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"label": "d",
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"label": "f",
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"comment": "diazepam and co codamol can definitely cause confusion in an elderly patient... ",
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"comment": "this has got an error?! correct explanation but you've marked the wrong answers ",
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"comment": "BNF says dexibuprofen -> “Patients commonly present with confusion” ?!",
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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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"name": "Drugs causing confusion and bradycardia",
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"name": "Elderly Care",
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"explanation": "1. The patient has developed AKI, which can result in a reduction in the clearance of his medication and an increase in adverse effects. The mechanism for confusion caused by benzodiazepine and codeine remains unknown, although the incidence is noted to be higher in the elderly population and in patient with decreased renal function due to a reduction in the clearance of the medication. Similarly, in geriatric patients, the bioavailability of acebutolol and its metabolite increases approximately by two-fold, due to the decrease in first pass metabolism and renal function in the elderly. Retention of codeine (co-codamol), diazepam and acebutolol in this patient may contribute to the patient’s confusion\n2. Acebutolol is a cardio-selective beta-adrenergic antagonist, which acts on the beta-1 receptors in the heart causing a reduction in heart rate and contractility. Ramipril can cause arrythmia but acebutolol, specifically, causes bradycardia.",
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"question": "Case presentation: A 75-year-old man is admitted to the care of the elderly ward following a urinary tract infection. PH Hypertension, Alzheimer’s Disease, BPH, Osteoarthritis, Severe anxiety. DH. His current regular medications are listed (below).\n\n\n\n\n **On Examination**\n\nHR 50/min regular, BP 135/75mmHg. He appears confused.\n\n\n **Investigation**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Urea|8.5 mmol/L|2.5 - 7.8|\n|Creatinine|125 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his confusion (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescriptions that are most likely to be a cause of his bradycardia (mark them with a tick in column B).",
"sbaAnswer": null,
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173,467,728 | false | 12 | null | 6,495,246 | null | false | [] | null | 6,790 | {
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"answer": false,
"explanation": null,
"id": "33874",
"label": "e",
"name": "Simvastatin;40mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33877",
"label": "h",
"name": "Zopiclone;3.75mg;Oral (PO);Nightly as required",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33870",
"label": "a",
"name": "Bisoprolol fumarate;5mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"explanation": null,
"id": "33872",
"label": "c",
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"picture": null,
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"id": "33873",
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"picture": null,
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"id": "33871",
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"picture": null,
"votes": 0
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"explanation": null,
"id": "33875",
"label": "f",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
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"explanation": null,
"id": "33876",
"label": "g",
"name": "Gliclazide;40mg;Oral (PO);Daily",
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}
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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": "2723",
"name": "Dosing error & drugs causing hyperkalemia",
"status": null,
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"id": "74",
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"explanation": "1. Both enalapril and spironolactone are known to cause hyperkalaemia. Enalapril is an angiotensin-converting enzyme inhibitor (ACE-i). It contributes to hyperkalaemia by inhibiting aldosterone synthesis. Spironolactone is an aldosterone antagonist. Aldosterone mediates the reabsorption of sodium and excretion of potassium in the distal tubules and collecting ducts of nephrons.\n2. Up to 900mg of allopurinol can be prescribed in a day but must be done in divided doses. The maximum per dose is 300mg.",
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"question": "Case presentation: A 65-year old man is admitted to the geriatric ward following a fall at home. He complains of generalised muscle weakness and lethargy. \n\n\nPH: Congestive heart failure, Diabetes Mellitus , Gout, Hypercholesterolaemia, Insomnia 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\n **Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\n\n\n - ECG: Flat P wave and tall tented T wave\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|135 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|280x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|91 fL|80 - 96|\n|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|6.1 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|280 µmol/L|60 - 120|\n\n\n\nQuestion 1: Select the TWO prescriptions that are most likely to be a cause of his hyperkalaemia (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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173,467,729 | false | 13 | null | 6,495,246 | null | false | [] | null | 6,791 | {
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"answer": false,
"explanation": null,
"id": "33885",
"label": "h",
"name": "Prochlorperazine;75mg;Oral (PO);Daily",
"picture": null,
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"label": "g",
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"id": "33878",
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"id": "33879",
"label": "b",
"name": "Enalapril maleate;10mg;Oral (PO);12-hourly",
"picture": null,
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},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33883",
"label": "f",
"name": "Ibuprofen;400mg;Oral (PO);6-hourly when required",
"picture": null,
"votes": 0
},
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"explanation": null,
"id": "33880",
"label": "c",
"name": "Rivaroxaban;20mg;Oral (PO);Daily",
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"id": "33881",
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}
],
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"__typename": "QuestionComment",
"comment": "why is co-careldopa not written 25/100mg?",
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"comment": "is that not a whopping dose of digoxin??\n",
"createdAt": 1737982396,
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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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"name": "Dosing error & drugs worsening Parkinson’s",
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"explanation": "1. Both metoclopramide and prochlorperazine are dopamine D2 receptor antagonists that can precipitate and worsen parkinsonian symptoms. Hence, BNF advises that they should be used with caution in patients already diagnosed with Parkinson’s disease.\n2. The maintenance dose of digoxin for atrial fibrillation is 125–250 micrograms daily. Hence, the dose prescribed is likely to be a transcription error of the micrograms to mg.",
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"question": "Case presentation: A 75-year old man attends the Parkinson clinic with increasing frequencies of involuntary movement. PH: Parkinson’s disease, Atrial fibrillation, Congestive Heart Failure, Migraine, Schizophrenia DH: His current regular prescriptions are listed below\n\n\n**On examination**: Pill-rolling resting tremor seen on right hand, cog-wheel rigidity, bradykinesia, micrographia\n**Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\nQuestion 1: Select the TWO prescriptions that are most likely to be a cause for the worsening of his Parkinson’s signs and symptoms? (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,
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173,467,730 | false | 14 | null | 6,495,246 | null | false | [] | null | 10,060 | {
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}
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"__typename": "QuestionComment",
"comment": "dizziness is also a common side effect of alendronic acid, i would say this can increase the patient's risk of falls too..?",
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"comment": "diazepam dose not too high for an elderly lady?",
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"comment": "6g of paracetamol a day is a bit more overkill tbh",
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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": "1. Ramipril is an angiotensin-converting enzyme inhibitor (ACEi) used to treat hypertension and heart failure. Antihypertensive medications such as ACEi and diuretics (i.e Furosemide) increase the risk of postural hypotension and therefore falls. This patient has a significant postural drop in their blood pressure (>20mmHg systolic) and this may have contributed to their fall. Mirtazapine also lists postural hypotension as a common side effect. Diazepam is a benzodiazepine used to treat muscle spasms and anxiety. Diazepam has sedative effects and may impair balance, increasing the risk of falls. \n\n2. Paracetamol should be prescribed in 500mg-1g doses 4-6 times per day with a maximum daily dose of 4g. This patient has been prescribed 6g daily, exceeding the maximum dose and therefore putting this patient at risk of paracetamol toxicity.",
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"question": "Case presentation: A 93-year-old female is admitted to the elderly care ward after having a fall. **PH** Heart Failure, Hypertension, Anxiety, Depression, Osteoporosis, Back Pain **DH** Her regular medicines are listed (below). \n\n\n\n**On Examination**\n\nTemperature 37.3°C, HR 84, RR 16\n\nWeight 54kg\n\n**Investigations** Lying and Standing Blood Pressure: Lying 136/92mmHg, Standing after 2 minutes 110/84mmHg.\n\nQuestion 1: Select the FOUR prescriptions that are most likely to have increased this patient's risk of falls.\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,467,731 | false | 15 | null | 6,495,246 | null | false | [] | null | 10,063 | {
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"id": "50075",
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"comment": "Patient borderline hypokalaemic. More likely salbutamol than the rare s/e of omeprazole causing Hyponatremia",
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"comment": "Rare side effect of omeprazole and it doesn't appear in appendix 1 would this be in the exam?",
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"comment": "Did somebody else think that the frequency of salbutamol (QDS) is the dosing mistake? ",
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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": "1. This patient is hyponatraemic. The three medications she is taking that are likely contributing to her hyponatremia are her omeprazole, carbamazepine and sertraline. It is thought that PPIs cause hyponatremia due to SIADH/salt-losing nephropathy due to acute interstitial nephritis however the mechanism is not fully understood. SSRIs cause hyponatremia due to SIADH, they inhibit the reuptake of noradrenaline which in turn stimulates ADH release. Finally, carbamazepine also causes hyponatremia due to SIADH. It does this via increasing ADH secretion, increasing sensitivity of the renal tubules to ADH activity and increasing aquaporin 2 channel expression.\n2. This patient would be taking 8g of carbamazepine daily, the maximum daily dose of carbamazepine is 2g.",
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"question": "Case presentation: A 33-year-old female attends the emergency department. She is complaining of feeling nauseous and has vomited 3 times. She also has a headache.\n\n\n\n\n **PH** Depression, seizures, gastro-oesophageal reflux disease, Raynaud's syndrome, asthma, allergic rhinitis\n\n\n **DH** Her current medications are listed (below). Weight 53kg.\n\n\n **On Examination**\n\n\n * GCS 15/15\n * Neurological examination: grossly intact\n * HS 1 + 2 + 0\n * Chest clear\n * Abdomen soft and non tender\n\n\n **Investigation**\n\n\nBloods:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|128 mmol/L|135 - 145|\n|Potassium|3.9 mmol/L|3.5 - 5.3|\n|Creatinine|67 µmol/L|60 - 120|\n|eGFR|90 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nCT head - no abnormalities detected\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of her abnormal blood results (mark them with a tick in column A)\n\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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"comment": "where would you find the timeline for when you stop drugs prior surgery on the BNF?",
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"comment": "The 'surgery and long term medication' treatment summary only has the ACE-I and lithium times on there, and that's it unfortunately. The other main one to remember is COCP: stop 4 weeks before. The 'diabetes, surgery and medical illness' treatment summary also has some info about stopping certain diabetic medications prior to surgery, I hope that's useful!",
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"question": "Case presentation: A 68-year-old man is recovering following an elective coronary artery bypass graft (CABG) procedure. Post-operatively, he has acute kidney injury (see investigations below) and has not passed urine for 13-hours.\n\n\n\n\n **PH** Ischaemic heart disease, Angina, Hypercholesterolaemia, Osteoarthritis, GORD, Hypertension\n\n\n **DH** His current regular medicines are listed (below).\nAllergies - aspirin, ramipril\n\n\n **Investigations**\nCr 156 µmol/L (60-120 µmol/L), baseline 80 µmol/L\n\n\nQuestion 1: Select the ONE prescription that should be stopped one week prior to his operation (mark them with a tick in column A)\nQuestion 2: Select the TWO prescriptions that should be withheld until his renal function improves. (mark it with a tick in column B).",
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"explanation": "This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However there is nothing in the stem to suggest that this is the case",
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"comment": "Why wouldn't you rate control first? \n",
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"comment": "because her rate is normal so rhythm control needed\n",
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"comment": "Why no rhythm control first for new AF?",
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"comment": "I think its cos it doesnt say this is new AF and doesnt say how long its been going on for so assume anti-coagulation first",
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"comment": "Also the rhythm is fine at 86bpm, no need to reduce it",
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"comment": "But she is taking escitalopram which is contra-indicated with rivaroxaban as they can both cause bleeding",
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"comment": "Not an absolute CI, can just add a PPI to reduce risk of GI bleeding",
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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 53 year old woman who has recently moved to the UK from Vietnam attends an appointment for initial assessment after registering at her new GP. **PH** Takayasu arteritis, hypertension, generalised anxiety disorder. **DH** felodipine 10mg PO OD, escitalopram 15mg PO OD, ferrous fumarate 210mg PO BD, calcichew D3.\n\n\n**O/E**\n\nHR 86, RR 14, BP 134/92, Temperature 37.0°C, O2 99% RA. HS I + II + 0, lungs clear. Alert and comfortable at rest. She has an irregularly irregular pulse peripherally and centrally. This is not recorded on her most recent health documentation from her home country a year prior and she denies any troublesome symptoms.\n\n**Investigations**\n\nECG: atrial fibrillation.\n\nFBC, U&Es, LFTs and clotting studies all NAD.\n\nQuestion: Select the most appropriate management at this stage.",
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"label": "e",
"name": "Clindamycin 300mg IV",
"picture": null,
"votes": 131
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "All mothers who have swabbed positive for GBS should receive intrapartum antibiotics to reduce the risk of neonatal sepsis. Benzylpenicillin sodium is recommended first line",
"id": "34040",
"label": "a",
"name": "Benzylpenicillin sodium 3g IV",
"picture": null,
"votes": 5209
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This formulation of benzylpenicillin is used to treat syphilis rather than GBS",
"id": "34042",
"label": "c",
"name": "Benzathine benzylpenicillin 2.4m units IM",
"picture": null,
"votes": 238
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ceftriaxone has activity against GBS but has a much broader spectrum of activity than would normally be required",
"id": "34043",
"label": "d",
"name": "Ceftriaxone 2g IV",
"picture": null,
"votes": 201
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amoxicillin has activity against GBS but has a much broader spectrum of activity than would normally be required",
"id": "34041",
"label": "b",
"name": "Amoxicillin 500mg IV",
"picture": null,
"votes": 223
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where is this on the BNF?\n",
"createdAt": 1675077808,
"dislikes": 1,
"id": "17427",
"isLikedByMe": 0,
"likes": 12,
"parentId": null,
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"displayName": "Contusion Hallux",
"id": 13333
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{
"__typename": "QuestionComment",
"comment": "Type in benzylpenicillin sodium --> go to the \"Intrapartum prophylaxis against group B streptococcal infection\" section \n\n",
"createdAt": 1709642643,
"dislikes": 0,
"id": "43841",
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"likes": 3,
"parentId": null,
"questionId": 6819,
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"accessLevel": "subscriber",
"displayName": "NICU Gastro",
"id": 10518
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"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": "2618",
"pictures": [],
"typeId": 2
},
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"demo": null,
"entitlement": null,
"id": "2752",
"name": "Group B Streptococcus",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
"totalCards": null,
"typeId": null,
"userChapter": null,
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"dislikes": 0,
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"question": "Case Presentation: A 26 year old woman is admitted to the maternity ward following induction of labour 12 hours previously. She is G2P1 and has no outstanding health problems, but is known to have swabbed positive for group B streptococcus during her initial booking appointment for her current pregnancy. NKDA\n\n\n**O/E**\n\nHR 94, RR 15, BP 132/82. Cervix dilated to 4cm, foetal head engaged. Contractions 1 in 10 minutes.\n\n**Investigations**\n\nCardiotocography is reassuring.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 6002,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,735 | false | 19 | null | 6,495,246 | null | false | [] | null | 6,823 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable",
"id": "34062",
"label": "c",
"name": "Erythromycin 500mg PO BD",
"picture": null,
"votes": 527
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tetracyclines are recommended as first line oral agents to treat acne vulgaris that has not responded to topical treatments. NICE recommends combination therapy (as opposed to antibiotic monotherapy), with topical azelaic acid.",
"id": "34060",
"label": "a",
"name": "Topical azelaic acid and Doxycycline 100mg PO OD",
"picture": null,
"votes": 4956
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable",
"id": "34064",
"label": "e",
"name": "Trimethoprim 300mg PO BD",
"picture": null,
"votes": 40
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting without specialist assessment",
"id": "34063",
"label": "d",
"name": "Isotretinoin 20mg PO BD",
"picture": null,
"votes": 237
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative topical treatment for acne vulgaris which is less effective than the treatment that the patient is currently using",
"id": "34061",
"label": "b",
"name": "Azelaic acid 20% cream (Skinoren) topical BD",
"picture": null,
"votes": 489
}
],
"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": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2756",
"name": "Acne Vulgaris",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2756,
"conditions": [],
"difficulty": 3,
"dislikes": 7,
"explanation": null,
"highlights": [],
"id": "6823",
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"learningPoint": null,
"likes": 2,
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"psaSectionId": 3,
"qaAnswer": null,
"question": "Case Presentation: A 19 year old man attends a follow-up appointment at his GP. **PH** acne vulgaris. **DH** 3% benzoyl peroxide with 1% clindamycin gel (Duac). He has been using this for twelve weeks following failure to improve his condition with benzoyl peroxide gel alone.\n\n\n**O/E**\n\nHe has a uniform distribution of open and closed comedones with occasional pustules on his face and upper back. No scarring or nodularity present.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 6249,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,736 | false | 20 | null | 6,495,246 | null | false | [] | null | 6,824 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As there is evidence of nephropathy in this patient, she should be started on a renoprotective agent pending a repeat urine dip and/or confirmation of end-organ damage",
"id": "34065",
"label": "a",
"name": "Start lisinopril 2.5mg PO OD",
"picture": null,
"votes": 3578
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen",
"id": "34069",
"label": "e",
"name": "Switch her insulin regime to a biphasic preparation e.g 30% insulin lispro/70% insulin aspart (Novomix 30)",
"picture": null,
"votes": 491
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the patient’s TSH level is normal and she is not complaining of any symptoms indicative of undertreating her hypothyroidism, this is not a necessary course of action",
"id": "34066",
"label": "b",
"name": "Increase dose of levothyroxine sodium to 150 micrograms PO OD",
"picture": null,
"votes": 333
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen",
"id": "34067",
"label": "c",
"name": "Increase nightly insulin detemir to 20 units",
"picture": null,
"votes": 144
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an unlicensed treatment for vitiligo and may be prescribed off-label by experienced clinicians",
"id": "34068",
"label": "d",
"name": "Start tacrolimus 0.1% ointment topical BD",
"picture": null,
"votes": 1365
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "ACE inhibitors are nephrotoxic, why is lisinopril renoprotective?",
"createdAt": 1737150842,
"dislikes": 0,
"id": "60842",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 6824,
"replies": [
{
"__typename": "QuestionComment",
"comment": "they're nephrotoxic in an AKI but protective in CKD because they do something good to the blood flow in the glomerulus ",
"createdAt": 1737740720,
"dislikes": 0,
"id": "61452",
"isLikedByMe": 0,
"likes": 1,
"parentId": 60842,
"questionId": 6824,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Epidermis Benign",
"id": 25779
}
},
{
"__typename": "QuestionComment",
"comment": "essentially they forcibly reduce glomerular pressure. helps with hypertension or with glomerular sclerosis, but once u have AKI and u can't compensate, it means ur pressure is *too* low and u gotta stop the ACEI's to maintain a normal filtration pressure",
"createdAt": 1738153553,
"dislikes": 0,
"id": "61857",
"isLikedByMe": 0,
"likes": 0,
"parentId": 60842,
"questionId": 6824,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pseudopseudopseudopseudohypoparathyroidism",
"id": 51334
}
},
{
"__typename": "QuestionComment",
"comment": "essentially they forcibly reduce glomerular pressure. helps with hypertension or with glomerular sclerosis, but once u have AKI and u can't compensate, it means ur pressure is *too* low and u gotta stop the ACEI's to maintain a normal filtration pressure",
"createdAt": 1738153558,
"dislikes": 0,
"id": "61858",
"isLikedByMe": 0,
"likes": 0,
"parentId": 60842,
"questionId": 6824,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pseudopseudopseudopseudohypoparathyroidism",
"id": 51334
}
}
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Retake Prophylaxis ",
"id": 48391
}
},
{
"__typename": "QuestionComment",
"comment": "what are the signs of nephropathy here am I actually going insane\n",
"createdAt": 1738153825,
"dislikes": 0,
"id": "61860",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 6824,
"replies": [
{
"__typename": "QuestionComment",
"comment": "The proteinuria I think. Tricky :/",
"createdAt": 1738173989,
"dislikes": 0,
"id": "61896",
"isLikedByMe": 0,
"likes": 0,
"parentId": 61860,
"questionId": 6824,
"user": {
"__typename": "User",
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"displayName": "Cor Pulmonale",
"id": 20073
}
}
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"user": {
"__typename": "User",
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"displayName": "Miabetes Dellitus",
"id": 24282
}
}
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"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2757",
"name": "Diabetes with evidence of renal impairment",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
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"userChapter": null,
"userNote": null,
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"conceptId": 2757,
"conditions": [],
"difficulty": 3,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "6824",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 2,
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"qaAnswer": null,
"question": "Case Presentation: A 39 year old woman attends her GP for a routine diabetic review. **PH** type 1 diabetes, hypothyroidism, Addison’s disease. **DH** soluble insulin (Humulin S) 10-12 units SC TDS with meals, insulin detemir (Levemir) 16 units SC ON, levothyroxine sodium 125 micrograms PO OD, hydrocortisone 20mg PO in the morning and 10mg PO in the evening. NKDA\n\n\n**O/E**\n\nHR 71, RR 11, BP 134/82, O2 100% RA, Temperature 36.6°C. HS I + II + 0. Chest clear. Vitiliginous patches on hands. Visual acuity and colour vision grossly normal.\n\n**Investigations**\n\nTSH: 1.2 (0.4-5.5)\n\nHbA1c: 46 (target <48)\n\nECG: normal sinus rhythm\n\nUrine dipstick:\n\nBlood -ve\n\nNitrites -ve\n\nProtein +1\n\nLeucocytes -ve\n\nA:Cr ratio: 3 mg/mmol\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 5911,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,737 | false | 21 | null | 6,495,246 | null | false | [] | null | 10,067 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has atrial fibrillation and a CHA₂DS₂-VASc of 5. (Age=2, TIA=2, treated hypertension = 1. 2+2+1=5.) Anticoagulation should therefore be initiated. Direct oral anticoagulants such as apixaban are the first-line medications used.",
"id": "50096",
"label": "a",
"name": "Start Apixaban 5mg Oral",
"picture": null,
"votes": 3003
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF). Warfarin was historically first line for anticoagulation in patients with AF although DOACs are now preferred as they have a lower bleeding risk and do not require regular monitoring.",
"id": "50098",
"label": "c",
"name": "Start Warfarin 5mg OD Oral and book follow-up in INR clinic",
"picture": null,
"votes": 209
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF) . Flecainide is a treatment option in paroxysmal atrial fibrillation as a ‘pill in pocket’ initiated by. This would not be appropriate here as it is a specialist treatment, this patient has a normal heart rate and there is no suggestion that their AF is paroxysmal.",
"id": "50100",
"label": "e",
"name": "Start Flecainide 50mg OD Oral",
"picture": null,
"votes": 284
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF). Although clopidogrel is used in the management of patients after a TIA, where patients have AF, anticoagulation with DOACs is more appropriate than antiplatelet treatment as they have a greater risk of clot formation.",
"id": "50099",
"label": "d",
"name": "Start Clopidogrel 75mg OD Oral",
"picture": null,
"votes": 638
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However, all of this patient's vital signs are stable.",
"id": "50097",
"label": "b",
"name": "Start DC Cardioversion",
"picture": null,
"votes": 159
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I thought you wait 2 weeks after a stroke to start a DOAC?",
"createdAt": 1706013728,
"dislikes": 0,
"id": "39641",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10067,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Yes for stroke but this question is for TIA",
"createdAt": 1706281920,
"dislikes": 0,
"id": "39900",
"isLikedByMe": 0,
"likes": 4,
"parentId": 39641,
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"__typename": "User",
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"displayName": "Acute Ketone",
"id": 1306
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"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Zygomatic Hallux",
"id": 37217
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"concept": {
"__typename": "Concept",
"chapter": {
"__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,
"highlights": [],
"id": "2657",
"pictures": [],
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"id": "3599",
"name": "Anticoagulation in a new diagnosis of Atrial Fibrillation",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
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"question": "Case Presentation: A 76-year-old man is admitted to the stroke ward following a TIA. **PH** TIA, Hyperlipidaemia, Gout **DH** Atorvastatin 20mg oral OD, Ramipril 5mg oral OD, Allopurinol 100mg oral OD. NKDA\n\n\n\n**On examination**\n\n* Irregularly irregular radial pulse and central pulse.\n* HS S1+S2\n* Chest clear on auscultation.\n* BP 130/80, HR 88, Temperature 37.1°C, O2 98% on room air\n\n**Investigations**\n\n - ECG: Irregularly irregular rhythm, no p waves\n - Transthoracic echocardiogram: normal\n - CT head normal\n - FBC,U&Es, LFTs and clotting studies are all NAD.\n\nQuestion: Select the most appropriate initial management at this stage, given the results of the investigations.",
"sbaAnswer": [
"a"
],
"totalVotes": 4293,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,738 | false | 22 | null | 6,495,246 | null | false | [] | null | 10,113 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "You cannot increase the dose of salbutamol to 400 micrograms INH QDS, he is already on the max dose of 200 micrograms INH QDS.",
"id": "50296",
"label": "c",
"name": "Increase the dose of salbutamol to 400 micrograms INH QDS",
"picture": null,
"votes": 292
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.",
"id": "50298",
"label": "e",
"name": "Prescribe amoxicillin 500mg PO TDS",
"picture": null,
"votes": 217
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has COPD that isn't controlled on his current medication. It wouldn't be the correct decision to stop his salbutamol as his condition isn't controlled on this - stopping this medication would make his condition worse.",
"id": "50295",
"label": "b",
"name": "No change to his medication",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has COPD that isn't controlled on his current medication. This isn't an acute exacerbation as his observations are stable and his bloods are unremarkable. He has no signs of steroid responsiveness so should be stepped up the COPD treatment ladder to a LAMA + LABA.",
"id": "50294",
"label": "a",
"name": "Prescribe a long acting muscarinic antagonist and a long acting beta agonist",
"picture": null,
"votes": 3592
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.",
"id": "50297",
"label": "d",
"name": "Admit to hospital with co-amoxiclav 1.2g IV TDS and clarithromycin 500mg IV BD",
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"question": "Case Presentation: A 68 year old man attends his GP for a COPD review as he is feeling breathless.\n\n\n**PH** COPD, hypertension, hypercholesterolaemia\n\n**DH** salbutamol 200 micrograms INH QDS, amlodipine 10mg PO OD, atorvastatin 20mg PO OD. NKDA\n\n**On examination**\n\nTemperature 37.4°C, HR 74, RR 22, BP 115/78, O2 96% RA.\n\nAudible wheeze heard in all lung fields.\n\n**Investigations**\n\nHb 126, WCC 8.3, Plts 303 x 10<sup>9</sup>, eosinophils 0.1 x 10<sup>9</sup>L, CRP 2\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,739 | false | 23 | null | 6,495,246 | null | false | [] | null | 10,116 | {
"__typename": "QuestionSBA",
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"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
"id": "50310",
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"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
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"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
"id": "50312",
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"explanation": "This is an incorrect option. This patient is in DKA and needs pharmacological intervention otherwise their condition will deteriorate.",
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"comment": "BP syslotic is above 90 so you don't give NaCl STAT, it's given over an hour 1L",
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"comment": "He's normotensive but still critically dehydrated. He is just compensating well. His intracellular and extravascular fluids are still low so you would still give stat fluids",
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"comment": "even 500ml bolus in children?",
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"comment": "Paediatric fluid bolus is 10mL/kg but we are not given his weight here...",
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"comment": "I think 16 is the cut off for adults, is it not?",
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"comment": "i thought so too but i guess on average a 16yr old is prob around 40kg and so around 400 makes sense i guess... or in dka its always 500ml",
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"question": "Case Presentation: A 16 year old boy is brought to the emergency department with shortness of breath. His mother says he has been complaining of feeling really thirsty for the last couple days. \n\n\n\n\n **PH** Nil.\n\n\n **DH** Nil. NKDA\n\n\n **On examination**\nTemperature 37.6°C, HR 104, RR 24, BP 114/72, O2 95% RA.\n\n\nRespiratory exam: deep laboured breathing seen.\n\n\n **Investigations**\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.31|7.35 - 7.45|\n|PaO₂|8.0 kPa|11 - 15|\n|PaCO₂|3.8 kPa|4.6 - 6.4|\n|Bicarbonate|23 mmol/L|22 - 30|\n\n\nBlood glucose: 22 mmol/L (<6.1 mmol/L)\n\n\nBlood ketones: 3.4 mmol/L (normal <0.6 mmol/L)\n\n\nQuestion: Select the most appropriate management at this stage.",
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"question": "Case Presentation: A 31-year-old female attends the GP complaining of pain on urination and urinating more frequently. She is 12 weeks pregnant, and the pregnancy has been uncomplicated so far. She is afebrile and there is no visible haematuria. **PH** Nil **DH** Nil Allergy to penicillin.\n\n\n**On examination**\n\nWarm and well perfused, CRT 2s. Mild suprapubic tenderness on palpation.\n\nTemperature 37.1°C, HR 84, RR 12, BP 115/78, O2 94% RA\n\n**Investigations**\n\nUrine dipstick: Nitrites ++, all other parameters negative.\n\nQuestion: Select the most appropriate management at this stage.",
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"id": "34088",
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"picture": null,
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"id": "34089",
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"name": "Gliclazide may cause weight loss",
"picture": null,
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"id": "34085",
"label": "a",
"name": "He should avoid missing meals to prevent low blood sugar from happening",
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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 55-year-old man attends the diabetes clinic for review of his diabetic medication. He still complains of thirst and frequent urination despite the up-titration of his metformin dose 3 months ago. \r\n\nPMH: Type 2 Diabetes Mellitus, Hypertension\nDH: Metformin hydrochloride 1g PO BD, Captopril 50mg PO BD\nInvestigations: HbA1c 65 mmol/mol (20-42)\nThe patient is advised to add a new prescription of gliclazide 40mg PO daily to his current treatment regime.\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,742 | false | 26 | null | 6,495,246 | null | false | [] | null | 6,831 | {
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"explanation": "Co-careldopa consists of both levodopa and carbidopa. Levodopa is converted into dopamine to help replenish the level of dopamine in substantia niagra. Carbidopa prevents the levodopa from being broken down into dopamine in parts of the body other than the brain. It does not decrease the risk of impulsive behaviour",
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"explanation": "Co-careldopa could cause excessive daytime sleepiness and sudden onset of sleep. Hence, patients should be warned of the risk and need to exercise caution when driving or operating machinery",
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"name": "Co-careldopa could lead to excessive daytime sleepiness",
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"comment": "Bit uncertain about this answer. Looking in the BNF (03.02.2022) drowsiness and sleep disorders are deemed to be rare or very rare. The BNF also states that this drug is associated with impulse control disorders and that patients should be aware of this, but doesn't specify frequency.",
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"comment": "There's a big bit on sudden onset of sleep in the 'Patient and Carer Advice\" section on the BNF page. I got caught out by this before, so always check there as well as side effects now, can be a place where they talk about specific well-known side effects (even if they are uncommon).",
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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 75-year-old man attends the Parkinson clinic with a 3-month history of rigidity, slow movement and a left-sided resting tremor. He denies any hallucination, incontinence or diplopia. Idiopathic Parkinson’s disease is suspected and a dopaminergic agent trial with 25/100mg Co-careldopa (carbidopa/levodopa) is to be initiated.\n\n\n\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "Patients should report to their doctors if they experience painful oral ulcers that come and go because they maybe suggestive of ulcerative stomatitis which is one of the first signs of gastro-intestinal toxicity",
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"name": "It is normal to get painful oral ulcers that come and go during the course of treatment and that he should not discontinue treatment because of this",
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"explanation": "Methotrexate is an immunosuppressant that functions as anti-folate. Hence, folic acid is usually co-prescribed to reduce the mucosal and gastrointestinal side effects of methotrexate. Patients are advised to take their folic acid on the day after their methotrexate as taking them on the same day may prevent methotrexate from working properly",
"id": "34161",
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"name": "He should take folic acid right after taking methotrexate to reduce mucosal side effects of methotrexate",
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"explanation": "Methotrexate is an immunosuppressant that functions as anti-folate. It is teratogenic, hence patients are advised to stop taking methotrexate for 6 months before attempting to conceive a baby with their partners",
"id": "34160",
"label": "a",
"name": "He needs to stop taking methotrexate for 6 months before attempting to conceive a baby with his partner",
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"explanation": "Methotrexate commonly causes diarrhoea and not constipation",
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"comment": "New guidelines say 3 months for men I believe\n",
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"comment": "Yeah but bnf still says 6 months so im guessing thats what the PSA will go with ",
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"explanation": "# Summary\n\nMethotrexate is one of several conventional disease-modifying anti-rheumatic drugs (DMARDs) used in a variety of autoimmune diseases. It is an inhibitor of dihydrofolate reductase, one of the key enzymes involved in purine and pyrimidine (and therefore DNA) synthesis. It is an immunosuppressive treatment that has several significant side effects, including hepatotoxicity, bone marrow suppression and pneumonitis. Folic acid should be co-prescribed with methotrexate as this reduces mucosal and gastrointestinal side effects (but should be taken on a different day as it reduces methotrexate's efficacy). Patients require regular monitoring with blood tests (full blood count, renal and liver function) and for women with the potential to become pregnant, highly effective contraception should be advised as methotrexate is teratogenic.\n\n# Definition\n\nMethotrexate is a conventional DMARD that inhibits DNA synthesis by inhibiting the enzyme dihydrofolate reductase. It has both immunosuppressive and cytotoxic effects and so is used in both autoimmune diseases such as rheumatoid arthritis, Crohn's disease and psoriasis, as well as in cancer treatment (e.g. as part of chemotherapy regimens for lymphoma).\n\n# Side Effects\n\n- Gastrointestinal upset (e.g. nausea, diarrhoea, abdominal pain)\n- Stomatitis and mucosal ulcers\n- Anorexia\n- Headache\n- Hair loss\n- Fatigue\n- Increased risk of infection; may reactivate latent infections\n- Teratogenicity \n- Myelosuppression with subsequent anaemia, leukopenia and thrombocytopenia\n- Hepatotoxicity including liver cirrhosis\n- Renal toxicity\n- Pulmonary toxicity especially pneumonitis; increased risk in rheumatoid arthritis\n- Photosensitivity reactions - may present with blistering or papular rashes and swelling of affected skin\n\n# Investigations\n\n**Baseline tests prior to starting methotrexate:**\n\n- Blood pressure\n- Weight and height\n- Pregnancy testing if appropriate \n- Full blood count (FBC)\n- U&Es for renal function (dose reduction may be needed; avoid methotrexate in severe impairment)\n- Liver function tests (avoid if baseline hepatic impairment)\n- Hepatitis B and C and HIV serology\n- Consider screening for tuberculosis and other lung disease e.g. with a chest X-ray\n\n**Monitoring whilst on treatment:**\n\n- FBC, U&Es and LFTs should be checked every 2 weeks until the dose of methotrexate is stable\n- They should then be checked monthly for 3 months, then at least every 3 months thereafter\n- More frequent monitoring may be required in patients at increased risk of toxicity\n\n**Ensure no contraindications are present, for example:**\n\n- Active infection - methotrexate should be paused during acute infections\n- Immunodeficiency syndromes\n- Ascites or significant pleural effusion (increases the risk of methotrexate accumulation unless drained)\n- Significant hepatic or renal impairment\n- Current peptic ulceration\n- Pregnancy or breast-feeding\n- Co-administration of another anti-folate medication e.g. co-trimoxazole\n\n**Consider cautions, such as:**\n\n- Excess alcohol intake (increases hepatotoxicity risk)\n- Renal impairment (may need to reduce dose)\n- Pre-existing haematological abnormalities e.g. anaemia, thrombocytopenia\n- Chronic respiratory disease\n- History of recurrent infections (e.g. urinary tract infections, chronic obstructive pulmonary disease exacerbations)\n- Frail or elderly patients (may require dose reduction)\n- Dehydration - may need to pause treatment e.g. if the patient develops diarrhoea or vomiting\n\n# Management\n\n- Methotrexate is usually taken as a weekly tablet, on the same day each week\n- Folic acid 5mg should be co-prescribed to be taken once weekly on a different day\n- Patients should receive the following vaccines:\n- Annual influenza vaccine\n- One-off pneumococcal vaccine (ideally prior to starting methotrexate)\n- Covid vaccination as per national guidelines\n- If aged 50+, the recombinant shingles vaccine (Shingrix, which is not a live vaccine)\n- Advise patients to avoid contact with people with chickenpox and shingles, and seek urgent medical advice if exposed\n- Advise patients that live vaccines (e.g. yellow fever) are contraindicated whilst on methotrexate\n- All patients should be under a specialist team (e.g. rheumatology), usually with a shared care agreement for prescribing and monitoring in primary care\n- A patient card should be provided with safety information and to show to other healthcare professionals\n- Medication interactions are important to be aware of, including:\n- NSAIDs increase the risk of methotrexate toxicity by decreasing renal excretion\n- Trimethoprim or co-trimoxazole may cause severe bone marrow suppression\n- Anti-epileptic medications may reduce effectiveness of methotrexate\n- Theophylline clearance may be reduced by methotrexate\n- Folic acid (may be included in multivitamin supplements) reduces effectiveness of methotrexate if taken together\n- Ensure women of childbearing age are advised of the risk of teratogenicity in pregnancy\n- Highly effective contraception is recommended\n- Methotrexate should be stopped at least 3-6 months before conception \n- Breastfeeding is also contraindicated\n- There is no strong evidence to suggest men need to stop methotrexate whilst trying to conceive, however the BNF suggests waiting 6 months after stopping methotrexate\n- Patients should be warned regarding the risk of photosensitivity reactions and advised to use sunscreen, protective clothing and avoid UV light exposure\n- If there are significant abnormalities in monitoring blood tests (e.g. thrombocytopenia, ALT or ALT > 100) or clinical signs or symptoms of complications (e.g. unexplained bruising suggestive of bone marrow suppression), hold methotrexate and arrange urgent specialist review \n- In cases of methotrexate toxicity, folinic acid (e.g. as calcium folinate) can be given to counteract methotrexate's folate-antagonist mechanism of action\n\n# NICE Guidelines\n\n[NICE CKS - DMARDs](https://cks.nice.org.uk/topics/dmards/)\n\n# References\n\n[BNF - Methotrexate](https://bnf.nice.org.uk/drugs/methotrexate/)\n\n[Specialist Pharmacy Service - Methotrexate monitoring](https://www.sps.nhs.uk/monitorings/methotrexate-monitoring/)",
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"question": "Case presentation: A 35-year-old man attends the inflammatory bowel clinic to discuss about the maintenance therapy for his Crohn’s disease. The thiopurine methyltransferase (TPMT) test that was done shows that he has absent TPMT activity. \r\n\nPMH: Crohn’s disease, Vitiligo, Grave’s disease\nDH: Carbimazole PO 15mg OD\nHe is advised to commence treatment with Methotrexate 10mg PO once weekly.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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173,467,744 | false | 28 | null | 6,495,246 | null | false | [] | null | 10,073 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no recognised interaction between sertraline and carbimazole",
"id": "50130",
"label": "e",
"name": "To stop taking her sertraline",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Smoking can potentially reduce the efficacy of hyperthyroidism treatment however this isn't the most important thing to tell her out of the options provided.",
"id": "50128",
"label": "c",
"name": "To stop smoking",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Treatment with carbimazole can cause bone marrow suppression. This is very serious side effect of carbimazole and needs to be mentioned when counselling on the drug. Any signs of infection, especially a sore throat should be reported immediately. After this, a full blood count should be taken. If this full blood count shows neutropenia then carbimazole should be stopped immediately.",
"id": "50126",
"label": "a",
"name": "To report having a sore throat",
"picture": null,
"votes": 4146
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mood changes are not a recognised side effect of carbimazole treatment",
"id": "50127",
"label": "b",
"name": "To report any changes to mood",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alcohol can still be consumed whilst taking carbimazole. This patient however is above the recommended weekly limit so should look to reduce her alcohol consumption if possible.",
"id": "50129",
"label": "d",
"name": "To stop drinking alcohol",
"picture": null,
"votes": 17
}
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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 38-year-old woman attends a follow up appointment at her GP for the results of her blood tests.\n\n\n\n\n **PMH** Depression, Asthma\n\n\n **DH** Salbutamol 200 micrograms INH PRN, Sertraline 50mg PO OD. NKDA\n\n\n **SH** Active smoker, smoking 10 cigarettes a day (5 pack year history). Drinks 20-30 units of alcohol a week.\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|<0.1 mU/L|0.3 - 4.2|\n|Free T4|44 pmol/L|9 - 25|\n|Free T3|18 pmol/L|3.1 - 6.8|\n\n\nBased on her blood results she is diagnosed with hyperthyroidism. It is decided that she will be started on carbimazole 15mg PO OD.\n\n\nQuestion: Select the most appropriate piece of information that should be relayed to this patient prior to starting carbimazole",
"sbaAnswer": [
"a"
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173,467,745 | false | 29 | null | 6,495,246 | null | false | [] | null | 10,121 | {
"__typename": "QuestionSBA",
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"answer": false,
"explanation": "Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.",
"id": "50336",
"label": "c",
"name": "That he will require serum lipid monitoring every 6 months",
"picture": null,
"votes": 222
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.",
"id": "50338",
"label": "e",
"name": "That he will require annual visual acuity monitoring",
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"votes": 109
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dizziness is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.",
"id": "50335",
"label": "b",
"name": "That he will likely experience dizziness when taking isotretinoin",
"picture": null,
"votes": 18
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"__typename": "QuestionChoice",
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"explanation": "Isotretinoin has been linked to increased risk of depression and suicide therefore it is very important that the patient is informed to report any changes in their behaviour or mood after starting isotretinoin.",
"id": "50334",
"label": "a",
"name": "To report any changes in his mood or behaviour",
"picture": null,
"votes": 3756
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nausea is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.",
"id": "50337",
"label": "d",
"name": "That he will likely experience nausea when taking isotretinoin",
"picture": null,
"votes": 12
}
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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 19-year-old man attends the dermatology clinic for his acne vulgaris medication. He has been taking tetracycline as instructed however his condition is not improving.\n\n\n\n**PH**\nAcne vulgaris\n\n**DH**\nTetracycline 500mg PO BD\n\nDue to his ongoing issues with his acne, his dermatologist commences him on isotretinoin.\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,746 | false | 30 | null | 6,495,246 | null | false | [] | null | 10,127 | {
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"__typename": "QuestionChoice",
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"explanation": "Regular blood pressure monitoring is only required in patients receiving IV nitrates.",
"id": "50366",
"label": "c",
"name": "He will need regular blood pressure monitoring",
"picture": null,
"votes": 499
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"__typename": "QuestionChoice",
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"explanation": "Regular heart monitoring is only required in patients receiving IV nitrates.",
"id": "50367",
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"picture": null,
"votes": 73
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Dizziness is a very common side effect of GTN, therefore when taking GTN it is advised that patient's sit down so that they do not fall.",
"id": "50364",
"label": "a",
"name": "He should sit down if possible when taking his GTN spray",
"picture": null,
"votes": 2490
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"explanation": "GTN is administered sublingually (under the tongue), not into the buccal mucosa.",
"id": "50368",
"label": "e",
"name": "He should administer his GTN spray into the buccal mucosa",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Diarrhoea is an uncommon side effect of GTN therefore he is not likely to experience it.",
"id": "50365",
"label": "b",
"name": "He is likely to experience diarrhoea when taking GTN",
"picture": null,
"votes": 77
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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 59-year-old man attends his GP complaining of chest pain. This chest pain is central, comes on with exercise and goes away with rest.\n\n\n\n\n\n\n **PH**\nHypertension\n\n\n **DH**\nRamipril 5mg PO OD\n\n\n **Investigations**\n\n\nECG - normal sinus rhythm\n\n\nTroponin I 3 ng/L (<14 ng/L)\n\n\nIt is decided that this gentleman has stable angina and should be given GTN (glyceryl trinitrate) spray for symptomatic relief.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,747 | false | 31 | null | 6,495,246 | null | false | [] | null | 6,914 | {
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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 = 20mg/kg 8-hrly\nWeight = 85kg\nTotal dose= 20mg/kg 8-hrly x 85kg\n= 1.7g 8-hrly\nDrug concentration = 5mg/mL\nMinimum volume required\n= 1700mg/(5mg/mL) = 340mL",
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"question": "A 75-year-old man who was admitted for a severe chest infection developed cellulitis on his third day of admission. He is to be treated with vancomycin 20mg/kg IV 8-hrly. Weight 85kg.\n\nPrior to administration, vancomycin needs to be diluted with sodium chloride 0.9% to a concentration not exceeding 5mg/mL.\n\nWhat is the minimum volume (mL) to which each dose of vancomycin should be diluted?",
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"__typename": "QuestionComment",
"comment": "the way this question is written is vague - the dose of the patch IS 9.5mg. A new one is just applied every day",
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"comment": "2 days as in prescribe for today, tomorrow and the day after, or 2 days as in 48 hrs!!",
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"comment": "ughh i totally missed the 2 days ",
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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": "Current dose of rivastigmine a day = 12mg\n12mg PO OD = 9.5mg/24 hours patch.\nTotal dose prescribed for 2 days\n= 9.5mg x 2\n= 19mg",
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"question": "An 80-year-old gentleman was admitted to the Hyperacute Stroke Unit following an episode of ischemic stroke. He was determined to have an unsafe swallow following SALT assessment and has been kept NBM since. His next SALT review will be in 2 days. PMH Alzheimer’s Disease. DH Rivastigmine 6mg PO BD.\n\nPatients taking 3-6mg PO OD should initially switch to 4.6mg/24 hours patch. Patients taking 12mg PO OD should switch to 9.5mg/24 hours patch.\n\nWhat is the total dose of rivastigmine patch prescribed for this patient before his next review?",
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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 = 0.1units/kg/hr\nWeight = 20kg\nTotal insulin needed/hour\n= 0.1units/kg/hr x20kg = 2units/hr\nTotal insulin needed for a day\n= 2units/hr x 24hrs = 48 units\n= 48units require 48mL of 0.9% sodium chloride.",
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"question": "A 5-year-old boy is admitted to Emergency Department with Kussmaul breathing and ketotic breath following 3 days of polyuria and polydipsia. He was diagnosed with DKA and was started on the appropriate treatment. Fluids was prescribed and fixed rate Actrapid infusion was initiated at a rate of 0.1units/kg/hr. Weight 20kg.\n\n\nFor intravenous infusion of Actrapid, give continuously in Sodium Chloride 0.9% @ 1units in 1mL of 0.9% sodium chloride solution.\n\nWhat is the volume (mL) of 0.9% sodium chloride solution needed for a fixed rate 24 hour Actrapid infusion?",
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"comment": "It is stated that 1mg is administered and then this is repeated a further 3 times. This means 4mg of Adrenaline was given in total meaning the correct answer is 40mL, not 30mL.",
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"comment": "It says the doses were repeated, to a total of 3 times rather than repeated 3 times \n",
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"comment": "im confused I thought 1:10000 meant 1g in 10,000ml ",
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"comment": "you're right - 1g in 10,000mL = 1000mg in 10,000mL (same thing) \njust cancel out the extra 0s from both sides then you get 1mg in 10 mL ",
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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": "The definition of 1:10000 is 1kg in 10000L = 1mg in 0.01L = 1mg in 10mL. Since each dose of adrenaline is 1mg, the corresponding volume given is 10mL. Since three doses of adrenaline were given, the total volume given was 30mL.\n\nConcentration ratios (1:10000 in this case) are based on units of kilogram and litre as they belong to the International System of Units (SI units) which are used by convention.",
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"question": "A 72-year-old patient suffered a cardiac arrest. Once intravenous access was obtained, 1mg of adrenaline was administered. This was repeated and in total, the same dose was given three times until there was return of spontaneous circulation. Adrenaline is available as a 1:10000 solution.\n\n\nWhat was the total volume of adrenaline given?",
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173,467,751 | false | 35 | null | 6,495,246 | null | false | [] | null | 6,930 | {
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"comment": "why is round to nearest 40 mean 360, wouldnt the nearest multiple of 40 be 380?",
"createdAt": 1642954595,
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"comment": "Because 360 is a multiple of 40 (360 / 40 = 9). 380 isn't (380 / 40 = 9.5)",
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"comment": "Ain’t nobody got time to do all this mathematics in the 1 min per question time pressures of PSA land",
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"comment": "Because up to 200 would be 20, 40, 60, etc. After 200, its 240 --> 280 --> 320 --> 360 (360 is closest to 350)",
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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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"name": "Weight-based dosing; calculation of infusion rate",
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"explanation": "The dose of gentamicin to be given is: 70kg x 5mg/kg = 350mg. As this is above 200mg, this is rounded up to the nearest 40mg, which is 360mg. Since this is given over 60 minutes, the dose given per minute is: 360mg ÷ 60 minutes = 6mg/min.\n\nThe fact that his BMI and creatinine clearance are both normal mean that additional calculations to account for extremes of body weight and impaired renal function respectively are not required. In addition, the volume of 0.9% sodium chloride required for dilution is a distraction.",
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"question": "A 62-year-old patient who weighs 70kg suffers from acute pyelonephritis. He is prescribed a gentamicin infusion of 5mg/kg using a once-daily regimen. The dose is rounded up to the nearest 20mg increment for doses less than 200mg and 40mg above this.\n\n\nGentamicin is diluted in 50mL of 0.9% sodium chloride and given over 60 minutes. His BMI and creatinine clearance are both within normal limits.\n\nWhat is the dose of gentamicin given per minute?",
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"comment": "If it is 1g twice daily then doesn't that mean 2g a day? Therefore 50% of 2g is 1g. Please correct me if I have missed something.",
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"comment": "as each dose is 1g - you halve each dose - so it becomes 500mg in the morning and then 500mg in the evening. So the total daily dose will be 1g ",
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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": "After adjusting for renal impairment, the dose to be given is: 50% x 1g = 500mg.\nHence, the rate at which levetiracetam is to be given is: 500mg ÷ 15 minutes = 33.3ml/min ≈ 33mL/min.\nThe volume of 0.9% sodium chloride solution required for dilution is a distraction.",
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"question": "A 47-year-old patient with focal seizures was initially prescribed levetiracetam (Keppra(R)) at a maintenance dose of 1g twice daily. Due to co-existing renal impairment, it has been decided that the dose should be reduced by 50% as per the manufacturer's advice. This is diluted in 100mL of 0.9% sodium chloride solution and given over 15 minutes.\n\n\nWhat is the rate (in mg per minute) of levetiracetam he is to be given at each dose? Round off your answer to the nearest mg per minute.",
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"comment": "I got 11 tablets because i thought that with the .5 tablet left after each regular dose you have to waste the other half as its a CD?",
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"comment": "if the breakthrough dose is 10mg, the daily dose must be six times more so 60mg (6 tablets). if shes taking 3 breakthrough doses thats another 3 tablets. 3+6=9 tablets.\n",
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"comment": "I assumed it meant the break through doses only as the 15 mg morphine was already part of her daily regimen. So I put 3",
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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": "Since the hospital only has 10mg tablets, that means for her regular morphine dose, she requires 1.5 tablets each time. 1.5 x 4 = 6\n\nShe has had 3 doses of 10mg morphine as breakthrough pain which is 3 tablets. 6 + 3 = 9 tablets.",
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"question": "Case Presentation:\r\n\r\nA 75-year-old woman is admitted to the medical ward for palliative care. Her regular medicines are listed (below). Weight 60kg.\r\n\r\n**PH** Hypertension, Hypercholesterolaemia, Osteoarthritis, Iron deficiency anaemia\r\n\r\n**DH** Amlodipine 5mg PO OD, Morphine 15mg PO QDS\r\n\r\nShe is still complaining that she is in pain. She is being given 10mg morphine tablets as a way to manage her breakthrough pain.\r\n\r\nThroughout the day, the patient requires 3 breakthrough doses to control her pain.\r\n\r\nGiven that hospital only stocks 10mg tablets, how many morphine tablets will the patient have had by the end of the day?",
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173,467,754 | false | 38 | null | 6,495,246 | null | false | [] | null | 10,148 | {
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"comment": "where do we find the deficit equation in the BNF?",
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"comment": "It's not in the bnf sadly",
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"comment": "Should dehydration not be corrected over 48hrs?",
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"comment": "Is this fluid deficit equation just for children?",
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"comment": "This answer is wrong!! The equation is for 48 hours so you need to divide by 2 to get the amount for 24 hours? So the 900 should be divided by 2",
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"comment": "For children with ≤5% dehydration, replace deficit in the first 24 hours",
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"comment": "Also would you not need to add resuscitation fluids as well as replacement and maintenance?",
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"comment": "do you not need to minus the initial bolus from the fluid deficit as the patient isnt shocked?",
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"comment": "why this equation, why not weight (grams) x Dehydration (as decimal)...... 18000*0.05=900",
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"comment": "how do you even estimate someone as being 5% dehydrated...?!?",
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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": "3677",
"name": "Fluid maintenance + replacement therapy",
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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 18kg. Therefore he will need 1000ml for his first 10kg of weight and 400ml for his next 10kg of weight. Therefore this patient requires 1400ml of **maintenance** fluid therapy.\n\nHe is also 5% dehydrated. To calculate the amount of **replacement** fluid therapy you use the following equation:\n\nFluid deficit (mL) = % dehydration x weight (kg) x 10\n\nSo in this case the amount of fluid that needs to be replaced would be:\n\n5 x 18 x 10 = 900ml\n\n900 + 1400 = 2300ml total fluid needed over 24 hours.",
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"question": "Case Presentation:\n\nA 4-year-old boy is admitted to the paediatric ward with diarrhoea and vomiting. Weight 18kg.\n\n**On examination**\n\nBP 104/62mmHg, HR 110, RR 23, patient is alert.\n\nMucus membranes appear to be dry.\n\nCapillary refill time <2 seconds.\n\nThis patient is determined to be 5% dehydrated. It is therefore determined that they require fluid replacement therapy alongside their regular maintenance therapy.\n\nWhat **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily fluid intake?",
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173,467,755 | false | 39 | null | 6,495,246 | null | false | [] | null | 6,851 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Weight gain is recognised as a common or very common side effect of pioglitazone due to fluid retention although the exact mechanism underlying this process is not known",
"id": "34200",
"label": "a",
"name": "Pioglitazone 30mg PO daily",
"picture": null,
"votes": 5470
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cholecalciferol does not commonly cause weight gain",
"id": "34203",
"label": "d",
"name": "Cholecalciferol 400U PO daily",
"picture": null,
"votes": 3
},
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"__typename": "QuestionChoice",
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"explanation": "Ramipril does not commonly cause weight gain",
"id": "34204",
"label": "e",
"name": "Ramipril 2.5mg PO daily",
"picture": null,
"votes": 5
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause weight gain",
"id": "34202",
"label": "c",
"name": "Atorvastatin 20mg PO daily",
"picture": null,
"votes": 18
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine does not commonly cause weight gain",
"id": "34201",
"label": "b",
"name": "Amlodipine 10mg PO daily",
"picture": null,
"votes": 100
}
],
"comments": [],
"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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"id": "2618",
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"id": "2783",
"name": "Pioglitazone side effects",
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"id": "9",
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"typeId": 5
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"question": "Case Presentation: A 65-year-old man attended his GP for the results of his blood test. PMH Type 2 diabetes mellitus, Hypercholesterolemia, Hypertension. DH Atorvastatin 20mg PO daily, Pioglitazone 30mg PO daily, Amlodipine 10mg PO daily, Cholecalciferol 400U OD, Ramipril 2.5mg PO OD.\r\n\r\n\n**On Examination**\n\nBP 135/80mmHg, HR 85, RR 14, Weight 65kg (63kg 4 months ago)\n\n**Investigation**\n\nTotal cholesterol 150 mg/dL (100-200), LDL 50mg/dL (0-99), HDL 100mg/dL (39-150)\n\nQuestion: After ruling out poor diet and lack of exercise, select the prescription that is most likely to contribute to his weight gain.",
"sbaAnswer": [
"a"
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"totalVotes": 5596,
"typeId": 1,
"userPoint": null
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173,467,756 | false | 40 | null | 6,495,246 | null | false | [] | null | 6,859 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Rotigotine does not commonly prolongs QT interval",
"id": "34244",
"label": "e",
"name": "Rotigotine 8mg OD",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly prolongs QT interval",
"id": "34242",
"label": "c",
"name": "Paracetamol 1g QDS",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Citalopram and escitalopram are examples of drugs that are used for depressive illness. They can commonly cause side effects including prolongation of QT interval especially when other risk factors are present such as age extremity, stress or shock. The exact mechanism of the effect of citalopram on QT interval, however, is not known",
"id": "34240",
"label": "a",
"name": "Citalopram 40mg OD",
"picture": null,
"votes": 5792
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen does not commonly prolongs QT interval",
"id": "34241",
"label": "b",
"name": "Ibuprofen 400mg TDS",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "C0-beneldopa does not commonly prolongs QT interval",
"id": "34243",
"label": "d",
"name": "Co-beneldopa 50mg BD",
"picture": null,
"votes": 21
}
],
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"__typename": "QuestionComment",
"comment": "Go on BNF and search \"appendix one\", then control F \"QT Prolongation\" and you can see all the drugs that cause it. \n\nAppendix one can also be used for other common electrolyte imbalances ",
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"createdAt": 1736357540,
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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": "2791",
"name": "Citalopram side effects",
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"name": "Psychiatry",
"typeId": 5
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"question": "Case Presentation: A 75-year-old man is recovering on the Orthopaedic Ward following an elective left knee replacement two days ago. Post-operatively, he was prescribed paracetamol, an NSAID and a weak opioid for pain relief. On the second day after his operation, he developed tachycardia. An ECG was performed showing sinus tachycardia with prolongation of QT interval. PMH Severe depression, Parkinson’s disease, IBD. DH Citalopram 40mg OD, Paracetamol 1g QDS PO, Ibuprofen 400mg TDS, Co-beneldopa 50mg BD, Rotigotine 8mg TD OD\r\n\r\n\nQuestion: Select the prescription that is most likely to contribute to the prolongation of his QT interval",
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"a"
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"typeId": 1,
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173,467,757 | false | 41 | null | 6,495,246 | null | false | [] | null | 6,864 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gingival hyperplasia is an uncommon side effect of all calcium channel blockers",
"id": "34266",
"label": "b",
"name": "Gingival hyperplasia",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hyperglycaemia is a rare or very rare side effect of amlodipine",
"id": "34267",
"label": "c",
"name": "Hyperglycaemia",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Peripheral neuropathy is a rare or very rare side effect of amlodipine",
"id": "34269",
"label": "e",
"name": "Peripheral neuropathy",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Peripheral oedema is a common or very common side effect of all calcium channel blockers. It is thought to be caused by arteriolar dilation that leads to increasing capillary pressure and extravasation of fluids into the surrounding tissues",
"id": "34265",
"label": "a",
"name": "Peripheral oedema",
"picture": null,
"votes": 6169
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Increased muscle tone is a rare or very rare side effect of amlodipine",
"id": "34268",
"label": "d",
"name": "Increased muscle tone",
"picture": null,
"votes": 16
}
],
"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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"id": "2796",
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"name": "General Practice",
"typeId": 5
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"question": "Case presentation: A 40-year-old man visits his GP for medication review. \r\n\nPMH: Diabetes Mellitus, Hypertension\nDH: Metformin Hydrochloride 500 mg PO TDS, Captopril 75 mg PO BD\nObservations: Temperature 36.5, Respiratory rate 14, Blood pressure 165/95, Heart rate 76, Oxygen saturation 100% (on air)\nThe patient is advised to add Amlodipine 5 mg PO OD to his current treatment regime in view that his blood pressure is not well controlled\n\nQuestion: Select the adverse effect that is most likely to be caused by this treatment",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
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173,467,758 | false | 42 | null | 6,495,246 | null | false | [] | null | 6,866 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to cause auditory nerve damage. On the other hand, streptomycin is associated with foetal ototoxicity",
"id": "34278",
"label": "d",
"name": "Auditory nerve damage",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to discolour the teeth. On the other hand, tetracycline and doxycycline are associated with bone and teeth discolouration",
"id": "34277",
"label": "c",
"name": "Teeth discolouration",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to cause hepatic failure in neonates",
"id": "34279",
"label": "e",
"name": "Hepatic failure",
"picture": null,
"votes": 118
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Co-amoxiclav is associated with an increased risk of necrotising enterocolitis in neonates",
"id": "34275",
"label": "a",
"name": "Necrotising enterocolitis",
"picture": null,
"votes": 4679
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to cause cholestatic jaundice in neonates",
"id": "34276",
"label": "b",
"name": "Cholestatic jaundice",
"picture": null,
"votes": 741
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Weird q as necrotising enterocolitis is only really a risk when in PPROM. Otherwise BNF says not harmful ",
"createdAt": 1676122748,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "Yep that's why I didn't choose it either",
"createdAt": 1703610085,
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"displayName": "Monoclonal Polyps",
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"__typename": "QuestionComment",
"comment": "is this the same as pseudomembranous enterocolitis?",
"createdAt": 1738158070,
"dislikes": 0,
"id": "61862",
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"__typename": "QuestionComment",
"comment": "No, that's caused by Clostridium Difficile",
"createdAt": 1738699890,
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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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2798",
"name": "Co-amoxiclav side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "66",
"name": "Obstetrics & Gynaecology",
"typeId": 5
},
"topicId": 66,
"totalCards": null,
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"question": "Case presentation: A 34-year-old pregnant woman is admitted to hospital for community-acquired pneumonia. She is a primigravida and is currently 22 weeks into her pregnancy. She has hyperemesis gravidarum and is not able to tolerate oral medication well. \r\n\nObservations: Temperature 37.5, Respiratory rate 32, Blood pressure 88/64, Heart rate 76\nOn examination: Coarse crackles at left lung base, normal antenatal examination\nThe junior doctor would like to discuss with the obstetric consultant commencing treatment with Co-amoxiclav 1.2 g TDS because the junior doctor is concerned that co-amoxiclav may increase the risk of a particular neonatal condition.\n\nQuestion: Select the neonatal condition that is most likely to be caused by Co-amoxiclav",
"sbaAnswer": [
"a"
],
"totalVotes": 5601,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,759 | false | 43 | null | 6,495,246 | null | false | [] | null | 6,869 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is not associated with NMS but an overdose of sertraline can cause serotonin syndrome, which share some similarities with NMS. Both NMS and serotonin syndrome can bring about hypertension, tachycardia and hyperthermia. However, NMS is different from serotonin syndrome in that it is associated with hyporeflexia, normal pupillary sizes and a gradual onset while serotonin syndrom is characterised by hyperreflexia, myadriasis and a rapid onset",
"id": "34291",
"label": "b",
"name": "Sertraline 50 mg PO OD",
"picture": null,
"votes": 1341
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to casuse NMS",
"id": "34293",
"label": "d",
"name": "Lisinopril 20 mg PO OD",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The clinical picture described above is that of neuroleptic malignant syndrome (NMS). NMS is an uncommon but potentially fatal side effect of all antipsychotic drugs. Antipsychotic medications lead to NMS through their antagonism of dopamine D2 receptors. NMS is characterised by a tetrad of hyperthermia, changed mental status, muscle rigidity and autonomic instability",
"id": "34290",
"label": "a",
"name": "Olanzapine 10 mg PO OD",
"picture": null,
"votes": 4179
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to cause NMS",
"id": "34294",
"label": "e",
"name": "Simvastatin 40 mg PO ON",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to casuse NMS",
"id": "34292",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 9
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "one day i'll get NMS and serotonin syndrome the right way round ",
"createdAt": 1737741426,
"dislikes": 0,
"id": "61454",
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"replies": [
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"__typename": "QuestionComment",
"comment": "\"Neuroepeleptic\" malignant syndrome = antipsychotic bad syndrome.\nIt has rise in CK, muscle ridgity - basically excess of motor side effects of antipsycotics anyway. + confusion and sweating",
"createdAt": 1738205190,
"dislikes": 0,
"id": "61915",
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"id": 25779
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"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",
"files": null,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2801",
"name": "Antipsychotic side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
"totalCards": null,
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"question": "Case presentation: A 35-year-old man presents to the accident and emergency department with a two-day history of gradual onset confusion and muscle rigidity. He is highly agitated and sweats excessively. \r\n\nPMH: Schizophrenia, Depression, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia\nDH: Her current regular prescriptions are listed below\nObservations: Temperature 40°C , blood pressure 181/95 mmHg, heart rate 100 bpm, respiratory rate 25; oxygen saturation 100% (on air)\nOn examination: Lead pipe rigidity. Normal pupillary sizes\nInvestigation: Negative urine toxicology screen\n\nQuestion: Select the prescription that is most likely to be contributing to the clinical picture described above?",
"sbaAnswer": [
"a"
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"typeId": 1,
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} | MarksheetMark |
173,467,760 | false | 44 | null | 6,495,246 | null | false | [] | null | 6,873 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clinical picture described above is that of a high anion gap metabolic acidosis with raised lactate level. Lactic acidosis is a rare or very rare, but potentially fatal side effect of metformin. Chronic stable heart failure is a risk factor for lactic acidosis. BNF advises that metformin should be witheld if dehydration occurs because acute kidney injury can precipiate lactic acidosis",
"id": "34310",
"label": "a",
"name": "Metformin hydrochloride 500 mg PO three times daily",
"picture": null,
"votes": 4147
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carvedilol is not known to cause lactic acidosis",
"id": "34311",
"label": "b",
"name": "Carvedilol 3.125 mg PO twice daily",
"picture": null,
"votes": 220
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to cause metabolic acidosis",
"id": "34314",
"label": "e",
"name": "Simvastatin 40 mg PO nightly",
"picture": null,
"votes": 771
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to cause metabolic acidosis",
"id": "34312",
"label": "c",
"name": "Lisinopril 10 mg PO once daily",
"picture": null,
"votes": 394
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline not known to cause metabolic acidosis",
"id": "34313",
"label": "d",
"name": "Sertraline 50 mg PO once daily",
"picture": null,
"votes": 262
}
],
"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2805",
"name": "Metformin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"conditions": [],
"difficulty": 2,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "6873",
"isLikedByMe": 0,
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"likes": 1,
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"psaSectionId": 6,
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"question": "Case presentation: A 65-year old man on the geriatric ward complains of nausea, vomiting and generalised muscle weakness. He was admitted to the hospital following a fall at home two days ago. \n\n\nPMH: Type 2 Diabetes Mellitus, Hypertension, Heart failure, Depression\nDH: His current regular prescriptions are listed below\nExamination: Dry lips and reduced skin turgor. Deep and laboured breathing. No added lung sounds. HS I+II+0. Abdomen soft non tender.\nInvestigation:\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.25|7.35 - 7.45|\n|PaO₂|11 kPa|11 - 15|\n|PaCO₂|3.8 kPa|4.6 - 6.4|\n|Bicarbonate|12.1 mmol/L|22 - 30|\n|Base Excess|-13.5 mmol/L|-2 to +2|\n|Creatinine|300 µmol/L|60 - 120|\n|Lactate|5.1 mmol/L|0.6 - 1.4|\n\nAnion gap: 29 mmol/L\nNegative urine toxicology\n\n\nQuestion: Select the prescription that is most likely to be contributing to the clinical picture described above?",
"sbaAnswer": [
"a"
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"totalVotes": 5794,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,761 | false | 45 | null | 6,495,246 | null | false | [] | null | 10,079 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Chlorphenamine is a H1 antagonist used to treat hayfever. It can commonly cause drowsiness and dizziness; the latter is more likely when taken with oxybutynin as there is a higher risk of antimuscarinic side effects.",
"id": "50156",
"label": "a",
"name": "Chlorphenamine 10mg PO PRN",
"picture": null,
"votes": 1835
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin does not commonly cause dizziness.",
"id": "50157",
"label": "b",
"name": "Metformin 500mg PO BD",
"picture": null,
"votes": 152
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide does not commonly cause dizziness.",
"id": "50158",
"label": "c",
"name": "Gliclazide 80mg PO OD",
"picture": null,
"votes": 1996
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause dizziness.",
"id": "50159",
"label": "d",
"name": "Paracetamol 1g PO BD",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cholecalciferol does not commonly cause dizziness.",
"id": "50160",
"label": "e",
"name": "Cholecalciferol 800U OD",
"picture": null,
"votes": 75
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "would hypoglycaemia due to Gliclazide not be a concern?",
"createdAt": 1673963724,
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"replies": [
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"__typename": "QuestionComment",
"comment": "It is of concern, but the question specifically asks for an interaction with oxybutynin (at least it's stated like this right now)",
"createdAt": 1737993594,
"dislikes": 0,
"id": "61678",
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"displayName": "Botox Ben",
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"displayName": "Fever Metabolism",
"id": 14043
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"concept": {
"__typename": "Concept",
"chapter": {
"__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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"demo": null,
"entitlement": null,
"id": "3611",
"name": "Interaction between oxybutynin and alendronic acid which increases the risk of dizziness.",
"status": null,
"topic": {
"__typename": "Topic",
"id": "130",
"name": "Geriatrics",
"typeId": 5
},
"topicId": 130,
"totalCards": null,
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"question": "Case Presentation: A 82-year-old woman attends her GP. She has been feeling dizzy since being started on Oxybutynin for urge incontinence. Her regular medicines are listed (below).\n\n\n**PH** Osteoporosis, Type 2 Diabetes Mellitus, Hayfever Overactive Bladder\n\n**DH** Alendronic acid 10mg PO once weekly, Metformin 500mg PO BD, Gliclazide 80mg PO OD, Paracetamol 1g PO BD, Chlorphenamine 10mg PO PRN, Cholecalciferol 800U OD\n\n**On examination**\nBP 136/76mmHg, HR 71, RR 14, Weight 50kg\n\n**Investigation**\n\nNeurological examination is normal.\n\nQuestion: Select the prescription that is most likely to interact with the patient’s oxybutynin to cause dizziness.",
"sbaAnswer": [
"a"
],
"totalVotes": 4070,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,762 | false | 46 | null | 6,495,246 | null | false | [] | null | 18,103 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alopecia is an uncommon side effect of sertraline.",
"id": "10028503",
"label": "b",
"name": "Alopecia",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Palpitations are a common or very common side-effect of not just sertraline, but all selective serotonin re-uptake inhibitors (SSRIs).",
"id": "10028502",
"label": "a",
"name": "Palpitations",
"picture": null,
"votes": 2602
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dehydration is not a side effect of sertraline. In fact, feeling of thirst is an uncommon side effect.",
"id": "10028506",
"label": "e",
"name": "Dehydration",
"picture": null,
"votes": 123
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Autonomic instability may be a feature of serotonin syndrome but is not a side effect of SSRIs.",
"id": "10028505",
"label": "d",
"name": "Autonomic instability",
"picture": null,
"votes": 177
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Galactorrhoea is a rare side effect of sertraline",
"id": "10028504",
"label": "c",
"name": "Galactorrhoea",
"picture": null,
"votes": 23
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
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"typeId": 7
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"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6078",
"name": "Depression",
"status": null,
"topic": {
"__typename": "Topic",
"id": "324",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 324,
"totalCards": null,
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"userChapter": null,
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"difficulty": 1,
"dislikes": 0,
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"question": "Case Presentation: A 30-year-old man presents to the GP for review of his mental health. He was recently diagnosed with depression and has been undergoing CBT over the last 2 months. He states these are helping but he describes ongoing anhedonia and sleeping difficulties. He has also recently come out of a relationship and he has had thoughts of self-harm but says he would never act on them.\n\n\nThe GP commences him on sertraline 50mg PO and arranges for a follow up in 2 weeks' time.\n\nQuestion: Select the adverse affect most likely to be caused by this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 2939,
"typeId": 1,
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173,467,763 | false | 47 | null | 6,495,246 | null | false | [] | null | 6,874 | {
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"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34317",
"label": "c",
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"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
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"__typename": "QuestionChoice",
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"explanation": "Taking digoxin levels more than 6 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level",
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"explanation": "This is the correct time to take a digoxin level, which is 6 hours after the last dose",
"id": "34315",
"label": "a",
"name": "Blood levels at 1400 hrs",
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"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34319",
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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 70 year old man is on the acute admissions unit being treated for exacerbation of congestive cardiac failure and new atrial fibrillation. **PMH** CCF, recurrent DVTs. **DH** lisinopril 15mg PO OD, carvedilol 25mg PO BD, spironolactone 50mg PO OD, isosorbide mononitrate 30mg PO BD, warfarin sodium 3mg PO OD. NKDA\n\n\nOn the morning drug round at 0800 hrs, he has been given his usual medications as well as 375 micrograms of digoxin in accordance with the rapid digitalisation protocol.\n\n**Investigations**\n\nU&Es: Na 144, K 3.9, Cl 99, Ur 4.2, Cr 117 (baseline 103), eGFR 52mL/min/1.73m^2\n\nQuestion: Select the most appropriate monitoring option to assess the need for dose adjustments of digoxin in this patient.",
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"a"
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173,467,764 | false | 48 | null | 6,495,246 | null | false | [] | null | 6,883 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be generally useful as mood disorders are common among patients with Alzheimer’s disease but is not essential",
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"label": "d",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary with this medication",
"id": "34361",
"label": "b",
"name": "Full blood count",
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"__typename": "QuestionChoice",
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"explanation": "An ECG should be performed to rule out bradycardia or high-grade heart block prior to starting this drug",
"id": "34362",
"label": "c",
"name": "No routine monitoring is required",
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"answer": true,
"explanation": "Donepezil increases cholinergic activity not just in the central nervous system but also peripherally, and may exert a parasympathetic effect on the heart. As such it is contraindicated in patients with high-grade heart block or symptomatic bradycardia and this should be ruled out with an ECG beforehand",
"id": "34360",
"label": "a",
"name": "ECG",
"picture": null,
"votes": 2569
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"__typename": "QuestionChoice",
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"explanation": "This is not necessary with this medication",
"id": "34364",
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"name": "Weight",
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],
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{
"__typename": "QuestionComment",
"comment": "Is it not technically the case that you check the pulse first to look for bradycardia, and if there is anything to suggest heart block you would then do an ECG?",
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"comment": "Where does it state this in the BNF?",
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"comment": "Cautions, further information\nElderly\n",
"createdAt": 1647223627,
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"comment": "Yes, immediately after it states ‘WITH A KNOWN HISTORY’. The way I approach these questions is that if the monitoring section is missing I know there is no routine monitoring. If the question has thrown something in the stem to suggest some form of cardiac disturbance the answer provided here would then be valid.",
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"comment": "Doesn't state this on the BNF",
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"comment": "Cautions, further information\nElderly",
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"comment": "Donepazil on the BNF has no section for \"Monitoring Requirement\", cautions in the elderly state known history of bradycardia would make this a potentially inappropriate prescription. Can we have the question re-worded to include a PMH of bradycardia, please?",
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"comment": "There is no routine monitoring on the bnf for this drug",
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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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"demo": null,
"entitlement": null,
"id": "2815",
"name": "Donepazil side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
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"question": "Case Presentation: A 75 year old man attends the memory clinic with his partner. He has been having difficulty with remembering important personal details such as his debit card PIN as well as social appointments he has made with friends and family. **PMH** Bradycardia, diverticular disease, haemorrhoids. **DH** senna 7.5mg PO BD, Anusol cream topical ON.\n\n\n**Investigations**\n\nAddenbrooke’s Cognitive Examination: 81/100\n\nA diagnosis of early Alzheimer’s disease is made and he is advised to start donepezil hydrochloride 5mg PO OD and to attend a follow-up appointment in 3 months.\n\nQuestion: Select the most appropriate monitoring option required before starting donepezil hydrochloride.",
"sbaAnswer": [
"a"
],
"totalVotes": 6241,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,765 | false | 49 | null | 6,495,246 | null | false | [] | null | 6,889 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine is known to be cardiotoxic and serious adverse effects include myocarditis and cardiomyopathy. In the absence of symptoms or clinical suspicion it is not necessary to conduct routine monitoring with stress echocardiography",
"id": "34394",
"label": "e",
"name": "Stress echocardiogram",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A rare but serious adverse effect of clozapine is agranulocytosis. The white cell count must be checked at the start and closely monitored throughout the duration of treatment",
"id": "34390",
"label": "a",
"name": "Full blood count",
"picture": null,
"votes": 5701
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to check or monitor bone profile in treatment with clozapine",
"id": "34391",
"label": "b",
"name": "Bone profile",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to check or monitor serum magnesium in treatment with clozapine",
"id": "34393",
"label": "d",
"name": "Serum magnesium",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be checked at the start of treatment but it is not necessary to monitor renal function during treatment",
"id": "34392",
"label": "c",
"name": "Renal function tests",
"picture": null,
"votes": 12
}
],
"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": "2618",
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"demo": null,
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"id": "2821",
"name": "Antipsychotic side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
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"question": "Case Presentation: A 24 year old man has been detained under a Section 2 order for an acute psychotic episode on a background of treatment-resistant schizophrenia. The consultant psychiatrist decides to commence clozapine (Clozaril) 12.5mg PO OD with dose escalation planned over the next few days and weeks.\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 5741,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,766 | false | 50 | null | 6,495,246 | null | false | [] | null | 6,890 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Taking lithium levels more than 12 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level",
"id": "34398",
"label": "d",
"name": "Blood levels immediately before next dose",
"picture": null,
"votes": 47
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lithium levels should be taken no earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34399",
"label": "e",
"name": "Blood levels immediately post-dose",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34396",
"label": "b",
"name": "Blood levels 2 hours post-dose",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the correct time to take a lithium level, which is 12 hours after the last dose",
"id": "34395",
"label": "a",
"name": "Blood levels 12 hours post-dose",
"picture": null,
"votes": 6013
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34397",
"label": "c",
"name": "Blood levels 6 hours post-dose",
"picture": null,
"votes": 121
}
],
"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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"question": "Case Presentation: A 36 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.\n\n\nQuestion: Select the most appropriate monitoring option to assess the need for dose adjustments of lithium carbonate in this patient.",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
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173,467,767 | false | 51 | null | 6,495,246 | null | false | [] | null | 6,895 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to perform routine monitoring with stress echocardiography during anti-hypertensive treatment with ACE inhibitors",
"id": "34422",
"label": "c",
"name": "Stress echocardiogram",
"picture": null,
"votes": 23
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although peripheral oedema is a documented side effect with ACE inhibitors, it is generally not necessary to monitor weight during treatment",
"id": "34424",
"label": "e",
"name": "Weight",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to perform routine monitoring with spirometry during anti-hypertensive treatment with ACE inhibitors",
"id": "34423",
"label": "d",
"name": "Spirometry",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended that renal function be checked prior to and monitored during anti-hypertensive treatment with ACE inhibitors. The treatment may be modified or stopped if there is any evidence of new renal impairment",
"id": "34420",
"label": "a",
"name": "Renal function tests",
"picture": null,
"votes": 5630
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to monitor the heart rate during anti-hypertensive treatment with ACE inhibitors",
"id": "34421",
"label": "b",
"name": "Heart rate",
"picture": null,
"votes": 50
}
],
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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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"name": "ACE inhibitor side effects",
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"typeId": 5
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"question": "Case Presentation: A 52 year old man attends his GP to receive the results of an ambulatory blood pressure monitoring study. **PMH** stable angina pectoris. **DH** bisoprolol fumarate 10mg PO OD. NKDA\n\n\n**Investigations**\n\nClinic BP: 151/95mmHg\n\nAmbulatory daytime average: 142/84mmHg\n\nHis GP decides to prescribe ramipril 2.5mg PO OD and schedules a follow-up appointment in 2 weeks.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,768 | false | 52 | null | 6,495,246 | null | false | [] | null | 10,084 | {
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"__typename": "QuestionChoice",
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"explanation": "Furosemide is a loop diuretic used in the symptomatic treatment of cardiac failure. Daily weights are an effective way to measure the effectiveness of furosemide by quantifying fluid losses.",
"id": "50181",
"label": "a",
"name": "Daily weight measurements",
"picture": null,
"votes": 3643
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NT-proBNP is a hormone secreted by cardiomyocytes in response to stretching as a result of increased ventricular blood volume, it is therefore used diagnostically in cardiac failure. NT-proBNP is of little value in monitoring the symptomatic benefits of furosemide.",
"id": "50182",
"label": "b",
"name": "NT-ProBNP after 1 week",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide has been shown to lead to some haematological adverse effects such as agranulocytosis and aplastic anaemia, however, a full blood count has little efficacy in demonstrating the beneficial symptomatic effects of furosemide.",
"id": "50185",
"label": "e",
"name": "Full Blood Count daily",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urea and Electrolytes (U&Es) should be monitored during furosemide therapy as furosemide can lead to electrolyte imbalance and AKI. However, U&Es have little efficacy in demonstrating the symptomatic benefits of Furosemide.",
"id": "50184",
"label": "d",
"name": "Urea and Electrolytes daily",
"picture": null,
"votes": 305
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Echocardiograms are used in the diagnostic and prognostic monitoring of cardiac failure, however, it has little value in monitoring the symptomatic benefits of furosemide.",
"id": "50183",
"label": "c",
"name": "Echocardiogram after 1 week",
"picture": null,
"votes": 42
}
],
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"comment": "doesn't say in the bnf",
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"comment": "have you ever been to a ward like at all?",
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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 72-year-old female patient is admitted to the acute medical ward with breathlessness. She is due to commence treatment on Furosemide for congestive cardiac failure. Weight 72kg.\n\n\n**PMH**\nMyocardial infarction\nType 2 diabetes mellitus\n\n**DH**\n\n* Atorvastatin, 40mg nightly\n* Clopidogrel, 75mg OD\n* Bisoprolol, 5mg OD\n* Ramipril, 7.5mg OD\n* Metformin, 500mg BD\n\nQuestion: Which of the following is the most appropriate monitoring of the beneficial effects of Furosemide therapy?",
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173,467,769 | false | 53 | null | 6,495,246 | null | false | [] | null | 10,087 | {
"__typename": "QuestionSBA",
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"__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 utility with respect to starting this drug.",
"id": "50198",
"label": "c",
"name": "Troponin",
"picture": null,
"votes": 7
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"__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": "50200",
"label": "e",
"name": "Full blood count",
"picture": null,
"votes": 27
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Amiodarone contains iodine which in turn can commonly cause thyroid disorders. Both hypothyroidism and hyperthyroidism have been linked to amiodarone use. Amiodarone doesn't need to be withdrawn if it is essential and causes hypothyroidism, this can be treated with replacement therapy.",
"id": "50196",
"label": "a",
"name": "Thyroid function tests",
"picture": null,
"votes": 3967
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"answer": false,
"explanation": "While pancreatitis as a result of amiodarone use has been reported, this is a very rare side effect of amiodarone use. HPL also isn't a useful test as it can be raised for many reasons, it is also used for the **diagnosis** of acute pancreatitis, not for screening for acute pancreatitis.",
"id": "50199",
"label": "d",
"name": "Human pancreatic lipase",
"picture": null,
"votes": 8
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"__typename": "QuestionChoice",
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"explanation": "Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than magnesium.",
"id": "50197",
"label": "b",
"name": "Serum magnesium",
"picture": null,
"votes": 13
}
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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 64 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. \n\n\n**PMH** myocardial infarction with 100% LAD occlusion, hypertension, hypercholesterolaemia, COPD\n\n**DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 10mg PO OD, amlodipine 5mg PO OD, salmeterol 50micrograms INH BD, tiotropium 5micrograms INH OD, atorvastatin 80mg PO OD. NKDA\n\n**Investigations**\n\n24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds\n\nIt is recommended to start amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an Implantable Cardioverter Defibrillator (ICD).\n\nQuestion: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.",
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173,467,770 | false | 54 | null | 6,495,246 | null | false | [] | null | 10,136 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Fundoscopy isn't routinely used to monitor for adverse effects of corticosteroid treatment",
"id": "50410",
"label": "b",
"name": "Fundoscopy",
"picture": null,
"votes": 96
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hepatic function monitoring isn't routinely used for corticosteroid treatment",
"id": "50412",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cardiac monitoring is not routinely used for corticosteroid treatment",
"id": "50413",
"label": "e",
"name": "ECG",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
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"explanation": "A chest x-ray isn't routinely used to monitor for adverse effects of corticosteroid treatment",
"id": "50411",
"label": "c",
"name": "Chest X-ray",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prolonged steroid treatment is linked with growth alterations. Paediatric patients are likely to weigh more and have a reduced height if they are taking steroids for a prolonged time. Any slowing in growth should prompt a referral to a paediatrician",
"id": "50409",
"label": "a",
"name": "Height and weight",
"picture": null,
"votes": 3788
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "bnf says need to regularly check for cataracts and glaucoma - so fundoscopy should be correct?",
"createdAt": 1706629740,
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"comment": "fundoscopy looks at the back of the eye. I think you can see the beginnings of a cataract with the naked eye ",
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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 9-year-old girl is seen in the outpatient paediatrics with swollen, stiff and painful knees. This has been going on for the last 10 weeks.\n\n\n\n\n **Investigations**\n\n\nBoth knees are red in appearance. Both are swollen. Limited range of motion due to pain and stiffness.\n\n\nANA: +ve\n\n\nRheumatoid factor: +ve\n\n\nCRP: 36 mg/L (< 5mg/L)\n\n\nIt is decided that she is likely suffering from juvenile idiopathic arthritis and requires treatment with ibuprofen, methotrexate and prednisolone.\n\n\nQuestion: If she takes the prednisolone for a prolonged period of time, what parameters should be monitored?",
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173,467,771 | false | 55 | null | 6,495,246 | null | false | [] | null | 6,901 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Stopping strong opioids and NSAIDS simultaneously without additional PRN medication would result in a huge decrease in the pain relief for this patient",
"id": "34451",
"label": "b",
"name": "Stop regular morphine sulphate M/R and ibuprofen",
"picture": null,
"votes": 208
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Pain medication should be down titrated using the reverse ladder starting with strong opioids followed by weak opioids, NSAIDs and paracetamol. PRN Morphine sulphate can be prescribed as an intermediate step to provide analgesia when required. The patient is currently on a total of 40mg regular Morphine sulphate a day and her pain relief is well controlled with no PRN medication required. To step down her analgesic management, her regular morphine sulphate could be stopped while maintaining her usual PRN dose of morphine sulphate if additional pain relief is required",
"id": "34450",
"label": "a",
"name": "Stop regular morphine sulphate M/R and continue PRN morphine sulphate",
"picture": null,
"votes": 3293
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "40mg regular Morphine sulphate is equivalent to 400mg dihydrocodeine. Although decreasing the equivalent dose of dihydrocodeine is appropriate, 250mg is still more than the maximum recommended dose per day (240mg)",
"id": "34454",
"label": "e",
"name": "Substitute morphine sulphate M/R with dihydrocodeine 250mg PO",
"picture": null,
"votes": 1717
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "40mg regular Morphine sulphate approximates to buprenorphine 20 micrograms/h transdermal patch. Changing to 70 micrograms/h patch would be unnecessarily stepping up her pain control",
"id": "34453",
"label": "d",
"name": "Substitute morphine sulphate M/R with buprenorphine 70 micrograms/h transdermal patch",
"picture": null,
"votes": 289
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Similarly, stopping all three steps of the analgesic ladder without additional PRN medication would result in a huge decrease in the pain relief for this patient",
"id": "34452",
"label": "c",
"name": "Stop regular morphine sulphate M/R, ibuprofen and paracetamol",
"picture": null,
"votes": 88
}
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"__typename": "QuestionComment",
"comment": "I understand why the dihydrocodeine option is incorrect but I thought step-down on the WHO pain ladder is a weak opioid... Taking someone's regular morphine and relying on just paracetamol and ibroprofen doesn't sound like a nice idea(?)",
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"comment": "Most hospitals advise a slow tapering off/ weaning off the opioids, they say reducing about 10-20mg every 3-5 days until they no longer need it anymore, and this is usually with the help of the GP in the community, esp when patients are discharged.\n\nPersonally, it seems irresponsible to just take away her 40mg morphine suddenly and let her rely on just paracetamol and ibuprofen. but I believe the question is assuming that she WILL be using her PRN, hence not a sudden stop in morphine, this being the \"tapering\" or \"weaning off\" process. so its not entirely wrong, but also i dont think its entirely right either ( i wont recommend doing this when a doctor)\n\nHowever, that being said, this the best option out of all the options :D ",
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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 75-year-old woman is recovering in the Orthopedic Ward following a total hip replacement of her left hip 2 days ago. PMH Osteoarthritis, Type 2 Diabetes Mellitus, Hypertension. DH Paracetamol 1g QDS PO, Ibuprofen 400mg TDS PO, Omeprazole 20mg PO OD, Metformin 1g BD PO, Amlodipine 10mg PO OD, Morphine sulphate M/R (MST Continus ®) 20mg BD PO, Morphine sulphate I/R (Oramorph ®) 10mg/5mL PRN.\nHer surgery is uncomplicated and her postoperative pain is controlled with her usual analgesia. She has not taken any PRN Oramorph over the past 24 hours.\n\n**On Examination**\nHR 75/min and regular\n\nBP 120/75 mmHg\n\nRR 12/min\n\nO2 sats 97% RA\n\nTemp 37oC.\n\nQuestion:\nSelect the most appropriate decision option with regard to her pain management based on these data.",
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173,467,772 | false | 56 | null | 6,495,246 | null | false | [] | null | 6,908 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no clinical indication to change his form of statin or the frequency of his medication",
"id": "34488",
"label": "d",
"name": "Switch to simvastatin 20mg PO 12-hrly",
"picture": null,
"votes": 249
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the frequency of his medication",
"id": "34486",
"label": "b",
"name": "Atorvastatin 20mg PO 12-hrly",
"picture": null,
"votes": 79
},
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"__typename": "QuestionChoice",
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"explanation": "His LFT is not raised by more than 3 times the upper limit, there is no need to discontinue his statin at this point",
"id": "34489",
"label": "e",
"name": "Stop atorvastatin",
"picture": null,
"votes": 790
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the dose of his medication",
"id": "34487",
"label": "c",
"name": "Atorvastatin 40mg PO daily",
"picture": null,
"votes": 320
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "LFT should be done 3 months after initiation of statin medication. If the transaminase levels are raised by more than 3 times upper limit of normal, discontinue statin and repeat LFT in a month. If the transaminase are raised but less than 3 times upper limit of normal , continue statin and repeat LFT in a month. In this case, his transaminases are raised but not more than 3 times the upper limit, hence, his medication can be continued and LFT should be repeated in a months time",
"id": "34485",
"label": "a",
"name": "Atorvastatin 20mg PO daily",
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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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"name": "Statin side effects",
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"id": "75",
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"typeId": 5
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"topicId": 75,
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"question": "Case Presentation:\n\n\n\n\nA 55-year-old man presents to his GP for review of his blood cholesterol. He was started on atorvastatin 3 months ago for his hypercholesterolemia as his QRISK score was 20%. PMH Type 2 diabetes mellitus, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Metformin 500mg TDS PO.\n\n\n **On Examination**\nBP 125/85 mmHg\n\n\nHR 85/min\n\n\nRR 14\n\n\nO2 stats 95% RA\n\n\n **Investigations**\n 3 months ago, prior to treatment:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Albumin|40 g/L|35 - 50|\n|Alanine Aminotransferase (ALT)|30 IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|15 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|100 IU/L|25 - 115|\n|Gamma Glutamyl Transferase (GGT)|30 U/L|9 - 40|\n|Bilirubin|15 µmol/L|< 17|\n|Prothrombin Time (PT)|15 seconds|10 - 12|\n\n\n\n 3 days ago:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Albumin|45 g/L|35 - 50|\n|Alanine Aminotransferase (ALT)|85 IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|40 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|120 IU/L|25 - 115|\n|Gamma Glutamyl Transferase (GGT)|35 U/L|9 - 40|\n|Bilirubin|13 µmol/L|< 17|\n|Prothrombin Time (PT)|14 seconds|10 - 12|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of his hypercholesterolemia based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 5703,
"typeId": 1,
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173,467,773 | false | 57 | null | 6,495,246 | null | false | [] | null | 10,088 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's U&Es are normal. U&Es may become deranged in cases of digoxin toxicity (and as a consequence of ACE inhibitor therapy). In this case, there are no signs of digoxin toxicity and digoxin levels are below the therapeutic range. There is no indication to repeat the U&Es at this point.",
"id": "50205",
"label": "e",
"name": "Repeat Urea and Electrolytes",
"picture": null,
"votes": 56
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient's digoxin level is below the therapeutic range. Poor adherence to treatment could explain why this is the case. This patient is also tachycardic, suggesting that digoxin that their atrial fibrillation is poorly controlled. Checking adherence to digoxin would be the most appropriate next step before increasing the dose.",
"id": "50201",
"label": "a",
"name": "Check adherence",
"picture": null,
"votes": 3719
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's digoxin level is below the therapeutic range, they are therefore unlikely to be experiencing digoxin toxicity. An ECG may be helpful if toxicity is suspected to check for severe cardiac effects such as; sinoatrial and atrioventricular block,\npremature ventricular contractions (resulting in bigeminy or trigeminy) and PR prolongation and ST-segment depression.",
"id": "50204",
"label": "d",
"name": "ECG",
"picture": null,
"votes": 141
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's digoxin level is below the therapeutic range, decreasing the patient's dose of digoxin would therefore be inappropriate.",
"id": "50202",
"label": "b",
"name": "Decrease the digoxin dose",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's digoxin level is below the therapeutic range, stopping digoxin in this patient would not be effective in controlling their atrial fibrillation.",
"id": "50203",
"label": "c",
"name": "Stop digoxin",
"picture": null,
"votes": 22
}
],
"comments": [],
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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": "3618",
"name": "Digoxin Levels",
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"question": "Case Presentation: A 73-year-old gentleman takes Digoxin for atrial fibrillation. He attends the GP for a medication review. He is feeling well. His regular medicines are listed below. \n\n\n\n\n **PMH**\n\n\n * Atrial fibrillation\n * Previous MI\n * Peripheral vascular disease\n\n\n **DH**\n\n\n * Digoxin 250 micrograms OD\n * Ramipril 10mg OD\n * Amlodipine 5mg OD\n * Aspirin 75mg OD\n\n\n **On Examination**\n\n\n * HR 108 bpm\n * Blood pressure 126/84 mm/Hg\n\n\n **Investigations**\n\n\n * Digoxin level: 0.3nanograms/mL (Therapeutic range: 0.7-2nanograms/mL)\n\n\nBlood tests:\n\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|90 µmol/L|60 - 120|\n\n\n\nQuestion: Given the results of the above investigations, what is the most appropriate next step?",
"sbaAnswer": [
"a"
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173,467,774 | false | 58 | null | 6,495,246 | null | false | [] | null | 10,090 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this patient is hypertensive, she is asymptomatic and systemically well. Hypertension with a systolic pressure of over 180mmHg and signs of end-organ damage such as retinal haemorrhage, papilloedema, new confusion, chest pain or signs of heart or kidney failure would require immediate admission as this would suggest malignant hypertension. It would therefore not be appropriate to admit this patient. The most important step at this stage would be stopping her COCP as this could be a cause of her hypertension. (!)",
"id": "50215",
"label": "e",
"name": "Admit to hospital",
"picture": null,
"votes": 153
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Microgynon and Dianette are both combined oral contraceptive pills. Dianette is used specifically to treat acne. This patient has a blood pressure of over 160mmHg systolic and so any COCP would be inappropriate.",
"id": "50212",
"label": "b",
"name": "Change microgynon to dianette",
"picture": null,
"votes": 373
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is hypertensive. A systolic blood pressure of over 160mmHg (or >100mmHg diastolic) is a contraindication to COCP usage and it should be stopped.",
"id": "50211",
"label": "a",
"name": "Stop microgynon",
"picture": null,
"votes": 3199
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i) used to treat hypertension. Although an ACE-i would be the first choice of antihypertensive in a patient under the age of 55, stopping microgynon would be a more appropriate initial step. The patient's blood pressure may improve on cessation of the combined oral contraceptive pill.",
"id": "50213",
"label": "c",
"name": "Start ramipril",
"picture": null,
"votes": 158
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a blood pressure of over 160mmHg systolic and the combined oral contraceptive pill should be stopped. Taking a 7-day break from the pill would not be appropriate here. Breaks from the combined oral contraceptive pill are used to induce withdrawal bleeds.",
"id": "50214",
"label": "d",
"name": "Take a 7-day break from microgynon",
"picture": null,
"votes": 117
}
],
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"comment": "where is the supporting info?",
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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": "76",
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"typeId": 5
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"topicId": 76,
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"question": "Case Presentation: A 26-year-old female patient takes the combined oral contraceptive pill (COCP) for endometriosis. She feels well in herself. \n\n\n**PMH**\nEndometriosis\n\n**DH**\nMicrogynon 30 one tablet daily\n\n**On Examination**\n\n* HR 84 bpm\n* Blood pressure 166/92 mm/Hg\n\nQuestion: Given the results of the above investigations, what is the most appropriate next step?",
"sbaAnswer": [
"a"
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173,467,775 | false | 59 | null | 6,495,246 | null | false | [] | null | 10,144 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start insulin treatment.",
"id": "50453",
"label": "e",
"name": "Start humulin I long acting insulin",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start gliclazide 40mg PO OD.",
"id": "50452",
"label": "d",
"name": "Add gliclazide 40mg PO OD",
"picture": null,
"votes": 336
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. He should continue on this medication for another 3 months, if his HbA1c drops below 48 mmol/mol then his metformin dose may be reduced.",
"id": "50449",
"label": "a",
"name": "Make no changes to his anti diabetic medications",
"picture": null,
"votes": 2128
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. Stopping metformin now would be premature as his HbA1c is still above 48 mmol/mol.",
"id": "50451",
"label": "c",
"name": "Stop his metformin",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. ",
"id": "50450",
"label": "b",
"name": "Increase his metformin dose to 1g PO BD",
"picture": null,
"votes": 1473
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Isn't the target 48 if on metformin only? Why can't we increase the metformin?",
"createdAt": 1675355966,
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{
"__typename": "QuestionComment",
"comment": "literally",
"createdAt": 1706711460,
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"id": "40364",
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"comment": "He is above target, so you should titrate the metformin dose",
"createdAt": 1735817785,
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"__typename": "QuestionComment",
"comment": "48 = Add metformin\n53 = Target\n58 = Add another drug e.g. sulfonylurea",
"createdAt": 1706710423,
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"id": "40362",
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"comment": "'Increased if necessary...2 g total daily dose may alternatively be given as 1 g twice daily with meals only if control not achieved with once daily dose regimen. If control still not achieved then change to standard release tablets.'\n\nI suppose control is technically being achieved. Perhaps the take away here, is that if the clinician is struggling to overcome increased HbA1c, he should titrate up; if it's working don't interfere.\n\nJust to be clear, I got it wrong too",
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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 66-year-old gentleman attends the diabetes clinic for a review of his type 2 diabetes mellitus. \n\n\n**PMH** Type 2 diabetes mellitus, hypercholesterolaemia, hypertension, depression\n\n**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD, lisinopril 10mg PO OD, mirtazapine 15mg PO BD\n\n**Investigations**\n\nHbA1c 3 months ago: 59 mmol/mol (< 42 mmol/mol)\n\nHbA1c today: 51 mmol/mol (< 42 mmol/mol)\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,467,776 | false | 60 | null | 6,495,246 | null | false | [] | null | 18,115 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Given the BNF advises stopping statin therapy if serum transaminases are greater than 3 times the upper limit of the reference range it would be unwise to continue the statin",
"id": "10028564",
"label": "b",
"name": "Continue atorvastatin 20mg",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The BNF advises if serum transaminases are greater than 3 times the upper limit of the reference range then statin therapy should be discontinued.",
"id": "10028562",
"label": "a",
"name": "Stop atorvastatin 20mg",
"picture": null,
"votes": 2500
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no suggestion that the patient is acutely unwell or needs secondary care input, despite the abnormal blood test results.\n",
"id": "10028565",
"label": "c",
"name": "Admit to hospital",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect as statin therapy should be discontinued.",
"id": "10028566",
"label": "d",
"name": "Increase to atorvastatin 80mg",
"picture": null,
"votes": 22
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although other classes of lipid lowering drugs may be considered as a result, the most important action is to stop this patient's atorvastatin, in light of the recent blood test results.",
"id": "10028563",
"label": "e",
"name": "Add ezetimibe",
"picture": null,
"votes": 10
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
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"name": "Statins",
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"name": "General Practice",
"typeId": 5
},
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"question": "Case Presentation: A 59-year-old man attends the GP to discuss his most recent blood test results. He was commenced on atorvastatin 20mg PO ON for primary prevention of cardiovascular events. \n\n\n **Investigations**\nALT before treatment: 40 (10 - 50 IU/L)\nALT 3 weeks later: 163 (10 - 50 IU/L)\n\n\nQuestion: Select the most appropriate decision option with regard to the atorvastatin based on these data.",
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} | MarksheetMark |
173,467,903 | false | 1 | null | 6,495,250 | null | false | [] | null | 10,132 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen does not commonly cause weight gain.",
"id": "50393",
"label": "e",
"name": "Ibuprofen 400mg PO TDS",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Folic acid does not commonly cause weight gain.",
"id": "50391",
"label": "c",
"name": "Folic acid 5mg PO once weekly",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol does not commonly cause weight gain.",
"id": "50390",
"label": "b",
"name": "Salbutamol 200micrograms INH QDS",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate does not commonly cause weight gain.",
"id": "50392",
"label": "d",
"name": "Methotrexate 20mg PO once weekly",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Weight gain is a very common side effect of atypical antipsychotics. Olanzapine and clozapine are the atypical antipsychotics most likely to cause weight gain whereas atypical antipsychotics such as aripiprazole have a lower risk of causing weight gain.",
"id": "50389",
"label": "a",
"name": "Olanzapine 10mg PO OD",
"picture": null,
"votes": 3831
}
],
"comments": [],
"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,
"highlights": [],
"id": "2657",
"pictures": [],
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"demo": null,
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"id": "3661",
"name": "Olanzapine commonly causes weight gain",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
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"question": "Case Presentation: A 34-year-old gentleman attends his GP complaining of weight gain. His regular medicines are listed (below).\n\n\n**PH** Asthma, Schizophrenia, Rheumatoid Arthritis\n\n**DH** Sertraline 50mg PO OD, Folic acid 5mg PO once weekly, Olanzapine 10mg PO OD, Methotrexate 20mg PO once weekly, Ibuprofen 400mg PO TDS\n\n**On examination**\n\nBP 129/69mmHg, HR 68, RR 14, Weight 89kg (84kg one month ago)\n\nQuestion: Select the medication that is most likely to have contributed to this patient's weight gain.",
"sbaAnswer": [
"a"
],
"totalVotes": 3848,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,904 | false | 2 | null | 6,495,250 | null | false | [] | null | 18,106 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Low mood is not a known side effect of semaglutide.",
"id": "10028520",
"label": "d",
"name": "Low mood",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Semaglutide causes decreased appetite, which contributes to weight loss.",
"id": "10028519",
"label": "c",
"name": "Increased appetite",
"picture": null,
"votes": 51
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Semaglutide and other GLP-1 analogues work to cause weight loss, not weight gain.",
"id": "10028518",
"label": "b",
"name": "Weight gain",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Altered taste is a side effect of semaglutide however it is not as common as nausea.",
"id": "10028521",
"label": "e",
"name": "Altered taste",
"picture": null,
"votes": 37
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Nausea and vomiting are of the most common side effects of semaglutide, which is a GLP-1 analogue and one of the newer treatments licensed for management of type 2 diabetes and obesity. It is also one of the commonest reasons for non-compliance and discontinuation of the medication, and is worst when patients are first started on the medication.",
"id": "10028517",
"label": "a",
"name": "Nausea",
"picture": null,
"votes": 2598
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
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"id": "2693",
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"typeId": 7
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"chapterId": 2693,
"demo": null,
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"id": "6081",
"name": "Diabetes, GLP-1 analogues",
"status": null,
"topic": {
"__typename": "Topic",
"id": "162",
"name": "General practice",
"typeId": 5
},
"topicId": 162,
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"question": "Case Presentation: A 55-year-old man with type 2 diabetes presents to the GP for his annual diabetes review. His HbA1c is worse than before, and this is despite being on 3 anti-diabetic agents. The GP decides to commence the patient on semaglutide 3mg OD PO.\n\n\nQuestion: Select the adverse affect most likely to be caused by this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 2735,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,905 | false | 3 | null | 6,495,250 | null | false | [] | null | 6,881 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Renal function should be checked at baseline and during ongoing treatment as gentamicin is nephrotoxic",
"id": "34350",
"label": "a",
"name": "Renal function tests",
"picture": null,
"votes": 5353
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary as there is nothing to make one suspicion of any inflammatory process or ongoing infection",
"id": "34351",
"label": "b",
"name": "C-reactive protein",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be useful as a baseline but is not routinely done prior to administering gentamicin",
"id": "34353",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary as there is nothing to make one suspicion of any ongoing infection",
"id": "34352",
"label": "c",
"name": "Full blood count",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary prior to administering gentamicin",
"id": "34354",
"label": "e",
"name": "Visual fields assessment",
"picture": null,
"votes": 48
}
],
"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2813",
"name": "Gentamicin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2813,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "6881",
"isLikedByMe": 0,
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"likes": 0,
"multiAnswer": null,
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 65 year old man is admitted to the surgical ward prior to an elective total knee replacement. He is due to receive gentamicin 300mg IV as a one-off dose for surgical prophylaxis prior to the procedure.\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 5547,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,906 | false | 4 | null | 6,495,250 | null | false | [] | null | 6,887 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to monitor serum ACTH during treatment with prednisolone",
"id": "34384",
"label": "e",
"name": "Serum ACTH",
"picture": null,
"votes": 100
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The [BNFC](https://bnfc.nice.org.uk/drugs/prednisolone/#monitoring-requirements) states that for children taking oral prednisolone, blood pressure and urinary glucose should be monitored weekly",
"id": "34381",
"label": "b",
"name": "Blood pressure and urinary glucose ",
"picture": null,
"votes": 1878
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The BNFC advises that for patients with systemic sclerosis, blood pressure and renal function, specifically creatinine, should be measured as there is an increased incidence of scleroderma renal crisis.",
"id": "34380",
"label": "a",
"name": "Blood pressure and renal function",
"picture": null,
"votes": 525
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The BNFC recommends that for oral prednisolone, blood pressure and urinary glucose should be monitored weekly.",
"id": "34383",
"label": "d",
"name": "Height and weight ",
"picture": null,
"votes": 2674
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The BNFC recommends urinary glucose measurements.",
"id": "34382",
"label": "c",
"name": "Capillary blood glucose",
"picture": null,
"votes": 380
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "on the bnf it says \"The height and weight of children receiving prolonged treatment with corticosteroids should be monitored annually\"",
"createdAt": 1675271437,
"dislikes": 0,
"id": "17553",
"isLikedByMe": 0,
"likes": 21,
"parentId": null,
"questionId": 6887,
"replies": [
{
"__typename": "QuestionComment",
"comment": "But also if you scroll down a little further, it says BP and urinary glucose needs to be done weekly, specifically for oral pred whereas yours is for all corticosteroids",
"createdAt": 1675354480,
"dislikes": 1,
"id": "17623",
"isLikedByMe": 0,
"likes": 8,
"parentId": 17553,
"questionId": 6887,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Sclerosis Serotonin",
"id": 12407
}
},
{
"__typename": "QuestionComment",
"comment": "Saumiya's point is still valid tho - you would monitor all of those things. The options need to be changed",
"createdAt": 1698616140,
"dislikes": 1,
"id": "33302",
"isLikedByMe": 0,
"likes": 14,
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Epidermis Abdominal",
"id": 36610
}
},
{
"__typename": "QuestionComment",
"comment": "forreal",
"createdAt": 1706639933,
"dislikes": 0,
"id": "40301",
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"likes": 0,
"parentId": 17553,
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"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Lateral Kinase",
"id": 3545
}
}
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Saumiya",
"id": 29675
}
}
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"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2819",
"name": "Prednisolone side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"conditions": [],
"difficulty": 3,
"dislikes": 15,
"explanation": null,
"highlights": [],
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"multiAnswer": null,
"pictures": [],
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"psaSectionId": 7,
"qaAnswer": null,
"question": "A 7-year-old girl is seen in the outpatient paediatrics clinic with tiredness, weight gain and swelling of her hands and feet and around her eyes.\n\nInvestigations\n\nUrine dip: Protein 3+\n\nShe is given a provisional diagnosis of nephrotic syndrome secondary to minimal change disease. She is prescribed prednisolone 25mg PO OD and given a follow-up appointment in 6 weeks.\n\nSelect the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"b"
],
"totalVotes": 5557,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,907 | false | 5 | null | 6,495,250 | null | false | [] | null | 6,891 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to check serum prolactin at baseline prior to treatment as the anti-dopaminergic effects of all antipsychotic drugs may cause hyperprolactinaemia",
"id": "34404",
"label": "e",
"name": "No routine monitoring is required",
"picture": null,
"votes": 230
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Blood dyscrasias are a rare adverse effect of antipsychotic medications but routine full blood count monitoring is usually not necessary (exception: clozapine)",
"id": "34402",
"label": "c",
"name": "Leucocyte count",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended to check serum prolactin at baseline prior to treatment as the anti-dopaminergic effects of all antipsychotic drugs may cause hyperprolactinaemia",
"id": "34400",
"label": "a",
"name": "Serum prolactin",
"picture": null,
"votes": 4967
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This questionnaire will give an indication of the severity of any co-existing affective disorders. It is not used routinely to determine adverse effects of antipsychotic treatment on mood",
"id": "34401",
"label": "b",
"name": "PHQ-9",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to check or monitor liver function during treatment with aripiprazole",
"id": "34403",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 50
}
],
"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2823",
"name": "Antipsychotic side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
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"conceptId": 2823,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6891",
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"likes": 0,
"multiAnswer": null,
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 25 year old man is seen in the primary care psychiatry outreach clinic and diagnosed with schizophrenia with predominantly positive symptoms. He is advised to commence treatment with aripiprazole 15mg PO OD and to attend a follow-up appointment in two weeks.\n\n\nQuestion: Select the most appropriate monitoring option required before starting aripiprazole.",
"sbaAnswer": [
"a"
],
"totalVotes": 5299,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,908 | false | 6 | null | 6,495,250 | null | false | [] | null | 10,082 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to measure renal function prior to starting atorvastatin to assess for adverse effects. Monitoring renal function would not assess for treatment response.",
"id": "50174",
"label": "d",
"name": "Urea and electrolytes",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that liver function should be measured prior to starting treatment and at 3 months and 12 months afterwards as atorvastatin is known to be hepatotoxic. However, this would be monitoring the treatment for an **adverse** effect, the question asks for the test that monitors treatment response.",
"id": "50173",
"label": "c",
"name": "Liver function test",
"picture": null,
"votes": 1026
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Statins work by inhibiting the enzyme HMG-CoA reductase, an enzyme that is responsible for the synthesis of cholesterol. By blocking this pathway, statins reduce the total level of circulating cholesterol and LDLs. A lipid profile at the start of treatment and in subsequent consultations is important in monitoring treatment response.",
"id": "50171",
"label": "a",
"name": "Lipid profile",
"picture": null,
"votes": 2787
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This should only be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin. It also would not be used to measure treatment response.",
"id": "50175",
"label": "e",
"name": "Creatinine kinase",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Full blood count has no role in the monitoring of patients taking statins.",
"id": "50172",
"label": "b",
"name": "Full blood count",
"picture": null,
"votes": 6
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__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,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3614",
"name": "Atorvastatin treatment response should be monitored by measuring the patient's full lipid profile",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
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"question": "Case Presentation: A 56 year old gentleman attends a follow-up appointment at his GP. \n\n\n**PMH** hypertension\n\n**DH** ramipril 10mg PO OD, paracetamol 1g PO QDS\n\n**FH** Father died of heart attack at the age of 50. Mother died of an ischaemic stroke at the age of 64\n\n**SH** current smoker, 25-30 cigarettes a day but currently attending smoking cessation counselling.\n\n**Investigations**\n\nQ-risk score: 11%\n\nIt is decided that starting atorvastatin 20mg PO OD would help lower his risk of a cardiac event. A repeat consultation is booked in for 3 months later to assess treatment response.\n\nQuestion: Select the most appropriate option to monitor for treatment response at the next consultation.",
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173,467,909 | false | 7 | null | 6,495,250 | null | false | [] | null | 10,083 | {
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"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate is not known to cause any cardiac adverse reactions. An ECG is therefore not routine in the monitoring of methotrexate therapy.",
"id": "50179",
"label": "d",
"name": "ECG before starting",
"picture": null,
"votes": 10
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate is teratogenic and may also reduce fertility. It is therefore recommended that effective contraception is used during treatment and for 6 months afterwards for both men and women. Despite this, pregnancy prevention programmes are not routinely used in methotrexate therapy.",
"id": "50178",
"label": "c",
"name": "Pregnancy prevention programme",
"picture": null,
"votes": 150
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"answer": false,
"explanation": "Methotrexate level is not used in the monitoring of methotrexate therapy.",
"id": "50180",
"label": "e",
"name": "Methotrexate level every week",
"picture": null,
"votes": 3
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Methotrexate increased the risk of blood dyscrasias, liver cirrhosis and blood dyscrasias. Bloods should be checked every 1-2 weeks until dosing stabilised and then every 2-3 months.",
"id": "50176",
"label": "a",
"name": "FBC, U&E and LFTs every 1-2 weeks until stabilised",
"picture": null,
"votes": 3598
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although Methotrexate is a folate antagonist, Haematinics (B12, folate, ferritin and intrinsic factor) are rarely monitored. Folic acid is instead taken weekly, to prevent deficiency.",
"id": "50177",
"label": "b",
"name": "Haematinics every 1-2 weeks until stabilised",
"picture": null,
"votes": 42
}
],
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"explanation": "# Summary\n\nMethotrexate is one of several conventional disease-modifying anti-rheumatic drugs (DMARDs) used in a variety of autoimmune diseases. It is an inhibitor of dihydrofolate reductase, one of the key enzymes involved in purine and pyrimidine (and therefore DNA) synthesis. It is an immunosuppressive treatment that has several significant side effects, including hepatotoxicity, bone marrow suppression and pneumonitis. Folic acid should be co-prescribed with methotrexate as this reduces mucosal and gastrointestinal side effects (but should be taken on a different day as it reduces methotrexate's efficacy). Patients require regular monitoring with blood tests (full blood count, renal and liver function) and for women with the potential to become pregnant, highly effective contraception should be advised as methotrexate is teratogenic.\n\n# Definition\n\nMethotrexate is a conventional DMARD that inhibits DNA synthesis by inhibiting the enzyme dihydrofolate reductase. It has both immunosuppressive and cytotoxic effects and so is used in both autoimmune diseases such as rheumatoid arthritis, Crohn's disease and psoriasis, as well as in cancer treatment (e.g. as part of chemotherapy regimens for lymphoma).\n\n# Side Effects\n\n- Gastrointestinal upset (e.g. nausea, diarrhoea, abdominal pain)\n- Stomatitis and mucosal ulcers\n- Anorexia\n- Headache\n- Hair loss\n- Fatigue\n- Increased risk of infection; may reactivate latent infections\n- Teratogenicity \n- Myelosuppression with subsequent anaemia, leukopenia and thrombocytopenia\n- Hepatotoxicity including liver cirrhosis\n- Renal toxicity\n- Pulmonary toxicity especially pneumonitis; increased risk in rheumatoid arthritis\n- Photosensitivity reactions - may present with blistering or papular rashes and swelling of affected skin\n\n# Investigations\n\n**Baseline tests prior to starting methotrexate:**\n\n- Blood pressure\n- Weight and height\n- Pregnancy testing if appropriate \n- Full blood count (FBC)\n- U&Es for renal function (dose reduction may be needed; avoid methotrexate in severe impairment)\n- Liver function tests (avoid if baseline hepatic impairment)\n- Hepatitis B and C and HIV serology\n- Consider screening for tuberculosis and other lung disease e.g. with a chest X-ray\n\n**Monitoring whilst on treatment:**\n\n- FBC, U&Es and LFTs should be checked every 2 weeks until the dose of methotrexate is stable\n- They should then be checked monthly for 3 months, then at least every 3 months thereafter\n- More frequent monitoring may be required in patients at increased risk of toxicity\n\n**Ensure no contraindications are present, for example:**\n\n- Active infection - methotrexate should be paused during acute infections\n- Immunodeficiency syndromes\n- Ascites or significant pleural effusion (increases the risk of methotrexate accumulation unless drained)\n- Significant hepatic or renal impairment\n- Current peptic ulceration\n- Pregnancy or breast-feeding\n- Co-administration of another anti-folate medication e.g. co-trimoxazole\n\n**Consider cautions, such as:**\n\n- Excess alcohol intake (increases hepatotoxicity risk)\n- Renal impairment (may need to reduce dose)\n- Pre-existing haematological abnormalities e.g. anaemia, thrombocytopenia\n- Chronic respiratory disease\n- History of recurrent infections (e.g. urinary tract infections, chronic obstructive pulmonary disease exacerbations)\n- Frail or elderly patients (may require dose reduction)\n- Dehydration - may need to pause treatment e.g. if the patient develops diarrhoea or vomiting\n\n# Management\n\n- Methotrexate is usually taken as a weekly tablet, on the same day each week\n- Folic acid 5mg should be co-prescribed to be taken once weekly on a different day\n- Patients should receive the following vaccines:\n- Annual influenza vaccine\n- One-off pneumococcal vaccine (ideally prior to starting methotrexate)\n- Covid vaccination as per national guidelines\n- If aged 50+, the recombinant shingles vaccine (Shingrix, which is not a live vaccine)\n- Advise patients to avoid contact with people with chickenpox and shingles, and seek urgent medical advice if exposed\n- Advise patients that live vaccines (e.g. yellow fever) are contraindicated whilst on methotrexate\n- All patients should be under a specialist team (e.g. rheumatology), usually with a shared care agreement for prescribing and monitoring in primary care\n- A patient card should be provided with safety information and to show to other healthcare professionals\n- Medication interactions are important to be aware of, including:\n- NSAIDs increase the risk of methotrexate toxicity by decreasing renal excretion\n- Trimethoprim or co-trimoxazole may cause severe bone marrow suppression\n- Anti-epileptic medications may reduce effectiveness of methotrexate\n- Theophylline clearance may be reduced by methotrexate\n- Folic acid (may be included in multivitamin supplements) reduces effectiveness of methotrexate if taken together\n- Ensure women of childbearing age are advised of the risk of teratogenicity in pregnancy\n- Highly effective contraception is recommended\n- Methotrexate should be stopped at least 3-6 months before conception \n- Breastfeeding is also contraindicated\n- There is no strong evidence to suggest men need to stop methotrexate whilst trying to conceive, however the BNF suggests waiting 6 months after stopping methotrexate\n- Patients should be warned regarding the risk of photosensitivity reactions and advised to use sunscreen, protective clothing and avoid UV light exposure\n- If there are significant abnormalities in monitoring blood tests (e.g. thrombocytopenia, ALT or ALT > 100) or clinical signs or symptoms of complications (e.g. unexplained bruising suggestive of bone marrow suppression), hold methotrexate and arrange urgent specialist review \n- In cases of methotrexate toxicity, folinic acid (e.g. as calcium folinate) can be given to counteract methotrexate's folate-antagonist mechanism of action\n\n# NICE Guidelines\n\n[NICE CKS - DMARDs](https://cks.nice.org.uk/topics/dmards/)\n\n# References\n\n[BNF - Methotrexate](https://bnf.nice.org.uk/drugs/methotrexate/)\n\n[Specialist Pharmacy Service - Methotrexate monitoring](https://www.sps.nhs.uk/monitorings/methotrexate-monitoring/)",
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"question": "Case Presentation: A 36-year-old female patient attends the outpatient rheumatology clinic. He is due to commence treatment on methotrexate for rheumatoid arthritis. Weight 63kg.\n\n\n**PMH**\nDepression\n\n**DH**\nCerazette, 1 tablet daily\nCitalopram, 20mg OD\n\nQuestion: Which of the following is the most appropriate monitoring of a patient starting methotrexate?",
"sbaAnswer": [
"a"
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173,467,910 | false | 8 | null | 6,495,250 | null | false | [] | null | 10,135 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray is not routinely be used for monitoring prior to starting lithium.",
"id": "50407",
"label": "d",
"name": "Chest X-ray, thyroid function test, renal function",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray wouldn't routinely be used for monitoring prior to starting lithium.",
"id": "50405",
"label": "b",
"name": "Chest X-ray, ECG, renal function",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
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"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring. A CT head is not a required part of monitoring either.",
"id": "50408",
"label": "e",
"name": "ECG, liver function, CT head",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring.",
"id": "50406",
"label": "c",
"name": "ECG, liver function, renal function",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Renal function is monitored due to the risk of toxicity if there is improper clearance of lithium. Cardiac function is monitored due to the risk of cardiac disease such as QT interval prolongation.\nBody weight should also be measured prior to starting treatment and a full blood count should be taken.",
"id": "50404",
"label": "a",
"name": "ECG, renal function, thyroid function tests",
"picture": null,
"votes": 3589
}
],
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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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"name": "Monitoring is required prior to starting lithium",
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"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
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"question": "Case presentation: A 28 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.\n\n\nQuestion: Select the most appropriate monitoring that this patient should undergo prior to starting lithium carbonate.",
"sbaAnswer": [
"a"
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173,467,911 | false | 9 | null | 6,495,250 | null | false | [] | null | 18,108 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An echocardiogram may form a part of monitoring his heart function in the long term and may be performed during this admission if it has not been done for a while, however it will not show effective the furosemide is working.",
"id": "10028528",
"label": "b",
"name": "Echocardiogram",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Daily weights should be part of any inpatient diuresis management plan as reduction in weight suggests effective treatment.",
"id": "10028527",
"label": "a",
"name": "Weight",
"picture": null,
"votes": 2560
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A BNP blood test may be valuable in diagnosis of heart failure however it will not specifically or accurately measure furosemide efficacy in the same way that daily weights would.",
"id": "10028531",
"label": "e",
"name": "NT-proBNP test",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Blood pressure can be affected my various factors and is not a good marker of furosemide efficacy.",
"id": "10028529",
"label": "c",
"name": "Blood pressure",
"picture": null,
"votes": 39
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although imaging may form a part of diagnosing an exacerbation of heart failure, and may be done at intervals to assess progress, this would be with a chest x-ray rather than a CT scan.",
"id": "10028530",
"label": "d",
"name": "CT Thorax",
"picture": null,
"votes": 8
}
],
"comments": [],
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"name": "Diuresis monitoring",
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"name": "Medicine",
"typeId": 5
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"question": "Case Presentation: A 91-year-old man attends A&E with worsening shortness of breath and pitting oedema to both knees.\n\n\n**PMH** Congestive cardiac failure, Hypertension, Type 2 Diabetes\n\n**DH** Ramipril 5mg PO OD, Furosemide 20mg PO OD, Bisoprolol 2.5mg PO OD, Metformin 500mg PO BD\n\nShe is admitted to the acute medical ward and commenced on Furosemide 40mg IV PO.\n\nQuestion: Select the most appropriate monitoring option to assess efficacy of this treatment during his admission.",
"sbaAnswer": [
"a"
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173,467,912 | false | 10 | null | 6,495,250 | null | false | [] | null | 18,109 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although this patient has ana irregular rhythm, they do not require daily ECGs.",
"id": "10028535",
"label": "d",
"name": "Daily ECG",
"picture": null,
"votes": 23
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. One of the main advantages of DOACs such as apixaban is that they do not require routine monitoring, as opposed to warfarin, which was previously more commonly used for anticoagulation in patients with AF.",
"id": "10028532",
"label": "a",
"name": "No routine monitoring is required",
"picture": null,
"votes": 2586
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The thrombin time has no role in monitoring the effectiveness of apixaban.",
"id": "10028536",
"label": "e",
"name": "Thrombin time",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a routine blood test and is not indicated.",
"id": "10028533",
"label": "b",
"name": "Apixaban levels",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "INR is used to monitor warfarin, an alternative but now less popular anticoagulant, primarily due to the monitoring that is required.",
"id": "10028534",
"label": "c",
"name": "INR",
"picture": null,
"votes": 12
}
],
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"__typename": "Concept",
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"demo": null,
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"name": "Anticoagulation",
"status": null,
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"__typename": "Topic",
"id": "326",
"name": "Medicine",
"typeId": 5
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"question": "Case Presentation: An 88-year-old woman is diagnosed with non-valvular atrial fibrillation during an inpatient stay and is commenced on apixaban 2.5mg PO BD for stroke prophylaxis.\n\n\n**PMH** Congestive cardiac failure, TIA, Hypertension\n\n**DH** Amlodepine 5mg PO OD, Aspirin 75mg PO OD, Omeprazole 20mg PO OD, Ramipril 2.5mg PO OD\n\nQuestion: Select the most appropriate monitoring option to assess the effectiveness of this treatment.",
"sbaAnswer": [
"a"
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173,467,913 | false | 11 | null | 6,495,250 | null | false | [] | null | 6,900 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As his morning blood glucose level is persistently high, adjustments should be made to his long acting evening insulin dose instead of just giving a PRN short acting insulin",
"id": "34446",
"label": "b",
"name": "Biphasic insulin detemir (Levemir Penfill) 15 units SC and soluble insulin (Actrapid ®) 2 units SC",
"picture": null,
"votes": 552
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Decreasing the insulin dose to 13 units would be inappropriate as this could worsen his glycaemic control",
"id": "34447",
"label": "c",
"name": "Decrease Biphasic insulin detemir (Levemir Penfill) to 13 units SC BD",
"picture": null,
"votes": 207
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made",
"id": "34448",
"label": "d",
"name": "Increase evening Biphasic insulin detemir (Levemir Penfill) to 22 units SC",
"picture": null,
"votes": 417
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient has poorly controlled hyperglycaemia, with high levels of blood glucose in the morning. After ruling our DKA with serum and urinary ketones, a dose adjustment should be considered if glucose levels remain high. As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made",
"id": "34445",
"label": "a",
"name": "Increase evening Biphasic insulin detemir (Levemir Penfill) to 17 units SC",
"picture": null,
"votes": 3978
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Increasing to 22 units is more than 20% of his usual dose. Variable rate insulin infusion is considered in a hyperglycaemic patients who are nil by mouth and who have failed to respond to adjustments of their usual insulin regime",
"id": "34449",
"label": "e",
"name": "Stop biphasic insulin detemir (Levemir Penfill) SC and start variable rate insulin infusion",
"picture": null,
"votes": 248
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "where on the BNF can i find this?\n",
"createdAt": 1735803707,
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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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"name": "Insulin Titration",
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"question": "Case Presentation:\n\n\n\n\nA 25-year-old lady was admitted to the Respiratory Ward following an exacerbation of asthma. PMH Type 1 diabetes mellitus, Asthma. DH Salbutamol 200micrograms INH PRN, Fluticasone 50 micrograms BD INH 12-hrly, Biphasic insulin detemir (Levemir Penfill) 15 units SC 12-hrly.\n\n\n **On Examination**\n\nHR 90/min and regular\n\n\nBP 125/85 mmHg\n\n\nRR 25/min\n\n\nO2 sats 96% on room air\n\n\nTemperature 37.5oC.\n\n\n **Investigations**\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|4 mmol/L|3.5 - 5.3|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|85 µmol/L|60 - 120|\n\n\nUrinary ketones negative.\n\n\nAverage capillary blood glucose readings are 15 mmol/L prior to breakfast and 5.8 mmol/L prior to evening meal (normal range 3.5-5.5 mmol/L).\n\n\nVBG Ketones 0.3 mmol/L (<0.6mmol/L)\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the evening dose of insulin based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 5402,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,914 | false | 12 | null | 6,495,250 | null | false | [] | null | 6,903 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>",
"id": "34463",
"label": "d",
"name": "Nitrofurantoin 50mg QDS for 7 days",
"picture": null,
"votes": 705
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup> ",
"id": "34464",
"label": "e",
"name": "Trimethoprim 200mg PO BD for 7 days",
"picture": null,
"votes": 2144
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>",
"id": "34461",
"label": "b",
"name": "Nitrofurantoin 50mg QDS for 3 days",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup>. For UTI in males, antibiotic should be given over a total of 7 days",
"id": "34460",
"label": "a",
"name": "Trimethoprim 200mg PO BD for 3 days, 100mg PO BD for the next 4 days",
"picture": null,
"votes": 2235
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Piperacillin-tazobactam is reserved for patients with complicated UTI and in this situation, there is no evidence to support the susceptibility of the microorganism to piperacillin-tazobactam, hence, is less ideal than trimethoprim",
"id": "34462",
"label": "c",
"name": "Piperacillin-tazobactam 4.5g TDS IV",
"picture": null,
"votes": 59
}
],
"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
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"demo": null,
"entitlement": null,
"id": "2835",
"name": "Management of UTI in renal disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
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"topicId": 74,
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"dislikes": 5,
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"question": "Case Presentation:\n\n\n\n\nA 75-year-old man is transferred from the Acute Medical Unit to the Care of the Elderly Ward for treatment of his urinary tract infection.\n\n\n **On Examination**\nBP 115/75 mmHg, HR 95/min and regular, RR 12/min, Temperature 38 C. O2 sats 94% RA.\n\n\n **Investigations**\nUrine dipstick ++ leucocytes and nitrates\n\n\nUrine MCS\n\n\nS Nitrofurantoin\n\n\nS Trimethoprim\n\n\nR Amoxicillin\n\n\nR Co-Amoxiclav\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|4.8 mmol/L|3.5 - 5.3|\n|Urea|8.5 mmol/L|2.5 - 7.8|\n|Creatinine|210 µmol/L|60 - 120|\n|eGFR|26 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the management of his infection based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 5225,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,915 | false | 13 | null | 6,495,250 | null | false | [] | null | 6,910 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This option is less ideal for the reason mentioned above with regards to risk involved in patients with acute pancreatitis and as he is only on metformin, he should be started on dual therapy before moving on to triple therapy",
"id": "34499",
"label": "e",
"name": "Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD",
"picture": null,
"votes": 57
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has poorly controlled hyperglycaemia (HbA1c 65) and is already on the maximum tolerable dose of metformin. Due to his background of pancreatitis, an alternative to GLP-1 (liraglutide) and DPP4 inhibitor (sitagliptin) should be considered. DPP4 inhibitor reduces the degradation of GLP-1 by inhibiting the activity of serum DPP-4. An increase in GLP-1 results in an increased availability of incretins, stimulating insulin secretion from pancreatic β-cells. Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved",
"id": "34495",
"label": "a",
"name": "Add gliclazide 40mg OD",
"picture": null,
"votes": 4557
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved",
"id": "34496",
"label": "b",
"name": "Add sitagliptin 100mg PO OD to metformin",
"picture": null,
"votes": 1134
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved",
"id": "34497",
"label": "c",
"name": "Add liraglutide 0.6mg OD SC",
"picture": null,
"votes": 111
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is currently on maximal tolerable dose of metformin, there are other oral hypoglycaemic agents that should be considered prior to starting someone on insulin",
"id": "34498",
"label": "d",
"name": "Switch to biphasic insulin detemir 20 units SC",
"picture": null,
"votes": 54
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Doesn't Gliclazide also act on cells of the pancreas and therefore also be unsuitable for use in someone with Pacreatitis?",
"createdAt": 1646752679,
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"__typename": "QuestionComment",
"comment": "I just checked the BNF for all of these drugs + associations with pancreatitis - gliclazide was the only one that had no published information to contradict treatment",
"createdAt": 1736620914,
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"id": "60277",
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"displayName": "Embolism Bladder",
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"displayName": "Axillary JAK",
"id": 10451
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}
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"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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
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"demo": null,
"entitlement": null,
"id": "2842",
"name": "Diabetes Mellitus",
"status": null,
"topic": {
"__typename": "Topic",
"id": "75",
"name": "GP",
"typeId": 5
},
"topicId": 75,
"totalCards": null,
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"question": "Case Presentation:\n\n\n\n\nA 65-year-old man presents to his GP for review of his blood glucose. He was started on metformin a year ago when his HbA1c was found to be 55 and 58mmol/mol when tested on two separate occasions. PMH Type 2 Diabetes mellitus, Hypertension, Hypercholesterolemia, Chronic pancreatitis. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 1g BD PO.\n\n\n **On Examination**\nBP 125/85 mmHg\n\n\nHR 90/min\n\n\nRR 16\n\n\nO2 sats 94% RA\n\n\n **Investigations**\nHbA1c 65mmol/mol (normal range 20-48 mmol/mol)\n\n\nCapillary blood glucose 15.3 mmol/L (normal <6.1 mmol/L)\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data",
"sbaAnswer": [
"a"
],
"totalVotes": 5913,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,916 | false | 14 | null | 6,495,250 | null | false | [] | null | 10,092 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Starting vancomycin would be correct however there is no clinical indication for stopping this patient's colecalciferol.",
"id": "50222",
"label": "b",
"name": "Suspend his colecalciferol and start vancomycin 125mg PO QDS",
"picture": null,
"votes": 479
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no clinical indication for stopping this patient's colecalciferol.",
"id": "50223",
"label": "c",
"name": "Suspend his colecalciferol",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Starting this patient on vancomycin would be the right thing to do however this is the wrong dose, and you would still also need to suspend the PPI he is taking due to it exacerbating c. difficile infections.",
"id": "50225",
"label": "e",
"name": "Start vancomycin 100mg PO QDS",
"picture": null,
"votes": 1198
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This question requires you to know that PPIs increase the risk of clostridium difficile infection. In this case, the gentleman's omeprazole may be contributing to his c. difficile infection and therefore it should be stopped. The c. difficile infection should be treated, the first line treatment is vancomycin 125mg PO QDS (this patient is stable and therefore doesn't need a higher dose).",
"id": "50221",
"label": "a",
"name": "Suspend his omeprazole and start vancomycin PO QDS",
"picture": null,
"votes": 2077
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a c. difficile infection. Precipitants of said infection should be stopped (in this case the PPI) and antibiotics to treat the c. difficile should be given.",
"id": "50224",
"label": "d",
"name": "No change in treatment required",
"picture": null,
"votes": 17
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The right answer should at least say the right dose and frequency. I was put off it because it said OD and I knew that the right dose was QDS",
"createdAt": 1675101372,
"dislikes": 1,
"id": "17453",
"isLikedByMe": 0,
"likes": 18,
"parentId": null,
"questionId": 10092,
"replies": [],
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"displayName": "Gas Botox",
"id": 23026
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"__typename": "Concept",
"chapter": {
"__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,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
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"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3622",
"name": "Proton pump inhibitors increase the risk of c. difficile infection",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
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"difficulty": 1,
"dislikes": 4,
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"question": "Case Presentation: A 79-year-old gentleman has been admitted to a general surgical ward. He has recently been treated for a pelvic collection with IV cefuroxime and metronidazole. He has finished his antibiotics and a repeat CT scan of his abdomen and pelvis shows that the collection has resolved. \n\n\nToday he is complaining of loose stools.\n\n**PMH** Depression, hypertension, hypercholesterolaemia, osteoporosis,\n\n**DH**\n\nOmeprazole 20mg PO BD, sertraline 50mg PO OD, atorvastatin 20mg PO OD, alendronic acid 10mg PO OD, colecalciferol 800 units PO OD\n\n**Investigations**\nObservations:\n\nHR 65 bpm, RR 12, blood pressure 123/67 mmHg, O2 saturations 96% on room air, temperature 37.4\n\nStool type - 7\n\nC. difficile toxin - positive\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
],
"totalVotes": 3776,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,917 | false | 15 | null | 6,495,250 | null | false | [] | null | 18,111 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be equivalent to 90mg Morphine sulfate PO daily.",
"id": "10028545",
"label": "d",
"name": "Fentanyl 37.5 microgram/h transdermal patch 72-hourly",
"picture": null,
"votes": 84
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be equivalent to 120mg Morphine sulfate PO daily.",
"id": "10028544",
"label": "c",
"name": "Fentanyl 50 microgram/h transdermal patch 72-hourly",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Transdermal fentanyl is not available in this preparation.",
"id": "10028546",
"label": "e",
"name": "Fentanyl 90 microgram/h transdermal patch 72-hourly",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be equivalent to 180mg Morphine sulfate PO daily.",
"id": "10028543",
"label": "b",
"name": "Fentanyl 75 microgram/h transdermal patch 72-hourly",
"picture": null,
"votes": 230
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "He is currently receiving 80+80+(8x10) = 240mg Morphine sulfate PO daily. This is equivalent to 100 microgram/h fentanyl using a transdermal patch. More information can be found [here.](https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/)",
"id": "10028542",
"label": "a",
"name": "Fentanyl 100 microgram/h transdermal patch 72-hourly",
"picture": null,
"votes": 2131
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"id": "2693",
"pictures": [],
"typeId": 7
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"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6085",
"name": "Opioid conversion",
"status": null,
"topic": {
"__typename": "Topic",
"id": "327",
"name": "Paliative care prescribing",
"typeId": 5
},
"topicId": 327,
"totalCards": null,
"typeId": null,
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"question": "Case Presentation:\n\n\nA 82-year-old male is brought to the GP by his carer with worsening dysphagia. He has stage 4 Oesophageal cancer for which he is receiving palliative care for.\n\n**PMH** Oesophageal carcinoma, GORD, Hypertension.\n\n**DH** Morphine sulfate M/R 80mg PO BD, Morphine sulfate 10 mg/5 mL solution (Oramorph) 5 mL PO PRN. Paracetamol 1g PO QDS, Ibuprofen 400mg PO TDS, Omeprazole 30mg PO OD, Ramipril 5mg PO OD. He has taken 8 doses of her Oramorph in the last 24 hours.\n\nDue to his worsening dysphagia, the GP decides to convert his analgesic medication to a transdermal fentanyl patch at the same dose equivalent of morphine he is currently receiving.\n\nQuestion:\nSelect the most appropriate decision option with regard to his pain management based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 2586,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,467,918 | false | 16 | null | 6,495,250 | null | false | [] | null | 18,113 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no current indication to stop statin therapy. Statins should be discontinued if serum transaminases are greater than 3 times the upper limit of the reference range, or there are side effects which the patient cannot cope with.",
"id": "10028553",
"label": "b",
"name": "Stop atorvastatin 20mg",
"picture": null,
"votes": 425
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Other classes of lipid lowering drugs include ezetimibe, fibrates and new monoclonal antibodies. At this stage there is no indication for stopping or switching to a different medication.",
"id": "10028556",
"label": "e",
"name": "Switch to a fibrate",
"picture": null,
"votes": 34
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the dose for secondary prevention of cardiovascular events. There is currently no indication for this and given the ALT increase, it would be unwise to increase the dose at this stage.",
"id": "10028555",
"label": "d",
"name": "Increase to atorvastatin 80mg",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Although the ALT has increased since commencing treatment, current guidance is that unless serum transaminases are greater than 3 times the upper limit of the reference range, there is no need to discontinue statin therapy.",
"id": "10028552",
"label": "a",
"name": "Continue atorvastatin 20mg",
"picture": null,
"votes": 2111
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no indication for stopping or switching the statin for this patient.",
"id": "10028554",
"label": "c",
"name": "Switch to simvastatin",
"picture": null,
"votes": 41
}
],
"comments": [],
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"__typename": "Concept",
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"id": "6087",
"name": "Statins",
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"id": "329",
"name": "General Practice",
"typeId": 5
},
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"question": "Case Presentation: A 54-year-old woman attends the GP to discuss her most recent blood test results. She was commenced on atorvastatin 20mg PO ON for primary prevention of cardiovascular events. She describes no issues with the medication and reports no side effects. Her blood test results are below. **Investigations** ALT before treatment: 21 (10 - 50 IU/L) ALT 3 weeks later: 65 (10 - 50 IU/L) \n\nQuestion: Select the most appropriate decision option with regard to the atorvastatin based on these data.",
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"comment": "I get insulin but dont you start with saline infusion first?",
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"comment": "oh wait the Q asked high blood glucose levels",
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"comment": "was so confused because you can't write \"per hour\" anywhere",
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"explanation": "# Summary\n \n\nDiabetic ketoacidosis (DKA) is a serious complication often associated with type 1 diabetes, characterised by hyperglycaemia, ketonaemia, and acidosis. Key signs and symptoms include fruity-smelling breath, vomiting, dehydration, abdominal pain, hyperventilation, and altered mental status. Investigations include blood glucose and ketone measurements, blood gas analysis, urea and electrolytes, and possibly blood cultures if infection is suspected. Management strategies largely depend on the patient's condition, including hydration and insulin administration via various routes and in various volumes based on severity. The major complication is cerebral oedema, a rare but potentially fatal condition that might be caused by rapid correction of dehydration with IV fluids.\n \n\n# Definition\n \n\nDiabetic ketoacidosis (DKA) is a severe and life-threatening medical complication characterised by hyperglycaemia, acidosis and ketonaemia.\n\nIt is defined by acidosis (bicarbonate < 15 mmol/l or pH <7.3) and ketones >3.0 mmol/L. \n \n\n# Epidemiology\n \n\nDKA is most commonly seen in individuals with type 1 diabetes. However, it can occur in those with type 2 diabetes under extreme stress or illness. The condition can be the first presentation of diabetes, especially type 1 diabetes in children and young adults.\n\nIt is more common in children under 5. \n \n\n# Aetiology\n \n\nDKA can be precipitated by several factors, including infection, dehydration, stress, burns, fasting, or untreated type 1 diabetes. It is important to note that fever is not a typical part of DKA presentation. A raised temperature could indicate an underlying infection that may have triggered the DKA.\n\nRisk factors include:\n\n- Previous episodes of DKA \n- Peripubertal and adolescent girls \n- Comorbidities including psychiatric disorders\n- Difficult home life\n- Insulin pump therapy \n\n\n# Classification\n\n- Mild: pH 7.1-7.29 or bicarbonate < 15 mmol/L. Dehydration 5%\n- Moderate: pH 7.1-7.19 or bicarbonate < 10 mmol/L. Dehydration 5%\n- Severe: pH <7.1 or bicarbonate < 5 mmol/L\n \n\n# Signs and Symptoms\n \n\nPatients with DKA may present with:\n \n\n - Fruity-smelling breath (due to the presence of acetone)\n - Vomiting\n - Dehydration secondary to polydipsia and polyuria \n - Abdominal pain\n - Deep, sighing respiration (Kussmaul respiration)\n - Signs of hypovolaemic shock\n - Altered mental status, including drowsiness or coma\n \n\n# Differential Diagnosis\n \n\nThe main differential diagnoses for DKA in children include:\n \n - **Lactic Acidosis**: This may present with rapid breathing, abdominal pain, and altered mental status. The patient may have a history of severe illness or sepsis, hepatic failure or metformin use.\n - **Starvation Ketosis**: This usually presents with weight loss, nausea, and clear mental status. The condition is mild, with low-level ketonaemia.\n - **Inborn errors of metabolism**: Tend to present earlier in life with metabolic disturbances or failure to thrive. \n - **Sepsis**: The child will be generally unwell, with a high or low temperature, hypotension and tachycardia. \n \n\n# Investigations\n \n\nDiagnosis of DKA involves assessment of clinical features along with:\n \n\n - Blood glucose (>11.1mmol/L)\n - Blood ketones (>3mmol/L)\n - Urea and electrolytes\n - Blood gas analysis\n - Urinary glucose and ketones\n - Blood cultures (if evidence of infection)\n - Cardiac monitoring/ECG (for any ischaemic changes or changes secondary to hypokalaemia)\n \n\nNote that hyperglycaemia may not always be present in DKA.\n \n\n# Management\n \n\nManagement of DKA should be based on the A to E approach followed by the following treatments: \n\n - IV fluids (initial bolus of 10ml/kg 0.9% NaCl, even if the patient is shocked) given over 15 minutes.\n - Repeat as needed to restore circulation\n - At 40 ml/kg then discuss with a senior for consideration for inotropes \n - Insulin infusion at 0.1 units/kg/hour 1 hour after starting IV fluids\n\n\nFluids:\n\n- Further fluids, following initial boluses should contain 40 mmol/l potassium chloride to protect against hypokalaemia. \n- Total fluid required = deficit + maintenance\n- Hourly rate = [(Deficit - initial bolus) / 48 hours ] + maintenance per hour \n- Deficit \n - A 5% fluid deficit is assumed for children with mild or moderate DKA\n - A 10% fluid deficit is assumed for children with severe DKA\n - Deficit should be replaced over 48 hours alongside maintenance fluids \n- Maintenance \n - Calculated by Holliday-Segar formula: 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg, and 20 ml/kg/day for each additional kg over 20 kgs. \n \nImportant points to consider: \n\n- Monitoring should include hourly blood glucose and ketones, neurological observations and fluid balance. \n- Investigations should be done to determine the cause of the DKA. \n- Many patients will require HDU-level care. \n- Intravenous insulin infusion should not be stopped until 1 hour after subcutaneous insulin has been given.\n- Long-acting insulin should continue to be given.\n\n\n# Resolving DKA\n\nIVF can be stopped once ketosis is resolving and oral fluids are tolerated without nausea or vomiting. \n\nSubcutaneous insulin can be started once ketosis is resolving and should be started at least 30 minutes before stopping intravenous insulin. \n\nDischarge can be considered once a child is eating and drinking, and stabilised on their subcutaneous insulin regime. \n \n\n# Complications\n\n\nImportant complications to monitor for include:\n\n- Cerebral oedema:\n - Can occur several hours after the onset of DKA due to rapid correction of dehydration with IV fluids. \n - Due to the potential risk, fluid deficit correction is recommended to be performed slowly, over 48 hours. \n - Though rare, this complication is fatal in 1 in 4 children. \n - Risk factors include younger age and longer duration of symptoms. \n - Management includes hypertonic (2.7%) sodium chloride and restriction of IV fluids. \n- Hypokalaemia \n- Aspiration pneumonia \n- Venous thromboembolism \n - Thromboembolic prophylaxis is not recommended in children < 16 years \n- Inadequate resuscitation \n- Hypoglycaemia\n - Blood glucose levels can fall rapidly with intravenous insulin, and if blood glucose falls below 14 mmol/L, IV fluids should include glucose. \n\n# Prognosis\n\nEarly detection and treatment results in good outcomes for patients with DKA, with many children discharged within a few days of DKA. Poorer outcomes are associated with delays in treatment and the development of cerebral oedema. \n\n\n# NICE Guidelines\n\n[BNFC Treatment Summaries: Diabetic hyperglycaemic emergencies](https://bnfc.nice.org.uk/treatment-summaries/diabetic-hyperglycaemic-emergencies/) \n \n\n# References\n \n[BSPED Guidelines for Management of DKA in Children](https://www.bsped.org.uk/media/1959/dka-guidelines.pdf)\n \n[Patient Info: Childhood ketoacidosis](https://patient.info/doctor/childhood-ketoacidosis#ref-2)",
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"explanation": "# Drug choice feedback\n\nAny rapid-acting or short-acting insulin is appropriate for the treatment of diabetic ketoacidosis. Common ones include NovoRapid/Humalog and Actrapid/Humilin S respectively. Prescribing insulin by brand name is acceptable; an exception is made as each brand of insulin may have different formulations even if it belongs to the same class as another.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe dose of insulin to be administered is 0.1units/kg/hour IV. Since the patient's weight is 75kg, the dose is 7.5 units per hour IV. S/C administration is not appropriate for the treatment of DKA.",
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"question": "Case Presentation: A 27-year-old gentleman is brought to the Emergency Department with abdominal pain, vomiting, polydipsia and polyuria. Intravenous fluids have already been commenced.\n \n\n \n\n## PH\n \n\nNone\n \n\n## DH\n \n\nNone\n \n\n## On examination\n \n\nDrowsy but able to answer in full sentences. Sick bowl present on side table. Rapid breathing. Dry mucous membranes, peripheries cool, CRT 3s.\n \n\nTemperature 36.4°C, HR 105, RR 31, BP 95/78, O<sub>2</sub> 98% RA, GCS 14, Weight 75kg\n \n\n## Investigations\n \n\n| | | |\n| -------------- | :-------: | ------------------ |\n| pH | 7.2 | 7.35 - 7.45 |\n| PaO₂ | 12 kPa | 11 - 15 |\n| PaCO₂ | 3.2 kPa | 4.6 - 6.4 |\n| Bicarbonate | 12 mmol/L | 22 - 30 |\n| Sodium | 125 mmol/L | 135 - 145 |\n| Potassium | 4.7 mmol/L | 3.5 - 5.3 |\n| Non-fasting Glucose | 28 mmol/L | < 6.1 |\n| Ketones (Serum) | 4.5 mmol/L | < 0.6 |\n\n\n# Prescribing Request\n \n\nWrite a prescription for one drug that is most appropriate to specifically treat the high blood glucose levels.",
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"comment": "someone knows why is not benzylpenicillin is what bnf said",
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"explanation": "# Summary\n \nMeningitis is a potentially life-threatening condition characterised by the inflammation of the meninges, the membranes enveloping the brain and spinal cord. Its causes span from infectious agents, such as bacteria, viruses, fungi, and parasites, to non-infective causes like malignancy and certain medications. Symptoms are often non-specific, necessitating accurate differential diagnoses and prompt investigations. Timely management, including empirical antibiotics and targeted therapy post-identification of causative agent, is crucial to mitigate complications and improve patient outcomes. \n \n \n# Definition\n \n \nMeningitis is an inflammation of the meninges, which are composed of three layers: the dura mater, arachnoid mater, and pia mater. This inflammation may arise from both infective and non-infective aetiologies. \n \n \n# Epidemiology\n \n \nBacterial meningitis, while not the most common form of meningitis, is particularly significant due to its high morbidity and mortality rates. \n \nViral meningitis, predominantly caused by enteroviruses, is more common but typically less severe. Fungal and parasitic causes are relatively rare, except in immunosuppressed individuals. \n \nIn the United States, the annual incidence of bacterial meningitis is approximately 1.38 cases/100,000 population with a case fatality rate of 14.3%.\n\n# Aetiology\n \n \nInfective causes of meningitis include:\n \n \n - Bacterial: **Streptococcus pneumoniae (most common bacterial cause),** Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes, among others.\n - Viral: **Enteroviruses are overall most common** (Echoviruses, Coxsackie viruses A and B, poliovirus), herpes viruses (HSV2, HSV1), Paramyxovirus, measles and rubella viruses, Varicella Zoster Virus, Arboviruses, Rabies virus.\n - Fungal: Particularly Cryptococcus neoformans, mainly affecting the immunosuppressed population.\n - Parasitic: Amoeba (Acanthamoeba), Toxoplasma gondii.\n \n \nNon-infective causes of meningitis encompass:\n \n \n - Malignancies such as leukaemia, lymphoma, and other tumours\n - Chemical meningitis\n - Certain drugs, including NSAIDs and trimethoprim\n - Systemic inflammatory diseases such as sarcoidosis, systemic lupus erythematosus, Behcet's disease.\n \n \n# Signs and Symptoms\n \n \nThe cardinal features of meningitis include:\n \n \n- Headache\n- Fever\n- Neck stiffness\n- Photophobia\n- Nausea and vomiting\n- Focal neurology\n- Seizures\n- Reduced conscious level\n- Features of overwhelming sepsis, such as non-blanching petechial rash indicative of impending Disseminated Intravascular Coagulation (DIC). \n \nSpecific signs suggestive of meningeal irritation (and therefore not specific to meningitis) include:\n \n \n1. **Kernig's sign:** Kernig's sign is a test performed to evaluate the presence of meningeal irritation and stiffness in the hamstrings and lower back. To perform this test, the patient is positioned lying on their back with the hip and knee flexed at 90 degrees. The examiner then attempts to extend the patient's knee. If the patient experiences pain and resistance to knee extension, especially when attempting to straighten the leg, it is considered a positive Kernig's sign. This sign suggests meningeal irritation or inflammation.\n \n \n2. **Brudzinski's sign:** Brudzinski's sign is another manoeuvre used to assess for meningeal irritation. This test involves passive neck flexion, where the examiner gently flexes the patient's neck forward toward the chest while the patient is lying on their back. If the patient involuntarily flexes their hips and knees in response to neck flexion, it is considered a positive Brudzinski's sign. This involuntary movement indicates irritation of the meninges.\n \n \n \n \n# Differential Diagnosis\n \nThe key differentials for meningitis often present with overlapping symptoms. These include:\n \n \n- **Encephalitis**: Headache, fever, altered consciousness, seizures, focal neurological signs, behaviour changes.\n- **Subarachnoid hemorrhage**: Sudden severe headache, nausea and vomiting, neck stiffness, altered consciousness, seizures.\n- **Brain abscess**: Headache, fever, nausea and vomiting, focal neurological deficits, seizures, altered mental status.\n- **Sinusitis**: Headache, fever, facial pain, nasal congestion.\n- **Migraine**: Recurrent headaches, often unilateral and throbbing, accompanied by nausea/vomiting, photophobia, phonophobia.\n \n \n# Investigations\n \n \nDiagnostic investigations for suspected meningitis include:\n \n \n - Blood tests: Full Blood Count, Urea and Electrolytes, Clotting, Glucose, PCT\n - Arterial Blood Gas\n - Blood cultures\n - Bacterial throat swab for meningococcus\n - PCR for meningococcus & pneumococcus\n - HIV test\n - Imaging: CT Head if there are signs of raised intracranial pressure (ICP)\n - Lumbar puncture for Cerebrospinal Fluid (CSF) analysis, once confirmed there are no signs of raised ICP.\n \n \n## CSF Findings \n \n \nAnalysis of the cerebrospinal fluid in acute meningitis can provide important clues as to the underlying aetiology. Once establishing that it is safe to do so, a CSF sample should be taken via lumbar puncture and the opening pressure should be measured.\n \n \nThis can be examined macroscopically, and then sent for haematology, biochemistry, and microbiological microscopy, culture and sensitivities, as well as PCR.\n \n| | **Appearance** | **Predominant cell type** | **Culture** | **Protein** | **Glucose** |\n|---------------------------|-------------------------------------|---------------------------------------------------|--------------------------------------------------------|-------------|-------------|\n| **Bacterial meningitis** | Clear or turbid | **Polymorphonuclear** cells (i.e. neutrophils) | Positive | Raised | **Reduced** |\n| **Aseptic (viral) meningitis** | Clear or slightly turbid | **Lymphocytes** | Negative | Raised | **Normal** |\n| **Tuberculous meningitis** | Clear or slightly turbid ± fibrin web | **Lymphocytes** + polymorphonuclear cells | Negative gram stain; acid-fast bacilli positive (auramine staining) | Raised | **Reduced** |\n\n \nN.b. Cryptococcal meningitis may give any of the above results, so should be considered as a differential in any HIV or immunocompromised patient. Classically the opening pressure is very high, and this is a poor prognostic sign. If suspected, request cryptococcal antigen or India Ink staining.\n \n \n# Management\n \n \n- Empirical antibiotic therapy for suspected bacterial meningitis typically includes 2g of IV ceftriaxone twice daily to ensure CNS penetration, with IV amoxicillin added in patients at age extremes for listeria coverage.\n- In primary care, IM benzylpenicillin or ceftriaxone should be given while awaiting urgent transfer to hospital, especially if meningococcal disease is suspected.\n- Dexamethasone should be given if bacterial meningitis is strongly suspected in the absence of a rash\n\t- This has been shown to reduce neurological sequelae in bacterial meningitis but not meningococcal meningitis\n- In cases of suspected viral encephalitis, IV aciclovir should also be administered. For patients allergic to penicillin, alternatives such as chloramphenicol may be used. \n- It's important to note that any empirical antibiotic regimen should be adjusted based on culture results when available.\n \n **Additional notes**\n \nClose contacts of the patient should receive prophylactic antibiotics. This will be guided by specialists but may be a single dose of oral ciprofloxacin, or rifampicin.\n \nBacterial meningitis is a notifiable disease and any suspected cases should be reported to the local health protection team.\n \n \n# Complications\n \n \nMeningitis may lead to severe complications if not promptly treated, such as:\n \n - Septic shock\n - Disseminated Intravascular Coagulation\n - Coma\n - Subdural effusions\n - Syndrome of inappropriate antidiuretic hormone secretion\n - Seizures\n - Delayed complications: Hearing loss, cranial nerve dysfunction, hydrocephalus, intellectual deficits, ataxia, blindness\n - Death\n \n \n# NICE guidelines\n \n [NICE CKS: Meningitis - bacterial meningitis and meningococcal disease](https://cks.nice.org.uk/topics/meningitis-bacterial-meningitis-meningococcal-disease/)\n \n [NICE: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management](https://www.nice.org.uk/guidance/ng240/resources/meningitis-bacterial-and-meningococcal-disease-recognition-diagnosis-and-management-pdf-66143949881029)\n \n# References\n \n [BNF: Ciprofloxacin](https://bnf.nice.org.uk/drugs/ciprofloxacin/)",
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"explanation": "# Drug choice feedback\n\nCeftriaxone is the antibiotic of choice as empirical treatment before identification of the causative organism. It is active against the three most common organisms: _Streptococcus pneumoniae_, _Neisseria meningitidis_ and _Haemophilus influenzae_. Antibiotic treatment should not be delayed by investigations. For your information, patients aged over 60 and/or who are immunocompromised should also empirically receive amoxicillin to cover for Listeria.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose is 2g once/twice daily or 4g once daily intravenously. Cefotaxime 2g QDS is an acceptable alternative. Ceftriaxone can be given intramuscularly as well, although the intravenous route is preferred in hospital due to more rapid onset of action.",
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"question": "Case Presentation: A 25-year-old lady is brought to the Emergency Department with sudden-onset high fever, headache, photophobia and stiff neck. She is confused and is disoriented to time and place. No seizures reported.\n\n\n\n\n## PH and DH NIL (NKDA)\n\n\n## On examination\n\n\nAppears lethargic and irritable. Refuses food and drink. Photophobia noted. CRT 3s, peripheries cool. No rash, Kernig's and Brudzinski's sign positive. No neurological deficits.\n\n\nTemperature 39.6°C, HR 98, RR 22, BP 110/88, O2 98% RA, GCS 12, Weight 68kg\n\n\n## Investigations\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|144 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|15.3x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|320x10<sup>9</sup>/L|150 - 400|\n|Sodium|139 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Chloride|102 mmol/L|95 - 106|\n|Urea|7.2 mmol/L|2.5 - 7.8|\n|Creatinine|80 µmol/L|60 - 120|\n|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|\n|International Normalised Ratio (INR)|1.0|1.0|\n|Non-fasting Glucose|6.2 mmol/L|< 6.1|\n\n\nBlood cultures: pending\n\n\nLumbar puncture: not yet performed\n\n\n# Prescribing Request\n\n\nWrite a prescription for one antibiotic that is most appropriate to treat her condition empirically.",
"sbaAnswer": null,
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} | MarksheetMark |
173,467,921 | false | 19 | null | 6,495,250 | null | false | [] | null | 6,757 | {
"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "Make spaces for drug names e.g. dalteparin sodium as 2 words (with a space) correct answers. ",
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"comment": "BNF just has it as dalteparin - should give marks for it pls",
"createdAt": 1643896223,
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"id": "6924",
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"likes": 5,
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"displayName": "Jaundice Biopsy",
"id": 4252
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"comment": "what about Fondaparinux?",
"createdAt": 1737391039,
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"id": "61059",
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"likes": 2,
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"comment": "Why not apixaban because in the BNF it is used post surgery for this specific surgery of the hip\n",
"createdAt": 1737473950,
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"id": 3577
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"__typename": "QuestionComment",
"comment": "Surely enoxaparin 150mg/mL is correct too if its 40mg dose?",
"createdAt": 1737819347,
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"displayName": "Claire",
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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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"name": "Post-Operative Thromboprophylaxis ",
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"explanation": "# Drug choice feedback\n\nApart from mechanical means, administration of a low-molecular weight heparin should be offered to all surgical patients in whom the risk of venous thromboembolism outweighs the risk of bleeding. In certain situations, such as in high-risk patients and/or those undergoing orthopaedic procedures, DOACs can also be given as prophylaxis, as per the BNF.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose depends on the individual low-molecular weight heparin offered. This can only be given subcutaneously and once-daily. It should be continued until mobility is no longer reduced (generally 5-7 days) and reviewed at discharge.",
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"__typename": "PrescriptionAnswer",
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"question": "Case Presentation: A 52-year-old woman has been admitted to the orthopaedic ward for observation after an elective hip replacement. \r\n\r\n\r\n## PH\r\n\r\nFibroids, hypertension, previous facial squamous cell carcinoma\r\n\r\n## DH\r\n\r\nNifedipine (extended-release) 30mg PO OD\r\n\r\n## On examination\r\n\r\nAppears well and oriented to time and place. Bedbound - awaiting her first physiotherapy assessment. Anti-embolism stockings seen.\r\n\r\nTemperature 36.3°C, HR 72, RR 13, BP 135/78, O2 98% RA, GCS 15, Weight 82kg\r\n\r\n## Investigations\r\n\r\nFBC: Hb 139, WCC 11.3, Plts 278\r\n\r\nU&Es: Na<sup>+</sup> 142, K<sup>+</sup> 4.7, Cl<sup>-</sup> 105, Ur 7.2, Cr 69, eGFR >90mL/min/1.73m<sup>2</sup>\r\n\r\nClotting: normal\r\n\r\n# Prescribing Request\r\n\r\nWrite a prescription for one drug that is most appropriate for prophylaxis of venous thromboembolism in this patient.",
"sbaAnswer": null,
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} | MarksheetMark |
173,467,922 | false | 20 | null | 6,495,250 | null | false | [] | null | 6,763 | {
"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "Excessive respiratory secretions in palliative care \nBy subcutaneous injection\n\nAdult\n20 mg every 4 hours if required, adjusted according to response to up to 20 mg every 1 hour.\nBy subcutaneous infusion\n\nAdult\n20–120 mg/24 hours.",
"createdAt": 1737474056,
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"__typename": "QuestionComment",
"comment": "In a syringe driver 1.2mg in 24 hours would mean 50 micrograms per hour. So why is the correct answer not hyoscine hydrobromide 400 micrograms/mL injection, 50 micrograms SC every hour, continuous? ",
"createdAt": 1737819564,
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"__typename": "QuestionComment",
"comment": "why 5mg per hour ? : ) ",
"createdAt": 1737814379,
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"__typename": "QuestionComment",
"comment": "I did the same but I think because the BNF says '20 mg every 4 hours if required' so its 5 mg in one hour. Mean question but I can see what they're going for",
"createdAt": 1738115256,
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"displayName": "Craniofacial ",
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"__typename": "QuestionComment",
"comment": "marked wrong if you prescribe it as 1 mL of 400 micrograms/mL because you should put \"400 micrograms\" but in the other mock it was the other way around, so frustrating",
"createdAt": 1737825457,
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"__typename": "QuestionComment",
"comment": "Why not 20mg per hour as per bnf?",
"createdAt": 1737993363,
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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": "2699",
"name": "End-of-life agitation",
"status": null,
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"explanation": "# Drug choice feedback\n\nA trial of medicine to treat noisy respiratory secretions should be considered if they are causing distress to the family of the patient at the end-of-life. They can be treated using anticholinergics such as those given above, at their starting doses, before uptitrating. Atropine can also be used as recommended by NICE but it is used off-label.\n\n# Dose/Route/Frequency/Duration feedback\n\nIf the patient continues to have significant secretions not managed with PRN subcutaneous doses, the addition of these medications to the syringe driver can be considered.",
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"question": "Case Presentation: A 91-year-old gentleman has been admitted to the hospice for end-of-life care after being diagnosed with end-stage pancreatic cancer 1 year ago. The nurses looking after him has reported increased noisy respiratory secretions which is causing the family distress.\n\n\n## PH\n\nPancreatic cancer, Hypertension, Chronic Kidney Disease, Type 2 Diabetes Mellitus.\n\n## DH\n\nCurrent: Morphine 30mg SC, cyclizine 150mg SC, midazolam 20mg SC via a syringe driver diluted with sterile water given over 24 hours. Discontinued: Ramipril 5mg PO OD, Bendroflumethiazide 2.5mg PO OD, Metformin 1g BD PO (NKDA)\n\n## On examination\n\nAppears comatose, noisy respiratory secretions audible from the bedside.\n\n# Prescribing Request\n\nWrite a prescription for one additional drug that is most appropriate for treating his noisy respiratory secretions",
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"__typename": "QuestionComment",
"comment": "why not Mupirocin? ",
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"comment": "good q",
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"comment": "why is 7 days wrong in bnf they say 5-7 days for hydrogen peroxide",
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"comment": "I agree, does anyone know why?",
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"explanation": "# Summary\n \n\nImpetigo is a highly infectious superficial epidermal infection primarily caused by Staphylococcal or Streptococcal bacteria, commonly found in infants and school-aged children. Characteristic clinical signs include erythematous macules that vesiculate or pustulate, followed by superficial erosion with a golden crust. Although the diagnosis is usually clinical, a skin swab may be required in certain circumstances. Management is primarily via topical treatments such as fusidic acid, or oral flucloxacillin, and it's important to limit transmission by avoiding shared items and public places until 48 hours post-antibiotic treatment.\n \n\n# Definition\n \n\nImpetigo is a highly contagious superficial epidermal infection of the skin primarily caused by Staphylococcal and Streptococcal bacteria.\n \n\n# Epidemiology\n \n\nImpetigo most commonly occurs in infants and school-age children, with weekly rates of 84 per 100,000 children aged 0-4 in the UK. However, whilst less common in older individuals, it can affect individuals of any age. It affects boys and girls equally. \n \n\n# Aetiology\n \n\nThe aetiology of impetigo is mainly bacterial infections, specifically:\n \n\n - Staphylococcus aureus (80% of cases)\n - Group A beta haemolytic Streptococcus (Streptococcus pyogenes) (10% of cases)\n - In 10% of cases, both bacteria are present. \n\nThese bacteria can invade the skin through minor cuts, insect bites, or abrasions, leading to infection.\n \nImpetigo is very contagious and is spread through direct contact, with lesions appearing 4-10 days after contact. \n \nBullous lesions are almost exclusively caused by Staphylococcus aureus, as this bacteria produces an exotoxin targeting desmoglein - 1 (an epithelial intercellular adhesion molecule). \n\nRisk factors include:\n\n- Pre-existing skin conditions (i.e. eczema, cuts, burns, scabies)\n- Immunosuppression\n- Direct contact with an infected individual\n- Environmental factors such as crowding, humidity and poor hygiene. \n \n# Classification\n \nImpetigo can be sub-divided into:\n \n - Bullous: The child will have fluid filled lesions greater than 1 cm in diameter\n - Non-bullous: This is more common, and the child will not have bullae\n\nIt can also be divided based on aetiology:\n \n - Primary: Infection occurs in otherwise normal skin. \n - Secondary: Infection is related to an underlying skin condition (i.e. eczema) or breach to the skin barrier (i.e. bite or cut).\n \n\n# Signs and Symptoms\n \n\nThe primary clinical features of impetigo include:\n \n\n - Erythematous macule that vesiculates or pustulates\n - Superficial erosion with a characteristic golden crust\n - Impetigo may be bullous (causing large blisters) or non-bullous (causing sores)\n - Patches may be itchy or painful\n \n\nThese features are typically very infectious, prompting caution regarding close contact and shared items.\n \n\n [lightgallery]\n \n\n# Differential Diagnosis\n \n\n - **Eczema Herpeticum**: Presents with rapid onset of painful, punched-out erosions with or without vesiculation on a background of atopic dermatitis. It may also exhibit systemic symptoms like fever and malaise.\n - **Herpes Simplex Virus (HSV) infection**: This may manifest as grouped vesicles on an erythematous base, usually accompanied by pain and itching. It can also cause systemic symptoms.\n - **Contact Dermatitis**: This involves erythematous, pruritic rash, usually in a pattern suggestive of a contact allergen.\n - **Tinea Corporis (Ringworm)**: Exhibits annular erythematous scaly plaques, often with central clearing.\n \n\n# Investigations\n \n\nWhile the diagnosis of impetigo is often clinical, based on the characteristic signs and symptoms, in certain cases, investigations may be warranted:\n \n\n - A skin swab may be necessary for microscopy, culture, and sensitivity, particularly in cases resistant to treatment or in the context of recurrent infections.\n \n\n# Management\n \n\nImpetigo can typically be managed effectively in primary care. Key management strategies include:\n \n\n - **Localised non-bullous impetigo:** topical treatment with hydrogen peroxide 1% cream (apply two or three times daily for 5 days) is first-line\n - If unsuitable, second-line options include fusidic acid or mupirocin (if fusidic acid resistance)\n - **Widespread non-bullous impetigo:**\n - Topical (fusidic acid/mupirocin) *or* oral antibiotics for 5 days, such as flucloxacillin\n - Clarithromycin (penicillin-allergic) or erythromycin (pregnancy) are alternatives\n - **Bullous impetigo, or impetigo in those systemically unwell or at high risk of complications:**\n - Oral antibiotics as above for up to 7 days\n\n\nAdvise general hygiene measures:\n \n - Avoid scratching the lesions \n - Cover the affected areas and wash hands with soap and water \n - Avoid sharing toys and towels whilst the infection is active \n\n**Children should be off school until all lesions are healed or until 48 hours after starting treatment.** \n\nRefer to secondary care if:\n \n\n * Suspected complications of impetigo (sepsis, glomerulonephritis, or deeper soft tissue infection) \n * The patient is immunocompromised and infection is widespread\n\n# Complications \n\nPossible complications include:\n\n- Worsening or spread of the infection to cellulitis, ecthyma (a deeper form of impetigo), septic arthritis or sepsis\n- Scarring \n- Acute post-streptococcal glomerulonephritis \n \n# Prognosis \n \nInfection will resolve within 1-3 weeks, with this time reduced with proper treatment. Secondary impetigo is most likely to relapse if the underlying cause is chronic.\n\nThe risk of serious complications is low - however, it is most commonly seen in neonates or children with severe immunodeficiency. \n \n\n# NICE Guidelines \n\n[NICE Guidelines - Impetigo](https://cks.nice.org.uk/topics/impetigo/management/bullous-impetigo/)\n\n# References\n\n[NHS Information on Impetigo](https://www.nhs.uk/conditions/impetigo/) \n\n[Patient Info Impetigo](https://patient.info/doctor/impetigo-pro)",
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"explanation": "# Drug choice feedback\n\nThis child is suffering from facial impetigo, an extremely common superficial skin infection usually caused by _Staphylococcus aureus_ or _Streptococcus pyogenes_. As the infection is localised and the patient is systemically well, as well as the infection being non-bullous and not around the eyes, topical hydrogen peroxide 1% is first line as recommended by NICE. Fusidic acid can also be used, and is preferred if there is evidence of impetigo near the eyes. If impetigo were extensive, oral treatment with flucloxacillin would be recommended. \n\n\n# Dose/Route/Frequency/Duration feedback\n\nThe optimal frequency is two-three times a day for a duration of 5 days, as per NICE guidance.",
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"question": "Case Presentation: A 5-year-old girl attends her GP with her mother with non-bullous lesions on her cheeks and chin. They are mildly itchy.\n\n## PH\n\nAtopic Eczema\n\n## DH\n\nNone (Severe allergy to Penicillin - Anaphylaxis)\n\n## On examination\n\nChild looks well and not in distress. The lesions are tiny pustules localised to the face, some have evolved into honey-coloured crusted plaques, most tend to be under 2cm in diameter. MRSA is not clinically suspected.\n\nTemperature 36.7°C, HR 95, RR 25, BP 100/68, O<sub>2</sub> 94% RA, GCS 15, Weight 21kg\n\n## Investigations\n\nNone\n\n## Prescribing Request\n\nWrite a prescription for one topical drug that is most appropriate for treating her condition.",
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173,467,924 | false | 22 | null | 6,495,250 | null | false | [] | null | 10,051 | {
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"comment": "Should be able to give multiple versions of the same answer \nI put 1 week but its marked as wrong",
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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 a gastric ulcer secondary to helicobacter pylori infection. He should therefore be prescribed triple therapy. Classically, triple therapy consists of a proton pump inhibitor, and two antibiotics - clarithromycin and amoxicillin. This patient has a penicillin allergy however so amoxicillin is replaced by metronidazole.\n\n## Dose/Route/Frequency/Duration feedback\n\n400mg BD for 7 days is the optimum dose of metronidazole to treat helicobacter (alongside the rest of the prescribed triple therapy).",
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"question": "Case Presentation: A 63-year-old gentleman attends his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.\n\n\n## PH\nObesity, hypercholesterolaemia, hypertension\n\n## DH\nAtorvastatin 40mg PO OD, ramipril 5mg PO OD.\n\nHe is allergic to penicillin.\n\n## FHx\n\nNo upper gastrointestinal cancer\n\n## On examination\n\nHe is alert and oriented. Upon palpation of the abdomen, there is epigastric tenderness, there are no other abnormalities.\n\nTemperature 36.9°C, HR 80, RR 16, BP 143/92mmHg O<sub>2</sub> 98% RA, GCS 15, Weight 106kg\n\n## Investigations\n\nFBC: Hb 146, WCC 5.2, Plt 328\n\n2ww OGD performed: \"Benign gastric ulceration noted, no oesophagitis, no masses seen.\"\n\nStool antigen test for _H. pylori_: positive\n\n## Prescribing Request\n\nIt is decided he should be started on triple therapy. He has already had omeprazole and clarithromycin prescribed.\n\nWrite a prescription for one drug that is most appropriate to treat his helicobacter pylori infection.",
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{
"__typename": "QuestionComment",
"comment": "why not fondaparinux?",
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"comment": "it is an antithrombin, this patient needs LMWH or aspirin ",
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"comment": "What's wrong with enoxaparin sodium 150 mg/mL injection with 40mg SC daily? ",
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"comment": "Probably because in reality if you are trying to get 40mg from 100mg/ml you can give 0.4ml but if it's 150 its like 0.375 I think?",
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"comment": "i put stat as first dose is stat as bnf says: 40 mg for 1 dose, dose to be given 12 hours before surgery, then 40 mg every 24 hours. but got it wrong",
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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": "Prescribing VTE prophylaxis",
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"id": "13",
"name": "Neurosurgery",
"typeId": 5
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"explanation": "## Drug choice feedback\n\nThis patient requires a low molecular weight heparin as prophylactic treatment of venous thromboembolism prior to his surgery. The options available are tinzaparin, enoxaparin, bemiparin and dalteparin. They are often given at 6pm, this provides cover until the day of the surgery. DOACs such as rivaroxaban are now also licensed to be given as VTE prophylaxis **AFTER** (and so are incorrect answers for this question) specific procedures (such as knee and hip replacements) and these should be taken daily for 2 weeks. Similarly, Fondaparinux is not acceptable as per the BNF, which only provides information on prescribing it for VTE prophylaxis **post-surgery.**\n\n# Dose/Route/Frequency/Duration feedback\n\nThe following prescriptions are appropriate to provide prophylaxis against venous thromboembolism:\n\n- Enoxaparin 40mg subcutaneous OD\n- Tinzaparin 4500 units subcutaneous OD\n- Dalteparin 5000 units subcutaneous OD\n- Bemiparin 3500 units subcutaneous OD\n",
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"question": "Case Presentation: A 63-year-old gentleman is brought onto the orthopaedic ward for an elective total knee replacement of his right knee. \n\n\n## PH\nOsteoarthritis\n\n## DH\nIbuprofen 400mg PO QDS, lansoprazole 30mg PO OD. NKDA.\n\n## On examination\n\nTemperature 37.1°C, HR 68, RR 13, BP 131/75, O<sub>2</sub> 98% RA, GCS 15, Weight 90kg\n\n## Investigations\n\nNil\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to provide cover against venous thromboembolism. It is the day before his elective surgery.",
"sbaAnswer": null,
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"typeId": 4,
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173,467,926 | false | 24 | null | 6,495,250 | null | false | [] | null | 10,105 | {
"__typename": "QuestionPrescription",
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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": "Treating anaphylaxis",
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"id": "9",
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"explanation": "## Drug choice feedback\n\nThis patient is in acute anaphylaxis. The treatment for this is adrenaline (also known as epinephrine). As this patient is an adult the standard dose that he should be given is 500 micrograms IM in the anterolateral aspect of his thigh. There is a reduced dose of 300 micrograms for children aged 6-11 years, 150 micrograms for children aged 6 months-5years\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's anaphylaxis:\n\n- Adrenaline/Epinephrine 1 in 1000 (1 mg/mL) 500 micrograms IM every 5 minutes",
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"question": "Case Presentation: A 18-year-old gentleman is brought to the emergency department with a swollen face, widespread rash and difficulty breathing. His friend with him says that the symptoms randomly happened during a meal at a restaurant.\n\n\n## PH\nAsthma\n\n## DH\nSalbutamol 200 micrograms INH QDS. NKDA.\n\n## On examination\n\nAirway patent, patient is alert and orientated.\n\nTemperature 37.3°C, HR 128, RR 26, BP 101/653, O<sub>2</sub> 94% RA, GCS 15, Weight 60kg\n\nRespiratory exam: widespread wheeze heard on auscultation.\n\nCardiovascular exam: HS 1 + 2 + 0, his pulse feels weak.\n\nAbdominal exam: abdomen soft and non tender with no palpable organomegaly\n\nNeurological exam: grossly intact\n\nMultiple hives are seen over his abdomen and thorax when his top is removed.\n\n## Investigations\n\nFBC: Hb 139, WCC 4.6, Plts 255 x 10^9\n\nCRP 18\n\nU&Es: Na 140, K 4.2, Ur 4.9, Cr 54, eGFR >90mL/min/1.73m<sup>2</sup>\n\nCa2+ (adjusted): 2.3\n\nMg2+: 0.9\n\nPhosphate: 0.81\n\nLFTs: ALP 30, ALT 24, bilirubin 13\n\nECG - sinus tachycardia\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat this condition.",
"sbaAnswer": null,
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"typeId": 4,
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173,467,927 | false | 25 | null | 6,495,250 | null | false | [] | null | 6,781 | {
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"id": "33805",
"label": "b",
"name": "Ibuprofen;400mg;oral (PO);8-hourly",
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],
"comments": [
{
"__typename": "QuestionComment",
"comment": "all of these need looking at. ive put the correct answers for both and its marked them wrong.",
"createdAt": 1703264659,
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"comment": "my answers got changed as well",
"createdAt": 1704909039,
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"comment": "Omeprazole dose for both GORD and NSAID prophylaxis is 20mg OD, ",
"createdAt": 1705764279,
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"comment": "How would you know it is a prophylaxis dose and not a treatment dose? Is it just because he is in hospital?",
"createdAt": 1706141936,
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"comment": "well salbutamol is wrong surely it should be PRN?",
"createdAt": 1706635785,
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"comment": "I thought similarly- with a PMH of severe COPD they're surely not using salbutamol once daily.",
"createdAt": 1706746423,
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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": "2714",
"name": "Drugs causing diarrhoea & dosing error",
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"id": "74",
"name": "Elderly Care",
"typeId": 5
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"explanation": "1. Co-amoxiclav, proton pump inhibitors (omeprazole) commonly cause diarrhea. Oral use of ibuprofen generally do not cause diarrhea.\n2. Dalteparin sodium, given for prophylaxis of DVT in medical patients are prescribed at 5000 units daily. 12 500 units is given as treatment dose for a 60kg patient. The indication of dalteparin in this patient is for prophylactic use, not for treatment.",
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"question": "Case presentation: A 85-year-old man was admitted to the Acute Medical Unit for infective exacerbation of COPD.\n\n\n**PH** Severe COPD, Migraine, GORD, Osteoporosis.\n\n**DH** His current regular medications are listed (below). Weight 60kg.\n\n**On Examination**\nPatient complained of loose stools over the past 3 days. Dry mucous membrane, peripheral CRT 3s.\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to his loose stools (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,
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173,467,928 | false | 26 | null | 6,495,250 | null | false | [] | null | 6,785 | {
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"id": "33832",
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},
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"__typename": "QuestionComment",
"comment": "Woww fell for the mg/microgram thing again",
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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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"name": "Thrombocytopenia & dosing error",
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"explanation": "1. Penicillin (amoxicillin) commonly or very commonly cause thrombocytopenia. PPI and paracetamol also cause thrombocytopenia but are significantly less common\n2. Tamsulosin, an alpha blocker that is prescribed for benign prostatic hyperplasia, is given in 400 micrograms daily, not in milligrams.",
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"question": "Case presentation: A 55-year-old gentleman presents to his GP with repeated episodes of epistaxis. PH Mild depressive episodes, Osteoarthritis of right knee, Vitamin D deficiency, GORD, Benign Prostatic Hyperplasia, HTN. DH His current regular medicines are listed (below).\n\n\n\n\n **Investigation**\nPlatelet count 100 x 109/L (Normal value 150-400 x 109/L )\n\n\nQuestion 1: Select the ONE prescriptions that are most likely to be contributing to the low platelet count (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,
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"typeId": 3,
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} | MarksheetMark |
173,467,929 | false | 27 | null | 6,495,250 | null | false | [] | null | 6,786 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33844",
"label": "f",
"name": "Metformin;500mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33843",
"label": "e",
"name": "Lansoprazole;15mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33845",
"label": "g",
"name": "Paracetamol;1000mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
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"explanation": null,
"id": "33839",
"label": "a",
"name": "Pramipexole;2mg;oral (PO);12-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33840",
"label": "b",
"name": "Atenolol;50mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33842",
"label": "d",
"name": "Cholecalciferol 200 units + calcium carbonate 750mg (Adcal D3 ®);2 tablets;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33841",
"label": "c",
"name": "Alendronic acid;70mg;oral (PO);Weekly",
"picture": null,
"votes": 0
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Oral in frequency... seems like an error too...",
"createdAt": 1664933439,
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"comment": "BNF says common side effect of lansoprazole is insomnia ??",
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"comment": "1g of paracetamol oral daily isnt right.. surely it would be qds like in every other question Ive seen?",
"createdAt": 1704657346,
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"comment": "it's not the maximum dose sure but it isn't a serious dosing error",
"createdAt": 1706823803,
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"comment": "I put the correct answers but was marked incorrect?",
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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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"name": "Sleeping disorder & dosing error",
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"explanation": "1. Pramipexole, a non-ergoline dopamine agonist and systemic beta blockers (atenolol) commonly cause sleeping disorders. Although excess daytime sleepiness and sleep attacks are recognized side effects of pramipexole, the underlying pathophysiology remained controversial. Beta blockers cause night awakening and nightmares, likely due to the inhibition of melatonin secretion, a hormone that is involved in sleep and the body’s circadian clock\n2. Pramipexole, given for treatment of Parkinson's Disease has a maximum dose of 3.3mg daily. 2mg 12-hrly is more than the recommended maximum dose and alternative adjuncts should be considered instead.",
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"question": "Case presentation: An 80-year-old woman presents to her GP for her medication review, she complains of fatigue due to poor sleep. PH Osteoporosis, Type 2 diabetes, Dyspepsia, Parkinson Disease, hypertension. DH Her current regular medicines are listed (below).\n\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to her sleeping disorders (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,
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} | MarksheetMark |
173,467,930 | false | 28 | null | 6,495,250 | null | false | [] | null | 6,792 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33887",
"label": "b",
"name": "Amlodipine;5mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
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"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33892",
"label": "g",
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"picture": null,
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},
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"__typename": "QuestionChoice",
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"id": "33888",
"label": "c",
"name": "Warfarin sodium;5mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33889",
"label": "d",
"name": "Carvedilol;3.125mg;Oral (PO);12-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33893",
"label": "h",
"name": "Amitriptyline hydrochloride;75mg;Oral (PO);Daily in the evening",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
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"explanation": null,
"id": "33890",
"label": "e",
"name": "5% Chloramphenicol;2-3 drops;Ear drops;8-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33891",
"label": "f",
"name": "Promethazine hydrochloride;10mg;Oral (PO);8-hourly",
"picture": null,
"votes": 0
}
],
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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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"demo": null,
"entitlement": null,
"id": "2725",
"name": "Drugs causing drowsiness & constipation",
"status": null,
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"id": "74",
"name": "Elderly Care",
"typeId": 5
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"topicId": 74,
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"explanation": "1. Confusion is a common or very common side effect of a beta-adrenoceptor blocker such as carvedilol. Drowsiness is also listed as a common or very common side effect of amitriptyline. Promethazine is also known to cause drowsiness although the frequency of such side effect is unknown. Patients taking these medications should be reminded that their performance of skilled tasks like driving and operating heavy machinery could be affected.\n2. Constipation is a common or very common side effect of amlodipine, and can also be caused by amitriptyline due to its anticholinergic activity.",
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"question": "Case presentation: A 80-year old man is taken to A&E via ambulance after being found lying on the floor by his daughter. His daughter reports that his father has become increasingly drowsy and confused over the past few days. His father has also been complaining of constipation recently. **PH:** Atrial fibrillation, Congestive Cardiac Failure, Type 2 Diabetes Mellitus, Hayfever, Neuropathic pain, Otitis externa **DH:** His current regular prescriptions are listed below\n\n\n**On examination**: Abbreviated Mental Test Score 6/10. Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender. Bruises on left hip with no active bleeding. Pain on external rotation of left leg.\n**Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of the drowsiness and confusion (mark them with a tick in column A)\nQuestion 2: Select the TWO prescriptions that are most likely to be a cause of his constipation (mark it with a tick in column B)",
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173,467,931 | false | 29 | null | 6,495,250 | null | false | [] | null | 6,795 | {
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"explanation": null,
"id": "33910",
"label": "c",
"name": "Azelastine hydrochloride;1 spray;Oral (PO);Twice daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33913",
"label": "f",
"name": "Chloroquine;225mg;Nebulised (NEB);Once weekly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33911",
"label": "d",
"name": "Ibuprofen;200 mg;Oral (PO);8-hourly",
"picture": null,
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},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33908",
"label": "a",
"name": "Salbutamol (100 micrograms,dose metered-dose inhaler);200 micrograms;Inhaled (ING);When required",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33912",
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"name": "Dermacort hydrocortisone 0.1% cream;-;Topical;Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33914",
"label": "g",
"name": "Nitrofurantoin;22.5mg;Oral (PO);6-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33909",
"label": "b",
"name": "Budesonide;200 micrograms;Inhaled (INH);Once daily in evening",
"picture": null,
"votes": 0
}
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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": "Drug contraindications for G6PD & asthma",
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"name": "Paediatrics",
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"explanation": "1. Nitrofurantoin is an antibiotic that works by damaging bacterial DNA. Chloroquine is a medication used to prevent and treat malaria. Nitrofurantoin and chloroquine are contra-indicated in patients with G6PD-deficiency because are they known to cause severe haemolytic anaemia.\n2. Ibuprofen is known to cause bronchospasm in patients with asthma, especially those with a history of hypersensitivity to aspirin or any other NSAID. Ibuprofen inhibits the activity cyclooxygenase-1 (Cox-1). The inhibition leads to activation of lipoxygenase pathway that in turn increases the release of cysteinyl leukotrienes (Cys-LTs) that induces bronchospasm.",
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"question": "Case presentation: A 9-year old boy arrives at A&E with shortness of breath and wheeze. He presented to his GP two days ago with increased urinary frequency and dysuria. A diagnosis of lower urinary tract infection was made and antibiotic treatment was commenced. He has a past medical history of asthma which has so far been well controlled. His weight is 30kg. His mother who is accompanying him informs that the family has just come back from Nigeria and that they have been taking malaria prophylaxis. PH: Asthma, Allergic rhinitis, Eczema, Lower urinary tract infection, vesicoureteral reflux, Glucose-6-phosphate dehydrogenase (G6PD) deficiency DH: Her current regular prescriptions are listed below\n\n\n**On examination**: Breathing using accessory muscles, polyphonic expiratory wheeze\n\n**Vital signs**: Temperature 36.6°C, HR 90, O2 Sat 92% (room air), RR 26\n\nQuestion 1: Select the TWO prescriptions that are contra-indicated or should be used with caution in the context of G6PD deficiency (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that is most likely to have led to exacerbation of asthma symptoms (mark it with a tick in column B)",
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173,467,932 | false | 30 | null | 6,495,250 | null | false | [] | null | 10,061 | {
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50050",
"label": "a",
"name": "Aveeno cream;1;Application Topically;Twice daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"picture": null,
"votes": 0
},
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"explanation": null,
"id": "50051",
"label": "b",
"name": "Lymecycline;408mg;PO (Oral);Once daily",
"picture": null,
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},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50052",
"label": "c",
"name": "Adapalene;1 Application (thinly);Topically;Once nightly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50053",
"label": "d",
"name": "Benzoyl Peroxide;1 Application;Topically;Once daily (after washing)",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i thought there is no evidence that COCP could cause weight gain, and the only one is the injection",
"createdAt": 1706189689,
"dislikes": 1,
"id": "39823",
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"__typename": "QuestionComment",
"comment": "I'd like to see what the reasoning for this is too, almost everything I've read says there is no actual evidence for weight gain",
"createdAt": 1706446406,
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"__typename": "QuestionComment",
"comment": "Reassured that everyone else is on the same page RE the COCP",
"createdAt": 1706740654,
"dislikes": 1,
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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": "3593",
"name": "Combined Oral Contraceptive pill; adverse reactions",
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"explanation": "1. Rigevidon (Ethinylestradiol with Levonorgestrel) is a combined oral contraceptive pill (COCP). This patient suffers from migraine with aura. The COCP is contraindicated in patients with migraine with aura due to the increased risk of stroke.\n2. A common side effect of the COCP is weight gain.",
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"question": "Case presentation: A 23-year-old female attends the GP with migraines. \n\n\n**PH** Acne, Eczema, Anxiety, Migraines with aura.\n**DH** Her regular medicines are listed (below).\n\n**On Examination**\n\nTemperature 37.2°C, HR 84, RR 16, BP 124/78\nWeight 60kg\n\n**Investigations**\n\nNegative human chorionic gonadotrophin (HCG) pregnancy test\n\nQuestion 1: Select the ONE prescription that is contraindicated in this patient (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that is the most likely to cause weight gain (mark them with a tick in column B)",
"sbaAnswer": null,
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173,467,933 | false | 31 | null | 6,495,250 | null | false | [] | null | 10,107 | {
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"id": "50243",
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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": "The combined oral contraceptive pill, ramipril and metformin are all medications that need stopping before surgery and dosing error of a salbutamol inhaler",
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"explanation": "1. Ramipril, microgynon 30 and metformin should be held before surgery. COCPs should be held for 4 weeks prior to surgery due to the increased risk of thromboembolism. ACE inhibitors/angiotensin-II receptor antagonists should be omitted the day before surgery due to an increases risk of severe hypotension after induction of anaesthesia. Metformin can also be held before surgery if there is an increased risk of lactic acidosis occurring.\n\n2. The maximum dose of salbutamol per administration is 200 micrograms NOT milligrams.",
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"question": "Case presentation: A 42-year-old woman is admitted to the general surgical ward due to gallstones. It is decided that she should have an outpatient laparoscopic cholecystectomy.\n\n\n**PH** Depression, hypercholesterolaemia, hypertension, type 2 diabetes mellitus, asthma, chronic fatigue syndrome, allergic rhinitis\n\n**DH** Her current medicines are listed (below). Weight 118kg.\n\n**On Examination**\nHR 81/min, BP 112/80mm Hg, RR 14, O2 Sats 96% RA, temperature 37.1\n\nAbdomen soft, tender in RUQ. Bowel sounds present.\n\n**Investigation**\n\nUSS abdomen - thickened gallbladder wall and multiple gallstones within the gallbladder. No perforation.\n\nQuestion 1: Select the THREE prescriptions that are most likely to be stopped before her elective surgery (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).",
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173,467,934 | false | 32 | null | 6,495,250 | null | false | [] | null | 10,109 | {
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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": "1. ACE inhibitors, NSAIDs and thiazide like diuretics all increase the serum concentration of lithium. This is due to their effects on kidney function, a reduction in kidney function results in a reduced clearance of lithium. This in turn then leads to higher serum concentration of lithium.\n2. Bendroflumethiazide should be given as a 2.5mg tablet once daily in hypertensive patients, NOT 2.5g.",
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"question": "Case presentation: A 69-year-old gentleman attends his lithium clinic appointment \n\n\n\n\n **PH** Bipolar disorder, seizures, hypertension, depression, asthma, osteoarthritis\n\n\n **DH** His regular medicines are listed (below). Weight Xkg.\n\n\n **Investigation**\n\n\nLithium concentration 1.5 mEq/L (0.8-1.2 mEq/L)\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be interacting with his lithium to increase its serum concentration (mark them with a tick in column A)\n\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,467,935 | false | 33 | null | 6,495,250 | null | false | [] | null | 6,800 | {
"__typename": "QuestionSBA",
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"answer": false,
"explanation": "Doxycycline is an acceptable alternative in patients who are penicillin-allergic. However a discharge is inappropriate as the patient has a CURB-65 of 3D",
"id": "33949",
"label": "e",
"name": "Discharge with doxycycline 200mg PO OD and clarithromycin 500mg PO BD",
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"explanation": "This would be a possible option with a CURB-65 of 2. However the patient scores 3 and warrants more intensive treatment",
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"__typename": "QuestionComment",
"comment": "why is the CURB score 3? i understand 1 point for their urea and resp rate but what's the last point?",
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"comment": "I imagine this is the drowsiness that the patient has presented with. Perhaps this has been interpreted as confusion.",
"createdAt": 1643222934,
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"comment": "AMTS score 6/10",
"createdAt": 1710155512,
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"comment": "Not too sure how the CURB 65 is 3 so please do expand. I got a score of 2 on RR and Urea. BP was ok, No confusion and is under 65? ",
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"comment": "AMTS score was 6/10",
"createdAt": 1646839011,
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"comment": "Confusion is aka AMTS<8 ",
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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 62 year old man is brought to A&E with fever, productive cough and shortness of breath. **PH** Parkinson’s disease, osteoarthritis. **DH** co-careldopa 25/250mg PO TDS, codeine phosphate 30mg PO PRN (max 6-hourly), senna 7.5mg PO BD. NKDA\n\n\n**O/E**\n\nDrowsy but able to answer in full sentences. Appears sweaty. Peripheries warm, CRT < 2s. Coarse creps L mid to lower zone.\n\nTemperature 38.4°C, HR 112, RR 32, BP 115/78, O2 94% RA, AMTS 6/10\n\n**Investigations**\n\nFBC: Hb 124, WCC 16.3, Plts 203 x 10^9, MCV 82\n\nU&Es: Na 133, K 4.6, Cl 100, Ur 8.1, Cr 117, eGFR 83mL/min/1.73m^2\n\nCRP 155\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,936 | false | 34 | null | 6,495,250 | null | false | [] | null | 6,802 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin is a cardiac glycoside that increases myocardial contractility and decreases AV node conduction. It is a useful adjunct in patients with CCF and concomitant AF",
"id": "33957",
"label": "c",
"name": "Digoxin 750 micrograms PO",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "A glyceryl trinitrate infusion can be a useful adjunct treatment in fluid overload secondary to CCF. The patient’s blood pressure must be monitored closely due to its potent vasodilatory effects",
"id": "33958",
"label": "d",
"name": "Glyceryl trinitrate 100 micrograms/kg IV",
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"answer": false,
"explanation": "This would be an option in acute pulmonary oedema unresponsive to initial medical therapy",
"id": "33956",
"label": "b",
"name": "CPAP therapy",
"picture": null,
"votes": 60
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This novel drug combination is used in the chronic medical management of CCF with reduced ejection fraction and has no role in treating acute fluid overload",
"id": "33959",
"label": "e",
"name": "Sacubitril/valsartan 49/51mg PO",
"picture": null,
"votes": 16
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient is clearly fluid overloaded and requires immediate diuresis with a powerful loop diuretic like furosemide",
"id": "33955",
"label": "a",
"name": "Furosemide 40mg IV",
"picture": null,
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}
],
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"__typename": "QuestionComment",
"comment": "Patient has low sats with 92% - treat what kills first, patient should receive CPAP first",
"createdAt": 1675100290,
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"comment": "Correct! But the reason this patients sats are low is because of the pulmonary oedema. The fluid within the interstitial spaces is reducing gas exchange, hence the hypoxaemia. The only way to fix this is to get the fluid out of the lungs! \nCPAP would help and is indicated for cardiogenic pulmonary oedema - but it splints the airways open allowing for more gas exchange in the alveoli by preventing them from collapsing. This would be a temporary solution only (often used for patients who don't respond to medical treatment) and giving furosemide would actually likely solve the problem all together :) \nThis is why furosemide is indicated first. Hope this helps!",
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"comment": "can PE be excluded in this case?",
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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 72 year old woman presents to A&E with acute shortness of breath and chest pain. **PH** congestive cardiac failure, recurrent DVTs, osteoporosis. **DH** bisoprolol fumarate 7.5mg PO OD, lisinopril 40mg PO OD, spironolactone 50mg PO OD, warfarin sodium 8mg PO OD, alendronic acid 70mg PO once weekly, calcichew D3.\n\n\n**O/E**\n\nHR 98, RR 36, BP 149/97, Temperature 37.2°C, O2 92% RA. HS I + II + ?III, bibasal fine creps. Pitting oedema to buttocks.\n\nShe has been sat upright and started on 6L O2 via simple face mask.\n\n**Investigations**\n\nECG: sinus tachycardia\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "Flucloxacillin would be the first-line agent to treat cellulitis, but should not be used in view of the patient’s previous adverse reaction to penicillin",
"id": "33961",
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"name": "Flucloxacillin 500mg PO QDS",
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"explanation": "Vancomycin is an aminoglycoside antibiotic with anti-MRSA activity and is used to treat severe skin and soft tissue infections. Due to its narrow therapeutic range and side effects it is not a first-line agent to treat cellulitis",
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"name": "Vancomycin 15mg/kg IV BD",
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"explanation": "Linezolid is a very broad spectrum oxazolidinone antibiotic with powerful anti Gram-positive activity and is used to treat severe skin and soft tissue infections. It should not be initiated without specialist microbiology input",
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"explanation": "Phenoxymethylpenicillin is sometimes used as prophylaxis against skin and soft tissue infections in some patients, but should not be used to treat cellulitis as it likely has limited activity against Staphylococcus species",
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"name": "Phenoxymethylpenicillin 500mg PO QDS",
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"explanation": "Clarithromycin is a second-line agent to treat cellulitis in patients who are penicillin-allergic",
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"picture": null,
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"__typename": "QuestionComment",
"comment": "The reaction to tazocin should be listed under allergies to make this question clear and fair that it is in fact an allergy.",
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"comment": " clarithromycin is second line if allergy not clindamycin",
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"comment": "clindamyin is first line for severe infection which i think it what they're trying to get at (although could be much clearer)",
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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 attends A&E with a painful swollen left calf. **PH** type 2 diabetes, previous myocardial infarction. **DH** metformin hydrochloride 500mg PO TDS, glimepiride 4mg PO OD, aspirin 75mg PO OD, bisoprolol fumarate 5mg PO OD, ramipril 5mg PO OD. Previous adverse drug reaction to Tazocin – urticarial rash.\n\n\n**O/E**\n\nLarge erythematous patch on left calf, very tender to touch. Temperature 38.0°C. All other observations stable.\n\n**Investigations**\n\nWCC 15.9, CRP 89. Blood cultures pending.\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "Foscarnet is an antiviral drug with activity against some herpesviruses such as CMV. It has no role in the acute management of shingles",
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"name": "Foscarnet 40mg/kg IV TDS",
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"explanation": "Duloxetine is an SNRI used to treat neuropathic pain. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia",
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"explanation": "This patient is presenting with shingles. Oral acyclovir has been shown to reduce the duration and intensity of symptoms, but not to reduce the incidence of post-herpetic neuralgia",
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"explanation": "Paracetamol may provide some pain relief from symptoms but does not treat shingles itself",
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"explanation": "Gabapentin is used to treat neuropathic pain and some types of seizures. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia",
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"comment": "I thought you could only give Acyclovir if within 72 hours, wouldn't a 3 day history potentially be over this?",
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"comment": "only treat is pain is moderate or severe or weakened immune system, pt reports neither of these?",
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"comment": "'Consider oral antiviral treatment for patients aged over 50 years to reduce the risk of post-herpetic neuralgia.' under 'Herpesvirus infections' treatment summary",
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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 73 year old man attends his GP with a 3 day history of a painful rash. **PH** aortic abdominal aneurysm (<5.5cm), benign prostatic hypertrophy. **DH** tamsulosin hydrochloride 400 micrograms PO OD. NKDA\n\n\n**O/E**\n\nHR 70, RR 13, BP 132/65, O2 100% RA, Temperature 36.4°C. Erythematous vesicular rash on right side of abdomen in the distribution of T10 dermatome.\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "Venlafaxine is an SNRI antidepressant that is not licensed for use in children",
"id": "34019",
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"name": "Venlafaxine MR tablets 75mg PO OD",
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"explanation": "Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is not licensed for use 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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"question": "Case Presentation: A 9 year old girl attends a CAMHS appointment with her worried father. He explains that she has ‘not been herself’ for a very long time and has been getting worse over the last two months. Where she once enjoyed attending school and performed well academically, her teachers now report frequent truancies and a markedly steep decline in the quality of her schoolwork. She is not known to be bullied at school and has no past medical history of note.\n\n\n**O/E**\n\nDuring the appointment, she refuses to make eye contact with the CAMHS worker and answers most questions with ‘I don’t know’, but does report significant difficulty sleeping and not eating as much as she used to. When pressed about a horizontal scar on her left arm, she tearfully admits to self-harming herself with a penknife a few weeks ago.\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "flucloxacillin is recommended first line to treat lactational mastitis",
"id": "34045",
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"name": "Flucloxacillin 500mg PO QDS for 14 days",
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"explanation": "All tetracycline antibiotics are contraindicated in breastfeeding due to the risk of irreversible teeth discolouration in the infant",
"id": "34048",
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"explanation": "Clindamycin has activity against common Gram-positive bacteria responsible for skin and soft tissue infections, but would not be a first line option to treat uncomplicated lactational mastitis",
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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 24 year old woman has had pain in her left breast for the last three days. She is currently 6 weeks post-partum, and while she has been taking simple oral analgesia and continuing to express milk at the advice of her health visitor, her symptoms remain unresolving. She has no known drug allergies.\n\n\n**O/E**\n\nRight breast grossly normal, no palpable lumps. Left breast area of erythema at 3 o’ clock position from the areola, measuring approximately 2 x 3 cm. Warm and very tender to touch, but no nipple fissuring or fluctuant lumps on palpation.\n\nTemperature 37.1°C. HR 70, RR 12.\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,941 | false | 39 | null | 6,495,250 | null | false | [] | null | 10,115 | {
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"explanation": "Conservative efforts to calm this patient down have failed, it is therefore indicated to prescribe a pharmacological agent that treats his agitation. In this case the gentleman has Parkinson's disease which means haloperidol should NOT be prescribed. In its place lorazepam 1mg PO OD should be prescribed as it does NOT actively block dopamine receptors like haloperidol does.",
"id": "50304",
"label": "a",
"name": "Prescribe lorazepam 1mg PO OD",
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"explanation": "This is an incorrect option. This patient is agitated, has been aggressive towards staff and conservative managements to control his behaviour have failed. 'Sun-downing' refers to the phenomenon of patients with delirium experiencing worsening of their symptoms at night. Pharmacological management is indicated, no intervention could lead to further harm to members of staff, other patients or the patient himself.",
"id": "50308",
"label": "e",
"name": "No intervention required as this is likely 'sun-downing'",
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"__typename": "QuestionChoice",
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"explanation": "This would be correct if it was likely infection was driving this patient's delirious state however there is no evidence within the stem of this question indicating that this patient has an infection.",
"id": "50307",
"label": "d",
"name": "Prescribe IV broad spectrum antibiotics and monitor observations, WCC and CRP",
"picture": null,
"votes": 6
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Efforts to re-orientate this gentleman have already failed and he has been aggressive to staff. Pharmacological intervention is indicated.",
"id": "50305",
"label": "b",
"name": "Continue to try and re-orientate him, no pharmacological management required",
"picture": null,
"votes": 267
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"__typename": "QuestionChoice",
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"explanation": "You should NEVER prescribe haloperidol to a patient with Parkinson's disease. Haloperidol blocks dopamine receptors in the corpus striatum and in turn can seriously worsen pre-existing Parkinson's disease.",
"id": "50306",
"label": "c",
"name": "Prescribe haloperidol 10mg IM STAT",
"picture": null,
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"comment": "is there a section for delirium in BNF ",
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"comment": "oh yeah, because i'm sure he's going to comply and actually swallow the meds. -_-",
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"comment": "is efforts to calming him down the same as re-orientating?",
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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 78 year old man is currently an inpatient on the elderly care ward. The nursing staff are worried due to him exhibiting aggressive behaviour, he has struck one of the HCAs trying to assist him. Efforts to calm him down verbally have failed.\n\n**PH** Parkinson's disease, hypertension, hypercholesterolaemia\n\n**DH** Co-beneldopa 200mg PO BD, ramipril 5mg PO OD, atorvastatin 40mg PO OD. NKDA\n\n**On examination**\nTemperature 37.2°C, HR 84, RR 16, BP 134/82, O2 97% RA.\n\n**Investigations**\n\nBloods:\n\n- FBC: Hb 138, WCC 7.8, Plts 283 x 10^9\n- CRP 3\n- U&Es: Na 143, K 4.7, Ur 6.0, Cr 103 (baseline 100), eGFR >90mL/min/1.73m<sup>2</sup>\n- Ca2+ (adjusted): 2.3\n- Mg2+: 0.9\n- Phosphate: 0.83\n- LFTs: ALP 36, ALT 28, bilirubin 18\n- TFTs: TSH 1.2, T4 12, T3 7\n- Vitamin B12: 488 pg/ml\n\nMSU: no organisms detected.\n\nChest X-ray: no abnormalities detected.\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,942 | false | 40 | null | 6,495,250 | null | false | [] | null | 18,099 | {
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"explanation": "Vitamin replacement is an important aspect of managing patients with chronic alcohol consumption however this will not treat his acute withdrawal symptoms.",
"id": "10028498",
"label": "b",
"name": "Thiamine 100 mg PO OD",
"picture": null,
"votes": 97
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"__typename": "QuestionChoice",
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"explanation": "Though this patient describes nausea, the most appropriate management at this stage is to give a benzodiazepine to treat his acute withdrawal. Anti-emetics may be a part of his management plan but are not the most important aspect of it.",
"id": "10028500",
"label": "d",
"name": "Ondansetron 4 mg PO TDS",
"picture": null,
"votes": 2
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"explanation": "Benzodiazepines such as chlordiazepoxide are the recommended first-line treatment of acute alcohol withdrawal. This is an acceptable starting dose, with a formal regime to be decided based on this patient's CIWA scoring.",
"id": "10028497",
"label": "a",
"name": "Chlordiazepoxide 20mg PO 6-hourly",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "While this patient has a tremor, he is suffering acute alcohol withdrawal and propranolol is not appropriate for this.",
"id": "10028501",
"label": "e",
"name": "Propranolol 50mg PO PRN",
"picture": null,
"votes": 5
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be given if the patient was very agitated and either a risk to himself and/or others with verbal de-escalation tactics failing, however there is no description of this behaviour in the stem.",
"id": "10028499",
"label": "c",
"name": "Lorazepam 2 mg PO STAT",
"picture": null,
"votes": 100
}
],
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"comment": "when do you give thiamine/pabrinex vs chlordiaxopide ?",
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"comment": "chlordiazepoxide is used to treat the acute alcohol withdrawal symptoms\n\nyou use thiamine to prevent thiamine deficiency in severe alcoholics or to treat Wernickes - so would need to have: 1) altered mental state 2) ophthalmoplegia 3) ataxic gait",
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"comment": "Happy to be corrected but I interpreted this patient as having acute alcohol withdrawal symptoms (nausea, anxiety, tremor) so opted for chlordiazepoxide as this would manage the withdrawal symptoms. \n\nIf the patient presented with symptoms of Wernicke's (ophthalmoplegia, ataxia, and confusion) think it would more appropriate to give pabrinex first? ",
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"question": "Case Presentation: A 43-year-old man attends A&E with nausea, worsening tremor and says he is feeling very anxious and 'on edge'. He is a frequent attender with similar presentations and decided two days he was going to stop drinking completely. He says it has been at least 36 hours since his last drink. **PH** Chronic alcohol abuse, Depression **DH** Omeprazole 30mg PO daily, Sertraline 50mg PO daily NKDA\n\n\n\n\n **On examination**\n\n\nAppears anxious and sweaty, but orientated in time and place. Peripheries warm, CRT < 2s. Pulse regular.\n\n\nTemperature 37.4°C, HR 112, RR 14, BP 115/78, O2 94% RA, AMTS 8/10\n\n\n **Investigations**\n\n\nFBC, U+E, LFT, clotting profile - in-lab\n\n\nPoint of care glucose: 7 mmol/L (normal <6.1 mmol/L)\n\n\nQuestion: Select the most appropriate management at this stage.",
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173,467,943 | false | 41 | null | 6,495,250 | null | false | [] | null | 6,826 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Warfarin can interact with many other drugs because it is metabolised by cytochromes P450 enzymes. CP450 inhibitors such as erythromycin can potentiate the anti-coagulatory effect and make bleeding more likely",
"id": "34077",
"label": "c",
"name": "Warfarin can be safely taken along with antibiotics such as erythromycin and co-trimoxazole",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "With regards to blood test monitoring, patients only require a blood test once every 6 to 8 weeks if the INR levels have become stable",
"id": "34079",
"label": "e",
"name": "Once the international normalised ratio (INR) is within the therapeutic range, he still requires lifelong blood test on a weekly basis to ensure that the INR remains stable",
"picture": null,
"votes": 668
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "If a patient has forgotten to take a dose the day before, the patient is advised to skip the missed dose and take the normal dose at usual time. Patient is reminded to not take more than 1 dose a day",
"id": "34078",
"label": "d",
"name": "If he has forgotten to take a dose of warfarin the day before, he should take 2 doses today to make up",
"picture": null,
"votes": 51
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Warfarin is a Vitamin K antagonist that promotes anticoagulation. Food that contains a lot of vitamin K, for example green leafy vegetables and liver, can interfere with how warfarin works. Hence, patients are advised to keep a stable diet and consult their doctors before changing to a completely new diet",
"id": "34075",
"label": "a",
"name": "He should keep his diet stable and speak to his doctor before changing to a completely new diet",
"picture": null,
"votes": 4385
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Warfarin is a Vitamin K antagonist that promotes anticoagulation",
"id": "34076",
"label": "b",
"name": "Warfarin decreases blood clotting by working against Vitamin A",
"picture": null,
"votes": 39
}
],
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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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"question": "Case presentation: A 65-year-old man presents to the emergency department with sudden-onset shortness of breath. He also complains of stabbing chest pain during inhalation and exhalation. \r\n\nPMH: Prostate cancer, Hypertension, Diabetes Mellitus\nDH: Enalapril maleate 20mg PO OD, Metformin Hydrochloride 500mg TDS\nInvestigation: Computed tomographic pulmonary angiography confirms the diagnosis of pulmonary embolus.\nTreatment with 80mg Enoxaparin subcutaneous injection twice daily was initiated. Treatment with warfarin is to be commenced after 5 days.\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "Pramipexole is linked with impulsive control disorders such as binge eating, pathological gambling and hypersexuality. ",
"id": "34105",
"label": "a",
"name": "Pramipexole is associated with impulsive control disorder",
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"explanation": "Pramipexole increases risk of postural hypotension, especially at the start of treatment. Hence, it is recommended to monitor the blood pressure of patients on initiation of the treatment",
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"picture": null,
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"id": "34107",
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"name": "Maximum dose of pramipexole is usually given at the start to ensure complete control of the symptoms",
"picture": null,
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"explanation": "Pramipexole is a dopamine-receptor agonist that is used alone or as an adjunct to co-careldopa or co-beneldopa to treat Parkinson’s disease",
"id": "34106",
"label": "b",
"name": "Pramipexole is converted into dopamine in the body",
"picture": null,
"votes": 93
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dose of pramipexole needs to be reduced gradually before it can be stopped completely to reduce the risk of neuroleptic malignant syndrome(NMS). NMS is characterised by fever, altered mental status, muscle rigidity and autonomic dysfunction",
"id": "34108",
"label": "d",
"name": "He should immediately stop taking pramipexole if it causes him to feel dizzy",
"picture": null,
"votes": 413
}
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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 65-year-old man attends the Parkinson clinic with increasing frequencies of involuntary and uncontrollable movement. \r\n\nPMH: Parkinson’s disease, Diabetes Mellitus, Hypertension\nDH: Co-Beneldopa (immediate-release) 200mg PO QDS, Metformin hydrochloride 500mg PO TDS, Captopril 50mg PO BD\nThe patient is advised to add pramipexole 88 micrograms PO TDS as an adjunct to his current treatment regime to help control the dyskinesia.\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,945 | false | 43 | null | 6,495,250 | null | false | [] | null | 6,845 | {
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"__typename": "QuestionChoice",
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"explanation": "Manufacturer advises against the concurrent use of GTN and sildenafil because it increases the risk of severe hypotension and circulatory collapse",
"id": "34172",
"label": "c",
"name": "GTN can be safely used together with sildenafil",
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"explanation": "Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 3 doses",
"id": "34173",
"label": "d",
"name": "GTN can be taken at 10 minutes interval if required",
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"explanation": "Restlessness is a rare side effect of GTN",
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"id": "34170",
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"name": "He should seek immediate medical help if symptoms have not resolved after 2 consecutive doses",
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"__typename": "QuestionChoice",
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"explanation": "Glyceryl Trinitrate (GTN) is a medication used for prophylaxis and treatment of angina. It converts into nitric oxide, leading to vasodilation and increased blood flow to the heart",
"id": "34171",
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"name": "GTN works by making the heart beat faster and stronger so that more blood can be delivered to meet the body’s demand",
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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 63-year-old man attends his GP appointment with a 3-month history of chest pain on exertion. He reports that he sometimes gets out of breath and feels a constricting chest pain when climbing up the stairs. The pain usually goes away a few minutes after he sits down. \r\n\nPMH: Erectile dysfunction\nSH: Retired, lives with his wife\n\nThe patient is advised to take Glyceryl Trinitrate (GTN) spray to relieve the chest pain.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
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173,467,946 | false | 44 | null | 6,495,250 | null | false | [] | null | 6,846 | {
"__typename": "QuestionSBA",
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol is not associated with oral thrush. Oral thrush is a potential side effect of inhaled corticosteroids that are commonly used in asthma maintenance therapy",
"id": "34178",
"label": "d",
"name": "Salbutamol inhaler increases risk of developing oral thrush",
"picture": null,
"votes": 280
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": ". In a sudden asthma attack, patients should sit up straight and take one puff of reliever inhaler every 30 seconds up to 10 puffs. They should call 999 for an ambulance if the symptoms still do not resolve after 10 puffs",
"id": "34177",
"label": "c",
"name": "In an asthma attack, he can take salbutamol up to 50 puffs with a time interval of 2 minutes between each puff",
"picture": null,
"votes": 82
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles",
"id": "34176",
"label": "b",
"name": "Salbutamol is an alpha-1-agonist that relieves symptoms of asthma by relaxing the muscles of airway",
"picture": null,
"votes": 85
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles. Patients should talk to their doctors if they need to use the inhaler for more than 3 times in a week. This may be a sign that the asthma is still not well controlled and that an adjustment needs to be made to the current regime",
"id": "34175",
"label": "a",
"name": "He should talk to his doctor if he uses his salbutamol inhaler for more than 3 times a week",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol can cause potentially serious hypokalaemia not hyperkalaemia. It stimulates the entry of potassium into the cells, thus lowering serum potassium concentration",
"id": "34179",
"label": "e",
"name": "Salbutamol can lead to hyperkalaemia",
"picture": null,
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"explanation": "# Summary\n\nAsthma is a common disease of the airways, involving reversible bronchoconstriction, hyperreactivity and chronic inflammation. When bronchoconstriction is triggered (an “asthma attack”), patients experience episodes of wheeze, dyspnoea, cough and chest tightness. Initial investigations for all adults with suspected asthma are fractional exhaled nitric oxide (FeNO) or a full blood count looking for eosinophilia. If neither of these are confirmatory, patients should be assessed with spirometry including bronchodilator reversibility. Management involves a stepwise approach to medications, starting with “reliever therapy” (usually short-acting beta-2 agonists such as salbutamol inhalers) in combination with “preventer therapy” medications including inhaled corticosteroids, leukotriene receptor antagonists and long-acting beta-2 agonist inhalers. Allergen avoidance, smoking cessation, regular peak flow monitoring and inhaler technique are all key to good asthma control.\n\n# Definition\n\nAsthma is a common disease in both adults and children, characterised by intermittent \"asthma attacks\" with wheeze, cough, shortness of breath and chest tightness. There are several underlying mechanisms that centre around reversible bronchoconstriction, hyperreactivity and chronic inflammation.\n\n# Epidemiology\n\nIn the UK, approximately 8 million people have been diagnosed with asthma, of which 5.4 million are on treatment. Onset is usually in childhood and some find symptoms remit with age, although relapse is possible after long periods of being well.\n\nOn average, three people die from an asthma attack each day in the UK. The majority of these deaths are preventable, with an estimated 7/10 people with asthma not receiving basic preventative care such as inhaler technique checks and a personalised asthma plan.\n\nPeople experiencing socioeconomic deprivation are more likely to have asthma and to have worse outcomes (e.g. higher rates of hospitalisation). This is multifactorial, with these groups more likely to be exposed to triggers such as smoking and air pollution, and to have lower health literacy and access to healthcare.\n\n# Pathophysiology\n\nAsthma is often associated with a personal and/or family history of atopy, including the atopic triad of asthma, allergic rhinitis, and eczema. In asthma, there is an exaggerated response to a wide range of triggers. These include:\n\n- Cold air and exercise\n- Pollution and cigarette smoke\n- Allergens such as animal dander, dust mites and pollen\n- Irritants such as perfumes, paints or air fresheners\n- Medications such as NSAIDs or beta-blockers\n\nThese trigger a type 1 hypersensitivity reaction which is mediated by IgE. T Helper 2 cells produce IL4, IL5 and IL13 cytokines which activate the humoral immune system, leading to the proliferation of eosinophils, mast cells and dendritic cells. These cells then produce more inflammatory mediators such as leukotrienes and histamine.\n\nThis inflammation contributes to airway hyperresponsiveness leading to bronchospasm, as well as mucus hypersecretion that also obstructs airways. Over time in severe asthma, airway remodelling mediated by fibroblasts causes chronic obstruction and thickening of smooth muscle.\n\n# Risk factors\n\n- Family history of asthma or atopy\n- Personal history of atopy (eczema, allergic rhinitis, allergic conjunctivitis)\n- Exposure to smoke, including maternal smoking in pregnancy\n- Respiratory infections in infancy\n- Prematurity and low birth weight\n- Obesity\n- Social deprivation\n- Occupational exposures (e.g. flour dust, isocyanates from paint)\n\n# Symptoms\n\n- Wheeze\n- Dyspnoea\n- Cough\n- Chest tightness\n\nThe above symptoms should be episodic and usually show **diurnal variation** (worse at night or in the early morning). The patient may be able to identify specific triggers as listed above.\n\n# Signs\n\nIn between asthma exacerbations, clinical examination may be normal. If asthma is poorly controlled or during an exacerbation, signs include:\n\n- Tachypnoea\n- Increased work of breathing\n- Hyperinflated chest\n- Expiratory polyphonic wheeze throughout the lung fields\n- Decreased air entry (if severe)\n\n\n# Differential diagnosis\n\n- **Bronchiectasis** - usually associated with a productive cough, patients get frequent chest infections and coarse crackles rather than wheeze predominate on examination.\n- **Vocal cord dysfunction** - shares many triggers with asthma, inspiration more difficult than expiration, may have stridor.\n- **Chronic obstructive pulmonary disease** - patients usually >35 years old with a significant smoking history, may overlap with asthma in some.\n- **Gastro-oesophageal reflux disease** - microaspiration of stomach acid due to reflux can cause episodes of cough and wheeze which mimic asthma (although these may coexist and reflux can trigger asthma exacerbations). Symptoms are often postural and related to eating.\n- **Eosinophilic Granulomatosis with Polyangiitis** (Churg-Strauss syndrome) - small vessel vasculitis associated with pANCA, aside from asthma symptoms include nasal polyps, sinusitis, purpuric rashes and peripheral neuropathy.\n\n# Investigations \n\n- **FeNO (fractional exhaled nitric oxide) testing:** offer this **or** blood eosinophil count to all adults to confirm eosinophilic airway inflammation, asthma can be diagnosed if this is >50 parts per billion.\n- **Full blood count** to check **eosinophil count:** offer this **or** FeNO first-line to all adults - asthma can be diagnosed if this is above the normal reference range.\n- If neither of these confirm asthma, **spirometry** with **bronchodilator reversibility** should be offered to confirm airway obstruction (i.e. FEV1/FVC<70%). A bronchodilator (e.g. salbutamol inhaler) is given and spirometry repeated to assess response to treatment. An improvement in FEV1 of 12% or more or 200ml is diagnostic of asthma.\n- If spirometry is delayed or not available, patients may be asked to monitor their peak flow twice a day for 2 weeks and keep a diary of the readings. This is then used to assess **peak flow variability** (the difference between the highest and lowest readings as a percentage of the average PEF). Variability >20% is a positive result.\n- If none of the above are confirmatory, patients may be referred to specialist services for a **direct bronchial challenge test**, where histamine or metacholine is inhaled to trigger bronchoconstriction. Airway hyperresponsiveness is assessed by looking at the concentration of the triggering medication required to cause a 20% decrease in FEV1 - 8mg/ml or less is a positive result.\n\nNote: All of the above tests may be falsely negative in patients treated with inhaled corticosteroids.\n\n# Management of Chronic asthma\n\nThe aim of chronic asthma management is to achieve complete control over symptoms, with no need for rescue medications and no restrictions on physical activity. All patients should have a personalised asthma action plan which should be reviewed at least annually. Components of management include:\n\n## Non-pharmacological\n\n- Teach good inhaler technique and review this regularly\n- Spacer devices can be used to optimise medication delivery\n- Regular peak flow monitoring\n- Smoking cessation\n- Advice on avoiding triggers where possible (e.g. allergens, certain medications)\n- Ensure vaccinations are up to date, including annual influenza vaccination\n- Assess for occupational asthma by asking if symptoms are better when the patient is away from work and arrange specialist referral if this is suspected\n\n## Pharmacological\n\n- Prescribe all patients a combination inhaler with a **long-acting beta-2 agonist** (LABA) i.e. formoterol and a low-dose **inhaled corticosteroid** (ICS) i.e. budesonide to use as a reliever inhaler (i.e. PRN) - this is referred to as anti-inflammatory reliever (AIR) therapy.\n- Patients who do not respond adequately to AIR therapy, who are highly symptomatic at presentation or who present with a severe asthma exacerbation should be started on a low-dose **maintenance and reliever therapy inhaler** (MART). MART is a combination inhaler with ICS and a fast-acting LABA (e.g. beclomethasone + formoterol which is also known as Fostair), which is used as both a reliever inhaler (PRN) and as maintenance treatment (usually twice daily).\n- The next step would be increasing the ICS dose from low to **moderate** in the MART inhaler.\n- At this stage if asthma is not controlled, check FeNO and blood eosinophil count and refer to specialist asthma services if either are raised.\n- If neither are raised, consider adding either a **leukotriene receptor antagonist** (LTRA) such as montelukast (this is a tablet taken every night) or a **long-acting muscarinic agonist** (LAMA) such as tiotropium.\n- One of these should be trialled for 8-12 weeks alongside the moderate-dose MART - if asthma is well-controlled it can be continued.\n- If there is some improvement in control but this is still inadequate, the other medication can be trialled in addition (i.e. moderate dose MART + LTRA + LAMA).\n- If control has not improved, stop the medication and try the other one - if this is not successful refer to specialist services.\n- Options in specialist clinics include therapies such as **biologics** (e.g. omalizumab, which targets IgE).\n\nOther than patients who are not responding to treatment, the following situations shold also prompt a secondary care referral:\n\n- Uncertainty regarding diagnosis\n- Suspected occupational asthma\n- Severe or life-threatening asthma requiring admission to hospital\n- Multiple exacerbations requiring oral steroid treatment per year\n\n# Acute asthma\n\nAcute asthma exacerbations are graded in severity as below:\n\n\n| Severity | Clinical Features |\n|-----------------------|-----------------------------------------------|\n| Moderate | PEFR > 50% of predicted or best |\n| | No features of severe/life-threatening asthma |\n| Severe | PEFR 33-50% of predicted or best |\n| | Heart rate > 110 |\n| | Respiratory rate > 25 |\n| | Unable to complete sentences in one breath. |\n| | Accessory muscle use |\n| Life-threatening | PEFR < 33% of predicted or best |\n| | Oxygen saturation < 92% or cyanosis |\n| | Altered conciousness/confusion |\n| | Exhaustion/poor respiratory effort |\n| | Cardiac arrhythmia |\n| | Hypotension |\n| | Silent chest |\n\n\n## Investigations \n\n- **Peak expiratory flow rate (PEFR)** to help assess severity as per the classification above and monitor response to treatment.\n- **Arterial blood gas** if the patient is hypoxic to assess oxygenation and ventilation in patients - CO2 is expected to be low due to hyperventilation and if this is raised this indicates the asthma attack is near fatal.\n- **Portable chest X-ray** if a trigger such as pneumonia or a complication such as pneumothorax is suspected clinically.\n\n## Management \n\n- Recognise that this may be a medical emergency, assess using an ABCDE approach and escalate early to senior colleagues/critical care if not responding to treatment\n- Titrate oxygen to maintain saturations of 94-98%\n- Nebulised salbutamol driven by oxygen (if out of hospital, give up to 10 puffs of inhaled salbutamol and call an ambulance if not responding)\n- If the attack is severe or life-threatening or if response to salbutamol has been poor, add nebulised ipratropium bromide\n- Give prednisolone 40-50mg orally, or IV hydrocortisone if the patient is unable to swallow\n- Can consider IV magnesium sulphate and/or aminophylline if the patient is not responding to nebulisers\n- If the patient continues to deteriorate despite maximal therapy, they may require intubation and ventilation in an intensive care setting (for example in cases of severe hypoxia or exhaustion)\n\nFollow up after an acute asthma attack is crucial, with NICE guidelines stating that patients should be reviewed within 2 days of discharge from hospital to assess their symptoms, inhaler technique and current management.\n\n# NICE Guidelines\n\n[NICE - Asthma: diagnosis, monitoring and chronic asthma management](https://www.nice.org.uk/guidance/ng245)\n\n# References\n\n[NICE CKS](https://cks.nice.org.uk/topics/asthma/)\n\n[Report on health inequalities and asthma](https://www.asthmaandlung.org.uk/sites/default/files/2023-03/auk-health-inequalities-final.pdf)\n\n[Guideline on severe asthma in primary care](https://www.pcrs-uk.org/sites/default/files/pcru/articles/2019-Autumn-Issue-18-SevereAsthmaReferral.pdf)\n\n\n\n",
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"question": "Case presentation: A 25-year-old man attends his GP appointment with a three-month history of wheeze and chest tightness. He reports that the symptoms usually happen after his morning runs and on exposure to cold air. \r\n\nPMH: Eczema\nExamination: Widespread expiratory polyphonic wheeze\nInvestigation: Fractional exhaled nitric oxide(FENO) > 50 parts per billion (ppb); Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) < 65%; Expiratory peak flow variability >25%\nThe patient is to be offered a salbutamol inhaler (Ventolin Accuhaler®)as reliever therapy.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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173,467,947 | false | 45 | null | 6,495,250 | null | false | [] | null | 10,123 | {
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"explanation": "There are no interactions between ramipril and warfarin, it therefore does not need to be changed.",
"id": "50347",
"label": "d",
"name": "He should switch his ramipril to amlodipine due to potential interactions between ramipril and warfarin",
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"__typename": "QuestionChoice",
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"explanation": "Renal function is not routinely monitored in patients using warfarin.",
"id": "50348",
"label": "e",
"name": "He is likely to need renal monitoring if his warfarin dose needs changing",
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"explanation": "This is incorrect, concurrent illness can exaggerate the effect of warfarin which requires a reduction in dosage. This doesn't mean that you should completely stop this patients warfarin.",
"id": "50346",
"label": "c",
"name": "He needs to stop his warfarin immediately",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nausea is a rare/very rare side effect of warfarin so he is unlikely to experience it with a dose change.",
"id": "50345",
"label": "b",
"name": "He is likely to experience nausea if his warfarin dose needs changing",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "Acute illness can exaggerate the effect of warfarin and indicate a need to reduce dosage. Given this man has had a recent COVID-19 infection and his INR is out of therapeutic range for warfarin he will likely need his warfarin dose reducing.",
"id": "50344",
"label": "a",
"name": "His warfarin does should be reduced",
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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 74-year-old man attends warfarin clinic to have his INR checked. He has recently had COVID-19.\n\n\n\n**PH**\nAtrial fibrillation, hypertension, hypercholesterolaemia\n\n**DH**\n7.5mg warfarin PO OD, ramipril 5mg PO OD, atorvastatin 20mg PO OD\n\n**Investigations** INR 3.8 (2.0-3.0)\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,948 | false | 46 | null | 6,495,250 | null | false | [] | null | 10,124 | {
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"explanation": "Hepatic function is not routinely monitored in patients using unfractionated heparin.",
"id": "50350",
"label": "b",
"name": "He will need regular hepatic monitoring",
"picture": null,
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has chronic kidney disease stage 4, this means his eGFR is 15-29 ml/min. Hyperkalaemia is a recognised risk of chronic kidney disease, especially in the later stages of the disease. Unfractionated heparin inhibits aldosterone secretion, this in turn increases the risk of hyperkalaemia. As this patient is already predisposed to hyperkalaemia it is important to measure their potassium levels before giving unfractionated heparin and during their stay in hospital.",
"id": "50349",
"label": "a",
"name": "He will need to have his potassium checked before he has his heparin",
"picture": null,
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"explanation": "Alopecia is listed as a rare/very rare side effect of unfractionated heparin use, therefore they are not very likely to occur.",
"id": "50352",
"label": "d",
"name": "He is likely to experience hair loss whilst taking unfractionated heparin",
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"explanation": "Thyroid function is not routinely monitored in patients using unfractionated heparin.",
"id": "50351",
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"name": "He will need regular thyroid function tests for monitoring",
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"explanation": "Metallic taste is not a listed side effect of unfractionated heparin.",
"id": "50353",
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"name": "He is likely to experience a metallic taste in his mouth as a side effect of unfractionated heparin",
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"question": "Case presentation: A 64-year-old man is admitted to hospital for elective surgery. He has known oesophageal cancer and is having a subtotal oesophagectomy to remove his tumour.\n\n\n\n**PH**\nOesophageal cancer, chronic kidney disease (stage 4)\n\n**DH**\nRamipril 10mg PO OD, atorvastatin 20mg PO OD, epoetin alfa 3500 units IV BD\n\nAs this gentleman is having surgery, he needs to be prescribed unfractionated heparin\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,467,949 | false | 47 | null | 6,495,250 | null | false | [] | null | 6,912 | {
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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": "10% dextrose = 10g in 100mL = 100g in 1000mL\nAmount of glucose in 2 hours\n= 2/8 x 100g/1000mL\n= 25g",
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"learningPoint": "10% dextrose = 10g in 100mL = 100g in 1000mL\n Amount of glucose in 2 hours\n = 2/8 x 100g/1000mL\n = 25g",
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"question": "A 45-year-old man is admitted to Resus after collapsing and diagnosed with DKA. He is prescribed 3L of 0.9% Normal saline over 5 hours and a fixed rate insulin infusion of 7 units/hr. After the second bag, a repeat ABG is done, and due to a low BM, the saline is switched to 1L of 10% dextrose over 8 hours. \n \n\n\nInvestigations:\n \n| | | |\n| -------------- | :-------: | ------------------ |\n| pH | 7.30 | 7.35 - 7.45 |\n| PaO₂ | 11 kPa | 11 - 15 |\n| PaCO₂ | 4.5 kPa | 4.6 - 6.4 |\n| Bicarbonate | 18 mmol/L | 22 - 30 |\n| Non-fasting Glucose | 10 mmol/L | < 6.1 |\n| Ketones (Serum) | 2 mmol/L | < 0.6 |\n \n\nBP 125/85 mmHg (120/80mmHg on admission)\n \n\nFluid Chart:\n \n\n* 1300 0.9% Normal Saline 1L over 1 hour\n* 1400 0.9% Normal Saline 1L over 2 hour\n* 1600 0.9% Normal Saline 1L over 2 hour\n* 1600 10% Dextrose 1L over 8 hours\n \n \n\nHow much (g) glucose would have been given to the patient 2 hours after the first 10% dextrose 1L over 8 hours was initiated?",
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173,467,950 | false | 48 | null | 6,495,250 | null | false | [] | null | 6,916 | {
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"comment": "it says Tramadol 400mg TDS. So, 1200mg a day?",
"createdAt": 1705585987,
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"comment": "It says that for Ibuprofen not Tramadol.",
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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": "Current dose of tramadol a day = 400mg a day\nNumber of tablets a day\n= 400mg/ 200mg tablets\n= 2 tablets a day\nNumber of tablets for 10 days\n= 2 tablets x 10days\n= 20 tablets for 10 days",
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"question": "A 77- year-old man was admitted to the care of the elderly ward for infective exacerbation of COPD. PMH Mild COPD, Osteoarthritis of left knee. DH Paracetamol 1g QDS, Ibuprofen 400mg TDS PO, Tramadol 200mg BD PO, Ipratropium bromide 40 micrograms INH, Salbutamol 200 micrograms INH QDS\n\n\nTramadol tablets are available in 50mg, 100mg, 150mg and 200mg.\n\nHow many 200mg tablets should the patient be discharged with for a duration of 10days?",
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173,467,951 | false | 49 | null | 6,495,250 | null | false | [] | null | 6,928 | {
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"comment": "We are assuming 1 mL has a mass of 1 g.\n2% is 20 mg in 1 mL\n",
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"comment": "I thought if it's 2% you assume 2ml in 100ml? No? Not g in ml ",
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"comment": "If a percentage concentration is given and it's not specified that it's volume/volume or weight/volume or weight/weight (since a percentage conc can refer to any of these ratios), then you have to assume that it refers to the units that are given in the question - in this case w/v",
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"comment": "his weight is 60kg though...",
"createdAt": 1707748667,
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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": "The maximum safe dose that be given is: 3mg/kg x 80kg = 180mg. Now, 2% lignocaine is 2kg in 100L = 20mg in 1mL. Therefore, the maximum safe volume of lignocaine that can be given is 9mL.\n\nConcentration ratios (2% in this case) are based on units of kilogram and litre as they belong to the International System of Units (SI units) which are used by convention.",
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"question": "A 26-year-old gentleman who weighs 60kg requires 2% lignocaine as local anaesthesia for wound stitching. Local protocols state the maximum safe dose that can be administered is 3mg/kg.\n\n\nWhat is the maximum safe volume of lignocaine that can be given?",
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} | MarksheetMark |
173,467,952 | false | 50 | null | 6,495,250 | null | false | [] | null | 6,932 | {
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"__typename": "QuestionComment",
"comment": "on the BNF it says 4-6 hourly- so option 6 doses per day isn't there which would make max dose 1440mg?",
"createdAt": 1674672080,
"dislikes": 6,
"id": "17205",
"isLikedByMe": 0,
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"questionId": 6932,
"replies": [
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"comment": "Max dose of paracetamol is QDS - hence even though you can give doses 4-hrly apart, can't give more than 4 doses per day",
"createdAt": 1706821564,
"dislikes": 0,
"id": "40518",
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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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"typeId": 2
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"explanation": "The dose of paracetamol to be given for a 5-year-old is 240mg. The maximum number of doses that can be given per day is four. Therefore, the maximum total dose he can be given is: 240mg x 4 = 960mg.",
"highlights": [],
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"question": "A 5-year-old patient who weighs 30kg has mild pyrexia. He is prescribed paracetamol orally.\n\nWhat is the maximum total dose (in milligrams) of paracetamol he can be given per day?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
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