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"explanation": "Isotretinoin is not associated with excessive sweat. On the other hand, it can cause the skin to become dry and sensitive to sunlight",
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"explanation": "Patients are not allowed to donate blood while taking isotretinoin in case the donated blood is given to a pregnant woman",
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"name": "She can donate blood while taking isotretinoin",
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"explanation": "Usage of isotretinoin during pregnancy is linked to an increased risk of serious congenital abnormalities. Hence, patients who are sexually active are required to use effective contraception during the course of treatment and for four weeks after discontinuation of medication",
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"explanation": "Isotretinoin is a vitamin A derivative (retinoid) that is used to treat severe acne vulgaris",
"id": "34191",
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"explanation": "Isotretinoin does not specifically interact with pineapples. Patients are generally allowed to eat and drink normally while taking isotretinoin",
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"explanation": "# Summary\n\nAcne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.\n\n\n# Definition\n\n- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. \n- Vulgaris translates as \"common\", which is true as this condition affects over 80% of adolescents.\n\n# Epidemiology\n\n* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.\n* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.\n* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.\n* Acne affects both males and females, but the prevalence and severity may vary between genders.\n* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.\n\n# Risk Factors\n\nSeveral factors contribute to the development and exacerbation of acne, including:\n\n* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)\n* Increased sebum (oil) production\n* Blockage of hair follicles and sebaceous glands by keratin and sebum\n* Bacterial colonization (Propionibacterium acnes)\n* Family history of acne\n* Certain medications (e.g. corticosteroids, hormonal treatments)\n\n# Pathophysiology\n\n- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.\n- In acne, the corneocytes are excessively cohesive. They do not detach successfully.\n- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.\n- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. \n- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.\n- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. \n- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules. \n- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore referred to as blackheads.\n- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. \n- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. \n- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. \n- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. \n- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. \n\n[lightgallery]\n\n# Classification\n\n- Non-inflammatory: blackheads and whiteheads.\n- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)\n- Mild acne: predominantly non-inflammatory lesions. \n- Moderate acne: predominantly inflammatory papules and pustules. \n- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. \n\n# Clinical Features\n\n- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.\n- The face is most often affected. The neck, chest and back may also be affected.\n- Psychological dysfunction due to changes physical appearance\n- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. \n\t- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.\n\t- Hypertrophic: raised scars.\n\t- Keloid: raised scars that extend beyond the initial boundaries of the injury. \n- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. \n- Post inflammatory erythema: associated with inflammatory acne.\n- Acne fulminans: an uncommon but severe, serious acne presentation. \n\t- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) \n\t- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.\n- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. \n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n- Acne is a clinical diagnosis and investigations are not usually needed. \n- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)\n- Investigations will be required prior to commencing isotretinoin if indicated.\n- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)\n\n# Treatment\n\nManagement of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. \n\n- Each treatment combination is given as a 12 week course. \n- Combination therapies help reduce antimicrobial resistance. \n- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.\n- **Mild-moderate acne** is treated with any 2 of the following in combination:\n\t- Topical benzoyl peroxide.\n\t- Topical antibiotics (clindamycin)\n\t- Topical retinoids (tretinoin/adapalene)\n- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:\n\t- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.\n\t- Topical retinoids + topical antibiotics (clindamycin)\n\t- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.) \n\t- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) \n\t- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. \n\t- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women\n\nNB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.\n\t\n- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:\n\t- Acne fulminans.\n\t- Mild-moderate acne not responding to two 12 week courses of treatment as above.\n\t- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.\n\t- Psychological distress/mental health disorder contributed to by acne.\n\t- Acne with persistent pigmentary changes.\n\t- Acne with scarring.\n- Other available agents:\n\t- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. \n\t- Spironolactone: anti-androgenic - not often used. Not for male patients. \n\t- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. \n\t\t* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension \n\t\t* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment\n\t\t* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.\n\t\n\t\n# Complications\n\n- Post-inflammatory erythema\n- Post-inflammatory hyper- and hypo- pigmentation\n- Psycho/social/sexual dysfunction \n- Scars (atrophic, hypertrophic, keloid)\n\t- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:\n\t\t- Darker skin/Chinese/Hispanic origin \n\t\t- Less than 30 years of age\n\t\t- Previous keloid scarring \n\t- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time. \n\n# NICE Guidelines\n\n[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)",
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"caption": "*A mixture of papules, pustules and comedones seen on the anterior aspect of the chest.*",
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"caption": "*Ice pick scarring seen on the cheeks following severe acne.*",
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"caption": "*An example of moderate acne vulgaris seen on the face.*",
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"question": "Case presentation: A 32-year-old woman attends the dermatology clinic for her acne vulgaris medication review. She complains that her acne problem has not improved despite taking the medication prescribed diligently. \r\n\nPhysical examination: Widespread nodules and cysts over the face as well as the presence of multiple ice pick scars.\nDH: Topical adapalene once daily; Tetracycline 500mg PO twice daily\nThe patient is advised to commence treatment with Isotretinoin 25mg PO OD under the supervision of her dermatologist.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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"explanation": "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",
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"name": "He should immediately stop taking pramipexole if it causes him to feel dizzy",
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"explanation": "Pramipexole is linked with impulsive control disorders such as binge eating, pathological gambling and hypersexuality. ",
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"explanation": "Patients are usually given a small dose to start with before the dose gets gradually increased over time to reduce side effects such as dizziness",
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"name": "Maximum dose of pramipexole is usually given at the start to ensure complete control of the symptoms",
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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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"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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"comment": "why is round to nearest 40 mean 360, wouldnt the nearest multiple of 40 be 380?",
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"comment": "Because 360 is a multiple of 40 (360 / 40 = 9). 380 isn't (380 / 40 = 9.5)",
"createdAt": 1643127615,
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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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"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": "The question does not tell you what to round to? I rounded 2.27272727 to 2.3, in the actual PSA do you think this would be allowed? ",
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"comment": "the working out gives you exactly 2.25, so not sure how you got 2.27? I think it would be marked wrong imo",
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"comment": "when i worked it out it comes to 2.252 and it marked it wrong. ",
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"comment": "i mean how tf are you giving that specific a dose its gonna be 2.3 irl",
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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 = 7.5 mg/kg\nWeight = 7.5kg\nAmount of clarithromycin needed\n= 7.5 mg/kg x 7.5kg = 56.25mg\nVolume of clarithromycin solution\n= 56.25mg x 5mL/125mg = 2.25mL",
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"question": "A 6-month old boy is brought to the emergency department by his mother because he was very unwell and was noted to have blisters across both sides of his cheeks. He was subsequently diagnosed with erysipelas and was to be started on clarithromycin 7.5mg/kg PO twice daily due to a previous penicillin allergy. Weight 7.5kg.\n\n\nClarithromycin is available as 125mg/5mL oral suspension\n\nWhat volume (mL) of clarithromycin oral solution should he be given at each dose?",
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"comment": "rounding up got me\n",
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"comment": "My answer: 69. Correct answer: 66. Answer in the description: 69. Make it make sense quesmed",
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"comment": "NICE guideline for maintenance fluids states: 'Consider delivering IV fluids for routine maintenance during daytime hours to promote sleep and wellbeing'\n\nSorry Quesmed for trying to be nice to my patient and letting them sleep 😤",
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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 total daily requirement of maintenance fluids for a paediatric patient is as follows:\n\n- 1st 10kg = 100ml/kg/day = 1000mL\n- 2nd 10kg = 50ml/kg/day = 500mL\n- Remaining = 20ml/kg/day = 8kg x 20ml/kg/day = 160mL\n\nThe total is 1660mL a day. Hence, the rate in mL per hour is: 1660mL ÷ 24 hours = 69.2mL/hour ≈ 69mL/hour.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Total mass (g) of magnesium sulphate required = 28g\n\n10% 10mL ampoule\n= 10g in 100mL\n= 1g in 10mL ampoule\n\nTotal 10% 10mL ampoule required for 28g of magnesium sulphate\n= 28 10% 10mL ampoules",
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"comment": "In the stem of this question it says gliclazide BD which would mean you need the equivalent of 160mg/ day... however the answer doesn't seem to take this into account. ",
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"comment": "I agree, can some please explain this.",
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"comment": "160mg of standard formulation gliclazide would be bioequivalent to 60mg gliclazide modified release, which means 2x30mg gliclazide modified release tablets per day and therefore 2x14=28 across 2 weeks",
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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": "Tablets needed a day\n= Standard formulation gliclazide 80mg BD\n= 2 modified release 30mg a day\nTotal tablets in 2 weeks\n= 2 x 14 days = 28 tablets",
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"question": "A 75-year-old gentleman attended his GP clinic for a follow up appointment following his discharge from the hospital for a chest infection. The discharge summary noted that the patient was diagnosed with Type 2 Diabetes on admission and requested the GP to change his standard formulation gliclazide to modified release medication. PMH Type 2 Diabetes Mellitus DH Metformin 500mg tablets (2 tablets BD), standard formulation Gliclazide 80mg BD. \n\nGliclazide modified release 30mg and standard formulation Gliclazide 80mg are bioequivalent.\n\nHow many Gliclazide modified release 30mg tablets does the GP need to dispense for a treatment duration of 2 weeks?",
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"explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"id": "2799",
"name": "Combined Oral Contraceptive Pill",
"status": null,
"topic": {
"__typename": "Topic",
"id": "66",
"name": "Obstetrics & Gynaecology",
"typeId": 5
},
"topicId": 66,
"totalCards": null,
"typeId": null,
"userChapter": null,
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"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6867",
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"question": "Case presentation: A 40-year-old woman visits her GP to discuss about contraception. She is interested in having combined oral contraceptive pills (COCP) after hearing about them from her friends. \r\n\nPMH: Depression, Tuberculosis, Epilepsy, Iron-deficiency anaemia\nDH: Her current regular prescriptions are listed below\nHer GP advises her against COCP because one of her current prescriptions is known to reduce the efficacy of COCP\n\nQuestion: Select the prescription that is most likely to decrease the efficacy of COCP?",
"sbaAnswer": [
"a"
],
"totalVotes": 3364,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,266 | false | 27 | null | 6,494,949 | null | false | [] | null | 6,850 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin does not commonly cause bleeding",
"id": "34197",
"label": "c",
"name": "Digoxin 125 micrograms PO daily",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bisoprolol does not commonly cause bleeding",
"id": "34196",
"label": "b",
"name": "Bisoprolol fumarate 5mg PO daily",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "NSAIDs (indomethacin) and antiplatelet (rivaroxaban) interact to increase the risk of gastrointestinal bleeding. Indomethacin is a non-selective COX inhibitor, its effect on COX-1, in particular, decreases the production of thromboxane A2 and prevents platelet aggregation. When used in combination with antiplatelet or anticoagulant agents, it can increase the bleeding risk in patients",
"id": "34195",
"label": "a",
"name": "Indomethacin 100mg PO BD",
"picture": null,
"votes": 1253
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril does not commonly cause bleeding",
"id": "34198",
"label": "d",
"name": "Ramipril 2.5mg PO daily",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine does not commonly cause bleeding",
"id": "34199",
"label": "e",
"name": "Amlodipine 10mg PO daily",
"picture": null,
"votes": 5
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "rivaroxaban is an anticoagulant not an antiplatelet",
"createdAt": 1645692781,
"dislikes": 0,
"id": "7585",
"isLikedByMe": 0,
"likes": 6,
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"displayName": "MJ",
"id": 14826
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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": "2782",
"name": "Rivaroxaban side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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"userNote": null,
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"dislikes": 0,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case Presentation: A 54-year-old man is admitted to the medical ward with acute gout. PMH AF, gout, hypertension. DH His current regular medicines, in addition to rivaroxaban, are listed on the right.\r\n\r\n\nOn examination\nSwollen, red and tender left metatarsophalangeal joint.\nDark, black tarry stools reported.\n\nInvestigation\nFBC Hb 13g/dL (13.5-17.5g/dL)\nFine needle aspiration of joint: negative birefringent urate crystals seen in polarized light.\n\nQuestion: Select the prescription that is most likely to interact with the patient’s rivaroxaban to cause gastrointestinal bleeding.",
"sbaAnswer": [
"a"
],
"totalVotes": 1351,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,267 | false | 28 | null | 6,494,949 | null | false | [] | null | 6,853 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bisoprolol does not commonly cause renal stones",
"id": "34211",
"label": "b",
"name": "Bisoprolol 10mg PO OD",
"picture": null,
"votes": 76
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dalteparin does not commonly cause renal stones",
"id": "34213",
"label": "d",
"name": "Dalteparin 5000 units SC OD",
"picture": null,
"votes": 134
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause renal stones",
"id": "34212",
"label": "c",
"name": "Atorvastatin 10mg PO OD",
"picture": null,
"votes": 259
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tamsulosin does not commonly cause renal stones",
"id": "34214",
"label": "e",
"name": "Tamsulosin 400 micrograms PO OD",
"picture": null,
"votes": 503
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Loop diuretics act by competing for the chloride site on the Na-K-2Cl cotransporter and inhibiting sodium and calcium reabsorption in the thick ascending limb of Loop of Henle. This results in an increased excretion of calcium in the urine and a hypercalciuric state, which results in the formation of renal calculi",
"id": "34210",
"label": "a",
"name": "Furosemide 40mg PO OD",
"picture": null,
"votes": 4739
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Renal stones are not listed as a common side-effect in the BNF - the pathophysiology is nice to know, but if I can't find it on the BNF I would be at a loss. Is this a type of question I can expect to find in the PSA (one in which there's no indication on the drug's monograph other than 'electrolyte imbalance'?)",
"createdAt": 1676556223,
"dislikes": 0,
"id": "18391",
"isLikedByMe": 0,
"likes": 11,
"parentId": null,
"questionId": 6853,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I found it in the page for renal and ureteric stones, in the causes it describes all diuretics can cause stones... so just went with the only diuretic in the options :)",
"createdAt": 1710156994,
"dislikes": 0,
"id": "44423",
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"displayName": "Amnesia Defibrillator",
"id": 21454
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Roshimitsu",
"id": 27307
}
},
{
"__typename": "QuestionComment",
"comment": "Yes sir, assumed knowledge is what they call it :(\n",
"createdAt": 1706563399,
"dislikes": 2,
"id": "40214",
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"likes": 4,
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"displayName": "NS",
"id": 13195
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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": "2785",
"name": "Furosemide side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"explanation": null,
"highlights": [],
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"qaAnswer": null,
"question": "Case Presentation: A 75-year-old gentleman was admitted to the acute medical unit two days ago due to acute pulmonary edema secondary to decompensated heart failure. Subsequently, he complained of severe loin to groin pain that started this morning and was subsequently reviewed by the urology team. PMH HTN, Familial hypercholesterolemia, Heart failure, BPH. DH His current regular medicines are listed (below).\r\n\nInvestigation\nNon contrast CT scan revealed radiopaque stones in the right ureter.\n\nQuestion: Select the prescription that is most likely to contribute to his renal stones",
"sbaAnswer": [
"a"
],
"totalVotes": 5711,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,268 | false | 29 | null | 6,494,949 | null | false | [] | null | 6,864 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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
}
],
"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": "2796",
"name": "Amlodipine side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2796,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6864",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 6,
"qaAnswer": null,
"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"
],
"totalVotes": 6281,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,269 | false | 30 | null | 6,494,949 | null | false | [] | null | 6,868 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding",
"id": "34286",
"label": "b",
"name": "Methotrexate 7.5 mg once weekly",
"picture": null,
"votes": 889
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Both sertraline and diclofenac can increase risk of bleeding. Hence, it is generally recommended to prescribe a gastroprotective drug such as a proton pump inhibitor in people who are taking non-steroidal anti-inflammatory drugs (NSAID), especially for elderly patients",
"id": "34285",
"label": "a",
"name": "Sertraline 50 mg PO OD",
"picture": null,
"votes": 4172
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril can increase the risk of hyperkalaemia if used together with diclofenac. However, it is not known to to interact with diclofenac to cause ulceration or gastrointestinal bleeding",
"id": "34288",
"label": "d",
"name": "Lisinopril 20 mg PO OD",
"picture": null,
"votes": 108
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding",
"id": "34287",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 115
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding",
"id": "34289",
"label": "e",
"name": "Simvastatin 40 mg PO nightly",
"picture": null,
"votes": 93
}
],
"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": "2800",
"name": "SSRI - side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2800,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6868",
"isLikedByMe": null,
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"likes": 0,
"multiAnswer": null,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case presentation: A 55-year-old woman presents to her GP with a 2-month history of upper abdominal pain. He describes the pain as a dull ache that is relieved by food. He also notices three episodes of black, sticky stools. He denies having any change in bowel habits or rapid loss in weight. \r\n\nPMH: Depression, Rheumatic arthritis, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia\nDH: Her current regular prescriptions, in addition to Diclofenac 50 mg PO three times daily, are listed below\nOn examination: Mild epigastric tenderness on palpation. Bowel sounds present. Chest is clear with no added lung sounds. Heart sounds I+II+0.\n\nQuestion: Select the prescription that is most likely to be contributing to the melaena along with diclofenac?",
"sbaAnswer": [
"a"
],
"totalVotes": 5377,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,270 | false | 31 | null | 6,494,949 | null | false | [] | null | 6,884 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As an alpha-blocker, tamsulosin may exacerbate orthostatic hypotension, particularly in the elderly",
"id": "34365",
"label": "a",
"name": "Blood pressure",
"picture": null,
"votes": 6091
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary prior to starting this drug",
"id": "34366",
"label": "b",
"name": "Arterial doppler ultrasound",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that tamsulosin be avoided in patients with severe liver dysfunction but routine monitoring of liver function is not necessary",
"id": "34368",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 189
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tamsulosin blocks alpha adrenergic receptors rather than beta adrenergic receptors and has very limited activity on the heart",
"id": "34367",
"label": "c",
"name": "ECG",
"picture": null,
"votes": 246
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that tamsulosin be avoided in patients with severe renal dysfunction but routine monitoring of renal function is not necessary",
"id": "34369",
"label": "e",
"name": "Urea and electrolytes",
"picture": null,
"votes": 387
}
],
"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": "2816",
"name": "Tamsuolsin side effects",
"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 70 year old man is seen in the outpatient urology clinic for consideration of starting tamsulosin hydrochloride 400 micrograms PO OD to treat benign prostatic hypertrophy. **PMH** temporal arteritis, depression. **DH** venlafaxine modified release 150mg PO OD\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of tamsulosin.",
"sbaAnswer": [
"a"
],
"totalVotes": 6922,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,271 | false | 32 | null | 6,494,949 | null | false | [] | null | 6,883 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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",
"id": "34363",
"label": "d",
"name": "PHQ-9",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary with this medication",
"id": "34364",
"label": "e",
"name": "Weight",
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"votes": 63
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{
"__typename": "QuestionChoice",
"answer": false,
"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",
"picture": null,
"votes": 3492
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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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"votes": 48
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{
"__typename": "QuestionChoice",
"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": "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",
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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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"id": "2815",
"name": "Donepazil side effects",
"status": null,
"topic": {
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"id": "74",
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"typeId": 5
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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"
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173,458,272 | false | 33 | null | 6,494,949 | null | false | [] | null | 6,890 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
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"__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,
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"__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,
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"__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 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
}
],
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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,
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"id": "90",
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"typeId": 5
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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,
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173,458,273 | false | 34 | null | 6,494,949 | null | false | [] | null | 6,879 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst serum urea is part of routine renal function monitoring, it does not specifically affect digoxin toxicity. However, impaired renal function can lead to digoxin accumulation, so regular assessment of renal parameters (including creatinine) is recommended.",
"id": "34344",
"label": "e",
"name": "Serum urea",
"picture": null,
"votes": 680
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Serum chloride levels are not significant in the context of digoxin toxicity. This electrolyte is not a direct factor in potentiating digoxin’s effects or its associated adverse events.",
"id": "34341",
"label": "b",
"name": "Serum chloride",
"picture": null,
"votes": 12
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Increase in digoxin levels is known to be potentiated by electrolyte imbalances but particularly potassium, calcium and magnesium. These should be checked when a patient is presenting with symptoms of toxicity, but general renal function should be routinely monitored for the duration of treatment as well",
"id": "34340",
"label": "a",
"name": "Serum potassium",
"picture": null,
"votes": 4495
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phosphate levels are not directly related to digoxin toxicity. Monitoring serum phosphate may be relevant in other clinical contexts but is not a priority in patients treated with digoxin.",
"id": "34342",
"label": "c",
"name": "Serum phosphate",
"picture": null,
"votes": 37
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although abnormal sodium levels can indicate electrolyte imbalances, they do not directly potentiate digoxin toxicity. Monitoring sodium is important for general health but is not the primary concern in digoxin-treated patients.",
"id": "34343",
"label": "d",
"name": "Serum sodium",
"picture": null,
"votes": 113
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where is this mentioned in the BNF?",
"createdAt": 1705946039,
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{
"__typename": "QuestionComment",
"comment": "If you look in the 'Caution' section of Digoxin",
"createdAt": 1706092483,
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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 woman presents to A&E with acute confusion, nausea and vomiting. **PMH** permanent atrial fibrillation. **DH** digoxin 187.5 micrograms PO OD.\n\n\n\n\n **Investigations**\n\n\nDigoxin levels: 2.8µg/L (target 0.5 – 2.0µg/L)\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
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173,458,274 | false | 35 | null | 6,494,949 | null | false | [] | null | 6,886 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor renal function",
"id": "34378",
"label": "d",
"name": "Full blood count, renal function and weight",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor serum prolactin",
"id": "34379",
"label": "e",
"name": "Height, full blood count and serum prolactin",
"picture": null,
"votes": 20
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"__typename": "QuestionChoice",
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"explanation": "It is recommended to perform an ECG before commencing methylphenidate and to monitor blood pressure for the duration of treatment. Monitoring serum prolactin is not necessary",
"id": "34376",
"label": "b",
"name": "Blood pressure, ECG and serum prolactin",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate",
"id": "34375",
"label": "a",
"name": "Blood pressure, height and weight",
"picture": null,
"votes": 5157
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to monitor renal function",
"id": "34377",
"label": "c",
"name": "ECG, height and renal function",
"picture": null,
"votes": 55
}
],
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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 9 year old boy attends a specialist paediatric review with his parents. He has previously been suspended from school for being disruptive and refusing to settle during class. At home, his mother struggles to make him focus on his homework and conform to bedtimes, sometimes finding him awake and playing loudly in his bedroom past midnight. A trial of a low-sugar diet has failed to ameliorate his behavioural symptoms.\n\n\nTreatment with methylphenidate hydrochloride 5mg PO OD is to be commenced.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
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173,458,275 | false | 36 | null | 6,494,949 | null | false | [] | null | 6,910 | {
"__typename": "QuestionSBA",
"choices": [
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"__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 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
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"__typename": "QuestionChoice",
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"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": "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?",
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"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",
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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\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",
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"a"
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173,458,276 | false | 37 | null | 6,494,949 | null | false | [] | null | 6,907 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The maximum tolerated dose of metformin is 2g a day",
"id": "34481",
"label": "b",
"name": "Metformin 1g TDS PO",
"picture": null,
"votes": 345
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "His metformin can be up titrated to the maximum before starting on dual therapy",
"id": "34483",
"label": "d",
"name": "Add sitagliptin 100mg PO OD to metformin",
"picture": null,
"votes": 3086
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has poorly controlled hyperglycaemia (HbA1c 60) despite being started on metformin 500mg TDS. The maximum tolerated dose of metformin is 2g a day. His metformin can be up titrated to the maximum before starting on dual therapy",
"id": "34480",
"label": "a",
"name": "Metformin 1g BD PO",
"picture": null,
"votes": 3183
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "His metformin can be up titrated to the maximum before starting on dual therapy. If the patient fails to respond to dual oral hypoglycaemic agents, triple therapy can then be considered",
"id": "34484",
"label": "e",
"name": "Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD",
"picture": null,
"votes": 127
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with T2DM are often trialled on different combination of oral hypoglycaemic agent prior to initiation of insulin. In this case, uptitrating his metformin should be considered prior to changing his medication to insulin",
"id": "34482",
"label": "c",
"name": "Switch to biphasic insulin detemir 20 units SC",
"picture": null,
"votes": 40
}
],
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"comment": "from my understanding, \nMetformin immediate release:\n- Can titrate up metformin e.g. from 500mg BD -> TDS but only if HbA1c below 58 mmol\n- Max dose is 2g daily \n- If not tolerated, try moderate release first\n- If HbA1c rises to 58 (7.5%) on metformin: (should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%))\n\nwe should go straight for another drug as it is >58...??\n",
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"comment": "jg diff",
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"comment": "It doesnt say his metformin dose in the beginning\n",
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"comment": "i want to give him empagliflozin >.<",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation:\n\n\nA 52-year-old man presents to his GP for review of his blood glucose. He was started on metformin 3 months ago when his HbA1c was found to be 52 and 56mmol/mol when tested on two separate occasions. PMH Type 2 diabetes mellitus, Hypertension, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 500mg TDS PO.\n **On Examination**\nBP 125/85 mmHg\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Non-fasting Glucose|13.1 mmol/L|< 6.1|\n|HbA1c (Glycated Haemoglobin)|60 mmol/mol or %|20 - 42 or 4-6%|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|85 µmol/L|60 - 120|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data.",
"sbaAnswer": [
"a"
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173,458,277 | false | 38 | null | 6,494,949 | null | false | [] | null | 6,909 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered",
"id": "34493",
"label": "d",
"name": "Start bisoprolol fumarate 5mg PO OD",
"picture": null,
"votes": 445
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Starting on spironolactone would be the most appropriate management for a poorly controlled hypertension patient who have been started on ACEi, CCB and diuretics with a K <4.5mmol. [Click here for more information on NICE guidance](https://pathways.nice.org.uk/pathways/hypertension)",
"id": "34490",
"label": "a",
"name": "Start spironolactone 25mg PO OD",
"picture": null,
"votes": 4317
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There are 2 types of calcium channel blocker, dihydropyridine like nifedipine and amlodipine are used as antihypertensive medication. Non-dihydropyridine like verapamil and diltiazem are for rate control medication in arrythmias",
"id": "34492",
"label": "c",
"name": "Start verapamil 80mg PO TDS",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although his BP remains poorly controlled with three antihypertensive, the maximal recommended dose for ramipril is 10mg OD. 15mg OD will be more than the recommended dose",
"id": "34494",
"label": "e",
"name": "Increase dose of ramipril to 15mg PO OD",
"picture": null,
"votes": 105
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered",
"id": "34491",
"label": "b",
"name": "Start doxazosin 1mg PO OD",
"picture": null,
"votes": 276
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Would you not change him to a CCB now he is over 55 years of age?",
"createdAt": 1643636672,
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"comment": "he is already on amlodipine",
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"comment": "would you add bendroflumethiazide before jumping to spironolactone?\n",
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"comment": "He's already on Indapamide",
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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\n\n\nA 56-year-old man presents to his GP for review of his medication. PMH Hypertension. DH Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD\n\n\n **On Examination**\nBP 157/60 mmHg\n\n\nHR 85/min\n\n\nRR 14\n\n\nO2 sats 96% RA\n\n\n **Investigations**\n\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\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of his hypertension based on these data.",
"sbaAnswer": [
"a"
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173,458,278 | false | 39 | null | 6,494,949 | null | false | [] | null | 6,899 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Gentamicin nomogram is used to determine when the next dose of gentamicin is due. In this situation, the trough level (taken 6-14 hours after the initiation of gentamicin) is 6mg/mL. Referring to the Hartford nomogram, the next dose should be given in the next 24 hours from the 1st dose, hence, 375mg IV at 1600 tomorrow",
"id": "34440",
"label": "a",
"name": "Gentamicin 375mg IV 1600 tomorrow",
"picture": null,
"votes": 3713
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "According to the nomogram, his trough level falls under the every 24 hour frequency, hence, the next dose should be given at 1600 tomorrow and not the day after",
"id": "34443",
"label": "d",
"name": "Gentamicin 375mg IV 2300 the day after",
"picture": null,
"votes": 155
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As his trough level falls within the 24 hour frequency, the next dose should be given 24 hours from the first dose which was at 1600 and not from the time the sample was taken",
"id": "34444",
"label": "e",
"name": "Gentamicin 375mg IV 2300 tomorrow",
"picture": null,
"votes": 502
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose",
"id": "34442",
"label": "c",
"name": "Repeat the blood test at 1600 tomorrow",
"picture": null,
"votes": 414
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose",
"id": "34441",
"label": "b",
"name": "Repeat the blood test at 0400 today",
"picture": null,
"votes": 344
}
],
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{
"__typename": "QuestionComment",
"comment": "why do you not need to measure a pre-dose level as well as a trough level, to see if the next dose should be reduced/increased?",
"createdAt": 1706398815,
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"comment": "with gentamicin the dose stays the same and the interval between administration changes depending on the concentration plotted on that graph, assuming normal renal function",
"createdAt": 1708515257,
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"comment": "Where can you find the gentamicin normogram",
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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\n\n\nA 55-year-old lady presents to the emergency department with rigor and pyrexia complaining of 3 day history of dysuria and urinary frequency. A urine dipstick was performed, which showed positive leucocyte esterase and nitrates. Microscopy, culture and sensitivity confirmed urosepsis, with sensitivity showing susceptibility to gentamicin. She is started on gentamicin 5mg/kg IV OD. Her first dose of gentamicin was administered at 1600 today. Weight 75kg.\n\n\n **Investigations**\nSerum gentamicin at 2300 6mg/L\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Urea|6.5 mmol/L|2.5 - 7.8|\n|Creatinine|100 µmol/L|60 - 120|\n|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion:\nSelect the most appropriate decision option based on these data and using the[Hartford Nomogram](http://www.leedsformulary.nhs.uk/docs/RxGentamicinHartford.pdf)",
"sbaAnswer": [
"a"
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"totalVotes": 5128,
"typeId": 1,
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173,458,279 | false | 40 | null | 6,494,949 | null | false | [] | null | 6,911 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "25micrograms of liothyronine is bioquivalent to 100micrograms of levothyroxine sodium. As he is thyroid function is poorly controlled with this dose of thyroid replacement, changing it to another form that is of similar bioequivalence would not be beneficial for him",
"id": "34503",
"label": "d",
"name": "Change to liothyronine sodium 25 micrograms PO daily",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "His thyroid function test, particularly the high TSH is suggestive of poor thyroid control. Continueing him on the similar dose of thyroid replacement will not be help his thyroid function",
"id": "34504",
"label": "e",
"name": "Continue levothyroxine sodium 100 micrograms PO daily",
"picture": null,
"votes": 217
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "High TSH and low total T4 level indicate inadequate replacement of levothyroxine and hence should be uptitrated. The increase in dose should be done in steps of 25-50 micrograms every 3-4 weeks",
"id": "34500",
"label": "a",
"name": "Increase levothyroxine sodium to 125 micrograms PO daily",
"picture": null,
"votes": 4624
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "His thyroid function test suggest inadequate replacement and hence his medication should be increased and not decreased",
"id": "34501",
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"explanation": "The recommended increment in levothyroxine is a gradual increment of 25-50 micrograms every 3-4 weeks",
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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\n\n\nA 56-year-old man presents to his GP for review of his medication. PMH Hypothyroidism for 3 years. DH Levothyroxine sodium 100 micrograms PO daily.\n\n\n **Investigations**\nTSH 10 mU/L (0.4-5.0)\n\n\nTotal T4 0.5 nmol/L (1.1-3)\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the levothyroxine sodium prescription based on these data.",
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"comment": "BNF states that IV lorazepam can also be used in status",
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"comment": "but he doesnt have any IV access",
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"comment": "here it said the concentration of midazolam was 5 mg / ml. I said the answer was therefore 1 ml of solution (because there are 5 mg of midazolam in that). But it was wrong? Would you get this wrong in the real exam? Because in real life you would give 1 ml of solution???",
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"comment": "It's only wrong if the exam is asking you for the dose in mg and not the volume to be administered, which was the case for this Qu (the answer units were in mg). As a general rule of thumb, the prescriber states the dose in mg, as the person giving the medication would then need to decide how it's administered",
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"comment": "prescribed 5 mg midaz and oromucosal and it wasn't accepted bc they only take that combination with \"buccal\" ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Drug choice feedback\n\nThis child is most probably suffering from febrile seizures secondary to the ongoing viral infection, and given his past and family history of febrile seizures. Importantly, other major causes of paediatric seizures such as meningococcal disease or hypoglycaemia are excluded based on the examination findings and his blood glucose being normal respectively. As he is still seizing after five minutes, emergency treatment with either diazepam or midazolam should be initiated.\n\n# Dose/Route/Frequency/Duration feedback\n\nDiazepam should be given PR while midazolam should be given buccally. The optimal doses are as above.",
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"question": "Case Presentation: A 3-year-old boy attends the Emergency Department with his mother with a high fever and cough. No changes in urinary habit and no travel history noted. While waiting to be seen, he suddenly begins seizing.\n\n\n\n\n## PH\n\n\nFebrile seizures\n\n\n## DH\n\n\nNone (NKDA)\n\n\n## FHx\n\n\nFather had febrile seizures as a child\n\n\n## On examination\n\n\nThe child is having generalised, tonic-clonic seizure. He was not noted to be irritable, drowsy beforehand. No neck stiffness, no rash seen, fontanelle not bulging.\nNo cannula has been inserted.\n\n\nTemperature 38.9°C, HR 120, RR 25, BP 96/68, O<sub>2</sub> 98% RA, GCS 15 (before seizure began), Weight 15kg\n\n\n## Investigations\n\n\nBM: 5.5 mmol/L (normal range 3.5-5.5 mmol/L).\n\n\nAll other investigation results are pending.\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate for treating his condition should it still persist after five minutes.",
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"comment": "I do think it should specify if you are to do the stat dose or continuing 2ndary prevention ",
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"explanation": "# Summary\r\n\r\nAcute coronary syndrome (ACS) refers to a set of symptoms and signs that occur due to reduced blood flow to the heart at rest. It encompasses 3 distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). In the case of infarction, this is a medical emergency requiring urgent treatment. ACS is most commonly caused by the rupture of atherosclerotic plaques in coronary arteries leading to further narrowing, and potentially complete occlusion, of these critical blood vessels. Diagnosis involves clinical evaluation, ECGs, and troponin levels. Treatment strategies differ for STEMI and NSTEMI/unstable angina but include oxygen therapy if hypoxic, antiplatelet medication, glyceryl trinitrates, morphine, and percutaneous coronary intervention (PCI). Post-MI management includes aspirin, dual antiplatelet therapy, beta-blockers, ACE inhibitors, high-dose statins, and cardiac rehabilitation. There are many complications to be aware of post-ACS and these include arrhythmias, heart failure, and cardiac tamponade, and others.\r\n\r\n# Definition \r\n\r\nAcute coronary syndrome is a set of symptoms and signs that occur due to decreased blood flow to the heart at rest. It broadly refers to three distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). \r\n\r\n# Epidemiology \r\n\r\nIn the UK, there are over 80,000 hospital admissions due to ACS every year. Coronary artery disease remains the largest cause of death in the UK. \r\n\r\n# Pathophysiology\r\n\r\nCoronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. In stable angina, when the demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. Conversely, in ACS, the symptoms occur at rest. This is because there is sudden plaque rupture and clot formation in the narrowed coronary arteries. If there is partial occlusion of the coronary artery this leads to ischaemia and chest pain at rest (unstable angina). If the coronary artery becomes more occluded or fully occluded this leads to significant hypoperfusion of the myocardium and ultimately leads to infarction (death) of the myocardial tissue (NSTEMI or STEMI). \r\n\r\n# Risk Factors\r\n\r\nCoronary artery disease and the development of plaques can be attributed to non-modifiable and modifiable risk factors. Modifiable risk factors must be addressed in the management of IHD. \r\n\r\n* Non-modifiable:\r\n * Age\r\n * Male sex\r\n * Family history\r\n * Ethnicity (particularly South Asians)\r\n* Modifiable:\r\n * Smoking\r\n * Hypertension\r\n * Hyperlipidaemia\r\n * Hypercholesterolaemia\r\n * Obesity\r\n * Diabetes\r\n * Stress\r\n * High fat diets\r\n * Physical inactivity\r\n\r\n# Classification \r\n\r\nAcute coronary syndrome can be split up into three distinct diagnoses: \r\n\r\n1. **Unstable angina**: caused by partial occlusion of a coronary artery. Troponin negative chest pain with normal/abnormal ECG signs. \r\n2. **Non-ST Elevation Myocardial Infarction**: caused by severe but incomplete occlusion of a coronary artery. Troponin positive chest pain without ST elevation. \r\n3. **ST-Elevation Myocardial Infarction**: caused by complete occlusion of a coronary artery. Troponin positive chest pain with ST elevation on ECG. \r\n\r\n*Myocardial Ischaemia vs. Myocardial Infarction and the Release of Troponin*\r\n\r\nIt is important at this stage to distinguish between angina (stable angina is on exertion and unstable angina is at rest) and myocardial infarction. Angina refers to myocardial ischaemia that causes chest pain but does not lead to the death of myocardial tissue and does not lead to a troponin rise. In myocardial infarction, the hypoperfusion of the myocardium is so profound that it leads to the death of myocardial tissue. It is when there is myocardial tissue death that troponin is released into the bloodstream and a troponin rise is found on blood tests.\r\n\r\n*Type 2 Myocardial Infarction* \r\n\r\nIt is also important to mention that some patient may have myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm). These are usually termed type 2 myocardial infarctions and may not require the conventional treatment outlined below. \r\n\r\n# Symptoms and Signs\r\n\r\n* Chest pain - the classical presentation can be considered in terms of the SOCRATES mnemonic:\r\n * Site - Central/left sided\r\n * Onset - Sudden\r\n * Character - Crushing ('like someone is sitting on your chest')\r\n * Radiation - Left arm, neck and jaw\r\n * Associated symptoms - Nausea, sweating, clamminess, shortness of breath, sometimes vomiting or syncope\r\n * Timing - Constant\r\n * Exacerbating/relieving factors - Worsened by exercise/exertion and may be improved by GTN\r\n * Severity - Often extremely severe\r\n* Atypical presentations may include:\r\n * Epigastric pain\r\n * No pain (more common in elderly and **patients with diabetes**):\r\n * Acute breathlessness\r\n * Palpitations\r\n * Acute confusion\r\n * Diabetic hyperglycaemic crises\r\n * Syncope\r\n\r\n# Differential Diagnoses\r\n\r\nIt is important to remember that there are non-MI causes of chest pain and these should be considered when making a diagnosis:\r\n\r\n* Cardiac\r\n * Myocarditis\r\n * Pericarditis\r\n * Cardiomyopathy\r\n * Valvular disease\r\n * Cardiac trauma\r\n* Pulmonary\r\n * PE\r\n * Pneumonia\r\n * Pneumothorax\r\n* Vascular\r\n * Aortic dissection\r\n* GI\r\n * Oesophageal spasm\r\n * Oesophagitis\r\n * Peptic ulcer\r\n * Pancreatitis\r\n * Cholecystitis\r\n* MSK\r\n * Rib fracture\r\n * Costochondritis\r\n * Muscle injury\r\n * Herpes zoster\r\n\r\n# Diagnosis of ACS \r\n\r\nDiagnosis depends on a combination of clinical, ECG and biochemical findings which helps distinguish between the various types of ACS.\r\n\r\n* Unstable angina - cardiac chest pain at rest + abnormal/normal ECG + **normal troponin**.\r\n* NSTEMI - cardiac chest pain at rest + abnormal/normal ECG (but not ST-elevation) + **raised troponin**\r\n* STEMI - cardiac chest pain at rest + **persistent ST-elevation/new LBBB** (note that there is no need for a troponin in this case).\r\n\r\n## Diagnosis of STEMI\r\n\r\n* ST segment elevation **>2mm** in adjacent chest leads\r\n* ST segment elevation **>1mm** in adjacent limb leads\r\n* New left bundle branch block (LBBB) with chest pain or suspicion of MI\r\n\r\n## Diagnosis of NSTEMI\r\n\r\nDiagnosis of NSTEMI requires two of the following:\r\n\r\n* Cardiac chest pain\r\n* Newly abnormal ECG which does not demonstrate ST-elevation e.g. ST depression, T wave inversion or non-specific changes. \r\n* Raised troponin (with no other reasonable explanation)\r\n\r\n# Investigations\r\n\r\n## Bedside \r\n\r\n* ECG \r\n\t* Looking for ST-elevation, LBBB or other ST abnormalities\r\n\t* This is the most important investigation and should not be delayed for other investigations (e.g. bloods) because this will define immediate management.\r\n\t* If an ECG shows STEMI then troponin is essentially irrelevant and the patient requires immediate treatment.\r\n\r\n## Bloods \r\n\r\n* Troponin: performed **at least 3 hours** after pain starts. It will also need to be repeated (usually 6 hours after the first level) in order to demonstrate a dynamic troponin rise. \r\n* Renal function: good renal function is required for coronary angiogram +/- PCI due to the use of contrast. \r\n* HbA1c and lipid profile: looking for modifiable risk factors for coronary artery disease. \r\n* FBC and CRP - rule out infectious causes of chest pain\r\n* D-dimer - may be used in _appropriate_ patients to rule out PE. *Be very careful about who you do a D-dimer on!*\r\n\r\n## Imaging \r\n\r\n* CXR: should be completed in all those presenting with a chest symptoms. It will help to rule out other causes of chest pain (e.g. pneumothorax) and look for complications of a large MI (e.g. pulmonary oedema in acute heart failure). \r\n\r\n# ECG Interpretation - Cardiac Territories and Affected Vessels\r\n\r\nThe importance of a 12-lead ECG is that it allows one to view electrical activity of the heart from different \"views\". In MI (particularly STEMI) this allows you to understand which territory (and therefore which vessel) is being affected.\r\n\r\n| Location of ST elevation | Area of myocardium | Coronary artery |\r\n| -------------------------- | ------------------ | -------------------- |\r\n| II, III, aVF | Inferior | RCA |\r\n| V1-2 | Septal | Proximal LAD |\r\n| V3-4 | Anterior | LAD |\r\n| V5-6 | Apex | Distal LAD/ LCx/ RCA |\r\n| I, aVL | Lateral | Lcx |\r\n| V7-V9 (ST depression V1-3) | Posterolateral | RCA/ LCx |\r\n\r\n\r\nRCA: right coronary artery, LAD: left anterior descending, LCx: Left circumflex\r\n\r\n[lightgallery]\r\n\r\n[lightgallery2]\r\n\r\n[lightgallery3]\r\n\r\n[lightgallery4]\r\n\r\n\r\nNSTEMIs may also show T wave abnormalities (such as ST depression and T wave inversions) in vascular territories as above. However, changes can also often not include all the specific leads of that territory in an NSTEMI.\r\n\r\n# Troponin Interpretation\r\n\r\nTroponin is a myocardial protein that is released into the bloodstream when cardiac myocytes are damaged. Serum levels typically rise **3 hours** after myocardial infarction begins.\r\n\r\nDifferent hospitals have differing guidelines (and assays) for interpretations of results. In general there are three groups of troponin levels:\r\n\r\n* Low - definitely no myocardial cell death. The patient is not having an MI although they may be experiencing unstable angina.\r\n* Mildly raised - This is an equivocal result and may be due to other non-MI related factors (see below). These patients usually need a <u>6-12 hour repeat test</u>.\r\n * If repeat troponin is raised on the repeat they are having an MI.\r\n * If repeat troponin is stable or falling then they are unlikely to be having an MI.\r\n* Definitely raised with sequential dynamic troponin rises - MI confirmed (be aware of the possibility of a Type 2 MI)\r\n\r\n## Non-ACS causes of a raised troponin\r\n\r\nAlthough troponin is often used diagnose myocardial infarction, there are in fact many causes of a raised troponin:\r\n\r\n* Myocardial infarction\r\n* Pericarditis\r\n* Myocarditis\r\n* Arrythmias\r\n* Defibrillation\r\n* Acute heart failure\r\n* Pulmonary embolus\r\n* Type A aortic dissection\r\n* Chronic kidney disease\r\n* Prolonged strenuous exercise\r\n* Sepsis\r\n\r\nIt is therefore critical to have good clinical grounds to test a troponin in order to avoid unnecessary treatments and investigations.\r\n\r\n# Management\r\n\r\nAcute management depends on the type of acute coronary syndrome. It is broadly split into the management of STEMI and the management of NSTEMI/unstable angina. \r\n\r\n# Management of STEMI\r\n\r\n[lightgallery5]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg**\r\n - Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg)\r\n - For those going on to have PCI, NICE guidance suggests adding prasugrel (if not on anti-coagulation) or clopidogrel (if on anti-coagulation)\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Primary percutaneous coronary intervention (PPCI) for those who:\r\n - Present **within 12 hours of onset of pain** AND\r\n - Are **<2 hours** since <u>first medical contact</u>\r\n\r\nRemember that (particularly in STEMI) _time is heart_ therefore urgent treatment, escalation, and delivery of PPCI is critical to good outcomes.\r\n\r\n# Management of NSTEMI/Unstable Angina\r\n\r\n[lightgallery6]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg** and fondaparinux\r\n * Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given **prasugrel or ticagrelor** unless they have a high risk of bleeding where **PO clopidogrel 300mg** is more appropriate.\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Start antithrombin therapy such as **treatment dose low molecular weight heparin** or **fondaparinux** if they are for an immediate angiogram\r\n6. Patients with <u>high 6 month risk of mortality</u> should be offered an angiogram within 96 hours of symptom onset.\r\n\r\nNote that management of unstable angina is similar to that of NSTEMI with aspirin for all patients and fondaparinux and early angiography for those at high risk.\r\n\r\n# Post-MI management\r\n\r\n[lightgallery7]\r\n\r\n* ALL patients post-MI patients should be started on the following 5 drugs:\r\n 1. **Aspirin 75mg OM** + second anti-platelet (**clopidogrel 75mg OD** or **ticagrelor 90mg OD**)\r\n 2. **Beta blocker (normally bisoprolol)**\r\n 3. **ACE-inhibitor (normally ramipril)**\r\n 4. **High dose statin (e.g. Atorvastatin 80mg ON)**\r\n* All patients should have an **ECHO** performed to assess systolic function and any evidence of heart failure should be treated.\r\n* All patients should be referred to **cardiac rehabilitation**.\r\n* Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia. \r\n\r\n# Complications\r\n\r\n* Ventricular arrhythmia\r\n* Recurrent ischaemia/infarction/angina\r\n* Acute mitral regurgitation\r\n* Congestive heart failure\r\n* 2nd, 3rd degree heart block\r\n* Cardiogenic shock\r\n* Cardiac tamponade\r\n* Ventricular septal defects\r\n* Left ventricular thrombus/aneurysm\r\n* Left/right ventricular free wall rupture\r\n* Dressler's Syndrome\r\n* Acute pericarditis\r\n\r\n## Ventricular Arrhythmias\r\n\r\n* Ventricular arrhythmias can occur as a consequence of MI, during cardiac catheterisation, or after reperfusion.\r\n* Most post-MI ventricular arrhythmias are short lived and self-resolve.\r\n* However if sustained VT or VF occurs they should be treated as per the Advanced Life Support protocols.\r\n\r\n## Recurrent Ischaemia/Infarction/Angina\r\n\r\n* Occasionally inserted stents can thrombose requiring reintervention.\r\n* New infarcts can occur in different vascular territories - this is less likely in the age of PCI where all territory are imaged during the procedure.\r\n* Angina and chest pain can continue for some time after an MI and is more common in NSTEMI patients.\r\n\r\n## Congestive Heart Failure\r\n\r\n* Heart failure can occur as a consequence of impairment heart muscle function secondary to ischaemia.\r\n* It should be treated as any other acute heart failure.\r\n* Ventricular function may improve over months as the heart muscle recovers.\r\n\r\n## Heart Block\r\n\r\n* Various levels of heart block are common - particularly following **inferior** infarcts (because the right coronary artery supplies the SAN).\r\n* These may be treated with:\r\n * Simple observation (as many will revert back to sinus rhythm)\r\n * Transcutaneous/venous pacing (if symptomatic)\r\n * Permanent pacing (if failing to resolve)\r\n\r\n## Left Ventricular Thrombus/Aneurysm\r\n\r\n* Aneurysm can occur following an anterior MI where the myocardium can be susceptible to wall stress leading to an aneurysm.\r\n* It may be silent, cause arrhythmias or embolic events.\r\n* It is definitely diagnosed on ECHO but ECG may show persisting ST elevation.\r\n* Thrombus can form either within an above described aneurysm or around hypokinetic regions of the myocardium.\r\n* Thrombi can embolise causing complications such as stroke, acute limb ischaemia and mesenteric ischaemia.\r\n\r\n## Left/Right Ventricular Free Wall Rupture\r\n\r\n* Necrosis of the free walls of either ventricle can lead to rupture allowing blood into the pericardial space.\r\n* This leads to a rapid tamponade and normally leads to cardiac arrest/death within seconds.\r\n* Treatment includes pericardiocentesis and surgery but prognosis is extremely poor.\r\n\r\n## Acute Mitral Regurgitation\r\n\r\n* This can occur because of papillary muscle rupture and carries a poor prognosis. Occurs commonly due to infero-osterior MI. \r\n* This presents with:\r\n * Pansystolic murmur heard best at the apex\r\n * Severe and sudden heart failure\r\n* It is diagnosed on echocardiogram and may require surgical correction.\r\n\r\n## Ventricular Septal Defect\r\n\r\n* Interventricular septal rupture is a short-term complications of myocardial infarction.\r\n* Rupture caused by an anterior infarct is generally apical and simple.\r\n* Rupture caused by an inferior infarct is generally basal and more complex.\r\n* Without reperfusion, septal rupture typically occurs within the first week after the infarction.\r\n* Features of septal rupture include:\r\n * Shortness of breath\r\n * Chest pain\r\n * Heart failure\r\n * Hypotension\r\n * Harsh, loud pan-systolic murmur along the left sternal border.\r\n * Palpable parasternal thrill.\r\n* Diagnosis is with echocardiogram.\r\n* Patients are managed with emergency cardiac surgery.\r\n\r\n## Dressler's syndrome\r\n\r\n* Dressler's syndrome or post-infarction pericarditis typically presents with persistent fever and pleuritic chest pain **2-3 weeks** or up to a few months after an MI.\r\n* Note that patients can get pericarditis immediately following MI which is NOT considered Dressler's syndrome.\r\n* Symptoms usually resolve after several days.\r\n* Occasionally it can also present with features of pericardial effusion and has become relatively uncommon since the introduction of PCI.\r\n* Management: **high dose aspirin**\r\n\r\n# Prognosis \r\n\r\nDue to the development of PPCI and post-MI care (cardiac rehabilitation) the mortality rates following myocardial infarction continue to decline. Those patients who go on to develop heart failure after myocardial infarction have a significantly worse prognosis than those who do not. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines for Unstable Angina and NSTEMI](https://www.nice.org.uk/guidance/cg94)\r\n\n[NICE Guidelines for STEMI](https://www.nice.org.uk/guidance/cg167)\r\n\r\n# References\r\n\r\n[Patient UK Information on Acute Coronary Syndrome](<https://patient.info/doctor/acute-coronary-syndrome-pro>)",
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"explanation": "# Drug choice feedback\n\nNormally, a stat dose of 300mg of aspirin and clopidogrel each are given to patients with ST-elevation myocardial infarct. However, due to the patient's allergy to aspirin, only clopidogrel can be given. Alternatives are Ticagrelor or Prasugel.\n\n# Dose/Route/Frequency/Duration feedback\n\nFor clopidogrel, the correct dose is 300mg initially once-off. This is then decreased to 75mg per day for the next 12 months. It can only be given PO; no other routes of administration exist for clopidogrel.\n\nFor Ticagrelor or Prasugel, the doses are as stated above. Similarly, they can only be given PO; no other routes of administration exist.",
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"question": "Case Presentation: A 58-year-old gentleman is brought to the Emergency Department with sudden-onset 1-hour history of chest pain radiating to his left shoulder, accompanied by shortness of breath, nausea and diaphoresis.\n\n\n\n\n## PH\n\n\nHyperlipidaemia, Type 2 Diabetes Mellitus\n\n\n## DH\n\n\nAtorvastatin 40mg PO ON, Metformin 1g PO BD (reports allergy to aspirin)\n\n\n## On examination\n\n\nAppears distressed, very sweaty. Seated up in bed. Percussion resonant throughout. HS I + II + 0, chest clear. Calves soft and non-tender. No cyanosis.\n\n\nTemperature 36.6°C, HR 98, RR 28, BP 140/88, O2 98% RA, GCS 15, Weight 89kg\n\n\n## Investigations\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|144 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|223x10<sup>9</sup>/L|150 - 400|\n|Sodium|137 mmol/L|135 - 145|\n|Potassium|4.6 mmol/L|3.5 - 5.3|\n|Chloride|100 mmol/L|95 - 106|\n|Urea|8.1 mmol/L|2.5 - 7.8|\n|Creatinine|97 µmol/L|60 - 120|\n|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|\n|Troponin T|30 ng/L|<14|\n|Non-fasting Glucose|12 mmol/L|< 6.1|\n\nCXR: normal\n\n\nECG: ST-elevation in leads II, III and aVL with reciprocal changes\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate to reduce the chance of recurrent atherothrombotic events.",
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"comment": "How do you know its BD for 6 days / QDS for 3 etc? BNF doesn't say this?",
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"question": "Case Presentation: A 53-year-old gentleman presents to his GP with severe pain in his left big toe. It has become swollen, tender and erythematous over the last 12 hours.\n\n\n## PH\n\nHypertension, chronic kidney disease\n\n## DH\n\nRamipril 5mg PO OD (allergy to Naproxen)\n\n## On examination\n\nAlert and oriented. Left 1st metatarsophalangeal joint noted to be red, swollen, extremely tender with florid synovitis.\n\nTemperature 36.8°C, HR 85, RR 16, BP 129/81, O<sub>2</sub> 98% RA, GCS 15, Weight 82kg\n\n## Investigations\n\nNone\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating his condition acutely.",
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"comment": "according to BNF guidelines Simvaststin is indicated for DM, Atrovastatine doe's not mentions anything specific about DM \n\"Prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or diabetes mellitus\"",
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"comment": "Why not Simvastatin?",
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"comment": "If you type 'cholesterol' then click dyslipidemia, you'll see a table with strengths and see it's low intensity. I've just found it. ",
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"comment": "BNF treatment summary \nNICE (2016) recommend low-dose atorvastatin for patients who have a 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator), and for patients with chronic kidney disease. Low-dose atorvastatin should be considered in all patients with type 1 diabetes mellitus, and be offered to patients with type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors. Patients aged 85 years and over may also benefit from low-dose atorvastatin to reduce their risk of non-fatal myocardial infarction. SIGN (2017) recommend low-dose atorvastatin for patients who are considered to be at high risk of CVD and not on dialysis. ",
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"comment": "So it seems simvastatin is almost never the correct answer and atorvastatin almost always is ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Drug choice feedback\n\nThis gentleman qualifies for lipid-lowering therapy as part of primary prevention of cardiovascular events as he is at high risk of a first cardiovascular event. He has had type 1 diabetes mellitus for more than 10 years and has established nephropathy; either alone qualifies him for lipid-lowering therapy. The recommended pharmacological management is with atorvastatin.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe recommended starting dose by NICE is 20mg. Atorvastatin, like most other statins, is taken orally once a day.",
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"question": "Case Presentation: A 37-year-old gentleman attends an annual review with his GP. He is currently asymptomatic.\n\n\n## PH\n\nType 1 Diabetes Mellitus, diagnosed 11 years ago\n\n## DH\n\nInsulin Glargine (Lantus) 15 units, Insulin Aspart (Novorapid) 5 units at mealtimes (NKDA)\n\n## On examination\n\nAlert and oriented. Neurological examination normal. Fundoscopy normal.\n\nTemperature 36.2°C, HR 72, RR 13, BP 130/88, O<sub>2</sub> 98% RA, GCS 15, Weight 60kg\n\n## Investigations\n\nProteinuria 2+ on dipstick, no blood noted\n\n# Prescribing Request\n\nWrite a prescription for one lipid-lowering drug that is most appropriate for prevention of cardiovascular events.",
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"comment": "They should accept sertraline, citalopram etc",
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"comment": "Fluoxetine is preferred in children",
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"comment": "Where in the BNF does it talk about a child receiving fluoxetine ",
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"comment": "In the BNFc if you search depression, it is under drug treatment ",
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"comment": "As a general rule of thumb, if you don't know what the treatment is, first check whatever Tx summary is available in the BNF. It may not always be helpful but in this case, searching depression in the BNFc it tells you fluoxetine is the 1st line recommended pharmacological Tx for depression in children",
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"explanation": "# Summary\n\nDepression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.\n\n# Definition\n\nDepression is a mental health disorder characterised by:\n\n- **ICD-11 Criteria:**\n - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.\n\n- **DSM-V Criteria:**\n - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.\n - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. \n\nThis consists of the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure\n\n**Severity:**\n\n- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.\n- Moderate: Symptoms or functional impairment between \"mild\" and \"severe.\"\n- Severe: The number of symptoms, intensity, and impairment are all greatly increased.\n\n\n# Epidemiology\n\nDepression is a highly prevalent mental health disorder. It represents the third most common reason for consulting a general practitioner in the UK. Depression demonstrates a higher prevalence in females.\n\n# Aetiology\n\nThe aetiology of depression involves a complex interplay of genetic and environmental factors. History of previous mental health issues, physical illnesses, and social challenges like divorce, poverty, and unemployment can all contribute to its development.\n\n# Clinical Features\n\nDepression is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the presence of 5 out of the following 9 symptoms, occurring nearly every day for at least 2 weeks:\n\n1. **Depressed mood or irritability** for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful).\n2. **Anhedonia:** Decreased interest or pleasure in most activities, most of the day.\n3. Significant **weight change** (5%) or change in appetite.\n4. **Sleep alterations:** Insomnia or hypersomnia.\n5. **Activity changes:** Psychomotor agitation or retardation.\n6. **Fatigue** or loss of energy.\n7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.\n8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.\n9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.\n\n### Additional Features (Severe Depression)\n- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.\n- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).\n\n# Differential Diagnosis\n\nThe main differentials and their key signs and symptoms include:\n\n- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.\n- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.\n- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.\n- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.\n- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.\n\n\nVarious organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:\n\n- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.\n- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).\n- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).\n- Chronic conditions such as diabetes and obstructive sleep apnea.\n- Long-standing infections, such as mononucleosis.\n- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.\n\n\n# Investigations\n\n- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).\n- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).\n- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).\n\n# Management\n\nDepression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.\n\r\n**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**\n\n- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). \r\n- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) \r\n- 3rd line = Consider antidepressants \r\n\r\n**Mild depression unresponsive to treatment and moderate-to-severe depression:**\n\n- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)\r\n- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts \r\n\r\n**Severe depression and poor oral intake/psychosis/stupor:**\n\n- 1st line = ECT \n- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.\r\n\n**Recurrent depression:** \n\n- Treated with antidepressant + lithium \r\n\n\nMedical management of depression - additional notes:\n\n- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.\n- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.\n- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)",
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"explanation": "# Drug choice feedback\n\nAs this adolescent is suffering from severe major depressive disorder, and it has not been effectively controlled with cognitive behavioural therapy, pharmacological management may be initiated in conjunction. Fluoxetine should be prescribed, as this is the only antidepressant for which trials show that the risks are outweighed by the benefits. It has a long half-life which makes it useful in younger group of patients whose adherence to medication may be sub-optimal.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe initial dose is 10mg once-daily orally, which can be administered as a single or divided dose.",
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"question": "Case Presentation: A 11-year-old boy has been low in mood and energy. He has been unable to function well at school and socially. He reports being tearful and anxious, although has no thoughts of self-harm. There has been increased stress due to recent changes in his home situation. A trial of talking therapy has been initiated which although effective, has not resulted in the patient returning to his baseline.\n\n\n## PH\n\nNone\n\n## DH\n\nNone (NKDA)\n\n## On examination\n\nNo cyanosis. Normal consciousness but mildly distressed and agitated. \n\nTemperature 36.3°C, HR 80, RR 16, BP 110/68, O<sub>2</sub> 98% RA, GCS 15, Weight 42kg\n\n## Investigations\n\nNone\n\n# Prescribing Request\n\nWrite a prescription for one additional drug that is most appropriate for treating his condition.",
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"comment": "so is it fair to say \"uncommon side effects\" > more likely than \"frequency not known\"",
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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 & BM suppresion",
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"typeId": 5
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"dislikes": 23,
"explanation": "1. Oral use of tacrolimus commonly causes anaemia, leucopenia and thrombocytopenia. The risk of any bone marrow lineage failure is relatively insignificant compared to tacrolimus. ACEi rarely or very rarely cause pancytopenia. Paracetamol causes mainly agranulocytosis although frequency is not known. Atorvastatin, heparin, piperacillin-tazobactam and carbamazepine causes mainly thrombocytopenia.\n2. Piperacillin-tazobactam is commonly used as the first line treatment in neutropenic sepsis. Doses are usually 4.5g 6-hrly. The dose prescribed for this patient is likely to represent a transcription error of g to mg.",
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"question": "Case presentation: A 65-year-old gentleman is admitted to the respiratory ward following a chest infection. PH. Renal transplant, Seizure, Type 2 Diabetes, Hypertension. DH. His regular medicines are listed (below). Weight 70kg.\n\n\n\n\n **On Examination**\nMultiple purpuric rash noted on his ankles bilaterally.\n\n\n **Investigation**\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|100 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|0.5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|70x10<sup>9</sup>/L|150 - 400|\n\n\n\nQuestion 1: Select the ONE prescriptions that is most likely to be a cause of his pancytopenia. (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,458,363 | false | 7 | null | 6,494,955 | null | false | [] | null | 6,798 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33934",
"label": "f",
"name": "Phenoxymethylpenicillin;5 mg;Oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
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"explanation": null,
"id": "33932",
"label": "d",
"name": "Paracetamol;1 g;Oral (PO);6 -hourly",
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},
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"answer": false,
"explanation": null,
"id": "33933",
"label": "e",
"name": "Ibuprofen;400mg;Oral (PO);8-hourly when required",
"picture": null,
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},
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"label": "g",
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"picture": null,
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},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33929",
"label": "a",
"name": "Enalapril maleate;20 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33931",
"label": "c",
"name": "Simvastatin;40mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
},
{
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"answer": false,
"explanation": null,
"id": "33930",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Wouldn't ibuprofen also be avoided during pregnancy?",
"createdAt": 1642174226,
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"comment": "No so it says avoid unless benefit outweigh the risk. Simvastatin is like a big no no",
"createdAt": 1674940748,
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"comment": "Ibuprofen 4 hourly would mean they could have it 6 times in a day...? 4 times a day is the maximum is it not?",
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"comment": "Ibuprofen is avoid in 1st and 2nd trimesters unless essential which is the same guidance as ACE?",
"createdAt": 1737986035,
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"comment": "I think pregnancy is a complete C/I for ACEi",
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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": "2731",
"name": "Contraindicated in pregnancy & dosing error",
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"typeId": 5
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"explanation": "1. BNF advises that angiotensin-converting enzyme inhibitor (ACE-i) like enalapril ACE should be avoided in pregnancy unless essential. This is because it may adversely affect fetal and neonatal blood pressure control and renal function. ACE-I has also been reported to cause skull defects and oligohydramnios\n-BNF advises that all vitamin K agonists should be avoided in first trimester of pregnancy. Warfarin may cross the placenta and increase the risk of congenital malformations and neonatal haemorrhage, especially during the last few weeks of pregnancy and at delivery.\n-BNF advises that statins should be avoided in pregnancy due to the increased risk of congenital anomalies. The decrease in synthesis of cholesterol is thought to affect fetal development. Hence, BNF recommends the discontinuation of statin 3 months before attempting to conceive.\n2. The correct dose of phenoxymethylpenicillin for otitis media should be 500 mg to 1 g every 6 hours and not 5 mg 6-hourly.",
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"question": "Case presentation: A 36-year old woman presents to her GP with amenorrhoea. She reports that her period was supposed to due three weeks ago. She is quite concerned about this because her menstrual cycle has always been regular. Besides that, she notices that she has put on some weight and feels nauseous regularly. PH: Hypertension, Type 2 diabetes mellitus, Hypercholesterolemia, venous thromboembolism, otitis media, constipation DH: Her current regular prescriptions are listed below\n\n\n**On examination**:\nChest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender. Normal pelvic examination, normal breast examination\n\n**Investigation**:\nPositive human chorionic gonadotrophin (HCG) pregnancy test\n\nQuestion 1: Select the TWO prescriptions that should be avoided in the context of a pregnancy? (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,458,364 | false | 8 | null | 6,494,955 | null | false | [] | null | 6,779 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33789",
"label": "b",
"name": "Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33793",
"label": "f",
"name": "Ipratropium bromide;40 micrograms;inhaled (INH);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33794",
"label": "g",
"name": "Nicotine patch;14mg;transdermal (TD);Daily",
"picture": null,
"votes": 0
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"id": "33791",
"label": "d",
"name": "Ibuprofen;400mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33792",
"label": "e",
"name": "Salbutamol;200 micrograms;inhaled (INH);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33788",
"label": "a",
"name": "Paracetamol;1g;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33790",
"label": "c",
"name": "Atorvastatin;10mg;oral (PO);Daily",
"picture": null,
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}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Ive also learned that Ibuprofen should not really be used in Asthmatics. Is that a thing? ",
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"id": "40134",
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"comment": "Yeah, theoretically at least! NSAIDs are Contraindicated",
"createdAt": 1706550218,
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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": "Pre-operative medication review & paracetamol dosing error",
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"explanation": "1. Paracetamol 1g 6-hrly is the maximum recommended dose of paracetamol. Hence, it should not be co-prescribed with another medication which contains paracetamol in it (co-codamol).\n2. NSAIDs may lead to the worsening of renal function and hence, should be stopped during an AKI. Similarly, codeine (co-codamol) should be avoided in AKI due to the risk of adverse effects with reduced excretion.",
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"question": "Case presentation: A 45-year-old woman on the gynaecology ward is recovering from an elective total abdominal hysterectomy. PH Mild COPD, Polymyalgia rheumatica, Uterine fibroids, Familial hypercholestrolaemia. DH. Her current regular medications are listed (below).\n\n\n\n\n **Investigation**\n\n||||\n|---------------------------|:-------:|--------------------|\n|Urea|8.5 mmol/L|2.5 - 7.8|\n|Creatinine|145 µmol/L|60 - 120|\n\n\n\nQuestion 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)\nQuestion 2: Select the TWO prescription that are most appropriate to withhold until her renal function recovers.",
"sbaAnswer": null,
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173,458,365 | false | 9 | null | 6,494,955 | null | false | [] | null | 6,777 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33773",
"label": "d",
"name": "Cetirizine;10mg;oral (PO);PRN",
"picture": null,
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"__typename": "QuestionChoice",
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"id": "33771",
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"name": "Tramadol hydrochloride;100mg;oral (PO);6-hourly",
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"label": "e",
"name": "Tamsulosin;400 micrograms;oral (PO);Daily",
"picture": null,
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"label": "f",
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"id": "33776",
"label": "g",
"name": "Ondansetron;4mg;intravenous (IV);Daily",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
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"name": "Morphine sulphate;10mg;intravenous (IV);6- hourly",
"picture": null,
"votes": 0
}
],
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{
"__typename": "QuestionComment",
"comment": "tamsulosin also causes cosntipatin",
"createdAt": 1645437236,
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"comment": "It can but it is listed as an uncommon side effect in the BNF, the other 3 answers given (tramadol, ondansetron and morphine) are the 3 most likely to cause constipation as it is listed as a common or very common side effect in the BNF for those drugs",
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"displayName": "Dr Brighton",
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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": "Withholding drugs in AKI",
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"typeId": 5
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"difficulty": 2,
"dislikes": 8,
"explanation": "1. Opioids (tramadol and morphine sulphate) act on 𝜇-opioid receptors in the myenteric plexus to slow down bowel movements, which can lead to constipation. Ondansetron commonly causes constipation by delaying the colonic transit although the exact mechanism remains unclear. Cetirizine, tamsulosin and ibuprofen rarely cause constipation.\n2. Systemic corticosteroids (prednisolone) commonly cause fluid retention via the stimulation of mineralocorticoid receptors, which lead to sodium and water retention.",
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"question": "Case presentation: A 65-year-old man on the urology ward underwent a left-sided nephrectomy 2 days ago. Since the surgery, he had not been able to open his bowels. PH Benign prostatic hyperplasia, Osteoarthritis of left knee, Giant cell arteritis, mild hayfever, Back pain. DH His current regular medicines are listed (below).\n\n\n**On Examination**\nHR 84/min regular rhythm, BP 130/80 mmHg, symmetrical bipedal pitting oedema to mid calves\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his constipation (mark them with a tick in column A).\nQuestion 2: Select the ONE prescription that is most likely to be contributing to his fluid retention (mark it with a tick in column B).",
"sbaAnswer": null,
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173,458,366 | false | 10 | null | 6,494,955 | null | false | [] | null | 6,799 | {
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"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33940",
"label": "e",
"name": "Furosemide;40mg;Intravenous infusion (IV);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33941",
"label": "f",
"name": "Cisplatin;75mg/m2;Intraperitoneal infusion;On day 2, repeat every 3 weeks for 6 cycles",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33943",
"label": "h",
"name": "Warfarin sodium;5 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33942",
"label": "g",
"name": "Paclitaxel;135mg/m2;Intravenous infusion;On day 1 and day 8, repeat every 3 weeks for 6 cycles",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33944",
"label": "i",
"name": "Bisacodyl;5mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33936",
"label": "a",
"name": "Enalapril maleate;20 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33937",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33938",
"label": "c",
"name": "Gentamicin;700mg;Intravenous infusion (IV);12-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33939",
"label": "d",
"name": "Ceftriaxone;2g;Intravenous infusion (IV);Daily",
"picture": null,
"votes": 0
}
],
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"__typename": "QuestionComment",
"comment": "'deafness' in furoesmide - frequency not known in BNF. I dont think this can be used as an answer ",
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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": "2732",
"name": "Ototoxicity & dosing error",
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"explanation": "1. Ototoxicity is a recognised side effect of all aminoglycoside. The exact mechanism of gentamicin-related ototoxicity remains unknown.Furosemide is known to cause deafness, especially in patients with renal impairment. Ototoxicity is also a known side effect of cisplatin, a chemotherapy medication that interferes with DNA replication. The ototoxicity is likely to be dose-related and accumulative.\n2. The correct dose of gentamicin for Gram-positive bacterial endocarditis is usually about 1mg/kg every 12 hours. Hence, the correct dose for this patient should be 70mg not 700mg IV 12-hourly",
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"question": "Case presentation: A 65-year-old woman is admitted to hospital with native valve infective endocarditis. On the third day of her admission, she develops pulmonary oedema secondary to decompensated heart failure. She also complains of tinnitus and bilateral hearing loss. Her weight is 70kg. PH: Hypertension, Type 2 diabetes mellitus, GORD, Mitral valve prolapse DH: Her current regular prescriptions are listed below\n\n\n**On examination**:\nPansystolic murmur that is heard loudest at the apex and radiates to the axilla, coarse crackles at both lung bases, peripheral oedema until the level of mid-shins\n\n**Investigations**:\n\n- Transthoracic echocardiograms shows presence of vegetation at mitral valves\n- Positive blood cultures (streptococcus viridans)\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to the hearing loss. (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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173,458,367 | false | 11 | null | 6,494,955 | null | false | [] | null | 6,806 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although it is increasingly becoming more popular as a maintenance fluid, dextro-saline has limited use as a plasma expander due to its high dextrose concentration and tendency to redistribute",
"id": "33978",
"label": "d",
"name": "500ml 0.45% saline/4% dextrose over 15 minutes",
"picture": null,
"votes": 86
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "5% dextrose is generally not used as a plasma expander as it redistributes quickly across all fluid compartments",
"id": "33977",
"label": "c",
"name": "1L 5% dextrose over 1 hour",
"picture": null,
"votes": 81
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient is in net negative fluid balance and acutely hypotensive, which may be being exacerbated by beta-blockers and a blunted sympathetic response. A fluid challenge should be initiated and the blood pressure response carefully monitored",
"id": "33975",
"label": "a",
"name": "500ml 0.9% normal saline over 15 minutes",
"picture": null,
"votes": 6018
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"__typename": "QuestionChoice",
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"explanation": "A balanced crystalloid is a good option for fluid resuscitation. It should be administered far more rapidly than over 1 hour for its effects to be maximised",
"id": "33979",
"label": "e",
"name": "1L Hartmann’s solution over 1 hour",
"picture": null,
"votes": 173
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is in net negative fluid balance and acutely hypotensive. Slow fluid replacement is not an appropriate response to this situation",
"id": "33976",
"label": "b",
"name": "1L 0.9% normal saline over 4 hours",
"picture": null,
"votes": 598
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Easy\nMurtaza said we could have got it, so no arguing",
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"comment": "The above was approved and authorised in the Nomani Residence",
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"comment": "Is Hartmann's preferred for resuscitation post-op? ",
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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 36 year old man is recovering on the high dependency unit following emergency repair of a proximal aortic dissection. **PH** Marfan syndrome. **DH** atenolol hydrochloride 50mg PO OD, co-codamol 8/500mg PO QDS.\n\n\n**O/E**\n\nDrowsy but maintaining own airway. HR 64, RR 21, BP 95/56, O2 97% 2L NC, Temperature 37.4°C. Peripheries cool, CRT 4s. HS I + II + 0. Midline sternotomy dressing intact, 3x Jackson Pratt drains collecting serosanguinous fluid. Oral mucous membranes appear dry, skin turgor normal.\n\nFluids prescribed: 1L 5% dextrose with 40mmol K over 10h, 1L 0.9% normal saline over 10h, 250ml 5% dextrose with 20mmol K over 4h\n\nUrine output over last 24h = 1.3L\n\nSurgical drain output over last 24h = 1.5L\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "This is a selective oestrogen receptor modulator that stimulates ovulation. It should not be prescribed without a full assessment by a fertility specialist, and is not likely to be indicated as the patient is having regular bleeds which indicates she is ovulating",
"id": "34036",
"label": "b",
"name": "Clomifene citrate 50mg PO OD",
"picture": null,
"votes": 1060
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin hydrochloride may have some beneficial effects on fertility in patients with polycystic ovarian syndrome, but there is nothing in the stem to suggest that the patient has PCOS",
"id": "34039",
"label": "e",
"name": "Metformin hydrochloride 500mg PO OD",
"picture": null,
"votes": 208
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "While iron deficiency anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic",
"id": "34037",
"label": "c",
"name": "Ferrous sulfate 200mg PO TDS",
"picture": null,
"votes": 233
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "While megaloblastic anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic",
"id": "34038",
"label": "d",
"name": "Hydroxocobalamin 1mg IM monthly",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "All women who are attempting to conceive and low risk should be taking folic acid to reduce the risk of neural tube defects. Women at high risk (e.g. previous tube defects, family history, diabetics, on epilepsy medication, high BMI) should be on high dose folic acid (5mg OD). As this woman has diabetes she would be considered high-risk and hence 5mg is the correct answer.",
"id": "34035",
"label": "a",
"name": "Folic acid 5mg PO OD",
"picture": null,
"votes": 5389
}
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"comment": "Normal MCV is 80-100 ",
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"comment": "they're not being given folic acid because they're deficient, it's just a good thing to take before pregnancy and up to 3 months to avoid neural tube defects",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 34 year old woman presents to GP with her male partner to solicit advice in conceiving a child. They have been having regular unprotected penetrative sex at least twice a week for four months. She has had one previous pregnancy and termination at the age of 18, and bleeds regularly with a 28 day cycle. She has a background of T2DM which is diet-controlled. She wonders if the GP can prescribe anything that she should be taking while trying to conceive.\n\n\n**Investigations**\n\nFBC: Hb 115, WCC 5.2, Plts 240 x 10^9, MCV 91\n\nQuestion: Select the most appropriate management at this stage.",
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"answer": true,
"explanation": "Fluoxetine is an SSRI antidepressant that is licensed for use in children 8 years and older",
"id": "34015",
"label": "a",
"name": "Fluoxetine 10mg PO OD",
"picture": null,
"votes": 5203
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is an SSRI antidepressant that is not licensed for use in children under the age of 12",
"id": "34018",
"label": "d",
"name": "Sertraline 25mg PO OD",
"picture": null,
"votes": 124
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venlafaxine is an SNRI antidepressant that is not licensed for use in children",
"id": "34019",
"label": "e",
"name": "Venlafaxine MR tablets 75mg PO OD",
"picture": null,
"votes": 14
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"answer": false,
"explanation": "Citalopram is an SSRI antidepressant that is not licensed for use in children under the age of 12",
"id": "34016",
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"name": "Citalopram 10mg PO OD",
"picture": null,
"votes": 29
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is not licensed for use in children",
"id": "34017",
"label": "c",
"name": "Mirtazapine 15mg PO OD",
"picture": null,
"votes": 42
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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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173,458,370 | false | 14 | null | 6,494,955 | null | false | [] | null | 6,804 | {
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"explanation": "Co-amoxiclav is a safer option than amoxicillin alone as it has a lower risk of morbilliform drug eruption in the event of misdiagnosed infectious mononucleosis. However it has a much broader spectrum of activity which may not be necessary to treat likely uncomplicated streptococcal tonsillitis",
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"explanation": "Phenoxymethylpenicillin is recommended first line to treat streptococcal tonsillitis in all age groups. Clarithromycin is an acceptable alternative option in penicillin-allergic patients",
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"explanation": "Amoxicillin should not be given alone to treat suspected streptococcal tonsillitis due to the risk of misdiagnosed infectious mononucleosis and morbilliform drug eruption",
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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 12 year old boy is brought by his parents into a walk-in clinic with fever, throat pain and malaise. He has had these symptoms for the past 48 hours. **PH** asthma. **DH** salbutamol 200 micrograms inhaler PRN. NKDA\n\n\n**O/E**\n\nHR 110, RR 16, BP 110/75, Temperature 38.4°C, O2 100% RA. Alert and oriented. Bilaterally enlarged tonsils with patchy exudates. Swollen submandibular and anterior cervical lymph nodes.\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,371 | false | 15 | null | 6,494,955 | null | false | [] | null | 6,816 | {
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"__typename": "QuestionChoice",
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"explanation": "Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is indicated for treatment of fibroids rather than as emergency contraception",
"id": "34028",
"label": "d",
"name": "Ulipristal acetate 5mg PO",
"picture": null,
"votes": 26
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"__typename": "QuestionChoice",
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"explanation": "This is a progesterone-only contraceptive that has no emergency contraception effects",
"id": "34027",
"label": "c",
"name": "Noresthisterone 15mg PO",
"picture": null,
"votes": 28
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"__typename": "QuestionChoice",
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"explanation": "This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. 1.5mg is a standard dose but this should be doubled as the patient is taking a p450 inducer",
"id": "34026",
"label": "b",
"name": "Levonorgestrel 1.5mg PO",
"picture": null,
"votes": 3100
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"explanation": "Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is much too low to be used as emergency contraception",
"id": "34029",
"label": "e",
"name": "Ulipristal acetate 10mg PO",
"picture": null,
"votes": 63
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"__typename": "QuestionChoice",
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"explanation": "This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. The doubled dose accounts for increased metabolisation of the drug due to the patient taking a p450 inducer",
"id": "34025",
"label": "a",
"name": "Levonorgestrel 3mg PO",
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"__typename": "QuestionComment",
"comment": "big narsty\n",
"createdAt": 1675351012,
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"comment": "Where in the BNF does it say to double the dose?",
"createdAt": 1677759336,
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"comment": "Under the indications:\n\n\"Dose adjustments due to interactionsfor levonorgestrel\nWhen used orally as an emergency contraceptive, the effectiveness of levonorgestrel could be reduced in women taking enzyme-inducing drugs (and for up to 4 weeks after stopping); a copper intra-uterine device should preferably be used instead. If the copper intra-uterine device is undesirable or inappropriate, the dose of levonorgestrel should be increased to a total of 3 mg taken as a single dose; pregnancy should be excluded following use, and medical advice sought if pregnancy occurs\"\n\nIt's a bit of a mean question, I also chose the 1.5 mg option. Guess need to delve a bit deeper if the same option is listed twice at different doses ",
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"comment": "Carbamazepine = enzyme inducer. According to BNF:\nWhen used orally as an emergency contraceptive, the effectiveness of levonorgestrel could be reduced in women taking enzyme-inducing drugs (and for up to 4 weeks after stopping); a copper intra-uterine device should preferably be used instead. If the copper intra-uterine device is undesirable or inappropriate, the dose of levonorgestrel should be increased to a total of 3 mg taken as a single dose; ",
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"comment": "no amount of trying will ever get me to recall inducers/inhibitors. brazy",
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"comment": "she also has pcos",
"createdAt": 1737219071,
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"comment": "you can rule out use of ulipristal as she has asthma",
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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 30 year old woman attends a walk-in GUM clinic to request emergency contraception. She had protected sexual intercourse the evening before but realised afterwards that the condom had split without her noticing, and she is now worried about getting pregnant as she is not taking any other form of contraception. **PH** polycystic ovarian syndrome, trigeminal neuralgia, asthma. **DH** carbamazepine 300mg PO TDS, salbutamol 200 micrograms inhaler PRN, beclometasone dipropionate 200 micrograms inhaler BD, regular multivitamins. NKDA.\n\n\nHer last menstrual bleed was 16 days ago, but she has an irregular cycle ranging from between 24 days to 40 days. She has never been pregnant before and has never been admitted to hospital. On counselling, she mentions having used a Mirena coil in the past but had it removed due to pelvic pain, and feels she would not consider trying intrauterine devices again.\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,372 | false | 16 | null | 6,494,955 | null | false | [] | null | 6,839 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Lithium functions as a mood stabiliser. It is important to highlight to patients that lithium can leave a metallic taste in mouth so that they would not treat it as a symptom of toxicity and stop taking the drug",
"id": "34140",
"label": "a",
"name": "Lithium can leave a metallic taste in mouth",
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"__typename": "QuestionChoice",
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"explanation": "Patients should refrain from dietary changes which reduce or increase sodium intake so that the lithium levels will not go deranged",
"id": "34144",
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"name": "He should go on a low salt diet to reduce the risk of lithium toxicity",
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"__typename": "QuestionChoice",
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"explanation": "Lithium has a narrow therapeutic/ toxic ratio, hence it is important to ensure that the level stays within the safe range. Routine serum-lithium monitoring is done weekly after initiation and then 3-monthly for the first year when the levels have become stable. The test needs to be performed every 6 months after that and not only when lithium toxicity is suspected",
"id": "34142",
"label": "c",
"name": "Blood tests for lithium levels only need to be done if lithium toxicity is suspected",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Coarse tremor and polyuria are examples of symptoms and signs of toxicity. Patients should contact their doctors immediately if they experience any signs suggestive of lithium toxicity",
"id": "34143",
"label": "d",
"name": "It is normal to experience frequent urination and coarse tremor during the course of treatment",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended by the manufacturer to assess renal, cardiac and thyroid functions before the treatment. Lithium does not commonly affect the lungs or cause respiratory problems. Hence, chest x-ray is not required before the commencement of treatment",
"id": "34141",
"label": "b",
"name": "He will need to take a chest x-ray before starting his medication",
"picture": null,
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"__typename": "QuestionComment",
"comment": "Is a fine tremor nota normal side effect? With course tremors being a sign of toxicity? The type was not listed",
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"comment": "that's right!",
"createdAt": 1646832900,
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"comment": "great question! ",
"createdAt": 1643888733,
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"explanation": "# Summary\n\nLithium, commonly used in psychiatric disorders, may produce a range of side effects, which can be categorised into those seen at a therapeutic dose and those indicating toxicity. Therapeutic dose side effects may include fine tremor, dry mouth, GI disturbances, increased thirst and urination, drowsiness, and thyroid dysfunction. Signs of toxicity encompass coarse tremor, CNS disturbance (including seizures, impaired coordination, dysarthria), arrhythmias, and visual disturbance. Diagnosis relies on identifying these clinical features and serum lithium levels. Management involves supportive measures, electrolyte balance maintenance, renal function monitoring, seizure control, IV fluid therapy, and, in severe cases, haemodialysis.\n\n# Indications\n\nLithium is used primarily to treat bipolar disorder and mania, but can also be used in depression (especially if recurrent) and as mood stabiliser for aggressive/self-harming behaviour.\n\nIt is contraindicated in: Addison’s disease, cardiac disease associated with rhythm disorder, personal/family history of Brugada syndrome, low sodium diets and untreated hypothyroidism.\n\nIt should be avoided in severe renal impairment due to the risk of toxicity, as it has a very narrow therapeutic index.\n\n# Side Effects\n\nCan be remembered with the mneumonic LITHIuM:\n\n* **L**eucocytosis\n* **I**nsipidus\n* **T**remor (fine)\n* **H**ypothyroid\n* **I**ncreased weight\n* **U**\n* **M**etallic taste \n\nWomen of child bearing age should take contraception if commenced on lithium, which is generally avoided in pregnancy due to the high risk of development of cardiac malformations in the first trimester.\n\n# Monitoring\n\n- Before starting: renal (U+Es), cardiac (ECG), and thyroid function (TFTs). BMI and FBC should also be done beforehand.\n- Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment, and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels\n\n\n# Lithium Toxicity\n\n## Signs and Symptoms\n\n### Clinical features at therapeutic dose \n\n- Fine tremor\n- Dry mouth\n- Gastrointestinal disturbance\n- Increased thirst\n- Increased urination\n- Drowsiness\n- Thyroid dysfunction\n\n### Clinical features in lithium toxicity\n\n- Coarse tremor\n- Central nervous system disturbance, which may include seizures, impaired coordination, and dysarthria\n- Cardiac arrhythmias\n- Visual disturbance\n\n\n\n\n## Differential Diagnosis\n\nLithium side effects and toxicity may be mistaken for several other conditions:\n\n- **Neurological conditions**: Given the tremors, dysarthria, and impaired coordination, conditions like Parkinson's disease or cerebellar disorders may be considered.\n- **Endocrine disorders**: Increased thirst and urination could point towards diabetes insipidus or diabetes mellitus.\n- **Cardiac conditions**: Arrhythmias might suggest primary cardiac disease.\n- **Substance intoxication or withdrawal**: Some symptoms overlap with those of alcohol or benzodiazepine withdrawal, or other substance intoxications.\n\n## Investigations\n\n- Serum lithium levels: This is the gold standard for diagnosing lithium toxicity.\n- Electrolyte levels: To assess for any electrolyte imbalance.\n- Thyroid function tests: Given the potential for thyroid dysfunction.\n- Renal function tests: Given lithium's potential to cause renal impairment.\n- ECG: To assess for arrhythmias.\n\n## Management\n\nManagement of lithium toxicity is largely supportive and often requires specialist input. Key strategies include:\n\n- Maintaining electrolyte balance\n- Monitoring renal function\n- Seizure control\n- IV fluid therapy and urine alkalisation, which enhance the excretion of the drug\n- Benzodiazepines may be used to treat agitation and seizures\n- Haemodialysis might be required if renal function is poor\n\n# References\n\n[Click here to see the BNF guidance on Lithium](https://bnf.nice.org.uk/drug/lithium-carbonate.html)",
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"question": "Case presentation: A 32-year-old man attends the psychiatric clinic to discuss the long-term treatment of his bipolar disorder. He had an episode of mania two months ago but his condition is now under good control with combination of anti-psychotic and cognitive behavioural therapy. \r\n\nDH: Olanzapine 15mg PO OD\nSH: Works as a baker, lives with family\nThe patient is advised to commence long-term treatment with lithium to prevent relapse.\n\nQuestion: Select the most important information that should be provided for this patient.",
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173,458,373 | false | 17 | null | 6,494,955 | null | false | [] | null | 6,830 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alendronic acid reduces the rate of bone turnover",
"id": "34097",
"label": "c",
"name": "Alendronic acid works by increasing the rate of bone turnover",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alendronic acid is a bisphosphonate that treats osteoporosis by inhibiting osteoclast-mediated bone resorption",
"id": "34096",
"label": "b",
"name": "Alendronic acid is a Vitamin D3 supplement that helps to strengthen the bone",
"picture": null,
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"explanation": "Patients should stop taking alendronic acid if they experience worsening heartburn or chest pain because these symptoms may be suggestive of ulceration",
"id": "34099",
"label": "e",
"name": "It is common for people to experience worsening heartburn while taking the medication and that she should persists as the heartburn usually settles after the first few doses",
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"explanation": "Patients are advised to take it first thing in the morning on an empty stomach",
"id": "34098",
"label": "d",
"name": "She should take it with food to reduce irritation to the food pipe",
"picture": null,
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"explanation": "It is important to remind the patients to take it while sitting up or standing and stay upright for 30 minutes after taking it to reduce oesophageal irritation",
"id": "34095",
"label": "a",
"name": "She should take it while siting straight or standing and keep upright for 30 minutes after taking it",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case presentation: A 75-year-old woman is admitted to the hospital with left hip pain following a minor fall. She appears frail and has a low body mass index (BMI) of 18kg/m². \r\n\nInvestigations: Hip x-ray reveals an intracapsular fracture at the neck of femur. Dual-energy x-ray absorptiometry (DEXA) reveals a T-score of -2.8.\nA diagnosis of osteoporosis is made and patient is advised to commence treatment with Alendronic acid 70mg PO once weekly.\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "If patients have forgotten to take a dose, they should take the missed dose as soon as they remember. However, if it is almost time for them to take the next dose, they should skip the missed dose and take the next dose as usual. They should not take a double dose to make up the missed dose",
"id": "34139",
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"name": "If he forgets to take a dose of olanzapine, he should take a double dose to compensate for the forgotten dose",
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"explanation": "It is mandatory for all the patients taking clozapine, not olanzapine, to be registered with the patient monitoring service. The service provides centralised monitoring of leucocyte and neutrophil counts in order to manage the risk of agranulocytosis associated with clozapine",
"id": "34136",
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"explanation": "Olanzapine is linked to eosinophilia rather than low eosinophil counts",
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"explanation": "Increased appetite leading to weight gain is a common side effect of olanzapine. Hence, it is recommended to measure blood lipids and weight at baseline, every 3 months for the first year and then yearly for all the patients taking olanzapine",
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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 30-year-old man attends the psychiatric clinic for his medication review. He was diagnosed with schizophrenia three month ago and has been taking anti-psychotic and cognitive behavioural therapy. His symptoms have improved but he wishes to stop taking the medication because it is giving him continuous spasms and muscle contractions that greatly affect his daily living. \r\n\nDH: Chlorpromazine hydrochloride 25mg PO thrice daily\nSH: Works as a carpenter, lives alone\nThe patient is advised to switch his current treatment regime to olanzapine 10mg PO daily under the supervision of his psychiatrist.\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "COCP is associated with a small increased risk of cervical cancer if used for 5 years or longer",
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"explanation": "Combined oral contraceptive pill (COCP) contains combination of an oestrogen and progestogen. It is imperative to highlight to patients that there is a small increase in the risk of developing breast cancer so that they can make a more informed choice",
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"name": "It is linked to an increased risk of developing breast cancer",
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"explanation": "It is important to remind the patients that COCP does not offer protection against sexually transmitted disease as it is not a form of barrier contraception",
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"name": "She will be protected against sexually transmitted disease",
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"id": "34146",
"label": "b",
"name": "With typical use, it is more effective than contraceptive implant in preventing pregnancy",
"picture": null,
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"explanation": "Ovarian cancer is classified by UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) as a Category 1 condition. UKMEC defines category 1 condition as “a condition for which there is no restriction for the use of the method”",
"id": "34147",
"label": "c",
"name": "Ovarian cancer is an absolute contraindication",
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"explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"question": "Case presentation: A 30-year-old woman visits the GP to discuss about contraception. She prefers hormonal pills over other methods of contraception. Her last menstrual period was 10 days ago and her pregnancy test has come back as negative. \r\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT\n\nPMH: Allergic rhinitis\n\nDH: Cetirizine hydrochloride PO 10mg OD\n\nThe patient is advised to start taking ethinylestradiol 30 micrograms/ levonorgestrel 150 micrograms one tablet PO daily for 21 days of each cycle starting from today. She does not have any contraindications to the medication.\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "Beclometasone dipropionate is a steroid inhaler that constitutes the maintenance therapy for patients whose asthma symptoms are not controlled by a beta-agonist reliever alone. Patients are advised to rinse their mouths after using the inhaler to prevent infection such as candidiasis",
"id": "34115",
"label": "a",
"name": "He should rinse his mouth after using the beclometasone inhaler",
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"explanation": "If patients have forgotten to use their inhalers, they should use the inhalers as soon as they remember. However, if it is almost time for them to take the next dose, they should skip the missed dose and take the next dose as usual",
"id": "34118",
"label": "d",
"name": "If he forgets to use it, he should take a double dose to compensate for the forgotten dose",
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"id": "34116",
"label": "b",
"name": "He should not use his beclometasone inhaler if he does not experience any symptoms",
"picture": null,
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"explanation": "Spacers slow down the drug as it comes out of the inhaler and more of the drug gets delivered to the lungs as a result",
"id": "34117",
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"name": "He should avoid using a spacer if possible as spacer tends to trap some of the drug and reduce the total amount of drug being delivered to the lungs",
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"explanation": "It is imperative to highlight to the patients that with inhaled beclometasone, only very little of the drug gets into the rest of the body and that systemic side effects of steroids are only more likely to happen if the beclometasone is taken at high doses over a long period of time",
"id": "34119",
"label": "e",
"name": "He is very likely to experience stunted growth as a result of his current dose of beclometasone",
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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 8-year-old boy attends the paediatrics clinic accompanied by his mother.His mother reports that he has been experiencing night-time wheeze over the past month. He used his salbutamol metered-dose inhaler (MDI) three times last week to help him fall back to sleep. \r\n\nPMH: Eczema, asthma\nDH: Salbutamol (Ventolin Accuhaler) INH 200 micrograms PRN, emollient (ImuDERM)\nThe patient is advised to commence maintenance therapy with Beclometasone Dipropionate 100 micrograms PO twice daily.\n\nQuestion: Select the most important information that should be provided for this patient and his mother.",
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"comment": "Is not 140mg since she received 70mg in 12 hours so in 24hrs she will have received 140mg? ",
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"comment": "it would be 0.5 milligrams times 70kg (500micrograms/kg) which is 35 in 12 hours, then times by 2 to get 70mg in the day :) hope that helps!",
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"comment": "45 mcg in the first 6h, nothing for the next 12h followed by a repeat 45mcg in the last 6h of the day",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose of diazepam = 500micrograms/kg\nWeight = 70kg\nEach dose of diazepam\n= 500micrograms/kg x 70kg\n= 35 000 micrograms = 35mg\nTotal dose in 24 hours\n= 35mg x 2 = 70mg",
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"question": "A 45-year-old woman in the Psychiatric Ward with severe agitation on admission was started on diazepam 500 micrograms/kg by slow IV infusion over 6 hours. 12 hours after the completion of this infusion, she requires a repeat diazepam infusion. Weight 70kg.\n\n\nWhat is the total dose (mg) of diazepam that she will receive over the 24 hour period since her admission?",
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"comment": "on the BNF it says 4-6 hourly- so option 6 doses per day isn't there which would make max dose 1440mg?",
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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",
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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 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.",
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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?",
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"comment": "Mentioning that the infusion is done twice a day leads to much confusion. The question is not worded properly.",
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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 total dose to be given is: 20mg/kg x 75kg = 1500mg. We are not constrained by the maximum dose that can be given (2g) as 1500mg i.e. 1.5g is less than this limit. The shortest time period that vancomycin can be safely infused assumes it is run at at the maximum rate given. Hence, the time period is: 1500mg ÷ 10mg/min = 150 minutes. Given that there are 60 minutes in an hour, this is equivalent to 2 hours and 30 minutes.",
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"question": "A 58-year-old patient suffers from bacteraemia and MRSA was isolated from blood cultures. He is prescribed a vancomycin infusion of 20mg/kg twice a day. The maximum that can given per dose is 2g. The infusion runs at a maximum rate of 10mg/min. His weight is known to be 75kg.\n\n\nWhat is the shortest time period (in hours) over which vancomycin can be safely infused?",
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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 dose of amoxicillin normally for an 8-year-old child is 500mg three times a day. This can be increased to 30mg/kg three times a day. Based on the patient's weight of 35kg, the dose would be: 35kg x 30mg/kg = 1050mg. However, there is restricted to the cap of 1g per dose. Since this is given three times a day, the maximum dose is: 1g x 3 times a day = 3g a day.",
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"question": "A 8-year-old patient who weighs 35kg has community-acquired pneumonia. He is prescribed amoxicillin orally.\n\nWhat is the maximum total dose (in grams) of amoxicillin he can be given per day?",
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173,458,381 | false | 25 | null | 6,494,955 | null | false | [] | null | 6,926 | {
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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": "Based on the patient's weight, the total dose to be given is: 150mg/kg x 60kg = 9000mg. Given that the volume of 5% dextrose used is 200mL , the concentration of the infusion is: 9000mg ÷ 200mL = 45mg/mL. The time period over which the infusion is given (1 hour) and the concentration of the dextrose fluid bag are distractions.",
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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 was admitted following an episode of productive cough and fever. Sputum culture was positive for Pseudomonas Aeruginosa, sensitive to ciprofloxacin and gentamicin. He had completed a 6 day course of gentamicin during his admission and has clinically improved since. He will be discharged with a 14 day course of 750mg BD ciprofloxacin.\r\n\r\n\nQuestion: Select the adverse effect that is most likely to be caused by this treatment.",
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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 was admitted to the Cardiology Ward for recovery following a PCI for his STEMI. PMH Heart Failure, Hypertension, GORD, AF. DH His current regular medicines are listed (below).\r\n\n**On Examination**\n\nBP 125/85mmHg, RR 12, HR 75/min, Temp 37.2oC.\nHS I + II + S3\nNo radio-radial delay noted, CRT 2s, gynaecomastia noted.\nFine inspiratory crackles heard bilaterally.\nWeight 85kg\n\nQuestion: Select the prescription that is most likely to contribute to his gynaecomastia.",
"sbaAnswer": [
"a"
],
"totalVotes": 4930,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,384 | false | 28 | null | 6,494,955 | null | false | [] | null | 6,865 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Aspirin is not known to interact with simvastatin to cause myalgia",
"id": "34274",
"label": "e",
"name": "Aspirin 75 mg PO OD",
"picture": null,
"votes": 162
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to interact with simvastatin to cause myalgia",
"id": "34272",
"label": "c",
"name": "Co-amoxiclav 1.2 g IV TDS",
"picture": null,
"votes": 1634
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clarithromycin is a potent CYP3A4 inhibitor, which prevents the metabolism of simvastatin. This increases simvastatin plasma levels, significantly raising the risk of muscle pain, myopathy, and potentially life-threatening rhabdomyolysis. Patients on simvastatin should avoid clarithromycin or temporarily discontinue simvastatin when macrolides are prescribed.",
"id": "34270",
"label": "a",
"name": "Clarithromycin 500 mg PO BD",
"picture": null,
"votes": 2200
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to interact with simvastatin to cause myalgia",
"id": "34273",
"label": "d",
"name": "Lisinopril 20 mg PO OD",
"picture": null,
"votes": 456
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to interact with simvastatin to cause myalgia",
"id": "34271",
"label": "b",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 414
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "@serotonin stasis, suck ya mutha, whats that got to do with the price of fish?",
"createdAt": 1708698025,
"dislikes": 2,
"id": "42461",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 6865,
"replies": [],
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"accessLevel": "subscriber",
"displayName": "ButtMuncher",
"id": 47721
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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": "2797",
"name": "Statin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": 2,
"typeId": null,
"userChapter": null,
"userNote": null,
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"conceptId": 2797,
"conditions": [],
"difficulty": 3,
"dislikes": 7,
"explanation": null,
"highlights": [],
"id": "6865",
"isLikedByMe": 0,
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"likes": 1,
"multiAnswer": null,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case presentation: A 70-year-old woman is admitted to hospital for community-acquired pneumonia. During the ward round, she reports that she has been having muscle pain in both her arms and legs. \r\n\nPMH: Diabetes Mellitus, Hypertension, Myocardial infarction, Reflux oesophagitis\nDH: Her current regular prescriptions, in addition to Simvastatin 80 mg PO nightly, are listed below\nObservations: Temperature 37.5, Respiratory rate 32, Blood pressure 88/64, Heart rate 76\n\nQuestion: Select the prescription that is most likely to have interacted with simvastatin to cause the muscle pain",
"sbaAnswer": [
"a"
],
"totalVotes": 4866,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,385 | false | 29 | null | 6,494,955 | null | false | [] | null | 6,862 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that is used as a first line antihypertensive for patients with type 2 diabetes mellitus. Dry cough is a common or very common side effect of ACE-I. The mechanism of action is believed to be related to a decrease in degradation and subsequently an increase in buildup of bradykinin. NICE guidance recommends for an angiotensin receptor block (ARB), for example losartan potassium, to be offered if ACE-i is not tolerated",
"id": "34255",
"label": "a",
"name": "Stop lisinopril in exchange for losartan potassium 50 mg PO once daily",
"picture": null,
"votes": 4480
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is not known to cause dry cough. Amoxicillin is not required because the dry cough is less likely to be caused by infection in view of the clinical picture described",
"id": "34259",
"label": "e",
"name": "Stop sertraline and commence treatment with amoxicillin 500 mg PO three times daily",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is not known to cause dry cough",
"id": "34258",
"label": "d",
"name": "Stop sertraline in exchange for citalopram 20 mg PO once daily",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to cause dry cough",
"id": "34256",
"label": "b",
"name": "Stop metformin hydrochloride in exchange for gliclazide 40 mg PO once daily",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Captopril is another example of ACE-i and so is unlikely to help with the dry cough",
"id": "34257",
"label": "c",
"name": "Stop lisinopril in exchange for captopril 25 mg PO twice daily",
"picture": null,
"votes": 31
}
],
"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": "2794",
"name": "ACE inhibitor side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
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"conceptId": 2794,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6862",
"isLikedByMe": null,
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"likes": 0,
"multiAnswer": null,
"pictures": [],
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"presentations": [],
"psaSectionId": 6,
"qaAnswer": null,
"question": "Case presentation: A 60-year-old man visits his GP for medication review. He complains of a recent-onset persistent dry cough but denies having fever or any coryzal symptoms. The cough is not worse when lying down. The patient is not a smoker and the cough only happened after he started on a new prescription. \r\n\nPMH: Diabetes Mellitus, Hypertension, Depression\nDH: Metformin 500 mg PO TDS, Lisinopril 20 mg PO OD, Sertraline 50 mg PO OD\nObservations: Temperature 36.5, Respiratory rate 12, Blood pressure 125/85, Heart rate 78\nOn Examination: Chest is clear with no added sounds. HS I+II+0.\n\nQuestion: Select the most appropriate option for the management of the adverse drug reaction.",
"sbaAnswer": [
"a"
],
"totalVotes": 4525,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,386 | false | 30 | null | 6,494,955 | null | false | [] | null | 6,873 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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": 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": "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
},
{
"__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
}
],
"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": "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,
"videos": []
},
"conceptId": 2805,
"conditions": [],
"difficulty": 2,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "6873",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 6,
"qaAnswer": null,
"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"
],
"totalVotes": 5794,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,387 | false | 31 | null | 6,494,955 | null | false | [] | null | 6,889 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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": 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": "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": 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,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2821",
"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": []
},
"conceptId": 2821,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6889",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"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 |
173,458,388 | false | 32 | null | 6,494,955 | null | false | [] | null | 6,877 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Monitoring of blood co-trimoxazole concentrations may be useful for planning dose adjustments but aberrant levels do not necessarily correspond with development of adverse effects",
"id": "34331",
"label": "b",
"name": "Co-trimoxazole levels",
"picture": null,
"votes": 361
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Co-trimoxazole is known to cause hyperkalaemia in patients who are at risk of or have pre-existing renal impairment",
"id": "34330",
"label": "a",
"name": "Urea and electrolytes",
"picture": null,
"votes": 5160
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hypoglycaemia is a very rare side effect of treatment with co-trimoxazole but it is not routine to monitor blood glucose whilst on this drug",
"id": "34332",
"label": "c",
"name": "Blood glucose monitoring",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is advised to avoid using co-trimoxazole in patients with severe hepatic impairment but monitoring liver function is not routinely done",
"id": "34334",
"label": "e",
"name": "Liver function tests",
"picture": null,
"votes": 187
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-trimoxazole has anti-folate activity and monitoring haematics could be considered if taken for an extended period of time or in combination with another anti-folate drug such as methotrexate. However the planned treatment course here is only for 7 days and is unlikely to result in a significant effect",
"id": "34333",
"label": "d",
"name": "Haematinics (ferritin, B12, folate)",
"picture": null,
"votes": 698
}
],
"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": "2809",
"name": "Trimethoprim side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2809,
"conditions": [],
"difficulty": 3,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6877",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 67 year old man is admitted to the medical ward for treatment of a diabetic foot ulcer. **PMH** type 2 diabetes, hypertension, diabetic nephropathy. **DH** metformin hydrochloride MR tablets 2g PO OD, insulin glargine (Lantus) 9 units SC BD, doxazosin 4mg PO OD. Allergic to penicillin – urticarial rash. Allergic to gentamicin – anaphylaxis.\n\n\n**Investigations**\n\nFBC: Hb 130, WCC 17.3, Plts 235 x 10^9, MCV 87\n\nU&Es: Na 145, K 4.8, Cl 96, Ur 3.1, Cr 197, eGFR 48mL/min/1.73m^2\n\nLFTs: AST 16, ALT 23, ALP 54\n\nCRP 155\n\nUlcer swab MCS: mixed growth. Primary species Staphylococcus aureus and Staphylococcus epidermidis, isolated Elizabethkingia meningoseptica\n\nBased on the sensitivities and advice from microbiology, the patient’s consultant decides to start co-trimoxazole 960mg IV BD for 7 days.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 6431,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,389 | false | 33 | null | 6,494,955 | null | false | [] | null | 6,887 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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 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
},
{
"__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": 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
}
],
"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,
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{
"__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,
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"comment": "Saumiya's point is still valid tho - you would monitor all of those things. The options need to be changed",
"createdAt": 1698616140,
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"comment": "forreal",
"createdAt": 1706639933,
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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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"demo": null,
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"id": "2819",
"name": "Prednisolone side effects",
"status": null,
"topic": {
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"id": "91",
"name": "Paediatrics",
"typeId": 5
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"topicId": 91,
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"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
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173,458,390 | false | 34 | null | 6,494,955 | null | false | [] | null | 6,895 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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 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": 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": "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
},
{
"__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
}
],
"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": "2618",
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"typeId": 2
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"chapterId": 2618,
"demo": null,
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"id": "2827",
"name": "ACE inhibitor side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
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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"
],
"totalVotes": 5733,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,391 | false | 35 | null | 6,494,955 | null | false | [] | null | 6,882 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is of limited usefulness with regard to anticoagulation therapy",
"id": "34357",
"label": "c",
"name": "Factor VIII levels",
"picture": null,
"votes": 37
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "There are no routine monitoring parameters available for low molecular weight heparin, although one may consider assessing renal function prior to administering this drug. In some instances, Factor Xa levels can be checked and the dose modified but this usually guided by the haematology team",
"id": "34355",
"label": "a",
"name": "No routine monitoring parameter is available",
"picture": null,
"votes": 3582
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Heparin has no effect on the production of white blood cells and routine monitoring is not necessary",
"id": "34358",
"label": "d",
"name": "White cell count",
"picture": null,
"votes": 110
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be measured if the patient was receiving an unfractionated heparin infusion rather than low molecular weight heparin",
"id": "34356",
"label": "b",
"name": "Activated partial thromboplastin time",
"picture": null,
"votes": 479
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary when starting low molecular weight heparin",
"id": "34359",
"label": "e",
"name": "Prothrombin time",
"picture": null,
"votes": 318
}
],
"comments": [],
"concept": {
"__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",
"files": null,
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"id": "2618",
"pictures": [],
"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2814",
"name": "LMWH side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 72 year old woman is recovering on the surgical ward following a total hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. She is receiving tinzaparin 3500 units SC ON as prophylaxis against deep vein thrombosis.\n\n\nQuestion: Select the most appropriate option to monitor the effectiveness of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4526,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,392 | false | 36 | null | 6,494,955 | null | false | [] | null | 6,906 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia",
"id": "34478",
"label": "d",
"name": "Terbutaline 5 micrograms/minute for 20 minutes",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has a history of headache, abdominal pain and presented with generalized tonic clonic seizure. In addition, her blood pressure at 25 weeks was normal but is currently significantly elevated. Her signs and symptoms in combination with her investigation results of haemolytic anaemia, elevated liver transaminases and lower platelet count is suggestive of eclampsia with HELLP syndrome. Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol",
"id": "34475",
"label": "a",
"name": "Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV",
"picture": null,
"votes": 3609
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol. Dexamethasone is not necessary as this woman is currently 38 weeks pregnant",
"id": "34476",
"label": "b",
"name": "Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV,\ndexamethasone 8mg IV",
"picture": null,
"votes": 845
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia",
"id": "34479",
"label": "e",
"name": "Atosiban 6.75mg IV over 1 minute",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia",
"id": "34477",
"label": "c",
"name": "Two doses of Lorazepam 6mg IV followed by phenytoin 1.2g IV",
"picture": null,
"votes": 25
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "As she has HELLP syndrome, shouldn't the first line treatment be to deliver i.e. give IV dexamethasone + Magnesium sulfate and labetalol?",
"createdAt": 1646499276,
"dislikes": 1,
"id": "8072",
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"__typename": "QuestionComment",
"comment": "You wouldn't give dexmethasone because this is not pre-term (the pregnancy is >37 weeks). in addition the dexamethasone is usually given IM",
"createdAt": 1673877913,
"dislikes": 0,
"id": "16735",
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"id": 1333
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2838",
"name": "Eclampsia treatment",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
"totalCards": null,
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"question": "Case Presentation:\n\n\nA 38-week pregnant lady is admitted to the Emergency Department with generalized tonic-clonic seizure. Prior to the onset of the seizure, her husband mentioned she had been complaining of headache and abdominal pain. PMH Gestational diabetes. DH Metformin 1g BD PO. Weight 60kg\n\n\n **On Examination**\nBP 205/100 mmHg (on admission) (<140/90mmHg), HR 92/min, RR 22\nBP 92/50 mmHg (at 25 weeks)\n\n\n **Investigations**\nUrine dipstick ++ protein\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|110 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|8x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|80x10<sup>9</sup>/L|150 - 400|\n|Bilirubin|1.5 µmol/L|< 17|\n|Aspartate Aminotransferase (AST)|80IU/L|10 - 40|\n|Alanine Aminotransferase (ALT)|140 IU/L|10 - 50|\n|Creatinine|123 µmol/L|60 - 120|\n|Creatinine|0.66 mmol/L|0.19 - 0.36|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the treatment of her eclampsia based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 4488,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,393 | false | 37 | null | 6,494,955 | null | false | [] | null | 6,908 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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
},
{
"__typename": "QuestionChoice",
"answer": false,
"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
},
{
"__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",
"picture": null,
"votes": 4265
},
{
"__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
}
],
"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",
"files": null,
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"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2840",
"name": "Statin side effects",
"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 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,
"userPoint": null
} | MarksheetMark |
173,458,394 | false | 38 | null | 6,494,955 | null | false | [] | null | 6,905 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis",
"id": "34472",
"label": "c",
"name": "Carry out haemodialysis on the patient",
"picture": null,
"votes": 147
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is also not advisable to ignore the raised serum level and maintain his current dose, appropriate investigation should be done to identify the cause of elevated lithium in order to guide management",
"id": "34474",
"label": "e",
"name": "Maintain the dose of lithium carbonate",
"picture": null,
"votes": 294
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis",
"id": "34471",
"label": "b",
"name": "Stop the lithium and restart at a 300mg OD",
"picture": null,
"votes": 2491
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In this case, the patient had a serum lithium of 1.2mmol/L, which is higher than the target range, hence, further increasing the dose of lithium is inappropriate",
"id": "34473",
"label": "d",
"name": "Increase the dose of lithium carbonate to 550mg OD",
"picture": null,
"votes": 4
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Lithium carbonate has a narrow therapeutic index and hence monitoring of serum lithium is often done to ensure it is within therapeutic range. Concentrations are often taken 12 hours after administration and target range of 0.8-1.0 mmol/L is required. The patient’s examination findings are mainly side effects of the medication and not signs of toxicity. Hence, it is necessary to repeat a serum lithium level and check if his renal function is affecting the clearance of lithium",
"id": "34470",
"label": "a",
"name": "Recheck the level of lithium and his renal function",
"picture": null,
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"__typename": "QuestionComment",
"comment": "fine tremor = early sign of lithium toxicity, BNF says to reduce dose",
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"comment": "BNF: 'The early clinical features are non-specific and may include apathy and restlessness which could be confused with mental changes arising from the patient's depressive illness. Vomiting, diarrhoea, ataxia, weakness, dysarthria, muscle twitching, and tremor may follow. Severe poisoning is associated with convulsions, coma, renal failure, electrolyte imbalance, dehydration, and hypotension.'\n\nThis pt is only complaining of a fine tremor & metallic taste which are more consistent with side effects of lithium rather than toxicity. ",
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"comment": "\"... without features of ftoxicity, all that is usually necesary is to take measures to increase urine output (e.g. by increasing fluid intake but avoiding diuretics)\"\n\nSo when it is out of the therapeutic window but there are no features of toxicity, you assess renal function and double check lithium levels (to ensure its not an anomaly). At the same time, you try to encourage more fluid intake and to pass more urine. \n\nIf there are features of toxicity, you stop the dose. If conc is in excess of 2mmol/L, you consider haemodialysis (if neurological signs or renal failure present)",
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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\n\n\nA 45-year-old man was admitted to Psychiatry Ward following a failed suicidal attempt due to a depressive episode. PMH Bipolar disorder. DH Lithium carbonate 400mg PO OD.\nDue to the acute relapse of her bipolar disorder, it has been decided that her lithium carbonate will be increased to 500mg OD and the first dose was given at 0800 today. Weight 75kg.\n\n\n **On Examination**\nPatient had fine tremor on both hands and complained of a lingering metallic taste.\nBP 118/75 mmHg, HR 75/min, RR 12, moist mucous membrane with CRT 2s.\n\n\n **Investigations**\nSerum lithium at 2200 is 1.2 mmol/L (Therapeutic dose 0.6-1.0 mmol/L)\n\n\nQuestion:\nSelect the most appropriate decision option based on these data.",
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173,458,395 | false | 39 | null | 6,494,955 | null | false | [] | null | 6,900 | {
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"explanation": "Decreasing the insulin dose to 13 units would be inappropriate as this could worsen his glycaemic control",
"id": "34447",
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"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",
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"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,
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"__typename": "QuestionChoice",
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"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,
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"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,
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"comment": "where on the BNF can i find this?\n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"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.",
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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": 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,
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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": "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,
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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",
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"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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"comment": "If this guy has confabulation and retrograde amnesia, he has Korsakoff's syndrome, which is irreversible, so we're not exactly 'treating' it",
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"comment": "one pair is equal to 5ml (in BNF) so would it be correct to put 5ml in the dose\n",
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"comment": "Oh noo i just gave him some thiamine :(",
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"explanation": "# Summary\n\nWernicke's encephalopathy is a neurological disorder resulting from thiamine (vitamin B1) deficiency, often caused by conditions such as chronic alcohol abuse, malnutrition, bariatric surgery, or hyperemesis gravidarum. It commonly presents with a triad of ataxia, confusion, and ocular abnormalities. Key investigations include neurological examination and imaging techniques, while management primarily involves high-dose intravenous thiamine, such as Pabrinex IV. If left untreated, it may progress to Korsakoff's syndrome, characterized by irreversible deficits in anterograde and retrograde memory.\n\n# Definition\n\nWernicke's encephalopathy is a neurological disorder caused by thiamine (vitamin B1) deficiency, manifesting in a triad of specific clinical symptoms: ataxia, confusion, and ocular abnormalities.\n\n# Epidemiology \n\nWorldwide prevalence of Wernicke's encephalopathy, based on unselected autopsy studies, ranges from 0.8% to 2.8%. \n\nThe condition exhibits a higher prevalence in certain populations: 12.5% in individuals with a history of alcohol dependence, 10% in those with AIDS, and 6% in bone marrow transplant recipients. \n\nThe prevalence is higher in males, with a male-to-female ratio of 1.7:1, often attributed to the higher incidence of alcoholism in men.\n\n# Aetiology\n\nThe primary causes of Wernicke's encephalopathy include:\n\n- Chronic alcohol abuse: Alcohol interferes with thiamine absorption and utilization.\n- Malnutrition: This can occur due to inadequate dietary intake, malabsorption disorders, or increased requirements.\n- Bariatric surgery: Rapid weight loss and reduced nutrient absorption can lead to thiamine deficiency.\n- Hyperemesis gravidarum: Persistent severe vomiting in pregnancy may lead to nutrient deficiencies, including thiamine.\n\n# Signs and Symptoms\n\nWernicke's encephalopathy typically presents with a characteristic triad of symptoms:\n\n- Ataxia: Unsteady and uncoordinated movements\n- Confusion: Disorientation and difficulty with attention\n- Ocular abnormalities: This can include gaze-evoked nystagmus, spontaneous upbeat nystagmus, and horizontal or vertical ophthalmoplegia.\n\n# Differential Diagnosis\n\n- Meningitis: Presents with fever, headache, neck stiffness, and altered mental status.\n- Stroke: Sudden onset of focal neurological deficits, which may include difficulty speaking, face drooping, arm weakness.\n- Encephalitis: Characterized by fever, headache, behavioral changes, and sometimes, seizures.\n- Korsakoff's syndrome: Notable for severe anterograde and retrograde memory loss, often seen as a progression from untreated Wernicke's encephalopathy.\n\n# Investigations\n\nTo confirm a diagnosis of Wernicke's encephalopathy, the following investigations may be undertaken:\n\n- Neurological examination: Assessment of the characteristic triad of symptoms.\n- MRI Head: May show characteristic changes in specific brain regions, such as the mammillary bodies and periaqueductal area.\n- Blood tests: Although not definitive, they can reveal low thiamine levels and other signs of malnutrition or alcohol abuse.\n\n# Management\n\nManagement of Wernicke's encephalopathy primarily involves replacement of thiamine. High-dose intravenous thiamine, commonly given as Pabrinex IV, is the standard treatment. If left untreated, the condition can progress to **Korsakoff's syndrome**, which affects the mammillary bodies, leading to irreversible deficits in anterograde and retrograde memory.",
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"explanation": "# Drug choice feedback\n\nThis gentleman is likely suffering from Wernicke's encephalopathy. Apart from addressing problems of alcohol abuse and diet, stable patients require multivitamins including vitamins B1 and C. Pabrinex is recommended in such cases.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe intravenous route is recommended in the treatment of Wernicke's encephalopathy. The dose is expressed in pairs of ampoules, whereby each pair contains distinct vitamins that are only mixed just prior to administration. 2-3 pairs of ampoules are recommended TDS for 3 to 5 days, followed by 1 pair OD for a further 3 to 5 days guided by clinical improvement.",
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"question": "Case Presentation: A 58-year-old gentleman is brought to the Emergency Department by his relative. He is noted to have moderate confusion, double vision and unsteady walking.\n\n\n## PH\n\nAlcoholism, Chronic pancreatitis, Depression\n\n## DH\n\nSertraline 100mg PO OD (NKDA)\n\n## On examination\n\nAppears alert, but confabulation and retrograde amnesia suspected.\n\nTemperature 36.2°C, HR 67, RR 13, BP 125/78, O<sub>2</sub> 98% RA, GCS 14, Weight 81kg\n\n## Investigations\n\nNone\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating his condition.",
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173,458,467 | false | 2 | null | 6,494,960 | null | false | [] | null | 6,759 | {
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"comment": "Ondensatron can be given IV or IM in this circumstance? ",
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"comment": "yeah BNF says slow IV or IM so idk why theyre saying IM is wrong?",
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"comment": "if there's a cannula in situ, it's better to do IV route over IM",
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"comment": "why is domperidone wrong?",
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"comment": "don't give domperidone in someone with parkinsons ",
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"comment": "This is wrong domperidone is gold standard for GI side effects in Parkinson's but that's when nausea and vomiting is associated with opiates, so you would give ondansetron for this patient as the treatment is for post-op nausea and vomiting ",
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"comment": "Re. Cyclizine —> in practice it works better for patients who have nausea from ear related problems eg motion sickness, vestibular neuritis etc…\nOndansetron is typically a good choice for treatment or prophylaxis of post-surgical nausea :) ",
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"comment": "also: cyclizine = CI: heart failure",
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"comment": "Why not haloperidol as the QT interval is not prolonged in this patient? Unless there are other contraindications",
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"comment": "Parkinson's would be a CI as it's a dopamine receptor antagonist",
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"explanation": "Assess cause:\n\n- Infection\n- Hypovolaemia\n- Pain\n- Paralytic ileus\n- Drugs\n\nManagement:\n\n- Non-pharmacological\n\n - Minimise patient movement\n - Analagesia\n - IV fluids if dehydrated\n\n- Pharmacological\n - 5HT3 receptor antagonist e.g. Ondansetron - first line. Risk of QT prolongation and constipation\n - Histamine (H1) receptor antagonist e.g. Cyclizine. Avoid in severe heart failure\n - Dopamine (D2) receptor antagonist e.g. Prochlorperazine. Risk of extrapyramidal side effects (dystonic reactions)\n\nOther anti-emetics such as corticosteroids or Metoclopramide reserved for specific cases of post-operative nausea and vomiting.\n\n# External links \n\n- [NHS Greater Glasgow & Clyde: Adult Therapeutics Handbook: Management of Postoperative Nausea and Vomiting](https://handbook.ggcmedicines.org.uk/guidelines/pain-post-operative-nausea-and-vomiting-and-palliative-care-symptoms/management-of-postoperative-nausea-and-vomiting-ponv/)\n- [Up To Date: Postoperative Nausea and Vomiting](https://www.uptodate.com/contents/postoperative-nausea-and-vomiting)\n- [Norfolk and Norwich University Hospitals: Clinical Guideline for the management of post-operative nausea and vomiting in adults and children](http://www.nnuh.nhs.uk/publication/download/management-of-post-operative-nausea-and-vomiting-in-adults-and-children-clinical-guideline-v1-1/)\n",
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"explanation": "# Drug choice feedback\n\nThis patient requires an anti-emetic. Ondansetron is the most appropriate. Cyclizine is contra-indicated in light of her severe heart failure, whilst prochlorperazine is contra-indicated due to her mild Parkinson's disease, as it can result in extra-pyramidal side effects. Metoclopramide is contra-indicated as it is a pro-kinetic in the context of thias patient's gastrectomy\n\n# Dose/Route/Frequency/Duration feedback\n\nThe dose of IV ondansetron in post-operative nausea and vomiting is 4mg. Whilst it can be given IM, this patient already has a cannula in situ, hence the IV route is preferred.",
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"question": "Case Presentation: A 73-year-old woman admitted to the general ward for observation after a gastrectomy 12 hours ago complains of nausea and has vomited three times. She has been given adequate analgesia.\n\n\n## PH\n\nStomach cancer, severe heart failure, Type 2 Diabetes Mellitus, Obesity, Hyperlipidaemia, Mild Parkinson's Disease\n\n## DH\n\nRamipril 5mg OD PO, Bisoprolol 2.5mg PO, Spironolactone 50mg PO OD, Metformin 1g BD PO, Empaglifozin 10mg PO OD, Atorvastatin 40mg PO OD (NKDA)\n\n## On examination\n\nAppears unwell, not oriented to time and place. Peripheries warm, CRT 2s. Cannula in situ.\n\nTemperature 36.6°C, HR 97, RR 23, BP 113/80, O2 96% RA, GCS 14, Weight 95kg\n\n## Investigations\n\nFBC: Hb 144, WCC 7.3, Plts 324\n\nU&Es: Na<sup>+</sup> 136, K<sup>+</sup> 4.2, Cl<sup>-</sup> 105, Ur 6.8, Cr 98, eGFR 51mL/min/1.73m<sup>2</sup>\n\nECG: Normal sinus rhythm, QTc 430ms (<460ms)\n\n# Prescribing Request\n\nWrite a prescription for one medication that is most appropriate for treating her post-operative nausea and vomiting.",
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173,458,468 | false | 3 | null | 6,494,960 | null | false | [] | null | 6,769 | {
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"comment": "why not magnesium sulfate",
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"comment": "mag sulph is for seizure prophylaxis if i recall correctly, but you'd want to address the hypertension first",
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"comment": "I second this - I gave her magnesium sulphate bc she had hyperreflexia which is a sign of severe pre-eclampsia and you can give mgso4 in severe pre-eclampsia! if anyone knows the answer pls comment ",
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"comment": "the qu asked for what will help her hypertension tho",
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"comment": "why isnt oral labetalol hydrochloride accepted? treatment summary says oral or iv for bp>160/110",
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"comment": "under bnf hypertensive emergencies it recommends prescribing labetalol 50mg, why is this wrong?",
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"explanation": "# Summary\n\nPre-eclampsia is a placental condition that often affects pregnant women from around 20 weeks of gestation, characterised by hypertension and proteinuria. Other symptoms include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia. The exact aetiology is not entirely understood, but it may be due to dysfunctional trophoblast invasion of the spiral arterioles. Key investigations include blood pressure and urine protein measurements. Management strategies include anti-hypertensive treatment, with labetalol as the first-line agent. Magnesium sulphate is used to prevent and treat eclamptic seizures, but the ultimate curative treatment is delivery of the placenta.\n\n# Epidemiology\n\n\n\nPre-eclampsia affects a significant percentage of pregnancies worldwide, although the exact number varies significantly between different populations and healthcare settings. Risk factors include nulliparity, a previous history or family history of pre-eclampsia, increasing maternal age, pre-existing diseases such as hypertension, diabetes, renal disease, autoimmune disease, obesity, and multiple pregnancies.\n\n\n# Aetiology\n\n\n\nThe exact aetiology of pre-eclampsia remains unclear. However, it's believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.\n\n\n# Signs and Symptoms\n\n\nPre-eclampsia is characterised by:\n\n- Hypertension\n- Proteinuria\n- Peripheral oedema\n- Severe headache\n- Drowsiness\n- Visual disturbances\n- Epigastric pain\n- Nausea/vomiting\n- Hyperreflexia\n\n# Maternal complications\n\n- Eclampsia (seizures due to cerebrovascular vasospasm)\n- Organ failure\n- Disseminated intravascular coagulation (DIC)\n- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))\n\n# Foetal complications\n\n- Intrauterine growth restriction\n- Pre-term delivery\n- Placental abruption\n- Neonatal hypoxia\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for pre-eclampsia includes other conditions that can present with hypertensive disorders in pregnancy, such as chronic hypertension, gestational hypertension, and HELLP syndrome. Key signs and symptoms for these conditions include persistent high blood pressure, proteinuria, and various combinations of haemolysis, elevated liver enzymes, and low platelet levels.\n\n# Investigations\n\n\nKey investigations for pre-eclampsia include:\n\n- Blood pressure measurement: To confirm hypertension.\n- Urinalysis: To confirm proteinuria.\n- Blood tests: To assess kidney function, liver function, and clotting status.\n\n# Management\n\nAspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with one high risk factor or two (or more) moderate risk factors. \n\nManagement of pre-eclampsia primarily involves anti-hypertensive treatment, with labetalol being the recommended first-line agent. Other agents that can be used include Nifedipine, Methyldopa and hydralazine. \n\nMagnesium sulphate can be administered for the prevention and treatment of eclamptic seizures. \n\nThe only definitive curative treatment is the delivery of the placenta. It is also crucial to monitor the mother and foetus closely for complications.\n",
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"question": "Case Presentation: A 41-year-old woman, G1P0, who is 32 weeks pregnant is brought to the Emergency Department by her partner with severe headache, blurry vision, severe abdominal pain, nausea and sudden swelling of hands.\n\n\n## PH\n\nType 2 Diabetes Mellitus, Obesity\n\n## DH\n\nMetformin 1g PO OD, Aspirin 75mg PO OD (started from 12th week of gestation) (NKDA)\n\n## On examination\n\nAlert but in pain. Hyperreflexia noted. Mild tenderness in right upper quadrant of abdomen. Generalised oedema noted. No clonus. Cannula in situ.\n\nTemperature 36.2°C, HR 67, RR 13, BP 162/98, O<sub>2</sub> 98% RA, GCS 14, Weight 98kg\n\n## Investigations\n\nProteinuria 2+ on dipstick, no blood noted\n\nFBC, U&E, LFT and Clotting: Normal, HEELP syndrome negative.\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating her blood pressure. ",
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"comment": "Fluid replacement is the main 1st treatment in DKA so hartmans or saline is also correct",
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"comment": "This is hypoglycaemia not DKA..",
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"comment": "Why can you not give glucagon\n",
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"comment": "because the question states that an IV line is in situ so its preferred\n",
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"comment": "I made the same rookie error and gave IM glucagon ",
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"explanation": "# Summary\n \nHypoglycaemia refers to low blood glucose levels, usually defined as <3.5 mmol/L. It may present with shaking, sweating, palpitations, hunger, headache, double vision, difficulty concentrating, slurred speech, confusion, and coma. After checking a capillary blood glucose, emergency management involves giving fast-acting carbohydrates then rechecking blood glucose in 10-15 minutes. For patients who are unable to swallow, intravenous dextrose or intramuscular glucagon should be given. Once they have improved, ensure they eat something with a long-acting carbohydrate to prevent recurrence of hypoglycaemia. \n \n# Definition\n \nHypoglycaemia is defined as a low blood glucose level, usually below 3.5 mmol/L.\n\nWhipple's triad refers to:\n\n- A low blood glucose level\n- Symptoms or signs of hypoglycaemia\n- Resolution of symptoms/signs once blood glucose normalises\n \n# Aetiology\n \nHypoglycaemia is uncommon in patients who do not have diabetes - triggering factors include:\n\n- Alcohol\n- Insulin\n- Oral hypoglycaemic medications such as sulphonylureas\n- Decreased oral intake\n- Excessive exercise\n\nRarer causes include:\n\n- Insulinomas\n- Adrenal insufficiency\n- Reactive hypoglycaemia (e.g. after upper gastrointestinal surgery)\n- Self-induced hypoglycaemia\n\n# Signs and Symptoms\n \n- Hunger\n- Anxiety/irritability\n- Tremor\n- Sweating\n- Headache\n- Double vision\n- Slurred speech\n- Confusion\n- Decreased level of consciousness\n \n# Investigations\n \nIn the emergency setting, the main investigation is a capillary blood glucose (glucose may also be obtained from a blood gas).\n\nBlood and urine assays for sulphonylureas can be used if their abuse is suspected (in the context of suspected self-induced hypoglycaemia).\n\nIn unexplained hypoglycaemia, further investigations may be indicated (e.g. serum insulin, C-peptide and proinsulin testing to differentiate between endogenous and exogenous insulin, early morning cortisol) - these are covered in more detail in the endocrinology chapter.\n\n# Management\n \n**In patients who are conscious and able to swallow:**\n\n - Give 15-20g of fast-acting carbohydrate (e.g. 5 glucose tablets or 200ml of fruit juice)\n - Avoid chocolate and biscuits as their fat content may delay stomach emptying\n - Glucose 40% gel may be useful in patients who are able to swallow but are confused or unable to cooperate\n - Recheck blood glucose in 10-15 minutes, and repeat the fast-acting carbohydrate if still less than 4.0\n - Once blood glucose is over 4.0, give a long-acting carbohydrate (e.g. a meal containing potato or pasta, or a snack with biscuits or toast) to prevent recurrence of hypoglycaemia\n \n**In patients who are unconscious or unable to swallow:**\n\n- Take an A-E approach and consider if airway protection required\n- Administer 100ml of 20% glucose or 200ml of 10% glucose intravenously\n- In patients with no IV access, give 1mg of glucagon intramuscularly (this acts to mobilise glycogen from the liver and so is less effective in cirrhosis, malnourished patients, alcohol excess and sulphonylurea treatment)\n- Once blood glucose is over 4.0 and the patient has recovered, give a long-acting carbohydrate as above\n\n**For all patients:**\n\n- Review medications; may require adjustment of hypoglycaemic medications such as insulin or sulphonylureas\n- Ensure regular capillary blood glucose monitoring for at least 24-48 hours\n- Educate patients and families or symptoms of hypoglycaemia, how to self-monitor if appropriate and emergency treatment at home\n\n# NICE Guidelines\n\n[NICE CKS - Hypoglycaemia in Type 2 Diabetes](https://cks.nice.org.uk/topics/insulin-therapy-in-type-2-diabetes/management/insulin-therapy-type-2-diabetes/#hypoglycaemia)\n \n# References\n\n[Patient UK - Hypoglycaemia](https://patient.info/doctor/hypoglycaemia)\n \n[Diabetes UK - Hypoglycaemia Guidelines](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Archive/JBDS_01_HypoGuideline_4th_edition_FINAL_Archive.pdf)",
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"explanation": "# Drug choice feedback\n\nThis patient is suffering from hypoglycaemia and the intravenous fluid required urgently is glucose. Glucose 10% or 20% are the most appropriate. The next higher concentration is Glucose 50%, a possible alternative, but due to its high concentration, it can extravasate and is an irritant. Hence, it is not preferred. The next lower concentration is Glucose 5%, which is too low for any clinical effect unless a large volume is administered which is impractical.\n\n# Dose/Route/Frequency/Duration feedback\n\nA dose of 15g-20g of glucose needs to be administered, hence as long as the volume of a particular intravenous glucose concentration given achieves this dose, as stated above, it is acceptable. The duration of administration should not exceed 15 minutes, so that the hypoglycaemic episode is not unduly prolonged.",
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"question": "Case Presentation: A 24-year-old gentleman was found collapsed on the street and was brought to the Emergency Department.\n\n\n\n\n## PH\n\n\nType 1 Diabetes Mellitus\n\n\n## DH\n\n\nInsulin Glargine (Lantus) 18 units, Insulin Aspart (Novorapid) 6 units at mealtimes\n\n\n## On examination\n\n\nAppears sweaty, drowsy, not oriented to time and place. Tremor noted in hands bilaterally. Cannula is in situ.\n\n\nTemperature 36.7°C, HR 117, RR 25, BP 123/80, O2 97% RA, GCS 11, Weight 72kg\n\n\n## Investigations\n\n\nBM: 2.1 mmol/L (normal range 3.5-5.5 mmol/L)\n\n\nTFT: Normal\n\n\nECG: Sinus Tachycardia\n\n\n# Prescribing Request\n\n\nWrite a prescription for one intravenous drug that is most appropriate for treating his current condition.",
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173,458,470 | false | 5 | null | 6,494,960 | null | false | [] | null | 6,782 | {
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"comment": "The explanation doesn't give the answer for question 1. What's the third medication causing prolonged QTc???",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. Typical (haloperidol), atypical (risperidone) antipsychotics and mirtazepine are known to increase the QTc interval.\n2. Haloperidol, given to schizophrenic patients has a maximum dose of 20mg daily. The dose prescribed for this patient is likely to represent a transcription error of daily to 12-hrly.",
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"question": "Case presentation: A 52-year-old man was brought into the Emergency Department by the police under Section 136 following an episode of auditory hallucination. PH Schizophrenia, Severe depression, Hypertension, Ulcerative Colitis. DH His current regular medications are listed (below).\n\n\n**Investigation**\nECG shows a prolonged QTc interval 460ms (normal≤ 430ms)\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his prolonged QTc interval (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,458,471 | false | 6 | null | 6,494,960 | null | false | [] | null | 6,790 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. 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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"comment": "I don't know if I'm being an idiot but 30mg/kg is 3.6g?? eg. the dose he is on",
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"comment": "the max is 2.5g tho so that's the only reason \n",
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"comment": "should one of the dosing errors be levetiracetam?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. Beta blockers and non-dihydropyridine calcium channel blockers should not be co-prescribed as both exert a negative inotropic and chronotropic effect on the heart, causing a depression in both mechanical and electrical activity resulting in bradycardia and hypotension.\n2. Sodium valproate used for seizure management is prescribed at 20-30mg/kg daily. However, the maximum recommended dose is 2.5g daily. Hence this patient should only be prescribed 2.5g daily and not 3.6g daily. ",
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"comment": "is metformin not correct also, as it accumulates when renal function decreases as in AKI?",
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"comment": "only if creatinine is above 150 fella",
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"comment": "also ACEi are more important to stop as they directly impact renal function",
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"comment": "What about holding codeine during an AKI?\n",
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"comment": "how does the patient have an AKI if his Cr has only increased by 10umol? - needs to be at least 25umol in 48hrs or 50% increase in 7 days?",
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"explanation": "# Summary\n\nAcute urinary retention is a medical emergency typified by a sudden inability to pass urine, frequently observed in older males who have undergone recent surgery. Key indicators include pain and discomfort, distension of the bladder, and a lack of urine flow despite the urge to urinate. The condition may be precipitated by factors such as neurological disorders, obstructions, infections, certain medications, or post-operative complications. Investigations comprise a bladder scan, digital rectal exam, urinalysis, and evaluation of post-void residual. Management typically involves immediate catheterisation to relieve the distension, followed by treatment of the underlying cause.\n\n# Definition \n\nAcute urinary retention is a medical emergency marked by the onset of the inability to pass urine over a certain period of time, usually hours to days. \n\n# Aetiology\n\nAcute urinary retention can be triggered by several factors and situations, often in older male patients who have recently undergone anaesthesia for surgery. Any irregularities of the urethral tract such as benign prostatic hyperplasia (BPH) or stricture can elevate the risk of this condition.\n\nProminent causes of urinary retention can be classified according:\n\n- Luminal causes (stone, blood clot, tumour, UTI)\n- Mural causes (stricture, neuromuscular dysfunction)\n- Extra-mural (abdominal/pelvic mass/tumours, retroperitoneal fibrosis)\n- Neurological pathologies (cauda equina, MS)\n- Obstructive pathologies\n- Infectious diseases including UTIs\n- Medications \n\t- Anticholinergic types of medications inhibit parasympathetic activity on the detrusor muscle and its inhibitory effects on the bladder sphincters by blocking the action of acetylcholine, thereby preventing it from binding to receptor sites.\n- Post-operative complications\n- Constipation, especially in the elderly\n\n\nDrugs with alpha-agonist properties obstruct bladder contraction and promote sphincter contraction.\n\nAlcohol is another potential precipitant of acute urinary retention.\n\n# Signs and Symptoms\n\n- Inability to pass urine\n- Lower abdominal discomfort\n- Pain or distress\n- Suprapubic tenderness\n- Suprapubic mass (due to an enlarged bladder)\n- Delirium (hypoactive or hyperactive)\n\n# Investigations\n\nStandard investigations for acute urinary retention include:\n\n- Bladder scan/USS renal tract\n- Digital Rectal Exam\n- Urinalysis and urine MCS\n- Evaluation of post-void residual\n- Bloods tests: FBC, renal profile (renal function is often preserved due to the acuity, unlike in chronic urinary retention), CRP\n- Consider non-contrast CT KUB if stones suspected\n\nThe specific investigations required will be dependent on the accompanying symptoms.\n\n# Management\n\nThe immediate goal in managing acute urinary retention is to relieve the patient's discomfort by decompressing the bladder. This is typically accomplished with **catheterisation**, which can be indwelling or intermittent, depending on the patient's overall health status and the underlying cause of retention. \n\nPost-catheterisation, it is essential to address the underlying cause of retention. The management strategy will therefore depend on the aetiology:\n\n- For obstructive causes such as benign prostatic hyperplasia (BPH), medical management with alpha-blockers (e.g. tamsulosin - Note: Prescribe with caution in the elderly as can exacerbate postural hypotension) or 5-alpha reductase inhibitors (e.g. finasteride) may be employed initially. If medical management fails, surgical intervention like transurethral resection of the prostate (TURP) or prostatectomy may be considered.\n\n- Neurogenic causes require further specialist evaluation, and treatment options can range from medication to surgical interventions, including sacral neuromodulation or creation of urinary diversions, depending on the severity and cause of the neurogenic dysfunction. If there is acute urinary retention/faecal incontinence, saddle paraesthesiae and bilateral leg weakness, this is a neurosurgicalogical emergency necessitating an urgent MRI whole spine to rule out cauda equina syndrome.\n\n- Infections should be managed with appropriate antibiotics, and any identified drug-induced urinary retention should be addressed by discontinuing the offending medication, if possible, and providing symptomatic relief.\n- Bowel care - following PR exam and depending on patient factors such as age, diet and current medications, a laxative may be added or if these have proven to already be ineffective, an enema may be required.\n\n\n# NICE Guidelines\n\n[Click here for the NICE BNF Treatment Summary](https://bnf.nice.org.uk/treatment-summary/urinary-retention.html)",
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"explanation": "1. Codeine phosphate and morphine sulfate are examples of opioids and urinary retention is a common or very common side effect of all opioids. Imipramine sulfate is an example of tricyclic antidepressant. Urinary disorder is a side effect of imipramine and BNF has cautioned against the use of imipramine in patients with known urinary retention\n2. Enalapril maleate is an example of angiotensin-converting enzyme inhibitor (ACE-i). ACE-I should be stopped whenever an AKI arises because it is nephrotoxic and might lead to further renal injury. ACE-I inhibits efferent renal arteriolar vasoconstriction, thus lowering the glomerular filtration pressure.",
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"question": "Case presentation: A 80-year old woman is on a surgical ward recuperating from her total hip replacement that took place three days ago. She complains that she has been having difficulty fully emptying her bladder. The stream is weak and only a small of urine is passed during the day PH: Hypertension, Type 2 Diabetes Mellitus, Depression, Constipation DH: Her current regular prescriptions are listed below\n\n\n\n\n **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Slight tenderness on palpation of hypogastric region\n\n\n **Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\nNegative urine dipstick\nBladder scan reveals a post-void residual volume of 500ml\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|130 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|9.5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|270x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|88 fL|80 - 96|\n|Neutrophils|6.5x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|2.8x10<sup>9</sup>/L|1.5 - 4.0|\n|Sodium|141 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|130 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of the urinary retention?\nQuestion 2: Select the ONE prescription that is most appropriate to withhold until her renal function improves?",
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"comment": "BNF also states that aspirin in high doses can cause 'closure of fetal ductus arteriosus in utero' so I'd say thats a heart defect?",
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"comment": "adding to that, there are conflicting studies as to whether or not SSRIs cause congenital heart defects",
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"comment": "I thought this, but aspirin can be given up until birth for pre-eclampsia so must be low(ish) risk ",
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"comment": "BNF states that Tetracyclines should not be given in pregnancy! So there should be THREE options for part (A).",
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"comment": "The question wants medications that causes congenital heart defects not contraindications for pregnancy. Tetracyclines affect skeletal development and discolour teeth. Its on the BNF under pregnancy for tetracycline",
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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 40-week pregnant woman is admitted electively for induction of labour. PH Type 2 diabetes mellitus, Depression, Bipolar disorder, Hypothyroid, Tension headache, Acne rosacea. DH Her current regular medications are listed (below).\n\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to congenital heart defects (mark them with a tick in column A)\nQuestion 2: Select the FOUR prescriptions that are contraindicated in breastfeeding (mark it with a tick in column B).",
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"__typename": "QuestionChoice",
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"explanation": "Amoxicillin has activity against GBS but has a much broader spectrum of activity than would normally be required",
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"label": "b",
"name": "Amoxicillin 500mg IV",
"picture": null,
"votes": 223
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"__typename": "QuestionChoice",
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"explanation": "Clindamycin has historically been used to treat GBS but due to increasing resistance, it is recommended that sensitivities be performed before its use",
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"__typename": "QuestionChoice",
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"explanation": "This formulation of benzylpenicillin is used to treat syphilis rather than GBS",
"id": "34042",
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"picture": null,
"votes": 238
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"__typename": "QuestionChoice",
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"picture": null,
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"__typename": "QuestionChoice",
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"name": "Ceftriaxone 2g IV",
"picture": null,
"votes": 201
}
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"comment": "Where is this on the BNF?\n",
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"comment": "Type in benzylpenicillin sodium --> go to the \"Intrapartum prophylaxis against group B streptococcal infection\" section \n\n",
"createdAt": 1709642643,
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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": "Group B Streptococcus",
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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"
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"totalVotes": 6002,
"typeId": 1,
"userPoint": null
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173,458,476 | false | 11 | null | 6,494,960 | null | false | [] | null | 6,801 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a possible option in rate-controlling fast AF or to manage symptoms such as palpitations",
"id": "33953",
"label": "d",
"name": "Start bisoprolol fumarate 5mg PO OD",
"picture": null,
"votes": 3033
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "As the patient has AF and a CHA₂DS₂-VASc of 2, anticoagulation should be initiated to lower the risk of a cerebrovascular event",
"id": "33950",
"label": "a",
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"picture": null,
"votes": 2135
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"__typename": "QuestionChoice",
"answer": false,
"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",
"id": "33951",
"label": "b",
"name": "Make an urgent referral to A&E for synchronised DC cardioversion",
"picture": null,
"votes": 177
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"__typename": "QuestionChoice",
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"explanation": "There is no role for aspirin in the management of AF absent some cerebrovascular event",
"id": "33952",
"label": "c",
"name": "Start aspirin 75mg PO OD",
"picture": null,
"votes": 284
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a possible option as a ‘pill in pocket’ strategy if the patient had paroxysmal AF. However there is nothing in the stem to suggest that this is the case",
"id": "33954",
"label": "e",
"name": "Start flecainide acetate 50mg PO BD",
"picture": null,
"votes": 408
}
],
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"__typename": "QuestionComment",
"comment": "Why wouldn't you rate control first? \n",
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"comment": "because her rate is normal so rhythm control needed\n",
"createdAt": 1675290446,
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"comment": "Why no rhythm control first for new AF?",
"createdAt": 1705161638,
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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",
"createdAt": 1706281439,
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"comment": "Also the rhythm is fine at 86bpm, no need to reduce it",
"createdAt": 1708017911,
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"__typename": "QuestionComment",
"comment": "But she is taking escitalopram which is contra-indicated with rivaroxaban as they can both cause bleeding",
"createdAt": 1710170370,
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"replies": [
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"__typename": "QuestionComment",
"comment": "Not an absolute CI, can just add a PPI to reduce risk of GI bleeding",
"createdAt": 1710666727,
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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": "2734",
"name": "AF - warfarin appropriate to CHA2DS2VASc",
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"name": "Internal Medicine",
"typeId": 5
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 6037,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,477 | false | 12 | null | 6,494,960 | null | false | [] | null | 6,824 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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": "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": "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": 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
}
],
"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,
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{
"__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",
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"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,
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"displayName": "Pseudopseudopseudopseudohypoparathyroidism",
"id": 51334
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"__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",
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"parentId": 60842,
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"displayName": "Retake Prophylaxis ",
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"__typename": "QuestionComment",
"comment": "what are the signs of nephropathy here am I actually going insane\n",
"createdAt": 1738153825,
"dislikes": 0,
"id": "61860",
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"replies": [
{
"__typename": "QuestionComment",
"comment": "The proteinuria I think. Tricky :/",
"createdAt": 1738173989,
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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": "Diabetes with evidence of renal impairment",
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"typeId": 5
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"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.",
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"a"
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"typeId": 1,
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173,458,478 | false | 13 | null | 6,494,960 | null | false | [] | null | 6,805 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient’s long-acting insulin should only be returned to normal levels at the time of discharge and not whilst still on a VRII",
"id": "33974",
"label": "e",
"name": "Increase insulin glargine to 22 units SC ON and administer insulin lispro with next meal",
"picture": null,
"votes": 473
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "As the patient is able to eat and drink, she should restart her usual subcutaneous fast-acting insulin with her next meal with the VRII running for 30-60 minutes afterwards to ensure stable BMs",
"id": "33970",
"label": "a",
"name": "Administer insulin lispro with next meal and continue VRII for 1 hour afterwards",
"picture": null,
"votes": 3038
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "When transitioning from a VRII to normal subcutaneous insulin, the infusion should be left running for 30-60 minutes afterwards to ensure stable BMs",
"id": "33972",
"label": "c",
"name": "Administer insulin lispro with next meal and discontinue VRII",
"picture": null,
"votes": 1516
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin",
"id": "33973",
"label": "d",
"name": "Continue VRII for another 12 hours and discontinue if BMs are stable",
"picture": null,
"votes": 1030
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin",
"id": "33971",
"label": "b",
"name": "Administer insulin lispro with tomorrow's evening meal and continue VRII for 1 hour afterwards",
"picture": null,
"votes": 693
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "should say how long ago her surgery was/ how long she should be NBM - extensive bowel resection may need to be NBM for up to 48 hrs ",
"createdAt": 1646930924,
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"comment": "where is the guidance on this in the BNF?\n",
"createdAt": 1706612592,
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"__typename": "QuestionComment",
"comment": "nvm found it under \"Diabetes, surgery and medical illness\"\n",
"createdAt": 1706612840,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 50 year old woman is a surgical inpatient recovering from an elective anterior resection of sigmoid adenocarcinoma. **PH** type 1 diabetes. **DH** insulin lispro (Humalog) 10 units SC TDS with meals, insulin glargine (Lantus) 22 units SC ON.\n\n\n**O/E**\n\nAlert and oriented. Vital observations stable, surgical site dressing clean with limited strikethrough. Loop ileostomy in RIF, stoma bag collecting yellow liquid stool.\n\nShe is currently on insulin glargine (Lantus) 17 units SC ON and has been receiving a variable rate insulin infusion (VRII) for 12 hours since 7pm yesterday. Her pain and nausea are well controlled, and she recently started eating and drinking. She is now due dinner.\n\nQuestion: Select the most appropriate management with regard to her insulin at this stage.",
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"explanation": "Nitrofurantoin concentrates well in urine but requires adequate remaining renal function and should be avoided in patients with eGFR <45",
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"explanation": "Amoxicillin cannot be given as the patient is penicillin-allergic",
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"explanation": "Once a good first-line agent to treat uncomplicated lower urinary tract infections, there have been rising rates of antimicrobial resistance to trimethoprim recorded in many localities. Trust antibiotic guidelines should be consulted before prescribing this drug",
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"name": "Trimethoprim 200mg PO BD",
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"explanation": "Fosfomycin is an acceptable alternative in treating uncomplicated lower urinary tract infections if first-line treatments are ineffective or contraindicated",
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"name": "Fosfomycin 3g PO OD",
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"comment": "BNF says fosfomycin is given for 1 dose only not once daily ",
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"comment": "yeah OD.. for one dose",
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"comment": "why would you not go for trimethoprim?",
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"comment": "The bug is resistant to Trimethoprim according to the micro sensitivities testing",
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"comment": "BNF says to avoid if <45 eGFR but follows up with that it can be used with caution...?",
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"comment": "Use with caution as opposed to use fosfomycin which it is also sensitive to- with no issues. I see where you're coming but fosfomycin makes more sense\n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 71 year old woman is on the acute admissions unit being treated for acute confusion, urinary frequency and dysuria. **PH** breast cancer, focal segmental glomerulosclerosis. **DH** anastrozole 1mg PO OD, furosemide 120mg PO BD, atorvastatin 40mg PO ON, calcichew D3. Previous adverse drug reaction to penicillin – angioedema.\n\n\n**O/E**\n\nHR 84, RR 14, BP 147/76, O2 98% RA, Temperature 37.8°C, AMTS 4/10.\n\n**Investigations**\n\nU&Es: Na 143, K 4.7, Cl 103, Ur 6.0, Cr 210 (baseline 180), eGFR 32mL/min/1.73m^2\n\nUrine MCS grows gram-negative rods (R=resistant, S=sensitive):\n\nTrimethoprim – R\n\nNitrofurantoin – S\n\nPivmecillinam – S\n\nAmoxicillin – S\n\nFosfomycin – S\n\nQuestion: Select the most appropriate management at this stage.",
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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": "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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"explanation": "Methotrexate commonly causes diarrhoea and not constipation",
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"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": "Before treatment, patients should have full blood count and renal and liver function tests done. ECG does not constitute part of the pre-treatment screening",
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"name": "He needs to get an ECG as part of the pre-treatment screening",
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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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"id": "34127",
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"name": "She should not breastfeed if she is taking citalopram because citalopram passes into breast milk in large quantities and can lead to grey baby syndrome",
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"id": "34128",
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"explanation": "Agitation and sweating are not normal side effects of citalopram. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of serotonin syndrome",
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"name": "It is normal to experience agitation and sweating during the course of treatment",
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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": "A 30-year-old woman presents to her GP with a 3-week history of depression, hopelessness, fatigue, poor appetite, and difficulty sleeping. She recently gave birth to her first child a month ago. She denies hallucinations or thoughts of harming her baby. Her Edinburgh Postnatal Depression Scale score is 8/30.\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam\nPMH, DH: NIL\nThe patient is advised to commence treatment with citalopram 20mg PO once daily along with cognitive behavioural therapy and attend another appointment in two weeks’ time to review the medication.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
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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",
"id": "34100",
"label": "a",
"name": "Co-careldopa could lead to excessive daytime sleepiness",
"picture": null,
"votes": 5051
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients are reminded to take co-careldopa at the same time each day to help control their symptoms",
"id": "34103",
"label": "d",
"name": "He should take co-careldopa at different times of the day to decrease the risk of dizziness",
"picture": null,
"votes": 164
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients are usually started on low dose to reduce chances of side effects",
"id": "34102",
"label": "c",
"name": "Maximum dose of careldopa is usually given at the start to ensure complete control of symptoms",
"picture": null,
"votes": 48
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dose of co-careldopa needs to be reduced gradually before it can be stopped completely to prevent withdrawal symptoms such as stiff muscles, fever and altered mental status",
"id": "34104",
"label": "e",
"name": "Co-careldopa can be stopped instantly once the symptoms have improved",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"id": "34101",
"label": "b",
"name": "Carbidopa in the co-careldopa decreases the risk of impulsive behaviour associated with levodopa",
"picture": null,
"votes": 521
}
],
"comments": [
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"__typename": "QuestionComment",
"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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173,458,483 | false | 18 | null | 6,494,960 | null | false | [] | null | 6,837 | {
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"explanation": "At the beginning of treatment, patients are usually given a dose at the lower end of the licensed range and then slowly titrate upwards within the dose range to lower the risks of side effects",
"id": "34131",
"label": "b",
"name": "She will be given maximum dose at the start of treatment to ensure optimal control of her symptoms",
"picture": null,
"votes": 35
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Muscle stiffness and confusion are not normal side effects of haloperidol. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of neuroleptic malignant syndrome",
"id": "34134",
"label": "e",
"name": "It is normal to experience muscle stiffness and confusion during the course of treatment",
"picture": null,
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"explanation": "Haloperidol is an anti-psychotic that is used to treat schizophrenia and other psychoses. It is linked to extra-pyramidal effects such as akathisia due to it being a dopamine D2 receptor antagonist. Akathisia is a movement disorder associated with restlessness and inability to stay still",
"id": "34130",
"label": "a",
"name": "Haloperidol can cause akathisia",
"picture": null,
"votes": 2394
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haloperidol is linked to hypotension rather than hypertension",
"id": "34133",
"label": "d",
"name": "Haloperidol commonly causes high blood pressure",
"picture": null,
"votes": 54
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hyperprolactinaemia is a common side effect of haloperidol. Hence, BNF advises to monitor prolactin concentration (not oxytocin concentration) at the beginning of therapy, at 6 months and then yearly",
"id": "34132",
"label": "c",
"name": "She will have her oxytocin level measured as part of the baseline investigation",
"picture": null,
"votes": 18
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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": "Typical antipsychotic",
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"question": "Case presentation: A 30-year-old woman attends the psychiatric clinic with her partner. She reports that she has been hearing voices talking about her and that her neighbor is plotting against her. She also believes that her mind is currently being controlled by the government and many random thoughts have been inserted against her wishes. She has been out of job for 6 months as a result of her current health situation. Her partner thinks that her beliefs are unfounded. \r\n\nThe patient is advised to commence treatment with Haloperidol 2mg PO twice daily along with cognitive behavioural therapy.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
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173,458,484 | false | 19 | null | 6,494,960 | null | false | [] | null | 6,826 | {
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"choices": [
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"__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
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"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
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"__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,
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"__typename": "QuestionChoice",
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"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
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"__typename": "QuestionChoice",
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"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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"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.",
"sbaAnswer": [
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173,458,485 | false | 20 | null | 6,494,960 | 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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173,458,486 | false | 21 | null | 6,494,960 | null | false | [] | null | 6,923 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose of pholcodine = 5mg TDS\nConcentration = 5mg/5mL\nVolume of pholcodine per dose = 5mg ÷ 5mg/5mL = 5mL\nVolume of pholcodine required a day = 5mL x 3 = 15 mL\nVolume needed for 3 days = 15mL x 3 = 45mL",
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"question": "A 12-year-old boy is came to the GP complaining of dry cough. The GP started him on pholcodine 5mg TDS PO.\n\nPholcodine solution is available in bottles of 5mg/5mL.\nWeight 50kg.\n\nWhat volume (mL) of pholcodine solution is required for a course of 3 days?",
"sbaAnswer": null,
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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...",
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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?",
"sbaAnswer": null,
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173,458,488 | false | 23 | null | 6,494,960 | null | false | [] | null | 6,929 | {
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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": "A concentration of 20% is 20kg in 100L = 20mg in 0.1mL = 200mg in 1mL. Since the patient requires 10g of magnesium sulphate, the minimum volume of 0.9% sodium chloride is: 10g ÷ 200mg/mL = 50mL.\n\nConcentration ratios (20% 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 38-year-old patient suffers from hypomagnesaemia. She is prescribed a magnesium sulphate infusion of 10g once-daily for five days in a 0.9% sodium chloride solution. The concentration of magnesium sulphate should not exceed 20%.\n\n\nWhat is the minimum volume of 0.9% sodium chloride required to safely make up the magnesium sulphate solution?",
"sbaAnswer": null,
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173,458,489 | false | 24 | null | 6,494,960 | null | false | [] | null | 6,936 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "- Dose of labetalol given at 20mg/hour: 20mg/hour x 0.5 hours = 10mg\n- Dose of labetalol given at 40mg/hour: 40mg/hour x 0.5 hours = 20mg\n- Dose of labetalol given at 80mg/hour: 80mg/hour x 0.25 hours = 20mg\n\nTotal dose of labetalol given: 10mg + 20mg + 20mg = 50mg",
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"question": "A 37-year-old patient with hypertension in pregnancy is prescribed labetalol by intravenous infusion. She was initially given 20mg/hour, which was increased to 40mg/hour after 30 minutes, and then to 80mg/hour after another 30 minutes. This continued for 15 minutes, after which the response was satisfactory and the infusion was stopped.\n\n\nWhat is the total dose of labetalol given?",
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173,458,490 | false | 25 | null | 6,494,960 | null | false | [] | null | 6,857 | {
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"__typename": "QuestionChoice",
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"explanation": "Salbutamol does not commonly cause rash",
"id": "34231",
"label": "b",
"name": "Salbutamol 2 puff PRN INH",
"picture": null,
"votes": 24
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"__typename": "QuestionChoice",
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"explanation": "Hydrocortisone does not commonly cause rash",
"id": "34234",
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"name": "Hydrocortisone 0.5% cream TOP BD",
"picture": null,
"votes": 69
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dermol cream does not commonly cause rash",
"id": "34233",
"label": "d",
"name": "Dermol cream TOP OD",
"picture": null,
"votes": 7
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"explanation": "Prescribing amoxicillin in patients presenting with infectious mononucleosis can result in a widespread maculopapular rash. Drug induced maculopapular eruptions are due to delayed type hypersensitivity reactions and these eruptions are enhanced by viral infections such as EBV, possibly due to molecular mimicry between amoxicillin and viral molecules, inducing a loss of tolerance state towards amoxicillin and a transient immune reaction",
"id": "34230",
"label": "a",
"name": "Amoxicillin 500mg PO TDS",
"picture": null,
"votes": 4241
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"explanation": "Fluticasone does not commonly cause rash",
"id": "34232",
"label": "c",
"name": "Fluticasone 50 micrograms BD INH",
"picture": null,
"votes": 35
}
],
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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 5-year-old boy was brought in to the GP three days ago by his parents following a cough and sore throat that has been present for the past 4 days. On examination, he was pyrexic with a temperature of 38.5oC, his cervical lymph nodes were tender and swollen. He was prescribed antibiotics by the GP who then provided the parents with safety-netting advice. Today, he re-attended the GP with a widespread, itchy, macular papular rash that developed this morning. PMH Atopic eczema, Asthma. DH His current regular medicines are listed (below).\r\n\r\n\nQuestion: Select the prescription that is most likely to contribute to his rash.",
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173,458,491 | false | 26 | null | 6,494,960 | null | false | [] | null | 6,871 | {
"__typename": "QuestionSBA",
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"explanation": "Chlortalidone is a thiazide-like diuretic that can be used to treat oedema secondary to heart failure. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. Chlortalidone is predicted to increase the risk of digoxin toxicity when given with digoxin. (Severity of interaction: Severe; Evidence for interaction: Study). Chlortalidone can lead to hypokalaemia that increases risk of digoxin toxicity. Digoxin normally competes with potassium to bind to cellular Na+/K+-ATPase pumps. Hence, when potassium levels are low, digoxin can more easily bind to the pumps",
"id": "34300",
"label": "a",
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"explanation": "Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.",
"id": "34303",
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"name": "Rivaroxaban 20 mg PO OD",
"picture": null,
"votes": 42
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to interact with digoxin",
"id": "34302",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.",
"id": "34301",
"label": "b",
"name": "Carvedilol 3.125 mg PO BD",
"picture": null,
"votes": 769
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to interact with digoxin",
"id": "34304",
"label": "e",
"name": "Lisinopril 2.5mg PO OD",
"picture": null,
"votes": 237
}
],
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"__typename": "QuestionComment",
"comment": "from the BNF: Both Carvedilol and Digoxin can increase the risk of bradycardia.",
"createdAt": 1675198390,
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"comment": "Carvedilol increases the risk of bradys as seen here.\nChlortalidone directly interacts to cause digoxin toxicity to cause the ECG changes we are seeing \n\nSo debatably both cause the clinical picture but I think the digoxin toxicity with ECG changes is the major feature in this question",
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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": "A 67-year-old woman presents to the accident and emergency department with nausea, vomiting and confusion. Two days ago her GP started digoxin 125 micrograms PO once daily for her atrial fibrillation.\n **PMH:** Type 2 Diabetes Mellitus, Atrial fibrillation, Heart failure\n**Observations:** Temperature 36.5°C , blood pressure 125/80 mmHg, heart rate 54 bpm, respiratory rate 18; oxygen saturation 100% (on air).\n \n **On examination:** Irregular S1, S2 with presence of S3; chest is clear with no added lung sounds; abdomen soft and non tender\n\n **ECG:** Downsloping ST depression with a ‘hockeystick’ pattern, flattened T wave, shortened QT interval\nSelect the prescription that is most likely to have interacted with digoxin to cause the clinical picture described above?",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ipratroprium bromide does not commonly cause cholestatic jaundice",
"id": "34208",
"label": "d",
"name": "Ipratroprium bromide 40 micrograms INH TDS",
"picture": null,
"votes": 12
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clarithyomycin does not cause cholestatic jaundice",
"id": "34205",
"label": "a",
"name": "Clarithromycin 500mg BD PO",
"picture": null,
"votes": 780
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clindamycin does not commonly cause cholestatic jaundice",
"id": "34207",
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"explanation": "Salbutamol does not commonly cause cholestatic jaundice",
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"name": "Salbutamol 200 micrograms INH QDS",
"picture": null,
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},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Fusidic acid is associated with elevated liver enzymes, hyperbilirubinaemia and jaundice with systemic use. These effects are usually reversible following withdrawal of therapy.",
"id": "34206",
"label": "b",
"name": "Fusidic acid 250mg BD PO",
"picture": null,
"votes": 1666
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"comment": "jaundice is listed as a side effect of clindamycin with paraenteral use though?",
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"comment": "Yeah but PO fusidic acid has its own section on jaundice, deranged LFTs and hyperbilirubinemia. ",
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"comment": "and it is also listed as a SE for clindamycin for oral use as well",
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"explanation": "# Summary\n\n# Definition\n\nJaundice is yellowing of the skin, sclerae and mucosae due to raised plasma bilirubin. The causes of jaundice can be split up into pre-hepatic, hepatic and post-hepatic causes.\n\n# Epidemiology\n\nPrevalence varies globally, with regions such as Africa experiencing higher rates due to infectious causes like malaria. In the UK, annual incidence estimates range from 5 to 10%, with age, gender, and socioeconomic factors influencing prevalence.\n\n# Normal physiology\n\nJaundice can be classified according to whether it is pre-hepatic, hepatic or post-hepatic. \r\n\n- Normal bilirubin metabolism: red blood cells contain haemoglobin; haemoglobin is made up of haem and globin. \n- Haem is metabolised to unconjugated bilirubin. Unconjugated bilirubin is insoluble and is formed into a water-soluble conjugated bilirubin in the liver to aid excretion. \n- Conjugated bilirubin then passes into the common bile duct into the gut and is either re-taken up by the liver (enterohepatic circulation) or is converted to urobilinogen by gut macrophages. \n- Uribilinogen is reabsorbed and excreted by the kidney or is converted to stercobilin (leading to brown faeces). \n- Jaundice occurs when there is disruption to the above pathway at some point and leads to key distinguishing features.\n\n[lightgallery]\r\n\n# Aetiology\n\n## Pre-hepatic\n\n- Increased breakdown of haemoglobin into haem and globin – liver cannot conjugate bilirubin ‘fast’ enough, leading to raised unconjugated bilirubin. \n- Unconjugated bilirubin is not water soluble and so cannot enter the urine. It is therefore also known as acholuric jaundice.\n\nCauses:\n\n- Conjugation disorders, such as Gilbert's disease and Crigler-Naajjar\n- Haemolysis (such as malaria or haemolytic anaemia)\n- Drugs, such as contrast or rifampicin\n\n## Hepatic\n\n- The liver is unable to/has reduced capacity for forming unconjugated and conjugated bilirubin, resulting in a mixed conjugated/unconjugated hyperbilirubinaemia. \n\nCauses of hepatocellular dysfunction include:\n\n- Viruses (hepatitis, CMV, EBV)\n- Drugs, including paracetamol overdose, nitrofurantoin, halothane, valproate, statins, tuberculosis antibiotics\n- Alcohol\n- Cirrhosis\n- Liver mass (abscess or malignancy)\n- Haemochromatosis\n- Autoimmune hepatitis\n- Alpha-1 antitrypsin deficiency\n- Budd-Chiari\n- Wilson's disease\n- Failure to excrete conjugated bilirubin (Rotor and Dubin-Johnson syndromes)\n \n## Post-hepatic\n \n- The liver able to conjugate bilirubin, but unable to excrete it. \n- This results in a rise in insoluble conjugated hyperbilirubin, which is then unable to pass into gut (so no there is stercobilin and no urobilinogen production) which causes pale stools and dark urine. Bile salts are also then deposited in the skin, resulting in pruritus.\r\n\nPost-hepatic causes include:\n\n- Primary biliary cirrhosis\n- Primary sclerosing cholangitis\n- Common bile duct gallstones or Mirrizi's syndrome (CBD compression from a gallstone in the cystic duct)\n- Drugs, including coamoxiclav, flucloxacillin, steroids, sulfonylureas\n- Malignancy, such as head of the pancreas adenocarcinoma, cholangiocarcinoma\n- Caroli's disease\n- Biliary atresia\n\n# Signs and Symptoms\n\n- **Pre-hepatic:** haemolysis, anaemia (fatigue, chest pain, palpitations, lightheadedness)\r\n- **Hepatic:** RUQ pain, fever, viral illness, risk factors include: IVDU/tattoo, UPSI\r\n- **Post-hepatic:** dark urine, pale stools, itch \n\nNB: Courvoisier’s law – jaundice and palpable painless gallbladder not due to gallstones. Painless jaundice – red flag for **pancreatic cancer or cholangiocarcinoma**\r\n\n\n# Investigations\n\r\n\nBedside:\n\n- Urobilinogen is normally found in the urine. This is decreased or absent in cases of obstructive jaundice, but increased in cases of pre-hepatic causes of hyperbilirubinaemia or hepatocellular disease.\n\n| Urinalysis | Normal | Prehepatic disease | Hepatic disease | Posthepatic disease |\n| ------------ | ------- | ------------------ | --------------- | ------------------- |\n| Bilirubin | Absent | Absent | Present | Present |\n| Urobilinogen | Present | Increased | Increased | Decreased / absent |\n\nBloods:\n\n- FBC, U&E, LFTS (and split bilirubin to show conjugated/unconjugated amounts), reticulocytes, DAT, haptoglobin (goes down in pre-hepatic jaundice as it mops up free haem) \n- In LFTs - hepatocellular picture (raised AST/ALT), and cholestatic picture (raised GGT/ALP)\n- Synthetic function of the liver - albumin, INR/coagulation screen\n\nImaging:\n\n- 1st line is abdominal USS (to look for duct dilatation)\n- 2nd line is MRCP \n- CT/MRI may be done if the presentation is suspicious for malignancy\n- Liver biopsy may also be considered if there is diagnostic doubt\n\n# Management\n\n- Management of jaundice depends on the underlying cause. See separate management sections on the aetiologies described above in this chapter.\n\n# NICE Guidelines\n\n[NICE CKS - Jaundice in Adults](https://cks.nice.org.uk/topics/jaundice-in-adults/)",
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"thumbhash": "PQgCBgBRkNZlpzmnp5Z1KadW/8z63s0=",
"topic": null,
"topicId": null,
"updatedAt": 1710927207
}
],
"typeId": 2
},
"chapterId": 737,
"demo": null,
"entitlement": null,
"id": "2784",
"name": "Cholestatic Jaundice",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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"userNote": null,
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"dislikes": 8,
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"question": "Case Presentation: A 70-year-old man was admitted to the respiratory ward two days ago following a recent chest infection. PMH Community acquired pneumonia, Mild COPD, TB, Diabetic foot infection. DH His current regular medicines are listed (below).\n\n\nOn examination\nThere is visible yellowing of his sclera and evidence of pruritus on his arm.\nInvestigation\n\n||||\n|---------------------------|:-------:|--------------------|\n|Alanine Aminotransferase (ALT)|150 IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|50 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|450 IU/L|25 - 115|\n|Bilirubin|60 µmol/L|< 17|\n|Gamma Glutamyl Transferase (GGT)|50 U/L|9 - 40|\n\n\nQuestion: Select the prescription that is most likely to contribute to his cholestatic jaundice.",
"sbaAnswer": [
"b"
],
"totalVotes": 4401,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,493 | false | 28 | null | 6,494,960 | null | false | [] | null | 6,858 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Risperidone does not commonly cause tinnitus",
"id": "34239",
"label": "e",
"name": "Tinnitus",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Antipsychotics including risperidone common or very commonly causes galactorrhea. Antipsychotics, whose effects are mediated by the inhibition of dopamine D2 and D4 receptors, can result in extrapyramidal side effects when the D2 receptors in the hypothalamic tuberoinfundibular system is inhibited. This results in an increase in prolactin level causing symptoms such as galactorrhea, amenorrhea and impotence",
"id": "34235",
"label": "a",
"name": "Galactorrhea",
"picture": null,
"votes": 4568
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carbamazepine causes thrombocytopenia but not risperidone",
"id": "34238",
"label": "d",
"name": "Thrombocytopenia",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Risperidone does not commonly cause hypoglycaemia",
"id": "34237",
"label": "c",
"name": "Hypoglycaemia",
"picture": null,
"votes": 16
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Antipsychotics does not commonly cause alopecia",
"id": "34236",
"label": "b",
"name": "Alopecia",
"picture": null,
"votes": 29
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Risperidone is usually given to avoid galactorrhea though? Even on the BNF it isn't listed as a S/E?",
"createdAt": 1643493728,
"dislikes": 2,
"id": "6804",
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"likes": 0,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "idk which BNF youre reading but mine defo has galactorrhea \n",
"createdAt": 1643723042,
"dislikes": 0,
"id": "6874",
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"likes": 4,
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"displayName": "Acute JAK",
"id": 14062
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"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": "2790",
"name": "Risperidone side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
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"question": "Case Presentation: A 45-year-old gentleman attended his psychiatry follow-up appointment in the clinic. He was recently diagnosed with schizophrenia and was started on risperidone. PMH Schizophrenia DH Risperidone 3mg PO BD.\r\n\r\n\nQuestion: Select the adverse effect that is most likely to be caused by prolonged use of this medication.",
"sbaAnswer": [
"a"
],
"totalVotes": 4690,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,494 | false | 29 | null | 6,494,960 | null | false | [] | null | 6,851 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril does not commonly cause weight gain",
"id": "34204",
"label": "e",
"name": "Ramipril 2.5mg PO daily",
"picture": null,
"votes": 5
},
{
"__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
},
{
"__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
},
{
"__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
}
],
"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": "2783",
"name": "Pioglitazone side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2783,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6851",
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"psaSectionId": 6,
"qaAnswer": null,
"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"
],
"totalVotes": 5596,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,495 | false | 30 | null | 6,494,960 | null | false | [] | null | 6,878 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This should be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin",
"id": "34336",
"label": "b",
"name": "Creatinine kinase",
"picture": null,
"votes": 403
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This has no role or relevance in the monitoring of patients taking statins",
"id": "34337",
"label": "c",
"name": "Full blood count",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to measure renal function prior to starting atorvastatin but routine monitoring is not necessary",
"id": "34339",
"label": "e",
"name": "Urea and electrolytes",
"picture": null,
"votes": 36
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that lipids be measured prior to starting treatment and may be measured for the duration of taking atorvastatin, but not for assessing the adverse effects of this drug",
"id": "34338",
"label": "d",
"name": "Lipid profile",
"picture": null,
"votes": 162
},
{
"__typename": "QuestionChoice",
"answer": true,
"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",
"id": "34335",
"label": "a",
"name": "Liver function tests",
"picture": null,
"votes": 3739
}
],
"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": "2810",
"name": "Atorvastatin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
"totalCards": null,
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"qaAnswer": null,
"question": "Case Presentation: A 46 year old woman attends a follow-up appointment at her GP. **PMH** hyperlipidaemia. **DH** atorvastatin 20mg PO OD, started three months ago. **FH** father died of heart attack at the age of 53. **SH** current smoker, 15-20 cigarettes a day but currently attending smoking cessation counselling.\n\n\n**Investigations**\n\nQ-risk score: 14%\n\nQuestion: Select the most appropriate option to monitor for adverse effects of the atorvastatin at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 4357,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,496 | false | 31 | null | 6,494,960 | null | false | [] | null | 6,892 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is reporting regular bleeds with her last one occurring 5 days ago. There still is a minuscule chance she may be pregnant and one may choose to perform a urine pregnancy test before administering ulipristal acetate, but this is not strictly necessary",
"id": "34409",
"label": "e",
"name": "Urine pregnancy test",
"picture": null,
"votes": 829
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "There are generally no monitoring requirements prior to administering ulipristal acetate as emergency contraception",
"id": "34405",
"label": "a",
"name": "No routine monitoring is required",
"picture": null,
"votes": 2904
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hyper/hypotension is not a known adverse effect of this drug",
"id": "34406",
"label": "b",
"name": "Blood pressure",
"picture": null,
"votes": 187
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ulipristal acetate is metabolised by the liver and as such liver function tests are recommended when it is being used long-term to treat fibroids. This is not necessary if it is taken as a single dose for emergency contraception",
"id": "34407",
"label": "c",
"name": "Liver function tests",
"picture": null,
"votes": 2175
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to measure height and weight prior to administering ulipristal acetate",
"id": "34408",
"label": "d",
"name": "Height and weight",
"picture": null,
"votes": 194
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "BNF:\nPerform liver function tests before treatment initiation—do not initiate if serum transaminases exceed 2 times the upper limit of normal. During the first 2 treatment courses, monitor liver function monthly; for further treatment courses, perform liver function tests once before each new treatment course and when clinically indicated. At the end of each treatment course, perform liver function tests after 2-4 weeks. Discontinue treatment if serum transaminases exceed 3 times the upper limit of normal and closely monitor patient.\n\nPeriodically monitor the endometrium following repeated intermittent treatment.",
"createdAt": 1646856067,
"dislikes": 16,
"id": "8324",
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"parentId": null,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "if you read above that it says \"When used for uterine fibroids\" ",
"createdAt": 1646937391,
"dislikes": 0,
"id": "8367",
"isLikedByMe": 0,
"likes": 58,
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"displayName": "Cystic Prognosis",
"id": 2144
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "DNA Hypertension",
"id": 4721
}
},
{
"__typename": "QuestionComment",
"comment": "whatever you say im still doing the pregnancy test irl",
"createdAt": 1737648864,
"dislikes": 0,
"id": "61348",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 6892,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Vaccine Complement",
"id": 17667
}
}
],
"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": "2824",
"name": "Ulipristal acetate side effects",
"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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"conceptId": 2824,
"conditions": [],
"difficulty": 3,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "6892",
"isLikedByMe": 0,
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"likes": 1,
"multiAnswer": null,
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 27 year old woman attends the walk-in GUM clinic requesting emergency contraception. She had forgotten to take her combined contraceptive pill for two days in a row at the start of the week and had unprotected sex in the same period.\n\n\nHer LMP was 5 days ago and she has a regular cycle of 28 days. She has never been pregnant before.\n\nAfter counselling, it is agreed that she should take ulipristal acetate 30mg PO as a one-off dose for emergency contraception.\n\nQuestion: Select the most appropriate monitoring option required before administering ulipristal acetate.",
"sbaAnswer": [
"a"
],
"totalVotes": 6289,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,497 | false | 32 | null | 6,494,960 | null | false | [] | null | 6,888 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mast cell tryptase is usually measured following a suspected allergic reaction and has no role in assessing disease control in asthma",
"id": "34388",
"label": "d",
"name": "Serum mast cell tryptase",
"picture": null,
"votes": 37
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a useful marker of disease control in asthma",
"id": "34387",
"label": "c",
"name": "Respiratory rate",
"picture": null,
"votes": 94
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A peak flow diary will give useful information about disease control and whether any modifications to treatment or referral to secondary care is necessary",
"id": "34385",
"label": "a",
"name": "Peak flow",
"picture": null,
"votes": 4227
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a useful marker of disease control in asthma",
"id": "34389",
"label": "e",
"name": "Serum potassium",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This will give a full assessment of asthma severity and disease control, but should not be used routinely",
"id": "34386",
"label": "b",
"name": "Lung function tests",
"picture": null,
"votes": 278
}
],
"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
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2820",
"name": "Asthma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
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"question": "Case Presentation: An 8 year old girl has been having a nocturnal cough and reduction in exercise tolerance for three weeks. **PMH** hay fever. **DH** salbutamol 100 micrograms inhaler PRN. **SH** non-smoking household, no pets.\n\n\n**O/E**\n\nRR 11, Temperature 36.7°C. Chest clear.\n\nPEFR: 78% of predicted\n\nShe is prescribed beclometasone dipropionate 100 micrograms inhaler, 2 puffs in the morning and 2 puffs in the evening.\n\nQuestion: Select the most appropriate option to assess the beneficial effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4664,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,498 | false | 33 | null | 6,494,960 | null | false | [] | null | 6,898 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Effective treatment with levothyroxine would be indicated by a resolution of symptoms. The patient’s body temperature may well rise with successful treatment and as a result she may report feeling less cold, but monitoring temperature in of itself is generally not useful as a marker of benefit",
"id": "34439",
"label": "e",
"name": "Temperature",
"picture": null,
"votes": 111
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient’s respiratory rate is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit",
"id": "34438",
"label": "d",
"name": "Respiratory rate",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Effective treatment with levothyroxine would be indicated by a resolution of symptoms. A lower heart rate may be purely physiological in some patients and is not a useful marker of effective treatment with levothyroxine",
"id": "34437",
"label": "c",
"name": "Heart rate",
"picture": null,
"votes": 366
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Effective treatment with levothyroxine would be indicated by a resolution of symptoms including an improvement in the patient’s energy levels",
"id": "34435",
"label": "a",
"name": "Patient reports of energy levels",
"picture": null,
"votes": 3727
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient’s blood pressure is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit",
"id": "34436",
"label": "b",
"name": "Blood pressure",
"picture": null,
"votes": 108
}
],
"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",
"files": null,
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"id": "2618",
"pictures": [],
"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2830",
"name": "Levothyroxine monitoring",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
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"qaAnswer": null,
"question": "Case Presentation: A 34-year-old woman attends her GP with symptoms of tiredness, menstrual irregularities and feeling cold all the time. **PMH** coeliac disease\n\n\n**O/E**\n\nHR 53, RR 10, BP 106/65, Temperature 35.7°C. Peripheries cool. Mild periorbital oedema. Smooth non-tender goitre on palpation.\n\nHer GP makes a provisional diagnosis of Hashimoto’s thyroiditis. She books the patient for a blood test and prescribes levothyroxine sodium 100 micrograms PO OD.\n\nQuestion: Select the most appropriate monitoring option to assess the beneficial effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4323,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,499 | false | 34 | null | 6,494,960 | null | false | [] | null | 6,894 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to check liver function tests following a medical termination of pregnancy",
"id": "34418",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended that blood pressure be monitored closely for at least 3 hours following a medical termination of pregnancy with oral mifepristone and gemeprost pessary as there is a risk of severe hypotension",
"id": "34415",
"label": "a",
"name": "Blood pressure",
"picture": null,
"votes": 1917
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to measure C-reactive protein following a medical termination of pregnancy",
"id": "34416",
"label": "b",
"name": "C-reactive protein",
"picture": null,
"votes": 66
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A urine pregnancy test should be performed at 3 weeks following termination of pregnancy but not immediately after as it is likely to be still positive",
"id": "34419",
"label": "e",
"name": "Urine pregnancy test",
"picture": null,
"votes": 2600
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be performed if there is a clinical suspicion of STI or pelvic inflammatory disease but there is no information in the stem to suggest that",
"id": "34417",
"label": "c",
"name": "High vaginal swabs",
"picture": null,
"votes": 77
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "how are you monitoring BP when you can take the tablets at home for medical termination?",
"createdAt": 1737983508,
"dislikes": 1,
"id": "61652",
"isLikedByMe": 0,
"likes": 3,
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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,
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"id": "2826",
"name": "Termination of Pregnancy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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"question": "Case Presentation: A 21 year old woman is in the process of terminating a 9 week intrauterine pregnancy. She has received mifepristone 600mg PO two days ago and is about to receive gemeprost 1mg pessary and doxycycline 100mg PO BD for three days as antibiotic prophylaxis.\n\n\nQuestion: Select the most appropriate immediate monitoring option required once her pregnancy has been terminated.",
"sbaAnswer": [
"a"
],
"totalVotes": 4703,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,500 | false | 35 | null | 6,494,960 | null | false | [] | null | 6,902 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "200mg oral morphine sulphate is equivalent to 60mg diamorphine SC. 100mg SC diamorphine will be uptitrating her pain control, which is not necessary when it is currently well controlled",
"id": "34459",
"label": "e",
"name": "Diamorphine sulphate 100mg SC and 17mg SC PRN",
"picture": null,
"votes": 328
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "To convert oral morphine sulphate into subcutaneous infusion, the regular dose has to be half the daily amount of PO morphine sulphate (200/2 = 100mg)",
"id": "34456",
"label": "b",
"name": "Morphine sulphate 75mg SC and 13mg SC PRN",
"picture": null,
"votes": 1195
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient is currently on a total of 200mg morphine sulphate PO a day (75mg 12 hrly regular Morphine sulphate and 5 doses of 10mg/5mL of Oramorph® = 150mg + 5 x10mg = 200mg). To convert into subcutaneous infusion, the regular dose has to be half the daily amount of PO morphine sulphate (200/2 = 100mg) and the PRN dose one sixth the total amount given regularly (1/6 x 100 = 16.7mg)",
"id": "34455",
"label": "a",
"name": "Morphine sulphate 100mg SC and 17mg SC PRN",
"picture": null,
"votes": 3883
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "200mg oral morphine sulphate is equivalent to 60mg diamorphine SC",
"id": "34458",
"label": "d",
"name": "Diamorphine sulphate 50mg SC and 13mg SC PRN",
"picture": null,
"votes": 518
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "200mg morphine sulphate approximates to a buprenorphine '70' patch and a '15' patch",
"id": "34457",
"label": "c",
"name": "Buprenorphine 70 microgram/h transfermal patch applied 72-hrly",
"picture": null,
"votes": 158
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "hell yeah",
"createdAt": 1705707348,
"dislikes": 2,
"id": "39389",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 6902,
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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,
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"id": "2618",
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"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2834",
"name": "Opioid Conversion",
"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": 2,
"explanation": null,
"highlights": [],
"id": "6902",
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"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation:\n\n\nA 80-year-old man was admitted into the Care of the Elderly Ward a week ago for chest infection. His condition has worsened over the last few days and he is not for cardiopulmonary resuscitation. PMH Osteoarthritis, GORD, HTN, Heart failure, pancreatic cancer. DH Morphine sulphate M/R (MST Continus ® ) 75mg PO 12-hrly, Morphine sulphate 10mg/5mL (Oramorph ®) 5mL PO as required, Omeprazole 20mg OD PO, Bisoprolol 10mg PO OD, Ramipril 2.5mg PO OD. He has taken 5 doses of immediate release morphine in the last 24 hour.\nA decision is made by the palliative care team to stop all inappropriate medication and convert his analgesic regimen to a continuous subcutaneous infusion via a syringe driver.\n\nQuestion:\nSelect the most appropriate decision option with regard to his pain management based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 6082,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,501 | false | 36 | null | 6,494,960 | null | false | [] | null | 6,904 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Variable rate insulin infusion is only started when ketone levels falls below 0.6mmol/L",
"id": "34467",
"label": "c",
"name": "Change to variable rate insulin infusion",
"picture": null,
"votes": 267
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As K has dropped to 3.5-5.5mmol, 40mmol of KCl should be added to the bag of fluid as this patient would require continuous insulin infusion, which can result in the redistribution of potassium into the cells and the serum potassium level to decrease further",
"id": "34466",
"label": "b",
"name": "Increase fixed rate insulin Actrapid infusion to 2.8 units/hour",
"picture": null,
"votes": 745
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is on 0.1units/kg/hour of fixed rate insulin infusion, however, the response is inadequate (ketone reduction <0.5mM/h, glucose reduction < 3mM/h). Hence, decreasing the rate of insulin infusion will not be appropriate",
"id": "34468",
"label": "d",
"name": "Decrease fixed rate insulin Actrapid infusion to 1.5units/hour",
"picture": null,
"votes": 281
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Starting 1L of 10% dextrose over 8 hours is not necessary at this point as the blood glucose level is still above 14mmol/L but should be considered if the glucose level falls below 14mmol/L",
"id": "34469",
"label": "e",
"name": "Start 1L 10% dextrose over 8hours",
"picture": null,
"votes": 687
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is on 0.1units/kg/hour of fixed rate insulin infusion, however, the response is inadequate (ketone reduction <0.5mM/h, glucose reduction < 3mM/h). Hence, an increase in insulin rate by 1unit/hour increments hourly is necessary until the ketones are falling at target rates. As K has dropped to 3.5-5.5mmol, 40mmol of KCl should be added to the bag of fluid as this patient would require continuous insulin infusion, which can result in the redistribution of potassium into the cells and the serum potassium level to decrease further",
"id": "34465",
"label": "a",
"name": "Increase fixed rate insulin Actrapid infusion to 2.8 units/hour and add 40mmol/L potassium chloride to 0.9% normal saline bag",
"picture": null,
"votes": 2312
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "K should be given at 1mmol/kg/hr. So in 24hrs he shouldnt have more than 18mmol. Yet your flooding this child with 40mmol. Cant be right?",
"createdAt": 1647169980,
"dislikes": 2,
"id": "8500",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 6904,
"replies": [
{
"__typename": "QuestionComment",
"comment": "That's for maintenance fluids, not in the treatment of DKA. It's right. ",
"createdAt": 1673986642,
"dislikes": 0,
"id": "16831",
"isLikedByMe": 0,
"likes": 4,
"parentId": 8500,
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"displayName": "Neoplasia Dominant",
"id": 441
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},
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"__typename": "QuestionComment",
"comment": "I thought the same thing too.\nNICE guidelines for DKA in children: 'Include 40 mmol/litre (or 20 mmol/500 ml) potassium chloride in all fluids (except the initial intravenous boluses) given to children and young people with DKA, unless they have anuria or their potassium level is above the normal range. Do not delay potassium replacement, because hypokalaemia can occur once the insulin infusion starts.'",
"createdAt": 1703878666,
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"id": 4721
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{
"__typename": "QuestionComment",
"comment": "are the aims for ketone and glucose reduction available on BNF?\n",
"createdAt": 1705838664,
"dislikes": 0,
"id": "39488",
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"likes": 1,
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{
"__typename": "QuestionComment",
"comment": "I can't find it so I'm assuming not? ",
"createdAt": 1706810436,
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2836",
"name": "Diabetic Ketoacidosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "77",
"name": "Paeds",
"typeId": 5
},
"topicId": 77,
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"question": "Case Presentation:\n\n\nA 5-year-old is admitted to the Emergency Department 3 hours ago and is being treated for Diabetic Ketoacidosis with 0.9% normal saline and fixed rate insulin Actrapid infusion 1.8units/hour IV.\n\n\n **On Examination**\nRR 45/min (22-34).\n\n\nTemperature 37.5 <sup>o</sup> C\n\n\nHR 100/min (75-110)\n\n\nO2 sats 96% RA.\n\n\nWeight 18kg.\n\n\nBP 110/80 mmHg.\n\n\n **Investigations**\n 3 hours ago:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.2|7.35 - 7.45|\n|PaO₂|11 kPa|11 - 15|\n|PaCO₂|4 kPa|4.6 - 6.4|\n|Bicarbonate|12 mmol/L|22 - 30|\n|Potassium|6 mmol/L|3.5 - 5.3|\n|Non-fasting Glucose|18 mmol/L|< 6.1|\n|Ketones (Serum)|3 mmol/L|< 0.6|\n\n\nNow:\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.25|7.35 - 7.45|\n|PaO₂|10 kPa|11 - 15|\n|PaCO₂|4.5 kPa|4.6 - 6.4|\n|Bicarbonate|15 mmol/L|22 - 30|\n|Potassium|4 mmol/L|3.5 - 5.3|\n|Non-fasting Glucose|16 mmol/L|< 6.1|\n|Ketones (Serum)|2 mmol/L|< 0.6|\n\n\n\n\nQuestion:\nSelect the most appropriate decision option with regard to his DKA management based on these data.",
"sbaAnswer": [
"a"
],
"totalVotes": 4292,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,502 | false | 37 | null | 6,494,960 | 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": "34461",
"label": "b",
"name": "Nitrofurantoin 50mg QDS for 3 days",
"picture": null,
"votes": 82
},
{
"__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": 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
},
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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\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.",
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173,458,503 | false | 38 | null | 6,494,960 | null | false | [] | null | 264 | {
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"__typename": "QuestionChoice",
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"explanation": "Methotrexate is a competitive inhibitor of the dihydrofolate reductase enzyme, which is involved with catalyzing dihydrofolate to the active tetrahydrofolate. \n\n\n\nThis is needed for the synthesis of the nucleoside thymidine, and is part of the synthesis of purine and pyrimidine. In essence, methotrexate inhibits the synthesis of DNA and RNA",
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"explanation": "Vinblastine is a vinka alkaloid, which works by affecting the microtubule assembly, and subsequently the spindle formation",
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"explanation": "This option is incorrect as it is not a folate antagonist, but rather an alkylating agent. Alkylating agents work by adding an alkyl group to some of the proteins of the double helix structure of a DNA molecule. This prevents the linking up of the proteins, causing breakage of the DNA strands (the lack of which causes death of the cancer cell)",
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"id": "1319",
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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": "Which of the following drugs is a folate antagonist?",
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Subsets and Splits