 5.2 mmol/L (normal range 3.5-5.5 mmol/L)\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate for treating his condition.",
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173,467,721 | false | 5 | null | 6,495,246 | null | false | [] | null | 6,774 | {
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"comment": "Could lansoprazole be used here instead?",
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"comment": "yeah I had the same question, just cause hes allergic to one PPI does that mean hes off all of them? like is this like amoxicillin no penicillin rule?",
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"comment": "That's what I also put",
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"comment": "all H2 receptor are on hold, no?\n",
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"comment": "No, only ranitidine is discontinued due to impurities in the product. Others like famotidine are still available",
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"comment": "Why is ranitidine wrong? its in the bnf as an option ",
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"comment": "says do not prescribe lower down but just remove it from the bnf innit!",
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"comment": "go to 'clinical knowledge summaries' (one of the tabs), type dyspepsia -> functional dyspepsia -> H2 receptor antagonists",
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"explanation": "# Summary\n\nGastro-oesophageal reflux disease (GORD) is characterised by the reflux of gastric contents into the oesophagus due to a defective lower oesophageal sphincter. Key signs and symptoms include dyspepsia, sensation of acid regurgitation, and potentially more atypical symptoms such as epigastric pain and laryngitis. Alarm symptoms include weight loss and persistent vomiting. Key investigations include a trial of proton pump inhibitor therapy and oesophagogastroduodenoscopy (OGD) if certain symptoms are present. Management strategies include lifestyle interventions, proton pump inhibitor therapy, and in refractory cases, anti-reflux surgery.\n\n# Definition\n\nGastro-oesophageal reflux disease (GORD) is a clinical diagnosis based on the presence of typical symptoms (dyspepsia, \"\"heartburn\"\" or \"\"acid reflux\"\") resulting from the reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter.\n\n# Epidemiology\n\nIn the UK, about 10% of adults experience symptoms of GORD daily, with a higher prevalence observed in individuals over 50 years of age.\n\n# Aetiology\n\nGORD is caused by a defective lower oesophageal sphincter, which enables the reflux of gastric contents into the oesophagus.\n\nRisk factors contributing to the development of GORD include obesity, alcohol use, smoking, and intake of specific foods (e.g. coffee, citrus foods, spicy foods, fat).\n\n\n# Signs and symptoms\n\nTypical symptoms:\n\n- Dyspepsia (\"\"heartburn\"\")\n- Sensation of acid regurgitation \n\nAtypical symptoms:\n\n- Epigastric or chest pain\n- Nausea\n- Bloating\n- Belching\n- Globus\n- Laryngitis\n- Tooth erosion\n\nAlarm symptoms:\n\n- Weight loss\n- Anaemia\n- Dysphagia\n- Haematemesis\n- Melaena\n- Persistent vomiting\n\n# Differential Diagnosis\n\nConditions that may present similarly and should be considered in the differential diagnosis include:\n\n- Gastric ulcers: These may present with epigastric pain, nausea, vomiting, and weight loss.\n- Oesophageal cancer: This may present with dysphagia, weight loss, and potentially haematemesis.\n- Functional dyspepsia: This condition may present with similar gastrointestinal symptoms without a clear organic cause.\n- Hiatus hernia: Often coexists with GORD but can cause pain without significant reflux.\n\n\n# Investigations\n\n- Urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology **if** symptoms suggestive of H.pylori infection.\n- Oesophagogastroduodenoscopy (OGD) if alarm features or atypical, persistent or relapsing symptoms are present.\n- Oesophageal manometry\n\n**Referral criteria for urgent (within 2 weeks) OGD to investigate for oesophageal and gastric cancer:**\n\n- Aged 55 years and over with weight loss + dyspepsia/reflux\n\nReferral criteria for non-urgent OGD:\n\nAged 55 years and over plus\n\n- Treatment-resistant dyspepsia\n \nOR\n\n- Raised platelet count + dyspepsia/reflux\n- Nausea/vomiting + dyspepsia/reflux\n\n# Management\n\n- Lifestyle interventions - weight loss, dietary changes, elevation of the head of the bed at night, avoidance of late-night eating.\n- Proton pump inhibitor therapy. For patients <40 years old who present with typical symptoms and no red flags, commence treatment with a standard-dose PPI for 4 weeks in combination with lifestyle changes.\n\t- If the patient meets criteria for urgent OGD, they should only be commenced on PPI therapy after this has been done\n- Antacids for symptomatic relief.\n- Anti-reflux surgery for refractory cases.\n- Treatment for H.pylori infection if confirmed (PPI + antibiotics), with retesting using the urea breath test\n\t- It should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.\n\n# Complications\n\nPotential complications of GORD include:\n\n- Oesophageal ulcer\n- Oesophageal stricture\n- Barrett's oesophagus\n- Adenocarcinoma of the oesophagus\n\n# NICE Guidelines \n\n- [NICE: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management](https://www.nice.org.uk/guidance/cg184)\n\n# References\n\n- [BMJ Best Practice: Gastro-oesophageal reflux disease](https://bestpractice.bmj.com/topics/en-gb/82)\n- [European Association of Endoscopic Surgery: Recommendations for the management of gastroesophageal reflux disease](https://link.springer.com/article/10.1007/s00464-014-3431-z)",
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"explanation": "# Drug choice feedback\n\nThis gentleman has benign gastric ulceration. Whilst a proton-pump inhibitor is first line, his allergy is a contra-indication. Hence, H2-antagonists have to be used. The options licensed in the UK are as above. Antacids only provide short-term symptomatic relief but do not definitively treat benign gastric ulceration.\n\n# Dose/Route/Frequency/Duration feedback\n\nEach medication has its own optimal dose. All are orally taken and have varying dosing frequencies.",
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"question": "Case Presentation: A 57-year-old gentleman presents to his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.\n\n\n## PH\n\nObesity\n\n## DH\n\nNIL (Allergy to Omeprazole)\n\n## FHx\n\nNo upper gastrointestinal cancer\n\n## On examination\n\nAlert and oriented. Mild epigastric tenderness, otherwise abdomen soft and non-tender, no masses palpated.\n\nTemperature 36.8°C, HR 70, RR 13, BP 139/81, O<sub>2</sub> 98% RA, GCS 15, Weight 86kg\n\n## Investigations\n\nFBC: Hb 152, WCC 6.2, Plt 283\nUrgent OGD performed: \"Benign gastric ulceration noted, no oesophagitis, no masses seen.\"\n\nStool antigen test for _H. pylori_: negative\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating his condition.",
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173,467,722 | false | 6 | null | 6,495,246 | null | false | [] | null | 10,052 | {
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis gentleman has hypertension. This is confirmed based on the readings at the GP and the at home readings he has measured himself. As he is older than 55 years of age, the first line medication he should be prescribed is a calcium channel blocker.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe options to treat this gentleman's hypertension are as follows:\n\n- Amlodipine 5mg PO OD\n- Felodipine 5mg PO OD\n- Lacidipine 2mg PO OD\n- Lercanidipine hydrochloride 10mg PO OD\n- Nicardipine hydrochloride 20mg PO TDS",
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"__typename": "PrescribeAnswerData",
"label": "daily (OD)",
"value": 13,
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"__typename": "PrescribeAnswerData",
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"question": "Case Presentation: A 67-year-old gentleman attends his GP for a blood pressure review. He had high blood pressure at a previous review and has returned with his home blood pressure monitoring.\n\n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## Investigations\n\nBlood pressure at previous visit: 151/88 mmHg\n\nBlood pressure at today's visit: 148/90 mmHg\n\nHome blood pressure reading average: 149/89 mmHg\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his hypertension.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,467,723 | false | 7 | null | 6,495,246 | null | false | [] | null | 10,053 | {
"__typename": "QuestionPrescription",
"choices": [],
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"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "2657",
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"id": "3586",
"name": "Prescribing emergency oral contraception",
"status": null,
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"name": "Obstetrics & Gynaecology",
"typeId": 5
},
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"explanation": "## Drug choice feedback\n\nThis patient is asking for emergency contraception in the form of a pill. There are two options you can prescribe - levonorgestrel or ulipristal acetate. Levonorgestrel is only effective if the episode of unprotected sex has occurred within 72 hours of presentation whereas ulipristal is effective up to 120 hours after the episode of unprotected sex.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescriptions would provide emergency contraception for this patient:\n\n- Levonorgestrel (Levonelle) 1.5mg PO ONCE\n- Ulipristal acetate (ellaOne) 30mg PO ONCE",
"highlights": [],
"id": "10053",
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"__typename": "PrescribeAnswerData",
"label": "1.5 mg",
"value": 427,
"visible": false
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"drug": {
"__typename": "PrescribeAnswerData",
"label": "levonorgestrel 1.5 mg tablet",
"value": 2468,
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"question": "Case Presentation: A 19-year-old woman attends her GP asking for emergency contraception. She has had unprotected sex 48 hours ago. She does not want an invasive procedure or injection.\n\n\n## PH\nNil.\n\n## DH\nNil.\n\n## On examination\n\nNil.\n\n## Investigations\n\nNil.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to provide her with emergency contraception.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,467,724 | false | 8 | null | 6,495,246 | null | false | [] | null | 10,102 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "where do i find information on group b strep and the antibiotic of choice on the BNF?\n",
"createdAt": 1708363661,
"dislikes": 0,
"id": "42096",
"isLikedByMe": 0,
"likes": 8,
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"replies": [
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"__typename": "QuestionComment",
"comment": "you type 'group b streptococcal' on the bnf and it will come up as benzylpenicillin",
"createdAt": 1709829727,
"dislikes": 11,
"id": "44134",
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"displayName": "Thermoregulator Tachycardia",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "2657",
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"id": "3631",
"name": "Treating intrapartum group B streptococcus infection",
"status": null,
"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
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"explanation": "## Drug choice feedback\n\nThis patient has a group B streptococcus infection. Streptococcus agalactiae is the most common pathogen that belongs to the Group B streptococcus family. Treatment of Group B strep during labour is with IV benzylpenicillin, initially this should be a 3g IV infusion followed by 1.5g IV infusions every 4 hours until delivery.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's group B streptococcus infection:\n\n- Benzylpenicillin 3g IV once-off, and then 1.2g every 4 hours",
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"id": "10102",
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"__typename": "PrescriptionAnswer",
"dose": {
"__typename": "PrescribeAnswerData",
"label": "3 g",
"value": 383,
"visible": false
},
"drug": {
"__typename": "PrescribeAnswerData",
"label": "benzylpenicillin sodium 600 mg injection",
"value": 2067,
"visible": false
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"__typename": "PrescribeAnswerData",
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"label": "intravenous (IV)",
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"visible": false
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"__typename": "PrescriptionAnswer",
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"__typename": "PrescribeAnswerData",
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"label": "intravenous (IV)",
"value": 3,
"visible": false
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"question": "Case Presentation: A 33-year-old 37 week pregnant woman attends the maternity ward as she has gone into labour.\n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## On examination\n\nPatient comfortable at rest. No evidence of any oedema or the face or peripheral areas.\n\nSymphysial-fundal height is 37cm, the position of the foetus is a longitudinal lie with cephalic palpation.\n\nTemperature 37.3°C, HR 88, RR 16, BP 126/78, O<sub>2</sub> 98% RA, GCS 15, Weight 85kg\n\n## Investigations\n\nFBC: Hb 124, WCC 4.8, Plts 253 x 10^9\n\nCRP 2\n\nU&Es: Na 141, K 4.3, Ur 5.0, Cr 64, eGFR >90mL/min/1.73m<sup>2</sup>\n\nCa2+ (adjusted): 2.4\n\nMg2+: 0.8\n\nPhosphate: 0.82\n\nLFTs: ALP 31, ALT 23, bilirubin 12\n\nTFTs: TSH 1.3, T4 11, T3 8\n\nMSU: Streptococcus agalactiae\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to give while she is in labour.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,467,725 | false | 9 | null | 6,495,246 | null | false | [] | null | 6,776 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33766",
"label": "e",
"name": "Verapamil;120mg;oral (PO);Thrice daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33768",
"label": "g",
"name": "Allopurinol;100mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33763",
"label": "b",
"name": "Levetiracetam;750mg;oral (PO);Twice daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33767",
"label": "f",
"name": "Adalimumab;40mg;subcutaneous (SC);Two-weekly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33762",
"label": "a",
"name": "Bisoprolol fumarate;10mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33764",
"label": "c",
"name": "Ibuprofen;400mg;oral (PO);Thrice times daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33765",
"label": "d",
"name": "Sodium valproate;3.6g;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33769",
"label": "h",
"name": "Fusidic acid;250mg;oral (PO);Twice daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I don't know if I'm being an idiot but 30mg/kg is 3.6g?? eg. the dose he is on",
"createdAt": 1678452193,
"dislikes": 0,
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{
"__typename": "QuestionComment",
"comment": "the max is 2.5g tho so that's the only reason \n",
"createdAt": 1685466530,
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"displayName": "sophieaislinn",
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"__typename": "QuestionComment",
"comment": "should one of the dosing errors be levetiracetam?",
"createdAt": 1737935091,
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"id": "61640",
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"displayName": "Abscess Chronic",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2709",
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"__typename": "Topic",
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"name": "Internal Medicine",
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"explanation": "1. Beta blockers and non-dihydropyridine calcium channel blockers should not be co-prescribed as both exert a negative inotropic and chronotropic effect on the heart, causing a depression in both mechanical and electrical activity resulting in bradycardia and hypotension.\n2. Sodium valproate used for seizure management is prescribed at 20-30mg/kg daily. However, the maximum recommended dose is 2.5g daily. Hence this patient should only be prescribed 2.5g daily and not 3.6g daily. ",
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"question": "Case presentation: A 50-year-old man is admitted to the Cardiology ward following an episode of syncope. PH Angina, Seizure, AF, Ankylosing spondylitis, Gout, Cellulitis. DH. His regular medicines are listed (below). Weight 120kg.\n\n\n**On Examination**\nHR 50/min, BP 95/85mm Hg, RR 18, O2 sats 94% RA. HS I + II with no added heart sounds.\n\nQuestion 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,467,726 | false | 10 | null | 6,495,246 | null | false | [] | null | 6,777 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33772",
"label": "c",
"name": "Ibuprofen;400mg micrograms;oral (PO);PRN",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33773",
"label": "d",
"name": "Cetirizine;10mg;oral (PO);PRN",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33771",
"label": "b",
"name": "Tramadol hydrochloride;100mg;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33777",
"label": "h",
"name": "Morphine sulphate;10mg;intravenous (IV);6- hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33775",
"label": "f",
"name": "Paracetamol;1g;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33776",
"label": "g",
"name": "Ondansetron;4mg;intravenous (IV);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33774",
"label": "e",
"name": "Tamsulosin;400 micrograms;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33770",
"label": "a",
"name": "Prednisolone;10mg;oral (PO);Daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "tamsulosin also causes cosntipatin",
"createdAt": 1645437236,
"dislikes": 0,
"id": "7432",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
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{
"__typename": "QuestionComment",
"comment": "It can but it is listed as an uncommon side effect in the BNF, the other 3 answers given (tramadol, ondansetron and morphine) are the 3 most likely to cause constipation as it is listed as a common or very common side effect in the BNF for those drugs",
"createdAt": 1673599625,
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"__typename": "User",
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"displayName": "Odor Poisoning",
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"user": {
"__typename": "User",
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"displayName": "Dr Brighton",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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},
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"difficulty": 2,
"dislikes": 8,
"explanation": "1. Opioids (tramadol and morphine sulphate) act on 𝜇-opioid receptors in the myenteric plexus to slow down bowel movements, which can lead to constipation. Ondansetron commonly causes constipation by delaying the colonic transit although the exact mechanism remains unclear. Cetirizine, tamsulosin and ibuprofen rarely cause constipation.\n2. Systemic corticosteroids (prednisolone) commonly cause fluid retention via the stimulation of mineralocorticoid receptors, which lead to sodium and water retention.",
"highlights": [],
"id": "6777",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 0,
"multiAnswer": [
[
"b",
"g",
"h"
],
[
"a"
]
],
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 2,
"qaAnswer": null,
"question": "Case presentation: A 65-year-old man on the urology ward underwent a left-sided nephrectomy 2 days ago. Since the surgery, he had not been able to open his bowels. PH Benign prostatic hyperplasia, Osteoarthritis of left knee, Giant cell arteritis, mild hayfever, Back pain. DH His current regular medicines are listed (below).\n\n\n**On Examination**\nHR 84/min regular rhythm, BP 130/80 mmHg, symmetrical bipedal pitting oedema to mid calves\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his constipation (mark them with a tick in column A).\nQuestion 2: Select the ONE prescription that is most likely to be contributing to his fluid retention (mark it with a tick in column B).",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
"userPoint": null
} | MarksheetMark |
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